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].”
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.
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.”
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.
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