2021-22 Suicide Prevention Annual Report
Reporting Period: July 2021-June 2022
Attachment A: 2021-2022 Suicide Prevention Annual Report, County of Santa Clara 1 Table of Contents
Background 2
FY22 Suicide Prevention Highlights by Numbers 3
Suicide Data and Prevention Program Evaluation 4
FY22 Progress on Program Objectives
Objective 1: Strengthen suicide prevention and crisis response systems Objective 2: Increase use of mental health services
Objective 3: Reduce access to lethal means
Objective 4: Improve messaging in media about suicide
Objective 5: Create supportive community environments
9 25
35 39
42 Conclusion and Recommendations 48
Acknowledgments 50
2 BACKGROUND
Established in 2010, the Santa Clara County Suicide Prevention (SP) Program designs, implements, and evaluates population-based, public health approaches to reducing and preventing suicides. Suicide prevention in the County is guided by the County’s Suicide Prevention Strategic Plan, which was passed by the Board of Supervisors in 2010. The plan recommends the below five evidence-based public health strategies to guide a comprehensive community effort to prevent suicide. ● Strategy One: Implement and coordinate suicide intervention programs and services for high-risk populations
● Strategy Two: Implement a community education and information campaign to increase public awareness of suicide and suicide prevention ● Strategy Three: Develop local communication “best practices” to improve media coverage and public dialogue related to suicide
● Strategy Four: Implement a policy and governance advocacy initiative to promote systems change in suicide awareness and prevention ● Strategy Five: Establish a robust data collection and monitoring system to increase the scope and availability of suicide-related data and evaluate suicide prevention efforts
The SP Program coordinates the Suicide Prevention Oversight Committee (SPOC) and four Workgroups, which are each tasked with supporting a different strategy of the County Suicide Prevention Strategic Plan: Interventions (Strategy One), Communications (Strategies Two and Three), Policy (Strategy Four), and Data (Strategy Five). SPOC oversees and approves the work of the Workgroups.
The staff of the Suicide Prevention Program and SPOC are also in the process of drafting and amending a sixth prevention strategy related to ensuring all suicide prevention activities within the County are culturally informed and responsive This annual report covers the period of Fiscal Year 22: July 1, 2021 to June 30, 2022.
3 FY22 SUICIDE PREVENTION HIGHLIGHTS BY NUMBERS
17 school districts participated in the Schools for Suicide Prevention partnership
499 conversations with 301* texters took place over the County Crisis Text Line
307 school staff, health care providers, and behavioral health clinicians received technical support consultations in suicide prevention and crisis response
4,525 people trained to be community helpers for suicide prevention and mental health
35,809 calls received by the Suicide and Crisis Services hotline 4125 unique visitors* to suicide prevention resource webpages 8,473,687 impressions of public awareness campaign encouraging safe firearm storage to help prevent suicides in Santa Clara County * Unduplicated numbers
4 SUICIDE DATA AND PREVENTION PROGRAM EVALUATION
Suicide Death Data
After a three-year decline from 2014-17, the County’s suicide count and rate increased to 148 deaths (7.6 per 100,000) in 2018 and 169 deaths (8.8 per 100,000) in 2019. The 2019 count and rate represent a 10-year high for the County. The 2020 count does represent the beginning of a trend downward (8.5 per 100,000) (See Figure 1). The 2020 suicide death count within the County was 164. The 2021 data is still currently being analyzed but the suicide count within the County was 154 which represents a continued trend lower for the number of suicide deaths in Santa Clara County. This data shows that suicides did not increase during the COVID-19 pandemic. Based on the available data, the suicide rate and raw numbers appear to be trending down each year since 2019.
The County’s suicide rate continues to be lower than the California state ageadjusted suicide rate, which was 10.7 per 100,000 in 2019 (2020 state suicide data is not yet available) (Centers for Disease Control and Prevention, 2021).
Figure 1. 2016-2020 Suicides in Santa Clara County
Demographic Trends
In FY 22, the County Medical Coroner Examiner (MCE) launched a data dashboard which simplifies some of the process for the coding and analyzing the 5 County suicide data. The suicide prevention program and the suicide prevention data workgroup decided after review and conversation that that the data dashboard could be utilized in combination with analysis of case reports for the County’s suicide death data reports. For the 2021 death data report, the suicide prevention program staff will utilize the MCE data dashboard and coroner case reports to streamline the data cleaning and coding process. The ensuing analysis provided below was derived from pulling data for the calendar year from the MCE data dashboard and supplementing this with review from case files provided by the MCE.
The number of female deaths decreased by 14 from 2020 (44) to 2021 (30). During this same time frame, as the number of female deaths within the County decreased the number of male deaths remained consistent for both 2020 (120) and 2021 (120). The number of deaths for older adults (ages 65+) increased by one from 2020 (35) to 2021 (36) while the number of deaths for young adults (ages 25-34) remained the same from 2020 (31) to 2021 (31); in the Asian community there was an increase of two deaths from 2020 (29) to 2021 (31) while in the Black/AfricanAmerican community there was a decrease of 4 deaths from 2020 (5) to 2021 (1).
The number of deaths by drugging/poisoning as the method increased by 3 from 2020 (16) to 2021 (19). The two most predominant methods of suicide death (firearms and hanging) within the County from 2020 and 2021 both saw declines in raw numbers. The number of suicide deaths within the County by firearms saw a reduction of 12 deaths from 2020 (53) to 2021 (41). The number of suicide deaths by hanging also saw a reduction of 12 deaths from 2020 (67) to 2021 (48).
Suicide Attempts and Ideation Data
In FY20, the Data Workgroup worked with the Public Health Department (PHD) to obtain and analyze 2014-17 data from the state’s Office of Statewide Health Planning and Development (OSHPD) on hospitalizations and Emergency Department visits for suicide attempts and ideation. From January 2020, the PHD’s work on this data analysis ceased because of their epidemiologists’ need to focus on COVID-19 data and disaster response. In FY21, through its partners at Palo Alto University (PAU), the Data Workgroup developed a proposal to the Institutional Review Board (IRB) to directly obtain suicide attempt and ideation OSHPD data for analysis. In FY 22, the OSHPD completed their first review of the 6 request for the data and provided a letter of approval. The Data Workgroup will now continue the process of obtaining IRB approval from PAU with the approval of the state to release the data accompanying the application.
Suicide Prevention Program Evaluation
For FY22, funding program expenditures decreased by nearly 50% while the number served was higher than FY20. Two factors help to explain this occurrence.
First, FY20 allows for a closer comparison of numbers served given the program ran one media campaign in FY 20 and FY22 while in FY21 there were two media campaigns which helps account for the higher number served. For nearly half of FY22 the SP program functioned without a program manager (the division director acted in a dual capacity till a program manager could be hired) which reduced the program expenditure for staffing. In comparing the cost per person from FY20 and FY22 we see the program was efficient in expenditures decreasing the cost per person by nearly 44% compared to FY20 while creating over a million additional contacts.
Figure 2. Cost per Person Served by Suicide Prevention Program, FY20-22 FY 2020 FY 2021 FY 2022
Duplicated* N = 7,369,249 Duplicated* N = 21,525,755 Duplicated* N = 8,479,860 Number
Served
Program
Expenditure
Cost
per
Person
Number
Served
Program
Expenditure
Cost
per
Person
Number
Served
Program
Expenditure
Cost
per
Person
7,369,249 $1,861,691 $0.25 21,525,755 $1,885,929 $0.09 8,479,860 $974,089 $0.11 *This program cannot differentiate among duplicated individuals as no Protected Health Information (PHI) is collected among trainings, outreach activities, and communications campaigns. The same individuals may have participated in a number of the group services listed above. The reach of different communication campaign materials are also duplicated; i.e., the same individual may have seen the campaign different times and on different channels. Campaign exposure is largely measured by impressions, which refer to the number of times a number of individuals have been exposed to a public awareness campaign.
Some examples of evaluation successes during the past year include the following:
A focus on improving and supporting culturally competent suicide prevention and management in the county’s clinical services resulted in the initiation and expansion of group therapy offerings. New workflows were also designed, enabling the hospital system to move towards an ideal of all patients receiving a 7 same-day warm handoff with a Primary Care Behavioral Health clinician. In addition to organizing and completing a six-month suicide prevention training series, the community-based provider Momentum for Health completed several lasting organizational changes based on each of its monthly training series topics (Culture & Underserved Populations, Treatment and Comprehensive Assessment, Community Support Following Suicide Loss, Paperwork, Policies and Procedures, and Crisis and 5150). These efforts yielded impressive outcomes upon postassessment. Pre- and post- training survey results from the Kognito “At-Risk” and “Emotional and Mental Wellness” online trainings (offered to school staff to strengthen suicide prevention and response systems) indicated statistically significant improvements in suicide prevention helper-related competencies.
