"Living a fully ethical life involves doing the most good we can." - Peter Singer
"Common sense is not so common." - Voltaire
“There are two ways to be fooled. One is to believe what isn't true; the other is to refuse to believe what is true.” ― Søren Kierkegaard

Sunday, July 31, 2011

The Therapist Will See You Now, via the Web

The New York Times
By Randall Stross

SEE a therapist without leaving your home?

In an article in the American Journal of Psychiatry, Dr. Thomas F. Dwyer, a Massachusetts psychiatrist, says he has practiced “telepsychiatry,” via video teleconferencing, for five years. Its “adoption by psychiatrists and patients,” he predicts, “will proceed quickly if the organizers cope with the irrational responses of some users.”

But wait: That article appeared almost 40 years ago. It told how microwave television signals were used to connect a satellite clinic to Massachusetts General Hospital in Boston.

Today, even with the rise of the Internet, virtual therapy hasn’t been widely adopted. But several start-up companies are trying to make Dr. Dwyer’s decades-old vision a workaday reality.

Therapy delivered over the Internet, says Lynn Bufka, a psychologist and staff member of the American Psychological Association, “may open access to those who might be reluctant to go to an office or to those who might be physically or psychologically unable to.”

Proponents of Internet-based therapy point to some research suggesting that it is effective for certain kinds of conditions, like depression and anxiety. Reporting in The Lancet in 2009, a team of researchers found that cognitive-behavioral therapy delivered remotely to depressed patients in Britain continued to show benefits eight months later.

But companies promoting online therapy must contend with uneven or absent support from insurance companies, Medicare and Medicaid. Most states don’t require insurers to pay for “telehealth” services (those not delivered in person). And any reimbursements can be less substantial than for in-person treatment. Medicare offers reimbursement only if providers are very scarce, as in rural areas.

One company that is trying to match patients to therapists online is Cope Today, based in Raleigh, N.C. Tania S. Malik, its chief executive, said the company, which began in 2010, worked with the North Carolina National Guard for a pilot test of its service. It has since opened its service to individuals, whom it attracts primarily with search ads that are keyed to phrases like “online counseling” or “treating anxiety.”

Cope Today lets prospective clients view a list of therapists and their availability for consultation via video, phone or online chat. It provides the first 10 minutes of a session free, then charges $35 for 15-minute increments.

The entire story can be read here.

Saturday, July 30, 2011

Researchers Create The First Artificial Neural Network Out Of DNA


Medical News Today
Deborah Williams-Hedges
California Institute of Technology 

Artificial intelligence has been the inspiration for countless books and movies, as well as the aspiration of countless scientists and engineers. Researchers at the California Institute of Technology (Caltech) have now taken a major step toward creating artificial intelligence - not in a robot or a silicon chip, but in a test tube. The researchers are the first to have made an artificial neural network out of DNA, creating a circuit of interacting molecules that can recall memories based on incomplete patterns, just as a brain can.

"The brain is incredible," says Lulu Qian, a Caltech senior postdoctoral scholar in bioengineering and lead author on the paper describing this work, published in the July 21 issue of the journal Nature. "It allows us to recognize patterns of events, form memories, make decisions, and take actions. So we asked, instead of having a physically connected network of neural cells, can a soup of interacting molecules exhibit brainlike behavior?"

The answer, as the researchers show, is yes.

Consisting of four artificial neurons made from 112 distinct DNA strands, the researchers' neural network plays a mind-reading game in which it tries to identify a mystery scientist. The researchers "trained" the neural network to "know" four scientists, whose identities are each represented by a specific, unique set of answers to four yes-or-no questions, such as whether the scientist was British. 

After thinking of a scientist, a human player provides an incomplete subset of answers that partially identifies the scientist. The player then conveys those clues to the network by dropping DNA strands that correspond to those answers into the test tube. Communicating via fluorescent signals, the network then identifies which scientist the player has in mind. Or, the network can "say" that it has insufficient information to pick just one of the scientists in its memory or that the clues contradict what it has remembered. The researchers played this game with the network using 27 different ways of answering the questions (out of 81 total combinations), and it responded correctly each time.

This DNA-based neural network demonstrates the ability to take an incomplete pattern and figure out what it might represent - one of the brain's unique features. "What we are good at is recognizing things," says coauthor Jehoshua "Shuki" Bruck, the Gordon and Betty Moore Professor of Computation and Neural Systems and Electrical Engineering. "We can recognize things based on looking only at a subset of features." The DNA neural network does just that, albeit in a rudimentary way.

Biochemical systems with artificial intelligence - or at least some basic, decision-making capabilities - could have powerful applications in medicine, chemistry, and biological research, the researchers say. In the future, such systems could operate within cells, helping to answer fundamental biological questions or diagnose a disease. Biochemical processes that can intelligently respond to the presence of other molecules could allow engineers to produce increasingly complex chemicals or build new kinds of structures, molecule by molecule. 

Read the entire story here.

The original article in Nature is here.

Heart Warning Added to Label on Popular Antipsychotic Drug

The New York Times
by Duff Wilson

AstraZeneca is adding a new heart warning to the labels of Seroquel, its blockbuster antipsychotic drug, at the request of the Food and Drug Administration, company and agency officials said on Monday (July 18, 2011).

The revised label, posted without fanfare last week on the F.D.A. Web site, says Seroquel and extended-release Seroquel XR “should be avoided” in combination with at least 12 other medicines linked to a heart arrhythmia that can cause sudden cardiac arrest.

Sandy Walsh, a spokeswoman for the F.D.A., said the statement was only a precaution for doctors, and should not be considered a complete ban against prescribing Seroquel with the other drugs.

Ms. Walsh said the label was changed after the F.D.A. received new information about reports of arrhythmia in 17 people who took more than the recommended doses of Seroquel. Though it should not be a problem at a normal dosage, she said, it may still be good advice to avoid using the drugs together.

The arrhythmia, known as prolongation of the QT interval, referring to two waves of the heart’s electrical rhythm, is estimated to cause several thousand deaths a year in the United States.

As AstraZeneca prepares to report its second-quarter earnings at the end of this month, it faces additional scrutiny this week. The F.D.A. is considering the London-based company’s dapagliflozin, a proposed diabetes drug with Bristol-Myers Squibb, and is expected to decide soon on Brilinta, an anticoagulant. The company is facing the loss of patents for Seroquel next year and for the heartburn drug Nexium in 2014.

