A CULTURALLY SENSITIVE APPROACH TO THE PREVENTION OF INTERPERSONAL VIOLENCE AMONG URBAN BLACK YOUTH Arthur L. Whaley, PhD, MPH New York, New York
Black-on-black interpersonal violence is a major problem for black youth living in poor urban areas. Diverse lines of research converge to suggest that interpersonal violence among inner-city black youth may result from a combination of environmental stressors, racial identity problems, and health and mental health problems. A culturally sensitive approach to the prevention of interpersonal violence among black youth is described. It is concluded that insensitivity to the significant role of racial or cultural factors in black-onblack violence contributes to the relative inattention to the problem. (J Nati Med Assoc. 1 992;84:585-588.) Key words * black-on-black violence * racial identity * cultural stereotypes Homicide is one of the leading causes of death among blacks in the United States. The Report of the Secretary's Task Force on Black and Minority Health indicated that approximately one third of the excess deaths among blacks between 1979 and 1981 is attributable to homicide.' When these mortality rates are adjusted for age and gender, it becomes clear that young adult black males are the highest risk group. Black males are six to 10 times more likely to be victims of homicide than their white counterparts."2 Black people living in low-income communities also tend to be at greatest risk. In a recent study of excess From the Psychiatric Epidemiology Training Program, Columbia University, New York, New York. Requests for reprints should be addressed to Dr Arthur L. Whaley, Psychiatric Epidemiology Training Program, Columbia University, Tower 3-20E, 100 Haven Ave, New York, NY 10032. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 7
deaths in Central Harlem, where 40% of the people live below the poverty line, homicide was the third leading cause of excess deaths.3 These statistics dramatize the fact that homicide is a health problem of epidemic proportions in low-income black communities, particularly among young males. This article describes a culturally sensitive approach to the prevention of interpersonal violence among inner-city black youth.
THE ECOLOGY OF INTERPERSONAL VIOLENCE IN THE BLACK COMMUNITY Several authors suggest that intra-racial homicide in American society reflects a general trend toward violence in our culture. Holinger examined the national trends in America from 1956 to 1975 in the rates of suicide, homicide, and accidents.4 He found a significant increase in the incidence of suicide and homicide in the second decade. Moreover, his results revealed parallel changes in the suicide rates and homicide rates over time. He concluded that there is an increase in our tendency toward self-destructiveness, which he believes is a continuum along which suicide, homicide, and accidents fall. Bell points out that there has been a general increase in violence in the larger society.2 He cites, for example, the fact that other minority groups in similar circumstances as blacks are beginning to experience higher rates of interpersonal violence in their communities. Finally, intra-racial violence is not unique to black populations. In general, intra-racial homicide is more common than inter-racial homicide for blacks and whites.5'6 Thus, the literature challenges the notion that this problem is somehow inherent or unique to black communities. Although the problem of interpersonal violence is not unique to black communities, the fact still remains that 585
PREVENTION OF VIOLENCE AMONG BLACK YOUTH
homicide is a major health problem for these communities largely because of black-on-black murders. This problem needs to be addressed by health professionals. It has not been adequately dealt with by the health-care system for several reasons. The principal reason is the common misconception that violence in the black community is only connected with crime. Thus, violence is considered mainly a legal problem rather a health problem. This view is complemented by the racial or cultural stereotype of blacks as more aggressive and violent than whites. A large body of social-psychological literature reveal the prevalence of these racial stereotypes about blacks. One consequence of this racial prejudice is the differential treatment of black and white youth. Specifically, Lewis and colleagues found that black and white youth matched for their level of psychopathology and violent behavior were sent to correctional and mental health facilities, respectively.7 In a similar vein, a recent study of responses by psychiatric staff to violent acts by white and nonwhite adolescents revealed that physical restraint was used four times more often in the cases of nonwhite youth.8 Thus, there seems to be awareness of the fact that violent behavior can signify underlying emotional or mental health problems, but such judgments seem to be overridden by cultural stereotypes in the case of black youth. A distinction is often made between primary violence and secondary violence. The primary-secondary distinction has been used in two different ways. The first way is to distinguish between violence associated with interpersonal conflict versus crime.9 The second application of this distinction refers to whether the victim is family or friend versus a stranger or acquaintance. 