Category: Psychiatry

Newsletter At CAMH Pet Therapy Helps...-068b08cc0811ed97f736ccd97551bc74c2a7bf44

At CAMH, Pet Therapy Helps Decrease Stigma

00Emotion Regulation, Featured news, Happiness, Law and Crime, Loneliness, Psychiatry, Therapy May, 16

Source: Ryan Faist, Used With Permission

When I tell others that I volunteer with my dog in a pet therapy program, they assume my work involves children or the elderly. I am not surprised: the benefits of animal-assisted therapy for these groups are widely known.

But my dog Rambo’s “patients” are quite different. He and I volunteer at an inpatient unit at the Centre for Addiction and Mental Health (CAMH) in Toronto. The people Rambo sees every Tuesday reside in the Secure Forensic Unit.

Accused of committing crimes ranging from shoplifting to homicide, these individuals all suffer from severe mental illness. Their treatment at CAMH is court-ordered, and they are routinely assessed by mental health professionals to determine if they can be held responsible for their crimes.

Theresa Conforti, the co-ordinator for Clinical Programs and Volunteer Resources at CAMH, explains how pets factor into the equation:

“For the past 10 years, CAMH has had their own Pet Therapy Program that is very unique and caters only to the clients at CAMH. The clients value the unconditional love and affection the dog gives them on a weekly basis. The importance is that this program bridges the gap for those who have had to leave their furry friends to come to treatment, and for those who will not be able to own a dog due to financial restrictions or housing situations. The weekly visits ease loneliness, improve communication, foster trust, decrease stress and anxiety, and are a lot of fun!”

The program assesses the volunteers for eligibility, while the dog goes through an evaluation with a professional service dog trainer. Conforti notes:

“This works because those interested in volunteering at CAMH are not here to stigmatize our patients, rather they are here to make a difference and di-stigmatize mental illness.”

To say the experience has been rewarding for volunteers like me would be an understatement. Patients are happy to see Rambo, talk to him, pet him, or just be in the same room with him. Not only does he give them a break from their daily routines and the confinement of their unit at CAMH, but he also offers unconditional affection to those in the program.

And while the benefits of pet therapy are numerous, unconditional affection is the critical point here.

When people find out where Rambo and I volunteer, I am often asked whether I fear for our safety, highlighting the common misconception that individuals with severe mental illness are dangerous and violent. Stereotypes like this further perpetuate mental illness stigmatization.

But animals do not judge. They do not care about physical appearance, diagnoses, or criminal history. Conforti recalls:

“One of our dogs went on a unit and a selective mute client—a client who chooses not to speak—had knelt down and whispered in the dog’s ear. No one heard what the client said to the dog, but it was the first time the client had ever spoken. And he had chosen to do so to a dog that will not judge nor will expect much from him. I love that story because it shows that dogs are there to help, love unconditionally, and, most importantly, they do not stigmatize.”

This may be one reason animal-assisted therapy programs are gaining popularity globally. A program in Bollate, Italy, has introduced the use of dog therapy for prison inmates. Valeria Gallinotti, the founder of the program, explains:

“My dream was to organize pet therapy sessions in prison because it’s the one place where there is a total lack of affection, where dogs can create calm, good moods, emotional bonds and physical contact.”

The program has been a hit with inmates, who look forward to the dogs’ visits and have formed a sense of close companionship with them. When asked who his favourite dog was, one of the inmates said:

“Carmela arrived and didn’t know what to do. She was so scared, sort of like us when we arrive in prison. Now, like us, she too is getting used to the experience.” 

Whether part of psychotherapy, physiotherapy, or a prison inmate program, animal assisted therapy can give people the extra motivation needed to get through the challenge of treatment or confinement. Patients and clinicians alike have a lot to gain from therapists like Rambo.

– Essi Numminen, Contributing Writer, The Trauma and Mental Health Report

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller 

This article was originally published on Psychology Today

4 Killing the American hero...-87af2b2a2e425a66525e4cf405e5b09b887971ab

Killing the American Hero, Killing the Fair Trial

00Attention, Featured news, Health, Law and Crime, Media, Post-Traumatic Stress Disorder, Psychiatry, Psychopathy April, 16

Source: Quadraro on DeviantArt

Was he “insane” or not? That is the question jury members in Erath County, Texas addressed, on February 25th, 2015, during three hours of deliberation in the Eddie Ray Routh case.

Routh, a veteran of the Iraq war, was convicted of murder after he shot two fellow veterans, Chad Littlefield and Chris Kyle, who was famously known as the most prolific sniper in American history and whose memoir inspired the blockbuster film, American Sniper. Kyle, who worked to help veterans cope with post-traumatic stress disorder (PTSD), was asked by Routh’s mother to see if there was anything he could do for her son. When Routh, Littlefield, and Kyle went to a shooting range—a routine practice used by Kyle to help veterans ‘blow off steam’—Routh opened fire, killing both men.

