Counsel on Access to Lethal Means Developed by Dr Mark Ciocca and - - PowerPoint PPT Presentation

Take A Few Minutes to CALM Counsel on Access to Lethal Means

Developed by Dr Mark Ciocca and Elaine Frank elainefrank603@gmail.com

Before we begin

• Introductions
• What CALM is and isn’t
• Specific, effective PART of Suicide Prevention
• Not suicide risk assessment
• Can be effective in our personal lives as well
• Not THE answer but should be included
• Suicide is generally preventable
• Safe messaging and self care
• Anti-suicide not anti-gun or anti-drugs

Reducing Access to Lethal Means

Make highly lethal means less accessible Attempt suicide with less lethal means

• r

Delay suicide attempt

Why do it?

• Proven to be an effective intervention and

many people will not switch to another means

• Part of Indiana’s Suicide Prevention Plan and

the National Strategy for Suicide Prevention

• Most suicidal people are not sure whether

they want to live or die

• The actual act of suicide is often made very

quickly - particularly among young people

“Natural (Gas) Case Study” Self-asphyxiation by domestic gas, Great Britain

• Pre-1957: Carbon Monoxide (CO) proportion of

suicides = 40%

• 1957-1970: Transition from coal to natural gas: CO

content went from 12% 2%

• 1971: CO Proportion of suicides = 10%
• Overall suicide rate: 26%

Source: Kreitman 1976, Brit J Prev Soc Med.

Pesticides – Sri Lanka

• Pesticides are the leading suicide method in Asia, with an

estimated 300,000 deaths annually worldwide.

• In Sri Lanka, suicide rates rose 8-fold from 1950 to 1995.
• Restrictions were placed on sales of the most highly

human-toxic pesticides in the late ‘90s.

• Suicide rates dropped 50% from 1996 to 2005.
• Nonfatal poisonings and other suicides did not.

Gunnell 2007. Int’l J of Epidemiology.

Firearms – Israeli Military

• The Israeli Defense Force (IDF) is a population-

based army with mandatory draft for 18-21 year-olds

• From 2003- 2005, an average of 28 suicides
• ccurred each year, 26 by firearm, many on

weekends.

• In 2006, IDF required soldiers to leave their weapons
• n base during weekend leaves.
• The suicide rate decreased by 40%.
• Weekend suicides dropped significantly.
• Weekday suicides did not.

Lubin 2010, Suic & Life-Threat Behavior.

Preventability

• Many people who survive a nearly lethal attempt say

something like this : “I instantly realized that everything in my life that I’d thought was unfixable was totally fixable – except for having just jumped” from the Golden Gate Bridge

• 90% of those who survive a nearly lethal attempt do not

go on to die by suicide

What Means to Focus On?

* Frequency * Lethality * Decision Time * Availability * Cultural Differences

Suic icid ide Meth thods – In India iana 2015

GUNS SUFFOCATION POISON OTHER

54% 27% 13% 6%

ALL AGES

77% 9% 11% 3%

65+

49% 29% 15% 7%

25 - 64

U.S. Youth Suicide, 15-24 year-olds

Total Firearm Suffocation Poison Other

Nonfatal Self-harm Suicide

Methods of Self-Harm, U.S.

Sources: Suicide: CDC WONDER (2013) Inpatient: HCUP-NIS (2005)

Overdose/Poison 83%

Overdose/ Poison 16%

Firearm 51%

Suffocation 24%

Sharp 11%

Other 4% Jump 2% Sharp 2% Other 4% Suffocation 1% Firearm 1%

Decision Time

Among survivors of near fatal suicides, when asked about time from their decision to complete suicide and the attempt:

• 24% said less than 5 minutes
• 47% more said an hour or less

Putting time and distance between a suicidal person and lethal means MAY save a life

Simon TR et al, Characteristics of impulsive suicide attempts and attempters. SLTR 2001: 32 (supp) 49 – 59.

Deisenhammer, 2009 Time Between First Occurrence of a Thought of Suicide and Suicide Attempt (Among Attempters Treated at a Hospital)

Ambivalence

Drum, Brownson, Denmark, Smith. Professional Psychology: Research & Practice, 2009

Among the 5% who seriously considered attempting, past 12 mos n=1321 Began attempt, then reconsidered 15% Carried through an attempt 12%

Suicidal Behavior Among College Students

Suicide Plans Among Attempters

Borges et al. Risk factors for twelve-month suicide attempts in the National Comorbidity Survey Replication (NCS-R). Psychol Med. 2006

Had a Suicide Plan?

