Firearms and Mental Health

Firearms and Mental Health:

Methods to Reduce Mass Shootings and Gun Inflicted Suicide

Brian Long

The Chicago School of Professional Psychology

Abstract

Few issues bring up such divisive debate as firearm ownership.  While recent tragedies have reignited the debate and spurred interest in finding a solution to keeping firearms away from those suffering from mental, there has been little if any agreement on how to achieve this aim.  This paper examines the issues of firearm ownership from two mental health contexts.  First, how to address the question of ownership and firearm purchasing by those with diagnosed mental illness.  Second, how to reduce the risk of suicide by firearms.  Through the use of citizens advocacy and increased education about firearms issues and awareness, Mental Health Professionals can start to address the dangerousness of firearms.

Keywords: firearms ownership, confidentiality, informed consent, gun violence, suicide, prevention

The Second Amendment of the United States Constitution states, “A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed”.  However, interpretation of the second amendment is a powerfully divisive issue that has had a great impact on the mental health field.  While the intention of the founding fathers and writers of the constitution is under constant debate, there is some agreement that keeping firearms away from those who intend to harm themselves or others is national priority.  Recent tragedies have brought to light the challenges in gun control efforts and the dangers that guns can play in the hands of those suffering from severe mental illness.  Mental Health Professionals have a challenging role in the debate on firearm ownership, safety and the rights of those with mental health disorders.  Following the Tarasoff case, Mental Health Professionals are required to breach confidentiality to warn potential victims.  Should changes to the law be made to allow Mental Health Professionals to breach confidentiality to remove firearms and/or the ability to purchase firearms from individuals determined to be a potential danger to themselves or others?  There are two distinct issues that need to be addressed, 1) keeping mentally disturbed individuals from purchasing firearms and 2) removing access to already owned firearms from those experiencing a mental health crisis.  The removal of rights guaranteed in the constitution is a controversial debate, however the right of individual firearm ownership needs to be weighed against the right to safety of the general public.

Firearms and Mental Illness: Keeping Guns Away from Disturbed Individuals

            The Virginia Tech massacre in 2007 and the Newtown shooting in 2012, along with too many others, have brought to the forefront the debate on firearms ownership and mental health.  Sueng Hui Cho and Adam Lanza, and others in recent tragedies, had histories of mental illness.  In the case of Sueng Hui Cho, he was prohibited from purchasing firearms in Virginia (Virginia Tech Review Panel, 2007), but was able to buy firearms anyway because of incomplete national database participation.  In several of the recent gun tragedies, shooters were able to purchase firearms despite disqualifying mental illness that should have precluded them from being able to procure firearms.

The National Instant Criminal Background Check System (NICS) was created to regulate the purchase of firearms and prevent disqualified individuals from making firearm purchases (Price & Norris, 2010).  A firearms dealer is required to submit a background check to the FBI before completing any transaction.  The FBI maintains three databases, for this issue the database of concern is the NICS Index, which contains information about prohibited persons such as individuals with “disqualifying mental health history” (Price & Norris, 2010).  The Federal Gun Control Act of 1968 “prohibits possession of a firearm by, or transfer of any firearm to, a person who has been adjudicated as ‘mental defective or committed to a mental institution’ or is an ‘unlawful user or addicted to any controlled substance’” (Price & Norris, 2010).  Together these statutes were created to prevent those with mental illness from purchasing firearms.  However, submission of state level records to the national database is voluntary.  As of 2007 only 22 states had submitted files to the NICS database and firearm sales that take place at gun shows or between private vendors, which amount to 25% of sales, do not have to be reported (Price & Norris, 2010).  These two loopholes have allowed for numerous transactions that should have been stopped to go through, as was the case in the Virginia Tech shooting.

            Sueng Hui Cho was displaying signs of mental illness as early as middle school and according to Virginia law should have been unable to purchase firearms, however due to ambiguity in the wording of the statute at the time, his mental health status was not communicated to the relevant authority (Virginia Tech Review Panel, 2007).  Since the tragedy, Virginia law has been clarified in the hopes of avoiding a future tragedy, however other states have yet to make change to their gun purchase laws and seem to be waiting for their own tragedy before making changes.  A national standard needs to be created to coordinate state level disqualifying mental health information into the NICS database.