Routh’s defence lawyers pursued an insanity plea, citing a diagnosis of paranoid schizophrenia as the reason for his actions.

According to section 8.01a of the Penal Code of Texas, an individual may successfully plea not guilty by reason of insanity if evidence proves that at the time of the incident, the accused, as a result of “severe mental disease, did not know that his conduct was wrong.” Citing a police interrogation that took place after the incident—not before, as outlined by law—where Routh answered that he knew what he did was wrong, prosecutors argued that the defense was invalid. The jury agreed, and Eddie Ray Routh was sentenced to life in prison with no chance of parole.

Decisions in so-called insanity cases are often controversial. Routh’s case calls into question the legal system’s impartiality and treatment of mental health issues, in particular.

The case was widely publicized for its duration, which coincided with the release of American Sniper. The film was highly acclaimed and portrayed Chris Kyle as a hero, especially for the townspeople in Erath County. Typically, when a jury from a particular area is likely to be biased, it is common practice for defense lawyers to move the trial outside the district in which the crime was committed. In Routh’s case, this motion was denied, despite some jurors even admitting to having seen American Sniper before making their decision.

In addition to lacking impartiality, the Texas court also failed to properly account for Routh’s mental health.

Routh was diagnosed with paranoid schizophrenia by a psychiatrist prior to the incident at the shooting range. His medication was found when police raided his home. According to Routh’s family and friends, he had also experienced episodes of aggression, irritability, suicidal thoughts and attempts, and psychotic episodes. These episodes consisted of extremely erratic delusions ranging from vampires and werewolves, to him believing he was God and Satan.

But the insanity exclusion in Texas does not take a holistic view of an individual, instead using narrow and limiting language to define insanity. While Routh may have agreed that his actions were wrong after the event, there is no way to know what he was experiencing throughout. And if his previous psychotic episodes are representative, he may have been psychologically removed from reality at the time of his actions, possibly believing he was acting to save his own life.

Some argue that Routh and others like him should still be held responsible for their actions, despite their mental health problems. But, what many do not understand, is that being found not guilty by reason of insanity does not mean the individual walks free. In many cases, such a verdict could lead to extremely long detention in a psychiatric institution, where individuals are kept under close watch as they undergo treatment for their disorder.

In refusing to accept Eddie Ray Routh’s insanity plea, the Texas legal system is doing more than just punishing an individual who may not have been aware of his own actions, they are also denying treatment to a seriously ill person. At this rate, many mentally ill individuals will continue to be punished for actions they did not intend or understand, never receiving treatment and never having a chance to recover.

For more details about the Not Criminally Responsible Defense (as it is known in Canada), see our article entitled Myth Busting the Not Criminally Responsible Defence.

– Alessandro Perri, Contributing Writer, The Trauma and Mental Health Report

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller

This article was originally published on Psychology Today

1 A blood test to diagnose depression-118138414119886042cd33f08a35cf742e1cc5c5

A Blood Test to Diagnose Depression?

00Addiction, Depression, Featured news, Neuroscience, Psychiatry, SSRIs March, 16

Source: Andrew Mason on Flickr

Researchers at the Feinberg School of Medicine at Northwestern believe it may be possible to diagnose depression using a blood test. According to Eva Redei, a professor of psychiatry at the university, previous studies with lab animals have identified 26 markers in the blood (called biomarkers) that are associated with depression.

With human subjects, Redei identified nine biomarkers that differed between depressed and non-depressed individuals. The biomarkers signify a difference in gene expression associated with depression and allowed Redei to identify all those suffering from Major Depressive Disorder (MDD) in a sample of 66 adults.

Further, Redei was able to use biomarkers to identify adults with MDD who benefited from Cognitive Behavioural Therapy (CBT).  When depression symptoms were improving, some of the original biomarkers that helped to identify depressed individuals disappeared in blood samples.

If replicable, these findings would have major implications for the future of mental health diagnosis. Patients sometimes seek the attention of a primary care physician when they have concerns about depression. Unfortunately, such physicians are not as equipped or experienced as psychiatrists and psychologists in diagnosing and treating depression. This increases the time between when individuals begin to experience symptoms and when they are able to receive treatment. On average, an official depression diagnosis can take between 2 to 40 months.

At the same time, untreated depression has severe risks. “The longer depression is not treated, the more difficult it is to treat,” says Redei. “There’s also a higher chance of suicide, and adverse effects in the person’s work environment, home environment, [and] social structure.”

Untreated depression usually worsens over time, and to cope, patients may succumb to addiction, self-injury, and reckless behaviors such as having unprotected sex and drunk driving. Risk of suicide also goes up the longer depression remains untreated.

Using a test such as this to identify depression could reduce some of the stigma tied to the disorder and bridge the gap between mental and physical health. Depression affects the whole person, body and mind. A test such as this underscores that connection.

Does it all sound too easy?

Perhaps.  New biological findings in mental illness have a way of promising a whole lot more than they deliver.

