SAMHSA

Disaster Technical Assistance Center 

Supplemental Research Bulletin

Mass Violence and Behavioral Health

September 2017

 
CONTENTS

INTRODUCTION 3

DEFINITIONS OF MASS VIOLENCE 3

Terrorist Attacks 4

Active Shooter Incidents 4

BEHAVIORAL AND MENTAL HEALTH REACTIONS TO MASS VIOLENCE 4

Immediate Behavioral Health Reactions 5

Long-term Behavioral Health Reactions 6

Reactions in Children 8

BEHAVIORAL HEALTH INTERVENTIONS FOLLOWING MASS VIOLENCE 8

Adult Survivors 8

Screening for Trauma 10

Youth, Child, and Adolescent Survivors 11

MEDIA EXPOSURE AND MENTAL HEALTH FOLLOWING MASS VIOLENCE 12

INDIVIDUALS WITH PREEXISTING MENTAL HEALTH CONDITIONS AND MASS VIOLENCE 13

RESILIENCE 13

CONCLUSION 14

REFERENCES 15

SAMHSA is not responsible for the information provided by any of the webpages, materials, or organizations 

referenced in this communication. Although the Supplemental Research Bulletin includes valuable information 

and links, 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.
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INTRODUCTION

This issue of the Supplemental Research Bulletin focuses on how mass violence affects the behavioral 

health of adult and young (child and adolescent) survivors or witnesses of a mass violence incident. We 

discuss the phases of response experienced by survivors, as well as immediate and long-term reactions 

among adults and children and youth. This issue goes on to provide information on immediate and longterm interventions and the effects of mass media exposure following a mass violence incident. We briefly 

discuss the lack of research evidence in support of the idea that individuals with mental health issues are 

more likely than others to be perpetrators of incidents of mass violence. We conclude the issue with an 

examination of resilience.

Public health, behavioral health, and emergency management professionals can use this issue to 

improve their disaster behavioral health preparedness plans. We highlight several possible behavioral 

health inventions that may be helpful during the immediate and long-term phases of recovery from mass 

violence. Insights taken from this issue can also be used to help structure emergency planning exercises.

In this issue, national as well as international resources were used to describe some of the findings, 

as mass violence is an issue around the world, and some regions (for example, the Middle East) have 

experienced it for longer periods of time and with greater frequency than the United States. However, 

this issue will focus mostly on the effects of mass violence resulting from terror attacks or active shooter 

incidents in the United States rather than state-perpetuated violence.

Literature used in this issue includes scientific publications from the National Center for Biotechnology 

Information and U.S. National Library of Medicine (PubMed). Other sources were used to provide 

definitions and reflect policy-level interventions, including various federal agencies (such as SAMHSA, 

the U.S. Department of Veterans Affairs, and the U.S. Department of Justice) as well as nonprofit 

organizations (including the National Alliance on Mental Illness, the American Psychiatric Association, and 

the American Red Cross) and international agencies (such as the World Health Organization).

DEFINITIONS OF MASS VIOLENCE

The Office for Victims of Crime (OVC) and the American Red Cross define mass violence as

an intentional violent criminal act, for which a formal investigation has been opened by the Federal 

Bureau of Investigation (FBI) or other law enforcement agencies, 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. (U.S. Department of Justice [DOJ], Office of Justice Programs [OJP], OVC & American Red 

Cross, 2005, p. 3).

Additionally, the World Health Organization defines collective violence, the category closest to mass 

violence in one of its reports, as “the instrumental use of violence by people who identify themselves as 

members of a group—whether this group is transitory or . . . more permanent . . . against another group 

or set of individuals, to achieve political, economic or social objectives” (Collective violence, 2002). In this 

issue, we consider incidents of mass violence to include terrorist attacks.
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Terrorist Attacks

Terrorist attacks have increased in frequency in the last few decades, with the terrorists aiming either 

to create mass anxiety, fear, and panic and foster a sense of helplessness or to provoke reactions 

(Alexander & Klein, 2005; Horgan, 2017). According to LaFree (2017), terrorist attacks have increased 

steadily over the years—for example; in 2013 the total number of attacks was 135 percent of the total in 

1992. A fact sheet from the National Consortium for the Study of Terrorism and Responses to Terrorism 

(START) reports that, between September 11, 2001, and December 31, 2015, 3,140 Americans have 

been killed in terrorist attacks (Jensen & Miller, 2016).

Fifty percent of the total number of people killed in terrorist attacks were killed in highly lethal terrorist 

attacks, according to Martens, Sainudiin, Sibley, Schimel, and Webber (2014). They define highly lethal 

attacks as those in which 21 people or more were killed in a single incident. Data were gathered from 

the Global Terrorism Database (GTD) produced by START. The GTD includes broad categories of data 

for terrorist incidents from 1970 through 2011 (but excluding 1993) (Martens, Sainudiin, Sibley, Schimel, 

& Webber, 2014). However, in spite of their large death toll, these attacks comprised only 3.5 percent of 

all terrorist attacks (Martens et al., 2014). Terrorism is dynamic; the same terror group might, over time, 

change focus regarding the kind of recruit it favors, and accordingly change opportunities for involvement 

when the group is under pressure from authorities (Horgan, 2017).

Active Shooter Incidents

The FBI and Texas State University report that active shooter incidents increased in frequency annually 

in the period between 2000 and 2013. During this period, there were 160 active shooter incidents. During 

the first 7 years, an average of 6.4 incidents occurred annually, while in the last 7 years that average 

increased to 16.4 incidents annually (Blair & Schweit, 2014).

Shultz, Cohen, Muschert, and Flores de Apodaca examined firearms deaths in the United States from 

1990 to 2012 and included in their analysis active shooter incidents in schools (such as the Sandy 

Hook Elementary School shooting and the Virginia Tech shooting) (2013). They found that, while these 

incidents get high levels of attention, they are rare occurrences, and the fatalities resulting from them 

equaled 0.12 percent of national firearm homicide for the same period; their rarity and extremity however, 

combined with identification with the affected population, tend to get media attention (2013). Following 

the Sandy Hook Elementary School shooting, a Twitter national dataset analysis showed association with 

sadness and anxiety (Dore, Ort, Braverman, & Ochsner, 2015). The same study showed that for people 

living farther from the incident, or following a longer period, these reactions were shifted more towards 

anxiety. The authors argue that remoteness (either through time or location) prompted higher-level 

consideration of the unresolved causes of tragedy (Dore et al., 2015).

