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Adolescent Psychiatry

Protecting the interests of the child and of the school, The

current crisis in psychotherapy at boarding schools: Protecting the interests of the child and of the school, The

Gottlieb, Richard M

Despite considerable professional activity by therapists and consultants over the years, and despite the quite unique conditions for mental health work in this important area, surprisingly little has been written about psychotherapy in the special setting of boarding schools. Although only 6 years have passed since I first wrote about the requirements and rewards of boarding-school work (Gottlieb, 1991), a near-revolution has occurred, profoundly although silently affecting these schools, students, therapists, and families alike. These often invidious changes have for the most part followed in the choppy wake of the transition of our national health care system toward a managed-care model. Along with effecting changes in the financial organization of health and mental health, managed care has brought complementary changes in the kinds of treatments available and, perhaps most significantly, in the prevailing models of emotional illnesses on which professionals rely. Furthermore, in pursuit of reductions in mental health care costs, managed-care monitors have turned to less qualified (at times to unqualified or underqualified, and undersupervised) practitioners. Not only has quality of care suffered as a result, but the very concept of expertise itself (experience, qualification) has been undermined.

I was asked to give the keynote address for the April 1997 meeting of the Independent Schools Health Association-a national organization of independent schools, their health care givers, faculty, and administrators-on the subject, “Psychotherapy in the Boarding-School Setting: Protecting the Interests of the Child and of the School.” My response to this charge, which forms the basis of this chapter, was to question its premise. It seemed to me then, and it has continued to seem to me now, that the psychotherapeutic enterprise was under siege throughout our health care system. The boarding-school setting is no exception. It is perhaps an irony that the conditions for good, solid psychotherapeutic activity need protection every bit as much as the interests of child and school. Indeed, it is likely that the latter are vulnerable as long as the former lack protection.

For the past 23 years, I have worked with troubled students, consulted with troubled heads of schools about some very thorny issues, treated my share of faculty members and administrators, helped families not to interfere with the school’s mission for their children, and participated in admissions processes, readmissions processes, and disciplinary and dismissal proceedings. I have-with great satisfaction-attended my share of graduation exercises during which students and families with whom I had become close celebrated their having made it to the end. We have prevailed against what sometimes seemed insurmountable odds. Such deep satisfactions are among the common rewards for those of us who have chosen to work as educators and helpers with children and adolescents.

Yet, great as such satisfactions can be, it troubles me to have to add that there are new tensions abroad in the greater society that threaten our capacity to carry on this work with spontaneity and creativity. There are enormous hidden costs of complying with the letter of the law, of living in a more litigious environment, and of avoiding trouble. If one risks trouble by being affectionate with a student, if it is difficult to define the line over which one may not safely step, then one answer is to withdraw from spontaneity, creativity, and passionate involvement in the job at hand. This withdrawal, safe though it may seem, represents a sterilization of our work: Very few teachers and other school personnel have pursued their careers as a way to avoid intense engagement with others. Most love this work precisely because of its engagement with others. How many of us would really bring our lawyer along on a date in order to avoid being charged with sexual harassment? And yet, isn’t that what we are threatened with having to do in an atmosphere in which so much of our behavior seems potentially actionable?

We face a dilemma, and we need appropriate language to describe it. With constraints, intrusions, directives, and warnings impinging on our small world from the greater society, how can professionals respond without abandoning their missions or without losing track of the reasons why they have chosen this kind of work in the first place? How can educators comply with the legitimate claims of the outside world without becoming frightened into rigidity, emotional withdrawal, paralysis, indecision, apathy, or cynicism?

What Is “Protection, “; and Who Needs It?

The dictionary tells us that the verb to protect derives from a Latin word that means “to cover in front” or “to defend” (also “to cover over or from above” in the sense of providing a sheltering roof). We know from experience that psychotherapy requires protection for its effective conduct: protected space, protected time, protected communications, and protection for both participants from the immediate intrusions of the outside world and from each other. My experience has caused me deep concerns that psychotherapy in boarding schools has become increasingly difficult if not impossible and that-extreme as it may sound-if current trends continue, it is in danger of extinction.

