Brief Interventions to Maintain Safety | Part 2 Lethal Means Counseling
A second key intervention to implement with any client at risk of suicide - whether current thoughts of suicide, past ideation, or a previous attempt - is restricting access to lethal means (see also Part 1: Safety Planning). This evidence-based intervention is an important component of a comprehensive safety plan and focuses on limiting access to methods such as firearms or prescription medications that could be used in a suicide attempt. Restricting access to lethal means is essential for anyone at risk of suicide and is among the most effective strategies for preventing suicide - for several reasons:
1. Suicidal Crises can be Brief and Impulsive
Many suicidal actions are impulsive responses to what may be a brief crisis, with the acute period of heightened risk often lasting only hours or even minutes. During this time, if a person has easy access to lethal means - such as firearms, medications, or sharp objects - the likelihood of a fatal outcome increases significantly. Often, individuals in the midst of a suicide crisis are emotionally dysregulated, overwhelmed, and unable to think clearly enough to consider alternatives. In many cases, when given time to calm down or think things through, people choose not to act on suicidal thoughts.
2. Means Matter
The lethality of a suicide attempt depends heavily on the method used. In the United States, the majority of suicide deaths involve firearms. Because firearms are both highly lethal and readily accessible, they are a major focus of all lethal means counseling. Research shows that when access to highly lethal means is restricted, and someone in a suicidal crisis resorts to less lethal methods or delays the attempt, the chances of survival significantly improve.
3. Delay can Increase Survival
Creating any delay between a person’s thoughts of suicide and their ability to act can significantly increase the chances of survival. Even if the person proceeds with an attempt, using less lethal means offers a greater opportunity for them to reconsider, seek help, or be interrupted in the attempt and survive. Up to 90% of those who survive a suicide attempt do not go on to die by suicide later, highlighting the importance of restricting access to lethal means as a life-saving intervention.
Talking to Clients about Lethal Means Safety
As you work through the development of a safety plan with your client, you will naturally come to Step 6 - Making the Environment Safe, which opens up the conversation about lethal means safety. If your discussion does not follow from safety plan development, you can begin by acknowledging the fact that suicidal thoughts are present, or have been an issue in the past, and that you would like to talk about ensuring a safe environment. The following information, adapted from Means Matter, can be helpful:
Explain the Importance of a Safe Environment
If your client is not actively experiencing thoughts of suicide, they may not understand the importance of maintaining a safe environment. It is helpful to explain the impulsivity that can be associated with suicide attempts and the fact that, while they may not be experiencing thoughts of suicide right now, these thoughts can arise suddenly when under stress. Some clients also benefit from understanding how brain function is affected by stress, which can impair clear thinking and decision-making abilities.
Reinforce with your client that any steps they can take in advance of a crisis to limit access to means can serve to increase their safety. Remember here to focus on all environments. This is particularly important for young people in shared custody arrangements, where they may navigate multiple homes.
Ask About Firearms
Always ask your client about firearms and explain that their presence increases the likelihood that a suicide attempt will be fatal. It can be hard to ask about firearms but you should never just assume that your client does not have access to a gun. While they may not personally own a firearm, they may live with someone who does (e.g. a police officer, veteran, or hunter).
Suggest to your client that the safest option is not to have firearms at home until their situation improves. It can be helpful to emphasize the temporary nature of this action as for some people removing guns from the home can be very difficult and leave them feeling vulnerable. This can be particularly true for an individual experiencing PTSD who may see gun ownership as providing safety. If firearms cannot be removed they should be unloaded (or disassembled) and locked in a gunsafe lock box. Simply hiding guns is not a safe option as people, especially children, often find them. (See HERE for information on talking to veterans about safe storage).
Engage Family and Other Supports
Whenever possible, it is good to obtain releases to talk with family or other supports about your client's safety. Educating others about the impulsive nature of some suicide attempts, as well as the impact of access to lethal means, can increase participation in the establishment of a safe environment. Again, while it can be difficult to talk about gun ownership, one suggestion from the Means Matter site is to approach it as follows:
“I am concerned that [CLIENT] is struggling a little right now and has been experiencing some suicidal thoughts. I am not concerned for their immediate safety, but we know that emotions can escalate, and I’d like to work with you to make sure that we increase safety in the home.”
