0 98 mins 3 mths

The 11th Philosophy, Honey-Bee Critical Theory
A Doctrine of the 29th League, by riaaz ally 2017- present

“The Architectures of our Human Condition are continuously being defined through our achieved states of Critical Consciousness…”

Requirements for Malpractice
For a plaintiff to be successful in a malpractice claim, four basic elements are required, commonly called the “Four D’s.” These are:

Duty

Dereliction of duty

Damages or harm

Direct causation
The plaintiff (the aggrieved party) must prove the presence of these four ele-
ments by a “preponderance of the evidence,” which translates roughly as “more likely than not.” This is a less stringent standard than the “beyond reasonable doubt” standard used in criminal cases. If even one of the above four components is not proven, then the malpractice claim fails.
Duty
The rst required element for a malpractice suit to be successful is a duty to the patient. Psychiatrists cannot be held liable to the harm suffered by a person if there is no doctor–patient relationship established. A doctor-patient relationship is estab- lished explicitly when the physician agrees to treat a given patient for his or her condition. However, a doctor–patient relationship can exist implicitly as well if, on the basis of the conduct of the physician, the patient might reasonably be led to assume that a doctor–patient relationship has been established [2]. For example, a community physician might encounter an individual in a grocery store, listen to that individual’s medical concerns, and then provide medical recommendations. In that individual’s mind, he/she just received medical advice from a person known to be a physician, and thus he/she might reasonably assume that a doctor–patient relation- ship was established. Once a doctor–patient relationship exists (or is believed to exist by the patient), the physician owes the patient (at a minimum) a duty to diagnose and treat to the level of the average physician. A patient or physician may terminate the relationship (and therefore the duty) at any point; however, abandoning the patient without appropriate referrals, notice, or the opportunity to provide continuity of care places the terminating physician at an increased risk of malpractice [3]. Strategies such as developing a policy for providing advanced written noti cation along with a reasonable duration of medication to ensure that the patient does not run out while nding a new provider will help to lessen the risk of malpractice liability [2].
Dereliction of Duty
Once it is established that a physician owes a duty to the patient, this duty may be negligently breached if the physician deviates from the “standard of care.” What is the standard of care? The simplest answer is: what a physician, possessing “that reasonable degree of knowledge and skill that is ordinarily possessed by other mem- bers” practicing in the same specialty would do for the same type of patient, in simi- lar circumstances [4].

Although there are statutory differences between jurisdictions that directly impact the way in which psychiatrists are able to practice (e.g., different laws relat- ing to emergency involuntary commitment or involuntary medication), in general, in most jurisdictions, the generally accepted standard of good medical practice crosses state lines. In other words, a patient with bipolar disorder in Louisiana ought to be worked-up, diagnosed, and treated similarly to how that same patient would receive care in San Francisco. Some jurisdictions make exception to the national standard of care rule, which is outlined in the respective state statute.

There is no single authority that provides the de nitive answer as to what consti- tutes the usual behavior of ordinary members of the profession. Good starting refer- ences include published journal articles, textbooks, pharmaceutical package inserts, and practice guidelines, such as the American Psychiatric Association’s Practice Guidelines [5].

In addition to the standard of care, some jurisdictions utilize the “reasonably prudent practitioner standard,” which states that “a physician could be held liable if he failed to provide reasonable and prudent care in light of all the circumstances, even though the physician did adhere to the customary practice of the average phy- sician in the eld” [3]. Two different psychiatrists can approach the same patient differently. As long as the differing approach is reasonable and one that at least some minority (usually at least ve percent or more) of other reasonable practicing psychiatrists use in their practice, the approach could be considered to fall within the standard of care [3].

For example, the decision to use bupropion (a norepinephrine-dopamine reup- take inhibitor) over uoxetine (a selective serotonin reuptake inhibitor) as the initial choice of medication treatment for depression would constitute an ordinary difference that falls within the spectrum of common psychiatric practice. However, the decision to place a patient on bupropion as a rst-line agent for the treatment of depression would be negligent if it were known that this patient has a severe eating disorder with a history of purging and seizures, as bupropion is known to lower the seizure threshold. Without knowledge of the relevant history, the deci- sion to choose bupropion over uoxetine would seem innocuous. However, it would still be negligent.

Despite accepted differences within the eld, psychiatrists can and do make mis- takes. In the above example, the psychiatrist may have made what he considered to be a reasoned decision about the treatment of a patient, but by failing to obtain all of the relevant information necessary to make an informed decision, an “error of fact” has occurred. Without adequate information, the psychiatrist is acting blind and the ultimate judgment is awed. For this reason, errors of fact may be consid- ered negligent conduct and result in liability for the physician [6].

Errors can also occur when doctors make well-informed decisions that turn out to be wrong, with a good faith belief that the intervention will be helpful to the patient. This is called an error of judgment. In contrast to errors of fact, errors of judgment are less likely to result in liability for the physician [6]. Both errors of fact and judgment can be due to acts of commission (due to taking action) or omission (failing to take action).

Case law, as seen in Thompson and other cases, illustrates that expert witness testimony is required to establish deviation from the standard of care [1, 7]. Physicians are held to the standard of their average peer, not that of the exceptional provider who follows the latest, most up-to-date and not yet widely disseminated or practiced evidence-based treatments. As in Thompson, courts have held that jurors do not possess the specialized knowledge needed to establish deviation from the standard of care, as by de nition the medical standard of care requires specialized medical knowledge that an average lay juror is unlikely to possess [1].

One exception to the requirement for expert witness testimony is the doctrine of Res Ipsa Loquitur, translated as “the thing speaks for itself” [2]. There are occa- sionally malpractice cases where the facts are particularly egregious. While most lay people would acknowledge that they lack the expertise to form an education opinion about the best surgical approach to the repair of a leaking ventricular shunt, even someone who knows nothing about medicine would be able to nd fault with a surgeon who leaves a piece of surgical equipment inside the abdomen of their patient. This example illustrates several of the elements required for Res Ipsa Loquitur. The harm suffered by this patient would be unlikely to have occurred but for the actions of the doctor. Forgetting to remove the tool from the abdomen was a mistake made by the physician and not in uenced by the patient, who could do nothing to prevent it. Additionally, because the patient was under anesthesia, the physician carries special knowledge of the harm that occurred. For these reasons, in cases of Res Ipsa Loquitur, the burden shifts to the defendant (i.e., the physician) to prove that the harm did not occur. Fortunately, such Res Ipsa cases are rare in psychiatry [3].

Damages

Patients suffer adverse effects as a result of everyday medical decision-making. For a malpractice claim to be successful, the plaintiff must prove harm (physical or emotional). What separates the harm that is the basis for malpractice suits from the bad outcomes that are a risk of all medical interventions is the relationship of the harm to negligent medical care. If the patient suffers harm, but no negligence is demonstrated, the malpractice claim is unlikely to be successful. Common claims of negligence in psychiatry include failure to treat, failure to diagnose, failure to hos- pitalize, and failure to warn. In each of these examples, the physician has a respon- sibility to act to the standard of care within his or her scope of practice. A prudent psychiatrist who practices at or above the level of the average psychiatrist is not likely to be found liable if his or her patient suffers harm.

Imagine, for example, a patient with a history of depression but no prior suicide attempts who presents to a follow-up medication management appointment with her outpatient psychiatrist. At the visit, the patient endorsed no symptoms of depression or suicidal thoughts of any kind and demonstrated objective evidence of clinical response to the treatment, and there were no obvious acute modi able risk factors for suicide. In this situation, in a vacuum, most psychiatrists would consider it rea- sonable to keep that patient on her current medication and to continue treating her in the community. This same patient may go on to attempt or complete suicide, despite the above presentation. Retrospectively, claims can be made of negligence on the basis of failure to treat or to hospitalize. However, if a psychiatrist can dem- onstrate through their documentation that he or she reasonably followed the stan- dard of care and acted responsibly in light of the duties owed to the patient, the malpractice suit will have weak legs to stand on.

When an injured party wins a malpractice suit, the nancial damages can be either compensatory or punitive. Compensatory damages provide the injured party nancial reimbursement for elements directly related to the harm suffered, which may include lost wages, loss of earning capacity, past and future medical expenses, physical or mental pain and suffering, reduced quality of life, and permanent dis- ability. Punitive damages are what they sound like—a punishment for the defendant because of particularly egregious, careless, or malicious behavior. Compensatory damages are the usual type of damages awarded in malpractice cases. However, occasionally situations arise in which the conduct of the defendant is viewed as war- ranting the additional punitive damages, such as with a sexual misconduct malprac- tice claim against a psychiatrist.

Causation

The fourth required element for successful malpractice claims relates to proximate causation. Psychiatrists who deviate from the standard of care and whose patients suffer harm are not necessarily liable if there is no relationship between the devia- tion from the usual care and the harm suffered. That is, there must be a causal rela- tionship between the negligence and the harm. When a compelling argument can be made that the harm is related to the action of the physician, a successful malpractice claim nevertheless requires the causation to be proximate. It is not suf cient that the physician’s action played some role or that it possibly contributed to the harm. Proximate causation requires a “but for” relationship in that the harm would not have occurred but for the action of the physician (i.e., the harm wouldn’t have hap- pened had the physician acted differently).

In addition, malpractice cases often hinge on the concept of foreseeability as it applies to proximate causation. Foreseeability can be de ned as “the reasonable anticipation that harm or injury is likely to result from certain acts or omissions.” [8] Case law, as in Thompson, has established that the intervening event must be a sub- stantial factor in bringing about the injury. Thompson illustrates how courts may look at adjudicating the actions of a physician. The mere possibility of harm is insuf cient; a substantial probability is required for a nding of negligence [1].

