Abstract: In this paper, I am going to recount some interactions with a youth I have named Cheryl J., who had been ejected or prematurely discharged from numerous treatment programs before being placed in mine. I believe Cheryl has many of the characteristics and behaviours of adolescents labelled hard to serve. She developed a reputation in the Children's Services system (Ontario) as being untreatable, as were her own parents. I want to describe from our interactions, how I tried to understand her behaviour, her thinking and emotional responses. I look at how she conveys the meaning of her knowledge. In every way, Cheryl typifies the type of youth who should be in treatment.
In order to understand the impact of milieu therapy, I believe the question to be addressed is how does the youth in treatment process intellectually, socially, emotionally, etc.? This is no easy task! I believe the process of trying to understand residential treatment means to assess the impact the milieu has upon each youngster’s preconceived notions, his/her philosophies, his/ her abilities to abstract and to conceive. This means, how do the day’s events or expectations (such as daily activities, treatment planning and intervention techniques) come together and create meaning for the youngster? Thus, it is with these considerations in mind that I hope to demonstrate how a youth-staff relationship is established through communication and how the dialogue that follows assists the youth in dealing with the conflicts and pressures of the milieu.
How does therapy work?
1. For the staff?
In an interactive process such as milieu therapy, the youth worker is required to be aware of and able to identify in his/her actions the influence of the social organization on him/herself and the youngsters who come into contact with him/her. In the staff interactions, staff should become aware of the impact of an organization's expectations upon its members and their social relations. In other words, they should understand how each staff could and should participate in a set of social interactions within an organization in order to analyze the mechanics of the organization. Staff need to understand and then to apply their knowledge of how various socially organized practices impact upon social relations. This means visualizing their real-life experiences with this type of practice. There is the realization that a large part of this methodology is a reflection upon their own processing of information and how they come to understand their interpretations of the milieu process and the needs of the youngsters in treatment.
This may mean that staff may know what to do mechanically but not know how they have gained their knowledge. They have at least acquired some confidence about the ideas they have collected. In essence, they know the basis of this approach is to understand themselves in relation to others in a socially mediated context and how this appears to them in their reflective thought. Thus, they use existential reflection to give meaning and depth to their discourse. In a somewhat circular fashion, discourse becomes the foundation for their understanding.
Staff will begin to realize, for example, in their jobs, the way in which their use of language is influenced by what their expectations are and how they negotiate their interpersonal relationships. Staff expectations can invariably create uncertainties within the work place because child care work calls upon the worker to be reflective and self-referencing (to ensure empathy), as well as to be the one who sets the rules.
In order to clarify the task at hand for the youth worker, I will describe a communicative relationship between myself and a client, Cheryl J. I believe we established a communicative relationship through reflective understand ing and existential knowledge. From our experiences, Cheryl and I brought meaning to our relationship. We shared the moments of experiencing the knowledge we gained through reflective thought.
Meaning is centred on the dialectic between myself as full participant and the person studied, Cheryl J. It is mediated and influenced by the organized knowledge that is gathered by Haydon Youth Services. Finally, in describing the interaction with Cheryl, I enter into a discourse beginning with everyday concepts and seek to confirm my knowledge and understanding of Cheryl. This process stimulates more questions which in turn will precipitate additional questions. The act of knowing is never final.
For me, the task as the researcher is to develop an organized framework describing the interdependency and interactions between the client (Cheryl J.), her environment (the setting) and myself, as the worker. I must, in other words, reflect upon my experiences and demonstrate how they are a product of the social organization and my interactions with its characters.
2. For Cheryl J.?
Cheryl J. was a seventeen-year-old female, five foot seven, one hundred and twenty-five pounds, with short, unkempt dirty-blond hair, big hazel eyes and somewhat mobile features. Cheryl’s most prominent characteristics are the numerous scars running laterally from her wrists on the inside of her arms to where her elbows bend. Cheryl has a history of suicide gestures and attempts. She can be both verbally and physically aggressive. Cheryl has been in and out of six residential treatment programs over many years. She eventually wound up in an adult unit at Whitby Psychiatric Hospital, after she was discharged prematurely from the sixth adolescent treatment program, being viewed as untreatable and too much of a suicide risk.
