THE POWER OF PRECEDENCE

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.

 

BE THE BUS DRIVER

Last week a client, age 13, let me know that she had cut again, this time with fatal intent. She wasn’t sure why she had been so upset; she stopped because of the blood. The news was devastating for a number of reasons, but I had to set my feelings aside in the moment and focus on her. My feelings could wait—and they did. I drove the hour home filled with longing to be held and comforted.

That she trusted me enough to share what she had done was a good and powerful thing. It was a return on the investment of asking her calmly each week whether she had felt triggered since I had last seen her; whether she had cut; and, if she had, what her intention had been. By remaining calm and using neutral words, I gave my young client permission to speak and language she could and did use. After she and her mother and I contracted for her safety at home, and discussed alternatives, they left and I sat at my computer, dully typing up the notes of our visit.

One of the Level 4 clinicians walked past the open door and paused to check on me. Earlier he had shown me the form to fax to Emergency Services and advised me on the pragmatics. This clinician—whom I’ll call Ben—exudes a natural authority. The kind of person who’s good in a crisis. He encouraged me like a coach would: “You got this.” Then he told me a story, of a woman abused as a child. Her father, who was her abuser, would buy her modish clothes as compensation, which she hated to wear. They reminded her of things she would rather forget.

Ben asked this woman how she got through that time in her life. “The bus driver,” was her surprising answer. Every day she had to get on a bus, and every day the bus driver would—kindly, respectfully—compliment her appearance. This helped her realize that her secret was safe—no one could tell, just from looking at her, what she had been through. Ben concluded the story by saying that we can have a profound effect through simple kindness. “Be the bus driver,” he said.

I believe Ben sought to reassure me of the value of my mere attentive presence for clients—but his concluding remark had another effect. I have recently felt the kind of stress that calls all one’s choices into question. Through the filter of that stress, I heard him say, “You don’t have to be a counselor to make a difference in people’s lives.” Was that a novel concept? No. But his words gave me language to use with myself, as I contemplate the next steps on my path—language, and permission.