Hello and welcome. I'm Amy Cohen, a clinical psychologist and the director for SMI Advisor. I am pleased that you are joining us for today's SMI Advisor webinar, Lethal Means Counseling for Suicide Prevention. Next slide. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Next slide. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians, one Continuing Education Credit for Psychologists, one Continuing Education Credit for Social Workers, and one Nursing Continuation Professional Development Contact Hour. Credit for participating in today's webinar will be available until June 21, 2022. Next slide. Questions from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the questionnaire found in the lower portion of your control panel. We'll reserve a few minutes at the end of the presentation for Q&A. Next slide. And now I'd like to introduce you to the faculty for today's webinar, Dr. Craig Bryan. Dr. Bryan is the Stress, Trauma, and Resilience Professor of Psychiatry and Behavioral Health at The Ohio State University Wexner Medical Center and is the Division Director for Recovery and Resilience. He has served as the Lead Risk Management Consultant for the Strong Star Research Consortium and the Consortium to Alleviate PTSD, which investigates treatments for combat-related PTSD among military personnel. He is a wonderful colleague of mine, and thank you, Dr. Bryan, for leading today's webinar. All right. Well, thanks, Amy, for the introduction, and thanks as well for the invitation to join you all today for a brief amount of time to provide what I hope is kind of like a 30,000-foot view or introduction to the concept of lethal means counseling and walk you through some of the approaches that we have been developing and testing in my research program over the past few years. To begin, several disclosures. I have a number of grants that are related to the topic focused on firearm access as well as lethal means counseling from several different sponsors. I also have equity in a company that's designed for trainings and workshops on this related topic and other suicide prevention topics. Today, I'm hoping to accomplish a handful of objectives, first of which is recognizing several key assumptions that underlie the rationale, in essence, for lethal means counseling, determining the empirical support for lethal means counseling, and then finally helping you to incorporate lethal means counseling in a clinical practice using a four-phase approach. Let's begin with some basic concepts. Now, I guess I want to start before diving in with just one kind of quick caveat or, I guess, sort of housekeeping type of item, which is that the topics that I'm going to be talking about today apply to pretty much any method for suicidal behavior. I will note that I am going to spend a little bit more time and focus on firearms in particular, the reason being is that, first, it's one of the most highly lethal methods for suicidal behavior, but secondly, what we know from clinicians and practitioners is that of all of the different possible methods that could be used for suicidal behavior, firearms is the one method that often provides the greatest anxiety and uncertainty for healthcare professionals. I just want to kind of couch our time here together to say that I don't want you to walk away feeling as though this is only applicable to firearms with suicidal patients. It is generalizable to all methods, even though we will spend a little bit more focus on the particular method of firearm. Now as kind of a starting point, we can think of suicide prevention as being approached from two different angles or directions, the first of which is to prevent people from attempting suicide. The idea here being that if we can stop people from trying to kill themselves, then they are less likely to die as a result of that behavior. And I would argue that this first approach underlies most of what we do in suicide prevention, especially within the clinical realm, where in essence, we're trying to interrupt or somehow avert that forward momentum towards the decision to make a suicide attempt in the first place. But I want to highlight that there's actually a second way that we can prevent suicide, and that is by reducing the lethality of suicide attempts. And so what this means is that although there's certainly a great deal of merit in trying to stop people from trying to kill themselves, I think the reality is that we will not be able to stop everyone from engaging in such behaviors. And so under those circumstances, we need a plan B. We need a way to increase the likelihood that somebody survives a suicide attempt. And through this approach, we can actually reduce suicide rates at a population level, even though we maybe have not prevented suicidal behaviors from occurring. This is very similar and consistent with injury prevention models as a whole. For example, traffic crashes, where we want to take steps to prevent people or reduce the probability that we get into car crashes in the first place. But given that car crashes are sometimes going to occur despite our best efforts, we want other alternatives in place to increase survival should a car crash occurs. This is like the whole logic behind seatbelts and airbags, for example. Now, when it comes to the specific concept of lethal means counseling, the rationale for this particular procedure, which I would argue facilitates the second goal, improving survival rates after a nonfatal suicide attempt has occurred, there are kind of three key ideas that sort of bolster why we would want to be doing this. Now, the first of which is that periods of acute suicidal distress tend to be very time limited in nature. Now, we've actually known this for a long time, and I like to deliberately use references and citations that are older because I think it's really important to recognize that this knowledge has been around for a long time, but I just don't think we have fully leveraged it and integrated this knowledge into clinical practice. Now, we know, for example, that of those who attempt suicide, if we interview them afterwards, say in an ED or an ICU or an inpatient unit, somewhere between 25 to 40% will say that they made the final decision to act, that they were going to do it only five minutes before they actually attempted suicide. If we expand that time horizon to about an hour, we see that 70% of suicide attempt survivors will report that they made that final decision within that one hour timeframe. And so in essence, the window of time between the final moment where they say, I'm going to do it, and then they actually act upon the suicidal impulse tends to be very brief. Now, this is really important because I would say the bedrock of most of our suicide prevention efforts really have