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By Ofer Zur, Ph.D. and Nola Nordmarken, MFT
Table Of Contents
Self-Disclosure
Emotional Elements of Home Office Practice
Safety
Suitability
Screening
Ethical Considerations
Standard Of Care And Home Office Practice
Boundary Crossing Vs. Boundary Violations
Risk Management
Informed Consent
Privacy And Confidentiality
Benefits And Burdens For Therapists
Summary
The home-based psychotherapy practice presents practitioners, clients, and practitioners’ family members with a number of clinical and familial complications and boundary challenges that are unique to this type of practice setting. The primary factor regarding such complexities is related to the increased crossover of the professional and the personal life that occurs with a home office practice. The main concerns include how the increase in self-disclosure might affect clients and the process of therapy, as well as how an in-home office affects the quality of family life. While there are certain conveniences and financial benefits to practicing at home, there is also the prospect of deciding how to place boundaries regarding people, places, and times.
Therapists seeing clients in their own homes is clearly a boundary issue as it involves professional relationships outside the traditional place of business and the blurring of the personal and professional aspects of therapists’ lives (Gutheil & Gabbard 1993; Zur, 2003, 2007). The home office arrangement invites clients into the therapists’ most personal domain, their home. It exposes numerous aspects of the therapists’ lives to their clients, which would not be exposed in a traditional psychotherapy office. It also can easily expose clients to therapists’ family members, neighbors, pets, or whoever else resides in or near the house and vice versa, although this will vary from practice to practice.
Home offices come in different formats and arrangements. Some offices are located in detached units with separate driveways and entrances, distanced from the main residence. On the other end of the spectrum are the offices that are located in the therapists’ living room, home office, or converted bedroom within the home. In between these two arrangements, there are many variations in regard to which entrance or which bathroom clients use and what part of the therapists’ private home they get to see. The ages of the people who reside with the therapist will also vary significantly. The presence of young children or teenagers, who are often less conscious of physical and time boundaries, may also be more apparent to clients, creating not only more self-disclosure but potentially more disruption or background noise.
The predominant concerns with home-based therapy include the impact of a home-based practice on the efficacy of the therapeutic process as it primarily relates to self-disclosure and privacy and the fact that clients are invited into the therapist’s private space (Woody, 1999). Additional concerns include safety and privacy for therapists and their families and the impact of the practice on the therapist’s personal life and that of the family. This paper will describe the boundaries and concerns related to the home office practice. These include self-disclosure, emotional aspects of home office practice, safety, suitability, screening, managing time, places and people, privacy and confidentiality, informed consent, benefits and concerns for therapists, and, finally, ethical considerations (Zur, 2007).
In-Home Therapy and Home Visits: Home-Based Mental Health
The private practice of psychoanalysis began when Freud started a practice in his own home (Keisner, 1990). There are additional general references to home practice by Mahler, Jung, and other forefathers and foremothers who practiced, at least sometimes, from their homes. Winnicott, as one example, took young patients into his home as part of their treatment (Gutheil & Gabbard, 1993). Despite this long history, and the fact that interest in home sessions has not waned over the years, there is no body of formal literature that examines the conscious or unconscious motives of a therapist who chooses to practice in a home office setting nor the emotional consequences to the therapist, the therapist’s family, or the client. This absence of focus is interesting in light of studies from ecological psychology that have identified setting as the best predictor of human behavior (Barker, 1965). In contrast, industrial psychology has developed a general work-family theory to describe how the complex relationships between work, home, and family affect the general satisfaction of the individual and the family (e.g., Clark, 2000; Kanter, 1977).
