Countering Violent Extremism Through Public Health Practice Proceedings of a Workshop (2017) / Chapter Skim
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5 Applying Public Health Models and Approaches to Countering Violent Extremism
5 Applying Public Health Models and Approaches to Countering Violent Extremism
Pages 61-98
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From page 61... ...
. • Health professionals' poor ability to accurately detect credible threats is a critical concern particularly when the determina tion is used as justification for breaching civil liberties (Wynia)
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From page 62... ...
The evaluation of these programs, an es sential component of public health models, is also discussed, as are the set of practical and ethical challenges health professionals face when working in CVE roles. THE PUBLIC HEALTH APPROACH TO ADDRESSING THREATS Eisenman noted that more than 2,500 federal, state, and local agencies constitute the backbone of the U.S.
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From page 63... ...
Step 2: Identify Risk and Protective Factors Using Scientific Research Methods The second step, according to Benjamin, is to identify the risk factors and protective factors at the individual, community, and broad societal levels that contribute to making certain communities more susceptible than others to experience a health threat. Such factors include issues such as the
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From page 64... ...
Step 3: Develop and Test Prevention Strategies: Four-Tiered Model of Public Health Prevention Benjamin stated that the third step is to apply knowledge gained about the problem, as well as its risk and protective factors, toward developing hypotheses about potentially effective interventions and putting programs into place. He noted that actually measuring and evaluating the efficacy of public health programs tends to be erratic.
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From page 65... ...
He suggested that another primary prevention strategy with particular relevance to the CVE space -- and violence prevention more broadly -- is geared toward prevent ing early childhood trauma, which he described as a predictor of impulse control problems and future violent tendencies. The goal of secondary prevention is to reduce the effect of a disease or an injury that has already occurred, said Benjamin.
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From page 66... ...
Both Benjamin and Eisenman explored how public health's four-tiered model of prevention can help to map out strate gies for preventing extremist violence. Eisenman noted that most activities within existing CVE programs would fall under some level of the public health prevention model (see Figure 5-3)
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From page 67... ...
In the CVE space, he noted, primary prevention is con cerned with targeting the majority of the population who have not engaged in problematic behaviors associated with violent extremism. Eisenman explained that such activities can include community programs and coun ternarrative media campaigns to reduce risk factors and strengthen protec tive factors for individuals, families, and communities.
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From page 68... ...
He noted that many such activities may not be CVE specific, but are CVE relevant.4 Lin added that primordial prevention addresses broad health determinants at the 2 He noted such behaviors are often referred to as precriminal, but clarified that it is not a public health term and its use may be counterproductive and perpetuate stigmas. 3 For example, the Los Angeles Targeted Violence Threat Assessment Program is a secondary prevention program for people who have been identified with precursor behaviors but who have not yet committed a violent extremist act.
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From page 69... ...
Applying CDC's "10 Essential Functions of Public Health" to CVE Eisenman introduced CDC's 10 Essential Functions of Public Health in order to provide guidance about how the public health approach, sys tem, and workforce can contribute to preventing extremist violence. He explained that these 10 essential functions are widely accepted as forming the foundation for all public health activities, and presented a figure (see Table 5-1)
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From page 70... ...
Assure competent public and • Design and evaluate trainings for public health, personal health care workforce mental health, social services, education staff on violent extremism 9. Evaluate effectiveness, • Evaluate which/why programs work to direct accessibility, and quality of resource allocation personal and population-based health services 10.
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From page 71... ...
He proposed that CVE could be addressed within the wider context of violence prevention generally, with the public health sector serving as convener and helping to assemble community sectors and agencies around CVE, as well as providing technical assistance on program planning and grant funding. Furthermore, he sug gested that public health could contribute to policy making and program development, thereby helping to shift CVE away from its dependence on law enforcement and closer to the mental health education, youth develop ment, and other human services sectors.
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From page 72... ...
Steele suggested that integrating health approaches into CVE efforts could bring valuable lessons about how to mitigate that type of stigma, as well as offer guidance about tailoring interventions to reduce the potential for stigma. In discussing protective factors and the scope of interventions, Wynia noted that much discussion has centered on moving the bell curve by look ing at populations and the social determinants of peoples' choices and behaviors.
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From page 73... ...
SOURCE: Eisenman presentation, September 8, 2016. Public Health Approach to Building Community Resilience Eisenman called for the public health sector to help promote the concept of community resilience in the context of violent extremism.5 He defined community resilience from the perspective of public health as "the capacity of the community as a whole to prepare for, respond to, and recover from adverse events and unanticipated crises that threaten the health of all," and suggested that it could be reframed in a way that is pinned toward achieving CVE-specific outcomes.
