Lethal Means Counseling with Secure Storage Information

Lethal means counseling is an important part of safety planning for individuals at risk of suicide by firearm.  It helps reduce the risk of suicide by addressing and mitigating access to potentially deadly means. Reducing access to lethal means among persons at elevated risk of suicide has a robust evidence-base for creating environments that protect against suicide⁷. Implementing secure firearm storage combined with education and counseling on access to lethal means is a particularly effective strategy⁷.  Lethal means counseling impacts secure storage practices.  In one study⁵, lethal means counseling and provision of cable locks resulted in greater adoption of several secure storage methods over time. This study provides evidence that lethal means counseling led to a larger increase in the number of secure storage practices used over time compared to those participants randomized to counseling⁵. Lethal means counseling and cable locks can result in sustained changes in firearm storage⁵.

Research shows that when clinicians talk to patients about securely storing firearms, it can reduce the risk of suicide or other injuries⁸. One study showed that while the CALM training can improve comfort in delivering lethal means counseling for some staff, it’s not sufficient to delivering lethal means counseling for all staff. In that study, the majority of staff reported it being more helpful to include a brief script based on the CALM training, and that the brief script improved their comfort in effectively counseling on lethal means³. The researchers of that study suggest that the CALM training be accompanied by a script for staff trained in crisis support to use.

The “5 A’s for Firearm Safety Counseling” may be a promising clinical training tool that trains clinicians to give better advice on preventing firearm injuries. In the study, the training helped clinicians feel more comfortable discussing firearm risks, especially with patients at risk of suicide or in domestic violence situations². Teaching clinicians about firearm safety and giving them specific questions to ask may make these conversations more effective. After training, clinicians felt 60% more comfortable discussing firearm safety, which helps them encourage patients to adopt safety measures². Note that this study included a small sample size of clinicians and may not translate to other settings. One study found that hospitals with written protocols for lethal means counseling had higher rates of counseling for all suicidal patients, even if they were not planning to use a firearm, compared to facilities without protocols⁴. Additionally, hospital leadership buy-in is needed to advocate for the implementation of these protocols⁴. The interviews with clinicians in another study also revealed the need for clear guidance, training, and system-level policies to support lethal means counseling⁹. Tools like “Lock to Live” can enhance suicide risk assessment when specialists are unavailable⁹.

Many firearm owners do not perceive secure storage as an effective way to prevent firearm-related injuries and deaths, leading to low participation in these safety measures¹⁰.  Teaching people about firearm safety and promoting secure storage can help reduce risk of injury or death by firearm. This includes keeping firearms out of homes where someone is at risk, locking firearms, storing them unloaded, and keeping ammunition separate¹¹.  The three characteristics of secure storage are locking the firearm, storing the firearm unloaded, and storing the firearm separate from ammunition.

More research is needed on unique populations, such as youth, people living in rural areas, other populations disproportionately impacted by suicide, etc.  However, there is quite a bit of research on military personnel and veterans. Within the military, a preventive approach such as lethal means counseling may be especially important because military personnel are more likely to own firearms but the majority do not use secure storage methods. Military personnel are also more likely to use firearms when attempting suicide⁵. In one study, women veterans in the study all described positive experiences with firearm lethal means counseling and preferred a trusted, caring relationship, direct communication of rationale of questions, and discussion of exceptions to confidentiality¹². Negative aspects of counseling included conversations that felt impersonal, not sufficiently comprehensive, and fears regarding implications of disclosure¹². It’s important for staff trained in crisis support to communicate why such conversations are important, consider how they should be framed (e.g. around safety and genuine concern) and what they should entail (e.g. discussing concerns regarding disclosure¹². It might also be important for staff trained in crisis support to understand military terminology. This population has a history of under-reporting intimate partner violence and military sexual trauma. One study discusses the effectiveness of lethal means counseling among service members, particularly in relation to elevated post-traumatic stress disorder (PTSD) symptoms¹³. The analysis suggests that individuals with heightened hyperarousal may exhibit unsafe firearm storage practice, potentially undermining lethal means counseling outcomes¹³. The study suggests considering optimizing these interventions for those affected by PTSD to enhance safety measures effectively. The findings of the study also indicate that lethal means counseling significantly increases new usage among individuals with low and medium symptoms, while no significant differences were observed in those with high symptoms¹³. These results underscore the importance of interventions in promoting safe practices for all, and particularly for service members. Overall, one in three U.S. veteran firearm owners store household firearms loaded and unlocked, one in twenty believe that a firearm increases household suicide risk, and one in four consider their loaded and unlocked firearm to be inaccessible to suicidal household members¹⁴. Storage practices and risk perceptions are similar among those with and without self-reported suicide risk factors. Shaping risk perceptions may be a key component of interventions focused on secure storage safety among U.S. Veterans¹⁴.

