VER PHOTOGRAPH

Mass Violence: Planning, Responding, Recovering

A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center 

the Dialogue

2017 | VOLUME 13 | ISSUE 3-4
TABLE OF CONTENTS

1 In This Issue

2 Technical Assistance Snapshot

3 Contributors

5 Recent Technical Assistance Requests

6 Since Columbine: Evolution of Colorado’s Disaster Behavioral Health Response 

10 The Aftermath of the Virginia Tech Shootings

14 Lessons Learned From the Boston Marathon Bombing Victim Services Program 

17 Tragedy in the Sanctuary

20 Terror Attack at Work

22 Disaster Behavioral Health Challenges Encountered During the Response to the 

Pulse Nightclub Shooting in Florida

25 Recommended Resources

Cover photo: ORLANDO, FL/USA. OCTOBER 1, 2016. Place where Omar Mateen, killed 49 people

and wounded 53 others in a terrorist attack/hate crime inside Pulse, a gay nightclub in Orlando, Florida,

United States. Photo by Miami2you / Shutterstock.com.

The Dialogue is a quarterly technical assistance journal on disaster behavioral health which 

is produced by the Substance Abuse and Mental Health Services Administration (SAMHSA)

Disaster Technical Assistance Center (DTAC). Through the pages of The Dialogue, disaster 

behavioral health professionals share information and resources while examining the 

disaster behavioral health preparedness and response issues that are important to the field. 

The Dialogue also provides a comprehensive look at the disaster training and technical 

assistance services SAMHSA DTAC provides to prepare states, territories, tribes, and local 

entities so they can deliver an effective behavioral health (mental health and substance 

misuse) response to disasters. To receive The Dialogue, please go to SAMHSA’s home 

page (https://www.samhsa.gov), click the “Sign Up for SAMHSA Email Updates” button, 

enter your email address, and mark the checkbox for “SAMHSA’s Disaster Technical 

Assistance newsletter, The Dialogue,” which is listed in the Newsletters section.

SAMHSA DTAC provides disaster technical assistance, training, consultation, resources, 

information exchange, and knowledge brokering to help disaster behavioral health 

professionals plan for and respond effectively to mental health and substance misuse needs 

following a disaster.

To learn more, please call 1-800-308-3515, email dtac@samhsa.hhs.gov, or visit the 

SAMHSA DTAC website at https://www.samhsa.gov/dtac.

The Dialogue is not responsible for the information provided by any webpages, materials, or organizations referenced in this publication. Although 

The Dialogue includes valuable articles and collections of information, SAMHSA does not necessarily endorse any specific products or services 

provided by public or private organizations unless expressly stated. In addition, SAMHSA does not necessarily endorse the views expressed by 

such sites or organizations, nor does SAMHSA warrant the validity of any information or its fitness for any particular purpose.

The views, opinions, and content expressed in this publication do not necessarily reflect the views, opinions, or policies of the Center for Mental 

Health Services, SAMHSA, or the U.S. Department of Health and Human Services.
A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

In This Issue

IMAGE: Maybe a photograph of immediate aftermath of an incident of mass violence, or people consoling each other.

PHOTO: Stuart Elflett / Shutterstock.com.

On May 22, 2017, yet another incident of mass violence 

shocked the world. Twenty-two people died, and many 

more were injured, after a suicide bomber detonated an 

explosive device at a concert in Manchester, England. 

Unfortunately, incidents such as this are becoming all 

too common.

The U.S. Department of Justice’s Office for Victims 

of Crime (OVC) uses the following definition of mass 

violence:

An intentional violent criminal act, for which 

a formal investigation has been opened by the 

Federal Bureau of Investigation (FBI) or other

law enforcement agency, that results in physical, 

emotional, or psychological injury to a sufficiently 

large number of people to significantly increase the 

burden of victim assistance and compensation for 

the responding jurisdiction as determined by the 

OVC Director.

The inclusion of emotional and psychological injury 

in the definition is notable. The behavioral health 

impacts of mass violence events can be far-reaching.

Those immediately and directly affected include 

victims, their loved ones, and those who were close to 

the incident when it occurred. The effects may spread, 

touching lives, worldwide, as people with no personal 

connection to the event relive it via social media, 

television, and newspaper reports. These violent acts can 

occur anywhere and happen without warning, causing 

disorder, anxiety, fear, and grief. The unpredictable 

nature of mass violence often results in a stressful 

environment for survivors and responders.

This special double issue of The Dialogue focuses on 

the lessons learned from past incidents of mass violence. 

The authors describe how planning efforts contributed

to effective community response and recovery in events 

across the country. Events include the Orlando Pulse 

nightclub shooting and the Boston Marathon bombing, 

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 1
A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

as well as events in Colorado and Virginia. The writers 

are a diverse group, including disaster behavioral 

health and trauma experts, emergency management 

professionals, and local community health center leaders 

and staff. They illustrate that there is still no “one size 

fits all” approach to planning and response—describing 

plans that range from relatively small organizational 

emergency operations procedures to comprehensive, 

statewide disaster behavioral health initiatives. 

Ultimately, the authors bring unique perspectives to bear 

on mass violence events and are leading on-the-ground 

efforts to shape how communities anticipate and manage 

the resulting behavioral health impact.

Although mass violence events are tragic, many 

communities and organizations have come back stronger 

and more resilient. These events have encouraged 

disaster behavioral health professionals nationwide to 

address issues surrounding response planning. Many 

areas are now implementing robust all-hazards disaster 

behavioral health plans and holding large-scale mass 

violence planning exercises that engage a number 

of organizations and agencies. By conducting these 

exercises, responders are better prepared to handle

and recover from an actual mass violence event. The

exercises help them develop relationships and plans

that build bridges between traditional emergency

management functions and disaster behavioral health

providers to facilitate healing and recovery

Has your community experienced a disaster or mass

violence incident that has influenced subsequent

behavioral health responses? Please share your

experiences with us. We encourage you to contact us with

lessons learned or if you would like to learn more about

how you can help your community prepare or respond.

Captain Erik Hierholzer, B.S.N. Program Management

Officer, Emergency Mental Health and Traumatic Stress

Services Branch erik.hierholzer@samhsa.hhs.gov

Nikki Bellamy, Ph.D. Public Health Advisor,

Emergency Mental Health and Traumatic Stress 

Services Branch nikki.bellamy@samhsa.hhs.gov

Shannon Loomis, M.A. Director, SAMHSA Disaster

Technical Assistance Center dtac@samhsa.hhs.gov

TECHNICAL ASSISTANCE SNAPSHOT

In 2015, SAMHSA and SAMHSA DTAC 

assisted 4 states/territories with 5 CCP grants.

In 2016, the number of CCP grants rose to 

11 CCP grants across 9 states.

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 2
A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

Contributors

Eric Alberts, CEM, CHS V, 

FPEM, CHEP, FABCHS,

is a dedicated emergency 

manager who is passionate 

about the field in which he 

works and protecting those he serves. He began his 

career in emergency management in 2002. Mr. Alberts

has responded to emergencies of all types and sizes 

including a terrorist attack, four hurricanes, tropical 

systems, communicable disease outbreak, severe 

weather, wildfires, multi-type vehicle accidents, and 

mass casualty incidents. He is currently the Corporate 

Manager of Emergency Preparedness for the Orlando 

Health, Inc. hospital system in Central Florida. He 

is also a member of the Department of Health and 

Human Services – National Disaster Medical System -

FL-6 DMAT (Disaster Medical Assistance Team) as a 

Logistician, SMRT-5 (State Medical Response Team) 

as the Deputy Planning Chief, member of the Regional

Domestic Terrorism Task Force All-Hazards Incident 

Management Team (AHIMT), and State of Florida 

Division of Emergency Management AHIMT as a 

Qualified Liaison Officer.

Deborah S. Blalock, M.Ed., 

LPCS, CPM has been employed 

by the South Carolina 

Department of Mental Health 

since 1993. In August 2004, 

Mrs. Blalock became the Executive Director of the 

Charleston Dorchester Mental Health Center, one of 

the largest of the department’s 17 mental health centers. 

Prior to becoming the Executive Director, she was the 

center’s Director of Acute Services. In that role she was 

responsible for services that directly focused on people 

in crisis such as a Mobile Crisis Team, South Carolina’s 

first Mental Health Court, a Crisis Stabilization Center, 

and services in local detention centers. Mrs. Blalock 

has extensive training in crisis negotiation, crisis 

intervention, and critical incident management. 

