PROCEEDINGS PAPER
F amewo k o he ou each a e a school shoo ing and
he s uden s pe cep ions o he p o ided suppo
Tuija Tu unen
1,2
*, Henna Ha a uo i
3,4
, Jaakko J. Pihlajama¨ki
1
,
Mau i Ma unen
3,5
and Raija-Leena Punama¨ki
2
1
Hospi al Dis ic o Sou h Os obo hnia, Seina¨ joki, Finland;
2
Depa men o Psychology, School o
Social Sciences and Humani ies, Uni e si y o Tampe e, Tampe e, Finland;
3
Depa men o Men al
Heal h and Subs ance Abuse Se ices, Na ional Ins i u e o Heal h and Wel a e, Helsinki, Finland;
4
Depa men o Psychia y, Helsinki Uni e si y Cen al Hospi al, Helsinki, Finland;
5
Depa men o
Adolescen Psychia y, Helsinki Uni e si y Cen al Hospi al, Helsinki, Finland
Backg ound: A la ge numbe o be ea ed amily membe s, su i ing s uden s, and hei ela i es as well as
school s a and he wide communi y we e in need o psychosocial suppo as a esul o a school shoo ing in
Kauhajoki, Finland, 2008. A mul ile el ou each p ojec p o ided psychosocial ca e o he auma-a ec ed
amilies, s uden s, schools s a , and wide communi y o 2 yea s and 4 mon hs.
Objec i e: This a icle is wo old. Fi s , i p esen s he heo e ical a ionale behind he psychosocial suppo and
desc ibes he mul imodal elemen s o he se ices. Second, i analyzes he auma-exposed s uden s’ help-seeking
beha io and pe cep ions o he use ulness o he suppo hey we e o e ed in di e en phases o eco e y.
Me hod: In o ma ion o s uden s’ help-seeking and pe cep ions o suppo is based on a ollow-up da a om
4 mon hs (T1, N236), 16 mon hs (T2, N180), and 28 mon hs (T3, N137) a e he shoo ings. Mean age
o s uden s was 24.9 (SD10.2; 95% women). Thei pe cep ions o he o e ed psychosocial suppo we e
collec ed wi h s uc u ed and open ques ions cons uc ed o he s udy.
Resul s: The esul s con i med he impo ance o enhancing he na u al ne wo ks a e a majo auma and
o e ing addi ional p o essional suppo o hose in g ea es need. The s uden s’ pe cep ions o he p o ided
ca e con i med ha he model o he acu e and long- e m ou each can be used a e majo agedies in
di e se si ua ions and in o he coun ies as well.
Keywo ds: School shoo ing;psychosocial suppo ; auma;you h;be ea ed amilies
Responsible Edi o : G e e Dyb, No wegian Cen e o Violence and T auma ic S ess S udies, NKVTS, No way.
*Co espondence o: Tuija Tu unen, Hospi al Dis ic o Sou h Os obo hnia, Huh alan ie 53, FI-60220
Seina
¨joki, Finland, Email: uija. u unen@epshp. i
Fo he abs ac o ull ex in o he languages, please see Supplemen a y iles unde A icle Tools online
This pape is pa o he Special Issue: Unde s anding e o and iolence in he li es o child en and
adolescen s. Mo e pape s om his issue can be ound a h p://www.eu ojnlo psycho auma ol.ne
Recei ed: 15 Oc obe 2013; Re ised: 9 June 2014; Accep ed: 10 June 2014; Published: 2 July 2014
The accumula ed knowledge abou sho - and long-
e m consequences o a mass auma is inco po a ed
in se e al e idence-based and e idence-in o med
guidelines and consensus s a emen s o psychosocial
ca e a e disas e s (Call, Pe e baum, Jenuwine, & Flynn,
2012; Hob oll e al., 2007; NICE, 2005; P e e baum,
Shaw, & AACAP, 2013; TENTS, 2008). The guide-
lines emphasize bo h p omo ing esilience and ea ing
p olonged psychological dis ess a e auma ic e en s
and sys ema ic planning and managemen o ca e.
They also a gue o he use ulness o speci ic elemen s
o in e en ions in immedia e, acu e, and ongoing
phases o eco e y. In he ea ly- o mid- e m s ages o
mass auma a e ca e, he aim is o loca e he mos
ulne able and needy and o p o ide in o ma ion and
psychoeduca ion in o de o p omo e su i o s’ sense o
sa e y, o calm down hype a ousal, and o acili a e eel-
ings o belongingness and communi y e icacy (Hob oll
e al., 2007).
Suppo and se ices should be a ailable o bo h
amilies and indi iduals, and he in e en ions should be
based on assessed physical, psychological, and social
needs o he ecipien s. Psychoeduca ion p o ides balan-
cing e ec s, in o ma ion, and assu ance; opics can in-
clude common eac ions o auma, access o se ices,
and sel -help me hods (TENTS, 2008). Acco ding o he
PSYCHOTRAUMATOLOGY
EUROPEAN JOURNAL OF
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Ci a ion: Eu opean Jou nal o Psycho auma ology 2014, 5: 23079 - h p://dx.doi.o g/10.3402/ejp . 5.23079
(page numbe no o ci a ion pu pose)
guidelines, in he la e phases o eco e y, he p o ided
ca e in ol es mo e he apeu ic elemen s and is ailo ed
acco ding o su i o s’ and amilies’ unique needs. When
psycho he apy is used, T auma Focused Cogni i e Beha-
io al The apy and Eye Mo emen Desensi iza ion and
Rep ocessing (EMDR) a e p io i ized (TENTS, 2008;
Wo ld Heal h O ganiza ion [WHO], 2013).
