Noteworthy News Articles on Mental Health Topics, March 23-26, 2006 Shari Roan, Los Angeles Times- 3/23/2006 When a panel of medical experts voted last month to recommend a safety warning on medications used to treat attention-deficit hyperactivity disorder, Dr. Adelaide Robb could have predicted the public's response: panic. The government-appointed panel's conclusion — that the drugs may increase the risk of sudden cardiac death — hit the newspapers on a Friday morning. "By Monday morning, we were getting phone calls from parents who said things like 'I threw the medicine down the toilet, and now my kid is out of control,' " says Robb, a child and adolescent psychiatrist at Children's National Medical Center in Washington, D.C. "There was so much misinformation and fear." Experts such as Robb, as well as parents of kids with ADHD and many adults who take the medications, are hoping for a more reassuring word from a different group of medical experts who on Wednesday in Washington will take up the cardiac safety issue once again. The committee that convened last month was composed mostly of experts in heart disease who had met to discuss reports of sudden cardiac events linked to ADHD medications. Between 1999 and 2003, 25 people had died suddenly, and 54 suffered serious cardiac events such as a stroke, heart attack, hypertension or arrhythmia, while taking the medications. Nineteen of the deaths were among children and teenagers. The experts had been asked to advise the Food and Drug Administration on how to study the potential risk, but they stunned observers by criticizing, instead, the number of prescriptions written to treat ADHD and voting 8 to 7 to recommend the medications carry a black box warning on the risk of cardiovascular problems or death. A black box warning is the strictest safety warning imposed on prescription drugs and often results in a decline in prescriptions written for a product. Most experts agree that the potential cardiac risk in children and adults, and other possible risks, should be studied. The drugs can increase blood pressure and may be riskier in adults with heart disease, or children with structural heart defects. But some feel the committee overstepped its mandate. "This particular FDA committee had really gone beyond their bounds and, in a sense, became a renegade committee," says Dr. Andrew Adesman, chief of developmental and behavioral pediatrics at Schneider Children's Hospital in Lake Success, N.Y. "They took it upon themselves to make this black box warning." The discussion may unfold differently at the Wednesday meeting, in which a pediatric advisory committee will discuss safety issues, including the potential cardiac risk as well as a possible risk of suicidal thinking associated with some ADHD drugs. At issue is whether the deaths and cardiac events among ADHD users are clearly linked to the medications. About 2.5 million children and teens take ADHD medications. Most of the drugs contain methylphenidate, found in Ritalin and Concerta and many generic ADHD medications. An estimated 1 million adults also take the medications, which can help children and adults focus and control restlessness and fidgeting. But no one is sure whether the number of cardiac problems reported to the FDA is unusual, Adesman says. The rate of such problems in these children taking ADHD medications appears to be no higher than among children in the general population. "We don't have any data to suggest that the rate of serious adverse events is increased with these medications," he says. Uncertainty over risks Moreover, some experts say, it's unclear whether the people who died had other cardiac risk factors or were taking other medications that could have played a role in their deaths. Some committee members who voted for the warning explained they wanted the public to know there is uncertainty surrounding a cardiac risk. One panel member, Dr. Steven Nissen, a respected cardiologist at the Cleveland Clinic and the new president of the American College of Cardiology, also noted during the hearing that he thinks ADHD medications are overprescribed. But, says Robb: "Dr. Nissen is not a psychiatrist, doesn't know anything about ADHD and doesn't treat kids." Dr. Leonard Sax, a family physician and psychologist who has studied ADHD prescribing patterns, says the debate surrounding overuse of the drugs is a legitimate one. Sax thinks the medications are too often doled out to young children, especially boys, who are not developmentally ready for the rigors of today's kindergarten and first-grade curricula. "Too often these drugs are used for behavioral control, not to treat real ADHD," says Sax, who practices in Montgomery County, Md. Still, he says, this is a separate issue from the question of adverse events, and the February panel meeting was not the right forum for discussing it. "Calling attention to the extraordinarily rare cardiovascular consequences to get at [over-prescribing] is muddling the issue," he says. Methylphenidate has been in use for more than 50 years with good success, and its benefits have been noted in more than 200 studies, says Dr. Laurence Greenhill, a child psychiatrist and chairman of a committee appointed to study the issue by the American Academy of Child and Adolescent Psychiatry. Studies show that medication, along with behavior and cognitive therapy and a supportive school environment, is often the best strategy to treat the disorder. Research also shows that children and teens with ADHD who are not treated have a higher risk of failing school and of engaging in criminal behavior, and have more trouble making and keeping friends. The FDA may agree to another recommendation made by last month's advisory committee to provide an informational booklet on safety issues with all ADHD medications. However, an FDA official expressed doubts about the wisdom of the black box recommendation. "We don't usually write a black box for something there isn't pretty good evidence for," said Dr. Robert Temple of the FDA's Office of Medical Policy. Some doctors say the controversy is regrettable. "Now you have 2.5 million parents worrying about something where there is probably no reason for them to be worrying," Adesman says. "Physicians