Editor’s note: This story contains descriptions of gun violence and abuse, and could be triggering for survivors of gun or domestic violence.

It’s been nine years since Lisette Johnson’s husband shot her four times and then turned the gun on himself. Nine years since her heart rate dropped to a dangerously low level, her body was replenished with 14 units of blood, and doctors performed multiple surgeries to keep her alive. There’s still a bullet in her liver, and another in her chest wall. The physical recovery was a long, painful hell. But for Johnson, that wasn’t the hardest part of surviving. “In a weird way, the physical pain was easier to navigate than the emotional pain,” she says.

Patience Carter’s experience with gun violence was as public as Johnson’s was intimate. Two-and-a-half years ago, she and some friends were dancing at Pulse nightclub in Orlando, Florida, when a shooter opened fire, leaving Carter severely injured and claiming the lives of 49 people. But Carter no longer wakes up in the middle of the night screaming in fear. She says she’s moved on. “I knew I had to be my own superhero,” she says, a mantra that helped her recover both physically and emotionally.

Both Johnson and Carter survived the unimaginable. But what connects their experiences with gun violence is more than just the bullets. It’s the complex, and often overlooked, emotional recovery they both had to navigate in the months and years after their traumatic experiences.

One moment, four bullets, forever changed

Johnson, 60, met her husband when she was 22. “I was young and struggling and he was older and successful,” she says, describing him as charming and generous. “He would take me to nice restaurants and we’d have a lot of fun together.” The relationship slowly changed once they were married. Over time, her husband became more controlling, and regularly did things to make sure she knew he was in charge.

It started with cruel comments her husband would make about her weight and clothes, or a pinch under the table while they were out on a double date if he thought she was talking too much. Over time, his behavior escalated. “He would often just leave me places,” she says. “I was abandoned many, many times.” She says they would go to the grocery store and he would disappear and drive off—leaving her stranded with no car and all the groceries to pay for and carry home. After they had two children, her husband would use them as a way to keep Johnson in the house. “He would say he’d watch them so I could go out with my friends, but then he wouldn’t be there,” she says.

Johnson says it took her a long time to realize that she was being abused. After 27 years of marriage (and seeing her son start to imitate his father’s bullying behaviors), Johnson knew she wanted to end the marriage. But when she asked her husband for a divorce, he refused—and then his behavior escalated to outright aggression and stalking. By the fall of 2009, the abuse had gotten so serious that she decided to find a way to leave no matter what. She made arrangements to stay with a friend while she figured out how to take her kids and pull enough money together. She just wanted to get through her son’s birthday party that week first.

“My husband was weirdly calm the day of the party,” Johnson recalls. “I remember we had a bonfire and I looked up at the moon and just had this eerie feeling.”

“These aren’t like C-section scars where you have a beautiful baby at the end. It’s a very painful reminder.” —Lisette Johnson, domestic violence survivor

The day after the party, Johnson was on the computer in the bedroom when her husband walked in, pointing a handgun at her. “I love you too much to live without you,” Johnson remembers him saying. She stood up and tried to run out of the room, but couldn’t get away before he shot her.

She doesn’t remember what happened immediately after, but she was shot three more times before her husband turned the gun on himself. The last bullet landed two inches from her heart. Her daughter, who was 12 at the time, witnessed the whole thing and sent her 9-year-old brother running for help.

Johnson needed several emergency surgeries for her injuries; she stayed in the hospital for 11 days. During the first six weeks after she was released, she relied on friends and family members to care for her until she could get out of bed. And then there was the crushing emotional burden of trying to help her kids while still processing the whole ordeal herself. Johnson says her daughter, now 22, developed suicidal tendencies and an eating disorder and her son, now 19, suffers from depression. All three of them, she says, have post-traumatic stress disorder, a mental health condition triggered by trauma that causes ongoing flashbacks, bad dreams, emotional outbursts, and avoidance of certain situations or topics.

