Douglas Evans and Anthony Vega
In Denormalizing Violence: A Series of Reports From the John Jay College Evaluation of Cure Violence Programs in New York City
Crime has been decreasing since the mid-1990s, but violence is still a serious concern in many neighborhoods throughout the United States. Victims of violence often suffer psychological trauma as well as physical injuries, and research suggests the effects do not end there. Nearly half of all victims experience subsequent violent victimization. The criminal justice system may respond effectively to incidents of violence, but preventing violence and addressing the needs and ongoing risks of violence survivors requires the support of organizations outside the justice sector. Health agencies, in particular, are an important part of the societal response to interpersonal violence.
Hospital-based violence intervention is an emerging framework that recognizes the critical importance of supporting the health and broader social needs of violence survivors. Helping survivors and their families is necessary to prevent violent retaliations and one of the best opportunities for this work is when they are receiving treatment for their injuries in a hospital setting. Working with victims to surmount the trauma resulting from victimization helps to stop violence from reoccurring. Research on these programs is relatively new, but promising. Treating violence as a public health problem allows healthcare systems, including hospitals, to serve a vital role in broader efforts to reduce community violence.
Violence is increasingly framed as a public health problem (Slutkin 2012). Similar to infectious diseases, violent behavior is transmitted through close contact with others and it is one of the leading causes of death in the United States, particularly among teenagers and young adults (CDC 2017). As the most common destination for victims of serious violence, hospitals are a key resource in efforts to prevent additional violence. For one, persons seeking treatment are in a vulnerable state. Hospital-based violence intervention programs (HVIPs) may disrupt the cycle of violence by providing patients, and potentially their families and friends, with trauma counseling and referrals to social services (Cooper et al. 2006). At the community-level, HVIPs seek to prevent retaliations, to change social norms that associate violence with respect, and to provide outreach and counseling to victims, their family members and friends (Cooper et al. 2006).
The broad goals of HVIPs are to reduce violent retaliations, reinjuries, and criminal justice involvement, and to impede repeated violent victimization by providing violently injured victims with culturally sensitive, comprehensive, and multifaceted intervention programs (Cooper et al. 2006; Chong et al. 2015).
The first step is to identify patients injured by violence through the analysis of medical records and referrals. Staff members may assess the patient’s background—physical and mental health, education, family, employment, and criminal justice involvement—and offer psychological and social support (Cooper et al. 2006). Staff members typically engage with patients at their hospital bedside or in their homes to establish trust, to assess the risk of the patient retaliating, and to offer education about the psychological effects of violence and post-traumatic stress (Purtle et al. 2015a).
Many patients hospitalized for a violent injury have experienced violence-related trauma that HVIPs address to persuade them to adopt non-violent intervention strategies and to facilitate behavioral change (Purtle et al. 2014). Most HVIPs screen patients for violent injuries caused by domestic violence, child abuse, and/or self-inflicted injury because these patients are ineligible for participation in HVIPs.
Theoretical support for HVIPs is found in the Health Beliefs Model (HBM), which theorizes that people alter their risky health behavior as they begin to understand their vulnerability to its effects, the severity of its consequences, the benefits of prevention strategies in general, and their own ability to follow those prevention strategies (De Vos et al 1996). Because victims of violence perceive hospitals as safe environments, especially compared with courts or jails, they may be more receptive to support provided within a healthcare setting, including interventions that rely on psychological healing to prevent future violence (Cooper et al. 2006; Purtle et al. 2015a).
HVIPs utilize the window of time after a violent injury to share nonviolent conflict resolution strategies with surivors of violence. The window of time following a violent incidence is considered a “teachable moment,” when individuals may be more willing to learn about the risk of future violence (Johnson et al. 2007). During that time, violently injured patients begin to develop a narrative to explain the events leading up to their injury and the reason for their hospitalization. Hospital-based staff may be able to influence the patient’s narrative and outlook. Counseling patients helps reduce feelings of helplessness and thoughts of revenge, both of which influence a patient’s behavior as well as the behavior of their families and friends (De Vos et al. 1996).
