Navigating firearm safety discussions in clinical settings

When psychologist Michael Anestis, PhD, and his research team first met John*, the longtime firearm owner did not hide his skepticism about their discussion of secure firearm storage. “This is very stupid,” John told his counselor.

Anestis and his colleagues did not try to change John’s mind. As part of Project Safe Guard, a 2-year study on firearm suicide prevention, the researchers were using motivational interviewing—a technique that relies on open-ended questions and reflective listening—to understand, rather than challenge, participants’ perspectives. They asked participants how they stored their firearms, why they chose those methods, and what they would do if someone in their home were suicidal. Then, the researchers followed up 3 and 6 months later to see if anything had changed. At John’s 3-month follow-up, his stance remained firm: “I told you I wouldn’t make any of these changes because it’s a bunch of garbage.”

But before his 6-month follow-up, John and his fiancée separated. Shortly after, he gathered his seven firearms and handed them to his brother for safekeeping. “If I hadn’t had that first or second conversation with you, I would have attempted suicide,” he later told Anestis’s team.

The intervention involved no pressure or orders, just a conversation about firearms and storage practices. And when the moment came, John felt empowered to make a choice that saved his own life.

John was one of 232 firearm-owning members of the Mississippi National Guard who participated in Anestis’s study, published in 2021 (American Journal of Public Health, Vol. 111, No. 2, 2021opens in new window). The researchers found that providing free cable locks and administering lethal means counseling, where clinicians assess suicide risk and encourage safer storage of objects like firearms and medications, led to significant changes in how participants stored their guns. The findings reinforced Anestis’s belief in an approach to suicide prevention that “meets firearm owners where they’re at.”

More than half of suicides in the United States involve a firearm, making guns both the most common and the deadliest means of suicide (Kaczkowski, W., et al., Morbidity and Mortality Weekly Report, Vol. 72, No. 48, 2023opens in new window). Over the past 2 decades, findings like these have inspired new prevention strategies aimed at creating more time and space between firearms and someone experiencing a life crisis. Yet building the trust needed to implement these life-saving strategies remains difficult, especially given the charged political debates surrounding national gun policies. “There was very much an ‘us against them’ mentality across both sides of the issue,” said Anestis, who is also the executive director of the New Jersey Gun Violence Research Center at Rutgers.

For providers trained in medicine and psychology, predicting who will attempt suicide is a challenging puzzle. About 30% of those who die by suicide have a health care visit in the week before their attempt, and about half have seen a provider within the past month (Ahmedani, B. K., et al., Preventive Medicine, Vol. 127, 2019opens in new window). This makes firearm safety discussions in clinical settings increasingly crucial yet fraught with political and personal sensitivities.

In recent years, however, an unexpected alliance has emerged. Government officials, scientists, professional organizations like APA, and pro-gun leaders have begun working together toward a shared goal of saving lives. Collaborative efforts range from health care provider-led lethal means counseling to national education campaigns promoting secure firearm storage (Lemle, R. B., American Psychologist, Vol. 79, No. 9, 2024opens in new window).

These partnerships also offer a model for clinicians to approach firearm conversations in their practice—conversations that, when handled with care, can ripple outward and help shift cultural norms. “Our job isn’t to label people as bad or uninformed, or to force everyone to change,” Anestis said. “It’s to position people within their own value system to make healthy choices and stay safe.”

For some, like John, that conversation is all it takes.

*Name changed to protect their privacy.

Although there is no single path to recovery, most people who survive a suicide attempt go on to live out their full, natural lives: 9 out of 10 will not die by suicide at a later date, and two thirds will never attempt again (Owens, D., et al., British Journal of Psychiatry, Vol. 181, 2002opens in new window). But the difference between survival and tragedy is not solely a matter of chance: It can come down to what is within reach.

Firearms are uniquely lethal, with a gunshot proving fatal in about 90% of suicide attempts. By contrast, intentional overdoses lead to death only about 3% of the time (Conner, A., et al., Annals of Internal Medicine, Vol. 171, No. 12, 2019opens in new window). Many people think about suicide, but only a fraction act on those thoughts. When they do, the decision is often fleeting, with moments of acute risk lasting only minutes or hours. If a firearm is accessible in that brief, volatile window, the likelihood of death skyrockets.

