Eventually, the exciting but messy early era in MFT came to a close: the combination of attrition, licensing laws, new academic programs, published theory, and conferences made MFT a discipline unto itself. Practitioners came to appreciate that, while ideas from individual psychodynamics, interpersonal theory, medicine, and sociology were relevant to MFT, a new way of working required a new way of thinking and a new way of training.

An Opportunity

Care consultation and mediation (CCM) is being practiced by those who were trained outside the field—typically, in social work, nursing, legal mediation, counseling, and even financial management. These practitioners, as did the early MFTs, bring along the mind-set from their backgrounds and must learn their CCM skills on the job. Unfortunately, it can take years for that on-the-job training to turn into competence. The practice of CCM could benefit greatly from a new way of thinking and, with it, a new way of training.

There are tens of millions of potential clients and very few skilled professionals to serve them, but you won’t find a single training program that focuses solely on care consultation and mediation—again, a situation parallel to the field of MFT prior to the 1960s.

As with marriage and family therapy before the boom, health professionals believe that the field of CCM is not unique and that it’s being sufficiently addressed. It’s not. My practice is bursting at the seams. Though I can’t come close to covering the referrals that come my way, I have no one to refer to. I no longer market. Now I duck.

Lighted is not Enlightened

The need for CCMs is no secret, so what’s being done? The solution is being searched for under lighted lamp posts. There’s an old joke: It’s dark; a person loses a coin and is searching for it under a lamp post. A stranger comes along and agrees to help. After a while, the stranger asks how far from the lamp post the coin was lost. The searcher explains that the coin was lost across the street, a good distance from the lamp. The exasperated stranger wonders, “So why are you searching for the coin here if you lost it way over there?”

“Well,” the searcher explains, “this is were the light is.”

The lighted lamp posts, in this case, are academic programs in geriatrics, staffed primarily by research professors rather than by clinicians. But a degree program in geriatrics is no more an adequate training mode for care consultation than physics and wood shop are for hitting a baseball, or would be for physicians and nurses being training solely in human biology, hold the practicum. While understanding the physical and mental changes that take place in aging is useful, it’s insufficient training for clinical work.

To be effective, a CCM must be sensitive to at least as many influences in the lives of a client as should a family therapist. Typically, a CCM is brought in when a transition becomes necessary because the client is contending with the biological and psychological effects of aging. While finding the right placement for the client often becomes the focus, it’s commonly the easiest task.

Getting all those involved, especially the client, to agree to the transition can take the most delicate of negotiations. Negotiating a transition for the client can bring up latent or not-so-latent animosity between adult children and adult step-children, between parents and their children, between step-parents and step-children, and with anyone else who may have a long-term relationship with the client. One of the most challenging conflicts to contend with is when your client has remarried late in life and the couples’ children take sides against their respective step-parent. (You’d like to believe that everyone wants to do what’s best for the client but that’s not always the case.) And when every interested party is in agreement on the placement for the client, you still may have just started your work. If the client has behavioral problems, then you may have to become an ambassador between the facility and the client’s family. While the practice of CCM often brings images of “genteel old ladies and smiling family members,” when the negotiations get tough the negotiations are as genteel as partisan politics. CCM is not for wimps, at least not untrained wimps.

All this is to say that the competent practice of CCM is not something that you can pick up from reading a couple of books (as if there were any) or going it alone in the “school of hard knocks—not without casualties. As with any complex professional practice, your learning experience should be backed by theory, peer support, and supervision. If you can get that strictly on-the-job then you’re probably wearing tights and a cape.

Curriculum and Programs

A framework for a training program must take into consideration its current environment. As stated above, the practice of CCM is a distinct service but, at the same time, shares expertise with other counseling-related services—no point in throwing out the cat with the cat litter. CCMs will be typically working with a family, and often with physicians and other medical professionals, attorneys, guardians, caregivers, placement specialists, and others. Understanding of personal psychology, family systems, and social systems is essential. And as they’re usually working with elders, knowledge of the effects of aging is necessary. In short, while offering a distinct service, CCMs can learn much from what they share with other professionals in medicine, law, counseling, social work, personal coaching, and geriatrics.

