The "Maudsley Approach" To Anorexia

A conference of "Maudsley parents" meets in San Diego this week. They are involved in a new eating disorder treatment aimed at helping their anorexic children. The Maudsley Approach uses intense monitoring and family support to get adolescents to eat normal meals again.

Guests:

Jennifer Lombardi, Director of Admissions and Therapist at Summit Eating Disorders and Outreach Program in Sacramento

Dr. Walter Kaye, Professor, UCSD Department of Psychiatry - Director, Eating Disorders Program

Read Transcript

MAUREEN CAVANAUGH: I'm Maureen Cavanaugh, you're listening to These Days on KPBS. The eating disorder anorexia nervosa has been an insidiously difficult disease to treat, as teenagers get caught up in a cycle of starving and weight loss, are the disorder seems to get stronger and harder to turn around. Many anorexics have gone in and out of treatment programs without achieving a long-term solution. This week in San Diego, a group of academics, counselors and patients involved in a new treatments for [CHECK AUDIO] the Maudsley approach, it's been around for several years, but it's still in the process of taking hold as a significantly successful treatment for anorexia. I'd like to welcome my guests, doctor Walter Kay is professor with UCSD's department of psychiatry. He's director of the eating disorders programs, and doctor Kay, welcome to These Days.

KAY: Well, thank you.

MAUREEN CAVANAUGH: And Jennifer Lombardi is director of admissions and therapist at summit eating disorders other an out reach program in Sacramento. Jennifer, good morning.

LOMBARDI: Thanks so much for having me.

MAUREEN CAVANAUGH: Now, we invite our listeners to join this conversation. Have you or members of your family gotten treatment for anorexia? Did it work in how could that treatment have been better? Give us a call with your questions and your comments. Our number is 1-888-895-5727. That's 1-888-895-KPBS. Doctor Kay, I'm going to ask to you start out by giving us some basics on anorexia. How does the disease present itself?

KAY: This is a disorder that pretty typically happens in young women, usually in their teenage years, and they begin a relentless cycle of starting to starve themselves, and seeing themselves as too fat, wanting to be thinner. And one of the devastating parts of this disorder is people often don't see themselves as having a problem. They deny that they're losing weight. They don't see themselves as too thin, and it sets up a lot of conflicts and difficulties for the family of it's been a disorder that has been very difficult to treat. It's got a high death rate, five percent of people or more with [CHECK AUDIO] so that we've been searching for more effective ways to treat it.

MAUREEN CAVANAUGH: Now, what kinds of behaviors mark the start of anorexia? Do kids just stop eating or are -- is there a whole network of things?

KAY: It's actually a bit more complicated than that. Lots of people in this country diet and want to lose weight. Relatively few people, maybe about a percent of women, end up with anorexia. One of the things that we found over the last decade or so is that most often people have certain personality and temperament traits in childhood before they develop an eating disorder that tend to be compliant, perfectionistic kids, high achievers, get good grades in school, can be a bit anxious and [CHECK AUDIO] and create a vulnerability for developing this order. If you don't have those traits issue it's much less likely you're going to develop anorexia nervosa, and then something happens that we don't really understand very well. As people get into teenaged years they develop these symptoms of seeing themselves as being too if the and wanting to restrict to an extreme degree.

MAUREEN CAVANAUGH: And you said it's mostly -- starts in the teenaged years and mostly women. How high is that percentage of women patients?

KAY: It's roughly about 95 percent.

MAUREEN CAVANAUGH: I see. Jennifer, how severe is this disorder anorexia typically before a patient or a family seeks clinical treatment?

LOMBARDI: Well, you know, it's interesting, and I've been doing admissions work for about ten years now, and in that time, I can honestly say that I am assessing both -- primarily girls but also young boys at younger and younger ages. The youngest client I've ever assessed is seven. And there are actually treatment centers across the country that treat children as young as five years old [CHECK AUDIO] earlier and earlier age. And certainly, you know, I think -- I had this question the other day. One of the things that noticed, somebody asked me, what's the impact of our economic state on these illnesses, and typically what I'm seeing is because of the stress financially in our country right now, people are waiting longer to get into treatment, either because of the cost associated or another component of this illness is a tremendous amount of guilt and shame. And so typically I'm seeing patients that are waiting for a very well time before they actually seek treatment. And so when they come in, their quite ill both from at a behavioral standpoint as well as a medical standpoint.