Common Claims of Malpractice in Psychiatry

Recently published literature suggests that psychiatrists face a yearly risk of mal- practice suits of 2.6% [9]. Although this is less frequent than other medical special- ties, psychiatrists are unfortunately more likely to face state board discipline than other specialists [10]. In addition, when psychiatrists do face civil action, the mean defense costs of both paid and unpaid malpractice claims are higher than nearly every other medical specialty [11]. The published literature suggests that psychiat- ric malpractice claims are more common with male-gendered psychiatrists and are less common when the psychiatrist holds board certi cation [12].

Psychiatrists may be found liable for any number of reasons. As the case described in this chapter illustrates, malpractice suits are often multilayered and involve assertion of multiple, interrelated claims of negligence; it is rare for a suit to contain just a single allegation [2]. As of 2009, the most common claims that result in a nding of liability against a psychiatrist are incorrect treatment, suicide, drug reaction, and incorrect diagnosis [3]. However, only 10% or so of cases get to trial [2]. The following are brief examples or important points to remember about some of the more common types of psychiatric malpractice cases.

Suicide Malpractice

Viewed retrospectively by plaintiffs who have lost a loved one, suicide can be seen as something that should have been predictable. However, the “I should have seen it coming” does not re ect the currently published literature in psychiatry with regard to suicide risk. With well-informed risk assessments that take into account both known risk factors and the specific patient being evaluated, a risk of suicide, but not the act itself, can be reasonably predicted [13].

Given that the act of suicide is inherently dif cult to predict, the foreseeability of the actual act of suicide is less germane than the foreseeability of the risk of suicide. Psychiatrists are expected to consider the static risk factors (factors that do not change), such as previous suicide attempts, male sex, older age, and family history of suicide, as well as dynamic risk factors (factors that can change) and other modi- able clinical variables that may converge in an individual case to convey a risk of suicide [14]. Examples of dynamic variables include insomnia, anxiety, depression, psychosis, substance use, impaired attention, and access to rearms. Once the psy- chiatrist has made a determination that there is a foreseeable risk that a patient could be in an acute suicidal crisis, the psychiatrist must take precautionary steps. The focus is on reasonable assessment and mitigation of suicide risk.

One issue that complicates suicide malpractice is the issue of proximate causa- tion. Because the ultimate act of suicide, by de nition, requires that the patient take his or her own life, the claim that the suicide occurred proximately because of the actions of the psychiatrist, would on its face seem to make malpractice impossible. However, there is an assumption that suicidal individuals lack an ability to appreci- ate the impact of their behaviors. Thus, despite the patient engaging in the suicidal behavior, psychiatrists may nevertheless be held liable for contributory negligence, which is de ned as negligence in which the party harmed played some role in the harm suffered.

Medication Malpractice

Two of the more common types of psychiatric malpractice are claims of negligence for failure to diagnose and failure to treat. In both of these cases, malpractice claims may be challenging on account of the fact that two reasonably prudent practitioners may differ in their selection of drug to treat a given condition. However, liability may be found if the psychiatrist should have diagnosed a condition that would have altered the rational selection of one drug over another, but failed to do so.

Take, for example, a patient with a history of manic episodes who is placed on a stimulant medication for the treatment of poor focus, distractibility, and increased energy. Although stimulant medications are a common and rational approach for the treatment of attention-de cit/hyperactivity disorder, the failure to obtain the rele- vant history of manic episodes could result in a nding of liability if the patient goes on to become manic and suffers harm as a consequence. Similarly, medical conse- quences of prescription drug use, as well as issues related to informed consent, are important areas of risk for treating psychiatrists.

Sexual Misconduct Malpractice

It may be surprising that in one study, 5–10% of therapists admitted to sexual activ- ity with their patients [2]. Mental health professionals are in positions of power over their patients, who often seek out treatment in moments of vulnerability. It goes without saying that sexual contact with patients violates every published ethics guideline by every organizing body and association in medicine and mental health. Because of the intentional nature of the conduct, which is perceived to be wanton and exploitative, punitive damages can be awarded, in addition to the compensatory damages of unintentional tort cases. In addition to civil action, sexual misconduct is a primary reason for disciplinary action by state medical boards and can result in criminal charges in some states.

Suicide, medication, and sexual misconduct represent just three of the many pos- sible reasons that a psychiatrist could face a malpractice suit. A comprehensive review of the different types of psychiatric malpractice and a complete discussion of each is beyond the scope of this chapter, so psychiatrists involved in malpractice cases may want to consider reviewing the relevant case law and statutory language in their jurisdiction.

Malpractice Defense

A psychiatrist’s best defense against malpractice is to practice good psychiatry and to strive for excellent care. By staying on top of the latest published literature and being aware of published ethics and practice guidelines, psychiatrists can reduce the risk that they are falling below the standard of care. Physicians should remember that prudent care of patients includes a treatment approach favored by a respectable minority of similar providers. When in doubt about how to proceed in a clinical scenario, consider supervision and/or consultation with a colleague. If the case is ambiguous or if malpractice concerns are present, you should also consider speak- ing with legal counsel.

An adage exists that “if it isn’t documented, it didn’t occur.” While this is an oversimplification, physicians who take documentation seriously and not only re ect the diagnosis and treatment, but the rationale for how they arrived at their decisions, will be better protected should a malpractice claim be brought against them. The constraint of daily clinical practice places real-life limitations on documentation. Nevertheless, some documentation is better than none, and well-thought- out and reasoned documentation is even better yet.

Should a malpractice claim be brought, testimony at deposition may be required (testimony provided by a witness outside of court for the purposes of establishing what will be presented if the case goes to trial). If a deposition is required, it is imperative to prepare beforehand, both individually, as well as with the defense attorney. Psychiatrists should review the DSM criteria for the relevant diagnoses, as well as be prepared to describe the diagnoses and treatments to a lay audience with- out use of scienti c jargon. Memorizing key dates, clinical thinking, and interven- tions in the time leading up to the adverse outcome is particularly important. Ultimately, the ability to demonstrate reasoned thinking behind the clinical decision- making, as well as consideration of foreseeable harm and steps taken to prevent it, will go a long way toward the success or failure of the malpractice claim. It is impossible to be over-prepared for a deposition.

Considerations for the Forensic Expert Witness

There is case law requiring expert witnesses testifying to the conduct of a physician to be from the same specialty of medicine as the physician being sued [15]. Expert witnesses practicing in different elds of medicine are unlikely to be allowed to opine about the standard of care in a different eld [16].

In court, to encourage testimony, there is a witness immunity doctrine that prohibits lawsuits against witnesses based on testimony given in court. Even when an opinion is reached negligently, the immunity holds. This does not protect against criminal liability from perjury. However, although far less common than claims against clinical psychiatrists, forensic psychiatrists are not immune from claims of malpractice. Examples of claims that may be brought include defamation, invasion of privacy, breach of contract, failure to deliver a timely report, and failure to prop- erly diagnose. As with clinical medicine, practicing above the standard of care applies.

Conclusions

There are many different varieties of psychiatric malpractice and most suits involve multiple simultaneous claims. Liability against the psychiatrist may be found when there is negligent dereliction of a duty owed to the patient, directly resulting in harm. Psychiatrists wishing to minimize the risk of malpractice will strive to practice not just to the level of the ordinary practitioner, but instead to that of the exceptional provider. Rational, evidenced-based, and informed psychiatry that is clearly thought-out and articulated in the documentation will go a long way toward reducing malpractice risk.

xxx xxxx et al

that 1 rule…
tells me at distances smoking drugs
using telepathy tricks and voice technology
must be those
warped psychologies
sadistically aroused…
brains are drugged out and egoze are sadistic
science synthetic addiction…
so many different types of addiction ( for example like addicted to work…)
science experimenting and its scientific conclusions for the scientors and designers of their system is like the drug apparatus to feed the brains addiction, driven by its determined rationalism, which is to feed its point…a rationalism that has no point…( in other words, if it was a small case if it was a big case what was the need for torturing?…would there not be evidence already, including he say she say…there are lie detectors 98%, there are false confessions by those that may be highly trained in resistance tactics…still false…)
irrational rationalism
the determined structured plan, out there in the jungle interacting, mingling, majority this and that, the anti social…( socialising is not the psychiatric factor which determines the composition of an anti-social and anti-social behaviour, anti-social egoze…)
to cut off…
social interaction and legal…
so now am just sitting isolated with legal and they wrong claiming maybe out of touch incorrect or non existent incorrect and too
a higher state of moral consciousness since only suicide seems to come out as the objective reality…of their structured plans many outputs including the input…to make that output…
so am not suicidal quite right hey…simple logical reasoning

Suicide Risk Assessment

Ish P. Bhalla and Kevin V. Trueblood

11

Case Vignette

You are working as a hospital psychiatrist when you get a consult from the emer- gency department at 9:30 pm about a patient that presented for suicidal statements. The verbal sign-out from the emergency medicine doctor was that the patient is a 42-year-old man who presented as clinically intoxicated at 12 pm with a Breathalyzer of 0.16. He was cleared medically, and psychiatry was consulted for a suicide safety assessment before discharging him back to his home.

After coming down to the emergency department, you open the chart and dis- cover that the patient was brought to the hospital by law enforcement with docu- mentation stating that the patient was “making suicidal statements to his wife by phone. The wife called 911 concerned for his safety.”

You read the electronic chart on the patient and learn that the patient has had a his- tory of a prior suicide attempt 6 years ago. At that time, he overdosed on his prescribed antidepressants after losing his job and was hospitalized on a medical ward for 2 days of observation. After medical clearance, he was hospitalized for 2 weeks on an inpa- tient psychiatric unit and was then discharged home with outpatient psychiatric fol- low-up. He currently is prescribed sertraline 50 mg daily and aripiprazole 5 mg daily.

