Charlottesville, hate crimes are public health issue, experts say
BY CNN WIRE,
CHARLOTTESVILLE, Va. — As a white nationalist rally in Charlottesville, Virginia, turned deadly on Saturday, doctors and public health leaders were among those watching events unfold on their television screens and social media. Dr. Georges Benjamin, executive director of the American Public Health Association, was at a car dealership getting his vehicle inspected when he saw news reports of a car plowing into a group of counterprotesters. “I was horrified,” he said. Dr. Elizabeth Samuels, an emergency physician in New Haven, Connecticut, and Providence, Rhode Island, was closely following the events in Charlottesville from home. “I had actually been following the news, went out for a run and saw (counterprotester) Heather (Heyer) had been killed when I got back home,” she said. Dr. Jack Ende, president of the American College of Physicians and a professor at the University of Pennsylvania’s Perelman School of Medicine, also was watching from home. “I was shocked to see what was going on,” he said. “I was shocked and saddened.” Benjamin, Samuels and Ende all agree that the expressions of hate seen in Charlottesville over the weekend were a public health problem.
‘This is a public health issue’
Hate crimes directed at people based on their race, ethnicity, gender, nationality, sexual orientation, religion or other characteristics are a public health issue, according to a policy statement from the American College of Physicians that was posted on its website Monday. “Is it appropriate for a medical organization to take a stance on hate crimes? The American College of Physicians said, ‘Yes, it was,’ ” Ende said. “There are data indicating the public health ramifications of both the hate crime itself but also of the stigma of bias, the stigma of prejudice and hatred directed against somebody because of their sexual orientation, because of their race, because of their ethnicity or their country of origin,” he said. “For that reason, we felt that this is a public health issue, and we joined with other medical organizations to take a stance against hate crimes.” The American Psychological Association, the American Medical Association and the American Academy of Family Physicians also have issued policy statements on hate crime as a public health concern. The American Public Health Association has a site devoted to racism’s negative impact on public health and launched a national campaign against racism, including hate crimes. “We studied the statements of our sister groups before we came out with our own,” Ende said. “There is a consensus within the medical societies that this really needs to be kept on our radar.” The American College of Physicians’ statement, which its board of regents approved last month, calls for more research on the impact of hate crimes, the understanding and prevention of hate crimes and interventions to address the needs of hate crime survivors and their communities. “By identifying discrimination and hate crimes as public health issues, the ACP not only acknowledges the impact these factors have on our patients but also our role and responsibility to address them as part of our professional dedication to the health of our patients and the public,” said Samuels, who was not involved in the policy statement but attended a vigil in Providence on Sunday where people reflected on the violence. “When I have cared for patients assaulted because of their race, religion, gender, sexual orientation, age or disability, what has stood out to me is not so much the physical injuries inflicted — which are not to be minimized — but the psychological harm,” she said. “Hate-based violence and systemic racism are detrimental to public health.”
How hate hurts public health
Several studies suggest that experiences of racism or discrimination raise the risk of emotional and physical health problems, including depression, hypertension, cardiovascular disease and even death. A study of 1,016 Arab-Americans found that their reports of abuse and discrimination after September 11, 2001, were associated with higher levels of distress, lower levels of happiness and worse overall health. The study was published in the American Journal of Public Health in 2010. As for hate crimes in particular, a study found that lesbian, gay, bisexual and transgender high school students living in neighborhoods with higher rates of LGBT assault hate crimes were significantly more likely to report having suicidal thoughts or suicide attempts than students in neighborhoods with lower rates of hate crime. That study was published in the American Journal of Public Health in 2014. “Bottom line is that hate has physical and mental health consequences and should be considered within the remit of public health,” said Dr. Sandro Galea, dean and professor at the Boston University School of Public Health, who was not involved in the American College of Physicians’ latest policy statement. In other words, being considered within the remit of public health means that hate crimes have significant public health consequences, such as being associated with mental and physical problems. Galea said that he agreed with the policy statement, adding that what appears to be a recent rise in divisive language and outward expressions of hate is “deeply troubling” both as a citizen and as a doctor. He pointed to the weekend’s rally in Charlottesville as an example of that expression of hate. “The escalation to outright violence, including the killing of one person, are the tip of the iceberg, the ultimate manifestation of the consequences of hate,” Galea said. The American College of Physicians is not the first health organization to recognize hate crimes as a public health concern — and Charlottesville certainly is not the first city to see hateful rhetoric sweep its streets. Nor will it be the last, with rallies planned in other cities this weekend. America’s narrative includes not only the Civil Rights Act of 1968, the first federal statute to recognize hate crimes, but a haunting history of violent Ku Klux Klan gatherings and lynch mobs. As for why the American College of Physicians and other health organizations are only now recognizing hate crimes as a public health issue, Ende said the health community has evolved and become more “sophisticated in our sensitivity” to determinants of illness and social issues. Now, some medical groups are seeking out public health solutions.
