Saturday, May 02, 2009

Unusual Treatment Settings

A psychiatrist colleague is learning to do Cognitive Behavioral Therapy. He's treating a patient with agoraphobia, and goes to the patient's home to work with the patient on slowly coming out of his comfort zone.

It got me thinking about treating patients in their homes, or in places other than the office.

I've been to the homes of patients a few times-- none were my on-going therapy patients. As a resident, I rotated through an Outreach Team. These teams provide treatment to people with severe and persistent mental illnesses who have a history of non-compliance-- these patients don't keep their appointments, and they repeatedly get sick and end up in the hospital, sometimes many, many times. As the doctor on the team, I never went alone, always with a nurse or social worker who knew the patient, and mostly I was an observer. It was a great experience. As a clinic medical director, I went with our case manager a few times to see patients she was worried about.

So I'm thinking about the colleague who visits the patient in his home to help him negotiate the world. Is this a feasible way of treating people? The psychiatrist stays for an hour, and there's transportation time (I don't know how long that takes) financially, this could be an expensive endeavor. In this case, I believe the doc is salaried, and the patient is being seen pro bono as part of the learning experience. And what about the boundary issues involved in being in a patient's home?

I'm writing without really having a point I want to make. Does anyone else do Home Visit Psychiatry and what thoughts can you share?


Retriever said...

A professional should realize that their visit will cause incredible stress for most families, even loving supportive ones.

In my family caregiver role, I can say that I would be appalled at the idea of a clinician visiting my home. When there is serious mental illness in the family, the house is usually a mess, and the family are ashamed that the stress of the illness and keeping a person alive or containing violence has left them no time or energy to clean, de-clutter, etc. I remember being incredibly stressed when a social worker had to make a home visit every few weeks after the kid returned from residential treatment. We liked and respected her, and the kid and we were all happy and relatively well. But having to stay up all night the night before the visit to clean and tidy, in fear that she would consider it an unfit home if she saw it as messy as usual.

I remember being thrilled that one extremely nice one was allergic to our dog and cat. She could only stay 15 minutes before she couldn't breathe, so we had an excuse to meet her at her office. My point is, most families are terrified of clinicians because they have been blamed for the kid's problems, and are afraid of their home as well as their selves being found wanting. Also, the desire to be hospitable and put a good face on things when someone comes to one's house but families like mine don't have the energy.

All that being said, perhaps one visit so that a shrink could see an agoraphobic kid,or see the computer, dog, cat, trampoline, kitchen that a kid with PDD is obsessed with. Our family may be unique in having 3 people with diagnoses, so we may have a harder time housekeeping than some...

Christine said...

I second a lot of what Retriever said.

As a patient, I would feel incredibly awkward if my psychiatrist or psychologist were to come into my tiny apartment. I'd be much more anxious than in a normal visit, worrying constantly about what he's thinking... mostly wondering, "What conclusions is he drawing about me based on my apartment?"

And then there is the issue of cleanliness and having company over. When I am not doing well, my apartment is one of the very first things to go. Having someone over - especially my shrink - would just add embarrassment on top of whatever I was already going through. It might be hard for me to get up and moving to make it to an appointment, but the visit would be far more productive in a neutral environment than in my home.

As a future provider (possibly, but not necessarily psychiatry), I can't see much benefit behind having visits in the home. I might feel odd intruding, and I'd worry about multiple distractions interrupting the visit. I'll admit that, as mentioned, there are a few certain cases which nearly necessitate in-home care, and for those, in-home services should be available... but how would you decide who qualifies? How much of this would the insurance pay for? What are the legal and personal dangers of being alone with a patient in his or her home? I'm inexperienced, but it seems to me that this could be a challenge.

Moira said...

It's pretty common for providers of services for preschool children with PDD/autism-spectrum disorders to provide in-home visits to work with young children and their parents and siblings in a natural setting. Professionals who routinely do this include psychologists, occupational therapists, physical and speech therapists, and early childhood special ed teachers.

If the child is in a daycare setting, the professionals will also make visits to observe/work with the child at the daycare and consult/brainstorm with the daycare provider about strategies to help the child's development.

