In-home intervention with families in distress: changing places to promote change.
Abstract: This article examines the benefits of in-home family therapy with severely distressed families through the analysis of four cases that demonstrate the creative use of this intervention with families whose children were placed in a full-time day care facility. Although the efficacy of home intervention with distressed families has been documented, the case illustrations here analyze the process more fully--the how and the why it works. The first three cases explicate the contribution of home intervention to the engagement of social worker and client. Each case highlights how home intervention enhances the therapeutic alliance by promoting change from a different starting point--the client (home as a secure base for change), the worker (viewing the client from a different perspective), and the client--worker interaction (power sharing in setting boundaries). The fourth case (in vivo narrative reconstruction) serves as a striking example of how the home--as a multisystemic, intergenerational container of the family's past, present, and future--can be enlisted as a partner in reconstructing silenced chapters of the family narrative.

KEY WORDS: child welfare; day care; families in distress; in-home family therapy; out-of-home placement
Article Type: Report
Subject: Family psychotherapy (Usage)
Family psychotherapy (Methods)
Family psychotherapy (Case studies)
Authors: Waisbrod, Nirit
Buchbinder, Eli
Possick, Chaya
Pub Date: 04/01/2012
Publication: Name: Social Work Publisher: Oxford University Press Audience: Academic Format: Magazine/Journal Subject: Sociology and social work Copyright: COPYRIGHT 2012 Oxford University Press ISSN: 0037-8046
Issue: Date: April, 2012 Source Volume: 57 Source Issue: 2
Geographic: Geographic Scope: Israel Geographic Code: 7ISRA Israel
Accession Number: 302403780
Full Text: At its inception, social casework consisted of "friendly visits" by volunteers who delivered concrete and supportive services in the homes of poor families. These frontline workers were directly and intimately exposed to the lives of the families they visited. Early on, Mary Richmond identified the potential of the home visit as a tool in family assessment and evaluation, and gradually this function became the main reason that social workers ventured into a client's home (Camlio, 2007; Wasik, Bryant, & Lynos, 1990). Over time, the primary social work interventions became agency based; clients were required to meet social workers in the workers' offices to apply for concrete services or to engage in ongoing counseling (Allen & Tracy, 2004). This shift was considered part of the professionalization of the delivery of social services and was seen as benefiting clients because it both respected their privacy and encouraged them to take responsibility for initiating treatment (Cottrell, 1994; Woods, 1988). Although therapy largely moved from home to office, home visits continued for home-bound elderly people, people who were physically or mentally ill and living in the community, and families with problems of child abuse and neglect (Allen & Tracy, 2004; Carfilio, 2007).

The present article examines a special program--in-home family therapy in the child welfare domain. Four illustrative cases of in-home therapy with severely distressed families whose children were placed in a full-time day care facility are presented. These cases highlight unexpected applications of home intervention that warrant additional consideration by family service practitioners who are confronted with clients with particularly problematic family dynamics and who may well benefit from the creative use of this neglected approach.

REVIEW OF THE LITERATURE

Although still largely undemsed, home intervention has been increasingly implemented over the last two decades in the fields of child welfare and mental health (Carrilio, 2007; McWey, 2008; Yorgason, Mcwey, & Felts, 2005). The rationale for this approach is that it is a way of reaching out to "difficult" clients who have not responded to traditional agency-based interventions (Aponte, Zarski, Bixensfine & Cibik, 1991; Woodford, 1999). There is growing evidence of the effectiveness of home intervention with various populations--for example, depressive mothers (Ammerman et al., 2007; Beeber, Holditch-Davis, Belyea, Funk, & Canuso, 2004) and adolescent substance abusers and their families (Chemiss & Herzog, 1996; Henggeler, Pickrel, Brondino, & Crouch, 1996). It has been proven effective in reducing the numbers of child out-of-home placements (Barth et al., 2007; Henggeler, Melton, & Smith, 1992; Walton, Fraser, Lewis, Pecora, & Walton, 1993), in reducing behavioral and adjustment difficulties among children and adults with conduct disorders and mental health needs (Barth, 2007; Lindsey, Lee, & Sullivan, 2009; Yorgason et al., 2005), and in reducing emotional problems and psychiatric hospitalization among those diagnosed with mental illness (Frazer, Nelson, & Rivard, 1997).

Social work clinicians and theorists have offered a number of general explanations regarding the efficacy of home interventions. Home intervention enables social workers to get to know and connect to their clients' day-to-day realities in their natural environments in a sensitive manner. Furthermore, the natural setting expands possibilities for applying innovative techniques aimed at changing family patterns and implementing new ways of solving problems in an environment that is less resistant than a clinical setting (Boyd-Franklin & Bry, 2000; Cortes, 2004). The role reversal that occurs between a family and a social worker, when the family remains in its domain while the social worker must join with the family members on their terms, creates opportunities for new relations and responses that enhance the family's motivation for change (Boy&Franklin & Bry, 2000; P, eiter, 2000; Thomas, McCollum, and Snyder, 1999).

