How to Counsel

Learn how to effectively assess risk, talk with patients about access to firearms, and intervene appropriately

Engaging in 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, like diet, exercise, use of car seats, and secondhand smoke. Additionally, patients generally view their healthcare provider as a trusted source of information about their health and safety and that of their family.^1,2 Many clinicians, however, do not talk with patients about the risks of firearms in the home, even when it’s clinically indicated.^3-7

Clinicians can easily learn the basics about firearms, risks associated with access, and potential interventions 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

Clinicians across specialties cite similar barriers to discussing firearm injury prevention with patients, including lack of knowledge on the topic, concern about how such discussions would be received, and lack of time.^8-13

Despite concerns about alienating patients, research suggests that people are receptive to these conversations: 67% of individuals and 54% of gun owners say it’s generally appropriate for healthcare providers to talk with their patients about firearms.¹⁴ Furthermore, evidence suggests that larger proportions of individuals 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).¹⁵

For clinicians who are concerned there isn’t time to cover everything during each appointment, we recommend a risk-based approach. Some populations that clinicians see, like parents or caregivers of small children, warrant universal counseling, but for others, counseling about firearm injury prevention may be a lower priority that is only warranted when indicated.

The 3A’s Framework can help guide clinicians in clinical situations where firearms pose a risk of harm.

The 3A’s (Approach, Assess, Act) Framework is designed to guide clinicians through the process of talking with patients about firearm injury prevention. Practicing the 3A’s will help clinicians build rapport with patients and develop realistic and acceptable plans to reduce their risk of firearm injury. Each of the A’s has four elements.

The four elements of Approach are:

The first A is Approach. Conversations about firearm injury prevention will be more effective if clinicians frame them in the context of risk reduction. These conversations are about the patient’s and clinician’s shared interests – the safety and well-being of the patient, the people in the household, and in some cases, their communities. The goal is to increase safety by reducing access to firearms for people at risk.

Know why people own firearms and the basics of firearms, safer storage, and local policies.

Learning the basics about guns, the reasons people own them, and safer storage recommendations will help clinicians better understand their patients and their perspectives. Learning about local and state policies related to firearms, including temporary transfer laws and civil protective orders, is also a key part of staying informed as a provider and can be helpful when navigating potential interventions.

It also helps to learn and use neutral, technically correct, and non-stigmatizing language when talking about firearms and their use:

Talking explicitly about “preventing” or “reducing access to firearms” may help clinicians open the conversation and clearly articulate the goal: 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 they are 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.

Respect a patient’s decision to own firearms. As clinicians, we’re here to support people most at risk of firearm injury – firearm owners. This means recognizing that firearm ownership is common and may be an important part of a patient’s identity.  Many owners value their guns more than other possessions and associate them with safety, protection, and independence. 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.

Clinicians should practice cultural humility and be aware of their implicit biases related to firearms and firearm ownership when engaging in these conversations. Talking about firearms can be perceived as political, but politics and personal opinions have no place in these conversations. If they come up, redirect toward the shared goal of reducing risk.

Think about proposing steps, including small steps, toward reduced risk. The clinicians’ role is to keep patients as safe and healthy as possible; reducing some risk is better than not reducing any. Sometimes the safest scenario might not be achievable, so a safer scenario is the goal.

Let’s look at a few examples.

Someone who owns a firearm for self-protection may find the recommendation to keep their gun unloaded and locked up in a traditional gun safe 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 keep unauthorized users, such as children, from accessing it (e.g., a quick-access lock box or biometric holster).
For certain patients, removing all firearms from the home may be the safest option. If this isn’t possible and firearms will be staying in the home, clinicians can use a harm reduction approach to work with the patient to ensure that all guns are always stored locked up, unloaded, and separate from ammunition. Some people may be comfortable giving the key to the gun safe to a friend for safekeeping.

Find out what works for each patient. There’s no one-size-fits-all solution for reducing risk. The solution should be tailored to factors such as who’s in the household, who’s at risk, the level and type of risk (e.g., self-harm, unintentional injury, harm to others), as well as why firearms are owned and what types of firearms there are.

Clinicians can become trusted messengers by expanding their knowledge about the subject matter, using appropriate language, tailoring messaging, and engaging with patients to make realistic and acceptable recommendations.^9,16-20 As with smoking or other behavioral change, repeated discussions about risk of harm and access to firearms may be necessary to build readiness for change. Providers, especially those in clinical settings where longer-term relationships with patients are possible, may find it helpful to assess patients’ readiness for change.

The four elements of Assess are:

The second A, Assess, will help clinicians determine whether it’s clinically relevant to ask about access to firearms, and, if such a discussion is indicated, how to ask about access and then gauge willingness to work together on reducing risk.

Several factors increase the risk of suicide or interpersonal violence to patients or others.

Individual risk factors include:

Certain psychiatric disorders like depression, bipolar disorder, or schizophrenia^21,22
Substance misuse, especially alcohol and stimulants^23-26
History of suicide attempts²⁷
History of violence^28-30
Intimate partner violence or domestic abuse^31,32
Dementia or other cognitive impairment^33,34
Recent relationship or job loss³⁵
Storing guns in a way that they are easily accessible to at-risk people^36,37

Children in the home are also at elevated risk of unintentional injury.^36,37Clinicians should always ask about firearm access and storage when there are children in the home.

