Child Sexual Abuse Cases Harder to Track, Verify
Ellen Barry, Boston Globe- 4/29/2002

WORCESTER - Twice the little girl has come to this office for a talk about her private parts, and twice her mother has taken her back home. Nothing. Helene Murphy is certain she knows what happened to the girl. Murphy has sat beside the 31/2-year-old as she babbled sentences and fractions of sentences about her mother's boyfriend. She has noted the bed-wetting, the reluctance to make eye contact, the compulsive masturbation that has caused chafing. After 20 years in the field of sexual abuse evaluation, Murphy can tell this is going to be one of the cases that drive her crazy. ''We're talking about a girl who has much to disclose,'' said Murphy, director of social services at the University of Massachusetts Memorial Medical Center Child Protection Program. ''She's going home at night every night with this guy, because we don't have the information to say, `Grab this guy,' before it goes on and on.''
    The current priest scandal has put sexual abuse in the headlines for months, but doctors who evaluate abused children say the increased attention has done little for their beleaguered specialty. Twenty years since child sexual abuse burst into the public consciousness -- and 10 years after several high-profile convictions fell apart -- proving suspected sexual abuse has only become more difficult.
    According to research, the national number of child sexual abuse allegations declined sharply through the 1990s, along with the number of allegations that have been substantiated. In Massachusetts, the Department of Social Services became far more stringent about corroborating suspicions -- the number of cases screened out before investigation rose from 16 percent in 1990 to 40 percent in 1997. And some medical examiners say they simply require a far higher standard of proof before answering the terrible question of whether abuse occurred. ''We'll diagnose sexual abuse in about 25 percent of cases [in which abuse is suspected]. That probably means some false negatives,'' said Lawrence Ricci, who heads the Spurwink Child Abuse Program in Portland, Maine. ''But it's always a balance. When you're dealing with something of an inexact science, you have to decide which you're willing to accept. ''Gone are the days when we used to say in this field, `If we're going to err, let's err on the side of protecting the child.' It's always a pendulum.''
    It is this swing of the pendulum that frustrates Murphy. In a meeting three weeks ago, she said, a representative from the district attorney's office told her that the behavior of the 31/2-year-old girl wasn't enough evidence to merit a prosecutorial investigation. So the child would have to take a place on a long waiting list for psychological evaluation by a therapist specializing in child abuse, who will try to determine what, if anything, happened. ''It's a thankless kind of a thing,'' Murphy said, sighing. ''It's just in my gut and I can't do anything about it, and the child is going home with him.''

Spurred by a TV movie, the silence is broken
Reports of sexual abuse exploded in the 1980s, and with it came optimism that Americans could address the crime as a society. Jetta Bernier recalls the morning in January 1984 after ABC aired the docudrama ''Something About Amelia,'' in which an upper-middle-class father, played by Ted Danson, had a secret sexual relationship with his daughter. Reports began pouring in through the mail and over the phone, said Bernier, who was then a senior staff member at the National Committee to Prevent Child Abuse. ''The country went wild,'' she said. In the following years, therapists and social workers around the country attended abuse workshops while victims' advocates plastered bumper stickers swearing their faith in victims.
    But just as enormous was the wall of skepticism that followed. Starting in the early 1990s, a series of sensational cases were challenged one after another -- the McMartin Preschool case in California, the Little Rascals Day Care case in North Carolina, the Fells Acres Day Care case in Massachusetts -- leaving many Americans with the lasting impression that social scientists had whipped up children's claims. Ever since, said Tufts pediatrician Robert Reece, the specialty has been under attack. ''It's considered a soft science. Child abuse is considered by some to be a problem that's been blown out of proportion,'' said Reece, who wrote two textbooks on diagnosing and treating abused children.
    Since then, allegations of child sexual abuse have receded. After rising steadily from 1977 to 1992, the national number of substantiated reports turned and declined a remarkable 31 percent by 1998, from 149,800 cases to 103,600, according to a report for the Department of Justice done by the University of New Hampshire. The number of children reporting that they have been abused has dropped at a similar rate, suggesting that the decline relects a genuine drop, not simply a reluctance on the part of child advocates to report, according to David Finkelhor, who heads the Crimes against Children Research Center at UNH.
    In addition, Massachusetts officials have become increasingly cautious about corroborating allegations of sexual abuse. Between 1990 and 1997, the last year for which records are available, the number of sex abuse reports ''screened in'' for investigation in the DSS system has dropped 24 percent. Those allegations that were eventually supported by DSS fell from 44 percent to 33 percent.
    For doctors, proving an assault has become harder. Sexual abuse experts who used to assume that conclusive physical evidence of sexual abuse was frequent now believe that it is only present in 5 percent of cases, Ricci said. In a paper published last year in the journal Child Abuse and Neglect, Ricci and two colleagues dismissed the idea that abuse could be determined from watching for telltale signs in the child's behavior, such as masturbation, concluding that in there was ''no significant relationship'' between abuse and such behavior. ''Our understanding clearly puts the burden of evidence on the history from the child,'' Ricci said.
    How far to go to get that history is another matter. In the past, children were interviewed multiple times, privately, by therapists and police. But after Fells Acres, wary prosecutors have turned to the standardized Sexual Abuse Investigation Network interview, in which the child is interviewed only once by a therapist, as a multidisciplinary team of experts watches from behind one-way glass. In cases where there is strong evidence, prosecutors have 10 days to make a determination on whether there has been an assault.
    But often, strong evidence is hard to come by. At the Child Protection Program in Worcester, 10 percent to 15 percent of the children brought in readily disclose that sexual abuse took place, said pediatrician Christine Barron, who oversees the unit. Last year, Barron delivered a positive diagnosis in 43 percent of cases and a negative diagnosis in 26 percent of cases, she said. The remaining 30 percent of cases fall into the category of ''unclear'' and are referred for ongoing counseling, she said.

The difficult path toward the truth
Somewhere in that gray area is Murphy's patient. Murphy would like to see her take a ''psychological sexual abuse evaluation,'' in which the child would meet one-on-one with a therapist regularly over a period of weeks or months. ''There are very few children you can't get anything out of,'' she said. ''Set up that same child with a nurturing parent-type person and the child begins to build up a relationship with that person, and you'd be amazed at what can come out of a child's mouth.''
Too often, though, parents seeking follow-up have found therapists overloaded and treatment programs unavailable, said doctors interviewed. ''Those are the kids that are sitting on the waiting list for three months,'' said Andrea Vandeven, medical director of the child abuse team at Children's Hospital, who estimates that between a third and a half of the 200 to 250 sexual abuse cases she sees every year are not clear-cut enough for prosecution. When prosecutors demur, families are referred to therapists for long-term counseling. At that point, many cases simply recede, she said. ''If you can't get the child evaluated right away, it dissipates,'' she said. ''The family may barrage the child with questions, which causes the child to shut down.'' And often, Murphy is left to worry about the information that didn't quite come out. ''She talked a little about `Uncle Dan,''' Murphy said, using a pseudonym ''To even get a sentence like that, you're putting words together. The eye contact. `I don't want to see Uncle Dan. I don't want to go see Uncle Dan.'''

