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December 8, 2006
As
mental health advocates, we have articulated several reasons can
certainly foresee how civil commitment legislation would be harmful
to New York’s mental health system: Therefore,
mental health advocates are once again banding together with many
other organizations to endorse the recommendations of professionals
in the field of sex offender management – sexual offender
treatment providers and victim advocates – to advance a much
more effective approach to sexual offender management that is comprehensive
and much less expensive. This approach includes several components,
including:
CALL YOUR LEGISLATORS AND URGE THEM TO The Governor and the NYS Legislature are poised to reach agreement on misguided legislation that would confine sex offenders in state psychiatric facilities after they’ve served their prison sentences. If Enacted, this legislation would: *Jeopardize the integrity and safety of New York State’s mental health system by inappropriately placing dangerous individuals without valid psychiatric diagnoses (only 5% of sex offenders have a diagnosable major mental illness) in state psychiatric hospitals. * Endanger patients in state psychiatric hospitals courageously fighting to recover from mental illness. This is particularly unconscionable, given that persons with psychiatric disabilities are more than 20 times likely to be the victim of rape or sexual assault than the general population. How can a system that places the predator with the prey promote recovery? * Roll back the progress we’ve made in combating the misinformation and stigma that surrounds individuals with psychiatric disabilities. *
Squander hundreds of millions of dollars locking up a few hundred
sex offenders in inappropriate psychiatric facilities while failing
to address the management and monitoring of the thousands of sex
offenders currently living in communities throughout the state. Join a broad coalition of sex offender victims, treatment professionals, legal rights groups, mental health advocates and concerned citizens in standing behind the messages we’ll be delivering at an Albany news conference this Monday CALL
YOUR LEGISLATORS “I’m a registered voter calling from your district who is urging you to reject the rush to pass flawed civil commitment legislation and to take the time to work with the next Administration to craft real solutions based on facts not fear.” Call
the Assembly switchboard in Albany at 518-455-4100 and
ask for your Assemblymember’s office. To find out who your representatives are, go to http://nymap.elections.state.ny.us/nysboe/.
In addition to joining Tom at the Capitol on December 13th, we urge you to contact Governor Pataki to urge his approval of Timothy’s Law when it arrives at his desk. You
can contact the Governor by: IN THE NEWS: NYS
ATSA and Alliance Policy Statement Concerning Sexual Violent Predator
Legislation The Boards of the New York State ATSA and Alliance have developed the following statement concerning sexually violent predator legislation in New York to provide useful information as this legislation is again being debated. The New York State Association for the Treatment of Sexual Abusers (NYSATSA) and the New York State Alliance of Sex Offender Service Providers (Alliance) Boards endorse the public policy statement adopted by the National ATSA Executive Board of Directors on March 20th, 2001, a copy of which can be found on the New York State ATSA and Alliance website. The New York Boards, however, endorse the following updated policy statement that has special reference to the State of New York and is more current, being adopted in January of 2006: Sexual violent predator legislation may have a place in the treatment and management of sexual offenders and in the reduction of sexually violent crime. However, at this point, despite the fact that 17 states have passed such legislation and the fact that New York State is attempting to enact a form of such legislation through aggressive use of its current psychiatric civil commitment law, the unproven efficacy and potentially enormous costs of such programs mandate careful further study and design before enacting such legislation in the State of New York. We would thus recommend that a multidisciplinary group be established by the Governor and Legislature to study such legislation, reviewing the current laws, existing programs, and experience of existing programs, and experience of other states and countries that have enacted such legislation, along with current laws pertaining to sexual offenders in New York, in order to make recommendations relevant for New York. Any recommendations should include projected costs, an analysis of the impact of such legislation on the community and organizations involved, and methods of assessing the effects and outcome of such a program in an ongoing way. We state this for the following reasons: 1. It is clear that there are a number of individuals who are sexually violent predators and whose release into the community at all or without intensive supervision would place the public at risk. 2. As of July 2005, 17 states have adopted such statutes (Arizona, California, Florida, Illinois, Iowa, Kansas, Massachusetts, Minnesota, Missouri, New Jersey, North Dakota, Pennsylvania (for juveniles only), South Carolina, Texas, Virginia, Washington, and Wisconsin). Additionally, similar measures (so-called dangerous offender legislation) have been passed in Canada and in Australia. 3. Enormous costs are associated with such programs. Some have estimated potential costs for New York at $250,000/ inmate/annum. California in 2001 estimated its costs at $107,000/inmate/annum and expended $350,000,000 to build a new facility to house individuals committed under its program, with additional annual legal costs of up to $70,000/annum. 4. The number of inmates able to be released into the community varies greatly between programs in various states, ranging from a rate of 66% released in Arizona (law enacted 1996) to only to 2% in Florida (law enacted 1999). Nationally, as of December 2004, 3943 individuals had been committed under such statutes and only 12% released. 5. The costs of such programs can be reduced substantially by measures that would facilitate release of an individual into the community or community commitment in the first place. For instance, Texas has a civil commitment statute that is entirely outpatient. 6. The capability of releasing a patient into the community is dependent on a variety of factors including the availability of community housing and treatment and monitoring resources and these need to be considered as part of any such legislation. 7. The costs of such programs are not entirely within the control of the states that pass them because various federal class action suits and other standards insure substantial expenditures beyond what a state legislature might have budgeted. Additionally, should legislatures decide that such programs are not desirable, they are difficult to dissolve. 