Tag Archives: interdisciplinary

Rebuilding after brain injury

By Bethany Bray May 31, 2022

“I just want to feel useful again, like I have some purpose.”

“I just want to know is there anything I can do?”

“I just want to know I’m not going crazy.”

“I want to be happy again, have friends again and feel satisfied in relationships.”

These are among the heartbreaking responses Herman Lukow, a licensed professional counselor (LPC) and licensed marriage and family therapist, receives from clients who have experienced a traumatic brain injury (TBI) when he asks what they want and need from counseling.

Individuals who have experienced a TBI often find themselves facing change and challenge in nearly every aspect of life. Depending on the severity of the injury and their recovery trajectory, TBI survivors can experience memory loss, personality changes and difficulty with language, comprehension, impulsivity, anger and decision-making. This is in addition to physical issues such as having challenges with balance, coordination and mobility. Individuals with a TBI may no longer be able to work in the field or job they once had. They may lose the independence to do things such as drive a car, and their friends and loved ones may struggle — or even give up on — maintaining a relationship with this new, changed person.

These clients might come to counseling after experiencing a hospitalization and lengthy rehabilitation process involving countless appointments with a variety of medical specialists. Brain injury survivors “are so steeped in the medical environment,” Lukow says, that they’re used to practitioners telling them what to do. Professional counselors can be the first to flip that narrative and ask the client what they want and need.

Lukow, who spent three years as a postdoctoral fellow researching TBI at Virginia Commonwealth University’s (VCU’s) Traumatic Brain Injury Model System program, says he has had clients break down in tears because he was the first professional to ask them about their wants and needs since their injury.

A professional counselor can be the one to “honor what they want and empathize with them and help them understand this huge shift in their life that has occurred in a blink of an eye,” Lukow says. “This work takes a lot of patience, a lot of reframing. But some of my most appreciative clients have been TBI survivors.” In counseling, “they’ve finally found someone who doesn’t make them feel like a burden or judged.”

A difficult road

The Centers for Disease Control and Prevention estimates that on any given day, roughly 176 people die and 611 people are hospitalized in the United States because of a TBI.

The Brain Injury Association of America (biausa.org) defines TBI as an “alteration in brain function, or other evidence of brain pathology, caused by an external force.” One of the most common causes is falls, but TBI can also result from motor vehicle accidents, sports/recreation or workplace injuries, child abuse or intimate partner violence, blast injuries during war or disaster, or acts of violence such as assault or gunshot wounds. Nontraumatic (or acquired) brain injury can occur from a stroke, seizure, meningitis, lack of oxygen, exposure to toxins, pressure from a tumor, drug overdose and other scenarios.

Research suggests that certain populations are more likely to be affected by TBI, including veterans and members of the military, racial and ethnic minorities, survivors of intimate partner violence, those who live in rural areas and people who have experienced incarceration or homelessness. According to a recent article published in JAMA Network Open, it’s estimated that between 9% and 28% of U.S. soldiers who served in the conflicts in Iraq and Afghanistan experienced a TBI.

Not only do the causes and severity of brain injury vary, but each survivor will also have a different recovery trajectory and array of symptoms depending on which areas of the brain were affected, the person’s age, the support and treatment they received during recovery, and numerous other factors.

TBI “is anything but cookie-cutter,” stresses Michelle Bradham-Cousar, a licensed mental health counselor and certified rehabilitation counselor who recently completed a doctoral dissertation on counseling clients with TBI.

Not only will these clients’ needs and presenting concerns differ, but their therapeutic expectations, outcomes and what can be counted as “successes” will also vary, says Bradham-Cousar, who has a private counseling practice in Tampa, Florida. For one client, success may be returning to work full time; for another, it may be learning to calm down to keep from getting into fights with other residents of their group home (as was the case for one of Bradham-Cousar’s TBI clients).

“Success needs to be measured differently for each client — and it won’t look the same as your last client” with TBI, she emphasizes.

Lukow agrees, noting that benchmarks or signs that counselors may associate with improvement or growth in their other clients may not be apparent — or appropriate — with clients who have experienced a brain injury. Also, what might seem to be resistant behavior in this client population is often not intentional, he stresses. They may miss sessions or be hard to contact, but this is more likely to be caused by the memory and cognitive challenges they live with (e.g., confusing what day it is) rather than resistance.

Bounce forward

People who have experienced a brain injury will often hear well-meaning friends, family members, caregivers and even medical and other practitioners reference “bouncing back” when talking about their recovery. Lukow urges counselors to avoid using the phrase “bounce back” with these clients because there is no way for them to fully return to the life they had before their brain injury. Not only is such language unhelpful, but it can also give the recipient a sense of false hope.

Lukow instead uses the phrase “bounce forward” with his TBI clients. “In many cases, they can’t go back; they can only bounce forward,” says Lukow, who lives in Tennessee and works remotely as a staff counselor at a private practice in Williamsburg, Virginia.

Although these clients can’t go back to the way things were prior to their injury, they can work to move forward and make the most of their life with impairments through the support they receive and the skills they learn in counseling, Lukow says.

And these clients don’t always want or need encouragement, Lukow adds. At times, TBI clients may feel that the work they’re doing in counseling sessions only emphasizes what they have lost.

“Don’t always be a cheerleader,” Lukow urges. “Sometimes they don’t need to hear ‘that’s alright, you’ll get through it’ [from a counselor], but instead, ‘that really sucks.’”

Lukow specializes in counseling clients who have experienced TBI. He estimates that 10% to 20% of his current client caseload is recovering from a brain injury. During his time as a researcher at VCU, he developed resilience-based interventions for mental health practitioners to use with couples and individuals after a TBI.

It’s not uncommon for individuals recovering from a brain injury to be told by medical personnel, rehabilitation specialists and others that recovery ceases after a few years. An often-repeated message is that the only gains a person will make after a TBI are those made in the first two years, he says.

