Field Educator: A Scholarly Journal from the Simmons University School of Social Work

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Historically, social workers and other helping professionals, such as visiting nurses, have intervened on behalf of individuals, families, and communities. Often, these interventions take place in a client’s home. Wasik and Bryant describe home visiting as “the process by which a professional or paraprofessional provides help to a family in their own home. This help focuses on social, emotional, cognitive, educational, and/or health needs & often takes place over an extended period of time” (2001, p. 1). Traditionally, home visits focused on three overarching areas: poverty, infant and child care, and illness (Wasik & Bryant, 2001, p. 1). In the last decade, home visiting has also become a central feature of services such as home-based behavioral health and family wrap-around programs. Home visitors seek to provide child care information, health care, knowledge of community resources, and emotional support. Many social work internships include home visits, but interns are often confused and worried about what this means.Students often ask, “Do I want to do this? How will I do this? What do I say? What do I do? Am I safe? Is this neighborhood safe? Are the clients safe in this neighborhood? What about the location of my agency? What is expected of me? How do I help in an informal environment?” Interns need to know the importance of the home visit for building a helping alliance, offering the clues in making an accurate psychosocial assessment, and learning the advantages and challenges of home-based interventions.

Safety

Home visiting immediately exposes interns to the communities in which their clients live. Naturally, interns are initially concerned with the safety of the environment they will enter. Schools of social work should offer a safety preparation checklist for interns planning a home visit. Interns are encouraged to identify a safety partner for “check-in,” to identify the exact location of the home, to ask about the surrounding community, to clarify the purpose and time frame of the visit with the client, to determine appropriate clothing and accessories, and to ask basic safety questions. Interns are trained to use sight, hearing, and smell during travel and within the home. They are also encouraged to check in with themselves, and later with their partner, about their sense of safety. These basic rules can allay much of the anxiety of interns who are new to the community and to the social work field, and can thus allow them to attend to the client.

Engagement

The development of the professional helping-relationship is the core of social work practice and is the first step in the professional helping process. Meeting clients in their homes provides special opportunities to form alliances between workers and clients. Birkenmaier, Berg-Weger, and Dewees (2011) describe relationship-building as leading to the other processes that define social work practice: assessment, intervention, and evaluation. Initially, the role and importance of the relationship between the student and the client is the initial focus and purpose underlying the home visit. Brill and Levine define the helping-relationship as one that is “purposeful and goal-directed; otherwise, there is no reason for its existence. It is directed toward enabling the client to achieve a more satisfactory degree of functioning. As such, it is time-limited” (2005, p. 120). This relationship is needed in order to help the clients effectively find ways to manage or to resolve problem situations in their lives, and then to demonstrate an ability to generalize what they learn for future situations. This relationship is also referred to by as a working alliance that ensures accountability and responsibility between the helper and the client. This purposeful, time-limited relationship clearly emphasizes the commitment to working as a team in helping clients move from stress or crises to a situation that is successfully working for them. Four qualities are essential for a successful professional helping-relationship: empathy, genuineness, respect, and trustworthiness. Home visits can encourage these qualities. Interns are more likely to empathize with clients’ difficulties and recognize clients’ resilience if they see them in their own surroundings; for example, one intern said, “I had no idea how hard it is to get to a doctor here!” Miley, O’Melia, and DuBois state that “Respectful social workers regard clients as partners, listen to their opinions, communicate cordially, honor cultural differences, and credit clients as having strengths and potential” (Miley, O’Melia, and DuBois, 2011, p. 136). Willingness to visit clients “on their turf” can foster a genuine and respectful relationship that minimizes the power differential implicit in the helping- relationship (Brill & Levine, 2005, p. 120), and can thus suggest that the worker is trustworthy.

Environmental Assessment: The Community

Social work interns are taught to adopt an ecological perspective, seeing clients as making efforts to adapt through transactions and reciprocal exchanges with their surrounding social environment (DiNitto & McNeece, 2008, p. 35). As interns travel through the client’s neighborhood, they become aware of the ways that the community supports or hinders the client’s survival and development. The first thing they will notice is the availability of transportation; many interns better understand missed appointments once they see how many buses it takes to get to the client. Once the safety of the neighborhood has been assessed, resources can be located. If there are businesses, are they readily accessible to the client considering the client’s economic, ethnic, and educational background? In particular, are there institutions that support family systems, such as schools, day cares, banks, grocery stores, community and health centers, recreational and/or sports facilities, libraries, and bookstores? The intern can learn a great deal about the cultural life of the community by noticing local sites like restaurants or religious institutions.

The Physical Environment of the Home

A home visit provides an opportunity to see clients in the context of their physical environment at home. Assessment of the client system’s functioning is informed by observation of basic routines like eating and sleeping; for example, what is in the refrigerator? How many beds are present and for how many people? Decoration of rooms can indicate a family’s priorities, as well as the amount of energy and resources available in the family. What is important to this family? What is on the walls? What is on the bookshelves? Are there bookcases? Do they have DVDs, videos, or music? What type of videos and music does this family own? Do you see books or videos borrowed from the local library? Is there furniture? Is it brand new furniture or old furniture?

