Alexis Feliciano was having another terrible argument with his mother. And that could be dangerous.
A lifetime of hurt and anger demanding an outlet.
“She would start talking trash to me,” he says, “and what I would usually do — I would grab my weapon, go outside, and do what I had to do to somebody.”
This time, though, Feliciano didn’t do what he usually did. He walked to a friend’s house instead, and he cooled down.
He let his weapon be.
His decision was a reprieve for someone he might have ambushed that day in his Revere neighborhood.
It was also a hopeful moment for an intriguing experiment aimed at curbing America’s epidemic of urban violence.
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After decades of decline, shootings and stabbings have surged nationwide. Homicides in Washington, D.C., reached a 16-year high last year, leading the mayor to declare a public health crisis. Chicago saw a 50 percent spike in murders, punctuated by the single deadliest day in the city’s modern history. In Boston, a decline in killings in 2019 was followed by a sharp jump in 2020. And this summer, the violence is expected to crest again.
Researchers actually have a pretty good idea about how to push back against this sort of bloody tide — or at least slow its advance.
Smart policing that targets the relatively small number of people responsible for the majority of the violence in a given city, paired with social supports for those people, can make a real difference. But identifying — and funding — the most effective supports is a perpetual challenge.
Among those rising to meet it is a Chelsea-based organization called Roca, which is fast establishing itself as one of the most influential “violence interrupters” in the country.
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Headquartered in an old car dealership in the shadow of the Tobin Bridge, the group entered a period of rapid growth about a decade ago, expanding into Springfield, Boston, Lynn, and Holyoke. In 2018, Roca ventured out of state for the first time, launching a program in Baltimore, one of the most violent and addicted cities in the country.
The organization has cultivated donors like the Bill & Melinda Gates Foundation and Bank of America. Last month, Gabrielle Giffords, the former Arizona congresswoman turned national crusader against gun violence, appeared at the group’s annual fundraising breakfast. The Roca Impact Institute has trained police departments, courts, and community organizations in Massachusetts, Connecticut, New York, and Maryland.
The group works with 17-to-24-year-old men at the center of urban violence — providing high school equivalency classes, job training, and financial literacy courses.
But at the heart of its model is something more ambitious — an attempt to rewire the traumatized brain.
Roca’s participants have been berated and sexually abused. Shot and stabbed and thrown in the hole. They have watched friends die on the street and have slept on splintered park benches with weapons tucked into their waistbands.
And when you live under constant threat, fear and anger are always with you. These emotions serve a purpose; they are instruments of survival. But if they take over your life, they can be enormously destructive.
A fight with your mother can turn into a violent confrontation on the street. A sharp word on Facebook can feel like an intolerable challenge to your manhood.
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Building a more stable life requires dialing down the fear and anger and finding your way to better decisions.
That’s the aim of the intervention Roca has built with researchers at Massachusetts General Hospital, using a version of cognitive behavioral therapy, or CBT.
The Roca version isn’t formal therapy. It’s a set of skills that a young man can use to steer himself out of trouble.
And those skills are taught by youth workers, many of them people of color from the neighborhoods they serve — in makeshift classrooms in Roca’s offices, on street corners on hot afternoons, or in late-night phone calls when the fear and anger are peaking and a confrontation is edging toward violence.
Roca emphasizes repetition; it can take some time to digest these skills. But for some participants, the CBT intervention registers quickly.
Feliciano’s youth worker hit him with it on his first visit to Roca, when he was 18. He was skeptical. “I was like, ‘This is going to be bullshit, I’m not going to do this,’” Feliciano says. He’d been through all kinds of anger management programs as a kid. And none of them had made a difference.
But he found himself deploying CBT that very day, when he got into the argument with his mother and thought about terrorizing his neighborhood as he’d done before. When he backed off, instead. It was “the first thing that ever worked for me,” he says.
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Feliciano’s experience isn’t universal; CBT doesn’t stick for plenty of Roca participants.
But the more you learn about the psychotherapeutic tradition the Roca intervention is built on — its journey from rebellious challenge to potent cure — the easier it is to understand how it could change the lives of the most dangerous and vulnerable young people in America.
‘Action, action, action’
Albert Ellis was a confrontational figure. Profane.
They called him the Lenny Bruce of psychology.
On Friday nights, at the Manhattan institute that bore his name, he would perform what one journalist called “stand-up psychotherapy” to packed houses.
