Noteworthy News Articles on Mental Health Topics, November 1-10, 2003


Time on Side of Abuse Victims
Christi Parsons, Chicago Tribune- 11/2/2003

By dramatically changing the way Illinois law looks at child sexual abuse and the nature of the harm it causes, a new statute has opened the door for many more civil suits against alleged abusers. The new law puts Illinois among the most lenient in how much time can pass before such a suit is filed, by essentially suspending the age limit for some accusers. The law now acknowledges the difference between unlocking a repressed memory of abuse and actually recognizing that it was harmful, giving accusers time for both realizations to happen before shutting the door to litigation.
    It may seem a subtle nuance, but the new law's language radically shifts the landscape for abuse victims, who experts say may take decades to realize the consequences of what happened to them. The change means everything for adults who were sexually abused as children, say victims and their advocates. Whereas before the new law almost no one older than 28 had any legal recourse, now anyone of any age could conceivably bring a lawsuit.
    "It became crystal clear to me only last year that I was harmed by this," said Ken Kaczmarz, 34, who is suing the priest who he says abused him when he was 11 and 12 as well as other boys at a Southwest Side church. "It took me that long to realize that my absolute distrust for authority, the anger that I have--these things are without a doubt related to the abuse I suffered at his hands. I'm only ready now to confront it." Before the passage of the law, Kaczmarz was well past the civil statute of limitations to file a suit. Now, however, his lawyer can argue in court that the clock didn't start ticking for him until last year.
    Proponents of the law are worried challenges in two courtrooms in Springfield and Chicago may render it moot. The Springfield Diocese has challenged the civil part of the law in a case brought by an adult alleging sexual abuse while he was a child, and a Chicago parochial school is seeking similar action in a Cook County case, according to the law's supporters.
    Many experts on child sex abuse say suffering injury at a young age somehow creates a treacherous chasm between the knowledge of abuse and understanding of its consequences. Those who traverse that chasm still face a difficult fight in the courts despite the new law. Though it gives them greater standing to file suit, the law does not make it easier to prove the abuse occurred or an accused's guilt. By inviting so many lawsuits based on discoveries late in life, in fact, the law may even open a whole new line of defense for the accused. Still, the legal change is being heralded by countless survivors of abuse. Previously, people who reported years-old abuse to police or prosecutors found the law no longer allowed authorities to file criminal charges or civil suits.

States consider changes
Many states have begun to consider changing their laws to address the problem, with half a dozen legislatures examining measures to extend the statutes of limitations for lawsuits. California is in the midst of a one-year window during which anyone can bring a claim for damages regardless of when the alleged abuse occurred. And a year ago, Connecticut increased the age for filing suit to 48, .
    Inspired by highly publicized clergy sex abuse scandals within the Catholic Church, lawmakers in Illinois last spring passed the law clarifying and extending the limitations on both criminal prosecution and civil claims. Previously, prosecutors could pursue criminal charges only if an accuser was younger than 28. Gov. Rod Blagojevich signed the measure into law in July, allowing prosecutors to file child sex abuse charges in future cases up to 20 years after an accuser turns 18.
    A second change gives all accusers more time to file civil suits as well. Now they have 10 years after turning 18, instead of just two years. But a third significant change effectively suspends the age limit for many accusers: It gives them five years after they have not just recognized they had been abused but also after they have realized the harm it caused.
    Like policymakers all over the country, Illinois officials have only recently come to this viewpoint. The prevailing attitude was reflected in a 2000 opinion of the Illinois Supreme Court, ruling against a 32-year-old Kane County woman suing the priest who she alleged sexually abused her as a minor. In that case, the justices said they thought she'd waited too long to bring her suit because she had always been aware of what had happened to her. "The plaintiff does not contend that she repressed memories of the abuse committed by the priest," Justice Benjamin Miller wrote, "or that she was not aware that his misconduct was harmful. Rather, the plaintiff asserts that she did not discover until years later the full extent of the injuries she allegedly sustained as a result of the childhood occurrences." In those circumstances, justices said, the clock should start at the time an accuser turns 18.
    But among the vast and increasingly public network of sexual abuse survivors, that notion runs counter to what they believe about the effects of such abuse--and about the way victims arrive at a point where they can confront their attackers. Knowing that you were abused and realizing you were seriously harmed by it are two different things, many advocates and experts say. "It's almost medieval, the ignorance about the dynamic of child abuse," said Jeff Anderson, a Minneapolis based lawyer who is filing such civil suits in Illinois and other states. "There's a cultural denial that the most trusted people among us wouldn't do such horrible things, and that refusal to believe there's a problem affects the victims too. Courts and lawmakers don't understand why it is that people need more time before they can face it."

Realization years later
Psychologically, that often stems from the fact that it takes abuse survivors years to realize they were crime victims, some experts say. "Your age colors your sense of what's appropriate," said Susan Phipps-Yonas, a psychologist and expert witness who frequently testifies in sex abuse court proceedings around the country. "You may for a long time have such distorted cognitions about what happened and, to whatever extent the individual feels it was her fault or his fault, that complicated so much the ability to understand that this was abuse." Survivors have to first realize they were victims of abuse before they can come to the knowledge that the abuse harmed them, Phipps-Yonas said. In fact, the average age of the people who join support groups for victims of child sex abuse is high, with few members attending before age 30, Chicago-area support group members say.
    Illinois law now more clearly respects this reasoning. It also stipulates that none of the limitation periods run while an accuser is subject to threats, intimidation, manipulation or fraud. As a result of this change, many who were previously ineligible to pursue civil suits are now able to file them.
    Kaczmarz is among those plaintiffs. He said he remembered in 1992 that he had been abused by a priest when he was a child, just as stories of clergy abuse began appearing in the media. "I started thinking about my relationship with him, and all of these episodes in his office began coming back to me," Kaczmarz said.

Desire to protect others
Before the passage of the new law, Kaczmarz would have had no recourse, and the suit, which he filed in February, may well have been thrown out of court. Now, though, because he contends he discovered the harm within the last five years, he has standing to sue the priest and the religious order in court. At the very least, Kaczmarz hopes, the public nature of the suit will help prevent the priest from being put in positions of trust around children again.
    Dozens of other potential plaintiffs are in the same position now, said Joe Klest, a Chicago-area attorney who handles such cases and who also helped craft the law. While the change only allows criminal charges in future cases of abuse, victims of all ages who have discovered their injuries in the last five years can come forward in civil court. "This changes everything for a lot of people," Klest said. "Finally, there is something they can do about what happened to them."