The HEARD Alliance expanded its school-based partnership efforts to include social-emotional learning implementation technical assistance to strengthen the continuum of suicide prevention supports. The two HEARD Alliance consultation teams (Crisis Response and Social Emotional Learning) supported 17 districts and more than 95 staff members (unduplicated) with consultations and trainings (51 total). In aggregate, across four suicide prevention helper trainings offered, participants reported statistically significant improvements from pre- to posttraining in eight self-reported suicide prevention competencies related to knowledge, attitudes, and preparedness around being community helpers for suicide prevention.
The SP Program’s Communications Workgroup planned, developed, and implemented a comprehensive public awareness campaign to support suicide prevention in Santa Clara County (County) through safe firearm storage. The campaign achieved more than eight million impressions, and the campaign effort and evaluation generated significant learnings about ways to message effectively to gun owners about firearm safety practices. The Program provided four safe messaging trainings attended by a total of 75 public communicators, school staff, and local high school students and peer leaders. Post-workshop survey data indicated that 100% of respondents were somewhat or very likely to apply the safe messaging guidelines in their work.
8 The Program focused on community hanging means safety by conducting two roundtables centering on suggestions for prevention strategies, and by forming a working group focused on this topic to implement these recommendations. A collaboration between the SP Program and a team at Stanford published the Tool for Evaluating Media Portrayals of Suicide (TEMPOS) in the International Journal of Environmental Research and Public Health (IJERPH).
9 FY22 PROGRESS ON PROGRAM OBJECTIVES
Objective 1: Strengthen suicide prevention and crisis response systems Schools for Suicide Prevention (S4SP) Partnership
State policies AB2246 and AB1767 mandate that public schools serving grades K12 adopt policies addressing suicide prevention, crisis response, and student mental health. The SP Program launched the S4SP partnership in 2018 as a response to a needs assessment conducted with districts on their progress with implementing these policies. In FY22, the SP Program entered its fourth year of the partnership, and expanded reach to a total of 17 districts with varying prevention needs and technical assistance requests (see Figure 3).
Figure 3. School Districts Participating in S4SP Partnership Pilot Year (2018-
2019)
Year 2 (2019-2020) Year 3 (2020-2021) Year 4 (2021-2022) Alum Rock Union x x
Berryessa Union x x
East Side High
School Union
x x
Evergreen
Elementary
x x
Franklin-McKinley x
Fremont Union x
Gilroy Unified x
Los Altos
Elementary
x
Los Gatos Union x x x
Los Gatos-Saratoga
High School
District
x x x x
Milpitas Unified x x x x
Morgan Hill
Unified
x x x x
Mountain View Los
Altos
x x
Mountain View
Whisman
x x x x
Palo Alto Unified x x x
Santa Clara County
Office of Education
(SCCOE)
x x x (SCCOE
programs and
charters)
10 Alternative
Education
SCCOE Special
Education
x
Santa Clara Unified x x x x
Sunnyvale
Elementary
x x x
The S4SP partnership encourages school districts to follow a comprehensive, tiered approach to trainings in suicide prevention and mental health (see Figure 4), also known in the education field as Multi-Tiered Systems of Support (MTSS). This approach ensures that school personnel and mental health professionals are first trained to handle referrals of students who may be struggling with suicide (Tiers 2 and 3), because student referrals tend to increase after students and families have received training (Tier 1). As a result, S4SP participation emphasizes skills development among school staff to identify and manage warning signs of student mental health crises.
Figure 4. Multi-Tiered Systems of Support Approach to School-based Suicide Prevention Efforts
11 The SP Program provides trainings and consultations appropriate for each tier of work. The main helper trainings for Tier 2 work are the Kognito online health simulation trainings, which the SP Program offers through a cost-sharing arrangement with the County Office of Education and each participating school district.
For the 2021-22 academic year, more
than 2,000 school staff and
approximately 1,000 students were
trained in online Kognito modules.
Completed simulations included: AtRisk (screenshot, left), Emotional and Mental Wellness, Trauma-Informed
Practices, Resilient Together
(postvention), Building Respect (bullying prevention), and the Friend 2 Friend peer module. In four years of the partnership, more than *15,000 teachers, staff, and students have been trained in various Kognito simulations across 15 County school districts. *Indicates duplicated numbers, with school staff completing multiple Kognito simulations.
FY22 pre- and post- training survey results from the Kognito “At-Risk” and “Emotional and Mental Wellness” online trainings indicated statistically significant improvements in suicide prevention helper-related competencies (see Figure 5).
Figure 5. Change in Self-Report of Suicide Prevention-Related Competencies for Kognito “At-Risk” and “Emotional and Mental Wellness” online trainings (for elementary, middle, high school educators)
Pre-Training
(N= 1304-1317)
Post-Training
(N=1035-1048)
Variables M SD M SD t-test Cohen's d Effect
Size
1. I know the warning
signs for suicide. 3.54 0.77 4.39 0.63 -29.453*** -1.19537 Large
2. I am able to identify
someone who is at 3.4 0.8 3.99 0.58 -20.833*** -0.82972 Large 12 risk for making a
suicide attempt.
3. I am aware of the
resources necessary
to refer someone in
a suicide crisis.
3.49 0.86 4.12 0.56 -21.48*** -0.84892 Large
4. I am confident in
my ability to make a
referral for someone
in a suicide crisis.
3.38 0.89 4.05 0.6 -21.559*** -0.86437 Large
5. I have the skills
necessary to support
or intervene with
someone thinking
about suicide.
3.16 0.91 3.9 0.68 -22.363*** -0.90684 Large
6. I understand and
can identify ways in
which culture
affects how suicide
is expressed and
experienced.
3.26 0.9 3.76 0.76 -14.498*** -0.59475 Medium
7. I feel prepared to
apply concepts of
culture and diversity
in my efforts to help
people with their
suicidal distress.
3.12 0.91 3.74 0.78 -17.44*** -0.72552 Medium
Notes. M=Mean. SD=Standard Deviation. Scores: 1=Strongly Disagree, 2=Disagree, 3=Neither disagree or agree; 4=Agree; 5=Strongly Agree. *** p < .001.
HEARD Alliance Technical Assistance
While rolling out their choice of
mental health trainings, districts
concurrently focus on refining
suicide crisis response forms and
protocols, and developing and
training Crisis Response Teams,
with technical support from
Stanford University’s HEARD
Alliance. During the reporting
period, a questionnaire was
conducted with school districts in the S4SP partnership. Nearly all respondents indicated an increase in mental health related issues among their students and a sense of overwhelm among staff (screenshot, right).
13 The results of this survey were discussed at the mid-year convening with district partners to clarify needs and identify the most productive ways the team could support sites. The HEARD Alliance response was informed and tailored to address these reported needs
(screenshot, left).
In mid-FY22, the HEARD
Alliance received
supplemental funding
through the supplemental
Substance Abuse Block
Grant (SABG) American
Rescue Plan Act (ARPA) funds to expand partnership efforts. This expansion seeks to strengthen the continuum of suicide prevention by addressing the promotion of youth mental health and well-being through primary interventions (Tier 1) that support both suicide prevention and substance use prevention efforts, with an emphasis on social-emotional learning. In FY22, the HEARD Alliance team completed 51 consultations and trainings (in social-emotional learning or crisis response) with 95 administrators and staff from 17 participating districts. District activities are summarized below (see Figure 6). Beginning in FY23, the HEARD Alliance team is working on developing and implementing outcomes evaluation surveys for their work in social-emotional learning and in crisis response.
