Forensic Practice For the Mental Health Clinician: Getting Started, Gaining Experience and Avoiding Pitfalls

By David L. Shapiro, PhD and Lenore E.A. Walker, EdD

Mental health professionals have much to contribute to court-related decisions. Forensic work is interesting and rewarding, but it can also be challenging and stressful, even for experienced clinicians. Forensic Practice for the Mental Health Clinician: Getting Started, Gaining Experience, and Avoiding Pitfalls walks you through the steps required to navigate most aspects of forensic practice.

Each chapter focuses on a different type of assessment and role, including pertinent background, case references and elements that need to be addressed. Filled with practical information (and checklist summaries) to help keep you on track, Shapiro and Walker provide the necessary tools to prepare you for the work ahead.

Table of contents

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1. Introduction to Forensic Psychology Practice[expand]

Who Is an Expert?

Definitions of Legal Terms 4 Similarities and Differences Between Clinical and Forensic Evaluations

Informed Consent

Competence to Provide Informed Consent

Voluntariness to Provide Informed Consent

Functional Legal Capacities

Forensic Assessment Procedures

Clinical Psychological Testing Interpreted Forensically

Cognitive Assessment

Neuropsychological Screening and Assessment

Personality Assessment

Trauma Assessment

Behavioral Assessment

Malingering Assessment

Risk Assessment (Actuarials)

Other Forensic Assessment Instruments

Conclusions[/expand]

2. Ethical Standards, Best Practices, and the Law[expand]

History

Special Issues in Ethics Code for Forensic Practice

Misuse of Work

Competence

Delegation of Work

Avoiding Harm

Multiple Relationships

Advertising

Media Presentations

Assessment

Release of Raw Psychological Test Data

Specialty Guidelines for Forensic Psychology

Competence

Admissibility and Other Legal Issues

Understanding the Rights of the Examinee

Fees

How to Respond to a Subpoena

Standard of Care

Controversies Over the Standard of Care

Issues Regarding Recordkeeping

Conclusions[/expand]

3. Assessments for the Criminal Court[expand]

Criminal Law Definitions

Process of a Criminal Trial

Special Areas for Assessment

Competency to Stand Trial

History

Competency Process Today

Involuntary Civil Commitment

Competency to Waive Miranda Rights

Assessment of Other Competencies

Criminal Responsibility and the Evolution of the Insanity Defense

Battered Woman Syndrome Testimony

Gathering and Reporting Assessment Data in Criminal Cases

Social History

Neurological History

Specific Criminal Law Questions

Preparation of a Written Report

Conclusions[/expand]

4. Violence Risk Assessment[expand]

Early Beliefs About the Predictive Abilities of Mental Health Professionals

MacArthur Research

The Role of Mental Illness

Methods of Assessment

The Clinical Model

The Actuarial Model

The Adjusted Actuarial Model

The Structured Professional Judgment Model

Legal Background of Risk Assessmen

Prediction of Sexual Recidivism

Questionable Legislation and Ethical Conundrums on Sexually Violent Predators

Conclusions[/expand]

5. Family Law[expand]

What Can Family Court Do

Some Definitions

Ethical and Risk-Management Issues

What Is Marriage?

Voidable Marriage

Annulment and Divorce

Prenuptial Agreements

Wills, Trusts, and Probate Family Court

Trusts

Wills

Living Wills

Family Business Succession

Reproductive Rights, Health, and Infertility

Foster Parenting

Adoption

Assisted Reproductive Technologies

Definitions

ART With Cancer Patients

ART With HIV-Positive Patients

Embryo Distribution

Surrogacy

Abortion and Termination of Pregnancy

Assessment of Competency and Emotional Stability

Parental Notification Laws

Conclusions[/expand]

6. Child Custody and Child Abuse and Maltreatment[expand]

Best Interests of the Child and Children’s Legal Rights

Child Custody Evaluations in Divorce Proceedings

Presumptions

Domestic Violence Considerations

Criteria to Consider in Custody Determination

Preparing to Conduct the Child Custody Evaluation

Infants

Children With Special Needs

Substance Abuse

Domestic Violence and Child Abuse Allegations

Steps in the Child Custody Evaluation Process

The Child Interview

Parent Interviews

Collateral Interviews

Integrate Data to Answer Referral Questions and Write the Report

Fitness to Parent Evaluation

Child Abuse and Dependency Evaluations

Child Protective Services Procedures

Definitions of Abuse

Questions to Consider When Conducting Forensic Child Abuse Evaluations

Child Interview Techniques to Avoid Bias

Preparation Before the Interview

Conducting the Interview

Interviewing Young Children

Special Concerns When Interviewing Sex Trafficking Victim

Interventions With Children and Parents in Child Abuse Cases

Self-Care for Clinicians

Children’s Legal Rights

Conclusions [/expand]

