The Texas Tribune: Advocates Seek Mental Health Changes, Including Power to Detain

Matt Rainwaters for Texas Monthly

The Sherman grave of Andre Thomas’s victims.

SHERMAN — A worried call from his daughter’s boyfriend sent Paul Boren rushing to her apartment on the morning of March 27, 2004. He drove the eight blocks to her apartment, peering into his neighbors’ yards, searching for Andre Thomas, Laura Boren’s estranged husband.

Expanded coverage of Texas is produced by The Texas Tribune, a nonprofit news organization. To join the conversation about this article, go to texastribune.org.

For more articles on mental health and criminal justice in Texas, as well as a timeline of the Andre Thomas case: texastribune.org

Matt Rainwaters for Texas Monthly

Laura Boren

He drove past the brightly colored slides, swings and bouncy plastic animals in Fairview Park across the street from the apartment where Ms. Boren, 20, and her two children lived. He pulled into a parking spot below and immediately saw that her door was broken. As his heart raced, Mr. Boren, a white-haired giant of a man, bounded up the stairwell, calling out for his daughter.

He found her on the white carpet, smeared with blood, a gaping hole in her chest. Beside her left leg, a one-dollar bill was folded lengthwise, the radiating eye of the pyramid facing up. Mr. Boren knew she was gone.

In a panic, he rushed past the stuffed animals, dolls and plastic toys strewn along the hallway to the bedroom shared by his two grandchildren. The body of 13-month-old Leyha Hughes lay on the floor next to a blood-spattered doll nearly as big as she was.

Andre Boren, 4, lay on his back in his white children’s bed just above Leyha. He looked as if he could have been sleeping — a moment away from revealing the toothy grin that typically spread from one of his round cheeks to the other — except for the massive chest wound that matched the ones his father, Andre Thomas (the boy was also known as Andre Jr.), had inflicted on his mother and his half-sister as he tried to remove their hearts.

“You just can’t believe that it’s real,” said Sherry Boren, Laura Boren’s mother. “You’re hoping that it’s not, that it’s a dream or something, that you’re going to wake up at any minute.”

Mr. Thomas, who confessed to the murders of his wife, their son and her daughter by another man, was convicted in 2005 and sentenced to death at age 21. While awaiting trial in 2004, he gouged out one of his eyes, and in 2008 on death row, he removed the other and ate it.

At least twice in the three weeks before the crime, Mr. Thomas had sought mental health treatment, babbling illogically and threatening to commit suicide. On two occasions, staff members at the medical facilities were so worried that his psychosis made him a threat to himself or others that they sought emergency detention warrants for him.

Despite talk of suicide and bizarre biblical delusions, he was not detained for treatment. Mr. Thomas later told the police that he was convinced that Ms. Boren was the wicked Jezebel from the Bible, that his own son was the Antichrist and that Leyha was involved in an evil conspiracy with them.

He was on a mission from God, he said, to free their hearts of demons.

Hospitals do not have legal authority to detain people who voluntarily enter their facilities in search of mental health care but then decide to leave. It is one of many holes in the state’s nearly 30-year-old mental health code that advocates, police officers and judges say lawmakers need to fix. In a report last year, Texas Appleseed, a nonprofit advocacy organization, called on lawmakers to replace the existing code with one that reflects contemporary mental health needs.

“It was last fully revised in 1985, and clearly the mental health system has changed drastically since then,” said Susan Stone, a lawyer and psychiatrist who led the two-year Texas Appleseed project to study and recommend reforms to the code. Lawmakers have said that although the code may need to be revamped, it will not happen in this year’s legislative session. Such an undertaking requires legislative studies that have not been conducted. But advocates are urging legislators to make a few critical changes that they say could prevent tragedies, including giving hospitals the right to detain someone who is having a mental health crisis.

From the time Mr. Thomas was 10, he had told friends he heard demons in his head instructing him to do bad things. The cacophony drove him to attempt suicide repeatedly as an adolescent, according to court records. He drank and abused drugs to try to quiet the noise.

bgrissom@texastribune.org

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The Texas Tribune: Advocates Seek Mental Health Changes, Including Power to Detain

Matt Rainwaters for Texas Monthly

The Sherman grave of Andre Thomas’s victims.

SHERMAN — A worried call from his daughter’s boyfriend sent Paul Boren rushing to her apartment on the morning of March 27, 2004. He drove the eight blocks to her apartment, peering into his neighbors’ yards, searching for Andre Thomas, Laura Boren’s estranged husband.

Expanded coverage of Texas is produced by The Texas Tribune, a nonprofit news organization. To join the conversation about this article, go to texastribune.org.

For more articles on mental health and criminal justice in Texas, as well as a timeline of the Andre Thomas case: texastribune.org

Matt Rainwaters for Texas Monthly

Laura Boren

He drove past the brightly colored slides, swings and bouncy plastic animals in Fairview Park across the street from the apartment where Ms. Boren, 20, and her two children lived. He pulled into a parking spot below and immediately saw that her door was broken. As his heart raced, Mr. Boren, a white-haired giant of a man, bounded up the stairwell, calling out for his daughter.

