S3E29 / Lock It Up / Ali Rowhani-Rahbar, Cassandra Crifasi, Jennifer Stuber, Tony Gomez

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Americans have the right to own guns. But what responsibilities do gun owners have? to themselves? their families? and their communities?

Note: This season of American Diagnosis was originally published under the title In Sickness & In Health. 

This podcast was created by Just Human Productions. We’re powered and distributed by Simplecast. We’re supported, in part, by listeners like you.

Celine Gounder: Hi, everyone. Dr. Celine Gounder, here. I’m the host of “In Sickness and in Health.” We really appreciate all our loyal listeners, and I’m hoping you can help us grow this community even more. If you like our podcast, text a friend about it right now. The bigger we can grow this community the more episodes we can do, and the more ambitious our show can be. Thanks for listening. Now, here’s the show.

Tony Gomez: It was a Halloween, and most of my co-workers had headed home to either go trick-or-treating with their kids or see the little cute kids come from around their neighborhood for trick-or-treating.

Celine Gounder: We’re going to start this episode with Tony Gomez.

Tony Gomez: It was pretty empty in the office, and we heard some gunfire. … I was up on the ninth floor. I went to the window, looked out to see if I might see something to call in, be helpful, and my blinds rattled. And I immediately knew that some bullet had come near me… and I realized I’d been shot at… When I came to work the next day… I asked my co-worker to pull up the blinds at where I would have been standing, and I was down at the street level, and I could see that a bullet had gone just above me and just below me. So I called the police, ended up talking with them… I learned that it’s not uncommon… on New Year’s Eve and Halloween and other situations for people to just go out and randomly shoot off firearms in celebration or whatever. … I work with a bullet lodged in my floor that I think about every day, my close call. …there’s this whole trafficking system. Firearms being stolen out of homes where firearms aren’t safely stored is very common. It’s sadly too common…

Celine Gounder: On this episode of “In Sickness and In Health,” we’re going to talk about how safe gun storage can help limit access to guns… by unauthorized users, like minors, thieves… and people at risk of suicide. We’ll speak with folks from the public health world… and folks from the gun world… about how they’re working together to prevent suicides and accidental deaths, which makeup over 60% of gun-related deaths in the U.S. each year.

Celine Gounder: Tony Gomez, the man you heard at the top of the show, is in charge of Violence and Injury Prevention for Seattle-King County in Washington State. Seattle’s Mayor and City Council are trying to address gun violence through two new laws.

Tony Gomez: One of them is a safe storage bill…

Celine Gounder: Seattle’s Responsible Storage Law requires gun owners to keep their guns locked in a container when they’re not carrying them.

Celine Gounder: The other law toughens penalties for failing to report a lost or stolen firearm.

Tony Gomez: The worst-case scenario is a civil penalty up to $10,000 if a minor, at-risk person, or prohibited person gains access and kills or injures another, or uses it in a crime.

Celine Gounder: Tony thinks these new measures will help prevent guns from entering the black market and being illegally trafficked.

Tony Gomez: …it’s an underreporting, but we know that there’s about $3.5 million to $4.5 million worth of firearms stolen each year in our state.

Celine Gounder: But most importantly, he says, safe gun storage is the most effective way to prevent kids and young people from getting hurt by guns.

Tony Gomez: When I was a college student, and I was working in the Denver, Colorado area, the owner of the company I worked for, we did lifeguarding and swim lessons and swim team management…

Celine Gounder: He and the rest of his coworkers really liked their boss, and got to know him and his family pretty well.

Tony Gomez: And one day we got the call that the owner’s four-year-old son had shot himself in the chest.

Celine Gounder: Gun ownership in Colorado… where lots of people hunt and shoot for sport… is really common, so Tony and his coworkers weren’t all that surprised there was a gun in the home.

Tony Gomez: As the stories emerged publicly… it was learned that the firearm was up in a closet somewhere, and the bullets were in that same room but separated… and the little boy had seen his dad load the starting pistol for swim meets. He was the starter at many of the swim meets in the area, so the little boy knew how to load the starter pistol. And so he stumbled upon the .22 handgun, and put the bullets together, and shot himself in the chest…  it was just so so devastating.

Tony Gomez: I’ve heard a remarkable number of stories of children, and some now adults, in that moment of despondency, in that moment of crisis, going to look for the firearm they knew that was within the household, and it either being in a lockbox or being totally out of the house, and they’re here today to tell their story of the value of safe storage and being aware of those suicide risk factors. So those are the positive sorts of things that keep us empowered, inspired to continue to do good work in this area.

