J. Dale Munro, MSW, RSW, FAAIDD
Teenagers and adults with intellectual disabilities often dream about finding love, moving in together, getting married, and having children. Yet, historically, there has been resistance to people with intellectual disabilities becoming companions, living together or marrying, due in large part to fears about them procreating and "contaminating the gene pool." This resistance took the form of legal restrictions on marriage, eugenic laws leading to forced sterilizations, and at one time, many admissions to institutions (Kempton & Kahn, 1991). However, throughout history, many individuals married, raised children and did not come to the attention of service providers, because they were able to manage their lives (Koller, Richardson & Katz, 1988).
In the early 1960's, attitudes started to change. Society began to more openly discuss the topic of sexual expression, love and marriage concerning people with intellectual disabilities. The sexual revolution, along with advances in birth control methods, had the effect of decoupling sex from procreation. This removed one of the principle objections to love relationships and marriage for people with intellectual disabilities (May & Simpson, 2003). Unfortunately, even today, many of these couples have problems accessing counselling services because therapists often assume that "they are not good counselling candidates."
Based on 36 years of work as a couple and family therapist, the author believes that no clinical work is as exciting and rewarding, or as potentially challenging, as counselling and trying to improve the emotional functioning and relationships of couples with intellectual disabilities. The purpose of this paper is to review literature on the topic of marriage for people with intellectual disabilities and present an effective couple intervention model. In this article, a couple is defined as two people closely associated, bonded or paired with each other, at least one of whom functions in the mild or moderate range of intellectual disability. A couple can be a man and a womanor a same-sex relationship engaged, married, living together or in a committed love relationship.
Reviewing Marital Research
One of the most heavily discussed, written about, and researched topics in the history of the intellectual disability field relates to marriage and parenting. Despite methodological weaknesses in many studies (e.g., one versus both members of the couple having an intellectual disability), the findings are still interesting. Hall (1974) reviewed fifteen studies going as far back as the1920's and concluded there was considerable evidence that people with intellectual disabilities frequently had "successful marriages" (ie, no separations or divorces). Bass (1964) reviewed literature beginning in the 1940s and noted there was an increasing recognition of the ability of many people with intellectual disabilities to hold a job, marry and support themselves. She made a strong case for voluntary sterilization and preventing children.
Andron and Sturm (1973) surveyed 12 couples and found that they overwhelmingly felt that the companionship of marriage was much better than single life. Mattinson (1973) completed one of the most frequently quoted studies. Her research investigated 36 marriages
where both partners had intellectual disabilities, many of whom had been previously institutionalized. The majority of the couples (25) were affectionate, happy and felt their lives were better married than single. Edgerton (1967) found similar results. Floor, Baxter, Rosen and Zisfein (1975) did a follow-up study of previously institutionalized people regarding marriage and children. They found the children were fairly well cared for, at least in their early years. Frequent couple problems included chronically poor health of one partner, money management, and interference from "demanding relatives." Marriages did better when one partner had average intelligence, and when a relative, landlord or employer supported them.
Married people showed fewer social and personal problems (e.g., lawbreaking, work or alcohol-related problems) than single adults.
Ann and Michael Craft (1979) completed a pilot study of 25 marriages; and a more detailed investigation of 45 other couples. Marriages had lasted up to 25 years. Findings suggested a better marital "success rate" and chance of happiness than the population at large. Timmers, DuCharme and Jacob (1981) found that the majority of surveyed adults with intellectual disabilities wanted to be married and have children. Koller, Richardson and Katz (1988) concluded that about half of the adults were in marriages that "appear to be going well." Kempton and Kahn (1991) found that married couples with intellectual disabilities had about the same chance of divorcing as non-disabled couples, and they preferred marriage over single life.
The "Positive Support-Couple Therapy" Model
Little literature exists regarding clinical interventions for couples with intellectual disabilities. Couples and their families frequently report difficulties in finding therapists willing to work with them. With this in mind, the author has developed an intervention model for working with these couples that combines many of the best elements of established approaches, with strategies that recognize the complexity of these couples and their support systems. The author calls this the "Positive Support-Couple Therapy" Model (PSCT Model). It is particularly helpful where collaboration among the couple, extended family and service system needs to be high; conditions typically needed for couples with intellectual disabilities to maintain successful relationships. By proposing this model, the author wishes to make a strong case for therapists in general, to become more open to working with these couples.
