America Runs on ‘Dirty Work’ and Moral Inequality

Eyal Press

The New York Times

Originally posted 13 Aug 21

Here is an excerpt:

“Dirty work” can refer to any unpleasant job, but among social scientists, the term has a more pointed meaning. In 1962, Everett Hughes, an American sociologist, published an essay titled “Good People and Dirty Work” that drew on conversations he’d had in postwar Germany about the mass atrocities of the Nazi era. Mr. Hughes argued that the persecution of Jews proceeded with the unspoken assent of many supposedly enlightened Germans, who refrained from asking too many questions because, on some level, they were not entirely displeased.

This was the nature of dirty work as Mr. Hughes conceived of it: unethical activity that was delegated to certain agents and then disavowed by society, even though the perpetrators had an “unconscious mandate” from their fellow citizens. As extreme as the Nazi example was, this dynamic existed in every society, Mr. Hughes wrote, enabling respectable citizens to distance themselves from the morally troubling things being done in their name. The dirty workers were not rogue actors but “agents” of “good people” who passively stood by.

Contemporary America runs on dirty work. Some of the people who do this work are our agents by virtue of the fact that they perform public functions, such as running the world’s largest penal system. Others qualify as such by catering to our consumption habits — the food we eat, the fossil fuels we burn, which are drilled and fracked by dirty workers in places like the Gulf of Mexico. The high-tech gadgets in our pockets rely on yet another form of dirty work — the mining of cobalt — that has been outsourced to workers in Africa and to foreign subcontractors that often brutally exploit them.

Like the essential jobs performed by grocery clerks and other low-wage workers during the Covid-19 pandemic, this work sustains our lifestyles and undergirds the prevailing social order, but privileged people are generally spared from having to think about it. One reason is that the dirty work occurs far away from them, in isolated institutions — prisons, slaughterhouses — that are closed to the public. Another reason is that the privileged rarely have to do it. Although there is no shortage of it to go around, dirty work in America is not randomly distributed. 

The info is here.

Deinstitutionalization of People with Mental Illness: Causes and Consequences

Daniel Yohanna, MD

Virtual Mentor. 2013;15(10):886-891.

Here is an excerpt:

State hospitals must return to their traditional role of the hospital of last resort. They must function as entry points to the mental health system for most people with severe mental illness who otherwise will wind up in a jail or prison. State hospitals are also necessary for involuntary commitment. As a nation, we are working through a series of tragedies involving weapons in the hands of people with severe mental illness—in Colorado, where James Holmes killed or wounded 70 people, Arizona, where Jared Loughner killed or wounded 19 people, and Connecticut, where Adam Lanza killed 28 including children as young as 6 years old. All are thought to have had severe mental illness at the time of their crimes. After we finish the debate about the availability of guns, particularly to those with mental illness, we will certainly have to address the mental health system and lack of services, especially for those in need of treatment but unwilling or unable to seek it. With proper services, including involuntary commitment, many who have the potential for violence can be treated. Just where will those services be initiated, and what will be needed?

Nearly 30 years ago, Gudeman and Shore published an estimate of the number of people who would need long-term care—defined as secure, supportive, indefinite care in specialized facilities—in Massachusetts. Although a rather small study, it is still instructive today. They estimated that 15 persons out of 100,000 in the general population would need long-term care. Trudel and colleagues confirmed this approximation with a study of the long-term need for care among people with the most severe and persistent mental illness in a semi-rural area in Canada, where they estimated a need of 12.4 beds per 100,000. A consensus of other experts estimates that the total number of state beds required for acute and long-term care would be more like 50 beds per 100,000 in the population. At the peak of availability in 1955, there were 340 beds per 100,000. In 2010, the number of state beds was 43,318 or 14.1 beds per 100,000.

The info is here.

It’s in Your Control: Free Will Beliefs and Attribution of Blame to Obese People and People with Mental Illness

Chandrashekar, S. P. (2020).
Collabra: Psychology, 6(1), 29.
DOI: http://doi.org/10.1525/collabra.305

Abstract

People’s belief in free will is shown to influence the perception of personal control in self and others. The current study tested the hypothesis that individuals who believe in free will attribute stronger personal blame to obese people and to people with mental illness (schizophrenia) for their adverse health outcomes. Results from a sample of 1110 participants showed that the belief in free will subscale is positively correlated with perceptions of the controllability of these adverse health conditions. The findings suggest that free will beliefs are correlated with attribution of blame to people with obesity and mental health issues. The study contributes to the understanding of the possible negative implications of people’s free will beliefs.

