HomeMy WebLinkAboutStaff Report 456-10TO: HONORABLE CITY COUNCIL
FROM: CITY MANAGER DEPARTMENT: COMMUNITY SERVICES
DATE: DECEMBER 13, 2010 CMR: 456:10
REPORT TYPE: CONSENT ITEM
SUBJECT: Policy and Services Committee Recommendation to Approve the City
of Palo Alto Suicide Prevention Policy; Adoption of Two Resolutions:
(1) Supporting the Santa Clara County Suicide Prevention Plan; and
(2) Approving the 41 Developmental Assets Framework for Youth and
Teen Well-Being
EXECUTIVE SUMMARY
The Project Safety Net (PSN) community task force began to take shape during the
summer 0[2009 in response to the tragic teen suicides our community experienced. The
task force is broadly represented by parents, medical professionals, youth-serving non
profits, City Commission representatives, Palo Alto Youth Council and many others. The
mission of the PSN community task force is to develop and implement an effective,
comprehensive, community-based mental health plan for overall youth well-being in Palo
Alto. The plan, as described in the PSN report (CMR:312:10)
(www.CityofPaloAlto.orgIPSNreport), includes education, prevention and intervention
strategies that together provid~ a safety net for youth and teens in Palo Alto, and defines
our community's teen suicide prevention efforts.
The purpose of this staff report is to follow up on the referral of the PSN report by
Council on July 19,2010 to the Policy and Services Committee. The Council directed the
Policy and Services Committee to consider specific policy recommendations in the PSN
report that pertain to the City in support of teen suicide prevention and strategies for the
social and emotional health of youth and teens in Palo Alto.
Three policy recommendations emerged from the Policy and Services Committee's
deliberations; they are listed below:
1. Resolution supporting the Santa Clara County (SCC) Suicide Prevention Strategic
Plan (Attachment A)
CMR:456:10 Page 1 of7
2. Approval of a City of Palo Alto suicide prevention policy (Exhibit A)
3. Resolution adopting the 41 Developmental Assets framework for youth and teen
well-being (Attachment B)
RECOMENDATION
The Policy and Services Committee recommends that Council approve the following:
1. Resolution supporting the Santa Clara County (SCC) Suicide Prevention Strategic
Plan (Attachment A)
2. City of Palo Alto suicide prevention policy (Exhibit A)
3. Resolution adopting the 41 Developmental Assets framework for youth and teen
well-being (Attachment B)
BACKGROUND
In response to the five teen suicides the Palo Alto community experienced between May
2009 and January 2010, the City of Palo Alto and Palo Alto Unified School District
(PAUSD) along with many community partners have taken an active and progressive role
in developing short-and long-term plans in support of suicide prevention and the social
and emotional health of youth and teens in Palo Alto.
The PSN community task force effort is closely aligned with the 2010 Council priority of
"community collaboration for youth well-being". City staff has played an important
coordinating role in bringing the community together to both plan and take action in
support of youth well-being. The PSN report describes the process that the Palo Alto
community used to investigate, intervene and strive to prevent further teen suicides. The
report delineates specific resiliency and mental health promotion strategies that have
taken place, along with recommendations for future action.
It is the collective recommendation of the PSN community task force that the
recommendations in the PSN report be used as a foundation for a sustainable community
task force for youth and teen well-being; and that policy makers, administrators and the
broader community use the PSN report as a supportive document to help inform
community decision making in the interest of youth and teen well-being.
On July 19, 2010, staff made a presentation to the Council on Project Safety Net and
asked that the PSN report be referred to the Policy and Services Committee for further
review and recommendations. The Council directed staff to return to Council with
specific policy recommendations from the Committee that support teen suicide
prevention and strategies for the social and emotional health of youth and teens in Palo
Alto.
DISCUSSION
The Policy and Services Committee discussed the Project Safety Net report and
community task force efforts at the September 14 and October 12, 2010 meetings. At the
CMR:456:10 Page 2 of7
September 14, 2010 Policy and Services Committee meeting, staff recommended that the
Committee focus on those areas of the PSN report that are specific to the City and that
have potential City policy implications. Below are the focus areas discussed that have
City policy implications:
1. Ongoing staff support for PSN Community Task Force.
2. Approval of a City of Palo Alto suicide prevention policy.
3. Adoption of the 41 Developmental Assets framework.
4. Commitment to youth outreach and elevating the youth voice.
S. Commitment to the reduction of lethal means to self harm.
At the Policy and Services Committee's direction, staff brings items 2 and 3 (above) to
Council for action. Discussion of potential policy recommendations for items 1, 4 and S
continue, but specific action is not recommended at this time.
1. Ongoing staff support for PSN:
The City's role in PSN has been one of coordinator, finding the right people and experts,
bringing them together to collectively develop and implement a comprehensive
community-based mental health plan for overall youth and teen well-being in Palo Alto.
Staff has attempted to create the space and atmosphere that effectively harnesses the
tremendous community talent, expertise and goodwill that surround youth and teens in
our community. The coordinating role the City plays is a significant commitment and has
added additional strain on staff, who are still adjusting to 2011 budget cuts and staff
reductions, particularly in the Community Services Department. The challenge of
addressing the issue of insufficient resources for the task force is still an open question.
The PSN community task force remains an unfunded alliance of committed organizations
and individuals focused on youth and teen well-being. An encouraging development is
the quality and efficacy of the PSN efforts has. received local and national attention,
sparking interest from several foundations to consider supporting the effort. Although
staff does not have a recommendation for ongoing staff support for PSN at this time, we
are committed to continue coordinating the PSN community task force through the end of
the 2010-2011 school year in its current configuration. Over the 2011 winter/spring
season the PSN committee will explore options for a sustainable model to ensure the PSN
strategies expressed in the PSN report continue to be implemented.
2. Approval of a City of Palo Alto suicide prevention policy:
A fundamental strategy for PSN is to have City and PAUSD adopt a policy that speaks
specifically to suicide prevention (Exhibit A). In order to create a united and concerted
effort to reduce suicides, a community effort must involve community leaders and
decision makers. If it is clear from the top of an organization that suicide prevention is a
priority, then all levels of an organization will appreciate and understand that suicide
prevention is valued and necessary. Consequently, an important strategy is for elected
officials to adopt policies that commit to suicide prevention and mental health support for
CMR:456:1O Page 3 of7
all community members. One of the most noted and successful suicide prevention plans
is the U.S. Air Force Suicide Prevention Program. One reason attributed for its success is
leadership involvement from the top of the organization.
The City suicide prevention policy recommendation is aligned with the Santa Clara
County (SCC) Suicide Prevention Strategic Plan (Executive Summary SCC Suicide
Prevention Plan -Attachment D) that was adopted by the/SCC Board of Supervisors on
August 24, 2010. The City's Policy is incorporated in the Resolution as an exhibit. Staff
further recommends that Council adopt a resolution (Attachment A) supporting the SCC
Suicide Prevention Strategic Plan which SCC hopes all cities in the County will adopt
and implement. Implementation of the City suicide prevention policy will be a
collaborative effort, drawing on the expertise and resources of the many supporting
partners on PSN community task force.
3. Adopt the 41 Developmental Assets framework:
Resiliency is a key component to keeping youth safe and healthy. Project Safety Net and
PAUSD in conjunction with Project Cornerstone, a local non-profit helping communities
build "asset-rich" environments, have adopted the Search Institute's 41 Developmental
Assets framework for building resiliency and other positive character traits amongst
youth and teens. Staff recommends the City of Palo Alto join with P AUSD in adopting
the 41 Developmental Assets (Attachment C).
Developmental Assets provide a framework of 41 building blocks that enhance the health
and well-being of youth and teens. They are the experiences and opportunities that all
young people need to grow into healthy, responsible adults. A list of 41 Developmental
Assets can be referenced in Attachment C. The Asset model is a highly regarded
approach to mobilize communities with a common vision and language for what youth
and teens need to thrive.
Through years of research in youth development, these assets have been identified by the
Search Institute, an independent research and educational organization based in
Minneapolis, Minnesota. Their research has shown that when these assets are present,
they help prevent negative behaviors, risk-taking, and help increase positive, thriving
behaviors. Assets are cumulative: the more youth have, the better it will be. As the
number of assets increases, so does a child's well-being. As a framework for healthy
growth and well-being, assets give communities a set of benchmarks to measure the
positive development of their youth and teens -regardless of community size, geographic
region, gender, family economics, race or ethnicity. The Search Institute found that the
number of assets a young person possesses affects how they respond to and maneuver
through difficult life experiences. The fewer assets a youth has, the more likely they are
to participate in negative behavior to cope with difficult times. Young people who have
CMR:456:10 Page 4 of7
31-40 assets are more likely to bounce back from difficult situations and bounce back
more quickly.
PAUSD conducted a comprehensive Developmental Asset survey in fall 2010. The
results of this survey will be available in early spring 2011. The survey results will be
instrumental in shaping P AUSD and our community-wide plans and actions to support
youth and teens in the future.
4. Commitment to youth outreach and elevating the youth voice:
The City Council and staff are very committed to youth well-being as evidenced by the
broad and diverse programs and services provided by the City for youth and teens. As the
Policy and Services Committee discussed this item, it was agreed that encouraging and
elevating the youth voice in community decision-making was very important. A
commitment to continue an annual study session with the Palo Alto Youth Council and
City Council, and active participation of elected officials in an annual youth forum was
strongly supported.