Although that may be true for some of the physical aspects of TBI recovery, growth and progress in other arenas — especially the emotional and psychological aspects — can continue for years and even decades, Lukow says. He has seen TBI clients make strides many years after their injury, especially in coming to accept that they may never get some of their abilities back and will need to rely on aids, such as memory reminders, for the rest of their life. Learning and growth can also happen years later for clients related to their social skills and in responding to awkward questions and assumptions made by others. (Lukow explains that these situations occur because TBI is often an “invisible” injury and people misjudge or misunderstand the actions or challenges of survivors because they don’t look disabled.)

Hillel Goldstein, an LPC with a private counseling practice embedded within the Brain Injury Foundation of St. Louis, agrees that recovery can occur long after the period of intensive treatment TBI survivors receive immediately after their injury. Goldstein once counseled a client who developed aphasia (language difficulty) after a TBI. This client, with the help of a speech therapist, was still relearning and mastering new words 10 years after his injury, Goldstein recalls.

“The good news is that brain plasticity is much better than we once thought it was,” Goldstein says. “But people are still told that they have a year to improve or a limited time.”

Asking the right questions

Individuals can experience an array of symptoms and difficulties after a brain injury that dovetail with mental health or the client’s presenting concern in a wide variety of ways. Because brain injury varies from person to person and there is no one concise set of symptoms, professional counselors must know some of the more common symptoms (e.g., memory loss) and — perhaps, more importantly — how to ascertain whether a client may have experienced a brain injury in the past.

Brain injury is nuanced and complicated, and there is a good deal of misunderstanding about it among the general population, Lukow asserts. Clients may come into counseling without realizing that their presenting concern (such as trouble maintaining relationships) could be tied to an unacknowledged brain injury or one that happened in the past.

Lukow points out that a person wouldn’t necessarily have needed to be hospitalized or even received a blow to the head for a brain injury to have serious consequences. A car accident, for example, can cause a person’s head to move so forcefully that the brain impacts against the skull without the head touching any part of the car.

Or clients may not realize that brain injury can be cumulative (e.g., “I had a few concussions back when I played lacrosse …”) and affect them later in life, Lukow says. He advises counselors to ask clients not only if they have had any brain injuries but also whether they have experienced any related issues such as a loss of consciousness, cognitive difficulty, a head or sports injury, or a fall.

Bradham-Cousar, a clinical assistant professor in the Department of Counseling, Recreation and School Psychology at Florida International University, urges counselors to listen for client language that may indicate they have had head trauma, including phrases such as “concussion,” “woke up a little while later,” “unconscious,” “got stitches,” “car accident” and “slipped and fell.”

Past brain injury can cause behavior and other deficiencies that are hard to pinpoint or connect to a diagnosis or for which psychiatric medicine doesn’t seem to help. Bradham-Cousar  provides examples such as a person who has trouble understanding social cues but does not have autism spectrum disorder, someone who has reading difficulties but does not have a learning disorder, and someone who struggles with attention span and focus but does not have attention-deficit/hyperactivity disorder. In other examples, an individual may struggle with anger, self-control, problem-solving, object recognition or articulating what they’re trying to say and not realize that a past brain injury could be the root cause, she adds.

Goldstein advises counselors not to overlook issues that the client feels are “minor,” such as a concussion, because these could be contributing to their mental health challenges. Counselors should also be aware that in some cases, TBI can cause violent behavior or the urge to self-medicate with alcohol or other substances. So, Goldstein says, practitioners need to be comfortable screening for substance use and be familiar with the reporting protocol for their state in case a client discloses violent behavior (including when the client is a spouse or a family member of a TBI survivor).

TBI survivors sometimes turn to alcohol or other substances to temporarily escape or “slow down” from impulsivity and other challenges, Goldstein notes. However, “one drink for someone with TBI is not the same as it is for someone without [a brain injury]. Their symptoms will be amplified by any substance use, including alcohol,” he explains. “Brain injury and substance use don’t mix. It’s one of the worst things they can do to themselves, but it’s commonly seen among those with TBI.”

Complicating factors

The counselors interviewed for this article note that TBI can co-occur with common challenges that bring clients into counseling, most notably depression, anxiety and issues that correspond with loss and relationship problems. And sometimes there can be a chicken-and-egg debate about which of these issues came first, which adds a layer of complication for practitioners trying to assess and plan treatment for a TBI survivor in counseling.

For example, isolation, loneliness, and a loss of meaning and purpose — the classic markers for depression — are common after TBI and the related challenges that come with it, Lukow says. 

In these situations, Bradham-Cousar notes that depression is often a secondary diagnosis to a client’s TBI that becomes co-occurring.

At the same time, it’s not uncommon for TBI survivors to be misdiagnosed with a mental illness because some post-injury symptoms can mimic those associated with other disorders, Goldstein adds. Brain injury can cause people to experience hallucinations, hear voices or have severe personality changes, impulse control problems and erratic moods that can resemble mania. This can lead to diagnoses such as personality disorders, psychosis, bipolar disorder or even antisocial personality disorder, Goldstein says.

“I call it [TBI] the great imposter,” Goldstein says. “Mental health [symptoms] are only part of the story. Sometimes it’s the tip of the iceberg, and sometimes it’s not at all what’s going on.”

Because of this, Goldstein recommends that counselors begin work with each client by first ruling out brain injury as the root cause of their mental health challenges. He stresses not to automatically assume that a client’s symptoms are psychiatric in origin. When it comes to mental health diagnoses and TBI clients, false negatives and false positives are very common, he says.

This challenge can be compounded when a client doesn’t recognize or disclose that they’ve had a brain injury (e.g., a concussion that they weren’t hospitalized for), Goldstein says. It’s also likely that the practitioner who referred a client to counseling — whether a medical or mental health professional — hasn’t ruled out TBI as the root of the individual’s symptoms because the connection between brain injury and mental health is simply not on the radar of most professionals.

“Even if a client has a big fat DSM diagnosis, don’t assume, and keep an open mind,” Goldstein says. “I implore [counselors] to rule out brain injury, and even if you think you’ve ruled it out, revisit it. Don’t assume the person that you’re seeing, no matter how they were referred, has a mental health diagnosis.”

Goldstein recommends that in addition to conducting a thorough intake process, counselors screen clients for brain injury by asking for access to their medical records and the ability to confer with the other professionals they are being treated by, such as a neurologist.

