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Suicide Assessment Part 2: Uncovering Suicidal Intent Using the CASE Approach: Page 10 of 17

Suicide Assessment Part 2: Uncovering Suicidal Intent Using the CASE Approach: Page 10 of 17

Step 2: The exploration of recent suicide events

The region of recent events may very well represent—from the perspective of motivational theory—the single richest arena for uncovering reflected intent. It is here that with an ambivalent patient or with a patient who strongly wants to die and is hesitant to share his real intent for fear of what will happen (possible hospitalization, involuntary commitment, or removal of a method of choice) that a skilled interviewer may uncover ideation and planning that provide a more accurate indication of the patient’s real intent, which is being consciously withheld.

It is also the arena when, with a patient whose unconscious defense mechanisms may be minimizing their conscious awareness of the intensity of their real suicidal intent, a more accurate picture of the patient’s intent may emerge. Specifically, the patient’s actions taken toward procuring a method of suicide and/or the amount of time spent preoccupied with suicide may betray the severity of the patient’s real intent better than his or her stated intent would suggest. In my opinion, the ability to explore effectively the region of recent suicide events represents one of the most critical of all clinical interviewing skills for mental health professionals to master. It is also the region of the CASE Approach where all 4 of the cornerstone validity techniques are put to strategic use. Consequently, it warrants some careful delineation.

Sometimes when the clinician raises the topic of suicide with techniques such as normalization or shame attenuation, the patient’s reported events do not lie within the previous 2 days’ time (in essence there are no presenting events), in which case the clinician immediately begins exploring the region of recent events. On the other hand, if the patient had reported a true presenting event, the clinician would have needed to make a bridging statement to transition into the recent suicide events after having explored the presenting event in detail (Figure 2). Often this is initiated by smoothly eliciting any thoughts in the past 2 months related to the same plan that the patient discussed in the presenting events. Once recent thoughts or actions regarding the same method have been explored, a gentle assumption is used to look for a second suicide method. My favorite gentle assumption is the simplest one, “What other ways have you thought of killing yourself?”

If the same plan was also contemplated or a second method is uncovered, sequential behavioral incidents are used to create another verbal videotape reflecting the extent of action taken with this new method. The interviewer continues this use of gentle assumptions, with follow-up verbal videotapes as indicated with each newly uncovered plan, until the patient denies any other methods when asked, “What other ways have you thought of killing yourself?”

Once the use of a gentle assumption yields a blanket denial of other methods, if, and only if, the clinician feels that the patient may be withholding other methods of suicide, the clinician uses a short series of denials of the specific. The interviewer must use his or her clinical judgment to decide whether or not the use of denials of the specific is indicated. None would be warranted if the patient had low risk factors, had high protective factors, and had reported minimal or no suicidal ideation to that point in the interview. On the other hand, if the clinician’s intuition was suggesting that this particular patient may be withholding critical suicidal ideation or planning, then denials of the specific could be employed. This technique can be surprisingly effective at uncovering previously withheld suicidal material. The interviewer doesn’t drive this technique into the ground with an exhaustive series of methods but simply asks for any unmentioned methods that are common to the patient’s culture and of which the clinician is suspicious that this specific patient might be withholding.

By way of example, if the patient has talked about overdosing, guns, and driving a car off the road, the clinician might employ the following short list of denials of the specific, pausing after each for an answer: “Have you thought about cutting or stabbing yourself?” “Have you thought about hanging yourself?” “Have you thought about jumping off a bridge or other high place?” “Have you thought about carbon monoxide?” As before, if a new method is revealed, the clinician uncovers the extent of action taken by asking a series of behavioral incidents. It is here—with the selective and well-timed use of denials of the specific—that a highly dangerous patient, who has been purposefully withholding his method of choice, may suddenly share it, perhaps prompted by a wedge of healthy ambivalence.

After establishing the list of methods considered by the patient and the extent of action taken on each method, the interviewer hones in on the frequency, duration, and intensity of the suicidal ideation with a symptom amplification. He might ask, for example, “Over the past 2 months, during the days when you were most thinking about killing yourself, how much time did you spend thinking about it . . . 70% of your waking hours, 80%? 90%?”

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