Psychotherapy at Home: “The couch is at the patient’s home”

Isabelle Uny Isabelle Uny

Isabelle Uny, who works as a psychoanalyst in Geneva, provides therapy sessions at home for the elderly. The unusual setting invites questions about this therapeutic practice. 

It’s 4.00 p.m. Isabelle Uny is leaving her practice in the Plainpalais district of Geneva and is heading towards the nearest bus stop. She would have cycled had the weather been better. Her working day is still not over. The particular nature of her job takes her outside of her practice. Since last autumn, the psychoanalyst has been running sessions for the elderly in the living rooms of their own homes. Several times a week she leaves her usual therapeutic environment to help the elderly who would not otherwise have access to this kind of treatment. This innovative approach – which meets a requirement for many elderly people – is also encouraging the (re)assessment of psychotherapeutic practice.

The idea for the initiative was conceived in the practice of the psychotherapists Isabelle Uny and Jean-Christophe Bétrisey, and the psychiatrist Jean Sarazin, who have worked together in Geneva for 12 years. “Our aim is to visit patients, make ourselves mobile and get out of the practice,” remarked the psychotherapist who previously spent several years working with the elderly in care homes. “Old people face various issues, such as loneliness, bereavement and health problems. Various structures are in place to help them to deal with physical decline but little emphasis is placed on the psychological suffering that sometimes comes with this.” Based on this premise, the psychotherapists are developing a new home-visit therapy service called “Ecoutadom”. It was launched in autumn 2015 and is aimed at both elderly people living at home but also those in retirement homes or hospital.

Reversed perspective

After having arranged an initial consultation by telephone, Isabelle Uny is visiting her patient aware that the session will take place in a very different environment to her practice. If the initial request is made by the patient, the therapist takes the unusual step of going to visit them. “The couch is at the patient’s home and not the other way around,” she pointed out. Some people get a suitable area ready for the consultation. Others are caught by surprise when the therapist enters their home, realising that they have to sit down somewhere. There is a great deal of improvisation during the first meeting, but a routine starts to form after the second time. A relationship of trust is built. The therapist’s visit is expected. The place where the consultation takes place – which is always the same – is ready. Isabelle Uny is even offered a coffee or a glass of water. This is how the therapeutic setting for intimate discussion is created. “In my practice, I always try to imagine the world in which the person visiting me lives. Sessions in the home mean I see it for myself. I adopt a different tack and my work is perhaps done more quickly.” The photos hung on the wall, the living room decor and the furnishings of the rooms – a person’s home reveals lots of information. “However, nobody should feel judged by us and we must be careful not to be too intrusive. Looking at mess once too often is quickly interpreted,” revealed the psychotherapist.

An attentive ear

The social network of the elderly dwindles over the years. Some find it hard to give meaning to their lives. Others are unable to express their sadness. The Ecoutadom psychotherapists therefore try to help the elderly to enrich their daily lives and to boost their self-esteem. “We are there to listen and to help them come to terms with their decline and to accept that they need to ask for help.” 

People sometimes feel that they are at the end of their lives, exhausted or simply want to die. In such circumstances, the psychotherapist tries to support them during these final moments, to shed light on things, to prepare them for death, to add substance to their thoughts or to ease their anxieties. Having studied psychoanalysis at the Charles Baudouin Institute in Geneva, Isabelle Uny believes she has found a good way of putting the theories of the establishment’s founder into practice through her home-visit psychotherapy programme. In his “psychagogy”, Charles Baudouin bases his methodology on three levels, depending upon the degree of involvement of the sub-consciousness. Three different methods are adopted depending on the case – educational methods (conscious realisation of an idea previously aware of), suggestive methods (subconscious realisation of an idea previously aware of) and psychoanalytical methods (subconscious realisation of an idea previously unaware of). “When conducting sessions in the home, I focus on the various levels by reflecting on what is happening in the present, in the body and in the person as a whole.”

The limitations of the environment

In spite of everything, Isabelle Uny is the first to say that this type of setting can be “destabilising”, at least initially. The psychotherapist recalls a discussion that moved towards the subject of religion. The patient asked her: “Do you have faith?” Faced with this question, which the patient would probably never have asked had she not been at home, Isabelle Uny had to think on her feet. “Such questions continually test the boundaries of the setting. As a therapist, I have to consider whether my response will help the person or support them on their path. I only answer if there is a therapeutic objective,” she observed. In her practice, the psychotherapist never reveals any personal details. Outside of her comfort zone, she always has to tread carefully, reflect on her internal mind-set and avoid stepping beyond the boundaries. This is why peer evaluation and supervision is so important. Constantly reviewing their practices, the Ecoutadom therapists frequently discuss new situations which they have been faced with and assess the best options. “We don’t rely on past achievement. Our profession is extremely demanding and we continually have to revaluate what we do and demonstrate creativity.” 

Despite taking this “risk”, Isabelle Uny does not feel marginalized when practising psychotherapy in the home. She firmly believes that her technique is beneficial and often sees marked progress in the patients she visits regularly. “Over the course of the sessions, I notice, for instance, that some patients become more mobile. They take the time to dress smartly, do their hair up or even put on make-up. They rediscover their self-belief and may even soon be able to go out again.” 

Isabelle Uny now sees almost a quarter of her patients at home. The figure is even higher for her colleague Jean-Christophe Bétrisey. Only visiting patients at home would become too complicated due to work schedules and for logistical reasons, but the psychotherapists from Ecoutadom are planning to expand their service. Passionate about this field of work they are opening up, they endeavour to raise awareness of their services amongst the general public, elderly care networks and colleagues who they encourage to set up similar initiatives.  

Name: Isabelle Uny
Profession: Psychologist specialised in psychotherapy (Swiss Federation of Psychology), trained at the Charles Baudouin Institute of Psychoanalysis and Psychotherapy
Areas of expertise: Creating a welcoming and caring atmosphere, adaptability, ability to think on your feet, creativity