throughout the country were flooded with phone calls. And there are families who, despite reassurances from their physician, will have unnecessary cardiac evaluations or will take their kids off the medications." Nancy Starke was among the worried parents. When she heard about the cardiac risk, she dashed off an e-mail to her daughter's doctor. "It alarmed me," says Starke, who lives in Los Angeles. "But I also thought there was probably more to the story." Starke's daughter's doctor reassured her that the risk, if it even exists, is extremely low. That's good news, Starke says. "The medication makes her so much more productive and helps her attitude." Teri Burley, the mother of two teenage sons with ADHD, took a deep breath when she heard the news. But, as a leader with a local chapter of the nonprofit support group Children and Adults with Attention Deficit/Hyperactivity Disorder, Burley says she has learned to do her own research. "I get on the Internet and look for information," the Placentia woman says. "I call doctors. I get second and third opinions. Sometimes I call drug companies and ask for more information. I try to do the research and then make a choice." Burley opted to keep her sons on medication. "I think the risk is very slim and that the benefits outweigh the drawbacks. And no medication is perfect." Many parents are initially reluctant to put their kids on stimulant medications and remain uneasy about the treatment, Robb says. The current controversy may add to their hesitation. "It also scares people from coming in for treatment," she says. "Instead they don't do anything and the kids continue to struggle." * A medication used to treat the sleep disorder narcolepsy may soon be approved to treat attention-deficit hyperactivity disorder. A Food and Drug Administration advisory committee will review the safety and effectiveness of the drug, which is known by the generic name modafinil, at a hearing Thursday. Cephalon, the maker of modafinil, now sells the medication under the brand name Provigil for narcolepsy, which is an extreme tendency to fall asleep during normal daytime activities. But studies have shown that the medication also helps people with ADHD. In a report published in the December issue of the journal Pediatrics, children and adolescents taking the medication in a randomized, double-blind study showed significant improvement in such symptoms as inattention, impulsivity and hyperactivity. About 48% of the patients taking the medication were rated as "much" or "very much" improved by their doctors compared with 17% of the patients taking a placebo. The drug did cause side effects in some children, including insomnia and decreased appetite, according to Dr. Joseph Biederman, lead author of the study and professor of psychiatry at Harvard Medical School. If approved for treating ADHD, the drug would be sold under the name Sparlon. The medication is a stimulant but is chemically different than Ritalin, which is a brand name for the generic drug methylphenidate. Art Therapy: The Healing Canvas Jenny Hontz, Los Angeles Times- 3/23/2006 Six women sat at a table covered with colored pencils and pastels, each of them focused on drawing a house with rooms representing their emotions and desires. Susan St. Jon, 63, made an abstract sketch of an African jungle home, with a circle of blank space in the center of the page. It reminded her of a vacation house in which she'd watched wild animals creep dangerously close. The white space, she surmised, was a window onto her uncertain future. "Wherever it's going to take you, it's going to take you," she said, "regardless of what you do." The assignment was part of an art therapy support group at UCLA's Ted Mann Family Resource Center. On this, St. Jon's third bout with cancer — the disease has spread from her breast to her brain and lungs — she's struggling to decide whether to pursue chemotherapy or give up the battle. "I've already come to terms with death," she said. "I won't panic, and I won't be pushed." Art therapy harnesses the creative process to explore such difficult issues. It's been used to treat mental and physical health problems for more than 50 years and is offered in schools, hospitals, prisons, hurricane shelters and private practice. But only now are scientific studies beginning to show its effectiveness. In art therapy, patients express their feelings not just through discussion, but through drawing, painting and sculpting. That's why this type of therapy is thought to be especially helpful for people who have difficulty articulating feelings — including children and those suffering from Alzheimer's disease, strokes and post-traumatic stress disorder. However, much of the research has centered on cancer patients. In a pilot study funded by the National Institutes of Health, cancer patients who received eight weeks of group treatment sessions of mindfulness-based art therapy (a combination of meditation and art therapy) reported a significant decrease in distress, anxiety and depression. They also reported significantly improved quality of life and vitality. The study of 111 women, published last fall in the Journal of Psycho-Oncology, did not determine whether the art therapy or meditation component was most beneficial, but "one informs the other," said study author Daniel Monti, director of the Center of Integrative Medicine at Thomas Jefferson University in Philadelphia. "The two sort of work together." A Northwestern Memorial Hospital study of 50 men and women published in January in the Journal of Pain and Symptom Management found that an hour of art therapy significantly reduced a broad spectrum of cancer-related symptoms such as pain, anxiety, exhaustion, depression, loss of appetite and shortness of breath. Patients rated symptom severity on a scale of 0 to 10 before and after treatment; only nausea was unaffected. "A lot of people look at art therapy with suspicion. Is it just a diversion, doodling or baby-sitting?" said American Art Therapy Assn. director Cathy Malchiodi. "With research, doctors are seeing how much progress patients are making, and they realize it's not just entertainment." That's not to say that art therapy is for everyone. Although therapists emphasize that patients