Higher Standard of Care Is Urged for Massachusetts
Rick Klein, Boston Globe- 9/23/2003

The state pays $2 billion annually to private companies to care for children, counsel juvenile offenders, treat the mentally ill, and provide a range of other human services with few guarantees that taxpayers or the state's most vulnerable citizens are being served adequately, according to a report released yesterday. The report, by the Massachusetts Taxpayers Foundation, said the system is so thick with bureaucracy that it has lost sight of the best interests of those who need services. At the same time, private providers have little incentive to improve, the report contends. "The system's not focused on the clients' needs," said Michael J. Widmer, president of the Massachusetts Taxpayers Foundation, which prepared the report along with the Massachusetts Council of Human Service Providers Inc. "When one talks about reform in government, this is where the difference is made," Widmer said.
    The study recommends major changes to the way human service contractors are selected and monitored. It calls for further use of main contractors who would then subcontract individual services, so that each client will have a single case manager to oversee all services for which he or she is eligible. Contracts should emphasize performance, the report says, rather than serving the highest number of people at the lowest possible cost. Quality standards should be built into human service contracts, incentives should be provided to reward "superior performance," and contracts should be structured so that some payments are made only after "specified outcomes" are achieved, the report says.
    Legislative leaders said the report could serve as a blueprint for the next stage of the reform of human service agencies. Senator Susan C. Tucker, cochairwoman of the Legislature's Human Services Committee, said lawmakers are beginning to realize the urgency of bringing performance measures to oversight of state contractors in human services. "The system is uncoordinated and underfunded and under extreme duress," said Tucker, an Andover Democrat. "Tackling these problems is, in my view, the next step in human service reform. We owe it to people who need our help, and we owe it to the taxpayers."
    The state contracts with about 1,100 human service providers that provide assistance to 600,000 Massachusetts residents through agencies including the Departments of Mental Retardation, Social Services, Mental Health, and Youth Services. Among the services provided by private contractors are pychiatric treatment for those with mental illnesses, child care so single poor parents can work, and beds and counseling for juvenile offenders. The state's $2 billion annual expenditure for such services from private contractors amounts to 9 percent of the state budget. Such outsourcing was little used until 30 years ago (in 1971, the state spent just $25 million on contracts with human service providers) and has steadily risen as a portion of the state budget.
    Now, oversight agencies like the state auditor's office and the inspector general's office delve into the details of individual contracts in search of fiscal mismanagement. But they rarely, if ever, look at whether contractors are successfully serving clients, Widmer said. While some savings can be generated by imposing quality standards, doing so will not help the state significantly as it copes with tight budgets, the report said. Widmer said savings should be used to raise rates for better-performing providers; some social service workers now make less than $20,000 a year, making it difficult to attract and retain skilled employees. This year, Governor Mitt Romney and the Legislature approved a sweeping restructuring of health and human service agencies, establishing clearer management lines and grouping agencies that serve similar clients in clusters in which officials thought they could be run more efficiently. For the most part, however, those changes did not affect the inner workings of the agencies.
    Barry Ingber, a spokesman for Service Employees International Union Local 509, said that running services through another layer of contractors would reduce accountability in the system. He also said the report should have done more to involve front-line workers in formulating policy. Still, he praised the report for trying to address salary issues for workers. "We just need to be sure that the extra funds go to the workers," said Ingber, whose union includes about 3,000 private-sector members.
    Susan Wayne, president of the Justice Resource Institute, which receives about $50 million from the state for a range of children's and public health programs, said she would welcome performance standards. For example, she said, contractors could be rewarded with extra money or extra contracts if they succeed in controlling the behavior of most mentally ill teenagers under their charge within 10 months.

Overwrought Moms Turn to Parenting Coaches
ABC News, 9/23/2003

On a typical day at the office, Peggy Alvarado has some unique discussions with her clients. "So tell me more about your potty training issues with Gabrielle," she urges one. "It's hard not to feel like a failure when you're trying to help your child go through a developmental stage," Alvarado sympathetically tells another.
    Alvarado is part of a relatively new industry. She's a "parenting coach." She doesn't have a degree in child development or psychology, and in fact, for 13 years she was a software developer. But now Alvarado runs her own business, charging an average of $300 per month per client, to moms, like herself, who phone her Manalapan, N.J.-based office seeking guidance, or send e-mails to her Web site. "The parents I've encountered are good parents," she said. "They're just having issues with dealing with the relationship, their spouse, their child, their own parenting skills, their own stresses."

Answers — for a Price
Buffi Neal, a 36-year-old mother of two from Annandale, N.J., is one of thousands of parents who are turning to coaching for help. It's a growing trend, for those who can afford it. Neal has been a client for seven months and has spent over $2,000 thus far. She started talking to Alvarado because she was struggling with typical day-to-day pressures of raising her son, Derek, 4, and daughter, Amanda, 6. She felt she needed more than a self-help book but didn't feel the need for a psychologist."I felt unfulfilled," Neal said. "I felt out of balance and I was trying to struggle home, my family, my children, my work and I never felt like I was doing anything well … I feel like there's such pressure to be the perfect mom."
    So she shares those feelings with her parenting coach.
"I feel tired," Neal told Alvarado. "I feel tired, like if it's all on me, it's all on my shoulders."
"Yeah," Alvarado said. "So when do you want to have them start cleaning their rooms every night again?"
"Yesterday," Neal responded.
"I imagine that you're torn between trying to keep on top of the kids to keep their rooms clean all the time, at the same time trying to just let it go so you could spend good quality time with them," Alvarado said.
"Exactly," Neal responded.
"It's a tug of war for you," Alvarado said.
"Right," Neal said.

Parent Coaching Draws Critics
Not everyone thinks that parenting coaches are such a great idea. Dr. Carol Goldberg, a clinical psychologist in Syosset, N.Y., holds a Ph.D. and has been in private practice for over 25 years. "I think the risk with any coach is that there are a lot of unknowns," Goldberg said. "It's sort of like a grab bag.You can get somebody who's qualified who knows a lot, or you can get somebody who's totally unqualified. And because there's no state regulation you don't know the difference."
But Neal says that Alvarado has helped keep her on track as a mother. "Peggy's the one that says 'what kind of mom do you want to be?' And I tell her 'this is what's important to me.' And then she makes sure I do that. She keeps me honest. She keeps me on track with my goals."

