Noteworthy News Articles on Mental Health Topics, May 7-16, 2000

Sex Abusers Find No Way Out of Prison
Christi Parsons, Chicago Tribune- 5/7/2000

Two years ago, Illinois judges began shipping dangerous sex offenders who had finished their prison terms to a new therapy center in a Downstate prison. Since then, 108 men have been sent in, but none has been deemed sufficiently rehabilitated to be let out. The track record of the Illinois Sexually Violent Persons program is typical of similar programs across the country, which are releasing very few sex offenders from their high-security institutions. State officials defend laws such as Illinois' Sexually Violent Persons Act, which allows courts to commit repeat offenders to secure institutions even after their prison sentences are over if doctors think they still pose a threat to society. The laws allow the states to keep the residents locked up until doctors and psychologists convince a judge they will not commit sex crimes again. Administrators of the treatment programs say their therapy regimens--most only a few years old--simply need time to work. But the release rate so far raises questions about whether the states have instituted programs that can actually rehabilitate offenders.
    After 10 years of similar programs around the country, some experts are pondering whether it is possible to rehabilitate repeat sex offenders at all. The practical effect of the law, some say, is simply to lock up society's most-feared criminals and throw away the key. "It's what we feared," said Ben Wolf, a staff attorney with the American Civil Liberties Union. "They're pretending that they're going to provide treatment to help these people, and it has not thus far proven to be true." The laws allowing sex offenders to be held beyond their prison terms have withstood several challenges. Three years ago, the U.S. Supreme Court upheld a Kansas law allowing the state to commit sex offenders to secure mental institutions if courts rule they are likely to rape and molest again. As long as states are making an effort to treat people, the court found, such laws are permissible.
    But scrutiny is now turning to the nature and quality of the treatment in such programs throughout the country, which are releasing patients at very low rates. The Supreme Court is considering a challenge by one Washington state patient who contends he is not getting adequate care. The Washington program, the oldest in the nation, has released only five patients in almost a decade. Kansas, whose law was a model for the Illinois statute, does not expect to release a patient for at least five years. One patient is about to be sent from Kansas' state hospital to a secure group home, but doctors don't know how he will do in the more relaxed setting. In short, they have no idea if his four years of treatment were successful, said Lyn Goering, assistant secretary of the state's Society and Rehabilitation Services agency. "We're still waiting to see about that," Goering said.
    To a large degree, the treatment programs are experimental, experts say. Several states have fashioned behavioral training programs that try to teach sex offenders strategies for controlling their impulses, accompanied by tests to determine which strategies work best for a particular patient. In Washington, for example, psychologists are trying to recondition some patients by showing or describing arousing scenes while flooding them with ammonia fumes. "The ammonia is used to try to get the person to no longer associate pleasure with that sexual encounter," said Roxanne Lieb, an expert on the program at the Washington State Institute for Public Policy, a research arm of the state legislature.
    The Illinois program tries to move patients through a five-stage process, which begins with self-evaluation and ends, theoretically, with the transition out of the institution. Counselors offer individual and group therapy and encourage patients to write in journals, according to the Illinois Department of Human Services, which runs the program. They also offer courses in anger management, substance abuse and communication techniques to the 108 patients currently in the program. (Four other residents who were in the facility while judges reviewed their cases were released after it was determined that they did not need the treatment.)
    But no one knows how well such therapies work. Until the new laws were passed in the 1990s, no one was spending much money or time trying to treat sex offenders. In fact, when the American Psychiatric Association launched a five-year study into mandatory therapy for sex offenders, researchers had a hard time finding many people who knew much about it. Except for a few dedicated specialists, "many psychiatrists were unfamiliar with the fundamentals of the assessment and treatment of sex offenders," according to the association's recent task force report. The panel of psychiatrists ended up criticizing the laws. "This, to us, looked like basically a long-term preventive confinement, in spite of what the Supreme Court said," said Dr. Howard Zonana, the Yale University psychiatry professor who headed the panel. "What doctor is ever going to go on the line and say someone is safe to be released?" If lawmakers simply want to keep dangerous sex offenders behind bars, he said, they should pass tougher sentences instead of foisting the problem onto the mental-health system.
    Civil commitment is an expensive choice. In Illinois, the state is spending roughly $87,000 on each resident, more than five times what the Department of Corrections spends to incarcerate the average inmate. Sex offenders can be treated, though, according to the panel of psychiatrists. Rapists are likely to rape again after treatment, Zonana said, but people who commit incest are less likely to molest in the future. The study showed that people who abuse alcohol or drugs or have learning disabilities don't do as well in therapy. Also, if a sex offender suffers from more than one diagnosed illness, he or she is more likely to continue committing sex offenses after treatment, according to the report. Ultimately, the task force decided that few perpetrators can be considered untreatable. But success in treatment doesn't necessarily mean curing every patient, Zonana said. "Even with major depression, we say we do a good job when we get a response from 80 percent," he said.
    Supporters of the laws say success shouldn't be judged by the small number of people getting out. The therapy programs are relatively new, they say, and the patients deeply disturbed. Rehabilitating them is not a short-term project. "A person can jump on the bandwagon for defining success as release," Lieb said. "But I'd argue there's something wrong with the commitment process if, a short time after they're found dangerous, someone is saying they're safe to go." If the program is keeping dangerous people off the streets, that's just what lawmakers had in mind, said one architect of the Illinois law. Now the special unit at Sheridan Correctional Center is so full that it is moving to a larger site in Joliet. And while state officials look for an even larger facility, some observers wonder if the doctors providing the treatment face an impossible task. "I tried to make it clear when I presented the bill that this was a possibility," said Rep. Tom Dart (D-Chicago), a former prosecutor who wrote the law along with Atty. Gen. Jim Ryan. "These are very dangerous people, and a quick fix is probably unrealistic. In the meantime, having them away from society is the best thing for everybody."

Six Leading American Psychotherapists on What Has Changed About What Troubles Us
Moderated by Ariel Kaminer, New York Times Magazine- 5/7/2000

Are there facets of the inner life that emerge only within the framework of psychotherapy? How do patients' concerns reflect larger cultural dynamics? To discuss the secrets of the 50-minute world, we set up a conversation among six experts with a variety of professional perspectives. Our panel included: Ethel Person, a professor of clinical psychiatry at Columbia University who practices in New York and is the author, most recently, of "The Sexual Century." Peter D. Kramer, author of "Listening to Prozac" and "Should You Leave?" who teaches psychiatry at Brown University and practices in Providence, R.I. Martin S. Bergmann, a psychoanalyst who teaches psychiatry at New York University; he is the author of numerous works, including "The Anatomy of Loving." Amy Bloom, author of "Love Invents Us," a novel, and the forthcoming collection "A Blind Man Can See How Much I Love You," who has a private practice in psychotherapy in Connecticut. Jonathan Lear, who is a member of the Committee on Social Thought at the University of Chicago; his next book is "Happiness, Death and the Remainder of Life." John A. Talbott, a professor of clinical psychiatry at the University of Maryland, Baltimore, who has written extensively on chronic mental illness and publicly financed treatment.

