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Special Report   |    
Highlights of the 2005 Institute on Psychiatric Services
Deborah Christie-Smith; Connie Gartner
Psychiatric Services 2006; doi: 10.1176/appi.ps.57.1.12
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The 2005 Institute on Psychiatric Services, held October 5-9 in San Diego, drew 1,412 participants to a varied program of more than 300 lectures, symposia, plenary sessions, workshops, and poster sessions. The American Psychiatric Association's (APA's) fall conference on clinical care and service systems has been held annually for 57 years.

The theme chosen for the 2005 Institute by APA President Stephen S. Sharfstein, M.D., was "Recovery and Community"—a theme with increasing resonance in the two years since the President's New Freedom Commission outlined steps for transforming the nation's mental health system to one that is recovery oriented and driven by the needs and preferences of consumers and their families. Dr. Sharfstein began his address at the institute's opening session with the sentence, "I am a community psychiatrist." He then used the trajectory of his own career, beginning in the late 1960s, to illustrate how the mental health field has evolved to a point at which the Commission's vision for a transformed system seems so timely and compelling to so many.

Of the 105 members of his graduating class of 1968 at the Albert Einstein College of Medicine, 24 chose psychiatry, Dr. Sharfstein noted, and most of them did so because of an intense interest in—even a romance with—psychoanalysis. However, a residency at the Massachusetts Mental Health Center led to his employment at the Brookside Park Family Life Center in a working-class Boston neighborhood, where he helped introduce the concept of "neighborhood psychiatry"—delivering a range of services and supports to chronically ill deinstitutionalized individuals in their homes and neighborhood.

It was at the Brookside Center where Dr. Sharfstein, who was later to head APA's Office of Economic Affairs, wrote his first economics paper. The paper described the case of a 52-year-old woman with four children and a history of many prolonged hospitalizations, who became his patient. He decided to do everything possible to interrupt her pattern of relapse and readmission by personally providing in-home services and round-the-clock crisis intervention and enlisting her family, neighbors, and clinicians at local emergency departments to contact the neighborhood center immediately when she showed signs of decompensation. After several episodes of this kind of response and support, the patient understood that she was not going to return to an inpatient setting and settled down to outpatient care. In the economics paper that he wrote three years after accepting this patient, Dr. Sharfstein showed that although the costs in the first year of community-based care were as high as the cost of a continuous hospital stay for one year, the community costs decreased dramatically in the second and third year as the patient entered recovery and resumed her life as a mother and homemaker.

Dr. Sharfstein noted that his experience with this patient taught him more than he learned in the economics course that he later took at Harvard Business School. In addition to learning about costs of care, Dr. Sharfstein also learned about the importance of continuity of care. He realized that the patient's recovery depended upon having a single trusted physician as well as the steadfast support of the Brookside Center, which brought together the range of services that the patient needed to contribute to her community.

In the mid- and late 1970s Dr. Sharfstein learned more lessons when he worked at the National Institute of Mental Health (NIMH), becoming director of the Mental Health Services Division at the age of 35. At NIMH he helped with the renewal of the Community Mental Health Centers Act of 1976, worked to initiate the Community Support Program (CSP), and became very involved in the efforts of the Carter Mental Health Commission—drafting and lobbying for the Mental Health Systems Act of 1980.

During his tenure as a government employee, Dr. Sharfstein wanted "to see people up close," so he moonlighted at a neighborhood mental health center in Bethesda, where he had a caseload of 12 patients with severe mental illness. Dr. Sharfstein found that "being a real psychiatrist in the real world enhanced my credibility within the bureaucracy." It was not uncommon for him to be called out of meetings to attend to distraught and agitated patients whose illnesses were challenging their efforts at recovery.

In 1986 Dr. Sharfstein moved to Sheppard Pratt in Maryland, the only private hospital in the country at that time that sponsored a community mental health center. When he became the organization's fifth president in 1992, he drew upon the many lessons he had learned and began a process of transforming this esteemed, long-stay, psychoanalytically oriented private hospital into a private-public community health center with the entire state of Maryland as its catchment area. Today Sheppard Pratt Health Systems is the largest provider of psychiatric care in the state of Maryland. Dr. Sharfstein noted that the all-important lesson about providing continuity of care is a special challenge in the large system that he oversees.

Dr. Sharfstein ended his address with praise for the work of the President's New Freedom Commission and for the leadership of Charles Curie, administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), and Anita Everett, M.D., senior medical advisor at SAMHSA, whose efforts are keeping the theme of "Recovery and Community" in the public eye.

