Counseling Practices to Ameliorate the Effects of Discrimination and Hate Events: Toward a Systematic Approach to Assessment and Intervention

A treatment model for the psychological sequelae of discrimination is illustrated via three treatment cases in which experiences of racism, gender and/or ethnic/religious hostility were a primary focus of intervention. The client’s level of psychological functioning, acuity of hate victimization, coping and identity re-formation strategies are addressed in this phase-oriented model of counseling. The five treatment phases are: (a) event containment and safety, (b) assessment of client-event characteristics, (c) addressing diversity in the counseling alliance, (d) acute symptom reduction, and (e) identity recovery and reformation. Counseling tasks with clients of hate victimization include the amelioration of acute post-event symptoms, re-framing of aversive outgroup attitudes, alleviating disturbance of ingroup identity, and the eradication of avoidant intergroup behaviors. It is proposed that the effective treatment of victims of chronic harassment and acute hate incidents requires the integration of behavioral, cognitive, and multicultural counseling modalities. Amelioration of the Effects of Discrimination 3 Counseling Practices to Ameliorate the Effects of Hate Events And Discrimination: Toward a Systematic Approach to Assessment and Intervention The past two decades have seen a refinement of theory concerning multicultural counseling and psychotherapy (Comas-Diaz & Jacobsen, 1991; Sue & Sue, 1991, Atkinson, Morten, & Sue, 1993; Sue, 1998). One of the more promising consequences of these efforts has been the articulation of treatment strategies which are exemplars of effective intervention with specific ethno-cultural groups and/or cultural problems (Coleman, 1995). A significant issue for practitioners serving multicultural populations concerns our ability to address our client’s experiences of hate victimization in organizational, community, and interpersonal relationships. This very serious societal problem is most frequently encountered by members of “at risk” minority outgroups; persons of color, the disabled, and gay men and lesbians. Additionally hate aggression mitigates against positive intergroup attitudes for not only victimized individuals but also their families and communities. Social problems of racism, heterosexism, gender, and ethnic bias implicitly have been a topic of concern to multicultural practitioners and theorists. Yet until very recently there has been little effort to explicitly consider this issue in terms of counseling practice. As suggested by community-based research (Carlson & Rosser-Hogan, 1994) the impact of intergroup conflict upon the targeted individual has important implications for psychological practice, particularly for psychologists in multicultural settings (Ryan & Bradford, 1993; Kim-Goh, Suh, Blake, & HileyYoung, 1995). This paper presents a five-phase intervention model, which integrates cognitivebehavioral and multicultural approaches, to treat clients who have been the victims of harassment and hate crimes. The model is based upon empirical study of hate victimization, consultation with service delivery professionals with hate crime victims, and most importantly treatment with victims Amelioration of the Effects of Discrimination 4 of hate acute aggression and chronic harassment. The contribution of the interventions to the recovery from hate victimization is considered in three treatment case studies. Legal and Behavioral Characteristics of Hate Victimization The treatment of victims of intergroup conflict requires that the practitioner consider not only the psychological but also legal implications of the critical event. In the U.S., federal and state legislation have established legal criteria for bias-motivated crimes. Hate crimes are frequently characterized by physical assault, homicide or attempted homicide, anonymous symbolic forms of harassment, and damage to property (Levin & McDevitt, 1993). The victims of hate crimes are protected under criminal and in many states civil law. To be classified as a hate crime, the offense must evidence an animus by the perpetrator for the victim’s ingroup. By contrast, forms of noncriminal hate victimization which do not result in damage to property or harm (or threat of harm ) to the person are referred to as hate incidents (Los Angeles County Human Relations Commission, 1994). Hate incidents include experiences of interpersonal denigration, occupational discrimination, and more insidious forms of bias (Cervantes, 1995). Determination of community-wide base rates of hate crimes and hate incidents is of value not only to policy makers but also professionals involved in service delivery to at-risk populations. Klonnoff and Landrine (1995) provide