Noteworthy News Articles on Mental Health Topics, September 13-22, 2006
Lawsuit Challenges Use of Federal Aid for Bible-Based Counseling
Neela Banerjee, New York Times- 9/13/2006
A group called Americans United for Separation of Church and State filed suit yesterday to block federal financing for an organization that provides marriage counseling based on the Bible.
The lawsuit is another challenge to the Bush administration’s efforts to channel money for social services to religious organizations. While religious groups are not barred from getting public money, such financing can only be used for secular purposes, not “worship, religious instruction or proselytization,” according to government guidelines.
Americans United, a watchdog group based in Washington, D.C., filed the lawsuit in Federal District Court in Tacoma, Wash., on behalf of 13 state residents. They object to federal funds being used to support the Northwest Marriage Institute, which states in its newsletter that it offers “Bible-based premarital and marriage counseling.” The institute, in Vancouver, Wash., received $97,750 in federal grants in 2005 from the Department of Health and Human Services.
The lawsuit argued that the institute uses federal funds for religious purposes, including developing materials with religious content, buying equipment for use in religiously based programming and paying part of the salaries of employees who do Bible-based counseling.
“This program trains people in how to make their marriages conform to one narrow interpretation of faith,” said the Rev. Barry W. Lynn, executive director of Americans United, in a written statement. “The federal government has no business forcing the taxpayer to subsidize that.”
A spokesman for the Health and Human Services Department declined to comment on the suit, saying that the agency generally does not comment on pending lawsuits.
Bob Whiddon Jr., director of the Northwest Marriage Institute, said he had not yet seen the lawsuit.
But he said the grants were meant to strengthen his organization by paying for consultants to improve its business practices and to buy equipment, not for programs.
“The grants say that I’m allowed to do things that will allow me to increase the capacity of my organization to serve the community,” Dr. Whiddon said in a telephone interview. “None of what we do with the money is for religious purposes.”
The administration has failed to provide clear guidelines about what federal funds can be used for, said Robert W. Tuttle, a law professor at George Washington University who is an expert on religion-based initiatives.
The government instructs organizations broadly that they are prohibited from using funds for religious purposes. But, he said, it does not answer the seemingly small, yet sometimes critical, questions that could occur in daily practice.
For example, could software bought with federal money be used for religious purposes? Or is it acceptable to give federal money to improve the management practices of an obviously religious organization like the Northwest Marriage Institute, when those changes would affect both its secular work and religious mission?
“The government studiously avoids clearing up these questions because it doesn’t want to discourage people from applying and look hostile to faith groups,” Professor Tuttle said. “I honestly don’t think it would discourage people. Instead, it would give them a good sense of how to avoid being sued.”
Columbine Massacre Still Fascinates
Associated Press, 9/14/2006
DENVER -- The Montreal school shooting has exposed a persistent fascination with the 1999 Columbine massacre among many young people, with some students modeling themselves on the Colorado killers and citing the bloodbath as a sick source of inspiration. Earlier this year, five teenagers were accused of plotting an attack at a Kansas high school on the seventh anniversary of the Columbine attack, which remains the deadliest school shooting in the United States. And two weeks ago, a Hillsborough, N.C., teenager whom authorities described as obsessed with Columbine and other school shootings sent an e-mail to Columbine's principal before killing his father and firing shots at his former high school.
On Wednesday, a gunman in Montreal killed one and wounded 19 in a shooting rampage at a college. Kimveer Gill, 25, said on a blog that he liked to play ''Super Columbine Massacre,'' an Internet-based computer game that simulates the April 20, 1999, attack by the two students who killed 13 people and then themselves. Players take the role of Eric Harris or Dylan Klebold, killing classmates and teachers. ''Lfe is a video game you've got to die sometime,'' Gill wrote in an online profile. Gill also wrote that he hated jocks, preppies, country music and hip-hop -- similar to the screeds Harris and Klebold. During Wednesday's attack, Gill wore a black trench coat, just as the Columbine attackers did as they began their rampage.
Scott Poland, a psychology professor at Nova Southeastern University in Fort Lauderdale, Fla., has counseled students and teachers in the aftermath of 11 school shootings, including Columbine. He said Columbine has been a twisted source of inspiration to some teens. ''We can't make it account for all violence in young people, but I don't think we can dismiss it,'' he said. He said that the Columbine killers' clothing and weapons have been glamorized, and added: ''I think all of this, unfortunately for a few young men, is something they are aspiring to have, the power and the image.'' The Internet has made information about Columbine easy to find, and extensive media coverage has helped keep attention focused on the killers, Poland said. ''All of this can contribute to a really disturbed kid being one step closer to carrying out an act of violence,'' he added.
Ian Bogost, a Georgia Tech professor who recently published a book on video game criticism, said Thursday in an online posting that ''people like Gill don't kill because they read a particular book, listened to a particular band or played a particular video game.'' ''They kill because they have myriad other problems that extend back in time for years, some of which they express through using and internalizing media,'' Bogost said.
Danny Ledonne, creator of the Columbine game, estimated it has been downloaded more than 100,000 times. He said in an interview that his game and others are not responsible for the Montreal shootings. ''Yeah, there are violent video games, violent movies, but guess what? I can turn on the news and see violence in the real world. Violent video games are a reflection of our societal issues,'' he said. He said he purpose of the game ''was to give some insight into these two young men, to put you into their heads, so to speak, to perhaps understand why they may have done this.''
Last year, the American Psychological Association recommended that all violence be reduced in video games marketed to young people. ''Not every single child who plays violent games goes out and shoots people, but personal problems or whatever is going on in their lives may make them vulnerable to this kind of influence,'' said trauma psychologist Elizabeth Carll, who co-chaired the APA committee behind the resolution.
Marjorie Lindholm, who as a Columbine sophomore hid in a room with a mortally wounded teacher, said of the Montreal attack: ''Anybody who has enough hate in them to carry out something like this, they would do it with or without the video game.'' Similarly, Tom Mauser, whose son, Daniel, was killed at Columbine, said he does not see video games as the primary reason for youth violence. ''I think someone has made up their minds. I don't think those games help, and they desensitize,'' he said. ''I think they are aggravating factors. I don't think they take the place of their consciences.''
Yale Rape Crisis Center To Open
Kim Martineau, Hartford Courant- 9/16/2006
NEW HAVEN -- Yale University announced Friday it will open a rape crisis center that will combine counseling and education/prevention programs under one roof, responding to years of complaints from students that fragmented services were discouraging them from getting help.
A clinical psychologist will head the new center, resembling sexual assault centers that have been established at Harvard and Columbia universities. Yale made its announcement after releasing the results of an internal study that recommended hiring a rape crisis coordinator and making it easier for students to find support. The study also recommends that Yale improve its reporting procedures, to boost student confidence that sexual violence is taken seriously. "There were so many options and so many areas cross-cutting each other it was hard to know where to go and it discouraged students from taking any action," said Allyson Goldberg, a Yale junior and co-coordinator of the student group Rape and Sexual Violence Prevention.
Yale's move comes after years of activism on campus and beyond. Six years ago, students formed RSVP to raise awareness about sexual assault on campus and pressure the university to take greater action. The problem gained national attention when feminist author Naomi Wolf wrote a New York magazine cover story in 2004 describing a pass she claims a distinguished English professor made at her while she was a student at Yale. Wolf accused the university of sweeping her complaints, made nearly 20 years later, under the rug.
