How to talk about firearms with patients
NEW YORK — Talking to patients about firearms is a challenging but important practice. In a session here, experts discussed how clinicians can start the conversation and when it is most appropriate to do so.
Gun ownership in U.S.
“No matter where we stand on this really complex debate about pushing toward increased firearm access, pushing toward increased firearm restrictions and improved safety measures, perhaps what we can all agree on — no matter where we stand on the safety issue, or on the political side of this — is that it should be at least as easy to access a good therapist, a good clinician, a good psychiatrist, a good crisis service, as it is to get your hands on a firearm. And wouldn’t it be great if they were both destigmatized,” John S. Rozel, MD, associate professor of psychiatry and adjunct professor of law at University of Pittsburgh Medical Center, and Healio Psychiatry Peer Perspective Board member, said during his presentation.
Gun owners account for about one in three households in the U.S., according to estimates from 2016. And, according to Abhishek Jain, MD, forensic psychiatrist at Columbia University, studies have shown firearms result in 10,000 to 12,000 annual homicides; 20,000 to 22,000 annual suicides; 50,000 to 80,000 annual injuries and an estimated $2.8 billion in health care costs each year.
“Gun access is ubiquitous, and is a risk factor for violence and suicide, but if we start to understand guns — the terminology, and the culture — we can be more effective as clinicians and can use that understanding and good clinical skills to have effective and useful conversations with our patients and their families,” Rozel said.
Tips for clinicians
Rozel and Jain, along with colleague Layla Soliman, MD, forensic psychiatrist at University of Pittsburgh Medical Center, presented tips for clinicians, like using motivational interviewing to engage patients; collaborating in the clinic to provide patients and their families with handouts on gun safety, or having gun locks readily available for patients at the front desk; and being knowledgeable about the different types of firearms and their associated terminology.
According to Soliman, asking about guns is more than just a checklist item, and having access to guns means different things to different people. “We make an error if we just tell the patient to get rid of it — risk doesn’t happen in a vacuum,” she said, adding that clinicians should consider general risk factors for violence, such as past violence, substance use, personality traits, life stressors and certain types of active psychotic and mood symptoms when making an assessment.
Soliman also made a strong argument for documentation, and suggested clinicians record the following items when discussing firearms with patients:
- what we said;
- how they responded;
- what we agreed;
- involvement of family, collaterals; and
- reference to what information we gave them.
Clinicians should ask about firearms as part of any risk assessment, they said. “If we’re scratching our heads about suicide or violence risk, or self-injury risk, we should probably be asking about firearms,” Rozel said, but added one caveat. “For outpatient providers, if it’s the college professor with panic disorder, there would be a reasonable argument to say no, unless there’s a change in risk.” Additional reasons to ask include: substance use, anger issues or impulsivity and accidental injury in the home, especially involving children.
Lastly, instead of simply telling patients to remove guns from their homes, the group suggested a shift toward promoting safe storage. Some options for gunowners include:
- storing guns somewhere else: in storage, with a safe friend, with law enforcement;
- selling guns: pawn shops, buyback programs, gun dealers, Armlist.com; and
- safer storage options: locks, safes, disassembled with ammunition separate.
“Talking to our patients about firearms can be a very challenging topic, but it’s important,” Jain said. “It’s important to have a collaborative approach not only with our patients, but also in the community and to have a voice in the community when it comes to these issues.” – by Stacey L. Adams
Soliman L. The gun talk: How to have effective and meaningful conversations with patients and families about firearms. Presented at: American Psychiatric Association Annual Meeting; May 5-9, 20178; New York.
Disclosures: The authors report no relevant financial disclosures.