Question: If I can start the ball rolling, what are the issues that people today talk about only in the context of psychotherapy? Are there any privileged realms?
Ethel Person: I think there is one realm. I think that people do not discuss their fantasies in public as much as they do in therapy because those really tap a deeper part--and a very idiosyncratic part. I mean, typical fantasies like I want to get rich or I want a new job, that kind of thing people will talk about, but some of the kinkier sexual fantasies don't get discussed in public. Or the fantasies about which one is embarrassed.
Question: Does the list of things that people are willing to talk about only in psychotherapy change over time?
Person: Yes. Therapy is still where people talk about their most painful feelings. But they talk about much more personal things in public now than they did 20 or 30 years ago.
Peter D. Kramer: I think it's a problem for therapy. I think that the power of therapy depends on novelty and surprise. And the enormous openness about sexuality, jealousy, violent thoughts and so on impoverishes therapy to some extent. I think therapy was probably easier to do when it was more surprising to speculate, as Freud did, that the patient may have sexual feelings of which he or she is unaware. That wouldn't shock anyone--it wouldn't be transformative anymore.
Question: So as opposed to opening up other possibilities, you feel that having gotten those kind of basic surprises out of the way lessens the possibilities for what can be discussed in therapy?
Kramer: I think that one of the great jobs of psychotherapy is to create a place where very shameful aspects of the self can safely be revealed. So I think it lessens the force of revelation that so much is already revealed.
Martin S. Bergmann: Cultural changes do in some way affect what patients talk about. To give an example, I have had experience with patients who develop cancer or other disabling diseases and then look upon themselves as "damaged goods." Now, to me, "damaged goods" is a very typical American way to look at oneself, in commercial terms. For example, "My child is a high-maintenance kid." That is also along the same lines.
Kramer: I don't know, I think there's always a temptation to believe it's a recent development. But the role of the therapeutic space as a refuge from this tendency to value very exactly every person and activity in the culture seems very much in sharp focus at the moment.
Amy Bloom: But I think the stain of the commercial actually works both ways. I have walked into colleagues' offices in the last five years and found people with drug company clipboards or newsletters. I'm sure they were in some people's offices before, but certainly nobody I wanted to go and have a cup of coffee with.
Jonathan Lear: There's a shift in popular culture in its relation to psychotherapy. Last decade, three popular shows on television were "Seinfeld," Friends" and "Ally McBeal." They all shared this underlying assumption that human intimacy of the standard one-heterosexual-married-couple isn't possible. And that what there really is in the world is a conversation among one's friends or business partners or flatmates about why this more traditional idea of intimacy is just not going to work. And so it's a basically ironic stance. And then there's a shift, I think, last year to "The Sopranos." You know, this guy is a gangster, and he has his women on the side and whatever, but he's trying to make his marriage work. He's trying to deal with the responsibilities of the office. And trying to come to terms with, in terms of what Ethel was saying, very primitive fantasies that are under the surface and got him where he is. There's a kind of earnestness. It seems to me like the nature of the refuge shifted, like irony as a defense against the kinds of anxieties that have been discussed is collapsing.
Bloom: Tony Soprano has a terribly earnest therapist as well. I mean, she seems utterly unable to marshal any sort of useful defenses.
Person: If I were to say that there was a shift, it's that people's sense of being not in control in their lives is much more paramount than it was previously. And I would tie it to this major dislocation in terms of the way success and money are regarded. I'm not sure that the therapist's office is always a refuge. It's often a place that people come in order to figure out how to be in control--which too often means being in control financially.
Question: Can you tell me some of the ways that these economic displacements manifest themselves in the therapeutic context?
Bloom: Because most of the people I work with don't actually have a lot of money, it has seemed to me over the last 20 years that there was a significant number of people who, although they would go on having unresolved issues in their lives, most of their dramatic crises that led to really terrible outcomes in their lives would have been resolved if they had had $50,000. Now, that's not to say that they couldn't also have been avoided if they had been more resourceful and less conflicted about their ability to get help. But it does often seem to me that that point at which you find yourself out of your apartment and without a car and unable to move your furniture--some of those things could be avoided.
Kramer: This may be half a step back, but I think some of the same issues that we've been talking about could be put in this different way, which is, I think the culture has become hard for melancholics. If you're in a culture where there's a great deal of social disruption, where people are expected to be extremely autonomous, where the divorce rate is high, where the form the families take is very diverse, it is hard to have those underlying personality traits that we talk about as melancholic--that is, being deliberate, attaching very strongly, being loyal, being somewhat prone to depression, having low energy, even if you tend to use it well. And I do think a lot of what we see in our offices is related to a particular sort of social disruption. People might be helped by having greater resources, but they'd also be helped by having a more reliable standing and a more reliable set of connections in the culture.
John A. Talbott: I can affiliate myself with Peter's remarks because I think that the people I treat, who are cognitively impaired, are also clueless to some extent about what cultural changes are going on. I think there's a sense of wanting to be part of the mainstream, but the mainstream has shifted so much.
Bloom: Peter, you're saying that as the culture has shifted, it has become less accepting of certain kinds of personalities with certain sort of clusters of traits, even if the person functions reasonably well. I think that that is true. I mean, you get a great deal more leeway as a tearing narcissist in this culture than you do as someone who tends to be a little broody and little thin-skinned and maybe a little slow to speak and, you know, given to pondering. I don't think that gets you a lot of room culturally right now.
Bergmann: It occurs to me that the changing roles of women, the changing expectations of women as they affect the point of view of the man, have created new kinds of martial tensions. I think that is a very important part of our culture. Also the whole question of to what extent libidinal satisfactions are obtained outside of personal realms.
Lear: What do you mean by that?
Bergmann: Well, let's say a professional whose satisfaction is entirely in terms of her relationship to her clients. That is her personal value system. Whatever operates there is the equivalent to what one used to call love life. There is less separation between personal and professional, and for many people the professional has become the personal. So I see it in two ways; I see it in terms of the professional invading the personal to an enormous extent, and I see it also in terms of new problems created within the couple as a result of the changing position of the woman in the marriage and the inability of the man to live up to these expectations or to be able to do justice to it.
Person: You're not saying she's more consumed than male professionals, are you?
Bergmann: No. In the lives of many males, the professional was always really the dominant place where most of their ambitions, most of their love needs and most of their hostilities were expressed, so that by the time you came home at 7:00 to your family in Westchester, you know, you read the New York Times and you went to sleep. It is now also much more characteristic of women. I don't mean that it's getting better or worse.
Lear: There's a theme I hear emerging. I think the issues that are being raised in the social sphere, issues about ambition, striving, competition, both in the workplace and at home, have been undertheorized by therapists and analysts. Something strikes me--you know, Aristotle says that philosophy begins in leisure. It's only when people are freed up from just struggling for survival that they can think about the meaning of life. And I think something's very similar in psychotherapy. This is a very wealthy society. And--a similar point--when people get freed up via drug therapy from the acute crisis of mental illness, they're freed up to worry about the meaning of their lives. I mean, to worry, "Am I capable of a deep, intimate relationship?" is to some extent a luxury. So it's possible that there's going to be a freeing up to be worried about the kinds of issues that psychotherapy addresses.
Bloom: Well, there'll be a freeing up, but I guess one of the questions that that raised here is, given the direction of the culture, will people worry about the nature of their intimate relationships? Or will they feel that that's the last thing in the world they would want to spend time on--that though they have terrible relationships, they should go out and buy something?
Lear: I don't think that'll last. That's a defense that won't--
Bloom: No, I agree that it's a defense that leaks all over the place, which is why you see people with money in treatment.
Question: A number of you have started doing couples therapy, as opposed to classic one-on-one analysis. Is that part of a general profession-wide outreach? Or does it reflect some other trend?
Kramer: I think it's not a coincidence. I turned to couples therapy as a more important part of my practice partly because of the notion that there are some people who really do have different and more complete selves in a relationship than they have in isolation. I think the issue of the fragility of the couple has become extremely important and shows itself in all sorts of areas even when divorce is not an issue. In terms of the balance of power within marriage, in terms of aspirations of young women, it just seems to me that some constant awareness of the fragility of marriage permeates all sorts of aspects of therapy.
Bloom: Actually, two changes that I have observed are that I certainly see far more same-sex couples than I used to whose concerns are not either cultural homophobia or internalized homophobia. And those people tend to be, I have to say, highly committed. I think the other change is, people are more expressive more quickly of their loneliness within the marriage. It's not that they are more lonely, but they no longer feel that it's quite as much of an individual failure to admit that they are lonely within the marriage, now.
Bergmann: There is a much stronger agenda of each partner that I think there used to be. They are trying to negotiate it between the two, but the agendas are much more definite. And I would say to your same-gender couples--of which I have had only two examples over the years, but they're important--I think part of their determination to make it is also ideological: to prove that homosexuality is not a disease, that it can be linked to a permanent relationship. And that, of course, can add to the stability.
Bloom: That may be what drives the heterosexual couples as well.
Bergmann: But they don't have so much to prove it, you see.
Bloom: That's not clear to me anymore.
Question: I have a question that's far off topic: How and to what extent do religious issues or concerns arise in the therapeutic context?
Person: They come up in terms of the degree of someone's faith and the degree to which that faith may conflict with their wish to change their lives in any way. And it's harder for people who belong to certain faiths to enter into therapy for the fear of violating some tenant of that faith.
Talbot: The Group for the Advancement of Psychiatry asked the readers of Dear Abby: If you have suffered from schizophrenia, what was the most important factor in your recovery? We got hundreds of responses. To us, the single most striking factor saw the role of their own religion and spirituality. They felt, rightly or wrongly, that a spiritual connection, the ability to believe that they were going to be better through a higher power, was the most important thing. And it was really astounding to the scientists who were looking at this, because we had expected answers like medication or psychotherapy.
Bergman: It doesn't surprise me. The ability to believe is a kind of a human capacity to create within yourself the image of somebody caring for you. And that image then does something for you. So that it's really a kind of miraculous capacity to imagine a love object and then the love object, which has been imagined, is actually helpful.
Bloom: I have certainly had more people talk about their spiritual advisers and their spiritual counselors than I did when I first started practicing. People seem to take for granted that their religious leader is also available to offer some sort of counseling service.
Lear: There's again a general theme in which this fits, which is the possibility of living with certain kinds of intimacy. It's not just intimacy about people; it's an intimacy with certain kinds of ideals. Again, I think the ironic relationship to ideals is collapsing, and I think religious ideals are one example of that phenomenon. It's part of the wider phenomenon.
Question: So it's now possible to talk about spiritual issues and financial issues in a psychotherapeutic context. To what extent do disappointed expectations come up in the kinds of concerns that patients discuss in therapy? Is that a theme?
Person: Yes, there are disappointed expectations in their lives. I think one of the common ones now is that people who are very ambitious and make lots of money are very disappointed in the quality of their lives. It has cost them too much in other areas. They come into treatment because of the emptiness that they feel.
Bergmann: I agree. I think, Who comes to us? Always people for whom something expected didn't happen. It's almost by definition a prerequisite for coming to us. I think the whole enormous increase in psychotherapy after World War II was to a certain extent based on the question: After the refrigerator, after car, after washing machine, what's next? Because these things were endowed with magic that they could not deliver.

Walking Toward Mindfulness: Where Meditation is Going
Jennifer Egan, New York Times Magazine- 5/7/2000

