Home Office

(2007).
Psychoanalytic Psychology, 24:173-179

Brief Reports
Ethical Considerations of the Home Office
Karen J. Maroda, Ph.D., ABPP
The home office has a long tradition in psychoanalysis, based
somewhat on the mistaken belief that Freud actually practiced out
of his living quarters. The reality is that he practiced out of a
completely separate apartment across the hall. This article
examines the analyst's motivations for having a home office, as
well as the potential impact of having one on the analyst's patients
and own family. The home office is considered as fertile ground
for acting out by both analyst and patient, and the corresponding
ethical issues are discussed.
The home office has historically been part of the analytic tradition, perhaps
because so many clinicians have sought to emulate Freud, who practiced out
of his apartment in Vienna. Many American analysts in the fifties and sixties
went so far as to copy Freud's fainting couch, Oriental rugs, and African
artifacts, presumably in an attempt to pay homage to the Master and be
inspired to equal his achievements. The home office was never defended
because it didn't need to be. If it was good enough for Freud, then it was
certainly good enough for us.
But did Freud really have a home office? Bynner (1994) notes that office
psychiatry was a phenomenon of the late 19th century, when patients were
treated outside the asylum for the first time. There was no context for this type
of treatment and no physical setting for it to take place. The asylum was for
psychotics. It was not for the middle- and upper-class hysterics first treated
by Breuer and Freud. The modern office building, or any Victorian
equivalent, did not exist. It was up to Freud and his contemporaries to create
their own therapeutic environment.
Freud initially practiced out of his living quarters, but after an
explosion in the workshop of a clockmaker one floor down from Freud's
apartment led to its vacancy, Freud leased these rooms. In November 1896,
he opened his practice immediately underneath his private quarters (Scholz-
Strasser, 1998, p. 10). Freud's sister occupied the apartment across from his
living quarters. When she moved in 1908, he moved his office to this area and
occupied the entire floor of his apartment building. Even though there was a
door connecting the two apartments, Scholz-Strasser reports the spheres of
life were
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rigorously separated (p. 11), contradicting the popular notion that Freud
practiced out of the apartment he lived in.
During this period of time, it was the practice of shopkeepers and
merchants to live in apartments above their stores. Given that Freud moved
his office outside of his living quarters at the first available opportunity, it is
questionable whether or not he actually had the equivalent of today's home
office. (In the United States, independent practice physicians shifted their
offices from the home to office buildings between World Wars I and II,
because economic development created these office centers and an alternative
to home practice.)
Granted, some analytic clinicians in urban areas do as Freud did. They rent
two apartments and use one for living and one for working. But, most home
offices are not completely separate, ranging from home additions or carriage
houses with separate entrances, to rooms situated squarely in the analyst's
home. Home offices often do not have their own waiting areas, this space
being assigned to foyers, hallways, and even the analyst's living room. They
also rarely allow for patients to come and go without being seen by each
other, often passing each other at close proximity (particularly when analysts
schedule their patients back-to-back).
I realize that questioning the home office is not a popular position,
particularly within the analytic world, where it has become an entitlement.
The amount of defensive anger that this topic generates suggests that at least
some analysts with home offices feel guilty. Many of the analysts I have
spoken to informally say they could not afford a separate office, especially in
cities like New York and Boston, where office rents are quite high. Yet, other
professionals in these cities manage to arrange for office space. And many of
the analysts who claim that office space is unaffordable seem to enjoy an
affluent lifestyle. Clearly, affordable is a relative concept.
What has always struck me as particularly odd is that some analysts who
argue fiercely for the concept of neutrality and who view self-disclosure as
excessive and intrusive, do not hesitate to have their patients sitting in their
home, observing all manner of domestic activities, including sometime
glimpses of the analyst's family and friends. Most analysts with home offices
agree that these keyholes into the analyst's life are undesirable, but they also
admit that this is very difficult to control and happens with some frequency.
Certainly boundary crossings and violations that might occur in the home
office setting could also occur in an office building, and this has more to do
with the character of the analyst than the setting. And we all know of
therapists who have lost their way while practicing in an office building. Yet
there is such a thing as an optimal environmentone that is constant, private,
quiet, and emphasizes the professional nature of the relationship. All contexts
are not equally conducive to analytic work. Nor are all environments
conducive to maintaining the work ego considered essential to analytic
practice. Because we all struggle at times with maintaining the proper
boundaries, it seems reasonable to select an environment that does not blur
them at the outset.