Discussion

The purpose of this brief report was to test the hypothesis that belief in free will is strongly correlated with attribution of personal blame to obese people and to people with mental illness for their adverse health outcomes. The results showed consistent positive correlations between the free will subscale and the extent of blame to obese individuals and individuals with mental illness. The study employed both generic survey measures of internal blame attributions and a survey that measured the responses based on a person described in a vignette. The current study, although correlational, contributes to recent work that argues that belief in free will is linked to processes underlying human social perception (Genschow et al., 2017). Besides theoretical implications, the findings demonstrate the societal consequences of free-will beliefs. Perception of controllability and personal responsibility is a well-documented predictor of negative stereotypes and stigma associated with people with mental illness and obesity (Blaine & Williams, 2004; Crandall, 1994). Perceptions of controllability related to people with health issues have detrimental social outcomes such as social rejection of the affected individuals (Crandall & Moriarty, 1995), and reduced social support and help from others (Crandall, 1994). The current study underlines that belief in free will as an individual-level factor is particularly relevant for developing a broader understanding of predictors of stigmatization of those with mental illness and obesity.

Business gets ready to trip

Jeffrey O'Brien
Forbes. com
Originally posted 17 Feb 20

Here is an excerpt:

The need for a change in approach is clear. “Mental illness” is an absurdly large grab bag of disorders, but taken as a whole, it exacts an astronomical toll on society. The National Institute of Mental Health says nearly one in five U.S. adults lives with some form of it. According to the World Health Organization, 300 million people worldwide have an anxiety disorder. And there’s a death by suicide every 40 seconds—that includes 20 veterans a day, according to the U.S. Department of Veterans Affairs. Almost 21 million Americans have at least one addiction, per the U.S. Surgeon General, and things are only getting worse. The Lancet Commission—a group of experts in psychiatry, public health, neuroscience, etc.—projects that the cost of mental disorders, currently on the rise in every country, will reach $16 trillion by 2030, including lost productivity. The current standard of care clearly benefits some. Antidepressant medication sales in 2017 surpassed $14 billion. But SSRI drugs—antidepressants that boost the level of serotonin in the brain—can take months to take hold; the first prescription is effective only about 30% of the time. Up to 15% of benzodiazepine users become addicted, and adults on antidepressants are 2.5 times as likely to attempt suicide.

Meanwhile, in various clinical trials, psychedelics are demonstrating both safety and efficacy across the terrain. Scientific papers have been popping up like, well, mushrooms after a good soaking, producing data to blow away conventional methods. Psilocybin, the psychoactive ingredient in magic mushrooms, has been shown to cause a rapid and sustained reduction in anxiety and depression in a group of patients with life-threatening cancer. When paired with counseling, it has improved the ability of some patients suffering from treatment-resistant depression to recognize and process emotion on people’s faces. That correlates to reducing anhedonia, or the inability to feel pleasure. The other psychedelic agent most commonly being studied, MDMA, commonly called ecstasy or molly, has in some scientific studies proved highly effective at treating patients with persistent PTSD. In one Phase II trial of 107 patients who’d had PTSD for an average of over 17 years, 56% no longer showed signs of the affliction after one session of MDMA-assisted therapy. Psychedelics are helping to break addictions, as well. A combination of psilocybin and cognitive therapy enabled 80% of one study’s participants to kick cigarettes for at least six months. Compare that with the 35% for the most effective available smoking-cessation drug, varenicline.

The info is here.

Stop Blaming Mental Illness

Alan I. Leshner
Science  16 Aug 2019:
Vol. 365, Issue 6454, pp. 623

The United States is experiencing a public health epidemic of mass shootings and other forms of gun violence. A convenient response seems to be blaming mental illness; after all, “who in their right mind would do this?” This is utterly wrong. Mental illnesses, certainly severe mental illnesses, are not the major cause of mass shootings. It also is dangerously stigmatizing to people who suffer from these devastating disorders and can subject them to inappropriate restrictions. According to the National Council for Behavioral Health, the best estimates are that individuals with mental illnesses are responsible for less than 4% of all violent crimes in the United States, and less than a third of people who commit mass shootings are diagnosably mentally ill. Moreover, a large majority of individuals with mental illnesses are not at high risk for committing violent acts. Continuing to blame mental illness distracts from finding the real causes of mass shootings and addressing them directly.

