Noteworthy News Articles on Mental Health Topics, March 6-11, 2007

A requirement of his treatment, the plan catalogs on five single-spaced pages the tactics Mr. Price has learned to stop molesting.

There are 42 so far, including avoiding places where children congregate, abstaining from alcohol, shunning the Internet and sniffing ammonia whenever he has a deviant thought.

“It was just like a hunt for me,” Mr. Price, 59, a former Sunday school teacher, said of his sexual crimes. “I kept choosing children because they were easier prey; they were easier to deal with than women.”

Treatment plans like Mr. Price’s, known as relapse prevention, have been a cornerstone of efforts to reform sex offenders for the past 20 years. Yet there is no convincing evidence that the approach works, or that others do either.

Similar to aspects of Alcoholics Anonymous, relapse prevention has sex offenders own up to wrongdoing and resign themselves to a lifelong day-to-day struggle with temptation. But one of the few authoritative studies of the method, conducted in California from 1985 to 2001, found that those who entered relapse prevention treatment were slightly more likely to offend again than those who got no therapy at all.

Clinicians who work with sex offenders cling to relapse prevention nonetheless, and its durability speaks volumes about the troubled, politically fraught science of treating sex offenders. Not only is relapse prevention of questionable value, but so are the tests to gauge whether sex offenders in treatment still get inappropriately aroused, the drugs used for so-called chemical castration and the methods of predicting risk of reoffending.

Treatment methods have become particularly topical as thousands of sex offenders are confined or restricted beyond their prison terms under civil commitment laws on the books in 19 states. The laws have been found constitutional in part because they aim to provide treatment if possible; New York legislators announced last week that the state would soon allow civil confinement.

On average, the civil commitment programs cost four times more than keeping sex offenders in prison. But too little research has been conducted into how to treat sex offenders, experts say, putting psychotherapists and others working in civil commitment centers at a distinct disadvantage.

“It has never been regarded as a legitimate and recognized topic for research by psychologists,” said Robert A. Prentky, director of research at the Justice Research Institute in Boston. “There is a very strong undercurrent of disrespect for this area of research and perhaps even skepticism, frankly.”

As recently as the 1970s, research on treating sex offenders was practically nonexistent. Barbara Schwartz, a psychologist with New England Forensic Associates in Arlington, Mass., said that when she wrote her first paper on rehabilitating sex offenders in 1971, “I read everything there was to read, and I had a half of one page of references.”

That is partly because sex offenders present major challenges as research subjects. There are far fewer convicted sex offenders than most other kinds of criminals, so sample groups are unreliably small. And sex offenders tend to be so secretive that “it’s really hard to get information from them that you can have confidence in,” said Ted Shaw, a forensic psychologist in Gainesville, Fla., who has treated offenders since 1982.

Even now, in an advanced phase of California’s treatment program for the most persistent sex offenders, Mr. Price says he questions his ability to keep his urges in check. His relapse prevention plan says that if let out, he will seek more treatment at Pure Life Ministries in Kentucky, whose Web site says its goal is “leading Christians to victory over sexual sin.”

“I’m very afraid of just being out there,” Mr. Price said, sitting near the nasturtiums and petunias he had grown in a courtyard of the Atascadero State Hospital here, which includes a wing for civilly committed offenders. “I’m less dangerous than I was, but I’m definitely in touch with my dangerousness.”

During one therapy session, Mr. Price and five other men aggressively tested one another’s ability to stay straight, while two social workers moderated. Sitting in a circle in a locked conference room, briefly sealed off from the loud, grim bustle of the hospital halls, they fell into an argument over whether to protect a young new arrival from predatory older residents.

“If I can save this kid from being hustled or taken advantage of,” said Paul George, a convicted pedophile who has admitted roughly 100 offenses, “I’m going to at least try to make that effort.”

But another man pointed out that Mr. George had habitually groomed child victims by acting as their protector, asking him, “How was that different from this situation?”

At most civil commitment centers around the nation, offenders young and old meet several times a week for group therapy rooted in relapse prevention as well as what are known as cognitive-behavioral techniques. While the former is meant to curb sex offending in particular, the latter are intended to change broader destructive patterns of thinking and reacting, and are commonly used in treating other ailments like anxiety.

Civilly confined men move from one phase of treatment to the next, learning to recognize which situations, thoughts and behaviors have led them to offend, developing skills to avoid them, and applying those skills to their daily lives. They try to learn empathy by writing detailed letters to their victims and even essays in their voices.

“It’s a slow business,” said David Thornton, the treatment director at Wisconsin’s civil commitment center. “You’re talking about years of work, two steps forward, one step back.”

Dr. Thornton said relapse prevention forced sex offenders to focus too heavily on a concrete list of high-risk situations — sometimes as long as 50 pages — that could overwhelm them and lead to failure. Wisconsin’s program rejects relapse prevention and sticks to cognitive-behavioral techniques in an effort to change deep-rooted traits and behaviors.

“It’s much less dependent on the guy having some conscious, deliberate self-control plan in his head,” Dr. Thornton said. “You’re trying to change how he automatically functions.”

Instead of helping a sex offender compile a list of specific situations to avoid, therapists in Wisconsin might seize on the fact that he reacts impulsively when something upsets him, teaching him self-regulation skills. Instead of having the offender recount every last detail of his crimes, they might help him correct long-held misperceptions about children (that they enjoy sex), power (that it is best attained by raping or molesting) and so forth.

Some who represent offenders in Wisconsin, though, say that even the new program there has not answered offenders’ frustrations about their ability to progress in it and to demonstrate that progress.

