Increase and Enhance Protective Factors

Adverse childhood experiences (ACEs) are potentially traumatic events that happen while a person is growing up, and they can have a lasting, negative effect on an individual’s health into adulthood. Examples include experiences such as abuse, neglect, exposure to violence, parental incarceration, divorce, or household issues with mental health or substance use. ACEs increase the risk for poor health outcomes, including the risk of suicidal behaviors.

The type of ACE that was experienced also significantly affects a person’s risk of attempting suicide. According to the research,¹² suicide attempts were approximately:

• 2 times as likely where there was a substance use issue in
  the home. 
• 2 times as likely for those whose parents had divorced
  or separated.
• 2.5 times as likely for those with an incarcerated
  family member.
• 2.5 times as likely if a mother experienced violence in
  the house.
• 3 times as likely for those who had a relative with mental illness in the house.
• 3 times as likely for those who experienced physical abuse or sexual abuse.
• 5 times as likely for those reporting emotional abuse.

Though ACEs may increase the odds of having health challenges, ACEs do not necessarily lead to worse health outcomes. Increasing protective factors may help mitigate risk associated with ACEs and improve health outcomes. The risk of negative health effects of ACEs can be reduced when people have a strong support system and the skills to successfully cope with life’s many challenges. For adults, learning how to adapt to change and recover from setbacks can mean thoughtfully considering behavior and attitudes, learning from the past, and finding healthy ways to cope with daily stress. Some ways to build and maintain a healthy foundation at any stage in life include:

• Building strong relationships with family and friends.
• Setting realistic personal goals.
• Acknowledging when positive choices have been made.
• Eating well, getting plenty of sleep, and staying active.
• Taking proactive action when faced with a challenge.

For children, this positive support can be provided through:

• Caring relationships with parents, teachers, counselors, or other adults actively involved in a child’s life.
• Good peer relationships.
• Positive coping style.
• Good social skills.

This is particularly important for youth who identify as lesbian, gay, or bisexual (LGB). The CDC has reported that LGB youth are 4.5 times more likely, and questioning youth are over twice as likely, to consider attempting suicide as their heterosexual peers.¹³ Note that this CDC report did not include gender identity, such as transgender, as that data was not being collected until recently. Suicidal behavior among this population can be related to experiences of discrimination, family rejection, harassment, bullying, violence, and victimization. For those youth with baseline risk for suicide, especially those with a mental health condition, these experiences can place them at increased risk.
Schools have a great ability to lessen the impact of traumatic events in a young person’s life. Schools can become trauma-sensitive schools, which then makes them a protective factor for affected students and increases the social-emotional and academic skills of the entire school body.

Another way to help build a foundation for a healthy and successful life is through social and emotional learning (SEL). SEL is the process through which children and adults acquire and effectively apply the knowledge, attitudes, and skills necessary to understand and manage emotions, set and achieve positive goals, feel and show empathy for others, establish and maintain positive relationships, and make responsible decisions. For children, making SEL skills part of the learning equation helps them succeed in school and life. With social and emotional skills, children can manage their feelings, build healthy relationships, and navigate social environments.

When the adults in children’s lives are supported by good policies and training, children develop the skills needed to prepare them for the world. The Wisconsin Department of Public Instruction (DPI), in partnership with the Collaborative for Academic, Social, and Emotional Learning (CASEL), is committed to providing resources to schools and families to support comprehensive social and emotional learning opportunities for students.

DPI also provides information and resources for youth suicide prevention to school staff, administrators, school boards, and other members of the school community. These resources include data about youth suicide; information about Wisconsin laws addressing prevention; web-based training; student programs; as well as strategies for prevention, intervention, and postvention.

Alongside building individual resilience, there is a need to build resilient, healthy communities, as well as prevent ACEs at the community-level when possible. Community resilience is built by strengthening social inclusion and connectedness, economic opportunities, affordable housing, welcoming and affirming spaces, equal access to high-quality schools, and environments that promote good physical and mental health. In this way, the systemic root causes of risk behaviors and negative health outcomes can be addressed to improve health for all Wisconsin residents.

12. Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span. Journal of the American Medical Association. 2001;286(24):3089–3095.

13. Center for Disease Control and Prevention. Youth Risk Behavior Survey—Data Summary & Trends Report: 2007–2017.

1A: Implement strategies that reduce the impact of adverse childhood experiences

Social isolation and feelings of loneliness are key risk factors for suicide among both adolescent and adult Wisconsin residents. Research consistently demonstrates the role of connectedness and sense of belonging as protective factors for suicide. Social gatherings for adults and extracurricular activities for youth are important protective factors. Affinity groups or cultural events that validate and celebrate students’ race, ethnicity, or sexual identity can be particularly important.¹⁴ Youth who feel connected at school and at home were found to be as much as 66% less likely to experience health risk behaviors related to sexual health, substance use, violence, and mental health in adulthood.¹⁵ Both perceived and actual social disconnectedness can lead to suicidal thoughts. This is a great cause for concern in Wisconsin as many people in the state experience low levels of social support.¹⁶

Enhancing connectedness and social cohesion is one of the most direct ways we can address mental health challenges related to suicidal thoughts, including depression, hopelessness, anxiety, and substance use. Connectedness to others, including family members, teachers, and coworkers, as well as community, faith-based, and social organizations, plays a critical role in protecting individuals from suicide. Community-based efforts in workplaces, schools, and other public spaces can encourage openness around talking about suicide. Policies can be designed to ensure the availability of welcoming and affirming spaces, promote positive interactions in the community, and thus increase the feeling of belonging.

