Noteworthy News Articles, March 22-31, 2000

Noteworthy News Articles on Mental Health Topics, March 22-31, 2000

Women Often Bear Emotional Brunt of Illness, Study Says
CNN, Barry Jacobs, Psy.D. & Julie Mayer, Psy.D.- 3/22/2000

Fern Zeigler, head of a national support group for caregiving spouses and partners, knows why the women in such support groups are stressed out. She's been there. "As a woman, I expect to be able to handle everything myself -- work, home, husband, kid," says Zeigler, who directs the King of Prussia, Pennsylvania, Well Spouse Foundation. "I find it difficult to ask for help. I think that I should be strong and not burden anyone else." Zeigler's pattern -- asking too much of herself and not enough of others -- is hardly unusual. A recent study suggests that many women who face illness, whether their own or that of a spouse, feel a sense of overwhelming responsibility. And that's one reason why women tend to suffer emotionally more than men when serious illness strikes.

When women take on too much
The study, published in the January 2000 issue of Social Science and Medicine, looks at the ways couples adjust during the first year after surgery for colon cancer. It found that women who have colon cancer or who care for spouses with the same ailment suffered greater emotional upset and felt less satisfaction in their marriages than men in the same situations. The study's authors -- Laurel Northouse and colleagues at the University of Michigan School of Nursing -- noted that women who took care of a partner reported even greater stress than women who were sick themselves and receiving care from a spouse. The reason? Northouse and her co-authors suggest that though women are more comfortable disclosing their emotional distress to others, they are already stretched thin by their day-to-day activities both inside and outside of family life. When illness is added to the load, it can easily become too much. Because women are generally expected to be responsible for the care of others, the findings suggest, they also have greater difficulty seeking and accepting help from family and friends when they are thrust into the roles of either patient or caregiver. Experts on how families adjust to illness say their observations mirror the study's findings. "Caregiving fits with female role socialization, and therefore many women take to it quite a bit more naturally than do men," says Susan McDaniel, Ph.D., of the departments of family medicine and psychiatry at the University of Rochester School of Medicine and Dentistry in Rochester, New York. "They are in danger of serious burnout because others step back and let them do all the work themselves, and because they tend to reject help from others."

The road back from burnout
The perceptions of friends and family also may determine how much help is extended to people of either gender. "Because men who do any significant kind of caregiving are often seen by family and friends as heroic, they are more likely to be offered social support and tangible assistance by them," says Carol Levine, M.A., director of the Families and Health Care Project of the United Hospital Fund of New York City and the long-time caregiver for her neurologically impaired husband. Women, says Levine, may feel "abandoned and isolated" in comparison. The solution for women, whether they find themselves in the role of caregiver or patient, comes down to learning to share the burden. There are many useful strategies for dealing with emotional pain and frustration and for relieving some of the stress. Zeigler, for instance, says she has reached out to friends and other support communities to help pull her through the difficult times. Although women living with illness may feel isolated and alone, she says, helpful resources are out there, and they don't have to go it alone.
Women who face a serious illness, or the illness of a loved one, may often feel isolated or unable to fulfill their many roles and obligations within the family. How can you, as a female patient or caregiver, better cope with the stress and emotions that you face? Here are some tips that may make your life easier:

Choose healthcare professionals who are sensitive to many women's reluctance to ask for help during the course of their own or their partners' serious illness.
Seek as much medical information as possible, so that you don't feel in the dark about what you are facing.
Expect to experience some degree of emotional distress. Sharing those feelings with supportive professionals, friends, or other caregivers through support groups sponsored by the Well Spouse Foundation or other organizations can help decrease a sense of isolation.
Talk to your partner. While many women tend to avoid sharing upsetting emotions with their sick or caregiving spouses for fear of burdening them, doing so can actually bring the couple closer together emotionally, help preserve the intimate marital connection and decrease the stress of the medical situation.
Don't wait for others to step forward to volunteer. Make specific requests of specific people to help out in concrete ways.

If caregiving becomes too overwhelming, approach other family members about pitching in more on a regular basis. Seek the help of professionals to come up with alternative means of taking care of a sick partner, including increasing the use of nurse's aides in the home, utilizing day treatment programs and even considering temporary nursing home placement.

Treatment of Rape Victims Becomes More Compassionate
Jolie Ann Bales, CNN- 3/23/2000

More than once a minute, 78 times an hour, 1,871 times a day, girls and women in America are raped. When this traumatic event happens to a woman in the vicinity of Duke University Medical Center in Durham, North Carolina, now she'll be spared the glaring lights of the emergency room. Instead, while she goes through the necessary medical treatment, evidence gathering, and questioning by police, she'll be cared for in a softly lit room with comfortable furnishings and pastel-painted walls. The team of medical personnel -- including specially trained female nurses who collect evidence using state-of-the-art equipment -- will do what they need to do, but will also pay close attention to the emotional needs of the survivor, whether she's 15 or 45. The full spectrum of care will be on hand, from trained counselors to practical amenities such as fresh clothing and toiletries.
Much has changed since the first rape crisis centers sprang up 30 years ago in the wake of the "Break the Silence" movement that began in New York. The message was a profound and powerful one, says Marybeth Carter of the California Coalition Against Sexual Assault: Rape affects all of us, and you are not alone. Out of that early movement came the early hotlines, staffed at first by untrained volunteers. Then in 1974, realizing that women who had been raped had nowhere to turn for help, Gail Abarbanel founded the Rape Treatment Center in Santa Monica, California, offering psychological intervention as well as medical help.

