Introduction
Voluntary self-prohibition (VSP) is a novel firearm suicide prevention policy that allows individuals to voluntarily sign up for a no-buy list for firearms, preventing themselves from purchasing guns from sellers who participate in background checks.Reference Ayres and Vars 1 As of December 2024, Delaware, Utah, Virginia, and Washington state have VSP laws in place. 2
Suicide is the most common type of gun violence in the United States. Suicides account for more than half of all gun deaths, and guns are the method used in more than half of all suicides. 3 Guns are especially dangerous as a suicide attempt method because they are so lethal. Ninety percent of suicide attempts using a gun result in death, even though guns are only used in 5% of attempts.Reference Anestis 4 As ease of access often influences the choice of method in suicide attempts, suicide attempts using firearms are nearly always lethal, and access to firearms is a modifiable risk factor for suicide. Preventing firearm suicide by interrupting access to firearms — by removing existing guns and/or preventing the purchase of new guns — is a promising strategy.Reference Anglemyer, Horvath and Rutherford 5 Gun ownership is a significant predictor of suicide even when controlling for other factors, and recent gun purchasers appear to be especially vulnerable.Reference Studdert 6
The acute period of heightened risk during suicidal crises is often only minutes or hours long, and the immediate lethality of firearms means attempters may turn a brief moment of anguish or agitation into a fatal action.Reference Hawton 7 VSP aims to put time and space between suicidal individuals and firearms before a suicidal crisis occurs.
VSP is intended for use when patients have good insight and are euthymic, stable, and wanting to protect themselves during a future suicidal crisis. VSP is similar to a psychiatric advance directive and intends to protect patients who do not already own firearms and who may recognize their own risk for suicide, such as patients who experience recurring suicidal ideation and/or behavior due to episodic mood disorders or other mental disorders. If someone later wishes to be removed from the list, they can be removed after a waiting period — a safeguard against impulsivity. 8 VSP laws are not an appropriate tool to use during a crisis and do not include a mechanism for relinquishing existing firearms. This stands in contrast to Extreme Risk Protection Order (ERPO) laws, popularly known as “red flag laws,” which create a civil court order that temporarily prohibits people who are behaving dangerously and at risk of violence (including self-harm) from purchasing and possessing firearms. 9
Psychiatrists are key stakeholders in the implementation of VSP laws, as they may exercise clinical judgment and recommend this tool to patients for whom it is an appropriate intervention. Physicians can provide leadership in firearm suicide prevention by counseling patients — especially patients at risk for suicide — about their access to guns and tools they might use to reduce access during crises.Reference Betz and Wintemute 10 As a significant proportion of people who attempt suicide have contact with a healthcare provider in the weeks or months preceding their attempts, the importance of thoughtful, intentional clinical intervention and a robust group of tools for different scenarios and risk profiles is evident.Reference Ahmedani 11
As VSP laws are relatively new (the law first went into effect in Washington in 2019) there is limited data to determine whether psychiatrists know about the law, and whether — and in what circumstances — they are willing to recommend VSP to patients with recurring suicidal thoughts and behaviors.
Three states (Delaware, Virginia, and Washington) that have VSP laws also have ERPO laws. Given the relevance of ERPO laws to suicide prevention in clinical settings, another question of interest is how VSP may affect uptake of ERPO laws in states that have both laws, such as Virginia. 12
In addition to VSP and ERPO, clinicians may use lethal means counseling and/or safety planning as interventions to prevent suicide. Both lethal means counseling and safety planning involve a clinician working with a suicidal individual to create a barrier between the individual and lethal means.Reference Knapp 13 Both safety planning and lethal means counseling are interventions that pre-date VSP and ERPO.
ERPO laws are often known by different names at the state level; for instance, Virginia’s ERPO law is known as a Substantial Risk Order (SRO), which will hereafter be used to refer to the law. Though clinicians cannot file an SRO petition in Virginia, they can work with law enforcement to initiate an SRO. 14 As VSP and SRO policies are designed to address different suicide risk profiles, we sought to understand whether psychiatrists would improperly interchange these relatively new policies (SRO went into effect in Virginia in July 2020 and VSP went into effect in July 2021). Such insight has implications for policy and practice.
Methods
We designed a 17-question online survey and invited a convenience sample of Virginia psychiatrists to participate via an email that included a survey link ( Appendix ). The email was sent to psychiatrists and psychiatry residents through our partners in local psychiatric associations, academic centers, and clinical sites throughout Virginia. Those who completed the survey chose whether to include their contact information for the chance to win 1 of 5 $100 Amazon gift cards. We opened the survey on August 1, 2022 and closed the survey on August 31, 2022.
