I work with mentally ill and dually diagnosed children and teens at a most-restrictive lockdown inpatient unit. I was in a particularly difficult group one day. The patients were arguing and I was basically setting down boundaries as quickly as I could speak. Out of the chaos, a voice emerged. I do not know how many times she said it, but a clear strong voice rose above the rest: “I’m sick of being sick and I’m sick of using.” Strangely, the group fell silent. She sat slumped in her chair, hair down covering her face, arms crossed.
I began meeting Shannon regularly. My rule with the patients was that I would meet with them for one one-hour session per week and they could request additional time. I am not sure what helped Shannon engage in treatment but I think that she genuinely was sick of street life. When she was a child, her parents moved to a trailer “out in the middle of nowhere”; she described how they smoked and injected meth all day. Towards evening, on a regular basis, her stepfather would like to blast heavy metal music and “kick the shit out of my mom. She would be too out of it to do anything about it.” Shannon described the horror of trying to soothe her younger brother on their bunk bed, while this was going on beneath them. This is when the running began. Shannon would run away from home frequently to get away from the violence. She said she wanted to “live with CPS.” Shannon’s father threatened to cut her throat if she continued talking that way. Father, it turns out, was not only beating mother but was sexually abusing Shannon. Shannon began trying to get Child Protective Services (CPS) involved by telling everyone she knew what was going on at home.
Eventually, Shannon, her younger brother, and her mother moved; mother decided she could not take the beatings anymore and Shannon was raising concerns about her father molesting her. Shannon expected things to get better—they did not. In fact, mother blamed Shannon for “breaking up the family by talking like that.” Mother began using more meth than before and began drinking heavily; she had to prostitute herself to get drugs, exposing the children to very dangerous people and situations. Eventually Shannon’s mother became pregnant and Shannon had a younger brother; she struggled to connect with him since she had already had an infant brother die. The reasons for the death remain a mystery: mother blamed father, father blamed mother. For some reason, no charges were filed against either parent and Shannon cannot (or will not let herself) remember many details. She simply woke up one morning and her brother was gone.
Shannon recalled suffering much abuse at the hands of her mother. On one occasion mother became inebriated, got in her car with the children and rammed it into telephone poles while screaming at them. She had multiple arrests and involuntary psychiatric hospitalizations and things continued to get worse as her drug use increased. Dad was either in jail or out with warrants; in any event, he had little contact with them. Mother became increasingly paranoid and suicidal, often beating Shannon and telling her that everything was her fault. When she was not blaming Shannon, she blamed herself and would make suicide attempts in front of the children. Shannon would intervene and mother would lash out at her. Shannon took the beatings because if mother were focused on her, then she would not try to kill herself or beat her younger brother.
Mother went to jail on drug charges and Shannon recalled that this was when she started smoking cigarettes, marijuana, and drinking. At this time, she was 11 years old. Father was never around so Shannon, being the oldest, took care of her younger siblings. Eventually, they were not able to keep up on rent, lost their apartment, and moved in with relatives. The relatives, also addicts, were seldom around. Father went to jail and Shannon was responsible for the household. CPS intervened and removed the children from the home, placing them in separate homes; they are not allowed to have contact with each other.
Shannon hated being in foster care and could not stand the lack of contact; she desperately wanted to live with her father and siblings. Over the course of the next five years Shannon ran away from every foster placement and group home given to her. She became increasingly involved with street life and was adopted by a street family. This street family (i.e. gang) convinced her to try meth. Shannon became addicted and continued using marijuana and alcohol. She hated herself for using meth because she had seen what it did to her mother; nonetheless, she was hooked. Concerning this time she said: “I lost my soul. I lost all morality and self-respect.” At one point, I had to make a CPS report when Shannon disclosed abuse occurring with one sibling who, for whatever reason, still resided with father. Shannon raged at me for this. My nickname was now “asshole”; in her mind, my actions were going to aid CPS’ intent to separate her family and increase the likelihood that father would harm her. She refused to speak to me and caused problems on the floor. My efforts to explain that CPS took it as an information-only call were useless. I had really damaged the relationship.
Instead of attempting to draw Shannon back into one-on-one therapy, I attempted to work with her and the other patients on the floor. I moved from a psychoanalytic emphasis upon frame to a more existential-phenomenological approach. I recalled R. D. Laing’s dictum that people stop acting insane when you stop treating them like they’re insane. I thought about how R. D. Laing worked with patients and wondered if I could bring a similar sensibility to the milieu; maybe I should just spend as much time with them on the floor as possible. I did not get rid of the one-on-one therapy, but it was drastically reduced.