“Keep your mind open, and consult, consult, consult with people who are experts in areas that can help you tease apart where these symptoms are coming from,” Goldstein says. “Don’t assume that what you’re seeing is due to a mental health disorder. Your default should be that their brain has been injured.”

Helping clients adjust to loss and change

The crux of what many clients who have experienced a brain injury need in counseling is help adjusting to change and processing loss. Most professional counselors already have an array of tools that can help in this realm, from coping mechanisms and goal setting to the therapeutic relationship itself. 

“Often, they need [empathic] listening from a counselor and a large amount of time just to talk about their situation, what they need and what they’re struggling with,” Lukow says.

Any counseling technique or method that builds coping skills or helps clients deal with life changes and loss would be appropriate and helpful to use with clients who have experienced TBI, Lukow notes. This population may also need grief counseling and help with managing emotions and improving communication and social skills. Seemingly small skills, such as being able to politely ask someone to slow down or repeat themselves when they are outpacing the client’s cognition abilities in a conversation, can go a long way to boost the person’s self-esteem, rebuild their relationships and, in turn, reduce isolation, Lukow says.

Stress recognition and management are also important skills for brain injury clients to learn, Lukow adds. Techniques such as diaphragmatic breathing, muscle relaxation, guided imagery and mindfulness, as well as activities such as walking or exercising, painting, coloring, and listening to white noise or ambient sounds, can help these clients learn to calm themselves.

“[Brain injury] survivors are ‘allergic’ to stress,” Lukow says. “When their stress gets worse, their impairments get worse.”

Occasionally involving a client’s spouse, partner or loved ones in individual counseling sessions can also be beneficial for both parties. They provide comfort and moral support to the client in session, Bradham-Cousar explains, and in turn are better able to understand the client’s needs and therapeutic goals. For TBI clients who struggle with memory challenges, having another person in session can also serve to provide them with reminders of what was said and what was assigned as homework.

TBI clients’ loved ones can also benefit from group counseling. The counselors interviewed for this article agree that the supportive environment that group counseling provides can be extremely helpful for this client population and their family/caregivers. (For more on this topic, read the article “Life after traumatic brain injury: Lessons from a support group.”)

Bradham-Cousar specializes in counseling clients who live with disabilities, including cognitive difficulties from a brain injury, stroke or dementia. A large part of what these clients need, she says, is therapeutic work to move them toward acceptance of the change in their lives, including the things they can no longer do. She often uses cognitive behavior therapy and a working

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alliance approach to foster trust with clients who are brain injury survivors and adjust their thought patterns and perspective. Counselors can also help the client see the opportunity to gain new skills; they’re not just losing things but gaining them as well, she says.

Grief counseling and psychoeducation about grief can also help this client population process the many losses they have experienced, including the loss of a part of themselves, Bradham-Cousar adds.

“Counselors can help these [clients] to grow and understand their regenerated self and look at it [through] the eyes of a new opportunity, a new chance. They still have a life to live,” says Bradham-Cousar, a past president of the Florida Counseling Association and the American Rehabilitation Counseling Association. “It’s a transformational process. … They need to move forward to accept that they’re not as they used to be.”

Similarly, Lukow finds that using a solution-focused approach, as well as equipping clients with coping mechanisms and skills that can boost their self-esteem and resiliency, is helpful for clients who have experienced brain injury. For instance, a counselor might suggest that a client who struggles with memory issues set up a “launch pad” — a spot in a visible area of the home, such as a kitchen counter, to keep their keys, wallet and other essential items they need when going out so that they’re less likely to forget or lose them.

Much of this work, Lukow says, is supporting clients as they navigate the learning curve of trying new skills, abandoning things that aren’t working for them and finding solutions and workarounds to live life.

For example, a TBI survivor who is unable to drive may struggle with this loss of independence and feel like a burden for having to ask for rides from others. A counselor can help the client process these feelings so that it’s easier for them to ask for help and find solutions that boost their self-worth.

One such solution could be supporting the client as they learn how to take the bus, Lukow suggests. “Help them find a [bus] schedule and look together, asking, ‘Which stop is closest to your house?’ ‘How much does it cost?’ etc. Something as little as looking up a bus schedule can be a success. And with it, a shift in thinking: ‘Yeah, I can’t drive anymore, but it doesn’t mean I can’t get around.’”

Goldstein notes that motivational interviewing can be useful in helping TBI clients to focus on adjusting to change. Influenced by Irvin Yalom and Viktor Frankl, Goldstein also uses an existential approach to guide clients to make meaning of their new circumstances.

This client population “is searching for new meaning in a hugely altered life. They need to construct new meaning, and it’s sometimes not the meaning that they were hoping to construct,” Goldstein says. “These folks need to adjust to ‘the new me.’ They’re forever changed. As with big changes in our lives that are negative, there’s grief, and if we don’t work through the grief, it metastasizes.”

Language workarounds 

Brain injury often affects a person’s ability to speak. Counselors who work with this population must be knowledgeable of and comfortable using adaptive technology or creative workarounds to communicate with clients who may not be able to respond verbally.

Bradham-Cousar sometimes uses a speech-generating app such as UbiDuo 3 with clients because it allows them to type responses to counseling prompts on a smartphone or other device. She also has an extra keyboard linked to a computer monitor in her counseling office for clients to use to type and display their thoughts during sessions.

Bradham-Cousar suggests that counselors use a collaborative approach by asking clients (during the intake process) to identify adaptive tools or supports they are comfortable using. Counselors can also find information on meeting these clients’ adaptive needs by searching for “brain injury” on the Job Accommodation Network’s website at askjan.org.

In addition to specializing in psychotherapy for brain injury, Goldstein’s subspecialty is helping clients with aphasia. He says that counselors need to be comfortable not only with using different modalities and tools to communicate with TBI clients who struggle with speech but also with long periods of silence in counseling sessions. This can be hard for some practitioners.

Goldstein urges counselors to become sensitive to the wealth of information communicated through a client’s body language and leverage what skills a client does possess. Remember, he says, that these clients have the same range of needs and emotions that verbal clients have; they know what they want to say, but it just won’t come out.