An article that same year by the Yale Alumni Magazine confirmed weaknesses both in Yale's handling and reporting of sexual assault and harassment complaints. Following the alumni magazine piece, the national watchdog group Security on Campus filed a complaint with the U.S. Department of Education accusing Yale of underreporting the incidence of sexual violence. Two years later, that complaint is still pending.
Ironically, colleges considered to be models in responding to sexual assault also report a high incidence of those crimes. Harvard, for example, leads the Ivy League in reported sex crimes. Between 2002 and 2004, the latest statistics available, Harvard reported nearly 70 on-campus sexual assaults to Yale's 12. The Harvard numbers reflect the comfort students feel in coming forward, but also the university's diligence in reporting all that goes on, the school has said.
Most sexual assaults on college campuses go unreported for the same reasons that 85 percent of sexual assaults nationally go undocumented. Victims worry they'll be blamed, especially if drinking was involved. They may be reluctant to accuse someone they know of a crime. And they may not know how to proceed, overwhelmed by the medical, legal and emotional issues.
Carole Goldberg, a psychologist at Yale, will run the program under the university health center. Students will have access to a sexual assault counselor, available to talk or meet with them to guide them on how to proceed -- with medical help, counseling, or the decision to call the police and press charges. Education and prevention programs also will be offered.
The Yale study took seven months to finish and five months to release. The report recommends that Yale improve its reporting by compiling an internal report of sexual assault and harassment complaints on and off campus each year to supplement statistics sent to the federal government.
You Are Cleared for Takeoff
Alex Williams, New York Times- 9/17/2006
A few days after the terror arrests in London last month, a small commuter plane with three tourists was banking off the coast of Costa Rica when a sudden sound, like a muffled explosion, shattered the calm. The rear door of the plane, improperly shut, had blown open. There was a moment of panic for two of the passengers. But Roger Knox, a graphic designer making a connecting flight before boarding a jetliner home to San Francisco, was not worried. He had just doubled his usual preflight dose of Ativan, a prescription anti-anxiety drug, in anticipation of the ride on the small plane. Mr. Knox, 46, said he is generally so drug-phobic that he doesn’t take aspirin for a headache. But he is also a white-knuckle flier, and over the last few years, with advice from his doctor, he has experimented with drugs to massage his nerves before flying. “My meds never give me a feeling of being high or stoned,” Mr. Knox said. “They can make me a bit drowsy, but for someone used to adrenaline-pumping, think-I’m-going-to-freak-out anxiety, that’s a welcome change.” Terror alerts. Long security lines. Overstuffed transcontinental jets. It’s all more tolerable with a prescription drug to round off the edges, many people have found. “I’ve kind of gotten over the stigma that I need to tough this out,” Mr. Knox said.
As the era of populist anti-anxiety drugs has merged with the post-9/11 era of fraught air travel, nervous fliers increasingly turn to pills to make the hours of sealed confinement more bearable, according to therapists, flight-anxiety counselors and nervous fliers. For many stressed-out travelers, tossing back a prescription pill before a flight — rather than a couple of bourbon and sodas, the old method — is as routine as picking up a paperback on the way to the gate.
“Everybody personally and professionally that I know who is afraid to fly gets their hands on Xanax,” said Jeanne Scala, a psychotherapist in Roxbury, N.J., adding that she has seen an increase in patients and friends talking about taking medication for flying jitters. “They’ll do anything to take the edge off the anxiety of sitting in a plane,’’ she said. “They just want to zone out, they want to sleep. So they’ll take Ambien, Sonata, even pain medication like Soma, which is for back pain. People use whatever they have — the pharmacy in their house.”
Tom Bunn, a licensed therapist and a former commercial pilot who started company called Soar in 1982 to counsel people with fears of flying, said he saw an increase in chatter about anti-anxiety medication on the message board of his company’s Web site after 9/11. “Everybody started saying, ‘Take it like candy,’ ” said Mr. Bunn, who is nevertheless skeptical about drugs’ effectiveness and safety and does not recommend them in his program. Ron Nielsen, a pilot for US Airways who also leads a flight-anxiety course, called Cleared 4 Takeoff, said scares like the London arrests of men accused of plotting to blow up planes with liquid explosives serve as a trigger for underlying fear, which leads many fliers to consider medication. “That’s one of the first things that come up every class,” Mr. Nielsen said. “The average fearful flier is more likely to say, ‘Give me something, I gotta go to Boston.’ I think every time you have a spike in collective anxiety in culture, people get to desperate places, people say ‘O.K., I’m willing to do this, whereas yesterday I wasn’t.’ ”
There are plenty of options for the highly nervous flier. Xanax, Valium and Klonopin — among the most popular — are benzodiazepines, a class of anti-anxiety drugs often prescribed for use on an occasional basis. All have slightly different characteristics, times of duration and side effects, said Dr. Thomas R. Swift, president of the American Academy of Neurology in St. Paul. (Benzodiazepines are different from older sedatives like Seconal, a barbiturate, and from antidepressants like Zoloft and Prozac meant to be taken daily when used to treat panic disorders and other ongoing anxiety problems.) Some fliers said they preferred a drug like Xanax to alcohol because its effects are typically mild. It does not make them spacey or fuzzy-headed, they said. They do not stumble off a plane as if their legs are filled with putty, making it appealing to business travelers who must attend meetings after landing.
“Benzodiazepines tend to be a relatively safe drug,” Dr. Swift said, adding that the main side effect in small doses is sleepiness. The risk comes in, he said, when people borrow them from well-meaning friends. “It’s almost always a bad idea,” said Dr. Swift, referring to pharmaceutical-swapping. “The doctor that prescribed the medicine for the person had it knows the person’s medical history. That’s not true for person who borrowed it. There could be a contraindication to that drug.”
Doctors also caution against chasing an anti-anxiety pill with a drink, because alcohol functions as a “powerful augmenter” to benzodiazepines like Xanax, said Dr. William Rickles, an assistant clinical professor in the Department of Psychiatry at the University of California, Los Angeles. Unlike with powerful barbiturates, the mix “doesn’t drop your blood pressure and doesn’t stop you breathing, so it doesn’t kill you,’’ Dr. Rickles said. “But you might sleep for a long time.”
For some fliers, sleep is the goal. Dr. Neil B. Kavey, director of the Sleep Disorders Center at NewYork-Presbyterian Hospital/Columbia University Medical Center, said he has witnessed a dramatic increase in the number of patients who use these sleep drugs for flights — most to combat jet lag, but some who simply knock themselves out to avoid anxiety — over the last year or two. “When I noticed the increase, I worried a bit if I would see people awakening on airplanes too heavily drugged,” he said. “But I don’t think I’ve had any incidents.”
The new generation of prescription sleep drugs, which includes Sonata and Lunesta as well as the popular Ambien, is marketed as safer than an older generation of sleeping pills. (Ambien became a cocktail-party topic earlier this year, after reports that some users claimed they went on eating binges or driving excursions they didn’t remember. And last summer, a London-bound plane was diverted after a passenger who later said that he had taken Ambien — and drank two individual-serving bottles of wine — tore off his shirt and made threatening remarks.)
