Reason Magazine - Staff

The Federalization of Medicine

info@reason.com (Maia Szalavitz) — Wed, 03 Oct 2007 12:11:00 EDT

After three trials (two mistrials), one appeal, and having served more than three years of a mandatory 25 year sentence, pain patient Richard Paey was given a full pardon by Florida Governor Charlie Crist on Sept. 20. Paey had been convicted of “drug trafficking” due to the high doses of opioids he’d been prescribed for pain resulting from multiple sclerosis and failed back surgery in the aftermath of a car accident.

Even though three months of surveillance produced no evidence he had sold or given away any medication, and even though he’d been prescribed the same dosages for years, the weight of the drugs alone (which, ironically, mostly contained acetaminophen, the active ingredient in Tylenol) was enough to provoke the mandatory minimum sentence.

While Paey was in prison, officials refilled a morphine pump that he had fitted during the course of the proceedings. That pump, paid for by the state of Florida, delivered over the course of each 48 hour period a larger dose of opioid medication than Paey had been convicted of possessing in the first place.

Strangely, Florida’s parole board recommended against even commuting Paey’s sentence to time served. But Gov. Crist and his cabinet saw Paey’s case for the injustice it was, and unanimously voted to grant him a full pardon. One of those cabinet members, Attorney General Bill McCollum, a long-time supporter of mandatory minimum sentences, said during the hearing, “This is not a pleasant case. Our laws are very much to blame.”

Paey’s is only one of the most egregious cases of injustice resulting from a recent crackdown on “prescription drug abuse.” Dozens of doctors have also been charged with trafficking, and the overwhelming majority have been convicted or taken pleas, even when there was no evidence that they profited from drug sales or intended to provide highs to addicts. The initiative has been pushed in the media and through the courts by the DEA and the Justice Department starting with the Oxycontin hysteria of 2001.

Siobhan Reynolds, the founder of the advocacy group Pain Relief Network who brought the Paey case to national attention, spots a pattern in the few victories pain patients and doctors have won. She notes that the doctors who avoided conviction and patients who ultimately received justice had all been charged at the state level, not in federal courts.

“We’re thrilled by this victory,” she says, “And this shows beyond a shadow of a doubt that if these matters are to be handled by law enforcement at all, they ought to be handled by the states. Here, where things went terribly wrong, they were able to correct the situation. But at the federal level, we’ve been trying to stop this outrageous crackdown for five years, and haven’t gotten anywhere.”

The most notorious federal case is that of Dr. William Hurwitz, who was originally sentenced to 25 years in prison for drug trafficking. His first guilty verdict was overturned on appeal because the jury had not been allowed to consider his defense that he was merely practicing medicine.

In his second trial, he was convicted on 16 counts of trafficking, but acquitted on 29 other charges. Several of the jurors later told John Tierney of the New York Times that they did not think he was a drug dealer, but that he had “fallen down on the job” by not cutting off patients who showed signs of addiction. In other words, Hurwitz was at worst a bad doctor, not a criminal drug dealer.

Though the judge recognized that Hurwitz had been practicing medicine and even said in her sentencing statement that, “the mere prescription of huge quantities of opioids doesn't mean anything,” she nonetheless did not throw out the “trafficking” verdict. However, she did sentence Hurwitz to just five years, significantly below the federal sentencing guidelines. Prosecutors are now appealing the sentence, claiming that the judge erred in her attempt at mercy.

Other doctors convicted on the federal level include Bernard Rottschaefer, who got six years despite the fact that the prosecution’s star witness admitted to having perjured herself; Deborah Bordeaux, MD, who got 8 years for having worked less than two months at a clinic that prosecutors said conspired to sell Oxycontin to addicts; and Ronald McIver, who was sentenced to 30 years. There have been dozens of others, and, thus far, federal appeals courts have offered little relief.

There have been many convictions in state courts, too, but there have been a few significant victories. California doctor Frank Fisher was originally charged with multiple counts of drug dealing, and even murder, in the death of a patient who turned out to have died of gruesome injuries as a passenger in a car accident. The state had claimed the drugs in her system, not the crash, had killed her. Fisher faced decades in prison, but over time the state’s case collapsed. They finally tried him on fraud charges, and Fisher was acquitted.

In Pennsylvania in 2006, Paul Heberle was acquitted on 26 prescription-related charges, including trafficking and fraud. He’d been asked by the state to take over the care of patients of another doctor who’d been sent to prison for “drug dealing,” and was then prosecuted for having treated some of them.

“I think the states—perhaps because they are closer to the people—are more accountable than the federal government,” says John Flannery, who was Paey’s attorney for his appeal and clemency process, “It’s also a fairer fight in the states because you are not overmatched by the unlimited resources of the federal government.”

Ron Libby, author of The Criminalization of Medicine: America’s War on Doctors and professor of political science at the University of North Florida, is less sanguine. “The only pattern I see is towards being tougher and having a more law enforcement mentality," he says.

But compared to federal prosecutors, who have taken these cases with relish, and even compared accused doctors to the Taliban, state prosecutors seem to be at least somewhat more concerned about the effects of the anti-drug crusade on pain care.

In 2005, the National Association of Attorneys General sent a concerned letter to the DEA and a response to a call for comments signed by the attorney generals of 29 states, the District of Columbia and two territories. The response said, in part, that the AG’s “are concerned that recent DEA actions send mixed messages to the medical community and are likely to discourage appropriate prescribing for the management of pain. Those actions also put the DEA at odds with advances in state policies regarding prescription pain medication.”

The DEA’s only attempt at helping doctors figure out what the police and federal prosecutors see as “appropriate prescribing” and what they call “drug dealing” had been a 2004 FAQ, which was created over years of collaboration between medical experts and law enforcement. It was withdrawn after Hurwitz planned to use it in his defense. Though a “clarification” was published in the Federal Register, re-enforcing the primacy of law enforcement concerns over medical judgment.

Reynolds and PRN would like to see the federal role eliminated entirely through legislation. “Public opinion affects state officials but it does not affect the DEA,” she says. “We’re working with the subcommittee on crime to put together legislation that would shore up the medical exemption to the Controlled Substances Act and restore the supremacy of the states.”

The U.S. Supreme Court, in its decision of the assisted suicide case, Gonzalez v. Oregon ruled that federal prosecutors do not have the power to choose to criminalize entire areas of medical practice. In the majority opinion, Justice Kennedy wrote, “This power to criminalize…would be unrestrained. It would be anomalous for Congress to have so painstakingly described the Attorney General’s limited authority to deregister a single physician or schedule a single drug, but to have given him, just by implication, authority to declare an entire class of activity outside 'the course of professional practice,' and therefore a criminal violation.”

The DEA and the Justice Department have nonetheless continued to make federal criminal cases out of what previously would have been at worst incidents of medical malpractice and have in many cases simply been instances of doctors using treatments drug cops don't understand. And they have considerably hampered advances in pain treatment in the process.

Maia Szalavitz is author of Help At Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006) and a senior fellow at stats.org. Her latest book, co-written with Dr. Bruce D. Perry is The Boy Who Was Raised as a Dog and Other Stories from a Child Psychiatrist's Notebook. (Basic Books, 2007).

Tough Love and Free Speech

info@reason.com (Maia Szalavitz) — Fri, 24 Aug 2007 16:30:00 EDT

Sue Scheff has some serious chutzpah. Portrayed by ABC News, the Washington Post, the Wall Street Journal and Forbes as a beleaguered mom running a small business to help parents find treatment for troubled teens, Scheff's been telling reporters about a service called Reputation Defender, which she says allowed her to triumph over a bunch of rage-filled Internet cranks. Scheff says these vengeance-seeking wackos nearly destroyed her, an innocent businesswoman, with a series of libelous comments posted on online discussion boards. They had called her a “fraud” and “con artist,” she says, and claimed that she was referring teens to tough love programs that then abused them.

What none of this media coverage mentions is that a few years back, Scheff was sued for the same types of comments now directed at her—highlighting the abuses of a "tough love" rehab center (in this case, one of Scheff's rivals). At the time, she framed the suit against her as an attempt to squelch her free speech.

The major news organizations also mention an $11 million libel judgment Scheff boasts about winning against one of her critics, a woman named Carey Bock. But none of these accounts actually looked into the details of that judgment. Bock’s home had been destroyed by Hurricane Katrina during the course of the legal action. Due to her address change, and the stress and depression brought on by the storm, she wasn't even present at her own trial, nor was she represented by counsel.

Bock's current lawyer, Tom McGowan, says he's seeking to have the judgment set aside, because Bock never received notice of the trial date. “They get pretty wacky on these sites, but it’s an outrage what’s going on,” says McGowan. If Bock had actually made it to court, the outcome may well have been quite different.

While all of this may seem like an installment of "News of the Weird," it has serious implications for free speech on the Internet—and highlights how the media often fails to get the whole story.

The saga begins in 2000, when Scheff sent her own daughter to a program affiliated with the World Wide Association of Specialty Programs and Schools (WWASP, sometimes called WWASPS). Scheff was initially a booster of WWASP, and even referred other parents to its programs. For a referral, WWASP paid $1000 per child, or offered a month’s free treatment for the referrer's child. WWASP clients spend at least 18 months in treatment, at $3000-$5000 per month.

At some point, Sue Scheff became aware of online bulletin boards where teens who had been in WWASP programs were telling horrific stories of sexual, physical, and emotional abuse. Users also posted media accounts detailing how nine WWASP-affiliated programs were closed following police investigations, regulatory infractions and/or allegations of child abuse.

