Firearms lethal means safety among Veterans: Attitudes toward involving a concerned significant other

Abstract

Introduction:

This quality improvement project evaluated the acceptability and feasibility of involving concerned significant others (CSOs) in lethal means safety with Veterans who had suicidal ideation or a prior suicide attempt.

Methods:

Using a mixed-methods design, dyads were recruited to participate in qualitative interviews on current practices, attitudes, and recommendations related to secure firearm storage from the Veteran and CSO perspectives. Veterans (n = 29) and their CSOs (n = 4) were individually interviewed.

Results:

A majority of Veterans (n = 25) emphasized the importance of engaging in safe firearm practices, and many indicated that they wanted to discuss firearm access openly. In addition, most Veterans (n = 26) were receptive to a CSO limiting firearm access. Although the number of participating CSOs was small, all (n = 4) indicated a willingness to securely store firearms and emphasized the importance of having direct conversations about firearm storage with Veterans.

Discussion:

Findings provide initial support for receptiveness toward a person-level intervention incorporating a CSO into firearm safety planning for Veterans at risk for suicide.

Lay Summary

Firearms are the most common lethal means of suicide used by Veterans. Secure storage of firearms is linked to decreased risk for suicide. To prevent death by suicide via firearm, Veterans’ viewpoints on secure firearm storage and discussions on lethal means safety need to be understood. As part of a quality improvement project, the authors interviewed Veterans who experienced suicidal thoughts or attempts, as well as their family members or friends (designated as concerned significant others, or CSOs), to understand their views, practices, and recommendations on secure firearm storage. Overall, Veterans understood the importance of safe firearm storage practices and wanted to have open and direct conversations about secure firearm storage and mental health. The Veterans’ CSOs had similar viewpoints in that all were willing to assist with safe firearm storage in times of suicidal distress or crisis, and they would approach discussions on secure firearm storage and suicide prevention directly. Findings support the acceptability of involving a CSO in a lethal means safety intervention for Veterans who own firearms.

Introduction

Suicide is a significant public health issue in Veteran populations, with 33.9 per 100,000 U.S. Veterans dying by suicide in 2021.¹ Firearms are the most frequent means of death by suicide among U.S. Veterans, likely because they are the most lethal.¹ Nearly half of all Veterans own a firearm,² and one in three of those owners keep at least one firearm unlocked and loaded.³ As part of their military service, Veterans are typically trained in and comfortable using firearms, which may contribute to the frequent use of firearms in deaths by suicide among this population.⁴ Thus, firearm ownership is common and, as noted, accounts for the highest rate of death by suicide in Veterans.¹

Secure firearm storage can lower use of firearms in suicide attempts. Among civilians, suicide rates are lower in homes in which firearms are stored unloaded and secured and ammunition is stored separately.⁵ Furthermore, states that have restrictive gun laws have lower suicide rates.⁶ Similarly, among Veterans discharged from psychiatric inpatient settings, those who lived in states with more restrictive gun laws were less likely to die by suicide.⁷ Although limiting access to lethal means has been recommended as a focus for suicide prevention in the United States, there continue to be challenges to the implementation of some recommended lethal means restrictions.⁸ Initial evidence has shown that a brief community-based intervention consisting of secure storage methods, as well as distribution of gun locks and gun safes, may improve rates of secure storage.⁹ Furthermore, in other countries, when access to means is limited via public health, regulatory approaches, or circumstances rendering the lethal method difficult to obtain, deaths by suicide drop precipitously.^10,11 Thus, limiting access to lethal means has the potential to dramatically reduce suicide rates, yet there are few interventions at the individual level.

Of the few that exist, the most notable are brief counselling from a physician or health care provider and community-based interventions.^9,12–15 Some literature indicates that even brief discussion of lethal means safety with a health care provider, pamphlets, and provision of gun locks results in improved secure storage practices.^12,13,16 Similarly, another intervention that installed long gun cabinets in households and provided secure storage messaging also improved secure storage practices.¹⁷ However, other brief lethal means counselling interventions did not change secure storage practices.^18–20 Finally, none of these approaches involved concerned significant others (CSOs) limiting access to lethal means or assisting in safe firearms storage.