don't need any artistic talent to reap benefits, some people feel uncomfortable expressing themselves through art. In the Northwestern study, 63 patients who were approached declined to participate. Some were too sick, but at least one person had tried art therapy before and simply didn't like it. Others prefer tackling problems on an intellectual level, sometimes finding the emotions stirred up by art therapy difficult to tolerate. "It's not really my cup of tea," said UCLA cancer support group member Caren Desacoff, 54, whose drawing of a house triggered memories of her unhappy childhood. She left the group early after starting to have a seizure. "I shouldn't have been there. I really did feel kind of overwhelmed. I was going into a really dark place." Most members of the UCLA group, however, described art therapy as relaxing, energizing and cathartic. "It was the most important nonmedical thing I did," said breast cancer survivor Kerry Smallwood, 49, who attended for more than a year. "It was very powerful how the artwork accessed deeper emotions, things that were unconscious, things that you didn't necessarily think to talk about." Monti, who conducted the NIH-funded study, is currently overseeing another five-year study comparing mindfulness-based art therapy with talk-based support groups for 339 breast cancer patients. It is the largest comprehensive study on art therapy to date. Already, pilot data suggests that the art therapy is more effective in reducing stress and depression. The reason, Monti posits, is that meditation and art making, when combined with discussions about the meaning of the art and the feelings evoked, engages more of the brain than merely talking. "It provides a means of conceptualizing and expressing the illness experience and ways to cope," he said. Monti also plans to perform brain imaging research on a subgroup of cancer patients in the study to determine precisely how art therapy might affect the circuitry of the brain. Brain matters Psychiatrists already have strong theories about how art therapy works, especially as it relates to trauma treatment. Allan Schore, associate clinical professor of psychiatry and biobehavioral sciences at UCLA's School of Medicine, says that traumatic and stressful memories are stored in the right hemisphere of the brain, which processes emotions, visual and nonconscious information. The left brain controls logical thinking and verbal skills. But for therapy to be effective, "it has to get into the right brain," Schore said. Creating art is a fast way to access the right brain and the emotions stored there. "Saying I'm scared and angry is one thing. Taking a crayon and scribbling on a piece of paper is a visceral way of not just saying it, but experiencing it," said Jan Oxenberg, a TV writer who tried art therapy after she was involved in a shooting during a civilian ride-along with the LAPD. While making art activates the right brain, talking about it and constructing a coherent story about the traumatic experience activates the left hemisphere as well. Integrating the two leads to healing. "What is expanded is the interconnectivity of the brain," Schore said. Interest in art therapy for trauma has skyrocketed in recent years because of world events such as the Sept. 11 attacks, the Asian tsunami, Hurricane Katrina and the Iraq war. According to Malchiodi at the American Art Therapy Assn., membership has grown from 4,000 to 4,500 since Sept. 11, and many art therapy programs are having to turn away applicants. San Francisco art therapist Linda Chapman, creator of a model for treating pediatric trauma patients, conducted a 2001 UC San Francisco study of 85 hospitalized children and adolescents suffering from trauma after violence, abuse, accidents and chronic illnesses. Results were published in the Journal of the American Art Therapy Assn. Chapman found that art therapy significantly reduced some of the acute symptoms of post-traumatic stress disorder one week and one month after discharge from the hospital. However, it did not reduce the symptoms of PTSD compared with control groups at a six-month follow-up. Chapman said it was impossible to control whether participants had suffered additional traumatic experiences and that more research is needed. In fact, a large study of art therapy for veterans with PTSD is in the planning stages. Stanford art therapy researcher Kate Collie and a committee of the American Art Therapy Assn. are designing the study, which may include recent Iraq War veterans, one of eight of whom exhibit signs of PTSD, according to an Army survey. The long-term goal is a clinical trial. A small 1997 study of in-patient Vietnam veterans with PTSD published in the Journal of Traumatic Stress compared the effectiveness of a single session of 15 different treatment methods administered to 25 veterans over 16 weeks. Art therapy was the only treatment method that reduced PTSD symptoms in the most severe patients. Researchers theorized that it not only provided a distraction, but it helped vets deal with traumatic memories at their own pace. Pacing is also crucial for young trauma victims, who can get overwhelmed recounting frightening experiences. By choosing specific art materials, therapists can help children experience their emotions in small, manageable doses. Chapman often starts with No. 2 pencils and tiny pieces of paper. The familiar tools and their manageable size give kids a sense of mastery and control — over the art and over their feelings, she said. In fact, when young trauma victims are given a choice of No. 2 pencils, colored pencils and markers, they often pick plain pencils. That's because color evokes emotion, Chapman said. Used correctly, however, color can be a powerful tool. When Chapman worked with kids in pain, she would ask them to paint the color of pain onto a drawing of the part of the body that hurt. Most kids would choose red or black. Next she would have them pick a color to take away their pain, usually blue or white. Chapman found the simple act of painting over the problem area would soothe them. Revelations and renewal Art therapy can be an especially useful diagnostic tool with kids and others who have a hard time talking about feelings. Art therapist Esther