WEBVTT

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Dr. Samantha Hack: Welcome. This is the Mental
Health Recovery and Wellness Webinar Series.

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This series is made possible by the VA Office
of Mental Health and Suicide Prevention,  

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Psychosocial

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Rehabilitation and Recovery Section. The
VISN 5 Mental Illness Research, Education

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and Clinical Center, or MIRECC, and in Partnership
with the Employee Education System. The planning

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committee members for this Webinar series
include Daniel Bradford, Valerie Fox, Spencer

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Glipa, Catherine Lewis, Marty Oexner, Kathryn
Peacock-Dutt, Donna Russo, Tim Smith, my co-host

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Ralf Schneider, and myself, Samantha Hack.

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Today's Webinar is entitled,
"Firearms and Suicide:

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Using Dialectical Behavioral Therapy Tools
in Lethal Means Safety Counseling." Our presenters

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for today's Webinar are Drs. Lauren Lovato
Jackson and Meredith Sears. Dr. Lovato Jackson

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is a staff psychologist in
the Reach Vet Coordinator

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at the Long Beach VA Healthcare System. She

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is also the former program manager for the
Long Beach VA DBT program. In addition to

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her DBT work within VA, she also currently
trains providers in the Los Angeles Department

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of Mental Health System as a consultant with
the Treatment Implementation Collaborative.

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Dr. Sears is a staff psychologist on the Suicide
Prevention Team at the San Francisco VA Healthcare

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System and the Associate Director of the SS
VA Dialectical Behavioral Therapy Program.

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She is also a health scientist assistant clinical
professor at the University of California,

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San Francisco. Her areas of teaching and research
are in lethal means safety counseling and

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DBT. At this time I'm happy to turn the Webinar
over to our presenters.

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Dr. Meredith Sears: Thank you so much Samantha.
All right, so today we're going to be talking

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about the connection between firearms and
suicide, and specifically how to use skills

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drawn from Dialectical Behavior Therapy, or

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DBT, to have hopefully, a
fruitful and collaborative

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discussion with a Veteran who is at elevated
risk for suicide. I am Meredith Sears. I am

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going to start us off today talking about
why it's important to talk to patients about

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access to firearms, especially when there
is a concern for suicide, and what your goals

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will be when you engage in those lethal means
safety counseling conversations. And then

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I will hand it off to Dr. Lovato-Jackson who
is going to tell you about storage options

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for firearms, and specific DBT strategies
like dialectics, validation and pros and cons,

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to help make lethal means safety counseling
less contentious and more effective. And as

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was already mentioned, if you want to go ahead
and put questions in the chat, Lauren is going

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to keep an eye on those as I present, and
I will do the same for her. So we will be

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answering some of those in the chat and then
we will reserve the majority of the questions

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that are easier to answer verbally for the
end of the presentation. So, first off, I

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want to start us off with a discussion of
the rationale for the whole concept of lethal

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means safety counseling. Um, so why should
we providers talk to Veterans about firearms

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and suicide. The first reason is that firearms
are responsible for the majority of Veteran

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suicide death. So as you can see here, um,
completed suicide in the US among males, male

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adults, firearms were responsible for about
54% of the suicide deaths. Among male Veterans,

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firearms were responsible for a whopping 70%
of firearm suicide deaths. And in females,

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the pattern,

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although
the number of firearms used, or the rate of

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firearms used is lower among females, you
can see that the pattern is similar, where

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female Veterans are more likely to die by
firearms suicide than by alternative means.

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Not only are firearms responsible for a really
big proportion of Veteran suicide deaths,

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and as you can image, Veterans are much more
likely to own firearms than civilians, um,

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but suicide is actually 5 times more common

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among firearm-owning
households, than in households

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where a firearm is not present. And I'll just
mention that that language is very intentional.

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It's not necessarily that the owner of the
firearm is more likely to die by suicide,

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but just having access seems to increase suicide
risk. So this suggests, on the face of it,

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that if we can reduce access to firearms,
especially when people are at elevated risk

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of suicide, and decrease just that one number
that we saw before, that 70%, that 42%, that

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might be a substantial hit to suicide rates
overall. So you might be thinking a couple

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of things. One, is it really just access to
firearms? And two, if we reduce access to

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firearms when people are at elevated risk
for suicide, might people just select another

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method and still die by suicide, and so do
we really want to pay a lot of attention to

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reducing access to firearms? So I will answer
those questions now. Um, first off, let's talk

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about whether there might be some other reasons,
other than simple availability, that increases

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the risk of suicide in households where a firearm
is present. So the real question here is

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correlation versus causation. Are people who
have guns at higher risk for suicide for reasons

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other than simple availability? So, for example,
are they more likely to have experienced a

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mental health problems, seriously considered
suicide, or attempted suicide. And the answer

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to all of these is a resounding no. Simply
having access to firearms does seem to increase

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the likelihood of suicide death, just all
on its own. One reason for this is the lethality

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of firearms. So, according to the CDC, 1.4
million Americans attempt suicide every year.

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That's a pretty extraordinary number, especially
considering that we lose about 46,000 people

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to suicide. So 46,000 out of 1.4 million attempts
are fatal. That's a lot of non-fatal attempts.

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So when you compare the means used in fatal
attempts versus the many attempts that people

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survive, you can see that firearms are, not
surprisingly, way over represented in fatal

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attempts. So here we have 51% of fatal suicide
attempts are by firearms, and only 1% of nonfatal

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self-injury are by firearms. This is largely
because firearms are so lethal.  

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So, the probability

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of surviving a firearm suicide attempt is
about 5 to 10%, and that's a pretty conservative

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number, whereas the probability of surviving
a suicide attempt by any other means, any

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other means, that includes overdosing, poisoning,
sharps, is about 95%. So, this is why we place

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a huge emphasis on talking with Veterans about
firearm access in particular when they are

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in a suicidal crisis, because on some level,
even if they were to, in a suicidal crisis,

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if they didn't have access to their firearms,
even if they were to replace the firearm with

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some alternative means, they would still be
more likely to survive that suicide attempt.

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So that's once of the reasons we focus a lot
on firearms, is just getting, reducing access

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to firearms can increase survival rates, whether
because someone does not make a suicide attempt,

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or even if they do make a suicide attempt
they are more likely to survive. And I'll

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just mention, just because 
I think it's interesting, 

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um, we actually have quite a lot of evidence

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that people don't tend to substitute means.
So, people tend to have preferred means when

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they've thought about suicide. And when they
don't have access to those preferred means,

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they don't have access to really readily available
means, we actually have data that suggests

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that they don't even make suicide attempts,
much less die by a suicide attempt. So I will

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just mention one of these, which is think
is particularly interesting, and that's the

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Israeli Defense Board. In the early 2000s,
they were really struggling with suicide by

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firearms in their active duty soldiers. And
so they implemented a really simple policy,

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they just asked the soldiers to check their
weapons in on base when they left home for

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weekend leave, and then they would check their
weapons back out when they returned on Monday.