Mental illness is, regrettably, a rather loosely defined and loosely used term, and this contributes to the problem. According to the American Psychiatric Association, “Mental illnesses are health conditions involving changes in emotion, thinking or behavior…associated with distress and/or problems functioning in social, work or family activities.” That broad definition can arguably be applied to many life stresses and situations. However, what most people likely mean when they attribute mass shootings to mental illness are what mental health professionals call “serious or severe mental illnesses,” such as schizophrenia, bipolar disorder, or major depression. Other frequently cited causes of mass shootings—hate, employee disgruntlement, being disaffected with society or disappointed with one's life—are not defined clinically as serious mental illnesses themselves. And because they have not been studied systematically, we do not know if these purported other causes really apply, let alone what to do about them if true.

The editorial is here.

Cruel, Immoral Behavior Is Not Mental Illness

James L. Knoll & Ronald W. Pies
Psychiatric Times
Originally posted August 19, 2019

Here is an excerpt:

Another way of posing the question is to ask—Does immoral, callous, cruel, and supremely selfish behaviors constitute a mental illness? These socially deviant traits appear in those with and without mental illness, and are widespread in the general population. Are there some perpetrators suffering from a genuine psychotic disorder who remain mentally organized enough to carry out these attacks? Of course, but they are a minority. To further complicate matters, psychotic individuals can also commit violent acts that were motivated by base emotions (resentment, selfishness, etc.), while their psychotic symptoms may be peripheral or merely coincidental.

It bears repeating that reliable, clinically-based data or complete psychological autopsies on perpetrators of mass public shootings are very difficult to obtain. That said, some of the best available research on mass public shooters indicates that they often display “rigidness, hostility, or extreme self-centeredness.” A recent FBI study found that only 25% of mass shooters had ever had a mental illness diagnosis, and only 3 of these individuals had a diagnosis of a psychotic disorder. The FBI’s cautionary statement in this report is incisive: “. . . formally diagnosed mental illness is not a very specific predictor of violence of any type, let alone targeted violence…. declarations that all active shooters must simply be mentally ill are misleading and unhelpful."

Psychiatric and mental health treatment has its limits, and is not traditionally designed to detect and uncover budding violent extremists. It is designed to work together with individuals who are invested in their own mental health and seek to increase their own degrees of freedom in life in a pro-social manner. This is why calls for more mental health laws or alterations in civil commitment laws are likely to be low-yield at best, with respect to preventing mass killing—and stagnating to mental health progress at worst.

The info is here.

The Troubled History of Psychiatry

Jerome Groopman
The New Yorker
Originally posted May 20, 2019

Here is an excerpt:

Yet, despite the phenomenal success of Prozac, and of other SSRIs, no one has been able to produce definitive experimental proof establishing neurochemical imbalances as the pathogenesis of mental illness. Indeed, quite a lot of evidence calls the assumption into question. Clinical trials have stirred up intense controversy about whether antidepressants greatly outperform the placebo effect. And, while SSRIs do boost serotonin, it doesn’t appear that people with depression have unusually low serotonin levels. What’s more, advances in psychopharmacology have been incremental at best; Harrington quotes the eminent psychiatrist Steven Hyman’s assessment that “no new drug targets or therapeutic mechanisms of real significance have been developed for more than four decades.” This doesn’t mean that the available psychiatric medication isn’t beneficial. But some drugs seem to work well for some people and not others, and a patient who gets no benefit from one may do well on another. For a psychiatrist, writing a prescription remains as much an art as a science.

Harrington’s book closes on a sombre note. In America, the final decade of the twentieth century was declared the Decade of the Brain. But, in 2010, the director of the National Institute of Mental Health reflected that the initiative hadn’t produced any marked increase in rates of recovery from mental illness. Harrington calls for an end to triumphalist claims and urges a willingness to acknowledge what we don’t know.

Although psychiatry has yet to find the pathogenesis of most mental illness, it’s important to remember that medical treatment is often beneficial even when pathogenesis remains unknown. After all, what I was taught about peptic ulcers and stress wasn’t entirely useless; though we now know that stress doesn’t cause ulcers, it can exacerbate their symptoms. Even in instances where the discovery of pathogenesis has produced medical successes, it has often worked in tandem with other factors. Without the discovery of H.I.V. we would not have antiretroviral drugs, and yet the halt in the spread of the disease owes much to simple innovations, such as safe-sex education and the distribution of free needles and condoms.

