It has happened so many times over the years that I don’t have a particular patient in mind as I write this. My first contact with a family is usually the mother of a patient. We usually talk on the phone for anywhere between 15-45 minutes so that she can get information from me and a sense of whether I am competent. And I get information about whether the referral is appropriate for me as well as a head start on honing the focus of my assessment. Mom usually tells me a list of concerns about her child. Things that don’t seem right. Things that seem harder than they should be. I am a child and adolescent clinical psychologist. Parents don’t want to meet with me if they think there is nothing wrong.

However, parents often tell their children, in front of me, “There’s nothing wrong with you.” It is meant to be a reassuring statement. It is not, even when it is said in all sincerity. (“There’s nothing wrong with you. The problem is that your school does not know how to teach you.”)

When a parent says this, it is damned confusing to a child or a teen. I mean little kids have fun when they come to my office. I play with them and mix in silly questions like, “If you had three empty swimming pools and could fill each with a different food or drink, what would you put in each one?” I also ask about things they would change about themselves if they could, questions about painful feelings, and other more heavy questions. Interviews with young children are not so much about questions and answers as how they interact with me and whether I can get a flavor for their personality and general cognitive level.

The other kids know. They know that they are struggling in school. They know that they are not getting invited to birthday parties. They know that they are getting yelled at by their parents. They know that their grades are bad. The older ones know which teachers actively dislike them.

This way of communicating sends the message that to have something wrong with oneself is too bad to speak of and must be avoided. It is a layer of non-acceptance that can make happiness very difficult. The confusion of being told that “nothing is wrong” when it is patently obvious plants the seeds of externalizing blame and/or internalizing shame, neither state being compatible with taking responsibility for one’s own life. Is it so bad to say something like, “Everyone has things they are good at and things they have to work on. You have a hard time making good choices sometimes. We will help you with this.”

This is part of the reason that the message I saw on Facebook the other day, “There’s nothing wrong with you” got me fired up. It is a seed that can grow into much unhappiness. I see so many wonderful people in my professional and personal life who struggle with perfectionism, never being satisfied that they are worthwhile and good people. I see very successful and outwardly happy people who I can tell, due to my own empathetic skills and life experience, seem like they are faking it. Pain has a way of bubbling to the surface, even when well hidden.

My own perfectionism, which has waned over the years, seems so unnecessary now. The part that remains is fairly stubborn but I will keep working on it. I know that parenting cannot stem the tide of the influence of our culture. But parenting matters and it matters a lot.

I try not to be preachy in my blog because I have tried to focus on my own personal experience. That tone is the most healthy for me. I was kind of preachy yesterday. But that’s okay. You can handle me being fired up every once in awhile. I also did not want to make my blog into a “psychologist’s blog” including advice. But today, I would like to share what I think is the very most important way to teach our children self-acceptance.

Work on your own self-acceptance. I have decided that not only am I not perfect but that perfection is a goal that is unworthy of me or of my family.

I deserve better. And so do you.

I had an entirely different idea for a post today. Then as I was closing Facebook in order to write it, I saw another one of those inspirational quotes that has come to make my skin crawl. There were examples of how potentially negative attributes have positive implications, as well. The ending of the quote was, “There’s nothing wrong with you.”

Why do so many feel it necessary to say this? I believe it is very unhealthy.

Everyone and I mean everyone has faults. Lots of personality qualities have both positive and negative implications. The positive implications don’t erase the negative or vice versa.

Why do we need to convince ourselves that we are somehow perfect?

We aren’t. It’s a lie. It’s an utter and outright lie.

The problem is not being imperfect. The problem is not accepting that we are still good and worthwhile despite imperfections.

There are lots of things wrong with me. There are mostly things right with me.

There are ugly things about me. There are mostly beautiful things about me, and I’m not talking about pretty.

There are dishonest things about me. I am mostly honest.

There are selfish things about me. I am mostly fair and generous.

If I have to tell myself that I am perfect to feel better about myself, how will I ever look at myself honestly, trust myself, value myself, and grow as a person?

Finally, let me put it this way. I am a clinical psychologist. My job is to help children and teens be happier and healthier. I know of no effective treatment that involves my telling my patients lies or teaching them to lie to themselves.

