Zero Suicide in Healthcare

zero suicide in healthcare“Over the decades, individual [mental health] clinicians have made heroic efforts to save lives… but systems of care have done very little.” With this quote from SAMHSA’s Suicide Prevention Bureau Chief Richard McKeon, we launched our two-day kick-off meeting of the new Zero Suicide in Healthcare Advisory Board last week in Baltimore, Maryland.

Nearly 20 years ago, I received a phone call that I was unprepared for. I had just returned home after having completed the National Counselor Exam. I fancied myself a “master” counselor, since I was to graduate later in the week. However, my confidence and belief in myself evaporated, for as soon as I walked in the house, I received a call from a 50-year old parishioner outreaching someone/anyone from his church to say goodbye, for he had a shotgun and was intending to end his life by suicide that night.

My first thought was not fear, wondering what to do and how to help (that came second). It was ”You’ve got to be kidding me. Really?!” I had just — just —  finished a 60-hour Community Agency Counseling master’s program over the last four years, complete with video tapes of my work, internships and practicums, and I did not receive a shred of preparation for this moment, not five minutes. “The system” did not see suicide care as relevant, and as a result, I was on my own to know what to do.

It was the next morning before I returned home, having muddled through how best to help. The bad – law enforcement chided me when I ultimately talked the individual into meeting me in the McDonald’s in the back of a Wal-Mart in rural Tennessee (the guy with the shotgun). The okay – I built rapport, engaged and we collaborated together. The good – a psychiatrist sent me to the man’s home to remove the shotgun with an eye to means reduction for safety planning.

A year later, I started my first job in community mental health, and our clinic was never far from the issue of death and suicide. Many of the individuals we served in the rural clinic were diagnosed with Severe and Persistent Mental Illness. Years later, I would learn that those with Schizophrenia, Bipolar Disorder, Major Depressive Disorder, Borderline Personality Disorder and Anorexia Nervosa possess suicide rates 10 to 15 times greater than the general population. Once again, my organization did not prepare me to assess or treat these individuals, and they provided little support other than access to psychiatrist orders for involuntary inpatient care. We (and those at risk) were largely on our own.

Over the past five years, we have surveyed more than 30,000 in the behavioral healthcare workforce across nine states, and asked clinicians, case managers, peer specialists, and other community behavioral health center staff to rate their own skills, training, and supports to effectively engage those at risk of suicide. On average, there is about a coin-toss chance that they will at least “agree” that they have what is needed. About one in four report that someone under their care and responsibility has died by suicide (and for almost half that group, this tragedy has occurred more than once).

It’s not that agencies delivering behavioral healthcare services don’t believe that suicide is part of their responsibility; they just don’t think about how little focus and systematic support they actually provide. In 2010, Forbes put it more strongly in “The Forgotten Patients” that fear, logistics, and high risk “make suicide the neglected disease.” Suicide care is actually peripheral for most behavioral healthcare leaders when you examine the approach their companies deliver on a day to day basis.

As a nation, our core healthcare systems have dabbled in suicide prevention. Neither Medicare, Medicaid, state authorities, nor health plans routinely report suicide deaths as a core key quality performance indicator. “The National Institutes of Health is spending a paltry $40 million in 2010 studying suicide, versus $3.1 billion for research on AIDS, which kills half the number of Americans. (Another government agency spends $48 million on hotlines and prevention)” (Forbes, 2010).

Last year, the revised National Strategy for Suicide Prevention included a goal to establish suicide prevention as a core responsibility of health systems. Our Zero Suicide Advisory Board has set out to make suicide care the bull’s eye, not an obligatory afterthought. One of our members, Paul Schyve, of Joint Commission has called this shift in focus a “burning platform,” as we now understand that suicide is imminently preventable and that systems are powerful in a way we did not even a decade ago.

In 1975, the Golden Gate Bridge was nearing its 500th suicide death, and the community was distressed; something should be done. Although a barrier was considered, nothing came of it. Of the three reasons offered, cost and aesthetics were only numbers 2 and 3. The primary reason: most did not believe those “truly” intent on suicide could be stopped. It seemed an exercise in futility. This pernicious myth continues to have deep roots in the medical and behavioral communities. It underlies our fear as systems leaders, and disables us from addressing this most challenging and complex problem.

