A Survey of the Attitudes and Practice Experiences of Home-Based Practitioners

This article reports on the findings from a study that assessed the attitudes and practice experiences of home-based therapists. Existing research in the field of couple and family therapy encompasses largely qualitative information detailing the experiences of this therapist population. We explored several hypotheses generated from the qualitative literature on home-based therapy. Study results corroborated much of the qualitative data on home-based therapists’ experiences and reveal the profile of today’s home-based therapists along with their attitudes and therapeutic practices. A surprising result was that various aspects of home-based therapy models seem incongruent with therapist attitudes about the delivery of home-based services.     

Families-at-risk and home-based intervention: A therapist training model

Home-based family therapy programs are designed to provide intensive family intervention for at-risk children and adolescents. However, examination of the literature reveals limited publications about training therapists for this difficult task. The purpose of this paper is to describe a therapist training model based upon a family-as-context approach to crisis intervention. Specific units covered during the course include: family-as-a-system, structural family therapy, family crisis intervention, family assessment and simulation. It is concluded that the effective prevention of placement for at-risk children and adolescents requires both a home-based family treatment program and a specific therapist training model for family intervention.John J. Zarski, PhD, is a professor in the marriage and family therapy training program at the University of Akron. Carol A. Pastore is program coordinator for the T.I.E.S. program in Canton, OH. A. Lynette Way and Richard N. Shepler are home-based therapists with T.I.E.S. The authors would like to express their appreciation to Professor John West for his helpful comments on drafts of this article.     

Home-Based vs. Clinic-Based Parent–Child Interaction Therapy: Comparative Effectiveness in the Context of Dissemination and Implementation

Disruptive child behavior disorders remain a major public health issue despite the proliferation of several strong Evidence-Based Practices (EBPs) for these children and their families. This may stem from barriers to treatment facing many families in need, particularly families with low resources. Home-based treatment may be best suited for this population; however, EBPs are not always available or tested as home-based interventions. The current study compares an intensive home-based adaptation of Parent Child Interaction Therapy (PCIT) to the standard clinic-based model in the context of a statewide implementation. As part of the statewide implementation, therapists entered archival data into an online system. Data was gathered for 314 families receiving PCIT, with 181 children in clinic-based PCIT and 133 in intensive home-based PCIT. Consistent with other trials of PCIT, results of the current study indicate that both versions of the therapy were effective in reducing child-behavior problems and increasing parenting skills; however, there were marked differences in attrition. Intensive home-based participants were twice as likely to complete treatment (64.66%) compared to clinic-based participants (33.15%) despite facing more adversity. These results underscore the importance of scientifically-sound adaptations of EBPs, as well as the role of comparative effectiveness studies as a critical tool in the integrative model of intervention science.     

A family-based approach to adult mental disorders

Recent research studies have provided strong support for a collaborative approach between families and mental health services in the clinical management of major mental disorders. A comprehensive approach to adult mental health care that employs cognitive-behavioural family therapy as the basis for clinical assessment and treatment is described. This model emphasizes home-based intervention, collaboration with primary care, targeted specific interventions, achievement of the personal goals of index patients and their family members, long-term rehabilitation, and assessment of benefits and costs.     

Collaborative Home-Based Therapy (CHBT): A Culturally Responsive Model for Treating Children and Adolescents Involved in Child Protective Service Systems

Mental Health professionals are challenged with utilizing innovative treatment models to meet the needs of diverse communities. Enhancements in interventions have led to a reconceptualization of the role of mental health professionals, specifically, family therapists. This paper presents a collaborative, home-based model for working with children and adolescents involved in foster care. We begin by examining literature on home-based therapy. This review provides a framework to understand the need for a culturally responsive approach. A collaborative, home-based approach is presented along with unique issues and guidelines for practice. A clinical case is presented to illustrate implications for treatment.     

Evaluating Training Needs for Home-Based Family Therapy: A Focus Group Approach

Therapists and supervisors engaged in the delivery of home-based services participated in two rounds of focus groups. Participants discussed the challenges they face doing home-based therapy, and how an accredited family therapy program could modify its curriculum to better prepare trainees to meet these demands. Eight topic areas considered necessary for home-based practice were identified and the implications for training reviewed. The focus group methodology is described in detail and is recommended as a useful tool to assess training needs and as a way of promoting improved collaboration among training sites.     

An outreach approach to high risk parents and their infants

This paper describes a special project designed to evaluate services to high risk parents and their infants. Twenty-three families were served by intensive outreach and home-based model of intervention. Sixty-one percent of these parents had significant mental health problems prior to referral. The paper describes the sample, outlines the approach to therapy and gives a specific case example. The data post-treatment is summarized and results detailed.     