Celine Gounder: In the past, Tony has worked with various initiatives that encourage safe storage among gun owners. He says they had some success, but hopes Seattle’s new laws will help make safety the standard across the board, once and for all.

Tony Gomez: …restaurants and healthcare providers are supposed to report foodborne illness to us. Swimming pools are supposed to report drownings and near-drownings. Firearm owners need to be reporting to law enforcement when their firearms are stolen because the law enforcement community has a good tact of, “Don’t let your firearm become a crime gun, lock it up.” They are concerned about unsafely stored firearms getting in the hands of criminals that then they’re going to have deal with out in the community and whatever situation would present.

Celine Gounder: But what exactly do we mean when we say safe storage? Tony explains the best practices that public health experts and gun owners have come up with.

Celine Gounder: The least safe storage method is an unlocked firearm.

Tony Gomez: So that means it’s available, it’s out, it’s not in a safe storage device… it also includes that firearm being loaded… So there are bullets in the firearm, and it’s therefore a very dangerous weapon because it does have the two components: the easy access, as well as the ammunition within it.

Celine Gounder: An intermediate storage practice would be…

Tony Gomez: …firearms that are locked up that have ammunition in them.

Celine Gounder: This part, surprised me.

Tony Gomez: Too many times we’ve seen where the key to the gun safe, the lock box is available to family members, burglars, and others. And we’ve seen those situations result in tragedy. Even combination devices can be a problem… because oftentimes, the combination has been shared with all household members…

Tony Gomez: The other intermediate storage practice that’s of concern, it’d be a firearm that’s unlocked. So it is in a dresser drawer, in a duffel bag, in the basement, wherever. That it’s unloaded. It doesn’t have ammunition in there… but why that’s an intermediate storage practice and a practice of concern is that, typically, the ammunition is available somewhere else in the household…

Celine Gounder: And, the safest storage practice…

Tony Gomez: …what most entities recommend is that firearms would be stored in an approved safe storage device, and that the ammunition be locked and stored separately.

Celine Gounder: An approved safe storage device could be a lock box, a gun safe, or a trigger lock.

Celine Gounder: Tony says that… though most gun owners support safe storage practices… there is some resistance. Most gun owners, these days, have guns for self-protection. And anything they see getting between them… and their loaded gun… they see as a problem.

Tony Gomez: …the reality of it is, is that the chances of a criminal intruder coming in versus all the other adverse things that can happen from a firearm being in a household, right now, best evidence we have shows that the risks of unsafely stored firearms are greater than any risks of a locked up firearm and needing to access it.

Cassandra Crifasi: I don’t anticipate needing to use a gun in self-defense in my home. We have a security system. We have a big dog. Those are the things that I feel are going to be far more effective.

Celine Gounder: This is Cassandra Crifasi.

Cassandra Crifasi: I’m an Assistant Professor in the Center for Gun Policy and Research in the Department of Health Policy Management at the Johns Hopkins Bloomberg School of Public Health.

Celine Gounder: Cassandra grew up in Washington state, twenty minutes outside of Seattle. Her family was a gun owning household. Her dad was a Vietnam vet.

Cassandra Crifasi: From a very young age, I knew that he owned firearms, and that they were a tool for hunting or for other things, not something to be played around with otherwise.

Celine Gounder: Cassandra went to Central Washington University for undergrad, where she did a lot of bird hunting. It was then that she started acquiring her own firearms.

Cassandra Crifasi:  I had a shotgun that I purchased at that point, and as I got older, because of interest in sport shooting, acquired a lever-action .22 rifle and a couple of handguns.

Celine Gounder: You’ve heard from Cassandra before. I reached out to her not just because she studies gun violence… but also… because… she’s a gun owner. And… there’s another reason I wanted to hear her take.

Celine Gounder: And how old are your kids?

Cassandra Crifasi: They’re my stepkids. I have two of them. One just turned twelve, Tony, he’s a boy, and Caitlin turned ten in October.

Celine: Cassandra’s a mom. She and her husband both own guns. For Cassandra and her husband, gun safety isn’t just about what device they use to secure their guns, but about the lifestyle they’ve adopted.

Celine Gounder: And how do you and your husband talk to your kids about having guns in the home, and what do you teach them about that?

Cassandra Crifasi: They know that we have guns in the home. They’ve been aware of that for as long as I have been around, and probably before then also. We talk about guns as being tools, certainly not toys, not something to be touched or accessed when parents aren’t around. But at the same time, we know that children are curious and inquisitive, and we’re not going to leave it up to them to be sure that they’re not doing something they’re not supposed to do. Like if kids never did what they weren’t supposed to do, we would let them make more decisions for themselves. So on that note, we keep all of our guns locked in a safe. …the kids know where the safes are because they’re part of the furniture in the house, but they don’t know how to access them, and that’s intentional because kids are curious and will get into things.