Self-Disclosure
The concept of self-disclosure relevant to clinical practice has a long history of research and discussion, very little of which addresses the issue of self-disclosure as it relates directly to home office practice. Among the earliest, most popular modalities, psychodynamic therapy and behavioral therapy were in agreement that therapist self-disclosure was out of place in the therapeutic relationship (Auvil & Silver, 1984; Jacobs, 1999). Therapist self-disclosure gradually gained increased acceptance with the rise of the humanist movement in the 1950s and 1960s. With this new approach came the possibility that therapists might give information about themselves to clients as part of a therapeutic process that valued the congruence and transparency of the therapist in relation to the client (Jourard, 1971; Rogers, 1951, 1961). A political dimension was added by the feminist movement, in which self-disclosure was viewed as supporting the development of a more egalitarian relationship, allowing a client to choose a role model (Simi & Mahalik, 1997). Some modern psychodynamic therapists have also considered the possibility of a positive role for self-disclosure in their modality (Bridges, 2001; Jacobs, 1999). Although professional attitudes toward self-disclosure have been generally tied to theoretical orientation (Williams, 1997), a clear evolution can be detected in which self-disclosure has been becoming, clinically and ethically, an increasingly more acceptable therapeutic tool (Lazarus & Zur, 2002; Zur, 2007).
Simply defined, self-disclosure, as it relates to home office practice, occurs when psychotherapists reveal personal rather than professional information about themselves that would be unlikely to be revealed in a traditional medical or business office setting. Such information can be biographical, familial, or any other aspect of the therapist’s personal life. Self-disclosure is usually discussed in terms of therapists’ deliberate and intentional verbal expressions of personal information. From a broader perspective, self-disclosure is the process by which therapists reveal, intentionally or unintentionally, any personal aspects of themselves to their clients (Barnett, 1998). Under this broader definition, self-disclosure is neither always a deliberate action nor by choice of the therapist. A certain amount of self-disclosure is unavoidable in any practice setting and a large majority of psychotherapists (93.3%) admit to utilizing self-disclosure to some degree (Pope, Tabachnick & Keith-Spiegel, 1987). Even for those analysts who strive to maximally minimize self-disclosure, it is generally conceded that every intervention hides some things about the analyst and reveals others (Chused, 1990; Greenberg, 1991). Thusly defined, the issue is not whether to disclose, but how to manage the unavoidable condition of constant disclosure, regardless of the practice setting (Livingston, 2000). The degree of non-verbal, and in some cases unintentional, self-disclosure is automatically elevated when a clinician practices within his or her home.
The home-office situation automatically reveals where the therapist lives, the price range of their residence, the socio-cultural aspects of their neighborhood and how well kept their homes and gardens are. Depending on where the office is located the home office may also reveal how the therapist’s living room is furnished and kept and what these things might possibly reflect about their level of functioning and what they value. Depending on planned boundaries, or accidental occurrences, they might reveal how clean the bathroom is, their domestic partnership status, how many children they have and how they behave, or how the therapist behaves in relationship to family members or pets (Maeder, 1989).
When practicing from a home office, a therapist has a responsibility, which involves a series of conscious decisions about what categories of things will be communicated through non-verbal self-disclosure. This includes, among other things, whether or not clients come into contact with family members, which parts of the home are available to clients, or how art, family pictures, or other objects visible to the client may indicate aspects of the therapist’s values or personal relationships (Zur, 2007). The therapist has the additional responsibility of maintaining an awareness of how these aspects of self-disclosure might influence individual clients and their unique treatment needs. A variety of unexpected events can arise at the home office. There may be children’s fights, loud music, and interruption of the session by family members or unwitting neighbors or friends. Children, in particular, are likely to innocently cross boundaries, drawn by curiosity or when seeking company, support, and help from the therapist-parent. The concern is that for some clients, such exposure can be too overwhelming (Pepper, 2003).
Another category of non-verbal self-disclosure addresses the communication issue of “metacommunication.” in which an intentional or unintentional interpersonal meaning is received along with the literal message itself (Perlmutter & Hatfiels, 1980; Schwartz, 1993). For example, the literal message “I work from my home office” holds the simple literal meaning regarding an office in the building in which one lives, while the metacommunication may very well be “I am willing to allow you into part of the personal space of my self and the elements of my own life”.
