Category: Guilt

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Assisted Dying: We Need a Larger Conversation

00Aging, Caregiving, Decision-Making, Empathy, Featured news, Guilt April, 19

Source: Alberto Biscalchin at flickr, Creative Commons

We know that death is inevitable, yet most imagine it in the distant future. But those with a terminal illness face the harsh reality of death’s imminence. Cancer is the most common terminal illness, and in 2016, an estimated 1.5 million new cases will be diagnosed in the US, and almost 600,000 people will die from the disease.

Over the past decade, European countries such as Belgium and the Netherlands have legalized assisted dying. More recently, Canada passed Bill C-14 in June 2016, allowing assisted dying to be an option for those with a terminal illness. According to Health Canada, since the bill passed, there have been a total of 2,149 assisted deaths, and 63 per cent of them were cancer-related.

I lost my grandparents to terminal diseases, and saw what they endured. I wonder what choice they would have made had assisted dying been legal at the time. Both my parents believe that if someone is suffering, they have a right to end their life. As both of them had to care for their own ailing parents, they shared similar sentiments. In my mother’s words:

 “You feel frustrated, because you’re helpless. There is no cure and there is literally nothing you can do. You get very depressed, angry, and sad yourself. It’s also so hard to watch someone who was once so strong not be able to tie their own shoe anymore.” 

My father recalled a moment with my grandmother, when she could no longer bear her suffering. “I remember being in the kitchen with her and she put her head down on the table and said, ‘I just want it over with.’”

Since my paternal grandparents did not suffer long, my father does not think assisted dying would have been an option for them. My mother, however, feels differently and would have suggested it to her mother if the law would have been in place.

The right to assisted death provides some with relief. Barb Gibson Clifford, from Alberta, has stage 4 uterine cancer and in a short film by Dying With Dignity Canada, explains how this legislation impacts her:

“It’s terrifying to think that, if I don’t have choice, it could be very nasty, both for myself and for my family members. I’m so grateful to those nine judges of the supreme court for choosing to be in consensus about what they were doing. I cheered. I cheered in my kitchen.”

There are others who do not agree with their family members’ choice of assisted death. Former journalist, Deborah Binner from the United Kingdom, watched with inner turmoil and despair as her husband, Simon, made the choice to travel to Switzerland to end his life. This came after he received a motor neuron disease (MND) diagnosis. In her story, she explains how her husband’s choice made her feel:

“I didn’t want Simon to suffer but I didn’t want him to die, either. Watching him plan his own death, while I still wanted more time, was overwhelmingly traumatic. He had rights, but how much of his life was mine? I won’t join any campaign or celebrate his ‘choice’; nor would I condemn any other human being for making the same one.”

In a study of terminally ill patients in the United States, approximately 60 per cent supported assisted dying, but roughly 10 per cent considered it for themselves. Those who were more likely to consider it had depressive symptoms, essential caregiving needs (washing, eating, etc.), and pain. There are still some patients who do not make this choice for themselves. 

Michael Wenham from the United Kingdom, who also has MND, writes on his blog, “Investment in universal best palliative care is the true expression of compassion, not the offer of a cocktail of barbiturates, which is a perversion of therapy.”

With assisted dying laws being introduced in a number of countries, there is still a divide. It is a choice that affects many people and their communities. The conversations around Bill C-14 and other assisted dying laws tend to focus on ethics and morality. Yet, it is important that we recognize the human life behind these legislations. 

– Amanda Piccirilli, 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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Pressures to Breastfeed Can Harm Maternal Mental Health

00Child Development, Decision-Making, Embarrassment, Featured news, Guilt, Health, Parenting, Postpartum, Stress, Suicide January, 19

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Florence Leung of British Columbia, Canada went missing on October 25, 2016 while struggling with post-partum depression. Less than a month later, her family discovered that she had taken her own life, leaving behind a husband and infant son.

In an emotional public letter, Leung’s husband Kim Chen wrote an impassioned plea to new mothers asking them to seek help if they felt anxiety or depression. He also revealed that his wife’s difficulties with breastfeeding, and the resulting feelings of inadequacy, likely contributed to her condition. Urging women not to criticize themselves about an inability to breastfeed or a decision not to breastfeed, Chen wrote:

“Do not ever feel bad or guilty about not being able to exclusively breastfeed, even though you may feel the pressure to do so based on posters in maternity wards, brochures in prenatal classes, and teachings at breastfeeding classes.”

Speaking with the Trauma and Mental Health Report, Melissa (name changed) said that she was struck by Chen’s words, and recalled the scrutiny around breastfeeding she experienced with her first child:

“I was tired, sore, and the baby was cranky and constantly wanting to feed. It surprised me that, despite my vocal frustration and obvious difficulty breastfeeding, the nursing staff and lactation consultants were adamant that I continue to breastfeed exclusively.”

