The CASE Approach
The Chronological Assessment of Suicide Events
The art of suicide assessment is composed of three tasks: 1) gathering information related to the risk factors for suicide, 2) gathering information related to the patient’s suicidal ideation and planning, and 3) the clinical decision making that is subsequently applied to these two databases. Errors can occur in any of these three tasks. Much attention has been given to the first and third tasks.
Much less attention has been given to the practical art of eliciting suicidal ideation. But in many respects, it is the validity of this elicited information that is the cornerstone of suicide assessment. If the client does not invite the clinician into the nitty-gritty details of his or her suicidal planning and intent, the best clinician in the world, armed with the best risk factor analysis available, can only
offer a tentative guess as to the patient’s immediate dangerousness. Moreover, there is little doubt that two clinicians, after eliciting suicidal ideation from the same patient, can walk away with a surprisingly different database depending upon how the questions were phrased and the degree with which the patient felt comfortable discussing his or her suicidal ideation.
The CASE Approach is a flexible, practical, and easily learned interview strategy for eliciting suicidal ideation, planning, and intent. It is designed to increase validity, decrease errors of omission, and increase the client’s sense of safety with the interviewer. The techniques and strategies of the CASE Approach are concretely behaviorally defined. Consequently it can be readily taught and the skill level of the clinician easily tested and documented for quality assurance purposes.
What specific problems does the CASE Approach address and what were the design goals?
As clinicians, the practical problems related to uncovering a valid history of suicidal ideation are compounded by the hectic clinical settings in which we find ourselves practicing. The time constraints related to managed care pressures, the down-staffing that causes increased workloads, and our increasingly litigious society put pressures on us when we are already heavily pressured.
Moreover, complicated suicide assessments have a knack for occurring at “wrong” times: in the middle of an extremely hectic clinic day or in the chaotic environment of a packed emergency room. 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.
Among the more common errors that occur during the elicitation of suicidal ideation are: omissions, distortions, and assumptions — a potentially deadly combination. In my experience, most errors in suicide assessment do not result from a poor clinical decision. They result from a good clinical decision being made from a poor database.
With the CASE Approach the goal has been to create a practical interviewing strategy that can be reliably utilized no matter how tired or overwhelmed the clinician may be or how hectic the clinical environment may have become. To be effective such an interview strategy should accomplish the following goals:
- the approach should be easily learned
- the approach should be easily remembered
- the approach should not require written prompts
- the approach should help to ensure that the large database regarding suicidal ideation is comprehensively covered (e.g. it decreases errors of omission)
- the approach should increase the validity of the information elicited from the patient (whether this information be a denial of suicidal ideation or an explication of the extent of ideation and planning)
- the approach should be easily taught and the skill level of the clinician easily tested
- the approach should be behaviorally concrete enough that it can subsequently lend itself to empirical research
The CASE Approach is one such method. It is not presented as the “right way” to elicit suicidal ideation. It is presented merely as “a reasonable way”. From an understanding of the CASE Approach clinicians can directly adopt what they like and reject what they do not like. The goal is not to present a cookbook way of interviewing but to excite the clinician to discover his or her own way of strategically eliciting suicidal ideation.
Where can I learn more about the CASE Approach?
Click here for a 2-part article on the CASE Approach and uncovering suicidal intent.
The most detailed and user friendly description of the CASE Approach can be found in Chapter 6 of The Practical Art of Suicide Assessment An attempt was made to fill this text with sample questions, effective strategies, case histories, and excerpts from actual suicide assessments. Earlier chapters of the book focus on the risk factors, etiologies, and phenomenologies of differing suicidal states from those seen with psychosis to borderline personality disorder. The text also leads the clinician into a self-exploration of his or her beliefs, biases, and unconcious fears concerning the topic of suicide. In this regard an attempt is made to prepare the clinician to gracefully handle one of the most difficult of all client questions, “Do you think it is okay to kill yourself?”
The CASE Approach is also delineated in the chapter on the risk assessment of suicide in Chapter 17 of Psychiatric Interviewing: the Art of Understanding, 3rd Edition. In the chapter on violence assessment, Chapter 18, it is also shown how the principles of the CASE Approach can be easily modified for the assessment of potentially violent patients, such as with criminal, school, or domestic violence, in which instance the modified interview strategy is called the Chronological Assessment of Dangerous Events (the CADE Approach).
TISA provides critically acclaimed workshops given by Dr. Shea on suicide assessment, as well as experiential trainings resulting in certification in the CASE Approach. Click here to learn more about these educational opportunities from TISA. These workshops are specially designed to meet the unique needs of differing professionals including mental health professionals, school counselors, and primary care providers.
“The CASE Approach provides a strikingly graceful and sensitive way to actively explore the client’s hidden world of suicidal ideation and intent. In over 30 years of training psychologists, social workers, and psychiatric residents it is, without a doubt, the most practical and engaging clinical strategy I have ever passed on to my students. I am convinced it will save lives.”
Bruce Baker, D.Ed.
Multiple year winner: Outstanding Teacher Award
Dartmouth Medical School