MAUREEN CAVANAUGH: I want to remind our listeners that they are invited to join the conversation at 1-888-895-5727. That's 1-888-895-KPBS. Doctor Kay, how is it possible for people to turn off their natural appetite to such an extent? Most people have trouble staying on a modern diet plan. Do we know how that mechanism works.

KAY: Actually, we're learning quite I bit about it. And one of the things that's quite important to recognize, as we morn more about how the brain works, we're beginning to understand that anorexia is in a large part a very severe biologic disorder that's driven by biologic processes in the brain, and one of these powerful processes are that the centers in the brain that make food rewarding and make us hungry don't seem to be working as well in people with anorexia. Of they just don't get hungry in the same way that you or I would, if we starved ourselves eating $500 a day for a year. And also there are other centers in the brain that are very powerful for inhibition and behavior, and it may be that these centers are over active in people with anorexia. Of so in a way, they have too much gas peddle, too little brake [CHECK AUDIO].

MAUREEN CAVANAUGH: So -- okay, so that's the research in what's going on in the brain of someone suffering from anorexia, what's going on, doctor Kay, what are the physical consequences of anorexia? You said that it is one of the behavioral disorders that leads most often to death; is that right?

KAY: Well, when people starve themselves, you eat 500 calories a day, your body compensates by shutting down all kinds of metabolic processes. So anorexia has the effect that virtually every organs in the body -- the bones never develop to be as strong as they should, because the body steals the proteins from the body to stay alive, the brain shrinks, almost every system in the body is involved.

CAVANAUGH: And so what have been the tradition treatments, I'm gonna ask you both, starting with you, doctor, Kay, used to treat anorexia?

KAY: Well, are the most typical treatment has been forcing people to eat and gain weight. Of and that's very important because it can be life saving. The problem that we have had is that we've done that by putting people in the hospital and in residential programs, and that can be very valuable and very important. The problem that we have had is that there's been a high degree of relapse. You get somebody up it a high body weight -- a normal body weight, then they go home and they relapse, and they're back in for another cycle of treatment.

MAUREEN CAVANAUGH: And Jennifer, we have heard what doctor Kay has said that anorexia patients often go in and out of treatment facilities sometimes for years. What is your take on why this disease has been so difficult to treat in a clinical setting?

LOMBARDI: Well, I think from a parent perspective, if we were having this conversation 10, 15 years ago within our treatment community, we would have said that the reason why this young woman is struggling, [CHECK AUDIO] you know, she has a controlling mother. And we really started to vilify families for quite some time and tried to exclude them from treatment. And so I think there should a piece of the treatment approach historically that has been in keeping with that. And what's changed now, specifically with this new treatment approach called Maudsley, that's sort of coming on line in the United States, is it takes a completely different perspective on the family's involvement. It actually says that the family is primary in helping this son or daughter recover. So I think what we've seen in the last few years is a shift of involving families more and more with the [CHECK AUDIO] you involve that family in reseating this person.

MAUREEN CAVANAUGH: And that, of course, the modally parents' service is gonna take place this Thursday in San Diego -- I'm sorry? Friday. I forgot the day. Friday, and it's going to have -- it's going to be a combination of academics and counselors and Maudsley parents meeting here to discuss this treatment approach. Doctor Kay, tell us about the Maudsley approach.

KAY: Yes, I agree with Jennifer. What we've done, what the shift is, instead of making parents kind of the bad guys and to blame, we actually want to make parents the allies. And we say to them very simply, really, you're not to blame. You haven't caused this. There's a powerful biology that's at play here, and we're going to work with you and help you understand how to interact and even manage your child with anorexia at home so that they don't go through these cycles of relapse.

MAUREEN CAVANAUGH: I mean, who came up with this?

KAY: It was developed at the Maudsley hospital in London several decades ago and has been studied in various kinds of studies over the last 20 years and been shown in each of these studies that it's superior from other forms of treatment. So it's got the name Maudsley because of where it was developed. It's also called family based treatment in this country too. So it's kind of got two names.

MAUREEN CAVANAUGH: So how much more successful is this approach?

