Experts on the Zero Suicide Model

The Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30 featured 11 outstanding presentations by leading experts on the Zero Suicide Model for healthcare. The presentations covered the model’s history, evidence base, core elements, screening and assessment tools, use in primary care, emergency departments, and crisis care systems, and special implications for preventing suicide among Black adolescents, LGBTQ youth, and members of tribal nations.

DOWNLOAD Click here to download a PDF of summaries of the 11 “Aim for Zero” presentations, compiled by The Sophie Fund.

Here is a listing of the 11 individual summaries:

“Vision Zero: Eliminating Suicide & Transforming Healthcare” C. Edward Coffey, a professor of Psychiatry and Behavioral Sciences at the Medical University of South Carolina [WATCH VIDEO]

“If Preventing Suicide is Our Target, Suicide Safe Care—in all Healthcare Settings—Is the Bullseye” Michael Hogan, former New York State Commissioner of Mental Health and co-developer of the Zero Suicide Model [WATCH VIDEO]

“A National Perspective on Zero Suicide in Healthcare” Richard McKeon, Branch Chief for Suicide Prevention at the Substance Abuse and Mental Health Services Administration (SAMHSA) [WATCH VIDEO]

“Implementing Zero Suicide in Health Systems” Brian Ahmedani, director of the Center for Health Policy and Health Services Research at the Henry Ford Health System [WATCH VIDEO]

“Best Practices for Primary Care” Virna Little, Chief Operating Officer & Co-Founder of Concert Health, a national organization providing behavioral health services to primary care providers [WATCH VIDEO]

“Zero Suicide Work in Emergency Departments: Opening Pandora’s Box” Edwin Boudreaux, professor of Emergency Medicine, Psychiatry, and Quantitative Health Sciences at the University of Massachusetts Medical School [WATCH VIDEO]

“The Promise of 988: Crisis Care for Everyone, Everywhere, Every Time” [WATCH VIDEO] David W. Covington, member of the Executive Committee of National Action Alliance for Suicide Prevention

“From Equality to Equity in LGBTQ Youth Suicide Prevention” Keygan Miller, Senior Advocacy Associate for The Trevor Project [WATCH VIDEO]

“Singing in a Strange Land: Suicide Prevention for Black Youth” Sherry Molock, associate professor in the Department of Psychological & Brain Sciences at George Washington University [WATCH VIDEO]

“Making Suicide a Never Event – Zero Suicide in Indian Country” Sadé Heart of the Hawk Ali, Tribal Lead and a Senior Project Associate at the Zero Suicide Institute and former Deputy Commissioner of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services [WATCH VIDEO]

“A Zero Suicide Story” Wykisha McKinney, Zero Suicide Program Manager at The Harris Center for Mental Health & IDD (Intellectual or Developmental Disability) [WATCH VIDEO]

READ MORE: The Zero Suicide Model in Tompkins County

If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.

Zero Suicide: A Personal Story

Wykisha McKinney lost her brother Johnny to suicide in 2004 and subsequently struggled with suicidal thoughts herself as she coped with a beloved sibling’s death.

In “A Zero Suicide Story,” a presentation at the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30, she shared her personal story to illustrate the importance of the Zero Suicide Model’s commitment to patient care and a “just culture” for care providers, and the key role that loss survivors like herself play in implementing safer suicide care.

McKinney, Zero Suicide Program Manager at The Harris Center for Mental Health & IDD (Intellectual or Developmental Disability), said that Johnny was a Texas A&M University grad, an advocate for Black LGBTQ people, and a case manager at a Houston-area clinic for men who were HIV positive.

He was diagnosed with AIDS in 2000 and the illness took a heavy toll on him physically and emotionally, she said. He took his own life shortly after his doctor advised him to be admitted to the hospital to treat his worsening infection.