While doctors and a physical therapist helped Johnson’s body heal, her therapist—whom she had been seeing prior to the shooting—worked with her to address her paralyzing symptoms of PTSD, the worst of which lasted for years. “I had nightmares for more than two years,” she says. “They would be of my husband and at the beginning of the dream, we’d be in love. I’d see him and say, ‘Oh thank God you’re not dead. I dreamed this horrible thing happened to you.’ But then he would start to berate me, and it would turn into a nightmare. I think it was because I was mourning. My husband was still my husband—I did love him at one point.”

Nearly ten years later, Johnson considers herself “80 percent recovered.” She’s still terrified of being shot again, which has manifested into a general fear of finding herself in another violent situation—making her unable to watch violent movies or even go to concerts or sports games. “It’s still something I think about every day,” she says. “When I look at the scars, these aren’t like C-section scars where you have a beautiful baby at the end. It’s a very painful reminder.”

How the brain processes trauma

It’s easy to hear the harrowing stories of gun violence survivors and assume that all of them will suffer from PTSD. However, Sarah Erb Kleiman, PhD, a clinical psychologist specializing in the diagnosis and treatment of trauma and PTSD, says that while a long emotional recovery like Johnson’s can be common, not every survivor’s story looks the same. “It’s important to know that not every trauma results in PTSD, and even for those who are diagnosed with PTSD, it isn’t a life sentence,” she says.

To her point, a report in the Journal of Traumatic Stress estimated that 7 to 10 percent of trauma victims suffer from PTSD. (Specific statistics for gun violence victims and PTSD, however, remain unclear, partially because the 1996 Dickey Amendment forbids the Centers for Disease Control and Prevention (CDC) from using its funding in a way that “may be used to advocate or promote gun control,” limiting the scope of research they can do on the issue.) That means as many as 9 out of 10 trauma survivors likely don’t experience the extremes of PTSD—but that doesn’t make their emotional recovery any less difficult.

A traumatic experience like a shooting generally has an immediate impact on the brain. Colleen Cira, PsyD, the founder and executive director of the Cira Center for Behavioral Health, says it’s very common for the nervous system to be on high alert the first month after trauma, a condition she calls acute stress disorder. “The body is in a state of hyper arousal,” she says. “That means the nervous system is constantly running as though there is a danger 24/7, even when [the person] is now safe, leading to a feeling of always having to look over your shoulder, irritability, and anxiety.”

But someone else who experienced the exact same trauma could experience the total opposite effect, where the body shuts down. “When that happens, it leads to feeling withdrawn, numb, and empty, and the inability to have loving feelings toward people who we do care about,” Dr. Cira says. Both instances, she adds, are normal reactions in the month immediately following the event.

Surviving a mass shooting

In the month following the Pulse nightclub shooting, Patience Carter had nightmares and would sometimes wake up screaming. “I was too afraid to sleep. Having the door open scared me. Having it closed scared me,” she says. But, unlike Johnson, she was never formally diagnosed with PTSD.

Carter was one of 53 people injured at Pulse that night in 2016, and 49 people were killed—including one of her own friends. “I was on vacation with my best friend, Tiara, and it started out as the best night ever,” she remembers. “Tiara’s cousin Akyra, who was 18, was just offered a scholarship to college for basketball, so we were celebrating that.”

Around 2 a.m., the night was starting to wind down and Carter was ready to head home. Tiara started to call an Uber when loud gun shots rang throughout the club. “Instinctively, I dropped to the floor, and Tiara and I ran behind the bar to hide.” Carter slowly inched backwards, until she was outside. “Akyra started running toward me and I asked, ‘Where’s Tiara?’ Akyra told me she was still inside, so we ran back in to get her,” Carter says. They found Tiara, but couldn’t escape the club a second time. When a herd of people started running to the bathrooms, they ran with them and were the last few to get into a stall.

The gunfire stopped and everything was quiet for a few minutes. Then she heard the shooter’s footsteps entering the bathroom. “We heard him come in, and he just started blasting the entire bathroom,” Carter remembers. “I started to process what was happening and that I was most likely not going to make it out alive.”

