In 2018, there were almost 40,000 fatal firearm injuries in the United States (WISQARS (Web-Based Injury Statistics Query and Reporting System), 2020). The burden of firearm injuries and deaths is not distributed evenly in the U.S. Black and American Indian/Alaska Native individuals are 7.5 and 1.9 times more likely to die from firearm homicide than White individuals, respectively. The fatality of a suicide attempt varies, with firearms being the most lethal method (Conner et al., 2019). Because of the brevity of the suicidal moment and frequency of ambivalence in intent, if a more lethal method is unavailable, a delay in suicide attempt might allow suicidal impulses to pass (Hawton, 2007). Based on opportunity-reduction theory (Clarke, 1997), lethal means restriction attempts to reduce an individual’s access to the methods for suicide which have the highest fatality rate. Lethal means restriction for firearms has been shown to be a promising intervention to reduce suicide by firearms, both at the policy (Rosengart, 2005) and individual level (Nordentoft et al., 2017). Policies such as mandatory firearm purchasing waiting periods are effective (Luca et al., 2017).

A few individual-level studies have suggested the potential for lethal means counseling and Extreme Risk Protection Orders (ERPOs) to prevent suicides (Swanson, Norko, et al., 2019) and mass shootings (Wintemute et al., 2019). Currently law in 19 states and the District of Columbia (D.C.), ERPOs allow for the temporary restriction of firearm access for individuals at extreme risk of harming themselves or others. As providers of care to individuals at increased risk of firearm death, social workers and other health professionals have been called upon to be allowed to independently file ERPO petitions (ERPOs: New Recommendations for Policy and Implementation, 2020). However, the majority of states with an ERPO law do not currently allow these professionals to file. Further, there are significant gaps in the literature to understand how health professionals should use ERPOs, whether filing independently or with law enforcement or encouraging other parties to file. The goal of this study was to understand the process of filing an ERPO when health care, mental health, or social service professionals cannot independently file an ERPO, but instead contacted an ERPO petitioner for a client at risk of harming themselves and/or others.

Health professionals may be ethically and legally required to intervene in cases where their clients are at significant risk of harming themselves or others (Gorshkalova & Munakomi, 2020). These professionals may observe behaviors that fall under “duty to warn” laws, which require specific categories of professionals to warn a targeted victim of a violent act by their client; in many states, they must also notify law enforcement (Henderson, 2015). As ERPOs are non-criminalizing, they may be an additional tool health professionals seek for their clients who have access to firearms and are deemed to be at extreme risk of harm to themselves and/or others. Thus, health professionals may play a pivotal role in the ERPO process.

Only two states and D.C. allow a health professional to file an ERPO themselves: Maryland and D.C. allow physicians, psychologists, clinical social workers, and other therapists; and Hawaii allows medical professionals to file. Additionally, New York allows school administrators or their designee, which may include school nurses or social workers, to file. In other states, if a respondent exhibits or describes a behavior to a social service, mental health, or health professional, and the behavior falls under “duty to warn” laws, the professional must break confidentiality to report the behavior to law enforcement. If knowledgeable about the ERPO process, the professional may recommend to law enforcement that an EPRO should be filed, although law enforcement would make the judgement whether the information provided by the health professional met the definition of “extreme risk.” Alternatively, a professional and client may collaboratively choose to contact law enforcement or a family member to pursue an ERPO as part of establishing a safety plan with a client exhibiting suicidal or homicidal ideation.

Prior calls have been made to include health professionals as independent filers for ERPOs (ERPOs: New Recommendations for Policy and Implementation, 2020), but little research has been conducted to assess their role in filing an ERPO or contacting law enforcement to file an ERPO. One study of clinicians in Maryland—where physicians can independently file—found limited knowledge about ERPOs, but high willingness to file if appropriate (Frattaroli et al., 2019). Efforts have been made by health professionals and law enforcement to jointly assist individuals experiencing an acute mental health crisis (Hnatow, 2015; MSW@USC, 2018; van Dijk et al., 2019). It is therefore important to understand how health professionals are interfacing with law enforcement when health professionals cannot file themselves. The results of this qualitative study will inform continuing discussions of the role of health professionals in the ERPO process.

