Home visits, In-Vivo De-sensitizations, Adventure Therapy, Rituals and Other Clinical Experiences that Take Place Outside the Office
What Films Can Teach Psychotherapists About the Ethics of Out-Of-Office Experiences in Psychotherapy
By: Ofer Zur, Ph.D. and Birgit Wolz, Ph.D.
Out-Of-Office Experiences in Psychotherapy
Adopted from: Zur, O. (2005). Beyond the Office Walls: Home Visits, Celebrations, Adventure Therapy, Incidental Encounters and Other Encounters Outside the Office Walls. The full text is available at: http://www.zurinstitute.com/outofofficeexperiences.html
Interactions between clients and therapists outside the walls of the office, or what have been termed, “Boundary Extensions” (Jones, Botsko, & Gorman, 2003) or “Out-Of-Office Experiences” (Zur, 2001a), are the focus of this chapter.
Types of Out-of-office Experiences:
- Home Visits
- Home visits to homebound or bedridden clients.
- Home visits to families who do not have the means, organization or cohesiveness to travel to family sessions at the office.
- Home visits that are part of a case management, child welfare or child abuse prevention program.
- Home visits as part of family therapy assessment and/or intervention.
- Hospitals, Jails and Other Visits
- Hospital visits.
- Jail or prison visits.
- Visits to psychiatric wards.
- Visits to a drug rehabilitation programs.
- Interventions that are only possible outside the office space:
- Adventure or outdoor therapy.
- In-Vivo or De-sensitizations behavioral interventions, such as going with an agoraphobic client to an open space or flying with a client who suffers from fear of flying.
- Accompanying a client to a dreaded medical appointment to which s/he would not go on his/her own.
- Therapists joining their clients at their first AA meeting to help them overcome shame.
- Accompanying an athlete to practice or track meet.
- Consulting with an athlete-client at the gym, track or field.
- Going on a brisk walk with a depressed, medically non-compliant patient.
- Social training and nature outings as part of inpatient treatment.
- Attending celebrations or rituals outside the office:
- Attending a client-artist’s gallery exhibition.
- Attending a client’s graduation, wedding, Bar-Mitzvah or confirmation
- Joining an architect to view his/her new building upon its completion.
- Going to see the performance of a young client who has overcome shyness and is appearing in a school play.
- Walking Side-by-Side Rather Than Sitting Face-to-Face
- Many adolescents and other clients prefer to discuss difficult topics while on a walk outside the office. Such side-by-side interaction may allow less defensiveness, more revelation of shameful material and less reactivity to therapist’s non-verbal reactions and cues.
- Incidental encounters in the community:
- Therapists accidentally bumping into clients in the community or on college campuses.
- Incidental encounters in health clubs, playgrounds, trails, school yards, shopping malls, etc.
- Encountering a client at a training institute holiday party.
- Encounters outside the office as part dual relationships:
- Therapist encountering a client who is also a fellow church member during Sunday service.
- Therapist playing in recreation league with a client.
- Therapist encountering a client in mess hall or in a movie on an aircraft carrier or at a military base.
- Therapist serving on a small-rural community task force with a client.
There is often a faulty belief in the field of psychotherapeutic ethics that any encounter outside the office is considered dual relationships. The first six (of seven) types of out-of-office encounters described above do not constitute dual relationships as the therapist is operating exclusively in his or her clinical role. The fact that the intervention takes place in the client’s home or on a trail does not mean that dual relationships exist. Similarly, attending a wedding, Bar Mitzvah or confirmation does not add an additional role to the therapist. Only the seventh and last type described above constitutes dual relationships.
Home Visits
Therapists conduct assessments and treatments in clients’ homes for clinical, pragmatic and other reasons. Some clients cannot make it to the therapy office because they are too ill, disabled or too poor. Some families are too disorganized, do not have the means of getting to the office or live too far away to bring all family members together for an office visit. Other families might derive special benefit from a home visit where the therapist can observe the complexities and hardships of their lives and become familiar with the context of their family life, support system (or lack thereof) and neighborhood. In some cultures, such as that of certain Indian tribes, the home is a much more acceptable venue for mental health interventions than the medical office (Schacht, Tafoya, & Mirabla, 1989). Therapy or assessment at the client’s home has been referred to as “in-home” therapy (Volker, 1999), “home-based” therapy (Boyd-Franklin & Bry, 2000) or simply a “home visit” (Morris, 2003).
Boyd-Franklin and Bry (2000) listed special opportunities offered by home-based therapy in comparison to office-based therapy: meet important members of the family, friends and community who are not likely to attend an office session; engage the truly significant and powerful figures in the family; get a first-hand view of the family living situation, especially in regard to overcrowding, poverty, disorganization, etc.; observe the family culture as it manifests itself in food, icons, music, etc.; learn first hand the family child-rearing practices; and experience the family home through the family members’ own eyes.
Most of the literature on home-based therapy has focused on interventions that were either part of family therapy (Bass, 1988; Berg, 1994; Christensen, 1995; Halvorson, 1992; Kanter, Snyder & McCollum, 1999, Washburn, 1994) or some type of case management regarding abuse, neglect or foster child concerns (Morris, 2003). Home-based therapy has been reported with American Indian families (Schacht, et al., 1989), with families whose problems did not improve with traditional out-patient treatment (Cherniss & Herzog, 1996), with drug-abusing adolescents and their families (Berg & Miller, 1992; Erkolanhti & Ilonen, 2004; Henggeler, et al. 1996), with the chronically mentally ill (Heath, 2005; Menikoff, 1999), with juvenile offenders in danger of out-of-home placement (Gordon, Arbuthnot, Gustafson, & McGreen, 1988), with teenaged mothers (Cherniss & Herzog, 1996), youth (Bass, 1988) in conjunction with Head Start projects with disadvantaged families (Synder & McCollum, 1999; Volker, 1999) and Families in Extreme Distress (Rabin, Rosenbaum & Sens, 1982). While home-based therapy is, in many situations, the only available option, there are actually very few studies that compare its efficacy with traditional, office-based therapy (Christensen, 1995, Morris, 2003).
