State of Mind: Evaluating Competency to Stand Trial

July/Aug 2007

State of Mind: Evaluating Competency to Stand Trial 
By David Surface
Social Work Today
Vol. 7 No. 4 P. 17

See how forensic social workers wrestle with professional ethical issues that emerge in determining mental fitness to face prosecution.

In movies and TV shows that focus on the drama of criminal trials, one familiar character is the police psychologist or psychiatrist called to examine the defendant whose mental competency is in question, the learned professional who takes the stand and testifies whether the defendant is mentally capable of standing trial. In real life, however, the professional playing this role is more likely to be a social worker.

Katy Heffernan, MSW, LCSW, is a forensic social worker with the office of the public defender in New Haven, CT. Her interest in forensics has its origins in her family roots. “I come from a family of attorneys and teachers,” she says, “and I’ve always been interested in people who get arrested and why that happens. At the time when I first wanted to be a forensic social worker, I thought that was what forensic social work entailed.”

Heffernan recalls walking into the law and psychiatry department in the New Haven mentalhealth center and saying, “I want to work in forensics.” A social worker looked at her and said, “Well, what does that mean?” Heffernan laughs, “And I said, ‘I have no idea, but I know I want to do it.’ And that started my education.”

Like the young Heffernan, many social workers have only a spotty knowledge of what forensicsocial work is all about. Child custody issues involving separation, divorce, neglect, termination of parental rights, the implications of child and spousal abuse, juvenile and adult justice services, corrections, and mandated treatment—these are just some of the wide range of court proceedings in which forensic social workers are involved. One of the most interesting and challenging is evaluating for competency to stand trial.

The Competency Evaluation Process
The process of evaluating whether a client is competent to stand trial involves two major areas. First, clients must understand the legal proceedings against them, what they’ve been charged with, what the roles of the different court personnel are, the difference between pleading guilty and not guilty, and what accepting a plea bargain means.

The second factor is the clients’ ability to assist in their own defense. Are they able to work with their attorneys and take an active part of their own defense? “Without those understandings,” explains Heffernan, “it isn’t ethical for someone to go before a judge and enter any kind of a plea. The competence statute really protects people’s rights.”

The duties of forensic social workers who evaluate for competency to stand trial vary from state to state. In Nevada, for instance, social workers can evaluate competency to stand trial on misdemeanor cases. Tom Durante, LCSW, is director of social work at Lake’s Crossing Center for the Mentally Disabled Offender, a forensic mental health center for the state of Nevada. “What we do is gather a little historical background about clients’ mental health histories and their mental status—how they’re doing that day,” Durante explains. “Then, finally, there’s the competency evaluation, which is seeing if they know their charges, know their attorney, and know the legal system well enough to stand trial.”

Heffernan works on the front lines of forensic evaluation. “Clients come into my court and, sometimes, they are too paranoid and they can’t participate. Maybe they’re responding to internal stimuli or voices and aren’t able to attend to the information. I try to work with people to find out if they know where they are, why they’re here. I evaluate and give my opinion as to whether there needs to be an order from the court.”

If a client’s mental status is in question, the social worker tells the defense attorney who then brings the issue to the judge. Alternately, the state’s attorney or the judge could raise the issue. The judge then issues a court order mandating the office of forensic evaluation to do a formal competence to stand trial evaluation.

While a formal evaluation is often done by a psychiatrist working alone, in states such as Connecticut, the evaluation is performed by a team of mental health professionals, including a psychiatrist and psychologist; this team is often led by a forensic social worker. “I talk with the team who’s going to do the formal evaluation,” explains Heffernan. “Then I step out at that point.”

After the formal evaluation of competence to stand trial, the next phase is often “restoration,” in which clients are sent to a particular setting, most often a hospital, where they are “restored to competence.” Clients are usually in the hospital for 60 to 90 days for the initial restoration, during which time they not only undergo a full evaluation by psychologists, psychiatrists, and social workers but also attend class to learn about the court process so they face their charges as a competent person.

Social workers are also frequently involved in the restoration process. First, a clinical social worker on the hospital unit assesses mental functioning and other clinical issues. In addition, a second social worker may fill the role of “forensic monitor,” working in concert with the clinicalsocial worker but with a focus on assessing the client’s competence to stand trial. This social worker typically writes the report that ultimately goes to the court. If the defense attorney or state’s attorney doesn’t agree that the client is now competent to face charges, social workers in the position of forensic monitor may be asked to testify in court to defend their report.

The Forensic Track: Blazing Your Own Trail
In Connecticut, Heffernan explains, there is no formal academic track for a social worker who wants to pursue forensic work, “so I made up my own.”

At that early point in her career, Heffernan had been thinking that she would get a degree in forensic psychology. But after meeting with people in the outpatient clinical, secure hospital, and state lab settings, everyone advised her to get a social work degree.

“In Connecticut, the licensed clinical social workers are valued pretty highly,” says Heffernan. “They can get degrees on par with other people who have PhDs because of the extra training they go through with the social work degree and then the two years of training afterwards for the licensure. In this state, we’re fortunate that they really do respect the academic work that goes into becoming an LCSW.”

Early Choices: Finding the Forensic Path
Durante describes how he first became involved in this line of work. “I was actually first introduced to forensic social work in 1988 when I was offered a position as a private contractor here at the agency I work with now.” Durante worked at Lake’s Crossing Center for one year, during which time he absorbed knowledge about the process of evaluating clients for competency to stand trial. Although he went on to work in the civil hospital setting, he came back to forensics. “I found it to be a fascinating field,” he says.

“I liked doing psychology work, and I also liked working in the criminal justice field,” says Heffernan. “And I was looking for something that would combine the two.” Heffernan had worked with adults with profound mental illness, substance abuse, and cognitive disabilities and had developed a good background in psychiatric difficulties. But what was missing was the criminal justice aspect. “So,” says Heffernan, “I just started calling people and asking if I could have interviews.”

Heffernan met with people at the Whiting Forensic Institute, a secure hospital lockdown setting where people who are acquitted of serious charges for reasons of insanity are held for restoration to competency. “So I met with them,” she says. “I went to the forensic lab just to see what was out there and what would satisfy my clinical side and my interest in criminal justice.” Heffernan ended up with a master’s degree in social work and focused her field placements within forensic settings.

