Thursday, 6 August 2009

Missed Sessions

From time to time patients don’t want to come to sessions. At first I used to worry about this and tended to take it personally – what had I done to cause someone not to want to see me? This question remains part of my reflection on missed sessions but I’ve learned that frankly, it’s not all about me!

I don’t subscribe to the theory that there is no such thing as a meaningless occurrence: sometimes a missed meeting is just a missed meeting. And sometimes there is a greater pattern to events. It can be a test, to see if the discussion of returning as much personal authority to a patient as possible has any real meaning; to test that boundary and the boundary of continued relationship. If I am rejected, how will I respond? This has implications too for modelling how rejection might be managed in other relationships.

The therapeutic literature offers different understandings of missed sessions. My own experience suggests that if a client is serious about addressing their distress they will make the effort not to miss sessions. For some clients, therapy is the equivalent for them of buying a new handbag or doing yoga, it’s primarily a statement about who they believe themselves to be and how they want to portray themselves, and when something more interesting than therapy turns up they’ll give up therapy. Some clients are told to go to therapy, very often to gain access to their children or to mime their desire to change, and these clients too are very unlikely to really engage in the relationship. Why should they? They haven’t chosen to, they’ve been ordered to.

When a person finds themselves in an institution where conformity is given high value and behavioural modalities are to the fore they - we, you, I - will seek ways of not conforming at the same time as not being punished for non-conformity. Many of the people I see do this by saying they’re Pagan, which is also a way of demonstrating that the institution cannot fulfil their individual rights. Instead, they manifest me. I’m not part of the medical team and I’m not a mainstream representative. I’m not an employee of the hospital and I don’t have any institutional power. The first question they ask me is if I will do a spell to change their situation. Who can blame them for wanting to know where my boundaries are? I make contractual safety boundaries clear from the beginning “I don’t hurt you, you don’t hurt me,” and very early on in our meetings we talk about the importance of relationship and the uses and abuses of power.

For me, missed sessions can be part of that discourse. One or two missed sessions now and again, well, that’s life. Any apparent pattern can be interesting. A missed session with no reason given is worth talking about, several missed sessions in a row are definitely worth talking about, particularly if this happens around the same time that a client told me something that might result in shame for them, or if they’re also pushing other people away.

Authenticity is central to being Pagan, central to being a properly functioning human being and entirely peripheral to life in an institution. Institutions demand Approved Behaviour rather than authenticity. Just the right amount of crying, but no self-pity; being positive but not manic; sufficient sorrow for past deeds, perhaps even a little panic, but don’t get stuck there. In some US institutions it’s wise to become a very practiced, repenting Christian. For people with anything like psychosis this is terrifically dangerous. Knowing that you will be rewarded if you just consistently appear one way rather than another is very unhealthy. (Which is exactly how we are all expected to behave.) For people who then become dangerous to the people they’ve charmed, this has implications. As a Chaplain I don’t get told and have a positive disinterest in a patients past, but I’d be foolish to ignore the implications of our setting.

There’s an institutional significance to the notion of missed sessions for Chaplains. If a patient doesn’t want to meet with a psychologist or doctor or nutritionist or any other professional it’s too bad, they have to get to the meeting or the meeting comes to them. This is reflected in their notes, a judgement about them and their behaviour is made, formally and informally. If a patient doesn’t want to see the Chaplain, he doesn’t have to, and he doesn’t have to give a reason. This offers religious freedom, protection from religious abuse and is useful in other ways too. But the difference in response between any other professional service and the Chaplaincy service reflects the importance that spirituality – all of them, not just Paganism - is afforded by institutions. That’s not the end of the world. “Professionalism” is the last refuge of many things.

The liminality around the role of chaplains and spirituality offers more space in which to practice, and that’s a double-edged sword. We have to be very clear about our boundaries and behaviours. Once more, I am thrown back on the importance of authenticity: I need to be aware of my own responses. Am I annoyed, interested, bored, upset, sad, glad to be getting off early when a patient doesn’t want to see me? What does that tell me about the relationship, about my role, about my way of being? Once I have that clear-ish, I can bring my authentic self to the relationship. What happens when I say, “I felt dismissed when you wouldn’t meet with me last week. And I still care for you”? Possibilities, sometimes in the form of terrifying chasms, can open up.

Chaplains can offer a model of relationship which is caring, boundaried, deals with power with a clarity and complexity that may never have been encountered before. That’s a heady responsibility and a wonderful opportunity.

pic by Terry Border "Bent Objects"

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