Scheff later wrote on her website that she had become uncomfortable with some of the organization's methods. She removed her daughter from the program, and began posting her own allegations against WWASP on online forums, under several different names. She also set up her own consultant business, called Parents Universal Resource Experts (PURE), and began taking referral payments for placing teens, just as WWASP does.

While this sort of practice isn't illegal, it's widely considered unethical. Conflicts of interest arise when consultants get higher referral fees from some programs than they get from others. The temptation arises to place kids in the programs that pay more, even though these may not be the programs best suited to a particular child. Once you're being regularly paid by a program, it’s hard to be objective about its quality. This is why codes of ethics in psychology and psychiatry typically bar such "dual relationships."

Under the Lanham Act, which bans business competitors from making false and inflammatory claims about rivals, WWASP sued Scheff over her critical online posts. Because the court was able to substantiate Scheff’s claims with vivid testimony from victims, WWASP lost.

Soon, however, the online boards buzzed again with yet more reports of abuse at new programs, and this time they included programs where Sue Scheff was referring children. It was around this time that Scheff launched her own lawsuit against Bock. Scheff had helped Bock remove her two sons from a WWASP program, but Bock eventually become outraged by what she considered to be Scheff’s unethical referrals. The $11 million judgment resulted only after Bock didn't show up in court to defend herself.

(Note: The original version of this article stated that the judgment against Bock was "default." Technically, this is incorrect. There was a trial and verdict. But Bock wasn't present, nor did she have counsel present to represent her.)

Meanwhile, child welfare investigators substantiated charges of abuse in 2005 at the Whitmore Academy in Utah, a program to which Scheff made referrals. Regulators shut the program down. Just last month, another complaint was filed against Scheff and another program where she places teens, the Focal Point Academy in Nevada. In that filing, a Florida couple alleges that Scheff failed to disclose that she was being paid by Focal Point, nor did she tell them that the business was licensed only as a foster home, not for residential treatment. The complaint describes these failures to disclose as “fraudulent misrepresentations” and “kickbacks.”

The complaint also details how the couple’s teenage son, R.G., was sexually abused by other boys at the program, who “would hold R.G. down in order to take out their penises, which they would rub on his face, while they threatened and beat him.” He was also allegedly repeatedly threatened with anal rape—and the complaint charges that he was beaten after reporting the bullies to school authorities, who neither reported the sexual abuse to the state as legally required, or made efforts to stop it.

Eventually, Scheff hired Reputation Defender to rehabilitate her image online. Reputation Defender sells itself as a service that removes reputation-damaging posts on the Internet, or at least attempts to make them less prominent on search engines. Scheff and Reputation Defender appear to have contacted the Internet service providers for the site that hosts the most popular discussion boards for victims of tough love programs, a site called fornits.com. According to fornits founder Ginger McNulty, two different service providers recently removed fornits.com from their servers after complaints. Both ISPs refused to divulge the source of the complaints. But the timing is awfully suggestive.

(Disclosure: McNulty did some paid web design work for my book Help at Any Cost.)

The Electronic Frontier Foundation—a premier defender of free speech on the net—was quoted in Forbes as supportive of Reputation Defender. But its spokesperson, staff attorney Kevin Bankston, said that the group was described to him as using positive articles to defend against negative ones, not suppressing speech. “To the extent that Reputation Defender is using baseless legal threats to get speech critical of its clients taken taken down—that is something we’d have serious problems with,” he said.

Fornits is a mostly unmoderated forum, and, as a result, can sometimes include obscene, angry, and off-color rants and slurs. But it's also one of the best sources parents and journalists have for finding out about abuse in residential teen tough-love programs, often straight from the mouths of abused teens and their parents.

Before the Internet existed, thousands of teens who felt they had been harmed by tough love had few ways of complaining, or finding out if others had endured similar experiences. Without places like fornits, they can't be heard, in part because journalists have few other ways to find them.

“It’s unfortunate that nuts and angry people have chosen to attack Sue Scheff in obscene terms,” says attorney Phil Elberg, who represented fornits when it was sued along with Bock by Scheff (the fornits case was dropped). Elberg's one of the few lawyers to have won multimillion dollar judgments against tough love programs. He adds, “This has allowed the focus to shift away from the tactics that Scheff has used and the fact that she describes herself on the net as a child advocate and a critic of the industry, when in reality, she symbolizes so much of what is wrong with it.”

Also unfortunate is the reporting by ABC News investigative reporter Martin Bashir on the new show, I-Caught, as well as coverage in the Washington Post, the Wall Street Journal and Forbes. All told only half the story. Both McNulty and McGowan say they tried to contact these reporters to set the record straight, but were ignored.

The whole sordid story reveals the flaws in both unmoderated online media and in what passes these days for journalism. One way Reputation Defender has managed to move positive stories about Scheff up the ranks on Google is by posting “news stories” she has written on citizen journalism sites like NowPublic. But the mainstream media is not supposed to be as easy to game.

They could start correcting the record by reporting on Reputation Defender’s attempts at censorship and obfuscation, instead of cheering on efforts to silence websites that, for all their flaws, have a history of exposing real incidents of child abuse.

Maia Szalavitz is author of Help At Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006) and a senior fellow at stats.org. Her latest book, co-written with Dr. Bruce D. Perry is The Boy Who Was Raised as a Dog and Other Stories from a Child Psychiatrist's Notebook. (Basic Books, 2007).

Romney, Torture, and Teens

info@reason.com (Maia Szalavitz) — Wed, 27 Jun 2007 15:35:00 EDT

When Republican presidential candidate Mitt Romney said he’d support doubling the size of the prison at Guantanamo Bay, he was trying to show voters that he’d be tough on terror. Two of his top fundraisers, however, have long supported using tactics that have been likened to torture for troubled teenagers.

As The Hill noted last week, 133 plaintiffs filed a civil suit against Romney’s Utah finance co-chair, Robert Lichfield, and his various business entities involved in residential treatment programs for adolescents. The umbrella group for his organization is the World Wide Association of Specialty Programs and Schools (WWASPS, sometimes known as WWASP) and Lichfield is its founder and is on its board of directors.

The suit alleges that teens were locked in outdoor dog cages, exercised to exhaustion, deprived of food and sleep, exposed to extreme temperatures without adequate clothing or water, severely beaten, emotionally brutalized, and sexually abused and humiliated. Some were even made to eat their own vomit.

But the link to teen abuse goes far higher up in the Romney campaign. Romney’s national finance co-chair is a man named Mel Sembler. A long time friend of the Bushes, Sembler was campaign finance chair for the Republican party during the first election of George W. Bush, and a major fundraiser for his father.

Like Lichfield, Sembler also founded a nationwide network of treatment programs for troubled youth. Known as Straight Inc., from 1976 to 1993, it variously operated nine programs in seven states. At all of Straight’s facilities, state investigators and/or civil lawsuits documented scores of abuses including teens being beaten, deprived of food and sleep for days, restrained by fellow youth for hours, bound, sexually humiliated, abused and spat upon.

According to the L.A. Times, California investigators said that at Straight teens were “subjected to unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threats, mental abuse… and interference with daily living functions such as eating, sleeping and toileting.”

Through a spokesperson, Lichfield has dismissed the similar charges against WWASPS to The Hill as “ludicrous,” claiming that the teens who sued “have a long history of lying, fabricating and twisting the story around to their own benefit.”

Straight would use virtually identical language in its denials: In the 1990 L.A. Times article cited above, a Straight counselor downplayed the California investigators’ report by saying, “Some kids get very upset and lie and some parents believe them.” Both Straight and WWASPS have repeatedly called their teen participants “liars” and “manipulators” who oppose the programs because they want to continue taking drugs or engage in other bad behavior.

Curiously, however, both programs regularly admitted teens who did not actually have serious problems. In 1982, 18-year-old Fred Collins, a Virginia Tech student with excellent grades, went to visit his brother, who was in treatment for a drug problem at Straight in Orlando, Florida.

A counselor determined that he was high on marijuana because his eyes were red (this would later turn out to have been due to swimming in a pool with contacts on). He did admit to occasional marijuana use, but insisted he was not high at the time, nor was he an addict. Nonetheless, he was barraged with hours of humiliating questions, strip-searched, and held against his will for months until he managed to escape.

He won $220,000 in a lawsuit he filed against the program for false imprisonment, intentional infliction of emotional distress, assault, and battery. Ultimately, Straight would pay out millions in settlements before it finally closed. However, to this day, there are at least eight programs operating that use Straight’s methods, often in former Straight buildings operated by former Straight staff. They include: Alberta Adolescent Recovery Center (Canada), Pathway Family Center (Michigan, Indiana, Ohio), Growing Together (Florida), Possibilities Unlimited (Kentucky), SAFE (Florida), and Phoenix Institute for Adolescents (Georgia).

Sembler has never admitted to the problems with Straight's methods. In fact, when he recently served as Ambassador to Italy, he listed it among his accomplishments on his official State Department profile. Although all of the programs with the Straight name are closed, the nonprofit Straight Foundation that funded them still exists, though under a different name. It's now called the Drug Free America Foundation, and it lobbies for drug testing and in support of tougher policies in the war on drugs.

One of the plaintiffs in the current case against WWASPS, 21-year-old Chelsea Filer, spoke to me when I was researching a TV segment on the industry. She told me that she was forced to walk for miles on a track in scorching desert heat with a 35-pound sandbag on her back. “You were not allowed to scratch your face, move your fingers, lick your lips, move your eyes from the ground,” she said. When she asked for a chapstick, “They put a piece of wood in my mouth and I had to hold it there for two weeks. I was bleeding on my tongue.”