The survey assessed knowledge and past use of VSP and SRO and willingness to recommend VSP in the future. The survey also included four vignettes that presented respondents with scenarios carrying different levels of risk related to firearms access and suicide and/or interpersonal violence. Before each of the vignettes, respondents had the opportunity to review a “terminology” section that provided definitions of VSP, SRO, lethal means counseling, and safety planning.
Of the four vignettes presented to respondents, we wrote one vignette (Scenario 2) as a scenario in which VSP would be strongly indicated, and one vignette (Scenario 4) as a scenario in which an SRO was most strongly indicated. We wrote the other two scenarios (Scenario 1 and Scenario 3) as scenarios that would be good candidates for SRO. These scenarios were designed to assess respondents’ clinical judgment regarding firearms access and their willingness to use VSP and/or SROs in more equivocal situations.
Scenario 1 described a patient who had recently been hospitalized and had access to an unlocked and loaded gun. The patient reported resolution of suicidal thoughts but still had low mood. This vignette was written as a scenario that would be a good candidate for SRO either alone or in combination with other interventions.
Scenario 2 described a patient who had been discharged from an inpatient psychiatric unit six months ago following a suicide attempt but did not own a gun, had good insight and judgment, and appeared euthymic. The patient expressed concern that suicidal thoughts and behaviors may return. This vignette was written as the scenario in which VSP is most strongly indicated.
Scenario 3 described a patient who was experiencing depression and suicidal ideation without plan or intent. She lived with her parents, who owned a gun. This vignette was written as a scenario that would be a good candidate for SRO either alone or in combination with other interventions.
Scenario 4 described a patient with a history of explosive anger who had plans to act on violent threats. Her parents owned several guns and stored them unlocked. This vignette was written as a scenario where use of an SRO is most strongly indicated.
For each of the vignettes, respondents could choose to suggest VSP, work with law enforcement to initiate an SRO, engage in lethal means counseling, and/or develop a written safety plan. Respondents were permitted to choose multiple interventions, specify additional interventions, or choose none. The Institutional Review Board determined that this survey did not constitute human subjects research.
Results
Sixty-three Virginia psychiatrists participated in the survey; however, ten respondents chose not to answer every question. Fifty-four respondents answered all questions related to the four vignettes. The following percentages are calculated based on the number of psychiatrists who responded to each question.
Most (90.5%) respondents reported not knowing about Virginia’s VSP law and 43 (68.3%) respondents reported not knowing about Virginia’s SRO law.
In Scenario 2 — the scenario in which VSP was most strongly indicated — 40 respondents (74.1%) chose VSP either alone or in combination with other interventions.
In Scenario 4 — the scenario in which SRO was most strongly indicated — 39 respondents (72.2%) chose SRO either alone or in combination with other interventions.
Among psychiatrists who did not choose to employ an SRO in Scenario 4, substitution of VSP alone was rare. Of the 15 respondents (27.8%) who chose not to employ an SRO, only one respondent (6.7%) chose VSP alone when an SRO was strongly indicated. Of the 15 respondents who chose not to employ an SRO, six respondents (40%) chose to use VSP and other interventions, and eight respondents (53.3%) chose to use other interventions not including VSP (Figure 1).
Substitution of Interventions when SRO Was Not Chosen in Scenario 4 (n=15)
Although awareness and use of VSP was low among respondents, after reading the definition in the “terminology” section and the four vignettes, 44 respondents (83%) agreed or strongly agreed that VSP could be a useful tool for their patients. Respondents most commonly reported that they encounter a patient for whom VSP would be an appropriate recommendation a few times a year (35.2%) followed by monthly (29.6%) and weekly (16.7%) (Figure 2).
Frequency of encountering a patient for whom VSP would be an appropriate recommendation (n=54)
Discussion
Most Virginia psychiatrists surveyed had never heard of or used VSP or SRO. However, after brief education, most respondents either agreed or strongly agreed that they would recommend use of VSP to patients who may benefit from such intervention. This combination of low awareness and high perception of usefulness suggests that increased education among clinicians should be a priority in states where VSP is law. Low awareness of SRO also suggests the need for a more deliberate and robust education effort among psychiatrists.
This education is especially important because the consequences of suggesting VSP when an SRO is indicated could be grave. Unlike SRO, VSP is a mechanism that cannot address existing firearms in the home, may or may not be voluntarily filed by the patient, and likely will do little to prevent imminent violence — especially violence against others. As VSP laws become more common, clinicians must recognize that VSP is not an appropriate tool to use in a crisis and is not a substitute for SRO.