Figure 6. FY22 HEARD Alliance District Support
District Consultations District Activity Highlights
Alum Rock Union 2 consultations;
4 participants
- Consultation planning intervention/postvention for ’22-’23 school year - Consultation for SEL plan and implementation
Berryessa Union 2 consultations; 11
participants
- Consultation for crisis intervention/postvention and SEL planning and implementation
- Follow-up consultation support
Eastside Union HS
District
1 consultation; 2
participants
- Consultation planning intervention/postvention for ’22-’23 school year - Beginning work on CRT formation and forms review
14 Escuela Popular
Charter (ESUHSD)
1 consultation; 3
participants
- Ongoing support via email
- Updates on training opportunities
- Linkage to partners to support efforts
Evergreen Elementary
SD
2 consultations; 21
participants
- Continuous email updates and check-ins
- Consultation planning intervention/postvention for ’22-’23 school year Franklin-McKinley
School District
1 consultation; 3
participants
- Consultation planning intervention/postvention for ’22-’23 school year - SEL consultation; Intervention forms review
Fremont Union HS
District
1 consultation; 1
participant
- Crisis manual and forms review
Gilroy Unified 6 consultations; 6
participants
- Support with mapping out MTSS plan and CASEL Phase 1 (preassessment) - Introduction to SEL supports
- Introduction to Dr. Steven Sust, Explore SEL curriculum opportunity with Gilroy HS
Los Altos Elementary
School District
3 consultations; 14
participants
- Consult for intervention technical assistance
- Kognito trainings and forms review
Los Gatos Union
School District
5 consultations; 9
participants
- Beginning of the academic year meeting with mental health counselors - Consultation planning intervention/postvention for ’22-’23 school year - Consult about Bullying prevention resources
- Consult regarding multiple concerns such as choking game and eating disorders
Los Gatos – Saratoga
Joint Union HS
District
1 consultation;1
participant
- Continued communication via email
Milpitas Unified 3 consultations; 1
participant
- Consultation planning intervention/postvention for ’22-’23 school year - Consultation about SEL plan & implementation
- Continued communication via email
Morgan Hill Unified 1 consultation; 1
participant
- Completed check-in survey
- Expressed being overwhelmed with increased needs and responses - Staff taking on multiple roles
MVLA 6 consultations; 1
participant
- Postvention consultations following the loss of a student to suicide - Consultation planning, intervention/postvention for ’22-’23 school year - SEL, crisis response, substance use consultation
Mountain View
Whisman
1 consultation; 1
participant
- Completed check-in survey
- Continued communication via email
Palo Alto Unified 3 consultations; 3
participants
- Completed check-in survey
- Email correspondence with resources and updates
Santa Clara Unified 3 consultations; 2
participants
- Wellness Centers discussion and visit planned for review of services - Email correspondence with resources and updates
15 Sunnyvale Elementary
SD
2 consultations; 2
participants
- Reviewed CRT & safety manual
SCCOE
Early Learning
Program
1 consultation; 4
participants
- Consultation planning intervention/postvention for ’22-’23 school year - Consultation about crisis protocol, CRT, intervention forms, parent engagement issues
- Second consultation about crisis protocol, CRT, intervention forms, parent engagement issues
SCCOE
Opportunity Youth
Academy
2 consultations; 5
participants
- Consultation planning intervention/postvention for ’22-’23 school year - Beginning CRT work and forms review
CHAC youth mental
health services
4 consultations - Planning for crisis intervention forms & protocols alignment with SCC Districts forms & protocols
- Staff training planned for August 2022
Health Systems
Research supports the idea that deaths by suicide may be effectively prevented by focusing on clinical settings. For example, studies have shown that suicidal individuals are likely to encounter medical services within the weeks or months prior to a serious suicide attempt or death; 45% are seen by the primary care provider (PCP) in the month prior to dying by suicide, and 60% are seen by their PCP in the preceding year (Ahmedani et al., 2014; Bongar & Sullivan, 2013; Walker et al., 2019). By contrast, only about a third engage with mental health care providers in the year prior (Ahmendani, et al., 2019), leaving PCPs as the most common point of contact (Luoma et al., 2002).
Beginning in FY21, the SP Program contracted with Community Connections Psychological Associates (CCPA), led by Drs. Joyce Chu and Chris Weaver (clinical psychologists and professors at Palo Alto University with expertise in suicide prevention for cultural populations and in forensic psychology, respectively), to provide culturally competent downstream implementation support for primary care and behavioral health clinical sites seeking to enhance their system-wide suicide services. The overarching goal is to ensure a coordinated and culturally-responsive system of clinical care that comprehensively detects, assesses, and treats suicidal thoughts and behaviors with attention to recovery orientation and cultural competency for the diverse populations of Santa Clara County.
16 The pilot and proof-of-concept efforts in FY21 culminated in the formation of collaborative workgroups and detailed needs assessment data from targeted pilot collaboration sites that represented key entities within Santa Clara’s health services system that manage diverse suicidal clients – ambulatory/primary care and contracted behavioral health clinics. In FY22, focus was maintained on improving and supporting culturally competent suicide prevention and management in the county’s clinical services, targeting both behavioral health and ambulatory care stakeholders as initial clinical sites or teams.
Ambulatory Care – Primary Care Behavioral Health (PCBH) outcomes A needs assessment conducted in FY21 indicated that primary care physicians were hesitant to screen patients for suicide risk because of barriers to access when physicians needed to refer patients to a PCBH clinician. The needs assessment also identified opportunities to streamline PCBH workflows, in order to simplify the handoff process for physicians and to create appropriate referral pathways for different levels of suicide risk. The PCBH team agreed to embark on a multi-year process to re-envision PCBH, with goals that include developing a PCBH model that fits the needs and demands of primary care physicians in the County Health System; and integrating evidence-based, culturally-responsive suicide risk assessment and management throughout the new workflows.
Critical among the successful changes that happened in FY22 was the initiation and expansion of group therapy offerings through PCBH. At the beginning of the year, therapy groups were identified as the primary mechanism that successful PCBH programs use to handle high patient flows and to buffer the transition process for patients awaiting connections to individual therapy. Working through challenges with scheduling and billing, PCBH went from offering no routine groups to now offering multiple standing groups for high-patient-flow intervention needs (e.g., depression), with plans to expand into additional groups and to make group referral the default process for taking new patients into PCBH care, as appropriate. An additional side effect of this is that the intake process to assess for group therapy fit presents an opportunity to insert suicide risk screening, likely in the form of a Columbia brief risk screener.
17 New workflows were also designed, enabling PCBH to plan for an ideal of all patients receiving a same-day warm handoff with a PCBH clinician. Workflows were designed to make sure that the first patients to not get warm handoffs, in the event of clinician absence and/or patient overflow, would be triaged appropriately, including suicide risk screening. Once put into practice, this process should allow further streamlining of risk assessment that needs to happen at the hands of the physicians and will likely be a point of further future optimization of care.
Behavioral Health – Momentum for Health outcomes
Working with the community-based behavioral health provider Momentum for Health, a needs assessment conducted by CCPA at the end of FY21 yielded five core areas of suicide risk management requiring focused attention: Culture & Underserved Populations, Treatment and Comprehensive Assessment, Community Support Following Suicide Loss, Paperwork, Policies and Procedures, and Crisis and 5150.
In addition to organizing and completing a six-month suicide prevention training series, Momentum completed a number of lasting organizational changes were made with each of the monthly training series topics in mind. Momentum now has a) a catalog of suicide assessment and support options in multiple languages, b) multiple copies of dialectical behavior therapy for suicide treatment manuals and conceptualization worksheets at each clinical site, c) materials promoting both internal and external resources where staff can seek care or support following a suicide loss, d) boilerplate documentation templates and ongoing modifications to their assessment and tracking tools, and e) clarified and centralized procedures for 5150 procedures within the continuum of Momentum care.
These efforts yielded impressive outcomes upon post assessment. Quantitative ratings measuring a wide swath of suicide prevention areas indicated the areas of focus that would become the five topic areas for the six months of dedicated suicide prevention efforts. Upon post-test, each of these areas demonstrated substantial improvement (see Figure 7). Needs assessment participants were also asked to check any from a list of similar suicide prevention practice areas that needed improvement. Pre- versus post-test comparisons again showed a decrease in areas of concern (see Figure 8).
18 Postvention/Grief Support
Figure 7
Figure 8
19 The SP Program initially finalized a contract for postvention grief support services and trainings with Bill Wilson Center (BWC) at the conclusion of FY21. The goals for this contract included the development of Critical Incident Stress Management (CISM) training curriculum to increase the capacity of the County’s Behavioral Health Services Department staff to provide grief support services following critical incidents and loss,
including suicide. The CISM
training content was
developed in partnership with
the SP Program’s
Interventions Workgroup, with
the first training held in
September 2021 (screenshot,
right). Additionally, the BWC
contract included providing community grief support/postvention services to community groups and County partners affected by suicide or loss on request (e.g., when a school district experiences the death or suicide of a student). In response to local tragedies and the increased need for community support, the contract was amended prior to the end of the fiscal year to include funding to support at least double the number of additional postvention responses.
Service provided Number offered Participants/Number
served
Critical Incident Stress
Management (CISM) training
3 trainings 87
CISM postvention responses 40 responses (individual
and group)
344
Across the three CISM training offerings, participants reported statistically significant improvements from pre- to post-training in six self-reported preparedness measures related to grief response.
Figure 9. Change in Self-Report of Grief Response Preparedness for CISM trainings
20 Pre-Training
(N= 61-75)
Post-Training
(N=33)
Variables M SD M SD t-test Cohen's
d
Effect
Size
1. I feel adequately prepared to
identify the dynamics of the
stress/grief response after
change or loss.