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From page 74... ...
Working on Violence as a Public Health Issue: Reflections from a Practitioner in the Field Wen introduced the concept "hurt people hurt people" as framing her work in addressing violence from a public health perspective. For example, she reported that among the people currently incarcerated in Baltimore City, 40 percent have mental illness and 80 percent use illegal substances; nationwide, only 11 percent of addicts can get the help they need.
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From page 75... ...
She emphasized that the simple investment in a child's glasses can potentially be a violence prevention strategy: it may prevent a child from being labeled disruptive and losing traction in school to the point that 6 Program information available at http://health.baltimorecity.gov/VisionForBaltimore (ac cessed November 8, 2016)
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From page 76... ...
She explained that the Baltimore Safe Streets program,8 based on the national Cure Violence program, continues to face funding problems on a yearly basis, despite former gang members and criminals making efforts to stop conflict (mediating nearly 700 conflicts in the previous year) and to give back to their communities.
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From page 77... ...
A common thread among those who become radicalized is that somebody close to them notices that something is "off" or wrong. By educating a community through the Cure Violence program, or other health-based violence prevention approaches, and by using a pool of credible messengers, a community is able to detect and interrupt this radicalization process.
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From page 78... ...
PUBLIC HEALTH MODELS FOR EVALUATING CVE PROGRAMS Evaluating Community-Led Interventions Ramchand remarked that there is a tradition in public health to be gin working toward prevention immediately when a crisis emerges, even before the mechanisms that underlie the outcomes are fully understood.10 Ramchand explained that this tradition holds in the CVE domain: while experts continue to do the important work of investigating the factors that lead certain individuals to violent extremism, community-led organizations and programs are already on the front line implementing interventions to prevent it. However, he emphasized that because little is known about the actual efficacy of the CVE interventions, it is now critically important to sci entifically assess and evaluate those programs.
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From page 79... ...
A further benefit he highlighted is that instilling a culture of evaluation within those community-led organiza tions allows them to take ownership of identifying and initiating their own program changes and improvements as needed. Developing a Tool Kit to Aid Community-Based Organizations: Getting to Outcomes RAND was commissioned by DHS in 2011 to develop a tool kit to aid community-based programs in evaluating their own CVE programs, explained Ramchand.
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From page 80... ...
. Reasons for Lack of CVE Program Evaluations To tailor the tool kit for CVE, Ramchand explained, program admin istrators were asked specifically about evaluation activities and why such activities were not pursued.
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From page 81... ...
He observed that programs targeting individuals are generally focused on the following outcomes: • Countering violent extremist opinions and ideology • Improving psychological well-being and addressing moral concerns • Enhancing positive social networks • Reducing political grievances • Improving social and economic integration In contrast, he observed that programs targeting the communities sur rounding individuals at risk of extremism are generally focused on the following objectives: • Helping community members understand and identify violent e xtremism and its risk factors. • Building community capacity to identify and engage with those at risk.
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From page 82... ...
Applying a Public Health Approach to the Evaluation of CVE Lin traced the development of a pilot evaluation program for pre venting violent extremism in the greater Boston area. She noted that the project's timeline allowed for independent external evaluators to become in volved in a formative evaluation capacity before the pilot was implemented, which informed the program's design.
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From page 83... ...
She explained that this challenge in particular limits the application of secondary prevention strategies that are typically used in the public health sector -- namely, screening people in order to detect and treat conditions at an early stage. Thus, the limited evidence available about risk factors obstructs secondary efforts to detect and intervene with people who have the propensity for violent extremist behavior.
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From page 84... ...
12 As discussed by Joumana Silyan-Saba earlier in the proceedings, the Los Angeles Region Intervention Steering Committee is convened and coordinated by the Los Angeles Mayor's Office in partnership with the DHS LA Regional Office. It has used a joint public health and mental health approach to help augment the Los Angeles CVE framework by building logic models, a services flow chart, evaluation tools, training plans, and other types of supporting materials needed to implement a program.
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From page 85... ...
Tabletop Exercise to Assess Mental Health Capacity According to Weine, the steering committee has grappled with whether the program should be a targeted violence program that incorporates school violence, workplace violence, and hate crimes, rather than focusing exclu sively on violent extremism. To explore this possibility, he reported that the steering committee has plans under way to work with LA County DMH to expand the school violence program into a broader violence prevention program that includes expertise on violent extremism.16 As part of that process, a pair of tabletop exercises were conducted in 14 Run by the LA County Department of Mental Health Emergency Operations Bureau.
