She’d never been afraid of horses before. Yet she froze outside the corral — her mind racing with fear as she watched the palomino quarterhorse walk around the corral in an isolated box canyon.

Since the Dec. 2, 2015, terrorist attack in San Bernardino, Paula Harold had been afraid, distressed and despondent — diagnosed with post-traumatic stress disorder.

Now she was supposed to go in there and begin equine therapy. But she stood behind the fence – heart beating fast, breathing shallow, her body flooded with anxiety.

“I’m scared,” she said softly to horse expert Angie Sheer and therapist Susan Lilly at Buffalo Meadows Ranch in Redlands. “I don’t know if it’s going to charge me.”

Most days, Paula just stayed home. Reading. Doing housework. Afraid to go out.

She had tried things to stop the anxiety and the depression and the fear after the attack, when she’d seen bullets come through walls as she crawled down a hall to get away while a grazed coworker fell to the floor.

Now she wondered how she could return to her job as a San Bernardino County Environmental Health Services supervisor when she no longer believed in herself.

Invisible wounds

Paula is among 57 county workers trying to put their lives back together after an attack by their coworker, health inspector Syed Rizwan Farook, and his Pakistani-immigrant wife, Tashfeen Malik, at the Inland Regional Center in San Bernardino.

Fourteen people were killed and 22 others wounded when a couple bent on hatred walked into a county holiday party/training event with assault rifles and opened fire shortly after pledging allegiance to the Islamic State.

At the time, the FBI called the mass shooting the deadliest terrorist attack on U.S. soil since 9/11.

Trauma experts say survivors were left with the invisible wounds of post-traumatic stress, which can haunt people like Paula for years or the rest of their lives.

Documented as early as Homer’s “Iliad,” the condition has been known by many names, including “soldier’s heart” and “shell shock,” but was seared into public consciousness by the troubling experiences of returning Vietnam War vets. In the late 1970s, it was given the name post-traumatic stress disorder or PTSD.

Researchers estimate 70 percent of U.S. residents, or 226.2 million people, have experienced trauma, and at least eight percent later developed post-traumatic stress. There don’t appear to be studies less than 10 years old updating figures for the new millennium’s era of increased terrorism and mass shootings. In 2005, the National Institutes of Health reported PTSD would likely rise sharply in the next decade and become one of the century’s top health issues.

Post-traumatic stress can occur after someone has experienced or witnessed a frightening event, such as natural disasters, terrorist attacks, military combat, rape and sexual abuse, neglect, serious accidents, violent attacks, hostage situations and diagnosis of a life-threatening condition.

According to trauma experts and the American Psychiatric Association’s latest diagnostic manual, PTSD involves disabling, simultaneous reactions to trauma lasting more than a month. Those reactions include distressing, intrusive memories taking shape as nightmares and flashbacks; avoidance; negative thoughts or feelings like guilt and helplessness; hypervigilance and fear, which limits sleep, concentration and feeling secure.

While anatomical or physiological differences in the brain and harmful childhood experiences such as abuse or illness can leave people more at risk for PTSD, the most influential factor is how close they were to the traumatizing event, said trauma science pioneer Frank Ochberg.

“A perfectly normal person will get PTSD given enough stress,” he said.

Journey toward healing

Paula was standing in the conference room, waiting to be in a group photo, when she saw a man in black walk in with a rifle. She remembers her confusion as bullets and gunpowder flew. She heard the shots but can’t remember seeing or hearing anything else.

Her mind blanks until she’s in the hall, crawling away while Marilyn Krichbaum, a coworker returning from the bathroom, drops to the ground after a bullet grazes her stomach. Paula crawled into a nearby room following others who’d escaped, then saw there was no way out.

She crammed into a storage cabinet and prayed the shooting would stop. Coworkers hid in other cabinets while lead Environmental Health Specialist Hal Houser, Vector Control Program Manager Jason Phillippe and Public Health Assistant Director Corwin Porter held the doors closed.

Paula’s husband, Tony Harold, drove her home that night and held her the rest of the evening. They’d always been a strong team. Shaken up after not reaching her for hours, Tony knew he’d have to be mentally tough — the backbone who’d pull the family together.

He answered the front door when journalists came knocking – which sounded to Paula like gunshots.

He set up cameras outside the house. Applied for a concealed weapons permit. And never left her side.

When it was clear she’d been left with post-traumatic stress disorder, they began a journey toward healing whose end remains out of sight.