“The program has gotten larger, more involved and progressively longer,” said Robert W. Peterson, a lawyer in Wisconsin who has worked on such cases since 1998 and says he has seen the state’s program shift repeatedly in design and focus.

“Regardless of the structure of the treatment program, the duration of the treatment program, the nature of the treatment program,” Mr. Peterson said, “what we basically have is living experiments.”

Research Is Sparse

Reliable studies on the treatment of civilly committed offenders do not exist, since so few have been set free. Much of the research into the treatment of sex offenders has come out of Canada, where national criminal history records are easily accessible.

Canadian psychologists have studied not only treatment outcomes but also risk assessment, or determining who is likely to reoffend.

Combining findings from hundreds of smaller studies, R. Karl Hanson, senior research officer for the Department of Public Safety and Emergency Preparedness in Canada, has found that roughly 15 percent of convicted sex offenders are caught reoffending after five years and that those driven by deviant sexual interests, like pedophiles and exhibitionists, are the likeliest to do so.

Dr. Hanson’s research has also suggested that even lifelong offenders tend to stop, for the most part, by the time they reach their 70s.

He said various studies had shown that “most treatments don’t work very well,” but that, over all, treatment had a modest beneficial effect. One analysis that he published in 2002 found that 12 percent of offenders who got treatment were caught committing new sex crimes, compared with 17 percent of untreated offenders.

Researchers have found that chemical castration, or using hormonal drugs to curb sexual appetite, can be problematic, too.

Doctors have experimented for decades with antiandrogens, which block the effects of sex hormones like testosterone and are most commonly used to treat advanced prostate cancer. But while some consider antiandrogens crucial for the most predatory offenders, the drugs remain controversial, not least because they are expensive and can cause weight gain, osteoporosis and breast development. It is also hard to ensure that released offenders keep taking the drugs.

More than half of states with civil commitment programs say they allow voluntary antiandrogen treatment, but as of last fall, only California, Illinois, Washington and Wisconsin had more than one offender taking the drugs, which can cost several hundred dollars a month. Dr. Fred S. Berlin, founder of the Johns Hopkins Sexual Disorders Clinic in Baltimore and a longtime critic of civil commitment, said he was troubled by the scant use of antiandrogens.

“I get letters from men around the country, in prison or sometimes civil commitment, asking if I can help them in their efforts to have it made available,” Dr. Berlin said, “because the administrations in their facilities are not even willing to discuss it with them.”

Here in California, where about 40 civilly committed men took antiandrogens several years ago but only four do now, Jesus Padilla, a clinical psychologist at Atascadero State Hospital, said the drugs did not address the underlying emotional problems that lead to offending, nor even necessarily eliminate sex drive.

“I’ve had numerous situations where they say they are working just fine,” Dr. Padilla said of civilly committed men on antiandrogens, “only to catch them having sex with each other or engaging in deviant sexual fantasies even though their testosterone level was down to zero.”

Some doctors see more potential in antidepressant drugs, which can dampen sexual desire while also curbing compulsive behaviors like chronic masturbation, which can preclude offenders from participating in treatment. Some civil commitment programs prescribe antidepressants sparingly or not at all, while others, including South Carolina’s and Wisconsin’s, have dozens of men taking them.

One approach that civil commitment centers have avoided is surgical castration, though at least one state, California, allows it if the offender pays for the procedure himself.

In Virginia, the General Assembly considered a proposal last year to allow voluntary surgical castration as an alternative to civil commitment, but took no action. One pedophile in Virginia castrated himself in a jail shower with a shoelace and a razor blade as his civil commitment trial approached.

Douglas Carlin, a convicted rapist who completed treatment and was released a year ago from the commitment center in Florida, said he thought a lot of offenders there were deceiving their therapists.

“Most of those guys, they are just faking it to make it,” Mr. Carlin said. “They’re just waiting to get released so they can go right back to what they were doing.”

Tools of Assessment

Therapists can gauge the success of various treatments by observing offenders’ behavior, interviewing them and using two instruments. All have serious shortcomings.

One instrument, the polygraph, is routinely used to determine if people continue to offend once conditionally released or have deviant thoughts in the course of treatment. Civil commitment centers also use polygraphs to make sure an offender has admitted all his crimes, a requirement for progressing past the early stage of relapse prevention treatment.

“Usually they will give up lots of information soon after failing a polygraph test,” Dr. Thornton, the Wisconsin treatment director, said.

But polygraphy, which measures blood pressure, breathing rate and perspiration while a series of questions is asked, is generally considered so unreliable that its results are inadmissible as proof in court. Some offenders, especially psychopaths who feel no anxiety when lying, can beat it, experts said.

“Polygraph on its own isn’t the answer to anything,” said Dr. Don Grubin, a forensic psychiatrist at Newcastle University in Britain who has studied the tests. “As part of a bigger package it seemed to have an effect — to help reduce the risk of reoffending.”

The other device routinely used at civil commitment facilities is the penile plethysmograph, which measures changes in the circumference of the penis while the offender is shown sexually suggestive pictures of men, women or children.

Some clinicians and offenders say it is easy, particularly in a laboratory, to stifle arousal and thus cheat on a plethysmograph test.

Mr. Carlin, the Florida rapist, said that during one plethysmograph test, “I just stared at a shelf of cleaning products and read the labels.”

The field of risk assessment, or determining which sex offenders are likely to repeat their crimes once released, has been equally slow to evolve, even as judges and juries are keeping more men locked up after their prison sentences in the belief that they will be dangerous on the outside.

A cottage industry of professionals who diagnose sexually violent predators has developed in the last two decades, and several hundred psychologists, often with little or no background treating sex offenders, make a lucrative business of recommending who should be committed.

