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` FALL - WINTER 2024
_____________________________________________________________________________________
A PUBLICATION OF
THE AMERICAN ACADEMY OF EXPERTS IN TRAUMATIC STRESS
THE NATIONAL CENTER FOR CRISIS MANAGEMENT
OURNAL OF THE
AMERICAN ACADEMY OF EXPERTS
IN TRAUMATIC STRESS
IN THIS ISSUE: A MESSAGE FROM THE PRESIDENT
Brad Lindell, Ph.D.
________________________
THE INTRODUCTION OF THE
AMERICAN ACADEMY OF EXPERTS IN TRAUMATIC STRESS
SCHOLARSHIP PROGRAM
RECENT RECIPIENTS OF DIPLOMATE AND FELLOWSHIP WITH THE
ACADEMY AND CERTIFICATION UNDER THE TRAUMATIC STRESS
AND CRISIS MANAGEMENT SPECIALTIES
DILEMMAS IN ASSISTED SUICIDE REQUESTS
FOR MENTAL HEALTH PROVIDERS
BILL OWENBY
PHYSIOLOGICAL RESPONSE OF THE HUMAN BODY TO TRAUMATIC
EVENTS – POTENTIAL IMPACTS OF FREQUENT ACTIVATION OF THE
AUTONOMIC NERVOUS SYSTEM
WAYNE MAXWELL
PREVALENCE OF DEPRESSION, ANXIETY AND POST-TRAUMATIC
STRESS IN WAR- AND CONFLICT-AFFLICTED AREAS: A META-
ANALYSIS
ISIS CLAIRE Z. Y. LI, WILSON W. S. TAM, AGATA CHUDZICKA-CZUPAŁA, CYRUS S.
H. HO, ROGER S. MCINTYRE, KAYLA M. TEOPIZ, ROGER C. HO
ANXIETY MANAGEMENT WITH THE VALSALVA
BREATHING MANEUVER: A SIMPLE PROTOCOLREUBEN VAISMAN-
TZACHOR, PH.D., FACFEI, FAPA, DABCHS
POLITICAL POLARIZATION IS AFFECTING MENTAL HEALTH, AND
PATIENTS WANT THERAPISTS WHO SHARE THEIR VIEWS
ELISA BRIETZKE
ESSENTIAL BACKUP: COMPREHENSIVE STRESS MANAGEMENT
TRAINING AT THE SAN FRANCISCO POLICE DEPARTMENT
DOUGLAS CYR
PRISON LIFE
ASA BROWN, Ph.D.
EMBRACING OUR DARK SIDE
ROBERT D. BAIZE
PUBLICATIONS AND WORKSHOPS BY ACADEMY MEMBERS
PRACTICAL DOCUMENT FROM A PRACTICAL GUIDE FOR CRISIS
RESPONSE IN OUR SCHOOLS
AMERICAN ACADEMY OF EXPERTS INTRAUMATIC STRESS
• SUGGESTIONS FOR ASSISTING CHILDREN IN THE AFTERMATH
OF A TRAGEDY
• TEACHER GUIDELINES FOR CRISIS RESPONSE
• PARENT GUIDELINE FOR CRISIS RESPONSE
• SCHOOL CRISIS RESPONSE: A PRACTICAL CHECKLIST
RESOURCES FOR DEALING WITH TRAUMATIC EVENTS IN SCHOOLS
NATIONAL CENTER FOR SCHOOL MENTAL HEALTH
MANUSCRIPT GUIDELINES FOR THE
JOURNAL OF THE AMERICAN ACADEMY OF EXPERTS IN
TRAUMATIC STRESS
LIST OF PROFESSIONS AND SPECIALITES OF
MEMBERSHIP OF THE ACADEMCY
APPLICATION FOR THE AMERICAN ACADEMY OF
EXPERTS IN TRAUMATIC STRESS SCHOLARSHIP
PROGRAM
J
Journal of the American Academy of Experts in Traumatic Stress
2
THE JOURNAL OF THE
AMERICAN ACADEMY OF EXPERTS IN TRAUMATIC STRESS
VOLUME 9 FALL-WINTER 2024
__________________________________________________________________________________________
IN THIS ISSUE: A MESSAGE FROM THE PRESIDENT
BRAD LINDELL, Ph.D.
________________________
TO GO DIRECTLY TO AN ARTICLE, CLICK ON ARTICLE NAME
THE INTRODUCTION OF THE
AMERICAN ACADEMY OF EXPERTS IN TRAUMATIC STRESS
SCHOLARSHIP PROGRAM
DILEMMAS IN ASSISTED SUICIDE REQUESTS
FOR MENTAL HEALTH PROVIDERS
BILL OWENBY
PHYSIOLOGICAL RESPONSE OF THE HUMAN BODY TO TRAUMATIC
EVENTS – POTENTIAL IMPACTS OF FREQUENT ACTIVATION OF THE
AUTONOMIC NERVOUS SYSTEM
WAYNE MAXWELL
PREVALENCE OF DEPRESSION, ANXIETY AND POST-TRAUMATIC
STRESS IN WAR- AND CONFLICT-AFFLICTED AREAS: A META-
ANALYSIS
ISIS CLAIRE Z. Y. LI, WILSON W. S. TAM, AGATA CHUDZICKA-
CZUPAŁA, CYRUS S. H. HO, ROGER S. MCINTYRE, KAYLA M. TEOPIZ,
ROGER C. HO
ANXIETY MANAGEMENT WITH THE VALSALVA
BREATHING MANEUVER: A SIMPLE PROTOCOL
REUBEN VAISMAN-TZACHOR, PH.D., FACFEI, FAPA, DABCHS
POLITICAL POLARIZATION IS AFFECTING MENTAL HEALTH, AND
PATIENTS WANT THERAPISTS WHO SHARE THEIR VIEWS
ELISA BRIETZKE
ESSENTIAL BACKUP: COMPREHENSIVE STRESS MANAGEMENT
TRAINING AT THE SAN FRANCISCO POLICE DEPARTMENT
DOUGLAS CYR
PRISON LIFE
ASA BROWN, Ph.D.
EMBRACING OUR DARK SIDE
ROBERT D. BAIZE
PUBLICATIONS AND WORKSHOPS BY ACADEMY MEMBERS
PRACTICAL DOCUMENT FROM A PRACTICAL GUIDE FOR CRISIS
RESPONSE IN OUR SCHOOLS
AMERICAN ACADEMY OF EXPERTS IN TRAUMATIC STRESS
• SUGGESTIONS FOR ASSISTING CHILDREN IN THE AFTERMATH
OF A TRAGEDY
• TEACHER GUIDELINES FOR CRISIS RESPONSE
• PARENT GUIDELINE FOR CRISIS RESPONSE
• SCHOOL CRISIS RESPONSE: A PRACTICAL CHECKLIST
RESOURCES FOR DEALING
WITH TRAUMATIC EVENTS IN SCHOOLS
NATIONAL CENTER FOR SCHOOL MENTAL HEALTH
MANUSCRIPT GUIDELINES FOR THE
JOURNAL OF THE AMERICAN ACADEMY OF EXPERTS IN
TRAUMATIC STRESS
APPLICATION FOR THE AMERICAN ACADEMY OF
EXPERTS IN TRAUMATIC STRESS SCHOLARSHIP
PROGRAM
STRESS SCHOLARSHIP PROGRAM
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Journal of the American Academy of Experts in Traumatic Stress
3
AMERICAN ACADEMY OF EXPERTS IN TRAUMATIC STRESS
The Journal of the American Academy of Experts in Traumatic Stress (JAAETS) is published for the American Academy
of Experts in Traumatic Stress and the National Center for Crisis Management as a benefit of membership with the
organizations. The JAAETS is the official publication of the American Academy of Experts in Traumatic Stress. The
JAAETS, like its membership, is multidisciplinary in nature. The articles included in the JAAETS focuses on the many
facets of traumatic stress and crisis management and includes theoretical perspectives, empirical research, prevention
and post-intervention strategies, treatment outcome studies, among other type of topics.
The Journal of the American Academy of Experts in Traumatic Stress serves its multidisciplinary membership who
address the needs of survivors before, during and in the aftermath of traumatic exposure (both man-made and natural
disasters). The journal publishes theoretical articles, case studies, editorials, as well as other topics that are relevant
to traumatic stress and crisis situations.
Publication Dates: The Journal of the American
Academy of Experts in Traumatic Stress, is published
quarterly in June, September, December and March by
The American Academy of Experts in Traumatic Stress,
127 Echo Avenue, Miller Place, NY 11764.
Membership: For information on becoming a member
of the American Academy of Experts in Traumatic
Stress and the National Center for Crisis Management
please go to www.AAETS.org or www.NC-CM.org or
see the membership application included in this
publication. Members receive a complimentary
subscription to this journal.
Copyright and Copying: Copyright © American
Academy of Experts in Traumatic Stress and the
National Center for Crisis Management. All rights
reserved. No part of this publication may be
reproduced, stored or transmitted in any form or by
any means without the prior permission in writing
from the American Academy of Experts in Traumatic
Stress with the exception if the copying is for
educational purposes, for example, distribution to
workshop or conference participants. The JAAETS can
be forwarded to professionals who have an interest in
joining the organization. The JAAETS cannot be sold.
Disclaimer: The American Academy of Experts in
Traumatic Stress or the National Center for Crisis
Management cannot be held responsible for errors or
any consequences arising from the use of information
contained in this journal; the views and opinions
expressed do not necessarily reflect those of the
Academy or the Center. The publication of
advertisements does not constitute any endorsement
by the American Academy of Experts in Traumatic
Stress or the National Center for Crisis Management
unless stated as an endorsement.
Journal Inquires and Reprints: Inquires and reprints
for the journal should be directed to Annmarie Arleo,
Director of Operations at aarleo@aaets.org.
Manuscript Submission: Manuscripts for the Journal of
the American Academy of Experts in Traumatic Stress
should be submitted to manuscripts@aaets.org.
Correspondence: Correspondence regarding the
Journal of the American Academy of Experts in
Traumatic Stress should be addressed to:
American Academy of Experts in Traumatic Stress
127 Echo Avenue, Miller Place, NY 11764
Journal of the American Academy of Experts in Traumatic Stress
4
AMERICAN ACADEMY OF EXPERTS IN TRAUMATIC STRESS
NATIONAL CENTER FOR CRISIS MANAGEMENT
ADMINISTRATIVE OFFICES:127 ECHO AVENUE, MILLER PLACE, NY 11764
TEL. (631) 543-2217 • (800) 810-7550 • FAX (631) 543-6977 • www.NC-CM.org • www.AAETS.org
Dear Colleague,
I would again like to welcome you to the Journal of the American Academy of Experts in
Traumatic Stress (JAAETS), the official publication of the American Academy of Experts in
Traumatic Stress and the National Center for Crisis Management. The JAAETS is published
four times a year.
The Academy is excited to announce the formation of the American Academy of Experts in
Traumatic Stress Scholarship Program. The Academy will award scholarships to members
and their immediate families who are embarking on education and/or training in the areas
of traumatic stress or crisis management. More information about the scholarship
program and the application is included in this edition. Interested members can also
obtain information and apply online by clicking here.
The Academy is also excited to inform you of a number of new sections in this edition of
JAAETS including:
• Members who have recently received the Diplomate or Fellowship advanced
credentials or certification under the Traumatic Stress or Crisis Management
Specialties Programs. The Academy congratulates all members who have been
credentialed.
• A section that outlines members’ publications, workshops, and trainings.
• A list of the professions and specialties of the Academy membership.
Members who would like to be include their publications or workshops in future editions
of JAAETS, at no charge, please contact Annmarie Arleo at aarleo@aaets.org. The
Academy continues to offer email blasts to the membership and associated networks
announcing members’ publications, workshops, and trainings.
The current edition of JAAETS includes a number of articles on diverse topics. This edition
again includes practical strategies for addressing traumatic events that have a widespread
impact on the school community as well as strategies for dealing with survivors of
different school ages. Guidelines for teachers and parents are again included to assist in
efforts in addressing the needs of school age survivors.
As I encouraged you in the past, please provide feedback to the Executive Board of the
Academy and Center regarding the JAAETS and offer suggestions for improvement. Thank
you for your continued commitment to helping survivors of traumatic stress and crisis
situations and for your continued support of the Academy and the Center.
Sincerely,
Brad Lindell, Ph.D.
President
Administration
BRAD LINDELL, Ph.D.
