Coping Strategies and Screening for PTSD

PTSD Effects on Mass Shooting Survivors

Introduction

Post traumatic stress disorder (PTSD) is common among soldiers returning from active duty overseas, where they encountered combat, shelling, intense encounters with the enemy and so on (Thomas et al., 2010). Symptoms of PTSD can range from anger, hostility, and aggression, to depression and suicidal ideation (Jakupcak et al., 2007). While it is understandable that combat veterans might experience PTSD, what is less frequently appreciated is the fact that survivors of mass shootings can also experience PTSD (Cimolai et al., 2021). This is important because PTSD, if undiagnosed and untreated, can wreak havoc on a person’s personal and professional life or on a person’s development if the individual is still a child when the traumatic event occurs (Bardeen et al., 2013). Moreover, it is also important because mass shooting events have occurred with more frequency in recent years: there was the Las Vegas shooting in 2017 that killed 60 and injured nearly 1000; the Orlando night club shooting that killed 49 and injured nearly 60; the El Paso Walmart shooting that killed nearly two dozen people and injured just as many; the Virginia Tech shooting of 2007; the Sandy Hook shooting of 2012; the Aurora movie theater shooting of 2012; and dozens of others. Clearly there is a need to understand the impact that PTSD can have on survivors of these shootings. This paper will discuss the PTSD effects on mass shooting survivors and show that survivors should be both screened just as returning soldiers from combat are screened for potential PTSD and taught coping strategies—for the risk of not treating PTSD among mass shooting survivors is too great for it to be ignored.

What is a Mass Shooting?

A mass shooting event has been defined by the non-profit association Gun Violence Archive as “an incident in which four or more people, excluding the perpetrator(s), are shot in one location at roughly the same time” (Cimolai et al., 2021, p. 1). Mass shooting events can thus occur anywhere: beaches, schools, theaters, public places like shopping centers, private places such as temples or churches; stadiums, concerts, parks, work places, and so on. In fact, mass shooting events have occurred at all of these venues in recent years. One of the deadliest places where mass shootings have occurred is, unfortunately, the school place setting. As Cimolai et al. (2021) point out, the prevalence of mass shootings at schools is rare—but when a mass shooting does occur at a school it is often very deadly: “Four of the top deadliest shooting in the past 21 years, where the fatalities were between 13 and 33, were in schools, accounting for a majority of gun violence–related fatalities: Columbine High School, Littleton CO (1999); Virginia Tech, Blacksburg, VA (2007); Sandy Hook Elementary School, Newtown, CT (2012); and Marjorie Stoneman Douglas High School, Parkland, FL (2018). About 60% of all school shootings occurred in a high school setting” (p. 2). School shootings are especially likely to induce PTSD because survivors are not just adults and children who happened to be present at the shooting but also members of the community—families and others who are impacted indirectly by the shooting. One does not need to experience a traumatic event directly to be traumatized by it (Knight, 2013).

Mental Health Consequences of Mass Shootings

Mass shootings are traumatizing events that can have a severe impact on the mental health of survivors (Lowe & Galea, 2017). Just as soldiers or police officers can experience trauma in the line of duty, survivors of mass shootings can be doubly at risk for developing PTSD because they are not trained for such a situation nor are they likely to be expecting it in the course of their everyday lives. Likewise, just as a witness of sexual abuse can be counted as a victim of sexual abuse, a witness of a mass shooting may also be one who experiences PTSD from the event. Thus, when a mass shooting incident occurs and people survive it, returning to a state of normalcy can be quite difficult. North et al. (1997, 2002) have shown that the effects of PTSD can linger for years following a mass shooting event.

One vulnerable population to gun violence is children: as Cimolai et al. (2021) explain, this population needs to be given more careful consideration because “overall, the impact of gun violence is not felt just during the incident but has long-term consequences for onlookers, family, and the community. Children often unwittingly experience the trauma with few psychological tools to deal with the event” (p. 1). Thus, children should receive special attention when discussing PTSD effects on mass shooting survivors—especially since “young children (age 2 to 9) when exposed to direct or indirect violence have increased rates of PTSD” (Cimolai et al., 2021, p. 2). One of the most common symptoms among children who are exposed to gun violence is anxiety sensitivity, which is characterized by an irrational fear that negatively impairs one’s ability to socialize, function physically, or have normal cognitive functioning (Cimolai et al., 2021). Children are also more likely to have both internalizing and externalizing issues as an effect of PTSD. They may develop physical illnesses because they are unable to express how they feel; these are known as psychosomatic responses, in which the body is made ill even though there is no physical underlying cause—the cause is purely psychological.

