[acb-hsp] Perceived Competence in Multicultural Counseling

[J.Rayl]

Although this article is about racial-ethnicity, it likely applies to blindness / disability as well, I'm thinking.  Your thoughts?  --Jessie



Perceived Multicultural Competency of Certified Substance Abuse Counselors.

by Pamela S. Lassiter , Catherine Y. Chang

In this study, the authors explored the self-perceived multicultural counseling competencies

of substance abuse counselors. Overall, the results indicate that substance abuse

counselors perceived themselves to be competent; however, differences existed on

the basis of race and educational level. Implications for practice and future research

are discussed.

Interest in multicultural issues and awareness of the importance of cultural sensitivity

and multicultural competence in counseling have increased over the past several decades

(see Ponterotto & Casas, 1987; Pope-Davis & Coleman, 1997; Sue, 1998). One reason

for this increase is the growing demographic diversity in the United States, as demonstrated

by the 2000 census (U.S. Census Bureau, 2000). In fact, the estimate in the 2000

Census was that midway through this century minorities will constitute more than

50.0% of the population.

The increase in diversity in the U.S. population has specific ramifications for substance

abuse counselors, because members of minority groups may be at higher risk than the

dominant population for substance abuse problems. According to the National Household

Survey on Drug Abuse, many members of minority groups may be at risk for substance

abuse problems because of the socioeconomic disparities among racial and ethnic groups

in combination with a strong correlation between low socioeconomic status and substance

abuse (Substance Abuse and Mental Health Services Administration [SAMHSA], 2002).

In fact, American Indians and Alaskan Natives reported the highest rate of alcohol

dependence, and individuals of mixed racial and ethnic heritage reported the second

highest rate, compared with other racial and ethnic categories. Additionally, individuals

of mixed racial and ethnic heritage reported the highest rate of need for treatment

and the highest rate of treatment received for illicit drug addiction (SAMHSA, 2002).

This suggests that substance abuse counselors are likely to encounter clients who

represent diverse racial backgrounds, and, therefore, they need to be adequately

trained and competent in working with racially diverse clients.

The Association for Multicultural Counseling and Development (AMCD) established the

Multicultural Counseling Competencies (Sue, Arredondo, & McDavis, 1992) as a guideline

for training professionals. These guidelines include (a) counselors' awareness of

their own cultural values and biases, (b) counselors' knowledge of their client's

worldview, and (c) counselors' implementation of culturally appropriate intervention

strategies (i.e., culturally skilled counselors; Arredondo et al., 1996). AMCD assumes

that counselors who become competent in these areas will have the awareness, knowledge,

and skills necessary to effectively counsel culturally diverse clientele.

Culturally competent counselors are less likely to reinforce stereotypes and to demonstrate

biased behaviors toward their clients. In addition, multiculturally competent counselors

are more aware of assessment issues and interventions relevant to diverse populations.

These counselors are less likely to misdiagnose clients' issues and are more likely

to choose culturally appropriate assessment and intervention strategies (Arredondo,

1999; Kiselica, Maben, & Locke, 1999; Ponterotto, Rieger, Barrett, & Sparks, 1994).

Although multicultural competence has been a topic of discussion and research for

school counselors (see Holcomb-McCoy, 2001), play therapists (see Ritter & Chang,

2002), marriage and family therapists (see Constantine, Juby, & Liang, 2001), and

counselors in general (Fuertes, Bartolomeo, & Nichols, 2001; Ladany, Inman, Constantine,

& Hofheinz, 1997; Manese, Wu, & Nepomuceno, 2001), there has been little discussion

of multicultural competency in the professional substance abuse literature. In the

past, questions have arisen concerning the general training and preparation needs

of substance abuse counselors (Armstrong, Boen, & Whalen, 1978; Gideon, Little, &

Martin, 1980; Skuja, 1980), but few have focused specifically on multicultural competencies.

Although many professional organizations and accrediting bodies promote the education

of multiculturally competent counselors (see Association for Play Therapy guidelines

[Association for Play Therapy, 2005]; AMCD multicultural competence; Council for

Accreditation of Counseling and Related Educational Programs requirements [CACREP,

2001]), similar movement in the substance abuse profession is absent. For example,

in their survey of substance abuse experts, Klutschkowski and Troth (1995) asked

practitioners to list and rank the ideal components for inclusion in a substance

abuse training curriculum. Of the components identified, ethics and counseling techniques

were ranked at the top. Although they were still considered important, needs for

special populations and multicultural counseling were at the end of the list.