‘We have the capacity as a nation to … fix this’
The American Academy of Family Physicians points to educational programs directed at the prevention of hate crimes as a possible solution, and such programs could be implemented in community centers and schools. The American Psychological Association cites research suggesting that getting people from conflicting groups in the same room in a peaceful way to hear each other’s perspectives, such as in a town hall meeting, or teaching the history of hate in America — such as how there was prejudice against German culture during World War I — are both approaches to turning bias around and possibly preventing hate. The American Medical Association even urges the expedient passage of appropriate hate crimes legislation. The American Public Health Association’s campaign against racism includes three potential public health solutions to hate crimes and racism, Benjamin said. They mostly focus on public discussions. “The first one is naming it. Identifying it. That is a very, very important first step, you know, putting it on the agenda,” Benjamin said. In other words, he said, calling out a hate crime or racism by name can initiate public discussions. Then, as part of that discussion, the second step would be to identify how racism is driving policies, practices or social norms, he said. For instance, “when you have two societies that live on different sides of the railroad tracks and there’s differences in their economic well-being and health … was that constructed?” Benjamin asked. The third step would be taking action, such as promoting or facilitating research and interventions through educational programs or community forums, to address racism and hate crimes from a public health perspective. “The public health community is good at understanding the data, thinking about the population-based impact of it and then working with others, because we don’t do this alone. We work across many sectors to find solutions,” Benjamin said. “I think we need to recognize Charlottesville is an overt expression of something that has been going on for a long time in our country,” he said. “That is a stain and a terrible, terrible situation in our country that we have to fix, and we need to do it now. We have the capacity as a nation to come together and fix this.” Ref
Can Racism Cause PTSD? Implications for DSM-5
By Monnica T. Williams, Ph.D.
Monnica T. Williams, is a licensed clinical psychologist and associate professor
at the University of Connecticut in the department of Psychological Sciences.
Allen was a young African American man working at a retail store. Although he enjoyed and valued his job, he struggled with the way he was treated by his boss. He was frequently demeaned, given menial tasks, and even required to track African American customers in the store to make sure they weren’t stealing. He began to suffer from symptoms of depression, generalized anxiety, low self-esteem, and feelings of humiliation. After filing a complaint, he was threatened by his boss and then fired. Allen’s symptoms worsened. He had intrusive thoughts, flashbacks, difficulty concentrating, irritability, and jumpiness – all hallmarks of posttraumatic stress disorder (PTSD). Allen later sued his employer for job-related discrimination, and five employees supported his allegations. Allen was found to be suffering from race-based trauma (from Carter & Forsyth, 2009)
Epidemiology of PTSD in Minorities
PTSD is a severe and chronic condition that may occur in response to any traumatic event. The National Survey of American Life (NSAL) found that African Americans show a prevalence rate of 9.1% for PTSD versus 6.8% in non-Hispanic Whites, indicating a notable mental health disparity (Himle et al., 2009). Incresed rates of PTSD have been found in other groups as well, including Hispanic Americans, Native Americans, Pacific Islander Americans. and Southeast Asian refugees (Pole et al., 2008). Furthermore, PTSD may be more disabling for minorities; for example, African Americans with PTSD experience significantly more impairment at work and carrying out everyday activities (Himle, et al. 2009).
