Ryan Howes' recent post on what he referred to as the Last Minute Bomb prompted me to think about two things; my own "door knob moments" with patients, and the client's experience of leaving a session. While door knob moments can rattle even the most seasoned professional, a much more weighty consideration is that all too often therapists skilled in the art of opening a door lack the skill to close it. This leaves clients raw, hanging psychologically and at the sufferance of a world insensitive to their state of mind.

From a therapist's perspective, door knob moments can be enlightening, infuriating and often roundly amusing. These moments are enlightening because they can point to the level of exposure that a client is willing to both proffer and endure. They are infuriating because they can throw a treatment plan, whether casual or formal, into a completely cock-eyed hat. And they are amusing because they often point out fairly directly that, as therapists, we are not prescient, nor uber-perceptive, nor somehow "greater than"...but honestly just dumb old homo-sapiens who can be conned or duped like the next guy.

Personally, my favorite door knob moment was with a delightfully sincere and devout Roman Catholic woman in treatment with me for 3 plus years who, on a wintery Saturday morning as she sashayed demurely out of my office said, "Did I mention that I used to be a stripper and a prostitute and that the guy who runs my AA meeting was my pimp? - we should probably talk about that...". Sheesh - talk about re-orientating!

For the therapist, this kind of situation is about adaptation, flexibility and egolessness. It takes a certain degree of emotional and professional maturity to say to oneself, "Oops." or "Interesting." or even "Nope. Missed that..." instead of "I can't freaking believe this!...whom does s/he think s/he is, pulling this crap with me...!" - blah, blah, blah...

The reason that these qualities are so important is that if the therapist gets caught up in the tide of his/her own (ego-driven) reaction, s/he will not be able to respond in a way that simultaneously validates the moment, brings closure to the session despite that moment, and ensures the safety of the client.

The more subtle version of this validation-closure-safety dynamic is the ability to close a session in a way that leaves the client with a sense of being grounded. What brought this to mind in light of Ryan's post was the comment yesterday by one of my clients that, no matter how upsetting our sessions may at times be for her, she always leaves "feeling great".

From a purely narcissistic standpoint, a comment like that should make me feel great, but it has much more gravity than that. It is a marker for the quality of the client's experience in terms of the therapist's ability to leave her with a sense of containment and groundedness that she can take back into the world.

Twenty-five years of social service has often led me - intentionally or unintentionally - to be cast in the role of a supervisor and teacher of others in the field. One of the primary requisites I impress upon my charges has always been exactly this -- developing the ability to close a session in a way that grounds the client. Too often I have witnessed this inability result in disastrous consequences.

Early on, while working as a teacher and advisor in a small private college, one of my colleagues ended a session with a young man who left campus and promptly, and intentionally, drove his car into a tree at 90 mph. The boy survived. My colleague did not - she resigned the next day and at last report was a sheriff in Texas. I was left with a lifelong lesson that you can't leave them hanging just because the hour is up.

A considerably less dramatic, but nonetheless telling, instance came to my attention the other day. I was told about a woman regarded as driven and planful who began seeing a counselor. Within months this financially independent full-time executive assistant/full-time student who was determined to complete her MBA became a hard drinking, Oxycontin-snorting, highly promiscuous party girl who quit school, quit her job, lost her house and is now living with her boyfriend of less than four months, by whom she is intentionally pregnant, in his mother's house. You can't make this stuff up.

Empirically, one obviously can't draw a straight line from this woman entering counseling to the dramatic change in both her behavior and her choices. Clearly, there's more to it. But, in the interest of objective, critical thinking, one must ask, "What changed?"; well, she entered counseling.

What this situation points to is that this young woman had some issues restive beneath the surface and, in addressing them, they were exposed. No worries - that's what's supposed to happen.

The radical change points to the possibility, if not the probability, that, once exposed, those same issues were not covered over to make them manageable outside the sacred space of the consulting room.

This woman's counseling experience at the very least contributed to her transformation into the walking wounded and these changes in choice and behavior - blunting, distracting and anesthetizing as they were - presented themselves as the only coping mechanisms she could muster.

In deference to Ryan's positioning of his blog section, In Therapy, as something of a Consumer's Guide, what's important to recognize here is that counseling brings things out and things brought out must be put back, otherwise they have a very good chance of showing up sideways.

It is indeed the therapist's responsibility to hold space for the client's sense of place and groundedness, ensuring their safety at the end of a session. It is also the client's responsibility to ensure that the therapist is proactive in this and that, while they may leave a session feeling a little loose, they aren't likely to start unraveling.