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Content warning: discussion of suicidal ideation and suicide watch protocol.

Today is an emotionally tough day. Bowing out is fine. Being furious is 100% reasonable.

Warning.
Suicide watch protocols in in-patient settings

The protocol is either visual checks every 15 minutes (Q15) and control of environment (no self-harm material) or 1 to 1 pairing, staff assigned to the patient 24/7.

The protocol calls for step-down as time passes.
1/30
(I have no idea what BoP uses, but this is the clinical, and I’d be surprised if BoP is significantly different.)

(I also note this has never been my wheelhouse at all. But there’s academic work on it. mdedge.com/psychiatry/art…

(And more sources later)
Both protocols have significant flaws.

15 minutes is plenty of time to die if someone is determined. Without getting into details, people have gotten creative, and suicidal ideation doesn’t come with reliable narration. People do lie about their emotional state. Often well.
3/30
About 1/3 of in-facility suicides happen while the patient is on watch.
1 to 1 distresses the client - there’s no privacy, not even for toileting. Both 1 to 1 & q15 escalate any ongoing paranoia.
Watch proves to a person who already feels out of control that they’re not.
4/30
Which is why the protocol steps down.
Ideally, you don’t want to keep someone on watch for more than 72 hours maximum.

In part because watch itself makes suicidal ideation worse, but also because even suicidal ideation reverts to mean, most of the time. 5/30
A q15 means:
no clothing but a quilted safety smock, which can’t be used as a noose.
No bedding, just the bare, usually vinyl, mattress.
Lights always on.
Very limited reading material, usually no access to other media.
Toileting only with permission, under observation.

6/30
You can see how this would make ideation worse.

While I see people saying suicide watch should be perpetual after an attempt, in jail?

The defendant is both legally innocent, and will need to be competent to stand trial. BoP can’t psychologically break them worse. 7/30
A prior attempt 18 days ago?
In an in-patient setting, that person should be stepped down. Their dignity matters.
1st thing a patient gets back is clothing & toileting - no safety smock, self-directed toileting.
Time between check lengthens, usually by 15 minute intervals.
8/30
Then bedding, then dark overnight because sleeplessness makes ideation worse. 1st, do no harm.
During this time, however, patients who are motivated also improve at convincing the staff they’re not suicidal.

In today’s case? He was a highly skilled manipulator & liar. 9/30
3 hour checks would be about right at 18 days out.

One of the better documented suicides in legal captivity was Göring, during the Nuremberg trials. He’d been convicted & sentenced, and was scheduled to hang the next day.
And yet, he used a cyanide capsule. 10/30
One aspect of Göring’s decision was likely denial of control.
By being the agent of his own death, he denied his captors - whom he considered the enemy - the justice they wanted to impose on him.

Göring was not even the first of the Nuremberg suicides. 11/30
Suicide in people who have demonstrated a history of antisocial behavior is not always existential despair.

It can also be an expression of control & defiance, a refusal to submit to people they don’t consider their equals, stealing victory & creating a mess & ruin.

12/30
In fact, of the personality disorders, Narcissistic Personality Disorder correlates most strongly with suicide attempts & suicide completion. There’s an urban myth that narcissists don’t commit suicide, and that’s entirely wrong. 13/30
With narcissism, which often has solipsistic elements, the person may believe that the world ends for everyone when they die.

It can be a giant fuck off to everyone.

But also being unable to use their learned tools - manipulation, privilege - is an existential horror. 14/30
78% of people who attempt suicide as inpatients don’t admit their suicidal ideation to staff.
We know the jail suicide rate is 3x the rate of the population as a whole.
Inescapable captivity - which this one had never experienced - and total loss of autonomy breaks people.

15/30
Is today’s suicide convenient for a lot of people? Maybe.

But I always take selfish, stupid & lazy over competent conspiracy. (Incompetent conspiracies are another matter.)
But I’d call it revenge. A FU to victims, justice system, associates.

(Think of the probate...)

16/30
But it’s also deeply inconvenient, because as twitter today proves, there will be conspiracy thinking about this forever. Nobody will escape it.
I see the theories already forming& they’re taking the form of 9/11 truthers: Let It Happen On Purpose, Made it Happen on Purpose.