Emotional Elements of Home Office Practice
In the absence of data from formal studies on the emotional impact of a home office practice, several authors have addressed the topic and offer some intriguing possibilities for consideration. An in-depth discussion of transference is beyond the scope of this paper. however Gordon (1997) offers the following practical considerations with regard to this issue relevant to home office practice. Freud coined the term transference and generally defined it as a distorted perception of an individual based on one’s past significant relationships. He believed that transferences are particularly activated with differences in power, which tend to recapitulate the powerfully ambivalent child-parent relationship. The term has made its way from psychoanalytic circles into mainstream psychology. Although therapists from some modalities, cognitive-behavioral therapists for example, do not utilize the concept of transference, therapists from many modalities share a general acknowledgment that most relationships can be seen as objective and subjective, real and symbolic. at the same time. The increased self-disclosure, as well as other elements of the setting present in home office practice, might complicate this process. The primary way by which a therapist of any orientation can manage these perceptions, which are distorted by earlier experiences, is to provide “reality clarification.” In its simplest form, this involves reminding the patient about the reality of the present therapeutic relationship by clarifying the reality of the roles, tasks, boundaries, and ground rules of treatment, thereby bringing them back to the present from feelings transferred from their past child-parent relationship. The reality clarification serves to restore the reality of the person, the role of the therapist, and the reality of the therapeutic work.
Keisner (1990) has written one of the very few articles devoted exclusively to the home office setting. He suggests that, in addition to the more conscious motives for a home office choice of venue, such as financial and various increased conveniences, there may be unconscious motives related to the therapist’s personal issues of separation anxiety, individuation, narcissism, or dominance. The therapist can literally go to work without leaving the security of home, having all of the comforts and pleasures of home instantly available between sessions. Security objects in the form of satisfying people, pets, food, one’s own bed, etc. are constantly available. This provides almost instant gratification for a variety of needs. Hence, according to Keisner, home practice may support the gratification of certain symbiotic needs and help to defend against separation anxiety.
Mahler, Pine & Bergman (1975) suggest that working from one’s home may also relate to a therapist’s issues regarding stages of the separation/individuation process as it involves “coming home and going to work,” “leaving and returning to” security people and objects multiple times each day. The process shares familiar features of the rapprochement phase of separation/individuation.
Both normal and pathological narcissistic needs may also be in play, as therapists working in the home setting are “showing” their clients the level of monetary, social, and class success they have achieved. The therapist can ask him- or herself how much the admiration is needed to support one’s sense of self-esteem. With regard to the clients’ experience, it is helpful to note that when therapists share the most satisfying aspects of their lives with clients, it can trigger issues related to envy. While many clients fantasize that therapists possess what they want for themselves, actual confirmatory data can be deeply humiliating. Also, paradoxically, sharing certain information with a client can decrease the client’s sense of what is shared because it is experienced as a flaunting of differences (Schwartz, 1993).
Territoriality research suggests that people are more powerful and dominant when they are in their own place (Martindale, 1971). Although this is true of a traditional business office, a home office presents far less neutral territory to both the therapist and the client. The therapist can consider this aspect relative to their own internal dynamic while also being aware that it might create an obstacle to their clients freely expressing their own power and natural dominance.
Safety
Safety considerations are of paramount importance in the home office setting, as it normally does not provide the therapist with the same level of protection as a standard medical or business office (Zur, 2007). When working with potentially violent clients in a standard office, there are often other therapists, staff, or receptionists in close proximity. In extreme cases, therapists may resort to the use of panic buttons, the door to the consulting room may stay open, or another therapist may be present during the interview. These options are not very readily available or even advisable in the home-based setting.
Safety issues go beyond the therapist’s well-being as the home office setup may expose children, spouse, or other family members and pets to potentially volatile or violent clients. The concern with a dangerous client in the home office is that if he or she was not screened out on the phone or identified in the course of some other pre-therapy interview, that client has become privy to the location of the therapist’s residence and with whom the therapist lives, who lives nearby, and even the layout of the house. Screening for violent, dangerous, paranoid, intrusive, psychopathic individuals or any client who may pose a danger to therapists or their families is extremely important in the home office practice. Such patients are never acceptable for treatment in the home office.