7. Juvenile Justice [expand]

Delinquency

The Brain and Other Developmental Factors

Social Factors

Assessment of Juvenile Competency

Steps in Juvenile Competency Evaluation

Assessment of a Juvenile’s Psychological Status

Assessment of Juvenile Competency to Stand Trial

Steps in Juvenile Competency Evaluations

Assessment of Substance Abuse With Juveniles

Assessment of Risk of Future Violence

Steps in a Risk Assessment Evaluation With Juveniles

Juvenile Sex Offenders

Steps in Risk Assessment Evaluation for Juvenile Sex Offenders

Assessment of Waiver to Adult Court

Evaluation Standards for Waiver to Adult Court

Conclusions [/expand]

7. Civil Courts: Personal Injury Torts [expand]

Civil Court Definitions

Process of a Civil Court Case

Consultant or Evaluator

Preparation for Conducting a Forensic Psychological Evaluation in Civil Cases

Steps in a Forensic Psychological Evaluation in a Civil Personal Injury Case

1. Observation, Clinical Interview, and Mental Status Evaluation

2. Standardized Test Administration and Results

3. Review of Documents

4. Integration, Discussion, and Diagnosis

5. Treatment Plan and Follow-up

6. Preparation of Report

7. Prepare for Testimony

Special Gender Violence Cases

Discrimination and Sexual Harassment

Other Gender Violence Torts

Conducting a BWS Evaluation

Sexual Assault Claims

Conclusions [/expand]

9. Civil Litigation: Malpractice Risk Management Issues [expand]

Trends in Malpractice Litigation

Basic Concepts and Definitions

Waivers of Privilege

Concept of Tort

Professional Relationship

Standard of Care

Elements of Malpractice

Harm or Injury

Direct Causal Connection or Proximate Cause

Damages

Areas of Malpractice Litigation

Negligent Diagnosis

Premature Discharge

Breach of Confidentiality

Sexual Misconduct

Injuries Due to Nontraditional Therapies

Failure to Obtain Informed Consent

Abandonment

Suicide

Failure to Protect Third Parties

Defenses in Malpractice Actions

Conclusions [/expand]

10. Administrative Hearings for Licensing Boards [expand]

Similarities and Differences in Administrative Law

How Do Licensing Boards Function?

Due Process Issues

Risk Management Consultation

Assessing Standard of Care for Psychotherapists

Process of an Investigation

Rights in a Licensing Board Complaint 286

Consultation With the Response to a Complaint

Possible Sanctions

Negotiating a Settlement

Assessment Role of the Forensic Mental Health Clinician

Conclusions [/expand]

11. Immigration Court [expand]

What Does Immigration Court Do?

Competency for Removal Evaluations

Violence Against Women Act

Asylum and Hardship Cases

Asylum for Undocumented Children

The Process of Immigration Proceedings

Who Is Subject to Removal or Deportation?

Possible Relief From Removal

Relief by Incompetency

Assessment Instruments

Conclusions [/expand]

12. Communication With Attorneys [expand]

Marketing Your Practice for Referrals

Negotiating Fees

Consultation in Preparing a Report

Preparing for Trial

Voir Dire of Credentials

Direct Examination

Cross-Examination

Hypothetical Questions

Preparation With Relevant Case Law

Attacks on Psychological Tests

Issues About Fees

Other Types of Cross-Examination Attacks

The Ziskin Cross-Examination Approach

Depositions

Conclusions [/expand]

Epilogue, References, Index

 

Read Excerpts From the Book

Competency to Stand Trial (From Chapter 3) [expand]

Competency is an important issue in several areas of the law (see Chapters 2, 7, 8, and 11). Competency to stand trial is perhaps the most frequent request, although psychologists also may be called on to evaluate competency to provide informed consent, competency to waive Miranda rights, competency to confess, competency to plead guilty, competency to represent oneself, competency to waive an insanity defense, and competency to be executed. Although the USSC ruled in 1993, in Godinez v. Moran, that all competencies were the same legally, as clinicians, we know that different functional capacities are involved. This discussion provides more detail from that clinical point of view.