Ac i a ing he su i o s’ na u al suppo sys ems is
one o he p ima y aims o p o essional a e ca e, as
social suppo has been ound o be a majo p o ec i e
ac o in he eco e y p ocess (B ewin, And ews, &
Valen ine, 2000). The iming and na u e o su i o s’
esponses and men al heal h p oblems di e , and he e-
o e he emphasis is on he long- e m ailo ed ca e and
in e en ions e en o se e al yea s (Hob oll e al., 2007;
TENTS, 2008). A e a shoo ing inciden , he school is a
na u al en i onmen o p o ide psychosocial suppo o
auma-a ec ed s uden s and o iden i y hose in need
o in ensi e suppo (P e e baum e al., 2013). Rescue
wo ke s and heal h ca e p o essionals a e unde in ensi e
s ess a e mass auma such as a school shoo ing and
ou each p og ams should include p e en ion o ica -
ious auma iza ion (Galea, Nandi, & Vlaho , 2005;
TENTS, 2008).
Kauhajoki school shoo ing
In Sep embe , 2008, a s uden o Seina
¨joki Uni e si y o
Applied Sciences en e ed he school building in Kauhajoki
a med wi h a hand gun and opened i e indisc imina ely.
He sho o dea h nine o his classma es and a eache
and h ea ened se e al o he s. He also se i es and
damaged he p emises. O he s uden s and he school
s a managed o escape om he building (Minis y o
Jus ice [MOJ], 2010). The majo i y o he s uden s we e
emales aged be ween 15 and 25. A he ime o he
shoo ing, he e we e app oxima ely 260 s uden s and 40
s a membe s inside he school.
The eme gency si ua ion ollowing he shoo ing las ed
se e al hou s in he own o Kauhajoki and e e y school
in he icini y was ale ed. The s uden s we e kep inside
hei school buildings o se e al hou s, because o he
po en ial dange . Malicious h ea s ia SMS-messages
owa d o he schools in he Sou h Os obo hnia a ea
sp ead quickly, as did umo s o possible new massac es.
Subsequen ly o he school communi ies also expe ienced
he e o caused by he massac e. Thei need o psycho-
social suppo was also acknowledged. The agedy was
o e whelming o he police, escue wo ke s, heal h ca e
p o essionals, and o he au ho i ies, and hey needed
ex a supe ision and suppo .
Aims o he s udy
The e is li le esea ch abou he ways o deli e ing
heo y-based psychosocial ca e a e mass auma, and
abou ecipien s’ expe iences o he p o ided suppo .
The aim o his a icle was wo old:
1) To desc ibe he amewo k o a mul ile el ou each
model, which p o ided psychosocial ca e o he
amilies o he deceased, s uden s, and school s a ,
as well as he wide communi y in he a e ma h o
he school shoo ing agedy (pa 1).
2) To analyze he su i ing s uden s’ help-seeking
beha io and hei pe cep ions o he use ulness
and he healing elemen s o he mul i-le el suppo
(pa 2).
Pa 1: Implemen a ion o an ou each model
P epa a ion, managemen , and o ganizing c isis help
E e y municipali y in Finland is obliged o o e psycho-
social i s aid and suppo a e ca as ophes and
disas e s. This ac i i y is commonly a anged by he local
c isis eams, o example, wi h psychologis s, gene al
p ac i ione s, and social wo ke s wi h expe ise in au-
ma ic s ess. The local c isis eams a e, howe e , in ended
o p o iding only he immedia e and acu e suppo .
As he need o long- e m suppo was an icipa ed a e
he school shoo ing, a mul idisciplina y p ojec was
ounded. The aim o he ou each was o ensu e ha
all auma ized pe sons and g oups would ha e access
o psychosocial suppo acco ding o hei needs and
phases o eco e y (Ala-aho & Tu unen, 2012; Tu unen
& Punama
¨ki, 2014). Table 1 p esen s examples o he
psychosocial suppo p o ided o he amilies o he
deceased, s uden s, school s a , and he wide commu-
ni y in he immedia e, acu e, la e , and ongoing phases o
eco e y.
Implemen ing psychosocial ca e a immedia e and
acu e phases
The ecipien s o he immedia e suppo we e he e ac-
ua ed s uden s, school s a , and amilies sea ching o
hei lo ed ones, as well as o he ci izens in shock. The
in e en ions included helping amilies o connec wi h
hei child en, p o iding ac s ega ding he si ua ion, and
gi ing in o ma ion abou he se ices ha we e a ailable
o hem. Fu he mo e, hey in ol ed moni o ing o e -
whelming and incon ollable auma eac ions, and p o-
iding suppo and medical assessmen o hose in need.
An ou pa ien c isis clinic p o ided se ices 24 hou s
a day o he i s 2 weeks and, ul ima ely, du ing o ice
hou s. A elephone ho line wi h heal h ca e specialis s
answe ing ques ions was open du ing he i s days, and a
websi e was launched o c isis suppo and in o ma ion.