Paul Taylor, a hair colorist in White Plains, was an unnerved air traveler who had to experiment with anti-anxiety drugs to find one that worked for him. Mr. Taylor, a native of South Africa who has been flying home routinely for years, said he developed a severe aversion to air travel after a trip in the late 1990’s that required an emergency landing. Then a few years ago, a sympathetic acquaintance gave him a Valium for an upcoming trip to Seattle. He tried it. Nothing. On the flight, Valium failed to “shut down the little people in my brain, as I call them,” said Mr. Taylor, 43, referring to his neuroses. “I was literally grabbing onto the arm of my partner the whole way and freaking out.” A year or so later he confessed his fears to a doctor, who prescribed Xanax. Thanks to that, combined with the cognitive therapy he learned from the Soar program, for him the skies have never been, well, quieter.
Although doctors and therapists confirm that drug use among jittery fliers is common, it is impossible to measure how common, because many people who pop the occasional pill do so without mentioning it to any professionals, especially if they received it from a friend. Others just have a few Klonopin that they got from their general practitioner for anxiety issues in general, and decide to take them for a flight as needed.
There are nervous fliers who have drugs in their pocket but don’t use them, said Marvin Aronson, a psychotherapist in Mount Vernon, N.Y., who treats flight anxiety. “It’s just having them that can make the difference,” he said. (These fliers may want to bring the prescription bottle; the Transportation Security Administration requires that prescription drugs carried on board have a label matching the ticketholder’s name.)
And drugs are certainly not the only option for jittery fliers. “We have some people call up and want nothing but natural remedies,” said Dr. Rickles, who uses techniques like biofeedback and virtual-reality therapy to help many patients combat their fear of flying. Some people with extreme phobias, he said, “generally don’t like to take drugs, because they are afraid that a drug might do something and then they can’t get it out of them.”
Jerilyn Ross, president of the Anxiety Disorders Association of America, a nonprofit group of health care professionals in Silver Spring, Md., said that anxious fliers, like many people suffering anxiety, “used to take Valium and hide it” because they believed there was a stigma attached to self-medicating for anxieties like fear of flying. But now, she said, “it’s much less frightening” and “people are much more open about it,” due in part to the torrent of information — and pills — available on the Internet. Certainly, some people, particularly those suffering an acute fear of flying, have turned to pills since the heyday of barbiturates like Seconal and Nembutal in the 60’s and 70’s, doctors said. But these days, there are even more reasons why tremulous fliers may want to indulge.
For Kermit Morse, a computer systems analyst at a bank in Columbus, Ohio, going through security lines at airports is an added psychological hurdle as he tries to find a new peace with flying. He flew routinely until a few years ago, when a growing sense of fear due in part to the post-9/11 jitters stopped him in his tracks at the gate at the Columbus airport just as he was about to board a flight to Dallas. “I was at the gate and I could not walk down the jetway,” Mr. Morse, 48, recalled. “So I went home.” He saw a doctor, who for a time put him on a daily regimen of Paxil, a drug often prescribed for acute anxiety disorders. For his first flight after that, it worked. Sort of. While on a plane flight, the fear “didn’t seem to be as he intense,’’ he said, though he still found himself “looking for anything that might indicate there’s a problem with the plane.” At least, Mr. Morse added, “I could actually get on the plane.”
Driving Stoned and Carefree
John Keilman, Chicago Tribune- 9/18/2006
Over the last eight years, high school students who have gotten in trouble for drugs and alcohol have told counselor Cathy Cratty the same alarming story about driving under the influence.
"It just kept coming up, left and right: `We know we shouldn't drive after drinking, but it's OK to drive after smoking pot,'" said Cratty, who works for Highland Park-based School District 113.
According to national surveys, high school students are as likely to drive high as they are to drive drunk. But experts say many of those teens never hear a warning about taking to the road while stoned and don't think they're doing anything dangerous. "They perceive themselves as being less impaired when smoking marijuana," said Jocelyn Boudreau, a social worker at the Rosecrance adolescent treatment center in Rockford. "The overarching and clear message to teens has been: `You drink, you drive, you die.' "There really hasn't been that same kind of consistent message for marijuana."
That's largely because pot's role in fatal crashes is far from clear. The National Highway Traffic Safety Administration, which keeps statistics on wrecks involving alcohol, does not have enough data to generate similar numbers for marijuana. Heidi Coleman, chief of the safety administration's impaired driving division, said many police officers likely never detect pot because they aren't trained to read physical cues--such as pupil size, body temperature and heart rate--that suggest the drug's presence. "They may suspect that a driver is impaired, but if they don't test positive for alcohol, officers may let them go," she said.
Research into marijuana's impact on driving is similarly limited, she said. While state law treats measurable levels of pot or other drugs as evidence of DUI (similar to a blood-alcohol reading of 0.08 percent or higher), science is more nebulous. Some studies have linked marijuana to decreased attentiveness, slower reactions, diminished motor skills and a worsened ability to estimate distance, but there is no consensus about how severe the effects are or how long they last.
The debate over what really constitutes impairment will likely play out in a Lake County courtroom later this year when Richard Wood, 17, faces trial in the deaths of two friends who were passengers in a car he wrecked Nov. 13. Prosecutors, who say the Mundelein teen had used pot within 24 hours of the crash, have charged him with aggravated driving under the influence of drugs and reckless homicide. Wood's attorney, Robert Gevirtz, would not comment on his client's alleged marijuana use but said he would prove that his client was not impaired at the time of the crash.
Tabitha Fischer, 19, has no doubt that marijuana worsened her driving when she was growing up in Belleville, even though she saw nothing wrong with it at the time. "When I was doing it, I thought I was a better driver," said Fischer, who recently completed a year of substance abuse treatment at Rosecrance. "As I look at it now ... I'd go through stop signs, stoplights, and I'd just laugh it off. I didn't focus on anyone else on the road, from what I can remember. It was like I was the only person there."
She said she never heard anything in class about the hazards of driving while high. That's something Cratty has tried to change in Highland Park by making marijuana, not alcohol, the culprit for the fatal wreck that the high schools simulate every year. Though it's hard to gauge the presentation's impact, she said students have been glad to see the schools discuss the threat of the popular drug. "I think they're somewhat surprised that we recognize that," she said.
Why Mommy Smokes
Hilary MacGregor, Los Angeles Times- 9/18/2006
Many women immediately quit smoking when they find out they are pregnant, knowing the habit is unhealthy for their unborn child. But sometimes that concern takes them only so far.
A new study has found that women who were unmotivated to remain smoke-free after the birth of a child were more concerned about their weight than those who intended to kick the habit for good. "Thinking about weight is important in understanding women's smoking after pregnancy," said Michele Levine, a professor of psychiatry and psychology at the University of Pittsburgh Medical Center, and lead author of the study. "Women are complex creatures. More than just whether they are going to breast-feed the baby, or are addicted to nicotine, or are addicted to alcohol, healthcare providers need to think about psychological issues like weight worries."
Levine said a normal woman would have to gain 80 to 100 pounds to equal the risk of smoking postpartum.
For the study, which will appear in the October issue of the Annals of Behavioral Medicine, Levine and colleagues interviewed 119 women who had smoked at least eight cigarettes a day but who quit when they found out they were pregnant. During the women's third trimester, researchers asked whether they planned to resume smoking after the birth.
They found that 65% of the women were highly motivated not to smoke again, with 74% of that group confident they would be able to stick to their plan.
The 35% who were less motivated to stay smoke-free after giving birth were more concerned about managing weight than those who were determined to give up cigarettes for good.
"The big question is what they actually do," Levine said. "But at the third-trimester point, weight concerns were more related to motivation to quit smoking than any other factor."
