ISIH S3 E28 / Gun Violence in America: Trusted Messengers

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Celine Gounder: Hi, everyone. Celine Gounder, here. I’m the host of “In Sickness and in Health.” We really appreciate all our loyal listeners, and I’m hoping you can help us grow this community even more. If you like our podcast, please nominate us for the Discover Pods Awards. Go to awards.discoverpods.com to submit a nomination. That’s awards.discoverpods.com. But be sure to do so by October 22nd! That kind of recognition will help us grow the show. Thanks for your support, and thanks for listening. Now, on with the show.

Celine Gounder: Welcome back to “In Sickness and in Health,” a podcast about health and social justice. I’m Dr. Celine Gounder. This season we’re looking at gun violence in America.

Ralph Demicco: I had one case, in particular. This Saturday morning, this lady came in, and she was dressed in a business suit, you know, very professional looking woman… She walked up to the counter, and she looked down, and she said, "I think I'd like to buy that gun." I looked at her, and I said, "Do you really think you should be buying a gun?" She immediately broke down, started crying... and I said to her, “I just get the feeling that you’re buying this gun to do harm to yourself, and I don’t want this to happen.”

Celine Gounder: There are almost 24,000 suicide deaths by firearm in this country each year. These deaths are occurring among gun owners… their kids… and other family and friends. We live in two very different worlds when it comes to guns in the U.S. The people for whom their only experience of guns is as a problem… and the people for whom guns will never be a problem… until… they are. What can we say to gun owners to help them understand that we care about their safety? How do we make sure that message gets through?

Ralph Demicco: I’ve had a number of them over the years. You just sense something's wrong. Somebody doesn't have any level of experience with firearms, and you just don't sell them a gun on the spot.

Celine Gounder: On today’s episode of “In Sickness and in Health” we’ll speak with gun owners, gun dealers, and gun trainers… and with doctors and public health researchers… who’ve found a way to bridge the divide… talk… and work together. Much of this work comes down to having trusted messengers… people who understand the language and culture… who know how to reach the folks who are at highest risk.

Celine Gounder: Health care providers too often fail to recognize patients at risk for suicide.

Emmy Betz: I do think sometimes, healthcare providers, it's like they don't want to open Pandora's box, or what they see as Pandora's box. They're not sure what to do next or feel like they don't have things to offer to patients.

Celine Gounder: This is Emmy Betz. She’s an ER doc at the University of Colorado School of Medicine. She also studies suicide and injury prevention. 

Celine Gounder: Emmy says that even when healthcare professionals know a patient’s at risk for suicide, they don’t necessarily inquire about access to guns. 

Emmy Betz: I think in the case of firearms, there's also an extra layer of maybe fear, not wanting to offend patients, not wanting to get into political arguments, ignorance in terms of not knowing what to say. If it's a provider who doesn't own a firearm and isn't comfortable with firearms, they may not know how to ask or what to say if the person says that they do have a firearm.

Celine Gounder: Emmy says there’s a lot of work going on right now to raise awareness among doctors and nurses… teaching them not just to ask patients about firearms… but more importantly, how to engage patients in these conversations in productive ways.

Celine Gounder: As health care workers, we don’t just care for patients who look and think and speak just like us. It’s part of the job to learn how to cross all sorts of cultural divides, and the language we use is a big part of that.

Emmy Betz: It's about learning how to talk with patients so that they recognize that you respect them, that you respect their individual perspectives and wishes, and that even if you don't know everything about whatever culture it is that they're a part of, that you are open to learning about it, and that you've at least, maybe, tried to learn some of the key points.

Celine Gounder: In addition to having some understanding of a patient’s culture, Emmy says health care workers also need to know where to refer patients… and what resources and options are available.

Emmy Betz: I think physicians need to learn a little bit about the basics, about handguns, long guns, storage options… where to send people if they want more information.

Celine Gounder: These conversations are especially important to have with older patients.

Emmy Betz: ...suicide rates do go up in the older ages including by firearm... and that's particularly true among older men.

Celine Gounder: Suicide is the biggest gun-related risk for aging patients. But it’s not the only one.

