Noteworthy News Articles on Mental Health Topics, January 15-23, 2001

HMO Dispute Threatens Mental Health Care
Associated Press, 1/15/2001

HARTFORD, Conn.-- A dispute between a health maintenance organization and a psychiatric hospital is threatening to shut out 100,000 Connecticut residents from one of the most extensive networks of mental health care in the state. Officials at Hartford Hospital's Institute of Living say the crisis was prompted by the routine refusal of Cigna Behavioral Health to pay for the ongoing hospitalization of deeply disturbed patients even when the clinical need was clear. ''I'm concerned they are driven by financial targets,'' said Dr. Harold I. Schwartz, vice president of behavioral health at Hartford Hospital.
    During negotiations on a new contract with the hospital, Cigna eventually agreed to pay for most of the care it had denied in 2000, hospital officials said. But they said the institute will not accept a new contract unless Cigna changes its practices. The two sides are now trying to agree on a new contract, and hospital officials say they want assurances they will not be fighting with Cigna on a regular basis. ''We've got to have a contract that guarantees changed behavior on their part or we're not interested,'' Schwartz said.
    If Cigna and the hospital are unable to agree on new terms, subscribers who want to continue using Hartford Hospital-affiliated psychiatric services would most likely be forced to use out-of-network benefits, if they have them, or pay out of pocket for their care.  Internal hospital records show that Cigna has overly restrictive policies regarding inpatient admissions and lengths of stay, and that it denies payment for inpatient care far more frequently than other HMOs, Schwartz said.
    In the first 11 months of 2000, the institute cared for 58 Cigna patients, who stayed an average of seven days, hospital officials said. They said that's in line with other companies. But, they said, Cigna denied payment for more than one-third of those days for an average funded stay of 4.6 days. Officials at Cigna denied that financial issues are a factor in making clinical decisions. ''At Cigna Behavioral Health we consider clinical issues and financial issues as totally separate,'' said Dr. Vicki Rothenberger, a senior vice president of the Minneapolis-based company. ''Clinical determinations and discussions take place doctor to doctor, or clinician to clinician. They have no financial concerns and no goals or targets.''
    When a patient's needs are assessed, Cigna uses guidelines established by the American Psychiatric Association, Rothenberger said. Clinical experts look at the severity of the illness, the intensity of the treatment and the kinds of support a patient needs to get better.  Cigna clinicians may decide a patient no longer needs hospitalization, but Rothenberger said that doesn't mean the patient doesn't need additional care. ''We look at the whole comprehensive course of care, not just how long the patient is in the hospital,'' Rothenberger said. ''Many patients, they want to continue their treatment in an outpatient setting where they have family support. We actually think that's a good thing.''

Virginia Girl Fatally Injured at Home After Years of Intervention
Patricia Davis and Brooke A. Masters, Washington Post - 1/17/2001

Just eight weeks after Lesley Dodson lost a painful court battle to win custody of her former foster child, she was allowed one final visit to say goodbye to 3-year-old Katelyn Michelle Frazier. The staff at Children's Hospital tried to prepare Dodson for what she would see. Katelyn's body was on a gurney, a sheet tucked carefully around her waist. She wasn't breathing; a machine was making her chest move up and down to help preserve her organs for donation. Dodson pressed her cheek against Katelyn's and began kissing the child she had fought so hard to call her own. "You play with all the Barneys and all the Elmos and all the Poohs," said Dodson, 28. "You just play. Because for the first time, you can be a child, and no one will hurt you."
    Katelyn was fatally injured two days after Christmas in the squalid Alexandria apartment where she lived with her mother, Pennee Frazier; Frazier's boyfriend, Asher Levin; and three siblings. She had been there just three months after a life in foster care, mostly with Dodson. Her death from "blunt impact head trauma" has been ruled a homicide. No one has been charged. Almost immediately, Katelyn's death evoked comparisons to the death of Brianna Blackmond, a District child who was killed a year earlier. Although both children died shortly after being returned from foster care to their troubled mothers, there is at least one glaring difference: Katelyn did not fall through any cracks of an overburdened system. Her case received intense, almost ardent scrutiny throughout the girl's three years, sources said.
    She was the subject of more than 15 court hearings before two judges. Politicians knew about her case and asked questions. Virginia's attorney general intervened. And social service providers went to the home to help Pennee Frazier more than 30 times in the 13 weeks after Katelyn was returned from foster care – including a final visit Dec. 22, just five days before the fatal injury. Still, Katelyn's death has put Alexandria's foster care system under a microscope, with questions being raised about the judges' decisions and the Division of Social Services' handling of the case. Indeed, the identity of the killer isn't the only complicated, unanswered question in Katelyn's death. How could a family under city supervision be living in filthy conditions? Should a child have been returned to a home where her mother had previously neglected her? Were authorities so impressed with Frazier's efforts to improve that they downplayed her mental health problems? Was the case plagued by bad decisions or was the tragedy simply unpreventable? Because of a court-imposed gag order, almost everyone involved has declined to comment publicly. But a review of some key sealed court documents obtained by The Washington Post and interviews with sources who have knowledge of the case help illuminate the decision-making process.

Parental Rights
After taking Katelyn from her mother at 2 months, Social Services at one point sought to terminate Pennee Frazier's parental rights. But that goal changed after a judge ruled that the city had not met the high legal threshold for such a drastic step. As Frazier tried to prove that she was capable of caring for her children by turning her life around and attending parenting classes, Social Services workers orchestrated more than 90 short-term visits between Frazier and her children. Although Katelyn was shuttled among five foster homes and her biological mother, the 15 months she spent with Dodson stand out as an oasis of stability. In that Alexandria apartment, friends watched Katelyn blossom into a healthy, energetic and inquisitive child. "She was always happy, always smiling," said Tamar McNear, 28, who was Katelyn's babysitter while the child lived with Dodson and another foster family. "She called Lesley 'Mommy' . . . and I knew [Lesley] loved Katelyn, that she was her whole little world."
    Sources said that at the last hearing before Katelyn was killed, Bruce C. Adams, the lawyer appointed by the judge to represent her interests, said he thought Dodson should raise the child. But the judge ruled for the biological mother. In his decision, obtained by The Post, Circuit Court Judge John E. Kloch said Dodson had "failed to show special facts and circumstances which would constitute an extraordinary reason for taking the child from its natural parent." City officials said the gag order prevents them from discussing the case, but City Manager Philip G. Sunderland said: "Extraordinary care, attention and resources were provided by city staff, the courts and others to help Katelyn. Unfortunately, tragedies are rarely foreseeable, and this case is no exception."
    The decisions made in Katelyn's case have reignited a passionate debate about whether the foster care system leans too heavily toward reuniting biological families. Historically, social workers and the courts nationwide have worked mightily to keep those families together. But in recent years, some children's advocates have questioned that logic. "There is a child welfare philosophy that it is best for a child to be with their natural parents, and that isn't necessarily true," said Lelia Smith, executive director of Prevent Child Abuse of Metropolitan Washington. "The child has a right to stability, and . . . you've got a woman on substance abuse in an unstable living situation with additional children. She appears to have some of the highest risk factors for child abuse out there." But Richard Wexler, Washington director of the National Coalition for Child Protection Reform, warned that Katelyn's case may simply be an exception. Studies show that 154,000 foster children are returned to their biological families each year and that 0.03 percent are killed, he said. Studies also show that child deaths are more likely when overworked social workers have large numbers of troubled families to supervise."If the result of this case is that more children are kept away from their parents for longer . . . you'll wind up taking a huge number of cases," he said. "The one thing that will guarantee is that more children will wind up dead."

