Adolescent inpatient work

[MiniLop]

Hi all, I'm currently on internship working at an adolescent inpatient unit. Without going into detail, it's been a tough transition and peers I've spoken with at other units report having similar experiences. I've had difficulty finding resources (books, articles, etc.) aimed at work with this particular population. Does anyone have any recommendations as far as books, articles, group ideas, etc.? Or has anyone worked in an adolescent inpatient unit and want to share their experience?

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[WisNeuro]

Rathus and Miller have a DBT skills manual for adolescents.

 

[PhDenial]

Rathus and Miller have a DBT skills manual for adolescents.

Seconded! I'm completing a practicum at an inpatient adolescent unit and use the DBT Skills Manual for Adolescents by Rathus and Miller. It's been great. Obviously you'd have to adapt it for inpatient populations. For example, the group I run is only 45 minutes long, and we spend a lot of time "warming up" in the beginning and having the adolescents reflect on what they've been going through.

 

[BuckeyeLove]

I had a rotation on one at the state facility I was at on internship. There were actually two units for them, one for general behavioral stuff, the other for SO's. We used that exact manual Wis referenced. Also, what is the nature of the unit? (i.e, general psychiatric/behavioral, or is it a specific population of adolescents?) Also....keep your head on a swivel.

 

[futureapppsy2]

I had a rotation on one at the state facility I was at on internship. There were actually two units for them, one for general behavioral stuff, the other for SO's. We used that exact manual Wis referenced. Also, what is the nature of the unit? (i.e, general psychiatric/behavioral, or is it a specific population of adolescents?) Also....keep your head on a swivel.

Agree that the specific population may really guide what you want--good resources for first episode psychosis will be different from those for emotional regulation deficits/depression/SI which will be different from those with eating disorders, etc. Generally, most inpatient units will focus on crisis and stabilization, unless they are specific to more intensive treatment for a certain clinical population, so DBT and family and patient psychoed are often focuses.

 

[MiniLop]

Thanks for the feedback, everyone. I have been using the adolescent DBT manual, though a lot of it has been a tough sell with this unit. There's very little psychosis with the adolescents; vast majority are ODD and impulse control issues. There's often comorbid SI and such, but mostly the emphasis is on behavioral issues. Lots of fighting/violence on the unit. There's a lot of DBT and similar stuff that I think would be helpful, but I've been struggling a bit with getting buy-in during group.

 

[Mindfulpsych22]

Thanks for the feedback, everyone. I have been using the adolescent DBT manual, though a lot of it has been a tough sell with this unit. There's very little psychosis with the adolescents; vast majority are ODD and impulse control issues. There's often comorbid SI and such, but mostly the emphasis is on behavioral issues. Lots of fighting/violence on the unit. There's a lot of DBT and similar stuff that I think would be helpful, but I've been struggling a bit with getting buy-in during group.

Well there’s why you’re struggling. I believe almost all the therapies that have any effectiveness for ODD and behavioral issues involve a high degree of intervention/involvement with parents and the kid’s environment. Probably spending group time with any activities where you can practice cognitive flexibility with situations that typically elicit oppositional behaviors may be a decent way to spend the time. Hell- you can use their opposition to the therapy itself as a situation to start with. There are some interesting moral reasoning activities for teens that I remember coming across at different points in time- so maybe search for these?

 

[psych.meout]

Well there’s why you’re struggling. I believe almost all the therapies that have any effectiveness for ODD and behavioral issues involve a high degree of intervention/involvement with parents and the kid’s environment. Probably spending group time with any activities where you can practice cognitive flexibility with situations that typically elicit oppositional behaviors may be a decent way to spend the time. Hell- you can use their opposition to the therapy itself as a situation to start with. There are some interesting moral reasoning activities for teens that I remember coming across at different points in time- so maybe search for these?

I'd venture a guess that emotional dysregulation is more of the problem. These kids probably aren't fighting simply due to deficits cognitive flexibility or moral reasoning. They have difficulty tolerating distress and uncomfortable thoughts and emotions, lashing out because they can't self-regulate their emotions. There's a plethora of real and imagined insults and aggression in an inpatient unit full of kids like this, which sets them off and causes fights.

The DBT stuff sounds like a good fit.

 

[Mindfulpsych22]

I'd venture a guess that emotional dysregulation is more of the problem. These kids probably aren't fighting simply due to deficits cognitive flexibility or moral reasoning. They have difficulty tolerating distress and uncomfortable thoughts and emotions, lashing out because they can't self-regulate their emotions. There's a plethora of real and imagined insults and aggression in an inpatient unit full of kids like this, which sets them off and causes fights.

