Frustrations in the GymThe purpose of this assignment is to examine ethical issues for professionals working in exercise psychology, rehabilitation, and in other professions related to physical activity as a means for maintaining individual health and well-being. Ethical principles and guidelines, previously discussed, will be applied to these various environments for critical analysis and discussion. Despite the differences in environments, the ethical situations exercise psychology professionals face, often, fall within the same parameters as those of other helping professions.For this assignment, first, read the following article from the Argosy University online library resources:Pauline, J., Pauline, G., Johnson, S., & Gamble, K. (2006). Ethical issues in exercise psychology. Ethics & Behavior, 16(1), 61–76.Now, answer the following questions: Are issues of competency and training more complex for exercise psychology professionals than for applied sport psychology professionals? What ethical dilemmas are unique to the relationship between a client and an exercise psychology professional? Are there distinct differences in this relationship compared to a relationship between a client and a sport psychology professional?Answer each question in 200–300 words. Your response should be in Microsoft Word document format. Name the file SP6300_M4_A1_LastName_FirstInitial.doc and submit it to the appropriate Discussion Area by the due date assigned.Through the end of the module, comment on the posts of two of your peers. In your reviews, check whether the answers given to the second question support their answers to the first one. Discuss any inconsistencies or similarities in your classmates’ answers. All written assignments and responses should follow APA rules for attributing sources.Assignment 1 Grading CriteriaMaximum PointsIdentified and described the differences in competency and training issues for exercise psychology professionals as compared to applied sport psychology professionals.8Analyzed and described the ethical dilemmas unique to exercise psychology professionals.8Compared the relationship between a client and an exercise psychology professional with that of the relationship between a client and a sport psychology professional.8Reviewed the posts of at least two peers and pointed out any inconsistencies and similarities.8Wrote in a clear, concise, and organized manner; demonstrated ethical scholarship in accurate representation and attribution of sources, displayed accurate spelling, grammar, and punctuation.4Total:36 Ethical Issues in Exercise PsychologyJeffrey S. Pauline, Gina A. Pauline, Scott R. Johnson,and Kelly M. GambleSchool of Physical Education, Sport, and Exercise ScienceBall State UniversityExercise psychology encompasses the disciplines of psychiatry, clinical and counselingpsychology, health promotion, and themovement sciences. This emerging field involvesdiverse mental health issues, theories, and general information related to physicalactivity and exercise. Numerous research investigations across the past 20 yearshave shown both physical and psychological benefits from physical activity and exercise.Exercise psychology offersmany opportunities for growth while positively influencingthe mental and physical health of individuals, communities, and society.However,the exercise psychology literature has not addressed ethical issues or dilemmasfaced by mental health professionals providing exercise psychology services. This initialdiscussion of ethical issues in exercise psychology is an important step in continuingtomove the fieldforward. Specifically, this article will address theemergenceof exercisepsychology and current health behaviors and offer an overview of ethics andethical issues, education/training and professional competency, cultural and ethnic diversity,multiple-role relationships and conflicts of interest, dependency issues, confidentialityand recording keeping, and advertisement and self-promotion.Keywords: ethics, exercise psychology, sport psychologyThe emerging field of exercise psychology consists of diverse mental health issues,theories, and general information related to physical activity and exercise. Exercisepsychology encompasses approaches from the fields of psychiatry, clinicaland counseling psychology, health promotion, and the movement sciences (Buckworth& Dishman, 2002a). The establishment of optimal mental health withnonclinical, clinical, and population based settings is often the primary focal pointof exercise psychology practitioners. Physical activity is viewed as a treatmentETHICS & BEHAVIOR, 16(1), 61–76Copyright © 2006, Lawrence Erlbaum Associates, Inc.Correspondence should be addressed to Jeffrey S. Pauline, School of Physical Education, Sport,and Exercise Science, Ball State University, Muncie, IN 47306-0270. E-mail: [email protected]modality for mood alteration, management of psychopathology and stress, and enhancedself-worth. Exercise psychology practitioners also focus on factors relatedto exercise program characteristics that influence exercise adoption and adherencefor individuals, groups, and communities (Berger, Pargman, & Weinberg, 2002).The field of exercise psychology and consulting has many opportunities forgrowth. Potential employment opportunities can be found in the areas of collegesand universities, management of corporate fitness programs, counseling in