Family Therapy and Mental Health

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Family Therapy and Mental Health

• University of Guelph
• Office of Open Learning

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Course Instructor

• Carlton Brown, M.Sc., M.Div., RMFT
• 3-1216 Upper Wentworth Street, Hamilton ON L9A
  4W2
• Tel [phone]
• Email carl_at_mftsolutions.ca
• Slides http//www.mftsolutions.ca/Pages/MentalHea
  lthCourse.html

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By the End of Today

• Schizophrenia and Bipolar Disorder
• DSM Criteria
• Types of Intervention
• Medications
• Videos
• Student Presentation
• Experiential Activities

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How Are We Doing So Far?

• Comments and/or Fishbowl
• What do you like about mental health?
• What do you not like about mental health?
• What do you want to do before the end of the
  course?

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Definition of a Mental Disorder

• clinically significant behavioral or
  psychological syndrome or pattern that occurs in
  an individual and that is associated with present
  distress (e.g., a painful symptom) or disability
  (i.e., impairment in one or more important areas
  of functioning) or with a significantly increased
  risk of suffering death, pain, disability, or an
  important loss of freedom.

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Mental Disorder, continued

• Must not be expectable and culturally sanctioned
  response to a particular event (e.g. death of
  loved one)
• Must be a current manifestation of dysfunction
• Deviant behaviour and conflicts with society are
  not included unless the deviance or conflict is a
  symptom of individual dysfunction, as above

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But What About....

• Mental Order, or a
• Manual of the Sanities
• Christopher Peterson and Martin E.P. Seligman
  (2004), Character Strengths and Virtues A
  Handbook and Classification. Washington DC and
  New York American Psychological Association and
  Oxford University Press

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The DSM

• Preamble
• Childhood, Cognitive Disorders, Medical
  Conditions and Substance Abuse
• Schizophrenia and Other Psychotic Disorders
• Mood
• Anxiety
• Interlude
• Body, Faking, DID, Sex, Eating, Sleeping,
  Impulse-Control and Adjustment
• Personality and Postlude

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Mental Illness Categories

• Thinking
• Feeling
• Behaving

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Beware of Categories!

• Thinking affects feeling
• e.g. expectation, mood, and winning the lottery
• Feeling affects thinking
• e.g. Becks Cognitive Triad
• Im worthless
• The world is unfair
• Its not going to get better
• Thinking and Feeling affect Behaviour
• Behaviour affects Thinking and Feeling

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Thinking (Psychosis)

• DSM Chapter on Schizophrenia and Other Psychotic
  Disorders
• psychosis si'kos?s
• noun ( pl. -ses -?sez)
• a severe mental disorder in which thought and
  emotions are so impaired that contact is lost
  with external reality.
• ORIGIN mid 19th cent. from Greek psukhosis
  animation, from psukhoun give life to, from
  psukhe soul, mind.

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Psychotic

• delusions
• hallucinations
• lack of insight
• or maybe with insight
• broaden to include other positive symptoms of
  schizophrenia (disorganized speech, disorganized
  or catatonic behaviour)
• too broad unable to cope with life
• loss of ego boundaries

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(No Transcript)
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Im Still Here

• The Truth About Schizophrenia

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Schizophrenia

• lasts for at least 6 months
• includes at least one month of active symptoms
  (delusions, hallucinations, disorganized speech,
  disorganized behaviour, negative symptoms - 2 or
  more unless severe)

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Schizophrenia and Other Psychotic Disorders

• Schizophrenia
• Schizophreniform Disorder
• less than six months, better functioning
• Schizoaffective Disorder
• active symptoms before or after (active symptoms
  mood)
• Delusional Disorder
• one month of nonbizarre delusions

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Schizophrenia and Other Psychotic Disorders

• Brief Psychotic Disorder
• 1 day to less than 1 month
• Shared Psychotic Disorder
• same content as another person of longer duration
• Psychotic Disorder due to a General Medical
  Condition (including substance-induced)
• Psychotic Disorder Not Otherwise Specified (NOS)

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Schizophrenia

• Characteristic signs and symptoms
• Positive and negative symptoms
• Present for most of a month (less if treated)

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Schizophrenia

• Some signs persisting for at least 6 months
• Marked social or occupational dysfunction
• Not better accounted for by something else

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Schizophrenia

• Wide range of cognitive and affective dysfunction
• A lot of variation among individuals