Honesty is the best policy and a keystone of self-acceptance.

 

I had my penultimate Lupron shot. Yes, my second to last jab, on the right hip this time, with a syringe of Lupron stored in a package decorated with a photo of a smiling African American man, whom I am to assume is to represent a prostate cancer patient. Because, you know, both women and men love it when we get our hormones turned off by Lupron. It’s a party!

Lupron made me infertile by disrupting the signal between my pituitary gland and my ovaries. Yeah, I know, I talk a lot in my blog about breasts, a secondary sexual characteristic. However, the ovaries, primary sexual organs, are also commonly involved in breast cancer treatment. That’s because a lot of breast tumors, including the ones that were discovered in what was formerly my right breast, grew in response to progesterone and estrogen, two female hormones.

I could complain about the fact that a big part of my breast cancer treatment has been both a surgical and chemical warfare on my femininity. Remove my breast, then remove my lady chemicals. Go ahead, make me a man!

I’m not going to complain about this. Yes, losing a breast is a big deal. But that happens to many women, regardless of the hormone responsiveness of their tumors. Having had tumors that are progesterone or estrogen responsive is actually a positive prognostic indicator. Reducing hormonal activity is something that can be done to reduce the chance of breast cancer recurrence.

Chemically induced menopause is rough. I can tell you this first hand. Menopause symptoms, on average, are worse. I can tell you this, first hand. At the peak of my menopause symptoms misery, I had about 50 hot flashes EVERY DAY. Does that sound intensely uncomfortable? If yes, I have done an effective job in describing it. IT WAS RELENTLESS.

Currently, I experience almost no menopause symptoms. Also, I do not menstruate. And it is impossible for me to get pregnant. In other words, I am in a state of bliss.

It is likely temporary. Lupron does not permanently shut down my ovaries. In six months, my body will be adapting to the absence of Lupron. I will be 49 years old. At that time, I may become fertile again. My menopause may pause! Thanks a lot, menopause! Let me get used to you for two years and then throw a wrench into the works!

Yes, Virginia, I’m going to have to start thinking about birth control again. Aaaaaaaaaaaaaah!

The last time I took a pregnancy test was at least five years ago. I knew it was unlikely that I was pregnant, but things were not as usual, and I wanted to be sure.

Based on my family history, I am likely to go back to a peri-menopausal state after I discontinue my Lupron shots. In other words, it unlikely that I will be able to conceive, but still possible. My last method of contraception was an I.U.D, which I loved, but then had to have removed, because it secreted female hormones, and I am not allowed to have those.

Yes, I know that I am solely responsible for contraception. And I have talked to my nearly 50 year old husband about perhaps, just perhaps, getting a vasectomy. The first time I raised the issue was when I was 37 years old. I did not raise it again until I was a breast cancer patient, nearly 10 years later. Neither conversation went particularly well. In my husband’s defense, I probably raised it too early the first time, and the second time, he was likely stressed by the prospect of his wife dying.

I may be a two time champion of menopause achievement. It is not a title that I particularly relish but I guess they are far worse things in life to bear, like CANCER!!!!

As I’ve mentioned before, I am a fan of the show, RuPaul’s Drag Race. It is a comedy reality competition show. The contestants are drag performers. RuPaul Charles, who is a famous drag performer who also sings, created the show and hosts it.

RuPaul is a gay man in his early 50s. He dresses in women’s clothing when he performs. You know that he’s been called all kinds of names, been gossiped about, and beat up, many times in his life. One of the expressions he uses in his books (yes, I’ve read more than one of his autobiographies) and on the show is, “What other people think of me is none of my business.”

For those of us who are plagued with self-doubt, who feel lack of validation, who perceive and/or receive rejection from others, this is a very powerful statement.

At first, it sounds like a joke or some overly glib line.

How other people treat you is your business. These are actions.

But how many times have we read each others’ minds when we really don’t know? I know that I have done this a lot in my life, less so in recent years. But I still do it. We can’t know what another person is thinking. And if we did, pandemonium would ensue!

