PTSD and Violence, Abroad and At Home

From “The Interrupters” to adverse childhood experiences: CeaseFire is just one of the approaches to violence that’s an attempt to move the discussion into the field of public health.

The Interrupters movie

Violence interrupter Ameena Matthews with The Interrupters producer/director Steve James, producer Alex Kotlowitz, and co-producer/sound recordist Zak Piper

 

The habit-forming pain,
Mismanagement and grief:
We must suffer them all again.

—W.H. Auden, “September 1, 1939”

Last September 11 I was at home reading when I heard a disturbance outside. Which, normally, would only get my attention far enough to ensure no one was in physical danger; otherwise I’ve gotten numb to people screaming at each other outside my apartment. I’ve only lived in a couple apartments in the city in which I wasn’t regularly interrupted by angry neighbors, like the guy who would beat on the door so hard the entire building shook when he got locked out, drunk in the middle of the night, by his significant other, or the woman who would sit in the bathtub in the bathroom adjacent mine and yell at a likely non-existent person about how she was going to kill him or her and the phantom’s family.

I’m not sure whether I have bad luck or whether it’s just unavoidable in the city.

Usually the incidents last just long enough to wake me up or ruin my night. But this one escalated—it emerged that the man had a domestic animal, which he was either threatening to hurt or kill, or in his anger was at risk of doing so. It was, in short, a hostage situation with a pet. Which was terrifying enough, but the man sounded incoherent and frightened, frightened of something vague and ominous.

And then a woman shouted: You’re not in Iraq. You’re in Chicago. You’re not in Iraq anymore.

This came rushing back to me when I read Alex Kotlowitz’s first post as Chicagomag.com’s writer-in-residence at Off the Grid, about the intersection of PTSD, urban violence, and war:

Eddie saw some of himself in his [veteran] brother. And then he looked at the kids from his neighborhood, Little Village. And he saw some of his brother in them. They were fidgety, had trouble staying in one place. They got agitated easily. They had no patience. They couldn’t focus. “They’re looking for something to calm them down,” Eddie said, and so many turn to smoking weed and drinking. They, like his brother, he realized, suffered from PTSD.

This in turn reminded me of a piece by Steve Bogira—a reporter who’s spent much of his career documenting the same streets as Kotlowitz—that’s stuck with me for a long time, “Child Abuse on the Brain.” Eddie Bocanegra’s observations about himself, his brother, and the kids in Little Village echoed what Bogira, and the subject of his piece, psychologist Bruce Perry, saw in the children he worked with (emphasis mine):

All children feel stress from time to time, during periods of being hungry, cold, or frightened. Perry says moderate doses of stress in childhood are healthy, training the sympathetic nervous system how and when to respond. Usually a parent or another adult feeds the crying baby or hugs and reassures the terrified toddler, keeping the event from being too traumatic. “But imagine what happens to a child with neglectful or abusive parents. When the child gets hungry, he or she may cry for two hours because the parents are out. And imagine if they wake the child up sometimes in the middle of the night and beat him. Or sexually abuse him. The child is going to be exposed to too much stress hormone–and that’s going to change the way the brain develops, so that the child becomes more impulsive, more aggressive. They’ll be physiologically tuned up–they’ll look like they’re in a popcorn popper.

(While you’re at it, Bogira’s story in the Reader this week is about schizophrenia and its frequency among African-Americans and the poor; interestingly, Perry argues that PTSD and schizophrenia manifest themselves in similar behaviors, and in this week’s piece Bogira notes that there’s evidence, if yet inconclusive, that cities nurture both pre- and post-natal risk factors for schizophrenia. I couldn’t help but notice some overlap between the two stories.)

Our situation now with the neighbors, who may or may not be the same ones, is strange as it may sound to say, worse. The fear and violence hasn’t returned, but for stretches—days to a couple weeks—there’s coming and going at all hours of the night. (Well, not all hours, just the ones between one and four or five in the morning.) Mostly drunken shouting and swearing, but the other night what sounded like patio furniture being moved constantly for 20 minutes.