Researchers found that the more confident a woman was about her ability to maintain her weight without smoking, the more likely it was that she planned to quit for good. Researchers also found that women who intended to breast-feed were more likely to plan to abstain from smoking.
Dr. Sharon Phelan, an obstetrics-gynecology professor at the University of New Mexico and a member of the American College of Obstetrics and Gynecology, said a percentage of women who smoke do so to control their weight. When they get pregnant, she said, they get the support they need to quit because many people are aware that smoking carries health risks for a fetus. (The practice can decrease the amount of oxygen that gets to the baby, which interferes with fetal growth and can lead to pre-term delivery.)
"The irony is, after they have the baby there is not that external support," Phelan said. "Friends don't understand why they won't join in for a cigarette, and the father of the baby, who was supportive during the pregnancy, no longer is. That makes it hard for a woman to stay smoke-free."
Dr. Jeanne Ballard, who consults for a quit-smoking hotline in Indiana that counsels many pregnant women, said women need to be reminded there are other ways to lose weight: Breast-feeding, for example, uses 500 to 600 calories a day.
Post-birth, exposure to second-hand smoke can increase a child's susceptibility to chest colds and ear infections, experts say. It can also increase their risk of asthma and crib death.
A Psychiatrist Is Slain, and a Sad Debate Deepens
Benedict Carey, New York Times- 9/19/2006
In the hour before he was killed, on Sunday, Sept. 3, Dr. Wayne S. Fenton, a prominent schizophrenia specialist, was helping his wife clear the gutters of their suburban Washington house. He was steadying the ladder, asking her to please stop showering debris on his clean shirt; he had just made an appointment to see a patient and wanted to look presentable. She said she would be happy to go along, to help control the patient. It was a running joke between them. For in this part of the country, Dr. Fenton was the therapist of last resort, the one who could settle down and get through to the most severely psychotic, resistant patients, seemingly by sheer force of sympathy and good will. An associate director at the National Institute of Mental Health, he met with patients on weekends, sometimes late at night, at all hours. “Absolutely the most nonthreatening person you ever, ever met,” his wife, Nancy Fenton, said in an interview last week.
At 4:52 p.m. that Sunday, the Montgomery County police found the 53-year-old psychiatrist dead in his small office, a few minutes’ drive from his house. They soon tracked down the patient he had agreed to meet that afternoon, Vitali A. Davydov, 19, of North Potomac, who admitted he had beaten the doctor with his fists, according to charging documents. When the young man left the office, “Dr. Fenton was on the ground, bleeding from the face,” the documents said. Dr. Fenton had known that the patient presented some risk: he was young, male, severely psychotic and struggling with a mental state that was frightening and unfamiliar. The psychiatrist was trying to persuade his patient to continue taking medication, Mrs. Fenton said.
The killing, besides devastating the two families involved, has deeply shaken mental health workers around the country. In the days since, many have wondered about their own safety and about the dangers of allowing patients with severe psychosis to go without medication.
Dr. Fenton’s death is not likely to change psychiatric practice, experts said, but it may become a touchstone for one of the most contentious debates in psychiatry: whether people suffering from psychosis should be compelled to accept treatment to reduce the risk of violent outbursts. “We have been thinking about all these things in the past week, that’s for sure,” said Dr. Thomas H. McGlashan, a psychiatrist at Yale and a close friend of Dr. Fenton’s, who worked with him decades ago at Chestnut Lodge, a renowned psychiatric hospital that closed in 2001. “Yes, there is a risk of violence with some patients, and no, it’s not black-and-white, like some would want you to see it. It’s not just that Wayne is dead, but that the kid’s life is ruined too.”
Violence is less common among those with mental illnesses than is sometimes assumed. Many people with schizophrenia are withdrawn, more likely to be targets of an assault than to commit one, said Bruce Link, a professor of epidemiology at Columbia. But studies suggest that those with untreated psychosis — often characterized by intense paranoia and imaginary voices issuing commands — are at least two to three times as likely as people without mental disorders to get into physical altercations, including fights using weapons, Dr. Link said.
An analysis published last month in The American Journal of Psychiatry found that people with severe mental illness committed about 5 percent of the violent crimes in Sweden, though they made up a small fraction of the population. The United States, which has higher crime rates, has a much smaller proportion of crime attributable to the mentally ill than Sweden, experts said. Yet the risk is real, if remote, for those who meet one on one with severely psychotic patients and try to negotiate difficult issues like medication. So-called antipsychotic drugs effectively blunt symptoms of psychosis and tend to reduce the risk of violent outbursts, psychiatrists say. But the medications are mentally dulling and often cause weight gain, among other side effects, and many patients either stop taking them or refuse them altogether.
In part to forestall violent episodes, several states, including New York and California, have tightened their treatment laws to compel some mental health patients to accept treatment, even if they have not committed a crime. The issue is divisive among former psychiatric patients, researchers and practicing psychiatrists. “This is an extremely important issue for psychiatry, and there are two sides of this story,” said Dr. William T. Carpenter Jr., the director of the Psychiatric Research Center at the University of Maryland and the editor of the journal Schizophrenia Bulletin. “As doctors, we think patients ought to do what we think they should do, and if someone needs to be on medication it’s difficult not to wish there was some way to do that.” On the other side, Dr. Carpenter said, “you have a significant civil rights argument.”
In the wake of Dr. Fenton’s killing, some patient advocates cautioned against exploiting the tragedy to promote forced treatment. “The main concern is that we not let fear and stereotypes based on this case drive public policy” in support of forced commitment and drug treatment, said Will Hall, a mental health advocate in Northampton, Mass., who was hospitalized as a young man and treated with antipsychotic drugs for about four months after a suicide attempt. A better way to prevent violence, Mr. Hall said, “is to offer patients who refuse medication on any ground a much wider range of options, including psychosocial treatments.” Yet alternatives to drug treatment are not yet widely available. And with the news of Dr. Fenton’s killing in their thoughts, some psychiatrists said they were thinking carefully about the precautions they take every day.
“When a patient is revving up and paranoid,” Dr. McGlashan said, “instead of becoming imperious or dogmatic or rigid I might admit that I’m kind of nervous too. If you’re scared, you let the patient know that. Because a lot of their behavior is coming from their perception of being threatened. If you let them know that you are feeling threatened, vulnerable and not interested in controlling them, that can help defuse the situation.” All of which, of course, Dr. Fenton understood. But the need was urgent, Mrs. Fenton said. The need was urgent, the family was desperate, and that was enough for her husband, as long as she had known him. Someone wanted his help, so Wayne would go.
Democrat, Republican and a Bond of Addiction
Mark Leibovich, New York Times- 9/19/2006
WASHINGTON, Sept. 18 — Scenes from an uncommon political marriage: Representative Jim Ramstad, a Republican from Minnesota, and Patrick J. Kennedy, a Democrat from Rhode Island, are deep in conversation on the House floor, Mr. Ramstad’s hand draped over his colleague’s shoulder. Later that day, Mr. Ramstad receives a note in the Republican cloakroom from Mr. Kennedy, who needs a ride to a support group they attend in Georgetown. “Patrick’s not driving currently, so I’m sort of his chauffeur,” Mr. Ramstad says.
