Relationship

Relationship

The relationship level explores the close relationships that may influence a person’s risk of suicide. Relationships include those with family, friends, and other people. For firearm suicide prevention, the relationship level encourages engagement and support by others in the temporary separation of firearms from the at-risk person. At this level, health care providers have an important opportunity to engage in firearm suicide prevention by providing lethal means safety counseling to patients or parents of pediatric patients who may be at risk of suicide.

Lethal Means Safety Counseling

Lethal means safety counseling is a process that healthcare providers undertake to help patients and their families or friends find ways to reduce access to lethal means of suicide attempt, at least temporarily, during times of elevated risk of suicide. They first work to determine if a person at risk of suicide has access to lethal means, like firearms. The provider then works with the person and their family or friends to reduce access until the risk of suicide decreases.

 

Who should receive lethal means safety counseling?

Any patient at an elevated risk of suicide, such as someone who is depressed or engaging in risky alcohol use, and especially if they have disclosed suicidal ideation or attempt, should receive lethal means safety counseling. Lethal means safety counseling should be provided even if the at-risk person does not have access to a firearm at the time of the clinical interaction, as they might purchase or otherwise access firearms in the future. Family or friends should be included in the counseling if possible.

 

Conditions when firearm information might be particularly relevant to the health of a patient and potentially to others

Condition Examples How to Respond When Patients Have Firearm Access
ACUTE RISK
Acute risk of violence to self or others (based on information or behavior)
  • Suicidal ideation or intent
  • Homicidal ideation or intent
  • This is an emergency
  • Act promptly to ensure safer storage, in cooperation with patient if possible
  • If necessary, disclose to others who are able to reduce risk (family, caregivers, psychiatric services, law enforcement)
INDIVIDUAL RISK FACTORS
Individual-level risk factors for violence to self or others or unintentional firearm injury
  • History of violent behavior
  • Risky alcohol or substance use
  • Serious mental illness, especially in combination with risky alcohol or substance use, violence, or during acute exacerbations
  • History of violent victimization
  • Dementia or conditions impairing cognition and judgment
  • Counsel on safer storage (5 Ls or similar - see below)
  • Counsel on risk reduction
  • When capacity is diminished, consider disclosure to others who are able to reduce risk
DEMOGRAPHIC GROUP
Member of a demographic group at increased risk for violence to self or others or unintentional firearm injury
  • Middle-aged and older White men
  • Young Black men
  • Children and adolescents
  • Counsel on safer storage (5 Ls or similar)
  • Counsel on risk reduction
  • For minors, involve parents

Chart adapted from: Wintemute GJ, Betz ME, & Ranney M.L. (2016). Yes, you can: Physicians, patients, and firearms. Annals of Internal Medicine.

 

What should lethal means safety counseling include?

Lethal means safety counseling should be straightforward and practical. It should include asking about firearm access and intent to access firearms, discussing the risk of easy access to lethal means, providing locale-specific safer storage options, and using motivational interviewing techniques as one way to explore barriers to and pros/cons of safer storage options.

If the patient indicates that a firearm is in the home, questions on the following topics should be asked:

 

The 5 Ls:

The 5 Ls mnemonic was proposed in: Pinholt EM, Mitchell JD, Butler JH, & Kumar H. (2014). “Is there a gun in the home?” Assessing the risks of gun ownership in older adults. Journal of the American Geriatrics Society.

 

Who should be trained in lethal means safety counseling?

Lethal means safety counseling training should be provided to all trainees in medicine, mental health, nursing, and related clinical healthcare fields, and made available to more experienced clinicians as well. Additional specialization should be based on setting, such that those providers who interact with patients – especially if the patients are high-risk – at entry points to the healthcare system. This in-depth training should reach providers in the following settings: Primary care (family medicine, internal medicine, pediatrics, geriatrics, and OB-GYN), emergency and urgent care, as well as crisis centers, and behavioral health.