Moreover, consideration of assigning a Council member to be a Youth Council liaison,
something the Parks and Recreation and Human Relations Commissions have recently
done, was another idea discussed. The Community Services Department staff will
continue to look for· new and creative ways to get adults and teens together to build
positive relationships, problem-solve and further build a supportive community for youth
and teens. Although no specific policy recommendation is being made on this item at this
time, staff and the Policy and Services Committee remain committed to making positive
connections with the youth and teen community through existing City programs and
servIces.
5. Commitment to the reduction of lethal means to selfharm:
A tremendous amount of empirical evidence exists to support strategies to reduce lethal
means to self-harm when attempting to stem suicide contagion; a phenomenon defined by
the Centers for Disease Control and Prevention (CDC) as exposure to suicide or suicidal
behavior of one or more persons influence others to commit or attempt suicide. Due to
the high level of impulsivity involved with suicide and the lack of impulse control
inherent to the teenage years, lethal means restriction to self-harm is critical and a
paramount strategy for PSN. Studies have shown that 70% of those aged 13 to 34 who
attempt suicide set the interval between deciding to kill themselves and acting at less than
an hour.
Beginning in November 2009, the City of Palo Alto Police Department retained a private
security firm to be on-site 7 days a week for the hours the Caltrain passenger line
operated. The original objective was to continue this prevention effort through the end of
the 2009-10 school year. This· effort has now been extended to the end of the 2010-11
CMR:456:10 . Page 5 of7
school year at the request of the PSN Community Task Force. Moreover, the Police
Department continues to provide increased patrols along the rail line.
The City has and continues to accept donations to offset the cost for the contracted
security effort. To date, the community has contributed over $75,000 and fully funded the
cost of having the security personnel present from November 2009 through June 2010.
In addition, prior to the Police Department utilizing a security firm, a dedicated group of
volunteers in support of this strategy began to maintain a presence at key crossings along
the train tracks. This effort has come to be known as TrackWatch and continues today to
supplement the work of private security guards.
The City has supported the TrackWatch volunteers through providing, as follows: (1)
training on procedures and safety (in cooperation with Caltrain and the San Mateo
County Sheriff Transit Bureau); (2) equipment such as reflective safety vests; (3)
increasing wattage of pre-existing street lighting in the area and installed new light
fixtures to further illuminate the area during the evening; (4) services to clear 100 ft. of
vegetation in either direction of the crossing on the east side of Alma Street, which
significantly increased visibility at the crossing and, as well, Caltrain cleared and
removed significant amounts of vegetation within the rail line right of way, which
established a clear line of sight north and south of the crossing within the right of way;
(5) Caltrain, in conjunction with the City, performed a thorough safety inspection of the
fencing along the right of way surrounding the East Meadow train crossing and, as a
result, significant fencing improvements were made to restrict access; and (6) Caltrain
also improved the safety and suicide prevention signage at the East Meadow crossing
among other crossings.
RESOURCE IMPACT
The· resource impacts are essentially staff time. Specifically, staff will incorporate the
approval of a City suicide prevention policy (Exhibit A) in the resolution supporting the
Santa Clara County (SCC) Suicide Prevention Strategic Plan (Attachment A) and the
resolution adopting the 41 Developmental Assets framework for youth and teen well
being (Attachment C) into existing job descriptions and work plans. Staff will evaluate
resource impacts annually to ensure we are being effective while not compromising other·
City priorities as limited staff resources are allocated. If budget adjustinents or additional
resources are needed to further support the suicide prevention policy or resolutions staff
will bring such recommendations to Council as part of the annual budget process.
Recognizing the City has limited resources, funds to implement this policy shall be
provided as available, and shall be sought through private donations, grant applications
and other sources of outside funding. Additional funding will also be sought through
partnership with the Palo Alto Unified School District and other agencies with expertise
in this area.
CMR:456:10 Page 6 of7
POLICY IMPLICATIONS
The recommendations respond to the City Council 2010 priority of "Community
Collaboration for Youth Well-being." Specifically the policy implications are that City
staff and Council, through existing resources, will make a concerted effort to prevent teen
suicide. Among the prevention strategies will be community education on youth well
being, youth outreach, invigorating existing youth and teen programs to further improve
coping skills and resiliency, easily accessible mental health and suicide prevention
resources and the sUPP9rt of reducing lethal means to self harm.
ENVIRONMENTAL REVIEW
This is not a project under the California Environmental Quality Act.
ATTACHMENTS
Attachment A: Resolution supporting the Santa Clara County (SCC) Suicide
Prevention Strategic Plan
Exhibit A: City of Palo Alto Suicide Prevention Policy
Attachment B: Resolution adopting the 41 Developmental Assets framework for
youth and teen well-being
Attachment C: List of the 41 Developmental Assets
Attachment D: Santa Clara Co icide Prevention PI -Executive Summary
PREPAREDBY: ______ ~~--------~~--~--~------------
ROBDEGEUS
Division Manager, Recreation Services
APPROVED BY: a~ ------~~~-~~T~G-RE+=G~B~E-T~T-S-----------
\:) Director of Community Services
CITYMANAGERAPPROVAL~~LU ,~
CrJAMES KEENE
'\ 'l>'City Manager
CMR: Page 7 of7
Attachm.ent .A
Not Yet Approved
Resolution No. ---
Resolution of the Council of the City of Palo Alto In
Support of the Santa· Clara County Suicide Prevention
Strategic Plan and Approval of the City of Palo Alto
Suicide Prevention Policy
WHEREAS, the Surgeon General, Dr. David Satcher, in his 1999 "Call to
Action to Prevent Suicide," stated that suicide in the United States is a serious public
health issue and the most preventable form of death; and
WHEREAS, the National Strategy for Suicide Prevention: Goals and Objectives
for Action promotes "increasing the proportion of family, youth and community service
providers and organizations with evidence-based suicide prevention programs"
(Objective 4.7); and
WHEREAS, Santa Clara County has lost an average of 140 individuals in recent
years to suicide, and many other County residents attempt suicide or express suicidal
thoughts, making this a significant public health issue; and
WHEREAS, almost all Santa Clara County cities annually have residents of all
races, gender, ages, and other social characteristics either express, attempt, or die by
suicide, affecting many members of our communities, making this a community matter
requiring collective action; and
WHEREAS, it is essential to support the Santa Clara County Suicide Prevention
Strategic Plan goals to (1) reduction of deaths by suicide, (2) increase awareness and
understanding of suicidal deaths and what to do,(3) improve data collection, monitoring
and follow up, and (4) have residents respond to a person in need; and
WHEREAS, educating people on suicide risk factors, warning signs, and
protective factors and removing stigma about mental health treatment, recovery and
resiliency is enlightened action; and,
WHEREAS, Santa Clara County Board of Supervisors, along with the leadership
and staff of the Mental Health Department, the members of the Suicide Prevention
Advisory Committee (SPAC) and the many public participants, has sought to prevent
suicide by holding public meetings and discussion sessions and approving a county
prevention plan; and
WHEREAS, the City's Policy and Services Committee has approved a Suicide
Prevention Policy and Mental Health Promotion, which is attached to this Resolution as
Attachment "A";
101129 jb 0073463
Not Yet Approved
NOW, THEREFORE, the Council of the City of Palo Alto does hereby
RESOL VE, as follows:
SECTION 1. The Council of the City of Palo Alto hereby proclaims its support
for and approval of the County of Santa Clara's Suicide Prevention Strategic Plan, and it
calls upon all citizens, government agencies, public and private institutions, businesses
and schools to support the vision of preventing death by suicide and creating a healthier
and safer community.
SECTION 2. The Council hereby adopts a policy entitled "Suicide Prevention
Policy and Mental Health Promotion," which policy, attached hereto as Attachment "A",
is in furtherance of the County's Suicide Prevention Strategic Plan.
SECTION 3. The Council finds that the adoption of this resolution does not
constitute a project under the California Environmental Quality Act and no
environmental assessment is required
INTRODUCED AND PASSED:
AYES:
NOES:
ABSENT:
ABSTENTIONS:
ATTEST: APPROVED:
City Clerk Mayor
APPROVED AS TO FORM:
City Manager
Senior Asst. City Attorney
Director of Community Services
Director of Administrative Services
101129 jb 0073463
Exhibit A
Not Yet Approved
CITY OF PALO ALTO POLICY STATEMENT
SUICIDE PREVENTION POLICY AND MENTAL HEALTH PROMOTION
The Palo Alto City Council and City Administration understand the concern that
suicide poses to its residents and employees/employers. Within that framework, the City
shall adopt suicide prevention strategies and intervention procedures. These policy and
procedures will be compatible with the Santa Clara County Suicide Prevention Strategic
Plan that was adopted by the Santa Clara County Board of Supervisors on August 24,
2010. To meet these goals, mental health care shall be promoted and supported ,for
community members in need.
This policy shall advance current strategies and best practices as designated by the
Suicide Prevention Resource Center, a national agency promoting the National Suicide
Prevention Plan, and the California Suicide Prevention Plan.
This policy promotes planning, implementing, and evaluating strategies for
suicide prevention and intervention and encouraging mental health care.
This will be accomplished by City staff and residents gaining a better
understanding about the causes of suicide and learning appropriate methods for
identifying and preventing loss of life. The policy and procedures will include training in
identifying those at risk (gatekeeper training) and how to report suicide threats to the
appropriate parental and professional authoritie~.
This policy shall provide for active collaboration on similar work by the Palo Alto
Unified School district and other local and regional authorities, including Santa Clara
County government. This policy shall advance current strategies, including but not
limited to, parent education, youth outreach, mental health support of students, means
reduction, youth mental health screenings, and grief support amongst other actions.
The implementation of this policy (and related procedures), supports initiatives
and actions taken by the community task force, Project Safety Net, or any future similar
committee. Their activities will be agreed upon, implemented and evaluated.