Firearms, Mental Illness and Suicide: Preventing a Tragedy

            Many studies have connected the link between suicide completion and firearm use.  Statistics from 2009 show that, “Suicide by firearm was the leading cause of suicide death in the United States, with a rate of 6.3 per 100,000 people” (Sterzer, 2012).  Further the prevalence of firearms in the home, “Almost 40% of American households contain at least one firearm” makes firearms readily available to those contemplating suicide (Miller, 2008).  Due to the lethality that firearms present, suicide attempts involving a firearm are far more likely to be completed than other methods (Sterzer, 2012).  This makes removal of access to firearms for those individuals suffering from acute suicidal ideation a key component to mental health treatment.  While the risk of suicide remains elevated for some time after initially seeking treatment, short-term removal of firearms from the home may greatly reduce the chance of a lethal suicide attempt.  A study by Mike Crawford in Advances in Psychiatric Treatment found that 25% of all deaths occur within 3 months of hospital discharge (2004).  However, there are few laws in place to protect the mentally ill from the danger they pose to themselves during a suicidal period.  The bulk of the debate is centered on preventing those with mental illness from procuring firearms, there is little to no debate about the removal of firearms from those who already own firearms but are currently suffering from suicidal ideation.  Drafting legislation to remove firearms from mentally disturbed individuals will be a highly contentious issue.  However, Mental Health Professionals can work to create informal agreements with clients to voluntarily turn over firearms until after the mental health crisis has passed.  Similar to contracts drawn up between clients and therapists not to harm themselves, an agreement can be made to allow a third party to remove the weapons until a later time when the individual is no longer a danger to themselves.  These plans would have to be discussed and agreed to by the client, but could go a long way in removing the immediate ability for lethal self-harm.

Informed Consent

            Meyer and Weaver (2006) state that for there to be informed consent a person needs to be properly informed about the nature, risks, and benefits of the course of action the mental health professional would like to undertake.  This is related to the Fourteenth Amendment and the right to due process.  The three components of informed consent, voluntariness, disclosure and capacity, all need to be obtained for a person to be able to give informed consent.  When exploring the rights of patients to maintain firearm ownership during times of mental health crisis the issue of capacity takes center stage.  Is a person able to make decisions regarding their health and the safety of others when they are suffering from suicidal or homicidal ideations?  Each state has different laws regarding the purchase and ownership of firearms by those who have been determined to suffer from mental illness.  Depending on the state, disclosures made to a therapist could result in the loss of Second Amendment rights to own or purchase firearms.  Some recent state laws, such as Florida’s Privacy of Firearm Owners Act, have impeded health providers’ abilities to carryout their duty to protect by placing restrictions on asking questions regarding firearm ownership (Falls, 2011).  These questions will be addressed in the following section on informed consent and firearm ownership.

Restrictions on Patient Questioning

            During the initial interview and intake process it is important for mental health workers to be able to freely question their clients in order to develop a complete understanding of the situation and the potential risks they face.  In 2011 the state of Florida passed the “Privacy of Firearm Owners Act [FOPA], which prevented the state’s medical personnel from asking patients about gun ownership” among other things (Falls, 2011).  While this law was aimed at medical personnel, similar statutes could easily be expanded to include the mental health profession.  FOPA limited medical professionals from being able to ask patients about gun ownership or the ability to document ownership on the patient’s medical record.  However, in direct conflict with this law are the precedents that have come from the Tarasoff and Almonte cases, stating a need to protect the victims of potential violence.  The inability to ask certain questions restricts the professionals’ ability to assess potential danger of the client.  As stated in the article by Brian Falls (2011), “Asking suicidal or homicidal individuals about firearms is also paramount to the formulation of a safety plan prior to discharge from an emergency room.”  Several professional groups have joined in calling for a challenge to this law, included is the American Academy of Pediatrics (AAP).  In a statement by the AAP President O. Marion Burton, “Tragedies that could have been prevented by a simple conversation will, instead, occur” (Florida Gun Legislation Would…,  2011).  Fortunately, a Florida judge has issued an injunction against FOPA, however, similar statutes remain unchallenged in other states and new restrictions can be put in place (Falls, 2011).  Emergency planning and patients rights to gun ownership during times of mental health crisis will be addressed in later sections of this paper.

