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Home is where the client is

Dawn Friedman September 1, 2012

For some counselors, meeting clients where they’re at is more than a figure of speech. Counselors who specialize in home-based therapy work with clients in their living rooms and at their kitchen tables, giving much-needed assistance to families and individuals who otherwise might not be able to access mental health services. Home-based counseling eliminates barriers for families who don’t have good child care options or who have trouble securing rides to the clinic.

An ecological framework focused on family preservation shapes most home-based counseling programs, with counselors considering their identified clients in the context of the complete family and community systems. Parents at risk of losing custody of their children to social services are usually targeted for home-based services, which often involve other wrap-around help such as case management and psychoeducational support. Home-based work also makes sense for foster families who could use help navigating the intensity of the needs of the children in their care.

Theresa Robinson is an American Counseling Association member who works for a community mental health agency in Tucson, Ariz. She says her clients face multiple challenges — poverty, dual diagnosis and insecure housing are common concerns — so her agency uses a team approach that allows the counselors to focus exclusively on therapy, while ensuring that clients get the extra assistance they need. Monthly team meetings focused on the child and family keep everyone on course and ensure stability of services.

“We have care coordinators who do case management and family support specialists who help with parenting skills and psychoeducation,” she explains. “For example, in a family where the children are removed and are now in foster placement, the family support specialist will be going in to help the foster parent deal with parenting issues, and I’ll help the kids deal with the emotions and feelings around missing mom and dad.”

Robinson says being able to read her clients’ environments — to see how they use their space together and how that shapes their experiences — allows her to build rapport more quickly. “I do a lot of work with teens, and they show me their rooms, what they’re doing and drawing, and the music they’re listening to,” she says. “I think it makes them feel less defensive and less likely to shut down because I’m coming to their turf as opposed to asking them to come to an unfamiliar place and talk about their feelings. I think I’ve gotten a lot further a lot quicker [with home-based counseling].”

Safety first

Al Sylvia Procter, an ACA member in private practice in Valley, Ala., spends most of her time on the road traveling to her clients’ homes, many of which are in isolated rural areas. Procter was introduced to home-based work as a student, when she worked as an intern at a family services agency. Although the agency offered both office-based and home-based counseling, she found that home-based counseling generally served her clients better. When it came time for Procter to build her private practice, going into her clients’ homes seemed like the obvious choice.

Procter acknowledges that the 20 years she spent as a military police officer make her feel comfortable going into environments that other practitioners might avoid. Mindful of safety, Procter keeps her cell phone charged and always makes sure that someone else knows where she should be at any given time. She also schedules intakes at neutral, public locations such as libraries or even laundromats so she is able to explain her expectations, secure the client’s buy-in and gauge her own comfort level with going to that particular client’s home.

“I’m old school,” Procter says. “I’m just straightforward, and I let my clients know up front what I need to work with them. If they can’t do that, then maybe they need a different therapist. I’ve gone to houses with loose dogs, and I tell [the clients] to put them up, or else we can meet someplace else. If all else fails, we can terminate the relationship.”

For counselors accustomed to controlling the therapeutic environment, home-based work can be challenging. Houses may be dirty, and there isn’t always a clear place to do counseling. The client might not have a kitchen table or a couch to sit on in the living room.

Procter says home-based counselors should be prepared to confront conditions that are less than ideal, while still remaining flexible. “I don’t want them to have to clean for me,” she says. “I want their house to look the way it normally works.” She adds, however, that if health and hygiene issues are present, such as roaches crawling on the floor with the baby, she will address those issues in session.

Counselors interested in home-based work also need to be adaptable, Proctor says, because the number of interruptions is greater than when doing office-based work. For instance, clients might need to suspend a session to attend to a crying baby or to answer a knock on the door, or they may need to get up to start dinner. Rather than regarding these circumstances as distractions, many home-based counselors view them as opportunities to witness how the family is managing and to offer interventions where appropriate.

To save on gas and to lessen the wear and tear on her car, Procter schedules her clients by county, arranging appointments around the several multidisciplinary team and committee meetings that she participates in regularly. Because she maintains a home office, she saves on rent, and a portion of her living expenses and her other business-related expenditures such as mileage, Internet and cell phone are tax deductible.

Understanding services

Christine Woods is an ACA member in Rolla, Mo., whose private practice consists entirely of home-based clients. She says home-based work has been more effective for her than meeting with clients in an office. “My colleagues think I’m completely insane, but I do not like in-office therapy,” Woods says. “I get better results because [my clients] are more relaxed and more calm.” Woods also believes she is able to build the therapeutic relationship more quickly during home visits.