He found her on the white carpet, smeared with blood, a gaping hole in her chest. Beside her left leg, a one-dollar bill was folded lengthwise, the radiating eye of the pyramid facing up. Mr. Boren knew she was gone.

In a panic, he rushed past the stuffed animals, dolls and plastic toys strewn along the hallway to the bedroom shared by his two grandchildren. The body of 13-month-old Leyha Hughes lay on the floor next to a blood-spattered doll nearly as big as she was.

Andre Boren, 4, lay on his back in his white children’s bed just above Leyha. He looked as if he could have been sleeping — a moment away from revealing the toothy grin that typically spread from one of his round cheeks to the other — except for the massive chest wound that matched the ones his father, Andre Thomas (the boy was also known as Andre Jr.), had inflicted on his mother and his half-sister as he tried to remove their hearts.

“You just can’t believe that it’s real,” said Sherry Boren, Laura Boren’s mother. “You’re hoping that it’s not, that it’s a dream or something, that you’re going to wake up at any minute.”

Mr. Thomas, who confessed to the murders of his wife, their son and her daughter by another man, was convicted in 2005 and sentenced to death at age 21. While awaiting trial in 2004, he gouged out one of his eyes, and in 2008 on death row, he removed the other and ate it.

At least twice in the three weeks before the crime, Mr. Thomas had sought mental health treatment, babbling illogically and threatening to commit suicide. On two occasions, staff members at the medical facilities were so worried that his psychosis made him a threat to himself or others that they sought emergency detention warrants for him.

Despite talk of suicide and bizarre biblical delusions, he was not detained for treatment. Mr. Thomas later told the police that he was convinced that Ms. Boren was the wicked Jezebel from the Bible, that his own son was the Antichrist and that Leyha was involved in an evil conspiracy with them.

He was on a mission from God, he said, to free their hearts of demons.

Hospitals do not have legal authority to detain people who voluntarily enter their facilities in search of mental health care but then decide to leave. It is one of many holes in the state’s nearly 30-year-old mental health code that advocates, police officers and judges say lawmakers need to fix. In a report last year, Texas Appleseed, a nonprofit advocacy organization, called on lawmakers to replace the existing code with one that reflects contemporary mental health needs.

“It was last fully revised in 1985, and clearly the mental health system has changed drastically since then,” said Susan Stone, a lawyer and psychiatrist who led the two-year Texas Appleseed project to study and recommend reforms to the code. Lawmakers have said that although the code may need to be revamped, it will not happen in this year’s legislative session. Such an undertaking requires legislative studies that have not been conducted. But advocates are urging legislators to make a few critical changes that they say could prevent tragedies, including giving hospitals the right to detain someone who is having a mental health crisis.

From the time Mr. Thomas was 10, he had told friends he heard demons in his head instructing him to do bad things. The cacophony drove him to attempt suicide repeatedly as an adolescent, according to court records. He drank and abused drugs to try to quiet the noise.

bgrissom@texastribune.org

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IHT Rendezvous: Opera for an Era When Money Is Tight

VIENNA—Not long ago it looked as if cuts in arts funding would sound the death knell of the Vienna Chamber Opera, known in German as the Kammeroper, an ensemble esteemed for its chamber-scale productions in an intimate, inviting setting. The Austrian federal government’s decision to eliminate entirely its support, which constituted half of the company’s governmental subsidies (the other half coming from the city) effectively put the Kammeroper out of business.

Yet the 2012-13 season has seen the Kammeroper come roaring back with five new productions—including a “Bohème” finishing up performances this weekend— put on by a resident company with an established orchestra in the pit.

How to explain this turnaround? In fact, the old company, which was founded over 50 years ago by Hans Gabor and was subsequently run by Isabella, his widow, is history. The new Kammeroper, formally known as Theater an der Wien in der Kammeroper, is a case of one opera company rushing to fill the void left by the collapse of another.

Few opera companies today are in a financial position to go into expansionary mode. But, with the city willing to continue its support, the Theater an der Wien saw an opportunity, as its director of artistic administration, Sebastian Schwarz, who oversees the Kammeroper, explained by phone. Surprisingly, as he pointed out, the Vienna Staatsoper lacks a young artists program, so the new venture helps meet a need in the city. It also adds a degree of continuity to the Theater an der Wien’s own operations, which include world-class productions of interesting repertory that are assembled individually, with visiting performers and orchestras.

What has happened at the Kammeroper would be akin the Metropolitan Opera taking over the name and venue of a smaller New York company in financial trouble, giving the city the “Mini-Met” audiences have fancied for decades. The Kammeroper’s venue is especially choice: the gilded former ballroom, dating from the turn of the last century, of the venerable Hotel Post in the old Fleischmarkt district of the city. Outfitted with an orchestra pit, it comfortably seats 300. The performance I attended was packed, and with ticket prices ranging from 16 to 48 euros ($21-64), it is a bargain.

