124 Journal of Mental Health Counseling

Volume 37/Number 2/April 2015/Pages 124-137

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Older Adults and Integrated Health Settings: Opportunities and Challenges for Mental Health Counselors

Jill S. Goldsmith Sharon E. Robinson Kurpius

The growing number of older adults and the increasing recognition and growth of integrated health teams are creating expanded career opportunities for mental health counselors (MHCs). Collaborative integrated teams, staffed with medical personnel and MHCs, can provide com-prehensive patient-centered care that addresses client issues from a biopsychosocial perspective. However, working with older adults on an integrated health team or in an interdisciplinary set-ting presents unique challenges and raises ethical issues. The evolving opportunities and strate-gies to address accompanying challenges are highlighted so that MHCs can be prepared to work effectively with older adults in interdisciplinary settings and on integrated health care teams.

America is graying both literally and figuratively as baby boomers live longer due primarily to medical advances that have transformed previously life-threatening diseases into treatable chronic conditions (Centers for Disease Control and Prevention (CDC) National Center for Chronic Disease Prevention and Health Promotion, 2011; CDC & Merck Foundation, 2007). These baby boomers are transitioning into the phase of life termed “older adults,” those who are 65 and older (U.S. Department of Health and Human Services, Administration on Aging, 2013). By 2030 the number of older adults in the United States is projected to more than double, to about 71 million, or about 20% of the U.S. population (CDC & Merck, 2007).

The Institute of Medicine (IOM, 2012) reported that a growing older population “holds profound consequences for the nation” (p. 1). For example, one in five older adults in the United States has one or more mental health and substance abuse conditions that are typically comorbid with other health problems and often inadequately met in the current health care system (IOM, 2012). As older adults represent a larger proportion of the population, there will be a corresponding increase in the need for mental health care. Yet the number of mental health professionals working in or entering fields related to geriatric mental health or substance use is in short supply (IOM, 2012).

These alarming statistics raise the question: Who will provide the health services these older adults will surely need? The American Psychological Association (APA) Presidential Task Force on Integrated Health Care for an

Jill S. Goldsmith and Sharon E. Robinson Kurpius are affiliated with Arizona State University. Correspondence about this article should be addressed to Jill S. Goldsmith, 7024 N. 3rd Avenue, Phoenix, AZ 85021. Email: jillsgoldsmith@gmail.com.

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Aging Population (2008) recognized that one effective answer is integrated health care teams in which mental health professionals work collaboratively with medical professionals to treat older adults holistically. Noting that many of the current integrated health care practices include social workers and psy-chologists, Bowling Aitken and Curtis (2004) urged mental health counselors (MHCs) to “aggressively seek ways to enter this promising market” (p. 329). Given the rising numbers of older adults and the urgent need to take better care of them, MHCs should step up and join with other health professionals to provide them with comprehensive, integrated health care that addresses their physical, emotional, and interpersonal needs.

INTEGRATED HEALTH CARE

Interest in integrated health care has evolved as Western medicine increasingly recognizes how the connection between the mind and the body affects prevention and development of diseases. After studying the interplay of biological, behavioral, and societal influences on health and disease, the IOM (2001) reported that health and disease are determined by dynamic interaction of biological, psychological, behavioral, and social factors. It recommended that more resources be directed to interdisciplinary research and intervention studies that integrate biological, psychological, behavioral, and social variables. The integrated health care model meets this recommendation because it con-siders the biological, psychological, and social (biopsychosocial) processes in an integrated and interactive approach to evaluate and treat physical health and illness (Suls & Rothman, 2004). Because mind and body are not indepen-dent of each other, care should focus on the whole person (Bennett-Johnson, 2012; Hine, Howell, & Yonkers, 2008), with goals of prevention, noncurative relief, such as relief from chronic pain, and improvement in the quality of life (Alcorn, 1998). An integrated team with mental health professionals as mem-bers is particularly important for older adults because they prefer to seek men-tal health help in a primary care setting where there is less stigma associated with mental health care (Speer & Schneider, 2003).