Nevertheless, slapping together a training program by assembling professionals from other disciplines would be a mistake—remember the clunky skateboards. What we’re after is a program that makes the best use of available expertise, while starting on the road to attaining its own identity. The profession of care consultation and mediation is sufficiently complex and unique that it will eventually have its own literature, training, and perhaps, licensing—and, I hope, a shorter name.

The daughter of an elder contacts you. She reports the following: Her father is maintaining marginally at home. He attends a day program three days a week, but she feels this is not enough to provide the support that he needs. Her brother is power of attorney (POA), but the POA has not been activated since Dad is still able to make his own decisions. However, because Dad has not dealt well with his finances and is now in debt, her brother has stepped in to pay bills that Dad can’t cover. Because her brother is paying the bills, he believes that he should make all the important decisions for their father, even to the to extent of telling Dad not to take prescribed anti-depressants because he (her brother) believes them to be ineffective.

Who’s the client? The daughter who hired you and signed your fee agreement? The son, who’s been appointed the POA, is paying father’s bills, and might even be expected by the daughter to pay for your services, because, after all, you’re going to be evaluating their father’s needs and making recommendations? Let’s look at a few additional examples:

A woman suffers from early Alzheimer’s disease. Her daughter has arranged for in-home care, but it is insufficient to address that her mother is no longer capable of preparing meals or of, without supervision, safely taking prescribed medications. Her daughter manages her finances and knows that the needed 24-hour, in-home care is not financially feasible. Her daughter contacts you because she wants you to talk her mother, who still (legally) makes her own decisions, into moving to an assisted-living facility.

Who’s the client? The daughter who hired you? Or her mother who, while suffering from cognitive disabilities and memory loss, still has the legal right to make her own decision? And:

You are hired by a lawyer, the POA for an elderly woman, and on whose behalf asks for your assistance in dealing with the assisted-living facility where she resides. You contact the facility and the director complains that the POA’s client is disruptive and that they’ve exhausted their repertoire in trying to deal with her. But, much to your pleasant surprise, the director gushes over your stellar reputation and states that she’s delighted that you will solve their problems with this woman.

Who’s the client? The lawyer who hired you? The gushing director of the facility?

Who’s the client for dummies

In nearly all professions, determining who’s your client is simple. If you’re a doctor, your client (or patient) is the one with the booboo, and is always the one under whose name the service is charged. If you’re a lawyer, your client is going to be the one for whom you’ll be advocating or defending. If you’re an accountant, your client will be the one whose financial interests you’ll be looking out for. If you’re a counselor — okay, that one can get a little tricky because, while there may be an identified client for the requirement of insurance reimbursement, a family or marriage counselor might view the collective group as the client. Nevertheless, in nearly all cases, the care consultant deals with the issue of who’s the client more than any other profession.

So how can you be the Larry Bird of care consultation? How can you handicap your work with your clients? By regarding anyone but the elder as your client². No matter what, in your practice, you’re going to be dealing with conflicts among those involved with an elder in need. People see things differently, and those differences of opinion will often be the very reason you’re hired. But it’s one thing to work to resolve the conflicts among the elder’s posse. If you’re confused about who’s the client, you’ll be wasting your time trying to solve conflicts within yourself. Even Larry Bird avoided that thankless challenge while doing his job.

When numerous parties are involved, and if there are conflicts, your work can get difficult, very difficult. But if you seem to be having an especially hard time, ask yourself: Did I forget who the client is?

How it happens, how to avoid it.

When you have been hired, you’re being paid twice: you’re being paid money (indirectly, if you work in agency), and you’re being paid a professional compliment. It’s normal to feel gratitude towards the person who made the decision to retain your services, and it would be downright weird to respond along the lines of thank you for hiring me, but don’t expect to be more favored than that of other involved parties. Nevertheless, you must get that across in the form of making it clear that the elder is your client, and that every involved party is important in how they can serve the goal of assisting you in coming up with a plan and executing that plan to serve the needs of the client.

Getting across that the elder is the (one and only) client is an ongoing process. It will be reflected in how you gather information, in that no family member will be considered a more reliable informant than any other, unless demonstrated otherwise. It will be reflected in the manner of sharing information among those involved; you will make it clear to everyone that you will share information as necessary, and only as necessary, in a manner which will help you create a care plan for the elder. It will be reflected, most of all, in the care plan itself.

