by Carolyn Thomas ♥ @HeartSisters
I’ve written quite a lot here about my own debilitating experience with depression following my heart attack.(1) I have since learned that post-heart attack depression is alarmingly common – and alarmingly under-diagnosed – among women survivors. Mayo Clinic cardiologists report that up to 65% of us experience significant symptoms of depression, yet fewer than 10% are appropriately identified.
NYU Women’s Heart Program cardiologist Dr. Nieca Goldberg says women under age 60 are particularly susceptible to depression because a heart attack is such a major psychological trauma, especially when it occurs at a younger age. Studies show, she adds, that depression is an important risk factor for adverse outcomes in cardiac event survivors:
“It’s a life-changing, stressful event. It’s a shocking experience. There are constant concerns among survivors about whether they are going to be able to return to their usual life.”
Unlike longterm clinical depression, post-heart attack depression is often called “situational” depression, or “stress response syndrome”, and what mental health professionals call adjustment disorder that can strike following a traumatic life event as we struggle to make sense of something that makes no sense.
There are antidepressant drugs available, of course, but this treatment option may not actually be the miracle cure that Big Pharma wants us and our physicians to believe it is.
Depression has gone from being what was described in the 1960s by leading medical experts as a self-limiting, episodic disorder showing spontaneous recovery without treatment after a few months to now being a more chronic, drug-managed illness.
Not coincidentally, this growth has paralleled that of the drug companies selling antidepressant meds. In 1955, for example, only one in 468 North Americans was diagnosed with a mental illness; by 2008 it was one in 76. And since 1987 – the year Prozac hit the market – the number of North Americans off work on disability benefits for mental health reasons has tripled.
Here’s a distressing example: a new study(2) reported this month by Dr. Ramin Mojtabai at the Johns Hopkins Bloomberg School of Public Health found:
“Over the past two decades, the use of antidepressant medications has grown to the point that they are now the third most commonly prescribed class of medications.
“Much of this growth has been driven by a substantial increase in antidepressant prescriptions by non-psychiatrist providers without an accompanying psychiatric diagnosis and often for conditions such as tiredness, nonspecific pain, and headaches.
“Our analysis found that between 1996 and 2007, the proportion of visits at which antidepressants were prescribed but no psychiatric diagnoses were noted increased from 59.5 percent to 72.7 percent. To the extent that antidepressants are being prescribed for uses not supported by clinical evidence, there may be a need to improve providers’ prescribing practices or revamp drug formularies.”
University of Connecticut researchers(3) examined 38 pharmaceutical company-funded studies involving over 3,000 depressed patients and found that those taking antidepressants did improve, but the improvement differences between the medicated and placebo-taking groups were actually “miniscule”.
And a 10-year Dutch study also found that 76% of depressed patients who did not take any antidepressant drugs recovered and never relapsed. Another five-year study of 9,500 Canadian patients in Alberta concluded that the drug-taking group were depressed on average for 19 weeks, but those who did not take antidepressants were depressed for only 11 weeks. And the World Health Organization has found that non-medicated patients with depression enjoyed better health than those who took antidepressants.
It’s important to keep in mind that most published research favouring the use of antidepressant drugs has been funded by the drug companies that manufacture those antidepressant drugs.
A 2003 study in The British Journal of Psychiatry, for example, found that the drug giant Pfizer paid medical ghostwriters to create more than half of all medical journal articles published about its antidepressant drug Zoloft. The other half were written by independent academic researchers. Guess which articles were more positive toward Zoloft? See also: Partners In Slime: Why Medical Ghostwriting Is So Alarming
Having said all this, it’s also important to mention here, however, that pharmaceuticals can indeed help treat debilitating symptoms of severe mental illness for some people. And many who could benefit from these meds may unfortunately consider taking antidepressants a sign of weakness. It is not, of course – any more than it’s weak for a diabetic to take insulin.
And remember that a person struggling with severe depression is not able to merely use willpower to control their moods, any more than a diabetic can use willpower to change their blood sugar levels.