When I began working with Cheryl, she resided at Whitby Psychiatric Hospital, but was being integrated into one of Haydon's residential programs. During this transition period, Cheryl attended our day treatment program arriving daily by bus from Whitby at approximately 9:10 a.m. and returning in time for supper at 5:30 p.m.
Wednesday, 14 March 1989, I was alone in one of the group home’s residences, working in my office. Sitting at my desk which overlooks the street, I saw Cheryl walking towards the building. Since it was approximately 1:30 p.m., I knew Cheryl was AWOL from the day treatment program. Suddenly, she darted off to the side of the building. I rose from my desk to improve my view of her. I could see her near the corner of the building looking at the ground for some object. She bent over fairly quickly. Upon picking up something, she proceeded to scratch and tear at her left arm until blood flowed. She then repeated the same gouging to her right arm. I decided the only way to deal with Cheryl was to sit at my desk, continue at my work and allow Cheryl some space to act out.
Within a matter of moments, I heard her footsteps on the stairs, then across the porch, followed by the sound of her unlatching the front door. Since my office was adjacent to the front door and I had my door open, I felt her presence almost with the rush of cool air.
“Hi Don,” said Cheryl, sounding exaggerated in her cheerfulness.
I kept my head down and pretended not to be interested in her arrival.
“Hi,” I responded gruffly but not looking up from my work.
“Hi Don,” she said, stepping into the office so she stood almost over me and I would obviously look up.
It was now really impossible for me not to notice that she was bleeding from her cuts onto my floor. For me not to look up would certainly have given my plan away. So I did look at her cuts and then into her face.
“What are you doing, Cheryl?” I said, annoyed. “You are bleeding all over my floor. Will you get out of here?” As I brought my left foot around from beneath my desk, I rubbed the blood spots with the sole of my shoe into the hardwood floor and gestured her away with my left hand.
Cheryl looked stunned that I would be more concerned about the blood on my floor than her cuts and bleeding and that I was actually pushing her out of my office. But it was my belief that Cheryl had wanted to instill panic within me through her premeditated self-mutilation. Cheryl had hoped to overpower my emotions with her dangerous behaviour thereby dramatically attaining the upper hand in the relationship and the program. But when I did not respond to her cuts, not only did I appear insensitive, but more importantly, I was passing back to her the responsibility and ownership for her behaviour and feelings. Finally, I was telling her I would not be manipulated.
“But Don,” she protested as she backed out of my office sounding hurt
and looking dumbfounded, “aren’t you going to do something?”
“About what?” I said, sounding annoyed.
“My cuts,” she yelled, hoping to get me to clue in.
“Oh, Cheryl,” I said slowly, “I don’t know anything about first aid.”
Cheryl looked alarmed.
“But Don,” she protested and started to hold her cut left arm with her right hand.
“Obviously, Cheryl,” I said trying to emphasize a practical solution to her emotional manipulation, “you know more about this sort of thing than I do. I mean, you“ve cut yourself before so maybe you should bandage it up?”
Cheryl began to look more agreeable.
“I think there’s a first aid kit in the back staff office somewhere. Since it’s open, why don’t you patch yourself up?”
It seemed essential to force Cheryl to experience her own emotions rather than letting her get away with triggering mine. Above all, I believed it necessary for her to appreciate the pain she was inflicting upon herself, rather than to have her think she could control others by harming herself. The treatment question was, how could the staff make Cheryl learn to be responsible for her actions, so that she wouldn’t continue to be learnedhelpless and manipulative? Thus, the ultimate aim of my interaction with Cheryl was to make her fully appreciate the cause and effect of her behaviours.
Within ten minutes, Cheryl reappeared at my door. And it was an awfully
long ten minutes as I tried to control my own apprehension and anguish.
She was all smiles and superficially pleasant as if nothing of any
significance had occurred. But she showed me her arms. She looked proud
of the bandaging job she had done. There were big wads of cotton batting
lumped on her arms and secured untidily with white tape. It looked
grotesque, even though the wounds were covered.