Curt Drennen, Ph.D., is a 

licensed psychologist with the 

Colorado Department of Public 

Health and Environment. He is 

currently the Community 

Outreach Branch Supervisor within the Operations 

Section of the Office of Emergency Preparedness and 

Response. In this role, he is working in partnership with 

a diverse stakeholder group to improve the state’s 

capacity to respond to the psychosocial impact of 

disaster and public health emergencies. He has 23 years 

of experience in the fields of mental health and 

psychology with an emphasis in public psychology and 

administration, emotional intelligence, servant 

leadership, systems conflict management, crisis 

intervention, and behavioral health disaster 

management. Dr. Drennen has led six Colorado Crisis 

Counseling Programs and one SAMHSA Emergency 

Response Grant, and has provided CCP training to at 

least six other states.

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 3
A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

Russell Jones, Ph.D., is a 

Professor of Psychology at 

Virginia Tech University and 

a clinical psychologist who 

specializes in clinical child 

psychology, trauma psychology, and issues related 

to disaster and terrorism (www.firetrauma.com). He 

is an expert in the behavioral sciences. His research 

concerns the topic of childhood stress and coping with 

common stressful life events as well as major traumas 

(for example, natural and technological disasters as 

well as interpersonal violence). His major areas of 

study include disaster preparedness, posttraumatic 

stress disorder, depression, and posttraumatic growth. 

He and his students at the Stress and Coping Lab have 

been engaged in a program of research investigating the

mental health impact of the 4/16 shootings at Virginia 

Tech. More recently, he has been examining the impact 

of racial trauma as well as the transmission of historical

trauma on people of color. 

Veronica A. Kelley, LCSW,

is the Director and Alcohol 

and Drug Administrator for 

the San Bernardino County 

Department of Behavioral 

Health. Ms. Kelley is a member of the Governing 

Board for the California Association of Behavioral 

Health Directors Association (CBHDA), sits on the 

Executive Committee, and serves as the co-chair for the 

Substance Abuse Prevention & Treatment Committee 

as well as the Cultural Competence and Social Justice 

Advisory Committee. She represents CBHDA on the 

State Department of Health Care Services DUI Advisory 

Board and the California Mental Health Policy Council.

April Naturale, Ph.D. is a 

traumatic stress specialist who 

directed the mental health 

response to the 9/11 terrorist 

attacks in New York. Dr. 

Naturale helped launch SAMHSA’s National Suicide 

Prevention Lifeline, directed the BP Deepwater 

Horizon Oil Spill Distress Helpline, and led the 9/11 

10th Anniversary program. Dr. Naturale continues to 

provide crisis management and clinical intervention 

services, curriculum development, and field training in 

the aftermath of disasters, mass violence, and terrorist 

events. At ICF International, Dr. Naturale is a Senior 

Technical Specialist where she previously served as 

Program Director for SAMHSA DTAC and the World 

Trade Center Health Program’s Outreach and Education 

project. Currently, she is the lead architect of the Boston 

Marathon bombings behavioral health response and is 

training humanitarian aid workers with the European 

Union. She also provides posttraumatic stress and 

suicide prevention training to emergency response 

clinicians and the National Guard in Kiev, Ukraine. 

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 4
A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

In this section, read about recent questions SAMHSA 

Disaster Technical Assistance Center (DTAC) staff have 

answered and technical assistance requests to which they 

have responded. Send your questions and comments to 

dtac@samhsa.hhs.gov.

Request: A state disaster behavioral health 

coordinator reached out to SAMHSA DTAC through 

the DTAC email at dtac@samhsa.hhs.gov. The 

individual requested a literature review on the use of 

pharmaceuticals in the treatment of posttraumatic stress 

disorder (PTSD).

Response: SAMHSA DTAC provided a brief synopsis 

of findings following the conclusion of the literature 

review. The consensus among studies that looked at 

the efficacy of pharmacological PTSD treatment is that 

while drug research has shown promise, there is no 

single source that provides a high success rate for the 

mitigation or prevention of the development of PTSD 

symptoms in trauma survivors with pharmacological 

use. SAMHSA DTAC also sent the state behavioral 

health coordinator links and summaries to selected peerreviewed and federally funded publications. Below are 

some selections:

• Jonas, D. E., Cusack, K., Forneris, C. A., Wilkins, 

T. M., Sonis, J., Middleton, J. C., . . . & Olmsted, 

K. R. (2013). Psychological and pharmacological 

treatments for adults with posttraumatic stress 

disorder (PTSD). Comparative Effectiveness Review, 

No. 92. https://effectivehealthcare.ahrq.gov/

ehc/products/347/1436/PTSD-treatment-adultexecutive-130403.pdf

• Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, 

Y., Weeks, W. B., & Friedman, M. J. (2013). Metaanalysis of the efficacy of treatments for posttraumatic 

stress disorder. The Journal of Clinical Psychiatry, 

74(6), 541–550. http://www.ncbi.nlm.nih.gov/

pubmed/23842024

• Tips Hruska, B., Cullen, P. K., & Delahanty, D. L. 

(2014). Pharmacological modulation of acute trauma 

memories to prevent PTSD: Considerations from a 

developmental perspective. Neurobiology of learning 

and memory, 112, 122–129. http://www.ncbi.nlm.nih.

gov/pmc/articles/PMC4051832/

Request: SAMHSA DTAC received an email from an 

emergency manager requesting a literature review on the 

incidents of child abuse following disasters.

Response: There are mixed conclusions on the 

presence of increased incidents of child abuse following 

a disaster. However, there are some studies with 

strong evidence of a positive association. This is an 

area consistently under-researched as it is sometimes 

believed that children are resilient and do not face as 

many adverse effects following disaster events. Below is 

a resource for information on various topics concerning 

children’s well-being and the effects that disasters can 

have on them.

• Peek, L. (2008). Children and disasters: Understanding 

vulnerability, developing capacities, and promoting 

resilience—An introduction. Children Youth and 

Environments, 18(1), 1-29. ■

Recent Technical Assistance Requests

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 5
A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

Since Columbine: Evolution of Colorado’s 

Disaster Behavioral Health Response

By Curt Drennen, Psy.D., RN, Community Outreach Branch Supervisor, Office of Emergency Preparedness and 

Response, Colorado State Department of Public Health and Environment

“Yesterday, my life entered the most abhorrent nightmare anyone could possibly imagine.”

Sue Klebold, April 21, 1999

I recently read A Mother’s 

Reckoning: Living in the Aftermath 

of Tragedy by Sue Klebold (2016), 

the mother of Dylan Klebold, a 

perpetrator of the Columbine High 

School violence. She writes about 

pain, trauma, reconciliation, and 

return to health. I recommend 

this book, simply because it gives 

us, those in the field of disaster 

behavioral health, a very important 

perspective on the events that we 

plan for, train for, and unfortunately, 

too often respond to. 

It is somewhat clichéd to say that 

every disaster is different—but it 

is true, and that truth is magnified 

in incidents of mass violence. 

These human-caused events 

are unpredictable, varied, and 

devastating, not only to the direct 

victims/survivors, but to whole 

communities.

In the Beginning—Columbine 

High School Response

The initial response to the shooting 

at Columbine was chaotic and 

confused. The most effective work 

happened as a partnership among 

the school- and district-based mental 

health professionals, the community 

mental health center, and county and 

state victim advocates. But a host of 

volunteers, some with tremendous 

clinical acumen, descended onto 

the grounds of the school as well as 

Clement Park (a large urban park 

surrounding the school) to provide 

support running the gamut from 

crisis counseling to Critical Incident 

Stress Debriefing to Eye Movement 

Desensitization and Reprocessing 

(EMDR) therapy to “rebirthing”.

A critical lesson learned when 

Denver hosted the trial for Timothy 

McVeigh (Oklahoma City bomber), 

but unfortunately did not implement, 

is the importance of relationshipbuilding and the development of 

cross-system knowledge. During the 

trial, victim advocates and public 

mental health staff built relationships 

and a strong understanding of each 

other’s systems and the capacities 

and strengths of those systems. 

During the Columbine response, 

those relationships came back into 

play, allowing leadership to have 

instant trust and creating a fair and 

balanced division of responsibilities.

The National Institute of 

Mental Health proposes helping 

survivors with the following in the 

days after a disaster:

Getting food

Getting a safe place 

to live

Getting help from a 

doctor or nurse if hurt

Contacting loved one 

or friends

Keeping children with 

parents or relatives

Understanding what 

happened

Understanding what is 

being done

Knowing where to 

get help

SOURCE: Helping children and adolescents 

cope with violence and disasters: What 

parents can do. (2015). https://www.nimh.

nih.gov/health/publications/helpingchildren-and-adolescents-cope-withviolence-and-disasters-parents/index.shtml

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 6
A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

Improving Capacity With 

Training

Since that day in 1999, Colorado has 

purposefully grown its capacity to 

respond to the psychosocial impact 

of mass violence. The three years 

following Columbine included some 

major events: September 11, 2001, 

and the largest series of wildfires in 

Colorado’s history. During this time, 

a three-year school and community 

recovery program called Columbine 

Connections was implemented by the 

local mental health center, Jefferson 

Center for Mental Health. Lessons 

learned from these experiences led 

to the building of a strong disaster 

behavioral health response system. 

