Counseling Today, Knowledge Share

Creating successful home visits in community-based counseling

By Robin M. DuFresne and Allison K. Arnekrans March 9, 2020

Many newly minted counselors begin entry-level positions as home-based counselors, traveling to see their clients in homes, schools, community centers and elsewhere. Traveling to the client may seem foreign, particularly if the counselor’s internship experiences were all office-based. However, according to a 2005 study by D. Russell Crane, Harvey Hillin and Scott Jakubowski, home-based counseling has proved to be cost-effective and to reduce hospitalizations, so there is evidence for its usefulness.

Home-based counseling, which is sometimes referred to as community-based counseling, can be effective and beneficial with multiple client populations, including families, older adults, children, and individuals with developmental disabilities. Mood disorders, anxiety disorders, psychotic disorders, behavior problems and family disturbances are typical presenting problems that may benefit from home-based counseling. It is often helpful to have a counselor in the home environment to witness maladaptive behaviors, relational issues and other contextual considerations. Finally, home-based counseling can be particularly helpful for individuals who cannot or will not come to a counselor’s office for services.

Transferability of skills is one main benefit of home-based counseling, meaning that it can be helpful to those who struggle to transfer skills from one environment to another environment. For example, a child with intellectual disabilities and behavior problems may be able to successfully implement a calming technique in the counselor’s office but unable to do the same thing in the home. Learning and practicing the skill in the home environment with the counselor present to assist and support the child increases the likelihood of success. Additionally, the counselor can observe the parent or caregiver prompting the child to use the skill and work with them to increase consistent implementation. Another example is that of adults diagnosed with anxiety who struggle to use effective coping skills in triggering situations. In the home, the counselor can prompt the individual to recognize the triggers before anxiety begins and encourage the use of coping skills.

Home-based counseling offers the counselor a more enriched perspective of the client and the context of the presenting issues. Issues specific to the family or environment can be assessed through examples and observation in the here and now, which often leads to a more immediate feedback process. For example, family members may be on their “best behavior” while in the counselor’s office, or an individual family member may deny their part in a problem. Conducting counseling in the home allows the counselor to directly observe these behaviors and use immediacy to point them out, then work collaboratively to identify more appropriate behaviors.

In combination with behavioral indicators, the physical environment and the home’s level of cleanliness can provide the counselor with important information relative to the client’s situation. For example, a client who cannot pay her rent, has little food available for her family, and has broken floorboards in the kitchen may not have the same focus or motivation as a client in a more stable living situation.

Finally, clients may “no-show” or cancel office-based counseling sessions for a variety of reasons. Examples include the recent loss of transportation or employment, parental leave for a new baby, medical or health issues that warrant bed rest, severe and limiting psychiatric symptoms and so on. Home-based counseling provides the opportunity to meet clients where they are and with what they can contribute to the relationship.

For instance, clients diagnosed with a psychotic disorder may experience symptoms such as paranoia that prevent them from coming to the office and seeking treatment or engaging in other activities such as grocery shopping. A home-based counselor could work with such an individual in their home to help them identify their feeling of paranoia and learn to use reality-testing techniques to decrease the paranoia.

Although home-based counseling offers many benefits, ethical and safety concerns can dissuade professional counselors from providing this service. Additionally, the possibility of experiencing counselor burnout is a factor to consider when evaluating this type of format for sessions.

Ethical concerns

Counselors are required to act ethically when providing counseling services to their clients. Confidentiality, boundary issues and access to supervision are among the ethical concerns that counselors are likely to encounter when providing home-based counseling services.

Confidentiality

One of the primary ethical duties of counselors is to maintain their clients’ confidentiality. However, confidentiality is difficult to guarantee or provide in home-based settings, where the structure and consistency of the office-based setting are not in place. When entering a client’s home, the counselor cannot be certain who else might be residing in or visiting the home during the session. A roommate could walk through the front door, or a sibling might refuse to leave the common space — either of which could jeopardize the progress and process of counseling. Additionally, if multiple people are participating in the session, confidentiality cannot be guaranteed. Maintaining confidentiality can be particularly difficult if the home is small or if it lacks sufficient and safe space to conduct a private session.