physicalrehabilitation clinics, and individual consultation with a diverse clientele. Theeffectiveness of exercise practitioners or consultants is often dependent on theirability to develop a collaborative relationship with their clients and otherprofessionals.When consulting with exercisers and/or incorporating exercise into a traditionaltreatment plan, mental health practitioners may feel as if they are treading in unchartedwaters due to some of the unique consultation circumstances and settingsin the exercise environment. Until now, the literature has not directly addressedethical issues or dilemmas related to providing exercise adherence counseling servicesor including exercise as a component of a traditional treatment plan. Theheightened media attention and rising mental health care costs have increased theallocation of funding by federal agencies (i.e., National Institutes of Health) to enhancephysical activity patterns. Therefore, the need and opportunity for practitionersto assist with exercise adoption and maintenance is only going to increaseover the next decade as we continue to search for alternative treatment options tofight physical health problems (e.g., obesity) and mental health issues. With thisincreased opportunity and demand, the need to provide proper guidance to practitionersimplementing exercise as a component of therapy must be examined.Thus, the remainder of this article will focus on selected ethical issues and potentialethical dilemmas facing mental health professionals who provide exerciseadherence consultations and/or include exercise as a component of counseling ortherapy. Specifically, this article will address the emergence of exercise psychologyand current health behaviors, an overviewof ethics and professional resources,education/training and professional competency, cultural and ethnic diversity,multiple-role relationships and conflicts of interest, dependency issues, confidentialityand recording keeping, and advertisement and self-promotion. In conclusion,future issues and opportunities related to the field of exercise psychology willbe presented.EMERGENCE OF EXERCISE PSYCHOLOGYAND CURRENT HEALTH BEHAVIORSThe emergence of exercise psychology is due to the decline in lifestyle and behavioralchoices. In America today, choosing desirable health behaviors such as regu-62 PAULINE, PAULINE, JOHNSON, GAMBLElar physical activity and a healthy diet are not typically practiced to the degree theyshould be. According to the U.S. Department of Health and Human Services(USDHHS; 2000) Healthy People 2010 report, only 22% of adults in the UnitedStates engage in moderate physical activity for 30 min five or more times a week,whereas nearly 25% of the population is completely sedentary. Furthermore, whenpeople do attempt to modify a lifestyle behavior by, for example, increasing physicalactivity, many are unable to maintain the adapted behavior. The physical activityadherence research reports dropout rates up to 50% within the first 6 months ofthe start of an exercise regimen (Dishman, 1988).The cause for weight gain in Americans has been clearly identified. Simply put,we are eating more and exercising less than ever before. Americans are eatingapproximately 15% more calories than in previous years (Putnam, Kantor, &Allshouse, 2000). Combine the increased caloric consumption with the previouslymentioned physical activity patterns and you have a formula for weight gain for alarge segment of our society.Based on the aforementioned statistics and data regarding obesity, diet, andphysical inactivity, the outlook may appear bleak. However, there is hope due tothe development of effective behavioral and cognitively based intervention strategiesto assist individuals with the adoption and maintenance of more active lifestyles(Buckworth & Dishman, 2002b). Currently, there is an abundance of literatureindicating that the adoption of a more active lifestyle will enhance mentalwell-being (reduce depression and anxiety and enhance self-esteem) while decreasingthe likelihood of developing obesity and other risk factors (i.e., high bloodpressure and cholesterol) for chronic diseases such as cardiovascular disease andcancer (USDHHS, 1996). Furthermore, the literature clearly indicates that an individualdoes not have to be an athlete or exercise vigorously to engage in beneficialexercise (Public Health Service, 2001). The American College of Sports Medicine(ACSM; 2000) training guidelines for physical fitness and exercise performancerecommends for aerobic activities 3 to 5 days per week of moderate-intensity exercisefor 20 to 60 min (in at least 10-min sessions) and weight training that includesone or more sets of 8 to 12 repetitions of 8 to 10 exercises at least 2 days a week.Interestingly, many practitioners are utilizing exercise as a therapeutic modalityto improve traditional psychological services. Hays (1999) indicated that exercisecan be utilized to cope with clinical issues (e.g., depression, anxiety, and weightmanagement), issues of daily living, and improving self-care. Exercise psychologyresearch supports the use of exercise as a treatment modality for both clinical andnonclinical clients (Buckworth & Dishman, 2002a). Based on the well documentedphysical and psychological benefits of exercise, psychologists and counselorsneed to be aware of the benefits that can be gained by adding exercise to atraditional treatment plan. However, due