The Seattle City Council voted Monday to tax firearm and ammunition sales to fund research and prevention programs aimed at gun violence reduction. One initiative that local officials say the sales tax could fund is an “intervention” program under development at the city’s Harborview Medical Center, where patients admitted for gunshot wounds are far more likely to be rehospitalized for another gun injury, commit a crime, or end up murdered, according to a 2014 study by the hospital.
While many public health experts have singled out trauma wards as places to intervene in the cycle of urban violence, the proposed Harborview model borrows heavily from methods generally used in areas other than gun violence prevention. For instance, instead of losing contact with patients once they leave the hospital, as is normally the case, trauma center physicians and social workers would stay in communication with victims of gun violence, mimicking treatment services for those dealing with alcohol or substance abuse. The program was developed by University of Washington academics and physicians in 2014, and is expected to launch later this year.
Here’s what the new approach would entail, and why some people think it could dramatically curb gun violence.
Where does the idea come from?
Instead of turning to law enforcement for solutions to gun violence, physicians and social workers in Harborview’s trauma center consulted their own treatment methods for substance abuse. During the mid-’90s, the hospital developed a screening and counseling program for alcohol abuse, which is a leading factor in traumatic injuries. Patients hospitalized with alcohol-related injuries at Harborview met with a psychologist for 30 minutes before discharge. Together, they discussed alcohol-consumption norms, the negative social and physical consequences of alcohol, and a “menu of strategies” to help the patient avoid further harm. The patient’s personal responsibility for their drinking was emphasized.
The program showed promising results: In a 1999 study published in Annals of Surgery, researchers found that patients who underwent Harborview’s treatment regime after being admitted for alcohol-related traumatic injuries experienced a “progressive, sustained” reduction in their drinking. In comparison, a control group of patients who received no such intervention initially reduced their drinking after an injury, but their alcohol consumption returned to pre-admittance levels over time.
Harborview then combined this initial intervention with the Community Reinforcement Approach (CRA), a months-long behavioral program comprised of therapy sessions for alcohol abusers, which focuses on building positive motivations and meeting consumption goals.
Hospital officials want to try the same approach with victims of gun violence: When someone is admitted to Harborview with a gunshot, their treatment won’t stop when the bullet is removed and the wound stitched. A social worker will interview all victims of gun-related injuries and try to help them find reasons for avoiding risky behavior. They will then set up face-to-face meetings with both the victims and their family members. Over 12 sessions, they will look at the role guns play in the victim’s life and environment. Finally, they will identify goals for treatment and work to develop skills like conflict resolution and anger management.
Kevin Haggerty, a professor of social work at the University of Washington and one designer of the program, calls this “individual case management.” The goal, he tells The Trace, is not only to focus on a patient’s medical issues, “but on behavioral and social issues that could put them at risk for reinjury.”
Will it work?
Both Harborview’s research and the experience of law enforcement in other big cities suggest that the victims and perpetrators of most gun violence are usually the same. For instance, New York police report that roughly 200 to 300 individuals, most of whom are young males, are responsible for the bulk of gun violence in the city. They are also frequently its victims.
The Harborview proposal estimates that hospitals in Seattle, a city about 8.3 percent the size of New York, treat approximately 110 individuals for gun-related injuries each year. Individuals hospitalized with gun-related injuries in Seattle are twice as likely to be arrested for a violent or gun-related crime than those admitted without such an injury, according to the 2014 Harborview study. By intervening in the lives of these patients over a sustained period of time, doctors and staff hope to break the cycle of gun violence that generally resumes after a victim is released from the hospital.
“It’s really about what types of approaches are effective at helping people deal with environmental challenges,” Haggerty says. “How can we provide strong support for people so that they’re not reinjured?”
The program’s creators argue that this approach saves money by avoiding future costs to the legal and public health systems. The Harborview proposal cites studies of intervention programs for substance abuse that showed a savings of $5 to $10 for every dollar invested.
Earlier models of similar programs, which begin once a person has visited the ER for violent injuries, have shown promise. The Youth ALIVE! organization in Oakland, California, launched the Caught in the Crossfire program in 1994. That initiative pairs young adults who have encountered violence with young people hospitalized for similar injuries, offering counseling, home visits, and aid finding community services in an effort to prevent the injured from resorting to violence themselves. A 2004 study of Caught in the Crossfire in the Journal of Adolescent Health found that those patients who participated were 70 percent less likely to be arrested than those who did not.
Why wouldn’t it work?
Although both alcohol abuse and gun violence are examples of risky, dangerous behaviors, the social workers and physicians at Harborview acknowledge there is no evidence the hospital’s approach will work. There is no research that shows substance-abuse treatment methods can be effective when applied to gun violence victims, and ultimately reduce violent crime. Harborview will produce a study of its work, which will be the first of its kind.
“It’s important to note that we want to test this,” Haggerty says. “We’re not assuming that just because [substance-abuse treatment programs] are strong models that they’ll be effective in this case.”
The 2004 study of Youth ALIVE! and Caught in the Crossfire revealed some limitations to hospital-based counseling as a means of limiting gun violence. While arrests declined dramatically for those young people in the program, researchers found they were no less likely to be reinjured.
How will Harborview know if it works?
Much the same way it judged the success of its alcohol-intervention initiative: If the people receiving the treatment show a decline in frequency of hospitalization, arrest, or death. Caseworkers will also rely on participants to report on their health and mental status along with whether they avoid guns after receiving services.
[Photo: Joe Mabel]
