Noteworthy News Articles on Mental Health Topics, November 24-30, 2005


Domestic Violence a Global Health Problem
Associated Press, 11/24/2005

LONDON -- Women who are physically abused by a partner face a similar legacy of health problems whether they live in a modern city in the industrialized world or a traditional village in a developing country, the first global study on domestic violence has found. In interviews with 24,000 women in 10 countries, researchers found that while there are wide variations in the rate of women experiencing sexual or other physical abuse at the hands of their partners, victims are about twice as likely as other women to suffer ill health -- and the effect seems to persist long after the violence has stopped.
      The study -- conducted by the World Health Organization in collaboration with the London School of Hygiene and Tropical Medicine, and PATH, a global health organization -- is a landmark, said former U.N. Commissioner for Human Rights Mary Robinson. ''We don't actually know, unless we have studies like this, how serious and pervasive violence by intimate partners really is,'' said Robinson, who was not connected with the research. ''For the first time, this study has used consistent means to measure violence across countries, so that we can now reasonably compare.'' ''It tells a story that unfortunately is universal,'' she said. ''Violence by intimate partners is one of the most serious challenges to women's health.''
     Countries included in the study, released Thursday, were: Brazil, Ethiopia, Japan, Namibia, Peru, Samoa, Serbia and Montenegro, Thailand, Bangladesh and Tanzania. North America and Western Europe were not included because earlier studies had already examined the situation there.
     In the WHO study, rates varied between 15 percent of women having been a victim of domestic violence during their lifetimes in Japan to 71 percent in Ethiopia. Previous research has found rates of about 20 percent in the United States and Sweden and 23 percent in Canada and Britain, said one of the researchers, Lori Heise of PATH. Even though the lifetime risk of violence was similar in many nations, women in developed countries were less likely to be currently suffering abuse than were women in developing countries.
    The percentage of women who had been attacked by their partners in the preceding year was 4 percent in Japan and in Serbia and Montenegro, compared with between 30 percent and 54 percent in Bangladesh, Ethiopia, Peru and Tanzania. ''There are lots of ways you can interpret that. It might be that there's less violence in more industrialized settings now, but it also suggests that women in richer countries are able to get out of relationships,'' Heise said.
     The study found that the health impact of domestic violence went well beyond injuries. Women who had experienced physical or sexual violence by a partner at some point during their lives were more likely to report poor general health at the time of the interview, the study found. They were more likely to have pain, dizziness, gynecological conditions and mental health problems. They were more likely to have considered or attempted suicide and they were more likely to have had a miscarriage or an induced abortion, said the study's coordinator, Dr. Claudia Garcia-Moreno of the World Health Organization. ''Overall, the likelihood that a woman who has been abused would experience one of these health outcomes was between 1.5 and 3 times higher than for women who had never been abused,'' she said.
     One of the most striking findings of the study was how consistent this link was across all settings, Garcia-Moreno said. ''Whether you are a cosmopolitan woman in Sao Paolo or Belgrade, or you are a rural woman in Ethiopia or Bangladesh, the association between violence and poor health is there,'' she said. In rural Ethiopia, where two-thirds of women experience domestic violence, the impact on health was very similar to that seen in Britain, where 4 percent of women are experiencing violence, Heise added. The researchers said they hope the study will arm activists with new evidence and spur governments not only to take notice, but to take action.


Sex, Drugs and Hope
Barbara Kantrowitz & Pat Wingert, Newsweek- 11/25/2005

Doctors write millions of prescriptions annually for the class of medications called SSRIs (selective serotonin reuptake in­hibitors). These drugs--Prozac, Paxil, Celexa, Lexapro, Zoloft and Luvox--are among the best weapons available to fight depression. But for up to 60 percent of patients, there can be a debilitating side effect: a dwindling libido or difficulty with orgasm. Some researchers estimate that half of patients may throw out their pills because of sexual troubles. That's a major public-health problem because it means people with depression aren't getting the help they need. "Depression is potentially fatal," says Dr. Karen Swartz, codirector of the the Mood Disorders Program at Johns Hopkins University School of Medicine. "Not taking treatment is serious."
      Now, after more than 15 years of clinical experience with SSRIs, doctors have found lots of ways to help patients deal with the sexual problems caused by most antidepressants. At the same time, recent advances in understanding the nature of sexuality give doctors new tools to pinpoint trouble spots in each individual. Scientists divide human sexual response into four phases: drive (sexual desire or libido), arousal (erectile function in men and lubrication in women), orgasm and resolution (a feeling of well-being). In a study of 6,300 patients to be published next year, Dr. Anita Clayton, professor of psychiatry at the University of Virginia, found that two thirds of men who had sexual problems with SSRIs complained about desire and orgasmic function. The women were much more likely to complain of arousal problems. The simplest solution is to wait. In up to 30 percent of cases, patients develop a tolerance for the drug and their sex lives improve. But that can take up to six months. "People are willing to wait a little bit, says Swartz, "especially if they're getting good benefit for their depression, but not indefinitely."
     Another strategy is scheduling "drug holidays"--over the weekend, for example. That works for patients organized enough to go back on the medication on Monday and who don't mind scheduling sex. (It's not an option if you're on Prozac, which stays in the body longer than other SSRIs.) Doctors also sometimes suggest switching to another kind of antidepressant whose side effects may be less distressing to a particular patient. Dealing with nausea, for example, might not be as bad as an inability to have orgasms. Adding the antidepressant Wellbutrin, not an SSRI, also often helps--perhaps because it increases levels of the neurotransmitter dopamine, which is believed to increase desire.
     If the main issue is arousal, doctors might prescribe Viagra for men, says Dr. Michelle Riba, clinical professor of psychiatry at the University of Michigan. To improve lubrication for women, Riba suggests either a lubricant or more foreplay before sex. Even getting more sleep may help. "People with depression often can't fall asleep or stay asleep," says Riba, "so sleep can get all tied into it, along with the fact that they don't feel well."
     For any of these strategies to work, ongoing patient-doctor communication is critical. And that highlights another common problem. Most people get prescriptions for SSRIs from their primary-care physicians, who are often under pressure to keep office visits short and can't take the time for sensitive questioning about the quality of a patients' sex life. "W need to do a better job of talking to patients about potential side effects upfront," says Clayton. Internists also aren't necessarily aware of all the latest research; that's why Swartz suggests that patients ask for a consultation with a psychiatrist if they're having problems with side effects. Talking about something as private as sex is difficult, but for patients on SSRIs, it can be a big step on the path to recovery.

The Depression Arsenal
Millions of Americans take SSRIs. There's the rundown:
Fluoxetine (Prozac)- the first SSRI to hit the market, it stays in the body longer than other SSRIs.
Fluvoxamine (Luvox)- Approved for obsessive-compulsive disorder; also used for depression.
Paroxetine (Paxil)- Available in two forms, regular Paxil and Paxil CR, which is a controlled-release drug.
Escitalopram (Lexapro)- One of the newer SSRIs. Patients may see benefits in about four weeks.
Citalopram (Celexa)- Similar to Lexapro. Some find these newer drugs have fewer side effects.
Sertraline (Zoloft)- Used for panic disorders and post-traumatic stress, as well as depression.


The Dangerous World of Drugs
Dana Stephens, New York Times- 11/25/2005

"Down to the Bone," which won a Special Jury Prize at last year's Sundance Festival, is the kind of movie most independent films strive in vain to be: a small, beautifully faceted gem. Vera Farmiga gives a pitch-perfect performance as Irene, a mother of two who works as a supermarket cashier in upstate New York. Though she appears to be a competent employee and loving wife and mother, Irene's life is precariously built around a cocaine addiction. When she finds herself trying to cash her son's birthday check to pay off her dealer, Irene decides to check herself into rehab. But an affair with a charismatic male nurse (Hugh Dillon) threatens to drag her into the even more dangerous world of heroin.
     The story was based on nearly five years' worth of video shot by the director, Debra Granik, and her cinematographer, Michael McDonough, documenting a situation similar to Irene's. Ms. Granik writes dialogue that is spare enough to ring true, yet rich enough to flesh out every character, including Irene's young sons. She is also admirably rigorous in her avoidance of the pat narratives of abjection and redemption common in stories of drug addiction. Even as Irene makes bad choices, she remains a sympathetic and intelligent character, and the film's ambiguous conclusion is as heartbreaking, and as hopeful, as real life.



