Increase and Enhance Protective Factors

1A

Implement strategies that reduce the impact of adverse childhood experiences (ACEs) and promote social-emotional development in children.

 

Definitions:

  • Adverse childhood experiences (ACEs): ACEs are potentially traumatic events that occur in childhood
    (0–17 years old).

  • Social and Emotional Learning (SEL): According to the Collaborative for Academic, Social, and Emotional Learning, 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.

 

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.

 

Voices From the Field

"We know that just one engaged relationship with a trusted adult is the biggest protective factor for kids. We also know that these relationships and mutual supports are a key protective factor for adults when facing toxic stress. With the Coalition, we nurture the system of relationships around children by promoting compassion resilience of caregivers, by uplifting those most impacted by trauma as decision-makers, and by intentionally building community. When we transform our relationships, such as who listens to whom and who learns from whom, then we also change the power dynamics in the decisions that are key to reducing trauma and promoting the best outcomes for our whole community."

– Blake T., Milwaukee Coalition for Children's Mental Health

 

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

Opportunities for Action Resources
Support programs and policies that promote the development of social skills and emotion regulation as key components of children’s health and education. Safe Schools Initiative
https://dpi.wi.gov/sspw/safe-schools
Resources to Build SEL Expertise
https://dpi.wi.gov/sspw/mental-health/social-emotional-learning/build-your-sel-expertise
Adolescent Connectedness
https://www.cdc.gov/healthyyouth/protective/youth-connectedness-important-protective-factor-for-health-well-being.htm
The Collaborative for Academic, Social, and Emotional Learning
https://casel.org
Work with partners to facilitate the provision of supportive services for children and families who experience adversity. Compassion Resilience Toolkit
https://compassionresiliencetoolkit.org/
Student Services/Prevention and Wellness Team
https://dpi.wi.gov/sspw
Model School Policy Resource
https://www.sprc.org/resources-programs/model-school-policy-suicide-prevention-model-language-commentary-resources
Wisconsin Child Abuse and Neglect Prevention Board
https://preventionboard.wi.gov/Pages/Homepage.aspx
Wisconsin Safe and Healthy Schools
http://wishschools.org/
Resilient Wisconsin
https://www.dhs.wisconsin.gov/resilient/index.htm
Support the implementation of programs to create schools that are safe and just for all students, including lesbian, gay, bisexual, and transgender (LGBT) students. Trauma-Sensitive Schools
https://dpi.wi.gov/sspw/mental-health/trauma
Bullying Prevention Resources
https://dpi.wi.gov/sspw/safe-schools/bullying-prevention
Safe Schools for LGBT students
https://dpi.wi.gov/sspw/safe-schools/lgbt
GSAFE
https://gsafewi.org/
Use Youth Risk Behavior Survey data to inform school-based suicide prevention efforts. Youth Risk Behavior Survey Special Topic: Suicide and Help Seeking
https://dpi.wi.gov/sites/default/files/imce/sspw/pdf/yrbssuicidehelpseeking.pdf

 

 

1B

Promote healthy communities by increasing social connectedness in multiple settings, including schools, workplaces, and community, faith-based, cultural, and social organizations.

 

Definitions:

  • Mental Health First Aid (MHFA): MHFA is an 8-hour course that teaches a person how to identify, understand, and respond to signs of mental illnesses and substance use disorders.

  • National Alliance on Mental Illness (NAMI): NAMI is the nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness.

  • Question, Persuade, and Refer (QPR): QPR is a program containing the three steps anyone can learn to help save a life from suicide. People trained in QPR learn how to recognize the warning signs of a suicide crisis and how to question, persuade, and refer someone to help.

  • Social determinants of health (SDOH): SDOH are defined by the World Health Organization as the conditions in which people are born, grow, live, work, and age that are shaped by the distribution of money, power, and resources at global, national, and local levels.

  • Wisconsin Initiative for Stigma Elimination (WISE): WISE is a statewide coalition of organizations and individuals building resilient and hopeful communities by promoting inclusion and support for all affected by mental health challenges.

 

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.)

 

CDC’s Preventing Suicide: A Technical Package of Policies, Programs, and Practices highlights strategies based on the best available evidence to help states and communities prevent suicide.

Ideally, prevention addresses all levels of influence: individual, relationship, community, and societal.

