When you hear the word boundaries, what comes to mind? Teenagers and toddlers pushing limits? That friend who wants to borrow your trailer again? The extra hours you work because of unwritten rules for assuring high marks on your performance review? That patient with the perfect excuse for not finishing his/her homework?
As PTs, we generally are very nice, caring people. We are fixers: helpful and kind by nature, and the idea of boundaries might elicit discomfort. It can be hard to draw a line in the sand and let our ‘yes mean yes’ and our ‘no mean no’, versus saying “no problem,” which is code for, “I don’t like this at all, but if it will keep the peace…”. Some of us may even think setting boundaries is harsh and uncaring, coming down on people who are already struggling.
But have you ever thought of boundaries as a cornerstone for compassion? And have you ever thought boundaries could impact your patients’ outcomes just as much if not more than anything else you do?
Researcher, author and public speaker Brene’ Brown has gained a tremendous following for her TED talks and books on empathy, vulnerability and creativity. In a terrific interview with The Work of the People, she defines the terms this way:
- Boundaries: what’s okay and what’s not okay
- Compassion: the deeply held belief that we are inextricably connected to each other by something rooted in love and goodness
- Empathy: the skill set to bring compassion alive
She goes on to describe empathy saying, “It’s something we can teach. It’s about how to communicate that deep caring to people so they know they are not alone. Empathy is not feeling FOR someone, it’s feeling WITH them.” Her classic video on empathy is worth a watch.
In a recent systematic review in the Journal of Compassionate Healthcare, authors SE Lakee and S Meerman state:
“It could be concluded that there is strong evidence that a patient’s perception of working alliance has an influence on the results of therapy as evidenced by pain and physical functioning.” In the five studies that met inclusion criteria, a positive working alliance predicted pain reduction and improvement in physical function. As the authors describe working alliance, compassion and empathy are cited, “Therapists could enhance the personal bond by exhibiting compassionate health care…person centered care in which therapists demonstrate characteristics such as empathy, sensitivity, kindness and warmth.”
This comes as no surprise to those of us who have been involved with ISPI and EIM, as the leaders of our tribe have championed compassionate, empathetic care for years. Adriaan Louw, Tim Flynn and others have influenced a movement of rejuvenated PTs, helping us understand that fear, not faking, drives many of the patient behaviors that perplex and frustrate us. But where do boundaries fit in to the picture? According to Brown, “We squirm setting boundaries. Boundaries are the key to self-love and treating others with loving kindness. Nothing is sustainable without boundaries…Empathy minus boundaries is not empathy. Compassion minus empathy is not genuine. Boundaries are not fake walls, separation or division. They are respect: here’s what’s okay for me and here’s what’s not.”
Brown connects compassion, empathy and sustainability to boundaries, stating her most shocking finding 13 years of research is that “the most compassionate people were also absolutely the most boundaried.” A few years ago, I was impacted by Larry Benz’ EIM blog post, “Empathy: The Secret Sauce in Physical Therapy.” As he cited some great literature out of nursing and psychotherapy, the dots began to connect for me. Exquisite empathy actually protected professionals from burn out and compassion fatigue. Exquisite empathy was defined as being “highly present, sensitively attuned, with clear boundaries and heartfelt empathic engagement.” It was an Ah-ha moment for me: I could see a pattern of the highest times of professional and personal burnout in my life coinciding with those times of the most boundary-less-ness.
So, even if you squirm at the thought of setting boundaries, can you think of ways you can incorporate boundaries into your practice that will bolster your compassion and empathy? Can you connect the dots between therapeutic alliance, boundaries, compassion, empathy and sustainability? As we continue to offer highly skilled PT wrapped in kindness, let’s remember to care for ourselves AND our patients by maintaining clear boundaries.