Suppo o he amilies o he deceased
The ela i es o he deceased we e a a ge g oup o
psychosocial suppo , g ie counseling, and p ac ical
assis ance. They we e p o ided guidance, in o ma ion,
Tuija Tu unen e al.
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and psychoeduca ion abou common esponses o au-
ma and help ul coping. Addi ional psychosocial suppo
was a ailable o he amilies in he emo ionally cha ged
occasions, such as isi ing he scene o he massac e,
espec ing anni e sa ies, and a ending ials. Psycho he -
apy was o e ed o amily membe s who we e in need o
i acco ding o he clinical assessmen s, and p o ession-
ally led pee suppo g oup p ocess was used as a g oup
in e en ion o all he amilies o he deceased a he
ongoing phases o eco e y. The amilies we e o e ed i e
pee suppo ga he ings o e 2 yea s. These weekend-long
ga he ings consis ed o psychoeduca i e lec u es, pee
discussions, join e ening p og ams, as well as i uals o
longing and eco e y (Tu unen & Punama
¨ki, in p ess).
The amily o he pe pe a o also ecei ed psycho he -
apeu ic suppo , and a sepa a e g oup p ocess.
Suppo o he s uden s and school s a
The psychosocial suppo and se ices o he auma-
a ec ed school we e embedded in he school communi y’s
Table 1. The main elemen s o he psychosocial suppo p o ided o amilies, s uden s, and school s a acco ding o he le el o
in e en ions and phase o exposu e and eco e y
Families o he deceased S uden s and s a exposed o he shoo ings
Le el o
in e en ion Immedia e and acu e phase
La e and ongoing
eco e y Immedia e and acu e phase La e and ongoing eco e y
Indi idual Se ices o he c isis clinic
Suppo when isi ing he
scene o he massac e
P ac ical assis ance
Se ices o he c isis
clinic
Psycho he apies
Physio he apies
P ac ical assis ance
Se ices o he c isis
clinic
In e iews o assess he
se e i y o exposu e and
a ailable suppo
Se ices o he c isis clinic
In e iews o assess he need
o ex a suppo among he
mos se e ely exposed
Sc eening o he possible
pos auma ic eac ions a
2, 4, 16, and 28 mon hs
Heal h check-ups, medical
assessmen
Psycho he apies
Physio he apies and massage
Family G oup discussions
Suppo o amilies isi ing
he scene o he massac e
Telephone con ac wi h
e e y amily o ensu e he
su iciency and
app op ia eness o suppo
F equen con ac s by
elephone o assess he
unique needs o each
amily membe
Two home isi s o
assess he amily
si ua ion and needs
Suppo in emo ionally
demanding occasions
Family e enings a he
school
P o essionally led pee
suppo g oup p ocess
G oup In o ma ion abou he
se ices p o ided by he
Kauhajoki P ojec
Le e p o iding
psychoeduca i e
in o ma ion and an
in i a ion o join he pee
suppo g oup p ocess
P o essionally led pee
suppo g oup p ocess
Suppo in emo ionally
demanding si ua ions
Ri uals
G oup discussions
sepa a ely o he s a
and s uden s
Common sessions wi h
psychoeduca ion and
i uals
G oup discussions sepa a ely
o he s a and s uden s
Supe ision sessions o
eache s
Ri uals
Communi y Se ices o he c isis
clinic
G oup discussions in he
o he schools a he a ea
Pa en s’e enings in he
o he schools a he a ea
Media co e age wi h
psychoeduca i e and
calming con en
Se ices o he c isis clinic
Rein o ced you h wo k and
s uden wel a e
Comp ehensi e media
co e age a ound he i s
anni e sa y
Open doo s a he auma-
a ec ed school a e mo ing
back o he p emises
Ou each a e a school shoo ing
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e e yday li e in o de o make he access o se ices
as easy as possible. The ac ion plan was de eloped and
implemen ed in close coope a ion wi h he adminis a-
ion and s a o he school. Pa icipa ion in all se ices
was olun a y. The phase model o he suppo p o ided
o he auma-a ec ed s uden s and s a is summa ized
in Tu unen & Punama
¨ki (2014).
Indi idual suppo was p oac i ely o e ed especially
o hose who had a se e e auma exposu e and/o s ong
eac ions. Common sessions o he whole school com-
muni y we e conduc ed daily o he i s week o o e
p ac ical in o ma ion, psychoeduca ion, and join ac i -
i ies. Simila sessions we e a anged whene e inc easing
o auma- ela ed s ess was an icipa ed, ha is, mo ing
back o he eno a ed school, eleasing police epo s,
and he i s anni e sa y.
G oup discussions wi h psychoeduca i e con en we e
o e ed o s uden s and s a . The g oups ga he ed ini-
ially a couple o days a e he shoo ings, and h ee o
six imes du ing he mid- e m and ongoing eco e y
s ages. The g oups we e led by a c isis psychologis and
a psychia ic nu se. The psychoeduca ion in ol ed each-
ing s ess managemen echniques, no malizing o s ess
eac ions, and gene al knowledge o auma conse-
quences. In he s a g oups opics included also how
he auma may ha e an impac on academic pe o -
mance and how he eache s may help he s uden s o
egula e heigh ened emo ional a ousal. Acco ding o he
p inciple o wa ch ul wai ing (NICE, 2005) pos auma ic
s ess symp oms (PTSS) we e sc eened by heal h ca e
specialis s and a esea ch g oup a 2, 4, 16, and 28
mon hs. S uden s and s a exceeding clinically signi ican
le els o symp oms we e e e ed o he apeu ic se ices.
