Extreme risk protection orders, aka red flag laws, have been passed in 17 states and DC, and now Congress is considering a federal red flag law. But how do Extreme Risk Protection Orders work? And do they save lives?
Note: This season of American Diagnosis was originally published under the title In Sickness & In Health.
Celine Gounder: Hi, everyone. This is Dr. Celine Gounder. I’m the host of this show, “In Sickness and in Health.” If you like our approach to health storytelling, do me a small favor. Help us spread the word about the show… if you’re on Twitter, follow us and tweet us at @ISIHpodcast. Let us know what’s your favorite episode and why. It’ll help us bring you more and better stories… on the big health issues of the day. Thanks for listening. Now… on with the show.
Jeffrey Swanson: We have to figure out who are the… people, who… pose such a high risk… that it is justified to limit a constitutional right.
Amy Barnhorst: We don’t jump to mental illness in cases of the majority of violence that goes on, but in the cases of mass shootings, we often do.
Tom Sullivan: This is a law that’s going to save lives because in these cases… in 97% of the time, these people… will take their own lives
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.
President Donald Trump: Good morning. My fellow Americans, this morning, our nation is overcome with shock, horror, and sorrow. This weekend, more than eighty people were killed or wounded in two evil attacks…
Celine Gounder: President Donald Trump gave a statement in August after the mass shootings in El Paso, Texas and Dayton, Ohio.
President Donald Trump: We must reform our mental health laws to better identify mentally disturbed individuals who may commit acts of violence and make sure those people not only get treatment, but, when necessary, involuntary confinement. Mental illness and hatred pulls the trigger, not the gun.
Celine Gounder: Blaming mental illness for gun violence is nothing new for the President or his party. But his next words raised some eyebrows.
President Donald Trump: We must make sure that those judged to pose a grave risk to public safety do not have access to firearms, and that, if they do, those firearms can be taken through rapid due process. That is why I have called for red flag laws, also known as extreme risk protection orders.
Celine Gounder: This latest cluster of mass shootings has a lot of people talking about these kinds of laws. Extreme risk protection orders allow authorities to temporarily remove guns from someone who’s a threat to themselves or others. They already exist in 17 states and the District of Columbia.
Celine Gounder: In Dayton, Ohio, the crowd at a vigil for victims and survivors of the shooting demanded Ohio Governor Mike DeWine do something about guns. Their chant went viral.
Do something! Do something! Do something!
Celine Gounder: Days later, Governor DeWine gave his own press conference.
Governor Mike DeWine: Some in the crowd were angry. In fact, I’m sure everybody was angry.
Governor Mike DeWine: Some chanted, “do something,” and they were absolutely right. We must do something. And that it exactly what we are going to do.
Governor Mike DeWine: That’s why today I’m asking the legislature to pass a law to allow courts to issue safety protection orders.
Celine Gounder: Mental illness is usually one of the first things politicians blame for these shootings. But mental illness isn’t the driver of violence many people think it is…
Jeffrey Swanson: The likelihood of a psychiatric patient discharged from a hospital doing something violent with a gun… in terms of absolute risk, it’s 2%.
Celine Gounder: There are limits to what the mental health system can do to prevent violence before a crime has been committed.
Amy Barnhorst: They thought he was dangerous, too, but again, if he wasn’t arrested, and if he hadn’t been committed to a psychiatric hospital, he was legally allowed to own the guns.
Celine Gounder: But red flag laws have stopped some mass shootings already. And they’re even more effective when it comes to suicide prevention.
Julia Spoor: …if they had been able to hold on to his gun for a little while, while that crisis period passed… I believe that he… might still be alive today.
Celine Gounder: On today’s episode of “In Sickness and in Health”… extreme risk protection orders and mental illness.
Tom Sullivan: Hello.
Celine Gounder: Hey Tom, I tried you on your cell. I’m not quite sure. It’s just not going through. It’s going straight to voicemail. Ummm…
Tom Sullivan: Uh, let’s see, okay. I’ve got my landline in one hand, I’ve got my cell phone in the other hand.