A strong and effective educational program to promote the healthy mental,
emotional, and· social development of residents and employees/employers including, but
not limited to, understanding of problem-solving skills, coping skills, and resilience.
Additionally, an easily accessible list of mental health and suicide prevention resources
shall be maintained.
The City Manager or his/her designee shall establish a crisis intervention plan and
procedures to ensure public safety and appropriate communications in the event that a
10 1129 jb 0073463
Not Yet Approved
suicide occurs or an attempt is made by an individual in the City of Palo Alto. The City
Manager will explore how this policy relates to the City's Emergency Crisis Plan.
Funds to implement this policy shall be provided, as available, and shall be sought
through private donations, grant applications and other sources of outside funding.
Additional funding will also be sought through partnership with the Palo Alto Unified
School District and other agencies with expertise in this area.
This policy and related procedures shall be reviewed annually to confirm
compliance and to make any necessary revisions.
101129 jb 0073463
Attachment B
Not Yet Approved
Resolution No. ---
Resolution of the Council of the City of Palo Alto
Adopting the 41 Developmental Assets Framework For
Youth and Teen Well-Being
WHEREAS, nationwide research shows a significant correlation between youth
that have high numbers of assets to positive behaviors and attitudes and those with lower
numbers of assets to increased high-risk behaviors; and
WHEREAS, the Project Safety Net Committee (the "Committee"), a group of
community members who came together to address the social and emotional health of
youth and teens, has adopted the Developmental Assets (the "Assets") framework (the
"Framework"), and the Palo Alto Unified School District, the YMCA, the Palo Alto
Chamber of Commerce, the PTA Council and Youth Community Services also have
adopted the Framework; and
WHEREAS, the Committee in its July 2010 report has identified a spectrum of
support that our youth needs, and the City of Palo Alto (the "City") has partnered with
Project Cornerstone, a,santa Clara County-wide collaborative with a growing network of
community leaders and partner organizations working together, to implement the Assets
in communities; and
WHEREAS, the Assets, originally pioneered by the nonprofit Search Institute of
Minnesota, are defined as the positive values, relationships and experiences that help
youth and teens succeed and thrive; and
WHEREAS, the Council of the City acknowledges that the Assets are the
essential building blocks for a healthy community and that all citizens of Palo Alto,
young and old, should strive to be asset builders; and
WHEREAS, the City will incorporate the Assets approach into the planning,
development, implementation and evaluation of programs and services for youth and
teens; and
WHEREAS, the City will encourage City employees and community partners to
participate in training on the 41 Developmental Assets and the Policy and Services
Committee of the City Council, after review by the Palo Alto Youth Council, will be
given yearly progress reports on the implementation of Assets in the City.
II
II
II
101129 jb 0073462
Not Yet Approved
NOW, THEREFORE, the Council of the City of Palo Alto does hereby
RESOLVE, as follows:
SECTION 1. The Council of the City of Palo Alto hereby adopts the 41
Developmental Assets as a framework for guiding all policies and programs in the City as
they relate to youth and teen well-being.
SECTION 2. The Council finds that the adoption of this resolution does not
constitute a project under the California Environmental Quality Act and no
environmental assessment is required
-INTRODUCED AND PASSED:
AYES:
NOES:
ABSENT:
ABSTENTIONS:
ATTEST: APPROVED:
City Clerk Mayor
APPROVED AS TO FORM:
City Manager
Senior Asst. City Attorney
Director of Community Services
Director of Administrative Services
101129 jb 0073462
The 41 Developmental Assets
The 40 Developmental Assets have been identified through the research by the Search Institute (www.search-institute.org) of
Minneapolis, Minnesota as the "building blocks of healthy development that help young people grow up healthy, caring, and
responsible adults." Project Cornerstone (www.projectcornerstone.org) of Santa Clara County, California established the need
for the *41 st Asset through community outreach and input. The Youth Development Initiative has adapted the Developmental
Assets as its guiding theory in advancing the Youth Development movement.
Empowerment
Boundaries &
Expectations
Commitment to
Learning
Positive Values
Social
Competencies
Asset Name and Definition
1. FAMILY SUPPORT Family life provides high levels of love and support
2. POSITIVE FAMILY COMMUNICATION Young person and her or his parent(s) communicate posi
tively, and young person is willing to seek advice and counsel from parent(s)
3. OTHER ADULT RELATIONSHIPS Young person receives support from three or more non-parent
adults
4. CARING NEIGHBORHOOD Young person experiences caring neighbors
5. CARING SCHOOL CLIMATE School provides a caring, encouraging environment
6. PARENT INVOLVEMENT IN SCHOOLING Parent(s) are actively involved in helping young person
succeed in school
7. COMMUNITY VALUES YOUTH Young person perceives that adults in the community value youth
8. YOUTH AS RESOURCES Young people are given useful roles in the community
9. SERVICE TO OTHERS Young person serves in the community one hour or more per week
10. SAFETY Young person feels safe at home, schooL and in the neighborhood
11. FAMILY BOUNDARIES Family has clear rules and consequences and monitors the young per
son's whereabouts
12. SCHOOL BOUNDARIES School provides clear rules and consequences
13. NEIGHBORHOOD BOUNDARIES Neighbors take responsibility for monitoring young people's
behavior
14. ADULT ROLE MODELS Parent(s) and other adults model positive, responsible behavior
15. POSITIVE PEER INFLUENCE Young person's best friends-model responsible behavior
16. HIGH EXPECTATIONS Both parent(s) and teachers encourage the young person to do well
17. CREATIVE ACTIVITIES Young person spends three or more hours per week in lessons or practice
in music, theater, or other arts
18. YOUTH PROGRAMS Young person spends three or more hours per week in sports, clubs, or or
ganizations at school and/or in the community
19. RELIGIOUS COMMUNITY Young person spends one or more hours per week in activities in a
religious institution
20. TIME AT HOME Young person is out with friends "with nothing special to do" two or fewer nights
per week
21. ACHIEVEMENT MOTIVATION Young person is motivated to do well in school
22. SCHOOL ENGAGEMENT Young person is actively engaged in learning
23. HOMEWORK Young person reports doing at least one hour of homework every school day
24. BONDING TO SCHOOL Young person cares about her or his school
25. READING FOR PLEASURE Young person reads for pleasure three or more hours per week
26. CARING Young person places high value on helping other people
27. EQUALITY AND SOCIAL JUSTICE Young person places high value on promoting equality and
reducing hunger and poverty
28. INTEGRITY Young person acts on convictions and stands up for her or his beliefs
29. HONESTY Young person "tells the truth even when it is not easy."
30. RESPONSIBILITY Young person believes accepts and takes personal responsibility
31. RESTRAINT Young person believes it is important not to be sexually active or to use alcohol or
other drugs
32. PLANNING AND DECISION MAKING Young person knows how to plan ahead and make
choices .
33. INTERPERSONAL COMPETENCE Young person has empathy, sensitivity, and friendship skills
34. CULTURAL COMPETENCE Young person has knowledge of and comfort with people of different
cultural/racial/ethnic backgrounds
35. RESISTANCE SKILLS Young person can resist negative peer pressure and dangerous situations
36. PEACEFUL CONFLICT RESOLUTION Young person seeks to resolve conflict nonviolently
37. PERSONAL POWER Young person feels he or she has control over "things that happen to me."
38. SELF-ESTEEM Young person reports having a high self-esteem
39. SENSE OF PURPOSE Young person reports that "my life has a purpose."
40. POSITIVE VIEW OF PERSONAL FUTURE Young person is optimistic about her/his personal future
41. POSITIVE CULTURAL IDENTITY Young person feels proud of her/his cultural background *
ITALICIZED and Bolded Assets are focuses of the youth Development Initiative mission.
YOUTH DEVELOPMENT INITIATIVE
To bring youth and adults together to provide the supports and
opportunities that young people In San Mateo County need to thrive.
www.BetheDifference.org
Santa Clara County Suicide Prevention Advisory Committee Co-Chairs
Hon. Liz Kniss, Santa Clara County Supervisor, District 5
Victor Ojakian, Santa Clara County Mental Health Board Member
Santa Clara County Board of Supervisors
Hon. Ken Yeager, District 4, President
Hon. Dave Cortese, District 3, Vice President
Hon. Donald F. Gage, District 1
Hon. George Shirakawa, District 2
Hon. Liz Kniss, District 5
County Executive
Dr. Jeffrey Smith
Staff:
Nancy Dane Pena, Ph.D., Director, Santa Clara County Mental Health Department
Elena Tindall, M.Ed., Santa Clara County Mental Health Department
Prevention and Early Intervention Consultant
and temporary Liaison to the State Office of Suicide Prevention
Ky Le, Santa Clara County Mental Health Department Mental Health Services Act Manager
Jean McCorquodale, Mental Health Department Consultant
Tracy Hern McGreevy, Photographer
Other Acknowledgements:
IInterpret for simultaneous translation
EMQ for hosting meetings
Christine Nguyen for assistance at the public forum
CTI for Suicide Prevention Website Support
MIG, Inc. for graphic design and meeting facilitation
If you or someone you' know or love is in crisis,
there are services, resources and help available. Please contact:
Suicide and Crisis Services (SACS) Hotline
(408) 279-3312 (Central County)
(650) 494-8420 (North County)
(408) 683-2482 (South County)
National Suicide Prevention Lifeline
1-800-273-TALK (8255)
For Veterans
1-800-273-TALK (8255) press 1
Additional resources also are listed on the Santa Clara County's Mental Health
Department website: www.sccgov.org/spac under the Suicide Prevention and
Local Resources section on the Suicide Prevention Resources page.