Goldstein sometimes uses a method he calls “facilitated therapy.” He invites another professional who is working with the client (such as a speech and language pathologist) to consult or co-treat with him or come to counseling sessions to serve as a mediator/facilitator until he has forged a bond with the client and learned to “speak their language,” even if it’s nonverbal.

This was the case for one client whose speech was severely limited after his brain injury. However, the client was a gifted artist and would draw pictures during sessions to communicate. When Goldstein began working with this client, he involved the client’s vocational rehabilitation counselor in sessions because she had been working with him for a while and understood the nuances in the way he expressed himself.

“He had his own language,” Goldstein recalls. “He communicated wonderfully; it was just not via speech.”

Once Goldstein established a relationship with this client, they were able to communicate and do one-on-one sessions without the other professional. In addition to drawing and art, the client would play songs he had saved in an extensive library on his phone to express how he was feeling.

Counselors may have to get creative because these clients [can] have speech limitations and cannot do traditional talk therapy,” Goldstein says. “Look for the gifts they have and use it, use it, use it.”

Team approach

Counselors working with clients who have experienced TBI also need to be comfortable reaching out to, consulting with and co-treating with a number of professionals in different fields. Depending on the severity of their injury, TBI survivors may be treated by surgeons, neurologists, speech and language pathologists, occupational and physical therapists, social workers and vocational/career professionals, among others.

Goldstein recommends counselors build connections with a base of these types of professionals in their local area so they can consult and ask questions when facing a challenge or sticking point with a TBI client. When treating clients who have experienced TBI, “don’t fly solo,” Goldstein urges. “In this work, it’s not a two-way street [with other practitioners]; it’s a superhighway.”

The counselors interviewed for this article emphasize that counselors should resist the urge to refer TBI clients to a specialist right away. Counseling this client population can be complicated and challenging and it requires lots of patience, but the empathic listening and supportive relationship that a counselor provides can make a world of difference for these individuals and their families.

Goldstein encourages those counselors who are interested in this client population or who thrive working in multidisciplinary teams to think about specializing in counseling TBI clients. “Brain injury is scary, and it puts a lot of therapists off,” he says. “If you see someone with a brain injury and you’re baffled, pat yourself on the back, because you should be. And if you’re intrigued and interested [in this topic], consider it as a specialty.”

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Contact the counselors interviewed in this article:

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Related reading, from Counseling Today:

 

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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.

Wellness: Aiming for an ever-moving target

By Bethany Bray January 3, 2022

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 shouldnt 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.

Incorporating interprofessional education and practice in counselor development

by Judy Schmidt April 13, 2021

As the complexity of care for people with mental health needs increases, more counselors are serving on interdisciplinary teams responding to the acute and chronic needs of their clients. Many people with serious mental illness may also have co-occurring physical disorders such as cardiovascular disease or nutritional/metabolic diseases (e.g., diabetes, obesity), as reviewed by Mark De Hert and colleagues in 2011. These individuals require increased medical care involving physicians, nurses, dietitians, and radiologic and clinical laboratory specialists. Social work also coordinates care with mental health teams for community resource support and with vocational rehabilitation counselors to assist with employment needs. Thus, counselors’ understanding of the role and function of interprofessional collaboration in providing care is vital for achieving quality outcomes.

As a counselor educator, I strive to create opportunities for students to develop strong communication and leadership skills during their clinical training. When I invite alumni to talk with students about different aspects of building their career, many discuss their work on community-based mental health teams. They explain having to learn to work with people outside the counseling profession — nurses, psychiatrists, physical and occupational therapists, speech therapists, social workers, pharmacists, police officers and others. I began to understand the need for our students to have better skills for team-based care. So, I worked with our faculty to offer more opportunities to expose our students to a wider range of care providers and delved into the research on interprofessional education and practice (IPEP).

During this time, I engaged with faculty from physical and occupational therapy in our Department of Allied Health Sciences who were involved in IPEP. Through them, I started learning more about IPEP in medicine, nursing and other health affairs schools on campus. My personal exposure to interdisciplinary care began in earnest when, as part of my clinical faculty duties, I started working part time as the rehabilitation counselor on the acute inpatient rehabilitation unit at our hospital located on campus. This fully immersed me in an interprofessional setting with providers from all health disciplines.

This required me to be a member of a team of varied professionals focused on quality patient care that depended on strong communication, an understanding of team members’ roles in providing care, and the use of best practices for supporting the team. I witnessed (and contributed to) interprofessional practice at its finest being carried out every day. I was hooked and worked with other allied health faculty to find ways for our students to engage with one another. With the support of our dean, I became the coordinator for IPEP for our department.

Two years ago, when our university leadership developed a campuswide initiative for intentionally integrating IPEP and created a formal office for it, I was ready to represent our Department of Allied Health Sciences as the director of IPEP. I work closely with other directors from all health disciplines as well as public health, social work, business and education to intentionally build IPEP across curricula. Student and faculty support have been tremendous. I see the need to expand knowledge of IPEP to counselor education as a whole and to build these endeavors into our programs to ensure that future counselors can easily transition to interprofessional care and become leaders on these teams.

Thus, counselor educators should be aware of current interprofessional teamwork practices and curriculum frameworks that provide opportunities for students to understand their roles on these teams, effectively describe and implement counseling services, and uphold the culture of interdisciplinary care. Establishing opportunities for counseling students to participate in IPEP with stakeholders was a critical need noted by Kaprea Johnson and Krystal Freeman in 2014 in their work on integrating IPEP into mental health counselor education. This knowledge will help new counselors understand their role in a variety of settings and learn appropriate communication strategies for sharing knowledge in team settings. IPEP trainings for graduate students also helps dispel preconceived ideas about other professional team members’ roles and highlights the importance of quality care.

Core competencies

In 2009, the Interprofessional Education Collaborative (IPEC) was formed by six national health profession education associations covering nursing, osteopathic medicine, pharmacy, dentistry, medicine and public health. Their goal was to advance interprofessional learning strategies to enhance skills in team-based care that promote quality health outcomes. The collaborative also established core competencies in providing interdisciplinary care for student clinical training programs. By 2016, IPEC had expanded its academic partnerships to include 21 health-related institutions. Its vision is to promote interprofessional teamwork and collaborative practice that reinforces quality, accessible, person-centered care that improves population health. 

