October is Domestic Violence Awareness Month, or a time to begin to understand the effects of domestic violence, which have been researched extensively. Domestic violence is a social problem, affecting each member of a family—including kids, even when they are not the ones directly experiencing violence or aggression. Parents under stress can create children under stress. For children, witnessing domestic violence can lead to the development of many negative behavioral traits or mental health issues. Exposure alone can be traumatic.

Children who witness violence in the home are affected in ways similar to children who experience physical abuse. These children are also at a greater risk for both internalized and externalized negative behaviors, which can manifest socially, emotionally, psychologically, and/or behaviorally. Research shows us that boys exhibit more externalizing behavior, like fighting, bullying, lying, and cheating, while girls exhibit more internalized behaviors, such as anxiety, withdrawal, and depression.

In addition to potential problem behaviors, children also may experience psychological ramifications which lead to difficulties in school and lower scores on assessments of verbal, motor, and cognitive skills. Other limitations identified are slower cognitive development, lack of conflict resolution skills, limited problem-solving skills, and even a more rigid belief in gender stereotypes and reinforcement of male privilege.

When parents are engaged in any type of dynamic of domestic violence or aggression, their children can be at an extreme disadvantage when it comes to emotional development. They may tend to show higher levels of anxiety, lower self-esteem, and increased depression and anger. Violence puts a barrier between child and parent, making it difficult for children to develop a nurturing bond with either parent, which in turn can result in extreme anxiety or worry. The children may also display extreme separation anxiety when they go to school or when the parent(s) leaves. Studies show that separation anxiety even takes a physical toll, so children may complain of ailments like stomachache or headache as reasons they cannot go to school.

Exposure to domestic violence can create in the witness a sense of shame, guilt, and self-blame, conflicting feelings about a parent, fear of abandonment, symptoms of depression, and feelings of helplessness and powerlessness. With an increase in stress levels in the home, children can begin bedwetting again, lie to avoid confrontation, and have difficulty trusting others, especially adults. Stress is known to put any immune system in jeopardy—and children are no different. Stress and violence in the home can indirectly result in a short attention span, increased somatic complaints, and frequent illness.

Many children, as a result of exposure to domestic violence, become very secretive about their families and often do not invite friends to the home. They may begin to isolate and detach from the support that they could receive from those around them. Occasionally these behaviors are also linked to developmental delays and difficulty with emotional regulation, so that children feel shame, fear, confusion, and rage, often uncontrollable.

As these children age, it has been found that they also have higher levels of adult depression and trauma symptoms. Their reaction may be to internalize these symptoms, or they may cope with their stress by utilizing drugs or alcohol, fighting rules, ditching school, or running away. When child witnesses to domestic violence start dating, their relationships could have similar negative dynamics to ones their parents or guardians demonstrated. The risk of ending up in a controlling relationship or developing control issues is higher for these individuals.

It is important to note that not all children exposed to domestic violence will experience deficits or cope poorly. Some children demonstrate enormous resiliency and find ways to manage the tension in their homes. They might develop games or withdraw in order to manage the tension. Often they internalize the conflict and it resurfaces much later in life. In my practice, I see children who are high achievers with extreme expectations of themselves, who also have many outside interests, like sports or music. Outside interests and activities keep them out of the home most of the time, and these children tell me that this limits the amount of time that they don’t feel safe and gives them some sense of control in life.

The National Coalition Against Domestic Violence (NCADV) has created a website to help individuals who are in relationships plagued by domestic violence or provide people with resources to help family members and friends who are in abusive relationships.

References:

1. Brown, B.V., and Bzostek, S. (2003) Violence in the lives of children. CrossCurrents, 1, Child Trends DataBank
2. Edelson, J.L. (2006). Emerging Responses to Children Exposed to Domestic Violence. Harrisburg, PA: VAWnet, a project of the National Resource Center on Domestic Violence/Pennslyvania Coalition Against Domestic Violence. Retrieved 0ct 3, 2013 from michbar.org/publicpolicy/pdfs/Legislators_ResponsesDV.pdf

In my work with adult survivors of sexual assault, I am beginning to notice a pattern of behavior that I have termed “wounded attachment.” The impact of childhood sexual assault has reverberating effects on almost every facet of survivors’ livelihood, from relationships with family, friends, partners, spouses, and children to their jobs, finances, faith, etc. It is as if sexual assault redefines one’s pattern of and trajectory in life.

Sexual assault is the act of forcing, enticing, intimidating, or coercing another person to engage in a sexual activity, from fondling to coitus, when the other person is unwilling or unable (as is the case of one who is underage, drugged, or unconscious). Imagine yourself as a child, seeing the world through a child’s eyes, and then being introduced to a violent act—an act that serves to not only damage one’s physical body and mental/cognitive mind-set, but also disrupt one’s spiritual being.

This one act for some—repeated acts of violence for others—does untold amounts of damage to one’s psyche. Yet the resilience I’ve witnessed from many who choose to live their lives after the violence is remarkable. Unfortunately, for many the damage is such that many are unaware of how it has skewed their way of looking at the world. This sometimes is displayed in the relationships subsequent to the sexual assault.

Far too often, survivors believe that once the assault ends, it is done and they don’t need to talk about it. Yet the choices made, the decisions not made, and the relationships that come afterward tell a different story. Wounded attachment is an insidious component that I have seen repeatedly in my work with adult survivors of childhood sexual assault. What is wounded attachment? It’s the unconscious way of being attracted or attached to someone or something that reminds the survivor of or reinforces the wound/trauma, or in this case the sexual assault. At its core, it’s the way in which survivors subconsciously seek out relationships that reinforce the wounded aspect of themselves.

[fat_widget_left]Sometimes it is displayed in the choice of employment/work. For example, survivors may find themselves working at a job that belittles them, makes them feel worthless, or where they feel like they have to make everyone else happy at the expense of their own happiness, thereby reinforcing their wounded concept of self. Another example is when a survivor is continually engaged in romantic relationships that serve to reinforce the wounded parts of self.

As a child, depending on when the assault occurred and the developmental stage in which it occurred, the person seeks to please the adult and gain affection, attention, nurturing, love, trust, etc. A child who has been sexually assaulted blurs that idea of love, nurturing, trust, attention, and affection, and begins to believe that the only way to receive love, attention, etc., is to please the “assaulter.” This remains in effect as the child matures into adulthood.

