Battling America’s other PTSD crisis

Tina Rosenberg
Keith Davis on the streets of North Philadelphia January 9, 2015 in Philadelphia, Pennsylvania. (Photograph by Jeff Fusco/Getty Images for Yahoo News)

The fight that started Keith Davis on a path to a new life began when he was buying marijuana. It was early afternoon on Aug. 8. As he tells it, he was in at his usual hangout in North Central Philadelphia, in front of an abandoned church at 18th and Ridge. He was taking too long mulling over his purchase, and another man got impatient and told him to go buy his stuff somewhere else.

“I go wherever I want to go,” said Davis. The man said some things back. A fight broke out, which ended when the man pulled out a knife and stabbed Davis in the abdomen and left arm.

Davis, who was 21, was still punching at the man even as he watched the knife go in. He saw the blood, but he felt no pain. He thought about calling an ambulance. “But I don’t want to pay $2,000 for an ambulance,” he said. And an ambulance would probably mean police — nobody wanted that. “I ain’t no snitch,” Davis said in December, recalling his thinking. Hahnemann University Hospital’s emergency department, a place well known to Davis and his friends, was a little over a mile away. He started to walk.

Davis was terrified. He felt like he was falling for 20 minutes. He screamed and screamed, and then woke up. lorem ipsum 

This was Davis’ corner. He grew up a few blocks away in the Francisville neighborhood, and these were his people. But no one volunteered to come with him. “I didn’t ask nobody, and they know what kind of person I am,” he said — one who can take care of himself. As Davis walked, holding his stomach wound, the bloodstain bloomed across his shirt and began to drip onto the sidewalk. Strangers offered help, but Davis shrugged them off and kept walking. He got to the emergency room. He remembers one gentle doctor calming him down. “Let’s call your mom,” the doctor said, “and then we’re going to put you to sleep.” Nurses took off his sneakers, cut off his clothes and stuck a needle in his arm. He woke up a day later with 72 stiches in his left arm and more than 30 staples in his stomach.

It was the type of crime that kills more young men in America than any other: The ingredients are an argument over nothing, an audience (ensuring that neither man can back down) and a weapon. The weapon was a knife, so Davis woke up. It’s usually a gun, and often they don’t wake up.

That knife, though, did not just wound his stomach and arm. It also altered his brain. When he woke up in the hospital, he was surrounded by his family, but his first thoughts were new worries: Who can I trust? It now seemed too dangerous even to walk to the store. “I can’t let my guard down when I go around the neighborhood.” And then, “I need to retaliate.”

The Nightmare, 1781, by Henry Fuseli. (Bridgeman Art)

Just after he got out of the hospital, the demon arrived. Davis was alone; his girlfriend, Regina Stewart, was out at the store. He was on the border of sleep when he noticed a shadowy figure in the room. He was terrified. He told himself it wasn’t real, but it looked real. He felt like he was falling, but his body was paralyzed. He couldn’t talk or move, couldn’t save himself from the intruder. He fell for what seemed to him like 20 minutes. He screamed and screamed, and then Stewart tapped his arm and he woke up.

The intruder returned again and again. Sometimes it looked to Davis like an alien, sometimes a monkey sitting on his chest, sometimes a demon. “My mom told me the devil is riding on my back,” he said.

His body was slow to heal. He felt his wounds were on fire, and the Percocet he was given wasn’t enough. His abdomen wound kept him from standing straight, and he used a walker. His staples got infected, and he had to take courses of two powerful antibiotics. He spent six weeks hardly able to get out of bed or off the couch.

But gradually his physical wounds healed (although enormous bills remain; he has no insurance). The infection went away, and he started standing up straight and walking. By the usual standards of the emergency room, this is what we call “recovery.’

But to Theodore Corbin, an emergency department physician at Hahnemann, it wasn't enough. It was clear to him that patients like Davis, who land in the hospital with knife or gun wounds, can have more than bodily injuries. They often also suffer the psychological trauma we normally associate with war or catastrophic natural disasters. But our health care institutions have been slow to react to this phenomenon.

“So many young people come through the ED — shot, stabbed, assaulted,” said Corbin. “The status quo is to patch them up and send them out.” Doctors know it as “treat ’em and street ’em.”

