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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Major Banks Aid in Payday Loans Banned by States

Major banks have quickly become behind-the-scenes allies of Internet-based payday lenders that offer short-term loans with interest rates sometimes exceeding 500 percent.

With 15 states banning payday loans, a growing number of the lenders have set up online operations in more hospitable states or far-flung locales like Belize, Malta and the West Indies to more easily evade statewide caps on interest rates.

While the banks, which include giants like JPMorgan Chase, Bank of America and Wells Fargo, do not make the loans, they are a critical link for the lenders, enabling the lenders to withdraw payments automatically from borrowers’ bank accounts, even in states where the loans are banned entirely. In some cases, the banks allow lenders to tap checking accounts even after the customers have begged them to stop the withdrawals.

“Without the assistance of the banks in processing and sending electronic funds, these lenders simply couldn’t operate,” said Josh Zinner, co-director of the Neighborhood Economic Development Advocacy Project, which works with community groups in New York.

The banking industry says it is simply serving customers who have authorized the lenders to withdraw money from their accounts. “The industry is not in a position to monitor customer accounts to see where their payments are going,” said Virginia O’Neill, senior counsel with the American Bankers Association.

But state and federal officials are taking aim at the banks’ role at a time when authorities are increasing their efforts to clamp down on payday lending and its practice of providing quick money to borrowers who need cash.

The Federal Deposit Insurance Corporation and the Consumer Financial Protection Bureau are examining banks’ roles in the online loans, according to several people with direct knowledge of the matter. Benjamin M. Lawsky, who heads New York State’s Department of Financial Services, is investigating how banks enable the online lenders to skirt New York law and make loans to residents of the state, where interest rates are capped at 25 percent.

For the banks, it can be a lucrative partnership. At first blush, processing automatic withdrawals hardly seems like a source of profit. But many customers are already on shaky financial footing. The withdrawals often set off a cascade of fees from problems like overdrafts. Roughly 27 percent of payday loan borrowers say that the loans caused them to overdraw their accounts, according to a report released this month by the Pew Charitable Trusts. That fee income is coveted, given that financial regulations limiting fees on debit and credit cards have cost banks billions of dollars.

Some state and federal authorities say the banks’ role in enabling the lenders has frustrated government efforts to shield people from predatory loans — an issue that gained urgency after reckless mortgage lending helped precipitate the 2008 financial crisis.

Lawmakers, led by Senator Jeff Merkley, Democrat of Oregon, introduced a bill in July aimed at reining in the lenders, in part, by forcing them to abide by the laws of the state where the borrower lives, rather than where the lender is. The legislation, pending in Congress, would also allow borrowers to cancel automatic withdrawals more easily. “Technology has taken a lot of these scams online, and it’s time to crack down,” Mr. Merkley said in a statement when the bill was introduced.

While the loans are simple to obtain — some online lenders promise approval in minutes with no credit check — they are tough to get rid of. Customers who want to repay their loan in full typically must contact the online lender at least three days before the next withdrawal. Otherwise, the lender automatically renews the loans at least monthly and withdraws only the interest owed. Under federal law, customers are allowed to stop authorized withdrawals from their account. Still, some borrowers say their banks do not heed requests to stop the loans.

Ivy Brodsky, 37, thought she had figured out a way to stop six payday lenders from taking money from her account when she visited her Chase branch in Brighton Beach in Brooklyn in March to close it. But Chase kept the account open and between April and May, the six Internet lenders tried to withdraw money from Ms. Brodsky’s account 55 times, according to bank records reviewed by The New York Times. Chase charged her $1,523 in fees — a combination of 44 insufficient fund fees, extended overdraft fees and service fees.

For Subrina Baptiste, 33, an educational assistant in Brooklyn, the overdraft fees levied by Chase cannibalized her child support income. She said she applied for a $400 loan from Loanshoponline.com and a $700 loan from Advancemetoday.com in 2011. The loans, with annual interest rates of 730 percent and 584 percent respectively, skirt New York law.

Ms. Baptiste said she asked Chase to revoke the automatic withdrawals in October 2011, but was told that she had to ask the lenders instead. In one month, her bank records show, the lenders tried to take money from her account at least six times. Chase charged her $812 in fees and deducted over $600 from her child-support payments to cover them.

