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Suicide Assessment Part 2: Uncovering Suicidal Intent Using the CASE Approach: Page 9 of 17

Suicide Assessment Part 2: Uncovering Suicidal Intent Using the CASE Approach: Page 9 of 17

Frank has 5 children and 21 grandchildren and a pack of great grandkids to boot. His children are supportive, but only 1 lives nearby—Nick. It is Nick who has brought his dad in to the ED. Nick received a call from his dad earlier in the morning that he wasn’t doing well. Nick got off work early and was caught off-guard by the depressive look of his father. Later during the night, while the two of them were sitting on the front porch, his dad shared a secret that prompted Nick to get in the car and bring him down to the ED immediately. Apparently, his dad had taken a handful of aspirin and some antibiotics 2 days ago.

We are picking up this interview about 20 minutes deep, where the clinician is about to enter the region of presenting events using the CASE Approach:

Patient: It’s been a long haul over the past 2 years. Sometimes too long a haul, if you know what I mean. I’m way too old for all this crap.

Clinician: And it’s got to be hard to do it alone.

Patient: You bet! With Sally gone it’s all so very different.

Clinician: I’m sure the pain of her loss is beyond words. With that amount of pain on board, Mr Thompson, have you had any thoughts of killing yourself? (shame attenuation used to gently raise the topic of suicide)

Patient: I suppose my son may have already said something to you. . . . I took some pills . . . I know it was dumb, but nothing came of it anyway.

Clinician: When was that? (behavioral incident)

Patient: Couple of nights ago. But like I said, nothing came of it. I’m not sure I need any help. I’m not going to do anything stupid, you don’t have to worry about that. (Note that the clinician is not going to take the clients “stated intent” as necessarily an accurate picture of his real intent. Instead, the clinician is going to uncover Mr Thompson’s reflected intent by weaving a verbal videotape using behavioral incidents.)

Clinician: You know what, Mr Thompson . . . that may be true, but I just want to get a better feeling for what you’ve been going through so we can make a wise decision together. Where were you when you took the pills? (behavioral incident serving as an anchor point)

Patient: In the kitchen. I was sitting in a little kitchen nook where Sally and I used to eat lunch. I always loved that little place.

Clinician: (gently smiling) Yea, I bet it brings back warm memories of Sally.

Patient: (smiling back) Yea, it does.

Clinician: What kind of pills did you take? (behavioral incident)

Patient: Some aspirin, some penicillin.

Clinician: How much did you take of each one? (behavioral incident)

Patient: About a handful of each. (Note that there can be quite a difference in what a patient means by a “handful.” It is a perfect time to clarify with a behavioral incident.)

Clinician: When you say a handful, how many of each do you mean? (behavioral incident)

Patient: About 10 of each.

Clinician: Any other pills?

Patient: (pause) I also took about 5 digoxin I’m on, more than I’m supposed to, I know that. (This is a fact that the son was unaware of and had not reported to the clinician.)

Clinician: Did you have any pills left? (behavioral incident)

Patient: Not a lot, I don’t keep many pills in the house and my prescriptions have basically run out.

Clinician: Did you look for any other pills? (behavioral incident)

Patient: (pause) Not really pills (pause) I did go through the drawer wondering if there was any rat poison around, but I realized that was stupid too. (pause) Trust me, suicide is not the answer, God did not put us on this earth to kill ourselves. (Unexpected information is coming to the surface. Clearly, the son has not been told everything. The searching for the rat poison reflects more suicidal intent than might be expected from phrases like, “God did not put us on this earth to kill ourselves.”)

Clinician: I’m glad you feel that way. And maybe we can help some too. At least I hope so.

Patient: Maybe.

Clinician: You know, right after you took the pills, what was the next thing you did. (sequencing behavioral incident)

Patient: Went to bed, just to sort of to see what would happen? I was just so tired of it all.

Clinician: How did you feel about the fact that you woke up okay?

Patient: I don’t know. Sort of didn’t care. It’s just the way it is.

Clinician: Had you been drinking at all, even a little bit? (behavioral incident)

Patient: Nope. I’m trying to lay off the stuff. It just gets me more depressed. Don’t get me wrong, I’m still drinking, but not over the past couple of days. (Notice that the clinician does not pursue a complete drug and alcohol history here; this will be carefully delineated as a risk factor in a different section of the interview or may have already been done.)

Clinician: I know from your son that you called him the next day. Had you tried any other ways of killing yourself before you called him?

Patient: Nope. I just thought I needed a rest of some sort, and I wanted to talk it all over with Nick.

Clinician: Good. How about over the past couple of months, have you had any other thoughts of overdosing? (behavioral incident, the clinician is gracefully moving into the region of recent suicide events with a bridging question)

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