 

Is lethal means safety counseling effective?

Interventions by healthcare providers can affect a patient’s storage of firearms, which in turn can substantially reduce risk of suicide or other firearm-related injury. For example, healthcare professionals asked patients, “Does anyone in your home own a gun?” and then studied whether firearm safety counseling affected firearm storage practices among the patients who answered “yes.” They found that patients who received a healthcare pfoessional’s verbal or written recommendation were three times more likely to make safe changes in firearm storage practices than patients who did not receive counseling. Another study found that for every 2.5 gun-owning parents who received a pediatrician’s counseling and free cable locks, one parent reported using the cable locks six months later. These studies show that lethal means safety counseling is effective in improving firearm storage practices.

 

I am a healthcare provider. Where can I receive training on lethal means safety counseling?

Online trainings are available on how to counsel patients on access to lethal means.

Information on this page has been adapted from Breaking Barriers: The Emerging Role of Healthcare Provider Training Programs in Firearm Suicide Prevention

 

Resources

Educational Materials

Allchin A & Chaplin V, on behalf of the Consortium for Risk-Based Firearm Policy. (2017). “Breaking Through Barriers: The Emerging Role of Healthcare Provider Training Programs in Firearm Suicide Prevention.”

Defense Suicide Prevention Office’s powerpoint slides, “Lethal Means Safety Counseling to Reduce Suicide Risk” 

Department of Veteran Affairs’ “Safety Plan Quick Guide for Clinicians” handout

Department of Veterans Affairs and Department of Defense Clinical Practice Guidline for the Assessment and Management of Patients at Risk for Suicide

Harvard T.H. Chan School of Public Health’s Means Matter’s Recommendations to Clinicians

Johns Hopkins Medicine’s CLOSLER Initiative’s “The 5As of Firearm Safety Counseling”

Massachusetts Office of the Attorney General and the Massachusetts Medical Society’s “Talking to Patients About Gun Safety” handout

Massachusetts Medical Society’s Talking to Patients About Gun Safety Powerpoint Presentation

UC Davis’s What You Can Do Initiative’s health care provider handouts

Initiatives

Means Matter

Harvard Injury Control Research Center’s Means Matter Campaign’s mission is to increase the proportion of suicide prevention groups who promote activities that reduce a suicidal person’s access to lethal means of suicide and who develop active partnerships with gun owner groups to prevent suicide.

What You Can Do

UC Davis Health’s What You Can Do initiative provides resources to help health care providers get comfortable identifying risk and talking about firearms with patients when clinically relevant.

Research

General

Barber C, Hemenway D, & Miller M. (2016). How physicians can reduce suicide-without changing anyone’s mental health. American Journal of Medicine.

Barber CW & Miller MJ. (2014). Reducing a suicidal person’s access to lethal means of suicide: A research agenda. American Journal of Preventive Medicine.

Betz ME, Ranney ML, & Wintemute GJ. (2017). Physicians, patients, and firearms: The courts say “yes”. Annals of Internal Medicine.

Gerstein NS, et al. (2018). The gun violence epidemic: Time for perioperative physicians to act. Journal of Cardiothoracic and Vascular Anesthesia.

Olson LM, Christoffel KK, & O’Connor KG. (2007). Pediatricians’ involvement in gun injury prevention. Injury Prevention.

Pallin R, Spitzer SA, Ranney ML, Betz ME, & Wintemute GJ. (2019). Preventing firearm-related death and injury. Annals of Internal Medicine.

Ranney M, et al. (2016). A consensus-driven agenda for emergency medicine firearm injury prevention research. Annals of Emergency Medicine.

 

Effectiveness

Albright TL & Burge SK (2003). Improving firearm storage habits: Impact of brief office counseling by family physicians. Journal of the American Board of Family Practice.

Barkin SL, et al. (2008). Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial. Pediatrics.

