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Wellness: Aiming for an ever-moving target

By Bethany Bray January 3, 2022

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The COVID-19 pandemic has disrupted nearly every aspect of life, from parenting and family relationships to personal finances and career trajectories. Self-care and coping mechanisms that people previously relied on were often set aside or became harder to access because conditions related to the coronavirus were (and to a certain degree still are) in a constant state of flux. Answers to worries such as “Is it safe to go to the dentist?” or “Will I put my grandmother at risk if I visit her in person?” continue to change with each new phase of the pandemic — the initial uncertainty, the availability of vaccines, the rise of multiple variants, the reopening of schools and workplaces, and so on.

It has all made client wellness a moving target over the past two years. As a result, counselors might consider rethinking how they approach wellness — and all its dimensions — and foster collaboration with other professionals to help clients maintain their mental and physical health even as they are repeatedly thrown curveballs that interrupt their life patterns.

The domino effect

Wellness counseling looks beyond a client’s diagnosis or presenting concern, using a strengths-based approach to view clients holistically. The approach focuses not only on an individual’s mental and physical health but also on their spirituality, social connections, work life, financial situation, home environment and numerous other factors that vary slightly depending on the wellness model the practitioner uses.

And all of that — from clients’ social-emotional health to their financial stability and sexual wellness — has been affected by the COVID-19 pandemic over the past two years, says Christine Ellis, a licensed professional counselor (LPC) who is the founder and clinical director of a counseling practice in Wisconsin.

Ellis’ practice uses the National Wellness Institute model, which concentrates on six dimensions of wellness: emotional, occupational, physical, social, intellectual and spiritual. Because all the dimensions of wellness are interconnected, distress in one area has a domino effect on the others, Ellis says. For example, a client who feels heightened anxiety over the safety of their children returning to in-person school might also experience weight gain and other physical manifestations of stress or increase their intake of alcohol or other substances.

These circumstances have also resulted in Ellis receiving additional referrals and seeing more new clients at her practice. That has been something of a silver lining to the pandemic’s storm cloud, she says: “People have looked at their own wellness … [and] felt, finally, for the first time, ‘OK, now I have an excuse to ask for help.’”

Ellis says she and the other counselors at her practice have been intentional about maintaining a nonjudgmental atmosphere as clients talk through their pandemic-related stressors, which often include frustrations that stem from feeling limited or disrupted in their goals or life plans.

“We have been using a ton of distress tolerance techniques during the last couple of years,” says Ellis, a member of the American Counseling Association. “It’s been hard during COVID. How do you change when everyone is stuck? … When we hear clients say, ‘that’s not possible,’ our job is to validate that and recognize it as suffering. Then, we focus on small changes.”

Equipping clients with new and different coping mechanisms and talking through what they can and cannot change has been extremely important over the past two years, Ellis says. It has all been done with an eye toward empowering clients and giving them a sense of ownership over their own wellness. For some, this also included working on identity-related issues, such as no longer being a soccer mom and taking the kids to sports activities regularly or not being as productive or successful in their career while working from home.

Ellis has found that pandemic-related stress has been acute for clients who struggle with focus or attention challenges such as attention-deficit/hyperactivity disorder. She believes anxiety and distraction have heightened for these clients because routines have been upset and there have been so many unknowns over the past two years, such as “Will I get COVID-19?” or “Will my child be able to wear their mask at school?” Young and adult clients alike have needed to go back to the drawing board to find new coping mechanisms, Ellis says, because many of the tried-and-true tools they had been using no longer worked under such extenuating circumstances.

Clients’ mental well-being also took a hit when the pandemic disrupted or canceled activities that previously boosted their wellness, such as fitness or art classes, community parenting groups and church coffee groups, Ellis notes. Helping clients identify substitutions and replacements for these activities was vital in the early days of the pandemic and continues to be important now because routines are still in flux.

Perhaps a client previously maintained their physical and social wellness by attending a favorite fitness class, but the class got canceled or they no longer feel safe attending. Under that scenario, Ellis would validate the client’s feelings of loss and ask questions to spark ideas of alternative ways to attain those same benefits. She may ask, for instance, “How can you replace your water Zumba class? What about it do you like, and how can you find that elsewhere? How can you achieve the same things that you know you value, just differently?” Perhaps the client could call or video chat with a friend from the class or set up an area in their home to exercise on their own, she suggests.

A big part of this work, Ellis notes, is helping clients make the shift from an external source of motivation (relying on a class to boost their wellness) to an internal one (finding ways to boost wellness on their own).

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Christie Kelley, an LPC who uses a wellness approach at her solo private practice in Bristol, Connecticut, says her clients have been experiencing many of the same feelings and challenges that Ellis describes. Kelley has also seen an increase in new clients recently because, she says, many people are evaluating aspects of their lives and wellness and finding areas they feel are lacking or that need changing.

Many of Kelley’s clients felt they had more options — and more motivation — to tend to their wellness at the start of the pandemic, she says. It was easier to schedule breaks to get outside and engage in physical activity with their children while they were all home together or to do exercise classes at home via Zoom. But as more schools and workplaces began to reopen, the novelty of incorporating wellness into daily life faded for many people. 

More of Kelley’s clients now view wellness as separate from or less intertwined with their daily routines, she notes. This includes approaching physical activity as one more thing to add to their to-do list rather than weaving it into the workday, such as by walking a few flights of stairs during their lunch break.

Kelley has found she needs to emphasize to clients that wellness remains an interconnected part of life. “In my area, I’m really noticing more of an impact with the pandemic now. Many of the people I’m working with are experiencing more problems and hardships now,” says Kelley, an ACA member. “Where I have seen people struggle is getting back to this ‘new normal.’ They developed some ways of being healthy in their homes during the pandemic, but now many are going back to work and struggling with balance.”

Getting creative

Many clients have needed support and guidance from a counselor to manage their wellness because so many aspects of daily life have been disrupted during the pandemic. Ellis has found it helpful for counselors and clients alike to consistently seek fresh ways of looking at challenges and stressors.

If clients are feeling stuck or unmotivated, Ellis suggests asking them to name one thing they could do within the hour or that day to boost their wellness. It might be as simple as drinking some water, planning a healthy meal or finding a book to read that gives them more information and ideas on a wellness topic.

“We’re still going through this wave. … Things are not how we want them to be every day. How do we deal with that [through] a compassion-focused lens?” Ellis asks. “Have a beginner’s mind every day. Promoting how to look at something [as if it’s] the first time brings a freshness. That big picture view keeps us from being stuck and getting stuck. … Get away from the entrenched perspective.”

“We [counselors] can help clients see things that way: They can simply put their shoes on and walk around the block. You don’t have to run a mile, but take one step toward wellness,” Ellis says. “Wellness is also about allowing ourselves to sit with the discomfort of an emotion or feeling and simply working to observe it, asking it what it has to teach us — as [Buddhist teacher] Pema Chödrön’s work models — and then it can be used as fuel to motivate a new wellness behavior, activity, attitude or belief.”

Kristin Bruns, an associate professor and college counseling and student affairs program coordinator at Youngstown State University in Ohio, stresses that counselors not only need to get creative with their approach to client wellness but also ensure that the work is client driven and culturally sensitive. Counselors shouldn’t make assumptions about what wellness activities might or might not work for a client, Bruns says.

For example, a client may not feel comfortable or safe going back to the gym even if it has reopened. Or they may have lost their job during the pandemic and no longer have the financial means for a gym membership. A counselor’s role is to explore that with the client and prompt conversations to find other avenues that will work for them, Bruns says. An important aspect of this work is for counselors to be aware of resources within their communities — especially free and low-cost offerings — such as programs and groups at libraries, community centers and local nonprofits, she adds.

“Also, ask clients what their self-care looked like before the pandemic, what it looks like now and what would they like to change. That can help us work with them to figure out what they want to reengage in and what they might want to look different,” says Bruns, a licensed professional clinical counselor who sees clients part time and uses a wellness approach at a private practice outside of Akron, Ohio. “Use those basic counseling skills — really listen to what the client is telling us, and help [them] think of things that might fill that need. It’s easy to want to throw out suggestions, but it’s more powerful when clients come up with [solutions] themselves. It’s really powerful when we let the client be creative.”