17/
You note I haven’t used his name. And I won’t. Because a part of him wanted an immortality.

I feel bad for the therapist who had to have signed off on step down — this is the nightmare situation for any provider.

But therapists can be manipulated, too.

18/30
There are multiple investigations ongoing. Incriminating material was found, and it just became a lot easier for the various jurisdictions to use that material as evidence in both criminal and the civil suits.

We *DON’T* know what they have. And that’s good for justice.

19/30
In some ways, it is now safer for victims - of rape, trafficking & blackmail - to come forward.

My suspicion is that quite a few already have, and the FBI isn’t going to out them.

Les Wexner should talk more now.
20/30
And even if the conspiracy-minded are correct? Oh, they fucked up. Expect a big jurisdictional turf war: the ME will be New York City, not federal. The jurisdiction for murder is state. Federal custody makes that messy, but NYState could challenge & indict federal BoP employees.
Besides: attributing both superhuman competence to a cabal of assassins who managed to make a mess that will 100% be subject to FOIA, multi-agency scrutiny & true crime?
I’m sorry, please pick one.

I can think of a dozen ways that don’t rely on a Rube Goldberg conspiracy. 22/30
He lied to the guards & psychiatrist assigned.
He worked the system — just like he did in Florida jail — to get the privileges he wanted.
He observed the routine, used his brain, learned from his prior mistakes, and followed through with his intent to not be in jail again. 23/30
That’s actually the simplest explanation, and yes, it’s 100% unsatisfying.

But we know he was a finely-tuned manipulator.

Even if the only thing he ever did was successfully snow-job his way into wealth management, he conned his way into it.
24/30
I’m positive SDNY & FBI & NY investigators are pissed. But they wouldn’t ALL be in the jobs they have if they were willing to abridge justice. You’d have to assume layers of people willing to forego the win of a career & national security... for the sake of a petty mobster. 25/30
Narratively, the story that fits in John Le Carré is more emotionally satisfying.
A conspiracy means there’s someone in charge, someone to blame. An Intelligent Designer. Who might take a fall someday.

Stupidity & manipulation & fail-prone protocols don’t provide that. 26/30
We’ve spent 3 years watching the people around 😡💩.

They’re NOT this competent, and they suck at the cover-up. Go read the first chapter of Michael Lewis The Fifth Risk. The part about the transition committee. The tantrum over stealing *my* fucking money. It applies.

27/30
Remember the criminal mastermind that is Kush Sr: he tried to blackmail his brother-in-law as witness tampering.
Remember that Chris Christie & Rick Perry are the ethical geniuses in this crowd... and they’re barely competent criminals.
Tom Clancy would reject these dopes.
28/30
And this isn’t Putin. His assassinations work not because they’re master-strokes of planning, but because he sends disposable mooks & he doesn’t care if it’s obvious. He likes it OBVIOUS. His assassinations send clear messages.

29/30
This isn’t over.
But when we let the conspiracy override our cognition, we grant what we want to be true —that there is an Intelligent Design at work— instead of accepting the reality that jail staff can fuck up massively, and do, regularly.

We just don’t usually notice.

30/30
Sources on narcissism & suicide
(Abstracts, because I’m not hunting free copies and won’t send you at paywalls)

Muting the thread overnight.

Be excellent to each other.
Take deep breaths.
Call for help if you’re in a dark space. 1-800-273-8255 (US)
Crisis text line: US: text to 741741
UK: text 85258
Canada: text 686868
More hotlines, regional & group specific: suicidehotlines.com
There are not a lot of interior photos of MCC, but Centennial South (CO State Pen) was built on the same high isolation principles, then shuttered because continual solitary confinement does significant harm. To get an idea of interiors, see this article.

coloradoindependent.com/2019/08/08/cen…
The commercial portion of the thread:

I do accept coffee.
ko-fi.com/czedwards
And I write fiction. With conspiracies & competent villains.
czedwards.com/2019/04/15/reb…

The first book of the completed series is free at Smashwords smashwords.com/books/view/891
Or minimum at Amazon amazon.com/dp/B07GTSXB4P

Profits for this week’s sales go to RAINN
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