These principles are applied to the elicitation of suicidal ideation by organizing the sprawling set of clinically relevant questions into 4 smaller and more manageable regions. The regions represent 4 contiguous time frames from the distant past to the present, hence the name “chronological.” In each region the clinician investigates the suicidal ideation and actions present during that specific time frame. Generally, each region is explored thoroughly before moving to the next; the clinician consciously chooses not to move with a patient’s tangential wandering unless there is a very good reason to do so. In the description below, the term “suicide events” can include any of the following: death wishes, suicidal feelings and thoughts, planning, behaviors, desire, and intent.
In the CASE Approach (Figure 1) the clinician sequentially explores the following 4 chronological regions in this order:
1. Presenting suicide events (past 48 hours)
2. Recent suicide events (over the preceding 2 months)
3. Past suicide events (from 2 months ago back in time)
4. Immediate suicide events (suicidal feelings, ideation, and intent that arise during the interview itself)
The sequencing of the regions shown in Figure 1 was specifically designed to maximize both engagement and the validity of the obtained data. For most patients, once the topic of suicide has been raised, it seems natural to talk about the presenting ideation or attempt, if one exists, first. Following this exploration, it is easy for the interviewer to make a natural progression into recent ideation followed by past suicide events.
When performed sensitively by the interviewer, explorations of the 3 time frames before the interview generally improve both engagement and trust as the patient realizes that it is okay to talk about suicidal ideation. Once trust has been maximized, it is hoped that this positive alliance will increase the likelihood of the patient sharing valid information. It is then an opportune time to explore suicidal ideation and intentions that are being experienced by the patient during the interview itself, a critically important area of a suicide assessment. Here, the most subtle nuances of facial expression or hesitancy of speech may indicate that a suicide attempt is imminent.
The microstructure of the CASE Approach: exploring specific time frames
When exploring each of the 4 time frames, the CASE Approach addresses 2 complementary aspects of interviewing strategy: (1) Which data are important to gather in this time frame? (2) Which specific validity techniques may be the most valuable for uncovering the desired data and what sequence may enhance their effectiveness?
In this article, a brief but illustrative overview of the exploration of each time frame is presented. This overview emphasizes the required database for each region. In two of the regions—presenting suicide events and recent suicide events—the second aspect, concerning the actual choice of validity techniques and their sequencing, will be delineated in full, including a reconstructed dialogue of the techniques put into action.
For the interested reader, an article that details the recommended interviewing techniques and sequencing for all 4 time frames of the CASE Approach can be found at the TISA Web site (http://www.suicideassessment.com). A word-for-word annotated transcript of the entire CASE Approach used in a patient with a complicated presentation is also available.2