Nowhere is this seen more than in the area of depression (Anyone out there remember Peter Kramer’s 1993 classic, Listening to Prozac?)  Decades of research on SSRI’s, once hailed as revolutionary, are increasingly showing just how modest, indeed disappointing, the medication’s effects actually are.

So a healthy dose of skepticism is in order.

This study is one of the first in its category. Depression is an exceptionally complex disorder that can only be partially understood in terms of biology. For the above implications to be substantiated, many studies with larger sample sizes must replicate the findings.

In fact, a much larger study that looked for genetic associations with MDD in over 6,000 individuals (of whom 2,000 were diagnosed with MDD) found little to no genetic links.

Further, even if blood sampling were used to diagnose depression, it would not account for the social and environmental components of the disorder. It is possible that increased reliance on biological factors could lead to increased numbers of people being misdiagnosed and forced to suffer alone due to the narrow diagnostic scope that blood tests would provide.

Still, Redei’s research does show promise. She hopes that using blood tests to diagnose depression will help expedite the otherwise lengthy process. But she does not feel that current diagnostic practices should be replaced. Instead, the combination of blood tests and self-report evaluations of symptoms may be key to early diagnosis in the future.

Although further research is needed, the hope is that blood tests may eventually help clinicians with the question of which treatment may be most effective for which client. “I think this opens the possibility to begin to look at whether there are biomarkers that may be able to predict response to a behavioral treatment like cognitive behavioral therapy, pharmacotherapy and other forms of treatment,” says co-author David Mohr.

Redei’s research responds to the very real need for more efficient and effective methods of diagnosing depression.  And it opens doors to new ways of understanding the disorder and its identifying characteristics.

– Alessandro Perri, Contributing Writer, The Trauma and Mental Health Report

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller

This article was originally published on Psychology Today

Is Online Treatment the Next Frontier for CBT?

Is Online Treatment the Next Frontier for CBT?

10Cognitive Behavioral Therapy, Depression, Featured news, Psychiatry, Therapy, Trauma December, 15

Source: Mark Anderson on Flickr

Social media have dramatically changed the way many of us connect with family and friends. Some are now proposing that online relationships, particularly online therapeutic relationships may revolutionize mental health services by giving people with limited access a viable alternative to traditional treatment approaches.

One of these online alternatives, iCBT (internet-based Cognitive Behavioural Therapy) was derived from the tenets of traditional CBT pioneered by psychiatrist Aaron Beck.

Both target automatic negative thoughts that people have about themselves, the world, and their future, thoughts considered to be central to disorders like depression and anxiety.

But unlike traditional CBT where clients and therapists regularly meet in person, iCBT requires individuals to keep a journal recording their state of mind on an ongoing basis. Clients are given cognitive exercises, and their progress is tracked remotely by a therapist who reads the self-reflective journals, with feedback provided by e-mail.

The approach is currently being tested for its effectiveness in treating Generalized Anxiety Disorder (GAD). Psychologist and online therapist Marlos Postel conceptualizes iCBT as an approach that combines the advantages of structured self-help materials with the expertise of a therapist who directs activities and encourages clients.

Research from the University of New South Wales in Australia reports promising results, including improvements in patients with GAD, even compared to face-to-face treatments, with therapeutic gains maintained over three years.

Notably, many argue that online treatments eliminate an important ingredient, the therapeutic relationship between clinician and client. Research on the importance of this clinical relationship, the working alliance, has consistently shown it to be the single largest factor in predicting outcome. A central element of psychotherapy, it fosters trust, collaborativeness, and therapeutic change.

And some argue that underlying a strong alliance is the ability to detect non-verbal cues and subtle shifts in emotion that a client may demonstrate during therapy. Psychologist Madalina Sucala and colleagues from Mount Sinai School of Medicine in New York found that these cues account for a greater proportion of psychotherapy outcome than does treatment modality.

Notably, a different study conducted by Sucala found e-therapy and face-to-face approaches equivalent in outcome, despite the absence of non-verbal cues in e-therapy.

These discrepancies led researchers Gerhard Anderssona and Erik Hedman to suspect that some aspects of e-therapy may foster a different type of alliance between therapist and client. In a recent study, they found that iCBT creates a strong emotional connection between client and therapist because the therapist has more time to critically reflect on clients’ cases. Similarly, the online interactions did not affect client perceptions of how much their therapist cared for them or how much they trusted the therapist.

And co-director of the eCentreClinic and psychologist Nickolai Titov, an advocate for e-therapy, lists a number of advantages of the approach in a recent report. He found that iCBT is less-expensive—often 20-40% the cost of traditional therapy—and presents a viable alternative for rural locations where therapists are less accessible. Titov also found that many people can benefit from the relative anonymity of iCBT, as a common barrier to seeking therapy is embarrassment and fear of disclosure.