Teache s we e also o e ed supe ision.
A p o essionally led pee suppo g oup was also
conduc ed as a g oup in e en ion o he mos se e ely
exposed s uden s and hei amily membe s. I con ained
h ee 1-day-long wo kshops wi h psychoeduca i e in o -
ma ion; pee g oup discussions o pa en s, siblings, and
s uden s; and a isi o he school when he eno a ion
was comple ed. The i s mee ing ook place 3 mon hs
a e he agedy, he second a ound he i s anni e sa y,
and he las a ound he second anni e sa y.
Psychosocial se ices a he communi y le el
A e ca e se ices a he communi y le el we e ca ied ou
in coope a ion wi h he local au ho i ies such as you h
wo k and he managemen o he schools. The school
shoo ing also had an impac on he s uden s in he o he
schools in he a ea and he s uden wel a e sys ems we e
he e o e ein o ced in se e al school uni s. The media
was used as a means o p o ide in o ma ion o he
ci izens. The in o ma ion was psychoeduca i e in na u e,
and aimed a p omo ing pa en ing esou ces, no mal
ou ines, and social suppo .
Pa 2: Su i ing s uden s’ help-seeking beha io
and hei pe cep ions o he use ulness and he
healing elemen s o he mul i-le el suppo
Me hod
Pa icipan s and p ocedu e. Expe iences o he exposed
s uden s we e collec ed as a pa o a 2-yea ollow-up
s udy ca ied ou by he Na ional Ins i u e o Heal h
and Wel a e. The basic sample was 389 s uden s o he
exposed school, who we e app oached 4 mon hs a e
he shoo ing. The ac ual pa icipan s we e 236 s uden s
(60.7% esponse a e) a 4 mon hs a e he shoo ing (T1).
One- i h o he basic sample (20.1%; n78) declined
and ano he i h could no be eached (19.5%; n76).
The mean age o he pa icipan s was 24.9 (SD10.2),
and he majo i y we e emales (95%). The s uden s
pa icipa ed again a 16 mon hs’ (T2, n180) and 28
mon hs’ (T3, n137) ollow-up. The s udy p o ocol was
accep ed by he e hics commi ee o he Hospi al Dis ic
o Sou h Os obo hnia. Pa icipa ion was olun a y and
e e y pa icipan was asked o sign a w i en in o med
consen . The i s and second assessmen s we e ca ied
ou in he school and he hi d ollow-up ques ionnai e
was pos ed o he pa icipan s. The pa icipa ing s uden s
who epo ed high le els o PTSS o o he psychological
dis ess we e e e ed o he ou each se ices.
Measu es. The se e i y o auma exposu e was based
on he deg ee o h ea o li e and su e ed losses. A T1,
he s uden s answe ed yes o no o 19 ques ions con-
ce ning hei expe iences du ing he school shoo ings
(e.g., ‘‘I los a iend/ iends,’’ ‘‘I had o escape he
pe pe a o ,’’ o ‘‘I saw someone o ge sho ’’). The answe s
we e ca ego ized in o i e classes acco ding o he se e i y
o he exposu e including ca ego ies o ‘‘mild, mode a e,
signi ican , se e e, and ex eme exposu e’’ (Suomalainen
e al., 2011). ‘‘Mild exposu e’’ was a ed when he s uden
was no a he building a he ime o he shoo ings.
‘‘Mode a e exposu e’’ was a ed when a s uden e ac-
ua ed om he building wi hou being in a di ec li e
dange and did no lose any acquain ances. ‘‘Signi ican
exposu e’’ was when a s uden had o ac o escape he
shoo e , had o hide o a oid a dange o li e, saw bodies,
o los acquain ances. Exposu e was conside ed ‘‘Se e e’’
when a s uden was nea mo al dange , saw somebody
h ea ened wi h a gun, o los someone signi ican . When
he exposu e was a ed as ‘‘Ex eme’’ a s uden had been
in a mo al dange o saw someone being sho o los a
amily membe . Fo he analysis, a dicho omy a iable
was o med: (1) Se e ely o ex emely exposed s uden s,
and (2) Mildly o signi ican ly exposed s uden s.
The use o immedia e c isis suppo was assessed by
ou ques ions a T1: whe he he s uden was o e ed
c isis suppo immedia ely a e he inciden i espec i e
o he p o ide (yes/no), whe he hey had accep ed and
Tuija Tu unen e al.
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used any o he se ices (yes/no), and whe he hey had
a ended he sessions o he whole school communi y
(yes/no). Finally, s uden s we e asked abou hei pe cep-
ions abou he use ulness o he immedia e c isis suppo
using a 5-poin scale: 1helped a lo , 2helped enough,
3helped a li le, 4did no help, and 5hinde ed
eco e y. Repo ing 1 o 2 was eco ded as immedia e c isis
suppo being help ul, whe eas 3, 4, and 5 was eco ded
as immedia e c isis suppo no being help ul.