Kelley agrees that it’s helpful to ask clients about their self-care prior to the pandemic and to work on “translating” it for the current environment. Sometimes there is a need to expand clients’ understanding of self-care, she notes.

In the past two years, Kelley has noticed that her clients’ view of self-care has oscillated between basic tasks such as showering and getting dressed to more cliché ideas such as doing yoga — endeavors, she says, that are helpful but not the be-all, end-all.

Kelley begins conversations about self-care by asking clients about their hobbies and interests and the things that bring them joy. Then, she uses one of their answers to apply a clinical focus. For example, a client who loves tea or coffee can use their time spent with a warm mug to pause and do a mindfulness exercise.

“I’ve needed to challenge people’s understanding of self-care and wanting it to fit into a mold. My challenge is to try and help them expand their thinking process, their idea of what self-care is,” Kelley says. “Self-care is anything that you do for yourself; it doesn’t have to be this one thing. I try and help them have a broader idea of it.”

The use of telebehavioral health during the pandemic has helped in this realm, Kelley notes. Doing sessions via video has given her insights into clients’ environments, including elements that have sparked ideas to boost wellness and self-care. In one case, a client had set a goal to incorporate more mindfulness into his life, and during one of their video sessions, Kelley and the client started discussing a seating area in his house, visible in the camera, that he could use for that purpose.

“I never even [asked], ‘Could you use that spot [for mindfulness]?’ … [The conversation] just naturally went there. One of his goals for that week was to prepare it and use it for wellness,” Kelley recalls. “I’ve really been trying to work with people in a very organic and personal fashion, as opposed to a generalized idea of wellness. … It’s one thing to ask if they have a pet at intake [during in-person counseling] but another to see a pet on screen during video therapy. You can incorporate it into conversation or therapy goals. It’s something that they already [got] enjoyment [from], but now they can think of it as self-care.”

The use of telebehavioral health has also prompted Kelley to get creative and modify the wellness-focused activities she previously used with clients during in-person sessions. When teaching breathing techniques, she encourages clients to lie down or otherwise get comfortable off screen, if space allows, while she talks them through the exercise.

“It has been helpful for clients because they’re in their own space and are comfortable, but it also shows that they can do it in their home,” Kelley says. “It’s not as disconnected as sitting in therapy and having the thought that they’ll do it at home, but then they get busy and don’t. They’re more likely to do it outside of therapy [sessions] when they’ve already done it
at home.”

Addressing all aspects of wellness

As the pandemic drags on, clients are processing its effects more and more. Wendy Thorup-Pavlick, an ACA member with a wellness coaching practice in the western suburbs of Chicago, says many of her clients have become more aware of their own wellness. As a whole, they are also more open to a mind-body focus to help them make changes and find solutions for symptoms related to physical and mental stress, sleep problems, mental health challenges and other issues that have spiked during the pandemic.

“For many clients, the pandemic was the catalyst toward embracing a healthier, more balanced lifestyle,” says Thorup-Pavlick, an LPC and adjunct faculty counselor at the College of DuPage in Illinois. “Good health and wellness are more than the absence of disease or illness; it is multidimensional and interconnected. Wellness is a conscious, self-directed pathway to optimal living, and integrating a wellness approach allows clients to use wellness principles to build resilience and thrive amidst life’s challenges. Adopting wellness practices provides additional support to clients who may be feeling abnormal and continuous levels of stress caused by the pandemic.”

This unprecedented time affords counselors an opportunity to dig into wellness-focused techniques with clients to help them cope with stress, manage their emotions and attend to the whole self. One such tool involves keeping a food-mood diary, says Thorup-Pavlick, a certified health and wellness coach. Her clients have benefited from recording their food intake and sleep habits, emotions, moods and other mental and physical symptoms to observe patterns and connections during the pandemic.

Thorup-Pavlick says clients have particularly needed support related to sleep hygiene during the past two years. Adequate sleep is tied to wellness in numerous ways, including supporting a healthy immune system and cardiovascular health, improving cognitive function and emotion regulation, and managing weight gain, she notes. Counselors can provide psychoeducation that it is not only important to prioritize sleep and maintain a consistent sleep schedule but also helpful to limit caffeine intake before bedtime, engage in physical activity during the day, keep naps short, and foster a relaxing environment in their sleeping area, including turning off computer and smartphone screens.

Motivational interviewing can be a helpful technique for asking clients about their sleep habits and finding out what they already know about sleep hygiene. If the client is open to it, the counselor can offer more information, Thorup-Pavlick says. If clients wear a fitness-tracking device, such as a Fitbit, asking about the sleep data it has collected can also be a way to introduce the topic, she notes.

In addition, Thorup-Pavlick often asks clients the following questions:

  • What does your sleep schedule look like?
  • Tell me about your sleep environment.
  • How rested do you feel on a scale of 1-10?
  • What’s working well for you at the moment?
  • What isn’t working well at the moment?
  • On a scale of 1-10, how motivated are you to improve your sleep habits?
  • What do you think you should do first?
  • Whatever your first step is, is there anything that might stop you from doing it?

“The idea is not to become a sleep expert but to know when the client may need to seek additional medical attention for sleep-related issues and how those issues may impact the client’s emotional well-being,” Thorup-Pavlick says.

Those interviewed for this article agreed that counselors need to be proactive and ask clients about aspects of their wellness — including use of alcohol and other substances — both at intake and regularly throughout therapy.

Counselors can also prompt discussions about wellness with clients by creating a wellness wheel in sessions, Thorup-Pavlick adds. During this exercise, the practitioner guides the client to create or fill in a circle diagram based on the health of the different dimensions of wellness in their life, including occupational, physical, social, intellectual, spiritual, emotional and other realms.

“When life is in balance, the wellness wheel will be round; when out of balance, the wellness wheel may look and feel a little more like a flat tire,” she explains. “It can inform the mental health practitioner how ‘in balance’ each wellness dimension is for the client. … The wellness wheel is a tool that will help identify how clients view themselves and how satisfied they are in each dimension of wellness.”

From there, Thorup-Pavlick often prompts clients to create a “wellness vision” for themselves that connects to their core values. This involves talking through not only a client’s desired wellness outcomes but also the challenges and knowledge gaps they might face and the strengths, motivators and supports they can rely on as they work toward their goals. Creating a personalized plan helps clients make sustainable progress toward wellness, she notes.

“The focus should be on what the client wants to achieve and not what they want to eliminate,” says Thorup-Pavlick, a member of the Illinois Counseling Association and a board member of the Illinois College Counseling Association. “As clients begin to get excited about their desired wellness outcomes, they can incorporate behavioral changes that will move them toward achieving these wellness goals.”

Forging connections with the medical community

In addition to the physical health concerns related to the coronavirus itself, the pandemic has caused a wave of negative outcomes that might have been prevented or caught earlier if people hadn’t postponed or skipped routine health appointments and screenings, such as mammograms and colonoscopies, during the past two years. These distressing outcomes are higher among people of color and those of lower socioeconomic status. 

Professional counselors have a role to play in ensuring that clients are tending to all aspects of their wellness, including physical health, as the pandemic continues to disrupt life patterns, says Deanna Bridge Najera, an ACA member who works as a physician assistant (PA) in emergency medicine at a hospital in Maryland.

People have been canceling or delaying medical care for a wide variety of reasons, including resistance or discomfort with telemedicine or the inability to pay for services or prescriptions, Najera says. At the same time, medical offices have been overwhelmed, so it can be hard to get an appointment, and some have stopped accepting new patients, she adds.

This unprecedented time presents the counseling profession with an opportunity and a responsibility to forge connections with the medical community and do more interdisciplinary work, Najera asserts.

Not only do counselors have a responsibility to ask clients if they have a primary care provider and other questions about their medical care, but they should also be proactive and advocate to help them overcome barriers when there are gaps in that care, says Najera, who has a master’s in clinical mental health counseling as well as a master’s degree and licensure as a PA.

The first piece of this work is for counselors to become familiar with and connect with medical providers and other support services in their community. It also can involve advocacy with individual clients, such as helping them find health care services or supporting them while they call a pharmacist or a provider who prescribes psychiatric medicines.