In spite of the unique advantages of psychosocial intervention at home, family therapists using in-home intervention have reported feeling incapable of helping multiproblem families with this approach. They have had particular difficulty dealing with the issue of boundaries as well as the timing and pace of treatment (J. F. Adams & Maynard, 2000; Christensen, 1995). Moreover, at times, social workers are faced with opposition to in-home intervention on the part of colleagues who insist that it is imperative to meet clients within the social worker's professional domain. The opponents of in-home intervention claim that it precludes "true" evaluation of a family's motivation or resistance. In addition, they maintain that in-home intervention leads to loss of the therapist's authority and ability to control the helping situation, thus impairing treatment effectiveness (Thomas, McCollum, & Snyder, 1999). In light of these criticisms, this article attempts to add a layer of practice wisdom regarding the use of in-home intervention by analyzing cases in which this therapeutic approach was used with "hard-to-reach" families whose children were placed in a full-time day care facility.

CONTEXT: FULL-TIME DAY CARE SERVICE

The traditional intervention in Israeli child welfare services aimed at protecting children from abuse and neglect by their parents is out-of-home placement in a foster care or institutional setting. Professionals have believed that in addition to preventing the abuse, the new "home" will provide a corrective, nurturing experience for the child. In recent decades, there has been growing, widespread criticism of this policy, because it has been largely ineffective in improving children's behavior, adjustment, and achievement. In addition, it sometimes exposed children to further abuse in the new settings, and it disconnected children from their roots and familiar environments as well as the existing resources in their families and communities of origin (Benbenishty & Oyserman, 1995; Dolev, Benbenishty, & Timer, 2000; McSherry & Iwaniec, 2002). In an attempt to address these serious problems, 10 residential facilities for children ages five to 13 years in Israel developed a full-time day care model in cooperation with the Israeli Ministry of Welfare. The full-time day care facility is located within the families' home community and operates six days a week from 7 A.M. to 7 P.M. The program is designed for families who are unable to adequately care for their child or children but within which the risk of neglect or abuse is not so great that unsupervised parent-child contact at night and on weekends is contraindicated. The children are placed in fulltime day care by local departments of social services (DSSs) after having been declared "at risk" in their home environment. Only about 2 percent of the placements are court mandated. The vast majority of the parents are more than willing to send their children to full-time day care, because they view this program as an inexpensive and convenient arrangement that also removes the "threat" that the DSS will mandate out-of-home placement in foster care or a residential facility.

The full-time day care facility is a "home-like" setting in which groups of 15 children live on a campus, in separate apartments, with three counselors who function as parental figures. The children continue to attend the local schools in which they were previously enrolled and participate in after-school recreation, enrichment, and therapy in the full-time day care setting. There is ongoing, often daily, contact between the parents and a child's counselors, and parents are encouraged to participate in parent-child activities, which take place on a weekly basis, as well as the group, individual, and family counseling provided by staff. In addition, a child's counselor accompanies his or her parents to parent-teacher conferences at school and to appointments with the child and a pediatrician at the medical clinic.

Although parents are viewed as full partners in the full-time day care programs, it was initially assumed that meetings between the professional staff and families would take place at the day care facility. Social workers and counselors made a one-time home visit at the beginning of a child's stay, mainly for assessment purposes. In this way, the social work staff simply continued the intervention procedures they were familiar with from traditional residential settings. The proximity of the full-time day care facility to the families' homes and the concerted efforts of the staff to incorporate parents in the day care community did enable many families to participate in the agency-based programs. About 20 percent of the parents, however, refused or partially resisted invitations to participate in on-site contact with staff. One of the outreach initiatives in the full-time day care facility, on which this article is based, is in-home intervention. Although in-home intervention was initially viewed as a transitional phase that would help hard-to-reach families avail themselves of agency-based treatment, the response of the families and social workers and the results of the intervention were such that in-home intervention became the treatment of choice for a broad range of families. In the full-time day care facility on which this article is based, in-home family intervention has been implemented for the last six years with about 75 families.