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And they saw a 40% reduction in overall suicide
rates. So they didn't really see a change

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in weekday suicide rates, and they didn't
really see a change in weekend non-firearm

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suicide attempt rates. What they saw was just
an overall reduction because the weekend firearm

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suicide rate went down. There are similar
examples in the UK when they reduced carbon

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monoxide content in domestic gas,
which means basically in ovens. In the 1960s,

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suicide rates went down similarly because
that was a very readily available, very lethal

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means in everybody's home. Similarly, in Sri
Lanka, which is a very agrarian economy, a

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lot of people had access to toxic pesticides
and in the 1990s when they changed pesticide

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regulations and they reduced access to the
most toxic ones, suicide rates halved. So

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people do tend to have strong preferences
for a single method. In the U.S. a lot of

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our folks have access to firearms, and if
people have a preference for that method and

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if they have access to it, availability really
does seem to matter. One of the reasons we

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think availability matters so much is the
duration of suicidal crises. I think in kind

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of popular imagining often people think of
suicide as something that people kind of take

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a long march towards, and its kind of this
inevitable conclusion of a long passive suffering,

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and that's really not what we see born out
of in the data. What we really see is that

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a lot of suicide attempts, not all of course
but a lot of suicide attempts are quite impulsive.

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They occur in a moment of extreme emotional
distress when someone isn't problem-solving

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well; they encounter a problem and they don't
know how to solve it and they don't feel

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that they can ever solve it because the emotional
crisis is so intense in that moment. This

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research team went into hospitals, into their
emergency departments and talked with people

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who had survived very serious suicide attempts,
and they asked them, "How long was it from

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the moment when you first started thinking
about killing yourself, to the moment that

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you acted on those thoughts?" And not necessarily
for the first time ever, but in this episode

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of crisis and 48% said it was 10 minutes or
less from the moment that they started thinking

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about it, to the moment that they acted on
that thought and made an attempt. I believe,

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I can't remember the exact number off the
top of my head, but I believe it was over

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70% said it was less than 10 minutes from
the time that they decided to kill themselves

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to the action. So, that's a lot of people
in a very, very short period of time making

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this decision. And so access, as you can image,
matters enormously. So, the more we can kind

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of introduce barriers, make it a little bit
harder to access a loaded firearm in the case

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of a crisis, the more likely people may be
to sort of resolve that crisis, you know,

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take a breath, call the crisis line, what
ever it is. All right, so, what is our role

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as, sorry, I'm gonna summarize first. Access
to lethal means is an independent risk factor

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for suicide. Firearms are significantly more
lethal than other means of suicide. Most people

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don't seek out alternative means if they can't
access their preferred means, so, if that's

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a firearm. And then suicidal crises are
often brief. So, I'm gonna give you a little

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bit of a road map for how you might engage
in lethal means safety counseling in a session

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with a Veteran patient, and then we're going 

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to talk a bit about goals 
of what this conversation,

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what, what kind of, what the outcomes of this
conversation we want are. Um, so let's say

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you're talking to a Veteran, you've established
that this person seems to be at an elevated

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risk of suicide. They've got something going
on, they've got some stressors, they've been

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in and out of emotional crisis. I think it
would be a good idea to talk to them about

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firearms. So the first thing you're going
to do is raise the firearms issue. You're

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going to talk to them about access. You're
going to talk to them about their current

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storage method. Effective strategies for this
are really going to vary depending on a treatment

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context. So, if you have been, you know, engaged
in therapy with someone for six months and

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you know them really well, and you have a
bond and you have trust, that conversation

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is going to look pretty different than if
you're meeting them for the first time in

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a PCMHI context or in the emergency room,
or in an intake. Um, you're going to collaborate

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on a plan to reduce access to firearms, and
potentially lethal medications, and any other

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methods that they may be considering. So,
I really want to highlight the word collaborate

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and Lauren is going to be talking about this
in a lot more detail in a few minutes. This

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is not something where we just tell Veterans
that firearms are dangerous, you should get

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rid of them. This is a situation where they
get, ultimately, to make the decision about

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how they want to handle this level of risk,
and so your job is to educate and guide and

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to help them think through what the options
are and what the risks are. If it's indicated,

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you can ask the patient for 
a release of information 

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for you to contact and work with a friend

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or family member. So, if their plan for
reducing their firearm access, for example,

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involves giving the key to the gun safe to
their spouse, or doing a short-term loan to

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a family member so that they have the gun
out of the house, then that may be a situation

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where you want to say, um, "I'm really glad
that you're engaging in this, I trust you

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to do this, and I want to verify that you're
doing it so that I can help support you

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in making this choice," because it's not uncommon
for people when they're talking to you to

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kind of say, "Okay, you know what, this sounds
like a good idea" and then they get home and

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they're feeling okay, they're kind of, they've
decided they don't plan on going into crisis

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again any time soon and so it just seems less
important to actually execute the plan that

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they came up with you. So, if there is some
accountability that could increase the likelihood

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of success. You want to agree on roles this
is a smart goal, right? You're actually making

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a specific plan, so you want to figure out
what everybody is going to do, figure out

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a time table, and then you, as the provider,
can briefly document that plan in the suicide

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prevention safety plan. So, if you've done
a safety plan you already know that Step 6

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is options for increasing 
safety in the environment, 

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so you can actually say, specifically, in

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the safety plan, you know, made a plan with
the Veteran to reduce access to firearms.

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And then you want to follow-up with them as
indicated. So you don't want to just assume

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that it happened. You want to talk to them
about how it went, if they made any changes

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to the plan, and potentially document that
follow-up so it is easily available to future

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providers. So what are your actual goals
with these conversations? Um, one goal or

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course is to reduce access to improve the
likelihood that they might survive the next

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emotional crisis that they have, and Lauren
is going to talk in more detail about what

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that looks like. Another goal of lethal means
safety counseling is just psychoeducation

00:15:59.680 --> 00:16:05.440
for the community. According to the CDC, suicides
account for two-thirds of the total number

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of firearm related deaths in the U.S. I don't
know about you, but I don't hear about that

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a lot in the media. I hear a lot about homicide.
I hear a lot about risks of home invasions

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and robberies and burglaries and all these
things, and it just turns out that we are

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more at risk to ourselves when we own firearms
than we are than anybody else is to us, just

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statistically speaking. And that's something
that I just don't think is widely advertised,

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and I would like, personally, the entire United
States to become more aware of that. Most

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firearm owners don't believe that firearms
ownership and storage practices are related

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to suicide, and so that is something that
we can actually educate the public about.

