The majestic Cascade Mountain range represents more than a physical divide running north to south through the state of Oregon. The volcanic picket fence also serves as a cultural divide separating the urban centers of the Willamette Valley from the predominantly rural counties east of the Cascades.

To the east, the roads are a little rougher, the distance between houses a little greater. There are more sagebrush and pine trees than concrete and people. There’s also a rarely mentioned but crucial difference east of the Cascades: Rural counties in the state have a 50 percent higher suicide rate than their urban counterparts.

For years, researchers have tried to unravel the reasons behind this urban-rural disparity. Are these deaths of loneliness or despair? Are they a consequence of poverty? Are they due to a lack of mental health services?

While all of those factors may play a part, suicide prevention activists are increasingly looking beyond the why and asking how. There’s a growing understanding that when it comes to suicide, the most significant difference between urban and rural counties may be the ubiquitous presence of guns.

In 2017, more than 400 Oregonians died in firearm suicides, about half of those in rural areas. That’s the equivalent of seven Las Vegas shootings, 24 Parkland school massacres, or 15 Sandy Hooks. Oregon’s firearm suicides are a mass shooting occurring one death at a time. Nationwide, two-thirds of gun deaths are suicides. In Oregon, the rate exceeds 80 percent.

Oregon’s main firearm problem isn’t murder or mass shootings. It’s suicide.

But while many suicide prevention activists would love to see tighter restrictions on guns, they’ve come to realize that decades of arguing over gun control and the Second Amendment have only pushed the two sides further apart. Restricting access to guns has become one of the most polarizing issues in American politics with rhetoric reaching histrionic levels.

That’s spawned a new approach to preventing firearm suicides. Public health proponents are now reaching out to gun enthusiasts to try to find common ground. They are seeking to penetrate one of the most widespread subcultures in the United States, to gain their trust and to learn how bitter rivals can work together towards a common goal: keeping gun owners alive.

Driving the divide

In 2017, Dr. Paul Nestadt, a psychiatrist with the Johns Hopkins Bloomberg School of Public Health, wondered how much of the urban-rural suicide disparity could be attributed to gun ownership rates. His home state of Maryland was the first to have a systematized statewide medical examiner system that made reviewing the data on suicide easy. The state is also one of the wealthier in the nation, with good access to health care and, particularly, mental health care, in both urban and rural areas. Additionally, it’s one of the more racially diverse states. That allowed him to compare gun and non-gun suicides in urban and rural counties more directly.

He found that suicide rates were 35 percent higher in rural areas, primarily due to a higher rate of firearm suicides. When Nestadt looked at non-gun suicides in urban and rural areas, there was no discernible difference in rates.

“If you take guns out of the equation that rural predominance goes away,” he said. “In fact, for women, who rarely use guns, there’s a much higher rate of suicide in urban areas.”

Those same trends apply to the country as a whole, and they’re particularly evident in Oregon. The most urbanized areas of the state have a suicide rate of 14.6 per 100,000 residents, while the most rural areas have 21.8 suicides per 100,000. The non-gun suicide rates in Oregon are much closer: 7.5 per 100,000 in the most rural areas and 8.4 per 100,000 in the most urban areas.

“Basically the same thing holds up,” Nestadt said.

Other studies back up his findings.

A recent review of studies on firearm ownership and suicide found that a gun owner had a 300 percent higher risk of suicide than a non-gun owner. Moreover, that increased risk applied to every person in a home with a gun. Last year, a Centers for Disease Control and Prevention analysis found that the less urbanized a county, the higher the suicide rate.

“The fact is, even more than depression or substance abuse, the strongest predictor of how likely a person is to die from suicide is a gun in the home,” Don Gross, former president of the Brady Campaign to Prevent Gun Violence, wrote in a recent report.

No matter how you slice it — rural versus urban, men versus women, whites versus blacks, old versus young — the higher the rates of gun ownership, the higher their suicide rate. None of those differences can be explained by higher rates of mental health, suicidal thoughts or previous suicide attempts.

Deadly force

It’s not that gun owners are more likely to attempt suicide. But when they do, they are much more likely to die. Only 10 percent of people survive firearm suicide attempts, compared with 97 percent of those who swallow pills or cut themselves. In the vast majority of cases, pulling a trigger has an immediacy and a finality that cannot be reversed.

