Long-Term Outcomes For Mass Shooting Survivours

Since 1966, 1,102 Americans have been killed in mass shootings, according to an analysis by The Washington Post. Thousands more have been injured—both physically and psychologically. These survivors come from nearly every race, religion and socioeconomic background, living otherwise normal lives in Parkland, Florida; Aurora, Colorado; or the scores of other towns whose names have become etched in our minds. Although mass shootings account for only a tiny fraction of the country’s gun deaths, they are uniquely disturbing because they happen without warning in the most routine of places: schools, churches, office buildings and concert venues. “Simply by definition, mass shootings are more likely to trigger difficulties with beliefs that most of us have, including that we live in a just world and that if we make good decisions, we’ll be safe,” says Laura Wilson, PhD, co-author and editor of “The Wiley Handbook of the Psychology of Mass Shootings” and an assistant professor of psychology at the University of Mary Washington in Fredericksburg, Virginia.

Most survivors show resilience. But others—particularly those who believed their lives or those of their loved ones were in danger or who lack social support—experience ongoing mental health problems, including post-traumatic stress, depression, anxiety and substance abuse. The National Center for PTSD estimates that 28 per cent of people who have witnessed a mass shooting develop post-traumatic stress disorder (PTSD) and about a third develop an acute stress disorder. Research also suggests that mass shooting survivors may be at greater risk for mental health difficulties compared with people who experience other types of trauma, such as natural disasters. A study led by former Northern Illinois University (NIU) graduate student Lynsey Miron, PhD, after the 2008 shootings on NIU’s campus, found that although a large percentage of mass shooting survivors were either resilient or displayed only short-term stress reactions, about 12 per cent reported persistent PTSD, a number that’s higher than the average prevalence of PTSD among trauma survivors as a whole (Behavior Therapy, Vol. 45, No. 6, 2014). What’s critical, psychologists’ research suggests, is to ensure that victims feel connected to their communities in the aftermath of mass violence and that they have ongoing support available to them.

Memorial events—particularly those that are student and community initiated and led—are most helpful to survivors in terms of recovering after a mass violence event, suggests a study conducted after a murderer opened fire, stabbed passers-by and then rammed his car into a crowd near the campus of the University of California, Santa Barbara, in 2014, killing six people and wounding 14 others (Psychological Trauma: Theory, Research, Practice, and Policy, Vol. 10, No. 1, 2018). These events included a candlelight vigil the night after the tragedy and a memorial “paddle-out,” where thousands of the community’s surfers joined together in the ocean to remember the victims of the event. “As a community psychologist, I’ve seen first-hand the importance of mental health promotion efforts that have nothing to do with counselling per se, but that help the community heal together,” says University of California, Santa Barbara, assistant psychology professor Erika Felix, PhD, who led the study.

Stages of a shock and healing

In the aftermath of a shooting, people typically go through three stages of healing, according to a 2017 research bulletin compiled by the Substance Abuse and Mental Health Services Administration (SAMHSA): the acute phase immediately after the event, the intermediate phase several days to weeks afterwards and the long-term phase. The agency developed the report to help public health, behavioural health and emergency management professionals improve their disaster behavioural health preparedness plans.

In the acute phase—often characterised by denial, shock and disbelief—mental health professionals can best help survivors by providing them with resources and information. Through interventions such as psychological first aid, they can help normalise survivors’ immediate feelings of fear, anxiety and helplessness. “Simply ensuring victims are aware that support is available and accessible to them—even if they never take advantage of it—can help immensely,” says psychologist Dan Mosley, EdD, an American Red Cross disaster mental health services volunteer who most recently provided support to victims of the Las Vegas shootings. This is likely due to the empirically supported benefits of connection over isolation, he says, noting that knowledge of resources is one way of feeling connected and that people are less anxious and worried if they know help is available should they need or want it. Psychologists can also help families determine whether they want to speak with the media and help survivors understand which medical, funeral and mental health treatment costs might be covered by the U.S. Department of Justice’s Office for Victims of Crimes, says psychologist James Halpern, PhD, founding director of the Institute for Disaster Mental Health at the State University of New York at New Paltz (SUNY New Paltz).

