Mass shootings leave an imprint on the American psyche. Thoughts of “It could have been me” and a sense of vulnerability occur when shootings occur in places that citizens frequent, including schools, churches, concerts and shopping malls.

Mass shootings are prevalent in our society. The U.S. is an outlier among developed countries in terms of gun deaths. Mass shootings (defined as three or more killings in a single incident) occur on average about once per day in the United States. While mass shootings comprise a small fraction of all gun violence (suicides 61%, homicides 35%), a student’s risk of dying in a school shooting reached its highest level in the last 25 years.

Psychological impacts are notable for children and adults. Post-traumatic stress disorder (PTSD), anxiety and depression symptoms are notable across research of survivors. PTSD involves intrusive, distressing memories, avoidance of trauma-related stimuli, alterations in mood or cognitive functions (e.g., memory and concentration) and disturbances in reactivity (e.g., hypervigilance and sleep disturbances). While most survivors show resilience, beliefs emerge that the world is unjust and unsafe. Active shooter drills, which occur in 95% of public schools, can be helpful in preparedness but can cause stress and trauma in children. Some internal threat mode drills have included fake bullets, blood and dead bodies. In realistic simulations, students have sobbed, vomited or fainted, as well as sent goodbye text messages to their parents.

Increased stress is related to indirect exposure. Watching the news via television and internet media, as well as informal discussions with family and friends, are forms of indirect exposure that have resulted in higher anxiety symptoms. While individual factors affect symptom severity (such as level of exposure, previous trauma and level of social support), most Americans (79%) reported increased stress regarding their awareness of mass shootings in an online Harris poll this August. Most teens say that they are worried about a mass shooting, and many Americans report worry about going places, avoidance of places or events and making changes to their lives.

Managing distress is developmental in nature. For both adults and children, it is critical to limit exposure to news by taking media breaks. In addition, helping others has been shown to benefit both children and adults (e.g., sending letters of encouragement, donating to survivor funds, engaging in community service, doing random acts of kindness).

Besides these recommendations, the following are noted in research:

For adults: Talk to a supportive person.

Balance negative viewpoints. Engage in self-care. Process grief and survivor guilt. Take some action, like getting involved in community organizations, or calling on elected officials to address gun violence.

For children: Talk to your child to determine what he/she already knows. Gently correct misinformation. Reinforce a safe feeling at home. Monitor adult conversations. Be patient and monitor for symptoms of stress, fear or anxiety. Focus on the helpers (quick response of law enforcement/ medical personnel or heroic acts of ordinary individuals).

What can we do as a nation? A sense of helplessness may result after awareness of multiple mass shootings, but research has outlined action that can be taken, including prevention, positive school climate, access to mental health services and gun safety. Deductive threat assessment techniques with a team, school atmosphere with open communication and access to mental health services, in addition to preparedness initiatives, are all supported in the literature. Finally, many organizations, including the American Medical Association and the American Psychological Association, as well as 7 in 10 voters, support reinstitution of the assault weapons ban. Universal background checks and red flag laws are also popular.

Our nation is feeling vulnerable and stressed. Mass shootings result in elevations in post-traumatic stress, depression, anxiety symptoms, as well as modification to daily lives. The words of a Marjory Stoneman Douglas High School shooting survivor may provide the most apt conclusion. Morgan Williams: “I cannot stop hearing the sound of the gun as he walked down my hallway. I cannot unsee my classmates who were shot get carried out by police. I cannot unsee the bodies on the floor. Please keep in mind the horror of what we’ve gone through today.”

Melissa Fisher Paoni, Ph. D. is a licensed clinical psychologist with the Springfield Psychological Center, LLC.