Emmy Betz: With dementia, it's common to have behavioral disturbances, paranoia, hallucinations, aggressive behavior, and so there's a very legitimate concern that an older adult who is no longer recognizing people, when the family member or the home health care worker comes to their home, that they potentially, if they were armed, that that could potentially be really dangerous.

Celine Gounder: Conversations about guns can be especially hard to have with older men. Firearms can be a real source of pride... of identity... of a sense of freedom. Losing access to guns… can be just as big a blow… as having a car taken away.

Emmy Betz: ...it’s a strong part of how they see themselves potentially, and they may feel that losing access to their car, losing access to their firearms is a real blow in that sense… these conversations should ideally start early. … I view the provider’s role as... explaining to families, "Look, you're going to need to talk about driving, firearms, kitchen safety," a list of things and providing resources, but then recognizing that it's probably going to be really a family decision because, again, it's not about confiscation.

Celine Gounder: While doctors and nurses are important points of contact for gun owners in crisis… they aren’t the only ones… or necessarily the first. Some would argue that they’re not the most effective ones, either.

Ralph Demicco: There's always going to be that feeling that if it comes from the healthcare community, it must be anti-gun.

Celine Gounder: This is Ralph Demicco. You’ll get more of his take on the medical community later in the episode. But for now, you should know that he used to own Riley’s Sports Shop, the oldest gun shop in the state of New Hampshire.

Ralph Demicco: I worked in the firearms industry for 40 years. Prior to that, served four years in the military after graduating from college… I was in the Air Force. I served in, first in South Dakota, then Vietnam, and then North Dakota. I had not what you would call the best assignments in the world.

Celine Gounder: Riley’s Gun Shop is not just a sports shop, but an institution in the state. It was started by Richard Riley in 1953 in Hooksett, New Hampshire. Riley was involved in the political process, especially around firearms legislation. He was even state senator at one point. Ralph worked for Riley for a long time, and in 1987, he and a partner bought the business from him. But they carried on his legacy.

Ralph Demicco: He had a strict code of ethics and… he always stressed social responsibility... It was important to him to do the business in a fashion that did not bring disgrace upon us…

Ralph Demicco: He has always said, "Make sure the person to whom you are selling the firearm is the person who intends to be the owner. If you ever sense anything like, individual’s coming in and trying to buy a gun for somebody who says, 'Yes, yes, that's the one. Buy me that one,' we just shut a sale like that down."

Celine Gounder: In addition to looking out for straw purchasers, Ralph remembers Riley would instruct his clerks to look out for people coming into the store smelling of alcohol or drugs, trying to buy firearms under the influence. Riley, Ralph says, was diligent about reporting suspicious behavior to the local police or the feds. And, when he became the owner of the store, Ralph tried to do the same thing.

Celine Gounder: But… then one day... in 2009… Ralph received a phone call from a friend.

Ralph Demicco: My long time friend, Elaine, called, and I hadn't spoken with her for a while, and after a few formalities, she said, "By the way, were you aware that in the span of six days, three individuals each bought a firearm from Riley's and subsequently took their lives?" 

Celine Gounder: Ralph was shocked. He remembers thinking that perhaps the suicides were related… like some sort of suicide pact. But, no.

Ralph Demicco: No connection whatsoever.

Ralph Demicco: It really bothered me because my philosophy with my employees was you were never under any obligation to sell anything to anyone. They never worked on commissions, so there was never an incentive for them to sell. 

Celine Gounder: Their job, Ralph had stressed over and over... was not to make a sale, but to qualify the buyer… to assess how comfortable they were around guns, to screen their behavior… and make sure they were in the right state of mind to be purchasing a deadly weapon. But neither he nor any of his clerks had noticed anything odd about any of these three customers.

Ralph Demicco: They said nothing out of line. They displayed all the experience they had, and then they just left and went and took their lives. So those, I don't know how we catch.

Celine Gounder: This incident, however, made Ralph realize that… while there are some individuals who’ll always fly under the radar… perhaps there was more that he and others like him could do to help others.

Celine Gounder: So… when Ralph’s friend Elaine suggested a way to engage gun shop owners and firearms dealers in suicide awareness efforts, Ralph quickly came on board. Elaine is Elaine Frank. At the time, she was the director of Injury Prevention Center at Dartmouth College. 

