Mental health first aid for firearm owners: Addressing the elephant in the room

Abstract

Suicide is the leading cause of firearm-related death in Australia. Mental health first aid (MHFA) training has demonstrated capacity to address the risk factors for suicide. This article proposes that online mental health first aid training should be a requirement for acquiring or renewing a firearms licence in Australia.

Keywords

Australia mental health law and policy public law public health law and policy law reform firearms guns

On 7 May 1996, just nine days after the Port Arthur Massacre, Jim Bacon, the newly elected member for Denison and future premier of Tasmania, had the solemn honour of giving his first speech in Parliament. The Member outlined his vision through the key issues he sought to address, saying:

I think there needs to be a great deal better understanding and a great deal more effort put into recognising that mental health is as legitimate an area of study or health or of medicine as any other part of the health of our bodies; that the mind is albeit more complex and harder to understand, but just as much a part of us that can go wrong; that we can, whether it is temporarily or permanently, suffer from mental ill health. I think we greatly need to increase our understanding in that area.¹

There have been significant improvements in Australia’s understanding of mental health in the decades following Mr Bacon’s maiden speech to Parliament. Society’s understanding of depression, suicide, anxiety and post-traumatic stress disorder have improved dramatically. Unfortunately, however, the increased understanding has not permeated society completely as there are still significant mental health challenges – particularly in the firearms space. The Australian Institute of Health and Welfare reports that ‘almost 80% of firearm-related deaths in 2012–13 were due to suicide’.² In remote and very remote areas, rates of suicide with firearms are ‘4 and 6 times higher’.³ Table 1 outlines the number of deaths from intentional self-harm with a firearm as reported by the Australian Bureau of Statistics:

Table 1.

Deaths from intentional self-harm with a firearm in Australia from 2008 to 2017.⁴

	2008	2009	2010	2011	2012	2013	2014	2015	2016	2017
Deaths	183	174	171	144	177	166	178	177	183	162

While suicide is not the only risk posed by mental health and firearms, it certainly is the most prevalent cause of death – which is why this article’s focus is on suicide. Preventing firearm-related suicides and promoting positive mental health is one of the most important, but challenging, issues facing firearm owners, legislators and the community. Prevention is possible through addressing the risk factors for suicide. Three of the most significant factors are: stigmatisation of mental illness, a lack of knowledge and/or understanding of mental health and social isolation. Stigma is frequently defined as ‘a mark of disgrace’ and when someone is stigmatised, such as from having a mental illness, the stigma means that individual is seen as an illness first and as a person second.⁵ Hadlaczky et al describe stigma as ‘one of the greatest public health-related obstacles in suicide prevention’.⁶ Stigmatisation discourages those potentially experiencing a mental illness from seeking treatment due to the risk of diagnosis and the subsequent treatment they may receive from others. It also discourages people from discussing and learning about mental health as it is taboo. This results in a situation where ‘due to the lack of knowledge about mental health problems, parents, other relatives and peers could misinterpret or completely fail to notice symptoms of mental ill-health, and in this way further reduce the afflicted person’s treatment opportunities and perhaps even aggravate the condition’.⁷ Family, friends and peers play an essential role in promoting positive mental health through early recognition and intervention. Without the understanding and knowledge of mental health, coupled with a taboo or stigma, it can be enormously challenging for others to provide support and assistance.

Social support is not just essential for recognising and understanding mental health, it is fundamental to reducing the risk of suicide entirely. Ross et al note that ‘social isolation has been revealed to be one of the strongest and most reliable predictors of suicide’.⁸ They explain that

[as] proposed by the interpersonal theory, suicide is considered to be influenced by three different components; behavioural, emotional, and social. The theory proposes that feelings of being a burden to loved ones (emotional), and feelings of social disconnection and lack of belongingness (social), result in suicidal desire.⁹