There is a strong evidence base behind prevention strategies such as: group educational, social, or physical activities that promote social interactions, regular attendance, and community involvement among older adults; support for community centers and other venues that facilitate local residents’ efforts to socialize, participate in recreational or educational activities, gain information, and seek counseling; and intergenerational mentorship.

Interventions for preventing suicide that have the most complete and inclusive view of the issue will take into account the conditions in which we live, work, play, and grow, also known as social determinants of health (SDOH). SDOH contribute to health disparities among various groups of people in ways that are different across gender, race, class, disability status, and sexual identity. For example, ways in which individuals who identify as LGBTQ or people of color are often impacted include: lack of physically safe or socially inclusive and affirming environments; stigma; limited stable housing and employment opportunities; historical trauma; and discrimination. People engaging in prevention efforts should consider how interventions might take into consideration or address institutional racism, homophobia, and other types of oppression. Such prevention efforts may involve developing new partnerships or working across sectors including:

• Public health
• Business, labor, and economic development
• Health services
• Education
• Veterans and the military
• Government
• Justice
• Housing
• Media
• Community organizations (foundations, faith-based groups, etc.)

14. Wisconsin Department of Public Instruction. Wisconsin’s 2017 Youth Risk Behavior Survey Special Topic: Suicide.

15. Steiner RJ, Sheremenko G, Lesesne C, et al. Adolescent Connectedness and Adult Health Outcomes. Pediatrics. 2019;144(1):e20183766.

16. Behavioral Risk Factor Surveillance System (BRFSS), Emotional Support and Life Satisfaction, 2017.

1B: Promote healthy communities by increasing social connectedness

The means by which people attempt or die by suicide play an important role in prevention. Creating suicide safe environments means lessening the chances for someone who is thinking about or planning suicide to ultimately die by suicide. Temporarily removing access to lethal means when someone is experiencing thoughts of suicide may interrupt an attempt or make an attempt less lethal, providing additional valuable time for others to intervene. Encouragingly, research shows that most people (90%) who survive a suicide attempt do not go on to die by suicide, and 70% of people who survive a suicide attempt never reattempt.¹⁷ And safe environments can help prevent attempts in the first place.

One area of safety relates to firearms. There are growing efforts in Wisconsin and nationally to offer safe storage to gun owners who feel they or their loved ones might be at risk. These efforts have often taken the form of what is called “The Gun Shop Project.” The Gun Shop Project’s work is guided by the New Hampshire Firearm Safety Coalition, a group of mental health and public health practitioners, firearm retailers, and firearm rights advocates. The project developed materials with and for firearm retailers and range owners on ways they can help prevent suicide. Its objectives are to:

• Share guidelines on how to avoid selling or renting a firearm to a suicidal customer.
• Encourage gun stores and firing ranges to display and distribute suicide prevention materials tailored to their customers.

Another collaborative effort to educate and partner to prevent suicide is the American Foundation for Suicide Prevention’s (AFSP’s) work with the National Shooting Sports Foundation on the Firearms and Suicide Prevention Program. It is an educational program which focuses on risk factors and warning signs and actions that can be taken to create safety: temporary removal of firearms from the home during periods of risk; safe storage (locked and unloaded) at all times; and denying sale when appropriate. AFSP Wisconsin is training volunteers to lead this program throughout the state and partner with interested gun shop and range owners and the firearms community broadly. The education is paired with the distribution of resource materials to locations where firearms are sold.

Safety is also a concern with medications, especially prescription drugs, which are another means by which people attempt to take their own lives. Safe storage of medications includes storing them out of sight and even using a lockbox, safe, or locked medicine cabinet to prevent access by a person who is at acute risk of attempting suicide. Properly disposing of medications that are no longer needed is another way to create safety by reducing potential access.

Reducing access to lethal means, such as firearms and medication, can determine whether a person at risk for suicide lives or dies. Mental health professionals and laypeople alike can learn how to work with suicidal individuals to reduce their access to means. Counseling on Access to Lethal Means is a free online course that covers how to: identify people who could benefit from lethal means counseling; ask about their access to lethal methods; and work with them—and their families and friends—to reduce access. In addition, there are coalitions and local health departments that distribute gun locks and medication lock boxes to support lethal means safety efforts. Suicide recognition and response trainings often include information about local groups that coordinate these activities, and there are sometimes grants available to purchase these resources.

Safety planning for those at risk of suicide can include considerations about safe storage of the means one might use to kill oneself. The Safety Planning Intervention includes a written, prioritized list of positive coping strategies and resources that is created in collaboration with the person at risk. It is a prevention tool that is designed to increase survival in those who experience suicidal thoughts and behaviors. Safety planning is a core component of Zero Suicide trainings and is currently being used in multiple settings throughout Wisconsin and the United States.

17. https://www.hsph.harvard.edu/means-matter/means-matter/survival/

1C: Support efforts to increase safety with lethal means