The info is here.

​The Ethics of Neuroscience - A Different Lens

New technologies are allowing us to have control over the human brain like never before. As we push the possibilities we must ask ourselves, what is neuroscience today and how far is too far?

The world’s best neurosurgeons can now provide treatments for things that were previously untreatable, such as Parkinson’s and clinical depression. Many patients are cured, while others develop side effects such as erratic behaviour and changes in their personality. 

Not only do we have greater understanding of clinical psychology, forensic psychology and criminal psychology, we also have more control. Professional athletes and gamers are now using this technology – some of it untested – to improve performance. However, with these amazing possibilities come great ethical concerns.

This manipulation of the brain has far-reaching effects, impacting the law, marketing, health industries and beyond. We need to investigate the capabilities of neuroscience and ask the ethical questions that will determine how far we can push the science of mind and behaviour.

Moral Responsibility and Mental Illness: A Call for Nuance

Matt King & Joshua May
Draft Paper

Abstract:

Does having a mental illness, in general, affect whether someone is morally responsible for an action? Against this Naive view, we argue for a Nuanced account. Sometimes mental illness absolutely excuses, but other times it doesn't. In some cases, mental illness can actually enhance one’s responsibility. The problem is not just that different theories of responsibility yield different judgments about particular cases. Even in cases when all reasonable theories agree about what's relevant to responsibility, the ways mental illness can affect behavior are so varied that a more nuanced account is warranted.

The paper is here.

Why You Should Stop Using the Phrase ‘the Mentally Ill’

By Tanya Basu
New York Magazine
Originally published February 2, 2016

Here is an excerpt:

What’s most surprising is the reaction that counselors have when the phrase “the mentally ill” is used: They’re more likely to believe that those suffering from mental illness should be controlled and isolated from the rest of the community. That's pretty surprising, given that these counselors are perhaps the ones most likely to be aware of the special needs and varying differences in diagnoses of the group.

Counselors also showed the largest differences in how intolerant they were based on the language, which boosted the researchers’ belief that simply changing language is important in not only understanding people who suffer from mental illness but also helping them adjust and cope. “Even counselors who work every day with people who have mental illness can be affected by language,” Granello said in a press release. “They need to be aware of how language might influence their decision-making when they work with clients.”

The entire article is here.

Blaming Mental Illness for Gun Violence

BY Alex Yablon
The Trace
Originally posted September 1, 2015

Here is an excerpt:

Add it all up, and the “mental health” post-shooting playbook looks as calculated to ensure political inaction as it is the appearance of sensitivity. The general public would hardly disagree with statements by Trump, Bush, and others that the severely mentally ill pose a danger; in fact, surveys show that more Americans blame failures of the mental health system for mass shootings than any other factor. Meanwhile the Republican base — not to mention mental health professionals — would hardly countenance any action to expand the reach of background checks to block gun purchases by people with personality disorders or other mental health issues that are not quite so debilitating as conditions that require hospitalization, like schizophrenia or psychosis. So politicians can make statements like “The common thread we see in many of these cases is a failure in the system to help someone who is suffering from mental illness” (Scott Walker, the day after the WDBJ shooting), knowing full well they will not result in any action that could anger their pro-gun supporters.

In fact, framing incidents of gun violence as the product of unsettled perpetrators, versus firearms risks, may influence support for given solutions among the general public. An NPR article published on August 31 describes a psychiatric study in which two groups of subjects were given hypothetical news articles about a mass shooting, slightly altered to emphasize different underlying causes. Readers of the version emphasizing the need to “keep dangerous guns off our streets” were more likely to support limits on gun magazine capacity.

The irony of the psychiatric turn in debate on new gun law is that, for the most part, a body of research shows the severely mentally ill are among the least of our worries when it comes to violent crime, especially when compared to other risk factors. Alcohol, for example, is a factor in 40 percent of all violent acts committed in the United States today, according to the National Council on Alcoholism and Drug Dependence.

The entire article is here.

The full title is: The Political Strategy Behind the GOP’s Post-Shooting ‘Mental Health’ Playbook

The Death Treatment

When should people with a non-terminal illness be helped to die?

