How Surviving Trauma Can Kill

It is imperative that homeless shelters and services embrace the best practice of trauma-informed care. The sequelae, or after-effects, of childhood trauma can literally ruin one's life or lead to deadly circumstances. The Substance Abuse and Mental Health Services Administration, or SAMHSA, provides an excellent curriculum and lots of resources and research to help homeless providers get up to speed on this approach, though I can imagine the response of the typical director of an agency (having heard it just a few times): "We save people's lives by providing overnight shelter. That is the most important thing." "We don't have the time and money to train staff." "We have to treat everyone the same way, otherwise we are not being fair."

There are simple answers to each of these responses — the SAMHSA training is free and the entire curriculum and resource guide to providing trauma-informed care is on its website. And yes, it is important to treat everyone the same way. However, the standards of care outlined are a way to treat everyone humanely, not just trauma survivors. The irony is that so many adult homeless people are trauma survivors that treating the eight percent or so who are not is not likely to offend anyone.

Indeed, I would argue that homelessness is so traumatic that even without a history of trauma, by the time a homeless person has observed a few beatings or struggled through a winter on the streets, they are pretty darn traumatized. And I do understand that providing overnight shelter is the central mission of most shelters, but for those who are interested in saving lives, please read this real-life example to understand how understanding trauma can save lives, too.

Rod has worked his way out of homelessness twice in the time that I have known him. Most recently, he got a job on the night shift at a 7-11, and saved money until he was able to afford a run-down trailer. He slowly fixed it up, and has a picture of himself standing proudly in front of the repainted trailer. Last spring he was running to catch a bus, and slipped on the ice. Nine months later his leg is still swollen from a blood clot, and the doctors are suggesting amputation. Rod is hesitant to agree to the amputation, although he is exhausted, taking drugs to prevent clotting and fighting infection. He is allergic to opiate pain medications and does not drink alcohol, so he is using meditation to deal with his pain. He chooses to sleep in a tree rather than accept a medical respite program in a different city.

How does this relates to the after-effects of trauma? Trust.

Rod's lack of trust is the fundamental reason that he will not accept the doctor's recommendation. He was raised by an alcoholic mother and was verbally and physically abused. He left home as a young teen after his mother shot a bullet into the ceiling in an alcohol-fueled rage. He learned early on that the world is not a safe place, and even those whom you trust the most can be unpredictable and dangerous. That same self-reliance and independence which gave him the determination to work his way out of homelessness also must undoubtedly frustrate the doctors who work with him. Rod is understandably focused on survival — How will I walk outside in the snow with a prosthetic? How will I find a place to sleep with my limited mobility? How will I defend myself when I am attacked and robbed?

Considering his history of trauma, how can he trust a doctor to amputate his leg when he learned early on that even the people who love you will betray you? How can he trust a doctor to amputate his leg when experience tells him that the weak and vulnerable are targeted? How can he trust a doctor to amputate his leg when his experience tells him that bad things happen to good people?

So Rod uses a pulley to hoist himself into a tree each night. (He tells me that the police rarely look up when they patrol.) His eyes are rimmed with pink from fatigue and his worn and lined face is exhausted beyond description. Last week his leg had small black streaks, and he is fighting cellulitis.

Join me in asking the executive directors of homeless services to sign a pledge that they will educate themselves and their staff in trauma-informed care.

Photo credit: rearl