In one setting, she was involved with the initial evaluation for competence to stand trial; in another, she was involved in the restoration to competence. In still another setting, she participated in homeless outreach where she worked with clients with a multitude of psychiatric issues. “Then I applied for a position in the public defender’s office, and when one opened up, they called me,” she says.

Heffernan still works in the public defender’s office in what is known as the high court, or part A. “The people who come here are accused of felonies,” explains Heffernan. “I work with seven attorneys, three investigators, and three secretaries. I’m the only social worker in the office. It’s very interesting work because you never know what the client’s issues are going to be. My job is to assess the clients and see if they’re suffering from any kind of disability or substance abuse issue, if they’re victims of sexual assault themselves, if they’ve been arrested for sexual assault.”

Heffernan’s job takes her to a variety of settings, some of which many other social workers never get to see. Because the majority of her clients are incarcerated for serious felonies, such as murder, rape, robbery, and arson, Heffernan meets with clients in the lock-up of courthouses where they come to be arraigned or in hospitals where they’ve been admitted for various reasons. “I also meet with clients in various jails and prisons,” says Heffernan. “Unfortunately, in Connecticut, we have quite a few.”

Ethical Dilemmas: Legal vs. Clinical Agendas
Occasionally, the social worker and attorney’s agendas may conflict. “Let’s say you have a defendant who is a minor child, and the department of children and families has recommended that he go into a treatment program,” explains Heffernan. “Let’s also say that there’s an opening in the treatment program, but he has to enter it immediately in this very short time frame or else he goes to the bottom of the list. In order for the child to be released for treatment, he has to understand what’s going on and plead guilty for the judge to bond him out.

“But what if the social worker or the attorney doesn’t feel the child is capable of understanding the charges against him and is therefore not competent to stand trial? The problem is that it’s obviously not protecting his legal rights to just go ahead and put him in the treatment facility if it means he has to plead guilty to a charge he doesn’t understand. As a social worker, I’d absolutely want to make sure that he got the clinical treatment he needs, but as a worker within the legal system, I have to recognize that this isn’t in his best interests. I need to make sure he’s protected legally,” she continues.

Ideally, the social worker and attorneys work together to procure the best legal outcomes for the client. Unfortunately, this sometimes clashes with what the social worker believes is the bestclinical disposition for the client.

Heffernan tells of her own introduction to the kind of conflicts that can arise between legal agendas and social work priorities. “I had a case with this young woman and felt that she needed to be in a partial hospital program and also needed to be on medication and that these needed to be conditions of her probation. We wanted to recommend this to the court because we felt that would be the way she’d be most successful in her life and not come back into the court system,” she explains. “And the attorney came to me and took my file and said, ‘OK, I’m going to put this in her file. If she violates her probation and comes back, we’ll go with this plan.’ And I was very confused. I said, ‘No, this is what needs to happen.’ And then he told me that he’d just been before the judge and had gotten her a youthful offender disposition, which is a kind of probation which if the conditions are not violated for a year, the charge will not appear on your record. And he said, ‘As much as I agree with what you’re saying, and as much as I think that these conditions might enable her not to come back, I can’t do my job as a defense attorney if I agree to putting five or six conditions onto a probation that she might violate, then she’d come back and that charge would be on her record.’ So that was a huge education for me.”

There is another kind of ethical dilemma that forensic social workers may encounter while conducting evaluations of competency to stand trial; one that, in theory, poses a potential threat to the social worker’s career.

In Connecticut, there is a legal opinion written that public defendant social workers on the defense team are not mandated reporters and communications between the social worker and the client fall under the client-attorney confidentiality. “So if a client says to me, ‘Yes, I did this crime and I also molested a child last year,’ in a different setting, I would report that to department of children and families and start an investigation,” explains Heffernan. “But in this setting, I’m not allowed to do that.”

Fortunately, client-attorney confidentiality does not extend to crimes that may take place in the future, so social workers—like attorneys—are bound to report when their client makes a specific threat. “If the person says, ‘I’m going to leave and go molest someone,’ then the social worker, just like the attorney, has a duty to report that and warn the person. But in a treatment setting, if a client had said to me, ‘I molested my daughter two years ago, but I’m not doing it now,’ and she’s a minor, I would then have to report that,” she explains.

Shelly Bryant, LCSW, who also does competency evaluations at Lake’s Crossing Center, believes there is a substantive difference in the kinds of communication that pass between a client and a social worker in both a clinical and legal setting.

“Typically, a lot of what social workers talk about is confidential, but there’s no confidentiality in a competency evaluation. The kinds of things that we report to the court and the attorneys are very different from the kinds of things that a client tells a social worker in confidence,” Bryant says.

Durante’s perspective on the potential ethical conflicts in forensic social work is based on his understanding of who the forensic social worker’s client actually is. “With competency to stand trial, ultimately our client is the court,” says Durante. “We’re not taking a side—we’re assessing.”

Despite the fact that forensic social workers are not technically supposed to be working on behalf of the defendant, Durante does see his job as having a positive benefit for the people he’s called on to evaluate.

“At the same time, I think that part of our role in doing an evaluation in a professional manner is that, ultimately, we’re protecting who would be unfairly tried if they were unable to assist in their own defense,” says Durante. “So even though I do feel that we are a neutral party, at the same time, we are protecting individuals who are incompetent through our professional recommendations to the court.”

Social Workers and Forensics: A Good Match
Patrick Marquis, LCSW, who works with Durante at Lake’s Crossing Center, agrees that social workers offer unique perspectives and abilities that make them highly suited to forensic social work in general and evaluating competency to stand trial in particular.

“Part of our generalized education in social work probably gives us more of a systematic perspective than other disciplines,” says Marquis. “It’s such a focal point of our education to look at the person in the environment and how that has helped shape who they’ve become today—that may be a slant that we’re able to focus on more than other disciplines.”

Marquis points out that social workers have a particular and extensive knowledge base that helps them not only evaluate the client’s current status but also make choices and predictions about the client’s future. “We also have a good knowledge of the community resources that are available for a client who is going to be processed through the legal system. I think it’s crucial that we know what that client is going to need once the legal part is complete,” he says.

What initially surprised Heffernan was how social workers take the lead on the competency evaluation team. “The teams are very comprehensive with all the disciplines—the psychiatrist, the recreational therapist, and the psychologist,” says Heffernan. “I like where the social workers are situated within those teams. By virtue of being a social worker, you’re looking at the details within the whole picture, and when you go the psychology route, it’s much more narrowly focused, so it appealed to me to be aware of that narrow focus, but to be aware of the bigger picture.”