evidence of the frequency of gender-based hate incidents experienced by women. Ninety-nine percent of their 631 subjects reported having experienced gender-based discrimination during their lives, with 97 percent having experienced some form of gender-based discrimination during the past year. For gay men and lesbians, the incidence of verbal harassment in a 1 year period was reported as 62% and 52%, respectively; 18% of the gay men and 13% of the lesbians in this same sample reported being the victims of an anti-gay crime in the prior 5 year period (Herek, Gillis, & Cogan, 1999). In a study with 318 practicing psychologists, 52 Amelioration of the Effects of Discrimination 5 percent of the responding practitioners reported that psychotherapy treatment had addressed client experiences of intergroup race/ethnic conflict (Dunbar & Sue, 1996). These studies indicate that hate victimization occurs more frequently than do many of the recognized psycho-social stressors, such as unemployment, identified in the DSM IV (American Psychiatric Association, 1994). Sequelae of Hate Victimization Allport (1954) proposed that victims of discrimination employed an ego defense (or what might now be described as an attributional belief) which was either extrapunitive or intrapunitive. Extrapunitive attributions result in the victim blaming the social environment, while intrapunitive attributions result in victim self-recrimination and denigration. Contemporary researchers have noted that victims of chronic discrimination may experience a constellation of psychological symptoms including feelings of helplessness (Root, 1992), numbing, paranoid-like guardedness (Newhill, 1990), medical problems (Kriegrer, 1990; Shrier, 1990) dysphoria, poorly mediated affects (Wyatt, 1994), and denigration of one’s socio-cultural ingroups (Bell, 1980). In instances of recurring harassment, the victimized individual may become habituated to their victimization, resulting in dis-regulation their harm-avoidance skills. These would include failure to evaluate risk in novel situations or the use of an active coping response to defend against provocation. Root, in her work with victims of chronic racism and ethnic discrimination, has suggested that many clients evidence symptoms characteristic of posttraumatic stress disorder (1994). Other researchers of trauma have proposed a disorder independent from PTSD, which is attributable to chronic psychosocial stressors. Scott and Stradling (1992) have referred to this as the “Prolonged Duress Disorder.” Just as the severity and chronicity of hate victimization may vary, so too differences of individual vulnerability need to be considered in mental health treatment. As I have observed, the Amelioration of the Effects of Discrimination 6 client's level of psychological functioning prior to the hate incident may play a significant role in treatment outcome. Individual difference variables and prior trauma victimization may both heighten vulnerability to subsequent traumatic events (Ullman, 1994). Clinical researchers have noted that clients experiencing problems characteristic of DSM-IV Cluster B personality disorders, such as Borderline (Lonie, 1993) and Narcissistic Personality Disorder (Johnson, 1995), may be particularly prone to evidence trauma-type symptomatology in response to life stressors which are not objectively traumatic in terms of severity of threat to the individual. Furthermore, ingroup identity status may heighten awareness of and response to intergroup conflict. Highly ingroup identified clients marked by ingroup idealization may evidence greater affective disturbance secondary to aversive intergroup hostility (Bell, 1980). Coping with Hate Victimization An issue of significant importance to counseling practice is the client's ability to effectively cope with the experience of hate victimization. The coping research which examines adjustment to normative life tasks is of questionable applicability with clients who have experienced hate victimization. Rather, the individual's ability to effectively engage the perpetrating party, mediate the conflict in situ, or seek institutional redress is of significantly more importance than if the coping response is per se affective or cognitive, for example. In the study of victims of criminal assault, client employment of an active and self-efficacious coping style is related to better recovery (Sales, Baum & Shore, 1984). Additionally, there is evidence that coping with hate victimization varies by race/ethnic and gender groups. Dunbar, Liu, and Horvath (1995) have noted that active coping is more typically employed by members of empowered ingroups, while Liu and Dunbar (1994) reported that for Asian-Pacifics, greater ingroup ethnic identity was related to use of a more active coping response to hate victimization. Amelioration of