Although the assault is no longer occurring, if the child did not receive any type of counseling, intervention, or effective treatment to process and repair the damage to the mind, body, and psyche, then this adult is continuing to live out the wounds experienced as a child. As such, the adult becomes caught in a cycle of relationships that reinforce the wounded attachments. Awareness of this plays a crucial role in helping adult survivors of sexual assault move toward recovery, resiliency, and healing.

Most people have experienced trauma at some point in time. The nature of traumatic experiences varies by severity and frequency and also differs with respect to the effect they have on survivors. Some people who have experienced violence, abuse, or disaster develop significant psychological problems and posttraumatic stress (PTSD) as a result of the trauma, while others appear to be more resilient and rebound with very few psychological problems.

Predisposition to mental health issues and stress sensitivity are two factors that have been theorized to affect risk for PTSD in trauma victims. But another factor that is less understood in relation to PTSD is intelligence. Intelligence quotient (IQ) can impact emotional regulation and reactivity and, therefore, it could be assumed that people with higher IQs may be more resilient to trauma.

To test this theory, Naomi Breslau of the Department of Epidemiology and Biostatistics at the College of Human Medicine at Michigan State University recently led a study involving 713 17-year olds. The participants were assessed for trauma history, type of trauma classified as assaultive trauma (sexual trauma, rape, life threatening trauma), or general trauma (accident, illness, disaster) and IQ taken at age 6. Breslau used this information to see how these factors affected PTSD at age 17.

She found that surprisingly, individuals of assaultive trauma were not more likely to develop PTSD than those of general trauma. However, Breslau did find a link between IQ and PTSD. “A drop of one standard deviation in IQ score measured at age 6 increased the relative risk ratio of PTSD resulting from either trauma type by approximately 50%,” she said.

This result can be interpreted in several ways. First, individuals with a lower IQ may be less able to regulate emotional reactions and thus be more vulnerable to PTSD. Second, making meaning of trauma and assigning context to a traumatic event may be easier for people with high intelligence. This can protect people from negative emotional responses and triggers, and decrease their vulnerability to negative mental health outcomes like PTSD. Although these findings clearly demonstrate a link between IQ and resiliency/vulnerability, more work should be done to determine how this link impacts younger and older individuals.

Reference:
Breslau, N., Chen, Q., Luo, Z. (2013). The role of intelligence in posttraumatic stress disorder: Does it vary by trauma severity? PLoS ONE 8(6): e65391. doi:10.1371/journal.pone.0065391

Shouting, yelling, screaming. Nearly all parents have done it; nearly all children age 10 and under have heard it. In small doses, such as in emergencies, yelling is not believed to be harmful. Yet, as common as this interaction is within families, if it happens too often it can break down positive conflict-management skills and flood a family’s emotional field with negative affect.

Why Do We Yell?

The most basic reason we yell in any situation is because, on some level, we feel we are not being heard. Whether literally—the person is in another room, for example—or figuratively, not feeling heard is an incredibly frustrating experience. When we believe we have a valid point and are being intentionally ignored, misheard, or invalidated, inside our brains we are thinking, “They must not really be hearing me. I will speak louder. That should do the trick!”

Yelling also stems from a need for control. Yelling is a form of verbal aggression; it carries the message that the yeller desires to be the loudest and most dominant person in the room. If someone is yelling, it is a good bet that the yeller is feeling out of control and is feeling the need to dominate the interaction.

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Parents often experience frustrating and even oppositional behaviors from young children. Depending on your child’s age, he or she may be focusing on developmental tasks ranging from establishing a sense of independence to experimenting with rebellion. The act of not listening to you can actually be part of your child’s necessary development.

At various times of the day or week, parents’ reserves of patience and energy can already be low. For example, a full-time parent may feel that he or she can barely make it to nap time with sanity intact. A pre-nap meltdown from their toddler hits them at their absolute lowest point of the day. A working parent’s morning can be so tightly orchestrated that just the slightest alteration in routine can cause a cascade of setbacks and tardiness. Throw in an early meeting and some traffic, and there is a perfect storm of frustration which can come lashing out toward a child. Parents can reach a saturation point at which their own coping skills are no longer carrying them through a particular interaction. At these points, parents often resort to yelling in an attempt to regain a sense of validation or control.

What’s the Case against Yelling in Families?

Yelling raises blood pressure, heart rates, and adrenaline levels. Those who yell exhibit higher levels of the stress hormone cortisol in their bloodstreams over time. These physical consequences are also seen in those who are yelled at. Like second-hand smoke, second-hand anger can take a big toll on health.

That’s a case against yelling in general, but in families with children age 10 and under, there are several other reasons that yelling isn’t healthy.

Children look to their parents to maintain the safety—physical and emotional—of the family. Babies and very young children do not yet have the ability to determine the difference between a real threat to their safety and an upsetting or frustrating circumstance. Many parents can attest to this, hurrying to the scene after having heard their toddler scream as if hurt, only to discover the source of the scream was a minor frustration such as not being able to reach a toy. The child’s cognitions in this stage are quite concrete; circumstances are either “all good” or “all bad” and there is little room for ambiguity. Children under age 5 can therefore mistake a parent’s loud tone with an alert to a true threat. This can be terrifying for a child in this developmental stage.

Fear is one of the most basic and universal emotions—every animal experiences it. Fear is centered on a primitive part of our brain called the amygdala. When fear permeates a young child’s emotional experience, such as in a household with daily episodes of yelling, the amygdala will become overly active and this will inhibit the child’s brain from working on higher-level functions such as concentration, reflection, learning, decision making, and behavior planning.

With older children who are more verbal, the words that are shouted can be even more harmful than the tone itself. Even though yelling is an attempt to gain control through aggression, the irony is that in doing so, we actually lose control of our behavior and our ability to filter and manage what we are expressing. Negative labeling, blaming, and other harsh words are especially harmful to children because children accept unconditionally that what their parents say is true. Children between approximately ages 5 and 10 have the cognitive ability to understand the words themselves, but not the adult’s emotional context. They will internalize the messages from the parent without questioning if they are accurate, and will add those messages to their budding self-concept.

[fat_widget_left]Finally, many parents who yell can relate to this scenario: “When I don’t yell, my child doesn’t listen to me. He or she only seems to respond (do what I want) when I yell.” The escalation involved in yelling can become a self-reinforcing feedback loop. Children can become desensitized over time to their parent’s escalation pattern. The child, who is interested mainly in persisting in play or attending to his or her own agenda, will naturally search for ways out of responding to a parent’s demands. We cannot fault the child for this; it is simply a piece of his or her development. The more parent-free space and time a growing child can carve out, the more he or she can explore the world around him/her and his/her own inner experience. The child learns that the parent will eventually escalate to yelling each time, and so the child learns that he or she does not need to respond until and unless yelling is used. The “pre-yelling” time becomes seen by the child as “don’t have to listen yet” time. And the parent, on the other side of this interaction, keeps needing to up the ante over time to get the same response.