At the core of the new Kammeroper is an ensemble of seven young singers, which Mr. Schwarz described as constituting a “cast for ‘Così Fan Tutte’ ”—two sopranos, a mezzo soprano, a tenor, a baritone and a bass, plus a counter-tenor. In addition to their Kammeroper duties, the singers take smaller roles at the Theater an der Wien.

“La Bohème” can make a special impact when cast with young singers, and so it does here, as performed in Jonathan Dove’s 1986 chamber version with newly composed modernistic music at the start and between acts by Sinem Altan. Basically, the opera is performed straight, but with choral and other big moments from Acts 2 and 3 excised. The interludes, which included prerecorded music, are atmospheric and intermittently engaging, but essentially peripheral. For one not knowing what to expect, it was a relief when—with Rodolfo and Marcello already onstage—the familiar music of Act 1 began to unfold and continued on uninterrupted.

The lively, updated staging is by Lotte de Beer, the young director of Robin de Raaff’s recent “Waiting for Ms. Monroe” at the Netherlands Opera. The set by Clement & Sanôu, who also did the lighting, focuses on the modern kitchen of the bohemians’ apartment, which also, somewhat confusingly seems to be part high-end boutique (at least until the merchandise is removed after Act 2). In any case, it is handsome and full of stylish details. The playwright Rodolfo writes at a laptop and throws pages of his opus into the oven for warmth.

There is an inevitable loss of grandeur in Act 2, but Ms. de Beer nicely handles Rodolfo and Mimi’s growing attraction to each other and the conflicts of Act 3. The setting of Mimi’s hospital room for Act 4 is rather contrived, however, especially since the others, not at first being allowed in, communicate with her from pay phones in the lobby, which detracts from the emotional impact. Mimi has lost her hair, presumably as a result of treating a fatal illness different from that specified by Puccini. Still, this is an engaging show

The vocal ensemble, which is capably augmented by two guests, Oleg Loza as Schaunard and Martin Thoma as Benoit and Alcindoro, is uniformly strong. From the opera’s opening line by Marcello, one admired Ben Connor’s rich, fluent baritone, and it didn’t take long for the tenor Andrew Owens to catch his stride as Rodolfo and spin his own handsomely lyrical phrases and a fine high C.

All the singers displayed ample voices that could be overpowering in a hall this size, but they didn’t allow that to happen. Cigdem Soyarslan’s Mimi was a little uneven at first, but one came to appreciate her warm spinto sound, especially in her Act 3 aria, and Anna Maris Sarra sings Musetta with a glinting soprano that is heard to fine effect in her animated account of the waltz aria.

Igor Bakan brings a full, resonant bass voice and a strong emotional charge to Colline’s farewell to his overcoat. The fine Vienna Chamber Orchestra is in the pit, led with assurance by Claire Levacher.

The newly constituted Kammeroper has thus emerged as a bright spot on the Viennese opera scene.

Two more productions remain this season, a double bill of Britten’s “Curlew River” and “Prodigal Son” and Handel’s “Orlando.”

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Many States Say Cuts Would Burden Fragile Recovery

States are increasingly alarmed that they could become collateral damage in Washington’s latest fiscal battle, fearing that the impasse could saddle them with across-the-board spending cuts that threaten to slow their fragile recoveries or thrust them back into recession.

Some states, like Maryland and Virginia, are vulnerable because their economies are heavily dependent on federal workers, federal contracts and military spending, which will face steep reductions if Congress allows the automatic cuts, known as sequestration, to begin next Friday. Others, including Illinois and South Dakota, are at risk because of their reliance on the types of federal grants that are scheduled to be cut. And many states simply fear that a heavy dose of federal austerity could weaken their economies, costing them jobs and much-needed tax revenue.

So as state officials begin to draw up their budgets for next year, some say that the biggest risk they see is not the weak housing market or the troubled European economy but the federal government. While the threat of big federal cuts to states has become something of a semiannual occurrence in recent years, state officials said in interviews that they fear that this time the federal government might not be crying wolf — and their hopes are dimming that a deal will be struck in Washington in time to avert the cuts.

The impact would be widespread as the cuts ripple across the nation over the next year.

Texas expects to see its education aid slashed hundreds of millions of dollars, which could force local school districts to fire teachers, if the cuts are not averted. Michigan officials say they are in no position to replace the lost federal dollars with state dollars, but worry about cuts to federal programs like the one that helps people heat their homes. Maryland is bracing not only for a blow to its economy, which depends on federal workers and contractors and the many private businesses that support them, but also for cuts in federal aid for schools, Head Start programs, a nutrition program for pregnant women, mothers and children, and job training programs, among others.

Gov. Bob McDonnell of Virginia, a Republican, warned in a letter to President Obama on Monday that the automatic spending cuts would have a “potentially devastating impact” and could force Virginia and other states into a recession, noting that the planned cuts to military spending would be especially damaging to areas like Hampton Roads that have a big Navy presence. And he noted that the whole idea of the proposed cuts was that they were supposed to be so unpalatable that they would force officials in Washington to come up with a compromise.

“As we all know, the defense, and other, cuts in the sequester were designed to be a hammer, not a real policy,” Mr. McDonnell wrote. “Unfortunately, inaction by you and Congress now leaves states and localities to adjust to the looming threat of this haphazard idea.”