Celine Gounder: I should probably pause here to explain how Ralph and Elaine first met. Years before this, Elaine had reached out to Ralph about doing a program around firearm safety. Ralph remembers thinking at the time…

Ralph Demicco: Hmmm, somebody from the healthcare community wanting to talk about a program involving firearms. I said, I’d better get involved so I can, hopefully, guide all the good efforts in the right direction without the thing become inflammatory to the firearms community and ineffective.

Celine Gounder: There’s a longstanding skepticism that people in healthcare and people in the gun world have about each other. Ralph says he understands why.

Ralph Demicco: If I put myself in the shoes of an emergency room doctor in the city of Chicago, I mean, that has got to be the nightmare of nightmares. All he deals with is gun violence and people dying and injured from gun violence. It's hard for an individual like that to see that there is legitimate use of firearms in a place like New Hampshire for example.

Celine Gounder: Ralph says that historically, the medical community and the firearms community have never really been able to speak to one another in a meaningful way.

Cathy Barber: Ten years ago, the suicide groups weren't talking about guns, and the gun groups weren't talking about suicide. 

Celine Gounder: This is Cathy Barber. She’s a researcher at the Harvard Injury Control Research Center. She’s also the director of Means Matter, a project aimed at reducing suicidal persons’ access to lethal means of suicide. Cathy has an interesting take about why the two sides… never engaged on this before.

Cathy Barber: For the suicide prevention groups, I think they felt like, "Hey, this is too controversial." ... They felt shut down by doing anything about it because, through a pretty remarkable lack of imagination, thought that talking about guns meant talking about gun control...

Cathy Barber: For the gun group’s part, I think suicide just wasn't on their radar. 

Celine Gounder: Ralph and Elaine remained friends after working together that first time… and now that suicide had touched him and his store so directly, he agreed to work with her again. They started the New Hampshire Firearm Safety Coalition.

Celine Gounder: Armed with postcards and brochures with suicide hotline information, Coalition members went out to speak with gun shop owners in New Hampshire, asking them to display the information visibly in their stores. 

Celine Gounder: Ralph remembers resistance.

Ralph Demicco: I fielded some calls from dealers who said, "Hey, what is this? Is this a scam?"

Celine Gounder: But in the end, many came around.

Ralph Demicco: Almost 50% of them agreed to participate. According to Cathy, that's a great number. I didn't think it was a good number because I cannot understand why someone in the business would not want to minimize the possibility... of someone who purchases a gun taking their life.

Celine Gounder: In the beginning, the New Hampshire Firearm Safety Coalition consisted of Ralph, Elaine, a couple clinicians, and a firearm instructor who had witnessed a suicide at a shooting range. Eventually, more people from the gun world, gun stakeholders as Cathy calls them, began getting involved… especially once their monthly meetings got moved from the offices of the National Alliance for the Mentally Ill... to Riley’s Gun Shop… a place that felt a lot more safe and comfortable to gun folks.

Celine Gounder: The original goal of the Coalition was to help prevent suicide following a recent gun purchase or rental. They encouraged gun shops to screen their customers and give them information about the suicide hotlines. But as Coalition members learned from one another, about how suicide works, and about the gun business… they realized:

Cathy Barber: The far more prevalent type suicide’s with an existing household gun. "Hey, we could actually do a lot more good…”

Celine Gounder: The Coalition realized that gun shops don’t just sell or rent guns. They’re a trusted source of information about guns… including gun safety.

Celine Gounder: If a gun safety, suicide prevention message comes from a gun-retailer or firearm instructor...

Cathy Barber: It isn't an anti-gun message. It isn't a message like, "Oh, you shouldn't have guns," or anything like that… if you're worried that somebody might be considering suicide, one way that you could help is to offer to hold on to their guns, or help them put their guns into storage until they're feeling better. ...it's just a strategic kind of decision about storage.

Celine Gounder: That was the beginning of The Gun Shop Project, which Cathy’s now been working with Ralph and other gun stakeholders on for years. One thing she really appreciates about pro-gun folks, she says, is their ability to think outside the box. 

