FO RU M O N H E A LTH AN D NATI O NAL SE CURI TY

Family Safety and MilitaryServicemembers:
Understanding Risk andIntervention Strategies

Conference Report

Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University of the Health Sciences

F ORUM ON H EALTH AN D N ATION AL SEC URI T YFamily Safety and MilitaryServicemembers:
Understanding Risk andIntervention Strategies

Edited byRobert J. Ursano, MD
James C. West, MD
Carol S. Fullerton, PhD
Joshua C. Morganstein, MD
Alexander G. Liu, MPH
Trevor Stephens, BA
Elyse Frank, BS

A Conference of the:Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University School of Medicine

From the Conference Series:
FORUM ON HEALTH AND NATIONAL SECURITY

Family Safety and Military Servicemembers:
Understanding Risk and Intervention Strategies
Editor’s Note: This transcript has been edited, however, as in most transcripts some errors may
have been missed. The editors are responsible for any errors of content or editing that remain.

IPD 2017 by Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4712
First Edition

The Forum met in the National Intrepid Center of Excellence (NICoE) Auditorium, Walter Reed
National Medical Military Center, Bethesda, Maryland, at 8:00 A.M. on Wednesday, January 11th,
2017, James C. West, MD, presiding.

Contents
Panelists....................................................................................................................................... i
Participants................................................................................................................................ iii
Preface.......................................................................................................................................1
Executive Summary...................................................................................................................3
Opening Remarks......................................................................................................................9James C. West, MD, Robert J. Ursano, MD
Panel One: Defining The Problem.........................................................................................13
Speakers: Andrew Anglemyer, PhD, MPH, Daniel Webster, ScD, MPH
Panel Two: Understanding Risk............................................................................................29
Speakers: Kenneth MacLeish, PhD, Baruch Fischhoff, PhD
Panel Three: Interventions To Enhance Safety...................................................................51
Speakers: Catherine Barber, MPA, Shannon Frattaroli, PhD, MPH
Forum Discussion...................................................................................................................63
Moderator: James C. West, MD
Readings...................................................................................................................................77

i

Panelists
Andrew Anglemyer, PhD, MPH
Assistant Professor
Operations Research Department
Naval Postgraduate School
Monterey, CA
Catherine Barber, MPA
Director, Means Matter Campaign
Harvard Injury Control Research Center(HICRC)Harvard University
Boston, MA
Baruch Fischhoff, PhD
Howard Heinz University Professor
Department of Engineering and Public Policy
Carnegie Mellon University
Pittsburgh, PA
Shannon Frattaroli, PhD, MPH
Associate Professor of Health Policy andManagement
Johns Hopkins Bloomberg School of Public
HealthJohns Hopkins University
Baltimore, MD

Kenneth MacLeish, PhD
Assistant Professor of Medicine, Health, andSociety and Anthropology
Center for Medicine, Health, and Society
Vanderbilt University
Nashville, TN
Robert J. Ursano, MD
Professor and Chair, Department of Psychiatry
Director, Center for the Study of TraumaticStress
Uniformed Services University
Bethesda, MD
Daniel Webster, ScD, MPH
Professor of Health Policy and Management
Johns Hopkins Bloomberg School of Public
HealthJohns Hopkins University
Baltimore, MD
James C. West, MD
CAPT, MC, USN
Assistant Professor of Psychiatry
Assistant Chair, Department of Psychiatry
Scientist, Center for the Study of TraumaticStress
Uniformed Services University
Bethesda, MD

ii

Forum Planning Committee

Forum Editing Committee

Robert J. Ursano, MD
James C. West, MD
Joshua C. Morganstein, MD
Gloria Whaley, PhD
Liza Gold, MD
Eric Meyer, MD
Mary Lee Dichtel, RN
Alexander G. Liu, MPH
Trevor Stephens, BA
TSgt. Jorge Hastings
Joseph Piemontese

Robert J. Ursano, MD
James C. West, MD
Carol S. Fullerton, PhD
Joshua C. Morganstein, MD
Alexander G. Liu, MPH
Trevor Stephens, BA
Elyse Frank, BS

iii

Participants
Andrew Anglemyer, PhD, MPH
Assistant Professor
Operations Research Department
Naval Postgraduate School
atanglem@nps.edu
Catherine Barber, MPA
Director, Means Matter Campaign
Harvard University
cbarber@hsph.harvard.edu
Mark Bates, PhD
Associate Director for Psychological HealthDefense Centers of Excellence for
Psychological Health and Traumatic Brain
Injurymark.j.bates.civ@mail.mil
John Bradley, MD
Chief of Psychiatry
Veterans Affairs Boston Healthcare System
John.Bradley7@va.gov
Michelle Cornette
Defense Centers of Excellence for
Psychological Health and Traumatic Brain
InjuryDeployment Health Clinical Center (DHCC)
mcornette@iiinfo.com
Stephen Cozza, MD
Professor of Psychiatry
Center for the Study of Traumatic Stressstephen.cozza@usuhs.edu
Baruch Fischhoff, PhD
Howard Heinz University Professor
Carnegie Mellon University
baruch@cmu.edu

Midshipman Anne Fisher
U.S. Naval Academym181914@usna.edu
Brian Flynn, EdD
Center for the Study of Traumatic Stressbrian.flynn@usuhs.edu
Shannon Frattaroli, PhD, MPH
Associate Professor of Health Policy andManagement
Johns Hopkins University
sfratta1@jhu.edu
Carol Fullerton, PhD
Research Professor of Psychiatry
Center for the Study of Traumatic Stresscarol.fullerton@usuhs.edu
Robert Gifford, PhD
Center for the Study of Traumatic Stressrobert.gifford.ctr@usuhs.edu
Liza Gold, MD
Clinical Professor of Psychiatry
Georgetown University School of Medicine
lhgoldmd@gmail.com
Marjan Holloway, PhD
Associate Professor of Psychology
Uniformed Services University of the Health
Sciences
marjan.holloway@usuhs.edu
Irene Jacobs
U.S. Army Medical Research & MaterielCommand (USAMRMC)
irene.r.jacobs.ctr@mail.mil

iv

Kenneth MacLeish, PhD
Assistant Professor
Center for Medicine, Health, and Society
Vanderbilt University
k.macleish@vanderbilt.edu

COL Brett Schneider, MD
Associate Professor of Psychiatry
Uniformed Services University of the Health
Sciencesbrett.schneider@usuhs.edu

James McCarroll, PhD
Center for the Study of Traumatic Stressjames.mccarroll.ctr@usuhs.edu

April Thompson, LCSW
Center for Deployment Psychology
athompson@deploymentpsych.org

COL Dennis McGurk (MRMC), PhD
Director, Military Operational Medicine
Research Program
U.S. Army Medical Research & MaterielCommanddennis.mcgurk.mil@mail.mil

Robert J. Ursano, MD
Professor and Chair, Department of Psychiatry
Director, CSTS
Uniformed Services University
robert.ursano@usuhs.edu

Maj Eric Meyer, MD
Assistant Professor of Psychiatry
Uniformed Services University of the Health
Sciences
eric.meyer@usuhs.edu
CDR Joshua Morganstein, MD
Assistant Professor of Psychiatry
Uniformed Services University of the Health
Sciencesjoshua.morganstein@usuhs.edu
William Nash, MD
Director of Psychological Health
United States Marine Corps
william.p.nash@usmc.mil
Katherine Nassauer, PhD
U.S. Army Medical Research & MaterielCommand (USAMRMC)
katharine.w.nassauer.civ@mail.mil
CAPT Jeff Quinlan, MD
Chair, Department of Family Medicine
Uniformed Services University of the Health
Sciencesjeffrey.quinlan@usuhs.edu
Scott Salvatore, PhD
Chief, Behavioral Health Branch, Office of
Health Affairs
Department of Homeland Security
scott.salvatore@hq.dhs.gov

Daniel Webster, ScD, MPH
Professor of Health Policy and Management
Johns Hopkins University
dwebste2@jhu.edu
James C. West, MD
CAPT, MC, USN
Assistant Professor of Psychiatry
Assistant Chair, Department of Psychiatry
Uniformed Services University
james.west@usuhs.edu
Gloria Workman
Defense Centers of Excellence for
Psychological Health and Traumatic Brain
InjuryDeployment Health Clinical Center (DHCC)
gloria.m.workman.civ@mail.mil
LTC Gary Wynn, MD
Associate Professor of Psychiatry
Uniformed Services University of the Health
Sciencesgary.wynn@usuhs.edu
Suzanne Yang, MD
Uniformed Services University
suzanne.yang.ctr@usuhs.edu

Executive Summary and Recommendations

Preface
The Forum on Health and National Security: Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies directs our attention tounderstanding family safety and how military families perceive and make decisions
about risks. The Forum brought together a diverse group of scientists, clinicians,
program directors and leaders. The panelists and participants were leaders in military medicine, educators, and researchers from academic institutions, healthcareorganizations, and policy centers. The Forum gathered a broad array of perspectives
and ideas.
One of the most compelling paradigms to emerge in the Forum was that of decisions around personally-owned firearms in military households. The Forum reviewed
the perspectives of research currently available in broader populations, and thennarrowed down to consider the relevance and gaps in the science as it pertains tomilitary families. The group discussed military culture and risk decision making as
observed through the lenses of cultural anthropology and decision science. Finally,
participants heard about past and current interventions to mitigate risks associatedwith firearms in the home. Each topic was approached using a format of formal
presentation followed by open discussion. An extended period of discussion at theend of the Forum identified ways forward. We hope this volume effectively captures
the thoughts and ideas shared by this distinguished group and offers a valuable
contribution to both scientists and policy makers.

1

2

Financial Stress and Behavioral Health in Military Servicemembers

Executive Summary and Recommendations

3

Executive Summary
Family safety encompasses a broad array of concerns and interventions. Whether
deciding on child safety seats for cars, vaccination, or recreational activities andequipment, families face an array of decisions on a daily basis that affect health.
While a central component of military identity is the acceptance and managementof risk in military operations, this perspective is generally not part of the concept offamily safety. When it comes to the safety of military families, family members usually feel there are very few “acceptable risks.” The Department of Defense devotes
significant resources to ensure family strength and function by including core elements of adequate housing, financial stability, and services to prevent and mitigate
conflict in family relationships. Military commanders have long employed systemsof family readiness and ombudsmen to reach out to families of their servicemembers, ascertain their needs, and ensure resources are available to meet those needs.
One area of family safety that remains relatively unexplored is the possession of
personal firearms by servicemembers. In spite of a culture of weapon safety and strict
accountability and control of service weapons, the number and type of weapons
servicemembers keep in their homes is largely unstudied.
The Forum on Health and National Security is a conference series addressing
the intersection of health and national security needs. The goal of this Forum wasto better understand military family safety, and how military families assess andmake decisions about risk in their homes. Personal firearms present a compellingparadigm through which the complicated intersections of military culture, healthrisk behaviors, and family safety decision-making can be discussed. The practice of
keeping weapons in the home is a complicated issue. This forum did not address thisquestion but rather sought to understand the current state of the science and how it
might inform interventions to enhance family safety given the substantial number offirearms in households of all kinds. The goals of the Forum were to better understandthe prevalence of personal firearms, their relationship to suicide and interpersonal
violence, and consider how military culture affects decision making around risk ineveryday life, and interventions available to improve family safety.
In the last decade, the Department of Defense has seen rising suicide rates.
Numerous studies have looked at risk factors for suicide. Are there reasonableinterventions that might be employed to make families more safe and also lower thenumber of military suicides? What is the impact of a firearm in a home experiencing
conflict or intimate partner violence? What can the military learn from broader public policy interventions with regard to the risk of firearms in these homes? For these

The goal of thisForum was to better
understand militaryfamily safety, howmilitary families assess
and make decisions
about risk in their
homes

4

Financial Stress and Behavioral Health in Military Servicemembers

can be very difficult

reasons, the Center for the Study of Traumatic Stress convened a Forum on Healthand National Security: Family Safety and Military Servicemembers: Understanding
Risk and Intervention Strategies to better understand family safety as a broad topic
that influences safety with firearms. Scholars from across the country gathered to
discuss what is known, where the knowledge gaps are, and consider potential strategies to enhance family safety in the presence of personally owned firearms.

to separate belief

Understanding the Problem

from science.

When discussing personal firearms it is important to acknowledge that it can bevery difficult to separate belief from science. There is a reasonable body of sciencethat identifies risk associated with firearms in the home. The prevalence of firearmownership fluctuates around 35% of households and has notably dropped froma high of approximately 45% in the early 1990s. Three quarters of suicides occur
within the home, and although suicide is a rare event, keeping a firearm in thehome triples the risk of suicide. Perhaps related to familiarity with firearms, 70%of veteran suicides use a firearm compared to slightly less than 50% in the general
US population. Firearms are used in just over half of all intimate partner homicides.
Studies that have been done suggest that the risk of homicide in the home is 2.7
times greater in households that have handguns. Individuals are far more likely to be
killed in a conflict with an intimate or other relation than to be killed by an intruder
in their home, and women’s risk for being a homicide victim in the home is greaterthan men. The greatest absolute risk associated with guns in the home is teen suicide.
There are several challenges to studying suicide and gun violence in military
populations. Service branches are different in their demographics, culture, missions,and family structures; in addition the data itself is across multiple data systems. The
Army and Marine Corps have higher rates of suicide, with higher rates for infantry
and special operations as a combined group. In the Air Force, police and corrections
specialties have been noted to have relatively higher rates. The vast majority of
military suicides are male. The Israeli Defense Forces saw lower suicide rates after
a change sending soldiers home on weekend leave without their service weapons.
Firearm suicide numbers for military personnel stationed in Europe and Asia, where
local personal firearm laws are more restrictive, are significantly lower than in thecontinental United States.

When discussing
personal firearms
it is important toacknowledge that it

Perception of Risk and Risk Decision Making
Going into harm’s way is a part of expected life for servicemembers, and acceptance of this risk is part of military service. Familiarity with violence is therefore apart of military service. It is also something that sets military members apart frommuch of the civilian society. The term “military biopolitics” has been used to describea system of management and control of people and community in the military.
Investment by individuals into the biopolitics is a part of the formation of military
identity. Military biopolitics also includes structural factors, cultural assumptions,and labels that are part of everyday experiences and inform and provide meaning
to military experience. Military culture uses many words detached from reminders of death and violence to describe the tasks of violence that are part of military
missions. To an outsider, the military engages an extraordinary array of practices,
rules, and institutional mechanisms to manage and organize individuals. Military
medicine is part of the military biopolitics. It can be seen by servicemembers as partof the system of institutional management. Toughness, endurance, and fortitude areExecutive Summary and Recommendations

central to military identity, as are suspicion of pain and weakness. For some military
members, as for others in occupational groups and occupational medical settings,
the idea of having symptoms or difficulty may be perceived as of greater risk than
enduring them. This can lead to under-reporting in screening programs.
In other anthropological studies military members and veterans are also seen as
more competent and conscientious about gun safety. Military members may reportthey are reluctant to identify themselves in postdeployment screening as having
symptoms because so doing would either slow down their reunion or single themout for additional attention. Military or veteran status does not predict gun crime,
but may be highlighted in media due to public apprehension of military biopolitics.
Within the framework of military life, servicemembers and their families makemany decisions including where to live, where children will go to school, and whether
or not to continue military service. Families also make decisions around safety andhealth risks including the decision whether or not to keep personal firearms in thehome. Perceptions of risk vary for people over time and may not represent the actual
absolute or relative risk, but rather an internal belief that may be unrelated to facts
or data. Assessing risk perception and the ways in which individuals assess their own
risk can reveal strategies for increasing knowledge and enhancing the effectivenessof interventions. The field of decision science offers insight into how individuals
and families perceive and make decisions about risk. It is possible to do extensive
analysis of factors related to decision-making and completely miss the most relevant
factors due to inadequate understanding of the values and relative importance toindividuals. Risk communication around firearms should start with analysis of the
problems as perceived by gun owners, commanders, and family members. Fear andvulnerability have the potential to introduce significant bias into how risk is perceived and risk decision-making. Absolute risk (i.e “X per 1000 people per year”)
is more compelling than relative risk (i.e. “twice as likely”) in influencing people tochange behaviors. However, absolute risk for homicide or unintentional shootingin the home is very low. It may be helpful, therefore, to better understand what therelationships are between gun owners and their weapons. Another perspective which
may assist in thinking about programs is given by social psychology. This literatureoffers a concept of “refusal skills” that assumes that many people want to refrainfrom a certain behavior, but that they struggle with standing out negatively fromthe larger group if they do.

Interventions to Enhance Safety
There are many initiatives underway in a number of civilian communities toenhance family safety. There are two primary activities: 1) public education campaigns to bring attention to lethal means restriction for individuals in crisis; 2) public
policies meant to empower individuals and law enforcement in restricting access tofirearms for high risk individuals. This may address some risks for suicide since how
someone attempts suicide plays a critical role in whether they live or die. Suicide
attempts appear to be first contemplated within 10 minutes of the attempt in 48% ofcases. Between 5—11% of those who attempt go on to ultimately complete suicide.
Firearms as a method of attempt are irreversible and do not allow for reconsideration once the impulse is acted on. Firearm suicide lethality rate is between 80 and
90 percent. The vast majority of non-fatal suicide attempts are overdose or sharp
object attempts. These are fatal in only 8% of attempts.
Clinicians are limited in their ability to detect and prevent suicide attempts

5

Assessing risk
perception andthe ways in which
individuals assess
their own risk canreveal strategies
for increasing
knowledge andenhancing theeffectiveness ofinterventions.

6Interventions tailoredto address individualand community
needs can increase
engagement in thedesired risk reduction
behaviors.

Financial Stress and Behavioral Health in Military Servicemembers

because the risk population is so large and the event rate is relatively low. Clinicalproviders are also limited in their ability to reliably predict who will be violent.
Relying on the criminal justice system to identify those who may be violent focusesinterventions far down the trajectory of violence. There is a need to better understandrisk pathways and how and when intention of suicide shifts to action, and the extent
to which impulsivity is involved. Interventions that target only those with expressedsuicidal ideation will also miss the people for whom the decision to attempt suicide
is impulsive and rapid. Mental health clinicians must be trained to be comfortablein talking about firearms with their patients in a way that is consistent with theirpatients’ values about guns. Use of safe storage practices is known to be associatedwith lower rates of unintentional and self-inflicted shootings. In VA clinics currently
gun locks are available that even have the National Suicide Prevention Hotline printed
on them. Training professionals that work with individuals in significant distressshould include training in talking comfortably with people about firearm storage.
Interventions tailored to address individual and community needs can increase
engagement in the desired risk reduction behaviors. Peer support models have beenshown to have the potential to be accepted by lowering feelings of stigma in thisinteraction around firearm ownership. Peer interventions can identify individuals
in distress and provide an intervention similar to how we teach people to use theHeimlich maneuver to help a choking victim. Public health campaigns on drunk
driving provide another useful perspective. Over several decades our society changed
the culture to make it inappropriate to drive after drinking and appropriate forfriends and bystanders to intervene without stigma (i.e. “Friends don’t let friends
drive drunk”). Similarly there is now strong support among OIF/OEF veterans fortalking to a peer about a mental health problem or firearm storage. Every brochure
about firearm safety can include mention of being alert to signs of suicide and helping keep guns from someone until they have recovered in a manner similar to the“friends” campaign in prevention of drunk driving.
Another important strategy is to engage organizations that support the sale andownership of firearms as partners, not as “the problem.” This strategy has been used
to increase collaboration. A key element in these engagements includes normalizing
and destigmatizing gun ownership. It should also emphasize autonomy and offer a
range of safety options for gun owners. Importantly, a majority of the general population and the gun-owning population agree that it is appropriate to restrict access tofirearms for people who are violent toward loved ones. Many gun groups subscribe
to values such as safety, responsibility, protecting the family, and neighbors looking
out for each other. At present, public-private collaborations are underway with gungroups in over 20 states to add an “11th commandment” to the 10 commandmentsof gun safety — Be alert to signs of suicide and help keep guns from a loved one
until they have recovered. One of the challenges with firearms is differentiating what
is a temporary state of increased risk from what may be assumed to be a chronic,
unchanging state. The challenge in this approach (similar to asking for the keys inpreventing drunk driving) is framing removal of firearms as time-limited interventions rather than permanent. It may be helpful in this approach to focus on signsof distress. Gun shop owners are not comfortable with the expectation that theyscreen for suicide risk. They are more comfortable in delaying sales to individuals
when they are unsure of the purchasers’ motives, such as potential straw purchasers.
Their preferred tactic in these cases is to delay or redirect, rather than confront theindividuals. Some DoD programs are investigating these approaches.

Executive Summary and Recommendations

In addition to peer and community interventions, several public policies showpromise to reduce risk of gun suicide and gun violence. Two types of civil interventions, the domestic violence restraining order (DVRO) and gun violence restraining
order (GVRO), offer promise in identifying individuals at risk for committing violent
acts and intervening to limit their access to firearms. These laws acknowledge thatfamily members are often in the best position to recognize when an individual is at
risk for suicide or violence. DVRO laws are currently in place in all 50 states. GVRO
laws have been enacted in California and Washington in the last two years, with bills
under consideration in 12 additional states. The DVRO allows for restricting thepossession and purchase of firearms for a few days to a month. Evidence suggests
there is a reduction in intimate partner homicide associated with DVROs. GVRO
allows a family member to request a temporary order prohibiting the purchase orpossession of firearms. The intent of the GVRO is to intervene in cases of violencerisk before the criminal justice system is involved. Connecticut has a law that allows
law enforcement to petition for removal of firearms from an individual deemed arisk. Preliminary evidence suggests this has led to a reduction in suicide deaths. There
have not been any reported cases of GVRO issued for an active-duty servicememberof the 50 to 60 issued to date. It is unknown what the implications of this will beas there is presently no DoD or service policy for what to do if a GVRO is issued
against an active duty servicemember. One also needs to consider the spouse whocomes forward to protect their family member at risk. Doing so can affect family
relationships and work is required for families to reintegrate. Practically it can also
result in a spouse who subsequently is divorced, losing benefits. It may be a challenge
for military authorities to identify when such actions are taken in the community
as there is not a formal link between the community and command authority.
Commanders have authority to ask at-risk servicemembers to voluntarily transfer
temporary custody of their weapons to the command. The military has a long historyof issuing military protective orders (MPO) in cases of domestic violence. A militaryorder to remove firearms may be difficult to execute fully because servicemembers
move frequently and may have personal firearms lawfully registered across multiple
states. One important message certainly remains — family members can and shouldintervene to limit access to firearms for a loved one at risk even without involving
authorities.
Personalized guns — ones that only operate for the owner — have the potential
to reduce suicides and unintentional gun injury and reduce risk posed by approximately 500,000 firearms stolen from homes every year. Safe gun design technologies
include radiofrequency identification (RFID), biometrics, and dynamic grip recognition to create a personalized gun that can only be operated by the authorized user.
There is however, no current technology that would prevent a firearm from being
turned on its identified owner. For some, engineering safety into firearms has at times
been perceived as threatening freedoms. Personalized firearms also will not addressguns already in circulation.
It is very difficult to accurately identify individuals at risk for suicide. One solution to this is to focus on observable behaviors that identify individuals as at-risk ingeneral. Focusing on observable behaviors can also empower bystander intervention without specific skills or expertise. An analogy would be taking the keys fromsomeone observed to be intoxicated before they can get behind the wheel. This maylead to effective gatekeeper interventions with professions that work with at-risk
populations, people who are experiencing significant loss or disruption of their lives.

7

Focusing on
observablebehaviors can also
empower bystanderintervention
without specificskills or expertise.

8

Financial Stress and Behavioral Health in Military Servicemembers

Conclusion
The Forum on Health and National Security: Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies has reviewed critical areasof understanding risk and safety as perceived by servicemembers and their families.
In so doing, programs that are now moving into practice have been highlighted aswell as new avenues for research to maximize safe behaviors and safe families. Continuing the focus on safety offers opportunities to change culture to protect many
at risk, from children to adults and from servicemembers to veterans to civilians.

Opening Remarks

91

Opening Remarks
Speakers: James C. West, MD, Robert J. Ursano, MD

DR. WEST: This is our fourth Forum on Health and National Security. We havebrought you together to take on an issue, listen to a group of scholars talk about
their work, and then to exchange ideas. What is the issue? The original title of thisforum was “Personal Firearms and Military Servicemembers.” After some thought
the committee decided it is a broader issue — an issue of safety. It is an issue offamily safety. It is an issue of safety of individuals from self-harm and accidents, andfrom interpersonal violence. It is an issue of safety of families from interpersonal
violence and intimate partner violence. Seeing that the topic is broader than personalfirearms we have changed the title to “Family Safety and Military Servicemembers.”
Much of what we will talk about centers on personal firearms because that is aneffective paradigm through which we can focus the issue. We could also talk about
sharp objects around the house or dangerous furniture, but personal firearms provide
a means to focus the discussion. This topic generates significant emotion on bothsides of the issue and we will think about that as well.
Considering how we have structured the program, we will begin by hearing
about the epidemiology of guns, gun injuries, and gun violence. Then, we will takea step back and consider how people look at risk in their environment, based on
the science of how people assess and communicate risks. We will also consider how
culture affects risk decision-making. Finally, we will consider interventions that arein the world right now, trying to change risk, trying to change safety and consider
what’s working, and what’s not. Our hope is that, by looking at the problem fromthese three directions, we will identify new ideas and perspectives. Hopefully, everyone will leave the meeting having met somebody new with an idea that they might
have a chance to follow up on. More than anything, we hope the forum will spark
further inquiry and discovery.
Allow me to introduce Dr. Robert Ursano for some opening remarks. Dr. Ursano
is Chair of Psychiatry and the Director of the Center for the Study of TraumaticStress. He will introduce the topic.
DR. URSANO: The Forums on Health and National Security that have occurred
over the past several decades have addressed a wide range of topics. They havespanned everything from behaviors in chemical and biological warfare environmentsthat put people at risk and keep them safe, to questions of financial stress and its

Much of what we willtalk about centerson personal firearms
because that is aneffective paradigm
through which we canfocus the issue.