focused on this notion of being able to reliably detect warning signs and to somehow interrupt that forward momentum by perhaps screening, assessing for risk, and referring somebody to treatment or mental health care. The majority of the time, the majority of suicidal behaviors don't often afford particularly long avenues or significant avenues for us to intervene. And so that speaks to the importance of coming up with these backup plans that can improve survivability even if we cannot avert or prevent a suicidal act from occurring. The importance of this rapid transition to high-risk states is further emphasized and clarified by recent work by Alex Milner, who interviewed a sample of psychiatric inpatients who had attempted suicide and used an interview approach that's very similar to the timeline follow-back procedure that's often used for substance use disorder research. In essence, what he found was that in some cases, individuals would first experience the onset of suicidal ideation many years or weeks before a suicide attempt, but that was not always the case. There was actually a lot of variability around the onset of ideation. But a key point that Milner's team found is that within about six hours of the suicidal act, there was this very rapid transition through a lot of suicide risk stages, beginning with ideation and then identifying the method, location, the time of the suicide attempt, and then finally that final resolution that I'm going to do it, I know I'm going to make it happen, again, occurs on average within five minutes of the suicide attempt. And so this exponential growth in risk has now been seen in multiple studies, which again highlights this important point that suicidal crises tend to occur rapidly and within very short periods of time. Now, second key assumption or rationale supporting the value of lethal means counseling is that additional suicide attempts are unlikely if a suicidal crisis is survived. So in essence, suicidal crises come fast. They can come in many ways seemingly unexpectedly or out of the blue. And so if we can keep a person alive through that brief window of time, there's a really good chance that we will prevent their suicide permanently. And so what is supporting this? About 75% of those who survive their first suicide attempt will never make a second suicide attempt. So the modal number of suicide attempts is just one. And likewise, if someone survives that first suicide attempt, there's a 90% chance that they never actually go on to die by suicide. And so I've got a quote here that I take from Mike Anestis, another colleague and collaborator of mine related to firearm suicide that I think is really kind of a key concept here, which is that when you prevent someone from attempting suicide using a specific method on a specific occasion, there's a very good chance that you have prevented them from ever attempting suicide by any method. So that survival of a first suicide attempt is actually really key. Second chances matter. And then the third key rationale supporting lethal means counseling is that easy access to a lethal method is the strongest determinant of suicide attempt outcome. And I think this is another really important point because we often focus on things like suicidal intent or severity of hopelessness or suicidal ideation, those sorts of things. And in essence, these various constructs that sort of speak to, you know, how badly or how much does a person desire suicide or death, we find that those indicators of intent and emotional distress are actually not very well correlated with attempt lethality. A couple studies here, for instance, found that when we looked at suicidal subjective intent, you see the correlation coefficient with medical lethality of the attempt is very low, you know, 0.05. Another study by Perkola and colleagues looked at the frequency of writing suicide notes and communicating suicidal intent prior to the attempt to others. And what they found was that the rate of this sort of pre-attempt communication of suicidal desire was fairly comparable, two thirds across every single method that was used, whether it was highly lethal or less lethal. And so these other proxy indicators of severity of suicide risk don't really actually seem to be correlated with outcome. Now we also see data from epidemiological research supporting this important role of access or availability of means being strongly correlated with attempt lethality. Research done in Pacific Island nations, for instance, where consumption or drinking of pesticides was at least at one time a leading method of suicide death, found that unsafe storage and accessibility of these pesticides were associated with lethal outcomes more so than depression and suicidal intent and other indicators of kind of a mental state. In particular, when the pesticides were stored inside a farmer's home, for instance, and not locked up, that was a particularly strong indicator or correlate of suicide death. Other research here in the U.S. looking at firearms and the relationship of firearm suicidal behavior with other indicators of intent have similarly found this sort of lack of association between our classic indicators of intent. In this study by Peterson and colleagues, again, notice how old the study is in many respects. We've known this for a long time. These were patients that they interviewed who sort of miraculously survived self-inflicted gunshot wound. They found that none of them had written a suicide note. And this is a shocking statistic for many. Less than half actually met criteria for a mental health diagnosis. I have a completely different sort of presentation to talk about that, but I think this sort of assumption, this sort of prevailing model of suicide as being caused by mental health conditions or mental illness is actually not particularly well supported. And we do have several lines of data showing that, for instance, firearm suicides are much less likely to be related to mental illness and mental health conditions. And that increased risk for firearm-related suicide, it disproportionately affects particularly adolescents and young adults without mental health conditions. So maybe we'll have time later to perhaps talk about that a little bit more. Just having a firearm in one's house doubles the risk that somebody living in that house is going to die by suicide. And as I alluded to just a little while ago, the risk seems to be increased the greatest amount for occupants of the house who do not have mental health conditions. There's research now even showing that how somebody stores or locks up a method such as a firearm can influence the nature of their suicidal thinking. In this study by Lauren Cosom, for instance, they looked at gun owners, some of whom were