For these reasons, it is useful to find answers to the questions described above if an attempt has occurred, or if one has not, a detailed uncovering of suicidal ideation and reflected intent is helpful. At first glance, especially for a clinician in training, this list of questions may appear intimidating to remember. Fortunately, one of the validity techniques discussed earlier—the behavioral incident—can provide the clinician with a simpler and more logical approach than memorization. The reader will recall that behavioral incidents are used when the clinician asks for a specific piece of data (eg, “Did you put the gun up to your head?”) or asks the patient to continue a description of what happened sequentially (eg, “Tell me what you did next”).
In the CASE Approach, during the exploration of the presenting events, the interviewer asks the patient to describe the suicide attempt or ideation itself from beginning to end. During this description the clinician gently, but persistently, uses a series of behavioral incidents guiding the patient to create a “verbal videotape” of the attempt, step by step. Readers familiar with cognitive behavioral therapy (CBT) and dialectical behavioral therapy will recognize this strategy as one of the cornerstone assessment tools—behavioral analysis.
If the patient begins to skip over an important piece of the account, the clinician gently stops the patient. The clinician “rewinds the videotape” by asking the patient to return to where the gap began. The clinician then uses a string of behavioral incidents from that point forward to fill in the gap, until the clinician feels confident that he has an accurate picture of what happened.
This serial use of behavioral incidents not only increases the clinician’s understanding of the extent of the patient’s intent and actions, it also decreases any unwarranted assumptions by the clinician that may distort the database. Creating such a verbal videotape, the clinician will frequently cover all of the material described above in a naturally unfolding conversational mode, without much need for memorization of what questions to ask when.
The serial use of behavioral incidents can be particularly powerful at uncovering the extent of action taken by the patient regarding a specific suicide plan, an area in which patients frequently minimize. For example, the series may look something like this in a patient who actually took some actions with a gun: “Do you have a gun in the house?” “Have you ever gotten the gun out with the intention of thinking about using it to kill yourself?” “When did you do this?” “Where were you sitting when you had the gun out?” “Did you load the gun?” “What did you do next?” “Did you put the gun up to your body or head?” “Did you take the safety off or load the chamber?” “How long did you hold the gun there?” “What thoughts were going through your mind then?” “What did you do then?” “What stopped you from pulling the trigger?”
In this fashion, the clinician can feel more confident at obtaining a valid picture of how close the patient actually came to committing suicide. The resulting scenario may prove to be radically different—and more suggestive of imminent danger—from what would have been assumed if the interviewer had merely asked, “Did you come close to actually using the gun?” to which an embarrassed or cagey patient may quickly reply, “Oh no, not really.” Once again, an example of reflected intent being potentially more accurate than the patient’s stated intent.
Also note, in the above sequence, the use of questions such as, “When did you do this?” and “Where were you sitting when you had the gun out?” These types of questions, also borrowed from CBT, are known as “anchor questions” for they anchor the patient into a specific memory as opposed to a collection of nebulous feelings. Such a refined focus will often bring forth more valid information as the episode becomes both more real and more vivid to the patient.
The exploration of presenting suicide events can be summarized as follows. The clinician begins with a question, such as, “It sounds like last night was a very difficult time. It will help me to understand exactly what you experienced if you can sort of walk me through what happened step by step. Once you decided to kill yourself, what did you do next?”
As the patient begins to describe the unfolding suicide attempt, the clinician uses 1 or 2 anchor questions to maximize validity. The interviewer then proceeds to use a series of behavioral incidents, making it easy to picture the unfolding events—the “verbal videotape.” The strategy and the metaphor of making a verbal video tape has been quite popular with residents and graduate students, as well as front-line staff, for the clinical task seems clear and is easily remembered even at 3 am in a busy ED. The best way to further our understanding of exploring the region of presenting events using the CASE Approach is to see the strategy in action.
Clinical illustration of Step 1: exploring the region of presenting suicide events (past 48 hours)
Frank Thompson is a good soul. He is also a tired soul. He commented to the charge nurse, “I’ve had a good life, I don’t know, maybe it’s just time to pass on.” Frank has been a farmer in the rolling hills of western Pennsylvania for over 5 decades. His dad was a farmer. His grandfathers were both farmers. He was married to a wonderful woman, Sally, for 50 years. She died of brain cancer 2 years ago. Frank is plagued by diabetes and moderately severe heart and lung disease from having sucked on far too many cigarettes for far too many years. He occasionally uses oxygen to help with his labored breathing. Frank has had 7 hospitalizations since Sally died. Since her death, he has developed a mild drinking problem. On top of it all, there is a chance that he is going to lose his farm to foreclosure.