Brent  DA, Baugher M, Birmaher B, Kolko DJ, & Bridge J. (2000). Compliance with recommendations to remove firearms in families participating in a clinical trial for adolescent depression. Journal of the American Academy of Child and Adolescent Psychiatry.

Carbone PS, Clemens CJ, & Ball TM. (2005). Effectiveness of gun-safety counseling and a gun lock giveaway in a Hispanic community. Archives of Pediatrics & Adolescent Medicine.

Grossman DC, Cummings P, Koepsell TD, Marshall J, D’Ambrosio L, Thompson RS, & Mack C. (2000). Firearm safety counseling in primary care pediatrics: A randomized, controlled trial. Pediatrics.

Grossman DC, Stafford HA, Koepsell TD, Hill R, Retzer KD, & Jones W. (2012). Improving firearm storage in Alaska native villages: A randomized trial of household gun cabinets. American Journal of Public Health. 

Rowhani-Rahbar A, Simonetti JA, & Rivara FP. (2016). Effectiveness of interventions to promote safe firearm storage. Epidemiologic Reviews.

 

Counseling Practices and Procedures

Betz ME, Kautzman M, Segal DL, Miller I, Camargo CA, Boudreaux ED, & Arias SA. (2018). Frequency of lethal means assessment among emergency department patients with a positive suicide risk screen. Psychiatry Research.

Betz ME, Knoepke CE, Siry B, Clement A, Azrael D, Ernestus S, & Matlock DD. (2018). Lock to Live”: Development of a firearm storage decision aid to enhance lethal means counselling and prevent suicide. Injury Prevention.

Betz ME, Miller M, Barber C, Beaty B, Miller I, Camargo CA, & Boudreaux ED. (2016). Lethal means access and assessment among suicidal emergency department patients. Depression and Anxiety.

Bryan CJ, Stone SL, & Rudd MD. (2011). A practical, evidence-based approach for means-restriction counseling with suicidal patients. Professional Psychology: Research and Practice.

Chang BP, Tezanos K, Gratch I, & Cha C. (2019). Depressed and suicidal patients in the emergency department: An evidence-based approach. Emergency Medicine Practice.

Pinholt EM, Mitchell JD, Butler JH, & Kumar H. (2014). “Is there a gun in the home?” Assessing the risks of gun ownership in older adults. Journal of the American Geriatrics Society.

Runyan CW, Becker A, Brandspigel S, Barber C, Trudeau A, & Novins D. (2016). Lethal means counseling for parents of youth seeking emergency care for suicidality. Western Journal of Emergency Medicine.

Runyan CW, Brooks-Russell A, & Betz ME. (2019). Points of influence for lethal means counseling and safe gun storage practices. Journal of Public Health Management and Practice.

Runyan CW, Brooks-Russell A, Tung G, Brandspigel S, Betz ME, Novins DK, & Agans R. (2018). Hospital emergency department lethal means counseling for suicidal patients. American Journal of Preventive Medicine.

Stanley IH, Hom MA, Rogers ML, Anestis MD, & Joiner TE. (2017). Discussing firearm ownership and access as part of suicide risk assessment and prevention:“means safety” versus “means restriction”. Archives of Suicide Research.

 

Training

Johnson RM, Frank EM, Ciocca M, & Barber CW. (2011). Training mental healthcare providers to reduce at-risk patients’ access to lethal means of suicide: Evaluation of the CALM Project. Archives of Suicide Research.

Sale E, Hendricks M, Weil V, Miller C, Perkins S, & McCudden S. (2018b). Counseling on Access to Lethal Means (CALM): An evaluation of a suicide prevention means restriction training program for mental health providers. Community Mental Health Journal. 

Simonetti JA & Brenner LA. (2019). Promoting Firearm Safety as a Suicide Prevention Strategy Within Health Care Systems: Challenges and RecommendationsPsychiatric Services.