My point is not that an independent office prevents boundary violations
and intrusions in the treatment, but rather that the home office creates a
situation where the patient is overstimulated by large amounts of personal
information. The critical variable here is that the home office offers up
personal information about the analyst's life that is not sought or controlled by
the patient and, worse still, is often not controlled by the analyst, either.
Unexpected guests, children returning from school, a service person, friend
or family member who arrives too late or too early, or a patient who has car
trouble, are all personal events that the analyst cannot always control. These
accidents combine with the patient's initial awareness of the analyst's
socioeconomic status, preferred style of living,
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make of car; the presence of children's toys or jungle gyms, and variety of
smells, all serve to flood the patient with images and information that may
well be overwhelming.
I have often thought about having a home office but have never done so. I
have been consulted by a number of patients who were in conflict with their
therapists, and I have been struck over the years by the frequency with which
personal information, often revealed through a home office, has had a
deleterious effect on the treatment. (As an aside, therapist couples who share
the same office space often stimulate the same issues as home office users.)
When I thought about having a home office, the reasons for it always came
down to my own convenience and the considerable financial savings
involved.
The people I polled informally for this article did not hesitate to admit that
these were the reasons for their decision to have a home office. But, they
usually quickly added that many patients had told them what a wonderful
experience it was to be seen in their homes. They also added that having a
home office made it easier to practice in the evening and on weekends, and
ultimately benefited their patients because it reduced their stress. I have no
doubt that most patients find the home office setting gratifying. It is precisely
the therapeutic value of that type of gratification that I am questioning. And I
do not agree that enabling the analyst to work later into the evening and on
weekends qualifies as a justification for this practice.
As I have reflected on the home office situation over the years, I have
wondered if clinicians who have home offices might not do so, not only for
the convenience and savings, but also out of a need to be known by their
patients. It seems to be a given these days that traditional analysis, as it was
portrayed in the literature, was not ever practiced in reality, in part because it
aspired to a degree of anonymity on the analyst's part that was both
impossible and undesirable to both parties. Isn't it more than a little ironic that
analysts who would refuse to answer any personal questions would have their
patients in their living rooms? Or let their patients see their children playing
in the yard with the nanny? Or let their patients see how rich or poor they
were? Perhaps the home office was actually a way for the analyst, hungry to
be known by his patients, to reveal himself.
Does the analyst practicing out of a home office have an unconscious need
to bring his patients into his personal life, perhaps to fill a void that exists
there? If so, relaxing the restrictions on self-disclosure will not necessarily
satisfy this need.
Another colleague I consulted on this issue wondered about the analyst's
need for admiration and envy. Is the home office another way to say, Look at
how nicely I live or, even worse, look at what I have that you do not. Are
analysts who struggle financially as likely to have home offices and reveal
this reality to their patients? How much do power and control figure into the
decision to have a home office?
Again, the counterargument revolves around how much is revealed in other
types of offices. I, myself, am a strong advocate of self-disclosure. Doesn't
that mean I would favor the home office for its self-revelatory features? No.
And my concerns about the home office fall in line with the guidelines I
provide for self-disclosure. That is, for the most part, self-disclosure should
be done at the patient's behest, so that he or she can be in control of when that
information is received. Yes, the transference is a moving train, but Oedipal
material, for instance, should arise when the patient is ready to face it, not
when he or she bumps into the analyst's spouse in the driveway. Patients
naturally want to know their analysts, but the timing and nature of the pursuit
of that knowledge varies enormously from patient to patient. An essential
ingredient in traumatic or destabilizing events is the element of control.
Patients instigate conversations about the analyst when they are
psychologically ready to deal with the reality of the analyst as a separate
person. The home
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office has the potential for forcing awareness about the analyst's life before
the patient is ready to know and process it.
The home office also delivers a double message. Inherent in the
professional relationship is the reality that patients cannot be a part of our
personal lives. That is why telling our patients too much about us can be
sadistic. I say this with the knowledge that maintaining the professional
boundaries in an ongoing, deep relationship can be quite a balancing act. But
having patients in the analyst's house certainly blurs this distinction between
personal and professional and is a potential tease for any patient who longs to
be a part of the analyst's life.