— David Surface is a freelance writer and editor based in Brooklyn, NY. He is a frequent contributor to Social Work Today.

Career advice
What kind of advice would these professionals offer to social workers interested in working within the legal system?

“Don’t be afraid to call people who are already in the field,” says Katy Heffernan, MSW, LCSW. “Don’t just look at books; talk to people who are doing it, find out how it works and what’s the best way to be prepared. That was the most helpful thing to me, and I find it’s the most rewarding thing to me now when people call me and say, ‘Can you tell me about your job?’ I don’t think there’d be one professional who’d say ‘I can’t help you’ if they’re approached by somebody who really wants to pursue a career in this area.”

Forensic social work seems to be gathering more respect. This year, Heffernan is being honored by the National Association of Social Workers as the outstanding social worker of the year from Connecticut. “Sometimes people look at forensic social work and say, ‘How can you work with people who aren’t victims?’ So it’s nice that, with all the various disciplines within social work, this year the award is going to forensic social work.”

Patrick Marquis, LCSW, points out that the kind of experience and knowledge that social workers gain while working within the legal system can have long-ranging benefits for social workers and their clients—even beyond the field of forensics.

“Even if we ever do branch off or move on to other fields, our knowledge of the legal system and how it works, how our clients interact with the legal system, how the legal system can work for or against them will be of great benefit to our clients in general,” Marquis says.

— DS

Saying Goodbye to Spot: Pet Loss Bereavement

July/Aug 2007

Saying Goodbye to Spot: Pet Loss Bereavement
By Lynn K. Jones, DSW
Social Work Today
Vol. 7 No. 4 P. 26

Furry or feathered, a pet's death must be respected with the same reverence as the loss of a beloved family member.

Jennie couldn’t sleep, lost her appetite, and was overcome by waves of grief that caused her to burst into tears at work and in public places. She exhibited the classic symptoms of grief for a loved one. In addition to feeling guilty, she was consumed with anger. But Jennie wasn’t grieving the loss of her spouse or a close family member; she was grieving for her pet Schnauzer, Jezabel.

In the wake of the tainted pet food incident, thousands are suffering from the loss of their pets. What compounds the grief for many is that they are grieving alone, feel silly for being so upset, and are burdened by the belief that they may have caused their pet’s death.

Silly or Not? 
Is the depth of grief that Jennie experienced normal? Susan Cohen, DSW, director of the human-animal bond program at the Animal Medical Center in New York City, says we now understand that deep grief in response to a pet’s loss is the norm, not the exception. People who have lost a pet experience the same range of grief responses as people who have lost a human companion.

The idea that humans and animals bond with one another is as familiar as the childhood stories of Lassie, Toto, and Black Beauty. The main characters of our grade school readers were Dick, Jane, and Spot. We have loved, been amused, and been charmed by Snoopy and Garfield. And recently, the escapades of the beloved yellow Labrador, Marley, captivated us in the New York Times bestseller.

But even though we have been socialized to understand the human-animal bond, we still fail to fully grasp how intense it is. Linda Peterson, ACSW, a Pennsylvania social worker who has been involved in pet loss counseling since 1989, says, “Our society doesn’t sanction deep, extended grief for a pet. I see quite a few people, even people in their 30s and 40s, who have not been through the loss of anyone close to them—human or animal. When they get hit with these tremendously overwhelming feelings [over the death of a pet], they feel ashamed. They just aren’t prepared for the depth of their feelings.”

Cohen agrees. ”When I first started doing this work, 50% of my job was telling people, ‘No, you are not crazy.’ Now, 25 years later, many more people are aware of this relationship, how important it is, and that people are very sad when their pet dies. They understand that they are not weird.”

Unconditional, Positive Regard
Pet owners experience a sense of unconditional, positive regard from their pets that most people find life-expanding. “When you lose your pet, you lose someone who thinks you are wonderful just the way you are,” says Cohen, “somebody who doesn’t care if you gained 30 pounds or lost money in the stock market—all the things that our human companions care about.”

For some people, their relationship with their pet may have been their only experience of unconditional, positive regard, says Linda L. Lawrence, MSW, LMSW, a social worker at Michigan State University College of Veterinary Medicine. “Our pets are always happy to see us and run to greet us at the door. They don’t hold grudges against us. They are always there. That is meaningful to everybody but especially to someone whose pet plays a central role in their life—a latchkey child, for example.”

But pets play more than a just psychological role in people’s lives. “The simple act of petting an animal has been shown to lower blood pressure by inducing an instant relaxation response,” says Alan Beck, ScD, director of the Center for the Human-Animal Bond at the Purdue University School of Veterinary Medicine in Indiana. “And animal owners have a higher one-year survival rate following a heart attack and lower cholesterol levels than those without pets—even when they have the same levels of exercise.” It turns out that pets are good for both people’s heads and hearts. When people lose them, they suffer not just a psychological stress but a physiological one, too.

Pets Are Family
Beck says that people view their pets, especially dogs and cats, as members of the family. He cites the way people behave with their pets. They carry photographs in their wallets and have pictures on their desk at the office right along with the pictures of their families. They include their pet in their Christmas card picture. People name their pets, talk to them, and often refer to themselves as “mom” and “dad.” They plan part of their day around their pets. They don’t begrudge discretionary spending for their pets. “These are behaviors that you reserve for members of your family,” says Beck.

Cohen agrees. “We think of them as members of our family, sort of like children but even better than children because they are more innocent.” The impact of losing a pet—considered a member of a family, like an innocent child—because it was fed tainted food is immense. “These are people who fed their pet food that caused their innocent animal to die—that is very, very difficult for people,” she says.

Guilt and anger when losing a loved one are typical reactions, but in the pet food incident, they may be severe. “As is often the case when there is some kind of accident, you really are not culpable, but at the same time, you feel culpable,” says Beck. “I think the recall is probably that way. People are probably thinking to themselves, ‘I really should have read those labels. I should have switched foods. I should have been more observant.’ I think most people were caught by surprise. I suspect that it was spotted pretty quickly, but that doesn’t stop the guilt.” Cohen adds, “Because we see pets as very innocent and very dependent on us, we feel extra responsible.”

There is a difference between a loss that is anticipatory and one that is traumatic, suggests Beck. “One of the problems with the food issue is that people didn’t have time to mobilize their feelings and start the mourning process in a healthy way. Whereas, if you know that your animal is going to die in a few weeks, then you spend some extra special time together. It makes it a little easier,” he says.

