I last wrote in a state of devastation that my thirteen-year-old client had reached a point where she’d felt she wanted to die, news that was coincident with a bout of uncertainty on my part about the career path I’ve been on. Before I share a positive development, it seems important to say a little more about that Tuesday evening.
It was my first time seeing Shona after her family’s February vacation abroad, and with the month of March came clinic “housekeeping” of various kinds. There was case management to check in on, and a quarterly review of Shona’s treatment plan. Did she still have the same goals for herself as when we began? Did she and her mom feel that progress had been made? What were our next steps?
From the start, our therapeutic pattern had been that Shona and I would spend the first half-hour or so alone, inviting her mom to join us for the time remaining. It was a pattern that paid heed to two needs: for Shona to have a chance to express herself without inhibition, and for the two of them to have space to strengthen their relationship, grappling with challenges in a safe and supportive environment.
Their work had paid off in a number of ways, from my perspective as observer, and we had had an outwardly positive, productive last visit, when we played with an experiential metaphor following an adventure therapy model. I felt good about where we had left things and was delighted, as always, to greet them in the waiting room. With the exigencies of paperwork in mind, I invited them back together.
The timing of that departure from precedent couldn’t have been worse. Because my attention was, from the first moment of session, divided—respectfully attentive to her mother, who speaks more assertively than Shona—and because there was “business” to see to, I gave insufficient consideration to Shona’s affect, registering that her spirits and energy seemed low but attributing that to the conflicts they described encountering upon their return home from the tropics.
They let me know that Shona had cut again a few days before, and we talked through that: what her trigger had been; whether she had tried other coping strategies and, if so, why they hadn’t worked; how she might move forward from there. We discussed the things that we usually discuss, but again, it wasn’t exactly the same. I neglected to ask the all-important question. Shona, thankfully, answered anyway.
Just as we were standing and confirming for the next week, Shona requested that her mom leave the room. Her mom seemed surprised, but unperturbed. “You want to talk to me alone?” I asked, redundantly. She did. After I escorted her mom out, I returned and focused on Shona. “You know how you always ask me my intent?” she said, without preamble. “This time I wanted to…” and she gestured to her wrists, her sign language for meaning to do real harm.
This moment contained more than words can relay. She would not have shared the difficult truth with me if she didn’t trust me, I know that—and I know that trust is built and sustained largely through reliability, which is a vital aspect of the therapeutic relationship. I am where my clients expect me to be, when they expect it; that simple, symbolic fact means a lot. I ask familiar questions that link each visit. I make myself as steady as I can, so clients can vary and change.
I think what I want to say here is that it doesn’t take long for rituals to root themselves. And unacknowledged changes in rituals can be upsetting, a private disappointment and source of confusion eroding trust in insidious ways. In daily life, this can be hard to address, but good therapy offers an opportunity to get one’s emotional needs met, if only within the bounds of that one relationship—and a good therapist pays attention for signs of those needs.
What do I mean about being steady so clients can change? From a biological perspective, no one is exactly the same from one minute to the next. We are all organic and constantly mortal, constantly a little deeper into our mortality, the conscious or subconscious fact of which can separate as well as unite us. But ritual matters. When I failed our precedent, it showed its strength. When I lacked awareness, Shona expressed herself—she sought the thing that was missing. She demonstrated that she had been actively present for our relationship, and she was courageous with me. In the midst of everything, I thanked her for that.