When I consider what people would hear if they could read my thoughts, I know that I would lose all of my friends and family. We all have careless half thoughts, mean thoughts, selfish thoughts, critical thoughts. But we have other thoughts, too. And sometimes, we may have a very nasty thought about someone, in the heat of the moment, only to soften later. I don’t want you to read my thoughts because they are private. It is my right to share them or not share them. In other words, they are my business.

And you know what else is my business? How I feel about me. Yes, I may sound like a children’s show, but think about it. What would your life be like if you worked toward accepting this in your heart?

“What someone else thinks of me is none of my business.”

Robin Williams was my middle school homework buddy. Yes, I used to do my homework in front of the television, which is a very bad habit. (Shhhhh, don’t tell my patients or my daughter.) As I recall, Mork and Mindy was a smash hit almost as soon as it debuted. Even as a kid, I could tell that the writing on that show was not that great. And some of the characters were not funny. But Robin Williams improvised a lot of his dialogue. He was fast, charming, impish, hilarious, and able to switch from utterly naive to lascivious in a split second.

As a young teen girl it was not lost on me that he was damned cute. So cute that despite my preference for clean cut boys (remember, I was a very young girl) who were on the pubescent side, I looked past Robin’s manly mane of chest hair that could clearly be seen peaking out of the top of his rainbow colored t-shirts. Mork was a stand up guy even when he’d sneak a dirty joke into each off his lightning fast riffs on the English language, pop culture, history, and astronomy.

Robin Williams went on to be a star and a good actor. I loved him as the lead in The World According to Garp. Very funny, very sweet. This was also the first time I noticed the sadness in his eyes. There is a common image of a comedian or a comedic actor as a “sad clown”. I don’t think that all funny people have to be sad but I do know that a good deal of famous funny people are sad. Frankly, I think most celebrities are sad. There is the drive to get attention with so much rejection interspersed. The attention and recognition are so inconsistent. When they come, I imagine it is like the high of a drug and you can never get enough.

I went on to enjoy most of his films over the intervening years and then he became involved in my school work once again in March of 1997. I was living in Florida at the time for my psychology internship. I had flown back to Chapel Hill, North Carolina for a couple of days because I was defending my doctoral dissertation. The doctoral defense is a centuries old tradition going back to the Middle Ages and deserving of its own post. Let’s just say that it is the day I wore a business suit, presented my dissertation research to five professors, they peppered me with questions for an hour and a half, then made me wait in the hallway for a half an hour while they determined whether I would get my Ph.D. or not. The whole thing lasted three hours and was the culmination of 6 1/2 years of graduate school.

There was another notable occasion occurring on campus that day. Robin Williams was just a little ways away filming Patch Adams. And I missed him! My friend and fellow graduate student, Jawana did not miss him. I excitedly asked her, “What was he like?” She replied, “He’s a small hairy man.” Ha! Not very nice, Jawana! Robin probably noticed this himself. Perhaps he would have compared himself to a muppet. Hairy, funny, and adorable.

Robin Williams, the world is never going to forget you and I’m not just saying that because I’m sad that you’re gone. You were a singular sensation. I could see the sadness behind your eyes. I could see the addiction to attention as well as other substances. The mania that delighted us when it was at the right speed. Nonetheless, you shocked me. You had lived through so much and escaped alive. You were 63 and somehow even though I’d heard you’d gone back to rehab, I thought you’d keep yourself around.

I am a professional who knows better. I was naive and hopeful. I thought you had enough Mork in you to keep you alive.

To feel alone with such love around you must have been devastating. I didn’t know you but you knew how to make me smile. Rest in peace.

There’s a famous developmental model in clinical psychology developed by Drs. Mark Greenberg and Carol Kusche. It is rooted in the larger cognitive behavioral model. The model is called, “ABCD”. It refers to Affect (emotion), Behavior, Cognition, and the Dynamic interplay among them. Because it is a developmental model, it refers to this interplay not only in a particular moment, but across time.

Sometimes AB and C work together in cohesion. Often they work at odds with one another. Sometimes they work in cohesion but in a way that is not healthy. “I am angry with you and I’m beating the shit out of you because I believe I am entitled to beat the shit out of anyone I don’t like for any reason.”
I know that many of us strive to live more peaceful, loving, and cohesive lives. And for extra credit, we are decent and upstanding people. I have worked hard over the years to live a life that is cohesive and healthy. I have focused on this in particular in my mindfulness practices in the last couple of years.

