School Shootings and Lessons Learned

In the aftermath of the Sandy Hook Elementary School shootings in Newtown, Connecticut, that took the lives of 20 very young children and 6 adults, the experience of mental health professionals who have been at the center of similar tragedies offers up some valuable lessons.

Montreal is a city that has experienced 3 school shootings that included 15 dead at the École Polytechnique in 1989, 4 dead at Concordia University in 1992, and most recently, Dawson College.

Psychiatrist Warren Steiner, MD, was the McGill University Health Center's psychiatrist-in-chief when 25-year-old Kimveer Gill stormed the atrium of Dawson College on September 13, 2006, killing 18-year-old student Anastasia De Sousa and wounding 19 others before killing himself.

That moment launched a "psychological first aid" response that was very different from the city's responses to previous school shootings.

With hindsight, Dr. Warren said he would do some things differently — and some the same — lessons that he hopes might help others who are dealing with similar situations.

"The consequences do continue for years afterwards, and they were not the consequences that we expected," he said. "It went far beyond PTSD [posttraumatic stress disorder].

In fact, research carried out by the team 18 months after the Dawson College shooting shows that substance abuse and major depressive disorder emerged as bigger players than PTSD.

"One thing we would have done very differently is talk about all sorts of psychological reactions, not just PTSD," he said.

Trauma Surge

When the first shots were fired at Dawson College, Dr. Steiner was across the street having lunch with his son. He returned to a Code Orange (community emergency) at the Montreal General Hospital, in which mental health services had all but been forgotten.

"It was just chaos. I went into the control room and they had no idea why I was there. We hadn't been thought of," he recalls.

"It was clear after 9/11 that the psychological consequences of these kinds of major disasters outnumber the physical consequences about 10 to 1...yet they had no idea why I was there."

But before long it was clear.

"Some of the shooting victims were coming for surgery, but then there was a flood — it's called a surge — of nonphysical trauma. We had hundreds of kids, parents, and staff. They were feeling completely overwhelmed. They were hysterical, sobbing, terrified, and having panic attacks," Dr. Steiner told Medscape Medical News.

"One fellow had been holding Anastasia [the victim who died] and talking to the shooter. Other people were covered in blood. These were horrible things these young people experienced."

From that moment, a massive psychological first-aid effort was launched, aimed at damage control.

No Guidance

"We decided to be proactive," he explained at a recent meeting of the Canadian Psychiatric Association. "We sought out people and tried to actively identify those at risk for late-onset distress."

But there was little to guide the team's proactive instinct.

It is not known whether specific interventions can reduce the risk for PTSD, and previous tragedies have yielded little research.

Within hours, a call made to Columbine High School generated little advice about how to proceed proactively, and there was even some lingering uncertainty about the potential of retraumatizing victims.

"It was at that point we realized we were on our own and had to develop a plan very, very quickly on the fly," said Dr. Steiner.

From there, a marathon began.

For the first week, Dr. Steiner and his team were on the scene of the shooting 24/7. At one point they numbered more than 100 mental health workers.

When the school reopened, floaters scanned the crowd for traumatized individuals, approaching them and offering psychological support.

They launched a focused outreach aimed at psychoeducation.

Articles were commissioned in the school newspaper, and handouts were distributed about the risks and signs of PTSD.

For more than 6 months, a block of 12 therapy rooms at the college remained constantly staffed, attending to a steady stream of traumatized students and teachers.

The message to everyone was "be very careful not to pathologize the normal healing process," said Dr. Steiner.

"You could be waking up at night with terrible nightmares and reliving it, or jumping at the sound of someone dropping their books — these are normal reactions; you are not ill because you're experiencing them."

Psychological First Aid

"Psychological first aid" has become "the intervention of choice" in the immediate aftermath of a tragedy, agrees psychologist Christopher Flynn, PhD, director of the Cook Counselling Center at Virginia Polytechnic Institute and State University in Blacksburg.

But the nature of that aid is still a subject of debate.

Within 15 minutes of the first shots in the 2007 Virginia Tech massacre — which eventually left 32 dead — Dr. Flynn too was mobilizing psychological first aid for survivors and the families of victims.

"They used to talk about critical incident stress debriefing, in which people would get together and talk about their immediate reactions to trauma, and that was thought not be particularly effective and in some cases actually did harm," he told Medscape Medical News.