The International Certification & Reciprocity Consortium/Alcohol and Other Drug Abuse

(ICRC; n.d.) set the standard for the practice of addictions counseling. ICRC listed

12 core functions in which counselors must demonstrate competence before becoming

certified (i.e., screening, intake, orientation, assessment, treatment planning,

counseling, case management, crisis management, client education, case consultation,

referral, and records and record keeping). The ICRC standards of practice refer to

the need for knowledge in the "social and cultural context of addiction" (ICRC, n.d.,

Foundations section, para. 2) and in the importance of "recognizing the needs of

diverse populations relating to the issues of ethnicity, race, gender, sexual orientation,

and HIV/AIDS" (ICRC, n.d., Foundations section, para. 5), but they place little emphasis

on multicultural training or competency in the initial certification process. According

to J. Scarborough, current ICRC president, written exams are reviewed for cultural

sensitivity, and state boards are encouraged to approve multicultural training and

education; however, "there are no plans to require multicultural training as a part

of the certification or recertification process" (personal communication, October

8, 2004). At this time, both certification and recertification require specialized

continuing education in ethics and in HIV/AIDS.

Because of the lack of attention in the substance abuse literature regarding multicultural

training of substance abuse counselors and because of the growing diversity of the

substance-abusing population, the primary purpose of this study is to explore the

self-perceived multicultural competence of certified substance abuse counselors.

We hope that practitioners' perceptions of multicultural competency and the factors

influencing those perceptions, solicited directly from practitioners, will lead to

greater understanding in the professional counseling and educational communities

of the training and preparation needs for practitioners. We are interested in the

following questions: (a) To what extent do certified substance abuse counselors rate

their multicultural competence? (b) Does a difference exist in perceived multicultural

competency on the basis of years of experience, education, ethnicity, or level of

certification? and (c) Does the number of completed classes in multicultural counseling

affect counselors' perceived multicultural competence?

Method

Participants

The population sample for this study was drawn from certified substance abuse counselors

in North Carolina. We chose North Carolina because it is considered to be the most

advanced in certification standards of all member states of the ICRC (J. Furtner,

personal communication, August 17, 2002). The participants included 98 certified

substance abuse counselors. Sixty-one percent (n = 60) of the participants were female,

and 39.0% (n = 38) were male. Participants ranged in age from 21 to 65 years, with

a mean age of 47.49. Eighty percent of the participants were Caucasian (n = 78),

and 20.0% (n = 20) were people of color (14 African Americans, 14.0%; 1 Asian, 1.0%;

1 Hispanic, 1.0%; 2 Native Americans, 2.0%; 2 of mixed heritage, 2.0%). Eighty-eight

participants (89.8%) reported their sexual orientation as heterosexual, and 10 participants

(10.2%) reported that they were gay, lesbian, or bisexual. Two geographic regions

were represented, with 56.0% of the participants from urban work settings and 44.0%

from rural work settings. Years of experience ranged from fewer than 5 to more than

20 years, with a mean of 13 years of experience reported. In terms of the participants'

highest degree earned, 4.1% held a high school diploma, 5.1% had received an associate's

degree, 23.5% had received a bachelor's degree, 62.2% had received a master's degree,

2.0% had received an education specialist's degree, and 3.1% held a doctoral degree.

The majority of the participants (75.5%) were certified clinical addictions specialists

(master's degree and beyond), with only 24.5 % certified substance abuse counselors

(bachelor's degree). In terms of training, 42.0% of respondents reported no formal

course work in multicultural counseling, whereas 22.0% reported having completed

one course. The remaining 36.0% had completed two or more multicultural classes in

their academic preparation.