Therapeutic Stance: Being Unconditionally Positive
The PSCT Model incorporates many elements of the "strength-based perspective" to clinical practice (Russo, 1999) and "unconditionally constructive mediation" (Munro 1997). This model provides a positive foundation from which to build effective working relationships with the couple, their extended families and service system representatives. Real problems are not ignored. But this perspective focuses on what is right, rather than what is wrong with the couple and other significant people in their lives. Couple resilience, resourcefulness, and one's ability to rebound from past trauma, rejection and ostracism are emphasized. The PSCT Model also draws ideas from Integrative Couple Therapy with its emphasis on cognitive-behavioral
strategies, empathy, acceptance, and support (Jacobson & Christensen, 1996); narrative therapy with a focus on social justice and liberation through the development of alternative, empowering stories (White, 1995); and more traditional couple treatment stressing a conjoint, social systems orientation, along with efforts to improve interpersonal communication (Satir, 1967).
To a large extent, treatment success depends on the therapist's persistence, high energy, unflappable optimism, flexibility, knowledge of community resources, persuasiveness, and sometimes the ability to be satisfied with small gains. Interviews and meetings should focus on "here and now" issues. Even more so than with other populations, professionals should speak in a simple, concrete manner, and avoid using jargon. Therapists must show patience and understanding, since the individuals quite frequently show up for appointments too early, or late, because precise time-telling is sometimes difficult for some of them. As well, the hygiene, etiquette and clothing of these couples may not always be up to nice, middle-class standards. But this does not mean that their love is unreal; or that their desire to be closer and happier, is not genuine.
In working with these couples, professionals must recognize the power of casual small talk, simple kindness, a sense of humor, and sharing a coffee as a low-key starting point in building a positive relationship and therapeutic alliance. Because these individuals frequently have faced social ostracism, this can result in a greater tendency for approval-seeking. Therefore, therapists must try to ensure that couple empowerment and the pursuit of their dreams is a real therapy outcome.
Four Alternative Roles for the Couple Therapist
Therapists using the PSCT Model must determine which role they might play to help the couple and the people around them. First, the couple therapist may play a consultant role, providing formal presentations or offering clinical advice to other couple therapists, community agencies, clergy or family representatives. Second, the therapist can act as an outside mediator who is brought in as an impartial third party to meet with key people and to help resolve complicated couple-family, couple-agency or agency-family disputes (Munro 1997). Third, the professional may work directly with the couple, playing a role similar to most couple therapists with a contracted number of conjoint sessions. However, since the self-reports of people with cognitive limitations at times can be somewhat misleading, a key feature of the PSCT Model is that a trusted staff from a local support agency who knows the partners well, is often asked to act as a co-therapist. This helps monitor whether the therapy is contributing to real and positive change in the couple's relationship, their coping skills and everyday life. For instance, in one case, the co-therapist followed-up a partner's complaint; and found bird-droppings and feathers in every room, over every square foot of the couple's apartment. This became a prime counselling issue and was successfully resolved. Fourth, on occasion, the couple therapist may provide individual counselling to one of the partners or make a referral to a clinical specialist to deal with serious individual concerns that impact the relationship (e.g., past trauma, sexuality concerns, drug or alcohol abuse, anger or grief issues).
Assessing the Couple, the Extended family and the Service System
In contrast to assessment methods utilized by most couple therapists, the PSCT Model suggests some differences with people with intellectual disabilities. For instance, besides assessing the couple, the therapist sometimes asks the couple's permission to meet with the extended family and the support agencies involved, to determine how helpful these outsiders are in the everyday life of the couple. Some family members (particularly parents or adult siblings) may exert powerful influence over the couple, to the point of overcontrol, overinvolvement, even sabotage (Munro 2007). As well, since women and men with intellectual disabilities are much more susceptible to sexual abuse (Randall, Parrila & Sobsey, 2000), and women more prone to domestic abuse (Welner, 1999), professionals must be sensitive to this possibility during the assessment process. Gathering a thorough biopsychosocial history of each partner is recommended.
