It was my first intensive in-home counseling session with Josh, a delightful blue-eyed 10-year-old who was living with his 72-year-old aunt, Katherine. She had been granted custody of Josh a few months before I was assigned to the case. Previous reports and intakes described Josh as a child at risk of being placed in a residential facility because of his oppositional and defiant behavior, his past history of running away and, most recently, his involvement in petty theft, both at school and at home.
The boy now in front of me was completely different from the one I had pictured after reading Josh’s chart. The report did not reference his loving and kind behavior, nor did it mention his enlightening curiosity, amazing intelligence or sharp intuition. Josh was not “his chart,” that was for sure.
Katherine, however, was not of the same opinion.
Katherine and Josh share a family history that includes rape, emotional neglect, physical abuse and domestic violence. In addition, alcoholism has run in the family for several generations and has already left Josh with unpleasant childhood memories.
Josh’s situation is not uncommon for in-home counseling. The families are often dysfunctional, the living conditions chaotic. The parents or other caretakers tend to be struggling with financial burdens, immigration problems, substance abuse or some combination thereof. When all that information merges into a single file, you are tempted to ask yourself, “How can I help this child?” The answer, in most cases, is that the family expects you to ease the situation, and you end up believing that you can.
But this is my real secret: I have fallen into the superhero trap numerous times. I have learned to escape it by accepting that healing is a complex process that does not depend solely on my skills as a counselor.
The challenge of establishing therapeutic alliance
The first visit to Josh’s home tried my empathy. It was like walking through a minefield, and signs of “danger” seemed to be everywhere. Katherine made sure I felt truly uncomfortable in her house. There weren’t any “welcome” signs or polite offers to take a seat. In fact, she seemed annoyed by my presence. Strangely enough, I appreciated her congruent behavior because I knew that authenticity was essential for building a therapeutic alliance.
Sweet and kind with me, Josh avoided all eye contact with his aunt during this first session. There was an aggressive, almost hateful, tone in his voice as well.
Katherine was equally aggressive. Her demeaning words indicated how challenging it was to cope with Josh’s defiant behavior. Despite being aware of the horrendous abuse Josh had endured, Katherine was not yet ready to show empathy for him.
Her list of complaints about Josh, in combination with her pointed put-downs of him, exceeded the acceptable. Feeling the need to intervene, I gently asked Katherine how she thought her words were helping Josh to adjust.
Katherine’s response to my intervention was infused with powerful emotions. She sounded furious and was particularly troubled by my being on “Josh’s side.” Katherine had expected intensive in-home counseling services to be all about Josh’s “terrible” behavior, not her rage toward him.
Josh is a beautiful child with a unique sense of humor. Quite often, he displays appreciation when adults show him respect and give him space to express his feelings. But Katherine was not friendly, nor did she think I would be a good resource for the family. I knew I would feel awkward returning to the house in a few days after all the friction surrounding this initial visit. But I decided right then that I would reflect on my feelings regarding this case before the next session. I didn’t want counseling this family to turn into an artificial process.
And I did return to the house with a new attitude, ready to attend to the family’s needs. After all, this was not about me.
Suggestions for in-home counseling practitioners
My work with children and adolescents began in 1992 when I was still living in Brazil, first as a teacher and then as a counselor for adolescents at risk. Looking back, I see how intense and rewarding it was. I have been an in-home counselor here in the United States since 2009. During this time, I have worked with very challenging and complex cases, inspiring me to share what I have learned so far. These are practices that have worked for me; I hope they will be helpful to other mental health practitioners as well.
- Be prepared as an in-home counselor to apply your crisis intervention skills. Your phone will ring at the most unexpected moments, and you need to be ready to help immediately. If you can’t be on-site, you may be able to assist over the phone. In cases of emergency, it is preferable to be with your client as soon as you can or contact an available practitioner from your agency and ask for help. Although intensive in-home service can at times sound like a “solitary flight,” having a good team in your agency to support you is critical.
- Use your supervision hour wisely. My most effective insights took place when I was exploring challenges and case outcomes with my supervisor. Clients benefit the most when a supervisor and supervisee work toward a common goal of supporting the client’s healing process.
- Creativity is a plus. Through the years, I have developed a good sense for how to use playful and creative interventions when working with children. I have encouraged clients to speak about their traumas by using puppets, drawing mandalas and solving puzzles with me. Other times, I have used music and dance as a focusing exercise. It is important though to find the right tone with each client.
- Assess and work with the client’s circle of healing — the support system that holds the client’s safety until the family is able to manage the distress more effectively. This circle might include, but is not limited to, extended family members, the school system, community and legal agencies, counseling services and so on. Katherine, as Josh’s guardian, became a fundamental component of his circle of healing (as you will see). Extended family members play an important role in intensive cases such as Josh’s, and counseling practitioners need to locate this support and find common ground so the child will feel safe again.
- Set clear boundaries. The very nature of intensive in-home counseling challenges practitioners on this issue. For instance, when you arrive, the family might be eating a meal together or have other visitors in their home. After awhile, the family will look at you as a new family member. This is a delicate situation that almost all intensive in-home practitioners face. It is important to work with your team when boundaries become an issue. I typically encourage other practitioners to avoid trying to resolve complex situations alone.
Here are some other thoughts on the issue of setting clear boundaries:
1) Be aware of your own emotional and personal needs.
2) Invest in self-care.
3) Consult your supervisor to address any difficulty you have setting boundaries with your clients.