Recent research indicates that Veterans would like assistance from individuals, such as friends and family members, in managing suicide risk.²¹ Despite growing evidence indicating that Veterans desire conversations on firearms safety, there is a lack of knowledge of whether Veterans at heightened risk for suicide also want assistance with safe firearms storage. Moreover, there is little guidance on how to frame these challenging conversations. One study noted that female Veterans preferred conversations about firearms access be initiated by family members when there were suicide risk concerns.²² When a conversation is initiated by a health care provider, Veterans emphasized that the provider should already have established trust and use a non-judgemental approach.^22,23 Furthermore, little is known about CSOs’ willingness to be involved in this process and how they think discussions about limiting access to firearms should be framed.

Given the mixed evidence in the literature, and lack of involvement by CSOs in firearms lethal means safety, a crucial next step in developing Veteran firearm interventions would be to solicit thoughts and ideas from Veterans and CSOs about involving a CSO in secure storage of firearms. Therefore, this evaluation examined 1) current firearm storage practices among Veterans with a history of suicidal ideation or attempts, 2) Veterans’ attitudes toward assistance with secure firearm storage from a CSO, 3) CSOs’ attitudes toward assisting Veterans with secure firearm storage, and 4) CSOs’ recommendations for discussing safe firearm storage with Veterans.

Methods

Project

The parent evaluation, a mixed-methods quality improvement project, was designed using a multiple case study, or collective case, design.²⁴ Here, the authors specifically report on a subset of data from qualitative interviews in which dyads were recruited to participate. The goal was to determine the acceptability and feasibility of involving CSOs in lethal means safety planning. The local Veterans Affairs (VA) Research Service reviewed and determined that the project was not considered research. Although details of methods are published elsewhere,^21,25 the authors provide a brief overview following qualitative guidelines.²⁶

Research team and reflexivity

Personal characteristics and relationships with participants

The entire research team was female and composed of two PhD-level psychologists, a PhD-level social worker, a master’s-level social worker, and a doctor of public health. The psychologists and PhD-level social worker were researchers at the time the project was conducted. The master’s-level social worker was a clinician, and the doctor of public health was retired. The PhD-level social worker, with prior training in qualitative research, led the qualitative analyses. The psychologists both had extensive training in clinical research, and the doctor of public health and the master’s-level social worker contributed expertise in suicide prevention. A trained master’s-level female research assistant conducted the qualitative interviews.

The authors had no prior relationships with participants, and participants did not have prior information regarding the project. Participants were given information regarding the goals of the project before their participation.

Study design

Theoretical framework

A systematic, iterative, and directed content analysis method was used to guide this evaluation.^27–29

Setting and participant selection

Participants were recruited from a large medical centre serving Veterans in the southern United States. Veterans were invited to participate through flyers distributed throughout the medical centre, presentations to Veterans receiving mental health services at the local VA health care facility, and through Veterans participating in other research studies. In addition, targeted recruitment of Veterans with a diagnosis of posttraumatic stress disorder, depression, or schizophrenia listed in their electronic medical records took place via invitations sent by mail. Letters and flyers requested that participants call the study phone number if they were interested in receiving additional information. Warm calls were also used to reach out to Veterans who were sent a letter. Overall, 29 Veterans and 4 CSOs were enrolled in the study. Non-participation before enrollment was not tracked. No one else was present during interviews aside from the participant and the interviewer.

Sample

Sample demographics are provided in Table 1. The inclusion and exclusion criteria were purposefully broad to maximize generalizability. Inclusion criteria for a Veteran included 1) enrollment in the local VA health care system, 2) minimum age of 18 years, and 3) having experienced suicidal ideation or a suicide attempt in the past. Exclusion criteria included imminent risk warranting crisis intervention; however, no participants were excluded for this reason.

Table 1.