The frustration worsened once the couple returned home. The week that followed was exhausting, spent trying to calm a screaming newborn who constantly wanted to feed. The couple attended several breastfeeding clinics that reiterated the same message: breast is best. Melissa and her husband felt confused and defeated.

Shortly thereafter Melissa became completely overwhelmed:

“I began to get scared, and not trust myself. My inability to easily nurse and soothe my baby without intense discomfort led to feelings of failure. My emotions were overwhelming. I wasn’t sleeping because I was constantly pumping breastmilk or nursing.”

Within a week after giving birth, Melissa’s infant was suddenly much quieter and less agitated. Upon closer examination, she noticed that the baby looked pale, and was lethargic and dehydrated. A frantic trip to the emergency room (ER) revealed the newborn was not getting enough liquids and nourishment—despite the many scheduled feedings. Melissa said:

“When the ER doctor apologized for the miscommunication and advised us that supplementing with formula is not only okay, but sometimes necessary, I felt a mixture of relief and betrayal. Relief because I knew we would be okay, yet betrayed by some health professionals who put their personal agendas above our health and well-being.”

In an interview with the Trauma and Mental Health Report, Diane Philipp, a Child and Adolescent Psychiatrist at SickKids Centre for Community Mental Health in Toronto, shared that she meets many mothers suffering from stress, shame, and guilt associated with breastfeeding. Philipp explained that the judgements of others place unnecessary pressure on mothers:

“It’s important for mothers to have access to frank and open discussions that are safe and non-judgemental where they can seek out information and make the most knowledgeable decision that is best for their child and for themselves in terms of breastfeeding.”

Every woman’s situation is unique. Lifestyle habits, medication use, and medical and psychological history can complicate the post-partum experience. With this context in mind, the healthcare team should provide a comfortable environment—free of judgement—when discussing post-partum issues, including how to provide an infant’s nourishment.

For mothers who are unable to nurse, be it for medical, physical, or personal reasons, their decision can be supported and honoured in a way that promotes emotional well-being and encourages healthy parent-child bonding. Philipp said:

“For parents who can’t breastfeed for whatever reason, wonderful attachment bonds can still be made. Breast milk is not the only ingredient in a valuable, long-lasting relationship.”

Melissa, now a mother of two healthy school-age children, remains sensitive to others’ assumptions of breastfeeding:

“I felt so pressured to get it right, and so judged when I couldn’t provide for my child. Even when you come to terms with your decision not to breastfeed, people question your choice. Looking at my children today, I know I did the right thing.”

– Kimberley Moore, 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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Prison Executioners Face Job-Related Trauma

00Decision-Making, Empathy, Featured news, Guilt, Law and Crime, Trauma October, 18

When an order of execution is issued by the courts in the United States, the prison warden or superintendent is responsible for the sentence being carried out—often by Corrections Officers (CO) who are unaware they will be tasked with killing a prisoner.

Complicating matters, human connections are frequently formed between guards and prisoners. According to Jerry Givens, who administered the death penalty in Virginia to 62 inmates over 25 years, COs may spend more time with death-row prisoners than with friends or family, and can develop empathy towards these inmates.

With potential bonds between death-row guards and prisoners in mind, a separate team of officers frequently conducts the actual execution. COs directly involved with the prisoners are often given smaller roles, such as walking the prisoners to the execution spot, or putting a hood over their head. This approach aims to reduce the emotionally damaging effects of executions on those in close contact with the inmates.

Authorities also try to disperse feelings of responsibility for the killing by having multiple guards involved in the execution process. With lethal injection, the method of execution used in most States, three COs are assigned to turn a key switch that releases the lethal drug into the prisoner. Only one “live” switch dispenses the fatal chemical. The CO initiating the procedure that ultimately kills the prisoner is not known.

Despite such measures, guards can feel mentally tortured by their participation in executions, both before and after.

As illustrated in Into the Abyss, a documentary detailing the death sentence of convicted killer Michael Perry, many execution guards experience post-traumatic stress disorder (PTSD). One guard explained his acute symptoms at the outset of his descent into PTSD. He began crying and shaking uncontrollably when “the eyes of all the inmates he had executed began flashing before him.” Another developed nightmares, cold sweats, and sleeplessness.

Other guards, like Givens, have reported depression, inability to sustain relationships, and changes in personality. According to Rachel MacNair, author of Perpetration-Induced Traumatic Stress: The Psychological Consequences of Killing:

“The inner lives of guards who execute become like those of battlefield veterans who suppress memories from themselves and others.”