Chairman
MARK D. LERNER, Ph.D.
Former Chairman
RAY SHELTON, Ph.D., B.C.E.T.S., F.A.A.E.T.S.
Director, Professional Development
ANNMARIE ARLEO
Director of Operations
Member Relations Specialist
Board of Scientific & Professional Advisors
PAUL J. ROSCH, M.D., B.C.E.T.S.
Internal Medicine & Psychiatry
President, American Institute of Stress
ALBERT ELLIS, Ph.D., B.C.E.T.S., F.A.A.E.T.S.
Clinical Psychology
Founder, Albert Ellis Institute
In Memoriam
GEORGE S. EVERLY, Ph.D., B.C.E.T.S., F.A.A.E.T.S.
Founder & Senior Representative to the United Nations
for the International Critical Incident Stress Foundation
JAMES T. REESE, Ph.D., B.C.E.T.S., F.A.A.E.T.S.
President, James T. Reese and Associates
Founder, FBI Stress Management Program
DAVID J. FAIR, D. Min., B.C.E.T.S., B.C.C.C., F.A.A.E.T.S.
Founder, Exec. Director, Crisis Response Chaplain Services
Chair International Conf. of Police Chaplains Ed. Com.,
Director of Chaplain Services, Multi Jurisdictional Law
Enforcement Agencies, State of Texas
KEITH A. ROBINSON, D.D.S., C.C.C., D.A.A.E.T.S.
Forensic Odontology
Crisis Chaplain
RAYMOND F. HANBURY, Ph.D., ABPP, F.A.A.E.T.S.
Clinical & Police Psychology
National Disaster Medical System
Director, N.J. Crisis Intervention Response Network
MOTI A. PELEG, D.S.W., B.C.E.T.S.
Clinical Psychology
President, Psychological Group of Northern NJ
FRANCINE SHAPIRO, Ph.D., B.C.E.T.S.
Clinical Psychology
Originator & Developer of EMDR
CHIEF RAYMOND CRAWFORD, M.S., B.C.E.T.S.
Chief of Department (Ret.)
Nassau County Police Department, New York
ALBERT R. ROBERTS, Ph.D.
Editor & Chief, Brief Treatment & Crisis Intervention
DANIEL J. McGUIRE, F.A.A.E.T.S., C.A.T.S.M.
President, CISM Perspectives
WILLIAM J. SEFICK, Ph.D., B.C.E.T.S.
Clinical & Sports Psychology
ASA DON BROWN, Ph.D., D.N.C.C.M., F.A.A.E.T.S.
Author, Professor, Speaker, Advocate
WILLIAM A. TARRAN, D.P.M., B.C.E.T.S.
Podiatric Medicine
STEVEN HANDWERKER, Ph.D., D.Div., B.C.E.T.S.
Founder & Chairman, International Association
for the Advancement of Peace
BEVERLY J. ANDERSON, Ph.D., B.C.E.T.S.
Clinical, Counseling & Police Psychology
President, American Academy of Police Psychology
VINCENT J. McNALLY, MPS, B.C.E.T.S., C.E.A.P.
Ret. Unit Chief for FBI Employee Assistance Program
President, Trauma Reduction Inc., Tampa, Florida
DAVID G. CURTIS, Ph.D., B.C.E.T.S., F.A.A.E.T.S.
Clinical & School Psychology
SAM D. BERNARD, Ph.D., B.C.E.T.S., F.A.A.E.T.S.
Disaster Psychology & Crisis Response
President, Bernard & Associates, P.C.
FRANCIS W. BROOKS, D.O., B.C.E.T.S., F.A.A.E.T.S.
Osteopathic Medicine
President, Central Florida Pain & Stress
Journal of the American Academy of Experts in Traumatic Stress
5
THE INTRODUCTION OF THE
AMERICAN ACADEMY OF EXPERTS IN TRAUMATIC STRESS
SCHOLARSHIP PROGRAM
The American Academy of Experts in Traumatic Stress, in collaboration with the National Center for Crisis
Management, is proud to announce a Scholarship Program for members of our organizations and their
immediate families who are in the process of or planning to obtain education and/or training in the areas
of traumatic stress or crisis management.
The program will begin offering yearly scholarships of at least $500 to five individuals who meet the
criteria set forth below. All applications being of equal quality, the first individuals to submit applications
will receive priority. The scholarships will be awarded upon a winner providing proof of enrollment and
payment for the education/training.
The following criteria must be met in order to be eligible for the Scholarship Program:
• Be a current member of the American Academy of Experts in Traumatic Stress or an immediate
family member of a current member.
• Currently receiving education and/or training in traumatic stress or crisis management; or planning
to become enrolled in said training.
• Currently attending an accredited institution or educational/training programs offering CEU’s
accredited by a recognized organization (e.g., Critical Incident Stress Foundation, American
Psychological Association, etc.) or planning to become enrolled. The Academy reserves the right,
after a review, to award scholarships to individuals attending educational/training programs that
do not meet the this criteria.
• Provide proof of enrollment and payment in an eligible program.
• If under the age of 18, applicant must have a parent or guardian co-sign the application.
• Must demonstrate a history of success in the educational or training environments.
• Complete the Academy’s application for the Scholarship Program and provide the required
documentation.
• Submit the completed application to the Academy by the stated due date.
CLICK HERE TO VIEW THE ONLINE APPLICATION
Journal of the American Academy of Experts in Traumatic Stress
6
RECENT RECIPIENTS OF DIPLOMATE AND FELLOWSHIP WITH THE ACADEMY
AND CERTIFICATION UNDER THE TRAUMATIC STRESS
AND CRISIS MANAGEMENT SPECIALTIES
ADVANCED ACADEMY
CREDENTIALS
FELLOWSHIP WITH THE ACADEMY
DR. LINDSIE R. WHITTED
DR. MARIGLO L. VICENTE
CMDR. RANDY P. AZZATO
DR. JAMES LYNN GREENSTONE
DR. PHILIP ROBERT RHOTON
DR. FABIANA FRANCO
DR. EDGAR ARCE
DR. JOYCE H. BROWN
DR. BRAXTON MORRISON
MR. DOUGLAS CYR
DIPLOMATE OF THE ADADEMY
MS. MAUREEN BROGAN
MS. AGNES WOHL
MR. DAMIEN HOFFMAN
MR. MICHAEL G. BROWN
MS. PENELOPE HAZINAKIS-SWAINSTON
MR. DOUGLAS P. CYR
DR. STEPHEN ODOM
DR. GORDON A R EDWARDS
MS. KASSIE CLAUGHTON
MR. MICHAEL L. GRABILL
MR. SHAUN J.F. BROOKHOUSE
CHAP. EURIPIDES RIVERA
DR. GEORGEKUTTY KOCHUCHAKKALACKAL KURIALA
MR. ERIC V. FORSBERG
PROF. CHRISTOPHER BROWN
DR. JASON WALKER
DR. KATHRYN JUZWIN
MS. NICHOLE C. OLIVER
DR. TAYLOR LARSEN
MR. BRIAN DICK
REV. THOMAS M. MULDOWNEY
DR. RODERICK LOGAN
DR. BOBBIE LEGG
MS. KAREN MCGRELLIS
MR. BRAXTON A. MORRISON
MRS. ASHLEY SAN GIACOMO
DR. JAN KEVIN MOISES
MRS. ALIDA HODES-GALLIN
MR. CHRISTOPHER CASTIGLIA-MARELLI
MS. LANA SEILER
DR. JORDAN HOWARD-YOUNG
MR. TIM DIETZ
DR. RONALD JOHN RECIO
DR. MICHAEL A. VOGEL
DR. TRICIA A. STALLINGS
MS. KENZI L. TURPIN
DR. TEHMINA SHAKIR
MS. DANA FREEMAN
DR. NICHOLAS BOYD
MR. RALPH CAHOON
MS. CHARLENE LUCAS
CDR MONIQUE J. RICHARDS
MS. KRISTEN LITVAK
MR. BILL E. OWENBY
MR. JAN ABRAHAM CRONJE
CERTIFICATION UNDER
TRAUMATIC STRESS SPECIALITIES
PAIN MANAGEMENT
DR. DARREN D. LOVE
DR. STEPHANIE MILNE
DR. STANLEY ZASLAU
ACUTE TRAUMATIC STRESS
MANAGEMENT
DR. ELAINE F. CARTER
MS. YING YAN CHIU
REV. DR. MARTIN PHILLIPS
MS. SUET KWAN WU
MS. KA WAI IP
MS. KA YIN CHAN
MS. YING SUET YEUNG
MS. CHOR YEE CHAN
MR. JOHN T. PRUCHA
MS. DEBBY WONG
MR. JAMES M. FLOYD, JR.
MS. CLAUDIA P. ROBINSON
MS. CAROLE W. JEWETT
BEREAVEMNET TRAUMA
DR. NIKOLE SCOTT
MRS. CHRISTINE DRONEY
DR. GEORGEKUTTY KOCHUCHAKKALACKAL KURIALA
CHILD TRAUMA
MS. JULIE COOPER
DR. GENE ANN BEHRENS
MRS. HANNAH WARE
MS. DELORES A. REDMOND
MS. MARIE FARELLA
CRISIS INTERVENTION
MS. REBECCA BROWN
MRS. CYNTHIA PEARSON
MR. MARK LASSO
MRS. JAIME BREWER
MS. NICOLENA HENSLER GORDON
MS. JODIE J. GREGORY
MR. JOSHUA GOSS
DR. DAN L. EDMUNDS
MR. ERIC A. ANDERSEN
DOMESTIC VIOLENCE TRAUMA
MS. RANDEE KOGAN
DR. ADAM LEE FORD
MRS. ROSIE MARTINEZ
MS. MISTY BIDDICK
MS. AMBER CARMICHAEL
MS. KARI B. HARRIS
RAPE TRAUMA
MS. AMBER CARMICHAEL
FORENSIC TRAUMATOLOGY
DR. SHONNA M. HILL
MS. AMY SEYMOUR
MS. TAMMY CHATFIELD
MR. BRUCE D. TAIT
DR. KATE RODRIGUEZ
MS. DEBRA TIRADO
MR. HANIF E.A. BENJAMIN
DR. JAMES HARRISON
ILLNESS TRAUMA
DR. HARMEHR SEKHON
MS. AARTI S. FELDER
SEXUAL ABUSE TRAUMA
MS. AGNES WOHL
MRS. CLARESSA PATTERSON
DR. KAYLA ALLISON
MS. ELENA ROTH
MS. SUET MEI HAU
STRESS MANAGEMENT
MR. BRETT COTTER
DR. KELLY R. DARDEEN
DR. MARYAM DAVODI-FAR
CHAPLAIN EDWARD J. SPENCE
MS. GWEN SOFFER
DR. DAVID WHITE
WAR TRAUMA
MR. ALLEN L. DAVIS
MR. JOHN PRUCHA
MOTOR VEHICLE TRAUMA
DR. CHRISTOPHER CONNELLY
CERTIFIED CRISIS CHAPLAIN
REV. DR. DAVID P. KENAT, JR.
DR. JOYCE BROWN
CHAPLAIN EDWARD J. SPENCE
REV. MICHAEL J. VINSON
CHAPLAIN JOSELENE GRAY
CHAP. BETH KEY
FR. MATTHEW MICHAUD
CERTIFICATION UNDER
CRISIS MANAGEMENT SPECIALITIES
EMERGENCY CRISIS RESPONSE
DR. JANE M. TUCKER
DR. SHONNA M. HILL
MS. FERRULE ROSE
CHAP. BEN WETHERILL
MR. ERIC N. POIRIER
MS. KARI B. HARRIS
Journal of the American Academy of Experts in Traumatic Stress
7
DILEMMAS IN ASSISTED SUICIDE REQUESTS
FOR MENTAL HEALTH PROVIDERS
BILL OWENBY, ABD, MC, LPC-S, LASAC, ACS, DCMHS, NCC, CCMHC,
CCTP, CCFTP, NLP, CIMHP, CCTMHP, C-DBT, DIPLOMATE
ABSTRACT
This article delves into the complex ethical and legal challenges that mental health counselors face when dealing with
patients contemplating assisted suicide, regardless of its legality in their state. It provides readers with insights into
ethical, clinical, legal, and moral guidelines, prompting self-reflection on how they approach such topics both
personally and professionally. The discussion explores the world of assisted suicide, addressing its global implications
and ethical intricacies. It introduces the "Predicament Model," which highlights how life circumstances can impact
suicide decisions. The article also examines the ethical, legal, and clinical hurdles faced by non-medical licensed mental
health professionals, along with their personal responses to such requests. It reviews the rationale, intent, options,
and considerations for assisted suicide, framing it as a client's choice rather than a fault. This comprehensive review
equips mental health counselors and healthcare professionals with a nuanced understanding of this contentious issue
within a multifaceted landscape.
