A Difficult Case

While I do not read “Dear Abby”, the advice column, very often an entry from July 12^th caught my eye:

“DEAR ABBY: I am the single mom of a 19-year-old daughter who copes with bipolar 2, ADHD, anxiety and depression. She has a mental age that’s younger than her adult self. Over the years, she has gone through therapy and changes in medication.

It has been recommended that my daughter attend a residential therapy program, but she refuses. Since finishing high school, she has refused everything: college classes, job applications, exploring other therapies or taking any small steps toward independence in the future. Her goals now center around socializing and smoking marijuana with a few friends. She rarely leaves her room except when they call. There are days I doubt she’s med compliant or wants the help others try to give.

It’s heartbreaking watching her being “stuck,” but I am also tired of being held hostage to her behavior and actions. Many days I want to pack up her stuff and tell myself she’ll figure things out. (I would continue to be here when she needs me.) Is this fair given her mental health challenges? Because she is at risk, I feel like anything I do is wrong. -- BURNED-OUT MOM IN COLORADO”

As a practicing psychiatrist, I deal with situations like this all the time. Of course, we are only hearing the parent’s side of the story in this vignette. We do not know what transpired in the daughter’s early life. Was there abuse or neglect? Even if there was, this might make us less sympathetic to the mother but it does not help us figure out what to do. Looking at a situation like this people might retreat into predictable corners:

• “Tough love”. Some might say the mother needs to lay down the law, give her daughter a deadline and kick her out of the house if she does not get a job or get into treatment. There are two practicable problems with this approach even if we leave aside any moral issues. First, It is actually increasingly difficult to remove an adult child from one’s home. In the eyes of the law, once an adult (anyone 18 or older) establishes your home as their primary residence they acquire legal occupancy rights. Even if there is no written lease and they have never paid a dime in rent, the law generally classifies them as a tenant at will. Because of this, the parents must go through the formal legal system to remove them. This is expensive, time consuming and emotionally exhausting. They cannot be committed to a psychiatric hospital unless they meet criteria for danger to self or others (see Part III of my “Rethinking deinstitutionalization” series, due out in early August). Secondly, even if such an approach succeeded, what then? Suppose the daughter ended up at homeless shelter and said she will kill herself? Now she enters the revolving door mental health system of short-term hospital stays and then out of the street. With luck, she might connect with a system that sets her up in housing and helps her find a job, but the odds of this are low. A lot depends on the nature of her mental illness as to whether she will be able to work at a job that provides stability.

• “Empathy” Others might see the daughter as the victim, likely having experienced some trauma. Therefore, we cannot expect her to work or go to school. She is self-medicating with marijuana and anyway what’s wrong with that? Society should provide her with disability payments or other guaranteed income. With therapy, maybe she will get better, but we can’t force her to go. Anyway, until our society is more just, there will be people like this. Would this approach really help her in the long run?

As clinicians, our approaches have to fall in between these extremes, of course. If the mother came to me I would clearly explore early issues of trauma or family strees that might have contributed to this. I would NOT tell her to try to evict her daughter but advise her to take away the incentives maintaining the daughter’s dysfunctional behavior. Stop paying for her smartphone, not doing her wash for her, requiring her to eat only at dinner table and not in her room and of course not giving her any money for her outside activities. I would reassess her medications and work to get her in therapy. Unfortunately, the chances of success would be limited, based on experience.

Our mental health system is so overwhelmed with serious mentally ill person with schizophrenia and bipolar it scarcely has the capacity to deal with problems like this daughter. There are probably millions of such people whose quality of life is poor and who need interventions that will lead them to independence. Understanding the genesis and treatment of personality disorders may need to have a greater research focus in mental health. A deeper question is how much each individual owes society vs. what society owes the individual.