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 or 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 occurred each year, 26 by firearm, many on weekends. • In 2006, IDF required soldiers to leave their weapons on 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
25 - 64 Suic icid ide Meth thods – In India iana 2015 7% 6% ALL AGES 15% 13% GUNS SUFFOCATION 49% POISON OTHER 54% 29% 27% 65+ 3% 11% 9% 77%
U.S. Youth Suicide, 15-24 year-olds Total Firearm Suffocation Poison Other
Methods of Self-Harm, U.S. Overdose/ Suffocation Poison Jump 2% Overdose/Poison 24% 16% Sharp 2% 83% Other 4% Firearm Sharp 11% 51% Other 4% Suffocation 1% Firearm 1% Nonfatal Self-harm Suicide Sources: Suicide: CDC WONDER (2013) Inpatient: HCUP-NIS (2005)
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.
Time Between First Occurrence of a Thought of Suicide and Suicide Attempt (Among Attempters Treated at a Hospital) Deisenhammer, 2009
Ambivalence Suicidal Behavior Among College Students Among the 5% who seriously considered attempting, past 12 mos n=1321 Began attempt, then reconsidered 15% Carried through an attempt 12% Drum, Brownson, Denmark, Smith. Professional Psychology: Research & Practice , 2009
Suicide Plans Among Attempters People who attempted suicide in past Had a Suicide Plan? 12 months No plan 43% Plan 57% Borges et al. Risk factors for twelve-month suicide attempts in the National Comorbidity Survey Replication (NCS-R). Psychol Med. 2006
Firearm Availability As A Suicide Promoter ▪ Suicide rates vary with rates of firearm ownership ▪ 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 ongoing 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.
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