"Psychological first aid suggests that the sooner we can bring resources to bear, the more likely it is that immediate stress disorders can be handled with decreasing likelihood of posttraumatic stress."

Indeed, the study carried out after the Dawson College shootings suggests this theory may hold true when it comes to PTSD. But the research also points to the risk for other outcomes, Dr. Steiner warned.

As expected, the study, which included a sample of 949 Dawson college students and staff, showed a 3-fold spike in the prevalence of any form of mental disorder after the shooting as compared with rates reported in the Canadian Community Health Survey (30.9% vs 10.9%), which was carried out the previous year.

In addition, PTSD prevalence was higher than in a Canadian military peacekeeping cohort (3.4% vs 1.4%).

Unexpected Finding

But the unexpected finding was that the increase in PTSD was stunted compared with the increases in both alcohol and illicit drug abuse (8.7% vs 2.6% and 2.6% vs 0.8%, respectively) and major depressive disorder (12.1% vs 4.8%).

"So the rate of PTSD was not as high as we expected. Is that because we focused on that? Would it have been even higher if we hadn't focused on it?

"People react in different ways.... They may be very jumpy or very anxious all the time, and their reaction may be to turn to drugs or alcohol to self-medicate. So one thing I would do differently is I would say, 'you are at higher risk for the development of mental health problems in general — not just PTSD,' " said Dr. Steiner.

But a similar study carried out by Virginia Tech, in collaboration with Harvard University, during the 4 months after that campus massacre shows a much higher rate of "probable PTSD" (15.4%), based on a cross-sectional survey of 4639 students.

The reasons for this apparent difference are not clear. Compared with the Dawson study, the Virginia Tech study was carried out much sooner after the tragedy and included a larger number of participants.

Despite intense counseling over prolonged periods at both schools, the nature of mental health interventions may have differed, and the time point in the school year (September at Dawson and April at Virginia Tech) may have affected the dissemination of psychological first aid.

In addition, the scope and duration of the shooting at Virginia Tech extended beyond that of the Dawson College incident.

Mental Health Prognosis

One thing both studies suggest is that the proximity of a person to a shooter or a victim can, to some extent, predict their future mental health risk.

In the case of Dawson, 13% of respondents saw the shooter, 35.8% saw someone wounded or killed, and 3.3% tried to help a wounded or dead victim.

Down the road, these were the people most at risk for psychological trauma, said Dr. Steiner, adding that in addition to degree of exposure, the study showed that female sex carried a higher risk for PTSD (odds ratio [OR], 3.54) and major depressive disorder (OR, 3.93).

At Virginia Tech, during several hours of uncertainty over the shooter's whereabouts, 64.5% of survey respondents were unable to confirm the safety of their friends, and 9.1% had a close friend who was killed.

In that study, the ORs for high levels of posttraumatic stress symptoms were highest for those who experienced the injury or death of someone close (2.6 - 3.6) and those who were unable to confirm the safety of friends (2.5).

Perhaps knowledge of these statistics may one day guide mental health professionals in counseling trauma victims about their future mental health, Dr. Steiner suggests.

"I would now say, if someone was in the atrium at the time of the shooting, it is imperative that they meet with a mental health professional to be evaluated, because they're going to be at the highest risk down the road."

Toward Healing

The long-term effect of the tragedy on the students of Sandy Hook Elementary School remains to be seen, and efforts are underway to help them recover some sense of normalcy.

When their classes resume in a new building, the pain and fear will still be fresh, but the act of returning will be an important step toward healing.

That was the case for the thousands of Dawson College students who on September 18, 2006, made a symbolic reentry into their college atrium — which just days before had been filled with bloodstained books and backpacks.

"It takes a lot of courage to come back 5 days later," Dr. Steiner acknowledged. He had fought for the resumption of classes as soon as possible, against some resistance.

"Quite a few teachers said we should just cancel the semester. But that builds up, and your negative expectations grow and grow. So we met all the teachers on the Friday in the gym and persuaded them. And they were on board after that," he said.

The following Monday, when the students returned, the teachers met them inside, and the atrium was filled with applause. Today, a peace garden stands as a memorial to the tragedy.

Medscape Medical News © 2012  WebMD, LLC

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Cite this: School Shootings and Lessons Learned - Medscape - Dec 31, 2012.