Loneliness Widespread Among the Elderly
Tracy Davis, Ann Arbor News- 11/25/2005

Almost 60 percent of people age 70 and older experience some type of loneliness, a new study by a University of Michigan doctoral student has found. It's a problem more common in older adults than in younger people, said Katherine Fiori, a Ph.D. candidate in developmental psychology. And it can be more pronounced for some during the holiday season, when many people are reminded of loss, say area professionals who work with the elderly.
      Fiori also found that the size of people's social circles didn't matter as much as the quality of the interactions with particular individuals. Having a few close friends or family, with whom a person could visit often, was more important than a wider range of more casual friends. Fiori also distinguished between types of loneliness, including emotional loneliness and social loneliness. Emotional loneliness is feeling left out, feeling alone and lacking in close companionship. Social loneliness is the feeling of having no one to turn to and of not belonging to a group. In her study, Fiori found that about 22 percent felt the former; 16 percent felt the latter and 19 percent felt both. Some 43 percent reported experiencing neither type. Fiori also compared results among those 70-84 and those 85 and older. Those 85 and older were more likely to report feeling lonely, she noted.
     Fiori presented the paper at the annual meeting of the Gerontological Society of America last week in Orlando, Fla. She is planning to publish a related study on social network types and mental health. Fiori said she became interested in the study in the past year after watching her grandfather cope with the death of her grandmother. "I think that's really affected me in how I look at this question,'' she said. "It's a really important topic for me personally.''
     Intervening and helping an elderly person to establish networks can be key in alleviating feelings of loneliness and depression, local geriatric care professionals say. Ruth Campbell, a clinical social worker at U-M's Turner geriatric Center, said holidays tend to remind people of lost spouses, children, or other family members. That's especially true when other friends or relatives are involved with their own immediate families. Still others might find large holiday celebrations overwhelming or confusing, especially if they are coping with hearing loss or other issues that make it difficult to interact, Campbell said. "It's hard so you start withdrawing,'' agreed Susan Huber, administrator of St. Joseph Mercy Hospital's Huron Woods, an assisted living facility for people with memory loss. "And then you feel more alone than if you were at home. Other people have no family to go to.''
     Huber said many of her charges are most vulnerable when they are in the early stages of disease. That's because they are aware of their losses, and depression and anxiety can be more prevalent. Both Campbell and Huber advise that people watch for signs of depression and try to reach out to the elderly in their community. Campbell points out that Medicare and other resources will pay for home counseling or social work visits. No exhaustive efforts need to be made, Huber said. Sometimes just visiting for coffee or baking someone cookies or bread can mean the world, she noted. "Sharing of ourselves, that seems to get harder and harder every year,'' she said.
     Links to local resources can be found on the Turner geriatric Center's Web site at www.med.umich.edu/geriatrics/communityprograms/index.htm.


The Struggle to Gauge a War's Psychological Cost
Benedict Carey, New York Times- 11/26/2005

It was hardly a traditional therapist's office. The mortar fire was relentless, head-splitting, so close that it raised layers of rubble high off the floor of the bombed-out room. Capt. William Nash, a Navy psychiatrist, sat on an overturned box of ready-made meals for the troops. He was in Iraq to try to short-circuit combat stress on the spot, before it became disabling, as part of the military's most determined effort yet to bring therapy to the front lines.
      His clients, about a dozen young men desperate for help after weeks of living and fighting in Falluja, sat opposite him and told their stories. One had been spattered with his best friend's blood and blamed himself for the death. Another was also filled with guilt. He had hesitated while scouting an alley and had seen the man in front of him shot to death. "They were so young," Captain Nash recalled.
     At first, when they talked, he simply listened. Then he did his job, telling them that soldiers always blame themselves when someone is killed, in any war, always. Grief, he told them, can make us forget how random war is, how much we have done to protect those we are fighting with. "You try to help them tell a coherent story about what is happening, to make sense of it, so they feel less guilt and shame over protecting others, which is so common," said Captain Nash, who counseled the marines last November as part of the military's increased efforts to defuse psychological troubles. He added, "You have to help them reconstruct the things they used to believe in that don't make sense anymore, like the basic goodness of humanity."
     Military psychiatry has always been close to a contradiction in terms. Psychiatry aims to keep people sane; service in wartime makes demands that seem insane. This war in particular presents profound mental stresses: unknown and often unseen enemies, suicide bombers, a hostile land with virtually no safe zone, no real front or rear. A 360-degree war, some call it, an asymmetrical battle space that threatens to injure troops' minds as well as their bodies.
     But just how deep those mental wounds are, and how many will be disabled by them, are matters of controversy. Some experts suspect that the legacy of Iraq could echo that of Vietnam, when almost a third of returning military personnel reported significant, often chronic, psychological problems. Others say the mental casualties will be much lower, given the resilience of today's troops and the sophistication of the military's psychological corps, which place therapists like Captain Nash into combat zones. The numbers so far tell a mixed story. The suicide rate among soldiers was high in 2003 but fell significantly in 2004, according to two Army surveys among more than 2,000 soldiers and mental health support providers in Iraq. Morale rose in the same period, but 54 percent of the troops say morale is low or very low, the report found.
     A continuing study of combat units that served in Iraq has found that about 17 percent of the personnel have shown serious symptoms of depression, anxiety or post-traumatic stress disorder -- characterized by intrusive thoughts, sleep loss and hyper-alertness, among other symptoms -- in the first few months after returning from Iraq, a higher rate than in Afghanistan but thought to be lower than after Vietnam. In interviews, many members of the armed services and psychologists who had completed extended tours in Iraq said they had battled feelings of profound grief, anger and moral ambiguity about the effect of their presence on Iraqi civilians. And at bases back home, there have been violent outbursts among those who have completed tours. A marine from Camp Pendleton, Calif., has been convicted of murdering his girlfriend. And three members of a special forces unit based at Fort Carson, in Colorado Springs, have committed suicide.
     Yet for returning service members, experts say, the question of whether their difficulties are ultimately diagnosed as mental illness may depend not only on the mental health services available, but also on the politics of military psychiatry itself, the definition of what a normal reaction to combat is and the story the nation tells itself about the purpose and value of soldiers' service. "We must not ever diminish the pain and anguish many soldiers will feel; this kind of experience never leaves you," said David H. Marlowe, a former chief of military psychiatry at the Walter Reed Army Institute of Research. "But at the same time we have to be careful not to create an attachment to that pain and anguish by pathologizing it." The legacy of Iraq, Dr. Marlowe said, will depend as much on how service members are received and understood by the society they return to as on their exposure to the trauma of war.

Memories Still Haunt
The blood and fury of combat exhilarate some people and mentally scar others, for reasons no one understands. On an October night in 2003, mortar shells fell on a base camp near Baquba, Iraq, where Specialist Abbie Pickett, then 21, was serving as a combat lifesaver, caring for the wounded. Specialist Pickett continued working all night by the dim blue light of a flashlight, "plugging and chugging" bleeding troops to a makeshift medical tent, she said. At first, she did not notice that one of the medics who was working with her was bleeding heavily and near death; then, frantically, she treated his wounds and moved him to a medical station not knowing if he would survive.
      He did survive, Specialist Pickett later learned. But the horror of that night is still vivid, and the memory stalks her even now, more than a year after she returned home. "I would say that on a weekly basis I wish I would have died during that attack," said Specialist Pickett, who served with the Wisconsin Army National Guard and whose condition has been diagnosed as post-traumatic stress disorder. "You never want family to hear that, and it's a selfish thing to say. But I'm not a typical 23-year-old, and it's hard being a combat vet and a woman and figuring out where you fit in."
     Each war produces its own traumatic syndrome. The trench warfare of World War I produced the shaking and partial paralysis known as shell shock. The long tours and heavy fighting of World War II induced in many young men the numbed exhaustion that was called combat fatigue. But it is post-traumatic stress disorder, a diagnosis some psychiatrists intended to characterize the mental struggles of Vietnam veterans, that now dominates the study and description of war trauma. The diagnosis has always been controversial. Few experts doubt that close combat can cause a lingering hair-trigger alertness and play on a person's conscience for a lifetime. But no one knows what level of trauma is necessary to produce a disabling condition or who will become disabled.
     The largest study of Vietnam veterans found that about 30 percent of them had post-traumatic stress disorder in the 20 years after the war but that only a fraction of those service members had had combat roles. Another study of Vietnam veterans, done around the same time, found that the lifetime rate of the syndrome was half as high, 15 percent. And since Vietnam, therapists have diagnosed the disorder in crime victims, disaster victims, people who have witnessed disasters, even those who have seen upsetting events on television. The disorder varies widely depending on the individual and the nature of the trauma, psychiatrists say, but they cannot yet predict how.
     Yet the very pervasiveness of post-traumatic stress disorder as a concept shapes not only how researchers study war trauma but also how many soldiers describe their reactions to combat. Specialist Pickett, for example, has struggled with the intrusive memories typical of post-traumatic stress and with symptoms of depression and a seething resentment over her service, partly because of what she describes as irresponsible leaders and a poorly defined mission. Her memories make good bar stories, she said, but they also follow her back to her apartment, where the combination of anxiety and uncertainty about the value of her service has at times made her feel as if she were losing her mind.
     Richard J. McNally, a psychologist at Harvard, said, "It's very difficult to know whether a new kind of syndrome will emerge from this war for the simple reason that the instrument used to assess soldiers presupposes that it will look like P.T.S.D. from Vietnam." A more thorough assessment, Dr. McNally said, "might ask not only about guilt, shame and the killing of noncombatants, but about camaraderie, leadership, devotion to the mission, about what is meaningful and worthwhile, as well as the negative things."
     Sitting amid the broken furniture in his Falluja "office," Captain Nash represents the military's best effort to handle stress on the ground, before it becomes upsetting, and keep service members on the job with the others in their platoon or team, who provide powerful emotional support. While the military deployed mental health experts in Vietnam, most stayed behind the lines. In part because of that war's difficult legacy, the military has increased the proportion of field therapists and put them closer to the action than ever before. The Army says it has about 200 mental health workers for a force of about 150,000, including combat stress units that travel to combat zones when called on. The Marines are experimenting with a program in which the therapists stationed at a base are deployed with battalions in the field. "The idea is simple," said Lt. Cmdr. Gary Hoyt, a Navy psychologist and colleague of Captain Nash in the Marine program. "You have a lot more credibility if you've been there, and soldiers and marines are more likely to talk to you." Commander Hoyt has struggled with irritability and heightened alertness since returning from Iraq in September 2004.
     Psychologists and psychiatrists on the ground have to break through the mental toughness that not only keeps troops fighting but also prevents them from seeking psychological help, which is viewed as a sign of weakness. And they have been among the first to identify the mental reactions particular to this war. One of them, these experts say, is profound, unreleased anger. Unlike in Vietnam, where service members served shorter tours and were rotated in and out of the country individually, troops in Iraq have deployed as units and tend to have trained together as full-time military or in the Reserves or the National Guard. Group cohesion is strong, and the bonds only deepen in the hostile desert terrain of Iraq.
     For these tight-knit groups, certain kinds of ambushes -- roadside bombs, for instance -- can be mentally devastating, for a variety of reasons. "These guys go out in convoys, and boom: the first vehicle gets hit, their best friend dies, and now they're seeing life flash before them and get a surge of adrenaline and want to do something," said Lt. Col. Alan Peterson, an Air Force psychologist who completed a tour in Iraq last year. "But often there's nothing they can do. There's no enemy there." Many, Colonel Peterson said, become deeply frustrated because "they wish they could act out on this adrenaline rush and do what they were trained to do but can't."
     Some soldiers and marines describe foot patrols as "drawing fire," and gunmen so often disappear into crowds that many have the feeling that they are fighting ghosts. In roadside ambushes, service men and women may never see the enemy. Sgt. Benjamin Flanders, 27, a graduate student in math who went to Iraq with the New Hampshire National Guard, recalled: "It was kind of a joke: if you got to shoot back at the enemy, people were jealous. It was a stress reliever, a great release, because usually these guys disappear."
     Another powerful factor is ambiguity about the purpose of the mission, and about Iraqi civilians' perception of the American presence. On a Sunday in April 2004, Commander Hoyt received orders to visit Marine units that had been trapped in a firefight in a town near the Syrian border and that had lost five men. The Americans had been handing out candy to children and helping residents fix their houses the day before the ambush, and they felt they had been set up, he said. The entire unit, he said, was coursing with rage, asking: "What are we doing here? Why aren't the Iraqis helping us?" Commander Hoyt added, "There was a breakdown, and some wanted to know how come they couldn't hit mosques" or other off-limits targets where insurgents were suspected of hiding.
     In group sessions, the psychologist emphasized to the marines that they could not know for sure whether the civilians they had helped had supported the insurgents. Insurgent fighters scare many Iraqis more than the Americans do, he reminded them, and that fear creates a deep ambivalence, even among those who most welcome the American presence. And following the rules of engagement, he told them, was crucial to setting an example. Commander Hoyt also reminded the group of some of its successes, in rebuilding houses, for example, and restoring electricity in the area. He also told them it was better to fight in Iraq than back home. "Having someone killed in World War II, you could say, 'Well, we won this battle to save the world,' " he said. "In this terrorist war, it is much less tangible how to anchor your losses."