Keywords: Assisted-Suicide, Ethical Dilemmas, Conflicts of Interest, Scopes of Practice, Professional Duty
Introduction
Writing this article presented several challenges, which
may be subjects of contemplation and debate for those
who read it. It is crucial to clarify that this review, and
by extension, the author, does not advocate for or
endorse any particular stance on the topic of suicidality.
Instead, its purpose is to draw attention to a burgeoning
field, a medical option, and the increasing likelihood
that mental health professionals will encounter
inquiries from colleagues, medical practitioners, or
clients regarding end-of-life discussions and options,
conceptualized and hereby referred to as Professionally
Assisted Suicide Services (PASS) for the purpose of this
article and subsequent studies or articles on PASS.
This review will delve into the history of suicide, its
prevalence, connections to various factors, associated
costs, and alternative options. Its aim is to prepare
readers for the potential emergence of PASS in their
clinical careers. It is essential to underscore that this
review does not negate the significance of suicide
prevention, efficacy, religious perspectives, political
considerations, ethical dilemmas, or legal obligations.
Instead, it endeavors to provide an academically
grounded exploration of PASS, recognizing the evolving
legislative landscape, the expansion of clinical
alternatives, and the increasing likelihood of mental
health professionals encountering these issues. Thus,
we aim to offer a neutral, supportive, and research-
based perspective on PASS for the inevitable moment
when an assisted suicide request becomes a
professional concern. This article is not all-inclusive, but
a brief review and introduction to assisted suicide, and
informs professionals of suggestions and starting points
for when professionals are challenged with this topic
and request.
History and Prevalence
The phenomenon of suicide has a shadowy history, its
origins eluding precise determination. There exists no
official record or even a close approximation of the first
documented instance of completed suicide in the
annals of human history. Some estimations posit that
suicide may have emerged approximately 70,000 years
ago, coinciding with the advent of cognitive evolution in
humans, which endowed them with abstract thinking
and forward planning abilities. The Sumerians, as the
earliest historical record keepers, offer some insights,
Journal of the American Academy of Experts in Traumatic Stress
8
yet significant gaps remain in our understanding,
leaving considerable stretches of history unaccounted
for. The earliest known suicide note dates back to
approximately 2040 BC in Egypt (Khan, 2020).
Presently, the World Health Organization (WHO)
estimates that approximately 800,000 people succumb
to suicide each year, equating to one life lost every 40
seconds. To put this into perspective, during the mere
10 minutes it takes to read this review, 15 individuals
will have tragically ended their own lives. Intriguingly,
suicide does not rank among the top 10 leading causes
of death worldwide; it hovers around the 15th position,
according to the WHO (2019). For reference, road
injuries claim the 10th spot with 1.2 million fatalities
annually, dementia ranks 7th with 1.62 million deaths,
and cardiovascular disease holds the grim distinction of
being the leading cause, claiming a staggering 18.56
million lives each year.
It is imperative to acknowledge that these figures are
estimations influenced by numerous variables, one of
which is the legal status of suicide in different regions
around the world, impacting reporting accuracy.
Suicidal tendencies manifest in diverse forms, ranging
from fleeting thoughts to passive ideation, acute crises,
pathological patterns, to intentional actions. The data
surrounding suicide is both fascinating and unsettling.
Men are twice as likely as women to engage in suicidal
behavior. Young adults, while more prone to suicidal
tendencies than other age groups, see a surge in suicide
rates among those aged 70 and older. Firearms emerge
as a prominent means of suicide in the United States,
accounting for 46% of cases, in stark contrast to only 4%
in comparable countries where firearm ownership is
less common. Astonishingly, suicide claims twice as
many lives as homicide, underscoring the sobering
reality that individuals face a greater risk of dying by
suicide than by murder. These statistics, while providing
context, should not diminish the gravity of the issue but
rather emphasize the likelihood of individuals
encountering suicide from various perspectives,
whether legal, medical, spiritual, or within the realm of
mental health. It is noteworthy that 98% of suicide cases
have a history of mental illness, with a strong
correlation observed between suicide and poor
socialization and social integration, even when
controlling for mental illness (Ritchie, Roser, & Ortiz-
Ospina, 2015).
Mental Health and Suicide
Delving further into the relationship between mental
health and suicide, a prominent factor emerges as a
common thread among psychiatric patients and the
general population: mood disorders, particularly
Depression or Major Depressive Disorder. It is
noteworthy to highlight the significant variations in
suicide rates worldwide, with a striking example being
Greenland, where nearly half (48%) of suicides occur
during periods of continuous daylight. Additionally,
alcohol is a factor associated with 1 out of 3 suicides,
and the media's coverage of political or famous suicides
has been shown to increase copycat effects, often
referred to as 'contagious suicide,' elevating the
occurrence rate by 14 times compared to the suicide of
a fictional character in a story, which sees only a
fourfold increase.
The dilemma at hand is intriguing; despite our extensive
resources, wealth of information, expectations,
assessments, safety protocols, predictive models, and
identification strategies, we still face substantial
challenges in predicting who, when, and why someone
might attempt or complete suicide (Pridmore, Ahmadi,
& Pridmore, 2019). One might think that individuals
engaging in Non-Suicidal Self-Injury (NSSI) provide a
reliable predictor, but this assumption proves incorrect.
Similarly, identifying those deemed at high risk does not
offer a clear solution, as only 5% of those classified as
high-risk actually go on to complete suicide.
Astonishingly, 50% of suicide victims fall within the low-
risk category, particularly among those who do not seek
hospitalization for stabilization (Pridmore, Ahmadi, &
Pridmore, 2019).
Over the decades, societies around the world have
adopted various lenses through which to approach
suicide prevention. This journey spans from the late
1900s when suicide was considered illegal and subject
to legal penalties, to religious perspectives in Islamic
and Christian belief systems that deemed suicide a sin
and a religious concern. The medical model
subsequently emerged, conceptualizing suicide as a
medical condition amenable to treatment. Even the
American Psychiatric Association's DSM-5 incorporated
it as a mental health disorder under the label "Suicide
Behavior Disorder" (APA, 2013), providing a category
for research consideration. This category defined
individuals who had attempted suicide within the last
Journal of the American Academy of Experts in Traumatic Stress
9
two years, deliberately with a clear expectation of
death.
However, examining the phrasing here reveals the
emergence of a new, more constructive model, known
as the Predicament Model. In this model, suicide is
understood as arising from, being sustained by,
attempted, repeated, and completed due to an
individual's predicaments in their environment. These
predicaments encompass various life challenges such as
divorce, job loss, systemic barriers, legal issues, housing
problems, medication concerns, access to quality
treatment, and most crucially, medical issues. When
considering medical issues in this context, it is not about
minor ailments like a toothache or upset stomach;
instead, it encompasses terminal illnesses, treatment-
resistant conditions, and a deteriorating quality of life.
In essence, it pertains to a life that has become
unbearable, leaving the individual grappling with
questions such as 'should I continue to live,' 'can I
endure this existence,' 'how do I cope,' and 'am I
allowed to end my life, especially by my own hand.'
The Presumed Cost of Suicide on Society
In the United States in 2013, the national cost
associated with suicide and suicide attempts amounted
to $58.4 billion. This figure is based solely on reported
data and does not account for cases that went
unreported, were underreported, misreported, or
miscategorized. The comprehensive study considered
both the direct costs linked to suicide completions/loss
and the indirect expenses encompassing lost wages,
taxes, services, insurance, and employment challenges
stemming from suicide-related issues. When factoring
in adjustments for statistics, the cost surges to an
estimated $93.5 billion. In today's economic landscape,
with inflation taken into account, the annual estimated
cost of suicidal behaviors in the United States has risen
to approximately $73 billion, a reflection of the ongoing
challenges in accurately identifying and quantifying the
numbers involved.
Suicide: A Consequence or A Choice?
What if suicide were not a behavior to be minimized, a
problem to be eradicated, or an outcome to be
interrupted, but rather a clear and competently chosen
option within the realm of treatment? This proposition
may have piqued your interest, triggering professional,
personal, spiritual, legal, and ethical alarms and
concerns. This review introduces a movement that has
been in existence for decades, continually gaining
traction and expanding in scope and legal recognition.
Its purpose is to provide information, education, and
preparation for the day when, inevitably, someone
approaches you seeking an evaluation of competency, a
referral, or even a hypothetical discussion on this
matter—because we are all aware of the underlying
motives behind those hypothetical 'what if'
conversations.
Why Assisted Suicide is Growing
The cost of assisted suicide can vary significantly due to
numerous factors, including the specific procedures and
medications employed, the jurisdiction where the
procedure takes place, and the individual patient's
insurance coverage and financial means. Here are some
key elements that can influence the cost of assisted
suicide:
Medical expenses: Assisted suicide typically involves
various medical costs, encompassing physician fees,
medication expenses, and other medical services like
consultations and laboratory tests. The precise costs
related to these services can fluctuate based on the
provider and the geographical location where the
procedure occurs.
Legal fees: Patients pursuing assisted suicide may incur
expenses related to legal services, such as consultations
with attorneys and the preparation of legal documents
like advance directives and living wills.
Administrative costs: Administrative expenses
associated with assisted suicide can include fees for
processing paperwork, obtaining necessary approvals,
and securing authorizations.
Travel expenses: Patients residing in regions where
assisted suicide remains illegal may need to travel to a
different location to access this option, adding
significant travel costs to the overall procedure
expenses.
End-of-life care: Individuals opting for assisted suicide
may also need to cover costs related to end-of-life care
services like hospice or palliative care, which can further
contribute to the overall expenses of their end-of-life
Journal of the American Academy of Experts in Traumatic Stress
10
journey.
It's crucial to acknowledge that while the cost of
assisted suicide may be substantial, it typically remains
significantly lower than the expenses associated with
end-of-life care for individuals who pass away from
natural causes. Assisted suicide can provide patients
with a heightened degree of control over their end-of-
life care, a factor highly valued by many patients and
their families. Nevertheless, the cost of assisted suicide
can still pose a formidable barrier for certain patients,
particularly those lacking sufficient insurance coverage
or financial resources.
The cost of assisted suicide varies based on multiple
factors, including the specific procedures and
medications used, the location where the procedure
occurs, and the individual patient's insurance coverage
and financial circumstances. Providing an exact
estimate of the cost is challenging due to these
variations.
However, drawing from available data, the cost of
assisted suicide can range from several hundred to
several thousand dollars. For instance, in Oregon,
where assisted suicide is legal, the medications used for
the procedure (typically a combination of barbiturates)
can cost several hundred dollars. In addition to
medication costs, patients opting for assisted suicide
may need to pay for medical consultations and other
services, contributing to the overall expenses.
It is noteworthy that, compared to the costs associated
with end-of-life care for individuals who die of natural
causes, assisted suicide tends to be considerably more
affordable. It offers patients a degree of control over
their end-of-life journey, a facet highly valued by many
patients and their families. Nevertheless, the cost of
assisted suicide can still be a significant hurdle for some
individuals, particularly those without adequate
insurance coverage or financial means.
When examining the broader financial landscape,
consider that more than half (60%) of people over the
age of 65 expend between $188,658 (Spillman & Lubitz,
2000) and $197,000 (Webb, 2010) on healthcare costs.
Individuals with chronic diseases can face annual
expenses exceeding $57,000 (Jha, 2018). Additionally,
the average monthly cost of hospice care can reach
$17,000 when dealing with terminal illness and care. If
a person passes away in a hospital setting, the costs can
soar to over $32,000 in a single month. In total, end-of-
life expenses accounted for 10% of all healthcare costs
in the United States in 2019, tallying up to a staggering
$365 billion (Ethos, 2022).
Why is Assisted Suicide Appealing
In the context of chronic pain and terminal illness, life
often becomes a profound challenge, marked by
difficulty and unbearable suffering. Assisted suicide, or
the option of suicide, can offer various forms of relief to
those currently enduring such circumstances.
Control: The prospect of losing control over one's own
body, life, and the trajectory of their illness can
engender fear, distress, depression, and a sense of
hopelessness and helplessness. Assisted suicide can
restore a sense of control, autonomy, and choice over
the course of treatment, the type of treatment, and the
manner of dying.
