Therapeutic Presence in Infant Feeding Care

Jessica Altemara, IBCLC

We go into a lactation consultation armed with passion, knowledge, experience, and tools. We gather a thorough history, problem solve, work on basics like latch and positioning, and prepare a care plan. We feel sure that, if they just follow this plan, families will quickly reach their feeding goals. Things go smoothly; rapport seems good and new positioning makes some immediate improvement. Parents appear receptive to the ideas and plan provided. They listen actively as we explain things. We walk away feeling optimistic for them and accomplished in our role.

Then, on follow up, it is found that only pieces of what was discussed seem to have been understood well. Or, more frustratingly, parts were completely misconstrued. Sometimes, it turns out, parents later express that major aspects of the plan, to which they seemed so receptive, are just not a good fit. Sometimes we hear from a colleague that parents describe the consultation as having gone quite differently from our own experience. Recounts by them, on social media, seem to miss pivotal details. Alternately, at times, parents may implement a care plan, as expected, and have success, while also becoming dependent on our judgment or demanding of our attention.

This leaves the puzzle of what additional tools we might utilize, with parents of infants, that would provide more consistency in reception to care plans and understanding in general. These tools might even be used in creating care plans that are able to be more accurate to the whole picture, so as to encourage ownership and empowerment. What can we pull from our “bag of tricks” that will enable parents to express their needs, integrate information, and assess our suggestions accurately, on the spot? How do we break through the “noise” of new parenting? One powerful tool of this nature is Therapeutic Presence. Therapeutic Presence is about being physically, emotionally, clinically, cognitively, socially, and operationally in the moment, in the service of another.  Studied and written about intensively by Shari Geller, PHD, originating from the writing of C.R. Rogers, the strength and power of holding Therapeutic Presence has been shown over and over. In fact, the practice of doing so quickly provides its own evidence, in the distinct change of experience for both clinician and client.

A major factor, in supporting families with infant feeding, is that the associated life transitions are typically filled with emotions. Adding to the natural evocations of life transitions, Western Culture is fraught with contradicting and judgmental messages about parenting, especially breastfeeding. Parents are frequently left on their own to manage what would traditionally be provided by an entire community. Considering the intimate nature of lactation care, those of us supporting families in this context, find ourselves in the center of a whirlpool of excitement, fear, celebration, pain, pressure, confusion, love, information overload, and exhaustion. This presents a unique challenge for enabling parents to integrate the wellspring of valuable guidance and information that we offer. This is where the presence that we bring to an encounter can make all the difference. When that whirlpool of emotions can be calmed, space for problem solving and information is created.

 Concretely, there are defined aspects to Therapeutic Presence. This will include grounding oneself; checking your internal barometer to be sure that things are balanced and clear, from a personal perspective. Also, included is making sure physical needs are met as well as possible. It is important to approach this engagement with a “blank slate” and avoid any projection of lingering previous experiences. Without a deep personal awareness, true therapeutic presence is simply not possible. When moving into an encounter with a family, this process will include matching tone, pace, and volume with those seeking support. It will mean remaining in the moment, without frequent inner “side conversations” about what will be said next or charting exhaustively. All thought about the next step on the checklist will be withheld. Subtleties are what can be noticed by the provider, in this context. Often, parents in the throes of the experience are not grounded enough to catch subtleties. Since most communication is nonverbal, self-awareness allows us to notice subtle physical changes in ourselves, which -if we are fully present- will give us insight into the experience of the parents, below the surface, and even their receptiveness to us. These insights can be shared, gently, with families, to guide the evolution of an encounter.  It is vitally important, as well, to be deeply aware of our own judgements and personal biases and develop tools for neutralizing them immediately, when they arise. Acceptance enables safety.

Therapeutic Presence will not, however, mean holding an intensity out of sync with that of the family. Too often, people think they must become the caricature of therapeutic presence often portrayed in popular media that includes an overly intense, hyperbolically “zen” provider who also seems to lack personal boundaries. True Therapeutic Presence is very different. In fact, a key aspect is to be the compass for the bigger picture -while still acknowledging the details of parents’ current experience. We can provide a sense of spaciousness that gives breath to the interaction. It means projecting a faith in their resilience and confidence in their innate wisdom. Primarily, it means creating and holding a space for processing. This might require comfort with venting negative emotions. It might include tears or angry sighs. It might mean gasps of anxiety or even panic. Holding space includes no fixing. It does not involve encouragement or comforting. It is rooted in empathy and personal comfort with the emotions or ruminations that need processing. It means sitting with and reflecting feelings at the intensity that matches the nonverbal level, with no need to “make it better”. It says, “It’s okay to feel any way that you feel and I accept these feelings without judgement.” Therapeutic presence means being the eye of the storm that allows for clarity, even if only briefly, and an emptying. Holding space for feelings creates space for learning and problem solving!

Therapeutic presence: Neurophysiological mechanisms mediating feeling safe in therapeutic relationships.

Journal of Psychotherapy Integration

Sep 2014, Vol 24(3), 178-192

Initial Exploration of Therapeutic Presence Pedagogy in Counselor Education

International Journal for the Advancement of Counselling

December 2018, Volume 40, Issue 4, pp 481–500