The base rate for firearm ownership in the United States is commonly
underestimated by clinical psychologists and other mental health professionals.
Between 40% and 45% of American households own a firearm and the average
number of firearms owned is four. The number of firearms in the United
States exceeds the number of motor vehicles; there are approximately
85 firearms for every 100 people living in the United States. Recent
public opinion polls indicate that 85% of registered voters support
the right of citizens to defend themselves in their homes with firearms
– and 64% support the right of law-abiding citizens to carry
firearms outside the home. Since the September 2001 terror attacks,
gun sales are reported to have doubled in volume.
There is no evidence that suggests that these base rates for firearm
ownership are lower among psychiatric patients or those receiving
emergency psychological treatment. Rates of gun ownership have been
found to range from 60.4% in families of patients diagnosed with dementia
(Spangenberg et al., 1999) to 75% in a sample of combat veterans diagnosed
with chronic PTSD (Freeman et al., 1994). It is extremely likely that
a significant minority of patients encountered by mental health professionals
will personally own or have easy access to firearms. Nevertheless,
clinicians appear extremely reluctant to inquire about a patient's
access to firearms. Inquiry rates have been shown to range from as
low as 6% for patients receiving psychiatric and substance abuse treatment
at a university medical center (Carney, Allen & Doebbeling, 2002)
to only 42% for elderly patients being treated by an internist or
family practitioner (Kaplan, Adamek & Rhoades, 1998).
Approximately 60% of the people who die by suicide each year in the
United States use a firearm to kill themselves (NCHS, 2002). In any
given year, the majority of firearm-related deaths are suicides. Self-inflicted
gunshot is the most common method of suicide for both men and women.
(In the year 2000, 61% of male suicide completers used a firearm,
compared to 37% of females.) Self-inflicted gunshots are fatal 78%
to 90% of the time, making them the most "effective" means
of suicide by far (Annest et al., 1995). Because the suicidal crisis
is usually a transient, acute state marked by despair and complicated
by impulsivity, the presence or absence of a firearm can have tremendous
impact on the outcome of this clinical emergency. Some have estimated
that when a firearm is present in the home, the risk of death by suicide
is five times greater than when firearms are absent (Kellerman, Rivara
& Somes, 1992).
Death by firearm accounts for approximately 73% of all suicides by
older adults. Firearms are associated with approximately 74% of all
elderly male suicides and 31% of elderly female suicides (McIntosh,
Santos, Hubbard & Overholser, 1994). This "gender gap"
in suicide completion among older adults may be attributable to choice
of method. However, it is important to note that among women aged
65 and older, the use of firearms for suicide increased from 24% to
35% between 1980 and 1992. Since 1982, firearms have been the favored
method of suicide among older women. Despite these statistics, less
than half of psychologists treating older adults consider the presence
of a firearm an important risk factor to address in treatment (Brown,
2001). We contend that deficient screening for firearms increases
patient risk for completed suicide.
Restricting a suicidal patient's access to lethal means requires
the clinician to inquire directly about firearm ownership. The psychologist
should assiduously assess the presence of, access to, and knowledge
the patient has about this highly lethal means. Because the availability
of firearms, especially handguns, plays such a prominent role as the
"method of choice" for many completed suicides, the psychologist
should ensure that any weapons in the patient's possession are placed
in the hands of a third party (Bongar, 2002). This promises to be
no easy task: Kruesi et al.(1999) found that only 62.5% of parents
of adolescent suicide attempters removed their guns from their home
or stored them in a more secure manner after receiving firearms safety
counseling. Because of the strong association between firearms and
suicide completion, we recommend inquiring about access to firearms
with all patients, not only those with active suicidal ideation.
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standards of care, 2nd Ed. Washington, DC: APA.
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Standard of care practices. Unpublished doctoral dissertation,
Pacific Graduate School of Psychology, Palo Alto, CA.
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