Aurora, Colorado. Fort Hood, Texas. Virginia Tech. The Washington Navy Yard. And, most recently, Charleston, South Carolina. Each of these places transitioned from being a name on a map to an instant reminder of the devastating aftermath of mass violence. Another is Sandy Hook, the Newtown, Connecticut, elementary school where shooter Adam Lanza killed 26 people, including 20 children, in December 2012.

In a report published last year, the FBI found that mass shootings in the United States have risen dramatically in recent years. In a study of 160 active shooter incidents between 2000 and 2013, the agency stated that an average of 6.4 incidents happened each year between 2000 and 2006. Between 2007 and 2013, that average rose to 16.4 incidents each year.

Deb Del Vecchio-Scully is the clinical recovery leader of the Newtown Recovery and Resiliency Team, formed out of a $7.1 million grant from the U.S. Department of Justice (DOJ) to bolster the Connecticut town’s mental health recovery and community resiliency in the wake of the shooting. According to Del Vecchio-Scully, this is the first time that a DOJ grant has been awarded specifically to provide mental health services following school-based violence.

When the grant was being written, Del Vecchio-Scully says, it was nearly impossible to gauge what Newtown’s needs would be in the months and years ahead. “There’s no road map,” she says, adding that the tragedy was unique because of the age of the children who were murdered and the impact the event had worldwide.

“What I’ve really come to understand about trauma is that in the aftermath of tragedy, regardless of how it happened — if it’s natural tragedy, if it’s violence — the reactions are extraordinarily complicated,” says Del Vecchio-Scully, a member of the American Counseling Association and the executive director of the Connecticut Counseling Association, a branch of ACA.

Since 9/11, psychological first aid has become the preferred modality suggested by the Federal Emergency Management Agency for use in the immediate aftermath of a disaster such as a mass shooting, says J. Barry Mascari, an associate professor and chair of the Counselor Education Department at Kean University in New Jersey. He explains that three core actions are involved in psychological first aid: protect, direct and connect. Protect survivors from further vulnerability, direct them to other services and connect them with their families and communities.

Counselors should think about that concept in terms of Maslow’s hierarchy of needs, Del Vecchio-Scully says. People’s basic needs must be met first, and the type of event will determine what those needs are — financial, social, psychological, emotional or practical.

Traditional counseling treatment and interventions are not part of psychological first aid. The goal of counseling is often to help people change, Mascari points out, but the goal in the immediate aftermath of a disaster is to help people get back to normal, which is the objective of psychological first aid. “You don’t want to start bringing in your other bag of tricks because [psychological first aid is] not treatment,” says Mascari, a member of ACA who is a co-editor with Jane Webber of the forthcoming book Disaster Mental Health Counseling: A Guide to Preparing and Responding, due to be published by the ACA Foundation next year.

Psychological first aid is also based on the recognition that individuals involved in a mass tragedy are experiencing normal reactions to an abnormal event, and the majority of people will return to normal in time, Mascari says.

Wait until called

After the events of 9/11, the United States learned one lesson in particular, Mascari says, “and that was that we weren’t prepared as a country to respond to these kinds of events.”

In the years since, individual states and the federal government have developed better-organized plans for responding to various types of disasters, including events of mass violence, Mascari says. Today, the response includes a hierarchy of those in charge and standards for survivor care.

Yet something that can still complicate the response to a tragic event is the influx of what Mascari calls “SUVs,” or spontaneous uninvited volunteers. “It was very clear both after the hurricane [Katrina] in New Orleans and after 9/11 that mental health professionals showed up expecting to do therapy with people and, in many cases, could have done more harm than good,” he says.

Del Vecchio-Scully also witnessed this after the school shootings in Newtown. “Communities can be overwhelmed by well-meaning helpers in the aftermath of a mass violence event, just as they are after a natural disaster,” she says. “Out of the goodness of people’s hearts, they want to help, and communities get flooded by individuals who may not have the training. Newtown was flooded by many whose hearts were in the right places but [who] did not really have the expertise to be doing what they were attempting to do.”

“You never want to be an SUV,” Mascari advises his colleagues in the counseling profession. “If you’re not deployed through an organization, you shouldn’t be there, because what happens is that you contribute to the disaster rather than help mitigate it.”

Counselors who are interested in assisting after a tragedy should start by seeking training beforehand to become an American Red Cross disaster mental health volunteer, Del Vecchio-Scully says. Among other places, the training is offered each year at the ACA Conference & Expo.

Mascari agrees that counselors should first get trained as disaster mental health volunteers and never self-deploy. He advises connecting with one of the responding organizations, such as the respective state mental health organization or the American Red Cross, to help in the aftermath of a disaster.