Many gun owners counter that without guns, people will find another way to kill themselves.

“So many people are like, ‘Firearms, they’re dangerous.’ I don’t understand that,” said Jarrad Robison, a Redmond gun enthusiast pushing for a Deschutes County ballot measure this fall to allow local sheriffs to not enforce any gun laws they deemed unconstitutional. “It’s not the firearms that are dangerous, it’s the evil person behind the trigger who’s dangerous. Firearms don’t just get up and shoot themselves. If we get rid of all the firearms, someone is going to find a way to do harm if that’s their intent.”

Research suggests that might not be true. One study in the U.S. found that every 10 percent reduction in firearm ownership was associated with a 4.2 percent decline in rates of firearm suicide, and a 2.5 percent decline in rates of all suicides. Other studies have shown that when kids go off to college and no longer live in a house with a gun, their risk of suicide drops ninefold.

When Israel was reeling from a high military suicide rate, the army prevented soldiers from taking their guns with them on leave lasting longer than a weekend. In the seven year period after the policy change, suicide rates among soldiers dropped 57 percent compared with the seven years before the change.

“When you look at the data, making it harder to get your hands on a gun makes it much harder to actually die,” Dr. Matthew Miller, associate director of the Harvard Injury Control Research Center, said in a recent presentation, “not just in the short run, but in the long run, and what that translates into is an enormous potential to save lives.”

In fact, almost any barrier to easy access can reduce suicide rates. One study found an adolescent’s risk of gun suicide is four times higher in homes with a loaded, unlocked firearm than in homes where firearms are stored locked and unloaded. And a 2004 study found that when states enact child access prevention laws the suicide rate among teenagers drops by 8 percent.

“And this is based on a law that’s, as you can imagine, very hard to enforce,” Nestadt said.

Many people think of suicides as the end result of a long tortured process, where someone agonizes about taking their life, until they can no longer take it anymore. It’s far more likely to be an impulsive act, a response to an acute crisis, a moment of desperation and hopelessness.

One survey of suicide survivors found that 71 percent reported it took less than an hour from when they first decided on suicide to their first attempt, 49 percent reported it took less than 20 minutes and 24 percent, less than five minutes. Most suicidal crises are self-limiting, precipitated by an immediate stressor such as a break-up, the loss of a job, or a run-in with police. If someone can survive that immediate crisis, their chances of dying are dramatically lower.

“All you need to do is throw a few roadblocks in there,” said Paul Kemp, co-founder of Portland-based Gun Owners for Responsible Ownership.

Red herring

Gun owners have looked skeptically at public health efforts to reduce suicide and other gun violence as an end run around the Second Amendment.

“There’s some people who are anti-gun. They don’t want issues fixed, they come down to just taking the guns away,” Robison said. “That’s not what it’s about. We need to educate people, and let them understand firearm safety.”

Other gun advocates see suicide as a red herring issue, a way to conflate an intractable health problem with a political agenda.

“In this state where we lionize suicide — it’s like a sacrament to us — I kind of find it ironic that people are now using suicide as a mask for their gun-control protections,” said Kevin Starrett, director of the Oregon Firearm Federation. “That’s really what it is. People don’t give a damn about preventing suicides.”

Gun control advocates say they’ve heard enough of those types of arguments, and that denying the link between guns and suicides is costing lives.

“There’s so many people that I talk to who refuse to admit the guns have any relationship to suicide,” said Penny Okamoto, executive director of Ceasefire Oregon. “Anything we do, the gun lobby says, ‘Oh they’re trying to take away our guns.’ That’s just hysteria that we’ve heard for two decades. It has not come true. What has come true is an increase in firearms suicides, an increase in gun deaths, an increase in mass shootings.”

With every high-profile shooting, the calls for new restrictions get louder, and the defense of gun rights in response more fervent. Both Okamoto and Kemp believe those voices represent a vocal minority when it comes to public health issues like preventing school shootings, accidental deaths and suicides.

“There’s a segment who you’re never going to change their minds. They think everything is one step away from taking over their firearms,” Kemp said. “What I hear more commonly is, privately people will support a lot of the things that we are saying. It’s getting them to speak publicly about it.”

