Firearm Suicide Prevention in the U.S. Military: Recommendations From a National Summit

ABSTRACT

The U.S. DoD has identified firearm suicide prevention as a key operational priority. One vital approach to addressing firearm suicides is through promoting lethal means safety, which involves the voluntary use of secure storage for personally owned firearms and/or temporarily moving firearms out of the home during risk periods. Despite promising approaches to lethal means safety, critical gaps remain in research, programming, and communication among and across scientists, DoD programmatic leaders, front-line commanders, and service members. To address these gaps, the first-ever national “Firearm Suicide Prevention in the Military: Messaging and Interventions Summit” was convened in June 2022, bringing together DoD personnel and researchers with expertise in firearm suicide prevention and lethal means safety. The Summit identified 10 recommendations to enhance firearm suicide prevention messaging and interventions in the U.S. military, including (1) repeal or amend prohibitions on questioning service members about personal firearms; (2) develop, examine, and use common language for firearm injury prevention; (3) implement a universal approach to training on comprehensive firearm injury prevention; (4) encourage leadership across disciplines and levels; (5) aim for broad culture change; (6) support innovative research; (7) consider various outcome measures; (8) promote “cultural competence” for better communication; (9) reduce territorialism; and (10) develop creative partnerships. Ultimately, these recommendations can facilitate productive partnerships with a shared goal: to develop, test, and implement strategies that standardize lethal means safety and reduce firearm suicides and other firearm injuries or harm among service members.

INTRODUCTION

Suicide is a leading cause of death in the U.S. Armed Forces.¹ Approximately 60%-80 of suicides among service members are enacted with a firearm.¹ Firearm access increases the risk of suicide because of the high lethality of firearm injuries (∼90% in suicide attempts²) and the highly dynamic nature of suicide that can include rapid change from low- to high-risk states.

Suicide prevention is a top priority for the DoD.¹ One of the most robust and promising approaches is “lethal means safety” (LMS)³—reducing access to lethal means, such as firearms, through the use of secure storage methods for personally owned firearms⁴ or temporarily storing firearms away from home.⁵ The DoD—in its Strategy for Suicide Prevention (Goal 6)⁶ and in its plan for integrated primary prevention⁷—calls for greater efforts to promote LMS in the military. LMS is one of five key priorities in the White House’s 2021 strategy for reducing military and veteran suicides.⁸

Existing LMS interventions vary in approach, content, and intended audience. Methods include broad education⁹; one-on-one counseling¹⁰; provision of locking devices (e.g., cable locks and firearm safes)^4,10; community partnerships between injury prevention professionals and firearm retailers and ranges (“gun shop projects”¹¹); online decision-making aids (e.g., “Lock to Live”¹²); and various state-based firearm storage maps.¹³ These and other studies demonstrate the importance of tailored language and approaches to increase the acceptability of firearm-related interventions.¹⁴

Critical gaps remain in research, programming, and communication among and across scientists, DoD programmatic leaders, front-line commanders, and service members. In June 2022, we held the first-ever national “Firearm Suicide Prevention in the Military: Messaging and Interventions Summit.” The 1-day event brought together leading researchers on LMS from the University of Colorado, Rutgers University, USU, The Ohio State University, and RAND Corporation; suicide prevention program leaders from the Army, Air Force, Space Force, National Guard, Navy, and Defense Suicide Prevention Office; senior enlisted service members from multiple branches; DoD medical leaders and commanders; and leaders from DoD research funding agencies. Focusing on DoD firearm suicide prevention messaging and interventions, the goals of the Summit were to review current programs across services; highlight new relevant data; generate key research questions; and identify opportunities for synergy across services. Through facilitated small and large group discussions and written feedback, attendees identified the following 10 recommendations related to firearm suicide prevention messaging and interventions in the U.S. military.