Cathy Barber: They'll just come up with things that never, that people in mental health and public health would never come up with. 

Celine Gounder: Cathy remembers a meeting she was at once with a man named Clark Aposhian. Clark heads up the Utah Shooting Sports Council. He’s also an NRA instructor and a gun rights activist. At the meeting, he spoke up and said, “I’ve got an idea for a PSA on suicide!” Cathy’s reaction?

Cathy Barber: My heart sunk, ‘cause I just thought, “Oh, my God, I hate PSAs on suicide prevention.”

Celine Gounder: Cathy says these PSAs are too much about pessimism and despair. She says they contribute to the problem rather than help solve it. But Clark’s idea surprised her.

Cathy Barber: He said, "Here's what I'm picturing. A guy’s at a shooting range, puts on his gun, and turns to the camera and says,

”Last year, I was at my lowest, going through some pretty serious depression. A couple of friends of mine stopped by the house and said they were worried about me and said they'd feel a lot better if they could hold onto my firearms until things turned around. I think they saved my life.” If your loved ones are struggling, talk…

Cathy Barber: And that's like, oh my God, that's a perfect PSA.

Celine Gounder: Cathy loved how clever it was.

Cathy Barber: It had so many things going for it. It shows recovery. It doesn't wait for the person who's struggling to ask for help. It doesn't wait for a disclosure of suicidality… It’s a nice “bro” way of showing that you care…

Celine Gounder: And most of all, it was genuinely welcoming of gun-owners… and that was key.

Cathy Barber: When it's only people who don't like guns or who are unfamiliar with guns who come up with protocols for how to talk with families and patients about guns, that's not the strongest approach. You know, if you don't trust the messenger, you don't trust the message.

Celine Gounder: As word caught on about the New Hampshire Gun Shop Project, other states began reaching out to Cathy and the Coalition, looking to organize similar efforts in their communities.

Ralph Demicco: The state of Maryland, I believe, was the first state to catch wind of our project, and they wanted all kinds of information, and we shared it all with them.

Cathy Barber: Battle Axe, Minnesota… during hunting season, they distribute placemats to all the diners… that promote this message of putting time and distance between a person at risk for suicide and their guns. In Tennessee and in Missouri, right now, there’s statewide Gun Shop Projects. … Virginia Lock & Talk has gotten pawn shop owners involved... In Texas, a third-generation rancher… has developed an app for families and patients who are at risk for suicide that helps them sort through what would be good gun storage options... and medication storage options... 

Celine Gounder: Currently, there are about twenty states with Gun Shop Projects in place… all inspired by Ralph, Elaine and Cathy’s efforts back in New Hampshire. 

Celine Gounder: While there’s occasionally pushback from people who think the Gun Shop Project is a Trojan Horse for gun control, both Cathy and Ralph say they’ve seen that... for the most part… gun shop owners, firearms instructors, and gun rights activists are willing to work with the medical and public health community to prevent firearm suicides. And they realize how crucial their involvement is.

Ralph Demicco: As I say to people, "Look, we're not psychiatrists. We're not psychologists. We stand behind the counter. We sell firearms.” That's what we know, but we also know when someone comes in, who's obviously not experienced or distressed or doesn't ask the right questions or doesn't answer the right questions, you need to be socially responsible and shut that sale down and ask that person... please, get some help… And so, what's that going to mean? Is he going to misjudge sometimes? Well, maybe, but you know what? He can go to bed at night knowing he didn't sell a firearm to somebody who could've been helped. 

Celine Gounder: Cathy says there are lots of ways to deliver suicide awareness messages in spaces welcoming to gun owners… and not just in gun shops.

Cathy Barber: So we've done an audit in New England and northeast states. We had volunteers sign up to take basic firearm training. So out of twenty courses that we took, only two of those twenty covered suicide in any way.

Celine Gounder: This matches up with my own experience… taking a gun training course about a year ago. There was no mention of suicide.

Celine Gounder: Cathy’s survey paved the way for trying to incorporate education about suicide prevention into firearms training classes.