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Schizophrenia

• Positive symptoms
• Excessive or distorted normal functions
• Negative symptoms
• Diminution or loss of normal functions

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Positive Symptoms of Schizophrenia

• Psychotic
• Delusions distorted thought content
• Hallucinations distorted perceptions
• Disorganized
• Disorganized speech distorted language and
  thought process
• Grossly disorganized or catatonic behaviour
  distorted self-monitoring of behaviour

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Negative Symptoms of Schizophrenia

• Affective flattening
• Restricted range and intensity of emotional
  expression
• Alogia
• Restricted fluency and productivity of thought
  and speech
• Avolition
• Restricted initiation of goal-directed behaviour

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Delusions

• Erroneous beliefs
• Usually involve misinterpretations of perceptions
  or experiences
• Many possible themes

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Delusional themes

• Persecutory someone (maybe you) is out to get me
• Referential that TV announcer is talking about
  me, newspaper article is about me, biblical
  prophecy is about me
• Somatic I have cancer, gas poisoning, a
  transmitter planted in my brain

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Delusional themes

• Grandiose I actually work for the CIA, Im the
  son of God, etc.
• (personal experience two deities can coexist on
  the same floor, but not two government agents)
• Religious delusions are common, especially if the
  person is having auditory hallucinations (Who is
  speaking?), and also because of lot of our
  subclinical cultural context is religious

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Bizarre Delusions

• Sometimes difficult to judge what is bizarre
• If clearly impossible or not derivative of normal
  life experience, then bizarre
• E.g. someone has removed all my internal organs
  and left no marks (bizarre) vs. the police are
  watching me when in fact not true (nonbizarre)

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Hallucinations

• Most common hearing a voice or voices
• Must be fully awake
• Must not be culturally condoned
• One or more voices carrying out a running
  commentary on the persons behaviour is
  considered particularly characteristic of
  Schizophrenia

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Disorganization

• Thinking
• Evidenced in speech, changes topics, tangential
  conversation, loose associations (I saw a duck
  which means Ill lose my job today)
• Severely disorganized word salad,
  incomprehensible
• Mild disorganization is normal in university
  course instructors and other non-schizophrenic
  individuals

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Disorganization

• Behaviour
• Avolition, non goal oriented behaviour
• Silliness
• Unpredictable agitation
• Poor attention to ADLs (activities of daily
  living), e.g. disheveled
• Inappropriate, e.g. winter coat in summer, public
  masturbation, unpredictable shouting, swearing

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Catatonia

• Decreased reactivity to environment
• Varying degrees
• May be unaware of surroundings, may actively
  resist movement, assume bizarre posture, etc.
• May be secondary to something else, not
  necessarily diagnostic of schizophrenia

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Diagnosis

• Characteristic Symptoms (2 or more)
• Delusions (1 if bizarre)
• Hallucinations (1 if commentary or two or more
  voices - see Im Still Here clip)
• Disorganized speech
• Disorganized behaviour
• Negative symptoms
• Social or occupational dysfunction

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Diagnosis, cont

• C. Duration
• Acute 1 month
• Continuous signs 6 months
• D. Exclude
• Schizoaffective Disorder
• Mood Disorder with Psychotic features
• E. Exclude general medical condition or substance
  abuse

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Diagnosis, cont.

• F. Consider Autistic or other Pervasive
  Developmental Disorder, Schizophrenia may be
  added under certain conditions

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Subtypes

• 295.30 Paranoid (high functioning)
• 295.10 Disorganized (hebephrenic)
• 295.20 Catatonic (Echolalia, Echopraxia)
• 295.90 Undifferentiated (Criterion A met)
• 295.60 Residual (at least one past episode of
  schizophrenia, some continuing disturbance)

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Schizophreniform Disorder

• Like Schizophrenia (Criterion A met, delusions
  and hallucinations), except
• Total duration is 1 6 months (i.e. less than 6
  months)
• Dont have to have impaired social or
  occupational functioning (Criterion B)

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Schizoaffective Disorder

• A. Meets criterion A for Schizophrenia and at
  some point of active illness has a significant
  mood disturbance (depressed, manic or mixed)
• B. At least two weeks of delusions or
  hallucinations without mood disturbance
• C. Mood symptoms most of the time

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Delusional Disorder

• One or more nonbizarre delusions that persist for
  at least 1 month
• Minor hallucinations allowed
• Functioning is not impaired apart from the impact
  of the delusion, e.g. if the mafia are after me,
  I might wear a disguise

