ONE WHITE MALE, REMOVED

THE DUALLY DIAGNOSED - patients or criminals?
Even the patient who goes into a psychiatric unit substance free runs the risk of leaving it addicted to alcohol or drugs or both.
What often happens is this: during a hospital visit the User tells his Carer that he is economising and is going to roll his own cigarettes. The Carer is pleased by this sign of responsibility on his part and goes out to buy his loose tobacco and Rizla papers (she does not realize that the tobacco is going to be mixed with cannabis). She is mystified when he urges her to leave early because he is worried about her going home alone after dark, but touched by his concern.

During the next hospital visit, a nurse tells her that her User is now psychotic, that he has seen a devil on the ward and that his medication has been put up. The Carer does not realize that he is now taking two toxic substances, one legal, the other illegal.

At the end of his hospital stay, the User is urged to become independent and is packed off to a hostel among other Users
taking drink and/or street drugs so that his substance use is powerfully reinforced. He then makes a rake's progress through
various hostels, ending up in the grimmest possible accommodation because by now he cannot be housed anywhere else.
He has become known to drug dealers, is haunted by them, terrified of them. His money is extorted from him. He continues to drink, partly because alcohol provides a quicker fix to mental health symptoms than medication. (Anyway, most people would prefer a pint of beer to a capsule of Risperidone.) His non-drinking friends fade away. He sometimes lives on the streets.

The User becomes psychotic but is not admitted to hospital because he is being cared for in the community, and he has in fact a list of out-patient appointments which he rarely keeps. His Carer makes an appointment at the CNWL Trust to ask about lack of in-patient treatment for him. The man at the Trust screws up his eyes as he reads her carefully-prepared notes:
he obviously needs reading glasses and is literally blind to her concerns.
"Why can't my son be treated in hospital?" the Carer asks. "He is mentally ill as well as alcoholic - he has dual diagnosis".
"It is government policy. Funding is directed towards care in the community - the Crisis Team, Outreach Workers, etc. The beds have been cut."
"Does the policy work?"
"I don't know" A half smile and a shrug. "I tell you what, why don't you try counselling?"

The Carer finds a counsellor. He recommends that she should lead her own life, get some hobbies and let her son hit rock bottom. "Let him drink, take drugs, get into debt, go on the street. What are your hobbies?"
"Well, swimming."
"Swimming, good." He writes it on the board. "What else?"
"Well, I used to do yoga but I hurt my shoulder."
"Yoga." He writes on the board. "What else?"
"I don't really enjoy hobbies, I feel too worried the whole time. What if my son hits rock bottom and dies?"
A half smile and a shrug.

The User leaves the hostel and comes home to Mother, swearing that he will never drink again. Together he and his carer draw up a plan: she will provide all his needs but not give him money, he will not have a latchkey, he will do his share of the housework. She tells him that if he gets aggressively drunk, he can't come into the house; if he is already there, and drinking, she will turn him out, even if she has to call the police.

For some weeks the user's health improves dramatically, the carer feels that they are mother and son again rather than carer and user. However, she assesses his state when she lets him in at the door, ready to slam it shut again. One afternoon the mother comes home carrying the fatted calf, in the form of a cake, and looking forward to tea when she hears a commotion coming from her house. ("Dear God, I don't mind too much about the furniture but please don't let there be a fire. How did he get the money?"). When she gets in, she eventually calls the Police.

Until recently being arrested involved a night in the 'accommodation suite', a mild reprimand and a cooked breakfast. But this time the police escort him out of the house and leave him in the street, frightened and frightening."
"Aren't you going to arrest him?"
"No, you wanted him removed, did'nt you?" The policewoman talks into her walkie-talkie: "One white male, removed."
Two hours later the carer rings up the police and asks them to find her son and send him back, but by then he has been arrested in another borough. He is taken to court and fined.

The alternative to calling the police in this situation is to take your ill and drunk user to the psychiatric unit where he is not admitted because he can't be assessed while drunk. While the carer is pointing out that he is also mentally ill, the user disappears. "He walked out, we can't detain him against his will." It is now 2.30 am. The carer runs round the nearby streets looking for him and eventually returns to the psychiatric unit and finds him there again. She is skilful at finding taxis in the small hours and persuading their drivers to take drunk men, so she and her user return home again, exhausted.

The next day the carer is so saturated with tiredness that she would do anything for some sleep. When she spends a day in bed, her user is distraught: he is afraid to see her looking ill in case there is no-one to look after him. She does not know what to do: if she continues to call the police when he gets aggressively drunk, she is afraid that he will be taken to court again and again and eventually sent to prison. As the professionals keep telling her that there are drugs everywhere, even in prison, she does not feel that prison will be redemptive. Her need for self preservation has wiped out her maternal instincts.

In any case, mental health workers do not seem to approve of parental love. It is seen as "over-involvement". even though it is age-old. The father of the prodigal son did not say "You made your own choice, you wasted your benefit in riotous living, I have my own life to lead, I have my hobbies." He said,

"For this my son was dead, and is alive again; he was lost, and is found." Barbara Robb