Instrument

The instrument used in this study was the Multicultural Counseling Knowledge and

Awareness Scale (MCKAS), developed initially by Ponterotto et al. (1994) and revised

by Ponterotto, Gretchen, Utsey, Rieger, and Austin (2002). The MCKAS is a 32-item

self-rating instrument that uses a 7-point Likert-type format and was designed to

measure multicuhural knowledge (i.e., general knowledge related to multicultural

counseling issues) and awareness (i.e., awareness of one's own subtle ethnocentric

biases). Responses for both subscales and the total score range from 1 (not a t all

true) to 7 (totally true). A midrange response of 4 on the Likert-type scale indicates

that the participant rates his or her competency on that item as somewhat true. The

MCKAS has 20 Knowledge subscale items (possible range of scores is 20 to 140) and

12 Awareness subscale items (possible range of scores is 12 to 84). Possible scores

for the entire measure range from 32 to 224. The researcher obtains the Knowledge

and Awareness subscale scores by averaging their respective item scores, and there

are no established cutoff scores that reflect satisfactory multicultural knowledge

or awareness.

Ponterotto et al. (2002) found internal consistency levels of .85 for the two factors.

Kocarek, Talbot, Batka, and Anderson (2001) reported coefficient alpha reliabilities

for the MCKAS (which they referred to as the MCAS) Knowledge and Awareness subscales

of .91 and .83, respectively, and an alpha of .91 for the total score. The coefficient

alphas for the present sample were .88 for the Knowledge subscale and .73 for the

Awareness subscale. Ponterotto et al. (2002) examined the convergent, criterion-related,

and discriminant validity of the MCKAS and found significant correlations to subscales

of the Multicultural Counseling Inventory (Sodowsky, Taffe, Gutkin, & Wise, 1994).

In a recent comparison study of three measures of multicultural competence, Kocarek

et al. (2001) concluded that the MCKAS (formerly the MCAS: B) is a psychometrically

sound survey, is a "strong measure of multicultural competency" (p. 493), and is

appropriate for general use. For further information regarding psychometric properties

of the MCKAS, see Ponterotto et al. (2002).

In a recent study conducted to revise the MCAS: B into the MCKAS, Ponterotto et al.

(2002) reported means and standard deviations for the subscales (Knowledge, M = 4.96,

SD = 0.80; Awareness, M = 5.06, SD = 1.14) based on a sample of 199 counselors in

training. Participants in that sample reported that the competency items listed were

somewhat true as applied to them. The MCKAS uses continuous scores to examine differences

among groups or score correlations with other variables (J. Ponterotto, personal

communication, September 2, 2002).

In addition to the MCKAS, participants completed a demographic sheet and responded

to the following questions: (a) "Please indicate the average percentage of clients

on your caseload who tended to be culturally different from you over the course of

your career as a substance abuse counselor," (b) "What would you estimate is the

percentage of supervision time spent discussing or exploring multicultural issues?"

and (c) "Please list some ways clinical supervision could be enhanced regarding multicultural

issues."

Procedure

Packets containing an information sheet about the study and a stamped, self-addressed

survey booklet, which included the demographic page, the MCKAS, and a consent statement,

were sent to 500 randomly selected certified substance abuse counselors from North

Carolina. Random samples were taken proportionately from mailing lists of the two

different levels of certification: certified substance abuse counselor (CSAC) and

certified clinical addictions specialist (CCAS). Of the 500 surveys sent, 100 were

returned. Of the 100 returned, 2 were unusable, so there were 98 usable surveys.

One person who received a survey stated that she no longer worked in the field, and

another recipient's family member wrote to say the recipient was deceased. Because

of an error in postal procedures, returns as a result of incorrect addresses were

not assessed. Follow-up reminders were mailed out approximately I month after the

initial mailing. The return rate for the final sample was just under 20.0%.

Results

We computed means and standard deviations for each subscale (Knowledge and Awareness)

of the MCKAS to examine the surveyed substance abuse counselors' self-perceived multicultural

competence. Higher scores on each subscale indicate higher levels of self-perceived

multicultural competence. The mean total score for this sample was 167.19 (SD = 19.81),

which is slightly higher compared with Constantine's (2002) mean of 164.34 on the

full-scale scores of school counselors. Because we were more interested in differences

in subscale scores among groups in the sample, we conducted further analysis to explore

counselors' perceptions.

To assess the appropriateness of running a multivariate analysis of variance (MANOVA)

to test for differences as a result of ethnicity, education, number of multicultural

classes completed, and certification level, we computed a Pearson correlation to

determine the relationship between the Awareness and the Knowledge subscales in this

sample. Results yielded a Pearson correlation of .25 (n = 98; p < .05), which indicated

a weak correlation between the subscales. On the basis of the apparently distinct

nature of these two variables, we used a MANOVA to analyze the data, using each of

the demographic variables as an independent variable and the Awareness and Knowledge

subscales scores as dependent variables. To have adequate cell representations for

analysis, we categorized ethnicity into two groups: Caucasians and people of color.