The DBT stuff sounds like a good fit.

I’m not saying the two are mutually exclusive. They are interrelated problems where poor emotion regulation patterns are often times maintained through intermittent reinforcement in the environment and more adaptive behaviors are not reinforced or under-reinforced.

I’m a DBT therapist who works almost solely with adolescents with very complex and severe emotion dysregulation problems (so I’m as pro DBT and understanding of dysregualtion as you can get) and I can tell you that just giving them information about skills to regulate their emotions when as the OP said they have “no buy in” is very unlikely to do anything. Often teens only buy into the idea they need these skills when their environment makes a lot of changes or requires these new behaviors from them- that is what I was pointing to with the difficulty the OP was expressing. I suggested the other activities because it’s something that they can do and practice in the group instead of just being passive recipients of information, which is more likely to lead to learning when they are not motivated to try skills on their own.

It’s also interesting that you’d separate out cognitive process from emotion regulation and from DBT (anyway, that’s my assumption based on the comment to not focus on cognitive flexibility and do “DBT stuff”) because true DBT actually puts a ton of emphasis on understanding and intervening on the cognitive component of emotional dysregulation and building cognitive flexibility. What I suggested the OP do is actually the DBT “check the facts” skill and “dialecting thinking” skill (both in the Miller and Rathus book). One of the reasons mindfulness is emphasized as the core skill is so that people can improve with observing interpretations and assumptions that influence their emotion reactions and learn to pause and separate their perceptions from the facts. What you say “there is a plethora of real and imagined insults” is exactly why flexibility is important because learning to see other ways to interpret imagined slights and to challenge ideas that seem like facts to them such as “fighting back is the only way to keep my respect” would be crucial for them to be able to do. That’s what I meant when I said practicing “cognitive flexibility”.

Also- Sadly the kind of “DBT” that they often get in the hospital (the “here’s some skills to regulate your emotions” approach) often times leads to them developing a negative and resistant view to DBT and believing it can’t help them and it being an uphill battle for outpatient therapists to get them to be open to it again.

 

[PsyDr]

Turkington wrote about cbt for psychosis. In my limited experience it is not super effective but worth a shot.

A lesser mentioned resource is the books by Glasser (e.g., Reality Therapy). Precursor to CBT; but has a lot of vignettes from adolescent inpatient settings. The material is dated, but IMO useful and an easy read.

I’ve also seen decent return on testing for IQ and considering Paigetian levels in those populations. Learned the latter from a European psychiatrist.

 

[MiniLop]

Well there’s why you’re struggling. I believe almost all the therapies that have any effectiveness for ODD and behavioral issues involve a high degree of intervention/involvement with parents and the kid’s environment. Probably spending group time with any activities where you can practice cognitive flexibility with situations that typically elicit oppositional behaviors may be a decent way to spend the time. Hell- you can use their opposition to the therapy itself as a situation to start with. There are some interesting moral reasoning activities for teens that I remember coming across at different points in time- so maybe search for these?

Thanks for the thoughts, everyone. I'm having trouble finding any moral reasoning group activities (aside from just discussing the original Kohlberg dilemma). Anyone have any leads? Or any suggestions of how to tailor DBT groups to make them more engaging for oppositional teens? I've been using the manual, but as I mentioned, it's been tough getting the groups engaged.

 

[foreverbull]

Not sure how helpful this is, but I co-facilitated many groups in residential for teens over several topics ( I had more time to build rapport, as our groups ran several weeks), but I ended up creating my own self-awareness psychoeducation group with activities to keep kids interested (emotion regulation, identity, I also taught the teens NVC, or nonviolent communication) and had them act out vignettes and scenarios. I used a fair amount of humor in these groups and dedicated the first portion to teaching (and had kids read the material out loud or write on the white board), the next portion to activities and/or the kids taking a survey or writing something down, discussion, etc., and closed with something each person learned. These groups ran 75 minutes long, which required a high level of planning and creativity to find a balance between teaching and activities to keep the teens engaged. I think my old agenda included a check in, teaching, activities, and checkout. That format seemed to work fairly well in the residential setting, so perhaps a similar format might be worth a try in inpatient?

 

[clausewitz2]

Turkington wrote about cbt for psychosis. In my limited experience it is not super effective but worth a shot.

