Noteworthy News Articles on Mental Health Topics, March 27-31, 2006



Freud in Our Midst
Jerry Adler, Newsweek- 3/27/2006

We stand now at a critical moment in the history of our civilization, which is usually the case: beset by enemies who irrationally embrace their own destruction along with ours, our fate in the hands of leaders who make a virtue of avoiding reflection, our culture hijacked by charlatans who aren't nearly as depraved as they pretend in their best-selling memoirs. As we turn from the author sniveling on Oprah's couch, our gaze is caught by a familiar figure in the shadows, sardonic and grave, his brow furrowed in weariness. So, he seems to be saying, you would like this to be easy. You want to stick your head in a machine, to swallow a pill, to confess on television and be cured before the last commercial. But you don't even know what your disease is.
     Yes, it's Sigmund Freud, still haunting us, a lifetime after he died in London in 1939, driven by the Nazis from his beloved Vienna. The theoretician who explored a vast new realm of the mind, the unconscious: a roiling dungeon of painful memories clamoring to be heard and now and then escaping into awareness by way of dreams, slips of the tongue and mental illness. The philosopher who identified childhood experience, not racial destiny or family fate, as the crucible of character. The therapist who invented a specific form of treatment, psychoanalysis, which advanced the revolutionary notion that actual diagnosable disease can be cured by a method that dates to the dawn of humanity: talk. Not by prayer, sacrifice or exorcism; not by drugs, surgery or change of diet, but by recollection and reflection in the presence of a sympathetic professional. It is an idea wholly at odds with our technological temperament, yet the mountains of Prozac prescribed every year have failed to bury it. Not many patients still seek a cure on a psychoanalyst's couch four days a week, but the vast proliferation of talk therapies—Jungian and Adlerian analyses, cognitive behavioral and psychodynamic therapy—testify to the enduring power of his idea.
     And Freud: the great engine of an ongoing middlebrow bull session that has engaged our culture for a century. Without Freud, Woody Allen would be a schnook and Tony Soprano a thug; there would be an Oedipus but no Oedipus complex, and then how would people at dinner parties explain why the eldest son of George Bush was so intent on toppling Saddam? (This is a parlor game Freud himself pioneered in his analysis of Napoleon, who'd been dead for a century when Freud concluded that sibling rivalry with his eldest brother, Joseph, was the great drive in his life, accounting for both his infatuation with a woman named Josephine and his decision—following in the footsteps of the Biblical Joseph—to invade Egypt.) In America Freud is now more likely to be taken seriously as a literary figure than a scientific one, at least outside the 40 or so institutes that specifically train analysts. Just last year, in fact, NEWSWEEK lumped Freud with Karl Marx as a philosopher whose century had come and gone, in contrast to the continuing intellectual relevance of Darwin. In an act of expiation, therefore, and to stake out the high ground before the tsunami of lectures, seminars and publications scheduled for his 150th birthday on May 6, we ask ourselves: Is Freud still dead? And if not, what is keeping him alive?
     That he retains any life at all is remarkable. To innocently type his name into a search engine is to unleash a torrent of denunciation that began the moment he began publishing his work in the 19th century. Merely being wrong—as even his partisans admit he probably was about a lot of things—seems inadequate to explain the calumny he has engendered, so Freudians invoke a Freudian explanation. "The unconscious is terribly threatening," says Dr. Glen O. Gabbard, professor of psychiatry at Baylor College of Medicine. "It suggests we are moved by forces we cannot see or control, and this is a severe wound to our narcissism." Resistance came early from a bourgeoisie appalled by one of Freud's central tenets, that young children have a sexual fantasy life—a theory that American adults rejected by a margin of 76 to 13 in a Newsweek Poll. And it's not just Western culture that Freud scandalized; as recently as last month, in an interview with David Remnick of The New Yorker, Sheik Nayef Rajoub of Hamas explained the necessity for Israel's destruction on the ground that "Freud, a Jew, was the one who destroyed morals."
     And opposition came from feminists who would have you know that they don't envy any man his penis. It is now universally acknowledged that Freud's ideas about women's sexuality—in summary, that they were incomplete men—were so far wrong that, as his sympathetic biographer Peter Gay jokes, "If he were president of Harvard, he'd have to resign." The low point of Freud's reputation was probably the early 1990s, when women were filling the talk shows with accounts of childhood sexual abuse dredged from their unconscious. This was a no-win situation for Freud—who, admittedly, had staked out positions on both sides of this question, as he often did in his long career. Those who took the side of the accused parents and siblings blamed him for having planted the idea, in his early work, that the repressed memory of actual sexual abuse was a common cause of adult neurosis. Those who believed the accusers charged him with cravenly surrendering to community pressure when he ultimately decided that many of these recovered memories were actually childhood fantasies. "Sending a woman to a Freudian therapist," Gloria Steinem said at the time, "is not so far distant from sending a Jew to a Nazi."
