(p. 323) Therapy with Victims of Hate Crimes
In psychotherapy with victims of hate crimes, therapists should keep in mind the importance of the psychological, in contrast to the legal, definition of what constitutes such a crime. In the legal domain, the central question is whether harassment or assault meets the legal threshold for a hate crime (if, indeed, hate crime statutes cover a particular incident in a particular locale and apply to the identity group membership on the basis of which a person has been targeted). For purposes of assessment and therapy, the victim’s psychological reality takes precedence over legal definitions. People in social groups that are targeted for significantly negative treatment may be psychologically impacted regardless of whether the action meets the legal criteria for a hate crime.
All victims of hate crimes are members of one or more stigmatized groups. However, while all such groups are subject to prejudice and discrimination, the specific nature of maltreatment varies among groups. In their work with hate crime victims, therapists need to have a working knowledge of both a client’s group and the nature of the stigma directed against that group.
Standard Clinical Assessment
During intake evaluation and ongoing clinical assessment, the therapist should assess not only those domains germane to a standard clinical intake but also domains associated with hate crime victimization. It is important to systematically screen clients across The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) diagnostic categories and to thoroughly evaluate and diagnose current and past symptomology. This can provide important information for conceptualizing a client’s reaction to experiencing a hate crime and specify empirically supported treatment (EST) options. At minimum, the intake evaluation should include a reliable and valid measure of pathology such as the Structured Clinical Interview for DSM (SCID-I) for the evaluation of Axis I clinical disorders. The SCID-II (or similar measure) may be used to evaluate the presence of Axis II personality disorders if the evaluator deems it clinically necessary.
The unstructured clinical interview should include at minimum personal and family psychiatric history, medical history, and social and occupational functioning. Finally, ongoing evaluation throughout treatment should be used to evaluate fluctuations in symptoms and treatment efficacy. Measures commonly used to assess symptoms in this way include the Beck Depression Inventory, Hamilton Rating Scale for Depression, and Beck Anxiety Inventory. Myriad measures exist for the ongoing assessment of various other symptom domains, and these should be used where appropriate.
(p. 324) It is important for clinicians to be aware that members of marginalized populations experience more frequent (and oftentimes more psychologically impactful) traumas than the general population. Furthermore, victims of hate traumas commonly find themselves surrounded by truly threatening stimuli. Developing a working knowledge of the types of traumas most commonly experienced by members of a given client’s group will facilitate a more thorough evaluation.
The evaluation of trauma experiences and posttraumatic stress disorder (PTSD) symptoms is critical in clients presenting in the aftermath of having been targeted by a hate crime. Thoroughly documenting past, current, and ongoing sources of hate trauma, including pretrauma and posttrauma functioning, will provide an optimal basis for conceptualizing clients’ symptoms and structuring their treatment.
One of the most commonly used assessments of traumatic experiences and PTSD symptoms is the SCID-I PTSD module. Administering this module as part of the standard SCID-I assessment battery provides a straightforward framework for identifying past traumatic experiences and evaluating the type and severity of subsequent symptoms. A similar measure, the Clinician-Administered PTSD Scale (CAPS), combines a Life Events Checklist (LEC) with an in-depth clinical interview aimed at assessing the severity and impact of a client’s PTSD symptoms. The CAPS can also be used to systematically evaluate fluctuations in symptomology over the course of treatment as described earlier.
Group Membership Assessment
Given the importance of careful structuring of assessment and treatment around the unique aspects of clients’ group memberships, it is necessary to also evaluate the extent to which they identify with that group. The measures used to evaluate such membership are as diverse as the groups they intend to measure. It is important to assess the extent to which a client is integrated into the group, has social support from the group, and perhaps experiences internalized oppression due to group membership.
Given the relative dearth of research on treatments for the victims of hate crimes, little can be said about clinical practices that have been empirically supported for this population. The following recommendations represent a sampling of therapeutic strategies that have demonstrated efficacy for the treatment of related populations or symptoms.
The treatment progression outlined here is designed with a number of considerations in mind. First, clients presenting for the treatment of symptoms associated with hate crimes will vary in severity, type, and duration of symptoms. Thus, the development of a graded and progressive treatment approach provides the clinician with a framework that can be tailored to meet the needs of the client without prematurely employing strategies that may increase the likelihood of early termination. Simple psychoeducation regarding the nature of responses to traumatic experiences and activation of clients’ social support-seeking behaviors may suffice for less severe cases. However, clients who are experiencing many symptoms or symptoms of greater severity or longer duration may benefit from the addition of skills training, cognitive reframing, and/or exposure techniques.
