Foundations of In-Home Therapy. Camille Lafleur, PhD, LCMFT Una Henry, MA The Family Center Kansas State University HBFTPartnership.







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Foundations of In-Home


Camille Lafleur, PhD, LCMFT

Una Henry, MA

The Family Center

Kansas State University


The HBFT Partnership


Training Objectives

Participants will…

be introduced to the web-based, clinical, collaborative partnership

review effective approaches addressing factors uniquely related to

home-based family therapy

learn to construct and apply a conceptual bridge from in-office to in-home

family work

identify the challenges associated with focusing the work of therapy in the

family’s home

explore ways to utilize therapeutic interventions to support their work with

families using an in-home family therapy approach

explore ways to utilize supervision to support the unique challenges related

to home-based work


Overview of the HBFT Training

The questions that guide our training include:

• How do you combine your training and experiences with

HBFT to provide the most effective in-home treatment?

– Most training programs focus on office-based therapy

• What specific theoretical approaches and

techniques/interventions have been found to be effective for

in-home family therapy?

• What are the unique supports HBFT therapists need to

provide effective HBFT treatment?

– Supervision

– Self-Care


What is HBFT and what do HBFT

Therapists do?

• HBFT is

– Theoretical approach of counseling

– Family systemic focus of treatment

– Services delivered in the home of the client

– Requires planning, persistence, flexibility,

patience and the ability to build trusting


• HBFT Therapists are

– Qualified mental health professionals

– Capable of formulating interventions

– Competent to work with both children and adults

together and separately


Common Experiences of HBFT

Evidence-Based Practice


Common Experiences in HBFT



Common Experiences

Environment & context • Natural environment of the home & community • Resources for therapy

Family roles & expectations • Family members as hosts

• Member familiarity with the environment • Ownership of the therapeutic process Therapist roles &


• Therapist as guest

• Facilitate a collaborative leadership and structure to establish a safe, therapeutic space for all involved

• Direct observations of family in natural environment • Link family work with larger social service system Focus of clinical work • Contextualized view of child’s behavior

• Broader approach to child’s therapeutic issues

Therapeutic relationship • Fluid relationship that transforms the home environment from visiting to therapy and back to visiting with each visit

• Potential to increase mutual respect and trust with each encounter

Macchi, C. & O’Conner, N. (2010). Common components of home-based family therapy models: The HBFT Partnership in Kansas. Contemporary


Advantages and Challenges of





Environment &


• Accessibility to additional

assessment information from the broadened context

• Observations of natural family processes are enacted in the natural environment of the home • Observations of unpredictable


• Multiple possible distractions • Safety concerns especially

regarding challenging clients, reporting issues, etc.

Family roles &


• Family accessibility to therapy • Accessibility and involvement of

additional family members and friends

• Generalizability of therapeutic skills

• Family Investment in therapeutic process

Adapted from Lindblad-Goldberg, M., Dore, M., & Stern, L. (1998).

Creating competencies from chaos: A comprehensive guide to home-based services. New York: Norton.


Advantages and Challenges of




Therapist roles &


• Teachable moments are based on actual vs. reported events

• Therapist’s power on someone else’s turf

• Maintaining professional

boundaries within a collaborative relationship

• Family readiness to change is not obvious

Focus of clinical


• Opportunities for therapeutic spontaneity and creativity

• Managing distractions • Confidentiality issues



• Opportunity to become more strengths-focused

• Increased experiences of cultural interplay between family and therapist

• Lack of trust in the system

Adapted from Lindblad-Goldberg, M., Dore, M., & Stern, L. (1998).

Creating competencies from chaos: A comprehensive guide to home-based services. New York: Norton.



Consider one of your cases or your most recent

HBFT case.

What indicators suggested

HBFT was the appropriate modality

with this family at this time?


Indications and Contraindications

for HBFT

• Family’s previous treatment


• Family issues


Indications for HBFT

Family’s previous treatment experiences

– Other less-intensive treatments have not worked

– Family has difficulty independently generalizing treatment strategies discussed in the office when they get home

Family issues

– Multiproblem families in perpetual crises – Child at risk of out of home placement

– Limited treatment accessibility to important members of the family system – Impression that some information about family dynamics are missing

• Seeing the family interact within the natural home environment

– Examples addressing specific clinical issues

• Children identified as SED

• Children and adolescents exhibiting antisocial behavior • Children involved with the juvenile justice system

• Children with autism

• Key member diagnosed with agoraphobia

Therapist factors

– Comfortable in unfamiliar environments

– Confident with the professional role required to structure a therapeutic environment in the family’s home