Here Life is Squalor and Chaos
Clifford J. Levy, New York Times- 4/29/2002

It was the fall of 2000 and state inspectors were due to arrive at Seaport Manor, an adult home for the mentally ill in Canarsie, Brooklyn. Upstairs, some of its 325 residents, bewildered and mumbling, shuffled along the dreary hallways. Downstairs, a handful of workers hastily doctored records, they said, to make it seem as if the home was providing proper care. The workers said they concocted case notes for manic-depressives who holed up in their rooms for so long they became malnourished. They invented psychiatric evaluations for residents who went untreated and turned suicidal. They scrawled therapy plans for women who prostituted themselves in the stairwells for cigarette money and for men who shook down other residents for their $4-a-day allowance.
    "We were told by the administrators at the home to be creative," said one worker, Toshua Courthan. "We were told we had to, or else we would lose our jobs. What the state wanted to see was that these people were being looked after, but they were not." Ms. Courthan was fired after reporting the falsifying of records and other misconduct at the home to the state, and she is suing Seaport. Her account was independently supported by other current and former workers, including two who participated that evening, as well as by an examination of some of the records.
    The inspectors who showed up that day in 2000, however, apparently never detected the hundreds of sham files, according to state records. Seaport, which receives more than $3.5 million annually from the government, stayed open. For its residents, life has remained as wretched as ever. Occupying a one-acre tract;' the five-story brick building sits behind a row of shrubbery at 615 East 104th Street, not far from the neighborhood piers. A generation ago the home, along with dozens like it, represented a briefly entertained hope for the thousands of mentally ill people being pushed out of state psychiatric hospitals. In these homes, residents would learn to live independently and enter a mainstream community.
    Just how profoundly that vision has collapsed can be appreciated in words from the state itself, which dubbed Seaport "The New Warehouse for the Insane" in a 1997 study by the Office of Mental Health. If the state gave Seaport a cynical nickname, though records show it did nothing meaningful to improve or police it. A portrait of life inside Seaport was gleaned from more than 10 visits, more than 500 pages of state inspection reports and government documents obtained by The New York Times, as well as more than 50 interviews with workers and residents.
    During a typical visit to the home, residents can be seen sitting for hours in the crowded smoking room, rocking back and forth, speaking only to themselves. Others can be spotted walking to the local liquor store, much to the dismay of those at the nearby day care center. Current and former workers said two residents openly deal crack from their rooms, contributing to the drug abuse, loansharking, prostitution and violence that have gripped the home for years. In this predatory atmosphere, the frail quickly learn that the safest place is behind the closed doors of their rooms. Others find different ways to get by. "It's tough around here," said a resident in her 50's who said she sells sex to workers and other residents for a few dollars. "You have to do it to survive."
    Ambulances are regular visitors. In a three-month period last year, they made 93 runs to the home, city records show, sometimes to take away the dying, other times to rescue the neglected. For years, workers said, a security guard subdued psychotic residents by beating them. Other employees are convicted drug dealers, prison records show. Several former workers said the home sometimes continued to collect the monthly disability benefits of residents after they died, or gave their Social Security numbers to illegal immigrants the home hired. There were dozens of numbers to choose from. From 1995 through 2001, one Seaport resident died roughly every month, according to an analysis by The Times. In all, at least 79 died, including at least three who committed suicide and two others whose bodies were discovered only after workers were drawn to the smell of decay. "This is the last stop," a resident named Jerry said in his room at the home. "They are not preparing anyone for living outside of here."
    For 26 years, the state has documented problems at Seaport and then averted its eyes. Since 1998, conditions have been so bad that inspection reports concluded that Seaport, as one said, was in serious noncompliance in all major areas of operation." The reports cited inadequate staffing and dangerous lapses in the distribution of medication. During a 1999 inspection, investigators refused to fully examine rooms because they were so fetid. They also remarked in their records how workers at the home were able to walk past disheveled residents without even noticing them.
    Only in recent months, after The Times began an investigation of Seaport by requesting government records and questioning officials, did the state say it would crack down on the home. Its response, however, has been erratic. Last August, the state said it would try to revoke the operators' license. Last month, it agreed to let them surrender their license, pay a $20,000 fine and close the home. But in recent days, the state, confounded by the prospect of finding new housing for the residents, indicated it might try to keep Seaport open by installing new operators. For now, the residents remain in Seaport under the same operators who the state has known for years have run a home of squalor and neglect. In 2001 alone, at least 18 residents died, The Times's analysis shows, 10 of whom were under 60.
    Seaport's operators -- Baruch Mappa, Martin Rosenberg and Emil Klein -- said through their lawyer they would not be interviewed. Before agreeing to surrender their license, the operators asserted in a disciplinary hearing before the State Department of Health that the home had undertaken renovations, overhauled medication practices and brought in more workers to increase supervision of residents. "Seaport doesn't take the violations or alleged violations lightly," Ronald J. Aranoff, the home's lawyer, said at the hearing.
    Over the years, Seaport, like many other adult homes, has often complained that the state has asked it to take responsibility for some of the most needy people while failing to provide enough money for their care. About 15,000 mentally ill adults live in more than 100 adult homes in New York. The Department of Health said it did not take more aggressive action against Seaport in previous years because it preferred to help troubled homes improve conditions. "Closure of a facility is disruptive to patients and residents, especially the elderly or mentally ill, and is typically pursued as a last resort after a home's repeated failures to comply with state regulations," said Robert R. Hinckley, a deputy state health commissioner.
    The failures of Seaport can be witnessed in varying degrees at other adult homes in the city. State inspection reports on many of the homes are grim and interchangeable. Even so, the state seems to have grown accustomed to slapping the homes with one hand and shielding them with the other, For the people who still live at homes like Seaport, many of whom are too sick to grasp the notion that they are entitled to something better, life is about doing what they can to endure.

Ritual Turmoil: Monthly Heightening Of the Daily Disorder
Residents and workers at the home call it payday. Once a month, Seaport's administrators hand out about $120 in allowance money to each resident from the disability checks they control. Then the pandemonium begins. In-house loan sharks chase residents down the hall, intent on collecting their money, according to numerous current and former workers and residents. They said two crack dealers also opened for business, packing in an assortment of fellow residents, and even the police said they have made drug arrests at the home in recent years. Those residents unwilling to take part in either enterprise run to their rooms, fearful of the opportunistic and desperately in need of their tiny allowances. Inevitably, the strong at Seaport always know when the weak are in line to get their money. "It would be just one big mess," Angela Peters, a former housekeeper and dietary aide, said of payday. "We couldn't do any work on the floor because it was so crazy."
    From the outside, Seaport looks like a decent alternative to the homelessness that defines another portion of the city's mentally ill. From the inside, based on visits to the home and extensive interviews, it does not. If a coed prison for the mentally ill were to exist, the inner workings of its yard might resemble Seaport. Except the prison would have security and a professional staff.
    Ideally, the home is supposed to act like a bridge, helping the mentally ill return to neighborhoods where they can attain some self-sufficiency. In reality, there is nothing rehabilitative about the place--it rarely tries to help residents obtain proper therapy, for training or, at times, even get dressed, according to state inspection reports and interviews with workers and residents. There is never enough staff, and administrators and workers typically have no mental health training. The state does not require it at adult homes, though their residents are deeply troubled.
    According to the 1997 state mental health study, of about half of Seaport's population, more than 80 percent had histories of multiple psychiatric hospitalizations, 35 percent had histories of violent behavior, 32 percent had abused drugs and 13 percent had attempted suicide. "It's just too sad a place to go to work," said Sherry Reiter, a social worker who was assigned in the late 1990's to a clinic in the home run by the Kingsboro Psychiatric Center. "The sadness and the violence are part of the milieu."
    Left with little supervision or treatment, residents often have psychotic episodes, records show. One man tried killing himself by taking an overdose of Tylenol, burning himself with hot water and then hanging himself with a pajama top coiled into a noose. A delusional woman repeatedly stabbed herself on the back and legs. Newcomers to the home quickly learn there is little to do. The most popular spot is the smoking room -- a cluster of worn benches, bare walls, a television (always on) and a floor littered, with cigarette butts, spilled coffee, ashes and discarded food. The recreation room could offer other possibilities, but rarely does. For much of 2001, it was closed because there was no one to run it, workers and residents said. At other times, a high school student served as recreation director. For these schizophrenics and manic-depressives, the student liked to hold screenings of "Face/Off," a violent action movie about changeable identities.
    In the late 1990's, a. report by a state watchdog agency, the Commission on Quality of Care for the Mentally Disabled, rated Seaport one of the worst adult homes. Yet in 1997, the state awarded Seaport $41,501.25 in bonus money intended for homes that provide quality care, state records show. The state allocated the money largely for computer training for residents. Seaport does not have computers for residents; it barely has a laundry room. The home had a single washing machine during one inspection, and it showed. Residents had "dirty, stained or ripped clothing" and were in need of a bath or shower, the inspectors wrote in their 1999 report.
    The wait to receive psychotropic medication is sometimes half an hour or more, so some residents do not even bother. The ones who do are lucky if they get the correct pills, state inspection reports show. Peering into medication boxes, one inspector encountered dead cockroaches. Andy Cadet, who ran the medication room for several months last year until she resigned, described the consequences of the chaos. "People were getting ill," Ms. Cadet said. "It was just a disaster." The home itself does not provide psychiatric services, but it is expected to ensure that residents obtain them, either from the Kingsboro clinic at the home or from other psychiatrists who periodically, visit. But the clinic, staffed by a psychiatrist and a few other trained workers, writes prescriptions that go unfilled. It asks that fragile residents be closely watched, and they are not, according to interviews with clinic workers and their records. The home's administrators, meanwhile, have long accused clinic workers of not doing their-jobs.
    At nights and an weekends, the residents are largely on their own. The clinic is closed, and the home has almost no one on duty. "Nobody wanted to take responsibility for patients who went berserk at night," said Louis Rossetti, who worked as a nurse at the clinic from 1980 until 1996 and then as a volunteer. "We would come in the morning and have to go upstairs and calm them down. It just over all got worse and worse."
    Ms. Courthan, Ms. Cadet and several other workers said a security guard, Lionel Harrington, used to beat residents to subdue them. For his part, Mr. Harrington said he only tried to crack down on the drug-dealing, loan-sharking and prostitution. He said the administrators at the home knew about the goings-on, especially the crack-dealing by one of the residents. "They are well aware that this man is destroying the residents in that building," Mr. Harrington said. He said he was fired late last year after he was late for work.
    Toward the end of the month, as residents start to run out of money, the atmosphere in the home turns even worse, workers and residents said. Used condoms can be found in the stairwells and hallways, as both male and female residents trade sex for spending money, drugs or cigarettes. "Generally, it was sex for drugs or sex for money," said Angela Johnson, a former worker at the home. "If someone wanted a dollar, it was sex for a dollar. Sex for anything was a big problem."