But of course children are not the only ones who can be adversely impacted as survivors of mass shootings. Lowe and Galea (2017) show that “mass shootings are associated with a variety of adverse psychological outcomes in survivors and members of affected communities,” including the parents of elementary school children who survived a mass shooting at their school (p. 62). However, some demographics have a higher risk of being affected by PTSD than others: for instance, Lowe and Galea (2017) have also found that women with pre-incident psychological symptoms are more likely to have PTSD effects. Additionally, those who are very close to the shooting and are an acquaintance of someone who died in the shooting are more likely to experience PTSD than those who only witnesses from a distance and do not know any of the killed. One final factor that makes a person more susceptible to PTSD after a mass shooting event is the extent to which the individual has access to psychosocial resources, such as social support and emotion regulation exercises (Lowe & Galea, 2017).

Longitudinal studies have been conducted to show that more than a quarter of survivors of mass shootings do experience PTSD while nearly another fifth of survivors experience other psychiatric problems (North et al., 1997). North et al. (1997) also found after conducting interviews with 136 mass shooting survivors that those with a previous psychiatric history, particularly in dealing with depression, were most vulnerable to developing PTSD. Moreover, PTSD was unlikely to go into remission even three years after the mass shooting incident (North et al., 2002). North et al. (2002), like Lowe and Galea (2017), also found that women and those with psychiatric histories were more likely to develop PTSD.

Adults who survive mass shootings can demonstrate PTSD effects such as “intrusion (flashbacks, nightmares, and unwanted memories); avoidance of trauma-related thoughts, feelings, and external reminders; alteration in arousal and reactivity (irritability, risky behavior, hypervigilance); and negative changes in cognition and mood” (Cimolai et al., 2021, p. 3). One high school survivor of the 2018 Stoneman Douglas High School shooting, for instance, was taken to the emergency room of a local hospital months after the shooting with “intrusive thoughts related to the shooting, nightmares of the shooter entering the building and killing multiple people, and avoidance of school and public places as they induced flashbacks and panic attacks” (Cimolai et al., 2021, p. 3). Her PTSD had been triggered simply by seeing graphic news on TV and social media about gun violence.

Adults may not even know they have PTSD until such time as symptoms like these emerge. Children, however, might show signs indicative of PTSD effects that adults can identify early on. Behavioral issues among children who survive mass shootings and who are experiencing PTSD can include “increased anxiety, development of new fears, sadness, lack of interest, prolonged crying, low frustration tolerance, and aggression. Parents might notice regressive behaviors (thumb sucking, sleeping in the parental bed), loss of acquired developmental milestones, change in eating habits, and sleep problems (nightmares, frequent wakening)” (Cimolai et al., 2021, p. 4). Children may also engage in repetitive fantasy play in which themes of trauma are consistently explored in the play.

There is also another element of PTSD that goes unexplored among mass shooting survivors—which is the issue of guilt. Although there is no reason anyone who survives a mass shooting should feel guilty, some survivors are so wracked with guilt that they end up taking their own lives later on. This is a serious effect of PTSD (Cimolai et al., 2021). In fact, suicide risk is one of the major reasons PTSD needs to be considered more fully when a mass shooting event occurs. There are numerous examples of this: within ten days of two separate mass shooting events there were three suicides of survivors: “two adolescent survivors of the Stoneman Douglas High School shooting and the father of one of the children killed in the 2012 Sandy Hook Elementary School massacre took their own lives” (Cimolai et al., 2021, p. 4). Guilt can overwhelm a survivor or a parent: one believes one could have done something more to stop the shooting. Cimolai et al. (2021) point out, for example, that “four students affected by the Columbine High School shooting reported in a qualitative study that guilt grew in the 2 weeks following the event along with ruminations on what they could have done to prevent the attack” (p. 5). Feelings of guilt, therefore, should be considered as an effect of PTSD among mass shooting survivors.

Other effects include major depression, social phobia, and psychosomatic disorders, in which a person feels physically ill even though there is actually nothing wrong with the person. Another common problem among survivors of mass shootings is substance abuse (Cimolai et al., 2021). Additionally, enrollment rates in school can drop among survivors, and those who remain enrolled can see their test scores fall. In short, PTSD effects can come in all shapes and sizes; there is no one-size-fits-all characterization of PTSD among mass shooting survivors. Every individual really has be taken into consideration and evaluated after a mass shooting, including not only those who were there but also community members, family members, friends, and so on. The effects can range widely not only in terms of how they present but in whom they are to be found.

