Why I coach

A Deadly Culture: Suicide by Gun

In 1997 Nevada ranked 47th on the healthiest states list due to a rough lifestyle, including smoking, motor vehicle deaths, low high school graduation rates, and violent crime. The Violence Policy Center ranked Nevada the second highest state in gun-related deaths, and the second highest in the number of teenage births. The most glaring statistic of all: Nevada led the country with the highest suicide rate since 1995 (Wagner, 1999).

What is the Real Diagnosis?

During these years, 75% of the state’s population lived in Las Vegas. With people going down the rabbit hole while chasing cheaper housing and employment, the taxation system was not in place to support a mass influx of people in need. The Office of Public Health stated that Nevada had not invested in health prevention; the Progressive Alliance cited a lack of social programs in the state (Wagner, 1999). The early diagnoses of the problem came up with the theory of overcrowding, but my impression was of skewed statistics due to the many people who were already hopeless and homeless showing up in Las Vegas during that time. The wave soon hit Reno. In a heartbreaking report, Million-Dollar Murray an officer who worked the beat in Reno states, “The most complicated people to work with are those who have been homeless for so long that going back to the streets just isn’t scary to them” (Gladwell, 2006, p. 6). In 2006 help for those who were homeless, drug-addicted and suicidal was not forthcoming because they were adjudged not deserving of it (Gladwell, 2006).

In 2009 Nevada was awarded the Garrett Lee Smith grant to combat the high rate of suicide. In that year the Centers for Disease Control and Prevention, and the Nevada Office of Health Statistics and Surveillance reported an approximate 3% increase in overall reported suicide rates. Since 2007 the overall increase in suicides was 5% (Wherry & Vaughan Allen, 2014, p. 29). In 2010 Nevada ranked suicide as the 6th leading cause of death for youth in the 15-34 year age range. Native youth had the highest rate of suicide amongst all groups compared in Nevada. The rate for Veterans was estimated at 25% of all suicides in Nevada (Wherry & Vaughan Allen, 2014).

New environmental interventions were set by state coalitions, but were they reaching the individual? The Nevada Youth Risk Survey for 1999-2013 shows the percentage of hopelessness, contemplation of suicide with a plan to carry out, and actual attempts, were significantly increased in the high school aged population (Wherry & Vaughan Allen, 2014, p. 34)—the leading method of choice was suicide by gun, hence the high number of gun-related deaths in Nevada.

By 2011 the number of suicides by middle-aged people were less than other age groups, but still the most common. Why? Could it be a ‘natural selection’ process?” The question could be answered with another statistic which tell us, “The average lifespan of someone with mental illness is 54 years" (Behavioral Health and Wellness Council, 2014, p. 5). But this was thought to be due to suicide and other chronic disease. Which causes which?

Much Diagnosing, yet no Solution

The main contributions of the state-run Office of Suicide Prevention in 2012 were new diagnoses of the problem: Bullying as causation for suicide in youth; substance abuse disorder, especially dual-diagnosis with mental disorder as a significant cause; diagnosable and treatable mental illness as a major cause of suicide. Access to firearms was also a significant factor—guns were used twice as often for suicide than in homicides in Nevada. The strategies to address suicide were to be in supporting healthy families, creating prevention programs, and for treatment and support services; a partnership to develop public health policies and to integrate behavioral health with the medical health system was planned; non-profit organizations, nursing homes, community centers, schools, EMS, Tribal health, and medical systems were to all be collaborative in this new model (Wherry & Vaughan Allen, 2014).

In response to this overwhelming health problem, the Governor of Nevada established the Behavioral Health and Wellness Council to evaluate and create a comprehensive plan for delivery of services to Nevada residents. The members of the council were to be from key agencies and to include all stakeholders, including private providers and those who seek services and their families. The proclamation cast a wide net to garner needed support from other states and the Federal government (Executive Order, 2013). A large government grant was spent in gatekeeper training, followed by development of screening for depression and suicide hotlines. Only 4% of the funds were applied to education for consumers or other preventative programs (Wherry & Vaughan Allen, 2014, p.48). Mental Health 911 suicide prevention trainings were held for professionals, and an increased number of groups collaborated in the making of a plan. The implementation of interventions included a texting suicide hotline TextToday, and two health promotion programs for gun awareness—neither of which I have ever seen. There was creation of a Committee to Review Suicide Fatalities; the grant basically disseminated to state workers to develop plans.