CASE ILLUSTRATIONS

The following are four case illustrations, each highlighting a different aspect of in-home family intervention. In addition, these case illustrations create a bridge between theoretical, abstract themes and the subjective experiences of social workers. The cases are not "representative" in a research sense; rather, they were chosen to highlight and represent various levels of meanings attached to in-home interventions, especially for heuristic purposes. Although all of the members of the social service staff at the full-time day care program used home intervention, we chose families from the caseload of one of the authors, Nirit Waisbrod (N.W.), because she had the most intimate knowledge of the therapeutic process with these families. Finally, the case illustrations were selected with an eye toward learning from successful interventions and outcomes.

The interventions described in the case illustrations are based on the strengths perspective (Saleebey, 2006), solution-focused therapy (Berg, 1994), and narrative therapy (White & Epston, 1990). The emphasis here is on the unique ways in which these approaches are applied in in-home intervention with distressed families whose children were placed in full-time day care facilities. All chent names have been changed to protect confidentiality.

The "A" Family: Home as a Secure Base for Intervention and Change

Case. Gabriel (51 years old) and Shelly (37) both emigrated with their families from North Africa. They were the parents of four children, two of whom, Rina (12) and Omer (11), attended the full-time day care facility. Gabriel worked as a custodian at a local factory, and Shelly was a homemaker; both were second-generation social welfare clients. Omer behaved very aggressively toward other children and did not accept the authority of teachers; every few days, Gabriel received a call at work from the principal instructing him to take Omer home during the school day. This demand evoked feelings of deprivation that Gabriel himself had suffered in school, and he voiced these feelings forcefully to the principal and teachers. In his meetings with the social worker in the full-time day care facility, Gabriel repeatedly asserted that social workers were uncaring and "paid attention only to those with money." Gabriel took complete charge of the family's interactions with professionals; Shelly either did not attend the meetings or sat silently while Gabriel reiterated his accusations to the social worker. The staff of the full-time day care recommended reaching out to the family through in-home intervention.

From the beginning of the in-home intervention, deprivation was the main topic. At home, both parents actively participated in the conversation. N.W. empathically listened to Gabriel and Shelly sharing the various experiences of deprivation and discrimination that they, their parents, and their children had experienced throughout their lives. These experiences were discussed over coffee in their living room, with the children drifting in and out and listening in. At the end of the third session, N.W. noted the following paradox:

For the first time, neither Gabriel nor Shelly came back with a retort focused on failure. In the next session, Gabriel turned to N.W. with this question: "So what do you think we can do so that Omer won't get kicked out of school every other day?" N.W. suggested that they start by thinking of ways that Gabriel could get the professionals to listen to his ideas. Shelly and Gabriel participated in role-playing interactions, and they were able to reconstruct some of the situations with professionals that they had perceived as discriminatory. At the same time, they maintained a "place of honor" for other memories of opportunities that they had been drafted as children of poor, North African immigrants. The weekly in-home sessions with the parents in the presence of the children took place for six months.

Gabriel and Shelly's main challenge as parents was to focus on opportunities to be protective and to teach their children to stand up assertively for their rights. The overall family pattern changed, from perceiving themselves as deprived victims to seeing themselves as survivors of the system. This change was evident in a marked decline in Omer's aggressive behavior in school.

Discussion. Many second-generation families in distress lack belief in themselves and experience senses of failure, loss of respect, humiliation, and helplessness with regard to changing the hardships in their lives (Sharlin & Shamai, 2000). These feelings of powerlessness may be exacerbated when social workers intervene from an external position to protect children (Noble, Perkins, & Fatout, 2005). Parents in the child welfare system often feel marginalized, stigmatized, and alienated and react with anger, detachment, or avoidance in their relationships with social workers. Social workers perceive this behavior as unappreciative and disrespectful, whereas clients perceive the social workers as part of an aggressive, intrusive, and discriminatory system. At the core of parents' emotional distress is an overwhelming sense of insecurity when facing what they perceive as a hostile environment. The recursive loop of mutual distrust and disrespect between clients and workers often creates an impenetrable impasse.

Although, in theory, all of the interventions N.W. used with the "A" family could have taken place in her office, in practice Gabriel's disadvantaged position in formal, institutional settings continually reinforced his feelings of insecurity and would not have allowed for the interventions to take place. The home and family provided Gabriel with a secure base from which he could safely explore his feelings of hurt and vulnerability and open himself to the possibility of hope and change. Gabriel prevented his wife and children from participating in joint sessions in the agency so as to protect them from the criticism of the authorities and so that they would not see him in the humiliating position of welfare client. He thus had to function as a parent in the threatening institutional environment alone. Home intervention naturally includes the entire family and, in this case, the family cohesiveness provided a secure base for both parents. Gabriel, as the head of the household, accepted N.W. into his home, and for the first time, Shelly took an active part in the therapeutic process. In the client's home, N.W. felt a greater obligation than she would have in her office to respect the family's anger and attempt to understand its source and legitimacy.

