Guns - Starting the Conversation

Today I talk about guns.  More specifically, I talk about talking about guns.

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Transcript

Guns - Starting the conversation

Welcome to PsyDactic - Residency Edition.  I am Dr. O’Leary, a nearly fourth year resident in psychiatry in the national capital region.  I create this podcast as a way to help me become a more competent psychiatrist.  By putting this content out into the world, maybe I feel more responsible for it, more responsible for my own education so that I don’t mislead others.  Maybe I am just hoping to be famous, but by my calculation, doing a podcast about psychiatry and psychology is not likely to make that happen.  I also want you to know that I am just one person with some thoughts, and though I try to base those thoughts on good evidence, they are, in the end just my opinion.  If you want to tell me what you think about my opinions, you can go to psydactic.com and fill out the response form there.  My opinions are not medical advice and my opinions certainly do not represent the opinions of the Federal Government, the Uniformed Services University’s Center for the Study of Traumatic Stress, the Department of Defense, or the National Rifle Association.

Today I am going to talk about guns.  More specifically, I am going to talk about talking about guns, but before I get started, I want to point you toward an even better podcast resource than this for having conversations about guns.  It is called, “Let’s Talk About Your Guns.” It is Hosted by Dr. James West and is part of the suicide prevention program at the Center for the Study of Traumatic Stress.  In fact, if you have limited time and decide to hit the stop button now and go to “Let’s talk about your guns,” instead, then you would likely get something better than I can produce on my own.  What I am going to do today is a primer and a review of some of the important points I have gathered from this and other sources that can be found at the end of the show transcript at psydactic.buzzsprout.com.  The benefit of this podcast is that I try to fit all this into about a half-an-hour program.  If you want a deep understanding of the importance of this topic and how to talk to patients, families, and even your friends about their guns, then subscribe to “Let’s Talk About Your Guns.”  They have provided me with no incentives whatsoever to make this recommendation, other than to have more competent colleagues and friends.

For health care providers, firearms safety is a major concern.  We think about things like murder, mass shootings and suicide, but these are just some of the concerns around gun safety.  Accidents make up 1-2% of firearms deaths yearly and there are many more injuries, physical and emotional associated with guns. I have many patients who had to witness a parent being threatened by their partner with a gun and the intensity of that experience often does not dim with time.  I don’t feel like I really need to go into reasons why firearms are a hazard to have laying around or freely accessible.  You can google “Pew research firearms” and see for yourself.

We know firearms are dangerous.  That is why people own them.  They feel the need to defend themselves, to defend their families, or they just like to hunt.  We don’t hunt with wet noodles, because noodles are not that dangerous.  From a very practical perspective, having more firearms and easier access to firearms means that there will be more intentional and unintentional injuries and death.  With more guns, there is just way more opportunity for this, in the same way that if you spend more time in a desert, you are more likely to see it rain, even though it is a rare event.  If you increase the amount of humidity in the atmosphere it will rain more often.

Because of this availability of guns, we have seen or heard about young people acquiring assault weapons or pistols and using them on teachers and classmates.  The shooter will often take their own lives afterward.  Media coverage surrounding the accessibility of firearms in this country tends to highlight extreme, inflexible, or entrenched views on firearms regulation, whether for or against more or less regulation.

In the context of all the controversy, if I were to say, “We should ask most of our patients about the guns in their homes,” many listeners will tighten at least one sphincter and maybe a few.  It may be that a sphincter involuntarily loosens and dumps the contents of your colon into your undergarments.  Talking about guns can be uncomfortable and even disorienting.  Many behavioral health providers have never owned or even held a gun.  When my wife, who is an immigrant, first watched an American football game with me, she had no idea what was happening and why.  Many providers can feel this way toward discussions about guns.  You may not know the difference between a pistol and a rifle, a shotgun and a 50 cal.  Even if you do, it may seem like too politically charged a topic to be able to have a reasonable conversation about.

So let me first tackle some myths about talking to our patients about their guns.

1. It doesn’t matter if they reduce their access to firearms, because they will just try something else.
   1. While it is absolutely reasonable that someone who is suicidal or homicidal can become stabby or cutty or swallow pills or jump from a bridge or poison someone to achieve the same goals, these things are not equivalent.  Bringing a bottle of pills to a gunfight is not as effective of a strategy and taking the time to drive to a bridge generally requires a lot more effort than going to the closet or the safe to get a gun.  Even if having less immediate access to firearms does not necessarily prevent a suicide or homicide attempt, using a gun is far more leathal than many other accessible methods out there.
2. My patient won’t return if we talk about their guns or having the conversation will inevitably damage the therapeutic relationship. This belief is based on the assumption that I can’t have a reasonable conversation with gun owners about gun safety.
   1. As behavioral health providers, we have to be able to separate ourselves from either our own entrenched and inflexible ideas about guns or what we expect our patients’ ideas to be.  Reasonable people can have very different opinions about the same subject and can respect the other person’s values, even if they don’t agree with their conclusion.
   2. Many gun owners are very concerned that their basic human rights are at stake here, or their ability to defend themselves or their families.  The primary way this belief is relevant to meaningful discussions about gun safety and risk management is that it helps you understand your patient’s values.  But peoples values or reasons for owning weapons generally doesn’t change the conversation about basic gun safety, because discussions about gun safety already assume that guns are present and accessible.
3. Another myth that providers might tell themselves is, “I don’t really know anything about guns so I am not qualified to have this conversation.”
4. You may not know the difference between an AK-47 or an AR-15, but the conversation you should be having about guns is not that kind of conversation.  You are not teaching a patient how to safely use a firearm.  You are helping others to safely possess firearms.  It is a conversation about risk management.
5. Talking about guns will include some aspects of education, but this education is primarily focussed on empowering the patient and their family to think about the real hazards of gun ownership and how to be good stewards of their right to possess firearms, not on what kind of firearms should or should not be possessed.
6. Also, I am not trying to change the patient or get the patient to rid themselves of firearms altogether.  I am trying to get the patient to decide whether or not they need to make some reasonable changes now or in the future to help protect themselves and their families.

