Could clinical psychology save Baltimore's 'high-risk' youth?

There’s a growing sentiment in research and policymaking circles that by the time “high-risk” youth reach their mid to late teens, it may already be too late to improve their core academic and social outcomes. For many youth, truancy has become a way of life, and little can be done to change that. In our recent paper, which received the 2017 Abell Award in Urban Policy, we attempt to reverse this narrative by tackling the issue of youth violence. In particular, we analyze trends and challenges that the city has faced and showcase recent research with enormous implications for reducing youth violence in Baltimore. Here’s a summary of what we found.

In Baltimore, young men often grow up experiencing regular encounters with violence and the criminal justice system, both of which are well documented. Beyond the social cost of crime, studies show that youth incarceration causally increases the likelihood of adult incarceration, to say nothing of its effect on future employment and quality of life.

The issue is vexing because we don’t have a mainstream policy solution that consistently works, despite decades of research and discourse on the subject. Some advocate for social programs providing youth with educational or vocational skills to improve long-term prospects while others advocate for longer and harsher punishments to deter youth from poor decision-making. Neither approach reliably succeeds; both are costly.

One possible explanation is that policymakers on both sides critically assume that youth are forward-looking and can be incentivized to change their behavior when faced with the long-term consequences of their actions. A growing body of research in psychology and behavioral economics suggests otherwise: that the majority of our actions are not driven by forward-looking thought, or even any thought all. Simply put, our brains prefer to work on autopilot. Automatic behaviors dominate our daily interactions, guided by a system of judgments and “rules of thumb” that have been subconsciously adapted over time, allowing us to respond efficiently to things we face regularly. For youth who spend their entire lives growing up in distressed communities, violence is commonly a symptom of “automaticity” that has been adapted over many years.

Enter cognitive behavioral therapy (CBT), a framework originating in clinical psychology designed to counter this very tendency. Through specific clinical exercises and counseling techniques, CBT makes individuals more aware of their instinctive thoughts, thereby disrupting the automaticity guiding how people perceive and react to the world around them. Although most commonly used in clinical settings for psychiatric illness and addiction, CBT can also be used to enable youth to step back in the heat of the moment and assess their instinctive thoughts to determine whether they are indeed accurate or somehow distorted. The key is to adapt CBT into a curriculum that is engaging to them.

In an important study pioneered by the University of Chicago Crime Labs, a team of researchers ran a series of experiments in conjunction with Youth Guidance, a local nonprofit organization, and the Cook County Juvenile Detention Center to test CBT-based interventions on high-risk teenage males in schools and detention centers.The in-school program administered by Youth Guidance offered a series of weekly in-school sessions engaging youth in rites of passage (i.e. exploring what it means to “become a man”) through group activities and experiences guided by clinical principles of CBT. One of the first exercises students encounter is the “fist exercise,” where students are divided into pairs, and each is instructed to get his partner to open his fist. Physical force is usually the default approach, to which the group leader points out that nobody had simply asked their partners to open their fist. Youth then are forced to reveal underlying assumptions and judgments, such as “he wouldn’t have done it”, or “he would have thought I was a punk.”

By year-end, program participation reduced total arrests by 28 to 35 percent and violent-crime arrests by 45 to 50 percent, all while increasing graduation rates by 12 to 20 percent. The program cost $1,100 per student, translating to a cost-to-benefit ratio of 5 to 1 up to 30 to 1, depending on how one quantifies the value of lower arrest rates and higher graduation rates.

Meanwhile at the Cook County Juvenile Detention Center, admitted youth were randomly assigned to reside in different wings throughout the facility, including several wings specifically designed to administer an immersive CBT experience. For only $60 per participant, the detention center found that being assigned to a CBT wing reduced a detainee’s likelihood to recidivate by 21 percent in the 18 months after a youth exited juvenile detention.

These results provide hope that effective policy can make a difference for high-risk teenagers in other areas, and our paper proposes piloting such programs in Baltimore. But the challenges are many. Baltimore and Chicago are different cities with different dynamics. CBT seems to be a key ingredient, but we don’t have an exact formula for designing programs around it. Starting an intervention from scratch is daunting and requires a commitment to possible trial and error and a willingness to shift away from traditional policy-making paradigms. Yet armed with this game-changing research, we now have the opportunity to make important contributions to the nationwide conversation on youth violence and to lift up the young men in our communities who were once summarily dismissed as a lost cause.

George Zuo ( is a doctoral student in economics at the University of Maryland at College Park. Together with wife Stephanie Zuo, who graduated from the Johns Hopkins School of Medicine in May, he co-authored the paper that was awarded the 2017 Abell Award for Urban Policy.

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