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https://doi.org/10.1177/1557988320982181
American Journal of Men’s Health
November-December 1 –15
© The Author(s) 2020
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Promoting Men’s Health Equity – Original Article
Young Black men experience a disproportionate burden of
violence-related death and disability, largely due to fire-
arm injury. Homicide is the leading cause of death among
Black males between ages 15 and 34 (Centers for Disease
Control and Prevention National Center for Injury
Prevention and Control, 2020). In 2018, nearly 14,000
individuals were killed in firearm-related homicides,
which made up 74% of all criminal homicides in that year.
Black males between ages 15 and 34 experience firearm
homicide deaths at rates over 10 times higher than corre-
sponding white males (Centers for Disease Control and
Prevention National Center for Injury Prevention and
Control, 2020). Approximately half of young Black men
who survive a violent trauma are hospitalized for a similar
penetrative injury within 5 years. Among this population,
20% will die from their wounds (Rich, 2009). In addition
to homicide, over 100,000 individuals suffered nonfatal
982181JMHXXX10.1177/1557988320982181American Journal of Men’s HealthRichardson et al.
research-article2020
1Joel and Kim Feller Professor of African-American Studies and
Anthropology, Department of African-American Studies and the
Department of Anthropology, College of Behavioral and Social
Sciences, University of Maryland College Park, College Park, MD, USA
2Department of Anthropology and the Department of African-
American Studies, Transformative Research and Applied Violence
Intervention Lab (TRAVAIL), College of Behavioral and Social
Sciences, University of Maryland College Park, College Park, MD, USA
3Department of African-American Studies, Transformative Research
and Applied Violence Intervention Lab (TRAVAIL), College of
Behavioral and Social Sciences, University of Maryland College Park,
College Park, MD, USA
Corresponding Author:
Joseph B. Richardson, Jr., Joel and Kim Feller Professor of African-
American Studies and Anthropology, Department of African-
American Studies and the Department of Anthropology, College of
Behavioral and Social Sciences, University of Maryland College Park,
1141 Taliaferro Building, College Park, MD 20742, USA.
Email: jrichar5@umd.edu
Shook Ones: Understanding the
Intersection of Nonfatal Violent Firearm
Injury, Incarceration, and Traumatic
Stress Among Young Black Men
Joseph B. Richardson, Jr., PhD1, William Wical, MA2,
Nipun Kottage, BS2, and Che Bullock3
Abstract
Violent injury is a leading cause of death and disability among young Black men, with the highest rates occurring in
low-income urban populations. Hospital-based violence intervention programs (HVIPs) offer a promising opportunity
to address the biopsychosocial factors that adversely affect this population. However, there are major gaps between
the needs of young Black male survivors of violent injury and the forms of care provided by HVIPs. Patient-centered
outcomes research provides a useful mode of inquiry to develop strategies to decrease these differences. Care for
survivors, including treatment for traumatic stress disorders, must be reconceptualized to center the lived experiences
of young Black men. This paper qualitatively explores how these survivors of gun violence express symptoms of
traumatic stress and the ways in which their narratives can inform the implementation of the biopsychosocial model
in HVIPs. A phenomenological variant ecological systems theory framework was used to analyze participant narratives
to aid in understanding their symptoms of traumatic stress and post-injury affective changes as both psychologically
and socially important experiences. Such insight may inform changes to HVIP practice to address persistent health
disparities related to violence.
Keywords
intentional injury, behavioral issues, male-on-male violence, risk factors, violence, men’s health interventions
Received February 28, 2020; revised November 18, 2020; accepted November 30, 2020
2 American Journal of Men’s Health
injuries from firearm-related violence (CDC, 2020). These
survivors experience significant challenges to their physi-
cal, psychological, and social well-being that are exacer-
bated by significant barriers to treatment (Hanson et al.,
2010; Kazlauskas, 2017; Motley & Banks, 2018; St Vil
et al., 2018; Vella et al., 2019; Wong et al., 2007).
The causes of interpersonal violence between Black
men living in socioeconomically deprived urban environ-
ments are complex and vary by context. Like other health
disparities, violent injury is related to the interaction of
structural, local, and individual factors including institu-
tional racism, mass incarceration, poverty, neighborhood
disadvantage, as well as social and individual trauma
(DaViera & Roy, 2019; Johnson, 2019; Pager et al., 2009;
Voisin, 2019; Wacquant, 2010). Interpersonal violence
itself contributes to further traumatization, community
disruption, and new forms of social interaction that pro-
duce additional violence (Duck, 2015; Motley & Banks,
2018; Rich & Grey, 2005; Voisin, 2019). These relation-
ships are evidenced by the high rates of repeat violent
victimization recognized in hospitalized trauma patients,
with the average rate in the United States being approxi-
mately 35% and reaching up to 65% (Cooper et al., 2000;
Richardson et al., 2016). Authors such as Anderson
(1999), Rich and Grey (2005), and Duck (2015) have pro-
posed conceptual models for how direct violent victim-
ization can result in reinjury. Nuanced understanding of
the mental health consequences of violent injury among
young Black men can better inform health services to
support survivors and reduce repeat violent injury.
Approaches to Researching Gun Violence
The combination of the biopsychosocial model of health
and phenomenological variant ecological systems the-
ory (PVEST) provides a useful framework to analyze
how individual experiences with violence are related to
social processes. Hargarten et al. (2018) characterize
gun violence as a biopsychosocial disease; this approach
acknowledges the complex relationships between bio-
logical, psychological, and socio-ecological processes.
The authors emphasize the importance of considering
pre-, peri-, and post-injury factors, which necessitate
solutions across numerous levels of intervention. The
biopsychosocial model requires that research is informed
by a holistic set of data that reflects the lived experi-
ences of survivors. This framework recognizes the ways
in which direct victimization, perpetration, indirect
exposure to violence, and institutionalized violence are
linked as consequences and causes of trauma endured
throughout the life course, socially, and intergeneration-
ally (Brackney-Wheelock, 2017; Johnson, 2019; Motley
& Banks, 2018; Voisin, 2019).