She offers an example of why home-based counseling has the potential to be so effective. “There was a situation where I was doing family therapy for a kid and her mom, and they were constantly fighting about chores,” Woods says. “One day, one of the assignments I had for them was to have mom show her daughter how to actually do those chores. The daughter says, ‘Oh my gosh! I get it.’ She needed her mother to show her, and from then on, they didn’t fight about chores. If I hadn’t been right there helping them work through the exercise, I wouldn’t have had that opportunity.”

Most of Woods’ clients come to her through referrals from other agencies and have more experience with case managers than with counselors, so part of her work involves explaining what counseling is and what she can and cannot do for clients. Because Woods is in private practice, she does not work with a team. Instead, she stays updated on community resources and helps clients get referrals to additional programs when their needs go beyond her scope of practice.

Woods echoes Procter’s advice concerning the need for home-based counselors to be clear and up front about their expectations. “I’m pretty blunt. I say, this is what my role is, and if you need case management, if you need parenting skills, we can hook you up with services to address that, but what I do is strictly therapy.”

Possessing the proper attitude is pivotal to the success of home-based counseling. “When people invite me into their homes, the most private place they have and the place they feel most secure, I recognize that it’s a privilege,” Woods says. In fact, she adds, demonstrating her respect for and acceptance of her clients is even more powerful in that context. “You cannot be judgmental. If the furniture is stained or the house is run-down, for them to be able to feel like they’re treated with respect when I walk in, that’s key to helping them feel OK and trust me.”

Mandate for the profession

Greg Czyszczon is an ACA member and doctoral candidate in counseling and supervision at James Madison University who is researching home-based counseling. He says discussions about home-based work can get muddied, both for clinicians and for clients, because paraprofessionals — college graduates with little to no clinical training — are sometimes hired to do home-based work with clients, and these services are often confused with actual counseling.

“In many areas of the country, people are allowed to offer services in-home that they could not offer in an office,” Czyszczon says. “An agency might send a 23-year-old with a bachelor’s degree in sociology [who maybe] worked for a year in an after-school program, and [he or she] would be the one working with kids who have trauma history and abuse history living in homes where there is substance abuse and domestic violence. For some reason, when it’s in-home, it’s acceptable to have people in there who don’t have training.”

That scenario is bad not only for clients, Czyszczon says, but also for counselors who are offering home-based services because the resultant confusion diminishes the therapeutic work that many appropriately trained clinical counselors are doing. In a 2011 presentation at the ACA Conference in New Orleans, Czyszczon and fellow ACA member Cherée Hammond advocated for the counseling profession to recognize home-based counseling as a specialized area of practice, much like play therapy or couples counseling. Czyszczon and Hammond believe counselors should have specific training on family systems, crisis counseling, resiliency, attachment, trauma-informed care, multicultural intervention, child development, substance abuse and serious mental illness before they begin doing home-based work. They would also like for ACA and the Council for Accreditation of Counseling and Related Educational Programs to join in the discussion. “We want to say, if you’re going to be a [home-based] counselor, then these are the recommended competencies in this in-home scenario, and we need to be specific about those as a profession,” Czyszczon says.

Gerard Lawson, an ACA member and associate professor in the Virginia Tech School of Education, has conducted research on home-based counseling and supervision and asserts that it is some of the most challenging work that counselors can take on. Offering home-based services aligns with the counseling profession’s social justice mandate, he says, but too often, those tasked with doing this work are ill prepared for its many challenges. These practitioners can also be confronted by a professional stigma that says home-based work is case management rather than true counseling, Lawson adds.

“These families [clients of home-based counseling] are multichallenged, often on the verge of homelessness, often with involvement with the court system, with addiction issues and poverty,” he says. “You’re working bad hours and going out to people’s homes. Maybe your caseload isn’t as full as someone doing office-based work, and that could create the perception that this is less than counseling. But, actually, it’s counseling-plus. It was the hardest work, bar none, that I’ve ever done in my life.”

“When I talk to supervisors about home-based work, what I try to tell them is that the system is upside-down,” Lawson continues. “There is no good reason that we should be sending people out who are working on their master’s degree or who are newly graduated to attend to cases that would be challenging for a more-seasoned professional. The best and the brightest [of our profession] should be doing this work.”

Lawson says isolation and burnout are issues for home-based counselors because they spend most of their time in the field and may not get the peer support that office-based colleagues receive simply by checking in with another clinician on staff. “Counselors [who do this work] are prime for compassion fatigue and vicarious traumatization. This kind of work places them at greater risk,” he warns. “That’s a recipe for burnout, or they’re just going to become numb to it, and they’ll invest less and less of themselves. The antidote to that is good supervision, but a lot of the supervisors have never done home-based work.”