8. Research on the effects of such legislation on recidivism and crime rates is sparse and not definitive. 9. It may be more cost-effective to extend the length of sentencing for sexually violent crime rather than creating a whole new sexual predator statute. Further research into this possibility is needed. 10. Detailed risk assessment could make more rational use of limited resources and increase the monitoring and scrutiny of offenders who are at greater risk and consideration of this should be included in any such legislation. 11. The current New York State Sex Offender Registration Act (SORA) was enacted 10 years ago and did not have the benefit of many of the risk assessment and actuarial instruments and other research that has been done since. This should be reexamined as part of any step towards sexual predator legislation. 12. Lifetime parole or probation for certain crimes has been enacted in some states with apparent reduction in crime rates and this should be considered as an integral part of sexual predator legislation. By Richard B. Krueger, M.D., Vice-President, NYASTA, for the Board of Directors. Putnam
County Needs a Psychiatric-Response Team and a Hot Line Putnam County has been without a psychiatric crisis-intervention team and a 24-hour mental-health hot line since 2005, when the state eliminated funding that supported them. Now, thanks to the insistence of local advocates, the pressure is on county government to fund the services. It is good to see that the Bondi administration and Legislature are taking the issue seriously. Michael Piazza, Putnam's mental-health commissioner, has estimated it would cost about $700,000 a year to run a 24-hour mobile crisis team. A task force has been set up to study how neighboring communities deal with psychiatric emergencies and how the approaches might work in Putnam. Members expect to make the results public in January. "There won't be a quick fix,'' County Executive Robert Bondi told The Journal News, "and we haven't answered who will pay for it.'' Advocates for better mental-health care are persuasive: In a psychiatric crisis, professional response is needed to de-escalate matters and help the individuals involved. Too often, such crises unnecessarily become police matters or involve hospitalization, which in the end is more costly to taxpayers - in addition to the often negative effects on patients. The state should pay for such crisis intervention, as it should in all counties, coordinating training and sharing best practices. Instead, the existence and makeup of such teams vary widely county to county and over time. Westchester tried to disband its crisis-intervention team about seven years ago, but public pressure kept it going. As patients, advocates and medical providers know well, access to mental-health treatment is sporadic, the victim of the stigma and indifference still widely associated with mental illness. Insurers pay for only minimal mental-health care, or none at all. Timothy's Law, which would force insurers to treat mental-health ailiments the same as physical ailments, remains stuck in Albany's political limbo. Earlier this year, Piazza said requests to restore the Putnam crisis team and hot line will be included on his department's upcoming "wish list'' submitted to the state and county as part of its annual mental-health planning process. Perhaps with a new governor waiting in the wings and better-than-anticipated state revenue figures, the funding for Putnam could be realized. In the meantime, the Putnam task force needs to continue its work, as do Putnam elected officials. No matter what transpires in Albany, Putnam residents must be able to count on better mental-health services. The county should be prepared to pay for them, perhaps lowering the costs by sharing resources with neighboring counties. Fast-growing Putnam County has made significant strides in overall emergency planning, and improving ambulance availability and response times throughout the county. Still, mental-health crises shouldn't be a step-child to public health - in Putnam or anyplace else.
OAKLAND, Calif., Dec. 1 — Until recently, many children who did not conform to gender norms in their clothing or behavior and identified intensely with the opposite sex were steered to psychoanalysis or behavior modification. But as advocates gain ground for what they call gender-identity rights, evidenced most recently by New York City’s decision to let people alter the sex listed on their birth certificates, a major change is taking place among schools and families. Children as young as 5 who display predispositions to dress like the opposite sex are being supported by a growing number of young parents, educators and mental health professionals. Doctors, some of them from the top pediatric hospitals, have begun to advise families to let these children be “who they are” to foster a sense of security and self-esteem. They are motivated, in part, by the high incidence of depression, suicidal feelings and self-mutilation that has been common in past generations of transgender children. Legal trends suggest that schools are now required to respect parents’ decisions. “First we became sensitive to two mommies and two daddies,” said Reynaldo Almeida, the director of the Aurora School, a progressive private school in Oakland. “Now it’s kids who come to school who aren’t gender typical.” The supportive attitudes are far easier to find in traditionally tolerant areas of the country like San Francisco than in other parts, but even in those places there is fierce debate over how best to handle the children. Cassandra Reese, a first-grade teacher outside Boston, recalled that fellow teachers were unnerved when a young boy showed up in a skirt. “They said, ‘This is not normal,’ and, ‘It’s the parents’ fault,’ ” Ms. Reese said. “They didn’t see children as sophisticated enough to verbalize their feelings.” As their children head into adolescence, some parents are choosing to block puberty medically to buy time for them to figure out who they are — raising a host of ethical questions. While these children are still relatively rare, doctors say the number of referrals is rising across the nation. Massachusetts, Minnesota, California, New Jersey and the District of Columbia have laws protecting the rights of transgender students, and some schools are engaged in a steep learning curve to dismantle gender stereotypes. At the Park Day School in Oakland, teachers are taught a gender-neutral vocabulary and are urged to line up students by sneaker color rather than by gender. “We are careful not to create a situation where students are being boxed in,” said Tom Little, the school’s director. “We allow them to move back and forth until something feels right.” For families, it can be a long, emotional adjustment. Shortly after her son’s third birthday, Pam B. and her husband, Joel, began a parental journey for which there was no map. It started when their son, J., began wearing oversized T-shirts and wrapping a towel around his head to emulate long, flowing hair. Then came his mother’s silky undershirts. Half a year into preschool, J. started becoming agitated when asked to wear boys’ clothing. En route to a mall with her son, Ms. B. had an epiphany: “It just clicked in me. I said, ‘You really want to wear a dress, don’t you?’ ” Thus began what the B.’s, who asked their full names not be used to protect their son’s privacy, call “the reluctant path,” a behind-closed-doors struggle to come to terms with a gender-variant child — a spirited 5-year-old boy who, at least for now, strongly identifies as a girl, requests to be called “she” and asks to wear pigtails and pink jumpers to school. Ms. B., 41, a lawyer, accepted the way her son defined himself after she and her husband consulted with a psychologist and observed his newfound comfort with his choice. But she feels the precarious nature of the day-to-day reality. “It’s hard to convey the relentlessness of it, she said, “every social encounter, every time you go out to eat, every day feeling like a balance between your kid’s self-esteem and protecting him from the hostile outside world.” The prospect of cross-dressing kindergartners has sparked a deep philosophical divide among professionals over how best to counsel families. Is it healthier for families to follow the child’s lead, or to spare children potential humiliation and isolation by steering them toward accepting their biological gender until they are older? Both sides in the debate underscore their concern for the profound vulnerability of such youngsters, symbolized by occurrences like the murder in 2002 of Gwen Araujo, a transgender teenager born as Eddie, southeast of Oakland. “Parents now are looking for advice on how to make life reasonable for their kids — whether to allow cross-dressing in public, and how to protect them from the savagery of other children,” said Dr. Herbert Schreier, a psychiatrist with Children’s Hospital and Research Center in Oakland. Dr. Schreier is one of a growing number of professionals who have begun to think of gender variance as a naturally occurring phenomenon rather than a disorder. “These kids are becoming more aware of how it is to be themselves,” he said. In past generations, so-called sissy boys and tomboy girls were made to conform, based on the belief that their behaviors were largely products of dysfunctional homes. Among the revisionists is Dr. Edgardo Menvielle, a child-adolescent psychiatrist at the Children’s National Medical Center in Washington who started a national outreach group for parents of gender-variant children in 1998 that now has more than 200 participants. “We know that sexually marginalized children have a higher rate of depression and suicide attempts,” Dr. Menvielle said. “The goal is for the child to be well adjusted, healthy and have good self-esteem. What’s not important is molding their gender.” The literature on adults who are transgender was hardly consoling to one parent, a 42-year-old software consultant in Massachusetts and the father of a gender-variant third grader. “You’re trudging through this tragic, horrible stuff and realizing not a single person was accepted and understood as a child,” he said. “You read it and think, O.K., best to avoid that. But as a parent you’re in this complete terra incognita.” The biological underpinnings of gender identity, much like sexual orientation, remain something of a mystery, though many researchers suspect it is linked with hormone exposure in the developing fetus. Studies suggest that most boys with gender variance early in childhood grow up to be gay, and about a quarter heterosexual, Dr. Menvielle said. Only a small fraction grow up to identify as transgender. Girls with gender-variant behavior, who have been studied less, voice extreme unhappiness about being a girl and talk about wanting to have male anatomy. But research has thus far suggested that most wind up as heterosexual women. Although many children role-play involving gender, Dr. Menvielle said, “the key question is how intense and persistent the behavior is,” especially if they show extreme distress. Dr. Robin Dea, the director of regional mental health for Kaiser Permanente in Northern California, said: “Our gender identity is something we feel in our soul. But it is also a continuum, and it evolves.” Dr. Dea works with four or five children under the age of 15 who are essentially living as the opposite sex. “They are much happier, and their grades are up,” she said. “I’m waiting for the study that says supporting these children is negative.” But Dr. Kenneth Zucker, a psychologist and head of the gender-identity service at the Center for Addiction and Mental Health in Toronto, disagrees with the “free to be” approach with young children and cross-dressing in public. Over the past 30 years, Dr. Zucker has treated about 500 preadolescent gender-variant children. In his studies, 80 percent grow out of the behavior, but 15 percent to 20 percent continue to be distressed about their gender and may ultimately change their sex. Dr. Zucker tries to “help these kids be more content in their biological gender” until they are older and can determine their sexual identity — accomplished, he said, by encouraging same-sex friendships and activities like board games that move beyond strict gender roles. Though she has not encountered such a situation, Jennifer Schwartz, assistant principal of Chatham Elementary School outside Springfield, Ill., said that allowing a child to express gender differences “would be very difficult to pull off” there. Ms. Schwartz added: “I’m not sure it’s worth the damage it could cause the child, with all the prejudices and parents possibly protesting. I’m not sure a child that age is ready to make that kind of decision.” The B.’s thought long and hard about what they had observed in their son. They have carefully choreographed his life, monitoring new playmates, selecting a compatible school, finding sympathetic parents in a babysitting co-op. Nevertheless, Ms. B. said, “there is still the stomach-clenching fear for your kid.” It is indeed heartbreaking to hear a child say, as J. did recently, “It feels like a nightmare I’m a boy.” The adjustment has been gradual for Mr. B., a 43-year-old public school administrator who is trying to stop calling J. “our little man.” He thinks of his son as a positive, resilient person, and his love and admiration show. “The truth is, is any parent going to choose this for their kid?” he said. “It’s who your kid is.” Families are caught in the undertow of conflicting approaches. One suburban Chicago mother, who did not want to be identified, said in a telephone interview that she was drawing the line on dress and trying to provide “boy opportunities” for her 6-year-old son. “But we can’t make everything a power struggle,” she said. “It gets exhausting.” She
worries about him becoming a social outcast. “Why does your
brother like girl things?” friends of her 10-year-old ask.