The Cruelest Cure
Lauren Slater, New York Times Magazine, 11/2/2003

I'm sitting in a room with six terrified people. Outside the window we can hear the roar of Boston's rush hour, cars sputtering at intersections, baseball fans shouting in the streets. Out there it is loud, but in here, at the Center for Anxiety and Related Disorders at Boston University, it is as hushed as a hospital, the faces of the patients slick with sweat. The director of the center, the psychologist David H. Barlow, is one of the leading researchers in the field of fear. He isn't here today, but his methods are guiding this therapy group, which is led by two strikingly young-looking graduate students. It seems somehow fitting that this center, the premier institution for the treatment of anxiety, is located smack-dab in the maze of Boston's crooked and crazy streets.
    Barlow's method for treating anxiety disorders is surprisingly simple, although its philosophical and clinical implications are anything but. He aims to reduce anxiety not by teaching customary relaxation techniques involving calming mantras or soothing imagery, but by doing just the opposite: forcing the patient to repeatedly face his most dreaded situation, so that, eventually, he becomes accustomed to the sensation of terror. Barlow claims he can rid some people of their symptoms in as little as five to eight days. His treatment promises to be psychotherapy's ultimate fast track, but while many clinicians praise its well-documented results, others take a dimmer view of what one clinician calls ''torture, plain and simple.''
    What critics malign as ''torture,'' Barlow calls ''exposure.'' Here's how it works. Ben, for instance, is 31 years old; he has come to the clinic to try to rid himself of panic attacks. His anxieties also stand in the way of his poetry writing, and he is fearful of people criticizing his work. One of his most feared situations is giving a public poetry reading and knowing that the audience is restless. Therefore, the patients and I are instructed to act as bored and rude as possible while Ben, hyped up on coffee, reads his poems aloud. ''Remember,'' says Molly Choate, one of the group leaders, ''as he reads, cough, whisper, laugh, rustle around.'' ''That's the part I hate the most,'' says Ben, standing at the front of the room. He knows the boredom will be faked, but this knowledge does nothing to assuage his fear. He begins to read. After the second line of the poem, the audience starts the exposure. A patient scrapes his fingernails over the rough surface of his seat, and others follow on cue, coughing, peeling the tabs off cans of Coke and slurping at the foam that wells up. A woman leans forward and whispers audibly in another woman's ear, ''Let's get out of here.'' Ben sweats as he forces his voice to go louder, pushing his stanzas over the background bustle. Someone snorts.
    ''SUD's?'' one of the group leaders shouts out, meaning, ''subjective units of disturbance,'' a state of fear the patient gauges himself. ''Nine,'' Ben says. The group leader seems satisfied. SUD's occur on a scale of 1 to 10. Ten is so-called toxic anxiety. One is cool and calm. According to Barlow, an exposure is only as good as the amount of fear it generates.''You did it,'' Choate says at the end. Ben is finished now. And what has he demonstrated? According to the group leaders, he has demonstrated that he is capable of withstanding cruelty, and thus he has toughened up his limbic system. On a neurological level, he is learning, as Barlow would put it, ''to talk to his amygdala.'' The amygdala is fear central in our brains, and Barlow's theory is that in panic and anxiety disorders, it reacts too strongly to tricky situations. By not collapsing, or fainting, or, most important, running away, Ben has trained his brain to believe in its own strength. He sits down and wipes his forehead with his sleeve. ''How'd I do?'' he asks the group. ''Great,'' everyone says in unison, though Ben looks unhappy. I wonder if this is because no one has praised his poetry.
    When it comes to treating anxiety, Barlow is by no means the only show in town. He's surrounded by myriad practitioners, many of whom praise him, some of whom deride him. Eva Selhub, an instructor at Harvard Medical School and the medical director of the Mind/Body Medical Institute, says, ''Just hearing about what he does gives me the fight-or-flight response.'' She laughs. ''We don't believe in revving up our patients. We believe that teaching patients how to reverse the stress response through breathing techniques is the way to go.'' Barlow, however, disagrees. ''We have found that relaxation can retard a person's progress,'' he says, ''because the message the clinician then sends is that it is dangerous to be anxious. And it isn't.'' Barlow, instead, gets his patients to drink a lot of caffeine while riding a chairlift or walking over a bridge, a kind of vaccination approach to the problem, injecting the patient with live virus until she builds up an immune response. ''Inoculation,'' Barlow calls it.
    His detractors call his inoculations superficial. Christopher McCullough, a professor at the Professional School of Psychology in Sacramento and a therapist in private practice, says that methods like Barlow's are ''all surface'' and ''teach the patient nothing about why they're anxious, about what the anxiety might mean.'' This view is echoed by his naysayers -- analysts, psychodynamic psychotherapists, psychopharmacologists -- all of whom work outside the subspecialty of behavioral therapy and research.
    But less predictable, and more interesting, are what those within the behaviorist subspecialty have to say about Barlow's approach. Barlow is in the odd position of being at once highly respected by academics while being, at times, criticized by colleagues who treat patients in the trenches. ''Yes, I've heard of him,'' says Victoria Wolfson, a psychiatrist on staff at the Boston Medical Center. ''But I think very few patients can tolerate that adrenaline-based approach.'' Echoing this view are cognitive behavioral clinicians like Selhub.
    Barlow's supporters are not swayed by these criticisms. After all, his success in ameliorating anxiety is by his reckoning as high as 85 percent. David Tolin, the director of the Anxiety Disorders Center at the Institute of Living in Hartford, says: ''Barlow's program is an ideal toward which other clinicians should strive. It is the most rigorously tested and documented treatment for anxiety. Most practitioners don't teach his approach because the field of psychology is relatively slow to adapt to evidence-based treatment.'' Reid Wilson, a professor of psychiatry at the University of North Carolina School of Medicine and an ardent Barlow supporter, adds that Barlow's work hasn't completely caught on because, as he puts it: ''We're still on the uphill climb. We haven't had the manpower to train enough people. Only a very small number of clinicians know about this. They don't understand that relaxation training could actually slow treatment instead of speed it up.''
    Relaxation training was founded, in part, by Joseph Wolpe, a South African-born psychiatrist who cultivated what is called ''systematic desensitization,'' a method whereby you gradually expose a person to his greatest fears while helping him ''go rag doll.'' The theory beneath the technique is that if you come to associate, say, snakes, not with heart-stopping surges of hormones but with rhythmic relaxed breathing, then after a while, snakes may make you sleepy.
    When Barlow was in graduate school, back in the 60's, he was one of Wolpe's students. He says it gradually dawned on him and others, like Isaac Marks, a psychiatrist at the Institute of Psychiatry at the University of London, that inducing calm, through pills or practice, is not necessarily helpful. Barlow's core belief is this: people aren't afraid of external things. It's all a matter of the relationship a person has to his or her own internalized terror. And once people disarm their terror, once they realize that they can survive it, then you have detoxified the problem and in some senses provided a cure. It has been a long time since anyone in the soft science of psychology has been able to claim a cure as a part of their repertory, though Barlow recognizes that he still doesn't have enough long-term data to guarantee that his patients will never relapse.