Help in Adjusting to Life at Home
No one has shown definitively that on-the-spot group or individual therapy in combat lowers the risk of psychological problems later. But military psychiatrists know from earlier wars that separating an individual from his or her unit can significantly worsen feelings of guilt and depression. About 8 service members per every 1,000 in Iraq have developed psychiatric problems severe enough to require evacuation, according to Defense Department statistics, while the rate of serious psychiatric diagnoses in Vietnam from 1965 to 1969 was more than 10 per 1,000, although improvements in treatment, as well as differences in the conflicts and diagnostic criteria, make a direct comparison very rough.
     At the same time, Captain Nash and Commander Hoyt say that psychological consultations by returning marines at Camp Pendleton have been increasing significantly since the war began. One who comes for regular counseling is Sgt. Robert Willis, who earned a Bronze Star for leading an assault through a graveyard near Najaf in 2004. Irritable since his return home in February, shaken by loud noises, leery of malls or other areas that are not well-lighted at night -- classic signs of post-traumatic stress -- Sergeant Willis has been seeing Commander Hoyt to help adjust to life at home. "It's been hard," Sergeant Willis said in a telephone interview. "I have been boisterous, overbearing -- my family notices it." He said he had learned to manage his moods rather than react impulsively, after learning to monitor his thoughts and attend more closely to the reactions of others. "The turning point, I think, was when Dr. Hoyt told me to simply accept that I was going to be different because of this," but not mentally ill, Sergeant Willis said.
     The increase in consultations at Camp Pendleton may reflect increasingly taxing conditions, or delayed reactions, experts said. But it may also be evidence that men and women who have fought with ready access to a psychologist or psychiatrist are less constrained by the tough-it-out military ethos and are more comfortable seeking that person's advice when they get back. "Seeing someone you remember from real time in combat absolutely could help in treatment," as well as help overcome the stigma of seeking counseling, said Rachel Yehuda, director of the post-traumatic stress disorder program at the Veterans Affairs Medical Center in the Bronx. "If this is what is happening, I think it's brilliant."

Tracking Serious Symptoms
In the coming months, researchers who are following combat units after they return home are expected to report that the number of personnel with serious mental symptoms has increased slightly, up from the 17 percent reported last year. In an editorial last year in The New England Journal of Medicine, Dr. Matthew J. Friedman, executive director of the National Center for Post-Traumatic Stress Disorder for the Department of Veterans Affairs, wrote that studies suggested that the rates of post-traumatic stress disorder, in particular, "may increase considerably during the two years after veterans return from combat duty." And on the basis of previous studies, Dr. Friedman wrote, "it is possible that psychiatric disorders will increase now that the conduct of the war has shifted from a campaign for liberation to an ongoing armed conflict with dissident combatants."
     But others say that the rates of the disorder are just as likely to diminish in the next year, as studies show they do for disaster victims. Col. Elspeth Cameron Ritchie, psychiatry consultant to the Army surgeon general, said that given the stresses of this war, it was worth noting that five out of six service members who had seen combat did not show serious signs of mental illness. The emotional casualties, Colonel Ritchie said, are "not just an Army medical problem, but a problem that the V.A. system, the civilian system and the society as a whole must work to solve."
     That is the one thing all seem to agree on. Some veterans, like Sergeant Flanders and Sergeant Willis, have reconnected with other men in their units to help with their psychological adjustment to home life. Sergeant Willis has been transferred to noncombat duty at Camp Pendleton, in an environment he knows and enjoys, and he can see Commander Hoyt when he needs to. Sergeant Flanders is studying to be an officer.
     But others, particularly reservists and National Guard troops, have landed right back in civilian society with no one close to them who has shared their experience. Specialist Pickett, since her return, has felt especially cut off from the company she trained and served with. She has struggled at school, and with the Veterans Affairs system to get counseling, and no one near her has had an experience remotely like hers. She has tried antidepressants, which have helped reduce her suicidal thinking. She has also joined Operation Truth, a nonprofit organization that represents Iraq veterans, which has given her some comfort.
     Finally, she said, she has been searching her memory and conscience for reasons to justify the pain of her experience: no one, Specialist Pickett said, looks harder for justification than a soldier. Dr. Marlowe, the former chief of psychiatry at Walter Reed, knows from studying other wars that this is so. "The great change among American troops in Germany during the Second World War was when they discovered the concentration camps," Dr. Marlowe said. "That immediately and forever changed the moral appreciation for why we were there." As soldiers return from Iraq, he said, "it will be enormously important for those who feel psychologically disaffected to find something which justifies the killing, and the death of their friends."

 

Psychotherapy Adds Meditation
Kay Miller, Minneapolis Star Tribune- 11/26/2005

MINNEAPOLIS -- It is deceptively simple advice: "Sink into your body, and then just breathe."
But in the six years since St. Paul psychologist Patrick Dougherty began applying what he learned from his own meditative practices to therapy sessions with clients, he has found that humble breathing exercises open them to new insights. Dougherty has worked with individuals and couples for 28 years, but he was frustrated with how long it took to make progress using traditional psychoanalysis. Meanwhile, his own inner peace was deepening with the study of Qigong, the ancient practice of manipulating body energy, and Taoism, a form of Eastern spirituality that dates to the 6th Century B.C. He began mixing East and West. "The goal is not just symptom relief but personal transformation," he said.
      The influence of Eastern spirituality in Western mental health has generated a lot of buzz: Time, Newsweek and Psychology Today have done cover stories on it. Oprah Winfrey has done shows on it. Bookstores are crammed with tomes on the topic. Susan Bourgerie and Judith Lies are traditionally trained Minneapolis therapists who, like Dougherty, were independently integrating principles they learned from Zen Buddhism and mindfulness-based stress reduction to individual and couple therapy. "Traditional psychotherapy hasn't completely failed us," Bourgerie said. But, she said, it tends to make clients fixate on thoughts and feelings while Eastern approaches urge them to open their eyes and connect with the rest of the world.
     In treating couples and individuals, especially those with anxiety, Bourgerie hasn't abandoned her training in family systems, psychodynamics and cognitive therapy. Instead, she subtly layers the Eastern approach of accepting life's suffering -- birth, death, anxiety, illness, loss and grief -- without expecting the pain to vanish. Clients learn to be aware of the moment, to let go of things they can't change, to acknowledge thoughts swirling in their heads and just let them be there, like clouds in the sky -- imagery that permeates Eastern thought.
     "I've had clients who said, `So this is what peace that passes understanding is all about,"' Dougherty said. "That's very common: peace in the midst of life's ups and downs." He is working with a couple who ended up fighting during every serious discussion. Dougherty suggested that they take two minutes to breathe and think about each other from their hearts: This person loves me and wants to get through this issue with me. We've gotten through many issues. And we're going to end up in a place that makes us both feel good. The couple are discovering that when they operate with open hearts they're more able to love and be loved, he said.
     Earlier that day Dougherty met with a client in his late 30s who had been a sexual-abuse victim. The man was ruminating on the toll that abuse had taken on his life. Suddenly he stopped. "OK, I know what I need to do," he said. "I need to breathe more, and I need to be present. Rather than looking at how much I'm a victim, how can I be present and take responsibility for my life?" It was a powerful moment, Dougherty recalled. The man talked about how scared he was to grow up and how he used his victim status to hide from life. "I didn't try to fix him. I just let him be present to that fear. It gave him a command of his own life that he never had when he was a child," Dougherty said.
     Why is this shift happening? "I think our lives and the things we've gone after have turned out to be pretty unsatisfactory to what really sustains us," Lies said. The original therapists were the priests and shamans, Bourgerie added. People came to one person for their emotional and spiritual needs. "Over the centuries, there's been a huge split between what is spiritual and what is psychological," she said. "One of our hypotheses is that that is starting to come back together again, into wholeness."