An Infant in a Shelter
Katelyn's odyssey began in February 1998, just two months into her short life, when concerned workers at Alexandria's Carpenters Shelter told the city that a mother had brought her two tiny girls into the shelter's nighttime-only overflow area. Social services workers found the children unwashed and smelly, and Frazier said the family had been living in a car. The city persuaded Frazier to temporarily hand over custody of Katelyn and her older sister, Jessica, then nearly 3. Court records show that Frazier has bipolar disorder, also known as manic depression, and was struggling with substance abuse.
    Although Frazier and Levin declined to comment for this article, Frazier spoke to The Post last year after Dodson's family told the newspaper about the custody battle. "There was no abuse and neglect," Frazier said then. "We were staying in a shelter, and you can't take showers. They had some bruises, sure, but I could tell you where every one came from." Still, within days, city officials sought a mandatory removal order. After a brief stay in emergency foster care, Katelyn and Jessica lived with a Fairfax County family for about seven months. But that family found caring for an infant and a child with emotional problems overwhelming, so social workers decided to split the girls up, sources said.
    They turned to two new foster families who lived near each other in Alexandria and had become friends during parenting classes. Zenia Reyes, 30, and her fiancee, Corey Grant, 31, took Jessica. Dodson and her husband, Rich Wray, took Katelyn. Reyes and Dodson both were told by Social Services that Frazier had all but exhausted her options and that the children would probably be available for adoption, sources say. Reyes and Grant said they weren't interested in having permanent custody of an older child with serious issues. But Dodson and Wray, who had been trying unsuccessfully to have children of their own, jumped at the chance to adopt Katelyn. "From Day One, I said we wanted her," said Dodson, a dental assistant.
    The pensive little girl in the bonnet quickly became "Kate," and Lesley became "Mommy." A sunny child who loved exploring everything from plants to audiotapes, Katelyn would make her foster parents laugh when she stood on one leg like a flamingo. "We took her everywhere," Dodson said. "Rich and I wanted her to have everything." In April 1999, Dodson took Katelyn to Florida to introduce her to her extended family and celebrate what she thought would be an adoption. But while they were gone, the case took a drastic lurch in a new direction, sources said. Juvenile and Domestic Relations Court Judge Nolan B. Dawkins ruled against terminating Pennee Frazier's parental rights and ordered Social Services to come up with a new foster care plan that had family reunification as its final goal, sources said.
    Frazier had recently begun to put her life together: She had moved in with her parents in Gaithersburg, started substance abuse treatment and was attending church regularly, sources said. She also showed up for her nearly weekly visits with the girls, trudging down to Alexandria on Metro to take them to the mall, McDonald's and public libraries. Foster care experts said both judges in this case were working within a legal system that has historically emphasized parental rights and family reunification. Although judges and social workers try to act in the best interest of the child, Virginia laws – like those in most states – still make it difficult to terminate the rights of a parent who is genuinely making an effort to get his or her child back. "There appear to be two conflicting philosophies: the rights of the parents versus the needs of the child. I believe the judge is being asked to be Solomon," said Smith, whose group is an advocate for child abuse prevention programs. "He says you haven't met the burden of proof for terminating parental rights. He didn't say this is in the best interest of the child." City officials started scheduling visits in Maryland and moving forward with plans to return Jessica and Katelyn to Frazier.
    But troubling new issues arose. Pennee Frazier's father, Donald, 52, had pleaded guilty in 1993 to one count of sodomy after a Montgomery County man came forward and told police that between the ages of 8 and 14, he had been repeatedly abused by Donald Frazier in the 1970s at the Fraziers' home while Frazier and his wife, Billie, were baby-sitting. Court records also show that Pennee Frazier had accused her father of molesting her but later recanted. The visits of Jessica and Katelyn were also troubling to the foster mothers. Both girls would come back late, exhausted and dirty. Jessica's long hair would be so matted with food that Reyes eventually cut it. Food that Dodson had carefully packed for Katelyn would come back uneaten. Reyes and Dodson told social workers of their concerns. Workers also talked to Donald Frazier's doctor, who said he did not believe that Frazier, who had been treated for mental illness, posed a danger to the girls, according to sources and Donald Frazier himself. Donald Frazier would not comment for this article, but he said last winter: "I'm no harm to the kids. I don't feel I am the same person I was a long time ago. I've become more of a Christian."
    As the case grew more complicated, the reunification dates kept getting pushed back, from late summer 1999 to February 2000. Meanwhile, Social Services workers were also becoming concerned about Dodson, fearing she had overstepped her role as a foster parent. She was having troubles of her own. Dodson had a miscarriage in fall 1999, and she and Wray were divorced in October of that year, although they have since reunited. Social workers believed Dodson was too attached to Katelyn. In mid-October 1999, Katelyn returned from a weekend visit at the Fraziers with red areas on her bottom, sources said. Dodson suspected sexual abuse and rushed Katelyn to Inova Alexandria Hospital. But a sex abuse expert in a follow-up visit in Maryland determined that the marks were diaper rash. In November, Jessica's preschool teacher in Alexandria saw bruises on her bottom after another visit with the Fraziers and reported the incident to Maryland officials as a suspected case of physical abuse. That complaint also was ruled unfounded, although Maryland officials had now become so concerned about the family that they wrote a letter to Alexandria opposing putting Katelyn and Jessica into the Fraziers' Gaithersburg home, court papers say.
    Still, the children were returned to Pennee Frazier on Feb. 14. Dodson and Wray took the day off from work. "We just enjoyed every second with her," she said. They played in her room, read her favorite books. But they weren't going to let Katelyn go that easily. Dodson filed a petition seeking custody of Katelyn and asking that she be removed immediately from the Fraziers' home. Wray's grandfather, retired Marine Col. Paul Maginnis, began calling the media and politicians, including state Sen. Patricia S. Ticer (D-Alexandria) and Attorney General Mark L. Earley (R). Earley's office charged right in. The state lawyers filed an emergency motion arguing that it was illegal to send the girls to Maryland over the objection of officials there. "The attorney general doesn't want to wait until a tragedy strikes to take action," his spokesman said at the time. "By then it's too late." Dawkins, the juvenile court judge, reversed himself, and social workers removed the children from the Gaithersburg home just 10 days after they had been delivered there.
    Jessica went back to Reyes and Grant, but social services did not return Katelyn to Dodson, choosing to send her to another foster family. Alexandria officials also arranged for Pennee Frazier, who by then had a third child and was pregnant with her fourth, to move into a publicly subsidized Alexandria apartment. Levin, the soon-to-be-born child's father, who is a convicted thief with another pending theft charge, joined her. In May, Jessica was returned to Pennee Frazier for a long-term visit, court papers say. In August, the fourth child was born. And in late September, Katelyn arrived for a long-term visit as well, although the city kept legal custody.
    Alexandria social workers continued to monitor the family, providing a level of supervision that child advocates said would be unheard of in the District. As part of the more than 30 visits from social services providers, the family received 10 to 15 hours a week of aid from a contractor who specifically works to help troubled parents provide better child care. "They sound like they're really doing their job," said Liz Siegel, a District lawyer who represents abused children. "You can't protect against everything." But Dodson hadn't given up. When Dawkins turned down her custody petition, she appealed to Circuit Court, where Kloch held a hearing from Oct. 31 to Nov. 2. He ruled that Katelyn had a "strong and positive attachment" to her biological mother, siblings and extended family. Despite a prior finding of abuse and neglect, Kloch said Frazier was a fit mother. Dodson had "failed to demonstrate that the best interest of the child would be served" by giving her custody.

Living, Dying in 'Squalor'
Police responding to the 911 call on Dec. 27 described Frazier's home as "squalor," with rotting garbage overflowing, food ground into the floor and dirty dishes and litter throughout the apartment, sources say. One of Katelyn's siblings had a rash over 80 percent of his body, and another had double ear infections that required medical treatment, according to documents. Katelyn was not breathing and was unresponsive. Frazier and Levin, the only adults known to be at home at the time, gave police inconsistent statements about the girl's injuries, according to court records, and the city took the three surviving children into protective custody.
    As local and state officials continued their investigation and Katelyn's name began to appear nightly on the local news, the Fraziers held a small memorial service in Gaithersburg last week. Katelyn's foster family sat in the front row on one side of the church. Her blood relatives sat on the other. The strains of "Jesus Loves Me" filled the Gaithersburg Church of the Nazarene, and tears flowed on both sides of the aisle. As Katelyn's face smiled at them from a collection of photographs on the altar, the pastor addressed the difficult situation before him. "This is not a courthouse today; this is a house of God," said Ben Spitler. "This is not a press conference." He asked that everyone pray for Katelyn and her siblings. For her mother, and for her foster parents. For the judges and the social workers. "We are all real people – not just names in the news," he said. As the service concluded and the chapel slowly emptied, Pennee Frazier finally reached out tentatively to tap Dodson on the back. Dodson turned toward her, shook her head no and walked out, the pastor's words still ringing in her ears. "We don't understand all this today," Spitler said. "There are a lot of questions. The hardest question is, why?"

