You’re working your way through your many patients one day, and this is what you encounter:
- A woman who won’t meet your gaze when you ask her questions.
- A man who rocks on the end of the exam table, arms crossed over his chest, eyes unfocused, even as he denies hearing voices.
- Another woman who says she’s not using heroin, but whose drifting gaze makes you want to snap your fingers in front of her face to get her to focus.
Nearby, you hear another provider leaving an exam room in disgust, saying, “What can you do if they just won’t listen? I can’t care more about their problem than the patient does, now can I?”
It’s just another typical day on an urgent care shift at a homeless clinic. All of the patients described here are showing tangible symptoms of complex PTSD.
Many of us know a bit about post-traumatic stress disorder, or PTSD, a constellation of symptoms that can arise after a severe trauma, like a car crash, a fire, or a rape. But few of us — not even medical providers who see it day in and day out — know very much about complex PTSD, or disorders of extreme stress, not otherwise specified (DESNOS).In older, quainter-seeming times, it was sometimes called shellshock.
I saw it in Haiti, where friends brought a woman to the aid tent and told me, in horror, that she wouldn’t drink water. When I gently pointed out that refusing to drink water would inevitably kill her, the woman would only nod, eyes averted, arms crossed. She could not have been more distant, more dulled, more, well, bored seeming.
If you are the medical provider in such a situation, there is a moment of disbelief. You think that the person you’re talking to must not understand what is at stake. Then, when you realize that she knows and really doesn’t seem to care, you think that if suicide is the goal here, there are better, less horrific ways to die. And then, when you realize that your patient truly won’t respond, no matter what you say, fatalism tries to take root. After all, what are you going to do? If she doesn’t care, what options are there?
But if you know anything about complex PTSD, then you also know that there will be times when something breaks through and she becomes unglued, hysterical with grief, and overcome with emotion. But getting her to focus then, being able to connect with her then, will be as difficult, if not more difficult, than the times she seems “gone.”
Complex PTSD is a result of repeated, sustained trauma. Disassociation is a major trait in complex PTSD. Many of us have heard of dissociation as a coping mechanism for children who are repeatedly abused.
Another characteristic of complex PTSD is emotional dysregulation. There are states of weeping, or rage, or other types of loss of control mixed in with states of dissociation.
Finally, there is also self-harm, which can take many forms.
The only major difference between the Haitian woman and that of many homeless people in ERs is that there were no drugs of abuse available in Haiti. Substance abuse, and active or passive self-harm, is a hallmark of complex PTSD. Add in some heavy alcohol, or crack, or heroin, and you get the full spectrum of complex PTSD expression seen in America.
Besides being a form of self-harm, substance abuse becomes another way to dissociate. For a chilling demonstration of complex PTSD and the factors that create it among the homeless, watch Ed discuss his experiences in these two videos, here and here.
Violence is a constant backdrop to life on the streets. Rapes, assaults, and death lurk around every corner. People can feel hopeless and lacking in control. Without a door to lock, there are no options for getting away from the constant risks. A sense of safety is not only denied, but violated, over and over. Many homeless people came from disrupted, disadvantaged childhoods, so the violation can be life-long.
Add to this constellation of traumas the availability of cheap, highly addictive drugs. I would argue that adding profound addiction to existing complex PTSD creates a form of complex complex PTSD. When you combine the difficulty of treating addiction with the difficulty of treating complex PTSD, you might begin to think, like your patients, that there is no hope.
But there’s a growing recognition of the role that complex PTSD plays in trapping people into homelessness, and important strides are being made in treatment.
One method of treating both complex PTSD and substance abuse helps individuals reach a stage called “seeking safety.”A brilliant step-by-step manual, written by Lisa Najavits and titled Seeking Safety, is the most ruthlessly practical psychotherapy manual I’ve ever seen. The book walks individuals and providers through the options for therapy (particularly group therapy, which is becoming a more common treatment for complex PTSD). In addition to presenting pragmatic, improvement-oriented suggestions and lists, Najavits acknowledges the difficulty of moving ahead, and the need to grieve.
There is something poignant and visually moving about observing group therapy for the homeless. Clustered in a room, sheltered in that moment from the extreme violence of the streets, people come together to learn how to ground themselves again in the world. Grounding steps include tasks like reaching out to feel an object, as well as identifying ways to re-connect with yourself.
Finding, creating, and maintaining a tiny sense of safety, even within one’s thoughts, is the goal of therapy. It is akin to building a matchstick house in gale force winds. Each added tiny twig of created safety strengthens the whole until psychological safety can be established.
Disclaimer: Identifiable patients mentioned in this post were not served by R. Jan Gurley in her capacity as a physician at the San Francisco Department of Public Health, nor were they encountered through her position there. The views and opinions expressed by R. Jan Gurley are her own and do not necessarily reflect the official policies of the City and County of San Francisco; nor does mention of the San Francisco Department of Public Health imply its endorsement.