2009-2010 Santa Clara County Suicide Prevention Advisory Committee Members
Jeff Arnold, M.D.
Santa Clara Valley Medical Center Emergency Room
Maryann Barry
Santa Clara County Custody Health Services
Dennis Burns
Palo Alto Police Department
Ginny Cutler
EMQFF Child and Adolescent Mobile Crisis Program
Robert (Bob) Garner
Santa Clara County
Department of Alcohol and Drug Services
Mitch Gevelber, M.D.
Santa Clara Valley Medical Center,
Adolescent Medicine
Kelly Green, Alternate
San Mateo County Transit District
Michael Haberecht, M.D., Ph.D.
Stanford Counseling and Psychological Services
Melanie Hale, M.S., lCSW
Foothill College
Tiffany Ho, M.D.
Santa Clara County
Mental Health Department
Hope Holland
Suicide Attempt Survivor / California Network of
Mental Health Clients/ Santa Clara Chapter of
National Alliance on Mental Illness
Don Johnson, Member
Mental Health Department's Ethnic and Cultural
Community Advisory Committee
Jennifer Jones
Suicide Attempt Survivor / Santa Clara County
Mental Health Department
Consumer Affairs
Sheila Mitchell
Santa Clara County Probation Department
Dave Newman
Law Enforcement Liaison, South County
Bernie (Deacon) Nojadera
Interfaith Advisory Committee,
Diocese of San Jose
Cary Matsuoka
Santa Clara County Superintendents' Association
ThuHien Nguyen, Ph.D.
Santa Clara County Mental Health Department,
Cultural Competency Coordinator
Erin O'Brien
Association of Mental Health Contract Agencies
Joseph O'Hara, M.D.
Santa Clara County
Medical Examiner-Coroner Office
Mary Ojakian
American Foundation for Suicide Prevention
Chris Pacheco
Council on Aging Silicon Valley
Dan Peddycord, R.N., M.P.A./H.A.
Santa Clara County Public Health Department
Hon.Joe Pirzynski, Vice Mayor
Town of los Gatos,
Santa Clara County Cities Association
Janin Rimper
Suicide and Crisis Services Volunteer
Amari Romero-Thomas
211 Santa Clara County, United Way Silicon Valley
Mark Simon
SamTrans, Caltrain, San Mateo County
Transportation Authority
David Sisson
Suicide Attempt Survivor/ Community Member
Wiggsy Sivertsen
San Jose State University
Kevin Skelly
Palo Alto Unified School District
Pamela Smith Martin
Hospital Council of Northern and Central California
Tasha Souter, M.D.
Veterans Administration Hospital, Trauma Recovery
Nicole Squires
Policy Aide to Supervisor Kniss
Eddie Subega
Santa Clara County
Suicide and Crisis Services (Hotline)
Paul Taylor, Alternate
Momentum
Kris Wang, Alternate
Santa Clara County Cities Association
lorraine Zeller, Alternate
Survivor and Peer Mentor
LETTER OF INTRODUCTION FROM THE
SUICIDE PREVENTION ADVISORY COMMITTEE CO-CHAIRS
To the Residents of Santa Clara County:
We are proud to present the Santa Clara County Suicide Prevention Strategic Plan, a report on
the heartbreaking and unnecessary deaths by suicide along with next steps to address this
tragic problem as identified by the broad-based membership of the Suicide Prevention Advisory
Committee for the Santa Clara County Suicide Prevention Initiative. This Plan will serve as a
valuable tool as we work cooperatively with individuals, communities, organizations and other
levels of government to make our County a place where programs and services diminish severe
depression and loss of hope and where understanding and outreach lessen the incidents of self
harm and loss of life.
The Plan was developed by members of the Suicide Prevention Advisory Committee and many
interested representatives of the public, with the support of the Santa Clara County Mental
Health Department. In addition to helping us understand the causes of suicide, the goal of this
report is to stimulate collaboration and active efforts to address key issues, including disparities
that lead to a disproportionate incidence of suicide among certain groups of individuals.
We hope this document will serve as a starting point for collective action, and we invite you to
join us and our key partners in the community to improve the outcomes of people in Santa
. Clara County who have been seriously affected by grief, trauma, stress, anxiety, major
depression, social alienation, low self-esteem, lack of family and community support, mental
illness, substance abuse, and feelings of helplessness, hopelessness and desperation. People of
all ages, races, ethnicities, income and educational levels, genders, sexual orientations, and
types of work are victims of circumstances that make them feel suicide is there only viable
alternative. While some groups are1nlQre frequently affected, no one is exempt.
We thank the members of the Board of Supervisors who supported this initiative, along with
the leadership and staff of the Mental Health Department, the members of the Suicide
Prevention Advisory Committee and the many public participants. We ask you to join us in
furthering this vital work and in helping us to accomplish the next steps.
Sincerely,
Hon. Liz Kniss
Supervisor, District Five
Vic Ojakian
Santa Clara County Mental Health Board
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EXECUTIVE SUMMARY
SANTA CLARA COUNTY SUICIDE PREVENTION STRATEGIC PLAN
Why We Care
Most people are surprised to learn that
every year more than one million deaths
worldwide are caused by suicides; and
every year there are an additional 10 to 20
million suicide attempts, often
accompanied by serious injuries. Even in
our own County, suicide is the leading cause
of death by fatal injury.i The numbers are
truly too large for us to ignore.
While suicide is confounding, suicide is
usually preventable, given the right
education, services and supports.
Prevention for natural disasters and
communicable diseases is typically centered
on risk reduction. Likewise, prevention for
suicide must be centered on risk reduction
through a variety of means. Suicide is most
often a fatal complication of different types
of mental illnesses which are treatable. Just
as with diseases of the body, the earlier
treatment is sought, generally the better
the outcome and the lower the risk of other
complications.
The Impact of Suicide in Santa Clara
County
In 2007, the most recent year for which this
data is available, the suicide rate in Santa
Clara County was 7.8 per 100,OOO.ii In
contrast to the 7.8 suicide rate, the
homicide rate in the same year was 2.6 per
100,OOO.iii Many more people kill
themselves than are killed by others and
this is consistent with national data that
show suicide is the 8th leading cause of
death in the U.S., compared to homicide
which is the 13th leading cause of death.
What We Did
The Santa Clara County Suicide Prevention
Advisory Committee (SPAC) is a 36-
member, broad-based group of experts in
the field; professionals in related fields such
as educators and school administrators, law
enforcement, public transportation, public
officials, and many others; specialists in
various age groups; mental health
consumers and family members from
diverse cultures and backgrounds; suicide
attempt survivors; individuals surviving the
death of a loved one by suicide; and
concerned members of the public. More
than 60% of the SPAC members have
personal experience with either the loss of
a loved one to suicide or as suicide attempt
survivors. The personal knowledge of loss
by suicide infused the committee's efforts
with a particularly deep commitment to
saving lives.
The SPAC held its first meeting on
December 9,2009. Between December
2009 and May 2010, the committee met the
second and fourth Wednesday of every
month. Members of the public also
attended the meetings and their
participation was welcomed in all of the
discussions and deliberations, including the
"break-out" sessions which followed the
whole-group dialogues and focused on
needs and strategies by age categories.
On April 28, 2010, the SPAC's findings and
preliminarily selected strategies were
shared more broadly with the community at
an extensively publicized and well attended
Public Forum. Translators provided live
translations from English into Santa Clara
County's additional threshold languages
(Mandarin, Vietnamese, Spanish and
Tagalog) and one of the break-out groups
was conducted in Vietnamese to better
insure that all who wished to contribute
were able to do so.
The Mental Health Department website was
an important communication link between
SPAC members, staff and the public. On the
website's Suicide Prevention page,
meetings were publicized; all data and
information shared at the SPAC meetings
were available on an ongoing basis; and
summaries of steps taken and preliminary
decisions were presented. During the six
month SPAC planning period, the website
received a total of 4,291 visits for a
combined total of 6,954 "views," defined as
the number of times visitors viewed
particular pages.
The Planning Approach
SPAC members moved through the
planning process in a way that honored the
deep emotional impact of suicide while
they absorbed data and information and
brainstormed about the needs in our
community. Guiding values for the planning
work were arrived at from the beginning of
the process.
Guiding Values
1. Suicide is a community problem. It
cannot addressed by
only one system or agency.
2. The plan should be
people most .,.i"h~ ... +£,1"1
by the
suicide-the
survivors, the family members, the
loved ones.
3. involved in this work should
engaged.
4. Suicide risk factors should be
considered every age across
the lifespan.
5. The resulting plan should not
duplicate existing efforts rather
leverage them.
6. The community should own the plan.
7. The work must be culturally sensitive
and competent.
8. The plan must
on continuous process improvement.
9. It is that the pian is
informed by public
Planning
Early in the process SPAC members also
adopted the following goals for the
prevention plan:
1. Reduce deaths from suicide in Santa
Clara County.
2. Increase awareness of why people
contemplate suicide and how to
access resources.
3. Improve monitoring of suicides
dear and comprehensive data.
4.· Empower to respond to a
person who is considering suicide
through training and education.
framework
The committee members utilized a
conceptual framework to assist their
planning that had proven successful with
the County Mental Health Department's
public planning efforts related to the
Mental Health Services Act. The approach
incorporates a lifespan perspective within
an adapted public health model that aligns
a continuum of health needs (in this case
suicide) with levels of promotion,
prevention, postvention, early
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intervention, and intervention strategies.
The postvention strategy was added to the
standard public health model to
accommodate a strategy unique to suicide.