Kemp’s group formed after a 2012 shooting at the Clackamas Town Center that killed two people, including his brother-in-law. Its members are gun enthusiasts, hunters and supporters of the Second Amendment who advocate for “common sense efforts” to reduce gun violence and promote gun safety.

A number of such groups across the country are seeking a middle ground between banning all guns and steadfastly fighting any regulation or restriction. And that’s opened the door for greater cooperation between public health advocates and gun owners.

Mutual readiness

Last year, the American Foundation for Suicide Prevention and the National Shooting Sports Foundation co-developed suicide prevention materials for firearm retail stores, focusing on risk factors and warnings, suggesting steps such as removing firearms temporarily, safe storage, and denying sales where appropriate. The materials have been distributed across the country to gun shops, shooting ranges and other sporting organizations.

“The program materials really focus on the idea of the importance of either removing or securing a firearm when you have a person at risk for suicide,” said Doreen Marshall, director of programs for the suicide prevention group. The two groups have not always seen eye to eye on gun safety strategies in the past, but Marshall said of late both organizations have developed a “mutual readiness” to do something about gun suicides.

“I think they have changed over the years where people became more aware of the data around suicide and this became something that became a growing concern to them that two-thirds of all firearm deaths are suicides,” she said. “It certainly was on our radar but there didn’t seem to be a readiness at any point in the past to have a firearm group engaged around suicide.”

The two sides spent a lot of time talking well before any materials were developed. The suicide prevention advocates had to learn about the firearm world first.

“It’s not like this hasn’t been tried before, this sort of working with firearm owners,” Marshall said. “I think where it has not taken hold on a large-scale effort is using the wrong language can actually turn off firearm owners. They can think this is a hidden agenda or they think there is something else going on.”

They had to learn how to communicate with gun owners and soon realized, they couldn’t just write the suicide prevention messages on their own. They would need to work with the gun owners to craft the wording if they wanted it to resonate with gun owners.

Firearm owners have always emphasized safety in gun safety courses, and keeping yourself and family members safe from suicide seem to fall in line with that message. That also meant altering the language they used. They stopped referring to guns as lethal means or weapons.

“To the typical homeowner, protecting their property or feeling like they own a firearm for sport, that’s not how they think of it,” Marshall said. “It sounds subtle, but it does make a difference when you think about reaching that community.”

Dr. Cassandra Crifasi, a gun injury researcher with the Johns Hopkins Center for Gun Policy and Research, has faced numerous hurdles in trying to get gun owners to talk to her.

“I feel sometimes I have a double whammy,” she said. “I’m a researcher, a pointy-headed academic at the Bloomberg School of Public Health. ‘Oh you work for Michael Bloomberg and you just want to take everyone’s guns away.’”

But Crifasi is a gun owner. And that gives her a credibility with other firearm owners many other researchers lack.

“No offense to many of my colleagues but gun ownership and gun owners have sort of a unique culture. You can think of them as a subgroup unto themselves with a variety of things,” she said. “When you come at their conversation as a pointy-headed academic, people are going to tune you out.”

Gun owners are more likely to listen to one of their own, someone who can talk about what shooting activities she enjoys, what she teaches her kids about guns or how she grew up with guns in her home.

“If you have never owned guns it’s a difficult connection to make,” Crifasi said. “Talk to me about how we can come up with things that are acceptable to us, that are based on evidence, that doesn’t infringe upon the 2nd amendment. Help me give you a voice so that you can contribute to the solution rather than having people tell you, “Well this is what you need to do now.’”

Crifasi and her colleagues conducted focus groups with gun owners in Texas to determine what gun safety behaviors were common. The concept of personal responsibility was paramount for many of them.

“A lot of these gun owners talked a lot about the scrutiny that gun owners and gun ownership is under, and that when you have one jackaninny who does something dumb that ruins things for everyone,” she said.

In the midst of the focus groups, a shooting in a Michigan Home Depot parking lot became national news. A woman fired her 9 mm handgun several times at a shoplifter’s car fleeing the scene. The gun owners cringed at the news. That person had clearly not been properly trained, they told the researchers, she didn’t know when it was appropriate to use a firearm, and shouldn’t be allowed to carry a gun in public.