Celine Gounder: OK, let’s just stick with the landline then. It’s not perfect, but it’s better than nothing.
Celine Gounder: The guy I’m trying to get on the phone with is Tom Sullivan.
Tom Sullivan: I am the father of Alex Sullivan, who was murdered on July 20th, 2012 in the Aurora theater massacre while he celebrated his 27th birthday.
Celine Gounder: A lot of gun laws were passed in Colorado since the shootings in Aurora and Sandy Hook. Year after year, Tom was a regular fixture at the Colorado statehouse to make sure those laws weren’t rolled back. And then… he made the decision to do more than advocate.
Celine Gounder: Now, why did you decide to run for state office?
Tom Sullivan: It’s like the old saying, and I think it was maybe John Dillinger. They asked him, “Why do you keep robbing the banks?” His response was, “Well, that’s where the money is.” And, in this case, in the legislature, that’s where they make the laws. So that’s where I needed to be, because standing out in front on the steps making the speech, writing an op-ed, talking to legislators, going to rallies, all of that only took you so far. You have to actually be in the chamber, and have a seat, to be able to enact and propose legislation, and that’s what I saw needed to happen.
Celine Gounder: Tom won the seat in 2018. One of the first things Tom did as state representative was sponsor a bill for an extreme risk protection order.
Tom Sullivan: It gives law enforcement or a family member… to petition the court to temporarily remove firearms from someone who has been deemed to be a danger to themselves or others.
Celine Gounder: Guns can be removed for 14 days. Then the individual and law enforcement go before a judge.
Tom Sullivan: At that point, they will both state their cases as to what the problems are, and whether things were blown out of proportion, or someone really is in the throes of some kind of episode.
Celine Gounder: If the judge doesn’t think there’s anything wrong, the person can reclaim their guns. But if the judge thinks that person poses a threat, the guns can be held for 364 days.
Tom Sullivan: What we have found is that, in some of these instances, after the 364 days, the extreme risk protection order has been removed, and this individual then finds out, “Do you know what? Maybe I didn’t really need them.” They never come and pick them up. Because, whatever the problems were, whatever the concerns were that they were having, those have been alleviated, and the answer wasn’t having an arsenal of firearms.
Celine Gounder: Before we get too far, I want to take a step back. The narrative lots of politicians push about extreme risk protection orders is usually focused on mental illness. You hear it all the time from our President.
President Donald Trump: These are very sick… it’s a mental health problem. He is a very sick puppy. He was a very, very sick guy.
President Donald Trump: Mental illness and hatred pulls the trigger, not the gun.
President Donald Trump: If you look at both of these cases, this is mental illness. These are really people that are very, very seriously mentally ill.
Celine Gounder: But is this even true?
Celine Gounder: Are people with a mental illness really more dangerous than the average person?
Jeffrey Swanson: The stereotype is that someone is in a psychotic episode, and they go out and shoot a bunch of strangers. I mean, if you learned everything you knew about schizophrenia by watching television in this country, you would think every person with that illness was a homicidal monster.
Celine Gounder: This is Jeffrey Swanson. He’s a professor in Psychiatry and Behavioral Sciences at Duke University School of Medicine.
Jeffrey Swanson: If you were to predict on the basis of, “Okay, this is a patient with an acute psychiatric disorder who has been hospitalized, we think you’re going to do something violent with a gun in the next year,” you’d be wrong 98% of the time.
Celine Gounder: That’s according to a report from the MacArthur Research Network. This report followed more than 1,000 people who had been hospitalized for a psychiatric crisis and were then released. The idea was to track these people and see what, if any, violence they committed after their release. So… what did they find out?
Jeffrey Swanson: They found that serious violence was infrequent. Minor violence was a little more common, but it was no more common, actually, in the patients who had been discharged from a psychiatric hospital than it was in a sample of randomly selected people who are living in the same census tracts.
Celine Gounder: So the report found that people with mental illness are no more likely to hurt someone else than the average person. But if mental illness isn’t driving violent behavior, what is?
