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In the lecture on grief by family therapist Aino Koskiluoma, substance addiction is described as a chronic illness which causes grief in itself. She talks about how unprocessed grief can lead to substance addiction.

If the release of emotions is blocked, life can start to feel as if it were unlived, or not genuine living. It may lead to a feeling that no one understands. The individual does not know what is important in life, and may easily resort to narcotics or drugs.

Unreleased emotions may also lead to physical symptoms, such as heart symptoms, shortness of breath and abdominal discomfort. The person may feel panic or terror, they may feel restless and have a sense of being in a dead end, they may develop self-destructive thoughts and fear that they might be losing their sanity.

Addicts bear guilt for the things they’ve done, look for the blame in themselves, feel remorse, and they may sink into self-pity. They may also feel anger, in which case they look for scapegoats for the way they feel. If the expression of emotion is forbidden, the feelings may turn towards themselves, making the risk of suicide very real.

Once the person has processed their emotions, they may find a sense of hopefulness. They may start to have a new attitude towards life, which may even lead to a new lifestyle and way of life. The person feels like they are in some way free and no longer experiences the addiction, but they may still feel fatigue, grief and longing.

The awakening of hope broadens the range of emotional expression, and the person gets a feeling of being able to manage things. They may even laugh at themselves. They no longer focus just on themselves, but find it easier to listen to others and to feel connected to them. The person has accepted their substance addiction, and this acceptance may turn into strength.

In the course of my field period, I went to the Mäkirinne youth home to meet the manager, Kalle Pakarinen.

I sat in a chair in Pakarinen’s room and we started our discussion. At one point we had lunch in the kitchen, connected to the living room, and had coffee with two young people who had newly arrived at the youth home.

A house in the country

The youth home is situated in the countryside, amidst fields and forests. It is a few kilometres away from the nearest public bus stop, and a fifteen minute ride from the railway station. It resembles an ordinary house built on slightly sloping ground.

There are seven places at the youth home, and one crisis place for young people aged 13-17, coming from regions across southern Finland. The young people are mainly placed in this youth home as urgent placements or after having been taken into care. An urgent placement lasts for 30 days, and it can be continued for another 30 days. The period can be extended even further if preparations for taking the young person into care are ongoing.  There is no time limit for a care order, the decision is reviewed periodically, and it ends at latest when the young person turns 18, or earlier if the criteria for continuation are no longer met. At the youth home, the staff consists of eight care workers and the unit manager. Without a framework agreement, the cost of care at the unit is 394 € per day, which adds up to 11.800 € per month.

At the youth home, physical holding is not in use, and it does not favour strict limitations. The young people are tested for drugs, and their clothing and room may be checked. If a young person comes to the youth home inebriated, they may be placed to sleep in an empty, bare room next to the entrance, to sober up overnight in order to guard their safety, as well as others’. Movement and contact with people may be restricted when necessary, within the boundaries set by child welfare legislation.

Substance abuse among the residents

The young people who come to the youth home have long histories of abusing a variety of substances. The most commonly used drug is cannabis, followed by alcohol, amphetamine and other substances.

The community’s functioning is based on abstinence. No substance use is allowed at the youth home. The community strives to find out the reasons behind each young person’s substance abuse. If the young person finds a way to connect with these causes, and finds things that can replace the addictive substance in their life, it becomes possible for them to quit using. The young person no longer needs addictive substances to ease the tangles in their life. If this does not happen, the youth may continue the substance abuse.

Pakarinen considers substance abuse among youth to be partly a matter or attachment relationship issues. The young person has not received enough adult support and care in their life, and has been left with a care deficiency.

Among these young people, one can observe substance abuse, crimes and debt and broken relationships. The meager finances of young families show, as well, but there are some clients who are not from families with limited means.

Understanding of substance addiction

Pakarinen considers substance addiction to be an illness when it is uncontrollable and accompanied by physical symptoms, from which the person seeks relief.

He feels that addiction is also a mental disorder, and that addictive substances are used to numb negative feelings.  How the addiction progresses, or how the person copes with it later on, is highly individual.

Pakarinen feels that substance abuse is linked to the young people having suppressed their feelings with the addictive substances.

The treatment period

Pakarinen describes how the placements have kept getting shorter.

For the most part, the young people come to the unit from home, when it has turned out to be impossible to support or secure their home environment. They may also come straight from jail to the youth home.

