This article describes a unique hospital‐based intervention for trauma, violence, and adversity in healthcare settings. Healing Hurt People (HHP) was built on the foundation of the Sanctuary Model that uses a trauma informed conceptual framework to address organizational approaches to helping victims of violent injury heal (physically and emotionally) from trauma. HHP is a collaborative model that brings together caregivers from multiple disciplines and systems that touch the lives of victims of urban violence. With support from the Philadelphia Department of Behavioral Health and Intellectual DisAbilities Services (DBHIDS) this program is being replicated at Philadelphia level I trauma centers.
HHP provides an innovative approach to providing behavioral health services for a marginalized population that would often not otherwise seek such services, despite their dire need. HHP's approach relies on trauma-‐informed practices that hone in on that very trauma that our young people (especially boys and men of color) and their families experience, which unfortunately feeds the cycle of violence. This humanistic innovation helps to heal that trauma. As HHP has grown and continued to identify the ever‐present need for trauma‐informed interventions for violently injured youth in Philadelphia, we have also seen the positive impact that this work can have on young people and their families.
Each year in the US, over 1.5 million victims are treated in hospitals for nonfatal gunshot, stabbing, and other physical assault injuries; approximately 30% are males of color. Male victims of interpersonal violence, particularly young male victims of color, face persistent barriers to accessing victim services that meet their needs, in part because of their own exposure to significant trauma and in part because of how they are often portrayed in news reports and media as dangerous perpetrators and unworthy victims. In addition stressed staff and institutions often respond to and mimic the traumatic experiences of their clients. To serve young male victims of color better, victim services need to understand trauma and increase their trauma‐informed care skills.
Interpersonal violence disproportionately affects African Americans, especially young African American males. In 2013 in Philadelphia, 247 people were victims of homicide. Of these, 77% (191) were African American and 58% (143) were between the ages of 18 and 34. Of the 1128 shooting victims in 2013, 84% (946) were African American and 78% (883) were under the age of 34.(1)
The physical consequences of nonfatal violent injury, including disability, pose a significant burden for these victims. However, beyond the physical consequences, the psychological consequences of violence, including depression, posttraumatic stress disorder and substance abuse are seldom taken into account by programs attempting to address community violence. Lack of access to health insurance, high rates of poverty and lack of marketable job skills further complicates the lives of these victims.
Recent studies among victims of interpersonal violence seen at Hahnemann Hospital indicate that rates of PTSD may approach 77% in this population. Despite this, there has been sparse research on the prevalence and consequences of PTSD in urban populations and even less research on potentially effective interventions.2
A significant body of research also shows that victims of interpersonal violence have a high rate of recurrent violence in the months and years after their initial injury. Studies in Chicago and Baltimore have demonstrated recurrence rates of penetrating injury (stabbings or shootings) as high as 44% at five years. Those same studies have shown a mortality rate of 20% at five years.(3,4,5,6)
The economic and societal costs of interpersonal violence have been estimated through a rigorous cost analysis. Corso and her colleagues calculated a lifetime lost productivity cost per homicide of $1.3 million and a lost productivity cost of more than $57,000 for each nonfatal injury. These lost productivity costs combined with the medical costs of interpersonal injury totaled $33 billion in 2007.(7)
Male victims of interpersonal violence, particularly young male victims of color, face persistent barriers to accessing victim services that work for them, in part because of their own exposure to significant trauma and in part because of how stressed staff and institutions respond to, and mimic, the traumatic experiences of their clients. To serve young male victims of color better, victim services need to understand trauma and increase their trauma-‐informed care skills.
Healing Hurt People (HHP) is a community‐focused, hospital-based program designed to reduce re-injury, retaliation, and PTSD symptoms among victims of violence ages 8‐30. It is the cornerstone program of the Center for Nonviolence and Social Justice at Drexel University in Philadelphia. HHP employs a trauma-‐informed approach that takes into account the trauma and adversity that clients have experienced over their lives and recognizes that addressing these issues is critical to breaking the cycle of violence and moving individuals towards healing. Unfortunately, the majority of our intentionally injured youth are boys and young men of color. HHP of the Center for Nonviolence and Social Justice is a member and leader of the National Network of Hospital‐based Violence Intervention Programs (www.nnhvip.org).
HHP was founded in 2007 by Dr. Theodore Corbin an emergency medicine physician at Hahnemann Hospital and Drexel University College of Medicine. He recognized that many of his patients suffered not only physical wounds, but also the psychological wounds of violence and trauma. Most of the psychological wounds went unaddressed in the traditional care received in hospitals. Built on the foundation of trauma-‐informed practice and the Sanctuary Model, HHP brings together a range of approaches to helping victims of interpersonal violence heal. The program focuses on victims between the ages of 18 and 30 who are at the highest risk for injury and trauma. In 2009, HHP was expanded to include St. Christopher's Hospital for Children where youth victims of violence between the ages of 8 and 18 are served.