Supreme Court OKs Extra Jail for Sex Predators
ABC News, 1/17/2001

A state's failure to provide treatment required by law does not turn a sex-predator's lawful confinement into unlawful punishment, said the 8-1 ruling in the case of a six-time rapist in Washington state. Instead, the justices said sex predators can take other action, such as filing a civil-rights lawsuit, to try to force a state to provide proper treatment or otherwise improve conditions. The high court held that such prisoners cannot win their release by merely challenging the conditions of their confinement. The case is a followup to the justices' 1997 ruling in a Kansas case that allowed states to keep sexually violent predators locked up even after they have finished serving their prison terms. Such confinement, intended to protect society, is not punitive and therefore does not amount to double punishment for the same crime, that 5-4 ruling said. Washington state's sex-predator law served as a model for the Kansas statute upheld by the Supreme Court.
    Andre Brigham Young, who was convicted of six rapes over a 31-year period, challenged his confinement under the law, saying he should get a chance to show that he was being subjected to unconstitutional double punishment. In 1990, shortly before Young was to complete a prison term for the last of his convictions, state officials began proceedings that resulted in him being confined indefinitely as a sexually violent predator. Young sued the state in 1994, saying he was being denied the treatment required under state law and therefore his confinement amounted to punishment. The 9th U.S. Circuit Court of Appeals ruled for Young, saying he should have a chance to prove to a federal judge that his confinement is indeed punitive because he was not receiving treatment.   In a separate lawsuit filed by another inmate, a federal court held the state in contempt in 1999 for failing to comply with an order to improve mental health treatment at the sex-offender facility. The state has been spending millions of dollars to improve the facility.  The state, in appealing to the Supreme Court, said inmates had two other options besides the type of claim filed by Young: a state court lawsuit accusing the state of violating the law requiring treatment for sex predators, or a federal civil-rights lawsuit seeking to improve the conditions of confinement. The Supreme Court reversed the appeals court ruling and sent the case back to the lower courts.
    The case, like the previous decision, turned on whether the post-sentence lockup was essentially the same thing as involuntary civil commitment for the mentally ill. If so, then the program passed muster. In this case, the court started with the premise that Young's confinement was like civil commitment and then looked at his claim that conditions of his confinement meant that the state was punishing him, not treating him. That kind of case-by-case analysis of whether an individual prisoner's confinement was civil or punitive is "unworkable," Justice Sandra Day O'Connor wrote for the majority. "An act, found to be civil, cannot be deemed punitive 'as applied' to a single individual," O'Connor wrote. Justices Clarence Thomas and Antonin Scalia wrote concurring opinions, with Justice David H. Souter joining Scalia's concurrence. Justice John Paul Stevens wrote the lone dissent. Stevens took issue with the majority assumption that Washington's law was civil, and agreed with Young that the state could be punishing him twice for the same crime. "If conditions of confinement are such that a detainee has been punished twice in violation of the double jeopardy clause, it is irrelevant that the scheme has been previously labeled as civil without full knowledge of the effects of the statute," Stevens wrote.

Michigan Mental Health Agencies to Lose $27 Million Over Error
Detroit Free Press, 1/18/2001

Because of budget errors made by the state Department of Community Health, Michigan's 49 community mental health agencies will lose $27 million this year, according to a published report. The money will be deducted from what the state pays each agency monthly, starting immediately, reported the Detroit Free Press Thursday. That may mean reduced services for mentally ill and developmentally disabled people throughout the state. About 224,000 people receive such services statewide.
    The state's error originated in October 1998, when the state began to require mental health agencies to convert to a managed-care system. Each agency received a chunk of state money to manage Medicaid recipients. But when the state calculated how much to give each agency, it overcounted a group of low-income people whose Medicaid coverage varies by the month. The state discovered the error when it was filling out paperwork for the federal government last fall. "We're just beginning to take a look internally as to what this is going to mean," said Dr. Altha Stewart, executive director of the Detroit-Wayne County Community Mental Health Agency. "We have not been forced as of now to make cuts, but I don't know if in another couple of months I'll be able to say that."
    More than a third of the money would have gone to agencies in the Detroit area, including about $6.4 million for Wayne County, $3.4 million for Oakland County and $2.1 million for Macomb County. "The people who will really suffer are the consumers. Every time I have to consider a cut, someone will not get a service they really need. That's not right," said Stewart, who oversees a $500-million budget. Many community mental health agencies already were struggling. Mental health was the only part of the federal- and state- funded Medicaid program that did not get a cost-of-living budget increase in the current fiscal year. David LaLumia, executive director of the Michigan Association of Community Mental Health Boards, said the state has not put new general fund dollars into the agencies' budgets for 10 years.
    The timing is particularly bad for Oakland County. Richard Visingardi, executive director of the Oakland County Community Mental Health Authority, was hired less than a year ago. He said this week that he discovered an additional $8 million budget shortfall for 1998-99 and an $18 million shortfall for 1999-00 because of budget design flaws under the agency's previous administration. He already has cut $8.5 million of his $202 million budget by eliminating management jobs and changing policies, and said he's looking for more ways to cut costs. "Right now, we are at the wall," he said. "I'm squeezing everything I can out of this place ... so we can spend the money on the people."

Truck Driver in Capitol Crash Had History of Mental Illness, Violence
Julie Tamaki, Los Angeles Times-1/18/2001

SACRAMENTO--The man authorities believe smashed a loaded tractor-trailer into the state Capitol on Tuesday, incinerating himself in a ball of fire, had a 15-year history of criminal violence and bouts of mental illness. Since 1986, Mike Bowers, 37, of Hemet had been in and out of prison for battery on a peace officer, child beating and assault with a deadly weapon. In 1999, psychiatrists at Patton State Hospital asked authorities to keep Bowers in custody. The Riverside district attorney's office agreed to petition the court, believing Bowers to be dangerous. But he was released that year after a jury found otherwise.
    Eight days ago, he passed a background check and was hired as a driver for Dick Simon Trucking Inc. of Salt Lake City. Some days later he picked up a load of Gold Cross Evaporated Milk from a Nestle factory in Modesto. "It was very unfortunate and extremely embarrassing," said trucking company President Kelle Simon. "I don't understand how the driver can have a criminal history if it didn't show up on the background check." Shortly before 9:30 Tuesday night, blaring his horn and driving at what police estimated was 50 mph, he drove the 18-wheel semi-truck laden with canned milk up the steps into the south entrance of the 127-year-old Capitol. The man believed to be Bowers died in the resulting fire, which chased hundreds of legislators and staff members from the building. The charred remains of the driver were removed from the truck cab Wednesday, and authorities were awaiting dental and DNA checks before officially confirming his identity.
    Searching for evidence to explain the crash, investigators came across a 1999 letter from Bowers to Gov. Gray Davis, sources in the Capitol said Wednesday. In the letter, described as "unthreatening in tone," Bowers reportedly complained about being held in Patton State Hospital. Bowers, a source said, wrote Davis that he had come up with a secret explanation for the fall of the former Soviet Union. The crash was the most serious at the Capitol since a 1984 firebombing that ignited a blaze in the old governor's office, now part of the Capitol museum.
    Assemblywoman Helen Thomson (D-Davis) said the suicide crash, which came a week after a shooting rampage in the Sierra foothills by a former mental patient that left three dead, is a wake-up call for reform of the state's rules on mental health commitment. Other legislators said the incident proves the need to revive a 1998 plan by former Gov. Pete Wilson to build a fence around the mostly unprotected Capitol. During the last lawmaking session, Thomson unsuccessfully promoted legislation to reform the 30-year-old Lanterman-Petris-Short Act, which makes involuntary commitment difficult, even in extreme cases. "What is so sad is that I get letters telling stories like this every day," Thomson said. "Now it is on the front door of the Capitol, very graphically and very tragically."
    Bowers' 15-year stint in and out of prison and mental hospitals began when he was convicted in Mono County in September 1986 of battery on a police officer, and sentenced to two years in prison. Between 1987 and 1991 he was paroled four times and returned to prison four times, said Terry Thornton, spokeswoman for the California Department of Corrections. During that time, his offenses included battery, assault with a deadly weapon, child battery and resisting arrest. In September 1991, Bowers violated felony probation related to his conviction in a 1989 incident in Riverside County in which he was charged with injuring a child and resisting law enforcement officers, authorities said. Bowers' then-girlfriend had called police saying that he was using physical force on her and their daughter, said Valerie Mraz, supervising deputy district attorney for Riverside County. Bowers had refused to let police in, barricading himself in his garage and later in the house. Police eventually forced the door open and took Bowers into custody, Mraz said. In prison, he was diagnosed as having a mental disease or defect. In July 1995, he was paroled and sent to Atascadero State Hospital.
    Three years later, state officials asked the Riverside County district attorney's office to extend Bowers' commitment another year. A jury trial was held on the issue, Bowers' term was extended, and he was sent to Patton State Hospital. In 1999, another trial was held after state officials sought a second one-year extension. The jury determined that he was no longer a threat to himself or others, and he was discharged in November. "He has a mental disease or defect that we didn't believe was in remission or would remain in remission absent treatment," Mraz said Wednesday. It was not the last encounter that Mraz's office would have with Bowers. He was arrested last December in the Lake Elsinore area and charged with a misdemeanor count of domestic violence for allegedly assaulting his spouse. Bowers, who represented himself in the case, was placed on probation. A number of conditions were imposed on him--including attendance at anger management classes, Mraz said. "Mr. Bowers was articulate and appeared to have some knowledge of the law," Mraz said. "There was no real outward manifestations of any grave mental illness."