Evidence is not fantastic for CBTp and people outside the original research group don't get great results. I think it is probably most helpful to avoid people falling into therapeutic nihilism and maintain motivation to keep working with people who have been diagnosed with psychosis.

I ran an ACT for Psychosis group on an inpatient unit for a while, though with adults. The materials are easily available online and it has been adapted to run as a three session closed group intervention taking into account the realities of turnover in most modern inpatient units. Very early days but interesting work. I would still be doing it but some unexpected personnel turnover issues made it untenable.

A challenge I ran into is that it has a very different message about psychotic experiences than people will be getting from their inpatient team. Thus we had a lot of people who had been very socialized into the role of "mental patient" who were not immediately receptive. I think it might go down better with adolescents who are not so habituated to being passive recipients of care.

Since it focuses on unusual perceptual and cognitive experiences rather than a diagnostic label it had applicability beyond primary psychotic disorders. A big lesson from the early Psychosis literature is that if you ask help-seeking adolescents about this sort of thing a good proportion will endorse psychotic experiences even if they end up mostly having mood or anxiety or characterological problems so might be useful even not in specialist settings!

 

[KunjooSea]

Seconded! I'm completing a practicum at an inpatient adolescent unit and use the DBT Skills Manual for Adolescents by Rathus and Miller. It's been great. Obviously you'd have to adapt it for inpatient populations. For example, the group I run is only 45 minutes long, and we spend a lot of time "warming up" in the beginning and having the adolescents reflect on what they've been going through.

Man, I hated inpatient. I was there twice for disorganized thinking and so on. DBT is a no-go. I do love Mindfulness and CBT. There is no way that I would reveal what has happened or is going to happen. I am 19 now and was in twice in 2017.

If they want to make these programs more amenable, stop treating us as criminals with hard beds and a schedule that achieves hardly anything. We have feelings and we are young. Maybe having a trusted teen be an advocate. As an example, intrusive tests like UDS. That will never happen to me. I don't even use drugs like, ever. If this is the type with a catheter I would hit you as soon as I could. On the other hand more complete libraries and shoes that don't your feet in the gym. Another thing I was waiting one time and this was at lunch. I started to go to the right and the alarm was set off.

One of the staff said I was brand new, that I had no idea that that was wrong. Have a process that respects our dignity and not a lot. Have an intake that is friendly gauging our timidity and helping with stress and anxiety. No strip searches but wanding. If you are self-harming, it is what it is and those kids will find a way anyhow.

I think the process would make staff more secure and crying kids getting support. Kids will respond better, trust me. Both of my parents are doctors and I complain about the environment. Boys chase me a lot and normally I don't bother me because it is puppy love. I never date outside of inpatient. The bottom-line is treating kids right. At 19 I have been through a lot and telling my past is none of their business. I don't want immersion therapy or EDMR? Radical acceptance is code word for switching anxieties.

But anyhow that is a teen speaking here. From Informed Consent, to AMA (Against Medical Advice) and a myriad of events like that. Personally doctors and nurses, EMS are good. LEOs need training for Epileptics. I was handcuffed and on my stomach. I was 14 for God's sake. I was terrified. Just a few thoughts.. Thank you very very much. chae

 

[PsyDr]

Evidence is not fantastic for CBTp and people outside the original research group don't get great results. I think it is probably most helpful to avoid people falling into therapeutic nihilism and maintain motivation to keep working with people who have been diagnosed with psychosis.

I ran an ACT for Psychosis group on an inpatient unit for a while, though with adults. The materials are easily available online and it has been adapted to run as a three session closed group intervention taking into account the realities of turnover in most modern inpatient units. Very early days but interesting work. I would still be doing it but some unexpected personnel turnover issues made it untenable.

A challenge I ran into is that it has a very different message about psychotic experiences than people will be getting from their inpatient team. This we had a lot of people who had been very socialized into the role of "mental patient" who were not immediately receptive. I think it might go down better with adolescents who are not so habituated to being passive recipients of care.

Since it focuses on unusual perceptual and cognitive experiences rather than a diagnostic label it had applicability beyond primary psychotic disorders. A big lesson from the early Psychosis literature is that if you ask help-seeking adolescents about this sort of thing a good proportion will endorse psychotic experiences even if they end up mostly having mood or anxiety or characterological problems so might be useful even not in specialist settings!

I agree.

