Targeting Violence

Spring/Summer 2011

On a Thursday afternoon, Elexson Hercules arrived at a gym in Boston’s Roxbury neighborhood bleary-eyed, but shyly smiling. A group of young men had gathered near the gym’s entrance. The current and former gang members spoke in hushed tones and scanned the gym warily. They didn’t bother Mr. Hercules, but he knew their violent world.

Within a six-month period in 2010, Mr. Hercules was stabbed seven times in a fight that sliced open his chin, and then, later, he was shot. The bullet lodged near his right hip. Both times, Mr. Hercules ended up in Massachusetts General Hospital. It was during his second hospitalization that something in him shifted. His girlfriend was pregnant and he worried about being a good father. He also met Amanda Breen, Mass General’s violence intervention advocate.

Ms. Breen was the only woman at the gym when Mr. Hercules arrived that day in March, but the 26-year-old seemed completely at ease in her casual pink turtleneck and UGG boots. When she saw Mr. Hercules, she immediately approached him and gave him a big hug.

“Congratulations! What is it like having a baby?” she asked, smiling warmly. “Everything you thought it would be?”

The proud father of a 7-day-old girl laughed. Though just moving out of his teenage years himself, Mr. Hercules had the responsibilities of an adult. “She sleeps during the day,” he said.

Ms. Breen knows how seriously Mr. Hercules, her 18-year-old client, is taking his new role in life. Recently, he delayed follow-up surgery to remove the bullet in his side. He wanted to be able to help his girlfriend during the birth of their daughter and in the exhausting weeks afterward.

Her work is rooted in Mass General’s mission to improve the community’s health, dating back to its founding and its pioneering work in the field of social services.

In 1905, Richard Cabot, MD, wanted to make “medical care effective” by understanding the broad context in which his patients became ill — what toxins or diseases they may have been exposed to at home or work and what they worried about. With his own money, he hired a social worker. In the following years, Dr. Cabot oversaw the development and growth of the first social services department in a hospital in the United States.

Today, Mass General continues to provide many types of social which the hospital has operated for 40 years. Among other activities, community health programs help immigrant children adjust to school and assist women with abnormal mammogram results in navigating the health system.

Reaching even further outside of Boston, Mass General responds to communities around the world through programs that train leaders in global health and send MGH physicians and nurses to disaster sites. Most recently, in October 2010, the hospital sent healthcare providers to Haiti to fight a cholera epidemic.

Ms. Breen is carrying on Mass General’s long tradition of taking on community issues that have no quick solution. She is the lone advocate for the Violence Intervention Advocacy Program (VIAP), which is supported by a grant from the Massachusetts Department of Public Health’s Bureau of Substance Abuse Services. Mass General is one of three hospitals in the state in the program administered through Boston University’s School of Public Health BNI ART Institute. At Mass General, the Department of Emergency Medicine oversees VIAP.

Bill Binder, MD, a Mass General emergency physician, says the hospital needs to look beyond treating violence injury by injury and address it as a social issue. Healing only the physical wounds of violence will not stop the cycle, he asserts.

Ms. Breen’s role is to intervene at the right time.

Just an average day

On a rainy Monday in February, Ms. Breen began her work in her cubicle crammed in the corner of an office building near Mass General. Ms. Breen wants to make a difference in people’s lives, but she’s practical. She knows what she is up against: The bonds formed in rough neighborhoods; the comfort of old habits; the sting of past insults.

“There is so much potential in so many people but it gets lost or mixed up,” Ms. Breen says. She peered at her computer screen. Listed in the emergency room database of patients, she saw the words, “gunshot wound.” Ms. Breen checked with the social worker responsible for that floor and learned the patient might be open to a conversation.

Wearing her polka dot rain boots, Ms. Breen headed across Blossom Street to Mass General.

Ms. Breen never knows exactly what she will walk into. She arrives with very little information, hoping to learn more from the patient. Emotions may be running high. Police officers sometimes pressure patients to reveal who shot them. Family members say they should have known better. All of the tension creates an environment where victims may believe that they are being blamed for their injuries.

“There are a lot of social factors. There are a lot of things going on in people’s lives,” Ms. Breen says. “And, quite frankly, regardless of what experiences they have had, I don’t think they deserve to be stabbed or shot.”

Sometimes when Ms. Breen asks her clients what they like to do, they go blank. Some don’t know themselves. Many have a fatalistic view of life — they don’t believe anyone will help them or that they have options.