Racism and PTSD
One major factor in understanding PTSD in ethnoracial minorities is the impact of racism on emotional and psychological well-being. Racism continues to be a daily part of American culture, and racial barriers have an overwhelming impact on the oppressed. Much research has been conducted on the social, economic, and political effects of racism, but little research recognizes the psychological effects of racism on people of color (Carter, 2007).Chou, Asnaani, and Hofmann (2012) found that perceived racial discrimination was associated with increased mental disorders in African Americans, Hispanic Americans, and Asian Americans, suggesting that racism may in itself be a traumatic experience.
PTSD in the DSM-IV
Currently, the DSM recognizes racism as trauma only when an individual meets DSM criteria for PTSD in relation to a discrete racist event, such as an assault. This is problematic given that many minorities experience cumulative experiences of racism as traumatic, with perhaps a minor event acting as “the last straw” in triggering trauma reactions (Carter, 2007). Thus, current conceptualizations of trauma as a discrete event may be limiting for diverse populations. Moreover, existing PTSD measures aimed at identifying an index trauma typically fail to include racism among listed choice response options, leaving such events to be reported as “other” or squeezed into an existing category that may not fully capture the nature of the trauma. This can be especially problematic as minorities may be reluctant to volunteer experiences of racism to White therapists, who comprise the majority of mental health clinicians. Clients may worry that the therapist will not understand, feel attacked, or express disbelief. Additionally, minority clients also may not link current PTSD symptoms to cumulative experiences of discrimination if queried about a single event.
Implications for Treatment
Racism is not typically considered a PTSD Criterion A event, i.e., a qualifying trauma. Mental health difficulties attributed to racist incidents are often questioned or downplayed, a response that only perpetuates the victim’s anxieties (Carter, 2007). Thus, clients who seek out mental healthcare to address race-based trauma may be further traumatized by microaggressions — subtle racist slights — from their own therapists (Sue et al., 2007). Mental health professionals must be willing and able to assess race-based trauma in their minority clients. Psychologists assessing ethnoracial minorities are encouraged to directly inquire about the client’s experiences of racism when determining trauma history. Some forms of race-based trauma may include racial harassment, discrimination, witnessing ethnoviolence or discrimination of another person, historical or personal memory of racism, institutional racism, microaggressions, and the constant threat of racial discrimination (Helms et al., 2012). The more subtle forms of racism mentioned may be commonplace, leading to constant vigilance, or “cultural paranoia,” which may be a protective mechanism against racist incidents. However subtle, the culmination of different forms of racism may result in victimization of an individual parallel to that induced by physical or life-threatening trauma. Bryant-Davis and Ocampo (2005) noted similar courses of psychopathology between rape victims and victims of racism. Both events are an assault on the personhood and integrity of the victim. Similar to rape victims, race-related trauma victims may respond with disbelief, shock, or dissociation, which can prevent them from responding to the incident in a healthy manner. The victim may then feel shame and self-blame because they were unable to respond or defend themselves, which may lead to low self-concept and self-destructive behaviors. In the same study, a parallel was drawn between race-related trauma victims and victims of domestic violence. Both survivors are made to feel shame over allowing themselves to be victimized. For instance, someone who may have experienced a racist incident may be told that if they are polite, work hard, and/or dress in a certain way, they will not encounter racism. When these rules are followed yet racism persists, powerlessness, hyper vigilance, and other symptoms associated with PTSD may develop or worsen (Bryant-Davis & Ocampo, 2005).
Changes in the DSM-5
Proposed changes to PTSD criteria in the DSM-5 have been made to improve diagnostic accuracy in light of current research (Friedman et al., 2011). The first section involving the experienced trauma has changed moderately, reflecting findings in clinical experience as well as empirical research. If a person has learned about a traumatic event involving a close friend or family member, or if a person is repeatedly exposed to details about trauma, they may now be eligible for a PTSD diagnosis. These changes were made to include those exposed in their occupational fields, such as police officers or emergency medical technicians. However, this could be applicable to those suffering from the cumulative effects of racism as well. The requirement of responding to the event with intense fear, helplessness, or horror has been removed. It was found that in many cases, such as soldiers trained in combat, emotional responses are only felt afterward, once removed from the traumatic setting. The most notable change to the criterion is from a three to a four-factor model. The proposed factors are intrusion symptoms, persistent avoidance, alterations in cognition and mood, and hyperarousal/reactivity symptoms. Three new symptoms have been added – persistent distorted blame of self or others, persistent negative emotional state, and reckless or self-destructive behavior. All of these symptoms may be also seen in those victimized by race-based trauma.