Why was Filer subject to such punishment? “I had less interest in school and more interest in boys and my mom was worried about me,” she says, explaining that her mother believed that the program was nothing more than a strict boarding school.

Because she has attention deficit disorder, Filer was unable to consistently follow the exacting rules, and repeated small violations were seen as ongoing defiance. “It broke my heart that my mom had no belief in me,” she says, describing how, because WWASPS had told her mother to dismiss complaints as “manipulation,” her mother ignored her pleas to come home.

“I’m not a bad kid,” she continued, “I never used drugs, I was never in trouble, I have no criminal record. I know my mom was worried about me—but so many times I told her that this is too much. I would gladly have gone to prison instead.”

WWASPS is linked with facilities Academy at Ivy Ridge (New York), Carolina Springs Academy (South Carolina), Cross Creek Programs (Utah), Darrington Academy (Georgia), Horizon Academy (Nevada), Majestic Ranch Academy (Utah), MidWest Academy (Iowa), Respect Camp (Mississippi), Royal Gorge Academy (Colorado), Spring Creek Lodge (Montana), and Tranquility Bay (Jamaica).

Although it has settled several lawsuits out of court, the organization has never publicly admitted wrong-doing. However, the U.S. State Department spurred Samoa to investigate its Paradise Cove program in 1998 after receiving “credible allegations of physical abuse,” including “beatings, isolation, food and water deprivation, choke-holds, kicking, punching, bondage, spraying with chemical agents, forced medication, verbal abuse and threats of further physical abuse.” Paradise Cove closed shortly thereafter. That same year, the Czech Republic forced the closure of WWASP-linked Morava Academy following employees’ allegations that teens were being abused.

The former director of the Dundee Ranch Academy Program in Costa Rica went to local authorities after seeing medical neglect and other severe abuse, although human rights abuse charges were ultimately dropped against the owner, Robert Lichfield’s brother Narvin. That program closed in 2003.

Police in Mexico have shut down three WWASP-linked facilities: Sunrise Beach (1996), Casa By The Sea (2004) and High Impact (where police videotaped the teens chained in dog cages).

In 2005, New York’s Eliot Spitzer forced WWASP to return over $1 million to the parents of Academy at Ivy Ridge students, because the school had fraudulently claimed to provide legitimate New York high school diplomas. He fined Ivy Ridge $250,000, plus $2000 in court costs. A civil suit has been filed for educational fraud in New York as well, by a different law firm.

Straight's Sembler currently heads the Scooter Libby Defense Fund, in addition to his work for Romney, and has worked tirelessly to keep the Vice President's former Chief of Staff out of prison, even after his conviction on charges of perjury and obstruction of justice. After all, if running programs that impose these kinds of "treatments" on American teenagers is not a prison-worthy offense, why should lying to a court be?

The Romney campaign is aware of the WWASP suits, and should be familiar with the Straight suits. If not, it's worth asking: Does Romney support these types of tactics for at-risk youth? Or does he take the line the organizations founded by his fundraisers take—that these dozens of lawsuits are merely from bad kids who make up lies?

Coming from the man who wants to double the size of Guantanamo, these aren't insignificant questions. If Romney doesn't believe the aggressive tactics he supports for use against enemy combatants ought to be used against troubled teens and youth drug users, he should say so, and show he means it by removing these men from his campaign.

Discuss this article online.

The Trouble with Troubled Teen Programs

info@reason.com (Maia Szalavitz) — Thu, 28 Dec 2006 13:34:00 EST

The state of Florida tortured 14-year-old Martin Lee Anderson to death for trespassing. The teen had been sentenced to probation in 2005 for taking a joy ride in a Jeep Cherokee that his cousins stole from his grandmother. Later that year, he crossed the grounds of a school on his way to visit a friend, a violation of his probation. His parents were given a choice between sending him to boot camp and sending him to juvenile detention. They chose boot camp, believing, as many Americans do, that “tough love” was more likely to rehabilitate him than prison.

Less than three hours after his admission to Florida’s Bay County Sheriff’s Boot Camp on January 5, 2006, Anderson was no longer breathing. He was taken to a hospital, where he was declared dead early the next morning.

A video recorded by the camp shows up to 10 of the sheriff’s “drill instructors” punching, kicking, slamming to the ground, and dragging the limp body of the unresisting adolescent. Anderson had reported difficulty breathing while running the last of 16 required laps on a track, a complaint that was interpreted as defiance. When he stopped breathing entirely, this too was seen as a ruse.

Ammonia was shoved in the boy’s face; this tactic apparently had been used previously to shock other boys perceived as resistant into returning to exercises. The guards also applied what they called “pressure points” to Anderson’s head with their hands, one of many “pain compliance” methods they had been instructed to impose on children who didn’t immediately do as they were told.

All the while, a nurse in a white uniform stood by, looking bored. At one point she examined the boy with a stethoscope, then allowed the beating to continue until he was unconscious. An autopsy report issued in May—after an initial, disputed report erroneously attributed Anderson’s death to a blood disorder—concluded that he had died of suffocation, due to the combined effects of ammonia and the guards’ covering his mouth and nose.

Every time a child dies in a tough love program, politicians say—as Florida Gov. Jeb Bush initially did on hearing of Anderson’s death—that it is “one tragic incident” that should not be used to justify shutting such programs down. But there have now been nearly three dozen such deaths and thousands of reports of severe abuse in programs that use corporal punishment, brutal emotional attacks, isolation, and physical restraint in an attempt to reform troubled teenagers.

Tough love has become a billion-dollar industry. Several hundred programs, both public and private, use the approach. Somewhere between 10,000 and 100,000 teenagers are currently held in treatment programs based on the belief that adolescents must be broken (mentally, and often physically as well) before they can be fixed. Exact numbers are impossible to determine, because no one keeps track of the kids in these programs, most of which are privately run. The typical way to end up in a government-run program, such as the camp where Martin Lee Anderson was killed, is for a court to give you the option of going there instead of prison. The typical way to end up in a private program is to be sent there by your parents, though judges and public schools have been known to send kids to private boot camps as well. Since they offer “treatment,” some of the private centers are covered by health insurance.

In the nearly five decades since the first tough love residential treatment community, Synanon, introduced the idea of attack therapy as a cure for drug abuse, hundreds of thousands of young people have undergone such “therapy.” These programs have both driven and been driven by the war on drugs. Synanon, for example, was aimed at fighting heroin addiction, its draconian methods justified by appeals to parents’ fears that drugs could do far worse things to their children than a little rough treatment could. The idea was that only a painful experience of “hitting bottom” could end an attachment to the pleasures of drugs.

But like the drug war itself, tough love programs are ineffective, based on pseudoscience, and rooted in a brutal ideology that produces more harm than most of the problems they are supposedly aimed at addressing. The history of tough love shows how fear consistently trumps data, selling parents and politicians on a product that hurts kids.

Attack Therapy Utopia
Synanon was a supposedly utopian California community founded in 1958 by an ex-alcoholic named Chuck Dederich. Dederich believed he could improve on the voluntary 12-step program of Alcoholics Anonymous. Rather than rely on people choosing to change, Synanon would use extreme peer pressure and even physical coercion to impose the confession, surrender, and service to others that 12-step programs suggest as the road to recovery.

At the time, heroin addiction was seen as incurable. But when a heroin addict kicked drugs after participating in Dederich’s brutally confrontational encounter groups, the founder and other members began living communally and promoting Synanon as an addiction cure.

The media took note, and soon state officials from across the country were visiting and setting up copycat programs back home to treat addicts. Only New Jersey bothered to do an outcome study before replicating Synanon. The investigation, released in 1969, found that only 10 to 15 percent of participants stayed in the program for more than a few months and actually ended their addictions, a rate no better than that achieved without treatment. A 1973 study of encounter groups by the Stanford psychiatrist Irvin Yalom and his colleague Morton Lieberman found that 9 percent of participants experienced lasting psychological damage and that Synanon groups were among those with the highest numbers of casualties.

But the research didn’t matter. To both the media and the politicians, anecdote was evidence. The idea that toughness was the answer had a deep appeal to those who saw drug use as sin and punishment as the way to redemption. And Synanon produced testimonials worthy of a revival meeting. Indeed, it eventually recast itself as the “Church of Synanon.”

By the early 1970s, the federal government itself had funded its own Synanon clone. It was located in Florida and known as The Seed.

In this program, teenagers who were using drugs or who were believed to be at risk of doing so would spend 10-to-12-hour days seated on hard-backed chairs and waving furiously to catch the attention of staffers, most of whom were former participants themselves. Like Arnold Horshack in Welcome Back, Kotter but with more desperate urgency, they would flutter their hands, begging to be called on to confess their bad behavior. Even before the excesses of the ’80s, parents were so frightened of drugs that they were willing to surrender their children to strangers for tough treatment to avoid even the possibility of addiction; some parents even hit their children themselves at Seed meetings, following the instructions of program leaders.

When kids entered The Seed, they lived in “host homes” —houses of parents of other program participants that had been specially prepared to incarcerate teenagers at night. If these “newcomers” didn’t give convincing enough confessions in group sessions, they would not be allowed to “progress” in the program and return to home and school.

In 1974 Sen. Sam Ervin, the North Carolina Democrat best known for heading the congressional committee that investigated Watergate, presented a report to Congress entitled “Individual Rights and the Federal Role in Behavior Modification.” Ervin and other members of Congress were concerned about federal funding for efforts to change people’s behavior against their will, seeing a fundamental threat to liberty if such efforts were successful. The report cited The Seed as an example of programs that “begin by subjecting the individual to isolation and humiliation in a conscious effort to break down his psychological defenses.” It concluded that such programs are “similar to the highly refined brainwashing techniques employed by the North Koreans in the early 1950’s.”