“Medical science — up to a point — is good at physical needs,” said Corbin. “Mental, not so much.” Even as Davis’ body recovered, the devil stayed firmly on his back.

John A. Rich, MD, left, and Theodore Corbin, MD, who both work with Keith Davis at the Health Management and Policy Center for Nonviolence and Social Justice, on Jan. 20, 2015, in Philadelphia. (Photograph by Jeff Fusco/Getty Images for Yahoo News)

Corbin, who also teaches emergency medicine at Drexel University’s School of Medicine, was trying to do something about “treat ’em and street ’em.” Hospitals didn’t try to fix psychological trauma. The vast majority didn’t even look for it. But Corbin realized that his patients’ psychological injuries fueled more violence, landing them in the emergency department again and again. People suffering severe psychological trauma live on a hair trigger. Davis jumps when someone opens a soda bottle. Some crime victims who never carried a gun start carrying after they are attacked, determined that next time they will shoot first.

In 2007, Corbin founded a program at Hahnemann — Healing Hurt People — to offer something new to victims of violent assault: treatment for the full spectrum of trauma.

 *****

Forty-five years ago, the medical establishment in America grasped the severe psychological injury that soldiers could sustain from exposure to the violence of war. We are just now starting to understand that the same is true of residents of violent urban neighborhoods, and that their trauma is both a public health and a public safety issue. Numerous academic studies have found rates of PTSD among people who live in violent neighborhoods higher than those of soldiers returning from Iraq and Afghanistan. Some research concludes that 46 percent of people in these neighborhoods will develop PTSD in their lifetime.

 Corbin and his colleagues are pioneering a new form of treatment that could help stop a cycle of death and dysfunction that has resisted other approaches. In doing so, they are showing Philadelphia how to offer a measure of hope to its own inner-city battle zones.

 

*****

This is what we think we know about PTSD: It is the product of an event so overwhelming that the brain cannot integrate it into the normal stream of memories. When in “fight, flight or freeze” mode, the brain concentrates on what is necessary to survive, and can fail to correctly place an event in context; later, the brain doesn’t know the event is in the past. Unless PTSD is treated, sounds, sights, touches or smells that remind a person of the traumatic event can trigger the perception that it is occurring all over again.

For decades, the medical establishment has understood that experiences like war, sexual assault or child abuse can produce PTSD. Why, then, are we only starting to focus on PTSD in people like Davis?

The most important reason is that society doesn’t view men like Davis as true victims of crime. Instead, we see them as people who involve themselves in criminal activity despite knowing the risks. “Somehow we’ve accepted the idea that young black men don’t get shot — they get themselves shot,” said John Rich, professor of health management and policy in Drexel University’s medical school and co-director of the university’s Center for Nonviolence and Social Justice. That view is common among doctors and nurses, Rich said. It used to be in the back of his mind as well.    

From 1998 to 2005, Rich was the medical director of Boston’s Public Health Commission and a primary care doctor at the Boston Medical Center, where he founded and ran the Young Men’s Health Clinic. Even for patients who came in for routine exams, violence was pervasive: They lifted their shirts to reveal the scars of gun or knife wounds. Rich spent several years talking to men who landed in the emergency department with these wounds.

His 2009 book about the lives of the men he met in the hospital, Wrong Place, Wrong Time, traces Rich’s journey away from the “they get themselves shot” point of view — and there is data to back him up. A Chicago Police Department analysis in 2011 showed that only about 10 percent of homicides were the cold-blooded strategic killings for drug turf that we assume to be widespread. Another 4 percent were retaliation — and some of the victims were relatives, friends or neighbors of the target, or simply got in the way of a bullet.

More than 70 percent of the homicide victims, meanwhile, died as a result of the same thing that injured Davis: a senseless altercation. The code of the streets demands that every perceived disrespect be answered, as those who don’t retaliate invite future victimization. And guns are ever present.

That doesn’t mean the victims were innocents. Most of the Chicago murder victims had a prior arrest history. Davis did as well. But the only infraction his stabbing had to do with was an attempt to buy weed. The vast majority of victims don’t “get themselves shot.” They are trapped in a culture that turns what might be a punch in the face elsewhere into second-degree murder.