CHADD: Media Reports of AD/HD Prescription Medication Abuse Create Confusion
U. S. Newswire, 1/18/2001

To: National Desk, Health, Medical and Media Reporters
Contact: Peg Nichols of CHADD, 301-306-7070, ext. 102
LANDOVER, Md., Jan. 18 /U.S. Newswire/ -- Some news media continue to report sensational anecdotes of abuse of medications to treat attention deficit/hyperactivity disorder (AD/HD) by people for whom these medications are not prescribed. CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder) is concerned that these reports may create confusion among the general public, patients and families with regard to the seriousness of AD/HD and the proven safety and efficacy of these medications when properly administered. CHADD is the nation's leading advocacy organization serving those with Attention Deficit/Hyperactivity Disorder (AD/HD) and their families, with more than 22,000 members.
    Stimulant medications do have the potential for abuse by anyone, which is why the U.S. Drug Enforcement Agency has ''placed stringent controls on their manufacture, distribution, and prescription,'' according to the National Institute on Drug Abuse. CHADD emphasizes the importance of working closely with physicians to diagnose and treat childhood mental disorders, and cautions parents and care givers to carefully supervise the administration of medications to children. CHADD advocates a multimodal approach to the treatment of AD/HD, including parent training in diagnosis, treatment and specific behavior management techniques, an appropriate educational program, individual and family counseling when needed, and medication when required. Medication is used to improve the symptoms of AD/HD. Research shows that children and adults who take medication for the symptoms of AD/HD attribute their successes to themselves, not to the medication.
    Attention Deficit/Hyperactivity Disorder (AD/HD) is a neurobiological disability that affects 3 to 5 percent of school-age children and approximately 2 to 4 percent of adults. AD/HD is characterized by developmentally inappropriate impulsivity and attention, and in some cases, hyperactivity. According to the 1998 NIH (National Institute of Health) Consensus Statement on the Diagnosis and Treatment of AD/HD, ''Children with AD/HD have pronounced impairments and can experience long-term adverse effects on academic performance, vocational success, and social-emotional development which have a profound impact on individuals, families, schools and society.'' Long-term studies show that children who receive adequate treatment for AD/HD have fewer problems with school, peers and substance abuse, and show improved overall function, compared to those who do not receive treatment.

'John's Law' Impounding Drunken Drivers' Cars Passes N. J. Assembly Committee
Kathleen Cannon, Associated Press, 1/18/2001

TRENTON, N.J. (AP) Drunken drivers would have their cars impounded to prevent them from getting back behind the wheel and risking even more lives under legislation spurred by the death of a Navy ensign last July. Friends and family members of John R. Elliott of Egg Harbor Township, who was killed when he was struck by a drunken driver who had already been arrested and released by police, trekked here Thursday to lobby for the bill. ''It was a violent and senseless accident which we believe should never have happened,'' the victim's father, Bill Elliott, told members of the Assembly Law and Public Safety Committee. The committee approved the bill, A-2755, and sent it to the full Assembly for consideration.
    Under the measure, police could impound a drunken driver's car for up to 12 hours after an arrest. The bill also says that people who pick up a drunken driver must sign a waiver saying they will not let the suspect drive while drunk after release from police. But a representative of Mothers Against Drunk Driving called for a longer impoundment period to given suspects more time to regain sobriety. Bill sponsor, Assemblyman Frank Blee, R-Atlantic, said after the hearing he would consider lengthening the impoundment to 12 to 48 hours.
    The bill, dubbed ''John's Law,'' was inspired by the July 22 death of the recent U.S. Naval Academy graduate. He was hit by a drunken driver who had just been released from police custody. The driver was picked up by a friend, who then dropped the drunken man off at his car. Bill Elliott, who was accompanied to the hearing by his wife, Muriel, daughter, Jennifer, and his son's girlfriend, Kristen Hohenwarter, brought petitions signed by 8,500 people endorsing the bill. He recounted how his son was driving home for his mother's birthday when the accident happened. ''John was the most joyful and enthusiastic young man. He had an irresistible love of life and an infectious sense of humor,'' the father said. ''He was simply the finest son a father could ever have,'' he said.

$12.8M Added for Mental Health: Community-Based Services Sought in Massachusetts
Anne Barnard, Boston Globe, 1/19/2001

Governor Paul Cellucci plans to submit a budget that includes $12.8 million in new funding for treatment of the mentally ill, administration sources said yesterday. The increases -- targeted to ease a funding crisis that has kept hundreds of patients in hospitals waiting for proper outpatient care -- are $6 million for mentally ill adults, $4.8 million for children, and $2 million for the homeless mentally ill, said two officials, who spoke on condition of anonymity.
    The numbers may not sound huge compared to the Department of Mental Health's $600 million budget, but mental health advocates said they were thrilled with the proposal. They called it a sign that the state is paying more attention to the problems of the mentally ill - particularly those who linger in hospitals for lack of community-based services that would allow them to live at home or in group homes. ''We're really happy that people are finally taking notice that this is a problem,'' said Donna Wells, of the Parent-Professional Advocacy League.
    Last year, Cellucci signed a bill requiring parity in insurance coverage for mental illness, and pushed through a $10 million infusion that paid for 352 new beds in intermediate facilities to spring stranded children from hospitals. But that only highlighted the need for even less restrictive, community-based services. ''We were frustrated that a lot of it was used for the [intermediate] residential bed end of things, [when] our families are very interested in the community-based services,'' Wells said.
    That's where the new proposal, part of the budget Cellucci will submit Wednesday, comes in. The $6 million for adults will fund community beds for 235 adults, the officials said, an increase of approximately 4 percent over the 6,000 the state already provides. It will also pay for 24-hour case management for 480 new clients mainly living in private housing. The $4.8 million for children will pay for integrated services from numerous state agencies that help families care for children at home. The officials could not provide figures on how many children would benefit. The $2 million for the homeless will fund between 25 and 35 intermediate beds and between 40 and 67 community beds.
    It's not an instant solution. On any given day, there are around 3,000 adults and 130 children waiting for community-based mental-health services, according to the state. ''Like many advocates, we will be asking even for additional sums,'' said Tim O'Leary, deputy director of the Massachusetts Mental Health Association, ''But this is a terrific commitment,'' particularly if it translates into adequate funding in future years. The proposal is not in itself enough to head off two lawsuits that groups of lawyers have threatened against the state, one on behalf of children and one on behalf of adults, said Frank Laski, executive director of the Mental Health Legal Advisors Committee, one of the groups now negotiating with the state. ''What we want is a comprehensive plan,'' he said. ''If this were part of a trend which would incrementally move the department's budget up so it could adequately meet the growing need, that would be a good sign.'' The state officials declined to predict future funding levels. But, said one, ''This is a significant improvement.''

Methadone Facilities Must Be Accredited
Associated Press, 01/19/2001

WASHINGTON – Methadone clinics must be accredited in a manner similar to other health facilities, say new government rules intended to improve the quality of treatment for heroin addiction. Under the rules, published Wednesday by the Substance Abuse and Mental Health Services Administration, clinics that distribute methadone and other addiction-treating medication must tailor therapy to addicts' differing needs, provide more physician supervision and take other steps proving quality. "We want to promote state-of-the-art treatment services," said Dr. H. Westley Clark, the agency's substance abuse treatment chief. "We already know every program is not going to survive this," he said, but added that most methadone clinics will meet the new accreditation standards.
    Until now, methadone clinics have been inspected by the Food and Drug Administration. Those inspections were widely criticized as inadequate, and the FDA is quitting them. Instead, the mental-health administration will contract with private organizations – the one that accredits hospitals is a candidate – to inspect clinics and report which ones meet new government quality standards. Clinics will have two years to comply.
    Methadone, a synthetic narcotic, suppresses withdrawal symptoms and curbs craving. It has been used for more than 30 years to treat heroin addiction. Another substance called LAAM is also used. Doctors anticipate FDA approval of a third therapy, another synthetic narcotic called buprenorphine, later this year. The White House drug-policy office estimates that the nation has 980,000 heroin addicts but that only about 20 percent receive methadone or LAAM. There are about 1,000 U.S. methadone treatment programs. They're controversial, as some neighborhoods object to the clinics despite scientific evidence of their effectiveness. Some states have no clinics; others have only one or two. Still more have long waiting lists of addicts seeking treatment.
    The new rules are "a positive step forward," but it's unclear how much they will improve patient care, said Holly Catania of the Lindesmith Center-Drug Policy Foundation, a New York-based institute that advocates drug policy reform. "I don't know if that in fact will happen from this change," she said. "What is disappointing is there's nothing in the regulations that would expand access to this lifesaving treatment." The foundation had pushed the government to allow private doctors to dispense methadone, something not in the new rules. Dr. Clark said that the first step is to improve existing care but that he also hopes to address accessibility. One new rule, however, should free some room in crowded methadone clinics, he said: Instead of restricting recovering addicts to a six-day methadone supply, those who do well after a year's treatment can take home a two-week supply, and those doing well after two years of treatment can take home a month's supply.

