Identifying Effective Approaches to Counseling on Firearm Safety

Each year in the United States (U.S.), over 40,000 individuals die by suicide, and
approximately half of these deaths occur by intentional, self-inflicted gunshot wounds. Given
these staggering statistics, efforts to minimize individuals' access to firearms during
at-risk periods has been identified as a critical if fraught suicide prevention strategy.
Among individuals at risk for suicide who present to clinical settings, a crucial component
of the clinical management of suicide risk is to ask about firearm ownership/access and
counsel on firearm safety (e.g., encourage an at-risk person to transfer the firearm to a
loved one until risk abates). Despite the clinical, ethical, and in some cases legal mandate
of this intervention, a substantial proportion of clinicians are woefully undertrained and
therefore unprepared to manage suicide risk and appropriately deliver counseling on firearm
safety. Clinical and empirical evidence suggests that even among patients identified to be at
increased risk for suicide, few clinicians ask about firearms or provide counseling on
firearm safety. One key reason for this fissure between recommendations and actual
implementation of recommendations is that strategies for discussing firearm safety in a way
that is impactful and yields patient adherence to recommendations have yet to be established.

One common approach to attempt to garner pro-health behavior change is the use of fear
appeals; however, research on the utility of this approach across non-firearm-related health
interventions has been equivocal. Given the cultural importance placed on firearms in the
U.S., the investigators contend that fear-based approaches to lethal means counseling may be
counter-productive by creating defensive avoidance, thereby detracting from the purpose of
counseling on firearm safety (i.e., patient safety).

Further, patient adherence to recommendations to limit access to a firearm during at-risk
periods may be increased when clinicians emphasize that limits on firearm access will decline
when suicide risk abates (i.e., limits on firearm access will likely not be permanent).
However, research has yet to determine if varying the level of fear messaging and/or emphasis
on temporariness is actually useful and acceptable.

To address this gap, the investigators will randomly assign participants to one of four
experimental conditions: (1) low-fear/not-temporary; (2) low-fear/temporary; (3)
high-fear/not-temporary; and (4) high-fear/temporary. Participants include undergraduate
students who are vulnerable to suicide and reported owning or previously owning a firearm,
reported access to a firearm, or reported possibly obtaining a firearm in the future. The
investigators hypothesized that individuals randomly assigned to the low-fear/temporary group
will (1) report greater intentions to adhere to recommendations to limit access to firearms
during at-risk periods than the other groups at both post-intervention and one-month
follow-up; (2) report greater actual adherence to recommendations at one-month follow-up; and
(3) rate the lethal means counseling session as more acceptable than the other groups.
Exploratory aims examined if the effects differed for individuals reporting actual current
firearm ownership or access, membership in the National Rifle Association (NRA) or a similar
organization, political affiliation, political ideology, greater personal importance of the
Second Amendment, or severity of suicidal symptoms. Findings have the potential to inform
clinical and public health approaches to limit at-risk individuals' access to firearms for
safety purposes.