1. Sale, E., Hendricks, M., Weil, V., Miller, C., Perkins, S., & McCudden, S. (2018). Counseling on Access to Lethal Means (CALM): An evaluation of a suicide prevention means restriction training program for mental health providers. Community Mental Health Journal, 54(3), 293–301. https://doi.org/10.1007/s10597-017-0190-z
2. Hoops, K., McCourt, A., & Crifasi, C. K. (2022). The 5 A’s of firearm safety counseling: Validating a clinical counseling methodology for firearms in a simulation-based randomized controlled trial. Preventive Medicine Reports, 27, 101811. https://doi.org/10.1016/j.pmedr.2022.101811
3. Mueller, K. L., Chirumbole, D., & Naganathan, S. (2020). Counseling on access to lethal means in the emergency department: A script for improved comfort. Community Mental Health Journal, 56(7), 1366–1371. https://doi.org/10.1007/s10597-020-00575-x
4. Runyan, C. W., Brooks-Russell, A., Tung, G., Brandspigel, S., Betz, M. E., Novins, D. K., & Agans, R. (2018). Hospital emergency department lethal means counseling for suicidal patients. American Journal of Preventive Medicine, 54(2), 259–265. https://doi.org/10.1016/j.amepre.2017.10.023
5. Anestis, M. D., Bryan, C. J., Capron, D. W., & Bryan, A. O. (2021). Lethal means counseling, distribution of cable locks, and safe firearm storage practices among the Mississippi National Guard: A factorial randomized controlled trial, 2018-2020. American Journal of Public Health, 111(2), 309–317. https://doi.org/10.2105/AJPH.2020.306019
6. Vibrant Emotional Health. (2023). Violence Assessment and Threat Management Guidance.
7. Centers for Disease Control and Prevention [CDC]. (2022). Suicide Prevention Resource for Action: A Compilation of the Best Available Evidence. Retrieved from https://www.cdc.gov/suicide/pdf/preventionresource.pdf
8. Allchin A., & Chaplin V. (2017). Breaking Through Barriers: The Emerging Role of Healthcare Provider Training Programs in Firearm Suicide Prevention. Washington, D.C. https://efsgv.org/wp-content/uploads/2017/09/Breaking-through-Barriers-September-2017-Consortium-for-Risk-Based-Firearm-Policy-FINAL.pdf
9. Siry, B. J., Polzer, E., Omeragic, F., Knoepke, C. E., Matlock, D. D., & Betz, M. E. (2021). Lethal means counseling for suicide prevention: Views of emergency department clinicians. General Hospital Psychiatry, 71, 95–101. https://doi.org/10.1016/j.genhosppsych.2021.04.011
10. Anestis, M. D., Bond, A. E., Moceri-Brooks, J., Bandel, S. L., & Semenza, D. (2024). Perceptions of the utility of secure firearm storage methods as a suicide prevention tool among firearm owners who currently store their firearms loaded and unlocked. Suicide & Life-threatening Behavior, 54(1), 122–128. https://doi.org/10.1111/sltb.13023
11. McCourt A. D. (2021). Firearm access and suicide: Lethal means counseling and safe storage education in a comprehensive prevention strategy. American Journal of Public Health, 111(2), 185–187. https://doi.org/10.2105/AJPH.2020.306059
12. Polzer, E. R., Holliday, R., Rohs, C. M., Thomas, S. M., Miller, C. N., Simonetti, J. A., Brenner, L. A., & Monteith, L. L. (2023). Women Veterans’ perspectives, experiences, and preferences for firearm lethal means counseling discussions. PLOS ONE, 18(12), e0295042. https://doi.org/10.1371/journal.pone.0295042
13. Stanley, I. H., Bryan, C. J., Bryan, A. O., Capron, D. W., & Anestis, M. D. (2024). Lethal means safety counseling among firearm-owning U.S. National Guard personnel: Hyperarousal symptoms as a moderator of treatment outcomes. Psychological Services, 21(2), 199–205. https://doi.org/10.1037/ser0000763
14. Simonetti, J. A., Azrael, D., & Miller, M. (2019). Firearm storage practices and risk perceptions among a nationally representative sample of U.S. Veterans with and without self-harm risk factors. Suicide & Life-threatening Behavior, 49(3), 653–664. https://doi.org/10.1111/sltb.12463

• Staff trained in crisis support completed the CALM training, accompanied by scripted language³. The script included their role, asking the patient directly about access to lethal means and how they are currently stored, and creating an individualized safety plan. Some of the scripted questions included:
  • Do you currently have access to firearms or other potentially dangerous things in your home that you could use to hurt or kill yourself?
    • If yes, What are they? Where are they kept?
    • If no, Do you think you will have access to it?
  • Have you tried to hurt yourself before?
  • Is there a way for you to either lock the (gun, pills, etc) up safely or give them to a friend or family member for the time being?
  • How long do you feel like you will be able to either lock these things up or give them to a friend or family member?

