Good afternoon. We'll go ahead and get started. Thank you guys for coming. I'm Ron Kennedy Bailey I currently chair of psychiatry at LSU School of Medicine in New Orleans and involved in work with gun violence Throughout my career and very excited to get the chair of the panel really three very exciting outstanding Clinician researchers I think in this a very relevant area. I think it's very clear that we all are increasingly aware of how much more substantial and substantive this issue has become I think in our Families and our lives and our society. I think as well as in our profession and organize a psychiatric medicine And we hope today really to address really three key things clinical data and harm reduction issues going in adolescence and juvenile and their Development it leads to and is engaged and involved in issues regarding gun violence and policy rate flat laws Should risk protection orders things of that nature really address and really drill down deeply into many of these are key concerns I'll make three very basic comments about each of our pretty outstanding speakers And you should have a chance to give a little more detail about exactly what it is They do what they can their own site in order. We're gonna have dr. Michelle joy currently Works at the VA in Philadelphia at the pin pin School of Medicine Joy's involved in both clinical and forensic work. We a teaser a little bit because she's been managing I think The candle on both ends doing a lot of work So happy she got got here and I like because she's been asking very busy You know, I'm involved in a lot of advocacy work in gun violence What adults are thinking? Allison juveniles as well Second we're gonna have dr. Bella sued. She's in Richmond, Virginia As soon as the chair of the division of a child and else's psychiatry there They're involved. I think in policy and Charles policy there instead of Virginia Points out that she actually was a point about governor Cain or Virginia Tech after the news like massacre on the mental health Recognition task force in Virginia to response to that concern and also, you know, she's very involved. I think in trauma Click recovery work and a lot of training. I think for students and resident trainees. I think in this field in this area Third we're gonna have dr. Josh Horowitz. Dr. Warren Horowitz is currently at Johns Hopkins We serves as the director of the Center for gun violence solutions Much work we discussed today how that comes that comes out of that Center He's worked to develop Pretty extreme risk protection concerns and focus. I think I'm in those laws We have a fair amount about that today with these RP laws I'll say no see as well has been involved in training and advocacy in the setting So look forward to I think the discussions today We hope to run about an hour and hope and leave for solid, you know, 20-30 minutes for question and answer Thanks for coming. We'll begin with dr. Michelle joy Thank you Good afternoon, everyone you kind of heard the basics of what I do right now in my career during the introduction, but maybe Adjusting what I'm going to say right now a little bit to update you on kind of what? The context of this to my life based on a talk we gave earlier today and just provide a little snippet of personal narrative, which is I Kind of got into this because my brother was shot when we were growing up I was 17 and he was 15 and he was shot with a shotgun Accidental shooting and so he was in the hospital before about two years and then my friend and colleague Aranda is here who has his own history about being shot. And so this comes from a place definitely of Impacts, you know on my family's life my friends life my colleagues life and I live in a part of West Philly I was saying this morning. I've seen three shootings from my window since I lived there in the last decade So, you know, this is real stuff. It's not just academic and Just to kind of keep that in the back of y'all's minds when we talk about this stuff, right? this is like real in the lives of our patients for sure, but also in some of our lives too, so It's gonna just talk, you know There's so much that each of us could talk about and just kind of the way I'm going to frame it is talking a little bit about the Data and statistics about gun violence, but I mean even with that rate like when we're talking about violence, that's one thing You know, it's leaving out suicide. It's leaving out accidental injury My brother was shot by you know Someone just visiting the house of someone else that had a gun and figured it was not loaded, right? So Stray bullets, you know, whatever it is like for the most part. I'm talking about, you know, intentional violence for this data But again, you know even as psychiatrists, I feel like the narratives are sometimes Mislinked, right? Because we're screening for suicide all the time. We're documenting suicide all the time We're training, you know our residents and med students in suicide, you know risk assessment and documentation all the time But then we don't do the same for violence, but then we're talking about guns sometimes it's all about you know, one or the other and and very Frequently not linking them all together. So I am focused in this Part of the talk but you know just to kind of say that it's all relevant and important So, I mean I can just start talking Well, they bring up the slides because I don't want to waste time but essentially, you know what I was first I'm gonna talk about was just some of the data and correlations of violence in particular and for that, you know Again we could spend a whole talk on on very many of these things But what we know is that I'll just scroll down. That's fine. You guys can imagine I just won't have my notes, but we're cool So that violence is really difficult to predict. I mean, I'm a forensic psychiatrist I'm actually supposed to be in trial right now in Philly about a shooting actually of a brother-brother shooting and So I'll be testifying in Wednesday on that but like even you know I probably shouldn't say this and then be cross-examined on it, but we're not great predictors of risk, right? We're not great predictors as humans as psychiatrists even as forensic psychiatrists There's not really distinct correlates a lot of the things that we think are are not and oftentimes that changes You know based on context in a lot of ways including age, which I know the next speaker I'll talk a fair bit amount to and I'll weave some of that in but but violence is difficult to predict You know on an individual level even though even with population-based correlates We know some things and others are kind of scattered at the same time Some of the things that we do know we know that there is a huge overlap both on a population and individual basis Between people that have been a victim of violence and being a later perpetrator of violence again You know, nothing is is necessarily always causal and it doesn't you know, there's a lot of context to these things including neighborhoods Opportunities things that I'll talk about in a moment But just to say, you know getting both as a piece of the data right now But also as we move on to you know, some things about what what can be in our interventions as psychiatrists, right? Because if it's not SMI if it's not, you know The mental health populations that everyone thinks it is what can we do and sometimes that's that's treating trauma, right? and even when we're treating the diagnoses that we treat making sure that we have a trauma-based framework for that and And to consider, you know this and and in the advocacy work I mean even if you're working, you know in a court context or advocating in that kind of context, right? We get when we get kind of support for victims and victims rights stuff That is also potentially getting support for you know defendants future defendants and populations that might overlap Okay So and we know that you know a major part of the way that that overlaps those populations is the same demographics, right? So young black men and urban environments tend to be the same people. Thank you the same people that are both victimized especially by gun violence and end up being later perpetrators of that in some way and in some part that is because Violence tends to be spatially concentrated and I'm talking about the micro levels micro streets micro blocks, right? So what's a better predictor of violence in some ways is where someone lives to like their address than anything about themselves Inherently, I mean, I'm sure it's similar and in some other states and I work pretty broadly around the country But um, but I know in Philadelphia when you look at the redlining maps, right? you look at the people that couldn't get loans for decades and the families that you know, we're we're Victims in their own way of structural racism for decades Like these are this area very same blocks that have this this crime and these kind of I'm going to say Opportunity for crime not that it's a you know, beneficent kind of thing But the but it's more about kind of the situations in context than the people themselves and especially, you know the next figure I'll talk about this more but especially for certain age groups like the people that are getting involved as juveniles and as Emerging adults and then you know, we're putting a label on them and a stigma for future violence for us A lot of times it's it's what's going on in their neighborhood and what they're exposed to So that's kind of what I was saying about the next you know Association is there is an association with age both for crime and for violence at firearm violence, too So this kind of basic inverse u-shaped curve where people, you know, there's in Adolescence increased risk a peak in late adolescence and then decline afterwards, so You know that parallels a lot of other risk-taking behaviors and parallels things like car crash data and all of this kind of stuff And we don't necessarily label someone always as a future, you know perpetrator just based on that So a lot of kind of the interventions and work is understanding these kind of socio economic and demographic risk factors And if someone is at risk for being a victim or perpetrator to kind of understand that within this context And supporting kind of this age groups natural ability and tendency to move away from crime and violence But we're psychiatrists, right? So is it you know mental health? Is it mental illness? The country tends to be relatively split and you know, we talked about this typically in terms of mass shootings, right? That's when it comes up and the country's split Is it guns? Is it mental health? And that's what the narrative tends to always be and that includes You know resource