Orlando police have estimated that around 320 people were inside Pulse nightclub on Saturday night when Omar Mateen opened fire. We know by now that 49 of them were killed, and that another 53 were injured. But almost everything else about this shooting — including the killer’s motive — remains uncertain.
Among those uncertainties is what happens now for the 200-something people who lived through the attack, both the injured and those who managed to escape physically unscathed. With survival comes a fresh set of challenges: Some of them will likely develop post-traumatic stress disorder. Some may battle guilt, or find themselves overcome by anger. Some may find it hard to feel safe for a long time to come. How each person responds to a traumatic event, though, is a complex equation, shaped by personal history, biology, social environment, and the nature of the trauma itself.
After a mass shooting, past research has shown, PTSD — one of the best-known and most widely studied trauma reactions — typically affects anywhere between 10 and 36 percent of survivors (though almost 100 percent, according to a review of mass shootings by the Department of Veterans Affairs, will report at least some PTSD-like symptoms). In general, PTSD risk is influenced by genetics, mental health at the time of the trauma, and even demographic factors like income level and marital status, but, by a long shot, the most important factor is the severity of the trauma, says Stacy Overstreet, a psychology professor at Tulane University who studies trauma responses. The closer a person is to the center of the event, and the higher the risk of death or injury, the more likely they are to develop the disorder.
That’s especially true for people whose pasts are already marked by traumatic events. “There’s some really interesting data from animal models that indicates when we’re exposed to trauma early in childhood, it can result in a permanent sensitization of our stress response system,” she says. “[It] learns to respond to other stressors in a really intense, prolonged way,” setting people up for more severe reactions to new traumas later in life.
But PTSD, and trauma responses more broadly, can also depend in part on how people process their immediate reactions. “All of us generally like to think that the world is a safe place, that we can control it to some degree,” she says. “Trauma, by its very nature, shatters those beliefs.” That’s especially true for those of the man-made variety — a shooting or terror attack, for example, upends our sense of safety more dramatically than something like a tornado or flood. “But as we make meaning of the event, the more that we can put those beliefs back together, the more likely we are to get over the trauma.”
In the days and weeks after a trauma, “almost everyone is going to have a nightmare or two, almost everyone is going to be trying to do some work and have an intrusive thought creep in,” she says. “If you can say, ‘I know this is pretty normal for people who have been through this, that helps you build a narrative of, ‘Hey, I’m doing okay, I’m going to get through this.’”
On the other hand: “If you say to yourself, ‘This must mean I’m going crazy,’ or ‘This must mean I’m not strong enough to handle this,’ or, ‘This must mean I’m a coward’ — those kinds of negative appraisals of the emotions that follow a trauma can really intensify [the emotions], or put you at risk for those symptoms developing into something like PTSD.”
It can also intensify feelings of anger, a common symptom of PTSD that can also exist on its own as a trauma response, affecting survivors who aren’t suffering from the full-blown disorder. “Maladaptive appraisals about oneself,” or negative thoughts of the type Overstreet described, have been linked to higher levels of anger following a traumatic event.
So has guilt, a response that can take a number of different forms — guilt over not intervening, over feeling relief at living through an event that others didn’t survive, over being at the scene of the trauma in the first place (for example, making plans to go to Pulse on what turned out to be the night of the shooting). “[Then there’s] the kind of existential question: Why me? Why did I come out alive and my best friend, my dad, my girlfriend, died?” says psychologist Yuval Neria, who heads up the PTSD research and treatment program at Columbia University Medical Center. “It takes years sometimes for the victim not to self-blame.”
There’s no litmus test for knowing who will be consumed by guilt after a trauma and who will push through it, but one mitigating factor is a person’s attributional style, or way of explaining why bad things happen. Someone with a negative attributional style is more likely to direct blame inward, and to channel their misfortune into grand, sweeping assumptions about the way the world works (psychologists describe this as internal, global, and stable). On the other end of the spectrum, someone with a positive attributional style tends to look outward, identifying more specific causes for their problems and recognizing those causes as temporary or changeable (external, specific, and unstable).
Overstreet puts it in terms of the stories we tell ourselves after living through danger: “How do you come to understand it?” she says. “[Victims] may make a meaning where they say, ‘I should have been able to save my friends from that event, it’s my fault we were there that night, and with all that’s going on in the world you can’t really be safe anywhere.’ However, If you create a narrative that’s like, ‘It’s true that we live in a world where anything happen, but all I can do is do my best to be safe,’ then you’re more likely to … be able to move on from it.”
Or even go one step further. After a tragedy, some people may experience what’s known as post-traumatic growth, dealing with a trauma by introducing positive changes into their lives. In some cases, survivors can come to view their experience as a marker of strength, something that helps them to appreciate their own resilience. “The experience of coming together as a society, as a group or a team, may facilitate that,” Neria says — but a key element of healing, he adds, is not to try and rush survivors into it.
“I don’t believe in too quick of remedies,” he says. “It’s too early to shift to, ‘We’re okay, it was horrible, but we are fine.’ I don’t think we are fine. We need to allow the victims to voice those feelings and emotions” — and to sustain the social support that too often dies off in the days and weeks following a tragedy. “The question is always, what do we do two or three days from now?”