“I don’t understand why my own bank just wouldn’t listen to me,” Ms. Baptiste said, adding that Chase ultimately closed her account last January, three months after she asked.

A spokeswoman for Bank of America said the bank always honored requests to stop automatic withdrawals. Wells Fargo declined to comment. Kristin Lemkau, a spokeswoman for Chase, said: “We are working with the customers to resolve these cases.” Online lenders say they work to abide by state laws.

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Iraq President’s Health Is Improving, Doctor Says

KIRKUK, Iraq (Reuters) - Iraqi President Jalal Talabani is now able to talk, his doctor said, adding he was hopeful the Kurdish statesman would soon be fit to return to Iraq from Germany, where he has been receiving medical treatment for a stroke.

A peace-maker who often mediated among Iraq's Shi'ite, Sunni and Kurdish factions, 79-year-old Talabani was flown abroad in December in critical condition.

"I am in continuous contact with the German team treating President Talabani," said Najmaldin Karim, who is also governor of the city of Kirkuk.

"He can talk now with the people around him and started to think in a good way. I and the German team are optimistic that he will get much better and can return back to Iraq soon."

During Talabani's absence, Iraq's political crisis has intensified, with thousands of Sunni Muslims taking to the streets in protest against the Shi'ite-led government

The veteran politician often worked to ease tensions in the country's fragile power-sharing government and negotiated between Baghdad and the autonomous Kurdistan region, which are locked in feud over land and oil rights.

(Writing by Isabel Coles; Editing by Nick Macfie)

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Adele, 'Les Miserables' cast sing on Oscar stage

LOS ANGELES (AP) — It was an extra starry, musical day at the Dolby Theatre.

Adele took the stage first Friday, followed by the cast of "Les Miserables," singing together of the first time.

Oscar nominees Hugh Jackman and Anne Hathaway, along with co-stars Russell Crowe, Amanda Seyfried, Helena Bonham-Carter, Sasha Baron-Cohen, Eddie Redmayne, Aaron Tveit and Samantha Barks rehearsed their performances on the Oscar stage. They were backed by members of the musical's stage productions from London and Broadway.

"Les Miserables" director Tom Hooper sat in the front row of the theater as his cast sang.

Moments earlier, Adele dazzled the tiny audience of show workers with her performance of the James Bond theme "Skyfall."

"I need a lot more reverb on me," she said after her first run. "You might need to get a new reverb machine."

The 24-year-old multiple Grammy winner arrived wearing a black tunic, black leggings and flats, with no makeup and her hair in a ponytail.

"I'm going to have very high heels on the night, guys," she announced from the microphone, sipping tea between verses.

"Do you need the dresses?" she asked, and a team of stylists brought out the gowns Adele is considering for her Oscar performance.

The dress producers favored? "It's very heavy — I mean I struggle to stand in it," Adele said. "Come and feel how heavy it is, so you don't think I'm a wimp!"

She performed her Oscar-nominated song five times before leaving the theater. "It's been good, yeah?" she asked producer Neil Meron, who nodded in approval.

Just after Adele wrapped, the star-studded "Les Miserables" cast took the stage. Hathaway chatted with Bonham-Carter as Jackman sang a capella. Then Hathaway checked her microphone with a quick verse.

"Ooh, that was flat," she said.

The entire cast assembled for a final run-through when Jackman spontaneously began singing "My Bonny Lies over the Ocean."

"My bonny lies over my daddy," the ensemble responded, breaking into laughter.

Other stars rehearsing Friday included Jennifer Hudson, who is set to perform a song from "Dreamgirls" at Sunday's ceremony.

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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.

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Magistrate Grants Bail for Pistorius

Mike Hutchings/Reuters

Oscar Pistorius in court on Friday.

PRETORIA, South Africa — After four days of combative hearings, a South African magistrate on Friday granted bail for Oscar Pistorius, the double amputee track star accused of murdering his girlfriend, in a case that has horrified and fascinated the nation.

Magistrate Desmond Nair announced the decision after hearing impassioned final arguments from the defense and the prosecution in Courtroom C of the Pretoria Magistrates Court in the presence of an emotional Mr. Pistorius, who has testified that he mistook his girlfriend, Reeva Steenkamp, for an intruder and never intended to kill her.