“This is one of our worst nightmares,” the gun owners told Crifasi. “Imagine if she had harmed an innocent bystander. Imagine how many more hoops people would want to add, or how much louder the call to ban guns would be because someone is engaging in some irresponsible behavior with a firearm.”

Making headway on reducing gun deaths could depend on treating gun owners as part of the solution, not as the source of the problem.

“I really try to keep that in mind,” Crifasi said. “How can we encourage responsible behaviors and get people to do the sort of things that everyone agrees they should do?”

Cultural approach

Guns are such an integral part of the social fabric, particularly in rural America, that many have come to believe reducing access to lethal means will not be accomplished through decree or legislative mandate. Instead, they are appealing to at-risk individuals and their families to temporarily store their guns outside of their homes or otherwise make those firearms inaccessible until a person at risk for suicide has recovered.

In Central Oregon, researchers have been working to identify the appropriate cultural framework to guide that conversation.

“When you go into primary care you have a lot of effort, rightfully so, around how do you do this in a respectful way to the Latino culture or the African-American culture,” said Susan Keys, an associate professor of public health at Oregon State University-Cascades. “And what do we ask on our intake forms in primary care? Are there guns in the household? Which we found out is a taboo. In rural Central Oregon, you don’t tell anyone how many guns you have or where you store them.”

In 2014, after a student shot himself at Bend High School, local clinics saw a surge in the number of patients expressing suicidal ideation. But many doctors struggled with how to talk to them about their guns.

“I would be talking to somebody about their blood pressure, and they would come out with, ‘I have been having these suicidal thoughts,’” said Dr. Laura Pennavaria, a family physician who is now the chief medical officer of the St. Charles Medical Group. “It felt like a giant hot potato to me.”

She met Keys at a community forum, and they started talking about how 60 percent of people who died by suicide had seen their primary care doctor within the past year, and 40 percent in the month before their death. They formed a suicide prevention work group to develop strategies for more productive conversations between doctors and patients at risk for suicide who owned guns.

Around that time, Keys had a chance meeting with Elizabeth Marino, a cultural anthropologist at Oregon State University-Cascades, and Keys told her about a training video she wanted to create to help doctors have that conversation.

“That seems like a cultural question,” Marino told her. “How you would have that conversation would be completely different based on how you think about those words.”

Marino had researched how various subcultures think about risk and knew different people can see opposite things as being risky. Some might view having a gun at home as risky, while others might see it as riskier not to have a gun protecting their home.

“Those are fundamentally different world views and that impacts how you have that conversation depending on which one of these you hold,” she said. “Of course it’s a continuum, not a dichotomy, but in United States this conversation has become dichotomized so it becomes even more important that that conversation at least understands where somebody might be coming from.”

Telling someone that having a gun at home is risky, and asking them to hand it over during a crisis, wouldn’t resonate with gun owners.

“What if you asked gun owners how they would have that conversation, if it’s possible to have a conversation, if they would feel comfortable talking to their physician?” Marino suggested.

Language matters

Keys and Marino decided to collaborate on a project and held focus groups with gun owners in rural Central Oregon, starting with the most basic questions: What does a gun mean to you? What does firearm safety mean to you?

“It’s dramatically different than what public health assumes,” Marino said.

When public health officials talk about firearm safety, for example, they’re talking about gun safes and storing ammunition separately. But when gun owners talk about gun safety, they talk about storing firearms out of the reach of children and training their children not to touch those guns.

“We just accepted the first step was not trying to empirically determine who was right and correcting them, but just listening to what the conversation was among firearm owners in rural communities,” Marino said.

Keys and Marino enlisted a social psychologist to fashion culturally appropriate messaging out of what they were hearing in the focus groups. They developed a brochure for gun owners that talked about suicide prevention efforts and held the second round of focus groups to test their messages. But there were still phrases and images in the draft brochures that gun owners didn’t like.

The original brochure, for example, had images of guns on it. Gun owners preferred images of the U.S. Constitution and other patriotic symbols that underscored a commitment to the Second Amendment.

