Applications of resilience: public health approaches to victims of hate crime

Working with victims from reporting to readjustment

 

I met our victims commissioner for the  Police and Crime Commissioner for the first time last week. He came along to our Public Health Board. He asked why I have a small team in Public Health embedded in our joint police/council community safety unit working on offenders but no mention of victims. And actually he’s right. This is an area we need to do more on.

Back in the day I was at Nacro I wrote a toolkit for the Home Office on hate crime, and another one on homophobic crime especially, working with the amazing Professor Ian Rivers now at Brunel.  Other colleagues worked with me on crime and disabled people. Some of the work I did at Nacro on health and crime is accessible here.

The resource manual Tackling Hate Crime produced by the Association of Chief Police Officers, London. 2000 did some great stuff in its time. But actually we do need to look at this afresh from a public health perspective. What I’ve done here is to summarise where the literature and practice seems to be at from my experience and knowledge. At some point I will try to properly write this up (anyone wanna help? then email me jim dot McManus @ Hertfordshire dot gov dot uk.) But this is offered to help practice.

I’m going to use LGBT hate crime as an example for the rest of this post, but I think there are applications here across all types of hate crime.  I’m not going to focus on bullying in schools because there is quite a lot out there, just check out Ian River’s site or Stonewall  and this post can be read in conjunction with that. Similarly for faith schools there is the work done by the Church of England recently

There are, it seems to me from the growing consensus in literature on hate crime, several public health tasks:

  1. Ensuring the Joint Strategic Needs Assessment accurately reflects community and agency intelligence on hate crime
  2. Defining and finding and encouraging reporting of cases
  3. Ensuring victims are supported effectively in the immediate aftermath, because this will have long term consequences for helping or hindering adjustment
  4. Ensuring consistent standards of practice are in place

The initial approach: seeing victimisation in lifecourse perspective

Working with victims of Hate Crimes is something which, at first sight, can feel awkward and difficult for many. It is easy to assume that because the vcitim is lesbian/gay/bisexual or transgendered that there will be specific issues. While this is often the case, there is usually a core of symptoms and experiences common to victimisation. Some of these can be evidenced by the fact that victims of hate crime may often have symptoms analogous to, or actually experience, Post Traumatic Stress Disorder. There can be significant long term sequelae from experiencing hate crime.

If reporting and response mechanisms, however they are adopted, are to succeed, there is a need to ensure that people who identify themselves as having been victimised are treated and welcomed appropriately and sensitively, and encouraged to make the journey towards resolution. There are, therefore, from a public health perspective short term and long-term goals which anyone working with victims needs to address.

This assumes that there are two roles to supporting victims in the short and long terms, “reporting” and “supporting”.

 

  • Reporting involves making a formal report and commencing the appropriate action to investigate, gather evidence, monitor, etc.
  • Supporting is the process of enabling the victim to make sense of the incident, to seek and offer appropriate help (informally or professionally), to readjust and come to terms with the incident, and rebuild their life.

 

In the immediate term after an incident of victimisation, it is likely that the reporting and supporting process will be provided at the same time, at least initially. This will require appropriate training of those who receive reports.

In the medium to longer term after an incident, it will be necessary to identify carefully whether and when to offer referral on to skilled sources of help, and to offer this sensitively.

Where a report is made by someone a considerable period of time after an incident (e.g. six months or more), there is still a need to ensure that the report is taken sensitively and confidentially, and that appropriate onwards referral for support is offered. This is especially the case where someone has not sought help before. “Flashbacks” to the event, emotional distress and other post-traumatic stress symptoms can often be seen at this point. If the person receiving the report is unsympathetic the person reporting may not seek further help and may present later with more significant emotional distress.

 

Work with rape and sexual assault victims, work with victims of racial hate crime and some projects in existing areas demonstrate some very good practice on work with victims. Lothians and Borders, the Metropolitan Police, Northumbria, Greater Manchester and Hampshire constabularies have all for long periods of time trained police officers to respond appropriately to victims and support them while obtaining necessary reports and statements. Manchester, London, Edinburgh, Hampshire and Lancashire all provide the option of using agencies external to the police where people can report and seek help. Victim Support and Citizens Advice Bureaux both have policies on working with diversity and may be sources of help and suppor. Local lesbian and gay switchboards may also prove useful sources of support, but in some areas are likely to need training to be able to deal fully with these issues.