“I’m not a cheap tent. I’m not going to fold up when things are bad,” he said.

Panic and fear

Post-traumatic stress can last for decades or become a life-long condition. Those who get early, effective treatment usually recover quicker and are less likely to have long-term PTSD.

Dec. 2 survivors didn’t get counseling the day of the attack, yet first responders did – as did survivors of the North Park Elementary School shooting that killed a teacher and student in San Bernardino this year.

Houser said what people need to know about that day is no trauma experts helped survivors at the scene.

“I don’t think there’s a dedicated, trained, terrorist response after-effects team – and that really needs to happen,” he said.

Time, his family and focusing on everyday life — lugging the kids to school, getting groceries and walking the dogs — have helped reduce his post-traumatic stress.

“All these things help you realize your life is still going. But you do always look over your shoulder,” Houser said, sounding sad.

He’s felt relief and guilt over surviving. He’d like the public, including mental health professionals, to better understand post-traumatic stress and legitimize what survivors feel after terrorist attacks.

“Especially for some of the survivors that laid on that floor in that room while the killer went around and shot people methodically that were still in agony, or sat there wondering whether he was going to come and shoot them – listening to these sounds for five minutes, wondering when the police were gonna be there to rescue them – that’s a lot of terror that can really mess up somebody’s mind,” he said.

Ray Britain, who was interim chief of the Environmental Health Services division Dec. 2, and other survivors never understood the term PTSD until they experienced the physical and emotional symptoms.

He’s had high anxiety that’s kept him home. Depression. And tension, with his body aching from adrenaline that flows in fight-or-flight reactions stuck on overdrive.

Insomnia – both going to sleep and staying asleep – comes as the event replays over and over in his head. He’s had panic attacks where his heart raced and he felt about to asphyxiate.

“I never experienced a panic attack before. But when you really feel one, you truly feel like you’re going to die,” he said. “Fear kind of consumes your life. You don’t want to go back to that place and be that helpless again.”

The nervous systems of those with post-traumatic stress become extremely sensitive and are over-stimulated by other people, said Maui-based clinical psychologist Patricia Watson, a senior education specialist for the U.S. Veterans Affairs’ National Center for PTSD.

“Many people kind of want to retreat into themselves and don’t want to be around others,” said Watson, who specializes in terrorism and disaster response.

Lost lives

That was true for Dec. 2 survivors. While some sought solace from family, friends and each other, others simply disappeared.

“I think there are people who have now been lost,” said survivor Julie Swann-Paez, adding her heart breaks over how her friends’ lives were impacted. “People who were happy people just aren’t happy anymore.”

Paula had once been confident, outgoing and calm. After the massacre, she became anxious, withdrawn and forgetful. Snippy and impatient at home. Feeling paranoid. In denial over whether the attack happened. She spoke with a voice that sounded like her trust in people had been broken and hid sad blue-gray eyes behind sunglasses.

Tony let her know she wouldn’t have to go anywhere alone. He drove her to her coworkers’ funerals and memorials, meetings with the FBI and survivors’ gatherings.

He took over her responsibilities at home – making dinner, doing dishes and their finances, shopping for groceries. He and the kids – daughter Elizabeth, 11, and son Jacob, 8 — did laundry. He told Paula to relax and just be with the kids, a strength and comfort to her and them.

Tony researched PTSD. He talked to friends with it, especially Marines who’d seen combat.

Paula often asked him, “Why am I here?” For a few months, she didn’t have the energy to do more than get dressed and brush her hair.

She felt safe enough to go to church, where the same people sat in the same places. She cried a lot there, leaning on her husband as they sat in a pew. He kept his arm around her.

Like others, she didn’t feel ready but returned to work part-time in January 2016 when county officials said she needed to.

‘It sounded like gunfire’

County vector control technician Debbie Munden was out of work with PTSD — unable to sleep, jumpy and hyper-aware – for six months, after she and her best friend, coworker Stacy Toynbee, had been in a parking lot in front of the Inland Regional Center’s Building 3 when they heard a few bursts behind the structure.

Debbie went cold.

“It sounded like gunfire, but your brain doesn’t want to believe that’s what it is,” she said.

After loud, rapid fire echoed off the buildings, they found refuge next door. Debbie later calmed hysterical coworkers while Stacy, a former Army medic, tended one of the wounded. Nearly two years later, Debbie said she’s still somewhat numb, with memory and concentration problems and a shorter temper.

