The Encounter at the Doorway By Tom Medlar, LMHC on 7/5/22 - 3:25 PM

Francis Thompson was born on December 18, 1859, and died on November 13, 1907. He is the author of the great mystical poem “The Hound of Heaven.”

I fled Him, down the nights and down the days;
I fled Him, down the arches of the years;
I fled Him, down the labyrinthine ways
Of my own mind; and in the midst of tears
I hid from Him, and under running laughter.

So begins the first verse of the poem that is considered a spiritual autobiography of Thompson’s attempted flight from God, and the gentle and persistent presence that always pursued him no matter how much of a mess he made of his life. Francis Thompson was often homeless on the streets of London and addicted to Laudanum (alcohol with a tincture of opium).

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One day Francis went to the office of Wilfred Meynell at the Merry England magazine. At his desk, Mr. Meynell saw the office door open slightly and close, then open and close again. In the doorway, Francis had no shirt beneath his coat, bare feet in his broken shoes, and a soiled and wrinkled manuscript in hand. He was scared. Thankfully for Francis Thompson and for the history of English literature, the impeccably dressed Mr. Meynell looked beyond the surface of Thompson’s broken-down appearance. He read the manuscript with mounting astonishment, helped Francis get into a hospital, and gave him a job. Francis relapsed into addiction several more times between periods of rest and recovery at a monastery in the countryside and bursts of literary productivity, until his death that resulted from the effects of addiction and tuberculosis.

I have personally witnessed dramatic and counter-intuitive ways in which demographics have changed in skilled nursing facilities over the past several years. The general population may be aging, yet the trend nationally has been one of younger adults increasingly being admitted to nursing facilities. A dearth of funding for home-based services, and a lack of available and appropriate residential programs for psychiatric and substance abuse issues are among the factors that contribute to these changes, and those that most directly impact the clinical work I do with these populations.

In the nursing facilities where I work, I have encountered relatively young residents with complex medical and psychiatric and substance use disorders. I can attempt to prepare for these doorway encounters, as did Mr. Meynell all those years ago when first meeting Francis Thompson. But as Meynell’s first impression of Thompson was skewed by his streetworn and drug-addled presentation, so, too, might be our own first impression of a younger person whose substance abuse and psychiatric history has taken a toll on their body and mind. Their need to be seen fully as a person is no less than was Thompson’s when he first appeared in Meynell’s doorway. And, like Thompson, each of the residents who present in my clinical doorway is so much more than their respective psychiatric and substance abuse histories.

Every person wants his or her life to turn out well. The person with a substance use problem yearns to be recognized as someone who wants their life to turn out well, and who needs the help of others to rebuild that life. The person we meet might be a creative genius, but that doesn’t matter; they are always an individual human person of infinite value.

Residents I spoke to with a history of addictive illness have offered insightful comments that have guided me in my clinical role at these various nursing facilities.

“Staff make negative assumptions based on a person being homeless and self-medicating,” according to Casey. “It’s hell out on the streets; you get overcome and paranoid sometimes, and you use again,” Rod said. “Don’t tell them ‘Just get off drugs,’ but help them to get a job, a home, and social contacts,” he added. “You know, they once had a job and they were in society once; they need programs to help get back in society.” Casey said that staff should realize that for the newly admitted resident “their body is going through a metamorphosis because they are not drinking or using drugs.”

Trent pointed out that “you’re not relaxed and calm when you come into a nursing facility.” He suggested that too often caregivers have a negative attitude: “You’re busy and irritated, and it makes me irritated and angry.” Trent suggested that “it should be up to the patient if they want to talk about it [addiction].” “Too much pressure and they close up. You feel pressured by people always on your case, and telling you what to do, when you have to figure out what to do; it can be overwhelming, and you can clam up and want to be left alone,” he said.

The individual with a substance use illness will “need a little love; something like a Big Brother program for grown-ups,” said Rod. “Help them get to a place where they can at least have hope,” he said. “It’s going to take love and patience to help them rebuild themselves.” Casey suggested that nursing facilities might offer practical and age-appropriate group activities, and not simply Bingo or crafts. She suggested bringing in persons from the community to offer life skills training on how to budget, how to use the internet, how to interview for a job, how to prepare food, find an apartment, or apply for disability income. “You’ve got to help open doors to encourage people to want to do better: Give someone a reason to get up in the morning; you’re never too old to love to do something new,” she said.

I think we cannot reasonably say, “Let someone else deal with this; I’m not trained or qualified to deal with this kind of problem.” The residents I spoke with pointed out occasional shortcomings of the inpatient addiction treatment programs where they sometimes fruitlessly sought help. Frank was impressed by the practical advice and suggestions he heard during his first alcohol detox admission. He was surprised to hear the same points during his second admission, and then disappointed to find during repeated subsequent admission that “they just talk from the textbook, and they don’t really have something new to say to you.” Frank spoke of a 19-year-old woman who had been through 30 detox admissions—citing the evident insufficiency of the specialized treatment offered. The residents spoke to me about the perceived limited knowledge and understanding of some professionals with specialized credentials for treating persons with addiction. The residents stated that they could encounter negative judgmental attitudes and unhelpful advice as often in specialized in-patient treatment programs as in skilled nursing facilities.

In my own experience working with these residents, I have found it important to encourage fellow clinicians and nurses to acquire additional training and certification, yet not discount the array of skills, knowledge, and personal qualities that they already bring to bear in the service of these residents. Residents with addiction and/or psychiatric disorders tend to have developed acute BS-detectors; they observe us with an X-ray type of vision. The person with an addictive illness has a refined intuitive ability to notice the underlying attitude of the nurse or clinician who encounters them. That capacity typically emerges from the deep emotional wounds of shame that accompany an addiction. The person with the addictive illness feels under a cloud of suspicion and judgment from the first encounter. We should strive to receive that person with a wise and open heart, as well as with a wily awareness of the risks of manipulation that can also be an unfortunate part of the picture. We cannot hide or disguise attitudes of fear or revulsion or judgment from the awareness of the persons we meet and work with.


The encounter at the doorway is a two-way process: I encounter my personal attitudes and values and beliefs about illness, addiction, and homelessness as I also meet with a person in need of kindness and patience and practical encouragement. My own genuineness and authenticity and humility have often made the critical difference as I greet the other at the doorway of despair or new opportunity.

File under: A Day in the Life of a Therapist, Musings and Reflections