PVEST is a variant of Bronfenbrenner’s (1979) eco-
logical systems theory, which links individual meaning-
making processes to multiple levels of context and group
membership to understand identity development, respon-
sive behaviors, and outcomes throughout the life course
(Smith & Patton, 2016; Spencer, 1995, 2006, 2008; Velez
& Spencer, 2018). This theoretical perspective provides
an integrating framework for understanding an individu-
al’s development in the context of “power dynamics and
interconnected systems [that] lead to differential out-
comes within socially constructed categories like class,
race, and gender” (Velez & Spencer, 2018). This approach
is useful in considering how previous exposures to vio-
lence and homicide may alter the ways in which poor
young Black men living in urban areas respond to and
express traumatic stress. This study employs PVEST to
analyze the psychosocial consequences of violent victim-
ization for young Black men treated in a hospital-based
violence intervention program (HVIP) in suburban
Maryland to improve social service and mental health
provision.
Effectiveness of HVIPs and the Need for
Patient-Centered Outcomes Research
According to the Health Alliance for Violence Inter-
vention, HVIPs are “multidisciplinary programs that
identify patients at risk of repeat violent injury and link
them with hospital- and community-based resources
aimed at addressing underlying risk factors for violence”
(The Health Alliance for Violence Intervention, 2020).
These resources vary by HVIP but typically include bed-
side engagement in the hospital after admission for vio-
lent injury, outpatient psychological counseling, case
management, mentoring, and connections to education,
employment, and housing services (HAVI, 2020; Purtle
et al., 2013).
HVIPs are often theoretically framed by the Health
Beliefs Model (HBM); this paradigm posits that people
alter risky health behaviors as they better understand their
decisions, the consequences of those decisions, and strat-
egies for prevention (De Vos et al., 1996, Evans & Vega,
2018). For HVIPs, this idealized HBM intervention
occurs during a “teachable moment” after an individual is
hospitalized for acute violent injury. It is during these
moments that a survivor is offered and provided social
services that enable them to identify and modify factors
that put them at risk for recurrent injury (Bonne & Dicker,
2020; Goldman, 2020; Johnson et al., 2007). However,
HBM frameworks face important limitations. Many fac-
tors that correlate to recurrent violent injury among this
population, such as history of criminal justice engage-
ment, unstable housing, substance use, and participation
Richardson et al. 3
in informal economies, are related to complex individ-
ual, interpersonal, and social processes such as mass
incarceration, redlining, and other processes of institu-
tionalized racism (Johnson, 2019; Rich & Grey, 2005;
Richardson et al., 2016; Voisin, 2019; Wacquant, 2010).
Because recurrent violent injury is interrelated to pro-
cesses of interpersonal and structural violence, interven-
tions that address root causes of violence and injury offer
advantages over behavior-based approaches (Juillard
et al., 2016). Using a PVEST perspective allows analysis
of how HVIPs frame health crises and provides an oppor-
tunity to examine the therapeutic approaches provided by
these programs. This perspective emphasizes subjective
experiences in numerous contexts, focuses on the life
course, and holistically conceptualizes contributing fac-
tors to injury, thereby offering a means to develop new
paradigms for care for HVIPs.
HVIPs have been reported to reduce both trauma and
criminal justice recidivism (Cooper et al., 2006; Shibru
et al., 2007); however, there is limited and mixed evi-
dence to support their effectiveness (Affinati et al., 2016;
Chong et al., 2015; Cooper et al., 2006; Dicker, 2016;
Juillard et al., 2016; Purtle et al., 2013; Smith et al.,
2013). Despite their increased risk for emergency depart-
ment visits for violent injury and participation in HVIPs,
there is dearth of qualitative literature on the effective-
ness of HVIPs, specifically psychological care, from the
perspectives of young Black male survivors of violence
(Monuteaux et al., 2017).
HVIPs frequently incorporate cognitive behavioral
therapy (CBT) into service models that guide care for sur-
vivors of violence while prioritizing varied psychosocial
health outcomes (Karraker et al., 2011; Monopoli et al.,
2018). However, HVIPs have no common therapeutic
model or set of outcomes that have been consistently
developed, measured, or validated using standardized
tools (Monopoli et al., 2018). No comprehensive, evi-
dence-based, and trauma-specific therapeutic model has
been developed to ameliorate traumatic stress among vio-
lently injured young Black men (Monopoli et al., 2018).
In the absence of the appropriate population-specific
model, the HVIP in the study used the Men’s Trauma
Recovery Empowerment Model (M-TREM). M-TREM,
which was developed as a trauma-specific intervention
for incarcerated and substance-abusing populations, as
well as other population-specific CBT interventions,
effectively reduce post-traumatic stress (e.g., Bosch et al.,
2020; Nancy Wolff et al., 2013; Roberts et al., 2015;
Wolff et al., 2015). While violently injured young Black
men often experience incarceration and substance abuse,
the present lack of a comprehensive therapeutic model
for this population presents a significant gap in evidence-
based treatment and understanding of interpersonal vio-
lence (Richardson et al., 2016).
To provide meaningful services, HVIPs must center
and emphasize the perspectives and priorities of young
Black male participants as therapeutic models and pro-
grams emerge. Patient-centered outcomes research
(PCOR) offers a viable means to access the unique per-
spectives of patients and their social networks; these data
can change and improve the pursuit of clinical questions
(Frank et al., 2014; Snyder et al., 2013). PCOR stresses
the importance of research “informed by the perspec-
tives, interests and values of patients” throughout the
entirety of the research process (Snyder et al., 2013).
Such research directly informs evidence-based practice
to improve the quality of services provided to young
Black men who survive violence.
Methods and Data
Design
A Researcher 2 Practitioner Fellowship funded by the
Center for Victim Research and a PCOR Seed Grant from
the University of Maryland, Baltimore Patients Program
provided the necessary financial support for the HVIP
Research Director and the HVIP violence intervention
specialist (VIS) to serve as co-investigators on this proj-
ect. These grants were designed to determine how survi-
vors of violent injury defined healthy outcomes and how
they envisioned strategies to empower them in health-
care decision-making processes. This research empha-
sized qualitatively exploring the intersection and impact
of the health care and criminal justice systems in the lives
of violently injured young Black men, with specific atten-
tion to the collateral consequences associated with both a
felony record and violent injury. In accordance with a
PCOR approach, this study explores the narratives of
these men in order to understand how participants
describe their mental health—psychological, affective,
behavioral, and social—experiences related to violent
injury with the explicit goal of identifying opportunities
to inform the types of services provided.
Subjects were drawn from low-income young Black
male survivors of violent nonfatal firearm injury who
were ages 18–30 and participating in HVIP programming
(N = 11). A focus group and individual in-depth semis-
tructured interviews were utilized to generate the data.
