The room was stuffy and hot, the scent of stale snack foods hung in the air and the boys in the anger management group in this locked facility were distracted. As a young clinician and group facilitator, I was frustrated.
We had been reviewing the steps of the “anger cycle” for weeks and no one seemed to be retaining the information. With an exasperated sigh, I tried to remind them that this material was designed to prevent the situations that got them locked up, and thus stuck here with me.
Before I could start back on the first step of the cycle, a boy who I will call Jay dismissively rattled off all eight steps as well as the positive coping skills taught to avoid violence. I was stunned. Jay was a frequent flyer to this detention facility. Of the many groups I’d had with him, he was never an active participant.
I asked Jay why, if he knew the material so well, he had never used them to avoid incarceration. He replied, “This stuff would never work in the neighborhood where I’m from; you try this, you’re gonna get punked.”
Jay, like many of the other boys in that facility, got into trouble due to the “code of the street.” This code dictates that any sign of disrespect must be aggressively avenged with retaliation.
After several conversations with Jay about why the skills we were teaching were not helpful, I began to question the effectiveness of teaching these kids skills that are irrelevant to the situations they encounter in their neighborhoods. This frustration would mount as I started to notice retaliatory violence glorified and celebrated in popular culture.
For example, in hockey there are “enforcers” on each team, prepared to defend the honor of a smaller, more vulnerable teammate. Similarly, in baseball, if a batter “shows a pitcher up” by staring at a home run ball for too long before running the bases, that batter is likely to be intentionally hit by the pitcher the next inning.
Indeed, the ubiquity of these messages explicitly endorsing “justified” violence make it very difficult for a clinician to teach a maxim such as “be the bigger person and walk away from a fight.” This is clearly not the message that popular culture is giving to young people.
Sadly, today the “code of the street” is not taken into account when arresting, sentencing and treating these adolescents. According to the Office of Juvenile Justice and Delinquency Prevention, in 2013 there were 1.1 million juvenile delinquency cases. Approximately 186,000 of these cases were for charges of simple assault. Most of these youth come from lower-income minority families.
Jay, like many young men charged with simple assault, was referred for anger management treatment. The group I facilitated centered on learning anger management and conflict resolution skills.
The assumption that all violence stems from the same emotions and thoughts has led many clinicians to apply this one intervention across the board. While anger management curricula can be quite effective for adolescent struggling with mood swings, impulsivity or difficulty with affect regulation, they often do not take into account the social pressures of maintaining a reputation.
Time and again I watched the students in my groups fail to utilize the strategies they were taught as they cycled in and out of lock-up. When they were faced with ongoing and real threats to their reputation, fighting back was not just a question of managing anger. To these boys, “anger management” can be another example of how the rest of the world doesn’t understand their dilemma.
Needless to say, clinicians like myself who facilitate these groups often struggle with burnout, and both parties can feel like failures perpetually frustrated with the other.
As with any form of effective treatment, the messages clinicians deliver have to be relevant to the lived experience of our patients. These youth are in a terrible bind: Fight or be shamed. If we, as clinicians in the juvenile justice system, fail to recognize this predicament, our interventions will be ineffective and our patients will feel unheard.
It is frustrating to be told you have “anger issues” when in fact you are following the example of those around you, including athletes and celebrities. With the current national attention on violence prevention, it is a glaring omission that we do not systematically train clinicians about the culture of violence in which so many youth are forced to live.
The principle of using evidence-based practices has forced health care to empirically support its methodology. We need to take this one step further. Treatments and models of care must be contextually relevant.
In order to decrease crime and violence in this country, clinicians must acknowledge and understand the code of the street. The work we have done through the Cambridge Safety Net Collaborative on the Fight Navigator curriculum integrates the lived experiences of youth into a violence prevention program.
The curriculum was developed through focus groups with mostly urban youth of color. They described strategies that work to respond to a threat in a manner that avoids violence and allows them to maintain a reputation.
In the same way that we know that talking about abstinence alone is not an effective way to prevent teen pregnancy, assuming that young people from dangerous neighborhoods can always “just walk away” will not reduce violence.
Cure Violence is a program that has also demonstrated success in reducing violence, by focusing on interrupting the transmission of violence with a public health approach. If we can intensify our efforts to provide tactics for effective de-escalation in this demographic, we could potentially keep a number of young people from entering the juvenile justice system.
Dr. James Barrett is the director of school-based programs at the Cambridge Health Alliance and an instructor in psychiatry at Harvard Medical School. He also serves as the clinical coordinator of the Cambridge Safety Net Collaborative with the Cambridge Police and is the author of the Fight Navigator violence prevention curriculum.
Dr. Elizabeth Janopaul-Naylor is a third-year psychiatry resident at Cambridge Health Alliance, affiliated with Harvard Medical School. She completed her undergraduate studies and medical school training at Brown University.