It consists of interventions after a suicide
has occurred aimed at reducing the impact
of suicide on surviving friends and relatives,
as being exposed to the death of a loved
one by suicide is itself a risk factor that
greatly increases one's risk of suicide,
especially in youth.
Need and Risk
Publk Health Model for
Suicide Prevention Planning:
The planning team designed and facilitated
the committee process in a manner that the
group followed ten planning steps in
preparingJhe plan:
1, Ii
10.
What We Learned
Committee members learned from
members who had first-hand experience
with the tragic loss of life by suicide or
attempting their own suicide that language
counts. Wording can communicate our
deepest bias and beliefs. People who have
survived their own suicide attempts or who
are grieving the loss of a loved one by
suicide are acutely sensitive to the
judgments communicated by word choice.
It was urged that the guidelines of the
National Suicide Prevention Lifeline be
followed in connection with word choice
when discussing or writing about suicide:
• People "die by suicide" not by
"committing suicide."
• There is no "successful suicide" only a
"completed suicide."
• There is probably someone in your own
personal network of family and friends
who has first-hand knowledge of the
pain of suicide-regardless of income,
race, or country of origin.
• Suicide attempt survivors are
individuals who have survived a prior
suicide attempt.
• Suicide survivors are family members, .
significant others, or acquaintances who
have experienced the loss of a loved
one due to suicide. Among the general
public this term is also used to mean
suicide attempt survivors.
• Suicidal act (also referred to as suicide
attempt) is potentially self-injurious
behavior for which there is evidence
that the person probably intended to kill
himself or herself; a suicidal act may
result in death, injuries, or no injuries.
• Suicidal behavior includes a spectrum
of activities related to thoughts and
behaviors that include suicidal thinking,
suicide attempts, and completed
suicide.
local and Data
While many of the committee members
have significant experience and expertise in
some aspects of suicide and with certain
age or other population groups, the data
review process gave everyone a similar
foundation of basic knowledge. Several
questions were considered as data was
reviewed, including:
1. Who is by
2. Who is at risk suicide?
3. factors may contribute to
4.
5. What
6. Wh'at resources are
to
suicide risk?
7.
8. What are the critical needs and
for our
SUICIDE DEATH RATES
Healthy People 2010 Goal
48 ui<:id
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Santa Clara County in 2007
7 8 suicides
• per 100.000
California Statewide in 2007
9 4 suicides
• per 100,000
Source: California Department of Mental Health, Office of Suicide Prevention. (2007).
Data Summary Sheet on Suicide Deaths and Non-Fatal Self-Inflicted Injuries.
by Age
Children and Youth. In 2005, 270 children
(ages 10 through 14) in the U.S. completed
suicide.iv Suicide is the fourth leading cause
of death among children between the ages
of 10 and 14 years.v
Youth and Young Adults. In Santa Clara
County, among teenagers ages 15 through
19, suicide is the third leading cause of
death.vi Santa Clara County's 2005-07
suicide rate average among youth ages 15
through 24 was 7.0 per 100,000.Vii
Nationally, suicide is the second leading
cause of death among college students.viii
However, while some college-related
factors may contribute to suicidal behavior,
it is important to note that same-aged
youth who are not in college are actually at
a higher risk for suicide attempts than are
college students.iX
Adults. The largest number of deaths by
suicide occurs in the adult age group. It is also
our county's largest age group (25-65 year
olds) at 55.6% of the total population. Among
that group (ages 26 through 59), the biggest
number occurs in the 45 to 54 year-old cate
gory, according to national data. This equates
to 7,426 deaths, a rate per 100,000 of 17. 19.x
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Older Adults. National data show the elderly
comprise 12.6% of the population yet account
for 16% of suicides. However, even this may
not reflect the true total. Suicide by senior
citizens is thought to go unrecognized more
than with other age groups.
Santa Clara County Suicide Deaths by Age
Total Suicide Deaths in 2007: 140
Source: California Department of Mental Health, Office of Suicide Prevention. (2007).
Data Summary 'Sheet on Suicide Deaths and Non-Fatal Self-Inflicted Injuries
In Santa Clara County, the suicide rate for
Blacks/African Americans is 15.0 per 100,000,
American Indians/Native Americans is 13.0
per 100,000, Whites is 10.7 per 100,000, 2 or
more races is 9.3 per 100,000, Asian is 5.2 per
100,000 and Hispanic is 5.1 per 100,000.Xi
COUNTY SUICIDE DEATHS BY RACElETHNICITY
Total Suicide Deaths in 2007: 140
Source: California Department of Mental Health, Office of Suicide Prevention. (2007).
Data Summary Sheet on Suicide Deaths and Non-Fatal Self-Inflicted Injuries
Four times as many men kill themselves as
compared to women, yet three to four
times as many women attempt suicide as
compared to men.
SANTA CLARA COUNTY POPULATION
AND SUICIDE DEATHS BY SEX, 2006-2008
Females
51%
Source: California Department of Mental Health, Office of Suicide Prevention. (2007).
Data Summary Sheet on Suicide Deaths and Non-Fatal Self-Inflicted Injuries.
The majority of research on lesbian, gay, and
bisexual people who attempted suicide
concludes that young LGBT people have a
significantly higher risk of attempting suicide
than heterosexual young people and that
most attempted suicides among LGBT people
occur during adolescence or young adult
hood.xii xiii Suicide attempt rates (over the
course of a person's lifetime) range from
52.4% (9th and 12th grade) for lesbian and
bisexual females to 29% for gay and bisexual
(9th and 12th grade) males.XiV This is in com
parison with heterosexual suicide attempt
rates of 4.6%, according to the National Com
orbidity Survey.xv Nationally, LGB teenagers
have been found to be more than three times
(3.41) as likely to attempt suicide as other
youth, and young men are at particular risk.xvi
Suicide by
Data reveal that the highest rates of suicide
appear to be in higher income areas of the
county, with the highest rates of suicide
being in Palo Alto, Los Altos/Los Altos Hills,
Sunnyvale and Morgan Hill; while lower
rates in general are in Milpitas, Santa Clara
and San Jose. However, a closer look at
suicides by zip reveals that frequent
numbers of suicides are found in both
higher income areas as well as in certain
lower income neighborhoods.
among
The presence of increased risk factors
among juvenile justice-involved youth can
be confirmed with Santa Clara County data.
Emotional problems were cited as the most
significant factor contributing to their
delinquency by both boys and girls in
custody with the Santa Clara County
Probation Department. Forty percent of
boys and 58% of girls in custody said
"something very bad or terrifying" had
happened to them. Nearly one-quarter of
all girls surveyed as they entered juvenile
hall said they wished they were dead.xVii
However, there have been no deaths by
suicide during the period since 2004 among
juveniles in custody in Santa Clara County
according to the Santa Clara County
Probation Department's Institution Incident
Report database. The decrease in suicide
attempts is attributed to changes made in
overall custody program and protocol, as
well as changes made to the suicide risk
protocol and response by the Mental Health
staff in the Hall. Staff has received more
training in trauma-informed care and all
staff is involved in increased care
coordination for youth considered at risk.
Among adults, nationally the suicide rate in
jails has decreased 70% from 1983 to 2003
. .
and has decreased 50% in prisons over the
same time period. In 2002 the suicide rate in
local jails (47 per 100,000 inmates) was more
than three times the rate in State prisons (14
per 100,000 inmates).xviii However, the
suicide rate in both settings remains high.
In California, between 2001 and 2006, there
were 190 suicides by adult inmates in
California. This is far fewer than the number
of deaths by illness but much greater than
any other cause, including more than double
the number of homicides.xix
In Santa Clara County, during the years
2000 through 2009, there were 212 suicide
attempts in the Main Jail and 81 suicide
attempts at Elmwood. During that same
time period, there were 12 completed
suicides in the Main Jail and two completed
suicides at Elmwood.xx
Suicides by
and Veterans
Active Duty Personnel
The number of suicides among active-duty
personnel has been rising. For example, there
were 147 reported suicides in the Army from
January through November 2009-an
increase from 127 in the same period of 2008.
Among non-active-duty reserve soldiers, 50
suicides were reported in 2008; but the
number had 'risen to 71 during the first 11
months of 2009.XXi Likewise, the Navy reports
"For the past 10 years, it (suicide) has been
the second or third leading cause of death
among active duty Sailors."xxii
Correspondingly, veterans, regardless of
when they served or in which branch, are
twice as likely as the general population to
die by suicide, according to an article in the
Journal of Epidemiology and Community
Health (July 2007).XXiii Suicides among
United States military veterans ballooned
by 265 from 2005 to 2007, according to
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statistics released by the Veterans Affairs
(VA) department. The VA estimated that in
2005, the suicide rate per 100,000 veterans
among men ages 18-29 was 44.99, but
jumped to 56.77 in 2007.xXiV
"Of the more than 30,000 suicides in this
country each year, fully 20% of them are
acts by veterans," said VA Secretary Eric
ShinsekL "Suicide rates among veterans in
all four branches of the military service are
significantly higher than in the general
population. xxv
::1iTll'lI'"I~' More Data Is
Varying levels of forensic analysis often may
be needed to determine if a death was
caused by suicide, homicide, accident or
natural causes. More extensive collection,
maintenance and analysis of data related to
suicides will be key to ongoing efforts to
effectively prevent suicides and to decision
making about where to allocate prevention
resources. Among areas that require more
study are: suicides by occupation, suicides by
(
month or season, police "assisted" suicides,
suicides by police officers, suicides labeled as
auto accidents, murder-suicides, and suicide
clusters and suicide "contagion."
..... ,i ......... "" Risk and Mental Illness
Varying studies have shown that between
60% and 90% of suicide victims had a
psychiatric illness at the time of their death.