10

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

More than anything,

impact on servicemembers’ risk for suicide and other risky behaviors. There is a slide
we frequently use in talking about health related to extreme environments, traumatic
events, and disasters. That slide is a Venn diagram with three interlocking circles.
One of those circles represents PTSD and psychiatric disease. Another of those circles
represents the experience of distress and how distress modifies our behaviors. And
the third circle, the one on which we focus today, is health risk behaviors. Behaviors
that, in fact, put us at increased risk.
In the world of psychiatry at the Uniformed Services University of the Health
Sciences (USU), which Dr. Kellermann has appropriately labeled “America’s Medical
School,” the issues are not only of psychiatric disease. Rather we address behaviors
that increase morbidity and mortality, the focus of behavioral health and humanfactors throughout the Department of Defense. If we can alter health risk behaviors,
we can change morbidity, mortality, and perhaps even happiness of individuals andfamilies.
In a discussion with my daughter five years ago, we were talking about one of
my grandchildren who was about to go next door to a neighbor’s house. She asked
him, “Who’s home?” And she asked, “What are you planning to do?” Afterwards I
asked her, “What things do you ask them about, and how do you decide what’s onthat list?” We had a discussion about the things that were on her list and the things
that are not on that list, which include things such as, “Is there alcohol? Is the alcoholout? Who else is there in the home?” And one that is not often asked, “Do they haveguns? Are the guns locked up? Where are they kept?”
The issue of developing family safety is deeply embedded in what is “safety.”
What is our understanding of the experience of and the perception of safety? Safety
is not just the absence of feeling anxious. It is truly a different experience, one forwhich we do not have a substantial scientific literature. Consider a few examples.
After 9/11 the experience of safety for many families meant keeping the children
home. That meant children did not go to school. This was documented by Chris
Hovens in New York City. After the sniper events in Washington, D.C., which mycolleague, Dr. Carol Fullerton studied, we saw different types of safety behaviors.
Safety behaviors included ducking down behind large objects when filling your carwith gasoline. Another aspect of safety behavior after 9/11 was that people decided
not to fly, a behavior that had substantial economic impacts on the nation.
Safety is a part of our lives, particularly in the face of frightening events andthose that we see as dangerous. Understanding how we perceive safety and, mostimportantly, how we can educate about safety. We are particularly focused on
educating patients, families and providers in our healthcare system. Our work is
principally on educating healthcare providers to be able to teach safety, learn about
safety behaviors, have effective interventions that alter safety behaviors, and can
impact a wide range of risky elements of our lives. That is our goal and hope fortoday; that at the end of the day we will have heard some new ideas and say, “Wellthat’s interesting. I had not thought about that one before.” As we think forward,
how can changing safety behaviors be more a component of our interventions as
we face a risky world for our families and, in particular, for our servicemembers
and their families.
DR. WEST: Hopefully, everybody has a seed planted right now. One of the goalsof a gathering like this is to connect people, whether it is somebody with money tosomebody who needs money; whether it is somebody with an idea for somebody
who has a means to investigate an idea; or whether it is somebody with a whole

we hope the forum
will spark further
inquiry and discovery.

Opening Remarks

bunch of means who has not had an idea in a while. That is the joy of a gatheringlike this. Before I introduce our first panel, I want to continue setting the stage. What
are we doing? Why are we here?
I got into this business fairly recently. I cannot claim the pedigree that Daniel,
Cathy, or Andy, or any of our panelists bring to us. But, boy, did I get to know themin the process of getting smart. Three years ago I got handed the Firearms Safety
Project. Like many organizations where there is turnover of personnel, the person
who preceded me, Colonel Dan Balog, was tasked with building a training programfor servicemembers on personal firearm safety as a means of suicide prevention. I
thought, “That sounds pretty good. I’ll take that on, but I don’t know much aboutit.” As I started learning I said to myself first, “What is the problem? What are wetrying to fix here?” The first thing you do in a project like this is build an enormous
body of literature. We have accumulated hundreds of articles on firearms, gunviolence, and safety interventions. That is how I have gotten to know a lot of thenames up here at the table.
My journey started when I started actually looking at numbers. Numbers made a
difference to me. Every time I have a conversation with someone on the topic of gun
violence they say, “Isn’t it horrible how much gun violence there is now?” The firstthing I say to them is, “Now? The numbers have not changed for 20 years.” If there
are two or three numbers you want to walk away with today, you can remember
30,000, 20,000, 10,000. Those are approximations. They go up and down a little bit
every year. In the last 20 years, every year 30,000 people die from a bullet that comesout of a gun: 20,000 of those do it to themselves, self-inflicted firearms injuries; andabout 10,000 are shot by someone else. Those numbers have stayed fairly stable.
Hopefully we can look at that and say, “That is still an unacceptable number. Thatis a lot of people dying from an identifiable cause. What should we be doing about
it?” When I came across those numbers, they motivated me.
As we start our panels, the first speakers, Andy and Daniel, are going to talk to us
about the numbers, about appreciating how gun violence spreads across society, bothfrom the perspective of suicide risk, as well as from the risk it poses to family safety,
family dynamics, and interpersonal violence, because it is all bound up in there.

11

In the last 20 years,
every year 30,000
people die from abullet that comesout of a gun: 20,000of those do it tothemselves.

12

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

Panel One: Defining the Problem

13

1

Panel One:
Defining the Problem
Speakers: Andrew Anglemyer, PhD, MPH, Daniel Webster, ScD, MPH

DR. WEST: Allow me to introduce our first panelist, Dr. Andy Anglemyer. Dr.
Anglemyer is currently Assistant Professor in the Operations Research Department
at the Naval Postgraduate School (NPS). His career in public health began long
before his formal education. He served five years as a linguist in the United States
Army and then left the military to study epidemiology and public health at the
University of California, Berkeley, where he received his Master’s in Public Healthin epidemiology and biostatistics in 2006 and his PhD in epidemiology in 2010. For
the last seven years, Dr. Anglemyer has been an active member of numerous HIV/AIDS treatment and prevention guideline development committees. If you look at
his CV, you will see much of his work has been in the area of health risk behaviors
and HIV. Additionally, in collaborations with the Centers for Disease Control andPrevention (CDC), he has helped train public health workers in Ukraine and Russia
with implementing and interpreting regional HIV surveillance.
What called Dr. Anglemyer to our attention were several recent articles he has
published. One was a systematic review of the impact of firearms and risk of suicide,the other a comprehensive look at military servicemembers, breaking it down by
military occupational specialty and risks imposed by the presence of firearms forthat group.
DR. ANGLEMYER: A couple of years ago we had the Ebola epidemic in West
Africa, and at the time I was teaching a statistics class at the Naval Postgraduate
School. The students knew that I was an epidemiologist by training, so they asked
me, “What do you think about this Ebola epidemic?” and “What is our personal
risk?” There was a nationwide survey done during that time about personal risk.
“What is your personal risk to get Ebola in this country?” At the time, it was very
high, something like 60% of people felt that they personally were at risk of getting
Ebola in the United States. There was significant media attention, and the students
were asking me about Ebola. I told them to get their flu shots because there will be
30,000 people who die from flu this year, and there will be very few who will everdie from Ebola in this country. It is all about understanding personal risk, and wewill cover that later today.

I told them to get their
flu shots because there
will be 30,000 people
who die from flu thisyear, and there will
be very few who will
ever die from Ebola inthis country. It is allabout understanding
personal risk.

14

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

There is strong

Today I will talk about firearms and suicide, but I am going to talk more specifically about firearms-specific suicide. As we know, about three-quarters of all
suicides occur in one’s home, which means about a quarter of suicides do not occur
in the home. They occur elsewhere, whether it be in a yard or a car or the park, or
wherever it might be. The annual rate of suicide in this country is approximately
12.9 per 100,000 residents. However, if we look specifically at the typical age range
for military personnel, the age-adjusted rate for suicide is around 15 per 100,000
for 20-to-34-year-olds in this country. I mention that 15 because in the active-duty
military, the annual rate is around 22.7 per 100,000 and is primarily driven by theArmy, based on sheer numbers. The overall suicide rate in the military has almost
doubled, at least according to data we have, from 2001 to 2011. At present theannual rate of firearm-specific suicide in this country is highest among all countries
with available data. It is approximately 6.3 suicides per 100,000 residents. Firearmownership, or the percentage of households with a firearm, in this country is around40%. There is strong evidence that access to or availability of firearms within thehome is associated with completed suicide. More specifically firearms that are stored,
either stored unloaded or not even locked, are far more likely to be used than firearms that are stored locked and unloaded. The evidence is that this is predominantly
among adolescents. Further, the increased risk for suicide associated with firearms in
the home is not unique to those with a history of mental illness or attempted suicides.
This gets to the idea that it might be an indicator more of impulsivity about suicide.
My prior research has been mostly with individual-level risk, but there is
far more data dealing with ecologic or policy-level data. Higher rates of firearmownership have been linked to higher rates of overall suicide and firearm-specificsuicide. However, suicide attempt rates are not necessarily significantly related to
gun ownership. Firearm ownership rates independent of underlying rates of suicidal
behavior largely determine the variations between states. More specifically, firearms
in the home impose a suicide risk that is above the baseline risk. It is an additiveeffect. As I said previously, we could talk here for weeks about all these topics. I
want to plant the seed that there are inevitably these ideas of method substitution.
If we are talking about firearms, what if there is a restriction on firearm access? An
anecdotal example would be in Australia. It is the classic example where, as firearm
availability decreased, overall suicide also decreased, and that extended for many
years after and it still does today.
The counter argument was if someone wants to commit suicide and they are
determined, they will find a way. There was an increase in rates of hanging, but thatrate had actually started before the availability of firearms decreased, and it did not
make up for the difference in overall suicides that were prevented. It is important tounderstand that we cannot really talk about firearms and suicide without considering
all the other risk behaviors as well, such as alcohol abuse. Prior research has shownthat military conscripts with no history of attempted suicide, if they had a historyof alcohol abuse or history with some type of engagement with the law, they wereat higher risk for suicide than those who did not have any such history. The odds ofalcohol abuse were much higher among those who were special operators engaged
in combat than those who were special operators not engaged in combat. In otherwords, if you are engaged in combat, you are far more likely to use alcohol, andmore likely to abuse alcohol.
I looked at the individual level not specific to the military, but in general. I am
calling it the risk for suicide when we look in the context of firearm ownershipevidence that accessto or availability of
firearms within thehome is associatedwith completedsuicide.

Panel One: Defining the Problem

or accessibility. This was a prior analysis I had done where my methodology wasa meta-analytic approach to all the available data. In this case, I examined all of
the available data that looked at individual-level data and whether one’s odds forcommitting suicide were increased or decreased depending on whether they had afirearm at home.
The overall picture here is very clear: you have a three times higher odds of committing suicide if you have a firearm in the home than if you do not. The interesting
thing I find here is that we are talking about conflicting evidence. I have done a great
deal of meta-analyses in various clinical contexts, but I have never seen one that is so
one-sided. Every one of these studies has an increased odds of committing suicide if
there is a firearm in the home except for one study that was not significant. However,
it is borderline significant, and it happens to be the top study and it happens to be
the only non-U.S. study. That study was performed in New Zealand. If you consider
the prevalence of firearm ownership in homes there, it is quite a bit different, andto include them with all other U.S. studies is a little bit of a source of heterogeneity.
Speaking of heterogeneity, one of the steps in doing these meta-analyses is tolook for signals. We can collate studies, synthesize them, and come up with thisnice, clean number at the end. Is there something else going on? Is there a trend? Is
this being driven by the types of studies? I did some other meta-analyses of thosestudies and sub-grouped them to see whether there was any signal. In other words,
was this being driven by men? Was it being driven by adolescents? Or studies thatwere high-risk versus low-risk? The short story is there is not. There is no signal that
I saw to explain the variability between the studies, other than it might be either
study design or just random variability.
Moving on to military suicide, I performed this study in conjunction with astudent on his master’s thesis at Naval Postgraduate School. He wanted to lookspecifically at the rates of suicide among subgroups within the military, whether it
be demographic subgroups, et cetera. As we will learn today, it is not easy to study
suicide in the military for various reasons: service branches are different, components, where the data are kept, which I do not know if we know where all the data
are kept. About 90% of his time was spent getting the data. Building on his work, I
then looked at other predictors of violent suicide using his data. This is just looking
at the rates of suicide specifically among enlisted active-duty members from 2005
to 2011. The rates of Army suicide are the highest of all branches, and not only is it
the highest, but it sustains that difference over time. From 2009 to 2011, it is moreor less the only branch that has sustained that elevated rate of suicide. The Marines
paralleled the Army for a while, until 2009, and then dropped off. The backgroundshows a troop surge in Iraq, troop surge in Afghanistan, and drawdown in Iraq. I
am not trying to draw a causal conclusion, but trying to understand whether there
was some other signal going on in a policy or maybe mission-related aspects. The
short story is we do not know.
The interesting thing I will point out is that not only is the relative rate of suicide
higher among the Army, in other words, they are relatively higher than all of theother branches, but also the absolute risk of the Army is far greater. It is an interesting concept because it is much higher for both absolute and relative risk.
Among all suicides, from the Defense Suicide Prevention Office (DSPO) data I
had from 2005 to 2011, of all those suicides of active-duty enlisted, I want to pointout a few things. Again, this is stratified by branch. One is that the bulk of all suicides
were male: 95% to 99%, depending on the branch. Among each branch I wanted

15

It is important tounderstand that wecannot really talkabout firearms andsuicide without
considering all theother risk behaviors
as well.

16

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

Veterans have four

to look at whether they were lower enlisted. Between 45 and 50% of suicides in the
Navy and in the Air Force were lower enlisted, E4 and below. That changes if you
look at the Army and Marines; it is about 67 to 70% of the Marines and the Army,of those that were suicides, were lower enlisted. That also follows along with ages.
Ages are a little bit younger for the Army and Marines than the Navy and the Air
Force, not substantially, although the Marines, the median age was 22, so that isvery different. It follows along with the education level as well. Generally speaking,the males’ highest level of education is high school and they are less than 25.
DR. NASH: Did you compare these demographics of suicides to the demographics of the service branches? The Marine Corps is a very young male service. I am notsure what percent of the Marine Corps is below E5, but I would not be surprised if
it is pretty close to 70%.
DR. ANGLEMYER: You are absolutely right. If the question is did we have an
actual rate of suicide by each one of these ranks, I do not have that today, but, we
did analyze that in our paper. One other thing I wanted to point out was the occupations of suicides. This was something I had done on my own. It is not that easy
to group occupations, as there is no standardized method of doing this. I went byprior publications in how I grouped the occupations. I would like to point out thatthe bulk of Army and Marines are infantry and special operators. It is no surprisethat the bulk of the suicides were also in the infantry and special operators, goingalong with what Dr. Nash said as well. We see the same thing in the Air Force, thebulk of Air Force personnel are working with aircraft in aircraft-related occupations,and no surprise, the bulk of the Air Force suicides were among those occupations as
well. Unlike every other branch, 20% of the Air Force suicides were among those
who were police or in corrections. The common denominator here is individuals
who frequently have access to firearms. The infantry, special operators, and thecorrections, are the three highest proportions of all the branches.
DR. WYNN: When you say infantry or special operations is a higher rate inArmy and Marines, it somewhat goes against the data we have seen that suggested
special operations has at times lower rates. Is there any effort to differentiate between
the Army, your 11 bravo and your 18s, or something that would say that these are
two separate, self-selecting populations for high-performance operators versus yourregular ground-pounder or non-enlisted infantry?
DR. ANGLEMYER: I would like to point out that these are proportions, notrates. I have not looked at the rates. These are just proportions of all suicides withina branch. I am grouping ground-pounders and special operators together. It is anumbers game with a sample size. If I wanted to do any sort of modeling at all, mysample size gets decreased quite a bit if I look at only special operators by themselves.
Ultimately, I do not have it and I will probably look at that myself again. I believe
our data are probably driven by infantry and not the special operators.
DR. WYNN: That would be our experience, too, because it is driven by infantry,
not special ops.
DR. ANGLEMYER: This is an epidemiology technique called a directed acyclic
graph. It is designed to understand all of the different components that affect relationships and to see the minimal number of covariates you would need in order toactually model it. In this case we found that the minimal set of covariates we would
need would be: sex, infantry, age, education, and their Armed Forces Qualification
Test (AFQT) score, or their entrance exam score. With that, I looked at the adjusted
odds of firearm-specific suicide among all suicides. Among all those who committed

times more firearms
than non-veterans andthey are more likely
to use those firearms
to commit suicide
than non-veterans.

Panel One: Defining the Problem

suicide, what were the odds of committing suicide with a firearm? If you were in the
Army and you were infantry or special operations, you had a two times higher odds
of committing suicide with a firearm than if you were non-infantry or non-Special
Forces. In the Marine Corps, it is roughly the same, almost three times higher odds
of committing suicide with a firearm. I could not perform the same analyses with the
Navy and the Air Force because there were not many infantry or special operationsin those branches.
A future strategy is that we need to identify personnel who are, in fact, at risk
and provide them with the necessary care. However, there will be some resistance toseek care because of stigmatization or maybe feelings of jeopardizing their careers.
The American Academy of Family Physicians emphasizes the need for clinicians tofirst identify those at-risk members by tailoring military-specific questions. On theother hand some suggest that, if we assume all military personnel are at risk andassess them appropriately by using a validated screening tool, this may be an effective approach to reducing suicide attempts.
I will leave you on this one note, and this is important in the context of firearmspecific suicide. Clinicians should recognize the unique risks that firearms pose forthis specific population. That is that veterans have four times more firearms thannon-veterans and they are more likely to use those firearms to commit suicide thannon-veterans.
DR. WEST: Thank you, Andy. As I said, our focus here is not just suicide, notjust guns; it is safety. As you look at safety through the lens of personal firearms,
you have to think about the interaction of firearms in relationships, in interactions
between people. That is what I have invited Daniel to talk to us about: how does
the introduction of a firearm into the equation of human relationship change thedynamic?
Daniel Webster is Professor of Health Policy and Management, with a joint
appointment in the School of Education’s Division of Public Safety Leadership at
the Johns Hopkins Bloomberg School of Public Health. He directs the Johns Hopkins Center for Gun Policy and Research. He has published over 100 articles on
topics of gun policy; violence prevention; youth violence, which is another area ofinterest of Dr. Webster; intimate partner violence, suicide, and substance abuse. His
research and leadership have been particularly evident in Baltimore, where he leads
the Johns Hopkins Baltimore Collaborative for Violence Reduction, a partnershipwith police and prosecutors to promote data-driven approaches to reducing violenceand enhancing police and community relations. Dr. Webster co-chairs the Advisory
Board for the Health Department’s Safe Streets Baltimore Program and previously
led Baltimore’s Homicide Review Commission.
DR. WEBSTER: You don’t hear it in my voice, but I am a southerner. I grew up
in Kentucky in my home with guns. One time, my granddad and I had an experience of going to Little Rock, which was analogous, not quite as dramatic, but his
experience rang true.
I am going to share with you today what we know from epidemiologic studies
about the risk of guns in the home, principally as it relates to violence and lethal
outcomes. I am going to briefly talk about unintentional shootings as well because
I think that is important. If you look at the numbers of unintentional shootings andhow they stack up, they certainly are a very small part of the overall problem. Theynevertheless still play a very interesting role in how people think about and makedecisions about whether to have guns and how to store them in their homes.

17

If you were in the
Army and you were
infantry or special
operations, you had a
two times higher odds
of committing suicidewith a firearm than if
you were non-infantry
or non-Special Forces.

18

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

We need to identify

I wanted to start with some general flavor of guns in America. Probably manyof you are familiar with recent trends. We do not really have the best way to track
actual numbers of gun sales in this country, but we do track background checks,
which are a fairly close barometer of that. What we have seen is some fairly substantial increases in the number of gun sales, principally during the Obama Administration, and I suspect that is not completely unrelated. However, there is anotherinteresting trend line that does not really correlate at all, almost negatively correlated,
and that is our best estimate of the prevalence of what percent of homes have gunsin them in the United States. These data come from what I think is generally themost respected source of trends and social phenomenon, the General Social Survey
done by the University of Chicago. You see that household prevalence has been
fluctuating between 30 to 35% for a while now after a really noteworthy decline
principally during the 1990s. I am not going to talk too much about youth in this,but I wanted to mention that there are a number of indicators of youth access to guns
and gun-carrying that also mirror these general trends of gun ownership. Generally
speaking, when guns are more readily available, they are also more readily available
to underage youth.
This is what our firearm homicide rate trends look like for youth through 2014.
Captain West mentioned we have had this high level of gun violence in the UnitedStates for a very long time; not much is changing, although there are importantchanges in different categories. One of our success stories has been for youth andtheir declining rates of homicides. I could show a slide with suicide rates for underage youth that also look good. My own hunch is, and some studies do show thiscorrelation, that these trends are positively correlated with gun availability in thehome. This shows which weapons are used when an intimate partner kills anotherintimate partner in the United States. These come from the Uniform Crime Reportsof the FBI. Just over half of the time those incidents do involve a gun, roughly 24%
a knife, and so on. Guns play an important role when we think about domestic
homicide and intimate partner homicide. That is probably the most relevant part ofthis conversation, and I want to explore the data a little bit.
I have to start with Dean Kellermann’s seminal study published in The New England Journal back in 1993, a very widely cited study. It was a case-controlled designof identifying cases of homicides in the home; he did a similar design with suicides.
Importantly, these homicide cases were not exclusively homicides committed withguns. It is homicides by any means. They identified matched controls based upon
the neighborhood, age, sex, and race of the individuals in the household. Then, theystatistically controlled for a variety of other behavioral risk factors such as substanceabuse and other measures of violence.
After controlling for other factors, the adjusted odds ratio was 2.7, so a fairly
substantial increase in homicide risk within the home associated with reporting atleast one gun in the home. These risks varied somewhat for different subcategories
and demographic groups. The risk for women was elevated the most with gunownership. Typically male ownership is quite substantially, three or more times,
higher than females. The risks were also greater for those under 40 versus above
40. Finally, while the population studies were largely metropolitan studies in threedifferent states, it was noteworthy that, if you just had a long gun in your home, you
did not see this statistically-significant elevated risk of homicide. It was connected
to handgun ownership.
DR. COZZA: The women had risk for women gun owners, not victims?

personnel who are,in fact, at risk andprovide them with
the necessary care.

Panel One: Defining the Problem

DR. WEBSTER: No. What we are looking here is at-risk for victimization.
Women’s risk for homicide victimization went up more with a gun in the home thanit did for men. Generally, what is driving the overall numbers is male gun ownership.
DR. URSANO: Let me just clarify, the gun ownership is related to the perpetration. In most cases the perpetrators are the family members themselves.
DR. WEBSTER: Most commonly yes, but not exclusively. It was not designed tojust do this, but when you look at what actually occurs within homes when people
die within homes, most commonly, it is not someone coming through the window,
an intruder going to kill someone. That is of a relatively small risk. Far, far morecommon is intimates or some family relations involved in conflict that becomes
lethal, sometimes due to the ready access of the guns.
DR. URSANO: Behind that is the neighborhood context and the question ofneighborhoods and rates of gun ownership by neighborhoods and how those vary
based on the risk of the neighborhood.
DR. WEBSTER: These were neighbor-matched controls. They went to somebody nearby, it was not a different neighborhood. There were a number of things
that were controlled for. However, critics of this study pointed out how different
cases and controls were on measurable risk factors. Very quickly, you can see that,while the cases will look a great deal like the controls, and what is then a concern
is, while Dr. Kellermann and his colleagues went to great lengths to try to identify
these risk factors and control for them statistically, the more different your casesand controls are on measurable factors, the more you worry about there might beimportant unmeasured factors that explain that risk. This bothered many people in
the gun industry, in particular, but some researchers as well.
The other questions had to do with measurement of the principal risk factor of
gun ownership. When there is a case, meaning a homicide in the home, particularly
if it is committed with a gun, you are going to have pretty good measurement about
whether a gun was in that home or not. Conversely, you knock on a neighbor’s door
in that area and say, “Will you participate in this study?” You start to ask questions
and you ask them about gun ownership. It may be that the control individuals areless forthcoming and there is unmeasured gun access in those homes. This could
cause the data to be skewed and would make it appear that there is a more starkdifference between gun ownership cases and controls.
The thing that I find most compelling has to do with the direction of the causal
arrow. Case control studies typically cannot disentangle that. If you generally live ariskier lifestyle and you think that you might need your gun, then you are going to
be more likely to get one, right? Conversely, if you generally do not have a lifestylethat risk comes to you, then you are not going to have a gun. Finally, getting to one
point raised earlier, which is if you look at a map of most cities and where homicides
occur, even domestic homicides, they are not randomly distributed. The cases fromthese metropolitan areas measuring how gun ownership and other factors affecthomicide in the home really tells us principally about what happens in the highestrisk areas. I am not sure what it tells us in the lower-risk areas, based upon this study.
Peter Cummings and colleagues at the University of Washington followed theKellermann study, with their own case-controlled study in a fairly large Health
Maintenance Organization (HMO) population. They had 117 homicide victim
cases. One important difference here is the measurement of the exposure of guns. It
was measured by whether they had a registered gun in the home or not, and it wasmeasured identically in cases and controls. That one concern in the Kellermann study

19

One of our successstories has beenfor youth and theirdeclining rates ofhomicides.

20

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

3.5% of adult womenis eliminated here. The weaker side of this study is that they did not have nearly as
much information on other potential risk factors. They went with available datathat they had on this HMO population.
Generally, what Cummings and company found was a twofold increase in
homicide risk connected to purchasing a handgun, and that risk extended bothto the purchaser’s risk, and also anybody in the purchaser’s family or household.
However, there are other reasons to be cautious about causal inference. The elevatedrisk for homicide connected to handgun ownership was also elevated for homicides
committed by means other than guns. The other interesting finding was that having
one gun did not significantly elevate your risk. It was one or more guns, so what I
suspect is not every gun owner is the same. If you have one, it is different than if you
have 10, and it may say something about your underlying risk profile.
Finally, the last of the case-controlled studies I will show you of this very specifictype, that we did, was a study using national data from the National Mortality
Followback Survey and the National Health Interviews Survey. We had nationaldata, and it was not restricted to higher-risk neighborhoods. Interestingly, theadjusted-odds ratio that they estimated from this study was notably lower than in
the Kellermann and Cunningham study. It was statistically-significant, 1.4, basically a 40% increased risk for homicides associated with gun ownership. Again,
the elevated risk was greater for female victims than for males, slightly higher for
non-whites than for whites. In a separate study using similar data, Dahlberg andcolleagues from the CDC found no association between gun storage practices inrelationship to homicide risk.
The study that I was a co-investigator on, led by Dr. Jackie Campbell, my colleague at Johns Hopkins, looked at the case-controlled study designed to examine
risk factors for lethal outcomes when there is some degree of preexisting physicalintimate partner violence. We collected data in 11 cities geographically dispersed
all around the country. One aspect of this study is that we only looked at female
victimization by the partners. We identified 220 of these cases and 343 controls
in a random digital survey methodology. We obtained the risk factor informationand cases from proxies, who knew the most about the victim in these cases andtheir relationship with their current or their prior intimate partner. This study went
into far, far more detail than any of the other studies to measure and control forthe nature of the violence in that home and in that relationship. It was a very longprotocol and we controlled for everything. We found a fivefold increase in homicide
risk connected to the abuser having a gun.
Briefly, I want to talk about gun use in non-fatal intimate partner violence. In anational study, one estimate for lifetime prevalence of having ever experienced this,
3.5% of adult women reported that a current or former partner had threatened orused a gun against them. If you look at cases that come to the attention of police,based upon a national system for incident-based reporting, 11% of female victimizations involve the use of a gun, five percent of male victimizations. Then, if you
look at the highest risk in this whole broad spectrum of intimate partner violencein cases where women felt so threatened that they went to shelters, 37% of that
population had a gun used against them. Studies that just look at the association
between whether having a gun generally is associated with any physical violence
have not shown significant effects, though it has been, interestingly, linked to higher
rates of psychological abuse, and some evidence that perpetrators’ access is linked
to the severity of the partner violence. Again, very difficult to disentangle whether

reported that a current
or former partner had
threatened or used a
gun against them.

Panel One: Defining the Problem

it is the gun or not because most of the more severe forms of violence actually do
not involve a gun.
One other study I want to note here was not designed so much for household
risk, but the added risk for having a gun, how much that elevated risk is connected
to your own history and risk for violence. Garen Wintemute demonstrated thatvery well in a study in California where he looked at people who legally purchased
handguns in the state and their prior criminal records and found, for example, thatpeople with misdemeanors were about five times more likely to then go on andcommit violence than truly law-abiding gun owners. If you look at the subcategoryof people with prior arrests for any violence, and these were misdemeanor formsof violence, much of it domestic violence, this elevated risk tenfold. I made manyof these other points about the risk varying, not being one risk, but the risk being
dependent on other risk factors.
Another point I want to make that is incredibly important when we talk aboutrisk perception and communications as it relates to guns in the home. I can makea very compelling case about elevated risk in the context of relative risk. However,
we also have to acknowledge, even though nationally we have a great deal of gun
homicides within homes, that we have many homes with guns. The absolute risk fora homicide within the home, and particularly the absolute risk for an unintentional
fatal shooting within the home is low. When we had these conversations about why
do so many people think that it is such a great idea to have a gun in the home when
you see a clear pattern of elevated relative risk? Of course, it applies to the suicide
data presented just a minute ago. My own takeaway is that it has to do with theidea that people probably respond more to absolute risk than they do to relativerisk, which is something that we have to acknowledge when we do our risk communication.
I want to also mention one of the criticisms from these case-controlled studies
which I think is off-base, is that these studies were designed to just look at the badoutcomes from guns and not the good outcomes. If there were a great number ofprotective, defensive gun ownership, you should have lower homicide rates within
homes with guns than with homes that do not have guns. There is some data on
defensive gun use, but quite honestly, I do not trust any of it. I do not think it issomething that we can accurately measure. It is a highly subjective thing about
whether, when somebody used a gun, it was purely a defensive action or not, because
most of the encounters really are some interpersonal conflict where one person uses
a gun, often not to shoot them, but to say back off or you cut me off in traffic. If you
surveyed two people in that exchange, one will say that was a defensive act against
somebody who was being hostile. If you interview the other person, they will saythat was an aggressive assault. It is a very difficult thing to disentangle, and that is
why I let people like David Hemenway and others spend their time trying to figurethat out, because I am not confident we can.
The data that we do have from the National Crime Victimization Survey gives two
different answers to whether using a gun when being criminally victimized lowers or
increases your risk. If you look at cases in which victims preempt the victimization
with pulling out their gun, then it looks like using a gun is to your advantage in lowering your risk. Again, that is a very subjective call often about if someone means somethreat to me. When Hemenway and Solnick examined these data of what victims did
once a crime was actually occurring, they found absolutely no effect from attempting
to use a gun versus an array of other things that you can do.

21

The absolute risk fora homicide within thehome, and particularly
the absolute risk foran unintentional fatalshooting within thehome is low.

22

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

Our big challenge isWith unintentional risk, Doug Wiebe did a study looking at what perhaps isrelatively obvious, but having a gun in your home elevates the risk for adults being
killed in unintentional shootings. There are other non-case-controlled studies, butmore associations by state levels of prevalence of gun ownership linked with higher
risk for unintentional shooting deaths for children and teens. We know from a few
different types of studies that safe storage of guns appears to lower risk for thoserare, but tragic, incidents.
I think our big challenge is perception of risk. In one of the first studies I did, I
talked to parents about risk of guns in the home, how they think about it, and what
they do. Generally, gun owners saw this as something that they could simply teachto their children, but often they had unrealistic ideas about what a child was readyto understand and act upon. Some programs like the NRA’s Eddie Eagle Program
make certain assumptions that children will obey these lessons not to touch a gun,for example. Controlled studies have found they simply ignore that. Interestingly
and importantly, parents could not predict with any accuracy whatsoever whether
their child would actually follow those instructions from the safety programs. The
main take-away here is that, from a health provider standpoint, the principal issue
is to help gun owners understand the developmental capabilities of their children
and teens and risk, so that they can act accordingly to protect them.
I presented data that were not military-specific. My sense is that these risks, thesegeneral patterns would play out in military contexts as well. It is a population thathas certain elevated risks with partner violence, substance abuse, PTSD, and so on.
So, I will leave it at that.
DR. WEST: Thank you, Dan. Thank you, Andy. One of our challenges with anissue like this is finding and recognizing that we need to separate what we believe
from what the science tells us. Frequently, science takes us in a different direction
from what we think ought to be true, and to be open to that. The example of that
was Andy’s demonstration of a suicidal individual that will just find another way,
the idea of means substitution, which to date has not really panned out in any
appreciable way. We are going to get to this as we hear from Ken and Baruch, but
think about how one’s culture and experiences may alter their risk profile.
Thank you, Dan, very much for saying why people do not listen to this and theidea that absolute risks mean more to individuals than relative risks. I think about
my own experience house hunting in very, very rural California and looked at ahouse up on top of a hill in the middle of nowhere. You could see for miles, but you
could see nothing for miles. I thought if somebody comes driving down my drivewaythat I do not know in the middle of the night, I might want to have a gun in thehouse. My absolute risk in that circumstance was very different than living comfortably in Bethesda where I know a 911 call will get a police response within minutes.
DR. ANGLEMYER: One thing I did not bring up is that the bulk of our literature on suicides that I presented, was on completed suicides. I did not talk aboutattempted suicides. I talked about completed suicides. By definition, looking at
firearm-specific suicide, you have a very lethal method. Your outcomes are biased
toward the more lethal methods. With only looking at completed suicides, we are
missing out on all of those attempted methods as well, and that is a gap. We needto talk more about attempted suicides and that they may lead to higher risk forcompleted suicide in the future.
Another thing I want to point out, speaking about methods, is that the data I
have from DSPO, the method was taken from, if I am not mistaken, the National

perception of risk.

Panel One: Defining the Problem

Death Index. The problem was we were missing about 30% of all suicides specificcauses of death. We know there were suicides, but we do not know if they were firearms or if they were hangings, et cetera. 30% is a great deal and it was not randomly
missing. It was much higher in, say, the Army versus the Air Force. We have no idea
why that is the case. You are limited in your strategies, which is one of the reasons
why we stratified by Service branch, because of the missing data, but also there wereidentification methods. At the end of the day I do not know why that is the case.
DR. SALVATORE: Dr. Anglemyer, was it a combination of data from the CDC
as well as the DoD Suicide Event Report (DODSER)?
DR. ANGLEMYER: Yes.
DR. SALVATORE: Was the DODSER information included as well?
DR. ANGLEMYER: Yes. The data that had the cause of death was from the
CDC’s National Death Index (NDI).
DR. MORGANSTEIN: I was thinking about the Australian study you mentioned
about altering societies’ access to guns, and about what happened with deaths. I
think one of the concerns the doctor raised goes back to the issue of absolute risk
perception that a weapon in the home is associated with an increase in keeping
myself and my family safe, so we will not become victims of crime, homicide, andtheft, or other things. I am curious what data exists around any possible rebound,or lack thereof, of other types of crime or victimization in societies that have chosen
to reduce access to firearms. I am thinking about that, also, in terms of the utility
around public health messaging in areas like risk perception and healthy behavior
change.
DR. WEBSTER: With the Australian study, I actually have not seen the more
broad numbers on whether the incredible societal experiment affected overall rates
of violence and crime. I will make one point in reference to an underlying question,
which is, if you try to individualize this to a house, if you say, you do not have a
gun in your home because it might elevate risk for suicide or partner violence orunintentional violence, but now you are making yourself more vulnerable, as ahome potentially? Philip Cook and Jens Ludwig did some research trying to pin
down whether there is an association between the prevalence of guns in an area,
household gun ownership, and the probability of burglaries, both when someone isthere versus not. They actually found that higher gun ownership was associated withhigher rates of burglary, and they speculated that one potential reason for that is thatsome thieves are specifically looking for firearms and that is the reason they would
burglarize the house. If they either know the fact that one person has guns that theymight want to get or based upon the bumper stickers on their cars, or somethingelse, they might assume that that would be the case. There is not compelling evidence
that places that have lower rates of gun ownership, then, suffer by higher rates ofhome-related crime.
DR. URSANO: Daniel, could I ask you to clarify, because I hear several different uses, and I had a different thought or term to use. You have made an importantdistinction between absolute risk and relative risk. I assumed you were using theepidemiologic term to distinguish that from where I think it is getting used as perception of risk.
DR. WEBSTER: Yes, they are two different things.
DR. URSANO: It is a different issue. Those are actually three different concepts:
absolute risk, relative risk, and perception of risk. It might be helpful to clarify that,
so we can use those better in our discussion.

23

Higher gun
ownership was
associated withhigher rates ofburglary… one
potential reason forthat is that somethieves are specificallylooking for firearms.

24

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

You can be told there

DR. WEBSTER: Yes, absolute risk is the rate of occurrence within a population
and a time. I grew up in an area where the majority of people had guns. While suicides were more common, domestic homicides were not all that common. People’s
general perception and experience is, this does not happen very often, despite many
people who I know have guns, and nothing bad is happening. Talking about theperceived risk is what is incredibly interesting. The very first slide I showed with theelevated rates of gun sales are driven, I think, in part by perceived risk. We do notknow everything that they are perceiving the risk to be. It could be that a politician
is going to come after their guns. Right now, living in an age where we are having
more mass shootings, where terrorism is a more real threat, even though the absoluterisk, if you look at the number of people on U.S. soil killed in terrorist acts, is a verysmall number. When you talk to people about their perceived risk, they have very
high rates of concerns on risk about ISIS coming to get them and a variety of otherkinds of things and mass shootings. Those risks are not zero, but I think people are
now carrying guns with them everywhere because they fear something that is ofvery low absolute risk.
You have incidents. A couple of years ago a woman was shot and killed by thetwo- or three-year-old son who was in her shopping cart at a Walmart in Idaho
because she was carrying her loaded pistol with her and the child got it out and shotand killed her. There are all sorts of things that you try to wrap your head aroundin that situation. The first thought that came to my mind when I heard that story
was, why does this young woman feel so at risk that when she shops at Walmart
she has to have a loaded pistol with her? Are people really being victimized while
they are shopping at Walmart? I do not know. There are many perceptions and fears
that are not all that rational.
DR. URSANO: When we think absolute risk, it is a number over a denominator.
The absolute risk may be 4 per 100,000 in men and 1 per 100,000 in women. The
relative risk is, then, times four, four times greater risk for men in that example.
However, the absolute risk is extremely low. A very different concept than perceptionof risk, which is an individual factor of how much risk do I think is there. I may bethinking, as your example with terrorism, the perception of risk goes up. The lastconcept I want to make sure we hold onto is the question of what I would call safety
behavior to manage risk perception. Safety behavior has a whole other dynamic. For
example, when people were notified that flooding was coming in New Orleans, only
about 60% of people actually evacuated. When the Weather Service does studies
of hurricane warnings and when they have told towns they need to evacuate, as aminimum, about 30% of people do not leave. You can be told there is risk and not
activate safety behaviors. You can activate safety behaviors when you perceive there
is risk, but there is actually a very low absolute risk. Getting those all together andunderstanding that interaction for any particular behavior, whether it has to do withguns or helmets with motorcycles, is an important component of thinking throughwhat may be effective and operating in these kinds of elements.
DR. HOLLOWAY: Do you know of any studies that have looked at homes thatutilize safe storage practices versus homes that do not, and if there is an alterationof changes in the risk estimates that are seen in those homes?
DR. WEBSTER: There is a study by David Grossman that comes to mind thatexamined cases between two population areas. They captured scenarios in whichchildren and teens were killed from unintentional shootings or self-inflicted suicide
at those shootings, and then did measurements with respect to not only gun owner-

is risk and not activate
safety behaviors. You
can activate safety
behaviors when you
perceive there is risk,
but there is actually avery low absolute risk.

Panel One: Defining the Problem

ship, but also very extensively on storage practices. There was a negative correlation
between practices where people kept guns locked up as opposed to more available
associated with those outcomes. In these outcomes were nonfatal events that led tosomeone coming to a hospital with an injury. There is surprisingly little that examined that very carefully. I mentioned the National Mortality Followback study, butthat was really on adults. Generally, when we think about risk and unintentionalshooting risk to adults, we do not think so much about storage. We think more about
handling. Are people handling firearms safely?
DR. HOLLOWAY: For us as clinicians that is a very important issue in terms of
the work that we do educating our patients. Without that scientific evidence, it isreally hard to make that argument to a patient. I would really love to see the fieldmove in that direction and generate that information for us. For example, they havethat belief up here, and it talks about safe storage practices and how we should talkto our patients about this. Again, it is really tough to have that conversation with apatient when there is really no scientific evidence backing it up.
DR. WEBSTER: We are going to be talking more about interventions in the later
panel. There is some evidence that policies that promote safe storage practices areassociated with decreased teen suicide risk, which is the most common thing. Getting
to the difference between perceived risk and absolute risk, long ago when I surveyed
public groups with parents, and “Talk to me about your perceptions and activities
as it relates to these risks of guns in the home,” they virtually never talk about teensuicide. If you just looked at the absolute risk, teen suicide is the greatest risk forsomething happening to your child with a gun in your home. When you talk to them
about what they are concerned about, they will only focus on unintentional andfor the very young child, who is more vulnerable. It is the teens who are at greater
absolute risk for both unintentional as well as self-inflicted.
DR. BRADLEY: The data are really compelling that the highest rates of misadventure with firearms happen in households where there are comorbidities, other risk
behaviors, substance use disorders, intimate partner violence, all sorts of emotional
dysregulation. These are exactly the target population that we want to focus on, andin terms of our educational efforts, those that are probably least likely to integrate
new information and change their behavior because of their dysregulation or difficulty with a process around shaping their ideas. It is very interesting in terms of
how we might approach a public health perspective on this in targeting this mosthigh-risk population.
DR. WEST: I also think of it in terms of discussions that many of us on the clinical side have had with patients. In particular with our population, when we are dealing with patients who are still struggling with hypervigilance, reactivity, perceived
risk in their environment, whether it is real or not, to figure out ways to have that
discussion with a Marine who is convinced that the only way he can sleep safely
at night is with that loaded pistol in the nightstand. What is the likelihood that heis going to have a nightmare, pull that out, and shoot his wife? That is much more
likely to happen than an unknown intruder coming in and making him suddenly
vulnerable. That is what I am hoping to get to more in the afternoon, the ways that
we have those conversations. That is the reason we put together that fact sheet, togive people some ability to open the discussion with patients.
DR. McGURK: Back to what Marjan was saying, I do not know that it has evenbeen published, but talking to colleagues in Israel who were in the Israel Defense
Forces (IDF), they used to let their servicemembers take weapons home, and they25

If you just looked at
the absolute risk, teensuicide is the greatest
risk for something
happening to yourchild with a gun inyour home.

26

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

There are otherstopped. It was not stopped due to the suicides, but when they did that for otherreasons the suicide rate went down significantly. It is not scientific, but it is a good
indication. We need to be really specific with messaging for our population because
what might be true for safety or intervention in the civilian world might have to be
tailored or completely different for the guy who is being safe for a very different
reason than somebody might break into my home; it is obviously safe because I
need to defend myself, due to my experiences. Those two things are related, but it is
at least a good indication of the idea. Of course, in the U.S. it is self; you own yourweapon. Our servicemembers are killing themselves. At least in the IDF the numbers
went down when they did not have that access.
DR. HOLLOWAY: I have seen that data for Switzerland as well.
DR. WEST: We do have data for American Armed Forces. In particular an article
by William Corr in the Medical Surveillance Monthly Report. It compared ratesof all different methods of suicides between active-duty servicemembers stationed
within the continental United States, stationed in Europe and Asia, and stationed in
a combat zone. What they showed was the number of firearm suicides went away inEurope and Asia. There was not an actual explanation for it, but, my feeling is thatone possible contributor is, when you go home at the end of the day in Europe andAsia, you cannot have a gun in your house in those countries. In the United States
it looks identical to a combat zone in terms of the rates.
DR. URSANO: I will infer that you are saying this because of the laws of thosecountries?
DR. WEST: It is because of those.
DR. URSANO: Not because of some military rules?
DR. WEST: No, it is because, when they live in a community in a foreign country,
they are not allowed to have that firearm in their home. It is a dramatic difference.
DR. URSANO: Andrew, I will use your comment earlier as illustrative because I
do not think it is accurate. In the data that you presented that looked at the UnitedStates, and you specifically said the one study that was an aberration was New Zealand. One would like to see, and perhaps Dr. MacLeish will expand on this, how infact the neighborhood which has been alluded to, or the culture of the country varies
these responses, even if we have the same laws in terms of possessions. There areother elements outside of both the individual and the family; it is also the neighborhood, which was touched on by both of our presenters, that we want to remember
as we think through these kinds of issues, both for understanding what is absoluterisk, what is relative risk, what is risk perception, what are safety behaviors, andhow to communicate those in any given culture or setting.
MS. BARBER: Marjan, I wanted to mention that, although the bulk of theevidence on the impact of safe storage is with respect to teenagers, Conwell’s casecontrolled study of suicide decedents ages 50 and over with matched controls did
find a protective effect of safe storage.
DR. BATES: I really appreciate the distinction with perceived risk and thepotentially very strong subjective elements which could even constitute subgroups.
Maybe this should be brought up later, but what evidence might be there for how
to communicate effectively with different types of perceived risk? Is it possible tomeasure changes in perceived risk? Also, is it possible to leverage the emerging
research on the behavioral economics and how people are predictively irrational? I
think a great deal of the time we assume rationality and it is really not the case inmany decisions that people make.

elements outside ofboth the individual
and the family; it isalso the neighbor­hood...that we want
to remember as we
think through thesekinds of issues.

Panel One: Defining the Problem

DR. WEST: You brought up an interesting point. One of the things as we put
together this program was thinking about influence and how you inform and influence decision-making. There is a great deal of literature on the impact of narrative
influencing, using stories rather than statistics. Everybody in this room is very goodwith statistics, and that is what convinces us. When you get out into the world,
we cannot convince them with numbers. Sometimes it does take stories tied to thenumbers to really get people to start listening.
DR. WYNN: I do find it interesting talking about this idea of the potential
conflict for an individual between threat perception, safety behavior, and means
restriction practices such as safe storage; that the way you potentially manage yourhypervigilance or hyperarousal is by keeping the gun next to your bedside is theantithesis of means restriction. Understanding the conflict for a given individual,
particularly in a clinical setting, is an interesting perspective. They literally can bein conflict that means restriction reduces my threat perception and safety behavior.
MS. BARBER: Not only is that true, but in terms of anxiety levels, having the
gun there as the talisman to help control your anxiety can actually increase theanxiety. The same way when my daughter had anxiety about going to sleep and wewould get a more and more protocolized bedtime routine. Eventually, we decided we
had to stop all these rules and go back to just two stories. Her anxieties actually went
down. There was a veteran who was talking about when he had PTSD and he had
to have his gun right next to him. He was working with a psychologist and decided
he would experiment, because he realized his world was not that unsafe. The biggest
indicator that his world was unsafe was the gun under his pillow, but he could notstand not having it there. He said “I will experiment and tonight I am going to put
it on the bedside table.” And he felt okay. A few days later he experimented withputting it on the other side of the room. His anxiety went down. Then, he had a safein his room and put it in the safe for a few days and did not shut the door. He took
himself by degrees, and his anxiety actually went down, which was incredible payoff
because he was both making himself safer and calming himself down.
DR. WYNN: I definitely agree there can be differentiation between anxiety
and sustaining that anxiety versus threat perception and safety behavior that canbe completely different. Even though we would often think of them very much inalignment, what you do as perception of safety behavior could actually be anxietyprovoking and anxiety-sustaining. I find it interesting from a clinical perspective
to make sure I think about this with patients. That may actually be the thing that
reduces risk for accidental or other injurious behaviors with firearms.

27

I think a great deal of
the time we assume
rationality and it isreally not the case inmany decisions thatpeople make.

28

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

Panel Two: Understanding Risk

29

2

Panel Two:
Understanding Risk
Speakers: Kenneth MacLeish, PhD, Baruch Fischhoff, PhD
DR. WEST: What we have done so far is to start stimulating the discussion,
to start identifying the problem. What is the problem? Is there a problem? I could
probably query everybody in the room and get many different opinions based on thescience that we have. I think we can all agree that there is certainly a concern here
and it is something that we need to be thinking more about and acting on, whether
as a clinician, a researcher, or as a policy person.
We are now going to take a step off into a more theoretical framework about
what it is we are talking about. Why did this come to mind as we were putting this
together? As you want to change somebody’s mind about why they do something or
why they make a particular choice regarding a health risk behavior, what is it thatthat individual brings to the discussion? Think about the principles of motivational
interviewing. One of the tenets is meeting the patient where they are. You must
understand where they are, whether that is through listening or through knowing
something about them and their culture when they walk in the room. That is partof what we are going to do. The other part is understanding how your message isheard, how your message is not heard, and the factors in your communication of arisk to an individual and how that potentially changes the outcome, because that iswhat we are trying to do. We are ultimately trying to change outcome.
With that in mind, our first speaker in the second panel is Ken MacLeish. I willecho the words of Harry Holloway. Many of you know Harry. He is one of ourdistinguished faculty in the Department. And anytime we would come up with aproblem that we couldn’t figure out or we were trying to struggle with, he said,“Well, you know, you ought to get an anthropologist in on that.” We were lucky as
we were coming up with this forum to find Ken MacLeish. He has done field workon military culture in Fort Hood, Texas. It was obvious that we needed to bring him
in to help us understand how our culture, the military culture, affects how we see,what we see as risky and how we tend to act in those circumstances.
Dr. MacLeish is an Assistant Professor of Anthropology, Medicine, Health, andSociety at Vanderbilt University. His PhD is in anthropology from the University ofTexas at Austin. He was a National Institute of Mental Health postdoctoral research
fellow at the Institute for Health at Rutgers University. He wrote a book in 2013

We are ultimately
trying to change
outcome.

30

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

How do thosecalled “War at Fort Hood: Life and Uncertainty in a Military Community,” in which
he was able to capture an extensive amount of information about a population thatis relevant to all of us during a very interesting time, and to actually translate that
into some very intriguing literature. His current research looks at moral, technical,
and experiential dimensions of war-related stresses and how they are perceived, andhow they are labeled and managed through frameworks such as resiliency, moral
injury, military veteran suicide, and nonclinical approaches to veteran mental health.
DR. MacLEISH: Thank you for that very gracious introduction. It sometimes
feels like it is an interesting mission to be a non-military person in a room full ofmilitary or military-affiliated folks talking about the military culture. It is theseconversations that can ultimately be really productive about the problems we are
all concerned about addressing. Thanks very much for having me as part of thisconversation.
I am a cultural anthropologist and I study people involved in war and how they
are affected by it in their everyday lives: military servicemembers, military families,
community members, and care providers. The thing I try to look at and synthesize
in my work is how structural factors, cultural assumptions, and diagnostic labels all
converge on those embodied in psychological everyday experiences. How do thosedifferent things come together and inform one another in terms of what war is likefor the people who participate in it and make it, and how their experience does ordoes not make sense to the rest of us or those of us who stand outside of militaryor war-making domains?
As I mentioned a moment ago, this is something that I have studied in field workat Fort Hood, in field work in Middle Tennessee with recent veteran populations andother places in the Southeast. Throughout this work, one of the central problems
that I found myself concerned with that connected the different areas I am interested
in is this obvious, but somewhat profound fact that one of the things that reallydefines military life and military experience is the fact that soldiers and other military
servicemembers are exposed to violence and put in harm’s way on purpose. This isan obvious and uncontroversial statement, but it is also something that lies at theheart of what distinguishes military labor and military life. What I would posit interms of the conversation that we are here to have today is if we want to think about
and talk about what risk and health mean for these communities and populations,then we need to be able to ask that question, or situate that question within theperspective of what is normal for many soldiers, veterans, and their families. What isnormal is something that is characterized by baseline conditions in which exposure
to harm and familiarity with violence and not having control over your own bodyare normal things, normal conditions. Soldiers are subject to an extraordinary arrayof practices and rules and institutional mechanisms and procedures that manageand organize their bodies and minds, whether to heal and preserve them and takecare of them, to make them disciplined and productive and useful tools of doctrine
and policies, or whether it is specifically to empower them to effectively exercise
violence, or to expose them, to place them in harm’s way in a course of deployment
and service in a war zone.
In my research I refer to this set of relationships, this set of mechanisms andpractices and procedures, to the way they cohere as a single system or assemblage as
military “biopolitics.” The goal with this term “biopolitics” is simply to signal anddescribe those forms of institutional management and control that are directed athuman life, whether it is life at the level of the individual body or life at the level ofdifferent things cometogether and inform
one another in termsof what war is likefor the people who
participate in it andmake it?

Panel Two: Understanding Risk

the community or the population managing, organizing, and exercising control overlife. In military settings this happens across a number of registers. Things like tacticaltraining or physical training, making bodies themselves useful and productive anddisciplined and strong. The use of and training in weapons and armor that extend
bodily capacities are central to soldiers’ ability to act effectively on the world andthe environment around them. It includes various kinds of medical and therapeuticinterventions, including trauma medicine or medevac techniques or protocols,orthopedic rehab to help people recover and become functional again in the wakeof injury, or psychotherapy and psychopharmaceuticals to help people manage thestresses associated with military life and deployment and war zone experiences.
These things also fall under this rubric of biopolitics and managing, controlling, andmaking life productive. Finally, this is also things that happen at the policy level.
Whether it is questions of foreign policy, when and where to go to war; questions ofdoctrine, and more granular things like deployment and unit structure; how exactly
people are sent into harm’s way, in what quantities or numbers, with what organization, with what kind of support. There are all sorts of factors that have helped drive
servicemembers’ experiences of the wars in Iraq and Afghanistan that in many ways
are linked directly to these kinds of macro-level and structural decisions.
Perhaps the most significant question is that of operational tempo. The Army,at the height of the wars in Iraq and Afghanistan during the time that I was doing
research at Fort Hood maintained an incredibly aggressive pace of deployments thatwere routinely 12 to 15 months long, sometimes longer. If you were lucky you had
12 months of dwell time in between deployments, a lot of that often taken up withfield training or pre-deployment training. While I was at Fort Hood it was home tothe most deployed unit in the entire U.S. military, the 9th Transportation Company,
which between 2001 and 2008 deployed to Iraq or Afghanistan eight times. That is
not quite representative. That is an exceptionally high number of deployments, but
again — aggressive operational tempo.
These are all these sorts of things under this rubric of military biopolitics, allof these efforts to manage individual groups to make them useful and keep them
healthy and productive. What this rubric does is make it possible for us to think
about ways that individual experience and structural conditions are directly interrelated with one another. The question for me as an anthropologist is what is normal
under these conditions of military biopolitics and these conditions of familiarity withviolence and exposure and control? This is one of the kinds of things that is normal.
This is an Army file photograph of a recruit in basic training at Fort Benning. Everytime I see this photograph this makes me feel happy to be indoors and, also, towonder what happened to the guys holding the camera after right after this picture
was taken. We can see in an image like this the kind of physical and psychologicaldiscipline and toughness and endurance and fortitude that are really central tomilitary identity and regular military life. There is an expectation of toughness andfortitude not only of the body, but also of the mind and of the disposition.
Going along with that is a concomitant suspicion of pain and weakness. Thereis an expression that I imagine a lot of folks in this room have heard and that manyfolks in my research report having learned. In the course of basic training, if you
get hurt and it is not life, limb, or eyesight, walk it off. This injunction to toughness
is essential to making useful, productive, strong military bodies that do what theyneed to do. It also creates a climate of suspicion of pain and weakness, where if you
go to sick call and someone cannot tell just by looking at you what might be wrong

31

I refer to this set of
relationships, thisset of mechanisms
and practices andprocedures, to theway they cohere
as a single systemor assemblage
as military“biopolitics.”

32

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

In the course of basicwith you, are you a scammer? Are you just trying to get out of work? Are you reallybroken? Are you really hurt? Expressing pain, expressing weakness is something thatcan easily make someone in the military context a target of suspicion or contempt.
Another kind of defining normal is familiarity with violence, whether it is the
expectation of exposure to violence and being in dangerous and violent situations
and, also, facility with using and exercising violence. Soldiers do all kinds of jobs.
Across the Service branches, servicemembers do all different kinds of jobs. I am
sure that I am prejudiced in large part by the time that I spent with Army folks andtime spent mostly with combat troops at the places where I have done my research.
Exposure to and participation in violence is something that, among folks I talk toin my research, really sets apart their experience from a nonmilitary experience inmany ways. The fact remains that this is something that happens on purpose, it is
not an exception and it is not an accident. This is a thing that you are trying to do.
That is the thing that you do for your job.
This leads to questions of institutional control. There is this familiar idiom that
the Army owns your body, which is something that operates across many registers.
The Army owns the question of whether you pass your PT test or not. The Armytells you that you have to get your peanut butter shot. The Army tells you when to
deploy and tells you when it is time for a change of duty station that might comeright before your spouse is about to get a promotion or your kids are in the middleof their school year. This significant amount of control happens at multiple registers
and reaches into different areas of people’s lives. The thing I want to emphasize isthat these are not necessarily bad things, or if we want to make an argument about
whether they are bad things or not, then that is a separate discussion. However, forthe folks with whom I spent time, this kind of toughness, loyalty to the institution,and discipline and responsibility that comes along with it are all tremendous sourcesof pride and investment and identity. These are things that people tend to feel really
good about. They also give rise to a number of important contradictions. There is
the fact of being worn-out or injured by the routine work of war. There is the way
that, from the perspective of many soldiers, military medicine essentially serves
the same system that is placing them in harm’s way and making all these difficult
demands on them in the first place, such that the labels and techniques that aremeant to help provide care and support can also be experienced as further efforts
of control or surveillance.
There is also the way that being sick makes you a problem. A friend of mine
is a retired cavalry Non-Commissioned Officer (NCO) and veteran advocate. He
says, “The Army is really good at taking care of large groups of people, but when
you get sick or when you get hurt, you become an individual, and the Army has no
idea what to do with individuals a lot of the time.” At the very least, there is thissense of standing out — that you are not there fully in your place in formation or
on the MTO. That is a problem for you and for everyone who is connected to you.
The reason I dwell on these points about military biopolitics is because I wantto suggest for the purposes of our discussion here we cannot even begin to define
what is risky or what is healthy without taking a lot of these contradictory demands
into account. At least that is what I would like to suggest. By way of an example,
this is another familiar image, I imagine. This is a page from a Post Deployment
Health Assessment (PDHA), a screening form asking a number of post-traumaticstress screening questions. This is, for folks who aren’t familiar with it, a form thatwould be administered to soldiers when they are returning from deployment andtraining, if you gethurt and it is not life,
limb, or eyesight,
walk it off.

Panel Two: Understanding Risk

undergoing Soldier Readiness Processing (SRP) on returning. They are questions
about traumatic stressors that might be associated with the war zones: did you see
dead bodies? Did you see people get hurt or killed? Were you engaged in combat?
Did you shoot your weapon? Did you ever feel you were in danger of being hurt?
Then, questions about things that are potentially symptoms of post-traumatic stress.
Have you had nightmares? Have you had intrusive thoughts? Have you experienced
emotional numbing or detachment? Or were you constantly on guard or watchful?
Among a lot of the folks I have spent time talking to, the correct answer to all ofthese questions is no. That is just what happens. This is a picture of what the SRP
site, one of the two SRP sites at Fort Hood, looked like when I was there. When you
come back and you are going through the screening, you are ready to go on blockleave and see your family, the correct answers are “no, no, no, no, no,” because you
do not want a flag in your file that is going to lead people to look at you askancedown the line. You also just do not want to get held up in this process of coming
home and getting to reunite with loved ones or go on leave.
A story I will share that really exemplifies what goes on here was related to me
by an acquaintance who I will refer to as Ernie. He was a senior infantry NCO. I
think he was maybe 36 or 37 years old at the time that we met him, and he had justcome back from his second tour in Iraq where he had led almost daily patrols. He
talked about coming back and going through screening and being administered the
PDHA. He said, “You know, they ask those questions because they want to know
if you’re crazy.” He also said, “You know, I just joke with them. I tell the lady somejokes. I just kind of try to make them relax. Because if I told them the truth about
how I felt or, you know, if I answered those questions truthfully, they would just takeme out of there in a straitjacket.” These are his words again: “I don’t want people towrite stuff down in my medical records for anything because, then, they are going tolook at you weird or they might send me to another unit, or something like that. You
know, they ask these questions like ‘Do you think you have any suicidal tendencies?
Do you ever feel invincible? Do you think you have any PTSD?’ And I would justsay I’ve just been like this as long as I can remember.’”
A lot of the time when I share this story, people’s reaction to it is, “Great, but
how can we get soldiers to tell the truth when they fill out the PDHA?” That is an
important question. The point that I am interested in is the way that an anecdote
like Ernie’s suggests that there are these contradictory stakes and incentives atplay when we are trying to get people to convey information that is understood torelate to health and risk. These questions that show, if you are crazy, in many ways
enumerate fairly normal and routine dimensions of being in a war zone: firing aweapon, seeing people get hurt, being afraid, experiencing intrusive thoughts, being
vigilant, or even being emotionally numb. Of course, being on the receiving end of
those questions, they come with a fair amount of dissonance. In an additional twist,
the divide between what seems to be risky or dangerous versus what is normal is toa certain extent built into the divide between the soldier or the veteran, on the one
hand, and the civilian or the clinician on the other hand. The civilian or clinician isasking these questions about something that is supposed to say if you are crazy that,appears essentially normal to the servicemember. There is this way that the actual
experience of being screened, in Ernie’s words, makes you crazy, because it either
makes you feel as though you do not fit with the norms that you are being asked,
but it also runs the risk that you are going to be slapped with a label of disorderthat does not comport with your own experience.

33

There arecontradictory stakes
and incentives
at play when weare trying to getpeople to convey
information that isunderstood to relate
to health and risk.

34

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

It is also a public andBy way of conclusion or by way of turning from these contradictions to the
topic of our discussion today, I wanted to say a few quick words about soldiers andveterans and guns. Among soldiers and veterans, gun ownership and regulation bring
together many of these dynamics that we could also associate with military biopolitics. These questions of control and labeling and, then, diagnosis and managing riskof violence. This is not least in the way that guns frequently figure so prominently
in the stereotypical public imagination of the potential dangers that soldiers andveterans are stereotypically believed to pose to themselves or others. For instance,in the case of Esteban Santiago, the Fort Lauderdale shooter committing these horrible events from just last week, and with other soldier or veteran shooters in mass
shooting incidents, there is frequently this sense of public scandal that the shooter
had access to guns and that their mental illness is something that should have been
flagged or managed or treated or intervened upon by a responsible institution. Thisis an understandable reaction in the wake of a horrible and upsetting event, but it isalso a public and cultural narrative that obscures the fact that military and veteranstatus and mental illness, including severe mental illness, are not things that predict
gun crime. In these public narratives they tend to take center stage anyway. I would
argue in large part because of the way that they trouble or bring to light the kindsof public anxieties that surround military biopolitics and the contradictions thatcome for the rest of society with thinking about the consequences of placing military
bodies in harm’s way.
As a counterpoint, I want to share a brief anecdote from some of the research I
am doing right now. This is a conversation I just happened to have the other day witha guy I will refer to as Charles who is a social worker with criminal-justice-involved
veterans, mostly recent veterans and some active-duty soldiers, in Middle Tennessee.
Charles is himself a veteran. He is a pre-9/11 senior infantry NCO, and he is an avid
collector of guns. We actually came into this conversation because he was telling me
about his collection. He was waxing poetic about the $3,000 FM17 SCAR he hadthat was the last gun that his wife let him buy, and that he was so excited about anddelighted with. We were chatting and he said, “You know, yes, most of the participants in our program have guns. In fact, I think probably just about everyone has
guns except for the people who have past felony charges or past felony convictions.
Almost everyone shoots for fun or they hunt, or some of them even do it for work.
They work at firing ranges or in hunting.” He said it’s therapeutic, a great way forpeople to blow off steam or bond with each other. He said that he even uses it as away to bond with clients or participants in his program, talking about shooting. He
was unalarmed by this prevalence of gun ownership in this particular populationthat he worked with. He said, “Yes, you know, soldiers and veterans tend to be morecompetent and conscientious when it comes to gun safety a lot of the time,” but healso allowed that they are more likely to have access to them and more likely to be
comfortable using them. This is in many ways all the more striking because Charles’
clients would appear to be ideal candidates for close gun safety surveillance andintervention of the kind that is typically argued for and talked about in the wake ofevents like the Fort Lauderdale shooting. This is a population who comes into theprogram Charles runs with drug and alcohol problems and domestic assault charges.
Many of them have Service-connected mental health diagnoses, are under judicial
supervision, and they are regularly visited in their homes by sheriff’s deputies andpolice officers. They are often under regular GPS tracking as part of their drugmonitoring program. For Charles, who regards most of his clients as significantly

cultural narrative that
obscures the fact thatmilitary and veteranstatus and mental
illness, including
severe mental illness,
are not things thatpredict gun crime.

Panel Two: Understanding Risk

at risk or precarious financially or in their relationships or just existentially, accessto guns is something that for him just seemed to be a fact of life, and not somethingthat appeared to him to be particularly risky on its own.
As a couple of takeaways from this latter example, I want to leave with thesuggestion that what counts as risk is fundamentally a cultural question. It depends
on context, it depends on meaning, and it depends on structures and modes ofcontrol that are going to incentivize or make logical or make inevitable various
ways of responding to various efforts to control. Second, that naming risk can, in
fact, produce new kinds of problems or new vulnerabilities. I think this vibes in aninteresting way with some of this discussion of perceived risk that we were having
just a moment ago. But even something like a PDHA, like the effort to screen forrisk factors, becomes a source of risk in itself; a source of perceived risk for folks
to be administered.
I will just add, as far as naming risks, naming risk also produces these kindof cultural effects where oftentimes the urgency that surrounds collective societal
questions about the sorts of help that soldiers and veterans need is driven by perhaps unsubstantiated ideas about what is risky, or even the idea that soldiers andveterans are themselves a risky population that imposes a danger to themselves andothers, and that that is what should motivate care for them or particular kinds ofintervention. In the face of this, it is important to gather data. It is important to
ask and investigate empirically how do the people actually live and make sense of
their experiences under conditions of military biopolitics? I would argue it is also
important to ask on a broader level how it is that American society and American
governmental institutions elect to own and intervene on the effects of war in theway it does now. Thank you very much.
DR. WEST: One of the things I picked up on that I had not thought about, but
I observed countless numbers of times was, as we are talking about culture, as weare talking about perception of risk, your example of how a soldier described theexperience of the Post-Deployment Health Assessment. What the soldier perceived as
the risk was being singled out. The risk was not existing with symptoms or walking
the world in a hypervigilant and hyperaroused state. The risk was getting singled
out and being late getting home or being subject to extra attention. One thing thathas been vivid for me is no lance corporal in the Marine Corps (generals love to go
visit lance corporals) ever wants to be known by a general. They would love to justdisappear, and they do, they disappear as soon as the general shows up. Thank you
for giving us that background.
One of the other things I wanted to highlight is an article Ken and JonathanMetzl published a couple of years ago; a great piece on mental illness, mass shootings, and the politics of American firearms. As you showed the shooter from Fort
Lauderdale, in my mind I look at something like that, and that is like the Ebola ofgun violence. It is really scary, but next to no chance I am ever going to run into it.
You and Jonathan did an excellent job of putting on paper the argument focusing
on what is important and not what is scary or newsworthy.
As we continue our discussion of risk, I would like to introduce Dr. Baruch
Fischhoff. As Bob and I were putting together this concept of the forum, he said,“You need to talk to Baruch.” So, I called Baruch and we had this wonderful discussion about our training product. He said, “But did you actually think about what
it is you are trying to change? How you are going to measure that, and how areyou going to know if it has an effect?” These involve concepts of how people are

35

What counts as risk
is fundamentally acultural question.

36

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

We try to figure

thinking about a perceived risk. I, as a doctor, will look at it and say, “Oh my gosh,
this is a huge risk.” They may look at it and say, “Well, no, I don’t like to wear ahelmet when I ride a motorcycle because freedom is more important to me,” or “I
want the visibility. I want to be able to see. It ruins my peripheral vision.” They will
make what I perceive to be a risky choice. This idea of better understanding whatsomeone sees as a risk and why, and how do I communicate what I know to change
their opinion, is what that discussion really changed for me.
Dr. Fischhoff is Howard Heinz University Professor in the Department of Engineering and Public Policy at Carnegie Mellon University. He has his bachelor’s from
Wayne State University, and his PhD in psychology from the Hebrew University ofJerusalem. He is a member of the National Academy of Medicine and has served
on many committees, and he is Past President of the Society for Judgment and Decision Making and the Society for Risk Analysis. He has chaired the Food and Drug
Administration Risk Communication Advisory Committee and has been a memberof the Eugene Commission on the Rights of Women, the Department of Homeland
Security Science and Technology Advisory Committee, and the Environmental Protection Agency Scientific Advisory Board.
DR. FISCHHOFF: I am really pleased to be here. Since I learned about yourCenter about 15 years ago, I have been a great fan and I have given many people
your two-pagers for different things. This is obviously an important mission.
Reading the materials, the more I read, the more I realized I didn’t understandanything substantively. I thought maybe the best way to do it was just to tell you
what people like myself do, which is in the space that you described earlier. Behavioral economics is a part of it, although different in I think perhaps a meaningful way
which we might usefully discuss. I am going to talk about other people’s problems,so a bit of relief here with this. The field that I identify with is called decision science. The field grew up after World War II. The field as it was originally conceptualized—and some of this has actually been lost by some of behavioral economics—isthat if we do our job right, we do the following. We do analysis. We try to figureout what are the facts relevant to the choices that people face. We do descriptive
research to determine what the people believe. While I was in that space, we tried
to see whether we could make a difference, see how well we are doing, and then,repeat as necessary. It sounds like a nice linear process, but you never get it right thefirst time. You find if you cannot help people, it could be you have misunderstoodyour problem, as Curt was suggesting. Or it could be that you just do not know;
we do not have the science in order to help people to make better decisions in aparticular place. I have had the opportunity to work on a wide variety of different
problems. You could think about any of these and think about what are the decisions that people face where might they struggle, and how might you need to help
them. I thought, then, I would show you a little bit about how we approached thework. I will start with the analysis. A few years ago, I was organizing the National
Academy of Sciences Sackler Colloquium on the Science of Communication. Whatwe were trying to do is to bring more basic researchers into this area. There are
relatively few people who speak both the language of analysis and the language ofpsychology and are concerned with applications. One of those people is a friend,
Detlof von Winterfeldt, who is the head of the Department of Homeland Security’s
Center of Excellence at the University of Southern California. I said, “Could you
show how you approached this?” He had two examples, one very complicated one
about risk analysis for the California Air Quality Board, and this story told without what are thefacts relevant tothe choices thatpeople face. We
do descriptive
research todetermine what
the people believe.

Panel Two: Understanding Risk

their permission about his wife’s decision whether or not to rotate their daughter inutero. She was in the breech position. A father tries to be useful and he said, “Well,
I’ll do the decision analysis.” So, he sketched this decision tree.
The problem with our field is that we teach these techniques for technicalmastery, not for conceptual fluency. So, really, anybody could draw a tree like this.
You start with the decision node, which is whether or not to turn the baby. You
then see what are called event nodes: what happens next? It could be okay or there
could be complications. If it’s okay, the baby could turn back and you might stillneed a cesarean anyway. There are two things that the discipline of sketching thisvery simple decision tree did that you might well have missed, had you not done it.
In fact, they were missed. He said as it turns out there is a one-third chance, or atleast there was 29 years ago, of the baby turning back. The OB/GYN, whom they
were perfectly happy with, it just had not occurred to her to tell that people might
not know that because it was second nature to her and it never occurred to them.
When Detlof proudly ran all the numbers, it turns out his wife didn’t care whether
or not she had a cesarean. This was an analysis of something, as there are otherthings concerned with a cesarean, but that wasn’t an issue for her at all. Without thediscipline, they missed both the critical fact and the critical value.
Here’s a study that Sara Eggers, a former grad student of mine did. The Court, in
Pearson v. Shalala in 1999, mandated a label on dietary supplements. It is still there
now. FDA said, “This is a terrible label. Could you evaluate it for us?” They wereinterested in saw palmetto, which is an herb. It is one of the few dietary supplementsthat has any evidence at all. It probably does not hurt you. It might help you if you
are a man that has benign prostatic hyperplasia. This is the decision tree. If you workthrough the logic, it turns out the main problem with saw palmetto, since it is cheapand has probably no side effect, is if somebody self-medicates during a time in which
they have a problem that could be treated. There are not all that many problems thatwould, but that would be your risk. It turned out that this was just a terrible label,the one that the Court had written. There were people, men that Sara interviewed
about this who said, “If there is a warning label, it must be high-potency stuff. Maybe
it has a chance of being effective. Maybe I am willing to do it just because there isa warning label.” Others would say, “FDA does not believe in alternative medicine.
It’s a political statement, not actually a risk statement.”
It turns out that for this particular decision it does not actually matter because
the men that Sara interviewed all said, “I’m not going to self-medicate for very
long.” The opportunity costs of not being treated in time were probably negligible.
It turns out that black cohosh root, which is an herbal product for postmenopausal
or menopausal symptoms has a very similar decision tree. However, you can imagine
other dietary supplements for which a decision tree is different, for which this terriblelabel could actually do people damage. But it set the Court’s intuition that this waswhat people needed to be told.
Here is another kind of representation. We did a project for CDC on the
pushback from measles, mumps, and rubella vaccines. This was a follow-on of a
project that we did for the VA on the pushback from the anthrax vaccine in the latenineties. We were trying to figure out in the run-up to interview in a bunch of firsttime moms in Pittsburgh, Kansas City, and Eugene, three cities with different local
cultures on these things. We thought it was important to circumscribe what are thethings that might be on people’s minds. As it turns out that there are a lot of things
that potentially are on people’s minds. People who are concerned about vaccines

37

We thought it
was important tocircumscribe what
are the things thatmight be on people’s
minds.

38

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

People who do formal

are interested in post-license marketing surveillance. They want to know how good
this passive reporting is. So, we structured our interviews, I would think of it asconstrained, but it was very open-ended for an experimental psychologist like us,very constrained for a proper ethnographer. We wanted to give people a chance totalk about everything and to prompt them on things that might otherwise get lost.
One of the things that we did, was this complicated model called the Influence
Diagram. It basically has the factors and the nodes. The links are potential connections. We tried to define it. That is what this complicated picture is. If you look, you
could say, “What is the message that is being given by the vaccine people?” If you
map the official communications into this tree, you get the picture on top that would
say: take it; it’s good for you. One strong leg. If you go to the anti-vaccine, this isfrom a British group, they address many issues, some of which, like post-marketingsurveillance for which the vaccine community has a story, but a story that they havechosen not to tell. As a result the accusations go unrefuted. If you are familiar with
this, they tell a story, and as several people have said, narratives have particular kindof value. They help retain more information than you could otherwise. This is theanalysis of things that could be relevant to the outcomes that are here, and this areflection of the psychology who deal with it.
Here’s another model that we did on cryptosporidium intrusions. Unlike theprevious one, this was a model where we actually were able to run the numbers andlook at the impact on this human-engineered system on public safety. One of thethings I realized in looking at the epidemiological paper was that people who doformal risk analysis, like that crypto model, work in areas where the data are nevergoing to be there. It is not like you can do a systematic review and look at what
the factors are. We are just never going to know how some things work if you aredesigning a nuclear power plant.
So, there is a norm in the pathological and epidemiological community, ofusing expert elicitation in order to find out what people, and what experts believe.
Referencing an article from my colleague Granger Morgan from Proceedings of the
National Academies of Science on how to do expert elicitation, it is not just asking
people; it is not just a survey. Here is a kind of expert elicitation. I was asked togive a talk at the Bank of England, where they have to do a public risk analysis forthe stability of the British banking system every six months. They were trying tocalculate uncertainties in errors when you do not really know. They sent me thispaper, something they publish regularly, which is their projection for the status of the
British economy. Does that communicate well or not? One of the interesting things
that they do, the first vertical line near the middle is the date that the projection
was made. They also show that they had historical uncertainty. That is, they usually
think, “Oh, well, somebody who doesn’t know where we are today, then they are
telling me something about where we are going to be tomorrow,” and that is part ofthe picture. You could ask, “Do you want to trust this kind of information? Is thisa good way of communicating it?”
The spirit in which these analyses are done, what we call these computable models, they try to force us to be precise in defining our terms. These models are meant
to be precise enough that, if you could solve the data needs, which often cannot
be done without expert elicitation, it forces you to be precise in talking about theterms. It guides in your hunt for data and expertise and facilitates discussion andcommunication. It helps you to structure the scenarios that you generate. It helps

risk analysis, like thatcrypto model, work inareas where the data
are never going to be
there.

Panel Two: Understanding Risk

you to use expert judgment systematically. In a way, it is our discipline for gettingin the heads of people and making certain that we do not leave things out.
I think that this is probably our largest contribution to the modeling that is
related to people’s decisions. We do descriptive research. What do we look at? We
look at how people think, which we tend to think is general among the non-impaired
population, because of the cognitive psychology. What people think can vary all overthe place. When people think, that is, when are they rational or when do they want
to be rational, what are the conditions that impair their ability to act in their own
best judgment, and how do individuals differ? I run an undergraduate major in decision science. We have four years to teach this kind of work. Let me just briefly show
you how we conceptualize it. One way to think about it is that people’s behavior
with respect to perceiving and communicating, making decisions, probably follow
simple principles. Here are some principles of judgment, how people perceive risk,
make sense of the world that is around them. Here are some principles of choice.
This is how people synthesize what they know into some kind of a decision. These
are truncated lists of the principles that you would teach if you were doing this ina major. Behavior follows simple principles. However, the set of principles is large.
The contextual triggers are subtle, and the interactions are complex. As a result,broad knowledge and detailed analysis are needed.
My temptation in reading about the problem was to say I immediately had somegreat ideas about what might work. However, anybody who has got a great idea
or a silver bullet or a simple solution for it is not doing the problem justice. I think
the real benefit of what we all bring is that, unlike the behavioral economists, weknow all of this stuff that psychology has discovered over its 100-and-some years ofhistory. Any bit of which might turn out to be relevant to the design of a particular
program or encoding or disentangling the kind of complicated processes that you
have there. The way to make use of it is to somehow get the equivalent of one of ourresearch seminars into the conversation with your research seminars, so we could
take advantage of your deep substantive knowledge and theoretical knowledge inother ways and see whether we have some kind of incremental value that we could
bring to it.
I will just mention very briefly the study of individual differences. It has turned
out that there appear to be stable differences in decision-making competence. Somepeople seem to have better cognitive abilities as decision-makers that are associatedwith better life experiences or outcomes. People have been trying for years to comeup with meaningful differences in interpersonal style and cognitive style, decisionmaking style, and they just haven’t gotten very far in these sort of complicateddomains. It is very important for those who run large organizations to recognize thatpeople are different. Then, they need to accommodate one another. I do not knowthat we have very much by way of predictive value there. That is not a directionthat I would go.
Let me just say one final thing. I think the critical topic about interventions isjust how important it is to evaluate them and just how rare it is that interventions
are evaluated anywhere. They are not pretested. They are not evaluated in the field.
They are not deeply informed by the research. Somebody has got a great idea andthey put out a product and their budget goes to the production values and dissemination. So, why do we not evaluate anything? It is because we have faulty intuitions
about how well we understand other people.
I chaired the FDA’s Risk Communication Advisory Committee. And at the end of

39

What are theconditions that
impair their ability
to act in their own
best judgment, andhow do individuals
differ?

40

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

What is the

my term, we edited this volume. You can find it online. It has 3,000-word chapters.
Each chapter summarizes science on something like communicating quantitative
information, doctor/patient communications, communicating uncertainty. You canlearn very quickly what is out there, how there is a best guess at some practical
implications like how to present risks. Each chapter has a final section on how toevaluate your communications for no money at all, so that there is no excuse for not
evaluating them, for a little money or for money commensurate with the personalorganization, political stakes riding on effective communications.
DR. NASH: I just wanted to ask what year that was published.
DR. FISCHHOFF: 2011.
DR. NASH: Thank you.
DR. FISCHHOFF: Let me just say one other thing. I once interacted with Irene
Bell Jacobs, a clinical psychologist in North Carolina. She was interested in people
who hurt themselves and raised the question of what is the interaction between
impulsive behavior and cognitive behavior and between the rational and the irrational, with the kind of deep forces that you all deal with. One of the things thatcame out of my conversation with her was fed by work we had done on adolescent
psychology. There is a stereotypical thinking that people who are impulsive make bad
decisions. However, the error can go in the other direction, that people who cannot
make decisions, or in a situation where they feel like they should, that can lead to
impulsivity. The frustration of being unable to deal with the situation can lead to it
and not dealing with the situation in a calm time can put you into a situation where
you are subject to affective and social pressures at other times. I would say I thinkthat dealing with applied problems is the way that we drive our basic research. I
think this would be a very fertile topic for us, if not for you. Thank you.
DR. WEST: One of your comments that got my attention was that we are very
good at tracking what we see, but we are very bad at detecting our biases. That, tome, resonated. Because when I think of bias, and I think of bias in this discussion, I
think about the influence of fear and vulnerability and the power that those systems
have in derailing our cognitive brain, and introducing all kinds of biases in terms of
how we see situations, risks, and the world. So, thank you for bringing that to us.
DR. NASH: Yes, great presentations. If I had a bigger budget at Headquarters
Marine Corps, the two skill sets I would love to hire is an anthropologist and anengineer to help “complexify” things that look simple but really aren’t. I have aquestion for Dr. MacLeish about the role of the function of euphemism in a culture.
You used one several times about the job of the military is to put people in harm’sway, which is not exactly precisely true. I mean, to the extent that there is only one
type of skill set in the military that goes to war unarmed, and that is a chaplain.
Certainly, in ground combat everyone else is going to kill someone. In my experiencein the deployment, there are a lot of euphemisms for the experience of killing. As ananthropologist, have you experienced euphemisms for killing? Are there taboos intalking about this? Am I breaking a taboo right now by bringing this up?
DR. MacLEISH: Yes, so a couple of things. One is that Ernie’s story certainly
suggests that there is a taboo about talking about killing people. He said in the longer
version of that anecdote, he says, “Okay, so the psychologist lady asks me, ‘Do you
ever have dreams about shooting people?’ And I tell her, no, you do not have to
dream about it when you do it in real life.” That is the thing that makes her laugh, atleast in his account. “Okay, this guy’s all right. He’s got a good sense of humor. Let’s
move on.” There is and isn’t humor. There is and isn’t a taboo. One of the things I

interaction
between impulsive
behavior andcognitive behavior
and between therational and theirrational.

Panel Two: Understanding Risk

did not get to talk about today was ways that people in my experience here relate
to some of the policing and surveillance around suicide risk. Military humor is fullof all these sorts of dark and sarcastic remarks and imagery.
There is a section in my book that talks about this bodily and textural imagery
that people use to talk about dead bodies. Some of it is quite grotesque and someof it is superficial or even comical or a source of humor. There is also a distinction
between euphemism and taboo in the language that is used to describe scenes ofviolence versus the language that is used to avoid talking about it. For folks whoare interested in this topic, there is an excellent book by Elaine Scarry, who is aphilosopher, called The Body in Pain. There is an entire section of the discussion
devoted to the structure of war and the idea that the way that war is describedin modern society is entirely premised on euphemism. Most of the language that
we use to talk about war invokes bodily metaphors to talk about war on a large
scale. You know, the arms or head of a movement of troops, but that substitutes
the language of neutralization or of objects or depersonalized targets to talk about
violence against actual bodies. That issue is very much something that happens inthese settings, and I think it happens in the ways that military personnel talk to one
another. It also happens in a different way in the interactions between a military
normal and an administrative or a civilian normal that is driven by all sorts of otherfactors, including fears and anxieties and taboos, if not what it is okay to talk about.
Then, just to state something real quick on the question of killing, I am sure a lotof this depends on if I spend my time largely among Marines where the slant toward
combat arms is much heavier in terms of what the composition of the total force islike, I am sure I would have a different perspective on this. The folks I talked withat Fort Hood were an interesting mix of combat arms and folks who were doing
all kinds of things. The breakdown Army-wide is something like 10% combat arms
and 90% support, or something like that. Of course, it is different in other places,
like Fort Hood is different among deployed forces. One of the things that people
would consistently talk about was, “Well, you know, I’m a bridge engineer and I did
convoy security or I’m an electronics warfare officer and I was manning a 50 cal
on a Humvee, or I’m in finance and I have deployed twice and I just sat at a desk at
Anaconda, or whatever, and never went outside the wire, but mortars would land
nearby on a regular basis.”
Because of the nature of these particular conflicts, there is also this sort ofambiguity about what it is that actually defines deployment, whether it is going out
and kicking down doors and engaging the enemy or whether it is being in a highly
unstable environment where violence can happen to you, regardless of what yourjob might be.
DR. URSANO: Maybe one way to turn that slightly to our present discussion
would be to say that euphemisms are frequently used to describe difficult topics.
One could talk about the euphemisms used for suicide, and one could talk about
the euphemisms used for gun violence. In trying to understand the language forcommunication, I have built two things out of that. One, Curt, you referenced thequestion of motivational interviewing earlier as a mode for behavior change, andone could wonder how one proceeds in management of euphemisms in a motivational interview. Having said that, let me go to my actually core point, which is tolink Baruch and Kenneth together. Kenneth made a comment which was namingrisks produces new problems and vulnerabilities. Baruch then talked from a broad
perspective about the question of decision analysis. I draw your attention, our atten-

41

There is a stereotypicalthinking that people
who are impulsive
make bad decisions.

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Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

We are very goodtion, to the last word “decision analysis,” not “decision”. Decision itself is a process.
The way in which someone decides to have a weapon, to not have a weapon, use a
weapon, to have a helmet, ride a motorcycle, not ride a motorcycle, what happens
along that is a decision tree.
The question becomes, what are the decision processes involved in each of theserisk behaviors and how we want to modify them to safety behaviors, and whether or
not there are interventions at different parts of those trees for the different types ofrisks. I would point out one other developed area for that. Doug Zatzick, who hasdone a lot of work on collaborative care and the treatment of PTSD in collaborative settings, the strength of his model is what he describes not as getting prolonged
exposure in PTSD, not as getting CBT in PTSD, not as getting people to treatment,
but it is problem-solving with the patient at each point. That problem-solving
method includes the questions of: How do I get there? What’s my family going to
do? I need a babysitter. This hurts too much. What can I take?
Do we do that when we work with our populations or our patients in thisprocess of trying to institute safety behaviors? Have we thought through the newproblems that come up when we tell you, “Gee, maybe you ought to lock up yourgun?” The new problem that comes up when we say, “Gee, you ought to wear ahelmet when you ride your motorcycle.” What is the next step of what the person
is going to say? And then, what are they going to say after that? Just as I love theexample about cesarean and turning the baby, it is the process of thinking down
the road as to what they are thinking about, not just the “tell them what they ought
to do”. So, it is a more complicated scenario, which I think both Ken and Baruch
highlight.
DR. FISCHHOFF: In risk analysis, a good analysis would adapt what they callboth fault tree and event tree analysis. A fault tree analysis is basically startingfrom what you do not want to happen, a loss-of-coolant accident, and you say,“What would the precursors be and let’s keep them from happening.” An event
tree analysis says, “This is what we are doing: They go to the job. They do thesechecks. And then, how could each of those things go wrong?” The world looks
different from the two perspectives, and certainly from both the design and analysis
perspective.
DR. WEST: As a former submariner, my heart was warmed to hear you say theterms “loss-of-coolant casualty” in the context right now, thinking through some
immediate actions. In addition to what Bob said about thinking about what theindividual is going to come back with on each step along the decision tree, andbacking what Baruch said, it is also listening for what comes back. You may predict
and, then, you are going to compare what you actually get to what your prediction
was. If the patient says, “I’m not worried about a cesarean section,” the decision
tree is over. You can move on. If the patient says, “Oh, absolutely, I’m going out toget a biometric gun safe and I’m going to unload and put the locking device on myweapons,” the decision tree is over. So, there is also that idea of taking feedback
after you have offered the suggestion.
DR. BRADLEY: I think we do a terribly poor job at that in clinical medicine. We
are frequently put in the paradigm of the expert giving advice, expecting the patient
to take the advice and implement it. The literature is clear that that happens muchless frequently than we would ever predict.
Being open to the problems that you anticipate if you were to make a decision
like this, and engaging that discussion is really the challenge for all of us. Then toat tracking what wesee, but we are very
bad at detecting ourbiases.

Panel Two: Understanding Risk

troubleshoot or murder-board every communication that we have where we think
we are being beneficent to a patient saying, “Well, what’s your take on this and what
are the problems in what I’m suggesting to you?”
DR. SALVATORE: Just a general question is, I wonder how a lot of some ofthis science can influence or help us go to the policy and decision-makers. In otherwords, you are talking and thinking about the state laws, you know, seatbelts, even
I was thinking of ice hockey; they used to play without helmets on until about 20
years ago. In the areas where we have fallen short in terms of population healthinterventions where broad-based policy decisions come in and really change theshapes and, then, behavior and there is activation of that safety. I’m curious, thoughts
on influencing policy and decision-makers?
DR. URSANO: It calls out for a case study approach. How did we ever get
seatbelts? I know it wasn’t instant, but there is a history of that. I do not know;
Baruch, do you have any findings on that one?
DR. FISCHHOFF: I was telling somebody, we lived in Eugene. My wife organized this group called Birth to Three for primary prevention of child abuse. Somebody who worked for her was married to the Speaker of the Oregon House, Grattan
Kerans. Oregon had a citizens’ legislature where they sit for six months every two
years and pass a budget. They voted against seatbelts. This would have been 1977
or so. Grattan went home, and his wife read him the riot act. Grattan said, “It’s apersonal liberty thing.” She said, “No, it’s a child safety thing.” So Grattan, being
the Speaker, was able to reconvene the House and have a revote, and it was passed.
I think it might have been the first state to have passed a mandatory seatbelt law.
What turns out in the education, we want to have those who have kids knowthat if you want to get your kids to do something, you model it for them, right?
It changed the dynamic in the car. There were the statistics and they did not carry
the day. There were two alternative framings, and then you could do it. It turns outthat Grattan’s wife provided the reassurance that there won’t be pullback; parents
will want this; we can handle it. So, it is some kind of mixture of all of these things.
DR. WEST: I can imagine there are many people in this room that remember
some of the arguments against seatbelts. “What if I have to escape? How will I be
able to escape the vehicle if I’m trapped?” We see these now as relatively illogicalarguments.
DR. CORNETTE: A couple of thoughts which really, I think, go across several
presentations so far. So, one is I have been out of the VA for a few years. I am
wondering, have there been such tremendous efforts with reintegration of servicemembers into civilian life in a way that was not true, for example, during theVietnam War? I know a lot of it focuses on identification of symptoms of PTSD andthings of this nature. I am wondering if anyone is aware of, either in the transition
from military to civilian life or even from deployment to coming back to garrison
on stateside, if there has been any addressing in any of these briefings of, say, risk
analysis and firearm ownership and firearm safety? Is that discussed at all? Or is it
all from a mental health/physical health perspective?
A related, well, somewhat related, question is, I attended a firearm consortium
meeting a couple of years ago, and there were folks there from the Harvard Injury
Control Center. There was a really rich discussion about how firearm ownership in
this country is such a part of the American identity for some individuals and how it
is so emotional and visceral. I think for a subset of individuals it is a part of masculinity and a part of how they think about protecting their families, and not so much

43

Firearm ownership in
this country is such apart of the American
identity for someindividuals.

44

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

How did we change

cognitive, actually. I think both are important. However, I am wondering in termsof messaging. I think about a military firearm problem as a subset of the American
problem, although probably enhanced. How do you think about messaging andaddressing what is so emotional for some of the individuals?
DR. McGURK: Can I just piggyback on that a little with what you said, Bob? I
think the example of seatbelts is good, but I think the example we need to literally
look at is how did we change the culture of, when I see my buddy has been drinking,
I say to him, “Hey, give me your keys.”? Because that more feels like the emotional,“What do you mean take my weapon? Why are you going to take my weapon if
you’re my buddy?” I think that this is great when we talk about what clinicians
could do, what motivates them. We need to go down that road, but we need to go
down the road of what message does a peer need to communicate. What message
do junior leaders give? This is what senior leaders want. You can model them. How
do you model getting a weapon when someone is having a tough time with theirspouse or having financial difficulties or got a UCMJ? Those are vulnerable periods
and buddies notice that.
How do we get past, “You’re going to take my keys? You’re not taking my keys.
I can drive. That shows I am a man because I can overcome the fact that I have hada few drinks and still drive.” We have changed that. Now if you do not ask, you feelsomewhat like you did not do what you needed to. You are no longer a good buddy
because you did not ask to take away your buddy’s keys.
DR. WEST: Go back to Michelle’s question. There is an interesting thing. I am
not sure we know what personal gun culture is in the military. We are barred from
actually asking. As a military officer I could not do a survey of military members tofind out who has personal firearms. We think that it is not dramatically more than
if you look at society as a whole. Gun owners represent 30% to 40%, and that has
been gradually going down over time. Am I correct, Cathy?
MS. BARBER: More like around 35 percent.
DR. WEST: It is a subpopulation. Do we target an intervention for the whole
population when we are interested in a subpopulation and their behaviors?
DR. GOLD: To go back to the example of using drinking and driving, what wehave done in a large way is ask people to recognize a moment of increased risk whichchanges the analysis, right? So that there are lots of people who are terrible drivers,
but if you are drinking and driving, that is a moment where we change perception
about taking action to minimize the risk.
I come to suicide more than anything else as a very similar idea. Where are themoments where risk is highest and, then, can we train people to recognize those and,then, destigmatize, make it okay to be your brother’s keeper at that moment? That
is what we have done with drinking and driving to a large degree, obviously not
100 percent, but to a large degree. I think that in the sense of risk analysis we say ifthere is a moment of increased risk, can people recognize that and take appropriate
action? One of the things in working with patients who may be suicidal is where
you bring in somebody else, a family member, a concerned person, and say, “Look,
can we talk about holding the gun for this person?” When the crisis has passed they
can have their gun back if they want it. You are not stealing their gun. You are notstealing their car when you take away the car keys. You are going to get them backwhen you are not drunk, when the risk level goes down.
I think that whether you are talking about the military as a subset of American
culture, as a way of intervention that resonates because it seems to work withthe culture of, when
I see my buddy has
been drinking, I say
to him, “Hey, giveme your keys.”?

Panel Two: Understanding Risk

people who are receptive to understanding that risk changes over time. Having a
gun increases risk, but so do other things that you have in your home. There are
moments when there really should not be a gun in the house, just like there are times
when you shouldn’t be driving.
DR. CORNETTE: I am thinking about that being at the clinical level of intervention, right? Part of what is driving my question about culture actually is, is it realistic
to think that we could have fewer people owning guns in this country? Have wegiven up on that? How do we target? That is a really massive endeavor. But, to theextent that that will likely lead to reductions in suicide rates and violence, is thatsomething we can attempt to address or target?
DR. URSANO: One thing, I would correct that; I would not hear this as a clinical intervention.
DR. CORNETTE: Well, public health and clinical at the individual level.
DR. URSANO: It is actually a peer intervention. It is the question of, can wetrain people in a Heimlich maneuver? So, when people are sitting in a restaurant andsomeone recognizes choking, is there such an intervention? I think Dennis’ example
was a peer intervention as well.
DR. McGURK: I think we probably need to do every level. I think we need peer,
clinician, leader, and self to every once in a while think, you know what? They told
me that these are some of the things. I am experiencing them. You know, maybe I
put the pause in there with a gunlock or I give it to my buddy for a little while. I
think we need to go every different avenue.
DR. WEST: There is a fascinating discrepancy there. Ken talked about the
point that the military is built on central control, but I will say in many cases illusions of central control. If I looked at the military police here on post, if there wassomebody in that situation that Liza described where there was an increased risk,
what happens? Well, they are going to get tagged, red-tagged, right? They cannot
draw their gun. They cannot get their service weapon. There is a system in place, thebig system. However, if they go home, they can have all the guns they want. Right
now, culturally, we may feel worried about it. We may feel bad about it. We are also
hesitant to intervene.
DR. QUINLAN: I do think that culture has changed some over the last decade or
so. You see now at The University if a student or staff member has suicidal thoughts
and gets seen for care, the command intervenes and asks whether or not they haveguns in the home. If they do, they ask if somebody who is a buddy can come andtake those guns. I think that is becoming more and more common in our culture.
So, I think there already has been a shift. I could not envision that happening 30
years ago when I first stepped in uniform, but it does happen, maybe not all thetime, but it happens with some regularity at this point in time. So, maybe that shift
has already started.
DR. HOLLOWAY: Just a couple of comments. One is I really liked your example,
Dennis, and it started me thinking. When I see a friend who is intoxicated, who has
had too much to drink, I have those observations; I have those skills to be able to say,“You’ve had too much to drink.” I think that with suicide many times what we see isfriends and family members really do not necessarily see the warning signs of suicide.
In that case, I think it makes it very difficult to be effective in intervening because
you are not really a trained clinician. We are trying to kind of get communities to doa better job of this, but I think people really struggle with it. It is really interesting; I
think over the past decade there have been a number of suicide case reviews, death45

When I see a friend
who is intoxicated,
who has had too
much to drink,
I have thoseobservations; I havethose skills to beable to say, “You’ve
had too much todrink.”

46

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

I think the word

reviews, within the Department of Defense. The pattern I have seen, which has been
just an observation, there is nothing scientific and published on this, but the pattern
I have seen, based on the death reviews, is that people in communities are actually
doing a good job of asking for the weapon and securing the weapon. There are times
that we actually see servicemembers say to a buddy, “John, take my weapon. I’m justnot doing well, and just hold onto it for me.” Great, checked, done it.
The problem that we see is about the decision-making that you talked about.
When do you make the decision to give it back? Those are the times that I haveseen where the suicide happens, where people in the community, and I think civilian
communities too, are just not educated enough or do not think about that decisionmaking piece of it or do not recognize the warning signs sufficiently to be able to
make an effective decision about the timing at which an individual is now safe tohave access to his or her firearm. I think that is a very interesting clinical issue anda public health issue for us to navigate in the days to come.
DR. COZZA: Marjan, just to add one word to your comment, rather than when
do you make the decision, how do you make the decision, “when” being one element.
DR. URSANO: And who could help you make the decision?
DR. COZZA: There might be something particularly charged about the autonomy issue with weapons that is different, this relationship that veterans have withweapons, how they need to have them close, which makes it more difficult for themto give up. As an example, the best intervention to decreasing teenage and young
adult drinking and driving has been the introduction of Uber. It makes it so easy. It
is an example of retaining your autonomy in a way that is socially-sanctioned andis used fairly easily. I do not know that there are any easy metaphors for a weapon.
This is just speculation, but I wonder, when some soldiers are suicidal, they feeleven a greater attachment to that weapon because suicide is an autonomous act
and that is an autonomous object. I think that is going to be tough to get them togive that up.
DR. GOLD: When we are talking about this, somehow the stigma associatedor the embarrassment or the shame of saying, “I’m too drunk to drive” has beenameliorated or mitigated to some degree. When you talk about how you get people
to respond to your question, even if they stopped selling every gun, no more gun sales
as of today, there are over 340 million guns. Unless you are going to go around andtake them all away, which cannot be done, then there are guns in our environment.
People have them, and we are going to have to figure out how to mitigate the risksof those.
One way is decreasing the stigma. The military understands that there are twosides of it. If you say that there is something wrong, you can be getting more thanyou bargained for. Generally speaking to say, “This is not a good time for me to havea gun,” just like it is not a good time for me to drive without necessarily tripping
any wires about saying “I have a mental illness” or “I’m having all kinds of otherproblems. I do not want to have to talk about those right now,” but just being able
to decrease the stigma of letting go of something that may be an integral part ofsomeone’s identity temporarily. I think the word “temporarily” is important, andhow and when you decide to give it back is also important. For people to understand,what I hear a lot is, “Well, I’m not giving away my guns.” We are not talking about
giving them away. We are talking about temporarily having someone else hold them
until you can take them back.
DR. URSANO: So, there are examples, just like the issue of giving up one’s keys,“temporarily” isimportant, and how
and when you decideto give it back is also
important. We are
not talking about
giving them away.
We are talking about
temporarily having
someone else holdthem until you cantake them back.

Panel Two: Understanding Risk

there are examples that are not while one has been drinking. It can be, “I’m sleepy,”“I’m tired.” “Will you drive? I don’t want to drive.”
DR. GOLD: Right.
DR. URSANO: We really need to call in the National Rifle Association (NRA)
to think through some of this. In a glib way, there are ways in which you pass yourweapon to someone else. If you are climbing over a fence, you are supposed to havesomeone hold the weapon while the other person climbs over, and then the weapon,
and then you climb over. We have to come up with analogies where that pass-off
occurs in benign settings. Then one could communicate a message in a way that it fits
in that paradigm, rather than this particular paradigm of, “You’re going to commit
suicide.” That is part of that context, much of that language that switches from thequestion, switches to protect your children rather than to take the weapon away.
DR. WEST: I like the fact that many people have related one of the really complicating issues when it comes to firearms as opposed to drunk driving. That is, you
cannot argue that drunk driving is caught up in identity. To say that this liquor is apart of me and it makes me who I am, it is just nobody would argue that. The issueof identity complicates any interventions that we consider.
MS. BARBER: When you first brought up this issue, you were saying the
problem of gun ownership. I think the way to shift it is to talk about the strengthsof gun ownership and the strengths of values of gun-owners, and to say there arevery positive values around protecting the family, around safety, around personal
responsibility and discipline. Take those positive values and take the gun in a community and ask the gun community to take on this “friends don’t let friends drive
drunk” approach to responding to the way risk can really vary over time. There
are times when having guns around is a bad idea and times when it is a great idea.
An advantage to having it reframed, and looking at the gun-owning community
as part of the solution instead of part of the problem, is being able to use these kindsof peer approaches that allow men to have a way of talking with one another when
you are in trouble. “Hey, emotionally I’m here for you. I really see you struggling
with your divorce.” If you can do that, great, but a nice way of showing support
if you are feeling a little awkward is saying, “I really see you struggling with thisdivorce. Can I hold onto your guns for you?”
DR. NASH: It’s not just men though. In recent years, suicide by weapon, guns,
has gone way up in women, too. So, I do not think it is just a male issue.
MS. BARBER: Yes.
DR. McGURK: DSPO is leading an effort to look at means safety, means restriction. You mentioned the NRA. DSPO has the NRA and gun shop owners involved.
There is another place where you could give autonomy, either with a gunlock ormaybe it is just that “I bought my weapon at your store. You’re the gun shop owner.
Hey, why don’t you hold this?” Or you are at the range and could just leave it there
for a little while, and nobody else knows but me. The gun shop owner holds it until
I come back and fire at the range the next time. He does not ask me, “Is that because
you’re depressed?” Or maybe he does. He gets involved, and I have another resource.
DR. WEST: One of the things that I heard about identifying people at riskthat was a little distressing is the idea of identifying people at risk specifically forsuicide. If the average person sees somebody as potentially suicidal, there are awhole bunch of other things that come into play versus seeing somebody just atincreased risk. Seeing and identifying distress rather than a clinical condition thatneeds intervention, they could do something at a peer level. It does not attach an

47

The way to shift it
is to talk about thestrengths of gunownership and thestrengths of valuesof gun-owners, andto say there arevery positive values
around protecting thefamily, around safety,
around personal
responsibility anddiscipline.