 

The short-term goals for working with someone who has very recently been victimised or assaulted and is presenting to report the crime or share the experience are:

 

  1. To be able to report the experience and have it taken seriously in a non-judgmental atmosphere
  2. To be listened to without judgment or fear of retribution on moral or legal grounds
  3. To have someone (e.g. a friend or partner) present and treated as a significant other if they wish.
  4. To be assessed for extent of physical, psychological and emotional trauma and supported in seeking appropriate help
  5. To make necessary practical arrangements (e.g. escort home, reporting missing wallet, credit cards, property etc.)
  6. To have an opportunity to tend to personal care and hygiene after any necessary medical or forensic examinations
  7. To be able to feel safe to express or not to express emotional response, as the person chooses
  8. To make arrangements for, and have any dependents informed, should they wish
  9. To be taken seriously.

 

More detail on these goals is written into Table 2 below.

 

These goals could be written into standards and procedures for each agency. Each agency should also assess what training is required for staff and volunteers.

Local Authorities and Police Authorities should consider what issues arise in light of s.17 of the Local Government Act 1998. Local Authorities may need to adopt diversity policies where these do not exist and train staff likely to deal with victims (e.g. housing front-line staff, social services staff, etc.)

The issue of friends and partners needs specific attention. One thing common to both victims of homophobic hate crime and disability hate crime (especially hearing impaired and deaf people) and some faiths is the very strong social relationships. Kinship and family is not just biological. The nature of kinship in the lesbian and gay community alone  is such that friendships can be extremely important relationships[1]. It is important that friends and partners are informed about what is happening and that the victim of crime is able to have them included or not, as s/he wishes.

 

We can actually derive some standards for long-term outcomes of victimisation, which, while in this context written for an LGBT community, are actually pretty applicable across hate crime categories. I’ve adapted these with kind permission of John Wiley & Sons (Chichester) from Evosevich, J.M. and Avriette,M. (2000) The Gay and Lesbian Psychotherapy Treatment Planner. Chichester : John Wiley & Sons. ISBN 0-471-35081-8

 

Long Term Behavioural, Social and Cognitive Goals

 

  1. Physical recovery from trauma/injury and appropriate rehabilitation (e.g. physiotherapy)
  2. Eliminate intrusive thoughts, nightmare and memories
  3. Resume social activities and employment
  4. Increase feelings of confidence and satisfaction with personal identity
  5. Appropriate preparation and support for any court appearances (or restorative justice work) to ensure that the victim does not experience a regression into self-victimisation or other harmful responses to the incident
  6. Enhance personal awareness of safety and ability to protect self
  7. Increase trust in reporting and enforcement systems
  8. Return to the level of emotional and social functioning before the assault.

Suicide and self-harm remains a risk from a public health perspective which needs to be prevented. While from a US perspective, this recent report prvides some valuable insight

 

Using this work

These suggested good practice standards could form the basis of action in any joint work between Police and Crime Commissioner, Public Health and other agencies.

I’ve developed some definitions which could be regarded as standards here using Evosevich and Avriette as a springboard, and synthesising the literature from Ian Rivers and a range of others, to provide what could become a victims response tool for LGBT hate crime, and other hate crime, from a Public HEalth Perspective

There are several sections to this:

  •  getting a clear set of definitions
  • some short term goals which should help the trajectory towards response and readjustment
  • some suggested standards for counsellors/responders

 

 

Table 1 : Behavioural Definitions

This table is intended to help anyone supporting a victim of hate crime to define some of the key problems and issues experienced by the victim.                       

This list can then be used to look at whether people might want referral to psychological or other support, or how serious the experience was.

Number Behavioural Definition of being a Hate Crime Victim
1 Self-report or account by others of physical assault by stranger because of sexual orientation
2 Self-report of being forced to engage in sexual activity with another person
3 Bruises, cuts, abrasions or other trauma
4 Physical pain, wound, disability, fracture or other physical problem requiring treatment
5 Recurrent, intrusive and disturbing thoughts, dreams and memories of assault
6 Blaming victimisation on characteristics of oneself (e.g. being camp, weak because of sexuality, etc.)
7 Restricted range of affect (i.e. reducing or restricting ability to show affection, emotion, etc to friends/family/partners)
8 Prolonged disturbance of mood and affect (e.g. depression, irritability, anxiety, apathy, withdrawal)
9 Avoidance of social activities (e.g., work, activities with partner/friends or family)
10 Subjective sense of numbing, detaching or absence of emotional responsiveness
11 Avoidance of people, places and activities that are reminders of the assault
12 Difficulty sleeping, poor concentration, restlessness

 

Table 2 : Short-Term Objectives in Detail

This table is intended to develop further the short-term goals for the victim identified above both for reporting and supporting agencies. It is adapted, with permission, from Evosevich and Avriette[2].

