Last October, Aireana and her boyfriend were driving
through Oakland when a man on the street opened fire on their car. Her two
children, ages 6 and 1, were in the backseat.
Aireana remembers feeling
something slam into her jaw and hearing a sound like a firecracker popping in
her head. Her boyfriend hit the accelerator and swerved down the street. He and
Aireana turned at the same moment to check on the kids. They were safe. Then
her boyfriend looked at her and saw blood spurting from her neck. “Oh, my God,”
he said, panicking, and crashed into a parked car.
In the shock after the crash, Aireana had only one
coherent thought: I cannot die in front of my kids. They cannot see me
die. She unbuckled her seat belt and pushed herself out of the car. As she
stood, she felt dizzy and closed her eyes. But the thought of her children
propelled her forward. They can’t see my body lying here dead. Still
dazed, she walked away from the car. She could hear her daughter screaming
behind her, “My mom’s dying!”Earlier that afternoon, Aireana had gotten her kids ready to go to the park. She had taken meat out of the freezer to thaw for dinner. Her life, at 24, finally felt on track. That year had been hard: She had been unemployed for the first half of 2013 with no stable place to live. After scoring a new office job that summer, she moved into a two-bedroom apartment with her kids. She remembers feeling pretty as she looked at herself in the mirror on the way to the car.
A bullet had smashed through her front teeth, grazed
her tongue and broken her jaw. In the emergency room, the surgeons repaired her
tongue. Later, they wired her jaw shut so that it could heal. Aireana stayed in
the hospital for more than a month. When she went home, her face was still
puffy and swollen, and she had a hard time talking. Fragments of the bullet were
still lodged in the side of her neck.
“You’re so lucky,” her friends kept telling her.
“Why are you still so sad? You’re okay—you’re alive.” But Aireana couldn’t stop
thinking about the shooting. She felt guilty, as if it were her fault that she
had been hit. Why hadn’t she lifted her arm to block the bullet? Why hadn’t she
ducked? The shooting played over and over in her dreams. Sometimes, reliving
it, she remembered to duck, and then the bullet passed over her and hit one of
her children. She’d wake up in a panic, soaked in sweat.
Every day at 3 p.m., Aireana paused at her front door.
She knew she should go out and meet her daughter, who would be walking back
home from school just around the corner. But the busy street overwhelmed her.
Sometimes she would make it down to the end of the driveway in front of their
apartment and then turn back.
In the aftermath of the shooting, she struggled to pay
her bills. The phone company cut off her cell phone, but she didn’t care. She
didn’t want to talk to anyone. Instead, she spent most of the day asleep. When
she became tired of lying in bed, she’d curl up on the living room floor.
In America, violent crime is down significantly since
1993, when the nation’s gun homicide rate hit its peak. But there are still neighborhoods
in majority Black cities like Oakland, Detroit, New Orleans, and Newark, New
Jersey, where shootings are a constant occurrence and where the per capita
murder rates are drastically higher than the rest of the country.
3,500 American troops were killed during the eight-year
war in Iraq. Within the same time
period, 3,113 people were killed on the streets of Philadelphia. According
to FBI data, between 2002 and 2012 Chicago lost more than 5,000 people to
homicide—that’s nearly three times the number of Americans killed in action in
Afghanistan.
Over the past 20 years, medical researchers have found
new ways to quantify the effects of the relentless violence on America’s inner
cities. They surveyed residents who had
been exposed to violence in cities such as Detroit and Baltimore and noticed symptoms
of post-traumatic stress disorder (PTSD): nightmares, obsessive thoughts, a
constant sense of danger.
In a series of federally funded studies in Atlanta,
researchers interviewed more than 8,000 inner-city residents, most of them
African-American. Two thirds of respondents said they had been violently
attacked at some point in their lives. Half knew someone who had been murdered.
Of the women interviewed, a third had been sexually assaulted. Roughly 30
percent of respondents had had symptoms consistent with PTSD a rate as high or
higher than that of veterans of wars in Vietnam, Iraq and Afghanistan.
Experts are only now beginning to trace the effects of
untreated PTSD on neighborhoods that are already struggling with unemployment,
poverty and the devastating impact of the war on drugs. Women—who are twice as
likely as men to develop PTSD, according to the National Center for
Post-Traumatic Stress Disorder are more likely to show signs of anxiety and
depression and to avoid places that remind them of the trauma.