Making matters worse is the fact that while urban violence may not be as intense as what soldiers face in Iraq or Afghanistan, it’s much longer-lasting. In a real war zone, a soldier can leave the battlefield. Keith Davis continues to live in his. In a place like Francisville, there is nothing “post” about posttraumatic stress. 

This is dangerous. Violence creates trauma, but trauma also creates violence. Hurt people hurt people. People with PTSD are hypervigilant, seeing disrespect where none exists. They self-medicate with alcohol and drugs. They are emotionally numb, indifferent to death. They turn away from the comfort and stability offered by family or friends. All those things lead to violence. And with PTSD, it is hard for them to leave the streets and create new lives.

The 1800 block of Ridge Avenue in Philadelphia, where Keith Davis was stabbed in the summer of 2014. (Photograph by Jeff Fusco/Getty Images for Yahoo News)

“You feel: ‘I’m not going to allow myself to be vulnerable to this situation ever again,’” said Tony Thompson, a social worker with Healing Hurt People. “You look at the world differently: Every action, every movement is about creating a sense of safety. Instead of waiting for somebody to hurt me, I’ll be ready for them when they come.”

*****

When Theodore Corbin went to medical school, he chose emergency medicine because it was the only department that takes everyone, regardless of ability to pay. By the time he graduated in 1997, he knew he wanted to focus on the health of young men of color. But he soon realized that his traditional emergency room work wasn’t enough. For every victim of violence who dies, there are 94 nonfatal violent incidents. Even with gunshot wounds, four victims survive for every one who dies.

Corbin would patch up their physical injuries. Then they would be back out on the street — if they were lucky, with a referral in their pocket to a social service organization. Soon they would get shot or knifed again, a cycle that sometimes ended when the patient received an injury he didn’t survive.

Violence creates trauma, but trauma also creates violence. Hurt people hurt people. lorem

In the winter of 2002-03, Corbin learned of John Rich’s work on the health of young black men. In 2005, Rich moved to Philadelphia. He and Corbin are now married.

At the same time, Corbin was talking to Sandra Bloom, a Philadelphia psychiatrist and a leader in the field of treating trauma, about what was practical for a clinic to do. Traditional psychotherapy was not an option — it was too expensive and took too long.

But Bloom had something else — a program called SELF, which is an acronym for four pieces necessary to heal from trauma: Safety, Emotional management, dealing with Loss and building a Future. Bloom had developed a curriculum for groups that, while not classic therapy, helped participants learn about what was happening to them and discover ways to get better.

Corbin, Rich and Bloom founded Healing Hurt People, which relies on the SELF curriculum for its trauma treatment. In January 2008 the program enrolled its first client, and the following year it opened in a second site at St. Christopher’s Hospital for Children, where it treats children together with their families. Today, both the Hahnemann and St. Christopher’s sites work in some way with about 35 clients every month and have to turn away many more. HHP is also the headquarters of the National Network of Hospital-based Violence Intervention Programs, with 26 members in the U.S., Winnipeg and London.  

Healing Hurt People offers traditional services: connecting clients to schooling or drug treatment, resolving legal issues, finding housing, writing résumés. What makes it different from other programs is that it also diagnoses and treats PTSD, and takes trauma into account in all its other services. Not every client participates in the SELF groups, but all are invited to, and some do more than one round.

*****

 

Keith Davis might never have joined a SELF group if not for a cheerful young social worker named Meredith Gill. Gill uses a wheelchair herself, and has a Labrador/golden retriever service dog named Tom who accompanies her almost everywhere. Davis was working his way down the hospital hallway, bent over his walker, when he saw Tom and asked to pet him. Gill introduced herself and they went into Davis’ room to talk.

Keith Davis, left, speaks with social worker Tony Thompson at the Health Management and Policy Center for Nonviolence and Social Justice, Jan. 9, 2015, in Philadelphia. (Photograph by Jeff Fusco/Getty Images for Yahoo News)

Everyone else in the hospital had asked Davis the same question: What happened? Gill didn’t. “It’s kind of comforting that I’m not interested in getting any information,” she said. What she asks people — and others in the hospital do not — is whether they will feel safe when they leave, and what they need.

A day later, Davis got a visit from Thompson, Gill’s colleague. Thompson tried to calm Davis, who was extremely anxious. He suggested that Davis stop by the program.