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Delusional Subtypes

• Erotomanic Anne Murray is in love with me
• Grandiose I am an advisor to the president, or
  I have a special message from God (nonbizarre)
• Jealous my spouse is unfaithful
• Persecutory Im being poisoned, blackballed,
  talked about
• Somatic I have bad body odor, lice, my bowel
  isnt functioning properly

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Brief Psychotic

• Sudden onset of positive symptoms
• Lasts at least a day but less than a month, and
  the person returns to full functioning
• Exclude Mood Disorder with Psychotic Features,
  Schizoaffective Disorder, Schizophrenia,
  substance abuse and general medical condition

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Shared Psychotic

• Develops in an individual who has a close
  relationship to another who already has a
  psychotic disorder with prominent delusions
• Results in shared delusions
• Very rare

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The Positive and Negative Syndrome Scale (PANSS)

• A medical scale used for measuring symptom
  severity in patients with schizophrenia
• Name refers to the syndrome of positive symptoms
  (present) and negative symptoms (absent) observed

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The Positive and Negative Syndrome Scale (PANSS)

• Developed by Kay, S.R., Fiszbein, A. Opler, L.
  (1987)
• Integration of the Brief Psychiatric Rating Scale
  and the Psychopathology Rating Scale
• 30-item scale 7 positive symptoms, 7 negative
  symptoms, 16 general psychopathology items
• Scored on 7-point Likert scale by severity

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The Positive and Negative Syndrome Scale (PANSS)

• Benefits
• Broad evaluation
• Good reliability and validity (used extensively
  in research)
• Challenges
• Assessment is based on patients perceptions
• Long interview (30-40 min.) could be hard to
  focus or tiring for patient

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Impact on Relationships

• Video clip - A Beautiful Mind
• True story
• Man with schizophrenia
• Well developed delusions
• Some of what you see is true
• Some of what you see is not true
• Imagine being his wife

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Psychosis and Marriage

• Michael P. Maniacci, The Psychotic Couple in
  J. Carlson L. Sperry, eds (1998), The
  Disordered Couple (Bristol, PA Brunner/Mazel),
  pp. 57 - 81

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Psychotics do Marry

• Large variation in functioning
• Often intelligent eccentric good mate
• Tend to attract partners who are either
  controlling or dependent
• Either tends to increase stress on the
  psychosis-prone partner so that illness
  precipitates

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Development of Psychosis

• Predispositions
• Detached style of relating
• Eccentric
• Sense of not belonging, or of being different
• Two parallel thought patterns develop
• Consensually validated
• Idiosyncratic (private fantasies)
• Meet the minimum requirements of community, live
  in private world

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Development of Psychosis

• Add stress
• Detached style leads to social isolation and
  makes goal-attainment difficult
• Failed goals leads to setting higher goals and
  more failure
• Retreat into private (fantasy) world, now even
  less successful
• Biological vulnerability activated

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Relational Dynamics

• Controlling partner expects performance, places
  demands, increases stress, and obtains secondary
  gains when partner falls ill
• Dependent partner leans on psychotic partner for
  leadership, increases stress, psychotic partner
  falls ill, and dependent partner rallies
  temporarily so the psychotic partner can rest

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Postpsychotic Conflicts

• Psychosis gives the affected partner a vacation
  but the experience is traumatic to the partner
  and to the patient

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Treatment

• Manage the psychosis
• Engage the non-psychotic partner to address his
  or her needs and lend support and understanding
• Explore the relational dynamics
• Modify individual psychodynamics

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Manage the Psychosis

• Medication helps
• Dopamine receptor antagonists (standard
  antipsychotics or neuroleptics)
• Haldol (haloperidol)
• Thorazine (chlorpromazine)
• Serotonin-dopamine antagonists (atypical
  antipsychotics or neuroleptics)
• Risperdal (risperidone)
• Clozaril (clozapine)

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Newer Antipsychotics

• Olanzapine
• Sertindole
• Quetiapine

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Treatment Protocols

• Choose a medication that has tolerable side
  effects, start with a low dose
• Standard antipsychotics have extrapyramidal side
  effects (movement disorders)
• Atypical antipsychotics have a host of other side
  effects (leukopenia, weight gain)
• Consider ECT as an alternative therapy

