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What Happens to the Survivors?

Long-term outcomes for survivors of mass shootings are improved with the help of community connections and continuing access to mental health support.

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 percent of people who have witnessed a mass shooting develop post-traumatic stress disorder (PTSD) and about a third develop 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 percent 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 passersby 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 firsthand the importance of mental health promotion efforts that have nothing to do with counseling 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 afterward and the long-term phase. The agency developed the report to help public health, behavioral health and emergency management professionals improve their disaster behavioral health preparedness plans.

In the acute phase—often characterized 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 normalize 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 characterized 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 centers and other community organizations about the importance of trauma-informed resource building and information sharing, Halpern says. Providing trauma-informed care, experts note, involves understanding, recognizing and responding to the effects of all types of trauma and emphasizes physical, psychological and emotional safety for both consumers and providers, to help survivors rebuild a sense of control and improvement.

Two evidence-based programs 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) programs. 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 behavioral health reactions—flashbacks, debilitating anxiety or self-medication—can solidify into mental health or substance use disorders that require more specialized care, says Karla Vermeulen, PhD, an assistant professor of psychology at SUNY New Paltz.

Some people enter this phase when they realize 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 emphasize their strength and resilience, these victims and families will suffer from these losses for the rest of their lives," he says.

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