The Effect of Bilingualism on Self-Perceived Multicultural Counseling Competence

Nathaniel N. Ivers, José A. Villalba

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Ethnic and linguistic minorities continue to underutilize and prematurely terminate counseling services at higher rates than their ethnic majority counterparts. To improve the provision of counseling services to culturally diverse clients, new avenues supported by theory and research need to be uncovered. One factor that has received little empirical attention in the counseling and multicultural literature is bilingualism. This study examined the effect of bilingualism on counseling students’ multicultural counseling competence, while controlling for ethnicity and multicultural training. Results supported the hypothesis that bilingual counseling students would self-rate their multicultural counseling competence higher than would their monolingual counterparts. Implications for counselor training, counseling practice and future research are discussed.

Keywords: bilingualism, multicultural counseling competence, multicultural training, ethnicity, counseling practice

Over 30 years ago, Sue et al. (1982) urged members of the counseling profession to increase their efforts to train multiculturally competent counselors who possess the requisite knowledge, awareness and skills to meet the needs of culturally diverse clients. Sue et al. (1982) contended that traditional counseling approaches were myopic and monocultural, and contributed to the tendency for ethnic minority individuals to underutilize and prematurely terminate counseling services. Since 1982, the counseling profession has made great strides in improving counselors’ effectiveness in working with culturally diverse clients (Chao, 2012; Worthington, Soth-McNett, & Moreno, 2007). However, ethnic and linguistic minorities continue to underutilize and prematurely terminate counseling services at higher rates than their ethnic majority counterparts (Sentell, Shumway, & Snowden, 2007; U.S. Department of Health and Human Services [DHHS], 2001). To continue to improve the provision of counseling services to culturally diverse clients, new avenues supported by theory and research need to be uncovered (Worthington et al., 2007). One factor that has received little attention in the counseling and multicultural literature is bilingualism. The purpose of this study was to expand the current bilingual counseling and multicultural counseling competency literature by examining the effect of bilingualism on counseling students’ self-perceived multicultural counseling competence (MCC).

Multicultural Counseling Competence

Since the introduction of the tripartite model of cross-cultural counseling competence (Sue et al., 1982), much has been accomplished with respect to MCC, and the model has been expanded (Sue, 2001; Sue, Arredondo, & McDavis, 1992; Sue et al., 1998) and operationalized (Arredondo et al., 1996). Mental health associations (e.g., American Counseling Association) have adopted multicultural counseling competency accreditation standards (Council for Accreditation of Counseling and Related Educational Programs [CACREP], 2009). State licensing boards have established regulations requiring multicultural training, and mental health professions have introduced multicultural competency principles into their professional codes of ethics (Chao, 2012).

In addition, quantitative and qualitative studies have shed light on factors that influence counselors’ effectiveness in understanding and working with culturally diverse clients (Worthington et al., 2007). Much of this literature can be organized into the following two broad categories: outcomes research associated with cultural responsiveness and correlates of MCC (Ponterotto, Fuertes, & Chen, 2000; Worthington et al., 2007). Concerning cultural responsiveness, studies (e.g., Atkinson & Lowe, 1995; Worthington et al., 2007) have revealed that counselors who understand, acknowledge and address cultural issues in counseling (i.e., cultural responsiveness) are more effective in their work with ethnic minority clients. Specifically, results have revealed that cultural responsiveness increases client satisfaction, self-disclosure, eagerness to continue counseling and perceptions of counselor efficacy (Atkinson & Lowe, 1995; Ponterotto et al., 2000).

In the majority of MCC quantitative studies, researchers have utilized self-report instruments to uncover factors that influence MCC (Ponterotto et al., 2000; Worthington et al., 2007). These factors have included demographic variables (e.g., age, gender, race, ethnicity, sexual orientation; Constantine, 2001; Fassinger & Richie, 1997; Ivers, 2012; Ottavi, Pope-Davis, & Dings, 1994); multicultural training (Dickson & Jepsen, 2007); and hypothesized correlates of multicultural counseling competencies, including racial identity development (Chao, 2012), gender role attitudes (Chao, 2012), attitudes associated with racism and discrimination (Constantine, 2002), worldview (Sodowsky, Kuo-Jackson, Richardson, & Corey, 1998), social desirability (Sodowsky et al., 1998), empathy (Constantine, 2001), emotional intelligence (Constantine, 2001), theoretical orientation (Constantine, 2001), and mortality salience (Ivers & Myers, 2011). One variable that has received limited attention in the multicultural counseling competency literature, despite its association with culture, is bilingualism.

