Integrated Health Care

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

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 comprehensive 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 setting presents unique challenges and raises ethical issues. The evolving opportunities and strategies 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 psychologists, 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 considers 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 independent 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 members is particularly important for older adults because they prefer to seek mental 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 interprofessional 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 professionals: non-targeted and targeted integrated care teams. A non-targeted practice provides 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, crisis 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,
5090% of clients with mental health needs rely solely on their PCP for those
services. However, because PCPs may not be trained in mental health diagnosis, many mental health issues go undetected (CDC, 2012). For example, as
many as 50% of primary care patients with depression are not accurately diagnosed, and 3050% 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 adults
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 intervention 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 satisfaction (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 appropriate professional experience (ACA, 2014, C.2.a). The American Mental
Health Counseling Association Code of Ethics (AMHCA, 2010) also explicitly 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 counseling 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 experience, 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 conferences, 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 education 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, however, 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 explicitly expressed disinterest in working with older adults with comments such as,
This area of age, death, and dying is something Im not particularly comfortable 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 concerns (Robinson Kurpius & Vaughn Fielder, 1998). Attending a weekend workshop 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 conditions and the aging process so that they can discern the differing roles of psychopathology and biology in a patients 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 patients 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 patients daily medical
condition, may believe the patient is actively dying and may recommend no
treatment. Family members complicate the situation when they do not understand or have trouble accepting the patients current condition and prognosis
and may insist on acute or aggressive care. At times, health care professionals
and family members may ignore a patients 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 financial 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 perspectives, 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 perspectives, MHCs can help mediate differences of opinion about future treatment,
educate family and patients in a supportive way about a patients condition and
prognosis, and help guide the team, the family, and the patient toward a mutually acceptable plan. In sum, when MHCs understand the medical concepts,
the medical culture, each professionals 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 ones competency, doing so may subject 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 management (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 loyalties 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 voluntary consent, the MHC must act in the patients 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 counselors 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 medicine that includes CAM therapies, there remain questions about the effectiveness 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 benefits 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 guidelines 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 MCHs
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 patients
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 professionals have access to patient records, including the chart notes made by the
MHC (Belar & Deardorff, 2009; Kelly & Coons, 2012). Electronic medical
records make a patients 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 MHCs 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 teams 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 confidentiality 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 teams existence and composition, the information 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 patients views on confidentiality 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 strictures, 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 specifies 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 professionals 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 protect 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-oflife 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 assessment, 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 assistance (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 counseling 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 complex issue morally, legally, and perhaps spiritually for MHCs. Great care must
be taken to avoid asserting ones 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 MHCs 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 hospital, 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 4550-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 MCHs 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 patients 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 hospital presents, practical issues arise that affect the depth of conversations on such
topics as informed consent, confidentiality, and scope of treatment. Such conversations may need to be tailored to brief and solution-focused interventions.
Because the MHCs notes become part of the hospitals 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 patients medical condition, length of hospital stay, and desire to talk. For
example, while a brief intervention can help a patient with symptoms of depression, 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 extraordinarily rewarding and relieve the patients 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 settings. 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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