allocation around those conversations So what do we know? And I know you know I've kind of spent a long time on what we you know, those kind of risk factors at the beginning But kind of going through more quickly We know that this country has a lot of guns. I don't need to go through all this Specific statistics, but we own most of you know, almost a majority of the world's guns civilian guns with only 4% of the population We most people, you know, almost a majority of households have one gun a lot of households, you know in some places I think Alaska is near the highest in the top three I know Delaware is near the lowest but on average five guns for a lot of these Homes and most people think that this is for self-defense, right? but we also know that it doesn't help in self-defense like the The kind of idea that a home invasion is going to happen and you're gonna you know Pull out a piece and that's going to protect you in some way. It is comforting to people and But but you know on a on both a population based level and individual kind of case control level and you know Obviously, we can't always control the data and in a meaningful ways But what we know is on kind of in a home With a gun after a person purchases a gun in states with higher levels of guns, right in countries We see higher levels of violence and gun violence in the US, you know as Obama became president We came to the level of having more guns than people. So in this country, so I always tell you know, my my students and residents Universal screening right and I'll get to that in a minute. But you know, I don't I work in the US I work in Philly and I work with veterans like the chance that someone doesn't have a gun I would be pretty surprised right? So I don't like you know, oh my gosh They have a gun. What are we gonna do about it? Right? Like I just assume everyone has a gun and go from there I've seen memes like, you know little things on social media like haha. I told my VA psychiatrist I don't have a gun and I don't drink right and it's like two, you know glocks and a six-pack So but what we do know is that we have a lot of guns and a lot of violence including homicide And that contributes to the death of certain populations the same one that I said You know victims and perpetrator being young black men in urban environments Which contributes to disparity in life expectancy with these populations, too And this fact, you know these micro streets these environments these contexts for Opportunities again air quotes right for violence like that's what this is about And so that's also social networks. I mean in Philadelphia They had like I think it was called the like the hundred I don't know the hundred shootings analysis project and you know, they can't it's it's all about arguments, you know Might be about drug dealing or you know Relationships or something like that, but it's usually not the home invasion that sometimes that does happen But that's you know, not what usually happens So here's some of what I was talking about before just in terms of those kind of relationships these You know correlations so homicide is higher in areas where ownership of firearms is higher, right? People are mainly if they're killed They are killed by firearms, you know, you tend to say like what's the difference between an assault, you know and a murder? It's the presence of a firearm right like a fist isn't going to do the same thing in most situations as a gun is And you know just data and the reason why I find data really really important in some of these conversations While balancing it with lived experience of a lot of these things is you know, I want to give people the Opportunity to make decisions about what they're going to do So, you know if they feel that they are safer if my patients feel that they are safer with a firearm I can give them the data I can give them, you know, some of these correlations But I also don't look like a lot of my patients. I have had some experience, you know with gun violence myself With my family colleagues, I've had a gun pulled on me before but you know, it's it's not I don't look I'm not going to tell someone You know one of my patients like no, no, no, you're safe Like look at me like here as I sit in my office and you don't look anything We don't look anything like each other and you have no reason to trust me, right? so it's like a balancing of knowing the data and being able to speak from that data and also kind of Recognizing that each person is an expert of themself and an expert of their own lived experience And so yeah, I'll bring it up. I mean someone asked earlier like people don't rely on data, right? Like you're not just going to give someone data and they're going to change their you know, their way of Living their life, especially if it's about Their own personal safety. So, you know, we are both if if my patient is worried They want to have a gun for safety reasons and I want them to have a gun because I want them to have a gun We are both if if my patient is worried they want to have a gun for safety reasons And I want them to store their gun safely for safety reasons. We're coming to a mutual understanding We're both talking about this person's safety, right? So that's a great place to kind of begin a conversation with someone and kind of go from there It's a public health problem I only have I think like four minutes left but you know, this was kind of It it always gets, you know escalated in various political contexts about how much of a health problem this is if it's appropriate for us and And you know if it isn't and you know even within my own family like People would not go to see a psychiatrist they would not go to see mental health ever because their guns would get taken away right and this is perceived as intrusive it's You know perceived as political agenda and like we know for all kinds of things in medicine The moment you tell someone stop doing this right don't do this I'm, you know, the authority is the moment they turn their brains off, right? And so, you know, this is about having more of a harm reduction kind of motivational interviewing conversation with with patients Um, so in the last two minutes, I guess i'll just say, you know, we know it's not it's not mental illness It's not serious mental illness except in very limited and isolated context right drinking a lot of people drink People shoot when they drink right? So on a population level that's big first episode psychosis it can be be big Meth use is actually really high individualized rate of violence So in the u.s. We're like Yeah, let's treat mental health problems, but it's not what works what works tends to be You know limiting access limiting means And uh in all of these kind of conversations that I have with patients It's not about making something safe right and this is the last slide So it's not about making something safe necessarily same way I'm, not telling someone like never shoot up again, and that's the end of story, right? Don't come back here until you've stopped using, you know you're talking about how to clean the works and you know what medication assisted treatment is and and Conversations like that. So having it in the same way, um giving out free gun locks Um, you know treating trauma having these conversations from a motivational interviewing perspective Um having them from a harm reduction perspective Um, and then that's in the right that's in the consultation room. That's with your patients Uh, you know one-on-one To whatever level you want to bring in that data and also recognize themselves as as authorities in their lives but also advocacy right and all this could be their own talks, but you know understanding that this is about um About at its basis right like the demographics of this is structural inequality It's exposure to violence. It is like supporting communities and community building both in a preventive We're talking about public health a preventative measure, but also in like secondary tertiary prevention ways Once someone is you know arrested charged, you know What are the kind of resources that we can give that person and that family in that community? So that is my last slide for now and I will move on. Yeah Thank you, Michelle, thanks to APA actually for making this a panel discussion We kind of pulled this together in the last three weeks or so So i'm so glad to see you guys in the audience because we were worried that there would be no one here so clearly this is something that We all are kind of a very polarizing topic in some ways and we often get told Stay in your lane And and I think that these are the conversations that we need to have to show that as health care providers We are very much in a lane because of the impact that gun violence has on people I'm a child and adolescent psychiatrist from Virginia and basically came to this pretty honestly from the fact that I see young kids and When I began to get interested in this I was around in my late 40s And I used to think to myself how come as a 47 year old woman I have never seen a dead body in front of me Whereas I have my nine-year-old child who's coming into my clinic anxious as anything Aggressive as anything who has seen, you know people lying in their front stoop, you know in a pool of blood And there's something wrong with this picture then I got involved with the Commission that Tim Kaine pulled together for the Virginia Tech massacre and really came sort of full face In front of guns and the NRA and so on so forth in the panel discussions that we would have and then As a child and adolescent psychiatrist working at the juvenile justice center in Richmond. I see kids between the ages of you can call them kids young adults 13 to 21 who have Their lives full of replete with trauma and I usually take a pretty Thorough developmental history and in each of them. These are phenocopies of each other And the beauty of the phenocopy Sort of visualization is the fact that you can really learn a lot from them And so I feel I have learned quite a bit which has fueled my interest in the prevention arena In looking at what can we do, but how can we understand it systematically as to how? individuals end up getting violent and have guns in their hands and why is this bimodal distribution of what Produces the use of guns in two different populations. So I'll just kind of start off with stuff And I thank Josh Horvitz here from Hopkins who really has been Wonderful in the way of providing data to Virginia and the laws the different laws and we keep talking about The travesty of how these laws never get implemented, but these are good discussions to start this conversation So just some data of some sobering teen facts. We Richmond used to be the murder capital