In the early years of psychotherapy when analytic thinking was prominent, home visits were not considered a valid clinical option for clinical-transferencial reasons. However, with the cultural and civil rights revolution of the ’60s and the proliferation of psychotherapy in the ’60s and ’70s, family therapists became more likely to conduct in-home therapy and social workers viewed house visits as a routine part of case management practices. However, it was not until the passage of Public Law 96-272, also known as the Adoption and Child Welfare Act of 1980, that home-based family therapy became significantly more common (Morris, 2003). The law was enacted partly in an attempt to avoid out-of-home placement of foster children and to also increase their safety through case management and home-based family therapy. The proliferation of case management, primarily conducted by social workers as part of their assessments of child abuse, child neglect and domestic abuse, as well as the increased use of interventions since the early ’80s, have made home visits a normal part of case management assessment and intervention. However, the increased focus on risk management and defensive medicine in the ’90s has generally made therapists of all orientations more cautious and less willing to leave the office with the resulting frequent avoidance of in-home therapy (Williams, 1997).
Following are more detailed reasons for home visits:
Physical/practical reasons
The home visit is likely to be the only option open to many. One of the most obvious reasons for choosing home-based therapy is to treat a homebound, ailing or dying client who is physically unable to leave the house (Morris, 2003). This includes hospice clients, perhaps dying of cancer or AIDS, who choose to die at home. Then, too, there are such cases as the overwhelmed new mother who is suffering from postpartum depression, the acutely, and thus homebound, agoraphobic, paranoid or OCD patient. (Christensen, 1995; Morris, 2003, Rabin, et al., 1995, Zur, 2001a). Also, sometimes clients or families are simply too poor, disorganized or chaotic to get to the office. (Schacht, et al., 1989). Similarly, there are clients who are in acute crisis, which prevents them from coming to the office (Cortes, 2004; Rabin, et al., 1995).
The geriatric population is growing exponentially (Brickey, 2000), and the need for home visits is growing at a parallel pace. Untreated mental illness in elderly patients causes increased suffering and morbidity. In the United States more than 3 million persons, aged 65 and older, are in need of mental health care, yet over half of these individuals do not receive adequate psychiatric services (Kohn, et al. 2002). Traditional, clinic-based mental health programs have not been sufficiently responsive to the needs of mentally ill, elderly patients. Physical, economic and social barriers may often prevent aged persons from receiving essential psychiatric treatment. Access to such services by homebound mentally ill, elderly patients is even more limited. In addition, elderly patients are generally more reluctant to seek out psychiatric care and are often less likely to recognize the signs and symptoms of mental illness. Too often senior citizens’ concern with physical disabilities may distract them from addressing their psychiatric needs and may limit their access to traditional psychiatric services. There is a need for innovative programs, such as in-home mental treatment, that reach out to the aged population and bring treatment to them (Bruce & McNamara, 1992). While telehealth is also a growing treatment modality (Maheu & Allen, 1999), most older patients are neither inclined to seek such web-based treatment nor are they familiar enough with the technology to utilize such services.
Clinical reasons
A home visit can also be a strategic clinical intervention and not one necessitated by the patient’s inability to come to the office or connect with the therapist via the Internet. As touched on above, home visits provide the therapist with an expanded opportunity to become familiar with individual clients or family members on their own turf (Speck, 1964). It enables her/him to observe the home and get a first hand sense of its organization, hygiene, atmosphere and resources, or lack thereof (Volker, 1999). Therapists can also get to see what kind of neighborhood the house is located in and what kind of people visit or drop by (Gordon, et al. 1988; Synder & McCollum, 1999). During such a home visit or in-home session, the therapist can personally assess neighborhood issues, such as safety, crime, recreation, transportation and communal support. Home visits reveal to the therapist an enormous amount of information in comparison to office-based therapy (Cortes, 2004; Morris, 2003). This includes family religious and cultural symbols, sleeping arrangements, how people move and occupy different spaces within the house and the fluidity of boundaries in regard to visitors. And, as a guest in the home, the therapist will experience the customs and rituals of hospitality (Schacht, et al., 1989).
Case management
Social workers and other psychotherapists regularly conduct home visits for purposes of assessment, crisis intervention and treatment in cases ranging from child abuse and child neglect to domestic violence and other family disturbances (Kanter, 2000; Synder & McCullum, 1999). The Adoption Assistance and Child Welfare Act of 1980 (P.L. 96-272) legitimized and helped the proliferation of home-based mental health assessment and interventions. The law was enacted to address concerns that the foster care system had not done enough to avoid out-of-home placement of children (Morris, 2003). As a result of the law, numerous programs were developed where mental health and other professionals would work with families at home to help keep children safe in their own homes with their biological parents, siblings and extended families (Bryce & Lloyd, 1981).
Cultural
Home-based therapy has been used extensively with ethnic minority clients and families, primarily due to the fact that members of these communities often do not trust, and even fear, “foreign” or “main stream” mental health professionals. There is often a reluctance to go to a strange place, such as a formal medical office, to talk to a stranger about personal problems (Shacht, et al., 1989). In addition, transportation concerns, distance and accessibility prevent some poor, minority clients from getting to the therapist’s office (Bryce & Lloyd, 1981). Making a home visit with a client from an ethnic minority can be an important component in getting a first-hand view of their home, icons, rituals, neighborhood, community and support system. It is likely to help break the ice, decrease suspicion and increase trust (Morris, 2003).