Cheryl had a look of satisfaction on her face; obviously, she was happy with her repairs. When I asked her why she had cut herself, a mischievous smile suddenly surfaced upon her lips. I interpreted the look in her eyes as meaning that she had now attained the pleasure she had been seeking and I had been careful to avoid. I recalled the superego lacuna theory (Johnson, 1949) that I had learned about early in my career (1972) as a child care worker at Chedoke Hospital in Hamilton, Ontario. I wondered to myself if this piece of knowledge explained Cheryl’s behaviour? In essence, had Cheryl’s acting out suicide gestures and self-mutilation been reinforced by her parents” reaction to her behaviours? It was also apparent Cheryl had learned to play these dangerous games in many of her other placements.
Was Cheryl using her self-harming behaviours for power, to either distance significant others (such as parents, staff, etc.) and then to draw them in? Did Cheryl want to control the emotional/ physical space within her relationships by acting bizarre? Whatever her motives, it was necessary to continue my confrontation of Cheryl so that I could understand her thinking. When I pursued the issue of Cheryl cutting herself she realized that I would not be satisfied until I received an answer. It was probably true for Cheryl, when she stated that at times she really could not control herself. Undoubtedly, Cheryl does experience difficulties understanding her emotions and restraining her impulses. When Cheryl “let go” or “gave in” to her urges, she may have felt a relief. Thus, in some ways, she exhibited a comprehension of her behaviours. But I also believed that Cheryl had, at times, also learned to control her urges (Ellis & Dryden, 1987). It was important to check out my assumption.
“Are there times when you make a choice to control
some of your behaviours?”
“So, when you cut yourself, aren’t you really doing it after you say to yourself, it’s too hard to control myself and it shouldn’t be so hard?”
“I’m not sure.”
“You have a strong urge to cut and harm yourself, but you don’t have to give in to it, do you?”
“Sometimes you only cut yourself a little, like a scratch and not a real deep cut. Isn’t that true?”
“So you don’t always give in completely to your urge to cut yourself, do you?”
“Is it always too hard to control yourself, your urges, or is it just hard?”
“That’s right. You see the difference between too hard and hard?”
“And sometimes to control yourself is not as hard?”
“And you don’t like it when things are hard for you?”
“So sometimes you give in?”
“How do you feel when you try to resist a strong urge to cut yourself?”
“Jumpy, I guess.”
“And you can’t stand that unpleasant jumpy feeling?”
“So eventually you feel you must give in?”
“And do you feel better?”
“Not always, at times.”
“Because it’s over with. But then you don’t feel so good because you get into trouble?”
“So you not only hurt yourself emotionally “you feel down on yourself and maybe you also harm your relationships with other people. People get upset with you?”
“Do you sometimes cut yourself on purpose because you want to get at other people, have power over them, push them away, like your dad?”
“you’re pretty angry at your dad, aren’t you?”
“He’s mad at me.”
“Did you ever cut yourself at home?”
“I don’t know.”
“Isn’t that how you wound up in the hospital?”
There was a long silence and a downcast look.
The research on sexually abused youngsters indicates quite clearly that these children display more problematic behaviours, such as anxiety, running away and self-mutilation, than non-abused children (Finkelhor,1984). While there were extensive reports in Cheryl’s history detailing physical abuse by her father, there was no mention that she had been sexual abused. However, it seemed probable to me (and to other workers) that Dad may have also sexually assaulted Cheryl and covered up his acts with physical punishment. I also felt that Mother was fully aware of Cheryl being abused but chose to ignore the reality and to blame Cheryl for causing it. In short, neither parent wanted to accept the responsibility for Cheryl’s “messed up” life and thus refused to deal with or acknowledge any abuse or the real reason Cheryl was in treatment. As for Cheryl, her suicide attempts may have been her way of dealing with her emotional turmoil and confusion that, resulted from her being traumatized by her parents.
