Recommendations for Clinicians
Lethal Means Counseling
If you’re concerned that a patient or client is suicidal, in addition to using your standard clinical strategies to assess and manage suicidal risk, talk with them and their family members about whether there are firearms and other lethal means at home. (Need to brush up on your standard clinical strategies to assess and manage suicidal risk? Click here for info on workshops.)
Speak with the Client’s Support Person (e.g., parent, spouse, friend)
If the client is an adult, follow your agency’s protocols regarding gaining the client’s permission to contact a family member or other support person.
- Explain that you’re concerned their loved one is at risk for suicide. If the patient has attempted suicide or disclosed suicidal thoughts, let the support person know that there are steps they can take to make the home safer should the person attempt suicide in the future. If the patient has not disclosed suicidal thoughts but is struggling a great deal, explain that suicidal thinking can sometimes emerge and that it may be prudent to take some safety steps at home.
- “When it comes to suicide, the most lethal method of attempt (and death) is firearms, and the most common method of attempt (but not death) is medications. So let’s start there.”
- Raise the topic of guns at home. Rather than asking directly, which may feel intrusive and raise fears about losing their gun rights, consider other approaches like, “What some families in your situation do is store their guns away from home until the person is feeling better, for example with a relative or at a gun shop or self-storage rental. If you have guns at home, I’m wondering if you’ve thought about a strategy like that.” This way you’ve let them know that you are talking about strategies that are under their control. You’re not questioning their decision to have guns, you’re simply addressing short-term storage options to protect the patient during this vulnerable period.
- When assessing firearm access with parents of a patient who is a minor, try to speak with the gun-owning parent. Often clinicians speak with the mother. But it is often the male partner who knows how the guns are actually stored and controls the storage decisions.
- Ask about all firearms. If there’s one gun, there’s usually more than one.
- Assess each relevant household (e.g., for a teenager in a joint custody situation, ask about both parents’ homes).
- Advise that the safest option is storing firearms away from home until the situation improves. Options include:
- Relative or friend – Storing the firearms with a trusted friend or relative may be an acceptable option to the owner. Not everyone can hold on to firearms, however. See summary of federal laws regarding people prohibited from receiving firearms. Also see summary of state laws that may constrain temporary firearm transfers.
- Gun shops and shooting ranges sometimes offer storage services. Gun shops sometimes do this for a fee, and a few specialize in the service. Others sometimes do it for regular customers as a courtesy. Depending on the storage arrangement, you may need to go through a background check to retrieve your guns. Some shooting ranges and sportsmen clubs offer locker rental services for storing guns. These don’t require a background check for retrieval.
- Pawn shops – Pawning guns for a small loan is one way to store guns in most states. Typically you pay a 15-20% monthly interest fee. When you’re ready to get your guns back, you repay the loan and go through a background check. This option and self-storage rentals may not be good options if money is tight, as inability to keep up with monthly charges risks forfeiture of the guns.
- Self-storage rental units – Most allow unloaded firearms. Monthly rental costs depend on size of the unit and whether they are climate controlled.
- Local law enforcement may be able to store the guns. Not all agencies provide this service. See: Questions about Removing or Storing Firearms
- Sympathize with gun owners who find the option of living without a firearm at home, even temporarily, very difficult. Don’t minimize that this is a tough sacrifice. You’re all on the same team trying to keep the patient safe. But be firm that the safest option is keeping guns out of a suicidal person’s home.
- What if off-site storage isn’t an option? Not everyone is comfortable storing their guns away from home, especially if they keep one or more for self-defense. And some people’s collections are too large to move. Options:
- Lock the firearms and ensure the person at risk has no access to the key/combination. This is second best compared with away-from-home storage because keys and combos can be found and locks thwarted. Lock all firearms unloaded in a gunsafe or in a tamper-proof, lockbox. Lock the ammunition separately. Better yet, advise the family not to keep ammunition at home until the situation improves.
- Another option: disassemble the guns and store a critical part like the slide or firing pin locked or away from home.
- Hiding unlocked guns is not advised. Family members–especially kids– tend to know one another’s hiding places.
- Some self-defense owners will find locking an unloaded gun unacceptable. Help them think through how to weigh the risks of suicide vs. other threats to the family’s well-being during this time of elevated suicide risk. Some will opt to store a loaded gun in a quick-release handgun safe that only they have access to.
- Make the plan as specific as possible with timeline and roles (e.g., “Let me summarize what I’ve heard: you’ll hold onto the keys to your husband’s guns for now, and tomorrow his brother will pick them up. You’ll email me to confirm this has happened.”)
- Document the plan in your notes.
- Follow-up to ensure that the plan was enacted.
- Don’t limit your conversation to lethal means. Lethal means counseling is only one part of a comprehensive approach to activating the client’s support system.
- Safely dispose of unused, expired, and unwanted medications.
- Lock abuse-prone medications like opioids (prescription pain pills), anxiety pills, muscle relaxants, amphetamines, sedatives, and barbiturates.
- Keep small quantities of those medications the family needs on hand. Lock the rest. The goal is to limit medicines on hand to a quantity that even if taken together would not cause serious harm.
- A pharmacist can advise on specific medications and quantities. For example, if the patient is at risk for overdose but must take a regular prescription, they may be safer with weekly or monthly refills
Counseling the Adult Client
- Express your concerns about his or her safety and your wish to keep them safe.
- For patients who have struggled with suicidal thoughts, work with them on a safety plan to recognize when things are escalating and to practice ways to make it through spikes in suicidal thinking safely.
- Consider delivering the firearm safety message and creating a safety plan even if your patient is not currently feeling suicidal but they are clearly struggling with a very difficult mental health or substance abuse issue, –especially when there are other life crises compounding their pain, like a relationship break-up, major argument, arrest, job loss, etc.
- Sample language: “I’m glad to hear you’re not feeling suicidal. I do want to mention this though. Sometimes a crisis hits and people who are already struggling suddenly experience strong suicidal feelings. Those feelings often go away in a matter of hours or days, but they can feel overwhelming. If a period like that hits, I want to be sure you make it through safely and call for help. One step would be to store your guns away from home until you’re feeling better.” Continue with other steps of basic safety planning as well.
- Get releases to talk with a spouse, partner, or other support person. Enlist them in keeping lethal means out of the home and providing other support.
- Help the client understand that risk sometimes escalates rapidly – for example right after a fight with a family member. Not having lethal means quickly at hand is like keeping the keys to the car away from a person who’s been drinking. It reduces bad outcomes in volatile situations.
- Review the firearm and medication storage information listed above and collaborate on a plan.
- If your patient is the gun owner
- Storing the guns away from home is still the safest option. Review the storage options listed above.
- In-home locking is also an option, but provides little protection if the patient holds the key. Will s/he consider having a support person change the locks, hold the keys, or change the combination to the safe?
- For gun owners who are loathe to hand over the keys to someone else, anything that puts time and distance between them and the guns will help. For example, keeping the keys to their gunsafe in a bank safe deposit box, means they still control access, but they don’t have immediate access during a mental health crisis. (These are relatively inexpensive – often about $50/year.)
- Collaborate on specific plans, assign roles and timeline, document the plan in your notes, and follow-up at the next appointment or earlier.
- Assess suicidal risk on an ongoing basis; things can improve or deteriorate rapidly.
- Note: Most people who kill themselves (except with pills) do so on their first attempt. Many never sought treatment for suicidal feelings. As a clinician, you may come into contact with them over some other issue–marriage counseling, court-remanded anger management, substance abuse treatment, etc. This underlines the importance of including suicide assessment with all clients.
Also see Frequently Asked Questions.