Psychiatrist Suspects Parasite Linked to Schizophrenia
Jordan Lite, New York Daily News- 11/26/2005

NEW YORK - Dr. Fuller Torrey is studying whether a parasite in cat droppings causes schizophrenia, a mental illness that strikes 2.2 million Americans and is characterized by hallucinations, delusions and trouble regulating emotions. The Washington-area psychiatrist has found that people with schizophrenia were more likely to have had pet cats as young children, or their mothers kept the animals during their pregnancies. Torrey is now testing antibiotics against the feline parasite, Toxoplasma gondii, to treat schizophrenia, according to an article in December's Esquire. "My wife thinks I'm probably ultimately going to be assassinated by (cat lovers)," Torrey said. Still, "not only cats, but virtually all animals carry transmissible agents, and some carry transmissible agents that have had profound implications for the human race," he said.
     Torrey, president of the Stanley Medical Research Institute, believes that ingesting or inhaling parasitic spores from cat waste causes schizophrenia. While hardly conventional wisdom, his theory is part of scientists' growing interest in the potential environmental influences on the development of mental illnesses, said Dr. Donna Anthony, clinical program director for psychotic disorders at New York-Presbyterian Hospital/Westchester. While today most experts believe that schizophrenia is inherited, some in the past blamed it on a patient's upbringing. "I don't think the cause (from cats) is so direct, but certainly all the research into possible contributions of (infections) before birth and in early childhood bringing out a predisposition to schizophrenia is a productive line of research," Anthony said.

 

Psychotherapy Gains Following in Russia
Associated Press, 11/27/2005

MOSCOW -- Valentina's world collapsed when her husband of 15 years left her for a mistress. ''Doctor, what am I to do?'' the 41-year-old blonde tearfully asked the therapist. ''I don't want any other man, I want my own!'' The scene playing out on TV screens in Russia was not a soap opera but real-life psychotherapy, a practice that was reviled by communism as a bourgeois indulgence but now is making inroads both on private couches and on TV shows.
      While Soviet academics studied psychology as a pure science, experts say practical therapy was virtually nonexistent, and the state routinely used psychiatry to commit dissidents to grim institutions. Even the term ''psychoanalysis'' was officially forbidden until the early 1990s, being considered a ''bourgeois'' and dissident branch of psychology, said Olga Kvasova, a lecturer at the Moscow State University's Psychology Faculty. The 1991 collapse of the Soviet Union and the ensuing economic and political reforms ushered in freedom of speech and self-expression and acquainted Russians with everything from Western consumer goods to seeing a therapist. ''It is not yet a boom, but ... its popularity is definitely on the rise,'' said Mikhail Labkovsky, a psychotherapist who hosts a talk show on Ekho Moskvy radio.
     Colleges with psychology programs also are experiencing an influx of students, with tens of thousands of psychologists graduating every year. Kvasova said there are 55 schools with psychologist-training programs in Moscow alone, compared with a mere dozen for the whole of Russia some 15 years ago. Some students and specialists also get trained abroad. ''This field is becoming popular. A greater number of people are interested in psychology and want to study it,'' Kvasova said.
     But for now seeing a therapist is almost exclusively for the urban rich, with sessions costing $20 to $100 an hour in a country with an average monthly salary of $300. For the less well-heeled there's ''We'll Solve Everything'' -- a new talk show on Russia's Domashny channel. It's hosted by Dr. Andrei Kurpatov, a 31-year-old St. Petersburg psychotherapist who has written more than 20 books on psychological problems and was counseling Valentina in a Moscow apartment -- under the TV lights.
     Valentina, one of Kurpatov's television patients whose name was not given, could not come to grips with her recent divorce and wanted her husband back. After he heard her out, Kurpatov gave Valentina a plate with two cucumbers, two tomatoes and a knife and told her: ''Please make me a salad yesterday.'' Valentina paused and then answered with a sigh, ''No, doctor, yesterday's salad should have been made yesterday.'' She added that she realized she had to begin a new life. Kurpatov says that one point of his show is simply to ''show that psychotherapy exists, that one can come and get help.'' Some experts criticize Kurpatov for sometimes lecturing his TV patients on what to do and think but acknowledge that his show is educating Russians about the benefits of psychotherapy.
     Tatyana Dmitriyeva, head of the country's chief psychiatric hospital, the Serbsky Institute -- which in Soviet times was infamous for diagnosing dissidents as schizophrenics, said it was good news for a country that experienced tremendous economic and social hardship in the 1990s, leaving many Russians in depression, and where alcoholism and suicide rates are high.
     A big barrier to mental health, Kurpatov said, is that having been raised in a Soviet state that controlled both their public and private lives, many older Russians are reluctant to take charge of their lives. ''When Russians come to me they say, 'Doc, I have problems, please find me a husband! How come you are not finding a husband for me?''' Kurpatov said. ''Here we are trying to convey the idea of personal space, of personal responsibility for one's life and the decisions that you make.''



Mental Health Care Cost Tears up Family
Meg Breslin & Bonnie Rubin, Chicago Tribune- 11/27/2005

The teenager had been hospitalized four times for suicide threats, started rumors that popular boys got her pregnant and even pulled a knife on her younger brother. Then she falsely accused her stepfather of sexually abusing her. Jodi and Tom Connor, like thousands of parents in Illinois, felt they were running out of options for helping their mentally ill 16-year-old daughter. Their savings were depleted, insurance benefits exhausted and two state grant applications for intensive therapy rejected.
     So they considered the heartbreaking option suggested by mental health workers: They could turn over custody of Samantha to the state so it would pay for her mental health care. But losing custody also meant the Connors would essentially give up their rights as parents to Samantha, a slight, dark-haired beauty whose emotions regularly swung from teary bear hugs to sudden bouts of anger.
     If they gave Samantha up to DCFS, the Connors would have no legal say over her care--where she would live, the medical attention she would get, even how often they would visit. Caseworkers would be assigned for routine visits to the Connors home, monitoring their younger son. In fact, there would be no guarantee of quickly regaining custody if Samantha's health improved. They would have to petition the court to get her back. "It was a terrible choice," said Jodi Connor. "... They make you give up custody in order to get the help she needs." Samantha hated the idea, too, despite assurances from her mother that she loved her and was not abandoning her. "It's like they just didn't want me," Samantha said later.
     Mental health advocacy groups say swapping custody for care is a long-standing practice that only now has begun to generate a serious response. Sen. Susan Collins (R-Maine) has proposed federal legislation designed to curtail the practice with a bill dubbed the Keeping Families Together Act. Cook County Assistant State's Atty. Teresa Maganzini said relinquishing custody is a sad option that reflects how desperate many parents are to get treatment for their children. "Even if it were just a small number of cases, it's obviously concerning that it's that tough to get help for families," she said. "...But it appears to me to be a big problem and a problem that seems to be growing."
     In response to a Freedom of Information Act request by the Tribune, DCFS identified 1,200 cases in which children have been "locked out" of their parents' homes from 1998 through May of this year. However, officials say they don't know how many of those children were mentally ill or runaways with no psychiatric diagnosis. There's no data on the number of those children turned over to foster care.
     Sometimes parents give up custody by refusing to pick up mentally ill children from psychiatric hospitals, forcing the child into foster care for mental health services. Peter Tracy, who directed mental health for DCFS before leaving the agency five years ago, said he discouraged hospital officials from advising parents of this option. He documented about 100 psychiatric lockouts annually. "No one at the hospitals wants to admit they do it," Tracy said. "Yet parents used to say to us that they were advised by their psychiatrist that this is the only thing" that can be done.

Money problems
A combination of problems has put families like the Connors in this spot. Over the last decade, the state has not spent enough money on community mental health services, many critics say. Parents of kids with severe illnesses often have to resort to residential treatment centers. The centers provide long-term care and therapeutic services in a dormitory-type setting for as much as $120,000 per year. Medicaid and private insurance rarely cover such placements.
     Parents also have been squeezed by health insurance that refuses to pay for long hospitalizations--the average stay has shrunk from 59 days a decade ago to a week. Most managed-care plans will pay for no more than two weeks of treatment, just enough for a patient to be stabilized on medications but not long enough to begin the arduous work of changing behavior.  And parents have fewer places to turn. Illinois has closed five state-run mental health units for children and adolescents since 1993, losing more than 100 beds. That left Illinois with few state-run psychiatric hospitals for children. Of Illinois' 102 counties, 88 do not have a single child psychiatrist.