The singular focus group, composed of six participants,
was conducted to determine a range of survivors’ experi-
ences, level of shared experience, differing needs for ser-
vices, and possible differences in psychological well-being
after discharge. The findings from the focus group directly
informed the research questions and instruments used dur-
ing the ensuing in-depth qualitative interviewing phase of
the project. Each survivor was interviewed one time, with
interviews lasting approximately 60 min. The interviews
4 American Journal of Men’s Health
were also filmed and recorded as part of a digital storytell-
ing project (Richardson & Bullock, 2019). Semistructured
interviews were used to provide an understanding of the
complexity of psychological and social experiences relat-
ing to injury. Survivors were asked open-ended questions
regarding the day they were injured, their experiences at
the HVIP, their psychological well-being, and their per-
spectives on what changes would best allow the program
to meet their needs. Participants were paid $50 cash and
received free Uber rides to and from the interview loca-
tion. The choice to offer this mode of transportation was
informed by best practices for trauma-informed research
with young Black men who have survived violent injury
(Richardson et al., 2020).
There are notable methodological considerations and
challenges to conducting research with young Black men
who have sustained a violent injury. Practically, these chal-
lenges included scheduling and coordinating the focus
group and interviews between survivors and the research
team. The intersectional relationships of race, gender,
class, and violent injury contribute to compounding chal-
lenges. These factors are exacerbated by fatigue, traumatic
stress, and sedation, which are common after violent injury
(Liebschutz et al., 2010; St Vil et al., 2018). The VIS
played a key role in the recruitment for and facilitation of
individual interviews and the focus group. This approach
was chosen because of the VIS’s use of a relational model
of engagement and his established trust and rapport with
survivors (Wical et al., 2020). By sharing his personal his-
tory of surviving violent assault and experiencing trau-
matic stress, the VIS provided a shared language to discuss
survivors’ own physical and mental health. These com-
monalities with survivors were essential in fostering trust
in the program; this was beneficial in achieving sustained
participation in the research and program. The VIS has for-
mal training in M-TREM, trauma informed care, motiva-
tional interviewing, certification from the CITI program
for research with human subjects, and received extensive
mentoring from the program director.
Participants and Setting
The inclusion criteria for the study were (1) survivor of a
gunshot wound; (2) history of criminal justice involve-
ment (incarceration, probation, or parole); (3) participa-
tion in the HVIP; and (4) at least 18 years old. Five of the
11 participants (45%) had experienced 2 or more hospital-
izations for a violent injury. All of the survivors had been
treated at the same level II trauma center in Maryland.
Each member of the sample also participated in the pro-
gramming offered by the HVIP. The hospital is located
in a suburban region of Maryland, approximately 1 mile
from the District of Columbia’s northeastern border.
Participants in the HVIP and the study were residents of
Washington, DC or Maryland. Some participants resided
in communities where they were chronically exposed to
high levels of structural and interpersonal violence, and as
a result, many experienced a continuum of trauma over
the life course. The survivors who participated in HVIP
programming were representative of the patient popula-
tion that received care for violent injury; relevant sociode-
mographic information is summarized in Table 1 (from
the hospital trauma registry). All participants in this study
were low-income and lived in public or section 8 housing.
Importantly, several survivors also experienced housing
insecurity due to “bar notices,” which legally barred them
from the apartment complexes or housing projects where
they had previously lived.
The HVIP where the study took place was not for-
mally evaluated for its effectiveness in reducing trauma
and criminal justice recidivism. In the first 16 months of
the HVIP, 116 participants received psychosocial ser-
vices. Only one survivor returned to the hospital for a
violent injury during this time period. This less than 1%
violent trauma recidivism rate is in stark contrast to the
pre-HVIP rate of 32%. Seventy percent (70%) of pro-
gram participants (N = 71) were involved in the criminal
justice system under community supervision (primarily
probation). Only seven (6%) of these participants com-
mitted technical violations of their probation (i.e., testing
positive on drug urinalysis, allowing ankle monitor to
shut off). Two participants (2%) from the total population
of program participants were arrested and convicted
for new offenses. This is notably lower compared to a
Table 1. Sociodemographic Information of Patients Treated
for Violent Injury.
Sociodemographic Information from Trauma Registry (%)
Gender
Male 87.0
Female 13.0
Age
0–12 0.1
13–18 7.2
19–30 44.3
31–50 36.1
51–65 9.5
>65 2.8
Race/ethnicity
Black 75.0
White 6.4
Hispanic 12.4
Other/Unknown 6.2
Mechanism of injury
Gunshot 31.6
Stab 30.6
Assault 37.8
Richardson et al. 5
longitudinal 9-year national study on criminal justice
recidivism, which found a recidivism rate of 45% in men
in the first year following release from detention (Alper
et al., 2018).
Procedures
Institutional Review Board approval was obtained through
the University of Maryland, College Park. Survivors gave
written and informed consent for the focus group. The
consent process was also completed for their interviews
that were filmed and recorded as part of the digital sto-
rytelling project. The researchers utilized a “spirit of
informed consent” approach (Fluehr-Lobban, 1994), as
they repeatedly asked interviewees throughout the
research process if they were comfortable with the dis-
semination of their narratives in the film. This was par-
ticularly important due to the sensitive nature of the
questions asked during both the focus group and inter-
views. Survivors were given the option to have their inter-
view removed from the project at any point. The duration
of the interviews ranged from 45 to 60 min. The research
director of the HVIP was the primary interviewer with co-
facilitation of the focus group by the VIS. Both interview-
ers were Black men with high levels of trust and rapport
with the survivors; they have extensive training in trauma
informed care. Additionally, the research director has sig-
nificant experience with researching violent injury and
trauma among young Black men. The positionalities of
the research director and VIS were vital in facilitating
conversations regarding survivors’ experiences of injury
and mental health. The interviewers facilitated these con-
versations in an informal manner and displayed clear and
nuanced understanding of the survivors’ lives.
Data Collection
The duration of the study was approximately 15 months;
this includes recruitment and facilitation of the focus
group and interviews. There was a high level of retention,
as only one survivor did not continue participation in
the project. Upon obtaining consent, the semistructured
interviews and focus group were conducted at the
University of Maryland, College Park. The guide for the
semistructured interview explored the lived experiences
of violent victimization, individual and community-level
criminal justice involvement, family reactions to injury,
experiences of traumatic stress, and barriers to care.
