Contemporary issues facing aging Americans: implications for rehabilitation and mental health counseling. (Contemporary Issues in Aging).
As rehabilitation and mental health counselors transition into the 21st Century, many of these concerns have given way to seemingly more perplexing issues such as dwindling social security income, increased life expectancy, the phenomenal growth of the aging population, long term care needs, age discrimination and the like. A large portion of the literature regarding aging Americans have focused on the impending retirement of the "Baby Boom generation" (e.g., those persons born in the United States between 1946 and 1964) and the impact of their retirement on various aspects of American life (i.e., social security, employment, long term care, etc.) (Dennis & Migliaccio, 1997; Thomas, 1999; Wellner, 1999).
Persons 85 and older constitute the fastest growing segment of the U.S. population and are projected to double to more than 70 million by 2030 (Administration on Aging, 2000). Minority persons, who constitute the fastest growing segment of the elderly population, are expected to increase more than 500% by the middle of the next century (Scharlach, Fuller-Thomson, & Kramer, 1999). For example, the Hispanic elderly population is projected to increase sevenfold between 1990 and 2050, while the African American elderly population is projected to increase by more than 200%. According to the National Association of Area Agencies on Aging (NAAAA) (1999), the number of baby boomers are currently estimated at 76 million and constitute one of the most educated and publicized generations in the country.
Aging Americans are a very heterogenous group possessing significant within group differences. For example, the elderly of today and those of tomorrow, (the Baby Boom generation) constitute two significantly different cohort groups. Consequently, contemporary issues facing aging Americans will impact these groups very differently. For example, persons who are now in their 60s were born in the early 1930s; a time when the United States was coming out of a the Depression. They may remember World War II as part of their adolescent years, the beginning of the space race as they entered into young adulthood, experienced the turmoil of the 60s, Viet Nam, the Civil Rights and Women's Right Movement as middle-aged adults. Many of these persons grew up expecting to work in the family business when they came of age. Within this same cohort are also those persons who were expected to enter through the back door, drink from the "colored" fountain, and not expected to look their white counterpart in the eye. For this latter group, their experiences may have included overt racism and discrimination, encounters with groups such as the Klu Klux Klan, being denied admission to "all white" institutions of higher learning and limited access to employment opportunities.
Members of the baby boom generation are now ranging in age between 35 and 53 and have considerably different life experiences from their older cohorts. Members of this cohort experienced the 1960s as teenagers. Some likely were the "flower children", and Viet Nam war veterans, protesters and draft dodgers. Some marched with Martin Luther King, Jr., were followers of Malcolm X, watched Jackie Robinson and other African American athletes break barriers and gain entry into professional sports. Others matured alone with musical groups such as the Beatles, the Monkeys and the Jackson Five and were introduced to desegregated high schools, culturally and/or ethnically diverse peers during college or military service.
The historical experiences of both these groups will not only play a major role in shaping their perceptions of issues but will also directly impact their ability to deal with such issues. A keen awareness of the within group differences is paramount to understanding the impact that current issues will have on the lives of aging Americans and is essential to the development of adequate and appropriate services.
Contemporary Issues Facing Aging Americans
Aging Americans are confronted with a host of issues and concerns which can be addressed by the rehabilitation and mental health community. The remainder of this paper will examine contemporary issues facing aging Americans, discuss implications for rehabilitation and mental health counseling practices and offer suggestions to meet the needs identified herein.
Financial Instability or Limited Resources
Many aging Americans have grave concerns regarding their financial futures. Research suggest that this is a valid concern as a substantial number of aging Americans have not adequately prepared, financially, to retire or leave the work force (Administration on Aging, 2000; Simon-Rusinowitz, 1999; Stansky, 1997). There appears to be a variety of reasons for this lack of preparation. For example, many such persons may not be financially stable at retirement because of frequent changes in jobs, inconsistent contributions to retirement funds or a belief that Social Security would be adequate. Though some aging Americans have made preparations via financial investments and pension plans through their places of employment, a larger majority will have inadequate funds available upon retirement (Rubin, White-Means, & Daniel, 2000; Thorson, 2000).
A primary factor leading to a lack of financial preparation among women and minority elderly populations are insufficient employment histories. "There are pockets of older Americans, particularly women and minority group members, whose sparse work histories have placed them in economic jeopardy" (Silverstone, 1996, p.27) and thus have left them financially unprepared to exit the work force (Dariety, Guilkey, & Winfery, 1996; Rappaport, 1998; West, 1997). Minorities (including women) experience culture-specific constraints and barriers that affect career development (Marsella & Leong, 1995). Consequently, their work experience may have been quite different from those of a white male workforce (Kerka, 1995; Rappaport, 1998; Smith, 1995; West, 1997). Traditionally, women and ethnic minority group members have been employed in lower paying, unskilled or semiskilled jobs and may suffer from disproportionately limited resources as compared to their white male counterparts. Consequently, many must rely on social security benefits as the sole resource when considering retirement (Darity, Builkey, & Winfrey, 1996; Rappaport, 1998; Thorson, 2000).
Concomitantly, work histories consisting of low wage jobs, high unemployment, intermittent employment and discrimination in hiring and rates of pay have contributed to higher poverty rates among minority elderly. Not surprisingly, the incidence of poverty among minority elders remains high. Whereas the 2002 Census found 8.9% of older (age 65+) Whites living in poverty, 21.9% of elderly African American lived in poverty as did 21.8% of older persons of Latino origin (U.S. Census, 3/2002). Moreover, the rate of poverty among older American Indians ranged from 21.3% in urban areas to 37.5% in rural and/or reservation areas (Staveteig & Wigton, 2001; Vinje, 1996) while 1990 poverty rates for older Asian Americans was reported to be 13% (U.S. Census, 1990). Social security is expected to be only one part of a person's retirement income, however, 75% of elderly African Americans rely on it for at least half of their income compared to 66% of whites. The social security administration further reports that 45% of African Americans and 44% of Latinos relied on Social Security for 90% or more of their income compared to 29% of whites. A higher percentage of elderly minorities relied on social security for all their income, 33% compared to only 16% of whites (Hendley & Bilimoria, 1999; Smith, 1995; West, 1997). For those who live in poverty, the lack of adequate resources will necessitate a reliance on the social security system.
Because social security payments are based on a person's average yearly income, including years without income, periods of unemployment results in reduced monthly benefits (Hendley & Bilimoria, 1999). Many minority elders have worked at manual labor, domestic service, and/or temporary or part-time jobs that offered neither pensions nor social security benefits. Low wage jobs not only provide less of an income from which to save for retirement, but also are much less likely to be covered by private pension plans. Further, low paying jobs form the least stable part of the labor market, leaving these workers jobs more vulnerable to unemployment. Consequently, low paid workers have little opportunity to accumulate assets on which to live in later years. Only 34% of elderly African Americans, and 25% of elderly Latino households indicate they had pension coverage as a retirement resource compared to 45% of White elders (Hendley & Bilimoria, 1999; West, 1997).
According to Scharlach, Fuller-Thomson, and Kramer (1999), retirement is basically a misnomer for minority older people. They report that 60% or more may use the term "retirement" as a way of indicating that they have reached a certain age, but not necessarily retirement status. The majority of these people never retire and few have the benefits or wherewithal to assume a truly retired role (Scharlach, Fuller-Thomson, & Kramer, 1999), as most have not had the benefit of a systematic retirement or pension plan. Consequently, many older minority Americans will remain in the work force well beyond retirement age by necessity rather than choice (Dennis & Migliaccio, 1997; Rappaport, 1998; Thorson, 2000).
Aging Americans, who either by choice or necessity, remain in the work force must be prepared to deal with a number of work related issues. A global economy and ever changing technological advances constantly challenge today's workers to up-grade skills and expertise. Training and re-training have become standard practice in most jobs (Coates, Jarratt, & Mahaffie, 1991; Evans-Klock, Kelly, & Richards, 1999). Today's market has created an interesting and perhaps for some, distressing shift that is changing the generational/hierarchical dynamics of the workplace. Managers, supervisors and interviewers are getting younger as workers are getting older. This widening chasm can present a formidable challenge to aging Americans who remain in the workforce. One issue facing older Americans is the added responsibility of adjusting to and accepting inter-generational differences in communication, social behaviors, and work habits which are beginning to permeate the workplace. The negative perceptions of "old age" by a youth oriented culture place these workers in a potentially oppressive situation with younger, more powerful professionals. As for minority with disabilities and women workers, the added stigma of "old age" may serve to exacerbate already existing discrimination (Thorson, 2000).
A second concern involves skills obsolescence. Many older workers have not been offered the training opportunities afforded younger workers (Imel, 1996). In a study of workforce age demographics, Barth, McNaught, and Rizzi (1993) found that 34% of the managers surveyed reported their companies spend little money training older workers, compared to 21% who spend very little on training workers under age 35. One the other hand, it is plausible that younger workers may not require as much training due to the "currentness" of their skills. Compared to younger workers, older workers are viewed positively on low absenteeism, low turnover, work attitudes and motivation, job skills, and loyalty. However, employers tend to be overly concerned about health care cost, a lack of flexibility in accepting new assignments, general suitability for retraining, and the individual's ability to learn new skills (Barth et al., 1993; Taylor & Walker, 1998).
Age discrimination is a third issue that some older workers will likely face in the workplace. According to Taylor and Walker (1998), older workers are incorrectly labeled as less productive and less adaptable, and more expensive and eager to retire early. These mis-perceptions are manifested as managers frequently rate older workers below average on many traits considered desirable for the changing workplace, such as, avoidance of workplace injury and ability to learn new skills, as well as low on flexibility and acceptance of new technology (Imel, 1996; Lagana, 1995; Taylor & Walker, 1998). The prevalence of such perceptions may influence employers to attempt to ease older workers out of the workplace within the next two decades and/or to institute hiring practices which would lessen the number of older workers being added to the workforce. It has been suggested that such "ageism will not be easily tolerated by tomorrow's older population" (Silverstone, 1996, p. 29) and consequently, is projected that the number of age discrimination claims will increase significantly (Stansky, 1997).
Long-term Care Concerns
With an overabundance of wellness, fitness, and nutritional information readily available, combined with cutting edge medical technology, Americans are living longer and healthier lives than ever before. However, despite this reality, debilitating illness, disease or injury eventually accompany advancing age. In a profile of older Americans, the Administration on Aging (2000) concluded that 53% of persons over 65 report having at least one disability, and 33% report having a severe disability. It is further estimated that 7.3 million elderly persons require assistance with activities of daily living (i.e., eating, dressing, bathing, getting in and out of bed, etc.). The number of persons with disabilities and those needing assistance increase dramatically for persons 80 and above. Consequently, the need for long-term care is a growing concern for many Americans. Aetna Retirement Services (1999) reported "an estimated 15% of U.S. adults are providing special care for seriously ill or disabled relatives" (p. 2), and that 20% to 40% of caregivers are caring for children under age 18 at the same time. They further reported that 33% to 55% of caregivers work outside the home. Similar findings were reported in a survey conducted by the National Alliance for Caregiving and the American Association of Retired Persons (1997). They found that an estimated 22.4 million U.S. households are providing informal care to a relative or friend age 50 or older, or provided such care at some point during the last twelve months. The following characteristics regarding caregivers were reported: 72% are women (typical age 46), 64% work full or part time, and 41% care for children under the age of 18 while caring for the elderly relative or friend. Adults who are caught between caring for aging parents/relatives and raising children at the same time have been referred to as the "sandwich generation" (Dixon, Amuso, & Stozier, 1999).
A closely related concern is the dwindling number of relatives/children available to care for aging adults. Many younger aging Americans (baby boomers) made the choice to remain childless, or to delay marriage and starting a family. Further, among the oldest of the old (85+), many may have outlived their children. These two factors have resulted in a growing number of aging Americans with fewer options in terms of their own care later in life. According to the Administration on Aging (2000) many aging Americans have had relatively few children, sparking concern that those who need assistance in advanced age will have only a small circle of immediate family to draw upon.
Though a higher proportion of health problems among minority elders exist, it does not lead to higher rates of institutionalization for this population. A smaller percentage of non-white (3%) than white (5.8%) elderly live in nursing homes. Contributing factors point to discrimination in referrals when institutional health care or long term care services are needed, geographical separation from support networks, potential linguistic isolation, shorter life spans for most minority individuals, and greater involvement of families and other unpaid sources of assistance (Administration on Aging, 2000). Additionally, some ethnic groups place high value on caring for elderly members within the family context and/or attach a social stigma to institutionalization. However, because of increasing assimilation into the dominant culture and geographical separation, it has been suggested that cultural values regarding the provision of care to older family members are being challenged.
As of January 1, 1997 with the signing into law of welfare and health care reform legislation, the cost of financing long-term care rests with individuals. For those who are able to afford long-term care insurance, benefits now extend from nursing homes to assisted living facilities, residential care homes, and in-home care. However, for those who are not able to afford such insurance, and rely on entitlement programs (Medicare and Medicaid), there is increasing evidence of the inability of such programs to cover the costs of long term care. Clearly, personal responsibility will play a key role in the financing of future long term care. Consequently, those who are inadequately prepared for whatever reasons are not likely to receive necessary care (Hendley & Bilimoria, 1999; Rappaport, 1998).
The traditional practice of aging Americans caring for grandchildren raises issues that should not be ignored (Brown, Monye, Robinson-Brown, & Brandon-Moye, 1995; Chalfie, 1995). Increases in teen pregnancy, alcohol and substance abuse, increased awareness and reporting of domestic violence, the increasing lost of parents to illness (i.e., AIDS) and accidents, as well as the growing phenomena of parents simply not wanting to take care of their own children have contributed to the growing number of grandparents assuming parenting responsibilities for their grandchildren. In some instances, grandparents are stepping in to avoid having grandchildren turned over to foster care, or because the child's parents have been deemed "unfit" by the courts. For whatever reason, research indicates that approximately one in ten grandparents are currently assuming primary parenting responsibilities for their grandchildren for at least six months with the majority providing care for at least three years (Minkler & Fuller-Thomson, 1999). Furthermore, approximately 353,000 grandparent caregivers are caring for grandchildren with neither parent present. The median age of grandparent caregivers is 57, with 77% ranging in age between 45 and 64, and 23% are 65 and older. The majority (68%) of grandparent caregivers are white. However, older African Americans are nearly twice as likely as whites the same age to be caregivers. Of all elderly caregivers, about 41% live in or close to the poverty level (Chalfie, 1995; Thorson, 2000).
The psychosocial impact of grandparenting can be overwhelming for many aging Americans. Increased financial stress is a major concern as often there is little or no financial support from the grandchild's parents. Seeking financial assistance through public sources also can be stressful in terms of securing transportation to keep necessary appointments, missed time from work for appointments, completing required governmental forms, and so forth. Financial and work related problems may arise if the grandparent have to miss work to attend to a child's health issues or time off from school (i.e., holidays and vacation) (Brown, et al, 1995).
Secondly, the grandparent's health may be negatively impacted by the added physical demands of attending to the needs of a small child who may not yet be able to feed or dress him/herself, or attend to many activities of daily living. Similarly, older children may be involved in extra curricula activities which require the support of an active adult. Such physical demands can be quite taxing and may result in increased physical strain and decreased quality of life. In a study which looked at 173 care giving grandparents and 3,304 non-care giving grandparents, Minkler and Fuller-Thomson (1999) found that 50% of the caregivers were more likely to have limitations on activities of daily living, 17% were limited in their ability to move around the house, 3 out of 10 had difficulty completing daily households tasks, and 4 out of 10 had difficulty climbing stairs or walking up to six blocks. Caring for a grandchild with a disability can further compound the financial, psychosocial and health related difficulties experienced by grandparents. Additionally, altered social relationships, delayed retirement plans, increased psychological stress and limited resources are but a few ways in which grandparents may be impacted by the increased responsibility of caring for grandchildren (Kluger & Aprea, 1999; Sands & Goldberg-Glen, 1998).
Victimization and abuse
Victimization and abuse that many older Americans experience are issues of which helping professionals must be cognizant. It is estimated that 1 million elderly persons are physically abused each year. Abuse takes many forms, ranging from physical, psychological, and sexual to abandonment and financial abuse. In many instances the perpetrators of abuse are family members who have become caretakers (Dyer, Pavlik, Murphy, & Hyman, 2000; Hoban & Kearney, 2000). Research indicates that the majority of those abused are women (Hoban & Kearney, 2000; Marshall, Benton & Brazier, 2000). The effects of abuse can compound other problems. For example, Dyer, et al (2000) reports that when comparing abused and unabused elderly persons, those who have been abused have a higher occurrence of dementia (51% vs. 39%) and depression (62% vs. 12%). Moreover, elderly persons known to have been abused physically or mentally have a significantly higher mortality rate than those who have not been abused (Lachs, Williams, O'Brien, Pillemer, & Charlson, 1998).
The process of aging creates not only physical challenges and limitations but can have profound psychological impact on elderly persons. Elderly person often face adjustment issues related to the loss of significant others in their lives, such as spouse, siblings, and close friends. Many persons face depression related to loss of physical functioning and independence. A challenge for mental health professionals attempting to meet these needs is that older persons tend to be reluctant to seek mental health counseling for such issues (Lagana, 1995; Thorson, 2000). Moreover, the problems for older women are different than those of men, and may be exacerbated as they live longer than men and are more often widowed. Fifty seven percent of women over the age of 65 were not married compared to 23% of men. Of this number, 45% were widows. Although the majority of older persons are alone due to death of a partner, the number of divorced persons has grown at a significant rate since 1990 and the majority of elder person divorced or widowed and living alone are women (Administration on Aging, 2000). Elderly women also are more likely than men to live in poverty or on limited incomes and have fewer opportunities for social activities. These factors contribute to depression due to increasing isolation associated with decreased social activity (Burnette & Mui, 1996). Furthermore, elderly women who are disabled are more likely to be institutionalized than men. These factors are likely to create a more emotionally stressful situation for women than their male counterparts (Burnette & Mui, 1996; Riker & Meyers, 1995; Thorson, 2000).
Emotional and psychological difficulties related to retirement should not be overlooked when addressing the mental status of aging populations. For many elderly, the changes associated with retirement (e.g., reduced income, decreased social engagements, diminishing physical strengths and stamina, etc.) brings about decreased life satisfaction and greater psychological distress. These changes frequently influence subjective reports of well being for both men and women (Kim & Moen, 2001). The impact of retirement can be more negative depending on marital status, ethnicity, gender as well as whether retirement was voluntary or involuntary (Kim & Moen, 2001; Zimmerman, Mitchell, Wister, & Gutman, 2001). Consequently, an assessment of retirement related issues and changes should be addressed by mental health professionals working with aging populations.
Implications for Rehabilitation and Mental Health Counselors
As identified herein, priority service needs of aging Americans include assistance to deal with financial and legal issues, the elimination of victimization, employment, training and retraining, increased long-term care options and support, increased resources for caregivers, and an understanding of the diversity within the population. The skills that counselors will be required to possess and the services that will be necessary to address the needs of aging Americans are varied and complex. Several of these skill areas are discussed below.
Guardianship and advocacy are services that rehabilitation counselors can provide to aging Americans. This aspect of service has become necessary as many may not have family support networks in place to assist when such activities are necessary (Hall, 1993; Moen, 1998). Professional advocacy for changes in the laws impacting older Americans is increasingly necessary. Specific changes are needed in the areas of health care reform, anti-discrimination and nutrition, all of which are vital to ensuring an adequate quality of life for the elderly (Buchowski & Sun, 1996; Thorson, 2000).
Skilled case managers will be needed to coordinate all of the various services that will be required to meet the needs of aging Americans. For example, many elder individuals need help in securing authorization for medical procedures, scheduling medical appointments, arranging transportation, securing a second opinion and obtaining referrals from their primary care physicians, and so forth. Assistance also may be needed in following up with insurance companies, obtaining in-home health assistance and coordinating referrals for the primary physician to other needed medical services. Additionally, skilled case managers possess knowledge of community resources and can make appropriate referrals for financial counseling, transportation, long-term care, meals on wheels, housing assistance, etc. A closely related service which some rehabilitation counselors can provide, and all can refer out to is benefits planning.
Activities related to benefits planning are closely related to case management and involve helping persons prepare for a secure future. This aspect of planning is becoming more and more complex and involves educating persons to the importance of finances--in terms of both asset accumulation and asset distribution and protection. As employers move away from defined pension plans, baby boomers or their agents will have to assume greater responsibility for retirement planning than previous generations. This will require counselors to increase their knowledge in these areas as well as to become familiar with and seek advise from financial planners and to attend related educational seminars (Timmermann, 2000).
Gerontology counseling has been defined as the process of helping older individuals to overcome losses, to establish new goals while in the process of discovering that living may be limited in years but not necessarily in quality, and to reach decisions based on the importance of being in the present as well as looking for future opportunities (Riker & Meyers, 1995). Similarly, gerontology counselors must possess a variety of skills in order to meet the needs of the population they serve. These skills include provision of appropriate referrals and information in the areas of independent living, personal growth counseling, adjustment counseling, employment, financial, leisure, family, grief and peer counseling, medical case management, and advocacy (Riker & Meyers, 1995). With the exception of financial counseling, many rehabilitation and mental health counselors have been uniquely trained to provide services in the above areas and should be prepared to meet the needs of aging Americans. However, training regarding issues facing aging populations may well be considered specialized by most rehabilitation and mental health counselor training programs and consequently, may not have been available to many program graduates. Counselors who are interested in serving aging Americans may need to seek post-masters training in gerontology or geriatrics counseling and rehabilitation.
Employment and training
As previously mentioned, many older Americans are healthier and choosing to remain in the workplace longer. Other older workers are remaining in the workforce because they cannot afford to leave. Many of these individuals could benefit from the skills of a rehabilitation professional knowledgeable of career/vocational counseling issues facing older workers. Disability management specialist, many of whom have rehabilitation and mental health counseling backgrounds, are uniquely employed in industries where they can assist employers in assessing the needs of their aging work force, as well as developing training programs to help employers retain older workers.
Given the demographic trend toward increased diversity in the aging population, the ability to work effectively with persons from diverse backgrounds will be paramount. Culturally skilled counselors (Ivey, Ivey, Simek-Morgan, 1997; Sue & Sue, 1999) are better prepared to identify the cultural, historical and ethnic factors which may influence the minority elderly perceptions of the issues they face and can assist the client to respond comfortably within their cultural context. For example, in the area of long-term care, home health care providers are increasingly recognizing the need for culturally diverse skills in the area of planning in order to assist culturally diverse persons to avoid unnecessary institutionalization. Furthermore, the disparity of equitable, quality treatment has been documented and a call for increased advocacy for elderly minority persons has been reported in such areas as nutritional needs (Buchowski & Sun, 1996), adequate health care plans and benefits (Collins, 1995), access to long-term health care (Hall, 1993), and general health care quality (American Public Health Association, 2001; Etchason, et al., 2001; Shi, 1999).
If rehabilitation and mental health counselors are to assist aging Americans to cope with and adjust to the realities of limited financial resources, continued workplace participation, long-term care concerns, grandparenting issues and the like, they must be able to demonstrate a wide array of competencies (e.g., knowledge of community resources, career counseling skills, knowledge of workplace accommodations, knowledge of disability and aging policies impacting older Americans, psychosocial implications inherent in caregiving responsibilities, etc). Such competencies are typically acquired in pre-service training programs. With the exception of the aforementioned reference to specialization of aging issues by some rehabilitation and mental health counseling programs, many graduates exit rehabilitation and mental health counselor training programs with the requisite skills and knowledge to began providing quality services to aging populations. However, with the inclusion of specialized practica and internships placements in agencies serving aging populations, graduates will be able to gain a deeper understanding of many of the issues discussed herein. Furthermore, rehabilitation and mental health counselor training programs are encourages to develop interdisciplinary collaboration with related programs such as gerontology and aging studies, to enhance learning opportunities for students who express interest in working with aging populations.
Margaret Kuhn (2002), one of the founders of the "gray panthers" in 1971 and who remained active in the fight for the rights of elderly persons until her death in 1995 once said,
aging is a life-spanning process of growth an development from birth to death. Old age is an integral part of the whole, bringing fulfillment and self-actualization. I regard aging as a triumph, a result of strength and survivorship. (http://184.108.40.206/cgi)
In a society that is youth centered, it has been easy to relegate the elderly to be the end of existence so that they take on the status of invisible citizens. However, as the elderly populations continues to grow, their voices will merge with Ms. Kuhn's, demanding adequate, appropriate, and compassionate care to enable them to live this last life stage with dignity and pride. The needs of aging Americans cannot be ignored nor can they be met by gerontology professionals alone. Aging Americans will need assistance from professionals who possess expertise in a wide variety of areas (i.e., employment related services, long-term care services, financial services and the like). Rehabilitation and mental health counselors possess valuable skills and expertise that will be highly beneficial in meeting the contemporary issues facing aging Americans. As the aging population continues to grow, rehabilitation and mental health counselors should be at the forefront of service delivery.
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Charlotte Dixon, Rh.D., University of South Florida, Department of Rehabilitation and Mental Health Counseling, College of Arts and Sciences, 4202 East Fowler Avenue, SOC 107, Tampa FLorida 33620-6911. Email: Dixon@Chuma1.cas.usf.edu
Charlotte G. Dixon Michael Richard The University of South Florida Carolyn W. Rollins Florida State University
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|Author:||Rollins, Carolyn W.|
|Publication:||The Journal of Rehabilitation|
|Date:||Apr 1, 2003|
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