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Issues and standards in counseling lesbians and gay men with substance abuse concerns.

In this article, the author analyzes the issues and standards facing mental health counselors (MHCs) when working with lesbians and gay men who have substance abuse problems. In order to provide professional and affirmative services to clients from this population, it is critical for MHCs to understand the social and historical context of the lives of lesbians and gay men. Therefore, some of the major factors that contribute to substance abuse problems in the gay community are explored. Finally, guidelines regarding legal protections for this population are provided.


According to reports, more than 16.6 million people aged 12 or older have problems with substance abuse or substance dependency in the United States (U.S. Department of Health and Human Services, 2002). According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.), substance abuse is a maladaptive pattern of using alcohol or other drugs that results in significant adverse consequences such as problems at home, school, or work place; placing oneself in dangerous situations; legal troubles; or deteriorating interpersonal relationships (American Psychiatric Association, 2000). Despite the growing acceptability of gay men and lesbians over the past three decades, sensitivity to the mental health service needs of this population is still lacking (Benshoff & Janikowski, 2000; Hellman, Stanton, Lee, Tytun, & Vachon, 1989). Cabaj (1996) indicates professionals that help in substance abuse treatment centers may often lack knowledge about lesbian and gay issues and be unaware that they have clients who are lesbians or gay men. Although it has become known that lesbians and gay men have a higher rate of substance abuse compared to that of the general population, studies show that only about 1% of the clients in traditional substance abuse treatment programs identify themselves as being a lesbian, gay man, or another sexual minority such as bisexual, transgender, or transvestite (Hellman et al.). It is speculated that many lesbians and gay men are not comfortable with the idea of sharing the secret of their sexual orientation with their counselors or their fellow clients in the mainstream treatment agencies (Pride Institute, 1997). The reason behind this secrecy might be their fears of not being supported by their counselors and worries about being harassed by their fellow clients once their sexual orientation becomes known. After all, mental health counselors (MHCs) are usually trained to deal with clients' substance abuse issues, but they may not have received multicultural education on issues related to clients with a nonheterosexual orientation (Eldridge & Barnett, 1991). The purpose of this paper is to highlight information on (a) factors that contribute to substance abuse problems among the lesbian and gay male population and (b) professional standards that pertain to MHCs when addressing substance abuse problems with clients who are lesbians or gay men.


There is no single explanation why some people develop substance abuse problems and others do not (Mendelson & Mello, 1985). Rathbone-McCuan and Stokke (1997) stated that substance abuse has "a complex etiology which includes genetic/biochemical, psychological, and social/environmental factors interacting to create a probable cause-effect equation" (p. 170). This complexetiology approach has been helpful to many MHCs who work with clients with substance abuse concerns (Steven-Smith & Smith, 1998). From the environmental and psychosocial perspectives, there are several explanations for the high rate of substance abuse within the gay community including effects of the gay bar scene, internalization of society's homophobia and nonacceptance of self, the experience of childhood sexual abuse (CSA), the effects of HIV/AIDS, and painful coming-out experiences (Kus, 1988; McKirnan & Peterson, 1989).

Gay Bar Scene

Traditionally, the gay bar scene has been regarded as a key risk factor for substance abuse problems among the gay community (Steven-Smith & Smith, 1998; Weinberg, 1994). For many individuals who are gay, gay bars have functioned as a haven for them to meet new friends and sex partners. Also it is a place which is free from the stigma and prejudice of a largely homophobic society (Benshoff & Janikowski, 2000; Hooker, 1967). Cohler and Galatzer-Levy (1996) state: "Among young gay men and lesbians, the bar represents an important opportunity for affirming one's identity, being together with others like oneself, meeting friends, and enjoying music and dancing" (p. 209).That is, the attraction of the bar is not merely alcohol, illicit drugs, or sex; it is a place where a person can feel normal. Cabaj (1996) indicates that the role models for some young people who are coming-out may be those individuals using alcohol and other drugs whom they met at parties or in bars. In addition, Weinberg (1994) suggests that pressures experienced by gay men in a bar setting derived from a number of different sources which include the use of alcohol to facilitate cruising, the expectations of friendship groups, and a variety of inducements provided by bar management. Another study conducted by Mattison, Ross, Wolfson, Franklin, & HNRC group (2001) indicates that 50% of their gay male subjects who attended the gay circuit parties reported using alcohol, Esctasy, and Special K within the past 12 months.