Responses had significant variation in depth and clarity
depending on the survivors’ level of comfort and ability
to discuss each question. Individuals were not asked to
share any specific details of current and open criminal
justice cases. Sample questions for topics covered in the
focus group and interviews are included in Table 2.
Analysis
Upon transcription, an iterative coding strategy was uti-
lized to determine emerging codes and themes among
participants. This emergent thematic analysis did not
allow the use of a priori codes other than symptoms of
traumatic stress disorders, as defined by the Diagnostic
and Statistical Manual 5th edition (DSM-V). This
approach was chosen to allow emergent themes regarding
how survivors express their mental health and post-injury
experiences to serve as the primary analytical categories.
The codes relating to DSM-V diagnostic criteria were
used to highlight the nuanced ways that survivors dis-
cussed their mental health as both psychologically and
socially dependent experiences.
Dedoose qualitative software was used for data anal-
ysis. A codebook was developed based on recurring
themes throughout the transcribed interviews. The
research team discussed each code and reached consen-
sus on how codes should be applied. Codes that were
not unanimously agreed upon were not used. Formal
definitions and representative cases were determined
prior to the final coding process; this allowed the code-
book to be iteratively modified to reflect changing con-
ceptualizations of themes and relationships between
codes. Generated codes included traumatic stress experi-
ences, masculinity, criminal justice involvement, struc-
tural barriers to services, importance of fatherhood,
substance use, and participation in the HVIP. Data satu-
ration was reached after the eighth interview; the addi-
tional interviews were analyzed to ensure no new
information could be garnered. The results from the
data analysis were shared with all participants who
were able to be contacted; this was done in order to
ensure that the findings reflected their experiences.
Results
Participant experiences of traumatic stress symptoms
included hypervigilance, avoidance, sleep disturbance,
irritability, isolation and distrust, spirituality, and violent
injury serving as a “wakeup call” for a change in the sur-
vivor’s life. Several themes are consistent with the litera-
ture descriptions of traumatic stress among this population
(Liebschutz et al., 2010; Rich & Grey, 2005; Smith &
Patton, 2016). Patients described these experiences as
influencing their psychological recovery from trauma,
ability to maintain social relationships, and HVIP
engagement.
Hypervigilance
Survivors emphasized how getting shot affected their
sense of safety in differing social contexts. They explained
6 American Journal of Men’s Health
that these experiences of hypervigilance were profoundly
impacted by their return to the same neighborhoods and
social contexts in which they were injured. Biggs, a
17-year-old who was shot 8 times, noted his comfort
level in his neighborhood before and after his injury,
Before I was grooving but now it just be like, everything,
walk pass me, anything, you looking, anything, everything.
Before I got shot I just be jolly, I wasn’t thinking nothing but
now it is just being on everything. Cars, everything, people,
everything. They got they hands in they jacket, I be looking
at all that.
Survivors highlighted how hypervigilance may reduce a
patient’s ability to receive services. Lo, a 23-year-old sur-
vivor, explained,
I am sitting in the lobby, at first I was comfortable, I was
sitting in the lobby just talking to my girl, I get to looking
around and I just, I started judging myself, I am like you are
too comfortable now. You feel me, so, I didn’t even wait for
the nurse to come call my name, we just went right back out.
That is how bad it got me, you feel me. I was just thinking
like anybody could do anything right now.
This sentiment was echoed by Slim, he noted a prefer-
ence for care received off-site from the hospital.
It’ll be much better if the program (HVIP) were up here (on
university campus) cuz then you don’t have nothing to worry
about, you can go somewhere, you ain’t gotta worry about
looking over your shoulder, looking around every five
minutes, really gotta watch everybody around you and stuff
like that when you go to [the hospital]. It’ll be better if you
could just go to campus, the hospital is not safe.
Some survivors clarified that they had experienced hyper-
vigilance before being injured. The prevalence of trau-
matic stress symptoms prior to injury was frequently
associated with chronic exposure to violence during
childhood and adolescence—including witnessing the
deaths of close family members. Lo, who as an adoles-
cent, witnessed his cousin die from a gunshot wound, and
noted that he experienced symptoms of hyperarousal
from this incident. Lo explained,
We was kind of more, just like stuck. Because I was like 14
years old so, when he got hit, uh, we heard the gunshots,
came up stairs, ran upstairs, we was in the basement, ran
upstairs, and we just seen him, right there. And he was like
gasping, gasping, gasping, and then he just went stiff, like he
just went. Like it was like a cold feeling in the room, he just
went stiff. All of us, we too young, you know what I am
saying, we ain’t even call the police we just called his mom.
His mom, she drove all the way there, you feeling me, called
the police and then they pronounced him dead right there.
Lo noted that the untreated trauma from this event was
compounded by his recent injury,
If I couldn’t see the whole room, I wouldn’t be able to sit
there and be comfortable, you feel me like, like every time
somebody walk in there, I would be in McDonalds,
somebody would walk in, and I am always thinking like, do
I know you, why are you looking at me so long. . .But then
afterward my injury, it just got bad.
Table 2. Sample Questions from Focus Group and Individual Interview Guides.
Focus Group
Topic Sample question
Social Context of Violence Is there a code of the street, and if so, what are the codes?
Gun Violence Reduction What do you think could be done to decrease the rates of gun violence in the area?
Physical Consequences Since you have been injured how has your life changed physically?
Changes to Mental Health Have you experienced changes to your mental health after injury?
Coping What do you do to cope with these feelings?
Experience at HVIP What was it like when you were first in the hospital and contacted by the program?
HVIP Services How could services be changed to better meet your needs?
Qualitative Interviews
Topic Sample question
Lived Experiences of Violent Injury What was going through your mind once you were hit (shot)?
Criminal Justice Involvement Have you ever experienced any difficulty in finding a job due to a criminal record?
Family Reactions to Injury How did your family react to you being injured?
Barriers to Care What has been the biggest difficulty in receiving the services you needed?
Experiences of Traumatic Stress Have you experienced any nightmares, flashbacks, or changes in mood?