Seroquel is one of the top-selling drugs in the world, at $5.3 billion last year, including $3.7 billion in the United States. Introduced in 1997, it has been approved for schizophrenia, bipolar disorder and severe depression. Seroquel has caused legal problems for AstraZeneca, including a $520 million payment in 2009 to settle government charges of illegal marketing. Thousands of lawsuits are pending over side effects like diabetes.

The previous Seroquel labels had mentioned the risk of a prolonged QT interval, but had not identified other drugs to avoid, Stephanie Andrzejewski, a spokeswoman for AstraZeneca, said Monday. The new warning also is separated from other warnings and precautions on the label, she said, “to provide some additional guidance to physicians” treating patients ”who are already at risk of QT prolongation.”

The new warning will be added to printed labels as soon as possible, Ms. Andrzejewski said.

The new label lists the other drugs to avoid as antiarrhythmic drugs like quinidine, procainamide, amiodarone and sotalel; antipsychotic drugs like ziprasidone, chlorpromazine and thioridazine; antibiotics like gatifloxacin and moxifloxacin; the anti-infective drug pentamidine; and synthetic opioids like levomethadyl acetate and methadone. The label also raises caution about use by the aged and people with heart disease.

James J. Pepper, a lawyer in Pennsylvania who is involved in drug litigation, has been arguing for months in letters to government officials that Seroquel has a potentially deadly interaction with methadone in regard to the QT interval.

“This is a huge, huge step,” Mr. Pepper said of the label change, though he said he thought it should be stronger.

Ms. Walsh said the F.D.A. action was unrelated to Mr. Pepper’s arguments.

Three months ago, Dr. Janet Woodcock, director of the F.D.A. Center for Drug Evaluation and Research, rejected those arguments in a letter to the Project on Government Oversight, a nonprofit group in Washington, which had also raised the issues. Dr. Woodcock wrote that a thorough agency review had found it “exceedingly unlikely” that patients faced an unreasonable risk from the interaction between Seroquel and methadone. The review found only one death that was probably caused by the interaction, she wrote.

Dr. Woodcock concluded that the F.D.A. would take no action to change the label. Ms. Walsh said that conclusion was still correct, because the F.D.A. had found no biological basis for a problem or unusual numbers of deaths at normal dosages.

Methadone use and deaths have increased drastically in recent years as more doctors prescribe it for chronic pain. The number of methadone prescriptions for pain in the United States rose to 4.3 million in 2010 from 2.2 million in 2006, IMS Health, an industry data firm, said Monday. The use for pain has surpassed that for heroin withdrawal and maintenance.

Friday, July 29, 2011

Harvard Psychologist Resigns

The Chronicle of Higher Education
by Tom Bartlett

Marc Hauser, PhD
Marc D. Hauser, the Harvard psychologist found responsible for eight counts of scientific misconduct by the university, has resigned, ending speculation about whether the embattled professor would return to campus this fall.

In a letter dated July 7, Mr. Hauser wrote to Michael D. Smith, Harvard's dean of the Faculty of Arts and Sciences, that he was resigning effective August 1 because he had "some exciting opportunities in the private sector" and that he had been involved in some "extremely interesting and rewarding work focusing on the educational needs of at-risk teenagers."

The letter states that he may return to teaching and research "in the years to come." It does not mention the scandal that damaged his once-stellar reputation and stunned his colleagues in the field.

Last August, The Boston Globe reported that a university investigation had found Mr. Hauser guilty of misconduct, though the nature of that misconduct remained murky. The picture became somewhat clearer after Mr. Smith, the Harvard dean, sent a letter to faculty members saying that Mr. Hauser was "solely responsible" for eight instances of wrongdoing involving three published and five unpublished studies.

An internal document provided last August to The Chronicle by a former research assistant in Mr. Hauser's laboratory revealed how members of the lab believed Mr. Hauser was reporting faulty data and included e-mails demonstrating how he had pushed back when they had brought problems to his attention. Several lab members alerted the university's ombudsman, setting in motion an investigation that would lead to the seizure of computers and documents from Mr. Hauser's laboratory in the fall of 2007.

Read the entire article here.

Thursday, July 28, 2011

Facebook friend request from a patient?

The Lancet, Volume 377, Issue 9772, Pages 1141 - 1142, 2 April 2011
doi:10.1016/S0140-6736(11)60449-2
Widespread use of new technologies such as social networking sites are creating ethical problems for physicians that some doctors' organisations are beginning to address. Sharmila Devi reports.
Social networking sites such as Facebook and the ubiquity of search engines such as Google are creating new medical ethical dilemmas as physicians around the world grapple with how to responsibly include new technologies in their professional lives.
In the USA, birthplace of most of these technological advances, various associations of health-care professionals are starting to issue codes of conduct when dealing with new digital media. Other countries, such as the UK, Canada, and Australia, are also debating what rules should be set. But some doctors believe such codes will have to evolve and adapt as younger generations, used to living an online life from an early age, start to dominate health care and to teach subsequent waves of professionals.
Websites such as Facebook allow individuals to post messages, photos, and videos and share them with an online group of friends. They can also be used to reach out professionally to a wider range of people than was possible with some traditional marketing methods. But used unwisely, such sites can blur the lines between the personal and professional and cause embarrassment.
“Older generations will moralise and say it's unethical and unprofessional [to be friends with clients on sites such as Facebook]”, says Ofer Zur, an Israeli psychologist based in California, USA, who offers online courses in digital medical ethics. “Younger generations have less of a sense of hierarchy and see the internet as an equaliser that opens doors. I am typical of the older generation because I sometimes cringe at the things my daughter posts online.”
Although it would seem obvious for many professionals to maintain as strict a boundary between them and clients in the online world as in the physical world, Zur said online interactions should be looked at on a case-by-case basis. For example, a physician in a small community might find that Facebook simply replicated the flow of information that already took place amid existing close relationships, he says.
Cases where health-care professionals have taken things too far are rare but well publicised. In February, a physician assistant working at a medical centre in New York state was found to have posted photos on Facebook showing him holding a syringe at a man's neck. He said: “When you can't start a line in a junkie's arm…go for the neck”, reported The Journal News, a local newspaper.
Such behaviour is unanimously condemned as inappropriate. More difficult to answer are questions such as whether health-care professionals should be allowed to research a client's background on the search engine Google? Does a blog's informative value outweigh any possible breach of confidentiality? Should medical students post online any personal information about themselves for fear of jeopardising relations with future clients and employers? “Questions about the internet are becoming a common inquiry among our members who want to take advantage of it, especially younger members and students, and the number one concern is confidentiality and how to preserve it”, says Erin Martz, manager of ethics and professional standards at the American Counselling Association. “We actually just received our first ethical complaint that's Facebook-connected and technically-driven. I do think Facebook can be quite dangerous.”
The rest of the article is here and can be accessed through psycnet.apa.org/psycinfo with your APA log in.