This fatalistic view just doesn’t match the science, nor the increasingly rich voices of those who have lived with and attempted, but survived, serious suicide attempts. In the documentary “The Bridge,” Kevin Hines talks about his last five seconds in 2000. In one fatal second, he leaps over the 3½ foot rail of the iconic bridge in a bid to end his pain. In the very next second of the four-second fall, he realized he would do anything to be back on the bridge with his hands firmly gripping the steel rail.

Intense ambivalence (what Europeans have called “personal indecision”) seems a universal part of human existence with suicide. Despite enormous psychic pain, our bodies and minds fight to survive until the end, a trait that Dr. Thomas Joiner has said abides deep “within our cells and within our souls.” This was made painfully aware to me when I learned about a woman who police say died by suicide; however, the grieving family insists she was murdered, because she was found hanging with her feet tied and her hands bound behind her back.

Tragically, even alone, suicidal individuals often realize how difficult it is to end their lives because they themselves fight back. Their bodies don’t cooperate and their minds are wired for self-preservation. When we as individuals add our help, we save lives. And, we know today that diagnosis is not destiny: 19 of 20 survivors we save go on to live out their natural lives.

What if healthcare leaders focused on suicide care like they have hospital-acquired infections, wrong-site and wrong-patient surgery, medication errors, and patient falls? What if systems of healthcare devoted their enterprise resources, performance improvement, manualized protocols, automated software systems, and data tracking to suicide?

In 2001, the Henry Ford Health System in Detroit, Michigan initiated its Perfect Depression Care program and suicide deaths were reduced 75% in the first four years (inspiring parallels to an earlier leadership and culture change initiative in the US Air Force, which produced similar results). In 2010, I met Don Berwick, then-CMS Director and author of “Crossing the Quality Chasm.” I asked him if he was aware of the impact his direction had made with suicide care at Henry Ford. “Yes, absolutely,” he replied, and without transition, he immediately began telling the story of reducing infections in hospitals through the Institute for Healthcare Improvement. In healthcare, we use our systems to attack complex problems every day. For Berwick, suicide was no different.

In 2009, innovative partners across ten states began coming together to develop a framework for Zero Suicide in Healthcare. The National Council for Behavioral Health called it “Not Another Life to Lose,” leaders in Texas have named it “Suicide Safer Care Centers,” and New York’s Institute for Family Health has labeled it “the Power of Zero.” The elements are the same: top leadership commitment, workforce assessment and training, universal screening, standardized assessment, and clinical pathways to care, including a collaborative safety plan, and access to evidence-informed treatment for suicidality and mental illness.

In 2013, there are a growing number of demonstration models to showcase suicide care as core business, including one of the largest Community Mental Health Center systems in the country, Centerstone America. Virna Little, Senior VP with the Institute for Healthcare Improvement, shared with our Zero Suicide Advisory Board an in-depth look at how her nearly 30 integrated Federally Qualified Health Center sites have hotwired their EHMR Epic to protocolize suicide intervention and care (YouTube playlist).

I have had the privilege of co-leading this effort with Mike Hogan, who has headed up statewide programs for more than 30 years. In the past, Mike has said, “Suicide represents a worst case failure in mental health care. We must work to make it a ‘never event’ in our programs and systems of care.” Following Virna’s presentation, he noted, “This moves in the direction of a standard of care approach… It would not be responsible not to provide care and support based on the current state of knowledge.”

Today, healthcare systems are beginning to address suicide as they have other illnesses and safety issues (like reducing seclusion and restraint in inpatient units); to take suicide out of the shadows and bring it into the light, making it part of their measurements of success or failure. Treating suicide can no longer be a single-person approach; it must be a team effort with systems leading the way in education, measurement, support and care. These efforts in healthcare will go a long way to making this a nation free from the tragedy of suicide.

*Note: David Covington is a member of the National Action Alliance for Suicide Prevention executive committee and Vice-Chair of the National Suicide Prevention Lifeline Steering Committee. Organizations interested in learning more should visit Special recognition to SAMHSA, the Suicide Prevention Resource Center, and Universal Health Systems for their support and partnership. 