“Do you know why your family is trying to control you?” he asked a volunteer who stood with him at the front of the room. “Because they’re out of their minds,” he said, inserting an epithet between “their” and “minds.”
Ellis had come of age in the early 20th century, when Freudian psychoanalysis dominated the field. He made no secret of his contempt for it.
Freud’s insistence that the Oedipus complex was some sort of catchall explanation for human suffering was “foolish.” And neurosis, Ellis said, was “just a high-class word for whining.”
“The trouble with most therapy is that it helps you feel better, but you don’t get better,” Ellis once told The New York Times. “You have to back it up with action, action, action.”
The approach he developed was called rational emotive behavior therapy, or REBT — a pragmatic, knock-it-out-in-a-few-months alternative to the slow crawl of psychoanalysis.
At the heart of that approach was an insistence that his patients recognize and challenge their irrational beliefs: “I need to be loved by everyone” or “There is a perfect solution to my problem and it’s disastrous if I don’t find it.”
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It was these beliefs, Ellis argued, that led to self-destructive emotions (say, depression or anxiety) and behaviors (drinking or lashing out). And if people could identify and move away from these beliefs, they could change their lives.
REBT, honed in the 1950s, faced sharp criticism at first.
“I was hated by practically all psychologists and psychiatrists,” he once said. “They thought it was superficial and stupid. They resented that I said therapy doesn’t have to take years.”
But his work and that of a psychologist named Aaron Beck formed the basis for what came to be known as cognitive behavioral therapy — an umbrella term for a group of approaches that, broadly speaking, ask patients to deliberately monitor the connection between their thoughts, feelings, and behaviors.
It proved potent.
Decades of rigorous research have shown CBT to be effective in treating depression, anxiety, and post-traumatic stress disorder. It is now considered the gold standard treatment for a variety of mental health issues — not a cure-all but the most tested and best-performing psychotherapy in the world.
The trouble is that while CBT and other mental health care might be needed more than ever, there aren’t enough people to deliver it. Debra Kaysen, a professor of psychiatry and behavioral sciences at Stanford University, says this gap is “big enough that I don’t know that we can train enough social workers, psychologists, psychiatrists to fill it.”
In many parts of the world, the response has been to train paraprofessionals — medical personnel without formal mental health training or teachers and other respected community figures — to deliver care. And the results are promising.
Kaysen and several colleagues found that counselors in the Democratic Republic of Congo trained to use a form of CBT were effective in alleviating symptoms of depression, anxiety, and post-traumatic stress in victims of sexual violence.
In rural Pakistan, a similar intervention with depressed mothers reduced their suffering and improved their babies’ health. And here in the United States, a Roca-like program called READI Chicago, which offers employment services and youth-worker-delivered CBT, appears to reduce the risk of gun violence.
Cognitive behavioral therapy is scalable, then.
What’s required is leaders committed to putting it where it’s needed.
Building an intervention
Today she would say it was a calling.
But when she was a young woman growing up in Baltimore, Molly Baldwin didn’t quite understand what was driving her. She just knew she needed to help.
At 16, she volunteered at a children’s hospital and spent the summer trying to convince her mother to take in a disabled child.
After college brought her to Massachusetts, she picked the brain of Kip Tiernan, the raspy-voiced radical who founded Rosie’s Place, the nation’s first homeless shelter for women.
And in the early ’80s, Baldwin organized against the state’s death penalty. At one point, she tried to work at a locked unit for young women, “but I just couldn’t do it,” she says. “I couldn’t lock the door.”
In 1988, she was tapped to lead a program in Chelsea aimed at preventing teenage pregnancy. She quickly broadened its scope to include the young men — many undocumented and involved in gangs — who were getting the girls pregnant.
That was the start of Roca, which stood for Reaching Out to Chelsea Adolescents but was also Spanish for “rock”: something solid for young people to grab on to.
Baldwin quickly made a name as one of the most persistent activists in the region. And the Roca model fits her personality.
One of the organization’s signature strategies is something called “relentless outreach.” Instead of waiting for young men to put down their guns and seek services, Roca’s youth workers go after them — knocking on their doors again and again in a bid to build trust and draw them into the program.
Baldwin trained that same relentless outreach on outside experts who she thought could help Roca improve its model. And at one point, she worked a connection at the behemoth then known as Partners HealthCare and got to Luana Marques.