IPEC has four core competencies that guide the development of curricular content:

  • Values/ethics for interprofessional practice to build and maintain mutual respect and shared values in patient care
  • Knowledge of roles/responsibilities in interdisciplinary teams to help assess and address health care needs
  • Interprofessional communication that is supportive and responsive to team-based care and treatment and prevention of disease
  • Teams and teamwork that uphold high values and principles recognizing different team members’ roles in planning, delivering and evaluating patient care, programs and policies

The overarching goal for IPEP is for health care workers to learn from, with and about each other.

These competencies also promote the principles of the “Quadruple Aim” in health care. Three of the principles were originally developed in 2007 by the Institute for Healthcare Improvement to promote health system reform to improve patient experiences, reduce costs and increase better outcomes. The fourth principle, improving the clinical experience for providers, was added in 2015, primarily to address and manage clinician burnout.

Counselor training opportunities that embrace these competencies help students understand their team roles, effectively describe and implement their services, learn appropriate methods for sharing knowledge in team settings, and uphold the culture of interdisciplinary teamwork. Overall, curriculum structures that promote opportunities that integrate the IPEP competencies help develop graduates who are leaders in their field. These graduates will possess the skills for teamwork that can address challenges in providing quality health care, including in the counseling field.

IPEP in relation to accreditation and licensure requirements

CACREP recognizes the need for counselor education programs to provide specific information and training to students about interprofessional care and their respective roles on these teams. On its website, CACREP states that it is a member of the Health Professions Accreditors Collaborative, which works to promote learning opportunities that prepare students for interprofessional practice. Requirements for interprofessional education opportunities are outlined in the 2016 CACREP Standards in Section 2, Standard F.1.c. and Section 5, Standard D.2.b.

The 2014 ACA Code of Ethics clearly states in Section D, Relationships With Other Professionals, the importance of being a part of interdisciplinary teamwork (Standard D.1.c.) and understanding the professional and ethical obligations as a team member (Standard D.1.d.). In 2017, the Code of Professional Ethics for Rehabilitation Counselors provided guidelines for certified rehabilitation counselors working as members of interdisciplinary teams that provide complex and comprehensive services to people with disabilities. Section E, Relationships With Other Professionals and Employers, outlines these ethical responsibilities in Standards E.1., E.2.a. and E.2.b.

Thus, counselor education programs are called to build relationships among all stakeholders (administration, faculty, students and community partners for clinical training) that are crucial for successful IPEP development and implementation, as noted by Daniel Kinnair and colleagues (2012) and Kaprea Johnson and Krystal Freeman (2014).

IPEP experiences for counselor education and development

Innovative ideas for incorporating IPEP experiences in counselor education include collaborative learning experiences with other professions, problem-based learning events and simulation activities. One of the best approaches for initially developing IPEP in counseling programs is to seek opportunities with other departments on campus that may have similar graduate-level introductory courses that include content on disability rights and current health care issues such as quality indicators of care, disparities in care, implicit bias and leadership development. These topics lend themselves to developing interdisciplinary journal clubs, case-based events for problem-solving and opportunities for students to talk about their different professions or why they chose their career path in graduate school. Most importantly, these activities will help students begin to understand and clarify their roles and how they fit in interprofessional teams. Their professional thinking may be challenged by understanding different viewpoints, decreasing the use of jargon, and building confidence and leadership for future teamwork.

IPEP events that are more intentional with specific learning outcomes require more planning. However, working with other health professionals on campus or in field placements to design opportunities will prevent reinventing the wheel and will model interprofessional collaboration for students. Examples of IPEP activities designed around specific learning objectives for students include case-based learning experiences, seminars with small-group discussions and debriefs, and clinical simulations that use videos or actors to play patients and portray different health issues and patient ages. Service-learning opportunities, particularly focused on rural health care, can bring students together from many disciplines, including business, education, legal care and faith-based organizations. These opportunities serve as excellent avenues for learning from, with and about each other to serve the community.

Field placements for clinical work offer built-in opportunities for IPEP in clinical agencies where interdisciplinary teamwork is provided. These preceptors will have practical knowledge to share about their teamwork and examples of interprofessional care that works and does not work. They can also offer opportunities for counseling students to incorporate counseling theory with IPEP practice and to reflect on potential ethical dilemmas for counselors when providing team-based care. These environments can help all students, not just counseling students, learn how to deal with complex issues and bridge theory to practice difficulties in providing clinical care as new professionals. Furthermore, these experiential learning opportunities are very important in IPEP because they offer environments in which professionals and students can interact and reflect on practices for improved care.

It is important to note that the four IPEC core competencies discussed earlier should always guide a program’s IPEP initiatives and curriculum. Students and faculty should be able to explain how the activity meets the competencies. Evaluation by participants for each event is critical to ensure that the goals of the training are being met and that it represents a valuable learning opportunity. Faculty development for counselor educators and other health disciplines and IPEP partners is critical to designing, developing, implementing and assessing successful learning opportunities.

In the planning of IPEP events, it is crucial to involve students from the beginning. They may have friends or contacts in other departments or community agencies that have resources or programs that can be used to help with planning and executing events. Encouraging students to take leadership roles in working with faculty to develop IPEP on campus is an excellent way to build their leadership skills and a commitment to interprofessional learning.

Value in counselor development

Incorporating IPEP into counselor education programs can increase opportunities for clinical participation with other related disciplines in a manner that helps counseling students develop a strong professional identity. Well-planned IPEP activities build on the knowledge being learned in the classroom and increase critical thinking skills by evaluating complex care needs from multiple perspectives. In addition, students see faculty and professionals from other disciplines working together during IPEP activities, modeling effective interprofessional teamwork that may not be experienced during training.   

IPEP training offers opportunities for students to better understand aspects of patient-centered care, holistic treatment and shared decision-making practices that guide teams in their goals for achieving outcomes. But most importantly, students enjoy IPEP events. They naturally form their own interdisciplinary groups for further discussion after participating in IPEP opportunities and develop friendships that can lead to building a better workforce in the future.