Specialized care in the aftermath of assault
This past fall, when Duke's specially designed center opened, it joined an evolving nationwide trend toward gentler, specialized, more effective treatment in the aftermath of assault. The facility, like others across the country, has been consciously designed as a safe, calm setting, where patients who've undergone sexual trauma can be offered more than emergency medical treatment. There is mounting evidence that early intervention and immediate counseling speeds a rape survivor's recovery. Every state now has Coalitions Against Sexual Assault (CASA) programs designed to support rape crisis centers and the clients they serve. Most states now have Sexual Assault Response Teams (SARTs) composed of specially trained legal, medical and counseling professionals and advocates working together. Such teams today routinely offer advice on sexually transmitted diseases, HIV, pregnancy, infection and other risks. They usually have on hand the morning-after pill, as well as other treatments and drugs for specific medical needs. Trained counselors are on hand 24 hours a day. Some institutions, such as Stuart House in Santa Monica, have special services just for children who've been raped.

Advances in psychological care
Research underscores the profound and complex trauma experienced by rape victims. A study funded by the National Institute of Drug Abuse found in the early 1990s that survivors were at increased risk for a broad array of mental health problems, from attempted suicide, to increased drug and alcohol abuse to major depressive episodes. Post-traumatic stress disorder, a debilitating condition arising after trauma such as combat, is now recognized as a common consequence of rape, said Ivonne Zarate, educational coordinator of the Santa Barbara Rape Crisis Center. Zarate noted that a form of this disorder -- referred to as rape trauma syndrome (RTS) -- strikes, at some point in their lives, a third of those who've been raped. Fortunately, advocates and counselors at many rape trauma rooms are trained to recognize the physical, mental and behavioral stress reactions that come with RTS and can address the problem early. Spouses, children, lovers, and friends may also be significantly affected by a survivor's rape. Most crisis centers provide free counseling to all those in her circle. Despite the innovations, though, a majority of people fall through the cracks. According to a U.S. Department of Justice survey, only about 16 percent of rape victims -- of all ages -- report the crime in the first place. Overall, says Marybeth Carter, the message still needs to get out to communities, to parents, to doctors: Rape can happen to anyone, anywhere -- and when it does, comprehensive care is a necessity.

Insanity Defense Fails for Man Who Threw Woman Onto Track
Julian E. Barnes, New York Times- 3/23/2000

A jury yesterday rejected the insanity defense of Andrew Goldstein, the schizophrenic man who threw a woman to her death in front of a subway train last year, finding him guilty of second-degree murder. The verdict brought a conclusion to a case that led to two trials and intense scrutiny of the state's mental health system, as well as changes in the way the seriously mentally ill are cared for in New York. In this trial, defense lawyers had pinned their hopes on taking Mr. Goldstein off his anti-psychotic medication and putting him on the stand, to better show jurors his mental state at the time of the attack. That strategy was thwarted when Mr. Goldstein struck a social worker, and the judge ordered that he be offered his medication each day. He took the medication and did not take the stand. Jurors were apparently swayed by the prosecution's argument that Mr. Goldstein was calm and knew what he was doing when he grabbed the victim, Kendra Webdale, on January 3, 1999, on a 23rd Street station platform as an N train approached. "He seemed to know what he was doing," one juror said after the trial. "He picked her up and threw her. That was not a psychotic jerk, an involuntary movement."
    Mr. Goldstein faces 25 years to life in prison when he is sentenced in State Supreme Court in Mahattan on April 6th. Kevin Canfield, a lawyer for Mr. Goldstein, said he intended to file an appeal. He also said he would ask the judge to impose a lesser sentence of 15 years to life. "Most likely he will be in prison his entire life," Mr. Canfield said, "but who knows? If they come up with a cure for schizophrenia, maybe he could be released in 20 years." While the case spurred a torrent of criticism of a mental health system that had repeatedly released Mr. Goldstein despite his long history of violence and mental illness, legal and mental health experts said yesterday that the verdict was not surprising, because the law makes it difficult to use mental illness as a defense (see companion article given below).    The jury deliberated for less than two hours yesterday. As the foreman read the verdict, Mr. Goldstein's face turned red and he removed his glasses. Kim Webdale, Kendra's sister, cried out, put her face in her hands and wept, the sobs shaking her body. "The prosecutor showed that there are other reasons for Andrew Goldstein's actions besides his psychosis," Kim Webdale said outside the courthouse, after thanking the jurors and showing them pictures of her sister. Patricia Webdale, Kendra Webdale's mother, said the trial was more difficult the second time but that testimony was less emotional and that witnesses painted a better scene of what had happened on the subway platform. "It has been such a nightmare, I didn't think I ever would use the word happy," she said. "But I thought of my daughter Kendra when I heard it, and it was more than I had hoped for. I felt like jumping for joy." The Webdales have filed a $20 million lawsuit against the city hospital system, for failing to properly treat Mr. Goldstein before the attack, and the state Metropolitan Transportation Authority, claiming negligence, carelessness and recklessness.
    The prosecution's case in the second trial differed only subtly from the first.    William Greenbaum, an assistant district attorney, spent less time trying to establish Mr. Goldstein's hatred of women and focused more on his actions immediately before the attack. He referred to the testimony of one eyewitness, Dawn Lorenzino, who in this trial told jurors that Mr. Goldstein had shuffled oddly on the platform but began walking normally as he positioned himself behind Ms. Webdale. Ms. Lorenzino testified that Mr. Goldstein did not simply push Ms. Webdale, but that he picked her up bodily and threw her in front of the train. In interviews, jurors said that his apparent deliberateness and preparation, as well as the fact that he caught himself before falling in front of the train, helped convince them that he knew what he was dong was wrong. Mr. Greenbaum argued that Mr. Goldstein had learned to use his mental illness as a shield, to protect him from the consequences of his actions. Prosecutors again and again told jurors Mr. Goldstein's first words to the police after the incident; "I'm psychotic, take me to the hospital."
    Mr. Goldstein's trials have been watched closely, in large part because the killing of Ms. Webdale touched off an examination of the state's mental health system. Mr. Goldstein was not taking his medication at the time of the attack and was originally portrayed as having refused psychiatric treatment. Last August, Govenor Pataki signed "Kendra's Law," which was named for Ms. Webdale and allowed caseworkers, family members or roommates to seek a court order forcing a patient to comply with treatment. The law also provided money for additional treatment, as did another bill signed in November by Mr. Pataki that provided $125 million in housing and services for the mentally ill. "I don't think Kendra's Law would have passed without the death of Kendra Webdale," said Paul F. Stavis, the director of the law and psychiatry center at George Mason University Law School in Arlington, Va. "Goldstein is the paradigm of someone who needs the supervision formerly provided by the institution, You can't have someone like him in the community unsupervised." But Mr. Goldstein's thick file of medical records showed that he had in fact frequently sought help, only to be turned away repeatedly, even after he shoved and hit several people. He was given short-term psychiatric treatment but was repeatedly discharged and he was rejected several times from long-term hospitals.
    During his first trial, from October 7th through November 2nd, Mr. Goldstein's lawyers made much of how the mental health system had failed their client. But several jurors in that trial said they were worried about acquitting Mr. Goldstein by reason of insanity, out of fear that he would be sent into the same mental health system that had turned him out. In the second trial, Mr. Canfield emphasized Mr. Goldstein's illness, but avoided blanket condemnations of the system. The first trial ended in a hung jury after two jurors held out against convicting Mr. Goldstein of second degree murder. The heated deliberations lasted more than five days. But this jury had no such problems reaching a verdict. Several jurors said the initial vote was 10-2 for conviction on the most serious charge. Jurors said the two holdouts wanted to discuss whether Mr. Goldstein acted deliberately or with "depraved indifference" but were quickly convinced to join the majority. "We have to be held accountable, all of us, for our actions," said one juror, who works for a cable television company. The jurors said they believed Mr. Goldstein was mentally ill, but not so ill that he did not know right from wrong. "The evidence was pretty compelling," one said.