Guidance, But No Answers
The term "parenting coach" may suggest that it's all about parent education, but according to Alvarado's coach-client contract, "the coach's job is not to provide advice, counseling or consulting." So what do they do? "As a coach, I don't provide answers. That's more of a consultant,"Alvarado said. "As a coach, what I do is I'm expert at asking the kind of questions that [let the client see something maybe they hadn't seen before."
    It may sound like the type of advice that you can go to your mom or a girlfriend for, but Alvarado insists that it is more than that. "Best friends or moms sometimes can't help but bring their own opinion into the conversation — like they kind of know what's best for you or they kind of want the best for you," she said. "So it becomes like — their agenda becomes part of the conversation."
    Offering support and boosting confidence is one thing, but are coaches capable of detecting serious problems? "I think that anything that is done over the phone misses certain cues," Goldberg said. "I would be concerned that somebody who does not have a depth of training would be able to know when they are in over their head."
    Neal says that her parenting coach has put her life in balance. "I think what I got out of Peggy — Peggy's coaching is that if my life is in balance," she said. "I'm happier, and therefore I'm a better mother."
    Goldberg says that parents should be careful. "There's nothing that is harmless," she said. "Anything that deals with your head, with your behavior, with your children is important, and it is important to get the best for you."

Michigan Mental Health Services Criticized in State Capitol
Laura Potts, Detroit Free Press- 9/25/2003

Changes in Michigan's mental health system need to start with services for people with mental illness and disabilities, advocates told senators Wednesday in Lansing. With dozens of people hoping to testify at the second meeting of the Senate Health Policy and Department of Community Health Appropriations Committee, Chairwoman Beverly Hammerstrom, R-Temperance, scheduled a third hearing for Oct. 1. The committee is seeking ideas for improving the state's mental health system, which is facing growing criticism over its quality of care.
    Dr. Virginia Killough of Marquette told the committee she had no recourse when her local Community Mental Health authority denied services to her 12-year-old autistic son. "The recipient-rights system is broken. It's a joke," she said of the process for people who are not happy with their services. "All we want is to run our own programs . . . because we can do it best." Other families echoed Killough's sentiments, saying the state often takes months to discuss service complaints and rarely provides recourse for families. The county agencies providing the services also said they want better care for people who rely on the system.
    But Community Mental Health directors told the committee that in recent years, federal requirements have whittled away at what services can be provided and CMH authorities are being bogged down with administrative tasks and reviews that use up funding. "It's valuable data . . . but administratively, we have to pay for these things," said Jeff Patton, executive director of the Kalamazoo County CMH authority. "I think some of those things can be streamlined." "We do more than give people medication. We help them live in a community setting," he said.
    Mike Bowden, director of behavioral health services for Sparrow Hospital in Lansing, said the patient-care documentation hospitals must provide to CMH authorities is labor-intensive and time consuming -- so much so that some hospitals are discontinuing mental health care. Reimbursement from county agencies also is a problem, he said, and hospitals are now having to provide more inpatient psychiatric care because all but three state psychiatric hospitals have closed. "The state hospital safety net is no longer there," he said.

Researchers Debate Health Risks of Pot
Randy Dotinga, ABC News- 9/26/2003

It's no secret that marijuana makes people high. But can it also send them six feet under? That's the crux of an ongoing debate in the latest issue of the British Medical Journal between experts who disagree about the potential health risks of smoking pot.
    The latest volley in the battle came this month, when an American doctor took aim at suggestions by a British team that marijuana could be a major killer. "I don't think it [marijuana] contributes very much to people dying. It's not in the league of alcohol or tobacco," says Dr. Stephen Sidney, an associate director of clinical research with the Kaiser Permanente health plan who has studied the effects of marijuana use on life span.
    The debate began in May, when the journal ran an editorial by a British medical professor and colleagues suggesting the United Kingdom isn't paying enough attention to the health risks of marijuana. "We were concerned that smoking is constantly being regarded as a major public health hazard, while cannabis, which is also usually smoked rather than consumed any other way, seems to have been completely overlooked," says Dr. John A. Henry, a professor at the Imperial College School of Medicine at St Mary's Hospital in London. Tobacco smoking kills almost 1 percent of smokers each year in the United Kingdom, and if marijuana had the same effect, some 30,000 people would die from it annually, Henry and colleagues wrote. "Even if the number of deaths attributable to cannabis turned out to be a fraction of that figure, smoking cannabis  would still be a major public health hazard," the team wrote.

Studies Debunk Pot-Death Connection
The suggestions in the editorial spawned a flurry of letters and commentaries. In the most recent one, printed in the Sept. 20 issue of the British Medical Journal, Sidney points to two studies that debunked any connection between marijuana and higher death rates. In a Swedish study, researchers found no link between marijuana use among more than 45,000 male military conscripts, aged 18 to 20, and their death rates over the next 15 years. Another study of 65,171 men and women enrolled in the Kaiser Permanente health plan found that, with the exception of AIDS patients, marijuana users were not more likely than others to die over a 10-year period.
    Sidney acknowledges the follow-up periods are short, and says the marijuana users in the studies could still suffer from higher rates of disease later in life. Even so, evidence suggests smoking pot is much safer than smoking cigarettes, he says. "One of the reasons is that marijuana is not inherently as addictive as tobacco because it doesn't contain nicotine. Many more people get addicted to tobacco smoking than marijuana smoking." Also, pot users take much less smoke into their lungs than tobacco users, and many stop using marijuana as they get older, Sidney says. "It's the unusual person who's smoking seven marijuana cigarettes or joints a day. They're not smoking more than one on average, and they tend to quit."

Substance May Contribute to Mental Illness
Some studies have linked marijuana use to a variety of medical problems, including schizophrenia, head and neck cancer and lung cancer, but the research isn't conclusive, Sidney says. There's also evidence that suggests people with heart disease should be careful about smoking pot.
    What to do? "There are common-sense measures about using marijuana," Sidney suggests. "It should be discouraged in teenagers. Young teenagers getting involved in drugs are going to have more of a problem with it. And people ought not to be driving around in cars and operating dangerous machinery when they're intoxicated with anything."
    On the other side of the debate, Henry wants to see more prevention efforts, if only because pot smoking may contribute to mental illnesses such as schizophrenia. "This alone is sufficient for a public health campaign, given the disabling nature of the disorder for the individual and the massive public health burden it imposes on society," he says.