“When it comes to suicide, the most lethal method of attempt (and death) is firearms, and the most common method of attempt (but not death) is medications. So let’s start there.” [from meansmatter.org]
Address Medications
For any client at risk for suicide, medications should not be kept in large quantities in the home. This is particularly important for prescription painkillers due to their lethality and potential for misuse. Encourage your client (and family) to lock away medications that are not immediately needed (including OTC medications) and to safely dispose of any expired or unwanted medications. It is helpful to reinforce that the goal here is to limit available medications to a quantity that if taken impulsively would not cause serious harm.
Don’t Forget Alcohol
Alcohol can both increase the chance that your client acts impulsively and increase the lethality of a drug overdose. It is a good idea to discuss limiting alcohol use when feeling overly stressed. While this can be challenging for many people who feel that alcohol is the only way they can, in fact, not feel stressed, it is a good idea to underscore its impact and when possible encourage clients to keep only small quantities at home.
Work Collaboratively
Establishing a safe environment requires that your client is actively invested in their own safety. One helpful approach is to have your client begin to describe how they would go about establishing a safe home environment. Encourage them to think through practical steps, such as identifying who can support them and where potentially harmful items can be securely stored. Collaborating in this way to develop clear, actionable steps not only helps with logistics but can also foster greater ownership of the intervention plan, increasing the likelihood that your client will follow through.
Document the Plan
Document all discussions you have with your client and their family or support network regarding reducing access to lethal means. Detailed documentation is important, particularly when reviewing the plan at subsequent sessions. For example, note who agreed to move a weapon, where they planned to store it, and other specifics.
Even if there is no indication of the presence of lethal means, it is good practice to write out, for example, “client denied any access to a gun,” rather than simply checking a box in your EMR. This demonstrates that the conversation took place and that you are aware of the importance of this element in your overall plan for safety.
Follow Up
Like safety planning, discussing access to lethal means is not a one-time discussion. It is important to follow up with your client to ensure that they followed through on any established plan to restrict access, explore any additional concerns, and modify as needed. Should your client travel to visit friends or relatives, and there are continued concerns regarding thoughts of suicide, it is always good practice to ask about lethal means access at their new location.
Common Questions About Lethal Means Safety
When discussing restricting access to lethal means, two key questions often arise:
Won’t a person simply substitute one method for another?
Why focus mainly on firearms and medications—what about other methods? Doesn’t everyone have access to items like ropes, belts, or sharp objects?
While substitution of methods can happen, it does not always happen, and the focus on firearms and medications is due to their high lethality. As mentioned, firearms, in particular, have an extremely low chance of survival once used in a suicide attempt—there is no opportunity for reconsideration or reversal. In contrast, other methods may allow for a change of mind, offering an opportunity for a life-saving intervention. In other words, there is far more time for someone to interrupt the attempt, for someone to change their mind, or, if found later, a greater chance of survival.
Of course, if your client expresses thoughts about using other methods, such as hanging or ingesting harmful substances, it is equally important to address access to these means. For example, if a client mentions poisoning, cutting, or hanging themselves, it is essential to discuss removing ropes, chemicals, or sharp objects from the environment.
It is important to recognize that you cannot remove every potential means of suicide, nor can you control what a client does outside your presence. This reality is one of the most challenging aspects of working with at-risk clients. However, you can do everything within your power to emphasize the importance of creating a safer environment. By limiting access to lethal means, you give your client a critical opportunity to pause, reconsider, and seek help before taking irreversible action.
Summary
Reducing access to lethal means for individuals at risk of suicide is one of the most effective interventions to reduce suicide deaths. In talking with your clients about their thoughts of suicide, your goal is always to promote interventions that can put a barrier between these thoughts and their capacity to act. This focus on DELAYING SUICIDE ACTIONS can make the difference between life and death.
Resources for Clinicians
Counseling on Access to Lethal Means (CALM)
This free video-based training, developed through the Suicide Prevention Resource Center (SPRC), addresses means restriction and provides guidance on how to work with clients on restricting access to lethal means.
Lock to Live
This evidence-based decision-making aid can guide in how to reduce access to potentially dangerous things, like firearms, medicines, sharp objects, or other household items.
Means Matter
The Means Matter Campaign, part of the Harvard School of Public Health, promotes activities that reduce a person’s access to lethal means of suicide. This site provides detailed information for clinicians on how to address access to lethal means with clients.
Further Reading
National Action Alliance for Suicide Prevention. Lethal Means Stakeholder Group. (2020). Lethal means & suicide prevention: A guide for community & industry leaders. Washington, DC: Education Development Center.
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