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AIM for Zero: An Approach for Integrating Suicide Prevention in Health Care

New York State has received national recognition for its work integrating suicide prevention into health and behavioral health systems. As called for in the State Suicide Prevention Plan, we set out to systematically support health systems in reducing suicide deaths among those receiving care—beginning with settings that care for those most at-risk. Our evolving approach, refined over the course of implementing several large, federal suicide prevention grants, is called AIM for Zero. It draws heavily on the national Zero Suicide model and combines it with a helpful clinical framework developed by experts in New York called AIM (Assess, Intervene, Monitor).

The Zero Suicide Model:

Zero Suicide is the country’s leading model for suicide prevention in healthcare. It is both an aspirational concept and a practical set of tools based on empirical evidence:
A majority of suicide deaths occur among individuals with recent contact in the healthcare system, often within the last 30 days.

  • To truly have impact requires a systemic approach; depending on the heroic acts of individual clinicians and crisis workers is wholly inadequate.
  • Treating underlying behavioral health conditions, such as depression or alcohol use disorder, among those at increased risk for suicide is necessary but not sufficient.
  • Effective interventions must also directly target suicide risk.

Implementation of the Zero Suicide model starts with a commitment from health system leadership to reducing suicide deaths among all those receiving care. Click here for more information on Zero Suicide and to access the Zero Suicide toolkit. If you’re interested in the AIM for Zero Suicides Implementation Guide, click here.

Suicide Safer Care Practices: The AIM Model

The AIM model provides a clinical framework for reducing suicide risk. Developed by Dr. Barbara Stanley, Director of the Suicide Prevention, Training, Implementation and Evaluation program at Columbia University and the New York State Psychiatric Institute, the AIM model highlights three domains of clinical practice essential to reducing suicide risk:

  • Assess all individuals for suicide risk using evidence-based screening tools
  • Intervene with at-risk individuals, using suicide specific interventions
  • Monitor at-risk individuals with increased follow-up contact and regular screening

AIM Model

The AIM model is composed of three domains: Assess, Intervene, Monitor.

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ASSIP: A Novel Intervention For Those With A Recent Suicide Attempt

The Attempted Suicide Short Intervention Program (ASSIP) is a promising three session intervention for patients who have attempted suicide within the past 60 days. The goal of ASSIP is to listen to an individual’s story and to respect each person as experts of their own actions. The program helps people understand their suicidal crisis and find ways to establish effective coping strategies for the future. ASSIP is now available via Telehealth to individuals 18 years of age and above who are residents of New York State as part of ongoing research. ASSIP is designed to complement, not replace, other recommended treatment; the ASSIP team will coordinate with the client’s primary treatment team.

See What ASSIP Has To Offer

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Culturally Competent Practice

Clinicians working with individuals from different backgrounds, including but not limited to cultural, ethnic, socioeconomic, or sexual orientation, must be aware of the role of cultural competency in working with diverse populations. For instance, a presenting behavior may have different connotations and meaning in the patient or client’s culture than in the culture of the clinician. Cultural competence does not require a clinician to be an expert in every culture, but rather implies that the clinician must be aware of how his/her own interpretation of symptoms and functional analysis of suicidal behavior impacts the assessment and therapy process. Not fully understanding a patient or client’s views on suicide may yield barriers to discussing suicide, and result in an insufficient understanding of risk and protective factors which may exacerbate suicidal thoughts and behaviors rather than lessening symptoms. For example, when a group of American Indian/Alaska Native (AI/AN) youth describe their culture’s concept of suicide, they report that suicide is considered an expression of the tribe’s current and past suffering, not an individual issue. Hence, for the AI/AN population, closeness to the tribe is a protective factor, and including members of the tribe in the intervention yields culturally competent treatment.¹

Culturally informed suicide prevention requires retaining curiosity/asking questions about:

  • The meaning of suicide to a culture
  • Constructs of identity in a culture
  • How the culture reacts to suicide independent of an external mental health system

If the patient does not speak English, an interpreter or a language line is needed. Using a family member, especially a child, to translate should be avoided. The clinician needs to be aware of basic skills in providing therapy through an interpreter, such as asking questions directly of the patient or client, instead of asking the interpreter “ask if she…” or “tell her that.” Therapy with an interpreter impacts the therapeutic encounter, as therapy no longer consists of a dyad but a triad. While being aware of the interpreter’s presence, the clinician should talk to the patient or client, read body language, and show empathy to the patient or client, not the interpreter.²

The Suicide Prevention Resource Center further recommends that mental health professionals and administrators:³

  • Understand the cultural context of those that they serve
  • Ensure that the administrative and treatment team include representation of the cultures that they serve
  • Provide information and resources that respectfully address the values, beliefs, culture, and language of all the populations they serve
  • Allow for cultural considerations to be communicated, such as preferences regarding personal space, geography, familiarity, and words that should be used or avoided

Resources

References

  1. Wexler LM, Gone JP. Culturally responsive suicide prevention in indigenous communities: unexamined assumptions and new possibilities. Am J Public Health. 2012;102:5 800-6.
  2. Hamerdinger S, Karlin B. Therapy using interpreters: Questions on the use of interpreters in therapeutic setting for monolingual therapists. Retrieved from www.mh.alabama.gov.
  3. Suicide Prevention Resource Center. Culturally competent approaches. Retrieved from Suicide Prevention Resource Center

Suicide Safer Care Practices by Setting

The New York State Office of Mental Health is launching several Zero Suicide initiatives across the state, utilizing the AIM for Zero approach. While the overarching approach is the same, adaptations have been made to accommodate unique challenges of different treatment settings.