History: Hospital Emptied, Its Troubles Relocated
In the early 1970's, Kingsboro Psychiatric Center in Brooklyn, one in the state's array of vast mental hospitals, began aggressively emptying its beds as New York undertook the process of what came to be known as deinstitutionalization. Kingsboro was looking for places to relocate its patients when Mr. Mappa, a local real estate developer, was looking for another business enterprise. His brainchild was to open Seaport Manor in September 1975 and take in many of those who were being cast out of the hospital's wards. Only three miles from Kingsboro, the new building had a kitchen, dining room, recreation room and 13 bedrooms on the first floor; and 40 bedrooms on each of the second through fifth floors.
    The idea, shared by Mr. Mappa and the state, was that the home would make for a civilized alternative to Kingsboro. Mr. Mappa would also make money. Residents would sign over their monthly government disability checks for rent, and outside providers would pay fees to the home for the opportunity to treat residents.
    Yet neither Mr. Mappa nor the two business partners he brought in had any mental health expertise. The money from the government never seemed enough, and the care that came to be provided by the medical professionals was never adequate. As a result, a troubled psychiatric hospital was emptied and effectively recreated in a place even less equipped to deal with hundreds of seriously ill people.
    In the late 1970's, Seaport was a focus of an investigation into adult homes by a deputy state attorney general, Charles J. Hynes, who is now the Brooklyn district attorney. A grand jury found that at adult homes in Brooklyn, the condition of residents "was permitted to deteriorate to unconscionable levels." Ultimately, no charges were brought against Seaport or its operators, and leading state officials brushed aside Mr. Hynes's damning portrait of the adult home system. The state did make a few changes at Seaport, including opening a clinic in 1979, one run by workers who came over from Kingsboro. But over the years, the state has cut the number of clinic workers to roughly 8 from nearly 20, Kingsboro workers said.
    For much of the past decade, the home -- with more mentally ill people than most psychiatric hospitals in the nation -- has been run by Esther Elizabeth Rosenberg, the daughter of one of its operators. Ms. Rosenberg, 47, graduated from Brooklyn College in 1990 with a degree in sociology and had little work experience of any kind when she took over the home, according to court records and interviews. The state has essentially called her incompetent. "The administrator is not capable of managing this facility and correcting the problems," a 2000 inspection report, said. "We recommend enforcement be pursued." But the state's own documented dealings with Seaport show that nothing much was done. It was not until March 2001, after years of incriminating inspection reports and concerns that residents were being neglected, that the state tried to discipline the home by levying a $7,000 fine. But while it got Seaport to remove Ms. Rosenberg, it let the operators appoint her son-in-law, Seth Fried, as. administrator.

The Workers: `I Knew Jack-Diddly About Medication'
It was clear that Toshua Courthan was in over her head. She had no mental health training yet after only a short time at Seaport, she was promoted to case manager and then director of social services, playing a pivotal role in overseeing more than 300 chronically mentally ill people. Over her two years at the home, she said, she was pressured to commit or she witnessed a startling variety of misconduct, from the forging of records to the misreporting of deaths. She decided in her second year that she could not keep silent, she said, and began secretly telling state inspectors about problems at the home. The inspectors took her calls, but otherwise seemed uninterested, she said. The state confirmed her calls.
    In early 2001, Ms. Courthan, who is black, was fired, and she sued the home in Federal District Court in Brooklyn, charging that administrators had made racially insensitive comments to her. Aaron Charles Schlesinger, a lawyer for Seaport Manor, did respond to three phone message comment. In court papers, Seaport denied Ms. Courthan's charges. A review of inspection reports and interviews with more than 15 current and former workers support her account of life at the home: "Seaport's thing is, "Let's fill the beds,'" Ms. Courthan said. "'We don't care if they are psychiatrically unstable.' They don't care about these people."
    Ms. Courthan was hired as a receptionist at Seaport in 1999. With low salaries and mismanagement, workers were constantly quitting, and she was rapidly promoted. Her sister, Ms. Johnson, who had worked as a clerk for the City Board of Education, was 'later hired and put in charge of the medication room. Ms. Johnson found this strange, she recalled, because "I knew jackdiddly about medication." Soon, Ms. Courthan and Ms. Johnson were helping to run the place, at $8 to $9.50 an hour: They received strong evaluations from administrators and were popular with residents, according to records and interviews, but were swamped with work. They were supposed to meet with residents monthly, file reports and ensure the residents were being seen by psychiatrists. But they rarely did.
    This was- obvious to state inspectors. In a January 2000 inspection report, they noted that of 30 resident files they had examined, 14 did not have current annual evaluations, let alone monthly case notes. Later that year, the home was expecting another inspection, and Ms. Courthan and Ms. Johnson said Ms. Rosenberg, the home's administrator, told them to put the files in order, by forgery if necessary. Ms. Courthan and Ms. Johnson said they and other workers stayed late one night and concocted hundreds of records, making up psychiatric evaluations and signing them with the names of fictional doctors. Ms. Cadet, the former medication worker, said she witnessed the forging. By the time the night was over, records, some of which were shown to The Times, reflected that many residents had seen a nonexistent Dr. Rollins and received the same diagnosis. "Everybody, if you looked at their charts, they were all paranoid schizophrenic," Ms. Courthan said. While inspectors evidently did not detect that documents were being faked en masse, they had previously criticized the home's record-keeping, noting that files were "altered' or missing." Ms. Rosenberg would not comment.
    Ms. Courthan and Ms. Johnson said the deception did not end with the forged records. One night in November 2000, a resident named Dorothy Clinton set herself on fire and later died at the hospital. Based in part on interviews with Seaport employees, the medical examiner's office ruled the death an accident. The home contended she had ignited herself while smoking crack in bed. Ms. Courthan, Ms. Peters, the former housekeeper, and other workers say the tale of crack smoking was wholly invented; they tell a different story. Ms. Courthan said she had recommended that Ms. Clinton be hospitalized that day because she seemed delusional and suicidal, but that an administrator had blocked the request. That night, Ms. Clinton, 48, got dressed up, putting on earrings and makeup, and then intentionally ignited herself while in bed, residents and workers said. Ms. Courthan said she wrote in Ms. Clinton's file the next day that she should have been hospitalized. When Ms. Rosenberg found out, she ordered Ms. Courthan to remove those notes, Ms. Courthan said. "Esther told me, 'If you speak to the coroner, and say anything about how depressed she was, it is going to be a problem for us and it will be a problem for you,'" Ms. Courthan said.
    Ms. Clinton's death was one of the few the state has investigated at adult homes. But while it cited the home for having inadequate staffing, state records show, it does not appear that it addressed the question of whether Ms. Clinton had been suicidal and whether her death could have been prevented. Three months later, Ms. Courthan was dismissed, and she said she tried to unburden herself to inspectors one final time. She faxed them a letter on Feb. 6, 2001, repeating and elaborating on many of her allegations. An examination of the letter shows she wrote of how she and other workers had forged the records, saying that they made up, "the forms A to Z." Again, she said, inspectors did nothing.
    Asked about Ms. Courthan and Ms. Johnson, Robert Kenny, a spokesman for the State Department of Health, at first said that the two had talked to inspectors only in early 2000 and complained only about administrators stealing money from residents. Mr. Kenny said the inspectors cited the home 18 months later for failing to manage residents' accounts properly. Pressed further, Mr. Kenny acknowledged that the inspectors had talked to the two women more regularly and that they had received the faxed letter from Ms. Courthan. He said her allegations "were not new to inspectors." After Ms. Courthan was dismissed, the home had Ms. Johnson arrested and charged with stealing $200 from residents. She was fired. The charges were later dropped.