In addition to her work as a PA, Najera provides psychiatric medication management services part time at a community mental health agency and is a backup psychiatric provider for Shippensburg University and Gettysburg College. She is also employed part time in the Carroll County Health Department in Maryland, working with clients in the reproductive health program. “We [professional counselors and medical providers] have to both play in the same sandbox,” Najera says. “It’s about meeting [clients] where they’re at and best supporting them on their journey. It has to be a team taking care of the whole person. We have to play well together … [and] it works a lot better when we all have open communication with each other.”

Ellis says that part of working as a wellness-focused counselor is serving as a catalyst to connect clients with medical care and other essential services. “We [counselors] are active listeners, so we are often the first people to hear about problems they’re experiencing,” she notes. “We are ethically bound to connect with other practitioners, help make connections and referrals, and have good relationships with [interdisciplinary professionals] in the community.”

For instance, if a client were to mention during a counseling session that they are suffering from back pain, Ellis says she would first provide empathy and prompt the client to talk about how the physical pain has been interfering with their everyday life and affecting their moods, sleep and other aspects of wellness. Then, she would shift the conversation to focus on how the client can advocate to find solutions to move toward how they want to feel. This may include making phone calls together during session to schedule appointments or ask questions of medical providers, she says.

“When people are not taking care of themselves, sometimes they need that little piece of support and the message that ‘I’m worth it,’” Ellis emphasizes.

Najera believes counselors should build connections with clients’ primary care providers, and if they don’t have one, explore why that is and support them in finding one. Ensuring a client’s medical provider is aware of their counseling goals also affords counselors the chance to consult or hand off care if things go beyond their scope of practice, she adds.

“As mental health professionals, we [counselors] cannot prescribe medical things,” Najera continues. “It makes sense to tell clients to go take a walk, but if they go out and have a heart attack, you may be at risk for being accused of giving medical advice.”

“It’s a gray zone,” Najera admits. “Talking about a sleep schedule or healthy diet is fine [as a counselor], but making recommendations about specific things to eat isn’t OK. You don’t know if they might have blood pressure issues or diabetes” or other diagnoses that require a specific diet.

Counselors can still work from a wellness perspective without advising clients beyond their scope of practice — it just takes a little creativity, Najera says. For example, suggesting breathing exercises to a client who struggles with lung function may go beyond a counselor’s scope. However, studies show that singing can help with improving lung function after illness or injury, diaphragmatic breathing, and one’s mental wellness and ability to cope with stress. Using music therapy or encouraging clients to sing to a favorite song to boost their mood would be a creative way to reap those benefits without overstepping professional boundaries, she says.

Listening for client statements such as “My doctor told me to walk every day, but it’s been too hard” can also give counselors an avenue to talk about the reasons why it’s been a challenge and support the client in reaching their walking goals without making medical recommendations, Najera says. She recommends counselors ask clients about their goals and any potential barriers by saying, “It sounds like this is important to you. How do we work on that goal and support you? What would keep you from doing it?”

Najera also suggests counselors ask permission to contact a client’s medical provider(s) on intake forms. Once permission is granted, the counselor has a “permission slip” to make phone calls or send emails or faxes to connect with other providers. However, Najera reminds counselors that doctors and other specialists are often busy and “off limits” for direct contact. Instead, they can work with nurses and other support staff. Many medical offices’ automated phone systems have an option for other providers (e.g., “Press two if calling from another provider’s office”); counselors shouldn’t hesitate to use that option, she says, because they are part of the client’s care team.

Najera also recommends that counselors write a standard letter or email for collaborative care: “Dear Dr. so-and-so, I am now meeting with your client, so-and-so. What recommendations do you have to benefit their overall health and wellness?” Even if that initial communication doesn’t result in a reply, “it creates an avenue for conversation and opens the door,” she says.

When looking to consult on a client’s wellness goals, counselors should make it easy for the provider to respond, Najera advises. “It may be as simple as [sending] a fax or email saying, ‘I’m seeing Jane Doe, and we’re talking about exercise. Is it OK to recommend walking X times per week?’ That way, the provider is able to answer with a simple no or yes and sign off that they are OK with the recommendation,” she says.

Counselors could also prepare letters outlining their contact information, services and areas of specialty and drop them off at local medical offices. This serves not only to spread awareness of their availability for referrals and other patient care but also to offer counseling services to medical staff themselves, many of whom are burned out right now, Najera notes.

“What would be amazing is to say [to medical staff], ‘We recognize that this is a really crappy time for you, and I’d be happy to see you for counseling sessions.’ Being flexible and willing to offer sliding scale and/or evening appointments makes the point that we’re all on the same side,” she says.

Extending counselors’ reach

Interdisciplinary work extends beyond just medical providers, Najera says. Counselors could partner with school-based and community mental health providers, hospital case managers or local law enforcement to help with issues such as crisis management and evaluation.

If a counselor runs a therapeutic group for teenagers who struggle with eating disorders, for example, they could reach out to other local providers and agencies that serve youth to see if they have any clients who might benefit, she says. Or a counselor who specializes in trauma could forge a connection with a wound care center in their area to counsel patients and help them work through the range of emotions associated with losing a limb.

“There’s a lot of ways counselors can stretch and grow and expand their services,” Najera points out. “We [counselors] don’t need to stay in our offices. Integrated care is meeting people where they’re at.”

Bruns is co-directing a federally funded grant to foster wellness on the Youngstown State University campus. She says one of the project’s biggest takeaways so far has been the importance and power of interdisciplinary partnerships. Sharing resources and working across specialties enriches and strengthens services on both sides.

“Don’t take for granted what we [counselors] know about wellness. We have a lot to share. Don’t underplay the value of wellness and self-care, both in our own lives and for our clients. The impact of small changes in self-care and wellness can shift a person’s life, and there’s so much power in that,” Bruns says. “On an individual basis, you can create a culture of wellness wherever you are. We have a part to play, to create a culture of wellness one person at a time. We all have a space where we can make that difference.”

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Counselors and the urgent care clinic: A new accessible delivery option

By James Todd McGahey and Melanie Drake Wallace June 18, 2021

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Few would argue that 2020 was a watershed year in many respects. The COVID-19 pandemic, social and economic inequities, a racial reckoning, and environmental disasters collided and coalesced into a reality marked by tremendous challenges, the likes of which could hardly have been predicted. This confluence of factors has created an increasing need for counseling and mental health care.

The dramatic increase of individuals reporting mental distress has garnered national attention and sharpened societal recognition of the relationship between mental and physical health. Consequently, mental health and well-being, or a lack thereof, have taken on new urgency and can no longer be ignored.

Our recent work, respectively, as a mental health counselor in an urgent care setting and a professional counselor supervisor and educator has given us a unique, firsthand perspective on this valuable opportunity. We believe that the immediate/urgent care facility offers a promising new setting for the provision of mental health care. A number of urgent care facilities have already incorporated mental health services into their practice with positive results. Mental health providers have become vital components of integrated and interdisciplinary teams. Therefore, the primary objective of this article is to promote and highlight the integration of collaborative mental health resources into these care clinics.

Mental health care and urgent care

A drive down most urban thoroughfares, suburban boulevards or even rural town roads often leads to a sighting of an urgent/immediate care facility or at least an advertisement for one. The proliferation of these clinics over the past few decades has resulted in their ubiquitous presence on the community landscape and the health care scene.

The dramatic increase in mental health issues across the population, exacerbated by the COVID-19 pandemic, demands a mitigation strategy. An effective intervention that has also seen a rapid increase recently is the incorporation of mental health care within the urgent/immediate clinic setting. There have been positives and negatives regarding both results and outcomes, inspiring us to examine the advantages and disadvantages of this burgeoning concept.

History

The urgent care concept of providing accessible health care emerged in the 1970s. Initially, these clinics were staffed by physicians who provided basic care for minor issues such as colds and sore throats and minor accidents requiring first aid. Over the years, the number of immediate/urgent care facilities increased and the range of treatments expanded.