Richardson et al. 7
Avoidance of External Reminders
Survivors noted avoiding external reminders and triggers
to prevent re-experiencing unwanted traumatic memo-
ries. For some, avoidance also served as a protective
strategy against repeat victimization. They stated that the
primary way in which they sought to reduce the severity
of their symptoms required a change in their previous
routines and peer groups. Even after receiving services
from the HVIP, a focus group participant remarked that
he still would not leave his home,
I’m still doing the same thing I do when I be leaving here.
And that is really nothing, I’m in the house. Doing nothing,
for real.
Other survivors agreed with this protective strategy, and
another focus group participant explained,
Like just stay out of the neighborhood, stay lowkey, and just
don’t go in drama no more and stay out of bad neighborhoods
that will happen again and all that.
Survivors’ feelings about their neighborhoods and the
social context in which they were injured are complex, as
some survivors felt most comfortable in their neighbor-
hood despite wanting to avoid external reminders associ-
ated with being shot. Slim, a 29-year-old who was shot in
the chest and had been recently stabbed 12 times in the
head, face, ribs, and back, stated,
I am right back where I got shot. I am around the same
people, like you think, like I said, my neighborhood is one
of the neighborhoods where everybody grew up with each
other so, I am going around where I am comfortable
around.
The external reminders of being violently injured were
not limited to survivors’ neighborhoods, as they also
reported hesitancy to return to the hospital for mental
health counseling. Sonny, a 27-year-old survivor of three
gunshot wounds, described that he was only able to visit
his brother once during his brother’s hospitalization for a
gunshot wound. His brother was shot 2 weeks after Sonny
was shot and treated in the same hospital. Sonny explained
being retraumatized visiting the hospital,
I visited one time in that hospital man, one time. Just
because I couldn’t, it just hurt bruh, it was just like man, his
injuries was a little more severe than mine. . .Man, he was
shot 5 times, twice in the face, once in the trachea, you
know what I am saying, two in the chest, one in his lung
can’t come out. . .I thought my brother was going to have a
hole in his throat. . .we are really losing now, this is, this is
a loss.
Sleep Disturbance
Survivors reported serious changes in their ability to fall
asleep and their quality of sleep. T.O. explained,
Yeah, I have trouble sleeping, sweating, sweats, and when I
do sleep, I sweat in my sleep, nightmares.
Sonny had similar experiences with cold sweats and
noted the lack of information he was given on possible
symptoms he might experience,
I ain’t even know that it would react that fast but that is what
I was experiencing immediately, day one out of the hospital.
The psychological discomfort that arises from an inabil-
ity to sleep coupled with the lack of consistent access to
therapy contributed to polysubstance abuse, as survivors
attempted to regulate their changing emotional states and
sleeplessness. Sonny highlighted the inseparability of
these factors,
I try to like do what we talk about in the group (counseling)
is, you know coping methods and I am working on adjusting
my negative coping methods into more positive coping
methods. . .I might be up two days straight, I won’t sleep at
night. . .it’s not that I am scared to go to sleep but it is just
like, I am so anxious, I am so turned up, I need something to
calm down, let me go hit this J (marijuana). . .let me go
drink this Seagrams (liquor). . .let me go hit this boot
(intravenous injection). . .hit the molly. Those coping
methods right there, I am trying to figure out a way to flip
that.
Survivors also emphasized how the rapid discharge from
the hospital and return to the neighborhood of their injury
impacted their ability to sleep. Many survivors returned
to their neighborhoods within 24–48 hr after being treated
for a gunshot wound. Tip stated,
Going straight back out there, like ain’t nothing happened,
man it was heavy, man. It was heavy. That is why all my
thoughts was war time. I couldn’t sleep, none of that.
Increased Irritability
Multiple survivors described profound changes to their
mood and behavior, with feelings of increased anger being
the most common and harmful to their well-being. Smokey
explained, “Like my anger was worse, like everything was
more on a different level. But the anger was at its most
high.” Tip reiterated this sentiment, “My attitude, defi-
nitely. Um, my eating habits, my breathing, my anxiety.
Mainly anger though.” These changes were contrasted
with the pre-injury ability to control their mood, Slim
8 American Journal of Men’s Health
clarified, “A lot of frustration, attitude. Like, different
stuff, like, before I got shot you couldn’t really get to me
about nothing for real. But, now like a lot of stuff get to
me. Like everything. I’ve been more irritable.”
Survivors also noted how increased irritability and
loss of emotional regulation caused issues for their care-
givers who were not accustomed or familiar with these
symptoms. Lo elucidated these experiences by describing
how his parents’ movements inadvertently reminded him
of the person who shot him, “If I was sleeping and some-
body came in the room without knocking, like I would
just spaz out on them, I got mad at them. . .like it is the
same instance from that night I got shot, somebody crept
around and hit (shot) me. . .if they (parents) was bringing
me food or they (parents) was coming in there to turn a
light off or something and I just woke up and they was in
there, like I don’t know, like I was spazzing out.”
Smokey noted his initial desire to retaliate against his
victimizer, which was exacerbated by his increased irrita-
bility. Smokey explained, “And the things [the VIS] was
telling me was, straight, you know control my anger and
stuff, and the thing I had after I got shot was just anger, I
couldn’t trust nobody, and I was just seeking murder, like
I wanted revenge real bad.” However, because of his trust
and relationship with the VIS, Smokey utilized coping
skills and therapy to decrease his feelings of anger.
Affective Experiences After Injury
While survivors did report symptoms that are clearly
defined by the DSM-V, they also expressed experiences
relating to their injuries that are not delineated in formal
definitions.
Isolation and Distrust
Survivors described self-imposed forms of social isola-
tion as necessary coping mechanisms to combat their irri-
tability, loss of emotional regulation, and decreased
behavioral inhibition. Survivors perceived social with-
drawal as a mechanism of reducing harm to their family
members. Cain explained,
When I am in like a depressed type of stage and I don’t, I
don’t want to talk to anybody. Not even my family, so it’s
like, I am going to just shut everybody out. At a certain point
in time, until I get myself together. And I know that is not
always right to try and just do things on your own because
that is, that is not how it always works. So, basically, I tried
to just stay away for a while, try to work on myself and my
anger.
Isolation was a particularly salient experience in cases
where survivors did not have friends or family members
who were able to care for them. Slim highlighted how the
dearth of viable social support restricted his ability to
share his experiences of traumatic stress, “Because I am
from where you don’t talk about shit. Everything is
omerta (code of silence), keep it quiet, stay to yourself
with it. You hold it in. You know what I am saying, I
never had no father. I don’t know about talking to another
man about me.”