The changes to the DSM increase the potential for better recognition of race-based trauma, although more research will be needed to understand the mechanism by which this occurs. Additionally, current instruments should be expanded and a culturally competent model of PTSD must be developed to address how culture may differentially influence traumatic stress. In the meantime, clinicians should educate themselves about the impact of racism in lives of their ethnic minority clients, specifically the connection between racist events and trauma (Williams et al., 2014). Ref
The Link Between Racism and PTSD
Our screens and feeds are filled with news and images of black Americans dying or being brutalized. A brief and yet still-too-long list: Trayvon Martin, Tamir Rice, Walter Scott, Eric Garner, Renisha McBride. The image of a white police officer straddling a black teenager on a lawn in McKinney, Tex., had barely faded before we were forced to grapple with the racially motivated shooting in Charleston, S.C. I’ve had numerous conversations with friends and colleagues who are stressed out by the recent string of events; our anxiety and fear is palpable. A few days ago, a friend sent a text message that read, “I’m honestly terrified this will happen to us or someone we know.” Twitter and Facebook are teeming with anguish, and within my own social network (which admittedly consists largely of writers, academics and activists), I’ve seen several ad hoc databases of clinics and counselors crop up to help those struggling to cope. Instagram and Twitter have become a means to circulate information about yoga, meditation and holistic treatment services for African-Americans worn down by the barrage of reports about black deaths and police brutality, and I’ve been invited to several small gatherings dedicated to discussing these events. A handful of friends recently took off for Morocco for a few months with the explicit goal of escaping the psychic weight of life in America. It was against this backdrop that I first encountered the research of Monnica Williams, a psychologist, professor and the director of the University of Louisville’s Center for Mental Health Disparities. Several years ago, Williams treated a “high-functioning patient, with two master’s degrees and a job at a company that anyone would recognize.” The woman, who was African-American, had been devastated by racial harassment by a director within her company. Williams recalls being stunned by how drastically her patient’s condition deteriorated as a result of the treatment. “She completely withdrew and was suffering from extreme emotional anxiety,” she told me. “And that’s what made me say, ‘Wow, we have to focus on this.’ ” In a 2013 Psychology Today article, Williams wrote that “much research has been conducted on the social, economic and political effects of racism, but little research recognizes the psychological effects of racism on people of color.” Williams now studies the link between racism and post-traumatic stress disorder, which is known as race-based traumatic stress injury, or the emotional distress a person may feel after encountering racial harassment or hostility. Although much of Williams’s work focuses on individuals who have been directly targeted by racial discrimination or aggression, she says race-based stress reactions can be triggered by events that are experienced vicariously, or externally, through a third party — like social media or national news events. She argues that racism should be included as a cause of PTSD in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (D.S.M.). Williams is in the process of opening a clinical program that will exclusively treat race-based stress and trauma, in a predominantly black neighborhood in Louisville. Shortly after the Charleston shooting, I called Williams to discuss her work; what follows is a lightly edited and condensed transcript of our conversation.
What is race-based stress and trauma?
It’s a natural byproduct of the types of experiences that minorities have to deal with on a regular basis. I would argue that it is pathological, which means it is a disorder that we can assess and treat. To me, that means these are symptoms that are a diagnosable disorder that require a clinical intervention. It goes largely unrecognized in most people, and that’s based on my experience as a clinician.
What are the symptoms?