Our interdisciplinary team includes researchers who have practiced clinical social work and mental health care, experts in qualitative methods, and injury prevention and public health researchers with expertise in firearms, violence, and ERPOs. All authors are primarily affiliated with academic institutions, range in career stage from graduate students to mid- and senior-career faculty, and are affiliated with Schools of Social Work, Public Health, and Medicine. None of the authors were directly involved with developing or advocating for the passing of Washington State’s ERPO law. As law enforcement officers filed the majority of ERPO petitions in this sample, we felt it was also crucial to include their perspective. We therefore conducted member checking (Creswell & Miller, 2000) with a law enforcement officer with a great deal of experience filing ERPOs and advocating to others for their use.

The ERPO law went into effect on December 8^th, 2016 (House Office of Program Research, 2016). As of September 30^th, 2020, an ERPO had been filed for 510 respondents in Washington State; however, for this study, petitions were only available from December 8^th, 2016 until May 10^th, 2019. Of the petitions filed for 237 respondents during this period, 81% were granted (Rowhani-Rahbar et al., 2020). In Washington State, only law enforcement, family, and household members may file an ERPO petition. Details on the process of filing an ERPO in Washington State is described in a previous study (Rowhani-Rahbar et al., 2020; Rooney et al. 2021).

An ERPO petition details the reasons for filing and may be accompanied by addenda such as police or jail incident reports, search warrants, law enforcement declarations, affidavits, and correspondence or images offered as evidence. A judge reviews these documents and determines if a temporary, ex parte, order should be issued. If issued, law enforcement will then seek to remove firearms from a respondent’s possession. A follow-up hearing must be scheduled within 14 days, at which point a judge determines if a one-year order is warranted. In this study, we only reviewed cases for which an ex parte order was granted, regardless of whether the one-year order was granted. All ERPO documents are public record unless sealed.

For this study, court documents of ERPOs were obtained through central databases maintained by courts in each county. Documents were available from between December 8^th, 2016 (day law was enacted) and May 10^th, 2019 (end of data collection). The research team gathered copies via a public access terminal, clerks’ desks, or remote access and abstracted records verbatim into Research Electronic Capture Database (REDCap) (Harris et al., 2009). The project manager and two research assistants summarized relevant domains summarizing characteristics of ERPOs, such as reason for ERPO filing and respondent and petitioner characteristics; more detailed information on this process is detailed in a prior publication (Rowhani-Rahbar et al., 2020). Long addenda to petitions were summarized in the database and scans of originals were available as separate files. The research team analyzed scans where available, and otherwise relied on verbatim abstracted versions.

As health care, mental health, and social service professionals are not able to file ERPOs for their clients or patients in Washington State, we included cases in which one of these officials contacted a family member of a respondent or law enforcement officer and the incident during which this contact was made led to the petitioner filing an ERPO. These cases were identified by reviewing the variable, “Who made contact with the petitioner to initiate the ERPO?” This variable was completed during the abstraction process by reviewing the entirety of the petition.

Of the 237 individuals who had an ERPO filed for them during the study period, 24 ERPOs met the case definition. As is typical for ERPOs in Washington State and other states, 23 of the 24 petitions were filed by law enforcement. All respondents were reported in the petition as white, and one respondent was also reported to be Hispanic. However, it is important to note these reported races/ethnicities may not be accurate or may not reflect respondent self-identified race; one respondent reported as white in the petition was identified as Native American, American Indian, and white in prior incident reports. Compared to the population of all ERPO respondents available in this study (237), women were overrepresented in this sample (37.5% in this sample vs. 17.9% of the 237 respondents) (Rowhani-Rahbar et al., 2020). ERPOs were filed because the petitioner assessed that the respondent was at risk of harming themselves (n=10; 41.7%), others (n=5; 20.8%), or both (n=9; 37.5%).

