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.1-4

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.5 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).6

 

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.7-12 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.13  The percentage of California adults who owns guns is lower than the national average (14% and 22%, respectively).13,14 Gun ownership is concentrated, with almost half of the guns in California owned by only 10% of owners.13

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.13

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.11 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 patient’s reasons for ownership can help build rapport and inform further discussions about storage and household safety.

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” is acceptable.
  • Talking explicitly about “preventing” or “reducing access to firearms” may help clinicians open the conversation and clearly articulate the goal of these conversations: to reduce the chances that someone who shouldn’t have access to guns gains access.
  • 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 of guns 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 or antagonistic to patients, and may create a barrier to developing an acceptable risk reduction plan. Instead, clinicians should use phrases like “hold for safekeeping” or “keep safe.”
  • Words like “temporary” or “voluntary” emphasize that a period of acute risk will likely be time-limited and can help the patient retain a sense of agency.
2. Assess risk for firearm-related harm

When a patient or someone else in the home demonstrates or is known to have risk factors for suicide, domestic violence, interpersonal violence, or unintentional injury, access to firearms further increases risk of harm. In such situations, access to firearms is clinically relevant.

The following increase the risk for firearm injury in households with guns:2,15-26

  • 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
  • Storing guns loaded and not locked up
3. Establish context and talk about firearm access

Before discussing firearm access, clinicians should inform the patient about their health and safety concerns, including what type of risk they’re worried about (e.g., self-harm, unintentional injury), who’s at risk (e.g., the patient or someone else in the home), and the severity of the risk. Having clinically-relevant, nonjudgmental conversations about risk and access to firearms can help prevent harm.

Opening the conversation
The point of entry for these conversations is context. Establish a context that makes talking about firearm access relevant to the patient’s health and safety.

Clinicians may choose to assume that the patient has firearms at home or directly ask about firearm access. In either case, it’s important to normalize firearm ownership and ask about the steps patients or caregivers take to reduce access to guns by those at risk. 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?”27
  • “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?”
  • “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?”
  • “Many patients I see have guns in their homes, and I talk with each of them about how to help them and their families stay safe. What steps are you taking to prevent unauthorized access to firearms?”
  • “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?”
  • “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?”27

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. Provide tailored counseling and recommendations

After a clinician identifies that a patient at risk has access to firearms, collaborate with the patient to find acceptable and realistic solutions for reducing access. Asking if the patient shares the concerns may yield insight into the patient’s understanding of the risks and help to collaborate.

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 may tailor their approach to:

  • 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

For example, a large proportion of gun owners have guns for self-protection. Consider that willingness to keep firearms stored in the safest manner (i.e., unloaded and locked up) may be affected by the perception of a trade-off between keeping people in the home safe from firearm-related harm and keeping them safe from intruders or other threats from outside the home.28

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

Using a harm reduction approach

The clinicians’ role is to keep patients as safe and healthy as possible. Taking a harm reduction approach to firearm injury prevention means accepting that firearms are a part of some people’s lives and helping those people minimize the associated risks. Taking a non-judgmental and non-coercive approach to discussing effective strategies for mitigating risk may be most effective. Any action a patient takes to reduce risk, even small actions, is a step towards the goal.

For example, someone who owns a firearm for self-protection may find the recommendation to keep their gun unloaded and locked up unacceptable given their goals. With a harm reduction approach, the clinician works with them to find a solution that would allow quick access to the gun and also keeps unauthorized users, such as children, from accessing it (e.g., a quick-access lock box).

When making risk-reduction recommendations, clinicians should collaborate with patients and empower them to make responsible decisions about firearm storage.

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

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