These lessons include:

1. Behavioral health response to disaster

or community crisis is not therapy. 

2. When critical events happen, people

want to help; they just don’t know 

how to get it.

3. Disaster behavioral health is larger 

than any one system.

4. Preparation is absolutely critical to an

effective response.

We chose to start our efforts 

with planning and training. With 

support from a 2003 Substance 

Abuse and Mental Health Services 

Administration (SAMHSA) 

Disaster Mental Health Planning 

grant, Colorado built its first robust 

behavioral health emergency 

operations plan. With a small 

local grant, we began educating 

our providers, helping them to 

understand that just because they 

are outstanding clinicians, does not 

mean they are prepared to respond 

to individuals in crisis. Colorado 

built two core trainings to guide 

knowledge development. The first 

training provided information on 

how to respond as a part of the 

larger system. It also addressed 

being a part of the larger emergency 

management system and provided 

guidance on early intervention. 

The second training focused on 

recognizing trauma and building a 

trauma-informed system of care. We 

then took these trainings to every 

community mental health center in 

Colorado and offered them several 

times over the next two years. We 

continue to update these trainings 

based on our direct experiences as 

well as current research.

Successful Partnerships

Following Hurricanes Katrina, 

Rita, and Wilma, Colorado 

welcomed over 14,000 evacuees, 

and participated in the first multistate national Crisis Counseling 

Assistance and Training Program. In 

October of the following year, a man 

entered Platte Canyon High School, 

holding a room full of girls hostage 

for the day. The incident resulted 

in the death of one of the students, 

Emily Keyes, and the perpetrator. 

In December, Colorado started 

an effort to build a partnership 

across systems to improve disaster 

behavioral health response. The twoyear effort that followed resulted in 

the formation of the Colorado Crisis 

Education and Response Network 

(CoCERN), a partnership of the 

public behavioral health system, the 

American Red Cross, the Salvation 

Army, victim advocates, and a 

variety of professional organizations 

with support from state public health 

and emergency management. This 

partnership set the structure for 

disaster behavioral health response 

in the areas of cooperation, resource 

management, communication, and 

standards of practice. The Colorado 

LESSONS LEARNED

TRAINING PLANNING/DEFINING ROLES PARTNERSHIPS

April 20, 1999

Columbine High School shooting

Colorado began to work on the capacity 

to respond by improving the disaster 

behavioral health trainings provided to 

community mental health centers.

July 20, 2012

Aurora Cinemark Theater shooting

Colorado began to work on defining 

specific missions that behavioral 

health teams can implement based 

on the event and environment.

November 27, 2015

Colorado Springs 

Planned Parenthood shooting

Improved partnerships at the state level 

and the clear role of disaster behavioral 

health led to a successful response.

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 7
A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

Standard of Practice for individuals 

wanting to participate in disaster 

behavioral health requires the 

following trainings: the Federal 

Emergency Management Agency 

(FEMA) Independent Study 

(IS)-100 course, Introduction to 

Incident Command System (ICS); 

FEMA’s IS-700 course, National 

Incident Management System; 

Psychological First Aid; and the 

Colorado Field Response Training 

or the Red Cross Disaster Mental 

Health Fundamentals.

With the CoCERN partnership 

in the middle of its development, 

Colorado experienced a major 

tornado in May 2008 that 

challenged the system. Lessons 

around communicating, identifying 

missions, and articulating 

boundaries were quickly integrated 

into organized processes. Then 

between 2010 and 2015, Colorado 

experienced an unprecedented series 

of natural and human-caused public 

health and mass violence events. 

Each event brought new challenges 

and stretched our understanding 

of what it means to respond to 

community crises.

Defining Disaster Behavioral 

Health—Aurora Cinemark 

Theater Shooting Response

By July 2012, our systems had built a 

great deal of institutional knowledge 

around a behavioral health response. 

When the Aurora Cinemark Theater 

shootings happened, Aurora 

Community Mental Health hit the 

ground running and was backed up 

by five sister community mental 

health centers. A key aspect of this 

response was the close support 

provided by their Emergency 

Support Function (ESF) 8 lead, 

Tri-County Public Health. TriCounty provided communication 

and logistical support as the mental 

health centers deployed teams of 

trained disaster behavioral health 

responders. As a result, teams 

responded to 77 requests for 

community support serving over 

1,830 individuals. The agency’s 

phone bank saw a 111 percent 

increase in call volume in the three 

months after the shooting with over 

11,000 calls, and they served an 

additional 1,100 people through 

walk-in clinics.

However, an event such as 

the theater shooting is not a 

singular event. Aurora’s response 

continued for the next several 

years. In partnership with the city 

and the state, the mental health 

center implemented a SAMHSA 

Emergency Response Grant (SERG) 

focused on community outreach, 

trauma education, and trauma 

treatment; assisted victim advocates 

in providing direct support to 

survivors, first responders, and others

affected by the shooting during the 

criminal justice proceedings and the 

trial of the perpetrator; and launched 

a community resilience center called 

Aurora Strong.

It became clear that disaster 

behavioral health needs to better 

define itself, its purpose, and its

mission. Colorado began to clearly 

articulate the purpose of disaster 

behavioral health: to support 

adaptive functioning by decreasing 

stress and fear in both survivors and 

responders. This clear articulation 

of the role of disaster behavioral 

health has continued to evolve with 

a document that defines specific 

missions that behavioral health 

teams can implement based on 

event and environment. We have 

found this articulation of possibility 

leads to continued development 

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 8
A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

of partnerships with local ESF 

8 leadership and emergency 

management.

Working To Improve 

Partnerships among Response 

Organizations—Colorado 

Springs Planned Parenthood 

Response

Recently, Colorado Springs 

experienced our latest mass violence 

event. While smaller in scale than 

Aurora or Columbine, the shooting 

at Planned Parenthood on November 

29, 2015 illustrated the variety of 

ways disaster behavioral health 

personnel respond to an event. 

The development of partnerships 

at multiple government levels and 

with various types of organizations, 

including Victim Advocates, 

encourages a more efficient and 

successful response.

The mission of Victim Advocates is 

to support victims’ navigation of the 

criminal justice system. This event

resulted in community victims, but 

also responder victims. However, 

because of strong relationships at 

the state level, support and guidance 

could easily be provided to local 

leadership, encouraging creative 

partnership to address the impact of 

this event. While the response was 

relatively short-term, the partnership

involving law enforcement victim

advocates, the community mental 

health center, AspenPointe, and El 

Paso County Public Health (as the 

ESF 8 lead) resulted in an immediate 

response that was impressive. Two 

sequential efforts were launched to 

support victims and the community 

as well as law enforcement 

personnel and their families. In the 

form of a mini-disaster assistance 

center, 3 days of direct care were 

provided to support victims and 

the larger community followed by 

2 days strictly for law enforcement 

and their families. Over the 5 days, 

the response team provided food, 

networking, therapy animals, gifts, 

and informal counseling, and the 

Colorado Acupuncture Medical 

Reserve Corps provided the National 

Acupuncture Detoxification 

Association auricular acupuncture 

protocol for stress.

Because of this successful 

response, the CoCERN partnership 

is furthering the emphasis on 

relationship-building among its 

partners, especially offices of victim 

advocates, the public behavioral 

health system, and local public 

health agencies.

A Passion for Supporting 

Disaster Behavioral Health

Disaster behavioral health requires 

an ongoing commitment to planning 

(developing emergency operations 

and continuity of operations plans); 

training (ICS, Psychological First 

Aid, roles, self-care, and limitations); 

exercises; and relationship 

development. Disaster behavioral 

health also requires advocates 

and leadership who battle against 

both the inertia of systems and the 

negative perceptions of behavioral 

health. One of the reasons I am 

passionate about building strong 

disaster behavioral health systems is 

that responders, survivors, and the 

larger community gain an experience 

with behavioral health professionals 

and systems that can have a positive 

impact. ■

After the Aurora Cinemark 

Theater shooting, the state 

mental health centers saw 

a 111 percent increase in 

call volume with 11,000 

calls, and they served an 

additional 1,100 people 

through walk-in clinics.

12

Minutes

The average activeshooter incident 

lasts 12 minutes.

Thirty-seven 

percent last less 

than 5 minutes.