experiencing suicidal ideation and some who were not, and they found that the suicidal gun owners who had locked up their guns using safes or locking devices of some sort were much less likely to say, I think I'm going to kill myself someday. By comparison, if the gun owner was actively suicidal, they were much more likely to say, and they did not lock up their guns. They were much more likely to say, I'm probably going to kill myself someday. We've got several lines of evidence now emerging at this sort of cognitive access, this mental access to methods also seems to alter or change how a person subjectively experiences suicidal ideation. And so there's sort of, having gone over now kind of the rationale, why would we want to even do this? Well, again, suicidal crises come on fast. They tend to be brief. If somebody can survive that suicidal crisis, there's a really good chance that they're never actually going to die by suicide. And then third, the key determinant of what happens of surviving a suicidal crisis largely depends upon convenient access to various methods, right? So I want to pivot and talk a little bit about the science of means restriction. So it's a related concept, but here means restriction more specifically refers to limiting or restricting access to a particular method. Now at a population level, there are two requirements for means restriction methods to work. The first is that a method must be sufficiently dangerous. It has to be lethal. Secondly, the method has to be used frequently within the population. And so this is an important point because in essence, what this means is you could potentially from a means restriction perspective, need to target different methods for different groups of people. Like if we were to focus, for example, on many over-the-counter medications, overdosing on over-the-counter medications is one of the most frequently used methods for attempting suicide, but it has a fairly low lethality profile. Fewer than 5% of those who overdose using over-the-counter medications will die as a result. So restricting most over-the-counter medications probably is not going to have a particularly large impact on population suicide rates, even though it's used quite frequently within the population. Conversely, an example I can give, this is an actual patient that I treated many years ago. The method that he was contemplating for suicide was to actually cut off his arm, to amputate his arm using a power saw. And his rationale was, I'll bleed out and if I do it in the right place, they won't be able to apply a tourniquet even if EMT shows up to save my life. And so it's kind of this way to ensure that no one will be able to stop the death from happening. So here is a sufficiently lethal, very dangerous method for suicide attempt, but it's not very frequently used in the population as a whole. So if we were to restrict or limit access to power tools or power saws, we would not necessarily expect a reduction in suicide rates. And so the method that we focus on has to be both lethal and common, which is why different strategies and different methods of restriction have worked in different nations and cultures. And we'll talk a little bit about some of those. Now here in the United States, the method that fits the bill most prominently is firearms. And so that's why I think it's most relevant for us to be talking about firearm availability within clinical practice with our patients, for those of us here in the US. We know again from epidemiological study that laws, for instance, that impact the availability or convenience of access of firearms are correlated with lower suicide rates. We can look across states. We can also see this across counties, no matter what the level of analysis is. If it's in essence more difficult to obtain and to manage and to store and to keep firearms, suicide rates tend to be lower in those areas. Likewise, states that have permit registration, license regulations for firearms also have been shown to reduce suicide rates because again, these things make firearms less accessible. One of the most compelling research studies that I think has been published on this topic actually comes from Israel. Several decades ago, the Israeli military had very high suicide rates amongst their service members, very kind of mirroring what we're experiencing in the US in the past decade or so. What the Israeli military did was they changed a simple policy. They realized that most of their suicides were occurring on weekends while service members were visiting family at home and they were using their government issued or their military issued firearm. What they did is they just said, hey, before you go on leave to visit your family over the weekends, just stick your gun in the armory, check it in, go home, come back at the end of the weekend, go to the armory, check out your firearm and then go on duty. They found that this simple policy change reduced firearm suicides by 70% almost immediately and because firearms were so frequently used, it was the primary method for suicide in this population that that one change led to a 40% reduction in all suicides by all methods. We also know that legislation restricting access to lethal means are associated with decreased suicide rates for other methods. So again, this is not just a firearm thing, even though that's, I think, most relevant in the US and we have seen in Canada, New Zealand, Australia as well, firearm regulations were associated with reductions in suicide rates. But again, different cultures, different nations, different groups have different types of methods that are the primary, the most accessible and frequently used. And so targeting those specific methods have consistently led to reductions. So carbon monoxide poisoning, for instance, this was a frequently used method in the UK for many years. People would basically turn on their stoves because carbon monoxide was in domestic gas supplies. It's like turn on their stoves, open the oven door and suffocate themselves. So carbon monoxide was restricted in domestic gas supplies. Suicide rates dropped by carbon monoxide asphyxiation as well as overall suicide rates. Barbiturates were a commonly used method in Denmark and a few other nations once there were restrictions imposed on the prescription of barbiturates by healthcare professionals. They saw reductions in overdose rates related to barbiturates as well as overall reductions in suicide since barbiturates was a leading method for suicide in those nations. I mentioned before pesticide consumption in Pacific Island nations like Sri Lanka, Malaysia and others when there was legislation passed to restrict or ban the most toxic additives to these pesticides. They saw this massive reduction in suicides shortly