Home-Based Family Counseling

Defining Terms

Professionalizing the Field

What would it mean to professionalize HBFC? The counseling field has professionalized a number of specialized services, for example, addictions, crisis and trauma, child and adolescent, and marriage and family counseling. We argue that HBFC is distinct from addictions, crisis, child and adolescent, and marriage and family counseling precisely because each of these elements is intricately woven into HBFC to create a unique field of counseling.

For the purposes of this article, professionalization means that standards for ethical practice have been established, including those for training and specialized knowledge and skills, and have been endorsed by recognized professional organizations. Professionalizing HBFC as a subfield of mental health counseling would necessitate an open discussion among members of the profession, the goals of which would include: (a) to define HBFC and recognize it as a distinct counseling specialty, (b) to describe the necessary skills and competencies needed to implement home-based interventions, (c) to offer standards for supervision of home-based counseling, (d) to consider the social justice and ethical considerations posed by HBFC, and (e) to recommend research into the efficacy of HBFC.

This process is necessary in order to distinguish HBFC from other forms of family counseling and to clarify the differences between social work and counseling roles within the home setting. Elucidating the necessary skills and knowledge to be an effective counselor in the home setting is essential. Including home-based competencies within the Council for Accreditation of Counseling & Related Educational programs (CACREP) requirements for training counselors in family counseling is imperative. Further research into the efficacy of HBFC is also essential. Guidelines for the supervision of home-based counseling need to be developed and more fully articulated within the field, and finally, the counseling profession must recognize the vulnerability of clients receiving home-based counseling and include this population in our advocacy efforts.

Distinguishing HBFC From Traditional Family Counseling

Families receiving in-home counseling tend to have greater needs and are at greater risk than families who are seen in more traditional settings (Keresman, Zarski, & Garrison, 1997, in Lawson, 2005). Families who participate in this service are often involved with social services, juvenile justice, and other mental health providers. For example, outpatient counseling may have been attempted but may have been deemed insufficient to meet the child’s and family’s needs.

Training and Essential Competencies

Researchers have been calling for counselor training programs to include home-based competencies in their curriculum (Cortes, 2004; Woodford et al., 2006). At least one attempt has been made at formalizing training for the home-based setting (Mattek, Jorgenson, & Fox, 2010), indicating an emerging recognition of the need for training standards for in-home counseling modalities. Failing to insist on the same high standards in training home-based versus traditional family counseling may send a message that the counseling profession places less value on the families served in the home than on those who receive services within a traditional outpatient setting and harkens back to less enlightened times. This article is a call to action and a call for social justice and equity for multistressed families.

Establishing Training Standards

For some time, counselor-training programs have neglected to offer the skills necessary for providing HBFC services. Others have expressed concerns that relevant skills have not been offered in a way that can be easily translated to work within the home setting (Stinchfield, 2004). In addition to the basic counseling skills required to provide traditional individual, group and family counseling, home-based counselors must be prepared with additional skills to support their work (Adams & Maynard, 2000).

In her qualitative research, Stinchfield (2004, p. 296) interviewed professionals providing HBFC and found that participants seemed to feel that their own training programs had focused on knowledge and assumed that students would “get [the application] once they leave school.” Other participants expressed concern that their training had been fitted to traditional counseling but had not been relevant to the challenges and unique qualities of the home-based setting. This research highlights the importance of training directly related to HBFC settings and reflects the concerns raised in the field.

Adapting CACREP Requirements to Fit the Home-Based Setting

Stinchfield’s (2004) participants raised concerns that the training they had received had not translated well to the home-based environment. Efforts should be made to examine how skills and knowledge already established by our accrediting body, CACREP, can be modified and expanded to meet the training needs of future in-home counselors. An important example of knowledge and skills that should be elaborated upon to establish relevancy in HBFC are the knowledge, awareness, and skills central to effective multicultural counseling. Standards for training in family intake, treatment plan development, and culturally sound intervention all require special adaptations when working with families in their homes. Among the standards for training that seem critical and particularly relevant to HBFC include, but are not limited to, assessment of crisis and crisis needs, knowledge and skill in assessing trauma and trauma needs, advanced knowledge and skill in cultural competencies such as working with families in poverty, gender issues, and avoiding the culture of poverty perspective when working with clients. An expanded list is included in Table 1.