How Long Will the Grief Last?
Cohen says that how long the grief lasts after losing a pet has not been carefully studied, and everyone is different. “It is clear that for some people, losing a pet is a big trauma. It is a big loss like any other big loss, and they will never be the same again,” she says.

The fact that it can take a long time “is where people get hung up,” says Peterson. “They say, ‘I have been upset for a couple of days or a week or two weeks, and I have to get beyond this. It is going on too long.’ I tell them that it is an individual thing. The more you loved your pet, the longer it is going to take to get through these feelings.”

Cohen says the duration of the grief often depends on what else is going on in the person’s life at the same time. This has also been Lawrence’s experience: “If you are going through multiple stresses at the same time, if you are going through a divorce, or recently lost your job, or have a family member who is ill and you have a pet die, that is going to compound the amount of time that the grief will last.”

Sometimes, the pet is the last link to a lost relationship. “I have had people who have lost a pet that was left to them by their children or that was part of their life before their spouse died. It is the last living connection to that child or spouse, and so their grief and their sadness and depression is huge,” explains Lawrence.

It may be especially painful for older people to lose a pet. For some, their pet is a cherished companion that has given them a reason to keep living. At a time when they are experiencing the death of friends, losing their pet could also be catastrophic. Because their pet may have been the sole focus of their attention and affection and may have been a substantial part of their daily routine, the loss they feel may be especially intense.

Beck suggests that most people recover from a pet loss sooner than a human loss. One reason may be that the major changes in one’s life that often accompany a human loss don’t occur when you lose an animal. “Things like your economy and where you live may change when you lose a spouse, for example, but aren’t a factor when you lose your pet. There are some studies that show that how long you have had the animal has some influence on the duration and the impact of the loss,” says Beck.

What About a New Pet?
Experts concur that the choice of whether or not to get a new pet soon after the loss of a pet is an individual decision based on what feels right to the pet owner in each situation. However, most also agree that the suggestion that a grieving pet owner should automatically replace the lost pet is a reflex that should be avoided. “Pets are not just a box of Kleenex, something that you can just go out and buy another one and have the same experience. They have their own personalities. Pets are spontaneous, and they do things that make you laugh, they surprise you with their love and their acceptance of you, and that makes them different,” says Cohen.

Beck says the suggestion that you should “just get another pet” is as inappropriate as saying, “I heard you lost your husband. By the way, I have a brother who is just right for you.” Beck has found that it takes people roughly two years before they replace their pet. However, some people want to do it right away. Some people want to replace their pet with the same breed all the time. Some want to maintain the original memory of their pet and switch breeds to avoid competition. According to Beck, both responses are common, but the loyalty to one breed is more common.

Peterson doesn’t encourage people to run right out and get another pet primarily because it takes a lot of energy to bring a new pet into the home at a time when energy is drained from grieving. The new pet is not going to be like the other pet; people are still remembering the pet that died and comparing the two, and in Peterson’s experience, that doesn’t work. Too often, people who have adopted a new pet too soon end up returning the pet or not being able to keep it, which is an added guilt factor. “That is another trauma, and you don’t want to set yourself up for that,” she says.

Supporting a Pet Owner in Loss
When social workers are confronted with a client bereft from the loss of a pet, “the most important thing is be accepting without judgment,” says Beck. “Regardless of your own personal feelings, owning a pet is very important to many people [approximately 60% of Americans own a pet] and very much part of the family community.”

“Most people who are grieving from the loss of a pet improve when someone is able to listen to them and not think that they are crazy,” says Cohen. Pet loss support groups have proved enormously helpful for many, especially for those who don’t have someone with whom to share the loss (see sidebar).

Considering the depth of feeling that people experience when they lose their pets and the numbers of pets that have been lost to the pet food incident, the impact of this crisis is devastating. Jennie and the others who are grieving for their pets will, for the most part, get better. Lawrence gives important advice: “Anyone suffering from the loss of their pet should be treated as though it was a human being that was lost, and they should be provided the same grief and loss services that you would to a person who lost their spouse, or child, or another family member.”

— Lynn K. Jones, DSW, is a freelance writer and an executive coach and organizational consultant in Santa Barbara, CA. As a specialist in organizational culture, she supports leaders and organizations in developing mission-driven cultures.

Pet Loss Support Groups
In her early career working with individuals with disabilities, Susan Cohen, DSW, observed the strong bond between humans and animals. Appreciating the important role that pets played in her clients’ lives, she established one of the first counseling programs in a veterinary hospital and the first pet loss support group. Now, collaborations between veterinary schools and social work programs exist around the country, as do pet loss support groups.

Pet loss support groups have proved a comforting place to share feelings such as confusion, sadness, and guilt with others in a compassionate environment. Cohen says that one way pet loss support groups are helpful is that people grieving a pet’s death hear how others are handling the process.

“They are often told by their friends and family that they did everything they could for their pet and they tend to discount it. ‘They are just saying that to me to make me feel better.’ But when they hear someone in their group say those things, they can see that they are beating themselves up unnecessarily and then they can say to themselves, ‘Wow, I think that guy did everything and look how hard he is being on himself. Maybe I am being too hard on myself.’ You can’t tell them that, but they can see it in someone else. And they can let themselves off the hook,” Cohen explains.

— LKJ

Pet Loss Resources
The Animal Medical Center
New York, NY
212-838-8100
www.amcny.org
Support groups and counselor referrals for the New York City area

Companion Animal Association of Arizona, Inc.
Scottsdale, AZ
602-258-3306
www.caaainc.org
A 24-hour grief-counseling hotline, support groups, and referrals

The Delta Society
Bellevue, WA
425-679-5500
www.deltasociety.org
Publishes 20-page Nationwide Pet Bereavement Directory

PetFriends, Inc.
Moorestown, NJ
800-404-PETS (7387)
Returns long-distance calls collect; free for residents of southern New Jersey and the Philadelphia area

St. Hubert’s Animal Welfare Center
Madison, NJ
973-377-7094
www.sthuberts.org

Double Trouble — Helping Clients With Co-occurring Disorders

May/June 2007

Double Trouble — Helping Clients with Co-occurring Disorders
By John K. Smith, PhD, LCSW
Social Work Today
Vol. 7 No. 3 P. 18

Co-occuring mental health and substance abuse issues challenge clinicians to be properly trained to recognize both disorders and obtain the right treatment for clients.

