The counseling environment is an essential component of the counseling process. Typical environments include the plush offices of private practitioners, the sterile rooms in public agency buildings and the generic spaces in school settings. The amount of space, the arrangement and quality of furniture, lighting and many other variables all have influence on the process or outcome of counseling. Likewise, human elements such as eye contact, comfort, voice, dress, demeanor and a multitude of factors also affect the relationship.
All of these elements and consideration are dramatically affected when counseling and mental health services are transferred from the conventional settings to an in-home setting. The expanding demand for counselors to deliver services in their clients’ home settings makes an examination of the issues surrounding the “house call counselor” necessary.
Historically, in-home visits have been the domain of social workers or agency, sectarian and government caseworkers. There is an extensive history, dating back to medieval times in England, of interventions that contributed to the assistance of the underprivileged or impoverished. Although counselors and social workers both provide helping services to clients, there are fundamental differences in their education, philosophy and mission. Social work emphasizes understanding systems, adjusting one’s environment, and engaging in advocacy and social justice. Counseling reaches into the human mind to interact with the thoughts, feelings and emotions of the family or individual. These two disciplines have an abundance of overlapping theories and techniques, and complement each other enormously. Increasingly, counselor education and training programs in each discipline incorporate essential and useful components from the other.
Funding for these services often comes through Medicaid or government-contracted private insurance carriers. Funds are also provided by state agencies, including child and family services, juvenile justice, foster care or Medicaid supplemental security income (SSI) consumers. Private service agencies employ counselors and other helping professionals to service these consumers, then submit or seek reimbursements for the services rendered. Counseling services commonly include but are not limited to individual therapy, family therapy and crisis intervention
Recent federal legislation in the form of the Affordable Care Act requires that mental and behavioral health coverage benefits equal the amount of physical health coverage. This parity requirement will likely result in an increased demand for mental health services. Many of these new consumers may come from lower socioeconomic levels, thus creating unique challenges that may be best addressed by the house call counselor. Some of these challenges will include lack of resources, primarily related to finances and transportation, contributing to limited access to traditional counseling settings.
Many house call counselors are new therapists at the beginning of their careers. They are usually pursuing full licensure, which in most states requires supervised post-master’s experience of two to four years. Agencies servicing this client population commonly offer free supervision for aspiring or associate counselors as an incentive for employment. This usually consists of monthly supervision meetings in which supervisors monitor and review the counselors’ ongoing cases.
Challenges of the house call counselor
Multiple challenges are present in the house call counseling environment. There is a huge risk for burnout, with exhaustion and stress potentially decreasing these counselors’ interest and commitment levels. Mental health occupations consistently rank among the higher stress jobs, and additional stressors included in the house call counselor’s role further exacerbate the burnout risk. General factors contributing to burnout include inexperience, improper or insufficient education and training, cultural and socioeconomic differences between the service providers and their clients, ethical dilemmas, safety and professional concerns, and compensation issues.
Specific challenges are numerous and can be unique to each environment, but I will touch on some of the common challenges that in-home counselors might confront, as well as possible “solutions.”
Bugs/sanitation: Poverty-ridden homes may consider pest control an unnecessary expense and house cleaning a low priority. In-home counselors should be prepared for the possibility that there may be limited or no clean places to conduct a counseling session, so dress appropriately.
Possible solution: Conduct sessions outside while walking or engaging in other expressive activities such as tossing a ball, playing dominoes or checkers, or using art or play therapy techniques.
Scheduling: An ancillary task for house call counselors is scheduling appointments. This can be frustrating and time-consuming, particularly if the client’s phone number changes often due to nonpayment or expiration of subsidized minutes. In addition, clients’ resistance to receiving counseling services can lead to unreturned calls or missed appointments. Consumers receiving these services also are not penalized financially, thus reducing the incentive for compliance.
Possible solution: The house call counselor should attempt to set a recurring time to meet with the client each week to minimize confusion and excuses. Also, discharging consumers from services after consecutive missed appointments may be a determent.