OPEN IN VIEWER

Table 1.

Table of Proposed Competencies.

Theory	Competencies That Should Be Adapted for HBFC	Training Modality
Family systems	Assess the family within a larger systems	Coursework
	Assess power dynamics within the family
	Knowledge of how family influences child and adolescent behavior	Coursework
	Interventions that engage the whole family, such as expressives	Coursework
Crisis and trauma	Assessment of crisis and crisis needs	Coursework/university supervision Field supervision
	Capacity to connect clients to essential services	Coursework
	Knowledge and skill in assessing trauma and trauma needs
Cross-cultural counseling	Understand the unique needs of families living in poverty	Coursework
	Avoidance of the “culture of poverty” perspective	Coursework
	Capacity to identify services related to unmet needs (dental care, food and clothing, etc.)	Field supervision
	Knowledge and skill in working with minority families	Coursework/field supervision
	Familiarity with culturally relevant community resources (churches, mosques, healers, etc.)	Coursework/field Supervision Coursework
	Understanding of gender issues in families across different ethnic and racial groups	Coursework
	Understanding of the unique challenges faced by immigrant families
Substance abuse counseling	Identifying and evaluating substance abuse problems	Coursework
	Developing and assessing interventions	Coursework/university Supervision
Child and adolescent	Play-based techniques designed for children	Coursework
	Sandtray adaptations for in-home work
	Expressive counseling approaches for children and adolescents

Note. HBFC = Home-based family counseling.

Explorations Outside of CACREP Standards

A number of key differences necessitate the addition of new competencies including such concerns as the use of space, confidentiality, responses to physical or verbal threats to the counselor, and so on. We call upon the ACA membership and those serving or supervising HBFC to expand on needed competencies specific to home-based interventions as well as to competencies that need adapting to fit this specialization.

ACA Ethical standards

The ACA provides the ethical standards for the field and are updated periodically to meet changing needs, particularly where new trends provide additional challenges. It is our assertion that the ACA code of ethics must be updated to give greater relevancy to the in-home setting. An important example of ethical standards that may require consideration pertains to gifts. Some counselors prefer to exchange no gifts at all and consequently are reluctant to accept a drink of water when in their clients’ homes. The difficulty here is that when we enter another’s home but insist that we operate strictly from ethics established for the more traditional settings, we are likely to act with cultural insensitivity or even to invite shame or insult. A healthy therapeutic relationship in the home setting may follow a shared cup of coffee or tea in the consumer’s home. We assert that in-home counselors should be allowed to weigh this option against its potential harms and to make informed decisions about accepting a drink, for example, without risking an ethical violation.

Guidelines for Supervision

We agree with other authors who argue that in order to assure that at-risk families receive quality services counselors in training must be equipped with necessary skills and competencies (Lawson, 2005; Stinchfield, 2004). A key value of counseling profession is quality supervision within the training process (Bernard & Goodyear, 1998) and we assert that this value should extend to trainees providing services within consumers’ homes.

Supervisors overseeing HBFC have unique responsibilities to their supervisees owing to the intensity of the work; at the same time, they experience unique challenges depending largely upon the organizational matrix in which they function. First, as there is no supervision model designed specifically for HBFC, each agency develops its own standards in accordance with state regulations. While such an approach could lead to innovation and better outcomes, in practice, it allows for a level of variability across agencies that may be seen as ambiguous or arbitrary to outside constituencies (social services, school systems, court systems, etc.). Some level of standardization is necessary so that the general public, consumers, and those who refer clients know what to expect from mental health agencies serving children and families under their care. More pressing to our field is that the lack of supervision guidelines leaves counselors at risk and clients subject to substandard care. Additionally, since we have no model and few standards for in-home supervision, those in supervisory roles may or may not have worked as in-home counselors themselves. Where such a scenario exists, it can present exceptional challenges for informed supervision, given the significant differences between HBFC and other forms of child and family counseling.