Peter Williams sits cross-legged on an upholstered chair near mine, eyes closed, hands resting near his socks. A thick, starchy silence pools around us. Williams takes several slow breaths and then begins, narrating aloud the contents of his mind:"…hearing…enjoying…buzzing in my feet…fear: will my feet be O.K.?…hearing… breathing…wondering: will my parents read this article?…enjoying…afraid…what do you think of me?…fear…it's O.K….compassion…butterflies in belly…fear…kindness…compassion…hearing…bird, house finch…naming…thinking…joy…" It's a blustery day in March, and Williams and I are in a meeting room at the Spirit Rock Meditation Center, 45 minutes north of San Francisco, in Marin County. He's actually meditating, having offered, quite graciously, to do this in my presence.
    "Mindfulness," a quality aspired to by practitioners of what is called insight meditation (known as Vipassana in the Buddhist tradition. This much I get; It's not about emptying the mind, which is what I'd always assumed. In a sense, insight meditation is the opposite; it involves noting the ebb and flow of one's feelings and thoughts and allowing oneself to "sit with," or fully experience, whatever comes up--even discomfort and pain. Outside the plate-glass windows, a group of people move with glacial, dreamy languor around a courtyard, some holding almost still, others consuming many minutes to traverse a tiny distance, a few creeping up the lower flanks of the fat, iridescent green hills that surround us. They're performing what is known as a walking meditation. Williams would be out there, too, if he hadn't chosen instead to speak with me about the two month silent retreat he and 69 others were about to complete. The members of the group have coexisted in close proximity--many as roommates--without exchanging a word or even a look; direct eye contact is discouraged as an invasion of privacy. As discordant as such a notion may seem at a time when communication is possible between people virtually anywhere, silent-meditation retreats have grown enormously popular in recent years; waiting lists and even raffles are common at centers around the country to handle the demand.
    Williams looks younger than his 40 years, and slightly rakish. A part-time professor of biology at the University of Vermont and a self-employed biology consultant, he has arranged his life in order to accommodate his first priority: spiritual awakening. This is his third long silent retreat in as many years. After a couple of minutes, he stops meditating and explains what he wanted me to notice: that the contents of the mind shift radically and constantly in the course of just a few minutes. He experienced joy, compassion and fear (something he hadn't been aware of ) almost back to back. Mindfulness means allowing these shifts to occur while remaining present--that is, without latching on to any one feeling (Oh, no, I'm afraid! Why am I afraid? It's bad, I have to find a way to stop being afraid…) or using it as fodder for a familiar narrative about oneself (I'm always afraid, it's a weakness in me; even when I was a kid, I was afraid all of the time…). Being "in the story" is a meditation term for getting caught in a repeating narrative about oneself that feels deeply true but in fact is just habit--the result of psychological conditioning. Of course, avoiding such thinking can be extremely difficult even while meditating--we're narrative creatures, and the mind's play often leads quite naturally into storytelling, as Williams illustrates: "There was this twang in the meditation hall, almost like a bass," he says, alluding to the majestic octagonal room where he and his fellow yogis, as they're known, spend the better portion of each day. "And instantaneously I heard the bass in a John Coltrane tune called 'Africa.' And I go into this kind of bliss, and I go, 'Ah, infant bliss.' And then I thought, Infant, oh my God: my friends Jim and Mary Claire have a little Infant named Luca. I'm remembering the time that Luca was in a car seat in the house, and I got this craving for a chocolate chip cookie. I put him a little bit hastily on a laundry bin full of clothes and the thing toppled. And he fell on the floor, he's six months old, and he hit his head, and he's bawling. I felt so bad. And then I thought, That happened because I was greedy, because I wanted a cookie. And so all of a sudden I'm feeling my childhood pain, my unworthiness. I start reviewing my tape loops: the times I've rushed through a door and didn't hold it for somebody. I'm sitting there in that unworthiness and feeling bad for quite a while."
    In analyzing how he swerved into this state of self-criticism, Williams says: "It's an example of the way in which we suffer. Where did that unworthiness come from? It came because there was a twang in the meditation hall, one condition in the mind creating another. I was identifying with it, holding on to it. But if you just sit with emotions, they disappear. Nothing lasts. And when they leave, there's just spacious sky. Awareness." The power of insight meditation, proponents say, lies in its ability to make people aware of, and ultimately free from, the obsessive and restrictive thought patterns that can compromise their relationships and work and lives. Of course, personal transformation, that quieter variant of the American dream, has been the goal of numerous practices and programs--from Gestalt therapy to Eastern religious practices, from encounter groups to EST--that have been grouped together by some as the Human Potential movement, an explosion of interest in consciousness and spirituality dating from the early 1960's. Nowadays, the Human Potential movement is wiser and more subdued; there is a general wariness of gurus and abusive teaching practices, a skepticism toward overnight enlightenment and an emphasis on incorporating personal growth and spiritual practice into an integrated life.
    Williams spent years in therapy, but found that psychology alone was not transformative enough. "Therapy helped me," he says, "but it wasn't until I went on a three month silent retreat that I really got a lot of what my therapist had been telling me for years. I could start to see, My God, I'm just sitting here editing and judging myself day after day after day. You get confronted with it, and it's so painful because there's no escape from it. And the only solution is kindness. Acceptance. Acceptance is not a passive thing. The more you accept, the more you energize your whole being." An enormous nexus exists between therapy and insight meditation; all five teachers on the Spirit Rock retreat are therapists, and they have a tendency to discuss meditation using therapeutic language. One teacher, Tara Brach, says: "More than any other kind of suffering people bring in to me is the suffering of feeling deficient, unworthy in some way. Psychotherapy works on that somewhat--you're bringing out the nature of the wound and how to address it. But what Buddhism brings to the mix is a way of cultivating compassion for what's going on. You're actually learning to reparent yourself."
    Williams, who became serious about meditation five years ago, credits the practice with enormous changes in his life: "I now say to myself: 'What's my deepest aspiration? What is my heart's desire?' And then I try to make decisions based in that." He veered off the Ph.D. track and now devotes more time to meditation, as well as to working with foster children. "You go through so much on retreat," he says. "It softens you, it tenderizes you, makes you a lot more vulnerable. It's also made me a lot more forgiving toward my family." Williams delights in pointing out the little ways in which a silent retreat can teach him about suffering. "One thing that has been driving me crazy is people coughing," he says. "When you become concentrated, you really polish the sense store, your awareness is really heightened. This person who sits near me coughs really loudly, and I literally feel it in the marrow of my bones. And there's nothing you can do, except just note the pain of the situation." Another time, a woman vomited beside him in the meditation hall, then resumed her meditation. "But life is chaotic, you can't control it," he says, laughing. "May everything in experience lead to awareness. O.K., I have this disgust, and I have this disbelief, and then it's gone. New experience. That's the absolute crux of the practice, learning to be at ease with pleasure and pain. Think about that: if you don't care if the next moment is comfortable or uncomfortable, you're free."

Psychiatrists Must Often Choose Between Two Seemingly Contradictory Points of View
Stephen S. Hall, The New York Times Book Review- 5/7/2000
A book review of: Of Two Minds: The Growing Disorder in American Psychiatry by T.M. Luhrmann.

There is a popular aphorism among research scientists to the effect that if, in the course of performing an experiment, you pose the question in the wrong way, you are doomed to arrive at the wrong answer. That bit of scientific folklore occurred to me repeatedly as I made my way through "Of Two Minds: The Growing Disorder in American Psychiatry," T.M. Luhrmann's fascinating anthropological study of the way young doctors learn to be psychiatrists. What becomes clear, as one reads deeper into her book, is that we are in the midst of an enormous social and medical experiment about the way we deal with mental illness in this country. Not only have we posed the question incorrectly, according to Luhrmann, but we are doomed to reach a tragically wrong, and profoundly immoral, answer by doing so. The question that lies at the heart of "Of Two Minds" is one that, in simplified form, has riven psychiatry for at least 20 years. Are mental illnesses like schizophrenia, depression and personality disorders a matter of biological dysfunction and thus best treated pharmacologically, or are they the product of psychosocial factors--family dynamics, early childhood experiences, the whole closet of Freudian baggage--and thus best treated by psychotherapy? What makes the question flawed, of course, is the way it is posed, as an either-or proposition. Luhrmann's book bears witness--unwittingly at first, then with increasingly clear-eyed intellectual analysis--to the fact that a third party, namely managed care, has seized upon that flawed question and answered it "irrevocably" in favor of biological psychiatry, with ramifications that will very likely be felt in this country for decades to come.
    Aspiring psychiatrists straddle two seemingly contradictory worlds: the hard, quantitative world of medical science and the more ambiguous, intuitional world of human interaction. Trained as doctors, they attend four years of medical school and serve internships for a year in settings that resemble "E.R.," not Freud's study in Vienna. Then they typically spend at least three years as residents specializing in psychiatric medicine, treating both the severely ill (in the hospital setting) and the less incapacitated (in outpatient clinics). It is during the formative years of residency that the two rival models of psychiatric medicine compete for the hearts and minds of tomorrow's practitioners, and it is the voices of this population--earnest, confused, overwhelmed and more and more cynical--that fill "Of Two Minds." As Luhrmann writes, young psychiatrists are in principle supposed to learn to be equally good at talk therapy and drug therapy, equally conversant in the theories underlining psychotherapy and biomedical psychiatry. But in practice, the two approaches are often seen as antagonistic. "By the end of your second year," a resident says, "you have to decide which camp you're in."
    In the course of nearly a decade of research, Luhrmann, a professor of anthropology at the University of California, San Diego, inhabited the various nests of these psychiatric fledglings. Her shrewd, witty observations ring true: when she innocently begins inquiring about a claim she's heard that residents as a university in Kentucky diagnose mental disorders in 30 seconds, administrators at the hospital she's visiting hasten to assure her that diagnoses are based on a thorough and painstaking patient interview, while the residents on the front lines respond by wondering what takes their colleagues in Kentucky so long. By good fortune, Luhrmann happened to choose a particularly pivotal moment in the history of psychiatry. Most readers will be familiar with the tectonic ideological stresses that have caused such visible upheaval in the field today:: the repudiation of many Freudian tenets, the rise and undeniable success of new medications to treat the most intractable forms of mental illness and the more impersonal, hurried approach that often comes with the dispensing of drugs. But these ideological differences reverberate day by day for trainees. "Working with these different models," Luhrmann writes, "changes the way the staff joke, the way doctors relate to nurses and even the sense of the unit's ultimate goal. Ultimately, these differences help to produce different moral sensibilities about mental illness."
    Part of this dynamic, of course, involves psychoanalysis' fall from grace. Almost willfully nonquantitative, as Luhrmann notes, the field never bothered to prove its worth with outcome studies, never conceded that talk therapy might be wholly ineffective against the most severe diseases and never owned up to the scandal of implicating family dynamics in models of illness that now seem firmly rooted in brain dysfunction. The handwriting on the wall, in terms of the beginning of the end of psychoanalysis' golden age, coincided with the handwriting on the prescription pad. In 1954, Smith Kline & French began to market the antipsychotic drug Thorazine as a treatment for severe illnesses, and as neuroscience became increasingly sophisticated and increasingly molecular in the decades that followed, "illness" as the term of choice for mental disorder subtly gave way to "disease." In one fascinating aside, Luhrmann reports that psychiatrists who trained during the 1960's began to distrust the psychoanalytic model in part because of heir own use of recreational drugs like LSD. "If a drug can do this to my sense of reality, what am I doing taking all this psychoanalytic stuff at face value?" one psychiatrist recalls thinking.
    Luhrmann is not the first observer to lament the loss of the psychodynamic component in the treatment of psychiatric disorders. The power of her book, however, derives from the intuition that initially brought her to the project: by focusing on trainees, she positions herself to understand sooner than the rest of us that the brief, swift and brutal impact of managed care is destined to diminish the practice of psychiatric medicine for years to come. "Patients are less well off without psychotherapy," she writes near the end of her book. "They do less well, are readmitted more quickly, diagnosed more inaccurately and medicated more randomly." She approvingly quotes one senior psychiatrist as saying, "You cannot adhere to untruths without being immoral in some way." Many readers may find Luhrmann's sympathetic discussion of psychotherapy a little too forgiving. I found it refreshing. All the same, I would have liked a less understated treatment of the enormous excitement about contemporary neuroscience, and perhaps more that a nod in the direction of some of psychotherapy's successes, like cognitive behavioral therapy.
    There are two casualties of psychiatry's split personality. The first, and most obvious, is the patient. Toward the end of her fieldwork, Luhrmann revisits a hospital where she spent considerable time in 1992; she describes the experience as "a little like coming back to a tree-lined London neighborhood after the blitz." A third of the staff had been fired; gardeners and cooks had been dismissed; salaries were about to be slashed; and many senior psychiatrists had left, in sorrow and disgust. "I left myself," one psychiatrist said, "when a patient came onto my unit and tried to hang herself twice by the end of the first day, and then Utilization Review (a hospital office that negotiates with the insurer) said she'd only been authorized for a two-day admission and would have to be discharged. I kept thinking about what the jury would say if she killed herself and I was the one held liable." The reader comes away with the overwhelming sense that an institutional, economic and almost philosophical form of medical malpractice has been unleashed upon psychiatric medicine, and it has condemned--in the name of controlling costs--thousands of patients to permanent illness.
    The other casualty is less obvious. One can foresee, in the not too distant future, what might be called a grand unification theory of psychiatry, a convergence of the psychosocial and the molecular, of talk therapy and drug therapy, where the psychological residue of hectoring mothers and absent fathers might plausibly find microscopic correlation in the residue of proteins in synapses, and where the psychoneurological patterns associated with those residues might plausibly be rearranged not only by drugs but by conversation. It is the demoralizing implication of "Of Two Minds" that we now might never have a chance or reaching that future at all.