Last in a Series about the Zero Suicide Model for Healthcare

McKinney said that her brother’s death led her to become a suicide prevention advocate who asks many questions:

“What if my brother would have been screened for suicide risk on his routine visit to his doctor who was aware that he was HIV positive, who was aware that he had had an escalation in his health problems, and who was aware that his health issues were getting to the point where he was thinking about and discussing end of life decisions? What if the hospital system and the clinics prepared their doctors who all worked with HIV positive folks diagnosed with AIDS were all trained in how to screen and assess for suicide, and collaboratively create a safety plan? What if they were able to connect Johnny to a mental health professional? So those [steps] would help to close those gaps.”

The Zero Suicide Model, McKinney said, “answers the ‘what if.’ It tells us what could happen if these things take place. It tells us what could happen if we add or tweak our policies and procedures in a way that could promote life-saving practices.”

McKinney said that the Zero Suicide framework is defined by a system-wide organizational commitment to safer suicide care and behavioral health care. “It represents a culture shift away from fragmented suicide care toward a holistic and comprehensive commitment to patient safety as the most fundamental responsibility of healthcare,” she said.

“For me as a survivor of suicide loss, someone whose brother was actively involved in the health system and visited a health care practitioner the day before he died, I see the value of Zero Suicide. My personal story speaks to the importance of Zero Suicide.”

She explained how Zero Suicide promotes a just culture of practice for healthcare practitioners. “The Zero Suicide framework is not designed to point fingers at people, which is what’s wonderful about it,” she said. “Oftentimes when you implement new new procedures or new practices or when you tell your organization we’re going to evaluate how we do things, people may think that you mean you want to evaluate what I did or what I’m doing wrong. But the Zero Suicide framework is designed to look at the system as a whole. So it looks at that system and it identifies where those gaps are.”

Survivors of suicide loss regularly ask themselves about the “what-ifs,” McKinney said. “I’m not in any way saying that my brother’s medical professionals were responsible for his death, woulda, coulda, shoulda or he would be here today. What I’m saying is that the Zero Suicide framework provides an opportunity where the Johnnys of the future or the Johnnys of today have more opportunity to receive help and care throughout their time with their doctors.”

McKinney said that her position at Texas’s Harris Center reflects how engaging suicide attempt survivors and loss survivors is a key component of the Zero Suicide framework.

“My perspective of the healthcare system and the mental health care system is a little bit different,” she said. “I can see both perspectives, the perspective of the organization and the perspectives of a survivor of suicide loss. It creates an equitable workplace. It helps with quality improvement as it inspires innovation to improve the services. Sometimes our executives have a perspective of what of what may be happening and it may be a little bit different from what actually is happening.

“And so engaging those with lived experience. especially those who’ve had experience with working through your health system, can help to open your eyes and enlighten you on how these systems that are embedded in our policies and procedures work. It helps to develop employee and volunteer skills and their knowledge of suicide prevention beyond the theoretical and textbook learning. For the organization, it builds community involvement, it helps us to build relationships of trust with the communities and individuals.”

Adoption of the Zero Suicide framework also provides valuable opportunities to people with lived experience, McKinney said. “It transforms our painful experience into creating positive solutions,” she explained. “For me, as a survivor of suicide loss, helping is healing. Helping was my therapy.”

READ MORE: The Zero Suicide Model in Tompkins County

If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.

Zero Suicide: Suicide Prevention for Black Youth

Sherry Molock, associate professor in the Department of Psychological & Brain Sciences at George Washington University, highlights the special suicide risk factors for youth of communities of color, and the need to use culturally salient approaches in suicide prevention, suicide risk assessment, and referral practices.

Suicide rates for Black children aged 5-12 are approximately double the rates for white children of similar ages, according to research data cited by Molock in her presentation, “Singing in a Strange Land: Suicide Prevention for Black Youth,” at the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30.

She pointed to other research that indicated that suicide attempts are greater among LGBTQ college students of color. She said that suicide attempts rose by 73 percent between 1991-2017 for male and female Black adolescents, while injury by attempt rose by 122 percent for adolescent Black males during that time period.

Part 9 in a Series about the Zero Suicide Model for Healthcare

Another important finding, Molock said, comes from the 2019 Youth Risk Behavior Survey conducted by the Centers for Disease Control and Prevention. While the survey showed lower percentages of Black high school students compared to their peers reporting feeling sad or hopeless or considering suicide, the percentage of Black students who actually had made suicide attempts was significantly higher (11.8 percent) compared to their white (7.9 percent) and Hispanic (8.9 percent) peers. “That trend has been changing for about the last five years,” she said.

