Serious Mental Illness & Addiction—Help!

Allies' member chris has been told it would be immoral to ask her son, alcohol-dependent and experiencing psychotic symptoms, to leave the house.

"I have a question about substance abuse and mental illness. My son is an alcoholic and is in psychosis. He has been this way for a number of years and has been to numerous programs and is always back in the house almost immediately. I am told kicking him out in any way would be unethical and immoral. His psychosis and substance abuse issues are completely co-mingled. Would you have any advice on the mentally ill and substance abuse?"

As the respondent already mentioned, the rates of co-morbidity of both substance use disorder and mental illness are very high. When you say psychosis, it suggests to me that your son perhaps has a serious mental illness, the definition of which has evolved, but that basically includes disorders that produce psychotic symptoms, such as schizophrenia and schizoaffective disorder, and severe forms of other disorders, such as major depression and bipolar disorder (www.bhevolution.org/public/severe_mental_illness.page).

These disorders can definitely complicate treatment and recovery. In an ideal situation, your son would be treated in an integrated program with an integrated team (psychiatrist, psychologist, substance abuse therapist—or some derivative of these three roles—along with a case manager/social worker to help with aftercare planning). Team members would meet regularly to go over your son’s care and progress.

The reality, however, is that this rarely happens. Busy clinics have limited psychiatric care and sitting in case meetings is poorly reimbursed. In the programs I’ve evaluated over my 24 years doing this work, I can count on one hand the times psychiatry of any sort was in a case meeting. And if they were present, it was because the program was a mental health program first and had grant monies to pay for the time spent in team meetings. With psychiatry in the room, the conversation narrows to include medications and therapeutic attendance. How substance abuse can complicate the behavior a psychiatrist is trying to treat is hard to disentangle. It takes people who are dually trained and experienced. Psychiatrists are in very short supply, even more so in busy public or insurance-based clinics. The chances are rather good that your son has not received much truly integrated dual-diagnosis programming.

Your son goes to a treatment program and then immediately returns to your home. Does he follow up with community-based treatment? Is he followed by a psychiatrist? There is much on this site about allowing your Loved One to live in your home. Your home is a reward, a huge reward, that gets awarded when a Loved One is trying to get and stay healthy by working a program of recovery. See the topic "home as a reward" to review our ideas on how to address having your Loved One live with you.

If your son is so seriously mentally ill that his problems with daily living make it impossible for him to live independently, then it would be worth talking to the Department of Mental Health. I had a parent who recently looked into this for her son. Here are her notes from the conversation she had. I specifically suggested she ask about DPH assigning her son a case manager, which is someone that helps the Loved One navigate the mental health system.

I recently talked to a supervisor at the Department of Mental Health for our local counties (MA), and here's what I found out.

1) Fill out the application available online.  https://www.mass.gov/dmh-application-forms

2) Application is assigned an eligibility specialist.

3) Criteria reviewed, and while this is general and not absolute, sounds like we need to meet this criteria:

– have a diagnosis that fits the criteria for eligibility

– involved in outpatient mental health, currently or previously

– must have had inpatient psychiatric stay, currently or previously

4) If we fit all criteria, application goes to a Needs and Meet department to do a formal in-person assessment.

5) If accepted, meet with team and recommendations are made with referrals for service. If denied, recommendations are made to applicant.

6) Typically a 90-day period for the application to be processed.

The person I spoke to stated that addiction does not qualify for mental health. If the court-ordered counseling is for addiction, then it does not count for outpatient mental health. If symptoms are related to addiction, as opposed to mental health, then criteria are not met. I specifically asked about being assigned a case manager, and that has its own qualifications to meet.

The DPH system has supportive homes and a larger system of care than for those with substance problems. Let us know if you are able to tackle this and what you learn from trying.

Our best wishes for you and your son.