Overall, responses to Scenario 2 (in which VSP is most strongly indicated) and Scenario 4 (in which SRO is most strongly indicated) indicate that most respondents selected the appropriate intervention either alone or in combination with other interventions.
While using VSP when SRO is indicated is a serious concern, our survey found that substitution of VSP alone was rare (Figure 1). In Scenario 4, when SRO was strongly indicated, only one respondent chose VSP alone. Instead, it was more common for respondents to substitute other interventions that did not include VSP. This suggests that in future efforts to educate clinicians, emphasizing the importance of correctly matching the available firearm dispossession tools — including interventions that are more familiar, such as lethal means counseling and safety planning — to the myriad scenarios faced is critical to patient safety. Such efforts hold promise for increasing uptake of these two promising suicide prevention policy tools.
Limitations
Limitations of this study include a small sample size and homogenous views on firearms access and lethal means safety among those surveyed, which likely affected choices of interventions. We also did not collect information on the demographics of the patients each psychiatrist typically treats; psychiatrists’ location in Virginia, which is a diverse state where attitudes about guns vary considerably; psychiatrists’ rationale for selecting or not selecting certain interventions; details about reservations psychiatrists may have about VSP; or differences among psychiatrists in terms of training and/or years of experience.
As we distributed the survey through our partners in academic centers and clinical sites throughout Virginia, we likely did not capture psychiatrists providing virtual outpatient services who may be licensed and treating patients in Virginia but are physically based in other states. This method of grassroots survey distribution also prevented us from knowing the precise number of Virginian psychiatrists who received the offer to participate and therefore we cannot calculate the overall participation rate.
Additionally, the use of the term “Substantial Risk Order” in the survey instead of the more general “ERPO” or the more colloquial and commonly used “red flag law” may have prompted psychiatrists to incorrectly indicate that they had not heard of or used the law. Additionally, in surveying psychiatrists, we surveyed only the most highly trained group of mental health clinicians who are likely to be the most skilled at identifying a patient’s level of risk and choosing the most appropriate intervention(s).
Conclusion
When a patient does not already own guns, has insight about their risk for suicide, and does not want to be able to easily access guns during a future crisis, VSP may be an appropriate firearm suicide prevention tool and can act as an advance directive that specifies the patient’s desire not to purchase firearms in the future.
As patients may disclose past or present suicidal ideation, behavior, and attitudes about firearms during clinical interactions, psychiatrists are in a unique position to present their patients with the option of signing up for a voluntary no-buy list — alone or in combination with other interventions — if such an intervention is appropriate.
In Virginia, Delaware, and Washington, where both VSP and ERPO (such as Virginia’s SRO law) currently exist, it is important for psychiatrists to have a thorough understanding of both interventions and to know when each intervention is appropriate. If a patient has access to guns and is a danger to themselves or others, an SRO would be indicated, and substituting VSP would be a dangerous misuse of the law.
This is a first exploration of how psychiatrists in one state understand two laws that are becoming more common. Increased education must clarify appropriate context for these tools and emphasize the risk involved in improper substitution of these laws. When used correctly, both VSP and SRO have potential to strengthen suicide prevention efforts in the clinical setting.
Appendix A: Survey
Evaluating Awareness and Use of Voluntary Self-Prohibition
Greetings,
This is a survey being administered by researchers at the Johns Hopkins Bloomberg School of Public Health. We are interested in learning about clinicians’ awareness and use of voluntary self-prohibition laws to prevent firearm suicide in Virginia.
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• We ask you to join our study because you are in the Department of Psychiatry. You do not have to participate. It is your choice. There will be no penalty if you decide not to participate.
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• If wish to participate, you will continue to a survey that contains 17 questions. There will be four case vignettes where you will be asked to assess a fictional scenario. The entire process will take 10–15 minutes.
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• You may feel uncomfortable at times, as the survey asks questions about firearms and suicide in a clinical setting.
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• You do not have to answer all the questions and you may stop at any time. We will use your answers in aggregate to identify trends in how clinicians view and use voluntary self-prohibition laws. Your answers will not be traced back to you.
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• If you choose to provide your email address, your survey responses will not be linked to the email address provided.
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• There is a risk that someone outside the study will see your information. We will do our best to keep your information safe by storing your email (if you choose to provide it) separately from data, storing all data on an encrypted computer not managed by JHSPH IT and accessible to study coordinator Ms. Isabel Barks, and deleting email addresses immediately after gift card distribution.