Creative Clinical Interventions Not Possible in the Office
There are many situations where interventions are only possible, or likely to be much more effective, if they are conducted outside the boundaries of the office. Some the most frequently cited examples for such out-of-office interventions are in vivo desensitization in the treatment of phobias (Lazarus, 1994a,b). In these cases a therapist leaves the office to go to an open space with an agoraphobic client or perhaps flies with a client with fear of flying as the final step in the behavioral therapy-based, systematic desensitization intervention. Similarly, the “anorexic lunch” and the “bulimic family dinner” have been reported by family therapists to be highly effective clinical interventions (e.g., Minuchin, 1974). Going for an aerobic walk with a depressed client may be the only effective intervention with a client who is neither compliant with medication nor with exercise prescriptions and who will not discuss his/her resistance but is willing to go for a vigorous walk with the therapist (Lazarus & Zur, 2002). Sports psychologists often accompany their athlete-clients to the field in order to instruct, support or observe the clients’ attitude and, most importantly, performance (Moor, 2003). Along the same lines, a therapist may choose to accompany a client to an important medical procedure to which the client would not go on his or her own, even though it poses a health risk (Zur, 2004). Similarly, treating a client’s complicated grief over a dead spouse, parent or child may require the therapist to accompany the client to the cemetery or to a funeral, if the client requests it, and it is clear that he or she would not/could not go on their own (Zur, 2001a).
Working with the chronically mentally ill outside the office has also been reported quite frequently (Banaka & Young, 1985; Heath, 2005; Orchin, 2004). This might include walking on nature trails or going for a ride in a car or just sitting on a bench in a nearby park. Clients who have been diagnosed with Anxiety or Bipolar Disorders or schizophrenia are often too agitated and, at times, paranoid to spend an entire session in the office. Walking and talking seem to be effective with some of these clients as they neither feel confined to the office nor need to face the therapist but rather are able to walk side by side and are helpfully distracted by the passing scene (Zur, 2001a). Working with restless or defiant adolescents in the office has also been reported to be challenging.
Zur (2001a) illustrates another case of out-of-office experience:Twenty years after Jill’s daughter died in a car crash, I accompanied her, at her request, on her very first visit to her daughter’s grave. The psychiatrist who Jill had seen immediately after the crash gave her Valium, to which she became addicted. Her second therapist dismissed her request to be accompanied to the grave as “resistance” and “acting out of the transference.” Clearly, neither was helpful in her hour of need and both proved to be harmful as they interfered with her grieving process. (p. 97)
Honoring Clients’ Accomplishments, Rituals and Life Transitions
Besides the situations where clients cannot make it to the office or the treatment plan is leaning towards an out-of-office intervention, there are other situations where the therapist’s decision to leave the office is likely to enhance therapeutic alliance and clinical outcome. The therapist may accept invitations to attend significant life transitions and rituals or celebrations in clients’ lives. Examples are: attending the wedding of a couple who finally decided to get married after many tumultuous years of pre-marital therapy or attending the graduation of a patient who never thought he would complete his studies. In their national survey Borys and Pope (1989) reported that more than a third of the therapists stated that they accept invitations to special occasions with a few or more clients. Other examples are accepting invitations to the funeral or memorial service of a spouse or child or joining clients to celebrate christenings, confirmations, bar mitzvahs and similar events.</>
There are other events that warrant leaving the office. Therapists who work with different cultures inevitably join their Native American clients in some of their sacred rituals, their Latino clients in weddings, their Catholic clients at confirmations, or their Jewish clients for bar or bat mitzvahs (Kertész, 2002, Zur, 2001a). Refusing to do so, in certain cultures, is likely to cause irreparable damage to the therapeutic alliance, to nullify trust and is likely to render therapy ineffective (Schacht, et al., 1989).</>
The kinds of interventions that involve stepping outside the office confines and joining clients in celebrations and rituals are designed to actively support clients, affirm or celebrate their achievements and enhance therapeutic alliance. Without exception, outcome studies literature has always pointed to the same conclusion: the therapeutic relationship is one of the better, if not the best, predictors of clinical effectiveness (e.g., Bergin & Garfield, 1994; Frank, 1973; Goldfried & Padawer 1982; Lambert, 1991; Miller, Duncan, & Hubble, 1997, Norcross & Goldfried, 1992), and out-of-office interactions are believed to enhance that relationship.
Incidental Encounters
Incidental encounters have also been referred to as “chance encounters” or “chance extratherapeutic encounters” (Hyman, 2002) and refer to unplanned, random or unexpected encounters between the therapist and a current client, which take place in public settings outside the therapist’s office (Harris, 2002; Sharkin & Birky, 1992).
Incidental encounters are a common and unavoidable occurrence in rural areas (Barnett & Yutrzenka, 1994; Cambell & Gordon, 2003; Hargrove, 1986), small towns (Shank & Skovholt, 1997) and university and college settings (Malley, Gallagher & Brown, 1992; Sharkin, 1995; Hyman, 2002). Incidental or chance encounters are also not extraordinary in small communities within larger metropolitan areas, such as political, gay and lesbian (Kessler & Waechler, 2005; Smith, 1990), disabled and deaf (Guthmann & Sandberg, 2002), ethnic (Schact, et al., 1989) or church (Llewellyn, 2002). In the practice of sport psychology (Moore, 2003) and in the military they are inevitable, especially on remote or isolated bases and aircraft carriers (Johnson, 1995; Johnson, Ralph & Johnson, 2005; Zur & Gonzalez, 2002). Clinicians in these communities and settings randomly and frequently encounter their clients in a wide variety of venues from the local food market, social, professional and political gatherings, various community functions, gatherings and events at the local gym, swimming pool and in recreational leagues.
