The rituals that have worked best in my sessions are invariably those discovered by my young clients. My role is simply to go with the flow. Fourteen-year-old Jeremy suffered from excruciating self-consciousness and anxiety, which provided fodder for other kids' taunts. He was as self-conscious in therapy as outside; he couldn't talk about his life or his feelings. At the time, I happened to have in my office a football-shaped, stuffed hedgehog for the younger children. One day, Jeremy picked it up and, somehow, we began tossing it back and forth. This seemingly boring, nontherapeutic behavior became an anchoring ritual. At every session, the first thing Jeremy did was seek out the hedgehog; if he didn't find it, he'd ask me where it was. And from the first, while throwing and catching it, he could open up about his problems with the other kids.

Soon Jeremy got his father to play a weekly game of catch. During these games, he began to talk about what was going on at school. "What do you think you might be doing that makes the kids act that way?" his father asked as they played. An ongoing conversation ensued with his father and mother about what he could do to improve his image at school--how to initiate conversations, how to ask questions in a way that wouldn't turn everybody off, when and how to respond to kids when they taunted him, and when to walk away. Jeremy's anxiety didn't magically disappear. But over time, these routine games of catch helped him share his schoolyard fears and helped his parents become better listeners and problem-solvers.

Rituals that work are entirely idiosyncratic. Patients make their own preferences clear, often quite insistently. Twelve-year-old Elena was a mass of adolescent angst, dressed in full-Goth garb. Contrary to her anarchistic attitude, she constantly obsessed about what everybody thought of her and worried nonstop about how she looked. She wanted me to listen to the CDs she'd burned between sessions and would invariably jam a few CDs into my boom box and play her ferocious music for me. Listening to the lyrics gave us an easy entree into conversations about her week, her friends, what she was thinking and feeling. If I forgot to ask about her latest CD, she'd remind me.

Eventually, after Elena talked about our "music sessions" at home, she and her mother (who quarreled often and fiercely) established their own music ritual. Mom played that "crunchy-granola '60s crap," while Elena blasted out her hard-edged punk sounds. These interludes became a buffer of peace during which mother and daughter could briefly suspend hostilities and begin to understand each other better. Elena didn't entirely stop obsessing about her looks or what people thought about her, but she did begin to acquire a little less moody perspective. The ritual, as so often happens, provided a structure for a connection with her mother that was both comforting and reassuring.

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