     His reputation has only barely begun to recover. In the wake of the repressed-memory wars, the vast Freud archive at the Library of Congress, much of which had been embargoed for decades into the future, has been opened to scholars. And Freud's debunkers are finding much to confirm what they've said all along, that his canonical "cures" were the product of wishful thinking and conscious fudging, and his theories founded on a sinkhole of circular logic. Efforts to validate Freudian psychology through rigorous testing or brain-imaging technology is still in its infancy. "I'm afraid he doesn't hold up very well at all," says Peter D. Kramer, a psychiatrist and author of "Listening to Prozac," who is working on a biography of Freud due to appear next year. "It almost feels like a personal betrayal to say that. But every particular is wrong: the universality of the Oedipus complex, penis envy, infantile sexuality."
     How much debunking can Freud withstand? Jonathan Lear, a psychiatrist and philosopher at the University of Chicago, identifies a "core idea" on which Freud's reputation must rest, that human life is "essentially conflicted." And that the conflict is hidden from us, because it stems from wishes and instincts that are actively repressed—you don't have to believe that it involves a desire to have sex with one of your parents, if that idea strikes you as outlandish—because our conscious self cannot bear to acknowledge them. Identifying and resolving those conflicts as they emerge into awareness, deeply cloaked in symbolism, is the work of analysis.
     Everything else is, ultimately, negotiable. Not even Freud's most orthodox adherents defend his entire body of work in all its details, but they do talk about the bigger picture. "He was wrong about so many things," says James Hansell, a University of Michigan psychologist. "But he was wrong in such interesting ways. He pioneered a whole new way of looking at things." Freud "helps us find deep meanings and motivations, and find meaning in love and work," says Dr. K. Lynne Moritz, a professor at St. Louis University School of Medicine and the incoming president of the American Psychoanalytic Association. Certainly he does, at least for some people, although that seems like a better recommendation for a poet than a scientist.
     But then, deep meaning is just what some people want out of life, a fact that helps support the 3,400 members of Moritz's group (up, barely, from 3,200 in 1998) and 1,500 in a rival organization, the National Association for the Advancement of Psychoanalysis. That compares with 33,500 in the American Psychiatric Association. Psychiatrists are medical doctors trained to treat mental illness; they typically see patients referred to them specifically for drug therapy, or they work in hospitals or clinics with the seriously ill. The American Psychological Association, which represents psychotherapists without medical degrees, has 150,000 members. In the Newsweek Poll, nearly 20 percent of American adults say they have had some form of therapy or counseling, and 4 percent are currently in therapy. The ability to tinker directly with the brain synapses, through drugs, holds the promise of making psychoanalysis redundant for some conditions. But patients respond differently, and for some a combination of drug and talk therapy seems to work best. Moritz maintains that for some conditions, such as adolescent borderline personality disorder, analysis remains the treatment of choice. As for Freud, he himself went through a brief phase in which he advocated drug therapy. Regrettably, the drug he advocated was cocaine. That remains the one salient fact that many Americans seem to have retained about him.
     A major factor in the decline of psychoanalysis is the reluctance of insurance companies to foot the bill for an open-ended treatment at a cost of more than $2,000 a month. Back in the 1950s, analysis was a status symbol and a mark of sophistication, a role filled in society today by cosmetic surgery. But it is still a valued luxury good for those with the time and the means to live up to the Delphic injunction to "know thyself." "There are many people who don't respond to brief therapy or to medication," says Gabbard, "people who want the experience of being listened to and understood, to search for a truth about themselves that goes beyond symptom relief." Take one of Moritz's patients, a married woman in her 40s we'll call Doreen in honor of one of Freud's most famous cases, who was given the pseudonym Dora. Doreen is the model of many early Viennese patients, an educated upper-middle-class woman with an overtly tranquil and satisfying life. Like most patients today, her symptoms were vague and general. Neuroses no longer seem to manifest themselves in hysterical blindness or paralysis. "I decided I have a good life, but it could be better," she says. At work she was too eager to please, taking on more than she could handle; with her family she felt the need to stifle her playfulness and sense of humor. Probably many people wouldn't think it necessary to devote four hours a week for four years (and ongoing) to solving those problems, but to her it's been worth it, totally. "It makes you examine your life, retell your life, to understand where your attitudes, your beliefs and behaviors come from," she says. "I'm so much happier now. It's not something I could do alone. You have to confront the parts of yourself that are painful and shameful and difficult to face. Dr. Moritz asks the questions that cause me to dig deeper into myself."
     That, of course, is the essence of Freud's technique. He was a man intoxicated with the voyage of inward discovery. You can see this clearly in his 1901 book "Psychopathology of Everyday Life." Here, Freud discusses an encounter with a young man who cannot recall the Latin word "aliquis" ("someone") in a passage from Virgil. To Freud, such moments are never without significance, and the very obscurity of the slip gave it added interest.
     Freud wouldn't waste couch time on a slip that was obvious to the person who uttered it. He employs his trademark technique of "free association" ("tell me the first thing that comes into your mind ... ") to uncover a link to "liquid," then to "blood," and through several other steps to the revelation that the young man was worried that a woman with whom he had been intimate had missed her period. What a tour de force for psychoanalysis!