During a recent commitment trial in St. Augustine, Fla., one psychologist with hardly any experience treating sex offenders told a jury he had evaluated 350 candidates for civil commitment and testified in dozens of commitment trials since 2000.

Some in the field question why professional organizations like the American Psychological Association have not set ethical and training standards for the many psychologists entering the civil commitment field.

“I don’t think, in my personal experience, that the vast majority of the examiners I’ve come across have sufficient working knowledge of the empirical literature,” said Dr. Prentky of the Justice Research Institute.

But that literature is still of limited use. Most actuarial tools used to predict someone’s risk of recidivism consider only unchanging factors, like their number of past offenses and the sex of their victims. Some scientists say that so-called dynamic factors — how much treatment an offender gets, for example, and how old he has grown — should factor heavily into actuarial risk assessment, too.

“Science hasn’t gotten there yet,” said Eric Janus, a professor at William Mitchell College of Law in St. Paul, Minn., who opposes civil commitment.

Professor Janus said he hoped for “an explosion of knowledge” about how to prevent sexual violence before it happened, which he said would prevent far more sex crimes than civilly committing offenders.

That sort of research is unlikely to happen in the United States, Dr. Berlin and other experts said, because so many Americans believe that the only investment in sex offenders should be punitive.

“People need to recognize that these are not just criminal justice problems but also public health problems,” Dr. Berlin said, “and the surgeon general as well as the attorney general ought to be supporting research in this area.”

Earlier efforts to rehabilitate sex offenders, like Freudian psychoanalysis and electric shocks to the skin, failed definitively decades ago. A recent case in Orange Park, Fla., offered more evidence that relapse prevention treatment is no solution, either.

There, the authorities say, a convicted rapist who had spent 12 years in prison and 5 at the Florida Civil Commitment Center raped and killed a young woman before dawn on Jan. 23 after following her into the veterinary clinic where she worked.

The suspect, Michael Renard Jackson, 37, won release from the commitment center in 2005 after reaching the highest levels of a relapse prevention treatment program, people familiar with the case said.

Or she would dress up to go out, and then struggle against a growing dread as the moments passed and he did not comment on how good she looked.

“I never once said anything, but I had this need for approval, this terrible dependence that he had no way to understand,” Ronni Weinstein, 61, a therapist living near Chicago, said about her former husband. Indeed, she added, she has since learned that her dependent urges might have been used to bind the marriage rather than undermine it.

“That’s what healthy couples learn to do,” she said, “to voluntarily depend on one another and decide who is doing what for the relationship.”

Neediness has a familiar face: the close friend who is continually asking for reassurance, for advice, for help with the wireless connection. The accomplished adult who lurches from one relationship to another, playing geisha for each new partner. The abused spouse who is afraid to walk out.

Yet only in recent years have researchers begun to realize that while in some guises dependence can undermine mental health, in others it can provide valuable social support.

At one extreme is an ingrained, helpless need to be cared for — a stubborn problem that psychiatrists diagnose as dependent personality disorder. In milder forms, dependency can come across as an annoying clinginess. But it can also be a protective warmth that cements romantic relationships in times of stress. It is the way people manage dependent urges, researchers are finding, that determines the effect of needy behavior on relationships.

“There are the dependent people who panic easily, who are calling a friend or spouse 15 times a day, undermining the relationship, and then there are those who have learned to modulate their impulses,” said Dr. Robert F. Bornstein, a psychologist at Adelphi University in Garden City, N.Y., and co-author, with his wife, Mary A. Languirand, of “Healthy Dependency” (Newmarket Press, 2003).“These people may have dependency needs that are very intense,” he continued, “but they have developed social skills, learned to make others feel good about helping them. That makes all the difference.”

A tug-of-war between headstrong independence and needy vulnerability is visible as early as infancy. In so-called attachment studies, young children or primates who are confident in their mother’s affections tend to be confident when exploring an unfamiliar room or meeting a stranger. Those who are less secure often cling to their mothers in new situations, noticeably fearful.

“This is an absolutely fundamental dynamic that underlies all of our interpersonal relations, as well as psychiatric diagnoses,” said Dr. Sydney Blatt, a professor of psychology and psychiatry at Yale University.

Researchers measure the strength of dependency traits by having people rate how highly they endorse certain beliefs, like, “After a fight with a friend, I must make amends as soon as possible”; “I am very sensitive to others for signs of rejection”; or “I have a lot of trouble making decisions for myself.”

In studies, people who score highly on these tests also tend to rate their parents as either authoritarian or overly protective (or one of each). “The message growing up is: You’re fragile, you’re weak, you need someone powerful to look after you,” Dr. Bornstein said.

That upbringing primes many people, as they grow, to seek similarly dependent pairings, with friends, colleagues and romantic partners. The pattern persists at least in part because it is frequently rewarded.

In one recent study, psychologists rated 48 men and women attending Gettysburg College in Pennsylvania on measures of dependency, and calculated their grade-point averages. After controlling for the students’ SAT scores and the difficulty of their course schedules, among other factors, the researchers found, to their surprise, that those students who scored highly on measures of dependency were doing significantly better, on average, than those who were more self-sufficient.

One likely reason, the authors found, was that dependent students were much more likely to say they sought help with course work from their professors.

In another experiment, presented in January at the American Psychoanalytic Association’s annual meeting, psychologists at the University of Leuven in Belgium measured dependency traits, relationship satisfaction and levels of conflict in 266 adults in long-term relationships. The researchers found that dependent partners scored significantly higher on satisfaction than more self-sufficient ones — but only when couples were struggling.

