Noteworthy News Articles on Mental Health Topics, April 17-23, 2000

Meditation as Good Medicine
Timothy Gower, L. A. Times- 4/17/2000

It's becoming the mantra of an increasing number of Americans. Research shows the ancient practice may help promote healing--and might just make you live longer. When Joannie Parker developed breast cancer, her doctors eradicated the disease with surgery, chemotherapy and radiation. But the rigors of battling cancer left the 66-year-old Westwood woman feeling as many patients do: stressed out. To deal with her anxiety, Parker enrolled in an eight-week meditation class at UCLA's Rhonda Fleming Mann Resource Center for Women with Cancer. During each 90-minute session, an instructor led the class through various meditative techniques, such as asking Parker and her classmates to imagine that they were sitting on a beach, with the ocean waves washing the cancer out of their bodies. Parker, who had never meditated before, believes the sessions were just as critical to her healing as the conventional medical treatment she received. "I would walk out of those classes feeling deeply relaxed and enormously calm and whole and well," she said in a telephone interview. "It's not at all strange."
    Personally, I was relieved to hear that last comment--about it not being strange. I've been something of a closet meditator for several years. To have this kind, intelligent stranger talk about the habit we share made it seem a little less, well, weird. On most days, after breakfast, I sit quietly on a sofa for a few minutes and simply try to clear up the jumble of thoughts in my head. I might breathe deeply and concentrate on the sensation of my diaphragm moving up and down. Or I might pick a word to focus on, such as "peace" or "calm." Some mornings I slip on headphones and listen to that CD of the chanting monks that was a hit a few years ago. I can't say why, but meditating acts like a desk organizer for my brain, clearing away much of the clutter. It also provides a boost of mental energy unlike anything I could get from a double espresso or a hit of ginkgo biloba. I've never mentioned any of this to my golf buddies. But who knows, maybe they're doing it too. After all, about 10 million American adults--or one in eight--meditate regularly, according to statistics in the Journal of the American Medical Assn. That's nearly twice as many as a decade ago. What's more, some very successful people have gone public with their embrace of this ancient practice. It's no surprise that actor and celebrity-Buddhist Richard Gere is on the list. But how about St. Louis Cardinal slugger Mark McGwire? There's also Monsanto Corp. Chief Executive Robert Shapiro, who meditates twice a day and has led meditation retreats for top executives of the giant chemical company.
    Further proof that meditation has reached the masses can be seen in the publication last year of the book "Meditation for Dummies." Author Stephan Bodian, former editor of Yoga Journal, says the basic, how-to "Dummies" format is tailor-made for the art of calming the spirit. The beginning meditator, he explains, "has the mind of a 'dummy.' Not in the negative sense, but in the sense of someone who's new and open to learning and doesn't know anything about the topic." The yoga-meditation connection may partially explain the growing number of meditators in the United States. Yoga classes, where students learn how to limber up and mellow out, are taught at most adult education centers. Instructional videos by the likes of yoga master Rodney Yee, fitness guru Kathy Smith and actress Ali MacGraw are among the most popular items sold by online retailer Amazon.com. Even Richie Aprile, the menacing Mafioso on TV's "The Sopranos," practices yoga. That is, when he's not running over guys who owe him money with his sport-utility vehicle. But there's another likely reason more Americans are turning to meditation: A growing body of research over several decades suggests that it might make you live longer. More than 25 years ago, Harvard Medical School cardiologist Herbert Benson reported in his best-selling book, "The Relaxation Response," that people with hypertension experience impressive drops in blood pressure when they practice Transcendental Meditation. Also known as TM, this form of meditation involves the silent repetition of a specific sound, known as a mantra.

Study Shows Benefits of Stress Management
In 1990, cardiologist Dean Ornish, founder of the Sausalito-based Preventive Medicine Research Institute, published a now-famous study showing that people with heart disease who adopted a regimen of lifestyle changes could unclog their arteries without drugs. While most people focused on the very low-fat diet Ornish fed his patients, he points out that exercise and stress-management techniques--including meditation --were just as important.  "We found a direct correlation to the patients' adherence to stress-management [techniques] and changes in their arteries. Just as strong as adherence to the diet," Ornish says. Some, though not all, studies have shown that meditating causes humans to produce lower levels of stress hormones, such as cortisol. Chronically elevated cortisol levels, Ornish explains, speed up the formation of artery-blocking plaques. Most recently, in March, a study conducted in Los Angeles found that African American men and women with hypertension who learned TM decreased the amount of fatty substance in the walls of their carotid arteries, which are in the neck. Carotid arteries clogged with fatty deposits can cause strokes and are considered by some experts to be a measure of heart attack risk. "The reductions were similar to that often seen with cholesterol-lowering drugs and also with intensive changes in diet and exercise," says Dr. Robert Schneider, one of the study's authors. He estimates the meditators cut their risk of heart attack and stroke by at least 10% to 15%.
    The U.S. government is clearly intrigued by the meditation-heart disease connection. The National Institutes of Health has awarded a total of $17 million to Maharishi University of Management researchers to study the role of TM in treating and preventing hypertension in African Americans. The health institutes, along with the American Heart Association, have also funded another researcher who is studying the effects of TM. Physiologist Vernon Barnes, of the Medical College of Georgia, in Augusta, is studying whether African American high school students with hypertension can keep their blood pressure in check by learning to meditate. Not all experts are sold on the idea of meditation as a heart saver. Cardiologist Edward D. Frohlich believes some researchers overstate the role of stress in heart attacks. "It's clear that stress has an adverse effect on coronary heart disease," says Frohlich, editor of the medical journal Hypertension. But, he adds, "it's one of the minor risk factors." That is, reducing your stress level isn't a bad idea, but if you're serious about avoiding heart trouble, it's more important to exercise, eat right and quit smoking. However, even if questions remain as to whether meditation prevents heart disease, there's strong evidence that it can alleviate symptoms of other conditions.

'Mindfulness' Taught to Patients in Pain
In Worcester, Mass., researchers at the University of Massachusetts Memorial Medical Center's stress reduction clinic have taught a form of Buddhist meditation known as "mindfulness" to more than 11,000 patients with various problems, including chronic pain and emotional distress. In one study, patients reported 35% fewer symptoms after completing the eight-week program. In another, people being treated for psoriasis who meditated saw their skin clear up four times faster than patients who didn't meditate. Meditation is taught, in many forms, at cancer centers throughout the United States to help patients cope with the disease. At Memorial Sloan-Kettering Cancer Center in New York, Barrie Cassileth, chief of integrative medicine services, believes in meditation, even if she's not sure how it works. "Who cares [how it works] if patients feel better, their pain is reduced and they gain a sense of control," says Cassileth, who is also the author of "The Alternative Medicine Handbook" (W.W. Norton, 1998), which examines non-Western medicine, often skeptically. Back at UCLA, psychologist Anne Coscarelli, director of the Mann Resource Center, agrees that meditation and other stress-reduction techniques are valuable, if a bit mysterious.  "We don't know what the physical impact is of doing these things," she says, "but we know that patients who are less distressed may be able to tolerate their treatments better."

