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Ask the Experts

Question:

What option does a parent have with a live-at-home son, who is separated from his wife and children, who does not want to take medication except lithium, cannot concentrate or work, is only comfortable in his parents' home and will not act upon the recommendation of professionals?

Answered by: Michael Grunebaum

Your situation sounds difficult. My initial response is to have many other questions such as: How long has this situation been going on? What was the reason for the marital separation? What other medication was recommended? What are the main reasons given for not being able to work (i.e. inability to concentrate/think? Fatigue? Depression? Anxiety? Alcohol or drug issues?)? What is it outside of your home that he can only be comfortable in the home? What have professionals recommended that he is not doing? Is he receiving any treatment other than lithium, such as counseling/psychotherapy or vocational rehabilitation services? What are his specific symptoms at the present time? What does he want going forward?

The answers to these questions, and many others, would be important to know, but nonetheless I’ll try to offer some thoughts. First of all, your situation sounds like one that lithium cannot fix all by itself, as you no doubt realize. In psychiatry, the “bio-psycho-social model” of illness is often useful for thinking about appropriate treatment. That is, the idea that mental illnesses have biological, psychological and social components, often points the way toward a treatment plan.

Medications, in this case lithium, are the biological part of the treatment. It sounds like additional medications have been recommended which your son refuses. Lithium is a mood stabilizer and is particularly good at preventing the manic symptoms of bipolar disorder, but probably less effective at preventing commonly associated symptoms such as depression, psychosis, and anxiety. Often additional medications are necessary to treat these other symptoms. It would be helpful to know why your son is refusing them: is he afraid of certain side effects? (perhaps other medications can be suggested that would not have those); does he have misconceptions about other medications, perhaps from unreliable internet sites? (accurate information could be provided).

In terms of the psychological components of your son’s condition, it seems from your description that he is not seeing a counselor or psychotherapist. It sounds like this could be an important addition to his treatment. This would get him out of the house - important in and of itself - and provide a safe place, hopefully, where he could talk about his problems and hopefully work towards some solutions. Research has shown that psychotherapy of various kinds adds additional benefit to medication in the treatment of bipolar illness. Aside from individual counseling, a consultation with a family therapist that would include your son, you and perhaps others in the household might also help to figure out a solution to the current situation where he seems to be “stuck” at home.

Finally, with regard to the “social” aspect of your son’s situation, it sounds like an evaluation of his capacity for work would be advisable. Programs such as New York’s VESID (Vocation and Educational Services for Individuals with Disabilities) could do a thorough evaluation of your son’s capacities for work and then could help him obtain appropriate assistance, training, education, or even a job. I have referred a number of patients to this free program and those who were motivated seemed to really benefit.

Which brings me to the last point – what does your son want? If you can identify what would motivate him, this might suggest a way forward. It often helps to start with what the patient wants and then identify what would be a sensible first step toward that goal. If all else fails, you might want to consult your family lawyer. Perhaps it would be within your rights to require that your son contribute to household expenses, and maybe this “tough love” would ultimately help him.