I spoke with a colleague, who at one time had a home office, but eventually
chose to practice solely out of an office building. Because he no longer
needed to defend his decision to have a home office, I considered him to be a
good person to interview on this topic. He readily admitted that he initially
wanted a home office for the convenience and savings. And he practiced out
of his home for several years. When I asked him why he decided to move into
an office building, he said his home office was a big dose of reality. He
described the intrusion of his family life into his work with patients, no matter
how hard he tried to prevent them. These intrusions included patients seeing
family photographs, voices and smells coming from the kitchen, and his young
son scratching on his locked office door trying to get his attention. He has a
lovely, large, expensive home in a wealthy neighborhood and admitted that he
would not have been as eager to allow his patients into a lesser home that
might have served to de-idealize him.
When I asked him how his patients responded to these intrusions, he said
that they clearly were affected by them, and some patients wanted to talk
about them. Many others refused to discuss the intrusion at all, even when they
were visibly upset. He interpreted this as a result of being overstimulated
and/or guilty about being upset by something that the therapist had not done
purposely.
He described other patients as reveling in the warmth and closeness of the
home environment, which I mentioned earlier as being seen as a benefit by
many who have a home office. But he said he perceived this as blurring the
personal and professional and often led to protracted fantasies about being a
real part of his life. In the end, he decided that the home office situation was
less than ideal both for him and for his patients.
An analyst friend of mine said he briefly practiced out of a home office but
discontinued it because he could not get comfortable having patients in his
home. Having practiced for many years in an office building, he said it never
felt right. The fact that clinicians who have always had home offices do not
feel this dissonance does not mean that there is not a difference in how people
work depending on the setting. This same analyst also told me of an instance
when a colleague of his, who was practicing in a home office, decided to
move out of state. The story goes that, for some unknown reason, the For
Sale sign went up on the lawn before her patients were told of her leaving.
The analyst did not notice that the sign had gone up, discovering it only when
her patients arrived in great distress.
By way of disclosure, I was treated in a home office by my analyst and can
vouch for the very warm feelings and gratification that I felt every time I
entered her home. During the time I was in analysis, which was from ages 31
to 36, it never occurred to me, similarly in the way it does not seem to occur
to many therapists, that there was anything negative about being seen in a
home office. If I was upset by something that happened, like a dirty look from
her adolescent son who resented patients coming to the house; or the smell of
dinner cooking; or hearing family members talking, I felt that it was my fault
for being so insecure. After all, having a home office was common practice.
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Unlike my colleagues' patients, I would usually mention my distress to my
analyst but rarely felt very satisfied in the outcome. What could she say when
I said her son looked so unhappy, and I felt both guilt about taking his mother
from him and also wondered why she had such a sullen child? I knew that my
feelings about this said a great deal about me, of course. But sometimes it was
hard to know when it was my issue or her reality. Pepper (2003) notes that
patients are often reluctant to discuss reactions to the analyst's personal life
revealed in the home office setting.
I have heard from several people who have home offices that they have
been intruded on at home by at least one patient, or even stalked. Do people
with home offices get more phone calls? Do their patients come to their
homes at times other than their allotted appointments? Do late-night
appointments in the analyst's home give the appearance of a date? I read a
detailed account of a treatment where the patient was quite regressed, with a
primitive erotic transference that the analyst described as very difficult to
manage. I met this analyst subsequently and asked about this case, only to
discover that the analyst had seen this patient in the analyst's living room. Was
this a factor in the patient's severe regression? Most analysts who practice at
home say that they screen patients to insure they are suitable for being treated
in a home office. But how does the analyst make this distinction? Unless the
patient has been hospitalized, how can anyone be sure of a person's likelihood
of malignant regression? And would the same degree of regression occur if
these patients had been treated outside of the analyst's home? Many people
who practice solely in a home office seem reluctant to discuss these issues,
waving them off with the rationalization that home offices are no different than
other offices.
In spite of my experience of being both overly gratified and frustrated by
the experience of being treated in a home office, it was not until years later,
when the aforementioned complaints came to my attention, that I began to
question the wisdom of anyone having a home office. In one of the few
references in the literature on the subject, Langs (1989) says
It is my impression that this setting has the potential for creating
complications and may generate discomfort and anxiety for the
therapist's family, causing them concern about meeting patients and
reacting properly; this is a particularly difficult matter for children
to handle, both in reality and fantasies. The personal setting also
creates some difficulties in analyzing transference resistances that
interfere with the progress of treatment. This is true because many
patients, particularly those who are borderline, will cling to the
real aspects of the situation rather than explore their underlying
fantasies, which they often keep secret. These patients frequently
attempt to make the therapist a person who will, in reality, offer
nonthera-peutic gratifications (see Chapter 20). Actually being in
the therapist's home may stimulate such fantasies and desires,
leading to serious obstacles for the therapy and problems that are
difficult to resolve. (pp. 43-44)
Langs' reference to the problems presented for the analyst's family
constitute another important home office issue. Most therapists who talk about
having a home office mention how difficult it is to keep young children out of
sight and sound, and it occurs to me that not only is there not enough attention
paid to the potential problems created for patients, but also the potential
problems for analysts and their families.