When counseling children and families, confidentiality requirements change. Children do not own the right to their own confidentiality; this belongs to the parent or guardian. Counselors explain to both the parents and the child the limits of confidentiality. In the office, the counselor can suggest that the parent wait in the waiting room while the session is occurring, affording the child the feeling of privacy or confidentiality. In a home setting, it may be more difficult to persuade the parent that they should leave the room during the session. The parent may insist that because the counselor is in their home, the parent has the right to be wherever they want to be within the home. Communicating the importance of allowing the child to have some privacy can be more difficult in such situations.

Boundaries

Counselors are taught to respect the boundaries of the counseling relationship and to consider how bending those boundaries might affect the counseling relationship. Typically, counselors do not interact with their clients outside of counseling sessions. Establishing these boundaries is much easier when there is an office space dedicated specifically to counseling and when time constraints must be observed (e.g., staying on task with a session because the next client has already shown up for their appointment). Once in a client’s home, however, boundaries can become blurry. Both the client and the counselor might struggle with boundaries of time and space.

There are a few ways that clients may blur the boundaries in their homes that are different from what is typically experienced in an office setting. For example, the client may feel inclined to provide food and drink as if they were entertaining a guest. This puts the counselor in the position of deciding whether to accept and what messages this decision may send. Accepting can set a precedent that the client needs to “entertain” at each session. The client may also feel that they have to clean their home or otherwise change their environment to impress the counselor. If the client is putting on a show, this may interfere with the authenticity of the counseling relationship.

Counselors may blur the boundaries by becoming so comfortable in the client’s home that they begin treating the counseling relationship as a friendship or become distracted by the environment. It can be easy in a relaxed setting to spend too much time checking in and lapsing into chitchat rather than focusing on doing the needed work on client issues. This can be particularly true if the location of the counseling in the home changes from session to session.

Supervision

Most counselors are required to undergo weekly supervision while accruing hours toward their license to practice independently. Access to this supervisor can be difficult, however, when counselors are not down the hall from or in the same building as their supervisor. This circumstance may tempt counselors to make decisions without seeking supervision or consulting on important issues when they should.

For example, a counselor might assess a client for suicidal ideation but be unsure about the results. Rather than contacting the supervisor, the counselor may decide to trust their own judgment. This could lead to a wrong assessment and intervention plan. It can also be difficult for the supervisor to monitor the services being provided or to evaluate the supervisee when the supervisee is not based at the same location. The feedback process is altered merely by proximity and immediacy in the home-based environment. This can have ethical implications that are different from those in the office setting.

Safety concerns

In addition to ethical concerns, client and counselor safety should be considered. A client’s home can be an unpredictable environment with safety concerns for the counselor. These can include safety concerns related to pets, physical barriers, the client’s neighborhood, other people associated with the client, and so on. For example, the counselor may be allergic to the client’s pets, or a pet might not be happy about having a stranger in the home and become aggressive. Conversely, the pet may be overly friendly. If the counselor is not comfortable with the pet’s behavior, the pet could misread the counselor’s actions and become aggressive. These interactions with the pet might make it untenable for the counselor to continue providing home-based services to the client.

Counselors also need to be aware of people in the household who could pose a safety concern. One example is when a client’s significant other is unhappy about the client seeking help. The significant other may become intimidating or aggressive toward the counselor to prevent the client from receiving services.

Clients themselves could be a threat to the counselor. If the client has a history of aggressive behavior, the counselor may want to consider seeing the client in an office or referring the client to an office-based counselor.

Counselors may also struggle with concerns over client safety. For example, a client could be expressing homicidal or suicidal ideation. Even though the client is not threatening the counselor, intervention may be needed to protect the client or others. Under such circumstances, a newer counselor may need to seek immediate supervision or a more experienced counselor to help them access more intensive interventions. If the counselor does not have direct access to their supervisor, they may not be able to intervene appropriately. At the agencies where we worked, we were encouraged to have contact information for our supervisors and an experienced counselor easily accessible in our cell phones and computers.

