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. Author manuscript; available in PMC: 2020 Oct 1.
Published in final edited form as: Prof Dev (Phila). 2019 Fall;22(2):3–10.

Treating Gang-Involved Patients: Embodied Trauma & How to Heal from Life on the Street

Brandy F Henry 1
PMCID: PMC7310987  NIHMSID: NIHMS1554188  PMID: 32577076

Abstract

People involved with gangs experience a disproportionate amount of violence and trauma which can lead to the development of mental health and substance use disorders. This paper arms social workers with knowledge and skills to assess and intervene with gang-involved patients. A review of the rates of mental health and substance use disorders within the population is provided, including a discussion of theoretical frameworks to understand how gang involvement relates to mental health and substance use disorders. Finally, a review of evidence-based practices for treating gang-involved patients is provided.

Introduction

Increasing attention is being paid to the impacts of mass incarceration in the United States (US). Much of this research has described the overrepresentation of people with mental health and substance use disorders within the criminal justice system (Prins, 2014). However, less attention has been paid to the role that gang involvement may play to exacerbate this disparity. The prevalence of gang involvement is also increasing. Between 2002 and 2010 there was an estimated 35% increase in the number of youth street gangs within the US (Howell, 2013). Also as of 2013, there were an estimated total of 30,700 different gangs within the US, with 850,000 members (Egley, Howell, & Harris, 2014). Prison gangs are also increasing, and within prisons gang-involved incarcerated people are estimated to comprise between 11.7%–24.7% of the total population (Winterdyk & Ruddell, 2010).

To effectively address this disproportionately high need, evidenced-based treatments should be used. However, while a multitude of evidenced based treatments exist, very few have been tested with people who are gang-involved. It is not reasonable to assume that the standard of care would also be as effective with this population due to their unique barriers in receiving treatment. For example, their involvement in illegal activity may make them hesitant to openly discuss their lives with treatment providers or other patients in group therapy. Additionally, gang territories or rivalries may restrict the movement of gang-involved people, preventing them from accessing services. Finally, their gang involvement may also moderate treatment effects like other cultural identities. For these reasons, it is important to use evidenced based behavioral health treatments for people who are gang-involved.

Few treatment programs specifically for gangs exist, and even fewer have been rigorously tested for effectiveness. As of 2006, there were only a limited number of correctional-based treatment programs specifically for people who are gang-involved. Additionally, very few had been evaluated and none had used appropriate comparison groups (Placido, Simon, Witte, Gu, & Wong, 2006).

Given the growing prevalence of gang involvement, social workers need to be prepared to provide culturally competent services to this population. This paper will help to fill the gap in social worker knowledge by providing a review of the literature which describes the rates of mental health and substance use disorders among people who are gang-involved. Next, a discussion is provided which describes theoretical frameworks for understanding the potential of causes for this problem. Finally, clinical tools for treating this population are reviewed.

Literature Review

The following review of the literature will provide a review of studies which have estimated the rates of mental health and substance use disorders among gang-involved people. First, rates of mental health disorders, including personality disorders and suicidality, will be reviewed, followed by estimates of the rates of substance use disorders. A review of rates of service use for mental health and substance use disorders is also provided. Finally, there is a brief description of rates of victimization of gang-involved people.

Mental Health Disorders

Coid et al.’s (2013) study, from the United Kingdom, was the most comprehensive study on rates of mental health and substance use disorders among gang-involved men. This was one of the few studies that covered a range of both mental health and substance use disorders. Their sample was a large, nationally representative group of young men (n = 4,664). Participants completed a questionnaire containing questions on both mental health as well as participation in violence and gang activities. Validated psychiatric rating scales were used to measure mental health. Men with no reported history of violence and men who engaged in violent activities but were not gang-involved served as comparisons groups (Coid et al., 2013). Within this study, men who were gang-involved were more likely to experience antisocial personality disorder. Specifically, men who were gang-involved were 56.39 times more likely than men without histories of violence and 5.49 times more likely than men with histories of violence to have antisocial personality disorder (Coid et al., 2013).