BEHAVIORAL AND MENTAL HEALTH REACTIONS TO MASS VIOLENCE

Following incidents of mass violence, the survivors or witnesses may go through multiple phases in which 

particular emotions, behaviors, and other reactions are fairly typical (Alexander & Klein, 2005; Freedy 

& Simpson, 2007; Goldmann & Galea, 2014; U.S. Department of Health and Human Services [HHS], 

SAMHSA, Center for Mental Health Services [CMHS], 2004; Yehuda & Hyman, 2005).
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1. Acute phase: Characterized by denial, shock, and disbelief. In this stage, behavioral health officials

can help survivors by providing them with resources and information. Mental health interventions

such as Psychological First Aid, debriefing, accelerated resolution therapy, Skills for Psychological

Recovery, and social support are most useful at this stage (Finnegan et al., 2016; Wade et al.,

2014).

2. Intermediate phase: Characterized by fear, anger, anxiety, transient panic, retaliatory attacks,

difficulty paying attention at work or school, depressed feelings, and disturbed sleep.

3. Long-term phase: Characterized by coming to terms with realities with alternate periods of

adjustment and relapse. This is the period when untreated behavioral health reactions might solidify

into illnesses that would need specialized mental health or substance use disorder-related attention.

Some of the survivors can incorporate these experiences into their lives and manage to increase their 

sense of personal efficacy through their suffering. However, not all who were exposed to trauma can 

come to terms with it, and these people find it difficult to reconstruct their lives (Goldmann & Galea, 2014; 

HHS, SAMHSA, CMHS, 2004; Yehuda & Hyman, 2005).

Mass violence can result in a wide range of consequences including anxiety, depression, reduced sense 

of safety, stress or posttraumatic stress disorder (PTSD), sleep problems, feelings of guilt and shame, 

and increased risk of smoking and misuse of alcohol and other substances (Aakvaag, Thoresen, WentzelLarsen, Roysamb, & Dyb, 2014; Collective violence, 2002; DiMaggio, Galea, & Li, 2009; Palmieri, 

Chipman, Canetti, Johnson, & Hobfoll, 2010; Zemishlany, 2012). These reactions depend on three main 

factors:

• The directness and severity of the exposure: This factor relates to type of trauma exposure, whether

it is a threat to life, severe physical injury, receipt of intentional injury, exposure to grotesque scenes,

loss of a loved one, or exposure of a loved one to violence (Goldmann & Galea, 2014).

• The presence of pre-disaster risk factors: Being part of a minority group, female, having lower

educational level, or having a history of mental or physical illnesses is associated with a higher risk

of developing longer-lasting mental health problems after a disaster (Collective violence, 2002;

Goldmann & Galea, 2014; HHS, SAMHSA, CMHS, 2004; Yehuda & Hyman, 2005).

• The post-disaster environment: This factor includes post-disaster life stressors (such as job loss,

property damage, or personal loss) and level of social support (Goldmann & Galea, 2014; Nandi,

Tracy, Beard, Vlahov, & Galea, 2009).

Immediate Behavioral Health Reactions

Immediate reactions to an incident of mass violence or other traumatic experience may be in many 

domains, including physical, behavioral, emotional, social, cognitive, and spiritual. Table 1 lists some 

examples (National Child Traumatic Stress Network [NCTSN] & U.S. Department of Veterans Affairs 

[VA], National Center for PTSD, 2006; HHS, SAMHSA, CMHS, 2004; Yehuda & Hyman, 2005). These 

reactions usually vary among people based on their personalities, prior experience and attitude towards 

life, and ability to integrate the experience into their lives.

Immediate reactions usually are reported among a larger number of individuals than longer-term 

reactions. Common reactions include physical symptoms such as headaches, fatigue, gastrointestinal 
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upset, appetite changes, chest pain, rapid heart rate, or high blood pressure; cognitive changes and 

dysfunction; and increases in emotions such as fear or anxiety, anger or rage, and sadness (Eastern 

Mennonite University [EMU], Center for Justice & Peacebuilding [CJP], Strategies for Trauma Awareness 

and Resilience [STAR], 2016). In keeping with these patterns of reactions, a study that followed Twitter 

accounts of students after violent attacks on college campuses reported a significant increase in tweets 

with negative emotions (Jones, Wojcik, Sweeting, & Silver, 2016).

PTSD is not usually diagnosed in the early post-disaster phase, although people may experience 

symptoms—intrusive thoughts, flashbacks, avoidance of reminders of the traumatic incident, negative 

thoughts and feelings, and arousal and reactive symptoms—that if occurring months or years later 

could lead to a PTSD diagnosis (American Psychiatric Association [APA], 2017). The APA writes that 

a diagnosis of PTSD requires the persistence of reactions for months and sometimes years, whereas 

similar symptoms in the first month after a disaster are those of acute stress disorder (ASD) (2017). 

The National Center for PTSD cites studies estimating ASD prevalence after natural and human-caused 

disasters at rates ranging from 7 to 33 percent (Gibson, 2016).

Another possible short-term reaction is sleep problems. In a study investigating prevalence of sleep 

problems in Israeli Jews after an actual or threatened terror attack or rocket attack, the prevalence 

of sleep problems was 37 percent, and it was higher for people with probable PTSD (81 percent) or 

probable depression (79 percent). Independent correlates for poor sleep in that study were being 

female, older, less educated, and having experienced a major life stressor or psychological resource loss 

(Palmieri et al., 2010).

TABLE 1: EXAMPLES OF BEHAVIORAL, EMOTIONAL, COGNITIVE, PHYSICAL, AND SPIRITUAL 

IMMEDIATE REACTIONS FOLLOWING MASS VIOLENCE (EMU, CJP, STAR, 2007; Aakvaag et al., 2016;

Alexander & Klein, 2005; DiMaggio et al., 2009; Freedy & Simpson, 2007; Goldmann & Galea, 2014; HHS, SAMHSA, CMHS, 2004; 

Palmieri et al., 2010; Seery, Silver, Holman, Ence, & Chu, 2008; Yehuda & Hyman, 2005)

Behavioral Emotional Cognitive Physical Spiritual

Sleep disturbances, 

nightmares

Jumpiness

Avoidance of any 

reminders

Increased substance 

use (alcohol and 

drugs)

Shock/disbelief/

numbness

Anxiety/fear/sadness/

grief

Anger/rage or desire 

for revenge

Re-experiencing 

pain associated with 

previous trauma

Confusion and 

disorientation

Poor concentration 

and memory problems

Repeated flashbacks 

Hypervigilance

Chest pain

High blood pressure

Rapid heart rate

Gastrointestinal 

changes

Shallow breathing

Dizziness or faintness

Chills or sweating

Fatigue

Sleep disturbances

Headaches

Grinding teeth

Emptiness/loss of 

meaning

Doubt

Feeling unforgiven

Feeling punished

Loss of direction

Cynicism/apathy

Alienation/mistrust/

crisis of faith

Long-term Behavioral Health Reactions

Most survivors do not develop disorders over the long term because of resilience, or “the ability to 

successfully adapt to stressors, maintaining psychological well-being in the face of adversity” (Goldmann 
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& Galea, 2014; Haglund, Nestadt, Cooper, Southwick, & Charney, 2007, p. 889). This concept is 

important, as a sizable percentage of people (40–78 percent) exposed to mass violence events and other 

potentially traumatic events are either entirely or almost entirely free of symptoms of disorders over time 

(Zemishlany, 2012). According to multiple studies, only a minority of survivors will develop conditions that 

reach diagnostic thresholds for PTSD, depression, and anxiety or have subclinical conditions months and 

years after an incident of mass violence (HHS, SAMHSA, CMHS, 2004; Miron, Orcutt, & Kumpula, 2014; 

Nandi et al., 2009).