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Ultimately what I would love to have, if anybody
has a great little tag line that they want

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to throw out there, I'm still looking for
one. Um, you know, ultimately I'd like to

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have something like friends don't let friends
have access to lethal means when they're in

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an emotional crisis. It's a little hard to
sew on a pillow, but eventually we're looking

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for something like this, where we can really
educate the public and so that, you know,

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eventually, I'd like it so that when a Veteran
sees a buddy whose struggling they say, "Hey

00:17:12.560 --> 00:17:17.040
man, you know, it doesn't seem like things
are going so well, um, maybe this would be

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a good time to, you know, 
store your gun differently. 

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Do you want me to help you 
get a lock of whatever?'

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So ultimately your goal is to develop a flexible
approach to means storage that is responsive

00:17:33.200 --> 00:17:39.200
to fluctuations and levels of risk. Um, so
you're not necessarily saying to the Veteran,

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"Hey, you sometimes get suicidal, you need
to just not have firearms in your home." You're

00:17:44.960 --> 00:17:48.880
ideally looking for something that is going
to accommodate both their desire to have firearms

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and the reason that they have for having firearms,
which are valid, and also improve safety.

00:17:55.600 --> 00:18:01.040
So ideally you have a Veteran who becomes
so aware of their own fluctuations and risks

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that they can kind of anticipate, Hey this
is one of these times when I shouldn't have

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access to my firearms. Okay, this is one of
these times when I'm pretty stable, things

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are going well and it's okay for me to have
the firearm. Um, and so you can imagine that

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self-assessing those fluctuations and acute
risk level requires a lot of skill. So it

00:18:19.440 --> 00:18:24.080
require mindfulness skills, which is one of
the reasons why DBT really focuses on mindfulness

00:18:24.080 --> 00:18:30.720
skills. It requires the ability to self-monitor.
So, in DBT we actually have Veterans fill

00:18:30.720 --> 00:18:36.640
out diary cards every single day where they
rate their suicidal ideations on a scale from

00:18:36.640 --> 00:18:42.000
0 to 5. So every single day they're exercising
that muscle of being able to self-monitor

00:18:42.000 --> 00:18:46.960
their risk, and when they start seeing that
number climb, they start thinking, okay, it

00:18:46.960 --> 00:18:50.000
seems like maybe things are maybe getting
into a more acute place and I need to change

00:18:50.000 --> 00:18:56.400
my storage strategies. Another strategy you
can use is looking at the warning signs that

00:18:56.400 --> 00:19:00.560
are listed on Step 1 of the suicide prevention
safety plan. So what are the kinds of things

00:19:00.560 --> 00:19:05.200
that start to pop up when I start getting
more acute. And Veterans can use that to

00:19:05.200 --> 00:19:13.040
assess their own fluctuations in acute risk
level. And then you're going to collaboratively

00:19:13.040 --> 00:19:18.160
identify patient-specific options for increasing
security of their firearm storage. The Veteran

00:19:18.160 --> 00:19:27.200
can then deploy as needed. And again, you
want to be really, really specific. Um, you

00:19:27.200 --> 00:19:30.240
can strive to provide a 
very clear, very transparent 

00:19:30.240 --> 00:19:32.800
rationale. So, I saw just out of the corner

00:19:32.800 --> 00:19:36.720
of my eye, someone brought up the 2nd Amendment
Rights issue, which is absolutely one of the

00:19:36.720 --> 00:19:41.280
biggest issues that we face in having these
conversations, is that sometimes the minute

00:19:41.280 --> 00:19:44.880
you mention the word firearms, the conversation
kind of shuts down, and they are not able

00:19:44.880 --> 00:19:48.320
to listen because they are so worried that
you're going to try to take away their guns.

00:19:48.320 --> 00:19:52.320
And so, you can head that off a little bit
by giving them a really clear transparent

00:19:52.320 --> 00:19:56.880
rationale where you're saying, Hey, this is
not political, I want to talk about your safety.

00:19:56.880 --> 00:20:01.760
There just happens to be this data that having
access to a firearm increases your risk . You

00:20:01.760 --> 00:20:05.200
can talk to them about impulsivity, talk to
them about all the reasons why you're concerned

00:20:05.200 --> 00:20:09.520
for their safety and why you care about them,
and really, really focus the conversation

00:20:09.520 --> 00:20:15.120
on safety. And join with them around that.
I've had some great conversations with Vets

00:20:15.120 --> 00:20:20.080
where, you know, I'm saying "I'm really worried
about your safety from your firearm," and they

00:20:20.080 --> 00:20:24.320
say "Well I'm worried about my safety from
other people," you know, they have PTSD and

00:20:24.320 --> 00:20:29.600
they want their firearm near them so that
they can feel safer, and I can say, "I'm so

00:20:29.600 --> 00:20:33.600
glad that we're on the same page, that we're
both worried about your safety. It's just

00:20:33.600 --> 00:20:38.080
that I'm a little more worried about your
safety from you, and you're more worried about

00:20:38.080 --> 00:20:42.400
your safety from other people so how can we
get on the same page about this?" But, at the

00:20:42.400 --> 00:20:47.840
end of the day, hopefully you can kind of
align with them about maintaining their safety.