Colorado Board's Advice Proposed for Sex-Offender Facility
Kieran Nicholson, Denver Post- 1/19/2001

Jefferson County plans for a juvenile sex offender facility near Pine will have to be presented to the Colorado Sex Offender Management Board under a bill proposed by Rep. John Witwer. "What this would do is require the county to go through an additional step before it could proceed with building that facility," said Witwer. "They would be required to go before the sex offender management board to get their advice on the proposed program." Jefferson County's plan for the facility, which could house up to 100 juvenile sex offenders on a 1,100-acre campus, has run into strong opposition from neighbors. The county hopes to have the facility operational by February 2002.
    "I think this is a step in the right direction," said Jana Black, a spokeswoman with Help Our Mountain Environment, a local group opposed to the Pine facility. "Hopefully, this legislation will make them think about the best practices they should use, and whether this facility is the best solution at all. If the (board's) recommendation is that this is not the best solution, maybe they will listen to that." The sex offender board was created in 1992 by the legislature. Last year, legislators mandated that the board "develop and implement guidelines and standards for a system of programs for treatment of juvenile sex offenders." The board has a July 1, 2002, deadline to finish its guidelines and standards. "In the meantime we want any public entity that is going to do any bricks-and-mortar building of a new treatment facility to go through the sex offender management board to get their advice for the best practices on the treatment of juvenile sex offenders," said Witwer. House Bill 1117, co-sponsored by Sen. John Evans, R-Parker, passed through the Civil Justice and Judiciary Committee Thursday by a 9-0 vote and now moves to the full House.
    Last January, Jefferson County commissioners passed a resolution limiting the number of sex offenders, including juveniles, to one per household. The resolution gave eight "group homes" in the county two years to comply and county officials began plans for a new juvenile sex offender facility. Under the resolution, the county can also grant a special exemption to allow more than one sex offender in a home if warranted. "It appears at this juncture, if there is no other change, that this bill would not be a hindrance to our moving forward in selection of a site and constructing a facility," said John Masson, Jefferson County spokesman. The county is mandated by state and federal law to provide treatment for juvenile offenders, who are wards of the county, Masson said.

Patient Suicide Brings Therapists Lasting Pain
Erica Goode, New York Times, 1/16/2001

For one therapist, it came out of the blue, the phone ringing late on a Friday evening, and then two police officers at his door, asking him to identify a battered body. For another, it began with an empty chair in a quiet consulting room, the clock ticking past the hour of appointment, foreboding turning to dread and later to certainty. Still another found out almost by accident. Arriving at the hospital where he worked as a psychiatry resident. He overhead a group of colleagues talking about a suicide. "Who was it?" he asked. The answer, he remembered, doubled him over, "like I had been punched in the stomach."
   Psychotherapists enter their profession knowing that the patients who seek their help are sometimes at risk for suicide. The illnesses they treat--depression, schizophrenia and other serious mental disorders--can be as deadly as any cancerous tumor. Yet, perhaps because suicide is a relatively rare event, or perhaps because of the intimate nature of the bond between therapist and patient, mental health professionals are frequently less prepared to deal with a patient's death than other medical specialists. And a new report suggests that even for the most seasoned clinicians, the suicide of a patient can have a long-lasting emotional impact.
    The report, based on in-depth interviews with psychiatrists, psychologists and social workers, found that after a suicide, many therapists carried unresolved feelings of guilt, anger, grief or betrayal around with them for years. Some experienced nightmares, extreme anxiety or other symptoms of stress after the death. Self-blame, fear of being blamed by others and a sudden lack of confidence, particularly in dealing with suicidal patients, were also common reactions. And rather than helping them come to terms with and learn from a patient's suicide, the report found, hospitals and other institutions often either blamed the therapists or offered empty reassurance that nothing could have been done to prevent the death.
    Dr. Herbert Hendin, the medical director of the American Foundation for Suicide Prevention and the lead author of the report, which appeared last month in the American Journal of Psychiatry, said that for most of the therapists, having a patient commit suicide was "the most traumatic event of their professional lives." "It is troublesome how long the difficulty stays with people," he said. "They don't seem to get the kind of working through you would think people would get in a professional situation."
    The report summarized the results of interviews, conducted over ten years, with 25 psychotherapists, who traveled to the foundation's national headquarters in Manhattan for day-long seminars. The broader purpose of the research project was to learn more about patients who killed themselves while in treatment. But the therapists were asked to fill out questionnaires about their emotional reactions to the death, sand they talked about their experiences at length with the research team. In most cases, the suicide had occurred less than five years before the therapists participated in the study. But in three cases, more than a decade had passed since the patients died. Most of the therapists who were interviewed, Dr. Hendin said, reported that they found the discussions to be therapeutic. "They had a great need to talk about it in a safe environment," he added, "and the fact that we are not involved in their careers or their hospitals I think was enormously helpful."
    Surveys indicate that one out of two psychiatrists loses a patient to suicide at some point, and about a third of those experience the loss while in training, when they often are working in clinics or on hospital wards with severely ill patients. Clinical psychologists and social workers face lower, but still substantial, odds of having a patient die. Yet while doctors in other areas of medicine are trained to view death as an inevitable part of their profession, and an unfortunate consequence of the illnesses they treat, psychiatrists are more apt to respond to the suicide of a patient as a personal failure.
    "Doctors are ashamed of this," said Dr. John T. Maltsberger, a co-author of the journal report. "There is a feeling in the profession that if you lose a patient to suicide, you probably did something wrong," Dr. Maltsberger said. "Well, sometimes that's true and sometimes it's not. The only thing you can do is learn everything you can." Dr. Maltsberger added that he hoped the study, which is continuing, would lead to more open discussion of the issue in the field and encourage institutions to provide more support to those who experienced a loss.
    For the therapists who participated in the interviews, grief was the emotion most frequently reported after a patient's death. Guilt, anger and fear of being sued were also common. Several attended their patient's funerals and maintained contact with the patients' families after the suicide. For young therapists, just starting out in their careers, the sense of shock was often particularly intense. Dr. Wayne S. Fenton, for example, a psychiatrist at the National Institute of Mental Health, who participated in the study, remembered that he had been in practice for only a year or two, 15 years ago, when a patient he was treating, a young man with schizophrenia, killed himself by jumping off a building. Dr. Fenton said the patient had recently started taking the antipsychotic drug clozapine, a treatment that at the time was still experimental. The young man, he said, improved "remarkably" on the drug. And when the psychiatrist met with him late on a Friday afternoon, they spent the session discussing the future, including the possibility that the young man could return to college.
    But at 7:30 that night, as Dr. Fenton prepared to tuck his three young children into bed, the hospital called to say his patient had not arrived at the outpatient program where he was supposed to spend the evening. A few hours later, there was another call: the police had found a body, they said, and wanted to show him photographs to identify. "This suicide was unexpected by everyone," Dr. Fenton said, "Particularly insofar as there was a feeling that here was a patient who was really improving tremendously." For years after the death, Dr. Fenton said, he became anxious every time the telephone rang at night, with "the feeling of your heart going into your throat, when you're afraid it's the worst."
    In Dr. Fenton's case, the administrators at the hospital where he worked were supportive. He participated in a "psychological autopsy" in an attempt to understand the suicide, and benefited from the guidance of other psychiatrists at the hospital who had had similar experiences. He also began to focus his research efforts on the relationship between suicide and schizophrenia. For other therapists interviewed in the study, however, the official inquiries into the suicide proved to be almost as traumatic as the event itself. In one case, a psychology intern found herself being grilled at a meeting held to discuss the death. The clinical director, she recalled, fixed his gaze on her and proclaimed, "It appears that Ms. C. died the way she was treated, with a lot of people around her but no one effectively helping her."
    Still other therapists said they had chafed at foolish or cavalier comments by co-workers and hospital staff. "All my colleagues looked at me differently and were either supportive to the point of irritation or on pins and needles," another therapist wrote. In a conference held to discuss his patient's suicide, the therapist continued, "I was angry at how it made a scapegoat of " the patient. For example, the therapist wrote, the assembled doctors concluded that "we did a good job on this case" and that the patient "didn't let us help him."
    Even veteran therapists in the study reported that the suicide of a patient had, at least for a time, shattered their confidence and caused them to second-guess everything they did. In the case of one psychiatrist who took part in the study, Dr. Mark J. Goldblatt of Cambridge, Mass., his patient's suicide set off a professional crisis that lasted more than a year. "I saw a lot of people who had done terrible things to hurt themselves," said Dr. Goldblatt, who would not discuss the case in detail. "But having it happen with somebody that I knew, it was shocking." "You think, What happened?" he said. "Did I do something wrong? Did I miss some clues?"
    Dr. Goldblatt detected, he thought, a subtle disapproval from other psychiatrists, an implication that he had not been intuitive enough, or that he had made a bad decision. He suspected that some members of the patient's family held him at least partly responsible. And, he said, "I thought I would never treat anyone who was suicidal again." But he did. And gradually he regained his balance. In fact, he ended up specializing in treating suicidal patients. "The question is, When are they going to act on it, and are they going to act on it," Dr. Goldblatt said. "That is what you are trying to understand."
    For Dr. Joan Wheelis, another participant in the study, it was a question that could be answered only in hindsight. One day in 1995, her patient, a severely disturbed, 23-year-old woman, was late to a session. "I always lived with a kind of anxiety about her," recalled Dr. Wheelis, a psychiatrist and psychoanalyst, who also practices in Cambridge. For almost two years the woman had been coming to Dr. Wheelis for therapy. In that time, the psychiatrist had been plagued by disturbing dreams about her patient, convinced that it was only a matter of time before the woman succeeded in killing herself. "It was not a question of if, but a question of when," Dr. Wheelis said.
    When the chair in her office remained empty for five minutes, Dr. Wheelis immediately called the woman's family. Her patient, she was told, had bought a gun, practiced once at a shooting range, and then shot herself. "It was a shock, but not a surprise," Dr. Wheelis said. "I was extremely dismayed that she hadn't said goodbye and that I hadn't been able to intervene." Yet after the death, she continued, her reaction grew more complicated. She learned that her patient had withheld much of her internal life from her therapist, instead recording her thoughts and intentions, including an account of a previous suicide attempt, on a series of cassette tapes. I felt fury, betrayal; I felt some guilt," Dr Wheelis said. "Although less so than I might have, given that I felt that in her case I really had done just about everything I could."
    After the death, she said, she had another recurrent dream: the woman stood holding a gun in her hands. She turned the gun on herself, then dissolved into dust. Six years later, Dr. Wheelis believes that the loss of her patient has made her more comfortable in treating other suicidal people. "I think I've become calmer and less quick to act, when there is really nothing more I can or should do," Dr. Wheelis said. "And I've become more humbled by how little one can do, ultimately, to keep someone alive."