At least in the short run, dependent traits seemed to buffer the relationships in times of crisis, the authors suggest. Afraid of losing the relationship, “individuals high on dependency may actually behave in a more positive way to their partner, like being more complying, being more loving,” said Bénédicte Lowyck, the psychologist who led the study.

In the long run, Ms. Lowyck said, it is not at all clear whether such protective instincts nourish a relationship or smother it. The answer will depend on the couple, experts say, and likely on the content of a partner’s dependence: how it is expressed, whether the person is generous as well as needy, flexible as well as anxious.

To distinguish different shades, or varieties, of dependency, two psychologists, Aaron L. Pincus of Pennsylvania State and Michael B. Gurtman of the University of Wisconsin, Parkside, administered an exhaustive battery of dependency-related questionnaires to 654 psychology students. The scales rated everything from social confidence to preference for solitude to urges to please others. The psychologists’ analysis of the answers suggested that there were three distinct varieties of dependent behavior patterns.

One was defined predominantly by submissiveness (“I don’t have what it takes to be a good leader” or “I am easily downed in an argument”). Another was characterized principally by exploitability (“I am afraid of hurting people’s feelings” or “I do things that are not in my best interest in order to please others”). And a third, which the psychologists call love dependency, was based on a longing for social connection (“Being isolated from others is bound to lead to unhappiness” or “After a fight with a friend, I must make amends as soon as possible”).

People who struggle with an exaggerated need for the comfort of others may show flashes of all three types. “But it is this love dependency that is the most adaptive,” Dr. Pincus said. “These are people that form very strong attachments, who are not happy unless surrounded by friends and family” and least likely to stumble over their own anxieties.

Dr. Weinstein, the Chicago-area therapist, said that in more than 30 years of practice she had seen dozens of couples in which submission and exploitation have ended marriages. And studies now suggest that in severely troubled, abusive relationships, the aggressor, as well as the victim, often have a dependent fear of losing the relationship.

“This is the kind of couple where maybe the husband says: ‘You’re going to the store by yourself? You’re going to leave me here alone? You can’t do that — here, I’ll drive you,’ ” Dr. Weinstein said.

“And this kind of trivial-sounding exchange can turn very demanding and even violent, because of this unreasonable fear of abandonment.”

Skilled therapists can help people manage such fears, but there is little research to guide treatment. In one approach, people learn to identify, and alter, some of the conversation habits that make their interactions with others so volatile.

For example, they learn to reduce the number of times they seek reassurance in a conversation — “You’re not just saying that, right?” “Do you really mean that?” — and, eventually, to shift the focus of the conversation to the other person.

The patient can also learn to defuse his or her fears of losing a relationship by taking some of the hard evidence of a partner’s commitment at face value: flowers, romantic dinners, back rubs.

The partner can help, too, at least in cases of garden-variety neediness. Psychiatrists often advise a kind of sympathetic distancing: acknowledge the person’s fears; offer some reassurance; but nudge (or push) the person to at least experiment with interests, hobbies or habits that don’t revolve around the relationship.

And then turn off the cellphone for a few hours.



A Diagnosis for One, but an Impact Shared
Harriet Brown, New York Times- 3/6/2007

It was the first time my daughter’s sixth-grade teacher had ever called, and clearly the news was not good. Breathless and upset, she phoned me at work to say that 11-year-old Lulu had been “out of control” for several hours that morning, yelling, crumpling papers, saying rude things and, eventually, running out of the building.

The class had been acting out a scenario about hunter-gatherers during a famine, she said, and Lulu was one of the children chosen to “starve to death.”

“No one else got upset,” the teacher said. “I don’t understand why she did.”

But I understood. From the moment I heard the words “starve to death,” I knew exactly what had happened.

Fifteen months earlier, Lulu’s older sister had received a diagnosis of anorexia, and our family had been consumed since then with helping her recover. Though we had tried to shield Lulu as much as possible, she had suffered along with the rest of us.

She’d seen her sister lie in a bed in the intensive care unit, listless and wasted. She’d sat at the table and listened to hysterical yelling and crying, suicide threats; she’d heard her beloved older sister say incomprehensible and scary things. She’d watched her sister eat her way back from the brink, bite after agonizing bite, and no doubt had seen more than we thought of our frustration, confusion and grief.

Now, finally, her sister was more or less recovered: weight restored, in school, back to her healthy and happy self. And I had been waiting for something like this to happen, ever since life in our house started to feel normal again.

In the nightmarish chaos of dealing with anorexia, my husband, Lulu and I had focused on helping her sister recover. Now that she had, it was safe for Lulu to feel all the terror, grief and rage of the last 15 months.

It was pure bad luck that it all came flooding out at school. The classroom role-play was the kind of flukish thing we couldn’t have anticipated.

Being the other sibling is always hard. When one child grapples with a life-changing diagnosis or accident, parents have to focus on that child. And there are ways in which it’s good for children to learn that other people have needs, and sometimes those needs come first.

The thing about eating disorders is that the reminders are everywhere. We all have to eat, after all. And there may be no time in a child’s life when she feels more self-conscious and vulnerable about body image and weight than middle school. Add to that our school district’s recent emphasis on nutrition, and I knew Lulu felt she couldn’t get away from her sister’s illness.

The classroom role-play was the most extreme example, but there were plenty of other triggers: posters in the sixth-grade hallway urging exercise and “healthy eating” to lose weight, a gym unit on fitness in which children were asked to record each other’s weight, a movie that mentioned anorexia. All of these brought up the painful feelings again and again.

Then, too, most people don’t truly understand how serious and pervasive an eating disorder can be. Lulu’s teacher was shocked that the classroom role-play had caused such a reaction; I’m sure she thought Lulu had some kind of underlying emotional problem. When my husband and I sat down with her and shared some of what Lulu had gone through, I watched her face change as she began to understand why our daughter had reacted the way she did.