00:20:48.960 --> 00:20:53.120
Broadly, your goal for lethal means safety
counseling is to place more decision points

00:20:53.120 --> 00:20:58.320
between suicidal impulses and suicide behavior,
to interrupt impulsive actions. So that means

00:20:58.320 --> 00:21:01.360
getting the guns totally out of the house
so that they re really inaccessible that's

00:21:01.360 --> 00:21:07.360
a pretty big barrier, or it may just mean
locking up the gun, putting the key in a different

00:21:07.360 --> 00:21:10.080
place, putting the ammo in a different place
- so it takes them 10 minutes to  

00:21:10.080 --> 00:21:10.880
collect everything

00:21:10.880 --> 00:21:14.880
that they would need, and that gives them
10 more minutes to calm down, call the crisis

00:21:14.880 --> 00:21:21.920
line, call a friend, whatever it is. We don't 
have specific data that shows us that decreasing

00:21:21.920 --> 00:21:28.160
access, you know, for example using locks
in the home as opposed to getting rid of the

00:21:28.160 --> 00:21:32.880
gun actually improved, or, um, actually reduces
suicide rates, but that's still something

00:21:32.880 --> 00:21:36.240
that someone really needs 
to study. But, intuitively, 

00:21:36.240 --> 00:21:39.920
and I certainly talk to 
Veterans who did experience

00:21:39.920 --> 00:21:43.680
that to be lifesaving. So I really do recommend
that this is one of these times when you want

00:21:43.680 --> 00:21:48.560
to kind of make the best guess we can ahead
of the research. And then you also want to

00:21:48.560 --> 00:21:53.440
underscore the temporary and flexible nature
of what you're proposing. The goal is not

00:21:53.440 --> 00:21:57.520
to have every Veteran store firearms out of
the home at all times. The goal is for them

00:21:57.520 --> 00:22:01.920
to be able to flexibly assess their own risk
and reduce access in a way that makes sense

00:22:01.920 --> 00:22:07.200
for them. One of the analogies that I really
like to use is drinking and driving. So, you

00:22:07.200 --> 00:22:13.200
can say to the Veteran, um, you know, If you
had a friend who came over and had a few glasses

00:22:13.200 --> 00:22:19.280
of wine and you didn't want them to drive
home, you wouldn't take their keys away for

00:22:19.280 --> 00:22:21.840
the rest of their life 
because they got intoxicated 

00:22:21.840 --> 00:22:24.240
once . You just want to hold on to hold onto

00:22:24.240 --> 00:22:28.240
their keys until they're sober enough to drive
home. And it's the same thing with firearms,

00:22:28.240 --> 00:22:31.920
right? You don't want to take away firearms
forever, we just want to make sure that you

00:22:31.920 --> 00:22:35.440
don't have them while you're in this really
emotional state where you're going in and

00:22:35.440 --> 00:22:44.720
out of crisis. Let's wait until the crises
pass and then let's revisit. All right, so

00:22:44.720 --> 00:22:49.120
now I'm going to turn things over to Lauren.
Lauren is there any question that would be

00:22:49.120 --> 00:22:54.240
helpful to answer right now, before we move
on to storage options, or shall we just plow

00:22:54.240 --> 00:22:56.080
ahead?
Dr. Lauren Lovato Jackson : I think there's

00:22:56.080 --> 00:23:02.720
a great question that just came in from
Don regarding a threat to self versus threats

00:23:02.720 --> 00:23:08.000
from others. The question is, Is there evidence
to suggest that reduced access to firearms

00:23:08.000 --> 00:23:13.760
compromise a person's ability to defend against
a threat? Short answer is yes, but Meredith,

00:23:13.760 --> 00:23:19.040
do you want to speak to that real quick?
Dr. Meredith Sears: I think you may be more

00:23:19.040 --> 00:23:23.520
familiar with the data off the top of your
head, but I can look up the data while you're

00:23:23.520 --> 00:23:27.520
talking
Dr. Lauren Lovato Jackson: Sure, um, Don really

00:23:27.520 --> 00:23:31.360
quickly, and I don't have the numbers off
the top of my head, and I hope this is the

00:23:31.360 --> 00:23:35.200
question you're asking, so let me know if
this is, if you had something else in mind.

00:23:35.200 --> 00:23:42.480
But, yeah, there is actually a number of studies
that kind of looked at what is the outcome

00:23:42.480 --> 00:23:49.920
in terms of increased actual safety when somebody 
has access to a firearm? And a couple of things

00:23:49.920 --> 00:23:55.280
that we do know is it actually seems that
the number of times in which somebody actually

00:23:55.280 --> 00:23:58.880
uses a loaded firearm during 
any kind of altercation 

00:23:58.880 --> 00:24:01.120
or assault is very, very, very rare. So, for

00:24:01.120 --> 00:24:07.440
example, in a home invasion if they, um, and
again, I'm paraphrasing and it's been a little

00:24:07.440 --> 00:24:13.360
while since I've looked at this research, but um,
I can send these resources to you. Um, it

00:24:13.360 --> 00:24:18.480
actually looks like the number of, the probability
of one actually using that firearm in that

00:24:18.480 --> 00:24:23.920
altercation is really rare, and also there
is also, on the flip side, some data to say

00:24:23.920 --> 00:24:31.680
if somebody does have a loaded firearm, it
actually can increase the probability that

00:24:31.680 --> 00:24:38.160
a transaction will escalate. So, there are
some things that we can look at and talk about

00:24:38.160 --> 00:24:42.080
with regard, and a lot of the times, and we
ll talk about this a bit more in a second,

00:24:42.080 --> 00:24:49.040
is, we need to validate the function that
firearms often times play and a sense of increased

00:24:49.040 --> 00:24:53.200
safety is key for a lot of the Veterans that
we work with. So there's a lot of room that

00:24:53.200 --> 00:24:57.280
we need to validate while also bringing in,
as Meredith was talking about, bringing in

00:24:57.280 --> 00:25:01.680
what we do know from the science. So I hope
that gives a little bit, again, I'm paraphrasing

00:25:01.680 --> 00:25:07.440
some of that, um, and I can send you more
specific resources if you're interested. Um,

00:25:08.080 --> 00:25:13.840
okay, so should we move on forward Meredith?
Are you ready?

00:25:13.840 --> 00:25:17.200
Dr. Meredith Sears: Yes, please.
Dr. Lauren Lovato Jackson: Okay great . So

00:25:17.200 --> 00:25:21.360
I'm gonna spend the rest of the time today
kind of talking about, um, now that Meredith

00:25:21.360 --> 00:25:26.480
kind of laid the rationale as to why we really
need to be bringing focused attention to firearms,

00:25:26.480 --> 00:25:30.240
um, I gonna plow into looking at how do we 

00:25:30.240 --> 00:25:34.080
have the conversation? So, 
tips, tricks, strategies,

00:25:34.080 --> 00:25:39.760
as many of us probably know, talking about
firearms can be really a tricky conversation.