The containment of Gabriel's anger and its validation through the statement that "you are very angry about the way in which you have been treated, and yet you have been able to build a family with Shelly and provide a home for them" were especially powerful because they occurred at home in the presence of Gabriel's children. The home domain also represented, in the most direct manner, the parents' responsibility to their children. Reframing Gabriel's anger as "concern for the family's welfare" within the home challenged both parents to overcome feelings of helplessness and transform their intense feelings into a catalyst for change. Working with the couple at home, in their own domain where they felt secure, enabled them to entertain alternative interpretations of their past experiences, including seeing the good in others, and to draw on their own resources to more effectively face and protest injustice.

The "B" Family: Viewing the Client from a Different Perspective

Case. Hannah was a 30-year-old divorcee and mother of two children--Sarah (nine) and Jonathan (seven). Both she and the father of the children immigrated with their families from the Caucasus region. She was unemployed and spent most of the day asleep in her bedroom. A social worker from the local DSS reported that the house was in a state of extreme physical neglect, with unwashed dishes, leftover food, and rodent droppings in the kitchen and dirty clothes, garbage, toys, and assorted household items strewn in the living area. Sarah and Jonathan were often absent from school, and Hannah tried to prevent contact between them and other neighborhood children after school by forcing them to stay indoors. Hannah refused the homemaker and child-care services offered by the DSS, and a child welfare worker was enlisted to arrange for a court order to place the children in the full-time day care facility.

During the first year that the Sarah and Jonathan were at the full-time day care facility, Hannah visited them only twice. All attempts to bring her there were unsuccessful, and there was total alienation between the mother and the day care staff. The day care staff described a dismal picture of the home situation, the mother's personality, and the children's emotional well-being and recommended transferring the children to a residential facility. As a final attempt, N.W. decided to offer the mother in-home family intervention in the evenings. The psychologist who was involved in the case expressed grave doubts about this intervention's chances of success and felt that the children should begin the preparation process for removal from their home.

N.W. phoned Hannah and asked if she could come to visit the family. Hannah consented immediately, and a date and time were set for the following week. When N.W. entered the home, she discovered that Hannah had cleaned the house in preparation for the meeting and had baked cookies. The initial session was devoted to informal "small talk" with Hannah, Sarah, and Jonathan and enjoyment of the refreshments. Toward the end of the "session," N.W. asked whether it would be good for the family if she came once a week to chat with everyone about how things were going at home, in school, and in day care. Hannah, Sarah, and Jonathan readily agreed.

N.W. reported back to the day care staff about her surprising experience during the home visit and got approval to embark on three months of weekly in-home sessions. At the end of this period, a fmal decision would be made about the children continuing in the full-time day care program or being removed from the home to a residential facility.

During the subsequent meetings, N.W. encouraged the family to go about their "business" after the ritual of entertaining her with snacks and conversation in the living room. The family seemed to make an effort to be on their best behavior in front of their invited guest. N.W. observed positive interpersonal patterns, such as Sarah helping her brother prepare his schedule for the following day and Sarah reading Jonathan a story, with Hannah proudly watching them. Sarah--who had previously been described by the psychologist, counselor, and a social worker as a "parental child"--was now viewed as a caring older sister. N.W. even observed and reported on Sarah's childlike behavior in the home. At times, she would crawl into her mother's lap, and Hannah would brush her long hair. Although Hannah did not maintain the standard of cleanliness that was evident during the first visit, there was a significant overall improvement in the state of the house.

The fact that N.W. was able to witness the family's positive behaviors gave her and the rest of the staff a basis for hope. In addition, she was able to give Hannah positive feedback and mirror the pleasure Hannah felt in her accomplishments. The full-time day care staff decided not to recommend out-of-home placement. The in-house intervention continued for approximately a year-and-a-half. N.W. became a kind of professional friend for Hannah, and Hannah consulted with her about her own medical care and job-seeking attempts. At the conclusion of the in-home intervention, Sarah and Jonathan attended school regularly and were allowed to bring friends home.

Discussion. This case demonstrates the profound impact of the change in position from difficult client to gracious host. This shift began with the initial phone call, in which N.W. had to ask for an invitation, a move that changed the "rules" of the interaction. Instead of the social worker being the inviter--who would feel rejected or, at the very least, disappointed if she was turned down--she became the invitee who appreciated the willingness of the client to host her. Hannah had been socially isolated for a long time and had no occasion to spruce up her house. The only "invitations" she received were from professionals who sat in an office and either passed judgment on her poor parenting or empathized with her difficulties. When cast in the position of opening her home to a somewhat hesitant guest, she entered the role of hostess and changed the way she saw herself as well as the way she was perceived by her children. N.W. began to change as well. This first tentative shift gathered momentum as N.W. reported on the visit to the rest of the staff. N.W.'s eyes were now open to new perspectives; a parental child became a responsible older sister whose mother was proud of her. It was this change in perspective that created the foundation for implementation of a strengths-based intervention.