More information
To learn more about marijuana, see the National Institute on Drug Abuse or, for a different perspective, try the National Organization for the Reform of Marijuana Laws

Virginia Doctor Indicted In OxyContin Scheme
Josh White, Washington Post- 9/26/2003

A McLean pain doctor was indicted by a federal grand jury yesterday on charges that he led a broad conspiracy to illegally distribute prescription narcotics across the nation, resulting in the deaths of at least three patients.  In a 49-count indictment, William E. Hurwitz, 57, was charged with drug trafficking resulting in death and serious injury, engaging in a criminal enterprise, conspiracy and health care fraud. Hurwitz was arrested yesterday morning at his ex-wife's home and was ordered held without bond until a hearing Monday. Should Hurwitz be convicted of the most serious charges, he faces life in prison.  The indictment in U.S. District Court in Alexandria grew out of a wide-ranging federal investigation into doctors, pharmacists and patients suspected of selling potent and addictive painkillers on a lucrative black market. More than 40 people have been convicted in the ongoing probe.
    Hurwitz's attorney, James Hundley, said the charges come from overaggressive prosecutors trying to scare doctors from prescribing painkillers. Hundley said Hurwitz says he was practicing good medicine.  "Dr. Hurwitz is a legitimate medical doctor with expertise in the area of the management of intractable chronic pain," Hundley said. "He was doing nothing but providing appropriate medical care. The government has come in and taken a medical issue and attempted to apply horribly twisted logic to it through criminal statutes."
    The indictment signals an aggressive push by federal prosecutors to hold doctors accountable for what happens to the drugs they prescribe. It also highlights the complexities of proving criminal culpability in cases of licensed and reputable physicians prescribing a legal painkiller. Hurwitz is one of a few doctors across the country who have been indicted on charges of over-prescribing drugs, and he is among the first to be charged with orchestrating a widespread conspiracy.
    The illegal sale of OxyContin and drugs such as methadone and Dilaudid has fueled an epidemic of abuse that has affected small towns throughout Appalachia, authorities said. Over the past few years, the abuse and sales have crept into suburban and urban areas, bringing associated crimes such as theft, fraud and homicide, authorities said.  OxyContin is a government-approved pill that releases its main ingredient, oxycodone, slowly over time to patients who need strong levels of pain relief. It is hailed as a miracle drug by cancer patients and others with intractable pain, but it is decried by local, state and federal authorities for its potential for abuse and lethal overdose.
    "The indictment and arrests in Virginia demonstrate our commitment to bring to justice all those who traffic in this very dangerous drug," Attorney General John D. Ashcroft said. "We will continue to pursue vigorously physicians, patients and others who are responsible for turning OxyContin from a legitimate painkiller to a vehicle of addiction and death."
    Patient advocates have said the prosecutions are troubling for those who need help for pain but are finding it increasingly difficult to convince doctors to treat them. "It's a terrifying turn of events that the medical community ought to look at carefully," Hundley said.  U.S. Attorney Paul J. McNulty said yesterday that Hurwitz was a "major and deadly drug dealer" who used the cover of medical pain management to dispense "misery and sometimes death."
    According to the indictment, Hurwitz's Northern Virginia pain practice was at the heart of a conspiracy to distribute the painkillers for profit. The grand jury alleges that Hurwitz prescribed "countless prescriptions for excessive doses" of controlled drugs with the goal of hooking his patients, getting them to pay him a monthly fee and encouraging illegal sales.  Assistant U.S. Attorneys Gene Rossi and Mark Lytle alleged that Hurwitz wanted "to make as much money as possible" and wanted the drugs to be resold throughout Northern Virginia, southwest Virginia, Tennessee and Kentucky.
    The most serious charges -- that the conspiracy caused fatal overdoses -- focus on patients Rennie Buras Sr. of Louisiana, who died on Oct. 9, 1999, and Linda Lalmond, who died in Fairfax County on June 1, 2000.  Bryan Slaughter, a Charlottesville lawyer, represented Lalmond's family in a civil lawsuit against Hurwitz that was settled earlier this year in Fairfax. He said Lalmond died days after first meeting Hurwitz and taking high doses of morphine. "Dr. Hurwitz's treatment was so far outside accepted medical practice that the result was certainly foreseeable in Linda's case," Slaughter said.
    The indictment also mentions the death of Mary Nye in Prince William County on Nov. 4. Hurwitz is charged with causing Nye serious bodily injury by prescribing her large amounts of OxyContin and methadone.  "Dr. Hurwitz got her hooked on narcotics and took advantage of her," said Manassas attorney Amy Ashworth, who represents Nye's widower, Paul.
    Hurwitz has been under scrutiny before. He lost his medical license for over-prescribing painkillers and was most recently placed on probation in Virginia in May. His marketing practices, authorities said, allowed him to keep patients in all parts of the country and Canada. The indictment alleges that Hurwitz prescribed medications in as many as 39 states, issuing the prescriptions with little or no physical examination and sometimes over the phone, fax, or the Internet.  Prosecutors allege that Hurwitz made large profits by charging an initiation fee of $1,000 for each patient and then $250 a month for maintenance. They said Hurwitz had about 470 patients in his clinic over the past five years, accounting for millions of dollars in profit.  Hurwitz shut his offices last year because he feared an indictment and wanted to give his patients time to find new doctors.

N.M. Court Tests Program for Mentally Ill
Associated Press, 9/27/2003

ALBUQUERQUE, N.M. - State court judges in Bernalillo County are beginning a program in which mentally ill people accused of felonies might be able to avoid jail by agreeing to treatment and other conditions.  The court will monitor participants in the pilot program to make sure they take prescribed medication, and will keep tabs on them through home visits and searches. 
    "The idea is to get them out of jail and into some kind of intense therapy," said Rachel Saiz, who is coordinating the program for the court's pretrial services unit.  Once pretrial services finishes eligibility screening, prosecutors will make an offer to dismiss charges or permit a plea once mental health treatment is completed.  Eligibility will be limited to people diagnosed with serious mental illnesses who face third- or fourth-degree felony charges such as burglary, car theft or felony shoplifting. People facing charges of sex crimes or child abuse are not eligible.   District Judge Neil Candelaria said the program, designed to stop repeat offenses, will be launched with 30 defendants who have volunteered to participate.
    The program was being discussed when a homeless mentally ill man, Duc Pham, shot an Albuquerque policewoman in July, then was fatally shot by officers attempting to detain him. Pham had multiple arrests in his background, but had repeatedly been found incompetent to stand trial.  Since the late 1990s, 70 mental health courts have been established or are in the planning stages, according to a September report by NAMI, a national advocacy group for the mentally ill.