To what extent do CSACs rate their multicultural competence? Means and standard deviations

for both subscales are reported in Table 1. Results suggest that CSACs rated themselves

as somewhat competent regarding both knowledge and awareness, although their mean

score for the Awareness subscale (M = 5.55, SD = 0.70) was slightly higher than their

mean score for the Knowledge subscale (M = 5.01, SD = 0.82). These scores are comparable

to Ponterotto et al.'s (2002) findings with a national sample of counselors in training

(N = 199); the authors used the MCKAS and reported subscale means of 5.06 (SD = 1.14)

for Awareness and 4.96 (SD = 0.80) for Knowledge. Ponterotto et al. (2002) found

that, "after averaging the items, respondents tended to indicate the competency items

were somewhat true as applied to them" (p. 166).

Is there a difference in perceived multicultural competency on the basis of years

of experience, education, ethnicity, or level of certification ? Our results suggest

that ethnicity and educational level had a significant influence for this population

on perceived multicultural competence, whereas years of experience and level of certification

did not (see Table 2). We found a significant multivariate main effect for ethnicity,

Wilks's lambda, F(2, 77) = 7.53, p< .01, and for education, Wilks's lambda, F(2,

77) = 3.24, p < .05. Follow-up univariate F tests indicated a significant effect

for ethnicity on the Knowledge subscale, F(1, 78) = 6.86, p < .05, but not on the

Awareness subscale, F(1, 78) = 3.77, p >.05. People of color rated themselves significantly

higher on the Knowledge subscale than did Caucasian participants, a finding that

is consistent with the results of other studies using the MCKAS (Kocarek et al.,

2001; Ponterotto et al., 1994).

In terms of educational level, we found a significant multivariate main effect for

the Knowledge subscale, F(1, 78) = 6.52, p< .05, but not for the Awareness subscale,

F(1, 78) = 0.96, p >.05. Participants who reported holding less than a master's degree

rated items on the Knowledge subscale significantly lower than did participants who

reported holding a master's degree or higher. We did not find main effects for level

of certification, despite the higher degree requirement for the advanced credential

(CCAS). We found no significant interaction effects for ethnicity, experience, classes

taken, or certification. An examination of other demographic variables revealed no

relationship between gender, age, or rural versus urban work settings and multicultural

competency for this sample.

Did the number of multicultural counseling classes completed have an impact on the

counselor's perceived multicultural competence ? We were interested to find that

there was no significant impact on MCKAS scores on the basis of the number of multicultural

courses taken. Ninety-seven participants responded to the survey item asking them

to "indicate the average percentage of clients on your caseload who tended to be

culturally different from you over the course of your career as a substance abuse

counselor." The mean percentages were as follows: clients who were the opposite sex

(M = 47.20%, SD = 25.47 %); clients who were racially or ethnically different (M

= 43.70 %, SD = 24.45 %); clients who were gay lesbian, or bisexual (M = 9.90%, SD

= 8.94%); and clients with physical disabilities (M = 8.40 %, SD = 8.83). When asked

to estimate the percentage of supervision time spent discussing or exploring multicultural

issues, participants reported a mean of 8.30% (SD = 10.98%).

We asked participants to list some ways clinical supervision could be enhanced regarding

multicultural issues. Three major areas emerged, on the basis of the frequency of

responses. These areas were emphasis in supervision, training needs, and requirements

for certification and licensure. In particular, participants made the following suggestions:

More emphasis should be placed on multicultural issues during supervision (n = 19),

group supervision should be used more to help counselors get diverse perspectives

(n = 6), more skill-based training in multicultural issues is needed for both clinical

supervisors and substance abuse counselors (n = 21), and multicultural training should

be a requirement for certification and renewal of certification (n = 5). Other comments

included, "I am surprised how much I did not know and that I need further training

on it," and the observation that this is "an area long overdue."

Discussion

Scores on the MCKAS in this sample suggest that CSACs as a group consider themselves

slightly more multiculturally competent in the areas of knowledge and awareness than

did national samples of counselors in training who were assessed with the same instrument

(Ponterotto et al., 2002). The fact that this sample included counselors who already

had completed their training and were in the workforce may explain their higher scores

compared with counselors in training. This may suggest that experience influences

one's perception of multicultural competence in the areas of knowledge and awareness.

In this sample, participants who held a master's degree or higher rated themselves

as more competent in the area of multicultural knowledge but not in the area of multicultural

awareness. On the basis of these results, it seems that as CSACs advance in their

educational level, so does their self-perceived competence in multicultural knowledge

but not in awareness. This might suggest that multicultural awareness cannot be taught

in class but must be experienced, which supports Sevig's (2001) findings and recommendations

that there should be a balance between cognitive and emotional learning in multicultural

counseling training courses. The present findings may also suggest that substance

abuse classes and seminars need to include a multicultural experiential learning

component.

Diaz-Lazaro (2001) found that cross-cultural contact in counselor training settings

had an important role in improving multicultural competency. Questions that arise

from the present study include the following: How can clinical supervisors provide

opportunities for experiences that potentially will broaden the multicultural awareness

of their supervisees? Can an increase in awareness, combined with perceived high

levels of knowledge, actually improve the multicultural counseling skills of substance

abuse counselors, as demonstrated in clinical practice?

Persons of color reported higher self-perceived competence in multicultural knowledge

than did Caucasians. These findings are consistent with the results of other studies

using the MCKAS (Kocarek et al., 2001; Ponterotto et al., 1994). This could imply

that substance abuse counselors of color feel competent in their knowledge of their

culture but perceive themselves as needing greater exposure to and awareness of other

cultures, which might explain their higher self-perceived competence in knowledge

but not in awareness.

Contrary to Ritter and Chang's (2002) study with registered play therapists and Kocarek

et al.'s (2001) study among master's-level counseling students, the number of multicultural

counseling classes did not have an effect on the self-perceived competence level

of certified substance abuse counselors. Educational level, however, did have an

effect on multicultural knowledge. Given that educational level affected multicultural

knowledge, it seems that completing a multicultural counseling course should also

affect knowledge. The lack of effect in our findings might be due to the mean age

and the years of experience of this sample as well as to the differences among play

therapists, counseling students, and substance abuse counselors. The mean age of

participants in this study was 47 years, and their mean years of experience was 13,

which indicates that those participants who held a master's degree might have obtained

their degree prior to the past decade, before emphasis was placed on multicultural

course work by academic programs. The clinical experience and continuing education

training of this older and more experienced sample might have compensated for the

differential in the number of multicultural courses taken in school. This study does

not address the number of continuing education hours focused on multicultural issues,

which might account for this lack of effect. Additionally, the differences between

this sample and the other samples may be due to distinct differences in experiences

and exposure among substance abuse counselors, play therapists, and counseling students.

Although participants reported that nearly half their clientele were ethnically or

racially different from them, it does not seem that much time is devoted in clinical

supervision to multicultural issues. In fact, many participants reported that clinical

supervisors needed to increase their skills and knowledge regarding multicultural

issues.

Aspects of this study that limit the generalizability of the results include the

self-report nature of the survey, the sample size, and the less than desirable response

rate. An additional threat to the generalizability of the results is the nature of

the sample itself. Because we only sampled North Carolina substance abuse counselors,

readers need to use caution in generalizing the results. In addition, we collapsed

the minority group into a single person of color group to have adequate cell representations

for analysis. Thus, we might have overlooked within-group differences. Although these

concerns limit the generalizability of the results, this study can serve as an exploratory

foundation for considering multicultural competence of CSACs.

Implications for Practice and Future Research

On the basis of the results of this exploratory study, important implications for

practice have emerged. With the goal of increasing multicultural awareness, practical

strategies for substance abuse professionals may include (a) participating in group

supervision made up of diverse counselors. This could help expand awareness and create

dialogue about multicultural client issues. Such strategies may also include (b)

increasing formal training opportunities and requirements for substance abuse counselors

and clinical supervisors, with an emphasis on awareness of one's own cultural background.

To facilitate multicultural awareness, supervisors might consider the following questions:

What does being a member of your racial group mean to you? What values and traditions

do you associate with your racial group? How might your racial heritage influence

your relationship with members of other racial groups?