Loss of firearm ownership and social isolation share a strong relationship as ‘similar to driving, for some, firearm ownership and use are integral and enduring aspects of their life, closely bound to their identity, occupation and self-esteem. For them, losing a firearm licence may be especially distressing’.¹⁰ This is why cancelling a licence, such as pursuant to s 51 of the Firearms Act 1996 (Tas), and then removing the firearms of someone experiencing mental illness, is not always an appropriate response for that individual’s wellbeing as it could increase their risk of suicide. When viewed from the perspective of a firearm owner who is a member of a gun club it becomes clear why removing access to their firearms could further increase social isolation, and subsequently, their risk of suicide. The risk of social isolation from firearm removal is especially significant for farmers as their firearms are tools of the trade. Kunde et al described how firearms are tools of trade when ‘during drought, farmers reportedly needed to euthanise animals’.¹¹ By removing someone’s tools of trade, they face potential exclusion and discrimination from current and future employers who require firearms as part of the job. This has potentially significant repercussions for their mental health:

Individuals with mental health problems also face extensive discrimination and marginalization …. This can lead to unemployment, poverty and homelessness. These prejudices can carry significant adverse effects on those who are afflicted by reducing their well-being, self-esteem and quality of life. Prejudice and discrimination against individuals with mental health problems also has adverse effects on intimate relationships and for the families and friends of the afflicted.¹²

As social isolation, alongside stigmatisation and misunderstanding are such significant risk factors for suicide the development of alternative strategies to approach the challenges and complexity of firearm ownership and mental illness is essential.

The proposal

The proposal made here is the first of its kind for Australia. While other nations have mental health screening mechanisms within their licencing systems, no nation currently requires training in mental health as part of a licence application. However, some private companies, such as gun ranges, have mandated mental health first aid (MHFA) training for their staff.¹³

A new applicant for a firearms licence would be required to complete an abridged online MHFA course which, upon successful completion, produces a certificate that can be attached to a licence application. The online course could be modelled on the current computer-based tests as required in most states by those applying for a driver’s licence. Practically, the proposal could be affected through amending the relevant legislative provision outlining the requirements for a firearms licence. For example, in Tasmania s 28(2) of the Firearms Act 1996 (Tas) could be amended to read:

s 28 Applications for licences

(2) An application for a licence is to –

…

(g) contain a current Mental Health First Aid certificate.

Someone renewing their firearms licence who has not previously completed an MHFA course, or whose MHFA certificate is about to expire, would be required to attach a copy of their valid MHFA certificate to their firearms licence renewal application. This would also be affected by amending the relevant provision. For example, in Tasmania this could be affected by amending s 36C(2) of the Firearms Act 1996 (Tas) to read:

s 36C. General discretion of Commissioner to refuse to renew licence or to alter or vary conditions of licence

(2) The Commissioner must not renew the licence –

…

(e) if the applicant does not hold a current Mental Health First Aid qualification.

This means that licence holders would need to ensure their MHFA training is current when renewing their licence. It is proposed here that the online MHFA courses would form part of the mandatory Firearms Safety Training Courses currently required in every state and territory in Australia to receive a firearms licence. The MHFA course would be available to access online as soon as the applicant receives the firearms licence training materials. The content of the course would need to be developed in consultation with various stakeholders and expert groups. The development and maintenance cost of the online platform would, most likely, be added to the cost of a firearms licence. One of the primary advantages to this proposal is the reduced cost to firearm owners. Attending an in-person MHFA course would be significantly more costly than an online course, and participants would incur travel costs as well as opportunity costs around the use of their time. Delivering an abridged course through an online platform eliminates most of these costs. Having the course available via distance is particularly important for rural and regional Australians who are both most vulnerable to suicide and would have to travel greater distances to attend an in-person course. Furthermore, the content of the course could be developed for national uniformity, consistent with the National Firearms Agreement, which would have the added benefit of sharing the operating costs across all firearm owners Australia-wide, and not state-by-state. This reduces the cost to firearm owners through economies of scale.

MHFA benefits

MHFA courses are similar to physical first aid courses in their structure and delivery. The primary difference is the focus on mental, rather than physical, health. The standard course is described as:

a 12-hour seminar delivered by trained presenters, which provides participants with evidence-based resources to provide help and appropriate referrals to people experiencing a mental health crisis (such as an episode of acute psychosis) or an ongoing mental health problem (such as depression). The underlying rationale of MHFA training is that people with mental health problems can be assisted by those in their social network, but that network members often lack the confidence and skills to provide basic help and appropriate advice.¹⁴

MHFA has several benefits that directly impact the risk factors for suicide. International research has highlighted some of these benefits:

MHFA ultimately increases mental health literacy of the general population. As such, it induces a series of cascading effects, including improvement in self recognition, increased insight into one’s own and others’ emotional well-being, and enhanced mental health-related vocabulary, thus also counteracting stigma. All these effects are expected to lead to increased coping skills and improved confidence to render informed peer support. Importantly, results indicate not only changes in knowledge and attitudes, but also changes in the behaviour of those who attend the training. This is of major importance because it shows a pragmatic change in trainees who become more active in supporting those with mental health problems and suicidality.¹⁵

This quote identifies the three most significant benefits to MHFA. First, MHFA improves mental health literacy, ie, the knowledge and understanding of mental health. Second, the increased understanding and knowledge builds participants’ confidence to respond to mental health situations and as a result increases help-providing behaviour. Third, with increased knowledge and confidence to respond to mental health situations, people can actively encourage positive mental health which combats the stigma and negative attitudes around mental health. These benefits are consistently identified in scholarly research. For example, Hadlaczky et al conducted a systematic search of the literature with three independent reviewers analysing over 590 papers. In conclusion, the results indicated ‘that the MHFA programme can be considered effective in increasing knowledge regarding mental health problems’.¹⁶

It is important to note that the knowledge gained through MHFA relates to a wide range of topics. While grounded in evidence and research, MHFA courses are focused on practical, rather than theoretical, knowledge and skills to promote positive mental health. As noted by Ross et al:

The programme teaches adult members of the public how to provide assistance to someone who has a mental health problem or is experiencing a mental health crisis, until appropriate professional assistance is received or the crisis resolves. While suicide prevention is only briefly covered, this course has been found to be effective in providing the knowledge required to intervene and increasing helping behaviours.¹⁷

The sort of knowledge gained through MHFA includes how to

identify the warning signs for suicide;

confidently support a person in crisis;

help the person stay safe; and

connect someone to appropriate professional help.¹⁸

This knowledge is essential to recognising the symptoms of mental illness and enabling early intervention. Early intervention has an important impact on the broader statutory regime around firearms. Under the various state legislation, such as s 148 of the Firearms Act 1996 (Tas), representatives of gun clubs and certain medical professionals have an obligation to report to the police anyone who ‘may pose a danger if in possession of a firearm’.¹⁹ Early recognition of mental illness enables gun clubs to refer their members to medical professionals before the mental illness makes the person ‘a danger if in possession of a firearm’ and therefore reportable under the legislation. Early recognition and referral has the added benefit of making firearm owners more amenable to seeking professional medical help due to the reduced risk of being reported. With MHFA training, gun clubs will also be better equipped to meet their reporting obligations as they will be able to accurately recognise if someone has a mental illness that would make them a danger if in possession of a firearm. Unlike physical health, which often has outward warning signs such as bleeding, bruises, or shortness of breath, mental illness has much more subtle and varied warning signs. For example, feeling down or sad almost every day ‘for more than 2 weeks’ is a warning sign of depression potentially warranting a visit to a doctor.²⁰ Unless the person is crying, it could be difficult to determine that someone is down or sad without speaking to them and understanding what questions to ask and how to ask them. Knowing the signs of depression, or any other mental illness, is especially useful if paired with the skills and confidence to approach someone and help support them until they can receive professional assistance. MHFA provides the skills and confidence to increase help-providing behaviour in mental health situations. As noted by a 2008 study conducted in rural New South Wales, ‘participants reported similar rates of contact with people with mental health concerns both before and after the MHFA seminars but felt more confident in their ability to help after training’.²¹ Another study argues that their ‘results show that the MHFA intervention is effective in increasing help-providing behaviour’.²² MHFA provides the skills and confidence to approach and speak with people experiencing a mental health challenge. This increase in skills and confidence ‘effectively decreases negative attitudes toward individuals suffering from mental health problems’.²³ As noted by the New South Wales study: ‘reduction in stigma of mental health problems is a critical step in encouraging help-seeking, alongside building confidence and knowledge about mental health problems’.²⁴ With the skills and confidence to approach and speak with people experiencing a mental illness, mental health first-aiders are in a strong position to refer the person to a health and wellbeing professional if necessary. As noted at the start of this proposal ‘mental health is as legitimate an area of study or health or of medicine as any other part of the health of our bodies’ and as such requires professional assistance.²⁵ Mental illness requires the same level of response and care as physical injury or trauma.

