In the first chapter of The Boy Who Was Raised as a Dog, author Dr. Perry is a newly minted therapist still working under supervision when he begins seeing a little girl named Tina. Dr. Perry writes about driving by Tina and her mom (and her little brother and another sibling who is still a baby) waiting in a bus shelter on a freezing Chicago night and feeling guilty because he doesn’t stop to give them a ride. He’s worried about boundaries because that’s something that we hear a lot about in therapy school (whatever the color — psychiatrist, psychologist or counselor) and he knows that if he gives the family a ride then his supervisors will not approve.

But the next time he not only gives them a ride but he stops at the grocery because Tina’s mom needed to grab some things. And then he helps them carry the bags into their run down one-bedroom apartment. He stands there by the table where he’s just put the grocery bags and he looks around and he understands Tina differently — he understands Tina better — because now he knows her life differently.

He tells his supervisor, feeling defensive and unsure, but the supervisor grins and says something like, “If only we could all visit our clients at home.”

Many of the community mental health agencies here in Central Ohio (and maybe out in the big, wider world) do visit clients at home. Homebased services are nothing new — social workers have been meeting their clients where they’re at since forever — but for counselors it’s still tricky. The counselor orientation tends to be about helping clients figure out what to do on their own while the social work orientation tends to be about helping clients do things whether they’ve figured it out or not (these are generalizations because social workers will work as counselors and counselors will sometimes work as case managers). When I was a case worker it was my job to say, “When you wake up tomorrow I want you to call Jobs & Family Services first thing and make an intake appointment then I want you to come here to get your bus ticket to head to the food closet.” But a counselor generally doesn’t give those kind of direct instructions, at least not when she’s being a counselor.

Counselors have it hammered into our heads that we need to watch for boundaries and transference and countertransference and building rapport without building dependence and so we debate about what’s appropriate and what’s not. Generally counselors aren’t supposed to visit their clients’ homes because that leads to a blurring to those sometimes already blurry boundaries but increasingly many of us do.

Right now the bulk of my case load is homebased and it’s true that my work with clients at home and my work with clients in my office is very different but I wouldn’t say one is better than the other. My clients who receive homebased care need homebased care, which looks a certain way and my clients who receive office care need office care, which looks another way. My homebased clients tend to more immediate needs and to younger children while my office based clients usually have room in their lives for a different kind of therapy. But these are generalizations and mostly it’s a matter of meeting with the client where they’re at (figuratively) no matter where you’re meeting them (literally).

When I started my internship I thought that I needed to come to every session with a general plan but now I see that it’s best to come to every session with curiosity. Even when we’ve established rapport and a treatment plan and I have a general idea of our direction, every session is a discovery and what I plan to do isn’t always what we need to do. I suppose with more experience I will have a better grasp of similar rhythms and will be better able to predict trajectories of growth but I like this feeling of wanting to know what happens next and trusting my clients to show me the way to helping them.

When I am with them at home this curiosity is even more vital because I never know what will be going on — if they will have their children with them and if the children will be tugging on me or if there will be a clear place to sit and focus or if my client will need to be doing something else while she talks to me. If I had a specific idea of how therapy ought to look, I might get frustrated. Some of the things I’ve learned about where to sit and how to sit and how to create a comforting space get lost when I am meeting a client at her kitchen table or even on the living room floor but then you realize that these things are important and nice to have but not vital. Sometimes all people need at that moment is someone who will be there and listen without urgency.

I’ll tell you, that’s been a bigger adjustment to me than building rapport in a stranger’s living room. My case worker training tends to sneak out and I find myself catching my client’s urgency. I want to give firm instructions and build a case plan. It would feel good (to me) to do that. But that’s not counseling and most of my client’s (although not all) have other people in their lives who will do that for them. Counseling involves more trust on my part than I expected. Counseling involves having faith in your training and then going with your gut because if you’re thinking too much about your training and your treatment plan you might forget how to listen to the person sitting in front of you.

When I was working on the treatment plan for my very first client I was floudering. I said to my supervisor, “But I just want to do a good job!” And my supervisor said, “But it’s not about you needing to do a good job; it’s about the client!” It took me awhile to undrstand what she meant; I wrestled with it and wrestled with it because I got into this business to help people so shouldn’t I want to help? But therapy is a tricky thing because if you want to help too hard then it becomes about your need to help and that’s a lot, as my supervisor said, to put on your client.

When I did case management it was my job to care whether or not people fulfilled their case plans. If Jane Doe didn’t make it to her Jobs & Family Services appointment then it changed the case plan and I was in charge of her case plan so of course I cared and so I did what I could to help her make it including doing the kinds of things a therapist would never do, which might be leveling consequences (at shelter it might be a rule violation) or putting her in the car and driving her there whether she wanted to go or not. With counseling it’s important not to attach emotionally to what Jane Doe does at all because a big part of what you’re doing is bearing witness to her decisions so that she can see them, too. It’s a kind of loving detatchment, which allows the therapist to simply be with the client.

Of course sometimes the lines do cross, especially with homebased clients because you are there in the life that is troubling them in a way you are simply not when they come visit you. Still, the orientation is different and sometimes I feel the case worker that I was rising up in me and trying to get me to help my client in a way that might hinder the specific counselor rapport that we’re building. Then I remember my supervisor telling me, “But it’s not about you needing to do a good job; it’s about the client!” and I set aside my need to be helpful, I stop and listen and I move forward trusting my training and trusting my orientation, and trusting my decisions will make big-picture sense whatever happens next.