On exam, the patient explains that he recently discovered that he may lose his house because of missed mortgage payments and has chronic back pain from a her- niated disk. He states that 3 weeks ago he started drinking four beers daily to help with his back pain, and while it helps somewhat, he still can’t exercise as much as he used to. He plans to see his primary care doctor next week to evaluate the pain. He said that he does not take any other drugs. The patient says that he has been going to psychotherapy weekly for the past several months and was prescribed the

I.P. Bhalla (*) • K.V. Trueblood

Law and Psychiatry Division, Department of Psychiatry, Yale University School of Medicine, 34 Park Street, New Haven, CT 06519, USA

e-mail: ish.bhalla@yale.edu

© Springer International Publishing AG 2017 121 T. Wasser (ed.), Psychiatry and the Law, DOI 10.1007/978-3-319-63148-6_11

aripiprazole last week as an adjunct to the sertraline for worsening depressive symp- toms. He denies owning or having access to rearms. He requests to go home so he can continue looking for a new job to pay his mortgage payments. He states “I don’t want to kill myself—I just said that because I was drunk.”

You call the patient’s ex-wife. She reports that she has had a limited relationship with the patient since their divorce 2 years ago, but he called her today while intoxi- cated and said that if he can’t be with her, he may as well take all of his pills and die. She immediately hung up and called the police. She says she is worried about the patient because he has been having a dif cult time with the divorce and seems depressed. He has mentioned to her thoughts of committing suicide recently, and based on her years of knowing him, she is worried that he might act on these thoughts. The patient is unable to identify any friends or family members that could provide additional collateral.

Pertinent data from the mental status exam includes soft speech, constricted affect, organized thoughts, a denial of auditory, and visual hallucinations without evidence of responding to internal stimuli.

Case Analysis and Example Risk Assessment

The above vignette describes a typical patient in the psychiatric emergency setting. A suicide risk assessment should be performed as a component of any psychiatric evaluation, though it is particularly important for this case since it was the reason psychiatry was consulted. Below is an example of the type of risk assessment documentation one would want to complete for such a case.

Risk Factors

Static risk factors in this case include divorced marital status, male sex, history of a suicide attempt, previous psychiatric inpatient hospitalization, and chronic back pain resulting in functional impairment.

Dynamic risk factors include recent suicidal thoughts with plan, current alcohol use, unemployment, financial problems, possibly losing his housing, current symptoms of depression, and poor social support.

Protective Factors

No known access to rearms, involved in weekly psychotherapy, has children.

Suicide Risk Categorization: High

Based on this case presentation and suicide risk assessment, the patient is currently at high risk for suicide and should be admitted to the inpatient psychiatric ward for safety and stabilization. Although he has several protective factors listed above, there are also many worrisome risk factors that support a high-risk classification in addition to components of his presentation. First, he was brought to the hospital involuntarily after making a suicidal statement with a plan to overdose on his medication. Further, the patient is dealing with current finnancial stressors that are similar to the circumstances which preceded his previous suicide attempt. While the patient has no known access to rearms, he has the means to carry out the potentially lethal plan he described to his ex-wife by phone. Another impair- ing stressor is his back pain leading to functional impairment and inability to exercise, which might have been a positive coping mechanism for him during times of stress.

Introduction

Suicide risk assessment can be quite an anxiety-provoking task for any psychiatrist. When a patient commits suicide, in addition to the sense of loss and perceived failure of psychiatric treatment, the mental health provider is often wary of lawsuits for medical malpractice or negligence in preventing suicide. Despite suicide being exceedingly rare with an annual prevalence of about 13 per 100,000 people or 113 suicides per day [1], suicide is the most common reason psychiatrists get sued and results in the highest number of malpractice claims [2]. In malpractice litigation, a well-documented suicide risk assessment will often mitigate a psychiatrist’s risk of being found liable for medical malpractice (for more information on malpractice, please refer to the Malpractice chapter in this text).

The goal of suicide risk assessment is not to “predict” suicide per se, but rather to perform a thorough, systematic evaluation of the available data to determine the current level of risk. This is an important distinction, as several studies have shown how poor psychiatrists are at predicting behavior [3]. Since suicide is a rare event with a low base rate, studies that investigate suicide are often quite limited and usually retrospective in nature, further limiting psychiatrist’s ability to use this information to predict who will commit suicide. Still, there is an expectation that a psychiatrist will take reasonable steps to gather data and conduct an informed risk assessment as a part of any psychiatric evaluation and use this risk assessment to inform and guide management of the patient.

While the potential consequences of underestimating suicide risk are fairly obvious (that the patient may attempt or complete suicide if not given the appropriate level of care), it is important to also be cognizant of the potential detriments of overestimating suicide risk and unnecessarily hospitalizing a patient, especially on an involuntary basis. These can include a disruption of the patient’s life (e.g., consequences from missed work), misallocation of economic and hospital resources, weakened therapeutic alliance, and possibly propagating a dependent and potentially counter-therapeutic relationship between the patient and the healthcare system.

This chapter is meant to outline the components of a suicide risk assessment, discuss the impact of various settings on risk assessment and the role of formal risk assessment instruments, and provide recommendations on documentation of a suicide risk assessment.

Psychiatric Evaluation

A thorough suicide risk assessment is a critical component of a comprehensive psychiatric evaluation and involves gathering information from the patient in an inter- view, performing a chart review, and contacting people that may have additional information, also known as collateral sources. One of the goals of such an evaluation, and the main objective of this chapter, is to conduct a suicide risk assessment which helps to triage the patient to an appropriate level of care. Here the primary decision at hand is whether there is enough of an emergent crisis to require hospitalizing the patient on a voluntary or involuntary basis. As part of this assessment, the psychiatrist should carefully weigh risk and protective factors gathered from the evaluation. Other goals of the initial psychiatric evaluation are to formulate preliminary diagnoses and to create an initial treatment plan. Of note, suicide prevention or no-harm contracts cannot take the place of a suicide risk assessment [4].

When performing a psychiatric interview in any setting, a psychiatrist should maintain a nonjudgmental approach. If the psychiatrist feels that there is a substantial risk for suicide based on clinical data gathered in the interview, if at all possible, he or she should try to incorporate questions about suicidal thoughts naturally in the interview. Questions should start broad and then become more focused based on the speci c answers provided by the patient. For example, an initial question might be “I understand that you have been feeling depressed lately. Has it ever gotten so bad that you have thought about hurting yourself?” Depending on the answers to such ques- tions and the other risk factors listed below, the provider can then ask about passive suicidal thoughts with questions such as “Do you ever think it would be better if you were not living anymore?” Importantly, a psychiatrist should pay attention to facial expressions when asking about suicide, rather than taking notes, as you may miss important clinical data about the patient’s affective state and level of risk [5].

According to the American Psychiatric Association Practice Guidelines [6], characteristics that a psychiatrist should consider during a suicide risk assessment which may increase or decrease risk include current presentation of suicidality, psychiatric disorders, personal and family history of suicide attempts, psychosocial factors, and psycho- logical strengths and vulnerabilities. In this chapter, we organize these characteristics a bit differently in order to provide a framework for clinical assessment. Assessment of suicide risk is a clinical decision and should be considered on a case-by-case basis, though epidemiological studies have identified a set of characteristics that can increase or decrease a patient’s perceived level of suicide risk. As part of a suicide risk assessment, a psychiatrist should carefully appraise these risk and protective factors as part of a systematic framework for understanding and assessing suicide risk.

Risk Factors

Risk factors for suicide are known factors that may increase the likelihood of suicide and are divided into static and dynamic categories. Empirical epidemiological studies on suicide factors often use an index called the standardized mortality ratio

Table 11.1

suicide

Risk factors for

Suicide risk factors

Static

History of suicidality Sociodemographic

Male
White race
Age > 65 or teens Rural residence LGBT

Psychiatric history Affective disorders Psychotic disorders Eating disorders Personality disorders History of hospitalizations

Medical comorbidities Life-threatening Functional impairments Pain

Family history of suicide

(SMR). The SMR is a measure of the relative risk of a particular risk factor after matching for age and sex. A comprehensive literature review of suicide risk factors is beyond the scope of this chapter, though some main considerations are discussed below. Table 11.1 lists static and dynamic risk factors for suicide.

Static Risk Factors

Static, or chronic, risk factors for suicide are de ned as various sociodemographic and diagnostic elements that generally do not or cannot be easily changed over time or by intervention. These factors mostly involve historical data. It is important to make this distinction for treatment planning purposes, as static factors are not a potential target for treatment.

History of Suicidality. Perhaps one of the most robust predictors of suicide is a history of a suicide attempt [7]. However, this relationship is more complex, as it has been found that up to two-thirds of completed suicides were on the first attempt [8]. It has been estimated that for every completed suicide, a patient attempts 10–20 times [9]. Still, patients with a history of suicide attempts or other types of impulsivity [10] should be considered at elevated risk for suicide. When assessing for a past history of suicide attempts, it is important to ascertain the motivations and intentions of the attempt in addition to the means of the attempt and intoxication status. More lethal motivations and means should be considered a higher risk factor.

