Table 1. Barriers to clinicians petitioning for ERPO.

Lack of knowledge or awareness	“Some clinicians don’t understand the law and it’s certainly not something that we’re educated about in training” “I think that most clinicians don’t even know that they could petition. They don’t know scenarios in which they should be considering [ERPOs], in which they might be applicable. They don’t know that process to make a petition”
Therapeutic alliance	“Other barriers…the worry about therapeutic alliance, this very legitimate worry, especially for outpatient [clinicians], you actually have a relationship with them. If they know that you can take away their gun and they don’t want that to happen, they might be less forthcoming” “The first principle by which we’re bound is do no harm, and I would argue that restriction of access to legal means when somebody is truly at risk of harm is sort of the ultimate expression of do no harm. So yes, you have to break a few eggs. You might impact your rapport with the patient. But in a cost-benefit analysis, if you truly believe that’s the right thing to do, you need to do it”
Time commitment	“…you’d be surprised at how unsupportive of [court appearances] a hospital administrator would be…but yeah that’s probably the most common barrier to somebody carrying [an ERPO] out is you simply can’t get to court.” “But I think the barrier’s just time of actually having to complete those in-person court appearances as a petitioner”
Urgency of situation	“I worry a little bit about something that involves two court visits not happening particularly quickly so I’m not sure in the immediacy of the moment it’s going to help. We tend to see patients when they’re in a crisis and we need a solution now not the solution in a few weeks.”
Gun culture and gun accessibility	“…I think that access to firearms in Baltimore city is like access to cupcakes in New York…. You don’t have to walk two blocks…I think taking someone’s gun away in Baltimore City doesn’t necessarily have the same protection that it might for somebody who doesn’t have such immediate access” “Especially with firearms, there’s a huge cultural component to familiarity with and comfort with and ownership of firearms…I think there are a lot of areas where, culturally firearms are hugely accepted part of everyday life and I think for clinicians in those areas, it may be really difficult to overcome the cultural context of that and to imagine utilizing an ERPO”
Fear for safety or repercussions	“I think on an individual level, it can feel risky.. you know patients if [the patient] or their families hold tightly to these second amendment concepts, they know where you work and it’s not hard with the internet to figure out where people live. And there is a certain amount of fear in aggravating…in not knowing how zealously people hold on to their gun right.” “If you don’t file the petition, can you be sued…that’s one of the concerns, I think. I don’t think a psychiatrist or any clinician should be punished if they didn’t file the petition”