Suicide Assessment Part 2: Uncovering Suicidal Intent Using the CASE Approach
The CASE Approach is built to uncover pieces of a puzzle that enhance the likelihood of an accurate clinical formulation of risk.
The Equation of Suicidal Intent, which was introduced in
• Stated intent: what the patient directly tells the clinician about his or her suicidal intent
• Reflected intent: the amount of thinking, planning, or actions taken on suicidal ideation that may reflect the intensity of the actual suicidal intent
• Withheld intent: suicidal intent that is unconsciously or purposefully withheld from the clinician
Reflected intent was defined as the quality and quantity of the patient’s suicidal thoughts, desires, plans, and extent of action taken on those plans, which may reflect how much the patient truly wants to commit suicide. The extent, thoroughness, and time spent by the patient on suicidal planning may, not in all, but in some patients be a better reflection of the seriousness of their intent and the proximity of their desire to proceed on that intent than the patient’s actual stated intent. Such reflections of intent may prove to be lifesaving pieces of the suicide assessment puzzle.
The interviewing strategy known as the Chronological Assessment of Suicide Events (the CASE Approach) was designed to minimize the likelihood that at the time of risk formulation, such essential pieces of the puzzle would be missing. The goal was to create a practical interviewing strategy that could be reliably used to maximize the validity of the patient’s stated and reflected intent while minimizing withheld intent-no matter how tired or overwhelmed the clinician might be or how hectic the clinical environment may have become. The ultimate goal of the interviewing strategy is to help the clinician determine the patient’s actual suicidal intent.
Key design elements and development
The CASE Approach is a flexible, practical, and easily learned interviewing strategy for eliciting suicidal ideation, planning, behavior, desire, and intent. It was developed to help the clinician explore both the patient’s inner pain and the suicidal planning that often reflects this pain. It was specifically designed to help transform the hindrances that often block the open sharing of suicidal intent. Used effectively, it may lead a seriously dangerous patient-predisposed to withhold his suicidal intent-to share his intent. It may also help clinicians to determine more accurately the dangerousness of a patient by bringing to the surface hidden elements of the patient’s reflected intent.
For clinicians, the practical problems related to uncovering a valid history of suicidal ideation, behaviors, desire, and intent are compounded by the hectic clinical settings of contemporary practice. The time constraints related to managed care pressures, the increased workloads necessitated by down-staffing, and an increasingly litigious society combine to place additional pressures on clinicians who may already be under considerable stress.
Moreover, complicated suicide assessments have a knack for occurring at the “wrong” times: in the middle of an extremely hectic clinic day or in the chaotic environment of a packed emergency department (ED) or crisis line center. And the stakes are high. An error can result in not only an unnecessary death-a terrible tragedy-but also in a lawsuit, much less important but very disturbing in its own right. In many suicide assessment scenarios, we find a harried clinician performing a difficult task, under extreme pressure, in an unforgiving environment. No wonder mistakes are made.
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.
Background
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.
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 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.
Behavioral incident
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.
As Pascal states, it is generally best for clinicians to make their own clinical judgments on the basis of the details of the story itself rather than relying on patients to proffer “objective opinions” on matters that have strong subjective implications. The following are prototypes of typical behavioral incidents:
• Did you put the razor blade up to your wrist? (fact-finding behavioral incident)
• How many bottles of pills did you actually store up? (fact-finding behavioral incident)
• When you say that “you taught your son a lesson” what did you actually do? (fact-finding behavioral incident)
• What did your father say right after he hit you? (sequencing behavioral incident)
• Tell me what happened next? (sequencing behavioral incident)
Clinical caveat: Behavioral incidents are outstanding at uncovering hidden information, but they are time-consuming. For instance, the time it would take to do a full initial intake only using behavioral incidents would be impractical. Obviously, the interviewer must pick and choose when to employ behavioral incidents, with a heavy emphasis on use when sensitive areas such as drug abuse, domestic violence, and suicide assessment are at issue.
Gentle assumption
Gentle assumption (originally delineated by Pomeroy and colleagues37 for use in eliciting a valid sex history) is used when a clinician suspects that a patient may be hesitant to discuss a taboo behavior. With gentle assumption, the clinician assumes that the potentially embarrassing or incriminating behavior is occurring and frames his question accordingly, in a gentle tone of voice.
Questions about sexual history, such as, “What do you experience when you masturbate?” or “How frequently do you find yourself masturbating?” have been found to be much more likely to yield valid answers than, “Do you masturbate?” If the clinician is concerned that the patient may be potentially disconcerted by the assumptive nature of the question, it can be softened by adding the phrase “if at all” (eg, “How often do you find yourself masturbating, if at all?”). If engagement has gone well and an appropriate tone of voice is used, patients are seldom bothered by gentle assumptions. The following are prototypes of gentle assumption:
• What other street drugs have you ever tried?
• What other types of vandalism have you been involved in?
• What kinds of problems have you ever had at work?
• What other ways have you thought of killing yourself?
Clinical caveat: Gentle assumptions are powerful examples of leading questions. The clinician must use them with care. They should not be used with patients who may feel intimidated by the clinician or with patients who are trying to provide what they think the clinician wants to hear. For instance, they are inappropriate with children when uncovering abuse histories because they could potentially lead to false memories of abuse.
Denial of the specific
After a patient has denied a generic question, it is surprising how many positives will be uncovered if the patient is asked a series of questions about specific entities. This technique appears to jar the memory, and it also appears to be harder to falsely deny a specific as opposed to a generic question.3 Examples of denial of the specific, concerning drug use, would be: “Have you ever tried cocaine?” “Have you ever smoked crack?” “Have you ever used crystal meth?” and “Have you ever dropped acid?” The following are prototypes of denial of the specific:
• Have you thought of shooting yourself?
• Have you thought of overdosing?
• Have you thought of hanging yourself?
Clinical caveat: It is important to frame each denial of the specific as a separate question, pausing between each inquiry and waiting for the patient’s denial or admission before asking the next question. The clinician should avoid combining the inquiries into a single question, such as, “Have you thought of shooting yourself, overdosing, or hanging yourself?” A series of items combined in this way is called a “cannon question.” Such cannon questions frequently lead to invalid information because patients only hear parts of them or choose to respond to only one item in the string-often the last one.
Symptom amplification
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.
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.
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