    Barlow's treatment is not for the faint of heart. ''A good patient is a real workhorse,'' Wilson says. ''A good patient doesn't only accept fear; he courts it, chases it. He says: 'C'mon panic. Give me your best shot.''' Depending upon where you stand, comments like this can sound either inappropriately sadomasochistic or in keeping with the current popular ethic of rugged self-reliance. I ask Wilson, ''What happens if in the process of getting someone really hyped up, a patient has a nervous breakdown instead?'' Wilson doesn't miss a beat. ''It's never happened,'' he says. ''If they can't take it, we don't feed them to the lions all at once. We let them go piece by piece in the beginning, if they really need to.''
    Not everyone, however, likes being fed to the lions. Pamela, a woman who fears public speaking, has tried Barlow's method, and she says, ''All it did was make me worse.'' While preparing for a speech, Pamela tried spinning around on her tiptoes while panting fast in order to get her nervous system as souped up as possible. ''I hyperventilated, drank coffee, and all it did was make me more of a wreck. I kept trying to do this. Eventually I got to the point where I was pretty much paralyzed.'' Pamela, who is not a patient at the center but read about Barlow in a book, decided to try his treatment solo, while not under the care of a therapist, which Barlow and his followers do not recommend. While it's easy to dismiss her experience on those grounds, her criticisms seem to make intuitive sense. ''What I really dislike about treatment like that is its assumption that we have to be strong in order to feel secure,'' she told me. ''That's what messed me up in the first place, the assumption my parents and society have always had that I should win and overcome.'' Pamela's solution was to totally give in. ''I realized,'' she says, ''that my anxiety was a product of this achieving mindset, and I decided not to push myself.'' To that end, Pamela gave up public speaking for a while. ''Who says I have to be great?'' she says. ''Who says I can't be mediocre and scared? For me, this was the real revolution.''
    Still, Barlow has success rates that match or beat other competing nonpharmacological interventions. Most of his patients get better in 12 weeks or fewer, and his data suggest they stay better up to two years after treatment, beyond which point he has not yet compiled further data. As to his claim to be able to make some of his patients symptom-free in a mere five to eight days, he offers several videotapes to make his case. One tape follows a fearful flier prior to treatment as she purposefully hyperventilates her way, back and forth, between Boston and New York. Some $2,500 and 124 hours' worth of treatment later, she is completely at ease. The film is grueling and convincing.
    For homework, Ben, the poet, is instructed to stand on a busy city street and read his work to all who rush past. A woman who fears cancer to the point of paralysis is instructed to drink three cups of coffee while watching ''Terms of Endearment'' repeatedly. A man who can't face being in a car is told to drive down a dark wet road at night. Jeff, a claustrophobic businessman, has the assignment of shutting himself in a small space for as long as he can stand it. When I spoke with Jeff about his treatment, he explained that he had decided to lock himself in the trunk of his car. The first time, he lasted only three minutes, in an intense state of anxiety. He curled up in a fetal position and balled his fist up near his mouth. Eventually he conditioned himself to last up to a half-hour in the trunk. By the last time, he says, ''I was bored.''
    Every one of Barlow's clients is bearing his cross with courage. And that fact reflects his core belief: not just anxiety but all mental illness (with the possible exception of psychosis) is ultimately a problem not of pain itself but of a person's relationship to his pain. Barlow is currently working on taking his treatment to those suffering from everything from depression to substance abuse. ''It's far too early to tell if this will work,'' he says. But he has begun treating a small group of depressed patients by teaching them to accept, and even seek out, their sadness. According to Barlow, attempts to suppress painful emotion lie at the heart of most pathology; the struggle involved in suppression only tightens the noose on an already vulnerable neck. So first sit still, Barlow says. Second, begin to act exactly counter to how you feel. (''Even the act of smiling can change our brain chemistry,'' Barlow remarks, ''so it's definitely O.K. to force a grin.'') Third, and most controversial, court the causes of your depression as a means of desensitizing yourself to them. ''When you fight your own internal censors, you're giving them too much power,'' says Reid Wilson, who employs Barlow's methods in his practice. ''You're saying they're worth the fight. Guess what? They aren't. There are some limitations to cognitive restructuring, because it's just like teaching relaxation. It sends the message that negative thoughts are bad, can even kill you. We practice the provocative approach of getting a person to confront repeatedly what they fear until they're so used to it that it ceases to mean a thing.''
    I, however, am not convinced. After all, depression is precisely a problem of meaninglessness, whereas anxiety, one might say, is a problem of excess meaning. What good would it do to teach a melancholic patient that his thoughts are null and void? He already believes that acutely. Furthermore, those in a state of severe sadness would probably lack the high, hopeful motivation that characterizes Barlow's anxiety patients. You can get a jittery, willful guy like Jeff to shut himself in his car, but could a depressed person really find the energy to care?
    At the end of 12 weeks, all but one of the patients in the group I observed are functioning effectively. They are free to write and read poetry, fly across the country, visit oncology wards, drive down wet roads in the middle of the night. Jeff, who tried drugs and meditation training before finally coming in desperation to Barlow's clinic, says: ''I'm not going to say I don't feel fear anymore. I do. But I can say that I'm able to now live somewhat of a normal life. I can do what I want. My fear is there, but I handle it.'' He pauses, then he says, ''I consider that a cure.'' And in its own way, it is a cure. Barlow claims to have carved out new territory in the world of mental health and to have moved the field of psychology and its allied professions a significant step forward in the actual practice of helping people. If he is able to generalize successfully from anxiety to other forms of mental distress, like depression, with the same success rates, he will have given us something as essential as antibiotics.
    For all his contributions, though, Barlow may remain a figure on the edge of mainstream recognition, and perhaps understandably so: he's asking us to accept a treatment that does not consist of soothing medicine in a plastic cup. He's asking people to accept that a cure not only hurts, but that it's also terrifying, and that's not an easy sell. It could be that Barlow has such high success rates because there's an element of preselection going on. Perhaps only certain types are willing to tolerate his regimen, and clinicians, after all, have to play to their crowd, a crowd in need of something softer. We want comfort, a hand held out, while someone else -- not us -- soldiers on.