of the United States It has reduced some but homicides by firearms and particularly the 2021 data is quite sobering in the sense that this is a second leading cause of death among the 15 to 24 year population The ones that I deal with and a third leading cause of death among Americans 10 to 14 years old So this is certainly a travesty Here are some of the stats. I won't go into it, but you can see that these are unfortunate things that happen to kids, and these are the kids that we deal with, so it's something which is very near and dear to my heart. I will be talking about, I am in my lane in about an hour or so, and talking about some of these things in greater details. And when you look at the National Youth Risk Behavior Survey, which the CDC kind of puts together, you do find that kids are inordinately afraid of going to school, and you're seeing that this statistic is increasing because of the media coverage of it, as well as the reality of what is going on around kids. And our generation of kids that are growing up are afraid of guns being in their neighborhoods, and I think so am I. Sometimes I wonder, you know, it's no longer the wrong place at the wrong time, it just could happen very randomly, and so it affects all of us in some ways. So as healthcare providers, what are the kinds of things, this is a very sobering slide, which kind of tells us that when we talk about things like asking about public health issues, like smoking in the home, how many of us should ask it, and how many providers ask that, that gap is narrowing. And when you look at physical violence, you know, every time you go and get your health check done, someone asks you, you know, are you falling, or are you feeling safe at home? These are things that we constantly ask, but we don't ask about community violence and the exposure to that. So it kind of tells you that we leave a lot of money on the table here. And when we look at, as I said, trauma is a huge thing, and when we begin to look at the impact of ACEs, not only does it have a whole bunch of stuff on mental health impact, but it also has physical impact downstream, but also breeds violence in some ways. So how do we understand why youth become violent? What does the evidence tell us? What are the risk factors? What are the protective factors that we have here? So I'm just going to sort of present before you some of the things that really are prominent, and these may seem kind of sort of up there, but I want you to start thinking in terms of public health approach, where we begin to look at risk factors, both from the individual characteristics of the kid, where they are living, the water that they swim in, and the community risks and the environmental risks that confer. And on the opposite side is to be thinking in terms of what can be done to prevent some of these risk factors by enhancing some of the protective factors. So that's where the prevention work becomes very important. So let's take a look at the individual factors. So where a child has been previously victimized, particularly, so let me give you a scenario of a young man who I saw who had come in for gun selling, and so on and so forth. And this young man was a really wonderful guy. We really, this population, by the way, as you can see, is one of my favorite populations, because I learned so much from them. And he told me that at the age of two, his mother, who was substance abusing, lost custody, DSS took him and put him and his three other siblings into foster care, not foster care, it was an aunt's care. And while he was there, this guy used to go three or four days without eating, never had clothes to wear. They were basically lived in tremendous poverty until the age of six, when mother got her act together, took the kids back, and he was the oldest child. And somehow he got to be the red-haired stepchild of the family, where the mother would kind of tell him, oh, you can handle it. So this guy, again, began to go through another six-year period where he really saw a lot of neglect, even from his biological mother, where the younger sibs would get new shoes and new clothes. And so he said, well, at the age of 11 or 12, he suddenly decided in his head that I've just got to figure out things for myself, and he began to shoplift, and that began the sort of the path to delinquency. And he was so smart, his IQ was probably in the upper 120s, and so he figured out how could he do this stuff the best. And eventually, to make a long story short, he really overcame a lot of other perils and kind of got into not only becoming the gang sort of boss around, but he began to dabble in guns. He said, why should I deal with the other stuff? Let me just do guns because I get so much money out of it. Very personable kid, and he told me the only problem was when he tried to sell a Glock to an undercover agent and decided to actually give him a jack of a car, and he got caught in that, and that's how he landed in front of me. But I could see sort of the evolution of how this kid, who was a sweet little kid, eventually go on to the path of delinquency. And so these kids will tell you about the history of trauma, history of the sort of the trajectory at age 11 or 13 where they begin to get into marijuana, the selling of marijuana, smoking it while stoned, using Xanax, and kind of committing crimes, and the use of drugs and alcohol. On the other side are the resilience factors which always counter that. That's sort of the optimism and the hope of how we think about social reengineering and social reconstruction, which seems to be a pipe dream but is achievable if we put our minds to it. So these are some of the things that I see in my incarcerated youth, that they have dealt with trauma in the form of neglect or emotional and physical and sexual abuse. And their experiences impact them in a way that they're socialized, and many have to skip developmentally appropriate rites of passage and fend for themselves without the maturity required to do so safely, leading to risky behaviors that lead to a life of crime. And that is sort of the genesis of what occurs, at least in my lived experience with young people. In the home, these kids are witness to a lot of violence, domestic violence, they kind of see their mothers being beaten, or vice versa, and looking at what the media portrays violence as. In effective parenting, a lot of these kids go from pillar to post, and you kind of see that there's no centering, there's no core structure which kind of allows them to what we take for granted as ways of growing up, and they grow quickly. And then they act out the adolescence later. Poverty has been shown to be a very strong predictor of firearm violence in connection with it, and I'll talk about it in my conversation in about an hour here. So trauma, as I said, is a huge, in my viewpoint, in the genesis of violence in youth. And these kids who have been witnesses to violence are most likely to be abused themselves, significantly higher risk for developmental and mental health problems, because two-thirds of these kids who come into the juvenile justice system land up on my doorstep. And we have a conversation about things like DMDD, or major depression, or PTSD, or plain old, I never use the word conduct disorder, because there's a very small population, just about 1% who are truly sociopaths, but most of them have come about it honestly. So I don't even use that descriptor as my diagnosis, because you can see and frame what's going on with them through this lens. So the reason why this is so, so important for us to understand it, although these are large issues, if we begin to look at gun violence from the top, from the surface, we're never going to get to what goes on. Prevention really needs to begin to societal and this restructuring of the poverty and the social determinants of health which sit, because without that, this population is never going to have a chance in anything to get better. And these are some of the things like connection of these kids in churches, athletics, and other activities, school attachment, adult role modeling and mentoring. In Richmond, Virginia, in the East End, where I began to do some of our prevention work, there's a group which is called Inspire, which is a cross collaboration between different portions of the community where parks and recreation, getting kids into, getting them membership into certain activities which they could never get into, begin to really develop grocery stores on bus lines so that the food insecurity, those kinds of things, the food deserts, all of these things which in which these kids grow up and they have a sense of foreshortened future are addressed in some ways. We as healthcare providers primarily act as tertiary care agents, right? We kind of see them when the morbidity and mortality is there, and that's when we walk in. But really it's the prevention piece, it's the primary prevention which we are disenfranchised from. We are not allowed to do those because they are not funded by anything. And fortunately the WHO shows that only 10% of this variation of developmental trajectory is impacted by social determinants of health. So they're really not in a Bailey Park, but we have to start becoming a voice in the discussion to really become advocates in that area. This is a very nice slide in my mind, early childhood. This is the development and progression of antisocial behavior, that when you have all of the things that I've talked about, that the kid begins to behave in a way which then causes them to be rejected by their normal peers, reduces academic failure, and then leads to commitment into a deviant peer group. This is the identification with the aggressor, where they kind of get in with gangs where they have to have a sense of identification. And by then the ship has sort of left the port in some ways, and you get delinquency. And that's how sort of this goes on. So when we as physicians, we have to begin to look in terms of primary prevention. And these are all of the different places, those little nodal points where you can intervene by putting in the best practices. And I'll just kind of stop with some of this, what I have experienced. And the data is kind of, we don't know. But what I find is that there is a bimodal distribution. There's a suburban youth that Michelle was talking about, which is sort of like a person like her brother, where safe storage or improperly stored firearms lead to violence related to guns. But then there is the delinquent sort of population, which is the urban inner city minority and the reasons for them. And so these are things that the kids tell me. I have to protect myself and my family as where I live is dangerous. They feel naked and insecure without