In 2007, two South Carolina COs who developed obsessive compulsive behaviour, nightmares, and other emotional disturbances filed civil lawsuits, claiming that their conditions resulted from performing executions. The COs alleged that they were coerced into carrying out executions and were not given any debriefing or counseling to help them deal with the emotional effects.

For some guards who need psychological treatment, it is simply not available. Other times, guards do not use available psychological help for fear of bei

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ng labelled ‘weak’ by their colleagues. Additionally, guards may not have the opportunity to talk about their involvement in executions with members of their families. Givens explained:

“When I accepted the job, I never told my wife or kids or anybody. I didn’t want them to go through anything I had to go through. If I told someone, they would tell someone. It would have been like a snowball and gotten bigger and bigger and everyone would know exactly what I was doing.”

This secrecy protects guards from having to explain or defend their actions. But it also prevents them from obtaining help to lessen the ill-effects of the associated trauma. Lack of disclosure precludes obtaining support.

The unacknowledged stress experienced by guards on execution teams risks dangerous mental-health consequences. As Givens, who now campaigns to end the death penalty, put it:

“It’s not an easy task to do. If I had known what I had to go through as an executioner, I wouldn’t have done it. You can’t tell me I can take the life of people and go home and be normal.”

– Veerpal Bambrah, 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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Unforeseen Stress When a Child Receives a Transplant

00Featured news, Guilt, Health, Post-Traumatic Stress Disorder, Stress, Trauma April, 18

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On April 13, 2016, Bill and Lindsay Brent received the phone call they were desperate for. Their youngest child Nathan would get the liver transplant he urgently needed. Within hours, the family from Barrie, Ontario was heading to The Hospital for Sick Children in Toronto.

By 8:00 the next morning, Nathan’s life-saving surgery was underway. Twelve hours after surgery began, the Brents’ feisty toddler emerged from surgery sedated, but holding his own, and began his road to recovery.

Twenty months earlier, Nathan was diagnosed with Alagille Syndrome, a genetic disorder affecting his liver, and severe enough that his only hope for survival was a liver transplant. But as the months passed, the situation began to look bleak. Nathan’s rare AB negative blood type greatly decreased his chances of finding a donor match.

Complicating matters further, Nathan was ineligible for the program; he required a liver from a deceased donor rather than from someone who was living. In his case, a pediatric donor would increase the odds of success, meaning that another child would have to die for Nathan to live.

And yet, despite insurmountable odds, thanks to the decision of one family, a liver was donated and Nathan survived.

Raelynn Maloney, a clinical psychologist and co-author of the book Caring for Donor Families: Before, During and After, says that the donor waiting period can be extremely stressful for families.

“Many traumas can occur during the ‘waiting period’; seeing a loved one suffer from illness without a clear outcome in sight, financial stress as families juggle care demands with work schedules, and, of course, the fear of running out of time.”

For the Brents, though, the psychological impact of their son’s traumatic journey started to surface only after the transplant was completed. Bill explains:

“Even though you are devastated when you receive the news that your child has a life-threatening illness, your need to remain focused on the outcome and to stay positive takes over. What has been shocking is the magnitude of post-transplant emotions that we’ve had to face. You’ve received a miracle, and yet, somehow, you are gripped with guilt and sorrow for the donor’s family, and an anxiety about the future that is so strong, it hinders your ability to feel good about life.”

For the couple, while they shared the same concerns for Nathan, their struggles with anxiety manifested in different ways. While Lindsay tended to ruminate and panic about the risks to Nathan post-transplant, such as illness, injury, and organ rejection, Bill reported an increase in social anxiety and was gripped with survivor’s guilt and depression. He says:

“It is very difficult for me to accept that my son needed someone to die for him to live. The donor family is in our thoughts constantly, and words cannot describe how thankful we are to them. They are our heroes.”

Maloney explains that recipient families can have a delayed reaction to the distress they experience while their loved one is on the donor list, and they are often unprepared for the rush of emotions that come after transplant.

While remaining focused on a solution, recipient families often do not allow themselves the space to grieve setbacks as they occur. Rather, they strive to maintain hopefulness while supressing the pain of the situation.

Maloney emphasizes that it may only be during recovery, when these families finally have a chance to process what they have gone through, that the traumatic grief hits.

The Brents recognized that, post-transplant, there was much more time to reflect on the enormity of what they had been through. Although grateful for Nathan’s outcome and the support of their family and friends, the Brents still faced ongoing emotional issues, all while trying to build normalcy back into their lives. Lindsay explains:

“Since Nathan has received his new liver, we no longer have access to the transplant support team that was available to us before the surgery. The medical team has moved on, the social support from the families at the hospital has been less frequent since we have returned home. In a way, Bill and I feel like we’ve lost family members, people that up until the transplant were a part of our innermost circle. In some ways, we feel left to navigate this post-transplant terrain on our own.”