Designed as a solution to substantial quantities and complexity of longitudinal data, the pen portrait method serves to generate a linear narrative that documents the story or trajectory of a phenomenon or other study focus (Sheard & Marsh, 2019). The heterogeneity in quantity (up to 900 pages in some cases), quality (e.g., availability of detailed incident reports), and structure (discrete fields or open-ended questions) of available court documents rendered line-by-line content analysis inappropriate and unfeasible. We therefore chose to use the pen portrait method to address these issues in addition to the longitudinal nature of some data, such as respondents with numerous experiences with law enforcement and health professionals over time. Using the pen portrait method allowed us to re-construct the case chronologically in narrative form to better understand the sequence and influence of events leading to ERPO filing. This synthesized unit of analysis also allows for review of both structured and unstructured portions of court documents.

The method consists of four steps, also used in this study: 1) understand and define focus of inquiry, 2) design a basic structure relevant to the dataset, 3) populate the content, and 4) interpret (Sheard & Marsh, 2019). The pen portraits included four primary sections (Figure 1 details source documents). Reported respondent demographics included demographics such as age, county, and reported race. Because the ERPOs were filed by the petitioner, most documents were from their perspective; as such, we refer to characteristics and events as “reported by” the petitioner. The second section summarized the petition using a chronologically re-constructed timeline of the incident during which the ERPO was filed, as well as descriptions of any other incidents leading up to the ERPO. Where available, these also included summaries of statements or affidavits provided by witnesses to the event, including those provided by the health care, mental health, or social service professional who initially reported the event. The third section, outcome, detailed whether the one-year ERPOs were granted by the presiding judge. If the order was not granted, this section also detailed the reasons provided. Finally, data on the respondent’s criminal charges and arrests were obtained from the Administrative Office of the Courts (AOC) and Washington State Patrol (WSP), respectively. These data were only considered after all other segments of the pen portrait were constructed to minimize bias these data may have on construction. The research team chose to use the charge and arrest data to clarify ambiguous reports of respondents’ involvement in the criminal legal system by the petitioner.

To populate the pen portraits, the entirety of the 24 petitions and all addenda were reviewed by the first and third authors. Next, individual pen portraits were constructed chronologically and deidentified for each respondent by the first author by reviewing the following documents (where available) in order: petition, law enforcement incident reports, affidavits from officers or health professionals, respondent motion to terminate ERPO, and court orders granting or dismissing an ERPO. The first author then clarified any ambiguities in arrest or criminal charges using the AOC and WSP data. The third author, who also had read all documents for all 237 respondents in our study population, then read and edited the 24 pen portraits for clarity or additions while reviewing the same documents. The final pen portraits ranged from one to three single-spaced pages depending on the quantity of data available. Throughout, researcher memos were written (Berger, 2015).

Pen portraits were analyzed using an inductive qualitative thematic approach (Braun & Clarke, 2006). In the first stage of analysis, the first and third authors identified as many themes as possible that emerged (no themes were defined in advance). The second author also reviewed pen portraits to identify themes specific to the ethical and legal considerations for mental health and social work practitioners relating to “duty to warn” requirements and resulting procedures (Gorshkalova & Munakomi, 2020). The themes from each pen portrait were then compared in entirety to others to elicit patterns by reported respondent characteristics, intent for ERPO filing (e.g., to prevent harm to self or others), and health professionals involved (Sheard & Marsh, 2019). During this phase, interpretations and classifications of themes were constantly revised using the constant comparison method, and negative cases where dissenting patterns of themes were observed. Throughout analysis, all themes, codes, and interpretations were discussed in weekly meetings. Differences in opinion were discussed until consensus was reached among all authors. Finally, pen portraits were reviewed again with the revised coding scheme.

All health professional groups and law enforcement officers sought to reduce risk of harm to the respondent and/or those they were threatening or attempting to harm when addressing a crisis and considering an ERPO. However, we found patterns in how these professional groups differ in their approach to achieve that goal, influenced by differing professional roles and responsibilities as outlined in ethical guidelines and protocols and behavioral health service gaps or connections (Table 1).

Each professional group had access to different information about the respondents to inform their risk assessment due to differing relationships (established vs. emergent) and care settings (in person vs. virtual). These factors include static and dynamic risk factors and setting of assessment (Table 2).