Dignity: Chronic pain, prolonged suffering, and terminal
illness can erode an individual's sense of dignity to an
alarming degree. When a person confronts the
challenges of life and understands that their illness is
terminal, their sense of dignity and self-respect often
diminishes. Assisted suicide provides an opportunity for
individuals to regain control, enhancing their sense of
dignity and allowing them to make choices about their
own death and the manner in which it occurs.
Financial considerations: The cost of end-of-life care can
be substantial, and the burden of self-funding or placing
the financial responsibility on family members can
exacerbate the sense of being a burden.
Personal beliefs: Some individuals hold personal or
religious beliefs that support the option of assisted
suicide as a means to end their own suffering through
choice and autonomy, regain control over their bodies
and outcomes, or subscribe to beliefs related to
reincarnation and repurposing in the context of their
end-of-life journey.
Current Barriers to Pursuing this Choice in Care
While assisted suicide is legal in some U.S. states and
countries globally, there remain substantial barriers
that can impede patients' access to this option. Here are
Journal of the American Academy of Experts in Traumatic Stress
11
some of the primary barriers that patients may
encounter when considering assisted suicide:
Legal restrictions: Assisted suicide is presently legal in
only a handful of U.S. states and the District of
Columbia, with specific requirements and procedures
varying by state. Patients residing in states where
assisted suicide is illegal can encounter significant legal
obstacles when attempting to access this option.
Physician participation: In states where assisted suicide
is legal, patients typically need to find a willing physician
to assist them in the process. Some healthcare
providers may decline participation in assisted suicide
due to personal or professional reasons, making it
challenging for patients to identify a willing provider.
Access to healthcare: Patients lacking access to
adequate healthcare, including palliative care and
hospice services, may be more inclined to contemplate
assisted suicide. However, limited access to these
services can amplify patients' difficulties in managing
symptoms and maintaining their quality of life,
potentially heightening their desire for assisted suicide.
Stigma and social pressure: Patients expressing a desire
for assisted suicide may encounter social stigma and
pressure from family members or others opposed to
this option. Such stigma and pressure can hinder
patients from openly discussing their desires and
seeking support from others.
Economic considerations: Assisted suicide can be costly,
and patients with limited financial resources may
confront significant barriers. In some instances, patients
may be unable to afford the expenses associated with
assisted suicide, encompassing physician fees,
medications, and other related costs.
Patients considering assisted suicide may face a range
of barriers that complicate their access to this option.
Mental health counselors and other healthcare
providers can play a pivotal role in assisting patients in
navigating these barriers and making informed
decisions about their end-of-life care.
It is important to note that to pursue assisted suicide,
patients must generally meet specific criteria, including
having a terminal illness with a prognosis of six months
or less to live, being mentally competent to make
informed decisions, and having the capability to self-
administer the medication.
Ethical Dilemmas as Non-Medical Professionals
Assisted suicide presents complex and contentious
ethical dilemmas for mental health counselors and
other non-medical professionals. Here are some of the
key ethical considerations mental health counselors
must grapple with when working with patients
contemplating assisted suicide:
Autonomy: The principle of autonomy, emphasizing the
patient's right to make decisions about their care, is
central to the assisted suicide debate. Mental health
counselors must navigate the delicate balance between
respecting the patient's autonomy and promoting their
overall well-being.
Non-maleficence: The principle of non-maleficence,
which underscores the duty to do no harm, necessitates
careful consideration of the potential risks and benefits
of assisted suicide. Counselors must weigh the potential
psychological harms associated with assisted suicide
against the potential benefits of relieving the patient's
suffering.
Beneficence: The principle of beneficence, emphasizing
the obligation to promote the patient's overall well-
being, requires counselors to explore all available
treatment options with their patients. This includes
palliative care, hospice care, and other forms of
supportive care.
Professional boundaries: Mental health counselors
must maintain appropriate professional boundaries
when working with patients considering assisted
suicide. They should not endorse or encourage assisted
suicide but provide patients with accurate information
about their options and support them in making
informed decisions.
Personal beliefs: Counselors may possess personal or
religious beliefs that conflict with the concept of
assisted suicide. It is crucial for counselors not to impose
their own beliefs on patients but rather to assist
patients in making informed decisions aligned with their
individual values and beliefs.
Ultimately, the decision of whether to support a
patient's request for assisted suicide is intricate and
highly personal. Mental health counselors must
meticulously consider the ethical implications of this
Journal of the American Academy of Experts in Traumatic Stress
12
decision in light of their professional obligations and
their own values, beliefs, and biases. The emergence of
Professionally Assisted Suicide Services (PASS)
introduces a novel care option that will undoubtedly
test the ethics, morals, beliefs, objectivity, and decision-
making models guiding counselors in navigating this
complex ethical dilemma.
Legal Dilemmas as a Non-Medical Professional
Assisted suicide is a highly regulated and legally intricate
issue, presenting mental health counselors with several
legal dilemmas when working with patients considering
this option. Here are key legal considerations that
mental health counselors must be aware of:
State laws: Assisted suicide is currently legal in only a
limited number of U.S. states and the District of
Columbia, each with its specific requirements and
procedures. Mental health counselors must have a
thorough understanding of the laws and regulations in
their state and ensure strict compliance with all legal
prerequisites when assisting patients contemplating
assisted suicide.
Informed consent: Patients must provide informed
consent before undergoing assisted suicide, indicating a
comprehensive understanding of the procedure's risks,
benefits, and available alternatives. Mental health
counselors bear the responsibility of guaranteeing that
their patients possess a clear comprehension of the
implications of their decision, making an informed
choice grounded in accurate information.
Professional liability: Mental health counselors may
face legal liability if they fail to adequately inform their
patients about the risks and benefits of assisted suicide
or if they do not adhere to legal requirements while
assisting a patient in this process. To mitigate legal risks,
counselors should seek guidance from legal counsel or
their professional association.
Scope of practice: Counselors should be mindful of the
scope of their practice and the legal restrictions
governing their involvement in assisted suicide. In some
states, mental health counselors may be prohibited
from offering any assistance with assisted suicide, while
in others, they may be allowed to provide counseling
and support services to patients considering this option.
Reporting requirements: Certain states mandate mental
health counselors to report any suspected cases of
assisted suicide or euthanasia. Counselors must be well-
versed in their state's reporting requirements and
ensure strict compliance with all legal obligations.
Mental health counselors must navigate a complex
interplay of legal prerequisites and ethical
considerations when collaborating with patients
contemplating assisted suicide. Staying updated on
legal changes and seeking legal advice when necessary
is crucial to delivering the best possible care to patients
within the boundaries of the law.
Professional and Personal Dilemmas
Assisted suicide is a profoundly personal and
emotionally charged issue, potentially giving rise to a
range of personal dilemmas and conflicts for mental
health counselors. Here are significant personal
considerations counselors may encounter:
Personal values: Counselors may hold personal or
religious beliefs that conflict with the concept of
assisted suicide. It is essential for counselors not to
impose their own beliefs on their patients but to
support them in making decisions aligned with their
individual values and beliefs.
Emotional toll: Assisting a patient in the process of
assisted suicide can be emotionally demanding for
mental health counselors. They may experience
emotions such as grief, guilt, or anxiety regarding their
role in the patient's decision and must find strategies to
manage their emotional well-being while providing
support.
Professional identity: Counselors might grapple with
their professional identity and role when aiding patients
in assisted suicide. Some may feel that participating in
this process contradicts their role as healers or helpers,
while others may see it as a compassionate and
essential aspect of their work.
Burnout: Assisting patients with end-of-life decisions
can be emotionally draining, placing mental health
counselors at risk of burnout if they do not adequately
manage their workload and self-care.
Relationship with the patient: Mental health counselors
often develop close relationships with their patients
over time, and helping a patient with assisted suicide
can strain these relationships. Counselors must be
Journal of the American Academy of Experts in Traumatic Stress
13
prepared for the possibility that their patients may
choose to end their lives and must maintain a
compassionate and supportive relationship throughout
the process.
Mental health counselors must navigate a variety of
personal dilemmas and challenges when working with
patients considering assisted suicide. Seeking support
and guidance from colleagues, professional
associations, and personal networks is essential in
managing these challenges and providing the best
possible care to patients.
A View Beyond the Beyond: What Happens After
After someone undergoes assisted suicide, several
steps are typically taken to ensure that the patient's
wishes are carried out and that their body is treated
with respect and dignity. These steps may include:
Verification of Death: After the patient passes away, a
physician or another medical professional will verify the
patient's death. This may involve checking for vital signs
such as pulse and breathing, as well as using medical
tests to confirm that the patient has died.
Notification of Family and Loved Ones: The patient's
family and loved ones will be notified of the patient's
death. They will also be provided with information on
how to access grief counseling and other support
services to help them cope with their loss.
Preparation of the Body: The patient's body will be
prepared for burial or cremation according to the
patient's wishes and any legal requirements. This may
involve washing and dressing the body, arranging for
transportation, and completing necessary paperwork.
Support for Family and Loved Ones: Hospice and other
end-of-life care providers may offer ongoing support to
the patient's family and loved ones. This support may
include counseling, grief support groups, and other
services to help them navigate the grieving process.
It's important to note that the specific steps taken after
assisted suicide may vary depending on the patient's
location and the laws and regulations governing end-of-
life care in that area. However, the primary focus after
assisted suicide is on ensuring that the patient's wishes
are respected and that their body is handled with care
and dignity. Additionally, providing support and
assistance to the patient's family and loved ones during
this challenging time is a crucial part of the process.
Certifications, Trainings, and Licensure Requirements
for PASS
In terms of training, mental health counselors typically
receive training on suicide prevention and intervention
as part of their education and ongoing professional
development. This training may cover topics such as risk
assessment, crisis management, and evidence-based
treatments for depression, anxiety, and other mental
health conditions that can contribute to suicidal
ideation.
However, training on assisted suicide specifically may
not be included in the standard curriculum for mental
health counselors, as it is illegal in many places and
conflicts with the professional duty of mental health
counselors to promote mental health and prevent
suicide. Mental health counselors may also receive
guidance from their professional organizations or
licensing boards on how to respond to patient requests
for assisted suicide, which may include guidelines for
ethical decision-making, referrals to other healthcare
providers, and other resources to support patients and
their families.
It is important for mental health counselors to stay
informed about the laws and regulations governing
assisted suicide in their location and to seek guidance
from their professional organizations and legal counsel
as needed to ensure that they are acting in accordance
with their professional duties and obligations.
Additionally, counselors may want to educate
themselves on end-of-life care and palliative care
resources in their community so they can provide
appropriate referrals and support to patients and their
families who may be facing terminal illness or other
end-of-life issues.
From an ethical perspective, many mental health
counselors would likely view assisted suicide as being in
conflict with their professional duty to promote mental
health and prevent suicide. Mental health counselors
are trained to help patients manage their mental health
conditions and develop coping strategies to improve
their quality of life, rather than to facilitate their death.
Journal of the American Academy of Experts in Traumatic Stress
14
In many cases, patients who express a desire for
assisted suicide may be struggling with mental health
issues such as depression, anxiety, or post-traumatic
stress disorder (PTSD), and may benefit from counseling
and other mental health services. Mental health
counselors may be able to help these patients manage
their symptoms and improve their quality of life, while
also addressing any concerns or fears they may have
about death and dying.
If a mental health counselor is approached by a patient
who expresses a desire for assisted suicide, it is
important for the counselor to discuss the issue openly
and honestly with the patient, while also maintaining
professional boundaries and avoiding any actions that
could be seen as facilitating the patient's suicide. The
counselor may also need to consult with their
professional organization, legal counsel, or other
experts to determine the appropriate course of action
in light of the specific laws and regulations governing
assisted suicide in their location.
For further consideration and a solid exercise, consider
your licensure board or organization’s code of ethics’
recommended Ethical Decision Making Model. For
licensed mental health counselors, the American
Counseling Association (ACA) recommends the
Forester-Miller & Davis Model (2016) as an appropriate
model to examine any ethical or moral concerns a
professional may be experiencing.
What kind of person would typically/broadly qualify
for PASS?
Assisted suicide, also known as physician/
professionally-assisted dying or aid-in-dying, is the
process of intentionally ending one's life with the help
of a physician or other medical professional. The criteria
for eligibility for assisted suicide varies depending on
the country and/or state where it is legal.
