Chapter 5 · Clinical Practice
Check yourself
Two questions on this chapter. Pick an answer to see the reasoning, and retake it as often as you like.
Mira is 34. She came in eight months ago for a worsening of long-standing depression; she'd been on antidepressants for years and felt they'd stopped working. Her adoptive mother was diagnosed with cancer six months before that and is in active treatment. Her marriage has been strained for over a year. She's been weighing whether to have children, knowing she's at the upper end of what she feels comfortable with biologically. She mentioned being adopted in the first session, said she'd never sought information about her biological family and didn't intend to, and named adoption as background rather than something she wanted to work on. Six months of work on the depression, the stressors, and the marriage has produced real improvement. In the last few weeks she's preoccupied with the question of children and more emotional than usual, and last week she mentioned in passing that she'd been thinking about her biological mother for the first time in years. She hasn't raised it again. What's your read?
Everything here is real at the same time. The depression is real, and six months of appropriate work has improved it. Her mother's illness, the marriage, and the question of children are each their own clinical territory. Adoption has now entered, in a particular way: she'd named it as background and declined to pursue it, and she has just mentioned her biological mother for the first time in years. The likely trigger is the convergence, since her adoptive mother's illness and the question of biological children both touch adoption structurally even though Mira hasn't connected them.
B does the small correct thing: "You mentioned last week that you'd been thinking about your biological mother. I wanted to make sure I didn't let that go by. Is that something you want to come back to today, or another time, or leave for now?" If she takes it up, the formulation expands to hold all of it. If she leaves it, you hold it in mind as something that's been signaled. A misses a real signal from a client who had to work up to saying it. C is the over-attribution failure wearing a helpful face: it decides for her that adoption is driving the depression and hands her a connection she hasn't made, which is a reliable way to get her to stop mentioning it.
A client came to you two years ago explicitly to work on his adoption. He was deep in fog work, active in the adoptee community, and the first year was almost entirely adoption material: grief, a search he started and stopped, his relationship with his adoptive parents. For the past several months he's talked about his career, a possible move, and a friendship that's gone bad. Adoption barely comes up. You've noticed yourself steering it back into the conversation a few times, and he engages briefly and moves on. Is the work drifting?
Adoption isn't always activated. The framework calls the background state a settled arrangement, and most adoptees spend most of adult life in it. A client who did a year of intense adoption work and is now talking about his career has most likely settled, and a career, a move, and a friendship falling apart are real clinical material in their own right rather than a detour from the real work.
The tell in this scenario is you. You've brought adoption back several times and he's engaged briefly and moved on, which is a client being polite about his counselor's agenda. B follows him. Formulation here gets revised, sometimes three or four times across a couple of years, and revision is the work developing rather than the work losing the plot. A treats settlement as avoidance, which is the over-attribution error, and it assumes gains slip without maintenance, which isn't how this operates. C sounds collaborative and still puts adoption back on the table as your agenda; a formal review of his adoption goals tells him what you think the therapy is really for. Keep watching for activation events, because a pregnancy, a death, or a DNA result could change this next month. When one lands, meet it.