The Deaths: Invisible Lives. End Without Notice
The final indignity for many of Seaport's residents comes with a shovel full of dirt at potter's field. Nearly one out of every four residents who died from 1995 through 2001 was sent to the island cemetery in the East River, without headstones to mark their graves or eulogies to recall how they weathered their troubled lives.
    Seaport, after profiting from them, made no effort to find them proper burial. In a way, it was almost fitting, given that the residents' deaths came with the same invisibility that surrounded their lives at the home. Of the 79 people who died in the seven-year period, the average age of death was 58. Twenty-four of the dead were under 50. "People were dying like flies," Ms. Peters said. "They have nobody who is looking after those people."
    It will probably never be known how many of the deaths could have been avoided. The home almost always either failed to notify the state about deaths or left out details care, records show. In turn, the State Department of Health could provide documentary evidence that inspectors looked into only three deaths at Seaport -- Ms. Clinton's and two others. Those three inquiries, in fact, were the only ones that appeared to have been done by state inspectors at 26 of the largest and most troubled adult homes in the city in the seven year period, when at least 946 residents died, according to the Times's analysis.
    Elayne Silverman, once a promising student who wanted to be a social worker, was only 39 when she took her life in April 1995 at Seaport. It was just after breakfast when she climbed the stairs to the roof, according to state records and interviews. No workers at the home noticed. Then again, it was a Saturday, and few were on duty. Either the alarm on the door to the roof was broken, or it went off and was disregarded. Ms. Silverman walked around for a while before taking off her clothes, folding them into a neat pile and then jumping, according to a Kingsboro clinic record.
    Even that failed to get anyone's attention. A neighbor eventually called the home and said a naked body was in the parking lot. When the clinic asked about the death, Seaport administrators could not explain how a home that sheltered numerous people with histories of suicidal behavior could allow such access to the roof, clinic records show. The state never investigated her death, or those of numerous others, according to interviews and records: Stephen Willner, 60, who succumbed to dehydration and malnourishment in 1999; Lewis Howard, 45, who died of kidney failure last year after no one responded when he passed out; and Albert Jarrell, 44, who had a heart attack in 1997 and was dead before workers thought to call 911.
    While residents are free to come and go from the home during the day, the home is required by law to keep track of them. Bed checks are mandatory, but rarely done, residents and workers said. If a resident is missing for more than 24 hours, a report must be filed with the state and the police. Artie Washington had not been seen for longer than that. Not only did Seaport not fill out a form, it did not even notice his absence. Mr. Washington was known around the home for his silly hats, from a Santa's cap to a Burger: King crown. He was last seen on the Friday morning before Labor Day weekend in 1998. Early Monday afternoon, workers concerned by "a foul odor," entered Room 333, according to state records. "We found him dead, just sitting in the bathtub," said Mr. Rossetti, the nurse at the Kingsboro clinic. An autopsy determined that Mr. Washington, 54, had died of a seizure. It is unclear whether he could have been saved had he been discovered earlier. Inspectors, in one of the three death inquiries they performed, criticized Seaport for allowing him to remain at the home even though he was unstable. Yet the state took no action to safeguard against similar deaths.
    So in July 2001, Rosendo Velez, 77, was found dead. Mr. Velez, nicknamed Keebler because he walked like the elves in the cookie commercial, had returned to the home in a drunken fog, workers said. He was left in his room unattended anyway, and was found drowned an hour later in his bathtub, fully clothed. It was not until three months later, in October, that the state cited the home for failing to supervise Mr. Velez. In the meantime, Martin Rochlitz, 51, was found decomposing in his sweltering room days after dying of a heart attack during an August heat wave, according to the coroner. Unlike the deaths of Mr. Washington and Mr. Velez, Mr. Rochlitz's did not even warrant a question by the state, its records show.

Holding On: Expecting Trouble, Fearing Even Worse
Kevin Johnson sees death all around him, and fears that his will be the next. He has seizure disorder, schizophrenia and cerebral palsy. He is mildly retarded and cannot perform basic arithmetic. At a recent lunch, he had difficulty pulling the wrapper off a straw. Yet, sadly, even he understands that at Seaport, the odds are against him. Mr. Johnson, 39, cannot forget all the seizures that have sent him tumbling to the floor of Room 106 during the past three years. Dazed and bruised, he is eventually found by a worker and taken to Brookdale University Hospital and Medical Center. Each time, Mr. Johnson is admitted to the hospital for a few days. In vain, it calls the home for his medical and psychiatric history. "They could not provide more information on the patient," a nurse wrote one day. As always, he is sent back to the home. His latest wound is a jagged gash on his forehead. He needed stitches to close it after banging his head on the floor during a convulsion. Still, he considers it a minor injury.
    What he dreads is a repeat of what happened on a Sunday morning in July 1999. He was left alone to shower, had a seizure and passed out. It is not known how long he lay there as he was scalded by water that inspectors have repeatedly warned is too hot. He needed two skin-graft operations to heal huge swaths on his chest, back and arms. Seaport never notified the state about his injuries, as was required, and Mr. Johnson was once again returned to the home. Left to himself, he has devised his own way of dealing with the seizures. "I sit on the bed and try to take it easy," he said the other day.
    III since he was a teenager, Mr. Johnson is 5-foot-8 and beefy, with a mustache, a round face and no family. He has a kindly disposition, but often reverts to long silences, as if he learned long ago that the way to make it through the day is by shutting everyone out. He sits in his room for hours, listening to oldies on the radio and worrying that if he walks around the home, someone will harass him for money, or worse. With the turmoil over Seaport's fate, Mr. Johnson's future is uncertain. For now, he soothes himself against his surroundings by reading the paperback King James Bible that he hides in the top drawer of his dresser. Sitting on his flimsy mattress as mice scamper by, he opens to the same. chapter, and mouths the words, over and over. Second Corinthians, Chapter 5: Do not despair, for there is a better place in the afterlife.

Could Anger Be a Hereditary Trait?
ABC News, 4/30/2002

For years, Linda Smith has fought to contain feelings of anger she knows are completely irrational — but when she is really angry, watch out. "I am suddenly enraged," Smith said. "It's like a pressure cooker has been building and building, and there has been a lid on it, and all of a sudden a plug blows." Smith has tried everything she can think of to contain her emotions, from clenching her teeth to clamping her jaw shut so that she does not respond to something that upsets her.
    Her story sounds familiar to Dr. Redford Williams, director of the Behavioral Medicine Research Center at Duke University School of Medicine. In his three decades of pioneering research into anger, he has proven that prolonged periods of anger raises our blood pressure, our adrenaline and our cortisol levels, causing damage to the immune system. Essentially, anger can kill us. Now Williams' latest research reveals something even scarier: Anger might be inherited.
    "There is not one illness that we know of that is not made worse or brought on more quickly by chronic anger," Williams told Good Morning America. He has found a tiny molecular variation of a gene that we all carry that will predict those more prone to anger. Those who have the genetic variation have blood pressure that will soar to dangerous levels, and are at greater health risk, Williams said.
    When Williams hooked Smith up to a blood pressure cuff and asked her to recall a situation that made her angry, the results were immediate. "I was about as angry as I'd ever been," Smith said, recalling one incident. Her blood pressure jumped from 109 over 60 to 135 over 74. Her heart rate increased from 80 to 91. "It does make me aware that I'm creating health risks," Smith said.
    The research is early, and in the meantime, Williams is even more intent on helping people defuse their rage at anger management seminars. It is still too early to think of screening everyone for an anger gene, but Williams said there may be a day when that gene for rage will tell us whose anger could literally kill them. "We're getting to the point where we can identify, on the basis of genetic characteristics, people who are at high risk," Williams said.
    If it is true that some of us inherit anger, we don't have to be completely at the mercy of our genes. In the book Anger Kills, Dr. Redford Williams and his wife, Virginia Williams, write that about 20 percent of the general population has levels of hostility high enough to be dangerous to their health. About another 20 percent have very low levels, and the rest of us fall somewhere in between. When we lash out, it is the lower part of our brain — the so-called "reptilian brain" — that has hijacked our body, Dr. Williams said. But, humans have a cerebral cortex that gives us the capacity to reason, if we give it a chance. When angered, we can command our cerebral cortex to evaluate our anger — to determine if we need to take action to right a wrong, or to change our reaction to the situation. Williams, who studies anger at of Duke University Medical Center, recommends the following anger management model, which can be remembered by remembering the phrase, "I Am Worth It."
    For every angry situation, ask yourself four questions.
I — Is this matter important to me?
A — Are my thoughts and feelings appropriate?
M — Is the situation modifiable, or is there anything you can do about it?
Worth It — Is taking action "worth it?"
    He suggests reasoning yourself when you find yourself getting mad. When you feel anger, ask yourself: Is my anger justified? Does the situation deserve continued attention? Do I have a constructive response? For example, if someone cuts in front of you in heavy traffic, is your anger justified? It may be, Williams said. But does it deserve your continued attention? He contends that no, it does not, because there is nothing you can do about it now. Shouting obscenities, blasting your horn or tailgating the other car is not constructive, and will only make your anger snowball and encourage negative health effects.

Mental Health Parity Urged by Bush
James Gerstenzang & Vicki Kemper, Los Angeles Times- 4/30/2002