Other studies have also found that actively gang-involved people were more likely to have symptoms of antisocial personality disorder. A study of Mexican American gang-involved men found higher levels of psychopathy among men who were gang-involved, as compared to comparison groups of men with histories of violence but no gang-involvement (Valdez, Kaplan, & Codina, 2000). A longitudinal study of adolescent boys in the US also found increased rates of antisocial personality disorder among those who were gang-involved. However, the rates of antisocial personality disorder within this population returned to pre-gang-involved levels after youth stopped their involvement with the gang (Gordon et al., 2004). Similarly, a study of detained gang-involved youth in the US reported higher rates of oppositional defiance disorder, as well as conduct disorder, which is a precursor to antisocial personality disorder (Harris et al., 2013).

Men who were gang-involved have also been found to have higher rates of suicidality. Coid et al. (2013) found that gang-involved men were 12.09 times more likely than men without histories of violence and 2.94 times more likely than men with histories of violence to have attempted suicide. Increased rates of depression and suicidal ideation among gang-involved youth in US high schools have also been demonstrated (McDaniel, 2012). Another study of gang-involved adolescents in the US also found an association between gang involvement and suicidal behavior (Madan, Mrug, & Windle, 2011). Detained gang-involved youth within a juvenile detention facility in the US were also found to have significantly more suicide attempts compared to non-gang-involved peers (Corcoran, Washington, & Meyers, 2005).

Higher rates of other mental health symptoms have also been demonstrated within gang-involved populations. Coid et al. (2013) reported that gang-involved men were 3.16 times more likely than men who had not been convicted of crimes categorized as violent and marginally more likely than men with histories of violence to have psychosis. Gang-involved men were also marginally more likely than both non-violent and violent men to have depression and anxiety (Coid et al., 2013). Among detained youth in the US, gang-involved youth were also found to have significantly more symptoms of anxiety and psychosis (Corcoran et al., 2005). A mixed gender study of African American gang-involved people in the US found significantly higher symptoms of post-traumatic stress disorder in people who were actively gang-involved versus formerly gang-involved, as compared to peers who had never been gang-involved (Li et al., 2002). The only study which reported to test for full diagnostic criteria of post-traumatic stress disorder found that detained youth who were gang-involved in the US had higher rates of the disorder, as compared to non-gang-involved peers (Harris et al., 2013).

Substance Use Disorders

Gang-involved people were also found to have higher rates of substance use disorders. Coid et al. (2013) found that gang-involved men were 11.71 times more likely than non-violent men, and 8.06 times more likely than violent men, to have substance dependence. Gang-involved people were also more likely to have alcohol dependence, at a rate of 5.49 times more likely than non-violent men and 2.97 times more likely than violent men.

Gang-involved youth in US high schools were found to be 5.50 times more likely to frequently use alcohol (1–2+ times weekly) than non-gang-involved youth. Additionally, gang-involved youth were also found to be 4.49 times more likely to frequently use substances (1–2+ times weekly) (McDaniel, 2012). Another study of gang-involved youth in US high schools replicated these findings. In this study, gang-involved youth, as compared to non-gang-involved youth, were 8.57 times more likely to use frequently use alcohol and 5.51 times more likely to frequently use substances (3+ times weekly) (Swahn, Bossarte, West, & Topalli, 2010). Gang-involved youth detained in the US were found to be 1.58 times more likely than non-gang-involved youth to be currently misusing substances (Harris et al., 2013). A study of African American gang-involved youth also found that gang-involved youth had significantly higher levels of substance use as compared to youth who were not gang-involved (Li et al., 2002).