N.W. and the family members had not been able to identify certain family characteristics as strengths that could be realized until the intervention process began at home. When social workers are excessively absorbed in problems and dysfunction, their distress-ridden professional language comes to the fore, and they tend to adopt a blaming, stigmatizing stance toward clients. Intervention that is distant from a family's natural setting increases the risk of defining family members according to their pathologies, deficits, and problems (Frankel & Frankel, 2006; Goldstein, 2002). By observing and becoming involved directly in the family's life as a welcome guest, N.W. was able to develop a more holistic perspective that enabled her to relate to the family's strengths and hopes (DeJong & Miller, 1995; Shane, Lopez, Floyd, Ulven, & Snyder, 2000; Saleebey, 2006). Moreover, by being a guest, N.W. assumed a stance of not-knowing, of being open to and reflective of new perspectives (Anderson & Goolishian, 1992), including the perception of strengths. In-home intervention may advance the viewing of family members as experts on their own lives (Madsen, 2007).

It was not only N.W.'s perspective that changed. When the "B" family opened their home to N.W., the family members began to enact new roles, including "showing off" their strengths. This can be perceived as conation: a conscious and purposeful self-determined act aimed at achieving a goal (Gerdes & Stromwall, 2008). As such, the family was developing an alternative to the dominant family narrative, particularly their own perception of chronic dysfunction and isolation. This, in turn, imparted new meanings to their experience (Glicken, 2004; White & Epston, 1990). Paradoxically, at home, where despair is often most evident, the family members could break out of the reified perspective of failure and hopelessness as N.W. witnessed their lives in what was, for her, a different context.

The "C" Family: Power Sharing in Setting Boundaries

Case. The members of the "C" family were Ilana (34), a single mother, and three children--David (11), Michael (nine), and Kim (seven). Illana was born in Israel to parents who had emigrated from the Caucasus region. David and Michael were referred to full-time day care after they had been caught stealing from a local store and revealed during the investigation that their mother was violent toward them. Both liana and her children expressed hostility toward the referring social worker and the staff in the day care facility, liana was a "no-show" at the first three scheduled intake sessions. She reluctantly agreed to allow N.W. to make home visits when she realized that this was a condition for David and Michael's eventual return home.

In the first in-home family intervention session, liana and the children refused to talk about the family, even when N.W. began with gentle, nonthreatening queries about their likes and dislikes, the recent holiday they had spent together, and their daily routine. After 10 minutes David and Michael left the living room, and Kim turned on the television. N.W. shared her dilemma with Ilana, explaining that the purpose of the home sessions was to see the family together. Ilana called the three children to the kitchen to prepare supper with her. N.W. offered to help, and Ilana instructed her to chop onions. At the end of the session, N.W. expressed her thanks to liana, not only for the meal but for helping her fulfill her task as a social worker. Ilana smiled in response, and N.W. suggested that Ilana take charge of the activity for the subsequent home sessions. David and Michael observed this "negotiation" between N.W. and their mother with puzzlement.

The activities in the following three sessions were playing cards, watching a movie, and drawing pictures. N.W. was invited by liana to participate in the activities. Needless to say, many of the family interactions were problematic, with Ilana taking a very controlling stance, David and Michael hitting each other, and Kim wandering off to watch television or play by herself in her room. N.W. did not comment on these behaviors, but continued participating in the activities under Ilana's direction. In the fifth session, N.W. began a conversation by asking about how the family decided on the session activities, and Michael started talking about his mom's strict discipline, including extreme punishments. Ilana was able to share her frustrations about trying to raise three children alone. The sessions began to include more talk about the here and now of what was happening during the activity as well as the family's difficulties during the previous week. In the 12th session, Ilana talked openly about her violent behavior toward her children and expressed her wish to search for a solution to the children's behavior problems without resorting to hitting them.

After two-and-a-half years' work with the family, the children were returned home. Three years later, the caseworker in the local DSS who was responsible for following the family reported that all three children were functioning normally in school--there was no evidence of antisocial behavior in the neighborhood and no recurrence of family violence.

