5

Collaborating with Communities to Improve Health Care System Implementation Success and Destigmatize Gun Violence Prevention

The workshop’s third session featured brief remarks by the three panelists and an extended discussion moderated by Marian Betz of the University of Colorado School of Medicine. The three panelists were LJ Punch from The T St. Louis and the Bullet Related Injury Clinic, Jake Wiskerchen from Zephyr Wellness, and the Reverend Michael McBride from LIVE FREE USA.

THE BULLET RELATED INJURY CLINIC

The T is a community of health working to reduce the effects of trauma in the St. Louis region, and the Bullet Related Injury Clinic (BRIC) exists as part of that work, explained LJ Punch. The BRIC serves as a resource to provide care for injuries to the body, mind, and soul that so many people are burdened with once they are discharged from the hospital after being shot and for the people near them who often also have bullet-related injuries to the mind and soul. Bullet-related injury, said Punch, is the term he uses to describe the constellation of physical, emotional, social, and spiritual injuries that occur after someone has been shot. The BRIC bridges the intense gaps in care that occur after interaction with the health care system and the long-term healing that is required in the weeks, months, and years ahead.

WALK THE TALK AMERICA: AT THE INTERSECTION OF GUNS AND MENTAL HEALTH

Walk the Talk America is a partnership involving Zephyr Wellness, an outpatient mental health practice, I.C.E. Firearm Training Services, and Mental Health America. Its mission is to reduce firearm suicides and other negative incidents associated with firearm ownership through formal education, outreach, and engagement with the mental health and firearms communities, Jake Wiskerchen explained. One influence on this program’s work, Wiskerchen said, is the idea that all mental health professionals need to develop their cultural competence by familiarizing themselves with the literature pertaining to firearms, which must extend well beyond the gun violence literature and into the full range of firearm-related matters, prosocial and otherwise (Pirelli et al., 2019).

Though mass shootings get a great deal of attention, the more serious issue in Wiskerchen’s opinion is the large problem of suicide by firearm that accounts for close to 65 percent of all firearm death and over half of all suicides. He noted that while 59 people, including the shooter, died in the Route 91 mass shooting on October 1, 2017, in Las Vegas, 67 people die by firearm suicide each day. This latter figure, he added, has been rising over the past few years. He also said that in many years, more police die by suicide than in the line of duty (Heyman et al., 2018), and that the rate of death by suicide in veterans is 1.5 times the rate of nonveterans when adjusted for population differences in age and sex (Novotney, 2020). Slightly greater than 70 percent of male veteran suicides are by firearm, while almost 50 percent of female veteran suicides are by firearm (VA, 2021). While the link between firearm access at a time of crisis and suicide has been well established, Wiskerchen argued that does not mean restricting gun ownership but rather restricting access during the time a person may be at risk of suicide.

Since March 2020, an estimated 12 million Americans became new gun owners, and Wiskerchen’s concern is whether these people are trained in the use of their gun and whether they are storing it responsibility. The challenge to mitigating firearm violence is by talking to firearm owners in a confident, competent manner. While some people might argue that suicide is not preventable, he would like the firearms industry to be a partner in addressing the problem.

Today, about one-third of American homes have a firearm, and somewhere between about 40 to 50 percent of Americans either live in a home with a gun or own one themselves, said Wiskerchen. That number, he noted, varies by geography, but regardless, the percentage is high enough that mental health practitioners such as himself have to be competent about firearms because firearm owners comprise half of their potential clientele.

Walk the Talk America has developed fliers with a link to free and anonymous mental health screening tools powered by Mental Health America that gun shops can include in gun boxes or put on the counter where people might see them. Wiskerchen noted that screenings work, and they can help people become more attuned to their symptoms, be better able to talk to their practitioners, and be better able to monitor their recovery. He said that almost two-thirds of the 4 million people who have taken the Mental Health America screenings are ages 11–24 years, with women accounting for 73 percent of those who engaged with the screening tool.