The feeling of laying in bed, trying to sleep while knowing it would be interrupted a couple hours in, reminded me in its own small way of this:

The amount of stress isn’t the only factor in PTSD, Perry says, but also its consistency. Rats who are shocked and exposed to loud noises at erratic intervals as pups overreact dramatically to the same stresses as adults, he says. They also have more difficulty learning certain tasks as adults. Rats who aren’t ever shocked as pups function adequately when stressed as adults. But the rats who handle stress best when they’re grown are those who were stressed on a regular schedule as pups.

At one point it got so bad, after pleas for silence quickly escalated to shouting matches through the window, that we moved the box spring and mattress into the living room and slept there for a whole workweek. It wasn’t so much the sleep deprivation that was the problem as constantly being on edge at the worst possible time, which overflowed into the days as irritation and frustration. Living out of half the apartment was preferable to the constant, hair-trigger tension—over, all things considered, a comparatively minor intrusion, especially in comparison to the subjects of Kotlowitz’s and Bogira’s work.

The Interrupters came out of a New York Times Magazine piece by Kotlowitz on CeaseFire, which focused in part on the parallels between violence and epidemiology, which the program is designed around:

The new recruits, with strong connections to the toughest communities, would focus solely on sniffing out clashes that had the potential to escalate. They would intervene in potential acts of retribution — as well as try to defuse seemingly minor spats that might erupt into something bigger, like disputes over women or insulting remarks.

As CeaseFire evolved, Slutkin says he started to realize how much it was drawing on his experiences fighting TB and AIDS. “Early intervention in TB is actually treatment of the most infectious people,” Slutkin told me recently. “They’re the ones who are infecting others. So treatment of the most infectious spreaders is the most effective strategy known and now accepted in the world.”

In other words, CeaseFire’s model starts with inciting incidents—sort of like the police, only they try to step in when a crime is likely, instead of already having occurred. It’s one aspect of the transmission of violence, but obviously not the only part. And others are applying public-health models to the more general causes of violence, in manners similar to Bruce Perry’s. Earlier this year, the New Yorker’s Paul Tough asked the question “can a stressful childhood make you a sick adult?” in his profile of San Francisco physician Nadine Burke, who is investigating the more generalized stressors of early and frequent exposure to trauma and its more generalized effects:

As she listened to Sullivan [a 16-year-old mother from San Francisco’s most violent neighborhood], Burke found herself inching toward a diagnosis that, a year earlier, would have struck her as implausible. What it Sullivan’s anxiety wasn’t merely an emotional side effect of a difficult life but the central issue affecting her health? According to the research Burke had been reading, the traumatic events that Sullivan experienced in childhood had likely caused significant and long-lasting chemical changes in both her brain and body, and these changes could well be making her sick, and also increasing her chances of serious medical problems in adulthood. And Sullivan’s case wasn’t unusual; Burke was seeing the same patterns of trauma, stress, and symptoms every day in many of her patients.

Some of the research that inspired Burke is summarized here on her blog, a two year study of over 17,000 adults who were asked to note the number of “adverse childhood experiences” they had experienced:

“Overall, 1,539 people died during follow-up,” Brown said. “People with six or more ACEs died nearly 20 years earlier on average than those without ACEs. It is also disturbing that two-thirds of study participants — persons who were relatively well off — had at least one of the ACEs.“

CeaseFire uses epidemiology as metaphor; as Kotlowitz puts it, founder Gary Slutkin “wants to shift how we think about violence from a moral issue (good and bad people) to a public health one (healthful and unhealthful behavior).” Burke’s (and Perry’s) practice begins literally in public health, yet there seems to be substantial overlap. It’s hard not to see the two threads approaching each other, bridging the gap between metaphor and reality.

 

Photograph: Kartemquin Films

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