3.6 0.85 4.45 1 -4.2618*** -
0.95551
Large
2. I feel adequately prepared to
recognize behaviors, thoughts
and feelings related to
stress/grief.
3.83 0.76 4.48 1 -3.366 -
0.78134
Medium
3. I feel adequately prepared to
articulate and practice effective
techniques for responding to
grief in children, youth and
adults.
3.44 0.84 4.36 0.99 -4.6524*** -
1.04581
Large
4. I feel adequately prepared to
identify specific dynamics of
suicide grief and sudden or
violent trauma.
3.52 0.86 4.36 0.99 -4.1361*** -0.9362 Large
5. I feel adequately prepared to
recognize and articulate stress
responses in yourself and coworkers in the aftermath of a critical incident.
3.66 0.77 4.42 1 -3.822*** -0.8972 Large
6. I feel adequately prepared to
apply principles and processes
of stress management to build
resiliency in the home and work
environment.
3.49 0.85 4.33 1.02 -4.0403*** -
0.93027
Large
Note re: interpretation tips: Any t-test value that has *** next to it is showing that there is a change that is more significant than chance. For example, we see that in “1. I feel adequately prepared to identify the dynamics of the stress/grief response after change or loss.” goes from an average of 3.6 on the pre-survey (most people chose either 3=Neither disagree or agree to 4=Agree) to a 4.45 on the post-survey (most people chose 4=Agree to 5=Strongly agree) with a significant t-test value of 21 -4.26 (meaning the change from 3.5 to 4.45 was significant enough that it is likely NOT due to chance).
Spirituality and Mental Health Policy
In FY21, the Suicide Prevention Policy Workgroup researched and developed a policy for BHSD to support the incorporation of clients’ spirituality as they recover from mental health conditions. The activities undertaken by the workgroup include the following:
• Conducted a literature review to identify the value of including a client’s spiritual beliefs in the achievement of their mental health recovery goals; • Reviewed the behavioral health policies from three California counties about the “Integration of Spiritual Interests in Recovery and Wellness”; • Interviewed local faith leaders regarding concerns/barriers and hopes/recommendations for improvement regarding faith/spirituality and County services;
• Gathered feedback regarding the draft policy from key stakeholders at a SPOC meeting and from other key BHSD staff;
• Incorporated feedback into policy language and finalized the draft; • Submitted policy draft to BHSD executive leadership for consideration.
In FY 22, two employees of the County (Dr. Renee Marquett and Dr. Michael Mann-Stock) presented the Suicide Prevention Policy Workgroup’s research and proposed policy to the BHSD Policy Committee. The proposed policy represented a culmination of the workgroup’s FY21 efforts related to the assessment and incorporation of spirituality into assessment and treatment planning practices. The policy committee was receptive to the presentation and the hope is with some additional revision the committee will approve the BHSD spirituality policy.
Regional/City-level Collaborations
Milpitas
In the reporting period, the city of Milpitas HOPE (Helping Others Process Emotions) Task Force made strides in its suicide prevention work through 22 continued community engagement, collaboration with city agencies, and concerted efforts to prioritize cultural diversity and ensure its presence within the task force.
The task force continues to meet monthly and in FY22 was comprised of Milpitas community members, local faith community leaders, local veterans, various Milpitas city officials, and representatives from Milpitas Unified School District, National Alliance on Mental Illness (NAMI), Counseling and Support Services for Youth (CASSY), Kaiser Permanente, and Child Advocates of Silicon Valley, as well as a Coordinator from the SP Program. In FY22, the task force built on the previous year’s work through defining prevention strategies, planning and offering new community events, and increasing task force influence in city suicide prevention operations. FY21 HOPE task force accomplishments follow:
● Senior support group
● Supported Holiday Magic events for Milpitas families and seniors, cultural communities
● Postvention protocol approved
● Town halls: LGBTQ, seniors
● ASIST training for city staff and community
● LIKE screening for youth and area families
● Established new initiatives with workgroups (New 2022-23 Work Group Updates –
○ a. Cultural Diversity/Outreach - Tegan McLane
○ b. Teens/Transitional Youth - John Macon
○ c. Veterans/Homeless – Saul Gonzalez
○ d. Older Adults – John Macon)
● Social Worker – Thomas Kingery from Avenidas (LGBTQ)
● Promoted HOPE and County events addressing mental health and suicide prevention;
● Recruited and welcomed new members that represent communities previously unrepresented on task force, including LGBTQ+ and veteran communities;
● Created work groups prioritizing efforts in specific Milpitas subpopulations disproportionately impacted by suicide;
● Increased visibility through sustained social media engagement and through development and launch of task force webpage;
23 ● Facilitated scheduling of and city official attendance at safe SP Program training on safe messaging on suicide;
● Planned and hosted 10 mental health town halls for various subpopulations in local Milpitas community;
● Established support groups for LGBTQ+ and older adult communities; ● Crafted official city condolence letter, to be shared following receipt of death report, with family and next-of-kin of suicide decedents that resided in Milpitas; and
● Drafted and submitted for city council consideration suicide postvention Standard Operating Procedures proposal for the city.
North County
During the reporting year, Project Safety Net (PSN) increased its presence in North Santa Clara County. Key highlights included:
• Named the 2022 Nonprofit of the Year for District 13 by California State Senator Josh Becker;
• Convened 12 meetings with Partners Council and Collaborative Action Teams (Community Education and Policy/Advocacy) with activities including postvention discussions, community event planning, and policy development;
• Had nearly 600 encounters through outreach events and community engagement activities;
• Hosted eight virtual community events reaching more than 200 participants with topics including: Self-care for Supporters; Policy forum with Supervisor Joe Simitian, Assemblymember Marc Berman, and Alex Briscoe with California Children’s Trust; Mobile Mental Healthcare Showcase; Sexual Orientation and Gender Identity Expression; and youthdriven initiatives (allcove); and • Formalized partnership with Momentum for Health, and with investment from the County of Santa Clara and El Camino Healthcare District, launched a two-year pilot of teen Mental Health First Aid trainings for North County and West Valley.
South County
24 The South County Suicide Prevention Workgroup formed in September 2017 in response to the Epi-Aid report on youth suicides, which found that Morgan Hill had the second-highest rate of youth suicides in the County. In FY22, members formally decided to sunset the workgroup given the decrease in momentum, attendance, and the desire to create a more aligned regional collaborative. The transition of the workgroup coincided with the sunsetting of the South County United for Health Leadership Team. Through multiple discussions addressing ways to address duplication of efforts, the Mental Health Committee was formed under the South County Youth Task Force to address suicide prevention, mental health, and substance use prevention. This committee aims to define its goals in FY23 as members work to address the behavioral health needs of South County. 25 Objective 2: Increase use of mental health services
Community Helper Trainings
The SP Program offers seven community helper trainings in suicide prevention and mental health (see Figure 10). These trainings’ main goals are to teach participants how to identify the warning signs of suicide or a mental health crisis, and how to support and refer individuals in crisis to seek professional help. In FY22, the program trained 4,525 community members and/or service providers through community helper trainings.
After two years of in-person training hiatus due to COVID-19 limitations, the Applied Suicide Intervention Skills Training (ASIST) offerings resumed in August 2021, with four trainings scheduled for the fiscal year. Additionally, recognizing the convenience and increased participation in virtual trainings over the course of the pandemic, the Program continued to host trainings through the Zoom platform.
With a significant decrease in staffing during the middle of the reporting year, the “Be Sensitive, Be Brave” (BSBB) training offerings were put on hold for several months, resulting in this year’s offerings decreasing to 20 hosted trainings, compared to last year’s 36 trainings. To address this issue, at the conclusion of FY22 the team initiated the ‘Training of Trainers’ process to increase the number of skilled partners who are equipped to deliver these trainings and support the SP Program’s FY23 BSBB offerings.
Figure 10. FY22 Suicide Prevention and Mental Health Helper Trainings Name Description Group(s) Trained in FY22 Number of
Trainings Hosted
Question,
Persuade, Refer
(QPR)
Basic helper training teaching the
QPR method of asking the suicide
Question, Persuading the individual to
get help, and referring the individual
to local resources.
General community, public
health nurses, college staff
Online codes
issued: 286
LivingWorks
Start
Multi-modal interactive training
simulations and scenarios to learn and
practice how to recognize when
someone is in distress, increase
comfort with supporting an individual
in crisis, and how to connect them to
an intervention provider.
General community, partner
organizations
Online codes
issued: 477
26 Be Sensitive, Be
Brave: Suicide
Prevention
Participants explore tailored content to
define suicide, identify specific
warning signs and how to talk about
suicide with compassion to account
for cultural differences.
