Proceedings of a Workshop

Managing, Reducing, and Preventing Fear of Violence

Proceedings of a Workshop—in Brief

The National Academies of Sciences, Engineering, and Medicine’s Forum on Global Violence Prevention¹ convened a virtual workshop on July 21–23, 2020,² to discuss the biological impacts, cultural influences, prevalent causes, and intervention strategies related to fear of violence. Keynote speaker Laura Rogers, acting director, Office on Violence Against Women (OVW), U.S. Department of Justice, explained how those who are being abusive use fear to control, manipulate, and silence their victims. Victims who fear retaliation, blame, or skepticism or the loss of livelihood or their children, may conceal the abuse; in other cases, fear motivates victims to seek help, and the extent of their fear may determine whether legal action is taken against the perpetrators. Fear is also correlated with the severity of posttraumatic stress disorder (PTSD); domestic violence trauma endures for victims and witnesses and can be passed down through generations. A better understanding of and reaction to fear, she continued, can enhance survival and make the world a safer place. The OVW programs authorized by the Violence Against Women Act (VAWA) support more than 400,000 victims each year with more than 200,000 protection orders, 1 million hotline calls, and 2 million housing bed nights. The VAWA fills resource gaps at state and local levels and supports coordination among police, prosecutors, advocates, and health providers to serve victims and to hold those who have perpetrated accountable.

THE BIOLOGICAL EFFECTS OF FEAR AND FEAR OF VIOLENCE

Rachel Yehuda, director, Traumatic Stress Studies Division, Icahn School of Medicine at Mount Sinai, remarked that when activated by fear, the sympathetic nervous system releases adrenaline (increasing heart rate and blood pressure) and cortisol (containing the response). Adrenaline and cortisol contribute to the formation of a memory of the trauma. While these short-term effects are somewhat universal, long-term effects, such as PTSD, vary. People suffering from PTSD relive the trauma in memories and nightmares and experience mood, cognition, and physiological changes. Epigenetics (the study of how the environment produces alterations on genes that change the way the genes function) allows for a deeper understanding of the long-term effects of trauma. The evidence for epigenetic alterations in PTSD is demonstrated by looking at the glucocorticoid receptors. In a study of combat veterans with PTSD, Yehuda found a lower methylation of the glucocorticoid receptor, which explained why the glucocorticoid receptor itself was more sensitive to the effects of cortisol and stress. This enhanced sensitivity of the glucocorticoid receptor is what causes people with PTSD to be triggered quickly by certain everyday events. Because glucocorticoids are responsible for many of the body’s functions, Yehuda said that a change in stress system functioning after trauma will affect several systems over

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time, such as the cardiovascular, reproductive, and immune systems. This biologic evidence helps pinpoint individual risk factors and improved treatments.

Joseph LeDoux, university professor and the Henry and Lucy Moses Professor of Science, New York University (NYU), and director, Emotional Brain Institute at NYU and Nathan S. Kline Institute for Psychiatric Research, described the common view of fear as an innate response; however, he asserted that the amygdala is an “unconscious threat detector” and fear is the “cognitive interpretation” of danger. Because drugs developed in animal studies are not designed to target the cognitive interpretation circuit, they may have limited effects for people. Successful therapeutic approaches address the objective responses (behavior and physiology) and the subjective states (fear and anxiety). Threats can be viewed as stimuli that elicit symptoms associated with different brain systems: the amygdala controls behavioral symptoms, striatal circuits control adaptive and pathological avoidance behaviors, temporal lobe circuits control memories (the basis of beliefs and expectations), and the prefrontal cortex integrates all into subjective experiences. He noted that targeting one symptom is insufficient; the whole organism has to be treated to tackle fear and anxiety.

Martin Teicher, director, Developmental Biopsychiatry Research Program, McLean Hospital, and associate professor of psychiatry, Harvard Medical School, measured the severity of exposure to 10 types of maltreatment across ages. Teicher noted that the most important predictor was peer emotional abuse at age 15: the greater the exposure, the more hyperactive the amygdala. Exposure to early physical maltreatment, however, revealed a blunting of amygdala response. Prepubertal children cannot control experiences through fight-or-flight reactions, and they might depend on a reduced amygdala response for survival. Adolescents, on the other hand, can use fight-or-flight reactions to reduce their exposure to abuse—in this case, a strong amygdala response may be adaptive. In less hostile situations, a hyperactive amygdala response can be disadvantageous, as individuals may misinterpret neutral expressions as threatening and develop anxiety, depression, or PTSD, and this may lead to unstable relationships. Those with a hypoactive amygdala response might not respond adequately to threats, repeat the same mistakes, and develop substance use disorders. Although some individuals appear to be symptom free after trauma exposure, their brains have alterations and stress-susceptible structures; however, Teicher explained that they have an additional set of alterations enabling effective compensation. Mindfulness lessens some of the symptoms in individuals with mild to moderate histories of childhood maltreatment, which correlates with changes in amygdala volume. He noted that, in the case of young adults, mindfulness was more helpful if it occurred closer to the time of trauma. A certain level of cognitive development and awareness in prefrontal development is needed to use mindfulness effectively.