Homophobia is defined as the irrational fear of people and things related to lesbians and gay men (Weinberg, 1972). There are two kinds of homophobia, externalized and internalized. Externalized homophobia comes from the heterosexual community who dislike or fear homosexuals. Conversely, internalized homophobia comes from within the lesbian or gay man. From an early age, most lesbians and gay men internalize society's ideology of sex and gender roles. As a result of these ideal expectations, they usually experience a certain degree of negative feelings about themselves when they are aware of their same sex attractions (Herek, 1996). Studies show that homophobia is one of the most insidious and pervasive factors affecting the gay population (Baker, 2002; Hilton, 1992; Warn, 1997). Warn suggests that homophobia most likely contributes to the persistence of alcohol abuse among lesbians and gay men. He further points out that alcohol may be used to ameliorate the tension created by environmental homophobia. In addition, internalized homophobia induces shame that overwhelms the client who then resorts to further substance use to reduce the negative feelings (Hardin, 1999; Weinberg, 1994).

Childhood Sexual Abuse (CSA)

Sexual abuse is defined as any unwanted sexual experience (Russell, 1983). Childhood sexual abuse is defined as sexual behaviors occurring between an individual who is 13 or younger and someone who is at least 5 years older than the individual (Jinich et al., 1998). The prevalence of CSA is hard to assess in the general population due to the stigma and secrecy attached to it (Klinger & Stein, 1996). It is estimated that between 200,000 to 300,000 female children are molested in the U.S. annually (Renvoize, 1982). Most studies on childhood sexual abuse have focused on the female population (Hughes & Eliason, 2002). The percentage of males who are sexually abused remains unclear (Stein, Golding, Siegel, Burnam, & Sorenson, 1988). For lesbians and gay men, the stigma attached to being a member of a marginalized sexual group and being a survivor of childhood sexual abuse makes the estimation of the prevalence of childhood sexual abuse among them even harder (Klinger & Stein, 1996). Hyde and Kaufman (1984) suggest that childhood sexual abuse is a profound psychological nightmare that could continue into adulthood and normally requires behavioral and psychological adaptation. Young (1990) indicates that when issues related to sexual trauma are not addressed, other symptoms may emerge. Bass and Davis (1988) suggest that substance abuse may become a strategy used by childhood sexual victims to cope with their pain. Hughes and Eliason state that "it is not clear whether substance abuse is directly related to childhood sexual abuse or if alcohol and other drugs abuse is an effort to cope with depression or other consequences of CSA" (p. 283). Some studies have found that there is a significantly higher rate (29% and 67%) of substance abuse among lesbians who are victims of childhood sexual abuse (Hughes, 1999; Hughes, Haas, & Avery, 1997). Similar results have been found in terms of substance abuse by gay men who have been the victims of childhood sexual abuse (Neisen & Sandall, 1990).

HIV/AIDS Effects

Since the first case of Acquired Immunodeficiency Syndrome (AIDS) in the early 1980s, AIDS has had profound effects on virtually every aspect of the lives of lesbians and gay men. Studies indicate that AIDS is caused by the human immunodeficiency virus (HIV; Hogan & Hudson, 1998). Being HIV+ means that an individual has been infected by the virus. There is currently no cure for AIDS. A positive HIV test result could lead an individual to feel extremely distressed. Fortunately, by the 1990s, promising progress had been made on AIDS research, which helps prolong the life of HIV+ patients. However, being HIV+ (sero-conversion) is still the source of enormous pain and stress for many lesbians and gay men. Many of them rely on a social network in the community. Through 1995, more than 300,000 people have died from AIDS in the United States (Hogan & Hudson). The experience of losing friends to AIDS leads many lesbians and gay men to worry constantly about their own health and the health of their friends and their lovers (Ratner, 1993). Because alcohol and drugs may suppress the immune system, the relationship between drinking, substance abuse, and AIDS has received great attention in the gay community (Alcohol, Drugs, and AIDS, n. d.). It is suggested that substance abuse is one of the defenses used by lesbians and gay men to suppress their feelings of loss and stress (Benshoff & Janikowski, 2000; Ratner).