10 It is the first usage that will be addressed here. There is no doubt that secondary violence, ie, violence associated with criminal activity is prevalent in low-income black communities. Nevertheless, the evidence strongly suggests that interpersonal violence of a primary nature is the most common. Overwhelmingly, victims of homicide in the black community tend to be relatives or friends.2'6 It is not enough to know, however, that violence in the black community is not predominantly crime-related. The factors that give rise to interpersonal violence must be explicated as a first step to developing prevention strategies. As with any complex behavior, interpersonal violence is the product of interactions between biological, psychosocial, and environmental forces. Several studies have indicated that interpersonal violence can be linked to acquired (as opposed to genetic) biological factors 586
such as head injuries.2'7 These postconcussion syndromes place a person at higher risk for violent behavior because of diminished capacity to tolerate frustration. Treatments developed for head trauma patients would be suitable for such persons. Another factor is stressful life events. Humphrey and Palmer compared 270 criminal homicide offenders and 194 nonviolent felonious property offenders. They found that the former group experienced a significantly greater number of stressful life events. When they divided the sample of violent offenders into subgroups by degree of familiarity with the victim, they found that those whose victims were family or friends had more experiences of loss. Finally, their data revealed that violent offenders experienced more chronic stress, while nonviolent felons experienced more acute stress. The role of chronic stress in interpersonal violence, particularly homicide, has been emphasized by other researchers as well. The most common chronic stressor that has been associated with extreme interpersonal violence in the black community is poverty.9'1' The effects of poverty on the emotional stability of individuals in the black community is the important point here. Chronic poverty may engender a myriad of negative feelings such as anger, depression, and anxiety because of the constant struggle to secure resources to survive on what may be in many cases a day-to-day basis. This may be even more devastating for teenagers and young adults who are in the formative stages of independent, adult life. The inabillity of black adolescents to master the transition to early adulthood can result in a number of negative outcomes, one of which is violent behavior.12 In a longitudinal study of urban black adolescents, Brunswick and Merzel found that the transition from adolescence to early adulthood was associated with more frequent reports of health problems for black males.'3 The stresses of developmental transitions can also impact on mental health. More attention has been paid to the mental health of violence-prone black youth in recent psychological and psychiatric literature. Recent clinical and research reports support the belief that mental health problems underlie the violent behavior of many black youth.'4"5 It should be noted that low self-esteem or racial self-hate are not among the factors that have been identified. In fact, Terrell and Taylor studied the self-concept of juveniles who commit black-on-black crimes and found that self-esteem did not distinguish between those who committed crimes against (black) persons and those who committed property crimes.16 They did find, however, that those JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 7
PREVENTION OF VIOLENCE AMONG BLACK YOUTH
who committed property crimes had a stronger racial identity than those who committed crimes against persons. Contrary to the racial self-hate hypothesis, strong identification with the race was negatively associated with black-on-black crimes. These findings implicate racial identity as a potential inhibitor of violent behavior. More specifically, it may be that a strong sense of racial identity is inversely related to interpersonal violence among black youth. These diverse lines of research converge to suggest that interpersonal violence among black inner-city youth may result from a combination of environmental stressors, developmental issues, cultural identity problems, and physical and mental health problems. The core theme throughout the literature on interpersonal violence in the black community is a low frustration tolerance and limited coping resources in the face of overwhelming emotional, developmental, sociocultural, and environmental stressors. These core issues should be the focus of prevention efforts and are appropriate for interventions based on a cognitivebehavioral orientation. Cognitive-behavioral approaches are applied to a number of emotional problems resulting from stress and maladaptive coping.'7"18 The very same types of emotional difficulties may manifest themselves in violent behaviors. These interventions may need to be adapted to accommodate the issues of racial identity that play a significant role in the psychosocial functioning of black populations.
