Population Health Institute
Translating Research for Policy and Practice

Written Protocols

Note: This strategy is based on the outreach and counseling strategies. Therefore, it does not follow the same format and does not include an evidence summary, implementation examples, or implementation resources.

 

Strategy Description

Leadership should ensure that clear, written protocols are in place for staff trained in crisis support to follow when firearms are involved. Written protocols are essential for ensuring consistency and effectiveness in firearm crisis intervention and suicide prevention efforts1.

Action Steps Based on the Literature 

Written protocols should be developed for…

  1. Firearm access screening question: Create a written protocol for asking a nonjudgmental firearm access screening question(s). Structured assessment questions are more accurate and reliable than unstructured clinical judgment2. A standard question normalizes and encourages dialogue about firearm access3. Determine which helpseekers will be asked the firearm access question.
  2. Lethal means counseling: Create written protocols for lethal means counseling, including suggested questions to ask and steps for discussing secure firearm storage practices. Written protocols improve the consistency and effectiveness of lethal means counseling, helping staff encourage safe storage practices4,5. Some staff prefer to have a lethal means or firearms counseling script to use, in addition to receiving training on lethal means counseling5.
  3. Safety planning: Create a written protocol for the safety planning process, including discussing access to firearms and how to keep the environment safe. Include an explanation about the purpose of a safety plan. Collaborative completion of the safety plan ensures the plan is flexible and tailored to the helpseeker’s needs6. At the end of safety planning, discuss how the plan will be used to help ensure the helpseeker can access it when needed6.
  4. Follow-up call: Create a clear program protocol for staff conducting follow-up calls, including steps for assessing wellbeing, reviewing safety plans, and coordinating care.  Follow-up calls help minimize hopelessness and psychological pain, and increase treatment engagement7.
  5. Trauma-informed and culturally humble practices: Ensure protocols include guidelines for trauma-informed and culturally humble practices8, recognizing diverse backgrounds and addressing power imbalances.
  6. De-escalation: Create a written protocol for when emergency services should be involved. De-escalation helps avoid unnecessary use of emergency services and focuses on collaborative and less invasive interventions6. Ensure crisis staff are aware of their own reactions or biases and use emergency services only when less invasive interventions, such as lethal means counseling and safety planning, have been unsuccessful.

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References

  1. 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
  2. Ahonen, L., Loeber, R., & Brent, D. A. (2017). The association between serious mental health problems and violence: Some common assumptions and misconceptions. Trauma, Violence, & Abuse, 20(5), 613–625. https://doi.org/10.1177/1524838017726423
  3. Richards, J. E., Kuo, E. S., Whiteside, U., Shulman, L., Betz, M. E., Parrish, R., Boggs, J. M., Rowhani-Rahbar, A., & Simon, G. E. (2022). Patient and clinician perspectives of a standardized question about firearm access to support suicide prevention: A qualitative study. JAMA Health Forum, 3(11), e224252.
  4. 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
  5. 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
  6. Vibrant Emotional Health. (2024). Safety Planning.
  7. Substance Abuse and Mental Health Services Administration [SAMHSA]. (2023). Crisis Center Guidance: Follow-up with 988 Lifeline Contacts and Those Discharged from Emergency Departments and Inpatient Settings.
  8. Substance Abuse and Mental Health Services Administration [SAMHSA]. (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-informed Approach.  https://library.samhsa.gov/product/samhsas-concept-trauma-and-guidance-trauma-informed-approach/sma14-4884

Related Strategies (view evidence summaries and related implementation examples and resources here)

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