Lethal Means Counseling

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In the context of suicide prevention, “lethal means counseling” means:

  • assessing whether a person at risk for suicide has access to a firearm or other lethal means, and
  • working with them and their family and support system to limit their access until they are no longer feeling suicidal.

Imagine two case scenarios:

  • Case 1: A 20-year-old with a drug problem moved back in with his parents after his girlfriend broke up with him. When he stopped going to work, his parents contacted a mental health center and urged him to see a counselor. He refused. He called his girlfriend hoping to get back together, but she wouldn’t speak to him. He felt desperate. He went to his father’s gun cabinet, removed a loaded gun, and shot himself in the head. He died within seconds.
  • Case 2: A 20-year-old with a drug problem moved back in with his parents after his girlfriend broke up with him. When he stopped going to work, his parents contacted a mental health center and urged him to see a counselor. He refused. He called his girlfriend hoping to get back together, but she wouldn’t speak to him. He felt desperate. He went to his father’s gun cabinet, but the guns were gone. He found a razor and cut his wrists. His parents found him an hour later and brought him to the hospital where he was treated and agreed to get help.

What was the difference between the two cases? In the second case, when the parents expressed concern that their son might be suicidal, the counselor not only spoke about ways to get help but asked about guns at home and suggested they be stored elsewhere until the situation improved.

Questions and Answers

Don’t Clinicians Already Ask about Lethal Means?

Often, no.

  • Grossman and colleagues reported that although 80% of emergency nurses in Illinois had recent experience with suicidal adolescents, only 28% provided education on means restriction to parents.
  • A study by McManus et al. interviewed parents or other caretakers whose adolescent had deliberately overdosed. Only 12% of those with medications at home and none of those with firearms at home reported receiving counseling from emergency department personnel about the importance of restricting the adolescent’s access to lethal means. Those who did receive such education were more likely than those who did not to restrict access.
  • A record review found that psychiatric residents at a psychiatric emergency department assessed firearm access in only 3% of pediatric patients (Giggie 2007). And a survey of psychiatrists found that half had never seriously considered assessing firearm access among their patients (Price 2007).

Does Lethal Means Counseling Change Behavior?

A program that trained emergency department providers to counsel families of youths at high risk for suicide on restricting access to lethal medications, alcohol, and firearms at home is listed on the SPRC’s evidence-based registry. Among families of high risk youth, those who received the counseling were significantly more likely than those who had not to remove or secure the items. See: Evaluation of Emergency Department Lethal Means Counseling

Is Lethal Means Counseling Acceptable to Providers and Prevention Groups?

An evaluation of the CALM workshops in New Hampshire (Counseling on Access to Lethal Means) found that the trainings have been well-received by the majority of trainees. The Harvard survey of state leaders in the suicide prevention movement found that 71% rated training on means reduction strategies as a high or very high priority (the second highest training need after training on evidence-based interventions). The CALM workshop was presented to a state firearm safety coalition; representatives from gun manufacturers and gun owner groups on the coalition found the workshop content acceptable and largely non-controversial.

Who Should Conduct Lethal Means Counseling?

Anyone who comes into contact with people who are feeling suicidal. This includes mental health providers, but many people who feel suicidal do not go to a psychiatrist or counselor – or, if they do, they may be there for other reasons like to shore up a failing marriage, cope with a gambling problem, attend court-ordered anger management sessions, etc. A wide array of providers may come into contact with suicidal people: police officers, school personnel, youth detention workers, corrections personnel, defense and divorce attorneys, leaders of grief support groups, emergency department and other health professionals, and so on.

Click here for information on how to conduct lethal means counseling.

 


 Giggie MA, Olvera RL, Joshi MN. Screening for risk factors associated with violence in pediatric patients presenting to a psychiatric emergency department. J Psychiatr Pract. 2007 Jul;13(4):246-52.

Grossman, J. Dontes, A., Kruesi, M., Pennington, J. & Fendrich, M. (2003). Emergency nurses’ responses to a survey about means restriction: an adolescent suicide prevention strategy. Journal of American Psychiatric Nurses Association, 9, 77-85.

McManus, B.L., Kruesi, M., Dontes, A.E., DeFazio, C.R., Piotrowski, J.T., & Woodward, P.J. (1997). Child and adolescent suicide attempts: an opportunity for emergency departments to provide injury prevention education. American Journal of Emergency Medicine, 15, 357-360.

Price JH, Kinnison A, Dake JA, Thompson AJ, Price JA. Psychiatrists’ practices and perceptions regarding anticipatory guidance on firearms. Am J Prev Med. 2007 Nov;33(5):370-3.