When the 2013 the funding ended, the state claimed successes such as “informed, engaged youth and families”…screening tools used in schools and ERs, treatment care pathways created, “aggressive follow-up” and sharing of information between agencies (Wherry & Vaughan Allen, 2014, p. 50). There would still be a long leap from plan to implementation. In order to determine sustainability of any program, we must ask “Where is the outcome? What statistics can we muster up to show these programs were received by the intended audience? Do we see a reduction in the suicide statistic? Was any of the funding vested in human capital such as peer-led services which will continue to operate after the government grants toll?”

With the beginning of a new grant period July 2013-2015, Nevada combined their divisions of public health and behavioral health “with the intent of working with ‘whole persons’” (Nevada Division of Public and Behavioral Health, 2013, p. 4). They would have four regional health programs and committees for mental health services, and one agency for substance abuse and prevention. They were to oversee evaluation and outpatient treatment, transitional housing, residential treatment facilities, co-occurring disorders treatment, counseling, education and prevention services (Nevada Division of Public and Behavioral Health, 2013). With a mental health block grant the division would expand the community capacity through a regional consortium of community delivery of services, crisis intervention including peer services such as “clubhouse” models, and alternatives to the emergency room for mental health crises. Mobile crisis units would be deployed; community triage beds would become available; residential treatment facilities would replace sending adolescents out of state, and a mental health emergency response system would be put in place.

The plan was to address housing, jobs and licensure for community programs, and increase mental health literacy through incorporation of SAMHSA models. In the first year workgroups suggested the ER beds be in existing hospitals, that the legal hold rules be expanded, and that several bases of power exist throughout the community in local mental health crisis units. While members of the board were paid from the government grant, proposed healthcare providers would be dependent upon Medicaid funds for payment (Behavioral Health and Wellness Council, 2014). As of December 2014 the interested private providers had not signed on to bring partial hospitalization or crisis clinics to the community. And although the council had pushed for new rules, and Nevada did create a new license for residential treatment centers for youth at NRS 449, the requirements were aligned with the abilities of large-scale corporations.

When we can only get to the planning stage, we have to wonder what is wrong here? Is there not enough offered to stakeholders? With each grants cycle of three years, grant funds are used to re-assess and plan new interventions—at the end of the cycle no programs (if any were implemented) survive, the state regroups and reforms their divisions of public health.

Interventions Which Have Worked (for others)

The Nevada Indian Tribes received SAMHSA grants in 2008, totaling 1.5 million dollars. Their immediate goals were to: Develop a Native youth suicide prevention program, community based interventions, improvement of data collection, increased awareness within the community to recognize those at risk, and what they can do about it. In partnership with HIS, UNR, Nevada Indian Health Board, Intertribal Council of Nevada and the Nevada Office of Suicide Prevention (Indian Health Service, 2008), they went about the work of creating an initiative called "Preserving Life". Here education and awareness of the risk factors or indicators were developed, communities were identified for common strengths and resources, and the implementation of culturally relevant prevention programs began. What was brought to the forefront, is that native people today walk with one foot in Indian culture and the other in the surrounding culture—they are divided heart from mine, and "they want meaning and knowing who they are, their history and worth in their existence (SPRC, 2009).

At the Indian Nations Camp (WIA project, 2008) in the Chiricahua Mountains each summer, youth from 16 different Arizona Tribes learn about budgeting and job readiness; attend substance abuse workshops--but most important here is the "Defining Your Inner Warrior" workshop. Indigenous people know they must have the right spirit within and that everything else flows from that spirit. The outcome of this camp points to the fact that resources and support for at-risk youth helps promote resiliency and community connectedness (SPRC, 2009b).

The Kahv'yoo Spirit program was developed to address high teen suicide rate among the seven districts in central Arizona. Through ground exercises with horses, youth work together to gain self-esteem, connection and coping skills. Equine-facilitated program outcomes of self-confidence, trust, self-responsibility and sense of belonging, make them a best practice according to the First Nations Behavioral Health Association (Sims Gerdes & Miritello, 2010).

The Circle of Care concept and cultural strategy was born in 2004 out of a SAMHSA initiative for the care of severely emotionally disturbed children, and support for the family through a Tribally-based health service model. The framework for service delivery is to be by Tribe members, for Tribe members--collaboration and support working within the community. This is "a paradigm shift away from traditional 'helping' programs” (Tulley, 2006 p. 15). Adaptations to culture include those tools for assessment, such as the Story Teller game. Hearing and understanding Tribe members who are trying to live in two worlds at once, requires people who have life experience in navigating this position.