The collaboration of behavioral and primary health care providers can take many forms, but in general integrated health care models emphasize interprofes-sional collaboration and communication about all aspects of patient care (Kelly & Coons, 2012). Kelly and Coons (2012) noted that integrated care can range from none to off-site collaboration, to co-location with collaboration but not an integrated system, to fully integrated with systematic support. Bowling Aitken and Curtis (2004) identified two models for MHCs working with medical profession-als: non-targeted and targeted integrated care teams. A non-targeted practice pro-vides a variety of services to clients who have a variety of health-related concerns. In the non-targeted practice, the MHC works in the office of a primary care provider (PCP) and collaborates throughout the day with medical personnel by providing mental health assessments, time-limited therapy, psychoeducation, cri-sis management, or case management. A targeted setting provides an integrated approach to treating specified health issues, such as cancer or diabetes. In a tar-

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geted integrated care practice, the MHC may or may not be co-located within a PCP office but will collaborate with the PCP to provide counseling, education, and case management (Bowling Aitken & Curtis, 2004).

Bringing mental health counseling to primary health care settings is particularly important because, as Bowling Aitken and Curtis (2004) found, 50–90% of clients with mental health needs rely solely on their PCP for those services. However, because PCPs may not be trained in mental health diagno-sis, many mental health issues go undetected (CDC, 2012). For example, as many as 50% of primary care patients with depression are not accurately diag-nosed, and 30–50% of the primary care patients who are diagnosed discontinue treatment before care is completed (Chen et al., 2006).

Two decades of research have shown that mental health and substance use services are best delivered to older adults in such easily accessible locations as primary care offices or senior centers (IOM, 2012). Not only do older adults underutilize mental health services (Speer & Schneider, 2003), they prefer to seek mental health care from their PCP rather than in traditional mental health settings (Bartels et al., 2004). PCPs, however, may mistake an older adult’s depressive symptoms as just a natural reaction to illness or to the many life changes that occur with advancing age. Often older adults share this belief and assume that nothing can be done, so they do not seek other help (CDC, 2012). Because older adults tend to seek help from their PCP, who may not have the training or time to detect or prevent mental health issues, an MHC member on a collaborative health team can provide effective professional detection and inter-vention in a setting where older adults seek the help they need (Bowling Aitken & Curtis, 2004; Hine et al., 2008; Speer & Schneider, 2003).

With its biopsychosocial foundation, integrated health care can increase patient adherence to medication, improve health, and heighten patient satis-faction (Chen et al., 2006; Hine et al., 2008; Katon et al., 2006). Clinical trials of integrated behavioral health and primary care models have demonstrated improvements in physical as well as mental health (Croft & Parish, 2013), and collaboration between PCPs and mental health specialists in integrated models has been found to be effective in service delivery and satisfying to older adults (Chen et al., 2006). For example, McGeary, McGeary, and Lippe (2014) reported that evidence-based clinical research “overwhelmingly” supported the use of interdisciplinary approaches to management of chronic pain; they urged clinicians to become aware of this. Collaborative care also reduces health care costs. In a meta-analytic review of 91 studies, active behavioral health treatment for patients with diagnosed mental health disorders reduced their medical costs by 16%, while for controls who did not get behavioral care, costs increased an average of 12.3% (Chiles, Lambert, & Hatch, 1999).