The intermediate phase is often characterised by fear, anger, anxiety, difficulty paying attention, depression and disturbed sleep, according to the SAMHSA report. In this phase, psychologists can play a critical role in helping communities get set up to provide more long-term support to survivors, says Halpern. That means training local mental health professionals, schools, faith-based organizations, recreation centres and other community organisations about the importance of trauma-informed resource building and information sharing, Halpern says. Providing trauma-informed care, experts note, involves understanding, recognising and responding to the effects of all types of trauma and emphasises physical, psychological and emotional safety for both consumers and providers, to help survivors rebuild a sense of control and improvement. Two evidence-based programmes are often used to help survivors manage their stress: the Cognitive Behavioral Intervention for Trauma in Schools (CBITS) and the Skills for Psychological Recovery (SPR) programmes. Both teach survivors tools, such as breathing and writing exercises to help manage their distress and encourage them to increase their participation in meaningful and positive activities. They also teach survivors how to rebuild and enhance their social connections and community supports.

Survivors enter the long-term phase several months after the event. While people in this phase continue to experience periods of adjustment and relapse, most survivors, particularly children, will no longer need continuous mental health support. Some have even grown from the experience, reporting greater self-worth and sense of life purpose and expressing feelings of gratitude for having survived the shooting, experts say. But for others, this can be the time when untreated behavioural health reactions—flashbacks, debilitating anxiety or self-medication—can solidify into mental health or substance use disorders that require more specialised care, says Karla Vermeulen, PhD, an assistant professor of psychology at SUNY New Paltz. Some people enter this phase when they realise that others in the community have been able to move forward, while they are still struggling, suggests Heather Littleton, PhD, an associate professor of psychology at East Carolina University in Greenville, North Carolina, who studied student adjustment after the 2007 Virginia Tech shootings. She found that rates of elevated PTSD symptoms persisted among survivors one-year post-shooting. This was consistent with the reports of local mental health providers, who noted an influx of survivors who sought treatment as time went on—after community focus and media attention had shifted—compared with in the immediate aftermath of the shooting. “It leaves them feeling lost and disconnected, so we need to make sure we have longer-term support in place for these individuals when they are ready for it,” she says. Halpern says that means training local mental health professionals in the importance of periodically checking in with their clients to assess how they are doing, staying active in the community to make sure people continue to be aware of trauma’s long-term effects and ensuring that they’re providing trauma-informed care, even years after an event has occurred. “No matter how much we emphasise their strength and resilience, these victims and families will suffer from these losses for the rest of their lives,” he says.

Who will need long-term help?

Not surprisingly, one factor that predicts how well mass shooting survivors will fare long-term is their proximity to the incident. A meta-analysis Wilson led examining PTSD symptoms among more than 8,000 participants found that those who were most directly exposed to the shooting—those who were physically injured, those who saw someone else get shot or lost a friend or loved one—as well as those who perceived that their own lives were in danger, are at much greater risk for long-term PTSD symptoms and other mental health consequences than survivors who may have been hiding nearby or otherwise farther from the incident (Journal of Traumatic Stress, Vol. 27, No. 6, 2014). In addition, prior trauma exposure, as well as how well people were functioning before an incident, also predisposes survivors to PTSD and poor long-term outcomes, according to a review of 49 studies examining the mental health consequences of mass shootings (Trauma, Violence, & Abuse, Vol. 18, No. 1, 2017). “If you already have mental health symptoms such as a pre-existing anxiety disorder or are on the borderline for depression, you’re going to be more vulnerable to psychiatric adversity after exposure,” says Sarah Lowe, PhD, the review’s lead author and an assistant psychology professor at Montclair State University in New Jersey. Previous trauma may also be a reason why women are more likely to develop PTSD than men after mass shootings since research shows women are more likely to experience particular forms of interpersonal violence. “It may be that women are more likely to have had multiple forms of trauma exposure—perhaps the survivor had also experienced sexual assault previously in her life—and faced additional trauma in the shooting,” Wilson says.