Dreifuss-Kattan, who leads the art therapy group at UCLA's Ted Mann center, also works with the university's Pediatric Pain Program. She recalls one teenager whose drug addiction was revealed in a single session. Although he said he "had pain all over," doctors could find no cause. But then he created a collage of a monkey with a skeleton on its lap. He told Dreifuss-Kattan, "When you take drugs you feel like a skeleton." "Millions of things come up with one picture that would take three months when you just talk," she said. "You go to a level of depth so fast." Art therapist Delaine Due, who works in a youth correctional facility in Oregon, has found that combining art therapy with journaling helps inmates reveal incidents and feelings they might normally find too uncomfortable to share with others. One boy in her group recently created a drawing with the word "Failure" in red on a black piece of paper. In his journal, he wrote about falling short of his mother's expectations. "If you just ask questions, you would not get that type of information," she said. "But with 15 minutes to sit with it and get the whole brain and body involved, it's a better intervention." Involvement of the body is a main difference between art and traditional psychotherapy. Physical activity — particularly the act of creation — can combat depression, said Noah Hass-Cohen, director of Phillips Graduate Institute, one of two art therapy schools in the Los Angeles area. "When we're depressed, we tend to be able to do less," she said. Making art is a safe way for people to jump-start their brains and bodies after a period of lethargy and inaction. Toni Morley and Angel Duncan, codirectors of the Memories in the Making Program at the Alzheimer's Assn. of Northern California and Northern Nevada, have documented positive effects of fine arts on men and women with dementia. Patients had a limited ability to verbalize their feelings, so observers recorded signs of emotion and compared the effect of attending two separate activity groups. Those in a watercolor painting group displayed more positive emotions and little sadness, anger and agitation compared with a group that discussed current events. One African American man from Louisiana, who was depressed when he joined the art group, painted his childhood farm home entirely in black. Within a month, he was painting in color and saying how much he looked forward to it. The art also helped some patients recall long-forgotten memories. One generally nonverbal woman with Alzheimer's painted a pale pink flower. When Morley asked if she'd seen the flower before, she put her hands on her hips and said, "Well, my dear, for my 30th anniversary, I booked a trip to the Hawaiian Islands. The flower grows everywhere on the Hawaiian Islands." If not for the painting, such memories probably "would not have come back," Morley said. A growing support group The benefits of making art extend to people who aren't suffering from emotional or physical problems, and a therapist is not necessarily required either. Older adults, for example, have been shown to improve their general health, mental health and social functioning through community-based art programs. In a 2001 study of 300 people ages 65 and older, Gene Cohen, director of the Center on Aging, Health and Humanities at George Washington University in Washington, D.C., found that art gave study participants a sense of accomplishment, boosted the immune system and decreased loneliness. Those who participated in art groups also had fewer doctor visits and used less medication than those in control groups. "Art is like chocolate to the brain," Cohen said. "It taps into both sides. It has benefited the soul of the species since the time of cavemen or before." Of course, that raises a fundamental question about art therapy: How much of the benefit derives from the art and how much from therapy? "There's always a dynamic tension between the two," said Paula Howie, president of the American Art Therapy Assn. Some programs emphasize one more than the other, and no one knows for certain which methods work best. At UCLA's art therapy cancer support group, the time is split evenly between making art and discussing emotional issues. After St. Jon disclosed that she might not seek treatment, art therapist Dreifuss-Kattan urged her to reconsider. She also offered a less fatalistic interpretation of the tunnel-like center of her sketch. "For me, the space here gives an opening, a possibility for a way through the jungle," she said. "It's a protected, quiet, contained area, but not enough to stay here because the lion might creep up." Group member Desacoff chimed in to add support. "I see a bridge," she said. "I see hope. I think there's brightness in your future." Creative therapy resources • For more information about art therapy, contact the American Art Therapy Assn. at (888) 290-0878 or http://www.arttherapy.org . • To find a licensed art therapist near you, go to http://www.arttherapistlocator.org Ronald Kotulak, Chicago Tribune- 3/24/2006 The discovery that the brain undergoes a second growth spurt during adolescence has potential implications not only for teen driving but also for other behavioral problems that have their roots in this period of development. Just as bad experiences or the absence of proper stimulation can stunt a young child's brain during the first surge in brain growth, too much of the wrong kind of stimulation may adversely affect the vulnerable adolescent brain, researchers say. For example, brain-imaging studies show that if normal, healthy adolescents are exposed to violent videos for a long time, they show similar neural network patterns in the areas governing emotions and self-control as youngsters who are chronically aggressive, according to two Indiana University School of Medicine researchers. Viewing violent videos does not turn all adolescents into aggressors, of course. But scientists now want to know what might make some youngsters more vulnerable to aggression after watching violent scenes. "The brain is reacting biologically to the experiences that the teenagers are having," said clinical psychologist William Kronenberger, who worked with radiologist Dr. Vincent Mathews on the study. Heavy