This approach makes a lot of sense to me. My kids are older now, but I remember such visits as being incredibly helpful and supportive. The professionals went out of their to reassure me that I shouldn't feel the need to clean and declutter for them, and my house was certainly not a model of tidiness and order.

Their visits were much more supportive and I would imagine that many people experience far more stress when relatives visit than when these professionals did. (I remember my own mother being incredibly nervous every time her mother-in-law came over when she was raising three rambunctious young children. Her mother-in-law would arrive and would run her finger over obscure places, like the rim of a lampshade in an out-of-the-way place that my mother hadn't thought to dust.

The professionals who regularly visited our home never did anything like that!

talesofacrazypsychmajor said...

It makes me think of the book "Snoop" by Sam Gosling. Seeing someone's living environment can tell a lot about them. I think of a therapist saw my apartment, they'd have a fuller understanding of me as a person.
That said it'd be incredibly awkward. I'd feel a lot of pressure shifting into the role of hostess rather than just patient. Do I offer food or a beverage? Can the neighbors hear the conversation?
But the thought of sitting in MY cozy chair rather than THEIR cozy chair is appealing. And the idea of being able to hug my cat during therapy:P

Novalis said...

I haven't done this much, but recently did visit the home of an agoraphobe with her social worker--totally different experience from the office for the reasons mentioned.

Given psychiatry's reputation in many quarters for meddling where it's not wanted, I don't see mental health housecalls going mainstream any time soon.

I have thought about knocking randomly on doors to stir up business though--would that be wrong? The strange shrink drop-in...maybe something for Sacha Baron Cohen to take up (please, no).

Anonymous said...

Hmmm, there was nothing "involuntary" about this home treatment, the therapist would rather the patient came to him, and the patient is free to cancel at any time. The stated issue is that the patient CAN'T leave the house and wants to be able to.

Interesting point about whether one offers beverages (I'll have to ask if that happens).

I think home visits for custody issues are different, and funny but I assumed a convenience factor for the patient, not a imposition issue. But now I can see that side as well.

Anonymous said...

I'm a (new, but nevertheless) EMT, so house calls are most of what I do (though I've never thought of it quite like that). Even in the emergency setting, some patients or their families are apologetic and embarrassed about their homes. Granted, they weren't expecting us to show up that day, either.

Still, house calls are a great option when people can't come to an office. This would apply to psychiatry, as well. If people can't come to you, you go to them. The agoraphobia case you mention seems like an "of course" situation, resources permitting. Other cases where the patient requests or OKs home visits sound like good ideas.

Sitting with a patient alone in their home could be a bit awkward. Emergency services usually come in groups, are busy while there, and leave in short order, unlike in a psychiatric hour. With psychiatry, I can see that boundaries could get messy, and housemates might be problematic. It might help to assure the patient that they don't need to do anything special and hospitality isn't expected.

In summary, yes, home visits sound like a good tool to have available when needed, though office visits are generally preferable when possible.

Rach said...

I would be concerned about safety -are there protocols set in place to protect the physician's safety from the patient? Dinah, you mentioned going as part of a team to see patients in their own homes. How does your colleague handle this? does he do certain things to ensure his own safety (it is possible, although rare for people without history of mental illness related-violence to become agitated or even violent). How does one protect himself?

Penelope said...

If home therapy is offered to the client, and the client accepts, I see no problem at all. Especially in this case, as the client is bound to their home.

Anonymous said...

I share Retriever's view. I'd be self-conscious of the state of my house and yard in front of my psychiatrist.

I have told him that I have trouble (when depressed) cooking, cleaning, straightening and that I have difficulty with maintaining organization. I likely would have put off starting with psychiatrist indefinitely at the outset if the appointment had to be in my home. Also, when I started with my psychiatrist I was married and my husband was around the house, so I would have worried that my husband would overhear my session with the psychiatrist, perhaps enough to edit what I say to only things that I would be OK saying to my husband. There were plenty of things I have told my shrink that I never told my husband. Also talking about my relationship with my husband would have been more awkward with my husband lurking in the next room. I would have been whispering which limits expression.

