EagleTribune.com, North Andover, MA

February 10, 2008

Home-based psychotherapy a growing field; violence extremely rare

By Courtney Paquette

The death of local psychotherapist Diruhi Mattian at the hands of her patient was very rare, and should not hinder the use of a growing approach to psychotherapy known as home-based care, according to doctors, psychology experts and those who work in the field.

Mattian was stabbed to death Wednesday night by her 19-year-old patient Thomas Belanger. The 53-year-old Wilmington woman went to the North Andover apartment Belanger lived in with his mother to take away a knife he said he was hiding. Mattian was afraid the 19-year-old might hurt himself or his younger sister. Belanger slit his own throat during the incident, but survived.

While Mattian's death was tragic, those interviewed said that in general, the benefits of home-based care for those with mental illnesses far outweigh the potential dangers. They said by working within a patient's natural surroundings — their homes, schools and churches — patients recognize themselves as members of their families and communities. In doing so, practitioners say, patients make steps toward living life as most people do.

"Despite the horrible thing that happened, we're in hundreds of homes every single week," said Skip Stuck, executive director of Family Continuity, the nonprofit mental health and social services agency that Mattian worked for.

"While Diruhi's death is an incredible tragedy, the reason why we have not had this happen before ... is because we go into homes as allies and advocates," he said.

That's what Mattian was trying to be for Thomas Belanger.

Home-based care a growing practice

Family Continuity, where Mattian worked for 10 years, provides home-based care for patients statewide. While its administrative offices are in Beverly, it has offices in Lawrence, Plymouth, Hyannis and Whittinsville, near Worcester. The agency is one of many contracted through the state Department of Mental Health to provide services in local communities.

Patients access the care Family Continuity provides in two ways. In about half of the cases, a patient, doctor or family member calls the agency directly to request care. In this case, the care is paid for through private insurance or out of pocket. The other half of patients are referred through, and paid for, by the state.

The state Department of Mental Health refused to provide information on how many people are treated, or any other information about community-based care for this story. Community-based care means a person is not admitted into an institution but has some sort of outpatient care in their community.

Stuck, the executive director at Family Continuity, said in the past year requests for home-based care from his agency have gone up 70 percent. Last year, the agency served about 5,000 families.

"What people are realizing, there's a variety of things you could be doing that help keep families together that don't require splitting them up," Stuck said.

Over the past 30 years, treatment for mental illness has moved away from institutionalization, according to Dr. Chris Gordon, medical director and vice president of clinical services at Advocates Inc., a nonprofit based in Framingham. Advocates Inc., like Family Continuity, provides a nexus of services designed to help people with mental illness live in their communities. Its supported-housing outreach program serves about 70 patients in 14 towns in the MetroWest area.

Gordon said community-based care has become more popular, and with it comes a rising appreciation that people want to be treated in their homes.

Prior to Wednesday, Belanger had been living in the North Andover apartment with his mother and sister, and he attended the Lighthouse School in North Chelmsford, a school for children with various disabilities. James Krasnoo of Andover, Belanger's attorney, said his client suffers from extreme bipolar disorder and has had several inpatient hospitalizations. His mental illness stems from physical and sexual abuse he suffered at the hands of his father from an early age, Krasnoo said.

By seeing people like Belanger in their natural environments, therapists get a much better understanding of what that person actually needs and prefers, and can connect the person to other appropriate resources within the community, Gordon said.

"There's been an increasing appreciation that people with all kinds of disabilities want to be treated whenever possible within their homes," Gordon said. "It's what people want."

In addition to intense therapy, home-based care workers provide a gamut of services. They help families with scheduling and organizing their bills. And they help families learn how to minimize stress, improve communication and learn how to better enjoy one's company. Their job is designed to be holistic, ultimately putting together the right resources to help their patients achieve optimum quality of life.

Those services aren't just delivered in their homes. Depending upon what patients need, therapists will work with them in schools, churches or other social settings.

"We really see our work as within the family," Stuck said. "We have high expectations that if we give them the help they need, we're going to succeed."

How safe is it?

Incidences of violence in these home settings are so rare, even the country's leading experts on dangerousness haven't studied the risks posed to therapists who treat patients in their homes.

John Monahan, a law professor at the University of Virginia School of Law, is considered one of the country's leading experts on dangerousness of people with mental illness. He said trying to figure out whether a patient is going to be a risk is extremely difficult.

"The research indicates that clinicians, using only their professional judgement, have not much better than chance," at predicting whether clients will commit violence, he said. "If no other reason than it's rare."

Gordon, from Advocates Inc., agreed.

"What happened up your way was extremely, extremely, extremely unusual and very, very rare," Gordon said. "We consider providing services to people in their home safe and effective."

Those who work in the home settings are among the most senior, well-trained clinicians in the field. Stuck said they hold doctorates or master's degrees. Mattian had a master's in social work in addition to more than a decade of experience at Family Continuity.

At Advocates Inc., the "front-line" therapists who make home visits are backed by a crisis intervention team of doctors, nurses and other psychologists and psychiatrists who can be called upon for help with a case, 24 hours a day, seven days a week.

Advocates Inc. also has a service known as the jail diversion program. One of the agency's outreach workers is imbedded in the Framingham Police Department so if there's an incident involving a person with a psychiatric illness, police respond with this clinician.

"We've gotten such great results, there's an effort to replicate this program statewide," Gordon said.

But these front-line clinicians need other qualities besides degrees, Stuck said.

His workers are flexible, he said, able to creatively seek solutions to challenges their patients face. They are also great listeners and have to be acutely attuned to other people's needs.

But above all, they are optimistic, Stuck said. They walk into every situation and case believing that they are not wasting their time, and that families and patients will respond.

"You make the assumption that there are weaknesses, but there's also got to be strengths," Stuck said. "What are you good at, what can you do well, where do you find your strength every day?"

These are the questions these therapists must help patients answer — and then turn that information into a solution for improving their quality of life.

"That, in a nutshell, is our philosophy," Stuck said.

No one, perhaps, embodies that philosophy more than the late Diruhi Mattian, he said.

"It does require a special kind of people," he said. "I know a lot of people who would make wonderful classroom teachers or wonderful librarians. This kind of work requires people who love just as much. Diruhi was one of the best examples of how great our staff is."