their guns. Guns give them a sense of power, when powerlessness is a common feeling growing up. And in some cases, a gun gives them a certain stature within the community. So these are some thoughts that I want to kind of leave you with, where there's this notion of what does the gun mean to the kid? There's a sense of power and control in owning that piece. Personal safety, and they'll give you reasons, they'll give you the stories of why they feel that way. The optics of how they look. You know, it looks cool to have this gun. A sense of foreshortened future. Many of these kids feel they're not going to live beyond the age of 21. So let's live it up to the hilt and guns become sort of a portion of that. And trafficking, gun trafficking and money. It's hugely, you know, it's very, very lucrative to get into this, but also gets you the longest sentences. This and sexually mediated, you know, charges. These are the two things that get you the longest sentences, but they're willing to take that risk. So I'm going to kind of, I know that I'm probably running out of time here. So some of these are some of the things that Josh will probably talk about, which are some of the reducing the access to lethal means. And these are many, which are legislative measures, increased enforcement, weapon amnesties, safer storage. I think there's a sit-in in Colorado where people were talking about the gun amnesty just about four or five days ago. You probably saw it in the media. So there's some good ideas. I don't want to, this is wonderful information we just don't have time to get into, but the connection between law enforcement and communities and really getting back that sense of trust between them, because I think we are at an all-time low as far as that's concerned. And unfortunately, that's, people are kind of, societal re-engineering is a very important one. And cross-sector collaboration for recognizing the multifactorial nature of these, of violence, that this is not just one reason, and how do the different sectors collaborate and begin to have a conversation, we being one of the people within it, because we have such a major impact. These indirect approaches, the one in the blue, is where I feel like we need to get invested in, that is parenting programs, life skill programs, alcohol-targeted measures, environmental and urban design, really helping parents be better parents who are at risk for creating this legacy of problems. So, I feel like it's a public health issue, and we are a very important part of looking and being sort of a strong voice in this arena, because as Frederick Douglass has so well put it, it's easier to build strong children than to repair broken men. And with that, I'll stop. Thank you. Thank you for being here. My name is Josh Horowitz. I am not a doctor. I've recently become a professor. I was an advocate for over 30 years working on gun violence issues. In the last year, I've moved to Hopkins along with my team, and we've created the Center for Gun Violence Solutions. And it is an interesting organization, which I'm really proud to be part of. Paul Nestat in the audience is part of it as well. Thanks for coming. But I want to also say that before I go, I guess I'm supposed to have no disclosures here, so I don't take money from drug companies or anything like that. I'm not a doctor, so that's good in that regard. But I do do a number of things. So at our center, we have some of the country's best researchers on gun violence prevention. So we conduct and translate rigorous policy research. We produce a lot of our own research that I rely on as an advocate. I use that research to develop new policies, advocate for policies, defend policies against the ever a lot of policies now under attack on Second Amendment grounds, and do a lot of implementation. So right now, for instance, there's a new federal grant program for training and technical assistance for extreme risk laws. We are the nationwide provider of that training and technical assistance, which is all about implementing extreme risk laws, sometimes known as red flag laws. We also do a lot of education, things like this. But we also want to learn from people. So I'm glad to be with my colleagues, where I always get to learn things. I also teach public health advocacy, which I've done for the last 12 or 13 years. And I'm always amazed how many health care providers take my classes and are getting their MPH, which I'm all for. I think it's a great combination to have an MD or a nursing degree and a degree in public health. It's amazing. But the way we look at our work is we turn research into action. And so I want to talk to you today about what that means and some of the research that we've been doing. I just want to, we've heard a lot about the epidemiology, so I'm going to be very brief here. One thing that I want to be very clear on is that while this is 2020 data and 2021, 2020, 2021, we have almost 50,000 people die by gun violence. Suicide is still the leading cause of gun death. And I think that's something that we really need to focus on, and I want to spend a little bit of time working on that. Homicide generally is a little over one third. The accidental shootings we heard about, there's legal intervention, and then some undetermined deaths as well. I also want to point out, just as others have, for every dot on that, there's a person behind that. I think we all have stories these days about people we know who have died. I have lost a dear friend to firearm suicide 30 years ago, and so that's one of the motivating factors I use to keep going in this field. A couple of things, this is looking at the change between 2019 and 2021. We have seen dramatic changes in the last two years. The homicide rate is up 45% for firearms. Suicide death rate is up 10%. It's actually down for non-gun suicide. The rise in suicide is completely related to firearms. And of course, the case fatality ratio with firearms is about 85%. So you think about addressing suicide in general, firearm suicide is a really important component of that. Other thing to note, and we've seen this, is that the disparities are really high. So especially for homicide, black people are 13.7 times more likely to die by gun homicide than white people. When you look at suicide, more white people die by suicide. However, the biggest increase is in black and brown communities right now. So I think that's something we really need to keep our eyes focused on. There's also, this is a good and bad news map for you. This is the gun death rate across the country. A person in Mississippi, which is at the top, is 8.5 times more likely to die by gun violence than someone in Hawaii at the bottom. Policy matters. Gun availability matters. So bad news to the states at the top, but we know that these things, good policy works. And I'm going to talk a little bit about that today. So at our center, we've identified, there's other things, but five core principles that if you wanted to layer on policy to the work that we heard Dr. Su talk about today. These are five policies that actually change the environment in meaningful ways and reduce, we heard both doctors up here today talk about access. What would help with that? So there's some wonderful community violence intervention programs. Not everyone, they're not all built the same. We've seen hospital violence prevention interventions. Not every program works the same, but there's some very promising interventions in the community violence front. Why do I have that as a policy? Because they cost. So policy is about how you spend money. And if you care about, so the policy there is the programming is individual, but the policy is as a society, do we value spending money on that? That's the policy I'm talking about. Number two, firearm removal laws, extreme risk laws, and domestic violence restraining orders. Those are policies that save lives. And I'm going to dig deep into the ERPA law in a second. Firearm purchaser licensing, when you license purchasing of firearms with an advanced background check, a fingerprint, and a waiting period, you save lives. You save, you reduce homicide, you reduce suicide, you reduce police-involved shootings. We're spending a lot of time with this policy because it has a wide effect across the board. The other thing that we know, and this is very clear in the data, is that when you make it easier for people to carry guns in public, death goes up. That is now across many studies. And it's not necessarily you pass an open carry law or make it easier for people to carry guns. It's not like the next day, there's quote, unquote, blood in the street. But over time, there is. And the states that have reduced access to carry have less firearm death and injury. And the fifth thing is, and I hope all of us here can agree on that, gun owners, non-gun owners, is that keep your guns locked. And what does that mean? Safe and secure storage. There are so many devices to lock guns right now, and some of them are really bad. So when I say safe and secure storage, I'm talking about unloaded and in a lockbox, locked in a lockbox. That's the way to secure your firearms. It's not a cable lock. Some newfangled way to lock your gun. It's in a safe, locked up. I just put one in my house. I installed it myself, and it cost me $80. And there's lots of giveaways now, and there's lots of easy ways to get safes for everybody. OK, I want to dig into the extreme risk protection order or red flag laws. The reason I want to do that is because it's something I helped develop. But I think it also answers some of the questions that we deal with at the intersection of guns and mental illness, which is oftentimes we see, is it gun violence? Is it mental illness? And what we want to get across here with the extreme risk laws are that it doesn't really matter the cause. It can be a head injury. It can be someone with severe mental illness or alcohol. What we need to do is, in moments of crisis, separate people who are at risk of violence from firearms. We can ask questions later. We can get treatment later when that's appropriate. But developing that is important. These laws came out of a meeting that was held at Johns Hopkins in 2013 with the organization I used to work, the Educational Fund to Stop Gun Violence, where we reviewed the evidence after the shootings at Sandy Hook. I will say, from meetings of this organization, I met a lot of the mental health care providers and psychiatrists and academics who informed my thinking about developing this tool. And I think that the piece is that we also came together in the wake of Sandy Hook, but we were all deeply concerned about firearm suicide. And so sometimes there's a critical opportunity to examine these issues. You want