The boarding-school setting has always presented its own special set of challenges to the therapeutic process. Our adolescent population has proved perennially difficult to engage in the “talking therapies.” The uneven schedule of the boarding-school year has always made it difficult to establish and maintain the kind of regular, reliable schedule of meetings that promotes stability in a therapeutic relationship. The special developmental issues and tasks of the adolescent period, most centrally those having to do with the movement toward adult separateness and the emergence of adult sexuality, may make us feel more like observers than persons with much influence over process or outcome.

From its beginnings, the practice of psychotherapy was a very private affair. Privacy was a condition of helpfulness. In the therapeutic situation, a client or patient could unburden himself of his deepest, closely kept, shameful, guilt-ridden, embarrassing, or humiliating concerns without fear that his secrets would ever find their way out of the consulting room. The therapeutic relationship was once understood to require absolute confidentiality in order for the patient to bring to light those concerns that troubled him most. At the same time, it was a fundamental tenet of the theories of psychopathogenesis that these private thoughts and concerns lay at or close to the heart of each person’s emotional troubles. It was understood that one’s emotional symptoms had been caused, ultimately, by disturbances in the private sphere, be they of intimate sexuality or aggression. Emotional symptoms, it was held, were reflections of disturbances in desiring or hating. Consequently, for emotional healing to take place, these disturbances had to be communicated to another person, identified, and understood in new ways. Sometimes, the simple bringing to light of long-held shameful secrets had a therapeutic effect.

Over time, we have witnessed the steady erosion of what bit of privilege has remained. From the point of view of the patient or client, it has become less possible to experience the consultation room as a “safe place.” Symmetrically, the therapy situation has become less safe for its practitioners as well.

What are the changes of which I speak?

In general, we operate in a more litigious environment than we ever have, as school personnel, physicians, therapists, helpers, teachers, and so forth. No one is unaffected by the menacing shadow of a lawsuit, and this is especially so with respect to issues of sexual abuse and sexual harassment.

In the name of cost containment, the unregulated and explosive growth of so-called managed-care health insurance has selectively promoted certain models of illness and treatment, severely narrowed treatment options, and contributed to making medical confidentiality largely a thing of the past.

Psychiatric medications-especially those that treat mood disorders-are far more effective than ever before. Paradoxically, their sometimes startling effectiveness, in combination with other factors, has contributed to the erosion of a legitimate place for the practice of psychotherapy.

Our Increasingly Litigious Environment-Sexual Harassment

We need no proof of the recently heightened tensions surrounding sexual harassment. Nonetheless, let me cite a headline over a story in the New York Times (Lewin, 1997): “New guidelines on sexual harassment tell schools when a kiss is just a peck.” According to the article, “to protect themselves from liability, many school districts have adopted tough sexual harassment policies that have made teachers nervous about any physical contact with students” (p. 8). To make matters more difficult, “the guidelines reiterate the Education Department’s position that schools can be held liable for student-to-student harassment if school officials knew about. . . [it], did not respond adequately, or failed to take adequate steps to prevent it” (p. 8). Beyond the threat of legal action by the Department of Education is a threat that worries schools far more: private lawsuits brought by parents.

SOME CONSEQUENCES OF ALLEGATIONS OF SEXUAL MISCONDUCT

A few years ago, my medical malpractice insurance carrier attached a new rider to my policy. The rider explained that, as it always had in the past, the insurance company would pay for all claims arising from my professional work and that it would pay for my legal defense up to the limits of the policy. In other words, the combined amounts of all defense costs plus all damages would be paid in full up to the overall limits of the policy, at that time in the range of several millions of dollars. However, the new rider stated that any claims involving an allegation of sexual misconduct on my part would be paid only to the amount of $25,000 and that the costs of my legal defense against such claims plus the amount of the settlement, if any, would in no event exceed $25,000. In other words, should an allegation be made against me of sexual misconduct, my insurance protection would virtually disappear. And note that all it would take to invoke this reduction of coverage was an allegation-not a finding, judgment, or settlement-of sexual misconduct.

