The term “intensive home-based family preservation” actually refers to a variety of treatment services and interventions provided in various formats, often with very different underlying treatment models and implementation strategies. Moreover, several different terms are used in the literature to denote these types of interventions, including family preservation services (the most common), intensive-in-home services, and home-based family therapy. Yet, despite the multiple terminologies, these interventions share a common theme and goal of trying to preserve the home and family. Indeed, several aspects of the underlying model of service delivery and corresponding ideologies generally serve to unify these programs and set them apart from other interventions.

The crisis intervention model, exemplified by the Homebuilders approach, was the first family preservation model developed. Based on social learning principles, interventions in this model are very brief (4–6 weeks) and emphasize concrete services (food, clothing) and counseling that targets family communication, behavior management, and problemsolving skills (13).

Services provided under the rubric of the home-based model tend to be more clinically oriented than crisis models, are often provided by masters’ level therapists, and are longer in duration (3–5 months). Interventions in this model frequently target problematic interactions among family members and between family members and the community (14). Clinical procedures are more complex than those in the crisis intervention model and involve a range of family, behavioral, and parent training intervention strategies. Multisystemic therapy (MST)(15) is an example of this type of treatment program.

Although services provided under this model share similar theoretical underpinnings and treatment goals with the two home-based models mentioned, they differ in that concrete services are generally provided by case managers rather than therapists, and therapists generally provide clinical services in the outpatient office. Functional family therapy is an example of this type of intervention (10). Given this chapter’s intended focus on the home-based treatment setting, the two types of intensive home-based family preservation that are primarily provided in home and community-based settings, the crisis intervention and home-based models are highlighted.

The first home-based family preservation services were provided in the early 1900s to families at risk of losing their children due to poverty and neglect. While these types of services fell by the wayside during the early part of the century, they reemerged in the 1970s, largely due to political concerns for youth in the child welfare system. In response to national unease about the rising numbers of children without permanent placement in foster care, the Adoption Assistance
and Child Welfare Act of 1980 (Public Law 96–272) brought new focus and resources to home- and family-based intervention programs. Foundations (e.g., the Edna McConnel Clark Foundation’s support of the Homebuilders model) played substantial roles in dissemination of these services (3). Yet, like most psychotherapeutic and psychosocial interventions, dissemination of home-based services preceded evidence of their effectiveness.

Early evaluations of intensive home-based family preservation programs consisted largely of descriptive information and quasiexperimental studies, primarily of the Homebuilders model. Homebuilders is a short-term (30–60 days) crisis intervention model variety of home-based treatment consisting mostly of concrete case management and behavioral interventions provided by bachelors’ level child protection workers. While some of the early outcome data concerning these programs seemed promising, closer observation revealed substantial methodological problems in many of the evaluations (selection bias, nonequivalent control groups). As these methodological issues were addressed and more rigorous research was performed, the early positive findings did not hold. Two comprehensive reviews on the effectiveness of intensive home-based family preservation services for children at risk of out of home placement due to abuse or neglect (2,16) indicate that crisis intervention types of intensive home-based family preservation services have had little impact in averting out-of-home placement. For example, in what is considered to be the most substantial, comprehensive, and methodologically sound evaluation of a family preservation project for child welfare youths to date;(17) researchers of a program in Illinois found that the 995 families that received the crisis intervention family preservation intervention fared no better than the 569 families that received regular services. No significant differences were found between the groups in terms of types and duration of out-of-home placement or subsequent child maltreatment. Three additional large studies (18,19,20) also considered to be methodologically sound and comprehensive, have found that crisis intervention family preservation services failed to produce statistically significant outcomes. Thus, despite widespread dissemination, crisis intervention family preservation services have not proven to be effective on closer evaluation.

A number of factors have been proposed (21) by researchers and policymakers to explain the apparent lack of effectiveness for crisis intervention types of intensive home-based family preservation services for children in the child welfare system. Lindsey, Martin, and Doh (16) have outlined five explanations that summarize current thoughts in this regard. First, intensive home-based services in the child welfare sector have largely relied on casework intervention and, thus, might be founded on intervention models that do not have established effectiveness with youth and families experiencing significant difficulties (22,23). Second, the intensive home-based family preservation treatment models employed in these studies might not have been flexible and comprehensive enough to meet the complex needs and problems often presented by the families. Third, the programs might not have been capable of addressing the severe psychosocial difficulties associated with the poverty experienced by many of the participating families. Fourth, the interventions might have been too brief as most problems presented by these families were chronic and enduring. And finally, it is notable that most studies did not actually succeed in targeting children truly at risk of placement (17). In summary, a general consensus is developing that suggests that children and families served by the child welfare system have needs that outstrip those provided by intensive home-based family preservation programs that employ the crisis intervention model.