OPPORTUNITIES FOR MHCS

Speer and Schneider (2003) reported that “gerontological mental health care for older adults in primary care settings is almost virgin territory” (p. 94). The surge in numbers of older adults and the growing interest in integrated

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health care teams in primary and long-term care settings, hospitals, fitness and nutrition settings, rehabilitation care centers, and hospice care, have created rewarding career opportunities for MHCs. MHCs can enhance patient care by, e.g., working with medical professionals to address psychosocial issues that often arise with chronic disease. Currently, 80% of older adults are living with one chronic disease and 50% with two (CDC & Merck, 2007). Cancer, diabetes, and heart disease are not necessarily the natural consequences of aging; often they are the result of lifestyle choices, such as smoking, poor diet, and lack of physical activity. Individual behavior is a major factor in 86% of premature deaths due to activity and diet patterns, tobacco use, and alcohol abuse, among others (Blount et al., 2007). Since primary care is the “de facto mental health system for 70% of the population,” adding behavioral health professionals to the primary care team can help physicians better meet patient needs (Blount et al., 2007, p. 291). MHCs can also help older adults improve their quality of life through behavioral modifications that may reduce their vulnerability to chronic diseases and thus the escalating cost of health care (Blount et al., 2007, CDC & Merck, 2007).

Depression is particularly prevalent among older adults who have chronic illnesses or limitations in physical functioning (CDC, 2012); the prevalence rate is 13.5% among older adults who require home health care and 11.5% among those hospitalized (CDC, 2012). Up to 37% percent of older adults receiving primary care suffer from depression (U.S. Department of Health and Human Services, Administration on Aging, 2001). Older Americans also have the highest suicide rate of any age group (CDC, 2007). Because MHCs are uniquely prepared to treat depression and to intervene when patients are suicidal, they are urgently needed to work with older adults, whether they suffer from illness, depression, or poor life style choices. Working with medical staff in integrated health settings, MHCs can address these issues.

CHALLENGES FOR MHCS TREATING OLDER ADULTS

These evolving opportunities for providing mental health care do not come without problems. Whether MHCs are practicing in an integrated healthcare team or in an interdisciplinary setting, they must deal with (a) competence related to specialized training and experience in working in integrated health care and with the older adult; (b) obtaining informed consent; (c) recognizing the limits of confidentiality; and (d) understanding their duties to warn and protect. Working in a hospital presents another new set of potential ethical dilemmas.

A growing body of literature relates to the ethical, legal, and professional issues of psychologists who practice in health settings and in multidisciplinary teams with medical professionals, and the APA (2011) has drafted guidelines for psychological practice in health care delivery systems. However, there is a dearth of studies of the role of MHCs on integrated health care teams, and there is little guidance for counselors on the ethical, legal, and professional issues that arise when working on such teams (Nicholas, Gerstein, & Keller, 1988). Yet a keen awareness of the ethical and legal codes that may apply could help MHCs confront and resolve any challenges.

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COUNSELOR COMPETENCE

The American Counseling Association (ACA, 2014) Code of Ethics and Standards of Practice (ACA Code of Ethics) requires that counselors “practice only within the boundaries of their competence, based on education, training, supervised experience, state and national professional credentials, and appro-priate professional experience” (ACA, 2014, C.2.a). The American Mental Health Counseling Association Code of Ethics (AMHCA, 2010) also explic-itly states that MHCs must recognize their boundaries and limitations (C.1. Competence a) and accurately represent these to others (C.1. Competence d). There is also a legal duty to render competent diagnoses and provide effective treatment (Wheeler & Bertram, 2012). Working in health care settings presents at least four competence-related issues.

Most important: MHCs must gain knowledge, skills, training, and experience that apply to the health care setting and the types of patients they will treat (Alcorn, 1998). While geropsychologists have didactic training and supervised experience to build their professional competencies (Karel, Altman, Zweig, & Hinrichsen, 2014), training for counselors to work with older adults in integrated health care settings is not as well-developed. However, the coun-seling skills taught in most graduate programs are easily adapted to such roles as program coordination, patient and family support, patient advocacy, staff development, and crisis management (Alcorn, 1998). Supervised experience in medical settings can also enhance skills. With the necessary training and expe-rience, MHCs can provide psychoeducation on health promotion, chronic pain and stress management, and other clinical services (Nicholas et al., 1988).