Washington State mandates that petitioners must describe behaviors, threats of violence, or intent to self-harm when applying for an ERPO. The most frequently reported behaviors in the petition at the time of a crisis moment alone or in combination were substance use or intoxication, engaging in preparatory acts while expressing intent to die by suicide, threats or attempted acts to harm others, behavior with a firearm that was deemed reckless, and “erratic behavior” or cooperation with law enforcement instructions. However, it is important to note that most cases described more than one of these behaviors in addition to other historical or contextual factors. Further, as responders to the physical location of a crisis moment, law enforcement officers were more able to directly observe and interpret behaviors such as intoxication, “erratic behavior,” and firearm behaviors deemed reckless (Table 3).

Alcohol and substance use were frequently discussed in the petition. As crisis line workers were only able to evaluate a respondents’ risk of harm via phone, intoxication was one of the most reported behaviors to law enforcement. In contrast, law enforcement officers were able to observe behaviors and physical signs suggesting intoxication, such as slurring words or smelling alcohol. Petitioners frequently attributed other dangerous behaviors, such as attempts or threats of self-harm or reckless behavior with firearms, to intoxication or other substance use.

Several petitions cited preparation and planning as evidence of intent to engage in suicidal behavior or self-harm and subsequently rationale for filing an ERPO. Example of these preparatory acts included engaging in steps to obtain a firearm, actually obtaining a firearm, or saying goodbye to family members. In one case, a respondent was reported to be attempting to persuade their family to leave their home to provide the respondent sufficient privacy to follow through with their plan to die by suicide.

Many of the cases where the petition was filed over concerns the respondent was at risk of harming others involved thwarted attempts to do so. For example, law enforcement officers were called in many cases to respond after a respondent disclosed to a crisis line worker they had a firearm in their possession and were on their way to harm a specific individual. In one such case, the respondent called a crisis line to express their frustration at the treatment they had experienced at a local hospital. They notified the crisis line worker they had retrieved their firearm and were returning to the hospital to shoot the staff. The worker notified law enforcement, who removed the firearm and facilitated admission for mental health treatment.

As they were able to physically observe respondents, law enforcement officers sometimes described behaviors with firearms as unsafe. These concerns were especially prevalent in cases where the respondent was exhibiting behaviors that could signal mental illness or dementia. Behaviors described included discharging firearms illegally and leaving firearms unsecured.

Law enforcement often described the behaviors of respondents at the scene of a crisis as “erratic.” Respondent cooperation, or lack of cooperation, with law enforcement was also frequently discussed in the ERPO filings. For example, law enforcement arrived at one respondent’s home after they reported suicidal intent, but they refused to leave their apartment as they requested time to prepare themselves to leave. Law enforcement described them as “uncooperative,” “stalling,” and “erratic” as they struggled to convince the respondent to come with them to seek help. Conversely, in another case involving a similar threat reported to a crisis line worker, the respondent was described as “cooperative” and “forthcoming” about their suicidal ideations, and law enforcement allowed them time to shower and change before transporting them to a treatment facility.

All respondents in this sample received at least a temporary, 14-day ERPO; additionally, for many respondents, this outcome was co-occurrent with other outcomes. In many cases, the professional guidelines/ethics/protocols, factors considered during threat assessment, and interpretation of respondent behaviors and response influenced the outcome of a crisis moment.

Clinical safety planning is often used to establish a strategy for how an individual will respond during a suicidal or homicidal crisis; for example, an individual may voluntarily remove access to lethal means, such as a firearm. Safety planning was not explicitly described in all cases, but when included was focused on participants who threatened harm to themselves. In these cases, we found ERPOs were filed in relation to safety planning in one of two ways: a) ERPOs filed by a family member or law enforcement as part of a safety plan developed between a health professional and a respondent and b) ERPO filing determined by the petitioner (sometimes at the recommendation of the health professional) to be necessary because other attempts at safety planning were unsuccessful. For example, in two cases, emergency medical staff or a therapist worked collaboratively with a respondent to establish a safety plan that included an ERPO. In these cases, the ERPO would restrict access to firearms in the near future, and was a part of a more comprehensive, agreed-upon safety plan to reduce imminence of future suicidal ideation. Conversely, another respondent had engaged in safety planning over several months to reduce their ability to act on their frequent homicidal ideations, such as removing themselves from situations when those feelings arose. However, both their therapist and law enforcement officers agreed additional steps were needed to restrict the respondent’s access to firearms because their safety plan was not sufficiently minimizing risk of harm.