In children, PTSD symptoms can sometimes be
misdiagnosed as attention deficit hyperactivity disorder (ADHD). Kids with PTSD
may compulsively repeat some part of the trauma while playing games or drawing,
have trouble in their relationships with family members, and struggle in
school. “School districts are trying to educate kids whose brains are not
working the way they should be working because of trauma,” says Marleen Wong,
Ph.D., the former director of mental health services, crisis intervention, and
suicide prevention for the Los Angeles Unified School District.
Men with PTSD are more likely to have trouble
controlling their anger, and to try to repress their trauma symptoms with
alcohol or drugs. Though most people with post-traumatic stress are not
violent, PTSD is also associated with an increased risk of aggression and
violent behavior, including domestic violence.
The Atlanta researchers found that civilians they
interviewed who had PTSD were more likely to have been charged with a violent
crime and incarcerated than other people of similar backgrounds without
PTSD—but the cause and effect behind this wasn’t clear. For some people, PTSD
symptoms may have contributed to their involvement in the criminal justice
system, while others may have developed PTSD later. “Neglect of civilian PTSD
as a public health concern may be compromising public safety,” the researchers
wrote.Despite the growing evidence of PTSD in civilians, little is being done to address the problem. Hospital trauma centers often provide adequate care for physical wounds, but do almost nothing to help patients cope with the mental and emotional aftermath of trauma.
A 2014 ProPublica survey of 21 trauma centers in the nation’s most violent cities found that only three—in New Orleans, Detroit and Richmond—routinely screened victims of violence for the disorder. Trauma surgeons said they were aware of the burden of post-traumatic stress on their patients, but it was hard to get hospitals to spend money on new programs or staff to deal with PTSD.
Even Chicago’s Cook County Hospital, where researchers found that 43 percent of injured patients showed signs of the condition, has struggled to raise funds to support a new program. Doctors said they also worried about the scarcity of mental health providers, especially for low-income patients without insurance. Some said they were reluctant to screen patients for PTSD because they could not be sure they would get treatment.
What’s more, many doctors and nurses assume that
shooting victims especially young Black men are responsible for what happened
to them, says John Porter, M.D., a trauma surgeon in Jackson, Mississippi,
which has a higher per capita homicide rate than Chicago’s.
The line of thinking is it’s their own fault, so who cares? We’ll save their life, but who cares? But post-traumatic stress doesn’t distinguish between “innocent” and “not innocent” victims. Researchers have found gang members are just as likely to suffer from post- traumatic stress as anyone else.
The burden of post-traumatic stress on low-income
communities of color gets very little attention. What public recognition it
does receive is often sensationalized: A TV reporter apologized this spring
after a segment on young people dealing with trauma in Oakland referred to PTSD
as “hood disease.” The line of thinking is it’s their own fault, so who cares? We’ll save their life, but who cares? But post-traumatic stress doesn’t distinguish between “innocent” and “not innocent” victims. Researchers have found gang members are just as likely to suffer from post- traumatic stress as anyone else.
“Someone in the community has to stand up and say,
‘Because of all the gun violence, we have a lot of traumatized people—and it’s
not just the people who are being shot and shot at, it’s the people who are
witnessing it, the vicarious trauma,’” says Arthur C. Evans, Jr., Ph.D., the
commissioner of Philadelphia’s Department of Behavioral Health and Intellectual
Disability Services.
With the support of Mayor Michael Nutter, Evans has
pushed Philadelphia to treat trauma as a major public health issue and to
develop a comprehensive approach to PTSD. Over the past eight years, city
officials have worked with hospitals, community mental health clinics,
pediatricians, schoolteachers and police officers to increase awareness of the
disorder and make sure residents are connected with treatment professionals.
“We have to stop telling our kids they just have to live with this,” Evans says. The city has paid to train local therapists in evidence-based PTSD treatments and has launched a Web site—healthymindsphilly.org, which allows people to screen themselves for the symptoms of PTSD anonymously as a way of reaching people who might be reluctant to visit a mental health clinic.
Philly has also partnered with local faith groups to
train leaders about mental health resources, because “in the African-American
community, people often go to their faith leaders before they will come to a
treatment professional,” Evans says. Philadelphia’s police department is
educating its officers about mental health and the effects of trauma. “People
who have untreated trauma are highly reactive, and it doesn’t take much to set
them off,” Evans says.