The answer is always, “I don’t know.” But the tide is turning. The Los Angeles Unified School District, for instance, requires that students be addressed with “a name and pronoun that corresponds to the gender identity.” It also asks schools to provide a locker room or changing area that corresponds to a student’s chosen gender. One of the most controversial issues concerns the use of “blockers,” hormones used to delay the onset of puberty in cases where it could be psychologically devastating (for instance, a girl who identifies as a boy might slice her wrists when she gets her period). Some doctors disapprove of blockers, arguing that only at puberty does an individual fully appreciate their gender identity. Catherine Tuerk, a nurse-psychotherapist at the children’s hospital in Washington and the mother of a gender-variant child in the 1970s, says parents are still left to find their own way. She recalls how therapists urged her to steer her son into psychoanalysis and “hypermasculine activities” like karate. She said she and her husband became “gender cops.” “It was always, ‘You’re not kicking the ball hard enough,’ ” she said. Ms. Tuerk’s son, now 30, is gay and a father, and her own thinking has evolved since she was a young parent. “People are beginning to understand this seems to be something that happens,” she said. “But there was a whole lifetime of feeling we could never leave him alone.”
A knife. Maybe even a gun. The threat of suicide or of harming someone else. Erratic behavior and a history of mental health issues. Any of it can be the recipe for tragedy. When police are faced with a person in emotional crisis, whether because of a traumatic event or a mental disorder, it can easily escalate into a life-or-death situation - one in which the officers end up using force, believing it's the only way to avert a disaster. But it may soon be a thing of the past in metropolitan Buffalo. The Buffalo Police Department and several other suburban law enforcement agencies have teamed up with county-funded Crisis Services to develop a program that would provide training to patrol officers to help them understand mental health issues and defuse crisis situations. The Crisis Services Police Mental Health Coordination Project, as the program is known, also brings together the county's many mental-health care agencies. The project's key players believe it would prevent harm to both people with mental disorders and the police and other first responders who confront them. In addition, they think it would better connect people with mental health needs to community services and reduce overcrowding in jails. The project is being headed by David Mann, a lieutenant with the Buffalo Police Department who is in charge of the Sex Offense Squad. "This will be helpful because earlier intervention for people in crisis can give them the support they need before the situation escalates into something dangerous," Mann said. More than 8,300 people were admitted to Erie County Medical Center's psychiatric emergency room - known as the Comprehensive Psychiatric Emergency Program, or CPEP - last year, county mental-health officials said. About 1 in 5 were brought there by police officers. Crisis Services outreach teams met face to face with 1,422 people in 2005, 793 of whom they ended up referring to the CPEP or Buffalo General Hospital. Buffalo Police Commissioner H. McCarthy Gipson said he hopes to begin developing a training program for his patrol officers next year. Gipson's
experience as the former superintendent of the Erie County jails
taught him that that the criminal-justice system is filled with
people with mental health problems, many of whom aren't getting
the help they need. The situation is often complicated because the inmates also may have substance-abuse problems that may mask their mental disorders. Members of the coordination project are hopeful that with Buffalo taking the lead, other local departments will follow. "We have so many police departments in this community," said Jessica C. Pirro, associate director of Crisis Services. "With Buffalo being one of the larger departments, that would make a great start. It could be a pilot project." Last month, the project's players held a conference in Cheektowaga to introduce other local police departments, as well as mental-health care providers and advocates, with the concept. Already, the City of Tonawanda's police have decided to participate in training and develop a program for officers. "We deal with a lot of mental-health calls," said Lt. Lori Rank, who will head Tonawanda's training efforts. "They range from disoriented people, people who need help, people who may be violent. We don't necessarily want to arrest these people, and we may not need to send them to [ECMC]." Learning how to better deal with people in mental or emotional distress would help eliminate some use of force, she said. Cheektowaga's department is looking into finding some grant money to help pay for its own version. "The police, we are not specialists on mental health," explained Lt. Scott C. Prell, who works the Cheektowaga police midnight shift. "We do run into people with mental-health issues all the time," he said. "If you're able to understand what's going on, it means you have more tools on how to de-escalate things." Heather Laney, an advocate with Mental Health PEER Connection, believes that the project has the potential to reduce the number of people with mental disorders who are jailed or forced to go to the hospital unnecessarily. "Anything that can help prevent the use of force, help prevent distress between the people trying to help and the mental-health consumers and increase understanding, I think, would be greatly appreciated by everybody," Laney said. Laney, who is acting as an adviser on the project, knows firsthand how people diagnosed with mental-health disorders are treated by the police. Three years ago, Buffalo police officers took her to a hospital against her will. A person close to Laney had called the police after he mistook something Laney did as a sign she was suicidal. She tried in vain to explain to the officers that she had no intentions of harming herself, but police forced her to go to a psychiatric emergency room - because Laney was known to have been diagnosed as a teenager with bipolar disorder and then later with post-traumatic stress disorder. "They found out I was on medication, and all my rights had gone out the window," she said. The model for the project is based on a system set up by police in Memphis, Tenn. Memphis began its program in 1988 after police officers there opened fire on an unarmed man who was known to have a serious mental illness. The man died, and the community outrage prompted the city to develop a "crisis intervention team." In the years since, the department found that the number of injuries to officers, as well as to citizens, dropped dramatically. Fewer people with mental illnesses were ending up in jail; instead, the number of people brought to hospitals and other mental-health care providers rose sharply. Just