Increased treatment options, expanded availability, timely care and affordability are among the reasons that an estimated 3 million patients visit urgent care centers weekly. Their convenience, accessibility and omnibus approach of addressing various medical issues, including the acquisition of a primary care doctor, make them an attractive alternative to the bureaucratic and often alienating nature of the traditional health care industry. The COVID-19 pandemic also exposed various weaknesses and inequities within our traditional health care system, positioning the urgent/immediate care industry as a vital component of a comprehensive plan to prevent and mitigate such crises.

Mental health issues

Urgent care, COVID-19 and lingering effects

The vital role of the urgent/immediate care facility has been confirmed throughout the pandemic. These facilities have functioned effectively as testing centers, providing rapid testing and results to the public. They provided access to health care providers as the pandemic burdened and overwhelmed traditional health care access.

With the growing relationship between mental health care and urgent care, providing mental health services for the increasing prevalence of mental health symptoms seems an essential and effective strategy. The COVID-19 pandemic is leaving a trail of lingering implications, including economic and psychological effects, that are not yet fully known.

Whereas physical risks and symptoms of the pandemic will improve with vaccines and increased knowledge of the virus, mental health issues may endure as people struggle from serious issues that may become chronic or episodic. As reactions to the pandemic and the accompanying stressful environment increase negative symptomology, an overall benefit may be the increased exposure of mental health issues.

 Growth of delivery systems

Other trends, primarily driven by the pandemic, include an exponential increase in the use of telemental health options. These include various mental health providers opting to use these delivery platforms with their clients and clients seeking mental health services from online counseling companies.

Online counseling service companies usually provide subscription plans and packages and match clients with a qualified provider. These companies have experienced strong growth recently, with the appeal being that all aspects of the care can be provided through an online platform. These aspects may include insurance utilization, intake interviews, therapy sessions and the ability to schedule appointments.

Traditionalists and critics argue that a vital element of the counseling relationship and process are forfeited in the telemental health format. In addition, most insurance companies have not embraced or reimbursed these efforts. Some disadvantages of online counseling include the loss of intimacy in the in-person counseling relationship, the lack of coverage by insurance, unreliable technology, the difficulty of treating serious mental health disorders, and the general absence of nonverbal communication. 

Advantages

Omnibus service and accessibility: Urgent/immediate care facilities currently have a large capacity and continue to expand in all areas of the country. The addition of providing mental health services in these existing and future facilities would expand exposure and treatment (proactive, reactive and crisis) to reduce the prevalence of mental health disorders — disorders that cost billions financially through expenditures and loss of work.

This omnibus approach is conducive to “one-stop shopping.” Many mental disorders present initially as physical symptoms. Thus, these can be treated by the health care provider, who can then refer the patient/client in house for mental health evaluation. This would prevent long delays in accessing services rather than patients being referred to outside mental health professionals who may have long waiting lists or may not be accepting new patients. The amalgamation of mental and physical health services in one facility would create a comprehensive continuity of care.

COVID-19 implications: The pandemic has increased the prevalence of mental health needs across all populations. Like the distribution challenges of the COVID-19 vaccine, distribution of mental health services is also a challenge. Using the existing delivery system and structure of the urgent/immediate care industry could provide a substantial increase and reinforcement to the existing mental health services that can be offered or provided to individuals in need.

Professional practitioners: Access to professional mental health providers, especially psychiatrists, has reached a crisis stage. The number of new physicians choosing psychiatry has been declining over the decades, whereas the number of retiring psychiatrists is increasing. Rural access to mental health care is extremely limited or unavailable, and urban access is limited by long wait times and “no new patient” policies. These factors are not conducive to successful treatment of mental health conditions.

Medical professionals available at immediate/urgent care facilities can collaborate with experienced licensed professional counselors/therapists who are educated and skilled in the treatment of mental health to successfully assess, diagnose and treat through medication, psychotherapy or a combination of the two.

Loneliness: AARP has warned that the coronavirus pandemic is also causing a loneliness epidemic, which with the aging population, accounts for almost $7 billion a year to the cost of Medicare. Loneliness is also a contributing factor in other conditions, making people more vulnerable to Alzheimer’s disease, high blood pressure, suicide and even the common cold. Some researchers propose that loneliness is more dangerous to people than obesity and smoking. Like mental health, loneliness carries a stigma that hampers assistance efforts.

The simple presence of another human with whom to converse, witness or socialize leads to more positive outcomes. One of the most effective methods of improving loneliness is cognitive behavior therapy (CBT), which helps individuals examine their thoughts, perceptions and assumptions and how they affect behaviors — including behaviors that may be leading to loneliness. Increased access to mental health providers in affordable, accessible and convenient urgent/immediate care facilities can help stem the negative effects of loneliness and other social isolation ailments that are growing as a result of the pandemic environment.

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Conclusion

The parity of behavioral/mental and physical health services has long been an issue. The Affordable Care Act addressed many of these issues by enacting legislation that required equal coverage of mental and physical health, but there is room for improvement.

The National Center for Health Statistics reported in 2018 that suicide ranked as the 10th-leading cause of death across all ages in the United States. In 2016, suicide became the second-leading cause of death for ages 10-34 and the fourth-leading cause for ages 35-54. Having immediate access to mental health care is critical to reducing this rate and many more mental health diagnoses.

The immediate/urgent care system, in concert with the mental health community and their professional providers, can be a strong partner in addressing these societal concerns. Counselors should take leadership roles in advocating for change, especially in these delivery systems. Appeals to local governments, insurance companies and counselor training programs may result in easier accessibility for all populations. Mental health professionals can advocate for urgent care clinics to create mental health positions in their groups, as many clinics have more than one location.

It is important that we highlight the potential of a seamless, omnibus approach of a single comprehensive visit or location for addressing all health needs or issues. Ultimately, with a marriage between urgent/immediate care clinics and mental health counselors, accessibility and quality of care can be increased and challenges and obstacles reduced.

 

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James “Todd” McGahey is a licensed professional counselor, a national certified counselor and an associate professor of counselor education at Jacksonville State University. He also serves as a consultant and mental health provider at Beach Family Urgent Care in South Carolina. Contact him at jmcgahey@jsu.edu.

Melanie Drake Wallace, a licensed professional counselor supervisor and national certified counselor, is a professor and department head of counseling and instructional support at Jacksonville State University. She also serves on the Governing Council of the American Counseling Association. Contact her at mwallace@jsu.edu.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Bringing CBT into the doctor’s office

By Bethany Bray September 12, 2018

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When you get your annual physical, does your primary care physician ask if you’ve been feeling atypically sad or anxious lately?

Primary care doctors are often the first professional a person will tell about symptoms related to depression or other mental health issues. With this in mind, two Pennsylvania counselors have created a presentation on coping skills and takeaways from cognitive behavior therapy (CBT) that medical doctors can use with their patients.

When Brandon Ballantyne and Kevin Ulsh spoke to the primary care physicians and other medical personnel at Tower Health in Reading, Pennsylvania, recently, they found an interested and engaged audience. The medical practitioners were particularly interested in learning more about how to help patients who present with anxiety and related problems during medical appointments.

Ulsh and Ballantyne are mental health therapists in the inpatient and partial hospitalization programs, respectively, at Reading Hospital, which is part of the Tower Health system. Ballantyne is also a licensed professional counselor and American Counseling Association member.

How can aspects of CBT be translated for use in the medical professions? CT Online asked Ulsh and Ballantyne some questions to find out more.

 

How did this come together? Did you reach out to the doctors, or did they invite you to come?

We have always been interested in the concept of extending coping skills practice and implementation into primary care settings. We believe that the primary care setting is where most individuals first report problems associated with anxiety, stress, depression and so on. In many situations, the primary care physician is the first provider to address such issues.

Recently, we have observed a growing trend to integrate primary care and behavioral health services. We decided to take these observations and build a coping skills lecture that can assist providers in the primary care setting with addressing stress and anxiety, along with other mood-related problems with the patients they serve. We developed an outline for a presentation and broadcast the idea to the primary care Tower Health continuing education team, who then gave us an invitation to present it as a part of their lecture series.

 

How did it go? Were the doctors open to your message? What were some of the things they asked or commented about?