The looming cuts come just as many states feel they are turning the corner after the prolonged slump caused by the recession. Gov. Martin O’Malley of Maryland, a Democrat, said he was moving to increase the state’s cash reserves and rainy day funds as a hedge against federal cuts.

“I’d rather be spending those dollars on things that improve our business climate, that accelerate our recovery, that get more people back to work, or on needed infrastructure — transportation, roads, bridges and the like,” he said, adding that Maryland has eliminated 5,600 positions in recent years and that its government was smaller, on a per capita basis, than it had been in four decades. “But I can’t do that. I can’t responsibly do that as long as I have this hara-kiri Congress threatening to drive a long knife through our recovery.”

Federal spending on salaries, wages and procurement makes up close to 20 percent of the economies of Maryland and Virginia, according to an analysis by the Pew Center on the States.

But states are in a delicate position. While they fear the impact of the automatic cuts, they also fear that any deal to avert them might be even worse for their bottom lines. That is because many of the planned cuts would go to military spending and not just domestic programs, and some of the most important federal programs for states, including Medicaid and federal highway funds, would be exempt from the cuts.

States will see a reduction of $5.8 billion this year in the federal grant programs subject to the automatic cuts, according to an analysis by Federal Funds Information for States, a group created by the National Governors Association and the National Conference of State Legislatures that tracks the impact of federal actions on states. California, New York and Texas stand to lose the most money from the automatic cuts, and Puerto Rico, which is already facing serious fiscal distress, is threatened with the loss of more than $126 million in federal grant money, the analysis found.

Even with the automatic cuts, the analysis found, states are still expected to get more federal aid over all this year than they did last year, because of growth in some of the biggest programs that are exempt from the cuts, including Medicaid.

But the cuts still pose a real risk to states, officials said. State budget officials from around the country held a conference call last week to discuss the threatened cuts. “In almost every case the folks at the state level, the budget offices, are pretty much telling the agencies and departments that they’re not going to backfill — they’re not going to make up for the budget cuts,” said Scott D. Pattison, the executive director of the National Association of State Budget Officers, which arranged the call. “They don’t have enough state funds to make up for federal cuts.”

The cuts would not hit all states equally, the Pew Center on the States found. While the federal grants subject to the cuts make up more than 10 percent of South Dakota’s revenue, it found, they make up less than 5 percent of Delaware’s revenue.

Many state officials find themselves frustrated year after year by the uncertainty of what they can expect from Washington, which provides states with roughly a third of their revenues. There were threats of cuts when Congress balked at raising the debt limit in 2011, when a so-called super-committee tried and failed to reach a budget deal, and late last year when the nation faced the “fiscal cliff.”

John E. Nixon, the director of Michigan’s budget office, said that all the uncertainty made the state’s planning more difficult. “If it’s going to happen,” he said, “at some point we need to rip off the Band-Aid.”

Fernanda Santos contributed reporting.

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Drone Pilots Found to Get Stress Disorders Much as Those in Combat Do

U.S. Air Force/Master Sgt. Steve Horton

Capt. Richard Koll, left, and Airman First Class Mike Eulo monitored a drone aircraft after launching it in Iraq.

The study affirms a growing body of research finding health hazards even for those piloting machines from bases far from actual combat zones.

“Though it might be thousands of miles from the battlefield, this work still involves tough stressors and has tough consequences for those crews,” said Peter W. Singer, a scholar at the Brookings Institution who has written extensively about drones. He was not involved in the new research.

That study, by the Armed Forces Health Surveillance Center, which analyzes health trends among military personnel, did not try to explain the sources of mental health problems among drone pilots.

But Air Force officials and independent experts have suggested several potential causes, among them witnessing combat violence on live video feeds, working in isolation or under inflexible shift hours, juggling the simultaneous demands of home life with combat operations and dealing with intense stress because of crew shortages.

“Remotely piloted aircraft pilots may stare at the same piece of ground for days,” said Jean Lin Otto, an epidemiologist who was a co-author of the study. “They witness the carnage. Manned aircraft pilots don’t do that. They get out of there as soon as possible.”

Dr. Otto said she had begun the study expecting that drone pilots would actually have a higher rate of mental health problems because of the unique pressures of their job.

Since 2008, the number of pilots of remotely piloted aircraft — the Air Force’s preferred term for drones — has grown fourfold, to nearly 1,300. The Air Force is now training more pilots for its drones than for its fighter jets and bombers combined. And by 2015, it expects to have more drone pilots than bomber pilots, although fighter pilots will remain a larger group.

Those figures do not include drones operated by the C.I.A. in counterterrorism operations over Pakistan, Yemen and other countries.

The Pentagon has begun taking steps to keep pace with the rapid expansion of drone operations. It recently created a new medal to honor troops involved in both drone warfare and cyberwarfare. And the Air Force has expanded access to chaplains and therapists for drone operators, said Col. William M. Tart, who commanded remotely piloted aircraft crews at Creech Air Force Base in Nevada.