Case management is an essential component of many HVIPs. Case managers meet with injured patients to address issues related to their medical treatment and any psychological or emotional symptoms resulting from their injuries. They work with patients and their families to avoid retaliations and to set goals for the immediate future as patients attempt to rebuild their lives. Case managers work to connect patients with community-based services and to facilitate non-violent problem-solving skills. Program staff members often refer patients for social services, primary and preventative healthcare, anger management, conflict resolution, and coping skills (De Vos et al. 1996; Zun et al. 2006). Other services may include victim compensation assistance, medical insurance supports, transportation to the hospital or court, and referrals for employment, education, and mental health treatment (Chong et al. 2015). Programs often stay in contact with victims between six and twleve months (Purtle et al. 2015a).
Researchers have evaluated the effects of some HVIPs in the United States. The National Network of Hospital-Based Violence Intervention Programs, established in 2009, has more than 30 members, including a number of neighborhood-based interventions. Many HVIPs have launched since 1990, including:
- Beyond Violence (Richmond, CA)
- Caught in the Crossfire (CiC) (Oakland, CA)
- Cure Violence (Chicago, IL)
- CHOICE program (Salinas, CA)
- Detroit Life is Valuable Everyday (DLIVE) (Detroit, MI)
- Healing Hurt People (Philadelphia, PA)
- Journey Before Destination (Washington, D.C.)
- Out of the Crossfire (Cincinnati, OH)
- Pennsylvania Injury Reporting and Intervention System (Philadelphia, PA)
- Prescription for Hope (Indianapolis, IN)
- Project Ujima (Milwaukee, WI)
- Rochester Youth Violence Partnership (RYVP) (Rochester, NY)
- Trauma to Triumph (San Jose, CA)
- Violence Intervention Advocacy Program (VIAP) (Boston and Springfield, MA)
- Violence Intervention Project (VIP) (Baltimore, MD; Philadelphia, PA; Sacramento,
- CA; Savannah, GA)
- Within Our Reach (Chicago, IL)
- Wraparound (WAP) (San Francisco, CA)
Evaluations have documented success in the form of lower levels of future offending, fewer retaliations, reduced hospitalizations, and cost savings from reductions in future injuries and incarcerations following HVIP interventions.
Caught in the Crossfire (CiC), one of the first HVIPs, launched in 1994 and was replicated in multiple sites. The program relies on peer-based crisis intervention specialists to visit violently injured youth in hospitals and to convince them, their families, and their friends to avoid seeking revenge while they offer youth mentoring and social services (Becker et al. 2004). An evaluation of the program indicated that compared with youth who did not participate, CiC youth were less likely to be arrested six months following their hospitalization, although there were no significant differences found in the number of re-hospitalizations between youth participants and non-participants (Becker et al. 2004).
Wraparound (WAP), a Hospital-based Violence Intervention Program in the San Francisco General Hospital, offers violence intervention and case management services to patients between the ages of 10 and 35 who are assessed as having a high-risk for re-injury (Kramer et al. 2017). The Wraparound program was associated with a decrease in the rate of participant re-injury of about four percent after controlling for demographic characteristics of patients (Juillard et al. 2016).
Research on the Baltimore Violence Intervention Program (VIP) also found positive results. Patients randomly assigned to the intervention program had a lower likelihood of re-arrest for a violent crime, a lower rate of subsequent convictions for both any crime and for violent crimes, and a shorter duration of projected incarceration time (18 versus 68 years) compared with patients randomly assigned to a non-intervention group (Cooper, Eslinger, and Stolley 2006). Evaluations of other HVIPs found decreased rates of re-injury, lower likelihoods of subsequent victimization, and fewer arrests after hospitalization and HVIP intervention (Zun et al. 2006; Becker et al. 2004; Juillard et al. 2016).