Coming-Out Process

Herek (1996) suggests that lesbians and gay men normally go through a life process in which they recognize their erotic/emotional orientation and eventually develop an identity that includes their sexual orientation. Some disclose their sexual orientation to others. The disclosure of one's lesbian or gay male orientation to others is termed coming out of the closet. On the other hand, being in the closet refers to a lesbian or gay man's passing as a heterosexual or straight person. Benshoff and Janikowski (2000) suggest that "many gay people demonstrate fears and anxieties about rejection from friends, families, and society. For many these fears and anxieties are born of actual, devastating experiences" (p. 289). In our society, individuals who are sexually attracted to and emotionally attached to persons of the same gender are treated with discrimination and called deviants and child molesters (Hardin, 1999; Hogan & Hudson, 1998; Kantor, 1998). Unfortunately, individuals who are without a well-developed repertoire of coping mechanisms may turn to alcohol and other drugs to relieve their emotional pain. Then they may be doubly stigmatized (Lewis & Jordan, 1989). Many people also view them as sinners and morally corrupted for abusing drugs (Erickson, 1998).


Laws and regulations, passed over the years, can encourage clients with substance abuse problems to seek mental health services. In addition, both federal law and professional standards of practice provide protection and guidelines for providing services to lesbians and gay men. The most significant federal law addressing issues associated with people who have substance abuse problems is the Americans with Disabilities Act of 1990 (Benshoff & Janikowski, 2000). The Code of Ethics of the American Mental Health Counselors Association (2001) provides specific guidelines on the issue of confidentiality. In addition, MHCs should adhere to the resolution passed by American Psychological Association (1998) Council of Representatives when working with clients who are lesbians or gays. Finally, preventing any kind of sexual harassment and physical assault in the work place should be emphasized throughout the practices of mental health counseling services (Riggar, 2002).

Federal Laws

There are federal laws that MHCs need to be aware of when they work with lesbians and gay men's substance abuse issues. First, in 1970 Congress passed the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act, also known as the Hughes Act (Dickman & Challenger, 1988). Benshoff and Janikowski (2000) pointed out that "for the first time in federal legislation, the Hughes act advanced the notion that alcoholism was a disease, amenable to treatment" (p. 34). Affirmation of substance abuse as a disability is found in the Americans with Disabilities Act (ADA) passed in 1990 (Rubin & Roesller, 2001). ADA started a new era in which people with substance abuse problems were encouraged to seek services under its protection. Although ADA recognized substance abuse as a disability, there are a few restrictions when considering alcohol and illicit drugs. The first restriction indicates that individuals with illicit drug problems will be excluded from coverage under the ADA if they are currently using drugs and not under the direction of a doctor (Benshoff & Janikowski). However, if they are no longer using the illicit drugs and have successfully completed treatment or are currently in treatment, they then are perceived as people with disabilities. Alcohol abuse and dependence problems, however, are not specifically addressed in the ADA. Therefore, it is interpreted that employers and MHCs can not discriminate against those who abuse alcohol. But it is strongly believed that employers may discipline workers who violate policies that conform to the Drug-Free Workplace Act passed in 1988. Meanwhile, MHCs may refuse to work with clients who come for services while intoxicated (Benshoff & Janikowski).

Taking these restrictions and ADA disability criteria into consideration, discrimination against a qualified client with substance abuse issues could result in legal actions against the MHC. The reasons for discriminating against a client vary (e.g., a client's age, gender, sexual orientation, personality traits, nationality origin, socioeconomic status, religious belief, or HIV/AIDS status). However, Principle 1 (Welfare of the Consumer) in the Code of AMHCA (2001) states that MHCs shall not condone or engage in any types of discrimination based on the factors listed above.

ADA also classifies individuals with HIV+/AIDS as people with disabilities. They are protected by ADA as long as they do not pose a direct health or safety threat to others (Benshoff & Janikowski, 2000). Actions such as requiring people to take an HIV test as a condition for admission to mental health services, refusing to admit eligible individuals, and providing segregating services to such clients are in violation of federal and state nondiscrimination laws (U.S. Department of Health and Human Services, 1995). Studies show that gay men, bisexual people, some heterosexual individuals, and injection drug users constitute the largest numbers of people who are HIV+ or diagnosed with AIDS in the United States (Brooks & Klosinski, 1999; Hogan & Hudson, 1998). ADA explicitly prohibits employers, government agencies, and places of public accommodation from discriminating against them on the basis of sero-positive status (Rubin & Roessler, 2001). Therefore, MHCs have the obligation to treat clients who are HIV+ or diagnosed with AIDS in a professional manner.