Certain situations are always considered higher-risk.

If a patient:

has thoughts about harming themselves or someone else, or
has made threats to hurt themselves or someone else

there is an elevated risk of injury or death, regardless of the presence of other risk factors.

If ideation, threats, or other risk factors are present, it’s relevant to ask about access to firearms.

It’s important to bring up firearm access in the context of the patient’s risk, health, and safety. Clinicians may choose to assume that the patient has firearms at home or directly ask 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, harm to others), who’s at risk (e.g., the patient or someone else in the home), and the severity of the risk.

The following phrasing examples might help in different clinical situations:

“I ask all caregivers about things that pose a risk to their families: pools, medications, firearms. Do you have any of those things in your home? 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 make sure the guns aren’t accessible to anyone at risk of misusing them or causing harm. What steps are you taking to prevent unauthorized access to firearms?”

Note: In some situations, it may be prudent to ask whether a patient has plans to acquire firearms even if they do not report current access.

If a patient is at risk and has access to firearms, assess their ability and willingness to collaborate.

The patient’s ability and willingness to collaborate on a plan for their safety will inform the clinician’s choice of intervention. Whenever possible, take a collaborative approach and work with the patient and their loved ones to reduce their access to firearms. Asking if the patient shares the concerns may yield insight into the patient’s understanding of the risks and perspective on prevention.

If the patient is unwilling or unable to collaborate, involuntary actions may be indicated to prevent harm.

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.

The following phrasing examples might help to talk about willingness to collaborate:

“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?”

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 or engage
Ensure the patient has access to resources about safer firearm storage
If the risk is non-emergent, defer discussion to a later visit; a patient has the right to not discuss firearm ownership if they so choose

The four elements of Act are:

The third A, Act, identifies the actions that clinicians can take to help prevent firearm injury based on the level (low, medium, high) and type (e.g., self-harm, unintentional injury, harm to others) of risk. Please note that these are broad recommendations and that the interventions may apply differently than is expressed in the examples presented here.

The four elements, or interventions, included under Act are:

Safer storage
Temporary transfer of firearms
Mental health hold
Civil protective orders

Explore how they correlate with level of risk, goals, benefits, and concerns in the table below.

Examples of interventions by level of risk

Level of risk	*Intervention(click to learn more)***	Intervention goal	Benefits	Concerns	Example
Low	Safer storage	Prevent or reduce firearm access by unauthorized or at-risk individuals.	Storing firearms unloaded and locked up reduces the risk of injury for everyone in the household.	Firearms remain accessible to people with keys or codes. Those who own for self-defense may be hesitant to lock up firearms.	Parent who has small children in the home but has no additional risk factors.
Medium	Temporary transfer of firearms	Temporarily remove firearms from the home during a time of crisis.	Various parties (e.g., family, friends, gun shops or ranges) may be able to hold on to firearms so they are out of the home entirely until the crisis passes.	There is little guidance on when guns can be safely returned. Voluntary transfer rules vary by state.	Person with intermittent or situational suicidal ideation who is willing to transfer their guns to another person temporarily.
Medium/High	Mental health hold	Temporarily separate someone who is at risk of suicide or violence because of a mental illness from lethal means, and connect them to treatment for the symptoms contributing to their risk.	This may reduce firearm access temporarily as well as address underlying mental health issues in an emergency.	This may not reliably separate the person at risk from firearms for the long term, as they may not be prohibited from ownership after discharge. Policies on mental health holds vary by state.	Person who meets emergency mental health hold criteria for danger to themselves or others and for whom psychiatric treatment may reduce the risk of harm.
High	Civil protective orders	Temporarily remove firearms from someone at immediate risk of harming themselves or others and prevent them from buying firearms for the duration of the order.	These can be requested by various parties such as law enforcement, family members, or employers. The orders do not require any criminal activity or mental health history, only a demonstrated risk of harm.	These may inflame already volatile situations. There may be a delay between an order’s issuance and the removal of firearms.	Person making threats of suicide or homicide who is unwilling or unable to separate themselves from firearms.

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. Presence of firearms in the home and how they’re stored may change. Checking in with patients at future visits about changes in risk keeps the conversation about firearms open and allows for continued rapport building so clinicians and patients can work together to prevent firearm-related harm.

Page last updated June 2022.

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Episode 12 – The 3A’s Framework for Reducing Firearm Injury

Dr. Amy Barnhorst introduces the 3A’s Framework, designed to guide clinicians through the process of identifying patients at risk for firearm-related harm and reducing their risk through appropriate interventions.

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Episode 3 - How to Counsel

This third episode of the explainer video series highlights how to have informed and respectful conversations with patients about the risks of firearm access and how to reduce that risk.

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Preventing Firearm-Related Injury and Death: A Targeted Intervention

This 45-minute video walks through how to talk with patients about firearm-related harm and is available for free CME credit.

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Reframe

AFFIRM has launched Reframe: Changing the Conversation about Gun Violence in America to foster productive dialogue, tell stories of prevention, and change the conversation about firearm violence.

Learn More External link

Safe Storage Printables

Download and print free educational materials on safe firearm storage for your clinic and your patients.

View the Printables

The Gun Shop Project

“Gun Shop Projects” are creating relationships with gun owner groups to enhance suicide prevention efforts.