Chance encounters in college and university communities have received extensive attention (e.g., Grayson 1986; Hyman, 2002, Malley, et. al, 1992). Due to the fact that most therapists in colleges and universities mental health centers are also students or professors, that the counseling center and student housing are often located on campus and given the particular nature of university and college campuses, incidental encounters are common and unavoidable (Iodupovici & Luke, 2002; Harris, 2002). Additionally, sports events, departmental social gatherings, graduations and other ceremonies significantly increase the probability of chance encounters between therapists and clients. Most of the concerns with chance encounters on campuses have focused on the issue of confidentiality. Unlike most common beliefs Pulakod (1994) reported that students are not as concerned about confidentiality as their therapists and, in fact, wanted more interaction, not less, when they accidentally encounter their therapists on campus. Sharkin (1995) pointed out that therapists avoiding interactions might inadvertently expose the therapeutic relationship rather than protect its confidentiality. In a title that speaks for itself, Hyman (2002) entitled his chapter on chance encounters between therapists and students on campuses, “The Shirtless Jock Therapist and the Bikini-Clad Client.”
In dealing with chance encounters most scholars agree that, when possible, and in situations where such encounters are expected, talking to clients and taking precautions is extremely important. These precautions usually involve discussing the possibility of accidental encounters with the clients at the beginning of therapy and understanding clients’ preferred ways of handling them (Sharkin & Birky, 1992). Intake material and informed consent can also prepare clients for an inevitable, incidental encounter (Iosupovici & Luke, 2002). Analytically oriented therapists tend to try to avoid incidental encounters all together and when that fails, at least to keep them to the minimum possible (Gody, 1996; Tarnower, 1966). In contrast, humanistic, feminist and existential therapists are more likely to focus on a genuine, appropriate and respectful exchange rather than indiscriminately trying to avoid or minimize any exchange whatsoever (Hyman, 2002). When encountering a client in public, several authors (e.g., Harris, 2002, Zur, 2001a) emphasize the importance of taking the cue from the client before choosing to ignore or address the client. Discussing incidental encounters with clients in subsequent therapy sessions can be beneficial. However, routine or brief encounters may not merit any lengthy discussion.
Outdoor or Adventure Therapy
The proliferation of drug rehabilitation inpatient programs and remotely located alternative boarding high schools in the last couple of decades has resulted in a huge rise in utilization of outdoor or adventure therapy. This therapeutic approach is known by various names. It has been called Adventure Therapy (Gass, 1993), Wilderness Therapy (Davis-Berman & Berman, 1994), Outdoor Therapy (Orchin, 2004), Camping Therapy (Lowry, 1974), Outdoor Pursuits and Risk Education (Ewert, 1987). What unifies these programs is that they are conducted in the outdoors where patients are physically and emotionally challenged to overcome their fears and reassess their self-perceptions. They examine their beliefs in both their limitations and abilities and learn to rely on themselves and the group in order to carry out a variety of tasks assigned them.
Adventure therapy or Wilderness Programs are mostly conducted in remote settings but can also be located in urban settings where there are indoor facilities for rock climbing or trapeze structures and rope courses (Levine, 1978). Outdoors, they mostly include activities such as backpacking, hiking, biking, camping, canoeing, rope courses, navigating, vision quests, rock-climbing and repelling down cliffs. These forms of therapy are usually highly structured and are composed of individual and group challenges with a corresponding mix of individual risk taking, overcoming fears and group cooperation (Schoel, Prouty & Radcliffe, 1988). It has been used extensively with high-risk adolescents in boarding schools and drug rehabilitation programs (e.g., Herbert, 1966). It has also been used as an adjunct to therapy with long-term mental illness (Banaka & Young, 1985; Berman & Anton, 1988; McClung, 1984; Stich & Senior, 1984), mental retardation (Dillenschneider, 1983), substance abuse (Gass & McPhee, 1990), fearful, withdrawn or avoidance clients (Orchin, 2004), rehabilitation of juvenile delinquents (Herbert, 1996), families in crisis (Glass & Shoffner, 2001) and the hearing impaired (Luckner, 1988). Dual relationships with clients almost always involve out-of-office experiences. Therapists and clients who happen to attend the same church, are active in local charities, belong to the same club or chamber of commerce or play in the same sports league inevitably face planned and unplanned encounters outside the office as part of these dual relationships. Dual relationships are common, inevitable, unavoidable, normal and a healthy part of communal life in numerous settings – rural, small town, ethnic and other interdependent communities. A detailed discussion of dual relationships is beyond the scope of this paper; however, the reader who wishes to pursue this topic may turn to the Lazarus & Zur (2002) text, Dual Relationships and Psychotherapy, which provides the most comprehensive, up-to-date review of the nature and types of dual relationships and the legal, ethical and clinical considerations. Out-of-office encounters that are part of existing social dual relationships have much less clinical significance as the therapists and clients are already involved in relationships outside the office walls. For example, if therapists and clients are also members of the same congregation, chance encounters are expected and normal and considered a natural part of communal life (Zur, 2000, 2001a).
Confidentiality, Time, Participation, Location and Safety Considerations
In the discussion of out-of-office experiences one of the most frequently cited concerns is the issue of confidentiality. Concern with confidentiality has been discussed relative to home-based therapy (Morris, 2003; Snyder & McCollum, 1999), incidental encounters, in general (Sharkin & Birky, 1992), and especially incidental encounters in college towns (Harris, 2002) where there is a good deal of incidental interaction on campus and in the community, as previously discussed. The concern in all these situations is that the therapist-client relationship can be revealed to other people in the community without the knowledge, consent or control of either therapist or client.
Home-based therapy presents a number of challenges to the privacy of the communication between therapist and client. Neighbors, friends and additional family members who may drop by the house or join a session or be invited by some family members to join the session are then privy to confidential communications. While these additional people are present at the therapy session with the family’s, or at least some family members’, permission, this situation still stretches the concept of privacy and confidentiality beyond the traditional professional view (Boyd-Franklin & Bry, 2000; Synder & McCollum, 1999; Volker. 1999).