History

Until the 1960s, there was no uniform understanding in the law of what constituted competency to stand trial. The examining professional would usually generalize from a mental status examination and opine whether the person was sufficiently mentally stable to stand trial. The USSC case of United States (1960) provided some legal parameters for this determination for the first time: whether the defendant had both a rational and a factual understanding of the proceedings and whether he or she could assist counsel with a reasonable degree of rational understanding.

The definition of these terms is not actually contained in Dusky, and thus many states use some variation of the criteria suggested by Lipsitt, Lelos, and McGarry (1971). Factual understanding referred to knowledge of the actual charges and their meaning. Rational understanding involved an understanding of the seriousness of the charges, the roles of various players in a criminal proceeding, the pleas available and their consequences, and an ability to reason through alternative strategies. The ability to assist counsel referred to several abilities: (a) whether there was any mental disorder that could interfere with the defendant’s ability to provide important information to counsel, (b) whether the symptoms of a particular disorder would interfere with the ability to work with an attorney, and (c) whether the individual could act appropriately in court. If a defendant was found competent to stand trial that would essentially be the end of the mental health professional’s role, unless, of course, a defense involving mental state at the time of the offense or criminal responsibility had also been raised.

However, what happens if a defendant is found to be not competent to stand trial? He or she would have to be hospitalized in a psychiatric facility (or at times treated as an outpatient) until she or he could be restored to competency. In theory, these individuals would be treated until their mental illness was in remission, such that they could meet the criteria for competency. Unfortunately, all too often, patients were taught by rote memorization the details of criminal proceedings, with little attempt to treat their underlying mental illness. This was called competency restoration, and sometimes mental health professionals were involved in developing the programs. Of course, many of these patients who had had their “competency restored” quickly relapsed and found themselves going back and forth from jail to the psychiatric institution.

In some cases, defendants were found incapable of having their competency restored, usually because the mental disorder was so severe that it did not respond to treatment. A legal dilemma arose here because such individuals might have to be detained (hospitalized) indefinitely for an act they had not yet been convicted of committing. Indeed, this is exactly what happened to a number of forgotten people languishing in hospitals or jails.

This came to the attention of the USSC in a case called Jackson v. Indiana. Jackson was intellectually disabled (at that time termed “mentally retarded”) and charged with a minor crime. But because of his low level of intellectual functioning, he was found incompetent to stand trial. This was not a mental disorder that might respond to treatment, and thus Jackson remained incompetent, and it was unlikely he would ever regain competency. His attorneys presented several arguments, one of which was due process: Every defendant is entitled to a speedy trial. His attorneys argued that if Jackson were confined indefinitely, the law was essentially creating a separate set of individuals —a disparity for those who are intellectually disabled and would therefore not be entitled to due process protections. This would be a constitutional violation. In addition, his attorneys argued that the reason for hospitalization had to bear a “reasonable relationship” to the purpose of the hospitalization— namely, to restore competency. If that could not be demonstrated, it would again be seen as a constitutional violation to deny someone his or her liberty with no way to recover it.

The USSC accepted the argument and ruled that a defendant could be detained as incompetent to stand trial only for a period necessary to determine whether the person’s competency could be restored within the foreseeable future. In theory, if the person suffered from a condition (e.g., severe brain impairment) that we knew ahead of time would not respond to treatment, the determination of unlikely to regain competency within the foreseeable future could and should be made early in the hospitalization. In actual fact, the state often requires extensive hospitalization when the charge is serious, regardless of the severity of the illness. One case seen by one of the authors (D.S.) involved a man in his early 60s who had killed two people. Upon examination, it was determined that he had suffered severe brain damage to his frontal lobes, for which there was no treatment. The charges were not resolved for 8 years, at which time the state and the judge finally agreed to a finding of “unlikely to regain competency in the foreseeable future” and had him civilly committed until he was no longer found to be dangerous.