Jeffrey Swanson: Substance abuse was the big deal. So if people had co-occurring substance abuse, which was quite a bit more common in psychiatric patients, then their violence risk was much higher.
Jeffrey Swanson: If you were to magically cure schizophrenia and depression and bipolar disorder tomorrow, violence against other people would go down by about 4%. If we cured substance abuse—alcohol use disorder and illicit drug use disorders—violence against other people would go down by about 35% or 40%.
Celine Gounder: Childhood trauma and a history of violent behavior are both better predictors of future violent behavior than is mental illness. And many times, the cause of violence isn’t some paranoid delusion… it’s conflict that emerges from the same triggers we all encounter.
Jeffrey Swanson: These are people who by and large are violent for the same reasons other people are violent. Psychopathology doesn’t add a whole lot to that.
Celine Gounder: Mass shootings seem so horrifying, so irrational… that it feels like the only plausible explanation for such act… must be that the shooter was totally disconnected from reality.. that they must be psychotic… insane… not like the rest of us.
Amy Barnhorst: It’s really just in this context of mass shootings that somehow people make this leap to think, “Well this person is obviously mentally ill because what kind of sane person would do something like this?”
Celine Gounder: This is Amy Barnhorst. She’s a psychiatrist at the UC Davis Department of Psychiatry and Behavioral Sciences.
Amy Barnhorst: There’s not really a strong correlation there in terms of people wanting to commit mass shootings because of delusional beliefs or voices in their head. Oftentimes, it really is driven by the same stuff: poor impulse control, anger, entitlement, a desire for vengeance.
Celine Gounder: Amy says these traits aren’t healthy… But they don’t constitute a severe mental illness either.
Amy Barnhorst: Anti-social behavior does not qualify as a mental illness. Anti-social behavior is just a reckless disregard for the rights of others and a willingness to commit criminal or violent acts to get what you want. It’s the definition of being a criminal, really. It’s not really a mental illness… The more important question is whether or not if we were to hospitalize that person, could we get them any better and make them less dangerous? And the answer is no, there’s no treatment for that.
Celine Gounder: There are only a few scenarios that prevent someone from buying guns legally. Felons, someone with a domestic abuse charge, and someone who’s been involuntarily committed for a mental illness.
Celine Gounder: But if a would-be shooter never seeks psychiatric treatment, he’ll never get diagnosed. If he’s never committed a crime before, there’s no grounds to block him from buying guns.
Celine Gounder: And even if he can’t buy a gun, few states have measures to remove the guns he might already have.
Celine Gounder: All these issues came to a head in 2014 when a gunman in Santa Barbara, California killed six people and injured another fourteen.
Amy Barnhorst: His parents had actually called up to Santa Barbara and requested that somebody go and check on him. The sheriffs went to his house because they were really worried about him committing an act of violence, and they interviewed him, and he seemed very well put together. He didn’t seem in the least bit mentally ill. He said he was fine. He denied any plans of violence or suicidality. They didn’t search his house because they couldn’t, and he had a whole closet full of semiautomatic weapons and ammo. And about two weeks later, he went out and killed a bunch of people.
Celine Gounder: California took note. The state passed a version of an extreme risk protection order that took effect in 2016. It’s called a gun violence restraining order or “GVRO.”
Amy Barnhorst: A gun violence restraining order that allows family members or police to petition to have a firearm removed from someone’s custody in the absence of a mental health history, a civil commitment, a criminal charge; just based on dangerousness.
Amy Barnhorst: Had the police had something like a gun violence restraining order, or the parents been able to file, they might have done that given the police the right to go in and remove his weapons from his possession or prohibit him from buying more weapons and thwarted that whole event.
Celine Gounder: A preliminary study estimates that more than 20 mass shootings were prevented in California between 2016 and 2018 thanks to its red flag law.
Amy Barnhorst: One of those was a man who threatened to kill his co-workers, and when they found out that he had just recently just tried to buy a shotgun, they were two days from the time that the gun was going to be released when the GVRO was filed, and so the retailer wasn’t able to release the gun.
Celine Gounder: Another one was a potential terrorist incident with a younger man who had been possibly radicalized online but had gone to travel in Turkey and Syria. He was in the midst, also, of purchasing an AK-47 and was in the waiting period. There was some concern that he was planning a mass shooting at some big public events that were going on, and so, law enforcement obtained a GVRO and he also was not able to pick up the rifle that he had already purchased.
Celine Gounder: Amy has first hand experience with these gun restraining orders. She directs a psychiatric crisis center where police sometimes bring her someone they’re worried about.
Amy Barnhorst: Sometimes I’ve told law enforcement, “Hey, I think it’s great that you brought this person in for mental health evaluation, and we’re going to really take a good look and see if there’s anything we can do for them. In the event that they don’t make it that far down the pathway, you might want to consider filing a GVRO just to make sure they don’t have access to weapons in the meantime.”
Amy Barnhorst: The other time I’ve used it is when I’ve had a patient who was suicidal.
Celine Gounder: Almost two thirds of gun-related deaths in the U.S. are suicides, and extreme risk protection orders have proven to be very effective when it comes to preventing suicide. Jeffrey Swanson conducted a study of people who had guns removed from their homes under the extreme risk protection order law in Connecticut.
Jeffrey Swanson: The average number of guns removed was seven guns per person, so these are people who have a lot of guns. And then, interestingly, when we matched the death records out several years follow up, we found a very high suicide rate, as I’ve mentioned, about forty times higher than the general population, but only a handful of gun suicides. And none of the gun suicides happened during the year when the firearms had been retained by the police. They all happened after the person became eligible a year later to get their guns back.
Celine Gounder: A suicide rate forty times higher than the average person. That means these extreme risk protection orders aren’t being applied arbitrarily. They’re keeping guns away from the people most at risk for suicide.
Jeffrey Swanson: We found, based on that analysis, that a bunch of lives were saved by simply removing the access to really efficient killing technology.
Jeffrey Swanson: How many gun removal actions do you need to do in order to save one life? … For every ten to twenty, one life was saved. So then you say, “Well, is that high or low?” Well, you know, if you’re someone who really cares about the Second Amendment right, you might think that’s unacceptable. If you’re someone like me, and you have suicides in your own extended family, gun suicides, you might think about it differently.
Celine Gounder: Julia Spoor is someone in that second camp.
Julia Spoor: My name is Julia Spoor, I’m 17 years old, I’m from near Philadelphia, Pennsylvania, and I am a gun violence prevention activist.
Celine Gounder: I asked Julia to tell me about her dad, Scott.
Julia Spoor: My dad was kind of my best friend.
Julia Spoor: He would always be just cracking jokes, making my sister and I laugh. … So I remember one time we went to the grocery store, and he just picked out a carton of eggs from the refrigerator. He was just picking them up and goofing around, and he dropped one. We ended up having to buy the carton of eggs. He was cleaning it up. For my sister who is six years older, she was in middle school at the time, she was so embarrassed. He was just making a fool of himself, and she was so worried that she would run into someone she knew, and she would be so embarrassed, but I thought it was the funniest thing ever.
Celine Gounder: Julia’s dad, like a lot of Americans, had a handgun.
Julia Spoor: My dad would go target shooting with his handgun. He would shoot at cans and empty milk jugs and things like that. My sister and I were never a part of that. He didn’t want us near the gun. It was always stored safely in the home. I never knew where it was. But after he purchased his gun, he developed depression.
Julia Spoor: I didn’t really notice that anything was wrong…
Julia Spoor: I know my sister noticed that his personality was changing a little bit. She knew that he had been hospitalized two times before for a suicide attempt. … When, I didn’t really know the full story. I didn’t really know where he was, and I honestly just didn’t think much of it because he always came back.
Julia Spoor: The first two times he attempted suicide, he was using medication and alcohol. So after his first suicide attempt, he came home with this sheet, and it told my mom and my family members that if there was a gun in the house, we should probably lock it up or remove it if we think that’s necessary.