Our students have their own campuswide Student Executive Committee with representation from all the schools participating in IPEP. They plan formal and informal events that promote IPEP and serve as liaisons between the IPEP office and student groups across campus to increase awareness of interprofessional learning and collaboration as part of their academic experience. These students are leaders on campus and are also developing into our future leaders in counseling and in team-based community care. Actually, they are why we have a deep commitment to IPEP on our campus. And they are worth it.

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Judy Schmidt is the director of Interprofessional Education and Practice (IPEP) for the Department of Allied Health Sciences at the University of North Carolina at Chapel Hill. She is a member of the leadership team for the university’s Office of IPEP, which is dedicated to working collaboratively to transform health education and prepare professionals from different disciplines to work better together for quality patient care. She is a clinical assistant professor in the department and a certified rehabilitation counselor. Contact her at judy_schmidt@med.unc.edu.

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit 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.

Encouraging T-shaped thinking in the counseling profession

By John McCarthy May 18, 2020

I thought it was a most ridiculous assignment. The instructor of my Introduction to Counseling course in 1988 asked us to write, of all things, a book report. “Make sure the book has nothing to do with counseling,” he directed.

I was incredulous. “My first class in counseling, and he’s asking us to do a fifth-grade assignment?” I wanted to learn everything I could about counseling, especially in an initial course, and a book report was not on my anticipated list of important things to do.

Years later, I realized that it was a brilliant stroke by the professor, and in 2020, I believe it could well be a portal to the future of the counseling profession. With a strong interest in creativity, I now realize the impetus of the assignment. The instructor wanted us novice students to know things outside of counseling. Go learn about Portuguese history, quilting or the evolution of vacuum cleaners.

The assignment concerned creativity and, in retrospect, was aimed at helping us counselors-in-training with our creative “shape.” Creativity involves being a “T-shaped” person, a term originating from a well-known design firm named IDEO. The T-shape idea entails a person knowing a great deal about a specific discipline and having a breadth of knowledge in other fields. It is not a matter of being an expert in only one area, represented by the vertical line in the T, but also being able to draw from other arenas, as represented by the horizonal line.

In her 2009 book What I Wish I Knew When I Was 20: A Crash Course on Making Your Place in the World, Tina Seelig related the importance of developing T-shaped thinkers in directing the Stanford Technology Ventures Program. The aim was straightforward: Students would have an extensive knowledge base in one discipline, perhaps science or engineering, along with, in this case, innovation and entrepreneurship.

It is the combination skills that can be central to creativity. Incidentally, it is these skills that represent the C (combination) in the commonly cited SCAMPER acronym of creativity. Linking ideas from counseling with web design, political science or chemistry can lead to innovative solutions in any number of roles that counselors play, including as consultants, crisis responders or group facilitators.

In her book, Seelig also observed, “Life presents everyone with many opportunities to experiment and recombine our skills and passions in new and surprising ways.” T-shaped thinkers can draw from other parts of their knowledge base in that recombining process to formulate more creative solutions to challenges.

Radical collaboration

The T metaphor isn’t just about individual counselors though. It also concerns our counseling profession and, in my opinion, how it can be strengthened in the coming years. Yes, integrated care is critical to counseling, but I believe that interprofessional partnership extends beyond this model.

“We believe in radical collaboration.” The last two words caught my eye as I read the “We’re glad you’re here!” brochure during a recent visit to the Hasso Plattner Institute of Design at Stanford University. Also known as the “d.school,” this internationally recognized institute offers students from an array of disciplines — including engineering, law, business and medicine — the opportunity to deepen their creative skills and gain design competencies toward solving complicated dilemmas.

The same brochure posed thought-provoking questions, one of which fits the notion of “radical collaboration” and the future of the counseling profession: Choose two diverse occupations and list ways that they could work together to answer a challenge in the real world. If counselors were chosen as one of the occupations, imagine the potential life-changing ideas that could be sparked in partnering with oceanographers, mathematicians or cybersecurity specialists. Imagine how social justice, advocacy and consultation could be integrated. Imagine how such an adventure could result in even more creative T-shaped counselors-in-training and professional counselors.

Work involving the search terms “interprofessional” and “counselor” would appear to be limited, although the topic has been discussed in the literature for at least 30 years. Elizabeth Mellin, Brandon Hunt and Lindsey Nichols conducted questionnaire-based research among counselors in 2011 that included a discussion on interprofessional collaboration. In a 2016 study, Christianne Fowler and Kaprea Hoquee (nee Johnson) described a one-day standardized patient experience among students in counseling, nursing and dental hygiene programs. In research published last year, Kaprea Johnson surveyed students in counseling, along with those in dental hygiene, nursing and physical therapy programs, and concluded that counseling students were as receptive as the students in health care programs regarding interprofessional training.

Examples of interprofessional interaction are seen in related mental health arenas. Last year, the American Psychological Association announced that it would be partnering with medicine, pharmacy, nursing and other areas to oversee organizational accreditation for interprofessional continuing education. According to the article announcing this recent development, the move was viewed as a benefit to the field, especially in relation to the amount and caliber of continuing education possibilities. A second instance is Robert Morris University’s Access to Interprofessional Mental Health Education program, which aims in part to train psychiatric mental health nurse practitioners to offer care as part of an interprofessional team.

Identity is central to our counseling profession, and T-encouraged initiatives with other domains can make us better as a whole, broadening our collaboration with — and increasing our visibility by — other fields. Continuing education regulations could be modified to include domains outside of counseling. Imagine counseling conferences with people from other areas such as pharmacy, dentistry, media relations, medicine, computer science and the design industry. Presentations by counselors in tandem with dietitians, architects and TV producers could deepen our knowledge bases and foster further cross-disciplinary collaboration.

Programmatic standards could be adjusted to encourage (or perhaps even require) counseling students to take at least one elective outside of the department. They could learn about the future of health care in a medical curriculum, about correctional reform in other countries in a criminology program, or about sustainability in an engineering course.

