The ongoing mental health crisis in America is coupled with an escalating suicide crisis that reached record highs in 2022, with nearly 50,000 deaths. Almost 55% of these deaths involved firearms. While gun control is usually discussed in terms of ending mass shootings, it will also stop a lot of self-inflicted violence. One of the best strategies for addressing this issue can saves lives, though it has an intimidating name: lethal means counseling.
Lethal means counseling is when — for the safety of a person in acute distress — firearms and dangerous medications are voluntarily and temporarily stored in secure areas. Many people undergoing mental health crises are at risk of hurting themselves, whether suicidally or unintentionally. Dr. Kurt Michael, the senior clinical director at The Jed Foundation, has seen many cases in which "a person’s access to lethal means is often a primary contributing factor as to whether death is the outcome of a suicide attempt," he said.
Perhaps the best way to illustrate lethal means counseling is through two morbid scenarios: In the first, a 20-year-old person in distress went to their father’s gun cabinet, removed a loaded firearm and shot himself in the head, dying within seconds. In the second scenario, he went to the gun cabinet and couldn't find any weapons. So he used a razor to open up his wrists and was found an hour later, rushed to the hospital and survived, agreeing to seek help.
While this trolley problem is indeed dark, it's a choice many people face every day. Lethal means counseling is a way to make the worst outcomes less likely.
While it is voluntary at first, lethal means counseling still requires a person to lose some of their immediate personal agency. Nevertheless, lethal means counseling seems justifiable because the temporary loss of freedom has the consequence of prolonging their lives. A similar argument can thus be made for mandatory waiting periods, which have been linked by the nonprofit think tank the Rand Corporation with lowered suicide rates as well as lowered violent crime rates. If a person wishes to shoot themselves but cannot easily obtain a gun, it is reasonable to assume they will have more time to reconsider that terrible decision.
Dr. Jacob Smith, an assistant professor of political science at Fordham University who has studied how gun control and mental health policies correspond to firearm fatalities, suggests this does indeed happen quite often.
"In our [2017 Policy Studies Journal] paper, we mostly looked at overall gun control policies and access to mental health rather than specific policies," Smith said, explaining that most states which implement gun control laws do so more with more than one, making it difficult to assess which laws have caused what specific effect. Despite this challenge, Smith and his team still found a definite pattern in terms of how gun control laws impacted suicide rates.
"What we do find in our research is that states with more gun control laws have fewer gun deaths (including those who die by suicide from guns) and for non-suicides (homicides and accidental discharge together), a combination of more access to mental health services and an overall stricter climate for gun control laws correlates with a particularly lower rate of gun deaths," Smith said. Specifically, the team found that more access to mental health care did not correlate with lower rates of suicide by gun; stricter gun control laws, however, had that desired impact.
"This relationship is perhaps due to the fact that many mental health treatments take time to have an effect, while the effect of removing a gun (or preventing one from having it in the first place) is immediate," Smith said, adding that more access to mental health care is still good for other reasons. "It is also very difficult under existing law to remove a gun due to mental illness, but having stricter gun control laws generally can either prevent (assault weapons ban) or delay (through background checks) when one has access to a gun."
The suicide crisis has hit young people especially hard, with suicide rates increasing most among children between the ages of 12 and 17. Magic Wade — an associate professor of political science at the University of Illinois Springfield whose 2023 study for the journal Homicide Studies found small cities have higher rates of gun violence than large ones — says that this is one reason to consider expanding child access prevention laws and increasing purchasing age requirements.
"These also enjoy broad-based support," Wade said. "According to a recent study by Crifasi et al. examining gun policy opinions of Americans from surveys conducted in 2017 and 2019, over 70% of respondents of any ethnicity (white, Black and Hispanics were compared in the study) support, 'Requiring by law that a person lock up the guns in their home when not in use to prevent handling by children or teenagers without adult supervision.'"
In fact, the data suggests that even purchasing a gun can be risky if one is predisposed to suicidality. Wade cited a 2020 study in the New England Journal of Medicine that studies gun owners in California over three decades. It revealed that new gun owners are at an increased risk of suicide first in the initial month and then for a full year after they acquire a firearm. One popular solution among policymakers is to implement an Extreme Risk Protection Order (ERPO) for people experiencing mental health crises. An ERPO allows law enforcement to remove firearms and ammunition from the home of an individual in that situation.
"21 states and the District of Columbia had enacted ERPOs, mostly since 2019," Wade said. "Such policies are still in the implementation phase where they need to be studied and potentially retooled or bolstered to maximize their intended effect. Notably, they are also typically geared toward preventing mass shootings, not suicides, although the latter is a welcome and logical byproduct."
She added that RAND conducted a systematic review of the research which found that ERPOs have “uncertain” effects on suicides and violent crime, although there is currently not enough time to accumulate evidence on their effectiveness. Despite this, Wade pointed out that as of 2023 "over 49 grants totaling roughly $200 million had been allocated for 'the creation and implementation of extreme risk protection order programs, state crisis intervention court proceedings, and related gun violence reduction initiatives'"
While the effectiveness of ERPOs is an open question, experts are more decisive about the effectiveness of other well-established gun control policies.
"If you look at overall gun deaths the link between gun control policies and firearms is strikingly clear — less gun control correlates almost perfectly with higher state firearm deaths overall," said Dr. John J. Donohue, a senior fellow at the Stanford Institute for Economic Policy Research who has done extensive research into gun control policy. "Part of that is gun control itself, part is that states with no gun control tend to have lots of guns in general, and part is poorer states tend to have less gun control."
He added, "Waiting period laws clearly reduce suicide and red flag laws can help if they are used. Beefing up background check systems and moving to universal background checks should also help. Safe storage laws have also been found to work. Not adopting right-to-carry laws also restrains violent crime as RAND has confirmed."
Yet gun control policies alone will not be enough to stop the rising tide of death. As Michael observed, mandatory waiting periods are most effective for first time gun owners. In many states the average household has seven to ten firearms, and therefore mandatory waiting periods cannot realistically prevent people in crisis from obtaining weapons.
"That is why as a first step, I urge individuals (or parents/guardians of minors) who have firearms to secure all of their firearms voluntarily with family or friends (or trusted others who are not legally prohibited from accepting a transfer of firearms) until the suicide crisis has subsided, especially for those deemed at imminent risk," Michael said. "If out of the home storage is not feasible or preferred, especially for firearms designated in the family’s self-defense plan, a work firearm, or for veterans who are very familiar and comfortable with firearms, I consistently recommend that families store those guns in a locked device, such as a small, push button safe to prevent access from unauthorized users."
Simply put, one does not have to be anti-gun to support policies that save lives. Michael described himself as "both a gun owner and a suicidologist" and as such "comfortable talking about both issues as they are inextricably linked." He says that as long as conversations about firearms are conducted in an apolitical, culturally respectful way, people can be saved on an individual level without government policy. That is where practices like lethal means counseling come into the picture.
"I have observed that many clinicians are hesitant or fearful to talk with their patients about firearms," Michael said. "They either don’t think that they have the qualifications to bring it up or believe that bringing it up will not make any difference in that person’s life. But in reality, culturally-affirming, honest, and empathy-based conversations that are respectful of an individual’s way of life can be life-saving." The goal for health care providers is not to confiscate the patient's guns, but to make sure they will not be used to harm themselves or someone else. In a compassionate system, this should be done in a way that consistently respects the patient's dignity.
"The focus is first on voluntary and temporary secure storage of firearms and respecting the family’s agency and right to self-determination in the matter," said Michael.