Jury Focused on Law, Not the Mental Health System
Nina Bernstein, New York Times- 3/23/2000

In the beginning, it seemed that the mental health system would be on trial along with Andrew Goldstein, the schizophrenic who pushed a woman he had never met to her death in front of a subway train. The killing spurred a torrent of criticism of a mental health system that had repeatedly sent Mr. Goldstein back to the streets, despite his history of violence and mental illness and his requests for hospital treatment or community care. In Mr. Goldstein's first trial, defense lawyers told the jury its verdict would be viewed as a broad statement on society's treatment of the mentally ill. And when that jury deadlocked, it turned out the two holdouts for Mr. Goldstein's acquittal by reason of insanity were people with an intimate view of the system; an emergency room technician whose two daughters are psychiatrists and social worker with mentally ill clients. But when a second jury swiftly reached a guilty verdict yesterday, it was after focusing principally on Mr. Goldstein's state of mind during the few seconds it took him to throw the woman, Kendra Webdale, to the tracks. Though jurors said they all agreed he was mentally ill, they saw intent in the planning and execution of his act, awareness of the consequences to his victim and an understanding that what he was doing was wrong. That led to a guilty finding under New York's insanity law, which holds the mentally ill responsible for crimes unless they are unable to distinguish right from wrong and are substantially unable to appreciate the consequences of their acts. "People who are mentally ill can nonetheless be guilty of crimes-- it's designed to achieve that result," Richard Ulviller, a professor of criminal law at Columbia University, said of the law. The verdict was not surprising, he added, considering Mr. Goldstein's statement in his police confession that he knew his act was wrong.
To argue that his psychosis compelled him to kill Ms. Webdale anyway is not an acceptable defense under the laws of New York and most other states, Professor Ulviller said, though a few states allow for what is known as an "irresistible impulse" defense. But psychiatry defines insanity more broadly than the legal system does. Merrill Rotter, a forensic psychiatrist who directs the division of law and psychiatry at the Albert Einstein College of Medicine, said that beyond areas of overlap with the legal definition, including delusions, hallucinations, false beliefs and false perceptions, psychiatrists looked for a subject's emotional lack of control. "Patients who are in the throes of an acute episode of schizophrenia often have associated with it impulsivity and aggression," Dr. Rotter said. "Those issues would certainly be part of the picture in somebody who's acutely ill." That is not enough for legal insanity, he added, "particularly when jurors are involved, because the tendency is to see responsibility instead of lack of responsibility."
After their verdict yesterday, some jurors in the Goldstein trial pointed to testimony by the prosecution psychiatrist that violence was not a feature of schizophrenia. But Michael Silverberg, president of the National Alliance for the Mentally Ill of New York State, said that he thought jurors had been influenced by the common refrain of advocates for the mentally ill: that people with mental illness are rarely violent. Schizophrenia can manifest itself in violence," he said. "From everything I've read about him, this is a young man who was just lost in psychotic thought processes. I think there's a lack of understanding of the sea of foggy thoughts that can go on in the mind of a man who is in a very psychotic state. Our society at large just does not understand mental illness." Other advocates for the mentally ill said they were disheartened at the end result for a man all acknowledge to be seriously mentally ill. Mr. Goldstein will very likely spend years in New York State Prisons, where psychiatric treatment for an estimated 5,600 seriously mentally ill inmates is minimal, they said. "He's going to spend the next decades of his life locked in a box 23 hours a day, being given a little bit of medication," said Heather Barr, a lawyer with the Urban Justice Center who specializes in mentally ill inmates. Ms. Barr said she worried that the jury feared a verdict of not guilty by reason of insanity would have freed Mr. Goldstein, who was clearly dangerous when not taking medication. In fact, she said, with an insanity acquittal Mr. Goldstein would have spent the rest of his life in a forensic psychiatric hospital--"the only part of the system where people don't get abruptly discharged and dumped on the street." Paul F. Stavis, a professor at George Mason University in Virginia, said he thought it was time for legal systems to abandon the insanity defense and adopt alternatives, like "guilty but mentally ill" pleas. "This might be a time for different approaches," Mr. Stavis said. "Jails are terrible places for people like this. They don't get the treatment they need and are badly treated."

