This technique is based on the observation that patients often minimize the frequency or amount of their disturbing behaviors, such as the amount they drink or the frequency with which they gamble. Symptom amplification bypasses this minimizing mechanism: it sets the upper limits of the quantity in the question at such a high level that the clinician is still aware that there is a significant problem when the patient downplays the amount.3 For a question to be viewed as symptom amplification, the clinician must suggest an actual number.
For instance, when a clinician asks “How much liquor can you hold in a single night. . . a pint? a fifth?” and the patient responds, “Oh no, not a fifth, I don’t know, maybe a pint,” the clinician is still alerted that there is a problem despite the patient’s minimizations. The beauty of the technique lies in the fact that it avoids the creation of a confrontational atmosphere, even though the patient is patently minimizing behavior. It always involves the interviewer suggesting a specific number, set high.
It is worth repeating that symptom amplification is used in an effort to determine an actual quantity and it is only used if the clinician suspects that the patient is about to minimize. It would not be used with a client who wanted to “maximize,” as with an adolescent who might want to give the impression that he is a “big-time drinker.” The following are examples of symptom amplification.
• How many physical fights have you had in your whole life . . . 25, 40, 50?
• How many times have you tripped on acid in your whole life . . . 25, 40, 100 times or more?
• On the days when your thoughts of suicide are most intense, how much of your time do you spend thinking about killing yourself . . . 70% of your waking hours, 80%, 90%?
Clinical caveat: The clinician must be careful not to set the upper limit at such a high number that it seems absurd or creates the appearance that the interviewer doesn’t know what he or she is talking about.
The macrostructure of the CASE Approach: avoiding errors of omission
The patient’s history of suicidal ideation and actions can appear, at first glance, as a sprawling hodgepodge of details spanning the patient’s life. The gathering of this vital information in a short period while attending to the delicate issues regarding patient engagement is a daunting task.
Besides invalid data, the other major problem for the front-line clinician is missing puzzle pieces, ie, errors of omission. A 2-part question faced the developers of the CASE Approach, “Why do interviewers frequently miss important data while eliciting suicidal ideation? Is there a way to decrease such errors of omission?”
The answers lie in a field of study known as facilics. Facilics is the study of how clinicians effectively structure interviews and has given rise to the supervision method known as “facilic supervision.” This is a supervision system designed to train clinicians to uncover a comprehensive database while ensuring that the patient feels that he has been talking with a caring clinician rather than “being interviewed” by some guy with a clipboard.
From a technical standpoint, facilics is the study of how clinicians structure interviews, explore databases, make transitions, and use time. Over the past 20 years, facilic supervision has become a popular tool.3,28,38,39 It is used to train psychiatric residents and clinicians across disciplines to efficiently and sensitively perform an initial interview—including a DSM-IV-TR differential and a bio-psycho-social-spiritual overview.40
According to facilic principles, clinicians tend to make more errors of omission as the amount and range of required data increase. Errors of omission decrease if the clinician can split a large amount of data into smaller, well-defined regions. With such well-defined and limited data regions, the interviewer can more easily recognize when a patient has wandered from the subject. The clinician is also more apt to easily track whether the desired inquiry has been completed and does not feel as overwhelmed by the interview process.
If the desired data within each region is logically chosen, the databases make innate sense to the interviewer and require little memorization. Such a simplified interview format is easily learned and hard to forget, and it provides a reliable interview strategy available on a consistent basis no matter how stressed the clinician may feel.