But many patients report that a fear of being prescribed antidepressant drugs is the top reason for not telling their doctors that they are suffering depression symptoms. A study called Suffering in Silence: Reasons for Not Disclosing Depression in Primary Care was published in the journal, Annals of Family Medicine.(4)
When journalist Jan Wong wrote about her own journey with debilitating depression in the memoir Out of the Blue, she described the life lessons that depression had taught her:
“The big life lessons are that you can have clinical depression and you can get over it. It’s completely treatable. It has an end. Second life lesson: you’ll probably be stronger when you come out of it than you were before. The third life lesson is you’ll probably be happier because you leave it behind and you will find a new life. The fourth lesson: that family matters. Everything else is extra.”
Besides drugs, what else could those of us living with depressive symptoms be doing for ourselves – with or without pharmaceutical help? Here are some non-drug options:
1. EXERCISE: This has been found to be among the most effective treatments for depression. A good 30-minute walk, swim or bike ride that raises your heart rate, for example, can also raise your serotonin level. Serotonin is a neurotransmitter (a chemical messenger in the brain that helps regulate sleep, mood and appetite). Selective serotonin reuptake inhibitors (SSRIs) are antidepressant medications that work on raising your serotonin level. But let’s aim to do it naturally with exercise – with no side effects. More is better when it comes to physical exercise, especially for women with heart disease.
2. TALK THERAPY: I found my own weekly visits to a therapist tough at first, but profoundly helpful in adjusting to the “new normal” of living with heart disease. Therapists can include psychologists, psychiatrists, social workers, or other mental health professionals. The two most commonly-used talk therapies for depression are cognitive-behavioral therapy (CBT) and interpersonal therapy. CBT focuses on identifying how negative thought patterns may be affecting how you feel. Interpersonal therapy focuses on how you relate to others. Both types of therapy can be effective in treating depression by helping people at risk for recurring depression avoid spiraling down into a full episode of depression.
Talk therapy, however, costs more than medication, at least in the short term, and may not be covered by insurance plans. But as one researcher observed:
“In the long run, talk therapy may well be worth it. People who take antidepressant meds may end up taking these drugs for many years. But with talk therapy, patients often go for only a few months to a year.”
3. WATCH YOUR COMFORT HABITS: Mindless consumption of coffee, alcohol, sugar, and recreational drugs can aggravate mood disorders. Sugary foods, for example, are absorbed quickly into the bloodstream. This may cause an initial surge of energy that soon wears off as the body increases its insulin production, leaving you feeling tired and low. And Dr. Daniel Hall-Flavin of Mayo Clinic believes that even modest amounts of caffeine can disturb your moods. He says if you are particularly sensitive to caffeine, you may find that consuming coffee, soft drinks or other caffeine sources disrupts your sleep, which in turn can affect your overall mental and physical health. See also: Mindless Eating: 8 Reasons Women Eat When We’re Not Even Hungry
Mayo Clinic experts also have this specific warning about drugs and alcohol:
“Stop drinking or using drugs. Many people with depression drink too much alcohol or use illegal drugs, which then worsens depression. If you can’t stop drinking alcohol or using drugs on your own, talk to your doctor or mental health provider. Depression treatment may be unsuccessful until you address your substance use.”
4. DIETARY SUPPLEMENTS: Although early research on the beneficial effects of omega-3 fatty acids on mood disorders is encouraging, more studies are needed. But omega-3 has very few side effects, along with claimed cardiovascular and other health benefits, so may be worth a try. These healthy fats are found in cold-water fish like salmon, flax seed, walnuts, and fish oil or flax oil supplements. For mild – but only mild- cases of depression, St. John’s Wort may rival antidepressant drugs, with generally few side effects, but it can interact with other drugs. As with all supplements, consult your doctor first. SAMe (pronounced “sammy”) is a synthetic form of a chemical that occurs naturally in the body (S-adenosylmethionine). This supplement is used in Europe as a prescription drug to treat depression. Remember, however, that dietary supplements are products of a completely unregulated industry whose claims do not even have to be based on evidence-based science. Always check credible resources like Mayo Clinic’s evaluation of drugs and supplements.