Ritalin Link to Death of Teen Ignites Controversy
Patricia Anstett, Detroit Free Press- 4/18/2000

A bleary-eyed Dr. Ljubisa Dragovic awoke at 5:30 a.m. Monday for another media call. This time it was Bryant Gumbel, from CBS' "The Early Show." Did Ritalin cause the death of 14-year-old Matthew Smith of Clawson? Gumbel wanted to know.  That's what Dragovic, the Oakland County medical examiner, said 200 reporters and parents have asked him since Thursday because Dragovic attributed a heart attack the teen had March 21 to his 8-year use of the drug. The family has retained the law firm of Geoffrey Fieger to investigate the death. "We're really in the infancy of the case," said Arnie Matusz, an attorney with Fieger, Fieger, Schwartz & Kenney.  Smith, a ninth-grader at Clawson High School, was skate boarding in his aunt's basement when he fell, turned blue and developed difficulty breathing, relatives have said.
    The case is believed to be the first in which a heart attack has been linked to long-term use of Ritalin, a stimulant drug used by more than two million Americans to treat attention deficit hyperactivity disorder, ADHD, and attention deficit disorder, ADD.   Dragovic said small blood vessels near Smith's heart were altered in a manner consistent with stimulant abuse. "There was no other disease," Dragovic said. Psychiatrists are criticizing him for jumping to what they say is the wrong conclusion. They cite the drug's 40-year safety record. Monday, they rushed to assure patients and their families about its lengthy safety profile.  "It's safe, time-tested and the potential benefit is so much greater than any potential risk," said Dr. Joel Young, a psychiatrist and medical director of the Rochester Center for Behavioral Medicine in Rochester Hills. "He is unnecessarily scaring people."  In a statement from Novartis Pharmaceuticals Corp., Ritalin's manufacturer based in East Hanover, N.J., spokesman Harry Rohme said there is no scientific evidence that Ritalin causes any serious cardiac problem, either heart attack or heartbeat irregularities. It's been used for more than 40 years and found safe in nearly 200 studies of 6,000 school-age children, he said. Last year, the American Heart Association reaffirmed the safety of the drug and said no specific monitoring was needed, Rohme added.
    Reports of heartbeat irregularities were raised by the 1996 death of an 11-year-old girl, Stephanie Marie Hall, of Canton, Ohio. The family sued but withdrew the lawsuit last week, Rohme said. Steven Okey, attorney for the family, did not return a call Monday. The Ritalin debate in metro Detroit comes one month after Hillary Clinton announced a $5-million federal initiative to study the impact of drugs such as Ritalin and Prozac on kids younger than 7. Citing a 200-percent increase in the use of psychiatric drugs in young children, Clinton announced that the Food and Drug Administration will begin developing research guidelines on dosage information and pediatric labeling for mood-altering medications. She also said the National Institute of Mental Health will dedicate more than $5 million to research the disorders and Ritalin use in preschoolers.
    Dragovic is alerting the FDA about the Clawson death. "They're dragging me out of bed, like I have all the answers.... What I know is this is a stimulant and there's widespread abuse." Dragovic, a father of seven, said he opposes Ritalin in young children. "That's my private opinion." Rick Berchou, assistant professor of psychiatry at the Wayne State University School of Medicine, has studied side effects of drugs used for behavioral and mental problems for more than 20 years. "I don't know of any deaths attributable to cardiac events from Ritalin," he said. "The problem is, when people take a medication, we tend to blame the drug." Genetic defects may cause sudden deaths that aren't well understood, Berchou said. Ritalin has been used safely in heart attack patients to combat depression because it is quicker than antidepressants, he said. Emerging research shows that ADD -- more typical in girls -- and ADHD -- more common in boys -- are genetically linked deficits in the brain. They cause distraction, forgetfulness, disorganization, impulsivity and inability to sit still and listen. Boys outnumber girls nearly three to one with the two problems. Ritalin is the best known of more than a half dozen commonly prescribed drugs for the problem. Later this year, experts expect to have longer-acting medicines on the market that patients can take once every 12 hours. Now, many people take forms of Ritalin that require several doses a day -- a problem that consumes time at schools when children go to offices for their mid-day dose.

Growing Up on a Ritalin-Prozac Cocktail: Is This What Ricky Needs?
Howard Markel, M.D., New York Times- 4/18/2000

Ricky is one of the most appealing teenagers in my practice. Bright, funny and a genuinely cool kid, Ricky suffers from the worst case of attention deficit disorder with hyperactivity that I have seen in 14 years as a pediatrician. He is also prone to serious bouts of depression, poor self-esteem, forays into alcohol and marijuana abuse, and, at unpredictable junctures, violent outbursts. A broken hand from punching a brick wall, physical attacks on family members, frequent run-ins with the police, and even suicide attempts have all brought Ricky into my clinic for medical care and counseling. Yet in the six years that I have been Ricky's pediatrician, I have never seen him when he was not medicated with a staggering combination of Ritalin, Prozac, and, at different times, far stronger psychotropic drugs under the supervision of a child psychiatrist.
    In Ricky's case, the medications for attention deficit disorder and depression have, at best, only partly ameliorated his problems. But at this point, it is impossible to be certain of the exact effects of this combination of drugs on his behavior. Ritalin, an amphetamine, has a paradoxical effect on children with the disorder. Instead of speeding these children up, it enables them to focus on learning tasks and even calms their hyperactivity. But the drug is not uniformly predictable and may cause several unwanted results ranging from insomnia and appetite suppression to behavioral outbursts. Prozac is thought to help alleviate depression by allowing serotonin, a neurochemical that modulates mood, to be absorbed from the synaptic spaces of neurons more slowly. But this drug, too, can have multiple untoward effects including insomnia, jumpiness, fatigue and irritability. When taken together, Ritalin and Prozac are usually well tolerated. But for some children, the combination creates mixed results.
    Ricky came to my practice as a 9-year-old with a history of taking these medications since before he began kindergarten, just like the children profiled in the highly publicized report in the Journal of the American Medical Association on the increasing rates of prescribing psychotropic drugs to American preschoolers. Even as a toddler, Ricky showed signs of excessive impulsivity. The long medical chart that followed Ricky to my clinic revealed that his parents had been concerned enough about his behavior to begin searching for professional help by the end of his third year. As a 4-year-old, and several times since, Ricky underwent a battery of neuropsychological tests that strongly suggested attention deficit disorder with hyperactivity and depression. And while such tests are hardly as exact a yardstick as those that measure blood sugar, they were done by highly regarded child psychologists and psychiatrists with whom I work on many difficult cases. The overwhelming consensus of medical and parental opinion has been to put Ricky on Ritalin and Prozac.
    The goal, of course, is to control or change behaviors that seriously interfere with the normal progression of childhood. Sometimes it is overworked pediatricians handing out drugs to get frenetic children out the door. In other cases, it is harried teachers demanding that difficult students be medicated into submission. But plenty of parents, like Ricky's, ask for powerful psychotropic drugs by brand name in hope of curing their children's poor school performance or behavior. What is so frustrating for all concerned is the wide gulf of uncertainty among doctors, regardless of their specialties, mental health professionals and parents over when to use psychotropic drugs and, just as important, when to stop using them.
    Psychotropic drugs can work wonders for a wide range of serious behavioral or psychological problems. Every child's health professional, myself included, is familiar with cases of children who were able to experience a more normal childhood and adolescence because they took these medications. Sadly, however, there are many other children for whom these drugs are bandages that only mask gaping psychic wounds, serious and poorly understood disorders of neurochemistry, and even counterproductive parenting techniques that give rise to complex and destructive behaviors. Like the proverbial snowball rolling down a hill, these problems can be compounded with each turn and revolution, and discovering what is at the center eludes even the most perceptive physician or caring parent.
    I see Ricky at least every month, and during times of crisis as much as daily. Working with this family for so long, I know he has good, attentive parents. I do not always agree with their decisions and they do not always agree with my medical opinions. For example, I have repeatedly pleaded with them at least to try to wean him off some of his medications. Each time I make the suggestion, Ricky's parents vociferously object, terrified at the mere mention of a son not buffered by psychotropic medications. "You just do not know what Ricky was like before we put him on these medicines," his mother says. I usually rejoin that Ricky is not doing so well on them. I must confess, however, that it is far easier for me in the confines of the clinic to suggest withdrawing the medications than for this parents to act on that suggestion. I do not know what it is like to have a violent 5-foot-10 teenager in the house. Chronic disease is disruptive for all members of a family it touches, but a chronic disease that manifests itself with hitting others, or worse, is downright dangerous.
    I continue to work with Ricky and his family and have incorporated other approaches, including special school and counseling programs, into his treatment plan. I also like to think that the hours we have spent together rehearsing how he will react to challenging situations have helped matters, but I have no proof that any of these methods are really working. Ricky's parents and his psychiatrist, far more impressed than I by pharmacologic approaches, continue to hope that some new medication will soon be developed that better controls his attention deficit hyperactivity disorder, depression and violent outbursts. Ricky's story reflects just a few of the many problems that result from prescribing these powerful medications to young children and their continued use well into early adulthood. It is a story replete with complicated diagnoses and, so far, without conclusion.
    We do not know if these psychotropic medications are helping or harming Ricky. We have long lost touch with the original psychopathology that brought about these interventions. And, frighteningly, we simply do not know if he will outgrow his more destructive impulses before any permanent harm results. In his more receptive moments, when Ricky and I are alone in the examination room simply talking to each other, I counsel him not merely to count to 10 before expressing anger or acting out but instead, to try counting to 1,000. Ricky always smiles at this advice, promises to try harder and bids me goodbye. But within a week, maybe two or three, I know I will receive a frantic call from Ricky's parents reporting his latest misadventure.

