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PTSD and the Homeless: Shell-Shocked on Your Streets

PTSD and the Homeless: Shell-Shocked on Your Streets

Picture of R. Jan Gurley

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.

homeless, doc gurley, reporting on health, health journalism, 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.

Tips for Reporters: You don't have to go to Haiti to find complex PTSD or shellshock. Is there a complex PTSD story in your area? Does knowing about complex PTSD change the way you view the homeless around you? Check out the website to find and connect with a local group.

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.


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Dear Jan,

I've taken considerable consolation from these posts.

There is a lot to understand. About culture and about social issues and society.

You are hitting some points that my famiy is in the middle of. Heroin. Homeless. Child Welfare is in there.

How are families to cope? I ask you? We want to help, but, they are PTSD (and us as well, we just are mor lucky with our stories, our lives).  And we are stymied.

We are there families.

What to do.

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a million thanks for putting a face on our lost brothers and sisters, I was there, a Viet Nam

era vet, who came back through desperation to be a professor for eight years in Asia. Luck, family,

Santa Cruz, love, fellow humans, sex drive, pride,  but a desire to never give up and waste the precious god given life anymore, AA was not it, yoga was, and grace, so grateful now, but want the whole life and quite a ways to go for it, when you are sick enough of it, and mad enough at the idiots in power, you finda way, community college, loans, odd jobs, live in a rural woods, whatever it takes, and listen to no inane bureaucrat, or shallow counselor, only you know what it was, you can make it again.

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Thank you for writing about this.

But I think the premise is faulty.  Seeking safety is a cruel joke. 

The humane thing to do is to either provide true safe permanent respite or to euthanize endlessly tortured people.  But anything else simply prolongs the torture and treatment goals to increase grounding - eg self awareness - makes people suffer more, not less.

I speak as one who was a provider and then became one of the "other".  Without exception, even though Iclearly and repeatedly explained what was happening to me, was tested and had confirmatory results, not a single physician addressed any trauma, made any referral or provided anything other than phony false hope predicated on deception, coercion and outright lies.

You are so rare in that you see and interact with patients as people.  But you are one in a million, if that.

If you want to get just a gentle, bloodless glimpse of what it's like, read C Fred Alford's work about whistle-blowers (The Experience of Choiceless Choice).  He coins the phrase,"knowledge as disaster" and lists what people have to deal with.  Essentially, it's that no one and nothing is free of corruption, can be trsuted and is safe.  Predators and prey.

I've been prey for so long and I'm so picked clean that physically dying is a longed for state.  I've already been socially murdered via ostracism, and experience violent trauma as a way of life.  Who can blame us from wanting it to stop?

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I have recently found myself homeless through no fault of my own. My landlords kicked me out of home where I lived for 20 years! I've been in a daze since these landlords started threatening me with eviction. My PTSD combined with chronic depression and OCD is off the charts! Family and friends support has broken down and I can't understand why. I guess it's because I've lived independently for long time and have hid my mental illness from them as best I could. They can't seem to fathom how hard it is for me to start over. I really am shelled shocked and wanting desperately to wake up from the ongoing nightmare that consumes my whole life now. All I have is my service dog and some possessions. I won't last on the streets, I'm too fragile! Thank you for reading.

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I have been intrigued by the prospect of acknowledgement of homelessness as a major trauma. I have worked in
Social Services for over 10 years. Colleagues and peers have traditionally assigned PTSD only to veterans. My observations took me in an opposite direction. Lethargic states that cut across age ,race and gender further convinced me that that PTSD could be the culprit. This article has brought me relief in knowing that homelessness is far more complex than the public is aware of.

Sylvester Coleman

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I'm one of that increasing number of people who don't live on the street but also have no fixed home. I go from friend's place to temporary rental, and it's only just occurred to me: I'm suffering from PTSD. I cannot imagine what the poor folks who sleep rough go through, for if my situation is already greatly affecting my life, then what it does to their is unimaginable.

Of course it becomes a vicious circle, so that I'm never well enough to look for or perform proper work, which in turn makes me ineligible to rent an apartment, which keeps me homeless, making me a mess.

What world do we live in that there are empty abodes all over the place and yet so many of us have no place to live!

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Thank you so much for writing this article and thank you to those who posted and shared so openly. I serve homeless men and women in LA's Skid row community and also have a family member that is homeless. I am looking for stats on the percentage of homeless people in Los Angeles who have PTSD and also for stats and research that reflect the same nationally. Can you point me in the right direction?

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Googling these words in the subject bring up a lot of scientific studies & papers.
You should also explore papers that talk about autism, and how many people on the streets exhibit signs of autism.
Both can create a "blocked off" reaction. Bet it's difficult to differentiate between the two.


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