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Sunday, November 3

Private Practice: Home Visits

Linda Walker, JD, MSW, LCSW

The NASW Illinois Chapter has started a shared interest group (SIG) devoted to the issues of private practitioners around the state. To be become involved in this group, please contact the NASW Illinois Chapter office: http://naswil.org/naswil/contact-us/.

For the majority of clinicians, private practice means having an office space where the client comes to us for therapeutic treatment. In our profession, this form of treatment has clearly defined boundaries. Ideally the therapist starts a session at a specific time, on time, behind the closed doors of a comfortably furnished office that has been designed to keep out distractions such as excessive noise and to create a peaceful environment. Typically the therapist is in control of everything about the setting, from the seating arrangement to the artwork on the walls. If the office space is part of a larger suite, then once the door is closed, it is understood that there will be no interruptions-no phone calls, no one knocking on the door, and so on. 

When I started my private practice, I decided to market myself in the area I knew and loved best: working with elderly clients over age 65. However, in order to truly serve this population, I knew from my prior agency experience that I couldn't expect all of these clients to come to me. Homebound seniors are a largely untapped market of clients who are in as much need of mental health services as the able-bodied seniors who still drive to my office. There are also thousands of persons with disabilities who are unable to easily get to a therapist's office and could benefit from home visits. 

Doing psychotherapy in someone else's home requires some adjustments to the traditional understanding of boundaries in the therapeutic relationship. This article will talk about some of the ways in which home visits differ from office-based visits.

Cost of Providing Services

Psychotherapy services for people over age 65 are typically covered by Medicare. Home visits are allowed and reimbursable. However there is no difference in payments for home visits versus office visits, nor is there any allowance provided for travel time or mileage. If you plan to do home visits, you may want to focus on a particular area so that you can concentrate your time in one general locale. 

Entering Someone Else's Home

Doing a home visit changes the dynamic of the relationship between therapist and client. Some elderly clients are a bit confused at first by the nature of the relationship, especially since most of them have never been in therapy before. For example, they may try to offer you food or drink and treat you as a guest. In reality, you are a guest in their home and you must act that way while you are there. However, it is important to balance this position as guest with also being therapist. If a client offers me refreshment, I almost always refuse. Once on an initial visit, the client invited me to sit at her dining room table where she had laid out lunch for me in advance of the (first) session. This was awkward. I chose to view this as the client's need to normalize the nature of our visit as well as a genuine need or desire to be hospitable. Thus I ate some food but, while thanking the client for her consideration, gently explained at the end that this would not be necessary in the future.

What about seating arrangements? In our offices, we set up the chairs and/or couches the way we want them to be. In someone's home, you don't have that option. I always ask the client where she would like me to sit. If she tells me anywhere, I then ask where the client is most comfortable sitting and choose my spot based on where she sits down. Sometimes the distance between us feels very far away, and I will ask for permission to move my chair closer to the client. 

Dealing with Intrusions

Unlike in the sanctity of your own office space, intrusions often occur when seeing clients in their own home. One way to avoid intrusions is to outline in the beginning of the relationship what the client should expect when you come to her home. I explain that we are using the comfort of her home as our office. I point out how important it is for us to have a quiet and secluded space to talk, without interruptions, television noise, or other persons potentially listening in. This is easier said than done and while, in theory, it is good to lay down expectations in the beginning, sometimes I feel more comfortable dealing with these issues as they arise. I think this is a matter of style. I prefer to focus in the initial session on establishing a therapeutic alliance rather than laying down a bunch of rules. 

Here is an example of an unavoidable intrusion: often, the client's telephone rings during a session (although now I often encounter this in my office as well). Seniors often expect calls from doctors or don't want to miss calls from family or friends, so they feel compelled to answer the phone. If the call is brief, I ignore the intrusion. If it is a social call and the client doesn't cut the conversation short, I will say something after she hangs up. This conversation is similar in tone to one you might have with a client who shows up late for a session-gently pointing out how you only have a certain period of time together and the importance of using that time doing the work of therapy. 

A similar problem has to do with other people being in the home during the session. In some independent living communities, I have experienced people just walking in, unannounced, to a client's home. Also, there may be a spouse, other relative, or paid caregiver in the home. This can also be a challenge. Out of respect for my client, I wait for my client to take the lead in asking people to leave the room or moving us into another location. After all, I am the guest in the client's home. However, if the client is not showing any inclination to secure our privacy, I will address the situation head on with everyone in the room, pointing out that the client and I have a meeting scheduled and that it is important for us to have privacy. Usually this does the trick. 

Other Issues

Time: It can be difficult to keep track of the time when you are in another person's home as there may be no clocks around. Rather than looking at my watch, I may ask the client if she minds my setting an alarm on my phone to go off five minutes before our time is over. Another option is to bring a small battery-operated clock that you can set down to look at. I always arrive promptly on time and leave on time. This helps to reinforce the professional nature of the visit.

Confidentiality: Whenever you go to someone else's home there is a potential for other people to see you coming and going and to inquire as to the nature of your visit. This is especially true if you are working in an independent living retirement community where people often try to strike up conversations in the elevator. Obviously it is important to be as discrete as possible. If I'm questioned about who I am visiting, I smile, say I'm visiting a friend, and then change the subject. I also try to avoid signing into the guest register, or I introduce myself to the receptionist and tell her the general purpose of my visits and the need to not disclose who I am visiting.


Home visits are a unique form of private practice. As our population ages, the need for therapists to serve people in their homes will only continue to grow. I encourage all therapists to consider adding this service to their practices. Not only is it a rewarding form of practice, but it is the most literal form of social work practice I can think of where we are "meeting the client where she is." 

Linda Walker, JD, MSW, LCSW, has offices in Evanston and Chicago. Linda provides psychotherapy to adults of all ages. In addition to her affinity for seniors, Linda especially likes to work with young adults, parents of LGBTQ children, and lawyers. 

Posted on 11/03/13 at 10:17 PM


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