Feds Crack Down on Ecstasy
Donna Leinwand and Gary Fields, USA Today- 4/19/2000

NORTH BERGEN, N.J. -- In a suburban ballroom, music without melody pounds from speakers piled almost to the ceiling. At this nine-hour rave party, only the ribcage-rattling bass matters. About 2,000 teenagers, most wearing nylon UFO brand parachute pants, writhe and hop on a packed dance floor. Alcohol is conspicuously absent, but the drug Ecstasy is everywhere. The aspirin-size pill provides the high of choice among these pencil-thin girls and hyperactive boys. They say it heightens their sensitivity to the vibrating bass, tickling the skin and sending chills up the spine. "Everything feels good,'' says Tricia Kaz, 18, a freshman at Seton Hall University in South Orange, N.J. She spent three weeks at a drug rehabilitation center after her mother found out about her Ecstasy habit, but she says she doesn't see the harm of a drug that produces no hangover or physical craving.
    Kaz and the other youths might be mistaken. New studies show that users of Ecstasy risk the possibility of brain damage from prolonged use. Law enforcement is intensifying its efforts to stop the growing demand for Ecstasy and to halt organized crime's penetration of the market. The pill, at $20 or so a pop, acts a little like stimulants such as methamphetamine and a little like a hallucinogen such as LSD. A hit produces a warm, fuzzy sense of well-being and the manic energy to dance until dawn. However, studies indicate that Ecstasy, the nickname for the drug compound 3,4 methylenedioxy-methamphetamine (MDMA), clicks off brain cells crucial to memory and sleep.
"The party's over," says Alex Stalcup, a physician who runs a drug treatment center in Concord, Calif. "Ecstasy hurts the brain. It is no longer a hypothesis. The drug is toxic. It is no longer appropriate to consider it a recreational drug."
    Until recently, law enforcement had shrugged its shoulders. Because Ecstasy users keep to themselves at dance parties, known as raves, there was no violence or theft associated with drugs, as there is with drugs such as cocaine and heroin. The Ecstasy scene is becoming more dangerous as the lure of phenomenal profits attracts organized crime. The drug costs just pennies to make. The international crime agency Interpol, the U.S. Customs Service and the Drug Enforcement Administration have tracked Israeli crime groups and Russian mobsters trading in Ecstasy. Last month, federal authorities arrested Sammy "The Bull" Gravano, a former mafia hitman, for allegedly running an Ecstasy ring in Arizona that distributed 25,000 pills a week, worth half a million dollars on the street. Between Oct. 1, 1999, and Feb. 29, Customs agents confiscated 4 million tablets, 1 million more than in all of last year. Seizures of Ecstasy, classified as a Schedule I drug, like LSD and heroin, are expected to grow eightfold by the end of the year. "It's truly a global business, and it has completely erased all the old routes law enforcement had mapped out for the smuggling of traditional drugs like heroin, cocaine and marijuana," says U.S. Customs Commissioner Raymond Kelly. Crime groups use computers to track international mail shipments of the drug from the Netherlands and Belgium through dummy addresses in Europe and into the United States. While his agency and others step up policing efforts, Kelly emphasizes that teenagers need to be warned about the drug's potential danger. "It has the 'love-drug, hug-drug' label to it," Kelly says. "Kids and their parents don't realize it has long-term implications. It is a killer, category one, dangerous drug. "
    Raves began in the 1980s as informal groups gathered on farms or in vacant buildings to listen to bass-heavy music, take Ecstasy and dance all night. Now, an Internet search will turn up more than two dozen raves in the USA on any weekend, many in legal venues that promise safety, portable potties and laser light shows. At the New Jersey party, a bouncer checked each "raver" for weapons and drugs, but the tiny pills slipped by easily. Ravers say they hide them in their shoes or take them beforehand. Marijuana passed security, too. Teens rolled joints openly and the odor of pot permeated the "chill out" room off the main dance floor, where the ravers cool off after dancing. The crowd was middle class, overwhelmingly white and unfailingly polite. Most were teenagers or in their early 20s. They had paid $20, $15 with a flier, to get in. Many said they don't take drugs but relish the atmosphere of acceptance at raves that they do not find among the cliques at school. "Drugs are everywhere. They're in school," said Sunny Pae, 20, a history major at New York University. " It's all about the music, the love, the vibe."
    Even those who shun the drugs admitted that an Ecstasy undercurrent defines the party, the music and even the fashion. The concession stand catered to Ecstasy users. The drug causes involuntary jaw clenching and teeth grinding, and nonstop dancing leads to dehydration. Ravers suck pacifiers to unclench their jaws and lollipops to lubricate their mouths. Two lollipops cost $1. A bottle of water or fruit juice costs $3. As the night wore on in North Bergen, teenagers huddled cross-legged in clumps, knees and shoulders touching or bodies intertwined like nesting hamsters. New acquaintances kissed for hours or massaged one another's shoulders. "Everything is so much better when you're on drugs," said a 15-year-old high school freshman from Bayonne, N.J., who sucked madly on a pacifier strung around her neck. Her name is being withheld because of her age. In a midriff-baring tank top and nylon pants, this A-plus honor student danced wildly for hours, fueled by three Ecstasy pills. "Raving is not a crime," she said.
    Possessing and taking Ecstasy are illegal, but the police rarely raid these well-publicized raves. In New Jersey, possession of Ecstasy carries a sentence of three to five years in prison, but a first-time offender could serve less than a year in county jail, says John Dangler, a Morris County, N.J., prosecutor, and "that's if it is a truckload or a tablet." Police know that Ecstasy and a handful of other drugs saturate these parties. Raiding raves is an inefficient use of resources, police say. In March, police raided a Toronto rave attended by 12,000 people but confiscated just 300 Ecstasy tablets. "Cops are still out there chasing major violent crimes like murder and rapes and serious drug dealers," says James Pasco, executive director of the Fraternal Order of Police. "What would a cop rather be doing, chasing a guy who just put a gun in a clerk's ear at the store or arresting a kid who is using a drug that doesn't promote violence?" Police departments concentrate on street-corner drugs because of their link to violence and crime, says Trinka Porrata, a retired Los Angeles narcotics detective. Police, she says, are conflicted about raiding raves. "If you bust up a party, then you're sending 800 kids on drugs on the road," Porrata says. "At a real rave, they go there, they do their drugs, they pass out, they sleep it off and then they go home."
    Yet the urgency to get the drugs out of reach of teenagers has intensified as new scientific studies warn that Ecstasy causes brain damage. Stalcup, the drug addiction doctor who describes himself as a "prototypical aging hippie" and has tried Ecstasy, often spends Saturday nights at San Francisco-area raves, where he treats overheated and dehydrated teenagers. He understands the allure. "Ecstasy really is quite grand," Stalcup says. "You feel warm and close to people. You want to hug people. You feel ecstatic and full of human kindness." Still, he worries. Scientists have studied images of the brain before and after Ecstasy. Stalcup describes the differences as "graphic and gruesome." Ecstasy kills off part of the nerve in the brain that releases serotonin, the chemical that controls sleep, sexual function, memory, appetite and mood, says Wilkie Wilson, a neuropharmacologist at Duke University who co-wrote Buzzed, a guide to abused drugs.
    A study by Johns Hopkins University researcher George Ricaurte in Baltimore compared the brain scans of 14 Ecstasy users to non-users(bold)' (/bold)scans and found nerve damage that persists for at least seven years. Teens have more serotonin-producers than they need, Wilson says, but some of those nerves are lost with aging. "Ecstasy users probably don't realize this, but they are aging themselves prematurely," he says. "I expect them to have clinical depression and sleep disorders down the road. It impairs learning, which is a particularly bad thing for teenagers." The National Institute for Drug Abuse has placed 350,000 postcards with warnings in racks at clubs and record stores and will spend $54 million on Ecstasy research this year - 40% more than in 1999. "We're not yet at epidemic proportions, but we are seeing an increase of Ecstasy and other club drugs in every major city and among high school kids," NIDA director Alan Leshner says. "We're trying to use science to get in the way of a potential public health plague." A few skeptics say that public health officials are exaggerating the long-term risks of Ecstasy use or base their warnings on incomplete scientific research. So far, the naysayers lack counterevidence. But there are three U.S. studies under way to determine whether the drug has any legitimate therapeutic use. The studies also are measuring health risks.
    Chemists created MDMA, or Ecstasy, in 1912 as an appetite suppressant, but it never became popular. In the 1970s, psychiatrists tried MDMA to eliminate inhibitions in psychotherapy, and many doctors found its effectiveness limited. In 1986, the government classified it - over the objections of some psychiatrists who supported its use in therapy - as a Schedule One illicit drug with no medical benefit. A federal conviction for possession of 2,800 grams, about 940 tablets, would bring a maximum of five years in prison. About 90% of Ecstasy comes from northern Europe, primarily the Netherlands and Belgium, where labs can produce a pill for less than a dime, the DEA says. Israeli crime groups, which mark up the wholesale price to about $4 a tablet, dominate distribution, the agents say. Last year, Dutch and Israel authorities seized more than 1 million tablets and arrested 49 people in the Netherlands, Israel and elsewhere. The pills fit easily in suitcases and carry-on bags. One courier stuffed a Winnie-the-Pooh doll full of tablets and carried it onto an airplane. Another dealer filled his child's electronic toy with the drugs to pass the Customs Service inspectors. Traffickers take advantage of relaxed European Union borders, shipping their drugs from Paris or Berlin instead of the heavily scrutinized routes from Amsterdam or Brussels. Concerned with the rapid expansion of Ecstasy trade, Interpol, the international police organization based in France, created a department devoted to tracking Ecstasy. "It's complicated because there is not just one group with one modus operandi," says Hezi Leder, police attaché for the Israeli embassy in Washington. Israeli authorities participate frequently in stings with U.S. and European authorities. Customs trained 13 dogs last month to sniff out Ecstasy. The agency also has formed an Ecstasy task force that catalogues smuggling methods and coordinates searches. The DEA is hosting its first Ecstasy conference in July in Washington. More than 200 international, federal, state and local law enforcement officials are expected to attend.
    Even as law enforcement tightens its grip on the international Ecstasy trade, U.S. entrepreneurs have begun to produce a version of the drug. Using Ecstasy recipes that don't rely on regulated chemicals, amateur chemists concoct the drugs at secret labs. In March, Texas State Police Lt. Patrick O'Burke and his officers shut down an Ecstasy lab on an 80-acre ranch near San Antonio, where they found enough chemicals to produce 750,000 capsules with a street value of $15 million. "This was big business," O'Burke said. "This was an organized criminal effort, very, very large scale." Retired Los Angeles detective Porrata predicts the problems with Ecstasy will begin to draw in local enforcement. When some California teens coming from a rave died after driving over a cliff, public pressure built to crack down, she says. "Since then, law enforcement has been going, 'Oh, my God.' The raves are everywhere now, and we're starting to see accidents and overdoses and kids dying from dehydration," she says. "Local police and the public are just waking up to it."