“It was then I started to process what was happening and that I was most likely not going to make it out alive.” —Patience Carter, Pulse nightclub survivor

The friends, all three of whom had been shot, were in the bathroom for three hours with the gunman while he engaged in a standoff with the police. (The shooter himself called 911, saying he was responsible for the shooting.) Finally, the police came into the club, exchanging gunfire in the bathroom with the shooter and ultimately killing him.

“I was trying to sit up, but there were bodies everywhere,” Carter says of the aftermath. “I saw Tiara holding Akyra across her body and we both started to freak out.” They tried to get help for Akyra, but it was too late. She had been shot twice in the arm and once behind her ear, and died on the scene.

Carter was in the hospital for six days. She had a metal rod surgically placed in her leg because the bottom portion of her femur was completely shattered. Unable to walk for almost three months, Carter relied on a physical therapist at home to help her rehabilitate. But when it came to her emotional recovery, Carter turned to her network of family and friends for support, rather than a therapist.

When emotional trauma is diagnosed as PTSD

As Johnson and Carter’s stories show, traumatic events can leave different emotional marks on survivors. According to Dr. Kleiman, it is so common to experience unwanted flashbacks, nightmares, fear, depression, or mistrust in the immediate aftermath of a traumatic event (like what Carter experienced) that they don’t necessarily warrant a diagnosis. For the majority of people, these symptoms—in all their varying forms—naturally fade over time, she says. “But for some people, the symptoms persist and worsen,” Dr. Kleiman says. A formal PTSD diagnosis like Johnson’s is made if symptoms persist for longer than a month after the event and get in the way of someone living their normal, daily life.

For a person who has PTSD, their body is basically in panic mode all the time, for a persistent period of time (reaching past that one-month window). “When the body senses danger, it goes into fight-or-flight,” Dr. Kleiman says. “The heart starts beating faster to pump more blood to the muscles so you can run away quicker, which is a very effective evolutionary program. But for people with PTSD, it’s like having an overactive alarm system. In other words, the surveillance is kicking into overdrive.” One example of this can be hearing a sudden loud noise, which causes someone to impulsively drop to the floor. Or experiencing a panic attack when watching a violent scene on TV. The body is sensing potential threats and sparking a physical reaction.

Why do some people experience such long-lasting, intense emotional trauma while others recover in a few months? Dr. Kleiman says it’s a question psychologists have been trying to answer for decades and still don’t know for certain. But there are some factors that make someone more at risk for developing PTSD or long-term emotional trauma. Someone’s mental health history—like depression or anxiety—as well as the severity of the event both certainly should be considered, she says.

“We also know that if someone knew the perpetrator, it puts you more at risk of developing long-lasting emotional trauma than if it was a stranger,” Dr. Kleiman says. This is especially the case if long-lasting abuse was involved, such as what Johnson experienced with her husband. “Knowing the bullet was meant for you makes it that much more difficult to process and overcome,” adds Dr. Cira.

What emotional recovery looks like

The wide range of experience makes grappling with trauma that much harder to address. But something all the experts interviewed for this article agreed on is that talking about what you went through—with a therapist as well as supportive friends and family members—helps. “If you try to bury the memory of what happened, your body is more likely to remain in this fight-or-flight response,” Dr. Kleiman says.

Of course, discussing such a traumatic event can be deeply triggering, making it hard to open up. “In therapy, often what’s done is phase-oriented treatment, meaning we don’t just jump right into it and start talking about the trauma,” Dr. Cira says. “It honors how sensitive it is, and how triggering it can be.” The first goal of recovery is to help the person in areas of their life where they have trouble coping, she says, explaining that the treatment is task oriented. For example, if someone has trouble sleeping, the therapy will first focus on that. This type of cognitive behavioral therapy (CBT) can be very effective in helping someone recover from a traumatic event, says Anka Vujanovic, PhD, the director for the Trauma and Stress Studies Center, co-director of the Trauma and Anxiety Clinic, and associate professor at the University of Houston.