While ERPOs are designed to be a non-criminalizing means to remove firearms, the results of a crisis moment did lead to respondent arrest in three cases. In these cases, the respondent was charged and convicted with felony harassment for the threats they made against others. Further, two respondents were arrested for violating their ERPO terms.

Sixteen of the 24 respondents in this study had at least 1 firearm dispossessed (55 firearms total were dispossessed). ERPOs for the remaining 8 respondents were filed to prevent access to firearms. Of the 10 respondents whose ERPOs were filed because the petitioner believed that the respondents were at risk of harm to themselves, 9 had at least one firearm dispossessed (22 firearms dispossessed). Of the 5 filed for risk of harm to others, only one respondent had a firearm dispossessed (4 firearms dispossessed). Among the 9 filed for risk of harm to both self and others, 6 had at least one firearm dispossessed (29 firearms dispossessed).

This study’s findings must be interpreted within the context of several limitations. First, the sample was racially and ethnically homogenous. There are several possible reasons for this. For one, respondent race and ethnicity was reported by the petitioner, and therefore may not reflect respondent self-identified race and ethnicity. One respondent was identified as Native American and American Indian in police reports attached as addenda, but as white in the petition itself, signaling potential misclassification, which is common in several racial groups (Rockett et al., 2010). Another explanation relates to the demographics of individuals who seek assistance from the mental health care system (Barksdale & Molock, 2008; K. M. Harris et al., 2005). Rooted in racism, historical and contemporary mistreatment of persons of color by health and mental health care systems cause inequitable provider care in addition to inequitable access to health care (Boyd, 2019); in this sample, it is possible that white respondents were more able to access mental health providers and emergency medical staff (e.g., due to insurance coverage of mental health services). Further, compared to the overall population of ERPO respondents in Washington State within the study time period, women were overrepresented in this analysis, which likely reflects women’s increased willingness to seek mental health care compared to men or trans individuals (Addis & Mahalik, 2003; Chandra & Minkovitz, 2006; Steele et al., 2017). While the homogeneity of this sample limits generalizability to more diverse respondents, it also provides insight into gaps in the ERPO process when a health professional is involved that need to be addressed, namely ensuring the process is equitably accessible to all individuals.

Second, the text analyzed was almost exclusively from the petitioner’s perspective; in this sample, all but one petitioner was law enforcement. We were only able to gain unfiltered insight into other perspectives in the four cases in which a professional provided an affidavit and one case in which the respondent provided an affidavit. Further, within each category of professional (respondents’ established mental health providers, crisis line workers, and medical staff working in emergency settings), the small sample limited further subgroup analysis (e.g., by gender or whether the respondent intended to harm themselves or another individual). Finally, we did not have access to data on health care or social service utilization before or after the ERPO, except in the rare cases where it was described in the petition.

Social workers provide mental health and case management services and are often charged with intervening in cases of individuals who may pose extreme risk of harm to themselves or others. They are therefore likely to encounter individuals who may benefit from an ERPO. This paper provides insight into the process and factors considered during risk assessment. Additionally, social workers practice in a variety of professional settings and practice with other professionals who may differ in training, professional ethics standards, and theoretical foundations of their practice approach. We therefore compare approaches across four groups of professionals: respondents’ established mental health providers, crisis line workers, medical staff working in an emergency setting, and law enforcement officers. We highlight the benefit of a multi-disciplinary approach to ERPO filing. This research showed that providers differed in their approach to risk assessment. Social work agencies should develop clear policies and procedures regarding the use of ERPOs. Additional research is needed to determine whether social workers and other mental health and healthcare providers should be able to serve as independent petitioners for their clients.