Alcoholism & Malnutrition Ravage Brazilian Tribe
Patrice M. Jones, Chicago Tribune- 4/20/2000

AGUA BOA, Brazil -- As late-afternoon storm clouds threatened a downpour over the Indian village of Agua Boa, 2-year-old Salvino Maxakali began to cry. The boy, who had been propped up on a crude wooden bed, had fallen face-first on the dirt floor. Living in a thatched-roof hut the size of a jail cell with 17 other people, he had been sick for months, his father said, his scalp and face swollen with red boils from an infection that could prove deadly if left untreated. His condition is not uncommon among the children of the Maxakali, a group of 900 Brazilian Indians who live in an isolated area of mystical beauty amid stark malnutrition, little education and minimal health care, in one of the most populous and richest states in the country. Known as one of the first indigenous groups to interact with Europeans when they arrived on Brazil's shores, the Maxakali ended up in the region, they say, after fleeing conflict and colonization. But what they have found is a microcosm of what Brazilian Indians face nationally: children with bloated bellies are a stark reminder of malnutrition that affects 30 percent of youngsters ages 1 to 5. Pupils are taught a curriculum that goes no further than the U.S. equivalent of 4th or 5th grade.
    Most damaging though is the pungent scent of alcohol that can be detected on the men and women, an addiction that has brought misery and even murder in this tight-knit community. As Indian Day was celebrated in Brazil Wednesday to commemorate the 500-year anniversary of the country's "discovery" by Europeans, the plight of Brazilian Indians like the Maxakali is being intensely debated. Indians are focusing on racism and isolation. The struggle for Indian rights has spread throughout much of South America. In Peru, indigenous peoples have been pushing to elect the country's first modern Amerindian president, Alejandro Toledo. In Ecuador, indigenous people were instrumental in a military overthrow of the government of former President Jamil Mahuad. "We consider this a holocaust," said Marcos Terena, a representative with the National Indian Foundation, or Funai. It is estimated that when the Europeans arrived in 1500, there were as many as 6 million Indians. Now there are fewer than 350,000. But the issues facing Brazil's Indians go far beyond their diminished numbers and even the land that they so dearly treasure.
    Once hunters, the Maxakali are a semi-nomadic group that lives on subsistence farming, harvesting sweet potatoes and corn. They occupy more than 10,000 acres in the state of Minas Gerais on fertile land where waterfalls spill out of shiny black rocks and lush greenery covers mist-shrouded peaks as far as the eye can see. But the idyllic setting has been a place of misery and death. "When they drink, brothers have killed brothers, husbands have killed wives, parents have hurt their children," said Edes Nunes, a longtime worker with the Maxakali and a representative with Funai. "They start out with the drink when they are babies because the [pregnant] mother drinks." Health workers, doctors and Funai officials all cite alcoholism as the number one issue facing the Maxakali. Alcohol has been cited as one of the leading causes of death among Brazil's Indians, leading to life expectancy of 42 years, compared to 67 years in the rest of the country. Children have low birth weights, are neglected or begin drinking before they are teenagers. Consumption of everything from rubbing alcohol to deodorants to perfume and even nail polish remover has been observed among those desperate for a drink, paralyzing agricultural production and the group's potential.
    According to Funai, the problem began 50 years ago when ranchers paid Maxakali workers with alcohol.  Funai negotiated settlements with the last remaining ranchers to leave Maxakali land just last year. Officials lament that with alcohol, like many problems involving Brazil's Indians, there is little money or political will to find help. Funai officials said a project that would have taken a holistic approach to alcoholism was tossed because it did not receive funding from the government. Few Maxakalo are willing to admit the problem.  But the group's chief, Divaldo Maxakali, acknowledges that his brother was among the many who died. After drinking, his brother wandered off and got lost in the heat of the sun. He was found dead seven days later. "They are getting addicted," he said, his eyes searching the floor. "The Indians need more health posts. It is a health problem." A 1973 Brazilian law prevents the sale of liquor to Indians, but there are ways around the law such as getting others to purchase it, Funai officials say. Sundays are the biggest days of consumption for the Maxakali. It is the day they go to a nearby town to sell their wares at a market.

