Shrinks Make House Calls

Thanks to a recent email from a reader, I learned that there are some therapists in New York City who are making house calls. It seems as though you can simply book an appointment and, sure enough, your doorbell will ring at the prescribed time by your own personal therapist who will work with you from the comforts of your own home. Of course the costs of these sessions are slightly higher (read: significantly higher) but you don’t need to worry about taxis, buses or even putting on shoes. You could probably have the session in your bathrobe if you insisted. However, while this arrangement seems like a therapeutic utopia on the surface, there is a problem.
In certain situations home visits are entirely justified. An enfeebled patient should not be denied services because they are housebound. And some people with crippling Panic Disorder with Agoraphobia* could be seen in their homes, at least until they have improved enough to come to the office. Aside from these and a few other possible exceptions, however, going to clients’ domiciles for treatment is not in their best interests.
Although many shrinks like to view therapy as similar to traditional Western medicine, there is a fundamental and key difference. Generally speaking, formal medicine is a passive experience. You tell the doctor your symptoms and then he/she addresses it for you. You get the surgery done, you take the pills, and then you wait for results. The brunt of the work is done by the doctor or the procedure or the chemicals. Of course your outcome likely improves if you are an active participant in your health (e.g., eating well, exercising) but when you are ill medicine is something that is done to you.


Therapy, on the other hand, is ideally something you do for you. You do the majority of the work. There’s no mistaking the connection between effort and outcome in the therapy world, and the more you want it the better off you will fare. Of course it’s entirely possible to be inspired from your own home, but an active participant in therapy views the commute as part of the therapeutic process. I am going to my therapist’s office to work on my problems. It is an active step that I choose to do to improve the quality of my life. I take time out of my schedule to make the trip there, engage in the treatment and then leave the office. If a therapist is coming to a client’s house simply to cater to convenience, that professional is potentially removing a piece of the motivational pie from the client and, quite possibly, hindering a more positive outcome.
So why do these shrinks make house calls to people who don’t require them? Like other businesses, it boils down to dollars and cents. A therapist who runs this type of practice can not only charge more money due to the unique service but probably can throw in fees for travel time and commuting fares. It’s a niche that hasn’t really been tapped into. However, that’s because it’s simply a bad idea. As discussed I don’t have a problem with therapists making good coin, but you have to be a clinician first and a businessperson second. And when you compromise a client’s treatment in even the most subtle ways to make more money, it’s a huge mistake.
* Contrary to popular belief, Agoraphobia isn’t really a fear of the outdoors, at least not in the shrink world. It’s a fear of having a panic attack with no means of escaping to a safe environment. This often occurs when the idea of being in a crowded place or large open area is introduced.

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18 Responses to “Shrinks Make House Calls”

  1. I think the concept of house calls are great. It adds an extra comfort for patients and I’ve always found that the more comfortable I am, the more open I am.

  2. I offer home visits in my private practice (and charge $25 more than an office session, which I hope isn’t outrageous) while the agency I work for is “community based.” I have found it to be very helpful to have access to the home to get a better understanding of the environment and circumstances for a client. It’s also a useful option when working with families when a child may refuse to attend office sessions. Paralleling Linda’s comment, an additional benefit is the client feeling more comfortable in his/her/their own environment versus “the expert’s” with all the pretty pieces of paper on the wall and big books everywhere.
    Dr. Rob Note: community based interventions certainly have their place and I should have noted that in the post. This piece isn’t about those types of programs. I think you should give serious consideration to the dynamic you create by home visits in your private practice, however.

  3. IRISHNBRITISH says:

    I have to agree with Rob. There is definitely something to be said about getting clients off their arses to participate in therapeutic sessions. It’s all about subtle empowerment.
    In my opinion, making home visits subtly implies that the client is having something done to them, rather than they are actually proactively seeking their own solution. Surely, the sense of achievement any successful intervention would have on a person who has made maximum effort to attend sessions, has got to be far greater than that of a client who has effectively had their therapy ‘served to them on a plate?’ Granted, there are always exceptions to the rule (but I don’t really want to get into all that, as it has already been covered), nevertheless, I agree: home visits are – in the words of Julia Roberts’ prostitute character in Pretty Woman – a “Huge mistake. Huge!”
    I mean, even SHE didn’t make house calls! I think my point is… always let the client come to you wherever possible.
    THIS is quite a difficult subject to tackle, Rob, but you did it justice. Thankfully, most therapists have an inherent understanding of the complexities this issue throws up but, sadly, there will also be some who will never understand its subtleties, no matter how many times this is pointed out to them or discussed.
    A therapist has definitely got to be a therapist before anything else and the impact of any ‘home’ intervention should always be fully considered at the outset. What’s right for the client is simply what is right for the client and if that means taking the approach “let’s see if you can get off your arse first” is what’s best for the client, then that’s what should be done. If that means you loose the client or even some money in the process then SO BE IT! However, if you act in an upfront and honest way and explain your reasoning, surely the majority of clients will want to stick around? Professional integrity should always be the number one priority and taking a client centered approach is always the way to achieve this goal. And, because ‘everything is relative,’ looking at what money brings to the client/therapist relationship should always be part of the equation too.
    What I really wanted to say was, in most cases, if a client is motivated for change, they will be motivated to come to the office. If they are not willing to come to the office, then I’d have to question their motivation and if I was questioning their motivation then I’d actually have to question if they were actually ready!
    Shit: I think I’ve written more than Rob!