thereafter because they in essence replaced a highly toxic pesticide with a less toxic pesticide. They restricted access to the thing that was most poisonous and it saved lives. We see the same thing with like bridge barriers, other like fences and other barriers placed in like heights for tall buildings, things like that. So again, the kind of conclusion is wherever a method is dangerous, sufficiently lethal and it's used frequently within the population, if we limit or restrict access to that method, then we see significant reductions in suicide rates. So now what does this mean for counseling our patients? Because one thing that I think needs perhaps it doesn't need to be said, but I'll say it anyway is that I'm not advocating that healthcare professionals start storing their patients' guns or their patients' medications and other possible methods for suicide. What we're expected to do is to initiate conversations with our patients around creating plans that can increase environmental safety such that the patient and others within their lives can perhaps enact strategies for limiting or restricting access to these methods. Now a common myth though that many clinicians experience is that they kind of worry that well, patients are going to listen to me, it won't actually work, what's the point doing this counseling? But I want to share with you that actually there's a growing body of data supporting the validity and the efficacy of lethal means counseling. Now the data is pretty slim in this area because it's been hard to do this type of research, but we have some data going back to the 90s for instance, conducted in emergency departments with adolescents who were being brought in by parents or caregivers after a suicide attempt typically via overdose. And what McManus and colleagues did in this study was randomize the parents to either receive lethal means counseling or not. And what they found was that the parents who received the counseling were significantly more likely to lock up or dispose of medications in the home afterwards. And so there is this almost a two and a half fold increase in safety precautions taken as a result of healthcare providers providing lethal means counseling. Caressi and colleagues also did a study in EDs again with parents of adolescents who had attempted suicide. They looked more broadly at methods beyond just medications for overdose and again found significant improvements in parents taking steps to lock up, secure, or somehow limit a range of methods that could potentially be used for suicidal behavior including prescription meds over the counter, meds, alcohol, and even firearms. What's interesting, I bold here, I put in bold firearms because what's fascinating is that in this study what they found was that in the control group, the group that did not receive counseling, none of the parents took steps to secure or limit access to firearms in the home. But 63% did if they received this lethal means counseling. And I think that's in some respects a shocking statistic. But one of the things we're learning in our research now with firearm owners is that there's a sort of like mental wall in essence between firearm ownership and the potential for suicide. And I think it's because we have at a societal level perpetuated this sort of perspective of suicide as a consequence of mental illness that can only be prevented via mental health treatments, et cetera, that firearm ownership or access to methods doesn't necessarily seem to be associated with increased risk for suicide. We have to somehow oftentimes join these two concepts together to help firearm owners and families that kind of think about the risk that's posed by access to highly lethal methods even if a family member attempted suicide using something else such as medications. This is the newest research that's been done. This is to our knowledge the first study that has looked at lethal means counseling specific to firearms. And this was a study that I conducted with Mike Anestis. We did this in Mississippi with military personnel. So we picked basically a setting in a population that I think many would assume would be very resistant and hostile to the notion of safe storage. And we also did this study critically in a community sample. And we wanted to do this in a community sample instead of like doing it in EDs or in other clinical settings because we realized that the case fatality rate of firearms is so high, 90 to 95%, that if someone shoots themselves, they probably will not live long enough to meet with us for us to counsel them to store their firearms safely. And so we really started looking at we need to get upstream when it comes to firearm availability. So we started to have these conversations with just the general community, regardless of their clinical status. And what we found was that in this study, when we randomized soldiers to either receive lethal means counseling or not, we found that the participants who received the counseling were 40% more likely to use one or more safe storage options like gun safes, gun locks, storing their ammunition separate from their firearm. We also did, we used a two by two factorial design in this study. And so another randomization was to distribute cable locks, kind of a cheap, easy way to secure firearms. What we found that just giving someone a method to engage in secure firearm storage significantly increased the likelihood of safe storage. And it was actually, that was a very potent and powerful intervention in and of itself. We think it's because it sort of made it easy. We gave them the tool that they needed to actually engage in the behavior. We're doing a lot more follow-up research on this now underway, but this was very promising initial results suggesting that even with populations and focusing on a particular method, firearms, that maybe is very uncomfortable or not as straightforward to talk about. And so I think having these conversations can increase the behaviors that we want whereby people will place barriers between themselves and that ready access to a lethal method. And so what does that look like? So I'll share with you our approach to lethal means counseling. This is actually the approach that we tested in that clinical trial that I just shared with you. So we do have some empirical support, you know, backing up this particular approach. The first thing that I want to note before kind of moving into the specifics of how to do this is just to call out that very rarely do mental health professionals and healthcare providers more widely regularly engage in lethal means counseling. This is, these are some statistics from several studies showing that, you know, very rarely are we actually engaging patients, whether it's in the ED, it's on