How to Counsel

Clinicians can learn how to effectively talk with patients about risk, access to firearms, and safety

Having culturally appropriate and respectful conversations with patients and making evidence-based recommendations can increase the safety of everyone living in homes with guns.

Clinicians routinely ask patients about lifestyle choices that affect their health and safety, and that of their families. Primary care providers discuss diet, exercise, and alcohol intake with patients, and new parents are asked about car seats, secondhand smoke, and water heater temperature. Many clinicians, however, do not talk with patients about the risks of firearms in the home, even when it’s clinically indicated.1,2

Clinicians can easily learn the basics about firearms, risks associated with access, and safe firearm practices in order to have knowledgeable conversations that result in realistic and acceptable plans to reduce the risk of gun injury.

No state or federal laws prohibit clinicians from asking their patients clinically-relevant questions about firearms.

Addressing Barriers to Counseling

Time constraint is a commonly-cited barrier to counseling patients about access to firearms, but a risk-based approach can help. Some populations clinicians see, like parents or caregivers of small children, warrant universal counseling, but for others, counseling on safe storage may be a lower priority.

Clinicians may be concerned about alienating patients, but research suggests that patients are receptive to these conversations: two in three patients say it’s generally appropriate for clinicians to talk with patients about firearms.3 Furthermore, evidence suggests that larger proportions of patients think conversations about gun safety are appropriate when the patient or someone in the patient’s home is at increased risk (84%-91%, depending on the risk factor).4

 

To help patients stay safe from firearm-related harm:

1. Be informed and respectful

Conversations about reducing risk of firearm injury will be more effective if clinicians understand and respect the reasons people own guns. The focus should be on the patient’s and clinician’s shared interest—the health and safety of the patient and their family. Opinions and politics about firearms have no place in these conversations.

Clinicians can become trusted messengers by becoming more knowledgeable about the subject matter, using appropriate language, tailoring messaging, and engaging with patients to make realistic and acceptable recommendations.5-10 As with other behavioral changes like quitting smoking or improving diet, repeated discussions about risk and access to firearms may be necessary to build readiness for change. Clinicians, especially those in clinical settings where longer-term relationships with patients are possible, may find it helpful to periodically assess patients’ readiness for change as related to firearm storage and access.

Firearm Ownership in California
Firearm owners have different perspectives and preferences, and different reasons for owning firearms. Fourteen percent of adults in California own a firearm, and compared to Californians as a whole, owners are more often male, older, and non-Hispanic white.11 The percentage of California adults who owns guns is lower than the national average (14% and 22%, respectively).11,12 Gun ownership is concentrated, with almost half of the guns in California owned by only 10% of owners.11

The most common reason for handgun ownership in California, cited by 57% of owners, is protection against other people. The most common reasons Californians own long guns are for sport shooting (34%) and hunting (19%). About 6% of firearm owners carry a gun for work.11

Appropriate language

  • Clinicians should use neutral, technically correct, and non-stigmatizing language when talking about firearms and their use. See Guns 101 for more on the basics of firearms.
  • “Firearm” is the technically correct term, but “gun” may be acceptable.
  • Safe (or secure) storage is part of “firearm safety” but not synonymous. “Firearm safety” refers to a wider range of firearm-related behaviors, including safe handling and use of protective equipment (e.g., eye and hearing protection) when someone is firing a gun.
  • If a clinician is concerned about a patient’s access to a firearm, words like “surrender,” “seize,” or “confiscate,” may feel threatening to patients, and may create a barrier to cooperation with the treatment plan. Instead, clinicians should use phrases like “hold for safekeeping,” “keep safe,” or “recover.”
  • Words like “temporary” or “voluntary” emphasize that a crisis will likely be time-limited and can help the patient retain a sense of agency.
2. Assess risk for firearm-related harm

Clinicians should screen patients for access to firearms when clinically relevant, such as when the patient or someone else in the home demonstrates or is known to have risk factors for suicide, domestic violence, interpersonal violence, or unintentional injury.