Magistrate Nair said Mr. Pistorius did not represent a flight risk and was not likely to interfere with state witnesses.

”The accused has made a case to be released on bail,” the magistrate concluded. Pistorius family members in the packed courtroom shouted, “Yes!”

The magistrate set bail at 1 million rand, or about $112,000.

Before announcing his ruling, the magistrate reprised the four days of conflicting arguments by defense and prosecution lawyers. Mr. Pistorius’s shoulders shook with emotion and tears fell from his eyes as, at one point, Magistrate Nair said, “The deceased died in his arms.”

Magistrate Nair said bail was not a matter of guilt and innocence but about determining whether justice would be served by holding a defendant in custody.

But he took issue with the testimony and actions of the prosecution’s lead investigator, Detective Warrant Officer Hilton Botha, who has since been removed from the case, saying the officer committed “several errors and concessions” and “blundered” in gathering evidence.

“It is his evidence that may have been tarnished by cross-examination, not the state case,” he said. At the same time, the state case was not so “strong and watertight” that Mr. Pistorius “must come to the conclusion that he has to flee.”

In a two-hour summary of the case and of the laws governing bail, the magistrate also read a series of character references from friends of the athlete, who described his relationship with Ms. Steenkamp, a 29-year-old model and law school graduate, as loving and happy.

The prosecution had opposed the sprinter’s application to be released on bail until a full trial, arguing that he might flee. It said Mr. Pistorius, 26, murdered Ms. Steenkamp when he fired four shots through a locked bathroom door at his home in a gated community in Pretoria on Feb. 14 while she was on the other side.

The sprinter, who underwent double amputation as an infant after being born without fibula bones and uses prostheses, has said he believed that the person in the bathroom was an intruder.

Magistrate Nair said that while the prosecution case rested on “nothing more than circumstantial evidence,” there were “improbabilities that need to be explored” in Mr. Pistorius’s account of events.

“The only person who knows what happened there is the accused,” he said. But “I cannot find that it has been established that the accused is a flight risk.”

He cited legal requirements that the defense must establish “exceptional circumstances” to qualify for bail in cases of premeditated murder.

Premeditated murder is the most serious murder charge under South African criminal law and carries a mandatory life sentence, with parole in 25 years at the latest.

Mr. Pistorius’s lawyer, Barry Roux, said Friday that if he were prosecuting the case, the charge would be culpable homicide — a less serious charge implying either negligence or a lack of intention to kill. Prosecutors say judges decide the sentence for culpable homicide depending on the circumstances.

With his head bowed as he entered the court on Friday in advance of the ruling, Mr. Pistorius appeared to be struggling to hold back tears, his jaw clenched, as the prosecutor described Ms. Steenkamp’s plight on Feb. 14.

Lydia Polgreen reported from Pretoria, and Alan Cowell from London.

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Tyler, Perry lead Songwriters Hall of Fame class

NASHVILLE, Tenn. (AP) — The Songwriters Hall of Fame is saluting 1970s and '80s rock 'n' roll with its 2013 induction class.

Joe Perry and Steven Tyler of Aerosmith and Mick Jones and Lou Gramm of Foreigner will join the hall of fame this year along with the writers of iconic rock hits "Love Is a Battlefield" and "Heartache Tonight." The ceremony will be held June 13 in New York.

Aerosmith and Foreigner will get the attention here, but inductees Holly Knight, JD Souther and Tony Hatch also have distinguished careers that helped define the sound of rock 'n' roll.

Knight wrote anthemic hits "Love Is a Battlefield" and "Invincible" for Pat Benatar and "The Warrior" for Patty Smyth. She also wrote several songs for Tina Turner, including "The Best" and "Better Be Good to Me," that became standards for the star.

Souther, who has a role on the music-inspired television show "Nashville," had a partnership with The Eagles that spawned several hits, including "Heartache Tonight," ''Victim of Love," ''New Kid in Town" and "Best of My Love."

Hatch made his mark during the British invasion, teaming with Petula Clark on hits like "Downtown" and "My Love" that helped shaped the future of pop music.