Lawson would like to see greater numbers of experienced counselors take on one home-based case to augment their in-office work. Spreading around this workload would create a larger peer group of counselors experienced in home-based work who could offer one another support, he says. It would also allow counselors who currently do mostly home-based work to see some clients in the office, supplying these counselors with the attendant peer support that comes with working on-site.

“Maybe it doesn’t become an exclusive sort of service anymore,” Lawson says. “For everybody that’s doing outpatient work, perhaps they flex their time and have one home-based client that they work with one day a week. That would decrease the stigma [of home-based counseling], and it would also mean that this would be less segregated. If everyone is doing it, then it becomes more of ‘This is what we do as a profession.’ We could say, ‘If these families haven’t been successful here [in the office], they need a more intensive level of treatment, and that should continue with the same counselor.’”

Like Czyszczon, Lawson sees home-based counseling as a matter of social justice and thus part of the counseling mandate. “The reality is that this population needs better service, but they’re given less and less attention,” he says. “As a professional, I find that troubling. And as a member of the community, I find that shameful.”

Although the work is difficult and stressful, Woods says she has no plans to go back to counseling out of an office. “Some people are made for office therapy, but I get better results when I work with people in their homes,” she says. “There’s a gift that I’m to learn from them just like there’s a gift that they’re to learn from me.”

 

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Dawn Friedman is a writer and counselor-in-training in the community counseling program at the University of Dayton. Contact her through her website at DawnFriedman.com.

Letters to the editor: ct@counseling.org

16 Comments

  1. LS

    You forgot to mention the big elephant in the room- Money. Reimbursement for services and ability to pay is an issue most of the time. If a client needs home-based counseling, can’t get to the office, can’t commit to a typical office visit schedule, maybe is disabled, maybe unable to secure childcare, etc, then I would guess that 9 times out of 10, they can’t pay a lot for counseling. In my experience, most of these home visit clients are Medicaid clients, which of course does not reimburse a lot. That’s why very few seasoned clinicians will see more than a couple of home-based clients, and typically home based work is something that newly minted counselors/social workers do. (not to mention the paperwork makes it even less desirable). Upside- Down definitely.

    Even if the client has decent private insurance or can afford a reasonable session charge, reimbursement is going to be an issue that needs to be addressed early on. How much are you going to charge for travel time? Some professionals would charge the same for the 45 minute ride as a 45 minute session, which would be very very difficult for most people to afford. If they could afford it, then most likely the client would switch to office sessions as soon as possible, to save money. Others might roll it into the standard session fee or use a sliding scale. In addition to the discussion about travel expenses, interruptions are also important. Rarely have I done a session where we weren’t interrupted. Do you stop the session clock then or just roll with it? Since I was working for a Medicaid-funded community-based agency, most therapists would just rolled with the interruptions in sessions, but bill Medicaid for the time. Finally, even home-based therapists have no-shows, which is extremely frustrating and time-consuming. How much does one charge for that? If one involved family member is home, but the IP is not, do you still do the session? But if the client is paying, that’s a hard call to make. But again, the biggest issue I see with home-based work is the money issue. In order to get fairly reimbursed, experienced clinicians would have to charge AT LEAST $75-100 for the session AND charge for travel expenses, including time and mileage, which would likely bring the total to $100-150+ a session, which few rural, homebound, and/or nearly homeless clients could afford. More food for thought. My hat goes off to people who do this work professionally.

    -I just completed a clinical internship doing home-based therapy and case management.

    Reply
  2. LifeCoach

    I’m a self-employed female certified lifecoach, and it’s my passion to help people. I don’t have all the schooling that a traditional counselor has…so I charge alot less. I do not charge a “traveling fee” if the client lives withing 10-15 minutes away. If more than that I charge a small fee of $10 per 1/2 hour or any part of. I figure, where else can I make that kind of money with no degree?

    Reply
    1. Ashley

      Do you still do these things? I’m in need of one bt no insurance and not alot of money to get one to come to me.

  3. Amy

    Any counselor with a degree over that of a master’s, thinks too highly of themselves and would never lower themselves (in their mind) to do home therapy. They view themselves like some God-like Dalai Lama whose clients should be willing to climb mountains, and travel many miles to seek their “enlightened” advice. This was a long article to simply state…”they’re just lazy.”

    Reply
    1. Rik

      Not true Amy, not everyone in the field is like you assume, but I would imagine you do not have a ton of experience either.

    2. Dionne Collins, MA, LLPC

      Hello: I have a Master’s degree in Counseling and have my own Practice and I do contract work for a mental Health clinic, as second job, providing Home based counseling in client’s homes. It is NOT an easy job and it does challenge me but l love what I do I because it “impacts” treatment in a positive way. It does take passion to do this level of work in this capacity!