 

Short-Term Objective for Victim Kind of Intervention from Counsellor or WorkerImportant : some of these interventions need skilled, trained and supervised people
q  Give an accurate and emotionally honest description of the assaultq  Identify and express any guilt, shame, anger, helplessness and/or self-blame associated with the assault q  Actively build the level of trust with the client in individual sessions through consistent eye contact, active listening, unconditional positive regard, and warm acceptance to help increase his/her ability to identify and express feelings.
q  Comply with a comprehensive evidence gathering process (physical, forensic, information, report forms, etc) to assure all relevant evidence is gathered and no serious injuries have been sustained and not diagnosed or treatedq  Report results from physical examination and pursure any medical treatment necessary q  Gather a history of assault including time, location, assailant(s), police involvement, etcq  Assess depression and/or suicidal tendenciesq  Encourage verbal expression and clarification of perception of facts associated with inciden

q  Appropriate referral to medical or dental etc support, and Genito-Urinary Medicine clinic if sexual assault

q  Understand and express how assault has impacted function in social, work and family/partner situationsq  Express an understanding of the psychological impact of the traumaq  Seek reading materials/support groups etc q  Explore feelings associated with the assaultq  Assist victim in identifying the negative impact that the assault has hadq  If appropriately qualified, administer a scale such as the Clinician Administered PTSD Scale (Blake et al, CAPS) or the PTSD Symptom Scale (Foa et al, PSS) to assist with diagnosis and to determine severity of symptoms and impairment. Construct therapeutic goals around this.

q  Support in finding reading materials, support groups, specialist counselling etc.

q  Understand effects of flashback etc reactions to incident and prepare for periodic “rough times” after incident.q  Identify any pattern of blaming self for assaultq  Obtain support from friends, partners and family members

q  End self-blame and place responsibility on perpetrator

q  Challenge negative self-talk and replace with more realistic beliefs

q  Educate about common reactions to assault, e.g. anxiety, flashbacks, avoidance, self-blameq  Help client find coping strategies for when this happens (e.g. friends, relaxation, etc) Identify friends and family members who are supportive.q  Explore solutions for creating support in friends, partner and family members

q  Explore and supportively confront client regarding self-blame and assist in placing responsibility on perpetrator

q  Educate client about challenging unrealistic self-talk and replacing it with realistic self-talk.

q  Assist in exploring restorative justice measures

q  Understand and express how societal homophobia and the perpetrator’s background of hate created the climate for the victimisation, not being gay or lesbian q  Educate client about the nature, incidence and severity of homophobic crime.q  Explore and confront self-blame
q  Be clear on advantages and disadvantages of prosecuting q  Ensure police give support and advice in time up to prosecution, advise getting sympathetic lawyer/advocate
q  Reduce anxiety q  Arrange avoided situations into an anxiety hierarchyq  Develop strategies to deal with these and reduce anxietyq  Practice relaxation and deep breathing techniques
q  List situations, places and people being avoided q  Arrange avoided situations into an anxiety hierarchyq  Develop strategies to deal with these and reduce anxietyq  Encourage discussion about these and confrting them with a supportive friend, partner or family member.
q  Reduce likelihood of future victimisation q  Encourage self-safety strategies (see reporting section of toolkit), attendance at self-defence classes, etc.
q  Challenge irrational fears about being re-victimised q  List situations being avoided and develop self-safety strategyq  Explore sources of fear and develop strategies to deal with this
q  Ensure rational fears about being re-victimised and fed into community safety process q  Reporting to police, community safety forum or through lesbian and gay agency
q  Dealing with problems of faith, religion, etc. q  Ensure availability of sensitive support. The Lesbian and Gay Christian Movement, Quest, Gay Jewish, Muslim and other groups have lists of sensitive and supportive clergy and support groups.
q  Ensure unhelpful coping mechanisms and relapses are dealt with and that more helpful coping mechanisms are found. q  Explore for unhelpful coping mechanisms such as self-blame, relationship avoidance, excessive spending, delusional behaviour, entertaining suicidal thoughts, putting personal safety at risk, etcq  Explore for relapse into any previous risky health behaviours e.g. unsafe sex, excessive alcohol or drug use, smoking, etc.q  Explore for relapse into previously terminated behaviours such as smoking, drugs, etc

 

Life Reconstruction or Deconstruction?