Competency Process Today

As mentioned earlier, most states have laws based on Dusky hat guide the procedure of a competency evaluation for the forensic mental health clinician to follow. We include a checklist (see Table 3.2) that many forensic mental health evaluators use in Florida when they write a report within a specified period of time for the court to make a final determination. As already noted, if the person is found that person is either remanded back to jail or released and the trial process proceeds. If the person is found not competent, then there are several alternatives to being sent to a psychiatric hospital or jail mental health clinic.

In particular, defendants may be conditionally released into the community with supervision by probation officers trained to deal with defendants with mental health problems and court-ordered to attend outpatient competency restoration programs and psychological intervention, which may include psychotherapy and medication management. Obviously, the judge must weigh public safety before such a community release can be granted, especially if there are charges pending for a violent crime.

Defendants whose competency has been restored are then sent back to the court for disposition of their charges. In some cases, they are competent but still mentally ill and not able to be held in the main jail due to their mental illness. Most jails today have special mental health units where these defendants may get treatment while awaiting trial. Some jails also have substance abuse treatment programs for inmates while awaiting trial, and other jails, particularly in large communities where many women are detained, may have special units for those who have been victims of domestic violence or other gender violence crimes. There is no question that today many jails have become the psychiatric hospitals of yesterday (see our discussion on therapeutic jurisprudence earlier in this chapter).

Most states now have laws that cover the question of what happens to the defendant who is found unrestorably incompetent. In most states, individuals can no longer be held indefinitely; they usually can be held a maximum of 3 years if the charge is a misdemeanor and 5 years if it is a felony. Defendants must be evaluated to determine whether they fit the criteria for involuntary commitment (usually danger to self or others by reason of mental illness). If they meet these criteria, they are involuntarily civilly committed until such time as the hospital determines that they are no longer a danger to self or others. If the court finds that they do not meet these involuntary commitment criteria, they need to be released.[/expand]

Questionable Legislation and Ethical Conundrums on Sexually Violent Predators (from Chapter 4) [expand]

The statutory definition of a sexually violent predator is not without complications. Although the precise wording differs from state to state, the core requirement is that the individual has to suffer from a mental abnormality or personality disorder that predisposes him to commit predatory acts of sexual violence. This poses some very real problems for clinicians. No mental health text recognizes the concept of mental abnormality, let alone a mental abnormality that predisposes someone to acts of sexual violence. In short, the term mental abnormality is so broad that it is virtually meaningless and does not actually identify any clear causal relation with sexually violent behavior. Further, there is no existing personality disorder that lists predatory acts of sexual violence in its diagnostic criteria. This legal standard is a fiction that has nothing to do with the realities of clinical and forensic practices. Nevertheless, evaluators are required to use the language spelled out in the statute. This leads to some awkward and at times strained connections between diagnoses and legal conclusions.

Recall that in Crane v. Kansas, the USSC stated that for the sexual predator laws to be credible, there must be a causal link between the diagnosis and the inability to control sexual impulses. Franklin (2013) illustrated the absurdity of trying to make a diagnosis fit the criteria. She reviewed a large number of sexually violent predator evaluations to determine the most frequent diagnoses mental health professionals doing such evaluations were making. The modal diagnosis was personality disorder not otherwise specified, a category used when no other diagnosis fully applies. This diagnosis, like the term mental abnormality, is so broad as to be virtually meaningless.

There are also oddities in the use of involuntary commitment after a finding that an individual fits the statutory criteria for a sexually violent predator. The laws dealing with criteria for involuntary commitment across the country speak of the fact that there not only be a finding of a mental illness but that there must also be an imminent danger to self or others. Courts have generally regarded this as a recent overt act. However, because the population on whom the sexually violent predator examinations are being performed has usually been incarcerated for a number of years, a recent overt act is unlikely to be present (with the exception of an exceedingly predatory prisoner). This has led some states to describe sexual offenders as qualifying for a special kind of involuntary commitment in that the commitment can be based exclusively on the ability to predict future sexual reoffending. As we already have noted, these predictions are far from accurate, and even the most widely used instruments rarely have predictive validity of more than 50%. Some states mandate the use of one of these instruments; in Florida, the instrument that is mandated has predictive validity at approximately 44%—less than flipping a coin.