Youth advisory group, older
adult faith group, general
community, high
school/college staff, nursing
students
15 completed;
Virtual (Zoom)
Applied Suicide
Intervention
Skills Training
(ASIST)
Participants learn to provide suicide
first aid to a person at risk, identify
key elements of a suicide safety plan
and the actions required for
implementation.
Mental health professionals,
community partners,
school/youth providers
4 completed; In
person (San Jose,
Milpitas, Gilroy,
Cupertino)
SP201: Suicide
Prevention and
Clinical
Management for
Diverse
Clientele
Participants learn to assess suicide
risk, safety plan, case conceptualize,
and treatment plan for managing
suicide risk in diverse populations.
BHSD clinicians, contracted
mental health professionals
2 completed;
Virtual (Zoom)
Be Sensitive, Be
Brave: Mental
Health
Participants learn to define mental
health, identify signs of mental
distress and mental health resources,
and how culture and diversity affect
mental health.
Youth advisory group, high
school students, faith
community, general
community, physical
therapists, college staff
5 completed;
Virtual (Zoom)
Kognito
simulations
Simulated online conversations in
grade-level specific modules on
various mental health and wellness
topics.
Elementary, middle, and high
school educators and staff;
high school students
9 school districts
participated (3,113
staff and students
trained)
In aggregate, across four of the suicide prevention helper trainings offered, participants reported statistically significant improvements in eight selfreported suicide prevention competencies related to knowledge, attitudes, and preparedness around being community helpers for suicide prevention (see Figure 11). The trainings analyzed include: Question, Persuade, Refer (QPR); LivingWorks Start; Be Sensitive, Be Brave: Suicide Prevention; and Applied Suicide Intervention Skills Training (ASIST).
Figure 11. Change in Self-Report of Suicide Prevention-Related Competencies for Trainings, July 2021-June 2022
Pre-Training
(N= 461-463)
Post-Training
(N=262-265)
Variables M SD M SD t-test Cohen's
d
Effect
Size
1. I know the warning signs for
suicide.
3.59 0.84 4.42 0.64 -14.916*** -1.07496 Large
27 2. I am able to identify someone
who is at risk for making a
suicide attempt.
3.38 0.9 4.37 0.65 -17.12*** -1.21232 Large
3. I feel prepared to discuss with
someone my concern about the
signs of suicidal distress they are
exhibiting.
3.29 1.04 4.31 0.7 -15.745*** -1.09734 Large
4. I am aware of the resources
necessary to refer someone in a
suicide crisis.
3.39 0.92 4.42 0.65 -17.563*** -1.23985 Large
5. I am confident in my ability to
make a referral for someone in a
suicide crisis.
3.2 1 4.28 0.7 -17.11*** -1.19829 Large
6. I have the skills necessary to
support or intervene with
someone thinking about suicide.
3.16 0.96 4.25 0.7 -17.664*** -1.24791 Large
7. I understand and can identify
ways in which culture affects
how suicide is expressed and
experienced.
3.35 1 4.18 0.71 -13.138*** -0.91803 Large
8. I feel prepared to apply concepts
of culture and diversity in my
efforts to help people with their
suicidal distress.
3.16 0.98 4.15 0.74 -15.426*** -1.10072 Large
Notes. M=Mean. SD=Standard Deviation. Scores: 1=Strongly Disagree, 2=Disagree, 3=Neither disagree or agree; 4=Agree; 5=Strongly Agree. *** p < .001.
Community Outreach - Tabling
The program’s Community Outreach Specialist was out on medical leave from December 2021 to January 2021 and out on family medical leave from February 2022 to May 2022. Additionally, the pandemic was still affecting the number of inperson tabling opportunities being offered. These limitations affected the tabling outcomes for this fiscal year.
534 members of the public were reached at 9 community tabling events. Upon request, various mental health resources were provided for Supervisor Susan Ellenberg’s office for their outreach efforts at National Night Out in September 2021.
28 Community Outreach Specialist, Day on the Bay - 10/16/2021 Community Outreach - Program Resources
A grief support resource was created in FY21. In FY22, several updates were made. These changes were also made to the other languages- Spanish, Vietnamese, Chinese, and Tagalog (attached). The updated versions were added to the program website and shared through the monthly newsletter.
In FY21 “Care Bags” were launched for patients who are released from the County acute psychiatric facility due to a suicide attempt or ideation. In FY22, a resource for suicide attempt survivors was created to be included with Care Bags (attached).
Translations will be available soon.
As an effort to continue infusing cultural humility into program resources, a suicide prevention guide was created for Black youth (attached). This resource was developed by the program’s Community Outreach Specialist, but drafts were provided to department staff for their feedback. These staff were identified as subject matter experts. Additionally, member of the community provided feedback on the resource prior to dissemination.
29 Community Outreach - Events
As the newly formed Prevention Services Division, efforts to provide divisionwide programming for the public were prioritized this past fiscal year. Both the Suicide Prevention Program and the Substance Use Prevention Program shared resources and program information at a back-to-school night event for Fremont Union High School District on August 12, 2021.
A joint program, panel-discussion was held on October 27, 2021. The panel was created for parents to learn about prevention and intervention strategies they can practice at home, and how to effectively communicate to help build resiliency in youth. Mental health experts and youth presented the strategies and held a Q&A session. 55 participants attended. They were provided with resource handouts, a cheat sheet of the recommendations reviewed, and a handout on how a parent can help support their child through a mental health or substance use crisis (attached). 15 participants filled out the post-survey. Survey results can be viewed below. 30 What useful techniques did you learn?
Resources
Recognition and resources for mental health
To be open with the kids, share personal stories, not be so hard on them.
Suggestions on how to build resiliency (i.e. allow teen to have control and to make choices, and select their own classes; let them be involved in activities that they enjoy; ask open-ended questions)
Learning that sleep plays a factor, I knew it was about focus but not so much mental health
School counselor and youth perspective
How to communicate with teenagers in order to prevent substance abuse and act when they do deal with stress and suffer from anxiety.
patience and resources
How to detect illness
How the teenagers look when are under drugs influences
Pacific Islanders Work
In FY22, the program continued prioritizing work within the local Pacific Islander community. As part of the Interventions workgroup, these efforts were identified as a subgroup led by Tarah Tupou, a doctoral candidate from Palo Alto University and a member of the Pacific Islander community. Tarah held talanoas* for 33 participants who were mostly Tongan, and TAY aged (18-24). Tarah took the results from the talanoas and created a presentation on the major themes identified. 31 These results showed stigma, lack of knowledge, familial pressure, and generational differences as major barriers to accessing help. The slides below are from Tarah’s presentation at the Suicide Prevention Conference on September 1, 2022.
T. Tupou, Getting to Know Pacific Islanders in Our Community, 8/29/2022.
Crisis Services
Crisis and Suicide Prevention Lifeline
The Suicide and Crisis Hotline answered a total of 35,809 calls from July 1, 2021- June 30, 2022. Comparing to total calls answered in FY 20-21, there was a decreased in 6.5%. This was contributed to lowered number of volunteer crisis counselors. Though total handled was less in FY22 comparing to the previous year, calls in came with higher level of crisis. The number of suicide and progress calls were also higher in FY22 comparing to the previous year.
SACS HOTLINE CALL VOLUME BY RISK OF SUICIDE FISCAL YEAR 2021-2022
32 CRISIS
CALLS JULY AUG SEPT OCT NOV DEC JAN FEB MAR APRIL MAY JUNE TOTAL Suicide in
Progress 2 1 0 4 1 5 0 3 7 4 3 2 32
High Risk 14 16 28 19 21 14 19 14 7 10 10 13 185
Medium Risk 71 100 158 130 132 75 112 120 98 99 75 178 1,348 Low Risk 755 1,145 1,492 1,360 1,248 1,254 1,266 1,118 1,118 748 1,116 826 13,446 NONE
CRISIS
CALLS
No Risk of
Suicide but
need
Support 2,213 909 1,524 1,644 1,354 1,480 1,565 1,738 2,213 38 73 43 14,794 Informational
(Triage,
Misc) 66 44 55 79 82 51 48 37 45 2,141 1,732 1,624 6,004 Total 3,121 2,215 3,257 3,236 2,838 2,879 3,010 3,030 3,488 3,040 3,009 2,686 35,809 Definitions
• Suicide in Progress: Caller is engaging in suicidal behavior • High Risk: Caller has a past history of a suicide attempt, currently has suicide ideation. He/she is able to describe a plan and access to means to killing self
• Medium Risk: Caller has a past history of a suicide attempt. Currently not suicidal but is depressed • Low Risk: Caller has no history suicide attempt, currently not suicidal, has a history of mental health treatment/services and needs support
• No Risk of Suicide but need support: Caller has no history of suicide attempt, currently not suicidal, no history of mental health services but needs support
• Informational (Triage, Misc): Called for information and referrals to community resources County 988 Transition
In 2020, the federal government mandated that all states transition to utilizing 988 as the new phone number to reach the national crisis and suicide prevention lifeline by July 16, 2022. In preparation of this transition, in March of FY22 the SP Program entered discussions with Behavioral Health Services Department (BHSD) leadership around development of a public awareness campaign promoting the transition to 988. Campaign discussions also included promotion of the County’s new consolidated, non-crisis phone line providing access to all County mental health and substance use treatment services.