Depression, intrusion (the inability to get the thoughts about what happened out of one’s mind), vigilance (an inability to sleep, out of fear of danger), anger, loss of appetite, apathy and avoidance symptoms and emotional numbing. My training and study has been on post-traumatic stress disorder for a long time, and the two look very much alike. Over the weekend, I received several distressing emails and texts from friends who were suffering from feelings of anxiety and depression. Do you think we should all be in treatment? I think everyone could benefit from psychotherapy, but I think just talking to someone and processing the feelings can be very effective. It doesn’t have to be with a therapist; it could be with a pastor, family, friends and people who understand it and aren’t going to make it worse by telling you to stop complaining. What do you think about the #selfcare hashtags on social media and the role of “Black Twitter” as resources for people who may not have the resources they need to help process this? Are online interactions like that more meaningful than they initially might seem? Ref
Within the context of immigration (particularly from the Caribbean), author Joan Wilkinson examines racism and emotional abuse. The findings reveal the need for more cultural sensitivity and awareness. Canadian Statistics tells us that 29% of women have been victims of wife abuse. The immigrant woman is not excluded from this group. Frequently women who immigrate to Canada from the Caribbean are vulnerable to emotional abuse to the extent that it affects their ability to seek social support. They often find themselves in abusive situations in their home, at their place of employment or even in their churches. Incapable of finding a safe way to escape their violent circumstances, many women blame themselves or may even rationalize the abuse they are experiencing, which, over time, results in significant impact on the self-esteem, self-confidence and/or the parenting capacity of these women. Unfortunately, due to a lack of cultural awareness and systemic racism, those who are placed in positions of power aimed at protecting society, for instance in the legal and judiciary system, may react with indifference or ignorance. For example, a woman may be told that women from her culture are known to prefer men who abuse them. This lack of knowledge regarding abuse and its impact on the victim only serve to contribute to the immigrant woman’s fear of reporting the various forms of abuse that have been inflicted upon her. As such, poor responses strengthen the feelings of distrust an immigrant woman has about various institutions, such as social work practitioners, the education and judicial systems. From another perspective, the failure to establish a supportive workable intervention with an abused woman should be viewed as revictimizing her. The response to immigrant women is often buttressed by racial stereotypes specific to a certain culture, and by societal norms that state women are supposed to be submissive. Often an immigrant woman is not aware of the societal support systems and is therefore unable to use them. The emotional abuse may also undermine her ability to seek economic independence. Unfortunately, she may soon forget her own inner resources and the resilience that helped her to migrate to begin a new life. Service providers such as counselors, police and settlement workers must consider the complexity of the issues facing immigrant women. They should possess knowledge of the woman’s culture and understand each woman individually within her own cultural context culture in order to be effective, while avoiding stereotypes when dealing with women of colour. This awareness would facilitate a more effective intervention with this often hidden and misunderstood client group. Ref
Emotional violence and controlling behaviour is behaviour which does not give equal importance and respect to another person’s feelings and experiences. It is often the most difficult to pinpoint or identify. Emotional violence includes the refusal to listen to, or denial of, another person’s feelings, telling people what they do or do not feel and ridiculing or shaming of their feelings. It happens when one person believes they have a right to control or dominate another person. Bullying , threatening, harassing, isolating and name calling are all forms of control. They can make people feel bad and worry about what is going to happen next. Emotional violence can also make people feel powerless, fearful or angry about the violence. Ref
What Is Psychological Violence?
Violence is a central concept for describing social relationships among humans, a concept loaded with ethical and political significance. Yet, what is violence? What forms can it take? Can human life be void of violence, and should it be? These are some of the hard questions that a theory of violence shall address. In this article we shall address psychological violence, which will be kept distinct from physical violence and verbal violence. Other questions, such as Why are humans violent?, or Can violence ever be just?, or Should humans aspire to non-violence? will be left for another occasion.
In a first approximation, psychological violence may be defined as that sort of violence which involves a psychological damage on the part of the agent who is being violated. You do have psychological violence, that is, any time that an agent voluntarily inflicts some psychological distress on an agent. Psychological violence is compatible with physical violence or verbal violence. The damage done to a person that has been the victim of a sexual assault is not only the damage deriving from the physical injuries to her or his body; the psychological trauma the event may provoke is part and parcel of the violence perpetrated, which is a psychological sort of violence.
