Nineteen years after I made my first home visit (ironically enough, to a family living in a New York City shelter for homeless families), I still find home visiting a source of excitement and delight. When you are home visiting with psychologically vulnerable families, you have to love this kind of work in order to keep doing it day in and day out. It can be very satisfying, but it is also very difficult. The work is made even more challenging by the fact that the home visitor often feels as vulnerable as the families. When you are visiting homes in the community, where you are without the structure and support of the staff and edifice of the agency for which you work, you often feel very alone and vulnerable.

When I use the phrase "psychologically vulnerable families," I don't mean families who necessarily have diagnosable mental or emotional illness or specific deficits. I do mean families who are experiencing pervasive stress on a daily basis over time, and who typically experience more than their share of devastating episodic crises as well. This kind of stress affects every aspect of a family's life and functioning. It erodes a family's strength and any stability in the family. This kind of stress also affects a family's would-be helpers. Home visitors have the daunting task of managing their own reactions to stress in order to help families manage theirs.

"Generic" home visiting will not meet the needs of psychologically vulnerable families. Intensive, specialized, and coordinated services are required. To be helpful to children and their parents in these families, a home visitor must be knowledgeable about the specific issues families are facing; flexible in her approach; nonjudgmental, yet able to set clear limits; and capable of protecting and nurturing herself. Although the home visitor must be able to give up the feeling of control that comes from being in a safe agency building with a pleasant office and administrative staff to answer phones and keep distractions away, the home visitor requires more important kinds of support from her agency or program. She needs training in all aspects of her specific work, ranging from how to protect her personal safety to how to understand substance abuse and its impact on children and adults. The home visitor needs regular, formal reflective supervision; informal peer support; and accessible mental health consultation. Agencies that serve psychologically vulnerable families need to support home visitors by developing strong collaborative relationships with all community resources, even though each home visitor will want to develop her own personal relationships with her counterparts.

The core contract

As a home visitor working with a psychologically vulnerable family, my goal is to let the family know that there is someone outside of their environment who is prepared to nurture, support, and "contain" them. I want to offer the family "corrective emotional experience" with someone who is steady and predictable. I want a mother to feel, "Yes, here is someone who will stabilize me even when everything is falling apart around me." I offer this kind of support through my relationship with the family, through the therapeutic alliance. I don't have to be a therapist to do this. I do need enough training to understand the specific needs families have, to know how to use my best tool - myself - in a meaningful way. To be helpful, I need many kinds of support - from my own agency, from people in other community resources, and from families themselves.

The contracts we as home visitors make with families create a framework for our therapeutic alliance. Some parts of the contract are unspoken. For example, by undertaking to visit a family's home, to stand on family ground, I agree to accept what the family presents. I realize that I don't control the situation (which may be hard for me, because so many people in helping professions want to control, in order to "make things right"), and that when I tread on someone else's ground, their rules prevail. Similarly I commit to being there for the family as frequently as they need contact with me. If a family needs face-to-face contact two, three, or four times a week, I will plan visits in the neighborhood so that I can drop by that often, even if it is for five or ten minutes, even if I use the pretext that I am just bringing something I forgot the day before. Or we contract that I come out to the family's home one day, and the next time they drop by the office to see me.

Some parts of the contract need to be talked about. For example, home visitors must be aware that their visit can be stressful for the family. I have heard mothers say, "Ms. Jones, I don't want you to come today. My house is a mess." Or, "Ms. Jones, don't come because my brother is sleeping on the couch." What these mothers are telling me is, "I'm nervous about you judging me. I'm nervous about you coming to my environment and saying that I'm a bad person, a bad mother." Now it is up to me to acknowledge the mother's feelings and support her by putting part of our contract into words. So I often say "I know you don't want me to come. I know it's hard for me to be there. I know you worry about what I'm going to say. But I'm going to really work hard not to do those things you worry about. This is our time together, and I'm going to try really hard not to make you think that I'm judging. And, really, that's not what I want to do."

