Some of the more common errors that occur during the elicitation of suicidal ideation are omissions, distortions, and assumptions—a potentially deadly triad. In my experience, as a past director of a psychiatric ED, a full-intake assessment center, and a call center, it appeared that errors in suicide assessment often did not stem from poor clinical decision making. More frequently, they seemed to result from a good clinical decision being made from a bad database. In my experience, the pieces of the puzzle most frequently distorted or missing at the time of the clinical formulation were those related to the extent of the patient’s suicidal history, planning, and current intent.
The CASE Approach is not presented as the right way to elicit suicidal ideation or as a standard of care, but as a reasonable way that can help clinicians develop their own methodology. From an understanding of the CASE Approach, clinicians may directly adopt what they like, reject what they do not like, and add new ideas. It can be used and/or adapted with any suicide assessment protocol the clinician deems useful. The goal of the CASE Approach is to provide clinicians with a practical framework for exploring and better understanding how they approach eliciting suicidal ideation, behavior, desire, and intent so that they may develop an individualized approach with which they personally feel comfortable and competent.
First developed at the Diagnostic and Evaluation Center of Western Psychiatric Institute and Clinic at the University of Pittsburgh in the 1980s, the CASE Approach was refined at the Department of Psychiatry in the Dartmouth Medical School and in front-line community mental health center work during the 1990s. Subsequent refinements in the 2000s have been implemented at the Training Institute for Suicide Assessment and Clinical Interviewing (TISA).
The CASE Approach has been extensively described in the literature.2-6 Interviewing techniques from the CASE Approach have been positively received among mental health professionals and suicidologists, substance abuse counselors, primary care clinicians, clinicians in the correctional system, legal experts, military/VA mental health professionals, and psychiatric residency directors.7-26 A free training monograph on how to teach the CASE Approach to psychiatric residents and other mental health professionals as well as an article emphasizing the importance of incorporating training in uncovering suicidal ideation in clinical interviewing courses for psychiatric residents and other mental health disciplines has appeared in the literature.27,28
Organizationally, the CASE Approach is a recommended practice by organizations as diverse as Magellan and the government of British Columbia.29,30 It is routinely taught as one of the core clinical courses provided at the annual meeting of the American Association of Suicidology (AAS).31 It is also one of the techniques described in the 1-day Assessing and Managing Suicide Risk (AMSR) course cosponsored by the Suicide Prevention and Resource Center and the AAS and in the 2-day Recognizing and Responding to Suicide Risk course sponsored by the AAS.32,33
The question of validity
The noted social scientist Thomas Kuhn once quipped, “The answers you get depend upon the questions you ask.”34 In no clinical task is this more self-evident than in the elicitation of suicidal ideation, which remains—excluding that subset of patients with characterological disorder who may garner comfort through talk of suicide—one of the most taboo topics in our culture.
Helping patients share this sensitive material in a valid manner becomes one of the cornerstones of the art of eliciting suicidal ideation. Excellent lists of potentially useful questions for uncovering suicidal ideation exist.35 It is important to contemplate not only what material needs to be asked but also what the impact of the phrasing of such questions is on the validity of the data received.