If someone is pushing down the memories of the traumatic event, Dr. Vujanovic says a therapist may try a practice called imaginative exposures, where the survivor retells the story of what happened over and over again, even recording and listening to it at home. This can help them get over the avoidance they likely experience when thinking about that memory. “It’s giving them a safe place and a structured way to  revisit that memory in its entirety so it can be reconsolidated in their brain with all their other memories that they’ve had.” Then, she says, it’s less likely to pop up in unwanted surprising ways, such as a sudden panic attack.

For her part, Johnson credits a combination of Eye Movement Desensitization and Reprocessing (EMDR) (a psychotherapy treatment originally designed to alleviate the distress caused by traumatic memories) and CBT in helping her move forward. “EMDR was enormously helpful in disassociating what happened with specific images or smells from that day,” she says. With EMDR, there are eight phases of treatment centered around three themes: past memories, present issues, and future actions. Throughout the sessions, a therapist helps patients separate sensory memories with the trauma that happened so they are no longer triggering. Traditional talk therapy helped with other problems Johnson was facing, such as depression and nightmares.

Unlike Johnson, Carter only went to therapy a few times. She says she stopped going because she didn’t feel anyone could truly understand what she went through. Instead, she worked through her trauma by focusing on her physical recovery, using outward milestones as signs she was able to move past what happened. “[The shooting] happened in June, and I was determined to go back to college in August without crutches,” Carter says. So that became her goal. In August, she traded her crutches for physical therapy, making bigger physical goals for herself, literally step by step.

That didn’t mean she didn’t feel immense grief and anger—especially when she was trapped in bed, unable to walk. “A few weeks after [the shooting], I woke up from my sleep just screaming because I thought I heard a gunshot,” she says. “I made a major decision that day. I just decided, ‘Enough.’ I decided I wasn’t going to let it affect me emotionally anymore.”

In place of therapy, she talked through what she was feeling—immense grief, anger, frustration at not being able to take care of herself—with Tiara and with Akyra’s brother, Alex. “They are the only two people I felt could really relate to what I was feeling, so I leaned on them a lot,” Carter says. This isn’t necessarily the way that most mental health experts would recommend dealing with a traumatic incident, but Carter says that it worked for her. While she says she sometimes feels a rush of fear when in a public place, Carter believes she has almost fully recovered from what happened. “The odds of being in a mass shooting are extremely low. So the odds of that happening to me again…I just walk in faith,” she says.

Post-traumatic growth

While trauma recovery is unarguably difficult, there’s a surprising outcome that’s often overlooked: post-traumatic growth. “This is the idea that, for some people, going through a traumatic event gives them a renewed sense of purpose or meaning in their lives,” Dr. Kleiman says. “It gives them a greater appreciation for their life, because they almost lost it.”

You can experience PTSD and post-traumatic growth at the same time, Dr. Kleiman says. It’s hard to say how common this phenomenon is (especially because not all experts support the idea, and studies on it have had mixed results), although a recent meta-analysis suggests that nearly half of people who experienced a traumatic event experienced feeling some kind of post-traumatic growth.

Johnson and Carter both say they have found their own silver linings. Johnson now works full-time with trauma survivors and does advocacy work related to domestic violence through her business, Shameless Survivors. “Connecting with other survivors has absolutely helped me,” Johnson says. “Not many domestic violence survivors have also survived gun violence, but they were still betrayed by someone who made them promises, and I know what that’s like.”

Carter wrote a book about her experience, Survive Then Live, which is coming out in June. “The book is about how to overcome pain,” she says. “Everyone experiences pain, just different levels of it. We can all relate to each other in some way. We all have these experiences in our past that damaged or hurt us, but we have to figure out a way to use those painful experiences as a way to help uplift other people.” She is also now engaged to Alex, Akyra’s brother, and they plan to get married in August.

“There is no right or wrong way to emotionally recover from trauma,” Dr. Kleiman says. “What happened will always be a part of someone’s story. But over time, it becomes a smaller and smaller part of who they are. Because the truth is, trauma will change you.” Accepting this change, she says, is an important part of recovery.  “For some people, this takes months. For others decades. But what we do know is that the human spirit is resilient, and most people do recover.”

Even if you haven’t experienced serious trauma, having a strong support system is crucial. Here’s why. Plus, how to start treating depression, if you need help.