From other parents whose children had recovered from anorexia, I heard the same kinds of concerns. Predictably, the younger the child, the more acting out the parents saw, including clinginess, tantrums, mimicking dangerous behaviors like not eating, and depression. There seems to be a kind of symmetry to the siblings’ recovery; it can take about a year to fully refeed an anorexic child at home, and another year for the sisters and brothers to get back to normal behavior.

Part of Lulu’s recovery is talking about it. Recently she came home from school upset after an argument with another sixth grader, a friend who insisted that it’s better to be thin than fat. With the image of her starving sister in mind, Lulu had replied, “I’d rather be too fat than too skinny.” Her friend’s response: “Thin is good — the thinner the better!”

Lulu was furious when she told me about this conversation. Didn’t her friend get it? Didn’t she know what anorexia was like?

No, I told her, she doesn’t. You said all the right things, but it will take more than a comment or two to change your friend’s opinion. I rubbed her back and sat with her while she cried.

I knew the pain would lessen but never go away completely. For better or worse, what had happened to her sister had happened to her, and to all of us. None of us would ever be the same again.



The Line Between Torture and Cruelty
Nicholas Bakalar, New York Times- 3/6/2007

The United Nations and the United States government make a distinction between torture on the one hand and “cruel, degrading and inhumane treatment” on the other. But a study published yesterday uses data obtained from survivors to suggest that the distinction does not exist in practice, and may inadvertently provide justification for torture.

The conclusions appear to contradict a Justice Department memorandum of Dec. 30, 2004. Citing the United Nations Convention Against Torture, the memorandum argued that a broad range of interrogation techniques, among them forced standing, hooding, subjection to loud noises and deprivation of sleep, food and drink, might be inhumane but did not constitute torture unless they resulted in “prolonged mental harm.”

“Until now, both sides of the debate have expressed opinions based on personal impressions,” said Dr. Metin Basoglu, the lead author of the study. “But these data clearly suggest that you cannot make a distinction between physical forms of torture and something else called ‘cruel and degrading treatment.’ ”

Dr. Basoglu is a psychiatrist and a specialist in trauma studies at King’s College London.

Using structured interviews and diagnostic questionnaires, including an established scale that seeks to draw out information on 46 forms of torture, the researchers examined 279 survivors from the former Yugoslavia.Most had experienced physical and psychological torture.

The interviews were conducted from March 2000 to July 2002, an average of eight years after the subjects had last been tortured.

The study, published in The Archives of General Psychiatry, found that most participants with little or no experience of physical torture nevertheless developed post-traumatic stress disorder at some point, and that some people survived even severe physical torture without suffering the disorder.

The presence of post-traumatic stress disorder or other long-term psychological suffering would therefore not constitute a usable definition for torture, because it would exclude many people who actually were severely physically tortured.

Dr. Israel Liberzon, a professor of psychiatry at the University of Michigan, said the lack of a control group made the findings less compelling.

Dr. Gregg Bloche, a psychiatrist and a professor of law at Georgetown University, said what the researchers did was “artful, even brilliant,” considering the circumstances.

“You can’tdesign alternative torture regimens,” Dr. Bloche said, “which is what you would have to do to meet the scientific criteria for a controlled clinical trial. You have to work with real survivors.”

The participants in the study were asked to rate types of stress on two 5-point scales — fairly to extremely distressing and slightly controllable to not controllable at all.

The physical torture categories included beating, burning and electric shocks. The other categories included rope bondage, cold showers, excrement in food and deprivation of basic needs like sleep or toilets.

On a scale of 0 to 4, the mean distress rating for physical torture was 3.2 to 3.8. The mean distress ratings for 16 of the 33 nonphysical stressors were in the same range.

For example, sham executions, the fondling of genitals and threats of rape were rated 3.6 to 3.7. On the scale measuring loss of control, there was no difference between physical torture and psychological manipulation.

A spokesman for the Justice Department, Erik Amblin, declined to specify what treatments would be cruel and degrading but would not qualify as torture.

Mr. Amblin did say, however, that “acting with the specific intent of causing prolonged mental harm” would be illegal under United States and international law.

Even though the United Nations Convention prohibits cruel, inhuman or degrading treatment as well as torture, Dr. Basoglu said, “the distinction makes people able to argue that torture is O.K.

“They distinguish low levels of physical pain and high levels, as if that’s what makes the experience traumatic. But it’s not dependent on the amount of pain. It’s the issue of control and the extent of distress one experiences.”




Study Examines Empathy During Psychotherapy
Judith Graham, Chicago Tribune- 3/6/2007

They're special, those moments of close connection when you become attuned to another person's mood, and it seems you can sense what he or she feels.

This "we're on the same wavelength" phenomenon is known as empathy, part of the emotional glue that helps bind people together.
Now it's being studied with the tools of modern science, sophisticated neuro-imaging scans and physiological tests that track how people's brains and bodies respond during social encounters.

The still-young field of scientific inquiry is called social neuroscience, and it's beginning to demonstrate that empathy has biological underpinnings as well as emotional dimensions.

The latest research comes from Boston, where Massachusetts General Hospital researcher Dr. Carl Marci has been examining empathy in the context of psychotherapy. His research appeared last month in the Journal of Nervous and Mental Disease.

The study is the first to try to measure how patients and psychologists react to each other during a therapy session and how empathy plays out between them.

The major finding validates the depth of connection that can occur: The more in tune patients and therapists appeared to be emotionally, the more closely their physiological responses mirrored each other.