Sociodemographics. There are many confounding variables that in uence the association between various sociodemographic characteristics and rates of sui- cide. Nonetheless, these static factors are generally considered to elevate suicide risk: male gender (have higher completed suicides but fewer attempts than females [11]), lesbian/gay/bisexual/transgender (LGBT) orientation, those living in rural or isolated areas [12], white race [13], age greater than 65 or 10–24 years old [1], and single marital status (including widowed or divorced).
• Psychiatric History. While suicide is often thought of as an impulsive action, a vast majority of patients who commit suicide had a diagnosable psychiatric dis- order. A history of certain psychiatric disorders is particularly associated with suicide including depression, anxiety, bipolar disorder, anorexia nervosa, and schizophrenia [14]. Having a history of hospitalization for a psychiatric disorder has also been found to be a risk factor [15]. Patients with personality disorders, especially borderline personality disorder, are at an increased risk for suicidal and self-injurious behaviors.
• Medical Comorbidities. Individuals with a history of medical diagnoses are at an elevated risk of suicide, particularly those recently diagnosed with seri- ous medical conditions with poor prognosis such as cancer [16]. Medical conditions leading to functional impairment such as severe pain are also risk factors for suicide [17]. Other types of acute stress can also be associ- ated with suicide, likely with a similar mechanism as a serious medical diagnosis [18].
• Family History of Suicide. A genetic link for suicide has been proposed [19]. Studies have found that those whose relatives have committed suicide [20, 21], have psychiatric diagnoses [22], or are impulsive as a personality trait [21] are at an increased risk for suicide themselves.
Dynamic Risk Factors
Dynamic, or modi able, risk factors are de ned as elements that have the potential to change over time and may be susceptible to psychosocial treatment. These factors deal with current symptoms. Since these risk factors change, they should be addressed on an ongoing basis.
• Current Suicidality. An obvious dynamic suicide risk factor is when a patient reveals to the clinician that he or she is thinking about suicide; this self-disclosure has been found to be a risk factor for suicide [23]. The presence of a lethal sui- cide plan has been particularly linked to increased suicide risk. However, feigning thoughts about suicide is also an easy and common method for malingering. When evaluating a patient who states that he or she is feeling like hurting or kill- ing themselves, the psychiatrist should also consider potential secondary gains.
• Substance Use. Alcohol and other drugs have been found to be a risk factor for suicide [24]. This includes current intoxication as well as diagnosed substance use disorders. One theory is that increased substance use can be a signal of wors- ening psychiatric symptoms. Another is that substances, particularly alcohol, can lead to disinhibition, poor decision-making, and impulsivity, putting the patient
at an increased risk for suicide.
• Current Psychiatric Symptoms. In addition to the current suicidal intent men-
tioned above, there are speci c psychiatric symptoms that have been associated with suicide. Hopelessness and a patient’s inability to list reasons for living are traits that are especially worrisome [25]. Shame, low self-esteem, impulsivity, aggression, psychological turmoil, and severe or unremitting anxiety are among other factors that are associated with suicide.
• Psychosocial Circumstances. Living and working situations are important to con- sider, especially a recent or abrupt change in status. Risk factors include unem- ployment, homelessness, and lack of social support including a poor relationship with family [26]. In addition, it has been found that a recent discharge from an inpatient psychiatric hospitalization is a strong risk factor for suicide [27].
• Access to Means. With the understanding that suicide is mostly considered an impulsive act, ready access to lethal means is a risk factor for suicide. Firearms in particular have been regarded as the weapon with the highest association with suicide risk [28]. Other dangerous and common means include overdosing on prescription medication.
Protective Factors
Equally important in suicide risk assessment is to consider protective factors or data that lessens the perceived risk for suicide. For several of the above risk factors for suicide, the absence of a risk factor is thought to be a protective factor. However, this is not always the case. For instance, a denial of suicide ideation should not be considered a protective factor because while patients with suicidal ideation are at a higher risk for suicide, available empirical data does not support the lack of suicidal ideation as a protective factor. One study found that in patients who had seen their psychiatrists on the day of their eventual suicide, suicidal intent was reported in only 22% of cases [29]. Another study found that 78% of patients who later suicided on an inpatient ward were documented to have denied suicidal ideation immediately prior to death [30]. Some patients may deny suicidal thoughts to mental health pro- viders after they have already decided to commit suicide to prevent clinical inter- vention. Table 11.2 lists protective factors against suicide.
Table 11.2 Protective factors for suicide
Protective factors
Social supports
Religious or cultural beliefs opposing suicide Reasons for living
Ability to cite these reasons Dependent children Pregnancy
Psychological state Future orientation Positive coping skills • Social Support. The perceived presence and availability of a person’s social network including family can be a protective factor. Patients can often utilize this support network in times of crisis before attempting suicide. There is also the sense of responsibility toward social contacts that can deter such behavior.
• Religious Beliefs Opposing Suicide. Religious beliefs are generally consid- ered a protective factor for suicide. Many religions believe that suicide is morally wrong with consequences in the afterlife, thus deterring a suicidal patient from attempting or committing suicide. In addition, religion usually offers social support in the form of pastors or other religious leaders and a sense of community among others of the same faith. However, there are some religions and cultures that do not view suicide with the same moral objection and can even honor suicide; thus religion in and of itself is not necessarily a protective factor.
• Reasons for Living. Patients who are able to cite subjective reasons for living are considered to be at lower risk for suicide. Also, those who have children, particu- larly dependent children at home, are less likely to commit suicide. This phe- nomenon has been found more in women, though there is some evidence to support a similar relationship in men. Pregnancy is also a protective factor.
• Psychological State. Patients who have positive and reasonable nonviolent future plans, so-called “future-orientation,” are at a lower risk for suicide [31]. Positive coping skills in the setting of stressful life events are also a protective factor.
Setting
Emergency Department
Suicidality is a common reason for presentation to the emergency setting. Patients in crisis can be referred by family or friends, brought in by police, or self-present to the hospital. The method of presentation is useful data when assessing risk. It is thought that patients who self-present are themselves seeking treatment and have insight into their illness, therefore lowering their risk for suicide.
Patients in the emergency setting should be screened for drug use by a urine toxicity test and for alcohol by a Breathalyzer, as patients are not always open about their substance use. A comprehensive suicide assessment may not be possible or advisable when a patient is acutely intoxicated from alcohol or another substance. For example, the patient may not be sober enough to answer questions, or immedi- ate medical intervention may be the priority, depending on the severity of intoxica- tion. If the patient makes statements about suicide, however, it may be necessary to increase supervision while in the emergency room. A formal psychiatric evaluation can begin after a period of sobriety.
Collateral information is especially important in the emergency setting, as patients may not be forthcoming regarding suicidality. Data from an outside source is useful to corroborate a patient’s story or may also call into question information provided by the patient, who may be exaggerating or minimizing symptoms.
Inpatient Setting
Suicidal emergencies are often a reason that patients are admitted to inpatient psychiatric wards, and suicide risk assessments in this setting should be con- ducted often. In addition to daily assessments, the inpatient treatment team should conduct suicide risk assessments upon admission, after periods where the patient’s clinical condition has changed and when the patient has new psy- chological stressors. Risk and protective factors during inpatient hospitaliza- tion are generally the same as other settings, though severe anxiety is one additional factor associated with an acute risk in the inpatient setting. Inpatient suicides have not been found to be associated with any particular admission diagnoses [30].
Suicides on inpatient psychiatric wards are relatively rare and, when they do occur, are considered a sentinel event (a reportable and unanticipated adverse event not related to the natural course of illness). That being said, inpatient suicide accounts for 16.3% of sentinel events reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) [32].
Outpatient Setting
Psychiatrists often complete formal suicide risk assessments early in the course of outpatient treatment but can easily forgo this process in subsequent appoint- ments especially when the patient was considered low risk from the beginning. Like other psychiatric symptoms, suicide risk can wax and wane, and assess- ment should be conducted not only at treatment onset but also during periods of clinical status change including an increase in psychosocial stressors and loss of social support. A positive therapeutic alliance can be a protective factor in the outpatient setting. When suspecting an increase in suicide risk, the pro- vider should consider performing a formal risk assessment including contact- ing collateral sources and consider sending a patient to the emergency department for safety.
Correctional Settings
Psychiatrists are often asked to evaluate the suicidality of inmates transported from correctional settings to the emergency room or as part of a team working with the correctional facility itself. People in jails commit suicide at a rate more than ten

times that of the general population [33]. Further, suicide is the most common cause of death in jails, accounting for a third of deaths in 2013 and is a leading cause of death in state prisons [34]. This trend is likely associated with psychoso- cial dysfunction of inmates, lack of suf cient mental healthcare, a sense of hope- lessness, and the psychological stress of being incarcerated. Studies have found that 63% of people who suicide in jail did so on their rst day [33]; therefore, recently incarcerated inmates should be considered at higher risk for suicide. Other speci c factors that may increase the risk of suicide while incarcerated include young age and male sex.
Approaches to Suicide Risk Assessment
Clinical vs. Actuarial Methods The clinical approach to suicide risk assessment values the provider’s judgment during the evaluation. This method takes into account the psychiatrist’s general impression and feelings after sitting with the patient but is considered subjective and not based on evidence. That being said, there is some data to support the patient’s subjective degree of psychological pain as a clinically useful indicator of current suicidality [35]. Traditionally in the eld of forensic psychiatry, psychiatrists have used actuarial methods to assign risk to patients based on particular patient characteristics. There is practical value in this approach because it allows an evaluator to assign a percent risk that a subject with similar characteristics will commit suicide in a speci ed amount of time, which can help to determine risk for longer-term placements. However, this approach does not have much clinical value, as the factors provide limited information about the immi- nence of such acts.
Structured Professional Judgment Bouch and Marshall proposed a novel approach to risk assessment that combines the clinical and actuarial methods [36], which allows a clinician to use evidence gathered from an interview to evaluate risk in a transparent and structured way. This method is called structured profes- sional judgment. The advantage of this approach is that it provides both imminent and long-term risk for disposition planning and can help inform decisions about monitoring plans for patients. Using this approach, psychiatrists should take into account various risk and protective factors when assessing suicide risk as part of the evaluation. A higher number of risk factors are thought to increase risk in synergistic fashion, meaning that two risk factors together are considered more dangerous than each in isolation [6].
The Limited Role of Suicide Risk Instruments There have been many suicide risk assessment tools developed for research purposes and to assist in clinical decision-making. These instruments should not be substituted for clinical rea- soning, though it can be used for adjunctive purposes or as a screening tool in

Table 11.3 Selected suicide risk assessment instruments

Risk assessment instruments Modi ed SAD PERSONS scale Beck depression inventory Beck anxiety inventory

Beck hopelessness scale
Beck scale for suicidal ideation High-risk construct scale

both psychiatric and nonpsychiatric settings [37]. In fact, one study assessed the sensitivity and speci city of such a tool as a screening test for inpatient admis- sion [38]. Table 11.3 lists some of the suicide risk assessment instruments which have been found to correlate with the decision to admit a patient to the psychi- atric ward. Like other useful screening tests, these instruments had high sensi- tivity but often low speci city.