Negotiating transitions: a supervision model for home-based family therapists

Home-based family-centered treatment programs provide mental health and case management services to families in their own home. Treatment objectives include the prevention of residential or psychiatric placement, strengthening the family unit, and promoting family self-sufficiency. Little has been written, however, regarding the supervision of home-based, family-centered therapists. The purpose of this article is to describe a supervision model to teach novice-level family therapists to think systemically and to do family therapy with multiproblem at-risk families.     

Brief Report: Safe at Home Base: Working Parents' Reasons for Choice of Home-Based Child Care

The current generation of working parents faces new challenges to the traditional family model. Despite this, they select forms of home-based child care more than any other type of care. Prior data also reveal that parents who use home-based care, center-based care, and family day care all cite quality as the primary reason for their choice. Given the similarity of reason and the difference in care actually used, working parents who use home-based care were interviewed on additional reasons for their choice. These parents lacked confidence in center-based care and preferred their children to receive one-to-one attention. Age of child, cost of care, and availability of centers did not affect choice. These adults seem to be selecting home-based care in an attempt to provide care as close as possible to parental care. They are making a statement on the importance of the home environment even as their participation in the workplace increases.     

Family therapy in the home

There is good evidence in other areas of therapeutic endeavour that home-based therapy may have advantages over clinic-based work for some patients. There are some families who have real difficulties in attending clinics. Despite these facts little has been written on the topic. This brief article reviews some of the objections to home-based family work and suggests possible solutions for the interested therapist.     

Therapists' perspectives on home-based family therapy

Abstract

As a result of the passage of Public Law 96-272, home-based family services have proliferated throughout the United States, with family therapy playing a vital role. Voices of therapists providing these services have been absent from literature. Ten therapists participated in this study; each had experience providing home-based and clinic-based family therapy. A qualitative strategy was used to explore therapists' perspectives on factors regarding home-based family preservation services. Four themes emerged from semistructured interviews: the home environment, safety, context preference, and efficiency and effectiveness. Three recommendations are drawn from results and discussed.     

Treatment Engagement: Building Therapeutic Alliance in Home-Based Treatment with Adolescents and their Families

Client engagement is an essential yet challenging ingredient in effective therapy. Engaged clients are more likely to bond with therapists and counselors, endorse treatment goals, participate to a greater degree, remain in treatment longer, and report higher levels of satisfaction. This study explored the process of engaging high-risk youth and their parents in a unique home-based family therapy intervention. Qualitative interviews were conducted with 19 families who completed family therapy sessions that included a core component aimed at increasing treatment engagement. Parents’ and youths’ perceptions of engagement suggest the importance of developing therapeutic alliance with therapists, who facilitated building a shared alliance among family members. Implications for improving client engagement are discussed within the context of alliance building with the therapist and among family members.     

Barriers and Facilitators to Implementing Attachment-based Family Therapy into a Child Welfare Setting: A Qualitative Process Evaluation

Child welfare systems (CWSs) worldwide show increased interest in adopting empirically informed clinical strategies to increase treatment effectiveness. Many empirically supported treatments (ESTs) exist, but little is known about EST implementation barriers and facilitators in CWS. This study explored CWS providers’ experiences of implementing attachment-based family therapy (ABFT) in home-based services of the Flemish CWS (in Belgium). Sixteen CWS providers (twelve counselors and four supervisors) involved in three home-based services were interviewed. The Consolidated Framework for Implementation Research (CFIR) was used to guide collection, coding, and analysis of interview data. Findings revealed that implementation success was related to ABFT's fit with the CWS's mission, philosophy, and existing practices. CWS providers’ belief in the compatibility between ABFT and CWS increased investment in implementation efforts and persistence to overcome challenges and setbacks. Some barriers pertained to the learning of ABFT and some barriers pertained to systems level challenges such as lack of leadership and support, poor coordination with referral sources and other youth care partners, and lack of policy support. For successful expansion of ESTs into CWS settings, various barriers at multiple systemic levels need to be addressed.     

Home-Based Preventive Parenting Intervention for at-Risk Infants and Their Families: An Open Trial

The purpose of this study was to examine the feasibility, acceptability, and initial outcome of a home-based adaptation of Parent-Child Interaction Therapy for at-risk infants with externalizing behavior problems. Seven 12- to 15-month-old infants and their families were recruited at a large pediatric primary care clinic to participate in a home-based parenting intervention to prevent subsequent externalizing behavior problems. Home-based assessments were conducted at baseline, postintervention, and a 4- to 6-month follow-up. Six of the 7 (86%) families completed the intervention, and all completers reported high satisfaction with the intervention. All of the mothers demonstrated significant improvements and statistically reliable changes in their interactions with their infant, and most reported clinically significant and statistically reliable changes in infant behavior problems. The current study provides preliminary support for the use of this brief, home-based parenting intervention in addressing behavior problems as early as possible to improve access to an intervention for at-risk infants and their families. Successes and challenges with the development and implementation of this intervention are discussed along with directions for future research and clinical practice.     