Therapists using modalities other than CBT have also started to come online. Clinicians using behavioural, interpersonal, and emotion-focused approaches have also begun offering online treatments. Even psychodynamic psychotherapy, which is traditionally a long-term, relational form of counselling, has been adapted into online formats.

Still, face-to-face mental health treatments are far from being replaced. Just as older styles of therapy are used alongside newer ones, online therapy may represent a promising treatment option for those comfortable with the format.

– Sumeet Farwaha, Contributing Writer, The Trauma and Mental Health Report

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller

This article was originally published on Psychology Today

A Contrast to Psychiatry: The ‘Hearing Voices’ Movement

A Contrast to Psychiatry: The ‘Hearing Voices’ Movement

00Conformity, Education, Featured news, Health, Identity, Psychiatry, Therapy May, 15

Source: Oiluj Samall Zeid / Flickr

The 1961 classic, The Myth of Mental Illness by Thomas Szasz, revolutionized the way we think about atypical mental phenomena.

And over the years, the diagnosis of schizophrenia has been criticized fervently, with some characterizing it as an umbrella term for separate psychological phenomena that vary in combination and severity from person to person.

Critics of the term have described the way experiences such as hearing voices are conceptualized and defined.  The International Hearing Voices Network (Intervoice) views hearing voices as a normal variation in human experience—albeit one of an unusual nature.

Representing a lesser known view within the field of mental health, the group encourages voice hearers to “accept that the voices are real, and to accept that the voices may have meaning (metaphoric or literal) based on one’s life experiences.”

In the interest of communicating different (and sometimes controversial) ideas in mental health, The Trauma & Mental Health Report recently spoke with a mental health nurse (who requested anonymity), whose current research examines voice-hearers’ narratives about their emotional experiences.  While not a member of Intervoice, the interviewee’s research represents an alternate approach to traditional psychiatry.

 Q:  Can you explain the structure and method of the narrative approach you are working on?

A:  Put at its most basic, I am following the method called ‘Dialogical Narrative Analysis’, outlined by Sociologist, Arthur Frank.  In my work, Dialogical Narrative Analysis examines the stories that voice-hearers have about their emotions and what those stories do for them.

Q:  How best do you think these experiences should be conceptualized if not as psychopathological?

A:  It would be best to ask those with the experience.  At the moment it seems as though they are greatly helped when they don’t dismiss their experiences as ‘illness’, but engage with them as meaningful.  Having seen the prolonged effects of both approaches over a number of years, I can say that it’s the voice-hearers and those with unshared beliefs [what we usually refer to as delusions] who clearly have the most to teach us.

Q:  Supporters of drug interventions often explain the use of pharmaceuticals for treatment as diminishing the occurrences of delusions or hallucination.  Can you comment on this way of thinking?

A:  It’s a normalizing practice; it seeks to return outliers to a normal.  I’m hardly the first to point out that what is considered normal is subject to extreme change.  This is how we get situations where persons and behaviours are rated as mad in one generation and acceptable in the next— like having a baby outside of marriage, or homosexuality.  This leads some in the Hearing Voices Movement to hope that what happened to the identity of being homosexual can happen to the identity of being a voice-hearer.

Q:  Does this point out a flaw in our cultural and scientific understanding of the meaning of ‘delusion’ and ‘hallucination’?

A:  The word ‘delusion’ is a judgment, and in the Hearing Voices Movement they tend to prefer the term ‘unshared belief’.  Many would agree that the problem with a ‘delusion’ is not so much in thinking, but in the interaction with humanity.  ‘Hallucination’ also implies a shared version of ‘real’ experiences which would be difficult to justify, a concept of normal which is utopian.

Many within the Hearing Voices Movement reject both terms.

Q:  Should therapeutic efforts end with the attempt to remove the occurrences of hallucinations or delusions?

A:  I think you can see now that I am not altogether in favour of ‘therapeutic efforts’.  Too often there is a lot of therapeutic effort, a lot of money, a lot of well-meaning people, and not very much thinking.  I am quite certain I would not like to be on the receiving end of ‘therapeutic efforts’.  I would like there to be justice and healing in communities.

Even if we were to know the complete neurological makeup of a voice-hearer’s brain, we would still lack true insight into the actual experience of hearing voices.  Understanding and accepting the lived experiences of these individuals is an indispensable tool for promoting coping and recovery.

It allows us to see the distressed individual not as some ‘gene-machine’ gone wrong, but a human who bears a certain relationship to himself and the world.

– Pavan Brar, Contributing Writer, The Trauma and Mental Health Report

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller

This article was originally published on Psychology Today

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Treatments Available to Long Term Abduction Victims

10Animal Behavior, Cognition, Depression, Dreaming, Family Dynamics, Featured news, Health, Parenting, Psychiatry, Psychoanalysis, Sleep, Stress, Therapy, Trauma April, 15

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Between 2002 and 2004, 16-year-old Amanda Berry, 21-year-old Michelle Knight, and 14-year-old Georgina DeJesus were abducted from the streets of Cleveland, Ohio. They were lured into the home of Ariel Castro where they spent the next 11 years in captivity.