Maloney acknowledges that there is an illusion held by the public that, after a transplant, all is well and life returns to normal. In reality, this is a time when transplant recipients and their families may need even more support as they try to reconcile the trauma of the illness with a hopeful and optimistic view of the future.

Now at home, Nathan continues to improve. Bill and Lindsay look forward to the time when this difficult journey will be surpassed by many happier, hopeful moments.

–Kimberley Moore, Contributing Writer, The Trauma and Mental Health Report.

–Chief Editor: Robert T. MullerThe Trauma and Mental Health Report.

Copyright Robert T. Muller.

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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Womb Wounds: Fetal Alcohol Spectrum Disorder

00ADHD, Alcohol, Child Development, Education, Empathy, Featured news, Guilt, Health, Neuroscience, Parenting, Pregnancy, Psychiatry, Stress, Trauma November, 14

“Fifteen years ago there were very few people who knew about FASD. If you were to go to court and say, ‘My son or daughter has FASD,’ a judge wouldn’t even know if it was a real thing.” – Jonathan Rudin, Justice Committee Co-Chair at the FASD Ontario Network of Expertise

Recently referred to as an “invisible condition” by the popular Canadian newspaper, The Globe And Mail, Fetal Alcohol Syndrome Disorder (FASD) often goes undiagnosed.

A supervisor at the Toronto Children’s Aid Society described to the Trauma & Mental Health Report the stream of FASD cases that have recently found their way into youth care and justice systems.

“You often don’t know a child has FASD because the mother is not around to confirm alcohol exposure during pregnancy. With one case, we suspected it, and did some digging. The grandparents of the child confirmed that the mother did consume alcohol during pregnancy. It was the grandparent’s report that changed everything. Nobody would have known.”

Characterized by growth deficiencies and central nervous system damage, FASD is an incurable condition. According to Ernest Abel, Professor of Obstetrics and Gynaecology at Wayne State University and Ronald Sokol, Professor of Paediatrics at the University of Colorado, FASD is the leading cause of mental retardation.

The Canadian Academy of Child and Adolescent Psychiatry explains that mothers often feel intense guilt and are typically blamed for damage to the child. For this reason, they are not always forthright about drinking habits. Stigma also plays a powerful role in motivating mothers to withhold information. And often, mothers consumed alcohol before they knew they were pregnant and are therefore unable to recall precise quantities and timing of drinks.

Adelaide Muswagon, a single mom, was featured in the Winnipeg Free Press in an article on FASD. “It took a lot of courage for me to get help. I know behind my back I was called an alcoholic and druggie. I can’t change what I have done; I already harmed my child. But I want expecting mothers to know my story, realize the consequences, and not make the same mistakes I did.”

The diagnosis of FASD is only given at birth for the most extreme cases. More often than not, symptoms are mild and fall within the normal range of development. For a firm diagnosis, confirmation of alcohol use during pregnancy is required. Because FASD can look like other medical, psychosocial and psychiatric conditions, children can be mistakenly labelled with Attention Deficit Hyperactivity Disorder (ADHD) or a behavioural disorder.

Fortunately, the behavioural symptoms associated with FASD are becoming better known. As we learn more about the hardships associated with the condition, mothers may question their decision to be vague or dishonest about drinking.

Liz Kulp, award winning author, advocate, and person living with FASD speaks candidly about her experiences in her book, The Best I Can Be: Living with Fetal Alcohol Syndrome-Effects.

“Finding out [why life was so hard for me] didn’t change how hard life is, but it did make me believe I was not a bad person. When I ask a question, it is because I don’t understand, not because I have not been listening, sometimes there is a blank space and I can’t get across it. I may look really normal and I work really hard to maintain. That is really stressful and sometimes I get frustrated. Sometimes the stress just builds up, especially when different people put different expectations on me all at the same time.”

For students, FASD manifests with attention problems and difficulties understanding instructions and rules. Common sense can be lacking, along with a tendency to take things literally. Learning issues lead to high drop-out rates. Youth with FASD often become involved in criminal justice systems, and many such individuals are overrepresented in prison populations. Jonathan Rudin, an Ontario lawyer and chair of the FASD Justice Committee says people with FASD are “usually not the mastermind behind the crime” but they are “easily convinced to take the rap.”

Catching the condition early in life and understanding its effects can help with education, parenting strategies, and legal provisions.

Moving through life without knowing why things are harder for you and why everyone else seems to be able to function with ease can be devastating. Sadly, people with undiagnosed FASD often grow up using alcohol to cope, possibly giving birth to a child with FASD.

Alleviating stigma around FASD by providing mothers with a non-judgemental space to speak about their drinking may help with diagnosis and treatment.

– Contributing Writer: Anjani Kapoor, 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