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

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1 Foundations of In-Home Therapy Camille Lafleur, PhD, LCMFT Una Henry, MA The Family Center Kansas State University HBFTPartnership.com 1

2 The HBFT Partnership 2

3 Training Objectives Participants will be introduced to the web-based, clinical, collaborative partnership review effective approaches addressing factors uniquely related to homebased 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 discover ways to prioritize therapist self-care to support effective work 3

4 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 4

5 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 relationships HBFT Therapists are Qualified mental health professionals Capable of formulating interventions Competent to work with both children and adults together and separately 5

6 Common Experiences of HBFT Evidence-Based Practice 6

7 Common Experiences in HBFT Foundation 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 & expectations 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 Family Therapy. 7

8 Advantages and Challenges of HBFT Environment & context Advantages 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 events Challenges Multiple possible distractions Safety concerns especially regarding challenging clients, reporting issues, etc. Family roles & expectations 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. 8

9 Advantages and Challenges of HBFT Advantages Challenges Therapist roles & expectations Focus of clinical work Teachable moments are based on actual vs. reported events Opportunities for therapeutic spontaneity and creativity Therapist s power on someone else s turf Maintaining professional boundaries within a collaborative relationship Family readiness to change is not obvious Managing distractions Confidentiality issues Therapeutic relationship 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. 9

10 Discussion 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? 10

11 Indications and Contraindications for HBFT Family s previous treatment experiences Family issues Therapist factors 11

12 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 12

13 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 13

14 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. 14

15 Focusing Therapy in the Home Introduction to and joining with the family Information gained from the family and the context Impact of the information and experiences on the therapist Environment and Context Family Roles and Expectations Therapist Roles and Expectations Assessment and Goaling Clinical Focus 15

16 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: Counseling and Therapy for Couples and Families, 12(2),

17 Bridging Therapeutic Training with In-Home Approach HOME-BASED FAMILY THERAPY PARTNERSHIP (HBFT Partnership) In-Office Work You bring Your Therapy Training and Experience Unique Features of In-Home Family Therapy In-Home Work This training addresses 17

18 Theoretical Foundations Self of the Therapist Ecological Perspective Family Systems Theory Family Resilience Framework 18

19 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 19

20 Self of the Home Based Family Therapist 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 himself 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) 20

21 Ecological Perspective 21

22 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 22

23 Therapeutic Strategies and Techniques 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 treatment? 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 experiences? 23

24 Managing Sessions Scheduling the Appointments Interruptions and Distractions Pacing Lawson, G. (2005). Special considerations for the supervision of home-based counselors. The Family Journal: Counseling and therapy for couples and families. 13(4). 24

25 Using the Home Environment Be humble but prepared Learn from what is said and unsaid Lawson, G. (2005). Special considerations for the supervision of home-based counselors. The Family Journal: Counseling and therapy for couples and families. 13(4). 25

26 Safety Issues Keeping the family safe Keeping the counselor safe Risk Assessment Safety Session Lawson, G. (2005). Special considerations for the supervision of home-based counselors. The Family Journal: Counseling and therapy for couples and families. 13(4). 26

27 Ethical and Professional Practice Therapists Use of Supervision and Self-Care 27

28 Supervision 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 Lawson, G. (2005). Special considerations for the supervision of home-based counselors. The Family Journal: Counseling and therapy for couples and families. 13(4). 28

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

30 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 supervisors 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 & Therapy, 22(2), ) 30

31 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 process Responding to unexpected circumstances and issues with flexibility Monitoring therapist experiences of burnout Balancing the demands of families in crisis, agency expectations, and personal life Proactively caring for self and personal relationships 31

32 Continuum of Therapist Self-Care Each therapist experiences varying degrees of personal and professional stresses Self-care varies along a continuum of stress management approaches Consider your current stresses and determine where you are on the continuum of self-care based upon your own responses to those stresses. Managed Stress Unmanaged Stress Preventative Increasingly Reactive Remedial 32

33 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 stressors Identify the types of approaches you currently use Build Knowledge Learn about the impact of varying types of stressors on professional responsibilities Develop Skills Develop the tools necessary for maintaining a balance between our personal and professional lives Managed Stress Adapted from Sue, D. W., & Sue, D. (2003). Counseling the culturally diverse: Theory and practice (4th ed.). New York: Wiley. Unmanaged Stress Preventative Increasingly Reactive Remedial 33

34 Impact of Self-Care on Clinical Effectiveness Competently working with all family members Paying attention to and responding to safety considerations 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: Counseling and Therapy for Couples and Families, 12(2),

35 Professional Quality of Life (ProQOL) (Hudnall Stamm, B.( ). 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 trauma Self-Care Strategies Personal Self-Care Collegial relationships and support Supervisory Support and Accountability Agency policies supportive of self-care activities. 35

36 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 36

37 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 37

38 Self-Care Strategies Skills 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,

39 Questions? 39

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