The following is an excerpt from a section we’re developing in our strength-based suicide assessment and treatment book. Check it out and provide feedback if you like.
Lethal Means Restriction (Safety)
Firearm availability or easy access to other lethal means is significantly linked to death by suicide (Bryan & Rudd, 2018). Access to lethal means is especially important because acute suicidal crises tend to be brief. If guns, razor blades, pills or other means are not immediately accessible, the crisis may pass without an attempt occurring. Summarizing pertinent research (Simon et al., 2001), Bryan and Rudd noted:
The final decision regarding the suicide attempt method typically occurs approximately 2 hours prior to the attempt, the final decision regarding the location of the attempt typically occurs approximately 30 minutes prior to the attempt, and the final decision to act typically occurs approximately 5 minutes prior to the attempt (p. 143).
Given that intense suicidal impulses usually pass quickly, limiting easy access to lethal means may be one of the most effective interventions available.
Bryan and colleagues (2011) published an article on how to engage clients who are suicidal in “means-restriction counseling.” As they noted, mental health professionals are expected to talk with clients about locking up and removing lethal means for suicide. However, little practical advice on how to do so is available (other than articles by Britton et al., 2016 & Bryan et al., 2011).
Early in her session with her counselor, 15-year-old Sophia (chapter 4), made it clear that she knew where her father kept the family’s guns. Although the counselor didn’t feel the need to immediately respond to her statement, as they worked on a collaborative safety plan later in the session, lethal means restriction came up for discussion:
Counselor: Sophia, we need to talk about a big issue that’s related to your safety. Is it okay with you if I just bring it up right now?
Counselor: When people are suicidal, guns are the most dangerous thing to have in the house. Because my biggest goal is to keep you safe, we need to talk about how to lock up the guns or get them out of the house.
Sophia: My dad will completely freak about that.
Counselor: That’s okay. Lots of people have strong feelings about keeping guns in their homes. Don’t worry about talking with your dad, because I can do that. I want to keep you safe, but also respect your dad’s rights.
Sophia: Yeah. No way am I bringing that up.
Sophia’s reluctance to bring up gun safety with her father is natural. Her clear statement, “No way am I bringing that up,” means that bringing up gun safety is the counselor’s responsibility—as it should be.
Although phone conversations about gun safety with parents or family members may be helpful, we prefer a face-to-face contact when possible. In our experience, the best approach is to be direct, straightforward, and matter of fact. The core message is that because often suicidal impulses briefly escalate but then subside, all highly lethal methods should be locked away or removed.
Bryan and colleagues (2011) recommended presenting options for restricting firearms access. They presented options such as completely removing the means from the home by disposing of it or giving it to a supportive person. They noted you can also have clients lock up the means and give the key to a supportive person, or dismantle the firearm and give a critical piece to a supportive person (Bryan et al., 2011, pp. 341-342).
Discussing firearms during counseling sessions can result in instant escalation and polarization. Preparation helps. We recommend the following:
- Be prepared talk about firearm safety. Talking directly about firearm safety is one of the most effective methods you have for reducing risk.
- Keep a laser-focus on safety; avoid using the word “restriction.” Your discussion isn’t about restrictions on firearms or gun rights. Your discussion is about safety.
- If it feels helpful, say, “I support your second amendment rights.” Conversations about firearms in the context of suicide prevention don’t need to be political.
- As needed, state unequivocally, “I want to respect your right to own your guns . . . AND I want you (or your daughter) to be safe and to live a long and fulfilling life.”
- Brainstorm different methods for enhancing safety. Recognize that there are two general approaches to gun safety: (a) removing firearms from the premises and (b) creating obstacles to impulsive use of firearms during a suicidal crisis (e.g., trigger locks, gun safes). Although removing guns is the safest alternative, creating obstacles is a reasonable alternative. You may want to conduct your brainstorming with the parent, client, essential support person, or all of the above.
- Remember that because there’s no single perfect safety solution and because nearly everyone is more agreeable if they participate in a decision-making process, less directive procedures like Socratic questioning and motivational interviewing may be preferable.
If you’d rather not be boldly direct about gun safety, consider using Socratic questions to help clients come to their own conclusions. Bryan and Rudd (2018) recommend questions such as, “What do you think about someone having access to guns when they’re really upset and are suicidal?” “What might be some benefits of temporarily limiting your access to firearms?” “If complete removal of the guns is not possible, what are some other options for practicing good gun safety while you’re going through this treatment?” “What do you think about putting together a plan for this?” (p. 148).
Motivational interviewing (MI) is another less-directive method for discussing firearms safety. Keeping in mind the core principle of MI—that clients should be the ones making the case for change—clinicians can use open-ended questions, reflections, affirmation, and other technical strategies to increase firearms safety (Miller & Rollnick, 2013). The following short exchange is excerpted from an extended case example where a veteran has refused to remove his firearms, and so clinician is using MI to elicit talk around adding obstacles to enhance safety (see Britton et al., 2016, pp. 56-58, for the full case example).
**To be continued**