00:25:39.760 --> 00:25:45.520
A number of people have asked about 2nd amendment
issues, um, a lot of our Veterans are very

00:25:45.520 --> 00:25:50.240
connected to their firearms, so this can be
tricky territory. And also, of course, it

00:25:50.240 --> 00:25:56.800
is really an important territory. So I'm going
to go into what we know about how to set ourselves

00:25:56.800 --> 00:26:03.920
and our clients up for success when we set
out to have that conversation. A little caveat

00:26:03.920 --> 00:26:09.520
here - it's interesting to note that there
isn't actually a tremendous amount of guidance

00:26:09.520 --> 00:26:14.320
out there for clinicians guiding us in how
to have this conversation. There is some,

00:26:14.320 --> 00:26:18.720
but as Meredith kind of mentioned earlier,
this is an area where a lot of research is

00:26:18.720 --> 00:26:24.560
still needed. Um, so what you're gonna hear
me do today is bring in what we do know from

00:26:24.560 --> 00:26:29.520
the research about how to have this conversation,
and you're going to see me present it from

00:26:29.520 --> 00:26:34.880
a DBT perspective. So, for those of you who
are doing DBT, comprehensive DBT or DBT informed

00:26:34.880 --> 00:26:41.360
treatment, our hope is, is that um, being
able to bring this content into your existing

00:26:41.360 --> 00:26:49.360
DBT work will be pretty seamless. So with
that, I will dive on in. Um, so probably one

00:26:49.360 --> 00:26:55.600
of the first things to know about doing this
work is just what storage options exist. If

00:26:55.600 --> 00:26:59.680
you're like me, prior to doing this work,
I would have been able to rattle off a couple

00:26:59.680 --> 00:27:04.080
of different storage options but me, personally,
and there is actually research to say a lot

00:27:04.080 --> 00:27:09.600
of providers are not too familiar with firearms.
Um, so I wouldn't have been able to tell you

00:27:09.600 --> 00:27:16.320
an extensive list of options available to
me when working with a client to increase

00:27:16.320 --> 00:27:21.280
overall safe storage practices. So one of
the first things that we as clinicians can

00:27:21.280 --> 00:27:26.480
do for ourselves is really kind of familiarize
ourselves with the hierarchy of storage options

00:27:26.480 --> 00:27:32.720
that exist. Just like Meredith mentioned,
and the goal isn't to have every Veteran remove

00:27:32.720 --> 00:27:36.480
permanently their firearms from their homes
that's probably not realistic and it's also

00:27:36.480 --> 00:27:43.360
probably not necessary. As we will talk about,
there are a lot of ways in which firearms

00:27:43.360 --> 00:27:51.600
can be used in a healthy way in an individual's
life. So, it's important for us to know

00:27:51.600 --> 00:27:55.920
that storing out of the home is definitely
an option. It is always probably going to

00:27:55.920 --> 00:28:01.680
be the safest option. That being said, if
we either can't work with the Veteran to get

00:28:01.680 --> 00:28:07.040
them to remove the firearm completely from
their home, or if that's either a willingness

00:28:07.040 --> 00:28:11.520
issue or there's resource barriers, there
are still a number of options available to

00:28:11.520 --> 00:28:18.080
us that we as clinicians can learn and work
to build motivation towards. So, for example,

00:28:18.960 --> 00:28:22.960
things that we can do in home environmental
adjustment that can be made through the course

00:28:22.960 --> 00:28:27.760
of our work with a client. Things like lock
the firearm and giving the key to someone

00:28:27.760 --> 00:28:33.280
else. Or even, say, if they don't have someone
to give the key to, maybe locking that key

00:28:33.280 --> 00:28:39.040
in a safety deposit box. Um, asking someone
who is a trusted friend of family member to

00:28:40.960 --> 00:28:46.160
change the combination on their gun safe.
This is one I regularly do, temporarily disabling

00:28:46.160 --> 00:28:52.720
a gun and then the client giving a key component
of the gun, such as the firing pin to someone

00:28:52.720 --> 00:28:58.720
else. And then even things like storing ammunition
out of the home. It's important to know that

00:28:58.720 --> 00:29:03.360
you may need to make small approximations
with some of these behavioral goals. I can

00:29:03.360 --> 00:29:12.240
think of one Veteran where, when I first started
working with this Veteran he kept his firearm

00:29:12.240 --> 00:29:17.120
loaded in his bed stand, and what we did over
the course of treatment is we slowly worked

00:29:17.120 --> 00:29:26.240
to remove the ammunition from the gun, and
then we worked to store the ammunition, so

00:29:26.800 --> 00:29:31.920
we got to a point where he was able to store
the firearm in a safe and then remove the

00:29:31.920 --> 00:29:37.120
ammunition and store it in the trunk of his
car, and then ultimately we worked towards

00:29:37.120 --> 00:29:41.120
storing the ammunition out of the home. So
you may have to take several passes at this

00:29:41.120 --> 00:29:44.240
and really think begin shaping this, just like we 

00:29:44.240 --> 00:29:47.280
would shape almost any 
other target and [inaudible]

00:29:47.280 --> 00:29:54.560
small approximations. If those things aren't
options, I'll loop back around out of the

00:29:54.560 --> 00:30:00.400
home storage options in a minute, but if those
options aren't possible, it is really important

00:30:00.400 --> 00:30:05.600
for us as providers to recognize that locked
guns poses lower risk, even though Meredith

00:30:05.600 --> 00:30:11.520
did say we don't currently have any research
to show what the change is, but it makes good

00:30:11.520 --> 00:30:16.960
intuitive sense, and again, what we're trying
to do, is we're trying to interrupt impulsively

00:30:16.960 --> 00:30:22.800
and mood dependence. As Meredith mentioned,
the combination of the lethality of the firearm,

00:30:22.800 --> 00:30:29.920
coupled with the impulsive nature of many
suicide attempts, that's what seems to be

00:30:29.920 --> 00:30:36.240
driving the high degree of complete suicide
by firearm in the country. So, really any

00:30:36.240 --> 00:30:42.320
step that we can implement to create some
time and some distance between a lethal firearm

00:30:42.320 --> 00:30:47.360
is always going to be a step in the right
direction. So, a lock imposes a lower suicide

00:30:47.360 --> 00:30:53.440
risk than an unlocked gun, no matter who holds
the key, and similarly, an unloaded gun poses

00:30:53.440 --> 00:30:58.080
a lower suicide risk than a loaded gun. Again,
I think that's worth highlighting for us as

00:30:58.080 --> 00:31:02.240
clinicians. I've been asked to consult on
a couple of pieces here and there where  

00:31:02.880 --> 00:31:03.840
a clinician

00:31:03.840 --> 00:31:10.320
will be in a difficult or challenging clinical
spot with a client who is posing an elevated

00:31:10.320 --> 00:31:17.520
risk for suicide and they've been doing their
best clinically and can't seem to get much

00:31:17.520 --> 00:31:21.280
movement in terms of removing the firearm
completely from the home or implementing a

00:31:21.280 --> 00:31:27.440
lot of the environmental recommendations that
were noted on the previous slide, and so,

00:31:27.440 --> 00:31:31.200
a lot of clinicians will kind of get into
this place where they really struggle and

00:31:31.200 --> 00:31:35.440
so I think it is really important for us to
note that even if the change that we work

00:31:35.440 --> 00:31:41.360
with our client to implement, using a cable
lock, that's an excellent step in the right

00:31:41.360 --> 00:31:45.360
direction, and that doesn't mean that that's
where we need to stop with this target.

