What I Do in the Five Minutes Before a Heavy Session
The text I get an hour before
It's 9:47am. My 11am client texts the practice.
"soooo...I relapsed."
I get a version of this text more often than I would have predicted when I first started doing this work. It comes through the patient portal, by text to my personal line if she has it, or as a frantic email at 6am the morning of the session. The wording varies. The clinical event is the same. A client I have been in regulation work with for weeks or months has had a behavior she did not want to have, and she has chosen to tell me about it before she walks into the room.
What I do between 10:55 and 11:00am, after that text has arrived, is the clinical work nobody trained me to do.
Today I'm going to walk through it. Because this preparation, the five minutes before a heavy session, is one of the highest-stakes windows in the entire week.
Why these five minutes matter
A client who is relapsing has already decided, somewhere in her body, what kind of clinician I am going to be when she walks in.
She decided it on the way to her car. She decided it again at the stoplight. She has been rehearsing the version of me who is disappointed in her, the version of me who is going to want to "problem solve" the relapse, the version of me who is going to look at her with the specific look she has gotten from every other provider she has ever told. By the time she opens the telehealth window or sits down across from me, her nervous system has rehearsed the script for the next 50 minutes in advance.
My job in the five minutes before she gets there is to walk into the room in a state that breaks her prediction. The clinician she is expecting cannot be the clinician she finds.
That is a regulation task. Which means it has to happen in MY body before it can happen in hers.
What the five minutes actually contain
Two minutes of meditation. Not because I am committed to a daily practice (though I am). Because I have just received information that activated my own nervous system, and I cannot co-regulate her from an activated state of my own. The two minutes are for me. They are how I clear the sympathetic charge from reading the text so that I can meet her without it sitting in my chest.
This is the part that I think about a lot. The dietitian who walks into a relapse session carrying her own activation is going to deliver an intervention that has her activation laced through it. The client will feel it. She will read it as judgment, even if no judgment was said out loud. Co-regulation runs both directions whether we want it to or not.
So the meditation is non-negotiable. It is clinical preparation, the same way a surgeon scrubs in.
A chart review with a specific purpose. I am not reviewing the chart to remind myself of her diagnosis or her meal plan. I am reviewing the chart to remember her. The specific texture of her presentation in the last session. What she was wearing. What she said about her mother. The thing she laughed about that surprised me. The phrase she used that I wrote down verbatim because I knew it was going to come back later.
The chart review is how I walk into the room with her already in my mind as a whole person. A whole person, recalled in specifics, is a different opening posture than a clinical case being managed. She can feel the difference inside the first 30 seconds.
Three to five questions I might ask. I draft them in the chart before the session. I will probably not use most of them. The questions are scaffolding. They are there in case the conversation goes flat, or stalls, or needs a doorway opened that she cannot open herself. The questions are usually some version of: what was happening in your body in the 20 minutes before. What were you trying to give yourself. What would you have needed instead, if it had been available. What does the relapse tell us that the regulation work has been missing.
I rarely ask any of them in the order I wrote them. I sometimes ask none of them at all. The questions exist so that I can sit in the room without an agenda, knowing the agenda is there in the chart if I need it.
A commitment to not committing. Before I enter the room, I tell myself the same thing I have been telling myself for years now. Do not commit to the direction of this conversation. Do not decide what this session is going to be about before she has spoken. Let her tell you what the relapse was, and then let her tell you what the relapse was about, which is almost never the same thing.
The clinician who walks in with the session pre-planned will deliver the session she pre-planned, and the actual session will go unheld. I have done this more times than I want to count. The discipline is to leave the plan in the chart and walk in with my hands open.
The honest version of how I feel
I am going to tell you the truth, because I think other dietitians need to hear it.
These five minutes sometimes feel like preparing for an exorcism.
There is a heaviness to the work that nobody warns us about in school. A client who is relapsing is in real pain. The pain has been compounding for days or weeks before the text arrived. By the time it lands in my inbox, the room I am about to enter is loaded with everything she has been holding alone in the meantime. I am about to be the first person she tells the full version of it to.
That is a serious clinical encounter. It deserves a serious clinical preparation. Some weeks the preparation feels light and the meditation comes easily. Some weeks it feels like I am about to do something heavy with my whole nervous system, and I need to know that going in.