     Does it detract from our appreciation of his genius that the freelance historian Peter Swales has shown that there most probably was no such young man, that the memory lapse was probably committed by Freud himself and that the woman he was worried about was Minna Bernays, the sister of Freud's own wife?
     Well, not to Lear. His reaction is, "I couldn't care less. I could imagine someone in Freud's position changing the story in that way. But it's just not very important to our appreciation of his work."
If Einstein had a romance with his sister-in-law, it wouldn't change what we thought about the speed of light. But this is Freud! His own thoughts and emotions were precisely the raw material from which he derived much of his theory. He is our postmodern Plato, our secular Saint Augustine. He fascinates us endlessly, even those who have made their reputations in part by denouncing him, like Frederick Crews, emeritus professor of English at UC Berkeley. Explaining Freud's enduring interest, he observes caustically, "Academic humanists find that by entering Freud's world of interlocking symbols and facile causal assertions they will never run out of shrewd-looking, counterintuitive things to say in their essays and books." As if that were a bad thing! Don't we all need an excuse now and then to sound smart by referring to interpreta-tion as "hermeneutics"? Kramer finds echoes of Freud in T. S. Eliot's dreamlike symbolism, in the emotional transference (of boss to father to son) in Joyce's "Dubliners." ("Transference" refers to the displacement of emotion that a patient undergoes in therapy, making the therapist the object of feelings the patient has toward a parent. Mr. Soprano, take your hands off Dr. Melfi's throat, please.)
     "We refer to Freud every day when we call someone 'passive-aggressive'," Kramer muses. "I don't know how people expressed that thought a hundred years ago." Not everyone is convinced by this argument, though: "Shakespeare managed to say an awful lot about human nature without the vocabulary provided by psychoanalysis," observes Patricia Churchland, of the University of California, San Diego, a leading philosopher of consciousness. She adds that in any case she finds that the language of analysis is being supplanted in popular culture by the jargon of neuroscience. People talk about getting their endorphins going. Someone acting rashly is said to be "frontal," referring to the part of the brain involved in impulse control.
     Admittedly, hermeneutics isn't exactly where the action is in American society today. In the id-driven worlds of politics, athletics and business, Freud is the ultimate non-bottom-line guy; he pays off five years down the road in the non-negotiable currency of self-knowledge. When President George W. Bush told an interviewer in 2004 that he wouldn't "go on the couch" to rethink his decisions about the Iraq war, it so outraged Dr. Kerry J. Sulkowicz, a professor of psychiatry at NYU Medical School, that he wrote a letter to The New York Times pro-testing this slur on analysis, with the implication "that not understanding oneself is a matter of pride." Sulkowicz knows this attitude firsthand as a consultant to corporate CEOs and boards of directors, where he struggles daily to beat some introspection into his clients' heads. "There's so much emphasis on 'execution' and 'action' in the business world," he says. "I try to convey that action and reflection are not mutually exclusive." Freud's insights into the irrational and the unconscious find application in the corporation, where even high-level executives may bring transference issues into the office, seeking from their boss the approval they once craved from their parents. Freud's writings on group dynamics and sibling rivalry can serve the thoughtful CEO well, Sulkowicz adds. It helps, though, if the source is somewhat obscured. "I hardly ever talk about Freud by name," he says.
     In the shadows, the tip of the cigar wiggles up and down in agitation. Americans! he seems to be thinking. A money-grubbing mob; they made me fear for the future of civilization itself. I should have told them when I had the chance.
     Freud, rooted in the great civilizations of Europe, wrote little about America, which he visited briefly in 1909, but his attitude was clear from a few terse sentences in his dark classic, "Civilization and Its Discontents." Published in 1930, when Freud was already an old man, the book was a psychological meditation on the social contract: the surrender of mankind's natural instinct for aggression and sexual domination in exchange for the security and comfort of civilized society. But in Freud's view, that is not an easy bargain. Those instincts are powerful and their repression creates unconscious conflict—what Lear described as the "core idea" of Freudian thought. And that is the source of the disease that we cannot name, and that we can never really cure, because it is built into the human condition. It is no accident, says Lear, that Freud's reputation reached a low point in the early 1990s, which was not only the height of the recovered-memory hysteria, but also of the post-cold-war optimism that made a best seller of Francis Fukuyama's book "The End of History." Fukuyama predicted that the dissolution of the Soviet Union would pave the way for the triumph of liberal democracy around the world—an idea that came crashing to the ground one sunny morning in 2001. "We are always susceptible," Lear says, "to the illusion that these are not our problems. The end of history was a brave hope that the ongoing dynamic of human conflict was over." But what Freud has to say, which is worth hearing even if analysis never cures another patient, is that history will never end. Because it is made by human beings.