KAY: Well, that's very important because it's not a cure, and it's not a miracle. It's actually a very difficult therapy for patients and parents to engage in because it really forces kids with anorexia to do stuff, up, eat and do things that they don't want to do. But it can be successful, but it doesn't work with everybody. So the success rate is somewhere probably between about 50 to 70 percent. Somewhere in that ballpark. So we still have a group of families and people with anorexia that don't respond as well as we'd like to with this treatment. [CHECK AUDIO] other forms of treatment in terms of just getting people up to healthy body weight and discharging them from a hospital.

MAUREEN CAVANAUGH: So this has a 50 to 70 percent success ratio. What do other treatment methods have?

KAY: [CHECK AUDIO] not surprising that 70, 7580 percent of the people relapse after they leave the hospital for treatment for anorexia. Of so it's certainly better than we've done before. But I want to emphasize that it's, you know, it doesn't work with everybody, and we still have a long way to go.

MAUREEN CAVANAUGH: Jennifer Lombardi, take us through what a Maudsley family, if I can put it that way, a family that's going to be taking the Maudsley approach to helping a teenager in the family with anorexia, what do they need to reason? What do they actually have to do?

LOMBARDI: Well, in essence, is involves very intensive one-on-one therapy between the family and a clinician who's been trained in this type of treatment. And the typical course of treatment is about 20 sessions over a period of six months. And in essence, what it looks like is the therapist who is trains and is sitting with the family, having a meal, and coaching them through how to get their son or daughter to eat. So in essence, it sort of builds an alignment between the therapist, and the family members, against the individual's eating disorder. And as you can imagine, that is not -- it's a very difficult thing to do, number one. Because patients who are involved in this type of treatment, just like any eating disorder patient is of course going to have a very strong reaction to it, but there's sort of this under tone that the family gets educated as doctor Kay was mentioning about anorexia, specifically, and about this concept that regardless, they're not going to let their son or daughter die. And the concept is to just get them to continue to eat, and eat one more bite beyond what they're comfortable with. Of and that's monitored over a period of time. And then, of course, you know, consultation with a physician to make sure that there aren't any medical complications that need to be addressed, you know, that puts the person at such risk that they would require medical hospitalization.

MAUREEN CAVANAUGH: Jennifer, I want you to take us actually into that dinner table, if you would. And you have a teenaged girl there, are the typical anorexic patient sitting there and saying they're not going to eat. They can't eat. They can't actually physically swallow. They can't eat, they can't eat. What is the family supposed to do?

LOMBARDI: So the family is coached on how to just be absolutely persistent and give -- basically very simple messages that not eating is not an option. That they're not going to let their son or daughter die. That going into the hospital is going to be the alternative, and that's something they're trying to prevent. And it's done with love and compassion but very persistent. And I do think that families sometimes struggle with this. Because we're asking them to do something that is extremely distressing, requires an extreme amount of patience. And it's quite frightening. I mean, they really get an opportunity to see firsthand how their son or daughter vie views food. And so it's persistence and it's repetition. And you know, when you have a therapist in the room who's been trained in this, it does bring a different dynamic, I mean, they're sitting in an office, you're having a meal with the family. The therapist has a degree of authority. So that brings a different dynamic to the table.

MAUREEN CAVANAUGH: Right. How does this not just degenerate into one angry out burst and people flouncing away and leaving the table? And how does this actually produce a positive result?

LOMBARDI: Well, eventually as doctor Kay was mentioning, the temperament of most of these patients is to be, you know, perfectionistic, people pleasing, they are very conflict avoidant. So oftentimes they can't tolerate that level of conflict or they can only tolerate it for so long. And when in the face of persistence and consistency, they sometimes will sort of cave to that and allow themselves to receive the support and the love that they -- you know, on the flip side, deeply long for. Because if you ask somebody who's been struggling with an eating disorder, most of the time at some time they will be able to acknowledge that this isn't working and that it's an awful way to live. And it's distressing, but it's not something that they acknowledge often with their parents. And so often having a therapist in the room that can get them to recognize that and utilize sort of those underlying personality traits as an internal motivator for change can be extremely effective. But as you mentioned there are indications where -- and doctor Kay brought this up, this does not work for every single family.

MAUREEN CAVANAUGH: Now, in tradition eating disorder therapy, doctor Kay, there is family involvement, but as you mentioned, it was sort of aimed as trying to figure out what was going wrong in the family that was causing the anorexic patient to display these kinds of symptoms. Is that also part of the Maudsley approach?