Francine Cournos, M.D., professor of clinical psychiatry at Columbia University in New York City and director of the New York State Psychiatric Institute, gave a lecture titled "Community Psychiatry: Is It Time to Go Global?" Dr. Cournos opened by expressing her personal goal to have "a nonacademic impact on mental health in the world." She asked, "How can we be more global in advocating for community psychiatry?"

According to a 1990 report by the World Health Organization, the leading cause of disability worldwide is unipolar depression, Dr. Cournos noted. In fact, of the top ten causes of disability, five are related to mental health, including alcohol abuse (fourth), bipolar disorder (sixth), schizophrenia (ninth), and obsessive-compulsive disorder (tenth). These illnesses are major sources of disability in both developed and developing countries. Dr. Cournos conceded that integrating mental health care into general medical care in developing countries is difficult. There are too few psychiatrists, and resources are limited. She noted that the situation in developing countries bears a resemblance to that in the United States before the community psychiatry movement got off the ground, and asked, "How can we bring the world model closer to a community psychiatry model?"

Dr. Cournos sees U.S. psychiatrists as representing an untapped resource in this regard. They are an international group—many having been born and educated in foreign countries—who retain ties to their countries of origin. Also, English has become the universal language of medicine. Many psychiatrists overseas read U.S.-based medical journals, especially Psychiatric Services, because books are prohibitively expensive. U.S. publications are having a substantial impact on psychiatry worldwide, Dr. Cournos noted. "How can we harness this?" she asked.

Dr. Cournos encourages U.S. psychiatrists to advocate for a change in attitude: "We need to be more conscious of this field and how to advocate for it." She cited the HIV model as an example of what is possible. HIV is a cause that has always had advocacy attached to it. Well-placed gay men, including actors, have effectively advocated for HIV awareness, research, and treatment. "If any issue is going to get mental health included in health care, it's HIV," Dr. Cournos said. The HIV epidemic is relevant to the mental health care field in several ways, she noted: HIV infection invades the brain at initial infection and has a profound impact on it. And mental illness and its management figure prominently at all stages of HIV infection. A person can get a psychiatric disorder at any stage of HIV infection, and psychiatric disorders can affect risk behaviors. "You can spread HIV because of your bad mental health," she said. Injection drug use is a primary driving force for HIV infection in both developed and developing countries. In addition, mental health issues affect adherence to medication regimens—and people who have HIV cannot afford to skip a dose of their HIV medication.

Dr. Cournos noted that another inroad is disaster psychiatry, especially in light of the recent reminders that disasters are happening constantly. The field of psychiatry is starting to think about outreach efforts on the part of mental health professionals in response to such events. It is unfortunate that the U.S. government has thus far not funded such efforts except through the research track, which, noted Dr. Cournos, does not allow for sufficiently focused projects—it facilitates activities at only the broadest level. For example, a project may be started without sufficient planning or funding for ongoing training of local professionals to continue the project. "When you think about what we're funded to do and what's really needed, they're far apart," Cournos lamented.

On the positive side, "a little goes a long way," she said. U.S. psychiatrists can make global community psychiatry a reality by establishing international collaborations with other psychiatrists and working with health care personnel in other countries who do not have specialty mental health training. She pointed out the satisfaction in giving one's own time and money to helping a clinic or hospital in whatever small way—while on vacation, or while traveling on business. Simply taking unused, older medications from their U.S. practices and giving these to health care workers overseas, or spending a small amount of time training them in techniques such as proper syringe use, can have an impact that far exceeds the personal cost to the psychiatrist. And the experience can be incredibly rewarding.

At a symposium titled "Recovery System Transformation in California," several long-time mental health advocates described the successful campaign for Proposition 63 and subsequent developments. In November 2004 Californians voted to impose a 1 percent tax beginning January 1, 2005, on personal income above $1 million to expand county mental health services. Current annual revenue from this tax is $600 million, about 15 percent of the mental health budget—a figure that is expected to grow to 50 percent within ten years, because, as one of the advocates noted, "Millionaires tend to make more money." In 2005 no new services were set up with Proposition 63 funds. Instead, the 58 counties in the state engaged in what one presenter called "the largest mental health planning process ever undertaken."