Molock called for more studies on youth of communities of color, better funding for Black researchers studying health disparities, and culturally competent providers for communities of color.

Molock cited lack of access to healthcare and economic instability as important risk factors for suicide among African Americans. She cited a Johns Hopkins University suicide study in Maryland that showed while suicide rates were cut in half for whites during the Covid-19 pandemic, they doubled for Black residents of the state.

“The negative impact of Covid is disproportionate in communities of color,” she explained. “The industries that were most heavily hit by the pandemic were the hospitality service communities, professions where Blacks and Latinos are more likely to work. The rates probably reduced for whites because they’re more likely to have a job that allows them to work from home, they have access to better healthcare, and more benefits for economic relief.”

Experiencing racial discrimination is among the particular factors placing African Americans at risk for suicide, Molock said. But she noted that nonetheless Black community norms don’t generally support seeking professional mental help treatment.

She explained that Black youth are more likely to discuss problems with family members or are discouraged from sharing information about mental health concerns with “outsiders.” She said that mental health help seeking may be more stigmatizing for Black adolescents, that their peers may not be supportive of seeking treatment, and that particularly Black males seek professional help as a last resort.

Structural barriers and social determinants of health hinder access to treatment, Molock said. She pointed to research that Blacks on average receive poorer quality of care than whites, and that Black youth are less likely to receive care for depressive symptoms and suicide attempts.

Rates of engagement in treatment and treatment completion are lower in Black adolescents compared to white peers, she said. Molock said that Black youth may be misdiagnosed or underdiagnosed because assessment tools are not designed to assess culture-specific expressions of depression.

“We have to ask ourselves,” she said, “are the traditional measures or questionnaires that we use to assess or even screen for depression a one-size-fits-all, or do we need to have more nuance in the way that we ask questions so that we can get at this phenomenon for Black youth?”

She said another key to suicide prevention in communities of color is increasing protective factors and decreasing risk factors.

“One of the most important ways that we can prevent suicide is to make sure that people have stable housing, they have food security, and stable employment,” she said. “If we can give people the basics of their necessities are fulfilled, then a lot of the stress and risk factors that are associated with suicide decrease significantly.

“Every child in the United States should have financial security. They should grow up in stable communities, have stable housing and have job training programs to increase financial stability. We should also strengthen access and delivery of suicide and mental health care.”

Molock called for peer programs that promote help-seeking behavior and services that partner with faith-based and other community organizations where people of color are more comfortable and trusting discussing personal problems.

READ MORE: The Zero Suicide Model in Tompkins County

If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.

Zero Suicide: LGBTQ Youth Suicide Prevention

Keygan Miller, Senior Advocacy Associate for The Trevor Project, spotlights the wide disparity in suicide risk for LGBTQ youth compared to straight cisgender youth.

In a presentation, “From Equality to Equity in LGBTQ Youth Suicide Prevention,” to the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30, Miller cited Trevor Project research indicating that 42 percent of LGBTQ youth—as many as 1.8 million young people—seriously considered taking their own lives in the past year.

That’s four times greater than their peers, they said.

“Most of us know that youth suicide in general is a problem,” Miller explained. “It’s the second leading cause of death amongst young people ages 10 to 24. But for LGBTQ youth in particular, this is dire.”

Miller explained that various aspects of the lives of LGBTQ youth such as discrimination and bullying help explain the disparity. They said that 75 percent reported that they had experienced discrimination based on sexual orientation or gender identity. “Discrimination comes from adults in their lives, peers in their lives, and outside authorities,” they said.

For example, Miller said, 48 percent of LGBTQ youth reported wanting counseling from a mental health professional but were unable to receive it in the past year. Discrimination is felt even when it comes to using basic services. Miller said that 58 percent of transgender non-binary youth reported being discouraged from using restrooms that correspond with their gender identity.