Trust and distrust also powerfully influenced their
experiences of traumatic stress. Slim further explained
how the loss of his close friends to incarceration and
being victimized by close friend who stabbed him multi-
ple times influenced his lack of trust of peers,
I don’t trust nobody. I don’t really, like my, there is no way I
can trust you, there is no way I can trust you. . .I can fuck
with you, but can’t trust you. . .I ain’t going to hold nothing
back as a friend, you can be my friend or whatever, you
know what I am saying, we can be cool, but I ain’t about to
trust you though.
Smokey was also shot by a close friend and expressed a
similar experience,
There is no way to trust them once your loyalty is broken,
it’s hard to trust somebody ever. . .you put your trust in at
one point in time, yeah that was my friend. But he snaked
(betrayed) me out over something, so it’s like, how can you
trust anybody?
The development of a trusting relationship between
patient and practitioner is essential for HVIPs to suc-
cessfully address the traumatic stress and mental health
challenges of young Black male survivors of violence.
Social isolation and distrust may be initial barriers, as
Tip described, “Trust nobody. Nobody. Even with y’all
(HVIP staff), when y’all called me, I was like trust
nobody.” Despite increased distrust of institutions and
individuals after their injury, participants had a high
level of trust in the VIS because he had a shared lived
experience with survivors. Wall stated, “I only trust
Chris (VIS) because he’s just like me, he been through
the same things I been through, if he can do it then I can
do it .”
Although Slim experienced intense feelings of dis-
trust, he explained that he was willing to work with the
HVIP to improve his life for his daughter. He stated,
I been thinking about my daughter man. . . I would be
fucking her up, you know what I am saying (by not
addressing trauma), like I don’t got it all for her, as far as me.
Not financially, not nothing like that, just as far as my
emotions, my mental, for her. If they say that this can help
me on them type of times, then I am all in, you know what I
am saying.
Richardson et al. 9
Spirituality
Survivors highlighted the multiple ways in which spir-
ituality shaped their experiences of traumatic stress.
Spirituality frequently served as a coping strategy, with
one survivor noting that he attempted to “pray off” any
intrusive thoughts. Cain explained,
I am just going to stay prayed up. And that is the most I can
do, just stay prayed up. And just like I said, just rebuke all
the bad thoughts that is coming into my mind, that comes,
rebuke them. Just start to think positive and that is what I
have been doing.
Several study participants reported that negative
thoughts included retaliating against the person who
had victimized them. For individuals with a limited
support system, praying served as an important mecha-
nism to stop thoughts of retaliation, decreasing the like-
lihood of further harm to themselves and others. Sonny
stated,
Honestly, I wanted to hit back (retaliate). That is what was
going through my mind, impulsive, just reaction. I already
knew what was going on in my situation, already knew what
it was in for, what I was doing was, it was just, that was the
only reaction to it.
However, he did not retaliate, he received spiritual sup-
port from his family in the hospital that allowed a
reframing of his survival as a spiritual blessing. He
explained,
My grandma, she was coming through and was disclosing,
just you know like, blessings. ‘You just don’t know, you just
don’t know,’ like that is what she was telling me. She was
like, ‘you just don’t understand, you know what I mean, like
how amazing [God’s] hand is and how he is over you right
now,’ you know what I am saying. And here you are, you
know you made a mistake and that was the most comforting
thing I could ever hear, to acknowledge right there, from my
grandmother.
Spirituality enhanced survivors’ efforts to change their
lives through participation in the HVIP—specifically
their relationships with the program staff such as the VIS.
Smokey described his experience, “I feel like God put
that somebody in my life that I needed to realize, to listen
to, something I never had. So, that’s how I took it, how I
look it. I ain’t never had nobody trying to keep me on the
positive route.” He further noted that he was particularly
receptive to trying to change his life because of his injury,
“Any time something real, real, like a situation like you
getting shot, stabbed. . . you make it through it, that’s
God trying to tell you something. He trying to tell you to
slow down, he trying to tell you, you blessed.”
A Wake-Up Call
Survivors reported that their violent injury and resulting
traumatic stress disorders were defining moments in their
lives. Despite feeling angry and desiring to retaliate with
violence, Cain highlighted that seeking revenge would
not benefit him,
I was thinking like, I am going to kill him. I am going to kill
him. . .it was just like, dang, like, maybe, like, you should,
like, take this as a lesson learned. . .like, a wake up call.
Yeah, a wake-up call. . .The path I was going down, like I
wasn’t, I am not an innocent person. I wasn’t just, oh, I am
innocent, I was doing everything right. I wasn’t like that, so
it’s just like damn. Like, you just gotta wake up. You know,
just take life more serious.
Not all survivors explicitly indicated that they viewed
their injuries as a “wake up call”; however, participants
often stated that they had been given a second chance to
make changes in their lives. All survivors who had chil-
dren emphasized that maintaining their safety and provid-
ing a better life for them was a primary reason for
changing their lifestyle. Smokey explained,
Yeah I have a daughter, but I was chasing the streets cuz I am
thinking, man this street money going to take care of her, but
for how long? That is the question I never answered. So,
once I finally answered that question, it was too late. . .So
it’s like, instead of going through that revolving door and
keep going back in circles every day or whatever, whatever.
Slow down. Be a father first. . .[My daughter] changed that.
Before my injury I wasn’t worried about nothing. I was a
loose screw. Like, I wasn’t even thinking. Like, a situation,
altercation could happen and the first thing I want to do is
react how I know. But now, once I had her and met my baby
momma, it’s like everything I started thinking more. So,
once I started thinking more, it was like, you doing something
you never did, you thinking. Shouldn’t that tell you
something? So, I started paying attention to what was more
in my gut then what was really on the mind.
After experiencing a “wake up call,” Slim clarified that
an essential part of providing a better life for his daughter
included addressing his traumatic stress symptoms,
Because I ain’t talk to nobody after I got shot. . .[my
grandmother] is like, I don’t act the same since the
situation. . .I was down (depressed). I had to learn how to
walk again, couldn’t pick my daughter up, can’t pick my
daughter up, in my arms, I can’t hold her. My daughter
notices it too. She want me to pick her up. I leave out the
house, when I leave out now, if I go out, she don’t want me
leaving. I get a call like two seconds after I go out the door,
I had to tell her I am coming back, I just told her I was
coming back before I went out the door but she is crying.
