A few notes on what the CASE Approach is not
It is important to remember that the CASE Approach is a flexible interview strategy devoted solely to the elicitation of suicidal events. It is not a complete interview and is always employed within the body of some other clinical interview, such as an initial assessment, ED assessment, or crisis call.
Neither is the CASE Approach a suicide assessment protocol. A suicide assessment protocol is composed of all 3 of the following tasks: (1) gathering information related to the risk and protective factors and the warning signs for suicide; (2) gathering information related to the patient’s suicidal ideation, planning, behaviors, desire, and intent; and (3) the clinical decision making that is subsequently applied to these 2 databases to create a formulation of risk. These are 3 very different tasks and skill sets.
The CASE Approach is merely designed as an aid to the second component of a suicide assessment approach—gathering information related to the patient’s suicidal ideation, planning, behaviors, desire, and intent. The CASE Approach complements, not replaces, the 2 other critical components of a sound suicide assessment.
Thus, the CASE Approach is not a method of uncovering the risk/protective factors for suicide; such vital information will be gathered in other areas of the overall interview. For example, the role of ongoing alcohol(Drug information on alcohol) use will be explored in the history of substance abuse. The presence and intensity of the patient’s anxiety/agitation will be explored in the exploration of the patient’s symptoms and his mental status. The presence of psychosis will be explored in the examination for psychotic disorders, and the availability of support systems (and other related critical risk factors such as Joiner’s concepts of not feeling that one belongs to a valued group or feeling that one is a burden to others) will be flexibly and sensitively explored in other areas of the interview, such as the social history or perhaps when the patient is sharing the pain of his presenting crisis or triggering stresses.
The data garnered from the CASE Approach on suicidal ideation, behavior, and intent is added to the previously or subsequently garnered information regarding risk and protective factors in other sections of the interview and/or from collaborative sources to be used in the third component of a suicide assessment protocol—clinical formulation of risk—using whatever style of clinical formulation the clinician feels comfortable using. The CASE Approach says absolutely nothing about how to formulate risk, it is merely an interviewing strategy that attempts to provide the best possible puzzle pieces from which a clinician can make a sound formulation of risk.
Moreover, the CASE Approach is flexibly adapted to the unique needs and personality traits of the individual patient, as well as the unique demands of the clinical situation—ED assessment versus ongoing psychotherapy versus inpatient setting. For instance, it was not designed nor is it recommended for use with children, although future child researchers may find that elements of the CASE Approach may prove to be useful.
Finally, the Case Approach is not a cookbook style of interviewing, applied in the same way with every client. The CASE Approach is altered markedly with a patient who might want to manipulate himself into a hospital or who might have borderline personality traits and for whom “suicide talk” may be used to seek comfort or concern from caregivers; it may also be markedly altered with actively psychotic patients. Practical details on how the CASE Approach is effectively adapted to patients with specific pathological states, such as psychosis or borderline personality, as well as a detailed exploration of the other 2 critical aspects of suicide assessment—risk/protective factors and clinical formulation of risk—are described elsewhere for the interested reader.2
Training applications, research directions, and implications for suicide prevention programs
The CASE Approach is designed to allow the clinician to enter the patient’s world of suicidal preoccupation sensitively and deeply. During the elicitation of suicidal ideation and intent with the CASE Approach, something else may have been accomplished that is very important: the interviewer has helped the patient share painful information that, in many instances, the patient has borne alone for too long. Perhaps the thoughtfulness and thoroughness of the questioning, as illustrated with the CASE Approach, will have conveyed that a fellow human cares. To the patient, such caring may represent the first realization of hope.
By using this strategy routinely, clinicians can become adept at it, learning how to flexibly alter it to fit the unique needs of specific clinical settings and with diverse types of patients. In most suicide assessments, the CASE Approach can be completed within several minutes. Even with more complicated patients, as might be seen in a particularly complex ED presentations, it rarely requires more than 5 to 10 minutes. In a patient who has low risk factors, has high protective factors, and answers negatively to questions in the regions of presenting suicide events, recent suicide events, and past suicide events, the CASE Approach can be completed in 3 questions. With such a patient, the clinician wouldn’t even enter the region of immediate events.