as in many other cities, Buffalo has seen interaction between the criminal-justice system and people with mental illness go terribly wrong. In 2002, Michael T. Bennett had been arrested after he was found wandering naked down a West Side street. Three days later, he began acting erratically in the Erie County Holding Center, throwing himself off his bunk and hitting his head on the cell bars. Guards were trying to subdue him when he died. While an autopsy found that Bennett died because of head trauma, a state corrections investigation said the cause of death was traumatic asphyxiation from when the guards tried to subdue him. The incident caused an uproar over the treatment of people with mental illness in the criminal-justice system in Erie County and prompted calls for new protocols and better care. Police and mental-health officials here hope that the police mental-health coordination project will help prevent tragedies and keep people from being sent to jail or the hospital unnecessarily. "If this is done appropriately and effectively, it should lessen the need for those kinds of interventions," said Michael R. Ranney, Erie County's director of intensive adult mental-health services. Judge Robert T. Russell from Erie County's mental-health court says he is excited about the prospect of having a police crisis intervention team. "I think for a community and as a society, we're better off having people trained than not," he said. ". . . They can work to have the person placed in the most appropriate facility: to protect the community and society and . . . get this person . . . to be productive."
Her mother called it a negotiable proposition. But to Jean Lynch-Thomason, a 17-year-old with bipolar disorder who started college this fall, her mom’s notion to fly from their home in Nashville to her campus in Olympia, Wash., every few weeks to monitor Jean’s illness felt needlessly intrusive. “I am so totally aware of the control you have over me right now,” Jean said, sitting in her parents’ living room one evening last June, before coolly reminding her mother of her upcoming 18th birthday. “In a few months the power dynamic is going to be different. For Chris Ference, 19, who is also bipolar, the fast-approaching autonomy of his freshman year held somewhat less appeal. His parents had always directed every aspect of his mental health care. Last summer, over Friday night pizza at his home in Cranberry Township, Pa., he told them that assuming control felt more daunting than liberating. “If it was up to me, I would just have it so you could make those decisions for me up until I was like, 22,” he said. “I mean, you’ve raised me well up to now. You know me better than anyone.” The transition from high school to college, from adolescence to legal adulthood, can be tricky for any teenager, but for the increasing number of young people who arrive on campus with diagnoses of serious mental disorders — and for their parents — the passage can be particularly fraught. Standard struggles with class schedules, roommates, and sexual and social freedom are complicated by decisions about if or when to use campus counseling services, whether or not to take medication and whether to disclose an illness to friends or professors. Keeping a psychiatric disorder under control in an environment often fueled by all-night cram sessions, junk food and heavy drinking is a challenge for even the most motivated students. In addition, the normal separation that goes along with college requires new roles and boundaries with parents, the people who best know the history and contours of their illness. Like Jean and Chris, young adults approach the move to a new life differently, some with defiant independence, some with avoidance. Each approach, say psychiatrists, counselors, dormitory assistants and other campus leaders, comes with its own risk. The students who are most dependent on their parents may be dangerously unprepared for the inevitable stresses of college life. On the other hand, students who are adamant about doing everything on their own may be afraid to reach out for help when they stumble. For parents, the anxious pride at seeing children go off to college is often tinged with fear that their child might fall apart, spiraling into depression or becoming suicidal. Are they going to therapy as they promised? Are they taking the right dose of medication at the right time? Should they as parents inform the school that their child has an illness? Is a fight with a roommate part of a normal transition to college life or a sign of impending trouble? Does an emotional e-mail message written at 3 a.m. represent a transitory moment of turmoil or a reason to get on an airplane? Once teenagers legally become adults, which in most states happens at age 18, they, not their parents, assume control over decisions about therapy and medication. If trouble arises, parents may or may not hear about it because college counselors are bound by confidentiality when dealing with adult students. THE
TRAUMA OF SEPARATION She was accepted at Evergreen State College in Olympia, Wash., a nontraditional college of roughly 4,400 students that issues written evaluations in place of letter grades. Evergreen’s environmental focus — the campus has its own organic farm, composting program and a contest for commuters who bike, walk or carpool to campus — felt like a good fit for Jean, who is passionately committed to the environment and social justice. A consciously quirky teenager who sews her own clothes (to avoid crass consumerism, she says) and who prefers bus trips to flying (to avoid contributing to the pollution caused by air travel), Jean is disarmingly straightforward and self-aware. She said she stopped taking medications when she was 14 because the side effects left her feeling “out of whack and emotionally inauthentic.” She is determined to stay off medications during college, and she devoted considerable advance thought to possible triggers for her illness, like the long rainy winters of the Pacific Northwest. “I don’t feel vulnerable about this transition because this is very much my decision,” she said. “This is a very autonomous move, very much me structuring my own life. I feel like I am putting myself in a situation with really clear intentions.” Jean’s parents, Amy Lynch, 52, and Phil Thomason, 53, were hesitant when Jean, the younger of their two daughters, refused to take medications after eighth grade. Her childhood and early adolescence had been a whirlwind of depression, rage and experiments with different medications and treatments. But when Jean was about 14, Ms. Lynch and Mr. Thomason said, she began to seem more stable. Her developing coping skills, combined with reports about negative side effects of psychotropic drugs in children, persuaded them to acquiesce to her demands to ride out the swings of her illness drug free. They said they believed Evergreen would be a good college for Jean. Still, the move — to someplace so far from home — made them anxious. In the months before Jean left, Ms. Lynch said she wanted her to go back on medication to smooth the adjustment to college life, a suggestion that Jean adamantly rejected. Ms. Lynch worried that Jean took for granted the tacit stability of being at home. When Jean’s depression sets in, she tends to close herself off from people. At home, Ms. Lynch said, “I can look at Jean and know in five minutes what’s going on with her and how to respond to it.” At such a distance it will be difficult to catch the signs. “I feel like we’re doing a high-wire act,” she said, “and I am not sure we have a strong enough net.” Rummaging through the accumulated possessions of adolescence in her bedroom over the summer, Jean singled out the items that she could not leave without: her sewing machine, her coffee maker, the social justice posters that covered her wall. With her mother out of earshot, she acknowledged that she understood her parents’ angst. “I get that this is intense for everyone,” she said. “I do.” HESITANT