At first the patients responded wildly; it felt like no amount of my time could satiate their need for attention. After a while, the frequent contact with me left most of them with little or nothing to talk about during the one-on-one sessions. The less available I was, the more anxious they became but simply being around them, being completely honest at all times, being calm, helped them feel contained. They were, for the most part, content. I knew I had wrecked the relationship with Shannon but decided I was just going to be a steady and kind presence with her on the floor. I was kind to her no matter what she did or said. She refused to eat food or drink water. I would quietly get her a bottle of water and place it in front of her. “I don’t want your f******g water asshole.” She would throw the water bottle and I would retrieve it, placing it again in front of her; I would then quietly leave. “I really care about you and your treatment” was my mantra with her. I meant it and I was unwavering in my belief that she was capable of completing treatment successfully.
While Shannon’s trust in me was growing, I knew that there would be a lot to weather before she was ready to leave. One day I followed a loud banging sound to find Shannon running and slamming her body against a door. She was hurting herself. I was surprised; I had thought things were going well in the therapy and I noticed that I was shaking a little. I struggled to find the right approach: I figured I could panic, call the police, attempt to find someone to help me restrain her or come up with something to say. I said, in a causal voice: “Hey, I was wondering if I could help you stop hurting yourself.” She did not stop. I did not change my casual comportment; I tried to stay calm thinking that laying down firm boundaries would only cause her to escalate. I noticed that the door had been left unlocked and that Shannon was too hysterical to notice. Then I said the first thing that came to mind: “Shannon, I can’t stand watching you hurt yourself.” She dropped to the floor and curled up in the corner. I approached her and was simply silent. She began sobbing; her voice deepened, the tears came, her nose ran, and her face was bright red. The words just flew out of my mouth: “You are going through withdrawals right now.” “What? That’s totally f*****d up Brent. You know I haven’t used in months.” She continued writhing and groaning. “No, you’re a runaholic.” She gave me a look of complete confusion. “You’re not getting your runahol, so you’re going through withdrawals.” Now she was completely perplexed. “You’ve run from your own home countless times and from every treatment center, foster home, and group home you’ve been in. You use running like you’re using a drug.” She still looked confused, but was calmer. I handed her some tissues. “This is the longest you’ve ever been in one place at one time, you don’t know how to handle it, and overall your treatment is going well. These are all firsts to you. It’s ridiculous to think that you should know how to handle these things, except to run. You’re dependent on running whenever you feel stressed.” She was now much calmer, wiped her eyes and I was surprised to hear her say with a laugh: “I remember that all of my paperwork ends with ‘she ran’.” After a few more minutes of digesting this idea, she left my office and returned to normal programming. Of course, she had to mutter “asshole” right before she left. Shannon continued making progress in treatment and graduated from the programme.
Outside of the obvious trauma, did Shannon have a mental health disorder? In my opinion, she did not. In my work with her there was no evidence of a mood disorder or attention deficit disorder, and I think anyone would be oppositional and defiant in her circumstances. Her drug use can be understood as a desperate response to survive in an unlivable situation. If anything, her life circumstances and the welfare system were more ill than she was; placing her in homes where she did not want to be and moving her through a host of professionals had established a serious barrier to my ability to serve her. Why should she listen to me? Shannon’s acting-out at times was simply her attempt to see if I would be present to her in a genuine way when she was done. As is typical, her perspective on things was not considered as she moved through the system. Shannon was shocked that I did not challenge her desire to return to her abusive family of origin or insist that she call father step-dad. Her biological father was completely absent so, qualitatively speaking, stepfather was dad. To challenge that belief would only have served to undermine further her felt experience of family and increased the likelihood of her lying to me. This is not to say that I would have recommended a return to the home; I simply let her have her belief and accepted that it was in fact of paramount importance to her. Why did she want to go back to that home? It perplexed me for it is counterintuitive to want to place oneself in a situation where harm has been done and is likely to continue. I thought about similar cases and it struck me: children and teens often want to be with whoever has been there the earliest and the longest. Shannon also bore much unconscious guilt over the breakup of the family and compensated by maintaining an idealized image of what it would be like to live there now: everything would be fine, nothing bad would happen. I would respond by attempting to awaken curiosity, not doubt: “I’m curious and I’m wondering if you’re curious about having a great time all the time with them.” She worked through that material. In the end she still wanted to return home but was able to afford a space where she could think about home in a less idealized fashion.
The destructive-addicted element of her mind may always remain a part of Shannon. Drugs and gangs are a part of the world and she will undoubtedly be tempted to relapse at some point. Also, she may discover that her past criminal history will limit future possibilities. The trauma she has endured will likely haunt her in various ways and it will take a lot more therapy to help her recover fully. I hope to have helped her understand that hope is possible, that trust is possible, and that relationships can help heal.
Brent Potter has a Ph.D. in Clinical Psychology from the Pacifica Graduate Institute and an M.A. in Psychology from Duquesne University. He has 16 years’ direct clinical experience and serves as the Director of the Society for Laingian Studies. He lives in Seattle, Washington where he works with children, adolescents, and adults in private practice. He also works with progressive programs treating homeless and other disadvantaged and vulnerable populations.