Victims’ coping strategies and support systems are also strong predictors of their long-term health and wellness. People who engage in self-blame for the tragedy—believing they should have done more to try and save friends who died, for example—are at greater risk for long-term poor psychological outcomes. On the other hand, those who have strong social support systems, particularly from family, appear to do better, Littleton says. In a survey she conducted with more than 300 female Virginia Tech students after the shootings there, she found that the more students felt like they had good support from their families, the better off they were in terms of adjustment (Psychological Trauma: Theory, Research, Practice, and Policy, Vol. 1, No. 3, 2009). A group of Virginia Tech researchers led by psychologist Andrew J. Smith, PhD, also found that when mass violence events occur on college campuses, a collective identity often forms that can help boost a sense of social support in the aftermath and perhaps promote seeking support (Anxiety, Stress, & Coping, Vol. 28, No. 3, 2015). This communal feeling contrasts with the secrecy, isolation and shame that survivors of individual traumas may face, such as people who experience sexual assault and domestic violence, the authors note. The grief process is also shared, often leading to healthy mourning and coping. “Bringing people together to promote connections and collective healing after a tragedy is often what strengthens families and communities the most,” Felix says. It’s also another area in which psychologists can play an important role by promoting ongoing events to bring communities together, she notes.

Building more supports

Psychologists are also working with educators to improve the mental health of children affected by mass shootings. Much of that work centres on giving teachers the tools and support they need after such traumatic events, says Robin Gurwitch, PhD, a child psychologist at the Duke University School of Medicine who studies resilience in children after trauma. “Teachers are one of the best supports that children have after these events,” says Gurwitch, a member of the U.S. Department of Health and Human Services’ National Advisory Committee on Children and Disasters. “We have to make sure they are getting the support they need as well as information on how to best help the children in their classroom.” Psychologists also help schools affected by shootings operate in a way that’s sensitive to the needs of staff and students, says Melissa Brymer, PsyD, PhD, director of terrorism and disaster programs at the UCLA-Duke National Center for Child Traumatic Stress. That includes screening students to determine who needs more intensive mental health services, monitoring those who are chronically absent and working with school nurses to investigate kids who report headaches, stomach aches or other concerns which hadn’t reported these symptoms before the event.

Psychologists are especially needed to help schools affected by a shooting adjust emergency drills so that they don’t trigger thoughts of past trauma. More research in this area is needed, but in the meantime, psychologists can talk to schools about how to make these drills less traumatic, Brymer says. For example, instead of announcing a drill over an intercom or whatever communication technique had been used in the real emergency, an assistant principal could go to each classroom to calmly announce a drill. Also, for students who are already prone to anxiety, schools might consider doing practice drills only with them and checking in with them the next day.

Psychologists are researching to inform other interventions as well. Armed with a grant from the National Institute of Justice, Brymer and her team are conducting a community-based participatory research examination of the adjustment and recovery efforts that took place in response to 12 recent mass shooting events—six school shootings and six community events. By examining multiple school shootings and mass violence events, this project will identify gaps in services and policies, refine recovery protocols in school and community emergency plans, foster collaboration among different responding organizations and agencies, and ensure that funding is available during critical phases of recovery. “The goal is to examine the similarities and differences between these events to understand better where practices might need to be altered to provide a better national response and recovery component when these events happen,” Brymer says. Psychologists are also eager to study other questions about survivor well-being, including how such experiences—particularly at a young age—shape one’s sense of safety and self-efficacy. “Those are the more existential consequences that I’d love to see more researchers start to examine,” Vermeulen says.

Credit: Amy Novotney for American Psychological Association, September 2018.