How Do We Break the Yelling ‘Addiction’?

1. Set a SMART goal around yelling: a Specific, Measurable, Attainable, Relevant, and Time-bound goal that solidifies your commitment to changing this behavior. Such a goal may sound like this: “Within the next month, I will decrease my instances of yelling on weekday mornings until I’m yelling once per week or less during that time period.” Write down your goal and put it in a place you will see it every day.

2. Find ways to increase true power, so that false control is less tempting. Yelling is false control. It feels powerful in the moment, but it undermines our internal self-control and the quality of our relationships over time. Ways to gain true power include:

• rearranging your schedule to relieve some of the pressure on certain times of the day or week that you tend to yell
• asking for help and delegating tasks to decrease your overall stress
• planning ahead for triggering moments, such as taking a distracting toy to the grocery store, or laying out your child’s school clothes the night before
• taking advantage of calm times to focus on strengthening a positive relationship with your children which will serve to buffer any episodes of yelling

3. Assume responsibility for the outcome of each interaction. You are the parent. You set the stage for the relationship between you and your child. If your child escalates, this does not mean you must escalate. If the situation escalates, this does not mean you must escalate. No matter how bad the traffic, how frustrating the missing shoe, how grating the whining, or how sassy the defiance—in the end, you always have a choice.

4. Speaking of choices, realize that yelling is only one of hundreds of things you can choose to do in a frustrating moment. Instead of yelling, you could:

• whisper
• sing
• dance a jig
• say a little prayer
• close your eyes and count to 268
• take a lap around the house
• splash your face with water
• go outside and yell at the snowman or rosebush in your yard instead

Some parents choose a grounding object, color, or mantra which they use to bring their attention away from their momentary anger and refocus it on their goal.

5. Return often to a developmental lens through which to view your children. At all times, children must be expected to behave as children. They cannot and do not think, process, or behave as you do. It is entirely predictable that children will lose things, drag their feet, misunderstand you, ignore you, and throw tantrums at inopportune times. The more you can remind yourself that this is developmentally normal, the less you will feel personally offended or annoyed by childish behavior.

6. When—not if—you do yell, be prepared to acknowledge and apologize for this to your children. Parents must be willing to role-model to children the process of owning up to poor choices and the effects they can have on others. If as parents we are not willing to do so, how can we expect the same from our children?

Breaking ingrained patterns of interaction like yelling is not an easy thing to do. Parents must take full responsibility for “being the change they want to see” in their families. Parents must make their tendencies and triggers conscious, face them honestly, and focus their attention on them if they wish to change. Keeping a written goal, a list of alternatives, and a developmental perspective will be of great help to the parent who wishes to reduce yelling. Over time, parents who make these efforts will be able to enjoy a great deal more peace in their family, a reduction in stressful feelings, and an increase in the amount of true power they are able to exert over their lives and actions.

May is Mental Health Awareness Month, a time to recognize a range of issues—depression, bipolar, and schizophrenia among them—and the effects they have not only on the people personally experiencing and struggling with them, but on society at large. But what does it mean to be aware of mental health, exactly, and how does that awareness manifest?

Events in the news regularly challenge our perceptions of mental health, or what we may perceive as a deficit thereof. From the marathon bombings in Boston to the Newtown tragedy to the discovery of three women held in captivity in Cleveland for nearly a decade, some of the most compelling stories in recent times have been widely associated with mental health concerns. In some cases these concerns relate to victims, in others to perpetrators of violent acts. In almost all cases, though, an initial wave of outrage gives way to apathy and disconnect as the story fades from public consciousness.

While dedicating a month to mental health awareness is nice, it’s clearly not enough. We wanted to know what our Topic Experts had to say about the matter, so we asked them the following questions: What does mental health awareness mean to you as a mental health practitioner? Is awareness, in your estimation, on the rise or decreasing in recent years? Why? What obstacles do therapists and nontherapists alike face in their efforts to increase awareness of mental health issues? What can be done to combat stigma?

Their responses follow:

• Sarah Swenson (autism spectrum): “I work as a psychotherapist with gifted children and adults. This is one of the most underserved populations in the entire area of mental health. Gifted children are routinely misdiagnosed with ADHD, OCD, impulse control disorder, and even disorders of the personality. Often, these children are medicated. This creates a chain of events with effects that extend well into the future. … It is not only to the general public that the topic of mental health awareness is significant. It is also of importance to our health care providers and the medical schools that train new practitioners. Only through the addition of coursework in the identification and clinical presentations of intellectual giftedness will the tide turn. If physicians know what they are looking at, their diagnoses and referrals will change, and children who need no medication in the first place will benefit because they will no longer be medicated into altered states that create negative environments for their giftedness to blossom and grow.”
• Tom Wooldridge (systems theory / therapy and family-of-origin issues): “What is mental health awareness? For me, it has two components. First, we pay attention to our own mental health. What is the legacy of mental illness in my own family-of-origin and how does it affect my day-to-day life? How am I dealing with the experiences—both positive and negative—that I had growing up? What is my attitude toward my own emotional difficulties? Am I able to relate to them nonjudgmentally and with compassion? Second, we recognize the impact of mental illness and emotional suffering on those around us—friends, family, and the larger community—and begin to struggle with the question of how this awareness can inform our day-to-day lives. What are our attitudes toward those we encounter who are struggling with severe mental illness? Over time, we hope to find ways to support them in their struggles and to recognize our ultimate interconnectedness.”
• Stephen L. Salter (values clarification / eating and food issues): “The efforts of the mental health awareness project, while coming from a caring place, can do more to obscure awareness than promote it. Sure, it might be useful to understand ‘bipolar’ and ‘depression,’ but the effort becomes counterproductive if it is not contextualized within the much larger question, ‘What does it mean to be human?’ Perhaps we’d be better served to offer a month contemplating that question. We assign some really strange names to people—like ‘schizophrenic.’ More often than not, it further exiles the ‘mentally ill’ into a class of otherness. To truly understand mental health, the first diagnosis must always be human.”
• Deb Hirschhorn (relationships and marriage): “The stigma must come out of ‘mental health’ in people’s minds. The recent mass murderers needed help long before they became adults—and the help came too little, too late if it came at all. Here is what should happen instead: School counselors should be vigilant and then call parents in to discuss their children when something seems not right about a child. However—and this is a big however—it should be handled in a way that does not make the parents feel ‘one-down,’ but rather with great humility and kindness on the counselor’s part. The message should be sympathetic to whatever the parents and child may be experiencing. After all, if the child is being bullied at school or excluded from cliques, the child may need help with social skills and the parents may themselves not be strong in this area. This is nothing to be ashamed of: We all have our strengths and our weaknesses, and that point should be made to them. I, for example, can’t sing on key to save my life, and these parents may be great musicians. Not everyone is great in the social area, parents included, and even ones who have those skills may not have the skill of passing it on to their children. School counselors should be referring such children as soon as the problem becomes evident, even as early as kindergarten, and the referral should be geared toward handling difficult social and academic situations, dealing with abuse at home, and self-esteem building. It should not automatically include a prescription for medication. Therapists of all stripes must recognize the inherent value in talk therapy so that we can promote that message to the public.”
• Deborah Klinger (eating and food issues): “I believe that mental health awareness is increasing. High school counselors whom I’ve come in contact with are knowledgeable and concerned about students’ mental health issues, and the universities in my area have excellent campus counseling services that liaise with psychotherapists in the community. None of this was the case when I was in high school or college. The National Association of Mental Illness (NAMI) holds local family-to-family support groups for family members of mentally ill persons. And I hear mention and discussion of depression, bipolar, eating disorders, etc., everywhere—in national news media, online, and in day-to-day conversation. Not only has awareness of mental health issues increased, but so has understanding and acceptance.”
• Lynn Somerstein (object relations): “Thanks for asking about mental health awareness. I am sad people remain largely uninformed about mental health issues and are often reluctant to seek help because of the stigma that still comes with the territory. Treatment should be made more available, too, to those who want help but can’t afford it. Many therapists make private, sliding-scale arrangements for those without health insurance, but what we really need is better government health care and education about the many different avenues available—from talk therapies to medication.”
• Olga Gonithellis (creative blocks): “Reflect, talk, act! This month is an excellent opportunity for every one of us to reflect upon the importance of mental health, to start talking, and to take action. One of the common misconceptions is that talking about it creates it. There is an irrational fear that by sharing knowledge and information about mental illness, one will reinforce its existence. However, opening up communication and sharing facts and experiences are helpful tools in dealing with all sorts of psychiatric conditions, from depression to panic and from body dysmorphia to schizophrenia. Using my area of interest as an example, there is growing scientific research regarding the prevalence of psychiatric issues in performers and creative individuals. By encouraging a genuine curiosity about this topic, we are able to dispel myths and to discover realities. Artists have been able to receive help and guidance on concerns such as performance anxiety, low self-esteem associated with stress in the entertainment industry, the connection between mood and creativity, and more. Similarly, there are many other topics related to what impacts mental health that need to be addressed in our homes, our schools, and our communities. However, without awareness and a nonjudgmental approach, we will not get very far. Let us use this month as a chance to reflect, talk, and act!”
• Andre S. Judice (posttraumatic stress / trauma and energy psychology): “Mental health awareness is the recognition that our psychological well-being is an important part of our own health, productivity, and happiness, as well as the well-being of our communities. In my opinion, mental health awareness is on the rise in our country. Certainly, recent events across our nation have called this issue to the forefront as we are forced to consider the motivations of people who set out to harm others. Unfortunately, it seems that to this day in our culture too few people understand the factors that contribute to or hamper good mental health. On the other hand, our efforts to increase people’s awareness of these factors, as well as the various ways that we can each be more psychologically well, seem to be taking hold. … I believe that one obstacle to increasing mental health awareness is in the various belief systems (be they entrenched family beliefs, religious beliefs, or other beliefs held by a given group) that lead people to adhere to ineffective and antiquated value systems in which others are told that they don’t need outside assistance but merely willpower to be better and help from within the group itself. In these situations, people needing more effective ways to improve their mental well-being miss important assistance and opportunities. Certainly, stigma associated with reaching out for help is another obstacle which seems best resolved with increasing numbers of people being open about their own utilization of mental help support systems.”