The use o psychosocial suppo a he acu e, la e , and
ongoing phases was assessed wi h 13 ques ions on he
sou ce and a ailabili y o suppo in all assessmen poin s
T1, T2, and T3. The sou ces o suppo we e g ouped
as social suppo om amilies and iends ( amily, o he
ela i es, iends), p o essional suppo (c isis wo ke s o
he school communi y, use o low- h eshold c isis clinic,
municipal heal h ca e cen e , s uden heal h ca e and/o
psychia ic ou pa ien clinics), and social suppo om
o he s ( eache s, you h wo ke s, wo ke s o he pa ish,
clubs, o ex acu icula ac i i ies). Conce ning he a ail-
abili y o di e en ypes o suppo , he s uden s es i-
ma ed whe he hey had ecei ed (1) no suppo , (2) some
suppo , (3) enough suppo , (4) oo much suppo , o (5)
had no been in e es ed in he p o ided suppo . Repo -
ing ‘‘ oo much’’ o ‘‘enough’’ suppo was a ed as ha ing
he suppo a ailable.
The pe cei ed e ec o he di e en ypes o psycho-
social suppo we e e alua ed wi h i e al e na i e
answe s (1) did no help, (2) canno say, (3) did help,
(4) was i i a ing, and (5) no in e es ed. Answe ing ‘‘did
help’’ was indica i e o pe cei ing he suppo help ul
while he o he al e na i e answe s we e indica i e o
suppo no being help ul. S uden s we e also asked i
hey had s a ed psycho he apy o egula mee ings wi h
heal h ca e p o essionals and whe he o no psycho he -
apy included EMDR. S uden s answe ed yes o no o
hese ques ions. The s uden s we e also asked abou he
ime when hey had s a ed psycho he apy.
S uden s’ pe cep ions o he p o essional suppo and i s
healing elemen s we e s udied wi h wo open ques ions.
S uden s answe ed a T1, T2, and T3 o ques ions:
‘‘Whe e did you ge he mos impo an help o you
auma ic and dis essing expe iences?’’ and ‘‘Wha
was he mos impo an eason o i s healing e ec .’’
The answe s indica ing p o essional suppo as being
help ul we e selec ed o u he analysis. Two code s
(a clinician and a esea che ) classi ied he answe s o
he ques ion ‘‘Wha was he mos impo an eason o
i s healing e ec ’’ in 10 ca ego ies acco ding o he
hemes o he answe s. The 10 ca ego ies we e hen e-
classi ied in o i e inal ca ego ies, which ep esen he
concep s o psychosocial suppo . The code s classi ied
he answe s sepa a ely and de ia ing sco es we e se led
by consensus.
S a is ical analyses
Dis ibu ions o he use and pe cep ion o psychosocial
se ices in immedia e and acu e phase we e p esen ed as
pe cen ages o ca ego ical a iables and as means (M)
and s anda d de ia ions (SD) o con inuous a iables.
Di e ences be ween he g oups (e.g., wi h di e en ex-
posu e se e i y) we e es ed using he chi-squa e es s and
analyses o a iance. In he analyses, wo- ailed signi i-
cance le els B.05 we e chosen. All analyses we e pe -
o med using SPSS 20.0.
Resul s
S uden s’ pe cep ion o he psychosocial suppo
Table 2 p esen s he use and pe cep ions o he di e en
ypes o psychosocial suppo in he immedia e, acu e,
la e , and ongoing phases o eco e y. A majo i y o he
s uden s (84.7%) had been o e ed immedia e c isis sup-
po wi hin he i s 24 hou s a e he e en s and 58.5% o
hem accep ed he suppo . Almos all o he s uden s
(92.4%, n110) who accep ed he suppo es ima ed ha
he suppo had helped hem ‘‘a lo ’’ o ‘‘enough.’’ Fu he -
mo e, mo e han wo- hi ds o he s uden s a ended he
common sessions o he whole school du ing he i s
week and mo e han hal a ended he g oup sessions.
Conce ning he se e i y o exposu e o school shoo ing,
all s uden s wi h se e e o ex eme exposu e o auma
had ecei ed he immedia e suppo , which s a is ically
di e ed om hose wi h less se e e exposu e (pB.05).
The e was no signi ican di e ence in pe cep ion o he
help ulness o he accep ed immedia e psychosocial sup-
po acco ding o he se e i y o he auma as epo ed a
T1. Simila ly, s uden s wi h se e e o ex eme exposu e
o auma used mo e p o essional psychosocial suppo
han he less se e ely exposed in bo h he acu e and
ongoing phases o eco e y (pB.001). The ype o suppo
in ol ed mos ly psycho he apy o egula mee ings wi h
heal h ca e p o essionals. One- i h (20%) o he psy-
cho he apies included EMDR- he apy as well. A majo i y
o he s uden s who we e o e ed p o essional help pe -
cei ed i help ul a a la e phase (89%) and (73%) a
ongoing phase o eco e y as epo ed in T2 and T3. The
pe cep ions did no di e acco ding o he se e i y o he
exposu e o school shoo ing auma.