Part 8 in a Series about the Zero Suicide Model for Healthcare

Miller cited social pressures experienced by LGBTQ youth. They said two in three reported that someone had tried to convince them to change their sexual orientation or gender identity. “Or it could be something as terrible as ‘conversion therapy,’ which is the idea that we can change someone’s sexual orientation or gender identity through a variety of means, which is a discredited and dangerous practice,” they said.

LGBTQ youth are also affected by the nation’s politics, Miller said. They said that three-quarters felt that the recent political climate has impacted their mental health or sense of self—”everything from something in your day-to-day life such as using the bathroom all the way up to the narratives that are being woven by people in the highest of power in this country.”

All this, Miller explained, affects the “crisis threshold” of LGBTQ youth. “We have to look at baseline vulnerability,” they said. “If someone has a lower baseline vulnerability when a stressor is introduced, they are not as likely to meet that crisis threshold as someone who has a higher baseline vulnerability. This is where we end up with a lot of suicidality.”

Miller said that vulnerability is particularly important for people who hold multiple marginalized identities. They noted that while Black LGBTQ youth suffer similar rates of depression as their LGBTQ peers, they are significantly less likely to receive care.

Mental health providers and other adults can take a number of actions to support LGBTQ youth, Miller said. They pointed to research indicating that having just one supportive adult in their life lowers the risk of suicide by 40 percent. “Imagine if they had multiple supporting adults in their lives and how much impact that could have,” they said.

Understanding identity issues, and the value of using preferred pronouns, enables adults to be more supportive, Miller said. “One of the things that our young people face in the mental health space is having to educate their mental health providers about their identity from a very baseline level,” they said. “So, if we have that baseline understanding, then we can really dive into what that identity means for that young person as opposed to having a 101-level conversation.”

Miller called for supportive and inclusive public policies to raise the baseline vulnerability level of LGBTQ youth, tackling challenges such homelessness, economic instability, and access to physical healthcare and mental health care. In schools, they said, this involves training teachers in mental health and suicide prevention, having crisis services in place, and educating students about mental health.

READ MORE: The Zero Suicide Model in Tompkins County

If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741. For LGBTQ youth support from The Trevor Project, call 1-866-488-7386 or text ‘START’ to 678-678.

Zero Suicide: Crisis Care for Everyone, Everywhere, Every Time

David W. Covington, member of the Executive Committee of National Action Alliance for Suicide Prevention, begins a call for upgrading mental health crisis response systems in America with an analogy to a 2010 accident at a gold and copper mine near Copiapó, Chile.

Thirty-three miners became trapped nearly a half mile underground, but were brought safely to the surface after 69 days through an intense international rescue effort, Covington recalled in his presentation, “The Promise of 988: Crisis Care for Everyone, Everywhere, Every Time,” to the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30.

“That obvious, caring, engaging, supporting, global collective impact and outreach has not been what we’ve seen for those whose darkness is not being trapped in a mine but having some kind of a mental health, substance use, or suicidal crisis,” Covington said. “For those individuals, it’s been far different.”

Covington’s presentation outlined the new vision for crisis care—“for anyone, anywhere, anytime”—that includes the introduction of the easy-to-remember 9-8-8 national phone number for the National Suicide Prevention Lifeline to assist people experiencing a mental health or suicidal crisis. Congress passed the National Suicide Hotline Designation Act in 2020 and the 9-8-8 number officially goes into effect in July 2022.

Part 7 in a Series about the Zero Suicide Model for Healthcare

The new vision for crisis care is reflected in the the National Guidelines for Behavioral Health Crisis Care issued in 2020 by the Substance Abuse and Mental Health Services Administration, Covington said. The guidelines, he added, stemmed from many efforts including the Crisis Now project of the National Association of State Mental Health Program Directors, developed with the National Action Alliance for Suicide Prevention.

Covington said the new model involves handling mental health crises with a minimum or total absence of police and hospital involvement—which the National Alliance on Mental Illness calls the “revolving door of ER visits, arrests, incarceration, and homelessness.” Rather, services are provided by mobile crisis response teams and non-hospital crisis care facilities.