Sample characteristics

Variable	n (%)
	Veterans (n = 29)	CSOs (n = 4)
Age, y, mean (SD)	47.9 (11.1)	33.3 (3.3)
Gender
Female	6 (20.7)	3 (75.0)
Male	23 (79.3)	1 (25.0)
Hispanic or Latino	0 (0.0)	1 (25.0)
Race
Black or African American	16 (55.2)	2 (50.0)
White or European	10 (34.5)	2 (50.0)
Multiracial	3 (10.4)	0 (0.0)
Suicidal ideation and attempts
Prior suicide attempt	18 (62.1)	—
Suicidal ideation, no suicide attempt	11 (47.9)	—
Mental health diagnosis*
Posttraumatic stress disorder	19 (65.5)	—
Schizophrenia or schizoaffective disorder	10 (34.5)	—
Major depressive disorder	9 (31.0)	—
Bipolar disorder	7 (24.1)	—
Alcohol or other substance use disorder	2 (6.9)	—
Other mental health disorder	5 (17.2)	—
Relationship to Veteran
Spouse or partner	—	2 (50.0)
Adult child	—	1 (25.5)
In-law	—	1 (25.5)

CSOs = concerned significant others.

^*Categories are not mutually exclusive.

Although it was not required, eligible Veterans were asked whether they had a CSO willing to participate. A CSO was broadly defined as a partner, a spouse, a friend, a parent, a sibling, an adult child, or other family member willing to participate in the Veteran’s mental health care. Eligibility requirements for CSOs included 1) age 18 years or older and 2) not at imminent risk for suicide.

Data collection

Procedure

A telephone screening was administered to determine initial eligibility, after which the Veteran or CSO was scheduled for a one-time, hour-long, face-to-face individual interview. Collection of qualitative data used an inductive approach and content analysis as the analytic framework.^27–31 Interview questions were framed around the topics of Veteran perspectives on CSO involvement and safe firearm storage recommendations. Interviews with Veterans and CSOs were conducted at the VA facility separately. To assess suicide risk, the University of Washington Risk Assessment Protocol was administered both before and after the interview.³² No participants were determined to be at high risk of suicide warranting crisis intervention during this project. This analysis uses a subset of data from a larger parent study on the broad role of a CSO in safety planning for suicide prevention.

Measures

Demographic questionnaire and mental health history

A demographic questionnaire was used to assess race, gender, age, relationship status, employment status, and military history. History of mental health disorders was gathered from the Veterans’ medical records.

Qualitative interview questions

An interview guide was developed for the project. For this analysis, a subset of questions specific to firearms was used. Veterans were asked a series of questions, including “Would you be willing to have a CSO safely store your firearm if you are having thoughts of suicide?” and “Do you have any recommendations for how to discuss safe storage?” CSOs were asked similar questions, including whether they would be willing to store their Veteran’s firearm if their Veteran was experiencing suicidal ideation and recommendations for discussing secure storage of firearms.

No notes were made during or after the interview, and there were no repeat interviews. All interviews were recorded and lasted approximately 60 minutes. Transcripts were not returned to participants for comment or correction. Given that this evaluation focused on feasibility and acceptability, saturation was not deemed necessary or appropriate.

Analysis and findings

Data analysis

A codebook was created through an inductive approach. The textual data were analyzed from familiarization to theme identification to indexing.³³ Transcripts were reviewed using the codebook. Important themes were identified and categorized by a coding team. Trained research assistants (n = 6) applied top-level codes established from the study aims and the interview guide to the transcriptions using the codebook. Thematic codes that were “grounded” (i.e., associated with five or more quotations) were sub-coded.³⁴ Quotations related to each top-level code were reviewed, and sub-code schemes were developed. The sub-code and definitions were documented in the codebook. These were applied independently to each top-level code individually. A similar procedure was conducted for sub-level coding, with important quotes identified during the procedure. Demographic data were analyzed via IBM SPSS Statistics, version 21 (IBM Corp., Armonk, NY), and organization of coding was conducted in Excel.

Results

Demographics

Demographic characteristics of Veteran (n = 29) and CSO participants (n = 4) are provided in Table 1.

Current storage practices among Veterans with a history of suicidal ideation or attempts

Three Veterans (10.4%) did not have a firearm in their home because someone else was storing it for them. One Veteran stated, “I told them … I’ve got these two pistols and I want you to hold onto these for me … you can have them because I don’t have any use for them” (Participant 739). For these three Veterans, CSO involvement appeared to be an acceptable strategy to limit lethal means. A few Veterans (n = 3; 10.4%) indicated that they had no desire to own a firearm. One Veteran stated, “Don’t have to worry about firearms; I don’t have any for my own safety” (Participant 636), and another reported, “I will not own a gun. I am totally anti-firearm” (Participant 247). Other reasons included being unable to own a firearm (n = 2; 6.9%) and not being interested in owning a firearm (n = 1; 3.4%).