The following increase the risk for firearm injury in households with guns:2,13-24

  • Alcohol or drug misuse
  • History of violence
  • Early psychosis, paranoia, or command auditory hallucinations
  • Depression
  • History of suicidal thoughts or attempts
  • Dementia or other cognitive impairment
  • Children in the home
  • Intimate partner violence or domestic abuse
  • Active suicidal ideation
  • Active intent to harm others
  • Unsafe gun storage
3. Establish context and ask about access

Clinicians should inform the patient about their health concerns when inquiring about firearm access. Having clinically-relevant, nonjudgmental conversations about risk and access to firearms can help prevent harm. Patients expect doctors to ask about safety issues. Once a clinician has determined someone is at increased risk, they should ask directly about access to guns and how guns are stored. Asking if the patient shares the concerns may yield insight into the patient’s understanding of the risks and help to establish a collaborative relationship.

Opening the conversation
The point of entry for these conversations is context. Establish a context that makes the question about firearm access relevant to the patient’s health and safety. Be ready to explain who’s at risk of what type of gun injury and why.

The following examples of phrasing might help in different clinical situations.

  • “Lots of patients I see have guns at home. Sometimes when someone is going through a hard time, they store their guns away from home, like with a friend or at a gun range or gun store. This is just temporary, until they’re feeling better. Is this something you’d be willing to consider?”25
  • “I ask all caregivers about things that pose a risk to their families: water heaters, pools, medications, firearms. Do you have any of those things at your house? What kind of safety measures do you have in place?”
  • “It sounds like he’s not doing well. I worry that if things escalate to a crisis, he might try to use one of the guns in the home. Have you thought about ways to make them inaccessible, to keep everyone in your home safe?”

Acknowledging patients’ reasons for owning guns
People own guns for a variety of reasons, and gun ownership may be an important part of a patient’s identity.9 Many owners value their guns more than other possessions and may feel they need them for protection or other reasons. Because of this, the risk-benefit analysis of keeping firearms in the home may be different for a patient than it is for their clinician. Acknowledging the reasons for ownership will help build rapport and inform further discussions about storage and household safety. Clinicians’ personal or political opinions about firearms are not relevant to the health and safety of their patients.

Encountering resistance
If a patient is hesitant to discuss guns, clinicians can try techniques that are used when discussing other sensitive health topics.

  • respectfully emphasize why access to firearms is clinically relevant
  • reinforce the goal: keeping the patient or someone else safe
  • explore the patient’s reasons for not wanting to answer
  • ensure the patient has access to resources about safe firearm storage
  • if the risk is non-emergent, defer a continued discussion to a later visit; a patient has a right to not discuss firearm ownership if they so choose
4. Engage in risk-based, context-specific counseling

After a clinician identifies that a patient at risk has access to firearms, they should collaborate with the patient to find acceptable and realistic solutions for reducing access. At-risk patients may not be firearm owners themselves but may live in homes with guns. In such cases, risk reduction may require collaboration with other household members or caregivers.

Clinicians should tailor their approach depending on:

  • who’s at risk in the home and for what kind of harm
  • who in the home owns the firearms
  • what types of firearms need to be secured
  • what are the reasons for ownership

Examples of escalating risk and interventions

Level of risk Examples Intervention Learn more
Patients or others in the home have risk factors for unintentional injury only Children in the home Safe storage in the home that renders guns inaccessible to unauthorized users Safe storage
Patients or others in the home have chronic or intermittent risk factors for intentional injury but are not at acute risk Depression without suicidal ideation, past history of suicide attempts, heavy drinking, history of domestic violence, dementia Voluntary, temporary storage outside home Temporary transfers
Patients or others in the home are in an acute crisis that could become lethal with access to firearms Active suicidal ideation, active threats of harm against others, acute risk of domestic violence Immediate separation from firearms Civil protective orders, mental health holds

 

5. Follow up with continued discussions

Risk for firearm injury is dynamic; circumstances in the home can change over time, as can risk. Patients may experience a suicidal crisis, a relationship may become violent, or an infant may grow into a curious toddler. Checking in with patients at future visits about changes in risk keeps the conversation about firearms open. Future check-ins also allow for continued rapport building so clinicians and patients can establish a collaborative working relationship to prevent firearm-related harm.