the Effects of Discrimination 7 Victims of overtly hostile and injurious hate crimes (as in cases of bias-motivated physical assault) often manifest a coping response marked by avoidance of outgroup persons (Dutton, Burghardt, Perrin, Chrestman, & Halle, 1994). As Herek (1999) and his colleagues found, hate crimes against gays and lesbians significantly compromise the level of trust of the larger social environment and yields more chronic psychological impairment than do similar non-hate related forms of criminal victimization. Counseling Interventions to Ameliorate Hate Event Sequelae: A Phase-Specific Approach The effective treatment of victims of hate events incorporates a variety of counseling goals which are subsumed by two superordinate tasks. The first counseling task is the alleviation of the psychological sequelae of hate victimization. This includes reduction of trauma symptoms of intrusive ideation, physiological arousal, numbing and avoidance behavior. The second counseling task concerns the client's re-establishing an adaptive ingroup identity, the employment of culturally congruent coping behaviors, and engagement in benign intergroup contact experiences. The phases of the treatment model are described below and summarized in Table 1. Phase 1: Containment and Safety. As in other crisis intervention models (Parad, 1965; Scott & Stradling, 1992), the initial task of the practitioner concerns client determining safety and capacity for self-care. In this treatment model, practitioner tasks include assessment of client risk for self-injurious/self-defeating behavior, potential for retaliatory aggression, and impairment of basic life functioning (e.g. work dysfunction or school truancy). As my experience has indicated, it is essential that the practitioner determine with the client the risk of further threat from the identified perpetrators. This has been most pronounced in cases of workplace harassment and community-based provocation, where the perpetrating party may continue to have contact with the client. In such instances, physical removal of the client from the environment may be necessary Amelioration of the Effects of Discrimination 8 prior to proceeding with counseling treatment. One of the hallmark features of the hate event experience is its de-humanizing nature. Victims of acute hate events may manifest symptoms typically characteristic of severe psychopathology, even when the client's pre-event level of functioning was highly adaptive. Initial appraisal should therefore explore for the presence of trauma-related symptoms such as intrusive ideation, avoidance of reminders of the event, numbing and dissociation, and physiological arousal. Additionally, in culturally-crossed counseling dyads, the practitioner should discuss the client's options of being in treatment with a person of his/her own race/ethnicity, religion, sexual orientation, or gender group. As discussed below, this issue remains salient throughout the course of treatment. Phase 2: Assessment of Client-Event Characteristics. The comprehensive appraisal of the hate victim includes analysis of the critical hate incident and measurement of the client's symptomatology and defining psychological resources. Practitioner tasks include determining the frequency of hate-based events, behaviorally defining the critical hate event as experienced by the client, and determining what social support is available to assist in the remediation of acute symptoms. In their study of hate incidents Dunbar, Sue, and Liu (1994) identified five factorderived types of hate victimization. The factor dimensions were described as interpersonal harassment, exclusion from social groups and networks, co-opting of personal achievement, personal invisibility, and restriction of opportunities for personal achievement. Subsequent research identified three factors of affective response to intergroup conflict; these were: anxiety/tension, dysphoria/sadness, and anger/aggression. These affective responses were found to mediate the victim's reported efficacy in coping with the hate event (Liu, 1995). These dimensions of victimization and affect response are used in a clinician rating scale in the proposed model. Client assessment for prior trauma history, as well as determination of the chronicity of discrimination can Amelioration of the Effects of Discrimination 9 assist the practitioner in defining subsequent (phase four and five) counseling intervention goals. It is particularly important to thoroughly explore the client's prior intergroup contact experiences and to determine whether the client was either victim or witness to experiences of violence and abuse. As has been noted, prior history of abuse is prognostically meaningful in terms of less effective help-seeking behavior and recovery from traumatic events (Cascardi, O'Leary, Lawrence, & Schlee, 