• Shannon McQuade (addictions and compulsions): “It would be helpful to simply acknowledge that we all have a nervous system that, like anything else in the body, can break down. We are all at risk for mental health issues. Like cancer, some are more vulnerable than others. Many people have been rushed to the emergency room believing they were having a heart attack, only to discover that they were actually having a panic attack. A mental assessment should be part of a regular doctor visit, with referrals made to specialists as needed. If everyone was being screened as though it were no big deal, we would see attitudes change. Additionally, an increasing number of mental health professionals are ‘coming out of the closet’ and risking exposure to put a face on mental health issues, letting people know that we (myself included) who struggle with these issues can lead full, happy, productive lives if we have the right resources. Dr. Marsha Linehan, developer of dialectical behavior therapy, announced in 2011 that she had struggled with borderline personality issues, a diagnosis that carries a very heavy stigma and is difficult to treat. Though she had been apprehensive in sharing this (with good reason) early in her career, she decided that sharing her experience and recovery would bring hope to others. I think this a great example of self-disclosure that is helpful to our clients and to the public in general.”
• Marian Stansbury (imago relationship therapy): “It appears the awareness of mental health has been increasing over the years, especially influenced by people like Oprah. Being aware of not only what we’re feeling in our bodies, but also in our emotions and in our thoughts, is critical for good mental health. An obstacle to this is when we judge ourselves as having something wrong with us and then have too much embarrassment or shame to ask for the support we need. Or, we worry about what others would think if they found out. Just as we go to medical doctors when we have pains in our bodies, it’s important to seek out mental health professionals when we’re having disturbing emotions and/or relationships. A quick quiz to assess our mental health: (1) Do we scan our bodies for tension and ask what might be causing us to tighten up? (2) Do we use the principles of rational thinking that will lead to more positive emotions? (3) Do we check our emotional levels each day? (4) Do we ask ourselves how we’re treating others? How we’re treating ourselves? These aspects all comprise good mental health. Meditation and exercise are two important ways to be more mentally aware and to assess these different aspects.”
• J. D. Murphy (drug and alcohol addiction): “Tragedies such as that seen in the recent Newtown school shooting that continue to make the headlines over recent months and years leads this therapist to conclude that the progress needed in the treatment of mental illness is far from where it needs to be! This despite the growing availability of effective treatment, mental health professionals, and treatment facilities. One would have to question if this escalation is due, at least in part, to the stigma that many place upon the thought of being considered to have a mental illness, or, for that matter, to even have a family member or close friend who is challenged by such. Undoubtedly, recent cutbacks in the funding of programs designed to provide treatment for those struggling with a mental or addictive disorder has and continues to have an adverse impact on these populations. Schools, communities, organizations, churches, and, yes, even governmental entities must begin to work together in more effective efforts to raise awareness, normalize, destigmatize, provide funding for and treat such individuals.”
• Angela Lee Skurtu (relational psychotherapy and sexuality / sex therapy): “Mental health awareness includes both awareness of the number of people affected by mental health issues and the need for affordable interventions. For example, major depression affects approximately 14.8 million American adults every year. The National Institute of Mental Heath (NIMH) reports that it is the leading cause of disability in the U.S. for adults and teens. However, many insurance plans will not provide a minimum number of therapy sessions for mental health. … Other obstacles include public perceptions of therapy and a tendency for bad therapy to have wide ripple effects. When clients experience bad therapy, they share that information with others. This further reinforces the stigma already attached to mental health. Compound this with images of therapy in the media, and we have further misunderstandings. … To combat stigma, we need to improve our field. We need to increase funding for research and consistently publish new research in magazines aimed toward the public. We need to put that research into practice in our daily treatment. When we get better at treating mental health issues, people will see the value of what we do and mental health diagnoses will be seen as what they are: health issues that benefit from treatment.”
• Kelley Garry Marschall (worry): “Part of therapy is meeting people ‘where they are at.’ And these days, people are incredibly busy. Folks worry they’re not doing enough at home, work, and in their communities. Mental health clinicians hanging on to the gold standard of workday office appointments as the only way to help people is no longer meeting people where they are. It just creates more stress. We can email, Skype, and talk on the phone with our physicians about our physical health; why not talk to our clinician about our mental health? If practitioners can be less ‘couch bound’ and more open, with a client’s permission, to using multiple modes of communication to help people, the more accessible, open, and everyday mental health becomes. Tossing the couch may help the stigma fade away in the bright sunshine of everyday accessibility.”
• Tonya Lapido (relational psychotherapy and multicultural concerns): “In 2004, none of my clients referred their friends or family to me. People said the same thing over and over: ‘You’re a great therapist but I’m not telling anyone that I’m in therapy.’ Previously, our society equated mental health with ‘being crazy.’ While some maintain that perspective, it is also countered with the understanding of mental health as part of health. The discussion of wellness and work/life balance brings mental health to the forefront as an aspect of life that needs attention. … I recently attended a large business luncheon. I was the only therapist, and as I described my services the conversation quickly turned to the stigma associated with therapy. Three people stood up and said that they had previously been in therapy and found it useful. They weren’t shunned but applauded. Everyone literally applauded them for being open about their experience with mental health. … Though some stigma remains around mental health and its treatment, our society is moving in the right direction. In 2013, I have seen a rise in word-of-mouth referrals in my practice. People are telling others not only about the benefits of therapy but also that they themselves are in therapy!”
• Irene Hansen Savarese (communication problems): “Awareness of self is essential for change. May is Mental Health Awareness Month. As a marriage counselor and a relationship specialist, awareness of self in my work with couples and families stands out. … When clients ask a therapist for help, they are very much aware that something in their relationship isn’t right. Often partners are focused on what the other is doing wrong or not doing right. They’ll tell me that they don’t feel understood and that they don’t feel respected by their partner. Most partners feel that they have tried everything to fix their partner in the hope of fixing their relationship. … In my initial sessions with partners, I talk about the importance of each partner developing an awareness of himself or herself rather than focusing on what the other should be doing differently. I also look at how they react to each other in conflict situations and whether they manage to keep connected and engaged. These are important first steps to ensure an attitude conducive to partners being able to reach out to each other and work as a team.”
• Sarah Noel (person-centered / Rogerian therapy): “As I see it, mental health awareness is about educating the public on mental health issues, treatment options, and success stories. The more information people have about mental health issues, the better able they will be to recognize signs and symptoms, in both themselves and others. Further, the more information people have about treatment options and success stories, the more hope they will have. Hope is a powerful thing and often leads people to therapy. … Like many issues, I think the stigma associated with mental health issues has declined as awareness has increased. I think one way to continue the decline of stigma is to look at ‘mental illness’ in context. For example, a child who is raised by neglectful, unloving parents may become fiercely independent, requiring little from anyone. This is incredibly adaptive behavior that will allow this child to survive; however, taken into adulthood this behavior can create myriad personal and professional relationship issues. Failure to succeed personally and/or professionally might lead to depression. Understanding ‘mental illness’ as something that was once adaptive but simply no longer works is empowering, not stigmatizing—if you were able to adapt in the past, you can do so again.”