to walk through that opportunity and save as many lives as possible. So we did this. Yes, it was in a mass shooting context, but it was with a deep commitment to stopping firearm suicide. So I'm not going to get into much of the advocacy part of that, but we developed recommendations for this new type of civil restraining order. It's a civil restraining order that allowed all judicial, allowed for, actually, let me just stop for one second. Who knows what an extremist protection order is here? Anybody ever used an extremist protection order? OK. I'm going to go a little slow right now. Extreme risk protection orders are civil restraining orders, not criminal. Civil restraining orders where law enforcement, family members, and in some states, health care providers can go to a court and ask for someone to have their guns temporarily removed because they are at risk of harm to self or others. You go to a court, you file papers that say this person is at risk. It's a civil motion. There's no jail time involved. And law enforcement, the person's given the opportunity to turn over their guns. If they don't do that, law enforcement will remove them. This is when all other access to lethal means reductions have failed, and you just have to get the guns out of somebody's hands. This is a method to do that. Hopefully, and so far, it's proven to be a very safe method. So in our report that we did 10 years ago, we said law enforcement should have this. We also wanted family members to be able to go to court. And we've updated these recommendations more recently to recommend health care providers have that. And so we wanted to also have due process protection, so there's always a judge involved in this. So in some states, it's similar to a temporary hospitalization or not necessarily a commitment, because that can be a permanent prohibition. This is often just six months or a year of prohibition to remove the most lethal means when it matters most. What are the factors for considering when someone's firearm should be removed? Some of the factors, Dr. Suh, that you put up there. Dr. Joyce, some of the factors that you put up there. Recent acts of violence, history or threatens of dangerous behavior, misuse of controlled substance, reckless display of firearms, recent acquisition. And remember, these are multifactorial. It's never just one factor. These are multifactorial. But what we did, and we weren't successful in every state, but our recommendation is that mental illness not be a criteria for removing firearms. We know this because there are, you know the statistics better than I do, there are 40 million, at least 40 million people in America every year who deal with, live with mental illness. A tiny, tiny percentage of them will ever be violent. Spending our time taking guns away from people with mental illness just isn't, won't stop this, solve this problem. It would be a huge mistake. Solve this problem, it would be a gigantic waste of resources. OK, we focus on dangerous behavior, and that's the first level we look at, but not mental health diagnosis. OK, so we started this in 2013. Connecticut, Indiana had similar laws, but we didn't really particularly like them very much. They did not have enough due process in them. Since we started our efforts with a group of academics called the Consortium for Risk-Based Firearm Policy, 21 states and the District of Columbia have enacted extreme risk protection orders. Now, I have two arrows there because Minnesota actually signed their bill last week, and Michigan signed it today, and our team was there as part of that. So really exciting day for us, and if you live in one of these states here that I'm showing you, you have an extreme risk protection order to work with. Now, I'm going to go to about 2.30. Does that make sense? OK, great. So we're here in California, so I just wanted to quickly show what petitioning for an extreme risk protection order looks like. Just like domestic violence protection orders, there's a temporary phase, which is often ex parte. The person who's concerned goes to court, files an affidavit, and the guns can be removed on a temporary basis, but for no more. California is the outlier for 21 days. Some states are as short as seven days. And then everybody comes to court and has a full discussion of that in what they call a permanent order. It's only one year, though. It's not a permanent order. And you can see all this material at the extreme risk protection order, actually at our website, Johns Hopkins is the easiest way, the Center for Gun Violence Solutions. How does IRPA work with suicide? Well, we're really, suicide prevention, we're really young into this process. We're going to want to see it work for a number of years. We know there's great variations in the states. Some are doing it a lot, some are doing it a little. Most of the petitioners so far have been law enforcement, except for Maryland, which is about 50-50. We've seen extreme risk laws used for many different pieces, for threats of harm to self, threats of harm to family, for threats of harm to self, threats of harm to others. We've only seen it to use to now disarm white supremacists. What are we finding in the data? Jeff Swanson, who's looked at the Connecticut data, believes that about for every 10 to 20 firearm removals, one life is saved. We've seen some studies in Connecticut and Indiana that seem to show that it's reducing suicide. There's a new multi-state study looking at, or across five different states. The main research there is with April Zioli and Shannon Frateroli, and they're starting to see the arrows point in the right direction there, but I'm going to wait until that data comes out. I'm going to jump. I have case examples, which I'm really happy to talk about, but the one thing to note, especially in this example, is that these are not always adversarial, especially in the harm to self category. Concerned family members are able to work with the courts to help have a conversation to remove firearms, and yes, sometimes they're contentious, but they're not always contentious. Sometimes the person whose firearm is removed is actually grateful, and so there's examples here in Washington state about a petitioner and respondent coming in hand-in-hand and working with the judge to remove those firearms. I'm not going to go through, but there's examples of preventing school shootings, preventing mass violence, and I mentioned taking guns away from white supremacists who are close to violence. So I'm going to finish by asking, what do we know about clinicians using extremist protection orders? So where are clinicians able to be petitioners? Connecticut, D.C., Hawaii, Maryland, and New York. Minnesota, the law just passed last week, and it's complicated. There's actually a requirement for healthcare providers under narrow circumstances to tell law enforcement. I'm not quite sure how that's going to work, so we'll have to see, but in those top five states, healthcare providers can be petitioners in their own right. Paul Nestat is on this study, so I don't want to talk too much about it, but the bottom line is when you ask clinicians, a lot of them don't know about it. Very few in states who have access to be able to be petitioners have used it. They have low knowledge of ERPO, so, hello, I'm trying to educate people. Red flag law, extremist protection order. You have it. You may very well have it in your state. You need to know about it, but they also said we have a lot of opportunities for use here. Our respondents said there's a lot of opportunities for use, and healthcare providers are interested in using it, but, of course, what's the major barrier? We don't know about ERPO, right? We don't have time to do it. Who can walk out of the middle of a shift and go to court and file paperwork? So one of the things Dr. Nestat's working on, along with Shannon Frateroli, is clinical coordinators or ERPO navigators, and, Paul, you want to say 30 seconds on that? Real quick, this is a program where we're going to have social work, which we actually just started already having, social work-trained clinicians that are available to the emergency room and for psychiatrists and for pediatricians at Johns Hopkins and throughout Baltimore that can help a clinician file an ERPO, interview a patient, do risk assessments, and also provide maybe less extreme measures for preventing gun violence, like providing safe storage, free cable locks, also counseling people on out-of-home storage, that kind of thing. So it's a program funded by the Baltimore Mayor's Office, actually, as a navigation pilot. So we can talk more about it later if there's time. I don't want to use your time. Incredibly excited about it. Paul's part of leading the nation in this, and we'd love to build this to other places, as well. I think in the remaining moments, I just want to say that, obviously, we have to be careful about disparities here. We need to be considerate of racial justice. When we implement these laws, we need broad coalitions, which includes the people most affected by this. And we also need to think of extreme risk laws as part of diversion and therapeutics, and not just something like, hey, we're going to grab someone's gun. We need to, the people who do this well involve family members, have dialogue around this, involve the community of the person who's having a firearm removed. And so far, so far, that we have seen almost no people being injured during removal, law enforcement being injured, petitioners being injured. This is people doing this with a lot of thought, and I think that's very important. There are resources here at the Center for Gun Violence Solutions. I mentioned that we are now the training and technical assistance provider for the Department of Justice. We have all sorts of resources available for you to learn more about this. There's also a continuing medical education YouTube you can watch to learn more about extreme risk protection orders. I will say, though, and this is, we need to do a much better job educating about this, but now that you've heard this, please take the time to learn about it, because there's nothing worse than having an extreme risk law in your state and not using it when there's an opportunity. And that's something that we'll learn over time, but as I look and do sort of the postmortems over some of these shootings, especially in states that have it, people always say, I didn't know. Well, now that we know, there's lots of resources to go out, and we are here to help you. We have people to do training, to do technical assistance, to help answer your questions in our new resource center. So please feel free, call us, bug us, get involved, but we're here to help, and you want to