Lethal Means Counseling Resources

• Counseling on Access to Lethal Means (CALM) (required login): This free, self-paced training explains why access the lethal means is an evidence-based strategy for suicide prevention. It also covers how to identify clients for whom lethal means counseling is appropriate and describes ways to talk through lethal means as well as advising clients on storage options and strategies for safety. This training takes about 4 hours to complete.
  • This training is composed of 6 lessons.
    1. Why does reducing access make a difference?
    2. Who needs lethal means counseling?
    3. What are lethal means?
    4. What are some ways to reduce access?
    5. How should I counsel clients about lethal means?
    6. What is the plan?
  • There is also a version for pediatric providers to prevent youth suicide.
  • CALM also hosts an online, live course called “CALM-SAFE: Firearm Literacy Education for Care Providers”. CALM-SAFE (Supporting Alliances through Firearms Education) is a 90-minute program to help providers who are not familiar with firearms to develop a culturally sensitive vocabulary and basic understanding of firearms to help them feel more comfortable and effective when speaking to gun owners about safe storage. It costs $40 per person, and there is also an option for a customized in-person or virtual CALM training for your organization.
• Talking About Lethal Means: This free, self-paced training course for crisis staff identifies the purpose and importance of lethal means conversations during a crisis conversation. The training also covers using validation and questioning to support helpseekers in reducing access to lethal means, and also exemplifies the difference between collaborative and directive language in a lethal means conversation context. This training takes approximately 2 hours to complete.
  • A strength of this training is that it focuses on what is best for the individual and encourages crisis staff to think about cultural humility. Another positive of this training is that it walks through different scenarios and the most appropriate way to respond.

• This video from the BulletPoint Projects highlights how to have informed and respectful conversations with patients about the risks of firearm access and how to reduce that risk. The majority of clinicians feel that preventing firearm injury is within the scope of their practice, and patients are generally receptive to having these conversations. However, many clinicians don’t routinely counsel patients, often saying they don’t know how to identify risk, how to bring up the topic, or what recommendations to make. The video offers five things to keep in mind when starting conversations about firearms:
  1. Be informed. Know why people own firearms and how to store them safely. 
  2. Be respectful. Owning firearms can be closely connected with a person’s identity or feeling of personal safety. Use neutral and non-stigmatizing language. 
  3. Focus on risk. Evaluate risk and talk about firearm access when it’s clinically relevant. Know the risk factors, like people with depression or people living with children.
  4. Practice harm reduction. Work with people to take steps that will keep them safe.
  5. Make individualized recommendations. Consider the type of risk, level of risk, and what works for the person.
• This guide from the BulletPoint Project helps readers learn how to effectively assess risk, talk with patients about access to firearms and intervene appropriately. The goal of these conversations is to reduce access to firearms for those at risk. It also introduces the 3A’s Framework:
  1. Approach
  2. Assess
  3. Act
• This online article from the American Psychological Association aims to teach readers how to put time and space between people at elevated risk for suicide and access to lethal means. For patients who have firearms in their homes, this could mean locking an unloaded firearm in a safe and storing ammunition separately; asking another household member to keep the firing pin or change the combination on a gun safe; or handing firearms over to a friend you trust. The article emphasizes the following steps:
  1. Familiarize yourself with firearm culture
  2. Get training
  3. Bring it up before a crisis
  4. Be conversational, not prescriptive
  5. Watch your language
  6. Involve family and friends
  7. Know the laws in your state
• This resource provides a brief overview of firearm suicide epidemiology, risk factors for suicide, and the evidence in support of temporary risk-based firearm removal for suicide prevention. It also introduces the concept of lethal means safety counseling. This tool discusses the importance of incorporating lethal means safety counseling training into healthcare provider training programs including best practices for training.

Secure Storage Resources

• This resource from Project ChildSafe and The Firearm Industry Trade Association provides a brief overview of the following types of gun storage: cable lock, gun case, lock box, electronic lock box, gun safes, console storage, cargo area storage, wireless gun safe monitor, and electronic holsters. Each has a brief description, as well as the key features, a picture, and approximate price.
• This resource from the federal Department of Justice speaks to firearm owners and uses familiar language to discuss handling and storage of firearms.
• The Lock to Live digital aid for parents has been successful in educating parents around secure firearm storage and child suicide and encourages them to change their lethal means storage practices.