As an in-home clinician, I recognize that there are challenges in providing in home counseling services. Some in-home clinicians have expressed concerns about their safety and the safety of their clients (Adams & Maynard, 2000; Worth & Blow, 2010). Due to the family’s complex needs, many clinicians find themselves having to provide in-home counseling in a chaotic environment, the family’s inability to cope with the chaos, and the lack of community resources available to the family to assist them in such turbulent times (Adams & Maynard, 2000). On a practice level, in-home clinicians have expressed concerns about managing boundaries, ethical challenges and maintaining confidentiality (Snyder & McCollum, 1999; Worth & Blow, 2010). Counselors have also expressed concerns about managing the counseling session in the midst of distractions and interruptions while working in the client’s home (Snyder & McCollum, 1999; Worth & Blow, 2010). Being part of the client’s environment, and at times becoming a member of the client’s community, imposes a unique challenge for in-home clinicians as they cannot use the physical space of their office to assist in buffering their feelings (Zarski, Sand-Pringle, Greenback, & Cibik, 1991).
Under those circumstances, it is important to explore the concept of countertransference. This term is widely used in clinical discussions and has become part of social work’s professional language. The classical view of countertransference is defined as a type of unconscious resistance in the therapist which was created by the patient’s verbalization, behaviors, and representation to the analyst (Mills, 2004). Freud viewed countertransference as a negative obstacle to the therapeutic process. Contrary to transference, he never considered countertransference a useful tool in the analysis (Freud, 1910). Since then, countertransference has undergone a significant transformation from its conceptualization, implementation in psychoanalysis and psychotherapy. Today, the description of countertransference includes remarks, thoughts, fantasies, and even non-verbal bodily reactions that become awake in us during the course of a session and which can be used as clinical data (Bichi, 2012). Due to this new view of the concept, countertransference can be a very useful tool in understanding a client’s suffering by what it invokes in the therapist. By being able to appropriately process the therapist's countertransference which is in direct interaction with the client’s transference, allows for the client to reenact earlier object relationships (Hanna, 1993).
In-home practitioners experience a heightened level of countertransference that may become an obstacle in the therapeutic relationship if not dealt with diligently. The “heightened” state of countertransference is different from the level of countertransference experienced at an office setting due to the multi-sensory exposure to stimuli within the home. The in-home counselor’s multi-sensory experience of the child’s life (house, neighborhood, friends, people, smells, sensations, conditions of the space, dangers) become the events that are witnessed “in-vivo” with all of the senses. This is not a story told to you by the child or the family, but a narrative that is being formed in front of your eyes that makes you a willing or unwilling participant of the story. In the following vignette I will demonstrate how one’s countertransference can be used as a significant tool for helping in-home clinicians facilitate the client’s healing process.
Luisa's Story
I met Luisa in her grandmother’s house. She was sitting in a black imitation leather recliner, and my eyes were immediately drawn toward her ankle. A monitoring device was wrapped around her pale limb. I had never seen one of those around the leg of a 13-year-old girl. In a very casual manner, I introduced myself: Hi, I’m Sakima. How are you doing? She responded, OK! Were you sent here by that motherfucker, ratchet-ass bitch from that agency? Luisa was referring to the care manager who contracted my services to provide in-home counseling. I said, (pretending not to know this person as I didn’t want to be associated with her negative feelings towards this worker. Luisa felt oppressed by those workers as they came to her house to tell her what to do, and that was certainly not my role) I’m not sure who you are talking about, but what is going on with this person?
Juvenile court mandated Luisa to in-home arrest after multiple infractions in the community such as drinking alcohol, marijuana use, and physical/verbal assaults with teachers, peers, and family members. When I met Luisa, she was living at her grandmother’s house. Luisa often gave her father and his girlfriend a shower of colorful language and physical rage. As Luisa continued with her destructive behaviors, she moved several times, was homeless on more than one occasion, stopped going to school, was arrested, was physically assaulted, became pregnant, was institutionalized, and had experienced countless heartaches in her relationship with her parents.
All my training about evidence-based practice was of very little use when the basic needs of this child were never met in a consistent manner. Luisa’s emotions were so dysregulated that she was not able to concentrate on how to learn a coping skill as she didn’t know where she would be spending the night. In light of all the chaos, I was not able to just close the case as I was the most consistent figure in her life, so I found myself vacillating between being a therapist and being her mother. I often wonder how much of my vacillation was my own need to protect her and guide her and how much of it was to provide adequate treatment for her behaviors. The ambiguity of my role and my boundaries with Luisa was a constant throbbing thought in my head while making decisions about her safety and her privacy. Is not uncommon for in-home clinicians to struggle in establishing healthy boundaries as well as the timing and place of treatment within families with multiple and pervasive multi-systemic needs (Adams & Maynard, 2000; Christensen, 1995).
During the intervention, I used my own feelings of inadequacy and my need to help her as an interpretation of Luisa’s feelings towards her parents and her place in the world. During the in-home practice, transference may take a more intense manifestation as clients experience their environment as part of their suffering and the therapist becomes part of that environment (Boyd-Franklin & Bry, 2000; Reiter, 2006b). Luisa would come to sessions so overwhelmed and full of anger towards the world and, at times, towards me. I would remain calm also unmoved by her reactions, and I would speak to her in a low voice with brief responses or just listen to the anger and bear witness to the tears. I felt so sad for her, and I knew that she was probably feeling the same. Her transference towards me was of anger. The experience of my countertransference was so much stronger because it is very different for a child to come to the clinician’s office, an identified safe space even if she has to return to her dysfunctional life. But when the in-home therapist gets to be in the puddle with the child and not be able to offer her even a moment of a safe space, it becomes very taxing on the clinician’s moral compass.
Luisa was angry at me because I was not her mother. She once asked, if I wanted to be her mother. I, [in return,] asked, What would happen if I was your mother? She said, “I don’t know, but I won’t be living this fucked up life.” Then I replied, “It sounds like you just want to be ok, not to have to worry about a place to live or where you are going to eat.” She considered this for moment, and then said, “Exactly, no kid should be living like this.” Nevertheless, though I was connected to the chaos, I was also connected to Luisa’s resilience and self-determination. She would find a way to contact me and follow up with her sessions. Luisa cultivated an underlying sense of hope over time that assisted in completing treatment. Regardless of the situation, the clinician must create a safe space to give room for the therapeutic alliance to flourish, while remaining in a dual role as being part of the environment but able to separate at the same time (Fuentes, Gelso, Owen, & Cheng, 2013).
An in-home clinician is part of a team that works with the child and the family to help them meet their goals. This helps to delegate some of the responsibilities, especially the ones that are related to care management and not necessarily to the therapeutic process but are essential for the person in treatment. In Luisa’s case, the cooperation of child protective services, care management organizations, and community leaders helped Luisa identify a safe place to live, develop vocational skills, and complete her high school education. As Luisa developed the necessary connections to natural support, the in-home services ended.
Written by: Dr. Sakima Gonzalez, DSW, LCSW