There are, however, significant pitfalls to providing in-home psychological services. One of the most significant is the potential for boundary issues. When providing in-home psychotherapy, the relationship between client and clinician is inevitably different from that in a traditional office, hospital, or residential care setting (Knight, 1996). Role identification is one of the primary boundary issues. The older adult is likely to view the clinician as a friendly visitor, a home health aid or social worker, or a friend. The clinician may also observe levels of need and case management issues that make it difficult to maintain a psychotherapeutic role. For example, a lack of food or adequate housekeeping help may tempt the clinician to run errands, rather than empower the client to learn to access adequate services himself or herself. One means of resolving this is, as stated earlier, working closely with other community service providers.

Confidentiality may also present challenges during in-home psychotherapy. Well-meaning neighbors may ask the identity of the clinician and why he or she is visiting the client. One way to manage this is to describe oneself as a "worker" or a "visitor" and decline to provide more detail. Family members may be physically present in the home and may want to know what the clinician has been discussing with the client. Similar problems arise in nursing facilities when the client has a roommate (Spayd & Smyer, 1996). The clinician might suggest the family member take up the discussion with the client. The clinician also attempts to find privacy somewhere in the home to conduct psychotherapy.

Other pitfalls to providing in-home treatment include the impact on the professional. There is significantly more time involved in delivering this mode of service resulting in increased expense. The authors' clinic is fortunate to have the support of both private and public funding to cover this cost; however, there continue to be enormous unmet needs.

An additional issue for the clinician is personal trauma. It may be difficult to keep one's own boundaries clear in the midst of unmet needs. The client may live in an area that is high in crime or otherwise potentially less safe than the office setting. Good consultation and supervision can help with boundary issues, and good choices about the time of day that sessions are scheduled are useful in maintaining safety. Telephone sessions, as described above, are another strategy.

Specific Treatment Issues

Many treatment issues regarding older adults are similar whether psychotherapy is in the home or in another setting. Rapport and trust are built using active listening, nonjudgmental response, continued awareness of transference and counter­transference issues, and so on. One subtle difference may be an increased dependency and power differential in the relationship. While providing treatment in-home can be an instant rapport builder and can aid in overcoming obstacles, it may be difficult for a client to work through negative feelings about the clinician or the treatment because of the lack of alternate resources or be­cause the clinician is "going to so much extra trouble" by making a home visit. The clinician must take extra care to evaluate with the client his or her needs in treatment.

Modes of treatment are also essentially the same as in other settings. This is important to note mainly because one might be tempted to think that there is something different therapeutically to providing in-home services. Dynamically oriented treatments, including life-review, relational, and psychoanalytic or psychodynamic treatments, can be conducted successfully. Transference and counter transference may take unique forms, for example the client may see one as a daughter rather than a mother figure; nonetheless interpretation is still valuable and useful. Cognitively and behaviorally oriented treatment is also useful. For a homebound older adult with physical and psychological impairments, this treatment might dictate a slower pace (Gallagher-Thompson & Thompson, 1996). Family systems work is also of value, and may be best conducted in the home where members of the system are comfortable and available. There may also be a unique set of system members. For example, a professional care provider may be an integral part of the family system. One potential pitfall to this in-home systems work that should be avoided is losing sight of the older adult's needs, and focusing solely on what may be compelling caregiver issues.

Case coordination may also become a larger treatment issue when doing in-home psychotherapy. As discussed earlier, liaisons with other care providers and community gatekeepers are often important and useful but may increase demands for the clinician's time.

In summary, there are many issues that impact an older adult's access to mental health services. Physical conditions can make it difficult to get to a clinician's office, finances and insurance benefits may be problematic, and the psychological constructs of today's older adult cohort often reject the concept of mental health services.

Strategies for overcoming the above access barriers include community outreach and work with other community gatekeepers such as social workers, physicians, home health workers, and so on. Education, good rapport-building, the use of cohort-appropriate terminology, and progressive informed consent are also useful. Telephone sessions, psycho-educational support groups, and in­home psychotherapy are additional ways to overcome obstacles. There are unique opportunities and pitfalls in providing any of these alternative psychological services. The authors have found, however, that treatment can be conducted in a variety of modalities and with significant positive outcomes for the older adult.

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