Resilience is usually affected by a person’s ethnicity, gender, psychosocial support, and socioeconomic 

status, with the least resilient being lower income and having lower levels of education (Goldmann 

& Galea, 2014; Hobfoll et al., 2009). Lower household income, exposure to ongoing stressors, and 

exposure to traumatic events were found to be associated with depressive symptoms in a study following 

the 9/11 attacks (Nandi et al., 2009).

Sometimes aspects of the disaster, particular disaster experiences, and individual differences seem 

to make it harder for survivors to activate resilience. Following the 9/11 terrorist attack in New York, 

the levels of PTSD and functional impairment declined after 4 years; however, there was a substantial 

increase in suicidal ideation and missed days of work in the same follow-up period (Neria et al., 2013). 

Additionally, in a study conducted 10 to 11 years following the attack, a markedly large group of survivors 

with mental health symptoms reported unmet mental health needs, especially those who lacked health 

insurance or social support (Ghuman, Brackbill, Stellman, Farfel, & Cone, 2014). The loss of someone 

close to the survivor was associated with a greater risk of mental illnesses including PTSD and major 

depressive disorder, as well as suicidal ideation, functional impairment, and missing work (Ghuman 

et al., 2014). After the 2005 bombings in London, a need for treatment was reported for 47 percent of 

participants who were screened for PTSD 2 years following the incident (Brewin et al., 2010). In school 

shootings, Miron et al. reported that people with greater emotional dysregulation and peritraumatic 

dissociative experience had quadruple the risk of developing posttraumatic stress symptoms 8 months 

after the incident (2014).

Following bioterrorism incidents (the anthrax attacks on Capitol Hill in 2001), among people with positive 

nasal swab tests, any post-incident psychiatric disorder was diagnosed (through structured interview) in 

54.6 percent, and PTSD in 27 percent (North et al., 2009). Of those who were physically exposed without 

a positive nasal swab test, 24.4 percent were diagnosed with a post-incident psychiatric disorder; of those 

who were not physically exposed, 19.8 percent were diagnosed with a post-incident psychiatric disorder. 

Panic disorder was diagnosed in 1.5 percent, anxiety in 1.5 percent, and alcohol use disorder in 2.9 

percent of the interview participants (North et al., 2009).

Other long-term implications of mass violence include substance misuse (Goldmann & Galea, 2014). In a 

meta-analysis studying substance use or misuse after mass trauma or terrorist incidents, the probability 

distribution for increased alcohol use following a terrorist incident, based on synthesis of 17 studies, was 

20 percent that prevalence would be as high as 14 percent after 2 years. Cigarette smoking prevalence 

increased by 6.8 percent, and prevalence of mixed drug use was 16.3 percent (DiMaggio et al., 2009). 

Similar results were also reported in New York City public high school students following the 9/11 attacks 

(DiMaggio et al., 2009; Wu et al., 2006). In another study, a 1 percent increase in death because of 

terrorism and mass violence was associated with an increase of 0.10–0.12 in alcohol and drug use 

disability adjusted life years (Kerridge, Khan, Rehm, & Sapkota, 2014).
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Reactions in Children

In children, the experience of disasters, violent victimization, and sudden death of loved ones depends on 

stage of psychological development, gender, anxiety level, life and family situation, and critical caretaking 

relationships (Kerns et al., 2014; La Greca et al., 2013; HHS, SAMHSA, CMHS, 2004; Pfefferbaum et al., 

2014b; Pfefferbaum, Varma, Nitiema, & Newman, 2014). Human-caused violence may affect the child’s 

trust in adults or in human nature. Children commonly implicate themselves in causing or worsening 

the incident, which might result in feelings of shame and guilt as well as self-blame (Aakvaag et al., 

2014; Gamwell et al., 2015; HHS, CMHS, SAMHSA, 2004). The higher vulnerability in children may be 

associated with their lesser ability to deal or cope with their experiences (Goldmann & Galea, 2014; 

Norris, Friedman, & Watson, 2002).

For adolescents, exposure to violent incidents may lead to fears, anxieties, and vulnerabilities that 

are usually associated with a younger age. Six months following the Boston Marathon attack, youthful 

marathon attendants were found to have greater psychopathology, with PTSD being reported 6 times 

higher among marathon attendants than non-attendants (Comer et al., 2014). Additionally, following the 

Utoya shootings in Norway, students’ grades and functioning in school was found to be impaired after 

experiencing trauma, and there was a reported increase in days absent from school (Strom, Schultz, 

Wentzel-Larsen, & Dyb, 2016).

BEHAVIORAL HEALTH INTERVENTIONS FOLLOWING MASS VIOLENCE

Mass violence affects large groups of individuals at the same time, whether they were survivors or 

witnesses of the event where it occurred or followed it through media outlets. Interventions are applied 

across all phases of disaster, with pre-event services planned to enhance preparedness, and post-event 

services designed to enhance resilience and reduce signs and symptoms of distress and disorders, and 

possibly to reduce long-term complications (Pfefferbaum et al., 2014b).

Interventions to counter the effects of mass violence require the coordinated effort of the individuals 

exposed, first responders, medical and mental health institutions, family, friends, and society, as well as 

local and national organizations. Generally, interventions aim to promote a sense of safety and calming, a 

sense of personal and community efficacy, connectedness, and hope (Hobfoll et al., 2007).

Adult Survivors

The immediate (up to 1 year post-disaster) mental health interventions in adult trauma survivors are listed 

and briefly explained in Table 2.
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TABLE 2: IMMEDIATE MENTAL HEALTH INTERVENTIONS FOR ADULT SURVIVORS OF INCIDENTS 

OF MASS VIOLENCE

Intervention Description

Psychological 

First Aid

“Psychological First Aid is an evidence-informed modular approach to help children, 

adolescents, adults, and families in the immediate aftermath of disaster and terrorism. [It] is 

designed to reduce the initial distress caused by traumatic events and to foster short- and 

long-term adaptive functioning and coping” (NCTSN & VA, National Center for PTSD, 2006; 

Fetter, 2005; Goldmann & Galea, 2014). Principles and techniques of Psychological First Aid 

are consistent with research, applicable in the field, appropriate for people at all developmental 

levels over the life course, and designed to be customizable to work well with a variety of 

cultures.