KAY: Well, you know, we -- the Maudsley approach specifically does not blame families. It works with families in appliance. You know, sometimes there are dynamics that may exacerbate the disorder. But there's different ways to understand it. For example, you may have a very anxious mom and a very anxious child. And sometimes two anxious people together make each other even more anxious. So instead of trying to blame somebody for this, what you do is you work with them, in a dynamic sense to really get them to understand how their anxiety is exacerbating each other, and really have kind of more other constructive coping strategies so that they can interact without this exacerbation.

MAUREEN CAVANAUGH: Right, and the way I understand it, tell me, correctly if I'm wrong, are is that the fundamental aspect of at least the first and most important phase of this program is simply the re-feeding; is that correct?

KAY: Absolutely. Exactly. You know, one analogy here is taking your child to the dentist. [CHECK AUDIO] I'm gonna start drilling, it may hurt, tell me if it starts and starts drilling and you go, it hurts, stop! And the dentist says I'm so sorry. Let me just wait for a second and he goes back and starts drilling again. You know, a parent isn't going to take their child out of the dentist chair and take them home because it's painful. He's gonna say caring and lovingly, look, you've gotta get through this because you've gotta have your teeth taken care of and in the long run, it's gonna be better for you. And that's kind of the approach that we get parents to use with Maudsley. This is painful, this is difficult, and you're not gonna like it, but [CHECK AUDIO].

MAUREEN CAVANAUGH: And the conference of Maudsley parents coming up in San Diego on Friday. And taking your calls at 1-888-895-5727. You're listening to These Days on KPBS.

I'm Maureen Cavanaugh you're listening to These Days on KPBS. My guests are doctor Walter Kay, he's professor with UCSD's department of psychiatry, director of the [CHECK AUDIO] and Jennifer Lombardi, director of admissions and therapist at summit eating disorders and outreach program. They will both take part in the Maudsley parents' conference that's coming up in San Diego this Friday. It's an opportunity for us to talk about this very promising treatment for anorexia called the Maudsley approach. And we're taking your calls at 1-888-895-5727. Let's hear from Elizabeth in San Diego. Of good morning, Elizabeth, welcome it These Days.

NEW SPEAKER: Good morning, thank you for tabling my call. I had a couple of questions, please, I was hoping you could address and share your knowledge. One is specifically to hear about your knowledge on bulimia. And also what can be done to further educate, as far as I'm concerned, the general populace and affect a change in basic cultural perceptions. I understand the Maudsley approach is a family oriented. But I believe in this enlightened day, I hope, of the Internet and just general knowledge to be able to bring the information out so that we can change those perceptions. And then my last one is about healthcare insurance coverage. Thank you. Of.

MAUREEN CAVANAUGH: Thank you. Thank you for that. Elizabeth, let me break down your questions, if I can. And maybe start and ask both doctor Kay and Jennifer whether or not the Maudsley approach is very used for bulimia.

KAY: Yes, it's being adapted to adolescents with bulimia. Of course, these are disorders that really -- this is a treatment that tend to work better on children and adolescents who are living at home. To that except, it's being adapted of it's hard to use on young adults and adults because you don't have the same degree of parental influence and control.

MAUREEN CAVANAUGH: And you gen, fer, I'm sorry.

LOMBARDI: I was gonna say, I agree obviously with what doctor Kay was saying. One thing I will say, that we have seen in our treatment center, that has shifted, I think is sort of a byproduct of what's been going on with Maudsley, it sort of goes back to what I was saying earlier about vilifying families and not involving them, one of the things we see with [CHECK AUDIO] or even binge eating is that having involvement and support outside of the treatment setting is extremely important. And part of that is the educational piece so that people do not the underlying causes of eating disorders, and then also figuring out what their role is going to be in supporting thirds requirement loved ones when they're not in treatment. Giving them specific suggestions around meal times, encouraging words, how often to eat with their loved one, what to say, what not to say. And what's interesting is, you know, we do a family education group, and we have had parents, we have had siblings, coworkers, long standing friends, and there's such a sense of relief to them to know that they do have an important role in their loved one's recovery, regardless of the type of eating disorder or what specific treatment approach that they're receiving.

MAUREEN CAVANAUGH: I want to talk with you both about some of the criticisms that I've read in doing some research on this topic. And that is some people say the Maudsley approach started -- was embraced perhaps because insurance companies didn't want to pay for long-term care for anorexics anymore. Center any truth to that, doctor Kay?