Sad reality
Doctors and social workers long had recommended at least a year of intensive therapy at a residential treatment center for Samantha. Yet the couple's private insurance wouldn't cover it, and their combined $130,000 income was too high to qualify for Medicaid, which wouldn't likely cover a residential placement anyway. By this point, the couple had already spent at least $25,000 on Samantha's care. The Connors faced the reality that health care covers mental disorders less extensively than it does other illnesses.
     The lack of coverage puts many parents in an impossible situation. "If a child can't function in the community or at home, what are the parents to do?" asked Evelyn Lush, the former director of youth services for the McHenry County Mental Health Board. Lush worked with the Connors, informing them of the custody option--a suggestion she's offered to at least one client a year for the last decade.
     Officials with the Washington, D.C.-based Bazelon Center for Mental Health Law, said the Connors' dilemma is typical for parents nationwide. A Bazelon report found that one in five families searching for such care considers giving up custody.
     For years, the Connors moved down the wrong path in their quest to help Samantha. As time passed--as with any other illness that goes untreated--she seemed to only get sicker. Diagnosed with attention-deficit disorder as a kindergartner, Samantha struggled in class and never developed lasting friendships. In adolescence, it became clear she was actually suffering from bipolar disorder. In the summer of 2001, she threatened suicide and was admitted to Alexian Brothers Behavioral Health Hospital. After her 28-day stay, insurance benefits had run out for the year and the family could afford nothing more than occasional therapist visits, even though doctors insisted she needed more. Samantha continued to talk of depression and suicide, dabbled in drugs and kept company with older men she met at parks and train stations. In a therapeutic journal, she wrote: "I do a lot of these things because I'm starving and begging for attention. Whether it be positive or negative, I just want people to like me more."
     The Connors moved from Hoffman Estates to Crystal Lake, and Samantha initially did well, making the pompom squad. But in 2003, as a high school freshman, she was hospitalized for the third time in three years for threatening suicide. A revolving door of emergency treatment began, with stays of no more than a few weeks allowed by insurance. The post-discharge scenario was always the same: brief improvement followed by a relapse and dashed hopes. Her schoolwork also plummeted, and what had once seemed like empty threats to hurt schoolmates took on new urgency. "At one point, she was threatening that she had a gun and she was going to kill some kids," Jodi Connor said.

Hard-to-get grants
The state does offer grants, typically $90,000-$95,000 a year to help parents with children in crisis. But many psychiatrists say the grants are vastly underfunded and extremely difficult to get. Individual-care grants are open only to those suffering from "severe impaired reality testing" or "hearing voices." Dr. Louis Kraus, head of child psychiatry at Rush University Medical Center, said the criteria was "absurd" because many very ill children are not psychotic.
     Stringent eligibility requirements amount to a de facto cap on the grants available, and many parents don't even bother to apply once they see the requirements, many child advocates say. Though 1,053 people requested grant applications in 2004, only 266 completed them and 89 were approved. The Connors twice were denied a state care grant. Each time, they were told she didn't meet the criteria. "They said she wasn't sick enough," Jodi Connor said. "My God, how sick do you have to be?"
     Samantha's condition continued to deteriorate, hitting a new low when she accused her stepfather of sexually abusing her. Six days later, she recanted. Blindsided by the allegations, Tom Connor considered walking away from the family. "It was difficult to balance my anger with her versus `she needs my help.'" Connor said. "She doesn't want this, I know. She doesn't realize what she's doing and the damage she's causing.... I can't abandon her. I just can't."
     Having exhausted their insurance coverage, the couple called friends affiliated with the Jewish Children's Bureau who agreed to take her in a North Side group home at a reduced cost. The Connors covered her medical expenses and paid $150 a month. Twice, officials there had her hospitalized for suicide threats. Samantha again claimed she had been molested by staff, then recanted. Unlike a medical hospital, the facility was unlocked, and she ran away repeatedly. Finally, group home administrators refused to take her back, insisting that she needed a more secure place.
     Some families sell their homes, seek loans or plunge into debt to pay for costly treatment centers. The Connors didn't consider those options, because their younger son was already upset by the turmoil and they wanted his life more secure--emotionally and financially. Samantha had shown little remorse after falsely accusing Tom, and the couple also feared that if they didn't act quickly, she'd target other innocent people. "I had to protect not only my family but the neighborhood," Jodi Connor said. Relinquishing custody seemed the only choice left, and they reluctantly took it.

State takeover
Once DCFS took over, Samantha was placed in a foster home in Aurora. There were no beds available at appropriate treatment centers, DCFS officials told the family. The Connors were irate, fearing that a foster home with light security and little therapy would be a disaster for a troubled girl who was running away. Sure enough, Samantha disappeared within 24 hours, and the staff had no idea of her whereabouts. Panicked, Tom Connor called county morgues daily, checking for her body.
     After a week, the Connors finally found Samantha in a Chicago hospital. She told her family she had been staying with a 33-year-old Cicero man who let her crash in his apartment. Samantha remembers little from that period, other than she felt out of control and manipulated. "They had a flier out on me when I ran," Samantha said. "They said `she's suicidal,' `no meds,' `mental illness,' all this stuff. They said `you NEED to find her.'" She agrees that was the case. "I would have gone and done something stupid," she said. "I would have gone and killed myself, killed somebody else."
     Alarmed by Samantha's actions, a Juvenile Court judge overseeing her foster care at last ordered DCFS to place her in a residential treatment center. Only then did she land in the Scott Nolan facility in Des Plaines. The Connors then stepped up efforts to get an individual care grant. This time, at the McHenry County Health Board's suggestion, Jodi Connor asked her state legislator's office for help. Connor says she's not sure if that's what pushed her request forward, but she soon heard her application was approved. There was no explanation other than Samantha now met the state criteria. Within hours, the Connors were in court to regain custody of Samantha and they succeeded. Now Samantha greets her parents for three-hour visits every other Saturday in the linoleum and cinder block visitors' room at Indian Oaks residential treatment facility in Manteno, more than two hours from the Connors' Crystal Lake home.

Slow progress
The Connors are grateful the strict environment keeps their daughter safe. But her progress is still slow, as she resists the center's rules and struggles to get along with peers. The years lost fighting for interventions seem to have only worsened the situation. "I just feel doors were slammed in our face at every corner," Jodi Connor said. "...If we had the money and the resources, this all could have been dealt with years ago."
     Samantha says the last year has left lasting scars for her too. "It's like they wanted me away to the point where they didn't even get to see me often," she said of her parents. Samantha feels like she's not getting any better at Indian Oaks. "I have homicidal thoughts. I'm still suicidal.... I'm not going to go through with killing myself, but ... I can't guarantee that I won't go through with hurting somebody else."
     In their darkest moments, after the teary calls from the treatment center when their daughter sounds so distant and defeated, the Connors still cling to what endures: unconditional love for their child. "I wish I could snap my fingers and make it all normal," Tom Connor said. "But you just have to grit your teeth and hope that your child participates in her own healing because, really, parents can only do so much."

Smart, Successful, Addicted, He Stole Thousands
Rick Green, Hartford Courant- 11/27/2005

"Good evening, Mr. Tassone!" Four crisp words and Bruce Tassone feels the potential of the night ahead, as if he's been handed a fresh $5,000 gambling stake for the craps table. Here is the respect a man arriving at his castle deserves. Handsome, lean and dark-haired, Tassone makes his way through his noisy living room of Foxwoods Resort Casino, a palatial mansion of alluring rooms and enticing passageways. The dealers and pit bosses greet him as he passes, welcoming him back.
      Foxwoods is not just where Tassone gambles. It is home. Kicked out by his wife and living in cheap hotels outside Boston, the idea hit him one day: Just live at the casino. With so many comp points accumulated from gambling so much -- he lays down more than $1,100 every time he bets -- it was obvious that Tassone should just move in. They do his laundry. He gets his mail here. It's only an hour and a half to work in Boston. They know his name. Nobody asks where the money comes from.
     Pumped from the tense drive, Tassone is psyched to be back at the craps tables. The dice feel cool, little reptiles jumping out of his hands, chattering across the felt. This is what he has been waiting hours for, since last night and the night before and when he was a squirmy kid, watching his dad decades ago, the old man's loud voice echoing across a smoky card room. "Hard six. You want a hard six," he reminds himself, alive again with these people, strangers, his casino family hunched around him, pushing and hollering and leaning over this big noisy gathering. "Two threes."
A $1,000 on the hard six and another $2,000 on the pass line and $10,000 behind ... Jesus, if his father could somehow see and understand this. He's winning. He's a pro. Everyone can see it.
     Limousines, free meals and hotel rooms. Golf clubs and Rolexes. It's all covered -- comped -- because casinos reward their big-time players. Tassone revels in all this, as if his whole life were leading up to this moment at the tables. "I know when the table is hot, and I know when the table is cold," he thinks. But oh, man, this is some kind of crazy hopped-up moment and maybe he can still make all this right. The dice clatter to a stop and yes, it is a hard six. Tassone's mind races, crashing against the crowd's energy like a giant ocean wave. "This," he feels again, "is such a rush."
     Everything else, all that mess, just melts away. A couple of sweet kids, forgotten back in Massachusetts. Career and marriage in the toilet. Friendships and business relationships ruined, roadkill he speeds by along his addiction highway. He's home. They love him here.