5. SUNLIGHT: Some people, particularly females over age 20, are vulnerable to a type of depression that follows a seasonal pattern. For them, the shortening days of late autumn are the beginning of a type of clinical depression that can last until spring. This is called Seasonal Affective Disorder or SAD. Research shows that neurotransmitters may be disturbed in SAD. Try spending more time outdoors during the day and by arranging your environment so that you receive maximum sunlight. Keep curtains open during the day. Move furniture so that you sit near a window. Build physical activity into your lifestyle before SAD symptoms take hold. If you exercise indoors, position yourself near a window. Make a habit of taking a daily noon-hour walk. Sunny winter vacation can temporarily relieve SAD symptoms, although symptoms usually recur after return home. Try to resist the carbohydrate and sleep cravings that come with SAD. And many people with SAD respond well to exposure to “light therapy” that involves sitting beside a specially designed bright fluorescent light box for several minutes day. Bu consult your health care professional before beginning light therapy.
6. REGULAR HUMAN CONTACT: Many people feel depressed because they are isolated, and they’re isolated because they feel so depressed. This is a tough dilemma when the only thing you really feel like doing is pulling the covers up over your head, all day, every day. When my (former) perky therapist suggested brightly that I should just sign up for a really interesting course at the university to help me “snap out of” my depressive state, I looked at her with utter dismay. I felt unable to motivate myself to wash my hair. How would I manage signing up for (never mind actually attending) a “really interesting” night school class?
But we are social animals. Counting on our close friends and family for regular companionship – even if just a short outdoor walk – can actually help to lift our spirits and get us through one day at a time. The Canadian Mental Health Association recommends:
“Support from family, friends and self-help groups can make a big difference.”
7. CHALLENGE YOUR THINKING: A book I recommend that can be almost-shockingly helpful with this option is Feeling Good: The New Mood Therapy by Dr. David Burns, who observes:
“Intense negative thinking always accompanies a depressive episode. The negative thoughts that flood your mind are what may keep you lethargic. One of the most destructive aspects of depression is the way it paralyzes your willpower. In its mildest form, you may simply procrastinate about doing a few odious chores. As your lack of motivation intensifies, virtually any activity appears so difficult that you become overwhelmed by the urge to do nothing. Because you accomplish very little, you feel worse and worse.
“If you don’t recognize the emotional prison in which you are trapped, this situation can go on for weeks, months, or even years. Your inactivity will be all the more frustrating if you once took pride in the energy you had for life. Your do-nothingism can also affect your family and friends, who, like yourself, cannot understand your behaviour.
8. GOOD NUTRITION: According to Dr. Fernando Gómez-Pinilla, a UCLA professor of neurosurgery and physiological science:
“Food is like a pharmaceutical compound that affects the brain.”
Foods high in folic acid, for example, include spinach, orange juice and yeast. Adequate levels of folic acid, says Dr. Gómez-Pinilla, are essential for brain function, and folate deficiency can lead to depression or cognitive impairment. The U.K. Mental Health Foundation also recommends including protein at every meal to ensure a continuous supply of the amino acid tryptophan to the brain – such as meat, fish, eggs, milk, cheese, nuts, beans, or legumes. Eat regular meals throughout the day to maintain blood sugar levels. Make sure you eat at least three meals each day. Missing meals, especially breakfast, leads to low blood sugar and this can cause low mood, irritability and fatigue. And not drinking enough fluids every day has significant implications for mental health. The early effects of even mild dehydration can affect our feelings and behaviour. See also: De-junk Your Kitchen to Start Heart-Smart Eating
9. YOGA: Yoga is another form of non-drug treatment for mild to moderate depression that may help. Yoga focuses on deep breathing and a series of stretches and careful movements. Researchers at the Walter Reed Army Medical Center in Washington, D.C., are now offering a yogic method of deep relaxation to combat veterans returning from Iraq and Afghanistan. Dr. Kristie Gore at Walter Reed says the military hopes that yoga-based treatments will be more acceptable to the soldiers and less stigmatizing than traditional psychotherapy. People who do yoga regularly say it can help to balance the mind and body, and helps restore a sense of well-being.
10. MINDFULNESS MEDITATION: A U.K. study published in the Journal of Consulting and Clinical Psychology found that a group-based mindfulness-based meditation practice was as good as or better than treatment with anti-depressants like Prozac in longterm prevention of a relapse of serious depression. Mindfulness meditation helped the study participants learn to focus on the present moment, rather than dwelling on the past or worrying about the future. This cost-effective non-drug therapy was also more effective in enhancing quality of life and better physical well-being for depressed patients. For others, meditation may be as simple as listening to soothing music, breathing deeply and totally relaxing the body, muscle by muscle, with a process called systematic relaxation, which allows both the body and the mind to relax.