1995). In phase two, psychometric assessment includes use of symptom-focused measures and clinician ratings scales which specifically pertain to intergroup conflict and/or trauma history. The following case illustrations employed the MMPI, which, in a recent meta-analysis has been deemed a viable clinical measure with persons of color (Nagayama Hall, Bansal, & Lopez, 1999) than other symptom measures. As such, the selection of symptom measures needs to be considered contingent upon the socio-cultural characteristics of a given client (Sue & Okazaki, 1995). Additionally, ongoing client assessment is one of the most important tasks of the counseling psychologist (Trevino, 1996). Assessment in treatment of hate events is a particularly dynamic process, in which careful monitoring of change in symptomatology, ingroup identity, and intergroup contact is essential in appraising the efficacy of treatment. Phase 3: Addressing Diversity in the Counseling Alliance. Treatment must explicitly deal with in-the-room issues of diversity as it influences the working alliance. From my experience, the impact of the practitioner's race and ethnicity upon the therapeutic relationship is obviously important. Practitioner-oriented researchers have noted the importance of counselor competence to adequately discuss race with their clients (Brantley, 1983), and to effectively determine the impact of chronic discrimination events upon the client’s level of functioning (Shannon, 1973). Accordingly, the role of the counselor's race, sexual orientation, ethnicity, and gender are often Amelioration of the Effects of Discrimination 10 magnified in instances in which discrimination and hate-related crime are the foci of treatment. The failure of White practitioners to comprehend the experiences of discrimination of their client’s of color has been noted by Ridley (1984), resulting in the reinforcement of a worldview in which intergroup contact is suspect and ineffectual. Furthermore, as has been made clear by the work of Helms (1989), the impact of both the practitioner's ingroup (i.e. race) membership and ingroup (i.e. racial) identity influence counselor efficacy. Phase three practitioner tasks include the self-assessment of competence in terms of culturerelated information and capacity to implement interventions in a culturally salient manner (Johnson, 1987). Particularly important in this regard is the practitioner's examination of countertransference experiences in working with victims of severe hate events. As I have found in consultation with victim assistance staff, practitioner reactions of ingroup guilt, political reification of the client and his/her experience, feelings of helplessness, and heightened awareness of personal biases and prejudice are particularly relationship-damaging in working with victims of hate events. Prior research has indicated that counselors more favorably assess victimized individuals, independent of the level of the client’s psychopathology (Ofri, Solomon, & Dasberg, 1995), and that practitioners may internalize the trauma symptoms of their clients, particularly in cases of violent hate events (Comas-Diaz & Padilla, 1990; Straker & Mossa, 1994). An additional phase three practitioner task is the articulation of culturally salient themes of the client’s ingroup resilience. By this I mean the practitioner actively encourages the client to relate their personal experience of victimization to that of members of their ingroup. This strategy is threefold, in that it serves to: (1) establish a commonality of personal victimization with that of a meaningful social network, (2) draws upon lessons learned from other credible ingroup persons about how to cope with adversity, and (3) reinforce the concept of change and adaptation as being a Amelioration of the Effects of Discrimination 11 desirable means to resolve problems associated with intergroup conflict. These themes of resilience provide the client with a chance to talk aloud how other people like them have dealt with challenge and coped. They may be embedded in folk stories, art, literature, ingroup significant others, music, or culturally proscribed traditions to solve problems. Phase 4: Acute Symptom Reduction. Subsequent to safety determination, initial evaluation, and cultural analysis, the practitioner needs to systematically resolve the cognitive, affective, and behavioral sequelae of the hate incident. These counseling practices are based upon empirically validated models of treatment with crime and sexual assault victims (Foa, Riggs, &Gershuny, 1995). The cognitive model developed by Resick in the treatment of sexual assault victims hold particular value in this regard (Resick & Schnicke, 1993). These include: (1) desensitization to intrusions related to the hate incident, (2) reframing the client's self-negations