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• You may be entered to receive one of ten $100 Amazon gift cards if you choose to provide your email address. If you choose to provide your email, your contact info will be randomized for the gift card drawing.
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• You may learn about voluntary self-prohibition and firearm suicide through completing this survey. We will use the aggregate data to analyze whether clinicians know about voluntary self-prohibition laws and how they are using them. We hope this knowledge will inform policymakers who may be interested in pursuing similar laws.
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• We will let the community know about the results of the study by publishing a manuscript with the aggregate data. This information will not identify participants individually but rather share more general findings from the study.
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• Again, we will offer you the opportunity to win a $100 Amazon gift card to join the study if you provide your email address.
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• Completing this survey and submitting it to us means you consent to participate in the study.
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• You may contact Isabel Barks at ibarks1@jhu.edu about your questions or problems with this work.
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• Call or contact the IRB if you have questions about your rights as a study participant. Contact the IRB if you feel you have not been treated fairly or if you have other concerns. The IRB contact information is:
Telephone: 410-955-3193
Toll Free: 1-888-262-3242
E-mail: jhsph.irboffice@jhu.edu
Section I
For this section, please read the following questions and select an answer.
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Q1. In what setting do you practice? Select all that apply.
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□ Emergency department (1)
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□ Inpatient unit (2)
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□ Outpatient practice (3)
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□ Partial hospitalization program or intensive outpatient program (4)
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□ Other (5) ____________________________________________
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Q2. Have you ever recommended Virginia’s “voluntary self-prohibition” or “voluntary self-exclusion” law to a patient?
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□ Yes (1)
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□ No (2)
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□ Unsure (3) ___________________________________________
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Q3. Have you ever worked with law enforcement to use Virginia’s Substantial Risk Order (SRO) to temporarily remove firearms from a patient at risk of harming themselves or others?
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□ Yes (1)
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□ No (2)
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□ Unsure (3) ___________________________________________
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Q4. Have you heard of Virginia’s SRO law?
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□ Yes (1)
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□ No (2)
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□ Unsure (3) ___________________________________________
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Q5. Have you heard of Virginia’s “voluntary self-prohibition” or “voluntary self-exclusion” law that allows individuals to put themselves on a no-buy list for guns, preventing themselves from purchasing guns from a licensed dealer?
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□ Yes (1)
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□ No (2)
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□ Unsure (3) ___________________________________________
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Q6. If yes, how did you hear about Virginia’s voluntary self-prohibition law?
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□ Through continuing education (1)
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□ From another healthcare provider (2)
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□ From a patient (3)
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□ From family/friends (4)
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□ From state representatives or their staff (5)
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□ In print or online media (6)
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□ Through social media (7)
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□ Other (8) ____________________________________________
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Section II
For this section, please review the terminology, read each of the four unique scenarios, and answer the question associated with each scenario.
Terminology
Voluntary self-prohibition is a policy that allows individuals to voluntarily put themselves on a no-buy list, prohibiting themselves from purchasing guns from a licensed dealer.
Substantial risk order (SRO) is a policy that allows law enforcement to petition a court to temporarily remove guns from those who pose a danger to themselves or others.
Lethal means counseling is a process whereby healthcare providers work with a patient at risk of suicide and their family or friends to reduce access to guns and other lethal means until the risk of suicide decreases.
Safety planning is an intervention whereby a patient works with a healthcare provider to plan for and stay safe in the event of suicidal ideation or urges to engage in suicidal behavior.
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Q7. Scenario 1: You are seeing a 65 year old male outpatient for a routine visit. He endorses suicidal thoughts and notes that he bought a gun yesterday planning to end his life. The gun is unlocked and loaded at his residence. He lives alone. The patient appears agitated and reports sleep disturbance. He insists that he does not need to make a follow-up appointment. You emergency petition him to the closest ED. After he is released, he reports resolution of suicidal thoughts but still has some low mood.
If all options were available to you, which of the following interventions would you choose to address this patient’s present or future access to guns? Select all that you would likely pursue.
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□ Suggest voluntary self-prohibition (1)
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□ Work with law enforcement to petition for a Substantial Risk Order (SRO) (2)
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□ Engage in lethal means safety counseling (3)
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□ Develop a written safety plan (4)
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□ Other (5) ____________________________________________
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□ I would not use any of these interventions (6)
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Q8. Scenario 2: The patient is a 45-year-old male who was discharged from an inpatient psychiatric unit six months ago following a suicide attempt. In your private practice office today, he reports a long history of suicidal thoughts and behaviors, but he states that he is doing well now and appears euthymic. He expresses concern that his suicidal thoughts and behaviors will return in the future. He does not own a gun. His insight and judgment are good.