Julia Spoor: So my mom relocated the gun. It was still in the house, but she hid it from my dad. But in September, later that year, in 2009, when he decided that he wanted to die by suicide… he just found the gun.
Celine Gounder: Julia lost her dad just before her eighth birthday. Her family was living in Florida at the time. Back then, there was no mechanism for the authorities to remove the gun from the house.
Julia Spoor: I think that it would have been just a great resource for my mom to have as an option, to go to the police and say that her husband has just attempted suicide twice. This is a perfect example of someone who should not have a gun, he’s clearly a risk to himself right now, and maybe not permanently, but if they had been able to hold on to his gun for a little while, while that crisis period passed in his life, and maybe he could have focused more on getting better and recovering and improving himself, I believe that he wouldn’t have died, and he might still be alive today.
Celine Gounder: This experience, along with the rash of school shootings in the U.S., made Julia a gun safety activist.
Julia Spoor: I’ve tried to turn any negative feelings I have and any upsetting grief I have into action, and the way that I see fit is through activism and through gun violence prevention. So that’s what I’ve been mainly focused on in terms of grieving the loss of my dad for the last probably four or five years now.
Celine Gounder: Julia founded a group called Students Demand Action. They focus on voter registration, especially for students, and what Julia calls common sense gun laws.
Julia Spoor: I think extreme protection orders are important for all states to have. … There should be something in place for people who present themselves as risks to either themselves, like my father, or someone else, like the shooter in Parkland and shooters in so many of these mass shooting situations that I’ve seen my entire life. So I don’t know necessarily if they would have prevented that one incident, but I know that every day there are incidents that happen that could have been prevented if extreme protection orders had been in place and had been utilized properly.
Celine Gounder: Tom Sullivan, the father of Alex Sullivan, who died in the Aurora shooting, doesn’t think an extreme risk protection order would’ve saved his son. But he thinks red flag laws might save others from another mass shooter or suicide. For Tom, a few weeks without a gun in the home might save someone’s life.
Tom Sullivan: Now, if we’d made a mistake, or someone gets things taken care of, we can fix a temporary removal. What you can’t do is, if that person gets to the point that they put the firearm underneath to their chin and pull the trigger, or point it at the wife and the kids, and kill them, and then kill themselves. That’s a permanent action. OK? We can’t do anything about that except grieve afterwards.
Celine Gounder: These laws are controversial despite their life-saving potential. After the extreme protection order bill was signed into law, Tom faced a recall vote. In June, gun rights activists finally dropped their recall efforts, but there remain strong headwinds against any gun regulation.
Celine Gounder: Mike DeWine called for red flag laws after the Dayton shooting. But he’s not the first Ohio governor to try to pass an extreme risk protection order bill. DeWine’s predecessor, former Governor John Kasich, proposed similar legislation when he was in office that went nowhere. That’s legislation that might have stopped the Dayton shooter.
Celine Gounder: With Congress back from its summer recess, we’ll have to see if these latest shootings can push U.S. lawmakers to take action. The House Judiciary Committee passed the Extreme Risk Protection Order Act in September. We’re still waiting on the full House… and the Senate to take up the bill.
Celine Gounder: Extreme risk protection orders aren’t perfect solutions. Some may be afraid to report concerning behaviors because they don’t want to get a family member or friend in trouble. Others won’t take seriously the warning signs they’ve observed. But these laws have had a measurable impact and saved lives in the states that have passed them.
Celine Gounder: Thirty-three states still don’t have red flag laws. A federal law could help change that.
Celine Gounder: The President has said he wants real solutions on gun violence. We’re all waiting to hear what those solutions are.
Celine Gounder: For more information about Extreme Risk Protection Orders… how they work… and how to implement them… check out the Johns Hopkins’ website: americanhealth.jhu.edu/implementERPO.
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: Today’s episode of “In Sickness and in Health” was produced by Zach Dyer and me. Our theme music is by Allan Vest. Additional music by The Blue Dot Sessions. Audio from Dayton, Ohio via Twitter from Annie Rose Ramos. 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.”