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1
Family Therapy and Mental Health
University of Guelph
Office of Open Learning
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Reflections on the Course So Far
Comments Questions Assignments
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Today
This is the End! Family Therapy and Eating Disorders Life in the CRPO Jeopardy Evaluations
Family Therapy &Eating Disorders
Assessment and Treatment
Spectrum of Weight-related Disorders
AnorexiaNervosa
BulimiaNervosa
Disordered Eating
Unhealthy Dieting
Binge Eating Disorder
Obesity
DSM 5 Criteria: AN
A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight.
C. Disturbance in the way in which one’s body, weight or shape is experienced, undue influence of body, weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight.
DSM 5 Criteria: AN
Restricting type: during the last 3 months, the individual has not
engaged in recurrent episodes of binge eating or purging behaviour. This subtype describes presentation in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise
Binge-eating/purging type: during the last 3 months, the individual has
engaged in recurrent episodes of binge eating or purging behaviour
DSM 5 Criteria: BN
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
Eating, in a discrete period of time (any 2 hr. period) an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
A sense of lack of control over eating during the episode (can’t stop or control what or how much one is eating)
DSM 5 Criteria: BN
2. Recurrent inappropriate compensatory behaviours in order to prevent weight gain (e.g. vomiting; use of laxatives, diuretics, enemas, or other meds; fasting or excessive exercise)
3. The binge eating and inappropriate compensatory behaviours both occur, on average, at least 1x/wk for three months
4. Self-evaluation is unduly influenced by body shape and weight
5. The disturbance does not occur exclusively during episodes of AN
DSM 5 Criteria: BED
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
Eating, in a discrete period of time (any 2 hr. period) an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
A sense of lack of control over eating during the episode (can’t stop or control what or how much)
DSM 5 Criteria: BED
B. The binge-eating episodes are associated with three (or more) of the following:
Eating much more rapidly than normal Eating until feeling uncomfortably full Eating large amounts of food when not hungry Eating alone because of embarrassment Feeling disgusted with oneself, depressed, or very
guilty afterward
DSM 5 Criteria: BED
C. Marked distress regarding binge eating is present
D. The binge eating occurs, on average, at least 1x/wk for 3 months
E. The binge eating is not associated with the regular use of inappropriate compensatory behaviours and does not occur exclusively during the course of AN or BN
Eating Disorders:Prevalence
Total # of cases in the population Indicates the demand for care Anorexia
0.3% for young females Bulimia
1% in women; 0.1% in men Binge Eating
1% in general population
(van Hoeken, Seidell & Hoek, 2005)
Eating Disorders:Incidence
# of new cases in pop. in a specified period of time (usually one year)
Represents the moment of detection vs. onset
Anorexia 8 per 100,000
Bulimia 12 per 100,000
(van Hoeken, Seidell & Hoek, 2005)
Eating Disorders &Mortality
mortality rate associated with AN is 12 times higher than the death rate of ALL causes of death for females 15 – 24 years old
20% of people suffering from anorexia will prematurely die from complications related to their eating disorder, including suicide and heart problems
National Association of Anorexia Nervosa and Associated Disorders
Etiologyor
Etiology
Eating disorders are multi-determined “Unlike some illnesses, recognizing the
cause(s) does not necessarily suggest a solution” (Lask & Bryant-Waugh, p. 51) e.g. CBT approach (Fairburn)