about victimization, (3) skills training in anger/affect modulation, and (4) use of dialogic and dialectic techniques in vivo for perpetrator confrontation. These steps in the treatment process are sequentially inter-related throughout stage four intervention. The employment of stimulus desensitization and imaginal prolonged exposure training is recognized as an effective intervention with trauma victims (Barlow & Cerny, 1988; Fairbank & Brown, 1987), and is viewed as a treatment of choice with sexual assault victims (Davidson & Foa, 1991). Multi-modal interventions employing progressive relaxation, visual imagery, and in vivo de-sensitization are all appropriate for use with clients of hate victimization. It is critical that symptom ratings be recorded routinely by the client and counselor in order to determine intervention efficacy. In acute symptom reduction, cognitive re-framing (Meichenbaum, 1977) and contingencybased problem solving (Linehan, 1993) are employed to diminish intrusive ideational material, victim self-denigration, and generalized aversive association to members of the perpetrator's Amelioration of the Effects of Discrimination 12 ingroup. I have observed, however, that the efficacy of these cognitive techniques is significantly mediated by the client's exposure to benign intergroup contact subsequent to the critical event. Training to develop client anger management skills is often required. This provides the client with tools to manage poorly modulated affects, particularly diffused hostility (Williams & Williams, 1993). Self-monitoring activities should be linked to targeted desensitization activities to alleviate anger response (Suinn, 1977). Alternately, the practitioner should also consider the appropriateness of referral for pharmacotherapy if acute post-incident ideation remains prominent. As I have observed, when (phase one) safety needs have been established, the client often attempts to comprehend the motives of their assailant and frequently evidences a desire to express their feelings about if not towards the perpetrator. Counseling should employ what Linehan (1993) calls dialogic techniques in this regard. This may include dialectic and role playing techniques to allow the victim to safely address feelings about the perpetrator. Journal writing and art therapy (Liebmann, 1996) techniques may be employed as well. Dialectic approaches, as defined by scientist-practitioners such as Greenberg and Safran (1989) provide a safe method of articulating, confronting, asserting, and externalizing the client's feelings and beliefs. The cultural appropriateness of this treatment modality must be particularly considered. Imaginal and dialectical forms of in vivo confrontation is not meant to be a prelude to an in situ encounter with the perpetrator. The few programs, which advocate victim-perpetrator interaction, have failed to demonstrate treatment effectiveness with either victims or perpetrators (Fred Persely, personal communication, March 19, 1996). In the absence of convincing evidence to the contrary, such "restaging experiences" are best seen as counseling-damaging acts and are to be generally avoided. Phase 5: Identity Recovery and Reformation. Intervention tasks of this stage of treatment include measuring and reinforcing symptom reduction and change, reframing distorted outgroup Amelioration of the Effects of Discrimination 13 attitudes, promoting benign intergroup contact experiences, and shaping an adaptive ingroup identity. These tasks are initiated once acute symptoms are in remission. One of the more significant issues in intervention with clients who have experienced hate events concerns the impact of the critical event(s) upon the individual's ingroup identity. One such method of assessment has already been demonstrated in Helms' research concerning racial identity. This egostatus model of racial ingroup identity has direct application for assessment and counseling with hate event victims. Conceptually, hate events pose a critical challenge to the client's self-construal of their relations with outgroup persons. In my clinical experience, post-event intergroup attitudes are significantly mediated by the history of pre-event intergroup contact and the individual’s ingroup identity. Identity recovery solutions sought by the client may yield a regressive shift towards greater outgroup denigration and avoidance of intergroup contact. This would serve to avoid reexperiencing the event and to minimize the likelihood of recurrence of victimization. Concomitant to this is a striving for greater engagement with ingroup members and (depending upon other preevent factors) an idealization of ingroup values, behaviors, and beliefs. This significantly characterizes the Immersion/Emersion racial identity status as described by Helms. Conversely, clients