Some authors view the concern with confidentiality in out-of-office experiences as exaggerated and point to the widespread erroneous belief that “privacy” and “confidentiality” are synonymous. Lazarus (2001) underscored this after a critic claimed that the very act of socializing with a client is a breech of confidentiality. Lazarus responded as follows: “When I am sitting at a lunch counter and socializing with a patient at his request, how does this violate his privacy or confidentiality? I get the feeling that [my critic] believes that I may be overcome by the urge to turn to the person alongside me and blurt out, ‘This is Tim Smith, a patient I am treating for guilt over his extramarital affairs,'” (p. 10). Ebert (1997) emphasizes the importance of the constitutional right for freedom of association. Similarly, Zur (2001a) also pointed out that it is the client’s right to determined if s/he is comfortable with public knowledge of the therapeutic relationship or not and, as an example, reports clients who openly acknowledged his therapeutic role during a wedding ceremony. Pulakod (1994) discovered that many clients, during incidental encounters, are not as concerned about confidentiality as their therapists are, and Sharkin (1995) pointed out that therapists, by avoiding interactions, might inadvertently breach, rather than protect, confidentiality.
Length of sessions and time of the beginning and end of sessions are often not under the control of the therapist during home visits, tour of a gallery or winery, attending a wedding or funeral, walking on a trail or participating in adventure therapy. While sometimes the therapist can determine the beginning of the therapeutic encounter, this is not always true for the end of sessions. In family-based, home therapy some family members may have to leave or choose to leave in the middle of a session, others may respond to a phone call or a knock on the door, which may cause them to leave the session. Therapists who choose to join clients in rituals, ceremonies, gallery openings or school plays have no control over how long these may last (Schact, et al., 1989). Adventure therapy often takes unexpected turns that do not conform to the 50-minute hour or any other pre-determined time frame (Gass, 1993). Most trained therapists who conduct home visits or adventure therapy or who leave the office for a variety of clinical reasons, do not expect to exercise full control over the length of the sessions and, therefore, incorporate a more flexible approach to time and space. When appropriate, these therapists do not even try to determine the end of the activity but instead, as often is the case with outdoor encounters, leave it open and let the process itself determine its end point. In the case of most chance encounters therapists have neither control nor ability to even predict when and where the encounter may take place and how long it will last.
Determining who is and who is not part of a certain clinical encounter cannot be taken for granted once the therapist leaves the office and conducts therapy in a client’s home or in public places. Conducting therapy at the client’s home requires flexibility and tolerance for unpredictability on the part of the therapist (Volker, 1999). Even when only the immediate family has been scheduled for a session, a curious or concerned aunt or uncle may decide to join in, one of the teenagers may get a call on their cell phone and leave to join his/her friends or a boyfriend may decide to check out the home-shrink. Experienced therapists expect such unexpected changes and many view such unpredictable changes as part of the assessment and intervene according to what is presented and who is present. While these unexpected events can add richness to the session, they can also pose difficult challenges, as in the case when an abusive or violent boyfriend or controlling and intrusive relative decides to join in. Obviously, while attending a school play, ritual, wedding, graduation or medical appointment, the therapist has no control over who is part of the occasion. Even when a walk with a depressed person or a private one-on-one basketball game with a resistive adolescent or a lunch with a bulimic patient is intended to be private, there is no way to predict when a friend or acquaintance may interrupt or even join in.
The safety of the psychotherapist in the course of home-based therapy is a consideration that has also frequently been raised (Synder & McCollum, 1999). Female therapists have reported concern with their physical safety when visiting a home where domestic violence has been reported (Volker, 1999). Similarly, visiting an unsafe neighborhood may pose a physical danger to therapists, especially if they are unfamiliar with the neighborhood and/or the local culture. The client’s safety is also of concern in out-of-office interventions. Situations may conceivably arise with clients who become acutely panicked, anxious, psychotic or paranoid while on a walk or anywhere else outside the office. Therapists who leave the safety of the office environment are inevitably exposing themselves and their clients to increased unpredictability and possibility of surprise (Orchin, 2004). Adventure or outdoor therapy with its physical challenges and risk definitely includes built-in safety considerations (Gass, 1993). While back-ups, cell phones, first aid kits and contingency plans are often available and established ahead of time in the office setting, more careful contingency plans must be constructed for encounters outside the office.
Ethics, Standard of Care, CPT and Risk Management Considerations
Professional associations’ codes of ethics, such as that of the American Psychological Association (2002), do not directly address the concerns of out-of-office interventions. Home-based therapy, outdoor intervention or in vivo exposure, like any other out-of-office intervention that is part of a theoretically-based treatment plan, are clearly within the standard of care of behavioral, family, adventure, humanistic, group and other non-analytic therapies (Lazarus & Zur, 2002; Williams, 1997). Similarly, attending a wedding, bar mitzvah or other ritual or visiting a patient in the hospital, all fall within the standard of care if they are done with planning, are congruent with the local culture and are executed with the client’s welfare in mind.
Many types of out-of-office experiences have been assigned Current Procedural Terminology (CPT) codes and have been recognized and reimbursed by the insurance companies. There are numerous CPT codes that address different types of out-of-office experiences. Mental health home visits are covered under codes such as Psychiatric Diagnostic or Evaluative Interview (90801, 90802); Health and Behavior Assessment (96150, 96151); Health and Behavior Intervention (96152-96155); Individual Psychotherapy (90804-90815); Family or Group Psychotherapy (90846, 90847, 90849, 90857); Pharmacological Management (90862); Central Nervous Assessments and Tests (96100, 96105, 96110, 96111, 96115, 96117); Psychiatric Evaluation and Preparation of Records (90885, 90887). Similarly, there are numerous CPT codes for hospital visits (i.e., 99221-99223); Hospice (99377, 99378); interventions that are neither in the patient’s home nor in the hospital (i.e., 97535); and Case Management (6034).