Bilingualism and Culture

The interconnection between language and culture gained popularity in the 1930s with the writings of Edward Sapir and Benjamin Lee Whorf (Whorf, 1956). Whorf (1956) contended that language and thought are inextricably connected—that language determines people’s thoughts, their conceptualizations and ultimately their culture. This view, known as the Sapir-Whorf Hypothesis, was widely accepted from the 1930s through the 1960s. However, due to competing models (e.g., Chomsky’s Universal Grammar Theory) and a lack of empirical support, the Sapir-Whorf Hypothesis lost favor and was largely discarded by the 1990s. A less deterministic version of the Sapir-Whorf Hypothesis was revisited by the Neo-Whorfians, who contended that language does, in fact, significantly influence the way in which people perceive the world around them. Recent studies have supported this contention, revealing that language affects people’s representations of time (Boroditsky & Gaby, 2010; Fuhrman & Boroditsky, 2010), perceptions of cause and responsibility (Fausey & Boroditsky, 2010), perceptual processing of images (Dils & Boroditsky, 2010), and conceptions of agency (Fausey, Long, Inamori, & Boroditsky, 2010).

Fausey et al. (2010), for example, examined the effect of language on causality and agency. The authors gave English and Japanese speakers a memory test following a video that participants watched in which people were seen engaging in accidental and intentional behaviors, such as cracking an egg or popping a balloon. Results revealed that English speakers recalled the person responsible for the accidental events more frequently than did Japanese speakers. Conversely, no differences among language groups were found in memory recall for the intentional events. The authors explained these results in terms of language and culture. They stated that, on average, English speakers use agentive language (e.g., Fred broke the balloon) more often to describe accidental events than do Japanese speakers, who more commonly use non-agentive language (e.g., the balloon broke) to describe accidental events. Framed from a different perspective, the cultural paradigms of independence or fatalism embedded in the participants’ native languages likely contributed to the respective memory recall abilities of English and Japanese speakers.

If culture and language are indeed interconnected, as the results of these studies suggest, it is plausible to infer that learning a second language would expose second-language learners to diverse cultural paradigms, and in turn facilitate multicultural counseling competency development (Ivers, Ivers, & Duffey, 2013). Ivers et al. (2013) postulated a connection among bilingualism, cognitive complexity and MCC. Specifically, they suggested that native English speakers learning a new language, who are accustomed to individualistically laced phrases in their native language, would likely be challenged to function in and make meaning of a fatalistically oriented language and culture. This level of struggle and cultural immersion likely would enhance the language learners’ cognitive complexities as well as their MCC (Ivers, 2012; Ivers et al., 2013).

Although Ivers et al. (2013) linked bilingualism and MCC conceptually, empirical studies related to bilingualism and MCC are limited. Most counseling articles on bilingualism have examined the construct in terms of increasing access and quality of counseling services for non-English speaking clients (Guttfreund, 1990; Smith-Adcock, Daniels, Lee, Villalba, & Indelicato, 2006) or on training culturally competent, bilingual counselors (Fuertes, 2004; Trepal, Ivers, & Lopez, 2014). Fuertes (2004) asserted that “language and culture are inextricably tied” (p. 88). He also shared that effective bilingual counselors recognize this connection and are culturally aware and knowledgeable about the sociopolitical realities and cultural backgrounds of their clients.

Few studies (Guttfreund, 1990; Ramos-Sánchez, 2007; Ramos-Sánchez, 2009; Ramos-Sánchez, Atkinson, & Fraga, 1999) have examined the effect of bilingualism on facets of MCC. Ramos-Sánchez (2007), for example, tested the effect of language switching and ethnicity on bilingual clients’ emotional self-disclosures. Trained observer ratings revealed that Caucasian counselors who engaged in language switching (i.e., speaking Spanish and English in session) elicited more emotional expression from their bilingual clients than did their monolingual counterparts. This result is similar to that of Guttfreund (1990), in which Spanish-English bilingual clients exhibited more emotional expressiveness when Spanish was spoken in the counseling session than when English was the primary form of communication in session.