who experience chronic insidious forms of discrimination may arrive at a very different identity solution. Under these conditions, ingroup denigration or denial is predicated upon the assumption that ingroup memberships are undesirable or ineffective in enhancing the quality of the individual's life. For these persons, an effort to minimize ingroup identity and/or awareness of between-group differences may occur. This identity solution is most characteristic of an Conformity-type racial identity status. Clinically, I have observed that, while more acute and injurious forms of intergroup conflict may result in idealized or exaggerated ingroup identity, more Amelioration of the Effects of Discrimination 14 insidious and recurring discrimination may discourage if not punish ingroup identity development. In clinical practice, these identity solutions are manifested by a marked splitting of ingroupoutgroup associations. Client attributions concerning between-group differences are fueled by affective polarization and the adoption of an outgroup-avoidant lifestyle. Treatment of ingroupoutgroup splitting constitute a critical task in client recovery. In counseling treatment with gay and lesbian clients, the pre-event status of identity development is correspondingly critical to post-event recovery. In the study of gay and lesbian identity formation, Cass (1979) and Troiden (1993) have viewed sexual orientation development as a succession of self-referenced status points, which ultimately result in a more coherent and stable identity. For Cass, gay and lesbian identity development identity includes progression through selfreference of one’s sexual orientation from sensitization, to identity confusion, to identity assumption, and finally resulting in identity commitment. For Troiden, the evolution of a gay or lesbian identity is marked by the employment of various strategies, such as denial, repair, avoidance, redefinition, and acceptance. Only this latter strategy yields a fully-integrated and healthy self-image as a gay male or lesbian. Both of these identity models share with the racial identity model of Helms (1989) recognition of the salience of intergroup contact experiences in identity formation. For clients at an Identity Diffusion stage of sexual identity (i.e. in which ingroup identity membership is ambivalent), as described by the Cass (1979) and Troiden (1993) models of gay/lesbian identity development, hate experiences may prove particularly destabilizing. A regressive identity solution for such a client would typically evidence internalized self-blame, with hate victimization being a consequence of an unhealthy lifestyle, resulting in the integration of societal stigmatization into his/her sexual identity. In contrast, for clients at a fully integrated stage of gay/lesbian identity (in the Cass model this is referred to as Identity Commitment) help seeking Amelioration of the Effects of Discrimination 15 and recovery could be expected to be significantly more efficacious. For persons with effective social supports and healthy self-regard, the discriminatory event may facilitate a more adaptive ingroup identity than had existed prior to the incident. These clients would more readily utilize mental health services and perceive an identified ingroup as a support mechanism. As such, even when the more acute symptoms of the hate event have been effectively ameliorated, further psychological intervention may be required to allow for a full recovery of selfhood and ingroup identity status as found prior to the critical event. Once more it should be stressed that the client's pre-event level of functioning plays a crucial role in treatment outcome. Case Illustrations of Assessment and Treatment Procedure and Assessment Methodology Three counseling cases are presented of clients who voluntarily initiated treatment at a private psychology group in the greater Los Angeles area. The psychology group where the clients were treated serves a heterogeneous socio-demographic client population. Some of the client demographic information was modified to preserve client confidentiality. Each client was initially seen for an individual assessment interview. Demographic information (e.g. client educational level, medical/developmental history, race/ethnicity, etc.) was recorded and DSM IV diagnoses were assigned. Counseling assessment included: (1) defining the presenting problems which precipitated treatment, (2) determination of DSM-IV diagnoses via administration of a modified version of the structured clinical interview for the DSM (First et. al., 1995) at treatment initiation, (3) reported (pre-event) intergroup contact experiences, and (4) psychometric assessment of symptoms and functional impairment. This information has been summarized in Table 2. Amelioration of the Effects of Discrimination 16