48

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

It was not just theidentity issue of not needing the gun. It identifies, “Man, you are really in sometough times. Why don’t I hold onto this for you? And we’ll talk later. You tell me
when you think it is okay.”
DR. FULLERTON: I wanted to follow up with something that Bob said about
analogies that we can look at that are more acceptable, particularly if it has to dowith protecting children, something like on airplanes putting your mask on first.
That level can go to public health messaging, or disaster behaviors. How in a situation of chaos, where your usual decisionmaking is not what it always is, how does
this apply to that?
DR. COZZA: I think one of the things that also is clear, but is sort of unspoken, is the use of weapons. When we come up with this public messaging, nobody,well, some people do, but it is the vast minority. The intention of the use when it ispurchased and owned, the risk pathways really need to be understood about howthat intention shifts and when it shifts, and if it shifts, it shifts impulsively, if it shifts
over time, and where are the opportunities for some kind of an intervention whenit comes to recognizing those shifts?
It is not about the intention to protect one’s self. It is how that intention may shift
to something where I might want to hurt myself or I might want to use it against
somebody else impulsively or my kids may want to play with it and be curious about
it. Those are never the intentions of purchasing the weapons, but they are possibilities
that could result. Helping people understand those inherent risks associated with
the intention of protecting yourself, I think that is complicated.
DR. FRATTAROLI: Just a comment about something that hasn’t been raisedwith regard to these two analogies that I think are quite interesting and appropriate,
although have limitations, as we have talked about.
Back to the original comment about policy, policy played a very importantrole in both of these things. With the increase in seatbelt use came mandatory laws
requiring seatbelts. With the change in drinking and driving behaviors came realconsequences for drinking and driving, which gets to the other point. For both of
those examples, there were real consequences with that change that happened. So,
it was not just the case that it was about personal liberties in the case of seatbelts. It
suddenly was about people dying or people being injured in ways that they did nothave to. With regard to drinking and driving, it was not just about being a man andbeing tough or being cool because you can drink so much. It was about who are
dying. A lot of people are dying, and there is an easy solution. You can still drink, justdo not drink and drive. So, I think when we think about other elements that went
into those changes, it was policy mandating things, enforcement of those policies,
and it was understanding consequences. When we think about suicide, in particular,
maybe euphemisms come in here as well, when we talk about suicide, it is often the
final solution, right? Solutions are good. So, is suicide really something that we, asa society, talk about avoiding really? I think we have to think about framing thisas a consequence that is undesirable, not just something that is heroic. It is in some
way still very much portrayed as desirable.
DR. SALVATORE: It is an interesting point, going back to the seatbelts. In local
law enforcement, even with mandated policies, they were still resisting to buckle up.
That was due, apparently, to the varied equipment and being in a hurry. It was not
until the intervention of getting seatbelt extenders in local law enforcement patrol
cars that they saw more compliance with seatbelts. It was that safety intervention

case that it was
about personal
liberties in thecase of seatbelts. It
suddenly was about
people dying or
people being injured
in ways that they did
not have to.

Panel Two: Understanding Riskof extending the seatbelt so it was easier to get and render equipment in a hurrythat compliance came up.
DR. CORNETTE: I do not mean at all to sound anti-peer intervention, anticlinical intervention. I am a clinician by training. I wonder sometimes, for example I
am looking at death reviews, and maybe it is a combination. Is it that individuals are
not accurately noticing things that would make a clinician say, “We should remove
the weapon,” or is it that the state of the science isn’t such that we know when to
remove it? I see this with mass shootings. In the recent example in Fort Lauderdale,
his weapon had been removed by law enforcement and returned. Was that a bad
decision? Should they have seen this coming, or is it that low base-rate behaviors
like homicide and suicide are really tough to prevent? It is a needle in a haystack and
we are giving ourselves too much credit in thinking that we are going to be able toknow when that occurs. I am not saying we definitely have to be looking at periodsof heightened risk as clinicians and as peers, but I sometimes worry that is often aknee-jerk in the media. “This person had a mental illness; they should have known.
They should have taken his weapon away.” Do we really know when to do that?
DR. WEST: Not only did he have a mental illness, he was an Iraq War veteran.
That also plays into the public perception. You are asking questions that are goodquestions. I do not think anybody in this room has any answer yet.
DR. WORKMAN: Well, I have a partial answer to part of that, and to speak to
Shannon’s comment, which is, legally, there was no basis for refusing to return it. No
matter how much risk he was assessed at, at the moment he was presumably asking
to get his gun back, I do not know, but I believe that there was no legal reason, legal
way to deny him that.
DR. WEST: Right. So, you have two arguments. One is, why was he not still in
the hospital? Well, because hospitals, there are laws as to how long people can beheld in hospitals without cause. There are laws as to how long people can have their
weapons withheld without a clear cause. These people are now in the position offeeling terrible; that I did what the law told me I was supposed to do, and this was
the bad outcome. They also probably gave firearms back to 10 other people wherenothing happened.
DR. CORNETTE: Right, and when we are looking only at the deaths, right,
and we are looking retrospectively at the bad outcomes, then it is easy to say. But
in how many cases was the right decision made?

49

It is a needle in ahaystack and weare giving ourselves
too much credit inthinking that weare going to be able
to know when that
occurs.

50

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

Panel Three: Interventions to Enhance Safety51

3Panel Three:Interventions to Enhance Safety
Speakers: Catherine Barber, MPA, Shannon Frattaroli, PhD, MPH
DR. WEST: Our last panel will focus on interventions, what do we know, what
have we measured, and what have we thought about that has not been tried?
Our next speaker is Cathy Barber. She comes from the Harvard T.H. Chan
School of Public Health, the Harvard Injury Control Research Center. She hasstudied extensively the issue of firearms and interventions and the outcomes of thoseinterventions. Her Means Matter Campaign addresses means restriction as a way
to minimize suicides. She will talk about interventions to enhance safety, primarily
through the lens of self-inflicted violence.
MS. BARBER: What I usually do in these sorts of presentations is spend half
the time on why means matter when it comes to suicide and the evidence on why
firearms, in particular, matter, and then, the other half on changing the discoursearound guns and on interventions.
If we are talking about preventable deaths in active-duty military, we are really
going to be focusing on suicide. Although I could not get these data for active duty,
looking at veterans, the vast majority of veteran firearm deaths are suicides. Typicallythe suicide prevention field has focused on the issue of “why”. Why is somebody
in such pain that they would take their life? Interventions are geared towards that,which is all to the good. However, switching one of those questions to “how,” weare learning in the field that how somebody attempts plays a really critical role inwhether they live or die. There are a few examples of where changing access to lethalmeans really has made a difference at the population level.
In Sri Lanka, which had one of the highest suicide rates in the nineties, the majority were pesticide suicides, hardly ever used as a method here. In the mid-nineties,
the most human-toxic pesticides were banned, and suicides dropped by 50%, which
is a stunning drop at a population level. The non-pesticide suicide methods did not
drop. The non-fatal pesticides attempts did not drop. Behavior was not changing,but fewer people were dying from the behavior.
In the Israeli Defense Force they were concerned about suicide, and most suicides, 90%, were by firearm. Many were on weekend leave. It is a small country,
and soldiers go home on the weekends. Following a policy decision that soldiersleave their weapon on base during weekend leave, suicides dropped by 40%.

Typically thesuicide prevention
field has focusedon the issue of“why.” However,switching one ofthose questions to“how,”…plays areally critical rolein whether they
live or die.

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Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

In one study inThis evidence is less convincing than in Sri Lanka just because the population issmaller, but it was instructive that weekend suicides dropped significantly and theweekday suicides did not. It is not a myth that, if you really want to kill yourself,
you can eventually find a way. If you are suicidal today and tomorrow and next
week and four weeks from now, yes, you can eventually find a way. Why was itthat suicides did not go down on Sunday and up on Monday? Should they not go
up on Monday?
There are three answers. The most important is that the acute phase of a suicidal
crisis is often, but not always, brief. By “acute phase,” I mean that period where you
are actually willing to pull the trigger or swallow the poison. You might be miserable
for a long period or a short period, but that period where you are actually willingto do something about it is often quite brief.
In one study in Austria, about 80 or 90 people seen in the hospital, were asked
following a suicide attempt, “You attempted suicide. When did you first start thinking about making that attempt?” For 48%, it was within 10 minutes of the attempt.
Many interventions are geared to the people in categories where they present assuicidal, and this is what you work on. However, we are missing those people whoare going from zero to 60 pretty quickly. This is not a suicide out of the blue. Rather,
it is somebody who has been struggling for a while, but is making that decision andtransitioning from the decision to action quickly.
For the other two parts of the answer, it is easier to go through a case example.
Robert is a 27-year-old with a drug problem. His girlfriend kicked him out and hemoved back in with his parents. They are concerned. They are worried. He is notshowing up at work. They call a clinic and try to get him to go. He wants nothing
to do with that because, from his point of view, he does not have a mental healthproblem. His world has been destroyed by his girlfriend leaving him. He calls her,hoping for a reconciliation, but she will hear nothing of it. He goes to the gun cabinet, but the guns are not there and he is intent on suicide. We do not know much.
We need more science on what goes on in this moment. In this case, he uses a sharp
instrument, a box cutter, to attempt suicide, and he survives. When you put together
emergency department and death certificate data, it is no surprise that eight or ninetimes out of ten, he is going to die using a gun. Just think through, lay a bet withyourself about what is that proportion when it comes to sharps or pills. The answer
is one or two percent are fatal when you look at emergency department data anddeath certificate data.
Many of you are clinicians, so you could very well say that many of these are
not real attempts to die; they are more in the line of gestures. Take away half of
those attempts or two-thirds or even three-quarters, which I think might be a little
too many, and you would still only end up with an eight percent case fatality rate.
Since the vast majority of nonfatal events are overdose or sharps, and that pie on
the right is 13 times larger than the one on the left, you would rather somebody
have to come up with another method other than a gun. That is the second part of
the reason that means matter.
The third part, with Robert, is did we actually save his life? He did not kill himself in the box-cutting incident, but history of suicide attempt is certainly one of thestrongest risk factors for suicide. What proportion of attempters eventually go on
to die by suicide? There is a lot we do not know in suicide. This is something that isreally well-studied. There are 90 studies that look at repetition of self-harm, 70 ofwhich looked at fatal repetition, and between 5% and 11% of people who attempt

Austria, about 80 or
90 people seen in thehospital, were asked
following a suicide
attempt, “Youattempted suicide.
When did you
first start thinking
about making that
attempt?” For
48%, it was within
10 minutes of theattempt.

Panel Three: Interventions to Enhance Safety

suicide eventually go on to kill themselves. This included one study that focused on
people who jumped in front of a train, presumably very serious attempts.
This is why means matter, those three reasons, and why firearms in particularmatter. It is not just the lethality, but if firearms are in the home the easy accessibility, not having to drive to a bridge. Everybody has fire in their home, but almost
nobody uses it for suicide in the U.S. because it is not a culturally acceptable method.
Firearms are irreversible. In just about every other method, except for jumps from agreat height, there is that moment where you could say, “Oh, my God, what have I
done?” and stop mid-attempt. And far more people start an attempt and stop thancarry through with one. We really would prefer that people not attempt at all. If they
are going to attempt, attempt with something where they can have that moment of“Wait a minute.”
Dr. Anglemyer presented the case-controlled studies. Sometimes it is hard to getyour head around odds ratio. A concrete example would be that there are roughly
six states that have really low gun ownership rates. There are 31 million people
living there. Take the same population in high gun ownership states. You see thetwo are not so different in terms of suicide attempts, a little higher here, incredibly
similar in terms of the non-firearm suicides, but it is the firearm suicides that reallymake the difference.
You could think, these states are really different. They are rural. Maybe it is not
the guns. Maybe it is that they are standing in for something else like a “let me do it
myself” kind of attitude or just rurality. That is a reasonable hypothesis. We looked atmental health surveys to compare gun owners and non-gun owners, and gun owners
are no more likely to have a mental health problem or to have considered suicide or
to have attempted suicide. It is not that gun owners are more likely to be suicidal;
just more likely to die in an attempt. That is where the conversation would screech
to a halt in the suicide prevention field because suicide prevention people said, “If
we are going to talk about guns that means we are going to talk about gun control,
and that is too contentious. So, let’s not talk about it at all.”
Nothing on the gun control agenda would take a big chunk out of suicide. Why
are we letting an issue like that derail us? Because, in fact, if gun owners are dying
by suicide at higher rates than non-gun owners, there is a responsibility to answer
that risk. As clinicians, as military leaders, as fellow gun owners, as suicide prevention advocates, these are our people, the same way old white guys are our people,
the same way that people with a family history of suicide are our people when it
comes to saying, okay, increased suicide risk; how do I help address that risk? Do
we do that with an anti-gun agenda? I would say no. I would say that is like sendingan anti-gay group to do suicide prevention in the gay and lesbian community. You
do not send such a group in to do suicide prevention work in the gay and lesbiancommunity because if they do not trust the messenger, they do not trust the message.
You are also likely to screw up the message.
What I want to see happen in the next 10 years is that anytime this sort ofscenario happens, like a woman is saying, “I’m really worried about my husband. I
am uneasy that he might be considering suicide.” Whoever she is talking to, whether
it is a therapist, a hotline worker, her commanding officer, a neighbor, a defense
attorney who is handling his drunk driving, I want them to say, “Is there somebody
who could hold onto your guns for now?” Thirty years ago, nobody had heard thephrase “designated driver” or “friends don’t let friends drive drunk,” and now it isubiquitous. There was a change in social norms that occurred. How are we going to

53

Firearms are
irreversible. In justabout every othermethod, except forjumps from a greatheight, there is thatmoment where you
could say, “Oh, myGod, what have I
done?” and stop
mid-attempt.

54

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

When a person

make that social norms change occur? How do we get that same friends-protectingfriends kind of approach?
As clinicians and gatekeepers we can think it through strategically like a battle
plan, okay, starting with one prong. We can train them in lethal means counseling.
By “gatekeepers,” I mean people like defense attorneys and clergy and divorce
attorneys, and so forth. When a person is in a position to be working with people
who are in their worst moments, they should learn how to talk comfortably andrealistically about firearm storage. Within the gun-owning community we can work
to add suicide prevention as a basic tenet of firearm safety. I am going to talk a little
bit more about both of those.
What made the difference for Robert was when his parents called the mental
health clinic, a clinician there suggested if they had any guns at home, now would bea good time to store them away from home, for the time being. A lot of clinicians do
not ask, but we are definitely working on that issue. That is something that within the
military you have the ability to create policies and implement practices around this.
I am not going to go into training around lethal means counseling, although wehave developed one for the Department of Veterans Affairs (VA). I want to highlightseveral points about it. One is how you raise the issue can really make a difference.
People focus on, “Yes, now we always ask; we always ask; we always ask.” Imagine
that you are working with somebody who is really struggling with a divorce anddepression and has disclosed how horrible they feel. You then ask, “Do you have anyguns at home?” And they’re like, “Oh-oh.” That might not open the door. Whereas,
if you say, “Lots of military personnel have guns at home, and sometimes what
people in your situation will do is store their guns away from home for now until
they are feeling better. Sometimes what they will do is disassemble their guns andput the firing pin in a safe deposit box. Or they will ask a wife to hold onto theirguns or a friend to hold onto the key to the lock. Have you thought about a strategy
like that?” The advantage to that way of backing into the topic is you have normalized gun ownership. You are not acting like it is something weird. You are giving apeer example and making clear that you are talking about steps that are under the
person’s control. It also gives the information, whether the person wants to disclose
about gun ownership or not. Obviously, there is a hierarchy of safety options, but
you work on where the patient is and what is acceptable to them.
You can be pretty creative with where you store your guns. If you do not feel
comfortable telling somebody you are in trouble and want to do it in a way that isvery anonymous, you can pawn your guns. That can be an inexpensive way of storing your guns securely. Use a self-storage facility or it is such an easy option withmilitary people where you have armories on base. It seems like there are ways thatthe military could streamline storage practices.
One other point about lethal means counseling goes back to this study. If you
are only doing lethal means counseling with these folks, you are going to miss a lotof people. You definitely see among hanging and shooting suicides that it is often
their first attempt. If you are waiting for somebody to disclose or to have a suicide
attempt history, you are going to miss a lot of people.
I think there is also an inoculation approach with lethal means counselingwhere, if somebody is really struggling and you ask them about suicidal thoughts,
and they say, “I’m really struggling, but I’m not there.” I think it then makes sense tosay, “I’m really glad to hear that. I just want to give you a heads-up that sometimes
when people are struggling in the ways that you have described, if something else

is in a position
to be working
with people whoare in their worst
moments, theyshould learn how
to talk comfortably
and realistically
about firearm
storage.

Panel Three: Interventions to Enhance Safety

happens, if another crisis happens, then sometimes suicidal feelings can come onvery strong. I just want to let you know that a lot of times those will go away in amatter of hours or days. Can we strategize some ways to get through that period?
If a period like that were to happen, I really want you to get through it safely. One
step would be to store your guns away from home for now.” Then go through otheraspects of safety planning and distraction and getting social support. The important
thing is planting the idea that when overwhelming suicidal feelings come on, you
can wait them out. It is not going to last forever, and you can do other things to
distract yourself.
In a survey of Afghanistan and Iraq veterans, when asked what they thought ofsomebody talking about a mental health problem or talking about firearm storage if
experiencing a mental health problem, there was strong support for peers bringing
up the topic.
The last topic I want to talk about is approaching gun-owner groups on thisissue because this is where the movement is already starting to go, and needs to go
more, which is approaching gun owners as part of the solution and not as part ofthe problem. This involves recognizing that gun groups have a strong culture aroundsafety, responsibility, protecting the family, and neighbors looking out for each other.
Those values are consistent with values around suicide prevention. I have beenworking with different gun-owner groups. Once they see the data, 500 accidental
firearm deaths a year, 21,000 firearm suicides a year, they want to tackle that. They
are good outside-the-box thinkers on how to reach middle-aged and older whitemales. Many gun advocates are starting to get involved in this work: The National
Shooting Sports Foundation, The Second Amendment Foundation, and a numberof state-based groups. The National Rifle Association will also be announcing
something soon on this issue.
The idea of suicide prevention scientists and gun-owner groups started back in2009 in New Hampshire. It has now spread, and there are projects underway inover 20 states. It started with the New Hampshire Firearms Safety Coalition, where
gun retailers and suicide prevention people came together to look at the role thatgun shops can play, because here is a great messenger, a trusted messenger, and agreat place to get information to customers about gun safety that includes suicide
prevention. We created a brochure that has gun safety rules. Everybody knows that
there are the “10 commandments” of gun safety. We said it is the 11 commandments,
and the 11th is to be alert to signs of suicide and to help keep guns from a loved
one until they have recovered.
In New Hampshire, if you are concerned that a family member or friend is at riskof suicide, you can offer to hold onto their guns. In some states the legal environment prevents you from making that specific suggestion. These interventions need
to be tailored to the state. We made unannounced visits to all of the gun shops in
New Hampshire after sending out this campaign, and 48% had one of the materials
visible, which is great uptake. If you have ever seen how chaotic a gun shop is withmerchandise all over the place. There is no wall space, and there is little counter
space. This kind of uptake is very encouraging.
DR. NASH: Did they have any incentive to comply with this program?
MS. BARBER: No. Zero.
DR. NASH: It was totally voluntary?
MS. BARBER: Totally voluntary. The letter went out under the signature of botha public health official, which did nothing to help, and someone who was known

55

Everybodyknows that there
are the “10commandments”
of gun safety. We
said it is the 11
commandments,
and the 11th is tobe alert to signs ofsuicide and to help
keep guns from a
loved one until they
have recovered.

56

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

Ten years fromvery well. He owned the biggest gun shop in New Hampshire and was also Vice
President of the Gun Owners of New Hampshire.
DR. URSANO: Have you done any work at our Exchanges that sell weapons?
MS. BARBER: I have been working on another intervention with a Utah suicide
prevention group called the Utah Gun Rights group and State agency people andresearchers. It is a five-minute curriculum that was added to the Utah concealed carryclasses. The Utah Gun Rights group, which is also the shooting sports foundation,
has been great on this issue. They supported adding this five-minute suicide prevention component to the concealed carry classes. There are 2,000 people who teachUtah concealed carry classes across the country. They previewed this module, andwe surveyed them. Over 1,000 responded. When we asked, “Would you be willingto teach this module?” only 9% said “no”; two-thirds said “yes,” and 25% said
“maybe.” That seemed like very positive reception. It is coming from gun owners
and from people who care about gun rights that is going to be the most compelling
way to deliver the message. Maybe it makes sense to get training on firearms. Havea whole contingent of clinicians from clinic go to the range and get trained together,and set up a relationship with people at the range, so that you can ask them questions that come up, such as “Where do we actually store guns?” or, “We are giving
out these locks. Are these locks crappy or are they okay?”
Pitching the idea to gun writers and magazines like Shooting Times and Guns
& Ammo, that is where we want the coverage of this issue. Ten years from now,
what we want is all mental health clinicians and gatekeepers having this on theirmind, that they can comfortably talk about guns in a way that is consistent with
their patients’ values around guns, and that within the gun-owning communitythat anytime there is a class about firearm safety or a brochure or website, thatit always mentions being alert to signs of suicide and helping to keep guns fromsomeone until they have recovered. The more those conversations are going on
outside the clinician’s office, the easier it will be to have these conversations inside
the office.
I want to end with a description of a 30 second video developed with the Utah
Gun Rights group. The script for this was written by the gentleman who heads the
Utah Gun Rights group. It starts with this guy shooting at the range. He turns tothe camera and says, “A year ago I was at my worst, really struggling with depression. A couple of my buddies came by and asked if they could hold onto my guns
for me. I think those guys saved my life.” He then goes back to shooting. Pro-gun,pro-peer support, pro-resilience, it is not a doom-and-gloom message. It is a messageof resilience, recovery, and peer support, and I think the direction we need to go tochange social norms. Thank you.
DR. URSANO: There are extensive efforts within DoD over many years, interms of outreach related to suicide at all levels, public service, et cetera. But inwhat you are talking about here, his comments were amazingly impressive. I wantto just echo the statistics that you were saying, because we know within the Army, inparticular, that the time between the decision to commit suicide and suicide is most
likely minutes and certainly no more than a week. We know that because, when we
begin to look at predictors that go back farther than that, we have none. So, when
you think stressors matter, the stressors that matter are the ones that a person is
feeling in the past two weeks.
Secondly, when you think about the challenge that clinicians have, we recently
looked at this, looked at it in lots of different ways. If you are sitting in the clinic

now, what wewant is all mental
health clinicians
and gatekeepers
having this on theirmind, that they can
comfortably talkabout guns in a waythat is consistent
with their patients’values.

Panel Three: Interventions to Enhance Safety

and you have identified a high-risk person, meaning they have previous suicide
attempt, they have suicide ideation, they have multiple self-injury. Out of 4,000 of
those people you identify, one will kill themselves.
Now we do not have that skill. I would like to think I did, but we do not interms of identifying one out of 4,000 people. So, the idea that clinicians are goingto make a big impact on this is only in the minutes when the patient calls you andthey are about to do it, because the haystack is too big.
DR. BRADLEY: I think that leads us into some of our public health approaches.
For example, in the VA, we do comprehensive suicide risk assessments. I think one of
the more important interventions that we have come up with is distributing firearm
locks. In clinics, in VA hospitals, everywhere, you can get a gunlock that has the
National Suicide Prevention Hotline number on it.
The message is, “We know you have guns. We accept that you have firearms inyour home, and we would like you to be as safe as possible with them. Here is a tool
you can use to increase your safety with this weapon that you have.”
DR. WEST: Our next speaker, Dr. Shannon Frattaroli, will talk about looking
at safety from the perspective of interpersonal violence, family safety, and intimate
partner violence. What do we know? What has been tried out there? What do weknow that works? What have we seen that does not work? Dr. Frattaroli is Associate
Professor of Health Policy and Management at the Johns Hopkins Bloomberg Schoolof Public Health and core faculty at the Center for Gun Policy and Research. Her
research focuses on policy and advocacy strategies designed to prevent injury andviolence, particularly firearm-related domestic violence, with particular attention on
how interventions are implemented.
DR. FRATTAROLI: I am going to talk about intimate partner violence andsomething that can work, something that has some potential in that area. But I am
also going to veer into self-harm, and will end with a potential strategy for bothself-harm as well as unintentional gun death. It will be a comprehensive approach
to all the good things that we have talked about today.
Understanding risks, we had a wonderful morning discussing where the risks
are with regard to firearms in the home, and where they are not. What I take awayfrom the information we heard this morning, from the literature that we have, isthat firearm access is an important risk factor when we think about certain typesof firearm injuries and deaths. Specifically when we think about intimate partner
violence, firearms become important. And when we talk about suicide, firearms arequite important, as Cathy just very comprehensively reviewed for us. We also heard
in the morning about how they are important with regard to the risk of unintentional
gun injuries. Let’s move on and talk about some intervention strategies to addressthese issues.
What I take away from the literature, and this is a result of discussions withmany people in the field over a period of time, some of whom are in this room, ismuch like the conversation that Bob just reinvigorated. We cannot look to the clinical world to predict who is going to be violent next. We cannot do it with regard tointerpersonal violence. We cannot do it with regard to suicidal behaviors. We know
from the literature that the best predictor of interpersonal violence is past violence.
If you have been violent in the past, then you are at high risk for being violent in the
future. That leads us with regard to intervention strategies to look at policies that
rely heavily on the criminal justice system. In relying on the criminal justice system,
we focus pretty far down the trajectory of violence. In order to be identified by the57

In clinics, in
VA hospitals,
everywhere, you
can get a gunlock
that has the
National Suicide
Prevention Hotline
number on it.