outpatient side, psychiatric inpatient. It's just not happening very often. I think part of the reason is because I think to be fair, no one's really kind of taught us how to do this. It's sort of like one of these things that's been recommended for a long time. We should probably, you know, talk with our patients about access and take steps to limit or restrict access to methods, but there really hasn't kind of been a clear guidance of what are the protocols, what are the steps that we should follow? And not surprisingly, healthcare professionals are less likely to do something if they don't feel confident or know how to do it. Now the way that we then approach this to kind of conceptualize this is it's based on the stages of change model. It's also based on motivational interviewing concepts and principles. And so I know that probably many of you are already up to speed or at least familiar with some of these key concepts, so we are not going to talk about them in depth, but I'm just going to briefly highlight that in essence, we sort of conceptualize when we're working with a patient and want to approach the topic of access to lethal means. One of the things we're kind of kicking around in our head is what stage of change are they in? And what I will note is that in many cases, many patients are all the way on the left-hand side on the pre-contemplation side where they don't see why or how having access to potentially lethal means is problematic for them, even if they have just recently attempted suicide or are actively suicidal. And so what that means is that we're oftentimes trying to move them from the left-hand side of this graph as far to the right as we can. Ideally, we'll get to an end state at the end of lethal means counseling where someone is in the action stage, which means we first need to identify access as a problem. We then need to build the patient's motivation for change, and then we need to develop an action plan. Motivation is usefully conceptualized on two dimensions, one of which is perceived importance of change, the second being perceived confidence. In my experience, most patients are confident that they can secure or limit access to the methods. They know they can do it. It's just not particularly important to them, or they don't see why they should do it, in which case the lethal means counseling then is often focused on building that perception of importance. Every once in a while, it's less common, but every once in a while, you will find instances where someone is saying that they're low on confidence, and usually that's because they don't have access to methods to make that happen. And I'm going to show you a video shortly where we're going to see this dynamic play out where we begin by focusing on building this patient's perceived importance of means restriction, and then secondly, we're going to shift and start focusing on increasing his confidence because we're going to learn initially that he says, I don't really have access, I don't know how to do it, and then I'm going to help him to see how actually he does have the capacity to do it. When we're focused on the importance dimension of motivation, the decisional balance tool is often employed where we help people to consider the pros and cons of changing. So what are the benefits of storing this method or this means in a different way? What are the downsides of safe storage? And they will also consider the pros and cons or the benefits and costs of keeping things the way they are. What's the benefit of having easy access to medications or to firearms, and what are the potential costs of that? This is a really kind of nice, useful way to allow the patient to consider both sides of the ambivalence and to help them identify their values that can increase their motivation for change. The core techniques that we use in lethal means counseling, again, are straight out of motivational interviewing. We'll use reflective listening, lots of open-ended questions as much as we can, as well as affirmations and summaries. And then we're going to proceed through lethal means counseling in these four stages. So we're going to begin with what's called engaging. So we're going to raise the issue, build a collaborative working relationship with the patient. A key sort of dynamic here is being mindful of those external pressures that can kind of push us to be very authoritative and try to fix the problem. We want to make sure that we're emphasizing listening to the patient's perspective first. We then want to focus the patient on the topic at hand and adopt what's called a guiding approach. So we don't want to be too directive where we're leading the conversation, but we also don't want to be following where, in essence, the patient is sort of meandering around and we're not necessarily moving towards the intended goals. And so that sort of guided approach that relies a lot on open-ended questions and Socratic questioning is sort of an ideal method and strategy for getting through the focusing stage. We'll spend most of our time in the evoking phase. This is where we ask a series of open-ended questions to understand the patient's perspectives, opinions, and values related to the issue of access to means. And hopefully we can start thinking and identifying their motives for making a change. It's key to recognize that sometimes we have to validate and listen to the patient's reasons for not making a change. Why would they want to maintain access to a method and hear that side of the argument before we move on to the reasons why they might want to change or limit access? If we push too hard for change, then the ambivalence they experience may cause them to default to the other perspective and fight back against us, so to speak. And then the final stage is planning, where we actually kind of come up with the tangible steps that are going to be taken to alter their environment and their access to the lethal method. Okay, so let me show you a quick video. It's about seven minutes long. Now, this is not a rehearsed video. This is someone who volunteered to have this video conversation, a video recorded for the purposes of training. So this is not a staff member, a student, anything like this. This is actually a service member who was going through a divorce at the time. And so he, again, graciously agreed to be videotaped for this purpose. And so he didn't necessarily know that we were going to talk about lethal means access in this particular meeting. He is a gun owner. And so you're going to see how I walk him through those four stages of the lethal means counseling approach. But first, I'm going to engage him. I'm going to do that by asking him about his guns, which he's more than happy to do. I'm then going to focus him by asking him to