Wednesday, July 27, 2011

Bullying and Suicide: Detection and Intervention

By Anat Brunstein Klomek, PhD, Andre Sourander, MD and 
Madelyn S. Gould, PhD, MPH
Psychiatric Times

Bullying is recognized as a major public health problem in the Western world, and it appears to have devastating consequences. Cyberbullying has become an increasing public concern in light of recent cases associated with youth suicides that have been reported in the mass media.



Most of the studies that have examined the association between bullying and suicidality have been cross-sectional. Those studies show that bullying behavior in youth is associated with depression, suicidal ideation, and suicide attempts. These associations have been found in elementary school, middle school, and high school students. Moreover, victims of bullying consistently exhibit more depressive symptoms than nonvictims; they have high levels of suicidal ideation and are more likely to attempt suicide than nonvictims.

The results pertaining to bullies are less consistent. Some studies show an association with depression, while others do not. The prevalence of suicidal ideation is higher in bullies than in persons not involved in bullying behavior. Studies among middle school and high school students show an increased risk of suicidal behavior among bullies and victims. Both perpetrators and victims are at the highest risk for suicidal ideation and behavior.

Suicide risk by sex

Cross-sectional studies of the differential impact of school bullying by sex on the risk of depression and suicidal ideation have shown significant associations, but the results are not consistent. Some researchers have found stronger associations among girls.
Kim and colleagues1 reported that girls who were involved with school bullying (as either victim or perpetrator) were at significantly greater risk for suicidal ideation. Roland2 found that girls who were bullies had more suicidal thoughts. Van der Wal and colleagues3 found a strong association between being bullied and depression and suicidal ideation in girls, and Luukkonen and colleagues4 found that being bullied and bullying others are both potential risk factors for suicidal behavior in girls.

On the other hand, Rigby and Slee5 found that the association between being a bully and suicidal ideation applied only to boys. McMahon and colleagues6 recently reported that boys who had been bullied at school were more depressed and had a higher risk of thoughts about harming themselves and self-harming behavior than boys who had not been bullied. Kaltiala-Heino and colleagues7 reported that among girls, severe suicidal ideation was associated with frequently being bullied or being a bully and for boys it was associated with being a bully. No association was found between boys and girls for depressive symptoms.8

Our earlier work tried to explain the differences in the risks of depression and suicidality between girls and boys; we suggested that there is a difference in the threshold for depression and suicide between the sexes.9 Girls who bullied others were at risk for depression, suicidal ideation, and suicide attempts even when the bullying was infrequent. However, only frequent bullying was associated with depression, suicidal ideation, and suicide attempts among boys.

There may be a different sex threshold in victimization as well. Among girls, victimization at any frequency increased the risk of depression, suicidal ideation, and suicide attempts. On the other hand, only frequent victimization increased the risk of depression and suicidal ideation in boys, although infrequent victimization was associated with an increased risk of suicide attempts.

The rest of the article can be found here.  The reader can sign up for Psychiatric Times (free) or google the title of this blog for the entire story.

Tuesday, July 26, 2011

Judge grants The Oregonian's request to release mental health evaluation

By Stuart Tomlinson, The Oregonian
Published June 22, 2011

A Columbia County Circuit Court judge has granted The Oregonian’s May request to release the mental health evaluation of Daniel Butts, officials said today.

Columbia County District Attorney Steve Atchison said Columbia County Judge Ted Grove will allow the release of the Butts’ mental health evaluation on July 15, one week before a scheduled hearing to determine if Butts can aid and assist in his defense.

Atchison said the mental health evaluation of Butts, 21, who is accused of shooting of Rainier Police Chief Ralph Painter on Jan. 5, was completed in mid-April. The evaluation was done by an Oregon doctor who traveled twice to the Columbia County Jail in St. Helens to assess Butts’ mental state.
It will be up to Grove to determine, based on the report, if Butts can assist in his defense. Atchison said the judge could rule that Butts can aid in his defense or is unable to aid in his defense. The judge could also ask for additional evaluations.

Under Oregon law, an aid and assist hearing is held, according to the statute, “if the court has reason to doubt defendant’s fitness.”

It can order an examination to determine if the defendant is incapacitated by mental illness; if he can understand the nature of the proceedings; assist and cooperate with his attorneys; and participate in his own defense.

After a hearing in February, Atchison emphasized that the evaluation and any treatment for mental illness is to make sure Butts can aid in his defense.

The entire story can be read here.

Monday, July 25, 2011

The Menace Within: The Stanford Prison Experiment


By Romesh ratnesar

It began with an ad in the classifieds.

Male college students needed for psychological study of prison life. $15 per day for 1-2 weeks. More than 70 people volunteered to take part in the study, to be conducted in a fake prison housed inside Jordan Hall, on Stanford's Main Quad. The leader of the study was 38-year-old psychology professor Philip Zimbardo. He and his fellow researchers selected 24 applicants and randomly assigned each to be a prisoner or a guard.

Zimbardo encouraged the guards to think of themselves as actual guards in a real prison. He made clear that prisoners could not be physically harmed, but said the guards should try to create an atmosphere in which the prisoners felt "powerless."

The study began on Sunday, August 17, 1971. But no one knew what, exactly, they were getting into.

Forty years later, the Stanford Prison Experiment remains among the most notable—and notorious—research projects ever carried out at the University. For six days, half the study's participants endured cruel and dehumanizing abuse at the hands of their peers. At various times, they were taunted, stripped naked, deprived of sleep and forced to use plastic buckets as toilets. Some of them rebelled violently; others became hysterical or withdrew into despair. As the situation descended into chaos, the researchers stood by and watched—until one of their colleagues finally spoke out.

The public's fascination with the SPE and its implications—the notion, as Zimbardo says, "that these ordinary college students could do such terrible things when caught in that situation" —brought Zimbardo international renown. It also provoked criticism from other researchers, who questioned the ethics of subjecting student volunteers to such extreme emotional trauma. The study had been approved by Stanford's Human Subjects Research Committee, and Zimbardo says that "neither they nor we could have imagined" that the guards would treat the prisoners so inhumanely.

