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2020 EAST PODIUM PAPER

Survivors of gun violence and the experience of recovery

O'Neill, Kathleen M. MD; Vega, Cecilio CPS-T; Saint-Hilaire, Sidney; Jahad, Leonard MS; Violano, Pina PhD, MSPH, RNBC, CCRN, CPS-T; Rosenthal, Marjorie S. MD, MPH; Maung, Adrian A. MD; Becher, Robert D. MD, MS; Dodington, James MD

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Journal of Trauma and Acute Care Surgery: July 2020 - Volume 89 - Issue 1 - p 29-35
doi: 10.1097/TA.0000000000002635
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Abstract

Survivors of gun violence have considerable mental health needs following injury, with rates of posttraumatic stress disorder (PTSD) and depression ranging from 40% to 65%.1–6 Despite this, gunshot wound survivors often return to the community where they were injured without receiving any formal evaluation of their mental health, support for their emotional needs, and little assistance in making the transition.1 The rate of recognition of symptoms of PTSD and utilization of traditional mental health care services among this population is also low; only 15% of those needing services access care in the year after their injury.1 In addition, survivors of gun violence are more than 20 times as likely to be reinjured as a result of repeat violence compared with the general population7 with reported rates of reinjury through violence ranging from 6% to 44%,6,8–10 This is also related to other significant downstream sequela because this population is four times as likely to die from a subsequent gunshot wound, and almost three times as likely to be arrested under a violence or weapon's charge.

Mental health, emotional recovery, and social well-being are important patient-reported outcome measures for survivors of interpersonal violence, including gun violence.11 Prior studies have demonstrated that emotional responses to intentional injuries are different than those from unintentional trauma12 and living in a community with chronic violence (as many survivors of gun violence do) is perceived as increasing the risk of retraumatization and future assaultive events.13 This is, therefore, a chronic stressor and has a strong influence on mental health recovery. Though the mental health and social well-being of survivors of gun violence are recognized as important benchmarks for recovery, the psychological experiences of gunshot wound survivors upon reentry into the community are largely unknown.

One very high-risk population, both in terms of increased vulnerability to being the victim of gun violence as well as suffering increased rates of morbidity and mortality from gun violence, is black men.5,14,15 In addition to the physical consequences of injury, black men also have increased susceptibility to mental illness following injury, particularly PTSD and depression. This is due to disproportionate exposure to preexposure and postexposure stressors including: racial discrimination, poverty, incarceration, and living in racially segregated areas with high levels of exposure to violence.16–18 Moreover, black men are less likely to be treated for their mental health symptoms.16,19 Despite these disparities in outcomes, relatively few studies have focused on understanding the psychological recovery experience of black men.

The aim of this study was to describe how black male gunshot wound survivors in the United States describe their experience of recovery and their perceptions of their mental, emotional, and social health following the event.

METHODS

Study Design

We used a qualitative research study design and a community-based participatory research (CBPR) approach.20,21 Institutional review board approval was obtained through the Yale Human Subjects Committee. Members of our academic research team had over 15 years of experience working with community leaders in the Greater New Haven, Connecticut black community that we leveraged for this research partnership.22–25 Our community/academic partnership agreed to a memorandum of understanding between the University and a nonprofit organization that had a Street Outreach Worker program working to interrupt violence within the community.

Recruitment

Our community partners used a snowball sampling method26 to recruit adult black men with a history of a gunshot wound. Individual street outreach workers distributed flyers to community members they knew had a history of a gunshot wound. These community members then contacted the investigators. Following the interview, each participant was asked to distribute more flyers to community members in their social circle that might be eligible for the study. Participants were excluded from the study if they were not community members and/or had been injured outside of the greater New Haven area, a medium-sized metropolitan area in the northeastern United States. After the first 10 interviews, we began purposeful sampling,26 asking participants to recruit individuals that had been shot in the last 5 years and/or were under the age of 30 yeas to ensure a diverse range of perspectives.

Interviews

Participants were informed that their interviews would be audio recorded and transcribed with the removal of any identifying information. Participants were paid US $40 in cash for their time. Consistent with CBPR principles, our whole team developed a semistructured interview guide of open-ended questions about the participant's personal experiences in New Haven, the circumstances surrounding their injuries, their experiences in the hospital, perceptions of providers, and their experience of recovery including whether they experienced symptoms of PTSD and depression (Fig. 1).