Table 3 p esen s s uden s’ pe cep ions o he suppo a
he acu e phase. I e eals ha s uden s p edominan ly
elied on hei na u al social ela ions o suppo . They
men ioned amily membe s (57%), and iends and pee s
(54%) equally o en as he main sou ces o suppo ,
assis ance, and consola ion. They accoun ed ha amily
suppo enhanced hei sense o sa e y and a ilia ion and
el a ease in sha ing he pain wi h he amily membe s.
The help ulness o pee s and iends as suppo pe sons
was based on sha ing o simila eelings o ho o ,
unce ain y, and common expe iences o ea o dea h.
Ou each a e a school shoo ing
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(page numbe no o ci a ion pu pose)

Abou a qua e o he s uden s e alua ed p o essional
help as help ul a he acu e phase, epo ed a T1, 4
mon hs a e he shoo ing. The mos healing elemen s
we e p ac ical assis ance, psychoeduca ion, and c ea ing
o he apeu ic alliance and emo ional ans e ence. S u-
den s pe cei ed ha he o ganized a e ca e helped hem
o eel mo e secu e. Teache s also se ed as a sou ce
o assis ance and condolence, and c ea ed a eeling o
s abili y o he auma-a ec ed s uden s, and 6% o hem
pe cei ed ha as help ul. The pa ish and chu ch we e
conside ed help ul (3%) as hey p o ided shel e , a
possible place o ga he oge he , and o enjoy silence
and indi idual suppo .
Table 4 summa izes he healing elemen s o p o es-
sional ca e ha he s uden s pe cei ed mos help ul a he
ongoing s ages o eco e y. They epo ed hem a 16 (T2)
and 28 mon hs (T3) a e he school shoo ing. Mo e han
a hal o he ecipien s ega ded he oppo uni y o
na a e, ame, and sha e hei igh ening expe iences as
being bene icial. The p oac i e a i udes and emo ional
suppo om p o essionals we e conside ed help ul, and
s uden s also emphasized he use ulness o psychoeduca-
ion and s ess managemen . They men ioned examples
such as ‘‘how o b ea he and calm you sel ’’ o ‘‘she ga e
pe mission o he emo ions I conside ed o be c azy.’’
Fu he mo e, hey emphasized he ele ance o con inu-
i y o he se ices (same p o iding p o essionals) and
speci ic he apeu ic in e en ions (medica ion and psy-
cho he apeu ic me hods). The s uden s el ha he
p o essionals enhanced he eeling o sa e y (‘‘Whe e
e e I me hem I immedia ely el sa e’’).
Discussion
In mass auma si ua ions, he need o psychological
suppo is eno mous and p o ision o se ices should s a
Table 2. Psychosocial suppo and ca e, and he apies o he s uden s o he exposed school
All
s uden s
Se e ely o ex emely
exposed s uden s
Mildly o signi ican ly
exposed s uden s
Type o he suppo
T1: n236
n(%)
a
n20
a
n(%)
a,b
n216
a
n(%)
a,b
Di e ence be ween he
exposu e g oups
Immedia e c isis suppo
c
Reached by immedia e ( i s 24 hou s)
c isis suppo
199 (84.7) 20 (100.0) 179 (89.9) x
2
3.96, d 1, p.047
Immedia e c isis suppo accep ed 113 (58.5) 15 (75.0) 98 (56.6) n.s.
Pe cei ed accep ed immedia e c isis
suppo as help ul
110 (92.4) 15 (100.0) 95 (91.3) n.s.
G oup and school sessions
A ended he common sessions o he
whole school
167 (71.1) 17 (85.0) 150 (69.8) n.s.
A ended he g oup sessions 140 (60.6) 18 (90.0) 122 (57.8) x
2
7.92, d 1, p.005
Acu e phases psychosocial suppo
c
F om amilies and iends 232 (98.7) 20 (100.0) 212 (98.6) n.s.
F om o he s 179 (79.6) 15 (78.9) 164 (79.6) n.s.
F om P o essionals 164 (71.0) 18 (90.0) 146 (69.2) x
2
3.84, d 1, p.050
Pe cei ed he ecei ed c isis suppo as
help ul
Families and iends (T1) 220 (97.8) 19 (95.0) 201 (98.0) n.s.
O he s (T2) 148 (89.2) 14 (93.3) 134 (88.7) n.s.
P o essionals (T1) 114 (78.6) 12 (75.0) 102 (79.1) n.s.
P o essionals (T2)
d
83 (89.2) 11 (91.7) 72 (88.9) n.s.
P o essionals (T3)
e
76 (73.1) 11 (91.7) 65 (70.7) n.s.
Psycho he apy o egula mee ings
T1-, T3 60 (25.4) 13 (65.0) 47 (21.8) x
2
18.05, d 1, pB.001
Psycho he apy included EMDR T1-T3 12 (20.0) 6 (46.2) 6 (12.8) p.015, exac
n.sno signi ican .
a
Valid pe cen ages shown (missing da a no included).
b
Pe cen ages shown wi hin he exposu e g oup.
c
C isis suppo a e he i s day
and wi hin 2 weeks a e he inciden , a ailabili y o suppo asked by di e en sou ces.
d
Answe s o he ques ion abou pe cep ion o
p o essional suppo a T2 (16 mon hs ollow-up), n123 wi hin hose who ha e ecei ed he se ices.
e
Answe s o he ques ion abou
pe cep ion o p o essional suppo a T3 (28 mon hs ollow-up), n104 wi hin hose who ha e ecei ed he se ices.