T-shaped efforts at the professional level would deepen our collective cultural competency and contribute to our collective mindfulness. Kio Stark devoted a 2016 book to talking with strangers, and her message aligns with the present-moment orientation that counseling espouses. “When you interact with a stranger,” she wrote, “you’re not in your own head, you’re not on autopilot from here to there. You are present in the moment. And to be present is to feel alive.”

Developing cross-disciplinary tentacles can aid our future. T-shaped counselors and a T-shaped profession can broaden our scope, charge innovative ideas, emphasize wellness and deepen counseling’s visibility.

Counseling is a holistic, collaborative approach. Let’s extend the letter T in encouraging creative counselors and, ultimately, an innovative counseling profession.

The letter of tomorrow is T. Now let’s all go read some books.

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John McCarthy is a professor in the Department of Counseling at Indiana University of Pennsylvania. Contact him at jmccarth@iup.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.

Maintaining counselor identity in interdisciplinary teams

By Princess Lanclos and Krystal Vaughn December 3, 2019

Professional counselors are increasing their presence in a variety of settings, including nonprofit agencies, clinics, private practice groups, schools, hospitals, and state and federal vocational rehabilitation centers. In these settings, counselors are likely to work with other health care professionals for the benefit of their clients. Some of these other professionals involved in the care of clients may include physicians, speech therapists, occupational therapists, and case managers. As we enter into new arenas, our ability to advocate for the counseling profession is imperative, yet many counselors may find themselves questioning how to do that while working in interdisciplinary teams.

One way that advocacy may be achieved in an interdisciplinary team is through active implementation of a shared decision-making model. According to research conducted by France Légaré in 2011, shared decision-making models have historically focused on the patient-physician dyad.

Both medical professionals and professional counselors are trained to make decisions to benefit their clients. However, counselors are typically trained to use an ethical decision-making model such as Holly Forester-Miller and Thomas Davis’ seven-step process:

1) Identify the problem.

2) Apply the ACA Code of Ethics.

3) Determine the nature and dimensions of the dilemma.

4) Generate potential courses of action.

5) Consider the potential consequences of all options and determine a course of action.

6) Evaluate the selected course of action.

7) Implement the course of action.

Medical professionals, on the other hand, may be trained to use a medical decision-making model. This model involves 1) the number of potential diagnoses and management options that must be considered during an encounter, 2) the amount and complexity of data to be reviewed as a result of the encounter, and 3) the risk of complications, morbidity and mortality associated with the encounter.

Alternatively, medical professionals may use a shared decision-making model. This model first determines if the decision is the right thing to do ethically. Next, the patient is provided with treatment options so that the patient can make an informed decision. Consent is then obtained. This model helps bridge health disparities by involving patients in many aspects of the treatment, including the informed decision-making process.

All of these decision-making methods share similarities, including placing emphasis on four common principles: autonomy, justice, beneficence and nonmaleficence. Additionally, both the ACA Code of Ethics and the American Medical Association’s code of medical ethics strive to protect the confidentiality of the client/patient. In The American Journal of Emergency Medicine in 2016, Chadd Kraus and Catherine Marco defined shared decision-making as a collaborative process that allows patients (or their surrogates) and clinicians to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values, goals and preferences.

Therefore, in an interdisciplinary team, a professional counselor may offer a unique perspective to benefit the client or patient. This can lead to counselors advocating for themselves and their profession. The question is, how do we bring awareness to these variations in decision-making models on the basis of any health care professional’s training program while also effectively training and implementing these approaches for both new and seasoned health care professionals?

Classroom

Professional identity and ethical decision-making begin early in a counselor-in-training’s academic career and are specifically reinforced in CACREP-accredited graduate training programs. These programs are composed of core courses (e.g., ethics, counseling techniques, assessment) that allow students to begin exploring and implementing the skills needed to handle ethical dilemmas. At this stage of professional development, graduate students are establishing ethical decision-making practices and the principles of autonomy, nonmaleficence, beneficence and justice, which are reinforced throughout their academic careers (e.g., practicum, internships).

Additionally, the opportunity to practice implementing a shared decision-making model may be offered in a classroom setting by engaging students in activities or courses in which they join with students from other disciplines to approach a case study and propose a holistic treatment plan that addresses each discipline’s scope of practice. Engrossing students in this practice may aid in postgraduate work and provide them a new perspective and appreciation for various treatment providers who might be serving their clients.

However, unless a student is placed at a practicum or internship site where multiple disciplines are offering services, the student may receive little guidance related to working within an interdisciplinary team. Therefore, we encourage counseling training programs to initiate relationships with potential internship sites that feature multiple disciplines so that students can experience the benefits and challenges of working within interdisciplinary teams. Alternatively, students could be placed at internship sites that actively consult with other treatment providers outside of the internship site.

Post-graduation

Think back to your first job after graduation or even to your current place of employment. Did/does your agency offer an opportunity for interdisciplinary consultation or encourage you to consult with a client’s treatment team in another health care setting? As a beginning professional in the field of counseling, did you feel comfortable discussing your treatment recommendations with another professional?

As members of interdisciplinary teams, counselors should understand not only the challenges but also the benefits of shared decision-making models in conjunction with an ethical decision-making model of their choice. Each of these models benefits the client and the field of counseling.

Implementing model and consultation

Many individuals are trained in graduate school to interact with the identified client but may have limited exposure to working within an interdisciplinary or interprofessional team. However, the reality is that the clients we see today may have a variety of treatment providers (speech therapists, occupational therapists, case workers, physicians, psychologists, etc.). It takes practice and experience to maintain our counselor identity while engaging in consultation with other treatment providers. Exploring instances in which consultation is needed and how it is implemented may aid in providing and advocating for quality holistic treatment for clients.

Consultation first requires knowledge of the treatment team. Who is the client working with outside of your agency or clinic? Do you have consent to speak with that individual in accord with Health Insurance Portability and Accountability Act (HIPAA) considerations? Counselors must reflect on how consulting with the treatment provider would aid in the client’s treatment. At times, we may consult to share treatment goals or treatment progress. However, at other times, we are consulting to gain information regarding another professional’s goals, methods or protocols. Once a working relationship is developed, the counselor may proceed to engage in the initial phase of consultation.

