Veronica Kelley was working at an office building across the street from the Inland Regional Center in San Bernardino, Calif., in December 2015 when a county employee and his wife entered with semiautomatic rifles and opened fire, killing 14 and wounding 22. Most of the victims were co-workers of the gunman.

The couple went on to wound two police officers later that day before being fatally shot by police.

Since then, Kelley, the 52-year-old director of the county Department of Behavioral Health, has broadened the department’s focus to caring for people struggling with psychological trauma from mass shootings — no matter how they’re insured. (The department also coordinates services for low-income people with serious mental illness and substance use disorders, and youths with serious emotional disturbances. Most are uninsured or have Medi-Cal, the state’s Medicaid program.)

Kelley and her department have seen firsthand how the psychological wounds of mass trauma can linger indefinitely. In the San Bernardino shooting, more than 400 people were either victims, witnesses or first responders. Kelley and her team also noticed how the trauma expands beyond those who were nearby: people who lost friends or relatives to the carnage, those who live or work near the notorious crime scene — or even people who were traumatized by watching news coverage.

After the three recent mass shootings in Gilroy, Calif., El Paso, Texas, and Dayton, Ohio, which killed 36 — including two gunmen — and wounded at least 51, the number of people indirectly affected by mass gun violence continues to multiply.

“What we notice is that there’s a slight uptick in attempted suicides” when there are other mass shootings, Kelley said. “We see a slight uptick in attempts and hospitalizations around our anniversary as well.”

The increase in suicide attempts is the reason Kelley closely monitors national news. After the recent spate of mass shootings, she alerted her crisis response team to be prepared for more requests to respond to mental health crises — and sent emails to all county department heads to keep an eye on their employees. San Bernardino is California’s fifth-most populous county, home to about 2.2 million people. With 22,000 employees, the county government is the largest employer in the county.

Kelley’s department also sends emails to survivors and posts social media messages for the public, reminding people about the potential recurrence of post-traumatic stress disorder. Separate messages linking to a suicide hotline number and the Disaster Distress Helpline were posted on the department’s official Facebook page — without gory details or even mention of the crimes — after Gilroy, El Paso and Dayton.

“Unfortunately, we’ve been forced to become pretty effective at this kind of work,” Kelley said.

California Healthline’s Anna Almendrala spoke with Kelley about what her department has learned about the long-term psychological effects of surviving a mass shooting, and the triggers that can set recovery back.

The following interview has been edited for length and clarity.

Q: Three high-profile mass shootings in eight days. What is going through your head right now?

We weren’t surprised. Unfortunately, I think when you’ve been in a mass shooting, it kind of presents you with your new reality. But I think you don’t really fully understand it until it happens in your community.

Q: In addition to the uptick in suicide attempts among San Bernardino survivors with each new mass shooting, did you notice an impact on mental health for residents who were not directly involved?

I think our shooting really helped educate people about the importance of wellness, and an increase in understanding that mental health and addiction are just one part of our whole physical wellness.

We’ve been reached out to by folks who are not Medi-Cal beneficiaries who are in need. And by folks, I mean bigger organizations, and bigger communities, like businesses.

The golf courses had never called us to come out to talk to them about mental health. And then they did.

Q: What advice do you have for people in places like Gilroy, El Paso and Dayton?

One of the things we really focus on is getting people to get off social media, stop watching the news and don’t read about this stuff over and over again.

Get active. We know the way to treat a traumatized brain is to kind of reboot it like you do with a phone or a computer — turn it on and off. The natural way to reboot a brain is physical exercise.

Our brains need to recover, and so they need uninterrupted sleep. They need natural sleep, not sleep that’s impacted by weed or alcohol.

Q: What needs to change when it comes to addressing mental health issues stemming from mass shootings?

Remembering that behavioral health first responders exist. Acknowledging the need for that. You call the fire department when a building is on fire. You can call behavioral health first responders as well.

We created community crisis response teams, and we respond to any sort of crisis. We’ve developed a system of care where we actually get referrals, including from law enforcement, and we actually deploy with law enforcement to these crisis calls.

Also knowing that recovery from trauma is different for everybody, and it takes however long it takes. The only way to get through it is actually to go through it.

Q: How do mass shootings differ from responding to other traumas, like fire or natural disasters?

Most of us know what fire looks like. We’ve created a fire in our living room in the fireplace, or we’ve been out camping. We know if there’s an earthquake, duck and cover.

But we are not all taught active shooter training. We haven’t all witnessed what someone getting gunned down with an automatic weapon looks like, and so we just aren’t as accustomed to it.

Also, when you have someone who takes a weapon and a lot of ammunition and then goes after human targets, that’s different. The trauma is more personalized. It is more horrific. I would say it is terrible to die in a fire, but I would say that it is more violent to die being shot 50 times.

Q: So you’re saying there’s something about being able to see the perpetrator?

Right. And especially that feeling of betrayal for our own county employees. That was a theme for a lot of them. He was one of them; they had just had a baby shower for him. He was considered part of the county family. And so it’s far more personal than if there was just a fire.

Q: You spoke to your counterpart in Santa Clara County, Toni Tullys, after the Gilroy shootings. What did you say?

One of the things I reminded her about, because it’s summertime and we’re still close to the Fourth of July, is that people shoot off fireworks. It is really triggering and activating for people who experience a shooting to hear fireworks go off.

If you’re going to go out, you might want to plan so that you get somewhere early. While that sounds horrifying that you would have to be so deliberate in living, it is helpful to reduce triggers and to be prepared in the event that something happens.

That’s what we were advised from the folks who survived Sandy Hook and from the Colorado shootings. We want to take all the things we’ve learned and share them.

Anna Almendrala is a correspondent, Kaiser Health News.

Image credit: Shutterstock.com