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.