by Jess Hill
In all of New South Wales there is only one long-term refuge for young women: the Lillian Howell Project in Erskineville, which has been there since 1986. In 2014, when the state government ran its scorched-earth reforms through the refuge sector, dozens of shelters lost their funding to larger (mostly religious) charities that had to serve general homelessness (not just victims of abuse) in order to win government funding. The government was ready to close Lillian’s, too, before a public campaign saved it from the chopping block. Today, Lillian’s accommodates up to eleven young women who have fled their homes. They enter a loving environment where the girls cook and eat together, watch DVDs and play games in the common room, and each has a room to herself. ‘We’re all about hugs,’ says Vivian Stasis, the manager at Lillian’s. ‘And they ask. A lot. “Can I have a hug?” “Can we have a group hug?”’ Stasis says that around 90 per cent of the girls who end up at Lillian’s have come from violent homes, and are from all walks of life. ‘There are kids here who are privileged, who are going to private schools, there are kids who are not so privileged.’
But it’s a rare and lucky homeless kid who ends up somewhere as loving and secure as Lillian’s. When Anna ran away from home at fifteen, she was bounced from shelter to shelter, and ended up sleeping rough in the dead of winter. Her sudden homelessness was triggered by a terrifying episode of violence. After a huge argument with Anna’s father, her mother and sister fled and left her alone in the house with him. She ran upstairs and hid behind a door, listening as he threw knives around the kitchen, bellowing that he would ‘salt the earth’ where he and Anna’s mum had planted a vegetable garden. Then he said he was going to get his gun – and if Anna ran he would kill her. She waited until he was at the other side of the house and made a run for it. For that entire night, she sat, freezing cold, on her youth group leader’s doorstop. ‘His dad opened the door the next morning and fell over me. They had me stay for about two weeks.’ After that she was moved on to a youth refuge, which was ‘incredibly violent’. The extreme conditions she endured while homeless were shocking to Anna. ‘Even though my situation was violent, I was still incredibly privileged. I went to a private school and had lived in incredible wealth.’ Anna ended up at a YWCA with mostly older, pensioned women, before her mother got some money together for her to live in a unit. Anna was in Year 9. ‘I bounced through a couple of schools at that point, then quit school for half a year, then went off and ran around like a ratbag. Sometimes I was home, sometimes I would sleep out in the street.’
THE CHILD ADAPTS
There’s no question that growing up in a violent home makes it more likely that a child will become either a victim or a perpetrator of domestic abuse themselves, will turn to criminality as they grow older, or will suffer significant physical and mental issues related to their trauma. But not every child who grows up with domestic abuse is condemned to suffer the impact for life. A review of 118 studies on children exposed to domestic abuse found that more than one-third were doing just as well, or better, than children from non-violent homes.29 The distinguishing factor here is a mystery – was it that they had one teacher who believed in their potential? A close friend who gave them a sense of security? A neighbour who provided a safe place to escape?
Many children, however, are not so lucky. For them, life becomes a farrago of symptoms, psychological and physical, that seriously impede their capacity to care for themselves and trust others. They can spend years searching for a way to explain how they feel, experimenting with prescription cocktails that improve things for a while, until they wind up feeling worse. No drug will heal their wound; even when they may appear to be coping on the surface, the original wound festers, untreated, until something comes along to tear it open and start the bleeding afresh.