When Ms. Breen entered the hospital room of one adult patient she found him resting in bed with his leg propped up and wrapped with bandages. His 2-year-old son snuggled next to him with a sippy cup. She introduced her program and tried to learn more about the patient.

He told her that he loved to work and had lost his job driving forklifts when a local discount store closed. He wanted help with his resume. They talked about counseling so he could learn how to handle his emotions.

“I grew up in the streets. I always defended myself. I grew up without a dad,” the man said. He paused. “My son, I’m going to teach him the right way. He has a dad.”

As a nurse checked his bandages, Ms. Breen sensed she had stayed long enough. She made plans to contact the patient again.

Catching a person mid-thought

The first time Ms. Breen visits patients is usually brief. She drops by for 15 minutes to a half hour. Some patients don’t want to talk to her. Others listen, but don’t return her calls later.

Of the 131 patients Ms. Breen saw at Mass General last year, 47 wanted her to help them after they left the hospital. Some required short-term assistance. Seventeen enrolled in the program for longterm management, which can involve Ms. Breen in many parts of their lives, from helping to file paperwork for insurance to preparing for job interviews.

The cases Ms. Breen handles are among the most brutal and tragic to enter Mass General: a student followed from school and assaulted by kids at a subway stop; a woman who overdosed on drugs and was thrown from a car; a woman raped by several gang members. This all happened in the same week in March.

The Violence Intervention Advocacy Program is designed for Ms. Breen to intervene while patients are in the emergency room or on the patient floors because it can be a teachable moment with victims and perpetrators of violence, explains Alasdair Conn, MD, chief of Emergency Medicine at Mass General.

Often, emergency room patients find themselves confronting the choices they have made that have landed them in the hospital and doctors find themselves suggesting alternatives — like quitting smoking or wearing a seatbelt, Dr. Conn says.

Ms. Breen brings a hopeful message. She tells some clients to take responsibility for what they did. She helps other clients understand that they did not deserve to be hurt and they may talk about safety issues. She discourages retaliation. And she helps them to plan their next steps. They talk about school, jobs and relationships. She lets her clients lead the conversation — a motivational interviewing technique she learned at Boston University.

If they agree, like Mr. Hercules did, she will stay in touch with them after they leave the hospital and help them build a network of people in the community that they can turn to as they sort out their lives.

Dr. Binder, co-principal investigator for the program, said Mass General is still figuring out how to measure the program’s effectiveness. Researching and measuring what works well, will help mold the program, he says. “It’s not going to stick on everybody,” according to Dr. Binder. “Honestly, if you hit 10 to 20 percent, you’re doing well.”

Ms. Breen measures her successes modestly. One client learned to call her back when he couldn’t make an appointment. For that person, learning to be courteous was a huge step forward, she says.

The right person for the job

Even though Ms. Breen grew up in the suburbs, north of Boston, she finds a way to connect with her clients, or in some cases, with the victims’ mothers, who can help her get through to the victims, says Ellen English, administrative director of operations for Emergency Services at Mass General.

Ms. Breen has experience working with the systems that her clients will need to comply with in order to get on the straight path. She has a bachelor’s degree in criminal justice from St. Anselm College in New Hampshire and a master’s degree in criminal justice and victim advocacy from Suffolk University in Boston. Before coming to Mass General, she worked in counseling and case management with women in the state prison system. She is also close in age to victims whose trust she will have to gain.

“We found ourselves a really good person to forge ahead with this program,” says Ms. English, who was involved with hiring Ms. Breen about a year ago. “She doesn’t have a big ego. She’s very personable. She’ll come up against a little rejection and push-back and she can talk through some of that. She gets through to people, which is pretty impressive.”

Ms. Breen’s backers at Mass General want to make sure that they find funding sources so the program can continue and potentially expand. In the fall, the program plans to add a college intern.

What you think about when lying in a hospital bed

One July night changed Mr. Hercules’ life.

It was around midnight on a Saturday in a neighborhood where Mr. Hercules had enemies. He was leaving his little cousin’s birthday party. As Mr. Hercules walked down the street, a vehicle pulled up and a person he knew fired at him. He dodged three bullets, but the fourth one got him.