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What MFTs can do

• Encourage patients to be patient with their
  doctors (the right medication at the right dose
  takes time)
• Encourage patients to tell their doctors what
  their side effects are (stiffness, weight gain,
  sexual dysfunction)
• Encourage patients to stay on their medications
  even when they feel well

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Effectiveness Research

• William R. McFarlane et al. (2003), Family
  psychoeducation and schizophrenia a review of
  the literature. Journal of Marital and Family
  Therapy 29 (2), 223-245

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Family Interventions for Schizophrenia

• The Role of MFTs in Treatment
• of Serious Mental Illness

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Background The Concept of
Expressed Emotion

• Expressed Emotion (EE)
• Came about from studying why patients relapsed
• Developed over a twelve year span, 1956-1968,
  involving three different research projects
• Found that patients were more likely to relapse
  if returning home to their parents or wives

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Background The Concept of
Expressed Emotion

• Patients were believed to be susceptible to
  sensory overload
• Three main components correlated highly with
  relapse
• Criticism, hostility, and over-involvement
• Challenge How to reduce these elements
• without blaming families?

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Family Interventions for Schizophrenia

• Four levels of intervention
• (Marsh Lefley, p.55)
• Family Consultation
• Family Education
• Family Psychoeducation
• Family Therapy

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1) Family Consultation

• Meet with family members at or close to initial
  crisis
• Connect through identifying and normalizing
  feelings
• Provide information regarding illness and
  treatment options
• Help formulate service plan
• Connect with community resources

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2) Family Education

• Approximately 80 of patients not on meds and 40
  on meds relapse within one year of discharge
• By reducing high EE in families, relapse rates
  can go down to 13
• Need to provide effective aftercare for patients
  by forming cooperative relationships with the
  patients families

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2) Family Education

• Survival Skills for Families
• Information about illness
• Information about illness management
• Coping Strategies
• Return to Functioning
• Continued Treatment or Disengagement

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3) Family Psychoeducation

• Takes advantage of group cohesion to
• address stigma and reduce isolation
• increase hope and empower families
• assist with problem solving
• model appropriate boundaries

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3) Family Psychoeducation

• Psychoeducational approach is in use most
  extensively with families of patients with
  schizophrenia
• Families are the de facto caretakers of
  individuals with schizophrenia since
  deinstitutionalization
• Families can be trained to create an
  interactional environment that compensates for
  functional disability

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3) Family Psychoeducation

• Need to regulate attention and arousal by
• Antipsychotic medication
• Reducing the intensity, negativity, quantity, and
  complexity of stimuli from the environment

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3) Family Psychoeducation

• Educational Workshop
• 4 -7 families, 1 ½ - 2 hours, bi-weekly for 6-24
  months
• Begin with informal lecture and discussion with
  AV aids, handouts, etc.
• Sessions centre around the Family Guidelines

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3) Family Psychoeducation

• Structure of sessions (p.376)
• Socialize, follow-up on task and weeks events
• Report from family
• Present relevant biosocial information
• Reminder/explanation of family guideline
• Define a workable problem
• Focus either on communication skills or problem
  solving
• Review

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3) Family Psychoeducation

• Other techniques
• Modeling (e.g. low-key)
• Sharing common experiences
• Normalize and validate
• Mourning losses
• Emphasize strengths
• Build hope and optimism
• Shifting boundaries (e.g. cross-parenting
  interventions)

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4) Family Therapy

• May be provided as an adjunct to other treatments
• Not recommended in the acute or stabilization
  phases
• Most common method is BFT (see Falloon, Boyd
  McGill, 1984 Miklowitz Goldstein, 1997 Mueser
  Glynn, 1999) with focus on communication skills
  and problem solving

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4) Family Therapy

• Medical Family Therapy (McDaniel, Hepworth
  Doherty, 1992)
• Integrates concerns about health and illness in a
  systems framework for psychotherapy
• An approach to psychosocial aspects of illness
• Can be adapted and expanded with different
  theoretical orientations

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Medical Family Therapy Techniques

• Recognize biological dimension
• Solicit the illness story
• Respect defenses, remove blame, accept
  unacceptable feelings
• Maintain communication
• Attend to developmental issues
• Increase a sense of agency in patient and family
• Leave the door open for future contact

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Soliciting the Illness Story

• Listen empathically
• Attempt to understand the families experience of
  the illness
• Empathy, respect, non-judgemental, emphasize
  strengths

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Soliciting the Illness Story

• Sample questions
• What do you think caused the illness?
• What do you fear most about it?
• What might make healing now a struggle for you?
• What changes in the family do you think will be
  needed now?
• How do you expect other family members will react
  to this?