Burnout

Being mindful of ethical concerns and safety concerns while trying to assist clients in making positive changes can lead to stress and burnout for home-based counselors. American psychologist Herbert Freudenberger first coined the term burnout in the 1970s as a way to describe the consequences of severe stress associated with the helping professions.

Burnout has three components: 1) loss of empathy, 2) a decreased sense of accomplishment and 3) feelings of emotional exhaustion. Common experiences of burnout can include sleep disturbances, blurred boundaries, feelings of relief when a client is late or cancels, and even realizations that one is not paying attention when the client is speaking. It is not uncommon for professional counselors to experience burnout at some point in their careers, but home-based counselors often experience these negative symptoms more frequently than do their office-based peers. Three possible reasons for this phenomenon are the physical demands of travel, the toll of consistently facing difficult client issues, and the realities of operating in professional isolation.

First, home-based counselors are moving around all day. The sense of being established and organized flies out the window when one’s trunk is filled with therapeutic toys and the filing system for client worksheets has toppled over in the back seat of the car. Home-based counselors bring their entire office on the road. This can present challenges in terms of the utilization of space, one’s level of organization, and how one’s work life impedes on one’s personal life — especially for counselors who must use their own cars on the job.

In addition to these challenges, home-based counselors must face off against weather conditions and the general wear and tear of travel. Traffic, construction, road hazards and car issues present ongoing and uncontrollable stressors for counselors working in the field. A colleague comes to mind who hated to travel on the weekends for her son’s soccer games because she was so frustrated by having to drive all week for work. She became exhausted by the physical demands of lugging her laptop and resources around and dispirited by having to repeatedly pay for car repairs. These external sources of stress piled up and finally led her to look for another position. Although the travel involved in a home-based position might provide counselors with variety, flexibility and stimulation, too much of any one of those things can lead to burnout.

Home-based counselors can also be affected by burnout as a result of encountering more intense client issues in the field. In general, home-based clients are seeking services due to a lack of resources, systemic issues, family/relational issues or co-occurring diagnoses. These cases tend to be more laborious, time consuming and complex than are cases for the average office-based client. This might be because of the amount of phone calls, interdisciplinary meetings, paperwork, crisis management and case management involved in the wraparound approach.

In addition, because home-based counselors travel from site to site throughout their workdays, they do not necessarily receive the downtime to process, reflect, or consult with other counselors and supervisors who could offer a supportive ear. As a result, compassion fatigue may set in and result in counselor burnout.

Additionally, home-based counselors often lack the structure of a set schedule. They may need to finish documentation at home or after hours depending on how the day went. The likelihood of burnout increases when boundaries are blurred, time “on” and time “off” are not distinct, and there is little to no time to process client issues.

Finally, the daily work of home-based counselors can be perceived as isolating or lonely. Although there is interaction and stimulation with many other people throughout the day, home-based counselors often lack professional support and the ability to vent and collaborate with colleagues after sessions. There is also less time for immediate supervision and consultation on client issues, mainly due to having to pack up and get to the next home. Details are lost, and there is less time for the home-based counselor to process and conceptualize, all of which invite burnout more quickly than normal.

Tips for success

At this point, we know that the work of home-based counselors can be physically and emotionally challenging, although it can also be very rewarding and client-centered. To mitigate against the effects of burnout, several tips and strategies can be implemented to more fully wrap around these counselors, increase employee satisfaction and improve client outcomes.

To address the physical demands of the position, home-based counselors should carefully consider their schedules and level of organization. Taking time each week to plan, pack, and create structure for themselves can be invaluable. For example, instead of driving from ZIP code to ZIP code, counselors should, if possible, map out their schedules based on mileage or on seeing all clients from one area on a specific day. Meetings and supervision can be planned for a day of the week that coincides with time for completing paperwork in the office, when the counselor will have access to a printer and other resources. “Work smarter, not harder” was a popular catchphrase in our agencies when we were providing home-based counseling services.

