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In the first two weeks after the Sandy Hook Elementary School shootings last year, more than 800 anguished people streamed through the main crisis counseling center in Newtown, Conn.
Since then, visits to the Newtown Youth and Family Services agency have nearly doubled, and the center has tripled in size to handle the aftermath of horror and heartbreak following the massacre that left 26 people, mostly children, dead.
“We continue to see clients with depression, anxiety, PTSD,” Candice Bohr, who runs the program, told NBC News. “Big increase in anxiety, anxiety disorders, children’s behavior issues, marital discord and stress management.”
Bohr said she believes that early intervention and extended care comforted her neighbors — including victims of the violence and others. “It makes a difference and we have seen it make a positive impact in people’s lives,” she said.
But how to treat the psychological wounds of such catastrophe is actually not at all clear. New research has debunked certain kinds of disaster crisis counseling and raised a thorny question: After senseless tragedy, can anything really help?
“In the first few days, you don’t even know your name,” said Patti Trentini, 53, of Irvine, Calif., whose parents both died on doomed Flight 11 on 9/11. “For the first six months, I was just so devastated, so angry. Until you’ve walked in their shoes, no matter what any doctor or PhD says, you can’t know.”
Early mental health response after a crisis is a relatively new field — and a controversial one, said James Halpern, director of the Institute for Disaster Mental Health at the State University of New York New Paltz and author of a book on the topic.
A practice used for years starting in the 1980s, known as psychological debriefing, forced trauma victims to recount the events and express their emotions in strictly structured sessions. It was widely regarded as cutting-edge treatment, until research revealed it didn’t help — and might actually harm the psychological recovery of victims. The World Health Organization has since denounced the protocol.
“What we should be doing is promoting safety and calm and social support and self efficacy — and hope,” said Halpern, who was among some 20 American Red Cross mental health volunteers sent to the Sandy Hook crisis, and one of six who worked directly with parents and others who lost loved ones.
“People were so burned by debriefing that there’s a lot of caution now,” he said. “People are absolutely committed to not being burned again on this.”
There’s a new model now, adopted by the Red Cross and other agencies, known as psychological first aid, which has good evidence to support responding to victims with kindness, compassion and practical assistance — but not necessarily discussion or “processing” of the event.
“One of the things we’ve learned is you don’t do therapy onsite,” said David Kaplan, chief professional officer for the American Counseling Association. “What you are there for, more than anything else, is to identify those who are having real difficulty.”
Most of those affected by a disaster will experience distress, but only about 2 percent will go on to develop severe psychological problems such as depression or post-traumatic stress disorder (PTSD), Kaplan estimated.
That’s the point of another focus, psychological triage, which works to identify the people most at risk of psychic harm after a crisis, said Merritt Schreiber, director of psychological programs in emergency medicine at the University of California, Irvine, School of Medicine.
He said that research shows PTSD actually may affect between 30 percent and 40 percent of direct victims of trauma and that it's important to reach them fast.
“We want to target high-risk people early,” said Schreiber, who also responded after the Newtown shootings. He’s developed a model, PsyStart, in which people are triaged to mental-health care within hours after a disaster, in much the same way that the most physically injured people are triaged to medical care.
“The message is one size does not fit all. We have really good treatments available and the challenge is to identify people who need more and connect them with an appropriate level of service.”
If people are identified and matched with care within a so-called “golden month,” 30 days after the trauma, they’re less likely to develop crippling PTSD or other problems, he said.
There’s good clinical research to support early intervention, and good evidence that certain psychological treatments, such as trauma-focused cognitive behavioral therapy, or TF-CBT, actually work to decrease psychological problems, the experts say.
But they also admit they’re still waiting for the research that confirms the best approach after actual disasters.
“When you talk about real-world events, we don’t have adequate science at the moment to inform us,” Schreiber said.
A new nearly $1 million project offered through the National Institutes of Mental Health aims to change that, offering social scientists like Schreiber the chance to design disaster mental-health interventions — and then test them in real-time crises.
“That’s what we need. We need to do prospective work,” he said.
In the end, experts and victims alike say that there’s no one way to help people who’ve been through unspeakable events such as the Newtown shooting.
Trentini said that a dozen years later, she remembers only a few things that helped ease the grief of losing her parents, James and Mary Trentini of Everett, Mass.
“There was one person who was just kind,” Trentini said. “She just came and sat with me and held on.”
That woman turned out to have lost a child in the April 1995 Oklahoma City bombings.
“It never really ends,” Trentini said. “The people I got the most from were people who had been through something just as bad.”
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JoNel Aleccia is a senior health reporter with NBC News. Reach her on Twitter at @JoNel_Aleccia or send her an email.