PLEASE NOTE: If these options have been tried and there is no change in a month, get a full evaluation by your health care professional. Depression can be devastating for heart patients, and it does not make you a better person to endure needless suffering.
Mental health professionals at Mayo Clinic also stress the connection between mind and body that has been studied for centuries. Some mind-body techniques they recommend to address depression symptoms include:
- guided imagery meditation
- massage therapy
They add that although the signs and symptoms of depression are the same for both men and women, women tend to experience depression twice as often as men do. This is true in most countries around the world.
Since hypothyroidism can also cause depression in women, this medical problem should also be be ruled out by a physician.
Also, women are more likely to experience the symptoms of atypical depression (sleeping excessively, eating more – especially carbohydrates, and gaining weight).
NOTE FROM CAROLYN: I wrote more about situational depression associated with heart disease Chapter 6 of my book, “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher Johns Hopkins University Press (and use their code HTWN to save 20% off the list price when you order).
(1) See also:
When are cardiologists going to start talking about depression?
The New Country Called Heart Disease
Depressed? Who, Me? Myths and Facts about Depression Following a Heart Attack
“I’m Not Depressed!” – and Other Ways We Deny the Stigma of Mental Illness After a Heart Attack
Should You Take Antidepressants – And If So, Which One?
Is it Post-Heart Attack Depression – or Just Feeling Sad?
Post-Traumatic Stress Disorder: Not Just For Soldiers Anymore
Women Heart Attack Survivors May Be as Psychologically
Traumatized as Victims of Violence
Why Aren’t Women Heart Attack Survivors Showing Up for Cardiac Rehab?
How That Ache May Signal Depression
Women’s Heart Pain May Be Both Physical and Emotional
(2) Proportion of antidepressants prescribed without a psychiatric diagnosis is growing. Health Affairs, August 2011, vol. 30 no. 8 1434-1442
(3) Kirsch, I., & Sapirstein, G. (1998). Listening to Prozac But Hearing Placebo: A Meta-analysis of Antidepressant Medication. Prevention and Treatment, 1 (Article 0002a)
(4) Suffering in Silence: Reasons for Not Disclosing Depression in Primary Care. Annals of Family Medicine 9:439-446 (2011)
18 thoughts on “10 non-drug ways to treat situational depression in heart patients”
Thank you for all this positive encouragement to tackle this issue. I see this is an older article but I thought I’d mention the gut-brain connection has been shown to impact mood/depression as measured by our microbiome.
I really began to look into it a few years ago when a casual acquaintance mentioned she had struggled with depression but found relief by concentrating her nutrition on prebiotics. What’s that I wondered, so I found out that probiotics like fermented foods such as yogurt and pickled foods are important for gut (and mood) but that prebiotics feed the good bacteria that help lift mood.
I think this strategy should be included in all depression treatment discussions. And I wonder how all the drugs one receives in hospital for cardiac issues impact the microbiome. It’s well documented that antibiotics wipe out the good, mood-boosting bacteria in the gut while they are destroying infections. Nutrition is more than simply cutting saturated fat and avoiding sugar, etc.
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Hello Tomi – I agree with you. I was just reading about an overseas study on this link between intestinal flora and brain function that concluded “in addition to the use of psychiatric drugs for treatment, we can also consider regulating intestinal flora to alleviate anxiety symptoms…”
These are preliminary observational studies but they do make sense, given how completely interconnected our body parts are to other parts!
Take care, stay safe… Happy New Year to you… ♥
Hi Carolyn — I sing the praises of your blog all the time!
Three years ago I went to A presentation by a University of California, San Francisco UCSF researcher Dr Kenneth R. Pelletier who said they were working on a new medical model for measuring personalized health that would include genetic testing, microbiome and the traditional markers like high blood pressure and cholesterol. He talked quite a bit about the microbiome and new testing services such as DayOne and Viome. There seems to be a lot of research going on now and it will be fascinating to see what shakes out. Very thought provoking.