Corinne Peek-Asa, professor of occupational and environmental health; director, University of Iowa Injury Prevention Research Center; and director, International Collaborative Trauma and Injury Training Program, Central Europe, inquired about the timing of biopsychological effects. LeDoux noted that immediate autonomic nervous system responses allow one to cope, but as the stress of a situation increases, the responses become toxic. Yehuda commented that how one thinks about an event is key to whether it elicits fear; the relationship between the severity of a trauma and the response is not linear. Although violence and maltreatment can have long-lasting effects, an opportunity exists to create “healing societies” that teach people how to think about adversity and build resilience. LeDoux pointed out that although the conceptualization of situations is part of the problem, it can also be part of the solution (e.g., mindfulness). Teicher added that although some effects of childhood maltreatment are instantaneous, other adverse symptoms are delayed by several years. During that time, it is possible to avert some future consequences such as depression and substance abuse.

PERCEPTION, CULTURE, AND PSYCHOLOGY IN RELATION TO FEAR OF VIOLENCE

Park Dietz, president, Park Dietz & Associates, and Threat Assessment Group, Inc., posited that many types of perceived threats are processed similarly in neuropathways. Positive reinforcement for overreactions could explain the variance in fear of violence. Many people are vulnerable to fear by what they experience only vicariously, regardless of how low the risk. This inability to gauge risk is perpetuated and exploited by the media, he continued. Reporting bias creates a distorted sense of reality in which rare risks (e.g., serial killer homicide or mass murder) feel pervasive and more common risks (e.g., domestic violence homicide and gang-related homicide) are minimized. Dietz advised that parents control their children’s screen time and content as well as teach them how to resist efforts to instill a sense of victimization and danger where none exists and that adults remain cognizant of the selection biases that determine what information their children receive.

Polly Wiessner, distinguished professor, Department of Anthropology, The University of Utah, defined culture as a “shared system of beliefs, norms, values, and practices that form an inherited lens for perceiving the world and learning how to behave.” She noted that modern technology increases the speed of change, integrating new ideas

into old belief systems. According to Wiessner, among the Enga in Papua New Guinea, culturally framed, real threats include payback murders, tribal fighting, illness and AIDS, crime, failure in education, economic concerns, accidents, and domestic violence. Culturally constructed fears include hell, ghosts, menstrual pollution, supernatural punishment, Facebook addiction, and witchcraft. Witchcraft is blamed for a person’s supposed misfortune (e.g., an illness that results from lifestyle choices), accusations of which result in fatal violence. The fear of witchcraft has been heightened by the Internet in this time of rapid change, where it can be difficult to separate fact from fiction. For example, Wiessner explained that a Google search for “witchcraft” might lead to a story about the Salem witch trials. Those in Papua New Guinea confronting this information without context may assume that “witches” exist and that they are tortured in America, thus justifying the killing of “witches” in their own community. Facebook posts and text messages further spread and escalate accusations of and actual violence toward “witches.” Although West African law enforcement and nongovernmental organizations have strengthened laws against those who kill “witches,” perpetrators are undeterred because they are convinced that they are protecting their community. Although it is challenging to combat these deep-seated spiritual beliefs, cultural education programs in schools, nonprofits, and churches that emphasize medicine and science aim to sever this link between culturally constructed fears and violence. Wiessner prompted the audience to consider whether those in the United States were immune to culturally generated fears, highlighting examples such as QAnon, fear of vaccinations, the 5G coronavirus conspiracy theory, and Islamophobia following the 9/11 attacks.