THE REQUIREMENT TO REPORT

Hearsay Concerning Sexual Abuse. Not long ago, some young men who claimed to have been sexually victimized as younger boys by a teacher at a boarding school in my area initiated lawsuits against that teacher, the school itself, and others. One of those sued was a psychiatrist who was working for the school, being paid on a retainer basis to do evaluations and psychotherapy with students. In their suit, the young men claimed that the psychiatrist had learned during his therapeutic work with one of them about the teacher’s sexual misbehavior, and yet, they alleged, the psychiatrist had not reported the problem to the authorities. The suit against the psychiatrist has only recently been dropped. Despite the ultimately favorable outcome for this psychiatrist, for years he had to conduct his affairs with this litigation continuously festering in the background. The many years of misery and apprehension, fearful preoccupation, and damage to his reputation cannot be undone.

Suspected Danger to Another. Many readers are familiar with the decision some years ago of a California court that held that a therapist had the absolute obligation to report to authorities and to any endangered person any knowledge he may have gained in the course of therapeutic work that a person was endangered, even if that person was endangered by that therapist’s patient and even if that patient had confided his intentions to harm during the course of treatment. There are few therapists, I believe, who, if they were told in therapy that their patient intended after leaving the session to murder another, would have any hesitation in reporting what they had learned to the appropriate authority. But, what about one of our boarding-school teenage boys, riddled with thoughts of violent, sudden impulsive actions toward a fellow student, who has presented himself for treatment because he is frightened of his own thoughts? What about a young, single, depressed faculty member who comes specifically to treatment for his attraction to a female student and his inner struggle against acting on this impulse?

Suspected Physical or Violent Abuse of a Child-Or the Worry That Such Abuse is Imminent. A few years ago, following a school vacation, a young male student mentioned to me in passing during a therapy session that his mother had chased him all about their apartment before dinner one night recently with a sharply pointed kitchen knife. As he was safely back at the boarding school, I decided that I did not have to worry about his immediate safety. In my mind, however, was a great concern for his safety when the school year ended and when he was scheduled to return to live with his mother full-time for the summer. In my mind also was a New York state law that required me to report any suspected physical abuse or endangerment of a child. There were some unexpected wrinkles as well. First, this child was a strapping 17year-old. The mother was smaller, slower, and weaker than her son. Second, this was a stratum of society from which-naively and, I am afraid, blinded by unsuspected class prejudice-I had not expected to see a case of violent abuse or endangerment. Yet, after the boy’s return home for summer vacation, he again reported to me that his mother continued chasing him about their home, kitchen knife in hand. It was a danger I could no longer defer reporting, so, after informing both mother and son that I would be doing so, I contacted the Bureau of Child Protective Services (BOPS) and made my report.

The results, as far as I knew them, were twofold. First, as I had known with certainty would happen, the boy’s mother forbade the continuation of his therapy. Second, the BOPS officer kept in contact with me for months thereafter, and it was clear that with that organization’s supervision, the threat of violence in the home had abated. In this instance, the interests of the child were protected to the extent that he was removed from danger; the interests of his boarding school were likewise protected, as he returned to school that fall and was ultimately graduated. Nevertheless, his therapy would have to wait.

DEALING WITH PARENTAL DISAPPOINTMENT

Some years ago, the head of a nearby school asked me to evaluate the extent of the continuing suicide risk for a student who had very recently executed a serious attempt on his life that had put him into a deep coma for 48 hours. The head and I worked out an understanding that I would be working for the school and not for the family. In initiating my discussions with the student and his family, I stressed that I would be conducting an evaluation for the school and that, furthermore, the school-not the family-would be paying my fees. After a careful and extensive evaluation, I informed the head that, in my opinion, the risk of more suicidal behavior was significant. He decided that it would better serve the interests of both school and student to deny him readmission.