Discussion. The power differential between professionals and clients and the goal of empowering clients is a central issue in social work in general (for example, Pease, 2002; Sakamoto & Pinter, 2005) and in family intervention with poor, vulnerable families in particular (Frankel & Frankel, 2006; Sutherland, 2007). The prevailing underlying assumption is that the professional determines the ground rules of therapy, including the establishment of the boundaries of the setting. Social work knowledge inherited from psychoanalysis "sanctifies" the structure and boundaries of sessions to such an extent that deviation from these are considered to be unprofessional. In professional spaces (for example, the office), clients can be intimidated by professional's privilege, based on professional knowledge and social power (E. M. Freedman & Couchonnal, 2006; J. H. Freedman & Combs, 1996). The privilege of social workers' stance of knowledge and power is challenged in home intervention. The social worker must adapt to a different power structure in which the parent is in charge of the setting and therefore must be consulted in making the rules for the session. In home intervention, the social worker's professionalism is measured by his or her ability to be flexible regarding boundaries and rules, and he or she must overcome the fear of treading on uncertain ground and losing control over the intervention situation.

Power sharing is enhanced in the home setting as a family sees a social worker's difficulties and limitations in responding to naturally occuring situations that are out of his or her control (Aponte, 1995). In the home, the social worker is involved in the reality of family life; he or she witnesses quarrels, shouting, and disorder as well as the sounds of happiness and laughter. As Pease (2002) pointed out, there is a paradox in being a professional social worker in that this role claims both privileged knowledge and a commitment to client empowerment. The social worker's direct and intense involvement in clients' lived experiences at home forces him or her to come to terms with this paradox and begin to perceive power as nondichotomous. The flexibility in power distribution and boundary setting in this case involved N.W.'s participation in the preparation of a meal as well as in a crisis in real time, following David's returning late from school. Such situations require authentic, spontaneous reactions from a social worker, during which he or she will reveal not only his or her skills, but also his or her failings, thus evening the power balance between worker and clients.

Power sharing is a bidirectional process. Family members' sense of empowerment enables them to accept the social worker as a partner (Madsen, 2007; Sutherland, 2007). The worker must recognize that, physically and symbolically, the home, as the therapeutic setting, belongs to the family and at the same time maintain his or her position as therapist. When power was clearly in Ilana's hands, she could negotiate with N.W. from within the family's boundaries. N.W. was able to contain the family's conflicts and dysfunctional interactions in the home sessions, and the distribution of power enabled the fanny to contain her as a professional within their home. Ultimately, it is this power sharing that serves as the foundation of a worker-client relationship based on mutual trust and the engagement in collaborative search for meaning that accepts the clients' narratives (E. M. Freedman & Couchonnal, 2006; Ryz & Wilson, 1999). When helping relations are based on an equal working alliance, workers and clients from distressed families are able to participate in the joint constmcfon of new solutions based on a family's uniqueness (Krumer-Nevo, 2003). After engaging in the power-sharing process that is inherent in home intervention, the "C" fanny was able to face and share the problems they had tried so hard to avoid and to embark, together with N.W., on a journey of change.

The intervention with the "C" family shows how the power sharing in setting boundaries that is necessitated by home intervention is not an obstacle to be dealt with but an important factor in promoting change. In this case, intervening in the home provided the opportunity for experiencing uncertainty as to how the worker-client relationship would develop when the worker was not in control of the setting. This naturally occurring empowerment enabled liana to initially take control of the boundaries of the sessions and then slowly reflect on and experiment with different ways of being in control and out of control in her boundary setting with her children. From the outset the family took charge of determining the nature and content of the sessions and, thus, could experience a sense of control that was a crucial foundation for experimenting with new ways of coping (Shapiro & Astin, 1998; Sutherland, 2007).

The "D" Family: In Vivo Narrative Reconstruction

Anna (35) was the single mother of two children--Natasha (12) and Ilya (seven), born of two different fathers who lived in Russia. Anna immigrated to Israel from the former Union of Soviet Socialist Republics six years earlier with her children, parents, siblings, and grandparents. About a year after their immigration, Anna's grandfather murdered her father in front of Anna. Two years prior to the intervention, Anna was involved in a serious road accident. She was diagnosed with posttraumatic depression that did not respond to medication. Natasha and Ilya were placed in the full-time day care facility.

In individual psychotherapy sessions with the children and sporadic contact with Anna, it became clear that in the "D" family, many topics were taboo. These topics included Anna's life prior to the accident, the children's fathers, and the murder by the grandfather. It was hypothesized that these blocked conversations about the past impeded development of new relationships and change, as both Natasha and Ilya remained extremely withdrawn and isolated in school and in day care.