In my thinking, the literature indicates that cultural factors direct A/V hallucinatory content. And the literature shows better outcomes for other cultures. Those data point seem to indicate, to me, that the cultural maxims we are providing for such patients are either suboptimal or harmful.

No idea what to do about that.

 

[WisNeuro]

One of the staff said I was brand new, that I had no idea that that was wrong. Have a process that respects our dignity and not a lot. Have an intake that is friendly gauging our timidity and helping with stress and anxiety. No strip searches but wanding. If you are self-harming, it is what it is and those kids will find a way anyhow.

Tell you what, you remove the liability for the providers/hospital when something does happen, and sure, we can do this.

 

[clausewitz2]

Tell you what, you remove the liability for the providers/hospital when something does happen, and sure, we can do this.

Yeah, while it is true that people bent on self-harm are going to find a way, there is a big difference between what you can do with a fragment of the toilet you managed to smash (true story) and a razor blade if properly motivated. This goes double for the damage you can inflict on others, if, say, you know that someone you are beefing with is also going to be on the unit and you'd like the opportunity to get away with a spot of the old ultra-violence (also unfortunately true story).

 

[clausewitz2]

I agree.

In my thinking, the literature indicates that cultural factors direct A/V hallucinatory content. And the literature shows better outcomes for other cultures. Those data point seem to indicate, to me, that the cultural maxims we are providing for such patients are either suboptimal or harmful.

No idea what to do about that.

The challenge is a system that can meet the needs of the distinct minority who fit older ideas of "process schizophrenia", i.e. what Kraeplin had in mind, i.e. chronic progressive decline in setting of persistent psychosis. While important not to underestimate their capabilities, it is simply not realistic to expect alot of these folks to engage in intensive employment and they are going to need a lot of assistance meeting organizational challenges and probably do better in supported living situations. My fear sometimes about the more strident recovery advocates is that they assume because they are functioning at a high level that everyone can function at a high level if they have the same diagnosis, but DSM entities just aren't a natural kind in that way.

You also want fairly aggressive intervention available for the small minority of people who have dramatic response to the right sort of dopamine blockade (in and out of state hospitals for years until they meet 7 mg of Zyprexa and then their life turns around completely and twenty years later they are buying a condo at the beach). The drug response literature suggests this is like 10-15% of people who get a psychosis diagnosis. You all might not see them that much because they often aren't especially interested in exploring their experiences in therapy since a pill genuinely makes things more or less alright (gotta love that sealed-over recovery style). The message, "you really don't need to take anything, you do you" is, in hindsight, not the thing that will enable them to reach optimal human flourishing. Maybe they don't need a schizophrenia diagnosis and older concepts like the cycloid psychoses captures them better but that is a debate for another time.

Unfortunately this means a big chunk of people who aren't made whole by pills but can function at some reasonable level despite having unusual perceptual and cognitive experiences are going to absorb the message "you can't do anything so shut up and take your meds" and have this hammered home over and over again in interactions with the mental health system. If there was any obvious way to predict what groups people first experiencing these symptoms are likely to fall into it is hard to know what the default position should be.


I think to the extent that there is empirical support for people with psychosis doing better in developing countries it has a lot to do with extended kin networks taking them in without the expectation that they ever be self-supporting or economically productive outside the home. Easier when the burden is shared among a whole bunch of relatives rather than just some parents/adult children.

/derail

 

[DynamicDidactic]

I think the bigger issue is that inpatient units are less than ideal settings for any longer term therapeutic change. Empirically, has any inpatient intervention shown any real-world long-term therapeutic benefit? I know the DBT inpatient controlled trials do not measure or show any useful clinical long-term benefits (only end of treatment). For example, DBT seems to be successful for suicide precisely because it avoids inpatient treatment (https://psycnet.apa.org/record/2018-02789-001).

 

[cara susanna]

I’m not saying the two are mutually exclusive. They are interrelated problems where poor emotion regulation patterns are often times maintained through intermittent reinforcement in the environment and more adaptive behaviors are not reinforced or under-reinforced.

I’m a DBT therapist who works almost solely with adolescents with very complex and severe emotion dysregulation problems (so I’m as pro DBT and understanding of dysregualtion as you can get) and I can tell you that just giving them information about skills to regulate their emotions when as the OP said they have “no buy in” is very unlikely to do anything. Often teens only buy into the idea they need these skills when their environment makes a lot of changes or requires these new behaviors from them- that is what I was pointing to with the difficulty the OP was expressing. I suggested the other activities because it’s something that they can do and practice in the group instead of just being passive recipients of information, which is more likely to lead to learning when they are not motivated to try skills on their own.