After the meeting, Mr. Kennedy and Mr. Ramstad sit with friends in their regular booth at Morton’s Steakhouse. The gathering resembles any Washington power table, except the men are sipping Diet Coke and mineral water, have just come from “group” and are occasionally crying. “We love each other for our imperfections and for our common humanity,” Mr. Kennedy says. The dinner last Tuesday celebrated Mr. Kennedy’s fourth month of sobriety, a process jolted into motion by an early morning car accident on Capitol Hill in May and a subsequent rehabilitation at the Mayo Clinic in Minnesota, where he was treated for an addiction to painkillers.
In the precarious course of his recovery, Mr. Kennedy, the 39-year-old son of Senator Edward M. Kennedy, Democrat of Massachusetts, has come to rely heavily on Mr. Ramstad, 60. He has served as Patrick Kennedy’s sponsor, his primary source of advice and support in what he calls “the daily fight for my life” against addiction. The day after the accident, Mr. Kennedy received a phone call from Mr. Ramstad, a recovering alcoholic who has been an evangelist in Congress for addiction treatment and 12-step recovery programs. The men did not know each other well. But in battling their addictions, the two built a fast kinship that flouts the partisan divisions of Congress, their own divergent politics and the conditional nature of so many friendships in Washington. They speak daily, often several times. Mr. Ramstad visited Mr. Kennedy during his 28-day rehabilitation, driving two hours each Saturday from his Minnetonka home. When the Rhode Island Republican Party chairman called for Mr. Kennedy’s resignation after his crash, Mr. Ramstad called it “a slap in the face” to all recovering addicts.
Former Senator Max Cleland, a Georgia Democrat who frequently attends the Tuesday dinners, said, “This is a story of a shared and common humanity and overcoming political differences in a town known for its inhumanity.” Mr. Cleland, who lost both legs and part of an arm in Vietnam, says he is in recovery from “the trauma of war.” “It’s a great brotherhood we all share,” he said of the dinner group. “And it has nothing to do with politics except that we’re all in it.” The political world could learn much from these gatherings, Mr. Ramstad says. “If we could turn Congress into one big A.A. meeting,” he said, referring to Alcoholics Anonymous, “where people would be required to say what they mean and mean what they say, it would be a lot better Congress.”
In a joint interview with Mr. Kennedy and Mr. Ramstad in Mr. Ramstad’s office, each man nods solemnly while the other speaks. Both are mindful of the confidentiality rules involving recovery groups. They say they agreed to be interviewed because their “sponsorship” relationship was revealed in court as a condition of Mr. Kennedy’s probation (he pleaded guilty to impaired driving). Mr. Kennedy has big expressive eyes, a lanky frame and slightly hunched posture that lends the impression of an overgrown boy. Mr. Ramstad walks chest-out and speaks with the practiced certainty of a man who has counseled numerous addicts over 25 years. The two men share a keen sense of the twin burdens that being an addict and congressman impose, Mr. Kennedy says. “To some degree, all politicians lead a double life, a public one and a private one,” he said. Mr. Ramstad has emphasized the importance of integrating what he calls “the political game face” with “the real person inside.”
Being a Kennedy carries its own weight, Mr. Kennedy says, given the legacy of drug and alcohol abuse in his family. His mother, Joan Kennedy, has endured a long battle with alcoholism, and his father was involved in a string of alcohol-related episodes earlier in his career. (Senator Kennedy says he will drink a glass of wine at home at night or in social settings. He describes himself as being “well” over the last 15 years, a recovery he attributes to his current wife, Victoria.) In a phone interview, Senator Kennedy says he shares a meal with Patrick once a week. His son is doing well, he says, thanks in large part to “the incredible generosity of spirit” of Jim Ramstad. Patrick Kennedy makes frequent references to the pressures and expectations inherent in his name. “When you grow up in my family, being somebody meant having power, having status,” he said. “The compensations you got were all material and superficial. I’ve come to realize, in the last few months, that that life made me feel all alone.”
Both Mr. Ramstad and Mr. Kennedy are active in a House caucus of about 60 representatives that promotes legislation for treatment of addiction and mental illness. Some of the members are addicts themselves, or recovering addicts, Mr. Kennedy and Mr. Ramstad say, but neither would estimate how many. Mr. Ramstad attended support group meetings with former Representative Phil Crane, Republican of Illinois, who battled alcoholism and says his own recovery was nurtured by the late Senator Harold Hughes, Democrat of Iowa, who spoke of his own struggle with drinking.
“There is a very powerful recovering community in this town,” said Capt. Ronald Smith, the former chairman of psychiatry at the National Naval Medical Center in Bethesda, Md., and a regular at the Tuesday dinners. A recovering addict, he has treated many senators and congressmen and leads the support group attended by Mr. Kennedy, Mr. Ramstad and Mr. Cleland. It is unclear, Captain Smith says, whether addiction is more common among politicians, but alcohol does tend to pervade political life, with its cocktail party fund-raisers, endless dinners and constant travel. Ann Richards, the former Texas governor who was buried Monday, used to visit prison inmates and say, “My name’s Ann, and I’m an alcoholic.”
Mr. Ramstad makes repeated mention of “July 31, 1981,” the day he awoke from an alcohol-induced blackout in a Sioux Falls, S.D., jail after creating a disturbance at a hotel coffee shop. He had just finished his first term as a Minnesota state senator. “If I had not wound up in that jail cell, I would not have sought treatment,” Mr. Ramstad said. “I would probably be dead today.”
Mr. Kennedy has endured several public battles with mental illness. He was treated for cocaine addiction as a teenager, suffered from depression as a young adult, was given a diagnosis of bipolar disorder after coming to Congress in 1994 and then became addicted to painkillers. He also was prone to binge drinking, which contributed to a scuffle with an airport security guard and a visit from the Coast Guard after a heated argument with a girlfriend aboard a yacht, among other episodes that became public.
The May car crash was the latest embarrassment. The police found Mr. Kennedy disoriented, claiming he was heading to a House vote though Congress was not in session (it was 2:45 a.m.). Mr. Kennedy, who had been driving without headlights before swerving into a police barrier, blamed a mix of prescription medications for the accident. Both men describe their signature humiliations — Mr. Kennedy’s accident and Mr. Ramstad’s arrest — as “blessings” that spurred them into recovery. “We both totally hit the wall, and it was publicized,” Mr. Kennedy said. “Or the barrier in my case.” Mr. Ramstad says he has come to “love Patrick like a brother,” although there is more of a paternal tone to his manner when they are together. At one point during the interview, Mr. Ramstad tells him to turn off his hyperactive cellphone. Mr. Kennedy sheepishly obliges. He says he is learning to take instructions from a Republican.