Veteran attitudes toward safe firearm storage

Most Veterans thought it was important to engage in secure firearm storage practices (n = 25; 86.2%). Despite that, all Veterans who participated had a history of suicidal ideation or attempts. One Veteran stated, “I don’t believe that people who have had suicidal ideations or have had suicidal attempts, I don’t think it’s right for them. I don’t think they should even consider owning a gun of their own volition” (Participant 903). Another Veteran described their secure storage practices, saying, “It’s locked up in a safe anyway, that’s a combination and a key, so by the time you get the damn thing open you’ve usually changed your mind because thank God it takes forever to get open” (Participant 439). One Veteran relayed, “I think all guns ought to have a trigger lock” (Participant 326). Thus, most Veterans in the sample thought safe firearm storage was an important practice.

Veteran recommendations for discussing safe firearm storage

Veterans indicated that it was important to have frank communications regarding safe firearm storage. Veterans stated, “Just be open and blunt” (Participant 677) and “It’s not time to beat around the bush. Just say it … Ask the question, that’s all” (Participant 209). Another Veteran (n = 1; 3.4%) recommended taking a non-judgemental stance regarding firearm ownership and to work collaboratively with Veterans to find solutions to secure storage, stating,

A Veteran might feel like if I had a gun and I was like mentally ill … my first thing would be like my rights are being violated. So, the approach should be like to, I’m not here to say that guns are bad, I’m not here to say that you’re going to use it, but can we work together and make some safeguard so that you will be taken care of … make the person relax and comfortable instead of just saying, you know, well, oh, we have to take these. (Participant 721)

Another Veteran (n = 1; 3.4%) indicated that a safety plan for firearm storage is crucial in a situation involving suicide risk, stating, “You need … a plan where you can get the gun away from them” (Participant 032). Similarly, one Veteran relayed, “Have it written down and then here’s the thing, if you’re having suicidal ideations, this might be a few good safety tips” (Participant 362). One Veteran indicated a key point is to “just point out that the risk of firearms and suicide are great and for your own safety and the safety of others around you that it would be in your best interest to have somebody else holding on to them” (Participant 555). Overall, Veterans generally recommended secure storage be discussed openly and bluntly. They believed that Veterans who were at risk should not have weapons and that if they did, the weapons needed to be stored and locked up. Notably, Veterans did recommend creating plans regarding secure storage that involve a CSO.

Veterans’ attitudes toward CSO involvement in firearm storage

Most Veterans (n = 21; 72.4%) were accepting of a CSO storing firearms or assisting them in limiting access to firearms. They felt CSOs should do anything in their power to keep the Veteran safe. One Veteran relayed, “I would put them in his possession because … in mine … it could create a problem” (Participant 653). One Veteran reported, “There was a time I wouldn’t [want a CSO involved] but at this time I would” (Participant 498). Another Veteran relayed, “I’d say leave them with someone you trust … most times you can tell when something is wrong with somebody” (Participant 399). One Veteran commented that the CSO might provide additional insight, stating, “Maybe she’d recognize something I didn’t” (Participant 498). Surprisingly, most Veterans were willing to have CSOs store firearms or assist in limiting access.

Although many Veterans indicated they wanted help with storing firearms, one Veteran noted, “Some would be ok with it; others would not (Participant 377). Another Veteran (n = 1; 3.4%) indicated that her relationship with her CSO (her ex-husband) was not amenable to this type of intervention. She stated, “He was trying to get me to kill myself” (Participant 406). A few Veterans (n = 4; 13.8%) indicated that involving a CSO was not applicable to them because it was not a method they thought of or used previously, or they did not own a firearm.