Figure 1
Figure 1:
Structured interview guide.

Participants were interviewed according to their preference either in an office space, their homes, the public library or another public location. Individual interviews were digitally recorded and professionally transcribed. One author (KMO), a white woman and academic researcher, conducted 13 interviews. In recognition of possible “outsider” influence on the interview, a second author (C.V.), a black man from New Haven who works as a street outreach worker, conducted seven interviews.

Data Analysis

The coding team consisted of one community member with experience in violence prevention, three investigators with experience in injury prevention research, and a qualitative research expert. We used the constant comparative method of qualitative analysis.27 Each member of the coding committee read the transcripts and cataloged the transcript data by assigning conceptual codes to different sections and then organizing these into a codebook with themes. The coding team met approximately once per month over 5 months until the codebook was finalized to discuss themes and discrepancies between individual codes. These codes and themes were organized on Dedoose Version 8.0.35, a Web-based qualitative research software.28 Our team concluded that we had thematic saturation (the point at which no new codes are being generated) after 15 interviews; we then completed five more interviews to confirm saturation.

The themes, along with illustrative quotations, were presented back to three groups to confirm validity and to engage in dialog about next steps: to the participants themselves (both one-on-one and at a group meeting); to our community partner organization; and to local community stakeholders (including the Center for Research and Engagement Steering Committee for New Haven Community-Academic Research, a committee for research on gun violence in New Haven, and multiple community planning meetings).

RESULTS

Sample

We conducted 20 interviews. All participants were black males. Their ages ranged from 20 years to 51 years. The time since injury ranged from less than 1 year to over 30 years, 75% had a history of incarceration and 50% reported ever seeking any form of mental health care (Table 1).

TABLE 1
TABLE 1:
Sample Characteristics

Themes

In discussing the aftermath of a gunshot wound injury, five key themes emerged as reactions to the event: (1) isolation, “It really made me not go anywhere;”2 Protection, “I gotta protect myself;” (2) aggression: “I'll be the one doing the shooting when that happens;” (4) normalization: “It did not really matter;” and (5) barriers to mental health treatment: “They not just gonna take advice from anybody.” Every participant in this study expressed at least one of these reactions (see Table 2 for exemplar quotes).

TABLE 2
TABLE 2:
Themes

Theme 1—Isolation: “It Really Made Me Not Go Anywhere”

Following firearm injury, 65% of participants described restricting themselves from visiting particular neighborhoods, streets, and places of business. In some cases, participants physically restricted themselves to stay in their homes. Others described isolating themselves not only from certain places, but also from certain people. They described behaviors such as avoiding old associates, crowds, or limiting their social circle to only a few people.

Theme 2—Protection: “I Gotta Protect myself”

While participants discussed a long history of exposure to violence, prior to being shot many “did not think it would happen to me.” After their injuries, they experienced a lost sense of invincibility. This was often exacerbated by a loss of “reputation” and “respect” from their peers and neighbors as an acute consequence of having been shot. Losing the protection of a good reputation and the perception of increased danger from their neighborhood led 55% of participants to admit that they considered carrying a gun or started to carry a gun right after they were shot.

Theme 3—Aggression: “I'll Be the One Doing the Shooting When That Happens”

Other participants described how they were not only more likely to carry a gun, but also more likely to use a gun. Of the participants, 15% described how every confrontation or disagreement after their initial injury was more likely to lead to gunfire.

Theme 4—Normalization: “It Did Not Really Matter”

For 50% of our participants, violence was so frequently a part of their daily lives that they were numb. They considered being exposed to violence as normal. Even the experience of being shot did not rattle or change this perception. Being shot was just a normal occurrence in their neighborhoods.

Theme 5—Barriers to Mental Health Treatment: “They Not Just Gonna Take Advice From Anybody”

Of our participants, 50% reported interacting with mental health professionals to discuss symptoms of PTSD or depression. These participants described negative interactions with mental health professionals and a number of barriers were identified. One major barrier was a lack of trust between the provider and participant. Providers often do not share the same racial, cultural, and socioeconomic background as the participants. Participants perceived that the mental health providers had little to no concept of the context in which they live. This eroded confidence in the ability of a mental health provider to give meaningful advice. Participants suggested that instead of looking to a traditional mental health care provider, the health care team should find a “credible messenger” to provide mental health care for survivors of gun violence.

