Sedona Summer Institute Presentation

1. July 2010 Developing a Comprehensive Suicide Deterrent Strategy for those with Serious Mental Illness David W. Covington, LPC, MBA Chief of Adult Services [email_address] Version 1.0

2. What we used to think…

3. What we know today…

14. FY2007 2 Suicides FY2008 3 Suicides FY2009 4 Suicides FY2010 12 Suicides Projected

16. “ Living Healthy Working Well”® Achieving Better Outcomes, Improved Life-span & Richer Quality of Life Six Cross-Cutting Leadership Principles 3 C r i s i s P l a n n i n g 4 H e a l t h / W e l l n e s s & L i f e s p a n L o n g e v i t y 1 2 S u i c i d e P r e v e n t i o n & I n t e r v e n t i o n C l i n i c a l C a r e M g m t Note: Psychiatric inpatient care may be an important treatment of last resort when medically necessary and community supports are insufficient. Four Clinical Initiatives/Key Programs

17. Site of more than 1,200 deaths by suicide.

20. Maricopa Workforce Survey (N=1,641)

21. Behavioral Health Workforce Survey (10/2009)

22. I Know Someone Who Died by Suicide

23. Question 16 of 16.

24. Question 13. TRAINING

25. Question 14. SKILLS

26. Question 15. SUPPORT

27. False. Over one million Americans attempt suicide each year, and over eight million have serious thoughts. Question 2. Prevalence of Suicidal Desire

28. Question 2. Prevalence of Suicidal Desire

29. False. Insufficient attention has been given to the very high suicide rates among elderly, nearly 50% higher than 10-24 group. Question 3. Youth Versus Older Risk Despite lower rates, youth deaths obviously account for much higher % of total deaths, e.g., 12% versus 0.3%. Age Attempts Per Death All Ages 25:1 Youth 100-200:1 65 and older 4:1

30. Question 3. Youth Versus Older Risk

32. Question 4. SMI Versus General Population

33. Question 5. Direct Suicide Questioning Elizabeth Kubler-Ross. Compared our culture’s feelings about talking openly about death and dying as looking directly into the sun. We tend to only glance at it because of its paralyzing glare and tendency to emotionally disable. She brought sun glasses by referring to death as a normal human process and event. The American Association of Suicidology believes the same is true for those doing this work, talking about death and suicide openly helps us see the person struggling and provide vital human contact and support.

34. Question 5. Direct Suicide Questioning

35. Question 6. Is Suicide Preventable? Not true. Many individuals struggle with ambivalence to the last moments, a fight between the will to live and the desire to end their pain.

36. Question 6. Is Suicide Preventable? In 1975, Dr. David Rosen wrote an in-depth study of six people who survived jumping from the bridge. Almost unanimously, the survivors said their "will to live had taken over" after they survived. "I was refilled with a new hope and purpose in being alive.” In 1978, Dr. Richard Seiden published "Where Are They Now?," a study of 515 people who were prevented from jumping from the bridge. He found only 6 percent went on to kill themselves. (San Francisco Chronicle, Nov. 2005)

37. Question 6. Is Suicide Preventable?

38. Questions 7 & 8. Planting the Idea Myth Not supported. Research has refuted this idea. Suicidal thoughts are one of the DSM symptoms of major depression. 8.3 million Americans had serious thoughts of suicide last year.

39. Question 7. Planting the Idea Myth

40. Question 8. Depression Linked to Suicide

41. Question 9. Emergency Intervention Do No Harm. This provocative question was meant to generate dialogue around the importance of emergency intervention by professionals. Our interest is “our” ethics to do no harm and help save lives. SAMHSA is currently producing an emergency intervention standard protocol for guidance on supporting those at imminent risk.

42. Question 9. Emergency Intervention

43. Question 10. Why People Die by Suicide Not true. It's often a process. Most gave some indication they were unhappy, depressed, or considering suicide. We want to combat stigma head-on so that there is more willingness to discuss openly.

44. Why People Die by Suicide, Dr. Thomas Joiner Capability + Intent

45. Why People Die by Suicide, Dr. Thomas Joiner Highest Suicidal Risk exists when the following three components are all present:

46. Question 10. Why People Die by Suicide

47. Question 11. Desire to End Psychic Pain Not generally. They want their pain to end – they don't necessarily want to die. Joiner’s model suggests thwarted belongingness and perception of burdensomeness.

48. Question 11. Desire to End Psychic Pain

49. Question 12. Axis II – Borderline Personality Not supported . Approximately 10% end up dying from their suicidal gestures. The life-time prevalence of suicide for Schizophrenia is also between 5% and 10%. “ Why People Die by Suicide” page 18-20

50. Question 12. Axis II – Borderline Personality

52. Adaptive Change Structure (2009-2011) Workgroups Public Sector Community Behavioral Health putting suicide prevention and intervention at the core of its business. Targets of Initiative Adults C&A 1. PNOs (SMI) 2. GMH/SA 3. Children’s PNOs

56. Original Founding Membership Steering Committee Representative Agency Senator Huppenthal Arizona Legislature Beth Alexander Maricopa County Public Defender Gary Brennan Children’s PNO - QCN Chief Broderick Superior Court of Arizona, Probation Nancy Diggs Office of the Monitor Christy Dye Adult PNO - Partners in Recovery Penny Free GMH/SA - TERROS Bill Kennard NAMI Arizona Nick Margiotta City of Phoenix Police Laura Nelson ADHS/DBHS Dr. Carol Olson MIHS County Hospital Melissa Taylor Arizona Legislature Dr. Thomas Joiner Florida State (Advisory Capacity)

58. Maricopa Programmatic Suicide Deterrent System Project: Five Key Threads

61. ASIST – Applied Suicide Intervention Skills Training 2,000+ Trained Staff Step 1: Certified Trainers Step 2: Monthly ASIST Step 3: National Webinars Step 4: Culture Change

62. Workforce Survey Findings ASIST . In comparing how groups performed on the survey, we found those with ASIST training basically tied those who were clinicians. As expected, nurses and physicians are also tremendous supports. Category N Place ASIST Certified T4T Trainers 29 1st Nurses/Physicians 139 2nd Clinicians 319 3rd ASIST Trained 152 3rd Administrators 170 5th Case Managers 453 5th

63. Comparisons for Target Answers

64. Equipping Maricopa’s Work Force with ASIST - 2,000+ in 2010 41% Updated 6/22/2010 The November 2009 workforce survey demonstrated that nearly 10% of the Maricopa workforce received the two-day ASIST training prior to this initiative (n=152). The data in this slide covers only additional staff newly trained in ASIST in December 2009 and calendar year 2010. 2000 823 Agency # Trained Target % Trained #2-Day Sessions Next Training # T4T TERROS 259 450 58% 9 6/29 4 Southwest Network 139 450 31% 10 6/24 3 CHOICES 111 450 25% 10 6/24 2 Valle Del Sol 70 150 47% 4 TBD 1 Quality Care / FIC 31 200 16% 2 TBD 2 Partners In Recovery 79 250 32% 4 TBD 1 People Of Color 34 250 14% 3 TBD 0 Community Bridges 79 200 40% 3 7/14 3 Ebony House 0 25 0 0 TBD 0 Jewish Family 0 135 0 0 TBD 0 NOVA 21 50 42% 0 TBD 0 SWBH 0 135 0 0 TBD 1 TOTAL 823 2,745 30% 45 17

77. David W. Covington, LPC, MBA Chief of Adult Services [email_address] twitter.com/davidwcovington Shawn Thiele, LCSW Chief, Child and Youth Services [email_address]