Upon learning of the decision, the family, especially the boy’s father, was furious at me. He demanded to read a copy of my evaluation; he hired another psychiatrist, who “found” that the boy was not at any continuing risk of suicide (“I’d stake my reputation on it,” the other psychiatrist told me); he threatened to sue the school for readmission; and he threatened to sue me for some unspecified form of professional malfeasance. As it turned out, both of the boy’s parents wielded considerable power in the community. As the situation deteriorated further, his father began to harass me with lengthy midnight telephone calls to my answering machine (he did not have my home number), during which, in an intoxicated state, he would threaten me with unimaginable ruin.

SOME NAVIGATIONAL AIDS: KNOWLEDGE, CLARITY

Certainly, navigation of these tricky shoals can present challenges. Yet, by what stars can we guide ourselves and our charges to a safe and secure course? To begin with, there is no substitute for a thoroughgoing familiarity with the legal, ethical, and regulatory environments that form a framework for our activities. We must know, for example, who has potential access to our records, both legitimately and by accident, and we must compose and keep those records while remaining fully mindful of their possible eventual disposition. Explicit discussions about the means with which we pursue our work, for whom we are working and to what ends, who shall pay our fees, and whose interest we serve will go a long way toward heading off troubles, as in my example of the disappointed father.

I never undertake to evaluate or treat a boarding-school child without the express consent of-or better yet, without the request-of that child’s parent(s) or guardian(s). Someone on a school’s staff will frequently call and ask me to evaluate a student, prescribe medication, or perhaps even begin therapy. My response, without fail, is to have that person ask the parents to call me. I will add, “You may want to tell the child’s parents the nature of your concerns and why you think consultation with me is advisable. You may want to tell the parents who I am and how I have worked with children from this school. But I will be able to begin to work with this student and his family only after the parents have asked me to do so.” (Emergencies, of course, must temporarily be handled differently, but situations of such extreme urgency are very rare indeed.)

AVOIDING CONFLICTS OF INTEREST

I make it clear to parents how and what I charge for my services, and I make it clear that I do not work for the school. It is a ready assumption of many parents that I do work for the school, and, in fact, many therapists who do boarding-school work are salaried by the schools at which they consult, are kept on a retainer arrangement, or operate as a kind of one-man mini-prepaid health plan, mental managedcare plan, or mental health maintenance organization (HMO).

The reason for my preference is quite simple. By working for a student and his family, I avoid conflict of interest. Much as we may wish that it were different, the interests of the child (and his family) can be quite divergent from or even directly at odds with the perceived or real interests of the school.

In my view, retainer and HMO/managed-care arrangements pose an additional set of conflicts of interest. These are the conflicts inherent in all managed-care types of arrangements: They may pit the interests of the patient against the financial interests of the therapist or doctor. The doctor who has contracted with the school to provide all of its mental health services for a prearranged fee will have diminished incentive to take on a difficult and time-consuming therapy situation with the aim of keeping the child functioning at school while he recovers. Such arrangements will tend to foster hasty suspensions and dismissals from school, actions that may be in the best financial interest of the therapist but not of the student, his family, or necessarily the school.

Some Ill Effects of So-Called Managed Care

A nationwide revolution has been in progress in our systems for the delivery of health care. In the name of cost containment, the unregulated and explosive growth of so-called managed-care health insurance has selectively promoted new models of illness and treatment, severely narrowed treatment options, and made medical confidentiality largely a thing of the past.

Although it is true that some practitioners working with boarding schools are directly affected by managed-care affiliations, for the most part medical and psychotherapeutic care provided to our students still remains outside the reach of managed-care networks. As managed-care companies increase in size, our status as outsiders to this extremely problematic system will disappear. As this happens, our efforts to protect the interests of the child and the interests of the school will have competition from a new corner-the compulsion (often contractual) to protect the interests of the insurance company, its executives, and its stockholders.

The managed-care industry has succeeded in redefining many of the key concepts and operations on which effective psychotherapy has been based in the past. To an alarming extent, even without exerting a significant and direct financial influence on us in boarding-school environments, the managed-care revolution has changed what we do.