Beyond home-based family intervention: A multi-family approach toward change

A growing specialty area in the mental health field involves working with emotionally disturbed youth and families-at-risk by providing services in the context of the home environment. A review of the literature provides documentation for family systems, social learning, and ecological interventions with at-risk families receiving home-based intervention but there is an absence of material on the use of multi-family groups with this population. The purpose of this article is to outline the implementation of a multi-family therapy (MFT) component for home-based programs serving at-risk families. Advantages and disadvantages when using MFT are also addressed.The authors are grateful to Linda Pannell for her helpful comments on drafts of this article.     

PARENT REINFORCEMENT FOR CHILD ACHIEVEMENT: THE USE OF A LOTTERY TO MAXIMIZE PARENT TRAINING EFFECTS

This study describes and evaluates a reinforcement program in which parents earned lottery tickets and won prizes for the progress made by their handicapped children during home-based intervention. An ABAB reversal design replicated across three families was used to assess the effects of the lottery on the children's mastery of language skills. Results showed that the reinforcement of the parents for training accomplishments, as indexed by their children's achievements, produced clinically significant increases in the children's progress when compared with the children's progress under the routine supportive practices of the baseline condition. The implications of the findings for parent training programs in general are discussed.     

Family involvement for children with disruptive behaviors: The role of parenting stress and motivational beliefs

Children with disruptive behaviors are at risk for adverse outcomes. Family involvement is a significant predictor of positive child behavior outcomes; however, little research has investigated parent psychological variables that influence family involvement for children with disruptive behaviors. This study investigated the role of parental motivational beliefs (i.e., role construction and efficacy) as a potential mechanism by which parenting stress impacts family involvement for families of children with disruptive behaviors. Results indicated that parent role construction mediated the relation between parenting stress and all aspects of family involvement examined (i.e., home-based involvement, school-based involvement, and home-school communication). Parent efficacy mediated the relation between parenting stress and home-based involvement only. Parents of children with disruptive behaviors reporting stress may experience negative beliefs about their role and efficacy to support their child's education, which may thereby negatively influence their actual involvement. Therefore, parent motivational beliefs may serve as an important point for intervention to support involvement of families of children with disruptive behavior.     

Contrasting strategic and Milan therapies

Three related models of therapy are often grouped together as the strategic therapies. These are the brief therapy model associated with the Mental Reseach Institute, approaches developed by Jay Haley and Cloë Madanes, and the model developed by the Milan associates. Controversy exists, however, as to whether the Milan model should be included as a strategic therapy. It appears that the similarities among the three models can mask deeper differences, thus confounding the confusion. This paper contrasts the models in their development, theory, and practice.     

It’s not what you said,it’s how you said it: An analysis of therapist vocal features during psychotherapy

Psychotherapy is a conversation, whereby, at its foundation, many interventions are derived from the therapist talking. Research suggests that the voice can convey a variety of emotional and social information, and individuals may change their voice based on the context and content of the conversation (e.g. talking to a baby or delivering difficult news to patients with cancer). As such, therapists may adjust aspects of their voice throughout a therapy session depending on if they are beginning a therapy session and checking in with a client, conducting more therapeutic ‘work’ or ending the session. In this study, we modelled three vocal features—pitch, energy and rate—with linear and quadratic multilevel models to understand how therapists’ vocal features change throughout a therapy session. We hypothesised that all three vocal features would be best fit with a quadratic function—starting high and more congruent with a conversational voice, decreasing during the middle portions of therapy where more therapeutic interventions were being administered, and increasing again at the end of the session. Results indicated a quadratic model for all three vocal features was superior in fitting the data, as compared to a linear model, suggesting that therapists begin and end therapy using a different style of voice than in the middle of a session.     

PROGRAMMING PARTICIPATION IN FAMILY ACTIVITIES FOR CHILDREN WITH AUTISM: PARENTS' USE OF PHOTOGRAPHIC ACTIVITY SCHEDULES

The parents of 3 boys with autism were taught to help their children follow photographic activity schedules depicting a variety of home-living tasks. A multiple baseline across participants showed that the home-based intervention produced increases in children's engagement and social initiations and decreases in disruptive behavior, which were maintained for as long as 10 months.