SOURCE: Nicoletti, J. (2012, December). Detection and 

disruption of insider/outsider perpetrated violence.

Lecture, Colorado Emergency Preparedness Partnership.

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 9
A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

The Aftermath of the Virginia Tech Shootings

By Russell Jones, Ph.D., Professor of Psychology, Virginia Tech University

Due to the nature of the event and 

the location, Virginia Tech did not 

have a “roadmap” to follow to 

guide response and recovery efforts 

in the aftermath of the shooting on 

campus in 2007. As such, initial 

efforts involved the provision of 

immediate comfort and stability as 

well as meeting the acute needs of 

family, friends, and coworkers. In 

the moments and days following 

the shootings, Virginia Tech framed 

its own recovery and identified 

steps to move forward. In my 

opinion, many of these initial 

steps led to an extraordinary level 

of safety and stability for those 

affected by the shootings.

At the outset, I should say how 

much I was moved by the flood 

of expressions of love, concern, 

support, and expertise shown 

by individuals, agencies, and 

organizations and by local, state,

and federal partners.

Acute Aftermath

Immediate actions were taken to 

assist and support the families of 

students and faculty who were 

injured or fatally wounded, as well 

as the Virginia Tech community at 

large. Many university departments 

spearheaded these efforts. For 

example, the Division of Student 

Affairs established a group of family 

liaisons. These Virginia Tech staff 

members served as contacts for 

families of the injured and deceased. 

Their assignments were to contact 

family members of the deceased and 

injured and to provide a wide range 

of help primarily serving as a contact 

between them and the university. 

These liaisons were tasked with a 

host of helping behaviors that ranged 

from contacting funeral homes 

and transporting the deceased to 

addressing more immediate needs 

such as finding lodging for the night. 

In the short term, arrangements were 

made for attendance at the 2007 

graduation ceremony the following 

month for affected students who 

were scheduled to graduate.

Arrangements were also made to

provide more long-term help, which 

included researching procedures 

for accessing victim compensation. 

Simultaneously, the Family 

Assistance Center, housed at the Inn 

at Virginia Tech, not only provided 

lodging for the families, but also 

served as an initial information hub. 

Media centers were also established 

with the primary goal of protecting 

families from their encroachment at 

this difficult time.

University-wide Counseling

Virginia Tech’s Cook Counseling 

Center initiated several efforts to 

meet the emotional and physical 

needs of students, including 

additional hours of service 

immediately after the event. Within 

30 minutes, two therapists from 

Cook Counseling Center arrived at 

West Ambler Johnston dormitory, 

the site where the first two students 

were killed, to help friends and other 

students who lived in the dorm with 

From 2000 to 2013, 39 of the 160

mass shooting incidents in the 

United States have taken place in 

educational environments.

SOURCE: DOJ, FBI. https://www.fbi.gov/file-repository/activeshooter-study-2000-2013-1.pdf

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adjusting to the tragedy. Special 

care was also provided to survivors 

who were in Norris Hall at the time 

of the shootings. Critical Incident 

Stress Management activities 

were also carried out by local and 

regional emergency medical services 

providers for those exposed in 

Norris Hall. Wounded individuals 

were taken to local hospitals for 

immediate attention. Virginia Tech’s 

Schiffert Health Center assisted in 

this process.

Counselors targeted other highly 

exposed individuals, including 

roommates of those killed, 

classmates and victim’s professors 

in other classes they attended, and 

students who shared membership 

in Virginia Tech’s clubs, sororities, 

fraternities, and other organizations. 

During the recovery process, 

psycho-education was provided 

across campus. Experts from 

national, state, local, and university 

departments distributed information

and made themselves available to 

every level of the university. To 

meet a variety of needs of faculty 

and staff, Virginia Tech’s Human 

Resources Department tasked their 

Employee Assistance Providers with

assisting in the recovery process.

University staff anticipated that 

people who attended the upcoming 

graduation would experience an 

increase in anxiety and sorrow. 

The Cook Counseling Center staff 

members attended the ceremony to 

provide counseling and recovery 

resources to those in need. Hokie 

United, Residence Life, Human 

Resources, and the Cranwell 

International Center representatives 

were also on hand to help.

Interagency Cooperation and Support

The Department of Criminal Injuries 

Compensation Fund arrived and 

provided their expertise to help the 

distressed families. Throughout 

the day and days following

the shootings, state and local 

police were available to provide 

announcements of death and injury. 

A 24-hour call center was also 

initiated to aid in the response 

effort. The Virginia Department of 

Emergency Management provided 

manpower to work with university 

personnel to aid in this effort.

Dr. Mark McNamee, the University 

Provost, secured grant funding 

from the U.S. Department of 

Education during the acute phase 

of the recovery period. The primary 

goal of this grant was to develop 

a model for identifying, assessing, 

and responding to students, faculty, 

and staff whose behaviors might 

suggest risk for perpetrating 

violence. Given the department’s 

SAMHSA offers the folowing coping tips for college students 

dealing with a disaster or other trauma:

■ Talk about it.

■ Take care of yourself.

■ Give yourself a break—turn off the television/radio.

■ Avoid using alcohol, drugs, and tobacco.

■ Get back to your daily routines.

■ Gen involved in the community.

■ Help others.

SOURCE: Tips for college students: After a disaster or other trauma. (2013). https://store.

samhsa.gov/product/Tips-for-College-Students-After-a-Disaster-or-Other-Trauma/

SMA13-4777. 

PHOTO: Monkey Business Images / Shutterstock.com.

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extensive history of developing 

and implementing programs to 

assist students facing a variety of 

challenges, it was hoped that many 

of the initial recovery efforts would 

be sustained while new efforts 

would be implemented in a timely 

fashion. Key partners identified to 

assist with the actual administration 

and implementation of the grant 

included the University Provost, 

the Division of Student Affairs, the 

Human Resources Department, the 

Virginia Tech Police Department, 

Virginia Tech professors and 

researchers in psychology and 

sociology departments, and several 

off-campus partners (such as the 

Community Services Board). It was 

decided that the Cook Counseling 

Center would serve as the primary 

vehicle for students to gain access to 

mental health services on campus, 

while services for the faculty and 

staff would be provided by Human 

Resources.

In the aftermath of a shooting, the American Counseling 

Association provides the following tips to help survivors cope:

■ Attend to self-care.

■ Pay attention to your emotional health.

■ Try to recognize when you or those around you may need extra

support.

■ Avoid overexposure to media.

■ Maintain contact with friends and family.

■ Focus on your strength base.

■ Talk to others as needed. 

SOURCE: Dailey, S. F. Coping in the aftermath of a shooting. https://www.counseling.org/

knowledge-center/coping-in-the-aftermath-of-a-shooting

PHOTO: Photographee.eu / Shutterstock.com.

Culturally Informed Care and 

Response Efforts

Culturally competent care is a key 

component of any recovery effort. 

The Virginia Tech community is 

composed of people of a variety

of races and ethnicities, including 

Caucasians, Koreans, African 

American, and Hispanics. It was 

determined that special attention 

should be given to the Asian 

population, given that the shooter 

was Korean.

The Cranwell International Center 

made impressive efforts to ensure 

the safety of and provide support 

to the Asian student population 

on campus and in the surrounding 

community. One-third of the April 16

victims were international students. 

Cranwell Center staff and volunteers 

called every international student. 

Additionally, phone cards were given 

to assist students’ communication 

with their loved ones. These efforts 

were facilitated through partnerships 

with several university organizations, 

including the Asian American 

Student Union and Multicultural 

Program and Services.

LESSONS LEARNED

Several recommendations were 

spelled out in the report of the 

Virginia Tech Review Panel to the 

Governor of Virginia, including that 

universities and colleges develop 

plans, establish a joint information 

center and create a family assistance 

center following a criminal mass 

casualty, provide scheduled briefings 

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Visitors to the Virginia Tech campus can visit the April 16 Memorial in honor of the victims of the shooting.

PHOTO: John McCormick.

to victims’ families, ensure the 

availability of short-and longterm counseling, and coordinate 

provision of training in crisis 

management (2007). The Virginia 

Tech community’s outstanding 

recovery efforts were due in part to 

a high degree of social support prior 

to, during, and after the shootings 

among members of the Hokie 

Nation. One of the greatest strengths 

of the Virginia Tech recovery 

effort was the fact that a solid 

infrastructure for both the university 

and the surrounding community had 

been established in previous years. 

The timely and insightful support 

from many community partners 

contributed to the recovery and 

transition efforts.

The openness to strategies based on 

our “best science” further enhanced 

and facilitated the recovery effort. 

The knowledge obtained from 

members of the Virginia Tech 

community as well as a host of 

local, state, and federal agencies 

and organizations proved to be 

invaluable.