TO LEAVE THE NEST Still groggy from an early morning drive to campus, his husky 6-foot-2 frame jammed into an auditorium chair in the student union, Chris shifted uncomfortably as a freshman orientation coordinator welcomed new students and their parents to the Behrend College, a Pennsylvania State University satellite campus in Erie, Pa. “Today really is the first day of your freshman year of college,” the cheery administrator told the group on a June morning more than two months before the start of fall term. Chris had initially been reluctant to go away to college. Though eager to leave the rigid structure and peer pressure of high school, where he told few friends about his illness, he preferred the idea of living at home during college and commuting to an engineering program in nearby Pittsburgh. It was his mother, Debbie Ference, a service director with the southwestern Pennsylvania division of the National Alliance on Mental Illness, an advocacy group, who nudged him to move away. He chose Behrend for its strong engineering program and small student body of about 3,700. A boyish and fidgety teenager who likes heavy metal music, Xbox games and anything having to do with electronics, Chris said he had given little advance thought to his new responsibilities in college. Just days before his orientation, he listened passively as his father, Michael Ference, and Ms. Ference talked about his care at school. They wondered aloud about whether he would be able to continue seeing his longtime therapist in Pittsburgh, more than two hours away. They raised the possibility of putting an advance mental health directive in place, so that they could be contacted if Chris was ever in crisis and unable to consent to parental notification. They discussed how they worried about the possibility of Chris mixing alcohol with his medications. Chris huffed in annoyance and told them he was “smart and moral enough” not to fall into that trap. The fact that Chris was willing to engage in the discussion at all was a sign, they said, of progress. Chris was first hospitalized and received a diagnosis of bipolar disorder at age 10 after a severe episode of depression, mania and suicidal thoughts. He was hospitalized again briefly in sixth grade, after the lithium that had stabilized him for two years became ineffective. But successful therapy and medication since then have kept the illness at a manageable level. He graduated from high school with honors, and in his senior year saw his therapist only every six weeks. A recent medication adjustment has left him able to feel and express more than he has in years. “This whole move is like a coming-out process,” said Mr. Ference, 50, a service coordinator for families with autistic children. “Up to now it’s been all parental motivation. But I think this is a healing process for him after so many hard years.” In a 2005 national survey of the directors of college counseling centers, 95 percent of counseling directors reported an increase in students who were already on psychiatric medications when they came in for help. While universities grapple with how to serve the growing number of students with mental disorders, students are taking the initiative by helping one another. Active Minds, a student-led mental health advocacy organization founded in 2001 at the University of Pennsylvania, now has 56 chapters at schools including Georgetown University, Columbia University, the University of South Florida and the University of Maryland. The National Alliance on Mental Illness has 30 campus affiliates, with 18 more in formation, groups that are set up as student clubs and are financed by school activity budgets and fund-raisers. Programs like the Jed Foundation, a suicide prevention program, and National Depression Screening Day, held each October, offer additional resources. While the overall message from the groups and programs focuses on the potential for success, students who have been through the transition of leaving home for college say it is also important to be honest about the challenges. DIFFICULT
EXPERIENCES At home in Old Bridge, N.J., she could retreat to the isolation of her bedroom when she was depressed — an impossibility in her crowded dormitory. The staggered class schedule left her lacking a dependable rhythm. Even getting dressed and walking to the cafeteria became an insurmountable task. “I was in excruciating pain. I couldn’t breathe,” she said. Though she had been suffering from depression since her early teens, she hid her struggle from family and friends. She sought counseling help for the first time in college, but still could not cope. After a two-year absence and the loss of $15,000 in state scholarships, Ms. Hollingsworth, now 22, is back at Rutgers finishing her degree in exercise physiology and psychology. She is founder of the Rutgers’ affiliate of the National Alliance on Mental Illness, one of the organization’s newest student chapters. At 37, Robert C. Haggard III, who three years ago founded a chapter of the same organization at Washburn University in Topeka, Kan., is still working on his bachelor’s degree in studio art. During his first attempt at college, right out of high school, Mr. Haggard said, “I wasn’t honest with myself that I needed assistance.” He tried to blunt the increasing severity of his bipolar disorder with alcohol, a common tactic for students with psychological disorders, experts say. He was on academic probation when, in 1992, he withdrew from school. He struggled though several jobs, a variety of medications, and a suicide attempt at age 29 before he started to get his condition under control. It has only been within the past four years, he said, that he has gained stability. “I study during the day, sleep at night, eat right and maintain a lot of structure and routine,” he said. “It sounds simple, but it can be a hard place to get to.” Dr. Richard Kadison, chief of mental health services at Harvard, said there were things students with mental illness could do before starting college to increase the chances of a manageable transition. Most important, he said, is establishing local health support on or near campus. Maintaining a relationship with a counselor from home can be helpful, but “you don’t want to end up in an emergency talking to someone at school that you have never laid eyes on,” Dr. Kadison said. LAST-MINUTE