Heroin's Resurgence Closes Drug's Traditional Gender Gap
Donna Leinwand, USA Today- 5/9/2000

Simona Troisi was a high school freshman on Long Island, at 14 already a user of marijuana and LSD, when she gave $40 to a friend to score some cocaine in New York City. The friend returned with a powder that gave Troisi a sickening high when she snorted it. ''I don't even know what it was,'' Troisi says. ''I just kept doing it because I had it.'' The strange powder was heroin, and within a few months, Troisi's recreational drug habit became a destructive lifestyle. She landed in a drug rehabilitation program after being charged with selling heroin to an undercover police officer. She had turned to dealing to help finance her appetite for tiny, $10 bags of the drug. Now 20 and nine months into rehab, Troisi symbolizes how thousands of girls across the USA have fueled a dramatic resurgence of heroin use among teenagers, particularly in suburban and rural areas.   Not since the late 1960s and early 1970s, when a typical dose was much less potent and almost always injected, has heroin been so hip among middle-class teens. Heroin's re-emergence comes at a time when girls -- once far less likely than boys to drink, smoke marijuana or use harder drugs such as heroin -- now appear to be keeping pace with them, says Mark Weber, spokesman for the federal Substance Abuse and Mental Health Services Administration.  Weber's agency, after finding that existing drug prevention programs helped reduce drug use only among boys, recently helped create an advertising campaign called ''Girl Power'' to deliver anti-drug messages specifically to girls. A television commercial now airing features Olympic figure skating champion Tara Lipinski and Brandi Chastain, a member of the 1999 U.S. Women's World Cup soccer team, urging girls not to ''blow it'' by using drugs. The agency also has begun an unprecedented effort to collect statistics on girls' drug use.
    The new surge in heroin use made national news with the overdose deaths of more than a dozen teenagers in Plano, Texas, and suburban Orlando in 1996. Since then, hospital emergency rooms on Long Island, N.Y., and in the San Francisco Bay Area, the Philadelphia suburbs and several other middle-class areas have been hit by clusters of teens on heroin. ''The picture is frightening,'' says Mitchell Rosenthal, a psychiatrist and president of a chain of drug treatment centers who will testify before the Senate Caucus on International Narcotics Control today about the emerging heroin problem in the suburbs. ''We've got a lot of suburban kids at risk. I don't think the modern affluent parent thinks about heroin being a danger in Scarsdale or Beverly Hills.'' One of four teenagers scheduled to testify today is Kathryn Logan, 19, of San Juan Capistrano in southern California. At 9, Logan stole sips of wine from unfinished glasses. At 13, she rifled through medicine cabinets for prescription drugs she could chop up and sniff. She packed the powder into ballpoint pen casings so she could get high during class. At 15, she snorted heroin and cocaine and smoked crack. ''I felt more normal when I was on drugs,'' says Logan, who developed bulimia, had an abortion and tried to commit suicide. ''I felt being sober was too boring.'' To pay for her habit, she stole money from her parents and at one point pawned her grandmother's diamond ring for $25. Even so, she kept up her grades, made the junior varsity tennis team and tried out for cheerleading. But she felt she didn't fit in at school, where she thought the people were ''rich and stuck up.'' Her father, a contractor, and her mother, a flight attendant, didn't seem to notice her drug use. ''I was always making up excuses. I had everything under control, the whole world under control. It was hard, let me tell you,'' says Logan, who entered rehab 79 days ago to avoid going to jail on alcohol and marijuana possession charges. ''My parents were clueless. I think they were in total denial that I was doing drugs until I told them about it.''

Heroin considered 'super cool'
Heroin use remains relatively rare among teens overall. A study by the University of Michigan last year estimated that about 2% of youths ages 12-17 had tried it. However, that was more than double the rate of seven years earlier. The same study indicated that 2.3% of eighth-graders in the USA, about 83,160 youths, had used heroin. Analysts continue to examine the reasons behind the surge. There are the usual factors: teen angst, peer pressure, boredom, the attraction of something dangerous for teens with money to spend. But analysts say it's also clear that new, highly potent forms of heroin from drug cartels in Colombia and Mexico have been key to attracting new users -- particularly girls. For years, most heroin had to be injected directly into a user's bloodstream to be effective. Girls typically prefer to sniff or smoke their drugs rather than inject them, so heroin was out of vogue, experts say. But now, with more potent heroin available as a powder in small bags or gel capsules, users can get high without injecting. That has made it more palatable to girls. ''Young girls don't like injecting regularly. It leaves marks. With the increase in purity of heroin, it made it smokable,'' Sen. Joseph Biden, D-Del., says. As co-chairman of the Senate narcotics caucus, Biden issues regular reports on drug abuse.
    ''We are seeing a wider range of users,'' says H. Westley Clark, a psychiatrist and director of the federal Center for Substance Abuse Treatment in Washington, D.C. ''We have been seeing younger people use. It has been fairly dramatic. These drugs are becoming equal opportunity drugs. There is no gender bias.'' Lynn Ponton, a San Francisco-area psychiatrist, says that just last week a 17-year-old girl she is counseling tested positive for heroin in a routine drug screening. ''Traditional gender roles associated with risk-taking are not holding ... for drug abuse,'' says Ponton, who wrote The Romance of Risk, a book about adolescent risk-taking. ''Once (a drug is) available and hasn't been used for a long time, it's deemed cool by the teenagers. Heroin is still considered a super-cool drug, and it has high risk associated with it. It's probably the mystique of the drug.''  Like the stimulant and hallucinogen Ecstasy, another favorite drug of the moment, heroin plays to girls' insecurities. Users lose their appetite, and so lose weight. The ''heroin girl'' look has been glamorized recently, from ashen, wafer-thin runway models to anthems by grunge bands. All this has recast heroin in a more favorable light for this generation of youths. Troisi, who is 5 feet 5 and weighed 80 pounds when she entered drug treatment, says she never associated heroin with images of needle-toting junkies from the 1960s and '70s. ''Think of all the heroin-chic pictures that have been in the culture for a number of years,'' Rosenthal says. ''Advertising campaigns show gaunt men and women. The stigma of heroin appears to have faded.''
    Heroin, a narcotic derived from the opium poppy, was developed in the 1880s as a pain reliever and substitute for highly addictive morphine. Scientists soon found that heroin is even more addictive. It was made illegal in the United States in 1914. Heroin is produced mainly in Southeast Asia, Pakistan, Afghanistan, Mexico and Colombia.  For street sales, heroin is mixed, or ''cut,'' with other ingredients, such as quinine or sugar. A hit of heroin produces a rush of euphoria followed by several hours of relaxation and wooziness. Twenty years ago, a milligram dose with 3.6% pure heroin (and cut with 96.4% other ingredients) cost about $3.90, says Richard Fiano, director of operations for the Drug Enforcement Administration. Now, the average milligram is 41.6% pure and costs about $1. Some Colombian heroin the DEA seized recently was 98% pure, Fiano says. Colombian drug lords used existing cocaine distribution networks to introduce the purer heroin to the USA, Fiano says. ''They have a very, very good marketing strategy,'' he says. ''They've come out with a new product line. They even have packaged it with brand names, just like buying a pack of cigarettes. They even gave out free samples.''