Celine Gounder: What struck me about their set up is that Cassandra and her husband James have separate safes for their personal firearms, each with different keys and different codes… and, they don’t know each other’s codes. They don’t have access to one another’s guns.

Celine Gounder: What’s the reasoning behind that?

Cassandra Crifasi: Part of it is, the responsibility, in my opinion, of a gun owner is that you control access to your firearms. You are the one that can access them, and no one else can have unauthorized access. And so, James and I keep our guns separate and our codes and keys separate, so that he can’t access mine, I can’t access his, because that, to us, reflects responsible storage and responsible gun ownership, because I am responsible for whatever happens to my firearm. If I store it improperly and someone steals it, or someone accesses it that’s not supposed to have it, and does something inappropriate with it, that’s my responsibility, and not that I have any fear that my husband is going to use my guns inappropriately, but we just don’t want to take that chance. We feel both very strongly that a key to responsible ownership is ensuring that you’re the only one that can have access to them.

Celine Gounder: I was curious about where they chose to store their guns, and wanted to better understand how they made this decision.

Cassandra Crifasi: We each have actually two safes on our side of the bedroom, a very small safe that’s bolted down, that stores a handgun, and then a standing safe for our long guns and other guns and ammunition. We chose the bedroom because we wanted it to be the furthest place from where people may be commonly spending time in our home, like if we have people over or guests over, there really isn’t a reason for people to be entering our bedroom, and so that’s why we chose the bedroom.

Celine Gounder: There’s a tremendous need for more awareness about the importance of safe storage when it comes to keeping kids and teens safe… but the science to back it is there.

Ali Rowhani-Rahbar: Some years ago, I believe it was around 2004, when a very seminal paper came out in the journal JAMA, where our colleagues showed that safe firearm storage is associated with about 70% reduction in risk of suicide and accidental shootings among adolescents.

Celine Gounder: This is Ali Rowhani-Rahbar. He’s an Associate Professor in the Department of Epidemiology at the University of Washington. He studies violence prevention.

Ali Rowhani-Rahbar: That is, to my knowledge, the best evidence, so far, we have in terms of the association between safe firearm storage and reductions in risk of self-harm and unintentional shootings among youth.

Celine Gounder: Ali also points to another study showing that kids with risk factors for self harm… like mental health issues and substance abuse… have as much access to guns as other kids do… This is really concerning, because it means firearms are not being safely stored… even when there’s a troubled teen in the home.

Ali Rowhani-Rahbar: There are some hypotheses about that. One is that the parents may simply not know that their teen may have actually access to the firearm. They simply may not know. … One of the questions that we analyzed… was exactly that… whether a teen could actually grab a gun and shoot it. 40% of teens said they can. I think some parents may be surprised to hear that statistic.

Ali Rowhani-Rahbar: The other thing is that parents may not be aware of the strong association that we see over and over and over again between in-home firearm access and risk of suicide and unintentional shootings. Risk of suicide, indeed, for every single member of the household, not necessarily the owner themselves, but everybody in the household.

Celine Gounder: In Seattle and across the country, there are initiatives to bring attention to this link, between guns in the home… and risk of suicide and unintentional shootings. Seattle’s Lock It Up Campaign, for example, partners with gun businesses and law enforcement agencies… who many gun owners consider credible and effective messengers… to provide information about safe storage practices to customers… and to anyone who applies for a concealed carry license.

Celine Gounder: Seattle Children’s Hospital puts on a firearm safe storage community events. Organizers provide trigger locks and lock boxes, and have hands-on demonstrations on how to use them.

Ali Rowhani-Rahbar: Hundreds of people show up, and they are enthusiastic about this. One of the studies we did showed that actually it was associated with some modest improvement in behavior that is increase in the percentage of individuals who stored their guns safely after the event.

Celine Gounder: There are guns in about one third of U. S. households, says Ali.

Ali Rowhani-Rahbar: And among gun owning households, there is tremendous variability in terms of storage patterns. I think at the national level, you find about one third of those gun owning households, somewhere around that range, to store their guns completely safely.

Celine Gounder: Ali says that while about 60% of gun owners have had some sort of formal firearms training, the stakes are high for everyone involved… not just the gun owners themselves.

Ali Rowhani-Rahbar: …the proportion of individuals who live in a gun owning household but themselves are not… owners of the gun who have received formal firearm training is very small, it’s about 14%. … Because of the strong association between presence of a gun in a home and risk of suicide for every member of the household, it’s really important to focus on not only the owner themselves, but also other members of the family.