describe his security safety precautions, how he locks up and stores his guns. We're going to find out he basically doesn't do it at all. He doesn't use any precautions. I then transition to the evoking stage where I'm going to ask him a series of open-ended questions to understand his thoughts, his beliefs, his perspectives on the matter. And then finally, we're going to move to an active planning stage where we come up with what is he going to do. So Ryan, what I'd like to do next is talk a little bit about firearms. I saw on the paperwork that you said that you do have firearms at home. What type of guns do you have? I've got a lot. I have several that I carry. A couple shotguns, a couple rifles. I've got some AR-15s that I have set up for like how I use at work, so. Yeah. Okay. What are the safety procedures that you use for all those guns? Well you know, honestly, it's just me and the house. So there isn't a lot of safety procedures. I don't own a safe. I've got a couple that are always loaded and always ready. Usually near the bed or on the nightstand. The stuff that I carry often, those are always loaded so that I can just grab whichever one I'm going to carry that day and head out the door. Okay. Do you ever like lock up or secure the firearms like when kids come over or family comes over anything like that? Yeah usually what I do is I would just kind of move everything that's out into like a closet or put it on a high shelf or something like that. I do have some like Pelican cases like your hard cases that I put under the bed and those those do have like holes to be able to lock but I never put locks on them sometimes I'll just throw them under the bed in a case. Yeah, so it sounds like under certain circumstances then you do kind of step up the safety, step up the security a little bit. Is there a particular reason why in some situations you do that? Oh well like I said when it's just me I'm not worried about it but when there's other people there that may or may not be familiar with how to handle a firearm safely you know I would hate for there to be some sort of accident or something. And then also like you know firearms are valuable so if I'm gonna have a lot of people around I don't want that kind of stuff to be out in the open where people have access to. Okay, are there other circumstances or other times where you think firearms safety should be increased or you think it'd be even more important to have greater safety? Like what? Well I mean what are your thoughts for instance about say someone who is drunk. Should someone drunk have easy access to firearms? No, no that's a good point. I mean obviously if you're impaired or not in the right state of mind you probably should have access to firearms. Okay so if you have some sort of like impairment of some kind like not able to make decisions clearly, not in the right state of mind, that would be dangerous. Sure. I always try like if I'm gonna go out drinking or whatever I always make sure I leave my firearm home and I don't have it with me. Oh okay, so you don't need to carry when you're going out drinking. Sure. That's sort of like, so you plan ahead kind of like having a designated driver you also. Yeah. Okay that's interesting. What about situations like someone who's suicidal or having suicidal thoughts? What are your thoughts about them having easy access to firearms? I mean it's not something I thought about much but I imagine like you know just kind of like what we talked about you're not in the right state of mind. You're not thinking clearly so you know removing something like that that could potentially cause harm you know if you were in a not in a good place I think that makes sense. Yeah okay well no like part of the reason I ask is because you know we've talked a little bit about how you've been having some suicidal thoughts recently and I'm wondering how your perspective there then applies to you when it comes to safety and suicidal thoughts. Yeah I mean again I hadn't really thought about that but it makes sense that you know maybe when I'm in that dark spot that I need to somehow make access well you know less access less available so that it's not so easy to just because like you know like right now since I have stuff on my nightstand or propped up against the bed you know it is probably too readily available for for the state of mind. Okay yeah it kind of does strike me that you're saying that probably there is sort of a safety concern when someone's sort of high risk or they're not in the right state of mind and that is something you've been experiencing lately but you say you haven't kind of thought of it for yourself you haven't kind of thought oh I've been having these thoughts maybe I should take some safety precautions. Yeah but now that you bring it up it definitely makes sense I guess the issue I have is like where I don't have a safe you know I'm not sure how I would approach that because I don't really feel comfortable like giving something. Right. I mean I have friends that I could trust with that but it would feel weird not having my guns I mean that's been a part of me and who I am for a while. I wouldn't really feel comfortable giving those to somebody. Yeah. So I'd have to come up with something else that yeah would work. Yeah no a lot of people feel that way they don't really feel comfortable giving their guns to somebody else and at the same time they realize something needs to be done and so you don't have safes what are other safety measures that you've heard of like friends or family members other gun owners have used that maybe don't necessarily involve safes or getting rid of the guns. Well I mean pretty much every gun you buy now comes with a trigger lock. Yeah. So something like that could work you know also I mentioned I have those hard pelican cases that I store my my guns in most of time anyway those do have the ability to lock you know maybe that's something where I could lock them with that and then maybe give that key to somebody else. Yeah. So that I was still in possession of firearms but didn't have access to them with something like that. I mean that those seem like pretty good ideas I mean what are your thoughts about them? I mean it would still be difficult to you know to not be able to grab my carry gun when I go out the door you know that's that's a part of my checklist when I leave my house. Right. So but I understand that at the end of the day it's fluids this is to save my life and that would be the whole reason of carrying it. Yeah. In the house anyway. Right. Yeah. I think that's probably something I could live with. Okay. Okay. Do you have enough gun locks for all of your guns and the pelican case like do we need to get you some extra gun locks or anything like that? I think I