Second, not all symptoms observed in such clients will be “pathological” in nature. Educating clients about normative and nonnormative responses to trauma and helping them engage social support in strategic ways is often adequate. Similarly, teaching them skills to effectively engage with others, regulate their own emotions, and tolerate posttrauma mood fluctuations provides knowledge and skills that can benefit virtually anyone. These modules of treatment assume only that a client lacks or should be reminded of a set of specific information and skills. The goal in the opening three modules of treatment is not to change anything about clients; it is to enable clients to be more effective in their use of knowledge and skills.
(p. 325) Psychoeducation
Psychoeducation is a key component of many ESTs. While the effectiveness of psychoeducation as a stand-alone treatment has received mixed empirical support, many ESTs provide psychoeducation as a major component of their treatment packages. Our perspective is that providing pychoeducation about a client’s symptoms and functioning can help to normalize their experience, provide a cognitive and behavioral framework for understanding their symptoms, and shed light on the multiple therapeutic alternatives available.
Although there are many forms of psychoeducation, we propose that psychoeducation for victims of hate crimes might include two specific foci. The first involves giving basic information about the impact of a hate crime. This description can be used in part to contextualize whatever symptoms the client is experiencing, a move that often reduces the client’s concerns about their significance. The second focus entails identifying the context of social stigma that makes hate crimes a reality and help clients to make sense of this stigma and its impact on clients’ lives. This discussion ideally includes information about how the client’s group membership may impart special risks and also special opportunities.
Social Support–Based Behavioral Activation
Hate crimes, by definition, are social events. Pathological trauma responses, by definition, are avoidant reactions. Taken together, these observations imply the unique functioning of avoidance subsequent to experiencing a hate crime and highlight the importance of monitoring clients’ social behaviors. Experiencing a hate crime can often lead to avoidance of the perpetrating member’s group, the victim’s own group, or even society at large. Helping clients to understand the genesis of their social deactivation, sharing resources for support within their community, and providing a systematic, safe behavioral activation plan can help clients increase their mood-enhancing experiences while helping them challenge their potentially overgeneralized avoidant strategies.
Behavioral Activation (BA), an empirically supported treatment developed for depression, is one model for structuring such an intervention. More recent efforts have also begun to explore BA’s effectiveness with PTSD populations with some success. Given that this is a highly tolerable treatment and is well matched to address the symptoms commonly experienced by survivors of hate crimes, we suggest using its targeted and graded methods of activation to help clients re-engage their environments.
Once the therapist has conducted a thorough evaluation and provided psychoeducation and social support–based behavioral activation, it is often useful to address skills deficits in a variety of domains. According to the Dialectical Behavior Therapy model, clients’ symptoms are exacerbated by skills deficits in interpersonal effectiveness, emotion regulation, distress tolerance, and mindfulness. Capitalizing on this framework, the therapist can give clients concrete skills that they can use to further enlist social support, understand and regulate their emotions, get through painful experiences without resorting to dysfunctional behaviors, and cultivate the ability to access and act from a wise mind state. These can be particularly important skills for those who have survived a hate trauma and continue to suffer from the symptoms of that experience.
Many clients will experience substantial improvement from careful assessment, psychoeducation, and skills training alone. However, for some clients, especially for those who have been multiply traumatized, intervening at the level of cognition can facilitate a more complete and enduring treatment effect.
Cognitive therapies involve identifying distorted thoughts and generating more adaptive, logical, and empirical alternatives. This approach can be particularly effective for clients who have employed overgeneralized or (p. 326) extreme cognitions after a traumatic event. Helping clients to understand the faulty nature of such distorted thoughts and aiding them in generating more realistic alternatives can provide them with the cognitive flexibility to adaptively distinguish dangerous from safe stimuli, which aids in the reduction of maladaptive avoidance behaviors.
Hate Crime–Specific Considerations
In addition to these more general considerations, there are issues related specifically to the treatment of hate crimes that warrant therapists’ attention. Taken as a group, these issues have received limited empirical support but considerable professional consensus.
It is widely recognized that establishing safety is a necessary foundation for improvement from varied forms of harassment and assault. In the case of violations rooted in the victim’s identity or group membership, however, it is very difficult to establish absolute safety because the social stigma that gave rise to or facilitated a hate crime persists as an ongoing reality. It is therefore necessary for hate crime victims to work on concrete ways to reduce the potential for further abuse while simultaneously coming to terms with the reality of being a potential target of social violence.