PREVENTION OF BLACK-ON-BLACK VIOLENCE AMONG URBAN YOUTH: A GROUP APPROACH The following culturally sensitive approach to prevention of interpersonal violence among inner-city black youth may be conducted either in a communitybased agency that serves substantial numbers of the target population or in a school setting. It should be delivered in a format for group activities composed of four 3-session units with each session being 11/2 to 2 hours long. The group format is important because of the need for positive peer relations and normalization of adolescent concerns. The groups should have peer coleaders who are trained and supervised by an adult program leader who is at least a master's level mental health professional. Each 3-session unit should be geared toward a specific topic. The unit titles should be presented in the form of questions, which serves several functions. First, the use of questions for unit titles allows the material to be delivered in a way that facilitates discussion. Second, JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 7
it creates a nonthreatening atmosphere by portraying the group meetings as exploratory rather than as lectures. Finally, it may communicate to participants the themes of each unit in a concise and clear fashion. These are all important considerations, particularly for inner-city black adolescents, who often feel alienated or estranged from our health and educational systems. Suggested units are described below. Unit 1, "Who Kills Black People?", is what Bell refers to as "consciousness raising."2 The goals of the three sessions in this unit are to dispel myths and stereotypes about black homicide as well as to give information on the problem in lay terms. Film presentations may be included ranging from documentary materials to popular movies related to the topic. The relation between what the media portrays and what health statistics show should be emphasized to make the participants more sensitive to cultural stereotypes and different sources of information. The goal of Unit 2, "Are Blacks More Violent Than Whites?", is to narrow the focus on racial stereotypes. Black perspectives on violence should be introduced through viewing and discussing speeches of famous black leaders such as Dr Martin Luther King, Malcolm X, and Nelson Mandela. In addition, the popular film by Spike Lee, "Do the Right Thing," may be useful for the analysis and discussion of this issue. The ultimate objective of this unit is to expand participants' perspective on violence as a means of coping with problems. They should learn the difference between violence and self-defense as well as the strength of nonviolence. The final session of this unit is devoted to issues of displaced aggression and fear of death as causes of interpersonal violence. Kastenbaum's recommendations for treatment of death-related anxiety are incorporated in this last session where appropriate.'9 A secondary goal is to enhance racial identity through exposure to role models and black history. The rhetorical question, "When Is the Time to Fight?", serves as the basis of Unit 3, whch explores the various reasons for interpersonal violence. At this point, the focus shifts to personal situations. The bulk of this unit uses cognitive-behavioral interventions to address coping skills deficits with regard to interpersonal situations. A number of cognitive distortions relating to the themes of physical appearance, sexual identity and sexuality, competency and peer status, and autonomy and control are common among adolescents.'7 One session is devoted to play-acting (a nonthreatening term for role-play), where participants act out provocative situations with alternative outcomes. Discussion fol587
PREVENTION OF VIOLENCE AMONG BLACK YOUTH
lows the various responses to the provocative situations. The title of Unit 4, "Knowing When to Chill," is an expression used by inner-city black youth meaning relaxation or positive coping. This unit is a continuation of the third unit. Stress-inoculation training is added to the skills taught.18 Coping self-statements and cognitive relaxation techniques are emphasized. These techniques should be tailored to the language and thoughts most familiar to the group. In fact, group members could be asked to generate ways to implement the techniques that are most useful to them. The final session should summarize the program and allow time for participant feedback.