Risk Management experts have raised legal (Bennett et al., 1990, Strasburger et al., 1992), ethical (Gottlieb, 1993; Pope & Vasquez, 1998) and clinical (Borys & Pope 1989; Simon, 1991) points relative to out-of-office interventions and the potential for abuse, exploitation and breaches of confidentiality. Employment of out-of-office interventions must always take these matters into consideration; however, avoiding all out-of-office experiences and restricting therapy only to the office would leave millions of bed-ridden, home or hospital bound, poor, disorganized, addicted, chronically mentally ill, and many other individuals untreated. It would eliminate home-based family therapy and adventure therapy. It would also lead to increased distrust among many minority and ethnic clients and many other clients who want their therapists to join them in celebrations, rituals or any of those events which are important to them and that they want to share.
Summary
Interactions with clients outside the office occur in different places and for different reasons. Many clinical interventions, such as adventure or nature therapy or family and child therapy can only be conducted outside the office. Similarly, therapy with bed-ridden or homebound patients or with poor or highly disorganized families can only take place at home. After the passage of Public Laws 96-272, also known as the Adoption and Child Welfare Act of 1980, home-based family therapy became significantly more common. The law was enacted partly in an attempt to avoid out-of-home placement of foster children by increasing their safety through case management and home-based family therapy. Some ethnic minorities and illegal immigrants are often reluctant to come to a formal office setting for a variety of reasons. There are also many instances where leaving the office is likely to increase therapeutic alliance and therapeutic effectiveness. These situations include attending clients’ graduations, weddings, school plays or art exhibitions, to cite some examples. Attending cultural rituals and making home visits are viewed as essential in establishing trust and credibility with certain ethnic minorities.
Other forms of interacting with clients outside the office walls are incidental or chance encounters and interactions in public that are a normal part of communal living in small or rural communities.
While traditional analytic therapy has viewed out-of-office experiences as negative, other orientations, such as humanistic, family, behavioral, feminist and cultural-based therapy, acknowledge that such encounters can be valuable to the clinical process. Interventions that are performed outside the office, are based on theoretical orientation, are in consort with community standards and customs and are conducted with the client’s welfare in mind are consistent with the standard of care. Professional organizations’ codes of ethics neither specifically mention out-of-office experiences nor state that they are unethical or ill advised.
Encountering a client outside the office often involves a different set of expectations and boundaries than the professional office represents. Therapists do not always control the start or end of these interventions or who is included or excluded. Privacy is often compromised in such interventions and safety considerations must be taken into account in certain environments.
In designing an out-of-office intervention, as with any other intervention, the therapist must consider the client’s culture, history, presenting problem, personality, family situation, economic status and any other element that rounds out the knowledge of the individual. Documentation of the rationale for leaving the office is important and so are consultations in complex cases. Always, as with any other intervention, the welfare of the client and the avoidance of harm are paramount.
Additional Resources
- Boyd-Franklin, N., & Bry, B. H. (2000). Reaching out in family therapy: Home-based, school, and community interventions. New York: The Guilford Press.
- Bryce, M., & Lloyd, J. (Eds.). (1981). Treating families in the home: An alternative to placement. Springfield, IL: Charles C. Thomas.
- Knapp, S., & Slattery, J. M. (2004). Professional boundaries in nontraditional settings. Professional Psychology: Research and Practice, 14(5), 553-558.
- Lazarus, A. A., & Zur, O. (Eds.). (2002). Dual relationships and psychotherapy. New York: Springer.
- Zur, O. (2001). Out-of-office experience: When crossing office boundaries and engaging in dual relationships are clinically beneficial and ethically sound. Independent Practitioner, 21(1), 96-100. At: http://www.zurinstitute.com/outofoffice.html
- Zur, O. (2005). Beyond the Office Walls: Home Visits, Celebrations, Adventure Therapy, Incidental Encounters and Other Encounters Outside the Office Wall. At: http://www.zurinstitute.com/outofofficeexperiences.html
Out-Of-Office Experiences in Psychotherapy in the Movies
A number of movies have presented issues of out-of-office experiences in therapy in different lights and different contexts. Following is a description of the movies and a summary of the cinematic presentation of out-of-office experiences in therapy.
For a detailed descriptions of the movies, click here.
Antwone Fisher
Antwone Fisher, an African-American in the U.S. Navy, has trouble with his anger. An African American psychiatrist, Dr. Jerome Davenport, helps him work through his extensive childhood trauma.
Client, Uninvited, Visits Therapist’s Home
When Antwone makes a surprise visit to the psychiatrist’s home, Davenport sets boundaries quickly.
Therapeutic boundaries are crossed and violated not only by therapists but also by clients. As was done in this case, it is the therapist’s responsibility to maintain appropriate boundaries when clients violate them.
Sessions Conducted in Places other than the Office
Later on in therapy the boundaries of this relationship loosen significantly. Sessions are held in a variety of settings, such as the psychiatrist’s living room with the door open and his wife in the house, and in a men’s room.
Dr. Davenport shows clinical flexibility and sensitivity when he expands the meeting places when working with a resistive and difficult client such as Antwone. As was discussed above, confidentiality issues are always a concern when therapists and clients interact outside the office. A discussion of how to handle them should be conducted prior to leaving the office, and clients must be informed that confidentiality could be compromised. Neither of these interventions constitute dual relationships.
Therapist Visits Client in Jail
Dr. Davenport visits his client in jail.
This visit is a clear statement of support by the psychiatrist of his mistrusting client. The intervention seems effective in increasing trust and enhancing the therapeutic alliance.
Invite a Client for a Session at the Therapist’s Home
While Antwone waits for Davenport at the psychiatrist’s house for a session, he meets Davenport’s wife, looks around and studies family pictures.
Any time that a client is invited to the therapist’s home for a session, there is always extensive self-disclosure on the part of the therapist. Home office arrangements or a onetime invitation must be done with full and careful consideration of clients’ factors, such as presenting problem, history, culture and quality of the therapeutic relationship. Introducing a client to a “normal” family may be part of a thought-out clinical intervention rather than the establishment of social dual relationships.