Society expects mental health professionals to anticipate these crises and intervene before it is too late. After all, people trust mechanics to keep their brakes from failing and primary-care doctors to catch developing illnesses. But suicidal crises can emerge suddenly, making it difficult to predict when someone will attempt to take their own life, according to psychologists who study suicidality.

In one major literature review of people who died by suicide, about half had denied experiencing suicidal thoughts when screened a week or month before their deaths. Another meta-analysis of suicide risk among psychiatric patients found that standard assessment tools were so unreliable that those labeled “high risk” were actually less likely to die by suicide than those deemed “low risk” (Obegi, J. H., General Hospital Psychiatry, Vol. 72, 2021opens in new window; Large, M., et al., PLOS ONE, Vol. 11, No. 6, 2016opens in new window).

Providers can look for common warning signs—certain psychiatric diagnoses, recent trauma, losing a loved one to suicide—but suicide is an “incredibly heterogeneous” phenomenon, said Anestis. “There is a lot of variability in the events and thoughts that lead up to self-harm,” and rarely a single cause.

Another part of the problem, according to Anestis, is that many health care providers receive limited formal training in suicide risk assessment and intervention, particularly concerning firearm access. Only 12 states require health care professionals to complete suicide prevention training despite robust evidence that such training increases providers’ confidence in assessing and treating suicide risk. Even among those states, only Washington state explicitly requires that training include guidance on evaluating access to lethal means (“State Policy Can Improve Suicide Prevention in Health Care Settings,” The Pew Charitable Trusts, March 6, 2025opens in new window; Stuber, J., et al., Psychiatric Services, Vol. 74, No. 1, 2023opens in new window). “People don’t get enough suicide prevention training in general,” Anestis said. “When you zoom in closer and ask about assessing firearm access and lethal means counseling, the gaps are even larger.”

That gap is hazardous given how prevalent firearm suicide is, especially within certain communities, said Russell Lemle, PhD, a senior policy analyst for the Veterans Healthcare Policy Institute. In 2014, recognizing that veterans die by suicide at 1.5 times the rate of nonveteran adults and that firearms account for over two-thirds of veteran suicides (PDF, 2.1MB)opens in new window, he launched a pilot lethal means safety program within the San Francisco Veterans Affairs Health Care System. The program trained providers to counsel veterans on reducing access to several lethal means, including medications and sharp instruments, but was tailored to the unique role of firearms in veterans’ lives. (About 50% of veterans report owning a firearm, compared with 22% of Americans, and one-third of veterans report storing at least one firearm loaded and unlocked.) Six years later, the federal Department of Veterans Affairs (VA) expanded that initiative, mandating a version of the training for all 200,000 VA health care providers and Veterans Crisis Line responders (Cleveland, E. C., et al., Injury Epidemiology, Vol. 4, No. 33, 2017opens in new window; Nichter, B., et al., Journal of Affective Disorders, Vol. 351, 2024opens in new window).

“In terms of training its mental health workforce, the VA is way ahead of many other institutions,” Lemle said. “Effective suicide prevention requires an understanding of firearm suicide prevention.”

Without proper suicide prevention training, many providers are left trying to predict the near unpredictable. But while pinpointing exactly when someone will attempt suicide is difficult, evaluating access to lethal means is a proven way to save lives.

That is why emergency medicine physician Emmy Betz, MD, MPH, believes providers should expand their focus from predicting suicidal behavior to also preventing access to deadly methods during periods of crisis. “Because suicide risk can fluctuate, it’s especially important to make the environment as safe as possible for someone struggling through a difficult time,” said Betz, who is also the founding director of the Firearm Injury Prevention Initiative at the University of Colorado School of Medicine.

Emergency departments, like the one where Betz works, are critical sites for identifying people at risk of suicide. Each year, nearly 650,000 emergency room visits are directly related to suicidal behavior. Yet Betz’s research has found that lethal means assessment, specifically asking about a patient’s access to firearms, is far from routine. In a review of 800 emergency department charts of patients who screened positive for suicide risk, only 18% included documentation that a provider had discussed firearm or other lethal means access, despite most clinicians acknowledging the importance of these conversations (Psychiatry Research, Vol. 260, 2018opens in new window).