00:31:45.360 --> 00:31:51.280
Again, small approximations may be necessary.
And then this last point here, it goes without,

00:31:52.080 --> 00:31:53.120
it may be obvious,  

00:31:53.120 --> 00:31:57.360
but it's worth really highlighting
- one thing we really want emphasized is that

00:31:57.360 --> 00:32:02.160
hiding a gun in terms of suicide or firearm 

00:32:02.160 --> 00:32:05.200
injury prevention is never 
going to be recommended.

00:32:05.200 --> 00:32:10.320
Unfortunately, it is really interesting diving
into this research, one thing that surprised

00:32:10.320 --> 00:32:17.280
me is that it seems like pediatricians are
actually driving a lot of the research in

00:32:17.280 --> 00:32:23.760
firearm injury prevention and the reason is
is they see a high degree of children, you

00:32:23.760 --> 00:32:28.720
know, stumbling onto firearms in the homes
that are "hidden," and of course we all know

00:32:28.720 --> 00:32:31.600
that children are curious 
and I think pediatricians 

00:32:31.600 --> 00:32:34.000
see the catastrophic outcomes of a lot of

00:32:34.000 --> 00:32:38.400
that. So, we want to just make sure we're
overtly stating that hiding a gun in the home

00:32:38.400 --> 00:32:44.400
is never going to be the recommended strategy
for increasing safety. So anything that increases

00:32:44.400 --> 00:32:49.280
the time and distance between a suicidal impulse
and a gun can reduce risk. And this should

00:32:49.280 --> 00:32:53.680
be our guiding light. The reason why it is
really important, again, for us, as clinicians,

00:32:53.680 --> 00:32:59.760
is as we've kind of already mentioned, having
these conversations can be really challenging.

00:32:59.760 --> 00:33:04.320
It can pull from mood dependence or it can
pull a client into emotion mind,

00:33:04.320 --> 00:33:09.360
it can pull ourselves, as clinicians into
emotion mind, um, because there

00:33:09.360 --> 00:33:17.360
are significant risks. And so being really
clear, in our clinical conceptualization,

00:33:17.360 --> 00:33:24.000
of what progress is, um, is, is really important
and this kind of really is, is what's hitting

00:33:24.000 --> 00:33:30.640
that home. Okay, so as I mentioned, I want
back around to off-site storage options. There

00:33:30.640 --> 00:33:35.120
are a number of off-site storage options to
be aware of. There are also a few legalities

00:33:35.120 --> 00:33:40.000
to be aware of I'll give you some resources
and show them, familiarizing yourself with

00:33:40.000 --> 00:33:48.800
legal, or laws and regulations in your state.
But in terms of off-site storage options,

00:33:49.680 --> 00:33:56.640
here are a couple that are really pretty routinely
used in firearms safety and safety counseling.

00:33:56.640 --> 00:34:01.760
So, one is relative, provided of course that
they aren't prohibited from possessing a firearm,

00:34:01.760 --> 00:34:07.840
being able to temporarily transfer your firearm
to a trusted adult is always a really good

00:34:07.840 --> 00:34:14.160
strategy. Another is storage facilities. Most
storage facilities will require you to store

00:34:14.160 --> 00:34:18.560
the ammunition separately, so that's just
something to note as you're helping your Veteran

00:34:18.560 --> 00:34:23.600
weigh through the pros and cons of these options.
Another option that a lot of people aren't

00:34:23.600 --> 00:34:26.720
aware of is actually police departments. So 

00:34:26.720 --> 00:34:29.520
some police departments will 
even store, temporarily,

00:34:29.520 --> 00:34:36.560
at no charge, a firearm if somebody is concerned
about a safety risk. Now, again, might seem

00:34:36.560 --> 00:34:42.320
obvious, but obviously, if we are working
with people who are emotionally dysregulated,

00:34:42.320 --> 00:34:46.960
maybe we're doing this for [inaudible] DBT where
skills may not be on board yet. We have to

00:34:46.960 --> 00:34:51.280
be prepared for a certain amount of potential
cognitive dysregulation and we have to coach

00:34:51.280 --> 00:34:53.680
it appropriately. So one thing we really want 

00:34:53.680 --> 00:34:56.240
to emphasize to our clients 
when we are considering

00:34:56.240 --> 00:35:00.480
police department storage options, is making
sure that the client actually calls the police

00:35:00.480 --> 00:35:05.280
department first to inquire whether storage
is an option, as opposed to just showing up

00:35:05.280 --> 00:35:10.320
with a firearm. Again, it seems like it might
be intuitive, that being said we want to make

00:35:10.320 --> 00:35:15.520
sure we're setting ourselves and our clients
up for success. Pawn shops - a lot of pawn

00:35:15.520 --> 00:35:20.880
shops, for a small very small loan, will be
a reliable storage option and then gun stores

00:35:20.880 --> 00:35:25.360
and gun clubs. And as you can see there are
a few of these items that have an asterisk

00:35:25.360 --> 00:35:31.920
next to it and these asterisks may require
a formal transfer order, um, and this is where

00:35:33.040 --> 00:35:38.240
this slide hopefully will be helpful to direct
you all. These are a couple of resources.

00:35:38.240 --> 00:35:45.280
Most of this resources have a directory by
state, where you can look up different laws

00:35:45.280 --> 00:35:51.520
related to formal transfers and firearms.
So, just it's just good to be aware of, what

00:35:51.520 --> 00:35:59.440
the laws are in your area. Um, I kind of debated
whether we wanted to even take this

00:35:59.440 --> 00:36:02.800
on, and then I figured, you know, what? It's
worth us noting. I'm not going to spend

00:36:02.800 --> 00:36:07.360
too much time on it, but this is something
that is really kind of catching more and more

00:36:07.360 --> 00:36:12.560
momentum. Some of you have maybe heard of
an ERPOS, or maybe this is your first-time

00:36:12.560 --> 00:36:15.680
hearing of an ERPO. It's 
relatively new legislature. 

