by Melissa Brymer, Ph.D., Psy.D.

Dr. Brymer is the head of the National Child Traumatic Stress Network, which promotes best practices for pediatric trauma recovery. The nationwide network comprises 87 sites, including Rady Children’s Hospital in San Diego. Between natural disasters, violence & terrorism, there have been many such events in recent years which have exposed children to extreme events, including mass violence.  The technical definition of mass violence is “an intentional violent crime which causes physical and psychological injury with at least four casualties, which increase the burden of victim assistance & compensation.”  School shootings and mass casualty events may not necessarily be the same thing (although colloquially, they are often conflated as such). Dr. Brymer pointed out that only eight of the last 22 school shootings met the full definition of a mass casualty event. For example, there are many school shootings where, thankfully, no one is injured.

Dr. Brymer discussed some recent mass casualty events to illustrate how each event is unique and presents different challenges for recovery. Each event has the potential to change perceptions & beliefs of professionals involved in the disaster field as well. For example, after Sandy Hook, it was realized that elementary schools are not necessarily safer or immune to violent events. After Parkland, we now appreciate that students exposed to a school shooting can be fierce and effective advocates for better safety, and that this may help them heal.  It is necessary for the mental health responder to know something about the community history, the unique features of each event, and relevant cultural traditions/rituals,  to be able to identify those individuals at highest risk, and interventions which might be effective.

The first example discussed was the shooting at Sandy Hook Elementary School, where the perpetrator was an ex-student, during what appeared to be the most positive part of his life adjustment. He returned to where he felt comfortable to enact his violence. The doors were securely locked, but he shot off the lock. Although no one knows how this happened, since no one realized the school even had an intercom system that could even be used, this system was accidentaly turned on at the start of the attack. This exposed all the children to the horrific sounds of the violent attack, extending the trauma well beyond the affected classrooms.

Another example discussed was the Festival 91 Harvest Concert in Las Vegas, which was unique since its impact was not confined to Las Vegas, where the attack took place. In fact, 62% of ticketholders were from California, and quickly scattered after the event, without access to organized intervention. The sheer size of this event (59 killed and  527 injured)was unprecedented. There are still so many questions unanswered about the perpetrator, which is unusual.  No motive has been put forth to explain his actions, posing a challenge for assembling a coherent narrative, essential for healing. Many “first responders” in this event turned out to be taxi drivers or random passersby who were not formally trained EMTs, thus putting them at risk. Dr. Brymer noted that it is important to remember that first responders and providers have their own grief after the event, not just victims’ families and survivors. Memorials and community support provide valuable support to all individuals affected in the community.In this event, the tragic loss of the Sandy Hook principal, vice principal, and school psychologist, wiped out the administrative “brain” of the school, so survivors had to cope with the loss of people they loved and with the loss of their institutional memory which helped the school function smoothly. Since children/teachers were relocated to another town while the school site was investigated, then razed to the ground and rebuilt,  the school community members were “refugees,” in that they could not follow their usual, convenient routine for four years. Familiar routines are helpful to children’s coping with a trauma. For example, the UN supplies a “School in a Box” to refugee sites, so disaster responders can get children in shelters and refugee camps into positive, structured educational routines as soon as possible.

To illustrate a different type of event, the San Bernadino workplace shooting incident was also discussed. This incident occurred at a holiday party/meeting of the County Public Health Department. One of the victims’  co-workers and his wife were the perpetrators; one the perpetrators being someone they had worked alongside for five years and thought they knew compounded the confusion and grief caused by the incident. The victims’ County EMT co-workers were the first responders, called upon to help their colleagues. The Public Health Department’s  work unit moved to a temporary location while their former office was remodeled so that the perpetrator’s familiar cubicle was not part of their environment as before. This physical disruption adds to the coping burden for survivors.

Dr. Brymer then presented the Five Steps for Mental Health Disaster Recovery, according to the current National Child Traumatic Stress Network (NCTSN) model, developed out their extensive experience with traumatic events.

In this model, the general approach to disaster response always starts with Re-establishing Safety. Besides the direct risk from the violent event, there may be new safety risks or severe adversities after the event (for example, in shelters or getting to them).  Both victim/survivor specific and community-wide safety measures are often needed. Extra law enforcement brought on to the scene must be encouraged to approach the survivors with sensitivity, as their presence may feel intrusive to some vulnerable groups. For example, after Sandy Hook, implementing a large police presence on a daily basis among elementary school age children involved thinking through how not to frighten them further. As it happened, someone donated hundreds of  small rubber ducks, so these were handed out by law enforcement on site for comfort,  as part of their routine function to make them less scary.

Once people are safe, Calming Efforts are needed. Many individuals may be shocked or acutely bereaved. Parents and teachers need information about how to help children cope. Resources and information on post-traumatic grief are often helpful.  Posters and signs from “kindred spirits” who have gone through similar tragic events are often very meaningful to current survivors. This helps them feel they are not alone and there is another community which understands some of what they are going through. The Sandy Hook Community received over 500,000 letters of support, which showed them how much people cared.  However, managing this logistically and respectfully was a challenge in itself.  In the end, the letters were organized into a “digital library” with open access.  The actual letters were then burned in a ritual, and the remains compressed into bricks, which formed the foundation of their new school.

Survivors need opportunities and interventions that help them Build their Self-efficacy, which may have been damaged during a sudden harmful event that left them feeling helpless.  Providing resources and information so that people can make good decisions is a basic step in this process. Allowing survivors to give their input into decisions that need to be made is also important. Community town hall meetings, mourning rituals, and religious services can provide opportunities for meaningful decisions to be made by the community. These efforts also provide community recognition and validation of the seriousness of the tragedy and its aftermath. This collective healing can be very empowering, thus enhancing recovery.