Jennifer Mascia, writer for The Trace, said that, according to a 2016 Harvard University and Northeastern University survey, an estimated 265 million guns are in U.S. civilian hands. Two-thirds of respondents claimed self-defense as the primary reason for gun ownership; yet, civilian defensive gun use is statistically rare. In 1994, 73 million fewer guns were reported to be owned, mostly for hunting or recreation. Between 1994 and 2016, violent crime decreased nationwide, and the gun lobby campaigned to lift restrictions against firearms in public and fueled fears of government gun seizure. According to the survey, with more guns in circulation, shootings increased, and the industry marketed handguns for self-defense, further inciting fear. She mentioned that approximately 8 million people own an average of 17 guns each, and few receive training. Gun owners are disproportionately older, Republican, male, white, rural, and afraid of “violent criminal thugs.” This racial conditioning of fear has real-world consequences, she continued, as a 2015 University of Illinois survey revealed that target shooters were more likely to shoot targets depicting black people than those depicting white people. Mascia explained that The Trace works not only to identify these problems but also to provide solutions that can be attained with readily available resources. Balanced reporting is crucial so that readers are left with a concern that leads to a sense of understanding and a sense of purpose, instead of to anger about and fear of violence.

Helen A. Neville, professor of educational psychology and African American studies, University of Illinois at Urbana-Champaign, explained that psychologists define color-blindness as “a perspective in which people ignore interracial divisions and attempt to understand or view people as individuals.” This perspective suggests fair-mindedness and a commitment to egalitarian principles. However, she asserted that color-blindness does not reduce racial prejudice or disparities—in a world of racial inequity and inequality, race and color matter. Color-blindness has also been studied in terms of power evasion, a dominant ideology to deny, minimize, and distort the existence of institutional racism. She stressed that this distortion of institutional racism is part of a larger cultural norm. When people say that racism does not exist, that simply provides a framework to further justify existing inequalities. She described the research of Lisa Spanierman, Arizona State University, which indicates that white people have an irrational fear of people of color, emerging from a lack of knowledge about race. This “white fear” has consequences: unarmed black men are 2.5 times more likely to be killed than white men. To reduce white fear, Neville suggested providing educational experiences to reduce color-blind racial ideology and increase racial awareness; creating opportunities for meaningful, sustained, egalitarian cross-racial friendships; and evaluating the effectiveness of interventions over time.

Moderator Jacquelyn Campbell, professor and the Anna D. Wolf Chair, Johns Hopkins University School of Nursing, asked how to reduce the power of media messages. Dietz encouraged viewers to look at contrasting points of view but to recognize that each exhibits bias. He advised media outlets against triggering emotions with bodies, sirens, lights, and blood. Campbell asked how to address violence when science is rejected. Wiessner explained that this can be difficult because science and religion are different domains—science deals with fact, and religion deals with morals, values, and traditions—and science can be rejected in favor of beliefs. As a starting point, she advocated for the blending of traditional beliefs with science to avoid polarizing people. Neville explained that when people are presented with information that contradicts their beliefs, they often have strong affective responses that prevent them from taking in new information and this motivates them to believe even more strongly in their assumptions. According to Wiessner, people’s ethnocultural empathy has to be increased so that they can process new information and decrease their defensiveness. Wiessner added that if it is impossible to eliminate culturally constructed narratives of fear, they have to be detached from violence. Mascia said that when facts and context replace fear-based messaging, the risk of violence can be accurately assessed.

Keynote speaker Christine Moutier, chief medical officer, American Foundation for Suicide Prevention, revealed that, according to a recent Harris poll, the vast majority of Americans view physical and mental health as equally important, and 94 percent believe that suicide is at least sometimes preventable.³ However, according to Moutier, although 25 percent of Americans have had a mental health condition in their lifetime, less than 50 percent of those receive treatment. Furthermore, there has been a 35 percent increase in the U.S. suicide rate from 1999 to 2018.⁴ Suicide is a health issue that arises from the union of biological, psychological, and social and environmental risk factors that intersect with ongoing life stressors, traumas, and events and that is enabled by lethal means. While some risk factors for suicide and violence overlap, Moutier and her colleagues do not conceptualize suicide as an act of violence, and the majority of suicide decedents have no history of violence toward others. Protective factors that could prevent suicide include social support, connectedness, mental health care, self-efficacy, problem-solving skills, cultural/religious beliefs, family modeling, coping skills, limited access to lethal means, and biological/psychological resilience. She emphasized that addressing violence and fear, preventing trauma, and treating anxiety can reduce suicide rates.

PREVALENT CAUSES OF FEAR OF VIOLENCE

This session of the workshop focused on prevalent causes of fear of violence, including abuse of children, elders, and the disabled; racism and xenophobia (e.g., fear of police and fear of interpersonal conflict from bigotry); fear of intrusion (e.g., active shooters and break-ins); and fear of sex/gender-based discrimination, including intimate partner violence (IPV).

