Framework of the outreach after a school shooting and the students perceptions of the provided support

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 æ Eu opean Jou nal o Psycho auma ology 2014. #2014 Tuija Tu unen e al. This is an Open Access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion 4.0 Unpo ed (CC-BY 4.0) License (h p://c ea i ecommons.o g/licenses/by/4.0/), allowing hi d pa ies o copy and edis ibu e he ma e ial in any medium o o ma , and o emix, ans o m, and build upon he ma e ial, o any pu pose, e en comme cially, unde he condi ion ha app op ia e c edi is gi en, ha a link o he license is p o ided, and ha you indica e i changes we e made. You may do so in any easonable manne , bu no in any way ha sugges s he licenso endo ses you o you use. 1 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. 2 (page numbe no o ci a ion pu pose) 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 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 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 3 (page numbe no o ci a ion pu pose) 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. 4 (page numbe no o ci a ion pu pose) 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 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 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 5 (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 (page numbe no o ci a ion pu pose) 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 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 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 7 (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 (page numbe no o ci a ion pu pose) 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 Re e ences Ala-aho, S., & Tu unen, T. (2012). 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Ou each a e a school shoo ing 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 9 (page numbe no o ci a ion pu pose)