Suitability
Suitability of clients to be treated in the unique setting of a home is a matter to be judged carefully. While this often less formal setting can benefit some types of clients, it is not appropriate for several others. Issues of parking, entrances, waiting areas, etc., are usually clearly defined in a standard medical practice but are often much less defined in the home office arrangement. Clients need to be informed of boundaries and respect them. They must honor instructions in regard to where to park and which entrance, waiting area, or bathroom to use. In the home office, a client may encounter family members or pets and may overhear personal or phone conversations by members of the therapist’s family. In the home office, clients may be able to wander about the house, accessing areas that are highly private and inappropriate to be accessed by clients. Experience in complying with these boundaries may serve as a growth opportunity for clients who need to develop a stable sense of separateness between themselves and others (Keisner, 1990). Therefore, patients who manage boundaries poorly are not likely to be good candidates for a home office sessions. These include the Borderline Personality disordered, those who have interpersonal or physical boundary issues, and those mentioned above. For the same reasons, patients who are highly dependent or reactive or those who develop intense emotional, erotic, sexual, or hostile attachments may also not be suitable for a home-based office configuration.
Some clients have reported feeling, initially, as if they were intruding upon the therapist’s private space, fearing that they were being asked to cross a boundary from a professional into a personal relationship. They sometimes, too, wondered about the professionalism of the therapist. If these feelings are dominant for a particular client’s personality or character, the home office may not be suitable. On the other hand, average and highly functional clients and those who can benefit from the warm and casual ambiance that home offices often exude, and the significant self-disclosure involved, are likely to be good candidates for such a setting.
Suitability can be neither accurately assessed ahead of time nor always predicted from the screening process. Therefore, therapists must continue to assess the appropriateness of this location for clients’ treatments.
Screening
Screening of clients for suitability, safety, and possible threat is vital in the home-based office. While the issues of suitability and safety are always part of screening in psychotherapy, they take on heightened importance when the office is located in the therapist’s home. In order to ensure suitability and safety for clients, therapists, therapists’ family members, etc., the screening process must be more rigorous and effective than the standard one (Zur, 2007).
There are several ways to increase the effectiveness of screening. The most common way to screen is via a phone interview. Some therapists combine such standard telephone interviews with a detailed questionnaire that is emailed, faxed, or mailed and reviewed prior to setting the first appointment. Such questionnaires often include detailed questions regarding prior psychotherapy, hospitalizations, suicidality, psychotic episodes, domestic violence, criminal activities, criminal convictions, addiction, and use of medications. When red flags go up owing to suspect responses regarding volatility or past violent, psychopathic, or criminal behavior in the background questionnaire, therapists may consider obtaining an authorization to release information and obtain additional information about the potential client before they decide to interview the person in their home. Carefully reviewing the responses and the collateral information can help therapists make informed decisions regarding the suitability of the client to the home office setting.
Another part of the screening process involves acquainting clients with how the home office is organized. The therapist will explain what they will encounter or may encounter in the office itself and in regard to where the office is located, the other inhabitants of the home, and, when relevant, the neighbors and the neighborhood. Some clients may be allergic to cats, birds, or flowers and therapists should incorporate this information into the screening process.
Some therapists who work out of their homes choose to take referral clients only and do not advertise through public channels, such as the Yellow Pages. Other therapists choose to arrange initial intake sessions in a local clinic or in a traditional medical or office setting and then transfer appropriate clients to the home office setting. Yet others maintain two offices, one at their home and one in a traditional setting, and, after conducting an initial interview in the standard office, make a decision as to which location is most appropriate for the client.