In places where assisted suicide is legal, the eligibility
criteria typically include:
Competent Adult: The individual must be a competent
adult, usually defined as being 18 years or older.
Terminal Illness or Serious Condition: The individual
must have a terminal illness or a serious and incurable
condition that causes unbearable suffering. The specific
medical conditions that qualify may vary by location.
Voluntary Decision: The individual must make a
voluntary, informed decision to request assisted
suicide. This decision must be free from coercion or
external pressure.
Self-Administered: The individual must be capable of
self-administering the medication or treatment to end
their life, with the assistance of a medical professional
if necessary.
Medical Review: The individual's request for assisted
suicide is typically reviewed by multiple healthcare
professionals to ensure that they meet the legal and
ethical criteria.
It's important to note that assisted suicide remains a
controversial and highly debated topic, and not all
countries or states have legalized it. Additionally, some
medical professionals may have personal or religious
objections to providing assisted suicide, which can limit
a patient's access to this option.
Summary
This comprehensive discussion revolves around the
multifaceted topic of assisted suicide, its ethical, legal,
and professional implications, and the role of mental
health counselors in addressing these complexities. It
delves into the global context of suicide, highlighting the
influence of mood disorders and external factors on
suicide rates. It introduces the "Predicament Model," a
perspective that emphasizes the impact of life
circumstances on suicide decisions.
The text discusses the societal costs of suicide and the
appeal of assisted suicide for individuals facing terminal
illnesses. It addresses current barriers to accessing
assisted suicide, including legal restrictions, physician
participation, and economic considerations. The ethical
dilemmas faced by mental health counselors in assisting
patients considering assisted suicide are explored,
emphasizing principles like autonomy, non-
maleficence, and beneficence. Legal dilemmas, such as
state laws and informed consent, are also discussed.
This article also outlined the post-assisted suicide
process, including death verification, family notification,
body preparation, and support for loved ones. It
touches on the certifications, training, and licensure
requirements for mental health counselors in the
context of physician-assisted suicide services (PASS).
Journal of the American Academy of Experts in Traumatic Stress
15
For further information in general, and to see where
your state may be in the process of assisted suicide and
to see about your specific non-medical versions of PASS,
please check out: www.dyingwithdignity.com for
further details.
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PHYSIOLOGICAL RESPONSE OF THE HUMAN BODY TO
TRAUMATIC EVENTS – POTENTIAL IMPACTS OF FREQUENT
ACTIVATION OF THE AUTONOMIC NERVOUS SYSTEM
WAYNE MAXWELL, MED, MPA, CCC, CTTS, FAAETS
The human body responds automatically to situations
which are perceived as a threat. The activation of the
system has been perceived, as recorded by Walter
Cannon years ago (1929), as the “flight-fight” response
which he records as: “Bodily changes in pain, hunger,
fear and rage”, ... experiences that are interpreted as
being some type of perceived threat to our human
bodies. Later, Jeff Wise, (2009) in his book, “Extreme
Fear: The Secret Science of Your Mind in Danger”,
expands the “flight-fight” response of Cannon, to the
“freight, freeze, flight, fight” response. This is a
significant indication of increased knowledge and
understanding of the autonomic nervous system in our
bodies and is reflected in much more research and the
resulting understanding of the autonomic nervous
system and the two sub-components of the system for
activation (sympathetic) and deactivation
(parasympathetic) system components.
Responses of our autonomic nervous system to
situations regularly encountered, and coping reactions,
result in increased demands and challenges on our
physiological and psychological functioning, as well.
Psychological (cognitive and emotional) functioning
impacts physiological functioning, and physiological
functioning impacts psychological functioning
considering the biochemical interactions which result.
FREQUENT OVER-REACTIONS – AUTONOMIC OVER
STIMULATION?
Is it possible that body reactions can become more
frequent, regular, and even when not necessary? Can
this result in increases in activation of the body system,
or even continuous activation above and beyond the
norm for on-going functional responses to meet the
perceived increases in demands and challenges?
Over functioning, continuous on-going functioning of
the autonomic nervous system’s sympathetic
component, are addressed in professional literature in
a number of ways as psychological disorders. Examples
include psychological trauma, critical incident stress,
post-traumatic stress disorder (PTSD), or other related
stress disorders, such as claustrophobia (fear of
confined spaces), agoraphobia (a fear of leaving home,
being in a crowd, in unknown public places). (Coleman,
2006)
On reading Wise’s book, one immediately relates to his
perspective of adding freeze and freight, mainly from
personal “front line” experiences. Some experiences
were in performing police undercover surveillance,
especially in rural, forested areas. The sounds, in such
situations, became much more significant in the quiet
of the night. A hearing super-sensitivity developed
which resulted in the freeze reaction, which I can clearly
and significantly relate to, probably because it was
experienced so many times.
During life, humans experience the functioning and
impacts of the autonomic nervous system being
activated or “turned on”. Some terms which have been
used for activation: flight-fight response meaning to
respond to a challenging situation with a running away
or “taking flight” or a fight response, and another,
adrenalin “dump”, the increased level of adrenalin in
the circulatory system from the adrenal glands, are
commonly used. Adrenalin is one of the body hormones
which creates the more commonly known physiological
and psychological responses resulting from activation of
the adrenal glands.
The adrenal glands, as all glands within the autonomic
nervous system, are activated by the penial gland,
located in our head near parts of the brain which are
receiving nervous impulses and emitting impulses from
the brain to various parts of the body in response to
sensory perception neurological impulses.
Journal of the American Academy of Experts in Traumatic Stress
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Many psychological disorders which are neurosis and
psychotic disorders involve hyperactivity of the
autonomic nervous system being activated. Many
researchers have addressed these issues in discussing
psychological trauma: Sigmund Freud, Sigbert Ganser,
from the late 1870’s, (Maxwell, 2003) to the present.
TRAUMATIC RESPONSE TO ADRENAL STIMULATION
Responses to adrenalin stimulation is a traumatic
response, at some level, to a situation which creates
challenges psychologically and physiologically as sensed
by the brain. Work on describing and defining trauma
has been done by Okum and Kantrowitz, (2008), has
broadened our understanding of the types of trauma. A
brief listing describing their work on trauma types
includes:
TRAUMA TYPES
DESCRIPTION
Dispositional
Lack of information on relevant
issues, such as: Job to take?
Medical referral to request?
Living arrangements? etc.
Anticipated
Usual life situations: Changes in
career, marriage, becoming a
parent, divorce, etc.
Traumatic
Uncontrollable, overwhelming
situations: 9-11, earthquakes,
sudden death of loved one, etc.
Maturational
Through stages of life:
dependency, emotional
intimacy, loss of job, inability to
get along with supervisors,
planning end of life activities.
Psychological
Issues which include disorders
like: claustrophobia,
agoraphobia, etc., as examples.
Psychiatric
Medical / physiological issues,
being at risk, unable to care for
self, etc.
It is interesting to note, that most people over time have
regarded only Traumatic types of stress as trauma. The
psychological /psychiatric types were apparently more
frequently thought of as stress responses, and it was
rare that Dispositional, Anticipated and Maturational
trauma were regarded as trauma. It, therefore, was the
reality that the other three types of traumatic stress
were very rarely thought of as traumatic stress!
The result has been that many have not realized that
our bodies were reacting to traumatic events with what
are now more frequently recognized as traumatic bodily
reactions to impacts of traumatic events with the
activation of the autonomic nervous system (ANS)!
The activation of the ANS and the secretions of other
ductless glands, which are controlled by the penial
gland in the head, including the hormone cortisol, has
control over ductless glands to some degree in the
human body. Constant overactive ductless glands and
mainly the impact of cortisol, correlates with what may
be the cause of several medical conditions, such as:
Obesity (waist fat)
Cancer
Diabetes (Increased
blood sugar)
Depression (negative
feelings)
High blood pressure
Senile dementia
(impaired brain
function)
Heart disease
(cholesterol)
Dr. Alan Watkins, a medical doctor with specialization in
internal medicine, has also been active as an
international trainer for managers of international
companies. In his book on management, (2014),
Cohesion: The Secret Science of Brilliant Leadership, he
references recent research which indicates a correlation
between high cortisol levels in the body and the
disorders identified above.
In addition to cortisol, Dr. Watkins identifies the
hormone, dehydroepiandrosterone (DHEA), which is
linked to creative positive emotion, passion,
enthusiasm, and interest; the opposite of cortisol,
identified above which is related to negative emotions:
anger, frustration, anxiousness. In situations when
cortisone is at high levels, as opposed to DHEA, the
Journal of the American Academy of Experts in Traumatic Stress
18
increases in the negative impacts on the body system
are increased.
RELEVANT DUCTLESS GLANDS – CONTROL OF
AUTONOMIC NERVOUS SYSTEM
The chart in table 1 below includes what are the more
commonly known hormones in our human bodies. As
noted above by Dr. Alan Watkins, Cortisol, known as the
stress hormone, is the hormone which has high
correlations with several other medical disorders, as
noted above. It should be noted, however, that
correlation is not indicative of a cause-effect
relationship, but only that when one factor exists, the
other occurs, for example, in this case, high cortisol
levels. To show a cause-effect relationship randomly
controlled trial based (RCT) research is necessary.
Research using RCT’s has, apparently, not been
published to date in studying this relationship.
A condensed listing of the glands of the autonomic
system follows:
High levels of Cortisol over long periods of time can have
lasting, negative effects on health. The reaction is
known as Cushing Syndrome or hypercortisolism. These
are stimulated by high levels of adrenalin and,
adrenocorticotropin (ACTH).
EXCITED DELIRIUM
This disorder, excited delirium, is an extreme reaction of
the autonomic nervous system. It is a disorder which
involves several additional factors including drug
(cocaine & other street drugs), alcohol use and
withdrawal, along with psychiatric illness. Cairns, Dr.
James T, (2005), Deputy Chief Coroner for the province
of Ontario, Canada. The signs and symptoms include:
• Bizarre and / or aggressive behavior
• Panic
• Impaired thinking
• Shouting
• Disorientation
• Violence towards others
• Hallucinations
• Unexpected physical strength
• Acute onset of paranoia
Interventions with those who are experiencing this
reaction have been noted more frequently during the
late 1990’s and early ‘20’s and I have had personal
contact with a police officer who encountered a person
apparently with this reaction disorder who resisted
arrest, was shouting and hollering, had unexpected
strength in resisting arrest, who had the symptoms
noted above. In an attempt to control the “intoxicated”
individual a restraint was used directed to pressure on
the sides of the neck, however, the person continued to
resist in an out-of-control fashion. The subject
eventually calmed, appeared to be unconscious, but
had died as a result of attempts to control.
The officer was charged with the death of the person,
went to trial, was found guilty and was sentenced to
several years in prison! This was before much was
known about Excited Delirium but is a potential reality
of being encountered today. More and better training
on the disorder has resulted in steps being taken to
better instruct police officers about this disorder and
therefore, greatly reduce the terminal impacts possible
with police intervention and attempts to control.
This disorder appears to result in the autonomic
nervous system being overstimulated with the use of
drugs and alcohol and possibly this results in a range of
reactions with the perpetrators which in efforts to
control can have a very high probability of death
occurring.
IMPACTS OF RELIGIOUS BELIEFS – CHRISTIAN, MUSLIM
AND BUDDIST BELIEFS ON THE AUTONOMIC NERVOUS
SYSTEM & RELATED ISSUES
Spirituality and religious beliefs which are associated
with Christianity are deeply believed standards by
which Christians should live as outlined by God’s
representative who came to earth, Jesus Christ. Failure
to live to these standards of beliefs and duties, as with
the Ten commandments in the book Genesis of the Holy
Bible. Failure to live up to these standards will result in
members of the Christian faith not going to heaven to
be with God but result in being sent to Hell as sinners.
How many people of the Christian faith have
experienced these types of stressors and thoughts as
they age and approach death? The numbers have
probably been quite large!
Journal of the American Academy of Experts in Traumatic Stress
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• Ineffectiveness of control weapons
Table 1. Commonly known hormones in the human body
DUCTLESS GLANDS
SECRETION (HORMONE)
LOCATION
IMPACTS
Penial
Pituitary
Thalamus
/Hypothalamus
Melatonin
Antidiuretic,
Oxytocin
Adrenocorticotropin (ACTH)
Head
Cardiac rhythms
Oxytocin: Feeling of trust,
empathy, and cooperation.
Thyroid
Parathyroid
Neck, Throat
Central nervous system
activation.
