Having the Gun Conversation with Patients and Families

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James D. Fouts, LSW

April 12, 2017

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About 33,000 people die from gun violence in the United States each year.  Of those, 21,000 are due to suicide.  Most studies indicate that after removing suicide from the equation, only 4-5% of all gun deaths are caused by someone with a diagnosis of mental illness.  

Firearms account for 57% of all suicides.   First suicide attempts with firearms are about 85% fatal, whereas only 2% of first attempts by self-poisoning are fatal.  The impulsive nature of some suicide attempts and the lethality of firearms make for a very dangerous combination for those at high risk for suicide.  Over half of the people who have survived an attempt report making the decision to die within an hour of the attempt. Many report making the decision within 5 minutes of the attempt.  Putting distance and time between the patient and a firearm can go a long way in saving a persons’ life.  

Using clinical skills to assess for suicide risk is only part of what it takes to keep patients safe.  Intervening during those high risk times is also necessary.  Discussing issues related to lethal means should be a part of any suicide assessment and intervention.  Many doctors have techniques for assisting patients and families regarding safely managing medications.  Studies however, indicate that many physicians are reluctant to discuss firearms.  Many doctors will not broach the subject with families or patients due to a false belief regarding prohibitions, a fear that it will alienate the patient or that they are just plain uncomfortable with the subject.  

Every step you put between a person and a firearm decreases the risk of suicide and homicide.  Keeping a gun unloaded decreases the risk by 10%.  Keeping it locked and unloaded decreases it another 10%, and keeping it locked, unloaded and stored separately from the ammunition decreases it another 10%.  Having the gun conversation should be a basic part of any suicide risk assessment and intervention.  

Patients or families may refuse to remove or adequately secure a firearm in the home.  The clinician may want to consider how that refusal increases the risk and the level of your response to that risk.  The most common argument against removing firearms is that they are needed for self-defense.  This is the time to remind the person that at times of high risk; the source of safety they may be depending on can become the greatest risk for death.  

When choosing to have the “gun conversation” here are some things to think about.  Many of these ideas come from the MEANS MATTER CAMPAIGN out of the Harvard T.H. Chan School of Public Health

1. Speak to the person about your concerns and get permission to speak to their family or concerned others
2. Explain your concern to the family about the risk for suicide
3. Ask if there are firearms in the home and explain that the presence of firearms increases the chances that a suicide attempt will be fatal
4. Ask about all firearms (The average home that has firearms has at least 3.) 
5. Ask about all homes that the patient has ready access to
6. Advise the family and patient clearly that the safest option is to remove firearms from the home until the situation improves

Options for storing firearms outside the home:

• Law enforcement may be able to store them or dispose of them (Check with them regarding their policies.  They may not do this or may require a letter from a clinician that the person is safe to have them back.)
• Store them where they can be locked at a trusted relative or friends house
• Many storage facilities allow the storage of unloaded firearms
• Some gun shops, gun ranges or gun clubs will store firearms for a fee
• Pawning the guns for a small loan amount and paying the loan and interest charge to retrieve them
• Storing the ammunition away from the home may be another option, but remember that ammunition can be easily purchased

Some people will not allow the firearms to be removed from the home.  Listed below are some options for storing the firearms at home.    

• Lock all firearms in a gun safe or lock box –unloaded and separate from ammunition.  
• A firearms dealer will advise you about the best gun safe to purchase.  Safes range in price from $35 to $3,000.  
• When using a digital gun safe or lockbox be sure to change the combination so that the person at risk cannot access it.
• Store the trigger lock or cable lock keys where the at risk person does not have access to them.  (Remember that most people living in the same household know the hiding places of each other.)  Many Police Departments will provide locks for free.