The Therapist As Scientist
Claudia Kalb, Newsweek- 3/27/2006

The year is 1876 and Sigmund Freud's scientific career is about to begin. The id, the ego, the superego? Nowhere to be found. When he travels to the University of Vienna's zoological station in Trieste, Italy, sometime around his 20th birthday, the young med student embarks on a far less esoteric task: hunting for the testicles of the eel. For millennia, the animal's mating habits had confounded scientists, including Aristotle. Could Freud solve the mystery? Not exactly. Four hundred dissected eels later, the organs remained elusive. But Freud did acquire enough material to write his first scientific paper. Title: "Observations on the Form and the Finer Structure of the Lobular Organs of the Eel, Organs Considered to be Testes."
     Long before the Oedipus complex, Sigmund Freud was a hard-core scientist. Early on, it was eel gonads; later, he studied the cellular underpinnings of the human brain. There were limits, however, to Freud's scientific pursuits—brain scans hadn't been invented yet, DNA wouldn't be discovered until after his death and, eventually, Freud abandoned biology for psychology. But today, as neuroscientists unravel the molecular pathways that make us think and feel and dream, the seeds of Freud's ideas are finding their way into the lab. Researchers are tapping into the chemistry of the unconscious, exploring the theory of repression, even testing ways to block traumatic memories.
     What they are finding does not necessarily prove Freud right or wrong—MRIs cannot begin to measure the subtleties of human emotion—and the work is still in its infancy. But after decades of polarization between neuroscience (the study of the brain) and psychoanalysis (exploration of the mind), the two fields are beginning to find common ground. Freud, says Dr. Jack Gorman, president of Harvard's McLean Hospital, would have approved: "I think he'd be right there with us in the lab."
     It was in the lab that Freud's interest in science exploded. After the eel, he studied the nervous system of the lamprey and the crayfish, even devising his own novel staining method so he could see the details of living cells more clearly under the micro-scope. By the early 1880s he had moved on to the human brainstem. In elegant drawings, which will be exhibited by the New York Academy of Medicine in May, Freud sketched spinal neurons and fiber pathways in meticulous detail. Science became Freud's mistress. "Precious darling ... I am at the moment tempted by the desire to solve the riddle of the structure of the brain," he wrote in a letter to his fiancée, Martha Bernays, in May 1885. "I think brain anatomy is the only legitimate rival you have or will ever have."
     But brain anatomy alone could not earn Freud the money he needed to marry and start a family. So "very begrudgingly," says Mark Solms, director of the International Neuro-Psychoanalysis Centre in London, Freud began to study live patients, too. He diagnosed cases of cerebral hemorrhage and spinal inflammation. He published volumes on cerebral palsy and aphasia, a loss of language due to brain injury. And, after studying with the neurologist Jean-Martin Charcot in Paris, he began treating adults with "hysteria," a catch-all diagnosis for symptoms which had no clear physical explanation, like hallucinations and temporary blindness. "This is when Freud began to realize that the study of the mind was important," says Dr. Regina Pally, a psychoanalyst at UC Los Angeles. "He discovered when he talked to patients that there were emotional conflicts going on that were being expressed in symptoms." Something bigger—the unconscious—Freud posited, must be at work.
     At the time, brain science was relatively primitive and matters of the mind were largely the province of philosophers. Freud was not convinced. The brain, he believed, was "a dynamic interaction between parts," says Solms, "not a concrete switchboard." In 1895, in his "Project for a Scientific Psychology," Freud attempted to present a cohesive model of the brain and mind. In dozens of pages of notes, he explored the biological roots of mental abstractions, even describing the neurons responsible for consciousness, memory and perception. But the science of the day fell short and Freud abandoned the project. (It was published after his death.) Still, "he was very prescient about how mental processes could work," says Dr. Eric Kandel of Columbia University. "He developed the notion that the neuron is the element of the brain and that contacts between neurons can be modified by learning."
     Today, neuroscientists have picked up where Freud left off. Brain scanners now allow researchers to observe the inner workings of the mind, from where dreams originate to how stress affects neurotransmitters. Kandel and colleagues at Columbia, for example, used functional MRI technology to track the brains of students as they were shown fleeting pictures of fearful faces. Participants said they never saw the images, but their brains revealed otherwise: the amygdala, the fear center, lit up. "It's one way to demonstrate that the unconscious really exists," says Gorman.
     Does the brain repress unwanted memories? And can you test that in a lab? Critics say no. Michael Anderson, a psychologist at the University of Oregon, says yes. In a series of experiments in which he set out to find the neurological footprints of "motivated forgetting," Anderson trained people to memorize simple unrelated word pairs like "ordeal" and "roach." Then he hooked them up to an fMRI and asked them to repress their own memories by looking at the first word and not thinking about the second. The scans showed an intriguing circuitry at work: the hippocampus (responsible for retrieving memories) exhibited reduced activity, while the lateral prefrontal cortex (which helps to inhibit reflexive actions, like pulling your hand back from a hot plate) showed more. Active repression also made it harder to recall the memory later. It's a long way from suppressing a linguistic roach to burying a traumatic experience with a real one, but Anderson believes the same mental mechanism is at work: "I think Freud was onto something."
     Other scientists are using brain imaging to uncover the neurological circuitry of the mind in conflict—the drive for pleasure and the simultaneous impulse toward inhibition. They're studying early-life trauma and its long-term effects. And they are even testing drugs in patients with posttraumatic stress disorder to see if they can intentionally quash bad memories.
     None of this, however, answers the most pressing question: does psychoanalysis actually work? Analysts have been reluctant to put their very private practice to the test, and the challenges are indeed daunting. Chief among them: how can you assess "outcomes" when individual experiences are so variable? But "it's imperative that we do this," says Dr. Steven Roose of Columbia's Center for Psychoanalytic Training and Research, who is now launching a multisite trial of more than 300 patients. The study will use standardized scales to compare psychoanalysis to two other forms of therapy (cognitive behavioral and dynamic psychotherapy). "We have to demonstrate that our treatment is effective if we want to maintain our standing in the world of clinical medicine." It will be at least five years before the results are in. Make room on the couch, and wait.