Thyroid: eating, drinking, sex,
aggression & others. Controls
central nervous system.
Adrenal,
pancreas,
kidneys
adrenalin (Epinephrine),
cortisol (Stress hormone),
dehydroepiandrosterone
(DHEA)
Near kidneys,
mid-torso
Stress response, blood glucose
levels ^, blood flow/pressure ^,
freeze-freight-flight-fight
response.
Gonads
(Female)
(Male)
Estrogen, Progesterone
Testosterone
Lower abdomen
Groin
Sexual response.
Journal of the American Academy of Experts in Traumatic Stress
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The same is true of those who believe in and follow the
Muslim faith, who, on considering the faith of
Mohammed, have not lived up to the standards set to
go to heaven to be with God and therefore face the
reality that they will not go to heaven, and will find
themselves in hell! Both the Muslim and Christian faiths
have the same general process outlined in both religions
for end-of-life heavenly decisions!
In this way, Christianity and Muslim beliefs are similar!
The impacts of these beliefs within both faiths are very
similar. How has this impacted the thinking of many
who were worried about not meeting the standards of
getting into heaven from their religious perspective?
Many have lived through this type of dilemma over
time! These issues are probably more significant and
have more significant impacts on the human body than
we realize from a traumatic stress perspective!
One of the only religions which does not appear to
follow this type of process is the Buddism faith which is
largely intertwined with the practice of meditation,
relaxation, and clearing the mind of thoughts. The
contrast between Christianity and Islam, and Buddhism
is significant. The former with a cognitive framework
which has tended to result frequently in cognitive
dissonance, and doubt about if one is living a good life
to get to Heaven, or is bound for Hell, as opposed to the
Buddhist faith and teachings.
For Christians and Muslims, the activation of the
autonomic system for not living to the standards of the
particular religions would probably be significant. For
Buddhism, it has not been the same situation. For the
autonomic nervous system, the sympathetic system
would probably be more constantly stimulated with
Christian and Islamic thinking about not making the
standard to get to heaven and the risk of going to Hell
was greater! The traumatic issues related to death and
dying from a religious perspective would be greater!
NEAR DEATH EXPERIENCES (NDE)
Some who have written about their “near death
experiences” (NDE’S) such as Anita Moorjiani, (2012),
who had been pronounced deceased by a medical
doctor as a result of cancer, then shortly thereafter,
returned to the living, have described their experience
with NDE’s.
Near Death Experiences are: “conscious, semi-
conscious or recollected experience of someone who is
approaching or has temporarily begun the process of
dying.” (Online search for near death experiences –
(NDE)). These usually involve descriptions of the
perception of surreal experiences such as seeing
themselves in various situations such as “perceiving …..
surreal phenomena”, as examples: “seeing themselves
from above or passing through a tunnel of light.” At
times, these experiences have been explained in terms
of religious / spiritual perspectives. The occurrence of
NDE’s appears to indicate that as many as 10 -20% of
persons who have been declared dead “have had a near
death experience”.
The knowledge of NDE’s being experiences has had, in
many cases, a calming effect related to experiencing
death and dying. The fears that have been associated
with death and dying from a perspective of traditional
religious teachings on death and dying, and
experiencing post death decision making of whether
one goes to “Heaven” or “Hell” are impacted and
questioned more with the NDE experiences of so many
being reported. The fear of dying appears to be less
today as a result of these experiences being shared!
In another paper online (2022-02-22) on NDE’s, some
key points related to NDE’s are that:
• The natural physiology of the brain is to keep
functioning.
• Just before death, neurochemicals in the brain
surge.
• According to near death survivors, “an experience
of comfort occurs”, making death an experience
which may be more acceptable, even welcoming,
for those who are approaching death.
These briefly described experiences and observations
which are being reported are having significant impacts
on human perceptions, reactions to and related
emotions to death and dying. These impacts are
appearing to have a calming impact in many cases, and
result in significant decreases in the fears of death and
dying which have resulted from religious beliefs and
teachings.
Journal of the American Academy of Experts in Traumatic Stress
21
RECENT VARIABLES CONTRIBUTING TO “OUT-OF-
CONTROL” CONFLICT SITUATIONS - GENERATION ME,
I GEN. AND OTHERS
Several notable additional factors have created
additional stress and activation of our autonomic
nervous system of the last five years or so. One of these
which has been noted and has had books and articles
written on the topic is the significant generational
differences which have been noted by many and in
many social settings over the period of time. Dr. Jean
Twenge (2014; 2017), has studied very thoroughly the
difference in those born following the rise in use of
“smart phones” by youth in North America from around
1995 to the present. Some of the major noted changes
in general differences have included which Dr. Twenge
has addressed include not going out without parents,
not going out on dates, experienced sex by completion
of high school, drove and had a driver’s license, are
examples of changes which have been noted. Dr.
Twenge’s work is extensive and also addresses
correlations of hours a day of internet or electronic
devise usage and unhappiness & suicide, less social
interactions, sports, religious activities, and more time
connected with internet news, TV and social networking
websites and acceptance of LGBT-oriented persons has
increased.
Dr. Twenge has also noted research, as one example, of
attitudes towards work versus life in preferring flexible
schedules for work, and wanting a balance of life and
work. It must be stressed that this is a very brief
overview of this issue as noted by Dr. Twenge’s work
and that of others.
Many of those who were born before the growth of
“Generation Me” and “i Gen” are very quick to identify
and acknowledge the realities of this new generation
which replaced the millennials, confirm the
generational differences addressed by Dr. Twenge.
Personally, I have been requested on a few occasions to
attend conflict situations in a workplace in the role of
Family – Employee Assistance Program counsellor,
when the issue has very obviously been conflicts
between newer staff representing Generation Me, and
the older generation, comprised of more senior,
experienced staff in an organization. The result was
deep psychological upset – trauma, especially for the
more senior supervisory staff!
COVID 19 PANDEMIC - MORAL DISTRESS
The impacts of the COVID 19 virus and the global
pandemic in 2019-21 had major impacts on all countries
and populations around the world. The spread of the
highly contagious virus resulted in action by
governments to make efforts to control the spread of
the virus, to save lives and to develop a vaccine which
would protect citizens from being infected by the virus.
The pandemic had additional impacts. One significant
impact was the appearance of what was labelled moral
distress, a reaction to the impacts of the virus spread
and the impacts were significant. Many were impacted
by first thinking about and being concerned about being
infected by the virus, spreading to others, especially,
family, and specifically, children. This, in turn, created
moral guilt, for example with many health care and
other human services professionals. The result was high
levels of stress ... of trauma, related to going to work,
having contact with others who may be infected by
Covid 19, becoming infected themselves, and taking it
home to family, children, and friends. In a previous
section of this article, the various types of trauma were
identified, Dispositional – a lack of information on the
issues; Maturational – with many more impacts on older
persons and their concerns about being infected by the
virus, Anticipated – the thoughts of being infected as
simply a part of living life, as well as the other types of
trauma which have been described in the book by Okum
and Kantrowitz, (2022), and noted above and in the
references. To many, since it has been several decades
since a pandemic has been experienced by mankind, the
experience was traumatizing!!
When the COVID 19 virus was first identified and
recognized as a very contagious virus, the stress …
trauma … reactions were significant. Many were very
quick to seek the vaccine. On the other hand, many
people who did not understand the science related to
viruses and the spreading of viral infections refused to
get vaccinated. This further complicated the public
response in “fighting” the virus.
Some of the major social reactions from sectors of the
population were the major blockages of transportation
routes, especially Canada – US border crossings, such as
in Alberta, and the significant blockages of Ottawa
streets near the Parliament Buildings which lasted for
Journal of the American Academy of Experts in Traumatic Stress
22
several weeks before the blockade was removed
without much conflict which can escalate, as it did in
many parts of the world.
A significant event in Nova Scotia, in Eastern Canada,
involved a mass shooting, in which an individual who
appears to have had some predetermined psychological
issues, and in experiencing the restrictions imposed by
government authority, reacted by shooting and killing
just over 20 persons. Most people he knew, others, he
didn’t. This is one example of many Covid 19 impacts
on populations which took place in various countries
around the world in late 2019 and the early 20’s!
APPROACHES TO UNDERSTANDING & CONTROLLING
HYPERAROUSAL
The identification of many significant factors which
activate the sympathetic nervous system which in most
situations are not even aware to people who have
higher levels of stress in considering our physiological
reactions to activities and events which impact us
significantly without us being aware of the impacts!
Further, as it has been noted, we are learning of the
negative impacts in a more thorough and significant
way! This reality causes many even increased stress and
over increasing activities of the sympathetic system.
We are recently much more aware of such events and
situations which create increased autonomic activities,
and this is resulting in many having increased focus on
body reactions and hyperarousal. This results in a
desire to identify types of events and situations more
accurately which create hyperarousal body reactions
more accurately. Further, the desire for more
knowledge as to what can be done to slow down or stop
these significant on-going over reactions with the
accompanying physiological and medical problems has
become a growing increasing desire.
There are several types of activities, protocols and
preventive activities which can be used to counter the
sympathetic nervous system reactions to these types of
situations when the learning and increased awareness
of body reactions to stressful situations. The critical
steps may include: Increased awareness of:
• Recognizing the reality that our body is
hypervigilant.
• Specific indicators that the SNS is in activation
mode.
• Techniques and activities to reduce SNS
overaction and the resulting stress impacts on
other parts of our bodies.
SYMPATHETIC NERVOUS SYSTEM ACTIVATION
HYPERAROUSAL training materials in the form of
comprehensive sheets that summarize information on
this topic have been developed by an Australian agency,
Open Heart Assets.
• Inability to relax, prepare for sleep, difficulty
“falling asleep”
• Constant rethinking of intrusive issues in order
to attempt to resolve the issues, solve the
problem(s), etc.
• Pulse rate above what is regarded as a resting
pulse rate.
• Diagnoses of some significant medical issues:
high blood pressure, cancer, strokes, etc.
APPROACHES TO ADDRESSING SYMPATHETIC
NERVOUS SYSTEM OVERACTIVATION
PHYSICAL ACTIVITIES – EXERCISE that may involve
walking, jogging, weightlifting, sports activities. All of
these create the bio-chemical system activities that
require the autonomic nervous system (sympathetic
mode) processes in the body. These activities require
the use of the autonomic nervous system in our bodies
to perform and sustain the activities in which we are
actively involved, and when the activities are
completed, the parasympathetic system is activated to
return the body function to a more calm, reduced need
for energy.
MEDITATION (& MINDFULNESS) - Meditation is a
process in which our bodies relax, which applies
conscious body relaxation when the full weight of the
body is resting in a tensionless relaxed manner while
sitting on a chair or the ground/floor. The chair or
ground take the full weight of the body. As relaxation is
occurring, deep breathing by thoroughly (deeply)
inhaling air through the nose, pausing and holding the
breath for a few seconds, then, exhaling through the
mouth. The lungs should be completely filled so that no
Journal of the American Academy of Experts in Traumatic Stress
23
more air can enter, and completely emptied until there
is no air left in the lungs which can be exhaled.
At the same time as breathing becomes thorough and
comfortable, it is to begin to work on “clearing our
minds of thoughts” as we allow our muscles to relax and
for the ground to take the full weight of our bodies. As
we breathe, we begin to do “body scans” by thinking of
any tensions in muscles in parts of our bodies which
should be relaxed and not have muscle tensions, even
with tensions in the muscles of the face.
It is in repeating these procedures that we begin to
achieve more total relaxation, to “turn off the
sympathetic component of the autonomic nervous
system, and to sense the reality of more complete “total
relaxation”. The more thorough the sense of relaxation,
the more calming the impact on the Central Nervous
System, and on the Autonomic Nervous system.
Practice over time will result in more positive, relaxing
results and more regular positive impacts on body
functions.
I took the first course to learn meditation and began to
practice the activity in the mid-1980’s. At first, I did not
sense or experience potential benefits and therefore
did not acquire more awareness of the usefulness and
potential positive impacts of meditation. It could be
that I was not sensitive to or not aware of tensions that
I may have been experiencing myself. However, in
2018-19, I took another course on meditation entitle
“Strategic Resilience for First Responders” presented by
Dr. Ruth Lamb of Langara College, Vancouver, BC, and a
team of local instructors in Nova Scotia. My personal
objective was to learn more and learn more techniques
for use in responding to stressful situations in which I
had been involved and to provide support and
counselling to others, mainly first responders.