REPEAL OR AMEND PROHIBITIONS ON QUESTIONING SERVICE MEMBERS ABOUT PERSONAL FIREARMS

Attendees identified a current, significant obstacle: A clause in the 2011 National Defense Authorization Act (NDAA) now codified into statute.¹⁵ This clause has been interpreted in a way that restricts individuals within the DoD (e.g., unit leaders, commanders, providers, and program leaders or evaluators) from asking service members about personally owned firearms not stored on military-owned property, unless the service member has active risk for suicide or harming others. This interpretation has been extended to include civilian researchers conducting DoD-funded studies. This clause has rendered it extremely difficult for the military or the scientists they fund to obtain reliable, vital information regarding firearm access, attitudes, storage practices, and use—even if such data are collected anonymously and reported in aggregate. A repeal of this NDAA clause—or at least an amendment that carves out exceptions for specific purposes (e.g., research that has received appropriate regulatory board approval and that seeks informed consent from willing study participants)—would require Congressional action. In 2021, some members of the House Armed Services Committee introduced legislation to overturn language in the NDAA clause, but the motion was defeated in committee. Approved research conducted with participants who voluntarily consent to take part in a study should not be a partisan issue. Furthermore, repealing or amending this clause would have no impact on the ability of service members to own firearms. Accordingly, this action represents not only one of urgent value but also one with minimal political risk.

DEVELOP, EXAMINE, AND USE COMMON LANGUAGE FOR FIREARM INJURY PREVENTION

There are various active research studies and programs related to firearm suicide prevention/LMS within the DoD. Examples include the “Go SLO” (Safes, Locks, and Outside the home) initiative in the Department of the Air Force, Project Safe Guard in the National Guard, and adaptation of the original Counseling on Access to Lethal Means training for delivery to military gatekeepers. Programs vary in their messages and components. Attendees recommended developing a common DoD-wide nomenclature for LMS and firearm injury prevention. This could reduce confusion about what policies/practices are being implemented while enhancing coordination, evaluation, and standardization of activities and messages within and across branches.

Attendees discussed that “lethal means” may not be immediately understandable to the public. Attendees also discussed that “firearm safety” is a term commonly used to discuss prevention efforts related to securely storing firearms. However, “firearm safety” can also refer to safe firearm handling (e.g., keeping a firearm pointed away from others) or using a firearm for safety (e.g., personal protection) and, therefore, may not be interpreted as encompassing secure, locked storage.

Terminology more closely aligned with military culture and operations might be more impactful. “Firearm risk management” was discussed as being particularly aligned with military culture because risk management efforts are implemented broadly throughout the military. Attendees also suggested that the concept of “risk management” is both already understood and flexible enough to allow for changing circumstances within an individual’s life (and changes in firearm access). “Firearm leadership” was also proposed—a concept used to describe leaders modeling and prioritizing important issues (e.g., sleep leadership and grief leadership), and expansion to firearms could lead to consistent messaging that promotes responsible behaviors associated with firearm ownership/handling across all branches of service. Messaging should be tested to examine whether referring to firearms as a risk would be acceptable and whether these terms or other terms (e.g., “firearm responsibility”) are effective.

IMPLEMENT A UNIVERSAL APPROACH TO TRAINING ON COMPREHENSIVE FIREARM INJURY PREVENTION

Attendees agreed that all service members should receive training, regardless of whether their occupation or assignment requires regular handling of firearms. Most existing LMS training has recommended narrow approaches by focusing on at-risk individuals (e.g., those with active suicidal thoughts). Adopting a universal approach for delivery to all individuals (not just those at risk) represents an “upstream” approach to preventing suicide that might change beliefs or behaviors before acute violence risk develops, encourage interventions with at-risk peers, support normalization of secure storage of personal firearms, and promote protective environments. Moreover, although there is a public perception that all military personnel are knowledgeable and trained in firearm use, attendees noted that this is not necessarily the case. Universal training—training all service members—could address differences in knowledge, experience, skills, or comfort with secure firearm storage. Universal training could also impact other firearm-related injuries and deaths beyond suicide (e.g., interpersonal violence and unintentional shootings), as well as firearm theft. Such a comprehensive prevention message would integrate well with the DoD policy on integrated primary prevention.⁷

ENCOURAGE LEADERSHIP ACROSS DISCIPLINES AND LEVELS

An upstream approach and comprehensive message focusing on preventing all types of firearm injuries could expand accountability for preventing firearm injuries. Attendees recommended engaging security forces and safety teams to share accountability for facilitating training and interventions related to firearm injury prevention efforts, aligning with findings that law enforcement, military personnel, and veterans are seen as credible messengers on firearm safety.¹⁴ Military leadership would also need to be accountable for this universal approach by creating infrastructure to promote the use of common nomenclature and to coordinate efforts across military branches and groups involved in prevention and training efforts.