The lecture went well. The doctors in attendance were attentive and interested. They asked several questions about how to address behaviors particularly associated with adolescent anxiety such as school avoidance and oppositional defiance. We addressed these questions by referring back to the cognitive model, which we highlighted as a foundation of our lecture.

We think it was important to have a discussion with the doctors about the clinical indicators of avoidance versus defiance. Utilizing a cognitive philosophy, we emphasized that avoidance typically shows itself as a behavior which prevents an individual from doing something that they would like to be able to do or would want to be able to do if not affected by anxiety. The anxiety that drives avoidance is typically a product of some anticipated fear. … The individual has cognitively come to the conclusion that the fear itself is an already established fact or guarantee.

Defiance, on the other hand, is a behavior that is driven by the desire to maintain control by resisting demands and expectations to comply with things that are simply undesirable. In other words, in the cognitive process that drives defiance, an individual may think, “If I don’t like it or don’t want to do it, then I don’t have to, and it doesn’t matter what anyone says.”

Therefore, primary care physicians may be able to get a better handle on what it going on with the patient, clinically, simply by asking about their thinking.

 

From your perspective, how could CBT be helpful in a medical setting? Please talk about why you chose to focus on CBT when you spoke to the doctors.

We chose to focus on cognitive behavior therapy when providing this lecture because CBT is an evidence-based approach that has been shown to be an effective form of treatment for multiple psychological problems across various populations. We believe that in the primary care settings, patients will benefit most from socialization to the cognitive model, so that they can gain a clear understanding of the difference between a thought and an emotion.

Once an individual understands the relationship between a thought, an emotion and a behavior, they acquire control over regulating their mood and reactions in a positive way. CBT-based skills are goal-oriented, problem-focused and able to be introduced and taught to individuals dealing with a wide range of psychological problems.

In the fast-paced primary care setting, brief psychological education and skills practice can be a piece of the treatment puzzle that not only addresses the emotional problems of the patient, but also offers skills that they can continue to utilize and benefit from outside of the office (such as deep breathing, sleep hygiene, behavioral activation, disputing cognitive distortions, thought journals, activity scheduling, etc.).

 

From your perspective, what are the benefits to this kind of collaboration? In other words, benefits not only for the professionals involved, but for the patients/clients too.

There are multiple benefits to this kind of collaboration. We believe that in most cases, the first call that patients make when they are not feeling well is to their family doctor. On some occasions, they are being seen by their family doctor for a physical health issue. However, in the midst of assessment, they may reveal an emotional problem or talk about a significant stressor that is causing psychological distress.

This is because for the most part, individuals attend treatment with a primary care doctor whom they trust. Maybe they have been seeing this doctor for most of their life. They have learned to confide in this doctor quite often. Therefore, they may be more open to acknowledging emotional problems within that office setting.

The type of collaboration that we facilitated reinforces the importance of integrating psychological education and coping skills practice into a primary care setting. For professionals, it improves the continuum of care and reduces the stigma of mental health problems. Ongoing behavioral health collaboration, and having a behavioral health component to primary care treatment, implies that psychological distress is a natural area of assessment which patients might otherwise be hesitant to acknowledge or discuss. In this way, patients can become more open to behavioral health support and more accepting of their need to seek outpatient therapy to further resolve symptoms.

 

What advice or tips would you give to counselors who might want to collaborate with medical professionals, like you did, in their local area?

We would suggest that mental health professionals in all parts of the country consider developing a presentation on one particular area of therapy and/or psychological education that you feel passionate about [and] which you also utilize with the clients you serve. The goal is to develop a component of that theoretical orientation that is applicable to a primary care setting. It has to be something that primary care physicians can utilize within the short amount of time that they have with their patients.

We found that in our lecture, doctors were most interested in the practical applications of CBT as it pertains to the acute management of anxiety. We assume that other helpful topics may be closely related to dialectical behavior therapy [and] concepts such as mindfulness, distress tolerance and opposite action.

 

Is this something you think that counselors could or should do more of? What did you learn through this process?

As a result of providing this lecture, we learned that primary care doctors are very much interested in behavioral health support and assistance. It seems as though there has been an increase of patients presenting to family physicians with emotional problems. The doctors that we spoke with were very thankful for the background on CBT and the skills practice that we provided. In fact, they practiced some of the skills with us.

It reminded us that regardless of the [health] profession, we all will be most effective [with] our patients if we are also taking good care of ourselves. Integrating behavioral health support, psychological education and coping skills practice into a primary care setting reinforces the importance of seamless multidimensional treatment, ultimately helping patients to receive effective care that addresses their physical and emotional needs, and offers the safety to accept the behavioral health treatment that they may otherwise be hesitant to pursue.

 

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Ballantyne and Ulsh can be contacted via email:

Brandon.Ballantyne@towerhealth.org

Kevin.Ulsh@towerhealth.org

 

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Related reading, from Counseling Today:

“Integrated interventions”

“The counselor’s role in assessing and treating medical symptoms and diagnoses”

“When brain meets body”

 

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Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Group counseling with clients receiving medication-assisted treatment for substance use disorders

By Stephanie Maccombs September 6, 2018

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Holistic care, or the integration of primary and behavioral health care along with other health care services, is becoming more common. In my experience as a mental health and chemical dependency counselor in an integrated care site, I have come to value the benefits that such wraparound services offer.

I now have the opportunity to consult with primary care providers, medication-assisted treatment providers, dentists, early childhood behavioral health providers and our county’s Women, Infants and Children team about their perspectives and hopes for clients. Every client has a treatment team, and each team member is only a few feet from my office door. I quickly realized the significant positive impact that close-quarters interdisciplinary collaboration has for many clients, and particularly those receiving medication-assisted treatment (MAT) and counseling services for substance use disorders.

MAT is a treatment model that lends itself to the integrated care setting. As described by the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT is the use of prescribed medications with concurrent counseling and behavioral therapies to treat substance use disorders. MAT is used in the treatment of opioid, alcohol and tobacco use disorders. The medications, which are approved by the Food and Drug Administration, normalize brain chemistry to relieve withdrawal symptoms and reduce cravings. MAT is not the substitution of one drug for another. When medications in MAT are used appropriately, they have no adverse effects on a person’s mental or physical functioning.

Medications used in MAT for alcohol use disorder include disulfiram, acamprosate and naltrexone. Those used for tobacco use disorders include bupropion, varenicline and over-the-counter nicotine replacement therapies. Medications used in MAT for opioid use disorders include methadone, buprenorphine and naltrexone — each of which must be dispensed through a SAMHSA-certified provider. Naltrexone is the only medication of the three that does not have the potential to be abused. Federal law mandates that those receiving MAT for opioid use disorder also receive concurrent counseling.

Embracing the advantages of integrated care

The combination of medication and therapy offers a holistic approach to treatment that is easily implemented in integrated care settings. The hope offered by the integration of services is embodied in an extraordinary case involving one of my clients who relapsed and arrived to counseling intoxicated, holding their chest. I was able to immediately consult with the client’s MAT provider, who ruled out the physical causes of chest pain after performing an electrocardiogram. Within 30 minutes, I was able to proceed with de-escalation of the client’s panic attack. The MAT provider educated the client on the next steps for care and on the dangers of using substances while taking MAT medications.

In a nonintegrated site, my only recourse would have been calling an ambulance for the client and a long wait at the hospital emergency room — and possibly a client who discontinued services. It is heartening when I can instead walk a client with symptoms of withdrawal across the hallway to the MAT provider or primary care provider, who can in turn offer targeted expert medical advice and medications to alleviate the symptoms.

Despite the substantial advantages that integrated care offers, however, most mental health and chemical dependency counselors are not adequately trained to provide effective counseling in integrated care settings for substance use disorders. In my experience, clients have better outcomes when receiving counseling services in conjunction with MAT. MAT alone can be effective, but the underlying thoughts and emotions that perpetuate use are not addressed unless concurrent counseling services are offered.

According to SAMHSA’s Treatment Improvement Protocol (TIP) No. 43, counseling for clients in MAT programs:

  • Provides support and guidance
  • Assists with compliance in using medications in MAT appropriately
  • Offers the opportunity to identify additional areas of need
  • May assist with retention in MAT programs
  • Offers motivation to clients

Although individual counseling is valuable, I am focusing on group counseling in this article because it offers similar benefits to individual counseling and is typically more cost-effective. In addition, TIP No. 43 notes that group counseling in MAT programs reduces feelings of isolation, involves feedback and accountability from peers, and enhances social skills training.

