Overview

The Collaborative Assessment and Management of Suicidality (CAMS) has been successfully administered using telepsychology in a variety of settings (Jobes, 2016). For example, the U.S. Army has successfully used a telepsychology version of CAMS within the Warrior Resiliency Program in San Antonio Texas for suicidal Soldiers in geographically remote locations for the past several years (Waltman, Landry, Pujol, & Moore, 2019). The exploratory use of CAMS via telepsychology in rural and frontier regions of the intermountain West of the United States is also now underway. The use of telepsychology and CAMS in forensic (prison) settings is also being explored. Finally, it is important to note the telepsychology use of CAMS is now being done with an on-going randomized controlled trial (RCT) at the San Diego Veterans Affairs Medical Center with suicidal veterans.

Basically, the common denominator for using CAMS within a telepsychology modality requires the parallel use of the Suicide Status Form (SSF). The SSF functions as the CAMS roadmap of the framework for assessment of suicidal risk, stabilization planning, suicide-focused treatment planning, the interim tracking of suicidal risk, to clinical outcomes and dispositions. To this end, it is critical that both the patient and clinician have access to copies of the SSF-4 which they can then refer to as they engage in CAMS-guided assessment, the on-going treatment of patient-defined “drivers” (those issues/problems that compel patients to consider suicide), and on-going treatment planning until the outcome/dispositions phase of CAMS-guided care is realized.

What we have seen in current uses of telepsychology and CAMS is that patients can check the clinician’s completion of the SSF as accurate, reflecting both the correct assessment and treatment information that the patient experiences. In this regard, the clinician’s accurate completion of the SSF can be a clarifying and even validating experience for the suicidal patient. Thus, it is crucial for a suicidal CAMS patient to have access to the appropriate hardcopy of the CAMS SSF-4 prior to each CAMS session. At some point in the future, the e-SSF, that has been developed with the help of Microsoft engineers, will be commercially available to supplement the CAMS telepsychology experience. But for now, we will rely on mutual access to the hard copy version of the SSF-4 and will then use it in parallel within telepsychology.

Informed consent to engage in telepsychology is crucial. Informed consent considerations are jurisdictionally defined by boards of mental health disciplines. There are also complex issues as to what to do remotely for a patient in imminent danger, discussion of this prospect may need to be included as part of informed consent (e.g., that 911 may need to be contacted for an emergency rescue if that is warranted to assure a patient’s safety). What follows are general guidelines for using CAMS within telepsychology across each phase of the CAMS therapeutic framework, including: (a) the CAMS initial session, (b) the CAMS tracking/update-interim sessions of care, and (c) the CAMS outcome/disposition final session when the full range of clinical outcomes are realized and documented by the Suicide Status Form.

I. CAMS Initial Session

A. The CAMS clinician will have a blank SSF-4 Initial Session Form at their location. In turn, the suicidal patient will have access to a hard copy of the SSF-4 at their remote location.

B. When the session begins, the CAMS clinician will explain the reasons for using the CAMS Framework™ with the patient noting that the purpose is:

1. To gain an understanding of the direct and indirect “drivers” that are causing the patient to consider ending their life;
2. To assess what might be the best way to support the patient (ideally outpatient care but acknowledging that hospitalization is sometimes indicated);
3. To develop a CAMS Stabilization Plan as a resource for the patient;
4. To develop a suicide-focused treatment plan to address the direct and indirect “drivers” that are causing the patient to consider ending their life.

C. The CAMS clinicians may acknowledge that one of the goals within CAMS is to avoid hospitalization if the patient can be supported on an outpatient basis (though occasionally there are times when hospitalization may be the best option). CAMS clinicians will follow the guidelines within their state and within their organization for standards related to hospitalization as well as their own clinical judgment.

D. CAMS clinicians may wish to refer to the attached CAMS Quick Reference Guide” to provide reminders about which forms to use and the clear goals of each CAMS session.

E. For Section A of the SSF Initial Session, both the patient and the therapist will collaboratively enter the information on the SSF. The patient will be asked to fill-in Section A and let the therapist know what is being written on their form so the therapist can follow along and fill-in their copy of the SSF. As each section is completed, the therapist should check with the patient by reading back what the therapist has written to ensure accuracy (which can be validating and builds rapport).