Pakarinen estimates that a little more than half of their clients are taken into care, and the other half either go home to their parents or move to their own flat. They aim to support the youths to finish elementary school and possibly to have started vocational education.

The statutory monthly allowance for the youths is 52 € per month. They may also receive a bonus for good behaviour and for remaining substance-free, about 22 € per month. In addition, the youths can maintain the yard or clear the snow for the benefit of the community, and for this they can receive payments of 7 € per hour.

The youths have the option of being home-schooled at the community, or they can be transported to the train and attend a school.

Pakarinen is of the opinion that the young people at the community are not yet quite ready to decide about their own affairs while they are under 18 years of age and under the guardianship of their parents. The youths function at the community according to their abilities. They proceed through their treatment stage by stage.

The youths have two personal coaches each, and to these they have the opportunity to talk about their issues. Each coach has two youths to coach. Part of the coach’s job is family work, focused on assessment and transition. Assessment-oriented work means that the young person’s situation is assessed, and transition-oriented work means that the focus is on bringing about change in the young person’s life situation.

As part of assessment-oriented work during the community treatment, each young person’s network is mapped with regard to resources and problems. For example, the workers consider if grandparents could support the youth, and whether the youth could contact other relatives. Part of assessment-oriented work is also considering where the youth will move to live after the treatment period.

In transition-oriented family work, discussions are conducted with the youths and their guardians. Efforts are made to open the situation and make it visible so that both parties understand it from the other’s viewpoint, as well. In the discussions, no attempts are made to name guilty parties, but instead the goal is to jointly agree on the changes to be made. It is possible to make efforts to change things in situations where a family member has mistreated the youth, or where the youth has to face seeing their parents inebriated.

The principles of community treatment

 The youth home has its own principles of community treatment. Their treatment differs from traditional community treatment in that each young person’s personal issues are processed privately, not in the community.

Communality means that the workers aim to have open dialogue with the youths. The purpose is to establish a connection. In addition, they try to bring the parents and youths into an open discussion with each other.

The coach and the young person try to have at least one hour of discussion once a week. The aim is to get to discuss why the youth uses addictive substances. This would be, in a way, getting to the core of the matter, according to Pakarinen.

Usually the things that come up in discussions with a young person have to do with bullying at school, physical abuse, or sexual abuse. When the youths have good networks close to them, Pakarinen considers their chances of recovery to be good.

Pakarinen feels that important aspects of the encounters between youths and coaches are especially equality, empathy and the right kind of presence, as well as setting clear and consistent boundaries, which signal caring. He feels that an adult can also admit to being wrong in some situations.

The youths can be told that there are alternative ways to act in their lives. Because some of the staff members have personal experiences of recovery, they can function as positive examples of recovery for the clients.

Everyday togetherness

At the youth home, community treatment largely consists of being together in the activities of everyday life, including various groups. On Monday evenings, the community members have a community meeting where they plan the programme for the next week. Each client makes their own plan. The youths each clean their own room, and they prepare food together.  At the substance abuse group they discuss issues related to addictive substances, under worker guidance. At the activity group the workers engage in hobby activities with the youths.

The coaches support the youths to find a hobby, unless they already have one. The workers want to offer the youths something meaningful to do, and alongside the activity they can have in-depth discussions, depending on the youths’ willingness and capacity. The youths can also participate in NA/AA groups, if they wish.

In the community, each young person prepares their own folder with a coach, and in this they collect a variety of memories from their time in the community.

In the spring, the community has a “get-together day”, with previous residents and coaches attending. At this occasion, everyone gets to hear how the previous clients are doing. Half a year after the treatment ends, the aim is that the youth home staff members make a phone call to the youth and ask about their situation.

Transition with monitoring

Pakarinen says that he likes the concept of transitioning with monitoring in place, because he sees that this approach is based on a plan where out-of-home carers are in connection with aftercare.

In his view, forward-thinking separation processing is sorely needed, and this would mean that all parties would go through what it means to start living independently, and what the relevant responsibilities are. Pakarinen feels that support for the transition stage could be started earlier than it is currently started.

Coaches can visit for example the Social Insurance Institution or aftercare services with clients, so the young person knows who will continue managing their affairs. The youth is entitled to aftercare once they accumulate transition funding from an out-of-home care placement lasting a minimum of six months. Aftercare services could also provide follow-up that would prevent the youth from being left to manage on their own.