Other studies (Ramos-Sánchez, 2009; Ramos-Sánchez et al., 1999) have specifically examined the effects of language on client ratings of counselors’ cultural competence. Ramos-Sánchez (2009) analyzed the effects of counselor ethnicity and bilingualism on Mexican-American bilingual clients’ perceptions of counselors’ credibility and cultural competence. Although no significant differences between ethnicities and bilingual ability were uncovered, rank-order results revealed that clients perceived Caucasian bilingual counselors as more culturally competent than their monolingual counterparts. Ramos-Sánchez (2009) explained these results in terms of cultural responsiveness, postulating that the Mexican-American client participants may have interpreted the Caucasian bilingual counselors’ willingness to learn and speak Spanish as a sign of respect for and responsiveness to their culture.

Ramos-Sánchez et al. (1999) also found a non-significant effect of language and ethnicity on MCC and credibility. The non-significant findings of each of these studies may have been the result of sample limitations (e.g., small sample size, non-representative sample), confounding variables (e.g., counselor skill level) and study design limitations (e.g., client ratings based on a single session). Additional studies are needed to further understand the influence of bilingualism on counselors’ multicultural counseling competency development (Ramos-Sánchez, 2009).

This study examined the effect of bilingualism on counseling students’ self-perceived MCC and generated the following research question: Do bilingual counseling students significantly self-rate their multicultural counseling knowledge and awareness higher than monolingual counseling students when controlling for ethnicity and multicultural training?

Method

This study was part of a larger project in which the authors examined factors associated with MCC. For the larger project, participants were 199 master’s-level counseling students enrolled in a CACREP-accredited counseling program at a university in the southwest region of the United States. The current study included 178 of the 199 master’s-level counseling students. Nineteen participants were excluded from the data analyses for a low census in the ethnic group with which they identified. This included participants who self-identified as Asian or Pacific Islanders (3% of sample), bicultural or multicultural (3%), other (2%), and those who did not select an ethnic group (1.5%). Two participants also were excluded from the analyses for not indicating their bilingual status.

Participants

The ages of the 178 participants were distributed as follows: the most frequent reported age range was 18–25 years (n = 76; 42.7%), followed by 26–35 years (n = 62; 34.8%), 36–45 years (n = 23; 12.9%) and 45 years and older (n = 17; 9.6%). Of the 178 participants, 142 identified as female (79.8%), 33 as male (18.5%), and one as transgendered (0.6%); two participants did not identify their gender (1.1%). The ethnic identity of the participants consisted of 83 Latinas/os (46.6%), 77 Caucasians (43.3%) and 18 African Americans (10.1%). Concerning bilingualism, 71 participants reported they were bilingual (39.9%). The majority of bilingual individuals identified as Latina/o (n = 57; 80.3%), followed by Caucasian (n = 9; 12.7%) and African American (n = 5; 7%).

Of those who reported they were bilingual, the majority (n = 60; 84.5%) indicated that they spoke English and Spanish. Including English, other languages and language combinations that participants reported speaking included French (n = 3; 4.2%); German (n = 2; 2.8%); German, Spanish and Russian (n = 1; 1.4%); Spanish and Portuguese (n = 1; 1.4%); and Polish and Spanish (n = 1; 1.4%). Of the 71 participants who reported being bilingual, three did not indicate the languages they spoke. Concerning multicultural training, 48 (27%) participants reported they had completed a multicultural counseling course at the time of the study, 35 (19.7%) indicated they currently were enrolled in a multicultural counseling course, and 95 (53.4%) indicated they had not yet taken a multicultural counseling course.

Instruments

     Demographic questionnaire. Participants identified their age range, gender, ethnicity, religious affiliation and sexual orientation, as well as whether they spoke more than one language (Yes or No). Participants who answered in the affirmative were prompted to identify the languages that they spoke. Participants also were asked to report the number of semesters they had completed in the counseling program, as well as whether they had completed or were currently enrolled in a multicultural counseling course.