marijuana smoking also can restructure the adolescent brain in ways that are disturbingly similar to the neural pathways found in schizophrenics, said Dr. Sanjiv Kumra and Dr. Manzar Ashtari of the Albert Einstein College of Medicine in New York. Like the Indiana team, the researchers used magnetic resonance imaging, or MRI, to peer into the brain. In this case they compared the brains of adolescent schizophrenics and healthy teens who had smoked marijuana heavily for a year. Repeated exposure to marijuana, they found, might interfere with development of the fiber bundles connecting the brain area that processes speech to the frontal cortex where executive decisions are made. "The same pattern of abnormalities that you could see in schizophrenia you could also see in adolescents who don't have schizophrenia but who just smoke marijuana," Kumra said. Several studies of adolescent marijuana smokers suggest that they are two to four times more likely to develop schizophrenia than non-smokers, she said. Drug Tally Shoots Down a Racial Myth Michael Levenson, Boston Globe- 3/25/2006 A new report by the Boston Public Health Commission explodes the myth that drug abuse is centered in the city's minority communities, indicating that while whites make up half of city residents, they comprise two-thirds to three-fourths of those who have died from drug abuse in recent years. The figures show the deadly grip of heroin, OxyContin, and other drugs tightening in Boston, where 50 percent more residents died from drugs in 2003 than in 1999, the time period covered by the study. Of the 145 drug-related deaths in 2003, most from overdoses, 94 of victims were white, 32 black, and 19 Hispanic. The gap between whites and minority group members in drug-related deaths persisted over the five years studied, although the size of the difference fluctuated. Death rates rose for all racial groups studied: whites, blacks, and Hispanics. Rich Barlow, Boston Globe- 3/25/2006 The pioneering psychoanalyst Carl Jung noticed something about mental illness. ''Among all my patients in the second half of life -- that is to say, over 35 -- there has not been one whose problem in the last resort was not that of finding a religious outlook in life." Jung's observation, quoted by psychoanalyst Kathryn Madden at an MIT conference last week, goes to an idea that has spurred three academic events in Greater Boston in recent months: the spiritual aspects of mental health and mental illness. ''Jung recognized that many deep psychological problems of the adult in treatment, including depression, were essentially problems of meaning and that addressing problems of meaning was the natural bailiwick of religion," Madden said in remarks prepared for the conference, the major sponsors of which were Boston's Trinity Church and the Technology and Culture Forum at MIT. Michigan Faltering in Prevention of Child Abuse Sharon Emery, Ann Arbor News- 3/26/2006 LANSING - Budget cuts, staff shortages and growing needs among financially struggling families have forced Michigan's child welfare system to all but abandon abuse and neglect prevention efforts and instead focus on cases where children already have been harmed, child advocates say. They point to the slicing of at least $12 million from family preservation and prevention services over the past six years, even as the state's economy tanked and investigated cases of abuse and neglect increased to more than 72,000 last year. Six out of every 100 Michigan children now live in a home investigated for potential abuse or neglect. At the same time, Department of Human Services caseworkers were among state employees cut in money-saving moves; child protective services remains 130 caseworkers short, DHS officials say. The result is a bottom-line litmus test of whether the state gets involved in a case, advocates say. "Cases that are marginal - worrisome, but not abusive or neglectful - just get screened out,'' said Sandra Frein, a member of UAW Local 6000, which represents caseworkers statewide, and a longtime child protective services caseworker in Ottawa County. "Think about it: If you have one case where there are some vague concerns about the home but no allegations, and then another case of a child with a black eye, which child are you going to assign (to your caseload)?'' DHS Director Marianne Udow insists that prevention efforts remain a key priority. She cites the 39 family resource centers in schools throughout the state that bring caseworkers into direct contact with families. But she acknowledges that things aren't what they used to be. "Staff are strained to do prevention services - there's no question, they're not able to do as much as they'd like to,'' Udow said. "But when budgets get cut, prevention is one of those things you cut. That's so short-sighted.'' The long-term effects of abuse and neglect are well-documented, advocates say: physical impairment, mental problems such as depression and lack of impulse control, low self-esteem, post-traumatic stress disorder. Citing the need for prevention measures, state Attorney General Mike Cox last week called for legislation to require protective services workers to investigate any home with children where police have responded to a domestic violence complaint. He noted studies show strong links between domestic violence and child abuse. "I don't know how we can have a child welfare system that can turn away from this service,'' Cox said. As for the additional caseworkers likely needed, he said that was for lawmakers and DHS to work out. Gov. Jennifer Granholm has called for 51 more CPS workers in her 2007 budget proposal, which lawmakers are considering. Her budget doesn't include additional funding for prevention programs, advocates say. Several key family preservation and abuse prevention programs now run solely on federal funds, including Families First and Strong Families/Safe Children, according to the advocacy group Michigan's Children. But even the federal money - funded through the Temporary Assistance to Needy Families program - is threatened by new federal rules that require states to ensure that 50 percent of the people receiving cash assistance are working or in training. With Michigan's work-participation rate at