MHCs should actively participate in any discussions or presentations regarding the legal issues related to ADA. They should also be informed about the criteria and restrictions set for people with disabilities by ADA. This mandate is especially true when MHCs diagnose clients with substance abuse. Professionals should understand that ADA and the AMHCA Code of Ethics prohibit MHCs from discriminating against any individual on the basis of gender, religious belief, sexual orientation, race, age, socioeconomic status, etc. In addition, MHCs should be familiar with ADA's protection of people with HIV+/AIDS. It is also important for MHCs to remember that ADA does not cover homosexuality, transvestitism, exhibitionism or other less socially acceptable sexual behaviors (Benshoff & Janikowski, 2000). MHCs should seek legal advice from ADA experts when it becomes necessary (Rubin & Roessler, 2001).


In order to ensure that people with substance abuse problems actively seek mental health services without worrying about being stigmatized or criminalized, Congress passed legislation (42 U.S.C. 290dd-3) and the U.S. Department of Health and Human Services issued a set of regulations (Vol. 42 of the Code of Federal Regulations [CFR, Part 2]) to protect clients' information related to their substance abuse treatment (Brooks, 2001). This general rule applies to the initial contact by a client for making a screening appointment. It also applies to former clients who have received mental health services from the agency. Violating the regulations is punishable by a fine of up to $500 for a first offense and up to $5,000 for each subsequent offense (42 C.F.R., Part 2).

MHCs should inform their substance abuse clients about their rights in regard to the confidentiality of the counseling relationship as well as the limitations and exceptions to this right. This procedure is to ensure that clients are fully aware that under certain situations, MHCs are allowed to disclose their substance abuse treatment information without client's consent (AMHCA, 2001). Section 2 of Principle 3 (Confidentiality) explicitly states that only under the most extreme circumstances should the client information be released. These situations include handling a medical emergency; making a mandatory report regarding child abuse, incompetent person abuse, or elder abuse report; protecting another individual from being harmed by a client (Duty to Warn); complying with a special court order following a court hearing in which disclosure is authorized; responding to a research or audit purpose; and communicating with an agency's internal staff.

Another issue related to a client's confidentiality is a client's sexual orientation, especially if a client is a gay or lesbian. MHCs should keep in mind that disclosing a client's sexual orientation without the client's consent can result in devastating consequences. It is possible that, in some states, lesbians and gay men might be fired from their job, denied housing and public services (e.g., health), discharged dishonorably from military service, or denied child custody (Hilton, 1992; Wagner, 2003). Given the severe consequences associated with being gay or lesbian, it is important for MHCs to make referrals without disclosing the client's sexual orientation. Some disclosures are permissible if a client signed a valid consent form which has not expired or been revoked by the client. Information for writing solid and valid consent forms is readily available (e.g., Brooks, 2001).

Studies show that people who are HIV+ or diagnosed with AIDS have been subjected to discriminations in many ways (Brooks & Klosinski, 1999; Crawford, Humfleet, Ribordy, Ho, & Vickers, 1991). In response to the stigma and discrimination towards people who are HIV+ or living with AIDS, each state has enacted its own rules about protecting clients' confidentiality right with regard to a client's HIV/AIDS status. Protections are ensured by both the Federal Alcohol and Other Drug (AOD) confidentiality regulations and state confidentiality laws. For instance, in Illinois, HIV Antibody/AIDS Status (410 ILCS 305; AIDS Act), and the AIDS Confidentiality and Testing Code (77 ILL Adm Code 697; AIDS Code) were enacted for clients with substance abuse problems. Therefore, MHCs should strictly adhere to the regulations and laws regarding HIV/AIDS issues.

MHCs should seek consultation from both the local and federal counsels to determine which state confidentiality laws and federal AOD confidentiality regulations affect their practices. In addition, MHCs should help their administrators develop appropriate protocols and a set of written policies to ensure that these laws are strictly followed. The written policy must ensure that a client's sexual orientation is kept confidential and that MHCs do not disclose such information to anyone without the client's consent.