Each of the symposium's presenters emphasized that the legislation envisages a transformed system based on "recovery, resilience, and wellness"—a system that will reflect lessons learned in California over the past 20 years. Richard S. Van Horn, president and chief executive officer of the National Mental Health Association (MHA) of Greater Los Angeles, described some of the painstaking political strategizing that led to the passage of Proposition 63. First, he noted that California advocates have a history of persuading politicians to vote for legislation to fund innovative services, as well as a history of demonstrating that such services can be highly effective—first in 1988 with the groundbreaking MHA Village program and again in 1998 with Assembly Bill 2034 (AB 2034), which greatly reduced California's homeless population. However, Mr. Van Horn noted, advocates also learned that the level of funding for services never increases and that "a cash infusion" would be necessary for system transformation.

A critical piece of the Proposition 63 initiative process was to enlist support of the mental health system's natural allies—education, law enforcement, labor, and hospitals. After the legislation was drafted by these stakeholders, advocates hired at great cost—about $1 million over the course of the campaign—a consultant group with a solid history of getting propositions passed. The consultants' initial advice seemed counterintuitive, Mr. Van Horn noted: "Run a stealth campaign—no press, no interviews." Advocates were to continue organizing and raising money but were not to speak with the press, because, as the consultant explained, "the press will have to give your enemies equal time—that's what the press does." The consultants also helped the campaign to "track the opposition," to poll heavily in the final week, and to target television ads on the basis of the polls. Proposition 63 passed by an 8 percent margin—54 to 46 percent.

Another symposium presenter, Mark Ragins, M.D., medical director of MHA Village Integrated Services in Long Beach, described trainings being conducted around the state to introduce agency staff to the "recovery culture." He emphasized the importance of "having everyone at the first meeting," including consumers and families and all clinical and administrative staff—human resources personnel, accountants, and quality improvement auditors. The training is designed to help staff move from caretaking and advice giving to collaboration and helping people find the ways and means to grow, Dr. Ragins said.

In the first small-group exercise, training participants are asked "to tell the story of how your heart got you into the mental health field." Dr. Ragins emphasized that transformation depends on tapping into the energy and passion that is often dampened by a focus on "diagnosis and distancing" and that many staff have become ashamed of, regarding such passion as unprofessional. Early discussions in the training sessions inevitably revolve around boundaries and ethics issues. "We are taught that we can't hug, we can't share bathrooms, we can't self-disclose," Dr. Ragins observed. When a recovery culture and a "matrix of emotional support" from colleagues permit staff to have an emotional connection to their work and to bring to it all their life energy, many of the learned boundaries are lowered, he noted.

Other issues for many trainees involve a fear of being overwhelmed by the painful problems of patients or memories of being hurt by patients in the past. Dr. Ragins noted that working in a recovery culture has taught him that staff burnout comes from blocking fears and other emotions and that encouraging staff to talk about these experiences helps to avoid their often paralyzing consequences. (A 42-page "toolbox" for implementing a recovery culture is available at www.mhala.org.)

The final presenter, David A. Pilon, Ph.D., director of outcomes and research at the National MHA of Greater Los Angeles, described efforts to develop measures for recovery. All California consumers who are served under the new legislation will be tracked on outcomes, in particular objective quality-of-life outcomes, such as residential status, employment, education, incarceration, and hospitalization. Although these measures are similar to those that Dr. Pilon helped develop in 1999 for AB 2034, he noted that the measure that would now top his list of key outcomes was listed only sixth among the AB 2034 outcomes: "Self-management of your life and exerting as much control as possible over both the day-to-day and long-term decisions that affect your life. Everything flows from that," he said.

Dr. Pilon and other researchers are currently conducting validity and reliability studies of the Stages of Recovery Scale, with detailed anchor points to help staff assess whether they are helping consumers work toward recovery goals. He noted the difficulty of measuring a recovery culture. "However," he said, "it is our belief that variation in outcomes are more attributable to the larger recovery culture in which evidence-based practices take place than the evidence-based practices themselves."

Marc Galanter, M.D., professor of psychiatry at New York University (NYU) in New York City, founding director of the division of alcoholism and drug abuse at NYU and Bellevue Hospital, and director of the NYU fellowship training program in addiction psychiatry, gave a presentation on healing through social and spiritual affiliation. He began by pointing out the increasing popularity of spirituality—surveys have indicated that some 95 percent of people believe in some "higher power." However, mental health professionals tend to lose sight of how pervasive spirituality is—how important it is to their clients. He defined spirituality as something broader than religion per se. Spirituality is "anything beyond the material that has meaning to people and helps them and motivates them in their lives."

