Consultation
and Advocacy: An Integrated Approach for Aging Care Management
Survey
of Research in Human Development for Professional Counselors
Abstract
This
paper presents a discussion supporting the integration of both Consultation and
Advocacy approaches to counseling in service delivery paradigms for members of the
aging population. A hypothetical Care Management case is used to show how the
two distinct approaches are complimentary, and how using an integrative
approach is empowering to the individual, and contains within it the potential
for maximizing their wellbeing.
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Consulting
and Social Justice Advocacy are two distinct, yet crucial aspects of the Mental
Health profession, each vying for recognition as a significant component of its
gestalt. In its totality, the profession
purports to function primarily as a service provider with the goal of
mitigating the resolution of difficulties encountered in the lives of
individuals, organizations and other systems. Yet how these two distinct facets,
consultation and advocacy, go about the business of completing their work is a
subject of continuous scrutiny by researchers in the field of mental health
counseling. Perusing the literature in both domains, one easily recognizes that
discussions about them speak more about their distinctions than their
similarities, further reinforcing their dispersion. The dilemma facing these
strange bedfellows is not easily apparent and perhaps therein lays a challenge
for mental health counseling researchers.
Ongoing discourse highlighting the qualities unique to each brand of
service delivery may assist in furthering a deeper understanding of them as
more alike than dissimilar, thus articulating more succinctly their role and
function within the context of professional practices, as complimentary rather
than disparate.
Kurpius
and Fuqua (1993) wrote that the term consultation includes a wide range of
services that can vary substantially (p. 599), and drawing from Lippitt and
Lippitt (1978), they list a variety of “consultant modes of intervention” which
typify the range of consulting services ascribed to providers of mental health
services. Their list describes the decidedly passive role of the consultant as
“expert”, “problem solver”, “linker”, “process counselor”, “trainer”, and
“objective observer”. In their article ‘Fundamental Issues in Defining
Consultation’, the writers also quote from a number of other sources that have
identified commonly perceived modes of interventive practices. These include Schein
(1969, 1978, 1991) who uses the terms “purchase of expertise”, “doctor-patient”, and “process consultant”,
and Caplan & Caplan (1993) who characterize the consultant as a “mental
health expert”, “client centered case consultant”, “consultee centered case consultant”,
“program centered administrative consultant”, and “consultee centered
administrative consultant”. Moe,
Perera-Ditz, Sepulveda, (2010) present a concise definition of consultation in
the article titled ‘Are Consultation and Social Justice Advocacy Similar?:
Exploring the Perceptions of Professional Counselors and Counseling Students’.
In this article (referencing Brown, Pryzwansky, & Schulte, 2010, Kampwirth,
2006, Kurpius & Fulqua, 1993), the authors identify consultation as an
activity that “typically involves acting on behalf of an identified client
through interaction with another professional consultee or other stakeholder in
the client’s welfare”.
These
descriptions serve to characterize the consultant/client relationship as being
predominantly vertical in hierarchical structure, and evidentiate how power in
this relationship is transmitted in a top-down fashion. The client, possessing
a lesser degree of knowledge about a critical situation, reaches out for
assistance from the consultant, who is better equipped with the skills set
required to adequately address the problem. When encountering their personal
limitations, the consultant does likewise, and turns to assistance from one possessing
an even greater degree of perspective in order to ameliorate the problem. The
consulting relationship is summarized in two outstanding features: (a) the
client actively seeks out the assistance, and (b) the client is given theoretically
based advice regarding how to address the problem (largely ignoring the context
in which they occur). In other words, within the consulting model, the client
comes to the counselor, problems in tow, mainly seeking guidance and internal relief from the pressures and
difficulties of a particular situation.
Perhaps Ivey & Collins see definite
limitations in this style of counseling. In their article ‘Social Justice: a
Long Term Challenge’ (2003), they address the point that it is virtually
impossible to solve some individual problems if the context in which they occur
does not change. Moe et al., (2010), referencing Prilletensky &
Prilletensky, (2003), and Constantine, et al., (2007), state that those using
the social justice framework are more prone to synthesizing concepts from the
social justice paradigm with those of other key counseling perspectives such as
multicultural theory (p. 107). Multicultural theory as defined by Ivey &
Collins (2003) is “an integrated theory contextualizing the field” (p. 293). The
authors compare traditional counseling approaches with those of the multicultural
approach, describing the traditional methods as focused primarily on the
discovery of the role of the past in the present, with application of behavior change treatments to facilitate
adaptation to changing conditions.