Emergency-room visits rise
The strategy appears to be working; heroin users are younger than ever. Surveys by the U.S. Substance Abuse and Mental Health Services Administration indicate the average age of first-time users plummeted from about 27.4 years in 1988 to 17.6 in 1997, the youngest average since 1969. Emergency-room doctors reported in 1997 and 1998 that heroin is involved in four to six visits out of 100,000 by youths ages 12 to 17, up from one in 100,000 in 1990. For young adults 18 to 25, 41 emergency room visits in 100,000 involved heroin, up from 19 in 1991. Among women in general, the numbers have doubled in a decade. Biden would like to direct more federal money to drug treatment for adolescents and law enforcement efforts in Colombia. Sen. Charles Grassley, R-Iowa, chairman of the Senate narcotics caucus, says that even if the USA directs more money toward Colombia, the focus should be on sending teens a clear anti-drug message, similar to the Reagan administration's ''Just Say No'' campaign.
    Troisi says a steady stream of information about the risks of different drugs might have steered her away from heroin. She and her friends had no idea how seductive and addictive the drug could be, she says. She adds that she had no trouble finding heroin in her affluent hometown, Selden, N.Y. ''I'm not saying that heroin is the normal thing, but it is going more mainstream,'' she says. ''When I first started, I was one of the first females, but I've seen more and more. I've seen them come into detox.'' In Selden, about 45 miles from New York City, there isn't a whole lot for teens to do, and becoming a drug user wasn't too different from finding a spot in an after-school club, she says. ''It seemed like this underground society,'' says Troisi, who says she grew up in a stable home with three brothers, including one who was high school valedictorian. Her father is a high school teacher. ''Boredom played a big part of it. A lot of my friends got involved in drugs real young. I kept away from it for a while, but I was real lonely. When I started using heroin, I just kept going back to it. I felt like I'd never feel comfortable with myself without it.''
    Like many girls who slide into addiction, Troisi wound up taking heroin the way she initially avoided: by injection. That way, Troisi, who sometimes spent more than $100 a day on drugs, needed less heroin to get high. By the time she was 15, Troisi says, she loathed getting out of bed without a heroin jolt. ''I used to sleep with a bag of it in my bra so I would have it first thing, so I could get out of bed and brush my teeth,'' she says. Troisi, who after nine months of treatment now weighs a healthier 110 pounds, thinks she will get better. What she calls the ''zombie'' feeling has faded. ''One day, I woke up and I felt good,'' she says. ''I eat now. And I go running, five miles a day sometimes. I feel like it's a new world. I still go through moods, but I know how to deal with those moods. I think I have a chance."

In Life, As on TV, Mental Health Fails to Rate
Alex Beam, Boston Globe, 5/10/2000

The question is: How can network television support three semirealistic shows about the traumas and occasional epiphanies of big-city hospitals - ''ER,'' ''Chicago Hope,'' and ''City of Angels'' - but not sustain more than two episodes of a semirealistic drama set in an urban mental hospital? There has been no shortage of reasons advanced for the failure of the critically acclaimed ABC teledrama ''Wonderland.'' The first episode was so violent that it scared away many viewers lured to the show by good reviews. Talk about madness - just as a deranged shooter starts spraying Times Square with bullet fire, an announcer intoned: ''`Wonderland' on ABC! Brought to you by the Saturn L-Series Performance Sedan!'' ''Wonderland'' fans argue that the show was set up to fail, competing against NBC's popular ''ER'' on Thursday nights. Or is the explanation simpler than that? Perhaps ''Wonderland'' hit a little too close to home?
    Twenty-five years ago, Time magazine writer Otto Friedrich began his book ''Going Crazy'' by describing the morning he forgot how to cross the street. For about 10 seconds, he stood in the middle of Broadway traffic, completely disoriented. How could he get to work? How could he live? I've had a similar experience, temporarily forgetting how to walk down the stairs. That's a slender little thread connecting us to the material world. ''He who has never felt, momentarily, what madness is,'' Herman Melville wrote, ''has but a mouthful of brains.''  It is said that about half the American population will have a brush with mental illness during their lifetime. Perhaps. Although there has never been a good time to be mentally ill in America - or anywhere else, for that matter - this may be one of the worst. Partly hidden from view by the medical health care crisis, mental health care is suffering, too; the delivery system has never been more wounded.
    A psychiatrist hoping to educate me in his field gave me Tanya Lurhmann's new book, ''Of Two Minds.'' It is an extraordinarily ambitious work. Lurhmann, a University of California anthropologist, conducted 10 years of field work among psychiatrists in training, some of them at McLean Hospital in Belmont. The title's ''two minds'' refer to the profession's split allegiance between ''talk therapy'' and pharmaceutical pill therapy. In the war between talk and pills, Lurhmann has no doubt that the prescription pen is mightier than the word: ''Psychopharmacology is the great, silent dominatrix of contemporary psychiatry,'' she writes. What feeds the psychopharmacology engine? According to Luhrmann, it is managed care providers' unwillingness to pay for hospital evaluations of mental illness. ''The less time a patient spends in the hospital,'' she writes, ''the more the doctors feel forced to medicate ambiguous symptoms.'' A Harvard Medical School study to be released today reveals that patients are three times more likely to receive treatment for depression, anxiety, and panic disorders from their primary care doctor than from a specialized therapist. Not surprisingly, the study concluded that most of the treatment was inadequate.
    And if a disturbed patient needs to be hospitalized, they won't be staying long. Nowadays, most HMOs will pay for a five-day diagnostic admission. As recently as 1993, a 13-day admission was standard. That's a 60 percent decline in less than a decade. And it's not as if people are getting more sane, is it? Just last week there was some unusual good news on the mental health front. Massachusetts became the 30th state to enact a mental health parity law, which forces insurers to provide benefits for psychological treatment comparable to those for physical illnesses. The bill isn't perfect; that five-day admission period won't be lengthened, and patients may lose some confidentiality protections they've enjoyed in the past. But the bill does represent an improvement. Severe mental illness is to be treated on a par with other ailments. And the ''worried well'' - a category that could include the late Otto Friedrich, or me - will have expanded access to therapists. The mental health glass looks half full, for once; maybe the level is rising.

Alcohol Abuse Symptoms Often Missed
Randolph E. Schmid, Associated Press- 5/11/2000

More than nine out of 10 physicians asked to diagnose patients with symptoms typical of early alcohol abuse failed to recognize that problem, a study by a leading substance-abuse center found. That failure is a ``lost opportunity'' to reduce substance abuse and cut its eventual costs to society, Joseph A. Califano, head of the National Center on Addiction and Substance Abuse at Columbia University, said Wednesday. His center's survey of physicians nationwide found nearly 94 percent failed to include substance abuse among five possible diagnoses they were asked to make based on the following symptoms typical of early stage alcohol abuse: A 38-year-old married patient has recurrent abdominal pain, intermittently elevated blood pressure, gastritis, waking up frequently at night and irritability. ``These findings add up to a monumental lost opportunity,'' said Califano, a former secretary of Health, Education and Welfare. He called on doctors to focus more closely on alcohol and drug abuse, urged medical schools to emphasize it in their teaching and suggested that state licensing boards stress the importance of this problem. Dr. Richard Corlin, a gastroenterologist in Santa Monica, Calif., said the symptoms ``are vague and common symptoms that can be related to a whole variety of conditions'' besides alcohol abuse. Other possibilities include ulcers, depression, recurrent gastritis and anxiety, he said. But, he added, they clearly could indicate alcohol abuse and doctors need to be made more aware of this possibility.
    Unfortunately, people with alcohol and drug problems may lie out of embarrassment or fear, doctors say. ``It's a tremendously courageous act by a patient with drug or alcohol problems to lay that out before their physician,'' said Dr. Macaran Baird, a family physician at the Mayo Clinic in Rochester, Minn. ``We need for them to help the physician.'' The symptoms listed in the survey present an ``interesting scenario,'' Baird added. ``I would be happy if a higher percentage of physicians listed alcohol abuse as a possibility.... We all want to do a better job.''  Califano said primary care physicians have a unique opportunity to identify and help treat substance abuse in its early stages when the potential for success is high. Barry R. McCaffrey, director of the White House office of national drug control policy, said he supports the call for additional training of physicians in substance abuse and addiction. ``Families have always relied on their doctors for health care advice. Drug abuse rips families apart. Giving the right advice on drug prevention and treatment can keep a family together,'' McCaffrey said.
    In addition to the failure to identify adult alcohol abuse, the survey found 41 percent of pediatricians didn't diagnose illegal drug abuse when presented with a classic description of a drug abusing teen-age patient. The survey found only about 20 percent of doctors felt very prepared to diagnose alcoholism and 17 percent felt prepared to diagnose illegal drug use. In contrast, nearly 83 percent felt very prepared to identify high blood pressure, 82 percent to diagnose diabetes and 44 percent to identify depression. Some 86 percent felt treatment for high blood pressure is very effective, and 69 percent felt diabetes treatment is very effective. But only 8 percent felt treatment is very effective for smoking, close to 4 percent believed it is effective for alcoholism and 2 percent for illegal drug abuse.
    The center said 58 percent of doctors don't discuss substance abuse with their patients because they believe their patients lie about it. Some 35 percent listed time constraints for not discussing it and 11 percent were concerned they won't be reimbursed for the time necessary to screen and treat a substance-abusing patient.  Of the physicians responding to the survey that presented the typical symptoms in the 38-year-old married patient, just 6.2 percent mentioned substance abuse. Female doctors did a little better, with 9.0 percent diagnosing abuse compared with 5.5 percent of male physicians. Some 9.4 percent of doctors who graduated from medical school in the last 10 years listed substance abuse as a possibility, a share that dropped the longer a doctor was out of school.   Doctors in family practice were the most likely to recognize the symptoms, 11.5 percent. Substance abuse was recognized by 6.8 percent of those in internal medicine, 4.3 percent of gynecologists and 2.5 percent of general practitioners. The survey of 648 physicians across the country has a margin of error of plus or minus 4 percentage points, the center said. The center also conducted a survey of 510 patients but noted that was done at only selected substance-abuse centers and was not statistically representative.

State, Mental Health Providers Reach $4M Settlement
John Christoffersen, Associated Press- 5/12/2000

HARTFORD, Conn. (AP) A mental health worker at a state facility was knocked unconscious when a youth struck him with a pipe. Only two days of inpatient care were authorized for the youth by Value Behavioral Health, a subcontractor of a managed care company hired by the state to provide the services, officials said. Taxpayers were forced to pay for another week to ensure adequate care, officials said. In another case, a child guidance clinic sought authorization to hospitalize a youth getting out of control. Value Behavioral said the case was not serious enough unless it involved broken bones or stitches, officials said. The youth subsequently became violent, requiring eight adults to restrain him, officials said.
    State officials on Thursday accused Value Behavioral and HealthRight, Inc., a Medicaid managed care company in Hartford, of denying authorization to provide mental health services for poor children. Officials announced a $4 million settlement with the companies, which had a contract with the state until last year. "The scheme was purposeful and systematic,'' Attorney General Richard Blumenthal said. ''The costs are measured not just in dollars but the suffering of these children.'' The companies denied any wrongdoing in the settlement, which ended a three-year investigation by Blumenthal's office. HealthRight is no longer in business, but issued a statement saying the settlement reflected a desire to resolve the issue without further costs. ValueOptions, a Falls Church, Virginia company which now owns Value Behavioral and is responsible for abiding by the settlement, could not be reached for comment.
    Denial of mental health services by health maintenance organizations is a national problem, Blumenthal said, citing a recent report by the Surgeon General's office. Officials could not say how many children in Connecticut were denied services, but estimated it involved hundreds. ''The harm here was really fundamental and far reaching,'' Blumenthal said. Representatives of the departments of Children and Familes, Public Health and Social Services, who joined Blumenthal in announcing the settlement, said they have implemented reforms to prevent a similar problem. Those measures include more rigorous contract requirements and increased monitoring of contract violations, officials said. The settlement money includes $3 million in cash and $1 million in services, officials said.