Mike B. is a 32-year-old Caucasian male. His problems likely started when he was in his late teens. He occassionally drank alcohol and smoked pot with friends—not much to be concerned about at the time.

When he turned 17, Mike began to isolate himself. He became angry and depressed and spent most of his time alone in his room listening to music and playing his guitar. He imagined that he was a rock star and began to spend a great deal of time writing songs and music. His alcohol and pot use increased because he believed it enhanced his creativity.

Mike barely scraped by, graduating from high school mostly because his parents constantly pushed him. Usually their pushing would result in loud arguments, with Mike retreating to his room and his music. Mike’s parents were hard workers and away from home much of the time. They were concerned about their son but felt he was simply “going through a phase.”

Again, because of his parents, Mike held a series of menial jobs, which at least afforded him the money to buy alcohol and pot, of which his use had increased. Mike would spend hours in his room at night with his music, which he believed was inspired by God. He required little sleep.

His behavior became increasingly bizarre and one night, when he was in his early 20s, Mike was arrested and hospitalized on an emergency hold after he was found running naked down the street, singing incoherently. Due to the severity of his psychiatric condition, it took awhile to stabilize him on a medication regimen. During his stay, his drug and alcohol use was never assessed. Mike was asked a few questions in an evaluation, but he reported that he only occasionally used alcohol and smoked pot.

Upon his discharge from the hospital, he was referred to a mental health clinic for continuing care. In addition to a psychiatrist for medication management, Mike was assigned to a clinical social worker for ongoing therapy and case management.

What Happens Next?
What happens next depends on which social worker Mike is assigned to. If the social worker is trained in assessing and treating clients with co-occurring substance use and mental disorders, Mike will likely receive concurrent or integrated treatment for both problems. The social worker will assess the extent and level of Mike’s substance use and determine his readiness to change his behavior. This clinician will be trained in the practice of motivational interviewing to help engage Mike in the treatment process, realizing that his readiness and willingness to treat his mental illness may be different from his readiness to treat his substance use problem (Miller & Rollnick, 2002).

Once engaged, the social worker can begin to use active treatment techniques proven to enhance positive treatment outcomes for clients with co-occurring disorders, such as cognitive-behavioral therapy, disease management and education, social skills training, and referrals to specialized 12-step support groups (Smith, 2007; Minkoff, 2000).

Inadequately Trained?
Unfortunately, the majority of practicing clinicians, including social workers, have not received adequate training in the assessment and treatment of clients with substance use disorders, especially those with co-occurring disorders (i.e., dual diagnosis).

While there appears to be a growing trend toward integrated treatment of co-occurring disorders, there is still a lack of available training and clinical supervision to assist clinicians in honing and improving their knowledge and skills.The current body of literature recommends that all clinicians be cross-trained. Despite overwhelming evidence about the prevalence of co-occurring disorders, the mental health and substance abuse treatment systems have been slow to adapt or respond to the demand for better and more effective treatments for this population. Clinicians have been forced to provide treatment to clients with co-occurring mental illness and substance use disorders without having adequate training or resources to do so.

One study by Carey, Purnine, Maisto, Carey, and Simons (2000) showed that clinicians were treating clients with co-occurring disorders but often felt unprepared and inadequate in their knowledge and skill levels. Most clinical training programs and graduate programs in medicine, psychology, social work, addictions, and other related areas offer little, if any, training or course work in the assessment and treatment of co-occurring disorders. Hall, Amodeo , Shaffer, and Vander Bilt (2000) reported that social workers employed in substance abuse treatment facilities lacked adequate ongoing clinical supervision related to substance abuse treatment and felt a considerable need for further substance abuse training, especially in dual diagnosis.

High Prevalence of Dual Disorders
Why is this so important? No matter in what treatment setting social workers find themselves, they will encounter clients with co-occurring disorders. The most frequently cited study on the prevalence of comorbid substance abuse and severe mental illness is the Epidemiologic Catchment Area study (Regier et al, 1990). This study found that the prevalence of substance abuse in persons with a severe mental illness was between 30% and 60%. While the specific prevalence of each disorder is beyond the scope of this article, bipolar disorder and schizophrenia had the highest rates of comorbidity. Recent studies have shown the prevalence of physical and sexual abuse among substance abusers entering addiction treatment to be approximately 50%, and there are reports of as many as 75% of women in certain substance abuse treatment programs being diagnosed with posttraumatic stress disorder, primarily due to childhood sexual abuse or trauma related to their substance-abusing lifestyle (Pirard, Sharon, Kang, Angarita, & Gastfriend, 2005). Given the high prevalence of co-occurring substance abuse and mental disorders, especially in certain populations, it is safe to say that most social workers are encountering a high percentage of these clients in their caseloads. Yet, the majority are ill-prepared to adequately assess and treat them.

Since social workers are on the front lines in many treatment and service settings, they must be prepared to adequately assess clients who may have co-occurring disorders. Due to the high prevalence of these disorders among the populations most served by social workers, it is poor practice to be unprepared to identify, treat, and/or refer clients with comorbid conditions. While social workers do not all need to be experts in treating co-occurring disorders, they may be the best suited of all clinical professionals to provide the integrated care and constant case management required for successful treatment outcomes.

Basic Competencies
Not all social workers work directly in mental health or substance abuse treatment settings, yet almost all social workers work with clients who are at the highest risk for either or both problems. The following basic competencies should be present for all social workers in all settings:

• ability to accurately screen and assess for major mental illnesses;

• ability to accurately screen and assess for substance use disorders;

• familiarity with motivational interviewing and other client engagement tools;

• knowledge of how to access both mental health and substance abuse systems; and

• familiarity with local resources and referral sources, especially those with specialized programs for clients with co-occurring disorders.

For social workers in either the mental health or substance abuse treatment fields, the following skills and competencies must be present in addition to the ones listed previously:

• knowledge and experience with the substance abuse/addiction recovery process, including the disease concept and the 12-step model;

• familiarity with substance intoxication and withdrawal symptoms and the detoxification process;

• knowledge of stages of change and models of recovery;

• ability to conduct a mental status examination, including risk assessments;

• ability to develop differential diagnoses and familiarity with criteria and terminology in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision;

• ability to utilize cognitive-behavioral therapy concepts and techniques;

• familiarity with psychotropic medications and psychopharmacological management of mental illness and addiction;

• access to ongoing clinical supervision by experienced and qualified clinicians; and

• attitudinal and philosophical support for the special needs of clients with co-occurring disorders.

