1. Zero Suicide in Texas (ZEST) Zero Suicide in Texas (ZEST) Collaborative Call: January 2016 DSHS: DSHS: Jenna Heise TIEMH: TIEMH: Dr Molly Lopez Dr. Erica Shapiro

2. WORKFORCE SURVEY DATA  ASIST Training: 4.5% (58)  ASK Training: 8.7% (113)  Other training: 20.1% (261)  Unsure about name of training: 18.3% (237)  I have not had a specific training: 48.5% (629 )

3. WORKFORCE SURVEY DATA QuestionSome TrainingNo Training I have received the training I need to engage and assist those with suicidal desire and/or intent. 64.4 %15.3% I have the skills to screen and assess a patient/client's suicide risk. 54.6%16.7% I have the support/supervision I need to engage and assist people with suicidal desire and/or intent. 54.6%16.7% I am confident in my ability to assess a patient/client's suicide risk. 65.2%29.6% I am confident in my ability to manage a patient/client's suicidal thoughts and behavior. 56.2%20.8% I am confident in my ability to treat a patient/client's suicidal thoughts and behavior using an evidence-based approach such as DBT or CBT 53.3%13.7%

4. SUICIDE SCREENING Goal : All children and adults served within the public mental health system will be screened for suicide risk using the Columbia Suicide Severity Rating Scale by providers trained in its use.

5. COLUMBIA SUICIDE SEVERITY RATING SCALE (C-SSRS) http://www.cssrs.columbia.edu/ Versionsof the C-SSRS: Versions of the C-SSRS: Subscales: Severity of Ideation Suicidal Behavior Intensity of Ideation Suicidal Behavior Lethality Frequency of Screening? Versions of the C-SSRS  Screener Version  Lifetime/Recent Version  Since Last Visit Version  Pediatric Versions

6. INDICATOR OF HIGH RISK ON THE C-SSRS  Active Suicidal Ideation with Some Intent, but No Specific Plan in Last 30 Days: Have you had these thoughts and had some intention on acting upon them?  Active Suicidal Ideation with Specific Plan and Intent in Last 30 Days: Have you started to work out the details of how you would kill yourself? Do you intend to carry out these plans?  Any Suicidal Behaviors during past 3 months:  Actual Attempt  Interrupted Attempt  Aborted or Self-Interrupted Attempt  Preparatory Acts or Behaviors

7. COLUMBIA SUICIDE SEVERITY RATING SCALE (C-SSRS) TRAINING: Who should participate in training? All behavioral health providers; staff providing hotline & crisis services, clinical assessments & medication management, rehabilitation & skills training, mental health or substance abuse counseling, peer support providers, & case management. C-SSRS Training: http://zerosuicide.actionallianceforsuicideprevention.org/sites/zerosui cide.actionallianceforsuicideprevention.org/files/cssrs_web/course.htm Community Expansion: Training in the use of C-SSRS to staff within other systems.

8. IMPLEMENTATION OF THE C-SSRS

9. RISK ASSESSMENT Goal: All children and adults within the public mental health system who are identified as potentially at risk during a suicide screening will receive an evidence-informed suicide risk assessment. This suicide risk assessment should include all of the core components of an effective risk assessment.

10. CASE APPROACH Raising the topic of suicide – normalization and shame attenuation Raising the topic of suicide – normalization and shame attenuation “You know, when my clients are feeling as stressed out and depressed as you have been feeling, they sometimes have thoughts about killing themselves. I wonder if you have been having thoughts like that.” “Considering all of the pain that you have been experiencing, I am wondering if you have had any thoughts about killing yourself?” “Have you had any fleeting thoughts about suicide, even for a moment or two?” Real Suicide Intent = Stated Intent + Reflected Intent + Withheld Intent Shea, 2009

11. CASE APPROACH Behavioral Incident – asking factual questions Behavioral Incident – asking factual questions “Tell me what happened next.” Gentle assumption – frame the question as an assumption of the positive “What other ways have you thought about killing yourself?” Denial of the specific – following a general question with specifics “Have you thought about shooting yourself?” “Have you thought about overdosing?” “Have you thought about hanging yourself?” Amplification of symptoms – suggesting an amount at the upper limits “When your thoughts of suicide are most intense, what percentage of the day are you thinking about suicide – 70%, 80%, 90%?” Real Suicide Intent = Stated Intent + Reflected Intent + Withheld Intent Shea, 2009

12. C ORE C OMPONENTS OF A R ISK A SSESSMENT Suicide Inquiry - Suicide Inquiry - Current and previous suicidal thoughts, plans, behavior, and intent Warning signs – Warning signs – characteristics that are temporally related to the acute onset of suicidal behaviors (hours to a few days) Risk factors – Risk factors – characteristics that statistically put an individual at increased risk Protective factors – Protective factors – characteristics that statistically indicate lower risk RISK ASSESSMENT

13. C ORE C OMPONENTS OF A R ISK A SSESSMENT CONT. Determine risk level – Determine risk level – develop appropriate treatment plan to address risk in least restrictive environment Documentation - Documentation - document risk level, rationale, treatment plan, and follow-up

14. WHAT ASPECTS OF YOUR RISK ASSESSMENT COULD BET STRENGTHENED? Best practices in risk assessment Best practices in risk assessment Clear policy around risk assessment Clear policy around risk assessment Substantial training to support risk assessment Substantial training to support risk assessment Clear process for decision making Clear process for decision making Level of risk clearly communicated to all staff? Level of risk clearly communicated to all staff?

15. ZEST GROUPS & MEETING DATES Wednesdays, 2pm CST Fridays, 9am CST Pecan ValleyAndrews Center Gulf Bend CenterHeart of Texas Center for Life Resources Nueces County Texana CenterTri-County Services Betty Hardwick CenterHarris County participants Helen Farabee Center Brazos Valley Star Care Lubbock Month Wednesdays, 2pm CST Fridays, 9am CST November Nov 18 h Nov 20 th December No Call January (2016) Jan 27 th Jan 29 th February Feb 24 th Feb 26 th March Mar 23 rd Mar 25 th April Apr 27 th Apr 29 th May May 25 th May 27 th June Jun 22 nd Jun 24 th July Jul 27 th Jul 29 th August Aug 24 th Aug 26 th