In a Nutshell

• School shootings negatively impact the mental health of young people across the country, whether or not an individual has directly experienced a mass shooting.
• Health promotion efforts are needed to address the collective trauma that young people experience.
• Trauma-informed health promotion campaigns could help deliver health education and provide support to a wide-range of adolescents and young adults and can create an inclusive, broad understanding of who can benefit from mental health services. 

Introduction

The public conversation has been overtaken by the implications of yet another mass school shooting.  The two most common themes in response to the recent shooting at Michigan State University – gun control and mental health – have dominated most of the public discussion, and for good reason.  While much of the conversation around mental health and gun violence is related to mental health issues as a potential cause of gun violence, the other side of the equation is a growing mental health crisis among America’s adolescents and young adults who are weighed down by the constant threat of a mass shooting.  

While statistically only a relatively small percentage of adolescents and young adults will experience a mass shooting at their school, every single young person is enduring the collective trauma of living under this ever-present threat and participating in active shooter drills in case it occurs in their schools.  In addition to policies that focus on preventing gun violence, Michigan should pursue ones that support and address the mental health needs of millions of adolescents and young adults who are coping with the reality and expectation of living through, or dying from, a mass shooting. 

School Shootings and Youth Mental Health

Many studies report a rise in mental health symptoms among adolescents and young adults in the U.S.  About half of all 18 to 25 year olds reported struggling with mental health in 2021, and nearly 20 percent of Michigan high school students reported seriously contemplating suicide.  Suicide is the second leading cause of death among 10- to 14-year-olds and the third leading cause of death among 15- to 24-year-olds.  While teen suicide rates peaked in the early 1990s, most of the progress has been reversed over the last decade. Teens suffering from depression and anxiety, particularly when untreated, are vulnerable to a host of poor health and social outcomes, including risky behavior, low academic performance, and substance abuse.

While many factors contribute to the growing need for youth mental health services, there is evidence that school shootings in particular have had their own sizable impact on youth mental health.  A 2018 PEW survey found that 57 percent of 13- to 17-year-olds are either very or somewhat worried about the possibility of a school shooting happening at their school.  Further, research has found that students who attend school near a school that experienced a fatal school shooting were prescribed antidepressants at a higher rate than those who attended school farther away.  For students that attended a school where a shooting actually took place, the consequences are starker.  For instance, in addition to direct adverse mental health effects, shootings negatively impact enrollment, attendance, academic performance, graduation rates, employment, and future earnings.

Youth Mental Health Services

Like much of the health care system, treatment for mental and behavioral health issues generally requires a person needing care to initiate the process and seek a qualified professional.  Services are generally offered or provided after a recognition or demonstration that an individual needs care.  This kind of ad hoc response is particularly problematic for mental health issues, as conditions such as depression and anxiety can make one less likely to take the proactive measures necessary for treatment.  The process can be defeating for many adults and can be even more daunting for young people.  While some schools offer or provide services through school-based health centers, these operate similarly in that they target students with a demonstrated needs – they do not address the collective need for mental health attention.  Further, Michigan struggles with provider shortages, including falling short of the recommended ratio of students to school health professionals. 

While adolescents and young adults have some access to mental health treatment, the systems are not designed to provide robust, proactive care for a population that is very much in need, especially during acute traumatic events.  We often see a very strong response in the aftermath of a school shooting in which crisis counseling centers are set up and professionals are called in to volunteer their time to meet the immediate, acute need.  Offering these services to the recently traumatized students, which occurred following the Oxford High School and MSU shootings, is essential, but it does not address the chronic mental and emotional toll taken on adolescents and young adults who live everyday asking themselves, “are we next?”

Trauma-Informed Health Promotion

Health promotion, prevention, treatment, and maintenance are all a part of the continuum of interventions for mental health disorders.  Because adolescents and young adults are experiencing a collective trauma, public health efforts should be focused on promotion and prevention as much as, if not more, than treatment and maintenance.   While prevention efforts such as screenings can potentially identify risk factors that make adolescents and young adults more likely to commit violence or engage in other unhealthy behaviors, health promotion efforts can benefit everyone, whether or not they have symptoms of a mental health disorder. 

Some of the leading health promotion efforts targeting youth mental health are anti-stigma campaigns, which are a form of health promotion that address some of the cultural and societal barriers that prevent people from seeking mental health treatment.  Studies show that social perceptions regarding mental health – that needing mental health treatment is a sign of weakness, that it is embarrassing, that nothing can be done, etc. – can act as major barriers to treatment for young people, sometimes even more than structural barriers, such as cost, access, and provider availability.  Anti-stigma campaigns work to change these public perceptions to normalize mental health treatment as something that is necessary for everyone, not just those with select disorders. 