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From page 86... ...
86 FIGURE 5-6 Proposed Los Angeles CVE intervention services flow chart. NOTES: CRT = Community Response Team; CST = Community Support Team; MH = mental health.
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From page 87... ...
THE ROLE OF HEALTH PROFESSIONALS IN CVE: LEGAL AND ETHICAL ISSUES Participants discussed the landscape of health professional ethics within the CVE space, focusing on the roles and responsibilities of health profes sionals with respect to threat assessment and obligatory reporting. Runnels observed that there seems to be a tension between what it means to be a health practitioner involved with CVE and what it means to be someone who does research in these areas, in terms of ethical issues, legal concerns, and the pressures to build an evidence base and actually take action by implementing programs and measures.
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From page 88... ...
For example, HIPAA allows for disclosure to law enforcement with a warrant, including provisions for "intelligence and national security activities" to assure "proper execution of a military mission," and to "provide protective services to the President." 18 New York requires mental health professionals to report anyone who "is likely to en gage in conduct that would result in serious harm to self or others" to the state's Division of Criminal Justice Services, which then alerts the local authorities to revoke the person's firearms license and confiscate his or her weapons. California mandates a 5-year firearms ban for any one who communicates a violent threat against a "reasonably identifiable victim" to a licensed psychotherapist.
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From page 89... ...
Because a small number of people do pose a threat that warrants reporting, health professionals are tasked with striking a delicate balance between their social responsibilities and their duties of care. He emphasized that legislatively mandated reporting inevitably leads to overreporting and false positives, because providers are concerned about the severe consequences of failure to report a patient who goes on to com mit violence.
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From page 90... ...
90 COUNTERING VIOLENT EXTREMISM of protecting the community. He provided several examples to illustrate.
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From page 91... ...
In the realm of ethics, remarked Wynia, the key criteria in determining when it is ethically justifiable to breach confidential ity include credible threat, significant harm, the presence of an identifiable third party, and the likelihood that the warning will be effective. Practical and Ethical Challenges in Individual Threat Assessment: Health Approach Perspective Can Health Professionals Predict Violent Behavior?
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From page 92... ...
Benjamin commented that individual threat assessment is con tingent on a clinician's ability to be astute in the difficult task of "connect ing the dots" to recognize that an individual is in the spectrum of threat. He observed that further upstream, public health focuses on risk assessment by astute citizens who "see something and say something." Both approaches need to be further refined.
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From page 93... ...
He contended that many nonmental health providers have an instinctive feeling about patients that factors into risk assessment; even though there are some criteria they consider when performing assessments, it is by no means a rigid proscriptive set of criteria. Threat Assessment Methodology and Expertise Weine observed that the threat assessment field grapples with the issue of whether the people being targeted in CVE interventions are the same people who go on to commit violence, and if efforts should be targeted on a specific subset of people.
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From page 94... ...
Wynia noted that individual threat assessment does not typically em ploy population-level strategies because they do yield such high numbers of false positives. Instead, they target a very rich sample of individuals in clinics and emergency departments who have a high probability of violence prior to screening, which makes testing that sample worthwhile.
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From page 95... ...
Weine cautioned against lumping together the psychiatric and psy chological assessment of suicide and homicide with the practice of threat assessment. He suggested that while the average clinical mental health pro fessional does have a poor ability to predict violent behavior, the emerging discipline of threat assessment is an entirely different, highly specialized discipline beyond the realm of the average emergency room physician's or outpatient clinician's expertise.
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From page 96... ...
Assimilation-related issues are very common in the community,21 and they are complicated by longstanding and targeted efforts by Al-Shabaab and other organizations to recruit community members to enter conflicts abroad.22 Hick noted the widespread belief that Somali youth in Minneapo lis are susceptible to radical messages and are at potential risk of commit ting violent extremism. He further stated that the vulnerabilities that drive certain individuals into such ideologies are not necessarily predictable on the basis of sociodemographics or various types of anticipatory guidance for health providers.
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From page 97... ...
Hick noted that progress is very slow, and a single high-profile incident can be a huge setback. However, he suggested that there may be an opportunity to use funding directed to CVE -- regardless of ideological or procedural concerns -- to promote community-wide equity of access to chronically underresourced mental health services.
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