Challenges to this proposal

This proposal has several challenges, or drawbacks, that should be noted:

• The Australian Bureau of Statistics data around firearm-related deaths does not state if the deceased person had a valid firearms licence. This means that some of the firearm-related suicides might not be from licensed owners, or people connected with the licensed firearm community, and so requiring MHFA from licensed owners may not affect the suicide rate by unlicensed owners.

• According to the Australian Criminal Intelligence Commission, in 2016 there were nearly 816,000 firearms licences issued in Australia; although this figure may not accurately reflect the number of individual licensees.²⁶ In 2016 there were 183 firearm-related suicides. These data demonstrate that it is only a small fraction of firearm owners who commit suicide with their firearms. It is arguably too significant an impost to require MHFA training as part of a firearms licence application or renewal given the proportion of suicides to firearms licences.

• Requiring firearm owners to complete MHFA training may lead to stigmatisation from the wider community. This stigmatisation could flow from the singling out of firearm licences compared with other licences, such as driver’s licences, that are not, as yet, required to complete similar training. The requirement may cause the wider community to, incorrectly, perceive firearm owners as being at greater risk of experiencing a mental illness, or posing a greater risk to the community because of their mental illness when combined with their access to firearms. The latter perception arises from the gap between public and professional understandings of mental illness, and in particular, the relationship between violence and mental illness. For example, some members of the public may, also incorrectly, assume that due to the nature of the Port Arthur Massacre the perpetrator had some form of diagnosable mental illness predisposing him to violence. However, at the time of undertaking his psychiatric assessment he was not diagnosed with such an illness:

Sunday May 5th [1996] and the Sun Herald introduces the suggestion of 'serious mental disability' in a front-page story with the heading 'They Knew 2 Years Ago'. This article provoked considerable reaction from various mental health organisations who were at pains to point out that schizophrenia does not naturally predispose people to murder, and questioning whether Bryant was really so diagnosed. The psychiatric report by Mullen (1996) makes it clear that though this was never the case, Bryant's mother (for whatever reason) had told people that her son was indeed diagnosed as schizophrenic.²⁷

This quote highlights how the gap between public and professional understandings of mental illness can propagate misconceptions and add to the stigmatisation of those with a mental illness.

• Accessibility to firearms is also a major factor influencing the risk of suicide. Research by Kunde et al studied the pathways to suicide by 18 male farmers in Australia and found that ‘farmers in this study had ready access to, and familiarity with firearms, critical elements in determining the suicide method. Farmers in this study had been familiarised with shooting firearms from a young age’.²⁸ The risk factor of social isolation would need to be weighed up against the risk factor of accessibility.

Conclusion

Requiring firearm owners to complete an online MHFA course will increase knowledge and understanding of mental health while reducing stigma. This directly addresses three significant risk factors for firearm-related suicide. MHFA has the added benefit of promoting help-providing behaviours. It is hoped that the benefits of MHFA will increase feelings of belongingness within the firearms community and reduce the overall occurrence of suicide. As Ross et al note: ‘by increasing feelings of belongingness by connecting with the person, and by furthering this connectedness through linking them with additional social and professional support, others can play a central role in reducing suicide risk’.²⁹ The proposal here aims to spark a public discussion on firearm-related suicide. There are many elements of this proposal that need to be worked out in consultation with key stakeholders including: firearm owners, police, legislators, health and wellbeing professionals, family and friends of those who have committed suicide with a firearm, and the wider community. This proposal should not be viewed as the complete solution to the challenge of firearm-related suicide. The complexity and ever-expanding knowledge of mental health requires ongoing evaluation and consultation as:

the requirement for continued research, regular reviews, ongoing evaluations and dissemination, and the sharing of experiences will all support the long-term sustainability of mental health promotion programmes and their role in enhancing the health and wellbeing of our communities.³⁰