probably have enough but I've never had everything locked up at once so I'd have to check. Well well maybe what would you I've got a actually a whole bunch of them in my closet maybe I could just give you extra take them home if you don't need them you could just bring them back. Yeah. Yeah. Absolutely. And with the with the pelican cases so locking up you said give the key to someone else do you know who that person would be that you're going to give the key to? Yeah I've got some really close friends that live near me so that if I did need access to them you know I could okay I could still get them but that I wouldn't have readily available access without having to go to somebody else. Yeah. Okay. And do they kind of have a sense of what's been going on lately like if you're like hey here's the key to my pelican safe so I don't have access to my guns would they kind of know what's up? Yeah I think so. Okay. We've talked a little bit so. Okay. Okay. I mean I think that sounds like a pretty good plan and would you say that's a pretty good plan for us to follow? I think I think it is I think it meets the intent and it's a good compromise it's something that I could live with. Okay. Okay well why don't we just jot this down so we make sure we're on the same page and I'll go grab you a couple extra cable locks here. Awesome. Thank you. Okay well I think that that pretty much brings me to the end. Hopefully that video was helpful. I've included at the end of the slide deck as well the bibliography if you'd like to see and pull up some of the references yourselves but I think we'll go ahead and stop and reserve the rest of the time for any questions or discussion that people might have. Thank you Craig so much for this very interesting and thought-provoking conversation today. Before we shift into question and answer and we do have some questions and answers already in the box I want to take a moment and let the audience know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, upcoming events, complete your mental health rating scales, and even submit questions directly to our team of SMI Advisor experts. You can download the app now at smiadvisor.org forward slash app and in fact you can even watch this video of this webinar in in about a week via your mobile app if you want to. So let me turn Craig to our questions that folks have and I know that a few people were having trouble listening to the audio but but hopefully most of the people were able to to hear because I thought it was an excellent example of turning someone from the beginning when they were talking about well you know my guns are really valuable wasn't even thinking about safety all the way around to yes can you give me some locks and it was almost myself kind of surprised by the fact that he said you know some of his guns just you know lean against his bed or in his side table I mean they were very accessible and that his kind of beginning where he was saying well sometimes when people come over I put him under my bed was about value not about safety and in a very short period of time you you got him to start thinking of them in a different way and he was able to admit that it would feel uncomfortable not to have them in the house but that probably quick access for himself or somebody else was not good so I thought that was really impressive and I was it resonated with me in the sense of it felt like motivational interviewing right all of those things that you used the content was different but it was about motivational interviewing but but I recognize also that is a different kind of process when someone is very comfortable with guns wants to have them around and we have a lot of people in this country who who are like that so I really appreciated the video I thought it was quite powerful let me turn to some of the questions from our audience so one of the early questions was you know the data that you presented about if someone survives a suicide attempt very low chance they'll try again right and they were wondering is there similar or parallel data about suicide ideation so if someone makes an attempt and and or or let me see is there data to support that if someone survives a suicidal crisis without having made an attempt that their risk is also decreased do you have any thoughts on that yeah so I if I understand the intent of the question I think the key thing and this is something that I you know emphasize the patients quite a bit is that you know recovery from suicidal crises from suicidal thoughts is the rule not the exception you know 99% of those who experience suicidal thoughts will not go on to die by suicide now we're starting to learn that there are different pathways that people follow one of which is people have an acute crisis and then it resolves and you know they they seem to be okay afterwards it really is kind of this acute you know problem then there are others who will have more sustained crises and then there's a smaller subset who have more chronically elevated suicidal thoughts that will persist for many many years and so we're just now starting to I think research and quantify what those different pathways and trajectories look like but I all that is to say is for the majority of people who experience that acute crisis it will pass and we've now published data we published an initial study just a couple years ago looking at this like what happens after a suicidal crisis and we found that basically within a year of the most recent sort of suicidal thoughts we found that 75% of those who experienced ideation had comparable levels of happiness well-being purpose in life they were actually indistinguishable from people who said they had never been suicidal and I think that's an important sort of communication that needs to kind of push out within suicide prevention is this notion that it really is this sort of for most people a confined crisis that's okay but things will actually kind of get better afterwards I worry that a lot of times the way we talk about suicidal thoughts and ideation as we overreact it's like this is this major catastrophe and we got to be careful but for the you know 90% or more it's a it's reflective of this really really bad distressing moment and so let's help a person get through that and then they'll be able to sort of kind of recover and get on with their lives so one question that came up which was also a question that came up to me was cable locks and the cost of them you know it would be great if many of our community mental health centers could have cable locks or other things available so at the end of these conversations we could say listen we've got some here let us give it to you while we've we've got them right at that moment where they're like yeah maybe I should do that so