  4. Joshua

    I really appreciated this article as a professional considering entering the field of home based counseling. I have worked in community mental health for the last 3 years and am preparing to begin my residency to become an LPC. I welcome the opportunity to learn from others in the field and enjoyed the insight and potential impact that this specialization offers.

    Reply
  5. Ellen

    Home based therapy would give the therapy some real insight on what the client goes through on a daily basis. My mother sent me to counseling when I was in grade school and high school. I feel that it did not work for me because the therapist was not getting the full picture. My mother would automatically state that I get upset and even lash out because my dad committed suicide. But my mother (deliberately) neglected to mention that she would be the one lashing out and flying off the handle to me, my brother and sister on a daily basis. She would even resort to calling us degrading names. My brother and sister would constantly bully me; none of us had out own space, and common things in the household would sometimes be monopolized by one member, whether it be the TV or the phone. I have mentioned these things to my therapist and all she would say it “How does that make you feel?’, or “What do you do when that happens?” What do you think/ As an impressionable child I would get upset and cry because I was hurt, (about the bullying, name calling and mental abuse by my mother).. So, I think that if the counselor would have seen how our household was on a daily basis, I wonder if she would have used a different approach. Honestly, I think that if a case worker would have a come to our house, it probably would have been brought up that we kids should have been removed, at least temporarily, so that my mother would get the wake-up call that she needed to get her temper under control. BTW, my mother never got any grief counseling when my dad committed suicide when I was three years old.

    Reply
    1. Dionne Collins, MA, LLPC

      Yes, this is the wonderful thing about home based therapy. You can provide therapy to a client in their comfort zone and approach therapy in a holistic way. This allows the therapist see all the dynamics of their client’s life and immediate environment, relationships, etc.

  6. Liz

    I’ve been doing home-based therapy for many years and love it. I’m a licensed Marriage & Family Therapist and to get that title I had to complete a masters program and then endure 3,000 hours (roughly six years of time) as an intern until I could take my state boards. It was a long haul but I enjoyed it all and am so glad I am where I am today.
    I find going into a clients setting, whether is be their home, office, or park, extremely beneficial. I get to know my clients on their turf. Home based services work especially well with the youth population. I can see them in their home and actually watch family interactions, or I can choose to sit alone with them in their backyard or other common area of their home. I work with business men/women who need stress reduction. They love the fact that I go their office and spend an hour with them in working on what ever issues they need assistance with.
    Many people have a stigma about going to a “therapist’s office” and this eliminates that. Many of the military clients I work with do not want to be seen going into a clinician’s office so I meet them where they want to meet.
    I have found no safety issues. As a therapist you get to know the person or family you are working with. You are intuitive and know if a situation may be unsafe. A lot of the safety issues involve common sense. How would meeting a client in your office be much safer? There are still safety concerns in an office setting.
    My fee’s are not out of the ballpark either. I have a fee structure that’s shifts depending where the client lives. I get many of my clients mainly because they need a home-based therapist. Parents are running all around taking their kids back/forth from school, sports practice, and health appointments. They are relieved when they find me.
    From my end, financially… think about it… I have very little to no overhead. I do not pay rent in an office which is a huge chunk of money. My car is my office and my main expense is fuel. Beside that I have malpractice insurance costs which would be the same if I were in an office. Bottom line, I don’t find myself driving all over. My clients are all spaced out and my day has a nice flow.
    I don’t want to be a therapist who sits in an office, with a waiting room, and having a train of clients coming in. I’m sure many therapists like that but it’s not for me. So if you are thinking of becoming a home-based therapist I would say “go for it”!!!
    Liz

    Reply
    1. Beth

      Liz, When you provide an insurance reimbursement form for clients. What do you put as place of service if you meet a client at a park?

  7. Johnny Smith

    my name is Johnny i am a registered addiction specialist. I have been in the alcohol drugs field for more than 10 years. I understand that there people that afraid to admit that they have a problem and they refuse to go to a 12 step meeting. I want to be able to come to them. I would appreciate any suggest on my goal to help others. Personal speaking I have a LATE start on my career with 15 years clean from drugs and alcohol.

    Reply
  8. Michelle

    What about meeting clients in public, for example i had a 17 year old client that wanted to meet at a restaurant due to transportation barriers. I informed him several times that i could not guarantee his privacy but he insisted. We only met there twice until his transportation voucher came through. Do you think this violated Hippa laws?

    Reply
    1. Dionne Collins, MA, LLPC

      Hello Michelle:

      I would say no, as a home based therapist myself. I meet my clients at the library and even at a cafe before. There were times this was needed due to a client having bed bugs for a period of time, not allowed to enter home under those conditions.

      there is just a need to be cautious of your surroundings and isolate your session from others with the client as best you can and do not discuss confidential information otherwise. Also, limit disclosure of you and your client’s identity.

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