Ethical Considerations
From an ethical point of view, there is no injunction in any of the major professional organizations’ codes of ethics against home-based practice. Such practice conforms to the standard of care. The American Psychological Association [APA] (2016), National Association of Social Workers [NASW] (2017), the California Association of Marriage and Family Therapists [CAMFT] (2011), and almost all other professional organizations’ codes of ethics regulate neither home office use or the related self-disclosure. Of course, they all have a mandate to avoid harm and exploitation and respect clients’ integrity and autonomy (Lazarus & Zur, 2002; Zur, 2004a). The well-being of the patient and preclusion of harm are, as always, the first consideration for the therapist. Consulting in the therapist’s home is neither unethical nor below the standard of care but requires augmented sensitivity to the ethical issues of confidentiality, privacy, safety, suitability, disclosures, and informed consent.
One of very thefew encouraging developments right now is the American Psychological Association’s 2002 revised Code of Ethics. It defines the previously ambiguous word “reasonable” in the code to mean the ” … prevailing professional judgment of psychologists engaged in similar activities in similar circumstances, given the knowledge the psychologist had or should have had at the time” (APA, 2002, par. 5). The importance of this new section is that it can reduce the risk to therapists who practice in their own home from the hands of the licensing boards and courts. The hope is that this new APA code establishes that it is unethical for an expert to negatively judge therapists who practice from their home, where appropriate and non-harmful significant self-disclosure is unavoidable. Therapists who maintain home offices, according to the new code, must be judged by standards and practices that are commonly applied by therapists with similar orientations, working in comparable types of situations (Zur, 2007).
Standard Of Care And Home Office Practice
The standard of care is defined as the qualities and conditions that prevail or should prevail in a particular mental health service and that a reasonable and prudent practitioner follows. The standard is based on community and professional standards, as well as on state laws, case law, licensing boards’ regulations, a consensus of professionals, ethics codes of professional associations, and a consensus in the community (Appelbaum, 1991; Caudill, 2004; Reid, 1998; Zur, 2004b). The standard of care is not an objective yardstick to be found in any textbook. It is closely tied to a theoretical orientation (Williams, 1997). The boundary crossings involved in appropriate home office psychotherapy practice, including the related extensive self-disclosure, clearly fall within the standard of care.
Boundary Crossing vs Boundary Violations
Boundary issues mostly refer to the therapist’s self-disclosure, home office, home visit, touch, exchange of gifts, bartering and fees, length and location of sessions, and contact outside the office (Guthiel & Gabbard, 1993). Boundary crossing in psychotherapy is an elusive term and refers to any deviation from traditional analytic and risk management practices, i.e., the strict, “only in the office,” emotionally distant forms of therapy (Zur, 2004a). While most analysts, ethicists, attorneys, and “experts” may use a broad brush in describing boundary issues, it is important that psychologists differentiate between harmful boundary violations and helpful boundary crossings. A boundary violation occurs when a therapist crosses the line of decency and integrity and misuses his or her power to exploit a client for the therapist’s own benefit. Boundary violations usually involve exploitive business or sexual relationships. Boundary violations are always unethical and are likely to be illegal. However, boundary crossings are often part of well-constructed treatment plans and, as such, they can increase therapeutic effectiveness (Lazarus & Zur, 2002). Obviously, home office practices always involve boundary crossing.
Critics of the use of home offices for psychotherapy practice express concern that practicing from a home office might involve boundary violations. The concern is that the use of a home office for psychotherapy may result in harmful boundary violation, as this setting is seen as contact outside the office and involves a significant increase in self-disclosure. Although conducting therapy in a home office definitely involves a boundary crossing, as the boundary between work and private life becomes somewhat permeable, it cannot automatically be conceived as a boundary violation. Home office practice can be conceived as a helpful boundary crossing, and perhaps even the superior environment, when treatment in this setting functions to increase the therapeutic bond. Outcome research has documented the importance of rapport and warmth for effective therapy and that rigidity, distance, and coldness are incompatible with healing. Appropriate boundary crossings are likely to increase familiarity, understanding, and connection, hence increasing clinical effectiveness (Lambert, 1991; Norcross & Goldfried, 1992).