MHCs also must have the training and experience necessary to participate in multidisciplinary treatment planning, assessment, and prevention programs and help conduct them (APA, 2011; APA Presidential Task Force on Integrated Health Care for an Aging Population, 2008; Belar & Deardorff, 2009). Training in individual, family, and group interventions is also helpful in working with the older adult (APA, 2008). Because that health care changes rapidly, MHCs must recognize the need for continuing education to stay competent (ACA, 2014, C.2.f; AMHCA, 2010, C.1). Attending workshops and professional con-ferences, doing independent research, and reading professional journals (Belar & Deardorff, 2009) can help them keep current.

Training MHCs to work with older adults should include diversity edu-cation that helps MHCs avoid biases that reflect ageist attitudes. Clinical supervision is critical for increasing self-awareness of attitudes, assumptions, and possible biases against older adults (Karel et al., 2014). Researchers, how-ever, have found that as yet graduate counseling students are not receiving the education they need to work with older adults and have negative attitudes about doing so. For example, Keaveny, Gildar, and Robinson Kurpius (2012) studied 106 graduate counseling students and found that the majority explic-itly expressed disinterest in working with older adults with comments such as, “This area of age, death, and dying is something I’m not particularly comfort-able with.” In their case conceptualizations, these graduate students attributed

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symptoms to old age and end-of-life issues for an older adult that they did not consider when a younger adult displayed the identical symptoms. Clinical supervision and training can address this potential ageism.

A second competence issue relates to knowledge of medical conditions, medications, and the aging process. MHCs trained in one health-related area are not necessarily competent to work with patients with other medical con-cerns (Robinson Kurpius & Vaughn Fielder, 1998). Attending a weekend work-shop does not make one competent (Belar & Deardorff, 2009). To understand the nature of health and illness in older adults, MHCs should have sufficient clinical experience to prepare them for the medical vocabulary, concepts, and perspectives they will encounter in interdisciplinary settings (Weiss, 1982). MHCs also need training to help them understand biologic diseases or condi-tions and the aging process so that they can discern the differing roles of psy-chopathology and biology in a patient’s condition (Swencionis & Hall, 1987). To be competent in health settings, MHCs must seek out training, including internships and supervision, to gain a working knowledge of health, illness, and clinical issues patients face (Alcorn, 1998; Nicholas et al., 1988).

To become a valued collaborator within an interdisciplinary, integrative health care team, it is essential that the MHC have a working knowledge of medical terminology, medications, and their side effects (Bowling Aitken & Curtis, 2004; Weiss, 1982). In fact, an MHC can help a PCP and the team by identifying such medication problems as noncompliance, intolerance, and negative side effects (Bowling Aitken & Curtis, 2004) and helping to determine whether patient cognitive changes are the result of normal aging, a medical or mental health condition, or simply a side effect of medication (APA, 2008). Finally, adopting the term “patient” as opposed to “client,” particularly in a hospital or primary care setting, and acknowledging the role of medications along with psychotherapy, demonstrates respect for and understanding of the perspectives of medical professionals and acknowledgement that as MHCs they are part of an interdisciplinary team providing comprehensive health care.

To be effective on an integrated team, it is also vital to understand the roles, competence, and care philosophy of other professionals on the team. This can promote collaboration through greater understanding and respect for varied perspectives on a health issue. For example, when a patient has a terminal illness, a physician who is focused on cure may advocate medical treatments to extend a patient’s life. A palliative care specialist may advocate psychosocial treatments to maximize comfort and quality of life rather than cure or extending life. A nurse, who is closest to the patient’s daily medical condition, may believe the patient is actively dying and may recommend no treatment. Family members complicate the situation when they do not under-stand or have trouble accepting the patient’s current condition and prognosis and may insist on acute or aggressive care. At times, health care professionals and family members may ignore a patient’s wishes and assume that their own choice of treatment options should be honored. Finally, insurance companies, hospitals, and health care settings where a patient resides may try to exert finan-cial pressure on one or more of those involved in treatment decisions.