Regarding my disorganization and cleanliness, I am positive I'd be like Retriever, staying up all night the night before the session trying to straighten, clean, vacuum, scrub kitchen, bathrooms, etc. Maybe that would be good for me, but sometimes I just can NOT do it and then I'd feel bad.

Then there's the social difference between me and my shrink. I know that he has had a professional colorist choose the colors in his rooms, had the kitchen and bathrooms remodeled recently, buys very expensive real art to decorate his home and antique oriental rugs, has expensive custom designed furniture and is extremely neat, well-organized and clean. I live in a 1958 house that has never had the bathrooms or kitchen redone, and my carpets are nearly 20 years old. Years of dog ownership has resulted in beaten-up flooring and walls, but the 2 dogs I currently have would instantly put mileage on brand new carpet and floors. I know that my home is not to the standards of his home nor the homes or his friends and that nice surroundings are important to him in his personal life. Even though he does not judge me in session, I would feel judged if he came here. I remember my psychiatrist telling me how awful the home of a friend is because the man has a room that's unused except for miscellaneous possessions, boxes, papers, etc. I have a room like that and I STILL can't control clutter in the rest of the house! Because my doc was so critical of that man, I never told him I have an unused room that's just storage. We don't have basements or attics in this part of the country and I just have too much stuff. I have lived here since 1981. It would take months of giving away and selling and throwing out to clear that room.

Then I'd worry if the chair for my shrink was comfortable enough, the lighting right, the seating arrangement proper for therapy. Yikes.

On the other hand, he'd find out things about me that he just does not understand now. I have explained that I have trouble with disorganization. He does not really understand the depths of the issue, though. He tends to discount it or ignore it. Maybe it is because he sees it as secondary, not the primary issue. It's a really big problem though. For example, he does not know that my flat-top ceramic stove and the counter on either side has had mail and paperwork on it for over a year. I keep trying to get through the paperwork and sometimes I get close, but essentially my kitchen is out of service because I am so disorganized. I should broach the subject perhaps, but I have told him I have trouble getting out of bed in the morning, have a hard time getting out of the house to go to work, etc so maybe he does get it. Still I do not want him here sitting with my clutter.

mysadalterego said...

I've done a few home visits, mostly on palliative care services. It was always really worthwhile. It used to be such a common thing in health care and for some reason has become an oddity.

It would be awkward for my shrink to do a home visit, but I'm sure it would open a lot of doors about things in my life that he never hears about, that I never would have thought to tell him. I think it's a good tradition, when I get out on my own, I hope to practice it more.

Anonymous said...

Many professionals do home visits if warranted. Pretty much it is only violating the person's boundaries when it is the cops busting down the door and the have the wrong address. Physicians sometimes do make house calls and certainly many psychiatrists work in multidisciplinary teams and go out on assessments. Public health nurses and home health care workers, social service agency "friendly volunteers", real estate agents, insurance agents, tutors, stockbrokers and don't forget vacuum cleaner sales people.
A mentally ill person with the potential to be violent,not to mention anyone who is just prone to violence without being mentally ill, can become so in any context. It is a false sense of security to think that the office setting is safer for the practitioner simply because they are on their own turf and know the lay of the land and where all the exits are.
Having said all that, take Charlton Heston with you and you will be fine.
Dirty houses---shrinks have those too.
Sometimes home visits are warranted. Sometimes, if there is no real reason the patient cannot be seen in the office, the shrink ought to be questioning their motives.

Catherine said...
This comment has been removed by the author.
Anonymous said...

As someone who has their life ruined by agoraphobia because I can not find a single psychiatrist to come to my house, I do not understand the comments about cleanliness of the home. I have bigger problems to worry about than if there is dust on the floor. I need someone to help me get my life back.
I am very sorry that my illness is "not convenient" for providers. Perhaps if I had a broken back, there would be an EMT available to ferry me to the ER. It is sad that mental illness is never seen as a REAL illness. Even by people who should know better.