Risk Management
The home office setting can give rise to heightened concerns regarding risk management. These concerns include issues of privacy and confidentiality (Woody, 1999) and informed consent. As was discussed above they also involve safety issues to the client, the therapists, the therapist’s family, and anyone else who resides at the therapist’s home. Concerns with sexual attraction are also important. It is important for therapists to avoid misunderstanding by a client who expresses attraction to them; it is best to carefully consider these issues when scheduling the last client of the day, especially if the therapist is single and living alone. Therapists need to be clinically thoughtful when it comes to any client who expresses attraction to the therapist or who expresses a desire to be treated as “one of the family”.
Doverspike (2004) describes an ideal situation in which “Reasonable clinicians protect themselves by protecting their patients” (p. 210). While this may be easier said than done, this should be the goal of therapists in general, including those who practice from their home. Clinical records that document our assessment of the suitability of clients for the home office practice and include informed consent that is geared to the home office, treatment plans, records of consultation, etc., can help the therapist practice ethical risk management in which the clients’ welfare, as well as the therapists’ personal and professional safety, is addressed.
Informed Consent
Most home offices provide rather different environments compared to traditional medical offices or office buildings. The detailed discussion of these differences must take place prior to the beginning of therapy at the home office. At the minimum, clients should be informed, verbally, during the screening interview, of what they can expect in the home office with respect to the neighborhood, parking, neighbors, family members, and pets; whether the office is located in the house or in an attached or detached unit; etc. (Zur, 2007). Clients should know in advance who they may have contact with. Some may need to know ahead of time if they are going to share a bathroom with the rest of the family. Concerns with privacy and confidentiality must be discussed in detail, as these are highly important issues in psychotherapy. It may be advisable to incorporate the home office informed consent into the general consent to treatment that clients sign before treatment starts.
Privacy And Confidentiality
HIPAA guidelines are applicable as they would be in a more traditional office setting practice. Additionally, the dynamics of time, space, and people are directly related to issues of privacy and confidentiality. Most medical or office buildings are designed to offer a relatively high level of privacy. Homes are not usually built with such concerns in mind. Most obviously, people who share the home with therapists are aware that the therapists serve psychotherapy clients (Pepper, 2003; Woody, 1999). Neighbors are also often aware of the type of business that psychotherapists conduct and therefore reasonably assume that people who show up to appointments are psychotherapy clients.
In some cases clients’ confidentiality may be even more protected, as they are seen by others as arriving or leaving a home residence rather than the business office setting of a psychotherapist. At most, observers might be left to wonder which visitors are friends and which are clients, if it is well known in the neighborhood that a therapist practices from a home office. This may be particularly relevant in rural or small town settings.
As in the traditional office, the concern with privacy and whether others can overhear conversations in the consulting room is an important issue. Sound-proofing the home office or using systems such as sound machines in the waiting areas are as important in the home office as they are in the standard office. However, a serious privacy issue is a concern if therapy involves yelling or other loud sounds that can be easily heard by family members. Therapists must also take care that curious children do not try to overhear private and confidential conversations in the consulting room.
Benefits And Burdens For Therapists
Working out of the home office provides therapists with benefits and burdens. Therapists working from home experience the benefit of escaping many of the frustrations encountered by most people who commute to an office. These benefits include avoidance of traveling in inclement weather, negotiating traffic, the effects of air or noise pollution, or high social density. Hence, therapists who work from home offices enjoy automatic stress reduction (Pepper, 2003). As some therapists put it, they are “at home.” This includes being available to tend to the home and family members between sessions. Some therapists report that family members indicate that their “at home” presence is felt even during working blocks of time, resulting in a greater sense of family unity. Other benefits that affect individual and family well-being include significant financial savings and the elimination of the need to negotiate with office building management, while unifying many management tasks such as bill payment. Working from home also supports ease in household management, as household tasks can be accomplished between client hours and the physical location places the therapist closer to children’s schools and other community obligations. Some therapists also report that they appreciate being able to actually spend more time in, and enjoy, the home they work so many hours to support.