Interview: Biology of the Mind
Claudia Kalb, Newsweek- 3/27/2006

In 2000, Dr. Eric Kandel, a Columbia professor and Howard Hughes Medical Institute senior investigator, earned a Nobel Prize for his work on learning and memory. But Kandel's early passion was psychoanalysis, and he is a leading proponent of merging the long-divided fields of neuroscience and psychology. His book on the topic, "In Search of Memory," hits bookstores this month. Kandel, 76, talked with Newsweek's Claudia Kalb.
KALB: How does Freud hold up?
I think he's a giant. Tremendously thoughtful, insightful and imaginative. There are things that he said that don't hold up. His view of female sexuality was wrong. But he gave us a nuanced and rich picture of the complexities of mental life. He's one of the great thinkers of the 20th century.
What are his greatest contributions?
Much of what we do is unconscious. That is a revelation that largely comes from Freud. The fact that dreams have psychological meaning, that infants are active, thinking individuals who have sensual as well as painful experiences also comes from Freud. The fact that by listening carefully to a patient, you can get a lot of insight into what the unconscious is talking about. This is revolutionary stuff.
Is psychoanalysis still relevant?
The problem with psychoanalysis, and it's a deep problem, is not with Freud. Subsequent generations have failed to make it a more rigorous, biologically based science. Psychoanalysis as a therapy has declined in popularity because it is time-consuming and expensive. Most importantly, people have lost confidence in whether or not it works. I think it's going to go down the tubes if the psychoanalytic community doesn't make a serious effort to verify its concepts and show which aspects of therapy work, under what conditions, for what patients and with which therapists. We need to look for the biological effectiveness of all kinds of psychotherapy, in the same way we do for drugs. I think that's the leitmotif of the next 15 years. If we can do it, it will revolutionize the field. After all, Freud always said that one day in the future we will need to bring psychoanalysis and the biology of the mind together.
When did you first get interested in psychoanalysis?
When I was in my early 20s. It had tremendous appeal as an intellectual adventure. This was an understanding of the human mind, of aspirations, unconscious mental processing, desires, dreams. I went to medical school with no idea of doing anything else but psychoanalysis.
You told the great neurobiologist Harry Grundfest that you wanted to find the ego, id and superego during your six-month rotation in his lab. What were you thinking?
I was a schmegeggy. To think that each one of these complex mental structures had a single locale and that I could find them in six months was absurd. I learned to be more realistic. Grundfest banged into my head that the brain needed to be analyzed one cell at a time.
You've come a long way. What's your new book about?
My book has two purposes. The most important is an introduction for the general reader to the new science of the mind and to the explosion that has occurred in the neurobiology of mental processes in the last 50 years. The second theme is my own life and work—how I got interested in the problem of memory and how I benefited from and, to modest degrees, participated in this revolution.
How does the future look?
The future of neuroscience is brilliant. The danger is that we're at the foot of a mountain range that people think we've already scaled. It's a huge mountain. It's going to take a century.

Massachusetts to Propose New Mental Hospital
Scott Allen, Boston Globe- 3/28/2006