Getting Alienated Freudians to Associate
Robert Boynton, New York Times- 3/25/2000

Sometimes a bookstore is just a bookstore. But sometimes, as today's Freudians should know, it is also a publisher, a Web site and a gathering place for readings, lectures and book parties. At least that is the case with Other Books, on the first floor of a turn-of-the-century brownstone on West 20th Street in Chelsea. The store's window displays an Interpretation of Dreams T-shirt and a "Freudian Slips" post-it pad to "write what's really on your mind." Inside the front room, titles like "Before I was I" and "Ours, Yours, Mine" are packed into bursting shelves, while crammed in the back are desks and flat screen computers for editing books and journals. And at the rear of the building is a small office (with couch, of course) where Michael Moskowitz, Other Press's publisher, sees his patients. An analyst, an academic and an editor, Mr. Moskowitz, 49, is a psychoanalytic entrepreneur with a mission. He wants to rescue psychoanalysis from the academic isolation and bitter scholarly skirmishes that have dogged it for the last 20 years by bridging the divide between clinicians and theorists who work in various disciplines. In the process, he hopes to turn Other Books into an intellectual center for psychoanalysis, psychology and cultural studies. "Post war American psychoanalysis did itself a tremendous disservice by cutting itself off from the culture at large," he said one day recently, sipping a glass of wine over lunch at a Chelsea bistro. A compact man with shoulder-length hair and piercing eyes, Mr. Moskowitz speaks of psychoanalysis with the pained concern one might use to describe a wayward child. "On the one hand, it refused to recognize that all sorts of non-analysts could legitimately use psychoanalytic theory. On the other hand, it cut itself off from real experimental science. At Other Press, we want to get scientists talking to humanists, clinicians to theorists, Lacanians to Freudians, and Americans to analysts all over the world."
    Compared with the near-glacial time frame one associates with psychoanalysis, Other Press's progress has been extremely rapid. In less than two years, Mr. Moskowitz has opened the bookstore, published the company's first 30 titles, acquired three journals (including Psychoanalytic Quarterly, the oldest independent journal on the topic, and founded a new interdisciplinary journal, Infant, Child and Adolescent Psychotherapy. Last fall Other Press purchased Karnac Books, Britain's preeminent psychoanalytic bookseller and publisher, along with its two London bookstores and a 250 title backlist. Now Mr. Moskowitz is trying to turn his Web site into what he calls "the Amazon of psychoanalysis," offering a psychoanalytic best seller list and chapters from Other Press's own books and journals. "We want to be the destination for psychotherapists and people interested in cultural studies and related areas," he explained. "There are over 500,000 therapists in the U.S. and several million around the world."
    Other Press publishes widely in the field, including a series introducing the notoriously difficult ideas of the French psychoanalyst, Jacques Lacan, that is being edited by Mr. Moskowitz's business partner, Judith Fehrer-Gurewich, a Belgian psychoanalyst with a law degree and a Ph.D. in sociology. It was she who raised funds for Other Press from European investment bankers with an interest in psychoanalysis. Other new books are John Gedo's "Evolution of Psychoanalysis." A comprehensive overview of the field, as well as the reissue of several psychoanalytic classics, like "The Fifty-Minute Hour" by Robert Lindner and the feminist study "The Mermaid and the Minotaur" by Dorothy Dinnerstein.
    Mr. Moscowitz is embarking on his venture at a time when psychoanalysis has taken a beating in both the academic world, where there have been nasty battles over Freud's theories and experimental practices, and the marketplace, where managed care and antidepressants have sharply curtailed the availability of therapy--especially expensive, time-consuming psychoanalysis. Leading university presses like Yale and Harvard as well as established trade houses have virtually ceased publishing psychoanalytic books. But Mr. Moscowitz is unfazed, and to scholars and analysts who have wearied of what they call the "Freud wars," Other Press represents a refreshingly open and non-dogmatic perspective.
    Johathan Lear, a philosopher and psychoanalyst who teaches at the University of Chicago, says: "The best response to the critics of Freud is not to answer them point by point, but to do something new and interesting. And that is precisely what Michael is doing by providing a forum for the most creative work going on today." Elisabeth Young-Breuhl, the Anna Freud biographer and co-author of "Cherishment," a study of Eastern and Western theories of emotional attachment, says, "A wonderful rejuvenation of psychoanalysis is taking place, and Other Press is the café for the process." Despite various setbacks, Mr. Moskowitz and others are convinced that psychoanalysis is developing a broader intellectual and social significance. "Twenty years ago, psychoanalysis was predominately white, male and middle-class," said Kirkland Vaughns, an African-American psychoanalyst who is the editor of Infant, Child and Adolescent Psychotherapy. "A tremendous amount has been learned since then that can benefit emotionally disturbed black and Hispanic kids who are usually sent straight to the juvenile justice system." There are few disciplines that have not been influenced by psychoanalysis, and new programs in psychoanalytic studies have recently been founded at Emory University, Columbia University and the University of Chicago. "As a cultural phenomenon, this is the great age of psychoanalysis," says Richard J. Bernstein, the head of the philosophy department at the New School for Social Research. "Our courses on it draw students from a greater variety of disciplines than ever before."
    The son of an immigrant Hungarian plumber, Mr. Moskowitz has always perceived himself as someone who was, as in the title of his book, "Reaching Across Boundaries of Culture and Class." He grew up in Port Jervis, N.Y., an upstate town, and his first encounter with Freud came at age 14 when he found a copy of "The Interpretation of Dreams" his sister had brought home from college. Arriving at Columbia in 1967, Mr. Moskowitz was shocked to find that the Psychology 101 course didn't include Freud. "No one reads that stuff anymore," he was told by a professor. Accordingly, in good 60's fashion, Mr. Moskowitz took over a class and brought in an analyst from the medical school. After receiving his Ph.D. in psychology from City University and his analytic training at New York University, Mr. Moskowitz taught, worked in mental hospitals and started a community-based counseling center for traumatized Vietnam veterans in New Haven. In 1992 he joined Jason Aronson, a publisher of books on psychology and Judaica, and for the next five years ran the psychology half of the business. In 1998 he was approached by Ms. Gurewich with a proposal to start a press of their own. Me Moskowitz is determined to develop Other Press's scope both here and abroad. He is talking to the London School of Economics about creating a think tank to analyze social issues from a psychoanalytic perspective, and he wants to start a journal in South America, where psychoanalysis seems to be thriving ("Every hill town in Argentina has an analyst," he says). But New York is still at the psychological heart. "What I love about the bookstore is that it is a real space, a safe community where all are welcome and ideas can be freely exchanged," Mr. Moskowitz said. "The fact is that we are biological animals who live in culture. Psychoanalysis is the only theory I know of that tries to explain both these things."