Fetal Brains Suffer Badly From Effects of Alcohol
Linda Carroll, New York Times- 11/4/2003

Thirty years ago, scientists linked prenatal alcohol exposure with a perplexing pattern of birth defects including neurological problems, low birth weight, mental retardation and a set of facial malformations. Up to that time, many doctors had assumed that alcohol was so harmless that it was sometimes administered intravenously to women who were thought to be at risk of losing their pregnancies.
    But in recent decades, scientists have discovered that alcohol can be remarkably toxic — more than any other abused drug — to developing fetuses. New research with imaging techniques is helping experts uncover which parts of the developing brain are damaged by alcohol exposure. By pinpointing the damaged areas, they are beginning to understand the origins of the problem behaviors and learning disabilities linked to alcohol. Scientists are also homing in on a protein important to the developing brain that is affected by alcohol. It is possible, they say, that a medication can be created to protect the brains of developing fetuses, even if pregnant women cannot quit drinking.
    It is not surprising that it has taken researchers so long to tease out the link between alcohol exposure and birth defects. For one thing, the effects of alcohol exposure seem to vary widely. Some fetuses seem to escape unscathed, even when their mothers drink heavily, while others are severely damaged. No one knows why. "It's not like thalidomide, where anyone who took it had an affected child," said Dr. Sandra W. Jacobson, a professor at Wayne State School of Medicine in Detroit, referring to the morning-sickness drug linked to birth defects in the late 1950's and early 1960's. "There's a range with alcohol. You might get the full-blown syndrome in 4 out of 100 heavy drinkers." There are also many babies who are affected, but not severely enough for the syndrome to be diagnosed. Some with fetal alcohol effects may appear relatively normal but have behavioral problems and learning deficits like those with the syndrome.
    Further complicating matters is the question of how much alcohol it takes to cause harm. In the past few years, successive studies have shown an effect at increasingly lower levels. One study, published last year, found a small but significant effect on average in children born to women who consumed just a drink and a half a week. "We were surprised by this," said the lead author, Dr. Nancy Day, a professor of psychiatry at the Western Psychiatric Institute and Clinic in Pittsburgh. The women in the study were recruited from a prenatal clinic between May 1983 and July 1985. "The children were in the normal range of growth," Dr. Day said, "but if you compare them to children whose mothers didn't drink at all, they weighed less, were shorter and had smaller head circumferences."
    The effect of low levels of alcohol appears to be subtle, said Dr. James R. West, head of the department of anatomy and neurobiology at the Texas A&M medical school. "Perhaps instead of having an I.Q. of 120, you might end up with 115," he said. "You might seem perfectly normal, but not have the motor skills to make the high school football team."
    Another factor making it difficult to tease out the impact of alcohol is its widespread effects on the developing brain and body. "Alcohol is a dirty drug," Dr. West added. "It affects a number of different neurotransmitters, and all cells can take it up." Compare this with cocaine, Dr. West said, which is taken up by only one neurotransmitter. It is also difficult to identify the effects of alcohol because a woman's drinking habits seem to make a big difference. Experts say it matters when a pregnant woman drinks, how often she drinks and what her pattern of drinking is: whether she drinks small amounts daily or periodically binges. Drinking in the first trimester can lead to facial malformations, while in the second it can interrupt nerve formation in the brain, Dr. West said. During the third, it can kill existing neurons and interfere with nervous system development, he added. Researchers have also determined that babies are more likely to be affected if mothers drink in a binge pattern, like five drinks one day rather than a single drink daily, Dr. Jacobson of Wayne State said.
    Because alcohol affects so many sites in the brain, researchers have come to believe that alcohol is far worse for the developing fetus than any other abused drug. Dr. Jacobson's study included cocaine users who also used varying quantities of alcohol. "We found more serious cognitive impairment in relation to alcohol than cocaine or other drugs, including marijuana and smoking," Dr. Jacobson said. The damage done to fetuses often has been wrongly connected to cocaine, many experts say. "The consensus, I think, at this point is that most of the adverse effects that had been reported due to cocaine and crack use were from alcohol use," said Dr. Kenneth R. Warren, the director of the office of scientific affairs at the National Institute on Alcohol Abuse and Alcoholism. "It is the leading cause of birth defects due to an ingested environmental substance in this country."
    In 1973, researchers coined the phrase fetal alcohol syndrome to describe babies born with a certain pattern of neurologic and physiologic defects related to alcohol exposure in utero. Early on, it was clear that exposed children were wired differently from normal ones and that they exhibited an array of disabilities. Dr. Ann P. Streissguth, the director of the fetal alcohol and drug unit at the University of Washington and a professor at the medical school there, ticked off a list: "These included attention problems, hyperactivity, learning problems — particularly in arithmetic — language problems, memory problems, fine and gross motor problems, poor impulse control, poor judgment, intellectual deficits and difficulty integrating past experience to plan and organize future behavior."
    Researchers wondered whether specific areas of the brain were being consistently harmed by alcohol exposure in utero. Poor judgment, for example, might point to damage to the frontal lobes. The lobes, as the control center of the brain, are involved in planning, organizing and inhibiting inappropriate responses, the researchers say.
    Thirty years ago, the only way researchers could learn about the effects of alcohol on the brain was to study children who died shortly after birth. "We knew from brain autopsies that in severe cases the brains were terribly disorganized," said Dr. Edward P. Riley, the director of the Center for Behavioral Teratology at San Diego State University. Now, researchers use imaging techniques like M.R.I.'s to look at the damage caused by alcohol. Several recent studies using magnetic resonance imaging have shown damage to the corpus callosum, a band of nerve fibers that connects the left and right sides of the brain.
    A report published in 2002 compared the brain scans of adults and children who had severe or mild alcohol-related disabilities with the scans of healthy counterparts. The researchers found that the corpus callosa were abnormally shaped in 80 percent of those who had been exposed to alcohol in utero. Another study found that the corpus callosum was smaller and shifted forward in children and young adults with the syndrome. Using a technique known as diffusion tensor imaging to look closer at the corpus callosum, researchers at Emory University have seen abnormalities in the myelin, the substance that insulates nerve cells. When the myelin is damaged, signals do not carry as crisply through the cells, said Dr. Claire D. Coles, director of the Fetal Alcohol Center at the Marcus Institute and a professor of psychiatry and behavioral sciences at Emory.
    Another study published in 2002 found that frontal lobe structures were smaller in teenagers and young adults who had been exposed to alcohol prenatally. By pinpointing which sections of the brain are most likely to be damaged by alcohol, scientists may find a way to block its effects.
    Researchers recently recognized that some of alcohol's effects were similar to those experienced by children born with defects in genes that control L1 adhesion cells. Fetal cells that are destined to grow into the brain and nervous system bind to one another with the help of adhesion molecules like L1, said Dr. Michael E. Charness, an associate professor of neurology at Harvard. In laboratory experiments, Dr. Charness and his colleagues showed that alcohol could interfere with L1's stickiness, thus hampering crucial cell-to-cell attachments.
In an article published in The Proceedings of the National Academy of Sciences in July, they showed that a protein, NAP, could block alcohol's effect on L1. When NAP was given to mice exposed to alcohol, the protein appeared to stave off neurological effects. "The idea of giving drugs to pregnant women is controversial," Dr. Charness said. "Drugs may have their own risks." But, he said, there are areas of the world where fetal alcohol syndrome is a huge problem. In parts of South Africa, the incidence of the syndrome in first graders is around 4.5 percent, he said. "The rate of drinking is high," Dr. Charness added. "And the women won't stop drinking despite interventions. It might be reasonable to give them a drug that can prevent the more serious effects of alcohol."

