Ethical Dilemmas for the In-Home Counselor
With an ever-growing field, counselors and their work are changing and developing constantly. Some counselors are choosing to work in the area of home-based counseling with children and families. These families are comprised of varying cultural and socioeconomic status. Because working with these families is often inconsistent, sporadic, and attends to families that are actively engaged in crisis, the traits of a professional working in this area must expand beyond traditional traits. It has been suggested that the in-home clinician should embody characteristics that include positive rapport, warmth, optimism, humor, and commitment.
Several advantages can be found when executing in-home therapy, including the therapist being able to build rapport, observe a child and family’s function outside of an office setting, making assessments, and modeling consistency and routine. Additionally, it is reported that children in families, who attend more sessions in therapy, have better outcomes than those families with poor attendance. It is more efficient at times for the counselor to come to the client, rather than vice versa, given transportation issues or hectic schedules.
While an effective counselor is as consistently mindful of areas of ethical concerns, it is even more important that the in-home or community-based clinician to be aware of ethical issues within the therapeutic relationship. The following are three common disadvantages of the in-home and community-based counseling field that prompt more specific ethical dilemmas.
The first is a lack of consistency for sessions, the second is safety concerns for both counselors and clients, and finally, appointments that may require extra scheduling time.
According to the ACA Code of Ethics in Section A.11, the counselor has an ethical obligation to attend to appropriate termination and referral for the clients they serve. If the counselor encounters a family in which appointments are inconsistent and sporadic, the continuity of care is disrupted, and handling termination at this time is difficult. The most appropriate way to terminate with an inconsistent and sporadic client is to first review your informed consent. Within your informed consent, there is most likely a clause regarding scheduling and maintaining appointments. If you are an in-home counselor, these appointments are often changed, but policy is in effect regarding termination, (ex. Two weeks without contact between counselor and client, the case will be closed). If after the informed consent is reviewed, and the client is continuing the pattern of “no-show,” frequent cancellations, and inconsistencies, a second conversation is recommended regarding that closure of the case will be taking place. If you are unable to schedule and keep a final appointment, a phone call and signed and mailed letter is recommended to be sent to the client as well as the reasons for closure.
Although our ACA Code insights our primary responsibility is to the client and their welfare, (A.1.a.), there are some safety concerns when encountering clients in the home that are not directly addressed for the mental health practitioner. We always want to ensure that the “therapeutic space” is a safe one; however, the environment around you as an in-home counselor also needs to be a safe place. As mandated reporters, we have exceptions for breaking confidentiality, (harm to self or others as reported by client), but, as an in-home counselor, we must keep ourselves safe as well. This may mean listen to your “gut” as a counselor. For example, turning around or cancelling an appointment when driving into a neighborhood that you are not sure that you feel safe in.
Also, keep your cell phone with you. It may not be apropos to bring it in a session with you, but when you are in the client’s territory, it is a necessity for your own safety. Also, it is highly recommended that safety plans and aggressive behavior policies be discussed both at time of intake and during the initial session. It is also an additional ethical action to inform your clients at which times or events the police can be involved. Additionally, regarding safety, because in-home counselors are driving to homes, schools, or other areas of the community, they will often need to allot extra time for the distance it takes to and from their client. Therefore, an approved 50-minute session in a traditional setting will require potentially 90 minutes, including travel. The ethical dilemma that arises here is when this is applied for billing purposes. Fees are outlined in Section A.10 in The Code, however, this is also an area to which more research and further supervision is recommended.
Unfortunately, there is not a singular theory that can encompass the needs for home-based therapy. Instead, home-based therapy combines techniques cognitive-behavioral therapy, multisystem therapy, social leaning theory, solution-focused therapy, and psychoeducation for the families. These provide additional barriers for counselors doing this work, because they must be trained in several areas and remain flexible when executing them on a case-by-case basis. Because of this, the ACA Code also recommends for counselors (both in- and out- for the home, to ensure they are familiar with their Professional Responsibilities, (Section C: Qualifications, Trainings, and Continued Education.)
About the Author
Megan V. Boyd, LPC, has been working for the past 3 years with a community-based mental health agency serving children and families. She received her MS in Community Counseling and is currently pursuing a PhD in Counseling Education and Supervision with Mercer University in Atlanta, Georgia. For further information about Megan V. Boyd and her work with in-home counseling, visit The Unconventional Counselor on Facebook for blogs, resources, and networking with other professionals.