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The MHC working on an interdisciplinary team should stay focused on how to serve the client best and work with the team by “drawing on the per-spectives, values, and experiences of the counseling profession and those of colleagues from other professions” (ACA, 2014, D.1.c). MHCs can help guide discussion of the different ethical standards of each professional and act as facilitators in reaching consensus, thus improving team functioning (Bowling Aitken & Curtis, 2004). By recognizing and respecting the different perspec-tives, MHCs can help mediate differences of opinion about future treatment, educate family and patients in a supportive way about a patient’s condition and prognosis, and help guide the team, the family, and the patient toward a mutu-ally acceptable plan. In sum, when MHCs understand the medical concepts, the medical culture, each professional’s perspective, and the ethical codes team members must honor, they can improve the likely success of an integrated team and help medical professionals recognize the value of the MHC.

Finally, it is imperative that MHCs not practice medicine by diagnosing a patient with a medical or physical condition, such as migraine headaches. Not only is it unethical to practice outside of one’s competency, doing so may sub-ject the MHC to a malpractice lawsuit (ACA, 2014; Belar & Deardorff, 2009). MHCs can avoid this pitfall by having a physician conduct an examination to rule out any organic reason for a problem before starting therapy (ACA, 2014; Belar & Deardorff, 2009, Swencionis & Hall, 1987). The duty to refer may also include referring clients to a psychiatrist or physician for medication manage-ment (Wheeler & Bertram, 2012).

OBTAINING INFORMED CONSENT

Informed consent defines the basic counseling relationship between the client and the counselor (Wheeler & Bertram, 2012). When working in a health setting, identifying the person from whom informed consent must be obtained can be difficult and complex. For example, having dementia does not automatically mean that an older adult lacks capacity to make a decision (APA Presidential Task Force, 2008). However, even if the patient has capacity to consent, the obligation to obtain informed consent may be difficult when it is unclear who is the “client” (Robinson Kurpius & Vaughn Fielder, 1998). For example, at times a physician may seek mental health consultation when a patient is noncompliant with treatment (Robinson Kurpius & Vaughn Fielder, 1998). Is the client the physician or the patient? When a family member or caregiver seeks help from an MHC or when a loved one seeks to end life-saving treatment, who is the client? Is it the family member or the patient?

To address such problems MHCs need to clarify the nature of their loyal-ties and responsibilities with all parties and plan for potential problems when working in inter-disciplinary collaboration (Nicholas et al., 1988). Robinson Kurpius and Vaughn Fielder (1998) noted that when a physician, caregiver, or family member seeks the referral to an MHC, the counselor must inform the patient about who sought the referral and who will pay for it. Cost may be of concern for older adults, especially if they are living on a fixed income and

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have little or no insurance coverage. Finally, if the patient cannot provide vol-untary consent, the MHC must act in the patient’s best interest and “embrace the diversity of the family system and the inherent rights and responsibilities” guardians have (AMHCA, 2010, 2. Informed Consent.c). The ACA Code of Ethics (ACA, 2014) extends the counselor’s responsibilities in obtaining informed assent from the older adult who cannot provide consent (A.2.d).

Unique informed consent issues may arise when an integrative team delivers complementary and alternative medicine (CAM), defined as “a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine” (Mosquera, 2008, p. 549). Despite the increased public interest in and demand for integrative med-icine that includes CAM therapies, there remain questions about the effective-ness and safety of most CAM therapies (Mosquera, 2008). As a result, there are unique risks in working on a CAM-oriented team. When on such a team, the MHC must therefore elicit informed consent to the nature of a CAM therapy, such as hypnosis, acupuncture, or guided imagery for pain management, so that the patient can make an informed and voluntary decision about the ben-efits of this type of therapy and the risks of not adhering to a more traditional medical approach (Cohen & Schouten, 2007).

Even though other team members may follow their own ethical guide-lines and talk to patients about informed consent, an MHC must ensure that the consent is truly informed. Thus, it is imperative that the MHC adhering to either the ACA or AMCHA Code of Ethics explain to patients both orally and in writing the risks and benefits of treatment by an integrative health care team, and also provide information about the counseling process and the counselor so that the patient can decide whether or not to participate in therapy (ACA, 2014, A.2.a). Information must be given in clear, honest, understandable, and sensitive language about the nature of the services provided; the procedures, goals, techniques, limitations, potential risks and benefits of services; the intended use of tests and reports; the implications of diagnoses; the MCH’s qualifications, credentials, and experience; and fees and billing arrangements (ACA, 2014, A.2.b). The obligation to obtain informed consent is not a single event; it is a continuous process that may require the counselor to obtain an updated informed consent if the counseling relationship or treatment changes (Wheeler & Bertram, 2012). The MHC must also obtain consent about the limits of confidentiality (ACA, 2014, A.2.b.). However, sometimes a patient’s medical condition makes it impossible to obtain written consent. At all times, an MHC must consider the needs of the patient, who may be too sick to give written affirmation of a willingness to talk with the MHC.

LIMITS OF CONFIDENTIALITY

In recent years, about 20% of claims filed against counselors have arisen from confidentiality and privacy issues (Wheeler & Bertram, 2012). Unique dilemmas related to confidentiality arise for MHCs who work in health care settings and on interdisciplinary teams. To provide comprehensive care effec-

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tively, members of integrative health care teams need to share information about the patient. This can raise ethical concerns about confidentiality (Belar & Deardorff, 2009). For example, in a hospital setting, many health care pro-fessionals have access to patient records, including the chart notes made by the MHC (Belar & Deardorff, 2009; Kelly & Coons, 2012). Electronic medical records make a patient’s records even more accessible to hospital staff (Kelly & Coons, 2012). Furthermore, MHCs may find themselves pondering the limits of patient confidentiality when a referring physician, who may not be part of the integrated team, demands information about a patient referred for mental health evaluation (Belar & Deardorff, 2009). How much information can be ethically shared? Keeping communications confidential may also be difficult when treating a patient at bedside in a hospital, particularly when the patient shares the room with another patient (Robinson Kurpius & Vaughn Fielder, 1998) or when medical staff or family enter and leave the room at will. The issue of confidentiality becomes particularly complicated when a caregiver has been tasked with making treatment decisions for the older adult or wants to provide information about the patient to the MHC. Finally, confidentiality concerns arise when releases signed by the patient or subpoenas are used to obtain patient medical records, including an MHC’s notes in the patient chart or medical records (Robinson Kurpius & Vaughn Fielder, 1998).

MHCs working in health care settings clearly have a less confidential relationship with a team’s patient than with an individual in a private setting (Kelly & Coons, 2012). Also, as with informed consent, an MHC cannot assume that another team member will adequately discuss the limits of confi-dentiality with a patient. There is a fine balance between not overwhelming a very ill patient and helping the patient to understand confidentiality and its limits in the context of the team approach to care and in the medical setting (ACA, 2014). MHCs can help patients understand the limits of confidentiality by informing them about the “team’s existence and composition, the informa-tion being shared, and the purposes for sharing such information” (ACA, 2014, B.3.b). Because an MHC has duties to “maintain awareness and sensitivity regarding cultural meanings of confidentiality and privacy” and to “respect differing views regarding disclosure of information” (ACA, 2014, B.1.a), at times there may be a need or a desire to limit access to clinical notes. If so, the MHC can raise the issue and help the team make decisions about a model for information-sharing (APA, 2008). Respect for the patient’s views on confiden-tiality and privacy, however, must be balanced with ethical standards and legal considerations. Thus, as part of the collaborative relationship, the MHC should have continuing discussions with patients about “how, when, and with whom information is to be shared” (ACA, 2014, B.1.a).

In addition to the ACA (2014) and AMHCA (2010) confidentiality stric-tures, MHCs who work in health care settings or as part of an interdisciplinary team should be aware of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH) passed in 2009 (Wheeler & Bertram, 2012). The HIPAA Privacy Rule applies to paper and electronic transmissions

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of protected health information by “covered entities” (Wheeler & Bertram, 2012). Whether an MHC is a covered entity or is working for one is beyond the scope of the current discussion, but an MHC on an interdisciplinary team will have to make this determination to ensure compliance with HIPAA. HITECH similarly has privacy and security requirements and penalties for their violation by covered entities. Wheeler and Bertram (2012) warn that MHCs who have confidential client information on smart phones or laptops that are stolen or lost may be required by law to report a breach of HITECH to clients affected, the federal government, and in some cases the media. Most state licensing boards also require a report. Furthermore, the 2014 ACA Code of Ethics speci-fies that any electronic record should be encrypted with security assigned to the record and that clients should be informed that records are being maintained electronically.

MHCs also must make every effort to ensure that staff of medical pro-fessionals respect patient confidentiality and privacy (ACA, 2014) and that information is shared with other team members only where patient privacy can reasonably be ensured (ACA, 2014). When working in a medical setting, it is also important to be familiar with medical provider confidentiality practices (Koocher & Keith-Speigel, 2008). In addition, MHCs only share confidential information with third-party payers when a patient has authorized disclosure (ACA, 2014). Finally, for patients who are not able to give consent, permission to disclose confidential information must come from an appropriate third party, such as a caregiver (ACA, 2014).

DUTY TO WARN AND PROTECT

Patient confidentiality must be tempered with the duty to warn and pro-tect the patient and others (ACA, 2014; Robinson Kurpius & Vaughn Fielder, 1998). MHCs working with older adults in health settings may face situations where there may be an ethical duty to breach confidentiality. For example, they may encounter patients with terminal illnesses who may seek to hasten their own deaths. According to the ACA (2014) Code of Ethics, “counselors who provide services to terminally ill individuals who are considering hastening their own deaths have the option of maintaining confidentiality, depending on the applicable laws and specific circumstances of the situation and after seeking consultation and supervision from appropriate professional and legal parties” (B.2.b). Also allowing the option of breaching confidentiality, the AMCHA (2010) Code of Ethics states:

Mental health counselors ensure that clients receive quality end-of-life care for their physical, emotional, social, and spiritual needs. This includes providing clients with an opportunity to participate in informed decision making regarding their end-of-life care, and a thorough assess-ment, from a qualified end-of-life care professional, of clients’ ability to make competent decisions on their behalf. (8. End-of-Life Care for Terminally Ill Clients. A).

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Thus, competing with duties to warn and to protect are duties to help patients receive quality end-of-life care and are given every opportunity to make informed decisions about their own care. Depending on state law, counselors may also be able to keep confidential the desire of terminally ill patients to hasten their own death. MHCs should discuss the limits of confidentiality with patients considering active euthanasia to avoid criminal charges and civil lawsuits against a loved one, often their caretaker, from whom they seek assis-tance (Hadjistavropoulos, 1996). Wheeler and Bertram (2012) recommend guidelines to help counselors address difficult issues related to confidentiality and its limits, such as apprising patients of those limits at the outset of counsel-ing and providing periodic reminders; consulting with a trusted colleague or supervisor; being familiar with state law; consulting with an attorney; making referrals where appropriate; knowing and following institutional policy; and documenting all actions taken or not taken and the rationale for each.