Therapist, Firm Named in Medicare Fraud Case
Chicago Tribune, 11/7/2003

The owner of a Chicago-area mental-health company and one of her therapists defrauded the federal Medicare program of more than $1 million in a three-year period, an indictment unsealed Thursday alleges.
    Theresa Phillips, 33, of Bolingbrook, owner of Healthcare Creations, allegedly recruited people as therapists who lacked the proper credentials to have their work reimbursed by Medicare. Fernandos Johnson, of the Chicago area, one of the "various unqualified individuals," also was indicted Thursday. Phillips' company provided psychotherapy services to nursing home patients. To get paid by Medicare, Phillips had a psychologist and a doctor sign progress reports for patients that other therapists had seen, even when the doctor and psychologist had not seen the patients themselves.
    The indictment alleges Phillips, Johnson, and others defrauded Medicare of about $1.3 million between 1999 and 2002 and that Phillips tried to move the money around among various bank accounts to hide her taking it from her company. Between April 29 and July 1, 2002, they cashed checks from Medicare worth almost $48,000, according to the indictment. The government is seeking about $1.3 million in cash and bank account funds from Phillips, as well as two Bolingbrook homes and a 2000 Mercedes Benz.



Desperately Trying to Relate to Her Body by Cutting It
Stephen Holden, New York Times- 11/7/2003

Marina de Van as a woman obsessed with cutting her flesh. From nail biting and nose picking to bulimia and drug taking, the list of potentially self-destructive compulsions to which we are susceptible is virtually endless. Marina de Van's "In My Skin," a harrowing portrait of a 30-something woman who succumbs to an obsession with cutting her own flesh, suggests that such extreme behavior is often a desperate attempt to re-establish a connection with the body that has been lost. In a sterile, corporate culture where human appetites are quantified, tamed and manipulated by market research and where people are rewarded for functioning like automatons, it implies, uncontrollable tics are really the anxious, protesting twitches of an oppressed animal spirit.
    Esther (Ms. de Van), the film's central character, finds herself on the fast track to disaster practically overnight after she injures a leg while stumbling around a junk-strewn building site in the dark. Amazed afterward that she felt nothing until she looked down and discovered she was trailing blood, she develops an intoxicated, almost cannibalistic fascination with her own torn flesh and ability to ignore physical pain. At the core of her compulsion is an elusive, increasingly desperate search to feel something, anything. When one arm goes to sleep while she's in bed with her boyfriend, Vincent (Laurent Lucas), she examines it as if it were detached from the rest of her body. During a stressful business dinner at which she gulps too much wine too quickly, she fantasizes that the same arm, severed at the elbow, is lying beside her plate, and she becomes so agitated that she excuses herself and rushes to the wine cellar to carve some sensation into the limb.
    The deeper Esther sinks into a self-consuming frenzy, the less she is able to hide her fetish from her suspicious boyfriend and her co-workers at a marketing company where she has just been promoted to be in charge of an international jewelry account. But her feelings of shame are no match against the force of disease that causes them. On the way home from that business dinner, Esther goes so far as to fake a car accident to explain her fresh self-inflicted wounds.
    Because the movie looks at the world through Esther's frightened eyes, the camera shares her voyeuristic fascination with her own torn flesh. Its refusal to blink at Esther's self-mutilation makes the film, which opens today at the Angelika Film Center in New York, often uncomfortable to watch. Anyone who is repulsed by images of sharp objects puncturing flesh is advised to stay away.  For the less faint of heart, however, "In My Skin," which Ms. de Van wrote and directed, is as unrelenting an exploration of isolation and dissociation as Roman Polanski's "Repulsion." That dissociation is illustrated late in the film by the use of a split screen. The intensity of its focus on Esther's loss of control ultimately forces us to identify her behavior with whatever embarrassing tics and eccentricities we might be struggling to conceal.
    Ms. de Van, who resembles a feral, gap-toothed version of the young Leslie Caron, is at once beautiful and ugly. And as the area of her wounds expands from a leg to an arm and eventually to her face, her fits of self-mutilation take on the intensity of auto-erotic trances. Some of the most disturbing scenes observe Esther digging out small pieces of her own flesh and chewing on them in a state of feverish distraction that evokes a guilt-ridden ecstasy and the character's helpless awareness of impending doom. In certain shots, she resembles a wild animal simultaneously attacking itself and licking its wounds.
    This remarkable debut film doesn't arrive out of nowhere. Ms. de Van has worked with the director François Ozon. Together the two wrote "Under the Sand" and "8 Women," and Ms. de Van also appeared in his ominous short film "See the Sea." As a director and screenwriter as well as an actress she has the goods.
    Written (in French, with English subtitles) and directed by Marina de Van; director of photography, Pierre Barougier; edited by Mike Fromentin; music by E.S.T. (Esbjorn Svensson Trio); production designer, Baptiste Glaymann; produced by Laurence Farenc; released by Wellspring. At the Angelika Film Center, Mercer and Houston Streets, Greenwich Village. Running time: 93 minutes. This film is not rated. With Marina de Van (Esther), Laurent Lucas (Vincent), Léa Drucker (Sandrine), Thilbault de Montalembert (Daniel), Dominique Reymond (The Female Client) and Bernard Alane (The Male Client).

 

Homeless Veterans Wage a New Battle--For Respect
Ken Kusmer, Associated Press- 11/8/2003