58

Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

We know from

criminal justice system, you have to commit a crime; you have to be arrested; youhave to be prosecuted and, in order to get into that system, to then be under somecrimes prohibited from purchasing and possessing a gun.
The Consortium for Risk-Based Firearm Policy asked, “Can we do better? Do
we have to wait until someone is so far along that trajectory that a conviction for aviolent serious crime happens before we can talk about prohibiting the purchase andpossession of guns through law?” After a lot of thinking and debate, the answer that
we came up with was “No”. We can responsibly recommend a strategy whereby we
do not need to wait for that point far along in the trajectory of violence in order tointervene with regard to the gun issue. Where we got this confidence about the ability
to intervene earlier came from experience with the domestic violence or intimate
partner violence world. What I have listed here are federal and state laws that haveto do with domestic violence restraining orders in this country.
We have talked about social norm changes and looked at examples of publichealth issues that can inform the challenges that we are here to address. I would
argue that domestic violence is one of those public health issues. We had a change
in this country a few decades ago with regard to how we look at domestic violence. One result of that change has been a series of laws that today exist in all 50
states, and have been in place for decades. These laws are well-accepted and havebeen through court challenges. They state that when a person is in danger in theirhome because of abuse by a loved one, the courts are open to them through a civil
process that allows them to go to their local courthouse and say, “I need help. My
husband, my partner, my boyfriend is abusing me, and I need help to be safe. I needhelp for my children to be safe. Court, can you please intervene to help me withthis situation?”
One of the provisions of domestic violence restraining orders in most states
and at the federal level is to allow for a temporary prohibition on the purchaseand possession of firearms. The temporary prohibition is dictated by the length ofthe domestic violence restraining order. So long as the restraining order is in effect,
under federal law, the person subject to that restraining order cannot purchaseor possess a gun. More than half of the states in this country have duplicated thefederal law on their own state laws. Last count, 18 states have gone further thanfederal law and say that, in addition to the full domestic violence restraining order,
the temporary order that is in place for a couple of days up to a month, dependingon the state, that reflects the time period when the petitioner goes to the court in theabsence of the respondent and asks for the court’s help. The court intervenes, again
without hearing from the respondent. It is an interesting process under our systemof law. We recognize that as a period of risk, and we are going to allow for guns
to be removed and new gun purchases prohibited during that ex parte temporary
phase. Eighteen states have gone above and beyond federal law and have put these
additional requirements into place. Eighteen states is a lot of states, so we are nottalking about a bicoastal phenomenon. These are states that are diverse, that areblue and red, that have rural and urban populations.
And as that public opinion bullet shows next, the reason for this is when you poll
people about this kind of policy asking, “Do you think that people who are violent
toward their loved ones at home should have access to guns,” very high numbers of
the general population of gun owners say that does not sound right. These people
who are violent at home, who have gone through a court process, and a judge has
agreed with the petitioner that they are violent and the court needs to intervene,

the literature thatthe best predictor
of interpersonal
violence is pastviolence.

Panel Three: Interventions to Enhance Safety

removing guns from the situation makes good sense. We support that from a policy
perspective.
We have a lot of law. We have a lot of public opinion, and there has been someresearch on this issue of how these laws work, what their impacts are. What we see
from the research is some evidence that suggests there is an association between
these kinds of laws and reductions in intimate partner homicide. The extent towhich these are directly attributable to these laws is something being worked out
in the literature, but I think by and large the people who work in this area feelthat it is a question of not whether or not these laws make a difference, but how
much of a difference they make. So, we have some evidence to suggest that there isan association between these types of laws and the most severe forms of intimate
partner violence that we all are in agreement that we want to avoid. This is one
strategy for addressing intimate partner violence and the risks associated with
intimate partner violence with regard to severity of abuse. A real challenge now,in my opinion, is that when we look at how these laws are being implemented andenforced, we have a pretty good idea that purchase restriction is working. It is asystematic kind of law where your name goes into the background check system
and it is pretty easy to facilitate.
On the other hand, we have a pretty good idea that not much implementationand enforcement of the possession prohibition is happening. There are many localities and efforts on the ground right now that are trying to increase the extent towhich local law enforcement, courts, and other partners in this process are focusing
on the implementation of the possession part. Figuring out how to safely remove
guns from respondents to domestic violence orders who have been prohibited frompossessing guns for the duration of the order is an important challenge that lies
ahead in terms of realizing the full potential of these laws. I think the military has
an interesting potential role to play in this. As an outsider, it seems to me there is atleast room for discussion.
When we think about domestic violence restraining orders and look at that setof risk factors related to the research that was presented earlier, we see that this is a
strategy for addressing that intimate partner violence that showed up in the literature
as important and that firearms were an important risk factor when we talk about
the severity and lethality of abuse. There is also potential for these types of laws toaddress much of what we see in intimate partner violence, which is the controlling
nature of that abuse, and the fear and intimidation associated with gun threats
and the presence of a gun in the home. In this area of domestic violence restraining
orders, we have a real opportunity, with some promising laws and better enforcement. How that plays out in the military is something that people in this room arevery well-positioned to answer.
The interesting thing from my perspective about domestic violence restraining
orders is that it fed into this initial question: Do we have to wait for a criminal
conviction before the law intervenes with regard to purchase and possession ofguns for people who are at high risk? Given that we do not have good science on
how to predict that risk I have heard from many in the psychiatric community that
this expectation is well beyond the evidence, and we need to be realistic with regard
to what modern medicine can predict when it comes to violent behavior. If we goback to the domestic violence restraining order intervention, what that is about is
opening up the courthouse doors to civilians, to people in regular family life, to say
to the system in this example on the civil justice system, “I need help. I need help

59

Do we have to
wait for a criminal
conviction before thelaw intervenes withregard to purchaseand possession ofguns for people whoare at high risk?

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Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

We are also very

because something is going on with my loved one at home, and I’m in a position torecognize that help is needed.”
The idea with this gun violence restraining order and moving further upstream
with regard to that trajectory of violent behavior is to say that, while science does
not point to particular characteristics or risk factors that can directly lead us to thenext violent act, that 1 in 4,000, or the next sort of mass shooter or the next person
who is going to kill one person with a gun, we do have this idea that those closest
to us in community are oftentimes sensitive when a person is in crisis, when their
loved one is in crisis. We hear this retrospectively in anecdotes from people who havesurvived terrible events. They will say, “Gosh, I tried to.” I was recently in Texas witha woman whose son killed her husband. She had done tremendous outreach to law
enforcement to try to get her son help and to try to get the guns he was buying awayfrom him. Law enforcement was not able to respond. They did not have the tools
to respond because her son had not committed a crime. He was a legal gun owner.
He was not doing anything wrong, but, as a mother, she feared that something was
terribly wrong with her son.
The question is, we have this history with domestic violence restraining orders.
Can we learn from that and put a similar tool in the hands of family members tosay, “I know that my loved one is in crisis. I am worried about them. I need to go to
the court and ask for the court’s intervention to help with this problem that we arehaving, with this crisis, to get us through this crisis with minimal damage.”?
The request from the court is to do two things. One is to ask the court, much
like a domestic violence restraining order, to issue an order that would temporarily
prohibit the respondent to the order from purchasing or possessing guns.
Much like the scenario that Cathy presented with Robert, the parents felt thatsomething was not right with their child, right? His girlfriend had broken up withhim. He had moved back home. He was not going to work. Mom and dad knew
something was wrong, but what could they do? Maybe they were the ones thattook the guns out of the safe. But Robert could have gone and bought a new gun.
He was not prohibited by any state law. The argument behind the gun violence
restraining order is that this provides a tool for family members who recognize their
loved ones are in crisis. It opens the courthouse doors in a way similar to what has
been happening for decades now in all 50 states with domestic violence, and has
the potential to intervene in cases where there is a suicide risk recognized by family
members and potentially interpersonal violence risks as well. The other component
with regard to a gun violence restraining order mirrors policies that exist currently
in Connecticut and Indiana which essentially allow law enforcement to remove gunsfrom an individual that they determine poses an immediate threat to harm, either
to themselves or to others.
We have several types of policies that could be put forward to move back on that
trajectory of violent behavior with the intention of, hopefully, identifying people whoare in a momentary crisis, who are at risk of committing violence, and intervene ina way that would remove that most lethal form of violence from their disposal. We
are also very mindful, when we talk about gun violence restraining orders, to talkabout the importance of due process protections to be built into these laws, so thatthey are consistent with our constitutional law.
On September 30, 2014, California Governor Jerry Brown signed California AB
1014 into law. California became the first state in the nation with a gun violence

mindful, when wetalk about gun
violence restraining
orders, to talk about
the importanceof due processprotections to bebuilt into these laws,
so that they are
consistent with ourconstitutional law.

Panel Three: Interventions to Enhance Safety

restraining order law. It went into effect on January 1, 2017, and California has, infact, issued gun violence restraining orders.
In addition, we saw this past election cycle on November 8th there was a lot ofcoverage of the election, but not much coverage on something that was happening
in the Pacific Northwest with regard to a gun-violence restraining order-type law.
Washington State, by ballot initiative, went to the polls, and by large margins voted
into effect what they call an extreme risk protection order. It is modeled on the
California policy. Washington State now also has this provision in law.
By my count, there have been bills introduced in about a dozen states throughout
the country. Texas has not introduced a bill, but they were interested in hearing
about it. This is one of these strategies that is very consistent with what Cathy wassaying, in that with this type of policy that outreach to non-traditional partners
to gun violence prevention is fully within the realm of possibility on some of thedirections that gun violence prevention is heading these days. When we think about
gun violence restraining orders, from my perspective, this has potential. We will see
what the results, the rollout, and evaluations say. I think there is real potential forthis kind of intervention to put a new tool into the hands of family members who
are oftentimes at their wit’s end when it comes to dealing with a family member who
is in crisis and who is suicidal. While we do not have good science on how to best
identify who is going to commit violence, I would argue that putting our resources
into family members who have that context that Baruch talked about, have an
understanding of the complexity of the situation, is a good place to look to start toassess risk earlier on than what the criminal justice system can offer.
Obviously, more research needs to be done, but, from my perspective, this is aninteresting and promising strategy that I would encourage you to think about for
military applications and to watch and engage with as it continues to roll out indifferent parts of the country.
The last intervention that I will pose is to look at the actual design of guns. When
we think about gun violence, we have talked a lot about access. We have talked
about ways to intervene, to remove guns from people who are in high-risk situations
temporarily. Another approach being talked about is safer gun design. Personalized
guns, smart guns are also words that are used to describe this. Currently, there arethree main types of technologies that are being used to personalize guns, and by
personalize, I mean these are guns that would only be operable by an authorized user.
The technologies being explored for this are RFID, or radio-frequency identification, biometrics, and dynamic grip recognition. How you hold the gun could be a
way to personalize. This type of technology has come a long way in recent years.
In fact, we have this. It is a picture of a German company that has designed what
I would call meets the criteria of a personalized gun, in that it is only operable by
the recognized or the authorized user. Shown here is a gun that uses RFID technology. You see this green light that indicates that the gun is working. The reason it isworking is because it is within distance of this watch, which is also the transmitterfor the technology. It has detected the device and, therefore, the gun will operate. If
the gun was not within the specified distance of the watch, that light would be red
and it would not fire. This is just one example of a gun that is available that has
been manufactured that provides another option for thinking about how we canmake homes safer when it comes to firearm risks.
When I think about personalized guns, there are implications for suicide, certainly teen suicide and, with regard to personalized guns, certainly implications for61

When I think
about personalized
guns, there are
implications for
suicide, certainly
teen suicide.

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Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

We need to beunintentional gun injury. We also think about the estimated 500,000 guns that arestolen from homes every year and what that means for the crime gun market if guns
were personalized.
This is an opportunity. It is a different kind of intervention than what we havebeen talking about. The question is these guns are being designed; they are going tocome onto market. How can we most effectively harness this technology with aneye towards safety?
The military is a very interesting setting to think about these guns, particularly
given the use of guns in normal operations, and your knowledge of guns. I think
there is potential for the military to inform some of the questions that we have about
how best to integrate this new technology into the modern world.
Lastly, I think that the panel has woven together very nicely many of the challenges and opportunities that we face with regard to firearm safety.
Thinking about military culture, to use Kenneth’s word, “military biopolitics,” I
think is a fascinating part of the discussion that we have begun to have here. We need
to be better about our communication strategies, how we roll out interventions, andhow we talk about guns. With regard to that third strategy and safer guns, smarterguns, personalized guns, what are the performance requirements for the U.S. military
with regard to this type of technology?
I also want to emphasize the importance of paying attention to the implementation and enforcement of the prohibitions and policies that we have put into place,because we have seen so many instances where good ideas are put forward, but thefollow-through to assure that they are implemented and enforced oftentimes does
not happen.

better about ourcommunication
strategies, how
we roll out
interventions,and how we talkabout guns.

Forum Discussion

63

4

Forum Discussion
DR. WEST: Thanks very much to our presenters. Let’s begin our discussion
session which will close out today’s forum.
DR. NASH: I had not heard of gun violence restraining orders, but I think thatis a fascinating idea. I have two questions. The first is, what have the courts in California, or wherever else they are doing this been using as evidence of credible risk?
I think that is one of the key pieces. How do they decide it? The second question
is about domestic violence restraining orders. Has anyone looked at consequences
for a marriage or family when one spouse gets a restraining order to have the otherspouse’s guns removed from the home? I wonder, because the people making thisdecision have to consider potential harm. I can imagine some servicemembers who
have guns and to have their spouse go to a CO and have the guns removed, theservicemember is going to have a hard time forgiving that.
DR. FRATTAROLI: I will start with the first question with regard to the criteria
the courts have for issuing gun violence restraining orders in California. Washington’s
law is modeled more or less on California’s law, so it applies here as well. The legislators who drafted the bill included a number of criteria for the judges to consider,such as prior acts or threats of violence, including self-harm and harm to animals,
particularly pets. There were a number of criteria that were built into the law thatprovide the judges with some direction as to what they could use when deciding thesecases. That having been said, I think there is a tremendous opportunity here to reallylook at these data, look at what judges are using, what passes muster for sufficient
criteria to merit a gun violence restraining order, and see what happens with thosecases. We are in new territory, and I think there is great potential to be delivered about
how we move forward, but California law does include some criteria.
With regard to the domestic violence restraining order issue, I was thinking of
two scenarios, and I don’t know how the cases or the population of couples involved
with restraining orders break out in terms of proportion that fall within each of thesecategories. For many relationships, this is the beginning of the end or the relationshipis over. That is precisely why, from the perspective of domestic violence researchersand violence researchers, this kind of intervention is so important. That final breakin the relationship is a period of extreme risk for often the woman in the relationship. The importance of removing lethal firearm or lethal means from that equationis thought to be important.
There are also lots of instances where a domestic violence restraining order does

There is atremendous
opportunity here to
really look at these
data, look at whatjudges are using,what passes muster
for sufficient criteria
to merit a gun
violence restraining
order, and see what
happens with thosecases.

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Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

Thinking about

not result in the end of the relationship. I don’t want to say “bimodal” because I
don’t have the evidence, but that is what you see a lot; it is the end or the start ofa process that never is realized because there is reconciliation and the couple getsback together. So, there are times in which the end isn’t the end.
DR. WEST: I want to bounce this one back to Bill, because there was something
we used to deal with in First Marine Division. When we had Marines placed underdomestic violence restraining orders, the Lautenberg Rule came into effect and theMarine was not allowed to be issued their service weapon. I don’t know if that isstill the case for our active-duty personnel. It essentially puts them in a limited-duty
status because they can’t use their service weapons.
DR. NASH: I do not have the answer to whether that is still in effect. That isdevastating to the career of someone like a Marine who really can’t function without
access to a weapon. So, we just have to factor that in.
DR. FRATTAROLI: Lautenberg, just to clarify, goes into effect with misdemeanor convictions for domestic violence, not domestic violence restraining orders.
So, it is a criminal process that triggers Lautenberg.
DR. NASH: If we had gun violence restraining orders that did not require aconviction or a misdemeanor, it could have the same consequences without there
being misconduct potentially.
DR. FRATTAROLI: Correct, it is a civil process, but thinking about those consequences for people who use guns for their employment is very important.
DR. WEBSTER: How are they going to assess what situations warrant gun
removal or not? Right now, the court has to do that anyway with the domestic
violence restraining order. The court has to do that when they have to determine
whether someone represents a threat to themselves or others in a variety of othersort of circumstances. I don’t see this as so dramatically different process-wise, andI think that is one of the appealing aspects of it. This isn’t so foreign a process. We
are just extending this.
We have had this conversation, and your question at least was raised in thecontext of domestic violence. As Shannon said, domestic violence in some way isalready covered by this, a lot of the scenarios that are being expanded for this in
regards to training go beyond husband-and-wife or boyfriend-and-girlfriend. In thesesituations, this is someone who represents a threat to themselves because you thinkthey are going to harm themselves. What got a lot of people on the bandwagon issome of the mass shooting scenarios where you see someone doing a set of behaviors,amassing ammunition and doing things that indicate something is really wrong, andwe have got to hit the brake somewhere. I don’t know, am I right that procedurally
it is not all that different?
DR. FRATTAROLI: Right. Oftentimes we talk about the GVRO building on thedomestic violence restraining order, which is in place in all 50 states and has been for
decades. I think, too, that a lot of the enthusiasm around this has been in response
to mass shootings. In fact, California is quite open with the fact that their legislation
moved because the University of California Santa Barbara shooting happened, andit was passed and signed by the Governor shortly thereafter.
DR. GOLD: The little bit of data that has come out from Connecticut, where
they also have a similar kind of process, and Indiana, although there is a problem
with the data, which seem to show that it does have some impact primarily on
suicide, right?
DR. FRATTAROLI: Yes. Jeff Swanson has been looking at Connecticut where

those consequences
for people who
use guns for theiremployment isvery important.

Forum Discussion

their order is limited to law enforcement. Civilians cannot approach the court; law
enforcement has to do it. What he has documented is that family members are goingto law enforcement and that in the overwhelming majority of cases it is in response
to suicide risk.
It appears this is sort of a gateway to treatment as well. This is something thatis triggering family and the respondent to realize that this is really serious. The
authorities are involved. We need to intervene with real help.
DR. GOLD: The bonus of it being a civil process is that it takes some of theadversarial nature out that is inherent in the criminal processes. Aside from the 18
states, in the other states you have to have a permanent restraining order, domestic
violence restraining order, to have a gun removed; whereas, with the temporary
order, you can get the ex parte temporary order and there is about a week at least
to the hearing for the permanent order. That week is going to be pretty high-stressfor everybody involved. It makes sense to make sure that guns are not available toanyone during that time.
DR. WEST: One of the things that I still have not seen clarified, and I think wemay be working it out, is looking at these new mechanisms, such as a gun violence
restraining order. On the clinical side of things, I don’t know if we have it worked
out how we are going to live in that world. In other words, if I, as a psychiatrist,
have a patient in my office who I know has a large collection of firearms or evenjust has a few firearms and, then, goes on to talk about all of the risks, all of theacute risks that say that this is a very high-risk individual to walk out the door,
not high enough to involuntarily hospitalize yet, somewhere in this gray area. Do
I call the police? Do I seek a gun violence restraining order for this individual?
DR. FRATTAROLI: You, as a clinician, are not eligible under either California
or Washington law. Those I have heard from most in the clinical community are
emergency room physicians with an interest in having petition authority, not thepsychiatric community.
DR. WYNN: In California we have a lot of active duty servicemembers. Is there acarve-out in any regard to the non-personal firearms? I am just thinking from a logistical perspective, to echo Bill’s perspective. When it comes to gun violence restraining
orders for domestic concerns, whether or not they get issued their weapon, go to
the range, and then, return that to an armorer are all under the supervision of acommander on post away from the capacity to interact with the potential threatened
victim, which is separate from we are going to take all your personal firearms. I am
just wondering, have we had any cases of GVROs involving servicemembers, since
there are tens of thousands of servicemembers in California and Washington? Wehave huge posts in all those places.
DR. FRATTAROLI: Yes. The California implementation has been, I would say,deliberately slow. There is a public education campaign that just started last month.
The last time I looked, there were on the order of 50 to 60 GVROs that had been
issued. I don’t know of a carve-out, but I think that is precisely why we need to be
having this kind of conversation with folks like you, because these laws are coming
and the military is a good partner to have at the table when these things are being
figured out.
The 50 or 60 that have happened in California, to my knowledge, have not
involved active-duty military. I have seen case write-ups of a dozen or so of them,and none of them were military people. I don’t know if, in fact, some of the exact
issues are playing out now.

65

It appears this issort of a gateway totreatment as well.
This is something thatis triggering family
and the respondent
to realize that this isreally serious.

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Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

The beauty of that

DR. URSANO: There is an empirical question as to whether or not it impacts on
the gun-related suicides. Dan and Andrew in a few years would be able to check thatout by state, as to whether or not the states which have implemented the program
actually show a change in fatality related to gun suicide.
DR. WEBSTER: I wanted to follow this thread and bounce it back in your direction. You get an active-duty military person, and something has happened where
someone said this looks really dicey; we’ve got to go to court. The court issues a
gun violence restraining order for an active-duty person. What is the military to
do? I mean, that was one of the reasons I think maybe why we even convened here.
DR. WEST: I would find it hard to imagine that a commander who, aware of a
gun violence restraining order, would allow that servicemember to be issued their
weapon without sending them into the military health system for evaluation of fitness for duty. Many of those things would be put in place. The challenge is manythings that happen in the community don’t make it back into the military, and themember will keep it secret.
DR. WEBSTER: Particularly related to family violence.
DR. WYNN: That is spurring an additional problem. Under the law, if theservicemember keeps it quiet, goes on post, does their job, gets their firearm fromthe armorer, goes to the range, fires a weapon, puts it away, goes home, they haveviolated California law because they have possession of a weapon for a period oftime, potentially. The court would have to adjudicate that. The lack of awarenessand communication between the military and how we handle on post brings up
questions about vetting or other issues. The discussion of how to manage that is vital.
DR. GOLD: I don’t know if there are any civilian law enforcement people here.
I do a lot of fitness-for-duty evaluations for law enforcement officers. And the issue
is always around whether they are safe to have their gun, and a lot of times thosefitness-for-duty evaluations are triggered by domestic incidents. At least in the civilian
community, when there is a domestic incident and the local police are called, andthey find out that the person involved is a police officer or a law enforcement officer,
contact is made with their superiors, that this person has gotten into trouble, andwhoever is in charge of confiscating their gun needs to come and confiscate theirgun. People are routinely sent out from various federal law enforcement agencies
to go to that person’s home and collect their weapon. And they are sent for fitnessfor-duty evaluation. The whole thing was triggered by somebody calling 911 andsaying this is a problem.
I don’t know if there is a similar kind of mechanism that exists or could be
implemented, but it seems to me that that could be model, sort of looking at how
law enforcement does it, because it happens automatically in the law enforcement
community, and there is no question about it being kept a secret from the employer
once the local police have been contacted and it is a law enforcement officer involved.
DR. NASH: Since I expressed some hesitancy or reservations about the GVRO,
I want to say also that the beauty of that initiative is that it empowers families.
As you well stated, the healthcare systems and the judicial systems are powerlessunless it is obviously extreme, in-your-face either psychotic or suicidal, homicidal,
or committed a crime. So, I think this can be translated to the military. At least in
the Marine Corps, I know commanders are all very serious and held accountable forbeing aware of the stressors and challenges of their Marines and family members,
and of providing resources and doing whatever it takes to get people through crises.
I don’t think it would be hard for them to do this. Maybe initially recommending

initiative is that it
empowers families.

Forum Discussion

as a voluntary measure having a sit-down with a Marine and say, “Hey, your spousecalled me up and she’s got some concerns.”
DR. WEST: That actually is current policy right now. There is a directive-type
memorandum from 2014 from the Assistant Secretary of Defense. It outlines thecommander’s ability to meet with servicemembers at risk. They may request thatthe servicemember voluntarily surrender their personal weapons to the custody ofthe command until such time as they are deemed safe again. It is a voluntary thing,
but really that opened a huge door because, until that time, it was considered taboo
entirely for a commander to inquire of a servicemember whether they even had
weapons.
DR. URSANO: Do we have education programs for spouses of military members
to be aware about things?
DR. WEST: No.
DR. URSANO: I wouldn’t think so. That might be a possible piece of the program to put together.
DR. WEST: Many of the uniformed people are aware of this concept of a military
protective order, which is a somewhat vaguer concept, but also a very circumscribed
concept on when commanders can issue an order to one of their servicemembers to
say you must do this or you must not do this. It is typically used in domestic violence
where an individual has an incident, especially when they live on base, the incident
occurs on base or the spouse comes in to the commander, expresses concern to thecommand of not feeling safe. The commander issues a military protective orderthat says you don’t get within 50 feet of your spouse, and then, it is handed over to
Family Advocacy to work on the problem.
DR. QUINLAN: One thing I would see, unfortunately, can break up all these
efforts is that we really don’t have any national way of knowing who owns gunsin any given state, right? The State of Virginia knows about one gun purchasedin the State of Virginia. They don’t know about any other weapons purchased inother states because they don’t share that information across borders in any kindof national registry.
I think they are good efforts, but there is more to that umbrella that probably
needs to happen for those things to be effective. Because maybe I just put myself inthe position the Virginia State Police coming to my house and saying, “Turn overyour weapon.” Yes, sure you can have this weapon, right? That doesn’t mean thatis the only thing I have in my house, unfortunately.
SPEAKER: I wanted to steer back to Cathy’s presentation for just a moment.
First of all, let me compliment you on just how you put a lot of complicated data
together in a very methodical and persuasive way. Do you have any outcome data
yet to suggest that the message resonates with friends looking after each other, yourfriends who you trust, your family member who you trust holding them for a while,and not the state or law enforcement taking guns away? It is intuitively appealing.
Do we have any idea whether it is actually effective?
MS. BARBER: We don’t have the outcome data in terms of suicide outcomes.
Certainly in places like New Hampshire, we are not at a point of message saturation
where we would really expect to have a measurable impact on suicide overall. It issuch a weak intervention to have posters up in a gun shop. It would be when thatmessage starts infiltrating into Hollywood scripts and all sorts of ways.
SPEAKER: Yes, giving a signal of acceptability may help open the issue for families to think about this and accessibility of means as both a risk factor for completed

67

I think they are goodefforts, but there ismore to that umbrellathat probably needs
to happen for those
things to be effective.