Insurer Seeks Return of Fees for Therapy
Richard Perez-Pena, New York Times- 9/27/2003

For years, health insurers have occasionally demanded a look at psychotherapists' notes of their sessions with patients, to ensure that the care they were paying for was appropriate, or that it actually took place. But now one insurer, Oxford Health Plans, is saying that in many cases, the notes are not enough evidence that the patients received what Oxford paid for. Oxford has audited hundreds of psychiatrists, psychologists and social workers in the New York metropolitan area, deemed their notes inadequate documentation of the sessions, and demanded repayment of thousands of dollars from each provider — in some cases, more than $100,000.
    The therapists and their professional associations paint Oxford's actions as another skirmish in a decade-long campaign by insurers to save money by denying coverage — but one that sets a new standard for aggressiveness. They say that no other insurance company has denied payment because session notes were not detailed enough or long enough. An Oxford spokeswoman said that as far as she knew, Oxford had never done so before, either.
    The providers say that Oxford has refused to say what standard of documentation they need to meet. The company insists that it has. "To say that we're going to reject a record because it's missing some particular element or it's too short, we've never seen that," said Seth P. Stein, executive director and general counsel of the New York State Psychiatric Association. "And to do it retroactively is absurd and unfair."  In a prepared statement, the company spokeswoman, Maria Gordon-Shydlo, described the audit as a fairly routine matter, conducted "to ensure that physicians are billing appropriately for delivered services and maintain proper documentation."
    Counselors say the dispute might change the nature of what goes on in those 45-minute blocks of talk, and not just by forcing them to take more notes. They say patients might feel inhibited, knowing that somewhere, there will be a written record of even their most painful or self-incriminating revelations, and that the record will be accessible to people outside the therapist's office. Other therapists predict an exodus from Oxford of those in the field who can make a living without being on the company's panel of preferred providers.
    The crux of the problem, from the therapists' view, is that there are no generally agreed-on rules for session notes. "No one has ever told me what my notes had to contain or how long they had to be," said one audited psychologist, who has been told to return more than $40,000. "On rare occasions, I don't take any notes at all, if the patient says they're uncomfortable with it."
    Most therapists interviewed spoke only on the condition of anonymity, saying they feared retribution. Some said they would challenge the audits in arbitration, or in court. A four-year-old New York State law sets some standards for insurance companies' refusing to pay for treatment, but experts say the law is murky, with many points yet to be clarified in court.
    Ms. Gordon-Shydlo said the company has told providers, in its quarterly magazine and its provider manual, that they are expected to meet the note-taking standards set by the federal government for Medicare and Medicaid, and by the American Psychiatric Association. Ms. Gordon-Shydlo, who responded late yesterday to two days of calls seeking comment, said she could not say precisely what those publications said, what the standards were or when they were sent to providers. The rules under Medicare and Medicaid are minimal, requiring a brief description of the session. Dr. Marcia K. Goin, president of the American Psychiatric Association, said that the group has no standards for note-taking in therapy, and that in some cases it would be acceptable not to take any notes.
    All of the seven therapists interviewed, and their professional organizations, said many of the notes rejected by Oxford would have met the Medicare and Medicaid rules. In any case, they say that as far as they know, Oxford has never given them any explicit rules, even after they have spent months asking what standards were used in rejecting their bills.
    According to the psychiatric and psychological associations, some insurers have issued general guidelines for session notes, but those standards have been no more rigorous or specific than the ones used by Medicare and Medicaid, and none of the insurers have made those guidelines binding. The therapists' groups said that when insurers have conducted audits, they have merely attempted to make sure the sessions actually occurred and that the treatment was not inappropriate. "The other insurers, in auditing providers, didn't attempt to penalize people for not following the guidelines," said Gayle Everitt, executive director of the New York State Psychological Association. "They just told them to change their practices. The guidelines were a quality-of-care tool, not an audit instrument."
    Lawyers in the health care field say insurers generally have the right to review patient records, and that they do so from time to time, to combat fraud and rectify lapses in care. Oxford audited 300 psychiatrists, psychologists and social workers in the metropolitan region, out of what it says are about 5,000 therapists in its system. The audits, which began last year, reached back to 1997, and the company sent letters seeking repayment this summer.
    Several therapists and their organizations said the people audited were those who relied heavily on Oxford-insured patients, many of them referred by the company. Ms. Gordon-Shydlo said she did not know how the therapists were chosen for auditing. "Oxford singled out people it has enormous power over, because it could terminate them as approved providers and take away most of their business," Ms. Everitt said. "They're just hitting people up for money. That's all this is about." Ms. Gordon-Shydlo said she did not know how many of the 300 the company demanded money from; the therapists say it was nearly all of them. She also said she could not comment on the amounts involved.
    Therapists said Oxford asked each of them for about 100 session notes, found what it said were faults, extrapolated those faults to apply to hundreds or thousands of other sessions and demanded refunds accordingly. Mr. Stein said that Oxford has not explained how it performed that extrapolation, and that he questions its justification. Therapists said the most common complaint by Oxford has been that session notes were not long or detailed enough, according to the interviewed therapists and their organizations. In many cases, the insurer said that while it was billed for a 45-minute session, the notes suggested only a 20- or 30-minute session, and Oxford demanded partial repayment of fees it had paid. Ms. Gordon-Shydlo said that was a frequent finding, as was the absence of any notes. She said she could not say what the difference would be between 45 minutes' worth of notes and 30 minutes' worth.
    If a psychiatrist treats a patient with therapy and medication, the payment per session is higher than for therapy alone. But psychiatrists who were audited said that when their session notes did not specifically mention medication, Oxford said payment should be made at the lower level and demanded reimbursement. Ms. Gordon-Shydlo said she did not know if that was true. "They're not interested in finding out what really happened," said a psychiatrist who has been told to repay almost $60,000. "I have said to them, I can document that a patient is taking medication, whether or not it's reflected in my notes, and they say they don't care." Similarly, other therapists said that they have offered appointment books and other documents to support their bills, and that Oxford has shown no interest in seeing them.
    Noemi B. Balinth, a psychologist and former president of the state psychological association, said Oxford claimed two of her office sessions with patients never took place, because at the top of the session notes she wrote that she had discussed the patient by phone. In one case, the call was with the patient, in the other, with the patient's mother. "The notes clearly reflect the sessions, and they clearly say the calls took place earlier in the day," said Ms. Balinth, who practiced in Forest Hills and Gramercy Park before moving to California two years ago, and whom Oxford told to repay $3,700. "They're just making it up."