Marijuana Possession To Be Legalized in Belgium
Chicago Tribune- 1/21/2001

BRUSSELS, BELGIUM -- The Belgian government has agreed to decriminalize the use of marijuana, following its neighbor, the Netherlands, in granting legal tolerance to use of the drug. The Belgian legislation, expected to be approved by the parliament early this year, will legalize possession of small amounts of cannabis for personal consumption. It will not allow sale of the drug, unlike in the Netherlands, where "coffee shops" selling marijuana cigarettes are a common sight in many cities.
    "We are establishing the basis for tolerance in the law, but our country will remain within the lines of international law," the government said in a statement Friday. The legislation, which modifies a 1921 law outlawing the drug, will still prohibit use of marijuana judged to be "problematic" to the user or a nuisance to others. The law also allows the cultivation of marijuana plants for personal use. The decision by the governing coalition of socialists, liberals and greens was criticized by the conservative opposition.

Denying Freedom To Sexual Predators
Lori Montgomery and Daniel LeDuc, Washington Post- 1/21/2001

Two months after a 9-year-old Frederick boy was allegedly beaten to death by a newly released child molester, the Maryland General Assembly is set to consider a proposal to keep sexual predators behind bars even after their prison terms end. The legislation -- sponsored by a Frederick County delegate whose district office is a half-mile from the ballfield where the boy's naked body was discovered Nov. 20 -- would compel authorities to identify the most violent sex offenders before they are released from prison. Instead of being freed, those felons would be confined for treatment until they were no longer a danger to society, or for the rest of their lives.
    The proposal faces tough opposition from civil libertarians and some state officials troubled by the seeming unfairness -- and enormous cost -- of incarcerating people who have served their sentences. Public safety and mental health officials have created a task force to study alternatives to civil commitment, including high-tech programs that force sex offenders to submit to regular lie detector tests or to 24-hour satellite tracking as a condition of probation or parole.
    Elsewhere, satellite tracking has produced particularly encouraging results. In Florida, where 500 criminals carry small transmitters monitored constantly by a network of Global Positioning System satellites, parole and probation violations have dropped dramatically compared with ordinary house arrest, Florida officials said. The system is so effective that a Daytona Beach probation agent was able to catch a child molester as he slowed his car from 46 to 28 mph last summer to watch a 5-year-old girl he had previously abused frolic in an above-ground pool. In a recent interview, Maryland Lt. Gov. Kathleen Kennedy Townsend expressed a preference for satellite tracking, calling it "an idea worth exploring." Next month, the University of Maryland will launch a pilot program using satellites to track a small number of juvenile offenders upon their release from institutions.
    Authorities also are eager to examine polygraph testing for sex offenders. Now used in 33 states, lie detector tests have been shown to help agents probe the minds of sexual predators, eliciting honest answers to questions about improper thoughts and surreptitious visits to playgrounds or pornographic Web sites. "The experience with civil commitment in other states has involved huge expense and endless litigation focusing on a relatively small number of offenders, with treatment costs exceeding $100,000 per offender," said Leonard A. Sipes, spokesman for the Maryland Department of Public Safety and Correctional Services, which formed the task force in partnership with the state Department of Health and Mental Hygiene. "The question for us is, do we focus on a handful of people under civil commitment or on a broader community effort?" Sipes said. "Do we focus our resources on 20, 30 or 40 offenders, or on hundreds?"
    That question gained new urgency after the killing and sexual assault of Christopher Lee Ausherman, whose body was discovered six days after Elmer Spencer Jr., 45, was released from prison. Spencer, who served 3 1/2 years of a 10-year sentence for what was at least his third attack on a child, could face the death penalty if convicted of Christopher's killing. The case horrified Del. Sue Hecht (D-Frederick), who has been pushing Maryland to adopt a civil commitment law for sex offenders since 1998. Hecht, the former director of a domestic violence center, has brought a Kansas couple to testify on behalf of her measure -- the parents of Stephanie Schmidt, 19, whose killing prompted Kansas to enact its civil commitment law in 1994. This year, Hecht plans to invite Christopher's mother to testify. "Now, unfortunately, we have a face, a name, a story" in Maryland, said Hecht, who is still drafting this year's legislation. "In our current system, people like Elmer Spencer are going to get out. It's our obligation to make sure those people don't get out," Hecht said.
    Since 1990, 16 states, including Virginia, have adopted civil commitment laws for sex offenders -- usually because of some gruesome crime, said Scott Matson, research associate at the Center for Sex Offender Management in Rockville. The Virginia law, passed in 1999, has not been implemented because lawmakers failed to budget money for treatment programs. The laws are abhorred by civil libertarians, who say they impose further punishment on people who have paid their debt to society. "If somebody serves their time, isn't that supposed to be enough?" said Del. Sharon Grosfeld (D-Montgomery), chairman of the House subcommittee on criminal law, which will consider Hecht's bill.
    The U.S. Supreme Court, however, has upheld the laws, ruling in a challenge to the Kansas measure in 1997 that civil commitment does not violate the Constitution's prohibition against double jeopardy so long as the purpose is to treat rather than to punish. Last week, the court voted 8 to 1 to affirm Washington state's civil commitment law, the first in the nation. The law had been challenged by a six-time rapist who claimed he was not receiving meaningful treatment. Nationwide, 894 sexual predators have been involuntarily committed to psychiatric hospitals. Authorities have judged just 44 to be "cured" and permitted their release.
    Therein, some argue, lies the problem with civil commitment. "You can't cure a sex offender," said Richard B. Rosenblatt, director of mental health programs in the Maryland prison system. "You manage a sex offender. You help the sex offender manage himself."  To that end, satellite tracking is winning fervent applause in pilot programs in 41 states. Colorado expects to have 500 people on satellite tracking by year's end. And Texas has enacted a civil commitment law that allows judges to substitute satellite tracking for confinement in a mental institution. Florida has the largest program, using satellite tracking primarily for sex offenders placed on probation. Since 1998, about 8 percent of criminals monitored by satellite have violated the conditions of probation, compared with 13 percent on electronic monitoring and 25 percent under ordinary house arrest, according to the Florida Department of Corrections.
    The system works by requiring a criminal to wear an anklet that cannot be removed. The satellite transmitter -- about the size of two videotapes -- must remain within a few feet of the anklet at all times, usually in a backpack or fanny pack. Thus outfitted, a criminal is tracked by satellite 24 hours a day and his movements stored in a computer. The transmitter alerts authorities if the criminal is not where he is supposed to be -- for example, at work by 8 a.m. And it will tell them if he is somewhere he shouldn't be -- loitering near a playground, for example. Settings within the transmitter immediately alert the criminal and the satellite monitoring company when he has crossed the barrier. That alert is relayed to authorities and, potentially, the victim. The technology, which costs $9 per day per criminal, also allows agents to create "hot zones" around the homes and workplaces of victims or any other geographic location likely to be a target, such as a schoolyard or ballfield. Victims can also be given pagers that sound an alarm if the criminal comes within a certain distance of their homes.
    "I like it because we have the ability to protect victims," said Kelley Shotwell, a Volusia County, Fla., probation agent who helped send a 60-year-old pedophile back to jail after his tracking device caught him driving slowly past the home of his 5-year-old step-granddaughter in July. "We knew immediately when he went into the hot zone," Shotwell said. Despite the apparent success of such programs, some in Maryland believe only incarceration can adequately protect the public. On Thursday, Attorney General J. Joseph Curran Jr. (D) traveled to Larned, Kan., to visit that state's facility for sexual predators. "The bottom line is I walked away believing there are people who do these sexually deviant acts . . . and, even at the end of their incarceration, that deviant behavior doesn't go away in some cases," said Curran, who supports Hecht's legislation. "I realize there are civil liberties concerns. At the same time," Curran said, "I'm persuaded that there is a need to do this."