The last item may be one of the most important. It is critical for social workers to understand that traditional mental health and substance abuse treatment models and philosophies do not adequately address the needs of this population. For example, traditional substance abuse treatment programs are often confrontational, emotionally charged, and require total abstinence and a great deal of reading and writing. This type of setting would be very difficult for someone with schizophrenia due to the nature of the disorder. Also, traditional Alcoholics Anonymous meetings may or may not be supportive of members who are taking medication—a must for those with severe mental illness.

Flexibility and creativity are needed when designing treatment for clients with co-occurring disorders. The bulk of the research and literature supports the use of an integrated (simultaneous) program that treats the client vs. the disorder in a way that maximizes successful treatment of each one. For social workers, this often means implementing one of the basic values of “meeting clients where they are.” Once engaged, social workers can help advocate for and navigate clients through the obstacles created by artificial systems of care funded and designed to treat problems, not people.

Navigating Through Troubled Waters
Since the late ‘60s and early ‘70s, large “systems” of care have been developed to provide treatment for mental health and substance abuse problems. Large federal, state, and county bureaucracies have been established to oversee various funding streams and the provision of care for people with mental health or substance abuse problems.

Unfortunately, the word “or” tells the whole story. People were identified by their problem type as if their problems existed independently. Historically, these systems of care have been exclusionary and required people with both problems to seek treatment from at least two separate, and usually complex, entities.

It is not uncommon for individuals with co-occurring substance use and mental disorders to face major barriers to accessing treatment. For example, they may attempt to enter substance abuse treatment only to be told they cannot be treated for their substance abuse because they have a mental illness, which disqualifies them from treatment. If they enter through the mental health “door,” they are turned away because they have an active substance abuse problem that must be treated before they can receive mental health care. Our most vulnerable and fragile clients easily fall through the cracks and do not receive the necessary care. And clients who are already treatment resistant may find the obstacles to access an easy excuse for avoiding the treatment they desperately need.

Clients who are successful at getting through the door must attempt to navigate through two systems simultaneously—a daunting task for anyone but especially those with severe mental illness and substance abuse problems. This is called parallel treatment, and it is probably the most common way that clients with co-occurring disorders receive treatment. The problem with this method of treatment (bureaucratic red tape aside) is that the mental health system and substance abuse system often have different approaches and philosophies of treatment.

Often these approaches are contradictory and contraindicated for clients. For example, some substance abuse treatment programs are not supportive of using psychotropic medications, while mental health providers may be overly reliant on medications. Psychotropic medications are a necessity for treating and stabilizing mental illness symptoms that may be exacerbated or reduced by the use of drugs and alcohol. In contrast, the use of drugs and alcohol may negate or potentiate the effects of the psychotropic medication and must be minimized or eliminated for treatment to be effective.

The real issue is the coordination of care within and between providers and systems of care. It is difficult at best to coordinate care because there is a lack of communication between the two systems and the providers within these systems. Because of the different philosophies and practices, coordinated care requires someone who can assist the client in navigating through these systems and ensure that treatment is working for the client rather than against him or her. Case management of these clients is ideally suited for social workers trained in both mental health and substance abuse treatment who can also advocate for their clients.

Ideally, the best and most effective treatment for co-occurring disorders is integrated treatment (Smith, 2007). Integrated treatment involves concurrent treatment for both disorders in one setting, usually with a multidisciplinary team of providers trained in the special needs of these clients. While the literature continues to support integrated treatment as the most effective form of treatment, there continues to be large-scale resistance from the systemic level to the provider level when it comes to implementation. Social workers have a unique opportunity to fill a major need by preparing to deal with these clients and stepping into treatment and case management roles that are becoming more prevalent.

What Next?
Practitioners and students wishing for more information on this topic may go to the Treatment Improvement Exchange Web site for access to several Treatment Improvement Protocols and Technical Assistance Publications (www.treatment.org/topics/dual_publications.html). An increasing number of workshops and trainings on these topics are slowly but surely becoming available.

Schools of social work and other similar professions need to incorporate coursework in the assessment and treatment of co-occurring disorders. Current practitioners should read the literature and attend continuing education workshops and courses to get the current best practices for assessing and treating co-occurring disorders.

— John K. Smith, PhD, LCSW, is a licensed psychotherapist with more than 25 years of experience in the mental health and chemical dependency fields and is program administrator for the Dual Diagnosis Day Treatment Program at Doctor’s Hospital of West Covina, CA. He is also a professor of alcohol and drug counseling at Mt. San Antonio College in Walnut, CA, and is the author of the recently published book Co-occurring Substance Abuse and Mental Disorders: A Practitioner’s Guide.

References

Carey, K.B., Purnine, D.M., Maisto, S.A., Carey, M.P., & Simons, J.S. (2000). Treating substance abuse in the context of severe and persistent mental illness: Clinician’s perspectives. Journal of Substance Abuse Treatment, 19(2),189–198.

Hall, M.N., Amodeo, M., Shaffer, H.J.B., Vander Bilt, J. (2000). Social workers employed in substance abuse treatment agencies: A training needs assessment. Soc Work, Mar; 45(2),141-155.

Minkoff, K. (2000). An integrated model for the management of co–occurring psychiatric and substance abuse disorders in managed-care systems. Disease Management and Health Outcomes, 8(5),251–257.

Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing (2nd Ed.): Preparing People for Change, New York: The Guilford Press.

Pirard, S., Sharon, E., Kang, S.K., Angarita, G.A., Gastfriend, D.R. (2005). Prevalence of physical and sexual abuse among substance abuse patients and impact on treatment outcomes. Drug and Alcohol Depen, 4;78(1),57-64.

Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B.Z. Keith, S.J., Judd, L.L., & Goodwin, F.K. (1990). Co–morbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiological Catchment Area (ECA) study. JAMA, 264, 2511–2518.

Smith, J. (2007). Co-occurring Substance Abuse and Mental Disorders: A Practitioner’s Guide. New York: Rowman and Littlefield.

Teaching the Rules of “Normal” Eating

May/June 2007

Teaching the Rules of “Normal” Eating
By Karen R. Koenig, LCSW, MEd
Social Work Today
Vol. 7 No. 3 P. 38

Our relationship with food is one of the most important we have. Therapists can help clients make it a healthy one.