Talking About Wu Wei: Two Therapists Examine Love, Longing & the I Ching
A book review of Cherishment: A Psychology of the Heart
by Elisabeth Young-Bruehl & Faith Bethelard
Stephen Wilson, New York Times Book Review- 3/26/2000

"Cherishment" has all the ingredients of a monograph--hypotheses, case studies, dreams and conceptual analysis--but it reads more like a love story. It is a product of the authors' personal relationship, an example of what it describes. Exhibiting it unashamedly as their "baby," Elisabeth Young-Bruehl lovingly chronicles its growth from page to page while Faith Bethelard feeds it with juicy tidbits from her life experience; it seems to smile up at the reader, inviting admiration--and it is bonny! Young-Bruehl and Bethelard were drawn together by their interest in psychotherapy. Late comers to the field and enthusiastic neophytes to clinical practice, they convened in December 1995 at a psychoanalytic conference at Yale University celebrating the centenary of Anna Freud's birth (Young-Breuhl is her biographer) and embarked on an extended conversation. The point of departure was a consideration of the therapeutic action of psychoanalysis, but their dialogue soon expanded to take in the I Ching, Homer, Confucius, Blake and the modern wisdom of the Japanese psychiatrist Takeo Doi, the author of "The Anatomy of Dependence," first published in English more than 25 years ago. All these writings are well known. What makes "Cherishment" special is the authors' joyful rediscovery of them, weaving the ideas into their thinking, absorbing them into their clinical practice, trying to enact them in their daily lives.
    We all crave indulgence from birth, and in the absence of tender care may grow up hard, unreceptive, emotionally stunted. Koi could not find an English word to express this primal longing for oneness with the mother, which if satisfied, produces a sense of infinite well-being and which in Japanese is linguistically acknowledged under the name amae. When asked to help himself at an American dinner party, Doi became uncomfortably aware that his deepest longings for amaeru (to have his needs automatically understood and met) were being symbolically denied. But if the West puts a premium on independence and weaning is its paradigmatic process, does this generate a tendency to lovelessness, a pathology of alienation and isolation? And if so, can it be reversed? Bethelard and Young-Breuhl plausibly render amaeru as cherishment, and have found the Greek word storge to cover the same emotional territory. This kind of fulfillment is clearly not unknown to Western man, they argue; it was merely cast off, left behind. And where mental disorder has arisen as a result of emotional deprivation, therapy aims to mitigate the damage.
    Psychoanalysis is many things--a cluster of theories about the mind, a technique for subjective exploration and perhaps above all a special kind of human relationship. It is far too complicated to be either right or wrong. No one has expressed the division between its theories and practice more starkly than Ian Suttie in "The Origins of Love and Hate" (1935). As Suttie puts it, Freud's theorizing has the stamp of loveless pessimism predicated on unconscious hatred, but, paradoxically, if psychoanalysis achieves a cure, it is cure brought about by love. Sandor Ferenczi's dictum "The physician's love heals the patient" is correct. Young-Bruehl and Bethelard are somewhere in this area, rescuing psychoanalysis from Freud's own revisionism, advocating a return to his early dualistic instinct theory, which proposed a two-track developmental pathway, driven by self-preservative ego-instincts on the one hand and sexual-object-related ones on the other. What Freud later joined together under the rubric of Eros--the life instinct--they cast asunder, untangling the search for relatedness from the drive toward impulse satisfaction. Both are in need of fulfillment, they say, both determine the pattern of our human bonds.
    But the redress of Freud is a job that has gone on throughout the 20th century, undertaken at first by the schismatics of Freud's own degeneration, then by numerous neo-Freudians, including Erich Fromm and Karen Horney in the United States and Melanie Klein, Ronald Fairbairn, Harry Guntrip and Wilfred Bion in Britain, all of whom are given scant attention in this book. In place of a hundred years of serious debate on psychoanalytic practice, we are occasionally offered a weird mixture of transparent obviousness and gnomic obscurity: "Being cherished may lay the foundation for becoming cherishing, as my Sun Dream showed, but there must be more to becoming able to cherish when you are being attacked. So I think we need to talk about what in the Taoist tradition is called wu wei...'Literally, Faith explained to me, wu wei means "not doing.' It is the ideal of the sage Lao-tse, who recommended it as the best way to deal with aggression--one's own, that of nearby others, and that manifest in all worldly affairs, from domestic arguments to wars."
    Bethelard seems to be gradually nudging Young-Bruehl away from her rationalist training to a place where love is communicated telepathically and aggression similarly defused. To cope with the most unyielding people, Bethelard reminds her friend of the Inner Truth hexagram of the I Ching: " In dealing with persons as intractable...as a pig or a fish, the whole secret of success depends on finding the right way of approach. One must first rid oneself of all prejudices and, so to speak, let the psyche of the other person act on one without restraint. Then one will establish contact with him, understand and gain power over him." No doubt, but the two friends' meliorism is tutored by their clinical experience; identification and love, they learn, are not enough to heal either a problem of sexual identity or a thwarted expectation to be loved.
    Undaunted, in the final chapter of "Cherishment" they set out on a working vacation in Greece. Their holiday employment is to search for the roots of human creativity! While crossing the Saronic Gulf in a hydrofoil, they encounter a nasty Frenchman with reserved tickets, who insists on moving them out of their seats--they do their best to wu-wei him. Maintaining their inner receptivity, they visit Delphi, home of the ancient oracle, and get caught in a thunderstorm. Suddenly, wondrously, the children of a delightful French family appear upon the ancient stage, playing joyfully in the rain. The authors realize that the world has produced a creative response to their hopeful expectancy; their forbearance is rewarded--and the French redeemed.