The first course I attended was based on Transcendental
Meditation. The second was in more depth creating
awareness of the 7 major nerve plexus (chakra) and
biofield physiology. The 7 centers include:
1. Coccygeal (Root) Plexus
2. Sacral Nerve Plexus
3. Solar Plexus Nerve Plexus (Solar Plexus)
4. Cardiac Plexus
5. Pharyngeal Center
6. Carotid Plexus
7. Median Plexus
MARTIAL ARTS SPORTS – I first had experience in
learning judo (3rd degree black belt), then karate (1st
degree black belt) and with specific defense and control
tactics training for law enforcement and human services
agencies when working with potentially resistant and
violent clients. This also includes other martial arts,
including jujitsu (in which a granddaughter is an active
participant at present, tai kwon do, muay tai, and other
combative sport activities with Eastern Asian origins.
The inclusion of martial arts sports, especially the KATAS
related to each, are examples of “moving meditation”.
This term refers not only to the non-movement of still
relaxing meditation, but also to meditation in motion.
(Cameron, Laurie J. -2019). This makes reference to the
relaxing, automatic, smooth movements which are
practiced regularly which, when repeated frequently
during “work outs”, become so smooth and automatic
that the similarity to meditation seems very signficant.
Relaxation, automatic, smooth moves, with practice,
automatically and smoothly performed is the essence of
well learned and practiced martial arts skills included in
the katas.
Personal experience in Judo (mid 1960’s–1970’s) with
the practice of katas in the more senior ranks and in
Uechi Ryu karate (mid 1980’s -1995), have provided a
much more thorough understanding of the meditative
overlap with the performance of the katas.
A relevant and interesting article which I received as a
member of Judo Canada, entitled: Judo, ADHD
(Attention Deficit Hyperactivity Disorder) and inner
adversity, written by Anthony Diao, addresses a very
relevant topic. In March 2022, the Neurodis Foundation
in Lyon, France held a conference on children’s
attention. Recommendations were developed and the
findings were: “1) give a clear objective, to organize and
plan the steps, 2) to select relevant information (to
reduce external stimuli, and better focus), and 3) to
repeat the learning phases to free up attentional
resources.”
In the article, Arthur Clerget, a black belt in Judo, and
who performed well in international competitions in
Judo, discovered he had ADHD at the age of 26! He
Journal of the American Academy of Experts in Traumatic Stress
24
later, on gaining insight into his personal ADHD
experience in learning Judo, makes the observation: “I
think judo is a gift for ADHD. He later writes: Judo can
strengthen this self-esteem, especially through the
group, the opposition, and the competition. This is the
story of hyperactive people sent to the dojos. …. The dojo
is a social space where hyper-actives are valued,
whereas school experiences may give them an image of
themselves as dropouts or maladjusted children.”
The message conveyed and the points made in this
article are strong experiential evidence of a significant
positive link that can exist between the sport of judo
and the hyperactivity generated by ADHD. A strong and
interesting support of the potential role of the dojo
(judo gym) in lessening hyperactivity of the autonomic
nervous system!
ACTIVITES RELATED TO MARITAL ARTS SPORTS – TAI
CHI, YOGA, etc. - The practice of these activities is very
similar to and overlaps with the katas of the martial arts
sports. The relaxing somatic experiences of Tai Chi, for
example, are very similar to the katas of the martial arts
sports. It is my sense based on personal experience,
that these activities are even closer to the practice of
meditation than are the katas of the martial arts sports.
I recall at one time while learning tai chi, the vivid
thought went through my mind “…. moving meditation
….”, as I became cognitively aware of how similar and
overlapping in sensations and experience tai chi was to
meditation!
PSYCHOTHERAPIES with psychologically based
principles which have been used to treat trauma and
facilitate relaxation have covered all types of therapies:
Talk Therapies
• Cognitive Therapy and focused on thinking,
memory, and problem-solving thinking processes,
etc.,
• Emotionally focused therapy (Rogers)
These therapies have focused upon having the person
seeking therapy talk about the events that have been
upsetting and difficult for them to live with and
consistently re-experience usually related to the recall
of various upsetting traumatic experiences. Recently,
with growing regularity, these types of psychotherapy
for traumatic events have been ever more strongly
criticized due to the re-traumatization of those being
treated with the “talk therapies.”
Dialectical therapy
A behavioral therapy is a modified type of cognitive
behavioral therapy. It teaches how to live in the
moment, cope with stress, regulate emotions and
improve the living experiences they have.
Didactic therapy
Increases reasoning and emotional regulation. Provides
problem solving skills needed for difficult thoughts,
feelings, behaviors and experienced in different
events/situations.
Critical Incident Stress Management (CISM)
A system of support and assessment for, primarily first
responders, and those who work in the medical and
social psychological field with responsibilities to assist
those who have experienced and have been impacted
by traumatic events. It is primarily a post incident
support system which offers approaches to addressing
the impacts of traumatic events and the need for
further psychiatric or pschological support. This
program, developed and implemented primarily by Dr.
Jeffrey Mitchell and Dr. George Everly in the context of
the International Critical Incident Stress Foundation
(ICISF) in Ellicott City, Maryland, USA.
ACUPOINTS – ACUPUNCTURE
Acupoints are “… any of the specific locations on the
body that in the practice of acupuncture and
acupressure are stimulated (as by the insertion of a thin
needle or by the application of pressure) to produce
beneficial effects (such as the relief of pain or promotion
of healing).
The acupoints were developed in the context of
Traditional Chinese Medicine (TCM), have been
researched for effectiveness in treating for the relief of
pain and promotion of healing.
Acupoints exist in all parts of the body, along what are
called major meridians of which there are twelve (12)
and eight (8) extraordinary meridians. All of the
Journal of the American Academy of Experts in Traumatic Stress
25
acupoints used in the therapies noted below are located
in the upper body, from an underarm point on both
sides of the body and on ribs on to the top center of the
head. A listing of these points include:
• Top of head
• Under nose
• Inner end of eyebrow
• Chin
• Side of eye
• Center end of collar bone (2)
• Under the eye
• Under upper arm on upper area of ribs.
TAPPING THERAPIES – These therapies involve tapping
with a finger on acupoints on the face, neck, and upper
body (under arms and on mid body end of collar bone.
The impacts have resulted in effective calming of
cognitive and emotions which a traumatized patient
may have. Both are similar in that they use some similar
acupuncture points, but also have points which are
different between the two therapies. From a tapping
perspective, these therapies are very similar, but vary
slightly in the number of points used, and a few of the
point may be used in only one of the therapies.
Personally, I have received training in both of these
therapies, and have used them when the situations and
nature of the impacts of trauma on clients, indicated a
significant positive result when one of these therapies
was used. I took training in TFT in 2004, and in 2016,
completed training in Emotional Freedom therapy.
• Thought Field Therapy (TFT) - The information and
training in TFT I attended to certify in this therapy
was developed by Dr. Roger J. Callahan, and
presented by Shad Meshad, MSW in a workshop in
2004. One of Dr. Callahan’s significant books which
I have read and refer to regularly is: Stop the
Nightmares of Trauma, which Dr. Callahan and his
wife wrote.
• Emotional Freedom Therapy (EFT) – Al Rodee (EFT
Atlantic) presented the course attended in 2016 on
EFT in the metro Halifax area to certify in the use of
this therapy.
A Review Article which appeared in Explore by David
Feinstein, (2018) titled: Energy Psychology: Efficiency,
Speed, Mechanisms, addresses the effectiveness of TFT
and EFT. The article reviews research based, in part, on
randomized controlled trials (RCT’s) which are a core
approach to research which indicates the effectiveness
of various techniques being used in therapy. Feinstein
reports that with the use of RCT based research that
positive changes in mental arousal using tapping
therapies resulted in the modification in emotional
learnings at their neural foundations. The research
revealed: “Potential advantages of integrating the
stimulation of acupoints within more conventional
treatment approaches, based on existing evidence,
include enhanced speed and facility for the efficiently
modifying deep emotional learnings that are no longer
adaptive”.
These therapies have proven to be effective in treating
trauma, especially with the work of Callaghan with his
focus on TFT.
THERAPIES RELATED TO EYE MOVEMENT
Eye Movement Desensitization and Reprocessing
(EMDR)
This therapy, developed by Dr. Francine Shapiro (1997),
involves a patient sitting and watching or moving the
eyes from left to right and back again repeatedly for a
number of times, without talking or moving other parts
of the body. After a sequence, the person is asked
about their thoughts, feelings, and general reactions to
the experience.
The eye movements are a repeat of eye movements
during REM sleep (rapid eye movement), which occurs
during sleep when the brain is processing information
during the previous period of being awake. The theory
and practice of EMDR was developed in the late ‘80’s
and early ‘90’s and was built on a body of research by
Dr. Shapiro and others.
Dr. Shapiro points out that it is first necessary to make
certain that a trusting therapist-client relationship
exists before using the therapy.
Observation and Experiential Integration (OEI)
This therapy was developed by Dr. Rick Bradshaw and
Audrey Cook, MPhil, RCC, and involves moving a finger
laterally, 8 –12 inches from one eye at a time and
Journal of the American Academy of Experts in Traumatic Stress
26
observing the movement of the eyeball as it follows the
finger. At times the eyeball may stop moving and then
jump ahead to follow the finger of the therapist. The
irregular eye ball movements may be found to relate to
thoughts of memories which are upsetting for the
patient. The relationship to REM sleep appears to be a
factor with this therapy, as well.
LIFESTYLE
The term “lifestyle” is a broader, more encompassing
term related to and impacting the activation of the ANS,
and can be inclusive of all of the activities, therapies,
techniques and activities addressed in this article. It
addresses the nature of relationships with family,
friends, work colleagues, the priorities we have within
our interpersonal relationships we have with others in
life. Our lifestyles reflect our personal values, our
personal perceptions in our daily lives which are
important to us as we experience life events, activities,
and pastimes.
The integration of the priorities we have in living and
how we interact with others, is reflected in the
description of and determination of our lifestyle. As we
learn more and develop more insight into our
interpretation of what life should and could be, and can
be, it is reflected in our relationships with family,
friends, work colleagues and others. What we can learn
from others: those older, younger, those from other
cultures, speak other languages, have other customs
and traditions, will have a major expansion of our
knowledge, understanding and appreciation of others.
Generally, we are able to travel more than ever before
and this is a reality for many, especially younger people.
The world is, in this context, becoming a “smaller
place”. More international travel for study and living
away from our countries of birth. Advances in
technology and the resulting increases in knowledge, as
the use of smart phones, etc. has significantly changed
the younger generations. Their lifestyles are different
from the former generations not influenced by or
learning from new technology.
SUMMARY
One of the primary noted factors influencing our lives,
as noted by this paper, is the frequent over reaction of
the autonomic nervous system (ANS), the system which
automatically in the flight -fight reactions, which in
many situations are over reacting and produces higher
levels of cortisol more frequently to move about the
body and prepare for challenges we may have to
confront. This has been correlated to physiological
/medical conditions like diabetes, high blood pressure,
heart disease, cancer, to identify some of the resulting
conditions.
This results from the various types of trauma being
experienced which are noted, as outlined by Okum and
Kantrowitz (2008), are directly related.
In order to address this autonomic nervous system
response to trauma, it is first necessary to be aware of
these issues, and the potential impacts of constant
overaction to the ANS. In so doing, we will be able to
recognize and plan for responses which will reduce or
possibly eliminate frequent over reactions and high
cortisol levels.
Some of the activities suggested: physical activities like
walking, jogging, sports activities, etc., meditation and
mindfulness, an accent on martial arts sports, and
related activities: tai chi and yoga. For counsellors and
psychotherapists, awareness of the limitations and
possible traumatic impacts related to the “talk
therapies”, and the issues related to doing more harm
to clients! This is a factor for recommending
consideration of the “tapping therapies” use for those
who have experienced trauma. The tapping therapies
are based on tapping on acupoints mostly around the
head, upper chest and on the ribs under the arms. The
tapping therapies are briefly noted, and an article cited
entitled: Energy Psychology: Efficiency, Speed,
Mechanisms, by David Feinstein (2018).
Psychotherapies related to eye movements are also
briefly mentioned such as Eye Movement
Desensitization and Reprocessing (EMDR) and
Observation and Experiential Integration (OEI).
The final topic which is very relevant and of priority is
lifestyle. The factors involved here, in most situations
are noted in other sections of the paper.