..... 'i ... llUiC Risk and Akohol
Alcohol is involved in an estimated 30% of
suicides.xxvi Alcohol causes depressed mood,
lowers inhibitions, and impairs judgment, any
or all of which may make vulnerable people
more likely to act on suicidal plans. These
same factors (lowered inhibition and impaired
judgment) are associated with domestic
violence and abuse, other factors that are
believed to increase the likelihood of suicide.
Suicide Risk Factors and Warning Signs
The U.S. Substance Abuse and Mental
Health Services Administration (SAMHSA)
Suicide Prevention Resource Center
identifies risk factors in three categories:
biopsychosocial, environmental, and
sociocultural. SAMHSA literature stresses
the importance of understanding these
well-documented risk factors because the
impact of some risk factors can clearly be
reduced by certain interventions (Le.,
medication for depression). Other risk
factors cannot be changed (Le., a previous
suicide attempt), however, awareness by
friends and family of the heightened risk,
particularly during periods of recurrence of
significant stressful life events, should lead
to strengthened social support.
Factors that May Protect Against Suicide
Protective factors buffer individuals from
suicidal thoughts and behavior. To date,
protective factors have not been studied as
extensively or rigorously as risk factors.
Identified protective factors are:
Iili Effective clinical care for mental,
. physical, use disorders
Ii! access for a va riety
interventions and support for help
seeking
Ii! Restricted access to highly lethal means
ofsuidde
Iili Strong connections to family and
community support
Ii! Support through ongoing medical and
mental health care relationships
Iili Skills in problem solving, conflict
resolution, and nonvio!enthandling
disputes
Ii! Cultural and religious beliefs that
discourage suicide and support self
preservation, xxvii
\
\
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Review and Summary of Local Needs
local Needs across the lifespan
The SPAC members agreed to utilize age groupings that worked well in the Mental Health
Department's Mental Health Services Act (MHSA) planning processes. These groups are:
4.
5.
Children
Youth
Adults
Youth o through 15
16
S9
60 and over
Across Groups.
25
The charge was to examine risk factors (needs and concerns) within each of the age groups that
,may contribute to the consideration or decision to take one's own life; second, to associate the
risks with targeted high risk sub-groups or "priority populations" based on the data review; and
third to recommend strategies most appropriate to diminish risk among that population
group/s in the context of Santa Clara County's demographics. The summary of that work is
presented below:
Children and Yauth Ages 0 through 15
Needs and Concerns
• Developmentally-based inadequate
sense of control in life
• Difficulty accessing available mental
health services, education and
support to prevent substance abuse
• Lack of strong resiliency skills to cope
with failure, disappointment, bullying,
and breakups
• Inadequate defined support,
connections to community,
unconditional acceptance, and sense
of communal responsibility for safety
• Low feelings are perceived as
abnormal
• Lack of self-esteem, sense of
accomplishment, and sense of hope
• Lack of respect for peers, adults, and
themselves
Priority Populations
Children and youth experiencing:
• Academic difficulties; changing
schools; life milestones
• Immigration concerns; refugee
experience; acculturation stress;
linguistic and/or cultural differences
• Trauma (sexual, physical, emotional,
exposure to violence)
• Suicide offriends; suicide attempts;
mental illness; substance abuse
• Separation from family; homeless ness
Juvenile justice/foster care system
involvement
• Gender identity issues-lesbian, gay,
bisexual, transgender, queer, or
questioning
• Neglect and/or without nurturing
adult
Recommended
• Mental health counselors in schools
• Screenings for risk of suicide and
other mental health concerns
w Targeted counseling for youth who
have lost a loved one to suicide
• Enhanced mental health resources,
school curriculum, and parent
initiatives
~ Identify coping mechanisms, access
points, and connectors for youth to
address life challenges
• Programs to protect youth from social
and geographic isolation and barriers
to peer interaction
" Programs that teach resiliency
Programs and services that enable
children and youth to cope with
failure and disappointment, bullying,
and breakups
• Training for those who interact with
at risk youth (community leaders,
clinicians, physicians, family
members, police, teachers, peers, and
others)
m Accessible, youth-centered crisis line;
and singleI' countywide access
pOint/telephone number for youth at
risk .
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Youth and Young Adults Ages 16 through 25
identified Needs and Concerns
• Sense of physical and emotional
isolation from family, social network
and/or peers
~ Stigma associated with mental health
and substance abuse services and
suicide prevention
Inadequate identification of mental
health issues by self and others
(caregivers, medical providers, etc.)
Paucity of service resources and
difficulty accessing age-appropriate
and linguistically available services
(inadequate referrals, poor
connections, barriers to qualify,
difficult to afford, language barriers)
m Transitioning between being
dependent on others to being
financially independent without an
adequate support network
Priority Populations
Young people experiencing:
• Suicide of friends; previous attempts;
thoughts of suicide
• Academic difficulties; immigration
concerns; refugee experience;
acculturation stress; linguistic and/or
cultural differences
• Transition from dependence to
financial and personal independence,
regardless of educational level or
pursuits
Trauma (sexual, physical, emotional,
exposure to violence)
• Mental illness; substance abuse; co
occurring conditions
• Homelessness; alienation from family
• Juvenile/adult criminal justice
involvement; transitioning from
incarceration to reintegrating with
society
Foster care system involvement
• Gender identity issues-lesbian, gay,
bisexual, transgender, queer, or
questioning
Recommended Strategies
m Screening and timely intervention of
those at risk of suicide
" School-based, culturally relevant
intervention services, including
consultation for educators and
parents, and peer to peer support
Peer stipend program for youth to
promote intervention and treatment
services
• Training, support and educational
materials for parents, partners, and
family members and educators
regarding safe handling of young
adult life challenges and crises
(Example: educational suicide help
hotline)
II Accessible and comfortable spaces
for adults at-risk of suicide, such as a
mobile crisis unit, satellite self-help
centers, and/or a community lounge
space
.. Age-appropriate crisis hotline
" Support groups for youth dealing with
teen suicide
• Prevention opportunities, such as
youth becoming engaged in public
service; school staff to be dynamic
and caring; youth centers; other ways
for students to develop skills to deal
with emotional challenges
" Previous attempters to share their
stories to encourage others to seek
help and have hope for improved life
satisfaction
00 Public recognition of individuals who
connect people at risk of suicide to
resources
.. Post-incident care for individuals and
families after a 5150 episode (forced
admission for psychiatric observation)
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Adults Ages 26 through 59
Identified Needs and Concerns
Inadequate identification of mental
health issues by self and others
(peers, medical providers, etc.)
• Paucity of service resources and peer
support strategy assistance as well as
difficulty accessing available services
• Stress associated with life transitions,
life events and trauma
• Stigma associated with mental health
and substance abuse services and
suicide prevention
Cultural perspectives on mental
health challenges and suicide
Lack of safe welcoming places and
opportunities to ask for assistance
and services
Older Adults Ages 60 and Above
Identified Needs and Concerns
Inadequate identification of mental
health issues by self and others
(caregivers, medical providers, etc.)
Paucity of service resources and
difficulty accessing available services
(inadequate referrals, poor
connections, barriers to qualify,
difficult to afford, lack of
transportation)
• Loss or diminishment of
independence, role, and physical
health; loss of loved ones; physical
difficulty in getting to services
• Stigma associated with mental health
and substance abuse services and
suicide prevention
• Cultural perspectives on and differing
definition of death and dying; cultural
taboos against discussing end of life
" Psycho-social stressors that may lead
to increased risk not only of suicide
but of homicide-suicides.
Priority Populations
Adults experiencing:
• Decreased functioning, isolation,
disabilities or poor health
• Trauma (sexual, physical, emotional,
exposure to violence)
• Suicide of friends; suicide attempts
Mental illness; substance abuse; and
co-occurring conditions
• Loss of income and/or a loved one
• Criminal justice system involvement
• Homelessness
• Gender identity issues: lesbian, gay,
bisexual, transgender, queer, or
questioning
Priority Populations
Older Adults who are:
Caucasian males
• Over75
• Isolated or grieving
(widows/widowers), experiencing a
loss in relationships or other
significant change
• Experiencing a loss of sustainable
income and/or personal resources
Functioning poorly, have disabilities
or poor health
• Experiencing immigration concerns;
refugee experience; acculturation
stress; linguistic and/or cultural
differences
• Coping with trauma (sexual, physical,
emotional, exposure to violence,
veteran)
• Mentally ill; abusing medication,
drugs, or alcohol
Recommended Strategies
• Screening and assessments for risk
• Support for adults at risk
Tools to safely handle life challenges
and manage crises, such as cognitive
behavioral therapy.