Since elementary school, Mr. Hercules had been involved in the gang MS-13. To the FBI, MS-13 is a nationwide gang of mostly Salvadoran- Americans notorious for their involvement in drugs, murder, rape and robbery. Mr. Hercules liked hanging with the gang in his East Boston neighborhood. He put the gang before everything, even his family.

He spent eight months in juvenile jail for assault and battery. The first time he was hospitalized at Mass General for stab wounds, he had taken on four guys in a fight. He was the shortest, but he had a chain to defend himself. He was in and out of programs to help him straighten out. Around his sophomore year, he dropped out of school.

He isn’t one to back down, but the night he got shot, Mr. Hercules says he wasn’t looking for trouble. He admits he had been drinking. When he realized he had been shot, he had conflicting thoughts — he wanted to somehow get up and get even with his assailant and he was mad. He also pondered his dream for a new life. How could this happen? I have responsibilities. My girlfriend is pregnant. What will she do if I’m not OK?

Mr. Hercules lay in his hospital bed alone, pinned down by his life’s choices and disoriented from medication.

It was then that Ms. Breen walked in to introduce herself. At first, Mr. Hercules was distrustful. He didn’t know Ms. Breen, but she seemed familiar and looked friendly.

The timing was crucial.

Mr. Hercules was finding the strength to consider change. “I’m done. I’m done with this,” he remembers thinking. “I just want to have a good future for my kids. I just want to change my life.”

Making difficult changes

Ms. Breen visited Mr. Hercules three times in Mass General. She listened to him. She helped him file paperwork. They talked about how he could mold the future he wanted for himself.

She sensed that he was serious about taking responsibility. He often talked about becoming a father.

Before meeting Ms. Breen, Mr. Hercules had been involved in the nonprofit, InnerCity Weightlifting. The new program’s goal is to find a common denominator — something that teens and young adults enjoy doing that will get them off the streets. InnerCity Weightlifting also offers participants the opportunity to become physical trainers so they can start businesses on their own.

Jon Feinman, director and founder of the program, also visited Mr. Hercules at Mass General. Ms. Breen met him there. For her, having community contacts, like Mr. Feinman, as well as school counselors and probation officers, is important. She is building a safety net for her clients. Now, Ms. Breen refers many of them to Mr. Feinman’s program — one of the few in Boston willing to take on gang members.

Ms. Breen stays in touch with Mr. Hercules and often will catch up with him at Mr. Feinman’s weightlifting program. She watches as Mr. Feinman quietly instructs Mr. Hercules to drive through his heels and stabilize his back as he jerks a heavy sandbag to waist level, then up and over his head.

Still wearing the glazed-over look of a tired new dad, Mr. Hercules completes a short workout and moves on to another task. A volunteer tutor has placed a folding table across the room. While current and former gang members socialize and a young man wearing a “do rag” and a heavy chain around his neck does push ups, Mr. Hercules and his tutor bend over an equation: 1/4 + 1/2 =?

He tries to come to the gym three times a week to work out and study. Mr. Hercules wants to take the G.E.D. and pass before he turns 19 — a goal he and Ms. Breen have discussed. Some day, he’d like to make movies and, perhaps, act in his life story. He’d also like to get certified as a trainer.

But Mr. Hercules can’t completely shake his past. He says he was recently going to pick up a birth certificate for his daughter when some guys hit him from behind and pushed him to the ground. He got up and ran. “I don’t want to ruin my future,” he said. “I don’t want to end up in jail.”

Finding peace

This year, Mr. Hercules is looking for peace.

“God is keeping me here,” he says. “Only he knows why he didn’t want to take me.”

Now, Mr. Hercules spends as much time as possible with his new daughter, Jennifer. She needs up to 24 diaper changes a day and cries much of the night. But Mr. Hercules is in awe. “It’s so sweet to see a human being come into my life,” he says. “She’s my own blood and I love her.”

Ms. Breen says the key for Mr. Hercules succeeding will be whether he can acknowledge the small steps he has taken and not get frustrated if he hits bumps along the way while trying to pass the G.E.D., raise his daughter or pursue his other long-term goals. Many times, her role is to get her clients on the right track and step back a little.

“I think you have to be optimistic, but you have to be realistic,” Ms. Breen says. “I’m here to support and help. It’s their life and they have choices and you have to respect that side of it.” ■

If you would like to learn about ways to support the Violence Intervention Advocacy Program (VIAP) or the Department of Emergency Medicine at Mass General, please contact Krista M. McCabe at (617) 726-1392 or [email protected]