By Rachel Aviv
The New Yorker
Originally published June 22, 2015

Belgium was the second country in the world, after the Netherlands, to decriminalize euthanasia; it was followed by Luxembourg, in 2009, and, this year, by Canada and Colombia. Switzerland has allowed assisted suicide since 1942. The United States Supreme Court has recognized that citizens have legitimate concerns about prolonged deaths in institutional settings, but in 1997 it ruled that death is not a constitutionally protected right, leaving questions about assisted suicide to be resolved by each state. Within months of the ruling, Oregon passed a law that allows doctors to prescribe lethal drugs for patients who have less than six months to live. In 2008, Washington adopted a similar law; Montana decriminalized assisted suicide the year after; and Vermont legalized it in 2013.

The right-to-die movement has gained momentum at a time of anxiety about the graying of the population; people who are older than sixty-five represent the fastest-growing demographic in the United States, Canada, and much of Europe. But the laws seem to be motivated less by the desires of the elderly than by the concerns of a younger generation, whose members derive comfort from the knowledge that they can control the end of their lives.

The entire article is here.

Mental Illness, Mass Shootings, and the Politics of American Firearms

By Jonathan M. Metzl, MD, PhD, and Kenneth T. MacLeish, PhD
American Journal of Public Health: February 2015, Vol. 105, No. 2, pp. 240-249.
doi: 10.2105/AJPH.2014.302242

Abstract

Four assumptions frequently arise in the aftermath of mass shootings in the United States: (1) that mental illness causes gun violence, (2) that psychiatric diagnosis can predict gun crime, (3) that shootings represent the deranged acts of mentally ill loners, and (4) that gun control “won’t prevent” another Newtown (Connecticut school mass shooting). Each of these statements is certainly true in particular instances. Yet, as we show, notions of mental illness that emerge in relation to mass shootings frequently reflect larger cultural stereotypes and anxieties about matters such as race/ethnicity, social class, and politics. These issues become obscured when mass shootings come to stand in for all gun crime, and when “mentally ill” ceases to be a medical designation and becomes a sign of violent threat.


The entire article is here.

My brain made me do it, but does that matter?

By Walter Sinnott-Armstrong
The Conversation
Originally published December 12, 2014

Here is an excerpt:

These extreme cases are easy. Despite some rhetoric, almost nobody really believes that the fact that your brain made you do it is by itself enough to excuse you from moral responsibility. On the other side, almost everybody agrees that some brain states, such as seizures, do remove moral responsibility. The real issues lie in the middle.

What about mental illnesses? Addictions? Compulsions? Brainwashing? Hypnosis? Tumors? Coercion? Alien hand syndrome? Multiple personality disorder? These cases are all tricky, so philosophers disagree about which people in these conditions are responsible — and why. Nonetheless, these difficult cases do not show that there is no difference between seizures and normal desires, just as twilight does not show that there is no difference between night and day. It is hard to draw a line, but that does not mean that there is no line.

The entire article is here.

Sick in the head? Pathogen concerns bias implicit perceptions of mental illness

By Erick M. Lund and Ian A. Boggero
Evolutionary Psychology 12(4): 706-718

ABSTRACT

Biases against the mentally ill are historically and cross-culturally pervasive, suggesting they may have an evolutionary basis. The prevailing view is that people seek to distance themselves from the mentally ill because they are perceived as dangerous, violent, and incompetent. However, because of similarities between sickness behaviors and symptoms of some mental disorders, it was hypothesized that mental illness stigma could be partially explained as a function of behavioral immune system biases designed to avoid potential sources of contagion. In two experiments, it was found that mental illness was implicitly associated more with disease than danger. In Experiment 1, this implicit association was exacerbated among people who have had their biological immune system activated by a recent illness. In Experiment 2, experimentally priming disease salience increased implicit association between mental illness and disease. Implications for the evolutionary origins of prejudice and the prevention of mental illness stigma are discussed.

The article is here.

Denied

When insurance companies deny the mentally ill the treatment their doctors prescribe, seriously ill people are often discharged, and can be a danger to themselves or others

By Scott Pelley
CBS - 60 Minutes
Originally aired on December 14, 2014

Here is an excerpt:

Two years ago tonight, we were reeling from the shock of the murders of 20 first graders and six educators at Sandy Hook Elementary School. Since then, we've learned that the killer suffered profound mental illness. His parents sought treatment but, at least once, their health insurance provider denied payment.