The trauma literature provided 

helpful insight. The adoption and 

integration of knowledge on several

topics proved to be quite beneficial. 

These topics included the integration 

of public mental health surveillance/

monitoring strategies with mental 

health assessment efforts, evidencebased treatments for traumatic 

stress, dissemination of evidencebased interventions, and conducting 

assessments and intervention-based 

efforts with people of color.

The high quality and quantity of 

culturally sensitive actions initiated 

by the Cranwell International 

Center at Virginia Tech was yet 

another ingredient in the success 

of the response efforts. Due to the 

efforts of many professionals at the 

Cranwell Center and throughout the 

university, culturally competent care 

was provided to many individuals, 

particularly members of the Asian 

community.

I am hopeful, as are thousands 

of others, that this senseless act 

of violence will inspire countless 

members of the Hokie Nation to

uphold the university’s motto, Ut 

Prosim (That I May Serve). ■

Virginia Tech Review Panel. (2007, August). Mass 

shootings at Virginia Tech, April 16, 2007: Report of 

the Review Panel. Retrieved from https://governor.

virginia.gov/media/3772/fullreport.pdf

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Lessons Learned From the Boston Marathon 

Bombing Victim Services Program

By April Naturale, Ph.D., Senior Technical Specialist, ICF International

The Boston Marathon bombing 

terrorist event of April 15, 2013, 

resulted in the death of three people 

and injury of several hundred 

more. Over the next several days, 

after a massive law enforcement 

effort ending in Watertown, 

Massachusetts, one of the suspects 

was killed, and the other was 

captured. Each year, the Boston 

Marathon is highly publicized and 

draws runners, supporters, and 

spectators from all parts of the 

globe. Graphic reports and videos of 

the bombing and survivors appeared 

in various media continuously for 

an extended period. This intentional, 

human-caused mass violence 

incident accompanied by graphic, 

gruesome, and extensive media 

exposure exacerbated the behavioral 

health risks of those exposed.

The National Child Traumatic Stress Network suggests the following 

tips for talking to children about mass violence:

Start the conversation. Encourage your child 

to ask questions, 

and answer those 

questions directly.

Listen carefully to 

find out what the 

already know.

Limit media exposure.

Gently correct 

inaccurate information.

SOURCE: Talking to children about 

mass violence. http://www.nctsn.

org/sites/default/files/assets/pdfs/

talking_to_children_about_mass_

violence.pdf

PHOTOS: Iakov Filimonov, 

imtmphoto, Lopolo, and BrunoRosa / 

Shutterstock.com.

The Massachusetts Office for Victim 

Assistance (MOVA) implemented 

a disaster response program with 

Antiterrorism and Emergency 

Assistance Program funds from the 

U.S. Department of Justice’s Office 

for Victims of Crime. MOVA funded 

victim services and behavioral 

health agencies within the affected 

areas as well as the Boston Police 

Department, Boston Public Schools, 

and the Watertown School system. 

The program is continuing through 

September 2017 to work directly 

with survivors, responders, and their 

family members, many of whom 

are still experiencing long-lasting 

negative psychological effects.

The overall goals of MOVA’s 

marathon bombing response 

program were to provide timely 

relief with immediate and ongoing 

victim assistance via victim 

navigators whose role was that 

of case managers and victim 

advocates, helping survivors 

identify their needs and access 

the services available to them. 

The overall objectives were to 

help guide individuals and the 

community onto a recovery path, 

increase opportunities to support 

and build resilience, and increase 

the capacity of the community 

to continue to address these 

concerns in the future. Services 

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have varied according to the 

disaster phases and have included 

crisis response; consequence 

management; crime victim 

compensation; criminal justice 

support (such as support for victim 

participation in criminal justice 

proceedings); crisis counseling; 

emergency transportation and 

travel; compensation for medical 

and mental health costs, lost wages, 

and funeral expenses; temporary 

housing; emergency food and 

clothing; repatriation of remains; 

victim advocacy, outreach, and 

education; victim notification; 

and vocational rehabilitation. A 

behavioral health response plan 

was developed to provide disasterspecific treatment interventions, 

and a large-scale media and 

communications effort provided 

outreach, information, and education

to the broadly affected community.

“There is a need for 

greater awareness of the 

negative physical, social, 

emotional, spiritual, and 

financial impacts of crime, 

particularly terrorism.”

Services provided have been 

informed by a needs assessment, 

along with survivor and family 

forums, victim compensation, and 

other provider reports and direct 

contact with survivors. Targeted 

outreach was possible due to the 

coordinated effort of federal, state, 

and local agencies. MOVA planned 

to reach those victims/survivors 

at highest risk of developing 

serious behavioral health problems, 

including survivors with injuries, 

amputations, burns, traumatic brain

injuries, or loss of hearing or vision;

families of homicide victims; close 

friends and coworkers of victims; 

school-aged children exposed to 

the bombing and the Watertown 

lockdown and shootout; and those 

at the next levels of exposure, such 

as first responders exposed to the 

fear, chaos, and injuries involved 

in the event, as well as their family 

members; survivors with prior 

trauma or mental illnesses, medical 

problems, or limited mobility or 

other functional and access needs. 

Successes

A continuum of care working group 

was initiated, bringing together 

over 30 agencies that interacted 

with survivors. The working group 

included state and city responders, 

federal law enforcement, community 

providers funded through the 

Victims of Crime Act, American 

Red Cross personnel, and members 

of the private sector. The group 

discussed and analyzed the types of 

services needed, both short and long 

term. They identified service gaps 

and made recommendations about 

how to address them. This working 

group provided an opportunity for 

members to learn about each other 

as well as a platform to discuss 

issues and activities.

There was an expressed need for 

behavioral health support from 

survivors and their families starting 

with the immediate days of the

attack throughout the following four 

years with a significant increase 

in requests just prior to and at the

time of the anniversaries. MOVA 

staff provided a compassionate 

presence and support during and 

after public anniversary activities 

such as the ceremony held at the Old 

South Church and the memorial on 

the campus of the Massachusetts 

Institute of Technology for Sean 

Collier, the university police officer 

who was killed by those responsible 

for the bombing. Staff also sent out 

SAMHSA’s Disaster Tip Sheets 

about what to expect leading up to 

the anniversary and suggestions for 

coping activities. Many survivors 

responded to a direct email 

campaign with comments about how 

helpful it was to have information 

about coping, recommendations to 

plan ahead, and the suggestion to be 

with others. They also noted how 

comforting it was to see the victim 

advocates at the anniversary events.

MOVA developed a media plan to 

provide messages of support, hope, 

recovery, and resiliency. Messaging 

was delivered via major television 

networks, and actual survivors used 

scripts in which they talked about 

their own experiences of the event, 

their reactions, and what they felt 

had helped them most.

LESSONS LEARNED

We learned that victim services 

response should be immediate 

and systemic; thus, political, law 

enforcement, and emergency 

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management leadership needs to be 

informed about what victim service 

agencies can offer in the wake of a 

tragedy. Victim services agencies 

must be represented on state, city, 

and local community emergency 

management planning committees 

before and after incidents. We also 

learned that due to the nature of 

disasters, it is crucial to hire project 

staff as soon as the determination to 

provide response services is made. 

Establishing new contracts was time 

consuming, and thus reaching out 

to behavioral health providers with 

existing contracts to provide crisis 

intervention and behavioral health 

support was more efficient. One 

challenge encountered was ensuring 

the administration of disaster and 

trauma-specific, evidence-based 

interventions targeted to the needs of 

the affected population.

We found it difficult to create and 

implement self-care activities for 

staff when they were not already 

part of how the office operates. 

Many staff working in the response 

had a shared experience of trauma. 

Creating more formal and informal 

opportunities for staff to discuss and 

address their own experiences would 

likely have reduced some of their 

concerns and distress.

There is a need for greater awareness 

of the negative physical, social, 

emotional, spiritual, and financial 

impacts of crime, particularly

terrorism. Providing broad public 

education on the signs and impacts of 

traumatic events can help to reduce 

stigma and increase help-seeking.

The Boston Marathon bombing 

response was exemplary, from the 

extraordinary immediate medical

care in the field and the nearby 

hospitals that saved lives, to the 

self-sufficiency with which the 

city picked itself up and continued 

its regular activities and more. 

Still, many of the experiences of 

the victims’ families, survivors, 

and various responders echoed 

those of prior terrorist events 

and mass shootings. We all need 

to share our lessons learned and 

recommendations so that we can 

identify best practices and learn 

from each other. We are Boston 

Strong, but every community that 

experiences these types of events 

can work together to support the 

needs of survivors. ■

Individuals demonstrate their solidarity with the victims of the Boston Marathon bombing by displaying 

a Boston Strong flag during the 2014 race.