President Bush on Monday stepped into the growing debate over insurance benefits for the mentally ill, calling for legislation to eliminate disparities between coverage of patients with mental and physical ailments. "Our health insurance system must treat mental illness like any other disease," Bush said in an appearance before mental health professionals in Albuquerque, before flying to Los Angeles.
    The president did not endorse a specific bill or detail provisions he could support. But lobbyists on both sides of the issue said Bush's speech signaled his willingness to work with lawmakers on a measure that would require wider insurance coverage for the most serious mental illnesses. These would include major depression, bipolar disorder, schizophrenia and obsessive-compulsive disorder. Such coverage generally is opposed by many of Bush's business allies, who warn about its effect on health-care costs. Bush took note of such concerns. While stressing that he hoped Congress could send him a bill this year, he said such legislation should "not significantly run up the cost of health care." White House Press Secretary Ari Fleischer added that the administration's goal was to achieve "maximum parity" in insurance coverage "without driving up costs so high that people lose insurance in the end."
    Bush also announced the creation of a presidential commission to recommend improvements in the nation's mental health care. The 22-member panel will be asked to identify patient needs and barriers to care, and to recommend improvements within a year. Bush named Michael Hogan, the director of Ohio's department of mental health, as chairman.
    At the center of the insurance debate is whether mental health patients should receive coverage that is on a par with benefits provided for physical illnesses. In most insurance plans, such parity has long been lacking, and the inequity has emerged as a political issue. Democrat Al Gore regularly won applause during his 2000 presidential campaign when he called for equivalent coverage.
    Bush's remarks were his most extensive on the insurance issue since he became president. "Our country must make a commitment," he said at the University of New Mexico appearance. "Americans with mental illness deserve our understanding and they deserve excellent care. They deserve a health care system that treats their illness with the same urgency as a physical illness." He added: "Health plans should not be allowed to apply unfair treatment limitations or financial requirements on mental health benefits."
    Bush identified such inequity in coverage as one of the three major obstacles to confronting what he termed "the hidden sufferings of Americans with mental illness." The other obstacles were the stigma that often surrounds mental illness and a fragmented system for delivering services to the mentally ill, he added. "Many Americans fall through the cracks of the current system," Bush said, in part because many mental disorders are hard to diagnose.
    These are some of the problems he wants the new commission to examine. A 1999 surgeon general's report found that more than 50 million Americans--roughly 1 in 5--suffer from mental illness each year, but that fewer than half of them seek treatment. The National Institutes of Mental Health estimates the cost of untreated mental illness, including criminal justice and social welfare costs, at about $300 billion a year.
    White House officials said they have begun preliminary talks with the congressional supporters of improving insurance coverage for mental illness. So far, Bush has been unwilling to require unlimited coverage for all of the 277 conditions listed in the Diagnostic and Statistical Manual of Mental Disorders. Still, supporters of parity in mental health coverage were heartened by his remarks on Monday.
    The American Psychiatric Association issued a statement expressing its "gratitude and praise" to Bush for "his commitment to ending discrimination ... against patients seeking treatment for mental illness by supporting mental health parity legislation." But a statement by the American Association of Health Plans, a trade group representing more than 1,000 health maintenance organizations, illustrated the difficulties the administration will face in trying to broker an agreement on the issue. "Proposals to mandate an expansion of mental health coverage at the federal level would add billions of dollars to health-care costs at a time when 40 million Americans lack access to health insurance, and many more are struggling to afford the coverage they have," the group said. Also, the Health Care Coalition, a group made up of such politically powerful groups as the U.S. Chamber of Commerce, the National Association of Manufacturers and the National Federation of Independent Business, has prepared an advertisement telling Congress to keep out of health care. "Not one more dime. Not one more dollar. Not one more bill that raises health-care costs," the ad says.
    Bush shared the stage Monday with Sen. Pete V. Domenici (R-N.M.), a conservative who has joined with Sen. Paul Wellstone (D-Minn.), a liberal, to lead the push for an insurance parity bill. Their measure would not require any employer or group health insurance plan to cover mental health care. It applies only to plans that already offer mental health coverage, and it exempts businesses with 50 or fewer employees. For Domenici and Wellstone, the campaign for stronger mental health coverage involves a personal element. Both have watched family members struggle with mental illness. Their bill would prohibit coverage limits imposed in a 1996 bill, and would expand the range of mental illnesses covered. It includes almost all conditions except substance abuse.
    California and 31 other states have mental health parity laws. The California statute requires equal insurance coverage for all severe mental illnesses. A Texas law, signed by then-Gov. Bush, is narrower, exempting small businesses and restricting the types of illnesses covered, while limiting outpatient visits to 60 a year and inpatient treatment to 45 days annually. The Congressional Budget Office estimated that the Domenici-Wellstone bill would increase health insurance costs an average of 0.9%, or roughly $23 billion a year. Opponents of the bill say the 0.9% figure is far too low.

Prosecution Witness in Yates Trial Assailed
Carol Christian, Houston Chronicle- 4/30/2002

Defenders of convicted capital murderer Andrea Pia Yates say recent comments from the prosecution's star witness suggesting that defense attorneys and their expert witnesses "distort the law" are inappropriate. Dr. Park Dietz, the California psychiatrist who testified that Yates was legally sane when she drowned her five children in June, was the subject of an April 23 article in the New York Times in which he discussed his role in the Yates case and his views on forensic psychiatry -- the application of psychiatry to matters of law. In the Times article, Dietz said it was difficult to set aside the compassion he felt for Yates and remain objective. "It would have been the easier course of action to distort the law a little, ignore the evidence a little and pretend that she didn't know what she did was wrong," Dietz said in the article.
    Dietz -- who has testified or consulted about such high-profile defendants as Milwaukee serial killer Jeffrey Dahmer, would-be presidential assassin John Hinckley and Unabomber Theodore Kaczynski -- also said the proper role of a forensic psychiatrist is to seek the truth, not to help any party in the case. "That's my core philsophical difference with both clinical psychiatry and the defense bar," he told the Times. "And it's one of the reasons that I appear mostly for the prosecution."
    Yates' lawyer, George Parnham, said Dietz's remarks were a "slam" against the defense lawyers and their expert witnesses. "Quite honestly, I'm rather astounded that Dr. Dietz would make these statements in light of the fact that he testified during our case about the existence of a nonexistent episode of Law & Order," Parnham said. He referred to Dietz's testimony that before Yates killed her children, she had watched an episode of the television drama Law & Order in which a woman drowned her children in the bathtub and was later judged to be insane. There was no such episode. When this was brought to Dietz's attention, he sent a letter to prosecutors Joe Owmby and Kaylynn Williford stating that he had confused other episodes and other actual cases of infanticide.
    Dietz is a technical adviser to the show as well as Law & Order Criminal Intent and has seen nearly 300 episodes of the two programs, he said. Parnham has said Dietz's inaccurate testimony about Law & Order could be the basis of an appeal of Yates' conviction. In the Times article, Dietz said he won't accept a case unless he has access to all information. "Prosecutors never have a problem with that, because their goal is to seek truth and justice, and all the data are important in that quest," he said in the question-and-answer interview.
    Dr. Lucy Puryear, a Houston psychiatrist who testified for the defense at Yates' trial, pointed out that the defense was not allowed copies of various documents, including the police offense report. Parnham was permitted to read the report but could not photocopy it and had to write notes about it based on what he could remember, Puryear told the Chronicle. "I was at a real disadvantage," she said.
    Puryear, former director of the Baylor Psychiatry Clinic at Baylor College of Medicine, also took issue with Dietz's remarks that mental health professionals tend to ask leading questions and videotape only part of their interviews, as was the case with Yates. In the Times article, Dietz said he saw some "shocking examples of leading questions" in interviews videotaped by the defense. Puryear told the Chronicle that Dietz also asked Yates leading questions. "It's almost impossible not to," she said, "particularly if you're interviewing someone with a mental illness. ... You try and help them express what they are thinking."
    In Dietz's eight hours of taped interviews with Yates, there were many instances where the material supported the defense view that she was insane, said Puryear, who specializes in women's psychiatric problems related to childbirth. "He edited it and showed the jury portions that supported his testimony," she said. In contrast, Puryear said, she interviewed Yates for an hour or two, began taping and showed the entire unedited tape in court.
    In the Times article, Dietz said he thought he would have considered Yates insane in a state where the legal test is whether she "emotionally appreciated the wrongfulness" of her actions. "And I certainly would have found her insane in a jurisdiction with the Durham rule that a defendant is insane if the crime is a product of a mental disease," he said. Puryear said the differing standards bring up basic questions: What is knowing? What is wrong? "What he means by `emotionally appreciated the wrongfulness' -- that is splitting hairs," she said. "It doesn't make any sense to have that kind of standard."
    Dietz, however, told the Chronicle that laws are supposed to reflect popular opinion. "Foolish or not, (legislators) are free to pass laws reflecting the views of people in a particular state or country," said Dietz, who has a doctorate in sociology as well as an M.D. and a master's degree in public health. "Respecting that diversity of laws is essential to functioning in the court system."
    Puryear also said she was troubled by Dietz's statement that the prosecution seeks truth and justice whereas defense attorneys and clinical psychiatrists want to help the defendant. "I think that's an unfair and biased approach to a case like this because if you are presuming the prosecution is the side that's right and the defense is the side that's biased, your testimony is going to be as prejudicial as he's claiming the defense testimony is," she said. "To make a statement that the prosecution is seeking truth and justice is somewhat scandalous," she said. Dietz told the Chronicle he was not arguing that prosecutors are good and defense lawyers are bad but that they are part of the U.S. legal system that imposes different duties on the two sides.