Shows cumula i e
numbe s and pe cen ages ac oss T1 o T3.
Tuija Tu unen e al.
6
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immedia ely, ye bea ing in mind ha he mos impo an
sou ce o suppo o he auma ized is he suppo gi en
by hei na u al ne wo ks. P o essional ca e can supple-
men he na u al social suppo by o e ing psychoeduca-
ion, suppo , and ea men in an ac i e bu disc ee
manne , p omo ing esiliency. The ailo ed se ices de-
sc ibed he e we e p o ided ia mul ile el ou each, which
ollowed he na ional and in e na ional guidelines, bes
p ac ices, and consensus s a emen s o acu e, mid- e m,
and long- e m psychosocial suppo a e disas e s.
The s uden s’ eedback, which is analyzed in his s udy,
shows ha hey ound he a ailabili y o psychosocial
suppo help ul. The impo an ole o in ima e ne wo ks
in enhancing eco e y concu s wi h ea lie s udies ha
a e conduc ed among school shoo ing su i o s (Li le on,
G ills-Taquechel, & Axsom, 2009; Mu onen, Suomalainen,
Ha a uo i, & Ma unen, 2012). Almos 99% o he
exposed s uden s in Kauhajoki ecei ed suppo om
amily, ela i es, o iends and almos all pe cei ed i
help ul. This is in line wi h he a achmen heo y e-
ealing ha he ea ly c ea ed a achmen sys em ac i a es
in he ace o h ea and dis ess, and he auma ized
indi iduals seek com o and sa e y om hei close
social ela ionships (Bowlby, 1969/1982; Mikulince &
Sha e , 2010, p. 12). Acco dingly, he guidelines poin ou
amily membe s and o he na u al ne wo ks as he mos
impo an sou ce o suppo o he auma ized su i-
o s (Hob oll e al., 2007; TENTS, 2008). The ole o
p o essional suppo is o acili a e ac i a ion o hese
na u al ne wo ks, o o e psychoeduca ion and suppo ,
as well as o sc een o hose whose na u al ne wo ks’
suppo ails, whose auma- ela ed dis ess is se e e, o
who o he wise a e a high isk o PTSD o o he psycho-
logical impai men (Hob oll e al., 2007; P e e baum
e al., 2013; TENTS, 2008).
The psychosocial suppo was o e ed o he amilies
o he deceased, and he s uden s and s a immedia ely
a e he agedy, and i was ex ensi ely and p oac i ely
o e ed especially o hose who we e in g ea es need as
is ecommended (Call e al., 2012; Hob oll e al., 2007;
P e e baum e al., 2013; TENTS, 2008). The acu e help
o he auma-a ec ed s uden s and s a included se e al
Table 3. Sou ces o he suppo among he s uden s exposed o he school shoo ings in acu e phase (T1): who p o ided he mos
impo an help and wha was pe cei ed as healing elemen (s)
Main sou ce o he suppo
n236
n(%) Healing elemen s Examples
Own amily and close
ela i es
134 (56.8) In imacy
Lo e
In imacy and speaking abou no mal daily li e issues
Mo he and he genuine conce n and lo e
I ha e he bes dad in he wo ld
F iends and ellow-s uden s 127 (53.8) Pee suppo
Unde s anding because o
simila expe ience
I is easies o alk o he close pe sons you can us
Jus being close, o al p esence, and eeling o
unde s anding wi hou wo ds
Teache s and o he school
s a
14 (5.9) Toge he ness
Unde s anding because o
simila expe ience
The bes help comes om people who had
expe ienced he same agedy
We eel a ached o ou school, and ha helps us
C isis psychologis s,
psychia is s, and o he
p o essionals
61 (25.8) Sha ing he s o y
P o essionalism
Psychoeduca ion
The apeu ic in e en ions
Enhancing sa e y
Sessions wi h he psychia is consis ed o eal lis ening
and deep unde s anding, no only o being oge he
The c isis psychologis lis ened, suppo ed, and
o wa ded o he medical doc o
C isis wo ke s p o ided in o ma ion abou how o cope
and how o deal wi h no mal daily li e issues and wha
helps you o con inue you li e
The g oups in which we we e oge he , ha was a
decisi e expe ience in eco e y
The awa eness ha he e a e c ises wo ke s a ailable i
needed, ha has helped me
Chu ch and pa ish 6 (2.5) Spi i ual consola ion My own pa ish and belonging o i , I was allowed o
sha e and lea e my wo ies o God
None o I canno say 18 (7.6) I know ha he e was all kind o help a ailable. Bu I did
no ha e ime o go, and also he s angeness o o he s
does no help
No e: The pe cen ages do no sum up o 100.0 because s uden s men ioned mo e han one sou ce o suppo and easons as healing
elemen s.
Ou each a e a school shoo ing
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(page numbe no o ci a ion pu pose)
psychoeduca i e g oup discussions and common sessions.