Resources for group counseling with MAT clients, or group counseling in integrated care settings, may not be easily accessible to many counselors-in-training or to practicing counselors. My goal is to share tips and resources with mental health and chemical dependency counselors that may be helpful in enhancing group counseling services for clients receiving MAT in integrated care settings. These tips and resources may also be useful to those providing group counseling services to MAT clients in settings that do not offer integrated care.

Tips and resources

1) Holistic education: MAT and integrated care are relatively new concepts for counselors, and we are still adapting. If it is new for us, it is new for our clients too. In the initial sessions of psychoeducational or process groups, the inclusion of education about MAT, the benefits of counseling in conjunction with MAT, and treatment in integrated care settings is essential.

Having access to a range of service providers is a benefit that clients should understand and utilize. Treatment team members can speak to the group about their role in client care and how their role may relate to the counseling group. For example, a dentist might help with appearance and self-esteem issues; an early childhood care provider might help the children of clients process situations arising from parental drug use; a primary care or MAT provider might link the client with hepatitis C treatment in addition to MAT. Such education can answer many questions that the group may have and help clients benefit from quality holistic care.

2) Dual licensure and continuing education: Many chemical dependency counselors refer out to mental health counselors and vice versa. In integrated care, it is ideal for counselors to be dually licensed. Dual licensure and training can assist counselors in identifying and addressing a variety of dynamics that may arise in group counseling with MAT clients.

For example, one client might have major depressive disorder and be using MAT for alcohol recovery, whereas another client might have symptoms of mania and be receiving MAT for opioid recovery. The way that counselors assist these clients may differ based on their knowledge of mental health diagnoses and the substance being used. Furthermore, counselors who are knowledgeable about these differing yet comorbid disorders will be better equipped to provide education to the group about the individualized and shared experiences of each member in recovery.

Some states have a combined mental health and chemical dependency counseling licensure board, whereas others have separate licensing boards. For more information about licensure, contact your state boards. If dual licensure is not plausible or desirable, I strongly recommended seeking continuing education in both mental health and chemical dependency counseling, as well as their relation to MAT.

3) Cognitive behavior therapy (CBT) and solution-focused brief therapy (SFBT) techniques: According to SAMHSA’s webpage about medication and counseling treatment, by definition, MAT includes counseling and behavioral strategies. The combination of MAT with these strategies can successfully treat substance use disorders.

One of SAMHSA’s recommended therapies is CBT, an evidence-based practice that has been shown time and time again to be effective in the treatment of substance use disorders. In an extensive review of the literature about the efficacy of using CBT for substance use disorders, R. Kathryn McHugh, Bridget A. Hearon and Michael W. Otto (2010) outlined a variety of interventions shown to be effective in addressing substance use disorders in both individual and group counseling. Those interventions included motivational interviewing, contingency management, relapse prevention interventions and combined treatment strategies.

Combined treatment refers to the use of CBT alongside pharmacotherapy, which includes MAT. Although some studies the authors reviewed indicated that MAT alone could be effective in treating substance use disorders, others demonstrated that combined treatment was most effective. Given SAMHSA’s recommendation, the literature review and my own personal experience, I believe that CBT may best benefit a group of MAT clients with substance use disorders in an integrated care setting.

Although CBT is suitable, I have learned that integrated care sites are much more fast-paced than the typical behavioral health counseling agency. Primary care and MAT appointments are as short as 15 minutes. In my work with our on-site behavioral health consultant, I noticed her quick and effective use of SFBT with individual clients. Although there is some research discussing the use and efficacy of SFBT in the treatment of substance use disorders, there is little information about using SFBT in groups with MAT clients in integrated care. This is a much-needed area for future research.

4) SAMHSA: SAMHSA has been mentioned various times throughout this article. That is a tribute to the value I place on the agency’s importance and usefulness. SAMHSA, in my opinion, is the best resource for exploring ways to enhance groups for clients receiving MAT. SAMHSA offers educational resources about a variety of substance use disorders; forms of MAT for different substances; comorbidities; and evidence-based behavioral health practices. SAMHSA is up to date, provides a variety of free resources for counselors and other professionals, and also has information about integrated care for professionals and clients.

According to SAMHSA’s TIP No. 43, groups commonly used with MAT clients include psychoeducational, skill development, cognitive behavioral and support groups. Suggested topics for individual counseling with MAT clients, which easily can be translated to group format, include feelings about coping with cravings and a changing lifestyle; how to identify and manage emergencies; creating reasonable goals; reviewing goal progress; processing legal concerns and how to report a problem; and exploring family concerns. Visit SAMHSA’s website (samhsa.gov) to enter a world of helpful information and resources for both personal professional development and client development.

5) Professional counseling organizations: Whereas SAMHSA offers information about substance use disorders, comorbidities, MAT, and individual and group counseling, the counseling profession’s codes of ethics and practice documents are crucial to the ethical provision of group counseling in this challenging field. Among the resources to consider are the 2014 ACA Code of Ethics, the Association for Specialists in Group Work (ASGW) Best Practice Guidelines (which clarify application of the ACA Code of Ethics to the field of group work) and the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling’s (ALGBTIC’s) competencies for providing group counseling to LGBT clients. ASGW also has practical resources to augment your group counseling skills through its Group Work Experts Share Their Favorite Activities series. Combining these resources with information acquired from SAMHSA and the tips in this article should prove helpful in designing and running effective groups for clients in MAT in integrated care settings.

Conclusion

As integrated care becomes more widespread, counselors must adapt their practice of counseling to the environment and to the full range of client needs. It is a counselor’s duty to utilize the benefits that integrated care has to offer, such as immediate and continual collaboration with treatment team members.

For clients in MAT, group counseling in integrated care can provide a multitude of benefits, including the opportunity to learn from each treatment team member, the opportunity to build community in the journey to recovery and accountability. To enhance group counseling in these settings, counselors might consider:

  • Including education from each service provider in the early stages of the group
  • Seeking dual licensure or relevant continuing education opportunities
  • Implementing theories that are suitable for the client issue and the setting
  • Using resources made available by SAMHSA and professional counseling organization such as ACA, ASGW and ALGBTIC

Implementing these tips and resources will result in a fresh and efficient group counseling experience for clients in MAT in integrated care settings.

 

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Stephanie Maccombs is a second-year doctoral student in the counselor education and supervision program at Ohio University. She is a licensed professional counselor and chemical dependency counselor assistant in Ohio. She has worked as a home-based addiction counselor and currently works in a federally qualified health center providing mental health and chemical dependency counseling services to adults participating in medication-assisted treatment. Contact her at sm846811@ohio.edu.

 

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Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Integrated interventions

By Laurie Meyers May 25, 2018

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W hen people think about integrated care, they may imagine a mental health care professional (or two) working in the same building with a physician or other medical professional and following a mutual agreement to refer cases to one another as needed. Others might picture a specialized setting, such as a pain clinic or cancer treatment center, where mental and emotional health concerns are addressed in relation to the medical or physical issue. However, multidisciplinary integrated care teams can now be found in hospitals, outpatient medical centers and community mental health clinics. Professional counselors who operate in these settings say that working in concert with other medical, mental and physical health professionals is the best way to provide clients with whole-person care.

Integrated care facilities are often in medical settings such as primary care clinics, but this doesn’t have to be the rule. Sherry Shamblin is chief of behavioral health operations for Hopewell Health Centers, a group of nonprofit community primary care and behavioral health clinics with 16 locations in southeast Ohio. She helped to develop a system that features primary care facilities in which counselors can conduct brief behavioral interventions and centers that focus principally on mental health but also offer primary care resources.

Shamblin’s thinking is that clients who already are struggling to manage serious mental health issues are often too overwhelmed to seek medical care. “If you’re depressed, you don’t really take care of yourself,” says Shamblin, a licensed professional clinical counselor with supervision designation. “You’re not valuing self-care and taking care of your [physical] health.” In addition, many psychotropic medications have side effects such as weight gain, which can increase clients’ chances of developing diabetes and other chronic illnesses, she notes.