"In other words, when we feel connected to someone, it's because we actually are experiencing something similar," said Marci, who worked with collaborators in New York City and New Hampshire. "Fundamentally, we're social beings, and our brains are wired to connect."

The physiological measurement used in the study was "skin conductivity," a sensitive indicator of arousal in the sympathetic branch of the autonomic nervous system.

Researchers obtained readings by attaching electrodes to patients' and therapists' fingers and recording their responses to imperceptible electrical currents. Some 20 patient/therapist pairs were studied during a session averaging 45 minutes. All the patients had a diagnosis of depression or anxiety and had worked with the therapists for some time.

This part of the study showed significant "concordance," or similarity, between patients' and therapists' level of arousal about 50 percent of the time. That was highly significant and not due to chance alone, the researchers said.

After the session, researchers asked patients to rate the degree of empathy demonstrated by their therapists, using a standardized questionnaire. The higher the level of perceived empathy, the higher the congruence in the pair's physical responses, researchers discovered.

In the last part of the study, two trained observers watched videotaped segments of therapy sessions when pairs were most and least closely aligned, according to physiological data. The purpose was to identify moments of apparent empathy by observing social and emotional interactions.

This analysis showed that patients and therapists were, indeed, having more positive interactions when their skin conductivity measurements were most similar.

That comes as no surprise to Anne Alonson, a clinical professor of psychiatry at Harvard Medical School who directs the Center for Psychoanalytic Studies at Massachusetts General.

"Everyone knows that emotions locate themselves in the body. What we're finding is, it's not just one person's body: People can join each other in feeling," she said.

Alonson gave the example of a recent session with a man who appeared quite downhearted but seemed not to know it. "He's talking, and I'm realizing that I'm beginning to feel really sad so I say, `I have a sense of sadness in myself, and I wonder if you feel it too.' At which point, he started to cry."

This kind of empathetic connection is fundamental to the therapeutic process, said Dr. Deborah Spitz, associate professor of psychiatry at the University of Chicago. "In working with someone, you need to know where they are, emotionally, in order to be able to help them," she explained. "You have to be able to meet them, and empathy helps you do that."

"I'm not at all surprised that is something we experience in our bodies as well as our brains," Spitz said.

Indeed, human brains appear hard-wired to "perceive and share others' feelings," according to Jean Decety, a professor of psychology who joined the U. of C.'s faculty last year. Decety was quoted in a U. of C. Magazine interview describing his groundbreaking neuro-imaging studies, which demonstrate that brain networks processing personal pain also light up when another person's pain is recognized.

That's compelling evidence of a biologically grounded emotional overlap between self and other, experts suggest.

There are limitations to the new research out of Massachusetts General. The sample size is small, and there were no controls. Patients' perceptions of empathy could be influenced by their underlying mental conditions and treatment status.

Still, Dr. K. Luan Phan, director of the brain imaging and emotions laboratory at the University of Chicago, believes the finding "that you can get a biological marker for a therapeutic relationship" is "very important and very exciting."



$100M to Bolster Psychiatric Research
Carey Goldberg, Boston Globe- 3/8/2007

The Broad Institute, the genomics powerhouse in Cambridge, announced yesterday that it will receive what it believes is the biggest gift ever for psychiatric research to a single US institution: $100 million to decipher the genetics of severe mental illnesses.

The money comes from the Stanley Medical Research Institute , a family philanthropy based in Maryland. It will be used largely to gather and analyze thousands of DNA samples from people with schizophrenia and bipolar disorder, in hopes of determining the complex genetics behind the diseases.

Only in the last year or so has gene-scanning technology reached the point that scientists think that aim is realistic, said Dr. Edward Scolnick , who oversees the Broad's psychiatric research. Researchers at the Broad and elsewhere are also using these genomic tools to make inroads on cancer, diabetes, and other diseases.

For mental illness, it could take several years to determine the key genetic risk factors, Scolnick said. But once that is done, "You can start developing new approaches for diagnosis, new targets for treatment, new understanding of which drugs to use in which people, and turn it into a rational science. That's the Holy Grail."

It has long been clear that schizophrenia and bipolar disorder, which afflict more than 6 million Americans, run in families. But the specific genes involved have proven largely elusive.

The symptoms tend to vary so greatly among patients that schizophrenia, for example, may actually be a handful of different diseases. Complicating matters further, these disorders are believed to stem from multiple genes that might be different from patient to patient, along with factors in a patient's environment.

Given that complexity, researchers believe they need many DNA samples to pick up the tricky genetic signals: perhaps as many as 10,000 for each disease, along with 10,000 from people without the disease for comparison, Scolnick said.

That DNA then needs to be scanned in its entirety for genes correlated to the disease, which is where the Broad's expertise comes in. The institute has been developing ever-faster and cheaper methods for genomic analysis, and can now scan a patient's sample for half-a-million genetic variations at once. In a couple of months, said Eric Lander , the Broad's director, that will be up to a million.

"If you're looking for a needle in a haystack, and you can sift the whole haystack, you'll find the needle," Lander said.

Other research groups have begun tackling the genomics of serious mental illnesses, and the National Institute of Mental Health maintains a huge repository of DNA from people with mental illness, said Dr. Tom Insel , the federal institute's director. But only recently has it become clear from work with other complex diseases that to crack the genetics of bipolar disorder or schizophrenia, many more samples are needed than had been thought, he said.

The gift to the Broad "is exactly the right thing at the right time at the right place," Insel said. "We now have the ability to do a lot of the genetics we couldn't do two years ago, and there's probably no better place than the Broad to do that."