I interviewed the manager of Saunalahti youth home, Sari Mäkinen, by phone. She described the youth home and its operating principles. Towards the end of the interview, we discussed ways to improve the relationship between out-of-home care and aftercare, as well as ways to develop the process of transitioning from out-of-home care to independent life.

Central location

Saunalahti youth home has seven places for young people aged 13–17 who suffer from substance abuse. The youths are placed at this unit mainly because of substance addiction. They come from different parts or Finland, but most are from the capital region.

The youth home is part of the out-of-home care system, and the youths are there as a result of an urgent placement or after having been taken into care. A referral from aftercare is possible, but rare.

The youth home is situated at a central location, near schools and services, which makes cooperation with parents easier. The parents often live nearby and can come to visit. The youths often have the opportunity to continue at the same school as before, to keep managing their affairs and to stay in contact with people close to them just as they have before.

Freedoms and limitations

The youths usually come to the youth home against their will, which distinguishes this youth home from the other communities that I have visited. This is especially linked to the age of these young people. Child welfare legislation determines that it is mandatory to interfere in the situations of youth under 18 years of age when their health or development is at risk.

Usually the youths are allowed to move about freely and to go to school on their own. The youth home can use certain measures to limit the residents’ freedom of movement. If the youth is under restriction, they are allowed to go on outings with a coach.  Constant supervision can be arranged in exceptional circumstances, meaning that a coach will keep the youth company from morning till evening. Drug screening is carried out regularly at this youth home.

The youth home does not offer replacement therapy. It is generally not provided for young people under 18 years of age, whereas in adult substance abuse services replacement therapy is in use. Mäkinen considered replacement therapy to be beneficial in some cases, because it stabilizes the way a person acts. The clients are not confused when in replacement therapy. Mäkinen has seen at her previous workplace that the therapy worked for some mothers of small infants. However, in her view it is essential to always have a proper plan for reducing the medication. It must not be allowed to become a permanent solution for years on end.

It is not possible to motivate all the young people to focus on recovery during their period in the youth home. The youths do not always understand the significance of the placement, at least not at that moment. They may later understand why others took such action. Mäkinen considers substance abuse to be about addiction, which means that family or other close relationships are not relevant at the time.

The placement period

The young people can be taken in for an assessment period, which lasts 1-2 months. During this time, their needs are assessed, as well as potential support forms for the future. On average, the youths stay at the unit from six months to a year. Mäkinen feels that usually substance abuse is not their only problem, but they may have difficulties at school, or mental health problems and other similar issues.

In Mäkinen’s view, the youths often have no ability to trust other people. Many of them have become disillusioned with their family and with officials. They do not always know why certain measures are taken. Mäkinen feels that officials should explain to the youths in plain language the reasons for taking certain kinds of action. From the young person’s point of view, it is not enough if the officials say that they are too busy.

Each youth has two personal coaches who familiarize themselves with their issues. They provide care and support. The coaches also help the youth with practical matters, making applications and having discussions with them. In addition, the personal coaches are in contact with the youth’s parents and arrange family meetings, with varying composition.

With the coaches, the youths learn to do laundry, to prepare food and to clean. The aim is that the youths learn these types of everyday chores during their time at the youth home.

With the personal coach, the youths can practice managing their money. They receive a weekly allowance of 14 €, and for remaining substance-free and for good behaviour they can earn more, up to a total of 18 €. The youths receive the money in cash. They do not have their own bank accounts, and they do not receive any money in the bank. Mäkinen considers one of the greatest challenges for these young people to be managing their spending. Learning this skill starts as late as shortly before transitioning and in aftercare. If they wish, the youths can earn extra money at the youth home’s summer jobs, for example painting things or by washing windows.

Plans for the future are made with the personal coach. According to Mäkinen, the youths have many dreams. With the coaches, they discuss ways to attain these dreams.

Most of the youths are clients of substance abuse psychiatric care or youth psychiatric care services, where they get to have discussions with people outside the youth home, about matters such as their substance abuse issues.

Family work with a resource oriented approach

At the youth home, the staff members launch a focused effort to carry out family work during the youth’s placement. Parents and other family members are brought along to participate in the work. If the youth has other important networks of people close to them, other adults can be included with the guardians’ permission, for example grandparents. If the youth has no parents or other guardians, the workers contact grandparents and other members of the extended family.

