More than 32,000 people in the United States die by suicide every year. It is this country’s 11th leading cause of death, and is often characterized as a response to a single event or set of circumstances. However, unlike these popular conceptions, suicide is a much more involved phenomenon. The factors that contribute to any particular suicide are diverse and complex, so efforts to understand it must incorporate a variety of approaches.


Suicide is a serious, but preventable public health problem. Integral Care, as the local authority for behavioral health and developmental disabilities, has taken the lead on initiatives to help educate our community in hopes of collaboratively preventing suicides from occurring.


If you or someone you are concerned about has expressed thoughts of suicide, please call the 24/7 Crisis Helpline at 512-472-HELP (4357) or our toll-free 24/7 Crisis Helpline at 844-398-8252.

What is Zero Suicide?

Zero Suicide is a commitment to suicide prevention in health and behavioral health care systems, and also a specific set of tools and strategies. It is both a concept and a practice. Its core propositions are that suicide deaths for people under care are preventable, and that the bold goal of zero suicides among persons receiving care is an aspirational challenge that health systems should accept.

-National Action Alliance for Suicide Prevention

What is ZEST?

The Texas Department of State Health Services (DSHS) has undertaken the aspirational goal of perfect patient safety for individuals receiving care through its public mental health system. DSHS, with support from a grant from the Substance Abuse and Mental Health Services Administration, is partnering with community mental health centers to develop suicide safe care in communities through the adoption of best practices.

The goals of the Zero Suicide in Texas (ZEST) initiative are to improve identification, treatment and support services for high risk youth by creating Suicide Safe Care Centers within the public mental health system; expanding and coordinating these best practice suicide prevention activities with other youth serving organizations and community partners to create Suicide Safe Care Communities; and implementing research-informed training and communications efforts to create a Suicide Safe Care State.

Integral Care has been part of the ZEST Initiative since September 2014. We were one of the first 10 LMHAs (Local Mental Health Authorities) to participate in the initiative. In order to become a suicide safe care center, we decided to focus on improving our assessment tools and also providing agency-wide training on suicide prevention.

Regarding assessment tools, we decided to add the Columbia-Suicide Severity Rating Scale (C-SSRS) (Lifetime/Recent Version, Adult and Pediatric/Cognitively Impaired) to our Crisis Assessment and also to both the Adult and Child Behavior Narrative assessments. The C-SSRS Screener has been used by all our prescribers as well, and is another tool available for all our staff.

  • The C-SSRS is the only screening tool that assesses the full range of evidence-based ideation and behavior items, with criteria for next steps (e.g. referral to mental health professionals).
  • The C-SSRS Full Lifetime/Recent Version (available separately for Adults & Children/IDD) allows practitioners to gather lifetime history of suicidality as well as any recent suicidal ideation and/or behavior.
  • The C-SSRS Screener Version is a truncated form of the Full Lifetime/Recent Version. It is 3-6 questions long and includes all the information necessary to make a decision about next steps. The Screener Version is collapsed from the Full Version; however, it is not available separately for Adults and Children/IDD.

We have also provided training on utilizing Safety Planning Intervention and SafeTALK. The purpose of Safety Planning Intervention is to provide people who are experiencing suicidal ideation with a specific set of concrete strategies to use in order to decrease the risk of suicidal behavior. The safety plan includes specific client-identified coping strategies that may be used and individuals or agencies that may be contacted during a crisis. The Safety Plan Intervention is a collaborative effort between a clinician or treatment provider and their client, and may take up to 45 minutes to complete. The basic steps of a safety plan include the following:

  • Recognizing the warning signs of an impending suicidal crisis
  • Using one’s own coping strategies
  • Contacting others in order to distract from suicidal thoughts
  • Contacting family members or friends who may help to resolve the crisis
  • Contacting mental health professionals or agencies
  • Reducing the availability of a means to complete suicide

SafeTALK is a 3 to 4 hour suicide prevention gate keeper training that helps participants recognize a person with thoughts of suicide and connect them with resources who can help them in choosing to live. The course uses audiovisuals and interactive discussion to help participants learn to:

  • Recognizing the warning signs of an impending suicidal crisis
  • Recognize that invitations for help are often overlooked
  • Move beyond the common tendency to miss, dismiss, and avoid suicide
  • Apply the T.A.L.K. steps: Tell, Ask, Listen, Keep Safe
  • Know community resources and how to connect someone with thoughts of suicide to them for further help
  • C-SSRS Brochure for the Community

Mission / Purpose

The Austin/Central Texas Suicide Prevention Coalition is a group of public and private agencies that aim to support suicide prevention efforts with partnering organizations, educate and advocate for best practices in suicide prevention, and serve as a resource to the community.