During interviews, careful attention should be paid to couple and family dynamics, including role clarity and the effectiveness of boundary-setting; problem-solving and decision-making; feelings of safety; housing and financial stability; and the current health of the couple and the extended family, including psychiatric difficulties. Professionals must listen with a "third ear" not only to what is being said, but also to what people are really saying (i.e., nonverbal meta-communication). Throughout, the therapist must be sensitive to the cultural or religious backgrounds of the partners, and other significant people in their lives.
A useful focal point for initial assessment interviews with the couple, and possibly the extended family, may include exploring family photo albums. This can act as a catalyst for discussion; and can give therapists a glimpse of how the couple and the extended family relate to each other. The assessment should note areas of couple and extended family strength, cohesion, affection, mutual support, and how well the couple is integrated into the everyday lives of their
families and community. The therapist, with the help of the co-therapist, must also assess the level of agency support the couple receives, with attention to the attitude, accessibility, and availability of needed services.
Throughout the helping process, professionals must remain in tune with intervention outcomes important to the couple ["What outcome would you like to see by the time we are done working together?"]. After carefully analyzing the couple, their families and the support system, professionals should begin to develop working hypotheses (to be continually updated and revised throughout the intervention process) about what may be contributing to the couple's current difficulties; and what might be done to resolve them.
Intervening with Couples, Extended Family and Service Systems
Because people with intellectual disabilities often have very involved families upon whom they can be very dependent, separate sessions with concerned relatives may be a significant part of the therapeutic process to help the couple. The couple's parents, siblings or grandparents may have many strong (sometimes misguided) opinions about the couple and their suitability for each other; whether they should go out, move in together, marry, or have children. Families may also be concerned about wills and estate planning; budgeting and money management; housekeeping, hygiene, proper food preparation and refrigeration; the partner's physical health; or the partner's propensity for genetic problems (e.g., Down Syndrome leading to early onset dementia). Families may worry that one of the partners is sexually promiscuous or shows other high-risk behaviour (e.g., hanging out a strip clubs, unprotected sex), or have criminal or abusive tendencies.
Therapists should view the strategic use of (well-timed and appropriate) humor, frankness, cheerleading, and brief inspirational or motivational talks as important tools for reducing anxiety and defensiveness when working with couples, their families or service system representatives. Also, it is likely that family representatives will need honest feedback and reassurance from therapists and agencies around five critical questions concerning the couple: (a) Is my adult child/relative physically and emotionally safe in this relationship, (b) Is my adult child/relative really happy with this partner, (c) Are money management, daily living and health needs going to be properly met, (d) Is reliable birth control in place to prevent pregnancy, and (e) Are they receiving enough agency support.
At the same time, if a couple is experiencing serious service system difficulties, the therapist and co-therapitst may combine forces with the couple and other significant people including family and local agencies, to organize special "couple-centered planning" meetings. These meetings are held regularly (e.g., every 4-8 weeks) for a several months or longer if needed, to address practical problems. Planning meetings can help to improve networking, information sharing and communication among key people, and encourage creative problem-solving; while permitting the expression of deeply held concerns. Advocacy for improving "instrumental supports" for the couple also may be suggested (e.g., housing, daycare, transportation, employment, budgeting, a disability pension and health services).
To Parent or Not to Parent? That is the Question!
For couples seriously considering pregnancy, the PSCT Model neither encourages nor discourages this possibility. Parenthood, as a personal right, has been gaining ground over the past two decades (May & Simpson, 2003) and it is assumed that there are competent and inadequate parents in both the disabled and the general populations. Research has demonstrated that many parents with intellectual disabilities can learn parenting skills and provide acceptable child-care, if given appropriate training and support (Aunos & Feldman, 2007).
It is not unusual for couples with intellectual disabilities requesting premarital or marriage counselling to have already decided that they do not want children (Craft & Craft, 1979). However, couples seeking counselling around this issue should be fully informed about the responsibilities, challenges and skills required to be adequate parents. Birth control and family planning options should also be presented - and the couple's physician or a public health worker may be of assistance. For couples needing considerable support to ensure proper parenting, it is both ethical and necessary (with the couple's permission) for therapists to interview the couple's parents (potential grandparents), other involved family and agency representatives, to realistically determine how much support might be available and needed. Too often, families (especially potential grandparents) are already overwhelmed by responsibilities involved in supporting one or both of the partners. Facing the possibility of having to nurture a small child (along with the child's parents) can create a formidable challenge (Parr-Paulson, 1998).