Click to view references

  1. Roszko, P. J., Ameli, J., Carter, P. M., et al. (2016). Clinician Attitudes, Screening Practices, and Interventions to Reduce Firearm-Related Injury. Epidemiologic Reviews.
  2. Wintemute, G. J., Betz, M. E., & Ranney, M. L. (2016). Yes, You Can: Physicians, Patients, and Firearms. Annals of Internal Medicine.
  3. Betz, M. E., Azrael, D., Barber, C., et al. (2016). Public Opinion Regarding Whether Speaking With Patients About Firearms Is Appropriate: Results of a National Survey. Annals of Internal Medicine.
  4. Pallin, R., Charbonneau, A., Wintemute, G. J., et al. (2019). California Public Opinion On Health Professionals Talking With Patients About Firearms. Health Affairs.
  5. Walters, H., Kulkarni, M., Forman, J., et al. (2012). Feasibility and acceptability of interventions to delay gun access in VA mental health settings. General Hospital Psychiatry.
  6. Sege, R. D., Hatmaker-Flanigan, E., De Vos, E., et al. (2006). Anticipatory guidance and violence prevention: results from family and pediatrician focus groups. Pediatrics.
  7. Shaughnessy, A. F., Cincotta, J. A., & Adelman, A. (1999). Family practice patients' attitudes toward firearm safety as a preventive medicine issue: a HARNET Study. Harrisburg Area Research Network. The Journal of the American Board of Family Practice.
  8. Pallin, R., Siry, B., Azrael, D., et al. (2019). ''Hey, let me hold your guns for a while'': A qualitative study of messaging for firearm suicide prevention. Behavioral Sciences & the Law.
  9. Betz, M. E., & Wintemute, G. J. (2015). Physician counseling on firearm safety: a new kind of cultural competence. JAMA.
  10. Olson, L. M., Christoffel, K. K., & O’Connor, K. G. (2007). Pediatricians’ involvement in gun injury prevention. Injury Prevention.
  11. Kravitz-Wirtz, N., Pallin, R., Miller, M., et al. (2019). Firearm ownership and acquisition in California: findings from the 2018 California Safety and Well-being Survey. Injury Prevention.
  12. Azrael, D., Hepburn, L., Hemenway, D., et al. (2017). The Stock and Flow of U.S. Firearms: Results from the 2015 National Firearms Survey. The Russell Sage Foundation.
  13. Pallin, R., Spitzer, S. A., Ranney, M. L., et al. (2019). Preventing Firearm-Related Death and Injury. Annals of Internal Medicine.
  14. Monuteaux, M. C., Azrael, D., & Miller, M. (2019). Association of Increased Safe Household Firearm Storage With Firearm Suicide and Unintentional Death Among US Youths. JAMA Pediatrics.
  15. Grossman, D. C., Mueller, B. A., Riedy, C., et al. (2005). Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA.
  16. Betz, M. E., McCourt, A. D., Vernick, J. S., et al. (2018). Firearms and Dementia: Clinical Considerations. Annals of Internal Medicine.
  17. Zeoli, A. M., Malinski, R., & Turchan, B. (2016). Risks and Targeted Interventions: Firearms in Intimate Partner Violence. Epidemiologic Reviews.
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  19. Wintemute, G. J., Drake, C. M., Beaumont, J. J., et al. (1998). Prior misdemeanor convictions as a risk factor for later violent and firearm-related criminal activity among authorized purchasers of handguns. JAMA.
  20. Rowhani-Rahbar, A., Zatzick, D., Wang, J., et al. (2015). Firearm-related hospitalization and risk for subsequent violent injury, death, or crime perpetration: a cohort study. Annals of Internal Medicine.
  21. Cunningham, R. M., Carter, P. M., Ranney, M., et al. (2015). Violent Reinjury and Mortality Among Youth Seeking Emergency Department Care for Assault-Related Injury: A 2-Year Prospective Cohort Study. JAMA Pediatrics.
  22. Swanson, J. W., McGinty, E. E., Fazel, S., et al. (2015). Mental illness and reduction of gun violence and suicide: bringing epidemiologic research to policy. Annals of Epidemiology
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