to issues pertaining to ethical dilemmasand/or competency, some practitioners may believe it is unethical to include exerciseas part of a treatment plan despite the literature supporting its use.ETHICAL ISSUES IN EXERCISE PSYCHOLOGY 63For most people physical activity poses minimal risks. However, it is importantthat all clients, regardless of ethnic or cultural background, obtain physician approvalto begin an exercise regimen. In addition to the physician approval, conservativetherapists desiring to add exercise to treatment should also have their clientscomplete the Physical Activity Readiness Questionnaire (PAR-Q; BritishColumbia Ministry of Health, 1978). The PAR-Q is designed to identify adultswho may not be suited to participate in physical activity due to various physicalailments.ETHICS OVERVIEW AND PROFESSIONAL RESOURCESThe purpose of an ethics code is to provide guidance and governance for a profession’smembers in working settings. An ethics code provides integrity to a profession,professional values and standards, and fosters public trust through the establishmentof high standards (Fisher, 2003). It should be noted that no code ofconduct or set of ethical guidelines can account for all possible situations or ethicaldilemmas. Ethical codes are developed from the current values and beliefs in societyas related to a profession. These values and beliefs, as well as common professionalpractices, can and do change with the passing of time due to numerous factors,making it necessary for ethical codes and standards to also change.The American Psychological Association (APA; 2002) ethics code is a well developedand ever-evolving document that provides ethical principles and codes ofconduct to govern and guide its membership. In contrast, the Association for theAdvancement of Applied Sport Psychology’s (AAASP; 1994) ethical code is derivedfrom the APA’s (1992) ethics code and has not been updated since its inception.It is designed to address issues specific to sport and exercise psychologywork. There are differences between APA and AAASP ethical principles andcodes. Those differences will be discussed later as they relate to exercise consultations.Whelan, Meyer, and Elkin (2002) provided a detailed discussion of theAAASP principles and ethical standards and serve as a good reference for a sportand exercise psychology practitioner preparing to be or currently involved withsport psychology consulting or exercise adherence counseling. Fisher (2003) andBernstein and Hartsell (2004) also serve as good sources for both general practitionersand exercise consultants.The ACSM is recognized by health professionals throughout the world as theleading organization and authority on health and fitness. The ACSM’s primary focusis to advance health through science, medicine, and education. Furthermore,the ACSM (2003) has established a code of ethics with the principal purpose of“generation and dissemination of knowledge concerning all aspects of persons en-64 PAULINE, PAULINE, JOHNSON, GAMBLEgaged in exercise with the full respect for the dignity of people” (¶ 1). To achieveits principal purpose, the ACSM (2003) established the following four sections:1. Members should strive continuously to improve knowledge and skill and make available totheir colleagues and the public the benefits of their professional expertise.2. Members should maintain high professional and scientific standards and should not voluntarilycollaborate professionally with anyone who violates this principle.3. The College, and its members, should safeguard the public and itself against members whoare deficient in ethical conduct.4. The ideals of the College imply that the responsibilities of each Fellow or member extend notonly to the individual, but also to society with the purpose of improving both the health andwell-being of the individual and the community. (¶ 1)Therefore, the ACSM is an excellent resource for mental health professionals toconsult for guidance concerning issues related to exercise, health, and fitness.EDUCATION/TRAINING AND PROFESSIONALCOMPETENCY MAINTENANCEThe field of exercise psychology is a merger between psychology and exercise ormovement science. Individuals specializing in either of these areas will have differentcompetencies and thus the ability to practice with different populations.Most professionals recognize the value of having individuals in the field from bothbackgrounds due to the uniqueness of their training. The APA (2002) ethics codespecifies that in emerging areas such as exercise psychology practitioners should“take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients,and others from harm” (p. 5).The ideal training for exercise therapists or consultants is an ongoing debate.The two primary sources of training for exercise practitioners are (a) psychology(i.e., counseling or clinical psychology) and (b) the movement sciences (i.e.,kinesiology or exercise physiology). As previously mentioned, psychology andmovement sciences have been meshed together to form the discipline of exercisepsychology. However, these two disciplines are indeed separate and pose a complexissue concerning training. Training for exercise practitioners is complex dueto licensure. Clearly, to refer to oneself as a “psychologist,” an individual must satisfythe state requirements for licensure within the state in which he or she works.Most people trained in the movement sciences