Rapid assessment determines those survivors in most acute distress and in need of medical 

attention. This can also be performed in trauma centers for injured survivors (Petrie & Zatzick, 

2010).

Community 

outreach

Community outreach could include initiating supportive and helpful contact sites; reaching out 

to survivors through the media, the Internet, and 24-hour telephone helplines; participating 

in or conducting meetings for preexisting groups as well as providing psycho-educational 

resources and referral information. Monitoring the well-being of the entire community or area 

that was harmed and/or threatened by the attack is critical, and integrating mental health 

interventions into existing community services makes them more acceptable to the population 

(Goldmann & Galea, 2014; Grills-Taquechel, Littleton, & Axsom, 2011; Hobfoll et al., 2011; 

Sherrieb & Norris, 2013).

Psychological 

debriefing

Debriefings are a type of intervention that can be used following a disaster or other traumatic 

event. The technique is applied within 48 hours of the traumatic event. In debriefing, victims 

are asked to describe the event and their emotional responses to it in detail. The method was 

suggested to reduce stress; however, there are some questions on the effectiveness of 

psychological debriefing, as it may strengthen the memories of the traumatic event, 

impair the natural recovery process, and even worsen the symptoms (VA, National 

Center for PTSD, 2016; Fetter, 2005; Goldmann & Galea, 2014; Sijbrandij, Olff, Reitsma, 

Carlier, & Gersons, 2006).

• Critical Incident Stress Debriefing (CISD), a psycho-educational small group process,

was developed exclusively for small, homogeneous groups who have encountered a

powerful traumatic event. CISD aims to reduce stress and restore group cohesion and

unit performance (Mitchell).

PsychoeducationPsycho-education is an important component of behavioral health interventions following 

immediate traumatic impact. In psycho-education, information is provided about post-trauma 

reactions, grief and bereavement, effective coping strategies, and when to seek professional 

consultation. Brochures or simple handouts are usually widely distributed in appropriate 

languages (HHS, SAMHSA, CMHS, 2004; Petrie & Zatzick, 2010).

Mental health 

consultation

Mental health professionals can be brought into decision-making and planning teams to advise 

leaders regarding mental health issues such as optimal scheduling, mental health support, and 

leave time for rescue and recovery workers, as well as other possibly sensitive procedures or 

activities (for instance, identifying body parts) (HHS, SAMHSA, CMHS, 2004; DOJ, OJP, OVC 

& American Red Cross, 2005).
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Activities for long-term mental health intervention include the following:

• Screening to identify individuals and groups in need of mental health and crime victim assistance

services and to prioritize the delivery of more intensive mental health services (Brewin et al., 2010;

Hobfoll et al., 2011; Johnson-Agbakwu, Allen, Nizigiyimana, Ramirez, & Hollifield, 2014).

• Providing a range of crime victim services. Crime victims, their families, and others affected by the

crime may receive crisis intervention and counseling, advocacy, grief and trauma counseling, and

information and referral (DOJ, OJP, OVC & American Red Cross, 2005).

• Providing mental health support and consultation for community events (Birkeland, Nielsen,

Knardahl, & Heir, 2015; Grills-Taquechel et al., 2011; Pfefferbaum et al., 2014b).

• Providing appropriate psycho-educational information to all affected survivor and responder groups

and health care and social service providers in the community (Alexander & Klein, 2005; HHS,

SAMHSA, CMHS, 2004; DOJ, OJP, OVC & American Red Cross, 2005).

Screening for Trauma

Screening for trauma is a very important step to help identify the affected people, gauge the severity 

of their condition, and determine whether they require referral to specialized institutions for treatment 

or further evaluation (Goldmann & Galea, 2014). Screening can be done through phone interviews to 

estimate the prevalence of PTSD and depressive symptoms. In a study conducted in Jerusalem using a 

sample of Jewish and Arab residents during a period of heightened threats, phone interviews to screen for 

behavioral health impact proved as effective as in-depth personal interviews in identifying the prevalence 

of these symptoms (Hobfoll et al., 2011). The researchers note that this method would prove very useful 

in reaching out to a higher percentage of the population, for epidemiological and census purposes as well 

as to guide public health intervention resource allocation (Hobfoll et al., 2011). It can also provide useful 

means in reaching out to displaced people (Goldmann & Galea, 2014). In a study evaluating the mental 

health of refugees, publicly listed telephone numbers with surnames known or thought to be related were 

searched, and a random sample was contacted and interviewed (Wagner et al., 2013). This can also be 

implemented using available lists to identify individuals who are known to have lived in the disaster area 

prior its occurrence to create a contact list to screen for post-disaster mental health impacts.

Mental health providers should keep in mind that not all people who were exposed to the potentially 

traumatic experience of an incident of mass violence will seek help. In a study, potential unmet mental 

health needs were reported in New York 6 months after the 9/11 terrorist attacks (Stuber, Galea, 

Boscarino, & Schlesinger, 2006). In that study, more than 60 percent of respondents with probable PTSD 

or depression did not seek help despite diminished functioning. Some barriers to help-seeking reported 

by the investigators were concerns about negative, inaccurate perceptions about mental health services 

and those who access them, along with the feeling that other people needed the help more than they did. 

On the other hand, people with physical health problems or who already were connected to mental health 

services had a higher probability of seeking mental health help (Stuber et al., 2006).
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Further in the recovery process, CMHS and others identify the following tasks for mental health services 

(2004):

1. Identify those in need of medical mental health attention for stress reactions (for example, those in

need of cognitive behavioral therapy or medications) (Goldmann & Galea, 2014).

2. Provide supportive assistance.

3. Facilitate connection of survivors with family and friends who can provide social support and ease

pain and suffering (Grills-Taquechel et al., 2011).

4. Provide information about the status of the crime scene, perpetrator(s), and immediate law

enforcement efforts (DOJ, OJP, OVC & American Red Cross, 2005).

Youth, Child, and Adolescent Survivors

For young disaster survivors, interventions should work to protect and enhance existing social support 

and foster resilience (Pfefferbaum et al., 2014b). The choice of an intervention must be matched to the 

child’s reactions and the course of symptom development and recovery following disaster exposure. In 

children, the course of disaster usually follows the same trajectory as in adults, leading either to resilience 

and recovery or development of chronic behavioral health issues (Pfefferbaum et al., 2014a). In ideal 

situations, the child’s close social circle or environment would be able to help mitigate the effect of 

disaster and initiate recovery.

The first level of intervention in children is the immediate social group including parents, siblings, and 

close friends who can help children cope with the situation by assisting with emotional processing, serving 

as familiar faces, and providing a distraction from the incident (2014a). Siblings and friends can provide 

social support and help maintain or regain everyday routine.