Worker Says Seniors, Mentally Ill Adults Created a Hazard
Ben Schmidt and Jennifer Fisher, Detroit Free Press - 4/20/2000

Phyllis McLenon says she may never go back to work at a Lincoln Park senior high-rise because of the explosive, dangerous conditions created when mentally ill adults are housed with low-income seniors. "Staff safety is a big concern, and this is why," said McLenon, deputy director of the apartment tower where a self-described schizophrenic killed two women in a spray of gunfire and critically injured a third Tuesday. "I may leave. I just don't know," she said. "This isn't worth my life."  HUD spokeswoman Sandi Abadinsky in Washington said she was not prepared to discuss McLenon's complaints.  Kenneth Miller, 56, opened fire on the women, including McLenon, in an administrative office after staff members and two tenants met with him to discuss his use of raunchy language and obscene jokes at the building. Before Tuesday, McLenon said 10 of the building's 114 residents had complained about his crude behavior. Swearing in public areas of the tower is prohibited, McLenon said. Residents also face automatic eviction for bringing in guns, she said. Miller wrote on his housing application that he suffered from schizophrenia and was taking antidepressants, McLenon said.
    McLenon said U.S. Department of Housing and Urban Development policies were changed several years ago to allow disabled people of any age to live in senior housing. Income-eligible seniors 62 and older used to be the only people who qualified for such housing. "A more transitional housing needs to be developed because when you put a 35-year-old person with a disability next to a 95-year-old, that can create a problem," she said. "We have no funding available for extra staff and specialists to deal with people who are mentally ill, yet we have people like that staying here. We can't discriminate against any disability. We can't even ask about it. This has been a concern of mine for years, and I've spoken out about it at HUD meetings." McLenon said she is unsure how many mentally ill people live in the tower. "There is nothing to hide here and no underlying reason," she said. "He ...would have done it sooner or later over something else."
    McLenon's complaints aren't the first of their kind in metro Detroit. Residents at the federally subsidized Carriage Circle in Pontiac have complained about the mix of elderly and mentally ill people, combined with management and security shortcomings. Some Lincoln Park residents, meanwhile, complained about the way management treats them. "Everyone in here is mentally ill or handicapped," said Terry Chico, 46, who has lived in the complex for three years. "They should be able to deal with people like that." Instead, Chico said, the housing commission holds eviction over residents' heads for everything stemming from foul language to having overnight guests. "We're yelled at and disrespected all the time by them," she said. Chico said she takes antidepressants, including Zoloft. Residents of the tower also complained about the way they are treated by management during a meeting Wednesday with Mayor Craig Sochocki. "They seemed to imply that it was insensitive," said an official who attended the meeting. Abadinsky said HUD officials combed through records Wednesday, searching for evidence of problems with the commission. She said the search found no evidence of complaints filed against the commission since 1995. In 1995, HUD wrote the Lincoln Park agency because there had been "too many customer-service complaints" about its handling of its rental-subsidy program, Abadinsky said. Abadinsky said HUD would continue to monitor the situation. Should the police investigation suggest negligence on the part of the commission, HUD would get involved, Abadinsky said. "We are certainly very concerned about this situation, that something like this could happen in HUD housing," Abadinsky said.
    Throughout the day in Lincoln Park, grief-counseling sessions were held. In the mayor's office at City Hall, about 15 people described as being the most exposed to the shooting attended a morning counseling session. At 11 a.m., 50 residents from the senior complex were bused to the recreation center, where counselors from Catholic Social Services provided for nearly two hours of help. Only two people showed up for a 7 p.m. session at the Lincoln Park Senior Citizens Center, where 15 grief counselors gathered to help. One was Barbara Bishop, 65, of Ecorse who said Alvita King had been her best friend for the past 43 years. King's death compounded the grief Bishop was already feeling for her own sister, who died only two weeks ago.  "It's pretty hard on me," she said. "Who's next?"

Physicians Find Fault With Aetna U.S. Healthcare Settlement in Texas
Richard A. Oppel, Jr., New York Times- 4/21/2000

Dallas, Texas- The settlement between Aetna U.S. Healthcare and the Texas attorney general that both sides called a "landmark" model for the rest of the nation has run into stiff opposition from some physicians and other state attorneys general. Aetna U.S. Healthcare, a unit of Aetna, the giant insurer based in Hartford, agreed last week to settle a lawsuit filed in Texas in 1998 by former Attorney General Dan Morales that accused it of providing improper financial incentives to doctors to limit patient care and other violations of Texas law. Both Aetna and the current attorney general, John Cornyn, described the settlement as a groundbreaking deal that could become a model for the rest of the nation and would improve care to Aetna patients and members of other health plans that might agree to similar settlements. The deal would help Aetna's efforts to improve its image after years of bruising battles with plaintiffs' lawyers and officials in various states who have accused the company and other managed care companies of shortchanging patients.
    After news of the settlement was first reported but before copies of it were widely distributed, physician groups reacted somewhat favorably. But after studying details of the agreement, which includes no fines, penalties or admissions of wrongdoing by Aetna, they and other critics said it offered Aetna many loopholes and did little to change the company's control of determining whether treatments are "medically necessary." "It sounded good when Aetna made a splash about how they'd made a settlement, but when we got to look at the details, we were extremely concerned. It is full of loopholes," said Dr. D. Ted Lewers, chairman of the American Medical Association. Dr. Lewers, who participated in a conference call today with officials from Mr. Cornyn's office to discuss the settlement, said he hoped existing Texas laws might plug some of what he said were large gaps. But he emphasized his group would fight efforts to make the settlement any sort of broad standard. "We don't want this to be a model for the nation."
    Kim Ross, chief lobbyist for the Texas Medical Association, said, "We have a number of concerns and will be seeking clarification as to the intent of the settlement" from Mr. Cornyn's office. Richard Blumenthal, the attorney general of Connecticut, who is investigating certain practices of Aetna, said the Texas agreement "perpetuates and disguises two central failings endemic to the industry, undisclosed financial incentives for doctors to limit care and undisclosed criteria for discouraging claims." "I think the hype and exaggeration that accompanied the announcement typified the industry's avoidance of truth and candor," he said. Lawyers in the office of Attorney General Eliot L. Spitzer of New York are also reviewing certain practices of Aetna and other managed care companies, including how they determine which treatments are medically necessary. Officials there reiterated today that they did not think the Texas settlement addressed their concerns.
    Aetna officials said they were surprised at the reaction and that they had worked hard to devise a settlement that eased concerns doctors had raised about managed care. Among other provisions, they said, it would give patients new appeals for certain treatment denials, create an ombudsman for Texas patients to help with appeals and complaints and allow doctors to participate in some Aetna plans without being forced into less profitable health plans. "There is a lot here, and for somebody to offhandedly dismiss it as not going far enough is overlooking the facts," said Dr. Arthur Leibowitz, the chief medical officer of Aetna U.S. Healthcare. "This is a true philosophical and practical shift for Aetna," he continued. "It's good for the consumer, and importantly we don't think the provisions in the Texas agreement will increase the cost of care in Texas." He noted that officials, including Gov. George W. Bush, the expected Republican presidential nominee, have cautioned against health care proposals that increased costs. He also emphasized that the settlement has factors unique to Texas that could be altered elsewhere.
    Officials from Mr. Cornyn's office emphasized that the agreement left out certain provisions that would otherwise be included only because those were already part of Texas law. And at least one consumer group hopes the settlement could improve care. "We would have liked to have seen penalties and stronger language, but we thought it was a good first step," said Reggie James, director of the Consumers Union office in Austin, Texas. But Mr. Morales said the settlement let Aetna off the hook. "I suppose the most troublesome aspect is the complete absence of any administrative sanctions, fine or penalty." The physicians complaints are similar to objections made by Richard F. Scruggs, a plaintiffs' lawyer in Pascagoula, Miss., who was instrumental in the tobacco settlements and is now involved in lawsuits against Aetna and other insurers. Mr. Scruggs, who called the settlement a "sweetheart deal," has been aided in some health care suits by officials at the Texas Medical Association.
    The Aetna settlement came two weeks after Mr. Cornyn was the host at a fund-raiser in Austin for the Republican Attorneys General Association, a group that has solicited money from corporations, including some that are, or could be, defendants in lawsuits by states. In a January 19th fund-raising letter circulated in Austin on "Texans for Attorney General John Cornyn" stationery, he said the group was "born out of concerns arising out of recent industrywide lawsuits that seek to promote public policy changes via the courthouse rather than the statehouse." He added: "I encourage you to round up your clients and come see what R.A.G.A. is all about." Donations to the group are reported only as unspecified contributions to a Republican national soft-money account that includes money from other sources. Federal Election Commission records show that account has taken in $65,000 from Aetna since December, although Aetna declined to say whether that was donated through the attorneys general association. A spokesman for Mr. Cornyn said he did not know whether Aetna had donated to the group, and Mr. Cornyn has said the group's activities pose no conflict of interest.