can specialize in exercise psychologybut will likely not be able to meet the requirements for psychology licensure.Thus, practitioners can not ethically refer to themselves as “exercise psychologists”because they will not be licensed as psychologists within their state of em-ETHICAL ISSUES IN EXERCISE PSYCHOLOGY 65ployment. Likewise, licensed psychologists with limited or no training in themovement sciences should not ethically refer to themselves as “exercise psychologists”because of a lack of proper training in exercise science.Education and training from both exercise or movement science and psychologyis a necessity for scholar–practitioners in the field of exercise psychology. Dueto the interdisciplinary nature of exercise psychology, students will most likelyneed to create an individualized plan of study suited to meet their future goals andcareer objectives by combining courses from traditional psychology, sport sciences,and sport and exercise psychology. In 1991, AAASP established certificationcriteria for becoming a certified consultant of AAASP. The interdisciplinaryrequirements of AAASP certification require coursework and practicum guidelinesfor students who desire or specialize in applied sport or exercise psychology(Sacks, Burke, & Schrader, 2001). The requirements appear adequate and are necessarybut reflect only minimal foundational training. AAASP certification requirementsshould not be viewed as sufficient training to become an effective exerciseconsultant. Furthermore, the attainment of AAASP certification requirementsdoes not permit an individual to ethically use the title “exercise psychologist.”The following is a recommendation of minimal interdisciplinary courseworkbased on most state licensure requirements and AAASP certification, to be competentto do specialized consultation in exercise psychology. This recommendation isnot a comprehensive list intended to address every possible career aspirationwithin exercise psychology, but it can provide some initial guidance. The interdisciplinarycoursework should focus on the areas of psychology, sport science, andsport psychology. The exercise psychology curriculum should include1. Traditional psychology courses such as human growth and development;biological, social, and cultural bases of behavior; counseling skills;psychopathology; individual and group behavior; psychological assessment;cognitive–affective bases of behavior; professional ethics and standards;statistics; and research design.2. Sport science courses should incorporate biomechanical and physiologicalbases of sport, motor development, motor learning, fitness assessment,fundamentals of strength and conditioning, aerobic and weight training,and sport nutrition.3. Last, sport psychology, performance enhancement, exercise psychology,health psychology, and social aspects of sport and physical activity shouldbe included.In addition to formal coursework, practical experience (i.e., internships and/orpracticum) focused on the application of psychological principles, theories, andpractices in the exercise setting is also a necessity. The practical experience mustbe supervised by a qualified specialist (e.g., licensed psychologist, licensed mental66 PAULINE, PAULINE, JOHNSON, GAMBLEhealth practitioner, or certified consultant of AAASP) within the field of exercisepsychology. The aforementioned curriculum and practical training seems to providethe necessary education for mental health professionals regarding the physicaland psychological benefits of exercise.Nevertheless, this initial, formal coursework and applied experience is not inand of itself enough to allow one to practice ethically throughout his or her career.Maintaining professional competence through continuing professional educationis extremely important in any field, including exercise psychology. The scientificand professional knowledge base of psychology and exercise/movement science iscontinually evolving, bringing with it new research methodologies, assessmentprocedures, and forms of service delivery. Life-long learning is fundamental to ensurethat teaching, research, and practice have an ongoing positive impact on thosedesiring services (Bickham, 1998). Both APA and AAASP provide a variety of opportunitiesand methods for scholars and practitioners to maintain professionalcompetency. Some of these methods include independent study, continuing educationcourses or workshops, supervision, and formal postdegree coursework.Maintaining professional competency is also an important ethical requirementthat is valued highly by the APA, the AAASP, and the ACSM. Over 96% ofAAASP professionals recently surveyed by Etzel, Watson, and Zizzi (2004) believedthat it is important to maintain professional competency through continuingeducation training. This very high percentage is a clear indication of the valueAAASP members place on maintaining professional competency. Maintainingprofessional competence through continuing professional education ensures thatthe scholars and practitioners in the field of exercise psychology are providing themost current services to their clients.CULTURAL AND ETHNIC DIVERSITYThe ethical standards of the APA (2002) and the AAASP (1994) clearly indicatethe importance of recognizing that human differences such as age, gender, and ethnicitydo exist and can significantly impact a practitioner’s work. The standardsemphasize the responsibility