After years of wondering if she was bipolar like her father, Anna was recently diagnosed with a condition that finally made sense to her – complex post-traumatic stress disorder (C-PTSD). It took a suicide attempt for her to seek help. ‘You know, child abuse and domestic violence is really common, so I thought I should be able to get on with this by myself. I spent a lot of time unsure why everyone else seemed to do things so easily – Why can’t I take a shower? Why can’t I just fucking brush my teeth? I wondered why I’d react so strongly to things other people let slide, why relationships with people I cared about would inevitably break down, and why I couldn’t get the treatment I needed.’ In hospital after she tried to suicide, doctors told her she was smart enough to know she’d have needed double the dose to kill herself, and then discharged her. ‘They were right,’ says Anna. ‘I didn’t want to kill myself. It was a cry for help.’ Staff gave her a contact number for a psychiatrist – ‘only because I asked for it’ – who had a six-week waiting list. Anna was on edge every day, thinking constantly about suicide. ‘Suddenly I decided that I would use my skills, and try and help myself. I began ringing different psychologists and psychiatrists and saying, “This is what I’m going through, tell me how you would help me.” I would sit there and listen, and then I would say, “Thank you very much, goodbye,” until I found three I thought might be on the money. And I paid for sessions with all three of them.’ Anna got lucky with the last one on her list. ‘She was the first person who talked about childhood developmental trauma and C-PTSD. I’d never heard those terms before. As soon as I left her office I started googling, and then I realised what she was trying to say to me.’
Complex PTSD, also known as childhood developmental trauma, was first conceptualised in the early 1990s by two of the world’s leading child trauma specialists, Judith Herman and fellow Boston psychiatrist Bessel van der Kolk.
The notion of trauma as a profound disruption to life and behaviour had only been officially recognised around a decade earlier. In 1980, traits that rendered many Vietnam War veterans pariahs – drug and alcohol abuse, chronic unemployment, homelessness, violence – were finally recognised as symptoms of a new condition: PTSD. The diagnosis was simple: a person who had responded to a traumatic event with intense fear, helplessness or horror then went on to re-experience the trauma over and again, through vivid recollections, nightmares, dissociative flashbacks and hallucinations. People with PTSD would become, among other things, hypervigilant, easily angered, irritable and pathologically detached from other people, and often had little hope for the future. PTSD became an official condition with one simple act: it was published in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, or the DSM-III.###
As soon as PTSD became an official diagnosis, it was applied to an enormous range of people who had suffered trauma, including children who had grown up with domestic abuse. But the childhood abuse survivors Herman and van der Kolk were seeing did not fit the PTSD diagnosis. Their trauma stemmed from ongoing abuse and was usually perpetrated by someone they trusted. While they shared several symptoms with sufferers of PTSD – hypervigilance and flashbacks, for example – they had a laundry list of extra symptoms. As van der Kolk explained, his clients were needy, reckless, clingy, angry, despairing, chronically ashamed or suicidal. They had severe problems trusting other people; frequently self-harmed; had trouble remembering large sections of their childhood; and often felt utterly disengaged or disembodied. They also shared a familiar script: that they were innately unlovable, and their loneliness was so intense nobody could possibly understand how it felt. They were often chronic over-sharers, divulging the most intimate details to virtual strangers, and they suffered a raft of physical health problems: from fibromyalgia and irritable bowel syndrome to headaches and back pain. No single diagnosis could describe their condition; instead, they were diagnosed with a mixed bag of PTSD, bipolar disorder, depression and, especially, borderline personality disorder.
Seeing the enormous harm misdiagnosis was doing to their patients, van der Kolk and Herman proposed a new diagnosis that made sense of their symptoms – ‘complex PTSD’, or the rather clunky ‘DESNOS (Diagnosis of Extreme Stress, Not Other
wise Specified)’. As van der Kolk writes, this new condition included the physiological and emotional responses common to PTSD, like hypervigilance and flashbacks. But complex PTSD was very different, because at its core it was a condition caused by betrayal. Children with complex trauma ‘develop a view of the world that incorporates their betrayal and hurt. They anticipate and expect the trauma to recur and respond with hyperactivity, aggression, defeat or freeze responses to minor stresses.’ Faced with reminders of their trauma or other stressful triggers, they tend to become ‘confused, dissociated and disoriented’. Because they are conditioned to expect betrayal, they ‘easily misinterpret events’ to make them signal a return of trauma and helplessness, a worldview that causes them to be ‘constantly on guard, frightened and over-reactive’. Because they have lost any belief in being looked after and kept safe, they organise their relationships around the expectation of being abandoned or victimised. ‘This is expressed as excessive clinging,’ he writes, ‘compliance, oppositional defiance and distrustful behaviour, and they may be preoccupied with retribution and revenge.’30 Because they feel they can’t rely on anyone, they are suspicious of others and have problems with intimacy, which results in social isolation. They are, wrote van der Kolk, often literally ‘out of touch’ with their feelings, and have no language to describe their internal states.