Family Structure and Communication

A home visit is certainly the best way to assess a family’s structure and communication patterns. While it is very difficult to interview several family members at a clinic appointment, a home visit will often make it possible for most family members — and sometimes neighbors — to join the conversation. Interns can assess alliances and hierarchies, for example, by observing who sits where. They can monitor who speaks to whom and who is listened to, and can assess whether communication is disjointed, sporadic, or poorly modulated. Assessment must be tempered by an interns’ reflection on their own reactions based on their family of origin and cultural messages. For example, an intern who became accustomed to a father who was quite argumentative but never violent, might not be concerned with clients’ raised voices and intense emotions; whereas, an intern raised in a quiet and conflict-avoidant family might see these clients’ communication as problematic. Interns must also be aware of clients’ cultural norms, like the power relationships between husband and wife.

Individual Client Assessment

Clients act not only to meet internal needs but also to meet the demands of the environment. Behaviors may be unacceptable and have negative consequences, yet they make sense when considering context. Seeing the client in the home can increase the intern’s empathy with the client’s situation. The visit can provide an opening for the student to explore the context of problematic behaviors and define the most appropriate method(s) to effectively help. A home visit may also help an intern to assess the difference for the client between stress and crisis. Stressors are viewed as neutral and lead to a state of stress when they require change (Boss, 2002). The source of stress can be the environment, the family, and/or the individual. Stressors can also be sorted according to their duration as either chronic or acute; chronic stressors are seen as those that last over a significant time frame while acute stressors occur suddenly over a short period of time. Stress can lead to crisis, a categorical variable since an individual, a family, or a community is either in or out of crisis (Boss, 1988). Crises can cause acute, moderate to severe discomfort, and can have minimal to severe impact on functioning. Weber states, “although crisis is a state of dysfunction, when someone or a family is in crisis, we do not label that person or family as dysfunctional. The label dysfunctional describes a chronic condition, whereas a crisis is an acute (temporary) condition that happens to both healthy/functional and unhealthy/dysfunctional individuals and families” (2011, p. 41). Home visits can elucidate sources of stress for the client and, over time, can indicate whether the client is in crisis or chronically dysfunctional.

Intervention

After problem identification and assessment, the intern develops goals and implements an action plan (Colby & Dziegielewski, 2010, p. 111). In addition to encouraging engagement with the client, home visits offer an unparalleled opportunity not only to observe but also to work with many parts of the client’s ecosystem. Garthwait says, “Social workers engaged in planned changes see the connections and mutual interactions between people and the social environments of which they are a part (2013, p. 177). Planned change involves the micro, mezzo and macro levels: interns can see clients in their own surroundings, can interview family members and neighbors, and can also work with other providers who visit the home or who are in the neighborhood. However, the intentional, methodical process of assessment and action planning needed in the “blooming, buzzing confusion” of a home visit can be overwhelming for a developing intern; it can be a struggle to identify the target for change and the priority of identified interventions. Interns must rapidly learn family dynamics: the distinct patterns of relating, decision-making, rules, scripts and division of labor (Hepworth, Rooney, Strom-Gottfried & Larsen, 2010). Social workers are no longer “friendly visitors”; understanding the professional social work role is particularly important in setting appropriate boundaries with clients in a home visit.

Need for Supervision

Because of these challenges, ongoing supervision to ensure the success of home-based practice is essential. Home-based practice can be challenging if the intern lacks a certain degree of awareness. For example, as Hepworth et al. say, “Discomfort can arise when you encounter a family that is vastly different from your own and whose norms are inconsistent with your values as well as those reflected in the dominant society” (Hepworth, Rooney, Rooney, Strom-Gottfired, & Larsen, 2010, p. 229). Wasik and Bryant emphasize the importance of supervision to reduce isolation, to solve problems, and to ensure accountability. They state, “Being able to discuss specific concerns and receive input and advice from other knowledgeable people is not only very productive for home visitors but can also serve as a stress-reduction process” (2001, p. 98-99).

Summary

Home visiting is an invaluable asset in social work field education. Home visits foster good engagement with clients and offer a broad yet intimate view of the client’s life. Interns learn the basics of psychosocial assessment, moving beyond the client to the family and the neighborhood. They also have opportunities to intervene at micro, mezzo and macro levels. However, interns also need structure and support in home visiting. First, they need to learn the basics of safety assessment and planning. In addition, interns need regular and intensive supervision to support them as they maintain professional boundaries, manage relationships with several people at once, attempt to set goals and prioritize interventions in a relatively uncontrolled environment, and immerse themselves in a complex and challenging culture.

Home Visit Safety Preparation Checklist

Home Visit Safety Checklist provides a framework for the field student to intentionally think about their home visit prior to, during, and after to ensure safety at all times.

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