Tag Archives: in-home counseling

Voice of Experience: Home visits

By Gregory K. Moffatt December 19, 2022

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It was early in the 1990s. I had been in practice maybe six or seven years. I’d paid my dues in general practice, hoping one day to focus exclusively on family and children. At that time, nearly all my clients were children or families with children.  

Most of my clients were either single-parent families, divorced and blended families, or families in the middle of divorce. It was heartbreaking for me to observe the pains of broken families — lost dreams, heartache, the unknown, financial devastation, and the many other factors that can make divorce so painful. These are things we have all seen many times even for those just starting out in the profession. 

One family was limping along trying to salvage their 10-year marriage. I’d seen them and their three children several times in my Atlanta office, but most of my clinical work focused on the marriage.  

The couple faced many challenges in finding times to meet with me. They both worked full time; he was a postal worker and she was a nurse. Their home was 35 miles from my office through heavy Atlanta traffic. For each appointment, they had to pick up children at daycare, scurry home as quickly as possible, change clothes, meet the babysitter and head north to my office to make our 6 p.m. appointment.  

To arrive on time, everything had to go as planned — no car troubles, no late days at work, no late or no-show babysitters. The stress of a long day at work, coupled with the rush to get out the door on time, often led to arguments in their 45-minute drive to my office. If this happened, they were so harried when they arrived that it took several minutes for them to recenter before we could get down to business in our session. 

Despite all of that, we were making progress until one day I got a call just 30 minutes before they were supposed to arrive. Everything had gone wrong that day, and they were not only canceling the appointment but also withdrawing from therapy. 

That is when I had an idea. I suggested we have a final session the following week, and I would help them find a referral. But this time, I offered to meet them in their home. They heartily agreed. 

Their dimly lit living room was full of commotion: Pets were running around, and I could hear young children in a nearby bedroom. But I realized the only one who was uncomfortable was me. They were more relaxed than I’d ever seen them. Although it was a less-than-ideal environment for therapy, they were comfortable in their own space. I saw them in a way I’d never seen them before. 

It was then that I realized that I was unintentionally adding to their marital challenges by the very nature of my practice. They had to spend extra money on babysitters — money they didn’t have. And before each appointment, they spent the entire day dreading the potential problems they might encounter trying to make it to my office by 6 p.m. — my latest appointment option. 

After this realization, I offered to meet with them twice a month in their home and they agreed. Six months later when we terminated, their marriage was much healthier. Just a year or so ago, I received an email from the wife. They are still married, their children are grown, and life has settled. 

Home visits create numerous challenges for us as counselors. Most obviously, boundary crossing is an issue, but in the home visits I’ve done, I’ve never had any problems arise from these boundary crossings. Until about 50 years ago, half of all physicians made house calls without any issue. And some still do! 

Safety, of course, is a concern, but social workers have made home visits for decades demonstrating that safety issues can be managed.  

Instead of making a home visit, I could have offered a later appointment time or one on the weekend, but that would have compromised my own family life boundaries. Finding a closer referral could have worked, but that would have required them to start over.  

While I admit these challenges, among others, need to be considered, if we really want to pursue diversity and consider cultural issues, shouldn’t that include the challenges I faced with this family? I am confident that I opened my mind to alternative methods of delivering clinical services in an ethical and responsible way.  

Just like telehealth, there is no one-size-fits-all approach. For example, I couldn’t meet alone with an individual client at their home. Although there are many limits to offering in-home services, I’ve never regretted making that decision. 

 

Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu. 

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.

Creating successful home visits in community-based counseling

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

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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.

Letters to the editor: ct@counseling.org

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.

House call counselors

By James Todd McGahey August 7, 2014

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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 knockknockquality 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.

 

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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.

 

Summary

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.

 

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James Todd McGahey is a licensed professional counselor and assistant professor at Jacksonville State University in Alabama. Contact him at jmcgahey@jsu.edu.

Lessons learned from intensive in-home counseling

Hannah Yakovah Hennebert November 1, 2013

16 Comments

KnockIt 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.

 

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Hannah Yakovah Hennebert 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 archetypes.rock@gmail.com.

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