00:36:16.560 --> 00:36:22.080
But it's, it's gaining momentum and there

00:36:22.080 --> 00:36:27.947
is a potential that this can show up on our
door. So it's just worth noting. So, an ERPO

00:36:27.947 --> 00:36:35.600
is an extreme risk protection order and currently
19 states have these in place. What an ERPO

00:36:35.600 --> 00:36:41.680
is, it's a piece of legislature modeled off
of domestic violence restraining orders, where

00:36:41.680 --> 00:36:47.680
if a family member or loved one of somebody
at risk of suicide is seeing cause for concern,

00:36:48.320 --> 00:36:57.240
what they can do is they can activate an ERPO,
which will then initiate a due process order

00:36:57.240 --> 00:37:03.920
that that individual will have their firearm
temporarily removed from them, and then, of

00:37:03.920 --> 00:37:09.120
course, there is a follow-up which evaluates
the level of threat and then determines what

00:37:09.120 --> 00:37:14.080
the next best step is for their safety and
constitutional right. Now, currently as it

00:37:14.080 --> 00:37:21.280
stands, only family members, or those close
to an individual can activate an ERPO Mental

00:37:21.280 --> 00:37:29.520
health providers are not people who can trigger
an ERPO yet. There is some of those entities

00:37:29.520 --> 00:37:37.440
that are lobbying for ERPOs. There is some
conversation about looping providers into

00:37:37.440 --> 00:37:44.800
this so that they themselves can also activate
an ERPO, but currently as it stands, providers

00:37:44.800 --> 00:37:51.040
are not able to activate this legal process.
Um, so again, just something worth noting

00:37:51.040 --> 00:37:56.000
as more and more states adopt ERPOS. Again,
it's becoming increasingly more likely that

00:37:56.000 --> 00:38:00.560
we will have a client who has either already
had an ERPO activated on them, or may have

00:38:00.560 --> 00:38:09.040
an ERPO activated in the future. So worth
noting. Okay, for tips and stylistic tricks

00:38:09.600 --> 00:38:16.160
from DBT incorporating firearm safety counseling.
So, again, as Meredith really emphasized,

00:38:16.160 --> 00:38:18.560
our goal is to make this process as collaborative 

00:38:18.560 --> 00:38:22.320
as possible. It can be challenging 
when we're talking about firearms.

00:38:22.320 --> 00:38:28.960
Again, firearms
tend to activate a lot of emotions, both for

00:38:28.960 --> 00:38:32.320
clients and for providers. And so, leaning 

00:38:32.320 --> 00:38:37.840
on DBT is a great way to 
approach this conversation

00:38:37.840 --> 00:38:42.240
and I think one of the things that I was really
delightfully surprised by when starting to

00:38:42.240 --> 00:38:47.733
dig into this area, is just how well suited
DBT is to have these conversations. There

00:38:47.733 --> 00:38:53.440
are a number of reasons for this. One is DBT
already designed for people at elevated risk

00:38:53.440 --> 00:38:58.160
for suicide. So, these are our clients, this
is the work what we're already doing, we're

00:38:58.160 --> 00:39:03.360
already having conversations about safety,
we're already keenly aware of safety issues,

00:39:03.360 --> 00:39:10.000
and we're, we're focusing on interrupted mood
dependent behavior, which is what DBT is all

00:39:10.000 --> 00:39:16.960
about. We're trying to, as clinicians, get
somewhere in between verge and action, and

00:39:16.960 --> 00:39:23.280
that is fundamental to preventing a firearm
related suicide as we just talked about. So,

00:39:23.280 --> 00:39:31.360
what we're trying to do in DBT is [inaudible]
up and running, so that we can engage somebody

00:39:31.360 --> 00:39:35.680
in value driven behavior as opposed to mood
dependent behavior. And of course, the whole

00:39:35.680 --> 00:39:42.720
DBT construct sets us up to hopefully do that
successfully. Another piece, in addition to

00:39:42.720 --> 00:39:48.480
the overall composition of DBT, there are
some key elements in DBT that are really important

00:39:48.480 --> 00:39:53.120
in approaching a conversation about firearms.
For example, the use of validation. What we

00:39:53.120 --> 00:39:58.160
know from the lethal means safety counseling
literature is that validation and, in particular,

00:39:58.160 --> 00:40:02.720
validating the functions of a firearm in a
particular patient's life is really, really,

00:40:02.720 --> 00:40:09.360
really important. And of course, as DBT clinicians
we know this. Being able to validate the function

00:40:09.360 --> 00:40:15.520
of a gun or a firearm, to be able to validate
whether it's in terms of their past or present

00:40:16.720 --> 00:40:25.040
experiences is fundamental to creating change.
So, DBT already sets us up really well to

00:40:25.040 --> 00:40:29.760
do this, and what we know from lethal means
safety counseling literature is that there

00:40:29.760 --> 00:40:36.560
are some key language elements to be really
mindful of when we approach this conversation.

00:40:36.560 --> 00:40:43.840
So drawing from the firearm lethal means safety
counseling research. What we know is you want

00:40:43.840 --> 00:40:46.960
to make sure were using lethal means safety, 

00:40:46.960 --> 00:40:50.000
as opposed to referring to 
lethal means restriction.

00:40:50.000 --> 00:40:55.360
Restriction was a word that was much popular,
even up to a couple of years ago. You will

00:40:55.360 --> 00:41:00.560
still hear it, and you really want to move
away from the word. That is coming from some

00:41:00.560 --> 00:41:09.280
research where, I believe it was a N of 270-ish
participants were presented with scripts and

00:41:09.280 --> 00:41:15.360
of those who heard the script lethal means
safety, as opposed to lethal means restriction,

00:41:15.360 --> 00:41:19.440
what we know is that they were much more likely
to engage in the conversation, and they were

00:41:19.440 --> 00:41:24.400
also much more likely to follow through with
clinical recommendations when they heard lethal

00:41:24.400 --> 00:41:27.680
means safety versus lethal means restriction. 

