About client relationships: who is the alliance really with?

Sunday, March 20th, 2011, Written by jackrosenberger

It happens not all that often, baruch Ha Shem, that one will have a young person in treatment that the parents decide needs to attend therapy less often than is clinically indicated. This is a real ethical dilemma.

On one hand, you are committed to the young person and their process. And they usually see the value more than the parents do, especially when the parents are not aware of whats going on in their life. On the other is the commitment the therapist made to the patient, to not demean oneself or one’s services. Even worse, one does not want to model how bullying works.

All too often, the discounted and diminished analyst becomes the object lesson in “This is how you don’t get walked on” and other misguided notions. Worst of all, though, is how the continued work with the therapist creates a rift in the young person’s attachment to the parents. Although this might seem like a good idea at first, creating and living with this kind of rift can only become the source of other attachment problems that will manifest later.

So the question becomes this: is some treatment better than none? In some cases the answer is a resounding YES. If the young person refuses to see any other clinician, and the problems are not set in the personality structure, then some short-term work might be ethical and acceptable. But if the problems are set in the personality structure; have had real-time consequences in his/her life; live in the disturbed attachment field (more on the attachment field later!); and have an inevitable quality to them, then perhaps the clinician has to have the humility to bow out. In this situation give referrals if that is possible. But be sure to keep the door open should some crisis emerge.

Oddly in these situations, crises have a way of rearing their ugly head. The act of setting the boundary with the parents can serve as a model for the patient; although boundaries might look odd and feel weird, they are necessary and help to keep everyone safe. To be on the safe side, document your decision and make sure you have assessed for safety. In this situation, it is the clinician’s job to worry about suicidality more than the parents, who will NOT hesitate to call counsel.

Most of all, trust your well honed clinical instincts, talk with other clinicians, and make sure your decision does not come from any other place but concern for the young person and good boundaries.  Our own unanalyzed counter-transference can always get us into trouble!

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