Some states have sought to pass laws restricting clinicians from routinely asking about firearm ownership or recording that information in medical charts. While often framed as efforts to protect patients from discrimination based on gun ownership, such laws can also hinder important conversations about firearm suicide prevention (Parmet, W. E., et al., The New England Journal of Medicine, Vol. 376, No. 20, 2017opens in new window). Even in the absence of explicit legal barriers, some providers hesitate to raise the topic out of concern for alienating patients, especially as firearm ownership becomes increasingly politicized. Others may simply lack experience with firearms themselves and feel unqualified to discuss secure storage practices.

Betz understands that hesitation firsthand. She did not grow up around firearms, and her medical training never covered firearm safety. So, a few years ago, Betz enrolled in a firearms training course led by another physicianopens in new window. “My time at the gun range taught me that maybe it’s not my favorite activity,” she said. “But neither is skydiving or rock climbing, and that doesn’t mean I can’t appreciate why other people enjoy or take pride in it.” While she does not believe every clinician needs firearms training, the experience helped her develop what she calls “cultural humility” in understanding how her patients think about gun ownership.

Anestis agrees that basic firearm literacy is essential for health care providers working with at-risk patients. “You don’t need to be an expert, but you should know the difference between a handgun and a rifle,” he said. “And you need to understand the storage options available so when you’re helping someone problem-solve how to make their home environment safer, you have something useful to say.”

That kind of thoughtful approach does more than build rapport. When health care providers discuss firearm access and secure storage, suicidal patients are 4 times less likely to attempt suicide or die by suicide. The key, according to Betz and Anestis, is framing the conversation in a way that respects patients’ values. Instead of focusing on gun control, clinicians should emphasize small, practical changes, like storing a firearm with a trusted family member or at a local gun range until a mental health crisis passes (Boggs, J. M., et al., Journal of General Internal Medicine, Vol. 35, No. 6, 2020opens in new window; Abaya, R., et al., The New England Journal of Medicine, Vol. 389, No. 18, 2023opens in new window).

While out-of-home storage is considered the most secure option, it may not be feasible or align with every patient’s preferences. “In-home access is important for many firearm owners to feel secure in their living space,” said Lemle. “We can acknowledge that out-of-home storage is the safest method while also recognizing that it may not align with some patients’ values. It’s not an all-or-nothing conversation.”

For those who prefer to keep firearms at home, clinicians can suggest strategies such as storing the firearm in a lockbox and placing the key in a less accessible location or giving it to a loved one. “The main point is putting some time and distance between a firearm and someone who is considering suicide,” Anestis said. The strategy is akin to using a designated driver after drinking: You are not taking away someone’s driver’s license or ability to drive forever but making sure they stay safe until the immediate risk has passed.

Firearm owners echo this sentiment. In multiple studies, patients reported being more receptive to discussions about gun safety when clinicians used language that aligned with their perspectives. Words like “temporary” and “voluntary” resonated better than “restriction,” and “access” felt less intrusive than “ownership.” When clinicians meet patients where they are, conversations are more productive, and outcomes improve (Khazanov, G. K., et al., Journal of Psychiatric Practice, Vol. 30, No. 2, 2024opens in new window).

In addition to direct conversations, providers can connect patients with resources that support safe decision-making outside of clinical settings. One such resource is Lock to Liveopens in new window, a free online tool developed by Betz that guides users through evaluating and securing potential hazards in their homes, including firearms, sharp objects, and medications. The site offers information on costs, legal requirements for firearm transfers, and practical strategies for securing medications while allowing for daily access. Betz also leads the Pause to Protectopens in new window program, which supports firearm businesses in suicide prevention efforts and provides an online map of businesses willing to temporarily store firearms.

For Betz, the goal is not to demonize firearms but to make these lifesaving decisions easier. “We know suicide risk shifts, sometimes within hours,” she said. “Our job is to help people get through those moments safely.”

In the mid-1990s, the Centers for Disease Control and Prevention (CDC) was barred from using federal funds to “advocate or promote gun control,” a restriction that effectively shut down research into firearm violence. That chilling effect remained until 2018, when Congress clarified that the CDC could, in fact, fund research on the issue.