One of the few studies that detailed types of substances used found that the rates of alcohol, tobacco, marijuana, and cocaine use were all higher for people who were gang-involved versus people who were not gang-involved. This study also examined current and lifetime substance use and found that both were higher among people who were gang-involved (Lanier, Pack, & Akers, 2009). Other studies documented differences between people who were actively gang-involved and formerly involved. People who were actively gang-involved have been found to be significantly more likely to use marijuana and cocaine than formerly gang-involved people (Katz, Webb, & Decker, 2005; Lanier et al., 2009). Lanier, Pack, and Akers (2009) found that alcohol and tobacco use remained higher for former gang-involved people. However, Li et al. (2002) found significantly higher rates of overall substance use in formerly gang-involved people, as compared to at risk youth who were never gang-involved (Li et al., 2002).

Mental Health & Substance Use Disorder Service Use and Victimization

People who were gang-involved were also found to be more likely to have used mental health or substance use disorders treatment services. Gang-involved people were 6.80 times more likely than non-violent men, and 2.53 times more likely than violent men, to have had a psychiatric treatment admission. They were also more likely to have consulted a psychiatrist or psychologist, with gang-involved people being 6.75 times more likely than non-violent men and 1.86 times more likely than violent men. Gang-involved people were 4.00 times more likely than non-violent men, and 1.45 times more likely than violent men, to have been prescribed psychotropic medication (Coid et al., 2013).

Gang-involved people were also found to be victims of violence more often. Coid et al. (2013) found that gang-involved people were 9.37 times more likely than non-violent men, and 1.09 times more likely than violent men, to have been the victim of violence. Additionally, gang-involved people feared violent victimization at a rate 7.84 times that of nonviolent men and 5.69 times that of violent men (Coid et al., 2013). Multiple other studies have found similar increased rates of violent victimization of gang-involved people (Decker, Melde, & Pyrooz, 2013). Finally, another study posited that since people who are gang-involved have increased involvement in violence they are also more likely to have a physical disability (Dunlap & Russell, 2014).

Theoretical Framework

The available theoretical literature provides insight into why gang-involved people have higher rates of mental health and substance use disorders. Theoretical explanations for gang related illegal behavior center on three theories; illegal behavior includes antisocial behavior and substance use. The three theories include: 1) selection hypothesis, 2) facilitation hypothesis, and 3) enhancement hypothesis (Madden, 2013). The selection hypothesis theorizes that adolescents who already engage in illegal behavior are more likely to join gangs, while the facilitation hypothesis posits that gang involvement leads to engaging in illegal behavior. The enhancement hypothesis blends the previous two ideas by hypothesizing that people who join gangs do have higher baseline rates of delinquency, but that gang involvement increases these rates (Gatti, Tremblay, Vitaro, & McDuff, 2005). One of the few longitudinal studies to study gang-involved people prior to initiation tested these three theories. The study sample included 756 at risk boys from Montreal, Canada. The boys were followed from kindergarten through high school, when gang involvement was assessed. They found that for boys who were sporadically gang-involved the facilitation hypothesis held true, but for boys who were consistently gang-involved the enhancement hypothesis held true (Gatti et al., 2005). Therefore, for antisocial personality disorder and substance use, it appears that the facilitation and enhancement hypothesis likely explain higher rates within gang populations.

Social network theory likely further explains how gang involvement acts as a facilitator or enhancer of antisocial behavior and substance use. Social network theory hypothesizes that individual level substance use is caused by substance use in peer and family groups. This theory has been widely applied to youth substance use with strong validity (Hoffman, Weathers, & Sanders, 2014). It has also been demonstrated to explain illegal behavior in neighborhoods with high crime (Browning, Dietz, & Feinberg, 2004). The only known study to test this theory for substance use with gang-involved youth found a strong association between cigarette smoking and cigarette use in their friendship networks. However, this association was not found with alcohol or marijuana use, which may have been a result of very low sample size (n = 60; Hoffman et al., 2014).