“When you physically feel better, your mood improves, your energy is better, [you] feel more like tackling things that seem overwhelming and your overall coping improves,” says Shamblin, a member of the American Counseling Association. “Although mental and physical [health] have been separated for a long time … [the division] is artificial. It’s all connected.”

Counselors at the mental health clinics ask clients at intake whether they have a primary care physician and, if so, who that person is and when the last time was that the client saw their physician. Counselors will also try to get clients’ permission to access their medical records. That way, counselors can work with clients’ physicians to help ensure that clients are getting the health care they need, Shamblin explains.

If mental health clients don’t have a primary care physician or only go when they are feeling really ill, the counselor talks to them about health and wellness and the importance of receiving regular checkups. “We try to help them view it [regular health care] as another component of staying well,” Shamblin says.

If Hopewell Health Centers’ clients don’t have a primary care physician but would like to start taking better care of their health, they don’t have far to go — the mental health care facilities have exam rooms and primary care providers on-site. Having these resources readily available not only makes it easier for clients to access health care but also allows them to receive it in a setting in which they already feel comfortable, Shamblin says. The counselor (or other mental health professional) and onsite primary care provider then become a team dedicated to maintaining the client’s physical and mental health.

In Hopewell Health’s primary care clinics, counselors (who are called behavioral health consultants, or BHCs) play several roles. In some cases, the BHC is brought in to help the client manage a chronic illness. For example, Shamblin says, a primary care physician might see someone whose diabetes or high blood pressure is not under control despite treatment. This would provide an opportunity for the physician or nurse to explain that they have a colleague on the team who might be able to help the patient with this struggle. They would then ask if the patient would like to meet with the BHC.

The BHC would then try to determine the factors that are keeping the patient from progressing. For instance, is the person not taking medicine consistently or not watching their diet? If treatment adherence is a problem, the BHC assesses whether patients are ready to change their behavior and, if so, works with them to set goals and offers ongoing support. If patients are not open to making a change in a particular lifestyle area — such as diet, for example — the BHC would work with them to identify another positive lifestyle change they could make, such as stopping smoking or getting more exercise, Shamblin explains.

In other cases, the BHCs working in the primary care clinics conduct brief interventions with patients. The primary care physicians screen patients by asking questions that assess for signs of depression or substance abuse. If the physicians get an answer that concerns them — perhaps a patient saying that they have been feeling overwhelmed or depressed, for example — they ask the patient whether they can bring in someone who might be helpful, Shamblin says. The BHC will then ask brief questions to help determine whether the patient needs intervention.

Sometimes patients feel better just being given the opportunity to have a short conversation about their worries, Shamblin says. In such cases, the BHC will ask if it is OK to check in with the patient the next time the person returns to the clinic. In some cases, the BHC will ask the patient to come back for a few brief counseling sessions. In other instances, the BHC determines that patients need more intensive mental health care and will refer them to the clinic’s mental health professionals who oversee long-term care, Shamblin explains. The BHC then becomes the liaison between the primary care and mental health providers and will check in with the patient periodically to see how the person is doing, she says.

Hopewell Health Centers was created in 2013 when two organizations, Family Healthcare Inc. and Tri-County Mental Health and Counseling Services Inc., merged in order to provide integrated care. Shamblin notes that the frequency of Hopewell Health Centers’ screenings and treatment of substance abuse has gone up with the introduction of the integrated care model. Some data have suggested that the area of Ohio where the clinics operate has the lowest depression rates in the state, she says.

Leading the way in integration

Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, is a leader in hospital and outpatient integrated care. Just ask ACA member Laura Veach, who explains that the Wake Forest system has moved beyond the concept of integrated medicine being simply “co-located” care. In fact, the system is so integrated that Veach, a counselor educator, is a full professor in the Department of Surgery in the Wake Forest School of Medicine, a position that Veach thinks may be unique. Veach is also the director of counselor training at Wake Forest Baptist Medical Center. Though affiliated with Wake Forest University, the center also works with other counselor educator programs.

Veach has played a crucial role in the medical center’s emphasis on integrated care. She says she feels particularly fortunate because she works with a group of surgeons “who get it and want the best for patients.”

“We [counselors] are embedded in the medical team,” Veach explains. “We started in surgery in the specialty of trauma surgery and began to test the feasibility of doing counseling and screening and intervention at the bedside and [then] became a training site. Now we include posttraumatic stress disorder [PTSD] intervention work, crisis intervention and grief and loss work with trauma patients who have suffered the loss of a loved one in a trauma incident that brought them to the hospital. That led to the pediatric trauma unit, where we work with families of children who are traumatically injured, as well as the children themselves.”

Counselors are also part of integrated care efforts in the facility’s burn center, which is one of the only certified burn centers in North Carolina. Those efforts include providing ongoing counseling sessions in the burn intensive care unit and the step-down unit. Wake Forest Baptist Medical Center has also expanded integrated care into medical inpatient units, where people come in for issues such as pancreatitis, infections, pneumonia and so on.

Wake Forest Baptist Medical Center has a system that scans medical records to help identify patients who might need counseling help. For instance, when patients come through the emergency room, nurses ask them about depression, anxiety, suicidal thinking or past suicidal behavior. Other patients may receive bloodwork that shows elevated blood alcohol content or urine drug screens. Veach emphasizes that these are not for legal use but to help the medical center provide better integrated care. Some people may have elevated liver enzymes, which can be a sign of alcohol abuse, she continues. The medical records also include the physician’s account of what the patient’s complaint is. The chart-scanning system analyzes all of this information to help identify and prioritize who the counselors and other mental health professionals on staff should see first, she says.

Counselors introduce themselves as part of the team to patients and let them know that they are there to support the patients’ recovery and health. They then ask if the patients are open to the counselor spending some time with them. The counselors are rarely turned away, according to Veach.

After reviewing informed consent and confidentiality policies with each patient, the counselors simply listen, Veach emphasizes. “We try to just be present with them, to not ask questions, to hear what they are struggling with,” she says.

Veach notes that most of the medical center’s patients have never been to see a counselor before. So the counselors and counseling graduate students who work on the integrated teams at Wake Forest Baptist Medical Center are essentially educating these individuals about what counseling can provide. They tell patients they are prepared to listen to whatever the patients most want to talk about or need help with.

“What we find most often is that people have a lot to share,” Veach says. “We’re not someone who’s coming to do something to them; we’re someone who is coming to be with them. They might say, ‘I really want to talk to my family about this, but they’ll worry.’ A counselor or addictions specialist can be there and not be judgmental.”

In the medical center’s trauma and burn units, counselors stay on the alert for signs of acute stress or PTSD in patients, Veach says. After being released from the medical center, patients return for medical follow-up visits for the next six months, and counselors continue to check in and evaluate their recovery during this time. In certain cases, the counselors set up extended mental health therapy sessions with patients (scheduled adjacent to their medical visits) or recommend that they see a trauma specialist, such as someone trained in administering eye movement desensitization and reprocessing therapy.

When Veach first started working in integrated care, it was common for surgeons to state that they didn’t need or want to know about patients’ emotional issues — they just needed to know how to repair individuals surgically. “In the past decade, we’ve seen a big shift to asking how do we more fully treat this person to help them have a better chance of healing and without experiencing more trauma,” Veach says. “I think more trauma surgeons [today] know that if we don’t address [these emotional issues] now, we’re going to see them here again.”

Many people undergoing medical treatment aren’t aware of the types of issues that counseling or addictions treatment can help them address, or they don’t know how to access those services themselves, so having counselors as part of the team at Wake Forest Baptist Medical Center is particularly valuable, Veach says. Counselors on staff can make recommendations and point patients toward other resources. For instance, Veach says, families may have been struggling for years to get a loved one into treatment for substance use; counselors on staff at the medical center can offer information on which addictions centers in the area offer family support.

In the trauma and intensive care units, the teams offer dedicated support time for families two days per week. Counselors are on hand during these times to offer snacks and encouragement, Veach says. The integration of mental health into the hospital also extends to support groups, including a weekly trauma survivors’ network, a family member support group and a peer-led burn survivors group, she adds.