Walk the Talk America also conducts training courses for mental health practitioners focused on firearms cultural competence. The training includes discussions about beliefs, behaviors, and activities of firearm owners, as well as an introduction to firearm basics and information about responsible storage and use of firearms. Concurrently, the organization also works to reduce the stigma of counseling among gun owners. “We want to demystify what the mental health process is,” Wiskerchen explained. Work with gun owners also addresses red flag laws and attempts to correct misconceptions about those laws. These discussions also focus on language, replacing the word safe, regarding storage and ownership, with the word responsible. Responsible storage, he said, is defined as preventing unauthorized access to a firearm, whereas many firearm owners think safe means they are safe because they have guns all over their homes that may or may not be stored responsibly.

LIVE FREE USA

Reverend Michael McBride began his comments by stating that he knows and continues to believe that gun violence is preventable, and that the trauma that often lingers and even lives inside the bodies, minds, spirit, and hearts of so many directly affected families and communities needs to be addressed through tailored health approaches that are of appropriate scale and are culturally competent. For the past decade, he has been involved in leading communities across the country that are committed to organizing, building power, and educating people to appreciate that there are strategies that can reduce firearm injuries, particularly as they relate to groups, cliques, and gangs and the conflicts that bubble up from the neighborhood and result in interpersonal violence. In his view, it is possible to address firearm injuries without increasing the prison population and the historical criminalization of people of color.

McBride’s work has used a racial equity and public health framework to address the problem using approaches such as harm reduction while trying to have the greatest effect on a community. He noted that in some communities less than 1 percent of the population can be producing more than 60 percent of the gun-related shootings and homicides, which means that it

is generally a small number of people who are caught in cycles of violence and firearm conflicts, which have persisted over generations. “What we find, though, is rather than dealing with these conflicts or these individuals or families with a targeted approach, the approach has been a collective punishment framework,” said McBride. The collective punishment framework, he explained, does not create the specificity or nuance needed to achieve a targeted universalism. Targeted universalism is the idea that there may be a universal goal, but because people live in different worlds, the interventions need to be targeted to reflect those different realities and lived experiences.

He noted that the strategies his organization takes differ depending on whether firearm injuries are the result of group violence, suicide, or intimate partner violence. This is important when these injuries involve people of color, he explained, because there are often unconscious biases that need to be examined by the deliverer in the public health system, either the intervention specialists or the interrupter that participates in these interventions. Often, said McBride, many people of color who come in contact with health systems and hospitals have already had a negative cultural interaction with a doctor, nurse, or security officer in the facility.

As an example, he said there are so many stories of individuals who have gone to an emergency department after they or a family member have been affected by a firearm injury and they and their whole family are treated not as victims but as criminals. This racialization of criminality is often left unexamined by many members of the hospital staff. Imagine, he said, being at the lowest point of your life, at the point of your deepest need, and you are feeling criminalized rather than being treated as a victim.

Part of the work that LIVE FREE USA does is to implement strategies across the spectrum of hospitals, law enforcement, and community benefit organizations that address the fact that people come into this system with unconscious biases that are unexamined. This is true whether that person is a recipient of system services, a victim, an employee, or employer. Moreover, these implicit biases often inform the level of service provided, the speed at which those services are provided, and even the bedside manner with which they are delivered. All of this is important, said McBride, because it is important when dealing with people who are living these very traumatic experiences that the immediate point of contact facilitates a pathway and a journey to healing, not criminalization or incarceration. “We believe that one of our first interactions has to be around how we help facilitate healing, not just for the person who is directly impacted, but their whole family network,” said McBride.

Doing this requires appreciating that the line between victim and perpetrator is often blurred and depends on where one enters the life of that individual, he said. It may be, for example, that a person has been victimized by violence early in their life and never had the opportunity to be treated with the

kind of care and tenderness that victims deserve. It may be that the person has never had the opportunity to experience a pathway to healing. McBride noted that many young people and families are experiencing death that is ubiquitous, yet they have no pathway or opportunity to benefit from a targeted approach that would address the trauma they have encountered.