The gene-scanning results will be posted publicly, he said, so that all researchers will have access to the data. After the initial sweeping scans of a patient's full DNA, researchers will then need to "drill down" into targeted areas of DNA to piece apart where exactly the genetic problems lie, he said.

Then, researchers say, comes the really hard part: figuring out how the genes act to produce the disease.

The Broad, a joint institute of Harvard and the Massachusetts Institute of Technology, will be using "the full armamentarium of modern genomics," Lander said.

Along with gene-scanning, that will include the rapid automated screening of hundreds of thousands of chemical compounds to see if they might prove helpful in treating the diseases, and a technique called RNA interference that can silence any particular gene so researchers can gauge the gene's effects. The aim, he said, is to "lay bare the molecular and cellular basis of psychiatric disease."

The Broad's approach has begun to bear fruit of late with other diseases, Lander said. For example, he said, up until a year ago, only two genes were known risk factors for Type 2 diabetes; now, the Broad has brought that number up to nine. There has been notable progress on the genetics of cancer, macular degeneration, and other diseases as well.

The Broad needed no hard sell to get the money. Scolnick said that last summer, he had begun discussing with the Stanley institute, which funds research on mental illness, whether it might increase the donations it had been providing to the Broad.

"I'd asked for some modest increases," he said, "and they came back after my proposal and said, 'We'd really like to do more, what can you realistically use?"'

The Broad's new Stanley Center for Psychiatric Research will receive $10 million a year for 10 years, out of the Stanley institute's $40-million-a-year operating budget, said Dr. Michael Knable , the institute's executive director. Previously the Broad had been spending only about $500,000 a year on psychiatric work.

The Stanley Medical Research Institute has an endowment of over $300 million, and says it is the biggest private source of philanthropic support for psychiatric research in the world.

Ted Stanley, 75, founded MBI Inc., a direct marketer of books, jewelry, and collectibles; he and his wife, Vada, fund the institute.

Knable, asked what results he expected, said: "I'm thinking that on the one hand, within 10 years we should be able to predict with pretty good accuracy who is at risk for schizophrenia before they get it," he said.

"And number two, I think we'll have new drugs entering the marketplace that are novel," not new versions of "the same old stuff we've had since the 1950s."

Shock Therapy Called Cruel; Kin Disagree
Michael Higgins, Chicago Tribune- 3/8/2007

In a one-of-a-kind case in Illinois, a Cook County circuit judge has ruled that it is illegal to use electric shocks from a cattle prod to control the violent outbursts of a severely autistic man.

Bradley Bernstein, 48, who can speak only about 12 words, had received the shocks for two decades under a court-approved settlement reached in 1987.

But this fall, officials at his Chicago group home halted the practice, saying that it is inhumane and that a new state law forbids it.

The judge's ruling on Friday was a victory for Trinity Services Inc., which runs the group home, and a defeat for Bradley's parents, Fran and Robert Bernstein of Lincolnshire. The Bernsteins said Wednesday they may appeal the ruling.

The Bernsteins have argued successfully for years that the threat of the electric prod, which delivers a jolt like a bee sting, is the only way to stop their son from banging his head against hard objects or punching himself in the face until he's bruised and bloody.

"This is a terrible situation for Bradley," Fran Bernstein, 75, said Wednesday. "I am so afraid for him. ... How can they make us stop something that's allowing him to live a fairly normal life?"

The Bernsteins say their son has hit himself far more often since group home officials discarded the Hot-Shot Power-Mite, a small livestock prod about the size of two cigarette packs. But Trinity officials say only one incident, which required Bradley Bernstein to be hospitalized in October, has been serious.

Ethical question
The case casts a spotlight on one of the most controversial issues in the field of autism and mental retardation: whether it's ever ethical to use pain to control self-destructive behavior.

People with severe self-destructive behavior--as many as 25,000 nationwide, a federal panel has estimated--may punch or bite themselves or bang their heads violently. They may do so to gain attention, express frustration or for reasons experts don't fully understand.

For the past two decades, there has been a strong trend away from the use of punishments, known as "aversives," to curb that behavior. Some states have banned the practice. But when it comes to certain extraordinarily difficult cases, the issue is not yet settled.

Last month, a federal judge in New York issued a temporary order that preserves the use of electric shock on New York residents who attend a special school for people with autism in Canton, Mass.

The Bernsteins' latest legal battle centered on a conflict between past rulings that favored the couple and a new law passed in May that says that treatment plans for people with developmental disabilities must not include electric shock or other aversive punishments, such as withholding essential food and drink or causing pain or humiliation.

At an oral argument last month, Trinity Services' attorney, Matthew Henderson of Chicago, said that although "no one doubts the sincerity of Mrs. Bernstein," the use of electric shocks on people with disabilities is outdated and morally wrong.

"Things that were done previously--five, 10, 20 years ago--are simply not acceptable anymore," Henderson said. "There were several staff members who just flat out refused to do it."

The Bernsteins' attorney, Robert O'Donnell of Vernon Hills, argued that the law didn't apply in Bradley's case. But Cook County Circuit Judge Kathleen Pantle disagreed. Bradley has a right to "adequate, safe and humane treatment," but the legislature decides what methods qualify, Pantle wrote in a 10-page opinion. Pantle said the law passed in May categorized electric shock and the other methods as "beyond the pale in all cases."

Shocks approved in 1986
The Bernsteins had hoped Pantle would follow the lead of an earlier Cook County judge, who said in 1986 that shock was the only method that worked for Bradley, in part because he is allergic to some psychiatric medications. That ruling led to a settlement with the state Department of Human Services in 1987, which permitted the shocks.

Black Americans are more likely than whites to suffer severe, untreated and disabling depression, U.S. research shows.