The original version of the brochure talked about “giving your guns to a friend or family member.” The gun owners said that was wrong. Giving a gun to someone has legal implications with the current laws around transferring gun ownership. The researchers changed the language to “temporarily entrusting guns” to a friend or family member.

“It seems silly, but we agonized about the language we were using,” Marino said. “But actually, it matters.”

The gun owners also strongly believed that some individuals would harm themselves no matter what people will do to help, and that notion was incorporated into the brochure.

“That’s a very commonly held belief and I think that’s the place where this conversation gets stuck a lot,” Marino said. “We wanted to very intentionally not fight that battle. We didn’t want to challenge people’s belief that some people would harm themselves no matter what.”

The researchers decided to include that language in the pamphlet.

The focus groups also told them it was important to acknowledge how hard it would be for someone to give up their guns.

“We know it’s a big step,” the brochure reads, “but it’s just a temporary step until things get better.”

The brochure explicitly states that gun ownership is “an American way of life” and “a constitutional right,” but follows that message with the notion that “with this right to bear arms comes responsibility.”

“It wasn’t about the firearm. It was about who was being responsible or irresponsible with their firearms,” Marino said. “And so we were entering that conversation saying, ‘Well, maybe we should start talking about part of what being a responsible firearm owner is: Knowing when to give up your firearm or knowing when to intervene and ask to temporarily remove someone’s firearm.’”

The researchers conducted a study where they randomly assigned gun owners to one of four messages: a general statement about the importance of mental health and suicide prevention, a typical public health message about risks of suicide and how to prevent it, a culturally appropriate message designed to respect the value of gun owners, and a combination of the culturally approved and public health messaging. They then asked the gun owners how likely they would be to discuss giving up access to their guns with a primary care provider or a family member.

“What we found was the group that was most likely to have that conversation is the group that combined the culturally informed and public health messaging,” Keys said. “The group that received only the public health messaging is just as likely as the group that receives really nothing.”

The typical public health messaging didn’t resonate with this audience, she said.

“But if you can integrate it with something that is culturally relevant, they are significantly impacted,” Keys said. “And the group it was most impactful for were the rural firearm owners and the most conservative.”

The researchers learned that if the people didn’t trust you, they wouldn’t listen to your information. But if you acknowledged their culture and their beliefs, they were willing to listen and really wanted some help.

“Many of them have lost friends or neighbors or other people who had died by suicide so we were able to establish that common-ground trust,” Keys said. “It’s us recognizing that we have to help each other, and that I want to hold your gun if you’re at risk, and I want you to have it back when you’re no longer at risk.”

Keys has now printed and distributed thousands of brochures titled with the message they heard directly from gun owners “People who love guns love you.”

“I would liken the friend-to-friend approach just like we have for drunk driving messaging,” Kemp said. “Friends don’t let friends drive drunk. It’s as simple as that.”

Gun owners might be more receptive to that message when it comes from a fellow gun owner. Johnathan Courtney, a suicide prevention coordinator with Best Care in Madras, and a former Army ranger, says that’s particularly true of veterans.

“It’s a lot easier to ask that question: Can you remove the gun from the home? Can I take the gun? Would you have somebody else you trust?,” he said. “They are more apt to do that.”

Helping a friend

It’s unclear just how effective that voluntary approach will be. Many gun owners still bristle at any suggestion of removing guns from their home or the notion that guns are the issue.

“Honestly, if I did have a friend or something that was going through something like that, I would help them in the best way to get them the help that they needed, not to hold onto their firearm,” Robison, the Redmond gun enthusiast, said.

Starrett said he held guns for a friend in a crisis a few years ago.

“I knew she was experiencing some real serious issues in her personal life and I knew she owned a gun she had a permit for, and I knew she was self-destructive in the past,” he recalled. “We just had a long talk, and I just said, ‘Let me have that gun for now,’ and she gave it to me.”

He locked the firearm in his safe and after a couple of months, when she was in a better place, he returned the gun. Still, Starrett said focusing on gun owners strikes him as an odd approach.

“Everybody wants to reduce suicide, but some people have this … what I consider fantasy-land unicorn approach to it,” he said. “Suicide is not a new phenomenon. Suicide has existed for all time. Guns don’t cause suicide — despair causes suicide. How do you legislate against despair?”