Predisposing, precipitating and perpetuating factors
Individual, family, and sociocultural factors
Assessment
ScreeningThe SCOFF Questionnaire
1. Do you ever make yourself Sick because you feel uncomfortably full?
2. Do you ever worry you have lost Control over how much you eat?
3. Have you recently lost more than One stone (6.35 kg) in a three month period?
4. Do you believe yourself to be Fat when others say you are too thin?
5. Would you say that Food dominates your life? A score of more than 2 positive answers indicates a
need for a more detailed assessment(John Morgan, BMJ, 1999)
AssessmentSymptoms of AN
weight loss amenorrhea depression irritability sleep disturbance fatigue weakness headache
dizziness faintness constipation non-focal abdominal
pain feeling of “fullness” polyuria intolerance of cold
Mehler & Andersen, 1999
AssessmentSigns of AN
emaciation hyperactivity cardiac arrhythmia congestive heart
failure bradycardia hypotension dry skin brittle hair
brittle nails hair loss on scalp “yellow skin”,
especially palms lanugo hair cyanotic and cold
hands and feet edema (ankle,
periobital)Mehler & Andersen, 1999
AssessmentSymptoms of BN
weight fluctuation irregular menses esophageal
burning/heartburn nonfocal abdominal
pain abdominal bloating/gas lethargy fatigue
headache constipation/diarrhea/
hemorrhoids swelling of hands/feet frequent sore throats depression swollen cheeks,
parotid/ submandibular gland enlargement
Mehler & Andersen, 1999
AssessmentSigns of BN
calluses on the back of the hand
salivary gland hypertrophy
erosion of dental enamel
periodontal disease tooth decay brittle nails
petechiae perioral irritation mouth ulcers blood in vomit edema (ankle,
periorbital)
Mehler & Andersen, 1999
Assessment
Multi-disciplinary Individual
Interview, self-administered questionnaires Family
Genogram, ecomap, family history Boundaries, communication, conflict, emotional
expression, etc. Nutritional Medical
Medical history, physical examination, lab tests
Assessment
Individual Interview Get the “story” of the client’s problem(s) “What brought you here today?” Obtain a complete history of ED
Track when and how concerns arose and how they translated into specific behaviours
How it started, when it was at its worst, what it’s like now Detailed nutritional history
Describe a typical day of eating Vegitarianism/veganism, nutritional supplements Perceptions about family’s view on food, weight loss, and
health
Assessment
Individual Interview Weight and shape concerns Other changes: isolation, mood, school, social Other mental health issues/diagnoses Self-harm and suicidality Family stressors/changes For adolescents:
Smoking, drinking, abuse of street drugs or medications
Sexual history Abuse history
AssessmentComorbidities
50-75% depression/dysthymia 25% O.C.D. (lifetime prevalence) 30%-37% substance abuse in B.N. 12%-18% substance abuse in A.N.
(binge-purge type) 42%-75% personality disorders 20-50% sexual abuse
AssessmentBody Mass Index
AssessmentBody Image
(Figure Rating Scale, Skunkard & Sorenson, 1987)
Measure of Body Image Distortion- Select the body that best represents the way you think you look- Interviewer estimates actual size- Degree of distortion = actual – perceived
AssessmentQuestionnaires
Most popular: Eating Disorder Inventory 3 (Garner, 2004)
91 item self-report Drive for thinness, bulimia, body dissatisfaction
Eating Disorder Examination 16.0 (Fairburn, Cooper & O’Connor, 2008) Structured clinical interview, used most in research EDE-Q 6.0 – 28 item self-report; validated with EDE
Eating Attitudes Test (Garfinkel & Garner, 1979) 26 item self-report of symptoms
AssessmentFeatures of Medical Concern
Marked food or fluid restriction Frequent self-induced vomiting (>2x/day) Frequent laxative or diuretic misuse (>2x/day) Heavy exercising when underweight Rapid weight loss (>1kg/week for several weeks) BMI of 17.5 or below Episodes of feeling faint or collapsing Episodes of disorientation, confusion or memory loss Chest pain, shortness of breath Swelling of ankles, arms or face Blood-stained vomit
AssessmentFamily Sessions
Meet with both parents and client, if possible Discuss confidentiality Complete genogram
At least three generations (child, parents & grandparents)
Try to engage each member, allow client to listen while mom and dad are interviewed (re. family secrets)
Ask about: addictions, abuse, moves, work, school, bullying, separation/divorce, miscarriages, any hx. of mental health issues, closeness/distance, conflict, cutoff, how emotions are handled (re. validation)
AssessmentFamily Sessions
Ask client (if appropriate) to tell the story of ED: When did it first start? What happened? What did you
notice? What else was going on at the time? Often goes on for a while before anyone knows
How did it progress? Normalize secrets and shame When did others first notice? Who noticed? What was
said/done? How did you react? When was the term ‘eating disorder’ first used? By who?