Church's Therapy Guidelines Questioned
Ralph Ranalli, Boston Globe- 9/28/2003

As promises go, the pledge by the Archdiocese of Boston to offer free therapy for life to victims of clergy sexual abuse was magnanimous, striking just the right tone for a church struggling for reconciliation amid the worst scandal in the history of the Catholic Church in the United States. Yet just weeks later, it appears the archdiocese may be struggling to provide the promised support while living with the administrative and financial ramifications of its pledge.
    Even as the church posted the guidelines for the free therapy program on its website this week, some victims and their advocates said officials at the archdiocese's Office of Pastoral Support and Outreach appear to be taking a harder line on rationing the church's financial support, including limiting the amount of therapy that victims receive. "People who were seeing a therapist twice a week have been told that they can only go once a week," said Ann Hagan Webb, New England cocoordinator of Survivors Network for those Abused by Priests. "Things also seem more structured now, and it is becoming more difficult to jump through the hoops you need to jump through to get an individual victim what they need." Under the new guidelines, the church will pay for one one-hour therapy session per victim per week and consider other requests to reimburse additional therapy, inpatient care, and psychiatric drugs on a "case-by-case basis," the website states.
    Carolyn M. Newberger, a Children's Hospital psychologist and expert on childhood sexual trauma, said the victims will probably need access to therapy over years, even decades -- although not necessarily on a weekly basis -- due to the nature of the trauma they suffered. Studies have shown that trauma changes the psychological, and even physiological, makeup of sexual abuse survivors in a way that makes them more susceptible to future trauma in times of great stress, Newberger said. A survivor might go for years without needing therapy, then suffer a trauma in their life that would make it a life-saving necessity, she said. "They wouldn't remain symptomatic, but they would need to be able to get back into treatment quickly because their previous experience of abuse has made them more vulnerable," she said. Newberger also said that while there is no "single formula" for treating victims of childhood trauma, many professionals now favor counseling that focus on coping in the "here and now" over therapies that encourage victims to reexamine and relive their trauma.
    While the archdiocese has offered therapy and other support on a case-by-case basis for several years through the Office of Pastoral Support and Outreach, formerly the Office for Healing and Assistance, it is now guaranteed under the recent tentative settlement agreement reached between Archbishop Sean P. O'Malley and lawyers for victims. Some therapy specialists estimate that if half of the more than 500 eligible victims take advantage of the program, the cost to the church could exceed $2 million per year. That would be in addition to the $85 million lump sum the church has agreed to pay victims under the agreement, reached earlier this month. With that potential cost facing an archdiocese already under serious financial stress, church officials have no choice but to standardize and set limits on the available support so that it is accessible to everyone who is eligible, an archdiocesan spokesman said. "The treatment being offered is once a week therapy for people who need it," said the Rev. Christopher Coyne, a spokesman for the archdiocese. "We are not going to pay for more than once a week, or for couples therapy and things like that. We can't be committing ourselves to huge amounts of therapy. . . . We just don't have the financial resources to do that."
    Yet not all advocates said they had detected a new era of frugality at the Office of Pastoral Support and Outreach. Diane Nealon, a social worker who works for Greenberg Traurig, a Boston law firm which represents more than 260 victims, said she believes the firm's clients' counseling needs are still being met "with a minimum amount of bureaucracy."
    Nealon said she has been told that some victims have been informed that the church would not pay for a therapy of their choice. She added, however, that some of those victims had chosen a therapy that the mental health profession has begun to consider inappropriate for trauma victims, such as regression therapy or intensive Freudian psychoanalysis. "I know that they are concerned about making sure that everyone is getting good care and, in that sense, they are monitoring what people are doing," Nealon said. "But I have never gotten the sense it is a dollar and cents issue."
    Some victims who spoke with the Globe, however, said they had a different impression. Arthur Austin, who sued the archdiocese over abuse he allegedly suffered at the hands of the Rev. Paul R. Shanley, said he had a severe emotional crisis and was hospitalized briefly at the psychiatric unit of Newton-Wellesley Hospital. At first, he said, officials at the Office of Pastoral Support and Outreach said they would pay for his hospitalization. Later, they said they would only pay for any costs that weren't covered by his insurance, coverage Austin said he was hoping to save for an emergency. The policy statement released by the archdiocese states that victims will be asked to use their insurance for inpatient care and medications before requesting reimbursement from the church. "I think the archdiocese should have been the payer of first resort, not last resort," the 55-year-old Braintree resident said. "After all, they were the ones who put me there."
    Another victim, who asked that his name not be used, said church officials questioned the appropriateness of his prescription psychiatric medication and said they would not pay for the Motrin and Prilosec pills he takes for the chronic headaches and gastrointestinal distress associated with post-traumatic stress disorder. "The feeling I came away with was of a security guard at the front gate," he said, "instead of someone there whose job was to help."

Mental Health System Said to Fail Indiana Gunman
Associated Press, 9/28/2003

GARY, Ind. -- A man who apparently killed his mother, brother, sister and a nephew and then turned his gun on himself had been failed by the mental health system because it didn't provide him with adequate treatment, an aunt said. Terry Lee Dennie was schizophrenic and may have quit taking his medications, said Louvenia Walton. "This should never have happened," she told the Post-Tribune. "There were plenty of warning signs that should have prevented him from this." "The system failed us. He needed help and didn't get it," she said.
    Dennie, 20, shot his four relatives early Saturday and then took his own life. The victims ranged in age from 2 to 41. His grandmother, Elizabeth Walton, 82, suffered two gunshot wounds but survived. She played dead and called police after the shooting stopped. Elizabeth Walton's son, Tyrone, told The Times of Munster that Dennie had waited for the victims to return home from a party celebrating another relative's recent college graduation.
    Police Sgt. Del Stout said Dennie's relatives reported they had long worried about his mental health problems. "Some of the family indicated that he had been violent toward his own family for some time. It's really a tragedy," he said Sunday. Family members said Dennie had recently been released from a mental-health treatment center and had a history of violence. Stout said he could not confirm that. Walton was hospitalized in stable condition Sunday with wounds to one arm and in the side, Stout said. Officers had not interviewed her because she was heavily sedated, he said.
    Police Chief Detective Thomas Branson said Sunday that Dennie had several run-ins with police, including one a year ago at the same house in which he held a gun and threatened to kill himself. That incident was ended when officers subdued Dennie using a shotgun loaded with bean bags and a stun gun, and he was taken to a clinic for mental evaluation, Branson said.

Texas Child Abuse Hot Line's Callers Left on Hold
Cindy Horswell, Houston Chronicle- 9/28/1003