They p o ided p ac ical in o ma ion, assu ance o sa e y,
and psychoeduca ion abou acu e s ess esponses. Con-
s uc ing a cohe en and sha ed na a i e abou he
auma is impo an as i is sugges ed o acili a e eco e y
om auma in ongoing phases (Shaw, 2000).
T auma- ela ed symp oms may be delayed in occu -
ence, and he eadiness o seek and ecei e suppo
a ies be ween indi iduals (Bonnano, 2004; Tu unen,
Ha a uo i, Punama
¨ki, Suomalainen, & Ma unen, in
p ess). The e o e ‘‘wa ch ul wai ing’’ p inciple was ap-
plied (NICE, 2005; TENTS, 2008) in o de o be eady
o po en ial delayed PTSS and e-e oked needs o
psychosocial suppo . P o essional suppo was especially
a ge ed o he mos se e ely exposed s uden s, and mos
o hem e alua ed he suppo as help ul in all phases o
eco e y. S uden s app ecia ed he s abili y and con inu-
i y o a e ca e se ices, and he neu ali y and p o es-
sional expe ise o hei amilia c isis wo ke s. They
exp essed posi i e iews on lea ning abou common
auma- ela ed esponses, e ec i e coping, and o he
ways o egula ing a ousals and s ess. F equen sc een-
ing u ned ou o be a help ul ool o moni o ing he
p og ess o eco e y p ocess, and he p o essional in e -
en ions and in ensi e suppo could be alloca ed and
a ge ed o hose su e ing om psychological dis ess.
The ollow-up showed ha s uden s who we e mos
se e ely exposed o he shoo ing we e common clien s in
psycho he apy. One- i h o he psycho he apies included
also EMDR- he apy, which is a ecommended ea men
in a ious guidelines (Duodecim, 2009; TENTS, 2008;
WHO, 2013). As a conclusion, he s uden s’ pe cep ions
o he p o ided p o essional suppo we e mainly posi-
i e, which indica es he use ulness o he ou each.
The s udy can be c i icized o d op-ou , e ospec i e
se ing o he s uden s’ expe iences, and na owness o
desc ip i e da a. The lack o sys ema ic collec ion o
expe iences and opinions o o he auma-a ec ed su i-
o s such as amily membe s o school s a is un o u-
na e. The s udy could each 60.7% o he auma-exposed
s uden s a 4 mon hs (T1) a e he school shoo ings,
indica ing easonably high esponse a e in he ield o
auma s udy. The loss o pa icipan s was no associa ed
wi h he se e i y o auma exposu e. I may ha e been
di icul o he s uden s o assess in e ospec he quali y
o he acu e se ices. E hically, howe e , he 4 mon hs
as a baseline o he ollow-up s udy was well chosen.
The esul s o bo h s uc u ed and open ques ions a e
cohe en , and suppo each o he . The s uden s’ sho
esponses o he open ques ions do no na u ally depic in
dep h hei expe iences o he auma iza ion, psychoso-
cial suppo and eco e y. Fo ha a quali a i e esea ch
me hod would be mo e i ing.
Conclusion
The access o he psychosocial se ices needs o be easy
a e a agedy ha a ec s a la ge numbe o ci izens.
Suppo and ca e should be a ailable o long enough
ime. The posi i e pe cep ions o he in e en ions p o-
ided wi hin his ou each model sugges ha like models
may be used in o he si ua ions and coun ies a e a
mass auma ic e en .
Acknowledgemen s
We since ely hank all he ela i es o he deceased and he s uden s,
s a , and managemen o he Seina
¨joki Join Municipali y o
Educa ion o allowing us o walk by hei sides in he a e ma h
o he agedy. We also hank he membe s o Kauhajoki p ojec ’s
boa d, s ee ing commi ee, and employees o he deep commi men
o he mu ual e o o he ou each. The con ibu ion and he sup-
po o he esea ch g oup om he Ins i u e o Heal h and Wel a e
has been in aluable. Tuija Tu unen hanks he Hospi al Dis ic o
Sou h Os obo hnia and he Finnish Cul u al Founda ion’s Sou h
Os obo hnia Regional Fund o inancial suppo .
Con lic o in e es and unding
The e is no con lic o in e es in he p esen s udy o any
o he au ho s.
Table 4. The help ul elemen s o he p o essional suppo
epo ed by s uden s o he exposed school a ongoing
eco e y phases a T2 (16 mon hs) and T3 (28 mon hs)
a e wa ds
Help ul elemen
T2
n42
n(%)
T3
n35
n(%)
Sha ing he s o y
Fo ming he na a i e, lis ening,
suppo ing
22 (52.4) 20 (57.1)
P o essionalism
Expe ise, neu ali y, ac i e suppo
9 (21.4) 13 (37.1)
Psychoeduca ion
No malizing, eaching sel -ca e
echniques
6 (14.3) 9 (25.7)
The apeu ic in e en ions
G oup in e en ions, he apeu ic
ela ionship
Medica ion/EMDR
3 (7.1) 5 (14.3)
Enhancing sa e y, con inui y
C ea ing eeling o sa e y
S abili y o he p o essionals
2 (4.8) 6 (17.1)
No e: The pe cen ages do no sum up o 100.0 because s uden s
men ioned mo e han one elemen o suppo as being help ul.
Only answe s wi h a gumen a ion we e classi ied.
Tuija Tu unen e al.
8
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