Now that I have tried to convince you to feel responsible for having this conversation, I should also talk about when having these conversations is critical.

There are times when talking about guns is especially important.  Most providers assess for what we call “lethal means” when a patient is suicidal or homicidal. That makes sense, because our patients with firearms can imagine using them.  Aside from the obvious reasons, what about patients who are suffering from conditions such as dementia, Huntington’s, Parkinson’s, or during a first break psychosis or mania?  Gun safety is especially important to discuss with patients and families during the early stages of progressive diseases so that clear safety goals can be established when people are presently better able to engage in planning and following through with a plan.  If your patient has children, then it is also reasonable to ask how they prevent their kids from getting their hands on those firearms.

You may or may not feel like it is important to screen all of your patients for gun ownership or access to firearms. Gun ownership in the US is common and in many communities it is normal and expected.  Nearly half of homes in the US have firearms in them.  In a similar way that it is important to ask people about wearing a seat-belt, it is reasonable to talk to patients about firearms safety, even if there are no acute safety concerns like suicidality.  I have mentioned before that many providers are concerned about scaring patients away if they engage in conversations about guns.

I have had patients become visibly angry or defensive when I start a conversation about guns.  How did I navigate this?  Poorly at first.  I feel like I am getting better, but it was very uncomfortable in the beginning.  In my mind, gun safety conversations are a mishmash of motivational interviewing and socratic questioning.

Some of the general principles I learned that have helped me to talk about guns are these:

1. Be matter of fact.  Don’t act like it is weird to have the conversation.  To get started it can be helpful to normalize gun ownership.  You can start by saying something like, “About half of homes in the US have firearms.  Do you also have firearms in your home?”  Sometimes I don’t even ask if guns are in the home and just ask, “How many firearms are in your home?” or, if a patient is concerned about others hurting them, “Do you sleep with a firearm by the bed?”  
2. Allow the patient to discuss why they have firearms, what they do with their firearms, and their history with firearms.  If you want to avoid simply asking if a patient has a firearm, you can get to whether a patient has ever used firearms by asking first about recreational activities, like, “Do you ever go hunting?” or  “Have you ever qualified with a firearm at the range?” You can also ask, “How old were you when you first learned to shoot?”  Then you can segue into current use of firearms.  Although you don’t have to know much about firearms to have a reasonable conversation, it can be helpful to know what different kinds of firearms are in order to infer what kind of activities a patient might do with those weapons.  If someone has an assault rifle in their home, yes, they might feel like they may need it to protect themselves from a tyrannical government, but they might also just think it is fun to run a course at a range.  Toy guns make up a significant part of the kids section at Target because they are loads of fun.  They can be fun for adults as well.  It is important they know or at least believe that you know that having firearms does not make them a threat to society.
3. Do not start with advice or recommendations and never tell the patient that what they do is wrong.  People don’t necessarily get as defensive if they feel like you are interested in their point of view versus if you are trying to change it.  Ask them to tell you why they decided to do what they do with their firearms.  “You mentioned that you have a handgun in your dresser.  Why do you keep it there?”  or “Do you ever have a chance to practice with your assault rifle?”  To help the patient to start talking about their value of self-defense or readiness to defend themselves, you might also ask, “Do you feel safe in your home at night?” or “Are you concerned about break-ins in your neighborhood?”
4. Speak people’s values back to them.  You might say, “You have noted that being able to defend yourself and your family is very important to you,” or “I can see that it is important to you to pass on your knowledge of how to use guns to your children.”  Let your patient explore how their values are manifest.  You can ask questions like, “How do you teach firearms safety to your children?”
5. Reassure your patient that your goal is not to take away their guns, but to understand how they plan for safety so you can help them to do that.  If you really feel completely lost in gun conversations, then it might be a good idea to take a firearms safey course yourself.  It is not necessary, but it can give you a better understanding of your patient.  Even if you fall on the political part of the spectrum that wants private gun ownership banned, your role in treating patients is distinct and your political beliefs are not going to help your patient make decisions that are in line with their values.  Keep your patient’s values in mind always.