            During the initial intake and interview, clients need to be made aware of their rights, how confidentiality works, and the limits that are in place.  Many clients are under the impression that anything said to a mental health worker is confidential, however there are several conditions placed on confidentiality and the client needs to be informed of these limits before beginning therapy.  The ACA code, section B.2. states several exceptions to confidentiality, these include, danger and legal requirements, contagious and life threatening diseases, and court-ordered disclosure (Herlihy & Corey, 2006).  In the case of firearm ownership, the main issue is with dangerousness to self or others.  The ACA code states, “counselors keep information confidential does not apply when disclosure is required to protect clients or identified others from serious and foreseeable harm” (Herlihy & Corey, 2006).  In Tarasoff v. the Regents of the University of California (1976) the duty to warn a specified victim was made a legal requirement that can come with civil penalties for failing to protect the victims of violence (Meyer & Weaver, 2006).  This was further expanded to include non-specific victims in the case of Almonte v. New York Medical College (1994).  In this case it was found that the defendant, Douglas Ingram M.D. was found liable for failing to act to protect the future and unknown victim of his trainee, Dr. Joseph DeMasi (Meyer & Weaver, 2006).  The Virginia Tech shooting in 2007 brings to the forefront the question of warning to protect unspecified victims of potential violence, when to breach confidentiality and what rights should the potentially dangerous retain in regards to firearm ownership.

  Confidentiality, Privilege, and When to Breach

            Meyer and Weaver (2006) describe confidentiality as the “ethical obligation to keep client information private unless legally compelled to disclose it.”  Privilege is the legal equivalent of confidentiality that establishes the right to privacy of communications between client and therapist.  In re Lifschutz (1970) established that this privilege is owned by the client and protected by law, however, there are exceptions to protected speech (Meyer & Weaver, 2006).  During the initial interview and intake process it is the obligation of the therapist to educate their client as to the bounds of confidentiality as discussed earlier in the section on informed consent. 

            Seung Hui Cho was reported and sent for counseling as early as middle school for writing about a desire to carryout a Columbine style shooting (Virginia Tech Review Panel, 2007).  While Cho was receiving support and evaluation from mental health workers following this event, his mental health record was not fully reported to the NICS and he was able to purchase firearms.  Cho’s mental health status should have disqualified him from being able to purchase firearms in the state of Virginia and nationally, however, the rules on reporting were unclear at best and he slipped through the cracks (Virginia Tech Review Panel, 2007; Price & Norris, 2010).  To prevent future tragedies and follow the trend of protecting potential victims from violence, should stricter standards for firearm ownership be federally mandated?

            Firearms provide the potential for one individual to perpetrate great violence against a large group of people in a very short period of time.  Gun tragedies are claiming victims in the dozens by lone gunmen.  As established in Tarasoff (1976), Mental Health Professionals have a duty to warn victims.  However, if the victim(s) are unclear, who do you warn?  With the destructive nature of firearms, would society be better served by removing the implement to carry out these crimes from individuals until they have received the care they need?

Addressing the Dangers of Firearms

            There have been many proposed solutions to help protect society from the risk of gun violence stemming from those suffering from mental illness.  Both protecting individuals from hurting themselves and preventing individuals from being able to hurt others need to be addressed.  There are many solutions that can be easily implemented.  While there is no single solution to eliminate the risks of firearm violence, the first steps need to be taken to tackle this deadly problem.  The first step should be to close the loopholes in the NICS database.  Second, the gun show exception for firearm purchases needs to be eliminated. Finally, Mental Health Professionals need to be educated about the importance of questioning their clients about firearm ownership during initial interviews with clients who are presenting symptoms that suggest violent or suicidal tendencies.  This should include training during their education on how to approach the subject and planning procedures for removing weapons from potentially dangerous individuals.

Closing the Loopholes

            The first step that states and the federal government should take is to improve the NICS database and close the gun show loophole for firearm sales.  While this will not completely solve the problem, it is easily done and the effects should be able to keep firearms away from many who would be a danger to themselves or others.  The largest problem facing states and NICS database compliance are differing definitions of “disqualifying mental illness”.  The federal government can take the lead by proposing a uniform standard that states can agree to or not. However, if they choose to follow a lower standard, pressure from citizen groups can be brought to bear on state officials to hopefully achieve national compliance.