• Accessible counseling and crisis
services
• Mobile crisis unit
• Self-help centers in communities
• Training, support and educational
materials for friends, family members
and employers regarding safe
handling of personal challenges and
crises, (Example, educational suicide
help hotline)
• Previous attempters sharing their
stories to encourage others to seek
help and have hope for improved life
satisfaction
• Work with business leaders and
organizations to promote mental
health awareness and education
• Public recognition of individuals who
connect people at risk of suicide to
resources
" Post-incident care for individuals and
families after a 5150 episode (forced
admission for psychiatric observation)
Recommended Strategies
" Education, informing materials, and
consultation support to primary care
providers
~ Depression screening, referral, linkage
services through primary care provider
• Accessible, age-appropriate counseling
services
" Accessible senior-focused crisis line; an
countywide access point/telephone nu
.. Home visitation follow-up services
and linkage of homebound seniors to
services
" Senior-focused intervention for
depression, death and dying issues
.. Public recognition of individuals who
connect people at risk of suicide to
resources
• Post-incident care for individuals and
families after a 5150 episode (forced
admission for psychiatric observation)
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Identified Ne~d$ and Com:~m$ Recommended Strategies
"~~~~~+~""~~~~~~~~~,-~-~"'~~---,--~~--+~-~~~~---~"~~--~--~~"-"~~~
• Paucity of service resources and Individuals experiencing: @ Screening and referral resources in
difficulty accessing available services • Trauma (sexual, physical, emotional, primary care and other caregiving
• Difficulty accessing available mental exposure to violence) settings
health services, education and Suicide of friends; suicide attempts Training for professionals, service
support to prevent substance abuse • Mental illness; substance abuse; and providers and community members
• Stigma associated with mental health co-occurring conditions on identification and response to
and substance abuse services and Juvenile/criminal justice system individuals at risk
suicide prevention involvement • Crisis hotline and single, countywide
• Cultural perspectives on mental • Immigration concerns; refugee access point/telephone number
health challenges and suicide experience; acculturation stress; " Accessible, affordable and
• Lack of safe of welcoming places and linguistic and/or cultural differences appropriate crisis counseling and
opportunities to ask for assistance Homelessness; significant loss of support services
and services social and/or economic support • Mobile crisis unit
• Gender identity issues: lesbian, gay, • Self-help centers in communities
bisexual, transgender, queer, or • Consultation phone services
questioning Ensure post-incident care for
The committee recognized the importance
of broadly increasing knowledge of the risk
factors and warning signs for suicide while
promoting help-seeking. By enhancing
awareness of sources of help and reducing
stigma associated with seeking help, these
activities should prevent deaths by suicides
as well as self-injury while trying to die by
suicide. This strategy will include one
universal message for the entire
community. In addition, other targeted
measures will be developed to engage
smaller groups targeting youth, older
adults, different language speakers, etc.
An educational campaign targeting
improved physician assessment for suicidal
risk and management of that risk is also
recommended for implementation.
individuals and families after a 5150
episode (forced admission for
psychiatric observation)
• Public recognition of individuals who
connect people at risk of suicide to
resources
A key concern that was raised by the
committee is that in implementing an
AdCouncil type public awareness campaign,
these acti~ities should be linguistically and
culturally appropriate for our diverse
community. It also should be broad in the
means used to communicate.
Additional Needs: Data Monitoring and
Evaluation
CommunitatilJln
SPAC members concluded it is important
that a body be established that will have
oversight and coordinating responsibility for
the Communication Practices Work Group.
The group's role will be to 1) ensure the
development of defined, clear, concise,
paradigm-shifting message for all efforts; 2)
ensure adherence to the guidelines for
responsible communication on issues
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pertaining to suicide and that messaging is
consistent across all media campaigns and
efforts; 3) coordinate education on
reporting suicide; and 4) establish and
maintain a permanent website that is
available for all to visit at
www.sccgov.org/spac.
Policy
Governance Advocacy
There is considerable infrastructure to be
created for an effective prevention
campaign to function and for effective
monitoring and evaluation activities to
proceed. The development of this
countywide infrastructure depends upon
advocacy for supportive, enabling policies
and legislation. The planning committee
recognized that this will be an ongoing
activity and will require additional
investments of time and resources for
successful implementation of this
prevention strategy.
Additional ", .. rr::n'",.au:',,: Data Monitoring
Evaluation.
As the SPAC reviewed national information
about suicide and suicide risk, it became
clear that nowhere in the nation is detailed
information available at the local level in a
way that provides policy makers and
stakeholders with the amount of
information needed to accurately describe
the profile of who is at risk of suicide.
further, there is no clear way in which
those suicide prevention efforts that
currently are in place, or may be
implemented with approval of this plan, can
be evaluated for their effectiveness without
a clearly defined, measureable monitoring
and evaluation process in place.
The data monitoring strategy will include
overseeing the coordination, collection, and
reporting of data in close partnership with the
Medical Examiner and Coroner's Office. With
the dissimilar number of agencies that are
mandated to report self injury and "proven"
suicides, there is much work to be done to
agree on the basic data needed; to establish
or adapt existing processes for reporting,
collecting, and analyzing that data in a timely
manner; and to rt:l0nitor data to evaluate the
success of these efforts.
local Suicide Resources: A Range of
Services
As a part of the process of determining local
priorities, the SPAC assessed available local
resources. Several Santa Clara County
Mental Health Department programs were
identified as contributing to the reduction
of suicides. Moreover, these programs
already are consistent with the
recommendations of the California
Strategic Plan on Suicide Prevention. A full
listing of agencies, programs and services
that interact with individuals who die by
suicide are listed in Attachment 2 in the
Appendix of the Plan.
Experts Recommend
Effective prevention strategies are
necessary to promote awareness about
suicide and to foster a commitment to
social change."xxviii Attachment 3 in the
Plan's Appendix outlines ten prevention
programs that address suicide and are
currently listed in SAMHSA's National
Registry of Evidence-Based Programs and
Practices registry. An additional two are
cdntained in the American Foundation for
Suicide Prevention's Resource Center
Evidence-Based Practices list.
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What We Recommend: Five Overarching, Interconnected Prevention Strategies
Strategy One -Implement Suicide Intervention Programs and Services for
Targeted High Risk Populations
Desired Outcomes
1. Decrease in the number of completed suicide acts.
2. Decrease in the number of attempted suicides.
3. Increase in the availability of culturally and linguistically appropriate and affordable
intervention services in a variety of venues.
4. Improved and earlier identification and engagement of people dealing with mental
illness.
5. Improvement in referral relationships to access appropriate care.
6. Increase in help-seeking behavior from individuals with mental illness and from
those who are connected to individuals with mental illness.
7. Increase in' support services to the family members and social network of individuals
with mental health issues.
8. Improvement in quality of life for individuals and their loved ones who are dealing
with mental illness.
9. Increase in diversity of services and programs that are tailored to high risk
populations-youth, elders, internet, face-to-face.
Strategy Two -Implement a Community Education and Information Campaign
to Increase Public Awareness of Suicide and Suicide Prevention
Desired Outcomes
The Community Education and Information Campaign will focus on achieving the following
outcomes:
1. 'Increased awareness of mental health issues, including depression and suicide
2. Increased public awareness of suicide
3. Improved identification of people who are feeling suicidal
4. Improved public knowledge of how to respond to a person who is feeling suicidal
5. Increased awareness of how to engage in and access support services, grief
counseling services, and postvention services
6. Decreased judgment or blame associated with suicidal thoughts and feelings
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Strategy Three -Develop Local Communication "'Best Practices N to Improve
Media Coverage and Public Dialogue Related to Suicide
Outcomes
1. Creation of a coordinated communication strategy that
• Ensures the development of a clear, concise, paradigm-shifting message
for all outreach efforts;
• Ensures that the guidelines for responsible communication on issues
pertaining to suicide are adhered to by media and agencies; and
• Ensures consistency in public messaging.
2. Educate various sectors of our economy: for~profit, government, non-profit.
3. Increase knowledge in local media on the importance of responsible reporting about
suicide as measured by adherence to Safe Reporting on Suicide guidelines
4. Obtain agreement and follow-through among key media outlets (traditional and
non-traditional) to coordinate public news releases strategically to address periods.
when suicide risk is higher (e.g., holiday season) and to respond appropriately to
suicide deaths, clusters, and suicide-homicide deaths.
5. Obtain agreement and follow-through among key media outlets (traditional and
non-traditional) to ensure the utilization of resource directories on local suicide
prevention and crisis services in multiple languages.
6. Obtain agreement and follow-through among key media outlets to ensure all
materials are linguistically and culturally appropriate for Santa Clara County's
residents.
7. Maintain a dedicated suicide prevention website and clarification of its target
audience and purpose.
Strategy Four -Implement Policy and Governance Advocacy to Promote Systems
Change in Suicide Awareness and Prevention
Desired Outcomes
While specific measurable outcomes need to be developed for this strategy, in general terms,
goals of this strategy are to:
1. Increase public awareness of suicide as a public health problem within an
organization by promoting adoption of policies and programs that either work to
prevent suicide or respond to emotional crises.
2. Promote local, state, and federal policies and programs that prevent suicide.
3. Disseminate information to individuals in the community regarding the Santa Clara
County Suicide Prevention Plan and its recommended activities.
4. Build partnerships with other local suicide prevention and mental health agencies,
governments, media, and other organizations with a stake in public health.
5. Help remove the stigma associated with suicide by bringing the subject out in the
open and discussing what can be done to prevent it.
6. Recruit individuals and organizations to advocate for policy change and/or adoption
in their workplace or community site.
7. Change laws-see Longer Term Actions below.
S. Advocate for prevention funding.
Strategy Five -Establish a Robust Data Collection and Monitoring System to
Increase the Scope and Availability of Suicide-Related Data and to Evaluate
Suicide Prevention Efforts
Desired Outcomes
Proving that this plan is making a difference by reducing the number of deaths by suicide can
only be accomplished by collecting data and monitoring the activities of the plan and its
outcomes. In order to do this the following goals must be met:
1. Expand reporting on suicide attempts and deaths;
2. Increase accuracy in reporting of data related to suicide and prevention
activities;
3. Increase the convergence of data reported by various entities;
4. Increase availability of comprehensive data on suicide-related activities in Santa
Clara County; and
Establish and define a centralized monitoring body of suicide prevention activities and
outcomes.