The cultural adaptations do not just include persons of different races, as there are now many overlapping "cultures", such as the culture of religion, urban culture, rural culture, organizational cultures, etc. There is one starting place for a language that speaks to all cultures—it is from the heart or spirit. Building resiliency, which begins from within each individual, builds a path to a healthy community—in my opinion, this is where we must begin. SAMHSA has capacity building programs and support infrastructure in place for training of community and peer led programs. Nevada state councils and coalitions could access co-occurring Disorder State Incentives, Strengthening Treatment Access and Retention, Addiction Technology Transfer Centers, and webinars from programs which have become sustainable. Nevada needs to build its own workforce in this area, and nurture existing peer resources. The current boards comprised of "all stakeholders" have little representation from consumers of mental health services or their families. There still exists a culture of "every man for himself" here in Nevada where resources meant to help individuals never gets to them because it is spent paying for committees to oversee, rather than create sustainable interventions which go to work, and put peer navigators to work. These peer professionals did not need to read in a book how to recognize the signs of hopelessness--they realize that consulting a therapist who may dictate how the therapy will go and what you should be thinking, is a losing proposition. Congress decreed in The New Freedom Commission on Mental Health (2003) that using peers to help those in mental health crises is a best practice and best use of resources, but to date the States have only seen fit to grab the Federal funds for training programs, so that peers could be hired to dole out medications in State-run programs. A provider's response to crisis, and recovery from a health crisis, both take more than "self-reflection"—it takes partnership and buy-in from the consumer of services the provider is offering. In this burgeoning consumer-driven health market, the consumer is ultimately the one responsible to seek out and use all resources to fulfill their healthcare needs; healthcare providers are contracted by the consumer to help them accomplish this.

Richard Horton, Editor-in-Chief of the Lancet medical journal recently wrote that chronic diseases fueled by health habits and rapid globalization, are the "social justice issue of our time" (Horton, 2015, p. 2378). In response, the World Health Organization is going to create a "community of practice", which Horton calls a meager stab at an overwhelming condition of the planet which ends up "too polite to make the impact it deserves" (Horton, 2015, p. 2378). He asks the same questions I do: Where are the people in this fight? Why are there no leaders or coalitions between governments and scientists and health professionals? Horton observes that lack of mobilization is due to becoming mired in processes, which kills all action—I agree.

References

Behavioral Health and Wellness Council. (2014). Draft Action Minutes, December 9, 2014. Carson City, NV: Author.

Executive Order 2013-26, Carson City, NV. December 16, 2013. Retrieved from: http://gov.nv.gov/News-and-Media/Press/2013/ Sandoval-Signs-Executive-Order-Creating-Behavioral-Health-and-Wellness-Council/

Horton R. (2015). Chronic diseases—The social justice issue of our time. The Lancet, Vol 386, Dec. 12, 2015, p. 2378.

Indian Health Service, Reno District Office of Environmental Health. (2008). Reno District Newsletter, Vol. 19, Issue 2. Reno, NV: Author.

Nevada Division of Public and Behavioral Health. (2013). Behavioral Health Strategic Initiatives. Carson City, NV: Author.

Sims Gerdes M, Miritello A. (2010). Kahv'yoo Spirit, Equine-Assisted Growth and Learning Adventure: A Youth Suicide Prevention Project. [presentation, 3/17/2010]. Sacaton, AZ: Gila River Indian Community.

SPRC, Suicide Prevention Center. (2009a). Indian Health Board of Nevada. Retrieved from: www.sprc.org/grantees/indian-health-board-nevada

SPRC, Suicide Prevention Center. (2009b). Maximizing Protective Factors for American Indian Youth. [presentation, Jan. 6, 2009]. Retrieved from: www.sprc.org/sites/sprc.org/files/event_materials/8CJimenez.pdf

Tulley SD. (2006). Final Report for Health Spirit Conference. Vernal, UT: Utah State University.

Wagner A. (1999). Nevada is Booming but so are Social Problems. Los Angeles Times, August 1, 1999. Retrieved from: http://articles.latimes.com/1999/aug/01/local/me-61476

Wherry M, Vaughan Allen M. (2014). Suicide Prevention. [Presentation]. Retrieved from: http://dpbh.nv.gov/uploadedFiles/01%202014-03-24_SuicidePreventionPresentation.pdf