Sheldon Greenberg, professor of management, School of Education, Division of Public Safety Leadership, Johns Hopkins University, explained that it has been difficult to affect change in the police force, as it is one of the most fragmented fields in the nation. Fear of violence may arise from living in a high-crime environment, prior victimization, physical or emotional isolation, observation of disruptive behavior, lack of trust in leaders, and failed safety programs. He described an opportunity for police to understand the “contagion” of fear from a public health perspective: fear causes sustained suffering, spreads quickly, and, in new strains, cannot be fixed by only treating symptoms, cannot be fixed with rhetoric, can be short term or persistent, can be addressed with an epidemiological approach, and requires reasonable precautions or a remedy. He suggested increasing cross-sector research; providing concrete steps to reduce fear; managing individual and community fear among frontline workers; better training for public health providers and law enforcement to address symptoms and causes and to avoid using language that embeds fear; and challenging industries and governments to stop both exacerbating fear to gain support and using fear to increase profits, oppress, or control.

Campbell defined IPV as repeated physical, psychological, and/or sexual violence. According to the Centers for Disease Control and Prevention (CDC), 3–4 million women experience severe physical violence by an intimate partner each year in the United States; more than 1 million are choked or suffocated.⁵ Nonfatal strangulation triggers fear of homicide. The Danger Assessment,⁶ originally developed by Campbell in 1986 as a two-part risk assessment tool for IPV, determines the likelihood of a homicide in a relationship and helps women to assess their level of danger and develop a safety plan. Several studies revealed that IPV victims have high rates of PTSD; however, they are often not diagnosed accurately because they may have had multiple traumas, depression, and, for women of color, macroaggressions from racism. Campbell pointed out that many victims are resolved not to be afraid as a way to demonstrate strength and resilience. These women often perceive a partner as temporarily violent as opposed to someone to be feared. Those who use violence against a partner have typically experienced violence themselves or have irrational beliefs, depression, alcohol use, traumatic brain injury, power conflicts, trust issues, and low self-esteem. She concluded that rethinking IPV through the lens of fear presents new opportunities for research and intervention design.

Desmond Runyan, the Jack and Vicki Thompson Professor of Pediatrics, University of Colorado, said that there are more than 7 million reports of child abuse, 600,000 substantiated victims, and 47,000 confirmed child sexual abuse victims each year in the United States. The National Survey of Children’s Exposure to Violence reported that ~8.4 percent of children are physically abused in their lifetime. According to data collected from 2008, 2011, and 2014 by the Juvenile Victimization Questionnaire, 34 percent of those who had not been injured, and 57 percent of those who had, reported being afraid in the future. He studied the impact on anxiety and depression from exposures to violence in a sample of 1,254 children over 20 years and he found no relationship between neglect at age 6 and depression and

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anxiety. According to the data, exposure to IPV was suggested to be scarier for children than experiencing sexual or physical abuse and psychological maltreatment was twice as likely to explain depression at age 12 compared to sexual or physical abuse. Sexual abuse was more potent than child abuse or witnessing IPV for explaining depression and anxiety at age 18. Runyan expressed hope for increased attention toward fear of violence among children.

Jeff Allison, former special adviser to the School and Campus Public Safety, Federal Bureau of Investigation, and chairperson of the Office of Community Oriented Policing Services’ School Safety Working Group, U.S. Department of Justice, explained that the national Averted School Violence database collects and disseminates case studies that law enforcement can use to understand and prevent targeted school violence. It contains 240 cases—170 averted and 70 completed attacks. When comparing averted and completed attacks, he continued, there is no significant difference between perpetrators and potential perpetrators. The case studies revealed the value of “see something, say something”; a positive school climate; trusted adults in the school; anonymous reporting systems; school resource officers (who had significant involvement in 40 of the 170 averted cases); education in self-harm and targeted school violence indicators; recognition of a connection between domestic violence and mass casualty school shootings; and knowledge that an attack may occur within 13 weeks after a mass casualty act (contagion effect) of targeted school violence, that threats are not always from current students, and that targeted school violence sometimes occurs following breaks in attendance. He commented that fear motivates schools to employ a variety of safety measures, and fear can motivate students to report concerning behavior. However, well-intentioned school safety measures can have the unintended consequence of making students more fearful.

Mark Lachs, director of geriatrics, NewYork-Presbyterian Health System, and co-chief, Division of Geriatric Medicine and Gerontology, Weill Cornell Medicine, explained that dementia, depression, and delirium are the most often discussed geriatric mental health conditions. He advocated that fear and anxiety be added to geriatric mental health education because medications for anxiety and fear have a higher potential for sideveffects in older adults; nonpharmacologic treatments used successfully in young people have been less well explored for older people; and fear, anxiety, crime, and victimization cause suffering and can initiate the geriatric cascade, which is a “dwindling physiologic reserve that can be unmasked by medical, emotional, or environmental perturbations.” Older adults have fears related to falling, an inability to drive, loss of independence, loss of control, nursing home placement, infantilization, social isolation, and death. Approximately 25 percent of adults over the age of 65 fall at least once per year, which leads to injury, restricted activities, deconditioned muscles, and likely another fall. Lachs stressed the need to intervene early and aggressively in such situations and to understand the role of ageism in upending the safety, perceived safety, and dignity of older adults.