Slovak K & Brewer TW. (2010). Suicide and firearm means restriction: Can training make a difference? Suicide & Life-Threatening Behavior. 

Slovak K, Pope N, Giger J, & Kheibari A. (2019). An evaluation of the Counseling on Access to Lethal Means (CALM) Training with an area agency on aging. Journal of Gerontological Social Work.

 

Patient Opinion and Culture

Betz ME, Azrael D, Barber C, & Miller M. (2016). Public opinion regarding whether speaking with patients about firearms is appropriate: Results of a national survey. Annals of Internal Medicine. 

Betz ME & Wintemute GJ. (2015). Physician counseling on firearm safety: A new kind of cultural competence. Journal of American Medical Association.

Forbis SG, McAllister TR, Monk SM, Schlorman CA, Stolfi A, & Pascoe JM. (2007). Children and firearms in the home: A Southwestern Ohio Ambulatory Research Network (SOAR-Net) study. Journal of the American Board of Family Medicine.

Knoepke CE, Allen A, Ranney ML, Wintemute GJ, Matlock DD, & Betz ME. (2017). Loaded questions: Internet commenters’ opinions on physician-patient firearm safety conversations. The Western Journal of Emergency Medicine. 

Marino E, Wolsko C, Keys S, & Pennavaria L. (2016). A culture gap in the United States: Implications for policy on limiting access to firearms for suicidal persons. Journal of Public Health Policy. 

Marino E, Wolsko C, Keys S, & Wilcox H. (2018). Addressing the cultural challenges of firearm restriction in suicide prevention: A test of public health messaging to protect those at risk. Archives of Suicide Research.

Walters H, Kulkarni M, Forman J, Roeder K, Travis J, & Valenstein M. (2012). Feasibility and acceptability of interventions to delay gun access in VA mental health settings. General Hospital Psychiatry.

 

Provider Attitudes and Beliefs

Becher EC & Christakis NA. (1999). Firearm injury prevention counseling: Are we missing the mark? Pediatrics.

Betz ME, Brooks-Russell A, Brandspigel S, Novins DK, Tung GJ, & Runyan C. (2018). Counseling suicidal patients about access to lethal means: Attitudes of emergency nurse leaders. Journal of Emergency Nursing.

Betz ME, et al. (2013). Lethal means restriction for suicide prevention: Beliefs and behaviors of emergency department providers. Depression and Anxiety.

Cassel CK, Nelson EA, Smith TW, Schwab CW, Barlow B, & Gary NE. (1998). Internists’ and surgeons’ attitudes toward guns and firearm injury prevention. Annals of Internal Medicine.

Everett SA, Price JH, Bedell AW, & Telljohann SK. (1997). Family practice physicians’ firearm safety counseling beliefs and behaviors. Journal of Community Health.

Grossman DC, Mang K, & Rivara FP. (1995). Firearm injury prevention counseling by pediatricians and family physicians: Practices and beliefs. Archives of Pediatrics & Adolescent Medicine.

Roszko PJD, Ameli J, Carter PM, Cunningham RM, & Ranney ML. (2016). Clinician attitudes, screening practices, and interventions to reduce firearm-related injury. Epidemiologic Reviews.

Shaughnessy AF, Cincotta JA, & Adelman A. (1999). Family practice patients’ attitudes toward firearm safety as a preventive medicine issue: A HARNET Study. Harrisburg Area Research Network. Journal of the American Board of Family Practice.

Webster DW, Wilson ME, Duggan AK, & Pakula LC. (1992). Firearm injury prevention counseling: A study of pediatricians’ beliefs and practices. Pediatrics.

Other Resources

Department of Veterans Affairs’ Rocky Mountain MIRECC’s (Mental Illness Research, Education and Clinical Centers) Lethal Means Safety & Suicide Prevention resource page

The Educational Fund to Stop Gun Violence’s resource page on lethal means safety counseling

This page was last updated on August 1, 2019.