Engaging with clients outside the office has generally been discouraged or called unethical, similar to the way in which uninformed risk management and ethics ‘experts’, have traditionally viewed dual relationships, bartering, self-disclosure by therapists, or gift exchanges between clients and therapists. Once we go beyond the unfounded ‘don’t list’ and take off our distorted ‘risk management glasses’, we can carefully and intelligently look at encounters between therapists and clients outside the office. We can realize that, indeed, meeting clients outside the office is, at times, unavoidable or unexpected and can also be part of a sound treatment plan.
Classic examples of therapy that takes place outside the office
- Home visits to a bedridden or immobile client
- Adventure-wilderness therapy
- Home visit assessments by therapists working for child protective agencies, primarily social workers
- Therapy with the homeless
- Home visits to a agoraphobic, paranoid, or highly depressed clients
- Hospital visits to distressed or phobic clients
- Equine therapy
Settings where encounters with clients are common and/or unavoidable:
- Small towns
- Rural and remote communities
- Colleges and university campuses
- Military bases and aircraft carriers
- AA or other 12-Step meetings
Leaving the office in order to increase clinical effectiveness and enhance therapeutic alliance – the best predictor of positive therapeutic outcome:
- Going for a walk with a client who is uncomfortable in the ‘face-to-face’ setting of an office and prefers, by far, a ‘side-by-side’ exchange on a nearby trail
- Accepting an invitation from an architect-client to view her recently completed unique and creatively designed home
- Accepting an invitation to watch a child perform in a school play after, with the help of therapy, the shy and intimidated young client overcame his fears and trepidations and was able to join the play
- After a lengthy, difficult and successful couples therapy, you accept the invitation to attend the two clients’ wedding. (To my surprise, during the ceremony that I attended at the couple’s strong request, they pointed at me and told everyone that my therapy with them was a key factor in their arriving at the special moment of union and commitment.)
- Accompanying a client, who is working in therapy on issues of grief and guilt, to his child’s grave for the first time in 20 years
- Accepting an invitation from a family, who had undergone intermittent-long-term therapy over 20 years, to attend the funeral of an elder family member who had been an important part of their long-term family therapy
It is important to be aware that none of the major professional associations’ codes of ethics prohibits out-of-office encounters. In fact, intervening in ways that are likely to increase therapeutic efficacy, which may include out-of-office experiences, is an ethical mandate.
Finally, when therapists conduct therapy outside the office walls they are advised to articulate their clinical rationale, what took place, and the outcome of the encounter in the clinical notes. Significant and unpredictable out-of-office encounters should also be noted in the client’s records as well. When encountering patients outside the office is highly likely, such as in small communities, it is advisable to discuss it with clients at the onset of therapy and refer to it in the Informed Consent for Treatment (Form #1 in our Clinical Forms). It is important to note that some out-of-office interventions are ill-advised with certain clients in certain settings. Some complex out-of-office interventions or encounters may require a consultation with an open minded and informed expert.