Crisis intervention training helps officers discern
between someone who is being obstinate and someone who “might have some other
issues that are driving the behavior,” Evans says. The training also helps
officers learn how to de-escalate a situation, rather than react with force. Philadelphia’s
broad approach to PTSD includes a technique that’s already being tried in other
cities: reaching out to victims of violence in the immediate aftermath of a
shooting and bringing trauma education right to their hospital bedsides.
When Aireana was lying in Oakland's Highland Hospital
last fall with her jaw wired shut, one of her visitors was Rafael Vasquez, an
intervention specialist with Youth Alive!, the nonprofit group that founded the
nation’s first hospital-based violence intervention program in 1994. Tall and
solidly built, Vasquez sometimes has to reassure patients he’s not an
undercover cop. His goal is to ensure that victims of violence stay safe after
they leave the hospital and that they never come back under similar
circumstances.
Over the winter, Youth Alive!’s licensed marriage and
family therapist, Nicky MacCallum, visited Aireana at home to conduct therapy
with her daughter. For people who have grown up in violent neighborhoods, the
traditional 50-minute therapy session is not always right for them.
“Many times young people would walk out not having
connected with the therapists, not feeling they could relate to them,” Vasquez
says. “They were overwhelmed by the whole experience.” MacCallum has held
sessions in coffee shops and parking lots and even on basketball courts while
clients shot hoops.
By bringing therapy out of the clinic and into the
community, Youth Alive! has seen an increase in the number of patients engaged
in active therapy: from about 5 percent of its clients to 35 percent. MacCallum taught Aireana’s 6-year-old how to calm
herself down with deep belly breaths. She talked to the girl about trauma in
age-appropriate ways, asking if she ever felt like a turtle, hiding in her
shell, or a prickly porcupine.
Sometimes MacCallum and Aireana’s daughter would sit on
the living room floor and draw together as a way to express emotions difficult
to put into words. Aireana started by sitting off to one side and watching the
sessions. When the therapist told her, “Adults can draw too,” she then picked
up a marker herself. This led to Aireana finally sitting down with MacCallum
for a session of her own. They started by talking through a list of trauma
symptoms: sleep problems, anxiety, fear of going outside. “I’ve got that,”
Aireana remembers saying. “That too.”
MacCallum diagnosed Aireana with PTSD. “Nicky helped
me,” Aireana says. “She was the first person I actually talked to who believed
it was real, that my feelings were real.” MacCallum and other therapists say
PTSD is the best diagnosis they can give in these instances—but that it’s not a
perfect fit. For clients who live in violent neighborhoods, the trauma that
they’re dealing with isn’t really “post.” “People in our community are
constantly re-traumatized,” MacCallum says.
The street where Aireana was shot was only minutes away
from the place where she had witnessed her first drive-by shooting when she was
8. She had been at a block party near her aunt’s house in East Oakland and
thought she heard fireworks. She has a vivid memory of what she found instead:
a car, in the middle of the road, with the driver slumped over, already dead,
and blood running out of the car. A few weeks after Aireana came home from the hospital last winter, a young man was murdered on the street in front of her house. She remembers seeing his last heaving breaths and his friends yelling and no one around to help. She broke down. This is happening all over again, she thought.
There’s no Department of Veterans Affairs to coordinate
care for Americans repeatedly exposed to violence and trauma in their own
neighborhoods. One of the first steps in addressing community PTSD, says Evans,
who is leading Philadelphia’s trauma response, is to “get people to come around
the table. Get a few mental health professionals, a few pastors
and a few human services people who are seeing the impact of this to come
together and have a conversation. That’s what we did.”
Community members who
want to learn how they can help loved ones struggling with PTSD or other mental
health issues can sign up for Mental Health First Aid, an eight-hour course run
by the National Council for Behavioral Health that can also assist community
groups with setting up their own training programs. The National Center for
Post-Traumatic Stress Disorder and the National Child Traumatic Stress Network
also offer resources for PTSD caused by community violence.
Over the summer in Oakland, Aireana’s children were
terrified by the sound of fireworks. They kept thinking they were hearing
gunshots. This past Fourth of July, Aireana decided she would try to help her
kids adjust to the sound, rather than shutting it out. As her neighbors set off
firecrackers in the street, she kept her kids at a distance.
She pointed to the lights: “That one’s cool.” A purple
explosion: “Oooh, nice.” Gradually, they walked closer. Later, she gave her
kids sparklers and watched them run around making glowing scribbles in the
dark. She had always loved fireworks. It was good to see her kids not being
afraid and enjoying them, too.