Smoking: There is a high correlation between smoking, low income and education, so many homes that counselors enter may be saturated with smoke. Consumers may also wish to smoke during sessions.
Possible solution: The house call counselor should initially set boundaries in a polite, nonthreatening way, such as no smoking or eating and no cell phones, electronic devices or televisions during sessions.
Distractions/disruptions: A private, sterile and quiet setting for counseling may be difficult to realize in the home. Expect the unexpected. Other family members, pets and visitors may not respect or be aware of the boundary issues inherent in a counseling relationship. These issues may also present opportunities for examination, learning and growth.
Possible solution: The house call counselor should emphasize the importance of the sessions.
Transportation: Some consumers may not have access to transportation, but getting them to related service appointments is necessary. Transporting consumers in your own vehicle is discouraged and sometimes even forbidden. Also, the wear and tear on a personal vehicle while servicing your clients can be costly and time-consuming.
Possible solution: Encourage use of other resources for transportation. Some insurance plans will provide this benefit. Also consider utilizing the client’s school or work setting if it is more convenient.
Pimping: Consumers of in-home counseling services may expect “gifts,” especially food, before agreeing to participate in a session, thus creating a dilemma for the counselor.
Possible solution: Food or other incentives should be used sparingly, and not consistently. Avoid building a contingency between material reward and participation in counseling sessions.
Safety: Many consumers of in-home counseling services are involved with other agencies (the local school system, law enforcement, protective services) and are mandated to participate in counseling. This can cause resentment and anger, which may be directed at the counselor. At times, conducting sessions in an isolated, private home with this population can be distressing.
Possible solution: Have an active cell phones present with you. Consider working with a co-therapist. Consider requiring the client to be the same gender as the therapist. Make it a requirement that no vicious pets be present. Dress inauspiciously. Develop an accessible exit strategy. Separate therapy from any punitive aspects of the referring agency. Identify family dynamics and structure and use nondirective, nonthreatening techniques to change maladaptive structures or dynamics.
Advantages of house call counseling
The following advantages to house call counseling are gleaned from my experience providing these services as well as anecdotal evidence from other practitioners.
Empathy/rapport: The home setting is conducive to building rapport because the client is comfortable and more expressive. The consumer’s home environment enables the counselor to experience the consumer’s world more closely and authentically.
Respect: Consumers feel respected and appreciated by counselors who make the effort to meet them in their homes. This may lead to more open communication and trust.
Accessibility: In-home counseling promotes access to additional services that may otherwise have been inaccessible due to various barriers. House call counselors can serve as gateway agents for improving the overall health and function of consumers and their families.
In vivo experience: The counselor can observe and interact in real-life situations and in the client’s environment where the elements of therapy are occurring. Counselors can provide interventions to the individual or system that can be implemented in real time.
Observation: House call counselors have the ability to observe the context, conditions and resources of the consumer. Counselors may also observe interactions, communication styles and patterns, and hierarchal and status structures that reveal pertinent information. They can experience unfettered the natural discipline and boundary issues practiced at the home environment and then formulate appropriate and effective strategies and interventions.
Appointments: Cancellations due to consumer barriers are reduced because the counselor brings the services to them. This also allows for some flexibility because the counselor sets his or her own appointments.
House call counselors can be an effective and viable component of the new behavioral and mental health care paradigm. However, proper training and education programs for counselors are encouraged to incorporate curriculum addressing the theory and practice associated with this delivery system. In-home counselors should be competent in areas that are present within this population, including drug and alcohol abuse, single-parent households, counseling children and adolescents, and legal and mandated issues.
Agencies and supervisors employing house call counselors should be aware and guard against the high levels of stress and ensuing symptoms that can affect these counselors. They may wish to provide more vigilant supervision and support, additional administrative and support personnel, and realistic treatment expectations. All of these recommendations will contribute to skillful and productive counseling that benefits all parties.
James Todd McGahey is a licensed professional counselor and assistant professor at Jacksonville State University in Alabama. Contact him at firstname.lastname@example.org.