People who attempted suicide in past 12 months

No plan 43% Plan 57%

Firearm Availability As A Suicide Promoter

▪Suicide rates vary with rates of firearm

• wnership

▪Case control studies show greater prevalence of guns and less securely stored guns in homes of those who die by suicide than in controls ▪85% of youths who die by suicide using a firearm obtained it from home ▪Parents underestimate the likelihood that their children have or could obtain their firearms

Cultural Differences

• Different methods are more or less “acceptable” in

different cultures or subcultures

• In US poisoning is the most frequent method for
• attempts. Firearms are the leading method for suicide

deaths

• In Asia, it is pesticide poisoning
• Consider the cultures in your communities

Counseling Steps to Take

• Express your concern directly to client/family and

explain that you believe the individual is at risk for suicide

• Discuss access to firearms and medications (and other

lethal means as indicated)

• Inform the client/family that securing access to lethal

means reduces risk

• Discuss how to accomplish this as well as the need for
• ngoing supervision, treatment and follow up
• Document as needed

Organizational Steps

• Establish a Task Force on Reducing Access to

Lethal Means involving community partners and the firearm community

• Adopt widespread training in CALM
• Create protocols to include CALM (initial or

follow up) as part of Behavioral Health visits

• Work with partners to disseminate lethal

means reduction in a collaborative and respectful manner

CALM

Part 2

Video Discussion and Counseling

Key Principles:

• Create a collaborative relationship
• Focus on increasing safety not on

issues of trust or guns

• Language matters

Principles and Rationale

• Once there has been a threat or an

attempt, probabilities have shifted.

• Familiarity with firearms may

increase rather than decrease risk

Principles and Rationale

• When a gun is used, there is little

chance for a good outcome.

• Accessibility, impulsivity, and

emotionality are interactive and potentially dangerous.

Conducting a Home Fir irearms Assessment

• Involve all adults, especially males.
• How many firearms are in the

home?

Conducting a Home Fir irearms Assessment

• How are the firearms stored and

secured?

• What type of safety measures are

currently in place?

• Is ammunition accessible?

Conducting a Home Fir irearms Assessment

• Who uses the gun(s) or has

knowledge of their use?

• Is access to a firearm a job

requirement for anyone in the household?

• Is access to firearms needed for

home security?

Conducting a Home Fir irearms Assessment

• If firearms are kept loaded and

accessible, why is that the case?

• What changes can be made to

increase the safety of the situation?

Conducting a Home Fir irearms Assessment

• Is there someone trusted to hold firearms if they are removed?
• What barriers or obstacles exist to their removal?
• Can a solution be found that preserves the individual’s sense of

control?

• Follow up and document

Reducing Access to Fir irearms

• Temporarily removing all firearms from the home is the most

effective option

• Where to store them?
• Family and friends (if legally able to have guns)
• Police in jurisdictions where they are willing*
• Gun shops and ranges, pawn shops, shooting clubs*
• Self-storage units may be appropriate

*Background checks and/or fees may apply

Oth ther optio ions to reduce access if if removal is is not acceptable le

• Lock all firearms in a safe or in a lock box

(Trigger locks are effective for small children and as an added deterrent)

• Change combinations and/or key locations
• Store all firearms unloaded
• Lock ammunition separately or remove ammunition from the home
• Remove a key component of firearms – such as the firing pin or the bolt

What about a self lf-defense gun ?

• First, discuss probabilities of suicide attempt by person at risk versus

risk of home invasion

• If self-defense is essential, keep the self-defense gun either in a quick

access lock box or on their person (in a safe or on your hip)

• If the gun owner is the person at risk, seek therapeutic and/or

creative solutions to reducing access if suicidal. e.g. put pictures of loved ones on the lock box

Firearm Life Jacket Handgun Lock Box

Some Options for Locking Up Guns

Thin ings you mig ight say to a person at t ris isk

• What helps you feel better when you are feeling bad?

Who can you talk to? What activities help?

• Some people in situations like yours become suicidal.

What would help you stay safe if that happened?

• Given how you are feeling, do you trust yourself to

make life and death decisions?

• Remember, these are temporary safety measures until

you are feeling better.

Reducing Access to Medic ications

• Remove any out of date, unused and excess medications and over

the counter remedies (see handout for safe disposal)

• At risk person should not have control of quantities of medication

especially drugs of abuse

• Avoid policies that require for long periods of time. Short term

prescriptions can also provide a check-in for patients

Reducing Access to Other Methods

Suffocation Difficult to remove all possible means Focus on maintaining emotional and visual contact and other parts of the Safety Plan Other Methods Reduce access wherever possible Maintain contact Focus on the rest of the Safety Plan