I am pretty happy. In general, I live a pretty balanced and cohesive life that makes sense. To be perfectly honest, I sometimes watch people I love say they want to be a certain kind of person, living by certain values, and then make choices that totally contradict their stated goals without apparent knowledge of this discrepancy. I have tried to make a habit of turning inward at these times. I am getting better at it. Bit by bit.

I decided a few weeks ago to dig deeply into the parts of myself that I try to avoid. To be honest, it is a narrow part of me but it runs very deeply, and when I hit it, it is very painful.

I know I am a good person who does mostly very good things. But there are areas in which I fail. Areas in which I let fears, irrational thoughts, and habits drive behaviors that are very much out of line with my values.

I lose my temper with my husband. I respond to situations as if they are much bigger than they really are. Sometimes, I let other people’s unhealthy behavior toward me define my own sense of worth. At times, I take on a love one’s hurt not only as if it were my own but as if it were my responsibility to fix.  Sometimes these misfires of affect, behavior, cognition, and their dynamic interplay are brief. Other times, they play out over the years, like increasingly gnarled tree roots underground. I can feel them. I know they are there but I can’t see them.

I know I am not alone in this. No one is perfect. But I’m tired of feeling happy and balanced so much of the time only to find myself acting grouchy, ridiculous, and sometimes outright mean, when I pass my stress tolerance. I used to live my life very near or at capacity so I stressed very easily. It’s not so easy now so I figure this is a particularly good time to work on this.

There is a concept of “radical acceptance” in mindfulness meditation. In my understanding, it means observing our own painful thoughts and feelings and allowing them to be, instead of resisting them.

This is why my blog sometimes reads like a confessional. I am, however, not seeking reassurance or absolution. I am trying to better understand myself and be a more balanced person.

I am also trying to show that it is possible to be a happy person without being a perfect person. Over the past year, I have begun to view a lot of coping statements people use as being counterproductive for me. I don’t like telling myself “beauty is only skin deep” or “fat is beautiful” when I am not feeling good about my body. Similarly, in terms of aging, I don’t want to tell myself, “I’m only as old as I feel” or “age is only a number.” I would like to keep working to a point where I say things to myself like, “I am overweight. That may not be the greatest for my health. What do I want to do?” Or, “I am getting older. I’ve had a serious illness. I’m living a pretty healthy life now, doing the best that I can. I think I will get on with my day.”

I am working to get to a point where self-examination is objective and leads to serenity or agency. I am getting there but I still have much further to go. I am trying to take apart the mechanism, bit by bit, that turns self-examination into doubts of worth.

I used to think that having a balanced life meant almost never feeling stress and shuffling through the states of joy, bliss, serenity, faith, hope, and resolve. I actually had a friend years ago who practiced mindfulness, who seemed this way. Then there was the day I tried to say something empathetic about her stress level because we were all working hard. She quickly and somewhat sharply told me that she “never” got stressed. Then I knew. She was one of the rest of us.

People are complicated. Life is complicated. We spend our whole lives at A, B, C, & D. And thank goodness. I want to live a long life and how boring would it be to have it all figured out.

I am generally a patient and polite person. There are a few situations, however, that can get me fired up in a hurry. One of them is when people don’t take “no” for an answer. If you call me at home and are trying to sell me something, I will say “No, thank you.” If you keep talking, I will say, “Please put me on your do not call list” and hang up.

If you are the outreach director for a private tutoring and one-on-one school, who calls me repeatedly to set up a meeting even though I have told you I cannot do so,  due to cancer treatment, I will be irritated with you and tell you that your calls aren’t welcome and to please stop. Guess what happened today? The same woman showed up to my office, uninvited. Do you know how many uninvited visitors I get in my little office with it’s discrete location? About one per year. I told her, “No, I am not able to meet with you. I know about your school. I asked you not to contact me.” She replied, “But I thought that you just didn’t want me to CALL you.”

“Coming to my office uninvited is even more intrusive than calling. Please don’t contact me again.” She apologized and left.

