The problem of maximizing validity was addressed in the development of the CASE Approach by returning to the core clinical interviewing literature where specific “validity techniques”—created to uncover sensitive and taboo material such as incest and substance abuse—had been described in detail. These techniques were designed by experts in various disciplines, including psychiatry, clinical psychology, and counseling.
Validity techniques are used throughout the CASE Approach and emphasize not only the impact of what we ask, but of how we ask it. Consequently, to understand the practical use of the CASE Approach it is first important to review those validity techniques used to sensitively raise the topic of suicide and also those used to explore the patient’s suicidal planning and behaviors once the topic has been raised.
Two validity techniques for sensitively raising the topic of suicide
Before one can explore a patient’s suicidal ideation, the topic must first be addressed. Sometimes patients do so spontaneously. In other instances, the interviewer must raise the topic in a fashion that is both engaging and likely to foster open sharing. Two validity techniques may prove to be of value here: normalization and shame attenuation.
Normalization (the process of normalizing the topic for the patient) is an unobtrusive method of raising the issue of suicide.3 The clinician can relate that he or she has had patients who were undergoing pains and/or stresses similar to those of the current interviewee and share that they had experienced suicidal thoughts. The clinician might say, “You know, Mike, some of my patients, when they are feeling as stressed out and depressed as you have been feeling, tell me that they sometimes get thoughts of killing themselves. I’m wondering if you’ve been having any thoughts like that recently?” or simply “Sometimes when people feel as much pain as you are feeling, they have thought of killing themselves, has that happened to you?”
A related but slightly different method is to use the validity technique called shame attenuation.3 With normalization, the patient is always asked to look at what other people have felt. With shame attenuation, the patient’s own pain is used as the gateway to the topic of suicide. The clinician might ask, “Considering all of the pain you’ve been feeling in the past couple of weeks, I’m wondering if you have had any thoughts of killing yourself?”
Both techniques are effective and engaging. Whichever one feels most comfortable to the interviewer and/or may be best suited for a specific patient can be used. Sometimes patients who may be feeling awkward about having suicidal ideation (secondary to stigmatization) may respond particularly well to the reassurance that other people have had such feelings. If the patient denies any suicidal ideation, ask a second time, softening the second inquiry by asking for even subtle suicidal ideation, “Have you had fleeting thoughts of suicide, even for a moment or two?” Sometimes the answer is surprising, and it may prompt hesitant patients to begin sharing the depth of their pain and the extent of their ideation.
Four cornerstone validity techniques used to explore the extent of suicidal ideation
The following four validity techniques although not developed with suicide assessment per se in mind, form the cornerstones of the CASE Approach:
• Behavioral incident
• Gentle assumption
• Symptom amplification
• Denial of the specific
These techniques were devised to increase the likelihood of eliciting a valid response to any question that might raise sensitive or taboo material for the patient.
The techniques were created to help clinicians explore traditionally sensitive histories, including sexual abuse, physical and psychological abuse, alcohol(Drug information on alcohol) and drug use, and violence and antisocial behavior. Consequently, in addition to being useful in eliciting suicidal ideation, these validity techniques are “the bread and butter” of busy mental health professionals, substance abuse counselors, crisis line workers and counselors, and primary care clinicians whose patients often have sensitive issues they hesitate to discuss.
A patient may provide distorted information for any number of reasons, including anxiety, embarrassment, protecting family secrets, unconscious defense mechanisms, or conscious attempts at deception. These distortions are more likely to appear if the interviewer asks a patient for opinions rather than behavioral descriptions of events.
Behavioral incidents, originally described by Gerald Pascal,36 are questions that ask for specific facts, behavioral details, or trains of thought (called fact-finding behavioral incidents), such as, “How many pills did you take?” or that simply ask the patient what happened sequentially (called sequencing behavioral incidents), such as, “What did she say next?” or “What did your father do then?” By using a series of behavioral incidents, the interviewer can sometimes help a patient enhance validity by re-creating, step by step, the unfolding of a potentially taboo topic such as a suicide attempt.