After pushing for decades to get mentally ill people out of state institutions, the Department of Mental Health is expected this week to propose its first new psychiatric hospital in almost 50 years, calling for one of the costliest building projects in Massachusetts history.
      Massachusetts has closed 13 of its 16 state hospitals since 1973 as mental illness increasingly has been treated on an outpatient basis. But state officials say the push to deinstitutionalize patients has overlooked the needs of hundreds who are too sick or too dangerous to themselves or others to live on their own.
     The nearly $300 million complex would replace two archaic hospitals in Worcester and Westborough and be located on the grounds of the Worcester hospital. In the existing facilities, patients are housed up to four to a room in dimly lit, monotonous wards, often for years at a time. In the new hospital, patients would have single rooms with natural light streaming in and easy access to parks, shops, and areas for socializing. ''The hospital has got to be the start of treatment, not the end. We really need spaces that give people hope that they will get better," said state Mental Health Commissioner Elizabeth Childs, who led the study commission that is expected to formally recommend a new hospital to the Legislature.
     Advocates for people with mental illness praised the proposal, saying that the new hospital would greatly improve conditions for people in the throes of serious mental illness without undercutting the goal of reducing the institutionalized population. Childs said construction of the 320-bed facility, combined with the planned closing of two hospitals, would reduce the number of psychiatric hospital beds in the state from 900 to 740, including beds at Taunton State Hospital and at two facilities for mentally ill people with chronic medical conditions. But the department projects that it could treat more people by reducing the average stay by each patient, which now hovers around 850 days. If the plan is approved by the Legislature, the new Worcester hospital could be completed as soon as 2010.
     State officials have not developed a firm cost estimate yet, but Commissioner David B. Perini of the Division of Capital Asset Management, who cochaired the commission with Childs, said the complex could cost in the ''upper $200" millions. Mental health officials say the hospital is sure to cost more than what is currently considered the state's costliest non-highway building project, the $180 million Worcester courthouse now under construction. However, Childs said, the high cost would be partly offset by savings in consolidating two hospitals into one and reducing the number of psychiatric beds, which cost $168,000 per year to run. In addition, she stressed that the hospitals in Worcester and Westborough would require $60 million in renovations over the next decade to remain open. ''There's a case to be made that this is a prudent, though large, investment," Childs said.
     The proposal grew out of an attempt by Governor Mitt Romney to save money in 2003 by closing the Worcester State Hospital altogether and either deinstitutionalizing or transferring the 175 patients still treated there. But the Legislature blocked the move and instead called for the Department of Mental Health to study the long-term need for psychiatric hospital beds. The study of psychiatric hospitals, completed in 2004, found Massachusetts had made great strides in reducing the institutionalized population more than 95 percent from the high of 23,000 in 1950, when people were sometimes wrongly committed for problems such as advanced syphilis or alcoholism. The report found that the department could reduce the number of patients still further by increasing services such as housing support that would allow patients with serious mental illness to live in their communities. But the report also found that the state has badly neglected the remaining hospitals that serve some of the most vulnerable people in the state. It recommended that a commission led by the Department of Mental Health and the Division of Capital Asset Management look into the feasibility of building a state-of-the-art psychiatric hospital.
     Unlike private psychiatric hospitals, where patients typically stay seven or eight days, state hospitals take patients whose recovery could take dramatically longer: people with schizophrenia that doesn't respond to drugs; those suffering from both mental illness and drug abuse; patients who repeatedly stop taking medications. More than a quarter of the hospitalized patients are state prisoners being evaluated for their competence to stand trial or receiving treatment after being found not guilty by reason of insanity.
     Childs said that a growing body of research suggests that a cheerful treatment setting helps patients with physical ailments heal faster. One study showed that patients left the hospital after abdominal surgery on average a day earlier if they were in a room with natural light compared with artificially lit rooms. ''If the setting is important in medical care, it's even more important in psychiatric care," Childs said. ''If we can get average length of stay down to a year, I'll be thrilled."
     Elegant Romanesque-style stone buildings, with a commanding clock tower atop the administration building, now dominate the hilltop where the new hospital would be built. When it was built in 1873, the Worcester Insane Asylum embodied the humane care for the mentally ill championed by reformer Dorothea Dix. Quiet and imposingly beautiful, the campus was a city unto itself, with a nursery for babies born there and cropland to raise food. ''The idea was to give people peace and quiet and serenity," Childs said. However, ''once you went in, you didn't come out," she said, pointing out that many patients lived out their lives there and were buried nearby.
     The state closed the old hospital in 1958, after completion of the nearby Bryan Building, still the main building of Worcester State Hospital. Lester Blumberg, general counsel for the Department of Mental Health, calls the building ''eight stories of institutional design" with long, dark corridors that encouraged patients to stay in their rooms because there was so little common space. Modeled on the medical centers of the time, he said, ''it's ready for retirement as a hospital."
     The new hospital would require almost complete demolition of the boarded-up 1873 buildings, but the result, members of the study commission say, could be a national model for humane care. Architects from Ellenzweig Associates of New York designed a decentralized campus loosely based on the idea of a New England village, with patients' rooms in clusters of eight to 10. Hallways, which would have rooms only on one side to avoid feeling institutional, would connect patients to meeting areas, a gymnasium, and a downtown area, where they could go to socialize, make purchases or attend meetings.
     At their final meeting earlier this month, some members of the study commission -- which included legislators, hospital employees and advocates for the mentally ill -- talked about their role in mental health history, assuming that the Legislature approves the hospital plan. ''Perhaps 100 years from now, someone will be doing research on state hospitals and realize a new way of hospitals started with us," Perini said.

What is Perfect Parent World?
Although many adults don't realize it, peer pressure is just as pervasive for parents as it is for kids. Perfect Parent World is a set of behaviors, a construct, about things you have to be and how you conduct yourself, that symbolizes that you are a good parent, that you belong to the group and that your opinion matters. Sometimes being part of Perfect Parent World, especially in Washington, is having a powerful job. But what you see in communities outside of Washington or Boston or Chicago is that there's this whole thing about women who don't have to work. Then the hierarchy is that the woman who works is lower than the woman who doesn't. Some things are the same in Perfect Parent World. You have to be thin, no matter how many pregnancies you have. And you have to have the right kind of car.

Who joins a mom clique and why?
This is not about mean girls growing up to be mean moms, but rather about how all of us are inevitably going to get into conflict with other adults and how things like groups influence whether we go through problems well or badly. What I see with mom cliques is that they are most prevalent with women who used to work and went home because they wanted to make this sacrifice for their children. I think many of them feel that they lost their public voice when they left their work, and our culture doesn't respect women's voices when they are at home as much as when they are at work. So they miss those feelings of respect, of confidence, the feeling that their voice matters. And when they're in a fight with a teacher or a coach or another parent, they are fighting for a sense of being a competent person. I went up against some of those moms and it was scary -- it was one of the few times I didn't want to continue my work. Dads are very much in groups, but they are less likely because of work to be in a clique.

What is the Washington version of the Queen Bee Mom and the Kingpin Dad?
The Queen Bee Mom is highly socially and academically intelligent. You throw in the Southern thing and she can make you do things and you don't even know that she's done it because it's so subtle -- often in the guise of being complimentary. She's appropriately dressed, often in the conservative Washington style, but not dowdy. She's effortlessly perfect. Queen Bees can be amazing leaders, but they always have to be in control of everything. A Kingpin Dad does not come to things at the school unless he is mad about something or it's a politically advantageous thing for him to do, like the school auction. He takes up room. If he's a lawyer, he thinks that threatening a lawsuit is an excellent way to resolve conflict.

How do baby boomer parents differ from Generation X parents in their attitudes toward conflict?
Boomer parents want a feel-good answer that solves the problem with no messiness. They don't want their kid to experience pain. Their issues are more about not wanting to say no to their children. Gen X parents have a herd mentality which you really see when it comes to technology. They don't ever question why you shouldn't have it or whether it's a good thing for their kid to be using, like a cellphone. The one thing about Gen X people is that they feel like they can become experts on any subject if they read it on the computer. They go into the school and they have become an expert on anything. Their attitude is, "I read it, therefore it's true, and I now know more than you do even though you've been working with kids for 15 years."