Keep in mind that I ordinarily accept meetings with people from private schools and tutoring businesses. But this woman happened to call when I was going through intensive cancer treatment. I told her that, also told her that I would contact her in the future if I wanted to meet. But she kept calling and today, she showed up on my doorstep. I have actually referred families to this school and I will likely continue to do so because the person who does marketing is not the same as the people who provide the educational services.

Honestly, I feel mean when I set limits like this. But I also feel justified in being firm and direct. These hard sell tactics rely on people’s inclination toward politeness and needing to be seen as “nice”. The strategy is one that takes advantage of most people’s positive nature. I know the people who are not taking my “no” for an answer are probably not thinking of it that way. But the strategy itself is extremely disrespectful.

Hmm, is it really “extremely disrespectful”? It is disrespectful for sure. But the fact that my heart rate is still slightly elevated and I still feel residual anger about this intrusion tells me that it is time for me to explore why this situation set me off so.

I am by nature, a generous and helpful person. My parents are also generous people. But I also remember growing up, thinking that they had trouble saying “no” when asked for a favor. (It doesn’t seem this way so much now, so I wonder if I remember correctly.) It was like it was bad to even ask because my parents would say “yes” unless it was a telemarketer. (When vacuum cleaner salesmen called, my mom would always say, “I have dirt floors.” Ha!)

When I am asked for something, my initial inclination is to give it. But I have learned over the years that this is not always a good idea and in some situations, it is downright unhealthy. I can take time and energy away from my family, friends, patients, and from myself. I have also learned that there are people in life who will ask over and over again, giving nothing in return. And then there are the people who don’t even ask, they just take.

When I say “no”, I have already gotten myself to do something that I am not typically inclined to do. When the “no” goes unheeded, I feel unheard. Oh dear, there’s a trigger. I hate it when I don’t think people are listening to me. When I am unheard, I start repeating myself, I get stern, I may interrupt. I don’t feel generous. I feel in need of protection. The word that keeps popping into my head but I haven’t yet written it down because it feels too strong is “violated”. I feel violated. Do I feel helpless? No, I don’t but I feel very very wronged and that I may lose something of myself, the years to building up assertiveness and confidence, if I back down.

I often used my writing on this blog as a way to figure out a puzzle. I think I have gained insight in writing this but really, I am only scratching the surface and there is much to be uncovered. I think that this triggering experience comes from some kind of combination of my personality, my experiences as an individual, and my experiences as a woman. I’m not really sure and I will never really know. I do know that my tendency toward strong reaction negatively impacts my relationship with my daughter and with my husband. With my professional life, I am able to regain external composure even if feel internal strain.

I will keep working on this.

Note: I actually wrote this post several days ago and didn’t publish it because it felt unsettled. I am currently exploring the situations that are most triggering for me, “buttons” that when pushed, elicit an irrational response. I am trying to shrink these buttons. As I say, I will keep working on this, as unfinished and unpolished as it is. But it is as it is.

About five minutes ago, I was trying to remember why this date is important. “Is today someone’s birthday?” I looked at the calendar. August 8th. The memory came to me accompanied by a small visceral twinge. Two years ago today, I had a right side mastectomy. Last year, the date took me by surprise, too. But when I remembered, I sobbed uncontrollably, on and off, for three days.

The sensation in my pectoral muscles has returned somewhat. I can feel pressure beneath my reconstructed breast. My kittens reminded me of this yesterday when they were chasing each other around the house, tearing through the living room. They both used me as part of their race track and kept running across my chest.

My abdomen is still numb, though this continues to dissipate. The plastic surgery nurse, who had the same reconstructive surgery as me, a TRAM, told me that the numbness lasted about three years for her. I also noticed that although my body doesn’t feel the same way it did before, it feels like mine.

I’ve noticed other physical changes. Last night, my husband went out for a late dinner and a walk along Alki Point, a beautiful seaside area. Along the walk, we were able to see the downtown skyline, the water, and two mountain ranges. We walked about two miles to a restaurant on the other side of the point, ate on a balcony overlooking the Puget Sound and the Olympic Mountains, and then we walked back two miles to where our car was parked. John had to pick up our daughter from band practice, so we were in a bit of a hurry walking back.

