After the Massacre

What can anyone really say about the horrific events in Newtown, Connecticut and the shooting spree that led to the deaths of six adults and twenty children?   The analysis of events are still underway and far too many things will likely never be known about what motivated the shooter.  Still, one thing is abundantly clear:  the trauma that the survivors are experiencing will likely continue with them for the rest of their lives, especially the families of the deceased and the children who saw classmates being killed.   Although Newtown is a fairly close-knit community, the burden of dealing with grief and trauma is likeely to overwhelm available mental health care providers.

Ironically, one of the adults killed at the scene was the school psychologist, Mary Sherlach, who was preparing for her own retirement after a decades-long career caring for children.    Though there are already comparisons between this tragedy and other school shootings such as Columbine High School massacre in 1999,  dealing with trauma in the aftermath of extreme violence has undergone significant changes between then and now.

While the Critical Incident Stress management model still has defenders,  it has been largely called into question  due to suggestions that interventions can do more harm than good.  A better alternative used in recent years is known as Psychological First Aid (PFA).     Developed through a joint partnership between the U.S. Department of Veteran Affairs and the National Child Traumatic Stress Network,   PFA is designed for first responders dealing with potentially traumatized people in the immediate aftermath of a disaster, whether man-made or natural.   PFA's principles are meant to meet four basic standards:

1. Being consistent with research on risk and resilience following trauma
2. Being applicable and practical in field settings
3. Being appropriate for developmental levels across the lifespan. 
4. Being culturally informed and delivered in a flexible manner

Although not all victims will develop severe mental health problems or long-term delays in recovery, it is often hard to predict who will be most affected immediately after the disaster.  PFA is designed to be delivered by mental health workers who are part of an organized disaster relief effort.   These workers are usually organized into first response teams either as part of a government relief agency or a non-government organization such as the Red Cross.    PFA is also designed to be delivered in different settings, whether it be a shelter, field hospital, school, or other building that has been set up to handle disaster victims.   

Along with information gathering to help providers make rapid assessments of a victim's immediate needs, PFA  involves establishing a human connection between the provider and the victim in a compassionate and non-intrusive manner.    Since many victims are going to be emotionally overwhelmed, providing reassurance and comfort is a vital part of the PFA process along with providing practical information to help survivors.   The help PFA providers can provide takes the form of verbal instruction, handouts and other instructional aids as needed.   Once the initial intervention is complete, survivors are connected with the social support they need, whether it be family members or mental health professionals providing in-depth counseling.  For traumatized children needing additional help, there are a range of specialized trauma treatment programs available that have been designed for use with children and adolescents.  Many of these programs will likely be made available for the survivors of the Newtown massacre.

With PFA, it is important to remember that, along with established procedures for PFA, there are a long list of things not to do when dealing with trauma victims.   These can include:

• Assuming that everyone exposed to a disaster will be traumatized
• Making assumptions about what survivors are experiencing and what they have been through
• Pathologizing acute stress reactions by labelling them as "symptoms" or using terms such as "syndrome", "disorder", or "diagnosis"
• Assuming that all survivors want to talk about what they have experienced or trying to "debrief" them by asking what happened
• Speculating or offering inaccurate information.  If a survivor asks a question, try to learn the facts to give an accurate answer

The current principles of PFA has been developed through experience in dealing with victims of previous tragedies, including other school schootings.   Very much a work in progress, PFA principles can be expected to change as new disasters occur and better training becomes available.   Though first responders will always be left with the feeling that they should be doing more for victims, their early intervention may well be the most important factor in avoiding the long-term emotional problems that disasters such as this latest massacre can bring.

To download the PFA manual (PDF)