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'''' ~ > -'" "''''', ~ ~
Next Steps
The desired outcomes for each of the five recommended strategies in the Suicide Prevention
Strategic Plan (the Plan) cannot be achieved through isolated actions or services. The scope of
the problem and the need for community-wide support necessitates long-term, sustained and
coordinated effort by many stakeholders. There is no time to waste. The goal of this section is
to commit Santa Clara County to concrete actions that will tangibly improve suicide prevention
activities in the county by December 31, 2010. These actions will lay the foundation for full
implementation of the Plan.
Infrastructure. These actions are intended to create the requisite infrastructure to implement,
coordinate and report on suicide prevention efforts throughout the county.
1) Establish a Suicide Prevention Oversight Committee (OC). The OCwili advise the Board of
Supervisors on the implementation of the Plan and will submit semi-annual progress reports
to the Board of Supervisors' Health and Hospital Committee (HHC). The OC will work closely
with the Mental Health Department (MHO), which will serve as the lead agency in
coordinating suicide prevention services/activities throughout the county.
2) Hire a Suicide Prevention Coordinator. To ensure timely facilitation and ongoing support
for implementation of the Plan, the MHO wiil designate one staffperson as the County's
Suicide Prevention Coordinator.1 This staff person also will serve as the County's liaison to
the California Office of Suicide Prevention.
3) Form Four Work Groups. As indicated in the Plan, the OC will form four work groups, each
of which will plan for, oversee, and report on the implementation and effectiveness of its
assigned strategies. The following four work groups will develop implementation plans for
each strategy:
a) An Intervention Strategies work group (Strategy 1) will compile a comprehensive
overview of existing and needed intervention strategies. It will coordinate a system of
suicide prevention services.
b) A Communications Practice work group (Strategies 2 and 3) will have oversight over all
resulting communication projects and activities related to suicide prevention, both
locally and regionally, including a Community Education Campaign.
c) A Policy and Governance work group (Strategy 4) will advocate for the adoption of
suicide prevention policies and protocols among agencies, systems and organizations
throughout the County.
d) A Data Committee (Strategy 5) will define the Plan's data requirements, sources and
reporting processes.
Implementation. Upon approval from the Board of Supervisors, the MHO will proceed
with the following actions which will either immediately reduce suicides or develop new
funding sources for suicide prevention activities.
I This assumes that the Board of Supervisors and the State will approve a fifth MHSA Prevention & Early
Intervention project.
1) Develop Formal MHSA PEl Project for Suicide Prevention. The MHO will develop a fifth
Prevention and Early Intervention (PEl) Project for Suicide Prevention and hire a Suicide
Prevention Coordinator. If approved by the State, "PEl Project 5" will fund approximately
$800,000 in new suicide prevention activities annually .for three to four years. Funding from
this project will support activities in each of the Plan's five strategies, laying the foundation
for new services and resource development. The ac will devise a process to apportion
available funding to each of the five strategies.
2) Implement Listening Campaigns. The Suicide Prevention Coordinator will begin
implementing "Listening Campaigns" to promote mental health and suicide prevention
awareness. The Listening Campaigns also will serve as an ongoing vehicle for incorporating
residents' input into the Plan's implementation.
3) Make Formal Connections to Statewide Suicide Prevention Efforts. The MHO will actively
coordinate with and leverage existing statewide suicide preventioQ efforts, including the
activities of the California Mental Health Services Authority (CaIMHSA). The MHO's goals
are to influence the development of statewide programs and to ensure that local funds
which have been assigned to support statewide PEl projects-have an impact on local
efforts.
4) Implement Approved Suicide Prevention~Related PEl Plans.
a) "First Break" Treatment Programs. Under PEl Project 3, the MHO will initiate services
to help individuals, especially for adolescents and Transitional Age Youth (16-25),
address the onset of serious psychiatric illness (with psychotic features).
b) Community Education and Training. Under PEl Project 1, the MHO will increase mental
health literacy and reduce stigma and discrimination within underserved cultural
communities by implementing Mental Health First Aid programs.
c) Integrated Behavioral Health. The MHO will implement early intervention services in
community-based, primary care clinics to serve approximately 4,200 patients annually
(once fully operational).
d) Gatekeeper Training. The MHO will implement "gatekeeper" programs for older adults.
The above concrete actions will augment current suicide prevention efforts. Modifications or
expansion of the aforementioned programs will be influenced by the ac as it implements the
Plan's five strategies.
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Safe Media Reporting on Suicide
Guidelines: What to Do
Always include a referral phone
number and information about local
crisis intervention services. Local
resources:
Suicide and Crisis Services (SACS)
Hotline
(408) 279-3312 (Central County)
(650) 494-8420 (North County)
(408) 683-2482 (South County)
National Suicide Prevention Lifeline
1-800-273-TALK (8255)
For Veterans
1-800-273-TALK (8255) press 1
Emphasize recent treatment
advances for depression and other
mental illness.
Ibr'IJmrp·. stories of people whose
tr~~at'nell1tl~aS.life-savi1Jgor who.
l;?lttflf.~ilft~'jrlfj.svp.ir.wit(jQ,ri,tattemp(i1Jg.
Safe Media Reporting on Suicide
Guidelines: What NOT to Do
Avoid detailed descriptions of the
suicide, including specifics of the
method and location.
Avoid romanticizing someone who
has died by suicide.
Avoid glamorizing the suicide of a
celebrity.
Avoid oversimplifying the causes of
suicides, murder-suicides, or suicide
pacts, and avoid presenting them as
inexplicable or unavoidable.
Avoid overstating the frequency of a
suicide.
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References
i California Department of Health: Epic Data
Ii Center for Health Statistics-Vital Statistics Query System.
http://www.applications.dhs.ca.gov/vsg/screen4a.asp?cnty cd=43&YEAR DATA=2007&Criteria=1&Res occ=Resid
ence&Birth Death=Death&stats=2&cod cd=424 Retrieved 3/4/10.
iiiCalifornia Department of Public Health, County Health Status Profiles 2009, retrieved 3/9/10
iv Youth Suicide Fact Sheet. www.suicidology.org. Retrieved 4/22/10.
v CDC. Suicide among children, adolescents and young adults-United States, 1980-1992. MMWR Morbidity
Mortality Weekly Report 1995; 44(15):289-91
vi Behavioral Risk Factor Survey, Santa Clara County 2004 Chartbook, Santa Clara County Public Health Department,
2004
vii Santa Clara County Youth Suicide Rate 2005-2007. California Department of Public Health, Center for Health
Statistics, Vital Statistics Query System. http://www.applications.dhs.ca.gov/vsg/default.asp. Retrieved 3/3/10
through kidsdata.org
viii American Foundation for Suicide Prevention,
http://www.afsp.org/index.cfm?fuseaction=home.viewPage&page id=E2464DF6-0397-BD56-A8E232923B04ED5C
Retrieved 3/4/10
ixixix Picture This: Depression and Suicide Prevention. Prepared for the Substance Abuse and
Mental Health Services Administration (SAMHSA) by the Entertainment Industries Council, Inc.
http://www.eiconline.org/resources/publications/z picturethis/Disorder.pdf. Retrieved 4/14/10
x Santa Clara County Suicide Prevention Advisory Committee Basic National Data, presented by Victor Ojakian on
January 13, 2010. http://www.sccmhd.org/SCC/docs/Mental Health Services
(DEPlIattachments/National State Data on Suicide slides Mtg 1 13 2010.pdf. Retrieved 4/23/10.
xi Ibid
xli Kulkin, H., E. Chauvin, & et al. (2000). Suicide among gay and lesbian adolescents and young adults: a review of .
the literature. Journal of Homosexuality, 40(1), 1-29.
xiii Remafedi, G., J. A. Farrow, et al. (1991). Risk factors for attempted suicide in gay and bisexual youth. Pediatrics,
87(6),869-875.
xiv Eisenberg, M. E., & Resnick, M.D. (2006). Suicidality among gay, lesbian and bisexual youth: The role of
protective factors. Journal of Adolescent Health, 39(5), 662-668.
xv Kessler, R., Borges, G., & Walters, E. (1999) Prevalence of and risk factors for lifetime suicide attempts in the
national comorbidity survey. Archives of General Psychiatry, 56, 617-626
xvi The Archives of Pediatric and Adolescent Medicine (May 1999)
xvii Court addresses causes of juvenile delinquency, San Jose Mercury News, November 23, 2002
xvIII Office of Justice Programs, Bureau of Justice Statistics. Suicide and Homicide in State Prisons and Local Jails,
Christopher l Mumola, August 21,2005, NCJ 210036. http://bjs.ojp.usdoj.gov/index.cfm?ty=pbdetail&iid=1126
xix Ibid
xx Data provided by the Santa Clara County Department of Correction, 4/5/10
xxi Ibid
xxii New Navy Program Encourages Sailors to "ACT" to Prevent Suicide. Navy.mil (Official Website of the U.S. Navy)
Story Number: NNS061203-09. Release Date: 12/4/20069:01:00 AM. Retrieved 4/22/10
xxiii Kaplan, M.S., Huguet, N., McFarland, B.H., & Newsom, IT. (2007), Suicide among male veterans: a prospective
population-based study, Journal of Epidemiology and Community Health, 61(7), 619-24.
xxiv Eli Clifton, U.S.: Suicide Rate Surged Among Veterans, Washington, Jan 13,2010
xxv Ibid
xxvi Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D. Factors Contributing To Suicide Risk, Updated: Oct 24th
2007
xxvii Protective Factor List Published by the U.S. Public Health Service 1999
xxviii Centers for Disease Control and Prevention, Suicide Prevention Scientific Information: Prevention Strategies."
http://www.cdc.gov/ncipc/dvp/Suicide/Suicide-prvt-strat.htm. Accessed 5/12/10.
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