Depression Cited in Assisted Suicide Case
Matthew Mosk, Washington Post- 5/12/2000

Attorneys for an Anne Arundel County teenager charged with assisting in his girlfriend's suicide asked a judge yesterday to declare that the youth was so impaired by depression he could not have understood he was committing a crime. The pretrial motion--similar to an insanity plea--came after a full day of testimony in the state's first-ever prosecution under Maryland's new assisted suicide law. Prosecutors brought charges against the teenager in March, saying the law applied because the youth was so involved in his girlfriend's death, which occurred in a secluded, graffiti-scrawled drainage pipe. They say he forged a suicide pact with her, handed her a .38-caliber revolver and then watched as she pulled the trigger. He is now 16, and he is not being named because he was charged as a juvenile.
    Both teenagers battled depression, according to court testimony. Jennifer Garvey, 15, had at least one prior suicide attempt. Defense attorney William Davis said after the hearing that his client's fragile mental state should be enough to render the youth "not criminally responsible." Such a finding would eliminate the possibility of the teenager's being sent to jail and would require that he receive appropriate psychiatric treatment. A judgment cannot be made until mental health experts complete an evaluation of the case. That could take up to 45 days. In the meantime, Davis immediately began attacking the state's case by arguing that police improperly held the teenager on the night of Garvey's death and coerced two lengthy statements from him before calling his mother and taking him to the hospital for a psychiatric exam. He brought forward a series of witnesses, all of whom offered a glimpse into the teenager's anguish in the hours immediately after he and Garvey penned their goodbye letters in an English composition notebook. The witnesses included the youth's mother, two mental health specialists who treated him on the night of the suicide, and Kathleen Steed, the first person to see him after the shooting. "He was in a very emotional state," said Steed, who is the mother of one of the youth's high school friends. "He was sitting slumped, crying. I would describe him as crushed."
    Prosecutors argued that despite the teenager's obvious depression, he clearly understood his rights, and his cooperation with police was of his own accord. "His mental condition was that he was upset. He had just undergone a traumatic experience," said Michael O. Bergeson, the deputy state's attorney handling the case. But "everyone found his speech was clear and coherent, and he never gave any indication that his cooperation was anything but voluntary."

Getting Feedback on Attention Deficit Disorder
Bob Condor, Chicago Tribune- 05/14/2000

When the American Academy of Pediatrics announced its first-ever guidelines for diagnosing kids with attention deficit/ hyperactivity disorder (ADHD or ADD) this month, a primary reason was to help prevent doctors from over-prescribing drugs such as Ritalin for treatment. The fear is too many doctors and parents alike turn to medications as the main option for handling what might be a child's misbehavior problems and not illness. Joel Lubar, for one, isn't surprised about the guidelines, which reportedly were three years in the making and debating. Lubar is a professor and researcher at the University of Tennessee in Knoxville who has been using a form of biofeedback called neuro-feedback--basically brain wave therapy--to treat ADHD/ADD for more than 25 years. What started as his idea is now a therapy practiced by more than 2,000 professionals in the U.S. "When we first started training people (at the Southeastern Biofeedback Institute in Knoxville), we saw psychologists or social workers," recalls Lubar. "Then we started seeing nurses and medical educators. In the last five years, we have trained psychiatrists, neurologists and pediatricians."
    Neurofeedback works this way: A person is evaluated by electroencephalogram (EEG) to determine his or her brain wave patterns. Next, one or two electrodes are attached to the person's scalp. Clips are also put on the ears. The procedure is quick and painless. As a session begins, the patient works on one of 520 possible game/puzzle displays. Examples might include a 16-piece puzzle of a hawk or space trip game with a traveling rocket.   The patient is rewarded when he focuses, which produces high-frequency beta waves in the brain. A piece of the hawk puzzle might be put in place or the rocket moves skyward. The patient makes no progress when low-frequency theta (more common in kids) or alpha waves (problematic for adults) are produced in the brain, which are related to daydreaming, loss of concentration and lack of attention. Neurofeedback training can require somewhere between 30 and 50 sessions for patients to learn how to recruit beta waves when they need them. Part of the training process is getting the patients to apply their new brain-control skills to such tasks as solving math problems, reading and listening. The work can be tiring. "We insist that practitioners stay in the room at all times during the session," says Lubar. "The whole thing is like learning a complex computer program."
    Lubar is careful not to claim neurofeedback as a substitute for prescribed drugs. He says the treatment should be an adjunct to Ritalin and vice versa. "We're all concerned that medications are over-prescribed for ADHD," he explains. "The MDs we train are not completely happy with the medication. They worry it works while in the system, but kids regress once they stop taking it. There is concern about possible long-term effects (not as yet studied). They come here thinking there must be a better way." Neurofeedback is certainly a reasonable alternative--and might prove exactly the therapy for parents hoping to get their kids off medication. Lubar, who has published and presented a formidable number of research papers, says 40 percent of children and adults with ADHD/ ADD are able to stop taking Ritalin and other medication after the appropriate number of neurofeedback sessions, and another 20 percent can significantly decrease drug use.
    "We are finding kids improve their grades in school and scores on achievement tests," says Elsa Baehr, a clinical psychologist and neurofeedback practitioner in Evanston. Lubar says his clinic sees similar results with children, while adults are better equipped to meet deadlines. Baehr operates the NeuroQuest CQ clinic in Evanston with her psychologist husband, Rufus. They are among about a dozen neurofeedback practitioners in Illinois associated with Lubar's training program (check out www.brainwavebiofeedback.org for more information). Baehr says cost for neurofeedback sessions are on a sliding scale for each patient, though a general guideline is $75 to $125 per session. Some insurance carriers will pick up some of the costs, but others do not. One of the advantages of neurofeedback training is the individual has developed a lifelong skill, says Lubar. "Some people might need booster sessions from time to time," he says. "For the most part, we are succeeding in moving people with up to 90 percent difference (in brain wave activity) back to normative patterns."

Doctor Lashes Out in Prozac Battle
Richard A. Knox, Boston Globe- 5/15/2000

Jonathan O. Cole, a Harvard psychiatrist who was one of the first to suggest that Prozac and similar antidepressants could precipitate suicide, is now criticizing drug companies and the US Food and Drug Administration, saying they are failing to take the problem seriously. Cole made his complaint in support of a federal court lawsuit that claims the drug Zoloft, a chemical cousin of Prozac, caused a 13-year-old Kansas City youth to kill himself. ''I still believe our 1990 article was correct and it does happen,'' Cole said of the alleged suicide-antidepressant link that he and other McLean Hospital researchers first suggested a decade ago.
    Although Cole had remained silent amid manufacturers' efforts to discredit his research, the Boston psychiatrist said he was angered by the actions of Zoloft's maker, Pfizer Inc., in fighting the lawsuit brought by the family of Matthew Miller, the Missouri teenager. The youth had been taking Zoloft for only a week when he hanged himself in his bedroom closet on July 28, 1997. His parents insist he had never displayed suicidal tendencies and had never been treated for behavioral problems. They say the boy had been unusually restless and jumpy in the days before his death - symptoms that Cole and other researchers say are warning signs of alleged antidepressant-related suicides.   ''Against this background ... There is a clear prima facie case that Zoloft caused Matthew Miller to commit suicide,'' said Dr. David Healy, a British researcher who is the family's chief expert witness. Pfizer lawyers, calling Healy a practitioner of ''junk science,'' are asking Kansas City Federal District Court Judge Katheryn Vratil to disallow Healy as an expert witness. Cole was recruited by the Houston law firm representing the Miller family to vouch for Healy's scientific rigor. Pfizer representatives say there is no credible scientific evidence that Zoloft and related drugs precipitate suicide. Company officials did not return telephone calls Friday seeking comment.
    In the decade since Cole and Harvard colleagues first reported on early cases of extreme agitation among people taking Prozac and related antidepressants, use of these drugs - called selective serotonin reuptake inhibitors, or SSRIs - has reached 84 million prescriptions a year. The wholesale cost of SSRI prescriptions last year was $7 billion, a 15 percent jump from 1998, according to IMS Health, a Pennsylvania research firm. Moreover, US physicians are prescribing Prozac, Zoloft, and a related drug called Paxil for ever-younger patients and for a broadening list of disorders.  A University of Michigan researcher reported Friday in Boston that nearly 2 percent of North Carolina children ages 6 to 14 received SSRI drugs in 1998. A growing number of physicians are giving children prescriptions for SSRIs along with stimulants such as Ritalin, the researcher said, despite the absence of any studies supporting such use.  Dr. Jerry Rushton and his colleagues found that Prozac, Zoloft, and Paxil are being used widely by children not only for depression, but for school phobia, anxiety disorders, bed-wetting, eating disorders, and attention deficit-hyperactivity disorder. Their study was presented at the annual meeting of the American Academy of Pediatrics and the Pediatric Academic Societies.
    While manufacturers have been successful so far in deflecting criticism, opponents say the tide may be turning, due to lawsuits, media reports, books, and statements from prominent scientists such as Cole. The Globe reported a week ago that Eli Lilly and Co., the maker of Prozac, was aware more than a decade ago that suicidal thoughts occurred in as many as 1 percent of patients who were given the drug in early trials. Furthermore, the patent for a new form of Prozac, invented by physicians at McLean Hospital in Belmont and scientists at Marlborough-based Sepracor Inc., specifically mentions suicide as a possible side effect of the original Prozac. Lily has embraced the new Prozac and plans to market it within two years.  ''I have seen patients and reviewed cases where an SSRI unmistakably precipitated a driven preoccupation with suicide,'' said Cole, 74. Such responses are unusual, Cole said, but they should be taken more seriously by manufacturers and federal regulators. ''It's a relatively small problem, but it exists,'' he said in an interview.  The problem, critics say, is that infrequent adverse effects are magnified when millions of people take a drug every day. ''I sense the scientific community is beginning to understand they made a mistake in concluding that they could rule out suicide as an adverse effect'' from SSRI drugs, said Thomas J. Moore, a drug industry critic at George Washington University in Washington, D.C.
    Nobody knows how many suicides have occurred among the millions of people who have taken SSRI antidepressants. Richard Ewing, a lawyer in a firm representing the Miller family, said the FDA had recorded about 2,000 suicides between 1988 and 1997 that may have been related to the drugs, but says the agency acknowledges that this is a small fraction of the probable cases. Healy, the British researcher, has estimated that as many as 50,000 suicides worldwide may be related to the drugs' use. Cole cited two studies by Texas researchers in 1993 and 1995 suggesting that about 1 in 200 patients reported having new suicidal thoughts while on Prozac, while none did while taking an older non-SSRI drug. This rate ''sounds about right to me,'' Cole said. It's ''rare enough to make most physicians not notice the effect, but common enough to cause serious adverse effects, such as death by suicide, in a few patients,'' he said.
    But Cole said no one has done the large-scale studies necessary to pin down the frequency of SSRI-related suicides. Such studies are not easy to do, since suicides are uncommon events even among clinically depressed people and researchers must distinguish those related to the underlying depression from those preceded by the extreme agitation, called akathisia. ''Although the manufacturers of SSRI drugs could and should have done these studies, to my knowledge no manufacturer of an SSRI drug has ever done a study where the primary outcome of interest was to measure ... suicidality'' that emerged during treatment, Cole said in a document filed with the federal court Friday.  Cole also said an FDA advisory panel convened in 1991 to consider the alleged SSRI-suicide link ''never came to grips with the reality or non-reality of the phenomenon.''
    But other researchers defend drug manufacturers and federal officials for the way they have responded to studies suggesting a suicide link. These include Dr. Anthony J. Rothschild of the University of Massachusetts Medical School, who coauthored a 1991 study that the SSRI critics cite as evidence of a suicide problem. Rothschild and his colleagues administered Prozac to three patients who had attempted suicide and found they developed severe agitation and suicidal thoughts once again. Those symptoms subsided when Prozac was withdrawn or when the drug was countered by one with calming effects, according to the study. But Rothschild said he thinks Eli Lilly and Co., Prozac's manufacturer, and the FDA ''adequately addressed'' the concerns. ''The thing that disturbs me'' about current SSRI critics, Rothschild said, ''is the tone that suggests there's almost a conspiracy to cover up information and not do the right studies."