In 1973, an investigation by the American Psychological Association concluded that the prison study had satisfied the profession's existing ethical standards. But in subsequent years, those guidelines were revised to prohibit human-subject simulations modeled on the SPE. "No behavioral research that puts people in that kind of setting can ever be done again in America," Zimbardo says.

The Stanford Prison Experiment became the subject of numerous books and documentaries, a feature film and the name of at least one punk band. In the last decade, after the revelations of abuses committed by U.S. military and intelligence personnel at prisons in Iraq and Afghanistan, the SPE provided lessons in how good people placed in adverse conditions can act barbarically.

The experiment is still a source of controversy and contention—even among those who took part in it. Here, in their own words, some of the key players in the drama reflect on their roles and how those six days in August changed their lives.

     *          *          *          *          *

The entire article can be here.  The article brings up a host of ethical issues related to research.

Sunday, July 24, 2011

Upcoming Article: Is Coming Out Always a 'Good Thing'?


*Social Psychological and Personality Science* has scheduled an article for publication in a future issue of the journal: "Is Coming Out Always a 'Good Thing'? Exploring the Relations of Autonomy Support, Outness, and Wellness for Lesbian, Gay, and Bisexual Individuals."

The authors are Nicole Legate, Richard M. Ryan, and Netta Weinstein.

Disclosing a lesbian, gay, and bisexual (LGB) identity to others, or ''coming out,'' has been shown in past research to be associated with mental health benefits (e.g., Ragins, 2004).

Yet, in a world that can be unaccepting of nonheterosexual orientations, coming out also involves risk. LGB individuals may anticipate stigmatization, negative judgments, or rejection feelings that deter them from self-disclosing their sexual identity.

Recent legislation like Don't Ask Don't Tell provides a clear example of this risk: those who came out as LGB in the military were discharged from service. Indeed, some research suggests that coming out can result in other negative consequences such as costs to well-being (D'Augelli, 2006).

It is thus the case that many LGB individuals are selective, varying from context to context in how much they disclose their sexual identity to others.

In the present article, we explore this within-person variability in disclosure using a self-determination theory framework (SDT; Deci & Ryan, 1985, 2000; Ryan & Deci, 2000). SDT (Ryan & Deci, 2000) is a theory of personality and motivation that concerns how social contexts impact motivation and well-being.

According to SDT, social contexts vary in their levels of autonomy support, defined as interpersonal acceptance and support for authentic self-expression (Lynch, La Guardia, & Ryan, 2009; Ryan, La Guardia, Solky-Butzel, Chirkov, & Kim, 2005).

In environments high in autonomy support, people feel accepted for who they are, are free to act and express themselves, and are more open to rely on others. In contrast, in controlling environments, people feel pressured to appear, behave, or perform a certain way (Deci & Ryan, 1985), and they exhibit less openness and more defensiveness (Hodgins et al., 2010).

It is thus likely that autonomy supportive environments reduce perceived risks for coming out, whereas in environments perceived as controlling individuals may be less likely to express a potentially stigmatized part of themselves that could incur censure.

In addition, we argue that the autonomy supportiveness of an environment influences the well-being experienced in that environment as a result of disclosure. Specifically, we expect that LGB individuals who disclose in environments low in autonomy support will not experience the typical boost to wellness from coming out reported in the literature.

Here's how the article ends:

"This research has implications for practitioners providing treatment to LGB individuals because it suggests that people experience greater wellness when they come out in certain contexts, but certainly not all contexts. This research also has implications for workplaces. Providing autonomy support is beneficial for all employees (Baard et al., 2004), but may be especially important for LGB employees' wellness and productivity. Future research should look at disclosing in workplaces that foster self-expression versus controlling work environments and compare wellness and productivity of employees of different sexual orientations. More generally the findings may speak to factors that can facilitate greater openness and wellness in individuals who face stigma, as well as to the costs of controlling social contexts and the self-concealment they often foster."

Thanks to Ken Pope for this information.

Saturday, July 23, 2011

California patients can sue if personal data are released during billing disputes



The Supreme Court of California has ruled that patients can sue doctors, debt collectors and others who disclose their medical information to credit agencies during billing disputes.

The ruling exposes California physicians to more lawsuits and hinders their ability to collect outstanding bills, said an attorney involved in the case.

In the past, the Fair Reporting Credit Act protected doctors from lawsuits over such disclosures. The law says if doctors or others receive notice that a debt is in dispute, they are required to furnish accurate and complete information about the debt to the requesting credit agency.

But in its June 16 opinion, the state's high court said a more stringent California law on patient privacy trumps the FRCA, preventing doctors from releasing any confidential information to creditors without patient consent.

"It really inhibits the ability of health care providers to document the basis for [debt] claims," said Charles Messer, an attorney who represented the bill collector, Stewart Mortenson. "It makes collecting medical debts much more difficult."

The decision stems from a billing dispute between Robert Brown and his dentist, Rolf Reinholds. In 2000, Brown was billed for a treatment he said he never received. The bill was referred to a debt collector, who contacted Reinholds for more information after Brown denied the debt, according to court records.

Reinholds sent Mortenson a copy of Brown's medical history. The record included medical histories of Brown's children, which were in the same file. As the billing dispute continued, Mortenson disclosed the medical information to three national consumer reporting agencies.
Brown sued Reinholds and Mortenson, alleging that he never consented to the record disclosure. Among other details, the information included Brown's Social Security number, address, date of birth and telephone number, court records show. Reinholds was dismissed from the suit after settling out of court, according to attorneys in the case.

Lower courts cited federal law

The trial and appellate courts ruled in favor of Mortenson. The lower courts said the confidential information provided was protected by the FRCA.

But the Supreme Court said the law is preempted by the stricter state measure, and that Brown's original claim could move forward. The court said the state privacy law also trumps the Health Insurance Portability and Accountability Act, which allows for certain administrative disclosures.

Brown, an attorney who represented himself, said the high court analyzed the facts carefully and came to the correct conclusion.

"It means people working with health care records in California have to be very careful they are not violating patients' confidentiality," he said. "Without patients' consent, medical information, including a patient's identifying [details], cannot be turned over to credit agencies."

The decision restricts the free flow of information needed for fair and accurate credit reporting, Messer said. Doctors are now subject to legal claims for complying with federal law and providing debt information, he added.