  4. rach says:

    Interesting point you make about dollars and cents, Rob – one could argue that if this is a ‘niche’ area of expertise (in the same way that one could specialize in eating disorders, couples issues or medico-legal issues), one could argue that there (potentially) may not be too many people doing this kind of work – therefore a person could charge whatever they want.
    Second point – if a person had enough clients, they may not need an office assuming they went “to their clients” rather than having their clients “come to them” – which of course would save on their overhead, which ultimately would bring in more money!

  5. Dr. Rob says:

    With all due respect, I fail to see how traveling to one’s home to do therapy is analogous to being an expert in eating disorders.
    Per your second point, again, I do not care if you make a great living as a shrink. It’s when that success comes at the expense of quality practice. Traveling therapy could (although not always) compromise the service, which is the thrust of this post.

  6. Anonymous says:

    I like this post! I agree with you Dr. Rob. As much as I would love for my shrink to come to my house to do the session I dont believe this is the best idea. People have enough problems with transference towards there therapists or shrinks and I would think that this problem would only get worse with having house calls. At least it would for me. That is why no matter how in love I am with my shrink and would love to get him in my house I would never ask for that to happen. But I do have friends that would hide the fact that they were dealing with the transference just to get their shrink or therapist to come for a home visit. Just seems to me like it could cause extra problems that there is no need for.

  7. Limoncello says:

    Home session can be wonderful for invalid or at the beginning of severe agoraphobia treatment. For any others, staying in patient’s own home may be distracting for both them and therapist (tea kettle, UPS, dinner on the stove, etc.). I’m also thinking that being in safe place, their own ‘turf’ if you will, may cause patient’s mind to be dormant that they may neglect to share something that may be vital or even breakthrough in the session. Better to keep them on their toes in a professional environment of doctor’s office. And you won’t see the husband walking around in boxers, scratching their butt three feet away from designated therapy area.

  8. ramica says:

    I would be *more* stressed by an in-home session than by one conducted in a neutral setting. I think I would feel more like a hostage than a client, because there’s no reasonable way to escape the session if it becomes overwhelming (not that I make a practice of that; it’s just nice to have the option).

  9. The Edge says:

    Speaking from my experience as a patient, it’s just as easy to sit on your arse in a therapist’s office as it is at home. Whether or not they’re doing the right things *outside* of therapy is more important than where the therapy takes place, IMO.

  10. Ben says:

    I’m a mobile therapist working from the “community-based” framework. The services are designed with an entirely different philosophy from that of typical outpatient therapy, but the reality is that these “philosophies” matter a great deal more to shrinks than to clients.
    I think Rob hit the nail on the head in terms of some of my clients. What we get too cheap, we esteem too lightly. Because you qualify for state services, you don’t pay one thin dime out of pocket and the shrink comes right to your door like Dominoes! There’s something to be said for having some “skin in the game,” so to speak.
    At the same time, if someone was paying EXTRA to have a housecall, you could argue that their increased financial investment offsets their decreased physical investment. Probably just depends on the client.
    I don’t think it’s accurate to paint all “housecall” shrinks with the same money-grubbing brush. Some of them probably have very reasonable sounding therapeutic rationales for what they’re doing. (At least, they’ll sound just as reasonable as your post against the practice.)
    To me, it comes down to outcomes. Has anyone done any research on therapeutic outcomes of home-based versus office-based services? If these clients are actually making less of an investment in their treatment because it’s being delivered to them in their homes, it ought to be reflected in outcome measures, however imperfect they might be.
    I’m far too lazy to log in to Ebsco, though. If anyone knows of any such studies, please post a reference here.

  11. Julie says:

    Therapeutic arguments aside, I can see why a therapist would make the decision to see someone in their home from a purely business standpoint.
    First, much lower overhead costs. No rent, no utilities, no fees, no upkeep, no having to furnish an office, none of the fees with having to keep an office, no having to pay a percentage to someone if they work as part of a group. They also would get the tax benefits of being able to write off all of their travel expenses to and from client’s houses as well as I would assume a tax benefit of having some sort of in-home office space in which to do paperwork.
    Second, they’re simply choosing to spend their “wasted down time in between clients” traveling from client to client instead of the way the rest of us do it, surfing the net, gossiping with our employees, reading People magazine. A lot of this just makes sense to me from a business standpoint.