CSO attitudes toward assisting Veterans with secure storage of firearms

Most CSOs (n = 3; 75%) said they did not have a firearm in their home, but that if they did, they would be comfortable storing it. One CSO relayed, “I don’t use guns, but if I had to, I’d go to a gun shop and buy a gun lockbox with a trigger lock on it” (Participant 3629). One CSO indicated there was a firearm in the home to which the Veteran had access primarily for the purpose of safety from intruders. The CSO stated,

We do. It’s locked but it’s still in the home … I tried to make him completely get rid of it. He got so angry, and so I guess I just didn’t want things to escalate so I just gave it back to him, but he put it somewhere the kids can’t reach, and him and I know where it is. (Participant 9288)

Thus, although most CSOs’ homes did not have firearms, in the one home in which the Veteran and their family did own a firearm, there was some disagreement regarding whether the firearm should remain in the home.

CSO recommendations for discussing secure storage of firearms with Veterans

All CSOs were willing to talk about secure storage of firearms with their Veterans (n = 4; 100%). CSOs thought the best way to discuss secure storage with Veterans was to be upfront about the subject. CSOs suggested starting with factors other than secure storage, such as reasons for living, and assuring them that the crisis was not their fault. One CSO stated,

I guess you can, especially when they’re stable and focused on their life, then explain how important their life is because when you’re in depression or suicidal thoughts, I’m sure you’re not thinking about the future so I wouldn’t know what to tell them in regard to that. (Participant 6790)

Another CSO relayed, “Letting them know first, it’s not their fault” (Participant 9288). Thus, all CSOs were willing to start a dialogue with their Veterans regarding safe firearm storage.

Discussion

This evaluation of the attitudes, practices, and recommendations from Veterans and CSOs about safe firearm storage has several preliminary findings. First, among the sample of U.S. Veterans interviewed, current practices with storing firearms among gun owners included some Veterans being willing to have others store firearms when in a crisis state. Regarding attitudes, Veterans who experienced suicidal ideation or a prior suicide attempt indicated it was prudent to limit access to firearms for those at risk of suicide. This is consistent with prior literature in that Veterans at risk of suicide noted that secure storage of firearms and limiting access provided time to move past the suicidal crisis.³⁵ Although many Veterans at risk of suicide were open to having a CSO assist with firearm storage, some Veterans noted that not everyone would be open to assistance from a CSO. When offering recommendations, many at-risk Veterans, and all CSOs, wanted to have candid discussions about safe firearm storage to prevent suicide.

Next, CSOs’ attitudes toward assisting Veterans with safe firearm storage were consistent. Although most CSOs interviewed did not have firearms in their homes, all expressed interest in providing this assistance. The CSOs offered recommendations on prompting a conversation with Veterans about secure storage of firearms. They noted that the discussion should be open and honest and provide reasons related not to firearms but to hope and reasons for living. This approach may help avert suicide and deescalate if Veterans are in a mental health crisis.

These preliminary findings indicate that Veterans at risk of suicide want to have frank discussions about access to firearms. Interestingly, some at-risk Veterans indicated they already had someone else storing their firearms. This combination of direct conversations and involvement of others may provide new directions for preventive interventions designed for Veterans and CSOs. Specifically, on the basis of both Veteran and CSO recommendations, such interventions might include Veterans creating secure storage plans with the involvement of a CSO and working collaboratively to identify feasible solutions for secure firearm storage. This further reinforces the notion that Veterans are willing to allow CSOs to assist in storing firearms. The results from this evaluation are consistent with findings from a study of female Veterans in which participants indicated they preferred a family member or friend to initiate a conversation about limiting firearm access, approaching them with care and without judgement.²³ Overall, the results suggest that Veterans at risk of suicide are willing to receive help from CSOs regarding safe firearm storage.

Implications

Existing firearm safety interventions seek to limit access to lethal means only among the patient population.^14,15 Several are implemented after an individual has been identified as being at risk of suicide. Consequently, current interventions related to access limitations are unlikely to reach a significant portion of Veterans not yet identified or who die by firearm suicide on their first attempt.³⁶ A feasible and acceptable universal intervention that can modify future potential risk (i.e., safe firearm storage), upstream and before a crisis, is needed. The universality of interventions such as this is underscored by the fact that individuals who have not recently used VA care are at higher risk for suicide.³⁷

CSO involvement in safe firearm storage can benefit Veterans in a multitude of ways, such as having an established secure firearm storage plan that can be activated in times of crisis and supporting and encouraging compliance with the plan. Having active and engaged planning conversations between Veterans and CSOs before they are needed is paramount in preventing Veteran suicide.