The Seed Germinates
Ervin’s report led Congress to cut off The Seed’s funding. But The Seed had produced two important true believers: Mel Sembler, who went on to serve as campaign finance chairman for the Republican Party during the 2000 election season and as U.S. ambassador to Italy from 2001 to 2005, and Joseph Zappala, who would go on to serve under the first President Bush as ambassador to Spain and who at the time was also a major Republican campaign donor.

In 1976 Sembler and Zappala founded a program virtually identical to The Seed, staffed by former Seed parents and participants (including some who had become Seed staffers). They named it Straight Incorporated. The federal agency that had funded The Seed, the Law Enforcement Assistance Agency, had been barred from funding further human experiments because neither the agency nor projects like The Seed had procedures for informed consent. Despite that fact, and despite the congressional critique of The Seed, Straight soon received federal money from the same agency. It, too, never informed parents that it was experimental.

Straight expanded rapidly in the ’80s, around the same time newspapers, TV, and other media were filled with dire warnings about the dangers of crack. Nancy Reagan called it her “favorite” drug program. In fact, it was a visit to Straight, suggested by Sembler, that had inspired the first lady to make drugs her cause.

An undated issue of Straight’s newsletter, Epidemic, from around this time carried a photo of the legs of a young-looking corpse with a tag on one toe: “Cocaine, crack and kids.” The accompanying article said crack was “almost instantaneously addictive”—“the most addictive drug known to man”—and passed along the tale of a 16-year-old girl who had recently tried smoking cocaine. “One night I noticed a big lump on my back,” she wrote. “I was rushed to the hospital and operated on and had two tumors removed. The tumors were caused by impurities in the coke which built up in my blood and got infected.” Such a story, if true, would have made medical history.

But for the media, drugs act as an anti-skeptic; the scarier the consequences, the bigger the story, the higher the ratings, and the lower the incentive to qualify extreme claims. The 1986 documentary 48 Hours on Crack Street purported to show the crack menace spreading ineluctably to the middle class. It drew one of the largest TV audiences ever for a news program.

Between 1981 and 1989, Straight opened sites in Atlanta; Cincinnati; Orlando; Boston; Detroit; Yorba Linda, California; and Springfield, Virginia. Former employees opened virtually identical programs in New Jersey, Kentucky, Utah, New Mexico, and Florida in the late ’80s and early ’90s.

Spanking and Motivating
As far back as 1978, however, employees had begun to quit Straight and contact regulators, reporting beatings and other maltreatment. “The program was getting…so bad that I felt it was hurting more kids than it was helping,” one anonymous former staffer told the St. Petersburg Times that year. Miller Newton, Straight’s national clinical director, admitted to authorities in 1982 that he had kept teenagers awake for 72-hour periods, put them on peanut butter–only diets, and forced them to crawl through each other’s legs to be hit in a “spanking machine.”

At Straight, The Seed’s hand-waving procedure to get staff attention during group sessions mutated into “motivating,” in which kids flapped their arms so vigorously it looked like they were trying to fly away. The movements were so violent that more than once teenagers hit those sitting next to them, resulting in broken bones.

Richard Bradbury, whose activism eventually helped shut Straight down, was forcibly enrolled in the program in 1983, when he was 17. His sister had had a drug problem, and Straight demanded that he be screened for one as well. After an eight-hour interrogation in a tiny room, Bradbury, who was not an addict, was nonetheless held. He later described beatings and continuous verbal assaults, which for him centered on sexual abuse he’d suffered as a young boy. Staffers and other participants called him a “faggot,” told him he’d led his abusers on, and forced him to admit “his part” in the abuse.

Straight ultimately paid out millions of dollars in dozens of lawsuits related to abuse and even kidnapping and false imprisonment of adults. But the Straight network remained in operation until 1993. Even today, at least nine programs in the U.S. and Canada still use tactics, such as host homes and “motivating,” that come directly from Straight. Some are run by former Straight employees, sometimes in former Straight buildings. Among them: SAFE in Orlando; Growing Together in Lake Worth, Florida; Kids Helping Kids in Cincinnati; the Phoenix Institute for Adolescents in Marietta, Georgia; Turnabout/Stillwater Academy in Salt Lake City; Pathway Family Center in Detroit; the Alberta Adolescent Recovery Center in Calgary, Alberta; and Love in Action, a program aimed at “curing” homosexual teenagers, located near Memphis. The Straight Foundation itself, which coordinated the organization and doled out the money, never died; it simply renamed itself the Drug Free America Foundation, which to this day works to promote student drug testing and to oppose efforts to end the drug war. Its website lists Mel Sembler and his wife Betty as “founding members.”

Meanwhile, other organizations found they could profit from tough love with legal impunity. As negative publicity finally began to hurt Straight and skepticism about the drug war itself grew, other groups began to use similar tactics, all converging on a combination of rigid rules, total isolation of participants from both family and the outside world, constant emotional attacks, and physical punishments. These programs were sold as responses not just to drug use but to teenage “defiance,” “disobedience,” “inattention,” and other real or imagined misbehavior.

Military-style “boot camps” came into vogue in the early ’90s as an alternative to juvenile prison. The media spread fears of a new generation of violent teenaged “super-predators,” and this solution gained political appeal across the spectrum. Liberals liked that it wasn’t prison and usually meant a shorter sentence than conventional detention; conservatives liked the lower costs, military style, and tough discipline. Soon “hoods in the woods” programs, which took kids into the wilderness and used the harsh environment, isolation, and spare rations to similar ends, also rose in popularity, as did “emotional growth” schools, which used isolation and Synanon-style confrontational groups.

Again, little evidence ever supported these programs. When the U.S. Department of Justice began studying the boot camps, it found that they were no more effective than juvenile prison. For a 1997 report to Congress, the department funded a review of the research, which found that the boot camps were ineffective and that there was little empirical support for wilderness programs. In late 2004 the National Institutes of Health released a state-of-the-science consensus statement on dealing with juvenile violence and delinquency. It said that programs that seek to change behavior through “fear and tough treatment appear ineffective.”

The Way of WWASP
But as the Martin Lee Anderson case makes clear, tough love continued to thrive. Indeed, the New York Times business section reported on tough teen programs as an investment opportunity last year, saying the number of teenagers attending residential programs to deal with drug and behavior problems had quadrupled since 1995. Exposés of programs like Straight or Florida’s government-run boot camps almost always include positive anecdotes along with the accounts of abuse. As a result, for parents terrified of drugs, these stories seem to portray the programs as the only ones tough enough to “do what works.” Since the media play positive anecdote against negative anecdote, often without citing the negative research data, exposés can actually serve as advertisements. The suggestion that the programs work serves to justify any abuse. In 2004, for example, Time quoted a father who said a tough-love program “improved his [son’s] attitude and sense of responsibility,” even as it reported that the family removed the child after finding some of the program’s disciplinary measures too harsh.

One of the largest chains of currently operating tough love schools is known as the World Wide Association of Specialty Programs (WWASP), sometimes called the World Wide Association of Specialty Programs and Schools. Like Straight, it took tactics from Synanon; its ideology, the language it uses, and its methods for discrediting teens’ complaints are eerily similar.

Variously claiming to hold 1,200 to 2,500 teenagers and reporting 2003 revenues of $80 million, the group currently has at least eight affiliates, in Jamaica (Tranquility Bay), South Carolina (Carolina Springs Academy), Nevada (Horizon Academy), Utah (Cross Creek Programs, Majestic Ranch Academy), Georgia (Darrington Academy), Mississippi (Respect Camp), and Iowa (Midwest Academy). WWASP is a series of limited liability corporations that frequently switch corporate officers and names. This strategy is often used to limit losses from lawsuits by disgruntled customers, and until very recently, WWASP has been successful in deterring major law firms from pursuing such cases against it.

Through its public relations representative, James Wall of Freeman Wall Aiello, WWASP denies charges of abuse. But nine of its affiliates have closed following abuse allegations and government investigations. Mexico has shut down three programs since the late ’90s; at one, police shot video of teenagers held in outdoor dog cages. (That program currently faces a civil suit by a boy who claims he not only was kept in a dog cage but was sexually assaulted and forced to eat vomit.) In 1998 the U.S. State Department found “credible allegations of physical abuse” at WWASP’s facility in Samoa, citing “beatings, isolation, food and water deprivation, choke-holds, kicking, punching, bondage, spraying with chemical agents, forced medication, [and] verbal abuse.” It called for an investigation by the local government, which resulted in the program’s closure. The man who ran that program, who once admitted to 48 Hours that teens had been bound with duct tape at the Samoa site, now operates the WWASP facility in Iowa.

In 2003 Costa Rican child welfare authorities raided WWASP’s Dundee Ranch Academy. They found staff “unqualified to attend to needs of children,” “inadequate food and meal portions,” and “some punishments [that] qualify as physical and psychological abuse.” The owner of the facility was arrested for human rights violations, and a source in the Costa Rican government says a prosecution is imminent. Yet Pillars of Hope Academy, an affiliated program for young adults run by Dundee Ranch’s owner, operates in the same building; it is not subject to Costa Rica’s regulations for programs aimed at minors.