In situations where there is suspicion that a child may be neglected or abused, it is imperative that professionals inform child protection authorities. The couple should know that this is a possibility prior to conception, if possible. Couples who unrelentingly want children will probably have them regardless of the views of others. In the end, if the couple unilaterally moves ahead with pregnancy, professionals and agencies should do everything possible to ensure proper parenting and child-care.
Private Sessions: What Couple Therapists Need to Know!
There appears to be systemic biases among many experienced therapists against working with couples with intellectual disabilities. It is not uncommon to hear therapists make erroneous statements that these couples are "too low functioning" or "lack the insight to be good counselling candidates." Yet, nothing could be further from the truth, especially for many adults functioning in the moderate or mild range of intellectual disability.
Private couple sessions are an important part of the PSCT Model. Therapy usually involves a short-term, action-oriented, contracted approach of six to twelve sessions; spaced out
every two to four weeks, later augmented by occasional "booster sessions" if needed. Biased therapists may assume that these individuals are incapable of "insight" (i.e., affecting action through understanding). In fact, many adults have some capacity to consciously change behavioural and cognitive patterns as a result of psychodynamic and behavioural insight, at least on a basic and practical level. Some have wisdom, intuition, verbal and memory skills well beyond assessed intellectual functioning; and these couples are often refreshingly honest, and motivated to accept help.
Private sessions, along with "active listening" and clinical note-taking, can reinforce for couples the notion that their relationship is special and significant. Being really listened to is a powerful therapeutic tool, since individuals with intellectual disabilities often have a history of being ignored, put off or not being taken seriously by others. Couples can improve communication, self-assertion, problem-solving and coping skills; develop better teamwork with their partner; resolve deep hurts and misunderstandings; and with extra practise can become more skilled at clarifying, labelling and channelling intense feelings.
Couples with intellectual disabilities tend to distrust clinicians who are too formal, pedantic, patronizing and serious. A therapist axiom for "hooking" couples into the counselling process might be: "Make sessions positive and fun, and half the work is done!" Most individuals with intellectual disabilities have a great sense of humor and love to learn; but on their terms, and often at a slower pace. With this in mind, the following strategies (sometimes skilfully modified from traditional counselling methods) are noted as being helpful.
First, interviews usually should be held in the privacy of a therapist's office. Because these individuals may have memory and scheduling difficulties, it is usually wise to call the couple ahead of time, to remind them of the next session. Sometimes, couples ask the therapist to come to their apartment or home for sessions, since many support agencies provide service in this manner. The therapist may do this, if the couple presents serious physical and mobility challenges. However, showing a willingness to come to the therapist's office can provide a general clue as to the couple's motivation for accepting help; can nudge them away from the rigidity of their daily routines; and avoids in-home distractions.
Second, when interviewing people with cognitive limitations, frequent repetition of clinical impressions and advice is often necessary, followed by a request that the couple repeat what has been said to ensure they understand. If individuals still seem confused, therapists should speak in a slower, clearer, more succinct manner, and request eye contact. Because generalization of learning for these individuals can disappear between sessions (especially at first), it is helpful to review the content of previous sessions at the start of each interview. Over time, as the information is repeated again and again, messages usually are retained.
Third, the structured, specific, more directive nature of cognitive-behavioral counseling strategies (Burns, 1980; Jacobson & Christensen, 1996) seem particularly well suited for
working with couples with intellectual disabilities. "Cognitive distortions" (e.g., "catastrophizing") can be explained simply as "ways your thoughts are playing tricks on you.". Behavioral rehearsal or role-play, used in conjunction with relaxation training, can be a particularly effective and often enjoyable learning tool. Couples can rehearse ways of improving interactional skills with partners (e.g., appropriate sexual advances); learn to deal with anxiety-producing situations (e.g., meeting the inlaws); or practice self-assertion strategies for coping with domineering relatives or friends.