Moderator James Mercy, director, Division of Violence Prevention, National Center for Injury Prevention and Control, CDC, questioned how to weigh the fear induced by active shooter drills against the cost of violence in schools. Allison said that Congress might appropriate $1 million to study the impacts of these drills on students; the most damage has occurred from drills that use projectiles or that are unannounced. Emmy Betz, associate professor, University of Colorado School of Medicine; director, Firearm Injury Prevention Initiative; and research physician, Eastern Colorado Geriatric Research, Education, and Clinical Center–Veterans Health, asked about police fears amid the backdrop of structural racism. Greenberg thought that officers tend not to take advantage of early intervention programs because they fear their concerns could jeopardize their jobs. He noted that officer “orientations” on implicit bias need to be replaced by training that will motivate behavioral and cultural change. He also noted that there is a serious issue surrounding how the police interact with people with disabilities; for example, students with disabilities are 2.4 times more likely to be arrested than students who do not have disabilities. Allison mentioned that police academies often inculcate fear in the name of officer safety and that officers are taught to take control of situations. Officers are now being taught de-escalation, integrative communication assessment, and tactical repositioning techniques. Greenberg said that over-response to scenes and lingering, especially in impoverished communities, has become a bad habit in police work. Allison added that some research suggests that a supervisor on scene can decrease the use of force. Betz wondered about the impacts of coronavirus disease 2019 (COVID-19) on abuse. Runyan thought that the rate of abuse could vary depending on the observers in the home. Lachs hypothesized increased rates of both underreporting and abuse and advised studying how COVID-19 has affected the efficacy of interventions.

INDIVIDUAL AND INTERPERSONAL INTERVENTIONS FOR FEAR OF VIOLENCE

Sean Joe, the Benjamin E. Youngdahl Professor of Social Development, Brown School of Social Work, Washington University in St. Louis; director, Race and Opportunity Lab; and principal director, HomeGrown StL, discussed interpersonal violence, self-directed violence, and dehumanization. Although there are many levels of successful intervention—individual, family, ecological, psychological, community, school, and policy—the next step might be to achieve

population-level outcomes that can be sustained over time. According to Joe, society has focused on ensuring public safety from young black men, but interventions are needed to increase the safety of men of color. He said that successful population-level interventions for reducing fear and interpersonal violence have to confront dehumanization and white superiority, which is apparent in police training and cultural practices. He suggested better understanding personal safety fears, increasing intergroup dialogue, and investing equitably in human capital development to address the role of racism and examine how interventions can reduce violence.

Gary Cordner, academic director, Baltimore Police Department Police Academy–Education and Training Section, described early studies that found that fear of crime and crime were not highly correlated, and that victimization and fear were often misaligned. He discussed Baltimore County police efforts in the 1980s to reduce fear of crime, which eventually led to the development of a problem-oriented approach similar to the Scanning, Analysis, Response, and Assessment model for police problem solving. Compared to community policing, this type of targeted strategy has been found to have larger effects on reducing fear of crime. Even though fear of crime is a perception, people make real decisions based on that perception, which can impact neighborhood vitality and commercial activities. He said that public policy should aim to calibrate people’s fear of crime to their actual risks. For example, the Seattle Police Department conducts a survey every 1–2 years that measures community concerns, including fear of crime. These data allow officers to attempt to reduce high levels of fear in safe neighborhoods and increase vigilance in less safe neighborhoods. This survey reveals trends that can be used to signal where targeted efforts may be needed. Collecting data from residents is affordable with online and text-based systems and feasible with police departments’ analytical capabilities. He advocated that fear of crime be specifically targeted as well as included as a metric to assess the effectiveness of police departments.

Fabio Idrobo, research associate, Population Health Division, Fundación Santa Fe de Bogotá, and adjunct assistant professor, Boston University, stated that there are 9.2 million registered victims of the Colombian conflict. Community members aware of past atrocities are fearful of being threatened or persecuted; those who do not accept the local militias’ norms can be retaliated against; mothers fear forced conscription of their children, and men fear not being able to provide for their families; and all fear gender, family, and drug-trafficking violence and being caught in crossfire. Aid workers fear “walk-in observers” from paramilitary groups, those who demand payment for protection, and neighborhoods that are inaccessible, owing to armed confrontations. He works with the Schools of Forgiveness and Reconciliation to change this narrative of fear, anger, and isolation among youth and adults. A safe space is created for them to express their fears and regain dignity. Idrobo said that fears will decrease when peace returns: the government could guarantee that the conflict will not be repeated, provide children with quality education and youth with job opportunities; and support groups that aid female victims.

