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Suicide Assessment Part 2: Uncovering Suicidal Intent Using the CASE Approach: Page 4 of 17

Suicide Assessment Part 2: Uncovering Suicidal Intent Using the CASE Approach: Page 4 of 17

As Pascal states, it is generally best for clinicians to make their own clinical judgments on the basis of the details of the story itself rather than relying on patients to proffer “objective opinions” on matters that have strong subjective implications. The following are prototypes of typical behavioral incidents:

• Did you put the razor blade up to your wrist? (fact-finding behavioral incident)

• How many bottles of pills did you actually store up? (fact-finding behavioral incident)

• When you say that “you taught your son a lesson” what did you actually do? (fact-finding behavioral incident)

• What did your father say right after he hit you? (sequencing behavioral incident)

• Tell me what happened next? (sequencing behavioral incident)

Clinical caveat: Behavioral incidents are outstanding at uncovering hidden information, but they are time-consuming. For instance, the time it would take to do a full initial intake only using behavioral incidents would be impractical. Obviously, the interviewer must pick and choose when to employ behavioral incidents, with a heavy emphasis on use when sensitive areas such as drug abuse, domestic violence, and suicide assessment are at issue.

Gentle assumption

Gentle assumption (originally delineated by Pomeroy and colleagues37 for use in eliciting a valid sex history) is used when a clinician suspects that a patient may be hesitant to discuss a taboo behavior. With gentle assumption, the clinician assumes that the potentially embarrassing or incriminating behavior is occurring and frames his question accordingly, in a gentle tone of voice.

Questions about sexual history, such as, “What do you experience when you masturbate?” or “How frequently do you find yourself masturbating?” have been found to be much more likely to yield valid answers than, “Do you masturbate?” If the clinician is concerned that the patient may be potentially disconcerted by the assumptive nature of the question, it can be softened by adding the phrase “if at all” (eg, “How often do you find yourself masturbating, if at all?”). If engagement has gone well and an appropriate tone of voice is used, patients are seldom bothered by gentle assumptions. The following are prototypes of gentle assumption:

• What other street drugs have you ever tried?

• What other types of vandalism have you been involved in?

• What kinds of problems have you ever had at work?

• What other ways have you thought of killing yourself?

Clinical caveat: Gentle assumptions are powerful examples of leading questions. The clinician must use them with care. They should not be used with patients who may feel intimidated by the clinician or with patients who are trying to provide what they think the clinician wants to hear. For instance, they are inappropriate with children when uncovering abuse histories because they could potentially lead to false memories of abuse.

Denial of the specific

After a patient has denied a generic question, it is surprising how many positives will be uncovered if the patient is asked a series of questions about specific entities. This technique appears to jar the memory, and it also appears to be harder to falsely deny a specific as opposed to a generic question.3 Examples of denial of the specific, concerning drug use, would be: “Have you ever tried cocaine?” “Have you ever smoked crack?” “Have you ever used crystal meth?” and “Have you ever dropped acid?” The following are prototypes of denial of the specific:

• Have you thought of shooting yourself?

• Have you thought of overdosing?

• Have you thought of hanging yourself?

Clinical caveat: It is important to frame each denial of the specific as a separate question, pausing between each inquiry and waiting for the patient’s denial or admission before asking the next question. The clinician should avoid combining the inquiries into a single question, such as, “Have you thought of shooting yourself, overdosing, or hanging yourself?” A series of items combined in this way is called a “cannon question.” Such cannon questions frequently lead to invalid information because patients only hear parts of them or choose to respond to only one item in the string—often the last one.

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