The CASE Approach

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What is the CASE Approach?

Concise Description: The Chronological Assessment of Suicide Events (CASE Approach) is an interviewing strategy for uncovering suicidal ideation, planning, actions, and intent developed from innovations in the field of clinical interviewing (e.g. concisely operationalized Validity Techniques; concisely operationalized techniques for sensitively structuring interviews from the field of Facilics; and advanced empathic principles). It was designed to be used by all mental health professionals as well as by primary care clinicians and other allied health providers. It is unique in two ways.

1) The CASE Approach functions as both a rapid, 3-question screening tool for the presence of suicidal ideation that can immediately – and in an engaging and conversational fashion – be flexibly expanded to sensitively uncover a client’s hidden method of choice for suicide (MOC), extent of actions taken using their MOC, and immediate intentions to use the MOC to proceed with suicide in clients at immediate risk (next 24-hours) or imminent risk (next seven days).

2) Unlike semi-structured interview formats, clinicians never use cue sheets – nor record information – while asking the questions used in the CASE Approach. Consequently, the clinician can utilize 100% of their attention for engaging the client while carefully observing for subtle nonverbal indicators that the client is distorting or withholding information, an advantage of critical – sometimes life-saving – importance with clients intent upon suicide.

The design of the CASE Approach allows it to be flexibly utilized as a solo method for screening and comprehensively uncovering suicidal ideation/planning/intent or in conjunction with well-established approaches. For instance, the CASE Approach is an excellent follow-up interview for immediate use after traditional screening tools such as the ASQ or the PHQ-9 identify the presence of suicidal ideation (SI). Through the use of the validity techniques of the CASE Approach, it can also be easily utilized to ensure the validity and comprehensiveness of the SI data base demanded by Part-B of the SSF-5 of the CAMS.

Intensive online training allows for the initial scaling and ongoing sustainability and implementation of the CASE Approach across various settings such as hospitals, emergency departments, mental health/primary care clinics, private practice settings, school counseling centers, and crisis lines as well as training centers (such as psychiatric residencies, graduate programs in clinical psychology, social work and counseling, and medical/nursing schools).

A look into the techniques and strategies of the CASE Approach

Structurally, in the CASE Approach interviewers explore four chronological regions regarding the client’s suicidal ideation in a sequential order. The delineation of the lifelong suicidal history of the client into four discrete, smaller regions, helps the clinician to sensitively stay-on-task while decreasing clinician errors of omission – errors that can prove costly in suicide assessment.

The four time frames are explored in the following sequence: 1) Region of Presenting Suicide Events (suicidal ideation or plan that the client presents when the topic of suicide is first raised by the clinician – only this initially shared method is explored in this region), 2) Region of Recent Suicide Events (additional ideation, methods, plans, or actions that the client reports experiencing over the previous two months), 3) Region of Past Suicide Events (past suicide attempts focusing primarily on the most serious attempt), and 4) Region of Immediate Suicide Events (suicidal ideation and intent immediately being experienced during the interview itself.

Macrostructure of the CASE Approach: Sequential Flow

Clinicians well-trained in the CASE Approach are able to skillfully explore each of the four chronological regions by sensitively interweaving seven innovative interviewing techniques from the field of clinical interviewing called Validity Techniques. These techniques include Normalization, Shame Attenuation, the Behavioral Incident, Gentle Assumption, Denial of the Specific, The Catch-All Question, and Symptom Amplification. The heart and soul of the CASE Approach is the graceful and flexible fashion in which clinicians interweave these Validity Techniques to meet the needs of each unique client within each of the four chronological regions of the CASE Approach.

In the Region of Presenting Suicide Events, the goal is to sensitively raise the topic of suicide and to explore – via the Validity Techniques – the extent of actions taken on that specific method, which may not be the client’s method of choice for suicide (MOC). The extent of the actions taken can be a telling reflection of the client’s intent.

In the Region of Recent Suicide Events, the clinician will carefully hunt for other methods that are contemplated, one of which, in a particularly high-risk client may have been a potentially withheld MOC. Various Validity Techniques are interwoven and repeated in specific sequences that have been shown to enhance the sharing of suicidal ideation. This flexible sequencing of the Validity Techniques is particularly important, for this is the region where high-risk clients will often reveal a hidden MOC.

In the Region of Past Suicide Events, the clinician focuses, not on the entire history of suicide attempts, but on the most lethal attempt to see if the stressors that triggered that attempt are similar to the client’s current stressors and the MOC is the same now as then. Both of which may indicate increased risk.

In the Region of Immediate Suicide Events, the clinician explores, via the Validity Techniques, the client’s suicidal thoughts that have arisen during the interview itself, including a careful exploration of hopelessness, feelings of entrapment, and intent to act on suicidal thoughts after leaving the assessment.

Where can I learn more about the CASE Approach?

TISA offers both a Basic and an Advanced Online Course on the CASE Approach. Please contact us for more information on our other training options.