Celine Gounder: A few years ago, she did a survey in Utah, of over a thousand firearms instructors certified to teach the state’s concealed carry permit classes. She showed the instructors a draft of a five-minute suicide prevention talk she’d created and asked if they would be open to including it in their curriculum. Two-thirds... said yes.

Celine Gounder: Key stakeholders in the gun world have the potential to serve as credible, influential messengers… not just about suicide risk and prevention, but about a wider range of gun-safety measures. 

Marc Holley: My name is Marc Holley, and I'm a Marine veteran…

Celine Gounder: After spending eight years in the Marines as a military police officer and a combat marksmanship coach, Marc came home to the Twin Cities and started a personal protection and coaching service, called Atlas Defense.

Marc Holley: So we do firearms training and situational awareness for employees and the community.

Celine Gounder: But Marc didn’t start Atlas Defense just to teach people how to safely operate firearms.

Marc Holley: I started my business to educate people about the gravity of the responsibility that comes with owning a firearm.

Celine Gounder: He’s pushing back on the hubris he sees among many of the students that walk through his doors.

Marc Holley: A lot of times, people may have preconceptions based on movies or video games about how to handle a firearm. If they apply that in real life, there is a much higher chance of a firearms-related accident or negligence around the firearm just due to maybe a poor attitude that was pre-existing before they even got into training.

Celine Gounder: It’s dangerous for anyone unfamiliar with a gun to be operating one. It’s even more dangerous when the person handling the gun is unaware of all the ways in which things can go wrong.

Marc Holley: A gun is easy to use when you're assuming that you're just automatically going to use it in self-defense. I'm the good guy, so of course I've got the right to use my gun anyway I want to, and my good guy bullets are only going to hit the bad guy. 

Celine Gounder: Marc makes it a point to emphasize to his students that that they’re going to miss most of the shots they make.

Marc Holley: ...there's a lot of people that have that idealized version of themself. So they’ll rise to the occasion, do the Bruce Willis thing and save the day...

Celine Gounder: Training, Marc says, is central to gun safety.

Marc Holley: Even in basic training we didn't fire a live round until, I think, it was probably about like four weeks into basic training… and we had been spending a lot of time of firearms handling, maintenance, dry fire drills. Dry fire is just where you just get used to pulling the trigger without actually shooting to help you stay on target and not worry about the recoil and stuff like that.

Celine Gounder: In class, as a trainer himself, he takes the time to ease students into getting to know their firearms first… before they ever start shooting. It’s like Marc is trying to convey a certain reverence for guns to his students…

Marc Holley: I would say probably the most heartening thing that comes out of most of my classes is that even the most hardline, fundamentalist kind of gun owner that comes to my one of my classes, they usually come out of that class with a different state of mind, with a different perception about the firearm.

Marc Holley: I've had several gun owners that have shook my hand after the class and say, "You changed my mind about why we had this class in the first place.”

Celine Gounder: And perhaps, if that message is going to stay with them, it has to come from someone like Marc. Who the messenger is… that matters.

Celine Gounder: In our next episode, we’ll hear how others are trying to bridge the divide… between the medical and public health community… and the gun community… bringing the two sides together to prevent suicide. That’s next time, on “In Sickness and in Health.”

Celine Gounder: If someone you know is in crisis or thinking of hurting themself:

  • Do not leave them alone.

  • Remove any firearms, alcohol, drugs or sharp objects that could be used in a suicide attempt.

  • Take them to an emergency room or seek help from a medical or mental health professional.

  • Call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255).

  • Or text the Crisis Text Line at 741-741.

  • Another resource for LGBTQ youth is the Trevor Project’s Lifeline at 866-488-7386.

Celine Gounder: “In Sickness and in Health” is brought to you by Just Human Productions. Today’s episode was produced by Virginia Lora and me. Our theme music is by Allan Vest. Additional music by The Blue Dot Sessions. If you enjoy the show, please tell a friend about it today. And if you haven’t already done so, leave us a review on Apple Podcasts. It helps more people find out about the show! You can learn more about this podcast and how to engage with us on social media at insicknessandinhealthpodcast.com. That’s insicknessandinhealthpodcast.com. I’m Dr. Celine Gounder. This is “In Sickness and in Health.”