Davis considered it. “When I got stabbed, I thought it was the end of my life,” he said. “I didn’t know what I was going to do, and I had nobody to go to.” One of his friends who got shot afterward used to step out in front of moving buses and hold his hands up to make them stop. Davis didn’t want to be like that. “I’m not going to make myself crippled or crazy,” he said, shaking his head. He waited until he could walk normally again, and then he came in.

Healing Hurt People works out of a nondescript office in a Drexel medical school building around the corner from Hahnemann. On Mondays at 3, clients gather in the conference room for a support group using the SELF curriculum. At the meeting on Dec. 15, the conference table was laden with pizza, chicken wings, Coke and Diet Coke.

“These young men are closed down, shut down, but they are actually looking for reasons to talk.” lorem ipsum — Tony Thompson

This meeting was the 10th of the series and would normally have been the last, but the leaders decided to add three more; the holidays are a rough time. Davis took a seat in front of a pizza, alongside six other clients (one of them female) and several program staff. Davis and Anthony Nuñez had been stabbed; the rest had suffered gunshot wounds.

Ruth Ann Ryan, a nurse who specializes in trauma treatment and worked with Bloom to develop SELF, led the group. She started by going around the table, asking everyone, staff included, how they were feeling and what their goal was for the week.

The men exuded bravado. “My goals are to finish doing what I got to do to survive,” said Davis, “and I don’t got no feeling right now.”

“I feel ... dehydrated,” said Nuñez, to general laughter. “I’ve been drinking beer.”

Most of the participants in this support group had spent a lifetime trying to avoid showing vulnerability. But then Ryan’s exercise started to prove its use.  

“I’m procrastinating, putting off the job thing,” Nuñez continued. His goal for the week was to get back on track.

That allowed Ryan to lead into a discussion of small steps to build the future. The clients largely counseled each other. One of the men said his next big step was developing patience: “One job application and I’m done,” he said.

“You got to do five a day,” said Davis. “I got two jobs,” he said proudly.

“What steps did you take?” Ryan asked.

“I filled out 25 applications,” he said. “Then three people call you for interviews. I see people waiting on one application — why not fill out 50?”

 

The discussion about job applications, part of “F” for future, was perhaps the least personal topic of the whole process. But Thompson said the men had been eager to talk all along. “These young men are closed down, but they’re actually looking for reasons to talk,” he said.

Keith Davis works his overnight shift polishing floors at a Rite Aid drugstore on Jan. 10, 2015, in Philadelphia. (Photograph by Jeff Fusco/Getty Images for Yahoo News)

“In your neighborhood people look at you like you're not tough enough. But you get them into a room with people who look like them, who have the same problems, and they speak.”

The SELF groups are therapeutic: Participants hear from others just like them that they’re not going crazy, their symptoms are normal. For many clients, this is enough. Some — perhaps including Davis — will need more. But one-on-one psychotherapy is nearly impossible to get. The SELF groups may be all there is.

*****

For most of the men, especially those with families, building a future and a normal life after trauma starts with a job. Just before Christmas, United Parcel Service was hiring extra help for the season. Davis applied and interviewed. But he had a record — all misdemeanors, but that still meant UPS wouldn’t hire him.

Thompson showed him the list. His infractions were light, and some were from before he was 18. “You can get these expunged,” Thompson told him.

An hour later, Davis called him from the courthouse. “I’m doing this right now,” he said. “I want a job, and I’m not going to wait for one to come to me.”

Davis had dropped out of high school just before his senior year, when a close friend was shot to death — so close that Davis now has the man’s name tattooed on his neck. He’s taking GED classes to get his high school diploma, and at the same time studying to be a nurse.

The 25 résumés paid off: He works for two cleaning companies. In the early evening, he buffs and polishes floors in a Jenny Craig weight loss center and a daycare center. Then late at night he takes the bus to the edge of town to do the same at a Rite Aid — on one day I saw him, his job started at 1 a.m. Then he gets a ride to two more Rite Aids before the night is over.

Keith Davis gets his son ready to take to his girlfriend's mother's house, Jan. 9, 2015 in Philadelphia. (Photograph by Jeff Fusco/Getty Images for Yahoo News)

“I like this job — it’s just like hustling,” he said. “I got to make this trip to get that money. I’d rather take the slow money than be in jail, or be killed. I got a future now.”