Starrett also questions whether it remains legal for someone to take possession of another’s guns after the passage of Senate Bill 941 in Oregon in 2015. That law requires a background check to transfer a gun from one private party to another. The law includes an exception for the purpose of preventing imminent death or serious physical injury, but the provision lasts only as long as is necessary to prevent the death or serious physical injury. Gun owners worry that’s an impossible standard.

“It’s so vaguely written,” Starrett said. “You as the person who took possession of the gun would need to be able to prove that you knew as a non-professional the instant the danger has passed.”

Redmond gun owner Danny Long said he has held guns for people in crisis at least three times, including one earlier this year.

“If you or anybody else suddenly says ‘I need a place to put some guns, I’m afraid that my spouse is going to use them to commit suicide,’ I’m going to take them, and I will keep them,” he said. “But I understand there could be legal ramifications for that now.”

The last time involved a veteran whose counselor asked him to get his guns out of his house for a short time.

“They have all been situations where someone was concerned because they were deeply depressed,” Long said. “But there’s always a concern that somebody is going to feel like if they shouldn’t have had them at one point, maybe they should never have them. Let’s take them away.”

But Long also balances the risk of a firearm suicide with a need for protection. He once rebuffed a home invasion by four men wearing Halloween masks by meeting them at the front door with his dog and a gun.

“Everybody wants to be safe. No one wants to get hurt. But I also don’t want to see my family get hurt,” he said. “I don’t know that I could’ve overcome those four guys without a gun.”

Friendly fire

Working with gun groups on suicide messaging is controversial for public health officials as well. Many of the researchers trying to find middle ground say they’ve received some pushback from gun-control advocates.

“The challenge is that every year we don’t do something we’re losing 20,000 people,” Marshall said.

Crifasi said she’s been in meetings where colleagues opined that if they could just educate gun owners about the risk of owning guns, they wouldn’t own them anymore. That reflects a lack of understanding of the history and culture of gun ownership in this country, she said, and ignores all evidence about measures that have reduced gun violence while allowing people to own guns.

“I cannot tell you how many times I’ve been asked, ‘You study gun policy. You study gun violence prevention. You know all of the data. How could you possibly still own guns?’” Crifasi said. “This is the disconnect.”

When Keys and Marino came out with their brochure, some physicians told them it felt too pro-gun.

“That just suggests to me that these conversations are hard, but they’re hard for everyone,” Marino said. “Everyone is bringing a larger narrative with them when they come to the table.”

Even though the doctors agreed with the end goal of reducing access to firearms and preventing suicides, it wasn’t phrased in language that would resonate with them. That, Marino hoped, would be a great lesson in empathy.

“You can see how the reverse would be true,” she said.

Legal means

This year, a new law went into effect in Oregon to address cases where a gun owner in crisis won’t voluntarily give up his or her guns. The Extreme Risk Protection Order law allows concerned family members or law enforcement to petition in court to have those guns removed and to prevent the person at risk from buying more guns until their crisis has passed.

In May, Marco Varlesi was the first person in Deschutes County to be granted an order.

His younger brother was spiraling out of control after breaking up with his girlfriend of 14 years. He was drinking a bottle of vodka each night, driving drunk and becoming more erratic.

“For whatever reason, he couldn’t pull out of his tailspin,” Varlesi said.

His brother called Varlesi’s children to say goodbye and told one of them, he was going to shoot his former girlfriend and then kill himself. Varlesi needed to get his brother’s guns out of the house before he did something he wouldn’t be able to take back.

“I told him, ‘Look, you need to turn your guns over until you’re in a better place,” Varlesi said. But his brother refused.

So on May 21, Varlesi went to the Deschutes County Circuit Court and got the order. He arranged to meet deputies at his brother’s home so they could serve the order. Varlesi’s brother had 24 hours to turn over his guns. Varlesi received the guns from his brother, then turned them over to police.

Varlesi said the order was a wake-up call for his brother, who entered a detox and then a rehab program two weeks after surrendering his guns.

“I didn’t like the bill when it came out. It just made no sense,” said Varlesi, a gun owner and firm believer in Second Amendment gun rights. “But for him, ironically, it was perfect. I’m happy with the outcome. It did what it was written to do.” •

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