INDIANAPOLIS - Darryl Boyd exudes strength from the shaved head crowning his 6-foot,5-inch, 235-pound Navy veteran's body to his T-shirt's image of bulging biceps pulling a forearm free of shackles. But look more closely, and you see the shirt's message: "Freedom from Active Addiction." Boyd speaks of a life filled with desperation: homelessness, alcoholism, crack addiction, mental illness, rejection. "Every time I'd get a fleeting glimpse of reality, it was depressing," Boyd said.
    Many of the estimated 500,000 homeless among the nation's 27 million veterans share parts of that reality. More than two-thirds of homeless vets battle addictions, according to the Department of Veterans. Affairs; nearly half contend with mental illness. This year, they are mustering to win more respect from Washington and the public. A federal panel on homeless veterans presented has urged more mental health funding and improved VA services.
    Veterans groups also are urging more help. Among their leaders is Chuck Haenlein, a retired Army officer and head of the board of the National Coalition of Homeless Veterans. He also is president of the private, nonprofit Hoosier Veterans Assistance Foundation, which houses 127 homeless vets in houses, apartments and a detox center in Indianapolis.
    In June, the foundation created a program allowing 40 vets to stay in four- to eight-bedroom houses as long as needed while they attend substance-abuse counseling at nearby Roudebush VA Medical Center. Drug or alcohol abuse in a homeless shelter typically means eviction. The new program requires drug tests, but backsliders get sent to a treatment facility. They get the second chances they need.
    Groups like Haenlein's are sprinkled across the country. The VA in August awarded up to $8 million in per-diem payments to programs in 25 states. Surveys show that veterans overall tend to have higher incomes, better educations and lower poverty and jobless rates than the general population, but they also have a higher rate of homelessness, the VA says. It estimates that about a third of homeless adults are veterans, mostly men.
    "It's not just homelessness itself. It's alcoholism. It's drug addiction. It's mental health," said Bob Rogers, a VA social worker who helps mentally ill homeless vets get help. Congress passed the Homeless Veterans Comprehensive Assistance Act in December 2001. It required the VA to provide more help for homeless vets and those at risk of becoming homeless, and to speed up their benefits claims.
    The law also prompted the creation of a 17-member VA Advisory Committee on Homeless Veterans. The panel presented its first report in July, delivering recommendations that include increasing to $100 million the total amount the VA delivers to local agencies serving homeless vets (the limit now is $75 million) and working with the Pentagon to counsel personnel at risk of homelessness. Veterans groups also are taking up the issue. The largest, the 2.8 million-member American Legion, named a task force in January to lift the profile of homeless vets and create more programs to serve them.
    Boyd enlisted in the Navy in 1982 and was a radioman on a submarine tender. After shipmates learned he was gay, he tried kill himself with 60 pain pills. The Navy discharged him in 1986, and Boyd worked as a barber. His mother threw him out when his crack habit nearly cost her her home. He lived on the streets of Indianapolis for more than a year, working as a prostitute and contracting HIV. The turning point came last year. He moved into a mission and completed a VA drug rehab program. He found a job moving skids of textbooks for a college and took real estate classes. Now he hopes to pass his state realty exam and pursue a goal of buying properties to create transitional housing for homeless veterans. Said Boyd: "I've got a plan going on here."

School for Autistic Children Sought
Mitra Kalita, Washington Post- 11/9/2003

The Fairfax County School Board is considering a proposal from parents to form a charter school for autistic children, offering intense, one-on-one instruction in their earliest years of schooling. The parents hope it will enable their children to go on to traditional classrooms and normal childhoods. But school officials, expressing concern about cost, accountability and effectiveness, are recommending that the board reject the plan or add several conditions, including providing assurances of a balanced budget and that organizers can provide the number of teaching hours proposed.  "There are legal issues for the county," said Thomas Brady, chief operating officer for Fairfax County schools. "Who does this independent public school charter report to? Do they meet state standards for special services?"
    Parents, who will make a formal presentation at the board's work session tomorrow, say they have spent years fine-tuning the idea and studying the best ways to educate children with autism, a neurological disorder defined by problems with communication, behavior and social interaction. The application submitted to the county is the seventh draft of a 116-page document.
    If approved, it would be the first charter school of any kind in Northern Virginia and just one of a handful in the state. Randolph Nicklas, chairman of the nonprofit group Parents for Autistic Children's Education (PACE), which developed the proposal, said he was aware of three charter schools for autistic children nationwide.
    Charter schools, dubbed by advocates as "public schools of choice," operate independently of state and local regulations but are financed by the school systems in which they are based. Fairfax school officials said the district would incur more than a half-million dollars in start-up costs for the charter school. Nicklas said the school would qualify for federal and foundation grants, which would defray some of the start-up and operating expenses. Unlike many other charter schools, the one proposed for Fairfax would teach students at several locations.
    Under the PACE proposal, the charter school would enroll as many as 60 students year-round from preschool to age 12 and disburse them among a half-dozen or so schools. One instructor would be hired for every student, and each would employ a teaching method known as "applied behavior analysis."  The method aims to make learning less frustrating for children by providing them with questions and answers at the same time. It also uses toys, nature and a child's surroundings to teach language and behavior. Lessons are repeated until they are learned. The annual cost per pupil is estimated at $40,000.
    Fairfax schools use this approach to teach some autistic students, who often learn alongside children with other disabilities. But Colleen Oppenheimer, mother of an autistic child, said she wishes for more consistency and expertise. Her 7-year-old son, Clifford, attends elementary school in Reston.  "Every year that he's been in Fairfax, the autism program has changed," she said. "First they were half a day. Then they were full-day. His class size doubled. Then he was moved into a reduced teacher-student ratio class."
    Years ago, Fairfax tried a pilot program using applied behavior analysis but dropped it because of the high cost and mixed results.  Of 10 students, two graduated to traditional kindergarten, recalled School Board member Tessie Wilson (Braddock), who has long been an advocate of the charter school.  "Does it help every child 100 percent? No," Wilson said. "But there were the two kids where the change in these children was nothing short of miraculous."
    At a meeting Thursday night, School Board members peppered staff members with questions about the role of the individual public schools where the charter-school students would attend class. They worried about the school system's liability if children don't emerge from the charter school ready for inclusion in regular classrooms.  The parents' group says the program is worth the risk. "Every parent's hope is that their child will lose the diagnosis and look like any other typical kid," Nicklas said.


Group Helps Victims of Abuse Break the Cycle
Anna Gorman, Los Angeles Times- 11/9/2003

Eliza's senior year in high school was filled with fear. She recalls her ex-boyfriend's controlling her every movement, practicing martial arts on her, leaving her with bruises and scrapes. Her grades dropped, and she quit participating in theater and soccer. Her acceptance to UC Santa Cruz was revoked. "I missed a lot of school because I was too scared to go," said the articulate 20-year-old, who did not want her last name used. "I didn't know where to go or what to do."
    Finally, during a doctor's visit, she learned about Break the Cycle, a nonprofit organization that provides free and confidential legal advice, advocacy and representation to victims of emotional and physical abuse.  About 550 youths received legal help from the group this year. A staff attorney listened to Eliza's story and then helped her get a three-year restraining order against her ex-boyfriend.
    In addition to legal services, Break the Cycle also connects the youths with shelters and support groups, and serves as a nationwide resource center on domestic violence. "It's not just about handing somebody a restraining order," said Jessica Aronoff, director of programs and policy. "It's about empowering them so they know they have rights, and so they know they can choose to take action to protect themselves."
    The organization began in Los Angeles in 1996, and recently opened offices in New York and San Francisco. Most clients are women ages 16 to 22, and many are either pregnant or have young children. Break the Cycle also runs a prevention program, teaching students about dating and domestic violence and training school counselors and law enforcement officers on how to respond. The organization received a $15,000 grant this year from the Los Angeles Times Holiday Campaign, which raises money for nonprofits in Los Angeles, Orange, Riverside, San Bernardino and Ventura counties.
    The youths who go to Break the Cycle's Los Angeles office are experiencing relationships in very adult ways, but don't have the experience to know what is healthy and what is abusive, Aronoff said. Some are terrified and crying, while others are fed up and angry. Each client has a terrible story to tell.
    Abra, 18, who is pregnant with twins, said she was sexually assaulted by the babies' father, who also bought a gun and threatened to kill her. Cynthia, 16, said her ex-boyfriend repeatedly abused her, throwing her against a concrete wall and slamming her against a wooden cabinet.  Break the Cycle helped both young women obtain restraining orders. In exchange for the services, the women are encouraged to give back to Break the Cycle by writing an article for its newsletter, speaking to a school group or creating artwork for the office.
    Eliza has given back by sharing her experience in a promotional video and speaking at a fund-raiser.  Even after she got the restraining order, Eliza said, it took a while to get her life on track and to stop blaming herself for what had happened.  Now Eliza is in her second year at the Art Institute of Los Angeles, and is determined not to get involved in another abusive relationship. "I know what I deserve now," she said. "I almost had to have everything taken away from me to start fresh and rebuild. Each day, it's getting better and better."

