Section VII Home

Behavioral Emergencies Update

Volume 4, Issue 2
Spring 2003
Section on Clinical Emergenices and Crises
American Psychological Assn.
Section 7 Contact Info

In this issue...

The President's Column: Has the Time Come for Required Training in Clinical Emergencies and Crisis Management?

Professional Development Institute at the 111th

How Do Clinicians Learn to Manage Behavioral Emergencies?

Assessing Access to Firearms: A Common Clinical Blindspot?

The Use of Validation in Family Adolescent Dialectical Behavior Therapy



Special Offer for Section VII Members



Assessing access to firearms:
A common clinical blindspot?

Bruce Bongar
Pacific Graduate School of Psychology and
Department of Psychiatry and Behavioral Sciences Stanford University
School of Medicine

Glenn Sullivan
Pacific Graduate School of Psychology

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.

Annest, J., Mercy, J., Gibson, D & Ryan, G. (1995). National estimates of nonfatal firearm-related injuries: Beyond the tip of the iceberg. Journal of the American Medical Association, 273, 1749-1754.

Bongar, B. (2002). The suicidal patient: Clinical and legal standards of care, 2nd Ed. Washington, DC: APA.

Brown, L.M. (2001). Suicidal risk factors with an elderly population: Standard of care practices. Unpublished doctoral dissertation, Pacific Graduate School of Psychology, Palo Alto, CA.

Carney, C.P., Allen, J. & Doebbeling, B.N. (2002). Receipt of clinical preventative medical services among psychiatric patients. Psychiatric Services, 53, 1028-1030.

Freeman, T., Clothier, J., Thortnon, C. & Keesee, N. (1994). Firearm collection and use among combat veterans admitted to a PTSD rehabilitation unit. Journal of Nervous and Mental Disease, 182, 592-594.

Kaplan, M.S., Adamek, M.E., & Rhoades, J.A. (1998). Prevention of elderly suicide: Physicians' assessment of firearm availability. American Journal of Preventative Medicine, 15, 60-64.

Kellerman, A., Rivara, F., Somes, G. (1992). Suicide in the home in relation to gun ownership. New England Journal of Medicine, 327, 467-472.

Kruesi, M., Grossman, J., Pennington, J.M., Woodward, P.J., Duda, D. & Hirsch, J.G. (1999). Suicide and violence prevention: Parent education in the emergency department. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 250-255.

McIntosh, J.L., Santos, J.F., Hubbard, R.W. & Overholser, J.C. (1994). Elder suicide: Research, theory and treatment. Washington, DC: APA.

National Center for Health Statistics (2002). Deaths: Final data for 2000. National Vital Statistics Report, 50.

Spangenberg, K.B., Wagner, M.T., Hendrix, S. & Bachman, D.L. (1999). Firearm presence in households of patients with Alzheimer's disease and related dementias. Journal of the American Geriatrics Society, 47, 1183-1186.