McBride’s hope is that as hospital systems become more integrated into the prevention side of gun violence they will take seriously the idea that their interaction and engagement requires a serious examination around the kinds of targeted strategies that are culturally grounded. In closing, McBride said:

DISCUSSION

To start the discussion, Dr. Marian “Emmy” Betz remarked that each of the panelists in some way touched on the importance of cultural competence or cultural humility and the need to be respectful and appropriate if the goal is to engage with people in ways that are meaningful. In that regard, she asked Punch to comment about what that means in terms of language and the words that health care providers, administrators, and programs use. Punch replied that the foundation at the BRIC is the concept of solidarity first, or what he calls radical generosity:

Punch noted as well that the BRIC does not use the term gun violence because those are two stigmatizing words, and instead refers to bullet-related injury. The word gun, he explained, brings up intense feelings that come from the partisanship that arises as soon as a discussion turns to guns. “People either have gun positive or gun negative postures, and not many people are gun neutral,” he explained. In addition, he said, as a trauma surgeon he has never seen a gun that shot one of his patients, but he has seen bullets, and bullets are the pathogens that create the physiologic, spiritual, social, and emotional reality of bullet injuries.

The term violence is even more problematic, said Punch, because in St. Louis, where bullets are endemic, he sees a significant population of

people who experience bullet-related injuries in a way that had nothing to do with their social and economic status, their demographics, where they live or what they do, who they are, and what they wanted to experience that day. Instead, they experienced a bullet-related injury while driving their car, walking, getting on a bus, or leaving an event. While an unhealed bullet-related injury can fuel future violence, he said, the way it is experienced in the body and in life is often more subtle than that.

Wiskerchen agreed with Punch that the term gun violence is problematic. He also agreed with the comments that Barnhorst made regarding cultural humility and the importance of being humble and curious to ask questions and not make presumptions about an individual’s perspective, whether it is a patient or a gun owner. Gun owners, he said, are not monolithic. It is not one culture that some parameters can quantify. In fact, even though he is a lifelong gun owner he did not consider himself part of the firearms community and culture until he joined Walk the Talk America in 2019. Because of discriminatory and judgmental peer pressure, he would not even talk about being a gun-owning clinician. He noted that even at its peak, the National Rifle Association only claimed 5 million members, while there are now as many as 130 million gun owners in America. Wiskerchen said:

Betz then referred to the work that the American College of Surgeons has done with the involvement of surgeons who own guns, recognizing that there is a great deal of diversity within health care regarding firearms.

McBride said it is important to consider that many people in the Black community who have been affected by firearm crimes or incidents have had to bear the stigma related to gun violence not as a means of protection but as a means of criminalization. Often, he said, he shows up at a hospital, sits with families or young people who have experienced an injury, and witnesses the kind of service extended to them that is never tender or soft and instead is met with fear, distance, and often with a law enforcement professional standing next to them. For him, this says that it is important to enter these settings grounded by a framework of trauma, not a framework of safety, which he has observed is often the first type of interaction with a medical professional in that space. “It is rarely a conversation about ‘are you well’ but rather ‘are you safe.’”

In addition, McBride said, there is often an interview with a law enforcement person while the injured individual is in the immediate aftermath of being injured, with family present in an agitated state, and there is concern

about “safety” in the emergency department, not a conversation about the well-being of the family that is clearly in an agitated state. What he would like to see happen when encountering people at possibly the lowest point in their life is to have mental health professionals and deescalating professionals present who can help people process their grief, anger, fear, and pain, right there in that emergency department and before getting into other kinds of considerations. In summary, he said, not only is language important, but so are practices. “It is about the way in which we show up that speaks both verbally and nonverbally to families and community members as soon as they walk through the doors,” said McBride.

Betz remarked that this characterization is so true, and that as an emergency department physician herself, she wishes she and her colleagues always provided a great experience. “I know for many reasons it is often not what we want to be, and there is a great deal of improvement that we need to keep pushing for,” said Betz. McBride replied that there are experts in the community—faith leaders, violence prevention interrupters, public health interrupters, and others—who are experts in providing culturally competent care and who he would like to see hospitals engage in ongoing dialogs before a trauma event occurs. The idea, he said, is to widen the circle of expertise beyond the medical sphere and create an ecosystem of expertise that can help guide interactions with those who have experienced trauma.

Punch noted that the BRIC now has a chaplain on staff and that one of the greatest new experiences in his career has been to recognize how much fun it is to work in the community. “In community, everything we bring to the patient is transformed into a much greater whole,” said Punch. He then raised the idea that medical professionals, including himself, do not understand the impact of what it means to have a bullet go through or be inside someone’s body. This, he said, is an example of how important it is to listen to patients and be humble.

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