A High Roller Behind Bars
The movie loops endlessly through his mind. What else can Tassone do but watch and try to figure it all out? Because it's no longer "Good evening, Mr. Tassone." It's inmate No. 25106-038. He's serving 18 months for ripping off more than $600,000 to pay for that glorious gambling habit and the two years he called Foxwoods and Mohegan Sun home.
     How did a smart kid from the Berkshires with a hockey scholarship, a six-figure-salary guy flying all over the country on construction projects for a successful and growing company - a player who just knew when the craps table was turning cold -- end up here with a bunch of white-collar crooks? This gambler never knew how to actually leave those tables. And no, he cannot forget his father, a failed gambler too. He's the one Tassone never could seem to please, not if it meant doing only 90 pushups when you promised to do 100.
     The movie keeps running, blurry images retracing a lifetime of gambling. Card clubs in California. Race tracks in Arizona and New Mexico -- it's all there, every day. Saratoga, Green Mountain, Atlantic City, Las Vegas and the Bellagio. Living, for months on end, at Foxwoods and Mohegan Sun. The big score back in 2003.
     Home now is a federal Bureau of Prisons minimum security camp at Fort Devens, Mass. An expert at the odds of gambling, Tassone now tutors other inmates in math. He reads, does his chores and watches sports on television with the other inmates, trying to avoid making those imaginary "mind bets" that compulsive gamblers can't resist.
     "There were hundreds and thousands of times, of New Orleans, driving a car ... and of Ohio and Thistle Downs," said Tassone, who is a youthful 42. "I've been to probably 30 dog tracks and 30 casinos. The last 25 years of my life have been a montage of gambling. It's depressing. "It is much harder going through life thinking about all the things that I have done ... in the name of gambling." This swollen river of gambling has run all through his life, from teenage poker games to the stealing and pawn shop scams to that last sordid night at Foxwoods. So Tassone starts the film again at the beginning, with a little boy in a dying factory town in the Berkshires and the search for love and warmth from a father who was happiest when he gambled. What he also remembers, way back, is that phone call.

A Professional Gambler
Tassone's father was in Las Vegas and the news was bad. That wasn't so surprising, because Anthony Tassone gambled and lost all the time -- football, baseball, the track in Pownal just over the Vermont border. But this call was more urgent, his mother more worried, as her husband delivered his miserable message from across the country. He had lost everything, and more, at the tables.
     Tony Tassone was out $40,000. Bruce's mother hung up the phone, sobbing. But the 5-year-old was told nothing and he wouldn't find the courage to ask his mother about it for years. The Tassones, though, quickly felt the sting of this major loss. The house had to be sold and they moved in with his grandmother, and, eventually, to a drafty trailer home Bruce was ashamed of. His mother worked two jobs, his father three, because in the Tassone household, paying back your debts was part of the gambler's code of honor. Bruce always paid close attention to these lessons because it was a world he longed to join. In gambling, they conversed in another language: Patriots, five times and under. How many other little North Adams boys knew what that meant? It seemed so exotic, glamorous.
     His father worked at Sprague Electric Co., a complex of interlocking factory buildings that ran through North Adams like a bony skeleton. Once, it was where seemingly everyone's dad worked -- over 4,000 employees in a town of 18,000 -- before integrated circuits arrived and jobs fled North America. On weekends, Tony Tassone played endless poker games at a social club, where the air was thick with the succulent smell of cigars and Italian sausage. Here, men swore, drank, told stories and, of course, gambled. "I would sit there with my cousin and watch boxing and other sports on television, while he played cards all night," Tassone said. "Someone would pick me up and take me home at 9 or 10 p.m. with the message that Dad's not coming home tonight, he's playing cards. I thought that was normal."
     As a teenager, Bruce's every-day after-school poker games with his buddies and evenings at the social club evolved into trips to the track at Saratoga or Green Mountain, where his father would place bets for him. "I fell in love with my father in that environment. He was happy when he won. When he lost, he wasn't. Even when he wasn't happy I got to see that. I got to see the change in moods and how he reacted. I saw that human side of him," Tassone recalled. "You get attached to it."
     By the time he was at Skidmore College, Tassone had the Daily Racing Form delivered to his room and spent all his time placing bets, going to the track. He flunked out by the end of the year. The same thing happened at the University of California, Berkeley, where a second chance at college evaporated in a noxious mix of horse tracks, card clubs and all-night drives to Vegas and Reno. When he returned east, the pattern repeated itself at the University of Massachusetts.
     "I saw myself as a professional gambler. As a kid, I can consciously remember this. My father was such a horrible gambler and a loser that I thought God would not let me be that same loser. I was smarter. I did really well on my SATs. I felt that I was smarter and more educated. I felt that I wouldn't fall into the same traps that he did." The smart son's crash would be far more spectacular.

`Heaven All The Time'
Much later, a psychiatrist would write that Tassone was in "an altered state of consciousness in which he simply did not think or care about his obsession with gambling." Another would say that Tassone "believes he has special mystical powers." Still another would conclude that a "two-year residency at Foxwoods and chronic out-of-control gambling" culminated in an "inability to consider the consequences of his actions."
     But in the fall of 2002, in the small realm of the world's largest gambling casinos in southeastern Connecticut, reckless behavior is handsomely rewarded. This is a place where patrons gleefully dump $1 million an hour into slot machines. A man who drops thousands of dollars per bet is a respected player. And this is Mr. Tassone - master of his gambling domain - a man with so many comp points he can live for free at Foxwoods and Mohegan Sun, eat at the best restaurants, stay in the best rooms. What it is, Tassone concludes, is "heaven all the time."
     His wagering, growing by the week, surges beyond $400 and $500 per bet, as he blows through hundreds of thousands of dollars in wins and losses. It is also a moment when his gambler's reputation is immense: The posh Bellagio casino in Las Vegas comps Tassone's entire stay after learning of his spending habits in Connecticut. As long as he is gambling, win or lose, the points keep racking up.
     Can we get you the suite this weekend, Mr. Tassone? If you need something, just give us a call. When his sister doesn't understand craps, a special table is set up with an instructor for her to learn. When he wants to bring his mother down to Mohegan Sun from North Adams, a limousine is sent to pick her up. "They'd put me in a nice room. I'd get the nice food. And I could live it up and forget about all the destruction and the pain I had caused my wife, my family, my kids," Tassone recalled recently. "My whole work day is thinking about how I've got to get out of there at 3 and beat the traffic so I can get back to the casino and gamble again."
     After his marriage implodes in 2001, Tassone more or less lives at Foxwoods and Mohegan Sun, making the drive to work in Watertown, outside of Boston, every morning and then racing back in the evening. But he's spent years burning through his bonuses, stock options and retirement savings, not to mention the nearly $150,000 salary he was earning as a vice president in charge of construction for Bright Horizons, one of the world's largest private day-care center operators.
     Broke and unable to think beyond the craps tables, during the summer of 2002 Tassone begins to use his company credit card to purchase computer equipment that he then hocks at pawn shops in Providence and New Haven, taking the cash to go and gamble more. By September, however, the credit card scam is slipping out of control, and he comes up with another scheme: a phony construction company that bills Bright Horizons for work at a real construction project he is supervising in Florida. As the vice president in charge of construction, Tassone signs the invoices and payment is wired to his bank account. "My intentions were to take the money and pay off the credit card. That was what the intention was. But I got the money and I gambled it and lost it."
     Over the fall and winter of 2002-03, Tassone's gambling -- and his stealing -- escalate. By March, he has embezzled nearly $600,000, with hundreds of thousands of dollars more stolen by pawning merchandise purchased with his company credit card. In April 2003, Tassone leaves Bright Horizons as federal investigators begin to close in. Tassone's mad gambling spree continues unchecked, as he wins and loses huge amounts of cash through the summer and fall. When he isn't embezzling from his company he is conning friends who wire money directly to Tassone at Foxwoods. "There were something like 360 wire transfers from close friends. I was manipulative as hell when I gambled," Tassone said. "They knew I had access to a lot of money and sometimes I would pay them back." When he was spending money and winning -- Foxwoods records introduced in court show that Tassone gambled nearly $1 million between 1999 and 2004 -- Tassone shared his wealth, bringing in friends and family for some of the high-roller action.
     At the casinos, "they always knew who I was. I liked that. It was all a reinforcement of some crazy image of who I thought I was. I finally was somebody because I could steal $700,000," Tassone said. "Throughout that whole period of time I'm thinking I could do this forever."