Serving as moderator, Greenberg asked how law enforcement and health care providers can minimize humiliation in discussions with youth as a way to avoid triggering violence. Cordner responded that his police academy is teaching empathy to help reduce culture clashes. Joe said that more science is needed to understand dehumanization to be able to better train police. He added that unless police misconduct is dealt with severely and consistently, fear of police interactions will not decrease. Greenberg wondered how to reduce fear of violence that has been perpetuated over many generations. Idrobo replied that increased self-esteem helps youth to manage their fears. Joe noted that equitable opportunity and personal safety matter, and he championed Cordner’s suggestion to use data to understand what crime is occurring, to identify fears, and to create appropriate interventions.

INSTITUTIONAL AND POLICY-LEVEL STRATEGIES TO REDUCE FEAR OF VIOLENCE

Fear Across the Lifespan

XinQi Dong, the inaugural Henry Rutgers Distinguished Professor of Population Health Sciences, Rutgers University, and director, Institute for Health, Health Care Policy, and Aging Research, explained that elder abuse does not prompt a “visceral reaction of injustice” the way that child abuse does because the knowledge base is too small. Elder abuse includes physical, psychological, and sexual abuse, as well as self-neglect, caregiver neglect, and financial exploitation. Older people are often unable to perceive threats, especially in the cases of financial exploitation or self-neglect. People with dementia, on the other hand, may experience paranoia that causes fear of threats that do not exist. Recalling the concept of violence as a “contagion,” Dong said that the first step to successful intervention is to recognize cultural norms and values and to consider the victim, the families, and the networks involved. The next step to combat elder abuse is to study resilience and to engage aging networks and community partners.

Kenya Fairley, Supervisory Family Violence Prevention Program Specialist, U.S. Department of Health and Human Services (HHS), discussed the Family Violence Prevention and Services Act (FVPSA), which dedicates federal resources to support domestic violence shelters and services for 1.3 million victims and their children each year, to

maintain state and national training, and to fund the National Domestic Violence Hotline and its projects. The FVPSA re-mediates victims’ fears by working across the federal government to leverage resources. For example, in the first phase of Project Catalyst, more than 600 health care providers were trained, 95 percent of whom reported an increased understanding of how education about adverse health impacts of IPV and human trafficking can improve patient care. The Domestic Violence and Housing Technical Assistance Consortium helps survivors navigate barriers to securing housing, and another project explores policies on perpetrator substance use coercion. She noted that the FVPSA emphasizes community-driven solutions; well-trained advocates provide emotional support, safety planning, education about healthy relationships, and direct referral to other agencies for survivors.

Virginia Duplessis, program director, Futures Without Violence (FWV), explained that to prevent violence, it is important to study the fears of both those who cause harm and those who are harmed. Survivors fear their partners, social stigma, and involvement at the systems level (e.g., with the police, child welfare, or immigration); thus, she advised that all interventions focus on healing and resilience, helping to reduce fear and inaction and motivating survivors to make safe choices. FWV aims to normalize advocacy services, so that help seeking is viewed as a sign of strength, and makes bidirectional referrals, so that access does not require disclosure. FWV offers an online toolkit that encourages health care providers to partner with local domestic violence programs to build capacity in clinical settings to prevent and respond to violence. She said that screening for domestic violence alone does not increase safety; providing universal education on healthy relationships and domestic violence advocacy services helps those who respond “no” on the screening and empowers others to share information with someone in danger. She emphasized that systems-level domestic violence interventions and policies should not contribute to or reflect existing inequities.

Captain Nasir Young, U.S. Army, observed that a student who is subject to disciplinary action and is referred to the Pennsylvania Youth Court’s program may have experienced trauma, neglect, or have limited resources, which may lead to poor decision making and being mislabeled as a “troubled child.” Youth Court is a student-run, peer-to-peer juvenile justice alternative that promotes restorative justice. Students are trained by law professionals, teachers, and justice authorities in various courtroom responsibilities. Student jurors are taught to ask empathetic questions that will prompt student respondents to be self-reflective about their actions, accept responsibility, and redefine themselves. One of the benefits of Youth Court is that students are empowered to help other students. One student learned how to “find better solutions to real-world problems and become a leader in school” as well as to “understand other people’s points of view.” He described a related program, the Youth Court Class, which aims to make students proactive citizens. In one of the sessions, students were provided information about the first, second, and fourth amendments⁷ and were asked to apply that knowledge to real-world scenarios with the police. This activity allowed students to create a seven-step process for responding to being pulled over by the police, and helped them to find innovative approaches to partnering with local police to make change in their community. Captain Young concluded that these programs can change fear of violence by reminding students that someone is on their side and by allowing them to explore their emotions with their peers.