Online Therapy: An Arm's-Length Approach
Ellen Almer, New York Times- 4/22/2000

When the mayor of a small Mid-western town and his wife decided they needed marriage counseling, they were wary of seeking out a local therapist, for fear of gossip. So without ever leaving their home, they turned to the place where millions of anonymous business and personal transactions take place each day: the Internet. The couple's cybersearch eventually landed them in the All Rivers Online Christian Counseling Center, where they plugged in their credit card number and began engaging in email counseling with a psychologist who billed himself as "Dr. Ralph." With Americans turning to the Internet to find the perfect sofa, or even a car, then why not a therapist?
    To the excitement, and alarm, of experts in the field, new mental health Web sites are beginning to pop up almost daily, and many are offering the type of counseling once available only in the intimacy of a therapist's office. The players range from the folksy, like "Dr. Ralph" D'Onofrio, a psychologist Internet entrepreneur whose other ventures include Child-prayer.com, a site that processes prayer requests for sick children, to nonprofit organizations that provide services like depression-screening tests, to Ivy League psychiatry professors who have developed sleekly designed Web sites featuring advice from doctors with high-brow credentials. Because of the free form world of the Internet, the therapists are not subject to the rigorous system of interstate licensing that governs conventional, in-office counseling. The phenomenon is so new that the major professional organizations are just working out their policies. Some experts on mental health agree that online counseling, through email, real-time email exchange, and eventually video conferencing, is one of the most promising developments of the maturing Internet because it opens up new treatment options to people in remote areas, the disabled and those who feel too stigmatized to seek treatment for mental illnesses.
    "This form of communication is very important, because we have overcome the basic limitations of space and distance--and those are worth overcoming," said Dr. Zebulon Taintor, chairman of the American Psychiatric Associations Committee on Telemedicine who is a professor of psychiatry at New York University. The committee has drafted some guidelines for online psychiatry that address issues like appropriate behavior for doctors. Dr. Taintor said he expected approval by the association in late May. But Mirean Coleman, head of the policy and practice of clinical social work committee for the National Association of Social Workers, said privacy issues related to the Internet would have to be remedied before her group would recommend online treatment. Indeed, skeptics say the medium's anonymity allows patients to misrepresent themselves by disguising their appearance. At the very least, the skeptics say, doctors are at a disadvantage when they cannot hear the inflections of a patient's voice. Nor, they point out, is there anything to prevent an unqualified entrepreneur from putting out a shingle as a mental health expert.
    And while the fledgling field of online psychiatry has yet to yield any documented disasters, some Web sites have taken precautionary steps to prevent crises like suicides. Some, for example, have installed emergency systems where severely troubled patients are automatically referred to a local suicide hot line. Some mental health experts see a world full of potential catastrophes. "I think it's terrible, and it could be disastrous," said Dr. Sheldon Miller, head of the department of psychiatry and behavioral sciences at Northwestern University and Hospital. "You just don't deal with strangers in that kind of format and expect anything wonderful to happen. There's no way of controlling the outcome, and I have a real problem with that."
    The ethical questions are just beginning to emerge, because medical-related Web sites, and particularly those devoted to psychiatric care, are "embryonic," said Claudine Singer, a senior analyst with the Internet research firm Jupiter Communications. Specific numbers for psychiatry related Web sites are not available, she said, and of the roughly 17,000 medical sites, only 200 can be considered legitimate. Like most everything on the Internet, it is the quality and thoroughness of the product that doctors are most concerned about. But unlike buying a broken Palm Pilot on eBay, going wrong with medical treatment can have serious consequences, doctors warn. There is always a danger wherever there isn't a complete diagnosis," Dr. Taintor said, stressing the importance of a traditional, in-office doctor's visit before engaging in online treatment. "You want to have as much data as possible, and anything that compromises that is dangerous." Dr. Taintor added: "If you were to ask where I recommend telemedicine, it's wherever a psychiatrist isn't available. I still think face-to-face treatment, with three dimensions and all the textures that go on between doctor and patient, is much more important."
    Of course, those who most zealously promote online psychiatric treatment say it could significantly change the way patients and doctors communicate with each other. "Going into chat rooms, you can see that people do establish intense relationships with other people, and they tend to disclose much more than they would when face to face," said Dr. Robert Gugliemo, formerly the senior director of New York City's Family Court Forensic Clinical Service and an assistant professor of psychiatry at New York Medical College who is now one of the new breed of psychologist turned entrepreneur. Along with a colleague, Dr. Arthur Sullivan, he has co-founded Mentalhealthline.com, a Web site that offer mental health services, including counseling through email.
    Not surprisingly, another reason for the enthusiasm of mental health professionals is money. Because mental illness tends to be a chronic problem, psychiatric Web sites could translate into repeat visits, turning them into a money making venture, Ms. Singer says. Dr. Gugliemo said, "There is a big expectation that this could be very profitable." There is some debate as to how patients should be charged for treatment. Dr. D'Onofrio, for example, charges according to how much time he spends reading and responding to an email; typically, after an initial free consultation, about $25 to $30 an hour. But others, like Dr. Taintor, shun the idea of billing by the hour. Dr. Gugliemo and Dr. Sullivan, meanwhile, hope to work with insurance companies to find ways to cover online counseling through corporate employee assistance programs.
    Dr. Peter Kramer, a professor of psychiatry at Brown University who is the author of "Should You Leave?" and "Listening to Prozac" said it was the uncertain future of conventional psychiatry that led him to explore professional opportunities on the Internet. "This is a hard time for psychiatry," said Dr. Kramer, who is on the advisory board of Here2Listen.com, a psychiatric service site that is backed by several Ivy League professors. "Now, doctors tend to be funded on an ad-hoc basis. I don't know just which direction things are going to take, but I thought that with this, at least there's some hope that if you get it right, you could set some standard of quality and build on that." Here2Listen.com, which was started in February, features articles by doctors on subjects like infidelity and ways to overcome shyness. The e-counseling portion of the site went on line on April 17, and includes a data base of 300 psychiatrists where patients search for the right doctor. "You can set your criteria, like that you want an African-American doctor in Chicago, and we'll find them for you," said Susan Sheehan, spokeswoman for Here2Listen.
    Patients plug in their credit card numbers and engage in one-on-one e-counseling in a secure chat room with a professional; fees vary according to what the individual doctor would charge for an in-office visit. Others, like Dr. Taintor, have been more fully engaged in using telemedical treatments for years, at least in a supplemental fashion. As part of his work with the Bedford Hills Correctional Facility in Westchester County, Dr. Taintor works with inmates who were seeing a therapist before they were imprisoned. In one case, a drug-addicted woman who had "really bonded" with one of the psychiatrists in Dr. Taintor's private practice was incarcerated at Bedford Hills. Now that woman speaks with her doctor each week via teleconferencing.
    Meanwhile, those involved in the nonprofit sector are also working on developing online tools for coping with often stigmatized mental illness, particularly depression. Shela Halper, vice president of education for the National Mental Health Association, said depression was the No. 1 searched illness on the Internet. In response, the association recently started offering depression screenings on its Web site. "Taking a depression screening test is one of the quickest and easiest ways of knowing if someone's experiencing depression," Ms. Halper said. "About nine million Americans experience it, but less than a third of them seek treatment because they're not aware of signs and symptoms," or they are afraid to talk to their doctor about it, she said. Taking a screening test online and then bringing the results to a psychiatrist can be the first step in treating a potential mental illness, Ms. Halper said.
    Of course, the new breed of Web doctors are beginning to realize for themselves the limits and opportunities associated with practicing on the Internet. In the case of "Brett"--the Midwestern mayor who sought online marital counseling with his wife--Dr. D'Onofrio, who is based in Indiana, said he realized that email alone would not give him enough information to treat them, and he added some telephone conversations to their counseling. "Email is great, but when they first contacted me I knew I needed to talk to them--there are some things you can only get over the phone," Dr. D'Onofrio said. "First, I feel out if I can be of help, and if they can be comfortable with me. Sometimes I'll tell people they need to go to a doctor."
    Privacy, also, is a natural concern when dealing with the Internet, particularly when sensitive information is being transmitted through computer servers that do not always seem secure. "As Ken Starr showed the world, you can retrieve lots of email messages you thought were deleted, even at the White House," said Dr. Taintor, who does not rely on email as a primary means of communication with his patients. And then there is the issue of licensing; how to translate interstate regulations into a world where no such boundaries exist? "In medicine, licensing is a control, a way to monitor," said Dr. Miller of Northwestern. "But the Internet doesn't deal with that, and the consuming public has no idea who's back there." A spokesman for the Federation of State Medical Boards said that the federation had not yet considered the licensing issue, and that so far, state medical boards were simply cautioning prospective users of mental health sites to check the credentials of the doctors. Of course, some doctors are hesitant about association themselves with what many consider an unreliable medium. "I think I'm wary," said Dr. Kramer, the Brown professor. "Or at least, I was wary, but I think there is room for extremely responsible material on the Internet."