Multicultural
theory, on the other hand, places greater emphasis on “the importance of
expanding personal, family, group and organizational consciousness of the place
of self–in-relation, family-in-relation, and organization-in-relation” (p.
293), supporting the need for counselors to incorporate the use of systems
approach with the consulting approach for identifying barriers that restrain
the client from reaching their full potential. With respect to the aging
population, social justice theory would suggest that any oppressive system that
treats minority populations as second class (i.e., less deserving of equal
access to resources) is considered a barrier. Incorporation of the
multicultural perspective in counseling practice with aging populations equalizes
the power differential, and reduces the impact of such discriminatory practices
that endow certain individuals with privilege, and rule others out as unworthy.
Integration of the consultation approach and the advocacy approach promotes
best practices by providing a solution that both relieves personal problems and resolves the contextual barriers
facing the client.
The
integrated approach is emerging as the preeminent approach for service delivery,
and in my role as a geriatric care manager this approach is quite useful as the
premiere method of helping. This “shift in the counseling paradigm” (Ratts,
2008) is most evident in the manner in which “clients” are identified. For
instance, in our work as service providers we are encouraged to use terminology
that is solution-focused and strength-based, and so we refer to our “clients”
as “Participants”. Using this terminology reframes the nature of the
relationship, and characterizes the client less as an individual who is a recipient
of services, and more so as one who is an equal contributor in the helping
process. Participants meet the consultant in the middle, according to their
strengths and present level of ability. When a resource is needed as a channel
for meeting service demands, instead of the consultant calling the resource on
behalf of the Participant, the Participant instead is given the contact
information and encouraged to do the footwork. If an application for housing
services needs filled out, the consultant offers their assistance in filling it
out, but the Participant is encouraged to rely primarily on their own ability,
and the help of informal supports (family, friends) to complete the task. The
role of mental health training in this event is important for cultivating
self-reliance in the individual where lacking, thus empowering them to advocate
on their on behalf. Collaborative empowerment
in service delivery helps individuals remain active in their communities,
rather than warehousing them out to nursing homes and long-term living
facilities.
The
theory behind this approach has been discussed at great length in the article
titled: A Framework for Understanding the Consultation Process: Stage by Stage
(Buysse & Wesley, 2004), wherein the authors identify consultation as an
eight stage process. An integrated lens may be used to support its significance
as a valid approach to service delivery in the field of geriatric care
management.
Stage
|
Consultation
lens
|
Social
Justice lens
|
Integrated
lens
|
1. Gaining Entry
|
Individual is the problem, strives to change the
individual in the situation
|
Individual has a problem, strives to change the situation
|
Problems are inside and outside the individual
|
2. Forming relationship
|
Establish parameters of relationship, ground rules for
participation
|
Frame relationship as both a process and a goal (Adams,
Bell & Griffin, 2007. Pg. 3)
|
Combine both approaches and moves against the status quo
(Adams, Bell & Griffin, 2007. Pg 3)
|
3. Gathering Information
|
Identify individuals’ contribution to problem
|
Identify external stifling factors contributing to the
problem (activist mentality)
|
Explore and identify internal and external contributing factors
as barriers to problem resolution
|
4. Setting the Goal
|
Consultant writes goals for the client
|
Advocate creates strategies for client to use
|
Designs strategies with the client, based on their unique abilities,
strengths and capacities
|
5. Selecting a Strategy
|
Consultant advises client on “what to do”
|
Advocate identifies environmental issues for the client
|
Counselor discusses options with client and encourages
them to chose the problem they’d first like to address
|
6. Implementing the Plan
|
Consultant remains objective, and available for further
advice
|
Advocate works closely with client, providing “hand-on”
assistance as active change agent
|
Counselor maintains appropriate distance, Supports and
encourages client (with informal supports) to be the change agent
|
7. Evaluating the Plan
|
Monitors progress in planned follow-up sessions, discusses
issues in retrospect
|
Assists client in understanding the context of the
oppressive environment, and empowers them with self-advocacy skills, so they
may become more self-sufficient (Ratts, 2008)
|
Continually monitors the progress, and reassess the plan
as needed; cultivates the ability to be flexible (Ratts, 2008. Pg. 6)
|
8. Holding a Summary Conference
|
Summarizes the outcomes and identifies successes and
failures
|
Prepares client to effectively manage similar problems in
the future (Brack, Jones, Smith, White & Brack, 1993. Pg. 620)
|
Paves the way for on-going collaborative interventions.
Plans series of follow-up meetings to monitor progress
|
The
following example shows how an integrated approach would best meet the needs of
an aging client participating in a service delivery paradigm that serves
individuals by helping them to remain independent in their homes, as opposed to
being warehoused in short or long term nursing facilities. In this example, the consultant would be the
Care Manager, and the client would be known as the Participant.