To ensure that the needs of counselors are being met, supervisors of HBFC have 24/7 responsibilities. Most often, this manifests in crisis phone calls after normal business hours. A significant challenge of HBFC overall is that many critical incidents take place primarily between the hours of 3 and 8 p.m., and supervisors remain unofficially on call during these time (Lawson, 2005). Such a reality places additional stress on supervisors.

Surely, the availability of supervisors to their supervisees is crucial. Therefore, supervisors should have a limited number of supervisees and a limited number of families on their supervisory caseload. For example, the Commonwealth of Virginia allows each supervisor a maximum of 10 supervisees who could collectively carry as many as 50 cases. Whether or not such a caseload for a supervisor is appropriate likely depends on the experience of the supervisor; however, such high numbers make it challenging for supervisors to be available to families if needed.

We would like to open the discussion with the following recommendations for developing relevant supervision standards and competencies for HBFC. First, supervision must be a core value of agencies serving families through HBFC, and significant organizational resources should be devoted to that practice. Second, supervisors of HBFC should have sustainable workloads that provide them adequate flexibility to meet the needs of their supervisees. Third, supervision should be developmental with regard to individuals’ level of training and experience; those new to HBFC necessarily require more supervisory time, and those more experienced may require less. Fourth, supervisors must be available to the families on their caseload when needed, particularly if live supervision is to be possible (Lawson, 2005). Fifth, supervision should be provided by licensed providers only. Sixth, videotaping should be used as a supervisory tool. Seventh, supervisors should meet and assess the family at the opening of services, and, finally, supervisors should themselves have provided HBFC.

Advocacy

Home-based counseling services are provided to families that often have difficulties advocating for their own needs and struggle or are reluctant to identify needed services (Newton & Sprengle, 2000). Advocacy for multistressed families is urgently needed in order preserve the integrity of poor and minority families in crisis and for the communities in which they live. An essential element of effective advocacy would include more aggressive efforts to recruit minority students in counseling training programs, particularly those with fluency in Spanish, French, German, and Russian, the five most common languages spoken in the United States, other than English (U.S. Census Bureau, 2007). Creating incentives for counselors and counselors in training to gain fluency in a second language is also vital. Further, the use of trained and qualified translators is desirable when translation is necessary.

The Need for Research

Currently, there is a lack of research supporting the efficacy of HBFC (Cortes, 2004; Lawson, 2005; Stinchfield, 2004; Woodford et al., 2006). There is a growing body of literature describing the efficacy of specific models of family counseling which use the home as a primary milieu. Many of these models have shown promise including multisystemic therapy, multidimensional family therapy, and functional family therapy. These models have shown particular efficacy in reducing recidivism (Schaeffer & Bourduin, 2005), addressing substance abuse concerns (Gordon, Graves, & Arbuthnot, 1995; Liddle, Dakof, Turner, Henderson, & Greenbaum, 2008), and have been used with success with other presenting problems. It may be important to note that there is some research to suggest that inconsistencies and errors in research design may have overestimated the efficacy of multisystemic therapy (Littell, 2005), however.

Despite this body of research, we believe there is a critical need to discover whether or not organizations that serve families in the home are making use of formal, evidence-based models or are operating on ad hoc approaches, idiosyncratic to each agency rather than theoretically informed practice as we have observed broadly. Further, if indeed organizations are making use of ad hoc practices, the efficacy of these interventions is in need of examination. Research exploring HBFC supervision practices is sorely needed. Finally, a better understanding of the lived experiences of those serving consumers and the experiences of the consumers themselves would benefit the field.

Conclusion

It has been our intention to call for an open discussion within the counseling profession about HBFC and to promote the need for professionalization. The collective knowledge of the members of ACA is needed to assure the ethical implementation of counseling interventions with vulnerable and high-risk populations. We hope this article will open the topic to frank discussion, not only to the topic of professionalization, but to the necessary training standards and companion ethical codes.