Autism's New Face
David Brown, Washington Post- 3/26/2000

Westin Beveridge, age 5, holds a pencil as if he were training to be a Japanese calligrapher. His fingertips are arrayed along the shaft, which stands nearly vertical. The letters he copies are as delicate as ones drawn with the finest sable brush. This is not a high-end enrichment program for children of the suburbs. This is the new face of autism. "Can you hold your pencil correctly, please?" says Wanda Watson, an occupational therapist, as she gently repositions the boy's hand. They get to H, deep into the land of attention and coordination. In a minute, the two are on the floor. Watson pushes a rubber roller along the boy's leg, helping him tolerate firm touch. "Do that again," he says at one point before withdrawing his leg at the last moment. The ambivalence, however, doesn't last long. Soon he is laughing as his mother and sister pat him enthusiastically in a game of duck-duck-goose.
    Autism, a disorder marked by social isolation, uncommunicativeness and strange repetitive behaviors, once had a different face. Its sufferers were the mute, endlessly rocking residents of hospital back wards, or the near-mythical "idiot savants," equally withdrawn but possessed of some rare talent. Now autism includes lots of people like Westin Beveridge. They are children whose symptoms are mild and treatable, although not likely curable. Across America, they are being found in epidemic numbers. Nationally, the number of children and teenagers labeled autistic rose from 23,000 six years ago to 54,000 in the last school year. In Maryland, the number of special education students with autism served through public schools has more than doubled from 697 in the 1995-96 school year to 1,880 in the current one. In Virginia, the number doubled in six years to 1,521 in 1998-99, the last year for which data are available. The number of autistic children in District schools is far smaller, with more year-to-year ups and downs than in larger school systems. Nevertheless, the trend here also appears to be upward. Although the disorder still accounts for just a tiny fraction of childhood disabilities, the increase is virtually without precedent. But are there truly more autistic children than there used to be? Some researchers and parents say yes, and they suspect that environmental toxins or childhood vaccines are causing the increase. Other experts, however, believe the numbers are rising steeply because children previously labeled with other disabilities--or missed altogether--are now being moved into the right diagnostic category. "In my heart of hearts, I think there's an increase," said Margaret Bauman, a prominent autism researcher at Harvard Medical School. "I'm probably biased because my practice attracts that kind of child. But from my own practice, I'm swamped. I don't know what accounts for it."
    The idea that children are being diagnosed autistic who once would have been considered merely eccentric seems unlikely to Karen Beveridge, 39, the mother of the Kensington child. "Believe me, Westin could have been born in 1850 and alarm bells would be going off," she said. "You don't get better at diagnosing this. I would be shocked to find that there isn't more around." If it turns out that the prevalence of a serious, often disabling neurological disease is doubling every five years, the United States is facing a public health emergency. On the other hand, if the increase is simply the result of a broader definition--and clinicians' improved ability to recognize the condition--then the trend actually may be good news. It means that many autistic children will no longer be overlooked. And it means the demand for services--which cost between $30,000 and $200,000 a year, virtually all paid by public funds--eventually will flatten out. Although nobody knows what to make of autism's growth, it has drawn a lot of attention. Two years ago, the federal Centers for Disease Control and Prevention (CDC) established the country's first formal surveillance program for autism, in metropolitan Atlanta. Last year the California state health department told the state legislature that the number of autistic children in the public schools had tripled between 1987 and 1998 and that the continuing upward trend will require "new and abundant resources." Some of the growing number of families touched by autism will rally on the Mall on April 8 in an event called "Hear Their Silence." To the dismay of many public health officials, the rise of autism is fueling a small but vocal movement that questions the safety of childhood vaccines. While there is little or no evidence that they cause autism, many parents still have doubts.
    "I don't know why Westin is autistic," Beveridge said recently. "I don't know if it was or wasn't vaccines. But until they can tell me why, I'm erring on the side of safety. He's not going to have them." The House Government Reform Committee plans a hearing April 6 to explore this hypothesis. The chairman, Rep. Dan Burton (R-Ind.), has a 3-year-old grandson whose autism he attributes to vaccination. Autism is a neurological disorder that appears to arise from errors in fetal development. It is three to four times more common in boys than in girls, and it is usually apparent by age 3. The disorder's most striking feature is profound social isolation. Autistic children classically dislike being touched or looking people in the eye, and they seem to take no pleasure in sharing experiences with others. Autistic children also experience delayed speech (and sometimes an absence of it). In addition, they often have an odd attraction to repetitive behaviors. A child may like to twirl endlessly. He may be fascinated by a specific sound--in Westin Beveridge's case, it was a neighbor's leaf-blower--or a single moving part of a complicated toy. Recent evidence suggests that early and intensive treatment, much of it one-on-one, can markedly improve the social functioning of autistic children. Historically, however, even "high-functioning" ones remain disabled in subtle or obvious ways through adulthood.