Study: ADHD Cases Linked to Lead, Smoking
Associated Press, 9/19/2006
CHICAGO -- About one-third of attention deficit cases among U.S. children may be linked with tobacco smoke before birth or to lead exposure afterward, according to provocative new research. Even levels of lead the government considers acceptable appeared to increase a child's risk of having attention deficit hyperactivity disorder, the study found.It builds on previous research linking attention problems, including ADHD, with childhood lead exposure and smoking during pregnancy, and offers one of the first estimates for how much those environmental factors might contribute.''It's a landmark paper that quantifies the number of cases of ADHD that can be attributed to very important environmental exposures,'' said Dr. Leo Trasande, assistant director of the Center for Children's Health and the Environment at Mount Sinai School of Medicine in New York.More importantly, the study bolsters suspicions that low-level lead exposure previously linked to behavior problems ''is in fact associated with ADHD,'' said Trasande, who was not involved in the research.The study's estimate is in line with a National Academy of Sciences report in 2000 that said about 3 percent of all developmental and neurological disorders in U.S. children are caused by toxic chemicals and other environmental factors and 25 percent are due to a combination of environmental factors and genetics.''The findings of this study underscore the profound behavioral health impact of these prevalent exposures, and highlight the need to strengthen public health efforts to reduce prenatal tobacco smoke exposure and childhood lead exposure,'' said the authors, led by researcher Joe Braun of the University of Wisconsin-Milwaukee.The study was to be published online Tuesday in the journal Environmental Health Perspectives.ADHD is a brain disorder affecting between 4 percent and 12 percent of school-age children -- or as many as 3.8 million youngsters. Affected children often have trouble sitting still and paying attention and act impulsively at home and at school. Researchers aren't certain about its causes but believe genetics and environmental factors including prenatal exposure to alcohol, tobacco or illicit drugs may play a role.Dr. Helen Binns, a researcher at Children's Memorial Hospital in Chicago, said the study is a thoughtful analysis but doesn't prove lead exposure is among the causes. It's possible, for example, that young children with ADHD are more likely than others to eat old leaded paint chips or inhale leaded paint dust because of their hyperactivity.The researchers analyzed data on nearly 4,000 U.S. children ages 4 to 15 who were part of a 1999-2002 government health survey. Included were 135 children treated for ADHD.They asked whether mothers had smoked during pregnancy but used blood tests to determine lead exposure, said co-author Dr. Bruce Lanphear, a researcher at Cincinnati Children's Hospital Medical Center.Children whose mothers smoked during pregnancy were 2 1/2 times more likely to have ADHD than children who weren't prenatally exposed to tobacco.Children with blood lead levels of more than 2 micrograms per deciliter were four times more likely to have ADHD than children with levels below 0.8 microgram per deciliter. The government's ''acceptable'' blood lead level is 10 micrograms per deciliter, and an estimated 310,000 U.S. children ages 1 to 5 have levels exceeding that.Based on study estimates, more than 5 million 4-to-15-year-olds nationwide have levels higher than 2 micrograms per deciliter, Lanphear said.Trasande said the study adds further proof that the government should lower its threshold for safe lead exposure.Exposure to tobacco smoke after birth was not associated with increased ADHD risks, even though childhood exposure to lead was.''Saying there are different periods of vulnerability to different toxins is perfectly plausible,'' said Dr. Robert Geller, a pediatric toxicologist at Emory University.''There may be very specific periods of vulnerability,'' depending on when the developing brain is exposed, Geller said.On the Net:
Environmental Health Perspectives: http://ehponline.org
Government: http://www.cdc.gov/lead
People Who Share a Bed, and the Things They Say About It
Kate Murphy, New York Times- 9/19/2006
While researching rural life more than 20 years ago, Paul C. Rosenblatt took his 12-year-old son with him to interview farm families in the Midwest. Father and son stayed in a farmhouse and had to share a bed. “It was terrible,” said Dr. Rosenblatt, a professor of sociology at the University of Minnesota, Twin Cities, because his son thrashed and turned so much that “his feet were in my face all night.” Tired and bedraggled the next day, he recalled thinking about how challenging it can be to adapt to sleeping with another person.
In more recent research — on grief — Dr. Rosenblatt interviewed couples whose children had died. “They quite often would tell me that they dealt with their grief by holding each other and talking together in bed at night,” he said. “It seemed that I kept being reminded of how sharing a bed impacts our lives and sense of well-being.” And yet, no one had really studied it, perhaps because sharing a bed is so mundane, Dr. Rosenblatt said. So he wrote “Two in a Bed: The Social System of Couple Bed Sharing,” published this summer by State University of New York Press. “It’s not a self-help book,” he said, but an examination of some of the common and often humorous issues couples face when sharing a bed, including spooning, sheet-stealing and snoring. “My hope is that the book will influence the world of sleep research so sleep is no longer viewed as an individual phenomenon,” Dr. Rosenblatt said.
There are thousands of studies on sleep and even more on marriage and relationships, but only a handful on couples sleeping together. The National Sleep Foundation, a nonprofit group in Washington that supports education and research on sleep and sleep disorders, estimates that 61 percent of Americans share their bed with a significant other. And while the very presence of another person in bed increases the chance of sleep disruption, 62 percent of those polled in the foundation’s annual sleep study said they preferred to bed down with their partner.
In researching his book, Dr. Rosenblatt said even though many couples said they slept better alone, they still shared a bed. “When I asked why, they looked at me as if I’d asked them why they keep breathing,” he said. For “Two in a Bed,” Dr. Rosenblatt interviewed 42 couples. Most of them were married heterosexual couples but some were unmarried hetero- or homosexual couples. Intimacy and comfort were the primary reasons couples gave for sleeping together. “Some mentioned sex, but not a lot,” Dr. Rosenblatt said. Most reported that the bed is where they talked. “The bed is where they found privacy and were able to leave behind the distractions and separate interests that keep them apart during the day. There’s also something about late night that allowed them to open up and connect.”
Several interviewees reported that difficulty sleeping together or sleeping apart had led to the dissolution of previous marriages, and that sleeping together was essential to maintaining their relationships. Dr. Rosenblatt found that it might also save lives. “It surprised me how many people thought they were alive today because they shared a bed,” Dr. Rosenblatt said. For example, he said a woman’s seizure was noticed immediately by her husband with whom she spooned every night. Similar stories came from couples where one partner had a heart attack, stroke or went into diabetic shock.
The couples Dr. Rosenblatt interviewed described how they had had to adjust to sleeping with their partner. Many reported conflicts over bedroom temperature, where to locate the bed and how to make the bed. Watching television, reading and eating in bed were other contentious issues, as was sleeping in the nude. There were quarrels over the alarm clock and whether to allow children or pets into the bed. “Each couple had to do a lot of problem solving to work out their systems for sleeping together,” Dr. Rosenblatt said. These systems, he said, usually became comforting routines of how couples prepared for bed, got into bed, behaved once in the bed, fell asleep and woke up.
The subjects he interviewed invariably had their own side of the bed, and responsibilities like putting out the cat or opening the windows before turning in. They usually had rituals like watching the television news before lights out or snuggling before falling to sleep. And they often had signals for when they wanted affection, wanted to talk or wanted to be left alone. “How they arrived at these systems could be said to mirror their relationships,” said Dr. Rosenblatt. The most successful systems were those formed out of compromise and sensitivity to the other’s needs.
“The issues change over time,” Dr. Rosenblatt said. Whereas a woman might have always been cold at night when she was younger, she might feel like a furnace from menopausal hot flashes as she grows older. Prostate problems might cause a man to get up more often in the night to use the bathroom. Illness and injury might prevent people from sleeping entwined with each other.
Not surprisingly, perhaps, those interviewed said dealing with a partner’s snoring and insomnia profoundly affected the couple’s sleep dynamic. “These are all things that no one teaches you how to cope with,” said Neil B. Kavey, a psychiatrist and director of the Sleep Disorders Center at New York-Presbyterian/Columbia University Medical Center. “There’s no counseling in this regard, but there should be.” Sleep centers are primarily concerned with treating disorders and don’t address the impact one partner has on the other. Whatever the cause of unrest, “sleep deprivation has consequences,” Dr. Kavey said. Those include impaired cognitive ability and irritability.