make sure that you know about it. And some of these slides, I use some of the work that I've collaborated on with Dr. Nestat, Shannon Frateroli, who's a professor at the Bloomberg School of Public Health, and Janelle Cubbage, who's a member of our team at the Center for Gun Violence Solutions. Thank you. Well, I sure want to thank all the speakers for what I thought were just really outstanding discussions, timely, pertinent, accurate, and I think really up-to-date, addressing really, I think, a message of critical importance, I think, in our time period. I made a few brief comments that I'll share, and then we'll take questions, I think, from the audience. I also want to thank this group. I've been doing this for some years, and, I mean, you guys ended exactly at 59 minutes. This was impressive. I have to give you some additional credit for that. Dr. Joy, I just kind of comment that the data, as you point out, emphasizes really that we have worsening violent trends, and I think that's kind of what's kind of struck me from the very beginning. The reality is we're not doing better, so probably we need more. You're also going to point out that, you know, more guns than people. I've been hearing this story increasingly now that we're approaching maybe 400 million guns in a country of 350 million people, what have you, that by definition cannot be effective for us going forward. I like your point that there's limited access of harm reduction strategies, so I think that Josh's point that even groups like this have to kind of figure ways to go back into your local communities and really push for execution and implementation of the harm reduction strategy that we do have, although it's also pretty timely. And your comments about Philadelphia I think were also really, really, really on target, issues regarding how we're going to address gun reform going forward. Dr. Seward, I just want to comment on your thoughts about these cities, and I'm struck by the fact that I'm in New Orleans now, I've been there for about two years. We hit a number of 84 gun violence deaths per 100,000 last year. The national average for the audience is six per 100,000, so New Orleans is 14 times the national average. I've read that St. Louis at some point has been number two, and they were at 42. So you also see remarkable differences, just about disparities in location. So I'll speak increasingly, I want you guys to talk about question and answer about the, I think, the regionality of these issues as well. It occurs differently in different places, and that may mean different strategies, different laws, implementation strategies may be important, I think, kind of going forward. I also thought Dr. Seward's comments about community violence really struck a nerve. And some of the activities we're involved in with adolescents or juveniles, if you will, address, I think, a full theme when it comes to the community. Schools are involved, local YMCA's and school systems and after school projects, people kind of talk about them a lot, but when they're not active and effective, we probably see, I think, substantial deficits in certain areas, and we see, I think, some of the abject complications that kind of occur because of that. And I also appreciate your comments about we really need a public health approach. We're now talking increasingly now in global health about total health. It's either the focus has to be not just on what we do medically, but also what we do in regards with mental health, but also how public health comes into play for a total perspective. And very often, the losses we've had historically may have occurred because we didn't address substantive problems with, you know, a broad-based umbrella-oriented, I think, type solutions. And Josh, I certainly appreciate your comments. I think we all are very excited about the center and the good work that's been put forth. And Bella pointed out, you know, a lot of the data she had actually comes from that setting. I'm jealous I'm not close enough to Baltimore now. I think you guys are doing great work, and your colleagues are coming through as well, so timely. I just want to point out that you mentioned 50,000. I think I read 43,000, 40,000 gun violence deaths and numbers that are increasing. But I think your point was correct. Most Americans are not really aware what drives them. It's not the fact that more of those gun deaths are suicide, they're homicide. I think you said one-third, and very often it's been one-third, two-thirds, or, you know, 40, 60. But the reality is it's the fear of homicide that drives the buying of guns and not using safe storage and carrying them, I think, indiscriminately and wanting laws to have open carry, all those type of things. So this fear, I think, tends to drive much of the adverse action of our community and our society. And I think that we've got to find ways in groups like this to be much more impactful and altering or changing that. I think the big five, I just want to comment about them, community violence, firearm removal laws, firearm purchasing, licensure, public carry, decreasing or recognizing that it actually increases violence. I'm in New Orleans. You read the Sunday paper and you would not think that many are aware of that issue regarding safe storage. I'll briefly share one. So I wrote a book on gun violence years ago and chapter six was actually essentially written by one of my junior faculty, a great young guy, my child psychiatry lead, I don't know about your child, and he had the experience of actually having a nine-year-old, excuse me, a four-year-old niece shoot his father. So the grandfather was in the home asleep. They were very comfortable with guns. They lived in eastern Tennessee. So the concept was that, you know, you are comfortable with long guns and you go and hunt and fish, that type of thing. But to have regular, you know, handguns around the house, even kids get comfortable with them, and the person was sleeping, he goes right next to them and she picked the gun up and put it to his head. The reality is you have that type of tragedy and then that one family tends to change. And they become much more, I think, adept and encouraging of these type of considerations. We've got to figure out a way to have that extrapolated across larger groups of people. And each family shouldn't have to have one tragedy, but recognize the value of much more safety and I think an overall gun culture. That to me seems to be a huge challenge. Can I simply end by saying I think you also make the point that taking away weapons from the middle of the aisle is remarkably counterproductive. I've unfortunately, like many of us, perhaps been in settings where we actually discuss these things before our state legislature. And there are groups on the other side, and you know what their names are, who are advocates of gun access, if you will, and the like. And often the laws that they criticize, this idea that they want to take your guns away from you, are the laws in the mental health spectrum of, you know, my whole career. You know, a psychiatrist, you're at a hospital, you discharge somebody, you make sure the family removes the guns and the knives and potential weapons. That is part and parcel of who we are, and part of I think much of our clinical work. So again, I thank all three of you very, very much. I ask for a brief round of applause. Outstanding discussion. Family, and we certainly would love to take any questions from the mic. And please speak into the mics as we're recording it. Thank you. I really learned a lot during this talk. I'm Arthur Liebham with the University of Louisville in Louisville, Kentucky. This is more of a comment, but as you can see, Kentucky wasn't on the list of states with emergency protective orders. But one thing we've been doing in the Louisville region, actually, as you know, Kentucky is a very conservative state. They tend to be more gun access rather than gun prevention. But we have a MIW process, mental inquest warrant process. It's our form of mental health commitment. And there is a process for when a patient wants to be released. If they want to be released for future treatment, there's something called agreed order that we do. It's a 60-day agreed order. They sign in court with their public defender. And typically, it was just, we'll keep taking our medications. We'll do lab draws. We'll go to follow up. And if they didn't follow along with that, they would be brought back for treatment again into the hospital. But one of the attendings looked through the law and said, well, there's nothing in here preventing me from requesting the firearms to be taken away, actually. So we petitioned the court. And in Louisville, Kentucky, we have a very liberal court system, so they're more agreeable to this. I'm not sure if this has become statewide in Kentucky, but they've actually started incorporating gun removal from people we think are serious risk, people who are suicidal, homicidal. So it's not actually technically an emergency protective order, requires psychiatric hospitalization to get there. But it at least can do a 60-day removal per court order. And if they don't go to follow up, or they're not seeing their psychiatrist or mental health provider, then they'll be come back in the hospital. So my point is, I'd encourage everyone, especially if you're in the inpatient setting in your states, if you don't have an emergency protective order, to look closely at the laws, because there are sometimes ways around this that at least we've used in our university setting. Yeah, that's, first of all, good for you guys. That's very interesting. One of the reasons we developed the extreme risk law is because we heard these stories all over the country. People were using all sorts of methods to remove firearms. And we said, let's create a very clear legal process that protects everybody. But I mean, good for you for doing that. And I think when you need to protect your patients, you want to do anything you possibly can, and that's one way to do it. Obviously, some states have firearm removal or firearm prohibition at the temporary hospitalization stage. California, you have a five-year prohibition, but it's clearly not what's going on in every state. I will say, we have a great group of advocates in Kentucky, and we are really hopeful that one day Kentucky will have an extreme risk law. So we hope we can make that happen. It won't be tomorrow, but we're working on it. One comment that I would like to make is that Josh's work and his institution's work, the ERPO laws, is tremendous. And in Virginia, we have the ERPO laws. And what my personal experience with it, I just, I'm doing this more as an educational sort of statement here, is that I've had