     Multicultural Counseling Competence and Training Survey-Revised. The Multicultural Counseling Competence and Training Survey-Revised (MCCTS-R; Holcomb-McCoy, 2005; Holcomb-McCoy & Day-Vines, 2004) has a three-factor structure, which includes Multicultural Knowledge, Multicultural Awareness and Multicultural Terminology. Items are scored on a 4-point Likert-type scale from “1” (Not Competent) to “4” (Extremely Competent). Scoring of the instrument is summative, with higher scores indicating a greater level of MCC. Holcomb-McCoy and Day-Vines (2004) reported the following internal consistency scores (Cronbach’s alpha) for each MCCTS-R subscale: Multicultural Knowledge, .95; Multicultural Awareness, .85; and Multicultural Terminology, .97. Holcomb-McCoy and Day-Vines tested the construct validity of the instrument using a maximum likelihood factor analysis with a direct oblimin rotation. The factor analysis indicated that the three-factor solution of Multicultural Knowledge, Multicultural Awareness and Multicultural Terminology accounted for 55.12% of the variance of MCC. In the current study, the MCCTS-R Knowledge and Awareness subscale scores were examined. The MCCTS-R Terminology scale was not included in the study analyses for two reasons. First, multicultural terminology is not as widely accepted as a key component of MCC. Second, the conceptual link between bilingualism and knowledge of multicultural terminology is unclear.

Procedure

Following approval by the university’s institutional review board, recruitment and administration of the study occurred in 12 intact master’s-level counseling classrooms at a university designated as a Hispanic Serving Institution in the southwest region of the United States. Researchers received permission from course instructors to recruit participants and conduct the study during class time. Classrooms were selected based on convenience. Prospective participants were recruited using a recruitment script. Those who chose to participate received a packet of instruments to complete, including the MCCTS-R and the demographic questionnaire. At the conclusion of the study, all students in the classroom, regardless of participation status, were presented with a debriefing statement that provided details of the study and literature pertaining to multicultural counseling.

Results

Descriptive statistics for the MCCTS-R Knowledge and Awareness subscales were conducted with respect to bilingualism and monolingualism (see Table 1). The means and standard deviations for each MCCTS-R subscale were comparable to those reported by Holcomb-McCoy and Day-Vines (2004). The internal consistencies (Cronbach’s alpha) of the MCCTS-R subscales also were similar to the internal consistencies reported in other studies (Holcomb-McCoy, 2005; Holcomb-McCoy & Day-Vines, 2004). The internal consistencies (Cronbach’s alpha) of the MCCTS-R Knowledge and Awareness subscales were .95 and .85, respectively.

Table 1

Language Group Differences: Means, Standard Deviations and Ranges

Dependent Variable Bilingual/Monolingual N M SD Range
Min. Max.
MCCTS-R Knowledge Bilingual 71 49.63 11.48 19 76
Monolingual 107 46.71 12.49 22 76
MCCTS-R Awareness Bilingual 71 29.42 4.57 9 36
Monolingual 107 27.93 4.61 16 36

     A multivariate analysis of covariance (MANCOVA) and a series of analysis of covariance (ANCOVA) procedures were used to address the research question. With the MANCOVA, ethnicity and multicultural training were used as covariates to control for the possibility that differences in multicultural knowledge and awareness between bilingual and monolingual individuals were a function of ethnic differences or multicultural training rather than differences in bilingual status. Results of the MANCOVA revealed a significant main effect for bilingualism (Wilk’s Λ = .955, F(2, 173) = 4.065, multivariate η2 = .045, p < .019). This finding indicates that the combination of self-report multicultural knowledge and awareness differed as a function of bilingualism, with bilingual participants self-rating their multicultural knowledge and awareness higher than non-bilingual participants. To disaggregate the MCCTS-R subscales, follow-up ANCOVAs were conducted. The results of the ANCOVAs (see Table 2) supported the hypothesis as well. While controlling for ethnicity and multicultural training, bilingual individuals self-rated their multicultural knowledge (F(1, 174) = 4.401, p = .037, ηp 2 = .025) and multicultural awareness (F(1, 174) = 7.847, p = .006, ηp 2 = .043) higher than did monolingual counseling students.

Table 2

ANCOVA Results for Bilingualism

Sum of Squares

        df Mean Square F Sig.
MCCTS-R Knowledge Between

626.217

1

626.217

4.401

.037

*
Within

24760.409

174

142.301

Corrected Total

26119.671

177

MCCTS-R Awareness Between

162.258

1

162.258

7.847

.006

**
Within

3598.004

174

20.678

Total

3805.693

177

**   p < .01

*    p < .05

Discussion

     This is the first study to examine the effect of bilingualism on counseling students’ self-perceived multicultural counseling knowledge and awareness. Bilingual counseling students in this study self-reported higher multicultural counseling knowledge and awareness than did their monolingual peers, which supports the research hypothesis. This result is a natural complement to the Ramos-Sánchez (2009) study in which clients considered bilingual therapists to be more multiculturally competent than monolingual therapists. In both the Ramos-Sánchez study and the current study, components of MCC were perceived as higher in bilingual individuals than monolingual individuals.

