Healing the hurt

Physician John A. Rich, MPH ’90, reflects on what he has learned in the decade since publishing a pathbreaking book on trauma in the lives of young black men.

Q: According to the Centers for Disease Control and Prevention (CDC), homicide is the leading cause of death among non-Hispanic black males ages 1 to 19 and 20 to 44 in the United States. The CDC also reports that the death rate for black males between 10 and 25 years old is 18 times higher than the rate for white males in the same age range. When you read these statistics, what comes to mind?

A: These statistics are important because they demonstrate a disparity based on so-called race. They’re challenging because they hide the complexity behind the issue. As public health and medical people, we know that race is not biological. Race doesn’t mean anything in terms of our genes, our health, our potential for health—other than it’s a reflection of racism, historical discrimination, and the more than 400 years that people of color have been subjugated.

The challenge of these statistics is that they sometimes stop people cold at race. Some people blame the young men who are victims and talk a lot about “black-on-black crime.” This is powerfully inaccurate. Violence happens within race because we are so segregated as a society. So when white people hurt other people, they tend to hurt other white people. Brown people tend to hurt other brown people. Those are the people who are in your sphere. There’s another important statistic out of the CDC that I’d like to point out. For every homicide in our country, there are 94 nonfatal injuries. Homicide is what we focus on in the news. And homicide is devastating—an incredible tragedy, both in terms of lost lives and lost human potential. But we have many times more people who are walking around bearing the physical and psychological wounds of violence.

Q: What are the biggest public misperceptions about violence in the lives of young black men?

A: The fundamental misconception is the refusal or the failure to see these young people as victims of violence, and this failure dehumanizes them. Another misconception is the idea that, by trying to understand the setting and the context in which these violent events happen, we’re somehow making excuses. As public health practitioners and scientists, what is most important for us is to find explanations that aren’t excuses.

Q: Working as a physician in the 1990s at Boston City Hospital, now Boston Medical Center, you witnessed close-up the physical and psychological toll of trauma and violence in the lives of black men. What transformed you from a physician attending wounds to a physician-documentarian writing about the lives of your patients?

A: I was always aware, even at Boston City Hospital, that I was one of very few physicians of color, particularly male physicians of color. When I interacted with these young people, I saw me in them and they saw themselves in me. And when I observed the ways in which they were regarded, I felt almost a vicarious wound, seeing their dehumanization.

At the time, I was also changing my way of thinking about science. When I went through the Harvard General Medicine Fellowship Program and when I got my MPH at the Harvard Chan School, I was trained in very quantitative methods. But around that time, I had colleagues at Boston City who began to introduce me to qualitative research—a different paradigm of knowing.

I began a very small research study where I interviewed patients, trying to understand why it was that young people who had been victims of violence were so likely to get injured again. The general assumption was these were bad people doing bad things, people who get injured and then go back to doing bad things. But I knew it was more complicated than that. It was a way for me to understand experiences that were not like my own. I began to exercise a different process of thinking about what one could learn when one put the voices of these young people at the forefront. I thought: Could I open a conversation by presenting the humanity of these young people, cutting through all the demonization that was happening?

Q: What are the most important questions that healing professionals should be asking young black men who have been victims of violence?

A: Rather than asking, “What’s wrong with you?” we should ask, “What happened to you?” Often, when providers see young people who have been victims of violence—people who have been traumatized and have the manifestations of post-traumatic stress—they sometimes misinterpret their behavior in that moment: not looking directly at the caregiver, talking about the experience in a matter-of-fact way. Providers often interpret those behaviors as not telling the truth. But through a trauma-informed lens, we know that those behaviors likely mean that the young person is experiencing dissociation—a well-described mismatch between what victims have experienced and how it comes out due to their trauma. It’s as though their ability to feel has been blunted. When a provider encounters a young person of color in that space, they frequently revert to their own deeply held stereotypes about who this person is. Curiosity completely disappears.

I would add that this is a critical public health issue. Violence does more than inflict acute damage. It leaves a deeper scar that increases the chances for future chronic disease and early death. We know that violence inflicts stress and psychological trauma not only on the victim but on the family and the community in which the young person lives. This vicarious trauma can then indirectly damage the well-being of neighborhoods. We have a responsibility in public health to research violence, to advocate for policies that address the underlying root causes, and to educate our students how to address trauma and adversity.

Q: In your book, you write that the moment of injury is a wake-up-call moment for many young men. How can those moments of injury be converted into moments of transformation?

A: The wake-up call is complicated. Some young people tell me that their injury was a wake-up call. When I hear this, I always ask, “Did you really need a wake-up call? What is it that you are waking up from?” Often, they don’t have an answer, and so I believe that the idea of a wake-up call is, in part, a resilience mechanism. It says: This violent experience must have happened for a reason. Maybe I needed to pay more attention to my son. Maybe I needed to get my life on track. It is the young victim’s way of trying to construct meaning from an utterly traumatic and senseless event.