Mäkinen sees parents as being generally willing and motivated to work for their youths. If the relationship between the parents is inflamed, they nevertheless try to establish at least some kind of discussion and contact between the youth and both parents.

Meetings can be held at the family home or at the young person’s home, with varying groups of people participating. The youths may also practice visits to their own home, under certain rules.

Mäkinen describes how the work at the youth home is resource oriented. In discussions, the workers want to highlight positive thoughts, and good things are supported. In family work, the starting point is to always find something positive. Difficult issues are still not bypassed, but the youths and their parents are guided to process everything at hand.

The workers adopt different approaches to family meetings, although the main emphasis is on discussion. They also use interviews, emotion cards or questions to be answered in writing, among other things.

Peers and groups

At the youth home, the youths have peer activities, which include a community meeting, a substance abuse discussions group and a community evening.

At the community meeting, the youths and adults have discussions together. They go through each person’s current feelings, how each one is doing, and then any matters that the youths want to bring up, such as discussion on shifting bedtime to later in the evening, or a discussion about buying a Playstation. At the meeting, the participants also go through the week’s menu.

At the substance abuse discussion group, the youths discuss addictive substances and information about the topic is disseminated, but emotions are discussed, as well. Emotions can be processed in writing, by drawing, or by using a variety of cards. Talking about feelings is difficult for these young people, according to Mäkinen. The coaches aim to get the youths to discuss emotions with them, if it turns out to be difficult in a large group.

On the community evening, the youths and coaches do something fun together: they may for example go to see a film or ride motocross.

Supporting the transition stage

When a young person turns 18, they become a client of aftercare services. The aftercare services are often contacted by youth home staff in advance. A worker may visit them, or they may visit the youth home, or the contact may happen by phone.

The youth home has three transitioning apartments where the youths usually move to practice, first staying overnight and then gradually lengthening their stay until they move into their own flat. Transitioning practice is started well in advance, before the youth becomes legally of age and is due to transition, so they can get sufficient experience of independent living before switching to their own flat. Young people from other youth homes utilize the transitioning apartments, as well.

The youth home’s ’birthday’ is celebrated annually, and at that time many of the youths who have stayed there before come to visit. Mäkinen has noticed that some of them seem to be managing quite well, and others appear a bit worse off. She cannot quote exact figures on how many of the youths recover, but she believes that most of them benefit from the placement period. When they turn 18, many of them go ”out of control”. For some, the situation cools down after a while, and then it is possible to assess if the youth home period was beneficial.

Improving seamless services between out-of-home care and aftercare

Mäkinen wishes that a common practice could be established of initiating work with aftercare while out-of-home care still continues. This would contribute to the young person’s sense of security. The services would function as a seamless continuum, and there would be no gaps between them.

If aftercare could start before out-of-home care ends, the youths would have a chance to get to know the new workers. They would learn to know how aftercare functions, and what rights they have.

Mäkinen considers it a good idea that aftercare could rely on peer support from young people who have transitioned from out-of-home care before, to a greater extent than is now the case.  The youths whose life situations are good could give hope to those currently going through transition. Mäkinen refers to existing practice at the ’Selviytyjät’ (’Survivors’) team of the Pesäpuu association, which has especially highlighted these matters.

I have now finished the field work period conducted in Finland as part of my research project, and returned to the United Kingdom to do further work on transitioning from out-of-home care. The primary reason why I chose to familiarise myself with the Setlementti Kalliola services in fall 2017 was the strong emphasis on communality described in their principles. What can I learn from four different places where I got to observe community treatments, and what ideas could be utilised in the context of young people transitioning from out-of-home care?

The impression that remains topmost in my mind is the significance of peers in these communities.  It is very obviously important to have the feeling that others understand, and that you are not the only one with these kinds or experiences. If you always feel different, and fail to connect with others, it leaves a sense of being an outsider to yourself as well as others. It can have the effect of living as if only pretending to live, while having no connection to one’s inner self. When you can for once be exposed, as faulty as can possibly be, alongside others, it is a liberating experience. You can learn from peers, in good and bad alike. In communities it is possible to see others and to receive support from them in daily matters, to learn new ways of doing things, and to find new directions in life. With the help of peers, you can find social relationships as well as role models whose lives you can follow. You can gain better insight to yourself, and possibly reduce feelings of being lonely or different.