Home intervention was suggested both as a technical solution to engaging Anna in weekly family sessions and as a means of initiating different conversations in the family's natural environment. In the first session, Anna sat dejectedly curled in a lounge chair, with her head down. Natasha and Ilya sat quietly next to each other on the sofa. N.W.'s attempts to get a conversation going were unsuccessful, with the children responding to her comments or questions in monosyllables. They were willing to play card games with her. During the third session, N.W. began to express her curiosity about concrete objects in the house. She focused on the furniture, pictures on the walls, embroidered pillows, and knickknacks on the shelves. The children were happy to talk about the different objects and turned to Anna to fill in with additional details and information.

In the sixth session, N.W. pointed to a shelf filled with dusty photo albums and expressed interest in their contents. Natasha and Ilya looked worriedly at Anna, but she commented that before the accident, she used to enjoy being photographed and looking at the pictures. N.W. suggested that the family choose an album they would like to look at today. Anna chose one and opened it at a particular photograph of Natasha when she was about 10 years old. During this conversation, Anna was able to refer to the accident and the subsequent losses. At the next meeting, the family chose pictures that held special meaning for them. Both Anna and the children chose pictures of the three of them together. In the ensuing conversation, N.W. asked, "Is there someone else whom you would like to be in the picture?" There was a long silence, and then David said that there was no father in any of the photographs. A discussion followed on "what is a father?" and "what is it like when your father is not part of your life?" Natasha began to speak about her pleasant memories of David's father. Anna, in turn, began to describe her own father. She then told the children about their different fathers and the similarities between each child and his or her father.

In the following meetings, N.W. suggested looking at photographs of Anna as a child. Through these pictures, Anna was able to speak about her family history in Russia, her loss of functioning as a result of the accident, and her father and grandfather and the relationship between them. The children listened to these stories with rapt attention. During moments of emotional intensity, one or all of the family members would take short breaks--to boil water for tea, to go to the bathroom, or to work on the computer.

The home intervention continued for four months. The day care staff reported that Natasha and Ilya seemed happier--more spontaneous in their play and more involved with their peers. Anna was still severely depressed and unable to adequately care for her children, so they remained in full-time day care.

Discussion. Many families in deep distress have undergone traumatic experiences that are too painful to talk about, and these unspeakable episodes engender incoherent family narratives. When, in addition, the family has immigrated from another country, the geographic, social, and cultural rupture often intensifies the fragmentation, leaving the family disconnected from its past, isolated in the present, and unable to envision a meaningful future (Madsen, 2007; Williams, 2006).

A family's narrative and identity is shaped through pictures, stories, ceremonies, and traditions that are unique to the culture in which the family lives (Entin & Allen, 1981). The "D" family had great difficulty in organizing Anna's personal and cultural life experiences and the family's history of loss and trauma in an integrated narrative. The continuity that is essential for assimilating experiences and constructing meaning in life had been fractured. The family had story fragments representing a fragmented identity that was characterized by "thin," at times nonexistent descriptions and provided limited space for the containment of life's complexities and contradictions (P. Adams & Abels, 2001; White & Epston, 1990). For the "D" family, the past was a source of threat, despair, weakness, and hopelessness. N.W.'s aim was to help the family to relate and enact a "thicker" or richer narrative that enabled family members to negotiate between dominant stories and life's experiences and to develop alternative life stories of the past, present, and future. (J. H. Freedman & Combs, 1996; Williams, 2006).

It could be argued that the narrative interventions evident in the case of the "D" family could have occurred in N.W.'s office at the day care facility. In fact, narrative family therapy is designed for the standard clinic setting, with the family bringing in objects or photographs to prompt memories and storytelling (J. H. Freedman & Combs, 1996; Weiser, 2002). There are two rationales, however, for narrative home intervention in cases such as that of the "D" family. First, even if Anna, Natasha, and Ilya could have been recruited for therapy sessions in the day care facility, it is unlikely that they would have responded to "show-and-tell" techniques involving bringing props from home. The withdrawn and suspicious family members were investing energy in the avoidance of revealing particulars about their past to themselves and others.

In addition, it is the in vivo aspect of narrative home intervention that creates the climate for significant change. In general, home has many significant meanings beyond being a physical domicile. Home fulfills needs and constructs roles, identities, and statuses; it serves as a foundation and structure for experiences, memories, dreams, and relationships. The power of the home as a therapeutic context derives from its function as container of existential meaning (Csikszentmihalyi & Rochberg-Halton, 1981; Mallet, 2004).