Sometimes a victim of hate crime will enter on a period of re-evaluating their entire life as it currently is. This can sometimes be a constructive process but is equally often a self-destructive and self-blaming reaction to trauma. Skilled support is necessary when this occurs, especially because relationships of all kinds can be severely damaged or terminated during this. At a lower level, any patterns of dependence (on people, possessions, faith or ideas) or addictions (smoking, illegal drugs etc) may be tackled. Sometimes people decide to lose weight or try to change their body appearance, etc. It is important to understand the context of where this is coming from and why. If it is an avoidance response to victimisation, it can block readjustment. If it is a reaction to self-blame or self-hatred, it can become highly destructive. Even if it is a genuine response to things the person feels are wrong (e.g. giving up smoking and losing weight and dealing with an unsatisfactory relationship), taking on too many things in the period after victimisation could have serious consequences for physical, mental and emotional health. Helping the person look realistically at this, encourage development of a “now, sooner, later” plan for their life and encourage getting expert help are all helpful responses to this.

 

Offering Skilled Therapeutic Support

A developing consensus in much of the research and published literature, and particularly in the British Psychological Society guidelines on working therapeutically with LGBT people makes clear that it is not enough for someone to say they are not homophobic in order to work with LGBT victims. Therapists, counsellors and crisis support people working with LGBT people who are victims need to be accepting of the social, cultural and emotional perspectives and issues of the victim. This can raise difficult issues for the worker and for the victim.

We need to consider what support is offered to someone who has been victimised. As can be seen from the goals above this will inevitably involve someone with appropriate skills and experience. It is advisable to consult an agency like PACE (www.pace.org.uk) about standards or the local psychology services. There needs, however, to be some kind of minimum standard to ensure that:

 

  1.  People who are victimised are treated supportively
  2.  Appropriate action is taken to enable the victim to adjust, heal and move on and deal with the perpetrator
  3.  The reputation of the reporting system and enforcement is not tarnished by allegations of poorly skilled staff or, even worse, homophobic or other harmful reactions

For that reason the following principles are offered as some training standards to consider:

 

FOR FIRST REPORTING AGENCIES AND PERSONNEL

 

  • Training in basic issues on homophobia etc as laid down in the training programme in the toolkit
  • Training in reporting procedures
  • Training in first-aid
  • Knowledge and awareness of procedures and sources of help and support
  • Awareness of sexual and mental health issues of victimisation
  • Refresher training annually
  • Availability of skilled supervision and personal support

 

Other Psychological Problems and Issues

There are a range of other problems which can be encountered when doing therapeutic work with the victim of hate crime, from anxiety to multiple loss, relationship issues, sexual dysfunction and family issues.

The American Psychological Association has a good LGBT resource section which provides a range of information and tools.  Equally there are some recent tools on responding to transgender victims of sexual assault which may be helpful.

I do get people asking me about conversion therapy and whether this can help. The developing consensus on this is it can do much more harm than good, and a joint British statement on this from the leading therapeutic and psychological organisations would strongly suggest this is an approach to avoid.

 

 

References

 

[1] McManus,J and Kelly,B (1994) Assessing Kinship Networks. Care Weekly, 1 December.

[2] See also Herek, G. and Gillis, J. (1999) “Psychological Sequelae of Hate Crime Victimisation among Lesbian, Gay and Bisexual Adults.” Journal of Consulting and Clinical Psychology. And McManus, J and Rivers,I (2001) Without Prejudice : A Briefing for Community Safety Partnerships. London : Nacro.

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What can a Public Health mindset bring to making communities safer?

Hertfordshire’s Police and Crime Commissioner has done something visionary.  He has set up a fund for communities to put together “innovative local schemes which aim to make our communities safer”. This fund is linked to the Police and Crime Plan for Hertfordshire, which takes an “everybody’s business” approach to reducing crime and making communities safer.

Less than an hour later I had tweets and emails asking me what evidence communities could use. Then people started asking me how they could develop and put evaluation frameworks around bids. Then partners asked – can we use the Herts Public Health Partnership Fund given to LSPs and Districts to match fund where there are clear links and overlaps? (The overwhelming view of the Public Health Board was yes.)