Survey Suggests Doctors Reluctant to Deal With Drug-Abusing Patients
Lindsey Tanner, Associated Press- 1/22/2001

CHICAGO (AP) A national survey of primary care doctors suggests that many are doing little to help drug-addicted patients kick the habit. About one-third of the 1,080 doctors surveyed said they do not routinely ask new patients if they use illicit drugs, and 15 percent said they do not routinely offer any intervention to drug-abusing patients. Of the doctors who do offer intervention, 61 percent said they recommend 12-step programs, which research has suggested may be less successful than formal addiction therapy, said Dr. Peter Friedmann, lead author and an assistant professor of medicine and community health at Brown University. Only 55 percent said they routinely recommend formal addiction therapy, such as methadone treatment or residential treatment centers. Results of the survey, mailed to doctors nationwide last year, appear in Monday's issue of Archives of Internal Medicine.
    The findings suggest that many doctors don't consider drug abuse a medical problem akin to chronic diseases like diabetes or high blood pressure, Friedmann said. National data from 1999 estimated that 14.8 million Americans were current users of illegal drugs.  Many abusers seek treatment for common disorders that may be linked to drugs, said Dr. H. Westley Clark, director of the Center for Substance Abuse Treatment at the U.S. Department of Health and Human Services. But if doctors don't inquire about the drug usage, they are not treating the problem, he said.
    Reasons suggested for failing to do so include pessimism about being able to do anything to help and skepticism about the success of drug treatment programs, Friedmann said. Some also think talking about drug abuse with patients is taboo, or feel it is outside their role findings that indicate better drug-abuse training is needed in medical schools, he said. Friedmann said the problem ''is pervasive enough in medical settings that all doctors should be trained and ready to identify patients with these problems and intervene.'' ''Primary care is supposed to embrace preventive medicine,'' said Dr. Terry Horton, medical director for Phoenix House, a national drug treatment program. ''If you don't identify the people, there's not a chance you can get them toward help.''
    Family physicians, internists, obstetricians and gynecologists, and psychiatrists were questioned. Psychiatrists and OB/GYNs were the most likely to ask patients about drug abuse, but OB/GYNs were least likely to intervene. Alan I. Leshner, director of the National Institute on Drug Abuse, which helped fund the study, says primary care physicians are in a prime position to help diagnose drug addiction and get abusers proper treatment. And despite common misconceptions, ''addiction is eminently treatable if the treatment is well-delivered and tailored'' to the patient's own needs, Leshner wrote in a 1999 Journal of the American Medical Association essay.

Maine Residential Drug-Treatment Program for Women May Be Shut Down
Associated Press, 1/22/2001

PORTLAND, Maine (AP) One of Maine's two residential drug-treatment programs for women is in danger. Catholic Charities Maine announced last week that it can no longer support Evodia House, which is running $50,000 to $80,000 in the red each year, because the deficits are eating into other programs. If the state Office of Substance Abuse cannot find another organization to take over when Catholic Charities' contract expires in June, the program will shut down after 13 years of operation.
    But even if another organization takes over, it's likely that the program will be scaled down significantly. The program's struggles stem largely from a 1994 decision by Congress that left most residential drug and alcohol treatment programs with funding problems.  William Cohen, then a Republican senator from Maine, led the effort to cut Medicaid and Supplemental Security Income payments to substance abusers. The change went into effect in 1996. Studies at the time found that many federal aid recipients were spending the money on drugs and alcohol instead of treatment. While the reasoning behind the cuts was sound, the implications were not fully thought out, said Kim Johnson, director of the Office of Substance Abuse.
    About 7,750 Mainers receive substance abuse treatment services. About 94 percent are treated as outpatients. The most extreme cases require residential treatment which is far more expensive. Maine has 15 residential treatment programs. Only two Evodia House and another program in Bangor solely serve women. Women treated at Evodia House can stay up to six months. The program, which targets women who have not succeeded in others, includes group counseling, personal counseling and life-skills training.
    Pam Smith tried 10 different programs before she turned to Evodia House. She said the support of the women there has been critical to her recovery. ''Everybody is here to help you,'' she said. ''I don't like to think of what would have happened if I hadn't come here.'' Like most woman there, Smith cannot afford to pay for the program on her own. It costs $87 per day for treatment and $447 a month for food and lodging.
    Evodia House's annual budget is about $500,000. The Office of Substance Abuse is giving it $281,000 this year. Stacia Fitch, director of Evodia House, said the program has been going deeper into debt since the change in federal benefits. ''I really don't know what's going to happen,'' she said. ''I'm hopeful that because there is such a need for this program, that somehow, some way, we will be allowed to continue.'' Johnson said that if another organization takes over Evodia House, it will likely have to start serving women with children. Medicaid will fund treatment for women who have children, but not for those who don't. Although women can get treatment at other residential facilities, some, particularly those who have suffered domestic violence, have a hard time in a coed environment, Fitch said.