More importantly, the results of this study suggest that bilingualism, rather than ethnicity or multicultural training, accounted for perceived differences in multicultural counseling knowledge and awareness. Controlling for ethnicity and multicultural training was particularly important in this study because previous studies have revealed strong relationships between these variables and MCC (Castillo, Brossart, Reyes, Conoley, & Phoummarath, 2007; Constantine, 2001; Ivers, 2012; Murphy, Park, & Lonsdale, 2006). Constantine (2001) reported that non-Caucasian participants received higher expert-observer ratings on their MCC than did Caucasians. Similarly, Ivers (2012) found that Latina/o counseling students self-rated their MCC higher than did Caucasian counseling students. Other studies also have suggested that non-Caucasian individuals are more open to cross-cultural relationships and are perceived as more culturally competent by others, when compared to Caucasians (Liang & Prince, 2008; Smith, Bowman, & Hsu, 2007). Therefore, it was important to substantiate in the current study that bilingual participants self-rated their multicultural counseling knowledge and awareness higher than their monolingual peers because of their bilingual abilities rather than their ethnicity, which is why ethnicity was incorporated as a covariate. The findings of the present study suggest that bilingual status, rather than ethnicity or multicultural training, was responsible for differences in self-perceived MCC.

The positive effect of bilingualism on counseling students’ self-perceived multicultural awareness may be explained, at least to some degree, by the Sapir-Whorf Hypothesis and contact theory (Allport, 1954). With both concepts in mind, it may be that bilingualism enhances individuals’ multicultural awareness through cultural immersion (i.e., contact theory). The act of learning a second language and interacting in more than one language inherently exposes an individual to latent, diverse cultural paradigms (see Sapir-Whorf Hypothesis; Hall, 1989). This sustained exposure to the deeper elements of culture arguably would increase second-language learners’ awareness of their own culture and other cultures, their ability to contest previously unquestioned beliefs about reality, and their sensitivity to diverse cultural worldviews. Sustained exposure also would provide opportunities for second-language learners to test their cultural biases and prejudices (Allport, 1954; Hall, 1989; Ivers et al., 2013).

Concerning multicultural knowledge, it may be that bilingualism inherently exposes individuals to cultural principles that are sewn into the fabric of language, such as is postulated in the Sapir-Whorf Hypothesis. Multicultural knowledge represents counselors’ understanding of their own culture as well as diverse cultures. Knowing more than one language, with different cultural aspects embedded in each language, may enhance individuals’ knowledge of diverse cultural values and beliefs. Similarly, exposure to and knowledge of diverse cultural paradigms gleaned from bilingualism may also make salient the underlying aspects of one’s own culture.

Implications

Implications for Counselor Training

     There are several implications for counselor education based on the findings in this study. First, the results of this study support Fuertes’ (2004) suggestion that counselor training programs “attend to issues of culture and language as part of their curriculum training and supervision” (p. 84). If bilingualism does indeed positively influence multicultural awareness and knowledge, it may be important for counselor educators to consider, where feasible and appropriate, how they might recruit and train bilingual individuals (Ivers et al., 2013; Smith-Adcock et al., 2006). In areas with high concentrations of non-English speakers, it may be reasonable for counseling programs to provide additional language training opportunities to students, such as second-language training courses, bilingual counseling courses and bilingual supervision (Fuertes, 2004; Smith-Adcock et al., 2006). These training opportunities would likely increase the number of counselors willing to provide counseling in a second language as well as improve the provision of counseling in a second language (Castaño, Biever, González, & Anderson, 2007; Trepal et al., 2014; Verdinelli & Biever, 2009). Also, as the results of the current study suggest, these programs would likely enhance counseling students’ overall effectiveness in working with culturally diverse clients.

Second, the results of this study may reinforce the use of cultural immersion assignments to enhance students’ multicultural awareness and knowledge in multicultural training programs. Contact theory (Allport, 1954), which is the theoretical framework upon which many cultural immersion assignments rest, suggests that exposure to and interaction with culturally different others can result in prejudice reduction. With respect to language, if it is true that culture and language are inextricably connected, as the Neo-Whorfians contend, it is likely that the in-depth, sustained contact and interaction inherent in learning a second language would expose bilingual counselors to latent and manifest cultural paradigms. This exposure may enhance counselors’ multicultural knowledge and awareness (Ivers et al., 2013).