The growing public interest in spirituality has had an impact on what government agencies look to in managing psychiatric problems, Dr. Galanter said. There has been more of a focus on complementary and alternative medicine. And the mental health field is starting to look at spirituality in terms of its contribution to motivation and resilience. Dr. Galanter noted several aspects of spirituality that have important implications for psychiatry. He noted recent findings on brain plasticity and the fact that humans are not just rational beings; there are irrational processes that have a biological basis. In addition, social influences encourage people to engage with these spiritual ideas.

He cited some interesting study results. It now appears that different parts of the brain can be activated or stimulated to produce out-of-body experiences. Self-transcendence and spiritual acceptance have been shown to be associated with serotonin levels. And the placebo response may be more important than the field of medicine has given credence to. In fact, it is possible that even the effect of treatment itself is a type of placebo effect—treatment seems to be more effective among people who have come to believe that it works.

Dr. Galanter raised the question of whether psychiatry has lost something by focusing more on pathology and less on spirituality. He gave the example of Alcoholics Anonymous (AA)—not a "religion" as such, but an organization that ascribes a value somewhat akin to religion—as a means of managing addiction. AA addresses the fact that addiction is a lifelong struggle for which no long-term treatment exists. It offers treatment in the form of support over the long term and has a higher success rate than conventional treatment. In the mental health field, if a patient relapses after substance abuse treatment stops, that treatment is said to have failed.

Unfortunately, there is not an AA equivalent for people with psychiatric illnesses that are not substance related, Dr. Galanter noted. There is no ideology that transcends the business of obtaining housing and adhering to medication regimens. One movement that comes close is Recovery, Inc., which provides support to persons with mental illness outside the domain of psychiatry.

Dr. Galanter is concerned that psychiatry may be "selling something to patients that they're not necessarily interested in buying …. That will have to change if we are going to be effective."

In a very well-attended lecture, Nancy Boyd-Franklin, Ph.D., discussed the treatment of African-American clients and their families. Dr. Boyd-Franklin, a psychologist, is a professor in the Graduate School of Applied and Professional Psychology at Rutgers University in Piscataway, New Jersey. She is the author or coauthor of five books, including Boys Into Men: Raising Our African-American Teenage Sons and Black Families in Therapy: Understanding the African-American Experience (her most recent).

Dr. Boyd-Franklin opened by noting that Hurricane Katrina has highlighted how many people are under the radar in terms of receiving appropriate services. She said she wanted to talk about the commitment that many psychiatrists have to working directly with members of racial and ethnic minority groups as well as other disadvantaged groups. She also pointed out that in addressing racial issues it is important not to "replace one cartload of stereotypes with another cartload of stereotypes": racial issues are a camera lens through which patients are viewed, and that lens needs to be adjusted for every individual patient. It is important to remember that there are enormous cultural differences within the black community itself.

Dr. Boyd-Franklin continues to be dismayed by how peripheral cultural studies are in training students—there is an "absolute deficit" in the training of residents in the mental health care field. African-American clients are being treated under the assumption that they want treatment, rather than under the assumption that they don't—an approach that puts both the clinician and the client at a distinct disadvantage. Many clients enter treatment with a "healthy cultural suspicion" of the process that persists irrespective of their cultural or socioeconomic background. She noted that in her lecture the most important question she wanted to address was, How do we connect across that racial divide?

The impact of racism on service delivery to African-American clients includes systematic misdiagnosis, mistreatment, and misrepresentation of African Americans. Until recently, there was no mention of "family" in the treatment of African Americans and other minority groups—all of whom come with an extended-family view of the world. The family is the buffer against the racism in the world and is incredibly important to African-American clients.

Dr. Boyd-Franklin noted that African-American families have strengths that can be advantageous in their treatment. Many African Americans view the psyche and the spirit as a unified entity—it is only in Western culture that these are viewed as two separate things. In many African-American communities, psychiatric work is considered to be antispiritual. If this belief is not incorporated into training, new psychiatrists will be set up to fail in African-American communities.

