Psych CASC / OSCE · Emergency psychiatry — self-harm and crisis
Assess self-harm and co-create a crisis safety plan — CASC communication station
MRCPsych/FRANZCP-style CASC: non-stigmatising self-harm assessment, intent continuum, Stanley-Brown safety plan, means restriction, and clear aftercare without no-suicide contracts or graphic method coaching.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes active time after reading. You are the psychiatry registrar in the emergency department. The patient is medically cleared. [1]
Candidate instructions. Establish rapport using non-stigmatising language. Assess the self-harm episode including intent continuum and functions. Explore current risk, supports, and means. Collaboratively create a safety plan including means restriction and crisis contacts. Agree follow-up. Do not use a no-suicide contract. Avoid graphic method coaching. Check understanding. The examiner plays the patient. [1][2]
Candidate scenario
Your patient is 24 years old. Last night after a breakup they cut their forearm and took a handful of ibuprofen. They say: "I wasn’t trying to kill myself — I just needed the feelings to stop. I’m fine now. I want to go home. My flatmate has no idea. There are more painkillers in the bathroom." They have cut on and off for a year when overwhelmed. No prior psychiatric admission. [2][4]
Marking domains
- Empathy, calm pace, non-stigmatising language (no "attention-seeking")
- Direct enquiry about intent to die then and now, expectation of outcome, ongoing ideation
- Exploration of NSSI functions (affect regulation) and stressors
- Protective factors, supports, substances
- Collaborative safety plan (warning signs, coping, people, professionals, means, reasons for living)
- Means restriction for medications; involve flatmate with consent if safe
- Clear follow-up and crisis pathway; summarises and checks understanding
- Avoids no-suicide contract and graphic method detail [1][3]
Reveal assessor key
Open. Thank them for talking; normalise that many people use self-harm to cope with overwhelming feelings; state you need to understand safety before discharge. [2]
Assess. "When you hurt yourself last night, what were you hoping would happen?" "Did any part of you want to die?" "How do you feel about that now?" Map frequency of cutting, triggers, alcohol, sleep, mood, reasons for living. Quote content mentally for notes. [4]
Functions. Link cutting to calming unbearable feelings; introduce that skills and a written plan can replace the behaviour over time without shaming. [2]
Safety plan. Co-write SPI steps; local crisis numbers; flatmate as optional support if they consent to contact; remove excess analgesics (pharmacy disposal or flatmate holding). Give them the written plan. [1]
Close. Summarise residual risk formulation; book urgent follow-up; explain when to return to ED; invite questions. If intent escalates or means cannot be secured, escalate to crisis team/admission pathway. Emphasise that psychosocial assessment and a plan are part of good care after self-harm, not a barrier. [1][3]
References
- [1]Stanley B, Brown GK, Brenner LA, et al. Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department JAMA Psychiatry, 2018.PMID 29998307
- [2]Klonsky ED The functions of deliberate self-injury: a review of the evidence Clin Psychol Rev, 2007.PMID 17014942
- [3]Kapur N, Steeg S, Turnbull P, et al. Hospital management of suicidal behaviour and subsequent mortality: a prospective cohort study Lancet Psychiatry, 2015.PMID 26254717
- [4]Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults Am J Psychiatry, 2011.PMID 22193671