It is critical that clients recognize that their abuse stemmed not from their identity or group membership but from the social stigma attached to that identity. This framing allows victims to differentiate themselves as persons from the social stigma that undergirded their victimization. The framing also underscores the fact that blame for the victimization rests not with the targets or their group but with the perpetrator and the form of social stigma that influenced the perpetrator’s behavior.
Even as victims need to accurately understand where the blame lies, they also need to strategize ways to minimize the chances that they will be revictimized. The failure to consider such strategies courts the risk of the victim’s feeling entirely powerless in the face of social stigma. The particular strategies that hate crime victims might use will be influenced by whether their stigma is readily visible to or is concealable from potential perpetrators. Visible stigmas render individuals obvious to would-be perpetrators and thus unable to avoid them. Concealable stigmas, on the other hand, may allow individuals to hide from would-be perpetrators, but they also carry the dangers of the denial of one’s identity and avoidance of contact with one’s community and the benefits that frequently ensue from such contact. Therapy with hate crime victims may return reiteratively to these concerns from its earliest to its final stages.
Clients’ Sense of Group Membership
A related issue for hate crime victims is assessing and addressing the impact that the experience has had on the victims’ sense of themselves as members of particular identity groups. At the most obvious level, the danger is that clients’ identity or group membership will become associated with the negative experience of a hate crime. Factors that are important in making this assessment are the pre-crime level of identity development, positive contact with other members of the client’s ingroup identity community, and the nature of the client’s relationship with members of the outgroup.
Individuals’ pre-crime levels of identity development will be a factor in what they feel and how much exploration of their feelings makes sense. People with a strong preexisting sense of identity may have a better foundation for working with such feelings. For victims who have not devoted much prior cognitive and affective attention to being a member of a stigmatized group, these explorations may require slower going and more time.
Feelings About Perpetrators/ Perpetrator Group
Clients who have been the victims of crimes often have strong ideas and feelings about their (p. 327) perpetrators. Such attitudes can be expected to be magnified when the victimization was rooted in the client’s identity/group membership. Not only do victims need to work with their feelings about the individual perpetrator, they often need to consider their thoughts and feelings about the perpetrator as a de facto representative of a group of people who usually hold more social power and prestige than do members of the victims’ own groups.
It is not unusual for clients to contend with fear and with resentment and anger about perpetrators and “their” groups. The therapy needs to allow room for the expression of such emotions as well as for the exploration of maladaptive behaviors in relation to the perpetrator’s group(s). Therapists need to make room for and legitimize these feelings and behaviors even as they help clients to move beyond a position that keeps them immersed in these feelings. Very intense and ongoing affective ties to perpetrators reduce not only clients’ comfort level but also their own experiences of themselves as separate agents of their own lives.
The framing of hate crimes as rooted in social stigma allows clients to recognize the essential unfairness of their victimization while moving beyond the intense affective ties to individual perpetrators and their groups. Exploring with clients their own ability to trust themselves, both as individuals and as members of a stigmatized group, serves as an important antidote to the sense of powerlessness and anger that are frequently aspects of their reactions.
Group Differences in the Therapy Relationship
When working with victims of hate crimes, it is often important to frankly acknowledge differences in group membership between the client and therapist. Therapists must be simultaneously willing to be educated by clients about their experiences and to take responsibility for learning about clients’ groups. Therapists who are not members of the clients’ targeted group may bear the brunt of the anger and fear that clients feel toward the perpetrator. In such cases, therapists can use clients’ expressions of anger and fear to help clients to make sense of and work through these feelings.
Involvement in the Legal System
In some cases, clients will have made the decision to report a hate crime to the police. In other cases, clients may call on the therapist to help them to think through decisions around reporting. Familiarity with local police climate and practices will be helpful in this process. In general, clients want to make decisions that increase their sense of their own agency and behavioral options. Clients should consider that involvement with legal systems may be frustrating and postpone their healing as well as contribute to a sense of efficacy in the face of a violation.
References and Readings
Barlow, D. H. (2008). Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed.). New York: Guilford Press.Find this resource:
Bradlet, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214–227.Find this resource:
Dunbar, E. (2001). Counseling practices to ameliorate the effects of discrimination and hate events: Toward a systematic approach to assessment and intervention. Counseling Psychologist, 29, 281–310.Find this resource:
Garnets, L., Herek, G. M., & Levy, B. (1990). Violence and victimization of lesbians and gay men: Mental health consequences. Journal of Interpersonal Violence, 5, 366–383.Find this resource:
Kaysen, D., Lostutter, T. W., & Goines, M. A. (2005). Cognitive processing therapy for acute stress disorder resulting from an anti-gay assault. Cognitive and Behavioral Practice, 12, 278–289.Find this resource: