Cross Cultural Counseling

 

Culture has been defined as "the shared values, traditions, norms, customs, arts, history, folklore, and institutions of a group of people." Why should we even be concerned about culture?

First, understanding culture helps us to understand how others interpret their environment. We know that culture shapes how people see their world and how they function within that world. Culture shapes personal and group values and attitudes, including perceptions about what works and what doesn’t work, what is helpful and what is not, what makes sense and what does not.

Secondly, understanding culture helps service providers avoid stereotypes and biases that can undermine their efforts. It promotes a focus on the positive characteristics of a particular group, and reflects an appreciation of cultural differences. Finally, culture plays a complex role in the development of health and human service delivery programs.

Factors that Influence Culture

While we know that cultural influences shape how individuals and groups create identifiable values, norms, symbols, and ways of living that are transferred from one generation to another, it is important for us to distinguish the differences created by such factors as age, gender, geographic location, and lifestyle. Race and ethnicity are commonly thought to be dominant elements of culture, but a true definition of culture is actually much broader than this.

For example, ethnic and racial groups are usually categorized very broadly as African American, Hispanic, American Indian and Native Alaskan, or Asian American and Pacific Islander. These broad categories are sometimes misleading, because they can often mask substantial differences within groups. The larger group may share nothing more than common physical traits, language, or religious backgrounds. We often fail to consider the distinct factors which influence culture within larger populations that determine how people think and behave. 

Values and Attitudes

Culture shapes how people experience their world. It is a vital component of how services are both delivered and received. Cultural competence begins with an awareness of your own cultural beliefs and practices, and recognition that people from other cultures may not share them. This means more than speaking another language or recognizing the cultural icons of a people. It means changing prejudgments or biases you may have of a people’s cultural beliefs and customs.

It is important to promote mutual respect. Cultural competence is rooted in respect, validation and openness towards someone with different social and cultural perceptions and expectations than your own. People tend to have an “ethnocentric” view in which they see their own culture as the best. Some individuals may be threatened by, or defensive about, cultural differences. Moving toward culturally appropriate service delivery means being:

knowledgeable about cultural differences and their impact on attitudes and behaviors;
sensitive, understanding, non-judgmental, and respectful in dealings with people whose culture is different from your own; and flexible and skillful in responding and adapting to different cultural contexts and circumstances.

Also, it means recognizing that acculturation occurs differently for everyone. This means more than different rates among different families from the same cultural background; it means different rates among members of the same family as well.

For example, the beliefs, customs, and traditions of people from other cultures are often at odds with Western medicine and its heavy emphasis on science. Consistent with the Anglo-American emphasis on scientific reasoning, Western medicine tends to emphasize biological explanations for illness (such as bacteria, viruses or environmental causes); whereas in other cultures the natural, supernatural or religious/spiritual reasons explain the cause of the problem (the yin and yang are out of balance; you have broken a taboo; or you have been thinking or doing evil.

Cultural competence is defined as “a set of cultural behaviors and attitudes integrated into the practice methods of a system, agency, or its professionals, that enables them to work effectively in cross cultural situations.” Cultural competency is achieved by translating and integrating knowledge about individuals and groups of people into specific practices and policies applied in appropriate cultural settings. When professionals are culturally competent, they establish positive helping relationships, engage the client, and improve the quality of services they provide.

Culture plays a complex role in the development of health and human service delivery programs the need for the provision of culturally appropriate services is driven by the demographic realities of our nation. Understanding culture and its relationship to service delivery will increase access to services as well as improve the quality of the service outcomes. Research has begun to provide the underpinnings for the development of standards for the delivery of services to diverse populations. The following Principles are drawn from research material on the role culture plays in providing services to older adults.

There is an ethic to culturally competent practice. When professionals practice in a culturally competent way, programs that appropriately serve people of diverse cultures can be developed. Each person must first posses the core fundamental capacities of warmth, empathy and genuineness. To achieve cultural competence, professionals must first have a sense of compassion and respect for people who are culturally different. Then, practitioners can learn behaviors that are congruent with cultural competence. Just learning the behavior is not enough. Underlying the behavior must be an attitudinal set of behavior skills and moral responsibility. It is not about the things one does. It is about fundamental attitudes. When a person has an inherent caring, appreciation and respect for others they can display warmth, empathy and genuineness. This then enables them to have culturally congruent behaviors and attitudes. When these three essentials intersect, practitioners can exemplify cultural competence in a manner that recognizes, values and affirms cultural differences among their clients.

Communication provides an opportunity for persons of different cultures to learn from each other. It is important to build skills that enhance communication. Be open, honest, respectful, nonjudgmental, and - most of all - willing to listen and learn. Listening and observational skills are essential. Letting people know that you are interested in what they have to say is vital to building trust. Communication strategies have to capture the attention of your audience. This means not only using the language and dialect of the people you are serving, it means using communication vehicles that are proven to have significant value and use by your target audience.

Culturally competent service providers must take into account the full range of factors that influence how any one individual service recipient behaves and communicates. The two levels of influencing factors are: overall cultural differences between racial and ethnic groups, as well as  individual-level differences (based on age, education, literacy, income, gender and geographic  location).
Acculturation is a process that occurs when two distinct cultural groups have continuous first-hand contact, resulting in subsequent changes in the original cultural patterns of either or both groups. The degree to which acculturation takes place is influenced directly by both the cultural and individual-level differences.

The DSM-IV TR Outline for Cultural Formulation When Assessing and Diagnosing Patients

Rendering psychological and psychiatric assistance to a diverse population carries with it some special issues as well as those more generally noted in other curricula. Consequently, faculty and clinicians in the mental health and behavioral health fields have been working to include diagnostic and clinical criteria that would assist practitioners in becoming more culturally and linguistically competent. One concise clinical tool to aid the clinician in this process is the Outline for Cultural Formulation (OCF) found in Appendix I of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (known as DSM-IV-TR) from American Psychiatric Association in Arlington, VA.

Although intended for use with the DSM-IV TR in assessing mental disorders, the OCF is applicable to other clinical health care encounters. It provides a systematic review of the individual’s cultural background, the role of the cultural context in the expression and evaluation of symptoms and dysfunction, and the effect that cultural differences may have on the relationship between the individual and the clinician. As a result of using the OCF, the clinician provides a narrative summary for each of the following categories:

1. Cultural identity of the individual
2. Cultural explanations of the individual’s illness
3. Cultural factors related to the psychosocial environment and levels of functioning
4. Cultural elements of the relationship between the individual and the clinician
5. Overall cultural assessment for diagnosis and care

1. Cultural identity of the individual. Note the individual’s ethnic or cultural reference groups. For immigrants and ethnic minorities, note separately the degree of involvement with both the culture of origin and the host culture, where applicable. Also note language abilities, use, and preference, including multilingualism.

2. Cultural explanations of the individual’s illness. The following may be identified: the predominant idioms of distress through which symptoms or the need for social support are communicated (such as “nerves,” possessing spirits, somatic complaints, and inexplicable misfortune), the meaning and perceived severity of the individual’s symptoms in relation to norms of the cultural reference group, any local illness category that the individual’s family and community use to identify the condition (such as those explained in the DSM-IV TR’s “Glossary of Culture-Bound Syndromes”), the perceived causes or explanatory models that the individual and the reference group use to explain the illness, and current preferences for and past experiences with professional and popular sources of care.

3. Cultural factors related to the psychosocial environment and levels of functioning. Note culturally relevant interpretations of social stressors, available social supports, and levels of functioning and disability. These stressors would include those in the local social environment and the role of religion and kin networks in providing emotional, instrumental, and informational support.

4. Cultural elements of the relationship between the individual and the clinician. Indicate differences in culture and social status between the individual and the clinician and problems that these differences may cause in diagnosis and treatment, such as difficulty in communicating in the individual’s first language, in eliciting symptoms or understanding their cultural significance, in negotiating an appropriate relationship or level of intimacy, and in determining whether a behavior is normative or pathological.

5. Overall cultural assessment for diagnosis and care. The formulation concludes with a discussion of how cultural considerations specifically influence comprehensive diagnosis and care.

The clinician assesses the first four interrelated sections, which provide information that will have an effect (in the fifth section) on the differential diagnosis and the treatment plan. Clinicians must cultivate an attitude of “cultural humility” in knowing their limits of knowledge and skills in applying the OCF with accuracy rather than reinforcing potentially damaging stereotypes and over-generalizations.

Cultural identity involves a range of variables not only including ethnicity, acculturation and biculturality, and language, but also age, gender, socioeconomic status, sexual orientation, religious and spiritual beliefs, disabilities, political orientation, and health literacy, among other factors. In addition, assessment of cultural identity must move from merely the clinician’s perspective to include the patient’s self-construal of identity over time.

The second section asks the clinician to inquire about the patient’s idioms of distress, explanatory models, and treatment pathways (including complementary and alternative medicine and indigenous approaches) and to assess these pathways against the norms of the cultural reference group. The third section highlights the importance of the assessment of family and kin systems and religion and spirituality. The fourth section focuses on the complex nature of the interaction between the clinician and the individual including transference and counter-transference, which may either aid or interfere with the treatment relationship. In the final section, the clinician summarizes his or her understanding of the previous sections and can apply this understanding to a differential diagnosis and treatment plan.

AAPI Mental Health

The National Asian American Pacific Islander Mental Health Association (NAAPIMHA) has found the DSM IV TR Outline for Cultural Formulation provides a rich theoretical framework in making culturally appropriate assessments, diagnosis, and treatment plans. Using the DSM IV TR, NAAPIMHA developed a curriculum and pre-service training program in 2002 that is designed to help reduce disparities in mental health care for diverse populations by building a workforce capacity. The aim of the curriculum was to address the mental health needs of Asian Americans and Pacific Islanders and was developed under a grant from the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

The curriculum, called Growing Our Own, is for the disciplines of psychiatry, psychology, social work, and counseling. It draws upon years of experience, assessing what does and does not work in providing culturally competent mental health services to the AAPI communities.

The five modules of the Growing Our Own curriculum build on each other and are intended to help the intern or resident develop an approach that avoids simplistic cookbook conclusions. The five modules are as follows:

Module 1 – Self Assessment helps interns or residents to recognize the biases that influence what we see and how these biases affect decision-making.

Module 2 – Connecting With Your Client is designed to help trainees become familiar with AAPI in general and provide them with the requisite knowledge, skills, and attitudes to communicate effectively with consumers and work with interpreters.

Module 3 – Culturally Responsive Assessment and Diagnosis is designed to identify factors that lead to the development of a culturally competent assessment and diagnosis.

Module 4 – Culturally Responsive Intervention focuses on concepts and strategies the intern or resident should consider in formulating and implementing a culturally responsive intervention plan, regardless of the particular intervention model employed.

Module 5 – Culturally Responsive Systems identifies barriers that consumers and service providers face under the current mental health system, highlights the important role of mental health professionals as agents of institutional change, and offers recommendations to help guide culturally competent systems change.

Clinicians should follow four steps when caring for all patients, but in particular those patients who are from a social or cultural background different from that of the care provider. Clinicians should think of these four steps as a “review of systems” focused on issues that, if not addressed, may lead to poor health outcomes. The four steps are:

1. Identify the core cross-cultural issues
2. Explore the meaning of the illness
3. Determine the social context
4. Negotiate

Step 1—Identify the Core Cross-Cultural Issues. When a clinician sees a patient from a different or unfamiliar socio-cultural background, he or she should consider a broad set of core cross-cultural issues that may be important for that individual. The clinician should try to place the individual patient on a continuum as it relates to issues that are important to all cultures by considering the following:

Styles of communication: How does the patient communicate? Communication includes issues relating to: eye contact, physical contact, and personal space; and issues about how the patient may prefer to hear “bad news.” For example, is the patient deferential or confrontational? Does the patient display stoicism or express symptoms willingly?

Mistrust and prejudice: Does the patient mistrust the health care system? If so, clinicians should recognize prejudice and its effects and attempt to build trust by reassuring the patient of one’s intentions. Keep in perspective “what’s at stake” for the patient, and show respect for the patient’s concerns.

Autonomy, authority, and family dynamics: How does the patient make decisions? What is the role of the family versus the individual in decision making? What support does the patient have from his or her family of origin, partner, and friends? What is the role of the authority figure within the family or social group? What role does community or spiritual leaders play in important decisions?

The role of the practitioner and biomedicine: What does the patient expect of clinicians and what is the clinician’s role? What are the patients’ expectations for the practitioner and biomedicine? What perspectives does the patient have about the practitioner? Does the patient consider the clinician to be a service provider or gatekeeper, for example? What are the patient’s views on alternative medicine versus biomedicine?

Traditions, customs and spirituality: How do these factors influence the patient? These attitudes include issues regarding medical procedures, such as drawing blood, and rituals pertinent to the medical encounter. What culturally specific “alternative” therapies does the patient consider, including culturally specific diet and preferences?

Sexual and gender issues: How central are these issues to the patient’s life? Is there gender concordance or discordance? What attitudes does the patient have toward the physical exam and the gender of the practitioner? Clinicians should use the preferred pronoun for patients who are transgender or transsexual and consider the issue of shame or embarrassment when discussing sexual issues. Consider also the differences in sexual behavior, orientation, and identity.

Step 2—Explore the Meaning of the Illness. Each patient will have a different understanding about disease and treatment. These perspectives will shape the patient’s behavior. It may be particularly helpful to assess the patient’s concept of illness, or “explanatory model,” when the practitioner does not feel he or she understands the patient’s behavior, when there is non-adherence to a treatment plan, or when there is some sort of conflict.

Clinicians can make such determinations by asking the patient the following questions:

What do you think has caused your problem? How?

Why do you think it started when it did?

How does it affect you?

What worries you most: the severity of the condition, or duration of the illness, or both?

What kind of treatment do you think you should receive? What expectations do you have?

Step 3—Determine the Social Context. The “social context” is of equal importance as an area of exploration, given how social and cultural factors are intertwined. Certain key areas should be considered when identifying the patient’s social context:

Tension (social stress and support systems): Does the patient have social support, or is he or she isolated?

Environment change (degree and reason for change, expectations, and acculturation): What was the patient’s previous health care experience, and how does that experience shape his or her interaction with the health care system now?

Life control (including social status, poverty, and education): What resources does the patient have? Can he or she afford medications?

Literacy and language: Does the patient have limited English proficiency or literacy, and how does such a limit affect his or her health care?

Step 4—Negotiate. Once the above information is obtained, the clinician should engage in negotiation with the patient to try to achieve the best possible outcome. Sometimes what is acceptable is better than what is optimal, if the risk of trying to secure the optimal would involve losing the patient’s trust. Such negotiation requires exploring the meaning of the illness for the patient and formulating a mutually acceptable plan.

Counseling Considerations

Counselors bring with them their own degree of effectiveness with these generic characteristics. They also bring with them their cultural manifestations as well as their unique personal, social and psychological background. These factors interact with the cultural and personal factors brought by the client. The interaction of these two sets of factors must be explored along with other counseling-related considerations for each client who comes for counseling. The effective counselor is one who can adapt the counseling models, theories, or techniques to the unique individual needs of each client. This skill requires that the counselor be able to see the client as both an individual and as a member of a particular cultural group. Multicultural counseling requires the recognition of: (1) the importance of racial/ethnic group membership on the socialization of the client; (2) the importance of and the uniqueness of the individual; (3) the presence of and place of values in the counseling process; and (4) the uniqueness of learning styles, vocational goals, and life purposes of clients, within the context of principles of democratic social justice (Locke, 1986).

The Multicultural Awareness Continuum (Locke, 1986) was designed to illustrate the areas of awareness through which a counselor must go in the process of counseling a culturally different client. The continuum is linear and the process is developmental, best understood as a lifelong process.

Self-awareness. The first level through which counselors must pass is self-awareness. Self-understanding is a necessary condition before one begins the process of understanding others. Both intrapersonal and interpersonal dynamics must be considered as important components in the projection of beliefs, attitudes, opinions, and values. The examination of one's own thoughts and feelings allows the counselor a better understanding of the cultural "baggage" he or she brings to the situation.

Awareness of one's own culture. Counselors bring cultural baggage to the counseling situation; baggage that may cause certain things to be taken for granted or create expectations about behaviors and manners. For example, consider your own name and the meaning associated with it. Ask yourself the cultural significance of your name. Could your name have some historical significance to cultures other than the culture of your origin? There may be some relationship between your name and the order of your birth. There may have been a special ceremony conducted when you were named.

The naming process of a child is but one of the many examples of how cultural influences are evident and varied. Language is specific to one's cultural group whether formal, informal, verbal, or nonverbal. Language determines the cultural networks in which an individual participates and contributes specific values to the culture.

Awareness of racism, sexism, and poverty. Racism, sexism, and poverty are all aspects of a culture that must be understood from the perspective of how one views their effect both upon oneself and upon others. The words themselves are obviously powerful terms and frequently evoke some defensiveness. Even when racism and sexism are denied as a part of one's personal belief system, one must recognize that he/she never-the-less exists as a part of the larger culture. Even when the anguish of poverty is not felt personally, the counselor must come to grips with his or her own beliefs regarding financially less fortunate people.

Exploration of the issues of racism, sexism, and poverty may be facilitated by a "systems" approach. Such an exploration may lead to examination of the differences between individual behaviors and organizational behaviors, or what might be called the difference between personal prejudice and institutional prejudice. The influence of organizational prejudice can be seen in the attitudes and beliefs of the system in which the counselor works. Similarly, the awareness that frequently church memberships exist along racial lines, or that some social organizations restrict their membership to one sex, should help counselors come to grips with the organizational prejudice which they may be supporting solely on the basis of participation in a particular organization.

Awareness of individual differences. One of the greatest pitfalls of the novice counselor is to overgeneralize things learned about a specific culture as therefore applicable to all members of the culture. A single thread of commonality is often presumed to exist as interwoven among the group simply because it is observed in one or a few member(s) of the culture. On the contrary, cultural group membership does not require one to sacrifice individualism or uniqueness. In response to the counselor who feels all clients should be treated as "individuals," I say clients must be treated as both individuals and members of their particular cultural group.

Total belief in individualism fails to take into account the "collective family-community" relationship which exists in many cultural groups. A real danger lies in the possibility that counselors may unwittingly discount cultural influences and subconsciously believe they understand the culturally different when, in fact, they view others from their own culture's point of view. In practice, what is put forth as a belief in individualism can become a disregard for any culturally specific behaviors that influence client behaviors. In sum, counselors must be aware of individual differences and come to believe in the uniqueness of the individual before moving to the level of awareness of other cultures.

Awareness of other cultures. The four previously discussed levels of the continuum provide the background and foundation necessary for counselors to explore the varied dynamics of other cultural groups. Most cross-cultural emphasis is currently placed upon African Americans, Native Americans, Mexican Americans or Hispanics, and Asian Americans. Language is of great significance and uniqueness to each of these cultural groups, rendering standard English less than complete in communication of ideas. It is necessary for counselors to be sensitive to words which are unique to a particular culture as well as body language and other nonverbal behaviors to which cultural significance is attached.

Awareness of diversity. The culture of the United States has often been referred to as a "melting pot." This characterization suggests that people came to the United States from many different countries and blended into one new culture. Thus, old world practices were altered, discarded, or maintained within the context of the new culture. For the most part, many cultural groups did not fully participate in the melting pot process. Thus, many African American, Native American, Mexican American, and Asian American cultural practices were not welcomed as the new culture formed.

Of more recent vintage is the term "salad bowl" which implies that the culture of the United States is capable of retaining aspects from all cultures (the various ingredients). Viewed in this manner, we are seen as capable of living, working, and growing together while maintaining a unique cultural identity. "Rainbow coalition" is another term used in a recent political campaign to represent the same idea. Such concepts reflect what many have come to refer to as a multicultural or pluralistic society, where certain features of each culture are encouraged and appreciated by other cultural groups.

Skills/Techniques. The final level on the continuum is to implement what has been learned about working with culturally different groups and add specific techniques to the repertoire of counseling skills. Before a counselor can effectively work with clients of diverse cultural heritage, he or she must have developed general competence as a counselor. Passage through the awareness continuum constitutes professional growth and will contribute to an increase in overall counseling effectiveness, but goes much further than that. Counselors must be aware of learning theory and how theory relates to the development of psychological-cultural factors. Counselors must understand the relationship between theory and counselors' strategies or practices. Most importantly, counselors must have developed a sense of worth in their own cultures before attaining competence in counseling the culturally different.

Cultural Constraints

People define cultural constructs within the context of their own life histories, growth, and current situations. A working framework for competence in the care of HIV-infected clients must take the following areas of cultural concern into account for each individual:

  • Demographics: race, ethnicity, gender, age, generation
  • Communication: language(s), literacy (reading, speaking, health)
  • Education level: functional as well as actual
  • Economic status of the individual and the environment in which s/he functions
  • Occupation/means of support: work status, current means of income (legal? illegal? borderline?), labor, profession
  • Geography: current residence, community/neighborhood, place of birth, legal status, travel, nationality, etc.
  • Environment and situational context: safety of communities in which the individual spends a significant amount of time; risks related to violence, fear of violence, or coercion; communities of risk (i.e., drug/alcohol use, anonymous sex)
  • Personal relationships: family, friends, partnerships, sex, drugs, etc.
  • Health (physical, emotional, mental): norms, beliefs, practices, preferred providers, taboos; definitions of health, disease/sick role, disability, and care; HIV and other disease diagnoses, treatments, achievements; perceptions (developed over time) of efficacy, value, and disparity/discrimination in relationships with various healthcare systems and providers
  • Gender and sex: gender, gender roles, transitions, sexual orientation, sexual intercourse
  • Community affiliations: religious, political, service, social, etc.
  • Culture-specific definitions: spirituality, art, ethics, value, locus of control, power
  • Individual experiences: development over time that has lead the individual to accept, reject, and/or modify cultural components that were imparted to him/her as a child; life experiences that have expanded, challenged, realigned, or reinforced early cultural influences; individual constellation of factors that make up her/his cultural orientation
  • Culture comfort: has the individual integrated a personal set of cultural influences into his/her life? how do those beliefs and practices intersect with health practices and self-acceptance? can the individual function within larger social systems (family, community, social structures)? is the individual in a state of cognitive dissonance, discord, or discomfort with/between the values of personal, familial, and/or social cultures?

Providers. Healthcare providers possess knowledge and skills that were developed in a process of professional education. They have their own language, expectations, and professional cultures.  They also have responsibilities:

  • To develop skills to assess individual client cultures and to work with the client to integrate components of that culture into a care and treatment plan that the client can accept.
  • To be open to learning about the ways of others and willing to see past stereotypes when working with individuals and families.
  • To suspend judgment, especially in the assessment phases of care.
  • To remember that individuals are unique even within groups: some Hispanics do not speak Spanish, some women are not mothers, some Catholics use birth control, and some college-educated people use alternative/traditional healthcare practices.
  • To adopt an attitude of service to the client and the community.
  • To explore, understand, and honor their own cultural definitions and values.
  • To constantly compare personal culture(s) within the context of professional obligations.
  • To deal with any dissonance that occurs between cultures by “honoring and setting aside” or by making personally acceptable changes and developing methods of dealing with larger culture clashes and ethical dilemmas that can occur in cross-cultural settings.
  • To accept responsibility as the power broker in healthcare situations to address healthcare in a holistic manner that includes culture.

Client. The client also has obligations:

  1. To share the components of her/his culture that will impact on the ability to seek care, to participate in the process of developing a healthcare plan, and to implement care prescriptions.
  2. To seek care from providers who understand his/her culture.
  3. To teach providers who are open to these discussions.

Unfortunately, many clients feel that they are in a “one down” position in ANY healthcare setting, especially if they are poor, do not understand healthcare systems, have cultural constraints against disagreeing with authority figures, or already suffer from discrimination by virtue of race, ethnicity, gender, status, or diagnosis (especially HIV, drug use, mental health problems, and STDs).  Because of this, the provider’s responsibility to honor various cultures is imperative.

Required Reading:

Counseling interracial couples and multiracial individuals: Applying a multicultural counseling competency framework

References:

Galbraith, C.  (2000, December).  Cross Cultural Considerations in Health Care:  One Hospital Responds.  Minnesota Medicine, 83. 

Beach, M.C., Price, E.G., Gary, T.L., Robinson, K.A., Gozu, A., Palacia, A., Smarth, C., Jenckes, M.W., Feuerstein, C., Bass, E.B., Powe. N,R,, & Cooper, L,A. (2005). Cultural competence: A systematic review of health care provider educational interventions.

Derald Wing Sue, Patricia Arredondo and Roderick J. McDavis. 1992, Multicultural Counseling Competencies and Standards: A Call to the Profession

US Dept of Health and Human Services, Cross Cultural Counseling CEUs social workers, lmft, lcsw, counselors, nursing

 

 

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