PHOTO: Provided by April Naturale.

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Tragedy in the Sanctuary

By Deborah S. Blalock, M.Ed., LPCS, CPM, Executive Director, Charleston Dorchester Mental Health Center/

South Carolina Department of Mental Health

On June 17, 2015, the unthinkable 

occurred . . . a self-avowed white 

supremacist entered Emanuel 

African Methodist Episcopal 

(AME) Church in Charleston, South 

Carolina, and after attending Bible

study with church members, opened 

fire, murdering nine. Because of 

a longstanding relationship with 

the Charleston Police Department 

(CPD), a Charleston Dorchester 

Mental Health Center (CDMHC) 

mental health professional embedded 

with the CPD was immediately 

deployed to the family staging area 

to offer support to the five survivors 

and nine victims’ families. Thus 

began CDMHC’s journey with 

Emanuel AME—a journey that 

taught all of us many lessons about 

responding to and recovering from 

an event like this one.

LESSON LEARNED

Relationships established before 

disaster strikes are invaluable.

It is critical to build partnerships prior 

to an incident that you can rely on 

during the response and recovery 

phases. You should work to identify 

key partners you can turn to in the 

event of a disaster. Ideally this would 

be done before a disaster and would 

cover a wide range of scenarios.

CDMHC assisted the Federal 

Bureau of Investigation (FBI) 

Victims’ Assistance Team in 

establishing a Family Assistance 

Center and established a Church 

Assistance Center for church 

members unrelated to victims. 

The church’s entrance became a 

memorial site where hundreds came 

to grieve and show love for the 

victims and survivors. Many were 

overcome by grief and in need of 

support. CDMHC deployed its RV, 

a mobile mental health clinic, to the 

site to offer support, as well as water 

and snacks. CDMHC also staffed a 

phone bank on a local news show to 

address the community’s concerns.

8% Other

6% Familial

No relationship 26%

22% Academic

Professional 38%

Relationship Between Active Shooter and Victims

SOURCE: New York City Police Department. Active shooter: Recommendations and analysis for risk mitigation, 

2012 edition. http://www.nypdshield.org/public/SiteFiles/documents/Activeshooter.pdf

LESSON LEARNED

A human-caused disaster is 

different from a natural disaster.

Survivors may view a human-caused 

disaster in a different light then a 

natural disaster, and the recovery 

process may follow a different 

trajectory. We as disaster 

Responders need to keep this in 

mind while aiding survivors.

Emanuel’s leadership recognized 

CDMHC as a partner 2 days after 

the shooting. CDMHC assisted 

the church in a funeral planning 

meeting with the victims’ families. 

The congregation of approximately 

550 had to plan, with limited 

resources, nine funerals, including 

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one for its pastor and three others 

for ministerial staff. This meeting 

was highly emotionally charged, 

and staff had to use their deescalation skills many times. As 

requested, CDMHC attended 

numerous prayer vigils. Church 

leadership asked CDMHC to attend 

worship services the Sunday after 

the shooting. The church, usually 

hosting 100 people on Sundays, 

was filled past its 1,200-person 

capacity on the first Sunday after 

the shooting. Worshippers were 

overcome with shock, sadness, 

and horror as they entered. Center 

staff attended Sunday services for 7 

months, and they offered support at 

every wake and every funeral and 

at the church’s weeklong children’s 

vacation Bible school. The 

CDMHC provided support for many

responders, including the coroner’s 

office, law enforcement, emergency 

medical services and fire personnel, 

clinical staff, and even members of 

the media.

LESSON LEARNED

Clinicians’ needs must be 

addressed regularly.

Self-care is important no matter what 

the disaster. For responders to be 

able to properly assist survivors, they 

must address their own personal 

needs. Response staff must be 

continually monitored for signs of 

stress and compassion fatigue.

CDMHC knew it had to further its 

reach to touch more affected by the 

tragedy. The center partnered with 

the Medical University of South 

Carolina’s National Crime Victims 

Research and Treatment Center 

(NCVC) to bolster capacity and 

expertise. Together, the agencies 

created informational flyers for

the church. The Substance Abuse 

and Mental Health Services 

Administration also created 

customized informational brochures 

which were distributed. The 

partners created and distributed a 

needs assessment survey to church 

members. While returning church 

members became very familiar with 

the counselors, many members had 

not returned, out of sadness and 

fear, and they had to be reached. 

Counselors attended ministry 

meetings, including the Women’s 

Ministry, Seniors’ Ministry, and 

Children’s Church. The clinical team 

facilitated a weekly grief support 

group that is still meeting, and 

helped plan and attended 2 weeks 

of memorial events with family 

members and survivors.

Businesses

Health care facilities

Houses of worship

Residences

Open spaces Government properties

Schools

73

45.6%

6

3.8%

7

4.4%

15

9.4%

16

10.0%

39

24.4%

4 2.4%

Things To Think About When Planning for 

Active Shooter Incidents: Location

Number of incidents, 2000-2013

SOURCE: U.S. Department of Justice (DOJ), Federal Bureau of Investigation (FBI). (2013). A study of 

active shooter incidents in the United States between 2000 and 2013. https://www.fbi.gov/file-repository/

active-shooter-study-2000-2013-1.pdf

From 2000 to 2013, six mass 

shooting incidents have 

taken place in the United 

States in places of worship, 

resulting in 21 deaths.

SOURCE: DOJ, FBI. https://www.fbi.

gov/file-repository /active-shooterstudy-2000-2013-1.pdf

LESSON LEARNED

In a church shooting, clinicians 

must be skilled in addressing 

spirituality.

When assisting disaster survivors, 

responders need to be aware of any 

factors that may play a role in the 

recovery process as well as how to 

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improve acceptance of resources 

and materials among survivors in the 

affected community. They must be 

sensitive to the beliefs of the 

survivors.

From the beginning, we knew race 

was wound very tightly in this 

tragedy. We had to make sure that 

we were not afraid to face the issue 

of race head on. We could not send 

two Caucasian clinicians to any 

function. If one was Caucasian, one 

had to be African American. We had 

to pay attention to the needs of those 

we were there to serve.

LESSON LEARNED

If race is a factor, it must be 

faced immediately.

I was worried that my race would 

hinder me from comforting those I 

was there to serve. I am Caucasian. 

The family members, the members 

of the church, and the leadership of 

the church accepted me, welcomed 

me. I am honored to say that I think 

they trusted me. Their strength, their 

resilience, their forgiveness, is real.

LESSON LEARNED

Cultural competency is crucial.

You will be more likely to succeed in 

outreach activities if you engage key 

members of the community to 

improve access to and credibility 

among survivors.

The NCVC received a grant from 

the Office for Victims of Crime to 

fund community efforts serving 

those affected. The grant has funded 

an Empowerment Center on church 

property housing the five (two 

NCVC, two CDMHC, and one 

Berkeley Mental Health Center) 

counselors and case managers. The 

grant funds were instrumental in 

supporting the survivors and families 

during the perpetrator’s federal death 

penalty hearings and trial. A victims’ 

support team was created. It included 

victims’ assistance staff from CPD, 

the Charleston County Sheriff’s 

Office, the FBI, and the U.S. 

Attorney’s Office; clinicians from 

NCVC and CDMHC; and, for the 

first time in a federal trial, a spiritual 

support team of clergy, in this case 

comprising members from the 

South Carolina Law Enforcement 

Assistance Program, Emanuel AME, 

St. Michael’s Episcopal Church, and 

many other local churches. The team 

was in the trial daily from its start 

on November 28, 2016, through its 

conclusion on January 5, 2017.

LESSON LEARNED

Mental health support must be 

for the long haul.

Long-term recovery survivor needs 

must be identified, and a plan put in 

place to address them.

This experience has been profound 

for all involved . . . one that shall 

never be forgotten. ■

The Emanuel African Methodist Episcopal Church congregation 

continues to move forward in the recovery process. 

PHOTO: Provided by Deborah S. Blalock.

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Terror Attack at Work

By Veronica Kelley, LCSW, Director, Behavioral Health, San Bernardino County Department of Public Health

On December 2, 2015, in Southern 

California, the Environmental Health 

Services (EHS) Division of San 

Bernardino County’s Department of 

Public Health (DPH) was holding 

their annual General Education 

Meeting. At a little after 11 a.m., 

two masked terrorists, later to be 

identified as a radicalized EHS 

staffer and his wife, ran into the 

facility hosting the meeting, the 

Inland Regional Center, and killed 

14 people and wounded 22 others.

