Early Mental Health Intervention Reduces Mass Violence Trauma

Early psychological intervention guided by qualified mental health caregivers can reduce the harmful psychological and emotional effects of exposure to mass violence in survivors, according to a national conference report released today. Experts emphasized that although more research is needed, existing data, including studies of other kinds of traumatic events, as well as clinical experience, provide useful guidance to the mental health community in responding to mass violence.

"School violence, shootings in the workplace, and terrorist acts have increased Americans' exposure to mass violence during the past decade, and psychological interventions are increasingly among the first responses to it. It is vital to the health and well-being of the American people that effective interventions reach the people who need them in a timely and efficient manner," said LTC (Dr.) Elspeth C. Ritchie, U.S. Army, chairperson of the planning committee for the conference.

The report calls on the scientific community to develop a national research program to examine the relative effectiveness of early mental health interventions following exposure to mass violence. Early intervention is defined as any form of psychological intervention delivered within the first four weeks following mass violence or disasters. Examples of early interventions include brief, focused psychotherapeutic intervention and selected cognitive behavioral approaches.

The report says that some interventions—including mass education via media outlets—although beneficial, have the potential for unintended harm. The report recommends that the leadership select professionals who have the training, expertise, accountability, and responsibility required to provide these interventions. Also, the report cites some evidence that early intervention in the form of a single one-to-one recital of events and discussion of emotions evoked by a traumatic event does not consistently reduce risk and may even put some survivors at heightened risk for later developing mental health problems.

The report is targeted to those who deliver these interventions to emotionally distressed persons following mass violence, to those who research these issues, and to employers who want to help workers who have experienced this type of emotional trauma. It is also intended to aid officials who must decide what mental health help to include in the local, state, and national responses to survivors of mass violence and terrorism. Prepared by 58 mental health researchers and clinicians from the U.S. and five other countries, the report details what is effective, what is not, and what questions require further research.

The report provides guidance on screening for mass violence trauma-related mental health problems, on follow-up with trauma-exposed persons, and on the expertise, skills, and training for providers of early intervention services. The report also addresses what is known about timing for various types of early interventions.

Participants agreed that it is sensible to expect persons to recover from the trauma of mass violence, although some groups may be more vulnerable, such as those with preexisting mental disorders. They also agreed that most survivors who show no clinically significant symptoms for approximately two months generally do not require follow-up and that participation of survivors in early intervention sessions should be voluntary.

The report includes an outline of a sample training program for an early intervention workforce. Recognizing that persons who arrive first at a scene of mass violence may not be trained to provide early mental health interventions, participants recommended that early response personnel be trained to make appropriate referrals when additional expertise is needed. MFT CEUs
Entitled “Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence. A Workshop to Reach Consensus on Best Practices," the report was developed by the National Institute of Mental Health (NIMH) at the National Institutes of Health in the U.S. Department of Health and Human Services, the U.S. Departments of Defense, Justice, and Veterans Affairs, and the American Red Cross.

Mental Health and Mass Violence

Americans have been exposed to increased levels
of mass violence during the past decade. School
violence, shootings in the workplace, and terrorist
acts both here and abroad—all have affected
individuals, families, communities, and our
country. This report addresses the urgent need to
evaluate the various psychological interventions
that are increasingly among the first responses to
these traumatic events. MFT Continuing Education
At a workshop, 58 disaster mental health experts from
six countries were invited to address the impact of
early psychological interventions and to identify
what works, what doesn’t work, and what the
gaps are in our knowledge. Prior to the workshop,
leading mental health research clinicians from the
United States, Australia, and the United Kingdom
prepared a review of the published, peer-reviewed
literature (tables appear in Appendix G and
references appear in Appendix I).
For the purpose of this workshop and report, an
early intervention is defined as any form of
psychological intervention delivered within the
first four weeks following mass violence or
disasters. Once established, services may remain
in place for the long term. Mental health
personnel will provide some of the components of
early intervention, while other components have
mental health implications but will be provided by
non-mental health personnel.
Workshop participants examined research on
critical issues related to the following questions:
What early interventions can be recommended
in mass violence situations?
What should the key operating principles be?
What are the issues of timing of early
intervention?
What is appropriate screening?
What is appropriate follow-up, for whom,
over what period of time?
What expertise, skills, and training are
necessary for early interventions, at what
level of sophistication?
What is the role of research and evaluation?
What are the ethical issues involved in early
interventions?
What are the key questions for the field of
early intervention that have not yet been
thoroughly researched?
There was general majority consensus among
participants on many points. Where significant
differences in opinion existed, participants were
invited to provide minority opinions (see
Appendix F). Some of those issues have been
reframed as research or ethical questions that can
benefit from further scientific inquiry and
discourse (see pp. 11-12).

Area of Consensus
Key Operating Principles of
Early Intervention
Workshop participants identified key components
of early psychological interventions as including
preparation, planning, education, training, and
service provision evaluation. It is essential that
these components be operationalized and used for
service delivery, research, education, and
consultation activities. Participants also indicated
that early mental health assessment and
intervention should focus on a hierarchy of needs,
e.g., survival, safety, food, shelter, etc. (see
Appendix A).
Conference participants agreed that:
A sensible working principle in the immediate
post-incident phase is to expect normal
recovery;
Presuming clinically significant disorder in
the early post-incident phase is inappropriate,
except when there is a preexisting condition;
Participation of survivors of mass violence in
early intervention sessions, whether
administered to a group or individually,
should be voluntary.
The term “debriefing” should be used only to
describe operational debriefings (see Appendix
D). Although operational debriefings can be
described as “early interventions,” they are
done primarily for reasons other than
preventing or reducing mental disorders.
Guidance on Best Practice Based
on Current Research Evidence
Thoughtfully designed and carefully executed
randomized controlled trials have a critical role in
establishing best practices. There are, however, few
randomized controlled trials of psychological
interventions following mass violence. Existing
randomized controlled trial data, often from studies
of other types of traumatic events, suggest that:
Early, brief, and focused psychotherapeutic
intervention can reduce distress in bereaved
spouses, parents, and children.
Selected cognitive behavioral approaches may
help reduce incidence, duration, and severity
of acute stress disorder, post-traumatic stress
disorder, and depression in survivors.
Early interventions in the form of single oneon-
one recitals of events and emotions evoked
by a traumatic event do not consistently
reduce risks of later post-traumatic stress
disorder or related adjustment difficulties.
There is no evidence that eye movement
desensitization and reprocessing (EMDR) as
an early mental health intervention, following
mass violence and disasters, is a treatment of
choice over other approaches.
Other practices that may have captured public
interest have not been proven effective, and some
may do harm.