Though Dr. Rosenblatt has written five other books and scores of scholarly essays and papers, he said his book on couples’ sleep has gotten by far the most attention from the news media and fellow academics. “I think it’s because it’s something most people have struggled with and can relate to,” Dr. Rosenblatt said. “And even though we may take sleeping with our partner for granted, it’s through these kinds of shared social systems that we build and nurture our relationships, and perhaps uncover the underlying meaning of our lives.”
Shock Therapy Loses Some of Its Shock Value
Jane Brody, New York Times- 9/19/2006
For an older woman I know who was suffering from “implacable depression” that refused to yield to any medications, electroconvulsive therapy — popularly called shock therapy — was a lifesaver. And Kitty Dukakis, wife of the former governor of Massachusetts and 1988 Democratic presidential nominee, says ECT, as doctors call it, gave her back her life, which had been rendered nearly unlivable by unrelenting despair and the alcohol she used to assuage it. Neither woman has experienced the most common side effect of ECT: memory disruption, though Mrs. Dukakis recalls nothing of a five-day trip to Paris she took after her treatment. The television host Dick Cavett, who also had the treatment, wrote in People magazine, “In my case, ECT was miraculous.” Mr. Cavett added, “It was like a magic wand.” But for a man I know who was suicidally depressed and given ECT as a last resort, it did nothing to relieve his depression but destroyed some of his long-term memory.
Such differences in effectiveness and side effects are not unusual in medicine and psychiatry, and they are not played down in a new book called “Shock,” which Mrs. Dukakis wrote with Larry Tye, a former Boston Globe reporter. The book, in which Mrs. Dukakis details her experience with depression and ECT, explores the history, effectiveness and downsides of this nearly 70-year-old treatment, a remedy that has been repeatedly portrayed in film and literature as barbaric, inhuman, even torturous.
Few people seem to know that ECT has undergone significant changes in recent decades, placing it more in line with widely accepted treatments like those used to restart a stopped heart or to correct an abnormal heart rhythm. After a rather precipitous decline in the 1960’s when effective antidepressant drugs became available, ECT since the 1980’s has experienced something of a comeback, and is used primarily in these circumstances:
• When rapid reversal of a severe or suicidal depression is needed.
• When depression is complicated by psychosis or catatonia.
• When antidepressants and psychotherapy fail to alleviate a crippling depression.
• When antidepressants cannot safely be used, such as during pregnancy.
• When mania or bipolar disorder do not respond to drug therapy.
Though there is no official count, experts estimate that more than 100,000 patients undergo ECT each year in the United States. ECT was developed in the 1930’s by an Italian neurologist, Ugo Cerletti, who “tamed” difficult mental patients with electric shocks to the brain after noting that such shocks given to hogs before slaughter rendered them unconscious but did not kill them. In its first decades of use, ECT was administered to fully conscious patients, causing them to lose consciousness and experience violent seizures and uncontrolled muscle movements that sometimes broke bones. It was sometimes used in patients without their consent, or at least without informed consent. And while evidence for its effectiveness did not extend much beyond depression, for a time ECT was applied to patients with all kinds of emotional disturbances, including schizophrenia. It was also widely used in mental hospitals to punish or sedate difficult patients, as was graphically depicted by Jack Nicholson in the movie “One Flew Over the Cuckoo’s Nest.”
Some people may also recall that Ernest Hemingway, who suffered from life-long and often self-medicated depression, committed suicide in 1961 shortly after undergoing ECT. He had told his biographer: “Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure, but we lost the patient.”
A Modified Treatment
Though the impression of ECT left in the public mind by such films and writings persists, ECT today is a far more refined and limited therapy. Most important, perhaps, is the use of anesthesia and muscle relaxants before administering the shock, which causes a 30-second convulsion in the brain without the accompanying movements. Thus, there is no physical damage. The pretreatment also leaves no memory of the therapy itself. The amount of current used today is lower and the pulse of electricity much shorter — about two seconds — reducing the risk of post-treatment confusion and memory disruption. While memory losses still occur in some patients, now the most serious risk associated with ECT is that of anesthesia.
Most patients require a series of six to eight treatments, delivered over several weeks. As my friend discovered, however, it is not universally effective. About three-fourths of patients are relieved of their debilitating symptoms at least temporarily. The remaining one-quarter are not helped, and some may be harmed.
Despite its long history, no one knows how ECT works to ease depression and mania. There is some evidence that it reorders the release of neurotransmitters, favoring an increase of substances like serotonin, which counters depression. Some experts view it as a pacemaker for the brain that disrupts negative circuitry. The beauty of ECT is the speed with which it works. Antidepressants can take as long as six weeks to relieve serious depression. Mrs. Dukakis reported that she had begun to feel better after the first in an initial series of five outpatient ECT treatments given over a two-week period.A Stopgap Measure
But — and this is a big but — ECT is not a cure for depression. It is more like a stopgap measure that brings patients to a point where other approaches, including antidepressants and cognitive behavioral therapy, can work to stave off relapses. Although some ECT patients never relapse, most are like Mrs. Dukakis, who over the course of four years has come back for seven more rounds of ECT. She explained that while she used to deny the early signs of a recurring depression, she now calls her doctor “as soon as I spot the gathering clouds.” “ECT has wiped away that foreboding,” she wrote, and “given me a sense of control, of hope.” It has also helped her get off antidepressants, which had side effects like bowel, sexual and sleep disturbances and an inability to experience “the full range of my feelings.”
ECT should not be administered without the patient’s (or the patient’s surrogate’s) fully informed consent, which includes consideration of all possible side effects. The most common side effects are headache, muscle soreness and confusion shortly after the procedure, as well as short-term memory loss, which usually improves over a period of days to months. But according to the American Psychiatric Association, there is no evidence that ECT causes brain damage. Abuse of the procedure has declined strikingly. Today fewer than 2 percent of patients hospitalized in psychiatric facilities in New York State receive ECT. Properly used, it can be lifesaving.
Though there is not nearly the money to be made from ECT that there is in selling antidepressants, work on improvements continues. Modern ECT is sometimes delivered to only one side of the brain, reducing the chances of memory deficits. Another new approach uses a magnetically induced current that can be aimed at specific regions of the brain, possibly altering them permanently. An advantage of this treatment, however, is that it does not require the use of anesthesia.
Exercise Helps Talk Therapy
Hannah Karp, Wall Street Journal- 9/20/2006
For most tennis players, love means nothing. But Zach Kleinian wants to know what love means to you. Kleinian is a professional tennis instructor turned therapist. From a court in Los Angeles, he works with as many as 50 clients a week on issues like anger management, addiction and narcissism --all through the game of tennis. His techniques include talking to clients about their concerns during rallies, analyzing their shots for hidden aggressions and using drills like "Dad and Me," in which the client has to say whether he's hitting each shot to fulfill his own expectations, or his father's. "The ball is just a metaphor" says Kleinian, who refers to his work as "zennis."
Kleiman has no formal training and he isn't licensed as a mental health professional. He has built a thriving practice through referrals from a group of licensed therapists and by word-of-mouth.
He is one in a tiny niche of mental-health practitioners who are combining physical activity and talk therapy. The methods range from strolls to more rigorous "Adventure Therapy" programs, which involve wilderness experiences like rock-climbing and camping. Atlanta psychiatist Sheldon B. Cohen runs with his patients, while licensed counselor Geri Dube takes her clients on walks around Seattle.