Marques grew up in Brazil. As a teenager she was painfully shy. But when her grandmother took her to lunch at the mall again and again and encouraged her to speak with strangers, she began to overcome her social anxiety.
Later, when she was completing her PhD in clinical psychology in the United States, she realized that her grandmother had delivered a sort of lay version of cognitive behavioral therapy.
In 2013, Marques founded the Community Psychiatry Program for Research in Implementation and Dissemination of Evidence-Based Treatments at Partners’ Massachusetts General Hospital, aimed at bringing the best clinical practices to disadvantaged communities.
When Roca pitched her on its vision for youth-worker-delivered CBT shortly thereafter, she was all in.
“For me, it wasn’t a leap,” says Marques, who is also a psychiatry professor at Harvard Medical School. “I was like, ‘This is done all the time globally.’ And if we wait for enough clinicians — number one, they don’t get the population, that’s one piece, and two, there are never going to be enough of them.”
Anisha Chablani-Medley, Roca’s chief program officer, was her main partner in the project.
“They had the brains,” says Chablani-Medley, “we had the language.”
Together, they honed a “life skills” program that youth workers can easily deploy and young people can easily digest.
The most complex CBT strategies — say, the kind of exposure therapy that therapists use to slowly walk their patients through trauma or that Marques’s grandmother used to lessen her social anxiety — are stripped away.
What remain are the basics.
First, Roca participants are taught to identify their destructive “think-feel-do” cycles. Someone criticizes you on social media or on the street. What do you think? I can’t be disrespected like that. How do you feel? Enraged. What do you do? Get high, or go after the guy who said something about you.
Then they learn seven skills they can use to disrupt those cycles and develop healthier ones — skills simple enough to be summarized on a poster hanging on a wall in Roca’s offices or distilled onto pocket-sized cards that can be attached to youth workers’ key chains.
Skill Number 1: Be Present. Forget about what came before. Focus on what you can do now to dial down your anger or anxiety. Go for a walk or grab a piece of ice and hold on to it until you cool down. . . . Skill Number 6: Flex Your Thinking. If you’re convinced that you’re not good at anything or that no one will hire you, examine that thought. Is it true? Is it helpful? Can you shift it just enough to break out of your rut?
On a recent afternoon in the back room at Roca’s small office in Lynn, staffer Sutton Bradbury-Koster offered a quick refresher on another skill — Act on Your Values — to Alfredo Urena, 22, and Feliciano, 20, the young man who’d managed to control his anger after arguments with his mother.
He started by folding several sheets of paper four times and then opening them up, so each was divided into 16 squares.
Then he asked Urena and Feliciano to write one thing they value in each square.
“I only have two,” said Feliciano.
“Only two?” asked Bradbury-Koster.
“There’s nothing else in this world that I value, bro,” he said.
Feliciano had jotted down the names of his girlfriend and his little brother. Bradbury-Koster did some good-natured prodding. What about money? Freedom? Feliciano mentioned getting high. “Do you value smoking?” Bradbury-Koster asked. “I do,” Feliciano said, “but that’s not appropriate!” “Appropriate or not, it’s your values,” Bradbury-Koster said.
Urena had filled out all the squares. Food. Marijuana. Video games. His grandparents. “Being able to feel.”
Then Bradbury-Koster asked the young men to cross off a quarter of the items on their lists. “I see what you’re doing and I don’t like it,” said Urena, leaning back in his chair, his curly hair rolling down to his red sweatshirt. He was smiling. Whittling it down was hard. But he got the point: “You’re trying to find out what’s the most important.”
That’s right, Bradbury-Koster said.
“A lot of times we know it,” he said. “A lot of times it’s in the back of our heads somewhere. But the trick is bringing it from the back to the front, so that when we’re doing things — in any situation — we’re doing them in line with our values. And I don’t mean to say it like a [jerk] here, but it’s also putting your money where your mouth is. I’ve heard plenty of people say, ‘Oh yeah, I value myself, I value my girl.’ And then they’re out here doing all this rah-rah shit.”
“Yeah,” said Urena.
Bradbury-Koster pulled up a slide on a screen, went through the think-feel-do cycle, and talked about using “act on your values” to break out of bad cycles.
Then he asked: Why does this all matter?
