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?
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.
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.
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.
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.
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 firstname.lastname@example.org.
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 email@example.com.
Knowledge Share articles are developed from sessions presented at American Counseling Association conference.
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