"It becomes a Catch-22 and exposes health care providers to liability," he said.
Messer is considering asking the U.S. Supreme Court to review the case.

Additional Information

Robert A. Brown v. Stewart Mortenson, Supreme Court of California, June 16 (www.courtinfo.ca.gov/opinions/documents/S180862.PDF)

Friday, July 22, 2011

UCLA hospitals to pay $865,500 for breaches of celebrities' privacy

By Molly Hennessy-Fiske
Los Angeles Times

Settlement with U.S. regulators also calls for UCLA to retrain staff and take steps to prevent future breaches. Some staff have already been fired for viewing the records of Farrah Fawcett, Michael Jackson and others.

UCLA Health System has agreed to pay $865,500 as part of a settlement with federal regulators announced Thursday after two celebrity patients alleged that hospital employees broke the law and reviewed their medical records without authorization.

Federal and hospital officials declined to identify the celebrities involved. The complaints cover 2005 to 2009, a time during which hospital employees were repeatedly caught and fired for peeping at the medical records of dozens of celebrities, including Britney Spears, Farrah Fawcett and then-California First Lady Maria Shriver.

The entire story can be found here.

Survey: 90% of companies say they've been hacked



By Jaikumar Vijayan
ComputerWorld>Security

If it sometimes appears that just about every company is getting hacked these days, that's because they are.

In a recent survey (download PDF) of 583 U.S companies conducted by Ponemon Research on behalf of Juniper Networks, 90% of the respondents said their organizations' computers had been breached at least once by hackers over the past 12 months.

Nearly 60% reported two or more breaches over the past year. More than 50% said they had little confidence of being able to stave off further attacks over the next 12 months.

Those numbers are significantly higher than findings in similar surveys, and they suggest that a growing number of enterprises are losing the battle to keep malicious intruders out of their networks.

"We expected a majority to say they had experienced a breach," said Johnnie Konstantas, director of product marketing at Juniper, a Sunnyvale, Calif.-based networking company. "But to have 90% saying they had experienced at least one breach, and more than 50% saying they had experienced two or more, is mind-blowing." Those findings suggest "that a breach has become almost a statistical certainty" these days, she said.

The organizations that participated in the Ponemon survey represented a wide cross-section of both the private and public sectors, ranging from small organizations with less than 500 employees to enterprises with workforces of more than 75,000. The online survey was conducted over a five-day period earlier this month.

Roughly half of the respondents blamed resource constraints for their security woes, while about the same number cited network complexity as the primary challenge to implementing security controls.
The Ponemon survey comes at a time of growing concern about the ability of companies to fend off sophisticated cyberattacks. Over the past several months, hackers have broken into numerous supposedly secure organizations, such as security vendor RSA, Lockheed Martin, Oak Ridge National Laboratories and the International Monetary Fund.

Many of the attacks have involved the use of sophisticated malware and social engineering techniques designed to evade easy detection by conventional security tools.

The attacks have highlighted what analysts say is a growing need for enterprises to implement controls for the quick detection and containment of security breaches. Instead of focusing only on protecting against attacks, companies need to prepare for what comes after a targeted breach.

The survey results suggest that some organizations have begun moving in that direction. About 32% of the respondents said their primary security focus was on preventing attacks, but about 16% claimed the primary focus of their security efforts was on quick detection of and response to security incidents. About one out of four respondents said their focus was on aligning security controls with industry best practices.

Thursday, July 21, 2011

danger + opportunity ≠ crisis

How a misunderstanding about Chinese characters has led many astray

by Victor H. Mair

There is a widespread public misperception, particularly among the New Age sector, that the Chinese word for “crisis” is composed of elements that signify “danger” and “opportunity.” I first encountered this curious specimen of alleged oriental wisdom about ten years ago at an altitude of 35,000 feet sitting next to an American executive. He was intently studying a bound volume that had adopted this notorious formulation as the basic premise of its method for making increased profits even when the market is falling. At that moment, I didn't have the heart to disappoint my gullible neighbor who was blissfully imbibing what he assumed were the gems of Far Eastern sagacity enshrined within the pages of his workbook. Now, however, the damage from this kind of pseudo-profundity has reached such gross proportions that I feel obliged, as a responsible Sinologist, to take counteraction.

A whole industry of pundits and therapists has grown up around this one grossly inaccurate statement. A casual search of the Web turns up more than a million references to this spurious proverb. It appears, often complete with Chinese characters, on the covers of books, on advertisements for seminars, on expensive courses for “thinking outside of the box,” and practically everywhere one turns in the world of quick-buck business, pop psychology, and orientalist hocus-pocus. This catchy expression (Crisis = Danger + Opportunity) has rapidly become nearly as ubiquitous as The Tao of Pooh and Sun Zi's Art of War for the Board / Bed / Bath / Whichever Room.

The explication of the Chinese word for crisis as made up of two components signifying danger and opportunity is due partly to wishful thinking, but mainly to a fundamental misunderstanding about how terms are formed in Mandarin and other Sinitic languages. For example, one of the most popular websites centered on this mistaken notion about the Chinese word for crisis explains: “The top part of the Chinese Ideogram for 'Crisis' is the symbol for 'Danger': The bottom symbol represents 'Opportunity'.” Among the most egregious of the radical errors in this statement is the use of the exotic term “Ideogram” to refer to Chinese characters. Linguists and writing theorists avoid “ideogram” as a descriptive referent for hanzi (Mandarin) / kanji (Japanese) / hanja (Korean) because only an exceedingly small proportion of them actually convey ideas directly through their shapes. (For similar reasons, the same caveat holds for another frequently encountered label, pictogram.) It is far better to refer to the hanzi / kanji / hanja as logographs, sinographs, hanograms, tetragraphs (from their square shapes [i.e., as fangkuaizi]), morphosyllabographs, etc., or — since most of those renditions may strike the average reader as unduly arcane or clunky — simply as characters.

The second misconception in this formulation is that the author seems to take the Chinese word for crisis as a single graph, referring to it as “the Chinese Ideogram for 'crisis'.” Like most Mandarin words, that for “crisis” (wēijī) consists of two syllables that are written with two separate characters, wēi (危) and (機/机).