Facilitating Helpful Connections is the next step in the recovery process. People do not heal after a traumatic event in isolation. Identifying those individuals with low social support, who may be isolated, or have special needs is critical. Being with people they love and connecting meaningfully with those who understand is the most healing environment for recovery. Social media can be helpful, but care must be taken; a strange and distressing modern phenomenon is the “truther” movement,  that is,  after an event, there are people communicating online who claim the event did not happen or was staged by actors, which is potentially harmful and invalidating. Survivors and their families are also usually targeted by trolls with aggressive and frightening threats. The members of the notorious Westboro Baptist Church may show up, for example to the school’s graduation, to heckle survivors with hate speech. This is a new and troubling phenomenon, for which awareness and prevention may help in advising survivors and in organizing post disaster events to prevent survivors from further harm.

Finally, Fostering Hope is important.  With acceptance that their lives are forever changed, survivors and their families must find a way to go on with the new reality. In this way forward, they benefit from memorializing their loved ones in creative ways, which add meaning to their lives and the lives of others. For example, after Sandy Hook, many parents created non-profit organizations which aim to contribute potential solutions to or prevention of school-based violence in their child’s memory. Safe & Sound Schools is an organization devoted to safe school environmental designs run by two Sandy Hook mothers. Dylan’s Wings of Change is dedicated to supporting children with autism, and The Avielle Foundation is run by two neuroscientist parents to find new information about the brain & violent behavior; both organizations are named after children who were murdered at Sandy Hook. Love Wins: An Ana Grace Project, Jesse Lewis: Choose Love Movement and Sandy Hook Promise are other organizations created in the aftermath, which augment healing for those involved and contributing, strengthening the community.

With the lessons learned from each event, the NTCSN has been working on modernizing disaster mental health response.  Particularly problematic for healing post-disaster is the tendency for a “let’s move on” attitude, which undermines how long grief and trauma recovery take. It is difficult to have the necessary patience in our “hurry up” culture. Profound grief and anger are difficult to sit with. Even clinicians may avoid contact with this, and seek to move on. It takes significant effort to create a cohesive, stable community over time, in which survivors can take the time they need to fully recover. Survivors must also be protected from intrusive media interviews, where they are urged to recount the event over and over again.

Many challenges remain. For mental health providers, shielding oneself from media coverage about the event is widely understood now to be essential in order to have the energy to effectively treat the survivors, but increasingly hard to do with the proliferation of media into many aspects of our life.   A particular challenge is how to include the injured and/or hospitalized survivors in  the community support events and grief rituals, such as memorials, when they cannot physically participate. When they recover from their injuries, they may find that the community has already moved on. A recent investigation showed that six years after the incident, the majority of the injured children never went back to school, thus missing out on the organized longer term “postvention”/recovery efforts and may be lost to follow-up. More research is needed to develop interventions which fit their needs.

A lesson learned from the school shooting in Chardon, Ohio in 2012 was that many first responders never get to learn the outcome of those they helped during the acute emergency, which can create an information gap that is hard to heal with. Sometimes rescuer/survivor reunions can be very helpful and healing. Other groups in disaster response often overlooked for trauma recovery intervention include law enforcement, members of the media, local funeral directors and any community organization which has been involved in the response in any way. NAMI has a good program available for law enforcement, Preparing for the Unimaginable.

The ABCs of second responder self-care during and after a disaster are

Awareness (that one has been affected and how)

Balance (restoring energy, rest, play & joy)

Connection (seeking out support resources & community)

Care must always be taken to restore oneself as needed when participating in disaster response.

There are a number of free online resources which can help mental health providers become more informed and prepared to offer post-disaster support. The NCTSN website, NCTSN.org, is the starting place for many resources. At https://learn.nctsn.org/, there is a course and an app for Psychological First Aid, courses in Trauma Focused CBT, Psychological Recovery Skills, Traumatic  Grief, and links to many other web-based resources. Some of these online courses are CE approved.

For parents, UCLA has created Helping Kids Cope, a parent-focused app which covers eight different types of disasters and how to help kids through them. It is important to remember that notable events such as sudden evacuations, parental panic, or periods of time without any power can be frightening for children, although these may be taken in stride by adults. To address this, graphically appealing children’s stories about some unlucky mice who cope with various disasters have been developed. These are posted online at the NCTSN center website in English and Spanish.

Dr. Brymer is the Director of Terrorism and Disaster Programs of the UCLA and Duke University and the National Center for Child Traumatic Stress Network. In this capacity she has been involved with the development of acute interventions, assessment, and educational materials in the area of terrorism, disasters, and school crises. Dr. Brymer is one of the primary authors of the NCTSN/NCPTSD Psychological First Aid and Skills for Psychological Recovery interventions and has served as a consultant for many Federal, state, and local agencies across the country and internationally after disasters, terrorism, school shootings, and other mass violence tragedies. She is the lead advisor to the Newtown Public Schools, and has established many long-term public disaster mental health programs for children and families. As Principal Investigator for the National of Institute of Justice project, “Examining the Short and Long-term Impact of School Shootings and Mass Violence in Communities,” Dr. Brymer is identifying ways in which victims and other individuals are impacted by such incidents and what services need to be brought in to promote healing. She is a consultant for the US Department of Education and a subject matter expert for the Disaster Mental Health Subcommittee of the National Bio-Defense Science Board, the Office of the Assistant Secretary for Preparedness and Response (DHHS/ASPR), and for Substance Abuse Mental Health Services Administration (SAMHSA).

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