Littleton et al. (2011) found, however, that one significant factor that determines whether a survivor experiences PTSD is the type of coping strategy the person employs after the mass shooting incident. Littleton et al. (2011) conducted a longitudinal study and examined survivors of the Virginia Tech mass shooting. They found that maladaptive coping correlated significantly with psychiatric stress over time. In other words, survivors who lacked a beneficial coping strategy were more likely to experience PTSD in the wake of the shooting. This suggests that one mediating factor in determining whether a survivor struggles with PTSD is whether the individual has a good coping strategy.

Screening Survivors

Numerous scholars and researchers have shown that soldiers returning to civilian life should be screened for PTSD before they are released from the military (). The reason for this recommendation is simple: people who are left undiagnosed and untreated pose a great risk to themselves and to others if they have PTSD and do not receive treatment for it. It is essential for mental health that individuals who are exposed to traumatic situations—like combat, or a mass shooting event—should be screened for PTSD. Lowe and Galea (2017) have noted that “trained crisis response teams that establish safety, evaluate the psychological needs of victims, connect survivors with a range of services to meet their needs, and evaluate response efforts have been proposed to mitigate the effects of school violence” (p. 79). The purpose of trained crisis response teams is to ensure that an environment in which proper evaluation can be conducted is established in the wake of a mass shooting. A mass shooting event should not be an incident in which police tape is put up and everyone is sent home. Those who are affected by it—who survive it or who are friends or family members of survivors, or are acquaintances of the dead—need to be evaluated for PTSD. That can take time, even months, and the important thing to do in the wake of a mass shooting is to establish a registry of all survivors so that follow-up screenings can be provided.

Lowe and Galea (2017) additionally point out that “the empirical research also lends support for approaches that identify survivors most at risk of adverse outcomes, including women, persons of lower socioeconomic status, those who faced higher levels of exposure, and persons lacking strong social support networks” (p. 79). By identifying individuals who are more likely to develop PTSD, trained crisis response teams can conduct follow-up interviews with these persons over the course of the following year to see whether they have developed PTSD and are in need of treatment.

In the interim, these same crisis response teams could teach individuals helpful coping strategies that can be used to empower people to work through the trauma and maintain control of their mind, health, body, and spirit. Coping strategies should, therefore, be part of an effective intervention strategy when helping survivors of mass shootings.

Teaching Coping Strategies

Kearney et al. (2012) have found that mindfulness training can help individuals cope with PTSD, depression, and quality of life issues. Mindfulness training teaches people how to be present and in the moment, embracing life rather than seeking to avoid it or hide from it. Mindfulness techniques can include meditation, awareness, prayer, breathing, and other activities that help one to maintain clarity, peace, and stability even in the face of tension and anxiety.

Mindfulness can help to prevent disengagement, problem avoidance, social withdrawal, wishful thinking, and self-criticism; it focuses on the positives of one’s self and life, and gives one the peace of mind and tranquility to move forward. Mindfulness facilitates fortitude and the application and development of grit. Grit and determination can empower a person to overcome trauma (Kearney et al., 2012; Littleton et al., 2011). Keys to developing the necessary ability to overcome trauma are emotion regulation and coping strategies that “encourage engagement with and acceptance of emotions, thoughts, memories, and sensory experiences” (Lowe & Galea, 2017, p. 79). The aim of this approach is to promote resilience; mindfulness training, coping, and emotion regulation all help one to develop resilience in the face of trauma.

Coping is one of the best strategies that can be implemented when trying to address the fallout of a mass shooting. That is why grief counselors are often called into schools when there is a shooting at a school. But what about at other venues, public or private? Who is there to provide support for survivors or to make sure a support network is available for them?

These are important questions to ask because it is not just a matter of making sure everyone is processing emotions well. It is also a matter of making sure people do not become a risk to themselves or to others. Suicidal ideation can be a real threat among mass shooting survivors. Some of them can feel such strong guilt for not having “done something” that they are driven to the edge of sanity and take their own life. This could be avoided with the right intervention. But many people do not know that they are in need of a coping strategy; they do not even know that they are traumatized. They are simply caught in a downward trajectory and are unable to stop the negative thoughts and feelings that return at the slightest trigger. Without a program in place to help people like this, the victim count of a mass shooting event may actually be much higher than is officially recognized.