Shortly after the shooting took 

place, the local law enforcement 

agency requested, along with the 

administration of DPH, assistance 

from the Department of Behavioral 

Health (DBH). As DBH staff were 

deployed, we discovered the survivors 

of the shooting were not the only 

group that required our assistance; the 

disaster responders were also deeply 

affected by the incident.

Pre-incident Planning Led to a 

Successful Response

Our response was successful in part 

due to existing emergency plans 

and prior staff training. Thanks to 

a well-developed infrastructure 

and community crisis response 

programs (funded through the 

Mental Health Services Act in 

California), DBH could immediately 

deploy Community Crisis Response 

Teams throughout the county upon 

request from the San Bernardino 

Police Department and county 

sheriff. This request allowed DBH 

to deploy teams, even while many 

of our clinic and administration 

sites were on lockdown due to the 

shooting and active pursuit of the 

assailants, to 10 county departments 

and nine community organizations. 

Deployment locations included 

the sites that EHS survivors were 

brought to from the triage area, 

the site where family could pick 

up a loved one, and the coroner 

substation. 

We also developed a liaison model 

of support for all the EHS staff and 

affiliated staff such as Public Health 

and Land Use Services staff, who 

worked hand in hand with EHS and 

who lost many coworkers that day. 

Based on the fire department model 

utilized when a fallen firefighter’s 

family is supported by colleagues, 

working in teams of two, 60 people 

were deployed as liaisons. These 

staff members were the points of 

contact for the families of the victims 

as well as the survivors and affiliated 

county staff. Liaisons assisted with 

timesheets, workers’ compensation 

paperwork, death benefits 

paperwork, funeral arrangements, 

and general support. These teams 

remain active to this day.

The community of San Bernardino showed support to the victims 

of the shooting and their families with candles, uplifting messages, 

flowers, and the American flag.

PHOTO: Ted Soqui Photography, 2015.

Adapting Response Plans To Fit 

the Immediate Need

DBH has extensive experience 

in addressing the needs of the 

community and survivors after 

incidents such as fires and other 

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natural disasters. This terrorist attack 

was vastly different from a fire; 

however, we had experience working 

under very stressful circumstances 

and could adapt our response to fit 

the incident.

DBH’s primary focus is on treating 

serious and persistent mental 

illness for the Medicaid population. 

However, in the aftermath of this 

incident, we utilized our crisis 

response skill set to address all 

issues that came up, including the 

immediate trauma response and 

retraumatization that occurred 

because of other terrorist attacks 

and related events. Having a system 

in place since 2005 to address 

community trauma, such as suicide 

and violent crimes, greatly enhanced 

our department’s ability to be fluid 

and effective in providing crisis 

intervention to our brothers and 

sisters in county government.

Helping the Helpers

This horrifying terrorist attack was 

perpetrated by one of our own, 

which added to the level of stress 

and anxiety among survivors and 

responders. All our behavioral 

health first responders were at 

risk for retraumatization and even 

vicarious trauma. We made special 

concessions to ensure that responders 

attended to self-care, brought in staff 

from neighboring counties to do 

Critical Incident Stress Debriefing 

for our staff, and tried to be proactive 

in sharing trauma tips from the 

Substance Abuse and Mental Health 

Services Administration (SAMHSA) 

related to such incidents. Helping 

the helpers has been critical as the 

trauma remains; our coworkers are 

still affected, but we as a county are 

surprisingly resilient and SB Strong!

LESSONS LEARNED

Be prepared. Having an 

infrastructure that works with law 

enforcement and other first 

responders is critical. This enabled 

DBH to respond immediately, while 

we awaited mutual aid from other 

local counties, the state, and our 

federal partners.

Be flexible. Not all emergency 

situations are the same. Be prepared 

to allow the team to adjust to the 

special needs of each incident.

Do not underestimate the 

impact of trauma on you. Our 

staff were immediately affected but 

carried out their duties as needed. 

Monitor staff stress levels. Allowing 

time for self-care is essential! 

Be open to many interventions. 

There is no one perfect method of 

crisis intervention. Assess the situation, 

and determine the appropriate 

inventions for the current need.

Understand trauma. Traumas 

vary, and in this case the trauma 

was complex. Trauma can be acute 

or chronic and lead to other, more 

negative effects such as vicarious 

trauma and compassion fatigue for 

behavioral health first responders.

Don’t forget the children. 

Remember that children are not 

small adults. Their needs should be 

addressed differently from those of 

adults.

Not all crisis response is 

clinical. We found that simply being 

present, acknowledging the horror, 

and providing physical comfort was 

at times as effective as a more 

clinically focused intervention.

Be prepared for a long recovery 

process. We have found that 

trauma responses have escalated 

after the year mark. As trauma and 

stress are cumulative, you need to 

be vigilant about trauma response 

and affiliated issues such as 

depression, anxiety, and 

posttraumatic stress disorder in the 

years and months following the 

event.

Use resources available. 

SAMHSA has a wealth of written 

brochures and tip sheets on trauma 

that we used, reproduced, shared 

with our community partners, and 

left with survivors and victims’ 

families. Having a tip sheet to leave 

that an affected person could use for 

guidance was very helpful. We also 

used social media in all its forms to 

share the same information. ■

RESPONSE STATISTICS

DBH deployed 200 clinical 

boots on the ground in the first 

48 hours after the event and 

provided over 10,000 counseling/

supportive contacts, both by 

telephone and in person. These 

contacts were provided 24/7 

following the event, for a total 

of 1,344 hours of continuous 

behavioral health crisis care 

through February 2016 (care is 

still being provided).

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 21
A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

 INTERVIEW

Disaster Behavioral Health Challenges 

Encountered During the Response to the Pulse

Nightclub Shooting in Florida

By Eric Alberts, CEM, CHS V, FPEM, CHEP, FABCHS, Corporate Manager, Emergency Preparedness, 

Orlando Health

In the early morning hours of June 

12, 2016, 49 people were killed 

and 53 wounded by a shooter at 

Pulse nightclub in Orlando, Florida. 

The New York Times identifies this 

incident as “the worst mass shooting 

in U.S. history.”1

1 Alvarez, L., Pérez-Peña, R., & Hauser, C. (2016, June 13). Orlando gunman was ‘cool and calm’ after massacre, police say. The New York Times. Retrieved from https://

www.nytimes.com/2016/06/14/us/orlando-shooting.html?_r=0

Many of the people injured in 

the attack–44–were treated at the 

Orlando Regional Medical Center 

(ORMC), which is less than a 

mile from Pulse. Of those 44, 35 

survived.

The Dialogue recently spoke 

with Eric Alberts, who manages 

emergency preparedness for

Orlando Health, a large health care 

organization that includes ORMC. 

He spoke about responding to the 

Pulse shooting, its ongoing effects, 

and lessons learned that may help 

others supporting behavioral health 

before, during, and after incidents of 

mass violence.

Did you have a behavioral health 

response plan in place prior to the 

event? How have things changed 

since Pulse?

Before Pulse, we tried to include 

behavioral health components in 

our exercises, and we have general 

policies that address behavioral 

health. Pulse highlighted the need

for behavioral health planning 

efforts and inclusion of behavioral 

health in exercises. We just did our

2017 annual full-scale community 

exercise, and because of Pulse, we 

had Employee Assistance Program 

(EAP) staff at two Orlando Health 

hospitals: ORMC and Arnold 

Palmer Hospital. They were there 

to talk with people who needed it, 

and there was a room set up where 

people could go for counseling. I 

was concerned about posttraumatic 

stress disorder and flashbacks. In 

the exercise, of course the injuries 

are fake, but police, fire, rescue, 

and Federal Bureau of Investigation 

(FBI) staff are there, and it looks and 

feels like a real incident. We wanted 

to make sure that we had behavioral 

health care there for our staff. 

ORMC staff members have dealt 

with recent incidents in addition 

to the Pulse nightclub shooting, 

including an incident in which a City 

of Orlando police officer was shot

and killed and another police officer 

died as a result. Again, Orlando

Health was concerned, and the EAP 

was on hand to provide assistance 

for our team members, too. It’s the 

new normal. Things have definitely 

changed since Pulse.

How did you provide behavioral 

health support to your staff and 

survivors of the event?

We had different levels and layers. 

We have chaplains throughout our 

hospitals that team members can talk 

to at any time. We also have our own

EAP team. Immediately after Pulse, 

we had our EAP team come and

they provided group and individual 

sessions for a few days. There were 

over 1,200 EAP sessions.

What were the biggest challenges 

(related to behavioral health 

preparedness and response) you and 

your staff faced?

