suicide rates was greatest when the mail contact was at its most frequent. In other words, the more frequently participants received letters, the more protective the intervention was against the “normal” trajectory, followed by those either in treatment or those not in treatment and not receiving the letters. Later, Carter, Clover, Whyte, Dawson, & D’este (2007) randomly placed 772 adults admitted to an emergency service for self- poisoning into a group that received eight postcard contacts using the same content as Motto or into a group that received usual care. They found a significant reduction in the number
of readmissions to the emergency service for self-poisoning in the postcard-receiving group. Given the success of these interventions, it is possible to consider them in clinical follow-up with suicidal adolescents, although this intervention in youth has yet to be studied formally. More recently, studies have applied the concept of caring letters to text messaging, with findings providing promising support for caring text messaging following treatment for suicidal ideation (Luxton et al., 2020; Reger et al., 2017).
SUICIDE PREVENTION IN CALIFORNIA
In 2004, California voters approved the Mental Health Services Act (Clark et al., 2013), until then known as Proposition 63 . The Act was meant to reduce the stigma of mental illness, but also to prevent suicide resulting from untreated mental illness. It was also meant to transform community services from being crisis- driven to being preventative, and to reach underserved and diverse communities (Each Mind Matters, 2020). In 2006, Governor Arnold Schwarzenegger directed the California Department of Mental Health to “administratively develop a statewide strategic plan on suicide prevention” (California Department of Mental Health, 2008). The information gathered and disseminated in the first part of the plan covered suicide risk factors and protective factors, as well as the demographics and means of suicide. Part 2 of the “Schwarzenegger Plan” recommended the establishment of an Office of Suicide Prevention, which was established but closed in 2012 (MHSOAC, n.d.). However, in 2020, Assemblyman James Ramos introduced a bill (AB2112) to create a new Office of Suicide Prevention (Ramos, 2020). In 2018, California set up the Mental Health Services Oversight and Accountability Commission (MHSOAC) to review the 2008 plan, which had never been fully implemented, and to create a new plan. In July of 2019, they released the first draft of Striving for Zero: California’s Strategic Plan for Suicide Prevention 2020- 2025 for public comment. In August of 2019, a third draft was released, which was also open for public comment. The final version is now available online (see the Resources section at the end of the course). The Commission describes its goal as the production of “an achievable policy agenda and a foundation for suicide prevention based on best practices” (MHSOAC, n.d.; p. 11). The Commission’s “overarching objective is to equip and empower California communities with the information they need to minimize risk, improve access to care, and prevent suicidal behaviors” (MHSOAC, n.d.; p. 11). The Commission calls for a partnership between government and private entities. The Commission also, in keeping with the Schwarzenegger Plan and with the urgings of Assemblyman Ramos, calls for the creation of a Suicide Prevention Office within the Department of Public Health. California suicide hotlines The California Mental Health Services Authority (CalMHSA) also funds crisis hotlines, and in 2017 the RAND Corporation published a report titled Suicide Prevention Hotlines in California (Acosta et al., 2017). According to the report, such hotlines can prevent suicide in two ways: by ensuring the callers’ immediate safety and by linking those at risk with services they need. The RAND Corporation studied the California suicide hotline system at the request of CalMHSA, which was looking for an evaluation of their choices concerning the distribution of resources. According to the report: CalMHSA funded the creation of one suicide prevention hotline and provided funding for three to five years to enhance 11 existing hotlines – for example, by supporting expanded language translation services, hours of operation, or modes of access (such as chat or text); facilitating accreditation … ; or targeting vulnerable populations with suicide prevention campaigns (Acosta et al., 2017).
A major feature of California’s suicide-prevention plan is use of the Public Health Model, which is composed of four constantly repeated steps: 1. Describe the problem. 2. Identify risk and protective factors. 3. Develop and evaluate interventions. 4. Implement interventions and disseminate information. California’s new plan has four strategic aims: 1. Establish a suicide prevention infrastructure : This will be an infrastructure of “information, expertise, evaluation, and communication” (p. 11), relying on best practices and standardized data. 2. Minimize risk for suicidal behavior by promoting safe environments, resiliency, and connectedness : One way to promote a safe environment is to remove possible means, such as guns, from the home, to prevent a transient crisis from turning lethal. Removing the means also allows time and opportunity for intervention. An individual can be taught resiliency and to know when to reach out for help. The media can learn to be careful in how they report high-profile suicides, and they can help to reduce stigma as well as disseminate information concerning resources. 3. Increase early identification of suicide risk and connection to services based on risk : Recognition of warning signs and use of screening tools should lead to connection to the proper services for each individual at risk. 4. Provide timely services and supports to people experiencing suicidal behavior, especially attempted suicides, and people experiencing the suicide death of a loved one : Aftercare must follow best practices, and there must be a swift response in support of families, loved ones, and, sometimes, entire communities. (MHSOAC, n.d.) The new plan also calls for an expansion of the California Violent Death Reporting System, standardization of suicide prevention training, expansion of current requirements to screen suicide risk, and uniform written policies for discharge. There are many other suicide hotlines in California, but there is no official directory for them (Acosta et al., 2017; Suicide.org, n.d.). The researchers asked a sample of adult Californians to rank the people or entities they would turn to if seeking help in dealing with suicidal ideation. The most- commonly reported resources were: 1. Meeting face-to-face with mental health professionals: 78%. 2. Talking with family and friends: 72%. 3. Visiting a website for information or resources: 66%. 4. Calling a crisis line: 62%. 5. Visiting a web-based chat platform: 46%. 6. Texting a crisis line: 43%. The report noted that communications trends are shifting toward chatting and texting, especially among youth. One problem with this shift is that chatting and texting are more costly for the call centers (Acosta et al., 2017).
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