Through the end of the fiscal year, the SP Program has facilitated the establishment of a working group comprised of BHSD leadership stakeholders and created a 33 workplan for campaign launch and implementation. Specifically, the primary campaign objectives are to, among Santa Clara County residents: drive awareness, consideration, and recall about the new 988 lifeline and consolidated non-crisis service number for mental health or substance use treatment; improve knowledge about where to seek help for non-crisis mental health and substance use treatment; improve attitudes and counter any negative perception towards seeking help for mental health services; and increase help-seeking behavior. The campaign is anticipated to air in September 2022 and continue with at least three four- to sixweek flights, targeted to various Santa Clara County cultural communities.
The SP Program has contracted with a media and communications agency to develop a campaign media plan, generate internal and public-facing creative materials (e.g., online ads, flyers, brochures, webpage content), and facilitate purchase and placement of ads on different distribution platforms. Furthermore, the Program has contracted with a research agency to conduct a comprehensive evaluation of the campaign following completion. The evaluation will explore how effectively the campaign increased awareness of 988 and willingness to use the service.
Crisis Text Line
The County BHSD partners with Crisis Text Line (CTL), a free crisis intervention service via text message. Community members may text RENEW to the national CTL number, 741741, to access trained volunteer crisis counselors by text (free, 24/7, anonymous). In FY22, 499 conversations among 301 texters took place under the County’s CTL. Some of the feedback from the texters included, “Very nice and heard me out. I feel better about my situation and got good resources.” Another bit of qualitative feedback from a participant included, “[scrubbed] listened to me vent, and helped talk me through a rather difficult morning. Their support left me feeling validated and heard. They helped me by providing a list of coping skills/activities to help refocus and redirect my feelings.
Thank you for being a friend in a desperate time of need.” 34 FY22 Crisis Text Line Conversation Content (Top Topics Discussed) Issue Percentage of Call Volume
Anxiety/Stress 35.5%
Depression/Sadness 33.1%
Relationship 29.0%
School (*) 28.9%
Suicide 24.5%
Isolation/Loneliness 19.2%
* Issue inferred from Conversation
34 39
53 45
34 48
30 35
48 37
51 45
30 32 36 32 27
34 20
28 36 32 36 33
Volume of Use
1 1
Month and Year
FY 22 Crisis Text Line Use
Conversations Texters Active Rescue
35 Objective 3: Reduce access to lethal means
Gun Safety
In FY22, the SP Program’s Communications Workgroup planned, developed, and implemented a comprehensive public awareness campaign to support suicide prevention through safe firearm storage in Santa Clara County (County). The campaign supported suicide prevention among adult men, particularly Caucasian, ages 45 to 65, who own firearms and are County residents. The campaign’s primary objectives were to improve knowledge about best practices for safe firearm use and safe gun storage; to improve attitudes toward practicing safe firearm use and storage of firearms; and to increase safe firearm behavior including use and storage practices among County gun owners and residents with firearm access.
The campaign ran from December 6, 2021 to January 23, 2022 and was comprised of print materials and radio, digital (online), and social media advertisements in English. These assets promoted a message encouraging safe firearm storage.
Specifically, the ads and materials highlighted that time between someone in mental health distress and a loaded gun could prevent suicide and indicated that safely storing guns provides that time. All assets pointed the audience to a campaign-specific web page, www.BeGunSafe.org, designed to address the campaign objectives.
The Suicide Prevention Program evaluated the campaign’s reach and impact among County residents, particularly among middle-aged gun owners as they were primary target audience. Reach and impressions data are included in the table below. According to US Census Bureau estimates (2020), 243,821 males ages 45 to 64 reside in Santa Clara County, and 118,252 of these are Caucasian.
Figure 12. Gun Safety Campaign Reach and Impressions
Campaign Totals
Total impressions Webpage visits Webpage views Video views Radio spots 8,473,687 4125 4569 79,087 371
36 The Program also evaluated the campaign using data collected through a detailed survey of the target audience. Evaluation survey data were analyzed, reviewed, and archived to inform future Program suicide prevention work and campaign efforts.
Campaign evaluation surveys were designed primarily for gun owners and those with access to firearms. To facilitate outreach to this group, campaign flyers with QR codes linked to the online survey were distributed to gun retailers in the County. Additional survey dissemination was achieved through sharing the survey link with community residents through direct partner network communication and social media outreach. While almost all survey respondents acknowledged that safe gun storage was important, fewer respondents found a connection between safely storing firearms and preventing suicide (see figure below).
Figure 13. Gun Safety Campaign Survey Results: Attitudes toward Gun safety and Suicide, All Respondents
This was especially the case among respondents who reported being gun owners.
When compared to non-gun owners, gun owners were significantly less likely to agree that safe firearm storage was one way to help prevent suicide. Gun owners were also significantly less likely to agree that time between a person experiencing suicidality and getting access to a loaded firearm could help prevent a death (see figure below). Generally, the campaign evaluation results reflected the difficulty in messaging about firearm safety to a traditionally reticent target audience in firearm owners. The survey findings provided foundational learnings to the Program that 37 will inform future efforts on promoting suicide awareness with challenging populations.
Figure 14. Gun Safety Campaign Survey Results: Attitudes toward Gun safety and Suicide, Non-gun Owners vs. Gun Owners
In a supplementary effort, the Program assisted in the planning and successful operation of a gun buyback event in Milpitas. As part of its continued membership and contribution to the District Attorney’s Gun Safety and Violence Prevention Workgroup, the Program worked with fellow Workgroup member organizations to organize the event and to facilitate distribution of gun safety informational materials, suicide prevention materials, and gun locks to event attendees. At the buyback event, more than 415 firearms were voluntarily turned in by residents and more than 150 gun locks were distributed.
Hanging Means Safety
The SP Program’s work on addressing ligature means safety originated based on county suicide data showing that hangings had become the most common means for suicide, and especially for youth and non-white racial/ethnic groups. In the fiscal year, the Program focused on community ligature means safety by conducting two roundtables centering on suggestions for prevention strategies, and forming a working group focused on this topic to implement these recommendations. An initial roundtable was conducted with community, county, and clinical professionals to explore possible strategies for intervention for ligature safety. This roundtable highlighted the gaps in knowledge for best practices around 38 ligature safety and, in response, a working group was formed. The working group conducted extensive literature reviews and presented their findings to roundtable members. The findings, along with original roundtable discussion results, comprised a comprehensive list of intervention recommendations grounded in research.
Below are some key findings from the literature review:
• There is a need to avoid contributing to the cognitive access of ligature means. In other words, avoiding “putting thoughts into people’s heads” about this method of suicide.
• Ligature use is most common in youth and non-white and non-Black groups • Suicide deaths by ligature occurs most often in community settings, such as public spaces or places of residence.
• Individual’s incorrect perceptions about ligature usage is a major influence for selecting this method of suicide. These misconceptions include thoughts that this method is easy, painless, non-technical, and avoids a grotesque image.
The working group chose to focus on two intervention recommendations: creating a brochure on ligature safety for providers and creating a separate brochure on ligature safety for caregivers. The group developed a provider brochure and is planning a pilot test with clinical professionals. The pilot will help to evaluate the brochure’s effectiveness in increasing provider knowledge on ligature means and how ligature means safety pertains to their work. The caregiver brochure is currently in development with plans to conduct a corresponding pilot test. 39 Objective 4: Improve messaging in media about suicide To further its evaluation efforts supporting safe messaging on suicide in the media, in FY22 the SP Program continued its collaboration with Stanford University’s Center for Youth Mental Health and Wellbeing. In the prior fiscal year, the partnership developed and finalized a tool that helps professionals in media, research, and suicide prevention, among others, to measure adherence to safe reporting recommendations. The product, the Tool for Evaluating Media Portrayals of Suicide (TEMPOS), is an innovative instrument that employs an accessible and standardized scale for users. Following its completion, the partnership applied TEMPOS to a dataset of 220 suicide-related news articles from June 2018, when Anthony Bourdain and Kate Spade died by suicide. The resulting analysis provided baseline data included in a journal article detailing tool development, application, and potential areas of utilization and ramifications. In FY22, the SP Program and Stanford teams drafted and submitted the article to the International Journal of Environmental Research and Public Health (IJERPH), which published the article in March 2022: https://www.mdpi.com/1660-4601/19/5/2994 Throughout the drafting process, the teams curated and made available a userfriendly and shareable version of the tool. In addition, the partnership has developed and placed online an interactive version of TEMPOS:
https://med.stanford.edu/psychiatry/special-initiatives/mediamh/tempos.html.