Last year one WWASP program in upstate New York, the Academy at Ivy Ridge, was forced by the state attorney general to return nearly $2 million for fraudulently claiming to offer New York high school diplomas. It says it is no longer affiliated with WWASP, but it has changed neither its staff nor its treatment methods. (It is currently facing a $100 million class action suit for educational fraud.) Another WWASP affiliate, Spring Creek Lodge in Montana, likewise claims to be independent now, although it has the same staff and still gets referrals through the WWASP phone line and websites. In July a press release announced a new website, troubledteenprograms.org, linking all of the WWASP-associated programs under the name “Teen Revitalization.”

WWASP seems to have learned Straight’s P.R. lessons well: Deny abuse; smear kids who report problems as drug addicts, liars, and manipulators; insist that the media “balance” negative stories with positive anecdotes; and when the charges begin to stick and the press and regulators have thoroughly discredited a program, simply change its name and reopen, changing location only if necessary.

In an email message, James Wall, the WWASP publicist, says: “Clearly you can speculate about similarities between Straight and WWASPS. However, the two are completely separate organizations with no links whatsoever. You should also note that WWASPS and associated organizations continue to thrive (in terms of growth) despite continued attacks from individuals (online, etc.) and the media.”

WWASP seems to have learned from Straight’s political and regulatory strategies as well. Since the 2002 election, founder Robert Lichfield, his family members (some of whom run WWASP programs), and their various business entities have donated more than $1 million to the Republican Party and its candidates. Together the Lichfields and their businesses are the third largest Republican donor in WWASP’s home state of Utah, according to the Deseret News. WWASP has moved to block or water down state legislation aimed at reigning in tough love programs in at least two states, Utah and Montana.

In 2004 Marty Stephens, speaker of the Utah House of Representatives, used a procedural maneuver to block a vote on legislation, which backers say had more than enough support to pass, imposing stricter controls on a WWASP facility near Randolph, Utah. Six days later, he received a check from Robert Lichfield for his gubernatorial campaign. Lichfield insisted to the Salt Lake Tribune that “that check had nothing to do with” the bill’s blockage. He added: “I’d like to use my means and resources to bless people’s lives. Does that also imply influencing policy makers to make good policies that support good family values, quality education, and the things I believe in? Definitely.”

Prior to 2005, Montana didn’t require teen programs to let the state know they existed, let alone impose regulation. But local and national exposés led to calls for greater oversight. In the 2005 legislative session, Spring Creek Lodge registered five lobbyists and spent at least $50,000 to block a bill that would have imposed strict state rules, according to the Missoula Independent. The legislation died in the state House of Representatives. An alternative bill, sponsored by Spring Creek’s competitors, passed. It created a governor-appointed board with five members—three of whom represent the industry. One of the members is the “principal” of Spring Creek Lodge.

The Tide Turns?
Thanks to the potent combination of political influence, industry and government fear-mongering, and media malpractice, tough love has so far survived its detractors. But Martin Lee Anderson’s death may have marked a turning point.

The case has revealed the politics of tough love in one of its home states, and has turned a new spotlight on the data. In a departure from the usual journalistic pattern, the early coverage of the case consistently cited the research finding boot camps to be no more effective than juvenile prison, and editorials mainly called for their closure.

The movement toward “evidence-based” social policy has been growing since the early ’90s, as insurers, patient advocates, and government agencies alike demanded proof that expensive policies produce demonstrable results. It also seems to have spurred at least some journalists to view scientific data as superior to anecdotes when assessing the performance of tough love programs. This has reduced the false balance in prior coverage that simply played success stories against abuse accounts. Some Florida papers even noted how the research and prior abuse scandals had led other states to shut down their government-run boot camps. They cited a Maryland scandal in which the Baltimore Sun photographed guards at a state-run boot camp openly beating inmates, which led that state to drop such programs. They also mentioned a similar scandal that prompted a federal investigation of Georgia’s public boot camp programs, leading to their closure. Some coverage of the Anderson case noted the 1999 death of 14-year-old Gina Score at a South Dakota boot camp following forced exercise similar to that endured by Anderson, an incident that led that state to shutter its programs.

As the Florida case unfolded, political missteps dogged boot camp supporters. First, the state refused to release the videotape of the boy’s beating to the media, leading to an outcry and greater media attention. Guy Tunnell, who had founded and staffed the sheriff’s boot camp in which Anderson died, had gone on to head the Florida Department of Law Enforcement; as a result, he was initially in charge of investigating the death. Email messages from Tunnell—who serves on the board of the Drug Free America Foundation—showed that he supported the boot camp he was supposed to be objectively investigating, and that he had adamantly resisted releasing the video. The revelations prompted the appointment of a special prosecutor, generating yet more media attention. No criminal charges have been filed so far, but Anderson’s family has filed a $40 million lawsuit against the state.

Because Anderson was African-American, some activists raised the question of racism. (Most teens killed in these programs have been white, since blacks are less likely to be able to afford the private camps and more likely to be incarcerated instead of diverted to public boot camps.) On April 19, students occupied the governor’s office in an attempt to spur the arrest of the guards responsible for Anderson’s death. Two days later, more than 1,500 people attended a rally at the state Capitol in Tallahassee calling for the state to shut down its boot camps. (Full disclosure: I spoke there about the dangers of the tough love approach.) The event was also aimed at keeping pressure on prosecutors to indict the guards and the nurse who didn’t stop the beating. At the rally, two Florida legislators spoke in favor of legislation that would shut down the boot camps. Tunnell was forced to resign as head of the Florida Department of Law Enforcement after he mocked two men invited to speak at the rally, referring to Jesse Jackson as “Jesse James” and to Illinois Sen. Barack Obama (who ultimately did not attend the event) as “Osama bin Laden.”

This series of events has placed an unusual spotlight on tough love, connecting it not with rehabilitation but with death, cronyism, and bigotry. Previous deaths haven’t generated anywhere near as much activism.

To his credit, Jeb Bush recently signed into law a bill that shuts down the state’s youth boot camps. The replacement programs it creates are prohibited from using physical punishment or “harmful psychological intimidation techniques,” including humiliation and attempts to “psychologically break a child’s will.” But the kinder, gentler programs will still be run by the county sheriffs, and the regulations (which are limited to Florida, of course) do not apply to the majority of programs, which are private. Right now, children sent to private tough love programs have fewer rights than convicted prisoners. A parent can send a child to a private program where he can be held incommunicado until he turns 18, without any medical diagnosis or rationale for the treatment and without any oversight or means of appeal.

In both public and private programs, policies on the use of force are far less stringent than they are for adult prisoners or psychiatric patients. At the government-run boot camp where Anderson died, for example, restraint, punches, and kicks were routinely applied to teens to punish them for not completing exercise, for “whimpering,” or for “breathing heavily.” Administrators who reviewed 180 “use of force” reports found inappropriate actions in only eight cases, even though most people would think that beating someone for “breathing heavily” is not acceptable. In a prison or mental hospital, by contrast, force is officially permitted only if the prisoner or patient is an immediate threat to himself or others. Parents who engaged in such practices could be charged with child abuse.

And the parents who send their kids to these camps? For the most part, they are uninformed about the absence of evidence supporting tough love programs and often desperate to save their kids from drugs and delinquency. Until we figure out a better balance between the right of parents to place their kids in whatever programs they choose and the right of kids to be free from inappropriate punishment by agents of their parents or the state, the abuse will continue. The shame of it all is that we know hurting kids doesn’t help them.

Maia Szalavitz (maiasz@gmail.com) is the author of Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead).

"The Doctor Wasn't Cruel Enough"

info@reason.com (Maia Szalavitz) — Fri, 02 Jun 2006 16:43:00 EDT

When Dr. Paul Heberle was arrested last April, dozens of chronic pain patients were left in agony. One of Heberle's patients called no fewer than 37 doctors seeking care—all of whom refused to see him once he revealed the name of his prior provider. Finally, Robert Holmes, a 40-year-old man who suffers from a lung injury and requires supplemental oxygen to breathe, resorted to visiting a methadone clinic for drug addicts. He was turned away there, too. More than twenty others reported similar experiences at a meeting of patients affected by the arrest. Six would later attempt suicide.

For many patients, the situation was devastatingly familiar. Heberle had agreed to care for many of them after their previous physician was arrested and then convicted on some of the same charges that Heberle now faced: illegal prescribing of narcotics. That doctor, David Klees, got 12 to 24 years in prison. This time, however, the government would find it wasn't so easy to railroad a pain doctor.

In the last five years—since a media panic over prescription drug abuse began with law-enforcement-driven reports of an "Oxycontin epidemic"—dozens of doctors have been prosecuted for "overprescribing" painkillers. The Justice Department and the DEA have pushed this aggressive new campaign in the war on drugs.

Overwhelmingly, these cases have resulted in convictions with heavy prison terms—or plea bargains with shorter sentences that nonetheless drove the doctors out of medicine. Advocates for pain patients report that, as a result, relief has been increasingly hard to find.

Fortunately, Heberle had an ally that Klees didn't: Siobhan Reynolds and her Pain Relief Network. As the DEA and local prosecutors went as far as creating a poster with Dr. Heberle's picture and the words "overprescribing controlled substances" and "Medicaid fraud" on it, Reynolds visited Erie, PA, to organize Heberle's patients and, for once, get their side of the story into the media.

Nearly all of the prior cases have followed a similar pattern. First, prosecutors blitz local media with reports of out-of-control prescription drug abuse problems and discuss the problem of "pill mills." Then, they swoop in with a SWAT team and arrest any doctor brave enough to actually treat chronic pain with doses of opioid medication large enough to work. They call him a "drug dealer" and "pusher with a pen."