It’s also interesting that you’d separate out cognitive process from emotion regulation and from DBT (anyway, that’s my assumption based on the comment to not focus on cognitive flexibility and do “DBT stuff”) because true DBT actually puts a ton of emphasis on understanding and intervening on the cognitive component of emotional dysregulation and building cognitive flexibility. What I suggested the OP do is actually the DBT “check the facts” skill and “dialecting thinking” skill (both in the Miller and Rathus book). One of the reasons mindfulness is emphasized as the core skill is so that people can improve with observing interpretations and assumptions that influence their emotion reactions and learn to pause and separate their perceptions from the facts. What you say “there is a plethora of real and imagined insults” is exactly why flexibility is important because learning to see other ways to interpret imagined slights and to challenge ideas that seem like facts to them such as “fighting back is the only way to keep my respect” would be crucial for them to be able to do. That’s what I meant when I said practicing “cognitive flexibility”.

Also- Sadly the kind of “DBT” that they often get in the hospital (the “here’s some skills to regulate your emotions” approach) often times leads to them developing a negative and resistant view to DBT and believing it can’t help them and it being an uphill battle for outpatient therapists to get them to be open to it again.

As a fellow DBT practitioner (although I work with adults), thank you for saying this. Commitment is one of the most important things in DBT, and the treatment isn't going to work if that isn't present.

 

[futureapppsy2]

Tell you what, you remove the liability for the providers/hospital when something does happen, and sure, we can do this.

I definitely get the liability point, but on the other hand, there's also significant data that a lot of what we do with regards to inpatient hospitalization is iatrogenic and potentially traumatizing to patients. Like @DynamicDidactic said, there's not a whole lot of evidence that a lot of what we do during inpatient treatment is helpful, and it's an easy argument that a lot of it violates due process and basic respect for human dignity. Particularly with regards to involuntary commitment decisions, there's research showing really poor inter-rater agreement between providers, and I've seen a lot of providers use it really inappropriately as a liability CYA/distress avoidance tool (e.g., hospitalizing anyone who even mentions suicide). That may well lead to greater concealment and lack of help-seeking.

 

[WisNeuro]

I definitely get the liability point, but on the other hand, there's also significant data that a lot of what we do with regards to inpatient hospitalization is iatrogenic and potentially traumatizing to patients. Like @DynamicDidactic said, there's not a whole lot of evidence that a lot of what we do during inpatient treatment is helpful, and it's an easy argument that a lot of it violates due process and basic respect for human dignity. Particularly with regards to involuntary commitment decisions, there's research showing really poor inter-rater agreement between providers, and I've seen a lot of providers use it really inappropriately as a liability CYA/distress avoidance tool (e.g., hospitalizing anyone who even mentions suicide). That may well lead to greater concealment and lack of help-seeking.

I completely agree with all of this. But, in our litigious society, can you blame providers for skewing more towards CYA?

 

[BuckeyeLove]

Particularly with regards to involuntary commitment decisions, there's research showing really poor inter-rater agreement between providers, and I've seen a lot of providers use it really inappropriately as a liability CYA/distress avoidance tool (e.g., hospitalizing anyone who even mentions suicide). That may well lead to greater concealment and lack of help-seeking.

As someone who works on an acute inpatient adult unit....I am glad on a daily basis I don't ever have to make those decisions.

 

[DynamicDidactic]

But, in our litigious society, can you blame providers for skewing more towards CYA?

I want to do the opposite. I want to team up with a lawyer to start suing clinicians that provide ineffective treatment for individuals at high-risk for suicide. Absolutely, no evidence-based reason to using psychodynamic therapy for a suicidal individual or to go inpatient for suicidal ideation.

But I think we digress from the OPs question. Good luck, it is only internship and will be over soon enough. Now you can make a more informed decision on what you are willing to do professionally.

 

[Mindfulpsych22]

Thanks for the thoughts, everyone. I'm having trouble finding any moral reasoning group activities (aside from just discussing the original Kohlberg dilemma). Anyone have any leads? Or any suggestions of how to tailor DBT groups to make them more engaging for oppositional teens? I've been using the manual, but as I mentioned, it's been tough getting the groups engaged.