The Air Force has also conducted research into the health issues of drone crew members. In a 2011 survey of nearly 840 drone operators, it found that 46 percent of Reaper and Predator pilots, and 48 percent of Global Hawk sensor operators, reported “high operational stress.” Those crews cited long hours and frequent shift changes as major causes.

That study found the stress among drone operators to be much higher than that reported by Air Force members in logistics or support jobs. But it did not compare the stress levels of the drone operators with those of traditional pilots.

The new study looked at the electronic health records of 709 drone pilots and 5,256 manned aircraft pilots between October 2003 and December 2011. Those records included information about clinical diagnoses by medical professionals and not just self-reported symptoms.

After analyzing diagnosis and treatment records, the researchers initially found that the drone pilots had higher incidence rates for 12 conditions, including anxiety disorder, depressive disorder, post-traumatic stress disorder, substance abuse and suicidal ideation.

But after the data were adjusted for age, number of deployments, time in service and history of previous mental health problems, the rates were similar, said Dr. Otto, who was scheduled to present her findings in Arizona on Saturday at a conference of the American College of Preventive Medicine.

The study also found that the incidence rates of mental heath problems among drone pilots spiked in 2009. Dr. Otto speculated that the increase might have been the result of intense pressure on pilots during the Iraq surge in the preceding years.

The study found that pilots of both manned and unmanned aircraft had lower rates of mental health problems than other Air Force personnel. But Dr. Otto conceded that her study might underestimate problems among both manned and unmanned aircraft pilots, who may feel pressure not to report mental health symptoms to doctors out of fears that they will be grounded.

She said she planned to conduct two follow-up studies: one that tries to compensate for possible underreporting of mental health problems by pilots and another that analyzes mental health issues among sensor operators, who control drone cameras while sitting next to the pilots.

“The increasing use of remotely piloted aircraft for war fighting as well as humanitarian relief should prompt increased surveillance,” she said.

Read More..

Drone Pilots Found to Get Stress Disorders Much as Those in Combat Do

U.S. Air Force/Master Sgt. Steve Horton

Capt. Richard Koll, left, and Airman First Class Mike Eulo monitored a drone aircraft after launching it in Iraq.

The study affirms a growing body of research finding health hazards even for those piloting machines from bases far from actual combat zones.

“Though it might be thousands of miles from the battlefield, this work still involves tough stressors and has tough consequences for those crews,” said Peter W. Singer, a scholar at the Brookings Institution who has written extensively about drones. He was not involved in the new research.

That study, by the Armed Forces Health Surveillance Center, which analyzes health trends among military personnel, did not try to explain the sources of mental health problems among drone pilots.

But Air Force officials and independent experts have suggested several potential causes, among them witnessing combat violence on live video feeds, working in isolation or under inflexible shift hours, juggling the simultaneous demands of home life with combat operations and dealing with intense stress because of crew shortages.

“Remotely piloted aircraft pilots may stare at the same piece of ground for days,” said Jean Lin Otto, an epidemiologist who was a co-author of the study. “They witness the carnage. Manned aircraft pilots don’t do that. They get out of there as soon as possible.”

Dr. Otto said she had begun the study expecting that drone pilots would actually have a higher rate of mental health problems because of the unique pressures of their job.

Since 2008, the number of pilots of remotely piloted aircraft — the Air Force’s preferred term for drones — has grown fourfold, to nearly 1,300. The Air Force is now training more pilots for its drones than for its fighter jets and bombers combined. And by 2015, it expects to have more drone pilots than bomber pilots, although fighter pilots will remain a larger group.

Those figures do not include drones operated by the C.I.A. in counterterrorism operations over Pakistan, Yemen and other countries.

The Pentagon has begun taking steps to keep pace with the rapid expansion of drone operations. It recently created a new medal to honor troops involved in both drone warfare and cyberwarfare. And the Air Force has expanded access to chaplains and therapists for drone operators, said Col. William M. Tart, who commanded remotely piloted aircraft crews at Creech Air Force Base in Nevada.

The Air Force has also conducted research into the health issues of drone crew members. In a 2011 survey of nearly 840 drone operators, it found that 46 percent of Reaper and Predator pilots, and 48 percent of Global Hawk sensor operators, reported “high operational stress.” Those crews cited long hours and frequent shift changes as major causes.

That study found the stress among drone operators to be much higher than that reported by Air Force members in logistics or support jobs. But it did not compare the stress levels of the drone operators with those of traditional pilots.

The new study looked at the electronic health records of 709 drone pilots and 5,256 manned aircraft pilots between October 2003 and December 2011. Those records included information about clinical diagnoses by medical professionals and not just self-reported symptoms.

After analyzing diagnosis and treatment records, the researchers initially found that the drone pilots had higher incidence rates for 12 conditions, including anxiety disorder, depressive disorder, post-traumatic stress disorder, substance abuse and suicidal ideation.

But after the data were adjusted for age, number of deployments, time in service and history of previous mental health problems, the rates were similar, said Dr. Otto, who was scheduled to present her findings in Arizona on Saturday at a conference of the American College of Preventive Medicine.