If all options were available to you, which of the following interventions would you choose to address this patient’s present or future access to guns? Select all that you would likely pursue.
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□ Suggest voluntary self-prohibition (1)
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□ Work with law enforcement to petition for a Substantial Risk Order (SRO) (2)
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□ Engage in lethal means safety counseling (3)
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□ Develop a written safety plan (4)
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□ Other (5) ____________________________________________
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□ I would not use any of these interventions (6)
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Q9. Scenario 3: Your outpatient is a 22-year-old female with a history of mood instability and suicidal ideation. She lives with her parents. She reports depression and “thoughts that I would be better off dead.” She reports that she has no plans or intent to act on these thoughts but mentions that her father owns a gun, which he keeps in his room. She firmly states “but I would never use a gun.” Both the patient’s mother and father are actively involved in her treatment.
If all options were available to you, which of the following interventions would you choose to address this patient’s present or future access to guns? Select all that you would likely pursue.
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□ Suggest voluntary self-prohibition (1)
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□ Work with law enforcement to petition for a Substantial Risk Order (SRO) (2)
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□ Engage in lethal means safety counseling (3)
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□ Develop a written safety plan (4)
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□ Other (5) ____________________________________________
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□ I would not use any of these interventions (6)
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Q10. Scenario 4: Your outpatient is a 18-year-old female with a history of behavioral problems and explosive anger. She was recently suspended from her high school, where she is a senior, for making violent threats. She reports feeling “so angry I want to kill someone” and says she has been planning to act on these violent thoughts for months. Her parents own several guns, which they store unlocked.
If all options were available to you, which of the following interventions would you choose to address this patient’s present or future access to guns? Select all that you would likely pursue.
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□ Suggest voluntary self-prohibition (1)
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□ Work with law enforcement to petition for a Substantial Risk Order (SRO) (2)
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□ Engage in lethal means safety counseling (3)
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□ Develop a written safety plan (4)
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□ Other (5) ___________________________________________
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□ I would not use any of these interventions (6)
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Section III
For this section, please read the following questions and select the answer that best describes your belief or attitude.
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Q11. Access to lethal means, such as guns, plays a significant role in the likelihood for an at-risk patient to die by suicide.
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○ Strongly agree (1)
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○ Agree (2)
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○ Neutral (3)
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○ Disagree (4)
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○ Strongly disagree (5)
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Q12. I feel comfortable talking to my patients about their access to guns.
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○ Strongly agree (1)
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○ Agree (2)
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○ Neutral (3)
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○ Disagree (4)
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○ Strongly disagree (5)
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Q13. I feel most comfortable discussing access to guns with…
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○ A patient who owns guns (1)
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○ A patient who does not own guns (2)
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○ A patient whose gun ownership status is unknown to me (3)
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○ I am equally comfortable discussing access to guns with all patients (4)
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○ I am not comfortable discussing access to guns with any patients (5)
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Q14. I would recommend use of voluntary self-prohibition for patients at elevated risk of suicide who are not actively in crisis.
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○ Strongly agree (1)
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○ Agree (2)
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○ Neutral (3)
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○ Disagree (4)
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○ Strongly disagree (5)
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Q15. I have reservations about recommending voluntary self-prohibition for patients at elevated risk of suicide who are not actively in crisis.
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○ Strongly agree (1)
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○ Agree (2)
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○ Neutral (3)
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○ Disagree (4)
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○ Strongly disagree (5)
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Q16. Voluntary self-prohibition could be a useful tool for my patients.
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○ Strongly agree (1)
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○ Agree (2)
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○ Neutral (3)
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○ Disagree (4)
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○ Strongly disagree (5)
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Q17. I encounter a patient for whom voluntary self-prohibition would be an appropriate recommendation…
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○ Daily (1)
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○ Weekly (2)
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○ Monthly (3)
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○ A few times per year (4)
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○ Never (5)
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Email address (You may be entered to receive one of ten $100 Amazon gift cards if you choose to provide your email address. If you choose to provide your email, your contact info will be randomized for the gift card drawing. If you choose to provide your email address, your survey responses will not be linked to the email address provided. We will delete email addresses immediately after gift card distribution. If you wish to be entered to receive a gift card, enter your email address below).
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Email confirmation Please confirm your email address.
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