Professional Therapeutic Standard of Practice

Before 1973, the standard procedure for treating substance abuse issues with lesbians and gay men was to first "re-orient" the client's sexual orientation before dealing with substance abuse issues (Cheng, 2002). That standard was changed after the American Psychiatric Association removed homosexuality from its list of mental disorders in 1973. Besides helping clients with substance abuse problems stay clean and live a meaningful life, MHCs have acted in affirmative and professional ways to deal with discriminations and stigma attached to clients due to their homosexual orientation.

However, some MHCs still approach substance abuse problems in the old harmful way (Cabaj, 1996; Committee on Lesbian and Gay Concerns, 1990). It is important to note that some MHCs may assume that a client's sexual orientation is the "real" cause of his or her substance abuse problems. Therefore, they may attempt to convert a client's lesbian or gay male sexual orientation to a heterosexual orientation before dealing with a client's substance abuse problems. Actions like this one violate Principle 1 (Welfare of the Consumer) specified in the Code of Ethics of the American Mental Health Counselors Association (AMHCA, 2001). There are two therapy approaches designed to change an individual's sexual orientation. They are Reparative Therapy and Transformational Ministry (Haldeman, 2002; Schneider, Brown, & Glassgold, 2002; Throckmorton, 2002; Yarhouse & Burkett, 2002). Reparative therapists apply psychotherapy techniques to reduce and gradually eliminate individuals' same sex attractions. Transformational ministers use Christian religious doctrines to get rid of clients' same sex desires (Throckmorton; Yarhouse & Burkett). Haldeman (1999) states that "the term reparative therapy inaccurately implies 'broken-ness' as the distinctive feature of homosexuality and bisexuality ... the more accurate term for therapeutic efforts to change homosexual orientation is sexual orientation conversion therapy, or simply, conversion therapy" (p. 1). In addition, reparative therapy and transformational ministry are based on the beliefs that same sex behavior is abnormal, unnatural, chosen, and sinful (Cheng, 2002). This belief contradicts the Resolution on Appropriate Therapeutic Responses to Sexual Orientation passed by the American Psychological Association Council of Representatives in August 1997 (American Psychological Association, 1998). Similar resolutions have been produced by the American Academy of Pediatrics in 1993, the American Psychiatric Association in 1998 and 2000 respectively, and the National Association of Social Workers in 2000. The resolution passed by American Psychiatric Association Council of Representatives (Schneider et al., 2002) concludes:
 Therefore be it further resolved that the American Psychological
 Association APA opposes portrayals of lesbian, gay, and bisexual
 youth and adults as mentally ill due to their sexual orientation
 and supports the dissemination of accurate information about sexual
 orientation, and mental health, and appropriate interventions in
 order to counteract bias that is based in ignorance or unfounded
 beliefs about sexual orientation. (p. 276)

Haldeman (1999) indicates that most so-called ex-gays are the ones who just live a celibate life. Simply stated, those ex-gays are just good at suppressing their natural same-sex attraction feelings under the pressure of social desirability expectations from their therapists and conservative religious groups. Interestingly, most conversion therapists claim that their success rate for treating gays and lesbians is about 30% (Birk, 1980; Hadden, 1966). When questioned about the 70% who do not convert, therapists respond that sexual orientation is not easy to change. In conclusion, any attempt to promote these two or similar therapies is likely to exacerbate the risk of harassment, harm, and fear to a client who is gay or lesbian (Cheng, 2002). MHCs who refer their clients who are lesbians or gay men to such therapy and ministry run the risk of law suit brought against them.