Protection for the home visitor needs to be part of her contract with a family from the beginning. For example, a home visitor should never be a witness to a drug deal. I have said to my clients, "I really don't want to be around if anything is happening like a drug deal. Will you help me know?" Families often want to give something back to you and will agree. Even if they are involved in the drug deal themselves, they will call and say, "You know, Ms. Jones, you might not want to come today because somebody is here," Often, they will try to protect you, by walking you to your car or giving you advice about where you should park or walk. I encourage families to help me this way, for it empowers the family and facilitates my own safety.

Views of vulnerability

In addition to high levels of chronic, pervasive stress, many families with young children are dealing with one or more specific issues, such as parental psycopathology, substance abuse, child maltreatment, and family violence. As I describe briefly what a home visitor needs in order to be helpful to families dealing with these specific vulnerabilities, I hope that you will recognize that I am describing variations on basic themes - the critical importance of the therapeutic alliance, the role for relevant knowledge, and the need for family and community support.

Parental psychopathology

As Jeree Pawl and Alicia Lieberman have observed, a mental health diagnosis is a poor predictor of parenting. As home visitors, we have to avoid the presumption that a mother who is schizophrenic, or a mother who is or has been clinically depressed, will be an inadequate parent. Parenting may be the thing she does best. The child should guide us in these cases. We need to pay attention to how we are experiencing a mother, but it is essential to observe how the child is experiencing the mother. We must respect the child's attachment to a "good enough" mother.

Even though we need not be diagnosticians or mental health therapists, as home visitors we should know about the signs and symptoms of mental illness and about treatment options. For example, the overwhelming majority of the mothers I see are depressed. Given the circumstances they live in, this is hardly surprising. So it is important that I know the signs and symptoms of depression. Too often I have missed important signals that a mother gave me - for example, saying, "Ms. Jones, I'm just tired. I can't do it any more. I don't feel like it." If I had been thinking about the possibility of depression, I would have kept a symptom checklist in my head and been able to say to myself, "Uh-oh, Ms. Smith is in trouble, in crisis. I have to step up my home visits and give her more support." Those of us who are trained in child development need to learn to use the same observational skills we use to tune into children's needs, in order to become equally attuned to parents' needs. We can learn to notice when parents are having shifts in moods, when they are feeling more "down" than usual, and when their behavior changes (this is of particular importance when substance abuse may be a concern.)

Again, the therapeutic alliance is critical. Only when parents trust you will they disclose to you the kind of trouble they are experiencing. Then your relationship allows you, again in Alicia Lieberman's words, to be therapeutic without having to be a therapist. Unlike a therapist, you don't need to restrict your focus to the issues that cause a parent concern psychologically. Addressing a concrete stressor, for example, by helping a mother who has nothing to feed her children get food stamps, has a major influence on a parent's mental state. Additionally, a mother who is depressed will sometimes like to talk with you about something she enjoys, like a TV show. That is therapeutic for her. Your reliable presence, your unconditional regard, just talking about ordinary things, can help to alleviate depression.

If you work with psychologically vulnerable families, you must have mental health consultation. This is not work that any home visitor, whatever her training and experience, should be doing by herself. Whatever your agency's agenda or structure, you need someone within the agency or readily accessible who can help you understand parental psychopathology and your role in assisting families facing this challenge. This can be done as part of regular supervision, or as a special externally provided training/consultation to agency direct service staff.

Substance abuse

Substance abuse is the reason that most of the families with whom I work in child welfare became involved in the system initially. Home visitors need to understand the impact of substance involvement on children and the parents themselves, so that they can help families get the services they need. You need to be aware of the differential effects of substances. For example, women who use crack cocaine are likely to be jumpy and apparently full of energy, while mothers who use alcohol or methadone are more "down" and lethargic, with flattened affect. This information has implications for treatment. You also want to be alert for changes that may signal substance abuse - for example, when a mother who has been fairly stable and competent in her financial management suddenly has no money for rent or food.