The study also found that the incidence rates of mental heath problems among drone pilots spiked in 2009. Dr. Otto speculated that the increase might have been the result of intense pressure on pilots during the Iraq surge in the preceding years.

The study found that pilots of both manned and unmanned aircraft had lower rates of mental health problems than other Air Force personnel. But Dr. Otto conceded that her study might underestimate problems among both manned and unmanned aircraft pilots, who may feel pressure not to report mental health symptoms to doctors out of fears that they will be grounded.

She said she planned to conduct two follow-up studies: one that tries to compensate for possible underreporting of mental health problems by pilots and another that analyzes mental health issues among sensor operators, who control drone cameras while sitting next to the pilots.

“The increasing use of remotely piloted aircraft for war fighting as well as humanitarian relief should prompt increased surveillance,” she said.

Read More..

In a Slight Shift, North Korea Widens Internet Access, but Just for Visitors

HONG KONG — North Korea will finally allow Internet searches on mobile devices. But if you’re a North Korean, you’re out of luck — only foreigners will get this privilege.

Cracking the door open slightly to wider Internet use, the government will allow a company called Koryolink to give foreigners access to 3G mobile Internet service by next Friday, according to The Associated Press, which has a bureau in the North.

The North Korean police state is famously cloistered, a means for the government to keep news of the world from its impoverished people. Only the most elite North Koreans have been allowed access to the Internet, and even they are watched. And although many North Koreans are allowed to have cellphones, sanctioned phones cannot call outside the country.

Foreigners were only recently allowed to use cellphones in the country. Previously, most had to surrender their phones with customs agents.

But it is unlikely that the small opening will compromise the North’s tight control of its people; the relatively few foreigners who travel to North Korea — a group that includes tourists and occasional journalists — are assigned government minders.

The decision, announced Friday, to allow foreigners Internet access comes a month after Google’s chairman, Eric E. Schmidt, visited Pyongyang, the North’s capital. While there he prodded officials on allowing Internet access, noting how easy it would be to set up through the expanding 3G network of Koryolink, a joint venture of North Korean and Egyptian telecommunications corporations. Presumably, Mr. Schmidt’s appeal was directed at giving North Koreans such capability.

“As the world becomes increasingly connected, their decision to be virtually isolated is very much going to affect their physical world, their economic growth and so forth,” Mr. Schmidt told reporters following his visit. “We made that alternative very, very clear.”

North Koreans will get some benefit from the 3G service, as they will be allowed to text and make video calls, The Associated Press said. They can also view newspaper reports — but the news service mentioned only one source: Rodong Sinmun, the North’s main Communist Party newspaper.

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India Ink: In Hyderabad, Anger and Frustration

Srinivas Mahesh, 28, was snacking outside his hostel near the Konark Theater in Dishknagar, his usual hangout in Hyderabad, when he heard a loud explosion Thursday evening. Not long after, he saw smoke filling up the air. Once he realized it was a bomb blast, instead of rushing back to his hostel he resolved to helping the injured.

“I saw disfigured bodies for the first time in my life,” he said. He helped three severely injured people into ambulances and took another injured man by auto to Osmania Hospital.

Mr. Mahesh, who is originally from Kurnool, came to Hyderabad two years ago to do a graduation in engineering from Ashok Institute in Dilsukhnagar. After yesterday’s blasts though, he might have to return home.

“My parents were visiting Hyderabad in 2007, when there were blasts. They had a tough time then,” he said. “After yesterday, they are convinced that this city is cursed and want me home.”

More than 24 hours after two bombs went off near the ever-crowded Dilsukhnagar bus stand, there is palpable frustration and anger in the area. N.Pradeep Reddy, 29, a chartered accountant who lives in Dilsukhnagar, heard the first blast and came to the balcony of his house. Then he saw the second explosion. Aghast, he couldn’t move for several seconds, he said.

Mr. Reddy’s family has been in Hyderabad for 10 years now, but now he is disillusioned with the charm of the city, he said. “No one cares for our lives here – not the politicians, not the media not the police,” he added.

Hyderabad has been the site of numerous explosions in recent years, including two in 2007 attacks that killed dozens of people.

Soon after Thursday’s blasts, the road in front of the Dilsukhnagar bus stand had a median dividing it into two. While traffic was allowed on one side, the other side of the road was cordoned off by the police.

“This is obstructing traffic and adding to the commotion,” said P. Sadanandam, who commutes through the road regularly. “They are not doing this for security, it is just so that the VIPs can visit the blast site and have a photo-op,” he said angrily.

Andhra Pradesh Director General of Police and other senior police officers visited the at blast site today to look for evidence.

All the shops on a two kilometer stretch on the Dilsukhnagar main road were shuttered down all day today. Some security men outside the shops said that this was not due to the bandh, or shutdown, that the Bharatiya Janata Party had called, but because the shop owners were sure that there would be no customers today. They might open on Monday, they said.

Narsing Vennala, 25, sells flowers on the main road. He is one of the only three flower vendors who reopened their shops today. A temple next door needs flowers, he said, and therefore he had to come to work.