around 23 percent, prevention funds likely will be redirected, child advocates fear. One of the most popular programs under siege is the Zero to Three Secondary Prevention program, which operates in 44 counties - down from 63 - and requires a 25 percent local funding match. K.P. Pelleran, state director of Fight Crime: Invest in Kids Michigan, which represents 298 police officials statewide, recently pleaded with lawmakers to reinstate money for the program. It funds local services, such as home visits, parenting classes and child care, to families with children age 3 and younger at risk of abuse or neglect. "As the debate continues for the need to increase the number of child protective service workers and foster care placements, one cannot overlook the fact that in order to qualify for such state services, children must first be abused or neglected,'' Pelleran said in a statement. "That is the saddest qualifier for these limited state services.'' Once funded in the state budget at nearly $8 million, the program is now down to $4.8 million. And I'd Like to Thank My Coach Mireya Navarro, New York Times- 3/26/2006 Whenever Bryce Dallas Howard teased her dad, the actor and director Ron Howard, about how much actors are paid, he'd say, "It's so that they can afford their therapist." But decades after her father made it in Hollywood, Ms. Howard, 25, is making her own way in acting, and she's therapist-free. She sees a life coach instead. Ms. Howard, who is on location filming "Spider-Man 3," said her coach helps her navigate the demands of show business on her own terms, including making time for writing and protecting a degree of privacy during press interviews without losing her cool. "It's not about rehashing the past," said Ms. Howard, who said she's "really into self-improvement." She called Sherri Ziff Lester, her coach, after a manager friend passed on her name last year. "With Sherri," she said, "it's, 'Let's talk about this week.' She asks me a series of questions so that I see my priorities and decide what I need to do." Life coaching has become a staple on television, with coaches helping sort out the lives of single men, ugly ducklings, sexually unsatisfied wives and other women in shows like "Nip/Tuck," "The Swan," "Starting Over" and "Modern Men." Life coaches, with their vague self-helpish title, have also come in for considerable skepticism and ribbing. "The Daily Show With Jon Stewart" just this week devoted a sketch to poking fun at the coaching and "coachees" who become coaches themselves. But behind the scenes life coaches are also finding plenty of work in the entertainment business. As their ranks swell nationwide — the International Coach Federation says its membership has doubled to 9,500 personal and business coaches since 2001, 56 percent of them in the United States — a growing roster is specializing in celebrities and Hollywood. Although the federation does not keep track of coach specialties, coaches who devote themselves to the entertainment business — many of them former actors, television network executives, film producers or scriptwriters who sell their services as insiders — say they have seen more acceptance and a doubling and even tripling of demand for their services in the last three or four years. Life coaches, who are unregulated and vary widely in their training and credentials, say they help clients define and pursue career and personal goals. The action- and results-oriented approach, they add, is appealing in a business where so much seems left to chance and few are prepared for success when it happens. In a profession with a propensity for coaching — the acting coach, the voice coach, the writing coach — there appears to be room for one more coach, the one in charge of happiness, not to be confused with the old-school therapist. "The difference between life coaching and therapy is that psychotherapy is about helping people heal their wounds," said Phil Towle, a psychotherapist and life coach, "and coaching is about helping people achieve the highest level of their fulfillment or happiness or success, whether they're wounded or not." Mr. Towle's work (at the rate of $40,000 a month) with quarreling members of the band Metallica was chronicled in the 2004 documentary "Metallica: Some Kind of Monster." Performers, directors, writers and others can now find workshops and programs with names like Center Your Celebrity and War and Peace in the Writers' Room, and they can find certificates for free coaching sessions in gift bags at events like the Oscars and the Video Music Awards. Coaches say personnel officials at studios and production companies are also increasingly calling on them not just to groom executives in management skills (the traditional use of executive coaching in major corporations), but also to troubleshoot in situations like helping a young producer handle personality and power clashes on a production. Scott Zakarin, 42, a film and television producer who most recently produced the reality series "Kill Reality" on E! and "The Scorned," the movie spawned by the show, credits his coach with saving his company. He said he turned to a life coach, David Brownstein, a few years ago because of confrontations and finger pointing in his production company and now has Mr. Brownstein on call as he strives to run his business without subsuming what he calls the visionary nature of his work. Mr. Zakarin, who said he knew Mr. Brownstein when the coach was a film producer himself, said friends who have formed their own production companies have their own life coaches to deal with similar problems. "Once they have their offices feng shui'd, coaching seems to be the next thing," he said. Penelope Brackett, a career and life coach in New Jersey, said she was virtually alone when she started coaching performers in theater, television and film in New York in the early 1990's. In the last two years, she said, even drama schools have embraced the concept of "getting a life and not just building a career or devoting yourself to craft excellence." A former actor, director and producer who last year published "Seven Keys to Success Without Struggle," a life-coaching book for performers, written with Lester Thomas Shane, Ms. Brackett said she is