Another important point Dr. Boyd-Franklin raised was that when a client receives a misdiagnosis, that misdiagnosis stays with the person for life. She showed the audience a video of an African-American woman who appeared to be perfectly rational, as well as a very good mother to her learning-impaired child, but who had been given a misdiagnosis and had had her two children taken away from her. It was not until the well-known psychiatrist Sal Minuchin intervened that she was able to convince the courts that she was a fit mother. The case illustrated that an M.D. has enormous power over a client's future—power to help as well as power to hinder. Dr. Boyd-Franklin concluded her lecture by leaving the audience with the following questions to ponder: What does it take for a client to be able to advocate successfully on his or her own behalf? What do you have to do to go beyond advocacy to empowerment?

In a symposium titled "Evolving Perspectives of Cognitive-Based Psychotherapies for Schizophrenia," several presenters shared new evidence of the effectiveness of cognitive-behavioral therapy (CBT) in the treatment of schizophrenia. Tania Lecomte, Ph.D., of the University of British Columbia, reported encouraging results from the first phase of a study that examined whether CBT helped young people who were struggling with residual positive symptoms after a first episode of psychosis. She and her colleagues have developed a manual for CBT-based group therapy for this population; the groups are conducted by caseworkers after two to four days of simplified CBT training.

Group participants learn about the stress-vulnerability model of illness in the first four sessions. The ABC model (Antecedent, Belief, Consequences) is used to teach a basic tenet of CBT—that thoughts and beliefs have an impact on emotions. Participants watch clips from movies, such as American Beauty, to learn how perceptual errors can lead to false beliefs, which in turn can result in distress and dysfunctional actions. Participants learn how to call into question an upsetting thought or belief and seek another interpretation. They use these skills to diminish their stress, improve their ability to cope with difficult situations, and maintain a positive perspective.

The researchers randomly assigned 105 participants, whose mean age was 23 years, to the three-month CBT group intervention or a skills-training group for symptom management. After three months, positive symptoms improved for both groups, but the improvement was significantly greater for the CBT group. Self-esteem improved only for the CBT group. The researchers attributed this finding to the strong focus in the manual on self-esteem, which is highly linked to problem behaviors among adolescents.

Louanne Davis, Psy.D., a researcher at the Roudebush Veterans Affairs (VA) Medical Center in Indianapolis, described the VA Indianapolis Vocational Intervention Program, in which CBT is used to improve work outcomes, such as job tenure and performance. The program designers thought that CBT would be particularly helpful in addressing expectations of self-failure in the workplace and other unrealistic expectations about work—whether good or bad—that can lead persons with schizophrenia to give up or to have conflicts with coworkers. In the first year of the three-year feasibility study, the researchers developed a treatment manual that adapts CBT principles to vocational issues.

The intervention is designed to help participants answer the question, How does your thinking interfere with your working? The "4 A's" model is used to teach participants to combat thinking errors: be Aware of the thought; Answer an inaccurate thought with an alternative perception; Act on the basis of a more accurate thought; and Accept that you can't change some things in your environment and that you will make mistakes. The group is held weekly for six months.

The VA researchers then tested the intervention by randomly assigning 50 individuals either to the CBT (individual and group) intervention or a standard work support group. Over two years the CBT participants spent significantly more weeks on the job and performed significantly better in the workplace. Measures of hope and self-esteem were sustained over time only for the CBT participants.

Another presenter, Paul Lysaker, Ph.D., also of the Roudebush VA Medical Center, who uses CBT in long-term individual therapy with persons with schizophrenia, presented evidence from qualitative research showing that CBT improves metacognition—the ability to think about thinking—among such patients. He pointed out that schizophrenia causes profound deficits in the ability to focus on one's internal experience, to share that experience with others, and to be aware of oneself as "an agent interacting with others." It may be difficult for someone with the illness to change maladaptive beliefs—which often go hand-in-hand with low self-esteem—if the person cannot focus on his or her own thinking. CBT is uniquely useful for addressing these primary deficits, Dr. Lysaker said.

In his latest research Dr. Lysaker used an open-ended, conversational 30- to 60-minute interview to ask his CBT patients to tell their life story at baseline and then five months later. He examined the interview transcripts for evidence of metacognition and found that the self-narratives at follow-up had changed—the changes were small, but patients were more aware of their own thoughts and better able to reappraise situations and to understand the minds of others.

People who do not have schizophrenia take metacognition for granted, Dr. Lysaker noted. Their ability to think about thinking is how they define their being in the world, place themselves in a context, in an ongoing self-narrative. For persons who have marked deficits in meta-cognition, individual CBT can be a painful process, as the patient and the therapist search for a sometimes elusive inner self.