The second level of intervention according to Pfefferbaum et al. is through linking mental health services 

with schools, parents, extended families, and peers (Pfefferbaum et al., 2014a). Interventions in schools 

and play areas (for example, certified pet therapy animals in play areas) are important, as they provide 

children access to mental health services (HHS, SAMHSA, CMHS, 2004). School-based disaster mental 

health services are accessible and reduce negative misperceptions associated with the use of mental 

health services. Teachers and peers can provide crucial support at this level of intervention. For example, 

following the 9/11 terrorist attacks, it was reported that 22 percent of children in lower Manhattan received 

disaster-related counseling, and of that group, 58 percent received it from either a teacher or school 

psychologist (Pfefferbaum et al., 2014b).

For adolescents, playing an active role in the relief effort and helping others might enhance self-efficacy 

and allow them a sense of greater mastery of their situations (Comer et al., 2014; HHS, SAMHSA, CMHS, 

2004; Pfefferbaum et al., 2014b; Pfefferbaum et al., 2014; Strom et al., 2016).

Over the long term, mental health intervention and treatment address the following areas:

• Understanding the child’s unique experience of the trauma

• Screening youth for behavioral health problems

• Assisting the child in developing coping strategies

• Addressing grief
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• Intervening with post-trauma difficulties such as a decline in school performance

• Identifying and redressing missed developmental opportunities and the effects of mass media

These areas include brief counseling and support groups, and cognitive behavioral therapy, among 

other types of therapy (Pfefferbaum et al., 2014a). As in the initial phase, the choice of intervention 

should depend on the child’s psychology, disaster exposure and outcomes, family and social factors, and 

factors related to the intervention and context of delivery (Pfefferbaum et al., 2014a). The interventions 

can be delivered on the individual level or as a group intervention. They can be delivered in various 

sites including schools, health and mental health facilities, or community settings. Selecting the setting 

depends on the location and magnitude of the disaster; characteristics of the disaster community; 

availability of venues (schools, clinics); accessibility for families; and expertise of professionals 

(Pfefferbaum et al., 2014a).

MEDIA EXPOSURE AND MENTAL HEALTH FOLLOWING MASS VIOLENCE

Since the advent of the 24-hour television news cycle, exposure to mass violence and natural disasters 

through the media has been widespread (Neria & Sullivan, 2011). Evidence from reviewing existing 

epidemiological studies showed initial rather than extended increases in rates of PTSD symptoms among 

individuals indirectly exposed to mass trauma through sources such as the mass media (Neria & Sullivan, 

2011). Exposure to graphic television images may exacerbate psychological symptoms in disaster 

survivors; in one study, the respondents who repeatedly viewed disaster images or videos had higher 

prevalence of PTSD (17.4 percent) and depression (14.7 percent) than those who did not (Ahern et al., 

2002). Additionally, among the study participants who experienced personal loss, the risk of PTSD was 

still higher among those who watched television than those who did not (Ahern et al., 2002).

Another consideration with media exposure is that the media shows more interest in events of greater 

horror and psychological impact and that excessive and repeated media exposure puts people at risk 

for secondary traumatization (Alexander & Klein, 2005; HHS, SAMHSA, CMHS, 2004). Media coverage, 

especially at earlier stages, could also present a risk of violations of privacy of the survivors and their 

families (HHS, SAMHSA, CMHS, 2004; DOJ, OJP, OVC & American Red Cross, 2005).

Additionally, heightened exposure through mass media and news reports could lead to an extra sense of 

insecurity and alarm and increase initial rates of stress symptoms, according to a study investigating the 

effects of indirect exposure to mass trauma through the media (Neria & Sullivan, 2011).

Children have almost unrestricted access to worldwide media coverage of acts of terrorism, and this could 

threaten their mental and physical health due to the crude nature of the events and their coverage (Leiner 

et al., 2016). Terrorist acts have been documented throughout history, but in recent decades, media 

coverage has given greater attention to violent events (Leiner et al., 2016). In a study following the Boston 

Marathon bombings, repeated bombing-related media exposure was associated with higher acute stress 

than was direct exposure (Holman, Garfin, & Silver, 2014). In another study following the same attack, 

the degree of media exposure following the attack predicted the onset of PTSD symptoms in adolescents 

(Busso, McLaughlin, & Sheridan, 2014). On the other hand, the mass media can be useful in spreading 

informational briefings, providing information about available resources, letting survivors know when and 

where to seek help, and covering activities and events planned to support the survivors emotionally and 

through the provision of resources (Alexander & Klein, 2005).
| Page 13

INDIVIDUALS WITH PREEXISTING MENTAL HEALTH CONDITIONS 

AND MASS VIOLENCE

There is a common misconception among Americans that individuals with mental health issues are 

responsible for most incidents of mass violence. Research contradicts this idea. For example, research 

has found that most terrorists are not mentally ill, and most do not have violent or psychopathic 

personalities (Alexander & Klein, 2005). In a review article, Swanson et al. reported evidence showing 

that most people with serious mental illnesses are never violent towards others despite having an 

increased risk of self-harm and suicide (2015). Metzl and MacLeish argued that notions of mental illness 

that emerge in relation to mass shootings frequently reflect cultural stereotypes and anxieties about 

matters such as race and ethnicity, social class, and politics (2015).

RESILIENCE

As noted, Haglund et al. define resilience as “the ability to successfully adapt to stressors, maintaining 

psychological well-being in the face of adversity” (Haglund et al., 2007, p. 889). Resilience embodies the 

personal qualities that enable an individual to thrive in the face of adversity (Connor & Davidson, 2003). 

According to Goldmann and Galea, resilience does not indicate complete absence of any psychological 

symptoms following a traumatic event, but rather the ability to return to pre-trauma levels of functioning 

(2014).

According to Connor and Davidson, resilience is a measure of stress-coping ability that varies with 

context, age, gender, time, and culture, as well as with different types of adversity (2003). At the 

beginning point of bio-psycho-spiritual balance “homeostasis,” an individual adapts body, mind, and spirit 

to current life circumstances. Internal and external stressors can affect the individual’s ability to cope. In 

time, response to stressors is a reintegrative process, leading to one of four outcomes:

• The disruption represents an opportunity for growth and increased resilience, leading to a new, 

higher level of homeostasis.

• The individual returns to baseline homeostasis.

• The individual experiences recovery with loss, establishing a lower level of homeostasis.

• The individual moves into a dysfunctional state.