Documentation and Legal Considerations

A thoroughly documented suicide risk assessment is not only meant to prevent malpractice litigation but also to improve the quality of patient care. Including suicide risk assessment as part of clinical documentation is particularly important when a patient’s care is to be transferred to another provider. It can also be a useful tool for a psychiatrist in any setting to organize a large amount of data and think critically about whether he or she has completely evaluated the patient’s risk and made an appropriate disposition recommendation commensurate with the degree of risk posed.

The standard of care for a psychiatrist when making a suicide risk assessment is beyond the scope of this chapter [39]. Malpractice has been discussed earlier in this book, and documentation is critical in court when a psychiatrist is sued for malpractice. Documenting a suicide risk assessment is clearly important in cases when a patient later attempts or commits suicide and also when the patient is admitted to the hospital, especially on an involuntary basis. Courts may interpret the lack of any suicide risk assessment documentation as a failure to complete the risk assessment at all. Documentation should be completed as soon as pos- sible after the evaluation and should generally allow the reader to understand the psychiatrist’s thought process and rationale for decision-making, which may include considering the risks and bene ts of a higher level of care. Suicide risk assessment is a nuanced and complex process, and one’s documentation should re ect this complexity.

The documented level of risk should match the clinical decision. For example, a patient found to be at high risk for suicide should not be discharged from the emer- gency room. On the other hand, a patient who is at low risk should not be involun- tarily admitted to an inpatient psychiatric unit on 1:1 observation status.

Conclusion
Patient suicide is a serious clinical concern and is a common reason for lawsuits against psychiatrists (though the absolute number of lawsuits against psychia- trists is low compared to other medical specialties). An integral part of a psychi- atric evaluation is a suicide risk assessment. Suicide risk assessments should be completed and documented in a timely fashion after evaluating a patient. Factors associated with suicide risk are categorized as static or dynamic. In determining a patient’s level of risk, these risk factors should be weighed against protective factors, as well as other components of the psychiatric evaluation which in u- ence risk, such as setting and clinical context. After assessing a patient’s overall level of risk, a risk management plan should be implemented in which treatment decisions are based on mitigating dynamic risk factors and making use of avail- able protective factors.
• As part of a psychiatric evaluation, a suicide risk assessment should be com- pleted and documented after each clinical encounter.
• Risk factors are empirically tested characteristics that are associated with sui- cide and should be carefully weighed against protective factors when deter- mining the level of risk.
• The category of assigned risk (low, moderate, or high risk) should match the level of care recommendation (inpatient psychiatry with or without 1:1 obser- vation, outpatient follow-up).
• The setting in which the evaluation was conducted plays an important part in the determination of risk.
• Suicide risk assessment scales can sometimes be an adjunct to a psychiatric evaluation but should not be used as a stand-alone risk assessment measure to guide a clinical decision.
• Legally, a psychiatrist is not expected to “predict” suicide or other self-injurious behavior but is expected to have documented evidence of having carefully con- sidered risk and protective factors before making a decision on disposition.


the rationalism of the guy all out their in the jungle interacting pursuing his objective reality fantasies

2 weeks
and 3 months
why not move now…all should have the ducks in a row…
or what is my plan? what case and when and so on…
then u should go now…
or is it one of those… not denial
not opposite evidence either…
at the juncture of the one adjacent to the opposite opposite
there are options
and what that is
time u see…at that juncture there are options too…hmm and it doesnt work out for u so why not move now
so when u make a move
or dont make a move
im still making my moves
why havent u made a move…
since i dunno what ur case is then,
but u make no sense do ya?
what ya gonna do at that juncture if havent even made a move now…
because theres so many moves…
between 2 weeks and 3 months would be logical
options and u havent made moves now or and even then at that obscure juncture…yes i can see why would be adjacent…because u think u right
thus
looking back from there
u should be able to see my moves, determine a few options, and me preempting urs, prove it reduces to? meaning the system thus time?…as it all gets folded up or gonna make a move of which u cant stop me from making my moves folding u up…
any perjury perhaps?
hmmm hmmmm
as time comes closer with what the actual result is…not even that juncture as it draws nearer since have to
fold that side and this side and continue folding until it reaches 3 points of only 1 closed…now at that juncture obscure one…
little off-course there hey a bluff maybe for the real point and some options u see
did u make moves and why not now?

thats a pretty good map
that too happens without such a system process flow i suppose
and no it doesnt have to be like the below…
just simple brain to brain no gadgets

not like girlfriend boyfriend or husband wife or civil
partner… languages verbal non verbal and body

it explains maybe not the right flow
synthetic doesn’t mean necessarily a chip
or a drug to induce it or evoke it
the science part… without it

all the things have explained
are those definitions more easily understood in practice
without the need of a EEG…
u can still map

by reaction
and the results of those integrated methods
eg. like pigeon holing or creating fear and the allegations and charges and the reported observations

intergrated
interrogation
to n fro
consonants
shocks for anxieties as well as behavioral analyses, action potentials over time?…thus the system not isolated to a cell like police cell has a fatal flaw too…putting a lid on it a dome on it…rather than gruffing all over the show such as to create clouds…i.e they think am at that what they want to analyse thus still continue whether its true or not…
synthetic telepathy
learned helplessness
opposites opposites
agree disagree
shouting down

swopping names, confusions, making clouds, delusions, blame games, brainwaves, vendetta, make an entrant, resistance tactics, how offensive tactics are used to make opposite opposite, which is still offensive covered or masked as resistance, opposite opposite opposite is the same direction as offensive…masked as resistance
surround voices, aggravations, irritations, hopes, let downs,
bed time stories
toxicity developments and methods

doesnt read like macro psychoses clouds…
as well as
the predictions which would follow
thru…
as per psychological torture…
would be the same as am writing now…
not the usual prediction…
thus would be
agitation tactics currently in use…
or whichever belt it would fall under….
wouldn’t be reading as per their logic of using their predictions
such as to gas light…
hows that for their ego for a little bit
desperadoes
their predicted outputs… such as a laugh…
severely irritated then
to this part here above…
reading in stills? or under ur breath?
so if u read the whole thing…and u revved up…
or maybe u shout it out and aggressive then u cant see it
but regardless of whether so or prove so or not
this would be part of ur total package if what u calling interrogation…
and making anxieties etc etc
all fitting into ur shock devices and reconstructed stories too…
exactly ur profile

so,
this will all bark out a technique
as well as its not in ur head…the sounds are from the external environment
what would it be saying about
the
supposed stress technique
to which good effect

and so in silence they would feel they need to persist
then i suppose they should be walking on eggshells too thinking am not doin anything about them
forcing 1 objective
with blame games,

READING IN STILLS…
UNDER UR BREATH I DID INTENTIONALLY at the moment of time was being interrogated over the voice to skull system…
1 WOULD BE UR FLIPPIN DANGEROUS, very like silence of the lambs
2 WOULD BE UR EYES ARE STILL IN UR HEAD AND ON CRACK COCAINE
3 WOULD BE THE LOGIC OF IT…WOULD TELL U IM BEING INTERROGATED AT THAT MOMENT IN TIME and flippn flippn clever…this whole thing is one big entrapment around the setup and thru it…wrapping it all up…folding them up im not folded unravelled and folding up, because it already is premeditated too…



typical stunt of his…
agree disagree make an interest…
talk something slightly off that agree disagree make a new entrant
dramatic or not
agree or dialectics of agree
dialectics of disagree
and dialectics of interest
and even agreeing to the opposites of that too…i.e. instead of attacking your psychology directly through the torture method, the theatrical is created amongst themselves, rather than aimed at you…
thats quite typical of his method
seems to be
telling their tutor something about himself isnt it…psychopath even as a job passed on hiding amongst professional circles, and other social circles, claiming perhaps even protections, which dont exist…perhaps in the times of the vikings…
this was related to assets…
now u see
what hiding they going to get…
in time…
as they enforce their sadisticness
another part of fear is denial
denial is a sickness to truth…like it says in …surah of the bee
when in total denial fear will fight back in many ways…
sick sick psychopath…to kill even…deaf dumb blind…
obsessed with the denial itself…egos…
or laugh like a bozo
and still not learn…
denial…
doesnt read like macro psychoses clouds…
as well as
the predictions which would follow
thru…
as per psychological torture…
would be the same as am writing now…
not the usual prediction…


thus would be
agitation tactics currently in use…
or whichever belt it would fall under….
wouldn’t be reading as per their logic of using their predictions
such as to gas light…
hows that for their ego for a little bit
desperadoes
their predicted outputs… such as a laugh…
severely irritated then
to this part here above…
reading in stills? or under ur breath?
learned helplessness
torture
and enhanced torture methods…
like no touch torture…
voice skull for example
noise and sound torture…
is to break the… or weaken the psychology also
along what other effects…
it dismantles u emotionally
and blows ur ear drums
splits ur frontals and occipitals i think is the right part of the brain it affects…make u psychopath…and if u read further u will see the other reconstructs of he say she says…like…anal stories…and what elses…its further below…its the output of what they trying to achieve in allegation and accusations through collecting he say she says and interrogating at distances…thus…further below u will see what i mean…denial?…and oh nothing tried?… stay out there and still try …as well as so that u thinking comes from another side of the brain…
not the main area
its also to make u brainless …zombie
to attack ur heart
and take advantage of the opposite pressures
and then to drive that even harder to which ever outputs to make markers and assumptions…
how many sorry’s will society accept as excuses…

Whatever is in the heavens and the earth glorifies Allah, for He is the Almighty, All-Wise.