Furthermore, team members partnered with a nationally-renowned journalist to generate a presentation on the TEMPOS development process, its potential uses, and the role of such tools in working with media members to help prevent suicide contagion through safe reporting on suicide. The group submitted a proposal to deliver the presentation at the American Association of Suicidology annual conference. The proposal was accepted, and the group presented at a featured workshop session at the conference in April 2022. The same group will share the presentation at the upcoming Suicide Prevention Program conference in September 2022. In the upcoming fiscal year, the SP Program and Stanford plan to refine and widely share the updated interactive web version. Furthermore, the SP Program has begun planning an analysis applying TEMPOS to a new dataset of suicide-related articles. The new analysis will provide additional tool validation and will help 40 evaluate impacts of Program efforts to improve safe messaging in local media (see images below).
Images 1 & 2. Products of Efforts around Safe Messaging in Media: Shareable Document (left) and Interactive (right) Versions of Evaluation Tool
In FY22 the Program continued to collect pre/post-training survey data from the safe messaging trainings conducted with media and communications professionals and youth in the county. In FY22, the Program provided four safe messaging trainings attended by a total of 75 public communicators, school staff, and local high school students and peer leaders. Post-workshop survey data indicated that 100% of respondents were somewhat or very likely to apply the safe messaging guidelines in their work. Ninety-seven percent stated that they understand the potential impact of reporting on suicide contagion (see figure below). Additionally, following training, 84% of respondents reported that they know how to write an article or press release that follows the Recommendations for Reporting on Suicide: https://reportingonsuicide.org/ (see figure below).
Figure 15. Safe Messaging Training Survey Results: Understanding Impact of Reporting on Suicide Contagion (left) and Knowing How to Write Items That Follow Recommendations (right)
41 The Program also conducts regular monitoring of the local media and response to reporters for stories on suicide, and tracks reporters’ responses to these outreach efforts. In the most recent fiscal year, 37 separate communications were conducted with local and national reporters regarding their articles or prospective reporting on suicide and mental health. Some of these communications involved proactive outreach to local and national media in partnership with Santa Clara Valley Health System Public Information Officers. Outreach took form of sharing with media members safe reporting guidelines ahead of the public release of information on a high-profile suicide death in the county. Local media coverage following the release was largely sensitive and demonstrated guideline consideration, possibly reflecting impact of the proactive outreach. Of the 37 total communication efforts, the Program fielded seven follow-up messages, some resulting in continued dialogue and fostered relationships with journalists. These communications led to relationships with media members who aided in other Program safe messaging efforts such as TEMPOS development and presentation to the public. 42 Objective 5: Create supportive community environments In FY21, the SP Program was brought under a new BHSD division, Prevention Services, joining the department’s Substance Use Prevention Services (SUPS) program. In FY22, the Prevention Services Division applied for and received supplemental Substance Abuse Block Grant (SABG) funding from the American Rescue Plan Act (ARPA) and Coronavirus Response and Relief Supplemental Appropriations Act (CRRSAA). The allocation of supplemental funding supports primary prevention efforts that apply to both suicide prevention and substance use prevention, and the Prevention Services Division has used the funding to supplement the work of existing contract providers across both SP and SUPS programs. The funding is supporting cross-cutting primary prevention efforts, including social-emotional learning in schools (see Objective 1: Schools for Suicide Prevention Partnership), as well as various youth engagement programs that work to build leadership skills and foster supportive relationships and community environments, including Youth Connect (below).
Youth Connect (formerly Youth Connectedness Initiative) Youth Community Service (YCS) seeks to increase youth connectedness to peers, adults, and their communities by promoting social-emotional learning, community service-based learning, and peer leadership. YCS’s Youth Connect (YC) applies the Search Institute’s Developmental Relationships Framework (DRF) in its focus on developing collaboration among youth, parents, and adult allies, to increase a sense of belonging among youth in their communities and to build healthy relationships that help youth thrive. YC programs are designed to foster protective factors which center youth voices and their lived experiences as part of the solution, in order to increase parents’ and youth-serving adults’ knowledge and awareness about strategies youth have identified as supportive actions and immediate actions to support youth.
Using the Search Institute’s DRF as a guide to inform and evaluate work for the academic year, YC Peer Leaders selected “Provide Support” as the overarching element of choice. Additionally, the YC team identified three target audiences for their efforts: youth Peer Leaders, youth activity participants, and adults (family 43 members, parents, etc.). A snapshot of activities for the targeted audiences are highlighted below.
Youth Connect - Peer
Leaders
Peers/Youth Community (parents,
intergenerational families)
• Hosted informational
presentations from local
agencies. Topics included:
intimate partner violence in
AAPI community, teen
dating violence, Wellness
Center resources, Project
Safety Net
• Trained in “Be Sensitive,
Be Brave” series
• Recommendations for
Reporting on Suicide
training
• Call to Action workshop
development
• Suicide prevention social
media campaign
• Title IX social media
campaign
• Middle school workshop
• LGBTQIA+ Resource List
• Counseling & Support
Services for Youth
(CASSY) Mental Wellness
Poster project
• Palo Alto Lunar New Year
Event
• Palo Alto Unified School
District schoolboard
postvention response
• Virtual workshops hosted by
the City of Mountain View
In mid-FY22, Youth Connect received supplemental funding through supplemental SABG ARPA funds to support collaborative primary prevention strategies that jointly address suicide and substance use prevention. ARPA funding will allow for YCS programming expansion to more school districts, particularly in the North County area, which currently has less coverage by existing Prevention Services Division substance use prevention contract providers. Programming expansion would include introducing the YC peer leader model, as well as substance use prevention trainings and presentations to more school districts in the county.
Youth Connect (YC) Peer Leader Program Evaluation
For FY22, Youth Connect continued their program’s evaluation and data collection process based on their FY21 outcome goals. YC Peer Leaders (N=17) were surveyed to assess YC’s impact on their knowledge and attitudes around belonging, sense of connectedness, and well-being. The reporting varies as some survey collection was based on qualitative and not quantitative responses.
YC program participants reported an overall positive program experience, with 70% rating their experience a 4 (highest) on a 4-point Likert scale, as well as high 44 confidence in their newly acquired abilities to plan and execute YC projects for peers and adults.
Connectedness:
The survey asked two questions about connectedness with adults, with 84% of respondents indicating that they have positive connections to both their parents and adults outside of their families. When explicitly asked about the Developmental Relationships experienced in the Youth Connect program, 90% of the Peer Leaders indicated that they do have at least one Developmental Relationship via the program. This is particularly notable as most respondents have only been in the program for one year and the program was often restricted to meeting remotely.
Newer students indicated that they were having difficulty finding friends they connected with at school but found “family” in the Youth Connect program.
Student support outside of the program is highlighted below via personal reflections of the program’s impact:
• “I also really liked learning from upperclassmen who knew more about the program than me and were able to provide wisdom during this program.” • “I don't have a favorite memory of Youth Connect- rather, my favorite times with Youth Connect have been all the times that we have had together and the community that we've fostered.”
• “Youth Connect gave me a space to build community with people I never thought I would talk to. I loved all of the in-person activities we were able to do and I made so many friends.”
• “The adults and people in the program have been super nice and fun to be around. I cannot wait for next year.”
Understanding the Developmental Relationship Framework (DRF):
Underpinning the youth’s work is the Developmental Relationships Framework. • 100% of the youth respondents indicated that they have received the element of “express care” from adults since starting the YCI program (77% rated this at a 4, the highest level of agreement).
• Additionally, youth were asked if they’ve increased the number of actions they have taken which embody the “express care” element. 100% of the 45 respondents agreed (77% responded with a 4, the highest level of agreement).
Here is how one student described the DRF and how it relates to Youth Connect:
“The Developmental Relationship[s] Framework is a set of elements that are used to strengthen the relationship between adults and kids/young adults. YC uses it as a basis for our projects and how we interact with each other between peer leaders and adults.”
Skill-Building:
Through the program, participants are gaining practical skills through the support and experiences in Youth Connect. All respondents reported feeling confident in their ability to lead projects and follow the project through to completion. As one student wrote:
“I've been in YCI for four years, and since then I feel like it has had a large part in growing my self-confidence: in school, in professional settings, and with friends.
