When Care Is Stretched: Why Psychosis Must Remain a Health Issue

Over the past few days Shine has heard from people with lived and living experience of mental illness who were deeply affected by the recent RTÉ Investigates programmes. In particular, we were contacted by older parents, especially mothers, of adult children who have experienced psychotic episodes.

The diagnosis may be psychosis, schizophrenia, schizoaffective disorder or bipolar disorder with a psychotic component. The label differs, but the emotional reality is consistent. Families are worried and under sustained stress. They are often trying to hold things together for someone they love in circumstances that are often unpredictable.

Currently there is a consistency in what many are being told, particularly where there are behavioural risks or a co-occurring addiction. Parents describe being told that there are no further services available. That they may need to consider seeking a legal order to protect themselves from their adult child.

We need to be clear about something. This is not about families failing. It is not about clinicians not caring. Community mental health professionals are deeply committed and carry significant responsibility. What we are seeing is the reality of working in a changed society, with more complex and layered presentations, within a system that has experienced sustained underinvestment over decades.

The context today is fundamentally different from a generation ago. We are seeing more dual diagnosis, greater interaction between addiction and psychosis, increased housing instability, social isolation and cumulative trauma. Needs are more complex and often intersect across health, housing, justice and social protection systems. The picture is less linear and risk profiles are more dynamic. Recovery pathways require longer time horizons.

At the same time, community mental health services have been expected to absorb this complexity without proportional growth in workforce capacity, specialist expertise or integrated pathways of care. The gap between need and provision has widened. That gap is structural rather than individual.

Families are often holding risk over prolonged periods. They are navigating crises, advocating for support and trying to sustain relationships while protecting their own safety and wellbeing. That carries emotional, financial and psychological consequences that are rarely acknowledged in policy terms.

Clinicians are often managing high caseloads and increasingly complex presentations. They are making decisions within governance frameworks that emphasise safety and accountability, often without the multidisciplinary depth or community supports required to deliver fully integrated care. Managers and policymakers are balancing demand across competing priorities in a system still transitioning towards a Sláintecare model of integrated, community-based services. Even the justice system is being drawn into situations that originate in health and social care need.

Everyone is trying to act responsibly. But everyone is operating within constrained capacity. The question we need to ask is what happens when those constraints begin to shape our expectations of what mental health services can hold?

Under the Mental Health Act a person is considered treatable when they pose a risk to themselves or to others. That principle reflects a recognition that severe mental illness can impair judgement and insight in ways that require therapeutic intervention. When families are advised to consider legal remedies in response to behaviour linked to psychosis, it is rarely because that is considered best practice. It reflects the limits of available pathways at a particular moment in time.

Over time, however, legal responses can begin to feel like the only route left. Responsibility can gradually shift away from health services and onto families and the courts. When that shift becomes normalised, it signals a drift away from a recovery-oriented and health-led model of care.

Psychosis recovery is often uneven and requires sustained engagement. Behavioural complexity or co-occurring addiction should not inadvertently displace mental illness from the health system into parallel systems that are not designed to provide clinical care.

Shine is the Schizophrenia Association of Ireland. We were founded in 1979 by families who believed that people experiencing schizophrenia and related mental illness deserved structured, compassionate and specialist support. That foundation remains relevant. It reminds us that progress in mental health requires deliberate system design, not assumption. Over decades we have seen what is possible when services are coordinated, person-centred and recovery-focused. We have also seen what happens when pathways fragment and responsibility becomes diffuse.  

Speaking up about this is not about apportioning blame. It is about recognising that a more complex society requires a more integrated and adequately resourced response.

If we are serious about delivering on national mental health reform, the shift required is not only financial. It is structural and cultural.

First, services must be configured for complexity. Dual diagnosis and intersecting needs should be addressed through integrated care pathways rather than parallel silos. Joined-up responses across mental health, addiction, housing and social care must be embedded as standard practice.

Second, we need sustainable workforce capacity that allows for continuity of care. Recovery-oriented practice requires time, relational depth and collaboration. Without manageable caseloads and specialist input, the aspiration of person-centred care cannot be fully realised.

Third, responsibility must be shared appropriately across systems. Families should be recognised as partners in care and supported accordingly. Community organisations should enhance, not replace, statutory provision. The justice system should remain a last resort rather than an alternative pathway for unmet health need.

These shifts align with the direction already set out in national reform. The challenge is implementation at scale and pace.

Everyone wants safety. Everyone wants stability. The question is whether we are prepared to align policy intent with operational reality in a society where needs are more complex and more visible than ever before.

Shine will continue to advocate for responses that are compassionate, recovery-focused and grounded in rights. Care should not narrow as complexity increases. It should become more integrated, more accountable and more resilient.

People living with psychosis deserve that. Their families deserve that. And the professionals working within our services deserve a system designed to meet the scale of today’s challenge.

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If you are affected by psychosis, or supporting someone who is, Shine is here to help.

Phone: 01 860 1610

Mobile: 086 040 7701

Email: support@shine.ie

Website: https://www.shine.ie

‍If you are in immediate distress, concerned about safety or need urgent help for a mental health issue:
Call 112 or 999 if emergency action is required (you or someone you know is about to harm themselves or someone else)
or
Call The Samaritans on Freephone 116 123  for 24-hour confidential, non-judgemental support, or email jo@smaritans.ie
or
Text About It. This is a free, 24/7 service. Free-text HELLO to 50808 for an anonymous chat with a trained volunteer, any time.