Voiceless, Defenseless And a Source of Cash
Clifford J. Levy, New York Times- 4/30/2002

The vans pulled up at the Leben Home for Adults in Elmhurst, Queens, collecting the mentally ill residents who had been led outside and told to take a seat. Among them were Robert Dowling, who communicates in half-sentenees and twitches; his roommate, Robert Fazio, who cannot bathe or dress himself; Seymour Levine, stooped and unkempt; and Gail Barnabas, so depressed she sometimes does not speak. None of them resisted, as if they were being chaperoned to a movie or a ballgame. The doors closed and the vans headed for the offices of a doctor who billing records show had never examined some of the residents, but who was about to perform a variety of eye surgery on them. The scene would be repeated throughout 1999 and 2000, a few residents at a time. In all, the doctor conducted nearly 50 operations on more than 30 residents, the billing records show. "So many people were having the eye surgery, it was like it was a catchable disease," recalled Peter Peterson, one of the more alert Leben residents.
    Few of the residents had been complaining about their eyesight, and their general physicians had not noted problems with it, according to Leben workers and medical records. Neither the ophthalmologist, who had built a substantial practice around adult home residents, nor Leben notified their families. The procedures, which ranged from cataract operations to laser surgery and required local anesthesia, cost the government more than $25,000, the billing records show. To this day, most of the residents cannot explain what was done to them, or why. Then again, having spent much of their lives in institutions, most are used to not asking questions. The State Department of Health, which regulates adult homes, did not learn of the eye operations until they were uncovered by The New York Times. The department is now investigating them.
    Ever since New York began closing its psychiatric wards in the 1960's and essentially replacing them with adult homes, the for-profit residences have become magnets for schemes that exploit the mentally ill, a yearlong investigation by The Times found. The investigation drew upon thousands of pages of billing and medical records and state files, as well as more than 200 interviews with workers, residents and family members.
    Those interviews and records show that at several homes, what little money some residents have is simply stolen by the operators. At dozens of homes, residents are brought before a swarm of outside providers for treatment -- from surgery to allergy shots -- that seems more intended to generate revenue from government programs than to improve residents' well-being.
    The State Department of Health, in fact, knew well before the eye operations that doctors might be taking advantage of residents at Leben, long one of the state's most notorious adult homes. In early 1998, department officials began investigating a complaint, later substantiated, that two doctors had coerced 24 Leben residents into having unnecessary prostate surgery. Yet the department's records show it otherwise ignored the home, and did not increase oversight or take precautions to safeguard the people who lived there -- or at any other adult home, for that matter. In the regulators' absence, at least eight Leben residents who had had the prostate surgery then had the eye procedures, according to billing records and interviews. The Health Department would not comment on its investigation of the eye operations. The ophthalmologist, Dr. Shaul Debbi, would not comment, citing the privacy of his patients. Leben's operator at the time, Jacob Rubin, would also not comment. He was removed by the state in May 2001 after The Times published two articles about malfeasance at the home.
    As with so much else involving adult homes for the mentally ill, this was not the way it was supposed to be. The homes, conceived as a decent alternative to the dead-end misery of the state psychiatric hospitals, were intended to give the mentally ill a chance at lives in which they might have jobs, receive better care and join society in an authentic way. Instead, The Times's investigation shows, many of the homes have become another universe in which the mentally ill are taken advantage of and poorly served.
    On one side are the homes' operators, a group of businessmen who include a disgraced lawyer and a state senator's husband who went unpunished by state officials despite stealing money from residents, court records show. On the other side are the providers, which include hospitals and doctors with tarnished state records. One nonprofit group, which offers psychiatric therapy to residents, even took the opportunity to use more than $1 million in government payments to engage in risky stock trading, according to its tax records. In the middle are thousands of vulnerable people. Nearly all the residents can legally sign consent forms, and persuading them to do so is not hard. Workers at several homes said that if residents do refuse to see doctors or other providers who have financial arrangements with the operators, administrators threaten to hospitalize the residents or to withhold their spending money, which is typically entrusted to the homes. "We would usually tell them, 'You don't see the doctor, you don't get your allowance,"' said Velma McFarlane, a former Leben worker. "I had to do that. I'm not lying. It makes me feel bad, but that was the policy."
    Some residents undoubtedly require an array of services. Studies have shown that mentally ill people suffer higher rates of heart disease, diabetes and other ailments. Some may also be resistant to care that they genuinely need. Yet at virtually all the 26 homes The Times examined, workers and residents spoke of coercive tactics aimed at dubious needs. While residents often go without proper psychiatric or medical care, they are paraded before allergists, vocational therapists, dermatologists and podiatrists, among others. The government should not be shocked that the system is rife with seeming abuse and waste. The way in which the state set up the homes all but invited it.
    The state decided it would pay the homes a small daily sum -- still only $28 per person -- to feed, shelter and supervise the residents. The fee is taken from the residents' monthly Social Security disability checks. The homes were to bring in outside health care providers. The operators, who have long complained that the state pays them too little, quickly learned they could make significant money by charging rent or fees to the providers. In return, they guaranteed a bountiful supply of patients. Or the operators could start side businesses, like van services that residents are required to use to go to clinics or doctors' offices. The fees are then billed to Medicaid or Medicare, which pay for services for the poor and mentally ill. Federal and state agencies rarely question the fees, and on average, along with disability payments, spend $40,000 annually on each resident, according to interviews and billing records. For the 15,000 mentally ill people in adult homes in New York State, that comes to $600 million a year.
    The evidence of fraud and waste has not entirely escaped state officials. The mental health commissioner, James L. Stone, described in a December report a "layering of services" in some adult homes that had led to excessive costs. His office oversees the mental health providers who treat residents, though not the homes themselves. But neither his agency nor any other arm of the state government -- including the Department of Health, the Legislature and the attorney general's office -- has made efforts to investigate or revamp the system, according to state records and interviews. Asked what it was doing to safeguard adult home residents, the State Department of Health could point only to a recent crackdown on part-time medical clinics across the state, some of which are in adult homes.
    Robert R. Hinckley, a deputy state health commissioner, said the department had refused to renew the licenses for 50 such clinics in adult homes statewide, and delayed approving licenses for an additional 23. "The disapprovals of part-time clinic applications for adult homes were based on quality of care concerns and the potential for Medicaid fraud," Mr. Hinckley said.
    Perhaps even more surprising than the state's limited response is the utter lack of one by the federal government, which shoulders an enormous portion of the more than half-billion-dollar-a-year industry. Through disability payments, Medicaid and Medicare, the federal government essentially supports the adult homes. Yet in 30 years, it has rarely if ever examined their finances or moved to protect the civil rights of the people who live in them. Danielle Grush, a spokeswoman for the' New York office of the federal Centers for Medicare and Medicaid Services, said the office was concerned about abuses in the homes, but she could offer no examples of inquiries into them. "There is an enormous amount of public money that goes toward supporting the people living in these homes," said Clarence J. Sundram, a former chairman of the Commission on Quality of Care for the Mentally Disabled, a state watchdog agency. "But they end up living in wretched conditions."

The Surgery: Eye Procedures By the Vanful
Workers at Leben still recall the peculiar sight: Mentally ill residents walking down the labyrinthine corridors of the home during 1999 and 2000 with their eyes bandaged or covered by dark sunglasses. "They didn't warn me or anything," Robert Fazio, now 61, said of his eye surgery. "They just took me. And then he put a laser beam in my eye." Dr. Debbi, who operated on Mr. Fazio, performed an assortment of surgery on the more than 30 Leben residents during an 18month period in 1999 and 2000. Some had cataract operations, according to billing records, and others had laser surgery for ailments listed as glaucoma and retinal tears. Some residents had more than one procedure. "He said it was cataracts, and if he corrected it, it would be beautiful," said Gail Barnabas, now 53. "We were all brought into the van on the same day. We were there from the morning until 4 p.m., and just made it back for supper. Everybody had it. The whole van was filled."
    Because adult home residents are often profoundly sick, the state requires the homes to notify their relatives of any medical procedures. Yet in numerous instances, relatives of the Leben residents said they were never told of the surgery. "I didn't know anything about it," said Henry Dowling, the brother of Robert Dowling. "I think that it was totally unnecessary. There was nothing wrong with him."
    For his part, Dr. Debbi was required by the state to ensure that the residents, like any other patients, fully understood the procedures, including the risks, before they signed consent forms. But a number of relatives said they found it hard to imagine their mentally ill family members making an informed decision on their own. Ms. Barnabas's sister, Barbara Casali, said Ms. Barnabas "never really complained about her eyes. I was very surprised when she said she was having a cataract operation. I said, 'You're kind of young to have it.' And she said, 'Well, the doctor says I need it, so I had it."' Cataract surgery is rare for someone Ms. Barnabas's age. And she was among at least three Leben residents in their 50's to have such a procedure, according to interviews and billing records.
    It was not just people from Leben who were being shuttled to Dr. Debbi's office during the 18-month period. He also performed roughly 70 procedures on residents from three other adult homes, according to billing records: Ocean House and Wavecrest in Queens, and Parkview in the Bronx, which have a total of 379 beds. In two brief telephone interviews, Dr. Debbi would not comment. "I would prefer not to cooperate -- why should I?" he said. "I prefer to keep my practice private, and my patients' care private." Jeffrey Edelman, whose family runs the Parkview and Wavecrest homes, praised Dr. Debbi. Mr. Edelman said he "would have no reason to believe that the surgeries were unnecessary. Dr. Debbi is as far as I know a very trustworthy individual." After The Times uncovered the eye procedures, a group that represents adult home residents, the Coalition of Institutionalized Aged and Disabled, filed a complaint last July with the Health Department, seeking an investigation of Dr. Debbi and the surgery.
    Most of the residents who had the surgery continue to live at the home, which is under new management and was recently renamed Queens Adult Care. Kurt Trentmann, who is one of the more lucid residents, said he had told a Health Department investigator that his cataract operation had made his vision worse, and that Dr. Debbi had not responded when he told him about complications. "I told Debbi that I was having problems with my eye, that everything was distorted," Mr. Trentmann, 55, said. "He says, `This is going to take time.' Well, it's been over two years now. And I haven't talked to him since." Mr. Trentmann has switched to doctors at a Veterans Administration hospital, who told him that Dr. Debbi had implanted the wrong lens, according to his treatment records.
    Others, like Mr. Dowling, 59, have no memory of the procedures. Dr. Debbi performed four operations on Mr. Dowling in four months, two cataract operations and two laser procedures, according to billing records. Dr. Debbi received more than $3,000 from Medicaid and Medicare for his services. Other costs for the four procedures totaled $2,500. Those eye procedures were just a few of a lengthy list of services for Mr. Dowling that numerous providers billed to Medicaid and Medicare. From 1998 through the first half of 2001, the services cost roughly $150,000, even though Mr. Dowling had no serious physical ailments, the billing records show. Among the fees were $70,000 for therapy, sessions and nearly $20,000 for van services to take him to appointments, the records show. During this time, Leben would not fix a broken lock on Mr. Dowling's door, his brother said, and his clothes were stolen.