MANAGED CARE HAS EFFECTIVELY PROMOTED ONE OF SEVERAL MODELS OF ILLNESS AND TREATMENT

For many years, there have been two major competing models for understanding the causes and directing the treatment of emotional disturbances: the so-called biological model and the psychogenic model. Much of the battle between these has been fought with depression as the paradigmatic illness and medication versus psychotherapy as the competing treatment modalities. From a scientific point of view, the struggle for dominance has been a draw, with the most definitive studies concluding that treatment approaches that combine medication and psychotherapy are more effective than either approach used alone.

Enter managed care, which effectively separates the financial interests of “providers” from the best medical interests of policyholders. Medication, by far the cheaper treatment modality, carries the day. Therapists from all disciplines will tell you that referring the managedcare policyholder for medication treatment proceeds unimpeded, but, for that policyholder to be able to have psychotherapeutic treatment, every kind of obstacle must be confronted and overcome. This begins with the need to secure the insurer’s “prior approval” for work with the patient in therapy. If approval is granted (i.e., psychotherapy is deemed “medically necessary” by the insurer), such approval is given for a few meetings only. The procedure must be repeated every few sessions; all the while, the continuity of the treatment hangs in the balance. Often, reporting a degree of improvement will render the future of the treatment bleak. Commonly, it is therapists’ fatigue that brings the effort to a close.

For those working in the boarding-school environment, there is spillover. The illness and treatment models favored by managed-care companies have taken on an authority that generates pressure for unrealistically brief diagnostic evaluations and the too hasty prescription of medication.

CARE MANAGEMENT HAS IMPLICITLY OR EXPLICITLY SEVERELY NARROWED TREATMENT OPTIONS

The narrowing of treatment options follows logically. If the most advantageous way of conceptualizing the cause of illness is as biologic, genetic, or constitutional, it seems to follow (not necessarily logically!) that psychotropic medications provide the best and most effective treatments. Certainly, they are the least expensive. Pressures can be great on the managed-care provider not to explain to the patient that there are other, if more expensive, ways to treat his illness. Although we may finally be seeing the end of the so-called gag clauses in managedcare providers’ contracts with insurers, each provider knows well that being a team player tends to maximize bonuses, minimize reimbursement “holdbacks,” encourage more referrals, and ensure his continued membership on the team.

“MANAGED CARE” HAS CONTRIBUTED TO MAKING CONFIDENTIALITY LARGELY A THING OF THE PAST

There are many threats to the assurance of the confidentiality that is the lifeblood of the therapeutic enterprise. These arise from sources with varying degrees of legitimacy. One of the most legitimate is one we have to negotiate on nearly a daily basis in boarding schools. Because our charges are minors, our schools must often act in loco parentis. To act effectively in the place of the parents, we require information. Our students, being immature of judgment, may not make their own best decisions. In the psychotherapeutic treatment of children, the exchange of information between therapist and parents is necessarily a much freer affair than it can properly be in the treatment of adults. Our teenage population confronts us with more complexity. We must sometimes make a judgment call with respect to communicating our concerns about a teenager-still immature, but much less so than younger children-to his parents or to those serving in their place.

The managed-care environment views the problem of confidentiality from an entirely different angle. The principle seems to be that he who pays the bill has the unfettered right to know what goes on! There is no question here of the impaired judgment of the immature; there is no question of clear and present dangers to self and others; there is only intrusion “justified” by a financial interest. The anonymity promised to therapists and policyholders alike is beyond the capacity of the insurers to provide, even if promised in good faith.

If there is spillover here of importance to therapy in school settings, it lies in the devaluation of privacy, the cheapening of confidentiality, and the increasing vulnerability of the private sphere to intrusion and violation-trends discernible not only in the care-management business but in our society as a whole.

Some Paradoxes of the Newer, Powerful Psychiatric Medications

We have in recent years been the beneficiaries of some nearly miraculous developments in chemistry. The genie in our pharmacologic bottle has been set loose, fetching us a bounty of highly effective psychiatric medications. Foremost among these have been the so-called SSRIs (selective serotonin re-uptake inhibitors). These medicines have been found highly effective in relieving certain depressions and ameliorating symptoms in some people suffering the ravages of obsessive-compulsive disorder. They also seem to relieve some symptoms of panic anxiety, social inhibitions or shyness, lack of assertiveness, and even delusions in some people.