two experiences where there has been the presence of a very, a situation which is going to erupt into something really bad where the kid had access to firearms. And we got the, I told the person who was talking to me to get, to invoke the ERPO laws. And the person from the police force said, what are you talking about? And this is a law which is actually implementable in Virginia. So there were two experiences like this. So one of the things that I was telling Josh is that the education of law enforcement, and this is where the cross-collaboration is really, really important. So it's not as if when the law is there, it's going to be implemented. But we, as health care providers, we should strongly be involved in making sure that the recipient of that law can actually implement it. So this is sort of early in the making, but I just want people to be aware of that. Let me just follow up, and I want you to hold that question. I don't want you to lose your thought. I noticed on the slide that really only two southern states had ERP laws. It was Virginia, I think, and Florida. I do wonder, based on your comments, but also I wonder what Josh's thoughts are, what are some strategies that may be effective in really moving the needle a bit? I mean, for instance, I'm in Louisiana. I can certainly imagine that the initial blowback on this consideration, like others where I live, would be antagonistic and negative, if you will. But we've seen some other areas in southern conservative states where we've been able to work around and work through and find some successes. Very often we can find some areas of collateral commonality, I call it. So one does wonder what may be some thoughts you may have in that regard, because again, we're in a city that has so much inside violence. I think it's really important to kind of get away from the polarized conversation with people, but really talk about safety as a driving force. Because I do believe that no one wants people to be killed or hurt. And how can you sort of create a bipartisan conversation and dialogue? Because when I initially began my work, I really realized that half the people weren't listening to what I had to say. And you quickly understand that you have to get to the reason why people are so threatened by it and really come up with a common sort of reasoning which can get people behind the argument. So I would encourage people to think in terms of the cross sort of really reaching out to the other folks in really using safety as a driving point of this conversation. And recognizing who are the people who are going to be detractors and making friends with them. Michelle, you have any thoughts? I was just, did you say Florida was one of the states? Florida, Virginia. That is so surprising to me as someone from Florida. And I got into this work, you know, in part, like I said, from Florida. But, you know, back in 2016, 17, when the Docs versus Glocks bill was, you couldn't even be a healthcare provider and ask someone, you know, if they had a firearm in their home. So if it can happen in Florida, I think, where did, how? That's my question. There's one easy answer for that and that's called Parkland, right? So, I mean, that's what, that's unfortunately, I mean, people should not wait till there's a tragedy. Right. But in Florida, it was really, it was just that tragedy. In Virginia, it was years of hard work. I mean, there's definitely some tragedies in Virginia, for sure. But it was just a lot of hard work and doing, and meeting and, you know, finding the people who could vote with you and working with them. And in Virginia, that turned out to be a lot of rural Democrats who were very, were nervous about this. And so once we actually convinced them, we were able to pass the law. But there was, in Virginia, as you can imagine, there's plenty of Democrats who were not eager to, were not eager to jump on this. Times have changed a lot. But that was, had to do with trust, long-term relationships, you know, bringing this up, losing a couple of times, right? But getting the idea socialized so when we had the right moment, we could get it done. Yeah, I think the bell is pointed, to kind of find a way to address, to get a bipartisan group, so you can get away from a strict party line of partisan votes. Thanks for the wait. Please identify yourself and your location, sir. Yes, hi, I'm Paya Maktari. I'm a psychiatrist, currently working in Kansas City, Kansas. And so, it's actually, you guys had excellent talk. So, thank you so much for sharing everything with us and for doing what you guys do, certainly. So, it's actually a, there's one question, kind of, for each of you. And then, as I was standing here, I had more of a global question. I'm sure all of you guys could chime in on. So, the first one, pretty straightforward, the ERPO. You mentioned different states have different levels of restricting once that's enacted and upheld by the courts. You mentioned seven days to 21 days is kind of when they don't have access to it. So, once that time period has passed, what's the process for the person to get the gun back? What do they have to demonstrate that they're now stable? So, let me just clarify. There's a temporary order and a permanent order. The temporary order is between seven and 21 days. And then, you have the permanent order, which is generally between six months and a year. So, permanent's not the right word, but it can last up for a year. So, I just wanna. Okay. It depends what state you're in. Some states are almost, are sort of like, we're gonna find you and give you your gun back, sort of. But a lot of states, you'll have to pass your background check. You'll have to petition for your gun getting back. But it gets back. It's not, you don't have to prove, in other words, that you are, that you have to prove that you should get it back. You get it back absent a new restraint order. And the same folks that attested you couldn't, that you're at high risk, that originally support the petition or were the petitioners, do they, at that point, also chime in, like, yeah, he's good now, give him the gun back? If they wanna do that, they have to bring a new order. They have to bring a new petition. They can't, they just can't sort of tell the court, oh yeah, there is no court proceeding at the return of firearms. You don't have to go and prove anything. You have to ask, in some states, you have to ask for the firearms back, but that's a ministerial thing. There's no court proceeding, unless there's a new petition brought. Gotcha, okay. And then, other question was for the first speaker. You talked about background checks. We all know about background checks and originally purchasing a firearm. I was always curious, because I've never bought one, but I have friends that buy one. They say how easy it is, especially even in where I'm from. When they do the background check and everyone talks about screening for mental health, and that's the reason we have mass shootings in America, very polarizing sort of comments like that. What is the process of the mental health background check in purchasing a firearm, given how confidential our records are in mental health? Do they typically scan for prescription drugs? Because that sort of thing, I know, is a little bit more available. There's only, depending on the state, there's only a very few things they look at. They're actually not looking at records. They're not looking at mental, they're looking at adjudications. So you're looking, in most states, only at a record of commitment. There may be, in some states, judicial temporary hospitalizations, and they may look at that, depending on the state, but you're not looking into somebody's health records. So a lot of times you say, oh, they'll do a mental health check. That's not true. You're looking at adjudications, and even when you find the adjudication, you have no idea of the facts behind it. Right, okay. Just gonna add something on that. You know, in Pennsylvania, and I'm sure probably some other states too, there's been these pushes even for, so in Pennsylvania, our involuntary commitments, a 302, so not the ERPOs, right, but involuntary commitments and having guns taken away after that. And our involuntary commitment is to physician, right? And so there's been thoughts that that is not, that that is a due process violation because it does not involve a legislative body and therefore a judicial decision. It's two physicians taking away someone's rights, and so there's even these conversations. As he was saying, what rises to the level of mental health background, right? Like even maybe an involuntary commitment of harm with a firearm might not be appropriate due process if it's just two physicians. So there's kind of these questions about what raises to that level, and a lot of it is either something that's adjudicated or self-report. Okay. This was a curiosity question. You mentioned working with the NRA or interacting with them. What is kind of a common theme aside from just constitutional right that they've kind of hung their hat on that you've kind of come across? Yeah, the second speaker, yes, yeah. Is that for me? Yeah. What is the question, sorry? What is the question? As you've kind of interacted with the NRA in Virginia, you mentioned, yeah, so what do they tend to hang their hat on outside of just the general constitution? You have taken off my polarizing hat. But that was very, it was, we were an eight-member panel, and after the Virginia Tech shooting, which you probably remember was a very, it got the national attention, 32 people dead, and so in each of our panel hearings, there were the parents of the victims in the front row, and I was absolutely shocked that by the second panel visit, the NRA was in full force, and they came to talk about gun rights and gun protection, and to me, it was like I couldn't believe my ears that this was happening, and they stuck with that for a while, and I realized after that, so that was where my education process sort of began, that this, the lobby and where that kind of sits and how powerful it is, but it's really not, and so learning from that, that was my first sort of educational thing in 2007, but it was clear that it was not a conversation that you could have in a rational way. You had to sort of come up with a way of kind of moving around it and having a conversation. And Tim Kaine from Virginia, as you probably know the senator, he's very progressive in his thinking and his thoughts and so on and so forth, so he has been really instrumental in getting a lot of the laws passed in Virginia. So as Josh was pointing out, I have been a resident of Virginia for the past 34 years, and we have come a long ways, baby. Mental health is concerned as far