Always there

Experts say trauma reminders can trigger intense, uncontrollable physical and emotional reactions such as fear, horror, shame, a pounding heart, muscle tension or trouble breathing. Vivid echoes of traumatic events can feel so real, they’re known as flashbacks.

“There’s no time sense. It’s now. And that can be very frightening,” said Ochberg, a psychiatrist and Michigan State University clinical psychiatry professor who edited the first text on treating PTSD and sat on the American Psychiatric Association committee that defined the condition.

“Unfortunately, a lot of people who have flashbacks believe they are psychotic. They believe they are going crazy,” he said.

Returning to work after the Dec. 2 attack, Environmental Health Services program specialist Sally Cardinale, 34, had flashbacks every time she went to the bathroom.

She’d been washing at a bathroom sink in the Inland Regional Center when a crack rang out that day. Someone looked into the hall and found a bleeding coworker, Anies Kondoker, standing outside.

“There’s a shooter!” said the woman at the door. Kondoker, who’d been hit in the arm and stomach, fled into the far stall.

A bullet slammed into a wall near Sally, leaving smoke. She and three others, including a cleaning lady, crouched on one toilet, hugging each other to avoid falling.

As shooting and screaming poured from the conference room, she thought she was going to die. The cleaning lady screamed and cried in Spanish.

Shut up. You’re gonna draw them here, Sally told her.

The gunfire stopped. Sally walked in a circle in front of a stall, wondering what just happened.

“You think you’d be the hero,” she said. “I was in shock.”

After returning to work in May 2016, Sally envisioned tiles flying off the wall whenever she was in the bathroom. Then she’d go over what she could do if shooting started again.

When she drove, hearing some songs on the radio took her back to Waterman Avenue, where bodies lay in front of the IRC on Dec. 2.

And Sally would again see a woman lying on the ground, her arms shaking in the air in complete shock, until the next time Sally had looked back and the woman’s body was covered. Sally had survivor’s guilt for some time because she hadn’t run in to thwart the attackers like she thought she would.

Jessica Ballesteros was once so intrepid, someone gave her a small rock with “fearless” imprinted on it. She no longer feels safe and is learning to cope with her fear.

“It will always be there. You can’t erase that,” she said.

Secondary trauma

Dec. 2 survivors wonder if it’s possible to completely heal from PTSD. Swann-Paez asked, “Is there any true recovery? Or do you just live with it?”

She had lain on the IRC conference room floor trying to play dead after being shot twice in the pelvis. The environmental health specialist focused on keeping her heart rate down. She blocked out the screams of friends and coworkers dying around her and told herself to stay calm as blood and urine spilled out of her.

“I can’t let this rewire my brain,” she thought.

Two years later, her mind still replays parts of the attack — Farook entering, coworkers dying. Yet she also replays memories of what she and others describe as secondary trauma – their problems getting medical treatment, medicine or equipment through the county’s self-administered workers’ compensation program.

Swann-Paez said their employer’s “betrayal” has caused her more depression, anxiety and post-traumatic stress than the attack itself – which left her with much less post-traumatic stress than some coworkers.

Ochberg, the psychiatrist, said people who were shot at recover more easily from trauma than someone who wasn’t but lost a coworker or friend and develops survivor’s guilt.

“If you somehow felt responsible for someone who died – that could really haunt you,” he said.

Medical treatment delays and denials are a moral injury that has worsened survivors’ post-traumatic stress, said Ochberg and Watson.

“It’s a secondary betrayal. I would absolutely expect that to prolong the course of recovery,” said Watson, the psychologist.

Fighting the stigma

For many sufferers, post-traumatic stress ebbs and flows over a natural course, during which other adversity in their lives or reminders of the original trauma can trigger symptoms months, years or decades later, Watson said.

Those effects can decline over time. The National Institutes of Health reports PTSD symptoms often never fade altogether.

Many people delay treatment for years to avoid scary memories and potentially-debilitating post-traumatic stress reactions.

Some don’t know what treatment is available, want to handle it themselves or don’t want to be stigmatized as having a mental disorder, Watson added.

There’s a movement by Ochberg and others to change the diagnosis from PTSD to post-traumatic stress injury, or PTSI, to destigmatize what psychiatrist Jonathan Shay describes as a biological injury to the nervous system marked by persistent adaptive behaviors that were needed to survive.

