TUCSON – the survivors’ physical wounds are healing.

But the path to recovery for Tucson residents is far from over.

For those who were there, knew someone who was there or even have in the past suffered from prolonged anxiety or depression, a gunman’s Jan. 8 attack outside a Safeway near here may play like a movie reel over and over again in their minds.

For most, the pain and sadness will wane with time, a tribute to the gift of human resilience.

For others, particularly those with a close connection to the event, it may persist, causing flashbacks, anxiety, insomnia, irritability, isolation and fear.

Three weeks after the tragedy, it’s too early to tell whether those symptoms will evolve into a more serious condition, such as post-traumatic stress disorder.

PTSD is a psychological condition that affects those who have experienced a traumatizing or life-threatening event such as combat, natural disasters, serious accidents or violent personal assaults.

If symptoms persist for more than 30 days, the possibility of the disorder becoming chronic or disabling does exist.

“To expect someone to act normally after an abnormal event is not reasonable,” said David Jacobson, manager of social work at University Medical Center, the hospital that treated and released 11 of the victims, including U.S. Rep. Gabrielle Giffords, after the shooting. Giffords is recovering at a Texas rehabilitation center.

“People are like sponges,” Jacobson said. “Once they’ve soaked up too much water, at some point they can’t soak it up anymore. Everyone reaches a breaking point.”

Six people were killed in the rampage. Jared Loughner, 22, of Tucson, is in custody and facing charges.

In the days after the shooting, several therapists in Tucson offered free counseling for those who were traumatized.

That effort will continue in the coming weeks, said Susan Warren, a licensed professional counselor in Tucson.

She and about 50 other professionals will team up to offer free therapy to the public. Dates and locations have not been finalized.

“It’s really important for people to know what to do and what not to do,” Warren said. “Many people want to focus on the issue, watch it on TV over and over again, and they are really just retraumatizing themselves.”

The victims

The blood, the loss of lives and the feeling of helplessness that arose as a gunman fired, first at Giffords and then at a line of her constituents, sparks flashbacks for some and causes heightened anxiety for others.

University Medical Center provided immediate attention to those whose wounds needed treatment.

Some said the hospital’s safe environment served as a safety blanket, a cocoon. Each individual’s mental health was assessed, and therapists were available at all hours.

As they were discharged, victims took with them the unsettling images of the day and a plan for long-term therapy.

Ron Barber, Giffords’ district director, was shot twice: once in the face and once through the leg, the latter of which nicked an artery.

Around him, friends and co-workers were wounded and killed.

In his retelling of the day’s events, he mentions the occasional flashback.

“(There was) a big pool of blood gathering underneath me, and right in the middle of it was a shell casing, a bullet shell casing,” he said. “I looked at my hands, and they were covered in blood.”

Barber said he will turn to a longtime friend and former colleague from the state Department of Economic Security to act as his therapist.

He also has a strong support system at home.

Even so, he acknowledges the day will likely continue to haunt him.

“Even though I feel I’m a pretty strong person in a lot of ways, I know that something like this could really have an effect on you that might not even be apparent right away,” Barber said. “So, I’m . . . not being shy about asking for help.”

Others who are struggling with similarly strong emotions say they also probably will take advantage of counseling.

Bill Hileman, husband of shooting victim Susan Hileman, told the media of his wife’s physical and mental afflictions a few days after the shooting.

Susan was clasping the hand of 9-year-old Christina-Taylor Green, whom she had taken to the event, when the bloodshed took place.

Although Susan attempted to shield the girl from the bullets, Christina-Taylor was fatally wounded.

After Susan’s breathing tube was removed, the first thing she asked Bill was whether the girl had survived.

Hileman recently recounted the tragic day on her blog.

“I know that it is possible to watch the light go out of another person’s eyes. I do not know if it is possible to live with that knowledge. I do know that I will try.”

The witnesses

Those who were spared physical wounds also are haunted by the shooting.

Shayne Spude, a bagger at the Safeway just north of Tucson, was speaking with another employee outside the store when the gunman opened fire. her fellow employee prevented her from being hit by throwing her to the ground, she said.

“I’m taking one step at a time, and I’m starting to feel better,” Spude said on Jan. 15, the day the store reopened.

Counselors have been on-site at the Safeway at Ina and Oracle roads since then to provide support for store employees, said Cathy Kloos, a company spokeswoman.

Safeway also provided counseling for employees from Jan. 9 to 14, while the store was closed.

“I am so angry,” said Laura Parker, a courtesy clerk, who was at Beyond Bread, about 75 yards from the storefront, when the shooting began.

Also affected were the first responders – firefighters, paramedics and emergency medical technicians. Capt. Adam Goldberg, spokesman for the district, arrived at Ina and Oracle roads to face the most demanding scene in his 22 years as a firefighter.

As the father of 8-year-old twin boys and a 5-year-old girl, he found the death of Christina-Taylor Green the most difficult to digest.

“It was a graphic and tragic scene that many of the firefighters will play over and over again in our heads,” Goldberg said. “We deal with children a lot, but it doesn’t make it any easier.”

The stress

The number of people who could suffer from post-traumatic stress disorder is unknown.

Symptoms of acute stress must persist for at least four weeks before a diagnosis can be made.

In the aftermath of the Sept. 11, 2001, attacks, many New Yorkers, Pentagon workers and other Americans experienced anxiety, depression, insomnia, flashbacks and irritability.

As the weeks passed, the percentage of those displaying acute symptoms waned, said Dr. John Markowitz, a research psychiatrist at New York State Psychiatrist Institute and a professor of clinical psychiatry at Columbia University.

“Who has the resilience to shake this off and who will fall into PTSD is a really interesting question that we don’t have a foolproof answer to,” Markowitz said.

In a five-year trial funded by the National Institute of Mental Health, Markowitz has studied the effectiveness of different kinds of psychotherapy for post-traumatic stress.

Having patients record their voice while they retell the traumatic event is among the most successful methods, Markowitz said.

After the session, the patient listens to the recording several times and returns the next week to retell the event. the process lasts 10 weeks in the trial, he said. “It clearly works, but it can be painful,” Markowitz said.

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