Welcome to my house.

We had been meeting for a month already, but this was the first time Nick connected from his flat for our weekly online psychotherapy session.

Because of our time difference—I am based in Europe, and Nick lives in the US, we were usually connecting during his early morning hours. I was by now fairly familiar with his work surroundings: a small office cubicle, neon lights, grey doors shut tight.

This time everything was different, and Nick looked younger and more relaxed. He was sitting on his tattered couch, and I could spot on the wall behind him a superb black-and-white photo of a beautiful model. It was certainly one of his own works—Nick was a successful fashion photographer.

Suddenly he volunteered to show me around, surprisingly eager to invite me in. And I quickly discovered, why. A wobbly image appeared on my screen: a tiny flat, barely lighted from a single window, some dirty dishes in the kitchenette, and a messy pile of clothes on a chair.

Up until this moment, I had seen Nick as anybody else “out there”—an extremely successful, nice-looking and polished man with a promising future in the glamour industry.

But now, he trusted me enough to show the other, well hidden, side of his identity—the one of an immigrant from a poor background, fighting for survival in a foreign capital.

Now I had an opportunity to appreciate first-hand the contrast between the two facets of Nick’s inner reality. As I discovered during our session, his “glamorous” dates had usually disappeared from his life after seeing this “other,” shadowy side of him. After a glittery night in a fashionable club and a drink at his place, they would dissipate in the morning light. They would never return his calls afterwards. Sharing this, a deep feeling of shame emerged in Nick.

As I expected, after this “house call” Nick cancelled the following session, and during several weeks tried hard to make me feel useless. But our therapeutic relationship survived, and once the shame finally stepped back, we could resume our work together.

Our further work naturally evolved from exploration of this internal split. Nick was now ready to get in touch with his more genuine desires and motivations.

“Do home visits,” Irvin Yalom advises in The Gift of Therapy.

And this is exactly what I am doing in my online practice. Or, at least, this is the way I like to see it.

“Home visits are significant events, and I do not intend to convey that the beginning therapists undertake such a step lightly. Boundaries first need to be established and respected, but when the situation requires it, we must be willing to be flexible, be creative, and individualized in therapy we offer.” Yalom wrote these lines at a time when online counselling had not really developed yet.

Decline and Revival of the House Call

From the earliest days of professional medicine to fairly recently, it was common for doctors to make house calls. Usually it was a general practitioner, a family physician armed with his Gladstone bag, coming to the patient’s bed. And if somebody were suffering from a mental problem, he would be seen by a priest, rabbi or any relevant spiritual authority, or left alone, living within the society as the village foul.

With the general specialization of medicine and its technological development, mental health practitioners have ended up locked in their therapy rooms, well protected from the unexpected. In America, house calls have fallen steadily down the list of medical priorities since the end of World War II. And the same trend has affected all Europe.

But recently there have been signs of a revival of the house call; for example this story published in the New York Times about a physician's assistant making house calls in New York. This initiative is isolated though.

Oliver Sacks had also visited one of his patients in her home to explore her way of dealing with a rare neurological condition: “I could get no idea of how she accomplished this from seeing her dismal performance in the artificial, impoverished atmosphere of a neurology clinic. I had to see her in her own familiar surroundings.” But these reassuring visits from an audacious doctor are rather an exception, mainly reserved for the rich and mighty. Most of the American and European population makes do with the “impoverished atmosphere” of a medical practice.

Why, apart from the time and money aspects, do home visits seems so bold and risky.

This warning from Counseling Today, a publication of the American Counseling Association, seems to answer this question: “A private, sterile and quiet setting for counseling may be difficult to realize in the home. Expect the unexpected. Other family members, pets and visitors may not respect or be aware of the boundary issues inherent in a counseling relationship.”

This “expect the unexpected” sounds familiar to any therapist who practices online through videoconferencing. Sometimes our webcams let us see our client’s children and pets, as explored by Joseph Burgo in the New York Times. As result, managing the boundaries easily turns into a tricky task.

When we enter the physical realm of our client, we instantly meet with the full complexity of his current existence, and not only its inner components. There is so much more to deal with than in our own “private, sterile and quiet” therapy room.

From the professional anecdotes shared by my colleagues, as well as in my own experience, the online setting brings up anxiety and suspicion amongst some of our peers working in a more traditional setting.

In other words it also feels bold and risky, exactly as the practice of the home visits does.

Lightly or not, any therapist starting to offer his services online undertakes such a “risky and bold” step automatically. The problem may lie within this “automatic” component: connecting with the client through a videoconferencing system, we are almost instantly propelled into his physical realm. The client’s interior opens up for us with just one easy click. In the past, to make a home call, the therapist had to drive or to walk; some conscious physical effort had to be made before he would stand on his client’s threshold ringing the doorbell.

When we meet with our client in his own home, we gain an instant and direct access to some of the things clients usually “tell us about.” These unexpected intrusions and visual clues enrich the peculiar “here-and-now” of every session, with, as counterparty, a loss of control over the environment.

Something similar happens whilst working online: anybody can enter the room from which the client connects, and thus interrupt the session. Distance makes any direct impact on the client’s space impossible. The therapist does not have any control over it; he can only witness what is happening “on the other side of the screen.” This situation naturally triggers therapist’s anxiety.