What factors make it hard for parents to communicate with each other?
In Washington, the issues of race and social class are really complex and very alive, but no one talks about it. Religion can be a filter. Even these humongous houses people live in can be a filter. From my conversations with parents, what emerges is that there's a really unspoken thing going on between white parents and black parents, and parents from other countries. There's an assessment by a lot of [nonwhite] people I've heard which is, "I don't trust white parents because they don't know how to get their kids under control." White parents often think black parents are too hard on their own kids. Too often these differences are never discussed, or even acknowledged.

What are the biggest mistakes parents make in dealing with other adults, such as teachers and coaches?
Parents should not act like everything is a life-and-death problem -- from a bad grade to not playing on the team to not getting a part in the play. If somebody is going to die in the next five minutes, then you move. If not, then you sit down and you figure out what you are going to do. Teachers often feel like parents do not respect their professionalism. That makes them feel mad and unsafe. They do not like parents who threaten them with a lawsuit, who fight the fights for their kid, or who think that whatever has happened to their child trumps everything else.

When should parents confront each other?
I get that it's important to pick your battles, but at a certain point you do have to pick a battle. The thing is that you really must demand of yourself and other people that they treat each other civilly. Parents should not be allowed to be in a parent meeting and get away with treating other people badly. You need to strategize about when and where you speak to the person, because that's just as important as the content of your words. The process involves breaking down how you articulate when things are going wrong for you, what you don't like, what you need, and then actually doing it. If you don't speak up, then the parent who is being rude or uncivil sets the agenda for the school, because your voice is not there demanding civility. If we want our kids to stand up, we've got to do it ourselves.

Serious consequences
Hospitals must keep patients who are brought in so drunk they can't function until they're sober. At U-M, officials say the largest number of cases are after finals and midterm exams, and during football weekends. Each year, says Dr. Brian Zink, associate professor of emergency medicine at U-M's Medical School, an average of four women are brought to the emergency department near death because their breathing becomes so impaired or they are at risk of vomiting and choking on the vomit.
     Even with less severe cases, there are serious consequences. "They are so intoxicated they can't function and someone is concerned about their well being.'' says Zink, also an associate dean for students. "We talk to them about how they are so vulnerable by demonstrating how much they have given up in control,'' he says. "They're so embarrassed by this.''
      In some of the cases, Zink says, the women are found undressed in someone's apartment - possible victims of sexual assault. After the women are sober, hospital workers ask them if they know who brought them in, whether there were sexual advances and if they got robbed. They also offer the women counseling for alcoholism and binge drinking.
     The number of girls between the ages of 12 and 20 who engage in binge drinking jumped by 10 percent between 1991 and 2003, according to the National Institute of Alcohol Abuse and Alcoholism. In 2001, approximately 44 percent of college students reported binge drinking, according to the NIAAA. The percentages of abstainers and frequent binge drinkers increased, indicating a polarization of drinking behavior, the group reported.

A factor in sexual assault
"The majority of rapes involving college students involve alcohol, either used by the victim, the suspect, or both,'' says Ann Arbor police Sgt. Jeff Connelly. Men who drink too much can become vulnerable, too. Over the past two years, there have been two reported cases of intoxicated men who woke up and found other males raping them, Connelly says. "People don't understand that when someone is highly intoxicated they don't have the ability to give consent,'' Connelly says. "When people take advantage of that they can be charged with a rape crime.''
      He says it's heartbreaking to watch the families of college student rape victims and suspects in court. Their lives are forever changed, he says. "Most kids have the outlook that it can't happen to me,'' Connelly says. "But it happens to someone. I don't think women understand the significance of what they've done. They become very vulnerable.''
     In an effort to curb the problem, Ann Arbor police speak to college classes, fraternities and sororities about excessive drinking. They explain how drinking games and birthday celebrations get out of control. One common scenario, Zink says, is that a woman turns 21 and takes part in a dangerous ritual of consuming 21 shots of liquor. If she doesn't vomit, the alcohol is absorbed and she falls unconscious. Pound for pound, women, on average, can't handle the same amount of alcohol as men, he says. "Women have less of the enzyme that degrades alcohol in their stomach and small intestine, typically,'' Zink says. "That means there is less of the early metabolism and breakdown of alcohol so they end up having higher blood alcohol levels.'' Other factors, like the amount of food in a person's stomach and the rate of drinking, also affect alcohol absorption. "We're seeing more students who are drinking to get drunk and are consuming large amounts of alcohol over a short period of time,'' Zink says.