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Soliciting the Illness Story

• Take a genogram with the family to trace their
  particular history with illness and loss
• Find out about family beliefs, myths, or legacies
  about illness and health
• What do these mean to family members?
• How do they contribute to or create a barrier to
  healing?
• Be sensitive to and curious about
• Cultural differences and religious beliefs

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Developmental Issues

• Progression of illness
• Interaction between illness and individual/
  family development
• Interaction between illness, patient, family, and
  caregiver system
• Put the Illness In its Place
• Dont allow the illness to dominate the familys
  schedule or organize the familys emotional life

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Family Treatment Models

• Behavioural Family Therapy

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Behavioural Family Therapy

• Non-blaming stance ideal for these families
• The concept that families develop patterns of
  behaviour that, while appearing counterproductive
  to the observer, nevertheless represent their
  best efforts to respond to their current
  circumstances is the cornerstone of BFT
  (Falloon, p.67)

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Behavioural Family Therapy

• Most extensively studied model of family
  intervention for severe mental illness
• Combines education and social learning strategies
  designed to equip families with knowledge and
  skills to better manage illness
• Particular focus on communication and
  problem-solving skills

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Behavioural Family Therapy

• Assessment (Falloon, 1991)
• Conducted on two levels
• Problem analysis
• Functional analysis
• Problem analysis is the process of pinpointing
  the exact behaviours that are causing concern
• Functional analysis attempts to define the
  context in which these behaviours contribute to
  dysfunction

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Behavioural Family Therapy

• Problem Analysis
• Individual, dyadic and family sessions are used
  to join with the family and to explore each
  family members perception of the problem
• Patience and focus are needed to help family
  describe problem in specific behavioural terms
• Charting may be used to track frequency of
  problem behaviours

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Behavioural Family Therapy

• Problem Analysis
• At the completion of this phase the therapist
  will
• Have pinpointed one or more family problems
• Have defined the frequency of their occurrence
• Have some preliminary hypotheses about the
  factors contributing to the problem(s)
• A hierarchy of problems to address may need to be
  established

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Behavioural Family Therapy

• Functional Analysis
• Extends problem analysis to the system level
• Identifies antecedents and consequences of
  problem behaviour
• Antecedents are stimuli that trigger behaviour
  (e.g. loud noise, drug use, lack of sleep)
• Consequences are reinforcing stimuli that either
  increase or decrease probability of behaviour
  reoccurring

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Behavioural Family Therapy

• Sample questions for functional analysis
• What would the person (or family) gain or lose if
  the problem were resolved?
• Who (or what) reinforces the problem with
  attention, sympathy, and support?
• Under what circumstances is the problem increased
  or decreased in intensity?
• What do family members currently do to cope with
  the problem?

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Behavioural Family Therapy

• Functional Analysis
• Also includes investigation into strengths and
  weaknesses of family in coping with problem
• Coping methods are evaluated in terms of
  effectiveness
• Shaping the familys existing coping skills is
  much easier than teaching new skills from scratch
• Narrative exceptions
• Solution focused translate old
  skills to new problem

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Behavioural Family Therapy

• Five Techniques
• Education
• Communication training
• Problem-solving training
• Operant conditioning
• Contingency contracting

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Behavioural Family Therapy

• Education
• Could include information on illness, individual
  and family development, principles of social
  learning, stress management, etc.
• Goal is to provide family with rationale for
  management of the problem and subsequent
  interventions

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Behavioural Family Therapy

• Communication training
• Skills include active listening, expressing
  positive feelings, making positive requests,
  expressing negative feelings, compromise and
  negotiation, and requesting time out
• See Mueser p.64-66 in text for summary of skills
  and steps to training
• Note communication skills need to precede
  problem-solving skills

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Behavioural Family Therapy

• 3. Problem-solving guidelines (Jacobson
  Christensen, 1996)
• In stating a problem, try to begin with something
  positive
• Be specific
• Express your feelings
• Be brief when defining problems
• Both people should acknowledge their role in
  creating and maintaining problem

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Behavioural Family Therapy

• 3. Problem-solving guidelines
• Discuss only one problem at a time
• Paraphrase
• Dont make inferences - talk only about what you
  can observe
• Be neutral rather than negative
• Focus on solutions