What happened? Get history of treatment and response, what worked or
didn’t Family involvement, reactions, response (e.g. anger,
fear/worry, hopelessness)
Levels of Intervention
LEVEL 1 Non-intensive outpatient treatment (community, group based) Psycho-education, motivation, body image, self-esteem May include individual and/or family therapy Medical management component (GP, psychiatrist, dietician)
LEVEL 2 Specialized intensive day treatment CBT, DBT, EFT, etc. Usually for clients not responsive to Level 1 approach
LEVEL 3 Inpatient care for more severe cases of eating disorders May include medical hospital admission for weight restoration e.g.
nasogastric tube Medical stabilization then combination of individual, family, and group
therapy
The Stages of Change & Motivation
The Stages of Change3. Preparation
“I know I have an eating disorder and I am getting ready to change”
2. Contemplation 4. Action “I think I have an eating “I have an eating disorder disorder but I’m not sure and I am actively working if I’m ready to change” on changing it” 1. Precontemplation 5. Maintenance “I don’t have an “I am in recovery from an eating disorder” eating disorder and I am actively working to
maintain it”
Relapse “I have been in recovery
and slipped back into old behaviors/patterns”
The Stages of Change:Precontemplation
clients present as HARD (hopeless, argumentative, resistant, debate)
use MI principles: respect, empathy, non-judgment
focus on engagement, therapeutic alliance use of humour give them information, don’t argue, counter
myths, raise some doubt, ask them to describe a typical day for them, monitor/observe the problem, screening tools
share information, be objective
The Stages of Change:Contemplation
ambivalence about change write friend/foe letters use decisional balance (cost/benefit analysis) not pushing, but allow them to make decision help decrease the cost of changing help clarify their vision of themselves and their life (ACT) encourage small steps to behaviour change with high
probability of success, frame as an “experiment” look for and encourage any shifts (complimenting) functional analysis - what function does the behaviour
serve? (behaviour chain, ABC exercise)
The Stages of Change:Preparation
feel consequences of behaviour more internal emotional shift starts increased commitment to self to change has made some small changes think about what you stand to lose and how
you will cope (5 yr. letter, goodbye letter) social skills training, problem solving,
assertiveness validate small changes, goal setting contracting for changes, monitor follow through
The Stages of Change:Action
have successfully altered behaviour clients in action SOAR (substitute alternatives, open up
to others, avoid and counter high risk situations, reward themselves)
client may feel over-confident – discuss slips vs. relapse relapse prevention strategies, coping w/triggers response rehearsal – “Practice, practice, practice!” substitute alternatives for problem behaviour encourage honesty in talking about problems and
progress encourage self-reward for positive changes made help them take responsibility (to own) changes made reinforce stories of change and increase hope
Motivational interviewing is a “client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence”
(Miller & Rollnick, 2002, p. 25)
Three essential questions: Are they willing to change?