regularly asked to give seminars at universities like Brandeis and Rutgers. Life coaches, who work in person or by phone and whose rates usually start at over $100 a session, partly credit the increased demand for their services to decentralized and scattered families: the life coach, some say, takes the place of the mother, father or some other elder, who gave counsel through life's decisions and conflicts. That many people have more than one career and are searching for pursuits with more meaning also plays a role, they say. In Hollywood coaches deal with short-term goals like easing writer's block so that a script gets finished as well as more encompasing challenges like hardening up-and-comers to take rejection or keeping those who make it from losing their heads in celebrity. "Being famous is not what it looks like on E!" said Ms. Ziff Lester, a former writer on television shows like "Beverly Hills 90210" and "Baywatch." "It hits you like a tidal wave, and unless you can navigate that ocean, you will drown." Carmit Maile, 31, the redheaded member of the Pussycat Dolls sextet, who recently changed her name from Carmit Bachar, said she started telephone sessions with Ms. Ziff Lester last July to keep her focused on what she wants to accomplish. The Dolls debut album, "PCD," went platinum, and just last week they embarked on a national tour, opening for the Black Eyed Peas. Ms. Maile, who said she found a certificate for Ms. Ziff Lester's services in a gift bag given to performers at a concert last year, added that she does not want success to keep her from working with children with cleft lip and palate. Ms. Maile, who had surgery for cleft palate, said she endured rejection in show business and wants to be a role model for girls like her who are not picture perfect. "My worry is to get lost in the shuffle of superstardom and not make an impact as a human being," she said, calling her coach a facilitator to help her stay the course. "There's so much that goes on that it's easy to lose your grounding." Success can bring just as much soul searching behind the camera. Jeff Davis, 30, the creator and an executive producer of "Criminal Minds," a drama on CBS, went to a coach as he was trying to cope, he said, with "the struggles of political fights and wrangling of egos" that he found when his show went on television. "I found myself going from writing scripts in a coffee shop one day to producing a television show in the blink of an eye," he said. He described the difference as "working with 100 people, finding myself swamped with questions and having to become a leader when you've hardly been doing it on your own." Mr. Davis, who said he was referred to his coach, Mr. Brownstein, by his studio, added, "I never had so many meetings in my life." Through coaching sessions twice a month, Mr. Davis got in touch, he said, with "my inner killer" and learned when to summon it and when to be nice. He said he also realized he wanted to create another show, for which he said he is about to write the pilot. The results, he said, have won him over to life coaching, despite his initial skepticism. "The entertainment industry can certainly use some help, considering the number of lunatics who work in it," Mr. Davis added. "It's literally like having a personal trainer. A life coach's job is to push you." But critics see life coaches as the ultimate overindulgence. "This is for people with too much money," said Jon Winokur, a Los Angeles writer who included the term life coach in his Encyclopedia Neurotica, a 2005 volume of "tics, twitches and safety-valve nuttiness," which also includes entries like "retail therapy." "You can find a market or a constituency for all kinds of insanity here," Mr. Winokur said. The American Psychotherapy Association does not have an official position on coaches, but Kelly Snider, speaking for the association, said "coaches need to be responsible for recognizing if there's a problem that must be dealt with by someone in the field of psychology." The International Coach Federation acknowledges that only a fraction of its members have gone through its certification process, which requires specific training and exams, because coaching has become more formalized only in the last decade or so. It urges consumers to shop around for those specifically trained in coaching skills. Those who pay for life coaches, sometimes at a financial sacrifice, say they need the supportive kick in the pants. "Life coaching has organized me and helped me do stuff more strategically," said Ari Shine, 30, a singer and songwriter who sees T. C. Conroy, a Hollywood coach who draws on her experience in the music business, including work with bands as a production coordinator. She is the former wife of Dave Gahan of the British band Depeche Mode. Ms. Conroy's session with Mr. Shine on a recent Thursday took the form of brainstorming over the best booking agent for him. During another session, with Nancy Noever, a production manager for television commercials in her 40's who is trying to sell her first television script, the coaching blurred the professional with the personal. "Weight is never where I want it to be, financial is never where I want it to be, time management is never what I want it to be," Ms. Noever said, as she sat on a sofa sipping from a water bottle across from Ms. Conroy, who took notes on a clipboard. "I have to figure out why can't I put myself first." "Why you haven't put yourself first," Ms. Conroy corrected, noting she could do it. Ms. Noever plotted ways to pay attention to her priorities — finishing the last 15 pages of her script, starting to lose 25 pounds, getting rid of her debt — with the expectation of not doing it perfectly the first time, as long as she set things in motion. "I'm much more important than a McDonald's commercial," she said, her confidence renewed.