According to Mascari, New Jersey was the first state — about a decade ago — to develop a disaster response crisis counselor program. It uses a formal certification process for the state’s disaster crisis response workforce. Other states have since followed suit, using New Jersey’s model to create similar programs, he says.

Finding a new normal

People are often resilient in the face of disaster, says Daniel Linnenberg, an assistant professor of counseling in the Warner School of Education at the University of Rochester. “However, it takes a long time for them to go from being a victim of an event to a survivor of an event to a ‘thriver’ of an event,” adds Linnenberg, an ACA member who teaches a course on crisis counseling and disaster mental health and is also a disaster mental health volunteer with the American Red Cross and in his home county in New York.

“There will always be that ‘hole’ of that event within them,” he continues. “But, generally, people go beyond that and sort of come to what they refer to as a new normal.” Still, Linnenberg says it’s important to “remember that the event may only take seconds, but the recovery time takes years.”

That process of building resilience can be aided by various factors, the most important of which is social support, Linnenberg says. For example, when people have loved ones around them to lean on, that can foster resilience. Possessing a sense of optimism, having meaning and purpose in life, and accepting that we don’t have control over the world can also foster resilience, he says.

One way that counselors can assist survivors in building social support is through peer groups, such as the one Linnenberg helped establish in the wake of a tragedy in Webster, New York. Linnenberg had been providing counseling in the aftermath of an ambush shooting of firefighters that took place in the Rochester suburb in December 2012. The peer group was set up for loved ones of the firefighter community because they didn’t naturally have a group of people to connect with who could understand what they were going through.

Although resiliency will look different for everyone in the aftermath of an event of mass violence, Del Vecchio-Scully says that counselors can foster resilience among clients by engaging in ego-strengthening exercises — namely, recognizing and honoring when they take a step forward in some way. Remind clients that simply getting up in the morning and completing a task such as attending a counseling appointment or going to work is evidence of resilience, she says.

Del Vecchio-Scully cautions, however, that when the immediate aftermath of an event of mass violence has passed, it will not be a “neat transition” from the psychological first aid stage to what survivors will need next. Counselors should be on the lookout for people who are struggling and might need mental health treatment, she says.

Trauma affects people on a number of different levels in a tragedy such as a mass shooting. The base level is personal trauma, or what the individual’s own experience in the tragedy was, Del Vecchio-Scully says. There is also vicarious trauma, which usually affects helpers who are repeatedly exposed to the traumatic stories of others, she says. Secondary trauma is experienced only where primary trauma has occurred and results from being exposed to others who have been traumatized by the same event, she explains. Shared trauma affects people at the community level — for example, a teacher who works at a different school in Newtown, she says.

Complicated reactions to events of mass violence and other disasters, including posttraumatic stress disorder (PTSD), complicated PTSD and traumatic grief, are sometimes missed or misdiagnosed, Del Vecchio-Scully says. Counselors working with people in the aftermath of disaster or violent tragedy need to understand that trauma is a neurobiological injury to the brain, she says. A traumatic event such as a mass shooting can affect the brain in such a way that fearful memories get stored and the fight-or-flight response gets frozen. A cascade of neurochemicals then leads to triggering, emotional flooding, avoidance and hypervigilant reactions, she says.

“The long-term impact of trauma on children is particularly concerning within the Sandy Hook community [because] the brains of those directly impacted are in their most formative stages, ages 5 to 18,” Del Vecchio-Scully says. “The dysregulation of the brain due to trauma may impact brain size, brain hemisphere integration — which is important for emotional regulation — and an ability to determine cause and effect. [There is also] the impact on academic learning and performance.”

Del Vecchio-Scully suggests that counselors work from a trauma-informed model, which “requires advanced training in the neuroscience of trauma and trauma-informed treatments that focus on whole-brain treatment.” She says the treatments include eye-movement desensitization and reprocessing therapy, brainspotting, the emotional freedom technique, trauma-focused cognitive behavior therapy, somatic experiencing and trauma-informed art therapy.

“Counselors must have a basic understanding of the brain’s reaction to trauma, avoid assessment/treatment that requires a client to ‘retell their story,’ utilize calming and soothing techniques to regulate the brain and then initiate a trauma-informed treatment approach,” Del Vecchio-Scully says.

Caring for the caregivers

Most recently in Newtown, Del Vecchio-Scully has been working to provide support for the mental health clinicians in the community. She says that two and a half years after the shootings, community members affected by the tragedy are still coming to see these clinicians for the first time, which means the impact hasn’t really lessened for these mental health professionals.

On top of that, the community’s mental health clinicians are likely navigating multiple layers of exposure to the tragedy. For example, a counselor might be hearing clients’ stories of trauma while simultaneously feeling personally connected to the trauma because their children go to school in Newtown.