Healing arts
Wendy Killeen, Boston Globe- 4/23/2000

It's a warm, brilliant fall day in Lynn as six women navigate a narrow trail through Lynn Woods to Dungeon Rock. Each quietly surveys the ground, searching for a symbol of her burden of drug or alcohol abuse. Haydee, 23, of Chelsea picks up a blob of fungus because "of the way it grows and feeds on things and does nothing for itself." After they reach the rock, the women slowly guide one another into the dark, slippery cave below. The smell is earthy, but a pocket of cool air circulates. The women are tentative. "You don't know what's creeping around," says Haydee (she does not want her last name used). At the bottom, they form a tight circle. In the pitch black, there is silence. Haydee says she thinks, "This is what it must be like to be dead. But I realize I'm not. I'm far from it. I realize my life is just starting out." Haydee tosses the fungus onto the floor of the cave. She and the other women climb out, emerging into bright sunlight. "It's like rebirth," Haydee says. The women walk back through the woods, singing. They each pick up a flower or leaf to symbolize their internal change. The items are later incorporated into handmade cigar-box shrines, covered with collages of empowering messages and images. A few weeks later, Haydee shares her shrine with fellow residents at Project Cope, a drug and alcohol treatment center in Lynn. "When I first came here, I was really tired, physically and mentally, and I didn't have any hope," Haydee says in a low, flat voice. A plaster cast of her hand sticks out of the box on a wire. A small globe sits in the palm. "Now I'm holding the world in my hand," she says, showing the hint of a smile. This is not your typical white-paper-and-markers art therapy. Key to Haydee's newfound outlook is a Lynn-based group called Raw Art Works, which brings eight-week programs to Project Cope that help young women like her face their demons and voice their dreams.
    Projects like Haydee's don't take place in an activities room at an institution but in housing projects, schools, and soup kitchens. This is big, colorful, clever art - and it's an adventure. "It's so nontraditional that all the defense systems you have in place can't protect you," says Mark Kennard, executive director of Project Cope. "We're looking to open people up, so it's perfect. It gets to life issues in a way that talking therapy doesn't." Raw Art Works, or RAW, as it's been dubbed by its founders, Mary Flannery and Kit Jenkins, takes its name from the French painter Jean Dubuffet. He coined the expression art brut, translated as "raw art," to describe the originality and emotional nature of the work of self-taught artists. Flannery says the name reflects a belief that "all individuals have wellsprings of creativity that shape and give meaning to their own lives and the life of the community." It also describes the raw, gut-level feelings art can evoke.
    Flannery, president of RAW, and Jenkins, executive director, first met in 1986, when they were working as art therapists at Danvers State Hospital. That year, they created the Art Workshop, the first studio for the mentally ill in Massachusetts located off hospital grounds. The workshop became the inspiration for RAW, which was established in 1988. "The patients decided what color the ceiling was going to be, and the layout of the studio," Flannery recalls. "It was beautiful to take those folks out of [Danvers State], an environment that was suffocating." The two would bus the patients to an old school in downtown Danvers. Working with schizophrenics and other patients who had been hospitalized for 10, 20, even 30 years, Flannery and Jenkins soon saw small but telling results. "We were so inspired by those moments when you are walking into a room and the patients are actively delusional and hallucinating, and you are thinking, there is no way to reach them, the door is so incredibly thick today," Flannery says. "And then you turn on the music, and they get their palettes and go to their art piece, and they are chatting to themselves, and maybe they'd start to talk to each other, and a calm would come in. The grounding and the profound insights into their work or their neighbor's work was just miraculous," she continues. "We would have had to be brain-dead not to get it."
    Flannery also began doing art therapy with young sex offenders as a consultant for the Massachusetts Department of Youth Services. In 1988, Edward Loughran, then commissioner of DYS, saw an exhibition of their work and was so impressed that he contracted with Flannery, and the new project she called Raw Art Works, to implement a statewide art-therapy program for youths in jail. The project began in two secure lockups. It quickly grew to nine sites and continues today, 12 years later. But Flannery and Jenkins wanted to reach kids before they landed in jail and to keep track of them afterward. To do that, they believed, they'd need a studio based in the community, not at an institution. "We wanted a place that would be a home," Flannery says. They chose Lynn as their base, partly because Flannery lived there and Jenkins lived in nearby Nahant, but mostly because of its profile as a tough city with an ethnically diverse population. According to the 1990 Census and statistics compiled by RAW, 15.9 percent of the 81,000 residents lived below the poverty level. The school dropout and teenage pregnancy rates were also high.
    Looking for support, Flannery began knocking on doors in 1993 and introducing art therapy to local politicians, business people, and teachers. She draped plastic trash bags over their suits, handed them paintbrushes, and had them create murals. It worked. RAW was offered fourth-floor space in a city-owned building in Central Square in downtown Lynn, for a reduced rate in 1994, and local corporate benefactor General Electric agreed to pay the first year's rent. "We started with one concept, which was to get street kids here," Flannery adds. She and Jenkins went to Lynn Alternative High School and picked six kids. "We told them we were going to take them out of school, give them pizza and loud music, and have them paint trash cans for an anti-violence week," Jenkins remembers. "We hoped we provided them with a stimulating enough experience that they'd go back to their school and say this is pretty cool." Again, the strategy worked. Seventeen students applied to RAW, and within months, 70 more were at RAW's door. They painted murals around the city, designed T-shirts and logos, and painted billboards for community events. And they made RAW Space their own, painting the furniture and walls wild colors and the floor black. A large pink paint spill on the floor was transformed into a decorative octopus, inspiring RAW's motto: "There are no mistakes, just art." The students at RAW also made their own rules for the studio: "Respect . . . Weapons do not enter . . . Challenge yourself . . . No ugly words . . . Listen to each other."
    As RAW's artwork and flashy painted van became more visible around the city, the phone began ringing. First, it was Cobbet Hill, a low-income housing complex, asking RAW to run art programs for its residents. Then other housing projects joined in. Over the last decade, RAW has steadily expanded to comprise 14 various programs.  The annual budget has increased from $79,000 in 1988 to $384,640 this year. RAW, which is nonprofit, is funded by contracts for services it provides, by grants from the Boston Foundation and Massachusetts Cultural Council and others, and by donations. Corporations are starting to hire RAW to provide art therapy programs to employees, taught in part by young adults who have gone through RAW programs. "It struck me that we were really part of the community when I saw two artists, one 76, with a walker, and one 7, get off the elevator and look at each other and say, `I'm an artist. Let me show you what I did,' " Flannery says. "The first hat we wore was `really good with youths at risk.' Now it's `really good with people.' "