Nearly 190,000 calls to Texas's 24-hour abuse hot line went unanswered last year because frustrated callers hang up after being left on hold.  The unanswered calls -- nearly a quarter of the total -- are only part of an escalating number from across the state flooding the hot line at the Texas Department of Protective and Regulatory Services in Austin.
    The department is designed to protect the physical safety and emotional well-being of Texas' most vulnerable residents, including children, the elderly and people with disabilities. The toll-free hot line was established to help people report cases of abuse and neglect and enable the agency to help launch investigations into the complaints.
    A Chronicle reporter called the toll-free line at 4 p.m. on a recent weekday and waited one hour and 43 minutes listening to jazz before speaking to a caseworker.  "We do have hang-ups when people wait a great length of time. But I think most call back later," said Pam Chick, the hot line center's administrator. "My biggest concern is that we may lose a call."  State officials do not know whether these callers hung up because they grew tired and gave up, changed their mind or had a wrong number.  But the missed calls raise questions about whether the most vulnerable people, especially children, are put at even greater risk of continued abuse. The problem also points to issues related to staffing levels, salary and worker turnover.   "Teachers who have called the hot line tell me that they were put on hold forever and didn't have time for it. The average citizen is likely to just give up and say forget it," said Trudy Davis, the executive director of the Advocacy Center for Children of Galveston County.
    The hot line center has come under close scrutiny since one of its caseworkers failed to report a call of suspected abuse involving a young League City girl.   A pizza deliveryman had noticed the girl, Linda Padilla, cowering with a bruised eye and being pushed out of sight by her father, who had ordered a pizza on June 8.   The deliveryman called the hot line, but the caseworker failed to pass the information to local police and social workers. Two months later, the child died after being beaten and sexually assaulted.  The girl's father, Frank, 44, is now in jail on $1.5 million bail. He is charged with physically and sexually abusing her while investigators look into the possibility of upgrading the charge to capital murder.   "One pizza deliveryman called the hot line about this girl before she died. But who knows how many others might have tried but gotten frustrated and hung up?" Davis said about the Padilla case.  The incident has served notice as to how crucial every hot line call can be, said Chick. 
    Part of the problem is that calls to the intake center have soared while staffing has remained stagnant. Workers attribute the higher number of calls to the state's growing population.  Protective Services records show 594,000 calls were answered last year -- 60,000 more than the year before. This figure does not count nearly 190,000 callers, who were answered by an automated system that counts the calls, but hung up before talking to a caseworker.  Yet the number of workers handling the calls has held steady at 222 for the past two years. The state budget doesn't call for more staffers for the next two years, either.
    The average caseworker handles 14 calls a day, but the length of each call varies by the type of case it reveals and what needs to be done about it, said Protective Services spokesman Geoff Wool.  When a hot line worker finally answered the Chronicle's call, he explained that the agency had implemented a new, Web-based computer system a few weeks earlier to speed the data entry process. But he couldn't recall any particular problem he had with the system that day.  "Just a lot of people are calling," he said.
    All calls are answered by a high-tech computerized system at the central location in Austin.  A tape-recorded voice initially greets callers and warns them not to hang up because each call is being answered in the order received. The voice also returns a few minutes later to apologize for any delay, saying the caseworkers are busy "processing a high volume of calls as quickly as possible."
    Most of the calls, which come in surges, are about suspected child abuse, Chick said. Others are reports about elderly abuse or a child care licensing issue.   Peak times for calls are often the first months after school starts or before it ends, just before the lunch hour and late afternoons, she said. She said that when kids get back in school, teachers notice abuse that may have occurred over the summer. Toward the end of the school year, they call to express concern about the child returning home full time. Other peak times reflect the flow of a work day.  During busy periods, callers could be left on hold an average of 10 to 15 minutes, Chick said, but the average call should be answered within three minutes. These response times, however, do not take into account the thousands of callers who hang up before a caseworker answers.
    When the Chronicle was permitted to eavesdrop on a recent hot line call, the urgency and complexity of handling such calls became clear.  A Harris County hospital worker had called to report on a 24-year-old mother who was being admitted to the hospital that day with a bipolar condition.  The mother had confessed to feeling little affection for her 6-year-old son and to whipping him with increasing severity.  During the 24-minute conversation, the hospital worker also detailed a second possible abuse case to the same caseworker. After the call, the caseworker then required additional time to enter data into the computer, check the computer for any possible history of family abuse and then consult with a supervisor before deciding to notify an investigative caseworker to visit the home of the mother.  The average call takes 30 minutes to handle after it is answered, Chick said, but it can take longer.
    Virginia Race, the worker fired for failing to report the pizza deliveryman's call, has declined comment about whether she ever felt pressured or overwhelmed by the volume of calls.  Yet Protective Services officials say the call about the League City girl should have been classified as "Priority 1" because the child was so young and had an injury to a vital area. That meant an investigative caseworker should have visited the family within 24 hours.  However, it is not surprising the family was never visible on the agency's radar screen. The father and his wife, Magdalena, a Romanian national, met and courted over the Internet, officials said, and had only had the girl living with them in their League City home for two months before the deliveryman spotted the black eye. "The mother (who never reported any abuse) was a victim of domestic violence herself. Her husband was threatening to deport her and she had no resources here," said Estella Olguin, regional spokeswoman for Child Protective Services. "We need to make sure we get to the bottom of why the deliveryman's call was not considered a high priority. These are often life-and-death calls that we hope the workers are trained to take," said Katherine Howard, director of Houston's Healthy Family Initiatives, a nonprofit home visitation program for families at risk.
    Chick believes her workers are prepared. At a minimum, those applying for the job must hold a college degree. Once hired, they undergo six weeks of intensive training in law, interview skills and answering calls on the high-tech phone system.   Starting pay for an intake caseworker is $25,932 a year.  "Caseworker salaries are really low," said Janet Parker, the Houston region representative on the Texas Council on Child Welfare Board, which provides citizen comment to the state agency. "That's why we lose so many of them. They can make much more teaching, plus have better hours and summers off."
    The low pay is not the only reason workers are leaving. The overwhelming number of calls and case workload is driving intake and investigative caseworkers from the job, said former CPS caseworker Angela Felder, now a child advocate with Justice for Children in Houston.  "When I was there, if people stayed a year, that was pretty good. You were considered tenured."  Felder quit her job as an investigative caseworker in 2001 after five years with the agency.
    Chick admits turnover rates have been high. "But because of the tough job market in Austin, we're doing better," she said, noting that the turnover rate for intake caseworkers answering the hot line was 29.1 percent in 2001 but dropped to 15.6 percent last year.  "More pay would help make the job more attractive, but that is not the main reason our workers do the job. They want to make a difference," Chick said.
    At the same time, she has had to come up with ways to protect her workers from burnout that comes after being bombarded by the pain and suffering of children, the elderly and other vulnerable people.  Workers fight the emotional gloom with desks that are comfortable and cheerful.  Colorful golf umbrellas poke above the maze of cubicles that fill two rooms where the hot line calls are answered. The umbrellas protect against the glare of the florescent lights. Stuffed animals, green plants, family photos and handwritten thank-you notes from abuse victims are a few of the other personal touches.  Besides maintaining a pleasant work atmosphere, Chick tries to reduce burnout by encouraging workers to take their breaks and making supervisors available for counseling. 
    She also is working to reduce the avalanche of hot line calls by creating a secure computer network for making electronic reports. Only professionals, such as medical and school personnel, can report abuse on this Web site.  By using this Web site, professionals can avoid being left on hold.  "We've been able to divert 17,000 calls a year from the hot line to these electronic reports," Chick said. "But our workers must still review and document these reports."
    Meanwhile, the population of youths 17 and under in Texas has grown to almost 6 million -- 8 percent more than five years ago. The number of confirmed abuse cases has mushroomed from 39,488 to 47,409 since the intake center was activated in 1999.
    Chick said she's thrilled her intake center's budget will remain at $7.3 million annually through fiscal 2005 and was not among the many budgets recently slashed by the Texas Legislature. Her annual budget was only slightly reduced, by $25,000, from the previous year.
    State Rep. Arlene Wohlgemuth, R-Burleson, who chairs the appropriations subcommittee on human services, said she was unaware of the large number of unanswered calls at the intake center.  "But there may be other ways to deal with the overflow besides hiring more workers that might only be used during peak times," she said, such as forwarding the excess calls to another location as is done with other state 800-call services.  She said the key is to find a way to reduce the ever-increasing instances of abuse, which she attributes to the "breakdown in the family."
    Whatever is done, professionals in the field know that maintaining the status quo is not enough to keep up with the growing number of calls and children who need help.  "We've fallen behind, and we just can't seem to catch up," said Parker, with the child welfare board.