So far, I have proposed that it is important to talk to patients about their guns, especially if they are in a higher risk group or in a group whose risk of death or injury by firearm or of harming others, even unintentionally, is going to increase over time (like patients with dementia).  But what are the primary goals of these conversations and how do we get there?  I think there is one overarching primary goal that can guide other goals. The patient will develop or reinforce an already existing realistic view of the risks associated with firearm ownership and at least consider some actions that can reduce that risk.

Probably the most important cognitive exercise that can achieve this goal is to have someone actually estimate that risk for themselves.  If you have ever used motivational interviewing before, you know that part of the process can be to ask a patient on a scale of 1 to 10, where 10 means I definitely want to change and 1 is I have no desire to change, where they are at right now.  Once we establish that they are for example at a 6, we can ask them to rate how confident they are that they would change if they tried.  They might say 3/10.  Then we can also ask questions like, “What might move your confidence level to a 7 instead of a 3?” or “What might move your motivation level to a 10/10 instead of a 6/10?”  What is most important is not that they are able to come up with an answer immediately, but that they were asked the question.  Now their mind has spent a little more time engaged in possibilities.

Let’s apply something similar to a fictional suicidal patient.  Natasha lives in a neighborhood where her neighbor had someone break into their home while she was sleeping and stole a purse before escaping when she heard the neighbor call out “Who's there?”  Natasha now feels like she needs to be able to protect herself and her boyfriend bought her a pistol and she got certified for concealed carry.  She doesn’t usually carry the gun because she can’t take it into work with her.  However, she keeps it loaded and within arms reach when at home.  She does not have children.  When watching TV, she has her gun on the TV stand.  When in bed, it is on the nightstand.  It is loaded, but the safety is on.  She reports that after finding out her boyfriend cheated, she left him and has had suicidal thoughts two or three times per week for the last month.  At one point, she held the gun in her lap and wondered if anyone would care if she shot herself.

As her provider, I likely will see her gun as a hazard and her risk of death by suicide as much higher with the gun in the house.  She has revealed at least one important value to me: she wants to feel like she can defend herself in her home.  What I can do in this situation is ask her to estimate her risk of dying or being injured due to a home invasion and her current risk of dying by suicide if the gun is in the home.  She could estimate her risk of home invasion as a 2/10 and her risk of shooting herself as a 4/10.  It doesn't matter at this point hoe realistic her estimates are.   We could ask if she still feels safer with the gun in the home.  She might also estimate the risk of shooting herself right now as lower than having someone come into her home.

What is important to note here is that it doesn’t matter whether her own risk calculation matches yours.  What matters is that she answered the question and in the future, that question may linger in her mind.  The important thing is to raise the hypothetical.  I might ask, “Thinking about that time you held that gun and wondered what it might be like to die, can you imagine a time when your risk of harming yourself could be much higher than it is right now?”

At this point, I would feel like I need to lower the temperature a bit and ask her about her use of the gun and whether she has friends who also have firearms.  I might ask something like, “Do you know anyone else who practices at the range?”  I will also explore if she has people in her life that she could trust to hold her firearm at any point if that became necessary, if she ever got to the point when she felt like her risk calculation changed.

There are also some other very practical things that can be done without her removing the firearm from the apartment.  In terms of recommendations, basic firearm safety includes storing all firearms unloaded in a locked container when not in use.  Additionally there are devices that can be used to secure triggers or obstruct the chamber when firearms are being stored.  Ammunition should be stored in a separate locked container in a different location.   Instead of simply telling a patient to do this and checking the box, it is better to ask them directly how they store their firearms when not in use.  “Do you store your ammunition in a separate container?”  Don’t forget to ask the patient why they store their firearms the way that they do.

Once you have established a relationship with your patient and they have been able to report their values and feelings and you have reported these back, then you can offer some advice.  You have more credibility now to say something like, “I’d like to take a little time to discuss some of the recommendations for safe storage of firearms.”

You can also start to create a real safety plan regarding the firearms with your patient.  “If you ever do get the to point where you don’t feel safe with your guns in your house, who would you call that you could trust to store them for you?”  We recommend safe storage of firearms in a home or in some other place because it places a barrier to access that might give someone’s brain enough time to override an impulse, to reconsider a course of action, to get back to the point where it can experience fear of death.  Being able to walk to a closet or pick a loaded gun up from a nightstand is far different than having to unlock a container, release a trigger lock, load the weapon and then fire it.

I am not going to cover today what to do in situations when you feel like there is an imminent threat, for example if your patient is actively homicidal or suicidal.  These situations are in practice independent of whether they have access to firearms, because we are discussing premeditated intent at that point.  What is far more common in clinical practice is that firearms are present and represent a possible risk in the future.  Mastering the skill of getting patients to be able to think about that risk will make us better providers.  I am still working to master that skill.

https://www.hsph.harvard.edu/means-matter/means-matter/

https://www.pewresearch.org/short-reads/2023/04/26/what-the-data-says-about-gun-deaths-in-the-u-s/#:~:text=In%202021%2C%2054%25%20of%20all,had%20undetermined%20circumstances%20(458). 

https://www.cstsonline.org/suicide-prevention-program/projects/talk-about-guns