Participant
Profile
John D. is a recent
referral to the County Area Agency on Aging. Referral was made by the
Social Worker at the local General Hospital. This Participant is a 78
year old male who lives alone in remote home location with no informal
supports. The Participant ambulates with a cane. He has been diagnosed with
Depression, Hypertension, Glaucoma and GERD, and takes physician prescribed
medication treatments including Wellbutrin, Amlodepine, and Prilosec. He had
recently been admitted after sustaining a head injury due to a fall that
occurred while transferring from the shower. The Participant reported that the
fall was due to sudden onset of dizziness. The Participant sustained a
concussion, took public transit to the hospital and was admitted, remaining
under observation for three days, and was discharged to his home. He has no
permanent impacts as a result of the injury, however, the Participant did
exhibit signs of bladder incontinence. He is alert and oriented to person,
place and time. The Participant seemed under normal weight for his height and
frame. His monthly income amount totals approximately $927 Social Security, and
a pension of $343. His hospitalization insurance is through Advantra. Care
Management services recommended for this Participant are as follows: PERS (Life
Alert), Adult Briefs, Senior Companion Program, Interfaith Volunteer Caregiver
Program, and Safety for Seniors Program. It is also recommended the Participant
begin Meals on Wheels Services.
Consultation
Process
Stage 1. Gaining Entry: A telephone call to the
Participant is made to schedule the meeting for the initial Level of Care
Assessment, and the Care Management Instrument assessment.
Stage 2. Forming relationship: Care
Manager begins to build rapport and trust in the onset of the relationship with
the initial phone call. Counselor identifies the Particpant’s unique
characteristics, strengths, risks and resiliencies, and begins to consider how
these will factor into intervention strategies later in the process.
Stage 3. Gathering Information: Care
Manager asks closed ended questions when harvesting for specific information.
Open-ended questions are used to help facilitate the Participant’s elaboration
on the details of an inquiry. For instance, the Care Manager may ask the
Participant to describe a typical day in his life, or to outline the patterns
of the week, in order to gain a perspective of the individual range of
activity, and to discern in depth his level of independence with activities of
daily living.
Stage 4. Setting the Goal: During the assessment,
the Counselor identifies risk and protective factors in the Participant’s life.
Formal and Informal supports are identified, and the counselor engages these as
resources that would be of use to the Participant when designing interventive
strategies for meeting his service needs.
Stage 5. Selecting a Strategy: Participant
identifies his main desire as being a wish to remain in his own home. Counselor
selects appropriate resources and collaborates with the Participant in
enlisting their assistance for meeting that goal. To address the Participant’s
incontinence needs, the counselor presents three separate options for service
providers, describes the pros and cons in their particular range of services,
and gives Participant choice to identify and select his preferred provider. To
address depression, Counselor arranges with the Senior Companion Program to
match a volunteer friendly visitor according to the Participant’s preferences
(male, female, time of day for visit, day of week etc.). The Participant is
given the volunteer’s contact info, and is encouraged to make the outreach
contact himself. Likewise, using the Interfaith Volunteer Caregiver Program, a
local volunteer would be linked with the Participant by providing
transportation to the grocery store. The Counselor would also help the
Participant enroll in the local ACCESS elder transportation system, which the
Participant would use for trips to doctor’s appointments. To meet the
Participant’s social needs, the counselor would identify the local area Senior
Center, and encourage the Participant to participate in its program offerings.
Coordinating these services on behalf of, as well as in tandem with the
Participant, will help to reduce the barriers that keep him isolated from the
community, and enable him to more fully engage his spectrum of capacities, simultaneously
promoting an improved quality of life.
Stage 6. Implementing the Plan: The
Counselor and the Participant make the contacts with service providers and
organizations and activate the solutions.
Stage 7. Evaluating the Plan:
Monitoring occurs through telephone calls at the two-week point, and then
monthly thereafter.
Stage 8. Holding a Summary Conference: A
home visit is scheduled at the six-month point, and then a complete
reassessment is completed annually.
Summary
When
faced with a critical situation, clients require the assistance of someone who
understands how the system can stand to interfere with those needs being met.
Service delivery systems are quite complex, and individuals often require the
skills of an informed expert to address and help resolve their problems. This
is why it is of the utmost importance that the counselor of today be equipped
with the education, skills and abilities to deal with the issues that are
endemic to the individual, as well as those that are specific to the
institutional systems they must interact with, in order to have their service
needs met effectively, thereby ensuring continuation of their highest level of
function.
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