    "RAW is a model for how to run a storefront, streetwise art-therapy program," says Cathy Malchiodi, editor of Art Therapy Journal and director of the Institute for the Arts and Health in Salt Lake City. "They have the core idea that art is a central part of people's lives, as important as good nutrition and exercise. They understand it personally and have the clinical expertise and a rapport with these populations. I've seen few places like RAW. I think there should be one in every major city." The teenagers enter RAW Space at 3:30 p.m. with a burst of energy. They're laughing and talking, pushing and playing. And they're loud. In the large back room, they eventually sit in a circle of metal chairs. The room smells of the popcorn being passed around, along with oatmeal-and-chocolate-chip cookies.  These are the RAW chiefs, 10 teenagers ages 15 through 18, who are paid to help lead programs for children and the elderly. This meeting is for leadership training, where they learn to set goals and handle difficult situations. They are preparing for a "slam," a kind of funky recital in which they will present their art, poetry, fiction, and performances to family and friends. Fernando Diaz, 18, a big, friendly guy, offers up his best skill. "I can cook," he says proudly. "I'm in culinary arts right now." It's decided that Diaz will make bread, while others videotape him. Getting up to announce his plans, Diaz is nervous, shy. His quick, goofy laugh, which erupts often, lightens the moment. Diaz, whose family is from the Dominican Republic, became part of RAW in the seventh grade. "I was a bad kid," he acknowledges. "Behavior problems and depression." Now a student at the Lynn Alternative High School, he spent a year in a residential treatment program in Middleton that he describes as feeling "like jail."
    After participating in youth groups at RAW, Diaz is now in his second year as a RAW chief. Along with therapist and staff member Jason Cruz, and another RAW chief, Junior Ysalguez, 17, he works with a group called Men 2 Be, boys ages 12 through 15. "They come in with different stories and talk about their problems at school and tell you exactly what happened; they don't alter the story," Diaz says. "It's like, `Wow, I remember when I was in that grade.' " And, he says, "if we hear anything negative, we try to handle the situation. They really mean a lot to us."  Diaz knows what it's like to not get along with people, to be alone and act out. And he realizes that RAW has helped him: "It keeps me busy and focused on something." And, he says, "I'm so open to things now; I used to be so narrow-minded. Now I listen to people and can take constructive criticism. That wasn't easy for me in the beginning. Now I can set goals for myself." He became interested in photography at RAW and has taken pictures of his home, neighborhood, school, and spots in Lynn for a portfolio. He hopes to study photography at Bunker Hill Community College. "I really want to do something and not fall behind, like a lot of my friends," Diaz says. "I think I can do better."
    On a recent evening, Diaz, Ysalguez, and Cruz gather at RAW Space for the weekly Men 2 Be group, together with Luis Mauricio, Ricardo Rodriguez, Hector Gio, and Jonathan Santos. The 13- and 14-year-olds sit around a large table and make figures from sheets of aluminum foil. And they talk - about school, report cards, potential fights, girlfriends. Nearby is a large, colorful abstract mural the boys created together that will hang in the housing project where most of them live. "We did it to stop the violence," says Mauricio. Cruz, a big man with a gentle voice and an easy manner, asks the boys about their fathers and what it means to be a man. "It's like I really don't have a father," Ysalguez says. "He's lazy and pisses you off." A man, they all agree, should be honest and responsible. Cruz instructs each of them to mold a piece of foil into a bowl-shaped bubble. "Take all your bad feelings, and all the questions you have about being a dad and a young man, all the pain and sorrow and sadness, and the hard times you are having, and put them in the bubble," he says. "It should start feeling heavy as you fill it up." He tells the boys to place the bubble in front of them. "Now you get to squash all those hard, sad feelings you have," he says. "Think about the energy you have." He counts slowly, 1-2-3-4-5. There's a loud bang as the boys smash the bubbles flat.  They then mold the flattened pieces of foil on top of one another to create a sculpture. "No matter how hard life is for you," Cruz says, "you can tear it down and build it back up. You can change it into any shape you want."
    Bill Ivey, chairman of the National Endowment for the Arts, visited RAW on a swing through Massachusetts last fall. As impressed as he was with the impact RAW has had on people's lives, he was floored by the art. "The art that is coming out of RAW is of very high quality," Ivey says, adding that he has a decorated paint tube from RAW on his desk in Washington. "They are working to ensure the quality of artmaking doesn't get buried under a social-service agenda." The key, Jenkins says, is that the RAW staff, which numbers just five, is made up of skilled artists, painters, and sculptors. "We are a staff that goes to galleries, that takes art classes, and feeds ourselves as artists," she says. Jenkins is on the staff of Lesley College's graduate school and was able to draw students from the creative arts therapy program to serve as interns at RAW. Three of those students were hired and make up the remainder of the staff. Kathe Swaback, on board from the beginning, is program director, and Jason Cruz and Julie Duffy are therapists.
    "People are always asking us, `Are you artists or counselors?' and we refuse to stand for either side," Jenkins says. "It has got to be strongly both. That's the reason the work looks like it does." Each spring, RAW hosts a major exhibit at RAW Space of work created by all the participants around a theme, ranging from self-portraits to the idea of home. This year's show opens on May 4 and will run for a year, until the next one. While the quality of the art draws attention from outsiders, it's also what helps engage the participants, Flannery says: "If troubled kids are afraid to reveal themselves in their art, the first step is to help them create art where they go, `Wow, I can't believe I just did that.' " For Flannery, an equal challenge is being able to serve kids as they get older and grow out of certain programs. That's why she created RAW Chiefs, the mentoring program, and Pacesetters, for youths older than 18.   "Most of them have lost a parent or siblings or been bounced around foster care, and their greatest fear is you are not going to love them anymore," Flannery says. "I would never say they are too old for the group. No way." Many youths have participated for as long as five years. Lynn's mayor, Patrick McManus, has supported RAW since he took office in 1992. "You see some very creative things," he says. "It forces all of us to ask questions about what the youths in our city are involved in and been through. The work is so dramatic, you can't help but ask, `Where is this coming from?' "
    The growth of Raw Art Works, its founders say, has been organic. Seeing many kids in troubled homes, for example, they knew they had to engage entire families. That, coupled with Jason Cruz's interest in the role of family in Hispanic culture, resulted in a program of art therapy for struggling Spanish-speaking families in a local housing project. In 3 years, Cruz, who is from Puerto Rico, has worked with 15 families. The Perez family, parents Ana and Jose and three of their five children - Yahaira, 17, Jose Manuel, 15, and Carmen, 9 - worked with Cruz weekly for two years. "When it looked like things were dark and ugly, you introduced a new way we could see things," Ana says to Cruz in Spanish. "We could see light, and it was RAW." Living in the Cobbet housing project, the family was isolated and stressed. There were cameras in the hallways, no place for the kids to go outside and play, and a rule against socializing in the corridors. Their small apartment became a pressure cooker. The parents felt torn between the old ways of the Dominican Republic, where they lived in the countryside, and the new urban, American ways of their children. No one in the family communicated. Cruz began by working with the family members in their home. Often, Jose Manuel would refuse to participate, go to his room, and slam the door. Cruz would mediate, encouraging family members to write their feelings about the conflict in notes they could exchange. The family would draw and write individually and as a group. For one project, the kids created a wall of clay, with each brick representing a hurtful statement or situation. "By the time it was done, it was stacked" about 2 feet high, Cruz says. Jose Manuel stood on one side, Carmen on the other. Cruz asked Jose Manuel how he could help his family. "Go through the wall," the teenager said. But Cruz told him he couldn't - he had to tear it down, brick by brick, by "saying what he feels about his sister in a nice way and saying, `I love you, Mom and Dad,' and meaning it." Cruz says the project showed Jose Manuel he was creating his own isolation from the family. After working with the families at home, Cruz brings them to RAW Space, where "they can get messy." One night, Jose, the father, who is very quiet and withdrawn, painted large flowers on one of the walls. "We didn't always want to speak about how we felt," says Ana. "We could paint how we felt, and it was better that way." The Perezes have since moved out of the housing project into their own apartment.