Also, of interest is that these offenders are being committed for treatment until their propensity to commit violent sexual acts has been treated and they would no longer pose a threat. However, there is no empirically validated effective treatment for this population. Even the USSC noted this in the Hendricks case. Many programs do what they think is right and “should work,” but there is little evidence to back up these theoretically based interventions, especially with long-term risk data. As an example, one state contracted with a mental health provider who purported to use “rational self-counseling.” There is no literature that describes “rational self-counseling” as an empirically supported and effective treatment for sexually violent individuals.

The way in which these laws are written also breeds ethical dilemmas. For instance, the laws allow for the completion of an evaluation based solely on a review of records if the individual refuses to cooperate in an examination. The American Psychological Association (2010) Code of Ethics states that one can only reach a diagnosis, conclusion, or recommendation when there are sufficient data to justify the diagnosis. Except in rare circumstances, this must include a personal interview. If the interview cannot be completed, then the limited validity must be reflected in the conclusions. One of the authors (D.S.) had the opportunity to review many of these sexually violent predator evaluations in his role as a consultant to several attorneys. In these reports, when the inmate would not cooperate in the interview, it was often noted. It was exceedingly rare, however, that any of the examiners actually qualified the validity of their conclusions; rather, it was simply left unstated, implying that the results were equally valid whether the inmate participated in the evaluation or not. Of course, this also renders the aforementioned mental abnormality questionable because it is not possible to find sufficient data to justify a diagnosis that does not exist (American Psychological Association, 2010).

The following legal cases have had an impact on the expert’s testimony about dangerousness:

• Baxstrom v. Herold: low recidivism among mentally ill patients
• Jurek v. Texas: dangerousness is not “unconstitutionally vague”
• Estelle v. Smith: Fifth and Sixth Amendment violations in psychiatric evaluations
• Barefoot v. Estelle: dangerousness evaluation based on hypothetical questions is not a constitutional violation
• Kansas v. Hendricks: sex predator laws do not constitute double jeopardy
• Young v. Weston: the state must provide treatment for sexually violent predators
• Kansas v. Crane: need for causal relationship between sexually predatory behavior and mental illness [/expand]

Assessment of a Juvenile’s Psychological Status (from Chapter 7) [expand]

Assessment of the psychological status a juvenile had at a particular time concerns estimating his or her psychological status retrospectively, at the time when a particular incident occurred, if criminal responsibility is part of the evaluation. However, it is not unusual to assess for current competency first. Competency evaluations themselves are based on current psychological status and are similar to the requirements under the Dusky standard described in Chapter 3 on competency in adult criminal cases, whereas responsibility depends on estimating the person’s competency at the time of the incident. Although the USSC decided in Godinez v. Moran (1993) that all competencies are the same for legal purposes, mental health clinicians know that there are different skills and abilities needed to be competent for different purposes. For example, a young man who is psychotic may have a good understanding of the trial process itself but cannot understand that the prosecutor is attempting to prove his guilt or that his defense attorney is required to defend him. In such cases, the defendant may not be willing to plead to insanity because he is unwilling to accept that he has a mental illness and so may be found incompetent because he cannot assist his attorney.

Incompetency for a juvenile to stand trial, then, requires a determination that a person does not have the requisite abilities of a rational and knowing understanding of the legal process and cannot assist his or her attorney at trial. This is different from a criminal responsibility decision that involves sanity issues at the time of the event itself. (We discussed these differences in Chapter 3.) Case law in most jurisdictions suggests that the two evaluations use separate factors, and one cannot be used as a substitute for the other. For example, a juvenile may be found to have been incapable of forming criminal intent because she was intoxicated or high at the time of an event, yet she may be competent to stand trial at the time of the evaluation. Although these legal concepts are similar for adults and juveniles, there are important differences. For example, maturity may be an important factor in assessing a juvenile’s competency or criminal responsibility. Grisso (2013) cautioned that whereas adults are usually found incompetent due to mental disorders or intellectual disabilities, some juveniles may simply not yet have developed the necessary abilities to control their behavior due to incomplete brain development. This is discussed more fully in the APA (n.d.) amicus briefs in Roper, Graham, and Miller as mentioned earlier and are available on the APA website (http://www.apa.org/about/offices/ogc/amicus). However, not all states have added a category such as incompetent due to developmental immaturity disorder to their competency laws and rules for juveniles. It is important to discuss these legal issues with the referral attorney.