The main reason is Kanye, his 9-month-old son. He and Stewart have been together since they were 15.   Stewart studies business administration in college and works two jobs, one of them a bus ride away outside the city, in King of Prussia. When they were 18, Stewart got pregnant with triplets who shared an amniotic sac and died in the fifth month of gestation. “I delivered them,” said Stewart. “I still consider them my children.” Once when I met Davis he had just come from getting Kanye Christmas presents — he bought clothes, and the Salvation Army gave him toys.

Another time, we met at a relative’s house. Davis was putting little jeans and sneakers on Kanye, getting ready to take him home. He lives with Stewart and Kanye most of the time. He’s worried for their safety, though, so he spends some nights at friends’ or relatives’ houses. “I don’t want people to know my whereabouts,” he said. He walked out the door and into the streets of Francisville, carrying baby, car seat and diaper bag.

*****

Left alone, PTSD can last for a lifetime; 40 years after the end of the Vietnam War, more than one in 10 Vietnam-era vets still have it. But PTSD is treatable — with various psychotherapies and some antidepressants, through coping skills such as meditation, mindfulness, yoga and acupuncture, with rapid-eye-movement therapy and, most controversially, with drugs like LSD and Ecstasy (administered correctly).

“I go there to let my feelings out. I can talk about what I want to do, like revenge, so I don’t actually do it.” lorem ipsum — Keith Davis

PTSD is more difficult to treat, however, when the traumatic event is simply the latest in a long line of traumatic experiences, and that’s more frequent in rough neighborhoods. If there is no posttrauma in many places, there is also no pretrauma.  

“The people coming into the emergency room are much more characterized by complex PTSD — the recent trauma has inflamed previous trauma,” said Bloom. “When a kid grows up in poverty with chronic discrimination, and sometimes various forms of child maltreatment, and is also exposed to community violence, it’s a pile-on effect. It’s like they’re growing up in a war zone. It changes their developmental pathways.”

In the last few years, researchers have begun to realize just how profoundly exposure to such social ills — not to mention addiction, incarceration and violence in the home — affects long-term mental and physical health. These events have a name: adverse childhood experiences, or ACEs. They are common everywhere but rampant in low-income neighborhoods.  

Corbin and the program staff screened their clients six weeks after their assault. They found that 75 percent of them had full-blown PTSD, and the median number of ACEs was 3.5. Nearly a fifth of the clients had seven or more ACEs.

These events sentence children to live in constant fight-or-flight mode, drowning them in cortisol and adrenaline, which wears down the body. ACEs also raise the risk of behavior and learning problems, depression, substance abuse, homelessness and crime — all behaviors that pass ACEs down to the next generation. And, when exposed to trauma, people with these childhood experiences are more likely to get PTSD.

*****

 

Sometimes very little treatment can help people make major changes in their lives. In November 2011, Jermaine McCorey was mugged and shot three times by a rival drug dealer. Over the next year he often imagined footsteps behind him. “I would be paranoid a great deal,” he said. “I’d find myself on edge all the time. I was reliving the whole situation in the middle of the day. My problem was with one guy, but I would think: What if there’s someone else?”

Atmosphere along Ridge Avenue in Philadelphia, where Keith Davis was stabbed last summer, Jan. 9, 2015. (Photograph by Jeff Fusco/Getty Images for Yahoo News)

Although that neighborhood had proved its danger, McCorey went back again and again, to be ready for his attacker if he showed up. “I’d find myself standing there where I was shot, waiting with a pistol,” he said. “I wanted to retaliate.”

On one of his trips to the scene, a half block from where he was shot, he was shot again. He doesn’t know why. This time a bullet severed an artery in his leg. He couldn’t feel his leg for a long time. “I thought I wouldn’t walk again, and I wanted to die,” he said.

Now 25, McCorey started coming to SELF groups after he was shot the first time. “I took it as a way to get one foot out the door of the drug game,” he said.

But one foot only. “I was in contemplation mode: Do I want to change or not?” he said. The answer, apparently, was no. He had moved to a different neighborhood after the shooting. “But I still managed to take my butt down there and sold just about every drug: crack, coke, weed, pills,” he said.