Commanders and other high-level leaders were widely considered a key group to prioritize firearm safety training and model responsible firearm use. Mid-level leaders and peers should also serve as “firearm leaders,” as they might be more relatable messengers and have more frequent contact with more service members. Attendees noted the importance of allowing some local tailoring of messages; similar concepts and words can reinforce a common strategy, but inclusion of branch-specific photos, for example, might increase the relevance of messaging. Fully supported research is needed to identify the best message and messengers within and across subpopulations of service members—including those who own personal firearms and those who do not.

AIM FOR BROAD CULTURE CHANGE

Attendees emphasized the importance of understanding and addressing overall military culture related to mental health, firearm ownership and safety, communication, leadership, and operational or mission-related priorities. Cultural considerations for firearm injury prevention efforts span all ecological levels on and off base and underscore the need for sustainable solutions, both top-down and bottom-up. For example, sustainable leadership structure and dedicated time for LMS training will be critical to maintaining momentum and communication among service members, particularly given frequent changes in assignment or station. There was consensus that effective efforts to prevent firearm injury and suicide require an adaptable, collaborative approach that will likely not yield immediate improvements in statistics, but rather a slow, steady shift in how and when LMS, firearm safety, and mental health resources are accessed and discussed across all ranks and branches. For example, firearm responsibility (e.g., responsible handling and storage) could be incorporated alongside discussions about responsible alcohol use into regular safety briefings before weekends or leaves. Approaches to other safety topics, such as training for personal motorcycle use, might also be models for firearm injury prevention. Normalizing these discussions can facilitate the broad cultural change required.

SUPPORT INNOVATIVE RESEARCH

For years, federal funding agencies have been unable or reticent to award research grants to study firearm injury prevention, resulting in scientific stagnation. Additionally, as described in recommendation 1, prohibitions on questioning service members about personal firearms have additionally stymied scientific progress. Attendees discussed the need for more experimental data on messaging and behavior change, including the use of pilot studies to inform larger-scale projects and identification of key firearm-owner subgroups to target with messaging. Attendees also discussed the need for qualitative studies to ensure that all interested parties’ voices are reflected in the research. Furthermore, attendees highlighted the need to focus on implementation science to optimally translate lab-based findings into military communities. Such a robust research agenda will require interdisciplinary approaches that integrate expertise from medicine/public health, psychology, economics, and sociology, among others, while also including the perspectives of community groups such as firearm owners, firearm retailers, and military personnel.

CONSIDER VARIOUS OUTCOME MEASUREMENTS

Attendees identified a critical need to consider the optimal outcome measures in determining the impact of LMS approaches. Although preventing firearm-related deaths is arguably the primary goal of LMS interventions, measuring the impact on deaths alone is insufficient. For example, if the proposed upstream approach was used to deliver LMS training to service members regardless of their current level of suicide risk, it would take time—perhaps years—for these types of interventions to demonstrate a reduction in firearm suicide rates. The conclusion should not be to abandon efforts if there are no near-term indicators that the intervention is impacting suicide rates. Rather, researchers should look to myriad intermediate outcomes, such as changes in beliefs, attitudes, and behaviors regarding safe firearm storage practices; message content and recognition; fidelity to intervention components; and nonfatal firearm accidents and suicide attempts. It will also be important to determine to what degree these intermediate outcomes measurably impact firearm suicide rates and other firearm injuries over time.

Relatedly, attendees discussed the benefits of developing a standardized set of common data elements (CDEs) for assessing firearm ownership, access, storage practices, and related variables (e.g., beliefs, attitudes, and behaviors). Developing firearm-specific CDEs has several advantages, including improving data quality, facilitating data sharing, and optimizing the interpretability of meta-analyses and other between-study comparisons. Accordingly, attendees are currently developing, testing, and implementing firearm-focused CDEs, which will be available at no cost to the field.

PROMOTE “CULTURAL COMPETENCE” FOR BETTER COMMUNICATION

Progress will require overcoming communication challenges among the DoD personnel, researchers, and industry partners. Attention to “cultural competence”—the ability to understand, appreciate, and interact with individuals with belief systems different from one’s own—could help interested parties address their own knowledge gaps or biases surrounding firearms and military culture. Researchers without military experience may be unfamiliar with the DoD structure, acronyms, workflow, and processes, including how to apply for DoD research funding. For example, many service members’ roles do not require specialized firearm training beyond that conveyed during basic training. Therefore, researchers should not assume that all military service members are familiar with firearms or the nuances of secure firearm storage. This has implications for developing interventions.