The first of three speakers in a symposium titled "Dangerous Ones: Assessing and Treating Psychopaths, Pedophiles, and Firesetters," all from the University of Massachusetts Medical School in Worcester, was Fabian M. Saleh, M.D. Dr. Saleh discussed diagnostic and treatment considerations for pedophilia. He started by noting some frequently asked questions about pedophilia: Are all child molesters pedophiles? Can they be treated? Do they offend because they themselves have a history of sexual abuse? In fact, Dr. Saleh said, pedophiles constitute a heterogeneous group. The only common denominator is that they have broken some law related to sexual behavior—the term "sex offender" is usually reserved for those who have committed a crime. Only a subgroup of sex offenders are pedophiles.

A person can be given a diagnosis of pedophilia on the basis of a police report, even if the person doesn't acknowledge having engaged in the offending behavior, which is often the case. Assessment involves examination of forensic, neurologic, medical, and psychiatric risk factors. The recidivism rate is substantial, which makes ongoing risk assessments important. Not all patients need pharmacologic treatment, but for those who do, it is important to ensure that the patient is healthy enough to withstand the treatment.

The ultimate goal of any treatment is that the individual does not offend again. However, treatment also aims to improve the patient's quality of life. Options include cognitive-behavioral therapy, relapse prevention therapy, testosterone-reducing medications, and orchiectomy. Studies show dramatic reductions in recidivism following orchiectomy. Dr. Saleh noted that he was not in any way advocating this procedure. However, such data can be a useful counter to opposition to pharmacologic treatment, he said.

The next speaker was Gina Vincent, Ph.D., who discussed assessment and risk of violence of individuals with psychopathic personality disorder. She began by pointing out that this disorder has not been recognized as a psychiatric disorder by psychiatrists or by the general public. Little is known about treatment. A common myth is that these individuals are not distressed by the condition, but that is not true. They can be depressed, and some commit suicide—they just don't make their distress known.

The definition of psychopathy used in the Psychopathy Checklist-Revised (PCL-R) includes three symptom clusters: an impulsive behavior style (a need for many stimuli), deficient affective experience (lack of empathy or capacity for remorse), and an arrogant interpersonal style, including manipulative behavior and pathological lying. There is potential for misdiagnosis of psychopathy as bipolar disorder, and vice versa. Psychopathy is highly correlated with substance abuse. People with psychopathic personality disorder have a hostile attributional style: Thinking that everyone else acts the same way they do, they tend to be paranoid. This paranoia, combined with their impulsivity and incapacity for remorse, puts these individuals at a high risk of committing crimes. They are five to ten times as likely to reoffend violently compared with other criminals. But it is counterproductive to isolate a psychopath; "they need someone to be better than," said Dr. Vincent—other people are their reason for living.

Because of a lack of funding, the disorder has been poorly researched, Dr. Vincent noted. A major problem in developing effective treatments is that "we have been trying to treat psychopaths despite their psychopathy—we need to design and use treatment specifically for them."

Finally, Jeffrey L. Geller, M.D., M.P.H., addressed "The Burning Issue of Pathological Firesetting." He noted that it is difficult to categorize fire setters according to their motivations—most people who are asked why they set a fire will reply, "I don't know." It is important to distinguish between arson and accidental fires, Dr. Geller noted. Examples of pathological reasons for fire setting are hero or recognition fires—for example, a fire set by a volunteer fireman—and fires set in the context of a delusion or hallucination. Alcohol is frequently a covariant that acts as a disinhibitor. "Pyromania"—a monomania—accounts for only a very small proportion of fire setting; the concept of pyromania is an old-fashioned one.

A problem with managing fire setting is that these individuals "think about it 24-7, so we can't compete with them," Dr. Geller said. And most of the time clinicians don't know they're dealing with a person with a history of fire setting, so it is difficult to treat fire setters. Also, fire setting is very contagious among psychiatric patients. There is no difference between fire setters and control patients in terms of the likelihood of setting a fire in the future.

Dr. Geller proposed that most deliberate fire setting—apart from that related to financial gain, such as a desire to collect insurance money—could be described as "communicative arson …. People set fires when no-one pays attention to the real deficits." The person sets a fire to communicate a wish or a need that he or she is not capable of communicating through other means, most likely because of a lack of verbal or social skills. There is a high likelihood that the person's desired outcome—a fire—will be achieved, which in turn increases the likelihood that another fire will be set. "Fire is easy," Dr. Geller said.

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