Common symptoms of complex PTSD are:
•distrust
•suicidal thoughts
•episodes of feeling detached from one’s body or mental processes
•isolation, guilt, shame, or a feeling of being totally different from other people
•helplessness and feeling hopeless
•self-harm, self-mutilation
•alcoholism or substance abuse.†††31
By the early 1990s, the concept of complex PTSD had gained so much credibility that the American Psychiatric Association asked van der Kolk to examine its validity as a psychiatric diagnosis, in preparation for the fourth edition of the DSM in 2000. After reviewing hundreds of studies, the DSM-IV committee voted 19 to 2 in favour of inclusion in the upcoming manual. But it never made it in. As the proposal was passed up the decision-making chain, it drew criticism from the DSM’s most powerful stakeholders. They were uncomfortable with the way the symptoms of C-PTSD overlapped with those of so many other disorders. For van der Kolk and Herman, this was precisely the point: their patients needed to be treated for the one common condition they actually had – C-PTSD – not a pastiche of inaccurate conditions and disorders, each with their own medication and treatment schedules. But neither van der Kolk nor Herman anticipated how fiercely the establishment would defend these conditions. At stake was millions of dollars in research funding and, since C-PTSD is not treated with medication, the potential for an untold loss of profits to the pharmaceutical industry. Introducing a new diagnosis of C-PTSD threatened nothing short of a revolution in how millions of trauma survivors would be treated – with therapy rather than medication.
Today, there is still no official disorder in the DSM§§§ to describe the full range of symptoms and behaviours experienced by children and adults who have lived through prolonged trauma. ‘Because they often are shut down, suspicious or aggressive they now receive pseudoscientific diagnoses such as “oppositional defiant disorder”, meaning “This kid hates my guts and won’t do anything I tell him to do”, or “disruptive mood regulation disorder”, meaning he has temper tantrums,’ writes van der Kolk in his bestselling 2013 book The Body Keeps the Score. Before they reach their twenties, he writes, many patients have accumulated a collection of impressive but meaningless labels and, if they receive treatment for them, it is usually whatever ranks as the trendy method of the moment – medications, behavioural modification, exposure therapy and so on. ‘These rarely work,’ writes van der Kolk, ‘and often cause more damage.’32
When people with C-PTSD finally get diagnosed, it can be a huge turning point in their lives – a feeling they have been ‘seen’. ‘I felt overwhelming relief when I finally got a diagnosis of C-PTSD,’ says Anna. She has been receiving specialised therapy for complex PTSD ‘on and off’ for three years now, but the struggle to overcome the symptoms may be lifelong. ‘C-PTSD divorces you from your ability to create emotional bonds. In relationships, I’m constantly waiting for the other person to betray me, because my parents – who I loved more than anything in the world – betrayed me constantly. It’s not just that trust has been broken with the parents and within the self, but with your relationship to the universe. It’s your whole schemata, and you can’t get it back. But you can work on it.’
C-PTSD is not a disorder, in the classic sense of the word. It is an identity that has formed around defence and survival – a genius adaptation by the child to survive physically and psychologically. The trouble is that once the child is safe, the tactics and beliefs they employed to survive are severely maladaptive. A trick like dissociation – mentally disappearing during a trauma – is a brilliant survival tactic. But if you dissociate when you’re at school, at work or crossing the road, it’s no longer serving you as a survival tactic; it’s putting you in danger. However, people with C-PTSD can become very attached to their survival mechanisms no matter how maladaptive they are – after all, they kept them alive in times of chronic threat.