Despite the limited findings of this studies, social network theory likely explains the mechanism for how gang involvement facilitates both substance use and antisocial behavior. People involved in gang networks have increased access to substances and are more exposed to antisocial behavior. There is also often peer pressure and social incentives to use substances and engage in antisocial behavior. For example, within many gangs engagement in violence is necessary to rise through the ranks and obtain access to sex (Coid et al., 2013). Thereby, the social network likely acts as a facilitator to increased substance use and antisocial behavior.

Based on the previously discussed literature review, it appears that the hypotheses of selection, enhancement, and facilitation have not been applied or tested with regards to their application to more broad mental health symptoms. However, these hypotheses likely apply to mental health disorders as well. In considering the selection hypothesis, preexisting mental health disorders may make youth more vulnerable to peer pressure, leading to increased rates of joining gangs. Indeed, mental health symptoms have been documented as individual risk factors for joining a gang. The documented factors include: psychopathic personality traits, high levels of anxiety, hyper activity, low IQ, and low self-esteem (Wood & Alleyne, 2010). Besides being easy targets for recruitment, youth with mental health disorders may also be viewed as particularly willing to take on highly risky jobs within the gang.

The facilitation and enhancement hypotheses also likely apply to mental health symptoms within gang populations. Mental health symptoms are likely enhanced or exacerbated because of repeated exposure to gang related violence. As previously discussed in the literature review, gang-involved people experience significantly higher rates of violent victimization. Additionally, within their study population, Coid et al. (2013) linked higher rates of mental health and substance use disorders as well as related service use to higher rates of reported victimization. This relationship is also supported by a long history of epidemiological studies which demonstrate a causal relationship between experiences of violence and the development of mental health disorders (Coid et al., 2013). One study demonstrated a connection between adolescent exposure to gang related violence and the development of mental health symptoms (Kelly, 2010). This suggests that while gang-involved people may have higher baseline rates of mental health disorders, the trauma associated with gang involvement may also exacerbate existing symptoms or contribute to the development of new symptoms. This is supported by the documented higher rates of post-traumatic stress disorder and its associated symptoms within gang populations (Harris et al., 2013; Li et al., 2002), and supports both the enhancement and facilitation hypotheses.

A limitation to this proposed theoretical explanation is an overlap in risk factors (Madden, 2013). Multiple studies have identified both substance use and certain symptoms of mental health disorders as risk factors for joining gangs (Howell & Egley, 2005; Wood & Alleyne, 2010). Additionally, the same mental health disorders that predict gang involvement also predict substance use (White, Xie, Thompson, Loeber, & Stouthamer-Loeber, 2001). Therefore, these parallel increases may simply be correlated and not causal.

Practice Guidance

Based on this review of the literature, it is recommended that preliminary steps be taken within existing mental health and substance use care systems to address the unique treatment needs of people who are gang-involved. Mental health and substance use treatment systems should provide clinicians with training to identify risk factors of joining a gang and to understand specialized treatment needs of gang-involved patients. Through enhanced training, treatment for gang-involved people could be integrated into existing systems. Integrated treatment is likely ideal for the average gang-involved patient, as these are probably the systems where they are already receiving care.

Within these integrated systems, mental health and substance providers should screen for risk factors to joining gangs and gang involvement during assessment. A validated gang risk assessment was recently developed that could be used for this purpose (Hennigan, Kolnick, Vindel, & Maxson, 2015). Patients identified as gang-involved or at risk to join gangs should be provided with enhanced services. If patients are assessed as being deeply entrenched in a gang, a referral to specialized services should be considered. While specialty service providers do currently exist, there are very few of these provider agencies. Therefore, it is also recommended that more specialty mental health and substance use provider agencies be created to provide the highest need patients with adequate care.

While few evidence-based treatments have been specifically tested with people who are gang-involved, there have been some studies on the topic. For example, one study examining a residential therapeutic community within the US found that formerly gang-involved people were less engaged in treatment and showed less clinical progress (Michelle, 2007). Another study examined adjudicated boys within the southern US. The study tested the effectiveness of family preservation programs at reducing anti-social behavior. Findings indicated that the program was less effective for gang-involved youth, as compared to non-gang-involved youth (Diamond, Morris, & Caudill, 2011).