Often kept in restraints and locked rooms, the women regularly had their lives threatened to deter any plans of escape.  They were given little food or the opportunity to bathe. Sexual abuse led to Knight being impregnated several times, only to be beaten and starved in order to force miscarriage.  It wasn’t until May 2013 that the women were finally rescued and Castro arrested.

Other cases popularized by the media include that of Elizabeth Smart, held captive for 9 months, and Jaycee Dugard who was held captive for 18 years. These victims are now free, but living with the emotional aftermath.

In a 2000 study by the Department of Neurological and Psychiatric Sciences at the University of Padova, interviews with kidnap victims showed common after-effects of abduction including vivid flashbacks of the events, nightmares, and feelings of depression, all common symptoms of Post-Traumatic Stress Disorder.  Hypervigilance was also reported, where individuals anticipated danger and frequently felt guarded, leading to trouble sleeping, eating, and social withdrawal due to difficulty trusting others.

Mental health professors David A. Alexander and Susan Klein, from the Aberdeen Centre for Trauma Research in the UK also add that some victims end up “shutting off’ their emotions or denying that they even experienced a traumatic event, which may stem from a desire to avoid anything that reminds them of their trauma.

How does someone this traumatized even begin to recover?  Clinicians who work with these victims help them find opportunities to make their own decisions, to slowly understand that they are no longer powerless.

Clinical psychologist Rebecca Bailey, therapist to Jaycee Dugard, is the author of, “Safe Kids, Smart Parents: What Parents Need to Know to Keep Their Children Safe.” In an interview with the Trauma and Mental Health Report, Bailey explained: “Number one is helping victims find their voice.  When you’ve been kidnapped, so much of your world is about having choices made for you…From day one you have to give them choices for everything, Do you want a glass of milk, or do you want a glass of water? Things like that.”

Another important aspect to recovery is the role of the family.  It is through a strong connection with the family that the victim can feel safe, comforted, and empowered.  Bailey mentions “tribal meetings” with families soon after rescue to reunify both parties and create a support system. Through these family systems, further recovery is possible.

Specific therapeutic approaches for victim recovery really depend on the individual.  In some cases Cognitive Behavioural Therapy can be used, in other cases experiential therapy or a more psychodynamic approach can be implemented.  Common techniques used in therapy with kidnapping victims are role-playing, therapeutic pets, music, or even walking through the wilderness in an attempt to trigger underlying feelings that must be dealt with.

Often, different therapies are combined to see which works best for the individual. Bailey reminds, however, that client interaction with the therapist also has a large impact on recovery.

Bailey: The most important thing is for the therapist to be mindful, authentic, and purposeful. Counterproductive would be having a therapist who says very little.  This could almost reinjure [the victim] because they need a certain amount of modelling as well.

Modelling how to have an authentic healthy relationship—after the abusive one they had with their abductor—is crucial to helping the victim integrate aspects of normal everyday life.

Still, even with proper therapy and a strong support system, the trauma of being abducted and held captive for years is unlikely to be erased.  In the case of the young women in Cleveland, along with many others, the journey to recovery has been a challenging one, but one that has been described as worth taking:

“I may have been through hell and back, but I am strong enough to walk through hell with a smile on my face and my head held high,” says Michelle Knight in a YouTube video addressed to the public.  “I will not let the situation define who I am.  I will define the situation.”

– Contributing Writer: Anjali Wisnarama, The Trauma and Mental Health Report

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller

This article was originally published on Psychology Today

Feature Image

Anorexia Affects More Men Than Previously Thought

10Bulimia Nervosa, Consumer Behavior, Diet, Eating Disorders, Featured news, Gender, Health, Psychiatry March, 15

Source: Federico Morando//Flickr

Zachary Haines was 16 years old when a physical examination put his 5’7”, 230-pound body within the obese range.  Soon after, Zachary began working out and watching his diet, entering his junior year at high school 45 pounds lighter.

But what started as a healthy lifestyle soon spiralled into a struggle with anorexia nervosa, an eating disorder characterized by severely restricting food intake.  Like many other men and boys, Zachary’s extreme weight loss was not identified as an illness.  In fact, it was ignored until he was hospitalized for malnutrition.  Despite having many of the telltale signs of anorexia, Zachary’s condition went untreated.

Anorexia and bulimia are traditionally seen as “female problems.”  But, recent studies show that approximately one third of people with anorexia and about one half of those with bulimia are men.

One of the  influences thought to impact these men are the shifting ideals in the media that are putting pressure on men to become thinner.

While there may not be a direct causal relationship between media portrayals of the ‘ideal’ man and the development of eating disorders, these depictions contribute to a cultural context that glorifies their apparent normalcy.   They may also influence males’ fears of becoming overweight, as male models face pressure to slim down and appear androgynous.