Anna says the need for people across various systems to understand C-PTSD is urgent. ‘Failing to treat the effects of trauma dooms women and their children to lives through a glass darkly: you escape the violence, but the lens of trauma never leaves you and your descendants. The fight against domestic violence doesn’t end when we flee the house in the middle of the night.’
*
Halfway through work on this chapter, I received a voice message from Carly’s godfather, who was letting her stay with them, following her fleeing her father’s home to Newcastle. ‘Today, an order was issued through the Family Court to have Carly returned [to her father],’ he said. ‘We’re expecting police and a really ugly scene.’
Two months earlier, Carly’s father, John, had applied for a recovery order, not long after she had run away. This had now been issued by the Family Court, with police directed to ‘find and recover the child’ and to ‘stop and search any vehicle, vessel or aircraft and to enter and search any premises or place’.
I spoke to Carly the next morning. She said that after seeing the recovery order, she’d spent the night in tears and had barely slept; she would be safe until 4 pm, she said, which was when the recovery order would take effect. I asked what she would do when the police arrived. ‘I’ll just stand my ground and tell them my story, and invite them in for a cup of tea,’ she said. ‘That’s basically it.’
The next day, Carly’s godfather called again. ‘At about 9 am, a paddy wagon came up my driveway,’ he told me. ‘Three police officers came to my door in full uniform, guns on their belts, all male, and said they had a recovery order for Carly.’ They informed him that John was waiting at the police station to collect her.
Carly’s godfather immediately called his partner, who was out with Carly. He told her she had to take Carly to the police. Not knowing what else to do, she drove Carly to the nearest station. When she got out of the car, Carly locked herself in and threatened to self-harm if police forced her to go inside. After her godfather’s partner explained the situation to an officer inside, ‘he recommended that she take Carly to the hospital to have a mental health intervention’.
The Emergency triage notes for Carly say she was diagnosed with ‘Adjustment Reaction Disorder with Depressive Features’ and ‘Significant Risk of Intentional Self Harm’. She was referred to a locked ward, where she received a second mental health assessment. The psychologist noted that Carly ‘presented as an intelligent, mature fifteen-year-old. Her distress appeared genuine, no calculated attempts to manipulate the assessment were perceived.’ The assessment also noted that if Carly was forced to return to her father, she would try to kill herself; that she had stashed a
razor blade in her bedroom, and if she couldn’t do it that way she would look for drugs to overdose on.
Carly was kept in hospital for almost three weeks. When she was ready to be released, her father – who still had sole parental responsibility – refused to let her stay with relatives. Carly was forced to find accommodation in a refuge. The rules were harsh: she wasn’t allowed to stay there during the day, so she had to spend daylight hours in the library or sitting in the local food court. For the four months she lived in the refuge, and despite asking for schoolwork, she received no schooling. All of this she went through without mental health support, and alone: by court order, she was still prohibited from speaking to her mother.
That was two years ago. Since then, life for Carly has changed dramatically. Now seventeen, she is no longer subject to the whims of the Family Court and is back living with her mother. Despite failing Year 9 (the year she ran away), she is now in a pre-university course, where she is topping a class of more than 200 students.
But the Family Court story hasn’t ended for her brother, Zac. Now fifteen, he still lives with his father. He hasn’t seen his mother in four years, and the last time he saw Carly was the night before she ran away. As I sit here writing, in front of me is a drawing with a love heart at the centre. It’s a picture Zac drew for Erin when they were at the police station, after they were intercepted in 2015. In a child’s writing at the bottom of the page, it says ‘Don’t stop trying, Mum.’
*The children’s treating psychiatrist had even stronger words: he predicted that a change in custody would cause them ‘grave psychological damage’. In that same report, he described Erin as an ‘intelligent, thoughtful person, with a secure attachment style, a high level of empathy and relational skills, and a high level of self-awareness/insight’.