25% Peers by Tuesday

walking on iceHis reaction was definitely not one I was anticipating: he looked disgusted, ready to spit. It was 2010, and I had just been blown away at the NAMI Arizona annual conference by Phil Pangrazio’s keynote. Phil is President and CEO of the Arizona Bridge to Independent Living (ABIL). Phil, himself disabled, oversees $30 million in a wide array of programs designed to empower people with disabilities to achieve or maintain independent lifestyles within the community.

After his keynote, I was excited to share with him the work we had accomplished in the Phoenix area, boasting five distinct Peer Run Organizations and an award-winning youth program, MyLife. We were moving from voice to leadership and from participation to action. We were providing meaningful roles at the table, and 2010 Arizona continues to stand in contrast to large parts of the country where peer roles are seen as a liability, still limited to janitorial or administrative functions, or seen only as a marketing tool.

Troubled by the disapproval I observed on Phil’s face as I described these programs, I asked for his feedback, and he explained in one word: “tokenism.”

Phil went on to say that in the disability field, the leaders are disabled. Unlike mental health, where clinical professionals and administrators invite “consumers” to the table, in his world, individuals with disabilities run the table, and the culture and outcomes are dramatically different. Those who have battled through discrimination are painfully familiar with the stages: exclusion, segregation, integration/tokenism, and ultimately inclusion.

Mental health activists like Judi Chamberlin, who originally lit up the field with “nothing about us without us,” borrowed these important slogans from the disability field. Some have attributed their usage and lessons to the anti-apartheid struggle. In the US, we have our first African-American president, but no NFL black coaches were hired in 2013.

Two years after my “ah-ha” moment with Phil, Arizona Governor Jan Brewer restored $39 million in funding for individuals with Serious Mental Illness (SMI) who did not qualify for Medicaid. Up until 2010, the Arnold v. Arizona Department of Health Services (ADHS) lawsuit demanded parity for individuals who had been determined SMI. However, the recession and deep budget cuts required the state legislature to eliminate most of these services (counseling, case management, brand medication, transportation, inpatient care, etc.) in exchange for generic medications and crisis services only.

While these cuts were in place, the Regional Behavioral Health Authority (RBHA) at Magellan Health Services tracked the outcomes for the nearly 7,000 individuals to assess the impact of these severe reductions in services. About 10-15% struggled significantly during this time period. These individuals were receiving the most intensive services, such as Assertive Community Treatment, Court-Ordered Treatment, and staffed residential services. However, to Magellan’s surprise, the majority of individuals faired at least as well or better over the two interim years, despite the drastic reduction in Medicaid services.

Based on these results, the RBHA team approached the state with the idea to do something different, to use the new funding in Maricopa County for a different kind of system, with certified peer specialists and family support roles as key components. ADHS responded positively, stating that this was not only permissible, but expected, and that RBHAs had the flexibility to propose their own plans, such as Magellan’s Toward a Peer Driven System of Care.

First, Magellan dramatically increased the funding for Peer and Family Run Organizations (CHEEERS, STAR, Visions of Hope, Hope Lives, Recovery Empowerment Network, and Family Involvement Center); however, they knew that these key agencies touched fewer than 10% of the total population with Serious Mental Illness in any given year.

The vast majority of services in the RBHA system were delivered through case management clinics operated by four organizations: CHOICES, Southwest Network, People of Color Network, and Partners in Recovery. These agencies operate 21 clinics and employ over a thousand case managers and medical management staff. Each site employed at least one Peer Mentor and one Family Mentor prior to 2012, but in large clinics with client populations ranging from 500 to 1,500, mentors could not make a significant impact.

The RBHA team vowed not to implement a veneer-like program that could be easily removed. Instead, they used the metaphor of making bread…peers would be “baked” into the recovery programs themselves. Could the team in fact change the nature of the service delivery system through the power of peers? Magellan decided to partner with ADHS and use the restored funding to kill tokenism. Hundreds of peer and family roles were planned and would be filled in the primary case management and medical management system. Trained peers would work as equal members of the team.