Limitations

Although this evaluation has several strengths, including attaining the perspective of Veterans and their CSOs on an often-avoided topic and recruiting a difficult-to-attain dyad sample (i.e., those with both a history of mental health disorders, suicidal ideation, and/or prior suicide attempts and with an available CSO), it also had limitations. One limitation was the smaller number of CSOs than Veterans, because many Veterans did not have a CSO who was available to participate. Thus, although a multiple case study design was chosen to account for dyads, it was challenging to recruit dyads from this population. Because of limitations in sample size and gender distribution, the authors did not conduct any sub-group analyses and opted for a descriptive presentation of the sample and qualitative findings. In addition, all Veteran participants were enrolled in VA health care, and, given that this evaluation is preliminary, the findings cannot be generalized to all Veterans enrolled in VA health care. All Veterans in this sample had experienced a prior suicide attempt or suicidal ideation. Thus, this is a specific at-risk population, and findings may not generalize to the broader population of Veterans who are not at risk of suicide.

Future directions and conclusions

Findings indicate that Veterans are receptive to a person-level intervention that incorporates a CSO into firearm safety planning for Veterans at risk of suicide. Future research should seek to develop and evaluate this type of intervention from the perspective of the Veteran and the CSO. Overall, reducing access to lethal means among those at risk for suicide has significant potential to save lives and may be a key area for future policy making and suicide prevention initiatives.

Biographies

Bryann B. DeBeer, PhD, is the director of the VA Patient Safety Center of Inquiry — Suicide Prevention Collaborative, a clinical research psychologist at the VA Rocky Mountain Mental Illness Research, Education, and Clinical Center, and an associate professor in the Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado. Her research focuses on understanding risk and protective factors for suicide, translating these factors into novel interventions, and leveraging implementation science to improve suicide prevention in organizations.

Monica M. Matthieu, PhD, is a research social worker in the Mental Health and Research Service at the Central Arkansas Veterans Affairs (VA) Health Care System. She is also an associate professor at Saint Louis University’s School of Social Work in St. Louis, Missouri. Her expertise is in the implementation and evaluation of evidence-based practices and policies, specifically for suicide prevention and trauma treatment with Veterans delivered in VA and community settings.

Linda C. Degutis, PhD, is a consultant in injury and violence prevention and policy. She is Adjunct Professor, Department of Behavioral Sciences, at the Rollins School of Public Health at Emory University, Lecturer, Department of Chronic Disease Epidemiology, at the Yale School of Public Health and former Director, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, and Past President of the American Public Health Association. Degutis chairs the Advisory Council for the College of Science and Health at DePaul University and is a member of the National Academy of Medicine.

Stephanie Clafferty, LCSW, is a social worker in the Mental Health Intensive Case Management program at the Central Texas Veterans Healthcare System (CTVHCS) in Waco, Texas. She has worked in various programs, including the Acute Psychiatry inpatient program, the Transition Care Management Program, and the Spinal Cord Injury program. She developed and implemented the Suicide Prevention Program across the CTVHCS and supervised staff in this program as well as social workers practising in various outpatient, inpatient, and residential programs.

Alexis Blessing, PhD, is a health science specialist in the U.S. Department of Veterans Affairs, VA Rocky Mountain Mental Illness Research, Education, and Clinical Center, and an assistant professor in the Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado. Her research areas of focus are college student and Veteran mental health and lethal means safety.

Cameron Quan, MS, is a health science specialist at the U.S. Department of Veterans Affairs, VA Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention. Quan received his graduate degree in psychology from the University of Memphis and plans to pursue a doctorate in clinical psychology. Quan’s research interests include traumatic stress, suicide, substance misuse, and understudied and underserved minority groups.

Sandra B. Morissette, PhD, is a professor of clinical psychology at the University of Texas at San Antonio. As Director of the Trauma Health Research In Veterans’ Experiences laboratory, her expertise is in studying co-occurring conditions, including posttraumatic stress disorder, anxiety disorders, and addictive behaviours. She has a particular interest in understanding factors that influence suicide risk among post-9/11 Veterans. She has published more than 130 peer-reviewed articles and book chapters.

Funding Statement

This study received funding from the U.S. Department of Veterans Affairs.