Invite a Client to Dinner at the Therapist’s Home
As he takes on the role of a surrogate father, the psychiatrist invites his patient to a family dinner at Thanksgiving. Antwone gets to meet Jerome Davenport’s parents, his sister, niece and his wife’s relatives.
It appears as if Davenport designed this invitation as a clinical intervention designed to give Antwone the opportunity to experience a supportive family for the first time in his life. It can be designed as a corrective emotional experience. As with any boundary crossing, client’s and therapist’s factors and the context of therapy must be taken into consideration before making such an invitation.
Post Therapy Incidental Encounter
When Davenport and Antwone run into each other on the military base after their work is terminated, the therapist says that working with him made him a better therapist and husband.
Accidentally bumping into clients after therapy has ended is very common in settings, such as military bases, university campuses and rural and small communities. A simple incidental or accidental encounter does not constitute dual relationships.
Basic Instinct
Detective Nick Curran and his colleague, Gus Moran, investigate a murder. Nick gets sexually involved with one of the suspects, Catherine Tramell. He is in psychotherapy with police psychologist, Dr. Beth Garner, who had also become his lover. In order to protect Curran, Garner gives Lt. Marty Nilsen access to the therapy notes about Curran.
Sexual Contact Outside the Office
- During their last therapy session it becomes obvious that Nick and Beth’s romance is over. This doesn’t keep Nick from visiting his ex-therapist at her apartment again to have passionate sex with her.
- During a subsequent team meeting at the police department his supervisor threatens Nick Curran with suspension because he acts unprofessionally in the murder investigation. Because she still loves Nick, his ex-therapist, Beth Garner, lies for him in order to bail him out. The psychologist convinces the other officers to make his suspension dependent on a psychiatric evaluation. To thank her for the favor, he kisses Beth in front of the office building.
- In one scene the police psychologist, Dr. Beth Garner, finds Nick at a bar and gets into an argument with him.
These out-of-office experiences are part of unethical (simultaneously and sequential) sexual dual relationships that also involve complicated professional dual relationships.
Encounters Outside the Office as Part of Professional Dual Relationships.
As the police department’s forensic psychologist, Beth Garner is part of the team that tries to solve murder cases. In one team meeting Garner, Curran and their colleagues discuss the murder of a former rock and roll star found brutally murdered.
Professional dual relationships, as often take place in police departments, military settings, universities and other settings, often involve non-therapeutically related professional meetings outside the office.
Bliss
Maria and Joseph see Alfred for couples therapy, while Maria secretly consults sex therapist Dr. Baltazar Vincenza. The latter therapeutic relationship ends when Baltazar starts teaching Joseph “the ways of love.”
Side-by-Side Rather Than Face-to-Face
Baltazar gives Joseph specific instructions about sexual practices while they are walking down a pier. They sweat in a sauna after Maria had been sexually aggressive with Joseph. The therapist tells his client that “most men fear a woman’s sexual power” and “maybe we have to let Maria get her anger out more often.”
It might be less intimidating for Joseph to listen to Baltazar’s instructions in Tantric sex while they take a walk, and share his fear about his wife’s sexual aggression while they sit in a sauna, than sitting face to face in an office. Significant numbers of clients prefers a “side-by-side” conversation rather than face to face. This is similar to the analytic setup where clients do not need to face their analysts when they free-associate or reveal shameful or hard to admit material.
Intervention not Possible in the Confinement of the Office
The sex therapist teaches Joseph to get in touch with his body by swimming lengths in a public pool to build up his physical stamina. Balazar also shows his client how to breathe through one nostril while hanging upside down by the heels in a gym.
Given the physical nature and declared goal of Baltazar’s therapy/teaching, these sessions have to be conducted outside the therapist’s office.
Dressed to Kill
After Kate Miller is brutally murdered Dr. Elliot, her psychiatrist, and Detective Marino try to find her killer. Kate’s teenage son teams up with a prostitute, Liz Blake, who witnessed the murder, to do an investigation of their own.
Investigating Outside the Office
Dr. Elliott tries to track the killer of his patient, Kate Miller.
Since his patient is dead, the psychiatrist’s actions can no longer interfere with the therapist-patient relationship between Elliott and Kate Miller. Of course, confidentiality concerns still apply.
Girl, Interrupted
After a half-hearted suicide attempt and being evaluated by psychiatrist Dr. Crumble, Susanna Kaysen spends one year at Claymoore. In this psychiatric hospital she receives treatment from Dr. Melvin Protts and Dr. Sonia Wick, while nurse Valerie looks after her. Susanna befriends the other patients, Lisa, Daisy, Janet and Georgina.
An Outing as Part of Inpatient Treatment
Susanna, Lisa and several other girls go with a couple of nurses to an ice cream parlor. In the store Susanna is unsuccessful in trying to hide from Mrs. Gilcrest and her daughter, Bonnie. Susanna had a sexual affair with her teacher, Professor Gilcrest, who seduced her during her school years. When Mrs. Gilcrest discovers Susanna, she insults her, “I know everything about you. I hope that they’ll put you away forever.”
Outings to nature walks, flying trapeze or to local malls are not an uncommon part of inpatient psychiatrist treatment. The concerns with such excursions are safety for clients and/or others and confidentiality.
Good Will Hunting
Will Hunting, a working-class young math genius, is wasting his talent. Mathematics professor Lambeau takes him under his wing and finds a therapist for his protege. In his therapy with Sean McGuire he begins the healing process of his childhood trauma.
Going for a Walk with the Client to Break the Ice
For their second session McGuire decides to effectively break the ice by taking his still highly resistive and distrustful young client to a park bench on a riverbank. In order to convey to Will the difference between real life experiences and book knowledge, this environment is more conducive than McGuire’s book-packed office. Will starts listening and begins to understand that he is hiding behind his knowledge and cockiness because he is too afraid to talk about himself.