— Dr. Mustafa Khattab, the Clear Quran

57:2
ﯦ ﯧ ﯨ ﯩ ﯪ ﯫ ﯬ ﯭ ﯮ ﯯ ﯰ ﯱ ﯲ ﯳ
To Him belongs the kingdom of the heavens and the earth. He gives life and causes death. And He is Most Capable of everything.

— Dr. Mustafa Khattab, the Clear Quran

57:3
ﯴ ﯵ ﯶ ﯷ ﯸ ﯹ ﯺ ﯻ ﯼ ﯽ ﯾ
He is the First and the Last, the Most High and Most Near,1 and He has ˹perfect˺ knowledge of all things.

— Dr. Mustafa Khattab, the Clear Quran

57:4
ﭑ ﭒ ﭓ ﭔ ﭕ ﭖ ﭗ ﭘ ﭙ ﭚ ﭛ ﭜ ﭝ ﭞ ﭟ ﭠ ﭡ ﭢ ﭣ ﭤ ﭥ ﭦ ﭧ ﭨ ﭩ ﭪ ﭫ ﭬ ﭭ ﭮ ﭯ ﭰ ﭱ ﭲ ﭳ ﭴ ﭵ ﭶ ﭷ ﭸ
He is the One Who created the heavens and the earth in six Days,1 then established Himself on the Throne. He knows whatever goes into the earth and whatever comes out of it, and whatever descends from the sky and whatever ascends into it. And He is with you wherever you are.2 For Allah is All-Seeing of what you do.

— Dr. Mustafa Khattab, the Clear Quran

57:5
ﭹ ﭺ ﭻ ﭼ ﭽ ﭾ ﭿ ﮀ ﮁ ﮂ
To Him belongs the kingdom of the heavens and the earth. And to Allah all matters are returned.

— Dr. Mustafa Khattab, the Clear Quran

57:6
ﮃ ﮄ ﮅ ﮆ ﮇ ﮈ ﮉ ﮊ ﮋ ﮌ ﮍ ﮎ ﮏ ﮐ
He merges the night into day and the day into night. And He knows best what is ˹hidden˺ in the heart.

— Dr. Mustafa Khattab, the Clear Quran

57:7
ﮑ ﮒ ﮓ ﮔ ﮕ ﮖ ﮗ ﮘ ﮙ ﮚ ﮛ ﮜ ﮝ ﮞ ﮟ ﮠ ﮡ
Believe in Allah and His Messenger, and donate from what He has entrusted you with. So those of you who believe and donate will have a mighty reward.

— Dr. Mustafa Khattab, the Clear Quran

57:8
ﮢ ﮣ ﮤ ﮥ ﮦ ﮧ ﮨ ﮩ ﮪ ﮫ ﮬ ﮭ ﮮ ﮯ ﮰ ﮱ ﯓ
Why do you not believe in Allah while the Messenger is inviting you to have faith in your Lord, although He has already taken your covenant,1 if you will ever believe.

— Dr. Mustafa Khattab, the Clear Quran

57:9
ﯔ ﯕ ﯖ ﯗ ﯘ ﯙ ﯚ ﯛ ﯜ ﯝ ﯞ ﯟ ﯠ ﯡ ﯢ ﯣ ﯤ ﯥ ﯦ
He is the One Who sends down clear revelations to His servant to bring you out of darkness and into light. For indeed Allah is Ever Gracious and Most Merciful to you.

— Dr. Mustafa Khattab, the Clear Quran

57:10
ﯧ ﯨ ﯩ ﯪ ﯫ ﯬ ﯭ ﯮ ﯯ ﯰ ﯱ ﯲ ﯳ ﯴ ﯵ ﯶ ﯷ ﯸ ﯹ ﯺ ﯻ ﯼ ﯽ ﯾ ﯿ ﰀ ﰁ ﰂ ﰃ ﰄ ﰅ ﰆ ﰇ ﰈ ﰉ ﰊ ﰋ ﰌ ﰍ ﰎ ﰏ ﰐ
And why should you not spend in the cause of Allah, while Allah is the ˹sole˺ inheritor of the heavens and the earth? Those of you who donated and fought before the victory ˹over Mecca˺ are unparalleled. They are far greater in rank than those who donated and fought afterwards.1 Yet Allah has promised each a fine reward. And Allah is All-Aware of what you do.

— Dr. Mustafa Khattab, the Clear Quran

57:11
ﰑ ﰒ ﰓ ﰔ ﰕ ﰖ ﰗ ﰘ ﰙ ﰚ ﰛ ﰜ ﰝ
Who is it that will lend to Allah a good loan which Allah will multiply ˹many times over˺ for them, and they will have an honourable reward?1

— Dr. Mustafa Khattab, the Clear Quran

57:12
ﭑ ﭒ ﭓ ﭔ ﭕ ﭖ ﭗ ﭘ ﭙ ﭚ ﭛ ﭜ ﭝ ﭞ ﭟ ﭠ ﭡ ﭢ ﭣ ﭤ ﭥ ﭦ ﭧ ﭨ
On that Day you will see believing men and women with their light shining ahead of them and on their right. ˹They will be told,˺ “Today you have good news of Gardens, under which rivers flow, ˹for you˺ to stay in forever. This is ˹truly˺ the ultimate triumph.”

— Dr. Mustafa Khattab, the Clear Quran

57:13
ﭩ ﭪ ﭫ ﭬ ﭭ ﭮ ﭯ ﭰ ﭱ ﭲ ﭳ ﭴ ﭵ ﭶ ﭷ ﭸ ﭹ ﭺ ﭻ ﭼ ﭽ ﭾ ﭿ ﮀ ﮁ ﮂ ﮃ ﮄ
On that Day hypocrite men and women will beg the believers, “Wait for us so that we may have some of your light.” It will be said ˹mockingly˺, “Go back ˹to the world˺ and seek a light ˹there˺!” Then a ˹separating˺ wall with a gate will be erected between them. On the near side will be grace and on the far side will be torment.1

— Dr. Mustafa Khattab, the Clear Quran

57:14
ﮅ ﮆ ﮇ ﮈ ﮉ ﮊ ﮋ ﮌ ﮍ ﮎ ﮏ ﮐ ﮑ ﮒ ﮓ ﮔ ﮕ ﮖ ﮗ ﮘ ﮙ ﮚ
The tormented will cry out to those graced, “Were we not with you?” They will reply, “Yes ˹you were˺. But you chose to be tempted ˹by hypocrisy˺, ˹eagerly˺ awaited ˹our demise˺, doubted ˹the truth˺, and were deluded by false hopes until Allah’s decree ˹of your death˺ came to pass. And ˹so˺ the Chief Deceiver1 deceived you about Allah.

— Dr. Mustafa Khattab, the Clear Quran

57:15
ﮛ ﮜ ﮝ ﮞ ﮟ ﮠ ﮡ ﮢ ﮣ ﮤ ﮥ ﮦ ﮧ ﮨ ﮩ ﮪ ﮫ ﮬ ﮭ
So Today no ransom will be accepted from you ˹hypocrites˺, nor from the disbelievers. Your home is the Fire—it is the ˹only˺ fitting place for you. What an evil destination!”

— Dr. Mustafa Khattab, the Clear Quran

57:16
ﮮ ﮯ ﮰ ﮱ ﯓ ﯔ ﯕ ﯖ ﯗ ﯘ ﯙ ﯚ ﯛ ﯜ ﯝ ﯞ ﯟ ﯠ ﯡ ﯢ ﯣ ﯤ ﯥ ﯦ ﯧ ﯨ ﯩ ﯪ ﯫ ﯬ ﯭ
Has the time not yet come for believers’ hearts to be humbled at the remembrance of Allah and what has been revealed of the truth, and not be like those given the Scripture before—˹those˺ who were spoiled for so long that their hearts became hardened. And many of them are ˹still˺ rebellious.

— Dr. Mustafa Khattab, the Clear Quran

57:17
ﯮ ﯯ ﯰ ﯱ ﯲ ﯳ ﯴ ﯵ ﯶ ﯷ ﯸ ﯹ ﯺ ﯻ ﯼ
Know that Allah revives the earth after its death.1 We have certainly made the signs clear for you so perhaps you will understand.

— Dr. Mustafa Khattab, the Clear Quran

57:18
ﯽ ﯾ ﯿ ﰀ ﰁ ﰂ ﰃ ﰄ ﰅ ﰆ ﰇ ﰈ ﰉ
Indeed, those men and women who give in charity and lend to Allah a good loan will have it multiplied for them, and they will have an honourable reward.1

— Dr. Mustafa Khattab, the Clear Quran

57:19
ﭑ ﭒ ﭓ ﭔ ﭕ ﭖ ﭗ ﭘ ﭙ ﭚ ﭛ ﭜ ﭝ ﭞ ﭟ ﭠ ﭡ ﭢ ﭣ ﭤ ﭥ ﭦ ﭧ
˹As for˺ those who believe in Allah and His messengers, it is they who are ˹truly˺ the people of truth. And the martyrs, with their Lord, will have their reward and their light. But ˹as for˺ those who disbelieve and reject Our signs, it is they who will be the residents of the Hellfire.