    The idea that autism can vary greatly in severity is a major insight of recent decades--and helps explain why counting the number of autistic children has been so difficult. Over time the condition's definition has been expanded, increasing the number of children who are classified as having a "pervasive developmental disorder," which includes autism. There also is significant overlap with other neurological conditions. About 75 percent of autistic children have some amount of mental retardation, and one-quarter have epilepsy. So the possibility of misclassification--especially for a child with borderline symptoms--is real. For whatever reason, estimates of autism's prevalence vary wildly. Two scientific analyses published last year came up with divergent best estimates--18.7 cases per 10,000 children, according to one researcher, and 40 to 50 per 10,000, according to another.
    A recent paper by two British epidemiologists suggests the skyrocketing numbers being seen by U.S. public school systems actually may fall within the range predicted by some European studies. They used 91 per 10,000 as the prevalence of children who meet, or just miss, the definition of an "autism spectrum" disorder. Although that is an extremely liberal estimate, the current enrollment of autistic children in California, the state with some of the best and most alarming data, is still smaller than the British study would predict. So it is possible California (and every other place in the country) is simply playing catch-up with a group of neurological disorders that were never as rare as people thought. On the other hand, it could be that the true biological risk for autism is changing. That possibility has parents--and researchers--casting around for things that are different now from the past. Vaccines are one of the things on the list.
    In 1998 a British researcher reported on 12 autistic children with intestinal problems. He speculated that the childhood vaccine that contains weakened measles, mumps and rubella viruses caused a low-grade infection that decreased the children's absorption of nutrients, which led to their disability. This theory has now been largely refuted. An epidemiological study from London showed a steady rise of autism since 1979, but no jump when the measles-mumps-rubella vaccine was introduced in 1988. It also found virtually identical vaccination status of autistic and non-autistic 2-year-olds. A Swedish study found no difference in prevalence of the disorder before and after the vaccine's introduction. Many parents, however, are convinced that if not that specific vaccine then maybe multiple vaccinations per se are somehow disordering the immune system and causing autism. Critics of this theory say the relationship between the first appearance of autistic symptoms at about 18 months and numerous doses of vaccine given shortly before then is nothing but predictable coincidence. Other theories have come and gone. A half-dozen studies suggesting that autistic children are more likely to be born in March or August than other months have now been disproved.
    Recently a team of researchers in Baltimore reported a higher-than-expected prevalence of autoimmune diseases in relatives of autistic children. Some people believe as-yet-unidentified environmental toxins may explain both problems. The federal Agency for Toxic Substances and Disease Registry recently finished a study of Brick Township, N.J., a community north of Atlantic City where the childhood prevalence of autism is reputed to be 1 in 200. Although the agency's final report (and a formal prevalence survey by the CDC) will not be released until later this spring, a registry scientist, Tomas Mignone, said recently that the town's water system, which supplies all residences, meets state and federal purity standards and that no unusual airborne pollutants have been found.
    Perhaps the strongest evidence against a postnatal cause of autism is the autistic brain itself. "The changes observed have varied, but none has ever been reported that could have occurred even in late gestation, or after birth," said Patricia Rodier of the University of Rochester, who has studied brains of autistic people. What seems certain is that genetic predisposition plays a huge role in determining who develops autism and who doesn't. If one child in a set of identical twins is autistic, there is an 80 percent chance the second child will be too. Siblings of autistic children have about a 5 percent likelihood of developing some autism-spectrum disorder--far higher than would occur by chance alone. (However, those numbers also prove that genes aren't everything.) At least a dozen genes help lay the groundwork for the disease, scientists believe. In an effort to promote research on the genetics of autism, an advocacy organization called Cure Autism Now two years ago set up a depository at Rutgers University where DNA samples from about 450 families with autistic members are stored. Gene sequences, as well as behavioral inventories, of the autistic people in the database will be made available to researchers worldwide through the Internet.