Del Vecchio-Scully’s team has been working to create peer support groups for the mental health clinicians working in the community. The helping professionals, who are from in and around the Newtown area, have a deep commitment to helping their community, Del Vecchio-Scully says. But clinicians in these kinds of situations can struggle to identify when they become impaired.

“If you enter into this work with an open heart, it isn’t a matter of if you’ll be impacted by the work but when this will occur,” she says. “Self-care when responding following a mass violence or natural disaster tragedy requires the basics of adequate rest; food and drink; time off and away from the situation; good, solid support from others; [and] methods of decompressing from what has been witnessed, including supervision, which for licensed people often lapses.”

In her role in Newtown, Del Vecchio-Scully participates in two peer supervision groups. It is an experience that she terms “invaluable.”

“Our team has worked with nearly 400 Newtown residents since its inception in July 2014,” she says. “I have worked very closely with a group of families whose children survived the shooting and were in the classrooms where the shooting took place. Bob [Schmidt, a fellow leader in the Connecticut Counseling Association] and I run a monthly group with these parents, and I have worked individually with some of the parents and kids. I have also worked in the Sandy Hook School providing support to the staff.”

Linnenberg emphasizes that supervision or peer support is a must for counselors who provide services in the aftermath of mass tragedy, no matter their level of experience. Self-care is also about knowing when to take a break, he says. “It’s more than drinking water. It’s more than getting exercise,” he asserts. “All those things are important, but it is really … forcing yourself to take time off even though you know you’re needed.”

Prevention on campus

One of Meggen Sixbey’s roles as a counselor is to try to prevent instances of violence before they happen. As the associate director for crisis and emergency resources at the University of Florida’s counseling and wellness center, Sixbey serves as a member of the university’s multidisciplinary threat assessment team.

Multidisciplinary threat assessment teams, which can be convened in a variety of communities, such as college campuses, typically bring together representatives from that community to address individuals who have raised a level of concern. On a college campus, the team might include representatives from the university administration, law enforcement, the campus counseling center and other sectors of the campus, says Sixbey, a member of ACA.

At the University of Florida, Sixbey says the team is called a behavioral consultation team, and its purpose is to bring a holistic perspective to individuals of concern. That individual might be someone who is threatening harm to others, Sixbey says, but it’s also possible that the person is a victim in some way, such as someone who survived a car accident or is being stalked.

All students, faculty and staff at the university have access to a phone number and email address that allow them to report a person of concern, Sixbey says. That information first goes to the office of the dean of students, which vets the reports and forwards the situations that need to be addressed to the multidisciplinary threat assessment team.

A counselor’s role on teams such as these is to act as a consultant and assess the situation with others on the team, Sixbey says. Although other team members might want a counselor to predict the likelihood of violence or pathologize behaviors, Sixbey says her role is to help cultivate a holistic perspective by looking at the whole of the person and the whole of the systems around the person. She often finds herself asking questions about what else could be done or what else is in play in the situation to help move the team forward in its assessment. “I don’t really come in with a diagnostic lens,” she says.

The ethical considerations surrounding a counselor’s participation on teams such as these can be complex. For example, Sixbey says if she is currently working with or has previously worked with a client at the university counseling center who subsequently comes up as a person of concern, she doesn’t typically consult with the team on that assessment because it would be a conflict of interest. But each situation must be considered on a case-by-case basis, she says. For instance, it may not be helpful to the person of concern if Sixbey recuses herself because that action may confirm to the rest of the team that the person is seeking counseling services or has sought them in the past.

In other situations, Sixbey might possess confidential knowledge about the person of concern that she can’t share with the team even though she is participating in the assessment. For example, during the course of the team’s assessment, a student could be asked to meet with Sixbey. That student could confidentially share with Sixbey that she is willfully stalking a faculty member, despite claiming publicly that it was a cultural misunderstanding. “A lot of that ethical piece is having this firsthandish knowledge that we can’t share,” Sixbey says.

In such situations, Sixbey has to consider how she can consult with the team in a helpful way while still honoring the legal and ethical guidelines of confidentiality. In this example, she might suggest to the team that if the student is to see the faculty member in person, a third person should be present. That way, Sixbey could protect the confidentiality of the student but also protect the safety of the faculty member.

The most helpful thing counselors can do to navigate ethical dilemmas associated with participation on multidisciplinary threat assessment teams is to consult with other mental health professionals, Sixbey says. “Consultation is key, and if we don’t do that, we’re doing ourselves a disservice.”

Some counselors might worry that a multidisciplinary threat assessment team is essentially a “profiling team,” Sixbey says. “That’s far from what these sorts of teams do if they’re doing it right.” In fact, teams such as the one Sixbey serves on focus mainly on ways they can help a person of concern be successful — “as opposed,” she says, “to cleaning up something that happens later because we didn’t do any kind of prevention.”