In a study to identify the trajectories of resilience in Israel, the authors looked at demographic predictors 

(Hobfoll et al., 2009). The article discussed predictors that distinguished the resistance trajectory from the 

chronic distress trajectory including being male, having a higher income, being secular (as opposed to 

being traditionally religious), and having higher education (more than high school). Expressing resilience 

does not automatically mean that people do not have any PTSD symptoms; in a study by Suarez, some 

of the pathways showed that resilience and posttraumatic responses were interrelated in the aftermath 

of violence in Peru (2013). The study population, however, showed higher functionality in the presence of 

resilience even while exhibiting PTSD symptoms.
| Page 14

CONCLUSION

Incidents of mass violence and terrorist attacks have an enormous behavioral health impact on most 

people, whether they are survivors, witnesses, or exposed through mass media. Most individuals will 

experience some immediate reactions, including fear, anxiety, and helplessness. Not all people who 

experience initial signs and symptoms of disorders and distress will develop long-term complications; 

rather, a small minority will. The task of behavioral health interventions in the immediate post-incident 

period is therefore to provide support (mental, social, and financial support), as well as reassurance 

and resources. A few months after that period of time, surveys need to be conducted to identify people 

at heightened risk of developing more severe and lasting reactions, such as PTSD, depression, sleep 

problems, and other mental health issues. Long-term interventions are usually provided through 

specialized mental health facilities; however, public links to these providers as well as helplines would 

still be invaluable. The most crucial point to emphasize here is that the reactions following mass violence 

as well as the interventions provided are not one size fits all—instead, they should be individualized and 

attuned to the culture of the people for whom they’re offered. Finally, on one hand media exposure can 

be associated with increased stress and anxiety and risk of re-traumatization, but on the other, the media 

outreach can connect with a broad swath of the public and contribute to mental health healing through 

providing information about resources and opportunities for emotional support for survivors.
| Page 15

REFERENCES

Aakvaag, H. F., Thoresen, S., Wentzel-Larsen, T., Roysamb, E., & Dyb, G. (2014). Shame and guilt in the aftermath 

of terror: The Utoya Island study. Journal of Traumatic Stress, 27(5), 618–621. doi: 10.1002/jts.21957

Ahern, J., Galea, S., Resnick, H., Kilpatrick, D., Bucuvalas, M., Gold, J., & Vlahov, D. (2002). Television images and 

psychological symptoms after the September 11 terrorist attacks. Psychiatry, 65(4), 289–300.

Alexander, D. A., & Klein, S. (2005). The psychological aspects of terrorism: From denial to hyperbole. Journal of the 

Royal Society of Medicine, 98(12), 557–562. doi: 10.1258/jrsm.98.12.557

American Psychiatric Association. (2017). What is posttraumatic stress disorder? Retrieved from https://www.

psychiatry.org/patients-families/ptsd/what-is-ptsd

Birkeland, M. S., Nielsen, M. B., Knardahl, S., & Heir, T. (2015). Associations between work environment and 

psychological distress after a workplace terror attack: The importance of role expectations, predictability and 

leader support. PLOS ONE, 10(3), e0119492. doi: 10.1371/journal.pone.0119492

Blair, J. P., & Schweit, K. W. (2014). A study of active shooter incidents in the United States between 2000 and 2013. 

Washington, DC: Texas State University and U.S. Department of Justice, Federal Bureau of Investigation.

Brewin, C. R., Fuchkan, N., Huntley, Z., Robertson, M., Thompson, M., Scragg, P., . . . Ehlers, A. (2010). Outreach 

and screening following the 2005 London bombings: Usage and outcomes. Psychological Medicine, 40(12), 

2049-2057. doi: 10.1017/s0033291710000206

Busso, D. S., McLaughlin, K. A., & Sheridan, M. A. (2014). Media exposure and sympathetic nervous system 

reactivity predict PTSD symptoms after the Boston marathon bombings. Depression and Anxiety, 31(7), 551–

558. doi: 10.1002/da.22282

Collective violence. (2002). In E. G. Krug, L. L. Dahlberg, J. A. Mercy, A. B. Zwi, & R. Lozano (Eds.), World report on 

violence and health (pp. 213–240). Geneva, Switzerland: World Health Organization. Retrieved from http://www.

who.int/violence_injury_prevention/violence/world_report/en

Comer, J. S., Dantowitz, A., Chou, T., Edson, A. L., Elkins, R. M., Kerns, C., . . . Green, J. G. (2014). Adjustment 

among area youth after the Boston Marathon bombing and subsequent manhunt. Pediatrics, 134(1), 7–14. doi: 

10.1542/peds.2013-4115

Connor, K. M., & Davidson, J. R. (2003). Development of a new resilience scale: the Connor-Davidson Resilience 

Scale (CD-RISC). Depression and Anxiety, 18(2), 76–82. doi: 10.1002/da.10113

DiMaggio, C., Galea, S., & Li, G. (2009). Substance use and misuse in the aftermath of terrorism. A Bayesian metaanalysis. Addiction, 104(6), 894–904. doi: 10.1111/j.1360-0443.2009.02526.x

Dore, B., Ort, L., Braverman, O., & Ochsner, K. N. (2015). Sadness shifts to anxiety over time and distance 

from the national tragedy in Newtown, Connecticut. Psychological Science, 26(4), 363–373. doi: 

10.1177/0956797614562218

Eastern Mennonite University, Center for Justice & Peacebuilding, Strategies for Trauma Awareness and Resilience. 

(2016). Common responses to high stress and/or trauma self test: Put a check beside the responses that 

describe you. Retrieved from https://emu.edu/cms-links/cjp/star/docs/Common_Responses.pdf

Fetter, J. C. (2005). Psychosocial response to mass casualty terrorism: Guidelines for physicians. The Primary Care 

Companion to the Journal of Clinical Psychiatry, 7(2), 49–52. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/

articles/PMC1079695

Finnegan, A., Kip, K., Hernandez, D., McGhee, S., Rosenzweig, L., Hynes, C., & Thomas, M. (2016). Accelerated 

resolution therapy: An innovative mental health intervention to treat post-traumatic stress disorder. Journal of the 

Royal Army Medical Corps, 162(2), 90–97. doi: 10.1136/jramc-2015-000417

Freedy, J. R., & Simpson, W. M., Jr. (2007). Disaster-related physical and mental health: A role for the family 

physician. American Family Physician, 75(6), 841–846.

Gamwell, K., Nylocks, M., Cross, D., Bradley, B., Norrholm, S. D., & Jovanovic, T. (2015). Fear conditioned responses 

and PTSD symptoms in children: Sex differences in fear-related symptoms. Developmental Psychobiology, 

57(7), 799–808. doi: 10.1002/dev.21313
| Page 16

Ghuman, S. J., Brackbill, R. M., Stellman, S. D., Farfel, M. R., & Cone, J. E. (2014). Unmet mental health care need 

10–11 years after the 9/11 terrorist attacks: 2011–2012 results from the World Trade Center Health Registry. 