THE POLITICS OF PSYCHOLOGICAL VIOLENCE
Psychological violence is of the utmost importance from a political point of view. Racism and sexism have been indeed analyzed as forms of violence that a government, or a sect of society, was inflicting on some individuals. From a legal perspective, to recognize that racism is a form of violence even when no physical damage is provoked to the victim of a racist behavior, is an important instrument for putting some pressure (that is, exercising some form of coercion) on those whose behavior is racist. On the other hand, as it is often difficult to assess a psychological damage (who can tell whether a woman is really suffering because of the sexist behavior of her acquaintances rather than because of her own personal issues?), the critics of psychological violence often try to find an easy apologetic way out. While disentangling causes in the psychological sphere is difficult, however, there is little doubt that discriminatory attitudes of all sorts do put some psychological pressure on agents: such a sensation is quite familiar to all human beings, since childhood.
REACTING TO PSYCHOLOGICAL VIOLENCE
Psychological violence poses also some important and difficult ethical dilemmas. First and foremost, is it justified to react with physical violence to an act of psychological violence? Can we, for instance, excuse bloody or physically violent revolts that were perpetrated as a reaction to situations of psychological violence? Consider even a simple case of mobbing, which (at least in part) involves some dose of psychological violence: can it be justified reacting in a physically violent manner to mobbing? The questions just raised divide harshly those who debate violence. On one hand stand those who regard physical violence as a higher variant of violent behavior: reacting to psychological violence by perpetrating physical violence means to escalateviolence. On the other hand, some maintain that certain forms of psychological violence may be more atrocious than any form of physical violence: it is indeed the case that some of the worst forms of torture are psychological and may involve no direct physical damage be inflicted on the tortured.
UNDERSTANDING PSYCHOLOGICAL VIOLENCE
While the majority of human beings may have been victim of some form of psychological violence at some point of their life, without a proper notion of a self it is difficult to devise effective strategies for coping with the damages inflicted by those violent acts. What does it take to heal from a psychological trauma or damage? How to cultivate the well-being of a self? Those may possibly be among the most difficult and central questions that philosophers, psychologists, and social scientists have to answer in order to cultivate the well-being of individuals. Ref
What You Can Do?
- Gun Violence PreventionSee research on gun violence and learn how to help people in an emotional crisis.
- Abuse of Women with DisabilitiesWomen with disabilities may experience unique forms of abuse that are difficult to recognize — making it even harder to get the kind of help they need.
- Abuso de Mujeres con DiscapacidadLas mujeres con discapacidad pueden experimentar formas únicas de abuso que son difíciles de reconocer.
- Warning signs of youth violenceLearn how to recognize danger signs and keep anger from escalating out of control.
- Raising children to resist violence: What you can doChildren learn aggressive behavior early in life. Several strategies can help parents and others teach kids to manage their emotions without using violence.
- Partner Violence: What Can You Do?This brochure briefly describes violence in the home and provides advice for victims, abusers, and family and friends.
- What makes kids care? Teaching gentleness in a violent worldIn a world where violence and cruelty seem to be common and almost acceptable, many parents wonder what they can do to help their children to become kinder and gentler — to develop a sense of caring and compassion for others.
- Understanding and Preventing Violence Directed Against TeachersInformation to help K-12 teachers to cope with and prevent the occurrence and threat of violent incidents in their classrooms.
- Talking to your children about the recent spate of school shootingsEvery child will respond to trauma differently. Some will have no ill effects; others may suffer an immediate and acute effect. Still others may not show signs of stress until sometime after the event.
- How to find help through seeing a psychologistThis brief question-and-answer guide provides some basic information to help individuals take advantage of outpatient (non-hospital) psychotherapy.
- Managing your distress in the aftermath of a shootingYou may be struggling to understand how a shooting rampage could take place in a community, even a workplace or military base, and why such a terrible thing would happen.
- Intimate Partner ViolenceNearly half of all women in the United States have experienced at least one form of psychological aggression by an intimate partner.
- Violencia en Contra de la ParejaMujeres con discapacidades tienen 40 por ciento mayor riesgo de sufrir violencia por parte de la pareja, principalmente violencia severa, en comparación con mujeres sin discapacidades.
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