Next, the prosecution brings out addicts for the cameras, who claim the doctor treated them without examining them and "caused" them to develop drug problems—but they don't mention the addicts' motivation for cooperating. In virtually all of these cases, addicts are motivated by reduced or dropped sentences charges from prosecutors, or by the hope of suing the doctors who got them "hooked." Prosecutors also usually fail to note that for most of these addicts, this is far from their first run-in with drug problems or the law.

At some point, however, the government team brings out its most devastating weapon: weeping relatives of patients who have died while under the doctor's care. Reporters are rarely keen to grill the grieving, so their stories tend to stress the prosecution's talking points rather than the fact that these deaths are virtually always either deliberate suicides or overdoses resulting from deliberate misuse of prescription medication. In the Heberle case, the death that started the investigation involved someone who had eaten a patch meant to be worn on the skin—thus immediately ingesting three days-worth of drugs.

Usually, the media buy the tale of evil substances and vile physician-pushers. But Reynolds offered a more compelling alternative narrative. She brought the suffering patients into the media eye. Rather than telling the tale of an evil drug-dealing doctor who brings down the poor addict, she and the patients provided another version of the story, in which the wonderful healer allows his grateful patients to function—until the cops drag him away.

And in fact, Reynolds' account is more accurate. Some 90 percent of people who abuse Oxycontin also have histories of using cocaine and psychedelic drugs. Were most of these people innocent "victims" of evil doctors? Isn't it more likely that they were prior heavy drug users who sought additional drugs and, because there's no objective way of measuring pain, were able to get them from compassionate doctors? Aren't doctors who do believe people's accounts of pain exactly the ones we want in practice?

In the Heberle case, one prosecution expert told the Erie Times-News that the doctor was:

prescribing painkillers to patients with documented prior substance-abuse problems and/or mental impairment.

The paper didn't note that there is nothing illegal about this. Nor did the reporter seem to realize that there's something profoundly sick about assuming that people who are mentally impaired or have a history of drug problems never need strong pain medication.

Fortunately, in the Heberle case, the jury didn't buy the lies. Heberle made no profit from the prescriptions he wrote; he was a former addict himself who was monitored for abstinence. What possible reason could such a person have for deliberately supplying addicts? The only sensible way to see him was as a caring physician, who, like anyone else, does not have a "pain-o-meter" or fool-proof lie detection device in his head or office.

The defense presented expert testimony that laid out the complexities of pain treatment. Although the prosecution essentially put on a malpractice case—representing violations of the standard of care as criminal when they actually are civil violations—the defense beat them back. Their cross examination of a prosecution witness who claimed that certain opioids should only be used for cancer pain was especially effective. The defense simply exhibited a small practice guide which shows that the medications are recommended for other pain as well.

Also effective was the defense expert, Frank Fisher, MD, one of the few physicians to be exonerated after being prosecuted for over-prescribing. He called the prosecution "a crime against humanity," and in conjunction with the defense team, debunked the idea that cutting off pain medication to people with past or even present addictions does anything to help them.

"They showed addictionology for the sham science that it is," says Reynolds, explaining that in previous cases, the defense often had a hard time getting the jury to see that medications can't "make" people into addicts and that no one, addicted or otherwise, benefits from a system where doctors presume all pain is faked.

"The government position is that the doctor wasn't cruel enough," she adds, describing how hard it was for previous defense teams to debunk the notion that addiction can be prevented or treated by stopping or failing to prescribe pain medication.

"By making the pain patients real, we made the good guys and the bad guys change places—and that's hard to do," she says.

Last week, Heberle was found not guilty on all charges. Unfortunately, at least one patient did not live to see the verdict— she had committed suicide, unable to find another doctor to prescribe the medications she needed. And Heberle, like Fisher, will no longer practice medicine, leaving many patients still without help.

As Reynolds asks, "How can they call this protecting the public health?" We hope the Heberle case is the beginning of the end of these senseless prosecutions.

In Defense of Happy Pills

info@reason.com (Maia Szalavitz) — Sat, 01 Oct 2005 00:00:00 EDT

The first time I did heroin, it was a Listening to Prozac moment. Like the patients that psychiatrist Peter Kramer describes in his 1993 book, I felt the way I wished to be, but better than I'd thought possible.

Moments before, I'd been insanely jealous: I'd found out my boyfriend had been with another woman. I was shouting at him in a grotty New York welfare hotel. I was filled with self-hatred. I'd been suspended from college because of my involvement with cocaine. I thought I had ruined my life. I was about as miserable and low as could be. And then I wasn't.

I was sitting in a dingy room with peeling paint and crooked furniture. My boyfriend and the couple who lived there desperately wanted me to shut up: He had large quantities of cocaine, they had large quantities of heroin, and neither wanted to attract attention. I'd always resisted heroin because from what I'd read, I knew I'd love it. But my anger got the better of me, and I impulsively snorted the huge line they offered in the hope of quieting me.

Suddenly every atom of my being felt nurtured; every ounce of my essence felt well and light. My jealousy no longer bothered me. I also felt very nauseated--but didn't mind. Nothing could touch me. If I'd been able to feel even close to this naturally on even a semi-regular basis, I thought, I'd never have gotten into such trouble. For once, I wasn't a raw nerve, vulnerable to every tiny stimulus. For once, all the voices in my head that said I was worthless, that told me I was irreparably selfish and vile, had shut up. For once, I felt everything would be OK.

Needless to say, I soon added heroin to my cocaine habit. Although most people don't respond to opioids with the kind of rapture I felt, for me it was love at first sensation.

During the next three years, I deteriorated rapidly, to the point where I found myself injecting both cocaine and heroin up to 40 times a day, broke, and begging a man I detested for heroin. I knew then that I had to stop. The impulse I had to try to seduce him to get the drug broke through my rationalizations about "not really" being an addict. But when I quit heroin that day at age 23, having asked my parents to take me to a hospital detox program for help, I thought I was doomed for life to my vicious internal milieu.

Fortunately, through 12-step programs, I was able to dramatically reduce the crime rate in my mental neighborhood. Using techniques they share with cognitive therapy, my groups taught me, for example, that when I thought others didn't want me around, that was my own, possibly flawed perception--not necessarily the truth of the situation. By behaving like someone I would want as a friend and cutting off the internal debate over whether or not this was "authentic," I was able to gradually stop torturing myself. By doing estimable actions, I gained self-esteem. This made escape with drugs much less attractive.

But these cognitive techniques did not eliminate my bouts of depression, during which all that self-hatred would return furious as ever--and during which I was unable to feel any joy or relief. Twelve-steppers insisted that pain, as the founder of Alcoholics Anonymous put it, was "the touchstone of all spiritual progress," that my depression was telling me something I needed to hear.

No Pain, No Gain

Few would dispute the notion that painful experience can build character, just as stressing muscles by lifting weights increases strength. But it's also clear that most people most of the time prefer to avoid pain. The tension between these facts has led to a curious situation in mental health: Unlike in any other area of medicine, treatments that reduce pain and suffering, rather than being welcomed as miraculous breakthroughs, often are denigrated as "quick fixes." They're viewed as band-aids that cover up, but do not solve, the real problem--only marginally more acceptable than illicit drugs. "I oppose the use of heroin for the same reason I oppose the use of Prozac," the psychologist Jeffrey Schaler writes in his 2001 book Addiction Is a Choice. "I think relying on these is an existential cop-out--a way of avoiding coping with life."

Peter Breggin, a longtime critic of psychiatry and author of the 2000 book Your Drug May Be Your Problem: How and Why to Stop Taking Psychiatric Medications, expressed a similar sentiment in a 1994 Psychology Today article. "When so many Americans feel depressed and hopeless," he wrote, "we are dealing with a social phenomenon. The very idea that drugs are the answer suggests a moral, psychological, or spiritual vacuum." From this perspective, psychiatric medications treat symptoms, not causes. Unless someone is getting to the root of the problem with talk therapy, according to this view, drugs are anesthetics that kill pain and temporarily improve function but allow patients to avoid necessary emotional struggles.

The influence of this critique was illustrated by the cover story of the November 2004 issue of Forbes magazine. Under the headline "Just Say No: How America Could Kick Its Prescription Drug Habit," the article clucked, "The 1990s made pill-popping for happiness an acceptable therapeutic alternative for millions of even mildly depressed patients." Forbes approvingly quoted a patient who said, "Drugs just mask the problem." A psychologist moaned, "Psychotherapy just can't compete with drug company advertising. We get crushed."

Anxieties about antidepressants, magnified by the ongoing debate over their side effects, extend beyond mental health professionals who face competitors with prescription pads. They also show up in the qualms of psychiatrists who worry that these drugs can be dangerous short cuts and in the public statements of regulators who suggest they're overused. Most important, the backlash against antidepressants may discourage people they would help from trying them by reinforcing the sense that there is something fundamentally suspect about turning to drugs for assistance in coping with life. Although the critics of drug therapy raise some valid points, the premise that pills are bad because they're easy is pernicious and needs to be challenged.

If a drug were discovered that could eliminate the need for arduous physical therapy following stroke or spinal injury, it would be hailed by patients and physicians alike, even though patients would lose the character-building opportunity of agonizing rehabilitation exercises. But when someone suggests giving Prozac without psychotherapy to an adult who suffered severe trauma as a child, many therapists wail that this "easy way out" will merely postpone the necessary painful reckoning with the past. Giving shy people medication to ease socializing is dismissed either as pathologizing normal human variation and creating greater conformity or as helping the socially awkward avoid the hard work needed to overcome their fears.