Addiction: A Brain Ailment, Not a Moral Lapse
Jane E. Brody, New York Times- 9/30/2003

For all that has been written and spoken about addiction as a medical disease, most people, including most physicians, understand little about what draws people to drugs and keeps them hooked, often despite severe consequences and repeated attempts to quit. A better understanding of the pull and tug of addiction can help those who are hooked and those who want the monkey off their backs for good. The savings in life-years, quality of life and lost income can be huge, not to mention the costs of drug-instigated crime and medical care.
    According to the National Institute on Drug Abuse, $133 billion a year is spent just on treating the short-term and long-term medical complications of addiction. Among the many health consequences of addictions are sudden cardiac arrest, irreversible kidney and liver damage, AIDS, fetal harm and many cancers, including cancers of the lung, bladder, breast, pancreas, larynx, liver and oral cavity. That it is possible to become free of addictions and remain so is unquestioned.

Seeking Definitions
The nature of addiction is the same no matter whether the drug is cocaine, heroin, alcohol, marijuana, amphetamines or nicotine. Yes, whether they know it or not, chronic cigarette smokers and users of chewing tobacco are addicts. Every addictive substance, according to a report this month in The New England Journal of Medicine, induces pleasant states or relieves distress.
    Furthermore, the authors of the report, Dr. Jordi Cami and Dr. Magi Farré of Barcelona wrote, "Continued use induces adaptive changes in the central nervous system that lead to tolerance, physical dependence, sensitization, craving and relapse." In other words, addiction is a brain disease, not a moral failing or behavior problem. People do not deliberately set out to become addicts. Rather, for any number of reasons — like wanting to be part of the crowd or seeking relief from intense emotional or physical pain — people may start using a substance and soon find themselves unable to stop.
    Of course, not everyone who smokes a cigarette, be it tobacco or marijuana, takes a drink, snorts cocaine or self-injects morphine is destined to become an addict. Most drinkers, for example, know when to stop before they become intoxicated or tolerant to large amounts of alcohol. Many people do not like the sensation of losing control and having their feelings and actions determined by a drug. Others refrain from taking the chance that trying a potentially addictive substance will lead to dependence and, so, never take a drink, a puff or a snort or swallow pills or inject a substance that is not medically indicated. Still others may be protected by their genes. Most Asians, for example, carry a gene that makes them physically ill and flushed before they can consume an addicting amount of alcohol.
    But genes can work two ways. The risk of addiction can be inherited. The genetics of alcoholism have been well studied, and heredity accounts for about 40 percent of the risk, though it is unclear whether what is inherited is an underlying emotional disorder that drives people to seek relief or a particular physiological reaction to addictive substances that gets them easily hooked. Dr. Nora D. Volkow, director of the drug abuse institute, told a conference on drug dependency in June that she had never met a patient who wanted to be an addict. "Sure," she said, "they start out wanting to take a drug. But the problem is we don't know who will become addicted." According to the Institute of Medicine of the National Academy of Science, 32 percent of people who try tobacco become dependent, as do 23 percent of those who try heroin, 17 percent who try cocaine, 15 percent who try alcohol and 9 percent who try marijuana.
    Dr. Cami and Dr. Farré observed that personality traits like risk-taking and novelty-seeking tendencies, as well as mental disorders, are "major conditioning factors in drug addiction." An increased risk of drug abuse has been associated with psychiatric disorders like schizophrenia, bipolar disorder, depression and attention deficit hyperactivity disorder, they wrote.

Changing the Brain
In a "perspectives" article in The Journal of the American Medical Association this month, Brian Vastag, reporting on the June conference, wrote, "The brain changes during addiction." Mr. Vastag explained that all drugs of abuse activated a pleasure pathway in the brain, the "dopamine reward circuit," which is connected to areas that control memory, emotion and motivation. Any activity that activates those pathways reinforces the pleasurable behavior. "Eventually," he wrote, "the dopamine circuit becomes blunted; with tolerance, a drug simply pushes the circuit back to normal, boosting the user out of depression but no longer propelling him or her toward euphoria." By repeatedly supplying the body with the substance, a new state of "normal" is created, causing the person to continue using the substance to feel normal.
    The changes in the brain, though not permanent, can be long lasting. Dr. Volkow found that the dopamine system of cocaine users remained impaired for up to three months after their last snort. And despite years of abstinence, former addicts may experience intense cravings when they are exposed to certain cues like watching drug use by a movie character.
    The Barcelona experts, in discussing the addiction mechanisms, noted, "Long-term administration of addictive drugs produces alterations in the brain that increase vulnerability to relapse and facilitate craving even months or years after successful detoxification." Those changes involve cognitive areas and drug-rewarding circuits.
    For someone who used drugs to relieve an emotional problem or psychiatric disorder that was not otherwise treated, the temptation to revert to the assuaging drug can be irresistible. Without follow-up treatment for both the addictive disorder and the underlying mental illness, the chances of a lasting recovery from addiction may be slim.
    Further, there is clearly not one route to recovery. Some addicts manage to kick their habits without any outside help; others require monthlong inpatient programs and continued reinforcement, either professional or lay. Still others may need a year of outpatient treatment plus aftercare. Many former addicts find that support groups of fellow former addicts like Alcoholics Anonymous and Narcotics Anonymous help them maintain their drug-free status.
    Because prolonged exposure to abused drugs results in long-lasting changes in the brain, "addiction should be considered a chronic medical illness," the Barcelona scientists said. As with other chronic illnesses, including hypertension and diabetes, addiction and its treatment require "long-term strategies based on medication, psychological support and continued monitoring," they concluded. In addition, other experts have suggested, treatment of addiction should be fully insured with no limit on the number of visits covered.