            The NICS database currently relies on states to voluntarily submit information regarding mental health status of in-state patients.  As of April 2007, less than half the US states were submitting mental health records to the NICS (Price & Norris, 2010).  A federal law requiring submission of mental health data will be met with significant opposition from the NRA and other pro-gun lobbies that exert considerable influence in politics.  Rather than trying to legislate change, the APA and other professional associations can lobby the representatives in their states to participate in the voluntary submission of mental health records to the NICS.  Recent gun tragedies have started a debate on how to best care for those with mental illness and how to keep guns away from those who are not able to use them responsibly.  Updating and maintaining the NICS database is one cost-effective method that is already in place and ready to go.  While it may lead to some people being deprived of their right to firearms, the risk posed to public safety is far greater. 

            One simple change that can be added to the NICS database to counter the gun lobby’s protests would be to add a clear method to be removed from disqualifying status on the NICS database.  If someone who has been prohibited from purchasing firearms due to mental illness, they could be removed from the NICS after completing and evaluation by a qualified professional.  This would ensure that the public is protected and individual rights would also have a mechanism in place to ensure they are protected.

            The next change that has been repeatedly brought up in national debate is the so-called gun show loophole on background checks.  As it currently stands, background checks are not required when private citizens, including private vendors at gun shows, sell firearms.  Given the evolution of technology and the ease with which documentation can be processed, there is no reason to maintain this allowance.  While many argue that sales between private citizens should not be regulated, there is already plenty of precedent for government regulation of private sales.  Car sales and ownership have to be registered with the local government, firearms should be as well.  The constitution states the right to ownership, not anonymous ownership, will not be infringed.

Asking Questions: Patients and Firearms

            The last step that Mental Health Professionals can take is to start including questions about firearms ownership in their initial client interviews.  Determining their clients views on gun ownership, if they own weapons, and if they are planning on purchasing a weapon can be used in performing a complete threat assessment.  While this would not need to be conducted in all situations, when a client appears that they could be a threat to themselves or others, clinicians should ask about firearms to get a clear picture of the level of threat their client poses. 

            Part of the education of up and coming Mental Health Professionals should include how to address firearm issues with clients and firearm removal plans in the case of suicidal patients.  If a client presents with suicidal or homicidal ideations and has disclosed firearm ownership, it would be imperative to remove the weapons from the individual before they can harm themselves or others.  Laws requiring the removal of weapons would be heavily challenged, but that should not prevent Mental Health Professionals from coming up with informal plans for removing firearms, with client agreement, from the home.  Should the client refuse to voluntarily give up their weapons then stronger actions, such as civil commitment, can be pursued to protect the individual or the greater public.

First Steps

            There are many actions that can be taken to address the dangerousness of firearms.  The Second Amendment is a founding principle of the United States and while its meaning is often debated; agreement is not going to be coming soon.  In the meantime, steps need to be taken to stop the recent spate of gun violence and school tragedies that are destroying our great nation.  A few simple steps can be taken to keep guns out of the hands that would do great harm to themselves or others.  By training Mental Health Professionals to ask about firearm ownership and working to create a clear national standard that all states can accept, we can reduce the risk of gun violence by the mentally ill. 

References

Crawford, M.J. (2004).  Suicide following discharge from in-patient psychiatric care.  Advances in Psychiatric Treatment 10, 434-438.  doi:10.1192/apt.10.6.434

Falls, Brian. (2011).  Legislation prohibiting physicians from asking patients about guns.  Journal of Psychiatry & Law, 39(3), 441-463.

Florida Gun Legislation Would Hinder Pediatrician’s Efforts to Protect Children. (2011).  Audiology Online, 10.

Herlihy, B. & Corey, G. (2006).  ACA Ethical Standards Casebook (6^th ed.).  Alexandria, VA: American Counseling Association.

Miller, M. (2008, June).  Handguns and health.   Harvard Mental Health Letter. p. 8.

Meyer, R. G., & Weaver, C. M. (2006). Law and mental health: a case-based approach. New York: Guilford.

Price, M., & Norris, D. (2010). Firearm Laws: A Primer for Psychiatrists.  Harvard Review Of Psychiatry, 18(6), 326-335. doi:10.3109/10673229.2010.527520

Sterzer, J. (2012).  The Good, the Bad, and the Ugly.  Journal of Legal Medicine, 33(1), 171-199.  doi: 10.1080/01947648.2012.657993

Virginia Tech Review Panel.  (2007).  Mass Shootings at Virginia Tech April 16, 2007: Report of the Review Panel.