IMPLEMENTATION AND EVALUATION OF THE APPROACH This culturally sensitive approach can be the basis for either a primary or secondary prevention program. The primary prevention efforts could be targeted for youth who live in communities where there is a high incidence of interpersonal violence but who themselves have not exhibited any risk of being violent. As secondary prevention, black youth identified as at-risk for violence would be the target of the intervention program. Clear behavioral criteria are necessary to establish risk to avoid the racial biases that were discussed earlier. These youth could be referred, for example, because of documented reports of getting into two or more fights in a month. They would be given individual evaluations to rule out organicity or severe psychopathology as the reason for their violent behavior. The evaluation of participants should include psychological measures that identify a tendency toward violence, emotional stability, and personal coping skills. In addition, indices of racial identity and cultural awareness should be used. The selected measures could be used as post-treatment measures as well. In addition, the number of violent incidents in the target setting (school or agency) in general and involving program participants could be compared pre- and postintervention. Finally, participants should rate the overall program anonymously.
CONCLUSIONS The problem of interpersonal violence among urban black youth is one that is quite prevalent but infrequently addressed. A major obstacle to the provision of services for this problem is the lack of awareness about the racial or cultural factors that mediate interpersonal violence among this group. This article discussed the 588
role of racial and cultural factors in black-on-black violence and presented a prevention strategy to address the problem in a culturally sensitive fashion. Literature Cited 1. Report of the Secretary's Task Force on Black and Minority Health. Executive Summary. Washington, DC: US Dept of Health and Human Services; 1985. Publication 0-487-637 (QL3). 2. Bell CC. Prevention strategies for dealing with violence among blacks. Community Ment Health J. 1987;23:217-228. 3. McCord C, Freeman HR Excess mortality in Harlem. N Engl J Med. 1990;322:173-177. 4. Holinger PC. Self-destructiveness of the young: an epidemiological study of violent deaths. Int J Soc Psychiatry.
1981;27:277-282. 5. O'Brien RM. The interracial nature of violent crimes: a reexamination. American Journal of Sociology. 1987;92:817835. 6. Humphrey JA, Palmer S. Race, sex, and criminal homicide offender-victim relationships. Joumal of Black Studies. 1 987; 1 8:45-57. 7. Lewis DO, Shanok SS, Cohen RJ, Kligfeld M, Frisone G. Race bias in the diagnosis and disposition of violent adolescents. Am J Psychiatry. 1980; 137:1211-1216. 8. Bond CF, DiCandia CG, MacKinnon JR. Responses to violence in a psychiatric setting: the role of patient's race. Personality and Social Psychology Bulletin. 1988; 1 4:448-458. 9. Tardiff K. Patterns and determinants of homicide in the United States. Hosp Community Psychiatry. 1985;36:632-639. 10. Humphrey JA, Palmer S. Stressful life events and criminal homicide. Omega-Journal of Death and Dying. 1986; 17:299-308. 11. Britt DW, Allen L. Homicides and race riots. J Community Psychol. 1988;16:119-131. 12. Baker FM. The Afro-American life cycle: success, failure, and mental health. J Natl Med Assoc. 1987;79:625-633. 13. Brunswick AF, Merzel CR. Health through three life stages: a longitudinal study of urban black adolescents. Soc Sci Med. 1988;27:1203-1214. 14. Paster V. Adapting psychotherapy for the depressed, unacculturated, acting out, black male adolescents. Psychotherapy. 1985;22:408-417. 15. Curry JF, Pelisser B, Woodford DJ, Lochman JE. Violent or assaultive youth: dimensional and categorical comparisons with mental health samples. J Am Acad Child Adolesc Psychiatry. 1988;27:226-232. 16. Terrell F, Taylor J. Self-concept of juveniles who commit black on black crimes. Corrective and Social Psychiatry and Journal of Behavior Technology Methods and Therapy. 1980;26:107-109. 17. Bedrosian RC. The application of cognitive therapy techniques with adolescents. In: Emery G, Hollon SD, Bedrosian RC, eds. New Directions in Cognitive Therapy. New York, NY: Guilford Press; 1981:68-83. 18. Meichenbaum D. Cognitive-Behavior Modification: An Integrative Approach. New York, NY: Plenum Press; 1977. 19. Kastenbaum R. Death-related anxiety. In: Michelson L, Ascher LM, eds. Anxiety and Stress Disorders. New York, NY: Guilford Press; 1987:425-441.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 7