The third, and fatal, misapprehension is the author's definition of as “opportunity.” While it is true that wēijī does indeed mean “crisis” and that the wēi syllable of wēijī does convey the notion of “danger,” the syllable of wēijī most definitely does not signify “opportunity.” Webster's Ninth New Collegiate Dictionary defines “opportunity” as:
  1. a favorable juncture of circumstances;
  2. a good chance for advancement or progress.
While that may be what our Pollyanaish advocates of “crisis” as “danger” plus “opportunity” desire to signify, it means something altogether different.

The of wēijī, in fact, means something like “incipient moment; crucial point (when something begins or changes).” Thus, a wēijī is indeed a genuine crisis, a dangerous moment, a time when things start to go awry. A wēijī indicates a perilous situation when one should be especially wary. It is not a juncture when one goes looking for advantages and benefits. In a crisis, one wants above all to save one's skin and neck! Any would-be guru who advocates opportunism in the face of crisis should be run out of town on a rail, for his / her advice will only compound the danger of the crisis.

For those who have staked their hopes and careers on the CRISIS = DANGER + OPPORTUNITY formula and are loath to abandon their fervent belief in as signifying “opportunity,” it is essential to list some of the primary meanings of the graph in question. Aside from the notion of “incipient moment” or “crucial point” discussed above, the graph for by itself indicates “quick-witted(ness); resourceful(ness)” and “machine; device.” In combination with other graphs, however, can acquire hundreds of secondary meanings. It is absolutely crucial to observe that possesses these secondary meanings only in the multisyllabic terms into which it enters. To be specific in the matter under investigation, added to huì (“occasion”) creates the Mandarin word for “opportunity” (jīhuì), but by itself does not mean “opportunity.”

The rest can be read at Pinyin.info

Wednesday, July 20, 2011

The Dark Side of "Comprehensive Soldier Fitness"

opednews.com
By Roy Eidelson, Marc Pilisuk, and Stephen Soldz  

Why is the world's largest organization of psychologists so aggressively promoting a new, massive, and untested military program? The APA's enthusiasm for mandatory "resilience training" for all U.S. soldiers is troubling on many counts.

The January 2011 issue of the American Psychologist, the American Psychological Association's (APA) flagship journal, is devoted entirely to 13 articles that detail and celebrate the virtues of a new U.S. Army-APA collaboration. Built around positive psychology and with key contributions from former APA president Martin Seligman and his colleagues, Comprehensive Soldier Fitness (CSF) is a $125 million resilience training initiative designed to reduce and prevent the adverse psychological consequences of combat for our soldiers and veterans. While these are undoubtedly worthy aspirations, the special issue is nevertheless troubling in several important respects: the authors of the articles, all of whom are involved in the CSF program, offer very little discussion of conceptual and ethical considerations; the special issue does not provide a forum for any independent critical or cautionary voices whatsoever; and through this format, the APA itself has adopted a jingoistic cheerleading stance toward a research project about which many crucial questions should be posed. We discuss these and related concerns below.

At the outset, we want to be clear that we are not questioning the valuable role that talented and dedicated psychologists play in the military, nor certainly the importance of providing our soldiers and veterans with the best care possible. As long as our country has a military, our soldiers should be prepared to face the hazards and horrors they may experience. Military service is highly stressful, and psychological challenges and difficulties understandably arise frequently. These issues are created or exacerbated by a wide range of features characteristic of military life, such as separation from family, frequent relocations, and especially deployment to combat zones with ongoing threats of injury and death and exposure to acts of unspeakable violence. The stress of repeated tours of duty, including witnessing the loss of lives of comrades and civilians, can produce extensive emotional and behavioral consequences that persist long after soldiers return home. They include heightened risk of suicide, posttraumatic stress disorder (PTSD), substance abuse, and family violence.

(dropping to the ethical concerns)

Ethical Concerns

We also believe that other key aspects of Comprehensive Soldier Fitness should have received explicit discussion in this special issue. It is standard practice for an independent and unbiased ethics review committee (an "institutional review board" or "IRB") to evaluate the ethical issues arising from a research project prior to its implementation. This review and approval process may in fact have occurred for CSF, but the manner in which the principals blur "research" and "training" leads us to wish for much greater clarity here. This process is even more critical given that the soldiers apparently have no informed consent protections -- they are all required to participate in the CSF program. Such research violates the Nuremberg Code developed during the post-World War II trials of Nazi doctors. That code begins by stating:

The voluntary consent of the human subject is absolutely essential.

This means that the person involved should have legal capacity to give consent; should be so situated as to be able to exercise free power of choice, without the intervention of any element of force, fraud, deceit, duress, over-reaching, or other ulterior form of constraint or coercion; and should have sufficient knowledge and comprehension of the elements of the subject matter involved as to enable him to make an understanding and enlightened decision.
Disturbingly, however, this mandatory participation in a research study does not violate Section 8.05 of the APA's own Ethics Code, which allows for the suspension of informed consent "where otherwise permitted by law or federal or institutional regulations." Despite the APA's stance, we should never forget that the velvet glove of authoritarian planning, no matter how well intended, is no substitute for the protected freedoms of individuals to make their own choices, mistakes, and dissenting judgments. Respect for informed consent is more, not less, important in total environments like the military where individual dissent is often severely discouraged and often punished.

More broadly, the 13 articles fail to explore potential ethical concerns related to the uncertain effects of the CSF training itself. In fact, the only question of this sort raised in the special issue -- by Tedeschi and McNally in one article and by Lester, McBride, Bliese, and Adler in another -- is whether it might be unethical to withhold the CSF training from soldiers. Certainly, there are other ethical quandaries that require serious discussion if the CSF program's effectiveness is to be appropriately evaluated. For example, might the training actually cause harm? Might soldiers who have been trained to resiliently view combat as a growth opportunity be more likely to ignore or under-estimate real dangers, thereby placing themselves, their comrades, or civilians at heightened risk of harm?

The entire piece can be read here.

Tuesday, July 19, 2011

Supervisor Self-Disclosure

*Psychotherapy: Theory, Research, Practice, Training* has scheduled an article for publication in a future issue: "Supervisor Self-Disclosure: Supervisees' Experiences and Perspectives."

The authors are Sarah Knox, Lisa M. Edwards, Shirley A. Hess, and Clara E. Hill.  Here's how the article begins:

[begin excerpt]

Farber (2006) suggested that, in addition to the inherent need for supervisee self-disclosure, supervisor self-disclosure (SRSD) is also crucial to supervision.

He asserted that supervisors disclose to build the supervision relationship, share discoveries from their own professional experiences, model skills, and provide feedback.