At the NAMI Utah conference a few weeks ago, Sally Spencer-Thomas, executive director of the Carson J. Spencer Foundation, spoke in her keynote about suicide prevention. She used a metaphor about water as it transforms into ice. Right up until the freezing point, one cannot discern with the naked eye what is about to happen; however, at the last moment, a few tell-tale crystals appear, and then a cataclysmic change occurs. The fluid instantly becomes a solid. It’s a miraculous event.

It got me to thinking, “What is the ‘last moment’ at which a behavioral healthcare culture is transformed by the power of peers?” At 40 degrees, water is cold, but not frozen. That change only occurs at 32 degrees. Similarly, transformation in the behavioral healthcare system does not happen when only 10% of staff are peers. Lori Ashcraft has taught for many years that the critical threshold is 25%. When one in four staff are individuals with lived experience and expertise, the organization hits a tipping point and it becomessomething different. Anything less is tokenism.

Earlier this year, I had a long breakfast with CHOICES Network CEO Ron Smith, a leading administrator in the Arizona system for over 30 years, and whose organization was central to the ADHS/Magellan initiative. He described a totally transformed system, and I was mesmerized as he told me about the difference in his teams, their outcomes, and how they were making it work. He talked about his refusal to create a second-class tier of employees (either through expectations or compensation).

Ron explained that his organization had one personnel approach for both traditional staff and the hundreds of new peer and family roles. If someone sleeps with a client or steals from the organization, their policy states that the employee is terminated, regardless of role; beyond that, they have learned to incorporate a lot of grace into their approach. A psychiatric nurse who doesn’t show for work the first day has typically been terminated in the past, but they learned that someone who has not worked for five years and struggled with anxiety might need a different approach. Ron described using full-time to part-time more frequently when problems occur, and taking advantage of family leave. They are also seeing significant reductions in turnover.

The two of us had worked together since 2009 and I was a little stunned by what I heard. Ron beamed as he talked about the difference in approach as these teams were melding together, and I asked him how he had learned so much, so fast. His answer was immediate: the recovery training by Lori Ashcraft and Recovery Innovations. Recovery Innovations trained all new Certified Peer Specialists, but more importantly, all CHOICES managers and executives who would be responsible for this new workforce.

While the 2010 Arizona system led the nation in many ways, peers touched relatively few individuals compared to the 21,000 total served with Serious Mental Illness. In the first year of the “Towards a Peer Driven System of Care” initiative, more than 700 peers touched more than 15,000 individuals. Peers weren’t cleaning toilets or shuffling papers. They were billing as wellness coaches, peer supports specialists, crisis navigators, case managers, supervisors, managers, and even a few CEOs. In short, peers were changing lives. The 25% threshold was breached and the system underwent a cataclysmic shift.

I grew up in Nashville, Tennessee, where the Cumberland River snakes through the city. I’m not sure anyone ever attempts to swim across anymore. Wading out into those waters would be pretty precarious, but I remember seeing my father’s pictures from the 1950s when the water would freeze over, and people would just walk and/or drive across. At the 25% level, organizations become something different, ones that hear the voices and value the lived experiences of peers, and that foundation creates solid footing, just like solid ice, for the path to recovery.

This month, the American Association of Suicidology contemplates by-law changes as they grapple with the best way to formally acknowledge and invite suicide attempt survivors into the field. Until two years ago, there was generally only token representation, but I believe we underestimate the impact such a change would achieve.  Recently, someone commented online, “I have long felt that the word of [suicide] survivors/sufferers is considered somehow suspect by many medical professionals. So long as that is so, or perceived to be so, there will be a silencing fear.” When peers are a central part of an organization, it can be the difference between walking on ice or sinking into the water.

Judi Chamberlin was fond of saying, “End psychiatric oppression by Tuesday.” I do not believe there are easy answers, but I believe the path is before us. When we breach the 25% threshold, something magical happens (see “Magic of Peer Voice”). Ask yourself, in whatever company, team, board, or meeting you lead, are there at least one in four (in addition to the policy makers, administrators, clinicians, family members, etc.) who are bringing actual lived experience and expertise? If you answer “Yes,” fantastic. You’re on the path. If you answer “No,” then enact change. Embrace 25%. As Nelson Mandela said, “It always seems impossible ‘till it’s done.”