Mental Abuse as Harmful to Women as Violence -- Study
Reuters News Service, 5/15/2000

CHICAGO -- Psychological abuse by a partner can be as damaging to a woman's health as physical abuse, a study released Sunday said. "We found that psychological violence was associated with many of the same health outcomes as was physical (violence committed by an intimate partner)," wrote study author Ann Coker of the University of South Carolina, Columbia. Researchers questioned 1,152 women recruited from health clinics over a two-year period ending in January 1999, and found 54 percent had at some time suffered physical or psychological abuse by an intimate partner. Fourteen percent of the women reported psychological abuse without physical abuse, with mental abuse defined as continual feelings of danger, loss of power and control, and entrapment.
    When discussing their health problems, the psychologically abused women were just as likely to report poor views of their physical and mental health as those abused physically. Women subjected to psychological abuse were about twice as likely as non-abused women to report chronic pain, irritable bowel syndrome, sexually transmitted infections, chronic pelvic pain, stomach ulcers, spastic colon, urinary tract and other infections, and migraine headaches. Physically abused women, most of whom reported being abused psychologically as well, also incurred direct injuries as a result of the abuse such as broken bones, arthritis, hearing or sight deficits, and seizures, the study found. The report's authors said hospital emergency departments should have a screening process -- which can be a brief questionnaire -- to identify victims of sexual assault and spousal violence. "As with screening for chronic diseases, early detection of spousal abuse could lead to an effective intervention to reduce associated morbidity and mortality," Coker wrote.

Drug Shows Promise for Alcoholics
Malcom Ritter, Associated Press- 05/16/2000

CHICAGO (AP) — A drug designed to help alcoholics abstain from drinking showed promise in its first American test, according to researchers. Acamprosate worked best in people who aimed to avoid alcohol entirely, rather than just cutting down, said researcher Barbara Mason of the University of Miami School of Medicine. ``It's not magic,'' she said. ``It's not something a spouse can put in the coffee of the alcoholic in the morning and the problem will go away. It has to go hand-in-hand with having abstinence as your treatment goal.'' Acamprosate is now sold in Europe, South America, Asia and elsewhere, and more than a million people have taken it, Mason said. It is manufactured by Lipha s.a. of Lyon, France, which paid for the new study. Mason presented the study's results Monday at the annual meeting of the American Psychiatric Association.
    Dr. Anita Goodman, executive vice president of Lipha's clinical development group in the United States, said the company plans to get the drug on the American market ``as soon as we can.'' That step, which would require federal approval, will take at least a year, she said Monday. Doctors already have some drugs available to maintain abstinence. One, disulfiram, makes a user feel nauseous and otherwise sick if he or she also uses alcohol. Another medication, naltrexone, acts on brain circuitry to reduce the desire to drink. Acamprosate acts on different brain circuitry. Mason's six-month study involved 601 alcoholics who were treated at 21 medical centers. They were randomly assigned to take either acamprosate tablets or a placebo twice a day, starting two to 10 days after their last bout of excessive drinking. They also received psychological treatment, education about effects of alcohol, strategies to help them cut down and quit drinking and exercises to identify what led them to drink.
    Only 41 percent of the participants, or 241 people, began the study with a goal of complete abstinence, Mason said.  Of those people, those on the placebo stayed away from alcohol on 58 percent of the days they were studied. Those taking 2 grams a day of acamprosate didn't drink on 70 percent of the days they were studied; for people on 3 grams, the figure was 73 percent. In all, the members of the placebo group cut their weekly intake of drinks by 36 percent; the two other groups each reduced it by 40 percent. Raye Litten, a program officer for medications development at the National Institute on Alcohol Abuse and Alcoholism, said acamprosate has a modest effect on drinking that's about the same as naltrexone. ``It's another way to treat alcoholism,'' he said. ``The more weapons you have to treat, the better off you'll be, because what works for one person may not work for another."

Cybersex Gives Birth to a Psychological Disorder
Jane Brody, New York Times- 05/16/2000