Mental Health Therapists Face Financial Stress as Fees Stagnate Coeli Carr, New York Times- 3/26/2006 For more than three decades, Jessica Hinterman, a licensed clinical social worker who lives in Park Forest, a Chicago suburb, has had a fulfilling private practice, a part-time one so she could spend more time raising her children. But in 2005, she earned at least 10 percent less than the year before, while her practice-related expenses increased. Contributing to this shortfall in revenue was the fact that in November 2004, she had withdrawn from the provider list of the only health insurance company with which she had a contract. "When you are on a provider list, the insurance company decides what you should be charging," Ms. Hinterman said. Though her customary fee at the time was $90 an hour, she could charge only $68 to $72 for patients insured by the company she had contracted with. About two-thirds of her patients were insured by that company. "I'd get a ceiling on what I was allowed to charge," she said, "and that ceiling was unrealistically low." Like many other health professionals, mental health practitioners like Ms. Hinterman say that they are feeling an economic pinch, partly because of insurance reimbursement schedules that they say have not kept pace with their expenses. Richard G. Frank, a health economist with a specialty in mental health issues who is a professor at Harvard, said: "Clearly, the earnings of mental health professionals — medical doctors, psychologists, social workers and counselors — have either been flat or been declining for the past five to eight years." "It's not so much the number of visits allowed by managed care to mental health professionals has changed," he said. "It's that fees paid to the mental health professionals have not been rising." Mr. Frank, who is the co-author of "Better but Not Well" (Johns Hopkins Press, 2006), which examines United States mental health policies, cites efforts by insurance companies to keep costs down as well as changing treatment patterns, including the increasing use of drugs, rather than psychological therapy, to treat mental ailments. Ms. Hinterman, too, observed that patients found prescription medicines a quicker fix than "prolonged and thorough introspection." "We just live in a culture that values speed and efficiency and wants to see complex problems resolved in half an hour," she said. Given those changes, she no longer wants to rely on the profession she trained for as her sole source of income. An experienced seamstress, in January 2004 she started Fiber Embellishments, a company that makes scarves, table linens, chefs' aprons and one-of-a-kind bags made of boiled wool; local retailers are already selling her goods. Ms. Hinterman's concerns about earning a livelihood as a mental health professional are not isolated. "A lot of people have taken a hit, there's no doubt about it," said Dava Weinstein, a licensed clinical social worker in private practice in Manhattan, who also teaches in the social work programs at Columbia University and Hunter College. She also volunteers on a committee that deals with reimbursement issues for clinical social workers at the New York City chapter of the National Association of Social Workers. "Some members have told me, 'I don't know how I'm going to pay my mortgage' and that they're struggling to pay bills," she said. Among the top complaints from social workers about health insurers and the managed care industry are reduced fees, late payments and "inappropriate assessment of the needs of patients." Although the colleagues he has spoken with may not be leaving the profession yet, Paul C. Berman, a licensed psychologist in Baltimore who serves as professional affairs officer for Maryland's psychological association, said there were "lots of gripes." Many psychologists in private practice, he said, have said their fees have been reduced year after year, requiring them to work many more hours to maintain the same income. Mr. Berman said that when he went into private practice in 1990, participating in the provider networks of various health insurance companies, his maximum allowable hourly billing rate was $95, with about half of that paid by the insurance company and the rest by the patient. Today, he said, rates have plummeted to the point that the usual total reimbursement for psychologists is $65 to $75 an hour. This drop has forced many practitioners to nearly double their client load simply to maintain their income, he said. Not only are lower fees problematic, but there is also the issue of not being paid quickly by managed care companies, and often having to resubmit claims. The time required to complete paperwork is, of course, not billable. What Mr. Berman, who is no longer part of any insurance company's provider network, has done — and what he encourages other psychologists and behavioral health care providers to consider — is to diversify the practice. He now sees only a handful of therapy clients a week, at $95 for a 50-minute session, and earns his living predominantly "outside the insurance reimbursement world," evaluating people on behalf of social service agencies, lawyers or the courts seeking expert opinions on mental fitness or in matters like custody hearings. Lynne Spevack, a licensed clinical social worker in full-time private practice in the Wall Street area and in Brooklyn, also advises her colleagues to be active in making changes. She consults with other social workers on how to expand their practices and leads monthly meetings for the New York City chapter of the social workers' association on topics like practice-building and marketing. Among her suggestions to colleagues is taking speaking engagements to raise one's profile. Ms. Spevack said that even if the practitioner lowered the fee for someone paying out of pocket, the negotiated fee could still be higher than a managed care company would allow, and the practitioner would be "free of the invasion of managed care, paperwork and other administrative burdens," she said. "We can learn to ethically sell ourselves. It's a skill set. There are no reasons people need to be leaving the profession." Mr. Berman says he also sees more of his colleagues revamping how they work, often displaying an array of feelings "similar to any life change," he said. "First, many practitioners thought managed care would die. "Then there was outrage. Then resignation. Then they felt overwhelmed. Where we are now is taking a proactive stance so we can meet the needs of the changing marketplace and survive financially and professionally."
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