Black-on-black interpersonal violence is a major problem for black youth living in poor urban areas. Diverse lines of research converge to suggest that interpersonal violence among inner-city black youth may result from a combination of environmental stressors, racial identity problems, and health and mental health problems. A culturally sensitive approach to the prevention of interpersonal violence among black youth is described. It is concluded that insensitivity to the significant role of racial or cultural factors in black-onblack violence contributes to the relative inattention to the problem. (J Nati Med Assoc. 1 992;84:585-588.) Key words * black-on-black violence * racial identity * cultural stereotypes Homicide is one of the leading causes of death among blacks in the United States. The Report of the Secretary's Task Force on Black and Minority Health indicated that approximately one third of the excess deaths among blacks between 1979 and 1981 is attributable to homicide.' When these mortality rates are adjusted for age and gender, it becomes clear that young adult black males are the highest risk group. Black males are six to 10 times more likely to be victims of homicide than their white counterparts."2 Black people living in low-income communities also tend to be at greatest risk. In a recent study of excess From the Psychiatric Epidemiology Training Program, Columbia University, New York, New York. Requests for reprints should be addressed to Dr Arthur L. Whaley, Psychiatric Epidemiology Training Program, Columbia University, Tower 3-20E, 100 Haven Ave, New York, NY 10032. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 7
deaths in Central Harlem, where 40% of the people live below the poverty line, homicide was the third leading cause of excess deaths.3 These statistics dramatize the fact that homicide is a health problem of epidemic proportions in low-income black communities, particularly among young males. This article describes a culturally sensitive approach to the prevention of interpersonal violence among inner-city black youth.
THE ECOLOGY OF INTERPERSONAL VIOLENCE IN THE BLACK COMMUNITY Several authors suggest that intra-racial homicide in American society reflects a general trend toward violence in our culture. Holinger examined the national trends in America from 1956 to 1975 in the rates of suicide, homicide, and accidents.4 He found a significant increase in the incidence of suicide and homicide in the second decade. Moreover, his results revealed parallel changes in the suicide rates and homicide rates over time. He concluded that there is an increase in our tendency toward self-destructiveness, which he believes is a continuum along which suicide, homicide, and accidents fall. Bell points out that there has been a general increase in violence in the larger society.2 He cites, for example, the fact that other minority groups in similar circumstances as blacks are beginning to experience higher rates of interpersonal violence in their communities. Finally, intra-racial violence is not unique to black populations. In general, intra-racial homicide is more common than inter-racial homicide for blacks and whites.5'6 Thus, the literature challenges the notion that this problem is somehow inherent or unique to black communities. Although the problem of interpersonal violence is not unique to black communities, the fact still remains that 585
PREVENTION OF VIOLENCE AMONG BLACK YOUTH
homicide is a major health problem for these communities largely because of black-on-black murders. This problem needs to be addressed by health professionals. It has not been adequately dealt with by the health-care system for several reasons. The principal reason is the common misconception that violence in the black community is only connected with crime. Thus, violence is considered mainly a legal problem rather a health problem. This view is complemented by the racial or cultural stereotype of blacks as more aggressive and violent than whites. A large body of social-psychological literature reveal the prevalence of these racial stereotypes about blacks. One consequence of this racial prejudice is the differential treatment of black and white youth. Specifically, Lewis and colleagues found that black and white youth matched for their level of psychopathology and violent behavior were sent to correctional and mental health facilities, respectively.7 In a similar vein, a recent study of responses by psychiatric staff to violent acts by white and nonwhite adolescents revealed that physical restraint was used four times more often in the cases of nonwhite youth.8 Thus, there seems to be awareness of the fact that violent behavior can signify underlying emotional or mental health problems, but such judgments seem to be overridden by cultural stereotypes in the case of black youth. A distinction is often made between primary violence and secondary violence. The primary-secondary distinction has been used in two different ways. The first way is to distinguish between violence associated with interpersonal conflict versus crime.9 The second application of this distinction refers to whether the victim is family or friend versus a stranger or acquaintance. 