I think you’ll get the most engagement if you can use interactive activities. If you have access to video equipment you can show clips of tv shows or movies and talk about the behaviors or reactions of the characters. I’ve noticed that teens more easily will talk about other’s behaviors than their own. Becoming an engaging story teller is also a skill worth building for working with teens. If you can find a story about a popular figure they admire or relate to who handled a challenging situation in an effective manner or applied strategies you are trying to teach them to get themselves somewhere, it may pique their interest. When teaching the “making meaning skill” (which is often referred to as “making lemonade out of lemons” I use the story of how Beyonce literally made “Lemonade” out of lemons (being cheated on and humiliated in the public spotlight).

 

[WisNeuro]

I want to do the opposite. I want to team up with a lawyer to start suing clinicians that provide ineffective treatment for individuals at high-risk for suicide. Absolutely, no evidence-based reason to using psychodynamic therapy for a suicidal individual or to go inpatient for suicidal ideation.

But I think we digress from the OPs question. Good luck, it is only internship and will be over soon enough. Now you can make a more informed decision on what you are willing to do professionally.

Wholeheartedly agree, but I think in most instances, it's not an individual clinician decision driving this, it's institutional policies that are centered around minimizing liability. You'd have better luck suing the institutions, but it'd be a Sisyphean task as they can just point to the other dozen hospitals in the same metro area doing the same thing and say that it's standard of care.

 

[PsyDr]

I want to do the opposite. I want to team up with a lawyer to start suing clinicians that provide ineffective treatment for individuals at high-risk for suicide. Absolutely, no evidence-based reason to using psychodynamic therapy for a suicidal individual or to go inpatient for suicidal ideation.

I'd really encourage you to read the legal literature about suicide lawsuits. There is considerable debate about this including one's duty to mitigate damages.

The national survey literature doesn't support the idea that suicide is always caused by mental illness. That's a difficult and highly unpleasant thing to wrap one's head around.

 

[Sanman]

I'd really encourage you to read the legal literature about suicide lawsuits. There is considerable debate about this including one's duty to mitigate damages.

The national survey literature doesn't support the idea that suicide is always caused by mental illness. That's a difficult and highly unpleasant thing to wrap one's head around.

As someone who has worked in palliative care, hospice, and oncology units with terminally ill patients, that doesn't really surprise me. There are quite rational reasons for suicide. Go see a late stage MS or ALS patient, if you don't believe that.

That said, is the national survey literature speaking to adolescent/young adult suicidal ideation? There is a difference between a depressed 14 y.o. considering suicide and a 68 y.o Stage 4 cancer patient. I'm not that familiar with the literature.

 

[PsyDr]

As someone who has worked in palliative care, hospice, and oncology units with terminally ill patients, that doesn't really surprise me. There are quite rational reasons for suicide. Go see a late stage MS or ALS patient, if you don't believe that.

There are also many irrational reasons for suicide that do not represent a diagnosable mental illness (e.g., impulsivity). And many of the major risk factors are not easy to reason out (e.g., why substance abuse increases ORs to that degree). And there are risk factors that cannot reasonably be intervened upon (e.g., gender, race, having a family member that committed suicide, etc.).

It's a very complex thing, with many many moral, philosophical, legal, economic, implications. I don't even begin to have answers.

My point is that suicide does not always mean the person had a diagnosable illness.

 

[Sanman]

There are also many irrational reasons for suicide that do not represent a diagnosable mental illness (e.g., impulsivity). And many of the major risk factors are not easy to reason out (e.g., why substance abuse increases ORs to that degree). And there are risk factors that cannot reasonably be intervened upon (e.g., gender, race, having a family member that committed suicide, etc.).

It's a very complex thing, with many many moral, philosophical, legal, economic, implications. I don't even begin to have answers.

My point is that suicide does not always mean the person had a diagnosable illness.

I don't disagree at all. My question was simply to ask if the research on suicide has more to say about teen/young adult risk factors being tied to specific (possibly different )concerns than suicide in the general population overall. Is there a higher level of diagnosed mental illness in that population of suicides? I am not sure as I work at the other end of the spectrum. If your point is about suicide generally and inpatient care, point taken.

 

[DynamicDidactic]

I'd really encourage you to read the legal literature about suicide lawsuits. There is considerable debate about this including one's duty to mitigate damages.

Any particular recommendations? I am not a law-person.

The national survey literature doesn't support the idea that suicide is always caused by mental illness. That's a difficult and highly unpleasant thing to wrap one's head around.

Not difficult to believe if you work with suicide.