Researchers at the Harvard School of Public Health analyzed data on 6,082 people who took part in a national survey conducted between 2001 and 2003.

They found that 17.9 percent of white Americans had depression at some point in their lives, compared with 10.4 percent of blacks of African descent and 12.9 percent of blacks of West Indian or Caribbean descent.

Rates of depression in the 12 months before they were surveyed were 7.2 percent for Caribbean blacks; 6.9 percent for whites; and 5.9 percent for blacks of African descent. Among those who reported depression at some point in their lives, rates of depression in the 12 months before they were surveyed were 56.5 percent for blacks of African descent; 56 percent for Caribbean blacks; and 38.6 percent for whites.

"Fewer than half of the African Americans (45 percent) and fewer than a quarter (24.3 percent) of the Caribbean blacks who met the criteria (for depression) received any form of major depressive disorder therapy," the study authors wrote.

About 57 percent of white Americans with major depression received treatment.

"In addition, relative to whites, both black groups were more likely to rate their major depressive disorder as severe or very severe and more disabling," the researchers reported in the March issue of theArchives of General Psychiatry.

Investigating why blacks may be less likely to develop depression and why they fare worse when they do develop the condition may help improve understanding about depression.

"Future research should explore the extent to which social support systems, including religious participation and psychological resources, such as high levels of self-esteem, can provide some protection to the black population from exposure to adverse social conditions." the study authors wrote.

Mr. Cunningham cut his legs and arms. He tried to hang himself with a tube from a breathing machine he used for sleep apnea. He smashed the machine to get a sharp fragment to slice his neck and ate pieces of it, hoping to cause internal bleeding. Five weeks ago, after being placed in solitary confinement again, Mr. Cunningham, 37, hanged himself.

With that, Mr. Cunningham, who lawyers said had a long history of mental illness, including depression, became the 13th inmate to commit suicide in Massachusetts since November 2004.

Mr. Cunningham’s case is one of 18 suicides and suicide attempts by inmates in solitary confinement described in a federal lawsuit filed Thursday by advocates for inmates and the mentally ill. They are seeking to prevent Massachusetts from placing mentally ill inmates in such segregated cells.

“We aren’t saying these folks should go free; we aren’t saying they shouldn’t be under high security conditions,” said Stanley J. Eichner, executive director of the Disability Law Center. But Mr. Eichner said putting prisoners in solitary conditions and denying them adequate mental health services was “literally the fatal flaw in the system.”

“How many more men will have to die,” he asked, “how many more men will be driven to harm themselves before this problem is fixed?”

The lawsuit reflects an increasing concern nationally as the number of mentally ill inmates rises, experts on inmates and mental illness say.

Several states, including Connecticut, New Mexico, Ohio, Texas and Wisconsin, have faced lawsuits that have recently been resolved by settlements or court orders requiring improvements in the treatment of mentally ill prisoners. Those changes include more frequent monitoring, better training of corrections officers and removal of fixtures that could be used for hangings.

In January, Indiana agreed to stop putting some mentally ill inmates in isolation cells. While not all agreements in other states have resulted in excluding mentally ill prisoners from isolation, many have called for better screening or monitoring of isolated inmates.

In California, after a record number of prison suicides — 44 — in 2005, a special master appointed by a federal judge reported that inmates “in overcrowded and understaffed administration segregation units are killing themselves in unprecedented numbers.” The judge, Lawrence Karlton, ordered the administration of Gov. Arnold Schwarzenegger to spend more than $600 million to improve mental health services.

In New York, the Legislature passed a law last year to remove mentally ill inmates from solitary cells, but Gov. George E. Pataki vetoed it. A 2002 suit seeking to end the practice is close to a settlement, said Nina Loewenstein, a lawyer for Disability Advocates, which filed it.

“That’s what states around the country are struggling with — when they have inmates that are very violent and out of control and need to be segregated from other inmates, but they are also mentally ill,” said Lindsay M. Hayes, a national expert in prison suicide prevention who was hired last year by the Massachusetts Department of Correction to study why the suicide rate was so high.

A segregated inmate is typically locked up for 23 hours a day, allowed out only to shower or get outdoor exercise in a small caged space.

In a report Mr. Hayes issued last month, he found that of 10 prisoners who killed themselves in 2005 and 2006, 5 had recently been on suicide watches and 9 committed suicide in solitary or segregated conditions. A prisoner who tried to kill himself was left brain dead.

“Confining a suicidal inmate to their cell for 24 hours a day only enhances isolation and is antitherapeutic,” Mr. Hayes wrote.

When the report was released, the State Department of Corrections said it would adopt all 29 of Mr. Hayes’s recommendations, which included better assessment, supervision and monitoring of inmates, and better officer training, a recommendation Mr. Hayes also made in a 2000 report. He did not specifically recommend excluding mentally inmates from segregation units, saying it was not his area of expertise.

The Department of Corrections declined to comment on the suit or its position on segregated cells.

But in a statement, the department said: “We are well aware of the national trend of the increasing number of prisoners with mental illness” and added that it was “committed to the full implementation of the Hayes recommendations and improvement of prison mental health care.”

The statement said the department had already taken several steps, including briefing senior staff, revising the training curriculum and evaluating cells for design improvements. It said it also was soliciting bids for a residential treatment facility for mentally ill inmates.

Leslie Walker, executive director of Massachusetts Correctional Legal Services, said that advocates had been pressing for change for 17 years and that she was not confident the state would do enough on its own.

Frances Armstrong, whose nephew, Andrew Armstrong, 22, killed himself in a segregation unit in 2005, said in an interview that Mr. Armstrong had been put in isolation several times for cutting himself.