Other Themes

It should be noted that there were other themes in the codebook outside of the main purpose of the study that are not reported here. These included strained relationships between the community and police, traumatic experiences within the hospital, the important role of social media, childhood traumatic experiences, the availability of firearms within the community, and attitudes toward firearms. These will be developed further in secondary analyses of the qualitative data set.

DISCUSSION

In this qualitative study of 20 black male survivors of gun violence, participants described their perceptions and experiences of psychological recovery after intentional injury from gun violence. Five key themes emerged, all of which highlight and describe a disrupted sense of safety after surviving a gunshot injury and returning to the community in which it occurred: Isolation, driven by fear of their surroundings and the chance the violent crime could happen again; (2) protection, the desire to carry a gun driven by a disrupted sense of safety and a motivation to project strength; (3) aggression, a willingness to retaliate with gun violence; (4) normalization, driven by the ubiquity of gun violence in the community; and (5) barriers to mental health treatment due to distrust of the medical community.

These five themes characterize the psychological and emotional experience of recovery from surviving gun violence. From these data we propose that a lack of support during the recovery period, exacerbation of symptoms of PTSD from community stressors, and maladaptive strategies in response to a disrupted sense of safety (including risky behaviors, such as carrying a firearm), suggest a mechanism for violent recidivism seen among survivors of gun violence.5,12,29

Our findings are consistent with other studies done in Philadelphia, Boston, and Baltimore examining the psychological and emotional reactions of survivors of violence and intentional trauma, though not necessarily gun violence.2,5,12,13,18,29,30 Black male survivors of violence describe a loss of reputation and disrupted sense of safety exacerbated by the stress of chronic violence within their neighborhoods throughout the literature.5,13,18,30 Multiple studies report persistent symptoms of posttraumatic stress among this population that is distinct from survivors of unintentional trauma.2,12,29 The concordance across the literature as well as in this study suggests a larger phenomenon in urban neighborhoods where survivors of violence experience chronic stressors that exacerbate and prolong symptoms of fear and imminent threat.

Our study expands on the current literature by highlighting the various reactions that survivors of gun violence have during their recovery period in response to this disrupted sense of safety. In particular, participants discussed a range of risky behaviors and maladaptive strategies to recover their sense of safety. These reactions have been alluded to in other studies, but to our knowledge have not been explicitly stated in prior literature. Finally, our study identifies a barrier to accessing mental health treatment: distrust of mental health care providers. Our participants suggested that one solution to improving mental health care access is to hire “credible messengers” who are able to establish relationships of trust and effectively bring this alienated population into treatment.

As described in sociology literature, black young men in racially segregated urban areas with low levels of confidence in police view respect and reputation as crucial to maintaining personal safety.31 Following victimization with a gun or other weapon, the perceived protection associated with having “respect” from the local community is acutely lost.5,31 A number of participants described feeling like a target for further violence as a result of having lost their reputation or being acutely disrespected. Either for this reason or because the circumstances around their shooting were unknown, many developed a sense of imminent danger upon returning to their communities.

In response, participants described several different strategies to protect themselves. Physical and social isolation from friends and family was one way that participants reacted to a disrupted sense of safety. As social support may be protective against the development of PTSD,32 this reaction may also be a source of stress that further leads to mental illness in this group. Other strategies included risky behaviors such as carriage of a weapon or firearm and/or an increased willingness to use a firearm during an altercation. These were considered an important means of self-protection following gunshot wound injury.

The “normalization” of violence described by participants reflects the extent to which these men are affected by chronic, persistent violence within their communities. This is similarly described by Smith et al.18 among young black men in Baltimore. Given the pervasive nature of symptoms of PTSD among the population within these communities, many perceived symptoms of PTSD as “normal;” further decreasing the likelihood that they would seek care for those symptoms. It is likely that the symptoms of posttraumatic stress—anxiety, disordered thinking, difficulty sleeping, feelings of hopelessness and depression—contribute to these patients' recidivism for violent injury.33

Participants expressed alienation and distrust of mental health providers within their communities. The cultural, racial and socioeconomic divide between mental health providers and the participants in this study resulted in many of our participants not seeking help for symptoms of mental illness. The men in this study expressed a desire for an individual that could intervene to support and assist other young men like them following injury with a gunshot wound. This “credible messenger” would ideally be someone with a similar background, who understands the emotions and reactions these young men may have from their trauma as well as the context of their upbringing and recovery environment in communities with high levels of gun violence.