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Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

The State Gunsuicide and a risk factor for interpersonal violence, that people start thinking, “Hey,the weapon is in the house. Is there a way that I can approach this short of the statecoming into the home?”
MS. BARBER: The survey we did with the firearm instructors was baseline
data. After they had been teaching the curriculum for a while, I suggested to themhaving this as a voluntary component of the concealed carry curriculum. The StateGun Rights group said, “Voluntarily? Looking at the data you have shown, we thinkit should be mandatory.” The public health person is saying voluntarily. The gun
rights people are saying mandatory. The instructors have just taken it up in the last
few months. In another several months, we will re-interview to see if attitudes havechanged about efficacy of this kind of thing.
DR. SALVATORE: Yes, to follow up on that point, I happened to attend theInternational Association of Chiefs of Police Conference this past September. The
New York Police Department Peer Support Program did a presentation, which I
don’t think has been published yet, on the decline of suicides since the inception of
their Peer Support Program. This is comprised of their active folks and retired peer
supporters as well. So, they looked at it to begin the internal study that is not yet
published. But, again, to the point of utilizing peers as the gatekeepers for interventions, it seems at least in local law enforcement to be gaining a lot of traction.
DR. CORNETTE: I know in reference to your point, DSPO is very heavily
invested right now in the gun shop work. I know they are working together withPaul Posner in training gun shop owners in screening and being cognizant of warning
signs. As part of that, they are planning a fairly rigorous evaluation. So, this is verymuch in the early stages, but I think that will be forthcoming.
MS. BARBER: From the surveys that we have done with gun shop owners, I
would say most of them would not like to be directed to screening for suicide risk.
They are not, of course, using things like the Columbia Suicide Rating Scale. Thatis getting way further into personal stuff than they would be interested in.
They are asking questions for selling guns, like “What do you want to use thegun for?” If they are seeing that something is up, when we asked, “What would
you do in that situation?” not that many replied, “I’d ask about suicide.” Theysaid, “I’d say the background check system was down for a while.” That is a goodintervention; the delay is great. But, if we go to them and the message gets a little
complicated and they think that we are expecting them to read people’s minds, theywant nothing to do with it. If they are expecting that they are just going to use thekind of radar that they have for straw purchases, and then deflect and put a person
off and say, “You don’t seem to have much experience with guns. Why don’t you go
get training and then come back?” Those sorts of ways of dealing with a situation
seem more acceptable.
DR. CORNETTE: I am not sure what the plan is in terms of what they are
expecting gun providers to say. I think it might be more being cognizant of warning
signs and engaging in behaviors like delaying sale. Like the responsible bartender
whose job it is to sell you liquor, making you stop if it looks like you have had too
much or you look distressed. I think it may be more at that level.
DR. WEST: I have heard this perspective come up several times now, that there
is discomfort in making laypeople feel responsible for decision-making as to whether
somebody is suicidal or not. I don’t know that we should be putting that power into
anybody’s hands or that responsibility on any individual. We should be empowering

Rights group said,“Voluntarily?
Looking at the data
you have shown,
we think [thecurriculum] should
be mandatory.”Forum Discussion

them to identify people that they are concerned about and, then, let somebody else
figure it out.
DR. MACLEISH: Just an observation on the deeper problem that suggestion
points to. I feel like other folks have articulated, too. Dr. Cornette, your observation
before or what you were saying, Bob, about you can identify warning signs and in 1
in 4,000 cases you will be right. Coming from sociological/anthropological perspective, how suicide and suicide risk are problematized in the first place creates thisweird disjuncture between an aggregate population that is statistically constructed as
possessing an identifiable suicide rate and any one individual who might or might not
do this thing. That disjuncture is really baked into how we, across a range of social
sciences, try to apprehend what suicide is. It raises these other questions about where
it is appropriate to try to identify risk or intervene. It is so easy for it to slip into
discussion of either it is matter of an individual interaction between one particularresponsible party and one specific potentially suicidal person or it is a matter ofthese highly-disembodied macro-level factors. If we think about risk as somethingthat is called into existence by all the efforts that we make to try to police it in thefirst place, but also exists at all these different disjunctures and potentially involves
all these different folks for whom the stuff that is at stake looks different, then what
are you comfortable asking someone about? What is actually within your power oryour ability to do? What sort of authority do you have to judge or evaluate what isgoing on and act if you can judge?
DR. URSANO: Just to echo a piece of that, we have lots of good data to saywhich question could we give a person to ask. So, what can a commander ask? Acommander can’t possibly answer the question, “Is this person going to commit
suicide?” They may answer, “Is this person in a group of people at risk?” Whatcan primary care answer? Primary care frequently can answer, “Does this person
have suicide ideation?” Then, you get to tertiary care in the mental health setting,
and within tertiary care in the mental health setting, you are being asked, amongpeople with suicide ideation, who is likely to attempt suicide? Then, among people
with suicide attempt, who is likely to complete suicide? The problematic issue isthat predictors of each one of those is different. So, what predicts suicide ideation
is depression. Depression does not predict committing suicide among people withsuicide ideation. It is not of use at all.
DR. WEST: The different risk groups, then, suggest different types of interventions. That may be one of the directions this needs to go. It is not about taking
guns away from people who are suicidal, but it is about identifying people who aperson observing behavior could say, “This looks like a risky gun-holder or a risky
gun-possessor. And I say this because I saw this.” Anybody can do that. It doesn’t
require an advanced degree.
DR. GOLD: Just to reinforce that, I know this is at the macro level, but suicide
is the 10th leading cause of death in the United States. It is the second leading causeof death for teenagers. I was listening as I was stuck on the Beltway to somebody
doing a reporting article about how 70 people a year die with space heater fires.
You get these stories about very statistically unlikely kinds of events, but you don’t
really hear a lot about suicide as a big public health problem in the United States. I
think on the lay level we are talking about raising a certain amount of awareness,making it okay to talk about suicide, to ask about suicide. You don’t have to know.
You don’t have to be a clinician. If someone is having a problem, you don’t have tobe able to necessarily diagnose anything to know that someone is having a problem.

69

The different
risk groups,
then, suggest
different types ofinterventions. Thatmay be one ofthe directions thisneeds to go.

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Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

Suicide is the 10th

DR. URSANO: Going back to your CPR model, there are more suicide attempts
in the United States every year than there are first heart attacks.
DR. GOLD: Yes. To really start at that macro level I think is useful, not somuch in any individual case, but in terms of destigmatizing it and making it okay
for people to ask, the same way the model of the bartender cutting someone off ora friend asking about car keys. The more of that we do, the easier it is for the otherpeople to be able to do the kinds of interventions that we are trained to do.
DR. WEST: Perhaps those types of things are successful because they are basedon observable behaviors. When you see somebody falling over at the bar looking fortheir car keys, I think nowadays 99 percent of people are going to walk up and say,“No, no, no, no, let me help you.” They are also going to do something like redirect
them maybe, not confront them head-on. Many would confront them head-on. I
look at how we have changed our approach to sexual assault in the military. It is
not a success story yet, but I think we are all finding that one of the big risk factors
is intoxicated individuals. So, how do we teach our servicemembers about sexualassault? We say, “When you see these situations developing, this is where a bystander
should step in and move the conversation in another direction. Don’t let Sailor X
walk out of the party with Sailor Y when you know one of them has no idea what
they are doing.”
DR. CORNETTE: One of the things I find so exciting about the policy is that itembraces this public health model, which the National Strategy and other documents
have really been embracing in recent years. We have to do something more than train
clinicians well. I also think what is very exciting about the recovering families, isthat one of the greatest limitations we have as clinicians is our limited contact with
our patients. Oftentimes at those periods of heightened risk they are not with us,
but their families and their friends are. I just think it is a really exciting intervention.
I see this in the context of gatekeeper training. For a long time, analogous to
CPR, there has been QPR, so the Question, Persuade, Refer training. So, the question
for training, which is for the public, and the idea is that you are training the masses
to at least identify with a few questions, persuade to seek treatment, and refer to aprofessional. The same with Applied Suicide Intervention Skills Training (ASIST),
which the Army has embraced, and there is now actually some outcome data on
ASIST. I see the right kind of questions, not clinical questions, but the right kinds ofquestions, as being very appropriate for the public.
I also have a question. This might be very naive, but I am not very knowledgeable about smart technology. Is there anything out there, any discussion about any
technology that would identify or the safety would become engaged if you were toturn the firearm at yourself?
DR. FRATTAROLI: Yes, the same company that designed and manufactures
the gun that I showed was thinking along those lines, and not just for self, but also
for range applications. Last time I talked to them it wasn’t ready yet. I’m not sure of
the technology, but they were talking about it. But I will just say, one thing that we
often talk about when we talk about personalized guns, and I don’t know if folksremember, I had an iPhone on the screen which was to help me to remember. WhenI first heard about personalized guns 25 years ago, I was here in Washington, D.C.
If I wanted to talk to my friends from the West Coast, I called them or wrote lettersand put stamps on them. I was here as a student, and I was writing papers and saving
them on big floppy disks. When I got into a car, the cab drivers didn’t have GPS. It
is quite striking to me that there is a lot of doubt as to what technology can do toleading causeof death in the
United States. It is
the second leading
cause of death forteenagers.

Forum Discussion

make guns safer. Our worlds have changed dramatically because of technology. Can
you prevent a gun from turning on the owner? Folks are saying you can. What else
can we do to make guns less lethal in the ways that we can all agree we don’t wantthem to be used? I think there are tremendous opportunities there.
DR. WEBSTER: I would just like to make a couple of points on the idea of thedesign feature that would, in essence, not allow someone to shoot themselves. I haveactually been doing some risk simulation models. That is the most important thing.
Look at what is by far the most common way someone dies when someone bringsa gun in the home. Even when you stack suicides with homicides, most of thosehomicides are outside the home. If you say, “What bad thing might happen in thishome?” it is not even close. It is adult suicide. I think there is worlds of difference
between what that might mean safety-wise unless you can design the gun so it doesn’tshoot you. Because if it is an option, rather than mandated, we will have more gunownership. How much we don’t really know.
There are a bunch of people who already have guns. We know that, right?
Now these safer products are available. How many of those current gun owners
say, “Oh, I am going to melt my gun down and I’ll just have the safe kind.”? Probably not too many. So, most of the folks you are protecting are the people who arebecoming new gun owners. They are bringing a safer thing into their home. What
we don’t really have some feel for is how many additional people who wouldn’t
have brought the gun in the home to begin with because they are concerned about
what their kids would do and about suicide of their teens and other suicide. So, I
actually think that is very important. Having a safety standard that would create acompletely different marketplace. You would constrain consumption. Fewer guns
would be sold because the price would go up; fewer options available. So there is a
lot of unknown fears. There is potential for certain kind of things to be prevented,
but the design feature of it won’t shoot the person holding the gun, I think that is
it. That is the most important thing.
DR. URSANO: Or your spouse.
DR. NASH: I want to come back to something you said earlier this morning,Curt, that I think is a huge unanswered question. We are making all these speculativeand non-speculative programs, interventions, based on an inadequate understandingof the relationship gun owners have to their guns. There was a psychoanalyst somedecades ago who wrote a paper called, “The Non-Human Object World”. It was
kind of a cool idea and sort of self-evident. People have relationships to objects, likecars, right? And gun owners have relationships with their guns. It is not the gun thatshoots people; it is the relationship between the two. I think that is an importantarea where we should learn more before we make decisions on behalf of gun owners.
Are there different types of relationships to guns, not only what they consciously
intend, but for safety, for power, for sport?
DR. MACLEISH: I was wondering the same thing and was going to ask Cathyand Shannon. The kinds of interventions that you all are describing, are there waysthat you could characterize some of the interactions you have been having or the
research that you are aware of to help us to get a sense of what is different about theconversations that you are having that are sort of oriented towards these ostensibly
kind of common-sense safety practices versus the kind of discourse that we hear in
public around gun safety and gun control. So, debates over whether you can freely
print an AR15 receiver or whether high-capacity magazines should be restricted orwhat constitutes an assault weapon, or whatever else. Like what is going on that71

What else can we
do to make guns
less lethal in theways that we can
all agree we don’t
want them to be
used? I think there
are tremendous
opportunities there.

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Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

I have had manymeans that those are the kinds of arguments that we are having in public, and at thismore granular level these other kinds of conversations that you all are describing
are apparently also there for the having, but don’t conform to what we are used tohearing?
MS. BARBER: My experience so far has been that these more collaborative kindof conversations are really welcomed on both sides, both people who are inclined
and disinclined towards guns. It is when you start with a legislative proposal andthen take sides over that legislative proposal, that things get more rancorous. But
when you start with a particular problem like how do we address this particularissue and how do we work together, that is where people begin trusting one anotheras they problem-solve together. That is what I have learned from working with different gun rights groups.
DR. FRATTAROLI: I have had many conversations with gun owners who havecome to different events. In my experience it is not hard to find areas of agreement if
you sit down and talk with people. I agree that the legislation is oftentimes a point
where people get sort of prickly, but it is not at all hard to find things that we canagree on. The Venn diagrams overlap quite a lot in my experience.
With regard to the gun violence restraining order and the larger work that The
Consortium for Risk-Based Firearm Policy has been doing, the feedback that I havebeen getting from gun owners is that they like the direction of these policy proposals
because they aren’t about guns; they are about dangerous behaviors. That is where
there is a lot of intersection between those two Venn diagrams. Yes, as a gun owner,
I can agree with you that not everybody should own a gun and there are people whohave done things that lead me to very decisively conclude that that person shouldn’t
have a gun. They have committed a felony. You know, they have been determined
to be violent against their family.
When you talk about behaviors and dangerousness of individuals that is anarea, even in the policy realm, where there is a fair amount of agreement. I knew
something was different. Our first reveal of the gun violence restraining order recommendation and a number of others was on the Hill. We had a press conference andwe were down in the cafeteria below the Capitol building. A representative fromGun Owners of America came up to one of our interns and said, “You know, I wasin the back of the room, and I agree with everything you guys have said.” I thought
this was not expected, and over time the response is essentially that, when you talkto individuals.
DR. WEST: I like the idea of the focus on behaviors. One of the things thatyou will see pushback from professional organizations like my own is a tendency
to equate diagnoses or illnesses with greater risk, which is not necessarily the case.
There are a lot more people with illness than there are people with risk that have theillness. Although there certainly have been prohibitions for decades now on those
who have been involuntarily committed to mental health treatment, that is a verysmall group. There are many of us that get nervous when we think about the ideathat if somebody has depression, they should not be able to buy a firearm.
DR. GOLD: I think that one of the things, as we are moving toward this more
behavioral-oriented approach for policymaking or suggesting, is that it is really
important to not contribute to the stigma about mental illness, which is frequently
where this discussion goes. When it goes there, the constructive part of the discussion
is essentially over because people with mental illness make up such a tiny percent-conversations
with gun owners
who have come todifferent events. In
my experience it
is not hard to findareas of agreement
if you sit down andtalk with people.

Forum Discussion

age of individuals, despite the public belief, in spite what happened a few days ago
in Fort Lauderdale. Those are the outliers, although they get the media attention.
We have talked in the Consortium about the evidence base for people who areat higher risk. That evidence base really has only, when you talk about overlaps with
Venn diagrams, there is only a tiny, tiny overlap with people with mental illness. It
is first episode psychosis untreated type, those very specific people. Those are people
who, by the way, typically come to a lot of notice from the people around them, bothfamily, law enforcement, employers, schools. It is not a surprise to anybody when
they end up doing something because people have been watching for a long time.
Those are folks who the GVRO approach would really empower.
Generally speaking, when we talk about behavior as we go forward, it is important not to say behavior equals mental illness or mental illness equals behavior. You
have to look at what the evidence shows about who is actually at risk and where
mental illness comes in. Remember, illness comes more as suicide, obviously.
DR. WEST: We have heard a lot about what we know, what we try, and what we
think works, what we understand about the process that is going on. What are thequestions for which we don’t have the answer? As a result of what we have talked
about here today, what we thought about here today, what is a question that you
want answered? I want to focus that on our military and our veteran populations.
They are different, but they have all had the common experience of serving in the
military. Shouldn’t we be taking what we know and expanding it, so that we canmake better informed interventions?
DR. FISCHHOFF: This has been really wonderful conversation. One thing that
may be useful as a kind of organizing methodology, but there are a lot of moving
parts to getting this going in, there is this concept that has come to be called risk
communication. This grew up as a kind of antidote to what is the called the Deficit
Model of Science Communication, assuming we just need to pour the information
into people. It was often they did a poor job of pouring information because you
didn’t listen to them, what were their issues and how do they understand, and how
do you communicate. What were the critical facts and how do you do it? Then, youblame the audience, so it is kind of a vicious circle. The methodology is something
like what was presented. You need to do your analysis. What are the problems ofpeople who are gun shop owners and family members and the commanders? What
are the problems that they are solving? What is within their capability? And then,what are the kind of solutions that we know based on the literature that can help?
There is a literature from environmental psychology on collaborative design
processes. It sounds like that is what you are doing. I don’t know whether you comefrom that literature or you just do it instinctively, but we know something about that.
In terms of coming up with words that people can say in social psychology,
maybe it is health psychology, there is an area called social skills training where
there is a practice called refusal skills, where they work with kids and say, “Theyare passing around the joint and you don’t want to do it. How do you avoid doing
that?” There are some messages that work for a lot of kids, and sometimes you havea group of kids with a skilled moderator that says, “Well, what will work aroundhere?” And you hear words; you find one that works for you. Maybe there aresome that work generally, and you have had the conversation. Even if what you say
doesn’t sound quite right, I know we are in this together and I am going to respect
your way to do that.
You need the people who are sensitive to the politics who can figure out who

73

Generally speaking,when we talk about
behavior as we go
forward, it is important
not to say behavior
equals mental illness
or mental illness equals
behavior.

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Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

It turned out theneeds to be at this conversation. How do we need to routine this before we have aconversation with somebody on the other side? I think you have the pieces within
the community, and just maybe more systematic organization. About 15 years ago,
we had some money to reduce sexually-transmitted infections among teenagers. We
talked to a lot of girls, because girls were the target, about the decisions that they
made that could expose them to STIs. It turned out the critical things were nondecisions. That is to say, you have gone to a party. The party has a particular script,
and you have committed yourself to that script. So, we developed an intervention.
It is one of the handful of things that ever made any difference in STIs, which was,
“Choose your own adventure.” We did a nice job of giving and completing themental models of users in an interactive DVD, explaining the fact that many STIs are
asymptomatic. “You want to believe he is being honest with you? Maybe he is, but
he couldn’t tell.” Something we know from basic literature, the number needed totreat is 4,000. That is not intuitive. You could not assemble that yourself. We knowthat many domains of people cannot tell how very small risks mount up throughrepeated exposure. You really have to run the numbers for people in order to do that.
The bulk of it was a “Choose your own adventure.” We dramatized going to a party,
and there is either a steady or a guy who gets up on you, and he keeps persisting,as men sometimes do. Then, it blocks it and says, “Mark wants you to go upstairs.
What would you do now?”
It makes the point that there are decision points. There are four decision points
in each of these stories. You have 30 seconds to come up with something that works
for you, and the actress will dramatize it. It has elements that work. We are in asense saying have the sex you want, which is probably not coerced sex. We had areduction in chlamydia rates in a fairly high-risk population, and if you believe theself-reports, they had less sex. I believe this is the only program that has ever reduced
teen sex. So, I am saying there are a lot of pieces from different literatures. It seems
like the process that pulls together all of your expertise, and maybe adds a coupleof ears of the anthropologists, and so on, might be useful.
DR. WORKMAN: I think today has been very informative for me, and I havegrown to appreciate the complexity of the problem, the situation. As these different presenters were speaking, one of the questions that remained unanswered forme is the impact on the spouse, the military spouse, or the family, when they docome forward to protect and to keep safe the servicemember, because it can be very
challenging for them. Having worked as a clinician in the past with active-duty
servicemembers, I recall a spouse who came into my office for her appointment,
and she said, “I’m very concerned. I believe my spouse is at home and he’s going totake his life.” This is what I am greeted with. As a clinician, I am thinking through,what I should do. Is he my patient? I encourage her to make the call to 911. She
is very upset, can’t even gather her thoughts. I make the call to him, and to 911,
to tell him, “911 is coming to your door and here is why.” The police brought theservicemember to me and I had to then get the command. Seeing the family after
that, I was dealing with the impact of this intervention on the part of the concerned
spouse. It was complex and it stirred the family system up.
DR. WEST: This goes back to Ken’s point about the average military member not
wanting to be recognized for their problem. They want to solve it within the family
unit or within the very, very small group. The fire team will know that so-and-so isa little bit slow, and they will drag them along as long they can, until it is clear thatthey are broken. That becomes a challenge to intervening, too.

critical things were
non-decisions.

Forum Discussion

DR. MACLEISH: Those are issues that have political and structural implications outside of the military as well that are unique and distinctive to the American
context. In other countries that have comparable military that have participatedin the same conflicts, there is nationalized health care. If you get a bad conduct
discharge, you can still go and get healthcare, you can still see a psychiatrist. There
are nationalized or highly-subsidized education systems, so you don’t have to worry
about losing education benefits. There is a more comprehensive and substantial welfare state and social safety net, so that if you are a military dependent or receiving
caretaker benefits from VA, and dependent on those things for your healthcare andyour income, that is a lot to put on the line to call the cops or speak to a clinician
or call up a social worker.
Those things are necessarily also at stake. Just as those kind of biopolitics operate
within the military, they also operate at a societal level as well in terms of what isreasonable and what people are going to either take a chance on or sort of feel thatthey are forced to live with.
DR. FLYNN: This has been very interesting for me for a lot of reasons, because it
seems like what we are really talking about here is community mental health, which
we have forgotten about. It is within a lot of our models. In that regard we havetalked about different parts of the community. We have talked about healthcare. We
have talked about clinical kinds of issues. We have talked about retail sales here andour gun shops on military bases at this point. We have talked about command issues.
We have not talked about other elements of the system, you know, like thechaplaincy or churches. We have not talked about schools in any role. There arestill Family Service Centers on bases. Years ago, there were and they would havea normal, natural kind of role in this. One of the questions I had is whether someof our participants have any thoughts about engaging those institutions and partsof the community on top of what we are talking about today? That is one of thethings that hasn’t been as clear as we need it to be. That is the overall conceptual
framework of dealing with this issue, dealing now with a proposed public health orcommunity mental health model that really incorporates all of our interests in this,and may be a very good model for bringing in elements of the community that wehaven’t talked about today.
DR. WEST: I want to give Dr. Ursano a few moments to close with some comments.
DR. URSANO: Thank you all for being here. Thank you all for sharing yourthoughts and your wisdom and your concerns. It is really difficult to get a setting inwhich you can quickly, as Curt and his team have done, create a community of trustin which we can talk in a way and which we can talk about things we worry about
as well as things we think we have solved. There is a lot to learn from the area ofsafety and risk that relates to the questions of suicide and other types of behaviors
for us to worry about. Hopefully, as we look over the transcripts and the thoughts,
we will be able to extract some principles that can help us not only on the suicide
front and the gun front, but others as well.
Have safe trips home, and thank you for coming.

75

That is the overall
conceptual
framework of
dealing with thisissue, dealing now
with a proposed
public health orcommunity mental
health model thatreally incorporates
all of our interests in
this, and may be avery good model forbringing in elementsof the communitythat we haven’t
talked about today.

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Family Safety and Military Servicemembers: Understanding Risk and Intervention Strategies

77

Readings
Anglemyer, A. (2015). Suicide and Violence Towards Others Among Those With High-Risk Behavior:
Firearm Access and the Inherent Risks.
Anglemyer, A., Horvath, T., & Rutherford, G. (2014). The accessibility of firearms and risk for suicide
and homicide victimization among household members: a systematic review and meta-analysis.
Ann Intern Med, 160(2), 101–110. doi: 10.7326/m13-1301
Anglemyer, A., Miller, M. L., Buttrey, S., & Whitaker, L. (2016). Suicide Rates and Methods in Active
Duty Military Personnel, 2005 to 2011: A Cohort Study. Ann Intern Med, 165(3), 167–174. doi:
10.7326/m15-2785
Barber, C., Frank, E., & Demicco, R. (2017). Reducing Suicides Through Partnerships Between HealthProfessionals and Gun Owner Groups-Beyond Docs vs Glocks. JAMA Intern Med, 177(1), 5-6.
doi: 10.1001/jamainternmed.2016.6712
Corr, W. P. (2014). Suicides and Suicide Attempts Among Active Component Members of the
U.S. Armed Forces, 2010–2012: Methods of Self-Harm Vary by Major Geographic Region of
Assignment. MSMR, 21(10).
Fischhoff, B. (2013). The sciences of science communication. Proc Natl Acad Sci U S A, 110 Suppl
3, 14033–14039. doi: 10.1073/pnas.1213273110
Fischhoff, B. (2015). The realities of risk-cost-benefit analysis. Science, 350(6260), aaa6516. doi:
10.1126/science.aaa6516
Fowler, K. A., Dahlberg, L. L., Haileyesus, T., & Annest, J. L. (2015). Firearm injuries in the UnitedStates. Prev Med, 79, 5–14. doi: 10.1016/j.ypmed.2015.06.002
Hepburn, L., Miller, M., Azrael, D., & Hemenway, D. (2007). The US gun stock: results from the2004 national firearms survey. Inj Prev, 13(1), 15-19. doi: 10.1136/ip.2006.013607
Leventhal, J. M., Gaither, J. R., & Sege, R. (2014). Hospitalizations due to firearm injuries in children
and adolescents. Pediatrics, 133(2), 219–225. doi: 10.1542/peds.2013-1809
MacLeish, K. T. (2012). Armor and anesthesia: exposure, feeling, and the soldier’s body. Med
Anthropol Q, 26(1), 49–68.
MacLeish, K. T. (2016). Imagining Military Suicide. Cost of War, War and Health.

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Mann, J. J., & Michel, C. A. (2016). Prevention of Firearm Suicide in the United States: What Works
and What Is Possible. Am J Psychiatry, 173(10), 969–979. doi: 10.1176/appi.ajp.2016.16010069
Martin-Storey, A., Prickett, K. C., & Crosnoe, R. (2015). Family process correlates of firearmownership and firearm storage among families with young children. Matern Child Health J, 19(1),17–24. doi: 10.1007/s10995-014-1490-3
McGee, K. S., Coyne-Beasley, T., & Johnson, R. M. (2003). Review of evaluations of educational
approaches to promote safe storage of firearms. Inj Prev, 9(2), 108–111.
Metzl, J. M., & MacLeish, K. T. (2015). Mental illness, mass shootings, and the politics of American
firearms. Am J Public Health, 105(2), 240–249. doi: 10.2105/ajph.2014.302242
Smith, P. N., Currier, J., & Drescher, K. (2015). Firearm ownership in veterans entering residential
PTSD treatment: Associations with suicide ideation, attempts, and combat exposure. Psychiatry
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Intimate Partner Violence. Epidemiol Rev, 38(1), 125–139. doi: 10.1093/epirev/mxv007

Center for the Study of Traumatic Stress
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Uniformed Services University of the Health Sciences
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Building B, Rm. 3068
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www.cstsonline.org