The thin ideal male image is also making its way into fashion.

In 1967, an average mannequin’s dimensions were a 42-inch chest and a 33-inch waist.  Today’s average dimensions are a 35-inch chest and a 27-inch waist.  With the average American man’s waist size being 39.7 inches, these changes represent a remarkably unrealistic objective.

For Zachary, fitting into smaller sized clothing after weight loss was a source of pride.

But during treatment this once enjoyable activity became emotionally painful:  In Zachary’s words, “The most anxiety-inducing part for me is trying on clothes.  If I go up a size, I think I’m going to be 230 pounds again.”

The signs that something was wrong were all there.

Despite working out for three hours per day while only consuming 1,400 calories, Zachary was continuously trying to lose more weight.  By relying on inaccurate results from the Body Mass Index (BMI), doctors missed his emaciation.  He had never fallen into the anorexic range because the BMI does not take into account the proportion of muscle to fat, even though his emaciation would have been evident if he were seen shirtless.

The growing number of stories like Zach’s has led to significant changes to how anorexia nervosa is diagnosed.

In the DSM-V (the most recent version of American psychiatry’s diagnostic manual), this change involved eliminating Criterion D, or amenorrhea (the absence of menstruation) to make the diagnosis gender-neutral.

Zachary recovered because he had support from his family and friends, private insurance, and access to physicians and psychiatrists, who he worked with closely.

To help his recovery, he had to change his wish to pursue becoming an athletic trainer to that of going into advertising.

Those without resources can also identify some of the signs of an eating disorder:  extreme exercise behaviors, compulsive thoughts of losing weight, constantly feeling cold, and extreme food restriction.

These signs don’t discriminate between men and women, neither should we.

– Contributing Writer: Danielle Tremblay, The Trauma and Mental Health Report

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller

Photo Credit: Federico Morando//Flickr

This article was originally published on Psychology Today

Child Criminals, Feature2

Children Who Kill Are Often Victims Too

00Adolescence, Attachment, Caregiving, Child Development, Empathy, Ethics and Morality, Featured news, Law and Crime, Parenting, Psychiatry, Punishment, Self-Control, Therapy, Trauma March, 15

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In 1993, in Merseyside, England, Jon Venables and Robert Thompson were charged with the abduction and murder of 2-year-old James Bulger.  Bulger had been abducted from a shopping mall, repeatedly assaulted, and his body left to be run over by a train.  Both Venables and Thompson were 10 years old at the time.

The public and the media called for justice, seeking harsh punishment and life imprisonment for the murder of a child.  The boys were labeled as inherently evil and unrepentant for their crimes.

When there are crimes against children, it is common for the public to view the victims as innocent and the perpetrators as depraved monsters.  But what do we do when the accused are also children?

Instances of children (12 years of age and younger) who have killed other children are extremely rare.  In a study conducted by University of New Hampshire professors David Finkelhor and Richard Ormrod for the Office of Juvenile Justice and Delinquency Prevention (OJJDP), murders of children committed by those aged 11 and under accounted for less than 2 percent of all child murders in the US. Cases also tend to differ significantly, so conclusions can be difficult to make.  But there are some similarities that have emerged, telling us about the minds of child murderers.

Children who murder have often been severely abused or neglected and have experienced a tumultuous home life.  Psychologist Terry M. Levy, a proponent of corrective attachment therapy at the Evergreen Psychotherapy Centre, notes that children who have severe attachment problems (which often result from unreliable and ineffective caregiving) and a history of abuse may develop very aggressive behaviours.  They can also have trouble controlling emotions, which can lead to impulsive, violent outbursts directed at themselves or others.

Other similarities among child murderers include having a family member with a criminal record, suffering from a traumatic loss, a history of disruptive behaviour, witnessing or experiencing violence, and being rejected or abandoned by a parent.  Problems in the home can be particularly influential.  If a child witnesses or experiences violence, they are likely to repeat violence in other situations.

What a child understands at the time of the crime is of great importance to the justice system.  The minimum age of criminal responsibility (MACR) is the age at which children are deemed capable of committing a crime.  The MACR differs between jurisdictions, but allows any person at or above the set chronological age to be criminally charged, and receive criminal penalties, which can include life imprisonment.

Many courts consider criminal responsibility in terms of understanding.  So they may consider someone criminally responsible if, at the time of the crime, they understood the act was wrong, understood the difference between right and wrong or understood that their behaviour was a crime.  But this approach has been criticized as being too simplistic.  Criminal responsibility requires the understanding of various other factors, many of which children cannot appreciate.

Children may know that certain behaviours are ‘wrong’, but only as a result of what adults have taught them, and not because they fully understand the moral argument behind it.  Morality and the finality of death are abstract concepts, and according to theorists such as Swiss psychologist-philosopher Jean Piaget (whose theory of child development has seen much empirical support), most children under 12 are only able to reason and solve problems using ideas that can be represented concretely.  It is not until puberty that the ability to reason with abstract concepts (like thinking about hypothetical situations) develops.