'Consciousness': Reality Programming
William Calvin, New York Times Book Review- 9/28/20032003

An articulate, liberally educated neurologist at the University of Edinburgh, Adam Zeman has written columns for The Times of London and is an occasional commentator for the BBC and the co-author of a book on ethical problems in neurology. His new book covers many aspects of consciousness for general readers. His treatment of the disorders of knowledge is superb. If you were intrigued with ''The Man Who Mistook His Wife for a Hat,'' you'll appreciate the buildup to what Oliver Sacks described in that work. Zeman's much more subtle examples give you some appreciation for how seeing and describing can become disconnected from recognition and other forms of knowledge.
    There have been a number of fine books on consciousness in the last dozen years, starting with Daniel Dennett's ''Consciousness Explained,'' which was written from the standpoint of a philosopher well versed in cognitive sciences and evolution. I am also fond of ''The Feeling of What Happens,'' by Antonio Damasio. Like Zeman, Damasio is a neurologist steeped in both literature and philosophy. But Zeman's ''Consciousness'' is the broader book, the one that could be used in an undergraduate humanities or psychology course to fill in the neuroscience background for readers coming to it for the first time. Indeed, Zeman first introduces his subject and then spends a hundred pages on neurobiology and human evolution before returning to consciousness. Readers impatient for consciousness per se can skim these chapters without losing the thread, though they are relatively painless introductions to what consciousness is built atop of.
    Consciousness implies both awake and aware. ''Sleep, like wakefulness, is organized from the brainstem,'' Zeman writes. ''It has a hidden structure of its own: in the course of the night we cycle repeatedly from light sleep to deep, from deep to dreaming sleep. The brainstem continues to generate these rhythms after the destruction of the hemispheres, as, for example, in the 'vegetative state.' By contrast, death of the brainstem is almost always followed, within hours or days, by death, pure and simple.'' The nerves controlling the entire body pass through the brainstem, and some brainstem strokes injure these connections while leaving the patient surprisingly alert and aware. ''In these circumstances awareness may survive while almost all means of expressing it are lost, an unhappy state of affairs known as the 'locked-in syndrome.' Sufferers from this disorder usually retain the ability to make voluntary up and down movements of their eyes, and can use these to communicate.'' He adds that we can't deny ''the disturbing possibility'' that this disorder may affect more people than we can now properly recognize as being afflicted by it.
    A couple of chapters after I read this, my 91-year-old mother suffered a similar brainstem stroke. There were periods when she could communicate only by moving her eyes and eyelids. Because she was sometimes able to get a few words out, it was obvious she was tracking what we said and was thinking ahead as usual; her consciousness was trapped in a body that would no longer obey her. We knew her wishes about such situations quite well, her sister having lingered five years in a similar state, but my mother was still competent to make her own decision if we could frame it for her limited ability to communicate. So her doctor told her that her situation was unlikely to improve, that we proposed doing nothing except comfort drugs and that she probably would die within a few days. Was that what she preferred? We thought she would have to communicate by blinking her eyelids. But she burst forth with her longest utterance since her stroke: ''You're the best doctor I ever had.'' Those turned out to be her last words. She died two days later.
    Consciousness is, however, more than just the minimum requirements of awake and focused. Zeman explains that ''sensation becomes conscious only when it undergoes some further process -- when it encounters past associations, or is used to govern future action, or becomes the object of reflection or is felt to impact upon the self.'' There is an ''important link between consciousness and volition. . . . Willed or voluntary acts are those with aims of which we are conscious and are -- usually -- prepared to acknowledge.'' Consciousness, he concludes, ''bridges perception and action, the events we perceive and the ones we bring about.''
But consciousness is fragile, and ''however magical it may be, it is a physical affair: mundane requirements for oxygen and glucose, electrical equilibrium, clean blood and adequate sleep must be met in the brain -- or consciousness fails. . . . However coherent our experience and behavior may appear, they are prone to fragment under stress. . . . Faints, fits and intoxication all reveal that perception, memory, movement and speech are separable capacities.'' He adds: ''It may be arrogant to deny that consciousness can ever slip its moorings in the brain -- after all, much of the world's population believes firmly that it can -- but the evidence in favor of this happening is tenuous at best.''
    Though the book's subtitle proclaims it a ''user's guide,'' the phrase is not easy to find in these pages, making one suspect it was tacked on by the publisher to make the book sound approachable and instructive -- which, fortunately, it is. However, it is not tuned in to two important issues that one would expect to find in a user's guide.
    The first concerns how aspects of consciousness develop in childhood. As a child, you eventually come to realize that someone else may not know what you know. This much is covered well. But such structured thinking begins as a 2-year-old makes the transition from two-word utterances to speaking long sentences that cannot be understood without some structuring principles. They are usually called grammar or syntax, and we use them to create past and future tenses and to nest phrases inside clauses and vice versa. Children understand structured sentences long before they can produce them -- if they can hear long sentences or watch them being signed. Certainly, one of life's major tragedies occurs when a child is not recognized as being deaf until well after the major windows of opportunity for soft-wiring the brain in early childhood have closed (much of structuring is not hard-wired instinct). We know how essential this tune-up period is for normal adult consciousness from the short-sentence, present-tense-only adult abilities of deaf children of hearing parents who failed to provide an environment during preschool years that was adequately rich in sign language. (Deaf children of signing deaf parents do fine.)
    That suggests that a child born both deaf and blind has little opportunity to soft-wire a brain capable of structured consciousness. But what about Helen Keller and what Zeman calls ''her rich inner life?'' Zeman, alas, makes the usual mistake of describing her as ''born blind and deaf,'' when in fact she probably had 19 months of normal exposure to language before being stricken by meningitis (by 18 months, some children start to express structured sentences, showing that they had been understanding them even earlier). So she probably soft-wired her brain for structured stuff like syntax before losing sight and sound.
    A user's guide also needs something about how we create a plan or utterance of high quality -- something better than our dreams, where we see cognitive processes freewheeling without much quality control. They provide us with a nightly experience of people, places and occasions that do not fit together. Fortunately our movement command centers are inhibited during most dreams, so we don't get into trouble acting on nonsense. Awake, we are always searching for coherence, trying to shape combinations that ''hang together'' well enough to act on. When our quality control fails and incoherence is the best thing our consciousness has available during waking hours, it tends to be called hallucination, delusion or dementia.
    A great deal of our consciousness -- indeed, our intelligence -- involves guessing well, as we try to make a coherent story out of fragments. Zeman lumps this under a search for meaning, but his description is memorable: ''Eye and brain run ahead of the evidence, making the most of inadequate information -- and, unusually, get the answer wrong. . . . Our knowledge of the world pervades perception: we are always seeking after meaning. Try not deciphering a road sign, or erasing the face of the man in the moon. What we see resonates in the memory of what we have seen; new experience always percolates through old, leaving a hint of its flavor as it passes. We live, in this sense, in a 'remembered present.' ''