Unfortunately for Cheryl, when she was first identified as being in need of protection from her parents at the age of about nine and one-half, her life soon became stuck in the proverbial revolving door. The Children's Aid Society would take Cheryl into care, work with her, but her parents would refuse to cooperate and eventually Cheryl would be sent home only to be abused a short time later and returned to care. Eventually, Cheryl was so damaged that she was viewed as pre-psychotic and thus, too difficult to be supported in foster care. She then followed the route of being placed in a group home, returned home, psychiatric hospital, return home, treatment program, return home, psychiatric hospital, treatment program, return home, etc. The question for me was how could I help Cheryl break this vicious cycle?
Prior to Cheryl coming to the residence, I had already concluded that she had established a rather successful pattern of intimidating staff by testing their sense of being in control with her outrageous acts and pretense of being crazy (or out of touch with reality) and unable to control her thoughts and impulses. Thus, when Cheryl was successful at challenging a program’s staff, it was then concluded she was unsuitable for therapy. She learned to act as a scary person and she enjoyed the power she attained in this role.
While undoubtedly Cheryl experienced a profound and desperate sense of self-loathing and debilitating emotions, first she needed to be stabilized before these problems could be worked on. Also, her learned helplessness and self-destructiveness could not be reinforced, but rather confronted. She needed to feel both psychologically and physically secure and that was unlikely to occur if she felt she could manipulate me with her suicide gestures and pretending not to be in touch with reality. Thus, I was trying to make her aware of how her thoughts and emotions were connected to her actions. Ultimately, I believed she unnecessarily gave into her low frustration tolerance and that she could, with support, deal with her feelings and environment more adaptively. I concluded that if I became alarmed, panicky or too concerned over her superficially cutting herself (and I was very aware of her cutting herself), she would have experienced a psychological joyfulness or secondary gain and then would have continued to try to manipulate me and all the other staff. She would have concluded we were afraid of her (or of her harming herself) and were prepared to do anything to appease her.
“So, you’re not to do this anymore. And I’m not going to kick you out of
the program because of your behaviour. I“ll make your life unpleasant
with consequences, okay?”
“Right now, you are supposed to be in our day program. If you want to see me at any time, you’re not to do it by playing these games of leaving the program without permission, harming yourself and trying to con me. You make an appointment like everyone else. I can even go to the school. Do you understand?”
“I’m sorry,” she said pleasantly.
“I know. Let me drive you to school and have one of the staff clean and rebandage your arms.”
In essence, it seems that meaning occurred with Cheryl as she brought knowledge of herself, of others and of life to Haydon Youth Services. Meaning begins and develops with the translation of the effects of the treatment intervention by Cheryl on her own experiences. This reflective process is the creation and discovery of meaning. As Cheryl reflects upon her learning experiences, not only does she become aware of the process of creation, but also of herself reflecting upon it.
On the other hand, in the daily events or program, the youth worker through his/her own dialectic is the model for Cheryl. As the worker, hopefully I demonstrated I was fully aware of what was going on inside of Cheryl. I strived to make the learning/ therapeutic experience clear and yet, to leave the discovery open, hoping only to influence the conclusion. As the worker, I should not inculcate what to learn, but how to learn (for example, how to socialize and/or to interact more effectively). As the youngster, Cheryl, reflects upon the youngster/ worker interaction, she then becomes constantly aware and sensitive to the creation and recreation of meaning.
For Cheryl, the therapeutic experience is the translation of the effect
of my intervention with her on the creation and discovery of meaning.
Cheryl’s self-explanation of her motives for her behaviour and her
understanding of the dialectic between us may in reality consist of
nothing but words. Her involvement in the program consists at one and
the same time of discovering self-awareness and also feeling bewildered
by the experience.
Ellis, A., & Dryden, W. (1987). The practice of rational-emotive therapy. New York. Springer.
Finkelhor, D. (1984). Child sexual abuse: New theory and research. New York. The Free Press.
Johnson, A. (1949). Sanctions for super-ego lacunae of adolescents. New
York. International Universities Press.
This feature: Pazaratz, D. (1993). The nature of the
communicative relationship within a residential milieu. Journal of
Child and Youth Care, 8, 3. pp. 51-58.