Prepubescent children are also not fully emotionally developed, and less able to use self-control and appreciate the consequences of their actions.  This, in combination with the fact that many child murderers are impulsive, aggressive, and unable to deal with their emotions, suggests that when children kill, they are treating their victim as a target, as an outlet for violence.  Most victims are either much younger than or close to the same age as the perpetrators, which may suggest they were chosen because they could be overpowered easily.

Research to date suggests that child murderers don’t fully understand the severity or implications of their crimes.  And psychiatric assessments have shown intense psychological disturbance, making true appreciation of the crime even less likely.  Yet many children have been found criminally responsible and sentenced in adult courts.

Jon Venables, Robert Thompson, and Mary Bell received therapeutic intervention while incarcerated, and have since been released.  As far as the public knows, only Venables has reoffended.  However, Eric Smith (convicted of killing 4-year-old Derrick Robie) remains behind bars today, even though he was imprisoned at 13.

Critics of judicial leniency for children accused of murder often cite the refrain ”adult crime; adult time,” choosing to focus on the severity of the crime rather than the age and competency of the offender.  Make no mistake; the murders of these children were brutal, depraved acts that caused intense suffering for the victims, their families, and communities.

But in our zeal, in our outrage, do we dehumanize these children?  Children who—like their victims—can be victims too.

– Contributing Writer: Jennifer Parlee, The Trauma and Mental Health Report

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller

Photo Credit:torbakhopper/Flikr

This article was originally published on Psychology Today

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Myth Busting the Not Criminally Responsible Defense

00Altruism, Empathy, Ethics and Morality, Featured news, Guilt, Health, Law and Crime, Psychiatry, Psychopathy, Psychopharmacology, Therapy, Trauma December, 14

“I thought he must die. He had no future, nothing good. I thought I was saving the child.”

Nerlin Sarmiento had expressed disturbing thoughts about her children long before tragedy struck her small family of four. On many occasions the 32-year-old Edmonton mother had confessed to doctors and family members that she had thoughts of harming herself and her children.

Precautions were taken: Sarmiento was admitted to hospital several times, prescribed psychiatric medication, discharged, and had her mother move in to help care for the children. 

On the morning of February 12th 2013 in Edmonton, Alberta, Sarmiento sent her ten-year-old daughter to school, then forced her seven-year-old son into the bathroom where she held him under water until he stopped breathing.

Sarmiento did not deny murdering her son. She called the police herself to report the crime. Her lawyers, however, argued that she should not be held responsible on account of her mental illness that prevented her from appreciating the moral wrongfulness of her actions.

Two psychiatrists testified at Sarmiento’s trial. They explained that she was experiencing a severe depressive episode as part of her previously diagnosed bipolar disorder. She felt despair so extreme she became convinced she was committing an altruistic act, saving her son from a life of predestined poverty and hardship. 

On September 12th, 2013, Justice Sterling Sanderman agreed. Nerlin Sarmiento was found not criminally responsible (NCR) on a charge of first-degree murder. 

The public outcry against the ruling was reminiscent of the aftermath of the Vincent Li and Guy Turcotte trials; they were found NCR on charges of second-degree murder and first-degree murder respectively.

NCR has been a hot topic featured prominently in the press following several high profile cases, but is often misunderstood.

In Canada, if the court decides that an individual has committed a criminal act (i.e., they are guilty), but lacked the capacity to know that their actions were not only criminally wrong, but also morally wrong at the time, a verdict of not criminally responsible may be given.

Psychiatrist Robert Dickey with Correctional Service Canada and the University of Toronto helped the Trauma & Mental Health Report gain a better understanding of NCR and bust some of the myths surrounding the defense. 

Myth 1: Almost anyone can claim they have a mental disorder and use the NCR defense.

Technically, this is true. But whether or not they would be successful is another story, says Dickey, explaining that if you don’t have a severe mental illness, it is very hard to malinger your way through an NCR assessment and defense.

He further explains that the finding of NCR is based on the exact mental state of the accused at the time of the crime. By the time someone is referred for assessment by the courts, their state of mind may be quite different than it was when the offense was committed. 

A good clinician will seek clear corroborating information that the individual was suffering from a psychotic illness at the time they were arrested. The police, jail and institutional records should give information as to the individual’s mental state at the time.

This is not a matter of being a little depressed, states Dickey. The individual must be so ill that they would not have been able to tell right from wrong, appreciate the wrongfulness of their actions or engage in rational choice when the crime occurred.

Myth 2: The NCR defense is a tactic for offenders to skirt the justice system.

Mostly false, says Dickey. If an individual does not suffer from a psychotic illness, pure psychopathy or criminality alone is not considered – by the law – to be a disease of the mind severe enough to qualify for a finding of NCR.