Given the role that SRSD may have in supervision, it is important to examine its impact on supervisees and on supervision.

Existing studies, primarily using quantitative survey methods, have described types and outcomes of SRSDs (Bahrick, 1990; Gray, Ladany, Walker, & Ancis, 2001; Hess et al., 2008; Ladany, Hill, Corbett, & Nutt, 1996; Ladany & Lehrman-Waterman, 1999; Ladany & Melincoff, 1999; Ladany & Walker, 2003; Ladany, Walker, & Melincoff, 2001; Norcross & Halgin, 1997; Walsh, Gillespie, Greer, & Eanes, 2002; Worthen & McNeill, 1996; Yourman, 2003). In the only qualitative study in this area, Knox, Burkard, Edwards, Smith, and Schlosser (2008) examined supervisors' perspectives about using SRSD with supervisees. Supervisors used SRSDs when supervisees struggled, and intended them to teach or normalize. Supervisors' disclosures focused on supervisors' reactions to their own or their supervisees' clients. These SRSDs had positive effects on supervisors, supervisees, the supervision relationship, and supervisors' supervision of others.

These results suggest that the supervisors were attuned to their supervisees' clinical needs and sought to intervene such that supervisees could function more effectively, all of which led to salutary results. Although Knox et al.'s results are intriguing, we wonder if supervisees feel the same way about SRSDs . . . do such disclosures have the salutary effects that supervisors perceived? Relatedly, the literature is replete with examples of supervisees' negative feelings about their supervisors, and also the belief that they must hide such feelings for fear of political suicide (Gray et al., 2001; Hess et al., 2008; Nelson & Friedlander, 2001). Learning about supervisees' reactions could thus help us understand the other side of the SRSD interaction. We need, then, a probing examination of supervisees' experiences of SRSD, so that we may "get inside" the phenomenon by asking those to whom it is directed how they experienced such disclosure.

A qualitative design could help us fill this gap in the literature by addressing the central question of the current study: How do supervisees experience SRSD? How does SRSD affect supervision and supervisees' clinical work? Examining such questions from the supervisee perspective is essential, and will add important new understandings to the extant literature. In the present study, then, we examined supervisees' experiences of SRSD, extending with a distinct sample the work by Knox et al. (2008) about supervisors' experiences of SRSD. We asked supervisees to describe in depth one particular instance of SRSD and its impact.

[end excerpt]

Another excerpt: "When describing a specific SRSD experience, supervisees reported a range of antecedents (e.g., difficult clinical situation, selfdoubt, tension in supervision relationship) followed by supervisor disclosures about clinical experiences or personal information. Supervisees perceived that their supervisors disclosed primarily to normalize, but also to build rapport and to instruct. The SRSDs had mostly positive effects (e.g., normalization), though some negative effects (e.g., deleterious impact on supervision relationship) were reported."

The author note provides the following contact information: " Sarah Knox, PhD, Associate Professor, Department of Counselor Education and Counseling Psychology, College of Education, Marquette University, Milwaukee, WI 53201-1881. E-mail: sarah.knox@marquette.edu.

Thanks to Ken Pope for this information.

Monday, July 18, 2011

Parents' Military Deployment May Harm Kids' Mental Health

MedicineNet.com

Children with a parent on long-term military deployment in Iraq or Afghanistan are at increased risk for mental health problems, new research suggests.

In the study, published in the July 4 online edition of the Archives of Pediatrics and Adolescent Medicine, researchers examined the medical records of 307,520 U.S. children, aged 5 to 17, who had at least one parent on active duty in the U.S. Army and received outpatient care between 2003 and 2006.

During that time period, nearly 17% of the children were diagnosed with a mental health disorder. The most common conditions were depression, behavioral problems, anxiety, stress and sleep disorders, the investigators found.

More than 62% of the children's parents were deployed at least once during the study period, with deployments averaging 11 months. Mental health problems were more likely to be diagnosed among children who had a parent who was deployed at least once to Iraq or Afghanistan. The risk of a mental health problem among the children rose with increased length of parents' deployment.

"We observed a clear dose-response pattern such that children of parents who spent more time deployed between 2003 and 2006 fared worse than children whose parents were deployed for a shorter duration," wrote Alyssa J. Mansfield, then of the University of North Carolina at Chapel Hill, now of the National Center for Posttraumatic Stress Disorder in Honolulu, and colleagues. "Similar to findings among military spouses, prolonged deployment appears to be taking a mental health toll on children."

In an accompanying commentary, Dr. Stephen J. Cozza, from the Uniformed Services University School of Medicine in Bethesda, Md., noted that as of 2009, 44% of active duty military members have children (an estimated total of 1.2 million children), in addition to 43% of Reserve and National Guard members. Since 2001, about 2 million U.S. military personnel have deployed at least once.

The study provides "an important contribution to our understanding of a child's health and its relationship to parental combat deployment," Cozza said in a journal news release.

"Brief screening for anxiety, depression, behavioral problems, academic difficulties, peer relational problems, or high-risk behaviors (such as substance misuse or unsafe sexual practices) is warranted and will help identify treatment needs," Cozza concluded.

Sunday, July 17, 2011

Practical Tips: Emailing Patients

Practical Tips for Psychologists When Using Electronic Media to Supplement Face to Face Therapy with Patients

Rachael L. Baturin, MPH, JD
Professional Affairs Associate


As electronic media is becoming more prevalent among patients, psychologists are starting to incorporate it more and more in their practices. Some psychologists use email and texting as a way to communicate with their patients between face-to-face therapy sessions. As such, psychologists should set up a policy on how they are going to use these means to communicate with their patients and psychologists should communicate this policy to their patients. Here are some practical tips that psychologists should consider when adopting a policy on the use of electronic media with patients:

1. Psychologists should clarify to patients what, if any, kinds of emails they will accept. Generally, emails should be professional in nature and should not get personal. If emails are becoming too lengthy or prolonged you should notify patients to come in or call to discuss the issue.

2. Emails should not be used in emergencies. Patients should be advised to contact psychologists by phone if an emergency arises.

3. Psychologists should advise their patients on headings that they will use in the subject line of the email (ex. billing question, appointment).

4. Psychologists should establish a turnaround time for their response to patients’ emails.

5. Psychologists should inform their patients about privacy issues. Patients should know who besides the psychologist processes emails during normal business hours, during vacations and when the psychologist is out sick.