One was trying to compassionately 

care for the families. They often 

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 22
A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

didn’t know where their loved one 

was, and then, when they figured out 

where they were, they weren’t sure 

what to do. They could be deceased, 

in critical condition, or okay. At 

ORMC we had to figure out how 

to provide services. Some families 

didn’t know before the incident that 

their loved ones were in the LGBTQ 

(lesbian, gay, bisexual, transgender, 

and queer/questioning) community. 

Others knew and were accepting.

Those in the hospital were quite 

shocked as well. Many families 

came here from out of the area and 

did not bring anything with them. 

They wanted to know where they 

could stay, where they could find 

something to eat, how they could get 

home, even where they could charge 

their phones. We provided $500 

worth of cellphone chargers alone. 

It’s things like that that people don’t 

think of. Our team members were 

trying to care for the patients, in the 

most acute situations, which was 

taking all of their focus, and then 

the families got involved. It was an 

emotional time for them.

Also, some of our staff knew 

people who were shot. The night

of the event at Pulse, I finally got 

home from my shift and saw prayer 

requests from our church for a 

member whose grandson was in the 

club during the shooting. He was 

there with his girlfriend to learn to 

salsa dance. He came to our hospital 

and unfortunately ended up being 

one of the deceased. I didn’t have 

confirmation that he was one of 

the deceased, so I couldn’t tell his 

grandfather that he didn’t make 

it. I went into work the next day, I 

confirmed that he was one of the 

deceased, and I went to the open 

casket funeral.

When you’re part of the response 

effort, it really does affect you. 

People think these bad situations 

will occur at a big mass gathering 

far from hospitals. Pulse was no 

more than half a mile from ORMC. 

You have to broaden your scope and 

realize what’s surrounding you.

Did you have any special training or 

resources to help effectively respond 

to the event?

I have a bachelor’s degree, nine 

certifications, and I’ve taken over

200 courses, which prepared me 

to be able to respond to this type 

of incident. I have responded to 

emergencies of all different types 

and sizes over the years. We also 

have regular exercises in our 

facilities. With that background and 

experience, you fall into place; you 

just do what you need to do. It’s 

different when you experience a real 

incident, but still you just go with 

your training. We held our yearly 

full-scale community exercise in 

March 2016, with the scenario of 

an active shooter in Orange County 

Middle School. The Pulse nightclub 

shooting happened in June. A lot of 

our staff said the exercise helped 

save lives. You have to get past 

the initial fear and go back to your 

training, methods, processes, and 

plans you remember in your head.

Were there any partners that played 

a key role in your ability to prepare 

for, respond to, and recover from 

this event? If not, whom would you 

recommend organizations develop

partnerships with? 

A ton of folks and agencies 

responded. The local jurisdiction, 

the City of Orlando, was a huge 

assistance. The FBI also played

a role in our full-scale exercise, 

which is how we understood 

how we would respond together. 

We’ve continued to broaden that 

partnership. For our latest fullPHOTO: cleanfotos / Shutterstock.com.

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 23
A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

scale community exercise just last 

week, six FBI agents came just for 

ORMC in the exercise. We continue 

our partnership to plan, train, and 

exercise together.

How did you coordinate and work with 

other responders and stakeholders?

That is a continual, ongoing process, 

through planning, training, and 

exercises. We continue to coordinate 

and collaborate with them. We 

learned from Pulse that you can’t 

know just one person in a particular 

agency—you need to know two or 

three. You need to know a couple 

of layers of individuals who work 

in those agencies. It’s a continual 

process, not a one-time thing. 

Someone gets a business card, puts it 

away, and thinks he or she is done. If 

someone doesn’t know you well and 

trust you, he or she won’t answer a 

phone call or email.

How did you and your staff cope with 

the event?

Our staff is compassionate, and 

we care about each other. We pay 

attention to each other. We have 

camaraderie, and we help to care 

for each other. Otherwise you 

feel isolated. For Pulse, we had 

approximately 500 people who 

responded, so we were not alone. 

They still talk about that experience. 

It all comes down to being open, 

talking to each other, and trying to 

care for each other.

How has this event changed your 

behavioral health emergency 

response plan?

After the incident, our EAP team 

developed a written crisis plan. It’s 

about a page and a half and pretty 

simple, but it brings to light that they 

have a role in crisis management or 

emergency response.

Days after the shooting, the 

Employee Assistance Program 

(EAP) conducted over 1,200 

sessions at the two Orlando 

hospitals treating victims.

What are EAPs?

Helpful Tip to Include in 

Disaster Response Plans: “An 

Employee Assistance Program 

(EAP) is a voluntary, work-based 

program that offers free and 

confidential assessments, shortterm counseling, referrals, and 

follow-up services to employees 

who have personal and/or workrelated problems.”

SOURCE: U.S. Office of Personnel 

Management. https://www.opm.gov/faqs/

QA.aspx?fid=4313c618-a96e-4c8e-b078-

1f76912a10d9&pid=2c2b1e5b-6ff1-4940-

b478-34039a1e1174

From your experience, what would 

you suggest other professionals 

include in their behavioral health 

emergency response plans?

I would just suggest they have 

behavioral health plans in the first 

place and don’t ignore behavioral 

health. If you ignore it, you will 

have major problems: employees 

leaving, lawsuits, or even workplace 

violence, if people aren’t given the 

proper treatment. Take it seriously 

because it could come back and 

cause something serious if you

don’t. Just because you have never 

been through a serious incident 

before with major behavioral health 

effects, and you think you can’t 

know the issues until you go through 

that kind of an incident, you can still 

leverage lessons learned from others 

and try to apply those practices

to your efforts. The information I 

provided within this article, Katrina, 

and 9/11 provide valuable lessons 

learned—learn and implement 

lessons from those experiences. 

Don’t ignore them.

Are there any other lessons learned or

other information you’d like to share?

I am not a medical clinician; I am 

administrative, but that doesn’t 

mean I can’t help save lives as well. 

I don’t provide direct patient care 

or EAP counseling sessions, but I 

helped ensure the correct stuff was 

in place to do that during and after

Pulse. HICS (the Hospital Incident 

Command System) saved lives when 

we had Pulse. To me that is 

extremely humbling, because I am 

not a clinician. It fuels the fire for 

me to want to keep doing this work 

and keep helping others in hopes of 

helping the efforts of saving lives. 

The trauma surgeon can’t do this 

alone. It still takes an administrative 

person, EAP counselor, security 

officer, and emergency manager to 

help with all those efforts. ■ 

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 24
A Quarterly Technical Assistance Journal on Disaster Behavioral Health 

Produced by the SAMHSA Disaster Technical Assistance Center the Dialogue

RECOMMENDED RESOURCES

Disaster-Specific Resources: 

Mass Violence or Riots

This part of the Disaster-Specific Resources installment 

of the SAMHSA Disaster Behavioral Health Information 

Series features resources about mass violence. The 

collection includes websites, tip sheets, toolkits, 

manuals, and videos about incidents of mass violence 

and their mental health and substance use (behavioral 

health) effects, school crisis response, coping with 

reactions to an incident of mass violence, and supporting 

children in coping.

Access the installment section at http://bit.ly/2oWAAE3.

Mass Violence and Terrorism

 SAMHSA’s National Child Traumatic Stress Network 

(NCTSN) provides links to tip sheets and information 

about how incidents of mass violence may affect 

children and families, how parents and other caregivers 

can support children in coping, and helping children 

and adolescents who were injured in mass violence 

incidents. Also included are materials for school staff 

and pediatric providers.

Access this part of NCTSN’s website at http://bit.

ly/2pNdFA0.

Psychosocial and Mental Health 

Interventions in Areas of Mass Violence: 

A Community-based Approach

In this guide, author Kaz de Jong and Médecins Sans 

Frontières provide information and suggestions for 

supporting people around the world who have survived 

human-caused disasters, including incidents of mass 

violence and terrorism. Sections of the guide explain 

how the traumatization process works; describe 

interventions; and cover special topics, including 

training, monitoring, and evaluation.

Access the guide at http://bit.ly/2qu9Hsb.

Acts of Violence, Terrorism, or War: 

Triggers for Veterans

In this article, the National Center for Posttraumatic 

Stress Disorder explains the ways in which veterans 

may react slightly differently from the rest of the 

population to incidents of mass violence, terrorism, 

and war. Authors present research findings about how 

these incidents may affect veterans differently, and 

they provide suggestions for veterans for coping with 

their reactions, finding additional help, and supporting 

children and members of their communities.

Access the article at http://bit.ly/2qtS1g8. ■

https://www.samhsa.gov

2017 | VOLUME 13 | ISSUE 3-4 | PAGE 25
Behavioral Health is Essential To Health

Prevention Works • Treatment is Effective • People Recover

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The SAMHSA Disaster Behavioral Health Information Series contains resource 

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CONTACT US materials.

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