Veach has been helping to implement brief intervention counseling services at Wake Forest Baptist Medical Center for a decade. As counseling services have expanded to be included in more and more of the center’s departments, she has been surprised at how receptive medical patients are to counseling. She says she has witnessed “a deeply heartfelt responsiveness” on the part of patients to being heard and understood. In addition, surgeons have begun to tell Veach how valuable counselors are to the team. They tell her they are heartened to see patients getting care from counselors that they, as surgeons, can’t provide themselves.

Putting people first

Marcia Huston McCall, a national certified counselor and doctoral student in counseling and counselor education at the University of North Carolina at Greensboro (UNCG), spent several decades in health care management before becoming a counselor. She worked in the finance department at Massachusetts General Hospital and then became the business director of several different departments in an academic medical center in Winston-Salem, North Carolina.

McCall, an ACA member, says she went into health care management as a means of helping patients. She thought her business acumen was her strongest skill set and her best way of contributing. Over time, however, she became convinced that the business side of health care was moving farther and farther away from helping patients. “Health care management got so corporate,” she says. “I felt separated from the patients, and I wanted to have that contact.”

McCall realized that the people part of her job was what she loved best and decided that a career shift into counseling would be a better fit. She entered the counselor education program at Wake Forest University and completed her practicum and internship hours in inpatient integrated care at Wake Forest Baptist Medical Center. UNCG also has a relationship with Wake Forest Baptist Medical Center, so McCall completed her doctoral internship there and continues to work at the center as a graduate assistant.

McCall has worked in both the outpatient clinic and the inpatient section of the medical center. She says it is crucial for counselors to be full members of the team by participating in rounds and team huddles. “Having the counselor as part of the team when all the patients are being discussed is really important because you’re not only offering perspective but also picking up on things that might be issues,” she says. “They’re talking about patients you might not see [in the outpatient clinic], but you can pick up on patients that you do need to see.”

“In inpatient, we screen patients ourselves, so we review all the new admissions to our floors and identify the patients we think [will] need our services,” says McCall, a member of ACA. If she notices a history of substance abuse or other mental health issues, McCall brings this up before rounds or in the team huddle.

McCall and the other mental health professionals at the medical center conduct brief assessments with patients for signs of substance abuse, depression, anxiety, suicidality and delusions. In some cases, they conduct brief treatment and perhaps even see the patient a few times, depending on the length of stay. McCall also refers patients for further psychiatric or substance abuse care if needed.

Counselors working in integrated care settings frequently need to use their skills to build rapport with patients. For example, a physician might see signs indicating that a patient has possible substance abuse issues and call a counselor in for an assessment. In many cases, patients will not have sought treatment for substance abuse previously and may have avoided acknowledging that they have a problem.

“We’re walking in, and they may not be very interested in talking about their substance issues, particularly with a stranger,” McCall says. “We have to approach resistant patients in an indirect way and try to understand what their issues are and what they want to do about them,” she explains.

In such instances, McCall says that she rolls with the resistance. Friends and family members have likely been asking these individuals to seek help, but the patients haven’t been ready to acknowledge that they need treatment. McCall validates their resistance by verbalizing the arguments they are making against getting help. She says these patients often respond to her validation by saying, “Yeah, but I really do need help.” She then asks them what they are willing to do to get that care. If these patients voice a desire to pursue substance abuse treatment, counselors at the medical center connect them with specialty resources outside of the inpatient or clinic setting.

“We help them find that treatment and do as much as possible to ensure they actually get there — that everything is set up,” McCall says.

Counselors serve as consultants for the medical team at Wake Forest Baptist Medical Center but also act as advocates for the patients, McCall says. A lot of bias still exists among medical personnel about mental health issues, she explains, so counselors are there to help ensure that patients are seen as human beings who have needs, no matter what they have been through.

Counselors may also get called in when a physician is questioning whether a patient might need psychiatric services. The medical center doesn’t have many psychiatrists on staff, so the physicians are hesitant to call them for a consultation if there is no need for immediate inpatient treatment, McCall explains.

By working in integrated care, McCall says she gets to be a kind of ambassador for the counseling profession. “I have the opportunity to work not just with physicians and nurses, but residents, medical students, pharmacy students and physician assistant students,” she says. “[I] really have the opportunity to interact with people who aren’t used to having counselors as part of the team.”

McCall would like to bring even more of the counseling perspective into integrated care. She contends that “behavioral health” is too narrow of a designation and believes that counselors should define their own roles and use terminology that is more appropriate to the counseling profession. McCall says she wants her team, as well as other medical personnel working in different integrated care settings, to be aware that professional counselors are not just behaviorists but also possess many other skills. For example, McCall envisions counselors having a central role to play in helping patients who have gotten a shocking diagnosis or who are struggling with the inherent vulnerability of being in the hospital.

McCall also cautions counselors entering the field to be aware that supervision in integrated care settings is rarely provided by other counseling professionals. It is vital for counselors to maintain their professional identity while operating within integrated care, she emphasizes, even if that means pursuing additional supervision outside of the integrated care setting. Receiving ongoing supervision when working in integrated care is critical because the work can be intense and overwhelming, McCall says. Peer support and supervision can help counselors deal with stress and avoid burnout, she concludes.

Training students in integrated care

Some counseling students interested in integrated care are adding medical knowledge to their counseling skills. Rachel Levy-Bell, assistant professor of psychiatry and associate program director and director of clinical training in the mental health counseling and behavioral medicine program at Boston University School of Medicine (BUSM), teaches and trains counseling students to work in integrated care. The program at BUSM focuses not just on counseling but also behavioral medicine, so students take integrated care courses, learn about psychopharmacology and human sexuality, and get bedside training in getting to know the patient beyond the disease, says Levy-Bell, a member of ACA. She supervises practicum and internship students working in Boston University-affiliated clinics and other Boston community centers.

As part of practicum, Levy-Bell trains small groups of counseling students to conduct biopsychosocial interviews. Each week, the 10-member group receives a list of patients and their medical issues. As the counseling students visit the patients, they take turns being the lead interviewer. Students ask patients about what brought them to the hospital and deduce whether they fully understand their condition and how their disease affects their lifestyle, relationships and work. They also ask how patients physically manage their disease, how they cope with its demands and whether spirituality or religion plays a role for them. They also assess for substance abuse.

At the end of the interview, Levy-Bell asks the patients how they felt the students performed. Many patients share that they like that the students spent more time with them than the medical personnel typically do and also comment that the students are better at maintaining eye contact with them when talking and listening. Afterward, the group goes back to class to evaluate and discuss the interviews: What went right? What do they need to improve? What did they learn?

Part of the training process is getting counseling students used to working in medical settings and grappling with issues such as how to build therapeutic rapport when the patient has a roommate or when medical equipment is everywhere and beeping noises are constant, Levy-Bell says. Students are also exposed to things that they’ve never seen before. These experiences might make them uncomfortable, but they have to learn to control both their verbal and nonverbal reactions to ensure that they aren’t indicating discomfort, she says. Levy-Bell also focuses on practical aspects such as teaching students not to faint — or, at a minimum, fainting away from the patient. She also teaches students to wear light clothing (hospitals are hot), to stay hydrated, to make sure they eat and to take a break if they feel unsteady — but to always come back.

Sara Bailey, an ACA member who works at Wake Forest Baptist Medical Center as part of her postdoctoral fellowship, says that regardless of whether counselors plan to go into integrated care, working in a behavioral health setting provides excellent training. In integrated care, counselors-in-training get the chance to see how other professionals such as doctors, nurses and other mental health practitioners work and handle challenges, she says. They also quickly become aware that all practitioners encounter individuals with alcohol or substance abuse problems.

“In a perfect world, this would be required,” Bailey says. “You get to hone your reflection and rapport-building skills and have to learn to do your best in a short amount of time.”

 

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Podcasts (counseling.org/knowledge-center/podcasts)

  • “Integrated Care: Applying Theory to Practice” with Russ Curtis & Eric Christian (HT030)

ACA Interest networks (counseling.org/aca-community/aca-groups/interest-networks)

  • ACA Interest Network for Integrated Care

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.