Sexual Harassment and Physical Assault

Some studies have shown (Baker, 2002, DeCrescenzo, 1994; Savin-Williams, 1998) that lesbians and gay men who are open about their sexual orientation are more likely to face sexual harassment, verbal abuse, and physical attacks in the society. Sexual harassment refers to any unwelcome sexual advances or requests for sexual favors, particularly when there is a power imbalance between the parties (Riggar, 2002). Sexual harassment can be committed by a person of either sex against a person of the same or opposite sex. Examples of sexual harassment could be a pattern of conduct, annoying or humiliating in a sexual way, that includes comments of a sexual nature and/or sexually explicit statements, jokes, facial expression, or anecdotes. Like harassment on the basis of race or religion, sexual harassment is a form of discrimination expressly prohibited by law. It is a violation of Title VII of the Federal Civil Rights Act of 1964 which indicates that it is illegal for an employer to discriminate against any person with respect to certain terms, conditions, or some privileges of employment solely due to this individual's sex (Andrew & Andrew, 1999). Andrew and Andrew suggested that, although the language in Title VII does not specifically mention or prohibit sexual harassment, courts have interpreted "terms, conditions, or privileges of employment" as sexual harassment. In addition, sexual harassment is also a violation of AMHCA's Code of Ethics (2001). Section G (Sexual Relationships) of Principle 1 (Welfare of the Consumer) of the AMHCA Code states that "sexual relationships with clients are strictly prohibited. MHCs do not counsel persons with whom they have had a previous sexual relationship" (p. 3). Furthermore, Section H of the Principle 1 in the AMHCA code states:
 Counselors do not engage in sexual intimacies with former clients
 within a minimum of two years after terminating the counseling
 relationship. The mental health counselor has the responsibility to
 examine and document thoroughly that such relationships did not have
 an exploitative nature based on factors such as duration of
 counseling, amount of time since counseling, termination
 circumstances, the client's personal history and mental status,
 adverse impact on the client, and actions by the counselor
 suggesting a plan to initiate a sexual relationship with the client
 after termination. (p. 3)

Section K of Principle 2 (Clients' Rights) states, "The client has the right to a safe environment free of emotional, physical and sexual abuse" (pp. 5-6). Finally, Section B of Principle 9 (Supervisee, Student and Employee Relationships) indicates "All forms of sexual behavior with supervisees, students and employees are unethical. Further, MHCs do not engage in sexual or other harassment of supervisees, students, employees or colleagues" (p. 12). It is worth noting that, Section E of Principle 10 indicates that the prohibition of sexual harassment does not forbid "the use of explicit instructional aids including films and videotapes. Such use is within excepted practices of trained and competent sex therapists" (p. 13). Physical assault refers to any invasive physical contact carried out without first obtaining the individual's permission. Physical assaults include "being punched, kicked, or beaten; being assaulted or wounded with a weapon; having arson or vandalism committed against property; being robbed; and/or being raped" (Comstock, 1991, p. 285). MHCs should inform theft clients that any kind of sexual harassment or physical assault will not be tolerated in the agency. MHCs should help their clients understand definitions of verbal abuse, sexual harassment, and physical assault in addition to providing concrete examples supporting the definition. Furthermore, clients should be encouraged to report any perpetration of these behaviors by staff members, fellow clients, or authorities. Mental health services agencies should establish effective grievance procedures and ensure a prompt agency response to any violation of these rules.


Affirmative attitude refers to a mental health counselor's willingness to accept a client as is regardless of sexual orientation. This stance requires that MHCs are aware of their own heterosexual bias or internalized homophobia. It also requires them to acknowledge the societal prejudice and discrimination experienced by lesbians and gay men who have substance abuse problems. Most importantly, MHCs should exempt themselves from engaging in or referring a client to any type of Reparative Therapy or Transformational Ministry. However, making appropriate referrals for clients who are lesbian or gay to sensitive and affirmative (gay-friendly) mental health agencies for services is acceptable and recommended. Conditions for doing so require that the MHC demonstrate strong and sound reasons such as being unable to serve this population due to lack of services or being unable to serve these clients objectively and adequately due to lack of knowledge or professional training. It is the responsibility of each MHC to ensure that his or her clients are receiving the sensitivity they need and deserve. Affirmative action also means making policies which include nondiscriminatory hiring clauses so that lesbians or gay men are hired. Mental health service agencies should also have written rules prohibiting any type of harassment or abuse of either to clients or staff.


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Zhankun Cheng, Rh.D., is with the Doctor of Rehabilitation Program at Southern Illinois University at Carbondale. E-mail: The author expresses sincere appreciation to Lisa Boisvert for her invaluable feedback and constant encouragement throughout the development of this article.
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Title Annotation:Practice
Author:Cheng, Zhankun
Publication:Journal of Mental Health Counseling
Geographic Code:1USA
Date:Oct 1, 2003
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