The Big Score
On a Friday night in March 2004, Tassone sits in a 19th-floor hotel room at Foxwoods' Grand Pequot Tower, broke. He's come to gamble with a friend, perhaps to climb back on the winning track again. But now he sits despondent and drinking in a hotel room -- with $25,000 just a few feet away from him, locked up in a safe. The money belongs to his buddy, who has cashed in his retirement, chasing a last big score with Tassone. Already, Tassone has blown through $1,000 his friend loaned him. But his mind is on all those big paydays of the past, the expense check he parlayed into a week-long binge and three weeks last summer when he could not lose at the craps tables.
     It's like this for compulsive gamblers, always thinking about that next shot at redemption. Except that now Tassone is under indictment for mail fraud, facing years in prison. Tassone is no longer welcome at Mohegan Sun, but here at Foxwoods the room is still comped. His friend, who has the safe combination, is down in the poker room. "One more time," Tassone says to himself, thinking that perhaps, somehow, he can win back all that money he has stolen and make it all right. "We were just going to play poker and try to make our way and try to build it up. The memories of those few big scores that linger out there are enough to keep you thinking I can do this one more time."
     Tassone calls maintenance and tells them he forgot the safe combination. Armed with the combination, he takes $4,000 and heads down for another session at craps, always his favorite game because piles of money are won - and lost - in minutes. After a few rolls of the dice, he blows through the $4,000 and races back to the room for another $6,000. He loses that, too. The tables are stone cold, but Tassone cannot quit. After an hour or so, he takes the last $15,000 and squanders it as this binge twirls into a final downward spiral.
     Staggering to his buddy's SUV out in the parking lot, Tassone finishes off a bottle of Tanqueray and gulps a handful of Trazodone, antidepressant pills he's been carrying with him for months. It's his birthday - March 12 - and the radio is blasting into the clear cold evening. Tassone dials a phone number and blacks out, alone in a car in a parking lot at the world's largest casino. The money is finally gone and there's no kindly blackjack dealer to nudge him awake so he can make another bet. They won't hold his mail for him, or take his laundry. The truth is, though, Tassone isn't so alone. On a typical Friday night, when upwards of 30,000 crowd the floors of Foxwoods, an estimated 4,500 are probably gambling compulsively.
     This time, Tassone leaves it all behind. An ambulance, alerted by his bleary call to a problem gambling hot line, rescues him and carries Tassone to a New London hospital, beginning a long journey to a place he has never been, a life apart from gambling. For now, home is prison -- where he will be until next summer -- where the days have a regimented boredom, the polar opposite of a casino's unpredictable excitement: read, mop floors, jog. He thinks about his children and a future career of counseling gamblers, where he can play a small role, perhaps, in saving others from a wretched gambling life like his.
     "To change the direction of my life after 30 years, that's hard," Tassone says during a recent interview. "I never felt like I had any other choice but to gamble. It's where I felt at home, it's where I felt safe. It's what I had done for so long. It was my identity, it was the easiest way not to deal with a whole bunch of things. "I don't want to romanticize any of this," he says. "When I was gambling I didn't have to think what a mess my life was."
     When he gets out, he will need money, and a lot of it. There is child support to pay and the $650,000 Tassone owes to Bright Horizons, plus hundreds of thousands of dollars more to friends, family and banks. But for Tassone, an addict, avoiding gambling is the biggest challenge of all. So every day, as he wonders about the future, Tassone returns to that endless tape of the gambling years. Sometimes he replays the comments he made to the judge last winter: "Living in the casinos and having them treat me like royalty ... I know today that I didn't set out to intentionally destroy my life or the lives of others. But I did." And always, there are those haunting, enticing words he can't get out of his head, words that now scare him to death: "Good evening, Mr. Tassone."




Study Links Teen Health, Early Stress
Associated Press, 11/29/2005

PORTLAND, Ore. -- Stress from abuse or neglect early in life may be linked to increased mental health problems during adolescence, according to a new study based on animal research. Children who have suffered abuse, neglect, or loss of a parent have an increased risk behavioral and emotional problems, including attention deficit and hyperactivity disorder, anxiety, depression, suicide and drug abuse, according to Oregon Health & Science University researchers.
      The study was based on rhesus macaque monkeys that were exposed to a stressful event before they were raised in a stable family environment. ''By studying a species that has responses to early-life stresses that are very similar to young children, we can get a developmental picture that is much clearer than in humans,'' said Judy Cameron, a senior scientist at the OHSU Oregon National Primate Research Center. Interpretations of human studies are often difficult because children experiencing early-life stresses frequently are exposed to many other situations that can influence behavior, Cameron said. The monkey study provides strong evidence that stress exposure early in life can have dramatic, long-lasting effects that persist into the teenage years and perhaps even adulthood, she said.
     The researchers studied 16 small social groups of monkeys for a three-year period. Because monkeys mature at a much more accelerated pace than humans, a monkey 2 to 4 years old would correspond to a human teenager. Certain monkeys were removed from their mothers at various stages early in life. These monkeys continued to be raised in the stable social groups with other monkeys -- similar to a human child who suffers the stress of losing a parent but continues to be raised in their family.
     The behavior of the monkeys appeared similar to children who develop a form of attachment disorder characterized by withdrawal from social interactions. Dr. Ronald Dahl, a University of Pittsburgh psychiatrist, said the study provided ''unique insights into these developmental interactions in ways that can not be achieved in controlled studies in humans.'' The research should help answer some important clinical questions about targeting early intervention for behavioral and emotional problems in youth, he said. The study was presented this week during the Society for Neuroscience meeting in Washington, D.C.




Older Anti - Psychotics Riskier for Elderly
Associated Press, 11/30/2005

NEW YORK -- Older anti-psychotic drugs are no safer and might even be worse for the elderly than newer ones that the government warned about earlier this year -- both raise the risk of death, a study suggests. The Food and Drug Administration asked drug makers in April to add warnings to the labels of newer anti-psychotics because studies showed the drugs nearly doubled the risk of death for older patients with dementia. These drugs are widely used to treat the aggressive behavior, delusions and hallucinations sometimes experienced by those with dementia, including Alzheimer's disease. Researchers at Harvard's Brigham and Women's Hospital in Boston worried that doctors would just switch elderly patients to older medications like Thorazine and Haldol.
      The researchers analyzed prescription and death records for nearly 23,000 older patients who took anti-psychotics. They found that 18 percent of patients on the old drugs died in the first six months, compared with 15 percent on the new drugs. ''If confirmed, our results suggest that conventional anti-psychotic medications should be included in the FDA's public health advisory,'' the researchers said. Their findings appear in Thursday's New England Journal of Medicine.
     Dr. Philip Wang, lead author of the study, said studies to determine the best way to treat behavior problems in the elderly are sorely needed. Doctors now rely heavily on tests done in younger people. ''All we can do is encourage clinicians to be thoughtful -- to balance whatever benefits there are with what appears to be risk,'' Wang said.
     William Thies, scientific director of the Alzheimer's Association, said he has not seen any evidence that doctors are switching to the older drugs. One of the concerns with the older drugs, he said, is their more severe side effects, including Parkinson's-like tremors and involuntary movements. While there may be a slight increase in the risk of dying, ''these medications are being used to treat a problem which is not trivial,'' Thies said.
     The newer anti-psychotics, such as Risperdal and Seroquel, came out in the 1990s and now account for 95 percent of the prescriptions for anti-psychotics, according to IMS Health, a pharmaceutical information and consulting company. The drugs were approved by the FDA for treating mental illnesses such as schizophrenia and manic depression, but doctors are free to use them for other problems.
     The study, using information from a Pennsylvania prescription program, looked at 22,890 people over 65 who began taking anti-psychotics between 1994 and 2003. Taking into account age, illnesses and other factors, the researchers calculated that those on the older drugs had a 37 percent higher risk of death. The risk was highest for those on higher doses and during the first 40 days of use. The causes of death were not disclosed. Heart problems and pneumonia accounted for most of the deaths in the studies cited by the FDA in its warning.
     On the Net:
New England Journal: http://www.nejm.org
Alzheimer's Association: http://www.alz.org



Competition Freaks
Marianne Szegedy-Maszak, Los Angeles Times- 11/30/2005

"WINNING isn't everything," Vince Lombardi famously said. "It's the only thing." For a particular group of competitors, Lombardi's one-liner is less a wry comment on cutthroat athletic competition than a simple fact of life. In boardrooms and bedrooms, in playing fields and universities, the hypercompetitive person appears — transforming even the most trivial transaction into a ruthless face-off with a winner and a loser.
     We know it when we see it. The squash champion father who introduces his 12-year-old son to the game by beating him 15 to 0, three games in a row. The ruthless queen bee who dominates her social group with cattiness and designer everything. The out-of-control soccer mom berating the referee from the sidelines; the husband banned from playing family board games because he ruins the game when he wins — and ruins the entire evening when he loses.
     Today, a broad array of recent psychological research has led some researchers to conclude that hypercompetitiveness resembles a diagnosable mental disorder — a volatile alchemy of obsessive compulsiveness, narcissism, neurosis and sometimes a dose of paranoia. Psychologists have even linked the hypercompetitive personality to such seemingly disparate conditions and behaviors as road rage, drunk driving, eating disorders, addiction and depression. It's a style and temperament that affects all other relationships and which, over time, becomes fundamentally impairing, causing fractured families, social isolation and even the disintegration of careers. Psychologists, therapists and psychiatrists are examining the forces that may create these personalities, and trying to figure out ways to better help them.
     Such win-at-all-costs behavior may be unsettling but, truth be told, it's not so very far from what our culture views as laudable. "We define the American dream as people pulling themselves up by their bootstraps," says Steven Eickelberg, a Paradise Valley, Ariz., psychiatrist who specializes in the psychology of high-performance competitors and whose clients include high-profile athletes and business executives. "But how many people do we walk over to be successful? When is this kind of competition admirable, and when is it pathological?"
     Nearly every day a story appears about a hypercompetitor dragging a company, or a team, or simply himself into a terrible mess. Only this month, Philadelphia Eagles wide receiver Terrell Owens was benched despite his magnificent performance while injured in the Super Bowl. Too many other times, his behavior was characterized by belligerence and vocal demands for attention. Owens recently complained that he didn't receive sufficient recognition for his 100th career touchdown reception during a game against the San Diego Chargers on Oct. 23. And when he thought that other players had been talking about him behind his back, he stormed into the locker room and challenged them to a fight.
     In fact, the pantheon of the hypercompetitive in American sports and business is littered with examples of bad behavior. In 1978, Oakland Raiders defensive back Jack Tatum, nicknamed "the assassin," hit another player so hard he became a quadriplegic. He not only didn't apologize but justified his action saying, "It was a clean hit."
     Then there's Albert J. Dunlap, a notorious chief executive who referred to himself as "Rambo in pinstripes." Dunlap's Agent Orange management style — which earned him the nickname "Chainsaw Al" — involved firing thousands of employees, demeaning anyone who disagreed with him and plowing through the company's assets. His actions helped bring Sunbeam Corp., which he took over in 1996, from a $1-billion company to Chapter 11 bankruptcy.
     At the core of every massive corporate unraveling, whether it is Sunbeam, Enron or the Helmsley Hotels, sits a hypercompetitive manager or CEO, says Barbara Kellerman, research director for the Center for Public Leadership at Harvard's John F. Kennedy School of Government and author of the 2004 book "Bad Leadership: What It Is, How It Happens, Why It Matters." "At a minimum, those whose competitiveness makes their reach exceed their grasp are ineffective and unethical; at a maximum they are downright detrimental to society," Kellerman says. Even without such public wreckage, there is something unsettling, even alienating, about the person who just can't seem to turn it off — for whom a game of Candyland with the kids is played with the same intensity as a championship tennis match.
     Hypercompetitiveness may be behaviorally inevitable, says UCLA evolutionary biologist Jay Phelan. That's because some degree of competitiveness is a very human trait. "We are built for always wanting to do a little bit better and accumulate more," says Phelan, coauthor of the 2000 book "Mean Genes: From Sex to Money to Food, Taming Our Primal Instincts." As humans, we have evolved to be competitive, he says. But some people are at the extreme end of the spectrum and compete to extremes. Because the world today is so much more complex, Phelan says, we have myriad more ways to compete — when we drive, shop and work and through the clothes we wear, the houses we buy, even the friends we have. But there's a difference in degree and tone between being competitive and hypercompetitive — one that clinicians believe may be rooted in questions of motivation, self-control and self-worth.