Geri Donenberg, professor of medicine, psychology, epidemiology, and biostatistics, University of Illinois at Chicago, discussed the impact of fear of violence through the lens of adolescent HIV prevention and treatment. Not everyone has benefited equally from HIV treatment advancements: marginalized individuals, those at the highest risk for HIV transmission, and those with poor viral suppression are most affected by a fear of violence. This fear can impede people from engaging in preventative behaviors (e.g., fear of being rejected or abused for insisting on condom use or stigmatized for taking an HIV test). This fear can also prevent people from working toward viral suppression. Peers may respond negatively to a person who is seen taking antiretroviral therapy, or a fear of family or intimate partner rejection, abandonment, or hostility may inhibit those who want to engage in HIV care. She added that those with mental health issues may be less likely to engage in protective behaviors and may be less inclined to follow the ideal regimen. Donenberg’s research-based interventions focus on strength building, such as through emotion regulation strategies and planning for the future; altering peer norms; improving parent–teen communication; and supporting adherence

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for youth with HIV. She concluded that HIV demonstrates how fear of violence can impact many levels of functioning from the individual to the family to the community to the structural determinants that affect health and well-being.

Moderator Stephanie Alexander, Health Science Administrator, Office on Women’s Health, HHS, asked about addressing fear through gender and racial lenses. Fairley championed services tailored to male survivors of domestic violence; anger, fear, and desire for assistance (e.g., counseling versus housing) may look different in men than in women, but those feelings are no less valid. She added that the FVPSA funds the National LGBTQ Institute on IPV, which studies relationship dynamics to identify aggressors and victims. Dong noted that men and women process information and fear differently, which leads to varied health impacts. Duplessis reiterated the need to change cultural norms and added that it is important to focus on health, safety, and resilience instead of on only deficits. Alexander questioned how to shift attention from the individual to community responsibility. Fairley emphasized that change happens steadily over time with continued efforts to build relationships, leverage resources, and empower the community. Duplessis added that CDC has technical guidance on improving prevention of and response to violence that can be adapted to be culturally relevant. Alexander inquired about Youth Court’s impacts on students’ interactions with police; Captain Young replied that interactions have improved, and a police mentorship program has been proposed.

Larger-Resilience Threat Management Frameworks

Megan Ranney, the Warren Alpert Endowed Associate Professor of Emergency Medicine, Alpert Medical School, Brown University, and founding director, Brown–Lifespan Center for Digital Health, explained a few ways that fear drives firearm injury. First, structural racism and fear of the “other” often drive gun ownership, including a false perception that everyone owns guns. Self-protection is the primary reason for a firearm purchase, yet having a firearm in the home increases the risk of firearm death both for the owner and for their family, she continued. Second, fear of the firearm itself prompts anxiety among some members of society, overshadowing evidence-based approaches to fighting firearm injury. Third, people’s fears are misplaced: for example, people are afraid of school shootings, but Ranney said that their fears are disproportionate, given that cities have experienced more gun violence than schools and that two-thirds of gun deaths are suicides. Fourth, fear of not being able to help or of being injured often prompts health care professionals to treat victims of gun violence differently from other patients. Finally, those who have been affected by gun violence have higher rates of anxiety, depressive symptoms, PTSD, substance abuse, sexual risk behaviors, and hopelessness. To reduce firearm injury, fear has to be reduced at the individual and interpersonal levels. Ranney’s strategies rely on cognitive behavioral therapy, motivational intervention, and peer support to prevent fear of future firearm injury and to address responses to past violence. The American Foundation for Firearm Injury Reduction in Medicine focuses on community-level interventions by educating and empowering health practitioners in a nonpartisan, nonpolitical way.

David Mitchell, lecturer and director/chief, University Police, University of Maryland (UMD), described his mission to protect people and property, reduce fear, and improve quality of life. He highlighted the Defense Logistics Agency’s 1033 program, which allows local police to borrow surplus military equipment. UMD’s armored emergency rescue vehicle was obtained through this program. This vehicle would be essential during an active shooter situation, but having the equipment to be prepared for an active shooter does not mean that the equipment should be used against peaceful demonstrators; police in battledress with weapons pointed at unarmed protestors cause friction, fear, and loss of confidence. Social media can be used to exacerbate fear of violence or to reduce fear. His team focuses on the latter by posting pictures of positive police interactions and sharing information about crimes and solved cases. He said that it is challenging to reduce fear and build community with high student turnover, but better hiring, training, and supervising lead to effective policing.