Transitioning from out-of-home care is a process that happens in stages. Afterwards it becomes easier to see what has been helpful in this process. The young person’s social relationships, which create a sense of continuity, as well as having a sense of life being meaningful, inspire faith in the future. Any activity that feels significant to the person brings a sense of meaning to life. Similarly, recovering from substance abuse is a gradual process that takes place through a series of epiphanies and through confirmation, received from other people, that you matter, and that you are capable of accomplishing things:

’They don’t care about my issues in rehab, not the same way… I had my own worker and it was confusing that this was for me. I went to that Hietalinna community and I didn’t have my own urge to stop, except that at the Hietalinna community it somehow became realized that I just wanted to have that flat and I thought that I can’t continue using. From Hietalinna community I attended NA and understood that it’s not a total necessity for me to keep using. Before that I had nothing else except that the purpose of life was to use drugs. Yeah, that came out a bit long maybe (laughter). Then I’ve ended up at K-tie and I’ve learned to clean, to cook and those are the basic things and then I’ve learned a little about living this life in all areas. I am really grateful. ’  

When everyday life is in a mess, regular daily rhythm matters. When you can manage to get out of bed, to take care of your hygiene and daily chores, you have hold of a lifeline. When you establish a connection with other people, the will to live can begin to return. The young person sees reasons to live. The completed housework and self-care also bring joy and a sense of capability. Getting more responsibility for daily chores or for instructing another youth give them a sense that they are trusted. The youth is not only being helped, but can help someone else, or act for the benefit of the entire community.  In this, we are at the core of reciprocity. Reciprocity ties us together through empathy. It creates a sense of belonging somewhere. In your own community, you can find acceptance and recognition. These experiences are not always easily extended to situations outside the community. However, they leave the young people with an imprint of the experience, one that can carry them outside the community, as well:

’So what I’ve learned from this experience myself is something like a community which should last through the treatment and beyond treatment. Or a kind of permanence, a thing that creates security, is maybe one of the most important things.’

 Youth: For me at least because I haven’t learned that bearing of responsibility and that independence because of having such over-protective parents. And this way it can now be learned again, and to take care of myself. So it probably helps with it later when at some point I move to live on my own.

Maritta: Yes. Would that important message to other young people be that you need to bear responsibility? 

Youth: And that you can get help. And that there are people who help. That has been really important, that there is like some place where you belong or you get that sense of togetherness and security and that you’re not alone.

Maritta: Important things.

Youth: Yes.

The staff members I met at the residential communities worked with the young people in an admirable manner. They kept to a certain professional role, and they did not attempt to become friends with the youths. They had respectful attitudes and they listened. When necessary, they were strict, but they always attempted to reach shared understanding through discussion and explaining.

Thinking back to my experiences of out-of-home care units that I have visited over nearly 30 years, I was surprised at the wonderful atmosphere and culture of discourse at this residential community. No one was shouting their head off, issuing threats, slamming doors or swearing loudly. The premises were also undamaged. I do not mean to say that the opposite is true of all other out-of-home care units or in all situations. I know that there are also home-like conditions in out-of-home care, as well as moments that connect the workers and children emotionally to each other. Nevertheless, this was an observation that alerted me to analyse the discourse practices at the residential community, and the possibility of the workers having altered their approach to their tasks.

The workers’ view is that the youths adjust to the prevailing culture at the residential community, and that the community teaches them to treat each other with tolerance and to speak politely to each other. The difference from out-of-home care places is that the youths arrive at the residential community voluntarily and as legally of age. In contrast, out-of-home care places rarely receive voluntary or adult clients. The young residents’ life situations can still be acute, which can be expressed as turbulent behaviour.

How much is it then about the workers’ approach to their job, and what attitudes they take towards young peoples’ problems? A critical analysis of this issue has been provided by the Canadian researcher Rebecca Ward (2016, 105). She considers it necessary to establish a therapeutic and empowering connection with youth in out-of-home care. This kind of connection is based on resources, on taking into account the developmental stage of each child or young person, and on reciprocity.

Ward considers it harmful to adopt a pathologizing approach, based on punishments and control of the young people’s behaviour through these. She has found that in such situations, youth often behave in an oppositional manner, and that it is then difficult to support them.

