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

Executive Summary

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.

iPanelists
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.

Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University of the Health Sciences
4301 Jones Bridge Rd
Building B, Rm. 3068
Bethesda, MD 20814
www.cstsonline.org