That shit fucks me up.
10 American Journal of Men’s Health
Discussion
This study advances previous efforts to place the experi-
ences of young Black men who survive violence into con-
text (Fader, 2013; Rich & Grey, 2005; Smith & Patton,
2016). Thematic analysis of participant interviews and
the focus group identified psychological and behavioral
impacts of injury—including hypervigilance, avoidance,
sleep disturbance, and irritability—consistent with the lit-
erature on traumatic stress disorders (Boccellari et al.,
2007; Corbin et al., 2013; Greenspan & Kellermann,
2002; Rich & Grey, 2005; Smith & Patton, 2016). These
align closely with the DSM-V diagnostic criteria B-E of
avoidance, intrusion symptoms, negative alterations in
cognition and mood, and alterations in arousal and reac-
tivity for post- and acute stress disorders (American
Psychological Association, 2013; Smith & Patton, 2016).
Participants also describe experiencing isolation, spiritu-
ality, and a “wake-up call,” which are consistent with
existing literature (Liebschutz et al., 2010; Rich & Grey,
2005; Smith & Patton, 2016). These phenomena—symp-
toms of traumatic stress, altered relationships to others,
and new forms of meaning making (e.g., spirituality) —
demonstrate the relationships between psychological and
social impacts of violence.
Psychosocial Well-being and Reinjury Risk
Participant experience of violence suggested important
interactions between psychological and social impacts of
violence occurring in domains of the self, intimate rela-
tionships, and place. Analyzing narratives through the
lens of PVEST provides an integrating framework for
how the lived experience of violent injury becomes incor-
porated into a survivor’s identity, thoughts, feelings, rela-
tionships, and ways of existing in the world (Smith &
Patton, 2016; Spencer, 2008). In relation to the self, out-
comes of violent injury, particularly feelings of anger,
intrusive thoughts, and sleep disturbance, disrupted par-
ticipants’ sense of control over themselves and their
safety. Similar to observations by Smith and Patton
(2016), several participants in this study noted substance
use as a coping mechanism for managing intrusion symp-
toms. Previous literature has described the expectation of
early mortality among Black male survivors of violence
(Liebschutz et al., 2010). Participants in this study noted
feelings of spirituality and purpose following their injury.
Survivors also held complex and sometimes contra-
dictory relationships to intimate people and places.
Feelings of anger motivated several participants to dis-
tance themselves from intimate family members and
caregivers, including parents, spouses, children, and sib-
lings, to protect their loved ones. While this strategy may
be considered protective it also limits social support
during recovery. Several participants noted a “wake-up
call” that motivated them to build stronger relationships
with their children and spouses. For other intimate rela-
tionships, such as peers, participants describe both feel-
ings of comfort and distrust. Although some participants
sought distance between themselves and intimate rela-
tionships as well as places and spaces to avoid reinjury,
many found themselves trapped in the social context that
led to their injury. Participants tended to return to the
same neighborhoods and social contexts in which they
were injured because they have deeply rooted social ties
and lack of housing options to move away. While inter-
acting with these same people and places, distrust of oth-
ers, fear of reinjury, and a disrupted sense of safety led to
both physical isolation and feelings of isolation. Such
isolation and self-reliance may limit recovery post-injury
as well as increase risk for violent reinjury and potential
violent early mortality by motivating behaviors such as
carrying a firearm, threatening to use or using a weapon,
responding to disrespect with aggression or violence,
and substance abuse (Cooper et al., 2006; Rich & Grey,
2005; Richardson et al., 2013, 2016; Teplin et al., 2005).
Implications for HVIPs
These experiences of injury have important implications
for HVIP practice including therapeutic interventions,
program structure, and program evaluation. The HVIP in
this study used PCOR to continuously engage in qualita-
tive research in order to understand the nuanced and com-
plex issues that young Black male survivors of violent
injury experience. This research informed the implemen-
tation of new services (i.e., the use of Uber Health) and
allowed the program to adjust how care was provided to
better suit the needs of survivors. A movement toward
shared-decision-making approaches offers a viable means
to effectively empower survivors in achieving their
desired health outcomes.
Participants identified several interventions as thera-
peutic including group therapy facilitated by a psycho-
therapist and co-facilitated by the VIS. Group counseling
provided a framework for discussing shared experiences
of violence and identifying coping methods. However,
this treatment failed to provide effective tools for manag-
ing substance abuse associated with intrusion symptoms.
Although not a clinical therapist, participants noted that
their relationship with the VIS was therapeutic and cen-
tral to their recovery (Wical et al., 2020). In many cases,
the VIS was the only person that survivors would trust
and build a strong relationship with; this bond helped
address feelings of isolation and distrust that may con-
tribute to reinjury. This relationship also improved help-
seeking behaviors for young men experiencing trauma.
Participants also noted the importance of caregivers in
Richardson et al. 11
their recovery, and as a result the HVIP developed care-
giver support groups that helped caregivers understand
and develop coping strategies for primary and secondary
trauma.
The psychotherapist and VIS noted that M-TREM was
not sensitive to the needs of the survivors, including flex-
ibility in programming. Participants noted jarring symp-
toms of traumatic stress, without coping skills to manage
them, immediately upon return to their neighborhoods
following hospital discharge. This suggests a gap in pro-
gramming that may leave participants particularly vul-
nerable. Previous studies on this CBT model were
conducted on incarcerated populations where attendance
and attrition problems were not significant barriers to
successful completion of the entire therapeutic course
due to mandatory conditions for release or institutional
practices. In contrast, the usage of services from HVIPs is
voluntary. Retention in the 18-week M-TREM course
among HVIP participants poses a significant challenge,
as one missed session required the survivor to wait until
the next cycle of M-TREM to begin again. Although par-
ticipants expressed that the M-TREM model was helpful
in developing coping mechanisms to deal with traumatic
stress, the HVIP was unable to evaluate its effectiveness
due to high rates of missed attendance. A modification of
the M-TREM model is necessary in which there are mul-
tiple days a week that offer the same module. Additionally,
a telehealth model should be implemented in order to
allow sustained participation during the COVID-19 pan-
demic. This approach also addresses survivors’ concerns
for their safety in receiving services at the hospital, as it
would allow survivors to receive care without having to
leave their home.