to develop the skills required to be competent to workwith a specific population or to be able to make an appropriate referral. The importanceof understanding the culture and background of a variety of populations is vitallyimportant in both exercise and therapeutic settings.Research indicates high rates of obesity and inactivity among women and minoritygroups. About 33.4% of all women are obese, compared to 27.5% of men(Goldsmith, 2004). The age-adjusted prevalence of overweight and obesity in racial/ethnic minorities, especially minority women, is generally higher than inWhites in the United States (Flegal, Carroll, Ogden, & Johnson, 2002). More specifically,among women, non-Hispanic White women have the lowest occurrenceETHICAL ISSUES IN EXERCISE PSYCHOLOGY 67(30.7%) of obesity, non-Hispanic Black women have the highest (49.0%), andMexican American women are in the middle (38.4%; Hedley et al., 2004).The importance of cultural sensitivity and awareness is clearly underscored bythe aforementioned data. Barriers to exercise adherence are often directly or indirectlyrelated to personal and cultural factors. Therefore, when working in the areaof exercise consulting, a practitioner needs to consider the impact, positive andnegative, of factors associated with gender, ethnicity, socioeconomic status, andother potentially relevant culturally based factors.In traditional counseling and clinical settings, the impact of factors associatedwith gender, ethnicity, and culture is also highly relevant for successful outcomes.In 1972, the Association of Multicultural Counseling and Development (AMCD),was established to assist with recognizing the assets of culture and ethnicity, andother social identities and to address concerns about ethical practice (Arredondo&Toporek, 2004, p. 45). These factors are also pertinent for practitioners who desireto include exercise as a component of treatment. A series of essential questions toaddress prior to prescribing exercise as a therapeutic modality include: Is exercisevalued in the culture and/or by the client? What is the prior exercise history of theclient? What types of social support are available to assist the client with exerciseadherence? Does the client’s culture create any additional barriers for adherencefor exercise and traditional treatment?MULTIPLE-ROLE RELATIONSHIPSAND CONFLICTS OF INTERESTMultiple-role relationships are often viewed as occurring when the therapeuticconnection has moved toward a friendship relationship (Bernstein & Hartsell,2004). Multiple-role conflicts in therapy and consultations for exercise adherencemay be encountered when clear boundaries have not been established. When therelationship boundary between the professional and client becomes clouded, thelikelihood of multiple-role conflicts greatly increases. Every practitioner needs tomaintain ethically proper professional boundaries. Establishing and maintainingsuch boundaries can be difficult due to the casual atmosphere that surrounds theexercise environment. The casual environment is created by the type of clothingworn during exercise, music being played, and the social atmosphere of many exerciseand rehabilitation facilities.A first step in maintaining appropriate boundaries is to establish a common protocolwhen communicating with all new clients. Instead of using first names,which seems to be a more common custom, it might be helpful to be consistentwith the practice of referring to clients by last name and title (Miss, Ms., Mrs., andMr. Brown). This practice encourages clients to maintain a distance from thetherapist.68 PAULINE, PAULINE, JOHNSON, GAMBLEMaintaining this distance becomes even more difficult when exercising withclients. Exercising together can be a great vehicle for building rapport and developingcommunication between practitioner and client. Conversely, exercising withclients may cloud the boundaries and thus cause some confusion or ambiguity regardingthe nature of the relationship between client and practitioner. There are nocurrent guidelines and/or laws relative to this specific situation. However, both theAPA (2002) and AAASP (1994) ethic codes indicate that multiple roles can be inappropriateand unethical if handled in the wrong way and need to be maintainedwith great caution. Clarifying the nature of the relationship during the intake andinformed consent process, prior to exercising with the client, is of primary importance.It is the practitioner’s ethical responsibility to have a candid discussion withthe client that clearly defines a therapeutic relationship and the limitations concerningnontherapeutic personal contact. For example, personal contacts such asengaging in recreational or competitive athletic teams, attending sporting events,and other general social functions together are in violation of maintaining therapeuticboundaries. The practitioner should have a clear rationale for prescribingexercise in a client’s treatment plan. In addition, the rationale for exercising together(i.e., to develop rapport) should be clearly communicated and understoodbetween practitioner and client.When exercising with clients, a common dilemma the practitioner faces is determiningwhat type of physical activity should be implemented. As previouslymentioned, research has found a variety of activities (aerobic and anaerobic) thatprovide physical and psychological benefits (USDHHS, 1996). In regard to adherence,it