Celine Gounder: As we talked about last episode, only a small fraction of gun owners who take formal firearms training receive education about suicide prevention… and on top of that… most living in a home where there’s a gun… have gotten no training… on firearms… on safety or suicide prevention… at all.

Celine Gounder: Something became clear to me during my interviews for this episode. It’s a theme emerged we’ve talked about before. The messenger matters. And then… I met Jennifer Stuber. Jennifer made me realize that sometimes, life just happens… and you have no choice… but to be… that messenger.

Jennifer Stuber: The reason I got into the suicide prevention field is in 2011 my husband was experiencing depression and anxiety, and he ultimately ended his own life by suicide.

Celine Gounder: People like Jennifer… who’ve lost loved ones to suicide or accidental shootings… can be just as powerful and effective messengers. Ironically, survivors like Jennifer, are also at higher risk of suicide themselves.

Jennifer Stuber: We know that in our culture that there’s some contagion effects that can happen there, that one of the highest, the most important risk factors for suicide is having suicide occur in your personal life, because it just becomes this possibility that perhaps you never considered before if you were to go through a time of struggle or strife.

Celine Gounder: Jennifer is an Associate Professor at the University of Washington School of Social Work. At the time her husband died, she was training mental health providers. She says up until then… not in her graduate training… nor in her workplace… were people really talking about suicide.

Jennifer Stuber: And I don’t think that’s uncommon. I think that we actually haven’t had suicide enough on the radar or in the public consciousness…

Celine Gounder: Jennifer’s husband struggled with depression and anxiety.

Jennifer Stuber: …he’d struggled with it to some extent… throughout his life, but his symptoms became far more acute during the downturn in the economy. He was a new partner, and he was concerned about whether or not he was going to be able to meet the demands in terms of billable hours, and was very very stressed about that.

Jennifer Stuber: …when he realized that his anxiety was causing him incredible difficulties with his ability to concentrate and sleep, he took a leave from his job, and then he felt so much stigma even though it’s really mainly in his head… I remember him saying to me, “Who wants a lawyer with a broken brain?” He didn’t have people around him… normalizing that experience that we all go through ups and downs, and it’s okay to take some time off when you’re in that kind of place…

Celine Gounder: Jennifer says her husband started to feel very disconnected from his job, which he once loved. And from his identity as a lawyer. She says the medications he was on… weren’t helping him.

Jennifer Stuber:  I think he felt hopeless and that he was a burden, which is obviously the most… it couldn’t have been further from the truth, but suicidal people, they’re in such deep pain. They’re not thinking rationally.

Jennifer Stuber: I think he felt like he had no other way out than to end his life.

Celine Gounder: The experience of Jennifer’s husband, is becoming more and more common. In the United States, suicide is on the rise.

Jennifer Stuber: We have, I think, a disconnection phenomenon happening in our culture… One of the things that we know that is protective against suicide is people feeling connected to community, people feeling like they have people they can turn to, people feeling like they have meaning and purpose.

Celine Gounder: The nature of family, friendships, and community… have changed drastically over just a couple generations. These changes in lifestyle, says Jennifer, have undermined our ability to have meaningful connections with others.

Jennifer Stuber: Well, I think we’ve got some really complex cultural factors that are at play that are going to be difficult to reverse.

Celine Gounder: Jennifer believes that her husband died, in part, because the people in his life… she, herself, and his healthcare providers… weren’t aware enough about suicide risk and prevention.

Jennifer Stuber: I don’t hold any anger about this at this point, but he did not get the proper care, and that’s because people didn’t have the proper training. I view that as a systems issue. I also didn’t have the proper training. I didn’t know what to do as his spouse. And so, I could have behaved better. The people providing treatment for him could have behaved better and been more supportive, but no one really understood what was going on. That has really become my life’s work.

Celine Gounder: After her husband’s death, Jennifer reached out to gun safety groups… including what’s historically been the preeminent organization in this space: the NRA.

Celine Gounder: In its early years, the NRA was all about teaching marksmanship and firearm safety.

Celine Gounder: Jennifer knew that history… and wondered… what was the NRA doing today… on suicide awareness? She couldn’t find any information about it on their website, so…

Jennifer Stuber: I called them, just decided to just give them a call, and what I basically learned is… that the NRA, like the rest of the public… just didn’t have an awareness that, again, the majority of gun deaths in this country are suicides.