6. Psychologists should maintain a copy of all messages sent to/from their patients in their records.

7. Psychologists should include a standard block of text to the end of the email message to patients containing the psychologist’s full name, contact information and reminders about security and the importance of alternative forms of communication for emergencies.

8. Psychologists should remember that email has inherent limitations in that the lack of non-verbal cues (facial expression, voice tone) may cause the intent of the communication to fail. For example, an attempt at humor may come off as being sarcastic even though it was not meant to be.

Saturday, July 16, 2011

Ethical dilemmas: A model to understand teacher practice

Ehrich, Lisa Catherine; Kimber, Megan; Millwater, Jan; Cranston, Neil


Over recent decades, the field of ethics has been the focus of increasing attention in teaching. This is not surprising given that teaching is a moral activity that is heavily values-laden. Because of this, teachers face ethical dilemmas in the course of their daily work. 


This paper presents an ethical decision-making model that helps to explain the decision-making processes that individuals or groups are likely to experience when confronted by an ethical dilemma. In order to make sense of the model, we put forward three short ethical dilemma scenarios facing teachers and apply the model to interpret them. Here we identify the critical incident, the forces at play that help to illuminate the incident, the choices confronting the individual and the implications of these choices for the individual, organisation and community. 


Based on our analysis and the wider literature we identify several strategies that may help to minimise the impact of ethical dilemmas. These include the importance of sharing dilemmas with trusted others; having institutional structures in schools that lessen the emergence of harmful actions occurring; the necessity for individual teachers to articulate their own personal and professional ethics; acknowledging that dilemmas have multiple forces at play; the need to educate colleagues about specific issues; and the necessity of appropriate preparation and support for teachers. Of these strategies, providing support for teachers via professional development is explored more fully.

In Trying to Test Students' Ethics, Colleges Find It Hard to Do the Right Thing





by Peter Schmidt
Chronicle of Higher Education


Union College, long focused on engineering and the liberal arts, five years ago adopted a new educational mission: teaching its students to be ethical.



It established an Ethics Across the Curriculum program that encourages faculty members to weave discussions of ethics into all of their courses, no matter the subject.



Although faculty throughout the college's four academic divisions have gotten behind the effort, it is hard to tell what, if any, effect it is having.



Here and elsewhere in academe, ethics instruction remains a means to unclear ends.



<snip>



"Ethical reasoning and action" is one of the "essential learning outcomes" that the Association of American Colleges and Universities says is "best developed by a contemporary liberal education."



But these days, making that claim is not enough: The accountability movement has put colleges under pressure to assess students' progress in meeting all educational goals.



Assessing ethical learning is especially challenging.



Sure, colleges can test students' recall of class lectures or assigned readings.



But being able to parrot Plato is a far cry from skillfully applying moral philosophy to today's moral dilemmas.



<snip>



Colleges might even be able to measure whether their students have become more sophisticated in the thought processes they use in working through ethical problems.



But the most widely used instruments for measuring moral reasoning are intended for research or to evaluate institutions, not for student grading, and educators disagree on their validity.

When it comes to measuring whether ethics instruction sticks, making students more likely to do the right thing throughout their lives, about all colleges can do is hope.



<snip>



But the truth is that there is no telling whether today's college student will go on to become a mensch or the next Bernie Madoff.



Ethical development lies "at the outermost ring" of the learning outcomes institutions are able to measure, says Trudy W. Banta, a professor of higher education at Indiana University-Purdue University at Indianapolis who has extensively studied assessment practices.



Of the tests of ethical learning devised so far, she says, "I don't know of anything that is even beginning to be universally accepted."



<snip>



Among the many challenges in assessing students' development is the lack of universally accepted "right" answers to many moral and ethical problems.



"By definition, you are coming up with some sort of normative value judgment on what the right outcomes are for students," says Richard Arum, professor of sociology and education at New York University and co-author of Academically Adrift: Limited Learning on College Campuses.



"It is hard to get objective measures that are not tied in with cultural assumptions."



If colleges send students the message that there exists a correct answer to any given ethical question, Mr. Arum says, they are likely to run into a problem routinely encountered by social scientists whose research involves surveys: People often answer a question with the response they perceive as most acceptable to others, failing to say what they truly believe.



Deni Elliott, a professor of media ethics at the University of South Florida and the founder of ethics centers at both Dartmouth College and the University of Montana, argues that colleges need to separate "instructional objective from pedagogical hope."



<snip>



Union College has left it up to faculty members to individually devise ways to determine how well students absorb and apply ethics lessons.



Many of its faculty members gauge learning mainly by judging how well students identify and analyze ethical problems in writing assignments, on essay tests, and in classroom discussions.



That approach, widely used throughout academe, puts a premium on ethical reasoning and rewards students for demonstrating critical thinking.



In focusing on cognitive development, however, such assessments get at only one of two key aspects of ethical thinking, argue experts like David T. Ozar, a professor of philosophy at Loyola University Chicago and veteran instructor of journalistic and medical ethics.



Also important, he says, is affective learning, the acquisition of attitudes and values that leave one more predisposed to act ethically.



"It is really hard to measure ethical learning because it's not declarative or semantic knowledge, but, like any expertise, it is knowing the right thing to do in the right way at the right time," says Darcia F. Narváez, an associate professor of psychology at the University of Notre Dame.



In her research, she has found that intuition plays such a big role in moral decisions that she argues it is a mistake to ignore its influence.



<snip>



The Union program seeks to promote ethical development through both the application of moral philosophy to various academic fields and practical discussions of the ethical codes under which those fields operate.



<snip>



Faculty members involved in the effort met this winter to compare notes on approaches that seemed to be improving their students' ability to spot and deal with ethical problems posed to them in assignments and on tests.



At about the same time, however, a committee of students, administrators, and faculty members gathered elsewhere on campus to talk over an effort to stem cheating through the adoption of a new honor code.



Kristen A. Bidoshi, Union's dean of studies, estimates that she deals with roughly 200 cases of academic dishonesty each year, out of a total undergraduate enrollment of about 2,500.



Claire M. Bracken, assistant professor of English at Union College and a member of the steering committee for its ethics-education effort, says she is hopeful that getting students "passionate and engaged with these issues" will lead them to retain the ethics lessons learned in college classrooms and behave more ethically throughout life.



But, she acknowledges, "There is no good way of knowing what they are thinking when they leave."


     *     *     *     *     *     *


Thanks to Ken Pope for the information.