On the other side, obviously, keeping appropriate boundaries is an ongoing challenge, especially if children of all ages are involved. Music, play chatter, or arguments are often disruptive if the office is within earshot of such sounds. Most therapists’ concerns revolve around their family members, who may complain about lost privacy, restricted movement, needing to keep noise to a minimum, needing to pay constant attention to which doors must be closed or open, which areas kept tidy, etc. While the home office relieves therapists from the rigors of commuting, it also denies them time to make the transition from work to home since these two domains are united. This may result in increased stress for therapists requiring them to frequently shift gears or change hats from the therapist mode to parent, spouse, or friend. Many therapists in private practice are already quite isolated from other professionals. The home office setting can only increase such isolation since there are no colleagues next door with whom to converse, consult, or socialize between sessions, during lunch or over a drink at the end of the workday.
Summary
The home office setting presents several challenges to therapists, clients, and those who reside at the therapist’s home. First and foremost, consulting at the home office is boundary crossing, as it crosses the boundary of the traditional therapy office, normally located in a medical building, clinic, or office complex. The most pronounced feature of the home office arrangement is the fact that clients are invited to the therapist’s home, thus crossing the boundary dividing the therapist’s professional and personal lives. This invitation intrinsically creates significant self-disclosure on the part of the therapist, as it reveals a wide range of personal information to the clients. Being invited to the therapist’s home may be, at least initially, intimidating for some clients; others may feel they are intruding on their therapist’s family and others may view it as unprofessional. The therapists’ conscious or unconscious emotional motives for the choice of home office practice can be considered as well as the possible effects on the emotional experience of the client.
The home office arrangement can vary significantly in regard to how much interaction and mutual awareness there is between clients and family members and how much is disclosed to clients. This in turn is dependent on the proximity of the office to the family. Some home-based offices are located in a detached unit completely separated from the house. For others, consulting rooms may be in the living room, the den, or a designated bedroom inside the main residence.
Therapists who work out of their homes must screen rigorously for client suitability to this venue while also guarding the safety of clients, themselves, and whoever else resides in the house. In addition to attending to clients’ needs, therapists working at home must also pay attention to their family members’ needs. While some adjustments are always required on the part of family members, major adjustments may place an undue burden on them and create stress on the part of the therapist. Privacy and confidentiality must be attended to, as the home office inherently exposes clients to others who will be aware of their client status. However, in some cases clients’ confidentiality may be even more protected in the home office setting than in a traditional business office setting.
Therapists must inform their clients in detail about the specific organization of their home office prior to the first session. Before the start of therapy, therapists must be clear with clients about where to park their cars and where to enter the house. Clients also need to know the location of the waiting area and the bathrooms and which area of the house they can use. If they may run across members of the household, they should be informed of this, as well. The therapist must also learn if clients are comfortable with the venue. Therapists will do well to assess the propriety of home-based therapy for clients, themselves, their family members. and the neighborhood on an on-going basis. Even though clients and family members may initially embrace or agree to such arrangements, they may later discover that it does not work for them.
Being invited into their therapist’s private space gives many clients a sense of comfort and trust. While this home setting is not appropriate for several types of clients, others can benefit from the significant level of self-disclosure and warm, more relaxed feeling characteristic of the home office. It is up to the therapist to conduct a thorough screening and make sure that the arrangement is beneficial for the client and the therapist and his or her family. In this setting, boundaries must be negotiated not only between therapist and clients but also between therapist and family members and at times between clients and family members or even pets. Negotiating the boundaries is not a one-time event prior to therapy; it is often a continuous process and as such can also be part of the clinical process, as well.
The home office presents a unique set of opportunities and complexities to clients, therapists, and therapist’s families. It is the therapists’ responsibility to make sure that clients are fully informed as to the nature and ground rules of home-based therapy and that they are suitable for treatment in such a setting, thus ensuring that it will benefit them rather than the reverse. This done, it can be an enriching, gratifying experience for both therapist and client.
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