10 It is the first usage that will be addressed here. There is no doubt that secondary violence, ie, violence associated with criminal activity is prevalent in low-income black communities. Nevertheless, the evidence strongly suggests that interpersonal violence of a primary nature is the most common. Overwhelmingly, victims of homicide in the black community tend to be relatives or friends.2'6 It is not enough to know, however, that violence in the black community is not predominantly crime-related. The factors that give rise to interpersonal violence must be explicated as a first step to developing prevention strategies. As with any complex behavior, interpersonal violence is the product of interactions between biological, psychosocial, and environmental forces. Several studies have indicated that interpersonal violence can be linked to acquired (as opposed to genetic) biological factors 586
such as head injuries.2'7 These postconcussion syndromes place a person at higher risk for violent behavior because of diminished capacity to tolerate frustration. Treatments developed for head trauma patients would be suitable for such persons. Another factor is stressful life events. Humphrey and Palmer compared 270 criminal homicide offenders and 194 nonviolent felonious property offenders. They found that the former group experienced a significantly greater number of stressful life events. When they divided the sample of violent offenders into subgroups by degree of familiarity with the victim, they found that those whose victims were family or friends had more experiences of loss. Finally, their data revealed that violent offenders experienced more chronic stress, while nonviolent felons experienced more acute stress. The role of chronic stress in interpersonal violence, particularly homicide, has been emphasized by other researchers as well. The most common chronic stressor that has been associated with extreme interpersonal violence in the black community is poverty.9'1' The effects of poverty on the emotional stability of individuals in the black community is the important point here. Chronic poverty may engender a myriad of negative feelings such as anger, depression, and anxiety because of the constant struggle to secure resources to survive on what may be in many cases a day-to-day basis. This may be even more devastating for teenagers and young adults who are in the formative stages of independent, adult life. The inabillity of black adolescents to master the transition to early adulthood can result in a number of negative outcomes, one of which is violent behavior.12 In a longitudinal study of urban black adolescents, Brunswick and Merzel found that the transition from adolescence to early adulthood was associated with more frequent reports of health problems for black males.'3 The stresses of developmental transitions can also impact on mental health. More attention has been paid to the mental health of violence-prone black youth in recent psychological and psychiatric literature. Recent clinical and research reports support the belief that mental health problems underlie the violent behavior of many black youth.'4"5 It should be noted that low self-esteem or racial self-hate are not among the factors that have been identified. In fact, Terrell and Taylor studied the self-concept of juveniles who commit black-on-black crimes and found that self-esteem did not distinguish between those who committed crimes against (black) persons and those who committed property crimes.16 They did find, however, that those JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 7
PREVENTION OF VIOLENCE AMONG BLACK YOUTH
who committed property crimes had a stronger racial identity than those who committed crimes against persons. Contrary to the racial self-hate hypothesis, strong identification with the race was negatively associated with black-on-black crimes. These findings implicate racial identity as a potential inhibitor of violent behavior. More specifically, it may be that a strong sense of racial identity is inversely related to interpersonal violence among black youth. These diverse lines of research converge to suggest that interpersonal violence among black inner-city youth may result from a combination of environmental stressors, developmental issues, cultural identity problems, and physical and mental health problems. The core theme throughout the literature on interpersonal violence in the black community is a low frustration tolerance and limited coping resources in the face of overwhelming emotional, developmental, sociocultural, and environmental stressors. These core issues should be the focus of prevention efforts and are appropriate for interventions based on a cognitivebehavioral orientation. Cognitive-behavioral approaches are applied to a number of emotional problems resulting from stress and maladaptive coping.'7"18 The very same types of emotional difficulties may manifest themselves in violent behaviors. These interventions may need to be adapted to accommodate the issues of racial identity that play a significant role in the psychosocial functioning of black populations.