When adults are found incompetent to stand trial, they are usually sent to hospitals or outpatient facilities to restore their competency. As mentioned in Chapter 3, this usually includes learning the various roles and procedures in the trial process, together with medication or psychotherapy to deal with mental illnesses when appropriate. Such competency restoration is usually inappropriate for juveniles, who are simply too immature to have developed requisite capacities to make some of the decisions required at trial. Disposition of these juvenile competency cases becomes more complicated, especially if the evaluator is required to offer an opinion to the court on what is the best intervention for a juvenile found to be incompetent to stand trial due to immaturity and not a mental illness or disability. In other cases, the evaluator must determine first whether the deficits can be remedied by an intervention and, if so, what type of intervention is required and how much time it might take for the needed change to occur. Some believe that if a juvenile cannot have competency restored within 6 months, then it probably is not restorable. Interestingly, although a time limit for remediation is required, the length of time before deterioration into incompetency might occur is rarely considered (Spear, 2000). [/expand]

What Does Immigration Court Do? (From Chapter 11) [expand]

Perhaps the newest area of practice for forensic psychologists in the United States is in the removal of illegal immigrants from the country. The Department of Homeland Security runs the court that has jurisdiction over people who have immigrated to the United States and are not yet full citizens. This represents a whole new judicial system that is not under the U.S. Department of Justice, with different laws and rules of procedure for the forensic evaluator to learn. There is a website for the Executive Office for Immigration that may be a good starting place for those practitioners who wish to work in this area. This court only handles people who are noncitizens, usually because they have gotten into some trouble either by not coming into the United States legally, coming in legally but overstaying their visa, or getting in trouble with the U.S. criminal justice system. It is within the past 10 years that the number of such people known to the immigration system have exponentially multiplied, so that in recent years, more than 500,000 people have come before this court, with half of them adjudicated. Approximately 10% of them are being held in detention, while the rest are allowed to await resolution of their case living at home without knowing when it will be resolved.

Interestingly, there are none of the due process rules for resolving these cases in the immigration court that are found in criminal courts. This means respondents are not entitled to an attorney, a mental health practitioner, or other rights that defendants might have at government expense if they can’t afford it. Because many immigrants cannot legally work in the United States, they usually do not have the financial resources to attain such services, but agencies, such as Catholic Charities or law schools, may be able to provide them attorneys at no cost. Many of these attorneys, along with the judges who serve on the court, have realized that some of these respondents have serious mental health problems that cause them to be incompetent to understand the removal proceedings. This has become a major area for forensic psychologists and mental health clinicians to assist the clients, the attorneys, and the court. We discuss these competency evaluations here. In addition to competency issues, an appeal may be based on other reasons the person may put forth to the court. The most common ones are (a) relief for victims of domestic violence under the Violence Against Women Act (VAWA) of 2013, (b) asylum due to potential harm if returned to one’s own country of origin, and (c) hardship cases in which it would be difficult for a U.S. citizen (such as a child) to be without the person scheduled for removal. Although we do not discuss it here, forensic evaluations of unaccompanied minor children are also being requested (Byrne & Miller, 2012).[/expand]

 

About the authors

Dr. David L. Shapiro, is a licensed psychologist, certified in Forensic Psychology by the American Board of Professional Psychology. He has been in independent practice of both clinical and forensic psychology for over 50 years, specializing in criminal law and malpractice cases. He served on the APA ethics committee as well as  state psychological associations. He has authored over 10 books, including descriptions of assessment instruments used in clinical and forensic cases. Dr. Shapiro is a professor at Nova Southeastern University’s College of Psychology, where he trains graduate students in forensic psychology. His most recent research projects include examination of duty to warn and protect statutes across the country, uses and abuses of the insanity defense, and issues in immigration cases. His website is drdavidshapiro.com.

Dr. Lenore E.A. Walker, is licensed psychologist, certified in Clinical and Couples and Family Psychology by the American Board of Professional Psychology. She has been in independent practice of both clinical and forensic psychology for over 40 years, specializing in working with people harmed by interpersonal, gender, and child abuse. Her research identified and applied the Battered Woman Syndrome, a subcategory of PTSD in clinical and forensic cases. She has recently retired as Coordinator of the Forensic Psychology concentration at Nova Southeastern University’s College of Psychology and remains on the faculty as Professor Emerita, conducting her research. She has authored over 20 books and professional articles that can be found on her website drlenoreewalker.com.

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