But why should someone who suffered trauma have to suffer more to overcome it, if there's a less difficult, equally safe, and effective alternative? Why shouldn't the shy be on a level playing field with the naturally outgoing if that is what they want? Why is it easier for us to let go of the idea that physical suffering is a message from God that we should bear in order to temper our souls than it is to shake the idea that emotional pain must be endured for our own good?

Considering these questions has helped clarify my thinking about how to deal with my own psychological problems and how to think about the wide variety of psychoactive substances available in our society. As a journalist who covers neuroscience and who has personally experienced some of the brain's aberrant states, I confront these issues almost every day. My chief conclusion is that while psychotherapy validated by research has its place, there is no convincing reason why it should be considered inherently superior to drugs.

Like Myself Again

I began taking antidepressants seven years after I kicked my heroin and cocaine addictions. Both my self-help groups and my individual therapist had discouraged medication, and I'd followed their advice. Twelve-steppers had warned me that avoiding my pain with drugs--any drugs--would only lead back to compulsive behavior.

But in 1996, when I sunk into a depression so profound that I was unable to feel the tiniest spark of pleasure, I began to question this position. A publisher had rejected the manuscript for my first book after paying me an advance, and I became so depressed that nothing felt right.

Having decided that the unstructured life of a freelancer was bad for my mental health in such circumstances, I got myself a good job, as an associate producer on a Barbara Walters AIDS special. I thought achieving simple goals like getting to the office would make me, at the very least, less anxious, and working to fight AIDS had energized me in the past.

Before the book was killed, even when I'd felt low, I could usually improve my mood by easing up on myself or seeking social support. I could use my cognitive techniques to recognize when I was grandiosely "catastrophizing"--for example, seeing one obstacle as a sign that everything else in my life was going to collapse. But the new job and the cognitive techniques failed me now. Even love from friends and family didn't help. I knew I'd lose all motivation, even to get out of bed, if meaningful work and socializing didn't at least reduce my dread.

Talking to people or thinking differently couldn't restore my ability to feel good. Even the best of news or most tender expressions of affection didn't interrupt for long the dull terror I felt. When I couldn't stop crying at the office, I finally went to a psychiatrist, who prescribed medication.

The first day I took Zoloft, I was reminded of my earliest recreational drug experiences. Before I'd tried hard drugs, I'd taken many psychedelics, and what I felt after popping that first pill was similar to a feeling I well remembered from using LSD: a sense in the pit of my stomach that things were about to get strange. Soon, in fact, I was having mild hallucinations: complicated, brightly colored geometric patterns when I opened or closed my eyes. I called my psychiatrist, who told me to halve the dose but recommended sticking with the drug, saying the images would pass.

Two days later, the psychedelic patterns were indeed gone, but the depression and pleasurelessness were as strong as ever, and I found myself missing the hallucinations. At that point, I understood for the first time part of why I'd continued using cocaine long after it had ceased to be at all enjoyable. The distraction of experiencing something, anything, was better than consistent anhedonia.

Ten days in, I felt the first therapeutic effects. I noticed that I wanted to write and that I felt better after writing. That tiny reward gave me more optimism.

When the medication fully kicked in, I again felt transformed, as I had in that welfare hotel a decade before. Unlike heroin, Zoloft did not make me euphoric, but it provided a similar sense of comfort and safety. I felt like "myself again," as one of Peter Kramer's patients puts it in Listening to Prozac. With antidepressants, I wasn't "better than well"; I was the way I am when I'm OK.

In other words, I stopped fearing encounters with friends and dreading the phone. I took pleasure in simple accomplishments. If something awful happened, I felt appropriately upset; the difference was that now I no longer cried uncontrollably while watching families reconnect in AT&T commercials. I began to discover that I wasn't wildly jealous when my (new) boyfriend spoke to another woman--or at least I now had the self-control not to act on those thoughts. I felt competent and far less needy. The reassurance I'd sought from 12-step meetings and phone calls for support didn't seem necessary any more. I could hate myself less because my selfish needs and intrusive worries were genuinely less pressing.

Paradoxically, what the drug gave me was greater control over my own thoughts and behavior and more self-sufficiency. I could still choose to act impulsively when irritated, but I could more easily choose not to. And unlike heroin, the Zoloft did not cause the craving that had ultimately led to obsessive, life-disrupting addiction.

Which was more "real"--my new equilibrium or my previous imbalance? It didn't matter, I decided, because on medication I was better not only to myself but to others as well. I became less needy, less self-centered, less demanding. I will never be a mellow person, but I was certainly calmer. The only downside was greater impatience with people who refused to get help for depression, who still exhibited the flaws I'd hated in myself.

Suicidal Strategy?

During my transformation, I began to recognize that, although the drug companies clearly have an agenda in pushing their view of psychiatric medication, psychotherapists do too. If pills really could overcome depression and addiction without endless digging and talking, they'd be out of business. Just as the "brain chemical imbalance" that supposedly causes depression is part of the pharmaceutical companies' sales pitch, as exemplified by those Zoloft commercials in which a blob with a face turns his frown upside down, the idea that talk is better and deeper and more humanistic is part of the therapists' sales pitch (no matter how much they sincerely believe it).

Each perspective, taken in isolation, relies on an outdated, dualistic view of the mind and brain. The drug companies portray depression as a biological defect that leaves people vulnerable to getting stuck in sadness; the therapists say our thinking and emotional histories trap us there. But neither view precludes the other; both can be right simultaneously because all experience must ultimately be coded by processes in the brain. Given this reality, if the easier, faster way is just as effective, why not use it?

Studies repeatedly find that on their own, drugs and certain talk therapies are about equally effective, with a combination of the two often superior. But the talk therapies which have been proven to work are hard to find. As Vanderbilt University psychologist Steven Hollon puts it, "The treatments shown in clinical trials to be specifically effective for depression are still not widely available."

Antidepressant opponents such as Peter Breggin argue that drugs can have terrible side effects, so even unproven talk therapies are preferable. Recently, for example, evidence about the relationship between suicide and selective serotonin reuptake inhibitors (SSRIs) such as Prozac and Zoloft has begun to emerge. Not only can they increase suicidal behavior among depressed people, but a study published in 2000 in Primary Care Psychiatry found that some normal people given these medications become suicidal. In clinical trials, suicide rates are two and a half times higher in subjects given SSRIs than in those given placebos, according to David Healy, a psychiatrist at Cardiff University. He estimates that up to 5 percent of the population may have severe negative reactions to SSRIs that can, in the worst cases, lead to suicide.

But that doesn't mean the drugs don't help others. For the majority of patients, SSRIs seem to reduce suicidal thoughts and suicide itself. Suicide rates in the U.S. have declined since the introduction of these drugs. Given that at least 50 million Americans have taken SSRIs since Prozac was approved in 1987, if their main effect was to increase suicide, the opposite should be true. Further, several studies that have compared local SSRI prescribing rates with corresponding suicide rates have found that the medications are linked with fewer, not more, self-inflicted deaths.

Other SSRI critics--such as Harvard psychiatrist Joseph Glenmullen, author of the 2001 book Prozac Backlash--note that SSRIs don't seem to have much advantage over placebos in clinical trials. This argument, like the suicide warnings, overlooks the importance of individual variations. Nearly every psychiatrist who has used SSRIs has stories similar to mine and those in Listening to Prozac. When you match the right person to the right medication, the positive change is remarkable and unmistakable. David Healy's research has shown that certain personality traits are associated with extremely positive (and others with extremely negative) reactions to these drugs.

The fact that good matches occur only in a small subset for each drug--and that bad matches occur as well--means that clinical trials wash out the contrast between the drug and placebo groups. Most people have a small positive effect, some are transformed, and some are made worse; grouping them together obscures these differences. Which is why Healy, the author of the 2004 book Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression, still prescribes SSRIs and does not want them banned.

Side Effects of Talk Therapy

When it comes to side effects, it's also important to recognize that drugs are not the only treatments that can cause harm. Some forms of psychotherapy can be at least as damaging.

It is now clear, for example, that hundreds if not thousands of families were split, many irrevocably, by false memories of incest created in "recovered memory" therapy. Some people received lengthy prison terms as a result of false accusations; many simply lost the invaluable emotional and health benefit of having a close, loving family. Others (including children) were hospitalized for years, tied to beds, and told they had to release "alter" personalities implanted during Satanic rituals in order to be healed. This sort of thing happened in mainstream hospitals such as Chicago's Rush Presbyterian as recently as the early '90s. "The entire history of the recovered memory phenomenon, each and every example, is an example of harmful therapy," says Richard Ofshe, a University of California at Berkeley sociologist and co-author of the 1999 book Therapy's Delusions: The Myth of the Unconscious and the Exploitation of Today's Walking Worried.

Other talk side effects come from therapies that rely on cult-like tactics or become actual cults. Synanon, the Northern California�based drug rehab organization, forced men to get vasectomies and pregnant women to have abortions if they wanted to remain part of the group--and told them they would return to their addictions and die in the streets if they left. Members were made to split up with their spouses or partners and rematched with others by the cult's leader.

To this day, the largest addiction treatment providers in the U.S., Daytop and Phoenix House, base their care on the confrontational "attack therapy" of the Synanon system, and program graduates trained in Synanon's methods staff and run many programs. Although some programs have tried to eliminate the excesses of this approach, reports of humiliating treatment are still common despite research showing it is harmful.

Both Synanon and the Los Angeles�based Center for Feeling Therapy often beat patients; the New York�based Sullivanian therapy cult resulted in numerous bitter child custody cases. And then there is "rebirthing" therapy, which in 2000 killed a 10-year-old girl in Denver. The "therapy" was an attempt to improve her difficult relationship with her adoptive mother by smothering her while trying to replicate the conditions of birth.