*Note: David would like to acknowledge key contributions from Lori Ashcraft and Carol Coussons de Reyes. Special thanks are also extended on the “Magic of Peer Voice” slide deck for input received from Lori, Larry Fricks, Gene Johnson and Eduardo Vega.

No Recovery By Force

breaking chainsThere were only two of us left in the group room and the ten chairs that had been in a circle were now scattered. To my left 15-year old Kenneth* towered over me holding his chair above his head, with huge tears streaming down, his lips quivering, the angriest I had ever seen him. To my right, I could see my co-worker Mark, standing outside in the hall, peering through the small round portal in the door. He was holding his hand to his ear like a phone and his eyes were questioning. We didn’t need to talk for me to know he wanted to call 9-1-1. I slightly shook my head no and turned back to Kenneth.

We frequently speak of clinical “judgment.” Just a few minutes earlier, Mark and I were leading a productive discussion with a group of adolescent males, and one of them related an ankle injury over the weekend that led to a visit to the “hospital.” Despite the different context, just the reference to the word set off memories in Kenneth of an involuntary hospitalization from two years prior. As he had done many times previously, he became very upset, began revisiting his inpatient experience and expressing anger at the psychiatrist who signed the order, an individual no longer with the clinic.

I, too, reflected on that day and remembered my concern for Kenneth’s safety. The risk appeared imminent and I had approached the psychiatrist with the order for detainment for assessment. When law enforcement arrived, and despite my encouragement to do otherwise, they shackled his hands behind his back and placed him in the back of the patrol car. He was a tall African American teenager and the challenges of that day had him scared and confused even prior to the arrival of the police. The officers weren’t taking any chances.

As Kenneth was once again perseverating about an event two years earlier, I reflected on the strength of our two year relationship, the gains we had made together and my genuine good intentions on that day… So, I determined it was time for Kenneth to make a breakthrough. I had not even finished the sentence but looking into his eyes I realized I had misjudged the depth of pain. “Kenneth, it wasn’t Dr. Eastman* that sent you to the hospital… I did.”

I never got to the part about my concern and rationale before the other boys were fleeing the group room, and there we stood together with Kenneth holding his chair above his head and Mark gesturing whether we should re-engage law enforcement once again. What neither Mark nor I grasped at that time was that being demeaned like a prisoner for transportation was not Kenneth’s worst memory.

I didn’t get it at that time, but Charlie Curie did. He who would go on to lead the Substance Abuse and Mental Health Service Administration (SAMHSA) for the federal government, but a couple years after my interaction in the group room, Charlie’s responsibilities included a state psychiatric hospital in Pennsylvania that began looking at care differently.

Previously, it was just expected that individuals in inpatient care would become agitated, angry and/or threatening, and the response would be a take-down code announced over the loud speakers. Male staff would come running from all parts of the facility and everyone nearby would take part in what could more closely resemble football field tackling. When it went wrong, it was more like fighting. When it went right, it frequently led to the individual being secluded in a padded room or carried by their limbs to a hard table where their wrists and ankles were restrained so that they could be forcibly injected with medication and left until the treatment took effect.

At that time, the behavioral health field saw seclusion and restraint as a key tool in the treatment arsenal. Charlie Curie’s team won the 2000 Harvard University Innovations in American Government award because they changed the expectation, and recast the use of seclusion and restraint as an organizational treatment failure. They began to tackle a culture where there had previously been psychiatric inpatient staff with metaphorical stickers on their helmets representing the number of successful “sacks.”

By 2004-2005, SAMHSA’s National Center for Trauma Informed Care (NCTIC) was beginning to educate the broader field on the very high rate of individuals with physical and sexual abuse histories in the public mental health system. Survivors and peers were sharing with us their trauma histories; encouraging us to address trauma in care; and highlighting the re-victimization experienced in residential or in-patient settings through practices like seclusion and restraint.