as advocacy is concerned, and we have right now a Republican governor, Governor Yankin, who has made mental health his thing, so I'm very, very pleased and surprised and happy. So it's going in the right direction. I think I can say that from my story that every good idea, you sow the seed and you watch that grow later on. This is not for the timorous or the person who wants immediate gratification. This type of work just takes a lot of time and really sort of setting the stage for 10 years, 15 years, 20 years, and I have seen it. I have seen it personally. I mean, I would also say not exactly, but kind of building on those two commentaries together and kind of reducing the polarization. You know, I live in Philly, and that's Philly, but I live in Pennsylvania, and that's Pennsylvania, right? And so when I have conversations with people in rural communities, more rural communities, like I said, I work kind of around the country, but most of my forensic work is, I don't barely do anything in Philly. It's in Pittsburgh and more rural to start with, but even then, I'll bring in NRA, kind of recommendations sometimes to my patients. So talking in a more clinical level, like things that, you know, like I said, if I'm gonna tell someone not to have a gun, not to do this, not to do that, they turn off their brains, right? But sometimes, you know, I'll even show NRA, like documentation, I guess, you know, things like don't point a gun at someone unless you intend to shoot it. Don't pull a trigger unless you intend to kill someone. Assume every gun's loaded. And right, there's like a fair amount of data. I think, I mean, maybe Josh can correct me, that like firearm training is not necessarily associated with, you know, better safety and stuff, but right, like these, like I forget even the courses that they call them for children and stuff like that. That's not what it's about. Yeah, but I do feel like sometimes that can bridge the ground a little bit. Like I said, my family would never, never go see like a mental health professional for fear of taking guns away. But if I start a conversation with, you know, well, the NRA kind of said, like it is kind of a way to decrease that tension and polarization sometimes. The National Rifle Association has a program which is called Child Safe. Paul Nasset, Johns Hopkins. For Dr. Soot, actually, I was wondering about a topic that hasn't come up in this discussion, a little controversial law, the voluntary do not sell list law, which exists in Virginia and very few other, only two other states. I'm just wondering how you see that law, if you ever use that law, how it might be potentially in the way of or complimentary to ERPTO laws. Voluntary giving up of your firearm. In Virginia, there's a law. Yes, there is a law. And I just don't know how it's implementable. I can't imagine anyone giving up their firearm voluntarily. So I just got to see, to actually see it happen, to believe it, because I think it is sort of, it's a way of kind of reducing some of the polarization around it. So I don't know what the thinking is. And I would love to hear Lori Haas, is the one who told me about it. And so I would love to see who, how. Yeah, it's hard to. I think you bring up a good question. It's a buyback or it's, because when you look at places like Australia, right, like that, you know, places that have, right, you have one event, and then there's none afterwards, because I think they had a big buyback or something. It's a little different. This is a different one. This is a, well, it's not a buyback. This is a law which says that if a person voluntarily wants to give up their firearm, they can, if they feel that they are in a situation. They are at risk. And I just kind of mean that, but this may be sort of a step in moving the needle in a different direction, I'm hoping. I think it's for people, I know someone who's done this, actually. So it's for people who have ideation, who don't want to go buy, or afraid they might at some point go buy a gun. And so they, yeah. So they put themselves, they put themselves, and Virginia has a list. You can put yourself on the list so that you're not in a, maybe you find yourself later in a crisis. You're not able to buy a gun. I think you have to, I think you have to wait 30 days before you can get a gun. Thank you. I'll ask before the next question. One does wonder if that type mindset would ever potentially be of some value, I think, in our society. I think many of us are aware, if you look at other countries, which are often groups I can already kind of criticize, when they have had buybacks, they've been surprising the number of persons who've actually, for any number of reasons, and I think you described it articulately, where this may occur. I did quite a bit of work about a decade ago in West Africa and Liberia that had a civil war, and they just had just legions of weapons all over the place. And at some point, to change the mindset of a person having fear, and wanted to keep and maintain and grow the number of weapons to respond to a violent event, some began, I think, acting in a different way. So that may be a strategy for some going forth that may have some sort of value as well. You have a comment before we go to him? No? Question? Yes, please. And I'm sorry I came in a little late, so if this is not appropriate, then we can just leave it. My name's Adrian Anzaldúa. I'm a psych resident from the University of New Mexico. We recently implemented one of these laws, and it gets used almost never, even when there is opportunity and it seems appropriate to use it. There's a lot of reasons why this might be the case, but one of the reasons voiced is that generally law enforcement is hesitant to do this for cultural reasons. And so we do have the benefit of a close relationship with Albuquerque Police Department, and they are actually quite psychiatrically informed. But I'm wondering if you have any advice on how to sort of promote that relationship further and encourage use of the laws that we have. Yeah, unfortunately, I'm familiar with the situation. In New Mexico, the law as it's written is difficult. It's not nearly as easy as some of the other states. Yeah, I don't think there's, just families can't petition by themselves. And so I think there's some policy reform that needs to be done to make it easier. And then you do have a big cultural issue in New Mexico. I mean, I've been out there trying to educate people, and law enforcement will say things like, I don't even like to enforce the law, it's too complicated. I mean, you're in a rural police department and they have the double-wide trailer, that's their headquarters, and so they don't wanna even arrest people. So it's just a very complicated situation there. I do think it's a matter of educating, and then obviously, we're learning to work through these things in some other states. But the number one thing I think is you need, you need just some policy change, some just small policy changes to make it easier. I'm hoping that some of the money from the Safer Communities Act will also go and encourage law enforcement. I'm not sure if when they apply, whether they actually wanna use it for this or not, but I'll look for that. But it is a problem, it for sure is. Michelle, and then we'll get one last question. We're not gonna miss you. I was just gonna say, I'm not in a state with this, and I wish to be, but I defer to people that are in those states. But even right now, I train police in terms of CIT, I'm on an advisory board for Philly in terms of literally training first responders in terms of going out to communities. And it's very different, I think, in a rural setting, and who are the stakeholders in this and everything like that. And for me, a big problem in training police officers and also just calling an involuntary commitment is what's the risk of police violence going out when there's a young black male that might be shot in the process of this. But I think to whatever extent having collaborative conversations of, I'm training them on this thing, but what can you train me on? And I'm at the VA where it's federal police, right? And so I've learned a lot of things from them where I've tried to instruct them to do something. They said, no, I need a probable cause for this. So I mean, that's probably pretty obvious, but I feel like any time when you can have like a bi-directional relationship and kind of say, what can I learn from you too to open that conversation. But. Go ahead. One of the things we could do for New Mexico is with the new resources in the Safer Communities Act, we actually are, we'll have subject matter experts who are law enforcement prosecutors. And I think maybe having people who are doing it well, for instance, in other jurisdictions and saying, look, this is what we're getting from it. Talk to your folks, talk to APD. That might be approach that we'd be happy to help facilitate if we can. That's wonderful. Thank you. Thank you for reminding me. You're welcome. Last question. Thank you guys for staying. Thank you so much for your wonderful talk. I'm Becky, I'm from New York City. I work with a group of psychiatrists called Psychiatrists for Gun Violence Prevention. And we have a website and we're looking to move a little bit from education, Grand Rounds, and having some of this wonderful information up for people to see, to advocacy. And I was wondering if you could briefly tell me either what our first steps should be, who should we build relationships with, because we're hoping to do more. You're into action. All right, all right. Well, I think we have a lot of resources at the Center for Gun Violence Solutions, so I would encourage you to get in contact with us, especially depending on what type of advocacy. I'd also highly recommend, do you know New Yorkers Against Gun Violence? So I would, I mean, have you met with them? Because there are, we work with them very closely, and they're a great state group. And so working with them, we always try to partner with locals, with local groups, and that's who we partner with there. And so that's sort of a way to figure out what's policy relevant, what's possible. And I think that would be a good place to, a great place to start as well. Thank you. With no further questions or comments, I want to thank the group again. Thank the audience for staying timely. I think points and discussions. We look forward to continuing to work in this direction going forward through next year. Thanks again. Thank you.

gun violence

clinical data

harm reduction

policy initiatives

trauma-informed

youth violence

public health

community-based prevention

extreme risk protection orders

firearm removal

interdisciplinary collaboration

violence prevention