From my perspective, this moment of injury can become a moment of engagement. When a young person who has almost no reason to be hospitalized—most young people are hospitalized only when they have appendicitis or break their arm or something like that—is suddenly shot, he or she enters a system that has the potential to help heal much deeper wounds that preceded the injury.

Q: How does the Healing Hurt People program, which you co-founded, leverage this potential turning point?

A: What we think is most important in Healing Hurt People is that someone is there for you. Someone who says, “Listen, this is not your fault. You didn’t cause this.” Or, “Let’s talk about how you think you played a role here.”

One of the social workers in the program says that after she establishes a relationship with a young person, she says to them, “So, how did we get here?” It’s an open question that doesn’t place blame. Then she asks, “And where are we going to go from here?” Which, I think, is beautiful, actually.

We also survey young people for what is holding them back, whether or not it was related to the injury. For example, we found that a lot of young people don’t have proper identification. And if you don’t have identification, there’s a whole world of opportunity that is cut off from you. So, sometimes we get the birth certificate in order to get the identification, which helps them get the insurance so that they can have access to the services that they need to recover from the injury. We might also talk about school or about a court case. At Healing Hurt People, they have someone who can help take on some of the seemingly overwhelming barriers that, even prior to the trauma, they couldn’t manage, often for reasons outside of their control.

Q: Healing Hurt People uses peer counselors—young people who, in many cases, were themselves victims of violence. How do they gain the trust of injured patients and help them see a different path?

A: The first thing they do is have a very familiar conversation with the injured person. If I were to show up at the bedside of the patient, for example, the first thing that they may think is that I’m the police. These trained counselors—some having had the direct experience of violence—can establish a strong relationship, can speak in the current lingo, and can help make the connection to both the patient’s practical, concrete needs and to their psychological counseling needs.

These young people often have many concrete needs: food, education, jobs. Safety is another—they may feel unsafe in their environment. They may need medical supplies. They may need to be able to get to their doctors’ appointments. There’s a whole range of day-to-day needs that are part of healing. Then, once these daily needs are met, we can begin to talk more deeply about their healing process. That’s how healing happens. But we first have to meet the most pressing concrete needs.

Q: Your book came out in 2009. A decade later, has anything appreciably changed?

A: The book was published before Trayvon Martin—who was 17 years old, unarmed, walking back from a convenience store—was killed in Florida by a white man claiming self-defense. The book also came out prior to the publication of The New Jim Crow, by Michelle Alexander, which discussed the mass incarceration of African Americans. The Black Lives Matter movement would later focus on how we can begin to talk about the value of the lives of young people of color. And the book was published prior to all of the discussion we’re now having about adverse childhood experiences, or ACEs.

But even with these signs of progress, there are still gaps. The trauma-informed movement has yet to fully reach young people of color. We’re only beginning to think about racial trauma and the wounds that it produces, even apart from the episodic and devastating injuries that happen in communities. How do we go beyond individual healing? How do we humanize our view of people who were previously dehumanized? And how do we change, at the institutional and structural levels, the forces that continue to undermine the healing and thriving of young people?

Q: Would any current gun-control proposal make a dent in the problem?

A: Any proposal that keeps illegal guns off the street would help. We’ve pushed for interventions such as universal background checks, waiting periods for firearm purchases, reporting of lost and stolen guns, people who are bringing into the state lots of guns from places where there aren’t background checks.

Anything that interrupts the flow of illegal weapons into communities means that there is less of an opportunity for young people who feel unsafe, or feel they need to protect themselves, to have those weapons.

Q: You wrote that young men of color often use violence to “become somebody.” A gender analysis would call that toxic masculinity—which affects all racial and ethnic groups. How do you weave gender analysis into your work?

A: The focus of Wrong Place, Wrong Time was on young men of color, given the statistics that we talked about at the beginning of our conversation and given the tendency to see black men as nonhuman—which has been endemic for centuries. Healing Hurt People actually also serves a large number of girls under the age of 18, because the program focuses not just on gunshot wounds but also on stab wounds and assaults. For young people of both sexes, there’s a lot of conflict and assaultive violence that happens in schools.

Toxic masculinity certainly goes beyond young people of color. It speaks to the way that we socialize men to be aggressive and to respond to insignificant slights as a way to protect their identity as men. It’s a response that has homophobia embedded in it. It’s a response tied up with many things. There are multiple intersecting identities that these young people bring. They bring their subjugated identities as people of color. And they bring the privileged identity of being men.

So how do we engage them in a conversation about both?  Healing Hurt People does take on this issue of toxic masculinity and how these young people—either as clients or as workers—are going to face up to it. The issue really captures their attention, because most have never heard the phrase before. Masculinity was thrown in their faces: Be a man, be brave, be courageous, don’t be afraid, don’t cry. We see a kind of freedom develop—particularly among trainees in the community health worker peer-training academy—to become very close and vulnerable to other young men. They are so relieved by the ability to let go of toxic masculinity that it actually becomes an important part of how they heal from the stress of trauma and racism.

Harvard Chan Frontier: Overcoming Violence
Overcoming Violence