It was during this same time that I began having long discussions with national peer leaders like Eduardo Vega and Tom Kelly about the impact of involuntary detainment. I remember vividly a conversation in which Eduardo talked about the unintended consequences, even when treatment is caring, effective and safe. After discharge, individuals often return to learn they have lost a job, been displaced from housing or lost key friendships, as their committal was signaled by their abrupt disappearance for days paired with the presence of law enforcement or emergency personnel.

However, I have also talked with many peers about the shocking impact when care feels more like a prison, and when inpatient staff threaten individuals with physical altercations to control their feelings and behaviors. Some peers disclosed that they would not share a concern for a friend with professionals, even if it was considered imminently dangerous, because they loathed subjecting someone they care about to such painful and traumatic disrespect and abuse (even if the alternative is their potential suicide). We simply have not walked in the shoes of those who have been there.

In 2009, when my new job was to oversee clinical and program outcomes for the behavioral health system in Phoenix, Arizona, I spent a lot of time shadowing the system. I spent a third shift in a patrol car with an officer responding to individuals in crisis and transporting them to key facilities (we were dressed in jeans and did not disclose our leadership roles). It gave me an up-close and genuine look at the way individuals in crisis were treated and how services worked.

It was my intention to go a step further and be the “undercover boss” in the court-ordered treatment inpatient evaluation process, posing as a consumer. I felt I could muster the courage to do it; however, the risk of seven to ten days inpatient, the potential for the kinds of trauma, forced medication, physical altercations, etc. that are still commonplace in many facilities across the country was more than I could take on given my family responsibilities (sole provider with two small children). I never went through with it, but I had intimate conversations with those who did. In recent months, the federal government has investigated the Arizona State Hospital related to allegations of excessive injuries for both peers and staff.

Several years ago, Recovery Innovations in Phoenix caught my eye as my team was reviewing a variety of metrics for our crisis stabilization and acute care hospital services, and we noticed something very different. While other facilities were reporting seclusion and/or restraint several times per day, there were entire months in which Recovery Innovations might report one, two or three incidents. Sometimes zero.

I previously assumed Recovery Innovation’s success had to do with engagement and collaboration, creating a culture of respect and openness, and naming things very differently. Individuals are “guests,” not “patients” or “consumers,” and the facility looks and feels much more like a retreat, with names on the doors instead of numbers (e.g., “Revive,” “Refresh,” “Rejoice,” etc.). The crisis stabilization program is referred to as the “living room” and the crisis respite is called “restart.” I also learned from their CEO Gene Johnson about an approach to “risk-sharing” with the individual as opposed to the more typical top-down method.

Earlier this spring, I spent most of a day shadowing in a facility west of Phoenix and noted what may be the silver bullet. Law enforcement arrives with an individual like Kenneth in the back seat of a patrol car at a secure area for intake, and a nurse and psychiatrist provide an initial intake and triage (just like other similar programs across the country). However, the first person in this room to greet the individual is a certified peer specialist who provides a brief overview of what to expect and offers support. This collaboration and engagement with peer supports staff on the medical team continues throughout the care, and it generates a very different type of culture and set of outcomes.

Back to that group from so many years ago. Forty-five minutes later we reconvened the group of teenage boys and I was very proud that Kenneth and I had mutually made some breakthroughs together. I solicited from the group feedback hoping that someone would praise him for talking through these painful experiences. “What did Kenneth do well?” I asked. One of the teens answered simply, “He put down the chair.”

Over a decade ago, Charlie Curie changed the view of seclusion and restraint from an accepted intervention to a treatment failure. Today, Gene Johnson and Recovery Innovations are taking the philosophy of “no-force first” to an entirely new level. There is a line of sight to safer, more effective and better care, and it may also be simpler than we think. It is time for us to take action, and peers with lived experience (better yet, lived “expertise”) stand ready to support. And, if we won’t, perhaps Kenneth would encourage us all to take a few days to go through the treatment ourselves. Then we might all better understand.

*Note: The names in the story were changed. Also, I have not made distinctions as to the differences between physical holds, chemical and physical restraints as they all share a common element of violating the autonomy of individuals in care, many of whom have previously experienced trauma (including physical and sexual abuse) and may have those memories reignited by these practices.