KAY: You know, it's always been -- it's been difficult getting insurance company often to pay for any behavioral disorder to the extent that people need treatment. But that isn't really the, you know, the focus or the -- the sense of Maudsley, I think, is much independent of anything that's going on in the insurance industry. It's because it works better. That's why we're embracing it.

MAUREEN CAVANAUGH: And Jennifer?

LOMBARDI: I would say that part of what I do here in my role at a treatment center is deal with insurance companies does deal with authorizations. What I'd like to say first is over all, it is increasingly more difficult to get authorization for treatment for any level of care, they request for shortened lengths of stay is certainly an ongoing issue. And you can speak to anybody who works in the field, and nay certainly would probably have had that experience. I will say that there has been at least from our perspective, some interest from the insurance companies to, first of all, understand this approach, and figure out how it applies to providing area for patients that fall into this age bracket and with this specific type of eating disorder, that being anorexia.

MAUREEN CAVANAUGH: Let's take another call. Enrique is calling from San Diego. Good morning, Enrique, and welcome to These Days.

NEW SPEAKER: Hello, thank you for taking my call.

MAUREEN CAVANAUGH: You're welcome.

NEW SPEAKER: Well, the reason for the call is I wanted to point out I have a daughter with this problem. And Wednesdays that, she has bulimia.

MAUREEN CAVANAUGH: Uh-huh.

NEW SPEAKER: And it's very hard to get help from institutions or organizations when you're limited in resources. Of you know? Because you get the suffering of your daughter, like my daughter, she suffers from a lot of depression. And this is a lot of frustration because you are limited to get some help from the government or different institutions.

MAUREEN CAVANAUGH: Enrique, let me pose the question to the people accident -- to my guests to see if there is any alternatives for someone with a limited income, limited resources to get treatment for a daughter suffering from anorexia. Anything -- any options out there doctor Kay that you would like to suggest?

KAY: Well, the UCSD, you know, medical center does have a carefree clinic as treatments. And wee working with a relatively long program so we're trying to disseminate and bring new treatments to San Diego for eating disorders in all sectors, and you know, we're working with the Gifford clinic to start up some new programs.

MAUREEN CAVANAUGH: I'm wondering, if someone has been suffering from anorexia for a long time, for years, if they're no longer a teenager, is there any way the Maudsley approach can help them?

KAY: It's worked in some instances if they'll give their family permission and bring their family in and get them involved. But it's -- it hasn't been tested that much.

MAUREEN CAVANAUGH: Have you seen any success in someone who's suffered, Jennifer, from anorexia for a long period of time?

LOMBARDI: Absolutely, I mean, I think it's penitentiary -- it certainly poses a lot of questions, because I know several years ago there was an article talking about eating disorders in midlife, and whether or not women ear even men start their eating disorders later in life, and what the research shows is that most of the time their eating disorder started when they were a teenager, and they may have been kind of in and out of their illness over a period of several -- a few decades. But certainly we have had instances of patients who've struggled for 20, 30 years and are finally at a place where not only are they ready to fully accept treatment. But that treatment is available to them. And we've come quite a long way, particularly in the last 5 or 6 years as doctor Kay was mentioning earlier in understanding these ills. So I would encourage anybody who's been struggling to definitely have hope.

KAY: I think it's very important that families and others not give up, because one of the things that we're learning about is it's not uncommon for people to have a disorder borrow actually many years but still recover. So in the long run, we see at least 50 percent of the people that have a really good outcome, maybe another 30 percent that actually do reasonably well. And then 20 percent that don't do so well at all. But often it takes -- people may be ill for 5 or 10 years before they enter this phase of recovery.

MAUREEN CAVANAUGH: I've heard it said that San Diego is becoming something of a center for people who are looking for this treatment and, actually, for research into eating disorders. Is that the case, doctor Kay?

KAY: We like to think so, yes. We're trying to do some innovative new treatments, for example, as Jennifer mentioned, Maudsley's a new treatment. There aren't a lot of Maudsley therapists. One of the things we have, we have a week long program where we bring the family in, child or sibs, mom or dad, and we work with them in a very intensive way to immerse them in Maudsley, [CHECK AUDIO] and the rest of the country, Ivan Eisler who's one of the founders of Maudsley who's at Maudsley in London worked with us in developing this multifamily approach and he's coming back to do a sabbatical with us for about six months this year as we develop an innovative new program.