I will sometimes play a song before a session like this. Something that brings my body up out of whatever state the day has put me in, something that reminds me who I am as a clinician and why I do this work. I do not list the songs. The list is mine. The point is that the work is allowed to need a soundtrack sometimes, and the clinician is allowed to use one.
What I walk in with
After the meditation, the chart review, the unused questions, and the song, I walk into the session with four things.
An open mind. An open heart. A desire to help her heal. Complete and total nonjudgment.
The fourth one is the hardest, and it is the one that determines whether anything else in the session has anywhere to go. A relapse session held with even a trace of clinician judgment is a session that will set the work back by a month. A relapse session held with complete nonjudgment is a session that often produces more clinical movement than the previous six combined.
This is the part that takes years of personal work to be able to offer. You cannot fake nonjudgment in front of a client whose nervous system has been scanning for judgment her entire life. She will feel a one-percent activation in your face before you have noticed it in yourself. The only way to walk in without judgment is to have done the work of finding the places in yourself where the judgment used to live, and to have moved through them on your own time.
Which means, again, you have to have done the work.
What a relapse actually is
A relapse is information.
A relapse is information.
A relapse is information.
I am going to keep saying it, because the framing of relapse-as-failure is so embedded in the way most of us were trained that the reframe has to be said three times before it lands.
A relapse is data the regulation work needed. A relapse is the client's body telling us, in the only language it has access to at that moment, that the conditions in her life exceeded the capacity her current skills can hold. A relapse is the next clinical formulation, handed to us by the body itself, in real time, with specifics.
The session after a relapse, held with the preparation I just described, is sometimes the most clinically productive session in the entire course of treatment. The client arrives with her defenses already lowered, because she has already broken her own rule by telling me. The work is to receive what she has handed me with the seriousness it deserves and the warmth it requires, and to help her see her own body as the source of the data the session is about to use.
The setback is the shame about the relapse. The clinical work is to disentangle the relapse from the shame as fast as humanly possible inside the session.
A reflection for your week
If you see clients, try this before your next heavy session.
Take two minutes to settle your own nervous system before you open the chart. Review the chart with the goal of remembering her as a person, with the specifics of her last session in your mind. Draft three questions in the chart that you may or may not use. Tell yourself, out loud or internally, that you will not commit to the direction of the conversation until she has spoken.
Walk in with the four things. An open mind. An open heart. A desire to help her heal. Complete and total nonjudgment.
Notice what changes about the session you have, when the session you have is held inside that preparation.
Where this leaves us
The five minutes before a heavy session are clinical time. The work that happens inside those five minutes, inside the clinician's own body and mind, determines what the next 50 minutes are going to be able to hold.
This is the work that does not show up on a CEU certificate. It is also the work that determines whether the rest of your clinical training does your clients any good when it matters most.
A relapse is information. The five minutes before the session are how we make ourselves available to receive it.
The course
The full clinical sequence for receiving a relapse without dysregulating, holding a session with complete nonjudgment, and translating relapse data into the next clinical formulation lives inside Level 1: Foundations of Psychonutrition.
The founding cohort is $797 for 15 seats. After the cohort closes, Level 1 moves to $997. Enrollment is at newapproachhealth.replit.app.
The field exists now. So does the training.
References
Brewer JA, Elwafi HM, Davis JH. Craving to quit: psychological models and neurobiological mechanisms of mindfulness training as treatment for addictions. Psychology of Addictive Behaviors. 2013;27(2):366-379. doi:10.1037/a0028490
Marlatt GA, Donovan DM, eds. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. 2nd ed. New York: Guilford Press; 2005.
Porges SW. The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. New York: W.W. Norton; 2011.
Siegel DJ. The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. 3rd ed. New York: Guilford Press; 2020.
van der Kolk BA. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York: Viking; 2014.
Witkiewitz K, Marlatt GA. Relapse prevention for alcohol and drug problems: that was Zen, this is Tao. American Psychologist. 2004;59(4):224-235. doi:10.1037/0003-066X.59.4.224
Emahlea Wilcher, MPH, RD, LD, is the founder of New Approach Health and creator of the Psychonutrition framework and CPsyN™ credential.