Therapeutic Boundaries

Therapeutic Presence in Infant Feeding Part 2

Jessica Altemara, IBCLC

Therapeutic Presence allows a provider to hold space with parents, being a mirror to their experience. This unique tool, as discussed in Part 1, changes the flow of an encounter to hold energetic space for feelings and create cognitive space for problem solving. Therapeutic Presence is a game changer because it turns us into a safe space for vulnerability, which leads to honest disclosure, trauma informed care, and care plans that are more likely to be followed. Reflecting things on their terms helps families feel seen, respected, and valued. They understand that we “get them” and trust our input. At this point they are much better able to hear us and integrate our teaching.

One major risk of engaging at this level, however, can be burn out. Putting all one’s energy into being fully present with another, sharing their feelings, and investing in their experience can be exhausting! This is where another aspect of Therapeutic Presence, one too often overlooked, comes in. In fact, this remains at the top of every list of factors in accomplishing Therapeutic Presence: Therapeutic Boundaries! Establishing emotional and energetic boundaries while also being fully engaged with people’s whole experience can seem impossible. This is, however, necessary to maintain true Therapeutic Presence.

Grounded sense of self provides an anchor that everyone involved needs. Therapeutic Boundaries are how we maintain this, while navigating the all-to-often rough seas of full emotional presence with families. Empathy is a reflection of emotion and a surface that reflects, by definition, does not absorb. This is, essentially, not holding any responsibility for fixing others’. This is where a lack of judgement for parents (or even babies!) is important. It turns out that judging is exhausting. It is important to be aware of our own triggers and biases; build a skill set for putting our personal agendas or needs aside, and truly meet parents where they are, at our core. This means being with someone, acting in the service of someone, and staying grounded in our separate-ness, at the same time. The concept of Therapeutic Boundaries is an essential aspect in having a sustainable Therapeutic Presence. We can facilitate, inform, hold space, and accept without owning; sitting in acceptance of what we truly control.

The ability to have boundaries while meeting people where they are improves with experience and intention. The Therapeutic Presence Inventory is a helpful tool to increase awareness of what our goals are for accomplishing this. Awareness of self is built through monitoring of thought patterns, biases, feedback provided by physical reactions, and pausing before engaging in impulses. Once self-awareness is present, exploration of self-differentiation can evolve. We must truly see ourselves as separate from parents and their decisions. One of the most important pieces is understanding not how we would feel in a situation but understanding how they are feeling, given their life experiences and cultural filters. Parents may see something very differently from us and have dissimilar priorities, values, or feelings about a situation. When we can see this as reasonable and demonstrate understanding of their experience, not only is Therapeutic Presence achieved, but so, too, is liberation from the burn out of owning their choices. Our job is to wholly meet people where they are, not where we think they should be.

What concrete measures can we build into our practice? With each transition we can check ourselves quickly to be sure we’re on the same level with parents. Does our physical affect match theirs? Is our verbal presentation as similar to theirs as is appropriate? If we feel up regulated, why? Do we need to down-regulate our breathing, posture, or vocal prosody? Is any inner dialogue we have staying present with families? If we were forced to be fully transparent with our thoughts and feelings toward those we’re with, would that be problematic? If so, steps can be taken to change how we see things, to include every benefit of the doubt possible. We must be very aware to meet parents where they are, even if where we are (or would be in the same situation) is very different. This helps avoid ownership of their choices. Absolutely nothing in a therapeutic encounter should be about us, which includes only empathetic and limited sharing of our own lives or experiences. Are we making it clear that any safe choice is wholly acceptable, not just to them, but also to ourselves? That must be sincere! When we sense emotional surges, it is important to pause and hold space for processing that, even if it means our agenda for the time needs to change. When we are so immersed that our self is all but absent, we are much less likely to internalize what happens for families in the moment or in the future.

As has been shown practically, experientially, and scientifically, Therapeutic Presence increases the impact of teaching and differential care. Committing to using this added tool is not just an act of “customer service”. It is a game changing transition that creates space for vastly improved clinical outcomes because parents shift into and out of more clinical aspects with the emotional and mental availability needed for success. Through intentional and complete Therapeutic Presence we can find far better consistency in outcomes, by getting on the same page with families at a deeper level. Even better, this practice is sustainable, as it decreases the risk of burnout due to ownership of families’ feelings, or frustration with poor acquiescence toward care plans. The best part is, sometimes Therapeutic Presence is all that might be needed to be the catalyst for empowered change in the lives of vulnerable families!

Therapeutic Presence: An Essential Way of Being

The Handbook of Person-Centred Psychotherapy and Counselling

(2nd ed.) pp.209-222.

Therapeutic Presence as a Foundation for Relational Depth.

Relational depth: New Perspectives and Developments (2013).

pp. 175-184.