– Culturally competent

– Established clear professional and personal boundaries


Contraindications for HBFT

Family’s previous treatment experiences

– Past HBFT efforts have proven unsuccessful

– Repeated HBFT efforts have contributed to, rather than relieving or transforming, the ongoing family crisis pattern

Family issues

– Conditions that apply to BOTH in-office and in-home therapy

• Member’s risk of exposure to abuse, violence or neglect suggesting additional safety concerns for therapist in the home

• Necessary assessments, medical treatments, or substance-related issues have not been addressed

– Family exhibits a pre-contemplative approach to the treatment process

Therapist factors

– Limited clinical experience who have difficulty constructing complex, multifaceted case conceptualizations

– Negative perceptions of home environment

– Limited time and resources necessary to manage additional case management responsibilities due to a large caseload

– Inadequate supervision and agency support – Lacking cultural awareness and sensitivity


Lindblad-Goldberg et al. (1998) note,

“The greatest clinical challenge is to

create, in essence, a wide-angle

therapeutic lens that allows the therapist to

conduct a comprehensive assessment,

and at the same time, a focusing

mechanism to zoom in on the key

elements requiring change within the

defined treatment period” (p. 143).


Lindblad-Goldberg, M., Dore, M., & Stern, L. (1998). Creating

competencies from chaos: A comprehensive guide to home-based services. New York: Norton.


Focusing Therapy in the Home

Clinical Focus

Therapist Roles and Expectations Environment and Context Family Roles and Expectations









Introduction to and joining

with the family

Information gained from

the family and the context

Impact of the information

and experiences on the



Cortes (2004) explained that the HBFT therapist who

uses an office-based approach in a family’s home…

“focuses on the content and process of the interaction

between client and therapist without considering the rich

context of the client’s environment. Consequently, misusing

or ignoring (my emphasis) meaningful elements that the

home environment provides in the counseling process, such

as living conditions and resources, is a common

phenomenon. In fact, Christensen (1995) found that this

information was ‘not usually used by therapists to develop

treatment goals and intervention strategies’.” (p. 310)


Cortes, L. (2004). Home-based family therapy: A misunderstanding of the role and a new challenge for therapists. The Family Journal:




Training and


You bring…

Bridging Therapeutic Training with

In-Home Approach


Features of




This training




In-Home Work



(HBFT Partnership)


Theoretical Foundations

• Self of the Therapist

• Ecological Perspective

• Family Systems Theory

• Family Resilience Framework


Self of the Therapist

• Assumption: every therapist, every person has a worldview;

that worldview influences how that person (therapist)

constructs, experiences, and behaves within his or her world

– whether that person is aware of it or not

• Relationship in therapy seems to be influenced by:

– The degree to which therapists and clients know themselves

– The openness of the therapists to know their clients as they are,

rather than as social or personal prejudice depicts them

– Therapists’ investment in learning about their clients’ social

norms and social systems

– Therapists’ and clients’ acquaintance with the larger systems to

which each party is connected


Self of the Home Based Family


• The effective use of self is the most powerful

technique that a family therapist can learn.

– Based on a therapist’s good understanding of herself or


• Work with low-income families calls for an active

approach to understanding of self because therapists

put more of themselves into the work to repair the

effects of social deprivation and damage to the psyche

and family.

• “Poor families whose boundaries can be diffuse and

confusing need therapists who are going to be actively

involved with them and anchored in their own personal

lives.” (Aponte, 1994)


Family Resilience Framework

• Belief Systems

– Make meaning of adversity

– Positive outlook

– Transcendence and Spirituality

• Organizational Patterns

– Flexibility

– Connectedness

– Social and Economic Resources

• Communication/Problem-Solving

– Clarity

– Open Emotional Expression

– Collaborative Problem-Solving


Therapeutic Strategies and


Consider examples of strategies and techniques that you

have used during each phase of therapy

– Joining

• How do you transition from being a visitor/guest to being

therapist offering leadership of treatment?

– Assessment

• How do you determine whether you should provide protection or


– Goaling

• How do you weave the elements of the home environment into

the goaling process?

– Interventions

• How do you use the home environment to create a teachable

moment that connects with the family’s values and daily living



Managing Sessions

• Scheduling the Appointments

• Interruptions and Distractions

• Pacing

24 Lawson, G. (2005). Special considerations for the supervision of home-based

counselors. The Family Journal: Counseling and therapy for couples and families. 13(4).