Additionally, supervisors should have access to and be mindful of home-based counselors’ caseloads and schedules. Travel time, weather conditions and the possibility of a session getting extended due to crisis should all be considered each day. On particularly hot days, Allison’s supervisor would have popsicles and cold bottled water available at the weekly team meetings. This was a small gesture, but it made the counselors feel cared for given the unique demands of their job.

In terms of addressing safety challenges, home-based counselors should remain prepared, observant and cautious of their surroundings. One way to prepare is to have the first meeting with the client in an office setting. The counselor can use this initial meeting to assess whether the client is an appropriate fit for home-based services. If the client shares that they have a significant other or a pet who has been aggressive in the past, for example, then the counselor might decide to refer to office-based counseling. If the client reveals having a pet that the counselor is allergic to, the counselor can refer to a different home-based counselor who is not allergic. Setting a starting and ending time for the home-based services is also advised.

Once in the community, safety precautions could include keeping a basic food and hygiene kit in the car in case of an emergency. Carrying proper identification, making sure one’s phone is charged, and wearing appropriate clothing and footwear are easy steps to take to retain some level of control. It is sometimes advisable to avoid certain roads or areas to reduce the risk of injury or crime. Counselors can position themselves near the door of the house or apartment if they fear that their client or someone else in the home could become aggressive. Counselors may also want to be aware of items that agitated clients or others in the home could use as weapons. Rather than meeting the client in a home environment that the counselor fears could be unsafe, the counselor might encourage the client to meet at a community center or somewhere else that is less isolated. In addition, there are benefits to learning about the resources available in the client’s community and networking with other local agencies concerning opportunities and supports.

The use of a team-based approach is one method for increasing support for home-based counselors while simultaneously decreasing the feelings of loneliness that they sometimes experience. Weekly team meetings at rotating locations, group text messaging, daily “counselor check-ins” by email or phone, quarterly retreats, and staff recognition/celebrations are other examples of intentional ways that supervisors can create a layer of protection and support for their home-based counselors. A team-based approach can also help to process any of the ethical concerns that may arise when counselors are in the field.

Finally, personal wellness and a SMART-based (specific, measurable, achievable, realistic/relevant, time-limited) self-care plan are essential to the success and sustainability of home-based counselors. Intentionally planning one’s schedule to include time for paperwork and continuing education is important to reduce the amount of work that flows over into time off the clock.

As much as possible, home-based counselors should provide distinction between their work selves and their nonwork selves — not only for themselves but for their colleagues and loved ones as well. For example, one of this article’s authors would use the ride home from her last session to mentally process the day so that she could “leave” her work in the car. Staying physically active and making room for rest are important too. Home-based counselors should also be sure to stay engaged with others through consultation, supervision and collaborative efforts. Engaging in personal counseling as a form of self-awareness and health maintenance can be helpful as well.

Home-based counseling can be a daunting experience for novice counselors, but it can also be a rewarding and enriching experience, both for them and their clients. Properly assessing clients and ensuring appropriateness for home-based visits is the first step toward a productive working relationship. Understanding the various aspects of the position, including ways to be strategic and maintain appropriate boundaries, is also essential for the home-based counselor. Likewise, it is important to implement regular ethical and safety checks, in addition to scheduling sufficient time for paperwork, supervision and collaboration each week. Each of these strategies can help counselors be successful out in the field, even with some of the most difficult client issues. Those who supervise home-based counselors should focus on using a team-based approach to help prevent isolation and burnout in these counselors.

At the end of the day, home-based counseling is challenging work, although it is also meaningful and often quite productive. We encourage you to think about it as a possibility when looking for your next job.

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Robin M. DuFresne is an assistant teaching professor and program coordinator for the clinical mental health and school counseling programs at Bowling Green State University in Ohio. She has worked in a variety of settings in community mental health. Contact her at rdufres@bgsu.edu.

Allison K. Arnekrans is an associate professor, faculty adviser for the Mu Kappa chapter of Chi Sigma Iota, and practicum and internship coordinator at Central Michigan University. She is a child and adolescent counselor by trade, with experience in community mental health, partial hospitalization and employee assistance program settings. Contact her at arnek1ak@cmich.edu.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

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