PTSD Care Needs Over Time - Learning to Live Again

David Zehrung, Ph.D., Licensed Psychologist

Shots fired… mass casualty event… Initial denial mingles with confusion, then anguish and even anger, but you realize you must deal with the torrent of texts, calls, media coverage, decisions to be made, travel, and coordination of family members and well-wishers.

Your first contact regarding care for your trauma may be mental health providers embedded in a crisis response team. But where do you go from there?

Perhaps you are blessed to already have a therapist you know and trust to assist with crisis management after your loss. You may have friends, family, and clergy who reach out, but there may be things you reserve for the confidential setting of psychotherapy. 

Perhaps counseling is a new idea for you, and you wonder if it might be helpful. A parent who lost a child to mass violence was prompted by their spouse to give therapy for PTSD a try. This parent found that “it was the best thing I ever did.”

After a mass attack what might your long-term mental health care needs involve? Once the initial crisis and burst of responsibilities ease, you may notice persisting changes in your sleep, appetite, alcohol or substance use, mood, irritability, and isolation from others. You may no longer view the world as a reasonably safe place. You may no longer trust others as you used to. Stress-related medical conditions may develop or worsen. You may avoid truly living and avoid the intrusive memories of your loss by working or seeking other activities that distract or numb you. 

If you notice these changes, but have not seen a therapist, it might be time for a checkup. If you are not sure if counseling would be a good idea for you, you might take a free online screen such as this one: https://screening.mhanational.org/screening-tools/. 

When evaluating potential therapists, there are the usual considerations, such as credentials, training, and experience in treating PTSD, but an important factor is your personal sense of whether you and the therapist are a good fit. As you might imagine, a strong working relationship predicts positive therapy outcomes. 

Psychotherapy can be very helpful for reducing the symptoms outlined above. While beneficial, it is not always a walk in the park, however, especially early on. One parent observed: “The first sessions were not easy. They were difficult. You touch upon life experiences, death experiences, you touch upon your ego, which is very difficult, you learn to let go. You learn to trust someone else to guide you.”

The process of healing and growth is seldom linear. Having said this, early stages of PTSD work often focus on gradually reducing the frequency and intensity of physical and emotional arousal (e.g., feeling keyed up all the time, insomnia, irritability, crying jags, waves of depression, and attacks of anxiety). 

As inner anguish improves in therapy, it becomes easier to focus on mending relationships that suffer in the wake of mass violence. Divorce rates increase after the death of a child. Other relationships also may suffer. Social and marital isolation is a real and common feature of PTSD. One parent recalled of their marital relationship after losing a child to violence: “We were on two separate paths, not holding hands. On two parallel paths. You should be able to hold hands, talk, at a minimum.” Counseling helped them bridge the gap that trauma created.

PTSD may involve deep changes to your core beliefs about the world, about your purpose, meaning, and identity. As psychotherapy helps ease other symptoms, the focus of sessions may evolve to address these deeper themes of life. For example, some survivors of violence may feel like life is now without meaning. Some take on the purpose and identity of an advocate, striving for justice, accountability, and policy changes. Some renew their emphasis on current relationships. Some mentor others who go through dark times. Some delve more deeply into their spirituality or faith. Some move through different priorities of purpose as they grow along their post-trauma journey. Having a sense of purpose is generally a wonderful thing. It takes wisdom, however, to discern when the application of a certain purpose is unhelpful. For example, one parent commented: “Purpose can slow down healing,” if pursued to the neglect of other important areas of a person’s life. A trusted therapist can walk with you through these changes, assisting with sorting out how you can not just survive or recover from that terrible event, but to actually grow in a deep and beautiful way. 

You might also address the theme of forgiveness later in your process of healing. Some individuals choose to work to forgive the attacker. Some choose to work to forgive others associated with the attack (e.g., school or law enforcement officials, business or political leaders, etc.). These are very personal and sensitive topics, but perhaps the most personal and sensitive topic is forgiveness of self. There can be deep guilt, similar to survivor’s guilt. You may find yourself ruminating over the idea that decisions you made could have possibly led to a different outcome for your loved one. This guilt can be soul-crushing, but to release it may feel disloyal or callous toward your lost loved one. Those who choose to forgive live longer, and with higher wellbeing. A skilled and trusted therapist can help guide you through these waters. One parent observed: “I found forgiveness. When that yoke was lifted off my shoulders, that’s when my capacity to do more grew.”

Even though you and your therapist do great work on your PTSD, you may discover over time that many things can renew the pain. Birthdays, holidays, anniversaries of important events, births, deaths, and other significant life events or milestones all provide opportunities for reflection upon experiencing life without your lost loved one. Intrusive memories and distressing dreams may return. So, some survivors schedule booster or refresher sessions for these times, even if they have already completed a course of therapy. 

As mentioned earlier, your journey through PTSD is unlikely to be linear. The stages and timing of work on the themes that I wrote about here are artificially sequential. You may find that you work on several themes concurrently, and then revisit themes as they become an issue again. How your healing unfolds is unique to you and your situation. 

One parent offered this encouragement regarding psychotherapy and healing from PTSD: “You can learn to live again and breath again and love again, and trust again. That’s what was revealed to me. There is hope.”