Membership has included representation from behavioral healthcare, hospitals, health departments, military, VA, school districts, colleges/universities, law enforcement, first responders, survivor and advocacy groups, faith communities, and numerous nonprofit agencies throughout the region. The Coalition will continue its focus on, and support of, the 2014 Texas State Plan for Suicide Prevention, which supports the 2012 National Strategy for Suicide Prevention’s Goals and Objectives.

Specific Coalition Goals

“Provide training to schools, community, clinical and behavioral health service providers on the prevention of suicide and related behaviors” (Goal 7, 2014 Texas State Plan for Suicide Prevention)

“Provide care and support to individuals affected by suicide deaths or suicide or suicide attempts, and implement community best practice-based postvention strategies to help prevent further suicides” (Goal 10, 2014 Texas State Plan for Suicide Prevention)

“Increase the timeliness and usefulness of national, state, and local surveillance systems relevant to suicide prevention and improve the ability to collect, analyze, and use this information for action” (Goal 11, 2014 Texas State Plan for Suicide Prevention)

The Executive Committee is co-chaired by Integral Care and Seton; they meet at least six times throughout the year. The coalition holds workshops, presentations, etc. for the general community to attend during the other six months.

Please email for more information.

Regarding assessment tools, we decided to add the Columbia-Suicide Severity Rating Scale (C-SSRS) (Lifetime/Recent Version, Adult and Pediatric/Cognitively Impaired) to our Crisis Assessment and also to both the Adult and Child Behavior Narrative assessments. The C-SSRS Screener has been used by all our prescribers as well, and is another tool available for all our staff.


Dr. Kelly Posner, of Columbia University, who created the C-SSRS, and her staff recently commented on the public health approach to helping those at risk of suicide – “The public health approach to risk identification and suicide prevention will be the way we move the needle on this issue. Due to the access and stigma barriers to mental health care these questions need to be in the hands of everyone so we can find people where they live and breathe. A recent large study of 11,000 students from 10 EU countries demonstrated that the suicide prevention training component that had the largest impact on suicide attempts was having peers role play with their peers. A healthcare system in Connecticut recently told us that they provide these questions to their janitors, which was quickly echoed by the VA hospital where a recent patient who never spoke to anyone except the janitor. So, having the questions and knowing when to worry about a patient is good prevention. Additionally, this gives the layperson the same language as the medical and mental health professionals, improving communication and care delivery.


This approach has been embraced across the DOD as the attached memo from the Undersecretary of Defense highlights. It states, “The Defense Suicide Prevention Office (DSPO) supports the use of the Columbia – Suicide Severity Rating Scale (C-SSRS) – Screening Version for use within military communities, and more specifically, with military commands, community counselors, Sexual Assault Prevention and Response victim advocates, chaplains, law enforcement, firefighters, first responders, attorneys, peers, and other gatekeepers.” In our work with the Zero Suicide model in the Air Force (see below), everyone – airmen, spouses, dentists, teachers, security, etc. – all have the questions for early identification of suicide risk. In the very near future, we will be presenting a training on this to all non-medical VA employees from the cafeteria worker to the cemetery employees.


We have also learned from our work with communities that putting a screener like the C-SSRS into the hands of teachers, parents, coaches, first responders and youth has the potential not only to save the lives of youth who are at risk of suicide but, because of the demonstrated connection between suicide and school violence (up to 80% of school shooters have a documented history of suicidal thoughts or behaviors), also has the potential to prevent these tragedies. We had the recent privilege to present this to the U.S. Senators from Florida at their School Safety Forum at the invitation of one of the Parkland parents who lost a child.

Integral Care offers community-wide suicide prevention training and services through:

Understanding the risk factors for suicide often helps in assisting those in our community who may be suicidal.

Click here for a listing of additional resources including training, hotlines, events, support groups and other websites.