WORRIES His mother headed in the opposite direction and wandered into a session on student support networks led by Sue Daley, the director of the counseling office. She listened intently as the counselor talked about problems students had encountered in recent years. She winced when the counselor related the story of a young woman who had a psychotic episode the previous year, during which she ripped tiles from her dormitory room ceiling because she believed the F.B.I. was monitoring her. “We sent her home so she could get her emotional self together,” Ms. Daley told the group. After the session, Ms. Ference complained that it sounded as if the goal of the counseling center was to get the “crazy kids” out of the way. “I was offended by that,” she said to Ms. Daley. “I want to be comfortable enough with this school that I know you will take care of my son.” In the car on the way home from the campus visit, Ms. Ference mentioned her discomfort with the counseling presentation. “We definitely have to put some outside counseling support in place, just in case you don’t like it there,” she said to her son. Looking through his thick pamphlet of brochures from the day, Chris responded, “Hey, we get a discount on computers and iPods!” Ms. Ference took a hand off the steering wheel to rub at the stress headache pulsating at her temple. About the same time in June at Bongo Java, a trendy coffee shop near her home in the Belmont-Hillsboro section of Nashville, Jean Lynch-Thomason pulled out a tattered journal, held together with silver duct tape. A picture of herself in the third grade, taped to the cover of the thick diary, stared back at her as she gathered her thoughts. As she prepared for college, she had been writing in the journal several times a day. More pensive than during the previous meeting when she matched wits with her parents about her desired independence, Jean confessed that she had been thinking quite a lot about her move in the fall. “There is a lot more fear and anxiety about this transition than I am letting on,” she said. “We can set up all the protective measures we want and still there is just no way to tell what is going to happen, and man, that’s hard.” She remained determined not to let her mother fly out to Washington to check on her. And she resolved to limit her own trips home, to cut down on unnecessary air travel. But she said she felt confident that she had done the most optimal planning possible. She had decided to have an apartment by herself so that she could prepare her own vegan meals. Living alone, she said, would also afford her the privacy to sleep well and have the solitude she craves when her depression sets in. That solitude, she added, might be a double-edged sword in a new environment where she would be more reluctant to engage with people during dark periods of depression. “I am in a good, copacetic place right now,” she said. “But I also know that there is every possibility that things could go bad. I just sort of feel like if I get out there and don’t do well, then I am letting everyone down.” Back at home soon after, she breezed past her mother, confident as ever. A
NEW PERSPECTIVE Mother and daughter said little at all, in fact, about the illness that has so defined their lives, and their relationship, choosing instead to ride bikes, work at a free store for the needy, and play in a fountain one night in the center of downtown. “I’m more settled, I guess,” said Jean, who will turn 18 next week. She was surprised that she so enjoyed the visit. “I was in a good place. She was in a good place. My illness just didn’t particularly seem relevant.” Some ideas that had made sense in the abstract — like living alone — felt unwise after she arrived in September and looked at a few apartments. When a friend from Tennessee offered her a tiny crawl space of a room in an overcrowded home he shared with several other students off campus, Jean said it felt just right. “It’s not like I’m going up to people saying, ‘Hi, I’m Jean, I’m bipolar,’ ” she joked. “But I’m surrounded by beautiful supportive people, and I know if I need it, they will call me out.” She has maintained sessions by telephone with her therapist back home every two weeks. But she has also met people at the campus counseling center. She said she liked that they encouraged holistic as well as purely medical approaches to treatment, and that she would not hesitate to seek help there if the need arose. Back in Nashville, Ms. Lynch said she may have underestimated her daughter’s ability to make good decisions for herself. The lushness and environmental consciousness of Evergreen and the surrounding area seemed to have a stabilizing effect on Jean, she said. There was not a trace of the early signs of mania or depression that Ms. Lynch could usually spot in her daughter well before others. She said she had decided not to raise the issue of medication again. For now. “I may have a different answer a few months from now,” she said. “But what I know today is that she seems to have learned a lot about coping. And that’s how we get through this, by what we know any given day.” Chris Ference has also changed since he packed his things and left home in late August. Sitting on the bed in his dorm room, sounding more mature than he had a few months earlier, he said the transition was smoother than he had anticipated. But he was still working out some of the particulars of dealing with his bipolar disorder. He told his roommate about his illness in mid-October, only because a reporter was coming to their room for an interview. “It’s cool. He’s cool. It’s fine,” he said, with a hint of wariness. “It’s probably good for him to know anyway, so he can understand it, in case I ever need him to help me out.” Discreetly taking his medications in a dorm room typically crammed with engineering students until the wee hours of the morning is also a challenge. In an effort not to draw attention to himself, he said, he takes his two medications late at night, right before he lays his head down to sleep. If anyone notices, they have not let on. He and his mother met with Ms. Daley, head of the counseling center, before school started. After the unpleasant encounter at summer orientation, Ms. Ference wanted some assurances that the school’s services were adequate. She left satisfied, she said, and Chris seemed comfortable enough with the counseling center to go there if he needed to. Chris said he doubted he would need help from Ms. Daley or anyone else at the center. He has friends and is playing guitar in a band, he keeps his partying “under control,” and he loves his engineering classes. He is under no illusions about his illness, he said. He knows it will be something that he has to learn to manage throughout his adult life. “But things are just going so good,” he said. “So far.”
