TCR: Dr. Shea, in your classic book, The Practical Art of Suicide Assessment (John Wiley & Sons, 2002), you describe the CASE approach to evaluating suicidal ideation. What is the CASE approach?
Dr. Shea: CASE stands for the “Chronological Assessment of Suicide Events.” It is an interviewing strategy for systematically eliciting the presence of suicidal ideation.
TCR: What, specifically, do you mean by “suicide events”?
Dr. Shea: By the word “events” we mean any suicidal ideation, plans, gestures, actual behaviors, even death wishes. So it is really quite comprehensive.
TCR: And what are the basic steps in the CASE approach?
Dr. Shea: We start by exploring with the patient the presenting suicidal ideation, which would be any suicidal thoughts they had in the past 24 to 48 hours. We then move on to the recent suicidal ideation, which we define as any suicidal thoughts and intent over the past two months. After carefully exploring this area, we move into all the past suicidal ideation that one thinks is pertinent to making the triage decision. And then, the fourth category is to move back into the immediate events–what types of suicidal thoughts the client is actually having during the interview itself.
TCR: As clinicians, we often have the experience of evaluating a patient who presents with suicidal ideation, only to find that this ideation may be chronic and thus not necessarily as worrisome as it appeared at first. It sounds like the CASE approach would be very helpful in these situations.
Dr. Shea: The beauty of the CASE approach is that when you gather a good chronological database on suicidal ideation and intent, you have a sort of “fingerprint” of what suicidal intent looks like for that particular patient, and it is the familiarity with that client’s fluctuations that can be pivotal in being effective in spotting when there is an important change. So you get a very good picture of what this unique human being thinks about when contemplating suicide, and you are going to get an idea of what it looks like when it starts to intensify before an attempt or an actual gesture, as opposed to what it looks like at baseline. So it is actually very effective at helping patients who have chronic suicidal ideation.
TCR: I would expect that this approach also helps us to be more systematic about our assessments.
Dr. Shea: Yes, by encouraging us to go through four chronological areas, it tends to decrease errors of omission. In addition, in the CASE approach we give suggestions about how to actually sequence the questions in each interviewing region and we describe validity techniques that have been developed by interviewers over the past several decades that we think are particularly good at uncovering sensitive material.
TCR: I’ve read about some of these techniques in your wonderful textbook, Psychiatric Interviewing: The Art of Understanding (W.B. Saunders Co., 1998). Can you outline a couple of validity techniques as they pertain to assessing suicidality?
Dr. Shea: There are four validity techniques that are the main components of the CASE approach: The behavioral incident, gentle assumption, denial of the specific, and symptom amplification. We find that these interviewing techniques are important because there is such a taboo about sharing suicidal ideation. The patient may fear that you will pass a judgment that it is unethical or immoral, or that you will hospitalize them, or that somehow their confidentiality will be broken, or that you will see suicidal ideation as a sign of weakness. So you may have a very hesitant client who doesn’t want to share this information.
TCR: Can you give an example?
Dr. Shea: Sure. Let’s say your client has mentioned to you that he has thoughts of killing himself and that he has a gun at home. If you ask an opinion-oriented question, such as, “Have you ever come close to using the gun?” the hesitant client may quickly say, “Oh, no, I was never close to doing that.” Well that might be valid or that might be invalid; that is just simply their opinion. Instead, in the behavioral incident technique, we simply want to get patients to describe what happened and then we will make the clinical judgment about whether they were close or not close. So, rather than asking the patient “Did you come close to shooting yourself,” you would say, “Where do you keep the gun?” And so they would describe where they keep the gun…in a drawer, or beside their bed or whatever. And then you would say, “Did you ever get the gun out with the actual thought of perhaps using it to shoot yourself?” And if they say they did, you would ask, “Where were you sitting when you did that?” That is called an “anchor question”–by anchoring them into a specific room, you are going to make sure they are actually thinking about a memory not just a combination of different vague feelings. So the client says, “Well I was actually up in my bedroom.” Then you would say, “Well, when you were holding the gun, did you load the gun?” And then if he said he did load the gun, you would say, “What did you do next?” If he said, “I put it up against my head,” you would say, “While you were holding the gun at your head, what thoughts were going through your mind?” It’s helpful to become very specific, even asking something like, “While you were holding the gun to your head, did you click the safety off or had you loaded the chamber?” Because clearly people who load the chamber of a semiautomatic or click the safety off are one step closer to pulling the trigger and killing themselves. Then you would ask, “How long did you hold the gun up to your head and what made you put the gun down?” I think it is pretty obvious that nine times out of ten, the clinician who asks a series of behavioral incidents like that is going to get more valid information than a clinician who simply asks, “Did you come close to shooting yourself?”
TCR: You also mentioned the “gentle assumption” technique. What would be an example of gentle assumption in the suicide assessment?
Dr. Shea: This technique is helpful when we are trying to get an idea about the number of suicide plans and the degree to which they have been thought out. So for example, let’s say a client told you that she had thought of overdosing, and you want to find out if she has developed any other suicide plans. A commonly asked question would be, “Have you thought of other ways of killing yourself?” With the gentle assumption, you simply transform that phrase into, “What other ways of killing yourself have you thought about?”
TCR: Because you are assuming that a typical suicidal person has thought about various ways of harming herself.
Dr. Shea: Definitely. In my ER work, I have found that it is common for people to consider different techniques, and to rule some in and others out.
TCR: Now one of the issues I think a lot of clinicians struggle with is how to deal with patients who have significant suicidal ideation, but it’s not entirely clear that they are committable. Do you have any tips for these situations? How can we rapidly instill a sense of hopefulness?
Dr. Shea: First it’s important to realize that too frequently people try to instill hope before they have completed the assessment and that, I think, can be an unfortunate move. If a clinician prematurely says something to a patient like, “I have worked with lots of people and they don’t have to act on these feelings, and I think you will find that to be true,” the problem is that some patients will react with the thought, “You don’t understand my pain. I am not like other patients.” So I recommend that the instilling of hope occur after you have done a good suicide assessment. And I’ll typically begin that process by saying something like, “Let’s try to see what other ways, besides suicide, might be available to decrease this pain for you.” If they feel that this is a clinician who is not just sitting there saying it is wrong to kill yourself but that he or she understands that coming up with the thought of suicide is an effort to relieve pain, that can make a big difference in the quality of the alliance.
TCR: Do you have any tips on how to sensitively discuss hospitalization if that seems necessary?
Dr. Shea: When the alliance has been built up well, I have found that it is vastly easier to convince the person to voluntarily enter the hospital. And even if that can’t be done, I believe it is much easier to go through with the commitment and have the patient understand better why it is being done. You can say, “It is obvious at this point that you do want to kill yourself and I don’t believe that I am someone who can convince you differently of that and you are entitled to have this thought. At this point in time, my role is to make sure that you are in a safe environment where you have a chance to look for the other options that you and I have been talking about instead of suicide. And so, my feeling is that I am going to have to move towards the idea of bringing you into the hospital, even if it is against your will, and I just want you to know that I am doing that because I care about you, and because I believe that there are other options for you beside suicide.”