Therapeutic work in home intervention is woven into a family's idiosyncratic history and dynamics as well as the broader cultural and social background because these are embodied in the home--food, smells, room arrangements, music, and so on. In narrative home intervention, family members are not given an artificial therapeutic task of choosing symbolic objects; the "artifacts" are part of the normal setting of family life and simply need to be noticed. The natural setting also allows the family to regulate the emotional intensity of their memories by using the natural rhythm of activities in the home, including taking breaks and moving from room to room. This enabled the "D" family to process experiences at their own pace. In addition, the narratives connected to the objects and photographs are performed in the family's most significant and intimate space, where the dominant, negative stories have been constructed and maintained. At home, family members clearly own their stories and are thus able to reauthor narratives by voicing untold storylines and subplots from a strengths perspective (E. M. Freedman & Couchonmal, 2006). In this way, for the "D" family, new alternatives became available, and family cohesion was deepened.

CONCLUSION

Families in extreme, ongoing distress experience difficulty in their intrafamilial bonds and in their relationships with the many professionals who wish to help alleviate their distress. One of the fields in which the rift and estrangement between social workers and clients is most blatant is child welfare, particularly when it involves the removal of children from the home. Out-of-home placement is far from being an ideal solution; research indicates that separating children from their families may lead to a sense of loss, lowered self-esteem, depression, and emotional disconnection (Baker, 2001; Page, 1999). In addition, criticism has been leveled at the lack of assistance provided to families before removing the children from the home and during the time they are in out-of-home placements (Dolev et al., 2000; McSherry & Iwaniec, 2002).

This article has described an intervention for distressed families whose children were referred to a full-time day care facility that was designed to address the difficulties family members experienced in their individual functioning, their relationships with each other, and their dealings with social workers. It is interesting to note that even though the children had been placed out-of-home, the home-based intervention enhanced family connections, often enabling the children to return home. Although the efficacy of home intervention with distressed families has been documented, the case illustrations here analyze the process more fully, presenting the how and the why it works. The first three cases explicate the contribution of home intervention to the engagement of social worker and client. Each case highlights how home intervention enhanced the therapeutic alliance by promoting change from a different starting point--the client (the "A" family), the worker (the "B" family), and the client-worker interaction (the "C" family). The "A" family was able to risk responding to the overtures of a representative of the hostile outside world only from within the secure base of their home. N.W. changed her perspective on the "B" family when she and they had to perform the guest and host roles that home intervention requires. The power sharing inherent in the interaction of therapist and head of the household in the "C" family led to growth and development in the executive role of parenting, including boundary setting. The fourth case (the "D" family) serves as a striking example not only of the power of the home as a setting for building a therapeutic alliance, but as a main player in the unfolding drama of the therapeutic intervention itself.. N.W. and the "D" family were able to enlist the home--a multisystemic, intergenerational container of the family's past, present, and future--as a partner in reconstructing silenced chapters in the family narrative.

In our experience, home intervention with the families of children in the full-time day care setting has been helpful with families who were previously considered "unreachable." Indeed, at the beginning of the project, home intervention was used as a strategy of "last resort." However, when staff realized how effective home intervention was, it became the preferred option for all families who were referred for family therapy. (Typically, about half of families are referred for family therapy; others are referred to different interventions, such as individual or group parent education.) There was improvement in family functioning in all of the families who participated in home intervention; however, 5 percent of families refused the home intervention or dropped out after one or two sessions. In-home family intervention is efficient when the therapist does not have to travel long distances to families' homes. This is possible in community and neighborhood services and institutional settings, such as the fulltime day care setting.

One final caveat: It is especially important when working with families with a history of violence to assess the level of risk to family members and the social worker when conducting sessions on a family's home turf. Social workers who do decide to embark with their clients on home intervention need to identify with the assumptions and goals of this method and to apply their professional skills with flexibility and creativity. They must be willing and able to relinquish some aspects of professional authority and feel comfortable with the rules that the family establishes regarding the setting. Ultimately, "changing places," moving therapy from the therapist's office to the clients' house, offers an opportunity to promote change for children, their families, and the social work professionals to whom these clients open their homes and their hearts.

doi: 10.1093/sw/sws020

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Nirit Waisbrod, PhD, is lecturer, Department of Social Work, Zefat College, Zefat, Israel. Eli Buchbinder, PhD, is senior lecturer, School of Social Work, University of Haifa, Haifa, Israel. Chaya Possick, PhD, is senior lecturer, School of Social Work, Ariel University Center of Samaria, Ariel, Israel. Address correspondence to Chaya Possick, School of Social Work, Ariel University Center of Samaria, P.O. Box 3, Ariel, Israel 40700; e-mail: chayapossick@gmail.com.

Original manuscript received August 6, 2009

Final revision received July 13, 2010

Accepted August 26, 2010
You see, Gabriel, in spite of the deprivation
   and discrimination you and your family have
   suffered at the hands of the establishment,
   here we are, sitting in your home that you
   have managed to establish with Shelly despite
   all of the odds. In light of this unbelievable
   success, I think you are the one that is best
   capable and able to help your son.
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