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Behavioural Family Therapy

• 3. Problem-solving guidelines
• Behaviour change should include mutuality
• and compromise
• Discuss pros and cons of proposed solutions
• Reach agreement

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Behavioural Family Therapy

• 4. Operant Conditioning Strategies
• Two predominant methods
• Shaping
• Time out procedures
• Taught through instruction, behavioural
  rehearsal, and modeling

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Behavioural Family Therapy

• 5. Contingency Contracting
• Used to replace hostile, coercive, blaming
  patterns by cooperative, mutually pleasing
  behaviour
• Contract between two or more family members that
  specifies behaviours each desires the other to
  perform
• Rewards are included and specified

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• Lunch

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Bipolar Disorder

• Cynthia

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Mr. Jones
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Manic Episode

• Abnormally and persistently elevated, expansive,
  or irritable mood
• Must last at least 1 week or result in a hospital
  stay
• At least 3 of
• Inflated self esteem or grandiosity
• Decreased need for sleep
• Pressure of speech

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Manic Episode, continued

• At least 3 of, continued
• Flight of ideas
• Distractibility
• Increased goal seeking or psychomotor agitation
• Excessive involvement in risky, pleasurable
  activities (shopping, sex, foolish business
  investments)
• Exclude Mixed Episode

100
Manic Episode, continued

• Marked impairment in occupational or social
  functioning
• Not due to substance or medical condition

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Major Depressive Episode

• Five or more of the following over a two week
  period, at least one of the first two
• Depressed mood (irritable child or adolescent)
• Diminished interest or pleasure in almost all
  activities most of the day, every day
• Significant unintentional weight loss/gain
• Insomnia or hypersomnia
• Psychomotor agitation or retardation

102
Major Depressive Episode

• Five or more, continued
• Fatigue or loss of energy
• Feelings of worthlessness or excessive guilt
• Difficulty thinking or concentrating
• Recurrent thoughts of death, SI, with or without
  plan
• Exclude Mixed Episode
• Significant impairment of occupational or social
  functioning

103
Major Depressive Episode

• Not due to drugs or a medical disorder
• Not due to bereavement

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Mixed Episode

• At least a week where, every day, the criteria
  are met for a manic episode and a major
  depressive episode
• Marked impairment in social or occupational
  functioning or requires hospitalization or has
  psychotic features
• Not due to drugs or a general medical condition

105
Hypomanic Episode

• Abnormally and persistently elevated, expansive
  or irritable mood lasting at least 4 days
• At least three of
• Inflated self esteem or grandiosity (non
  delusional)
• Decreased need for sleep
• Pressure of speech

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Hypomanic

• At least three, continued
• Flight of ideas
• Distractibility
• Increased goal-seeking or psychomotor agitation
• Excessive involvement in high risk pleasure
  activities
• Four of the above if irritable
• Otherwise like Manic Episode except not
  delusional or hallucinatory

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Bipolar Disorders

• Bipolar I
• One or more manic or mixed episodes
• At least one major depressive episode
• Dont count substance or medical condition
  induced episodes
• Exclude schizoaffective disorder and other
  psychotic disorders

108
Bipolar Disorders

• Bipolar II
• One or more major depressive episodes
• At least one hypomanic episode
• Bipolar I
• Mostly up, more likely hospitalized for mania
• Bipolar II
• Mostly down, more likely hospitalized for
  depression

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Treatment

• Lithium and other mood stabilizers
• Very effective, bad side effects
• Go back and review the treatments for
  schizophrenia
• Apply the same techniques, adapted for primarily
  mood disorders

110
Stigma Mental Health

• 1 in 5 Canadians will develop a mental health
  problem in their lifetime (CAMH)
• Many do not seek help because of the stigma of
  having a mental health problem
• Stigma includes
• Prejudice (neg. attitudes)
• Discrimination (neg. behaviours)

111
Stigma Mental Health

• Stigma affects people in three ways
• Exclusion from normal activities and
  opportunities including work, housing, etc.
• Internalization stigma is internalized,
  contributing to shame and isolation
• Contributes to maintaining the secret

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330 430

• Benny and Joon
• Therapist tag
• Charades
• SRS

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(No Transcript)
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430 500

• Next class Friday, October 1st
• Here (same place)
• Personality Disorders