The holiday season is traditionally viewed as a time of joy and connection, but it can also be a time of reflection and grief for survivors of firearm trauma. The consequences of firearm violence aren’t limited to physical injuries, and the unique mental vulnerabilities that trauma survivors experience may go unseen during busy holidays. Given this, it is important to understand and apply trauma-informed care when communicating with patients and survivors of gun injuries.
Trauma refers to the cognitive or emotional responses that can result from a disturbing event, series of events, or situation that’s perceived as harmful or life-threatening to the individual (CDC, 2022). Four key assumptions that guide trauma-informed care (the “Four R’s”) include: Realization of trauma and its impact, Recognition of signs and symptoms, Response to those impacted, and Resistance to re-traumatization (SAMHSA, 2014). Essential knowledge and strategies can support individuals and families affected by firearms-related injury, guided by the assumptions of trauma-informed care.
Realization of firearm-related trauma
The impact of trauma resulting from firearm injuries is widespread and pervasive among individuals and families. On a national level, homicides by firearm represent the third leading cause of death among ages 10-44 (WISQARS, 2024). Suicide by firearm closely follows in fourth for the same age group and represents the third leading cause of death among ages 45 and older (WISQARS, 2024). The frequency of non-fatal gun injuries is harder to estimate and only as accurate as the clinical documentation describing the event. In the pediatric population, documentation records estimate approximately three survivors per fatality (Fowler et al., 2017). There have been notable disparities and differing risk factors found within subgroups for each mechanism of injury (self-inflicted, assault, unintentional) that extend beyond the scope of this blog. Yet despite these differences, a commonality among gun injury survivors is that surviving a gunshot wound is linked to prolonged post-traumatic stress (Ranney, 2019). Mental health outcomes related to firearm injuries are far less understood, and for many survivors, mental healing is an ongoing and indefinite process.
Recognizing symptoms of trauma among survivors of gun violence
Recognizing the spectrum of physical, psychological, and emotional trauma symptoms in gun violence survivors is important in order to provide support and develop resources for affected individuals. Symptoms vary across individuals, but it is often the invisible wounds that remain problematic long after physical scars appear. I recently conducted a study that explored the experiences of 11 survivors of gun violence, eight of whom survived an intentional shooting by another person and three whose gunshot wound injuries were accidental (DeMello et al., 2024). The former described strong post-traumatic stress symptoms, including flashbacks, paranoia, distrust of other people, sleep difficulties, and anxiety. These interviews took place one to two years after the initial injury, and all but one of the 11 survivors reported that they had sought professional mental health treatment.
The symptoms resulting from traumatic experiences can be difficult to manage, often leading to unhealthy methods of coping. Most survivors in this study reported using marijuana to cope with pain and anxiety, while two survivors reported taking Xanax prescriptions that belonged to people they knew. One turned to a combination of alcohol and marijuana to self-medicate their symptoms. Unfortunately, these findings are not uncommon. Self-reported use of substance and alcohol has been documented in quantitative studies up to six years after a gunshot weapon injury, along with pain, anxiety, and decline in mental health (Geller et al., 2024; Vella et al., 2020).
Loneliness is another symptom that emerged from our survivor interviews. Loneliness is not included in the DSM-5 criteria for PTSD, but like trauma symptoms, it greatly affects quality of life. It is the opposite of connection. Descriptions of loneliness from survivors included feeling that friends and family, unlike the survivor, were able to move on with their lives after the physical injuries had healed. In the immediate aftermath of the injury, survivors reported feeling disempowered and left out of their own treatment plan as hospital clinicians talked about them in front of them, sometimes using insensitive communication. This sets the precedent for the patient’s distrust and noncommunication with health care providers.
Responding to those impacted by firearm related injury
For many people, understanding how to respond, talk about, or provide support for survivors can be an intimidating challenge. A trauma-informed approach can help you respond with empathy and awareness by acknowledging trauma’s widespread, yet widely varying impact. People respond to traumatic events differently and not everyone who experiences trauma will have lasting effects. So, while there is no one-size-fits-all approach to respond to survivor needs, there are trauma-informed principles that can guide efforts. Trauma-informed support hinges on principles of safety, trust, empowerment, validation, collaboration, and cultural sensitivity. Incorporating some or all these principles can make difficult conversations easier to navigate. It will also open doors and make patient survivors more amenable to seeking resources and treatment when the need arises.