Based on current projections over the next 10 years, Australia is going to lose almost 2000 lives to firearm-related suicide. If legislators, firearm owners and the wider community act now, some of those deaths can be prevented and countless lives can be both saved and improved. The topic of firearms legislation and gun control is often typified by its polemic and divisive debate. When it comes to firearm-related suicide it is essential that all stakeholders come together and adopt a collaborative and reasoned approach. MHFA provides the skills to recognise the signs of mental illness, provide support, and refer to health and wellbeing professionals. These skills apply to all people – not just firearm owners. Behind every firearm owner is a network of family, friends and co-workers, and each is just as vulnerable to mental illness as the firearm owner themselves. Mental health is not just about suicide, it is also about the untold number of people who live with mental illness. While the focus of this proposal has been on reducing firearm-related suicide, more broadly it is about promoting positive mental health. Going beyond the statistics of suicide, positive mental health means promoting happiness and wellbeing for every mother, father, son and daughter in the community – whether or not they own a gun.

Footnotes

Acknowledgments

This article is based on the author’s submission to the Tasmanian House of Assembly Committee into Firearms Legislation and Policy.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

1

Tasmania, Parliamentary Debates, House of Assembly, 7 May 1996, 45 (Jim Bacon).

2

Australian Institute of Health and Welfare, ‘Firearm injuries and deaths’ (Fact sheet, no INJCAT 187, 2017) 1.

3

Ibid.

4

Australian Bureau of Statistics, ‘Underlying cause of death, All causes, Australia, 2008–2017’ (Statistics spreadsheet, 3303.0, 2018).

5

Department of Health WA, ‘Stigma, discrimination, and mental illness’ (Fact sheet, February 2009) 1.

6

Gergö Hadlaczky et al, ‘Mental Health First Aid is an Effective Public Health Intervention for Improving Knowledge, Attitudes, and Behaviour: A meta-analysis’ (2014) 26(4) International Review of Psychiatry 467, 472.

7

Ibid.

8

Anna M Ross, Claire M Kelly and Anthony F Jorm, ‘Re-development of Mental Health First Aid Guidelines for Suicidal Ideation and Behaviour: A Delphi study’ (2014) 14 BioMed Central Psychiatry 241, 242.

9

Ibid.

10

Anne PF Wand et al, ‘Firearms, Mental Illness, Dementia and the Clinician’ (2014) 201(11) Medical Journal of Australia 674, 677.

11

Lisa Kunde et al, ‘Pathways to Suicide in Australian Farmers: A Life Chart Analysis’ (2017) 14 International Journal of Environmental Research and Public Health 352, 364.

12

Hadlaczky et al (n 6) 472.

13

Leah Mishkin, ‘Gun Ranges Work with Mental Health Professionals to Get Help for Members in Need’, NJTV News (Web Page, 3 December 2018) .

14

Gina-Maree Sartore et al, ‘Improving Mental Health Capacity in Rural Communities: Mental Health First Aid Delivery in Drought-Affected Rural New South Wales’ (2008) 16 Australian Journal of Rural Health 313, 314.

15

Hadlaczky et al (n 6) 472.

16

Ibid 471.

17

Ross, Kelly, and Jorm (n 8) 243.

18

Mental Health First Aid Australia, ‘Mental Health First Aid for the Suicidal Person’ (2018).

19

Firearms Act 1996 (Tas) s 148(3).

20

Department of Health, Symptoms of Depression (2018) HealthDirect .

21

Sartore et al (n 14) 317.

22

Hadlaczky et al (n 6) 472.

23

Ibid.

24

Sartore et al (n 14) 314.

25

Tasmania, Parliamentary Debates, House of Assembly, 7 May 1996, 45 (Jim Bacon).

26

Australian Criminal Intelligence Commission, ‘Illicit Firearms in Australia’ (Report, 2016) 27.

27

Sue Turnbull, ‘On Looking in the Wrong Places: Port Arthur and the Media Violence Debate’ (1997) 69(1) The Australian Quarterly 40, 44-45.

28

Kunde et al (n 11) 364.

29

Ross, Kelly and Jorm (n 8) 242.

30

Kate Byrne, Iain McGowan and Wendy Cousins, ‘Delivering Mental Health First Aid: An exploration of instructors' views’ (2015) 17(1) International Journal of Mental Health Promotion 3, 19.

Samuel HG Diprose Adams is an independent researcher from Hobart, Tasmania, specialising in firearms law. He has appeared before Parliamentary Committees inquiring into firearms legislation and policy.