What do you think about what our Topic Experts shared? What does mental health awareness mean to you? Let us know your thoughts in the comments section below.

Attention deficit hyperactivity (ADHD) manifests with symptoms of inattention, hyperactivity, and impulsivity. In the criminal population, impulsive behavior is a common thread. However, few studies have sought to determine whether ADHD increases the likelihood that a person will engage in criminal behavior. The effects of ADHD are broad, varied, and long term. To accurately predict how ADHD will influence future behavior, one must look at other environmental and familial factors. To this end, Jean-Baptiste Pingault of the Research Unit on Children’s Psychosocial Maladjustment at the University of Montreal and Sainte-Justine Hospital in Canada recently led a longitudinal study involving more than 2,700 individuals.

The participants were first evaluated for ADHD, physical aggression, inattention, and family adversity when they were 6 years old. They were reassessed annually for seven years. When they were 25, criminal records and teacher and parent reports were examined in order to find any association between the measured risk factors and criminal behavior. Pingault discovered that in certain analyses, childhood ADHD was linked to criminal behavior. But in the most sensitive analysis, the association was weak at best. However, childhood physical aggression was directly predictive of later criminal behavior.

The findings revealed that while less than 10% of the total sample exhibited physical aggression in childhood, this small group represented 30% of the criminal activity in adolescence and young adulthood. Further, these same participants were responsible for almost half of the criminal charges on record and nearly 60% of all the violent criminal charges. Family adversity also increased the risk for criminal behavior in the aggressive participants. Pingault believes these results show that not all children with ADHD are at risk of engaging in criminal behavior. But children with aggressive traits, and especially those with ADHD and family adversity, are more vulnerable to criminal activities. Therefore, efforts to reduce crime may not be most effective if focused solely on children and young people with ADHD. “Crime prevention should instead target children with the highest levels of childhood physical aggression and family adversity,” said Pingault.

Reference:
Pingault, J-B., Côté, S.M., Lacourse, E., Galéra, C., Vitaro, F., et al. (2013). Childhood hyperactivity, physical aggression and criminality: A 19-year prospective population-based study. PLoS ONE 8(5): e62594. doi:10.1371/journal.pone.0062594

According to the results of a recent study, not all aggression is bad. Konrad Bresin of the Psychology Department at the University of Illinois Urbana-Champaign recently conducted two separate studies examining the cathartic effect of aggression. Bresin wanted to counter the existing body of research on aggression, which suggests that for the most part, aggression is maladaptive and has only negative consequences, such as violence. Bresin based his research on the catharsis theory that implies there is a healing and anger-reducing affect that occurs through aggression. It is important that a distinction be made between aggression and violence, as the two behaviors are not mutually exclusive. Aggression, in this study, was the act of participants verbally retaliating against negative feedback. In one study, the participants were instructed to aggress toward the person who gave the feedback or a neutral individual. Measures of anger were assessed prior to and after the feedback was delivered. In the second study, Bresin wanted to see if participants who had reductions in anger in the first study would be more likely to aggress at a future time.

Overall, the results of both studies supported Bresin’s predictions and the catharsis theory. In the first study, the participants who aggressed against the source of the negative feedback had sharp decreases in anger when compared to the participants who aggressed against nonsource neutral controls. In the second study, Bresin found that these same individuals who had anger reductions were more likely to aggress in another experiment. These findings demonstrate that aggressing toward a source of frustration can have a very cathartic effect. Anger and hostility that may increase during a tense situation can be easily moderated with aggression. Although some forms of aggression are maladaptive, such as abuse, physical violence, and verbal abuse, adaptive forms of aggression appear to not only create a calming effect, but also empower participants with the tools necessary to regulate anger emotions in the future. This is especially important for people prone to violence. Because anger, aggression, and violence are quite different, being angry does not always cause someone to become violent. Bresin believes that this study shows how adaptive aggression can potentially reduce the risk of violence by decreasing feelings of anger and frustration. He added, “Future research may address the question of whether changes in anger following violence (or aggression) have similar relations to future violence.”

Reference:
Bresin, Konrad, and Kathryn H. Gordon. (2013). Aggression as affect regulation: Extending catharsis theory to evaluate aggression and experiential anger in the laboratory and daily life. Journal of Social and Clinical Psychology 32.4 (2013): 400-23. ProQuest. Web.

Children are a product of their environments. Just as children who are brought up in loving, supportive, and caring environments are more likely to behavior that way as adults, children who are brought up in fear, anger, and hostility have a higher chance of experiencing similar environments in adulthood. But does this same theory apply to acoustic and physical chaos? Syeda Shamama-tus-Sabah of the National Institute of Psychology at Quaid-i-Aaam University in Pakistan wanted to explore this question. In a recent study, Shamama-tus-Sabah reviewed parent and teacher reports on 150 elementary school children. The children ranged in age from 8 to 11 years old and were all living with educated mothers. The children were assessed for depression and aggression to measure adjustment.

Shamama-tus-Sabah found a direct link between chaos and adjustment. “The results indicate that children from high chaotic families exhibit more aggression and depressive symptoms as compared to children from low chaotic families as reported by their parents and teachers,” said Shamama-tus-Sabah. This finding suggests that children who are not living in structure and routine may be more likely to struggle with behavior problems. This can lead to risk taking, including alcohol and drug use, tobacco initiation, and even sexually risky behavior. When Shamama-tus-Sabah looked at gender as a contributing factor, she found no difference in the chaos-adjustment relationship for girls and boys.

Some research has suggested that boys are more sensitive to chaotic environments, and therefore have higher levels of maladjustment than girls from similar environments. This research provided no support for that theory, but future research might explore that more in order to see if other types of maladjustment, aside from depression and aggression, manifest in boys more than girls. In western cultures, chaotic homes are not uncommon. However, in Pakistan, the increase in chaotic home lives, with more parents working and cities becoming overcrowded, could increase the risk for maladjustment in the youth population. In order to get a broader picture of the effects of chaos, future work should examine the gender aspect more thoroughly and should include parents of varying degrees of education and socioeconomic status.

Reference:
Shamama-tus-Sabah, Syeda, et al. (2013). Chaotic home conditions and children’s adjustment: Study of gender differences. Pakistan Journal of Psychological Research 27.2 (2012): 297-313. ProQuest. Web.

Being stalked can be paralyzingly frightening. Victims aren’t traumatized just once; they’re perpetually unsettled by attempts at contact and often begin to feel like there’s no safe place to go.

The Bureau of Justice Statistics reports that about three million people are stalked every year, most by people they know—often a former intimate partner. As many as 10% of stalking victims fear for their lives, and all victims face massive disruptions to their routines. While stalking, like domestic violence, has been around for generations, it has been only in recent years that the issue has been taken seriously, and many victims may be hesitant to seek help.

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What Is Stalking?

At its core, stalking consists of repeated attempts to gain control over or terrorize someone. Stalking exists on a continuum. On the lower end, it might involve repeated phone calls, letters, or email contacts. In its more extreme manifestations, however, stalking might involve repeatedly going to a person’s house, making threats against a person, harming pets, stealing possessions, or interfering with a person’s relationships with friends, family, or coworkers. Stalkers may alternate between patterns of domestic violence and stalking.

Each state establishes its own legal criteria for stalking. Laws generally require multiple unwanted contacts and mandate that a victim fear for his or her safety. A coworker who comes back to see a person at his or her office daily, for example, would not be stalking, and a secret admirer who sends flowers once per week is not necessarily a stalker. Repeated contacts rise to the level of stalking when they’re designed to gain power over a person and cause emotional terror.

Why Do People Stalk?

Stalkers often emphasize that they “love” their victims and occasionally say they stalk to keep others safe. For example, an abusive ex-husband might say he stalks his ex-wife to ensure she’s properly caring for their children. Psychologically, however, stalking is a crime of control. Stalkers see their victims as possessions who are rightfully theirs, and stalking behavior is frequently activated by a breakup or an ex-partner’s new relationship.