Has to do with the importance of change When they connect changing with something they value, something
important to them Difference between where you are and where you want to be Identify and amplify values that are contrary to present behaviour
Are they able to change? May feel willing but not able, high importance but low confidence (e.g.
past failures) – provide hope, encouragement, share success stories, testimonials
If they believe it’ll work and that they can do it, they usually do
Are they ready to change? “I want to, but not now” – relative priorities One can be willing and able to change, but not ready to do so
Motivational Interviewing
1) Expressing accurate empathy “accurate empathy involves skilful reflective
listening that clarifies and amplifies the person’s own experiencing and meaning, without imposing the counsellor's own material” (Miller & Rollnick, p. 7)
understand client without judging, criticizing or blaming
acceptance of people as they are seems to free them to change
helps to reveal ambivalence about change
Motivational Interviewing
2) Develop discrepancies MI is intentionally directed towards the resolution of
ambivalence in the service of change create and amplify a discrepancy between present
behaviour and broader goals and values (“cognitive dissonance” - Leon Festinger, 1957)
seek to enhance this within the person (internal motivation) “people are more often persuaded by what they hear
themselves say than by what other people tell them” (Miller & Rollnick, p. 39)
rehearse eating disordered thinking when defensive discrepancy has to do with the importance of change
Motivational Interviewing
3) Avoid argumentation “the more a person argues against change during a
session, the less likely it is that change will occur” (p. 8) the least desirable situation is for the counsellor to
advocate for change while the client argues against it avoid labelling which encourages a defensive reaction monitor resistance for feedback about your approach
(e.g. is the client getting angry or defensive?); it may be a signal to shift your approach or respond differently
Motivational Interviewing
4) Roll with the resistance recognize and accept that a low level of importance
of change is a normal stage in the process reluctance to change problematic behaviour is to be
expected convey understanding and acceptance of
resistance turn the question or problem back to the client,
actively involving them in problem solving counsel in a reflective, supportive manner, and
resistance goes down while ‘change talk’ increases
Motivational Interviewing
5) Support self-efficacy belief in oneself and hope for the future hope and faith are important elements of change (re. common
factors – 15%) enhance client’s confidence in his or her capacity to cope with
obstacles and to succeed in change (e.g. exceptions) recognize and acknowledge past success (complimenting) assign tasks geared toward their level, with high probability of
success give choices and options and let the client choose how to proceed empower client by encouraging her/him to take responsibility for
any changes made, helping them own their success
Methods of Treatment
Family-Based Therapy
Family-Based Therapy
Began with Salvador Minuchin and his team at the Philadelphia Child Guidance Clinic Structural family therapy – applied family systems principles
to treatment; the family as the unit of treatment vs. the individual
Identify and change transactions that maintained the illness (second-order vs. first-order change)
Introduced the family meal as part of therapy in 1975 Reported effectiveness of 86% in 53 cases followed up
over almost eight years Results and treatment described in: Psychosomatic
Families: AN in Context (1978)
Family-Based Therapy
Research on family therapy with eating disorders continued at the Maudsley Hospital in London through the 80’s and 90’s
Result was the Treatment Manual for AN (Lock, Le Grange, Agras & Dare, 2001) Became known as the “Maudsley model” Believed parents should be seen as the most useful resource in the
treatment of adolescents with AN Described as a “new form of family therapy” developed primarily by
Christopher Dare Main contributions were: exonerating parents of blame, raising
parent’s anxiety to fully engage them in treatment, focusing on weight restoration before any other issues are addressed
Family-Based TherapyPrinciples
1. Agnostic – no blame, don’t look for cause
2. Pragmatic – initial focus on symptoms, other issues can wait until less symptomatic
3. Empowerment – parents are responsible for weight restoration, family as a resource
4. Externalization – not pathologizing, separate child from illness, respect
Family-Based Therapy
Phase I (Sessions 1-10) Parents restore child’s weight
Phase II (Sessions 11-16) Transfer control back to adolescent
Phase III (sessions 17-20) Focus on other issues
Termination
Family-Based Therapy
Phase I Joining, family history, ED history, assess family
functioning (e.g. problem solving, communication, roles, emotional expression, conflict resolution, boundaries, etc.)