Young Hispanic women and elderly Asian women are at exceptionally high risk of attempting or committing suicide, mental health experts and advocates testified yesterday at a State Assembly hearing. The problem is fueled by cultural and linguistic isolation, the stress of immigration and a shortage of psychiatric and counseling services, according to advocates who attended the hearing in Lower Manhattan. The hearing focused on two groups whose experiences with depression and other mental illnesses are poorly understood by public health experts because little research has been done in this area. In New York City, teenage Hispanic girls are hospitalized for depression at a rate of 388 per 100,000 (compared with 374 for teenage white girls) and are hospitalized after attempting suicide or talking about it at a rate of 95.5 per 100,000 (compared with 88.5 for teenage white girls). Asian women 65 and older in the city have a suicide rate of 11.6 per 100,000, more than double the rate for non-Hispanic white women in that age group. Those figures were cited by a psychiatrist, Dr. Lloyd I. Sederer, the executive deputy commissioner of the City Department of Health and Mental Hygiene. Sharon E. Carpinello, commissioner of the State Office of Mental Health, said that Central American and South American countries, especially Mexico, the Dominican Republic and Honduras, had some of the lowest suicide rates in the world, while Asian countries like Sri Lanka, China, Japan, South Korea, India and Singapore have some of the highest suicide rates. Observing that Hispanics in New York City report the highest levels of emotional distress — two to six times the level for whites, blacks and Asians — Ms. Carpinello said, “What is there about immigrating to this country and taking up residence that drives up the suicide rate?” A variety of explanations were offered at the hearing, which was led by Assemblyman Peter M. Rivera of the Bronx, chairman of a standing committee on mental health. Rosa M. Gil, the founder of Comunilife, a mental health agency, cited cultural factors. “Young Hispanic girls’ lives are marked by a deep sense of despair and hopelessness,” she said. “Through the imaginary life of television they see the other world, full of affluence, that is always trying to create additional needs and wants in them.” She added, “While the Latino family allows and even expects boys to rebel and be bad, girls are expected to be compliant and good,” resulting in internalized anger. A psychiatrist at the New York University School of Medicine, Dr. Antonio A. Abad, said that Hispanic adolescents reported higher rates of alcohol use than other youngsters and said there has been a surge in drug use in some Hispanic communities — both risk factors associated with suicide. The causes of depression in Asian women seem to be less understood. Cao K. O, executive director of the Asian American Federation of New York, said a survey in 2000 of older Asians in the city found that 40 percent reported symptoms of depression. A separate study of the effects of 9/11 on Asians in the city, Mr. O said, found that they “largely perceived professional mental health services to be unhelpful, inappropriate or irrelevant.” Two advocates at nonprofit groups — Ruchika Bajaj of the Coalition for Asian American Children and Families and Sandeep Bathala of Sakhi for South Asian Women — said that mental health services for women from India, Pakistan, Bangladesh and other South Asian countries were particularly scarce. Women who are not proficient in English do not get help, Ms. Bajaj said, “until symptoms reach crisis proportions.” The most dramatic points in the hearing were the vivid descriptions of circumstances that caused women to try to kill themselves. Dally M. Sánchez, an advocate with the Westchester Independent Living Center in White Plains, testified that at 9, she reported being sexually abused by a family member, whom she had to testify against, and that at 11, she made the first of seven suicide attempts. After several hospitalizations, she said, she found a peer support group and a Spanish-speaking therapist at 15. “Because of cultural barriers, trauma often goes untreated, undetected, ignored and suppressed,” she said. Irene Chung, an associate professor of social work at Hunter College, who is working with the New York Coalition for Asian American Mental Health to study Chinese immigrants who attempt suicide, described a woman who had been physically and emotionally abused by relatives. The woman sought medical attention for chest pains that turned out to be psychosomatic symptoms. “Her untreated depression in turn prompted her to cut herself with a knife when she felt there was no one she could turn to for help,” Ms. Chung said. Dr. Sederer said the Health Department has taken measures to help. As part of a citywide depression initiative that began last year, primary care physicians have been asked to routinely administer a nine-question depression screening tool to their patients. Dr.
Sederer also said the city had introduced depression screening into
the Nurse Family Partnership, a program that helps poor first-time
mothers, their babies and their families, and begun a Geriatric
Screening Initiative to detect and treat depression in adults over
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