In the US, the NIH is heavily invested in microbiome research and published this last year: Gut Microbiome and Depression: How Microbes Affect the Way We think. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7510518/
It also has this to say about cardiac issues:
“Cardiovascular disease: There is growing interest in a link between microbiota and cardiovascular disease based on data showing microbial metabolism of dietary phosphatidylcholine into the pro-atherosclerotic metabolite trimethylamine-N-oxide (TMAO) (29). A recent study of healthy patients challenged with dietary phosphatidylcholine showed increased plasma levels of TMAO that were suppressed by prior treatment with antibiotics. They also found that plasma TMAO levels were associated with increased risk for cardiovascular events in patients with cardiovascular disease risk factors (*30). In another study, the same group showed that healthy human volunteers who maintained a vegan diet, as opposed to those on omnivorous diets, did not demonstrate increased plasma TMAO levels after dietary phosphatidylcholine challenge, and this trait was associated with specific fecal microbiota compositional states (*31). Thus, there is much interest in this microbiota-dependent pathway that may offer diagnostic and therapeutic potential for cardiovascular disease.”
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Hi again Tomi – tracking personalized health factors has been increasingly popular since its adoption by the “worried well” of the Quantified Self movement. My understanding of the Viome example is that their customers can send biological samples – typically blood and stool – to the company; test results come back offering individualized recommendations about how to change diet and/or dietary supplements (conveniently available from the same company for about $200/month) that promise customers will “feel better or age more gracefully”.
The real corporate success, however, comes with diseases, which is where Viome and others in this growing industry are poised to market. I tend to follow this news with the same reserve I held for the worried well and their Quantified Self obsessions, I admit – but as you say, it will be “fascinating to see what shakes out…”
Take care, stay safe. . . ♥
Sorry, but this array of recommendations sounds like the old “pull yourself up by your own bootstraps” – if you can’t pull yourself out of depression all by your onesie, you’re a failure. Depression is a matter of chemical imbalance. I am NOT in favor of anti-depressants, which may help in the short term but are infamous for causing more problems long-term. I AM in favor of getting to the biochemical root of the matter. For many, especially with heart disease, that root is hypothyroidism. Cortisol dysregulation goes hand-in-hand with that. And poor neurotransmitter status is big as well. There’s probably other biochemical issues I know nothing about – yet. I will keep researching to figure out what will work for me since doctors are utterly useless for anything but trauma care.
You’re right – for patients with clinical depression, a thyroid issue may indeed be linked with depression, as I mentioned in this post.
In fact, the American Association of Clinical Endocrinologists issued a statement in 2002 that recommended: “The diagnosis of subclinical or clinical hypothyroidism must be considered in every patient with clinical depression.”
Post-heart attack depression, however, has been more accurately described as a form of “situational depression” or “stress response syndrome” – considered an adjustment disorder with similar symptoms to clinical depression, typically appearing within weeks following the traumatic event that triggers the condition, and usually fading within six months (often without any treatment).
It’s inaccurate, of course, to make sweeping generalizations like “doctors are utterly useless”.
Interesting research reports on medications, particularly for mild-moderate depression (= the majority of cases) yet doctors are still reaching for the prescription pad first.
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Hey. If you’re feeling like the world is coming to an end for you, one way or another, a temporary quick fix, if it works, sure beats the hell out of a slow fadeout.
This is sound advice for ALL of us every day and not just for depression. Easier to prevent a condition than to treat after the fact.
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My belief has always been that many conditions – not just depression – can be effectively managed with simple non-drug options (better nutrition, better exercise, better sleep, better stress reduction etc).
After my knee surgery I went to my doctor to get a pain medication prescription because of persistent knee pain and he said straight out to me that I needed to lose 30 lbs, and if I did not, I’d be gulping pain drugs for the rest of my life and how could that knee heal properly with all that extra weight pounding on it with every step? Why was he the first doctor ever to advise me honestly like this? I have now lost 35 pounds and my knee feels just fine.
Your list is not just for depressed patients but it’s good common sense healthy living for all of us.
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This is great. I wish I’d found it a few hours ago. I have only today posted a blog on the same topic with most of these and a couple of other strategies on self-management strategies for depression beyond medication.
I didn’t include sunshine – which is a biggie for me – along with fresh air …
I will have to go and put a link to your page in the comments so that people can have a look at your page also.