It is important to recognize the fact that research is
ongoing on this topic and approaches to treatment of
the impacts of the condition will be more significant in
the future. It is also important to recognize that other
Journal of the American Academy of Experts in Traumatic Stress
27
medical / psychiatric approaches will very likely involve
the various types of meditation directed to the
treatment for the unique physiological / medical
overreactions of the autonomic nervous system.
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Journal of the American Academy of Experts in Traumatic Stress
29
PREVALENCE OF DEPRESSION, ANXIETY AND POST-TRAUMATIC
STRESS IN WAR- AND CONFLICT-AFFLICTED AREAS: A META-ANALYSIS
ISIS CLAIRE Z. Y. LI
DEPARTMENT OF PSYCHOLOGICAL MEDICINE, YONG LOO LIN
SCHOOL OF MEDICINE, NATIONAL UNIVERSITY OF
SINGAPORE, SINGAPORE, SINGAPORE
WILSON W. S. TAM
ALICE LEE SCHOOL OF NURSING, YONG LOO LIN SCHOOL OF
MEDICINE, NATIONAL UNIVERSITY OF SINGAPORE,
SINGAPORE, SINGAPORE
AGATA CHUDZICKA-CZUPAŁA
FACULTY OF PSYCHOLOGY, SWPS UNIVERSITY OF
SOCIAL SCIENCES AND HUMANITIES, KATOWICE, POLAND
CYRUS S. H. HO
DEPARTMENT OF PSYCHOLOGICAL MEDICINE, NATIONAL
UNIVERSITY HEALTH SYSTEM, SINGAPORE, SINGAPORE
ROGER S. MCINTYRE
MOOD DISORDERS PSYCHOPHARMACOLOGY UNIT
UNIVERSITY HEALTH NETWORK, TORONTO, ON, CANADA
UNIVERSITY OF TORONTO, TORONTO, ON, CANADA
BRAIN AND COGNITION DISCOVERY FOUNDATION,
TORONTO, ON, CANADA
KAYLA M. TEOPIZ
BRAIN AND COGNITION DISCOVERY FOUNDATION,
TORONTO, ON, CANADA
BRAXIA SCIENTIFIC CORP., TORONTO, ON, CANADA
ROGER C. HO
INSTITUTE FOR HEALTH INNOVATION AND TECHNOLOGY
(IHEALTHTECH), NATIONAL UNIVERSITY OF SINGAPORE,
SINGAPORE, SINGAPORE
Background: With the rise of fragility, conflict and violence (FCV), understanding the prevalence and risk factors
associated with mental disorders is beneficial to direct aid to vulnerable groups. To better understand mental
disorders depending on the population and the timeframe, we performed a systematic review to investigate the
aggregate prevalence of depression, anxiety and post-traumatic stress symptoms among both civilian and military
population exposed to war.
Methods: We used MEDLINE (PubMed), Web of Science, PsycINFO, and Embase to identify studies published from
inception or 1–Jan, 1945 (whichever earlier), to 31–May, 2022, to reporting on the prevalence of depression, anxiety
and post-traumatic stress symptoms using structured clinical interviews and validated questionnaires as well as
variables known to be associated with prevalence to perform meta-regression. We then used random-effects
bivariate meta-analysis models to estimate the aggregate prevalence rate.
Results: The aggregate prevalence of depression, anxiety and post-traumatic stress during times of conflict or war
were 28.9, 30.7, and 23.5%, respectively. Our results indicate a significant difference in the levels of depression and
anxiety, but not post-traumatic stress, between the civilian group and the military group respectively (depression
34.7 vs 21.1%, p < 0.001; anxiety 38.6 vs 16.2%, p < 0.001; post-traumatic stress: 25.7 vs 21.3%, p = 0.256). The
aggregate prevalence of depression during the wars was 38.7% (95% CI: 30.0–48.3, I2 = 98.1%), while the aggregate
prevalence of depression post-wars was 29.1% (95% CI: 24.7–33.9, I2 = 99.2%). The aggregate prevalence of anxiety
during the wars was 43.4% (95% CI: 27.5–60.7, I2 = 98.6%), while the aggregate prevalence of anxiety post-wars was
30.3% (95% CI: 24.5–36.9, I2 = 99.2%). The subgroup analysis showed significant difference in prevalence of
depression, and anxiety between the civilians and military group (p < 0.001).
Conclusion: The aggregate prevalence of depression, anxiety and post-traumatic stress in populations experiencing
FCV are 28.9, 30.7, and 23.5%, respectively. There is a significant difference in prevalence of depression and anxiety
between civilians and the military personnel. Our results show that there is a significant difference in the prevalence
of depression and anxiety among individuals in areas affected by FCV during the wars compared to after the wars.
Overall, these results highlight that mental health in times of conflict is a public health issue that cannot be ignored,
and that appropriate aid made available to at risk populations can reduce the prevalence of psychiatric symptoms
during time of FCV.
Keywords: depression, anxiety, post-traumatic stress, mental illness, mental health, conflict, war, post-war
Journal of the American Academy of Experts in Traumatic Stress
30
Introduction
With the rise of conflict and violence (FCV) in places like
Sudan, Somalia, and Ukraine, the World Bank estimates
that a total of 82.4 million people were forcibly
displaced as of end-2020, a sharp increase from the
estimated 68.5 million in 2017 (1, 2). War is defined as
organized violence where violence is the primary means
of coercion to achieve the continuation of a group's
policy; the violence may target individuals or resources,
but it is always physical and extends beyond the nation-
state (3). As war-afflicted areas are often associated
with higher levels of psychosocial distress and increases
the susceptibility of a population to psychiatric
symptoms, there has been growing interest in the
psychosocial health of persons in war-afflicted areas (4).
The effects of wars on mental health, physical health,
economic security, and political stability are long-
lasting. A systematic review on long-settled refugees
estimated the prevalence of any psychiatric morbidity
to be about 20% in a population that has resettled for
at least 5 years and acknowledges risk factors predicting
higher rates of psychiatric symptoms such as post-
traumatic stress and the adverse socio-economic
situation (5, 6). This is further fueled by the recent
highly reported war in Ukraine which saw a rise in
displaced individuals and separated families, raising
global awareness for mental wellness during times of
armed conflict (7). The cumulative effects of the Ukraine
war are likely to predispose its civilians and military to
adverse mental health outcomes due to rapid
transformations of their lives, such as civilians taking up
volunteer military roles, or being exposed to trauma (8).
Along with the added stressor of the COVID-19
pandemic, the Russian invasion of Ukraine saw a surge
of mental health disorders along with a reduction in
mental healthcare-seeking behavior, highlighting the
need to underscore the importance of ramping up the
accessibility of mental health aids especially in times of
conflict (9, 10). This is congruent with a recent meta-
analysis that reported the prevalence of mental
disorders post-conflict, but was limited in its
assessment of psychiatric symptoms during the time of
conflict itself. Our analysis aims to highlight the well-
established link between FCV and mental health
disorders, and underscore the importance of providing
appropriate aid to populations affected by conflict (11).
The military, being at the forefront of armed conflict, is
often believed to be at higher risk of experiencing
psychiatric symptoms due to increased combat
exposure leading to psychological distress (12, 13). It
has been separately reported that civilians are often the
overwhelming survivors of war trauma and are
vulnerable subjects to the aftermath effects of war (14,
15). Previous studies have reported on either the
civilian or military population, but rarely both (16). By
comparing both these groups, this analysis can provide
meaningful insights on the types of interventions,
exposures, and perpetuating factors of psychiatric
symptoms in the context of FCVs. Furthermore, the risk
factors and maintenance factors of psychiatric
symptoms during wars and post-wars may differ and
hence affect their prevalence. Epidemiological studies
on this topic are notoriously subjected to large
heterogeneity owing to the method of sampling that
was implemented, the severity of the conflict and
country in which the sampling was done (11, 17). The
foregoing limitations in previous research makes
interpretation and estimation of global prevalence of
psychiatric symptoms related to FCV challenging (18).
Many studies have documented a population's war-
related mental suffering and estimated the
manifestations of mental health disorders caused by
armed conflict, but there is a lack of research that has
focused on comparing the severity of mental health
disorder symptoms experienced by military and
civilians. Our study aims to fill this gap in research. This
seems particularly important in the face of data of The
United Nations Security Council that stresses that 90%
of the victims of war are civilians, innocent people, who
should be especially protected during wartime conflicts
(19). Making a comparison of the negative mental
health effects resulting from participation in armed
conflict between civilians and trained soldiers may
provide a deeper insight into the types of symptoms and
their severity in both groups. We performed a
systematic review to investigate the aggregate
prevalence of depression, anxiety and post-traumatic
stress among both civilian and military populations
exposed to war, and better understand the
susceptibility to or permeance of psychiatric symptoms
depending on the populations and the timeframe with
reference to the given war. We aimed to address the
Journal of the American Academy of Experts in Traumatic Stress
31
heterogeneity by using a random effects model because
the weight given to each study would be less influenced
by sample size, followed by performing appropriate
subgroup analyses and meta-regressions (20, 21).
Methods
Search Strategy
The meta-analysis was reported according to the
Preferred Reporting Items of Systematic Reviews and
Meta-Analyses (PRISMA) guidelines (22). The protocol
for this study was registered and is under open access
by the International Prospective Register of Systematic
Reviews (PROSPERO). We used MEDLINE (PubMed) to
identify studies published from January 1, 1945, to May
31, 2022 and other electronic databases such as Web of
Science, PsycINFO, and Embase from inception to 31
May, 2022, to identify articles study prevalence of
depression, anxiety and post-traumatic stress based on
structured clinical assessment or questionnaires in
people exposed to FCV. We used the search strategy
{[“war” (All Fields)] AND [“mental health” (MeSH) OR
“mental disorders” (MeSH) OR “depression” (MeSH) OR
“depressive disorder” (MeSH) OR “depression” (MeSH)
OR “anxiety disorder” (MeSH) OR “anxiety” (MeSH) OR
“PTSD” (MeSH) OR “post-traumatic stress disorder”
(MeSH) OR “psychological impact” (MeSH) OR” post-
traumatic stress disorder” (MeSH)]} to search for
articles using PubMed, and identified further sources
using the reference lists from studies such as systematic
reviews from articles obtained through the initial
search. We included all studies (e.g., randomized cohort
trials, retrospective/prospective cohort studies, cross-
sectional study) according to the PICOS (see Table 1).
The literature search and data extraction were
performed independently by two reviewers. Quality
control was performed by two independent reviewers
with the modified Newcastle-Ottawa Scale to assess the
risk of bias in observational studies, and all emerging
conflicts were resolved by consensus (23).
Inclusion and Exclusion Criteria
The inclusion criteria for studies eligible for analysis
were as follows: (1) Population studied of either military
(Army, Navy, Air Force, Marines, Coast Guard, medics,
and Reservists/National Guard), civilians, refugees,
prisoners-of-war from countries directly involved in war
and conflict where violence is one of the means of
coercion; (2) The outcomes of interest were depression,
anxiety and post-traumatic stress; (3) The
aforementioned psychiatric symptoms were assessed
by structured clinical interviews or questionnaires. (4)
Populations were defined as military if the targeted
study population stated that they were from a military
background such as but not limited to Army, Navy, Air
Force, Marine, Coast Guard, National Guard, Veterans,
Prisoner-of-war; whereas a population was defined as
civilian if it were studying the general population,
civilian or refugees. (5) A study was considered as during
war if the data collection occurred during the time of
conflict; a study was considered as post-war if the data
was collected at least 4 months after the official end
date of the conflict, or if the direct stressor (exposure to
war) had been removed (e.g., in refugees population).
The exclusion criteria for the studies included: (1)
Population studied were the second or third generation
survivors of war, civilians not from countries directly
involved in war, non-deployed military, pregnant
cohort, cohorts comparing medical conditions (skewed
cohorts); (2) all participants received mental health
interventions (part of a randomized control trial).
Data Analysis
We used the Comprehensive Meta-Analysis (CMA)
Version 3.0 (Biostat, Inc., Englewood, NJ, USA) to
perform all statistical analyses. A random effects meta-
analysis was conducted to investigate the prevalence of
depression, anxiety and post-traumatic stress. The
random-effects model was utilized to account for
between-study variance (24).
Prevalence of the condition were reported as a
dichotomous variable (i.e., presence vs absence)
according to the assessments established by structured
clinical interviews or questionnaires. Forest plots for the
prevalence of each psychiatric condition overall and
within subgroups were made to represent the overall
estimate, as well as individual study estimates.