Safety, transparency, and trust are critical elements that must be established and sustained for effective support. Gun violence survivors often experience a compromised sense of safety. Providing sensitive, non-judgmental support can encourage disclosure of trauma-related feelings and emotions that may be difficult to cope with, especially during the increased social interactions of the holidays. Validating the existence of these feelings can support and guide the next steps toward healing. Since effective response aims to establish trust, professionals can help promote a psychological sense of safety in survivors and have transparent discussions about physical safety, particularly when there are concerns about access and household storage of firearms. These conversations, framed in safety and trust, not judgement, can be incredibly effective in empowering survivors to manage difficult emotions, engage in safe practices, and seek professional resources to address long-term health needs.
Several community-based and professional resources exist within the Houston area to support survivors and their families through the aftermath of gun violence. Community-oriented programs, like the Relentless Interrupters Serving Everyone program, operate within Harris County using a public health approach to interrupt violence, defuse tensions, and create safer communities (HCPH, 2022). Individual and professional resources are available through helplines like VictimConnect, mobile based apps like Transcend NMVC, and mental health support services through NAMI Greater Houston. UTHealth Houston also just established the first CDC-funded injury control research center in southwest Texas, led by Dr. Jeff Temple (https://lnkd.in/g2wNm8NS), so there is more to come in the way of injury and violence prevention, education, and research.
Resisting re-traumatization
When survivors of gun violence are exposed to situations that remind them of past traumatic events, re-traumatization can occur. Re-traumatization refers to the recurrence or worsening of stress symptoms after re-exposure to trauma-producing stimuli or situations. Symptoms of re-traumatization are like PTSD and can interfere with recovery from the initial event. Using the trauma-informed approaches described above can increase the awareness of symptoms and triggers related to traumatic experiences so that re-traumatization can be avoided. Using skills like active listening, understanding the stress response, recognizing trauma symptoms, and communicating openly and respectfully have all shown promise in helping to prevent re-traumatization.
Unfortunately, the health care setting poses a high risk for re-traumatization due to life-threatening and sometimes frightening experiences that can accompany clinical management of a gunshot wound. Patients have described traumatic experiences, also known as medical trauma, during specific procedures like rapid intubations, induction of anesthesia, and awakening from surgery in severe pain. Additionally, gun violence survivors have reported traumatizing experiences during care, such as hearing harsh discussions between clinicians about losing their body parts, not being involved in the decision-making, and hearing clinicians in the emergency room telling each other to “patch her up and get her sent to her room” (DeMello, 2024). These details and phrasings, stated that way at that point in time, can be denigrating and disempowering, eroding trust with clinicians and potentially affecting decisions to pursue health care after hospital discharge. Trauma-informed care training for health care staff helps clinicians incorporate culturally sensitive and supportive practices that create healing environments for patients who have experienced traumatic events. Notably, while trauma-informed care is relevant, it is not exclusive to managing trauma resulting from gun violence. Comprehensive frameworks, including hospital-based violence intervention programs, exist to guide trauma centers and the community to effectively care for firearm survivors after they are discharged (Timmer-Murillo, 2023).
Gun injury prevention within the home
Finally, it’s important to be mindful that shootings at home can increase over the holidays due to the sheer fact that families spend more time at home. As the saying goes, an ounce of prevention is worth a pound of cure. While there are many strategies for reducing interpersonal and self-inflicted gun injuries, the most simple and effective practice for everyday households is to keep firearms locked, unloaded, and stored away from kids and family members experiencing prolonged durations of sadness or anger. Safe storage prevents unintentional injuries and makes the gun more difficult to access, thus providing a household cooling off period for individuals intending to do harm. To learn more about firearm storage options and firearm injury prevention, see Gastineau and McKay (2023). Other safe storage educational resources can be found at BeSmartforKids.org. And for anyone at risk for harming themselves or others, removing the gun from the home completely, even temporarily, is a crucial move to preventing suicide and assault (McKay et al., 2021).
While there’s still much work to be done to heal the damage resulting from firearm injury, education, trauma-informed support, and practical safety measures can help mitigate firearm-related violence during the holidays. The trauma-informed strategies described in this post not only save lives but also contribute to a safer and more supportive environment for survivors and families during what should be a season of peace, healing, and connection.