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Thanks for the link, Jill – great minds must think alike, right? 😉
A wonderful post. If I might quibble a little bit, I’d change the order.
First, we all eat, so therefore, I’d start with number 8: Nutrition.
Second, as some heart patients have difficulty with exercise, I’d promote Mindfulness Meditation from #10 to number #2. It can literally help train your brain and body into a less stressed fundamental state. And it’s FREE!
Third, per your number two (and I understand you were not ranking, per se, just listing), I would add EMDR to the menu of therapy choices. When carefully supervised by a specially qualified and trained practitioner of Eye Movement Desensitization and Reprocessing, it can quickly rewire the brain’s trauma and it can “re-wire” more positive emotions.
I would add two items:
* Appreciate nature and get outside
* Incorporate spirituality in whatever form is right for you.
These two actions also lend themselves to brain health and perspective.
My husband is a psychologist and he wholeheartedly supports incorporating your list first, before medications in many or most circumstances, unless the person is experiencing long entrenched depression and/or suicidal feelings.
There ARE times for the medications, but fairly often, people procrastinate in applying these behavioral changes because without realizing it, they are hoping for a “magic” pill and some instant relief. Behavioral + Medication has always yielded the optimum result, because you change the less-than-optimum behaviors that contributed to your biological vulnerability. Resiliency is a multi-faceted state.
All the best,
Thanks, Mary, for your very thoughtful suggestions – each of which is such a helpful adjunct to this list. Even as I was writing this, it occurred to me that the list seems just way too long if you’re in the throes of depression! The trouble is that you’d likely have zero motivation to even brush your teeth from day to day, never mind pick up the phone and make appointments with outsiders, look up stuff, sign up for classes, plan healthy meals, or even read a helpful book! Anybody with enough energy to read should likely do #7 and read Dr. David Burns’ classic book. It’s been around since 1980 for good reason.
Although medication can relieve the symptoms of depression, it is not usually suitable for long-term use. Studies show that other treatments, including exercise and therapy, can be just as effective as medication, often even more so, but don’t come with unwanted side effects. If you do decide to try medication, remember that medication works best when you make healthy lifestyle changes as well.
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I’m going to “quibble” with Mary, the wife of the psychologist. I find what she wrote condescending and patronizing. (Wife of psychologist does not equal psychologist). My post is angry in tone because I know I have become depressed, and, as you suggest Carolyn, if you could care less about brushing your teeth, then being motivated to do anything else, even, or especially, something you would otherwise consider “wonderful,” just isn’t going to happen.
I came to this thread tonight because I may very well need at least short-term antidepressant medication, or, I need an alteration in the cardiac-related medication I am taking, which is more likely the case. I seem to be okay for a little over a month on any beta blocker, for example, and at very low doses. Then… either my body, or in this case, my mind, my emotions, are wonked.
The problem is that I know my physicians will also dismiss the notion that the beta blocker is a contributing factor in this. Before I attempt an antidepressant, (and it would have to be an SSRI), I need to challenge the beta blocker – and do it without risk. This, too, is a problem, because my physicians will say – “Just stop it.” Yes. They say – always say – to go ahead and stop medication cold.
Yes. Mary’s comment is not only condescending, but rather rude given that the damned order of things doesn’t make a difference and that you have presented them in such a way that you do not demean the value of antidepressants when necessary.
Jane, I didn’t take Mary’s comments at all as you interpreted them. For example, I assume that she mentions her husband only to quote his approach to treating depression (relevant because it’s a subject psychologists do deal with every day) – not to be “condescending”. Not sure why you would rush to label her comments as “rude” or “patronizing” simply because you don’t happen to agree with what she wrote.
By way of comparison, on this website I’ve sometimes quoted material from my daughter (who happens to be a probation officer) – information that she has shared with me about her training when it’s appropriate to my post topics. What she tells me is often surprisingly applicable! This does not mean I’m somehow trying to pass myself off as a probation officer – yet by your definition, you might feel free to similarly accuse me: “mother of probation officer does not equal probation officer”.
If you choose to leave future comments here, do so by sticking to opinions that reflect your own personal experience, not by being disrespectful to others you don’t even know – otherwise, your comments will not be approved for publication.