His 18-year-old sister is so paranoid about his coming to work a day after the blasts that she keeps calling him every half-an-hour to check if he is alright.  Mr Vennala walks home at 11 p.m. every night, and he plans to do the same even today.

“Whatever had to happen, happened,” he said. “Now how long can we stay hungry and not earn because of that?”

“Bharat mata ki jai,” (Victory for mother India) was loudly shouted by a bunch of residents. They said that was their answer to those that were against peace in the country.  There was also some anti-Pakistan sloganeering.

One resident estimated that there were 500 to 600 educational institutions in Dilsukhnagar. They have offerings ranging from short-term computer courses to three-year degrees. Thousands of students, from smaller towns and neighboring districts, live in hostels around their respective institutions. Many of them were on the streets yesterday to help the injured.

While some students don’t see any option but to stay in the city, others, like Mr. Mahesh, are packing their bags.

“I have to go home, even if I don’t like to,” he said “My family will be worried every day I stay in Hyderabad.”

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DealBook: In Dell’s Waning Cash Flows, Signs of Concern

The proposed Dell buyout may be motivated more by fear than greed.

Dell’s founder, Michael S. Dell, and the investment firm Silver Lake are offering to take the company private in a $24.4 billion deal. One interpretation of the offer is that savvy investors, using cheap loans, see a nice opportunity to unlock the value from a company that has fallen out of favor with stock investors. The fact that large shareholders are opposed to the deal, thinking it is priced too low, supports the idea that Dell is a diamond in the rough.

But there is an opposite interpretation: The buyout is a last-ditch effort to revive the company. To some, taking Dell private is what’s necessary to implement the sort of bold measures that could prevent the steady decline of a company that has been left behind in many of its markets. And like many acts of desperation, the risks are high that going private will fail.

This viewpoint starts with Dell’s cash flows. How much actual money a company makes each quarter is always an important metric. It’s especially critical at firms that go private in leveraged buyout deals. Once private, Dell would have a lot more debt – and it would need divert more cash to service it.

Going private may allow the company to slash costs, which preserves cash. But management may also feel liberated to spend more on initiatives it feels enthusiastic about, which would use up cash initially. In a botched buyout, management’s plans fail to produce results and a dangerous cash crunch occurs.

And there are some signs that Dell’s cash flows are weakening going into the deal.

The cash flow metric that matters is called free cash flow, which takes the money generated by Dell’s operations and then subtracts what the company spends on capital expenditures. Through the end of its latest fiscal year, which ended in February, Dell’s free cash flows were $2.77 billion. That is well below the $4.85 billion reported in the prior fiscal year. And the recent cash flows may have gotten a boost from financial moves that might be hard to repeat. In the most recent quarter, Dell generated a lot of cash from taking longer to pay its suppliers.

It’s easy to paint a grim picture from these numbers. A privately held Dell might have an extra $700 million to $1 billion of extra interest a year, which could in theory take annual free cash flows below $2 billion. That provides little margin for safety if Dell’s operations run into serious trouble, even if the company does decide to dip into its large pool of overseas cash.

But there are some reasons to believe this analysis is overly pessimistic.

First, the cash flow numbers probably don’t fully factor in how much cash can be generated by Dell’s recent acquisitions. Just as a couple of items helped bolster cash flows in recent quarters, others used up a lot cash, and may not do so in the future. For instance, Dell had a $450 million cash drain in the last fiscal year just from the “deferred income taxes” line. That could be the result of a one-off action rather than a recurring trend.

With all its acquisitions contributing, optimists might contend that Dell can produce $3.5 billion of free cash flow a year. If investors paid seven times that, the company would be valued at the $24 billion, which is where it is valued today on the stock market. Other shareholders think Dell is worth a lot more than $24 billion, and has the cash flows to justify it.

But right now, Dell’s cash flows are weakening. And if they continue to wane, Mr. Dell may soon have a tough job ahead of him. He may already know that — looking at those cash flows.

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The New Old Age Blog: For Traumatized Caregivers, Therapy Helps

I recently wrote about caregivers who experienced symptoms of traumatic-like stress, and readers responded with heart-rending stories. Many described being haunted by distress long after a relative died.

Especially painful, readers said, was witnessing a loved one’s suffering and feeling helpless to do anything about it.

The therapists I spoke with said they often encountered symptoms among caregivers similar to those shown by people with post-traumatic stress — intrusive thoughts, disabling anxiety, hyper-vigilance, avoidance behaviors and more — even though research documenting this reaction is scarce. Improvement with treatment is possible, they say, although a sense of loss may never disappear completely.

I asked these professionals for stories about patients to illustrate the therapeutic process. Read them below and you’ll notice common themes. Recovery depends on unearthing the source of psychological distress and facing it directly rather than pushing it away. Learning new ways of thinking can change the tenor of caregiving, in real time or in retrospect, and help someone recover a sense of emotional balance.

Barry Jacobs, a clinical psychologist and author of “The Emotional Survival Guide for Caregivers” (Guilford Press, 2006), was careful to distinguish normal grief associated with caregiving from a traumatic-style response.