References
BeSMART (2024). Secure gun storage. Retrieved from https://besmartforkids.org/secure-gun-storage/
Centers for Disease Control (2022). Building trauma-informed communities.https://blogs.cdc.gov/publichealthmatters/2022/05/trauma-informed
DeMello, A.S., de Vassal, L., Temple, J.R., Alvarado, I., Waguespack, A., Pappadis, M., Lee, Jong O., Wood, L.G. (2024). The Indefinite Nature of Mental Healing: A Qualitative Assessment of Psychosocial and Behavioral Outcomes of Adolescents and Young Adults After Non-fatal Firearm Injuries. Manuscript submitted for publication.
Fowler, K.A., Dahlberg, L.L., Haileyesus, T., Gutierrez, C., & Bacon, S. (2017). Childhood firearm injuries in the United States. Pediatrics, 140(1): e20163486. doi: 10.1542/peds.2016-3486.
Gastineau, K.A.B. & McKay, S. (2023). Firearm injury prevention. Pediatr Clin North Am, 70(6):1125-1142. doi: 10.1016/j.pcl.2023.07.003.
Geller, J. E., Teichman, A. L., Charles, E. J., Pierce, A., Patel, K., Park, J., Getrajdman, J., Piplani, C., Cong, A., Reese, J., Englert, Z. P., Narayan, M., & Choron, R. L. (2024). Firearm Injury, It’s Not Just Physical: The Adverse Impact on Patient-Reported Socioeconomic, Mental Health, and Quality-of-Life Outcomes. The American surgeon, 90(11), 3038–3045. https://doi.org/10.1177/00031348241262434
Harris County Public Health (2022). Community Health and Violence Prevention Services Division. Retrieved from https://publichealth.harriscountytx.gov/Divisions-Offices/Divisions/Community-Health-and-Violence-Prevention-Services
McKay, S., Bagg, M., Tallackson, Z., Donthula, D., Russell, B., Sha, N., Petronzio, A. & Henson-Garcia, M. (2021). Temporary firearm storage and safe firearm storage counseling at gun retailers and ranges in the greater Houston area: A potential new partner in addressing child and youth firearm injury? Journal of Applied Research on Children: Informing Policy for Children at Risk 12(2): 6. doi: https://doi.org/10.58464/2155-5834.1480
National Alliance on Mental Illness (NAMI, 2024). Resources. Retreived from https://www.namigreaterhouston.org/resources/
National Mass Violence Center (2024). Transcend NMVC Mobile App. Retreived from https://www.nmvvrc.org/survivors/transcend-nmvc/
Ranney, M., Karb, R., Ehrlich, P., Bromwich, K., Cunningham, R., & Beidas, R. S. (2019). What are the long-term consequences of youth exposure to firearm injury, and how do we prevent them? A scoping review. J Behav Med, 42(4), 724-740. https://doi.org/10.1007/s10865-019-00035-2
Substance Abuse and Mental Health Services Administration (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Retrieved from https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf
Timmer-Murillo, S.C., Schroeder, M.E., Trevino, C., Geier, T.J., Schramm, A.T., Brandolino, A.M., Hargarten, S., Holena, D., de Moya, M., Milia, D. & deRoon-Cassini, T.A. (2023). Comprehensive framework of firearm violence survivor care: A review. JAMA Surg, 158(5):541-547. doi: 10.1001/jamasurg.2022.8149.
Vella, M. A., Warshauer, A., Tortorello, G., Fernandez-Moure, J., Giacolone, J., Chen, B., Cabulong, A., Chreiman, K., Sims, C., Schwab, C. W., Reilly, P. M., Lane-Fall, M., & Seamon, M. J. (2020). Long-term functional, psychological, emotional, and social outcomes in survivors of firearm injuries. JAMA Surg, 155(1), 51-59. https://doi.org/10.1001/jamasurg.2019.4533
Victim Connect Resource Center (2024). Retrieved from https://victimconnect.org/
Web-based injury Statistics query and reporting system (WISQARS). Available: https://www.cdc.gov/injury/wisqars/index.html [Accessed 2 Dec 2024]
Authors:
Annalyn DeMello, PhD, MPH, RN, CNE
Assistant Professor, Department of Research
Cizik School of Nursing at UTHealth Houston
Annalyn.Demello@uth.tmc.edu
Assistant Professor, Department of Research
Cizik School of Nursing at UTHealth Houston
Christian.P.Owen@uth.tmc.edu