Using the Home Environment

• Be humble but prepared

• Learn from what is said and unsaid

25 Lawson, G. (2005). Special considerations for the supervision of home-based


Safety Issues

• Keeping the family safe

• Keeping the counselor safe

• Risk Assessment

• Safety Session

26 Lawson, G. (2005). Special considerations for the supervision of home-based


Ethical and Professional


Therapists’ Use of Supervision

and Self-Care



Supervision should provide the therapist support with

the following

• Managing appropriate boundaries

• Accessing available resources

• Receiving guidance and support

• Simultaneously maintaining varying

points of view

• Connecting therapist self-care and

the supervision process

• Creating a relationship with your supervisor that

involves vulnerability

28 Lawson, G. (2005). Special considerations for the supervision of home-based


Supervision Structure

• Observation is important

– Supervisor needs to be active

– Work as a team; paired with more experienced therapist

• Assessment of skills sets standards for

competent professional behavior

– Inexperienced focus on managing key HBFT skills, monitoring

abilities, safeguarding clients

– Experienced case consultation focused on safety, systems

thinking, using the home environment, and managing sessions.

• Attention to therapist’s worldview and

impact on clinical work

29 Lawson, G. (2005). Special considerations for the supervision of home-based counselors. The Family Journal: Counseling and therapy for couples and families. 13(4).


What is Therapist Self-Care?

According to Carroll, Gilroy, and Murra (1999), a

clinician’s personal and professional self-care

includes, but is not limited to, the following efforts:

– Intrapersonal work—clarifying your view of yourself as

an adult and a clinician.

– Interpersonal support—seeking and receiving help

and support from others, especially friends and family

– Professional development and support—attending

continuing education workshops and conferences,

and receiving support from colleagues and


– Physical and recreational activities—spending time

engaged in hobbies and activities that refresh,

rejuvenate and invigorate the mind and body


Carroll, L., Gilroy, P., & Murra, J. (1999). The moral

imperative: Self-care for women psychotherapists. Women


Therapist Self-Care

• Managing therapist anxiety

– Monitoring levels of comfort visiting

someone else’s home

– Reviewing personal expectations about

one’s own role in the therapeutic


– Responding to unexpected

circumstances and issues with flexibility

• Monitoring therapist experiences of


– Balancing the demands of families in

crisis, agency expectations, and

personal life

• Proactively caring for self and

personal relationships


Continuum of Therapist Self-Care

• Each therapist experiences varying degrees of personal

and professional stresses

• Self-care varies along a continuum of stress management


Consider your current stresses and determine where you

are on the continuum of self-care based upon your own

responses to those stresses.







Ongoing Activities of Self-Care

Effective self-care includes the following activities:

• Increase Awareness

– Engage in activities designed to help you identify personal and professional


– Identify the types of approaches you currently use

• Build Knowledge

– Learn about the impact of varying types of stressors on professional


• Develop Skills

– Develop the tools necessary for maintaining a balance between our

personal and professional lives





Managed Stress

Unmanaged Stress

Adapted from Sue, D. W., & Sue, D. (2003). Counseling the

culturally diverse: Theory and practice (4th ed.). New York: Wiley.


Impact of Self-Care on

Clinical Effectiveness

• Competently working with all family members

• Paying attention to and responding to safety


• Knowing yourself and assessing your well-being

• Becoming increasingly aware of the impact the

home environment is having on you

• Becoming increasingly aware of the impact your

presence is having on the family

• Setting appropriate and manageable boundaries


Cortes, L. (2004). Home-based family therapy: A misunderstanding of the role and a new challenge for therapists. The Family Journal:


• Professional Quality of Life (ProQOL) –

(Hudnall Stamm, B.(1997-2005



– This measure examines three domains of therapist experiences associated

with providing therapeutic services:

• Compassion satisfaction – the pleasure you experience associated with

doing your work

• Burnout – gradual onset of feeling so hopelessness and ineffectiveness

associated with job performance

• Compassion fatigue/Secondary trauma – the degree of impact you

experience from exposure to stressful events and client stories of


Self-Care Strategies

Personal Self-Care

Collegial relationships and support

Supervisory Support and Accountability


Self-Care Strategies

• Knowledge

– Read articles and books that address ways to

further your own self-care

– Discuss themes from your readings with your

colleagues while sharing self-care strategies

that have worked


Self-Care Strategies

• Awareness

– Establish a baseline measuring your personal

quality of life using ProQOL to determine

levels of…

• Compassion satisfaction

• Burnout

• Compassion fatigue/secondary trauma

– Share the ProQOL with colleagues and share

your results with each other


Self-Care Strategies


– Take regularly scheduled breaks

– Take regular vacations without work responsibilities – Nurture friendships

– Engage in hobbies and other personal interests – Limit number of work hours and caseload

– Participate in peer support and supervision – Engage in personal therapy as needed – Journaling

– Attend to religious or spiritual needs

– Participate in relaxing activities such as reading, prayer, meditation, listening to music


Barnett, J. (2005). Psychotherapist wellness as an ethical imperative. Innovations in Clinical Practice, 257-271.






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