Lethal Means Counseling for Suicidal Firearm Owners

Journal of Contemporary Psychotherapy https://doi.org/10.1007/s10879-023-09588-5 ORIGINAL PAPER Lethal Means Counseling for Suicidal Firearm Owners Samuel Knapp1 Accepted: 26 May 2023 © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023 Abstract The death of a patient by suicide is one of the professional events most feared by psychotherapists and firearms are the most commonly used means of suicide. However, as the number of firearm owners within the United States has increased in recent years, so has the risk of firearm-related suicides. Suicidal patients with easy access to their firearms may give in to the wish to die and end their life with little opportunity for reflection or forethought. Furthermore, because the topic of gun control has become so polarized, patients may not always be open to discussing barriers between themselves and their firearms. Nonetheless, psychotherapists using non-judgmental, respectful, and collaborative lethal means counseling can substantially reduce patient suicides. Keywords Suicide prevention · Lethal means counseling · Means safety counseling · Firearms Psychotherapists can expect to deal with suicidal behavior in their careers. A 2020 survey found that in the last year, 6% of psychologists had a patient die from suicide while in treatment and 29% had a patient attempt suicide while in treatment (Leitzel & Knapp, 2021). The CDC listed suicide as the 10th most common cause of death in the United States in 2019 (Xu, et al., 2021). Various psychological, social, cultural, biological, and environmental factors contribute to suicide, including access to firearms and other means of killing oneself. Firearms are used in about 50% of all suicides in the United States (Ehlman, et al., 2022). On its face, temporarily removing easy access to firearms among those who have a high risk of suicide appears to be a sensible way to reduce suicides. However, the topic of limiting access to firearms has become highly polarized and many patients may not wish to discuss such options with their psychotherapists. Fortunately, data on lethal means counseling suggests that psychotherapists can introduce firearm safety in a manner acceptable to most firearm owners and that doing so can help save lives. Samuel Knapp 1 Sunnyvale, California, US Background on Firearms and Suicide Persons commonly attempt suicide by firearms, overdoses (e.g., recreational or prescription medications), suffocation (e.g., drowning or hanging), or jumping. The use of firearms warrants special attention because almost 90% of attempts by firearms result in death, compared to between 3.2% (Han, et al., 2016) and 8.5% for attempts by all methods combined (Conner, et al., 2019). Those who attempted suicide with a firearm were far more likely to die at their first attempt compared with those who attempted suicide by other means (Ammerman & Reger, 2020; Anestis, 2016), in part because firearms allow little time to change one’s mind or to be rescued by others. Firearms were used in only 5% of all suicide attempts (Wang, et al., 2020), yet accounted for 50% of all suicides (Ehlman, et al., 2022). White Americans and males have higher rates of firearmrelated suicides. Nonetheless, access to firearms increases the risk of suicide for all persons regardless of their race or gender. Although men use firearms in their suicide attempts more frequently than women, women using firearms were just as likely to die in their suicide attempts as men (Bostwick, et al., 2016). About 32% of Americans own firearms and 44% live in a household with firearms (Saad, 2020), although firearm ownership has increased substantially since the COVID-19 pandemic (Miller, et al., 2022a). Firearm ownership rates vary across the United States with higher rates of ownership 13 Journal of Contemporary Psychotherapy in Southern or Mountain states and lower rates in the Northeastern states (Miller & Azrael, 2022). Rates of regional firearm ownership paralleled rates of regional firearmrelated suicides. For example, New York City, where firearm ownership is low, had 1.4 firearm-related suicides per 100,000. In contrast, Oklahoma City, where firearm ownership is high, had 13.4 firearm-related suicides per 100,000 (Kegler, et al., 2022). Firearm owners do not have high rates of suicidal ideation but do have high rates of suicides. Firearm ownership does not increase the risk of suicide for healthy people, but it does increase the risk of suicide for those who have suicide risk factors (Anestis & Capron, 2018). Firearm ownership increases the risk of suicide for all persons in the household, not just the primary weapon owner. The rate of suicide by firearms among women significantly increased after their co-inhabitants became handgun owners (Miller, et al., 2022b). Adult men used their own weapons for suicide 88% of the time, adult women used their own weapons 52% of the time, and youth (ages 18 to 20) used their own weapons 42% of the time (Barber, et al., 2022b). In households where parents said their children could not access their firearms, 21% of the adolescents claimed they could access the firearms in 5 min or less (Salhi, et al., 2021). Case Illustration1 Fred, a 50-year-old divorced US Army veteran, has become alienated from his ex-wife and children. Following a recent job layoff, he started to experience suicidal thoughts and developed a plan to kill himself using a firearm in his house that he has kept for personal safety. Upon the insistence of the team leader where he used to work, Fred has agreed to meet with a psychotherapist, even though he had some misgivings. However, during the first meeting, he developed a connection with his psychotherapist, Dr. Rodriguez. Dr. Rodriguez was pleased with his insight and openness to psychotherapy but she also noted that Fred’s suicidal thoughts appeared to fluctuate rapidly. Also, Fred stated that, if he were to kill himself, he would use a firearm, although he had not yet thought through other details of his plan, such as the time or location. Dr. Rodriguez worried that Fred might act on his suicidal impulses and shoot himself during one of his dark moods. 1 This is a composite and is not based on any one patient. The comments attributed to the participants in the case illustration are realistic representations of discussions in lethal means counseling 13 Fortunately, Dr. Rodriguez can significantly reduce the likelihood of a suicide attempt by engaging in lethal means counseling (sometimes referred to as means safety counseling), which attempts to create a barrier between patients and their preferred means of suicide. Lethal means counseling is based on the findings that the acute suicidal state is time limited and that patients will not find other ways to kill themselves before the suicidal crisis state has ended. Evidence of the effectiveness of lethal means counseling comes from studies of patient (...truncated)