Some mental health issues can lead to stalking. People with personality issues such as a borderline personality diagnosis may have trouble letting go of relationships and sometimes use manipulative tactics to control people. Erotomania is a delusion in which a person believes that another person—often a celebrity—is in love with him or her, and this can lead to stalking. However, not all stalkers have mental health conditions, and the overwhelming majority are men. Cultural and gender norms may contribute to stalking behavior.

What Can Victims Do to Get Help?

If you’re being stalked, don’t make excuses for the stalker or tell yourself you are overreacting. Tell a friend or family member what’s happening so you have a support person and a witness. If you are in immediate danger or are being followed, dial 911. There’s no price for overreacting, but underreacting to stalking can, in extreme cases, be fatal. Other things you can do to remain safe:

• Change your routine frequently so that it is more difficult for your stalker to find you.
• Instruct friends, family, and employers not to give out information about you without your express permission.
• Keep a log of every incident so you have evidence if you need to press charges.
• Seek a restraining order against the stalker, and call the police immediately if he or she violates the order.

References:

1. Help for victims. (n.d.). Stalking Resource Center. Retrieved from http://www.victimsofcrime.org/our-programs/stalking-resource-center/help-for-victims
2. King, M. W., & Sivak, A. (n.d.). Stalking: New studies shed light on a crime that terrorizes its victims. National Crime Prevention Council. Retrieved from http://www.ncpc.org/programs/catalyst-newsletter/catalyst-newsletter-2009/volume-30-number-11/stalking-a-new-study-sheds-light-on-a-crime-that-repeatedly-terrorizes-its-victims
3. Stalking. (n.d.). National Institute of Justice. Retrieved from http://www.nij.gov/topics/crime/stalking/
4. Stalking. (n.d.). USDOJ: Office on Violence Against Women: Crimes of Focus: Stalking. Retrieved from http://www.ovw.usdoj.gov/aboutstalking.htm

Intimate partner violence (IPV) occurs in a large percentage of young adult relationships. Several factors increase the likelihood of IPV, including low socioeconomic status, living in urban communities, drug and alcohol use, witnessing or experiencing familial or domestic violence, and younger age. It has also been theorized that many relationships that experience IPV also have a component of reciprocity. In other words, many victims of IPV may also perpetrate violence against their partners. And although it has been shown that more women are victims of IPV resulting in physical injury than men, it is unclear whether or not women perpetrate a large portion of retaliatory or reciprocal aggression in violent relationships.

To get a better idea of the rates of bidirectional IPV, Niki Palmetto of the Mailman School of Public Health at Columbia University in New York recently conducted a study based on self-reports from 618 young adult women in committed relationships. She looked at history of violence, victimization, and perpetration. Over one third of the women reported having experienced at least one episode of IPV, with 12% reporting only perpetrator violence, 3% reporting being the victim only, and 19% reporting bidirectional violence. This means that nearly one in five women in this study report being both the victim and perpetrator of violence in their relationships. Factors that increased risk for bidirectional status included history of childhood sexual abuse, exposure to family IPV, younger age, and longer relationship duration.

Palmetto also found that African-American women and those who had more than two previous pregnancies were most likely to report bidirectional violence. She believes that pregnancies can present a threat to both partners, thus increasing the risk for violence. Also, Palmetto theorizes that African-American women who contribute to the financial well-being of their families may have less tolerance for victimization and may be more prone to retaliating with aggression when they are victimized. This dynamic would directly increase the rate of bidirectionality among this segment of women. Palmetto also points out that this study was based on self-reports from a nondiverse sample of women. She hopes future research extends these findings by studying women of varying ages, ethnicity, and socioeconomic status. Until then, Palmetto feels her findings contribute significantly to this area of research. She said, “We believe this study to be a critical step in the examination of bidirectional violence within adolescent and young adult dating relationships.”

Reference:
Palmetto, Niki, et al. (2013). Predictors of physical intimate partner violence in the lives of young women: Victimization, perpetration, and bidirectional violence. Violence and Victims 28.1 (2013): 103-21. ProQuest. Web.

We all engage in manipulation from time to time. When your boss asks you what you thought of his or her terrible presentation and you render lavish praise, you’re concealing your real feelings in an attempt to elicit the reaction you want from someone in power. But in close interpersonal relationships, manipulation can take on a much darker hue, leaving its targets never quite knowing where they stand.

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The very nature of manipulation makes it challenging to know when you’re being manipulated. Manipulators attempt to conceal their motives and feelings, and their targets—who often struggle to sustain an honest, open, and manipulation-free relationship—may have to do some detective work to determine whether they’re being played.

What Is Manipulation?
Manipulation is the process of trying to change another person’s feelings, beliefs, or behaviors through indirect tactics. Rather than asking for what they want, manipulative people tend to use deception, coercion, even threats to get their needs met.

Manipulation is associated with a number of mental health conditions, including borderline personality disorder, passive-aggressive personality disorder, addiction, antisocial personality disorder, and narcissism. Not all manipulative people have mental health issues, but when manipulation becomes a primary style of interaction, it can indicate an underlying psychological issue.

Tactics Manipulators Use
If you’re concerned that you’re being manipulated, examine the tactics the other person is using. If you find yourself caught up in a web of deception and unclear motives, it could be manipulation.

Some common tactics manipulators use include lying, withholding information, denying feelings, playing the victim, blaming the victim, minimizing others’ feelings, pretending to be confused or ignorant, guilt, shame, and pretending that his or her tactics are intended to serve a higher calling such as God or a political cause. Manipulators also frequently use gaslighting—the process of provoking someone into an extreme or angry reaction, then blaming the other person for his or her reaction.