 

Drugs of Psychiatric Patients Subbed Without OK
Ellen Barry, Boston Globe- 11/10/2003

A doctor at a state mental health facility changed patients' medications last year so that they would be eligible for a study of a new psychiatric drug, violating basic guidelines for research on human subjects and causing dangerous side effects in a 43-year-old man with schizophrenia, a state investigation has found. The Disabled Persons Protection Commission uncovered numerous ethical violations at the Solomon Carter Fuller Mental Health Center by Boston Medical Center physicians contracted to treat patients there.
    According to a DPPC report, patients' medications were switched without informed consent and without a clear medical need, the changes were made more than two months before the human-studies review boards approved the research protocol, and the patients involved were clearly not eligible under the criteria for the study, which specified that subjects be outpatients. One of the four patients whose medication was switched, a man who had been stable for 10 years on the drug Clozaril, became so ill and acutely psychotic that he spent months in and out of hospital wards. He was diagnosed with neuroleptic malignant syndrome, a rare, sometimes lethal side effect of medication changes, according to the commission's report.
    When the man's health problems grew serious enough to discuss in a Department of Mental Health case conference, a top state mental health official expressed shock that there was a plan to use patients as human research subjects. "The incident . . . was an egregious series of events that led to a patient experiencing debilitating psychiatric and medical symptoms," wrote Clifford Robinson, Department of Mental Health area director, in a September memorandum about the investigation. The incident "delineated what can happen when a research project is introduced into a clinical environment that is unprepared for it."
    The DPPC is an independent state agency that investigates alleged abuse against any disabled person in the Commonwealth. A year ago, Janssen Pharmaceutica was preparing to introduce Risperdal Consta, a two-week injectible form of Risperdal, its drug to treat schizophrenia. To troubleshoot its instructions for physicians switching patients from oral Risperdal to Consta injections, Janssen asked a number of researchers -- among them Dr. Domenic Ciraulo, Boston Medical Center's chief of psychiatry -- to test the transition on a total of 60 adult patients who were on oral Risperdal, said Carol Goodrich, a Janssen spokeswoman. Each site would be paid on completion of the trial, Goodrich said. Janssen declined to reveal the amount.
    Ciraulo turned to the Fuller as a site for the study, delegating authority to its medical director, Dr. Douglas Hughes. The prospect of a clinical trial at the Fuller promised to bring prestige to a downtown community health center that, situated among many august research centers, "had not been an attractive place for residents and medical students," Hughes later told investigators. "We saw the Consta study as an opportunity."
    But as they looked for eligible subjects, one doctor began asking patients about participating in the trial. Last fall, months before review boards for Boston University and the Department of Mental Health had approved the study, the doctor switched four patients to oral Risperdal so they could be enrolled in the trial, the report said. By late January, one of the four became so confused and delusional that he was sent to the emergency room and frequently needed to be restrained. Months later, when he returned to the Fuller, he was emotionally drained and sensitive to any antipsychotic medication. Known among the staff as an avid and "very knowledgeable" Red Sox fan, the patient was asked by a state investigator for a favorite player on the current team. He mentioned Carl Yastrzemski, who retired from baseball 20 years ago, and had no response to the names "Nomar," "Manny," or "Pedro," the report said. The clinical trial at the Fuller was halted in February, and no patients there ever received Consta. The other three patients switched to Risperdal suffered no ill effects.
    Changing medications for research without the patients' consent is unethical, and it's especially questionable in a state institution, said Dr. Peter Lurie, a medical researcher with Public Citizen's Health Research Group, which monitors research ethics. Institutionalized patients, like prisoners, may feel pressure to become subjects, and researchers, as well as their institutions, could benefit financially from recruiting subjects, Lurie said. As soon as medication changes were made, the clinical trial was effectively underway, without oversight to protect subjects' rights -- "a flagrant violation of clinical ethics," he said. The names of doctors involved were deleted from the commission report, but Department of Mental Health officials and Hughes acknowledged their identities.
    On Sept. 29, Hughes resigned his position as medical director of the Fuller, explaining in a letter to center director Dr. Mary Louise White that he believed he "shared responsibility" for the change of medication, which he ascribed to a "failure of communication between the principal investigator and the physicians . . . at the SCFMHC." Hughes, who was listed as one of Boston magazine's "Best Doctors" in 2000, is now associate director of training and medical director of outpatient services at BMC's department of psychiatry. He is a paid speaker for Janssen Pharmaceuticals, and earned more than $30,000 in speaking fees last year, he said.
    The attending physician who switched the four patients, Dr. Valentina Jalynytchev, is still working at the Fuller, said Lester Blumberg, chief of staff at the Department of Mental Health. Jalynytchev did not respond to requests to be interviewed for this article, but told investigators that she believed preparing the patient to receive Consta -- the first injectible form of a newer-generation antipsychotic -- was a "good treatment option," made with "nothing but his best interest in mind."
    Both doctors plan to appeal the report's findings, said Ellen Berlin, a Boston Medical Center spokeswoman. Berlin would not say whether either doctor had been disciplined. The doctors could also be disciplined through the Massachusetts Board of Registration in Medicine, which reviews complaints of misconduct and regulates doctors' licenses to practice medicine. No public information is available about action in this case, said Nancy Achin Audesse, the board's executive director.
    In an interview, Hughes said Ciraulo had given him authority over the study at the Fuller, but he had received no training in working with human subjects. The physicians at the Fuller, he said, believed that it was permissible to switch patients' medications so they could be eligible for the study. When staff members complained that the switch was unethical, Hughes said, he asked Ciraulo informally whether informed consent was necessary. "I said, `Is this OK? Is this a problem? Can we not switch people's medications from one approved atypical antipsychotic medication to another?' " Hughes recalled in a telephone interview last week. Ciraulo, he said, told him doctors were free to do that.
    Through Berlin, Ciraulo declined requests to be interviewed for this article. But in the state report, Ciraulo was quoted as saying that he had "no clinical responsibility" over Fuller psychiatrists. His attorney told the Disabled Persons Protection Commission that the Fuller "does not allow [Ciraulo] . . . the authority necessary to deal with situations that may be regarded as his responsibility" as the leader of the study.Ciraulo, a well-published researcher, has received research grant funding from Janssen Pharmaceutica, served as a Janssen consultant, and received support from Janssen for the department of psychiatry, a Boston University faculty disclosure report said.
    Top officials of the Department of Mental Health first learned of the study in February, during a medical staff conference to discuss patients. After the meeting, the area medical director, Dr. David Hoffman, wrote of his shock to discover that a trial was underway: "I was never cc'd on any of this, and I didn't know anything about a drug study at the Fuller involving our patients as human subjects. At that point, I began to realize how problematic this was. The medication switch from Clozaril to Risperdal was a violation of the drug study's protocols." Within weeks, investigations were underway at the commission, the Department of Mental Health, and Boston Medical Center. The Consta study was terminated by the DMH's Research Review Committee on Feb. 21.
    In its review, the Department of Mental Health determined that neither Jalynytchev nor Hughes, her supervisor, intentionally jeopardized patients. "This was a physician who was poorly informed and poorly supervised about conducting research," said Blumberg, the chief of staff. "Her direct supervisor should have known, if he didn't know." Instead, Robinson, the Department of Mental Health area director, wrote a blistering memorandum pointing to a "major systems failure" in Boston Medical Center's patient safeguards. Robinson also criticized the hospital's internal review, which "failed to identify, in any material way, what went wrong, how broad the breakdown was and what could be learned from it." The review did not address the fact that Jalynytchev had switched the medication of four patients, not just the one who was injured, he wrote. "The absence of a sense of remorse in any document reviewed is another noteworthy commentary on the failure of this process to attend to the harm that resulted," Robinson noted. Berlin, the BMC spokeswoman, did not respond to the criticism of the internal review.
    Boston Medical Center "immediately implemented" a corrective action plan to improve aspects of patient care at the Fuller, according to a press release from the hospital. The two institutions are discussing a range of changes to prevent a recurrence, from appointing a liaison to oversee joint activities to eliminating all research, the release said.
    Researchers at the hospital are also being asked to undergo recertification in the ethics of human research. An e-mail widely circulated last week among medical center psychiatrists and psychologists announced that they will have to take monthly quizzes on such issues as federal regulations, internal review-board policies, and conflict of interest. The e-mail was provided to the Globe. The quizzes, which will be graded, may be a "bureaucratic hurdle," the letter explains, but the Office of Clinical Research sees it as "a necessary step to keep our researchers current on clinical research information and to provide appropriate protection for the subjects who volunteer for our studies."
    Mental health officials could prohibit Boston Medical Center from undertaking clinical trials at state facilities, Blumberg said. The episode has not jeopardized the mental health agency's contract with the medical center, he said. "It's been a long and positive relationship," he said. "Part of what is so troubling about this is that it's an anomaly in our relationship with them."