Jonathan Links, professor, Johns Hopkins Bloomberg School of Public Health, shared his system dynamics model COPEWELL, which predicts community functioning and resilience after traumatic events. According to Links, violence and fear of violence should be conceptualized as forms of trauma and its consequences, and the broader trauma framing should drive mitigation efforts as part of a larger resilience enhancement effort rather than as a specialized effort. When a community experiences a trauma, functioning (i.e., communication, education, economy, government, food and water, health care, housing, transportation, nurturing, well-being) decreases. Population factors (vulnerability, inequality, deprivation) and prevention and mitigation factors (natural systems, engineered systems, countermeasures) can influence the initial loss of functioning—the greater the resistance, the smaller the initial loss. Recovery factors such as social cohesion, preparedness and response, and external resources can replenish community functioning—the greater the recovery, the quicker the return to baseline functioning. He explained that resilience depends on resistance and recovery, but because the factors that influence resistance and recovery differ, intervention strategies will vary. COPEWELL is populated with publicly available data and can be run for various types of events; predicted community resilience decreases as the event magnitude increases. Links advocated for resilience at the individual, organizational, and community levels.

David Bixler, co-leader, the Boeing Company’s Enterprise Threat Management Program, explained that threat management monitors both actual and perceived threatening behaviors, threats, and acts of violence. For such a program to be effective, a company’s management must buy into its policy. Boeing’s policy highlights available resources and expectations for managers and employees, but it does not include a “zero-tolerance” policy because every case and every person is unique. Employees know that threats are taken seriously; every site has its own threat management team, and every reported case is investigated. The threat management teams are multidisciplinary, with representatives from security and fire, corporate investigations, human resources, law, health services, and the employee assistance program. All employees take threat management training every 3 years, which describes how to make reports via an anonymous hotline, human resources, or security officers. The program also aims to prevent fear of violence by providing threat “awareness training.” He added that COVID-19, civil unrest, and the current political climate have created an unprecedented situation of stress for employees that could drive poor decision making. He emphasized that the best prevention is early intervention: the longer threatening behaviors are allowed to continue, the more fear permeates the workplace.

Serving as moderator, Peek-Asa asked about the recent rises in fear and in firearms purchases. Ranney said that discussions of fear and anxiety have to be normalized, and interventions have to minimize fear. Mitchell expressed concern about the frequency with which weapons are carried to demonstrations, especially in light of the current climate of heightened anxiety and anger. Pointing to the displaced sense of control that gun purchasers have felt during COVID-19, Links emphasized that contextualization is key in discussions of fear of violence. Peek-Asa wondered how to use fear to motivate prevention. Bixler said that fear has to be dealt with one person at a time, because what drives fear in one person is different from what drives fear in another. Links championed campaigns focused on building resistance at an individual level but added that community-level interventions depend on interdependence and social cohesion. Ranney noted that fear can be used to motivate individual behavioral changes; however, because fear can also be counterproductive to behavioral changes, it cannot be the sole driver of change. Acknowledging the broad range of issues discussed, Betz concluded the workshop by suggesting that participants further examine the common threads illuminated during the workshop, in hope that doing so might inspire models of violence prevention that draw from new connections and more collaborative science.◆◆◆

DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Liza Hamilton and Linda Casola as a factual summary of what occurred at the workshop. The statements made are those of the rapporteurs or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the rapporteurs and the institution.

REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Elizabeth J. Letourneau, Johns Hopkins Bloomberg School of Public Health, and Hanni Stoklosa, Mary Horrigan Connors Center for Women’s Health & Gender Biology; Brigham and Women’s Hospital; HEAL Trafficking. Lauren Shern, the National Academy of Sciences, Engineering, and Medicine, served as the review coordinator.

SPONSORS: This workshop was partially supported by the Administration for Community Living; Becton, Dickinson and Company; Catholic Health Initiatives; Centers for Disease Control and Prevention; Education Development Center; National Institutes of Health; Medical College of Wisconsin; and U.S. Department of Defense.

For additional information regarding the workshop, visit: https://www.nationalacademies.org/our-work/forum-onglobal-violence-prevention#sectionWebFriendly.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Managing, reducing, and preventing fear of violence: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/26038.

Health and Medicine Division

Copyright 2020 by the National Academy of Sciences. All rights reserved.