Doctors Turn to the Mind for Healing
Charles McGrath, New York Times- 3/29/2006

Last November, just four months before she died, Dana Reeve, the widow of the paralyzed actor Christopher Reeve, taped the introduction to "The New Medicine," a two-hour PBS documentary that will be shown tonight. Ms. Reeve, who was fighting lung cancer at the time, is an ideal host for this program, which wants to argue that there is more to medicine than mere science, and that a growing number of physicians now accept the role of mental and emotional well-being in health and in recovery. She is warm but not smarmy, upbeat but not spacey, affirmative without getting weird or New Agey.
       Much the same is true of the documentary, which makes a modest case that hypnotism, visualization and meditation can all lessen stress and promote healing, but stops short of endorsing crystals, say, or "botanicals." There is a scene of some Buddhist monks mentally adjusting their inner thermostat and causing steam to rise off some wet bedsheets in which they happen to be wrapped, but no suggestion that this is something we should be trying at home.
     On the other hand, for a two-hour documentary, "The New Medicine" is remarkably thin on information. Instead of actual cases or histories, there are a number of heartfelt and even eloquent testimonials by doctors, like Jerome Groopman of Harvard and Ralph Snyderman, a former chancellor of Duke University, who believe in the new notion of integrative medicine — medicine that pays attention to the patient's history, values and lifestyle as well as to the numbers on his chart. As Dr. Snyderman points out: "We as a health-care system have kind of lost our way over the last two decades by becoming so enamored of technology and specialization that we've lost sight of the individual as an individual."
     Only someone who hasn't spent serious time in a medical waiting room lately could disagree. Yet "The New Medicine," which is more wishful than reportorial, never suggests how many like-minded physicians — doctors who actually practice this kind of medicine — there are or to what degree these ideas are embodied in the current medical school curriculum. The program's deeper argument — that modern science has done us a disservice by attending to the body but not the mind — also seems hard to quarrel with. But the evidence supplied for a mind-body connection is so slight and uncontroversial as to seem anodyne, and the success stories the program documents are far from miraculous. An expectant mother staves off infection and premature birth — for a while, anyway — by imagining a peaceful room with a balcony. A man about to undergo back surgery listens over and over to a CD murmuring that his team of well-trained health-care professionals will insure that he has a good result and, indeed, he comes through the operation just fine. A man with heart disease meditates and takes some classes in healthy cooking, and pretty soon his cholesterol is lower. A New Jersey psychologist teaches a teenager with cerebral palsy how to zonk out with self-hypnosis, which not only seems to help with pain but must be a great party trick as well.
     "The New Medicine" is done in the now familiar PBS style, leavening the talking heads with a cheerful soundtrack, snippets of cartoons and computer imagery, some educational close-ups of appropriate Old Master paintings, and even a clip of Vivian Blaine, from the 1955 movie version of "Guys and Dolls," singing, "A person can develop a cold," in the great anthem of the health hazards posed by being single. The program is not hypnotic, exactly, but more like the CD that the back patient listens to. It may not tell you much you didn't already know, but it won't make you feel any worse.

Study Backs Equal Coverage for Mental Ills
Robert Pear, New York Times- 3/30/2006

WASHINGTON— Providing insurance coverage for mental illness equal to that for physical illness does not drive up the cost of mental health care as many insurers feared, a new study of health benefits for federal employees says.

President Bill Clinton ordered such equal coverage for federal workers in 1999, and the changes took effect in 2001. Under the policy, known as parity, insurers were forbidden to charge higher co-payments or impose stricter limits on psychiatric care or treatment for alcohol and drug abuse.

The new study of those changes, being published Thursday in The New England Journal of Medicine, concludes that if mental health care is properly managed, expanding the coverage of it "can improve insurance protection without increasing total costs" beyond those paid by insurers that do not offer parity.

Providing equal coverage for treatment of mental disorders did not increase the use of mental health services under the federal employee program, the researchers said. But it did lead to "significant reductions in out-of-pocket spending" for many government workers and retirees.

A co-author of the study, Richard G. Frank, professor of health economics at Harvard, said, "The big winners, in terms of reduced out-of-pocket spending, were the sickest patients, including those who needed hospital care."

In the past, a federal employee often had to pay 30 percent to 40 percent of the cost of a hospital stay for a mental illness like major depression. With parity, the patient did not have to pay any of the cost, saving $300 to $400 a day in a hospital that charged $1,000 a day.

Dr. Howard H. Goldman, a professor of psychiatry at the University of Maryland, who led the research team, said insurers had borne slightly more of the costs after the adoption of mental health parity.

The researchers said they did not know whether any of those costs had been passed on to subscribers, in the form of higher premiums. But "even if the full cost of the new requirement was passed on to subscribers," he said, "the impact on premiums would be very small, probably less than half a percentage point."

Psychiatrists, psychologists, patients and their advocates have tried for decades to eliminate disparities in insurance coverage for mental and physical illnesses. Under the change ordered by Mr. Clinton to the Federal Employees Health Benefits Program, coverage must be "identical with regard to traditional medical care deductibles, coinsurance, co-payments" and limits on hospital stays and doctor visits.

The new study tried to measure the effect of Mr. Clinton's order by comparing the claims experience of seven health insurance plans within the federal program and several health plans offered by large private employers that did not provide parity. The researchers found increased use of mental health services, and increased spending for mental health care, under both types of insurance. The increase for federal employees was similar to that for the private-sector workers, and was not attributable to the requirement for parity, the study found.

Amanda L. Austin of the National Federation of Independent Business, a trade group for small businesses, said the experience of the federal program was not necessarily relevant to them.

Fewer than half the federation's 600,000 companies offer health insurance to their employees, and "the No. 1 reason is cost," Ms. Austin said. "The Federal Employees Health Benefits Program, with a pool of nearly nine million members, is very different from the type of insurance plans available to a small business with three employees."