Clients generally go to therapy to mend broken relationships, resolve childhood issues, find meaning and happiness in life, and learn how to cope more effectively with myriad stresses in their lives. Although eating or weight concerns may not be readily identified as problems, they often lurk in the background of sessions. Clients may guardedly allude to an eating binge, gripe about no longer fitting into clothes, or toss out an offhand comment about food rituals, such as eating in secret or weighing what they eat, but they won’t necessarily raise eating or weight as bona fide topics for therapy. It is our responsibility to help them understand that ongoing compulsive, emotional, and restrictive eating are as much grist for the mill as any other troubling and self-harming behaviors.

Therapists must have a proven model that will successfully help resolve these issues. It is not enough to tell overweight clients to join Overeaters Anonymous or Weight Watchers or even to visit their doctor to be put on a diet since 95% to 98% of people who diet to lose weight regain it in one to five years, and 90% of those people regain more than they originally lost. This statistic has remained steady for three decades.

Additionally, when people fail to keep off weight through dieting, they believe that it is their fault—that they lack willpower and self-discipline, don’t have a strong commitment to their health, and are helpless and hopeless. Nothing could be farther from the truth. Diets don’t work long-term because they distort and override natural appetite mechanisms, keep people overfocused on and obsessed with food and weight, generate extreme feelings of deprivation that lead to rebound eating, and leave dieters with lowered self-esteem from having failed when, actually, the deck was stacked against them.

Applying the Cognitive-behavioral Model to Eating
What works is an easy-to-follow, cognitive-behavioral treatment model that teaches clients the skills that “normal” eaters use to feel comfortable around food and maintain a healthy weight for life. Because the approach is skills-based, it motivates clients who feel frustrated and hopeless. The recognition that achieving a comfortable relationship with food does not happen through magic or quick fixes offers hope for permanently resolving their food issues and alters their attitude toward previous dieting failures.

Cognitive-behavioral therapy (CBT) posits that our beliefs produce our feelings and behaviors, and lasting change happens only from transforming irrational, unhealthy beliefs to rational, healthy ones. By altering our behavior, we may discover that our beliefs are invalid, and by modifying our feelings, we may notice shifts in our behavior; however, CBT encompasses a radical restructuring of the belief system which becomes the foundation for therapeutic change.

A cognitive-behavioral approach to learning “normal” eating has three facets, all of which must be addressed and attended to in order to achieve full recovery. The facets are as follows:

• reframing irrational beliefs about food, eating, body, and weight to rational ones;

• handling stress and distress effectively without focusing on food and weight; and

• practicing “normal” eating behaviors until they become habits.

By weaving back and forth among the three, clients make the small shifts necessary to let go of what is unhealthy and embrace cognitive, emotional, and behavioral health. Over time, clients think more rationally about food, eating, weight, and their body. Their emotional management skills begin to improve and new, functional behaviors supplant old, destructive ones.

Making Irrational Beliefs Rational
After explaining the CBT model, the focus is helping clients identify their beliefs about food, eating, weight, and body. This process may go slowly for clients unaccustomed to paying attention to their thinking, and the therapist should feel free to make suggestions. Exploring family of origin and cultural attitudes are the most productive ways to generate beliefs.

The next step is to distinguish rational from irrational beliefs by using the criterion of whether they are in the client’s long-term best interest; that is, are they cognitions that will enhance life? Examples of typical irrational beliefs of clients with eating problems include the following:

• I can’t stop myself from overeating.

• I’m a bad person for being out of control around food.

• I can’t trust my body to tell me when it’s full or satisfied.

• If I allow myself the foods I enjoy, I’ll never stop eating them.

• Food makes me feel better when I’m upset.

After irrational beliefs are identified, it is time to reframe them into positive, healthy, rational statements. Rational beliefs should be in the first person, present tense, and as concrete and simple as possible. Examples of the previously stated irrational beliefs reframed include the following:

• I can stop myself from overeating by paying attention to when I’m full and satisfied.

• Being out of control around food does not make me a bad person.

• Over time, I will learn to trust my body to tell me when it’s had enough to eat.

• By giving myself permission to eat foods I enjoy, I will be able to eat them in moderation.

• I can find effective ways to feel better when I’m upset besides eating.

Clients should review rational beliefs every day, the more frequently the better. Clients also need to continue adding to their beliefs’ list and reframing them as they recognize more of their “stinkin’ thinkin’.” Additionally, clients need to reframe their core beliefs, especially around instant gratification, magical thinking, perfection, reaching a specific body weight, deserving happiness, and being lovable.

Managing Stress and Distress Without Focusing on Food and Weight
Teaching clients how to meet their emotional needs without food is twofold: It helps them get their eating under control and leads to effectively meeting their authentic emotional needs. Every time clients who are stressed or distressed overeat or eat when they’re not hungry, they miss a valuable chance to improve their life. Not surprisingly, clients who learn to feel more comfortable in their bodies and around food also experience greater satisfaction with life in general.

Initially, emotional work should focus on teaching clients the purpose of emotions—to move toward pleasure and away from pain—on recognizing when they are experiencing them and distinguishing among them. Undoubtedly, clients will need to explore their fears about uncomfortable feelings before being able to experience and express them effectively. When clients comprehend how and why they abuse food to avoid and minimize internal discomfort, they can move on to allow themselves to bear and learn from emotional pain.

Using a step-by-step process to experience emotions gives clients something to do with feelings. When they get a hint that they’re feeling one, they should do the following:
• acknowledge that they might have a feeling;

• identify the emotion;

• experience it;

• recover from it; and

• deal with it (optional).

Each stage is crucial in emotional management and regulation. Because feelings are often ignored or go unrecognized, clients need help translating body sensations into emotions. Next, they require guidance in putting their finger on exactly what they’re feeling, not simply saying they’re upset or unhappy. Experiencing feelings is the most difficult step, but it becomes easier as clients address and resolve their fears of emotional pain. Recovering from experiencing an emotion means not making judgments about what was felt and, instead, applauding the self for tolerating intense affect. Clients may or may not need to do something with an emotion—a dressing down by their boss may require further discussion or clarification, whereas the loss of a loved one may call for tolerating waves of intense emotion, including grief, loneliness, and perhaps even conflicting feelings and little other activity.

Encouraging “Normal” Eating Behaviors
The word “normal” is in quotes because there are a range of eating styles—from people who eat two large meals a day to those who eat small amounts every few hours—but all “normal” eaters adhere to the following four simple rules:

• eating when they are hungry or have a craving;

• choosing foods that will intuitively satisfy them;

• eating with awareness and enjoyment; and

• stopping eating when they’re full or satisfied.