is vital to have clients’ input concerning activity selection. When clientshave input into the selection process, they will likely select/choose a physical activitythey enjoy. Enjoyment of the activity has been positively correlated to adheringand maintaining an exercise regimen (Wankel, 1993).Walking is one of the most commonly reported types of physical activity(USDHHS, 1996). Walking is an excellent choice of physical activity for numerousreasons. First and foremost, many people are able to walk. Furthermore, therisks associated with walking are minimal due to the low to moderate intensitylevel. Also, most people are able to walk and talk simultaneously, which is necessaryfor therapeutic consultations. Last, walking can be performed inside or outsideand requires minimal equipment or modification of clothing. For clients whoare able to and desire a more intensive level of activity, jogging is a viable alternativeto walking. When selecting jogging, a major requirement is for the therapistand client to have a high level of cardiovascular fitness. A high level of cardiovascularfitness allows them to talk with each other while exercising.Anaerobic activities such as strength training provide clients and therapistswith another viable option for activity selection. During strength training, there isample time for communication and discussion between practitioner and client.However, there are a few limiting factors when choosing strength training. MostETHICAL ISSUES IN EXERCISE PSYCHOLOGY 69strength training activities require specialized equipment and facilities and presentincreased potential for risk of injury. In addition, a couple of potential ethical dilemmaswhen including strength training are competency and confidentiality. Thetherapist may not have the knowledge base and/or experience to supervise astrength training program that would accomplish desirable health and therapeuticobjectives. It may also be difficult to maintain confidentiality due to other peopleexercising in very close proximity.The mental health practitioner should not assume the role of a physician, exercisephysiologist, or personal trainer in terms of providing or modifying an exerciseprescription. Furthermore, practitioners should be cognizant of their primaryrole, which is to assist with exercise adherence and consultation. Exercise psychologypractitioners ethically need to be aware of their professional limitations andcompetence boundaries vis-à-vis their education and training.Maintaining an appropriate distance is sometimes useful in diverting inappropriateattempts at amorous and other nonprofessional relationships. Sexualizingthe relationship with a client is clearly unethical as well as very unsound professionalpractice that harms both the client and practitioner (APA, 2002; AAASP,1994). Practitioners often hold an advantage of power over the people with whomthey work. Furthermore, practitioners occupy a position of trust and are expectedto advocate the welfare of those who depend on them.Physical contact within the counseling and exercise setting is often ethically appropriate.However, contact that is intended to express emotional support, reassurance,or an initial greeting can be misinterpreted as an invitation for advances. Thesocial environment, revealing clothes, and close proximity that surround the exercisesetting can lead to inappropriate advances by clients or practitioners. Recognitionof signs, both in clients and in therapists, and dealing with these feelings immediatelyand objectively is the best approach. The practitioner should discuss thesefeelings with an experienced, respected, and trusted colleague. If the practitioner isunable to control his or her feelings, termination and referral are recommended as amethod of protecting both the client and practitioner.However, on termination of therelationship, thetwoindividuals are not ethically “free” to pursue amoresocial or intimaterelationship. It is strongly suggested to have a cooling off period (severalmonthsto years) inwhichboth parties agree towait prior to pursuing a relationship ata different level.Amore conservative approach suggested by Bernstein and Hartsell(2004) is to followthe belief ofoncea client, always a client.With the adoption of thisapproach, once a professional relationship is initiated it must always be maintained,thus reducing the notion or intention of modifying any professional relationship.DEPENDENCY ON THE THERAPISTAnother issue that must be discussed in collaboration with multiple-role relationshipsis a client’s level of dependency on a therapist’s services and influence.With-70 PAULINE, PAULINE, JOHNSON, GAMBLEout question, as human beings we live in a world where dependency on others iscrucial to an individual’s survival. Memmi (1984) explained that the level of dependenceon others should be presented from three perspectives: “1) according tothe identity of the dependent (e.g., child, adult), 2) to that of the provider (e.g., humanbeing, animal, or object), and 3) to the object provided (e.g., winning a medalversus establishing a friendship)” (p. 18). For example, children (dependent) relyon their caregivers (provider) for acquiring and supplying food, water, and shelter(objects provided) to survive within our society. Therefore, as children developinto adults, they must acquire the knowledge and skills from a caregi

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