McLean Hospital Center Underscores Extremes of Psychiatric Care
Patricia Wen, Boston Globe, 1/23/2001

BELMONT - If you're rich and depressed, you no longer have to seek treatment in the same space as the rest of the gloomy masses. You can go first class. At a cost of $2,000 a day, the wealthy and troubled can check into The Pavilion, an upscale hotel-like center on the bucolic grounds of McLean Hospital. It's apparently the only psychiatric residence in the country that doesn't accept insurance and keeps well-heeled patients seeking treatment for chronic depression only with each other. Its exclusivity is beyond doubt. The center advertises only in three publications, The New Yorker and the alumni magazines of Harvard and Yale. The antique-style furnishings and plush new carpets fall short of Ritz-Carlton elegance, but it provides the amenities of a deluxe hotel from the fresh flowers in each room to meals delivered by a gourmet caterer.
    ''Our services are unmatched anywhere,'' said Dr. Alex Vuckovic, medical director of this six-bedroom residence located on the sprawling grounds of one of the nation's premier psychiatric hospitals. These luxurious accommodations come as mental health care facilities face mounting financial strain, caught between a growing number of low-income patients and increasingly tight government and private health insurers. In what may illustrate the radical extremes to which struggling hospitals will go to survive, Vuckovic talked about the Pavilion's record as ''a profit center'' at McLean, infusing needed revenue in a struggling hospital trying to serve a population that is far from privileged.
    But some proponents of mental-health reforms in the state worry about the political impact. They fear that, by skimming the most affluent psychiatric care patients off the top, programs such as the Pavilion could rob the reform movement of some of its most powerful advocates. ''It creates a situation where everyone is not in the same boat,'' said David Rochefort, a political science professor at Northeastern University who authored a recent report on mental health services in Massachusetts. ''It withdraws some potential momentum in the call for reform.'' Others also worry about the perception of hospitals decrying the lack of mental health care funds at the same time they're showcasing opulent treatment centers for the well-to-do.
    Vuckovic explains the genesis of this place without a twinge of guilt, saying today's managed-care crisis requires such entrepreneurial initiatives. Why not offer elite seats if it helps subsidize, in a way, the rest of the plane's passengers? And such elite seats. Patients, many of whom come from outside the state and typically stay about 14 days, get unlimited access to the hospital's world-class psychiatric, behavioral, neurological, and substance-abuse services. On a given night, the staff might help perform an overnight sleep-cycle evaluation for a patient, while also helping the person rent a popular video. That's assuming, of course, that the patient doesn't want to watch the extensive cable offerings on private televisions.
    In some ways, the Pavilion is a reminder of McLean's old days. McLean was an elite refuge for the wealthy, where poets such as Sylvia Plath and Robert Lowell nurtured their creative spirits while trying to quiet their inner demons, though the hospital is now much different. Today, as McLean serves a larger population, more than 60 percent of its patients pay for care through Medicare or Medicaid, about 30 percent are on managed-care or other insurance plans, and 10 percent are private self-pay patients.
    Vuckovic said he knew this place might have ''a public relations problem,'' viewed as a spa for the ''worried well.'' But the kind of people who enter the Pavilion are far from contemplating their next venture-capital deal. Instead, they are in the depths of serious psychological issues, mostly depression, he said. Most are young adults. He also said people who seek out his center are well aware they're nestled on the grounds of a psychiatric hospital, a stone's throw away from seriously disturbed patients who might be strapped to their beds. If you're just a weary soul in need of rest and relaxation, most people wouldn't risk the stigma that comes with being at the grounds of a psychiatric institution. ''If you have the choice between Canyon Ranch or McLean, I think most of these people would pick Canyon Ranch,'' he said, referring to the Canyon Ranch Health Resort in Lenox.
    Given the vacancy rate at the Pavilion, there clearly are many people to fill the rooms. When it opened in November 1999, there was already a waiting list. Its original three beds have now doubled to six, and there are plans to expand if there is more demand.  The center also has some out-patient consultations, though the overwhelming majority accept lodging at the Pavilion. The Pavilion may be the first psychiatric center exclusively for private-pay patients, but this kind of catering to the elite is not new. Massachusetts General Hospital has long operated Phillips House, where wealthy patients can pay hefty fees for deluxe hospital rooms.
    Patients say they come to the Pavilion, not for the upper class trappings, but for the outstanding care. One former patient, a 71-year-old retired lawyer from Memphis, said he understands the equity issues around health care, but he was too preoccupied with his own depression when he sought out the Pavilion. He said he had chronic depression for 25 years, and taking medications did not help.  The patient, who asked to remain anonymous, said he stayed far longer than the typical patient, once for seven weeks and another time for nine weeks. After extensive testing, the staff determined that he should try shock therapy, a treatment that has worked wonders.   ''I've been feeling as fine as I've ever felt,'' he said, adding that he is still taking some medication, as well as taking part in one-on-one psychotherapy. He said he does volunteer work on many local mental-health boards and is well aware that the vast majority of mentally ill people don't get adequate services. But he said his ability to afford a place like the Pavilion, and the inability of others to get bare-minimal care, wasn't on his mind during his stay. ''I didn't have a social conscience about it,'' he said. ''I was just looking out for my own health.''

Federal Report Condemns Placing Mentally Ill in Nursing Homes
Michael J. Berens, Chicago Tribune- 1/23/2001

Thousands of mentally ill patients as young as 22 are being improperly warehoused inside the nation's geriatric nursing homes, constituting a forgotten and misplaced population often subjected to inadequate care, a federal investigation has found. A six-month probe by the inspector general of the U.S. Department of Health and Human Services followed acknowledgment by dozens of states, including Illinois, that mentally ill patients have been improperly placed in geriatric facilities, sometimes with disastrous results.
    The Tribune reported in 1998 that Illinois had secretly and improperly transferred thousands of mentally ill patients to nursing homes in a now-defunct scheme to improperly bolster Medicaid funding. The practice led to dozens of deaths and injuries--including murder and rape-- sparked by inadequate treatment of those patients and the mixing of the mentally ill and elderly. The government study released Monday called for immediate reform in the screening and tracking of patients, improved training for health care workers and increased oversight of Medicaid reimbursements.
    Some government agencies report that mentally ill young adults account for less than 2 percent of nursing home residents, but the report by the inspector general put that figure at 20 percent. Placing mental patients in nursing homes instead of psychiatric facilities is a way for many states to try to force the federal government to pay most of the treatment costs for the mentally ill, the report concluded.
    In 1999, the Supreme Court ruled that such patients must be housed in the least restrictive settings possible, such as government-subsidized apartments. But mental health advocates say that thousands of young mentally ill patients in Illinois remain trapped by finances and circumstances inside nursing homes. "There are at least 6,000 mentally ill patients in Illinois nursing homes, and about one-third, or 2,000 people, don't belong there," said Mark Heyrman, a board member of the Mental Health Association in Illinois and a clinical law professor at the University of Chicago. By transferring 2,000 mentally ill patients to apartments, the state could save $60 million, which could be redirected to subsidize rent and treatment, Heyrman said. But the proposal has gone nowhere.
    State officials on Monday defended Illinois' mental health programs. The state spends $611 million annually on services, ranging from community-based treatment programs to employee training to special programs earmarked for children. Likewise, the state has formed a task force to assess compliance with the 1999 Supreme Court ruling, and the assessment will be submitted to legislators this year, said Reginald Marsh, spokesman for the state Department of Human Services. The inspector general report called mentally ill people the "unidentified population" because most states do not track the population well, even when they are paying for their care.  Indeed, officials for Human Services, which is responsible for overseeing mental health treatment in nursing homes, were unable to determine on Monday how many mentally ill patients reside in nursing homes.
    The Tribune analysis of public health records shows that there are 28 Illinois nursing homes predominantly filled with psychiatric patients, who number about 6,000. An additional 2,000 patients are scattered among more than 500 geriatric facilities.  Nationally, an estimated 70,000 mentally ill residents as young as 22 are living in nursing homes, but the number could be substantially higher, federal investigators said.
    The move to place mentally ill patients in nursing homes is the legacy of shutting down state-owned psychiatric institutions.  In many municipalities, de-institutionalization occurred without adequate funding to community-based treatment programs. As the fifth-largest state, Illinois ranks 30th for its level of mental health funding, federal studies show. The financially struggling nursing home industry has willingly opened its doors to the mentally ill as a way to fill an increasing number of empty beds.
    "I rarely see treatment for mentally ill patients in nursing rooms," said Wendy Meltzer, an attorney and director of the Chicago-based Illinois Citizens for Better Care. Public health investigative files reveal dozens of homes cited for treatment deficiencies, but the state most often doles out token fines. "The mentally ill are not attractive politically," said Meltzer, who monitors state-enforcement actions and sits on several legislative task forces. "They are not the middle class. The prognosis for them is not good. There's seldom any good, short-term solutions."
    State and federal officials have been engaged in a long-standing tug-of-war over who should bear responsibility for treatment of the mentally ill. In response to the inspector general report, federal Health and Human Services officials say state agencies need to step up oversight and services. Currently, states are required to bear all costs of nursing home treatment where half or more of the beds are filled with psychiatric patients. In geriatric homes, costs are paid by a combination of state and federal funds. To get around federal restrictions, state Department of Public Aid officials manipulated hundreds of medical records in 1998 to list thousands of mentally ill patients as physically impaired. In one case, the record of a severely mentally ill 65-year-old woman was altered to reflect that she suffered primarily from arthritis and cranial dermatosis--more commonly known as dandruff, the Tribune found.