Implications for Counseling Practice

The current results also provide potential implications for counseling practice. As mentioned in the introduction, ethnic minority clients continue to underutilize and prematurely discontinue counseling services (DHHS, 2001). An increased number of bilingual counselors could theoretically enhance access to counseling services for linguistically diverse clients. Furthermore, according to these findings, counselors might demonstrate higher rates of multicultural counseling knowledge and awareness. Sentell et al. (2007) reported that English-speaking Latinas/os and Asian Americans are more likely than non-English speakers to use mental health services. Furthermore, from 1980 to 2007, the percentage of individuals in the United States who spoke a language other than English at home increased 140% to approximately 55.4 million individuals. In addition, of the 55.4 million individuals who reportedly speak a language other than English at home, 24.5 million stated that their ability to communicate in English was below “very well,” indicating a need for assistance in some communication contexts (Shin & Kominski, 2010). These statistics and the results of the current study indicate a need for bilingual counselors who have the cultural and linguistic skills necessary to effectively serve this increasingly linguistically diverse population (Sentell et al., 2007).

Limitations and Implications for Future Research

The present study is an exploratory study of the relationship between bilingualism and multicultural awareness and knowledge, and has limitations that are important to take into account when interpreting results. First, the MCCTS-R is a self-report instrument and is potentially susceptible to intervening variables such as social desirability and ignorance bias (Heppner, Kivlighan, & Wampold, 1999). In addition, the convergent validity of multicultural counseling competency self-report instruments with other measures of MCC (e.g., client ratings, expert-observer ratings) have been called into question by researchers (Cartwright, Daniels, & Zhang, 2008; Worthington, Mobley, Franks, & Tan, 2000). Second, bilingualism in this study was determined by self-report. On the brief demographic questionnaire, participants reported their bilingual or monolingual status. Although there was no indication of participant dishonesty, different degrees of fluency in a second language are inevitable. Future researchers should consider measuring participants’ level of fluency in a second language to determine more specifically how different levels of second-language proficiency influence MCC.

Due to the potential limitations of self-report instruments, future studies that examine the influence of bilingualism on MCC may consider different measures of MCC, such as client or expert-observer ratings or written case conceptualization skills measures. Future studies also could address potential moderating variables between bilingualism and MCC. Ivers (2012) and Ivers et al. (2013) have hypothesized that cognitive complexity moderates the effect of bilingualism on MCC. Ivers et al. (2013), for example, using supporting multidisciplinary research, contended that second-language learning may enhance individuals’ cognitive abilities which, in turn, may increase multicultural competence. Future studies are needed to empirically test this hypothesis.

Conclusion

It is important that researchers and members of the counseling profession increase their efforts to understand factors that influence multicultural knowledge and awareness. This assertion is particularly true in light of the accelerated growth of ethnic and linguistic minority populations in the United States (Shin & Kominski, 2010), as well as the underutilization of counseling services by these populations (Sentell et al., 2007; DHHS, 2001). The purpose of this study was to examine the effect of bilingualism on counseling students’ self-perceived MCC. The results support the hypothesis that, after controlling for ethnicity and multicultural training, bilingual counseling students would self-rate their multicultural knowledge and awareness higher than their monolingual counterparts. These findings have implications for multicultural training, which in turn may influence counseling practice, perhaps by increasing the provision of and access to counseling services for culturally and linguistically diverse populations. For example, based on these findings, where feasible and appropriate, counselor education programs may consider ways of incorporating aspects of second-language learning into their curriculum, such as through the provision of auxiliary language training opportunities or participation in and support of study abroad programs that have language and cultural immersion components. This research is an initial, exploratory step toward examining the effect of second-language learning on counselors’ effectiveness in working with diverse clients.

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.

 

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Nathaniel N. Ivers, NCC, is an Assistant Professor and Associate Chair of the Department of Counseling at Wake Forest University. José A. Villalba is a Professor and Associate Dean at Wake Forest University. Correspondence may be addressed to Nathaniel N. Ivers, Wake Forest University, Department of Counseling, P.O. Box 7406, Winston-Salem, NC 27109, iversnn@wfu.edu.