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Suicide Assessment Part 2: Uncovering Suicidal Intent Using the CASE Approach: Page 7 of 17

Suicide Assessment Part 2: Uncovering Suicidal Intent Using the CASE Approach: Page 7 of 17

Step 1: The exploration of presenting suicide events

Whether the patient spontaneously raises the topic of suicide or the topic is sensitively uncovered with techniques such as normalization or shame attenuation, if the suicidal events are active during the previous 2 days’ time, they are viewed as “presenting events,” in the sense that the patient has been “currently” experiencing them. If a patient presents with such current suicidal behavior or with pressing suicidal ideation, it becomes critical to understand their severity. Depending on the severity of the ideation or attempt, the patient may require hospitalization or further crisis intervention. Moreover, the clinician’s formulation of the patient’s immediate risk will determine the urgency of recommended follow-up, whether this triage is made from an ED or from a crisis hotline.

But what specific information would give the clinician the most accurate picture of the seriousness of presenting suicidal thought or behavior? The answer seems to lie in entering the patient’s world at the time of the suicidal ideation, to find out exactly how close the patient came to attempting or completing suicide. If there was indeed an attempt, then answers to the following questions can provide valuable information:

• How did the patient try to commit suicide? (What method was used?)

• How serious was the action taken with this method? (If the patient overdosed, what pills and how many were taken? If the patient cut himself, where was the cut, and did it require stitches?)

• How serious were the patient’s intentions? (Did the patient tell anyone about the attempt afterwards? Did the patient hint to anyone beforehand? Did the patient make the attempt in an isolated area or in a place where he or she was likely to be found? Did the patient write a will, check on insurance, write suicide notes, or say good-bye to significant others in the days preceding the event? How many pills were left in the bottle?)

• How does the patient feel about the fact that the attempt was not completed? (A very good question here is “What are some of your thoughts about the fact that you are still alive now?”)

• Was the attempt well planned or an impulsive act?

• Did alcohol or drugs play a role in the attempt?

• Were interpersonal factors a major role in the attempt? These factors might include feelings of failure or speculation that the world would be better off without the patient, as well as anger toward others (a suicide attempt undertaken to make others feel pain or guilt).

• Did a specific stressor or set of stressors prompt the attempt?

• At the time of the attempt, how hopeless did the patient feel?

• Why did the attempt fail? (How was the patient found, and how did the patient finally get help?)

Answers to such questions can provide invaluable information regarding how serious the patient’s attempt was, reflecting the patient’s true intent to die, no matter what the patient’s stated intent may be. Statistical risk factors will not reveal whether a given patient intended death or not. Aside from patients who may accidentally kill themselves when not intending to die (ie, perhaps acute intoxication has so clouded the patient’s consciousness that he or she becomes unaware of how many pills have been ingested), in most instances people kill themselves because they have decided to do so. Suicide is not only an act of the heart but an act of the mind—a cognitive decision.

If no actual attempt has been made in the past 48 hours, then it is the reflected intent—the extent of suicidal desire, ideation, planning, and procurement of means—that will help the clinician determine the triage (inpatient versus outpatient) and rapidity of follow-up if outpatient care is recommended. This information is coupled with what has been uncovered regarding risk factors, protective factors, and warning signs in other areas of the interview in determining safe disposition and follow-up whether seeing the patient in a clinic or ED, or listening to the patient on a crisis line.

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