HHP is comprised of five major programmatic components, each of which is supported by evidence of effectiveness.(8) Assessment activities are first conducted to evaluate immediate risks for re‐injury and retaliation; to note histories of trauma and adversity; and to identify follow-up medical and psychosocial needs. Assessment activities also serve as a tool to educate clients about potential symptoms of post‐traumatic stress. Culturally competent HHP staff also serve in a mentorship capacity for clients. They provide social support to help manage the psychological sequella of violent injury, resist community pressure to retaliate, and envision a positive future. Therapeutic case management and navigation is provided to ensure that the service needs identified through assessment are met. These services may include follow‐up medical care, housing, health insurance, education, job training, criminal justice, substance misuse and mental health, and linkages to other resources. HHP clients also participate in trauma‐informed SELF psychoeducation groups. SELF is a 10-week curriculum that provides an environment and vocabulary that promotes healing, growth, and recovery from trauma, through the prism of Safety, Emotion management, Loss and Future. The SELF curriculum has demonstrated effectiveness in improving coping skills and feelings of loss of control among participants.(9, 10) The Child and Family Traumatic Stress Intervention (CFTSI) is also offered to youth (under 18) clients of HHP. CFTSI is an evidence‐based, four‐session, caregiver‐child intervention that is provided within 30 days of a potentially traumatic event (e.g., violent injury) to prevent the development of chronic PTSD.(11)
Recognizing the power of the alternative approach that HHP utilizes and impressed with the support that the Philadelphia Department of Behavioral Health and Intellectual DisAbilities provided, the Annie E. Casey Foundation and the Stoneleigh Foundation have joined HHP and DBHIDS to support research to demonstrate the effectiveness of the program. Annie E. Casey has committed funding through March of 2016, and is currently considering extending the funding through 2018. Stoneleigh Foundation has extended its funding through June of 2016 to complement the Annie E. Casey funding and the DBHIDS funded support of the programmatic components of the replication. In keeping with the proposed replication at three additional hospitals in Philadelphia over the next two years (Temple, Einstein and the Hospital of the University of Pennsylvania), this three‐pronged support provides a unique opportunity to track outcomes from this natural experiment in order to identify both the success of program replication and the outcomes related to HHP across the 4 clinical venues.
To date, HHP has served over 600 victims.
A rigorous outcome evaluation is underway, made possible by the replication of HHP to three new level I trauma centers in Philadelphia. The specific aims of this study are to:
- Assess the effectiveness of HHP for preventing violent re-injury and arrest for violent crime at one year follow‐up. Specifically, we will conduct a pooled difference‐in‐difference analysis comparing a pooled control group of 135 violently- injured HHP-eligible patients enrolled prior to program implementation to 180 violently-injured patients who receive HHP.
- Assess the effectiveness of HHP for reducing symptoms of depression and PTSD at six weeks and six months follow-up; comparing a pooled control group of 135 violently injured HHP‐eligible patients enrolled prior to program implementation to 180 violently injured patients who receive HHP.
- Explore factors related to HHP implementation fidelity that mediate and moderate client outcomes.
In short, we have proposed to conduct a difference‐in-difference analysis, comparing a control group of HHP‐eligible patients presenting at each hospital (prior to HHP implementation) to an intervention group of HHP participants at the same hospital after HHP has been fully implemented. Our primary outcomes have also evolved to allow for tracking outcome data that will be available across all sites and participants.
Our primary outcomes will be:
- Hospital recidivism for violent injury (i.e., violent re‐injury) and;
- Arrest for a violent crime assessed at one year follow-up by hospital and criminal justice records
Secondary outcomes include a range of psychosocial variables found in the table below, and will be assessed through audio computer‐assisted self-interviews (ACASI) administered at baseline, 6 weeks, and 6 months. We will compare outcomes between the control and intervention group at each hospital, and analyze results for each hospital individually as well as across all four hospitals. We will also monitor HHP program implementation fidelity through process measures that will be built into the HHP case management database.
The Healing Hurt People program works with a marginalized population to improve physical and emotional health as well as education and employment status at a pivotal moment in young peoples lives. We use trauma‐informed practice in the hopes that we will positively impact their trajectory toward better physical and mental health.
1 Philadelphia Police Department, Murder/Shooting Analysis 2013, http://www.phillypolice.com/assets/crime‐maps‐stats/HomicideReport-‐2013.pdf.
2 Corbin, T.J., Purtle, J., Rich, L., Rich, J., Adams, E., Yee, G., Bloom, SL. "The Prevalence of Trauma and Childhood Adversity in an Urban, Hospital‐based Violence Intervention Program." Journal of Health Care for the Poor and Underserved. 2013 Aug ;24(3):1021‐30.
3 Morrissey TB, Byrd CR, Deitch EA. The incidence of recurrent penetrating trauma in an urban trauma center. J Trauma 1991;31:1536 8.
4 Kennedy F, Brown JR, Brown KA, et al. Geographic and temporal patterns of recurrent intentional injury in south‐central Los Angeles. J Natl Med Assoc 1996;88:570 2.
5 Goins WA, Thompson J, Simpkins C. Recurrent intentional injury. J Natl Med Assoc 1992;84:431 5.
6 Reiner DS, Pastena JA, Swan KG, et al. Trauma recidivism. Am Surg 1990;56:556 60.
7 Corso P et al., "Medical costs and productivity losses due to interpersonal and self‐directed violence in the United States," American Journal of Preventive Medicine (2007) 32(6): pp. 474‐82.
8 Corbin TJ, Rich JA, Bloom SL, Delgado D, Rich LJ, Wilson AS. (2011). Developing a trauma‐informed, emergency department‐based intervention for victims of urban violence. Journal of Trauma Dissociation. 2011;12:510‐25.
9 Bloom, SL. (1997). Creating Sanctuary: Toward and Evolution of Sane Societies. New York: Routledge.
11 Rivard, J.C., Bloom, S.L., McCorkle, D. Abramovitz, R. (2005). Preliminary results of a study examining the implementation and effects of a trauma recovery framework for youths in residential treatment. Therapeutic Community, 26(1): 83‐96.
12 Berkowitz SJ, Stover CS, Marans SR. (2011). The Child and Family Traumatic Stress Intervention:
secondary prevention for youth at risk of developing PTSD. Journal of Child Psychology and Psychiatry, 52(6):676‐85.