“I’d like to think our team is preventing crimes and homicides and suicides and depression, just frankly, on a daily basis,” Sixbey says. The hard part is that the team members will rarely know just how effective their intervention and prevention efforts have been at heading off crises. “We know when a school shooting happens, for example, but we don’t know when a school shooting has been prevented,” she says.

Since the mass shootings at Virginia Tech in 2007 and Northern Illinois University in 2008, more college campuses have initiated multidisciplinary threat assessment teams, Sixbey says. In addition to defusing potential situations of mass violence, she says these teams allow counselors to feel they are part of a larger, more collaborative effort to help people.

“If it’s just us with that person behind closed doors, we’re going to have a really limited view,” Sixbey says. “We may have a tenth of the pie, and there’s 90 percent more that we just don’t know.”

Sixbey offers an example. Perhaps getting a family member involved in a situation might help a person of concern — and perhaps the dean’s office would be better positioned than the counseling office to get that family member involved. “Counselors [can] get caught in a role of [thinking], ‘It’s just me trying to help this person,’” Sixbey says, “and that can feel really daunting.”

‘It can happen here’

Although a community may be flooded with outside resources and supports in the immediate aftermath of a tragedy, many of those supports, such as the American Red Cross, will eventually leave. At that point, Linnenberg says, the community itself needs to be prepared to take over.

For that to happen, Linnenberg contends that the community must be ready before a tragedy takes place. That includes mental health counselors and school counselors in the community preparing ahead of time for what they would need to do should an event of mass violence affect their community, he says. It also means counselors should prepare others in the community as well. For example, school counselors might help students understand what actions they should take if an event of mass violence were to happen at their school.

Counselors should also get more involved in public policy, Mascari says. “We tend not to think that we should be active in public policy, but public policy drives almost everything we do,” he says. Mascari tells his students to listen to what is being said in the public arena and then respond so that fewer public policy decisions will be made based on fear and misinformation.

The supposed connection between mass violence and mental illness is a perfect example, Mascari says. “There is a constant tagline in the media about mentally ill people performing violent acts,” he says. But Mascari points to a New York Times article written by Richard A. Friedman in the wake of the Newtown, Connecticut, shooting that said “only about 4 percent of violence in the United States can be attributed to people with mental illness.”

“While it is true that policy should consider closer screening of people with violent histories or mental illness who want to obtain guns, people should not stigmatize the majority of [individuals who are] mentally ill as violent, because they are not,” Mascari says.

Regardless of who the perpetrators of mass violence are or where these traumatic events take place, counselors need to be ready to respond, Del Vecchio-Scully says. “Following mass trauma, the community looks to counselors for support,” she says. “Therefore, counselors must have a minimum, base knowledge of trauma assessment and crisis intervention to assist immediately following the event before referring to a colleague with the advanced skills needed to engage in treatment,” which could mean another counselor or a different clinician with appropriate training.

“Nobody expects these things to happen, but they are happening with an ever-increasing amount of frequency,” Linnenberg says. “You hear about them almost every day. … We cannot necessarily prevent them from happening,” he says, “but we need to be prepared for them happening.”

Even in the class he teaches on crisis counseling and disaster mental health, Linnenberg says he has students who don’t understand why the door to the classroom should be locked.

“We do not have that mindset that this could happen to us at any time,” Linnenberg says. “The likelihood is very, very, very extremely low. But there is always that possibility. And, in a sense, as a counselor, you never want to be the one thinking, ‘I didn’t think it could have happened here.’ Yes, it can happen here.”

 

 

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To contact the individuals interviewed for this article, email:

• Deb Del Vecchio-Scully at deborahscully@ymail.com
• Daniel Linnenberg at dlinnenberg@warner.rochester.edu
• J. Barry Mascari at jmascari@kean.edu
• Meggen Sixbey at sixbey@ufl.edu

 

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Harm to Others

Earlier this year, the American Counseling Association published Harm to Others: The Assessment and Treatment of Dangerousness by Brian Van Brunt. The book offers students and clinicians an effective way to increase their knowledge of and training in violence risk and threat assessment, and it also provides a comprehensive examination of current treatment approaches. Van Brunt offers numerous examples from recent mass shootings and rampage violence to help explain the motivations and risk factors of those who make threats.

 

See Counseling Today‘s Q+A with Van Brunt here: ct.counseling.org/2015/06/behind-the-book-harm-to-others-the-assessment-and-treatment-of-dangerousness/

 

For more information on the book, visit ACA’s Online Bookstore at counseling.org/bookstore or call 800.422.2648 ext. 222.

 

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Lynne Shallcross is a contributing writer to Counseling Today. She recently graduated with a master’s degree in journalism from the University of California, Berkeley. Contact her at lshallcross@berkeley.edu.

Letters to the editor: ct@counseling.org