Working as a clinician in a high crime neighborhood poses its own set of challenges.   It is hard to feel safe, especially if one doesn’t naturally blend in. It is hard to be accepted by ex-convicts and parolees, drug dealers, and murderers. It is a very educational experience but it comes at a high price.  About 50% of my caseload of 75 people were diagnosed with PTSD.  You think you know about PTSD until you come into contact with it every day.  You learn a lot about abuse, suffering, and trauma. The neighborhood felt like a war zone.  I hospitalized suicidal people every week.

I learned quickly that if one is non-threatening people will open up to you. One of my clients ran guns out of the neighborhood. He was Schizophrenic, early 20’s, malnourished, an addict, scared, close to his mother, and suicidal. For fun, to burn off steam, and to see if luck was on his side, he used to jump between the roofs of buildings with friends.  Another client was a drug dealer who told me why he went to prison.  He defended himself when a business competitor was choking him. He sliced their arm open with a knife, from elbow to wrist, the long way.

Many of these clients scared me. I didn’t like being in a room alone with them. You learn who is dangerous. When I was talking to a gang leader from prison for the first time, my countertransference got the best of me and I started asking him all sorts of questions designed to satiate my own curiosity about prison life. He was a small man and shook like a leaf from anxiety.  Had he been scared in prison? No, he said. He was a made man, a leader. He was protected. His gang would kill for him and die for him and other prisoners knew this.  He taught me about the ethics of gangs and their moral code.  When you came into the prison you had to show your papers and explain to his group why you were there. Murder? It depends. If you came home and found your girl in bed with another man and killed the man that was acceptable. If you killed a woman, you better have a good explanation. If you hurt a child? He said the best thing for you would be to stay in your cell. 

He explained to me that it was unacceptable to kill people indiscriminately.  He said any murder he ordered was well thought out and planned. It was never random violence. I asked him if I was safe with him in the room? Sure, he said, he was completely in control of himself, and I had done nothing. I believed him.  I actually found myself liking him and feeling sorry for him. He seemed so vulnerable, so cold, holding himself, shaking like a leaf waiting for medication.

Compare this to a man I met who when angry would be so overtaken with rage that his mind would go blank and he wouldn’t remember what he did. What did they tell him? What had he done? They told him he was cleaning a floor and someone got too close to him acting aggressively. He swore, and I believed him, that he had no recollection of throwing the man out the window, and then his dog after him. But, he had no remorse, and that concerned me. I was more afraid of this man than the gang leader, because this man was not in control of himself.  We were treating him for depression and anxiety, but there is no treatment for anti social personality disorder, and after a few sessions I told my supervisor I would not meet with him again.

There were other clients I refused to meet with.  An ex-convict asked me in our first session where I lived.  I lost my professionalism and responded “none of your business.” “But I can Google you” he said threateningly.  I knew he was right.   I was later told that he was just being provocative and was a pussycat. A female clinician reported never feeling unsafe with him. Maybe tall males reminded him of his judge or his parole officer and he was having a negative transference? It could be, but the reason was unimportant, and I refused to meet with him again.

There was also a man who said he trusted nobody – not me, not his mother, not his girlfriend. He showed me the pair of eyes he had tattooed on the back of his neck so he could see behind him.  He was not a drug dealer but had a penchant for robbing drug dealers. At times, they would shoot him.  Rushing a man with a gun did not scare him because he was not afraid of dying. He only had one kidney as a result. He was in prison numerous times in numerous states and had left the country but was captured and brought back.

Wanting to reassure him I was no threat, out of a salacious desire to hear more, and an ego driven desire to gain the trust of a felon who did not trust his own mother, I assured him that as a professional I could not divulge anything he told me. “But”, he said, “I’ve heard therapists mention clients’ names out loud within earshot of others in the waiting room. It happens. People slip.  I’m not going to tell you everything, and don’t slip.”  Anti-social people are often very smart.

Then there was the client who was middle age, bald, and had a suspicious appearance.  He told me that when he was younger he got into trouble, but not now. He was too old and had no energy and was medically sick and would get panic attacks. He liked spending time with his girlfriend of many years. The way he described his relationships I really liked him. He was caring and considerate and thoughtful. “Oh, don’t worry”, he said, ” I know you don’t fit in here and some of these guys will give you a hard time, but I got your back.” I didn’t think he could protect me, but his thoughts made me feel safer all the same.

I was getting worn down and there was no time at work for socializing with co-workers so there was little social support. This kind of work demands built in support systems and they were lacking.  There was no time to relationships at work to insulate you from the stress. Going home at night in the winter was no fun either. I didn’t feel safe until I got home.

When I finally got home, I would cry for no reason and bark at people I love. This is called secondary trauma, and it can happen to people who work with traumatized populations. It happened to first responders after 9/11.  Over-exposure to PTSD can be contagious, almost like a cold.  Working with a traumatized population must be coordinated and requires a team overseeing the well being of the care providers.

Most of the clients who had PTSD had traumatic lives before the triggering event. Their fathers or mothers beat them. They may have been sexually molested.  When soldiers go to war, all are exposed to the hell of war and most do not come home with PTSD. Why one person does and another doesn’t can depend on many factors and no two people react to stress in the same way.  How soldiers are welcomed home by their communities and families has as great an impact on their chances of developing PTSD as what they experienced.

The DSM does not describe PTSD sufficiently. It says that to get PTSD one must have been afraid for one’s life or thought that great bodily harm would befall you or someone you loved or have seen terrible physical harm befall a comrade or loved one.  The emphasis is on fear. A soldier client taught me this was simplistic. It is not just overwhelming fear that can trigger PTSD. Other feelings can trigger it as well. In fact, almost anything can trigger a traumatic response.

A client I saw weekly told me about his experience in Panama as a soldier in the US Army and how he saw a friend killed while standing next to him. He had all the classic symptoms of PTSD – a startle response when he heard any metallic sound (it reminded him of a grenade or gun). He couldn’t sit still. He was depressed with a depressed affect. He had flashbacks and nightmares.  But, his explanation of seeing his friend killed sounded too simple. 

It turned out that he had been beat with a cord as a child and when he went to hide they would track him down so there was no escape.  That was the beginning of the formation of his PTSD. The helplessness and fear he felt in battle reminded him of his childhood beatings.  He kept repeating the same stories so I asked myself what he wasn’t talking about. He always struck me as a gentle soul.  Where was the true trauma for this gentle man?

I recalled that he had been a sniper in the army. On a daily basis, he would look through a sniper scope and see a close up of the face of the man whose life he would then take.  He would do this repetitively.  So, one day I said to him “you’ve told me a lot about your father beating you as a child and your not being successful with women and your being socially isolated and seeing your friend get killed on the battlefield next to you. But, you have never spoken about what you did as a soldier. Weren’t you a sniper? ”

“Yes” he said “and I was extremely accurate so they started training me how to shoot from far away.”

“But when you shoot” I said, “don’t you see a clear picture of the man you are about to kill? Don’t you see his face?”

“Yes” he said, looking upset.

“What is that like?” I asked, tentatively.

“Oh that? I don’t talk about that. Oh no, not ever.”

There it was.

I finally understood that it was his guilt over killing and not his fear of being killed that caused this man to develop PTSD.  He couldn't even talk about it, and the unspoken gets expressed as symptoms and illness. Fearing you will lose your life can trigger PTSD, but so can feeling guilty that you gave up your soul.