Step one: The initial phase of consultation should include preparing for the call, including ensuring that all proper HIPAA release of information and agency paperwork have been completed. The counselor should be prepared with a concise yet well-thought-out reason for requesting consultation. What information would the counselor like to share or request? The counselor may also want to consider whether the person being consulted understands that the counselor is also working with the individual and how the counselor’s role relates to the treatment of the individual. 

Step two: The counselor should contact the consulting agency, provide the release of information, and schedule a consultation. Scheduling may be essential because many professionals are busy and might not be readily available to speak. It sometimes requires numerous phone calls to contact the individual provider. Even if the provider is available, he or she may not have the client’s chart or may still need to review the information, potentially causing frustration and delays. Therefore, if a call is scheduled, all parties should be prepared to participate fully.

Step three: The requesting provider should be well-prepared with information that might be shared or requested during the consultation call. A brief overview of how the client came to receive services from the counselor and what services the counselor is providing is a nice place to start. This should be followed by discussing the client’s condition, interventions, shared treatment goals, schedule/frequency of treatment, prognosis, and expected duration of treatment. At times, professionals may have similar treatment goals for the client but might be using different interventions or approaches. It is important to recognize that overlap may exist in the knowledge and skills of each provider. In such cases, it may be necessary to discuss why the providers and treatment modalities are mutually beneficial to the client. During the consultation, it may also be important to consider alternative or complementary therapies.

The counselor may be seeing the client more frequently than is the other provider, so a general impression of the client’s current condition and presentation may be helpful to the overall treatment team. The consultation call should allow the counselor to ask questions of the other providers and vice versa. Consultations can be held individually or with all members of the treatment team, depending on the levels of intervention and the specific consultation questions being asked.

Treatment teams may need to determine who will be responsible for which treatment goals or objectives. (Note: Professional counselors must be careful to stay clearly within their scope of practice.) At this point, it may also be important to schedule a follow-up consult, if necessary, and determine which of the treatment providers will start the call. Follow-up consults work best when they are planned, scheduled and predictable. This allows providers to align treatment goals and outcomes.

Step four: The counselor should document consultations in the client’s file. The consultation notes should include the name of the client, date and time of the call, and length of the call. The purpose of the call should also be clearly noted and supported by HIPAA release of information documentation. We recommend also dedicating a space on the consultation documentation form for a narrative that states the overview and outcome of the consult.

Case example

Sally is a 12-year-old female who is seeing a licensed professional counselor to help her reduce her anxiety symptoms. Initially, a licensed clinical psychologist diagnosed Sally with generalized anxiety disorder (GAD) and a speech language disorder and then referred her for speech, counseling, and medication evaluation. Sally lives at home with her parents and doesn’t have any siblings. The counselor would like to speak with Sally’s psychologist, school counselor, speech therapist, and treating child psychiatrist. The counselor requested that Sally’s parents sign HIPAA forms during the initial intake session.

Step one: After treating Sally for two to three sessions, the counselor forms consultation questions for each provider treating Sally. The counselor first would like to know from the psychologist whether Sally has any educational limitations that would prevent her from participating in cognitive behavior therapy. Second, the counselor would like to know how the school is addressing Sally’s symptoms of GAD, whether an accommodation plan is being or has been used for Sally, and whether the school counselor is working with Sally weekly. Third, the counselor would like to know whether the speech therapist is noticing signs of GAD during sessions with Sally and, if so, how the speech therapist is addressing those symptoms. Finally, the counselor would like to know what recommendations the psychiatrist has, while also providing the psychiatrist with information on Sally’s progress and the techniques being used in the counseling sessions.

Step two: The counselor will contact each of the four providers’ offices to request a consultation call. The counselor will also scan or fax the HIPAA release to each provider in a secure manner.

Step three: The counselor will review the file, treatment goals, progress, and schedule/frequency of treatment for Sally. The counselor should have questions prepared or outlined for each of the consultation calls. It will be important for members of Sally’s treatment team to consider how the various treatments may support one another, be similar, or be different. The team should also consider how often consultation will need to occur and who will be responsible for scheduling. For example, the psychologist may not have any additional contact with the family and require no further communication with the treatment team. However, the school counselor and speech therapist may be seeing Sally weekly, similar to the counselor. Therefore, frequent contact between these three providers may be necessary. Finally, the psychiatrist may request information only immediately prior to Sally’s next appointment.

Step four: The counselor will document each consult. The note should include the date and time of each consult, a summary of the consult, and the next scheduled consultation.

Conclusion

Using the aforementioned instructions while consulting with other health care professionals may aid in applying a decision-making model that will continue to benefit the clinician, the client, and the counseling profession as we continue to adapt and improve our provision of treatment for the populations we serve.

As professional counselors, we may find ourselves working alongside other professionals who hold more advanced degrees. Regardless, it is important that we maintain our counselor identity, uphold our professional code of ethics, and advocate for our clients’ well-being. When involved in interdisciplinary teams, it is imperative that we are able to work within our scope of practice as counselors and clearly state the rationale for the interventions we are providing in therapy. Additionally, implementing a shared decision-making model fosters an opportunity for us to advocate for our profession and our clients while in interdisciplinary settings.

 

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Princess Lanclos is a doctoral student in counselor education and supervision at the University of Holy Cross in New Orleans. She is a national certified counselor, a certified rehabilitation counselor, and a provisionally licensed professional counselor. Her areas of focus include substance abuse, counseling ex-offenders, and multicultural counseling. Contact her at princess_lanclos@uhcno.edu.

Krystal Vaughn is a licensed professional counselor supervisor specializing in working with children ages 2-12. As an associate professor at Louisiana State University Health Sciences Center–New Orleans, she enjoys teaching and providing clinical services. Her research interests include supervision, play therapy, and mental health consultation. She has extensive experience providing mental health consultation in child care centers, private schools, and local charter school systems. Contact her at kvaugh@lsuhsc.edu.

 

Knowledge Share articles are developed from sessions presented at American Counseling Association conference.

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.