Reduce parental blame, separate illness from client Heighten concern and seriousness of illness Charge parents with task of weight restoration Family meal: “Bring in a meal that would set your child on
the path to recovery” Coach parents: “One more bite” Assess family process during eating
Family-Based Therapy
Phase I Keep it focused on ED Help parents take charge of eating Mobilize siblings to support client
Phase II transition: When weight is at minimum 90% IBW Client eats without significant struggle Parents demonstrate empowerment over the eating
disorder
Family-Based Therapy
Phase II Support parental management until client can gain
weight independently Transfer control to adolescent Explore adolescent developmental issues relative to
ED (friends, dating, sexual orientation, dependence-independence, decisions about school/career)
Highlight differences between adolescent’s own needs and those of ED
Close sessions with positive feedback
Family-Based Therapy
Phase III transition: Symptoms have dissipated but body image concerns
may remain Phase III
Revise parent-child relationship in accordance with remission
Review and problem-solve re. adolescent development
Review progress and terminate treatment
Family-Based Therapy
Strengths of model: Thought of as more holsitic treatment Attempts to redress boundary issues, putting parents “back
in control”; empowering for parents Separates the person from the problem – less shame
Weaknesses of model: Disrespectful of client’s suffering from AN Seems manipulative at times (e.g. playing on parent’s fear) Critique of ‘evidence’ on which approach is based – may
only be effective for those <19 with a <3 yrs. in ED (Fairburn, 2005)
Multi-family Groups
Between three and eight families with several therapists for a number of sessions (8 – 12)
Grew out of FBT work; discuss issues and share a meal Collective sharing of experience and expertise Discuss both eating-related problems and non-eating
disorder themes A resource-focused, non-pathologizing approach to family
involvement Uses the ‘expertise’ of those who have struggled with the
illness – experienced families help new families Research on effectiveness is currently underway
Methods of Treatment
Collaborative Care
Collaborative Care
Cognitive-interpersonal maintenance model (Schmidt & Treasure, 2006; 2013)
1. Thinking style• Detail vs. global; rigid
2. Interpersonal relationships• Expressed emotion; accommodating and enabling
3. Pro Anorexia (impact of symptoms on brain/body)• Striving & mastery
4. Emotional & social style (vulnerabilities?)• Anxious; emotional suppression
Collaborative Care
Involve carers as a bridge to improve socio-emotional functioning
Carers support emotional functioning by: Moderating isolation Modelling healthy emotion regulation
Have to be the regulator when starvation makes it difficult
Listen to and understand emotions
Collaborative Care
Malnutrition/starvation damage Inhibits brain function
The very organ you need to get you out of the problem is offline
Problems become more complex More rigidity, less flexibility ED takes up more brain space
Similarities to autism spectrum traits
Collaborative Care
“Divide & Rule” ED splits up the family Happens so easily Happens with teams of professionals “Machiavellian rule”
don’t negotiate with terrorists
Collaborative Care
Family as part of the solution Working together
Collaboration, shared understanding, shared skills
Step out of ED traps Care for self, regulate emotion, reduce accommodation,
reduce disagreement and division
Provide skills for change Compassion, positive communication, behaviour change skills
Collaborative Care
Carers emotionally driven behaviours Accommodating – fear, avoid anger Enabling – fear, shame, disgust Calibration – avoid anger, jealousy
Collaborative Care
Parental avoidance Concern for child’s anxiety Avoid conflict by not challenging food rituals, by reducing
portion sizes, etc. Accommodation
Impacts all family behaviours A form of avoidant coping
Short-term decrease in distress for both parent and child Reinforces behaviour
Accept: food & meal rituals, safety behaviours
(e.g. exercise), OCD behaviours w/reassurance,
competition with other family members
Collaborative Care
Enabling Try to protect the person and family from
consequences
of ED Clean up kitchen/bathroom Cover up for lost food or money (e.g. stealing) Give money or resources to allow behaviour (e.g.