Fourth, better management of anger, jealousy and conflict is a therapy outcome frequently requested by one or both partners, or their extended families. The PSCT Model supports the feminist belief that couple therapy not continue, when one partner presents extreme abuse or battering. Yet, with "low -level violence" (e.g., threats, pushing and other physical aggression without battering), there is often value in treating the couple together (Jacobson & Christensen, 1996; Nichols & Swartz, 2004). Partners can be taught simple but effective strategies, such as the "Stoplight: STOP/THINK/GO method" of anger management. To illustrate, when angry, the partner is taught to use a visual or pictorial prompt (e.g., stoplight picture), and imagine a Red Light (STOP anger is escalating), Amber Light (THINK about what unpleasant consequences might occur) and Green light (GO). GO is a '"time-out" command to immediately "disengage" (Wolf, 2006), walk away or redirect oneself into other vigorous activities. At the same time, couples can be taught concrete "rules for fair fighting" (Bach & Wynden, 1968), such as no physical violence, focus on the "here and now" (not old hurts), and avoid global terms (e.g., "bitch", "jerk").
Fifth, reframing can be used to teach couples to re-think, change their perception and reinterpret people or situations, in a less emotional, more constructive and rational manner. For instance, a man became uncharacteristically hostile towards his "stupid, retarded wife", after she was diagnosed with diabetes. During counselling, the therapist reframed this concern by suggesting the diabetes was "actually an advantage", because now for the first time, they both would have to exercise, watch their diet and take better care of themselves. After several reframing repetitions, the couple accepted this explanation, lost weight, tension disappeared and their love returned.
Sixth, Koller, Richardson and Katz (1988) reported that sexual difficulties are more common in couples with intellectual disabilities. Educating couples about sexuality, related health and hygiene issues, or ways of dealing with sexual dysfunction can be helpful in reducing tension and increasing intimacy. Couples can be taught to make behavioural requests of each other, to increase demonstrations of affection (e.g., "Give me a hug, you big lug!"). Masturbation can be prescribed as sexual insurance for either partner, if intercourse is not an option.
Seventh, Mattinson (1973) noted that most couples with intellectual disabilities function on a complementary basis (ie, the skill of one partner supplements a weakness in the other).
Therapists can help couples to identify specific ways to better complement each other's weaknesses or stated desires, keeping in mind emotional and physical limitations. For instance, a man with severe speech difficulties was encouraged to use his wife as his interpreter, since she had an uncanny ability to understand him. In return, she asked him to accompany her for frequent doctors' appointments, which she found very anxiety-producing. In another case, the illiterate husband of a woman with physical challenges was able to run errands, feed, and bath her; while she agreed to read and write for him.
Eighth, healthy boundary-setting (Minuchin, 1974) is an approach that can be easily understood by most couples with intellectual disabilities. Strengthening boundaries may involve establishing conversational rules (e.g. only one person speaks at a time); insisting on less interference from in-laws (e.g., refusing visits with relatives who demean them); or encouraging more distance between a passive woman and her dominating partner (e.g., an evening out each week with her friends). On the other hand, relaxing boundaries may involve "giving permission" to isolated couples to get out more (e.g., cheap dates or vacations, join a fitness club) or increase their social network (e.g., joining Special Olympics bowling, People First advocacy meetings).
Ninth, for couples unable to read and write, therapists must be flexible in coming up with creative, practical approaches. For instance, one couple created (with therapists' help) a song with pragmatic coping strategies outlined in the lyrics. Near the end of each session, the therapists and the couple sang the song together (with much enjoyment), to remind the couple of specific coping strategies, updating and improving the strategies/song, when needed. For people with serious communication deficits, augmentative communication devices or visual tools (e.g., picture or symbol systems) can be used to improve specific skills (e.g., hygiene, basic cooking, manners and politeness, anger management, understanding public transportation schedules). The key is to be inventive and have fun with it!
Tenth, and finally, when appropriate, therapists can suggest that one or both partners might benefit from a psychiatric assessment, or should speak with their physician regarding psychotropic medication, to help treat mental health concerns. This, ultimately, can greatly improve couple relations (Carver, Waring, Chamberlaine, McCrank, Stalker, & Fry, 1987).
Case Illustration of the Intervention Model
Margaret (33) has Down Syndrome and John (35) functions in the mild range of intellectual disability. They recently began talking seriously about getting married and spend a great deal of time together. Mrs. Smith, Margaret's mother, contacted a clinical social worker specializing in intellectual disabilities, and requested couple counselling for Margaret and John. Mrs. Smith explained that they had been turned down by every other counselling program and clinician in the community. Mrs. Smith said that her husband was concerned that John had anger issues. With this in mind, the social worker contacted John and Margaret about coming in for a private session. Margaret was more than willing to come in for the first session, but John was somewhat reluctant ("Am I in trouble?").