As usual, I had my camera with me and as usual, there were interesting photo opportunities along the way. We agreed that John would just keep walking, at his normal pace and I would stop to take photos whenever I wanted as long as I could run and catch up with him. That way, he wouldn’t be late. I have a long hate-hate relationship with running. Actually, it is just strong dislike. But I thought I could probably do it.

There was one spot that was particularly photogenic, so I took several shots. Then I needed to run to catch up with my long-legged man. It took me awhile to catch up. When I did, I noted to John, “Hey, I’m not breathing hard.” After complimenting me, he said, “What’s it been, about five years since you’ve run that far?” I laughed. “John, it’s been about twenty years since I ran that far!”

Breast cancer is awful, there’s no doubt. Cancer is powerful and destructive. It is nice, however, that healing and resilience are also powerful.

The "flower houses" at Alki Beach.

The “flower houses” at Alki Beach.

Our view at dinner. Puget Sound and the Olympic Mountains.

Our view at dinner. Puget Sound and the Olympic Mountains.

 

Seattle skyline across Elliot Bay.

Seattle skyline across Elliot Bay.

As you know, I love photography. I mostly take nature photography, but I also take photos of people. My people shots are usually informal but occasionally I try to take a good portrait. I have come to view the goals of nature and portrait photography differently. In portrait photography, the goal is usually to capture a human image that looks better than a person usually looks in day to day life. If you think about it, people have ever changing appearance due to our changing mode of dress, use of make-up, but even more importantly, we have muscles and our bodies, especially our facial features are in motion. When I’ve had my portrait done professionally, the photographer puts effort into getting me to hold my body in a particular way, tilt me head just so, look at the camera, and usually, to smile. Backdrops and lighting are used.

I think the goal of nature photography is to capture the subject as it ACTUALLY LOOKS. I have taken so many photos only to think, “That looked so much better in real life. Because I try to capture natural subjects as they actually look, I don’t typically rearrange the environment to make a better photo. Occasionally, I use a flash and on the rare occasion, I might move a twig out the way that’s blocking the shot. When I move a twig out the way, I actually feel like I’m cheating, I try to remove myself from the photo except for choosing what part of what is actually there is going to fill the frame.

In this way, I think of taking portraits as requiring being more of a participant in the photo and of taking natural shots as being more of an observer, standing back so as not to mar any of the natural beauty before me.

A common way that I try to take myself out of my flower photos is when my body casts a shadow on the flower. I will move to take the shot from another angle or occasionally, I duck my body down, keeping my arm raised and snap. The latter approach doesn’t work particularly well but if I can’t take the shot otherwise, I often give it a try.

A few days ago, I was taking close-ups of roses, something I love to do. Roses are not just beautiful from a distance. They are mesmerizing up close. The texture of the petals, some creamy, some satiny, some velvety. And their multi-petal form creates interesting light and shadow and well as patterns within their overall forms. It was mid-day and the sun was overhead. I leaned over to snap a photo and I saw my shadow. I was about to make some attempt to remove my shadow when I realized, looking down through the view screen on my camera that my shadow actually added interest to the rose. It looked like it belonged and it actually enhanced the beauty of the bloom by showing contrast of light and shadow.

I often write in this blog about how much healthier I am when I feel connected to nature. Every time, it fills me up a little more. Over time, I am more frequently able to carry a feeling of joyful serenity for a little longer.

Mindfulness sneaks up on me with gentle waves that ebb and flow but still manage to build a reservoir.

DSC03396

As a clinical psychologist, an important part of my job is what is called “forming a therapeutic alliance”. This is a bond of rapport, trust, and understanding. It is a necessary component whether I am doing a short term assessment or long-term psychotherapy. I work with difficulties that require a team to effectively address.

As a child and adolescent psychologist, the size of the team is bigger than it is for adult clinicians. Although my primary alliance is to the child or teen, I must also form working alliances with parents, teachers, other mental health providers, and physicians. It is also not uncommon for me to have to interact with school principals, individuals with a school district or with the state superintendent’s office, occupational therapists, speech/language pathologists, or grandparents. I am fortunate in that my contact with child protection, case workers, and police enforcement is rare, but it does happen.