Some prominent doctors are critical of the approach, saying that it can violate professional guidelines meant to establish boundaries and maintain confidentiality. Therapists have also found some real-world risks. Clay Cockrell, a New York social worker who walks with his clients, has witnessed a mugging in Central Park and an explosion during his sessions. Psychotherapist Terri Hengesh, who hikes with her patients in Northern California, has run into snakes on the trail. (If you encounter a snake while walking with your therapist, is it really just a snake?)
The alternative treatments come as mainstream therapists are under pressure in part because of the success of drugs in treating mental illness. Patients are increasingly opting for medication over talk therapy. Nearly 15 percent of adults used an antidepressant at least once last year, according to pharmacy benefit manager Medco Health Solutions, up from 12 percent of adults in 2001. While drugs are often meant to be used in conjunction with talk therapy, medication is serving as a substitute. A study published this month in the American Journal of Managed Care found that fewer than 15 percent of patients received the suggested level of follow-up care after starting antidepressant medication--the US. Flood and Drug Administration recommends weekly face-to-face visits in the first four weeks. Health insurers often cover just half of the cost of mental health treatments, leading patients to drop out.
A number of studies have documented thepsychological benefits of exercise. While scientists have long known that a workout can temporarily boost serotonin levels and improve mood, the latest research shows that exercise can have a deeper and more lasting effect. One article in the American Journal of Preventitive Medicine last year found a correlation between the intensity of exercise and a reduction in depression. A 2005 study published in the Journal of Neuroscience found that exercise increases the growth of neuronal brain cells, possibly elevating mood permanently. Advocates of the combined approach say that being active during the session helps patients to relax and open up, and some patients say they find it easier to talk while looking forward and walking, rather than staring the therapist in the eye.
Jeffrey Marsh is working through childhood trauma on the court with Kleinian. Dr. Marsh, a professor of psychology who has his own practice and is president of the Gestalt Therapy Institute of Los Angeles, a professional group for psychotherapists who use Freudian analysis and other approaches, has referred more than 10 patients to Kleinian over the years. He cautions that the sessions should supplement, not replace, conventional treatment. "It's not therapy, but its very therapeutic," he says. (Dr Marsh and other clients interviewed waived confidentiality and allowed their names and sessions to be put on the record)
Kleinian generally starts sessions --at a rate of $90 an hour--with a personal question such as, "What quality would you like to express more of?" Patients' problems run the gamut. Brian Boyle, a 37-year-old TV writer from Seattle who has written episodes of "Friends," came because he was having trouble with a screenplay (Kleiman says Boyle's 120 mile-an-hour serve speaks to the fact that "he likes to start things, but the aggression that he has at the beginning dissipates.") To help Boyle get in touch with his characters, Kleinian starts with a role-playing exercise. "I'll do Walt, you do Ted," says Kleiman, referring to characters from the script. After a few silent hits back and forth, he says, "More Ted, please."
Jason Blum, a 37-year-old film producer, wants to discuss shame. He had just received a toy dump truck in the mail from a woman he had neglected to call after their second date. "I was quietly dumping her, but she was loudly dumping me. I'm ashamed that I couldn't take the initiative first," he says.
Couples come, too. John Peaslee, who had heard stories of Kleiman but was wary about doing something so "touchy-feely" signed up for lessons with his wife after she came home late and they got into a fight. "We were here for 10 minutes and Zach said to my wife, `You have control issues,' and to me, `You have intimacy problems.' The instructions were to play inside the box and I kept backing up," says Peaslee, a 55-year-old TV producer and writer.
Exercising your demons
While the vast majority of therapists stick to sessions in the office, some are experimenting with a combination of exercise and talk. Here are a few of the methods.
• Tennis- Zach Kleiman is one of the few doing "counseling' on the court. He avoids terms like forehand and follow-through, and instead uses drills like "Me Against the World," a three-on-one rally.
• Adventure therapy- There are more than 50 of these programs (activities include bungeejumping and rock climbing) in the U.S., mostly targeted at troubled teens. One recent study showed participants had better grades and communication two years later, but critics say programs are poorly regulated.''
• Running- Ozzie Gontang, a family therapist in San Diego, has run with patients - individuals, couples and families - since the 1970s. He says it's empowering for people who feel they "can't go on." Out of shape? Therapists will slow the pace if clients have difficulty talking and jogging.
• Walking- Practitioners include psychologist John F. Murray in Palm Beach, Fla., and licensed therapist Yafa Suslovich in Phoenix. One drawback: the potential to bump into acquaintances or co-workers. "Some people introduce me as their friend," says social worker Clay Cockrell.
• Yoga- Michael Russell, a licensed clinical social worker in Chicago, started integrating yoga into his practice five years ago, but says he's more focused on psychology than stretching. "I don't touch my patients like a yoga teacher would," he says. "That would be crossing a boundary."
Lawmakers Pave Road to Recovery with Legislation
Richard Clough, Chicago Tribune- 9/22/2006
WASHINGTON -- When seeking help for an addiction that nearly cost him his political career, Rep. Patrick Kennedy found a non-drinking buddy just across the aisle. Kennedy, a Democrat from Rhode Island, found not only a fast friend in Rep. Jim Ramstad, a Minnesota Republican and recovering alcoholic. He also found a legislative co-sponsor as the two try to translate their struggles into a law benefiting all addicts. They announced Thursday that they are pushing the Paul Wellstone Mental Health Equitable Treatment Act, which would put health insurance coverage for addiction treatment on a par with treatment of chronic diseases. They hope their willingness to share their addictions will give new impetus to legislation that has been languishing in Congress in one form or another for five years. "I have an addiction, I have a mental illness," Kennedy reporters Thursday as Ramstad stood nearby.
After a car crash in May led Kennedy to check himself into a rehabilitation clinic for an addiction to painkillers, the 39-year-old son of Sen. Edward Kennedy (D-Mass.) began his journey to recovery, with Ramstad, 60, as his sponsor. Since he got sober 25 years ago, Ramstad said, he has led legislative efforts to "reduce the stigma" of admitting to and seeking help for chemical dependency. He co-chairs the House Addiction, Treatment and Recovery Caucus with Kennedy. Ramstad candidly discusses his troubled past to warn of the dangers of alcohol and laud the benefits of treatment. "I don't want to go back to that jail cell where I woke up on July 31, 1981, as a result of my last alcoholic blackout," Ramstad said.
Ramstad and Kennedy have teamed with the Betty Ford Center and Caron Treatment Centers to push the bill named for Sen. Paul Wellstone, a Minnesota Democrat who died in a plane crash in 2002. The bill has 228 co-sponsors in the House but has not been scheduled for a floor vote. Douglas Tieman, CEO of the Caron centers, said getting insurance coverage for addiction treatment has been increasingly difficult since the early 1990s, when a health-care overhaul siphoned money away from mental health treatment. It has been difficult to lobby for coverage, he said, because addicts are widely dispersed and have no organized group to represent them. And addicts, he said, often have a more difficult time seeking help than those with chronic diseases, in part because addiction is often seen as a consequence of personal choices rather than a disease. "The person who drives too fast and gets in an accident, we don't leave them on the side of the road, bleeding," Tieman said, adding that addicts do not choose to become addicted.
Since the mid-1960s, the American Medical Association and the American Psychiatric Association have categorized alcoholism as a disease. Wellstone championed mental health parity throughout the 1990s, and he first introduced an equitable-treatment bill in 2001, along with Republican Sen. Pete Domenici of New Mexico. The current Senate bill has 69 co-sponsors. Kennedy and Ramstad introduced their version of the House bill last year.
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