In my work with substance abusing families, I have learned that abstinence cannot be a requirement for participating in a home visiting program. Even mothers who are in substance abuse treatment programs often continue to use. Although one of my former supervisors cautioned me not to work with a mother who was drunk or high, I realized that with this attitude I would not have made many home visits. I have often encountered mothers who are drunk or high, but unless I am concerned about my safety, I continue with the visit. Even though I may not be able to accomplish all the goals I want to in these circumstances, my overriding goal is to contain, stabilize, and support this family. This goal is still met through my appearance in their home.

Clearly, when I become aware of substance abuse in a family, I want to make sure that the family is linked with a substance abuse treatment person. This specialized help is important for the well-being of the family member who is using, for other members of the family, and for the children. It is also important because I as a home visitor don't want to be responsible for monitoring a mother's use of drugs (e.g., collecting urine samples). That is the substance abuse professional's responsibility. Substance abuse professionals can be very confrontational; they are often trained differently from mental health or child development professionals. This approach has documented effectiveness, but the responsibility of confrontation should be with someone other than me. I don't want to be the "heavy." My goal is to try to be caring and nurturing and supportive. I hope that our relationship will ultimately allow the mother to feel less stressed in situations that might otherwise make her feel that she has to turn to substances, but this is often a different approach from that of the substance abuse professional.

As a home visitor, I do have one monitoring role in my work with substance abusing families. I have to watch to see if a child protection referral is needed. I have to be clear about this responsibility and not collude with a family's denial around substance abuse. Even though I am not the person to say, "You need to stop this," or "You must do that," I do have a role as the protector of the child. The dual role of supporter of a mother who is abusing substances and monitor of her children's well-being is not an easy one. I have learned never to try to do this job by myself. Not only do I have a substance abuse treatment person on my team, but I get the help of every family member I can find. The grandmother, aunts, the boyfriend - I pull them into my orbit because they are my eyes and ears when I'm not there. They will help me monitor the situation.

Family members also offer respite care for the children. One mother who used cocaine never got off drugs completely while we worked together and continued to go on binges every other weekend. She would disappear for three or four days. I worked with her boyfriend, the father of the younger child. We arranged matters so that we could call him when the mother disappeared, and he would come and take care of the children. They never had to go into the child protective system.

Child maltreatment

A home visitor needs to be attuned to both the physical and the psychological signs of child maltreatment. Again, it is the trusting relationship between the home visitor and the parent that allows the home visitor to learn about what is happening and that helps parents change their behavior.

When I work with mothers who maltreat their children, I find that I am serving as the nurturing, supportive mother they didn't have. Although we don't use the terminology of transference and countertransference, the mothers and I talk about this aspect of our relationship. Often, long before a mother herself believes that behavior which we would call maltreatment is bad, she will make a decision to refrain from this behavior because I wouldn't like it. Or a mother will tell me, "Ms. Jones, I did something I am ashamed to tell you. I really didn't mean to, but I got mad and hit Tommy." Now we have something to work with, instead of the sullen silence of a person who won't tell me anything because she is afraid I will call Child Protective Services.

Once again, we as home visitors need to deal with our own subjective attitudes and feelings. We don't like people who prey on children. It doesn't feel good to me when I am working with a mother who hits her baby or neglects her children, and I may find myself acting in a non-therapeutic manner. But if I'm going to be of any help to that mother, including helping her refrain from maltreating her children, the mother has to feel that I won't perceive her as a bad person because she did what she did. This doesn't mean that I don't say, "This is not acceptable behavior." But before I get those words out of my mouth, I say, "You know that I really care about you, that I want you to get better, that I want you to have your children, and that I want your children to be OK - right?" After I see that the mother does believe me, then I set the limits. Often if you have built a trusting relationship with parents, they let you set many more limits than they normally would.

When child maltreatment is a concern, clarity about the home visitor's protective role is essential. Professional boundaries are always a tricky issue for home visitors, but never more than in these situations. Even though you are the supportive, nurturing person for the family, you are still a mandated reporter of child maltreatment. You can't get around that.