“Nightmares, lingering bereavement or the mild re-experiencing of events that doesn’t send a person into a panic every time is normal” and often resolves with time, he said.

Contrast that with one of his patients, a Greek-American woman who assisted her elderly parents daily until her father, a retired firefighter, went to the hospital for what doctors thought would be a minor procedure and died there of a heart attack in the middle of the night.

Every night afterward, at exactly 3 a.m., this patient awoke in a panic from a dream in which a phone was ringing. Unable to go back to sleep for hours, she agonized about her father dying alone at that hour.

The guilt was so overwhelming, the woman couldn’t bear to see her mother, talk with her sisters or concentrate at work or at home. Sleep deprived and troubled by anxiety, she went to see her doctor, who works in the same clinic as Dr. Jacobs and referred her to therapy.

The first thing Dr. Jacobs did was to “identify what happened to this patient as traumatic, and tell her acute anxiety was an understandable response.” Then he asked her to “grieve her father’s death” by reaching out to her siblings and her mother and openly expressing her sadness.

Dr. Jacobs also suggested that this patient set aside a time every day to think about her father — not just the end of his life, but also all the things she had loved about him and the good times they’d had together as a family.

Don’t expect your night time awakenings to go away immediately, the psychologist told his patient. Instead, plan for how you’re going to respond when these occur.

Seven months later, the patient reported her panic at a “3 or 4” level instead of a “10” (the highest possible number), Dr. Jacobs said.

“She’ll say, ‘oh, there’s the nightmare again,’ and she can now go back to sleep fairly quickly,” he continued. “Research about anxiety tells us that the more we face what we fear, the quicker we are to extinguish our fear response and the better able we are to tolerate it.”

Sara Qualls, a professor of psychology at the University of Colorado in Colorado Springs, said it’s natural for caregivers to be disgusted by some of what they have to do — toileting a loved one, for instance — and to be profoundly conflicted when they try to reconcile this feeling with a feeling of devotion. In some circumstances, traumatic-like responses can result.

Her work entails naming the emotion the caregiver is experiencing, letting the person know it’s normal, and trying to identify the trigger.

For instance, an older man may come in saying he’s failed his wife with dementia by not doing enough for her. Addressing this man’s guilt, Dr. Qualls may find that he can’t stand being exposed to urine or feces but has to help his wife go to the bathroom. Instead of facing his true feelings, he’s beating up on himself psychologically — a diversion.

Once a conflict of this kind is identified, Dr. Qualls said she can help a person deal with the trigger by using relaxation exercises and problem-solving techniques, or by arranging for someone else to do a task that he or she simply can’t tolerate.

Asked for an example, Dr. Qualls described a woman who traveled to another state to see her mother, only to find her in a profound disheveled, chaotic state. Her mother said that she didn’t want help, and her brother responded with disbelief. Soon, the woman’s blood pressure rose, and she began having nightmares.

In therapy, Dr. Qualls reassured the patient that her fear for her mother’s safety was reasonable and guided her toward practical solutions. Gradually, she was able to enlist her brother’s help and change her mother’s living situation, and her sense of isolation and helplessness dissipated.

“I think that a piece of the trauma reaction that is so devastating is the intense privacy of it,” Dr. Qualls said. “Our work helps people moderate their emotional reactivity through human contact, sharing and learning strategies to manage their responsiveness.”

Dolores Gallagher-Thompson, a professor of psychiatry at Stanford University School of Medicine in California, noted that stress can accumulate during caregiving and reach a tipping point where someone’s ability to cope is overwhelmed.

She tells of a vibrant, active woman in her 60s caring for an older husband who declined rapidly from dementia. “She’d get used to one set of losses, and then a new loss would occur,” Dr. Gallagher-Thompson said.

The tipping point came when the husband began running away from home and was picked up by the police several times. The woman dropped everything else and became vigilant, feeling as if she had to watch her husband day and night. Still, he would sneak away and became more and more difficult.

Both husband and wife had come from Jewish families caught up in the Holocaust during World War II, and the feeling of “complete and utter helplessness and hopelessness” that descended on this older woman was intolerable, Dr. Gallagher-Thompson said.

Therapy was targeted toward helping the patient articulate thoughts and feelings that weren’t immediately at the surface of her consciousness, like, for example, her terror at the prospect of abandonment. “I’d ask her ‘what are you afraid of? If you visualize your husband in a nursing home or assisted living, what do you see?’” Dr. Gallagher-Thompson said.

Then the conversation would turn to the choices the older woman had. Go and look at some long-term care places and see what you think, her psychologist suggested. You can decide how often you want to visit. “This isn’t an either-or — either you’re miserable 24/7 or you don’t love him,” she advised.

The older man went to assisted living, where he died not long afterward of pneumonia that wasn’t diagnosed right away. The wife fell into a depression, preoccupied with the thought that it was all her fault.

Another six months of therapy convinced her that she had done what she could for her husband. Today she works closely with her local Alzheimer’s Association chapter, “helping other caregivers learn how to deal with these kinds of issues in support groups,” Dr. Gallagher-Thompson said.

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