Boundaries, previously so neatly limited by the walls of our therapy rooms, get more easily blurred in the online work. Clients tend to feel less committed to this “virtual” relationship, and they do not grow attached to a specific physical place. In the peculiar online reality, we are introduced into our client’s homes before properly attending to the boundaries.

To deal with this situation on a daily basis mindfully demands flexibility and creativity. Friends and colleagues often ask me which way of conducting therapy I find easier, in person or online. I generally find that the online work is more demanding for the therapist, often draining. There is more to deal with, in particular all the unexpected intrusions and the wealth of material spontaneously emerging from the visual clues received from my client’s environment.

In the example of Nick’s session, the effect of his dirty laundry and unwashed plates was added to the normal unconscious processes happening between the two of us. As doctors who have been practicing home visits for years, an online therapist develops with time a particular mind-set, a lynx eye for the visual clues and a new, very particular pair of “rabbit ears,” adapted to this specific “here-and-now.”

A few years back, I saw a client in the hotel room where he was staying, grounded by panic attacks partly triggered by the coldness of that very room. André had reached out to me as I was at the time practicing locally in Spain but in his native French as well. He was in Spain on a 4-week business trip, but could not get out of his room on the third day, out into this foreign city that he perceived as dangerous and unfriendly.

I drove to his hotel daily for two weeks, usually in the evening. On that dark road in the middle of some unfamiliar outskirts of Madrid I felt anxious and unsettled by this potentially unsafe situation. I made sure my supervisor was aware of this happening and a friend had the hotel’s name and was waiting for my call at the end of every session hour. At the end in that hotel room there were two people scared to death, and I was the one attending to all this fear.

Now, a few years later, I would have simply connected with André through a videoconferencing system. I would certainly have felt safer, separated by the physical distance from this stranger in pain, but would I have been able to respond as effectively to his panic attacks?

Let’s explore what would eventually have had been different.

The fact that I was willing to make such a considerable effort as to drive to his hotel located far away from the city center facilitated the development of our therapeutic alliance. André got strong and tangible proof of his own importance to me. As result, he could trust me quickly, and a very particular kind of kinship (we were both strangers in this city) developed between us.

This alliance would have been much more difficult to build in an online setting, and very probably André would have not been able to engage with me in the same intense way.

Being physically let into this anonymous hotel room helped me to relate more authentically to André’s current experience. The anxiety I was experiencing was partly my own feeling in response to the unsettling conditions of our sessions, partly his mirrored terror. That hotel room was an unfamiliar, foreign space for Andrew as well as for me. I could easily relate to his experience of being lost, trapped and terrified.

When he was lying on the top of his bed, battling with overwhelming symptoms of an acute panic attack, I was able to hold his hand. At moments he was convinced he would die in this foreign city, and as he shared with me later, reflecting on these first days of our work together, this simple physical contact was what allowed him to believe in transience of this terrifying experience. He suddenly was not alone in that dark and deadly place.

This simple physical touch would have not been possible in the online setting. I would eventually have managed to compensate with some verbal stroking, but that would take much more time to sink in. And, maybe André would not have believed my willingness to be there for him after all.

I am also aware of the fact that maybe at the time when André reached out to me, his level of anxiety was such that he would not be able to tolerate the frustration and separation anxiety, that are intrinsic to the distant nature of online therapy.

When André’s panic attacks stepped back enough in order to enable him to fly back home, we eventually reassumed our work online. Through the webcam’s eye I could now discover some of his original surroundings: his bedroom, his office…

That was a very different experience altogether. I was not physically there, and some of the information was out of my reach (the smells from the kitchen where his wife was cooking dinner, or the view from the unique window of his room). But I was still able to grasp some precious components of his existence: the picture of his wife and kids on his office desk, or his surprisingly assertive and slightly aggressive voice that he used when a younger colleague would suddenly introduced himself into his office.

Working with this particular, moveable (as he kept connecting from different spaces at different times) “here-and-now” I could gain some further understanding of his life in that particular place—a small French city that I would almost certainly never visit.

Soon after returning home, André decided to stop therapy… abruptly and too soon, as I thought at the time. But he felt that his partner, who was now aware of his mental health problems, was now able to give him the necessary support.

Transitioning from one type of space to another—from that concrete hotel room to the virtual space of the online—was certainly far too premature for our new born therapeutic relationship. But somehow the authenticity and the immediacy of the experience we both had in the two weeks of my “home visits” gave him enough relational nurturing in order to strengthen his relationships at home.

“…We must be willing to be flexible, be creative, and individualized in therapy we offer.”
Both online work and home visits naturally induce therapist to a greater flexibility and creativity. Every client’s physical realm is unique, shaped by the realities of the place itself and the people who inhabit it. When the therapist is immersed, physically or virtually, into this realm he can only feed the work on it, adapting the therapy he offers.

Putting the online work into this perspective, allows every session to develop into a particularly significant event—a second best for a home visit.

Maybe the house call is finally back, but in a new form. Technology has developed, allowing therapists to penetrate into their patients’ homes without moving from their own practices or apartments. This change can become an opportunity to revive the old home-visit tradition—the most relational and supportive approach to healing. And this now can be achieved with a reduced cost and an extremely inclusive reach, not limited by the geographical location of the therapist or the client.

File under: The Art of Psychotherapy, Therapy & Technology