Because of recurring tragedies and an epidemic of suicides, we've been investigating the battles that parents fight for psychiatric care. We found that the vast majority of claims are routine but the insurance industry aggressively reviews the cost of chronic cases. Long-term care is often denied by insurance company doctors who never see the patient. As a result, some seriously ill patients are discharged from hospitals over the objections of psychiatrists who warn that someone may die.



The entire story is here.

When Hearing Voices Is a Good Thing

A new study suggests that schizophrenic people in more collectivist societies sometimes think their auditory hallucinations are helpful.

By Olga Khazan
The Atlantic
Originally posted July 23, 2014

Here are two excerpts:

But a new study suggests that the way schizophrenia sufferers experience those voices depends on their cultural context. Surprisingly, schizophrenic people from certain other countries don't hear the same vicious, dark voices that Holt and other Americans do. Some of them, in fact, think their hallucinations are good—and sometimes even magical.

(cut)

The Americans tended to described their voices as violent—"like torturing people, to take their eye out with a fork, or cut someone's head and drink their blood, really nasty stuff," according to the study.

The entire article is here.

Dealing with all the behavioral conditions of unknown etiology

By Steven Reidbord
KevinMD.org
Originally published May 1, 2014

Here are some excerpts:

A few years ago I wrote that uncertainty is inevitable in psychiatry.  We literally don’t know the pathogenesis of any psychiatric disorder.  Historically, when the etiology of abnormal behavior became known, the disease was no longer considered psychiatric.  Thus, neurosyphilis and myxedema went to internal medicine; seizures, multiple sclerosis, Parkinson’s, and many other formerly psychiatric conditions went to neurology; brain tumors and hemorrhages went to neurosurgery; and so forth.

(cut)

Patients are told they suffer a “chemical imbalance” in the brain, when none has ever been shown.  Rapid advances in brain imaging and genetics have yielded an avalanche of findings that may well bring us closer to understanding the causes of mental disorders.  But they haven’t done so yet — a sad fact obscured by popular and professional rhetoric.  In particular, functional brain imaging (e.g., fMRI) fascinates brain scientists and the public alike.  We can now see, in dramatic three-dimensional colorful computer graphics, how different regions of the living brain “light up,” that is, vary in metabolic activity.  Population studies reveal systematic differences in patients with specific psychiatric disorders as compared to normals.  Don’t such images prove that psychiatric disorders are neurobiological brain diseases?

Note quite.

The entire article is here.

Thanks to Ed Zuckerman for this information.

Psychiatric diagnosis: the indispensability of ambivalence

By Felicity Callard
J Med Ethics doi:10.1136/medethics-2013-101763

Abstract

The author analyses how debate over the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders has tended to privilege certain conceptions of psychiatric diagnosis over others, as well as to polarise positions regarding psychiatric diagnosis. The article aims to muddy the black and white tenor of many discussions regarding psychiatric diagnosis by moving away from the preoccupation with diagnosis as classification and refocusing attention on diagnosis as a temporally and spatially complex, as well as highly mediated process. The article draws on historical, sociological and first-person perspectives regarding psychiatric diagnosis in order to emphasise the conceptual—and potentially ethical—benefits of ambivalence vis-à-vis the achievements and problems of psychiatric diagnosis.

The entire article is here.

Responsibility and Blame in the Clinic

By Hanna Pickard
Flickers of Freedom
Originally posted January 17, 2014

Here is an excerpt:

But we can really help these patients if we adopt a stance that I call “Responsibility without Blame”. Here’s what this means. The problem behaviour is voluntary. Patients with PD are not mentally ill and they know as well as most of us do what they are doing when they act. They have choice and control over their behaviour at least in the minimal sense that they can refrain – which they will often do if sufficiently motivated.  That does not mean that refraining is easy.  Here a little more background is important: PD is associated with extreme early psycho-socio-economic adversity. Most patients come from dysfunctional families or they may have been in institutional care. Rates of childhood sexual, emotional, and physical abuse or neglect are very high. Socio-economic status is low. Additional associated factors include war, migration, and poverty. Problem behaviour is often a learned, habitual way of coping with the distress caused by such adversity, and patients may have hitherto lacked decent opportunities to learn alternative, better ways of coping. So, until the underlying distress is addressed and new ways of coping are learned, restraint is hard.

The entire blog post is here.