Post-Violence Outreach

Evidence is clear that firearm injury and death, including homicide and suicide, can have significant mental health and social impacts on victims, their family and friends, and their communities^2,3,4,5,6.

While not limited to firearm violence, findings from the National Crime Victimization Survey highlight the tremendous impact of violent crime on the lives of victims, including negatively impacting victims’ social and emotional well-being as well as causing issues in their relationships with friends and family, at work and at school⁷. A qualitative study of adults treated for unintentional or assault-related firearm injuries at an emergency room trauma center found that, even within a small group of adults, survivors have varied experiences, needs and outcomes³. Survivors in the study experienced psychological-related problems, changes in relationships and, for a few, a new sense of purpose³. People who experience firearm injuries are also at increased risk for increased substance and alcohol use, post-traumatic stress disorder (PTSD), future firearm-related injury, crime and death. These findings point to the urgent need for post-violence intervention for victims.

Impact of firearm violence extends to the people who are close to the victim. In a study that connected Medicaid claims and police data on nonfatal shootings in Indianapolis, Indiana, researchers looked at the prevalence of mental health issues for victims of nonfatal shootings and their family members in the 12 months prior to and 12 months after a firearm incident and then compared to prevalence of mental health issues in other Medicaid covered individuals². Youth family members and adult victims experienced the most significant increases in the prevalence of mental health issues. For youth family members of nonfatal shooting victims, the prevalence from before and after the shooting of the following mental health issues increased: any mental health diagnosis, disruptive behavior disorders, stress and anxiety disorders, depression and mood disorders, and substance use disorders. Adult victims had increases in prevalence for any mental health diagnosis, stress and anxiety disorders, depression and mood disorders, and substance use disorders. These results highlight the need to include family members in post-violence interventions.

Impact of firearm violence extends to those exposed to firearm violence in the community. A study examining the mental health impacts of exposure to firearm violence fatalities on racially and ethnically diverse adults in four large urban cities in the U.S. found that 24% of all participants reported exposure to firearm violence fatalities⁶. There were significant differences between groups, with Black (three times) and Latinx (two times) participants more likely than White respondents to have been exposed to firearm violence fatalities. These results underscore the need for targeted mental health interventions and further investigation into firearm violence as a social determinant of health. The intersection of race, cumulative violence, and adverse mental health outcomes necessitates a comprehensive understanding of how exposure to such tragedies affects individuals’ psychological well-being⁶.

Suicide attempts and deaths also have significant mental health impacts on individuals, friends and family members, co-workers, and community members^4,5. In the U.S. Department of Health and Human Services’ evidence-driven National Strategy for Suicide Prevention, authors offer that individuals who have attempted suicide and others who have been impacted by a suicide or suicide attempts can experience challenges including:

• new or worsened mental health concerns, such as anxiety and depression
• guilt
• social isolation
• the surfacing of unresolved or new risk(s) for suicide
• physical and/or emotional scars
• stigmatizing or discriminatory reactions toward the person who died or attempted suicide or toward their family and friends
• practical concerns resulting from the attempt or death such as financial worries
• unsafe communication or media reporting about the event
• additional suicides, including in rare instances, suicide or suicide attempt clusters⁵

The significant impact that firearm injury and death have on people’s lives highlights how critical post-violence intervention, or “postvention”, is for the health and well-being of victims, survivors, family and friends, and community members. Postvention includes debriefing, counseling, and other outreach and support, and should be provided in a culturally relevant way⁵. Family and social support, mental healthcare, and financial support services are important aspects of post-firearm injury support³. Trauma-informed and culturally competent services are invaluable for both neighborhoods and individuals exposed to firearm community violence and suicide.

Given the impact on people exposed to mass shooting violence, in schools and the community, and some of the barriers to accessing support, crisis line outreach should establish ongoing relationships with community organizations, schools, first-responders, news organizations, and local government so that those institutions and trusted messengers can share crisis line resources in the aftermath of a school or community mass violence event. Pre-existing relationships and open communication could help crisis line staff stay updated on relevant information or resources for survivors of community violence, e.g. reunification sites, resources.

According to the evidence-driven National Strategy for Suicide Prevention, best practice for suicide postvention includes engaging other community members, community organizations, and people with lived experience of suicide to inform, improve, and implement postvention efforts as they have community knowledge, connections, and unique insights to offer⁵.

The Suicide Prevention Resource for Action: A Compilation of the Best Available Evidence developed by the CDC’s National Center for Injury Prevention and Control included evidence-informed suggestions for postvention ⁴. Current evidence suggests that postvention and safe reporting and messaging can impact risk and protective factors at individual and community levels. They suggest two approaches to lessen harm and prevent future risk: 1) proactively and comprehensively supporting the needs of those impacted, and 2) ensuring safe reporting and messaging.

In the StandBy Support After Suicide program in Australia, a professional crisis team provides case management, outreach, telephone support, and referrals to community resources based on the needs of the individual. Studies of the program found that participants were less likely to experience suicidal ideation and social loneliness compared to similar groups that were not receiving services from the program⁴. Studies of two other programs initially developed for complicated grief and family bereavement have also found initial effectiveness in reducing suicidal ideation and attempt⁴.

Following an incidence of firearm violence or suicide, easily accessible, free and confidential support services, such as crisis lines, are important resource for helpseekers. According to findings from the nationally-representative (U.S.) Suicide Prevention Survey, adults see health and mental health professionals and mental health hotlines as trusted resources in coping with suicide⁸. However, most adults (83%) had never used a crisis line and about two thirds (68%) reported at least one barrier to reaching out to a crisis service, with top barriers including cost (25%), lack of confidence in service in their area (23%), and lack of insurance (22%). Given these findings, engaging trusted messengers to increase awareness of crisis lines services in the community before and after an incidence of violence or suicide is important, especially communicating that the services are free and do not require insurance.