If the NCR defense is successful, the individual is remanded to the custody of the Provincial Review Board, where the offender is encouraged to receive treatment. Interestingly, the board itself has no power to order the accused to engage in treatment. 

But if an accused does refuse, they are often detained in a secure facility. Dickey explains that with cases of major mental illness and the refusal of treatment, the physician can refer the offender to the Consent and Capacity Review Board. And the individual may be declared incapable to refuse psychiatric treatment and treated against their will.

Myth 3: When a person is found NCR for a crime, they essentially walk free. 

False. The vast majority of offenders found NCR spend a lot more time detained in a secure facility than if they had been found guilty and served a regular prison sentence, Dickey explains. Because the consequences of NCR are more restrictive and more ensuring of treatment, the issue is now more readily raised by the crown (prosecution) than the defense.

After the individual has been remanded to the Provincial Review Board, the forensic psychiatrist will testify as to the necessary level of security needed to manage the offender and their psychiatric care, while still ensuring the safety of the community.

So what’s in store for Nerlin Sarmiento?

When her trial concluded, she was remanded to the custody of the Alberta Review Board (ARB). At a hearing within 45 days from the end of her trial, the ARB determined whether she would receive an absolute discharge, a conditional discharge or be detained in custody. The results of Sarmiento’s hearing have yet to be made public.

 – Contributing Writer: Jennifer Parlee, The Trauma and Mental Health Report

 – Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

 Copyright Robert T. Muller

Photo Credit: Shutterstock

This article was originally published on Psychology Today

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LGBTQ Refugees Lack Mental Health Care

00Addiction, Depression, Education, Featured news, Gender, Health, Identity, Politics, Psychiatry, Psychopharmacology, Sexual Orientation, Stress, Suicide, Trauma November, 14

In 2012, the Canadian government introduced cuts to the Interim Federal Health Program (IFHP), which provides health coverage for immigrants seeking refuge in Canada. Coverage was scaled back for vision and dental care, as well as prescription medication. At the same time, the introduction of Bill C-31, the Protecting Canada’s Immigration System Act, left refugees with zero coverage for counselling and mental health services.

The bill affects all refugees and immigrants, but individuals seeking asylum based on persecution for sexual orientation or gender identity have been hit especially hard by these cuts.

LGBTQ refugees are affected by psychological trauma stemming from sexual torture and violence aimed at ‘curing’ their sexual identity. Often alienated from family, they are more likely to be fleeing their country of origin alone, at risk for depression, substance abuse, and suicide.

On arrival in Canada, refugees struggle with the claim process itself, which has been cited by asylum seekers and mental health workers as a major source of stress for newcomers. For LGBTQ individuals, the process is even harder, having to come out and defend their orientation after a lifetime spent hiding and denying their identity.

In 2013, six Canadian provinces introduced individual programs to supplement coverage. The Ontario Temporary Health Program (OTHP) came into effect on January 1, 2014, and provides refugees and immigrants short-term and urgent health coverage. But it still lacks provisions for mental health services.

Envisioning Global LGBT Human Rights, an organization and research project out of York University in Toronto, has been collecting data from focus groups with LGBTQ refugee claimants both pre- and post-hearing. A recent report by lawyer and project member Rohan Sanjnani explains how the refugee healthcare system has failed. LGBTQ asylum seekers are human beings deserving respect, dignity, and right to life under the Canadian Charter of Rights and Freedoms. Sanjnani argues that IFHP cuts are unconstitutional and that refugees have been relegated to a healthcare standard well below that of the average Canadian.

Arguments like these have brought legal challenges, encouraging courts and policy makers to consider LGBTQ rights within the framework of global human rights.

In July of this year, Bill C-31 was struck down in a federal court as unconstitutional, but the government filed an appeal on September 22. Only if the appeal fails could immigrant healthcare be reinstated to include many of the benefits removed in 2012.

Reversing the cuts to IFHP funding would not solve the problem entirely. LGBTQ asylum seekers face the challenge of finding service providers who can deal with their specific needs. The personal accounts collected by Envisioning tell a story of missed opportunity, limited access to essential services, and ultimate disappointment.

In the last two years, programs have sprung up to address these special needs. In Toronto -one of the preferred havens for LGBTQ refugees- some health providers now offer free mental health services to refugees who lack coverage. Centers like Rainbow Health Ontario and Supporting Our Youth have programs to help refugees come out, and to assist with isolation from friends and family back home, and with adjusting to a new life in Canada.

Still, the need for services greatly outnumbers providers; and accessibility issues persist.

Organizations like Envisioning try to create change through legal channels, but public opinion on LGBTQ healthcare access needs to be onside for real change to occur. Recent World Pride events held in Toronto were a step in the right direction. But specialized training of healthcare professionals and public education would go a long way in providing the LGBTQ community with the care they need.

– Contributing Writer: Sarah Hall, The Trauma and Mental Health Report 

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller

Photo Credit: https://www.flickr.com/photos/vhhammer/3238712773/

This article was originally published on Psychology Today