Perry and Tyler have survived a sometimes contentious relationship to become one of rock's most successful songwriting teams over the last 40 years. The Rock and Roll Hall of Famers, staples of classic rock radio and pop culture icons, are known for hits like "Sweet Emotion," ''Dream On" and "Livin' on the Edge," and released their 15th studio album last year.

Jones and Gramm are contemporaries of Perry and Tyler who also ruled radio for a time, but they sometimes came at it from a different angle. They could lay down a straight-up rocker like "Jukebox Hero" or "Feels Like the First Time." But they also could slow it down with hits like "I Wanna Know What Love Is" and "Cold as Ice" that helped foreshadow the ballad-driven rock of the late '80s.

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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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Wall Street Edges Ahead

Stocks rose on Wall Street Friday, bolstered by better-than-expected earnings from Hewlett-Packard.

The Standard & Poor’s 500-stock index climbed 0.4 percent, the Dow Jones industrial average rose 0.3 percent, and the Nasdaq composite index added 0.4 percent.

The S.&P. 500 has dropped 1.9 percent over the last two sessions, its worst two-day drop since early November, putting the benchmark index on pace for its first weekly decline of the year. The retreat was triggered by minutes from the Federal Reserve’s January meeting, released earlier in the week, that suggested stimulus measures may end earlier than thought.

Still, the index was up more than 5 percent for the year and has held above the 1,500-point level.

“When you get a move like that, you are bound to see a pause, and the Fed minutes is a good enough reason to at least reassess,” said Michael Marrale, head of research, sales and trading at ITG in New York.

But, he added, “ultimately, we are going to see rates go higher and, ultimately, that will take money out of bonds and into equities.”

Hewlett-Packard, the maker of personal computers and printers, climbed 5.1 percent after the company’s quarterly revenue and forecasts beat analysts’ expectations as it continued to cut costs.

Abercrombie & Fitch, the clothing retailer, dipped 1 percent after it reported a drop in fourth-quarter comparable sales, even as the latest quarterly earnings topped estimates.

The insurer American International Group posted fourth-quarter results that beat analysts’ expectations. Shares advanced 4.4 percent.

Marvell Technology Group, a chip maker, rose 5.8 percent after the company gained market share in the hard-disk drive and flash-storage businesses.

The European Commission forecast on Friday that growth in the 27-nation European Union would rise only 0.3 percent this year, while growth in the 17 members that use the euro would fall 0.1 percent for a second year of recession. Stock markets in Europe were mostly ahead in afternoon trading after a sharp pullback on Thursday.

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Gen. Philip M. Breedlove Likely Candidate for Top NATO Post

BRUSSELS — Senior NATO officials said on Thursday that Gen. Philip M. Breedlove, currently the commander of American Air Force units in Europe and Africa, was emerging as the likely candidate to be nominated by President Obama to be the alliance’s supreme military commander.

An opening to serve as NATO’s next military commander surfaced this week as the previous nominee, Gen. John R. Allen of the Marine Corps, announced that he was retiring.

General Allen, who served until earlier this month as the top commander in Afghanistan, said he was retiring to focus on family health issues. He had been caught up in the scandal that led to the resignation of David H. Petraeus as the director of the Central Intelligence Agency. Last month, the Pentagon officially cleared him of any misconduct after an investigation into his exchange of e-mails with Jill Kelley, a Tampa, Fla. socialite.

General Breedlove at present holds several positions. He is the Air Force’s top officer for both the European Command and for the Africa Command.

He was commissioned into the Air Force in 1977 from the R.O.T.C. program at George Tech. According to his official biography, he has commanded a fighter squadron, an operations group and three fighter wings.

Before his current command position, General Breedlove also served as vice chief of staff of the Air Force.

Senior NATO officials described General Breedlove as the leading candidate for the top alliance military post, but spoke on condition of anonymity because it has not yet been announced by Mr. Obama.

The disclosure on the likely personnel decision came as Defense Secretary Leon E. Panetta joined other defense ministers from the alliance for a two-day session. The future of the mission in Afghanistan was on the agenda for the defense ministers' meeting, the first since Mr. Obama ordered American forces in Afghanistan to be reduced by 34,000 troops within a year.

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