— Dr. Mustafa Khattab, the Clear Quran

57:20
ﭨ ﭩ ﭪ ﭫ ﭬ ﭭ ﭮ ﭯ ﭰ ﭱ ﭲ ﭳ ﭴ ﭵ ﭶ ﭷ ﭸ ﭹ ﭺ ﭻ ﭼ ﭽ ﭾ ﭿ ﮀ ﮁ ﮂ ﮃ ﮄ ﮅ ﮆ ﮇ ﮈ ﮉ ﮊ ﮋ ﮌ ﮍ ﮎ ﮏ ﮐ ﮑ ﮒ
Know that this worldly life is no more than play, amusement, luxury, mutual boasting, and competition in wealth and children. This is like rain that causes plants to grow, to the delight of the planters. But later the plants dry up and you see them wither, then they are reduced to chaff. And in the Hereafter there will be either severe punishment or forgiveness and pleasure of Allah, whereas the life of this world is no more than the delusion of enjoyment.

— Dr. Mustafa Khattab, the Clear Quran

57:21
ﮓ ﮔ ﮕ ﮖ ﮗ ﮘ ﮙ ﮚ ﮛ ﮜ ﮝ ﮞ ﮟ ﮠ ﮡ ﮢ ﮣ ﮤ ﮥ ﮦ ﮧ ﮨ ﮩ ﮪ ﮫ ﮬ ﮭ ﮮ
˹So˺ compete with one another for forgiveness from your Lord and a Paradise as vast as the heavens and the earth, prepared for those who believe in Allah and His messengers. This is the favour of Allah. He grants it to whoever He wills. And Allah is the Lord of infinite bounty.

— Dr. Mustafa Khattab, the Clear Quran

57:22
ﮯ ﮰ ﮱ ﯓ ﯔ ﯕ ﯖ ﯗ ﯘ ﯙ ﯚ ﯛ ﯜ ﯝ ﯞ ﯟ ﯠ ﯡ ﯢ ﯣ ﯤ ﯥ ﯦ
No calamity ˹or blessing˺ occurs on earth or in yourselves without being ˹written˺ in a Record before We bring it into being. This is certainly easy for Allah.


then also with those u get other direct physiological affects too…such as picked up weight, …not only from depression but also burning energy …as well as controlling your body through your mind…
ur balls can get sucked up
u cant urinate
u constipated
u over-eat …part of this supposed legal interrogation, uses radio frequency (RF or infra-red) shock, including dancing infront of the invisible RF beam like blocking and opening its penetrations, from where it comes from and cause disturbances to it so it wobbles, creates a wobble both visually and engages with your mind to force opposite pressures…ignoring it would too not be useful…such as ignoring it would be accepting defeat, not ignoring it would be applying pressure as some of the primary source descriptions above… agenda driven…in addition it messes around with ur balance or reading…since the RFs is wobbling around, ur concentration too is distracted…therefore concentrating harder would be too another dialectic of the application of this interrogation method which isnt interrogation…it is voice skull, no touch psychological torture components…the perception of ur environment both direct and indirect, internal and external, in the area around u is obviously the evoked potentials from whatever integrated use of humans, teams, and devices including harmonics which is hitting ur brain thru ur ear …and it goes wobble or maybe a clown does like one arm up and one arm down…how u like that and how u like that…no touch…not ur cochlear wobbling either

u can also be put to sleep or kept awake, sleep deprivation, as u can read in the brainwaves, its various states of consciousness, including when one is asleep during REM time…
when different psychological techniques are used in a team to a depressive state and actually controlled that u dont want to get up…

suppress ur lungs because u cant stop the voices…can make u get nauseated literally, can make u faint and feel dizzy even, blackouts, vaso vagels, hardening of the …cells in ur ears…caused from the sound torture…brain damage, as well as the sound maskings are to torture and create distortions of the brain…as described further below


Hearing is the process by which the ear transforms sound vibrations in the external environment into nerve impulses that are conveyed to the brain, where they are interpreted as sounds.
Sounds are produced when vibrating objects, such as the plucked string of a guitar, produce pressure pulses of vibrating air molecules, better known as sound waves.

xxxx, xxxx et. al

The ear can distinguish different subjective aspects of a sound, such as its loudness and pitch, by detecting and analyzing different physical characteristics of the waves. Pitch is the perception of the frequency of sound waves—i.e., the number of wavelengths that pass a fixed point in a unit of time. Frequency is usually measured in cycles per second, or hertz. The human ear is most sensitive to and most easily detects frequencies of 1,000 to 4,000 hertz, but at least for normal young ears the entire audible range of sounds extends from about 20 to 20,000 hertz. Sound waves of still higher frequency are referred to as ultrasonic, although they can be heard by other mammals. Loudness is the perception of the intensity of sound—i.e., the pressure exerted by sound waves on the tympanic membrane.

xxxx, xxxx et.al


The greater their amplitude or strength, the greater the pressure or intensity, and consequently the loudness, of the sound. The intensity of sound is measured and reported in decibels (dB), a unit that expresses the relative magnitude of a sound on a logarithmic scale. Stated in another way, the decibel is a unit for comparing the intensity of any given sound with a standard sound that is just perceptible to the normal human ear at a frequency in the range to which the ear is most sensitive. On the decibel scale, the range of human hearing extends from 0 dB, which represents a level that is all but inaudible, to about 130 dB, the level at which sound becomes painful.
In order for a sound to be transmitted to the central nervous system, the energy of the sound undergoes three transformations. First, the air vibrations are converted to vibrations of the tympanic membrane and ossicles of the middle ear. These in turn become vibrations in the fluid within the cochlea. Finally, the fluid vibrations set up traveling waves along the basilar membrane that stimulate the hair cells of the organ of Corti. These cells convert the sound vibrations to nerve impulses in the fibres of the cochlear nerve, which transmits them to the brainstem, from which they are relayed, after extensive processing, to the primary auditory area of the cerebral cortex, the ultimate centre of the brain for hearing.

xxxx, xxxx et.al

Only when the nerve impulses reach this area does the listener become aware of the sound mechanism of hearing; human earThe mechanism of hearing. Sound waves enter the outer ear and travel through the external auditory canal until they reach the tympanic membrane, causing the membrane and the attached chain of auditory ossicles to vibrate. The motion of the stapes against the oval window sets up waves in the fluids of the cochlea, causing the basilar membrane to vibrate. This stimulates the sensory cells of the organ of Corti, atop the basilar membrane, to send nerve impulses to the brain.

xxxx, xxxx et.al

Encyclopædia Britannica, Inc.
Transmission of sound waves through the outer and middle ear
Transmission of sound by air conduction

The outer ear directs sound waves from the external environment to the tympanic membrane. The auricle, the visible portion of the outer ear, collects sound waves and, with the concha, the cavity at the entrance to the external auditory canal, helps to funnel sound into the canal. Because of its small size and virtual immobility, the auricle in humans is less useful in sound gathering and direction finding than it is in many animals. The canal helps to enhance the amount of sound that reaches the tympanic membrane. This resonance enhancement works only for sounds of relatively short wavelength—those in the frequency range between 2,000 and 7,000 hertz—which helps to determine the frequencies to which the ear is most sensitive, those important for distinguishing the sounds of consonants.
Sounds reaching the tympanic membrane are in part reflected and in part absorbed. Only absorbed sound sets the membrane in motion. The tendency of the ear to oppose the passage of sound is called acoustic impedance. The magnitude of the impedance depends on the mass and stiffness of the membrane and the ossicular chain and on the frictional resistance they offer.
When the tympanic membrane absorbs sound waves, its central portion, the umbo, vibrates as a stiff cone, bending inward and outward. The greater the force of the sound waves, the greater the deflection of the membrane and the louder the sound. The higher the frequency of a sound, the faster the membrane vibrates and the higher the pitch of the sound is. The motion of the membrane is transferred to the handle of the malleus, the tip of which is attached at the umbo. At higher frequencies the motion of the membrane is no longer simple, and transmission to the malleus may be somewhat less
The malleus and incus are suspended by small elastic ligaments and are finely balanced, with their masses evenly distributed above and below their common axis of rotation. The head of the malleus and the body of the incus are tightly bound together, with the result that they move as a unit in unison with the tympanic membrane. At moderate sound pressures, the vibrations are passed on to the stapes, and the whole ossicular chain moves as a single mass. However, there may be considerable freedom of motion and some loss of energy at the joint between the incus and the stapes because of their relatively loose coupling. The stapes does not move in and out but rocks back and forth about the lower pole of its footplate, which impinges on the membrane covering the oval window in the bony plate of the inner ear. The action of the stapes transmits the sound waves to the perilymph of the vestibule and the scala vestibuli.
Function of the ossicular chain
In order for sound to be transmitted to the inner ear, the vibrations in the air must be changed to vibrations in the cochlear fluids. There is a challenge involved in this task that has to do with difference in impedance—the resistance to the passage of sound—between air and fluid. This difference, or mismatch, of impedances reduces the transmission of sound. The tympanic membrane and the ossicles function to overcome the mismatch of impedances between air and the cochlear fluids, and thus the middle ear serves as a transformer, or impedance matching device.
Ordinarily, when airborne sound strikes the surface of a body of water, almost all of its energy is reflected; only about 0.1 percent passes into the water. In the ear this would represent a transmission loss of 30 dB, enough to seriously limit the ear’s performance, were it not for the transformer action of the middle ear. The matching of impedances is accomplished in two ways: primarily by the reduction in area between the tympanic membrane and the stapes footplate and secondarily by the mechanical advantage of the lever formed by the malleus and incus. Although the total area of the tympanic membrane is about 69 square mm (0.1 square inch), the area of its central portion that is free to move has been estimated at about 43 square mm. The sound energy that causes this area of the membrane to vibrate is transmitted and concentrated in the 3.2-square-mm area of the stapes footplate. Thus, the pressure is increased at least 13 times. The mechanical advantage of the ossicular lever (which exists because the handle of the malleus is longer than the long projection of the incus) amounts to about 1.3. The total increase in pressure at the footplate is, therefore, not less than 17-fold, depending on the area of the tympanic membrane that is actually vibrating. At frequencies in the range of 3,000 to 5,000 hertz, the increase may be even greater because of the resonant properties of the ear canal.
The ossicular chain not only concentrates sound in a small area but also applies sound preferentially to one window of the cochlea, the oval window. If the oval and round windows were exposed equally to airborne sound crossing the middle ear, the vibrations in the perilymph of the scala vestibuli would be opposed by those in the perilymph of the scala tympani, and little effective movement of the basilar membrane would result. As it is, sound is delivered selectively to the oval window, and the round window moves in reciprocal fashion, bulging outward in response to an inward movement of the stapes footplate and inward when the stapes moves away from the oval window. The passage of vibrations through the air across the middle ear from the tympanic membrane to the round window is of negligible importance.
Thanks to these mechanical features of the middle ear, the hair cells of the normal cochlea are able to respond, at the threshold of hearing for frequencies to which the ear is most sensitive, to vibrations of the tympanic membrane on the order of 1 angstrom (Å; 1 Å = 0.0000001 mm) in amplitude. On the other hand, when the ossicular chain is immobilized by disease, as in otosclerosis, which causes the stapes footplate to become fixed in the oval window, the threshold of hearing may increase by as much as 60 dB (1,000-fold), which represents a significant degree of impairment. Bypassing the ossicular chain through the surgical creation of a new window, as can be accomplished with the fenestration operation, can restore hearing to within 25 to 30 dB of normal. Only if the fixed stapes is removed (stapedectomy) and replaced by a tiny artificial stapes can normal hearing be approached. Fortunately, operations performed on the middle ear have been perfected so that defects causing conductive impairment often can be corrected and a useful level of hearing restored.
Function of the muscles of the middle ear
The muscles of the middle ear, the tensor tympani and the stapedius, can influence the transmission of sound by the ossicular chain. Contraction of the tensor tympani pulls the handle of the malleus inward and, as the name of the muscle suggests, tenses the tympanic membrane. Contraction of the stapedius pulls the stapes footplate outward from the oval window and thereby reduces the intensity of sound reaching the cochlea. The stapedius responds reflexly with quick contraction to sounds of high intensity applied either to the same ear or to the opposite ear. The reflex has been likened to the blink of the eye or the constriction of the pupil of the eye in response to light and is thought to have protective value. Unfortunately, the contractions of the middle-ear muscles are not instantaneous, so that they do not protect the cochlea against damage by sudden intense noise, such as that of an explosion or of gunfire. They also fatigue rather quickly and thus offer little protection against injury sustained from high-level noise, such as that experienced in rock concerts and many industrial workplaces.
Transmission of sound by bone conduction