 

Success of Addicts Doing Treatment, Not Time, Questioned
Catherine Saillant, Los Angeles Times- 11/10/2003

Two years after implementation, the jury is still very much out in Ventura County over whether a voter-approved diversion program for nonviolent drug offenders is a success.
Under the provisions of Proposition 36, just over 4,000 county drug offenders have been referred to drug treatment and supervision rather than being sent to jail. Of those, 280 have completed required therapy sessions and are considered drug free. But is a 7% success rate good enough?
    Yes, say the county alcohol and drug administrators who run the $2.5-million program.  It will take time to work out kinks that could be impeding a higher number of graduates, said county Behavioral Health Director Linda Shulman in a briefing to the Board of Supervisors on Nov. 1.Since the program got off the ground two years ago, various agencies have been struggling with confidentiality rules and improving communication, she said.  Proposition 36, which California voters approved in November 2000, permits first- and second-time, nonviolent offenders convicted of simple drug possession to receive substance abuse treatment instead of incarceration.   Shulman said it is also important to recognize they are addressing a problem — drug addiction, often aggravated by alcoholism or mental illness — in which relapse is common.
    While the number of graduates is relatively low, about 40% of those referred are making progress in beating their addiction, Shulman said. "It is working. We've had successful graduates, and we are meeting statewide averages," she said. "It may not be working for 100% of them, but if it is working for 40% of them, that is 40% who are no longer doing drugs and no longer are a cost to our prison system."
    However, Dist. Atty. Greg Totten and Sheriff Bob Brooks have been openly critical. They say the diversion rules are lax and tracking of offenders is insufficient.Administrators need to better track how many participants have been convicted of a new criminal offense while enrolled and maintain a breakdown of the crimes they have committed, said Chief Deputy Dist. Atty. Michael Frawley. The county also should be reporting how many people are dropped from the program because they have used up the three chances, or strikes, allowed under the law, Frawley said. "We have had people who tested dirty 10 or more times before they are brought to the attention of the court," he said. "They are out in the streets and using a lot." Brooks suggested that recent spikes in property crimes in Ventura could be attributed to the new law. But Shulman and others dispute that, saying the correlation is unclear.
    Statewide, counties have responded favorably to the effects of Proposition 36, said Steve Szalay, executive director of the California State Assn. of Counties. Counties are treating more people than expected and are discovering that many have additional problems, such as mental illness or lack of job training, that stand in the way of recovery, Szalay said.  But overall, drug offenders are getting the treatment they need and are staying out of jail, he said. "We think it's been a success," he said. "Given the structure put forth in the initiative, it's done quite well."
    Though the initiative mandates that counties provide drug treatment, state funding is available only through 2006. UCLA researchers are conducting a five-year evaluation of the program, including potential cost savings.
    In Ventura County, nonviolent drug offenders are referred to a Proposition 36 courtroom. Each morning, a legal team meets with Judge Barry Klopfer to determine the best course of treatment for each defendant. The team is made up of a prosecutor, public defender, probation official and treatment provider. Klopfer, who helped Ventura County start its own drug court several years ago, said the collaborative approach helps him decide who really is interested in getting help and what kind of services they need. "That part has been a tremendous success," Klopfer said. "We are much more able to make use of what has been learned about the individual and their performance, to differentiate between those struggling but working on it and those who simply are not interested."
    The problem with the law is that it treats everyone as though they are equally motivated to change, the judge said.  That means that even if it is clear that someone is only going through the motions, Klopfer must still give the offender three chances before terminating probation. Some mechanisms to measure an offender's readiness to kick addiction would help keep out those who really don't want treatment, Klopfer said. And in an era of tight budgets, that might make sense, he said. "I want to provide treatment where the taxpayers, the citizens, are going to get the most for their money," the judge said. "If you want to call that cherry-picking, go ahead. But we make those judgments in our lives every day."
    Shannon Corpuz, 35, agreed that motivation is crucial. Corpuz, a Ventura painter, told Ventura County supervisors that, when he was first referred to the program for abusing methamphetamine, he didn't think he had anything to learn. After completing 12 months of treatment, he was drug-free for the first time in 12 years and has remained so for two years, he said.