Suicide Safer Care Practices by Setting

To learn more, visit our Suicide Safer Care Practices by Setting page to learn more about each practice.

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Engaging People with Lived Experience

Individuals who have direct experience with suicide or suicide loss have an important role to play in suicide prevention planning, including support services, treatment, community suicide prevention education, and the development of guidelines and protocols for support groups. Including people with lived experience is consistent with mental health recovery practices and person-centered care practices.
Activities designed to help anyone who has been suicidal share the following core values:

  • Foster hope and help people find meaning and purpose in life
  • Preserve dignity and counter stigma, shame, and discrimination
  • Connect people to peer supports
  • Promote community connectedness
  • Engage and support family and friends
  • Respect and support cultural, ethnic, and spiritual beliefs and traditions
  • Promote choice and collaboration throughout episodes of care
  • Provide timely access to care and support

Resources

  • The Way Forward: Pathways to hope, recovery, and wellness with insights from lived experience was created by the Suicide Attempt Survivors Task Force of the National Action Alliance for Suicide Prevention as a bridge to developing a conversation about suicide prevention between mental health policy makers and consumers advocates. The Task Force recommends that suicide prevention and behavioral health organizations engage, hire, and/or collaborate with peer support professionals.
  • NY Peer Specialists is a promising model for developing attempt survivor supports through the use of a peer specialist.
  • Introduction to Peer Services in New York State (video)
    Understand the role of peer specialists and how health and behavioral organizations utilize peer specialists in this video produced by the Center for Practice Innovations (CPI).
  • Lived Experience: What It Is and How to Include It (video)
    Leah Harris, a suicide attempt survivor and trainer with the National Center for Trauma-Informed Care, describes the benefits of involving people with lived experience to guide service design and delivery.
  • Peer Services in New York State (video)
    Learn about the peer certification process in New York State and identify resources and supports for peer specialists in this video produced by the Center for Practice Innovations (CPI).
  • Academy of Peer Services is an on-demand, online, training platform for individuals delivering peer support services in New York State. All courses are offered free of charge to peers working in the NYS Mental Health System.
  • Youth Power! works to ensure young people have meaningful involvement on all levels of the services they receive. Youth Peer Advocates use their own personal experience with recovery to make a positive difference in others’ lives.
  • National Empowerment Center’s mission is to carry a message of recovery, empowerment, hope, and healing to people with lived experience with mental health issues, trauma, and/or extreme states.
  • Engaging People with Lived Experience: A Toolkit for Organizations provides information on how to create an inclusive organizational environment and improve suicide prevention strategies by involving individuals who have life experience with suicide in planning, strategy implementation, practice reviews, policy development, and leadership.

Family Engagement

People often turn to family and friends for help, even when they do not seek help from professional caregivers. A strong support network can be a safety net in times of crisis and a trusted resource during recovery. Patient and family-centered care is an approach to the planning, delivery, and evaluation of behavioral health care that is grounded in mutually beneficial partnerships among professional caregivers, patients, and families. Families are essential allies, not only in direct care interactions, but also in quality improvement, safety initiatives, educating health professionals, research, facility design, and policy development. In suicide safer care, family members and significant others can play a valuable role in risk assessment, safety planning, and monitoring.

Resources

Suicide Loss of a Patient or Client

While agencies, lawmakers, families, and communities contend with rising rates of suicide, behavioral health professionals are facing another growing issue: How do we respond to the emotional and psychological toll that a suicide of a client has on professional caregivers? What are the best ways to support both staff and clients? While this remains a relatively new area of research, it has been estimated that each year 15,000 mental health professionals experience the loss of a client to suicide. For professional caregivers, concerns about litigation, stigma around suicide, and fear of negative reactions of colleagues can make the pain much greater than what was caused by the loss itself.

The following resources can help organizations dealing with a client’s suicide or opioid overdose. They discuss:

  • legal and regulatory issues
  • how to best support staff and other clients
  • how to handle grief
  • how to approach the family of the deceased
  • self-care

Resources

For non-behavioral health organizations resources visit our Communities and Coalitions page.

Self-Care for Clinicians

Professional caregivers who encounter high levels of interpersonal stress and loss in their jobs are at increased risk for mental health symptoms, vicarious traumatization, and compassion fatigue. Self-care is an essential survival skill for those who do the demanding work of treating and supporting suicidal clients, regardless of credentials or professional role. Self-care refers to practices that can reduce stress and help maintain/enhance short and long-term health and well-being, both personally and professionally.

Resources