It seems a Faustian bargain that among the most frequent major side effects of this class of compounds is a loss or disturbance of sexual interest and function. Patients report that they have lost their sexual desire or libido, that they have become difficult to arouse, and that their performance is adversely affected. For men, erection may become impossible or unreliable.

Most often, the loss of sexual interest and function is unwelcome, so much so at times that a patient will find these drugs intolerable. This is all well known. I want, however, to discuss the issue of the use-and I believe overprescription-of these medications in our boarding-school populations. We must bear in mind that the effectiveness of the SSRIs in teenagers can be equivocal. But the main difficulty has precisely to do with these drugs’ impact on sexual desire and functioning. In our special school population, libido occupies an absolutely central position. It would not be too much of an exaggeration to say that, for our teenagers, libido is the name of the game. What happens sexually during this developmental epoch is destined to be remembered and influential for a long time to come. It takes only a bit of imagination to begin to appreciate the developmental complications that can so easily be introduced into an already fragile situation, due to a medication that diminishes or ablates normal desire or that interferes with performance.

Against this background, it is difficult indeed to justify the casual prescription of these medications. Yet, the confluence of several factors can and do, in my experience, contribute to quick prescriptions for teenagers: their effectiveness in some situations; the now dominant model of illness and treatment; tendencies toward marginalization of the psychiatric profession to DSM-IV diagnosis and treatment with medication; and, finally, because asking a psychiatrist for a “medication evaluation” is one of the few-if not the only-remaining ways that a nonmedical therapist and colleague can request consultation, help, or supervision on a difficult case that is not going well.

Summary and Conclusions

I have turned the assignment a bit on its head. I have, I suspect, surprised you by directing your attention to the fact that psychotherapy is itself in urgent need of our protection. Only after we have ensured its increasingly imperiled place in the school community and the larger community we will be in a position to think clearly about the protection of its participants and its setting. How can we ensure that we will be able to carry on with this important work in the presence of an increasing array of threats and obstacles?

First, we must fully recognize the features of the terrain: the laws, the regulatory environment, requirements for oversight, administrative procedures, and the nature of the organizations and individuals with whom we interface. We must be prepared to be flexible and to negotiate. Second, we cannot forget that our accustomed way, though familiar and traditional, is neither infallible nor beyond the need for revision. Psychotherapy is not for everyone and not for every ill. Theories of emotional disturbance, like all theories, are subject to modification or outright discarding when they no longer fit the data.

Yet, excessive mindfulness of the intrusive elements is an encumbrance. I remind you again of the man who brought his lawyer along on a date for counsel regarding sexual harassment. If we become too frightened to touch, we are in danger of handling our charges with tongs. Students handled with tongs are as unlikely to prosper as are Harlow’s infant monkeys raised by wire surrogate mothers. There is, of course, a balance to be struck, and, in a therapist, achieving the right balance is a delicate matter of constitution, training, experience, one’s own therapy, and experiences in ongoing psychotherapy case supervision.

I have noticed over time that counselors do not regularly have access to experienced supervisors with whom to discuss their delicate and important work, and very rarely indeed is ongoing case supervision available. Yet, the nature and difficulty of the work cry out for the kind of supervision afforded psychotherapy trainees at all levels of development within graduate departments of clinical psychology, psychoanalytic institutes, medical school departments of psychiatry, and social work schools, to name but a few.

REFERENCES

Gottlieb, R. M. (1991), Boarding school consultation: Psychoanalytic perspectives. Adolescent Psychiatry, 18:180-197. Chicago: University of Chicago Press.

Lewin, T. (1997), New guidelines on sexual harassment tell schools when a kiss is just a peck. The New York Times (National Report Section), March 15, p. 8.