I work with the “it takes a village” kids. And I often take on the role of training the adults who are with the child daily about how to best support the child’s unique needs. The members of the village with whom I have the most contact are parents.

Parents are in a very influential position withe the kids I assess and treat. They often feel helpless. They often feel guilty about their children’s challenges. They often take out these painful states on the people they love the most, their children.

And to my patients, the teens especially, I often look like another adult who is going to tell them how they are screwing up their lives and making everyone miserable.

Because I primarily do short term assessment, I have to work fast. I don’t have the luxury of letting relationships and alliances develop slowly over time. In some ways, this is an advantage as the time limited nature of the process creates a sense of urgency to enact change, assuming the family is ready to make changes. Part of working quickly is that I need to communicate directly, I need to make recommendations, and I need to communicate hopefulness but also urgency not to continue to let problems worsen. Some of the kids I assess have long-standing undiagnosed and untreated difficulties leading not only to a worsening of the primary conditions but to the development of secondary disorders.

I don’t work for a system like a hospital or community health center. I have my own little private practice office. I don’t work in a prison but I do work to prevent children and teens from getting involved in juvenile justice. I don’t work in a mental hospital but I work to prevent teens from being hospitalized or help them transition back to the community from the hospital. I don’t work for the welfare office but I do work to support my patients’ educations as much as possible so that they can complete high school and perhaps even complete college so that they can become reliable members of our country’s workforce.

This is my long way of saying that my job involves a big team and a long view towards the future as well as responding to the present issues. Sometimes I forget how hard my job is.

What I do remember more easily are the times I felt like I needed to break an alliance in order to protect a child. Now I don’t mean calling child protective services, though that would certainly be an example. I am talking about other instances that are not as clear cut as making a suspected abuse report.

I am talking about times I have to give someone very firm direction or feedback when it is a risky thing to do and I have either exhausted other strategies or there are no other strategies available. Sometimes it means writing an email and leaving a voice mail with my patient’s psychiatrist who has been unresponsive despite our mutual patient’s level of depression, saying, “You need to communicate with me more frequently. _____ was talking about killing himself just three months ago. He is not doing well. I know you are busy, but I need to hear from you as soon as possible.” (I heard back within an hour.)

I am also talking about responding to a mom of a teen, adopted from another country. She was mad at him and told him that she was going “to give him back.” Since I had already conducted the background interview and he was there for testing. In other words, she was supposed to be in the waiting room, not in my office. I empathized with her frustration but told her that the next step was to do assessment. She kept telling him how horrible he was. Then I told her that her job was to “make things better instead of worse” and suggested that she go take a walk to regain her composure. She kept yelling. I told her that she had to leave. Believe it or not, I think that she really loved her son. I didn’t think she was a bad person. But she was not well herself, depleted, making bad decisions, and her behavior was hurting her son. It was not her fault that her son had the challenges that he did. But it wasn’t his, either. And it was her responsibility to be the adult.

I was pretty sure I would not see that family again and I didn’t. I knew I had hurt and angered that boy’s mother. I saw the opportunity to do was to let that boy know that the way he was being treated was unkind, unfair, and harsh. It was the best I could do at the time.

Most of the time, I am able to navigate these sometimes conflicting alliances.  It is complicated but doable. One of the things that makes it easier is that my professional relationships are not reciprocal. In other words, my patients and allied health professionals are not responsible for taking care of me.

This is not, however, the case in much of my personal life. In my personal life I have reciprocal relationships with friends, my husband, or with professional colleagues. And that’s where alliances get even trickier. Because now my expectations, my wants, and my needs enter into the equation; they become part of the team of my relationships.

With expectations comes fulfillment and disappointment.
With need comes receiving and hurt.
With wants come desire and loneliness.
With dependence comes relief and uncertainty.
With honest communication comes raw hurt and vulnerability.

Relationships bring the best and the worst to our lives, even with the right people. I am kind of impressed that people keep trying and that many people have strong and resilient relationships. This makes me hopeful. Just because my relationships can be difficult doesn’t mean that I am doing them wrong.

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