At the same time, focusing on the needs of the client does not mean ignoring the needs of everyone else. Parents who take care of an infant need to eat, sleep, and relax, if they are going to give the child the best care. That also goes for everyone involved assisting in the care (whether directly or indirectly) of the elderly client. So, if a member of the family is taking on the bulk of responsibility by, for example, taking the client to lots of appointments, or doing the bookkeeping, or acting directly as a caregiver, then providing some relief for that person is in the best interest of your client.

Footnotes:

¹The difference between family therapy and care mediation is discussed here.

²In theory, a lawyer, doctor, or care facility might hire you as a consultant to deal with one of their clients. If the contract is between you and the lawyer, or you and the doctor, or you and the care facility, (which means that they, not the elder, are paying for your service) and you don’t work with the client directly, then that becomes the rare case where that lawyer, doctor, or care facility is your client rather than the elder. Do not be surprised if this never happens in the life of your practice. Why? Because lawyers, doctors, and care facilities nearly always want to be lawyers, doctors, and care facilities rather than car consultants. They’re hiring you to take those responsibilities off their shoulders. This is a good thing for everyone concerned because you’re the expert on what you do. Likewise, you won’t be dispensing legal advice, medical care, or direct care to the elder, though one of your main jobs may be gathering information to aid the lawyer, doctor, and so forth.

First, the similarities. A care consultation session often includes family members of more than one generation and, nearly always, one or more siblings. Those present have been brought together to solve a problem that has proven intractable. One or two of those present may be the focus of that problem. Most participants have a history together, about which they have varying opinions and attitudes, and that history results in mixed emotions about each other. There are numerous alliances and conflicts among the members.

Now let’s look at the differences. The children are nearly always adults and are looking after the needs of their parents rather than the other way around. The client may not be present in the session. (As a family therapist, I often worked with children’s issues by working with only the parents—but that’s not typical.) The siblings don’t live together, lessening their need to get along with each other. While there may be significant cross-generational issues, everyone is a grown-up and may do as they wish — although the client may be (legally declared) incompetent to make certain decisions. Potential inheritance — money — is the tyrannosaurus rex in the room.

There’s one more major difference, and for the care mediator, it’s the one that counts. It’s the one you have to remember when a participant first confuses care mediation with family therapy, and unloads both barrels on someone in the session — maybe a sibling, maybe a parent, maybe you. Experience tells you that, once the congeniality force-field gets lowered for even a moment, the dung will hit the wind-powdered energy generator: factions among siblings and elders will pop-up so fast, and in such number, that you’ll need Deep Blue to keep tabs. If you’ve kept your wits about you, this difference will whisper in your ear that it’s time to hit the pause button before you and family fall down a rabbit-hole of such chaos that it would make Lewis Carroll renounce fantasy.

You’re going to have to jump through all the stages of, “Oh, hell!” — from denial to acceptance — in moments, because the only person that pause button works on is you. What you have to remember is that, in family therapy and care mediation, the goals are different. While, in family therapy, the “identified client” is nearly always a child who is misbehaving in some fashion — skipping school, disrupting classrooms, doing drugs, running away, and so on — the client is typically viewed by the family therapist as one who is “acting out” to take the heat off the real problem. For example, Johnny disrupts his school classes because, as long as he’s the problem his parents stop bickering and (in his mind) won’t get a divorce. The family therapist understands that Johnny won’t stop acting out until his parents’ marital issues are dealt with. Whether or not the marital issues are dealt with directly or by way of Johnny’s problems is based on the approach of the family therapist, but dealt with they must be if Johnny is going to change his behavior.

Hence, the goal of family therapy must always take into consideration that, since they must all live together, they need to get along well enough for that to continue. And to make that happen, your job as a family therapist may be to help them change the complex family dynamics.

In contrast, the care consultant’s job is not to be concerned with the family’s dynamics except in how it immediately interferes with the goal of setting up and maintaining care for the client. All the work in the session should be to that end. This does not mean that the care consultant can ignore family dynamics, or that a deep knowledge of family systems theory is unnecessary. It’s important to know what influences are present during the negotiations among family members. A 40-year-old adult child’s concerns may be as complex, indirect, and unconscious as is with the disruptive Johnny. However, in care consultation and mediation, your interest is in minimizing the focus on concerns that are disruptive rather than constructive to setting up care. Respectfully acknowledge those feelings, but do not let them take over the session.