binge foods) Make excuses for person with family, friends, and work
Collaborative Care
Calibration/competition Others have to eat with the person Person compares themselves to other family members,
especially siblings (e.g. twins) Enlists sibs in enabling behaviours Competes to eat less, exercise harder, etc. Judge their success/failure by other family members Person gets angry with others doing things he/she wants to
do Pressures others to engage in similar behaviours (e.g.
binging) Share the blame
Collaborative Care
Food exposure Similar to anxiety treatment Accept that anxiety will be present Understand rationale – make new memories w/food Extinction is context dependent – practice,
practice, practice! Learning that the sky won’t fall down Identify & challenge safety behaviours Laddering – one rung at a time Need to eat is non-negotiable
Collaborative Care
Collaborative care Try to involve all family members (e.g. colluding) Encourage families to care for themselves and
model good emotional regulation strategies Help families develop a strong alliance Teach families to reduce expressed emotion
(hostility, criticism, over-protection) and accommodating behaviours
Teach families effective communication and behaviour change strategies
Collaborative Care
Communication skills (MI) Empathy – reflective listening Explore discrepancies between values and
behaviour Support self-efficacy re. confidence to change Sidestep resistance w/empathy and understanding Not avoiding, not arguing Don’t get defeated if person lashes out
Four day skills training workshop
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Regulated Psychotherapy
Until this year, psychotherapy was unregulated
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Early Steps
1990’s or earlier Psychologists asked the Province for
exclusive right to the practice of psychotherapy
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Stakeholder Consultation
The Province undertook an early stakeholder consultation and drafted legislation in the 1990’s. It was flawed and did not proceed
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New Consultation
2000’s The Province tried again OAMFT got on the bandwagon and actively
lobbied for MFT inclusion Psychotherapy Act 2007
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Regulated Health Professions Act
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Almost, but not quite, entirely unlike tea…
The practice of psychotherapy is now restricted
The College regulates the practice of psychotherapy
The authorized act is not yet in force
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Psychotherapy Act Restricted titles 8. (1) No person other than a member shall use the title “psychotherapist”,
“registered psychotherapist” or “registered mental health therapist”, a variation or abbreviation or an equivalent in another language. 2009, c. 26, s. 23 (4).
Representations of qualifications, etc. (2) No person other than a member shall hold himself or herself out as a
person who is qualified to practise in Ontario as a psychotherapist, registered psychotherapist or registered mental health therapist. 2009, c. 26, s. 23 (4).
Offence 10. Every person who contravenes subsection 8 (1) or (2) is guilty of an
offence and on conviction is liable to a fine of not more than $25,000 for a first offence and not more than $50,000 for a second or subsequent offence. 2007, c. 10, Sched. R, s. 10.
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What this means
As of April 1st of this year You cannot call yourself a “psychotherapist”
unless you belong to the College For a limited time, you can still practice
psychotherapy without a license (as long as you don’t say that you are a psychotherapist or qualified to practice psychotherapy)
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Who can practice psychotherapy?
Doctors Nurses Social Workers Occupational Therapists Psychotherapists
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Further information
www.crpo.ca Regulated Health Professions Act, 1991, SO 1991, c 18 Psychotherapy Act, 2007, SO 2007, c 10, Sch R
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Professional Associations
E.g. OAMFT/AAMFT, OASW, OMA Support their members
Meeting places Educational events Insurance discounts
Do not regulate except to define who is and who is not a member (e.g. may have a Code of Ethics)
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Colleges
E.g. CRPO, OCSWSSW, CPSO Protect the public
Regulations Restrictions Penalties
Self-regulated Run by members of the profession
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You must belong to a College
You should belong to an Association Friends, support, fun, insurance The Association will help you practice within the
College’s guidelines!
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Questions about the final paper
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Break
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Final Evaluation and Closing
Goodbye! Remember that papers are due next year! Late penalty, 2% per day. Please email your final paper to
[email protected] or [email protected] on or before January 4, 2016 by 5:00 p.m. Eastern Time
Don’t worry, be happy!
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