One of the things that I try when I must make a report to Child Protective Services is to work with the family around the report. Sometimes they are in the room with me when I make the report. Sometimes I say, "Look, I know you're going to be mad at me, but remember, I told you as part of our contract that one of the things I had to share with others was if the child was being hurt. And I'm worried about your child. So I'm going to call Protective Services, but I'm going to hang in there with you, and I hope you can hang in here with me." Sometimes I lose families at this point; most of the time they do "hang in there." They seem to think, "I've got to deal with somebody anyway; I might as well stay with her."

I advise home visitors who are working with families around child maltreatment to consider yourselves an arm of the protective services system. In most communities you can't afford to think that you have done your part just by calling Protective Services. Home visitors are often the people who provide family preservation and support services that the Child Welfare Department should be providing, but isn't. Since you understand this, you should keep this reality in mind from the beginning of your relationship wit Protective Services around a family. Talk to the Child Protective Services worker about what your relationship is with the family and the worker in the same way you use the substance abuse treatment professional - to be the heavy, to be the person who comes into the home and says, "If you don't do x and z and if you don't let this home visitor in your house, you're going to lose your children." Then you can proceed to do your relationship-building work.

Family violence

A home visitor needs to be aware of the signs and symptoms of adult abuse - not only the physical signs, like bruises and black eyes, but also the psychological signs. Why is a mother who you know is very extroverted suddenly barely able to look you in the face? Once again, we need to be aware of and to deal with our subjective conceptualizations. Most of us feel really angry at mothers who stay with men who abuse them. They stay, and stay, and stay. You get them into a shelter, and they go back to the men. We have to realize that we are not living this mother's life; how can we be helpful if we are judging what she does? We must get past the rescue fantasy - the belief that all will be well if we can get a mother out of the house where she has been hurt.

Once more, relationship building is key A mother won't tell you that she has been beaten if she feels as if you are judging her, if she feels that she can't trust you, if she thinks you are going to run to the police and get an order of protection and have the man arrested when she is not ready to do this. I have to struggle with myself in these situations, but I know that my job is to try to understand what is going on and to discover ways to be genuinely supportive. My emotional connection to the mother gives me leverage to confront the reality that she is placing herself and her children in constant danger. The home visitor's message has to be, "I'll be here for you now, when you are ready to leave the person abusing you, and even if you don't ever leave."

Especially when family violence is a concern, it is helpful for home visitors to remember that the entire family is the client, not just the victim. Even the abuser is part of your client system, and I have learned that you have to include the abuser as part of your home visits in some way. In one family, the abusive father made the decisions for the family. There was no way I could have had a relationship with the mother without going through him. In another family a mother with whom I had been working disappeared, leaving no forwarding address. My efforts to find her failed until the boyfriend from whom she was running gave me her telephone number. Despite the aversion I may have had toward these perpetrators of violence, it was important that I had some positive relationship to them.

Although you make an effort to work with the whole family, you also make sure to get out of the home the minute that violence begins. During one home visit, the mother and father with whom I was working started to throw knives at each other. My first reaction was, "I can't leave! I'm a child welfare person. I've got to stay here and protect this child." Later, my supervisor challenged me, saying, "You know, you could have been dead, and the baby could have been dead. What good were you? What you should have done was to leave as soon as you saw violence occurring and call the police. You needed somebody else to handle it." As I have mentioned earlier, the safety of home visitors must be thought about before a program even begins. Standard protocols for crises and appropriate training are essential.

My experiences once again illustrate the fundamental lesson: "You can't do this by yourself." For your own safety and that of the family dealing with violence, you need access to family and community supports. At the very least, you need to involve the extended family, you need to be able to call upon police protection, and you need to know the person who runs the shelter for battered women. She will understand when you tell her that a mother with whom you are working may come in and out of her care.

Safety first
Home visitors need to feel safe as they travel through sometimes dangerous communities to build relationships with families. The following five strategies contribute to home visitors' safety and also enhance home visitors' subjective experience of security and trust in the agency for which they work.

1. Teaming: Particularly in the most dangerous neighborhoods, home visitors can go out together. They can plan their schedules so that they are visiting families who live close to each other. Or they can be assigned to work with families together, making decisions about who will have which roles with the family. Supervisors can routinely accompany home visitors to the most dangerous homes and neighborhoods.

2. Police training: Urban police departments are typically too inundated to do "community outreach." A police department representative can train agency home visitation staff on basic crime-prevention and self-defense strategies. Additionally, police personnel can inform staff about which specific geographic areas and times of day are most dangerous for home visits. Developing a relationship with the local precinct may also enhance the police protection the staff receives in the neighborhoods where visits are made.

3. Communication technology: Although non-profit organizations have limited resources for technology, they should allocate funds to buy beepers and/or cell telephones for home visitors. These not only provide an important connection between the home visitor and the agency on "field days" but may also be the only means for a home visitor to get help in a crisis. To avoid unnecessary costs, home visitors and administrators can devise protocols that specify the circumstances under which such items can be used.

4. Creation of crisis protocols: Each home visiting staff member should be given explicit instructions (written and oral) about what to do in a crisis or dangerous situation. Home visitors should have an opportunity to "role-play" their responses to these situations, so that they will be cognitively prepared to act swiftly and carefully if real crises occur. During any period in which home visitors are in the field, a specific supervisor or administrator should be designated as "on call." This person should be accessible and available, ready to respond immediately to home visitors' needs.

5. Participant involvement in home visitor safety: As part of parent involvement efforts, families who are participating in a home visiting program should be encouraged to help agency staff plan for home visitor safety. Families are often more knowledgeable than the police about the existence of "crack houses" in their neighborhood, gang activity, and other potential dangers. Families can be given formal or informal roles in supporting the safety of staff and improving community safety - for example, serving as escorts or creating community safety maps.

Lessons learned in home visiting with psychologically vulnerable families and their children

What have I learned in 19 years of home visiting with psychologically vulnerable families? Here are seven lessons that I have learned and find myself passing on to my students.

1. In home visiting, you really have to take a family-centered approach. The child is not your client; the mother is not your client. Everybody in the household is your client. The children, the cousins, the grandmother all have an impact on "your" family's life. I make it my business to know everybody coming in and out of the family's home, to speak to them when they come in, to tell them why I'm there, to explain what I'm doing, and to ask them how they're doing. This doesn't mean that I work intensively with everyone in the household, but it does mean that I treat them respectfully and recognize them all as part of the system that I'm working with.

2. A comprehensive, responsive approach to home visiting means that you have to do a little bit of everything. Clearly you won't be able to do everything that a family needs or perhaps even everything that you know how to do, but as a home visitor you will do many different things at different times. This kind of flexible responsiveness is part of the work. If you really believe in a responsive approach, you will find that families will let you know when they need you to be the case manager, when they need you to be the substitute mother, and when they need you to be the advocate.

3. Your goal is to focus on the parent-child relationship. Even in my direct work with mothers, my goal is to think about helping them to be better parents. Even though I may be working on issues that relate to their own psychological situation, I do this with the ultimate goal of helping them to be able to give their children a little more than would otherwise be the case. Direct parent-child interaction work should be included as part of all home visits.

4. The therapeutic alliance is crucial to effective home visiting with psychologically vulnerable families. The relationship you build with a family must be strong enough to withstand the stress of child protection calls, substance use, and whatever else you deal with together. The alliance allows you to be a "container" for the family, its stabilizing force, and the nurturer that, usually, the parents never had.

5. Make sure that you understand and respect the culture of each family with whom you work. When you walk onto somebody's turf, their culture rules. Sometimes this means that you disregard some traditional rules of "professional" behavior. If a mother offers me food, saying, "Ms. Jones, I just made this. Do you want to try it?," I accept. If I say no, I may be rejecting a piece of their culture, or their attempt to give something back to me.