REDUCE TERRITORIALISM

There are considerable between-branch differences in the programmatic approach to promoting LMS. In support of branch-specific approaches, one attendee shared an example comparison of the challenges in standardizing first aid kits across branches. Although standardizing first aid kits across service branches seems, at first blush, to be sensible and efficient, there are nevertheless between- and within-branch differences in content needs (e.g., antihistamines for the Navy) and storage options (e.g., fighter jets vs. submarines vs. body armor) for first aid kits.

Although branch-specific characteristics may necessitate branch-specific LMS efforts as well, DoD-wide redundancies or silos should be avoided. Instead, the lessons learned from one branch should routinely be shared with the other branches. In parallel, researchers need to be collaborative. Research necessarily has a degree of “competition”—there are a finite number of tangible resources (e.g., grant funding). Yet, territorialism inhibits progress. Multidisciplinary research groups must work together to address the goal of reducing firearm-related injuries and mortality.

DEVELOP CREATIVE PARTNERSHIPS

Attendees committed to cultivating partnerships and continuing the conversations started at the Summit and facilitating collaboration across sectors. Attendees also discussed opportunities for advancement through partnerships with experts in implementation science and communications. Partnerships should also push beyond research and academia, including the private sector, civilian, and veteran organizations. Service members living on installations regularly interact with civilian institutions and veteran networks, as do those who live off base. Thus, LMS efforts should not exclusively target DoD settings. Partnering with the DVA can facilitate the continuity of firearm suicide prevention clinical and research efforts during the transition from military service to civilian life—a high-risk period for firearm suicide.¹⁶ Innovative strategies can also be explored with a variety of traditional and nontraditional groups, including firearm manufacturers, firearm retail and range owners, and insurance companies.

SUMMARY

Firearm suicide is among the most pressing problems for the U.S. military. This national Summit resulted in an ambitious and complex set of recommendations and aspirational goals for advancing prevention of firearm suicide and other firearm injuries and deaths among service members. These 10 recommendations can improve the availability and quality of evidence-based, effective interventions for firearm suicide prevention. To accomplish this, a universal, upstream, coordinated, and outcome-based approach with a sustained commitment from the DoD is needed. This effort would be consistent with the stated goals of the DoD^6,7 and White House⁸ in protecting the lives of those who serve our nation and their families and maintaining total force readiness.

ACKNOWLEDGMENTS

The authors express their appreciation to all Summit attendees who contributed to the ideas presented in this article. In addition to listed authors, the Summit “think tank” includes, but is not limited to, the following individuals: Paula Krause, MSW, LCSW; David Obergfell, DSW, LCSW; Surita Rorie; and Ramya Sundararaman, MD, MPH.

FUNDING

M.E.B. and J.B.-A. were supported by awards from the Defense Health Agency (ID07200010-301) and the DoD/Medical Technology Enterprise Consortium (W81XWH-21-9-0011; MTEC-21-05-CrossCutting-032). C.J.B. was supported by Award Number R61MH125759 from the National Institute of Mental Health. C.H. was supported by awards from the U.S. DVA (Health Services Research and Development Service 1I01HX002947-01 and Clinical Science Research and Development Service IK1 CX002370-01A1).

CONFLICT OF INTEREST STATEMENT

Dr. J.S. has received consulting fees from Peraton to inform suicide prevention projects. No conflicts were reported by the other authors.

DATA AVAILABILITY

Not applicable.

CLINICAL TRIAL REGISTRATION

Not applicable.

INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS)

Not applicable.

INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)

Not applicable.

INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT

M.E.B. led the manuscript write-up. All authors contributed to, read, and approved the final manuscript.

INSTITUTIONAL CLEARANCE

Institutional clearance approved.

Author notes

The contents of this work are the authors’ sole responsibility and do not necessarily represent the official views of the DoD, DVA, or the institution/employer of any author. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The opinions and assertions expressed herein are those of the author(s) and do not reflect the official policy or position of the USU or the DoD. The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions, or policies of The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.