BMC Public Health, 14, 491. doi: 10.1186/1471-2458-14-491

Gibson, L. E. (2016). Acute stress disorder. Washington, DC: U.S. Department of Veterans Affairs, National Center for 

PTSD. Retrieved from https://www.ptsd.va.gov/professional/trauma/disaster-terrorism/debriefing-after-disasters.

asp

Goldmann, E., & Galea, S. (2014). Mental health consequences of disasters. Annual Review of Public Health, 35,

169–183. doi: 10.1146/annurev-publhealth-032013-182435

Grills-Taquechel, A. E., Littleton, H. L., & Axsom, D. (2011). Social support, world assumptions, and exposure as 

predictors of anxiety and quality of life following a mass trauma. Journal of Anxiety Disorders, 25(4), 498–506. 

doi: 10.1016/j.janxdis.2010.12.003

Haglund, M. E., Nestadt, P. S., Cooper, N. S., Southwick, S. M., & Charney, D. S. (2007). Psychobiological 

mechanisms of resilience: Relevance to prevention and treatment of stress-related psychopathology. 

Development and Psychopathology, 19(3), 889–920. doi: 10.1017/s0954579407000430

Hobfoll, S. E., Canetti, D., Hall, B. J., Brom, D., Palmieri, P. A., Johnson, R. J., . . . Galea, S. (2011). Are community 

studies of psychological trauma’s impact accurate? A study among Jews and Palestinians. Psychological 

Assessment, 23(3), 599–605. doi: 10.1037/a0022817

Hobfoll, S. E., Palmieri, P. A., Johnson, R. J., Canetti-Nisim, D., Hall, B. J., & Galea, S. (2009). Trajectories of 

resilience, resistance, and distress during ongoing terrorism: The case of Jews and Arabs in Israel. Journal of 

Consulting and Clinical Psychology, 77(1), 138–148. doi: 10.1037/a0014360

Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., . . . Ursano, R. J. (2007). Five 

essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry, 70(4), 

283–315; discussion 316–269. doi: 10.1521/psyc.2007.70.4.283

Holman, E. A., Garfin, D. R., & Silver, R. C. (2014). Media’s role in broadcasting acute stress following the Boston 

Marathon bombings. Proceedings of the National Academy of Sciences of the United States of America, 111(1), 

93–98. doi: 10.1073/pnas.1316265110

Horgan, J. G. (2017). Psychology of terrorism: Introduction to the special issue. American Psychology, 72(3), 199–

204. doi: 10.1037/amp0000148

Jensen, M., & Miller, E. (2016). American deaths in terrorist attacks, 1995–2015. College Park, MD: National 

Consortium for the Study of Terrorism and Responses to Terrorism (START). Retrieved from http://www.start.

umd.edu/pubs/START_AmericanTerrorismDeaths_FactSheet_Sept2016.pdf

Johnson-Agbakwu, C. E., Allen, J., Nizigiyimana, J. F., Ramirez, G., & Hollifield, M. (2014). Mental health screening 

among newly arrived refugees seeking routine obstetric and gynecologic care. Psychological Services, 11(4), 

470–476. doi: 10.1037/a0036400

Jones, N. M., Wojcik, S. P., Sweeting, J., & Silver, R. C. (2016). Tweeting negative emotion: An investigation of Twitter 

data in the aftermath of violence on college campuses. Psychological Methods, 21(4), 526–541. doi: 10.1037/

met0000099

Kerns, C. E., Elkins, R. M., Carpenter, A. L., Chou, T., Green, J. G., & Comer, J. S. (2014). Caregiver distress, shared 

traumatic exposure, and child adjustment among area youth following the 2013 Boston Marathon bombing. 

Journal of Affective Disorders, 167, 50–55. doi: 10.1016/j.jad.2014.05.040

Kerridge, B. T., Khan, M. R., Rehm, J., & Sapkota, A. (2014). Terrorism, civil war and related violence and substance 

use disorder morbidity and mortality: A global analysis. Journal of Epidemiology and Global Health, 4(1), 61–72. 

doi: 10.1016/j.jegh.2013.10.003

La Greca, A. M., Lai, B. S., Llabre, M. M., Silverman, W. K., Vernberg, E. M., & Prinstein, M. J. (2013). Children’s 

postdisaster trajectories of PTS symptoms: Predicting chronic distress. Child & Youth Care Forum, 42(4), 

351–369. doi: 10.1007/s10566-013-9206-1

LaFree, G. (2017). Using open source data to track worldwide terrorism patterns. Pathways to Peace and Security, 

1(52), 64–76. doi: 10.20542/2307-1494-2017-1-64-76
| Page 17

Leiner, M., Peinado, J., Villanos, M. T., Lopez, I., Uribe, R., & Pathak, I. (2016). Mental and emotional health of 

children exposed to news media of threats and acts of terrorism: The cumulative and pervasive effects. Frontiers 

in Pediatrics, 4, 26. doi: 10.3389/fped.2016.00026

Martens, A., Sainudiin, R., Sibley, C. G., Schimel, J., & Webber, D. (2014). Terrorist attacks escalate in frequency and 

fatalities preceding highly lethal attacks. PLOS ONE, 9(4), e93732. doi: 10.1371/journal.pone.0093732

Metzl, J. M., & MacLeish, K. T. (2015). Mental illness, mass shootings, and the politics of American firearms. 

American Journal of Public Health, 105(2), 240–249. doi: 10.2105/ajph.2014.302242

Miron, L. R., Orcutt, H. K., & Kumpula, M. J. (2014). Differential predictors of transient stress versus posttraumatic 

stress disorder: Evaluating risk following targeted mass violence. Behavior Therapy, 45(6), 791–805. doi: 

10.1016/j.beth.2014.07.005

Mitchell, J. T. (n.d.). Critical Incident Stress Debriefing (CISD). Retrieved from http://www.info-trauma.org/flash/

media-f/mitchellCriticalIncidentStressDebriefing.pdf

Nandi, A., Tracy, M., Beard, J. R., Vlahov, D., & Galea, S. (2009). Patterns and predictors of trajectories of depression 

after an urban disaster. Annals of Epidemiology, 19(11), 761–770. doi: 10.1016/j.annepidem.2009.06.005

National Child Traumatic Stress Network, & U.S. Department of Veterans Affairs, National Center for PTSD. (2006). 

Psychological First Aid field operations guide (second ed.). Retrieved from http://www.nctsn.org/content/

psychological-first-aid

Neria, Y., & Sullivan, G. M. (2011). Understanding the mental health effects of indirect exposure to mass trauma 

through the media. Journal of the American Medical Association, 306(12), 1374–1375. doi: 10.1001/

jama.2011.1358

Neria, Y., Wickramaratne, P., Olfson, M., Gameroff, M. J., Pilowsky, D. J., Lantigua, R., . . . Weissman, M. M. 