By then, researchers had already begun expanding “the scope and quality of gun-related research,” determined to answer long-overdue questions about firearm-related deaths (Cook, P. J., & Donohue, J. J., Science, Vol. 358, No. 6368, 2017opens in new window). The new federal funding declaration reflected both the progress and the urgency of that work. It also energized scientists, clinicians, and policymakers to study gun deaths in new ways, including by distinguishing firearm suicide as an issue separate from firearm violence.

That distinction is crucial, according to Lemle. High-profile crimes and mass shootings dominate headlines, defining the national imagination of firearms while leaving suicide largely in the shadows, despite it accounting for most firearm-related deaths. Lumping suicide into broader discussions of firearm violence also creates a misleading equivalence: In homicide, the gun user is the perpetrator; in suicide, the user is the victim.

Lemle has spent years trying to bring that nuance to the forefront of discussions on the psychology of firearm-related harm. Witnessing gun-related violence increases the likelihood of suicidal ideation as well as depression, posttraumatic stress symptoms, and anxiety. These effects diffuse and shape the cumulative mental and physical health of entire communities, which, in turn, can contribute to even higher levels of neighborhood violence (Guidi, J., et al., Psychotherapy and Psychosomatics, Vol. 90, No. 1, 2021opens in new window; Semenza, D. C., et al., Journal of Urban Health, Vol. 100, No. 6, 2023opens in new window). But while firearm suicide and violence intersect, conflating them can be dangerous, especially for people struggling with suicidal thoughts. “The vast majority of individuals with mental illness are not violent,” Lemle explained. In fact, they are far more likely to be victims than perpetrators (Swanson, J. W., et al., Annals of Epidemiology, Vol. 25, No. 5, 2015opens in new window; DeAngelis, T., Monitor on Psychology, April/May 2021).

For psychologists and public health experts, the challenge involves addressing firearm suicide without reinforcing the stigma that prevents people from seeking help. According to Lemle, that begins with changing the conversation, both in clinical settings and in the way the public understands and talks about firearm suicide: not as an issue of crime or punishment, but one of access, timing, and intervention. “If Americans are going to take firearm suicide seriously, they first need to see it for what it is,” he said.

One of the most effective forms of intervention can happen in spaces where firearm owners already gather. In January, Lemle joined a panel on firearm suicide prevention at the National Shooting Sports Foundation’s Shot Show, a trade event that attracts more than 60,000 attendees from the shooting sports, hunting, and firearm manufacturing industries. “To have an open conversation about firearm suicide prevention at the heart of this event speaks to how far we’ve come,” Lemle said. “We’ve stopped talking past each other and started listening.”

Other initiatives like Gun Storage Check Weekopens in new window, held in June and September, bring together firearm manufacturers, suicide prevention groups, law enforcement, and veterans’ organizations to promote safe storage through a unified message to “Make Sure It’s Secure.” Meanwhile, states have increasingly adopted policies to distribute free cable gun locks and offer rebates for gun safes, measures that promote safety while respecting gun owners’ autonomy. Federal efforts to expand these programs, particularly for veterans,opens in new window are already underway.

For psychologists like Lemle, this momentum is a hopeful sign. Trust between health experts and firearm advocates has been hard-won, built on a shared recognition of loss. Many of the firearm owners now championing secure storage have lost someone—a friend, sibling, or child—to suicide. They know better than most that access to a firearm in a moment of crisis can mean the difference between life and death.

This understanding is reshaping norms in the firearm-owning community. Conversations that once felt impossible are now happening in clinics, firearm shops, and living rooms. Lemle believes the future of firearm suicide prevention will be measured in quiet victories: a firearm locked away before a moment of crisis, a friend asking the right question at the right time, a family having a conversation they might have once avoided. “We’ve reached a new frontier, and I’m deeply encouraged by the coalitions of pro-firearm advocates, clinicians, policymakers, and more coming together on this,” Lemle said.

Cultural change often happens slowly, then all at once. The hope, Lemle said, is that one day, secure storage will be as instinctive as buckling a seat belt—not a political statement but a reflex. And that when someone is in crisis, they will have more than just a firearm within reach.