Experts Offer Fresh Insights Into the Mind of the Grieving Child
Erica Goode, New York Times- 3/28/2000

When her father died from leukemia, 3 year old Rachel asked her mother, "When is he coming back?" Mark, 7, complained of chest pains after his father died, and took to wearing his father's boxer shorts and ties. "He is gone, kaput, he's dead," Mark explained to a family friend. Hillary, 12, was embarrassed when her mother cried at her father's funeral, and refused to visit the cemetery in the weeks afterward. "Crying won't help," she said. "Why should I go to the cemetery? I talk to my father all the time anyway." Sigmund Freud believed that young children did not have the capacity to mourn: The psychological tasks involved in resolving grief, Freud asserted in "Mourning and Melancholia," are too difficult for children to negotiate. Only in adolescence, when development is more advanced, does true grieving become possible, he maintained. But a new book, based on a large scale study by researchers at Memorial Sloan-Kettering Cancer Center of families coping with the illness and death of a parent, offers a very different understanding of children's ability to come to terms with loss. In "Healing Children's Grief: Surviving a Parent's Death From Cancer" (Oxford, 2000), Dr. Grace Hyslop Christ, an associate professor in the School of Social Work at Columbia University who was one of two principal investigators in the Sloan-Kettering study, makes it clear that children, even very young children, do grieve, though their grieving differs at different ages, and often bears little resemblance to the mourning reactions of adults. More important, Dr. Christ, who gave her young subjects pseudonyms in her book to protect their identities, found that given adequate support and assistance, most of the children were able to move on with their lives, without developing serious psychological problems, at least for the short term. "Society tends to think about this experience as either devastating to children, that they should be kept from it, or the opposite, that kids are resilient and will bounce back on their own," Dr. Christ said.   "But we found that while children do go through pain, they can also learn, grow and recover with the help of supportive adults."
    Over the past decade, investigators have begun to gain a greater understanding of the impact of losing a parent early in life. Some studies have tackled the topic retrospectively, interviewing adults about their early experiences. Others, like the Sloan-Kettering study, have charted children's reactions as they unfold. What is apparent from such studies is that losing a parent is not a single event, which then has predictable consequences for the child. Rather, the way a child responds to the loss is the result of a complex interweaving of circumstances, including the emotional responses and parenting abilities of the surviving parent and the presence or absence of other stressors--financial difficulties, for example, or the death of another family member. Much also depends on the child's own natural strengths and weaknesses and the child's changing relationship with the dead parent over time. "I think a kid is a vulnerable as his parents and the support system around them" said Dr. Phyllis Rolfe Silverman, author of "Never Too Young To Know: Death in Children's Lives" (Oxford, 1999), and co-director of the Harvard Bereavement Study, a long-term study of 125 children who had experienced the death of a parent. In some ways, the Sloan-Kettering study, led by Dr. Christ and Dr. Karolynn Siegel, offers a best case example. They and their colleagues followed 157 children, aged 3 to 17, through the parent's illness and for 14 months after the death. The researchers not only studied the 88 families involved, administering a battery of psychological tests and interviewing the parents and children, as well as teachers and other family members in some cases, but they offered the families help, providing educational counseling and support in the months leading up to the death and afterward. For example, the researchers offered parents suggestions of ways to handle problems with their children if such problems emerged, and talked with the children themselves about what they were feeling and thinking. Children who had known psychiatric problems before the parent fell ill were excluded from the study, since it would be difficult to tell if later difficulties were related to the parent's death. Under these conditions, most of the children who took part in the study did relatively well. Of the 139 children above preschool age, for example, 84 had returned to normal levels of functioning at school and in relation to other family members and their peers by 8 to 14 months after the parent's death. Another 32 were functioning normally in all but one area, and were improving in that area. The remaining 23 children were either experiencing difficulties in two or more areas and showed no sign of improvement or had developed new psychological symptoms since the parent's death.
    Children of different ages, Dr Christ and her colleagues found, coped with the parent' illness and death in very different ways. Preschoolers, from 3 to 5, had the most difficulty understanding the irreversibility of death, even when they had been told ahead of time that the parent was going to die. For weeks, or even months after the death, they would ask when their mother or father was coming back, and they often needed very concrete explanations of what death meant; for example, that the body no longer functioned and that death made people feel sad and cry. Once the children accepted that the parent would not return, they often showed signs of distress, including night terrors, bed wetting, whining, stomach aches and intense anxiety when separated from the surviving parent. They were upset when the surviving parent showed strong emotions, and soon after the death, many began to demand that their lost mother or father be replaced. Rachel, for example, told her mother, "I don't have a daddy, but everyone else has a daddy." She offered to be her mother's husband, but her mother replied, "You are my daughter and I really want you to be my daughter." Rachel then suggested that perhaps their housekeeper could be her mother's husband, and when told that would not work, nominated the husband of her mother's best friend.
    Slightly older children, from 6 to 8, were generally quick to appreciate the permanence of death, but they were also likely to conclude that they were responsible for the death, or to draw other illogical conclusions about what was happening. An 8 year old girl in the study, for example, did not want to talk to the researchers about the probability that her mother would die. She was afraid that talking about it would make it happen. "It's a very vulnerable age," Dr. Christ said. Many of the children talked explicitly about wanting to die to be with the lost parent. But such statements, Dr. Christ said, usually represented intense longing and an expression of grief rather than suicidal feelings. At the same time, the children love to talk about the deceased parent and to tell stories about things the family had done together. One child, for example, cherished the memory of how her mother squeezed her hand on the day she died.
    For children from 9 to 14, the process of mourning was more complex and also at times more frustrating for the surviving parents. Many preadolescents felt in danger of being overwhelmed by the pain they experienced. As a result, they often shoved their feelings away and were reluctant to talk about the death, preferring to escape into school activities or visits with friends. Adolescents 12 to 14 were sometimes the hardest for the surviving parents to reach. Their egocentricity could be shocking to parents coping with their own grief; told of her father's diagnosis, a 13 year old went out to a party with friends. "What was I supposed to do?" she said to her mother, "Stay home and cry?" Most did not want to talk about the parent's death or to learn about the nature of the illness. One boy told his mother, who kept trying to keep him informed about his father's condition, "I want a report every three days unless something else happens." They missed the parent as a caretaker and also as a role model. But they hated the idea of showing emotion. "The mantra of his age group was 'I cry, but in my room alone,'" Dr. Christ said.
    It was the oldest children in the study, she continued, those from ages 15 to 17, who most resembled adults in their approach to death. Many went through a sustained period of grief immediately after the death. They were able to be helpful and supportive to surviving parents--sometimes so much so that the parent forgot that the child was still a child. For all age groups, the researchers found, children who adjusted most successfully had parents who were communicative and shared information about what was going on. Children in families where the parents refused to acknowledge or deal with the death, or where the loss was compounded by other stresses--money, the illness of other family members, a surviving parent's plunging into severe depression--had more trouble coping. In many cases, children in the study reported more stress and anxiety in the period before the parent died than afterward.
    Dr. Albert Cain, a professor of psychology at the University of Michigan who has studied bereaved children, praised the Sloan-Kettering study for its insights into the ways children deal with a forthcoming death. But he pointed out that because of the counseling offered to the families, it was difficult to tell how much of the later adjustment of the children was due to the intervention and how much to other factors, like the passage of time. And he cautioned that there was still much to learn about the long-term effects of the death of a parent in early life. "I think we're all agreed that no one walks away from that without enduring scars," he said, "but the issue is the extent to which you get continuing--not escalating--interference with development or distortions of adjustment." Still, Dr. Christ said that one of the most interesting findings of the study was that some parents who had serious psychological difficulties before a spouse died still managed to pull themselves together and prove very effective in parenting their children after the death. And while many dying parents worried that their children would remember them in the worst stages of their illness, Dr. Christ found that more often, the reverse proved to be true. "Children really focused on the positive aspects of the parent," she said, and they often worked to construct an image of the parent that they could remember and take with them into their later lives.