 

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

Opportunities for Action Resources
Facilitate outreach to individuals at risk of isolation, such as older adults living alone, or people living with disabilities, mental health conditions, or addiction. QPR Institute
https://qprinstitute.com/
Mental Health First Aid
https://www.mentalhealthfirstaid.org/
Programs and Services for Older Adults in Wisconsin
https://www.dhs.wisconsin.gov/aging/services
Engage faith-based organizations in efforts to prevent social isolation and provide training as appropriate. Faith. Hope. Life.
https://theactionalliance.org/faith-hope-life
Utilize peer or other support groups to facilitate meaningful social connections among those who are experiencing suicidal thoughts, who have attempted suicide, or who have lost loved ones to suicide. AFSP – I’ve Lost Someone
https://afsp.org/find-support/ive-lost-someone/
WISE (Wisconsin Initiative for Stigma Elimination)
https://wisewisconsin.org/up-to-me/
Alternatives to Suicide
https://www.westernmassrlc.org/alternatives-to-suicide
NAMI Wisconsin
https://namiwisconsin.org/education-programs/
NAMI Connection
https://www.nami.org/Find-Support/NAMI-Programs/NAMI-Connection
Prevent Suicide Wisconsin Suicide Loss Support
https://www.preventsuicidewi.org/suicide-loss-support

 

 

1C

Support efforts, including safe storage of medications and firearms, to reduce access to lethal means by people who are at acute risk of suicide.

 

Definitions:

  • Means reduction: Means reduction involves reducing a suicidal person’s access to lethal means or methods, which are the substances, implements, or weapons capable of causing death.

  • Counseling on Access to Lethal Means (CALM): CALM is a free online course that focuses on how to reduce access to the methods people use to kill themselves. It 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 to reduce access.

  • American Foundation for Suicide Prevention (AFSP): AFSP raises awareness, funds scientific research, and provides resources and aid to those affected by suicide.

  • Suicide Prevention Resource Center (SPRC): SPRC is the federally supported national resource center devoted to advancing suicide prevention infrastructure and capacity building through consultation, training, and the provision of information, resources, and tools in support of suicide prevention efforts.

 

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.

 

A Mount Horeb gun shop owner bought a safe to store guns for anyone if they feel they are at risk for suicide. What started as one small action to prevent suicides in one community turned into a larger conversation about safe storage of firearms and gun safety in Wisconsin.

Voices From the Field

"There is a desperate need in the firearms industry for simple training to recognize and limit access to people who may be in a time of crisis. This can be taught easily to gun shop and range owners and employees in very little time. A small investment of time is worth so much more than losing a person’s life. The Gun Shop Project as well as the National Shooting Sports Foundation both have excellent resources that can be obtained at little to no cost to the people wanting them. "

– Chuck L., Gun Shop Owner— Mount Horeb

 

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

Opportunities for Action Resources
Promote training for safety planning that includes lethal means safety and encourage the use of evidence-based safety planning tools. CALM – Counseling on Access to Lethal Means
https://www.sprc.org/resources-programs/calm-counseling-access-lethal-means
Safety Planning Intervention
http://zerosuicide.edc.org/resources/zero-suicide-research-base-engage-element-safety-planning
Safety Plan Mobile App
https://zerosuicide.sprc.org/resources/safety-plan-mobile-app
Means Matter (Harvard TH Chan School of Public Health)
https://www.hsph.harvard.edu/means-matter/
Emergency Department Means Restriction Education
(For adult caregivers of at-risk youth in the ED)
https://www.sprc.org/resources-programs/emergency-department-means-restriction-education
Lethal Means & Suicide Prevention: A Guide for Community &
Industry Leaders
https://theactionalliance.org/resource/lethal-means-suicide-prevention-guide-community-industry-leaders
Engage gun shops in safe storage efforts and disseminate gun locks and other firearm locking equipment. Firearms and Suicide Prevention
https://afsp.org/firearms-and-suicide-prevention-education-program
Project Child Safe
http://www.projectchildsafe.org/about
New Hampshire Gun Shop Project
https://www.hsph.harvard.edu/means-matter/gun-shop-project/
Gun locks can be distributed by local coalitions
https://www.preventsuicidewi.org/find-a-local-coalition
Encourage individuals to dispose of medications and household chemicals safely. Prescription Drug Take Back
https://www.fda.gov/drugs/disposal-unused-medicines-what-you-should-know/drug-disposal-drug-take-back-locations
Safe Disposal
http://dnr.wi.gov/topic/healthwaste/businesspharm.html