Safe reporting and messaging in postvention on firearm violence and suicide can enhance individual and community protective factors against additional harm⁴. An international systematic review and meta-analysis found that following best practices for reporting on suicides, including avoiding sensationalist reporting and holding up positive coping skills and capacity in navigating crisis situations, has been associated with significant decreases in suicide rates post reporting⁴. A study on best practices for language to talk about firearm injury and death, including suicide, homicides and unintentional shootings aimed to develop “culturally respectful, conversation-promoting language related to firearms, suicide by firearm, and community violence involving firearms⁹.” The language used in addressing, collaborating on, and messaging for preventing firearm injury and deaths makes a difference in people receiving those messages. Findings from the study suggest the following rephrasing and framing:

• use of “firearm” instead of “weapon”
• acknowledge many firearm owners have an interest in and commitment to safety
• use of “death by suicide” instead of “committed suicide” in order to remove judgement and reduce stigma
• talk about “communities that are disproportionately affected by violence”
• use of “formerly incarcerated,” “justice involved,” or “people who use violence”⁹

1. Suicide Prevention Resource Center (n.d.). Provide for immediate and long-term postvention. Retrieved from https://sprc.org/effective-prevention/a-comprehensive-approach-to-suicide-prevention/provide-for-immediate-and-long-term-postvention/
2. Magee, L. A., Aalsma, M. C., Fortenberry, J. D., Gharbi, S., & Wiehe, S. E. (2022). Mental health outcomes from direct and indirect exposure to firearm violence: A cohort study of nonfatal shooting survivors and family members. Journal of Criminal Justice, 83, 101961. https://doi.org/10.1016/j.jcrimjus.2022.101961
3. Hink, A. B., Atkins, D. L., & Rowhani-Rahbar, A. (2022). Not all survivors are the same: Qualitative assessment of prior violence, risks, recovery and perceptions of firearms and violence among victims of firearm injury. Journal of Interpersonal Violence, 37(15–16), NP14368–NP14396. https://doi.org/10.1177/08862605211005157
4. Centers for Disease Control and Prevention [CDC]. (2022). Suicide Prevention Resource for Action: A Compilation of the Best Available Evidence. Retrieved from https://www.cdc.gov/suicide/pdf/preventionresource.pdf
5. U.S. Department of Health and Human Services [HHS]. (2024). National Strategy for Suicide Prevention. Retrieved from https://www.hhs.gov/sites/default/files/national-strategy-suicide-prevention.pdf
6. Smith, M. E., Sharpe, T. L., Richardson, J., Pahwa, R., Smith, D., & DeVylder, J. (2020). The impact of exposure to gun violence fatality on mental health outcomes in four urban U.S. settings. Social Science & Medicine, 246, 112587. https://doi.org/10.1016/j.socscimed.2019.112587
7. Coen, E., & Thompson, A. (2024). Socio-emotional Consequences of Violent Crime, 2022. Department of Justice. Retrieved from https://www.ojp.gov/library/publications/socio-emotional-consequences-violent-crime-2022
8. American Foundation for Suicide Prevention, National Alliance for Suicide Prevention, & Suicide Prevention Resource Center. (2024, October). Public Perceptions of Mental Health and Suicide Prevention Survey Results. Retrieved from https://suicidepreventionnow.org/documents/executive-summary-2024.pdf
9. Betz, M. E., Harkavy-Friedman, J., Dreier, F. L., Pincus, R., & Ranney, M. L. (2021). Talking about “firearm injury” and “gun violence”: Words matter. American Journal of Public Health, 111(12), 2105–2110. https://doi.org/10.2105/AJPH.2021.306525

• The American Foundation for Suicide Prevention Healing Conversations program provides support for people impacted by suicide loss. They offer a one-time visit through phone, virtually, or in-person with trained volunteers who are survivors of suicide loss. 

• The Local Outreach of Suicide Survivor (LOSS) Teams program consist of people with suicide-centered lived experiences who are trained in trauma-informed crisis response and are called into different settings when a suicide loss occurs, e.g. community organizations, schools, and churches. LOSS teams operate in many different communities. Of note, LOSS teams more often operate in denser population centers. 

• Drawing on knowledge from research and clinical practice, along with input from trauma survivors, the Substance Abuse and Mental Health Services Administration [SAMHSA]’s Concept of Trauma and Guidance for a Trauma-Informed Approach provides an overview of trauma, draws connections between trauma and behavioral health, and provides guidance for a trauma-informed approach.
• The National Institute of Mental Health’s Helping Children and Adolescents Cope with Traumatic Events provides information for family, friends and trusted adults supporting children through traumatic events.
• The National Institute of Mental Health’s Post-Traumatic Stress Disorder provides an overview of Post-Traumatic Stress Disorder, or PTSD, and guidance for treatment and seeking help.
• The Suicide Prevention Resource Center’s website includes a number of short- and long-term postvention resources, including toolkits for postvention in specific settings, for example, After a Suicide: A Toolkit for Schools.
• The Action Alliance Survivors of Suicide Loss Task Force developed the Responding to Grief, Trauma, and Distress after a Suicide: U.S. National Guidelines as a call to action to create the resources, services, and systems needed for effective response to suicide.
• The Reporting on Suicide’s website frames suicide as a public health issue and provides resources, research and guidelines on media coverage and reporting after a suicide, including Recommendations for Reporting on Suicide. The website includes guidance in multiple languages and shares examples of best practice reporting.