00:41:27.680 --> 00:41:30.320
So incorporating that 
language into the conversation

00:41:30.320 --> 00:41:36.080
is really important. Similarly, we want to
use the word firearm over gun. This one, I

00:41:36.080 --> 00:41:41.760
have to be honest with you, it's hard for
me, I tend to be fairly informal. DBT, with

00:41:41.760 --> 00:41:44.400
it's flattened hierarchy 
and I get to be irreverent 

00:41:44.400 --> 00:41:47.040
and I get to just kind of own my style, um,

00:41:47.600 --> 00:41:52.080
I tend to, again, be a little less formal,
so this is one that continues to be my work,

00:41:52.080 --> 00:41:57.360
but we really do want to emphasizes the word
firearm over the word gun. And then this final

00:41:57.360 --> 00:42:04.400
point is interesting. When also considering
the language, we really do want to emphasize

00:42:04.400 --> 00:42:10.480
that there is a difference between firearm
safety or what the phrase firearm safety kind

00:42:10.480 --> 00:42:15.440
of usually connotes, versus what we were trying
to [inaudible]. So if you talk to an

00:42:15.440 --> 00:42:20.912
average Veteran and say, "Hey, let's have a
conversation about firearm safety," what that

00:42:20.912 --> 00:42:26.800
is likely going to prompt in their mind is
that you want to talk about safety measures

00:42:26.800 --> 00:42:32.000
for shooting . While, again, I've already
disclosed, I can't tell you that I was really

00:42:32.000 --> 00:42:39.120
too savvy, in terms of firearm ownership, to
have me as a clinician come in and watch someone

00:42:39.120 --> 00:42:44.400
initiate a conversation about firearm safety
to a Veteran who was very savvy and very trained

00:42:44.400 --> 00:42:51.760
in the operation of a firearm. That, that's 
probably validating [inaudible]. Instead,

00:42:52.560 --> 00:42:55.120
what we want to do, is we 
really want to differentiate 

00:42:55.920 --> 00:42:57.840
what we're trying to do with this conversation

00:42:57.840 --> 00:43:02.320
from this idea of having conversation about
basic safety measure for shooting because

00:43:02.320 --> 00:43:07.520
they know that. So we want to make sure we're
using phrases like lethal means safety,

00:43:07.520 --> 00:43:13.280
or even firearm suicide safety as opposed
to "Hey, I want to have a conversation about

00:43:13.280 --> 00:43:16.720
firearm safety." So you 
really do want to emphasize 

00:43:16.720 --> 00:43:20.800
that this is related to suicide, be pretty direct

00:43:20.800 --> 00:43:27.200
about, so that was not offending them. Okay,
so in addition to the language of relying

00:43:27.200 --> 00:43:32.160
on overall structure of DBT, one of the most
important things as clinicians we can do is

00:43:32.160 --> 00:43:37.440
really stay balanced in the structural dialect
of DBT, which is balancing acceptance and

00:43:37.440 --> 00:43:44.880
change. So, again, our goal is to make sure
that we're not getting into a situation where

00:43:44.880 --> 00:43:49.040
we find ourselves in opposition with our client,
because then that's just not going to be a

00:43:49.040 --> 00:43:56.240
very collaborative or effective conversation.
We know that when individuals are confronted,

00:43:56.240 --> 00:44:00.640
it turns, it pulls for them to often time
just stick their heels in more, which doesn't

00:44:00.640 --> 00:44:05.680
facilitate change in the direction we want
to go. So we really want to adopt a dialectical

00:44:05.680 --> 00:44:08.000
stance and you've got an example on your 

00:44:08.000 --> 00:44:11.280
slide, where this might 
sound something like, "Look

00:44:11.280 --> 00:44:14.960
temporarily giving up your firearm when
you rely on it for self-protection is really

00:44:14.960 --> 00:44:17.680
scary. And at the same time they're really
worried about we are really worried about

00:44:17.680 --> 00:44:23.920
your safety and we know that having easy access
to a firearm may make your next bad day fatal."

00:44:23.920 --> 00:44:29.600
So we really want to be thinking both and,
both and, instead of either / or in the service

00:44:29.600 --> 00:44:34.400
of promoting behavioral change. And similarly 

00:44:34.400 --> 00:44:39.360
with that, we really want 
to lean on validation. Um,

00:44:39.360 --> 00:44:44.800
even though validation is an acceptance-based
strategy, it is often times the grease to the

00:44:44.800 --> 00:44:50.880
wheel. Validation, actually if you ever, if
you do find yourself stuck at a crossroads

00:44:50.880 --> 00:44:57.440
with a client, validation often times is one
of the first places that I'll want to go to

00:44:57.440 --> 00:45:02.960
try to start to see if we can get some movement.
So, validation, confirming that which is true,

00:45:02.960 --> 00:45:07.840
accurate, and understandable given a person's
current situation, and / or past history.

00:45:07.840 --> 00:45:10.080
So, really thinking about 
those levels of validation 

00:45:10.080 --> 00:45:12.720
that we emphasize in DBT, and all of those

00:45:12.720 --> 00:45:19.360
are relevant to this conversation about firearm
safe storage practices. So, what we really

00:45:19.360 --> 00:45:23.760
want to do, when validating, is we want to
honor the wisdom. We want to honor our client's

00:45:23.760 --> 00:45:29.360
agenda when it comes to the role that the
firearm plays in their lives. For a lot of

00:45:29.360 --> 00:45:36.160
our clients, firearms are a form of social
connection, or may even behavior activation.

00:45:36.160 --> 00:45:44.240
Um, you know, there's lots of reasons why
firearm is similarly safety. Obviously, especially

00:45:44.240 --> 00:45:48.720
if there is a trauma related background, or
anything like that, um, and even just the

00:45:48.720 --> 00:45:55.440
culture that a lot of our Veterans are coming
from, um there's a very special relationship

00:45:55.440 --> 00:46:02.400
and a lot of learning history to be very mindful
of when we approach the conversation about

00:46:02.400 --> 00:46:09.520
implementing steps to access a loaded lethal
firearm. So the validation is going to be

00:46:09.520 --> 00:46:13.840
really, really important. It communicates
acceptance, and what we know from a tremendous

00:46:13.840 --> 00:46:18.080
amount of research is that it can reduce
negative affects, promote more disclosure

00:46:18.080 --> 00:46:23.920
of emotional states, improve emotion regulation
skills, and even be effective in lowering negative

00:46:23.920 --> 00:46:30.880
mood and aggressions. If you ever find that
you're stuck, again, this can be a tricky

00:46:30.880 --> 00:46:35.040
conversation to have. So, if you ever find
that you're at a stalemate with a client and

00:46:35.040 --> 00:46:39.680
you want to do validation, you think if this
lecture and be like, Okay, let's try and validate.

00:46:39.680 --> 00:46:45.040
Um, if you're ever stuck about what to validate,
here are some things that usually we can always

00:46:45.040 --> 00:46:46.720
find a kernel of truth.

00:46:46.720 --> 00:46:47.920
END RECORDING