The young Black male survivors of violence reported
harboring trepidations about receiving clinical counsel-
ing at the hospital due to issues concerning their personal
safety and retraumatization. HVIPs must take these per-
spectives seriously in order for high levels of care to be
provided. One innovative approach to improving the
health outcomes and empowerment of survivors would
be shifting the model from hospital-based to hospital-
linked. In this model, recruitment of participants can be
facilitated at bedside while the direct delivery of psycho-
social services is provided off-site. The participants in the
study routinely expressed that they preferred the program
to be facilitated on the university campus where the inter-
views and focus group were conducted.
The survivors explained that they felt as though the
campus was a safe space that reduced their level of hyper-
vigilance, the need to carry a firearm, and encouraged
them to attend college. The potential of a hospital-linked
model on a university campus offered a wealth of psycho-
logical support resources. The university’s Department of
Psychology and the Department of Counseling offered to
provide participants with additional mental health coun-
seling resources. In addition, the University’s Black
Cultural Center facilitated a Black Male Initiative pro-
gram (BMI) that provided academic, social and emotional,
and mentoring services for Black male undergraduate stu-
dents and young Black men living in the metropolitan
area. Additionally, BMI offered a Prison to College
Program, which provided academic, social, and mentoring
for incarcerated boys and young men involved in the
criminal justice system.
Strengths and Limitations
A major strength of this research is the central focus on
the perspectives of young Black men who were treated
for being shot and were involved in the criminal justice
system. This study is the only qualitative inquiry con-
ducted with specific recruitment of this population. Their
narratives provide an intimate look into their subjective
health experiences—both in ways that were and were not
similar to those described in the DSM-V. These young
men illuminated nuanced narratives of their coping strat-
egies, meaning-making processes, and personal health-
related goals.
Although this study has a small sample size (N = 11),
data saturation was achieved in the individual interviews.
A limitation of this study relates to only having one focus
group with survivors of violent injury; the findings may
not be representative of other groups. The demographic
composition of the sample decreases the ability to make
meaningful comparisons across racial and ethnic groups
(Sileo & Kershaw, 2020). There are important regional
considerations, as the rates of violent crime in Washington
DC are higher than the national average. This reduces the
generalizability of the findings, as exposure to violence
prior to injury may differ significantly between urban
areas. Additionally, the ways in which individuals
respond to and discuss their trauma are subject to change
over time, as the social contexts of HVIPs, neighbor-
hoods, and cities are dynamic.
Future Directions
HVIPs are well positioned to conduct research on the
needs of their participants and translate collected data
into meaningful services and health education messag-
ing. The use of a Researcher–Practitioner approach to
collect data was successful in increasing the rates of
recruitment and retention of study participants in this
study, as it reduced the distrust and stigma of researchers
and the health-care system. Using this approach, future
research should examine male-specific depressive symp-
toms in this population (Johnson, 2019). Lindsey, Joe,
and Nebbitt (2010) noted the centrality of family support
12 American Journal of Men’s Health
and frequent distrust of professionals as essential fea-
tures in improving the ability to identify mental illness in
African American adolescent boys. Further research is
needed to assess how the inclusion of family enhances
the provision of care through the HVIP model. This is
only study to use a PCOR approach with young Black
male survivors of nonfatal firearm violence. Future stud-
ies on firearm violence among this population particu-
larly among participants in HVIPs should be conducted
using a PCOR approach.
Unlike previous research on interpersonal violence in
this population, which noted that victims and perpetrators
are more likely to have loose social bonds with each
other, survivors in the HVIP frequently reported being
shot by a close friend. The dissolution of these close
friendships caused serious psychological damage to the
survivors; this group of men expressed higher levels of
distrust in HVIP staff and their social networks. More
contextual data are needed to understand this nuanced
pattern of injury and trauma, as little is known about the
experiences of young men who have been violently
injured in these intimate same-gender relationships.
To date, there is no evidence-based research showing
the effectiveness of CBT models used in HVIPs. Large-
scale studies must be conducted on the effectiveness of
any therapeutic model used to address traumatic stress in
young Black male survivors of violent injury. This will
require large-scale randomized control trials on the effec-
tiveness of CBT in the reduction of trauma symptoms and
the success of HVIPs in reducing trauma and criminal
recidivism. These forms of research must utilize the
growing number of HVIPs in the United States, several of
which are situated in the same geographical region.
Conclusion
Simply meeting participants where they are is an insuffi-
cient approach in increasing health equity. HVIPs that
provide direct services for young Black male survivors of
violent injury must engage in programming that under-
stands the intersection of race, gender, age, class, and
trauma. Approaches, including PCOR, that recognize sur-
vivors’ assets, engage them as partners in determining
goals, and seek to improve emotional expression and
communication are necessary. This must include an
understanding of the ways young Black men describe
their mental health symptoms similar to the DSM-V cri-
teria as well as their use of culturally rich jargon. The
findings presented in this study revealed alternative
expressions of traumatic stress used by survivors that
may be overlooked by the mental health researchers and
practitioners who study and provide services.
The effective delivery of culturally appropriate psy-
chosocial services for this population must first come
from understanding how violently injured young Black
men understand, process, and make meaning from their
experiences. HVIPs must provide a space and opportunity
to empower the voices of survivors, including the determi-
nation of what factors contributed to their injury. The
young Black men in this study routinely emphasized the
importance of considering both interpersonal violence
(firearm violence) and structural violence (incarceration)
in understanding their mental health. As researchers and
practitioners, in the words of author and social justice
champion Bryan Stevenson, “we must get ‘proximate’ to
suffering and understand the nuanced experiences of those
who suffer from and experience inequality, if we are will-
ing to get closer to people who are suffering, we will find
the power to change the world.” This methodological
approach and moral imperative allow the psychological
and social dimensions of survivors’ experiences to inform
how care is provided through HVIPs, providing a viable
means to improve health equity.
Acknowledgments
Thank you to the young men who participated in the interviews
and focus group for their honesty, insight, and contributions to
developing structurally and culturally competent strategies for
decreasing violent trauma recidivism and addressing traumatic
stress. Thank you to the anonymous reviewers who provided
significant assistance in strengthening this paper.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this arti-
cle: A Researcher 2 Practitioner Fellowship (funded by the
Center for Victim Research) and a PCOR Seed Grant from the
University of Maryland, Baltimore Patients Program supported
this research.
ORCID iD
Joseph B. Richardson https://orcid.org/0000-0003-3467
-0814
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