This is probably one of the best illustrations of how leaving the office can increase therapeutic effectiveness with certain clients. Leaving the office can break the ice and allow the client to express him or herself more freely. Patients feel less like a specimen or “patient” when the walk with their therapists is side-by-side rather than face-to-face in the office.
House of Games
Margaret Ford, a repressed psychiatrist, tries to help her patient, Billy, with his gambling addiction. Her patient is laying a trap for Margaret when she allows the con artist, Mike, to become her guide through this underworld of confidence games.
Leaving the Office in an Attempt to Help a Client.
Dr. Ford leaves the office for the House of Games to try to help her client.
While Dr. Ford does not encounter her client in her out-of-office venture, she still takes matters outside the office. She is neither effective nor appropriate in her venture to help her client. She puts herself at risk and potentially her client, too.
K-Pax
His new patient, Prot, who claims to be an alien from the planet K-PAX, intrigues Dr. Mark Powell. In order to evaluate his knowledge in astronomy the psychiatrist takes his patient to his astronomer friend, Steve Becker, and a group of astrophysicists. Later he brings Prot to a garden party with his wife, Rachel, his children and friends. Powell’s superior, Claudia Villars, does not agree with his approach.
Inviting a Client to the Therapist’s Home
After telling his reluctant wife, “I want him to spend Fourth of July with us to see whether a normal family can bring something out of him,” the psychiatrist brings Prot home to a garden party.
The therapist seems to design the client’s visit to his home as a therapeutic intervention. Obviously, this does not constitute a dual relationship as the therapist functions only in his clinical role. Inviting a client to the therapist’s home must be planned carefully and a risk-benefit analysis should be conducted. Articulating the reasons for inviting a client to one’s home as part of the clinical records is also important. Consultations are advised in complex cases.
Mr. Jones
Dr. Libbie Bowen treats Mr. Jones for Bipolar Disorder in a mental hospital. They fall in love and start a romantic relationship.
Sexual Experience Outside the Office
The therapist is involved in sexual relationships with her patient.
Needless to say, sexual relationships with a current or recently terminated client is unethical and, in most states, illegal. Obviously, leaving the office in order to be involved sexually is also unethical and probably illegal.
Prime
Rafi Gardet dates a younger man, David Bloomberg. After hearing about this relationship in their sessions for some time, her therapist, Dr. Lisa Metzger, finds out that Rafi’s boyfriend is her own son.
Incidental or Chance Encounter
Dr. Metzger bumps into her client in a department store. As she sees her son and her patient in the store, she abruptly pulls her husband behind a bed trying to avoid being seen by Rafi and David. Because her husband wants to know what is going on, she discloses the nature of her relationship with Rafi.
Chance encounters or incidental encounters between therapists and clients are very common in small or rural towns, university and college campuses, military bases and small communities, such as gay and lesbian, church or disabled communities. When therapists realize that chance encounters are likely, they should discuss with their clients how they prefer to handle it. While some clients are happy to acknowledge the clinical relationship, others prefer to keep more private. When possible and appropriate, it is better for therapists to take the cue from the clients when they meet accidentally in public places. While therapists should do their best to protect the privacy of the clinical relationships, sometimes this is not possible. It is also advised to not only discuss the issue with clients ahead of time, when appropriate, but also after such encounters. Research has pointed out that clients are not as concerned with incidental encounters as therapists are. It also has revealed that sometimes when therapists do not acknowledge clients in public places, it can make the clinical relationships more apparent.
Prince of Tides
Tom, an unemployed, aimless ex-high school football coach from the South, meets his sister’s psychiatrist, Dr. Susan Lowenstein, who wants him to shed light on their family life.
The movie depicts several out-of-office experiences between the psychiatrist and the patient’s brother. These experiences range from the psychiatrist watching her son play football with the patient’s brother to a sexual relationship. While they are dating, Tom and Lowenstein spend time together in her apartment, in restaurants and walking through the city.
Developing a social, supportive, non-sexual social relationship with a patient’s brother may not necessarily be unethical or below the standard of care. Therefore, the non-sexual or social exchanges outside the office with the brother or the patient may be ethical as long as they do not negatively affect the client. However, sexual relations with the client’s brother are unethical and may be illegal in some states. For more details see the Dual Relationships Section.
Stay
A psychiatrist, Sam Foster, treats art student and painter, Henry Letham. Foster tries to do everything to figure out why and where his patient wants to kill himself in order to prevent the suicide.
Out of Office, Detective-Like, Experience
Most of Dr. Foster’s interactions with Henry and his investigations about his patient are not taking place in an office. Because the psychiatrist wants to prevent Henry from committing suicide, he looks for his patient and finds him at different locations. For example, Foster follows Henry to a lecture hall and talks to him in the hallway. The therapeutic intervention looks like detective work as Foster tries to find out why, when and where Henry plans to kill himself.
As long as the therapist is acting in his clinical role and within the standard of care, his out-of-office experiences can be clinically justified and ethical. However, also acting in a detective role is not likely to be compatible with the clinical role. Therefore, the appropriateness of the out-of-office experience must be evaluated within the context of therapy and with a clear understanding of the therapist’s motives and the roles he assumes in relationship to his client.
What About Bob?
After one therapy session Bob Wiley follows his psychiatrist, Dr. Leo Marvin, to his lakeside summer home in order to further discuss his problems. There, Bob befriends Marvin’s son Sigmund, daughter Anna, and wife Fay.
When Clients Violate Boundaries and Follow the Therapist Outside the Office
Since Bob Wiley follows his therapist to a vacation location, most of the interactions between therapist and patient happen – against Dr. Marvin’s will – outside the psychiatrist’s office.
This comedy has best illuminated the fact that sometimes clients, rather than therapists, violate therapeutic boundaries. Similarly, when clients stalk therapists, they violate professional boundaries. Some ethics codes attend to such eventualities.
For extensive references list, click here.
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