While anyone can be manipulated, expert manipulators tend to target people with and take advantage of certain personality traits. These traits include:

• The desire to be liked or to please; these people are more likely to take extraordinary measures to gain favor
• Low self-esteem
• Dependency; people who tend to be dependent upon others will be more easily swayed by threats to withdraw love or support
• Naiveté or ignorance
• Loneliness
• Impulsivity, greed, and materialism
• Low assertiveness
• Fear of anger, sadness, and other negative emotions—either in oneself or from the manipulator

Why People Manipulate
For some people, manipulation may be an inadvertent strategy for dealing with a cutthroat world in which discussing feelings is often taboo. Manipulation is part of the normal range of behavioral tactics, and most people engage in manipulative strategies from time to time. People whose primary style of interaction is manipulation, however, tend to share some traits in common. These include:

• A need for control or power over others
• A need to raise their own self-esteem
• Fear of abandonment
• Feelings of worthlessness, helplessness, or hopelessness
• A willingness to prioritize their own feelings and desires over the needs and well-being of others

How to Handle a Manipulator
Many of us are highly aware when we’re being manipulated, but are still left unsure of what to do. Because manipulators often play the victim, some victims of manipulation might excuse their behavior or insist that the manipulator doesn’t really know what he or she is doing. Manipulators thrive on hiding their motives, so it can be challenging to get them to admit their true intentions, and many people will refuse to do so even under pressure. Instead, try the following tactics:

• Avoid allowing yourself to be shamed or guilted into doing something.
• When a manipulator makes a covert threat, ask him or her about the threat.
• Ask the manipulative person if he or she can tell you directly what he or she wants.
• Avoid sharing how the manipulation makes you feel, as these feelings can later be used as a tactic by the manipulator.
• Be direct, clear, and honest, and refuse to participate in the escalating game of manipulation.

References:

1. Psychological harassment and psychological manipulation. (n.d.). Psychological Harassment Information Association. Retrieved from http://www.psychologicalharassment.com/psychological_manipulation.htm
2. Simon, G. K. (n.d.). Dealing with manipulative people. RickRoss.com. Retrieved from http://www.rickross.com/reference/brainwashing/brainwashing11.html
3. Spotting emotional manipulation. (n.d.). Cassiopaea. Retrieved from http://www.cassiopaea.com/cassiopaea/emotional_manipulation.htm

Although jail time might seem like a distant possibility for most people, incarceration rates in the United States are steadily rising. One study published in the journal Pediatrics found that 41% of young adults have been arrested by the time they are 23. The U.S. Department of Justice (DOJ) reports that 6.6% of people serve time in prison at some point in their lives, and the statistic rises to a shocking 32% for African-American men. More than half of inmates are diagnosed with a mental health disorder.

As state mental hospitals continue to close and mental health services remain financially out of reach for many people, this number may rise. Moreover, prison itself can exacerbate preexisting mental health issues and create new mental health challenges among those who had never experienced them.

Mental Health Care Behind Bars

Jails and prisons are required to provide basic health care for inmates, but the quality of this care varies greatly. Often, prison-based mental health care focuses on stabilizing, rather than treating, inmates. A person experiencing hallucinations or psychosis might get medication to control the most severe symptoms, but people with anxiety issues, depression, posttraumatic stress, and other mental health conditions that don’t cause radical changes in behavior may go untreated. Prisoners rarely, if ever, get therapy or comprehensive treatment, so mental health issues that were previously controlled with medication and therapy may get much worse during incarceration.

Prison and Trauma

Even for the most hardened criminals, prison can be a scary place. The DOJ reports that 70,000 prisoners are sexually abused every year, and assaults, fights, and other acts of violence are common in a prison setting. But violence isn’t limited to inmates; prison guards work in a high-stress environment that can increase their likelihood of becoming violent. With little hope for reporting abuse by guards, some inmates may endure verbal abuse, threats of physical violence, and even severe attacks. Women inmates are at an increased risk of being sexually assaulted by jail and prison guards. This ongoing climate of trauma can create anxiety, depression, phobias, and PTSD in prisoners who previously had no serious mental health issues.

Lack of Support

Prisoners are, by definition, cut off from the rest of society, and their access to supportive friends and family may be limited. Many jails have instituted mail policies prohibiting letters and magazine subscriptions, and these policies can eliminate prisoners’ ability to communicate with and receive support from loved ones. Phone calls from jail can be costly, and prisoners from impoverished backgrounds may have families who can’t afford to cover the costs of collect calls, however infrequent. There’s little hope for getting any support in prison, as many prisoners are concerned more with gaining respect and avoiding fights in a relentless pursuit of safety. Support from loved ones can play a critical role in helping people overcome mental challenges, and isolation can increase a person’s risk of mental health issues such as depression and anxiety.

Getting Out

Most prisoners have ignored basic rules of society, so it can be difficult for prisoner rights issues to garner much public sympathy. But many prisoners are incarcerated for nonviolent drug crimes that are the result of substance addiction. And even inmates incarcerated for violent crimes do not typically serve life sentences. Most prisoners are ultimately released, and the mental health issues they develop in prison can increase their risk of reoffending and make it difficult to reenter society as a productive, nonthreatening citizen. Almost 70% of people who have been incarcerated are arrested again within three years, and the dire state of mental health care in prisons could play a significant role in this high rate of recidivism.

A mental health professional can help people who have come into contact with the prison system. A therapist can help prisoners reenter society or reestablish bonds with friends and family. Loved ones of incarcerated individuals can also get necessary emotional support in therapy. Therapy is a safe and confidential place for any and all people to get help.

References:

1. Chaddock, G. R. (2003, August 18). US notches world’s highest incarceration rate. The Christian Science Monitor. Retrieved from http://www.csmonitor.com/2003/0818/p02s01-usju.html
2. Gann, C. (2011, December 19). Study: Significant number of young Americans get arrested. ABC News. Retrieved from http://abcnews.go.com/Health/arrests-increasing-us-youth/story?id=15180222
3. James, D. J., & Glaze, L. E. (2006, December 14). Mental health problems of prison and jail inmates [PDF]. Washington, D.C.: U.S. Department of Justice Bureau of Justice Statistics.
4. Purdy, M. (1995, December 19). Brutality behind bars. The New York Times. Retrieved from http://www.nytimes.com/1995/12/19/nyregion/brutality-behind-bars-special-report-prison-s-violent-culture-enveloping-its.html?pagewanted=all
5. Recidivism. (n.d.). Bureau of Justice Statistics (BJS). Retrieved from http://bjs.ojp.usdoj.gov/index.cfm?ty=tp
6. Sakala, L. (2013, February 7). Return to sender: Postcard-only mail policies in jails. Prison Policy Initiative. Retrieved from http://www.prisonpolicy.org/postcards/report.html
7. U.S.: Federal justie statistics show widespread prison rape. (2007, December 16). Human Rights Watch. Retrieved from http://www.hrw.org/news/2007/12/15/us-federal-statistics-show-widespread-prison-rape
8. U.S.: Number of mentally ill in prisons quadrupled. (2006, September 6). Human Rights Watch. Retrieved from http://www.hrw.org/news/2006/09/05/us-number-mentally-ill-prisons-quadrupled