There is another route by which sound can reach the inner ear: by conduction through the bones of the skull. When the handle of a vibrating tuning fork is placed on a bony prominence such as the forehead or mastoid process behind the ear, its note is clearly audible. Similarly, the ticking of a watch held between the teeth can be distinctly heard. When the external canals are closed with the fingers, the sound becomes louder, indicating that it is not entering the ear by the usual channel. Instead, it is producing vibrations of the skull that are passed on to the inner ear, either directly or indirectly, through the bone.
an example
Thumping sound in your ears is usually caused by noise stemming from the surrounding blood vessels. It can be nothing but can also be something serious!
Thumping sound in ears like a ringing, rushing, whistling or birds twittering, commonly known as tinnitus, is often caused by an external source and not an issue in the ear itself. While the thumping sound in the ears is known as pulsatile tinnitus, it matches the rate of your heart beat. The sound may come and go, but when it is present you will hear a constant noise that does not regularly change in pitch or loudness. Learning about the different causes that can lead to this condition will help you determine how to properly manage your condition.
Causes of Thumping Sound in Ears
Typically, a thumping sound in the ear will match the rate of your heart. Checking your pulse while you are experiencing the sound will allow you to confirm this. After you determine the pace the thumping is occurring in, you can begin to narrow down what is causing the problem.
Generalized increased blood flow: Quickly flowing blood makes more noise than blood that moves slowly throughout the body. Strenuous exercise, pregnancy, over active thyroid or anemia can cause the blood in the body to flow more readily, leading to a thumping noise in the ears.

Localized increased flow: If a single blood vessels or a localized group of blood vessels is dealing with an increased rate of blood flow you can hear it in your ears. This is typically caused when the stapedial artery in the middle ear continues to have a strong level of blood flow. This vessel should close before birth, but in some cases it will remain functional. Tumors or areas pressing on the vessels in the ear can also lead to a thumping noise.
Turbulent blood flow: Hardening of the arteries or atherosclerosis can cause the blood flow near the ears to become turbulent. This will cause the blood flow in the ear to become noisy and disruptive, similar to the sound of rushing water.
Altered awareness: Multiple conditions can cause altered awareness that leads to a thumping sound in the ears. You may develop heightened sensitivity that causes you to be more aware of the noise made by the blood vessels in the ears. As these auditory pathways become more pronounced, the rushing sound can become louder. Altered awareness can also occur when hearing loss begins to occur. As your body becomes less able to take in sounds from the outside, it becomes more conscious of the sounds that occur within the body.
Miscellaneous: Benign intracranial hypertension can cause a thumping sound in the ears. This sound will be accompanied by headaches and visual disturbances and is more common in middle aged women than other groups. This condition may also be referred to as idiopathic intracranial hypertension or pseudotumor cerebri.


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depends what up n down n down n up and or which combinations…therefore collections of stories and inputs, all part of that…purposeful ensnaring…
and then theres more to it
to destroy u into every organ…
no touch torture…brainwaves as the direct targets, and the system of your entire body…brain to heart for example…
WHAT ARE BRAINWAVES?
add the brainwaves like in adams numerology sequence…
At the root of all our thoughts, emotions and behaviours is the communication between neurons within our brains. Brainwaves are produced by synchronized electrical pulses from masses of neurons communicating with each other.
Brainwaves are detected using sensors placed on the scalp. They are divided into bandwidths to describe their functions (below), but are best thought of as a continuous spectrum of consciousness; from slow, loud and functional – to fast, subtle, and complex.
It is a handy analogy to think of brainwaves as musical notes – the low frequency waves are like a deeply penetrating drum beat, while the higher frequency brainwaves are more like a subtle high-pitched flute. Like a symphony, the higher and lower frequencies link and cohere with each other through harmonics.
AND SOUND MASKING?
corrupt devices
corrupt papers
corrupt badges
corrupt right to silence
corrupt legal procedure
corrupt privilege’s against right to self incrimination… yes right…because of corrupt legal structure …enforcing corruption…
corrupt interrogation…
corrupt community policies and desperation to maintain the legal system which kept… who in power?
therefore?
distances and eves dropping and software?
i shouldn’t be able to hear u from here…
let alone what this cheap software is picking up on…
masking…
how can i floes a mask?…spectrums from where? and why? and when changed?
why can i here it from, here…the legal distance…and the legal decibels are…


Nuisance neighbours law
therefore,
lands on the police station,
muck the paperwork around for incoherences to social media profile for example…
which is already caught out as being made corrupted
therefore the question of which system and are those the right profiles
doesnt matter…
since it would be the correct move to file it on the correct persons for coherences…
thus so n so n so
and therefore too
taking down the system which doesnt want to listen
and make claim of which system
the users of it…
corrupt system blame games and participants
exactly
usually presumption would be…giving all the moves so they can work around it…
or is there no system…
shame and shame shame again
taking which laws into my own hands and pretending to be what…would apply to security company service providers licenses and taking the law into your own hands…as well as outlaw law, then presumably the critical theories and dialectical use of the moral high ground thinking around right and wrong would expose the critical path of the law, the correct route, enabling a buffer as well as tall wall to get around or over of the resistance tactical approach…
lool
whats happening with the ropes around their…necks
who knows when its just tight enough…as i tie it tighter and tighter and tighter…
pass on the system to who…psychoses to say…i cant because he and because she…blackmailing and so on and so forth…
comes back to the police station and entrapment as corrupt too
therefore ambiguity no excuses and neither any family participants…
like i said…

Then sitting at distances with charges on forever has no good intent and no good excuses for psychopathology too right

Sitting at distances for Interrogation…
For he say she say…

distances technology for he say she say? for first come first served, for entrapment?
For evidentiary rule…
For prolonged periods..
What about detainee rights
48 hrs, however after 4pm in south african law, may be detained for longer
Lawyers presence
So I can write it down then why u at distances

Why u conducting interviews as interrogations of social media… And investigations of social media
… Aren’t u suppose to data gather and all that
Then why u at distances interviewing and interrogating
Too if it were a risk to life…?
As well as community standards
Am for certain u are going to. Come to racketeering as 1
Illegal to conduct investigations over social media 2
Why haven’t u called the police to pick up 3
That 1 rule, u must come here and neither interrogation can happen in such a setting… It’s a law not a rule under evidentiary rule too… And also entrapment part of the legal procedures

social media dossiers are corrupt because what do u need a social media investigator for which is only worth the value of gathering data…
take to the police to sign off a dossier?…
charges in social media too, the minute the person is off social media, there is no 1 or 2 or 3 or 4 days, legal system or procedure or law,
instantly stops…
the business ends right there and then…
besides that too being illegal but u cant get it thru when there is only 1 objective
boxing the person in to isolation, does it make any sense?

havent even launched an attack yet, and all the things is in their hands…lool

harrk lol
hark the herald angels sing
so many print outs in the hoax file
it belongs in the bin…
u would be correct
there are other instances which tell u
the piece of paper belongs in the bin
😂😂

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