Pepper (2003) notes the burden placed on analyst's family to remain quiet
and/or invisible and the guilt that therapists often feel about this. He also
mentions that patients feel guilty about taking their therapists away from their
families. The colleague who mentioned to me that he had to constantly remind
his children not to play near his office window serves as an example of the
blurring of boundaries between professional and
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personal from the personal side. How does having a home office impact the
personal life of the analyst? How does it affect his or her marriage? And how
do children of analysts, who have no say, feel about this intrusion on their
freedom and having to share their parents with so many others? When I saw
my analyst's unhappy son, I felt bad for him. I immediately thought that I
would resent me, too. He should be able to talk to his own mother on a
Saturday morning and not have me, or any other patient, there to interfere.
Another worthwhile question is: Are therapists in home offices placing
themselves at greater risk for a patient complaint or lawsuit? I spoke to a
malpractice insurer who told me it was his opinion that therapists with home
offices were more vulnerable when complaints or lawsuits were filed against
them. He said to me, If you were are a judge or juror, faced with determining
whether or not a therapist had acted improperly, wouldn't you be affected by
the fact that the patient was seen in the therapist's home? I would be.
This does not mean that therapists with home offices are more likely to
commit boundary violations or act unprofessionally than their peers who
practice in office buildings. But might they be more likely to be punished by
the more disturbed patient that Langs describes who loses the distinction
between fantasy and reality and becomes enraged when further gratifications
are not forthcoming? And might a judge or juror be more inclined to believe
that something improper had occurred, simply because the patient was seen in
the therapist's home? Are patients more likely to stalk a therapist who
practices at home when the boundary between personal and professional does
not exist on the physical level?
I attempted to collect some data to see if there were any differences
between therapists who practice in home offices and those in office buildings
when it comes to complaints or lawsuits. I was amazed to discover that
virtually no one had explored this issue. In talking with malpractice carriers,
the APA ethics office, and the Department of Regulation and Licensing in my
own state, I found that no one asked where therapists practice, even when
there is a malpractice action. This article is the first step toward bringing this
issue to light and will be followed up by a research project aimed at
collecting data about boundary issues and office setting.
An APA ethics advisor I spoke with confirmed what common sense would
dictate. He said it was his impression after many years as an ethics consultant
that a more clearly demarcated home office presented less of a problem that
one that allowed, or even required, the patient to enter the household proper.
Therapists who have an addition put on their homes, or have a carriage house,
with a completely separate entrance and bathroom, seem less likely to have
problems than those who use a den, basement office, or living area, either as
the office or waiting room. Thus, any research that is done must distinguish
between the home office that is separate from the household as opposed to the
one that is situated within the analyst's actual living space.
Over the past 20 years we have been willing to question many aspects of
how we practiced and whether or not our methods were in the best interest of
our patients. As a result, we have concluded that the old authoritarian way of
interacting with patients was not helpful. In the spirit of continuing this
inquiry, I believe we need to further examine the impact of the office setting
on our patients. We have purported to be against any action that primarily
gratifies the analyst, particularly at the patient's expense. If we are to be
consistent, isn't it time to rethink the home office?
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References
Bynner, W. F. (1994). Science and the practice of medicine in the
nineteenth century. New York: Cambridge University Press.
Langs, R. (1989). The technique of psychoanalytic psychotherapy, volume
one. Northvale, NJ: Aronson.
Pepper, R. (2003). Be it ever so humble. Group, 27, 41-52.
Scholz-Strasser, I. (1998). Introduction and legends. In Sigmund Freud,
Vienna IX, Burgesses 19. (pp. 1-22). Austria: Universe Publishing.
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Article Citation [Who Cited This?]
Maroda, K.J. (2007). Ethical Considerations of the Home Office.
Psychoanal. Psychol., 24:173-179

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(2007).

Psychoanalytic Psychology, 24:173-179

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