Two days after two Stoneman Douglas students who had survived the school shootings in Parkland, Florida, the father of a Sandy Hook victim in Newtown, Connecticut took his own life. The shootings at the Parkland high school resulted in the deaths of 14 students and three staff members. The mass shooting at Sandy Hook Elementary School in 2012 ended in the deaths of 20 first-graders and six staff members.

The shootings profoundly affected 19-year-old Sidney Aiello, a former cheerleader, whose close friend had been killed in the massacre. Suffering from , she was diagnosed with , according to a news report that quoted her mother. A second student, a male sophomore at Stoneman Douglas High School, also killed himself; the name and circumstances weren’t immediately released.

Survivors of extreme forms of violence, including those experienced during warfare and a host of other experiences—like life-threatening car crashes, fires, and natural disasters—are at heightened risk of mental health problems, including suicide. Most people are surprisingly , but for those who are psychologically vulnerable to high and , the road to recovery may be difficult. Feelings of depression can be overwhelming and thoughts and behavior may be a consequence.

is largely viewed as a trait conducive to being human and engaging in healthy relationships of a deep nature. To be devoid of empathy is to be a loner psychologically, perhaps a . Too close identification with the suffering of others, on the other hand, can be crushing to one’s ability to rebound from tragedy. Following a close experience with a catastrophic and horrific event such as a mass shooting, the passage of time does not always heal the wounds.

From all indications, Jeremy Richman, age 49, had seemed to be coping as well as could be expected following his six-year-old daughter’s murder. By throwing himself into social activism as a full-time advocate for violence prevention with a focus on mental health disorders, he seemed to find a purpose in life. Richman even co-founded a nonprofit foundation named for his daughter that focuses on violence prevention through research and community engagement. He did mention in media interviews, however, that living with such constant grieving for his lost child was an everyday struggle. And, in the end, the struggle got the better of him.

In my past social work at hospice in family members as they faced the pending death of a loved one, I encountered a variety of reactions, including numerous instances of displaced onto the medical staff. What I found in working with these family caregivers is that underlying the outbursts of anger were feelings of self-blame and guilt over a situation which rendered them helpless. Two aspects of the guilt in the families of the terminally ill that are relevant to survivors of mass shootings are a sense of helplessness and survivor's guilt.

When a family member is terminally ill, the partner or spouse invariably will feel a sense of personal failure, for the is unable to do what they believe should be done—namely, to heal the one who is suffering and make the pain go away. Typically, a sense of helplessness ensues. Parents of ill children are apt to suffer exceedingly from this form of guilt. In addition, the fact that one person is doomed to die while the other lives on is disturbing to the mind and can lead to feelings of extreme discomfort. The term survivor's guilt is used to describe this phenomenon.

Survivor's guilt occurs when one person is spared death or disability while others are not. The expectation is that the spared one will be for being so fortunate. The reality, in many cases, however, is otherwise. The survivor may experience , depression, and be tortured by obsessive thoughts and images.

The concept of survivor syndrome and survivor's guilt was first described in 1961 by William Niederland. Based on his diagnosis and treatment of survivors of the Holocaust, Niederland was made aware of the impact of trauma and how survivors commonly were plagued by feelings of guilt merely over the fact that they were alive.

The combat soldier, the camp survivor, the person who lived through the bombing of Hiroshima or a horrific accident such as a plane crash, may feel a need to justify their own survival. Underneath, there may be a feeling of unworthiness. Soldiers often experience this form of guilt in their awareness of their comrades who were killed.

When the IV (DSM-IV) was published, guilt related to survival of trauma was removed as a recognized specific diagnosis and redefined as a significant symptom of post-traumatic disorder ( ). In the DSM 5, similarly, the trauma-related emotions of guilt, , and anger are included as criteria for PTSD.

Survivor's guilt is extremely common as an emotion affecting parents who have lost their children. All are apt to experience their own version of survivor's guilt in conjunction with a sense of helplessness. For parents who survive their children, their failure to carry out the most fundamental task of protection arouses special overwhelming despair. The phenomenon of guilt is meaningfully portrayed in the fictional 1980 film, Ordinary People. Following the death of his brother in a boating accident, the adolescent, Conrad, finds himself unable to function psychologically. He eventually attempts suicide by slashing his wrists. The weight upon his parents is huge, and their falls apart.

Because feelings of guilt are associated with self-destructive behavior and the ultimate form of self- destruction is suicide, persons in recovery from a traumatic event who are overcome by a sense of guilt are at high risk of thinking about and even attempting suicide.

The ability to come to terms with loss and grief, and thereby to transcend them, is a major factor in the grieving person’s successful recovery. In the aftermath of a mass tragedy, such as a school shooting, teachers and family members should be alert to signs of unresolved grief that does not lessen over time. Friends and family members who are worried about a loved one’s painfully slow recovery can informally assess the survivor’s suicide risk by simply asking a few simple questions. A useful scale devised by the Columbia Protocol is readily available online. The first two questions are:

1) Have you wished you were dead or wished you could go to sleep and not wake up?

2) Have you had any thoughts about killing yourself?

If these questions are in the affirmative, the friend or family member should ask about any specific plans to carry out the suicide wish and seek help immediately.

In the event of suicide, such as the three instances from Parkland and Sandy Hill, the new tragedies compound the original ones, and the whole community is unsettled. A major risk with suicide is the contagion it induces through suggestion. For family members and close friends, these preventable deaths arouse strong feelings of guilt, often exacerbated by a sense of public . Some individuals grieving over suicide are so overcome that they themselves are at serious risk of self-destructive behavior and suicide themselves. Family members often blame themselves and each other in an event of this sort.

groups for survivors can delve into issues as they arise. In helping group members understand the emotional impact of death and dying and to accept any alien feelings for what they are—an integral part of the grieving process—the practitioner can help them better cope with life after tragedy. It is essential that school counseling programs set up to help students cope following a shooting include suicide prevention as a key part of the counseling.