4) Kindly remind your client (and yourself) that you are his or her counselor. Children and adolescents will benefit from understanding that they are in a therapeutic relationship.
5) If you are working with clients who are part of a minority group and you are part of the same group, double your attention to your own needs. I worked with clients of Latino heritage who made me feel especially at home because I am a Latina myself. Sharing this experience with my supervisor helped me guard against beginning to feel too much at home.
- LUV your clients. LUV stands for listening to, understanding and validating clients’ needs when working with crisis intervention. LUV offers comfort not only to the client in distress, but also to the counselor who needs a therapeutic frame to reassure himself or herself that “something” is truly happening in therapy. During the crisis in Josh’s case, I was constantly “LUVing” the family. Katherine and Josh responded well to this approach, and that gave me more confidence when I had to face the next crisis (which comes almost weekly when you are working as an intensive in-home practitioner).
- Focus on strengths. Access clients’ strengths and encourage the family to transcend through creative coping. This might mean offering family members opportunities to engage in common projects together — such as cooking a meal or creating some artwork — to break the sense of hopelessness and remove focus from the negative aspects of their relationship.
Katherine held the most negative ideas about Josh. Perhaps to avoid frustration or disappointment, she did not want to believe in his potential for change. So, I had to think of ways to move Katherine toward a place of hope.
One approach that seemed helpful was scaling Josh’s behavior. Every two sessions, I would ask Katherine to pick a number from 1 to 10 that would describe Josh’s progress at school and at home that week. Scaling was an opportunity to explore new ideas for supporting Josh in his struggle to adapt to his new home. Slowly but steadily, Katherine responded to my intervention. When she realized things were indeed getting better, she started showing trust in my assessment and other interventions. I also applied scaling when asking Josh about his aunt’s relationship with him.
Now that we had a good alliance, I was also able to intervene by highlighting Katherine’s own survivor story. I encouraged her to think about how she could thrive (and had already thrived) despite all the adversities life had presented her. I often linked her story to Josh’s, emphasizing the personal traits that made him so resilient — just as Katherine had proved to be.
In one of our sessions, Katherine offered me a hug in appreciation for my efforts to help her nephew. Although surprised by her sudden openness, I had a warm feeling of hope for Josh’s case.
Working with families assigned to intensive in-home services is a humbling experience. If you are a counselor-in-training, chances are good that intensive in-home counseling will be your first job. Reflecting back, I remember arriving at my first client’s house with my mind totally set up for outpatient counseling. Intensive in-home service had not been part of the program in my training. I believe it would be very beneficial to include the intensive in-home approach in the crisis intervention syllabus. In fact, I have applied some of the interventions described in Lennis Echterling, Jack Presbury and Edson McKee’s textbook, Crisis Intervention: Promoting Resilience and Resolution in Troubled Times. For instance, their description of the LUV triangle guided my approach when I had to establish a new beginning with Katherine and Josh.
Taking care of ourselves
Counselors inevitably connect with their most powerful self to attune to the here and now when working in a crisis situation. It took me awhile to recognize this force within and judiciously use it as my most effective counseling tool. I like thinking of my counseling style as mother-in-counseling.
Mother-in-counseling becomes a container that always holds space for one more child. Josh’s case is an example among many of how the warmth of acceptance and love can make the difference. In an ideal situation, mothers develop unconditional love for their children. Love in counseling can be understood as support, trust and validation.
The mother-in-counseling character is intimately connected to my Jewish-Brazilian background, which makes me aware of the gifts and limitations I will encounter on my path. One of the most important gifts I have received from becoming mother-in-counseling is the sense that the process is not about me, which makes me feel safe and inspired to offer the care my clients need. Yet, as clinicians, we are invited to walk the path of self-awareness.
What character describes your counseling style? It feels liberating to be aware of my strengths, and challenges, as I strive to find my safe place as a clinician. I encourage you to look for this safe place as a technique to help manage stress and avoid burnout.
Seeing my mother come home from the hospital where she worked was part of my daily routine growing up. She never hugged us before first taking a shower because she was very conscientious about the risks of passing on any kind of infection to her children. It was hard to hold back my longing to hug her, and at times I felt as though she did not love me as much as I loved her.
I am not a nurse as my mom was, but I can certainly use some of her rituals to ensure that I am not passing on emotions that should have been left in the counseling room. In our encounters with clients in distress, we are at risk for bringing home feelings of rage, grief, anxiety and other emotions that do not necessarily belong to us. To protect against this after leaving Josh’s house, I would take some time to “sanitize” my mind and arrive home attuned to my own emotions.
I have found that both before and after an intensive session, listening to joyful songs while driving or going for a walk can have a cleansing effect on my emotions. Also, saying a short prayer while in the car helps me to focus on the soothing aspects of my life and access my own circle of healing. In my experience, it is well worth it to find a ritual that fits one’s own routine and hectic schedule as a counselor.
I want to close by reminding readers that counseling is about hope. There is a deep sense of spirituality that embodies the work of crisis intervention practitioners. In addition to my faith and spiritual belief that we are destined to be good people, I have also found comfort in establishing meaningful relationships with other practitioners whom I can trust to give me honest feedback. Finding inspirational and meaningful ways to deal with our own crises can inject an extra dose of enthusiasm into our work with intensive in-home cases.
Grace Y. Kolman is a therapist at Liberty Point Inc. in Staunton, Va., and a doctoral candidate with concentration in Jungian studies at Saybrook University. Contact her at email@example.com.
Letters to the editor: firstname.lastname@example.org