Rather than serving as a setback, this research provides helpful information that can be used to chart new courses for developing effective home-based interventions for youths in the child welfare system. Project 12-Ways (24) and multisystemic therapy (25) are two examples of intensive family and community-based interventions provided within the home-based model of service delivery that are promising for working with this population. Project 12-Ways is a systemically focused intervention, based on the eco-behavioral model, designed to work with families at risk of having their children placed due to abuse or neglect. The model defines intervention targets across the family’s social ecology and implements interventions in the home and social contexts to address these behaviors. Program evaluations indicate that in the short term, families served by Project 12-Ways were less likely to be rereported for child maltreatment or have children removed than comparison families (26,27). MST is also founded in ecological theory (4) and involves the implementation of empirically validated interventions to youth and family members with attention to the contexts within which they are embedded. An early randomized trial with maltreating families demonstrated that MST was more effective than parent training for improving family interactions (28). Importantly, a recently completed National Institute of Mental Health–funded randomized clinical trial compared MST with parent training plus standard mental health services (29) for adolescents at risk of placement due to physical abuse. Short-term results from this study suggest that MST holds promise for reducing youth out-of-home placement, and symptoms of depression as well as increasing youth perceptions of safety and parental use of nonphysical discipline (30).

MST, and the home-based service model within which it is delivered, differs from the intensive home-based family preservation programs that employ the crisis intervention model in several key ways that address the aforementioned challenges noted by Lindsey et al. (16). First, MST is well grounded conceptually and several randomized clinical trials support its effectiveness with juvenile delinquents and substance-abusing youths at risk of out-of-home placement (31). MST therapists are masters level and receive substantial supervision and ongoing training from doctoral-level clinicians who are trained in evidence-based practice. As adherence to the MST treatment model has been linked with improved youth and family outcomes (32,33,34), an ongoing quality assurance process (35) is used to support therapist fidelity to the treatment model. Thus, MST involves trained professionals implementing evidence-based practice in an environment that provides ongoing support and evaluation of outcomes.

Also addressing the challenges noted by Lindsey and colleagues (16), MST interventions can flex to meet the complex needs and problems often presented by families in the child welfare system. Interventions are based on the therapist and family’s shared understanding of the drivers of the referral problems. Therapists are trained to be generalists who can assess and provide evidence-based interventions to individuals within and across the multiple systems that affect families (36,37). For example, MST therapists working with families at risk of losing their children due to physical abuse must be able to provide interventions that address individual and family safety, abuse clarification, and psychopathology
and substance abuse in the youths and their family members, as well as peer, school, and community difficulties that are contributing to the identified problems. A third concern expressed by Lindsey and colleagues (16) was that the severe psychosocial difficulties and poverty often found in child welfare populations adversely affects attempts to provide family preservation services. While it is certainly true that these factors often serve as barriers to intervention on MST teams, the model promotes therapists doing whatever it takes to help families achieve sustainable outcomes. Thus, MST therapists are encouraged to provide case management as well as treatment interventions when indicated. For example, therapists might help families secure better housing, apply for financial assistance, obtain transportation, enroll in vocational training or any number of interventions as long as they are considered key in promoting clinical goals. This broad view of clinical services is designed to help lessen the impact of poverty and other adverse social circumstances that often surround families who qualify for intensive home-based services.

A fourth limitation regarding the crisis intervention model of intensive home-based family preservation programs is that their short duration of intervention is not sufficient to address the chronic and enduring problems often found in families served by child welfare. To address this issue, MST teams serving child welfare populations have averaged 6 to 8 months of treatment, and research to better understand the length of treatment needed to adequately serve this population is currently underway (38). Finally, to deal with the issue that many youths in the early child welfare studies were not truly at risk of placement, studies of MST for this population have taken great care to involve youths who are already targeted for potential placement, as evidenced by the 29% placement rate for youths in the control condition of the aforementioned randomized MST trial with child welfare youths (29). Hence, MST as modified for physically abused youths in the child welfare system at risk of out-of-home placement serves as an example of one potentially effective home-based method of treating these families. Importantly, key features of MST address some of the critiques of the early family preservation treatment models.

While innovative programs to separate juveniles from adults in the prison systems of Boston and Chicago at the turn of the last century set a promising tone for the potential of community-based services for delinquents, these rapidly devolved to current practices that largely consist of probation officers monitoring youths for compliance to court orders (2). This individualistic and often family-alienating focus prevailed throughout the 1900s, helping to create a multibillion-dollar juvenile prison industry that currently consists of more than 3,600 facilities estimated to house more than 110,000 juvenile offenders on any given day (39). Far from evidence based, current probationary and incarceration services are available nationwide. In contrast, it is estimated that fewer than 10% of families of youths on probation have access to evidence-based programs in their community, despite a growing national trend to make such services available (40,41).