  12. Hannah says:

    Isn’t it also very dangerous for the therapist? While there’s no guarantee you’d be safe in your office, isn’t there less guarantee when your patient is in their own element? Not that most patients are violent…

  13. Esther says:

    Interesting. I worked for a company that helps people with disabilities for a year. During my time there I heard about a therapist who offered home visits. However, it seemed mainly for people with developmental disabilities who would have trouble making regular appointments. Transportation can be a major issue. I see the value in home visits for such cases.

  14. I use to be “on call” for my clients when I was a biz consultant (charging 50-100%+ more per hour depending on after biz hours v. weekend)…but I never had to worry about: safety, liability, transference, distractions, HIPAA, etc.
    I’d be very concerned with safety and liability (my pt population regularly includes axis-II, PTSD, SA, etc). While I see the value in “home visits” in certain instances, I think 95% of therapy should be done in a controlled environment that is setup by the professional.

  15. Marcom says:

    I wouldn’t assume that just because a therapist makes house calls, they are motivated only by ‘da Benjamins’. I think that a therapist’s decision whether or not to make house calls should be a clinical consideration first, then a financial one. I agree with Michael J. Gialanella that family therapy can benefit from home visits, and the the therapist can gain valuable information about the clients’ living environment and habits by visiting their home. With home visits, therapists can teach parents, for example, to implement structure and limits in their homes, bringing the therapeutic experience much nearer to their daily experience than office-based therapy, and shortening the translation that parents have to make when they leave the therapy office then try to apply what they learned at home. Also, people are more likely to behave as they normally do when they are at home, giving the therapist more opportunities to work with them to reshape their behaviors and relationship patterns in real time.

  16. House Call Psychiatrists are a team of board certified and licensed psychiatrists in Manhattan with extensive experience making psychiatric home visits. They are available 24 hours a day, 7 days a week for convenient and private house calls within Manhattan.

    Our psychiatrists have been making house calls for many years on Assertive Community Treatment (ACT) teams which are home-based psychiatric outreach programs. They are also psychiatric emergency room physicians with admitting privileges to Roosevelt Hospital and St. Luke’s Hospital, members of the Mount Sinai Health System.

    House Call Psychiatrists offer a unique and high level service in the convenience of your home, office or hotel room. They are able to address most psychiatric issues in a timely and private manner avoiding other urgent care centers and hospital emergency rooms.

  17. DJ says:

    ” An active participant views the commute as part of the therapeutic process”?!
    Really?
    What does commuting have to do with motivation ? One could just as easily argue that the therapist needs to commute to the client to demonstrate his or her commitment to helping the client.
    “Aside from these and a few other exceptions,going to clients’ domiciles is not in their best interest.” Do you have the evidence to support that?

    I am no less motivated now that my psychologist makes home visits,than I was when I was commuting an hour each way to see him,but I’m less stressed and less exhausted.Have you ever commuted on the L.I.E. during rush hour?

    “So why do these shrinks make house calls to people who don’t require them ?Like with all businesses,it boils down to dollars and cents.”

    Really?My psychologist does not receive a penny more for home visits than for office visits,nor do any of his colleagues at the Bio-Behavioral Institute,whose directed is Dr. Fugen Neziroglu.

    “It’s a niche that hasn’t been tapped into.However,that’s because it’s simply a bad idea.”

    I’d love to hear you tell Dr. Fugen Neziroglu renown O.C.D. expert,,who has written at least 18 books,hundreds of journal articles, lectures nationally and internationally & is the Director of the BioBehavioral Institute in Great Neck, N.Y.,that making house calls “Is simply a bad idea “,for the therapists at Bio make house calls.

    I used to commute several hours to see my psychologist at Bio,in Great Neck.
    He happend to move to the neighborhood that adjoins mine. Do believe that I should drive two hours to see my psychologist in Great Neck, now that he is able to make a home visit to me,on his way home? I’m not the least bit less motivated

    I think you should try driving to your patients to show your commitment to treating them.If commuting is a measure of commitment to the treatment process,it should work both ways.

    If you have any evidence to support that “an active participant views the commute as part of the therapeutic process” ,that “going to patients’ domiciles is not in their best interest ” or that “It’s simply a bad idea”,I’d love to hear it.My psychologist would challenge your contentions by asking :”Do you have the evidence to support that?”

    When I first starting seeing him,I used to dread that question.I’ve learned to avoid the dreaded:”Do you have the evidence to support that?” by ceasing to make contentions that are not evidence based.

    You can,too,should you wish.

  18. anne says:

    My first appointment has been arranged for her to visit my home. Im too stressed out by the hospital setting, it is awful; you are all sat facing each other in a square shaped seating arrangement, which means you all have to look at each other. People with anxiety don’t need this!
    It used to be in rows, which was better and then they changed it. I told them my feedback but a year later its still the same. I used to get a panic attack when I had to sit there… facing anything from a weirdo to another panicky person made it a lot worse. The people who arrange the chairs are not bright are they?
    And they have the radio on… noisy, aggressive pop music which I hate – ugh! Half an hour of gangsta rap crap and all those broken faces made me feel quite ill. Damn stupid idea.
    Thats the NHS for you. No brains… no budget.

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