(2013). Mental and physical health consequences of the September 11, 2001 (9/11) attacks in primary care: A 

longitudinal study. Journal of Trauma Stress, 26(1), 45–55. doi: 10.1002/jts.21767

Norris, F. H., Friedman, M. J., & Watson, P. J. (2002). 60,000 disaster victims speak: Part II. Summary and 

implications of the disaster mental health research. Psychiatry, 65(3), 240–260.

North, C. S., Pfefferbaum, B., Vythilingam, M., Martin, G. J., Schorr, J. K., Boudreaux, A. S., . . . Hong, B. A. (2009). 

Exposure to bioterrorism and mental health response among staff on Capitol Hill. Biosecurity and Bioterrorism, 

7(4), 379–388. doi: 10.1089/bsp.2009.0031

Palmieri, P. A., Chipman, K. J., Canetti, D., Johnson, R. J., & Hobfoll, S. E. (2010). Prevalence and correlates of sleep 

problems in adult Israeli Jews exposed to actual or threatened terrorist or rocket attacks. Journal of Clinical Sleep 

Medicine, 6(6), 557–564.

Petrie, M., & Zatzick, D. (2010). Collaborative care interventions in general trauma patients. Oral and Maxillofacial 

Surgery Clinics of North America, 22(2), 261–267. doi: 10.1016/j.coms.2010.01.002

Pfefferbaum, B., Sweeton, J. L., Newman, E., Varma, V., Nitiema, P., Shaw, J. A., . . . Noffsinger, M. A. (2014a). Child 

disaster mental health interventions, part I: Techniques, outcomes, and methodological considerations. Disaster 

Health, 2(1), 46–57. doi: 10.4161/dish.27534

Pfefferbaum, B., Sweeton, J. L., Newman, E., Varma, V., Noffsinger, M. A., Shaw, J. A., . . . Nitiema, P. (2014b). 

Child disaster mental health interventions, part II: Timing of implementation, delivery settings and providers, and 

therapeutic approaches. Disaster Health, 2(1), 58–67. doi: 10.4161/dish.27535

Pfefferbaum, B., Varma, V., Nitiema, P., & Newman, E. (2014). Universal preventive interventions for children in the 

context of disasters and terrorism. Child Adolescent Psychiatric Clinics of North America, 23(2), 363–382, ix–x. 

doi: 10.1016/j.chc.2013.12.006

Seery, M. D., Silver, R. C., Holman, E. A., Ence, W. A., & Chu, T. Q. (2008). Expressing thoughts and feelings 

following a collective trauma: Immediate responses to 9/11 predict negative outcomes in a national sample. 

Journal of Consulting and Clinical Psychology, 76(4), 657–667. doi: 10.1037/0022-006x.76.4.657

Sherrieb, K., & Norris, F. H. (2013). Public health consequences of terrorism on maternal-child health in New York 

City and Madrid. Journal of Urban Health, 90(3), 369–387. doi: 10.1007/s11524-012-9769-4
| Page 18

Shultz, J. M., Cohen, A. M., Muschert, G. W., & Flores de Apodaca, R. (2013). Fatal school shootings and the 

epidemiological context of firearm mortality in the United States. Disaster Health, 1(2), 84–101. doi: 10.4161/

dish.26897

Sijbrandij, M., Olff, M., Reitsma, J. B., Carlier, I. V., & Gersons, B. P. (2006). Emotional or educational debriefing after 

psychological trauma. Randomised controlled trial. British Journal of Psychiatry, 189, 150–155. doi: 10.1192/bjp.

bp.105.021121

Strom, I. F., Schultz, J. H., Wentzel-Larsen, T., & Dyb, G. (2016). School performance after experiencing trauma: 

a longitudinal study of school functioning in survivors of the Utoya shootings in 2011. European Journal of 

Psychotraumatology, 7, 31359. doi: 10.3402/ejpt.v7.31359

Stuber, J., Galea, S., Boscarino, J. A., & Schlesinger, M. (2006). Was there unmet mental health need after the 

September 11, 2001 terrorist attacks? Social Psychiatry and Psychiatric Epidemiology, 41(3), 230–240. doi: 

10.1007/s00127-005-0022-2

Suarez, E. B. (2013). The association between post-traumatic stress-related symptoms, resilience, current stress 

and past exposure to violence: A cross sectional study of the survival of Quechua women in the aftermath of the 

Peruvian armed conflict. Conflict and Health, 7(1), 21. doi: 10.1186/1752-1505-7-21

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 

Center for Mental Health Services. (1994). Disaster response and recovery: A handbook for mental health 

professionals. Rockville, MD.

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 

Center for Mental Health Services. (2004). Mental health response to mass violence and terrorism: A training 

manual. Retrieved from https://store.samhsa.gov/product/Mental-Health-Response-to-Mass-Violence-andTerrorism-A-Training-Manual/SMA04-3959

U.S. Department of Justice, Office of Justice Programs, Office for Victims of Crime, & American Red Cross. (2005). 

Responding to victims of terrorism and mass violence crimes: Coordination and collaboration between American 

Red Cross workers and crime victim service providers. Retrieved from https://www.ovc.gov/publications/infores/

redcross/ncj209681.pdf

U.S. Department of Veterans Affairs, National Center for PTSD. (2016). Types of debriefing following disasters. 

Retrieved from https://www.ptsd.va.gov/professional/trauma/disaster-terrorism/debriefing-after-disasters.asp

Wade, D., Crompton, D., Howard, A., Stevens, N., Metcalf, O., Brymer, M., . . . Forbes, D. (2014). Skills for 

Psychological Recovery: Evaluation of a post-disaster mental health training program. Disaster Health, 2(3–4), 

138–145. doi: 10.1080/21665044.2015.1085625

Wagner, J., Burke, G., Kuoch, T., Scully, M., Armeli, S., & Rajan, T. V. (2013). Trauma, healthcare access, and health 

outcomes among Southeast Asian refugees in Connecticut. Journal of Immigrant and Minor Health, 15(6), 

1065–1072. doi: 10.1007/s10903-012-9715-2

Wu, P., Duarte, C. S., Mandell, D. J., Fan, B., Liu, X., Fuller, C. J., . . . Hoven, C. W. (2006). Exposure to the World 

Trade Center attack and the use of cigarettes and alcohol among New York City public high-school students. 

American Journal of Public Health, 96(5), 804–807. doi: 10.2105/ajph.2004.058925

Yehuda, R., & Hyman, S. E. (2005). The impact of terrorism on brain, and behavior: What we know and what we need 

to know. Neuropsychopharmacology, 30(10), 1773–1780. doi: 10.1038/sj.npp.1300817

Zemishlany, Z. (2012). Resilience and vulnerability in coping with stress and terrorism. Israel Medical Association 

Journal, 14(5), 307–309.