The Operators: Tainted Records And Family Ties
In 1991, a resident at Brooklyn Manor received $45,626 in retirement benefits, a veritable windfall in the world of adult homes. The money was entrusted to the home, and its operator, Benito Fernandez, took every penny of it, according to multiple reports by state inspectors. It was not an isolated case. Throughout the early 1990's, state inspectors cited Mr. Fernandez and his associates for mishandling or misappropriating residents' money, as well as for poor conditions and supervision at the 216-bed home, in East New York.
    Based on the inspectors' findings, the State Department of Social Services, which regulated adult homes at the time, refused to renew Mr. Fernandez's license. In 1996, an administrative law judge upheld the decision, citing overwhelming evidence. The department had won, yet its senior officials soon withdrew the case against Mr. Fernandez, who is married to State Senator Nellie Santiago of Brooklyn. In addition, the senior officials rebuked the inspectors, taking away their authority over the home and giving it to inspectors based on Long Island. The records in the case contain no explanation for the state's reversal. State officials, repeatedly questioned in recent months about the case, would also offer none.
    After the department withdrew its case, two nonprofit groups that represent adult home residents -- MFY Legal Services and Disability Advocates -- sued the department to force it to revoke Mr. Fernandez's license,` but lost the case on technical grounds. "I always had a sense that calls were being made to the higher-ups and political pressure was put on them," said Ann PeggBiddle, a lawyer for MFY at the time.
    Mr. Fernandez still runs the home. He and his wife did not respond to requests for comment. Shortly before she was elected in 1992, Senator Santiago was an administrator at the home, but the state ordered her removal after charging she had falsified records to make it appear as if she had attended classes required for administrators. Last year, after The Times began investigating adult homes, the Health Department, which now regulates the homes, returned Brooklyn Manor to the city inspection office's jurisdiction. It found the home in disarray and cited it for many serious violations, including inaccurate, incomplete or nonexistent records.
    Mr. Fernandez and Brooklyn Manor are hardly distinctive. He is among several operators with checkered records, and his home is symptomatic of a system that is loosely, regulated and licensed. The operators do not need mental health training, and the state often fails to scrutinize their backgrounds. A 1999 audit by State Comptroller H. Carl McCall found the Health Department did not verify references and financial information submitted by applicants and did not seek to determine whether the applicants had criminal histories.
    So, in addition to an operator like Mr. Fernandez, the state ends up entrusting the mentally ill to people like Beryl Zyskind. In the early 1990's, Mr. Zyskind ran what is now called Ocean House, and was charged by federal prosecutors with stealing money from residents, including $120,000 in Veterans Administration benefits from one resident who was a Vietnam War veteran. Mr. Zyskind, who was also charged with bank fraud, was convicted and sentenced to 30 months in federal prison. The state soon gave its blessing to a new boss for the 125-bed home. He was Mr. Zyskind's brother-in-law, Sherman Taub, a lawyer who had resigned from the bar after being accused of billing his law clients for $232,000 of his personal expenses, according to records from the Appellate Division of the State Supreme Court.
    In December, the State Commission on Quality of Care for the Mentally Disabled issued a report on Ocean House that alleged a staggering array of violations. It said Mr. Taub had engaged in an elaborate scheme to siphon millions of dollars from Ocean House through improper mortgage transactions and other maneuvers. It said a company co-owned by Mr. Taubs son, Jay, had received $420,00 in Medicaid payments by submitting improper claims for home health aid costs for residents. The Manhattan district attorney is also investigating the allegations.
    Ocean House is technically one of the few nonprofit adult homes in the city, but interviews and records suggest that Mr. Taub has run it like a profit-making entity. Among the items obtained by the home in recent years, according tot he records, were three Lexus luxury sedans, which cost at least $40,000 each. At the same time, residents were sleeping on soiled sheets in filthy rooms, inspections reports show.
    In a brief interview about the commission report, Mr. Taub said, "I can assure you that every allegation in there is not factual and not true." Ocean House's lawyer, Mel P. Barkan, acknowledged that Ocean House had paid for Mr. Taub's personal expenses. But he explained that such disbursements were subtracted from money that Ocean House, a nonprofit entity controlled by Mr. Taub, owed Mr. Taub. Asked about Mr. Taub's credentials for running a home for the mentally ill, Mr. Barkan said: "I think that he has a very fine understanding today of what is required to treat these people as well as they can be treated. And I think that this home is doing a very fine job."
    The State Department of Health was not aware of the allegations against Mr. Taub and Ocean House until they were brought to light by the Quality of Care Commission and Manhattan prosecutors. After the commission report was issued in December, the Health Department said it would try to revoke, the home's license. For now, Mr. Taub continues to run the home. The state has also not taken any action against Jay Taub, who runs a nonprofit adult home in Staten Island called Hylan Manor, even though he was implicated in the allegations against Ocean House.

The Providers: Thousands in Rent For Space Unoccupied
With vast amounts of government dollars available, the business of treating residents has attracted numerous players, from small practitioners to major hospitals. A rare look at the financial arrangements between the homes and providers was offered by the Quality of care Commission's report on Ocean House in December. investigators determined that Ocean House reaped at least $185,000 in rent annually from five providers, including $120,000 from St. John's Episcopal Hospital, and lesser sums from two home health aide agencies, an internist and a podiatrist, the report said. The investigators concluded that the hospital was paying for space that it never occupied, suggesting that the fees might have been kickbacks. One home health agency, Americare, paid $36,000 annually under a lease that included provisions for a waiting area in the basement and two parking spaces. None of them existed, the report said.
    Ocean House responded by saying that St. John's had merely not used space it was entitled to under its contract with the home. The home said Americare did have the basement area, and that the parking spaces were on a grassy spot next to the home. St. John's conceded it had rented space it did not use, but said it had not done so for "improper or fraudulent" reasons. In looking into some of the services provided to Ocean House residents, commission investigators found that St. John's had billed Medicaid for $300,000 in clinic sessions for Ocean House residents that were social or recreational not psychiatric, in nature. For example, at an art group run by the hospital, residents colored on a sheet and had soda and potato chips. There was almost no conversation, and the session ended within 20 minutes, the commission's report said. The cost: $141 per person per session. At other times, residents were taken on trips to the mall and the movies, or sang songs.
    St. John's said that it had done nothing wrong, but that it had changed its practices. Other hospitals have also been accused of inappropriate billing practices. In 1999, in one of the largest Medicaid fraud inquiries in the nation's history, Staten Island University Hospital agreed to reimburse the state $45 million for improper billing practices, largely at clinics for adult home residents. Groups that are nominally nonprofit have also been involved in scandals. Last year, the State Office of Mental Health closed down one, New Hope Guild Centers, which operated mental health clinics for adult home residents and others. The office charged that New Hope had expanded its services without approval, lied to cover up its violations and billed Medicaid for unauthorized services like biofeedback therapy. This month, two New Hope officials were charged by the state attorney general with defrauding Medicaid of $9 million.
    Other nonprofits continue to prosper from the homes. New Horizons Therapy Center which offers therapy and other programs for adult home residents, pays its executive vice president $135,000, according td its recent filings with the Internal Revenue Service. New Horizon has had such robust revenue from Medicaid, reaping $4.5 million annually, that in the late 1990's it made the more than $1 million in high-risk stock trades. New Horizon says it no longer engages in such trades. New Horizon's biggest competitor is New York Psychotherapy and Counseling Center, which had $8.5 million in annual revenue, also almost entirely from Medicaid, according to its tax filings. It paid its executive director and medical director $260,000 each, and spent $75,000 lobbying in Albany.
    That revenue derives from the close relationships the two nonprofit groups have built with the homes' operators, workers said. In 1999, for example, residents of Surf Manor in Brooklyn were told by the home that instead of attending a New York Psychotherapy program twice a week, they would have to go five days, even though they did not want to and social workers said they did not need to go that often. The change came about after the home's operator, Robert Lichtschein, set up a transportation service to earn Medicaid money by driving residents to a variety of appointments. Mr. Lichtschein said the residents had not been pressured to go. "The caseworkers here tell them that it is to their benefit to go out to different programs," he said.
    Muriel Dethomas, a former administrator at New York Psychotherapy, disputed that account. Ms. Dethomas said it was common for Surf Manor and other homes, as well as the clinic, to pressure residents to go to the program by telling them that if they did not, they would be hospitalized on evicted or would lose their allowance. "What they did was force them to come," Ms. Dethomas said. Eric Bettelheim, director of corporate administration at New York Psychotherapy, said he was not aware that residents had been pressured He said some residents might be making up complaints in an effort to retaliate against the home. "They might be trying to manipulate the situation," Mr. Bettelheim said.