Anti-stigma campaigns are generally education-based, contact-based, or protest-based, and there is mixed evidence as to their effectiveness in long-term behavior change.  A meta-analysis of anti-stigma campaigns found that these campaigns, particularly ones that are education-based, often have unintended negative consequences that further marginalize those with mental illness (known as “othering”).  The study calls for novel approaches to anti-stigma campaigns that can call attention to mental health issues and normalize them at the same time. This is particularly relevant in the mass shooting context, as the adolescents and young adults who are experiencing mental health issues in response to mass shootings are having a relatively normal reaction that is less likely to be stigmatized, but requires intervention, nonetheless.

Trauma-informed health promotion is one potential strategy that could be particularly beneficial for adolescents and young adults coping with the collective trauma of mass shootings.  “Trauma-informed care” generally refers to any health service delivery approach that centers on an understanding of and responsiveness to trauma.  The primary goal of this approach is to promote physical and emotional safety by empowering individuals to define their needs and participate in shared-decision making for treatments.

Combining the principles of trauma-informed care with standard health promotion strategies could potentially achieve better results than the anti-stigma campaigns, as this particular mental health crisis calls for recognizing the ongoing, collective weight of mass shootings more than any individual’s circumstances.  While trauma-informed health promotion has not yet been systematically studied or taken off as standard practice, it is a concept that is beginning to receive recognition in the health promotion literature.

Unlike previous campaigns, a trauma-informed health promotion campaign would begin with a recognition of the collective trauma caused by mass shootings, and would advertise and promote the use of services under this framework.  Mental health services should be presented as something everyone needs because of events they experienced together, instead of focusing on treatments necessary for only certain individuals.

Health promotion campaigns should emphasize the following trauma-informed principles:

• Safety – Campaigns should promote and prioritize physical and emotional safety.  The goal of any campaign should be to provide comfort through education and support.  For example, while some fear-based campaigns can attract attention, health messages that focus on positivity and agency are likely to be more effective for a population experiencing trauma. 
• Trustworthiness and Transparency – Health messages should be founded in honesty and accuracy.  For example, campaigns should aim to inform adolescents and young adults with information regarding the likelihood of mass shootings and mental health needs.  The message should not minimize nor overexaggerate the actual risk, and should remain upfront about how shootings across the country may negatively impact their health.
• Peer Support – Campaigns should create a space for youth to connect with each other in some form.  For example, adolescents and young adults could be encouraged to use their own social networks as emotional support as a component of mental health treatment.
• Collaboration and Mutuality – Campaigns should attempt to involve different groups and organizations in disseminating important health messages.  Engaging different levels of the community ensures that mental health treatment becomes interwoven in students’ daily lives.  For example, schools and community organizations could be involved in disseminating and promoting material. 
• Empowerment, Voice, and Choice – The central message of any health campaign should be informed by the stories, needs, and goals of those it seeks to serve.  For example, a campaign could begin with interviews or focus groups from witnesses and survivors to determine the types of messaging and information that would be the most beneficial to their community.
• Cultural, Historical, and Gender Issues – The lives of adolescents and young adults are varied and complex, shaped largely by their diverse experiences with the world, and any campaign should be tailored accordingly.  While a large population is in need, a one-size-fits-all approach will be ineffective, and any promotion strategy should be culturally competent and intersectional. 

Deploying trauma-informed mental health promotion strategies does not require the heavy-lift of constitutional and statutory change.  While appropriations may be necessary to fund certain efforts, these activities can be undertaken by a wide variety of actors, including school districts, universities, local health departments, state agencies, and private and non-profit organizations working individually or collectively without building out entirely new programs or infrastructure.

While it does not appear that there are existing trauma-informed mental health campaigns related to mass shootings in the state, there are many aimed at promoting mental health for adolescents and young adults that could be expanded or adapted to facilitate trauma-informed health promotion.  At the state level, the School Safety and Mental Health Commission – enacted as part of the Fiscal Year 2023 budget – has a general mandate “to reduce youth suicides and strengthen the mental health of school-aged children, adolescents, and their families” that could easily incorporate a set of mass-shooting specific recommendations.  School districts have also been utilizing COVID-19 relief money on mental health expenditures and could expand general programs to include trauma-informed mass shooting related efforts. Additionally, efforts exist at the local and philanthropic level to consider mental health and violence directly which could include similar trauma-informed principles, although they have not directly invoked this strategy so far.

Conclusion

School shootings have become an expected part of the news cycle.  The normalization of the experience in no way makes it less traumatic to live through or to witness.  While the primary goal should be focused on preventing these tragedies, significant consideration must be given to the reality of the culture and the enormous toll it has taken, especially on adolescents and young adults.  The anxiety and dread of the mass-shooting era is everywhere, and everyone is need.  Public health efforts, particularly health prevention and health promotion strategies, should recognize that.