E. JAMES ANTHONY, M.D. is Clinical Professor of Psychiatry and Human Behavior, George Washington University Medical School; Training and Supervising Analyst, Washington (D.C.) Psychoanalytic Institute; Consultant/Adolescent Psychiatrist, Chestnut Lodge Hospital, Rockville, Maryland; and past president, American Academy of Child and Adolescent Psychiatry. AARON H. ESMAN, M.D. (editor) is Professor of Clinical Psychiatry (Emeritus), Cornell University Medical College, and Faculty, New York Psychoanalytic Institute.

GUNTER ESSER, PH.D. is Professor and Head, Department of Clinical Psychology, University of Potsdam, Germany.

RICHARD M. GOTTLIEB, M.D. is Associate Clinical Professor of Psychiatry, Albert Einstein College of Medicine and a member of the faculties of the New York Psychoanalytic Institute and the Psychoanalytic Institute of the New York University School of Medicine, New York City.

WOLFGANG IHLE is Clinical Psychologist, University of Potsdam, Germany.

STEVEN L. JAFFE, M.D. is Professor of Psychiatry, Emory University School of Medicine, Clinical Professor of Psychiatry, Morehouse University School of Medicine,

and Director of Adolescent Substance Abuse Programs, Charter Peachford Hospital, Atlanta, Georgia. JENNI JENNINGS, M.A. is Coordinator, Youth and Family Centers, Dallas (Texas) Public Schools.

PHILIP KATZ, M.D. is Professor of Psychiatry, University of Manitoba, Winnipeg, and a past president of the American Society for Adolescent Psychiatry.

STEVEN H. KATZ, PH.D. is Clinical Psychologist, Jewish Family Service, Seattle, Washington.

BARBARA LAY, PH.D. is Clinical Psychologist, Central Institute of Mental Health, Mannheim, Department of Child and Adolescent Psychiatry, Germany.

HOWARD D. LERNER, PH.D. is Clinical Assistant Professor of Psychology in Psychiatry, University of Michigan Medical School, Ann Arbor; and Faculty, Michigan Psychoanalytic Institute.

RICHARD MAROHN, M.D. (deceased) was Professor of Clinical Psychiatry, Northwestern University Medical School, Chicago, Illinois; a member of the faculty of the Chicago Institute for Psychoanalysis; and editor of Adolescent Psychiatry.

GARY W. MAUK, PH.D., NCSP is Senior Research and Evaluation Consultant, Spectrum Consulting, North Logan, Utah.

JAMES NORCROSS, M.D. is Associate Medical Director for Child and Adolescent Services, Dallas (Texas) Mental Health/ Mental Retardation Center; and Clinical Instructor

of Psychiatry, University of Texas Southwestern Medical School, Dallas.

GLEN PEARSON, M.D. is Director, Child and Adolescent Services, Dallas Mental Health/Mental Retardation Center; and Clinical Professor of Psychiatry, University of Texas Southwestern Medical School, Dallas.

ELIZABETH PERL, PH.D. is Assistant Professor, Department of Psychiatry and Behavioral Sciences, Northwestern University Medical School, Chicago, Illinois, and is the author of a forthcoming book on psychotherapy with adolescent and young adult women.

DOMEENA C. RENSHAW, M.D. is Professor of Psychiatry and Director of the Sexual Dysfunction Clinic, Loyola University of Chicago.

MARTIN SCHMIDT, M.D. is Professor and Department Head, Clinic for Child and Adolescent Psychiatry and Psychotherapy, Central Institute for Mental Health, Mannheim, Germany.

JIM SHARPNACK, M.S. is a doctoral candidate in the Department of Psychology, Utah State University, Logan.

PHYLLIS TYSON, PH.D. is Associate Clinical Professor, Department of Psychiatry, University of California, San Diego, and Training and Supervising Analyst, San Diego Psychoanalytic Institute.

ALEX WEINTROB, M.D. is Clinical Associate Professor of Psychiatry, Cornell University Medical Center, New York City, and President, American Society for Adolescent Psychiatry, 1997-1998.

Copyright Analytic Press 1999

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