Whether confidentiality should be breached to prevent a death is a com-plex issue morally, legally, and perhaps spiritually for MHCs. Great care must be taken to avoid asserting one’s own views about these topics when counseling patients, who have a right to exercise self-determination about end-of-life care (AMHCA, 2010; Bevacqua & Robinson Kurpius, 2013). MHCs also should be aware that the ACA (2014) standards deleted the 2005 exemption that allowed MHCs to refer terminally ill clients who are considering hastening their own deaths because of the MHC’s personal beliefs and values. Thus, personal beliefs and values no longer exempt a counselor from counseling a terminally ill patient who seeks to hasten death.

Conflicts and dilemmas can also arise when such end-of-life decisions are made as refusing recommended medical care, passive euthanasia, and “do not resuscitate” orders. These decisions often involve medical professionals, family members or caregivers, clergy, and the patient, making this area particularly difficult for an MHC member of an integrative care team. Understanding the perspectives of team members and others involved in these types of decisions, the codes and policies affecting medical professionals (Hadjistavropoulos, 1996), and state laws can help the MHC facilitate team collaboration in ways that are ethical, legal, and effective.

WORKING IN HOSPITALS

Some MHCs may work on an integrated health care team in a hospi-tal, which presents unique challenges. In primary care or other nonhospital settings, there are opportunities to provide long-term counseling for such lifestyle issues as smoking cessation or diabetic compliance as part of a team intervention. In a hospital setting, however, counseling may be limited to one visit and may only address decisions that need to be made immediately, such as the course of future care or whether to sign a “do not resuscitate” order. Sometimes, the patient may want the MHC to just “be” with them, without really talking very much or trying to help make a decision. This in itself can be very therapeutic. While traditional counseling provides services to individuals

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and groups over the course of multiple 45–50-minute sessions, working in a hospital typically does not allow a MHC to conduct an uninterrupted session of traditional length. Hospitals tend to be fast-paced and patient stays brief. An MCH’s visit with a patient may be as brief as 15 minutes, and even then medical personnel or visitors often interrupt. Thus, opportunities to build a strong working alliance and detailed conversations about confidentiality may as a practical matter take a back seat to the exigencies of a quickly changing medical situation and the patient’s immediate needs.

Speer and Schneider (2003) stated that those who work on medical teams have been advised “about the importance of adapting to a faster pace and time-sensitive processes in medical care, the need to support and facilitate the physician-patient relationship, and the importance of rapid and timely input into clinical medical decisions and referrals” and to “hurry up,” collaborate, and “be ready for anything” (p. 94). In light of the unique environment a hospi-tal presents, practical issues arise that affect the depth of conversations on such topics as informed consent, confidentiality, and scope of treatment. Such con-versations may need to be tailored to brief and solution-focused interventions. Because the MHC’s notes become part of the hospital’s record, a counselor must also carefully consider what must be recorded; some information may be interesting but not necessary in a chart available to hospital staff. Finally, an MHC should have a realistic counseling plan and goals that take into account the patient’s medical condition, length of hospital stay, and desire to talk. For example, while a brief intervention can help a patient with symptoms of depres-sion, fatigue, stress, and nausea arising from chemotherapy, in-depth therapy to address self-esteem is not realistic. Nevertheless, helping patients address and resolve issues that arise at the most critical times in their lives can be extraordi-narily rewarding and relieve the patient’s emotional suffering.

CONCLUSION

As the numbers of older adults rise steadily, related career opportunities for MHCs will also increase, particularly in integrated health care settings. Older adults are more likely to seek mental health care in primary care set-tings. Thus, it is important for MHCs to build their skills and experiences in integrated settings and their relationships with medical professionals so that the biopsychosocial needs of older adults are met adequately. While unique ethical challenges can arise for MHCs working in integrated health settings and on medical teams, recognizing these issues and being familiar with the guidance that the ACA and AMHCA Codes of Ethics can provide may encourage more MHCs to seize this evolving opportunity to serve an increasingly prevalent portion of the American population, older adults.

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