During the first three couple sessions (which included an agency co-therapist familiar with the couple), it became clear that Margaret was not afraid of John's anger, and they complemented each other's limitations (e.g., John could read, but Margaret made friends easier). The therapy outcome most important to them was to get married. They had already decided that they did not want children and (with maternal and public health support), they were using reliable birth control. Along with receiving a disability pension, they both worked a few hours a week in supported employment. John admitted that he had a tendency towards becoming irritable and frequently did not sleep well, and he felt strongly that Margaret's father was "rude" and "bossy." Such talk clearly upset Margaret.
Following these early sessions, the therapist arranged a session with Margaret's parents. Mr. Smith expressed extreme hostility towards John. He suggested that John was always snubbing and insulting family members, and John's only reason to get married was: "The bum and his family know we're well off!" In actual fact, John had little contact with his family. Rather surprisingly, Mrs. Smith admitted that she had initially introduced the couple to each other, because Margaret had been "somewhat promiscuous" and "John seemed like a pretty nice guy who could keep her out of trouble."
Soon after, the therapist received a phone call from Margaret's brother (Steve), a police officer. He threatened to sue the therapist and co-therapist, if they continued to see the couple. At this point, the therapist contacted the Mrs. Smith and had a private session with her. He explained that it appeared that her husband and Steve also had "anger issues." The therapist noted that this situation needed to be ameliorated quickly, or John and Margaret's relationship (potentially happy) might not last. He asked Mrs. Smith to instruct her husband and son to "back off," so they could explore if marriage was the right path for John and Margaret. With much finesse, she was able to get them to lower the intensity of their disapproval.
The therapist and co-therapist again met with John and Margaret, and concluded that John's moodiness was a concern; and that he would have to change his perception of his possible future father-in-law, if the marriage had any chance of succeeding. John really wanted to get married. Six more couple sessions occurred in which the therapist helped John "reframe" his perception of Mr. Smith into that of "a very concerned and protective father". John (using role-play) was taught the "Stoplight: Stop/Think/Go Method" of anger management [described earlier] when around Mr. Smith and Steve. He encouraged John to go for a psychiatric consultation, where it was determined that he suffered from chronic, low-grade depression (dysthymia) and medication was prescribed. This produced a marked improvement in his moods and sleeping pattern.
Subsequent sessions focused on building relationship skills and possible marriage preparation (sexuality, money management, assertiveness with domineering friends and
relatives). The therapist and co-therapist convinced the couple to postpone the wedding for a year, so that current problems could be more fully resolved. By then they would have gone out for three full years ["Munro's three year rule!" encourages (able and disabled) couples not to rush into marriage, but to get to really know each other first]. At the same time, the therapist and co-therapist met on two occasions with Margaret's parents to help Mr. Smith gradually "reframe" John as "actually very good for Margaret." The agency co-therapist organized some "client-centered planning meetings" where other supports were discussed (e.g., marriage preparation classes with the couple's faith community, expanding leisure activities together and apart, finding an apartment, increasing John's employment hours for extra income).
About a year later, John and Margaret had a lovely wedding. Mr. Smith proudly walked his daughter down the aisle and he sprang for the cost of a honeymoon in Niagara Falls. The therapist used John and Margaret's case example for training seminars for local couple therapists in generic practice, to try to encourage their involvement with couples with intellectual disabilities. Ten years later, John and Margaret are still happily married; they have a lot of fun together; and once or twice a year they call the therapists for a "booster session" around troubling issues.
Despite social, economic, and intellectual disadvantages, research and anecdotal evidence (Schwier, 1994) suggest that love relationships and marriage for couples with intellectual disabilities can be just as successful as in the general population. Utilizing criteria suggested by Billinsley and colleagues (2005), the success of these couples can be measured in terms of the longevity of relationships; partner loyalty and commitment to each other; compatible sexual and intimacy needs; non-violence and shared power; common interests; and shared fun and companionship.
Much professional work remains to be done concerning understanding couple relationships, marriage and parenting for people with intellectual disabilities. There is a need for well-designed research in this area, first requested about forty years ago (Katz, 1968). There also is a need for much more clinical literature concerning methods, strategies and models of couple therapy with this important population; and for therapists in general, to expand their practice to include these under-serviced people.
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