This interviewer is earning his pay. He may also be saving Mr Thompson’s life. Mr Thompson’s intent to kill himself is much higher than his originally stated intent implied. In addition, it was only through the skilled use of a denial of the specific that the patient’s true method of choice emerged. With this added information reflecting the potential seriousness of Mr Thompson’s suicidal intent, hospitalization appears to be more appropriate, and there is now an opportunity to have the gun removed from the farmhouse as well.
The CASE Approach is built to uncover pieces of the puzzle that enhance the likelihood that our clinical formulation of risk will be more accurate. Some of the pieces of the puzzle will alert the clinician to the possible dangerousness of the patient (as seen with Mr Thompson) and others may point to the patient’s safety. It is not the domain of this article to discuss the way these pieces are used for clinical formulation—the third task of a suicide assessment. We are interested in the power of the interviewing techniques to uncover the pieces in the first place.
Also note that the interview strategy has uncovered clear-cut grounds for an involuntary commitment. The behavioral specificity of the CASE Approach is ideal for uncovering grounds for commitment. In this instance, the newly uncovered information serves to alert us to the intensity of the patient’s intent, which even if it has settled a bit could easily be rekindled to a dangerous level in a day or two, merely by the power of his grief or perhaps by news of a foreclosure with a subsequent return to drinking.
From the perspective of interviewing technique, notice that once the use of a gun was uncovered, the clinician deftly used a series of behavioral incidents to create a verbal videotape of what actually happened. Fact-finding behavioral incidents such as, “Did you load the gun?” and sequencing behavioral incidents such as, “What did you do next?” provided concrete information regarding the seriousness of Mr Thompson’s intent.
Also note that the string of behavioral incidents led the patient to remember and describe his inner world at the time of the gun incident. This is a common phenomenon—a rather beneficial side effect of the behavioral incident technique. The technique is designed to improve the validity of hard behavioral data, but as patients begin to re-imagine their experiences, they are often drawn into their internal cognitions and emotions at the time as well. This often provides a window into the soul of the patient. Within the soul, we may find strong reasons to live or, as with Mr Thompson, a shattered soul where there seems to be only good reasons to die as reflected by his telling comment, “She was my world.” It is exactly this type of important puzzle piece, which may not spontaneously emerge in an interview, that interview strategies such as the CASE Approach are designed to gently coax to the surface.
In short, while responding to a series of behavioral incidents, patients sometimes share the delicate arabesque that occurs as they weigh their reasons for dying against their reasons for living. As Jobes and Mann41 and others have pointed out, an understanding of a patient’s reasons for living is an important aspect of suicide assessment that has traditionally not been given the attention in the literature that it warrants.
There are other ways to approach the task of exploring the region of recent events. In another method (Figure 3), the clinician first generates the entire list of suicide methods contemplated by the patient and then explores each one in detail.
Both strategies are easy to remember. The clinician can try both strategies or develop entirely new ones. There is no correct strategy. The goal is not to have a cookbook method of exploring recent suicidal ideation but to be comfortable with a well-practiced strategy so that one can creatively modify it to the specific needs of the clinical situation at hand.
I want to re-emphasize that the extensiveness of the questioning during the region of recent events is entirely dependent on the interviewer’s ever-evolving read on the dangerousness of the patient. For example, if a client has low risk factors, has high protective factors, denies any thoughts of suicide during the exploration of presenting events, and reports only one fleeting thought of shooting himself (no gun at home) during the early exploration of the recent events, a clinician most likely would not use denials of the specific nor symptom amplification. It would not make sense to do so and might even appear odd to the patient. The CASE Approach is flexibly sculpted to the specific needs of the patient as determined by the perceptions of the clinician.
Step 3: The exploration of past suicide events
Clinicians sometimes, during the initial interview, spend too much time on this area. Patients with complicated psychiatric histories (eg, some people with a borderline personality disorder) may have lengthy past histories of suicidal material. One could spend an hour just reviewing this material, but it would be an hour poorly spent.
Under the time constraints of busy practices and managed care, initial assessments by mental health professionals usually must be completed in an hour or less. Time is at a premium. What past suicidal history is important to gather? In the CASE Approach the interviewer seeks only information that could potentially change the clinical triage and decision about the follow-up of the patient. Thus, the following questions are worth investigating:
• What is the most serious past suicide attempt? (Is the current ideation focused on the same method? “Practice” can be deadly in this arena. Does the patient view the current stressors and options in the same light as during the most dangerous past attempt?)
• Are the current triggers and the patient’s current psychopathological state similar now as to when the most serious attempts were made? (The patient may be prone to suicide following the break-up of relationships or during episodes of acute intoxication, intense anxiety, or psychosis.)
• What is the approximate number of past gestures and attempts? (Large numbers here can alert the clinician to issues of manipulation, making one less concerned, or may alert the clinician that the patient has truly exhausted all hope, making one more concerned. In either case, it is important to know.)
• When was the most recent attempt outside of the 2 months explored in Step 2? (There could have been a significant attempt within the past 6 months that may signal the need for more immediate concern.)