Trauma experts now can suggest several approaches to help, such as resiliency building, medicine, cognitive behavioral and exposure therapies, yoga, meditation, acupuncture and biofeedback.

New Jersey resident Sarri Singer, who began New York-based Strength to Strength to support terrorism survivors after living through a 2003 suicide bus bombing in Israel, said psychotherapy doesn’t work for everyone. She believes survivors recover better with support from other survivors.

Dec. 2 survivors say they wish they’d been given a list of what would help them recover and where to get help. Instead, they’re doing their best to figure it out themselves.

“We’re trying everything we can think of,” said Britain.

Moving past shock

Paula tried yoga, homeopathic remedies and aromatherapy for anxiety. She began medications in August 2016 as anxiety got bad and a doctor put her out on her first medical leave. Being at home with the kids and outside work helped most, her husband said.

She also felt more at ease because he’s nearly always got a gun on him.

It took more than a year before she could start moving past shock and begin to accept that the attack was real and people were gone – including two of her employees. Counseling, exposure therapy and time helped her process the attack.

When she began equine-assisted therapy in January, she felt worthless, isolated and weak. But with encouragement from Equus Medendi founder Sheer and therapist Lilly, Paula slowly went in the corral and later stood in front of the horse.

It took four or five more sessions before she felt comfortable being that close to one.

The short-term program – which involved working with the animal, but not riding — helped Paula build trust and body language awareness.

She learned how to regulate her breathing and heart rate, and how to recognize and process her feelings. She learned that when her anxiety is high, she needs to move. She got hope back by building her strength.

As good as it gets?

In the past six months, Paula’s been able to get out more — going to her son’s baseball games, picking out pumpkins at a farm. She’s guarded and processes things slowly, but has regained some patience and confidence. When she looks somber or withdrawn, Tony takes her hand and tries to lighten her spirit.

She’s gone back to work four or five times. Each time, anxiety and depression returned – worse than before.

“So everything we worked for, moving forward — alleviating stress and anxiety, depression is down — she goes back to work and all the triggers came back even stronger,” Tony said.

She last went out in July, after a break down at the San Bernardino office, where she and other Rancho Cucamonga staff relocated after five of those killed had worked in their office.

As the two-year anniversary approaches, some survivors’ workers’ comp cases are being closed when “qualified medical evaluators” or “examiners” list them as “permanent and stationary” with a certain disability level. Several of the nine survivors represented by workers’ comp attorney Geraldine Ly were listed as 18 to 51 percent disabled, with most on the higher end.

Permanent disability settlements are based on those levels and divided into weekly payments. Some survivors aren’t returning to work. Some are applying for medical retirements. Some survivors’ cases were closed far earlier and they were listed without any disability.

In July, a qualified medical examiner said Paula was 51 percent disabled but ready to work again in a different location, in a diagnosis that stopped her temporary disability income without notice.

Wanting her not to work for the county anymore, Tony urged her not to push herself too fast, but said the decision is hers.

However, Paula enjoys her job supervising restaurant and pool inspectors. She returned part-time in September.

“I thought by going back, it would return things to normal,” she said.

The first morning, she drove an hour through a thunderstorm, with lightning flashing all around her, to reach the Hesperia office where her new supervisor is also a Dec. 2 survivor.

“I can make it,” she told herself as she drove.

After working a month, Paula increased from three to four hours a day, three days a week.

Tony worries she can’t progress as fast as the county wants. He’s waiting to see how much she can endure and still keep going. Injured workers are supposed to use the settlement money to pay for future medical needs. He wonders why civilian terrorist attack survivors like his wife can’t get PTSD treatment as long as they need it, like veterans.

He refuses to believe what the psychiatrist claimed: that his wife is “permanent and stationary” — the doctor’s way of saying Paula’s condition won’t improve even with more treatment.

“I don’t believe that that’s as good as she’ll ever get,” he said.

Whatever happens, he’ll be there for the rest of the journey as they work together for Paula’s recovery.

“Those feelings never go away. You just kind of learn to manage them,” said Paula, sitting one morning in a corral shaded by pepper trees.

A quarterhorse named Heidi paced along the fence as she and Sheer watched. Once a skinny rescue animal who didn’t trust humans, the horse now weighs 1,100 pounds and is a trusted therapy team member.

“She’s beautiful and so strong and so powerful – and yet so vulnerable. And that’s what we can relate to,” Sheer said. “You can be both – and it’s OK.”

[This story was originally published by The Sun.]