It's not just wacky therapies that can harm. According to research by Yale psychologist Susan Nolen-Hoeksema, depression can be exacerbated by focusing obsessively on "the causes and consequences" of personal problems. Therapies that encourage people to ruminate on the origins of their depression thus can make the condition worse. According to a 1999 study published in the Journal of Personality and Social Psychology, many commonly used anger management treatments, which urge clients to "get it out" by yelling and hitting inanimate objects, actually increase rage.

Then there is the matter of all the time and money spent on therapy that could be used for more productive pursuits. Ofshe, who distinguishes between life problems that can be helped by counseling and support and major mental illnesses such as schizophrenia and clinical depression, tells me "all the evidence for years and years has shown that people who practice using psychodynamic techniques, all the therapies derived from Freud, every time anyone tried to treat any real mental disorder, it was a waste of time and money and when real treatment [was developed], they were diverted from something that could be helpful."

Many see such side effects as less problematic than those resulting from drugs, because the patient has a choice whether to follow the therapist's guidance, whereas drug side effects are involuntary. Yet talk therapies cannot work as their proponents intend if the patient doesn't comply, and noncompliance in addiction treatment can result in incarceration, so in that sense the side effects derive just as directly from the treatment.

As Healy points out, talk therapy can "wreck families, can wreck lives just as much as pills can.
People tend to see the risks from pills. They think if they [do] talk therapy, there can't be any risk. But no one ever got raped by a Prozac pill."

Although there is no way of knowing how many rapes are committed by mental health professionals, a survey of 1,320 psychologists by researcher Kenneth Pope, published in the journal Psychotherapy in 1991, found that at least half of therapists reported treating one or more patients who'd had a sexual relationship with a prior therapist. The respondents believed more than 90 percent of the patients had been harmed by the relationships. Earlier surveys found that between 7 percent and 12 percent of male therapists (including psychiatrists, social workers, and psychologists) admitted to engaging in a sexual relationship with a client at least once.

Amotivational Syndrome

Even if drugs outperformed both placebos and talk and had no side effects, there would still remain the complaint that these medications kill pain rather than address its cause. In a 2001 letter to the Archives of General Psychiatry, for instance, a psychiatrist described an alcoholic who kept drinking because Prozac made him feel better, leaving him less determined to get sober. The letter also mentioned a woman who lost her resolve to leave an abusive boyfriend after taking Paxil for several weeks.

But while the data from clinical trials of SSRIs in treating addictions are mixed, the findings are either positive effects in reducing alcohol and other drug use or no effect, not reduced recovery. And while some people may remain in abusive relationships because antidepressants dull their desire to get out, others find the courage to leave after being treated with SSRIs. Without better research focused on this issue, it's impossible to know which reaction is more common.

My own experience suggests that whether a drug paralyzes or activates you has as much to do with where you start emotionally as with the drug itself. Some heroin addicts find that the drug (or a maintenance substitute such as methadone) allows them to be kinder and more open to others because it reduces their overwhelming feeling of vulnerability and oversensitivity; others find it makes them stone cold and numb. It depends on where they begin: If they are too self-conscious and anxious to socialize, lowering the volume of those sensations can help; if they are already indifferent, the drug will make that worse.

Antidepressants are similar. Although they don't offer the unearned euphoria that so disturbs anti-drug crusaders, they do, like heroin, strengthen the voice that says it's going to be OK, which is so important for getting through tough times and which some people may not be able to access without chemical help.

It's the same with physical pain: Too much agony can be as life-destroying and consciousness-contracting as too much anesthesia, and the determination of how much is too much depends both on the original level of pain and on how the drug changes it. Just consider whether you are more agreeable to and nurturant of your loved ones when you have a ferocious toothache, or when the pain has been properly medicated. One cannot discuss a good or a bad drug--only a good or bad drug for a specific person and purpose.

The notion that emotional pain and difficulties inevitably lead to growth and maturity is a largely unexamined assumption with deeps roots in Western religion. Almost everyone can name individuals who believe their painful challenges made them into better people. This is part of why "tough love" approaches to emotional problems continue to thrive and why "easier, softer" approaches such as medication are so often dismissed. As Fox News Channel commentator Sean Hannity put it in 2002, "I've had a criticism of [psychiatrists] for a long time. I think they're too quick to overprescribe drugs and offer chemical solutions. They totally discount the spiritual side of the human nature."

But such critics rarely consider how often pain truly leads to growth--and how often it leads to stagnation, self-destructive escape attempts, and greater emotional damage. Few question whether the anecdote of the survivor made stronger is more common than that of the victim devastated. Most people can easily cite examples of both. Since pain is so common, however, we want to think it's essential to growth. We want it to mean something--and don't like to imagine we could learn to be happier, better people without it.

Being Jim Carrey

Focusing on the value of pain misses the critical role of pleasure in learning. Probably the most difficult task facing human babies is learning to speak, yet it occurs almost completely without punishment. Babies learn to talk because babbling feels good and earns them smiles and praise, and because speaking lets them get what they want far more efficiently and comfortably than they do by crying. They don't learn language by being hurt when they get a word or phrase wrong or hit for not talking; they grow into speaking by basking in love.

"In most cases," says Bruce Perry, a child psychiatrist and expert on childhood trauma, "the acquisition of any new piece of information is much more related to repetition than to anything else, and the most powerful biological source that fuels repetition is pleasure." People learn most lessons better when the experience engages and excites them, not when it's dull or painful. While overcoming challenges is part of the process, if there is no sense of reward and competence early on, most people are far more likely to quit than persevere. In fact, according to Perry, threatening and potentially painful situations make people behave less intelligently because their actions are guided by the lower, more reactive parts of the brain.

For the mental health professions, these findings mean the ability to feel joy--or at minimum, to feel OK--is at least as important to recovery from depression and anxiety as discovering the origin of the pain. In fact, in many cases restoring the ability to feel pleasure may be all that is needed. The source of the trouble could be some misfiring neurons, stuck in the angst of 20 years ago or simply signaling for no emotional reason at all. Regardless of the origin of the problem, if you fix the neurons, the distress is gone. A number of studies indicate that effective depression treatments, whether talk or drugs, lead to regrowth of neurons in an area of the hippocampus that is often damaged by emotional trauma.

While this phenomenon might be unsettling if, as in the movie Eternal Sunshine of the Spotless Mind, drugs made these changes by erasing the memories that make us who we are, there's no evidence that antidepressants do that. And those who argue that we should be able to impulsively act out our prickly, irritable, depressive characteristics to provide human variety are not usually the ones who have to live with those who do so.

One final argument for preferring talk to drugs is fear of dependence. Some antidepressant drugs do produce painful withdrawal symptoms, and it is unconscionable that some patients are given these medications without appropriate warnings and without first having tried other, less problematic treatments. But there's also no doubt that some talk therapies create dependence every bit as worrisome. Therapy cults aside, just think of those analysands who have therapy four hours a week and never make a decision without first consulting their shrinks.

While it's always better to have fewer needs, physical dependence on medication, in and of itself, needn't be a problem if the drug is readily available and safe. If the drug improves one's ability to work and love, who is being hurt? We're all dependent on air, food, and water, and maintenance medications will become a fact of life for most of us as we outlive the ages which our bodies evolved to reach. Whether the medication treats high blood pressure, pain, or depression shouldn't matter.

Suffering Is Not All It's Cracked Up to Be

This is not to say we have anything close to perfect medications--and for many people, the tradeoff between side effects, risks, and benefits weighs against taking those currently available. In this connection, full disclosure of the data on current drugs and more research and openness on those in development is critical.

Nor do I believe there is never lingering emotional distress that needs to be understood and conquered, or that there is no role for talk therapy or self-help. Many studies, including a 2002 review in the American Journal of Psychiatry and a more recent head-to-head trial published this year in the same journal, have found that certain talk therapies are just as effective as drugs. A 2003 study published in the Proceedings of the National Academy of Sciences even found that for people with childhood trauma, one such therapy was more effective.

But evidence-based therapy is hard to find outside university research studies. The therapy that helped the childhood trauma victims more than drugs, for example, was a cognitive-behavioral treatment that focused on dealing with current problems, not searching for their roots in the past. It wasn't the kind of "depth" treatment talk therapy proponents usually advocate.

Few patients outside of studies get therapy based on what the research finds effective; most practitioners ignore the data and do what their "clinical experience" suggests. Recognizing this gap, government agencies such as the Substance Abuse and Mental Health Services Administration have distributed literature and sponsored initiatives aimed at bringing "research into practice." But while the situation is far better than it was 10 or even five years ago, both researchers and patients say there's a long way to go. For talk therapy to be a genuine alternative or supplement to medication, the methods covered by insurers should be proven safe and effective, just as the Food and Drug Administration requires for drugs. Mental health advocates have long called for "parity" between coverage of mental and physical illnesses, but it makes no sense to cover talk unless therapists practice proven treatments.

In addition to insisting on evidence of effectiveness, mental health professionals need to understand that suffering isn't necessarily good for the soul. My own experience has shown me that therapy, self-help, and medication all have value. It has also shown me the pitfalls of each. Both depression and addiction have biological, sociological, and psychological dimensions that vary in importance depending upon the individual and his or her situation. This complexity means that no one solution will work in all cases and that the right approach for any given person may change over time.

I can say this: Painful talk therapy isn't morally superior to medication or to therapy that doesn't go "deep." Pleasure can be just as important for emotional recovery and growth as pain, if not more so. That's why drugs sometimes are the better fix.