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"Big Boys Don't Cry"Diagnosis & Treatment of Male Shame and Depression
Male Depression continuing education psychologist CEUs

Section 10
Differentiation of the Characteristics
of the Suicidal Depressive Crisis

CEU Question 10 | CE Test | Table of Contents | Depression
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

All inpatient units must have written and regularly updated policies and procedures for the care of suicidal patients. These policies and procedures may be understood as addressing four principal areas of concern:
o Environmental precautions
o Patient-specific interventions
o Privilege system
o Pass system

Environmental Precautions
An inpatient service that can appropriately accept and contain patients judged to be acutely suicidal must be architecturally equipped for safety (Benensohn & Resnik, 1973; Kroll, 1978; Schoonover, 1982). Windows must have stops to keep them from providing an opening through which a person could escape. Safety screens must be in a place that prevent exit and resist tampering or destruction. Obviously, all doors and other exits from the unit must be locked, equipped with an alarm, or staffed by someone who can prevent egress.

Toxic substances, including detergents and cleaning substances, must be kept in locked boxes, dispersed in limited quantities, and carefully overseen by the cleaning staff who bring these substances by cart onto the unit. Bathroom curtain rods must be designed to break if subject to any significant weight. Closet rods must also meet this specification. Wooden rods harden with age and can bear more weight, making J-hooks a desirable alternative (Libby, 1992). Finally, exposed pipes in low-security areas should be covered or rendered inaccessible.

Units should consider instituting "environmental rounds," in which clinicians and members of the plant and operations department inspect the unit. Established parameters for inspection, including those just mentioned, would be examined and new problems addressed as they arise.

Patient-Specific Interventions
The most intensive level of intervention is seclusion, with or without restraint, with either an open or closed door. Highly specific regulations exist for seclusion and restraint on a state-by-state basis. These regulations serve as the basis of unit procedural requirements.

An important unit procedure is the search of the patient's belongings. Sharps (pointed or bladed instruments) and flames (matches, lighters, and cigarettes) must be confiscated from the suicidal patient. All patients must surrender prescriptions and over-the-counter medications. Suicidal patients must surrender any substances that could be put to deleterious use (e.g., art supplies, detergents, dyes, etc.). Belts, shoelaces, and other articles of apparel represent dangerous devices for suicidal patients. However, staff must weigh the danger of these objects against the dehumanization of stripping patients of everyday elements of attire and convenience.

The use of the body search should be restricted to patients at high risk for suicide. A body search is intrusive and potentially humiliating or stimulating to vulnerable patients. Room searches, on the other hand, may be done with less concern and are one way the staff can demonstrate their rigor and commitment to safety.

Observation of the patient is fundamental to all inpatient units and is typically a dimension of nursing policy and procedure. Increments of observation should be specified and procedures articulated. One-to-one observation (constant observation) should be defined as either "at arm's length" (i.e., immediately next to the patient) or under the continuous eye of the staff. Typical increments of observation then proceed from 5- to 15- to 30-mm checks. Checks may be recorded either by staff or by the patient (self-checks), depending on clinical goals. Orders for intensive observation probably would last no longer than 24 hr and, optimally, require daily physician examination of the patient.

Supervision of the patient is different from observation and may warrant its own policy and procedure. Certain patients may require, for safety, supervision of their use of sharps and flames. Other patients may not be safe in the kitchen area because of the many materials and instruments that can be used for self-destruction. Bathroom use will need to be supervised for all patients who are on one-to-one status and for some patients who cannot safely be allowed access to pipes, rods, and pools of water. Finally, some patients may have "open areas" supervision, which indicates that they are safe in public areas where people are present, but they cannot be trusted to not secrete themselves away when alone. Staff supervision can be effective only for limited periods of time (i.e., hours to days) because of the limited capacity to control anyone, and in fact it should be in place for only a limited period of time, because prolonged supervision can invite regression.

Privilege System
A privilege system exists on all inpatient units and varies among hospitals and staffs. Privileges should be clearly defined and require a physician's order. A typical privilege system spans degrees of freedom from restriction to the unit, to permission to go off unit if accompanied (by staff or by family/friend), to permission to go off unit unaccompanied. Some units will differentiate ongrounds from off-grounds privileges.

By definition, privileges must be earned. The patient must demonstrate the clinical capacity to merit the lifting of restriction. Inpatient units are the opposite of a democracy; freedom is not inherent to life on an inpatient unit, especially for the involuntary or dangerous patient. Instead, restriction is normative and freedom is granted as a privilege when the patient has shown alliance, self-control, and responsibility for safety.

The patient's privileges (and passes) should also be consistent with his or her legal status. A patient committed to the unit by court order, for example, should have privileges consistent with the court's action, or there should be documentation as to why privileges do not conform to the court's order.

Pass System
Two types of passes generally are used: therapeutic and nontherapeutic. Therapeutic passes are provided to patients so that diagnostic or treatment plans may be pursued or to test patients' capacity to tolerate increasing degrees of liberty. Nontherapeutic passes may be offered to allow the patient to care for everyday needs (car, bank, or shopping) or for recreational purposes (exercise, entertainment, or socializing). Patients with restricted privileges may receive therapeutic passes; they should not receive passes for convenience or social purposes.

Passes may also be accompanied or nonaccompanied. It is important to distinguish accompaniment for support from accompaniment for safety. Many patients will benefit from pass accompaniment but will not be unsafe without it. Patients who require accompaniment for safety (those at risk of escaping or causing themselves harm) should be accompanied by staff adequate in number and strength to maintain safety.

No standardized system of policies and procedures exists for the four areas of concern discussed herein. Each hospital or inpatient unit has its own specific resources and concerns, making a universal system undesirable. Nevertheless a core set of policies and procedures is important, for clinical and risk management purposes, for all facilities. The Harvard University hospitals and the Harvard Risk-Management Program are in the process of developing such a set of guidelines for the care of the suicidal patient.
- Leenaars, Antoon, Maltsberger, John T., & Robert A. Neimeyer, Treatment of Suicidal People, Taylor & Francis: London, 1994.

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. Thus, space has been provided for you to make personal notes as you apply Course Concepts to your practice. Affix extra Journaling paper to the end of this Course Content Manual. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socioeconomic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 50 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress”. You will not be required to provide us with these Journaling Activities. Only the Test is to be returned to the Institute.

Personal Reflection Exercise #4
The preceding section contained information about differentiation of the characteristics of the suicidal crisis. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
LaCroix, J. M., Perera, K. U., Neely, L. L., Grammer, G., Weaver, J., & Ghahramanlou-Holloway, M. (2018). Pilot trial of post-admission cognitive therapy: Inpatient program for suicide prevention. Psychological Services, 15(3), 279–288.

Rath, D., Teismann, T., Schmitz, F., Glaesmer, H., Hallensleben, N., Paashaus, L., Spangenberg, L., Schönfelder, A., Juckel, G., & Forkmann, T. (2021). Predicting suicidal behavior by implicit associations with death? Examination of the death IAT in two inpatient samples of differing suicide risk. Psychological Assessment, 33(4), 287–299.

Rufino, K. A., Daruwala, S. E., & Anestis, J. C. (2021). Predicting suicide attempt history in a psychiatric inpatient sample: A replication and extension. Psychological Assessment, 33(7), 685–690.

Online Continuing Education QUESTION 10
According to Leenaars, what is the most intensive level of intervention in a suicidal crisis? Record the letter of the correct answer the CE Test.

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