PREVENTION OF BLACK-ON-BLACK VIOLENCE AMONG URBAN YOUTH: A GROUP APPROACH The following culturally sensitive approach to prevention of interpersonal violence among inner-city black youth may be conducted either in a communitybased agency that serves substantial numbers of the target population or in a school setting. It should be delivered in a format for group activities composed of four 3-session units with each session being 11/2 to 2 hours long. The group format is important because of the need for positive peer relations and normalization of adolescent concerns. The groups should have peer coleaders who are trained and supervised by an adult program leader who is at least a master's level mental health professional. Each 3-session unit should be geared toward a specific topic. The unit titles should be presented in the form of questions, which serves several functions. First, the use of questions for unit titles allows the material to be delivered in a way that facilitates discussion. Second, JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 7
it creates a nonthreatening atmosphere by portraying the group meetings as exploratory rather than as lectures. Finally, it may communicate to participants the themes of each unit in a concise and clear fashion. These are all important considerations, particularly for inner-city black adolescents, who often feel alienated or estranged from our health and educational systems. Suggested units are described below. Unit 1, "Who Kills Black People?", is what Bell refers to as "consciousness raising."2 The goals of the three sessions in this unit are to dispel myths and stereotypes about black homicide as well as to give information on the problem in lay terms. Film presentations may be included ranging from documentary materials to popular movies related to the topic. The relation between what the media portrays and what health statistics show should be emphasized to make the participants more sensitive to cultural stereotypes and different sources of information. The goal of Unit 2, "Are Blacks More Violent Than Whites?", is to narrow the focus on racial stereotypes. Black perspectives on violence should be introduced through viewing and discussing speeches of famous black leaders such as Dr Martin Luther King, Malcolm X, and Nelson Mandela. In addition, the popular film by Spike Lee, "Do the Right Thing," may be useful for the analysis and discussion of this issue. The ultimate objective of this unit is to expand participants' perspective on violence as a means of coping with problems. They should learn the difference between violence and self-defense as well as the strength of nonviolence. The final session of this unit is devoted to issues of displaced aggression and fear of death as causes of interpersonal violence. Kastenbaum's recommendations for treatment of death-related anxiety are incorporated in this last session where appropriate.'9 A secondary goal is to enhance racial identity through exposure to role models and black history. The rhetorical question, "When Is the Time to Fight?", serves as the basis of Unit 3, whch explores the various reasons for interpersonal violence. At this point, the focus shifts to personal situations. The bulk of this unit uses cognitive-behavioral interventions to address coping skills deficits with regard to interpersonal situations. A number of cognitive distortions relating to the themes of physical appearance, sexual identity and sexuality, competency and peer status, and autonomy and control are common among adolescents.'7 One session is devoted to play-acting (a nonthreatening term for role-play), where participants act out provocative situations with alternative outcomes. Discussion fol587
PREVENTION OF VIOLENCE AMONG BLACK YOUTH
lows the various responses to the provocative situations. The title of Unit 4, "Knowing When to Chill," is an expression used by inner-city black youth meaning relaxation or positive coping. This unit is a continuation of the third unit. Stress-inoculation training is added to the skills taught.18 Coping self-statements and cognitive relaxation techniques are emphasized. These techniques should be tailored to the language and thoughts most familiar to the group. In fact, group members could be asked to generate ways to implement the techniques that are most useful to them. The final session should summarize the program and allow time for participant feedback.
IMPLEMENTATION AND EVALUATION OF THE APPROACH This culturally sensitive approach can be the basis for either a primary or secondary prevention program. The primary prevention efforts could be targeted for youth who live in communities where there is a high incidence of interpersonal violence but who themselves have not exhibited any risk of being violent. As secondary prevention, black youth identified as at-risk for violence would be the target of the intervention program. Clear behavioral criteria are necessary to establish risk to avoid the racial biases that were discussed earlier. These youth could be referred, for example, because of documented reports of getting into two or more fights in a month. They would be given individual evaluations to rule out organicity or severe psychopathology as the reason for their violent behavior. The evaluation of participants should include psychological measures that identify a tendency toward violence, emotional stability, and personal coping skills. In addition, indices of racial identity and cultural awareness should be used. The selected measures could be used as post-treatment measures as well. In addition, the number of violent incidents in the target setting (school or agency) in general and involving program participants could be compared pre- and postintervention. Finally, participants should rate the overall program anonymously.