6. Focus on the emotional needs of the parents. Psychologically vulnerable parents are often little people in big bodies. They are people who had no one to make sure they ate breakfast and got to school safely, no one who told them that they loved them. You become that person. And after all my training, I think that what allows me to make a difference in families' lives is my ability to let people know that I really care about them.

7. Remember that you cannot do this work by yourself. Period. If you don't have a good infrastructure in your agency, you're in trouble. If you don't have good collaborative relationships with other community agencies and services, you're in trouble. If you don't have peace in your personal life, you're in trouble. I have learned to find a person to help me. I don't necessarily wait for my agency to sign an agreement with the other agency. I find and build relationships for myself. I find somebody whom I can call and say, "Girl, can you help me?" That's how I get things done.

Nurturing the nurturer

Home visitors are challenged in ways that other human services professionals are not. Because of the intensity of their experiences with families, they require a more extensive base of support than some other practitioners. The following ten strategies are ones that supervisors and administrators have found useful in nurturing home visitors, so that they can nurture families, so that they can nurture children.

1. Regular, formal reflective supervision: Home visitors need a safe time and place in which they can candidly discuss the families with whom they are working from both objective and subjective points of view. They also need to receive nonjudgmental and supportive feedback about their work.

2. Supervision in the field: Home visitors feel validated when their supervisors visit homes with them, with the goal of understanding home visitors' experiences with their families, not monitoring their performance.

3. Informal peer support: Home visitors should have as many opportunities as possible to come together with their colleagues to discuss the challenges of home-based intervention and share strategies for meeting the needs of their families and of themselves.

4. On-going didactic and experiential training: Having regular opportunities to think intellectually about home visiting and to learn new information about families and techniques for working with them helps home visitors to become and feel more competent.

5. Interdisciplinary case conferences: Because psychologically vulnerable families are often very complex, it is important to have scheduled, structured discussion of specific families that allows all the various professionals involved with the family to share their perspectives and expertise.

6. Accessible mental health consultation: The psychological challenges that families often face require that home visitors have access to a mental health professional who can help them make family assessments, inform them of the needs of individuals with specific mental health diagnoses, advise them on intervention strategies, make treatment recommendations, and perhaps provide short-term treatment.

7. Standard protocols for family crises and high-risk situations: Home visitors are much more effectively prepared for the challenging situations that confront them in the field if they are provided with explicit information on handling emergencies and crises (for example, when a child becomes ill during a home visit, when a family has no food or place to live, when the home visitor is exposed to inter-adult violence in the home, when the home visitor suspects or witnesses child maltreatment, etc.).

8. A focus on safety: Contemporary home visitors, particularly those working in urban areas, often must work in unsafe communities. Their safety should be a primary consideration of their supervisors.

9. Celebrations: The work of home visitors should be constantly celebrated, through staff-recognition programs, regular informal and formal meetings of staff in which efforts are recognized, impromptu meals that provide sustenance to both body and spirit, and praise from supervisors.

10. Mental health time-outs: Supervisors should be attuned to home visitors and recognize when they feel burned out or have had an experience that has been particularly exhausting, physically or mentally. In these circumstances, supervisors should help home visitors stop and take a "time out" (or a day off) from the difficult work of home visiting.

Being with families

Not very long ago, I was accompanied on a home visit by a student who reminded me of my 20-year-old self on my first home visit. I could sense her discomfort as she saw me sitting on the dirty floor, littered with dead roaches. I realize that over time I have learned to forget about dirt and dead roaches when I work with very young children and their families. My attention is so trained on that mother and baby that everything else goes out of my head. You need that kind of attunement in order to be able to respond appropriately when that magic "teachable moment" arrives. I have also learned to marvel at the fortitude that families show in coping with the exigencies in their lives. This work is not easy. It is tiring to be with families as intensively as I have described. However, it is important to keep going, keep going, keep going. You brush the roaches from your coat before you get into the car. You buy yourself a treat before you go on to another family. And in the end, when you start to look back, you can see the families are not in the same place where they were two months ago. You celebrate that. You nurture and give to yourself. And you go back out and do it again.

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