talk to us a little bit about two things one the cost of those like how much does that cost and two do you know of any universal or state-based programs or VA programs where they have these yeah so the the typical cut they're pretty cheap they're usually like 15 to 25 dollars a pop and yeah they're easy to access now that many states are subsidizing them law enforcement agencies the VA DOD and so there are lots of grant programs around this now they're cheap and they're convenient now one thing that I think it's important to note is some of the newer research that we're doing right now suggests that they're actually the least preferred method by gun owners they don't like them they don't particularly like them and so what we've started to do is kind of help them to see if this is maybe just a temporary strategy and then we will engage in conversations about what are the other security devices that are more attractive to you you know lock boxes safes in this case that you know the video it was a pelican safe which is kind of more of like a suitcase type of thing that can be used to store firearms some people prefer to dismantle their firearms and give a piece to like a friend there's actually a range of options that can be used to achieve the outcome so I point that out only because it's what we're learning now and so don't I think the mistake that many agencies and clinicians make it's like oh we've got the gun lock and so therefore the problem is solved not necessarily the last thing I'll say is be mindful actually we were surprised by this in our study a lot of people when we gave them the cable lock they were like well how do I use this and at first we were like what do you mean how do I use this and of course right logically what they'd never used one before and so they didn't know how to use it so we started to actually develop these like tutorials of how to lock up your gun using a gun lock and we're finding that again again and most gun owners have actually never secured the firearms they don't know how to access these so so I know it's a long answer but I do think it's worthwhile to get them there are lots of subsidy programs for that whereas I demonstrate in the video it's like I just give it to him make it easy say it's temporary and then maybe we can come up with another plan that works for you that's better longer-term solution right and I would just add to that that there are probably a lot of us in the audience as clinicians who don't know how to use them so if the person asked us why I don't know how to do it we should know so we should watch some of these you know instructional videos on how to do it so that we can actually walk them through it so I think that's really important someone also wrote in that the VA offers free cable gun locks to veterans and their families and that community services boards often offer them in the community so so I think people are starting to realize where they can get them so someone wrote in any suggestions from you on evidence-based or best practices for documentation when you have such a conversation is there anything what should we be writing down in the notes sure so what I what I typically write down in the note section is just you know facilitated or engaged in lethal means counseling focused on X method whatever that case may be I don't show it in the video just simply to save time right it's like writing down what the plan is and then in essence you can either make a copy of that for the record or what I typically do is just kind of like type in you know for here I would say you know patient is going to store firearms in Pelican cases lock it with you know a locking device deadbolt or whatever and give the key to a friend and and so it's like really kind of convenient and easy to document in just a few sentences sounds great I mean I just have learned so much today from you and I'm looking forward to making sure that I could do a good job on on this kind of counseling it's a skill that as you said in your presentation we aren't taught and it takes practice just like any motivational interviewing it takes practice and so I really appreciated today not only making the case for the importance of it but also showing us an example of you doing it that really sort of brought the skills to light for me on just a modeling and I think even those of us who are more senior in our practices we needed that so I really appreciated that today so let me move on and if anybody has any follow-up questions on this or any topic related to evidence-based care for SMI our clinical experts are available for online consultations any mental health clinicians can submit a question receive a response from one of our SMI experts on this topic or anything else consultations at our website are free confidential and we we answer within 24 working day hours so anytime during the week we will answer you within 24 hours so feel free to contact us on behalf of SMI advisor I'd like to invite you to learn more about APA's 2022 annual meeting the in-person conference takes place May 21 through 25 in New Orleans and the virtual meeting takes place June 7th through 10th if you can't attend the in-person during the live conference clinical experts from SMI advisor are leading a variety of sessions on how to improve care for those with SMI topics for these sessions include basics on how to use clozapine digital navigators making technology work how to improve physical health of patients and we even have some on gender expansive individuals in our population so quite a few different topics I encourage you to take a moment to consider coming and browse our agenda lastly the claim credit for participating in today's webinar you'll need to have met the requisite attendance threshold for your for your profession verification of attendance takes up to five minutes after we end the presentation today and then you'll be able to select next and advance to complete the program evaluation before claiming your credit and lastly please join us on April 28th 2022 as Dr. John Torres presents digital health navigators implementing technology for SMI and this is really relevant as we've gone through COVID to really think about how to leverage technology to help our clients access care and also meet their recovery goals how can we do that with technology again join us for this free webinar on April 28th 2022 at 3 o'clock Eastern Time thank you all for joining us today and again thank you Craig for this great presentation until next time take care everybody you

lethal means counseling

suicide prevention

acute suicidal distress

reducing lethality

suicide attempt outcomes

easy access to lethal methods

means restriction

firearms and suicide

four-phase approach

motivational interviewing techniques