Hunger and Cravings
Teaching clients the rules of “normal” eating starts with helping them identify physical hunger and cravings. Cravings are yearnings for a specific food that seem to spring forth organically—we want kiwi fruit, peanut butter, something salty, a Rome apple, a prune Danish. Clients can be taught to recognize hunger through connecting to body cues such as intestinal grumbles, light-headedness, queasiness, hollowness in the chest, emptiness in the stomach, a mild headache, or irritation. Food tastes best when we are moderately hungry, and clients should use a one to 10 number scale to determine their hunger level—zero is not hungry, and 10 is famished.

Clients who don’t allow themselves to be physically hungry and eat constantly to avoid hunger should be encouraged to tolerate hunger as they explore their beliefs about wanting food and feeding themselves. Naturally, discussions of physical hunger often lead to exploring other kinds of hungers and fears about wanting and needing too much. In order for clients to feel comfortable with this physical sensation, they may need work on allowing themselves to have needs and meeting them.

It is often difficult for clients to separate mouth hunger from stomach hunger and cravings. Mouth hunger is generated by emotional discomfort because chewing, swallowing, and filling up on food distract from and modulate distress. Clients learn to distinguish between mouth and stomach hunger by returning to examining body signals for food as fuel.

Making Satisfying Food Choices
The second rule of “normal” eating is choosing food that is intuitively satisfying. With a daily bombardment of messages about what we should and shouldn’t eat, it’s difficult to put aside nutrition and health information and turn inward to ask the body what it desires. Overeaters fear that if they ask themselves this question, the answer will always be high-calorie, high-fat food. But, in fact, when clients stop thinking in terms of “good” and “bad” food, they are able to make more satisfying choices. Foods are neither “good” nor “bad”; they may be nutritious or nonnutritious, but they have absolutely no moral value. Moreover, eating (or not eating) makes us neither saints or sinners. These are irrational thoughts left over from the diet mentality.

Compulsive/emotional eaters must learn to tune into what their bodies want and eat the foods that will satisfy them before they can start tweaking their diets to make them more nutritious. If they intervene prematurely, before “normal” eating beliefs and behaviors take hold, they will regress and return to obsessing about food in good and bad terms. To select satisfying food, they need to discover whether they want something light or substantial, salty, sweet, mushy, crunchy, hot and spicy, bland, creamy, or icy. What food they desire is related to their hunger level, as well as to their mood, activity level, and general food preferences.

To make satisfying food choices, clients must challenge and counter the inner critic that insists they shouldn’t eat anything fattening and must only eat healthy foods. They need to think like “normal” eaters—any food is fair game that they can eat any time (except, of course, if they’re allergic to it) in any quantity. Knowing this enables eaters to make choices they believe will satisfy them and stop when they are full or satisfied. They don’t have to feel guilty or finish all their food because they’re eating from a premise of abundance and choice, not deprivation, and from self-affirmation, not rebellion.

Eating Awareness and Enjoyment 
The main reason that people have difficulty eating with awareness and enjoyment is that they eat too quickly to taste their food. They’re in a rush to get rid of offending food so that they will stop feeling guilty or because they picked up a rapid eating habit in childhood. Teaching clients to slow down and taste their food will positively revolutionize their eating. Chewing food releases its flavor. Letting food sit on their tongue enables taste buds to do their job, which is to signal satisfaction to the brain. When people eat quickly, they don’t let food rest on their tongue long enough to know they’ve had enough. Instead, they keep eating and looking for satisfaction but never find it.

Stopping Eating When Full or Satisfied
Without a doubt, this fourth rule is the hardest to abide by. However, it becomes easier when clients have followed the first three rules. If they eat when they are moderately hungry, choose food they expect to enjoy, eat with awareness and toward a goal of pleasure, they will be in a good position to stop when they’re full or satisfied.

Full means they’ve eaten a sufficient amount of food and is a quantitative assessment; satisfaction is about fulfilled desire and is a qualitative judgment. Although some habitual behavior is involved in overeating, more often than not, eating beyond “enough” is linked to irrational beliefs about saying no to food, wasting it, leaving it on one’s plate, getting one’s money’s worth, and throwing it away.

Clients need to understand that everything they learned in childhood about eating must be evaluated as beneficial or not, including the eating behaviors and attitudes about food and weight of their role models. Most importantly, clients have to learn to tolerate the sadness and anxiety they will undoubtedly feel when they stop eating at fullness or satisfaction and have left over food. If they’re sad, they can remind themselves that they can eat the food again another time. If they’re anxious about not wasting food, they can consider that there are no longer food police in their life, and they alone are the arbiter of their behavior. Learning to ride out anxiety about uneaten, unfinished food is key to overcoming dysfunctional eating.

Clinician’s Own Eating and Weight Issues
Clients generally know little about us, but they can’t help but notice our weight. To help them, we must examine our own attitudes about food and body size. Are we avoiding their concerns because of our own body shame? How “fat phobic” are we? Can we help clients with their struggles in spite of our own?

Although we may not be able to resolve our eating and weight issues, we must recognize how we buy into fat phobia, diets, envying ultra-thinness, and not trusting our own bodies and appetites. Talking with clients who have similar concerns may expose our shame and make us uncomfortable, but we cannot help them if we are not willing to tackle the subject ourselves.

Getting Help
Once a client is well on his or her way toward “normal” eating, it is helpful for him or her to meet with a registered dietitian who will support nondieting and encourage intuitive eating. Continued discussion in therapy of situations that trigger food abuse is essential, as is ongoing work on experiencing and effectively expressing emotions. Self-esteem groups can be useful for clients with eating problems, especially if they are self-conscious about their weight. Additionally, reading about intuitive eating, joining an antidiet support group, online chat room, or message board, or attending a workshop will all help normalize intuitive eating and strengthen clients’ skills.

— Karen R. Koenig, LCSW, MEd, is a cognitive-behavioral therapist and educator in Sarasota, FL. She has more than 25 years of experience treating compulsive/emotional and restrictive eaters and is the author of several books including of The Rules of “Normal” Eating — A Commonsense Approach for Dieters, Overeaters, Undereaters, and Everyone In Between!

Reference

Bennett, W.I. (1995). Beyond Overeating. **NEJM##. 332(10);673-674.