Some practical strategies that may increase multicultural knowledge for substance

abuse professionals are as follows: publishing articles in monthly newsletters sent

out by certification organizations that address multicultural issues, increasing

formal training opportunities for substance abuse counselors in multicultural issues

using experiential learning, requiring training for clinical supervisors both in

multicultural issues and in developing multicultural skills in their students, and

requiring a specific number of training and retraining hours in multicultural issues

for certification.

Substance abuse counselors need to gain specialized knowledge and awareness in multicultural

issues because of some unique characteristics of the profession. One issue is the

preference for use of group counseling modalities (Capuzzi & Gross, 1992), in which

knowledge and awareness of cultural issues for members can be crucial to the success

of the group formation and to growth. Different cultures have various viewpoints

on common addiction treatment concepts, such as denial, resistance, and sociological

factors contributing to the problem. It is important for the substance abuse counselor

to have knowledge of the impact of identity development on stress and relapse potential

as well as of the effects of oppression for some groups. Counselors need to consider

cultural factors when recommending an appropriate type of self-help group for clients.

We hope that this study will initiate further exploration of the current status of

multicultural competency within the substance abuse profession.

The field needs continued research to better understand the impact of educational

and cultural variables on multicultural counseling competencies for substance abuse

counselors. Additionally, research that considers the difference between multicultural

knowledge and multicultural awareness is warranted, given that ethnicity and education

differed on the knowledge domain but not on the awareness domain. Research is also

needed to compare the perceived multicultural competence with indicators of actual

competence, perhaps generated from the perceptions of clients and supervisors. Given

the differences in perceived multicultural knowledge and awareness among substance

abuse counselors, play therapists, and counselors in training, in future studies

researchers should also compare multicultural competence across groups of counselors

and training backgrounds (e.g., school counselors, rehabilitation counselors, marriage

and family therapists). They might also consider minority group differences in multicultural

competence.

Other questions remain concerning actual amounts of time dedicated to multicultural

issues in supervision and students' perceptions of their supervisors' competency

levels. The goal of providing culturally appropriate substance abuse services should

receive greater emphasis in the field as a whole.

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Pamela S. Lassiter, Department of Counseling, College of Education, University of

North Carolina at Charlotte; Catherine Y. Chang, Department of Counseling and Psychological

Services, Georgia State University. Correspondence concerning this article should

be addressed to Pamela S. Lassiter, Department of Counseling, College of Education,

University of North Carolina, 9201 University City Boulevard, Charlotte, NC 28223-0001

(e-mail: plassite at email.uncc.edu).

TABLE 1 Means and Standard Deviations by Variable

for the Multicultural Counseling Knowledge and

Awareness Scale Subscales

Knowledge Awareness

Variable n M SD M SD

Ethnicity

Caucasian 78 4.93 0.82 5.63 0.69

People of color 20 5.31 0.77 5.24 0.66

Education

< Master's 32 4.63 0.78 5.30 0.64

> Master's 66 5.19 0.78 5.67 0.70

Multicultural classes

None 41 4.89 0.89 5.55 0.82

One class 22 5.04 0.79 5.72 0.57

Two or more 35 5.13 0.75 5.45 0.61

Certification

CSAC 24 4.73 0.94 5.33 0.68

CCAS 74 5.10 0.76 5.62 0.69

Total 98 5.01 0.82 5.55 0.70

Note. CSAC = certified substance abuse counselors; CCAS = certified

clinical addictions specialists.

TABLE 2

Univariate FRatios for the Knowledge and Awareness Subscales by

Ethnicity, Education, Multicultural Classes, and Certification Level

Variable MS df F

Ethnicity

Knowledge 3.66 1 16.86 *

Awareness 1.79 1 13.77

Education

Knowledge 3.48 1 16.52 *

Awareness 0.46 1 10.96

Multicultural classes

Knowledge 0.27 2 20.50

Awareness 0.19 2 20.39

Certification level

Knowledge 0.89 1 1.66

Awareness 5.46 1 0.001

Questia, a part of Gale, Cengage Learning. www.questia.com

Publication Information:

Article Title: Perceived Multicultural Competency of Certified Substance Abuse Counselors.

Contributors: Pamela S. Lassiter - author, Catherine Y. Chang - author. Journal Title:

Journal of Addictions & Offender Counseling. Volume: 26. Issue: 2. Publication Year:

2006. Page Number: 73+. COPYRIGHT 2006 American Counseling Association; COPYRIGHT

2007 Gale Group

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