F. For Section B of the SSF Initial Session, the therapist and the patient will switch tasks as the therapist will fill in the Section B while the patient provides responses and will ask the patient to fill in the information on the patient’s version of the form while proceeding through the risk factor/warning sign section.

G. For Section C Problem 1: The CAMS Stabilization Plan, the patient will enter information on the patient’s version of the CAMS Stabilization Plan and the therapist will enter the same information on the therapist’s version of the CAMS Stabilization Plan form. The dyad will then compare their forms to ensure that the information on the therapist’s CAMS Stabilization Plan form is consistent and accurate according to the patient’s perspective.

H. For Section C Problems 2 and 3 the therapist and patient will explore what “drivers” the treatment should focus on and complete the CAMS Treatment Plan accordingly. Both patient and therapist will enter the information on their respective versions of the forms.

I. The patient and therapist will each sign their respective versions of the SSF, and the therapist’s signed version will be scanned into the patient’s medical record. The patient will have their own completed version of the SSF and the CAMS Stabilization Plan to refer to as on-going care proceeds.

J. The therapist will complete Section D of the Initial Session SSF after ending the session with the patient and will scan the relevant documents into the patient’s medical record as it functions as the official medical record progress note.

II. CAMS Tracking Update/Interim Care

A. Both therapist and patient will have a blank copy of the SSF Tracking/Update-Interim Care version of the form at the start of the session.

B. The patient will complete Section A (the SSF Core Assessment) ratings on their form at the start of the session and will dictate their ratings to the therapist so the therapist can enter the information on the therapist’s copy of the SSF (including considerations of the overall risk of suicide and whether the patient managed their suicidal thoughts and feelings and remained behaviorally safe over the past week).

C. Once the SSF Core Assessment is completed, the therapist will shift to working on the treatment modalities identified in the first session to target and treat the patient-defined suicidal drivers. They are thus essentially engaging in a standard therapy session with the focus on treating the patient-defined drivers of their suicidality.

D. When there is about 10-15 minutes remaining in the interim session, the therapist should shift to checking in about the utility of the CAMS Stabilization Plan (if not done earlier) and then update and complete the CAMS Treatment Plan (Section B).  The patient should enter the same information on the patient’s version of the SSF; the therapist version of the SSF is always entered into the patient’s medical record. Both parties should check with each other to make sure the information on each of their forms is always accurate and identical.

E. The patient and therapist each sign the forms in their possession and copies of the clinician’s form are scanned into the patient’s medical record. The patient will retain and can refer to their copy of the interim SSF’s as treatment proceeds.

F. The therapist will complete Section C after the session ends and scan that along with other interim versions of the SSF (this page is not provided to the patient).

III. CAMS Outcome/Disposition Final Session

A. Resolution of CAMS occurs when the patient has had three sessions in a row of SSF Overall Risk ratings of < 3, and they have managed their suicidal thoughts and feelings, and have not engaged in any suicidal behaviors.

B. If the patient meets these criteria for a third session, the therapist and patient should use the CAMS Outcome/Disposition final session version of the SSF-4.

C. At the start of the final session, the patient should complete the SSF Core Assessment (Section A) and dictate their ratings to the therapist so the therapist can enter that information on the therapist’s version of the SSF Outcome/Disposition document.

D. The patient should complete the questions on the lower portion of the SSF Outcome/Disposition form (Section A) and provide that information to the therapist so the therapist can enter that information onto their form.

E. The therapist should note the clinical disposition and provide that information to the patient so the patient can enter it onto their form (Section B).

F. The patient and the therapist should each sign their respective forms.

G. Copies of the clinician’s final CAMS session form should be scanned into the patient’s medical record; the patient retains their own copy of the final session form.

H. The therapist completes Section C after the final session and enters that to the patient’s medical record.

Additional Resources

For more information on this topic, please download “Office & Technology Checklist for Telepsychological Services“, “Informed Consent Checklist for Telepsychology Services“, “Protocol for Using the CAMS Framework within Telepsychology“, “CAMS Reference Guide 2020“, “Telehealth Research Paper Waltman Landry Pujol and Moore“