Driving forces
Psychologists have long understood that the source of motivation for everyone — athletes, dieters, you name it — can be rooted in either an internal quest for excellence or an external motivator such as a trophy, money or fawning recognition from others. Internally motivated people are less likely to be hypercompetitive. They lack that constant push for recognition.
     In contrast, studies suggest that external motivation is central to the hypercompetitive psyche. A 2003 study of 319 young athletes in Texas underscores the influence of these inner and outer types of motivation. Published in the Journal of Psychology, it tried to predict from questionnaires whether an athlete would be a good sport, a graceful loser, a good team player, and someone eager to learn from mistakes and losses rather than acting defensively or angrily.
     The researchers found that sportsmanship didn't relate to what the sport or activity was, or even how intensely competitive the event might be. What mattered were qualities associated with internal motivation — such as enhanced self-esteem and a desire not to win but to master the task. In contrast, the athletes who said in a questionnaire that they participated in sports for external rewards such as social status and beating a competitor also scored as less sportsmanlike. They were also far less effectively competitive, losing focus and lacking internal self-discipline. Those who are externally motivated often think "their self-worth is contingent on winning," says John Tauer, a professor of psychology at the University of St. Thomas in St. Paul, Minn., who has studied achievement and internal motivation. "When they start any activity, their first thought is, 'I need to win.' "
     Motivation isn't the only thing that shapes a pathological competitor. Another noxious ingredient may be needed, according to a study published in the Journal of Personality Assessment in 1997. Richard Ryckman, a psychologist from the University of Maine, and coauthors conducted psychological surveys of hypercompetitive and healthily competitive undergraduates. They found that both groups scored high on measures of achievement and striving for an exciting, challenging life. The answers of the hypercompetitive people, however, indicated that they valued "power and control over others." Their responses, unlike those of the healthy competitors, also exhibited lack of care and respect for others. "The gist of this kind of competition is self-aggrandizement at the expense of others," Ryckman says.
     Contrast this with the mind-set of world-class competitor Lea Antonopolis-Inouye, now a financial planner in Huntington Beach, who played professional tennis from 1977 to 1988. In 1977, she was the junior Wimbledon champion. She played Wimbledon for the next 10 years, and competed in the U.S. Open and the French Open. As a head tennis pro at a private tennis club for two years, Antonopolis-Inouye says, she was confronted day after day with an abundance of noxious competitiveness. People jockeying for particular courts and trainers. Erasing names from the roster of practice courts and replacing them with others. She recalls one man at a tournament loudly demanding a forfeit because another team was 15 minutes late for a match. After a relentless half-hour, Antonopolis-Inouye gave his team the win he wanted. Yet, she says, real victory, the one that she tasted on the Center Court in Wimbledon as a junior, "is a by-product of super-hard work and dedication and being driven to perfection…. You can't just win. You have to forget about winning and work on other things."
     On the professional tennis circuit, Antonopolis-Inouye befriended such stars as Chris Evert and Steffi Graf, and observed that their competitive greatness was not predicated on a simple need to win or a fiercely competitive nature. Their goal, instead, was to achieve perfection of play and execution for themselves. "The most successful athletes that I have known have absolutely no irrational competitiveness," she says.
     Antonopolis-Inouye is speaking a foreign emotional language for the hypercompetitive person. After all, there is no doubt that being hypercompetitive often pays — and sometimes handsomely. Those punctual tennis players at the private club notched a win on their rosters. Former Tyco International CEO L. Dennis Kozlowski, superstar athlete Michael Jordan, even the imperious hotelier Leona Helmsley all have been held up as examples of hypercompetition by those who study the trait, and all reached stratospheric heights of money and influence. (Until, for Kozlowski and Helmsley, the fall came.) "The take-no-prisoners competitors can be very successful much more rapidly than win-win competitors, mainly because they are obsessed, single-track and totally focused on their own desired result," says Denis Waitley, former chairman of psychology for the U.S. Olympic Committee's Sports Medicine Council and president of the Waitley Institute in Rancho Santa Fe.

Why's it so bad for people, then?
"The problem? This obsession on winning and beating the competition becomes a reflex habit," Waitley says. That reflex is extremely difficult to control. Stuart Krohn, coach for the Santa Monica Rugby Club, recalls of his former hypercompetitiveness that "everything was a battleground — a ping-pong table, a conversation. I could feel the blood start to rush, and I could feel myself reacting to something that I shouldn't have reacted to." Even as a kid, he says, "it was all about winning."
      Krohn's competitive nature did reap returns. He played rugby internationally for decades, winning two world championships. Now 43, he led the Santa Monica club to win, last season, its first national championship in more than 20 years. But, he says, he also had to win every argument with his girlfriend, turned conversations at dinner parties into intense competitions, and nurtured a rage and hatred for other teams and referees that was sometimes overwhelming.

Relationship troubles
Hypercompetitive people typically may succeed in many parts of their lives, but interpersonal, especially intimate, relations are often deeply troubled, says psychiatrist Eickelberg. A 2002 study in the Journal of Social and Clinical Psychology examined romantic relationships of hypercompetitive people and found these people "reported lower levels of honest communication with the partner, greater infliction of pain on him or her, stronger feelings of possessiveness, higher levels of mistrust, stronger needs to control their partner, lower ability to take their perspective, and higher levels of conflict."
     Despite this list of problems, hypercompetitors tend to lack both insight and empathy and rarely enter the door unless a crisis or an ultimatum shoves them through it, psychologists say. It typically happens in middle age. Many, Eickelberg says, enter his office and announce, "My wife said I had to come." Others see enormous successes and achievements interrupted by jarring moments of reckoning: burnout, depression, divorce, a rift with a child, hitting a wall. A wake-up call eventually intrudes on the self-absorbed drive to win.
     Clinicians who work with hypercompetitive individuals say treatment is a long, hard, therapeutic slog. When winning has been paramount for one's entire life, the therapeutic dialogue is likely to be characterized by anger, challenges and endless jockeying for dominance with the therapist. The very dynamics that a spouse or partner in life found intolerable are in florid display in a therapeutic setting. The empathy gulf can be huge. Eickelberg sometimes asks his patients to figure out what a spouse is thinking or feeling. "I often get the response, 'I drew a blank' or 'I think she was doing good.' … Gradually you see that these are people who probably lack a healthy capacity to understand other people. And that is where you begin." Slowly, through a combination of good old-fashioned talk and behavioral therapy, a transformation can gradually take place. A hypercompetitor decides to volunteer in a school for disadvantaged kids, or devotes less time to the office, or reaches out to a spouse or a child in ways that were impossible before.
     This is not to say that all hypercompetitors will always come to some moment of truth. Kellerman, of the Center for Public Leadership, says: "There is no inevitability that these people have to fall in some way. We know that for every person who is caught, or who faces some great trauma in their lives, there are scores of others who don't."
     Life did change for Krohn — in his 35th year. His girlfriend dumped him, he says, because he was so intensely competitive with her. Then another thing happened that opened his eyes: A younger, less-experienced teammate was badly injured in a scrum. Only miraculous medical care prevented him from becoming a quadriplegic. Krohn visited his teammate in the ICU every day. "This guy was … fighting for his life, and I sat there with a lot of time to think," he recalls. "I finally realized that this is a game. I realized that everybody is not against me and life is not a full-time competitive arena."
     Krohn hasn't turned into a pussycat: He's still a "yeller" at practice and on the sidelines. Team members say he pushes players sometimes to the breaking point. But he has now been happily married for two years and says he approaches competition in a very different way today than he did eight years ago. In addition to coaching the Santa Monica rugby team, he is one of the founding teachers, and of course rugby coach, at View Park Prep Charter School in the Crenshaw district. He says with some pride that they haven't won a game in three years and they attract the kids who aren't doing other sports. "When I'm coaching the kids, I don't focus on winning above their character and their attitude toward the sport," he says. "They have to get that right first." He pauses briefly. "I didn't get that when I was a kid."