Consistent with CBPR, the community-academic partnership used the preliminary results from this study to inform the creation of the Yale New-Haven Hospital Violence Intervention Program (YNH VIP). Hospital-based violence intervention programs seek to address the poor outcome associated with gun violence by connecting survivors of gun violence with community-based services.34 Hospital-based violence intervention programs are comprised of an interdisciplinary team of social workers, peer mentors, and clinicians who identify those needing services, either during or soon after hospitalization. They then work with the patients and their families to meet a diverse set of psychosocial, physical, and socioeconomic needs.11

By providing greater support for survivors of violence in the form of social work, case management and other services, YNH VIP aims to mitigate the effects of trauma following interpersonal violence. A main component of YNH VIP was training and hiring a local community member from the New Haven Street Outreach Worker program as a full-time employee of the hospital who will serve as a “credible messenger” for a targeted mental health intervention. Next steps include implementing a VIP in more communities within the Yale New-Haven Health system.

There are a number of limitations in this study. First, some of our participants were many years removed from their injury and therefore their recollections were subject to significant recall bias. Secondly, it is possible that participants were influenced by social desirability bias—the desire to appear to adhere to social norms that suggest certain behaviors are more positive or negative than others35—in their responses. Thirdly, the majority of the interviews were conducted by a white woman. In recognition of possible “outsider” influence on the interview, 35% of the interviews were completed by a black man from New Haven who works as a street outreach worker. Of note, the coding team did not find major differences in the coding between those interviews conducted by K.M.O. versus C.V.. Finally, this research was conducted in a population of black men within a single metropolitan area in the northeast recruited using snowball sampling from a single community-based organization. As such, it is unclear whether our findings are transferable to other racial/ethnic groups, genders and areas in the United States.

One of our greatest challenges was recruitment of individuals to interview. Given the amount of distrust between the research and local community, particularly in communities of color in New Haven, we found that it was difficult to recruit young black men to talk to us about their experiences. This challenge was overcome, in part, by partnership with the Street Outreach Worker Program of New Haven. However, this reliance on our community partner may have biased our recruitment to include participants with a particular ideology or background.

CONCLUSION

In this study, we identify five themes which define the psychological recovery after intentional injury from gun violence. These themes describe the various strategies used by survivors of gun violence to cope with a disrupted sense of safety when returning to their communities. These maladaptive reactions suggest a mechanism for the violent recidivism seen among survivors of gun violence and offer potential targets to help this undertreated, high-risk population. For example, barriers to mental health treatment may be addressed through “credible messengers,” who can develop relationships of trust with similarly injured black men. Reducing and eliminating violence exposure and traumatic stress in racially segregated, economically disadvantaged neighborhoods needs to be a key public health and mental health priority. Based on our study, investment in training community members to conduct outreach and targeted mental health interventions during recovery from firearm injury for vulnerable populations is an important area of future research.

AUTHORSHIP

K.M.O., C.V., L.J., M.S.R., and J.D. were all intimately involved with the conception and design of the project. K.M.O., S.S.H., and C.V. were responsible for the acquisition and curation of the data. K.M.O., L.J., S.S.H., M.S.R., J.D., and P.V. were on the on the coding team that analyzed and interpreted the data. K.M.O., M.S.R., R.D.B., J.D., and A.A.M. contributed to the literature search, writing and provided critical revisions. All authors contributed to editing of the final article and gave final approval of this submission.

ACKNOWLEDGMENTS

The Avielle Foundation funded a portion of this work. This publication was made possible by CTSA Grant Number TL1 TR001864 from the National Center for Advancing Translational Science (NCATS), a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH.

DISCLOSURE

All authors have no conflicts of interest to disclose.

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Keywords:

Gun violence; mental health; outcomes

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