Boxer et al. (2015) found that gang involvement moderates the effectiveness of mental health and substance use treatment. This is one of the few studies that specifically aimed to test gang involvement as a moderator to mental health and substance use treatment efficacy. The study tested multi-systemic family therapy and took place in a non-profit mental health system across multiple states within the eastern US. All participants received multi-systemic family therapy, and people without gang involvement served as a comparison group to gang-involved people (n = 421). Findings showed that multi-systemic family therapy was significantly less efficacious for people who were gang-involved, and that gang involvement moderated treatment outcomes (Boxer, Kubik, Ostermann, & Veysey , 2015).

Specialized mental health and substance use treatments have been found to be effective for gang-involved patients. A randomized controlled trial of brief strategic family therapy was conducted with Mexican American gang-involved youth in Texas (n = 200). The control group consisted received referrals to standard of care treatment. Brief strategic family therapy is culturally appropriate treatment for Mexican Americans and was specifically adapted for gang-involved people for the purposes of this study. The intervention was found to be more effective than standard of care for both alcohol use and conduct problems (Valdez, Cepeda, Parrish, Horowitz, & Kaplan, 2013).

Another study evaluated the effectiveness of three cognitive behavioral therapy-based programs in a Canadian forensic hospital (n = 120). The programs were specifically designed for forensically involved psychiatric patients, and treatment was provided in an environment that attempted to isolated gang influences. The study examined treatment effectiveness, and whether it was equally effective for gang-involved patients as compared to those who were not gang-involved. Comparison groups who did not receive treatment were used to test overall effectiveness. Anti-social behavior was measured as the outcome. Outcomes for treatment groups were better, and there were no significant differences in outcomes between people who were gang-involved and those who were not (Placido et al., 2006).

Multi-disciplinary team treatment was also found to be as effective for gang-involved people as for those who were not. This treatment provides a diverse array of wrap-around services to address a wide spectrum of needs. It was tested in Southern California with youth who were newly gang-involved; youth who were not gang-involved served as a comparison group (n=282). Mental health and substance use outcomes tested in this study included anti-social behavior and substance use. No significant differences in outcomes were found between people who were gang-involved and those who were not. However, treatment did improve outcomes across both groups (Schram & Gaines, 2005). Finally, multiple studies found that gang-involved people accurately self-report substance use while in treatment (Johnson, Shamblen, & Courser, 2013; Katz et al., 2005).

Within evidenced-based practice evaluations, attention should be paid to attempting to uncover how gang involvement acts as a modifier to treatment outcomes. A potential hypothesis to explain these phenomena is that gang involvement acts as a cultural modifier to treatment. This hypothesis brings gangs under the umbrella of cultural competency, which has recently garnered substantial attention in provider training and program evaluation. Other research on cultural effects on mental health and substance use treatment has found that culture does act as a modifier to treatment outcomes (Whaley & Davis, 2007). Also important in considering this hypothesis is the related hypothesis that evidenced-based practices may not be consistent across all gang types. Gang type refers to the name of the gang. However, gangs exist in a sort of taxonomic order in which gangs are clustered by similar attributes. This is also reflected in racial or ethnic segregation within gangs. Therefore, gang type should also be examined. When studying treatments, level of gang entrenchment should also be investigated to determine if treatments are as effective for new recruits as they are for people who are more deeply involved in the gang. Qualitative studies might also be helpful to elucidate more nuanced information regarding populations and treatment efficacy.

Conclusion

People who are gang-involved represent a large but understudied population within mental health and substance use research. However, early research on the topic has found higher rates of mental health and substance use disorders within the population. Given the high rates of mental health and substance use disorders among gang-involved people, social workers likely work with this population on a regular basis. By implementing the knowledge and skills described in this paper, social workers can improve their ability to effectively treat the population by providing evidence-based services that have been tested with gang-involved people.

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