The psychological effects of mass shootings take a toll on first responders as well as the victims and eyewitnesses. What can agencies do to help?

Las Vegas residents aren’t the only ones grappling with the aftermath of the largest mass shooting in modern American history.

First responders to the incident will themselves be at risk for a host of acute stress symptoms, including insomnia, flashbacks, and irritation.

What they’ll be reliving is the carnage left behind by a gunman who managed to kill 58 and injure more than 500 people at a Las Vegas concert in just a few minutes.

After the shooting started, paramedics, police officers, and even off-duty firefighters went toward the sound of gunfire in the hopes of helping people.

Some first responders were injured and off-duty officers were killed.

In the wake of the shooting, experts warn that officers and first responders face the risk of developing post-traumatic stress disorder (PTSD).

While first responders are trained to deal with a variety of threats, experts point out no one can train themselves to be immune to a mass shooting.

Michael S. Broder, PhD, clinical psychologist, author, and former stress manager for the Philadelphia Police Department, said police officers and other first responders face additional stress because they feel they have to act to save others.

“If you’re somebody just witnessing the event, you really have yourself to worry about,” Broder said. “With a cop, they have to be taking care of themselves and doing their job.”

He said cops may feel “there’s no excuse for not doing your job because you’re stressed out.”

Following the mass shooting at Sandy Hook Elementary School in Connecticut in December 2012 that left 26 dead, the National Alliance on Mental Illness (NAMI), Office of Community Oriented Policing Services, and the U.S. Justice Department released a report to illustrate what psychology experts and police experts have learned about how first responders can be affected by tragedies.

“Normal reactions to trauma in the first 24 to 48 hours include replaying and re-imagining the event over and over,” the report authors wrote. “Some officers will have insomnia or nightmares or feel like they are on an emotional roller coaster. Some may worry about what to tell their kids and spouses and then say nothing.”

Additionally, officers can face specific pressures if they interact with families of the victims.

“Officers who were first on the scene or who worked the crime scene should not be reassigned to support families or to conduct death notifications,” the report authors wrote. “This can create potential conflicts, where officers have information about the scene that they can’t share, and can intensify feelings of guilt about not being able to save a life.”

Ellen Kirschman, PhD,has written multiple books about first responders including “Counseling Cops: What Clinicians Need to Know.”

She said first responders will also have to deal with the effects of the “fight or flight” response, where the body goes through a host of physical changes in reaction to a threat.

This response, which results in part from a flood of hormones, can cause “tunnel vision,” shaky hands, and knots in the stomach.

Kirschman said it can take days to get through this physical response, which can make responders more irritable in the short term.

Additionally, Kirschman said first responders at the scene of the shooting are at risk for acute stress responses in the immediate aftermath.

These stress responses “might take the form of not being able to sleep well, of having the incident replay itself over and over and over again,” she explained.

Officers might be “very, very self-critical over situations in which they have no control,” Kirschman stressed.

“I think feeling helpless is another aspect that pops up,” for first responders, Kirschman said. “When you think that you’re are supposed to be in control of a situation and you’re not.”

She said officers might also start to question religious beliefs, among other convictions.

“When innocent people are basically shot like fish in a barrel, that’s pretty hard to get over,” she explained. “Sometimes that causes police officers to question their belief in the goodness of people.”

Broder said there are clear actions departments can take to help first responders in the immediate aftermath.

“When those things happen, we do debriefing where we would get the people involved in a room and talk to them — give them a safe place to air their feelings and do follow-up sessions,” he said.

Broder explained that the event was a way to check in with officers to see if anyone was exhibiting signs of distress.

“The most important part of the debriefing group was the coffee breaks,” Broder said.

He explained that the goal of these breaks was to reach out to each officer individually without making them feel they were on the spot in front of the group.

“A lot of these cops would not be able to talk about certain things in front of their peers,” Broder said. “We would be very strategic about this with my team, and we would have coffee breaks. And we would make sure that one of us talked to just about everybody.”

Kirschman said once the immediate threat is over, departments need to do “psychological first aid.”

“Just check around. ‘Who’s OK? Is there somebody over there who looks like their blood pressure is going through the ceiling?’” she explained.

Kirschman said these events can even affect people who weren’t there, like dispatchers.

“You can’t forget the dispatchers, though they weren’t on scene, they were right there, listening to it all,” she said.

Kirschman said even those with acute stress reactions in the aftermath of the attack will likely recover within a few weeks. She said she prefers to use the term “post-traumatic stress injury,” rather than use the word “disorder.”

“We call it an injury because a disorder sounds like a life sentence,” she said. “We know… that people do recover from post-traumatic stress.”

Kirschman also said it’s normal that some people will feel fine for months, but then feel PTSD effects later if something triggers stressful feelings.

“If [you’ve] got symptoms after 30 days, that’s when you can be classified as having PTSD,” she said.

NAMI’s report has a detailed list of actions departments can take to mitigate the emotional and mental stressors related to a mass casualty event.

These recommendations include preparing for the possibility of a large-scale event by assigning a mental health incident commander, being aware of emotional exhaustion in officers, considering setting up formal peer support networks, and creating long-term infrastructure to support officer mental health.

Kirschman said the NAMI report and other research has helped psychology experts assist first responders after a mass casualty event.

“Those of us who deal with first responders have gotten a lot better at knowing how to deal with these events psychologically,” she said.