Research exploring the specific components associated with effective HVIPs indicates that providing patients with opportunities for mental health care and employment and high doses of exposure to a case manager in the first three months of the HVIP are associated with positive change (Smith et al. 2013). One analysis indicated that reducing violent re-injury by 25 percent over five years would yield cost savings even before including the costs of injuries themselves (Purtle et al. 2015b). One study estimated that losses from a year of violent injuries nationwide could be more than $70 billion, mostly due to losses in worker and household productivity (Corso et al. 2007).
If they reduce recidivism and re-hospitalizations, HVIPs are a cost-effective investment (Chong et al. 2015). In Baltimore alone, a HVIP saved $1 million in costs associated with repeat hospital visits, re-incarceration, and increased participant employment (Cooper et al. 2006). Yet, HVIPs can be costly and public funding is uncommon (Zun et al. 2006). Most HVIPs are grant funded, which makes it difficult for programs to secure consistent support and to expand to additional hospitals (Purtle et al. 2015a).
There are multiple challenges to implementing and evaluating HVIPs. One issue is the lack of coordination between hospitals and the criminal justice system. With enhanced communication, however, police could refer victims to HVIPs and HVIP personnel could advocate for prosecutors to be lenient on charges for individuals who complete the program and demonstrate positive change. Another challenge is determining an appropriate follow-up schedule with participants and obtaining an adequate sample size for control and treatment groups (Juillard et al 2016; Shibru et al. 2007). Demonstrating attitude change among patients is difficult, particularly in studies with small sample sizes and short follow-up periods. It can be difficult to track participants after they leave the program, and most HVIP evaluation studies have sample sizes under 200 participants (Mikhail and Nemeth 2016). Randomized controlled trials of HVIPs face other challenges related to the ethics of blinded trials and lower reliability when using self-report instruments (Mikhail and Nemeth 2016). Most evaluation studies are also unable to track patient admission to other nearby hospitals or emergency departments.
HVIPs can potentially yield numerous benefits. If the programs are able to prevent further violence, re-injury, and death, they can save lives and lessen the heavy financial, social, and human costs associated with future violence (Cunningham et al. 2008). The programs can also help to protect youth and reduce their likelihood of later engagement in violence. Because violence is one of the leading causes of death among people between the ages of 15 and 34, especially in disadvantaged communities, HVIPs that focus their programs on at-risk adolescent males can save many lives (Murphy et al. 2009; CDC 2017). Given their unique position in the lives of victims of violence, HVIPs are able to reach a wider range of people affected by violence, including individuals who are homeless and those with little to no contact with other systems such as schools and social services (De Vos et al. 1996).
The growing influence of hospital-based violence intervention programs reflects a shift towards a public health approach to reducing interpersonal violence. With an increasing number of HVIPs across the country, the stability of funding is a concern, but evaluations reveal important benefits—reductions in re-injuries, re-incarcerations, and lower financial costs associated with repeat violent victimization. Greater communication and coordination between HVIPs and other social supports, even including the criminal justice system, may encourage expansion of these programs. More research is needed, but the approach of HVIPs is straightforward: victims of violence are most susceptible to positive behavioral change when they are physically wounded, emotionally vulnerable, and when they engage with case managers and mentors from outside of the criminal justice system. Hospitals would seem to be an ideal environment in which to persuade survivors of violence to avoid retaliation and to break the cycle of violence.
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Funding for this report was provided by the New York City Council, the New York City Mayor’s Office of Criminal Justice (MOCJ), and the Robert Wood Johnson Foundation. Points of view or opinions contained within this document are those of the authors and do not necessarily represent the official position or policies of the City University of New York, John Jay College, or their funding partners.
The John Jay Research and Evaluation Center (JohnJayREC) is an applied research organization and part of John Jay College of Criminal Justice, City University of New York.
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Evans, Douglas and Anthony Vega (2018). Critical Care: The Important Role of Hospital-Based Violence Intervention Programs. In Denormalizing Violence: A Series of Reports From the John Jay College Evaluation of Cure Violence Programs in New York City. New York, NY: Research and Evaluation Center, John Jay College of Criminal Justice, City University of New York.
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