I have a patient who may be at risk for suicide and I know the patient owns a gun. What can I do?
This is a great question and increasing safety in order to prevent suicide is vital. Increasing safety, or means restriction, in general, includes removal of any method by which a patient is considering a suicide attempt, however in the military the most pertinent factor is firearms.
Suicide deaths by firearm are the most common method among active-duty personnel, accounting for approximately 68 percent of suicides in 2014, according to that year’s Department of Defense Suicide Event Report (DoDSER). Firearms are also the most consistently lethal method of attempting suicide. For these reasons, military mental health providers must be ready to address this issue.
Removal of firearms from at-risk patients has been demonstrated to reduce suicide attempts and likelihood of death by suicide in nearly every study conducted. Further, temporarily limiting access to firearms has not been linked to an increase in suicides by other methods; rather, the temporary removal of firearms may create the time and space for your patient to consider healthy alternatives and receive targeted intervention.
How do I actually limit access to firearms with military personnel?
Step 1: Know whether or not your patient has access to firearms. If there are safety concerns, health care professionals are specifically authorized to inquire about currently owned firearms and plans to acquire firearms and other weapons per Section 1057 of the 2013 National Defense Authorization Act and a 2014 memorandum from the under secretary of defense.
Questions to ask your service member patient include: Do you use a firearm in line with your duties? How many private weapons do you have? Where are they kept? Who has access? If secured, how are they secured? Do you have a gunlock or weapon safe? Do you store ammunition with your weapon(s)? Do you live in military or private housing?
Notably, firearm ownership may be an important component of many service members’ personal and professional identities. This conversation should be undertaken with this cultural awareness. As with many topics in mental health, the more comfortable you are as a provider in having the discussion, the more valuable the discussion will become.
Step 2: Temporary restriction of access to service weapons for active-duty personnel. This step is fairly straightforward. If a safety concern exists, the command can and should be notified, and access will be restricted. The command can restrict access to service weapons in line with general duties as well as training environments (e.g. range, field training, deployment build ups). However, in military suicides by firearm, more than 90 percent (2014 DODSER) were completed using a personal firearm – not a service weapon.
Step 3: Temporarily limiting access to personal weapons for active-duty members. Explain the recommendation and ask the service member to temporarily give up access to their weapons. If introduced as temporary and as a safety precaution, you may find most service members will be receptive. A plan should be established to verify restriction of means, and equally as important – how and when the service member will get their weapons back (see Step 5). Effective plans can include a partner locking away firearms, transfer of firearms to a relative’s home, and preferably, command involvement to store firearms in the command or installation armory.
Additionally, means restriction should not be considered an all-or-nothing proposition (i.e., complete access versus zero access). If a service member usually keeps his or her firearm loaded on a nightstand with the safety disengaged, a compromise might be keeping it unloaded and secured in a personal safe. Even this moderate delay in access could decrease the likelihood of suicide behavior. Removing all access is preferable for safety, but delaying access should be a consideration when exploring options with a service member.
Step 4a: High-risk service member refuses clinical requests for means restriction and lives on a military installation. On all military installations, the commander has the ability to restrict or remove firearms. Notifying the command can lead to removal of personal firearms by the command if warranted. These firearms will be stored in the command or installation armory until they are returned.
Step 4b: High-risk service member refuses clinical requests for limiting access and lives in private housing. This step will vary based on the state in which you currently reside. Each state has different laws regarding safety and access to firearms. It is best to familiarize yourself with your local options before you find yourself needing to use them. Regardless of which state you live in, the command retains the authority to require the service member to move onto the installation. See Step 4a if this option is used to limit access to firearms.
Note: Engaging authorities (civilian or military) to forcibly remove access to firearms likely will have an immediate, adverse impact on the therapeutic relationship. These steps should be considered, based on clinical judgment, for high-risk situations with the understanding that repairing the therapeutic relationship may be significantly challenging following this intervention. Suicide risk and access to firearms is obviously a very complicated situation.
Step 5. Return of weapons. This step is often the most overlooked step in the process of limiting access to firearms – how is access to the firearm(s) returned to the service member? Whether a family member, partner, friend or command is involved in the plan to temporarily limit access, you as the provider are the common denominator. You made the recommendation to restrict means and therefore the responsibility for planning the return also falls with you. A plan to return means, in which you are directly and collaboratively involved, is necessary to avoid potentially dangerous consequences for the service member as well as significant guilt and emotional consequences for the individual who returned the weapon (in the case of an adverse event). Established and agreed upon safety benchmarks between you and the service member will ensure this process is not overlooked and will be completed safely. Additionally, collaborative planning for the return of personal weapons likely will improve the therapeutic relationship and reduce the possibility that they may acquire another firearm without your knowledge.
These steps are meant as a guideline. They are not the only options, but they provide a framework from which to consider your plan for safe and legal means restriction. Good clinical judgment, peer consultation and consultation with your local judge advocate general (JAG) should always be used in complex situations. Good cultural competence regarding firearms is also highly encouraged – it’s not a topic you want to learn on the job when a patient’s safety is in question.
Find information and resources regarding suicide prevention in the military from the Defense Suicide Prevention Office.
Providers can enroll in CALM: Counseling on Access to Lethal Means training provided by the Suicide Prevention Resource Center.
The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Deployment Health Clinical Center or Department of Defense.