This set me thinking, what does Public Health have to bring to the table?  More years ago than I care to remember, I produced briefings on crime and community safety among other work I did in community safety and crime reduction. My public health training helped me find the evidence and organise it into tools which went to statutory crime and disorder reduction partnerships.

I often say one of the ways I describe Public Health  about four Ps:

  • A Perspective (or Mindset) which focuses on
  • Populations and sub-populations; which is
  • Prospective (it looks to what can be improved, prevented or avoided) and goes retrospective to understand where we are today
  • Protective – seeking to protect communities and individuals from risk to health and life

The mindset of Community Safety is very similar. Both Public Health and Community Safety work in similar ways: through communities, through skilling people up, commissioning and using interventions which have evidence of effectiveness and sometimes, when the evidence is silent, going back to good theory to build an intervention and evaluate whether it works.

The Evidence

Crime impacts on Health in a range of ways, and there is a great deal of literature on this. Things like acquisitive crime to feed drug habits, and the devastation of domestic violence and hate crime are perhaps the ones that spring readily to mind. But there are other issues too:

  1. Evidence suggests that ongoing stress from high levels of crime and high fear of crime contributes to a stress pathway that can lead to mental ill-health, poor resilience and even heart disease and stroke.
  2. Victims of crime are more prone to physical and psychological ill-health on an ongoing basis.
  3. Disabled people are typically more victimised for property crime than the general population
  4. Hate Crimes have enduring mental health consequences
  5. Victims of violence often develop adverse coping mechanisms which develop health problems
  6. Ongoing phantom pain and unexplained symptoms among people who are victims are not uncommon

By contrast, communities which have strong self-efficacy (i.e. they believe they can do what they need to) are more resilient (i.e. they can handle challenges and problems more easily and return to a good state of functioning more readily), healthier and more able to address issues of relevance to their communities like crime and disorder. They also have lower fear of crime.

Building resilient communities

So how do we build resilient communities? In essence where people share the same place and public realm we need to support communities find strengths, self-confidence, skills and solutions at individual and interpersonal level, have strong links with each other and develop a sense of affinity for those they live next to and nearby.   Where people share the same identity (sexuality, faith, nationality) finding common ground and sharing common interests are salient. This is neither new nor rocket science.

But often we lack the insight of the behavioural sciences. And it can be quite simple to harness these. We talk about community development in the UK. In the US they talk about Community Advocacy. Community Advocacy has at its hear building capacity in communities to help themselves, to do, to believe in themselves. The approach works in Community Safety as well as Health.  It is particularly effective for marginalised communities and those experiencing hate crimes and has a strong track record in the US. The role of a range of diversity groups  such as Faith Communities in Health Advocacy in the US is particularly striking, working as they do for very marginalised communities. We have much to learn from them.

Building resilient communities is something which public health and community safety could do together, because everyone benefits. Addressing specific types of crime (hate crime, domestic violence) also brings ongoing benefits to both agendas.

The Public Health Contribution

Taking just the range of issues above, Public Health has a lot to bring to the table. The prestigious John Jay College of Criminal Justice actually has a whole programme of courses on health and crime.  I am going to list just some of the things public health can bring to the table:

  1. Sharing epidemiological skills so we can understand better the distribution of crime in time and place
  2. Working together on public resilience and mental health agendas
  3. Finding and appraising evidence for effective interventions (see my next blog post)
  4. Helping NHS commissioners and providers respond early and effectively to victims of crime
  5. Training Police and others in preventing victims of hate crime becoming more traumatised
  6. Providing drug and alcohol services and pathways which cut crime and disorder and help people with problems
  7. Providing training to communities who want to implement and evaluate programmes
  8. Sharing evaluation, evidence appraisal and policy appraisal skills with people in crime reduction
  9. Ensuring services for those likely to become victims of hate crime encourage and support people to report
  10. Ensure the cycle of crime in troubled families is broken by finding effective interventions for people to thrive
  11. Find interventions which help children thrive emotionally and value themselves and others
  12. Using the public health role in licensing to the best good of communities

The new landscape of the NHS means NHS Clinical Commissioning Groups are responsible authorities for Community Safety Partnerships. This could be seen as yet another burden on new CCGs. The challenge is to find ways of integrating the CCG agendas with the community safety agenda, and picking some concrete issues and projects to start with.

My next blog post will do two things: signpost agencies to sources of good evidence in crime reduction, and signpost them to resources to help them evaluate interve