CAVANAUGH: And I know, Jennifer, you're headed here to San Diego to attend this conference on Friday. What's going to happen? What is this conference about?

LOMBARDI: Well, I think -- I'll certainly let doctor Kay chime in because I know he's speaking but we have some professionals and also a parent who's experienced this type of treatment. So I think there's gonna be a nice combination of update on research of the specifics of what Maudsley is, and then of course a firsthand experience in terms of how this treatment is experienced we a family and by a person who's been struggling.

KAY: And one of the very important things about this conference is it's put on my Maudsley parents which is a grass-roots organization that's been started by Harriet brown and Jane Crawford -- Crawly, who are doing this because they're passionate about eating disorders and are powerful advocates for this. And that's one things that we really need in this field is families to get involved and advocate for better treatments.

MAUREEN CAVANAUGH: Now, there conference on Friday, where is it and can the public attend?

KAY: Absolutely. It's at the embassy suites in La Jolla, you can Google either Maudsley parents or our website UCSD, to get information. We have had a good turn out. But there still are some openings, people can still register.

MAUREEN CAVANAUGH: Now, I realize that there's not only a San Diego hosting this conference and UCSD is working on the projects that you were talking about in conjunction with the Maudsley approach, but also Rady's Children's Hospital is getting into the whole concept of trying to nip eating disorders kind of in the bud, if you could say if that way.

KAY: Exactly, since these are disorders of children and adolescents issue the department of psychology at UCSD and Reidy's has been working together now to start a med psyche unit which will be provided for eating disorders and will provide short term medically focused lengths of stay for people to gain some weight or get medically stabilized and we hope that many of them will enter our day treatment outpatient Maudsley programs.

MAUREEN CAVANAUGH: You know, Jennifer, in talking about this, it sounds like it's a very intensive and somehow draining line of work to be in. Where do you get your success, your feeling of accomplishment?

LOMBARDI: Well, in working with patients, I think that's really where it radiates from. I have clients that I work with, and have been doing this for quite some time. And to see sort of that sense of hope come into their eyes again and recognize that they want a life outside of their eating disorder. I mean, issue I've been recovered 18 years and so when I see something like that, it's kind of like the person on the inside finally gets to wake up. And the realization that not only do they not want that life anymore with their eating disorder but they begin to believe that it's possible. And I do think having a very strong relationship with a good, well trained therapist in the field of eating disorders is critical. Because one of the things we like to say to our patients is right now the closest relationship you have is with why are eating disorder. So it stands to reason that the one thing that's going to come between that is help the person take the steps to fully recover is going to be a healing relationship. And unfortunately as we've been talking about today involving families whenever possible, they get to be part of that relationship building.

MAUREEN CAVANAUGH: Are there some warning no involved [CHECK AUDIO]? Is there something that families have to be very careful about before they start?

LOMBARDI: I do think they need to be -- they need to definitely educate themselves and be really clear on understanding whether or not the person they're going to be working with is fully trained in Maudsley. And the Maudsley [CHECK AUDIO] and I know that they're working very hard to not only make sure that there are enough clinicians across the country that are available for families to try this approach, but that they really truly do have the extensive training that's needed to do it well.

MAUREEN CAVANAUGH: And I'm wording, doctor, Kay, if the idea of really getting into psychotherapy in families really not the first part of the Maudsley approach. Are there some families that are basically too sick to undertake this kind of therapy.

KAY: Well, there are certainly families that it didn't work on. And I don't think we understand exactly why that is. We've recently been advantaged in a multi-center study that's trying to answer this question of [CHECK AUDIO] analyzing the data now, so hopefully in some relatively short time, we'll have better answers.

MAUREEN CAVANAUGH: So you're analyzing the data of the families that it works with and doesn't work it in trying to come up with some questions.

KAY: Exactly, exactly.

MAUREEN CAVANAUGH: Well, I want to thank you both for speaking with us today. Doctor Walter Kay, and Jennifer Lombardi. Thank you both.

LOMBARDI: Thank you.

KAY: Thank you.

MAUREEN CAVANAUGH: And if you'd like to comment, please go on-line, KPBS.org/These Days. You've been listening to These Days on KPBS.