YCI has really helped me learn my worth and has provided me a safe place to grow into who I am, and to contribute to my community.” Overall Program:
Peer Leaders rated their overall experience in the program positively. On more than one occasion youth in the program referred to the group as “family” and indicated feelings of connectedness created in the Youth Connect space.
The charts below reflect quarterly progress based on outcomes indicated for Youth Connect’s two additional audiences: youth activity participants and adult activity participants. The reporting varies, as some survey collection was based on qualitative and not quantitative responses.
YOUTH PARTICIPANTS
Short term: Increase reported
knowledge about DRF element(s)
among youth participants.
Medium term: Improve reported attitudes
around and
strengthen intention to implement DRF
element(s) among youth participants.
46 Q1
DRF Element:
“Provide Support”
N/A N/A
Q2
DRF Element:
“Provide Support”
Peer Leaders engaged with a high
school club, a local Poster Project
and explicitly extended the
opportunity to provide peer support
to include students outside Youth
Connect.
The Poster Project gave student artists outside
Youth Connect an opportunity to provide support
through art and an opportunity for youth to
express mental health advocacy.
Q3
DRF Element:
“Provide Support”
Youth Connect projects explicitly
focused on supporting peers with
topics related to suicide prevention,
postvention, teen dating, and the
LGBTQIA+ community. Data was
not collected on youth participants
this reporting period.
Data to be collected at the end of the school year
to capture youth participants' attitudes and
intention to Provide Support.
Q4
DRF Element:
“Provide Support”
(Continued from Q3) Youth Connect
projects explicitly focused on
supporting peers with topics related
to suicide prevention, postvention,
teen dating, and the LGBTQIA+
community. Data was not collected
on youth participants this reporting
period.
Youth participants in the middle school
workshop shared the following feedback:
• “Learned strategies to initiate the
conversation.”
• “…very helpful scenarios to help us think
through different coping techniques and
strategies.”
100% of survey respondents (5 people) felt the
workshop was supportive of youth in the
community and most respondents (4, with one
neutral response) expressed they would use the
tools learned in the workshop after the event.
ADULT PARTICIPANTS
Short term: Increase reported
knowledge about DRF element(s)
among adult participants.
Medium term: Improve reported attitudes
around and strengthen intention to
implement DRF element(s) among adult
participants.
Q1
DRF Element:
“Provide
Support”
N/A N/A
Q2
DRF Element:
“Provide
Support”
Combining survey data from workshops
during this quarter, all participants
increased reported knowledge about DRF.
Survey data from workshops, 5 out of 7
respondents, reported to have increased their
knowledge on how to foster positive
relationships; 4 out of 7 reported increased
understanding of challenges faced by youth;
and 2 out of 7 reported increased intention to
actively develop positive relationships.
Q3
DRF Element:
“Provide
Support”
Adult participants predominantly engaged
through activities not directly addressing
the DRF. Several workshops were
rescheduled.
Youth Connect did not provided adult
participants opportunities to explicitly engage
with the DRF during this reporting period.
Instead, included were several connection
points between Peer Leaders and adults in the
community, especially through suicide
postvention advocacy efforts.
47 Q4
DRF Element:
“Provide
Support”
Through pre/post surveys we saw almost a
2-point increase in participants’ familiarity
with the DRF. In pre-surveys, participants’
average response to knowledge of the DRF
was 2 while in post surveys it was 3.8.
(Scale: 1 - not at all, 4 - very familiar with
DRF)
Adults had opportunities to strengthen their
understanding of DRF elements through the
‘Call to Action’ workshops as well as the
workshop for middle school students (and
parents) around seeking support.
100% of respondents from the ‘Call to Action’
workshops indicated that they intended to
implement elements of the DRF in their
relationships with youth.
Additionally, through the postvention
campaign, adults were provided with direct
feedback about how to better support youth
when faced with a mental health crisis or death
in the community.
48 CONCLUSION AND RECOMMENDATIONS
In providing a summation of the County of Santa Clara Suicide Prevention (SP) Program’s FY22, the best words that can be utilized include “impact” and “determination in the face of adversity.” As Santa Clara County and much of the world continued to experience intermittent interruptions to professional and personal lives due to COVID-19, the SP Program’s activities generated nearly 8.5 million duplicated contacts. The scope and range of the programming was diverse and focused. Coupled with the strategic programming was a significant and continual effort to improve outcomes evaluation of SP Program activities using evidence-based methods. The program continued to increase its investment in evaluation activities in FY22 and began working with various external partners to improve their evaluation activities. The efforts and determination allowed the Program to meet the goals/recommendations put forward in its 2020-2021 annual report. These recommendations included the following:
• Grow and strengthen the program to be able to serve the population better and more comprehensively across the lifespan.
• Continue to support efforts to strengthen services and the continuum of care as related to suicide.
• Increase primary prevention efforts by incorporating upstream, public health strategies that focus on building resilience factors and on improving environmental factors.
• Develop a database of local, culturally relevant, evidence-based suicide prevention public awareness campaign materials.
Looking ahead, the SP Program has several evaluation goals to address in the coming FY23 (see below):
• Continue to develop an evaluation tool to track changes in pre- and postknowledge which can be applied to mental health professionals who review the program’s ligature safety caregiver brochure.
• Develop and refine an associated logic model/evaluation plan for the SP’s work focused on public awareness campaigns and the distribution of gun locks and firearm safety resources.
49 • Re-run some program evaluations in order to compare progress to the baselines that have already been conducted, e.g., using TEMPOS to assess recent safe messaging efforts, and re-running the BRFSS to assess use of behavioral health services at a population level.
• Continue to understand and improve systems-level suicide prevention outcomes and how to measure them, specifically in the health systems. • Continue to identify and implement evaluation strategies which effectively measure the Prevention Services Division’s outcomes on social/community connectedness.
• Identify or develop evidence-based evaluation methods or professional practices which allow for the measurement of services provided focused on socio-emotional learning environments and crisis responses systems within school districts throughout the County of Santa Clara.
50 ACKNOWLEDGEMENTS
Sherri Terao, Ed.D.
SPOC Co-Chair
Director, Santa Clara County Behavioral
Health Services Department (BHSD)
Victor Ojakian
Co-Chair, SPOC
Co-President, National Alliance on
Mental Illness
Survivor of Suicide Loss
Joy Alexiou
Co-Chair, Communications
Workgroup
HHS Public Information Officer
Joyce Chu, PhD
Data Workgroup Co-Chair
Palo Alto University
Sandra Hernandez, LCSW
BHSD Division Director
Mary Ojakian, RN
HEARD Alliance
Survivor of Suicide Loss
Shashank Joshi, MD
Lucile Packard Children’s Hospital
Stanford University/HEARD Alliance
Marianne Marafino
Co-Chair, South County Workgroup
Community Solutions
Joan Baran, PhD
Children’s Health Council
Linda Lenoir, RN, MSN, CNS
HEARD Alliance
Mary Gloner, MPH, MBA
CEO, Project Safety Net
Leif Erickson
Youth Community Service
Tegan McLane
City of Milpitas
Ashley Yee-Mazawa
Palo Alto Program Director,
Youth Community Service
Mora Oommen
Executive Director,
Youth Community Service
Jack Roach
LGBTQ Wellness
Charu Aggarwal
City of Milpitas
Lan Nguyen, MA
Suicide and Crisis Services, BHSD
Kathy Forward
Community Advocate
51 Chris Miller
Co-Chair, Interventions Workgroup
Paul Muller
Co-Chair, Data Workgroup
BHSD Administrative Oversight
Director: Sherri Terao, Ed.D.
Director, Access and Unplanned Services: Bruce Copley, MA Program Manager III, Systems Initiatives, Planning & Communication:
Jeanne Moral, MPA
Program Manager II, MHSA Prevention and Early Intervention Manager:
Roshni Shah, MPH
Suicide Prevention (SP) Program Staff
Prevention Services Division Manager: Mego Lien, MPH, MIA Suicide Prevention Program Manager: Michael Mann-Stock, DSW, LCSW, MSW Coordinators: Jasmine Lopez, MA; John Donoghue, MPH
Community Outreach Specialist: Evelyn Quintanilla
Management Aide: Sam O’Neill, MS
Suicide and Crisis Services (SACS) Staff
Manager: Lan Nguyen, MA
Volunteer Supervisor: Eddie Subega, LMFT
Thank You:
County of Santa Clara Board of Supervisors
Members of the Data Workgroup
Members of the Interventions Workgroup
Members of the Policy Workgroup
Members of the Communications Workgroup
Members of city-level suicide prevention taskforces
SACS and SP Volunteers