CONCLUSIONS The problem of interpersonal violence among urban black youth is one that is quite prevalent but infrequently addressed. A major obstacle to the provision of services for this problem is the lack of awareness about the racial or cultural factors that mediate interpersonal violence among this group. This article discussed the 588
role of racial and cultural factors in black-on-black violence and presented a prevention strategy to address the problem in a culturally sensitive fashion. Literature Cited 1. Report of the Secretary's Task Force on Black and Minority Health. Executive Summary. Washington, DC: US Dept of Health and Human Services; 1985. Publication 0-487-637 (QL3). 2. Bell CC. Prevention strategies for dealing with violence among blacks. Community Ment Health J. 1987;23:217-228. 3. McCord C, Freeman HR Excess mortality in Harlem. N Engl J Med. 1990;322:173-177. 4. Holinger PC. Self-destructiveness of the young: an epidemiological study of violent deaths. Int J Soc Psychiatry.
1981;27:277-282. 5. O'Brien RM. The interracial nature of violent crimes: a reexamination. American Journal of Sociology. 1987;92:817835. 6. Humphrey JA, Palmer S. Race, sex, and criminal homicide offender-victim relationships. Joumal of Black Studies. 1 987; 1 8:45-57. 7. Lewis DO, Shanok SS, Cohen RJ, Kligfeld M, Frisone G. Race bias in the diagnosis and disposition of violent adolescents. Am J Psychiatry. 1980; 137:1211-1216. 8. Bond CF, DiCandia CG, MacKinnon JR. Responses to violence in a psychiatric setting: the role of patient's race. Personality and Social Psychology Bulletin. 1988; 1 4:448-458. 9. Tardiff K. Patterns and determinants of homicide in the United States. Hosp Community Psychiatry. 1985;36:632-639. 10. Humphrey JA, Palmer S. Stressful life events and criminal homicide. Omega-Journal of Death and Dying. 1986; 17:299-308. 11. Britt DW, Allen L. Homicides and race riots. J Community Psychol. 1988;16:119-131. 12. Baker FM. The Afro-American life cycle: success, failure, and mental health. J Natl Med Assoc. 1987;79:625-633. 13. Brunswick AF, Merzel CR. Health through three life stages: a longitudinal study of urban black adolescents. Soc Sci Med. 1988;27:1203-1214. 14. Paster V. Adapting psychotherapy for the depressed, unacculturated, acting out, black male adolescents. Psychotherapy. 1985;22:408-417. 15. Curry JF, Pelisser B, Woodford DJ, Lochman JE. Violent or assaultive youth: dimensional and categorical comparisons with mental health samples. J Am Acad Child Adolesc Psychiatry. 1988;27:226-232. 16. Terrell F, Taylor J. Self-concept of juveniles who commit black on black crimes. Corrective and Social Psychiatry and Journal of Behavior Technology Methods and Therapy. 1980;26:107-109. 17. Bedrosian RC. The application of cognitive therapy techniques with adolescents. In: Emery G, Hollon SD, Bedrosian RC, eds. New Directions in Cognitive Therapy. New York, NY: Guilford Press; 1981:68-83. 18. Meichenbaum D. Cognitive-Behavior Modification: An Integrative Approach. New York, NY: Plenum Press; 1977. 19. Kastenbaum R. Death-related anxiety. In: Michelson L, Ascher LM, eds. Anxiety and Stress Disorders. New York, NY: Guilford Press; 1987:425-441.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 7