In both of the youth homes that I visited there was an emphasis on connecting with youth, in the way that Ward has promoted. The workers aim to establish a relationship with the young person, on an equal basis, and to build good dialogue with them. They can set limits to behaviour, but only when it becomes necessary.

As research repeats over and over how young people with out-of-home care background have poor educational and employment outcomes, is it perhaps that no one expects more of them, or that they are considered not capable of being educated, either? This argument can be immediately criticised as an urge to push youth into middle class or to get them to join some kind of rat race. The most important issue is considered to be their continued progress, from one day to the next, which naturally is of primary importance. There may be gaps in their education, or their studies may have been interrupted. They may also have difficulties with learning, concentration, or language development. Nevertheless, young people transitioning from out-of-home care often dream of education and permanent jobs. What if this is one reason why they cannot find meaning in their lives or consider themselves valuable? Finnish schools and special education are considered to be first-rate, but why do they leave some young people side-tracked? Does their background affect other people’s expectations of them?

I come from working-class background myself, and my teacher at lower elementary school had expressed doubts to my mother about my ability to enter ’oppikoulu’ [equivalent to the British grammar school].  Luckily, I later asked my mother why she did not believe that I could handle oppikoulu. My mother said that it was not she who thought that way, but my teacher. My childhood experiences have made me class-conscious.

Youth who are recovering from substance abuse also have experiences of not having been challenged the way they are at the residential community. Offering challenges and responsibility is obviously linked to perceiving a person as capable of responding to expectations. It is not only a matter of technical performance, or responding to the expectation in that sense, but also of the person wanting to become part of a community, and the community accepting them as a member.

’And the community is there to spur you on. And when you see that others can do it, then I will do it too.”

Sometimes challenging happens in a situation that leaves no choice, or is really pressing:

Youth: I have no options while I live at K-tie. Well, what has led to this. Not being able to go back, that there is nothing to go back to.

Maritta: Is it a little bit like a pressing need?

Youth: It is kind of like a pressing need. It’s good really, that there’s this pressure. If it wasn’t there, I wouldn’t necessarily be able to make it. 

Maritta: How does this pressure feel?

Youth: Not so bad any more. It feels kind of good now. And if not quite good all the time, at least like this way it’s possible to change. …

Maritta: At what stage did you notice that this pressure starts to change and starts to feel better?

Youth: At the point when I stopped fighting against the pressure and at the point when I became part of the community.

Maritta: Did that happen right at the beginning?

Youth: No, no. It took a couple of months. That I rebelled and I resisted everything and it affected others. It was noticed and they drew attention to it and I got feedback, criticism and assignments. And then when I had done those … It took some time. And it was a process, a bit like today, where you go through developmental trajectories and then you share them with others.

Maritta: So there they pressure you a little to talk to others as well, and to share your issues.

Youth: Yes.

When a young person gets to engage in doing something and receives positive feedback for it, it builds their self-confidence. They can see how other young people get a hold of working life, functioning as role models. Part of offering challenges and responsibilities is direct talk, which demands that the youth must act, but also aims to clarify the principles of the action. This signals caring, and that what the young person does next is not inconsequential.

Youth: And when you hear these stories, and when you’ve come to K-tie and you’re still like you hear non-existent voices a bit and then you get to go to a job trial, and you do well and get good feedback. It’s like if that one can do it, so can I, but about but anyway it somehow works better through example. Or having someone to kick your backside. Like often these things fall flat because they don’t tell you things straight or they let you be passive in these things. Maybe it’s been my problem, too, that there hasn’t been … while at K-tie they tell you straight that they will kick your backside if you don’t do your job properly. I’ve been told quite straight that if something doesn’t make any sense, then it just doesn’t make any sense. It’s not like everyone does it in their own way. You know, they say it straight and return you to the ground, because it’s what I’ve never really had at home.

 The young people also find it important that they are not allowed to skive from their duties. They are expected to do their part. Sometimes it feels like they are being pressured, but it has also supported them to dare to try things they would not have otherwise had the courage to attempt.

’At K-tie you learn a kind of responsible attitude and you don’t skive from things and things are planned in advance, so that has brought kind of security and direction to my life.’ 

’That treatment has pressured me to do things that have caused anxiety and fear. Like I have limited the things I can do a lot by thinking, that I’m not able to do this, or I can’t do that. So then I’ve had to do those kinds of things there in treatment, like being in front of others and talking about my feelings. So that’s the effect they’ve had. ’