“My pride kept me there,” he recalled. “You keep doing it until something happens.”

“Somehow, we’ve accepted the idea that young black men don’t get shot — they get themselves shot.” lorem ipsum — John Rich

Things changed after he was shot again. He started to look at his life in a different way. “We normalize getting locked up, shooting guns as something that just happens.” He shook his head. “It’s not normal.”

McCorey started to spend more and more time at Healing Hurt People. He became an informal adviser to the program, then in January started to work there part time while he goes to college. It’s now his job to meet people in the emergency department, to tell them about the program — and he’s got the weekend shift, when violence is highest. His own PTSD is better. “I sometimes have nightmares — that’s the only thing that lingers,” he said. The flashbacks and paranoia are gone. He lives a normal life, he said.

Many cities are reforming their social services to take ACEs and acute trauma into account — “trauma-informed care” is the jargon. Philadelphia is among the most aggressive. Last month, Drexel announced that the city is financing the expansion of Healing Hurt People to all of Philadelphia’s other major trauma centers — a first in any city.

As the program rolls out, it will be formally studied, with clients of the program compared with a control group. As of now, Corbin and his collaborators lack the hard evidence to demonstrate the effectiveness of Healing Hurt People. But other hospital-based antiviolence programs (without the emphasis on psychological trauma) have been studied and found effective, and a Justice Department task force on children exposed to violence recommends that every hospital emergency department have a psychological counseling program. “We can’t wait five years for this study,” said Arthur Evans, Philadelphia’s commissioner of behavioral health. “We have to intervene on the information we have. “

Corbin said that the Hahnemann and St. Christopher’s sites each connect with at least 50 people a month, and about three-quarters of them start some aspect of the program. That’s about 450 people a year per site who use at least one service, and a fifth of them do everything the program offers. The cost for this, said Corbin, is $330,000 per year per site. Healing Hurt People could be cost-effective even if it keeps just a few people out of the hospital or prison — two very costly places. It could save more if clients also become better parents, students and employees, like McCorey.

*****

 

Can Davis change his life as well? When he first went in to Healing Hurt People, he hoped they might be giving out money. He was disappointed, he said — but quickly added that it’s helped him in many other ways.  

Keith Davis at a rec center where he used to hang out, on Jan. 9, 2015, in Philadelphia. (Photograph by Jeff Fusco/Getty Images for Yahoo News)

He goes into the program not just for the Monday SELF meetings, but several times a week, “just to be around positivity,” he said. “I go to the meetings to let my feelings out. I can talk about what I want to do, like revenge, so I don’t actually do it.”

“When I first met him, he was very pessimistic, even cynical,” said Thompson. That has changed. “He takes a lot of initiative, and when he has trouble, he asks for help,” something he didn’t do before even while bleeding all over the sidewalk. He has plans for his own business — he priced used floor buffers, and concluded he could start his own cleaning company with $2,000.

Davis lives in two worlds now. When he goes back to his old corner, he pulls his jeans halfway down his butt before he greets his friends. It hurts that some of them never came to see him in the hospital. “Mom was right,” he said, shaking his head. “Some of them not my real friends. They on the corner and you walk by and say ‘wassup,’ and they be hating on you because you won’t stay on the corner with them.”

In a real war zone, a soldier can leave the battlefield. Keith Davis continues to live in his. In a place like Francisville, there is nothing “post” about posttraumatic stress. lorem ipsum 

The demons are still with him. One recent episode spooked him enough that he went in to see Thompson about it. It was his mother-in-law, however, who put a name to what was going on: sleep paralysis, an established syndrome. (The common sensation that the creature is sitting on your chest comes from the inability to breathe deeply.) He worried he could die from it.

It is no accident he took a job that doesn’t let him sleep.    

The forces pulling Davis backward are powerful: The lure of the corner and the life where he is known and respected. The knowledge that easy money is a phone call away. Medical bills. The demon on his chest, which might be exorcised only through psychotherapy he may never get.

Against that, though, there is the scar on his stomach to remind him, Kanye, Stewart, two close friends who also went through the program, and the challenge of testing himself with a different hustle. And there is how far he’s come: far enough to imagine himself another way, as a man who can stop on the corner, say “wassup” to his old friends — and then keep walking.