Jennifer Stuber: That fact is still not widely known. I think it’s becoming more widely known, but frankly, I blame public health and folks who have worked on the gun control side of this issue for not making that crystal clear to people in the public. And so that’s a big issue. And then I think there’s just a lot of myths about suicide. For example, the myth if someone is going to kill themselves there’s nothing you can do about it, and then what specifically you do is also not very well known in the public consciousness.

Celine Gounder: Jennifer says that for a long time, the suicide prevention researchers were focused on why people die by suicide… risk factors, like mental illness or substance abuse. More recent research has shown that it’s at least as important to understand how people die: the means, the tools they use.

Jennifer Stuber: What we know for example is that roughly 70% of all suicides, the very commonly available, commonly owned, used means of firearms and medications are used. …so it’s really important that those who are prescribing, selling, distributing those means are also disseminating an important safety message around suicide prevention.

Celine Gounder: Since her husband’s suicide, Jennifer has made it her life’s work to prevent suicide. She trains healthcare providers not only on how to identify and help someone at risk, but also on how to counsel patients about safe storage… how to limit access to lethal means of suicide… in times of crisis.

Celine Gounder: In her work, Jennifer makes it a point to focus not just on firearms… but all common lethal means… including… medications. She talks about gun safes and lock boxes… and about locking up medications… and safe drug disposal sites.

Jennifer Stuber: It’s not just about firearms. It’s about a safer home.

Celine Gounder: This kind of framing has allowed her to forge broader alliances… and find common ground with organizations as wide ranging as the Second Amendment Foundation, the NRA, and the Alliance for Gun Responsibility… and clinicians… working with everyone from veterans… to kids.

Jennifer Stuber: We have over forty-three partners at the table, and so I think what we’re doing is actually very important and very unique because what we’ve chosen to do is to say, “Hey, we’ve got a big tent. There’s a lot of people at this table who don’t agree on a lot of things related to guns, but what we’re going to focus on here is what we do agree on with respect to suicide prevention and what we want to try to move forward collectively.”

Celine Gounder: In 2012, Washington State passed the Matt Adler Suicide, Assessment, Treatment and Management Act. Matt Adler… was Jennifer Stuber’s husband.

Jennifer Stuber: It is the first law in the country that requires that all behavioral health providers in our state have some training in suicide prevention. It’s a minimum of six hours every six years…

Celine Gounder: After it passed, the law was amended to add a training requirement for all healthcare providers in the state, not just mental health providers.

Jennifer Stuber: We’re the only state in the country that has actually passed that law.

Celine Gounder: In addition to training healthcare providers, Jennifer and her partners do a lot of outreach to firearm retailers, instructors, and owners. They have a hunter safety program. A concealed-carry program. They set up tables at gun shows and provide free locking devices. They developed trainings with and for gun retailers, doctors, and pharmacists… about safe storage… of firearms… and medications… and they have access to those gun retailers, doctors, and pharmacists, because of the goodwill they’ve earned.

Jennifer Stuber: It’s really a public awareness campaign is where we’ve focused our time and energy. And again, there’s a big tent and a lot of different people at the table working on this.

Jennifer Stuber: There is hope. There is help. Sometimes it’s hard to find, but if you stick with it, I mean, most people who die by suicide, we know from attempt survivors that they’re really happy that they’re alive. That they really are happy that they didn’t die. We just do have to do more as a society though to prevent suicide.

Celine Gounder: If someone you know is in crisis or thinking of hurting themself:

  • Do not leave them alone.

  • Remove any firearms, alcohol, drugs or sharp objects that could be used in a suicide attempt.

  • Take them to an emergency room or seek help from a medical or mental health professional.

  • Call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255).

  • Or text the Crisis Text Line at 741-741.

  • Another resource for LGBTQ youth is the Trevor Project’s Lifeline at 866-488-7386.

Celine Gounder: “In Sickness and in Health” is brought to you by Just Human Productions. Today’s episode was produced by Virginia Lora and me. Our theme music is by Allan Vest. Additional music by The Blue Dot Sessions. If you enjoy the show, please tell a friend about it today. And if you haven’t already done so, leave us a review on Apple Podcasts. It helps more people find out about the show! You can learn more about this podcast and how to engage with us on social media at insicknessandinhealthpodcast.com. That’s insicknessandinhealthpodcast.com. I’m Dr. Celine Gounder. This is “In Sickness and in Health.”

Cassandra Crifasi Cassandra Crifasi
Dr. Ali Rowhani-Rahbar Dr. Ali Rowhani-Rahbar
Jennifer Stuber Jennifer Stuber
Tony Gomez Tony Gomez
Dr. Celine Gounder Dr. Celine Gounder