Sex is the hottest topic among adult users of the Internet, with studies showing that fully a third of all visits directed to sexually oriented Web sites, chat rooms and news groups. For most people these forays into cybersex are relatively harmless pursuits, but experts in the field say that the affordability, accessibility and anonymity of the Internet are fueling a brand new psychological disorder--cybersex addiction--that appears to be spreading with astonishing rapidity and bringing turmoil to the lives of those affected.  Researchers writing in the current issue of the journal , Sexual Addiction and Compulsivity, report that many of the men and women who now spend dozens of hours each week seeking sexual stimulation from their computers deny that they have a problem and refuse to seek help until their marriages, their jobs, or both, are in jeopardy. For some people, the route to compulsive use of the Internet for sexual satisfaction is fast and short, said Dr. Mark Schwartz of the Masters and Johnson Institute in St. Louis. "Sex on the Net is like heroin," he said. "It grabs them and takes over their lives. And it's very difficult to treat because the people affected don't want to give it up."
    Those most strongly hooked on Internet sex are likely to spend hours each day masturbating to pornographic images of having "mutual" online sex with someone contacted through a chat room. Occasionally, they progress to off-line affairs with sex partners they meet online. Dr. Al Cooper, a staff psychologist at Stanford who has conducted the largest and most detailed survey of online sex, calls the Net "the crack cocaine of sexual compulsivity." The survey, conducted online among 9,265 men and women who admitted surfing the Net for sexually oriented sites, indicated that at least one percent were already seriously hooked on online sex. The survey found that as many as a third of Internet users visited some type of sexual site. Projected to the country as a whole, this would mean that a minimum of 200,000 men and women have become cybersex addicts in the last few years, Dr. Cooper said. And, he added, because the respondents were self-selected and because denial of the symptoms of sexual compulsivity is commonplace, there are likely to be many more cybersex addicts than the survey indicated.
    "This is a hidden public health hazard exploding, in part, because very few are recognizing it as such or taking it seriously," Dr. Cooper wrote in his Sexual Addiction and Compulsivity report. Another author, Dr. Jennifer Schneider, a physician in Tucson, Arizona, who is associate editor of the journal, said in an interview that even when cybersex addicts and their partners sought treatment, they often concealed their real problem, and therapists often failed to ask questions that would disclose it. As a result, the diagnosis of cybersex addiction is often missed. Dr. Schneider said. Dr. Kimberly S. Young of the Center for Online Addiction in Bradford, Pa., wrote that "partially as a result of the general population had health care professionals not being attuned to the risks, seemingly harmless cyberromps can result in serious difficulties way beyond what was expected or intended."
    According to Dr. Cooper, who works at the San Jose Marital and Sexuality Center in Santa Clara, Calif., cybersex compulsives are just like drug addicts; they "use the Internet as an important part of their sexual acting out, much like a drug addict who has a 'drug of choice,'" and often with serious harm to their home lives and livelihood. Especially vulnerable to becoming hooked on Internet sex, he wrote, are "those users whose sexuality may have been suppressed and limited all their lives [who] suddenly find an infinite supply of sexual opportunities" on the Internet. Dr. Dana Putnam, a psychologist in San Luis Obispo, Calif. said other factors that could increase a person's vulnerability to cybersex compulsion were depression and other forms of emotional distress, relationship problems and a failure to get one's sexual needs met. However, a second survey conducted by Dr. Schneider among 94 family members affected by cybersex addiction revealed that the problem could arise even among those in loving marriages with ample sexual opportunities. "Sex on the Net is just so seductive and it's so easy to stumble upon it," she said. "People who are vulnerable can get hooked before they know it."
    To those who say a behavioral compulsion is not a true addiction, Dr. Schneider responded with a definition of addiction that would clearly apply to cybersex abusers: "Loss of control, continuation of the behavior despite significant adverse consequences and preoccupation or obsession with obtaining the drug or pursuing the behavior." Although behavioral addictions involve no external drugs, preliminary research has suggested that they cause changes in brain chemicals, like the release of endorphins, that help to perpetuate the behavior. The sexual stimulation and release obtained through cybersex also contribute importantly to the continued pursuit of the activity, Dr. Schwartz said. He wrote: "Intense orgasms from the minimal investment of a few keystrokes are powerfully reinforcing." He added, "Cybersex affords easy, inexpensive access to a myriad of ritualized encounters with idealized partners. Many cybersex abusers are re-enacting aspects of past losses, conflicts or traumas in order to foster illusions of power and love."
    Some cybersex addicts develop a conditioned response to the computer and become sexually aroused even before turning it on, Dr. Putnam said. This can exacerbate the problem for people whose jobs involve work on a computer. "Simply siting down to work at the computer can start a sexual response that may facilitate online sexual activities," he wrote in the journal. As for other addictions, tolerance to cybersex stimulation can develop, prompting the addict to take more and more risks to recapture the initial high, Dr. Schneider said. Online viewing that began as a harmless recreation can become an all-consuming activity and even lead to real sexual encounters with people met online. Cybersex compulsives can become so involved with their online activities that they ignore their partners and children and risk their jobs. In Dr. Cooper's survey, 20 percent of the men and 12 percent of the women reported they had used computers at work for some sexual pursuits. Many companies now monitor employees' online activities, and repeated visits to sexually oriented sites have cost people their jobs. And some people, including two physicians, have landed in federal prison for two years because they downloaded child pornography when authorities were watching, Dr. Schwartz said.
    Still, most who pursue cybersex consider it harmless and safe to do so. While social and safety concerns and fear of discovery may prevent someone from visiting an adult bookstore or prostitute, there are no such constraints when pornography and sexual partners can be called up at any time of the day or night on a computer screen in one's home or office, Dr. Putnam said. To those who say "What's the harm? They're not risking disease or death," Dr. Schenider, who has written extensively on sexual addiction, responds that the damage can be as devastating as that caused by compulsive gambling or addiction to alcohol or drugs. In her survey, 91 women and 3 men in committed relationships said they had experienced serious adverse consequences, including broken relationships, from their partners' cybersex addictions. Partners commonly reported feeling betrayed, devalued, deceived, ignored and abandoned and unable to compete with a fantasy. Among them was a 34-year-old woman married 14 years to a minister who she discovered was compulsively seeking sexual satisfaction by visiting pornographic sites on the Internet. "How can I compete with hundreds of anonymous others who are now in our bed, in his head?" the woman wrote. "Our bed is crowded with countless faceless strangers, where once we were intimate." A 38-year-old woman married 18 years to a man who compulsively masturbates to images on the computer wrote that her husband had once had an extramarital affair and that "the online 'safe' cheating has just as dirty, filthy a feel to it as does the 'real-life' cheating."
    Although Dr. Cooper's survey indicates that most female cybersex addicts are single, married women also become cybersex addicts and their husbands suffer the consequences. A 44-year-old man married 26 years to a woman who became hooked on cybersex wrote: "At first we had sex more than ever as I desperately tried to prove myself. Then sex with her made me sick. I get strong pictures of what she did and lusted after, and I get repelled and feel bad." Women who become cybersex addicts may face even greater risks than their male counterparts. Women, who tend to pursue relationships, are inclined to visit sexually oriented chat rooms rather than the pornographic Web sites that men prefer, Dr. Cooper said. As women become increasingly hooked on online sex, they are more likely to progress to off-line meetings, which can prove dangerous.
    Children, too, often become victimized by cybersex addiction in a parent. As Dr. Schneider noted, children can stumble upon the pornographic material left on or near the computer or walk in on a parent masturbating at the computer. Several mothers in her survey were worried because their husbands surfed the Net while supposedly watching the children, who got to view the pornography and sometimes the masturbation. Children may also suffer as a result of increasing conflict between the parents or breakup of the marriage. And even if the marriage survives, children may lack adequate parental attention when one parent is preoccupied with sex on the computer and the other is preoccupied with the cybersex addict. Once unleashed, the power of a cyber affair, cybersex, or both, can cause a formerly loving man to become evasive and to demand his privacy online, according to Dr. Young and her co-authors. "This 'new frontier' in relationship dynamics can lead a once warm and compassionate wife and mother to turn to the computer and its cyberworld lovers and/or sex partners and away from caring for her children." As Dr. Putnam put it, "Once people get hooked on cybersex, they tend to put themselves at risk and do things they wouldn't ordinarily do."

First Step is Recognizing the Signs of Internet Abuse
Jane Brody, New York Times- 05/16/2000

Addictive and compulsive disorders are notoriously difficult to treat, particularly when they involve a substance or behavior that, when used or practiced normally, is an essential or important part of living, like eating or sex. When people lose control of such behaviors, the goal of treatment is not to cut them out completely, as might be done with alcohol or nicotine, but to re-establish a healthier pattern of use. This is certainly the case for a recently recognized, fast-growing form of out-of-control sexual activity known as cybersex addiction or compulsivity in which people may spend dozens of hours a week online viewing sites that cater to sexual titillation and satisfaction. In treating cybersex addiction, the aim is not to deprive those afflicted of access to computers or sexual outlets but to prevent their abuse.
    Before treatment for any disorder can begin, a proper diagnosis must be made. Someone has to recognize that a problem exists and the person afflicted has to acknowledge the need for help to overcome it. As with other addictions, denial is a common element in cybersex addiction, and people typically maintain that denial until the bottom falls out, for example, with a breakup of a marriage or loss of a job. Partners of cybersex addicts are also sometimes in denial, distressed by a seriously disturbed emotional and sexual relationship but relieved that the addict is not pursuing real-life sex with strangers. A partner's first task, then, is to recognize the early signs of cybersex abuse. Dr. Kimberly S. Young of the Center for Online Addiction in Bradford, Pa., and her co-authors describe the signs of trouble in an article on online infidelity in the current issues of the journal, Sexual Addiction and Compulsivity. They include:
A change in sleep patterns- Online meeting places typically heat up in the wee hours, and cybersex compulsives often stay up later and later for the action. Or they may arise early for private computer time.
A demand for privacy- Dr. Al Cooper of Stanford University and colleagues found in a survey of more than 9,000 visitors to online sex-related sites that 72 percent of the men and 62 percent of the women kept secret how much time they spent online for sexual pursuits. An online sex addict may move the computer into a secluded area or room where the door can be locked and may react with anger or defensiveness if disturbed or interrupted while online.
Ignoring other responsibilities- The cybersex addict may spend more and more hours "at the office" at the expense of family time, or become so fixated on online sex that ordinary chores are ignored, like doing the dishes or laundry. In more that one case, parents have forgotten to pick up their children at school or an activity.
Evidence of lying- An addict may hide credit card bills for online services and lie about the reason for their extensive use of the Internet. Addicts may also quit or cut back their Internet use, but the effort is typically short-lived and frequently repeated.
Personality changes- "A person is often surprised and confused to see how much their partner's moods and behaviors have changed since the Internet engulfed them," wrote Dr. Young, who is the author of "Caught in the Net". A once warm and sensitive wife becomes cold and withdrawn. A formerly jovial husband turns quiet and brooding." And if the cybersex abuser is questioned about the relationship between these changes and Internet activity, there is a tendency to shift the blame to the non-offending partner.
Lost interest in partner sex- Many cybersex addicts have little or no interest in or energy left for more normal sexual outlets. Partners are often mystified by the demise of their sex lives and, if they know about the online activity, may despair of competing with idealized computer images.
Less interest in family- People have just so much time and energy; if much is devoted to online sex. Little is left for family rituals and outings or for building intimacy.
    As with most people who compulsively pursue an addictive substance or behavior, people hooked on online sex rarely seek treatment unless a crisis, like the loss of a spouse or a job, forces them to try to regain control. Even then, therapists say, cybersex addiction is difficult to treat, even more difficult than off-line compulsive sexual activity. As with substance abuse, a common recommendation for those trying to break a cybersex addiction is to join a 12-step program patterned on Alcoholics Anonymous. There are several for sex addicts, including Sex Addicts Anonymous, Sexaholics Anonymous and Sex and Love Addicts Anonymous.
    Dr. Jennifer Schneider of Tucson, co-author with Burt Schneider of "Sex, Lies and Forgiveness: Couples Speaking on Healing From Sex Addiction," points out that there is little point in normal partners' trying to reduce the lure of the Internet by agreeing to sexual practices that make them uncomfortable or by trying to improve their appearance with plastic surgery. But Dr. Schneider does suggest some changes involving the computer: moving it to an open area; using it only for specific planned tasks; using the Internet or going online only when other family members are present, adding Net safety tools and screens and arranging for accountability regarding Internet access at work. Dr. Mark Schwartz of the Masters and Johnson Clinic in St. Louis says most cybersex addicts also need professional help. "Treatment is much slower than with other addictions," he said. "It's a long, winding road with lots of lapses, relapses and acting out." His treatment approach often includes the use of a Prozac like drug, which counters underlying depression, suppresses the sex drive and makes treating the addictive behavior easier. Most effective, Dr. Schwartz said, is group therapy, which helps the addicts confront the way their behavior has taken over their lives. It may take four to five months before a cybersex addict is ready to begin serious efforts at controlling the behavior, and effective therapy can take as much as a year, he said.
    The partners of cybersex addicts also usually need professional help, Dr. Schneider said. Partners need confirmation that a real and serious problem exists and the realization that they did not cause the problem, cannot control it and cannot cure it. They need help in repairing their self-esteem and in learning to pay attention to their own needs and desires. People concerned about their use of the Internet for sexual satisfaction and their partners' can consult a helpful Web site established by Dr. Dana Putnam of San Luis Obispo, California: www.onlinesexaddict.org