Funding remains a major challenge for scaling up the new model of crisis care, Covington noted, with Congress looking to states to fund upgraded crisis services.

Covington said the new model for crisis care is in line with, and related to, the “extremely bold aspiration” of the Zero Suicide Model for healthcare, and is backed by a growing national momentum. “Let’s talk about how we might dare a much mightier system of care, and think about the way that we responded to those Chilean miners, without judgment, without shame. Instead, with an all-on full effort, an integrated and collective effort, to save their lives and support them, get them back to their lives,” he said.

The new model addresses what Covington called the “two sins” traditionally committed in crisis response.

The first, he said, is the message that reaching out for help leads to “punishment” in the form of a response by armed police officers. “Imagine that the darkness that you’re experiencing isn’t in a Chilean mine but in your living room in your apartment, and the response is law enforcement cars in the driveway, lights flashing,” he said. “About 70 percent of the time they’re handcuffed and placed in the back of the patrol car and transported to to a facility. While they may not in fact be arrested, it certainly feels like an arrest to the individual who’s in pain.”

The second sin, according to Covington, is “warehousing” individuals in a hospital emergency department as a way of handling individuals in crisis. He cited a 2013 Seattle Times report that found that in Washington State people in crisis arriving at hospital emergency departments were put into psychiatric boarding for an average of three days before getting access to mental health treatment. Some, the newspaper reported, waited for months.

“This is really hard for us to get our heads around, that this is the way we respond to people in a psychiatric emergency, in deep emotional pain, feeling suicidal,” he said. “We land up detaining them without real active care treatment for days, while they face the gauntlet of trying to get into a service. Many land up just falling through the bottom, falling through the cracks.”

Covington said the 9-8-8 hotline is an important step forward, likening it to the narrow opening that was drilled to make contact with the Chilean miners, to check if they were alive, and send them basic food and water supplies.

But, he said, “if 9-8-8 is all we do, then it’s going to be equivalent to those Chilean miners where we dig the four-inch diameter hole but we don’t actually get them out of that crisis, we don’t get them out of that hole. Many, many individuals will be supported through 9-8-8 and they won’t need more intensive services. But for those who need something more, making the connection is not enough.”

Covington said the new crisis care model envisions intermediate levels of support instead of the “red-light, green-light” approach that either directed patients toward the highest level of acute care or outpatient behavioral health care or follow-up care. He pointed to a flagship crisis response system in Arizona equipped with mobile crisis response teams and crisis care facilities.

“What a difference it makes when you have that approach,” he said. “Thousands of individuals are going directly into crisis care, and we’re reducing law enforcement engagement. You’ll see a much stronger fit of the level of service matching the clinical care they need. We haven’t eliminated psychiatric boarding in the Phoenix area, but we’ve reduced it by a staggering amount.”

Moreover, Covington added, “there’s a very significant reduction in overall healthcare spend as well as reductions in the exposure for hospitals. It’s an approach where care is much more like care than punishment.” The 9-8-8 number, providing an alternative for mental health crises to the 9-1-1 national emergency number in use since 1968, is an opportunity to reduce the involvement of police in the front end of a mental health crisis where there isn’t an explicit threat to public safety, he said.

Covington said the Community Mental Health Act of 1963, which provided federal funding for community mental health centers, never realized its promise.

“The challenges we face today as a result of the lack of that crisis system, the lack of that concerted engagement and outreach for those who are in pain or in darkness, are the extremely long waits in the emergency department, the extremely costly way that we go about this, concerns about the public safety of not having these systems in place, and far too many deaths that have occurred not only from suicide but from opioid overdoses, from alcohol related deaths, and other deaths that could have been avoided,” he said.

Covington said that innovations in crisis care began more than 60 years ago, with the first suicide crisis call center established in Los Angeles in 1958 leading eventually to the National Suicide Prevention Lifeline 1-800-273-8255 in 2005. He pointed to efforts in various states such as Georgia, Arizona, and Colorado to create unified systems of crisis response and care prior to the 2020 SAMHSA guidelines.

READ MORE: The Zero Suicide Model in Tompkins County

If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.