“It makes us think before we do something,” said Feliciano. “That was a big one for me before I came to Roca. I just did what I did. If someone would say something disrespectful to me, immediately I would react through a punch. Now I just — I walk away.”
Measuring the impact
Every day, Roca’s youth workers log into a performance management system and detail their outreach to young people.
Attempted contact? Click here. Successful contact? Click there. Did you connect by phone or in person? Does the participant have a job outside Roca? Has he been arrested or violated probation since your last visit? Did you deliver CBT? If so, which skill did you discuss? Flex Your Thinking? Act on Your Values?
The thousands of clicks add up to a rich trove of data. And Roca hired a research and consulting firm, Abt Associates, to sort through that trove, pore over criminal justice records, and observe several Roca sites to evaluate the effectiveness of the CBT intervention.
It’s difficult to make a definitive judgment at this stage. The intervention is relatively new. And it’s a challenge to disentangle CBT from the other elements of the Roca model.
But a draft of the Abt Associates report, three years in the making, suggests the intervention shows promise.
Evaluators found that the more CBT skills training participants received in their first three months, the more likely they were to engage in Roca’s programming down the line — a big priority for an organization targeting a demographic highly resistant to participation in just about any organized activity.
Learning more CBT skills increased the likelihood of their landing a job. And greater exposure to CBT was associated with fewer arrests.
This is not the final word on the organization’s bottom-line impact on its participants.
A much-anticipated independent analysis is coming in a few years, part of a long-running “pay for success” initiative that has seen investors like Goldman Sachs and The Kresge Foundation sink money into Roca with the promise of repayment and a small return — from the state government — if the organization meets certain goals.
In the meantime, though, Roca is hoping to look beyond measures of employment and arrests and examine CBT’s effect on mental health.
Kerry Ressler, a professor of psychiatry at Harvard Medical School and chief scientific officer at McLean Hospital, who is working with Roca on this endeavor, suggests that’s the most important measure of all.
“When you’re triggered, how do you respond?” he says. “When something happens to you in the real world, how do you use your conscious mind and these skills that you learned to respond in a way that you’ll later be happy with and not one that you will regret?”
On a recent afternoon, Henry Thai, a Roca youth worker in Lynn, drove across town to visit a young man on house arrest.
Thai was born in Cambodia during the rise of the Khmer Rouge and spent time in refugee camps in Thailand, Malaysia, and Singapore.
All he knew from that life, he said, was violence. And after he landed in Pennsylvania at 14, he brawled his way up the East Coast before settling in Massachusetts.
Now, he works 10 or 11 hours a day, six or seven days a week, trying to keep the peace — with text messages and long talks and plenty of CBT.
The young man he saw that afternoon, Elijah Fontes, is in a difficult position.
On July 4 of last year, he was behind the wheel when some fellow gang members allegedly shot a man to death and injured several others in a drive-by shooting.
Fontes, sitting on his mother’s deck, didn’t want to talk much about that day; his case is still before the court. But he was quite open about the rest of his life.
His mother’s battles with addiction when he was a child. His time in foster care. The beatdown he inflicted on another man as part of his gang initiation. The nights he slept in the park. The suicide attempts. Three frigid days in solitary confinement wearing only his boxer shorts.
“You’re forced to change into something you don’t want to be,” he said.
Now Fontes, 23, is trying to change again.
The human connection he forged with Thai, especially after the shooting that landed him in so much trouble, has been critical.
“At that time it was like, ‘It’s over,’” Fontes said. “But he never let me doubt myself. He never let me fall prey to not caring anymore.”
The CBT skills have made a difference, too. They helped him improve his relationship with his mother. And several months ago, he said, they pulled him back from a potentially disastrous confrontation with his girlfriend.
She was pushing him that day. He was saying hateful things back. And when she threatened to call the cops, Fontes said, he thought about laying his hands on her.
But then he stopped himself. Thought about what he valued. His freedom. His reputation; he was no domestic abuser. His infant son.
“He was getting overwhelmed, he was crying,” Fontes said. “And I don’t want him to be familiar with that. I came from a home like that. The yelling. It freaks a kid out.”
The fear and the anger can start buzzing at a very young age. Fontes knew that. He was starting to get a hold on those emotions now. To push his life in a new direction.
Hopefully, his boy would never have to do the same.
David Scharfenberg can be reached at david.scharfenberg@globe.com. Follow him on Twitter @dscharfGlobe.