Feet First: $50 to $75 a Session For Clipping Toenails
There is no evidence of a medical link between mental illness and diseases of the foot, but the amount of podiatric care in the homes might indicate otherwise. Talk to dozens of residents at the homes, and most say the same thing: they are lined up at least once a month to see a podiatrist. The session lasts a few minutes at most, and the government gets the bill. "They put your name on the list and then a nurse calls you in and tells you that you have to go to the' doctor," said Eileen Marcus, 45, who has lived at several adult homes in the city, including Oceanview Manor and Seaport Manor in Brooklyn. "It's outlandish. My nails don't grow that fast. That's all they do -- clip my nails." The cost is not insignificant, especially considering how little money is spent by the to house, feed and supervise the residents. An examination of several residents' billing records shows that Medicaid and Medicare were paying $750 to $1,000 annually per resident just for podiatric care.
    Posted on the door of the medication room at Seaport Manor one Friday last summer, for example, was the morning schedule for a podiatrist named Dr. David B. Fuchs. It was three pages long, with 137 names in all. Those who saw Dr. Fuchs each received a few minutes of his time at a cost to the government of up to $100 per person. The amount of care for one resident is evident in the case of Ernest Nelson, a 46-year-old who until this month lived at Seaport Manor. Between 1998 and the first half of 2001, billing records show, Mr. Nelson was treated for various conditions, including 19 times for dermatophytosis (otherwise known as athlete's foot), 7 times for ingrown toenails, 4 times for corns and calluses, 4 times for heel pain, 2 times for hammertoe and once for a sprained foot. In all, Medicaid paid more than $2,500.
    Dr. Fuchs defended his practice. "We see maybe 15 or 20 patients in a morning," he said. "They need the care. They have corns, they have calluses, they have pain." Mr. Nelson has a different take. "They are just trying to make money off of us," he said At Leben, numerous residents have been treated monthly by a podiatrist named Dr. Stephen Smirlock, whose license plate reads FOOTBIZ. Some residents saw him more than 40 times from 1998 through 2001, billing records show. Dr. Smirlock did not respond to three messages seeking comment.
    Some adult home administrators said paying podiatrists $50 or $75 a' visit to clip toenails was appropriate, even though state regulations say the homes should provide such basic care themselves. "Cutting somebody's toenails can be extremely injurious," said Benay Phillips, who helps manage the Elm-York home in Queens.
    Medical fraud investigators in New York have long been suspicious of the podiatric profession. In the late 1980's and early 1990's, so many podiatrists were punished for cheating Medicaid that the state attorney general's office had the entire profession severely restricted from the program. But podiatrists working in adult homes have found ways to get around the rules.
    And the state has largely stood by, records show, even though its inspectors have come across clues. At Seaport, they cited the home in January 2000 after discovering prescription podiatric creams in residents' rooms, a violation of rules that bar residents from administering prescription medication themselves. But the inspectors apparently never looked into why so many residents had the cream in their rooms in the first place. Had the inspectors questioned workers, they would have learned that podiatrists had prescribed so much cream that the home was running into a problem. It seems that there was not enough space left in the medication room to store the psychotropic drugs.

For Some, Marijuana Grows Mean
Howard Markel, M.D., New York Times- 4/30/2002

Recently one morning, I received an urgent call from the mother of an 18year-old named Daniel, whom I treat for marijuana abuse. For most of the past few years, Daniel had smoked more than a quarter of an ounce of marijuana daily and was almost always high, except, perhaps, when he was asleep. His marijuana problem has led to many others: he has been hospitalized, fired from jobs and thrown out of high school. He has faced run-ins with the police and lost the trust of most of his family members and friends. "Daniel had another relapse," his mother said that morning. Released only a month earlier from a drug rehabilitation program, Daniel and a friend had obtained some potent hash-oil-laced blunts, or marijuana-filled cigars, and smoked themselves into oblivion.
    Marijuana, of course, can make one giddy and euphoric, but it can also make one quite paranoid. Instead of the mellow high they were promised, the young men became enraged and began fighting over who would take custody of the remaining marijuana. In an angered haze, Daniel pulled out his jackknife and threatened to use it if his friend refused to give up the blunts. In reality, he nicked the other boy's skin. But at the time, Daniel was convinced that he had killed his friend. Inebriated and frantic, Daniel ran home to confess his crime to his mother. When she called me, he was already being evaluated in the emergency room.
    Since the 1960's, many Americans have been more lenient in assessing the risks of marijuana than those of heroin, cocaine or even alcohol. Marijuana does not destroy the liver, as alcohol does; nor is it as vicious a drug of abuse as heroin or cocaine. Indeed, the physical manifestations of dependency on pot are small in comparison. And because marijuana's active ingredient, tetrahydrocannabinol, or THC, is lipophilic, it remains in the fat cells of the body for days to weeks, slowly working itself out without any of the harsh physical withdrawal symptoms seen in the alcohoiic or heroin user who goes cold turkey.
    But today marijuana is anywhere from 10 to 20 times as potent as what was passed around at Woodstock. With that increase in potency, the risks of daily dependence have increased. In fact, many users are dependent on marijuana and suffer from all the psychological ramifications, if not the serious signs physical addiction. These include feeling a need to use the drug daily to cope with life, consuming ever-increasing amounts to achieve a high, expending considerable money and effort to get and use the drug in.relation to other needs or priorities, lying about drug use to family members, and losing loving, trusting relationships. With marijuana dependence, these destructive forces can be every bit as severe as the forces that can bring havoc to the lives of people who rely on the bottle, the syringe or crack pipe.
    Addiction specialists have long understood that some people have a genetic or neurochemical predisposition to particular drug addictions or dependencies. One colleague explains it this way: "These people have a light switch in the brain, and if they come in contact with their substance of abuse, that switch is turned on and is very hard to turn off." Moreover, marijuana use is widespread among American teenagers. In the past year, more than 40 percent of all high school seniors used marijuana at least once and more than 10 percent of them used it monthly, or more often. Invariably, some of these young people, like Daniel, are hard-wired for THC dependence. But we have no diagnostic test to predict which ones they are.
    When I visited Daniel in the hospital, he was relieved that he had not injured his friend but ashamed about his relapse. "I keep saying I will quit," he told me, "but every time I begin to do well, I go right back to it." He is hardly alone. Among addicted teenagers, who do not always think through the long-term consequences of their actions, well over two-thirds who try abstinence will relapse. At the end of our chat, Daniel timidly asked, "Maybe this is just too big for me to fight, you think?" As he spoke, I could see more of the 9-year-old I used to reward with lollipops for taking vaccinations than the troubled young man he is today. I reassured him that he did not have to fight this alone, that there were people who cared about him who wanted to help and that he needed to keep trying. As I left his room with a profound respect for the illness he was battling, I could only hope that next time he might be able to wrestle it to a draw.

R.I. Senate Panel Hears Domestic Violence Bills
Associated Press, 4/30/2002

PROVIDENCE, R.I. -- Before Russell Arlia could be arraigned on charges that included stalking his ex-wife, he killed her then himself, sparking calls for a better state system for handling domestic violence. Friends of Barbara Lombardi, Arlia's former wife, believe she'd still be alive if he hadn't been allowed to go free on bail. She was shot in her Coventry home March 12, one of three murders in the state in a five-week period which authorities say were committed by people with a history of domestic violence. ''There's no time to debate this any longer,'' said Carolyn Petreccia, a longtime friend of Lombardi. ''Legislators need to let abusers know we are not going to tolerate this.'' Changing state law won't be easy, however.
    One proposal before the Senate Judiciary Committee Tuesday would give bail commissioners the power to hold accused offenders without bail. Both the American Civil Liberties Union and the judge who oversees bail commissioners believe the proposal unconstitutional. The state constitution allows suspects to be held without bail prior to a court hearing for certain crimes, which don't include domestic violence cases.
    Albert DeRobbio, a Providence County District Court judge who oversees the state's bail commissioners, believes letting them decide whether to hold suspects in domestic violence cases, but not other crimes, would violate the state constitution. ''What would they base that discretion on?'' he asked. DeRobbio supports allowing bail commissioners to hold without bail suspects who have violated parole, regardless of the crime.
    Lombardi was killed by Arlia just three days after he was released on $500 bail for stalking her and violating a protection order. Arlia had harassed her for two years. Petreccia said Lombardi filled a notebook with safety directions and instructions she had received from authorities. ''Barbara changed her phone number and changed her routine many times. She tried to do everything right,'' said Petreccia. ''This tragedy translates into a failure of the system,'' she said.
    The Senate panel will also consider making stalking a felony on a first offense for all offenders who have shown a pattern in their behavior. The law now allows the offense to be treated as a felony on first offense only if the offender has violated a restraining order. ''We've seen some glaring discrepancies in how the system works to protect people such as Barbara Lombardi,'' said bill sponsor Sen. Leo Blais, R-Coventry.