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Love and boundaries in relational practice

A client tells Dianne Clarence she loves her. For a moment, she panics — not sure how to answer.

Feb 03, 2018, By: Dianne Clarence, BScN, IBP, RN(C)

“I love you,” she says.

I’m caught totally off guard and take a minute to gather my thoughts. Her hair is green, her head half-shaved. Rings pierce her nose, and her ears have spiked studs. She embodies the literature’s description of someone at high risk. In her life, love has been risk-filled and rare. Still, she offers her love to me, her expression open, big brown eyes reading the dilemma flashing across my face. I’m six inches taller, two generations older and, as a registered nurse, a cog in the system against which her wild-coloured tattoos rant. As she looks at me, waiting, my mind races. As an RN, am I allowed to love her back?

For a millisecond I consider making light of it with a “back at ya” but reject this response as superficial and disrespectful of our relationship. Memories flash through my mind as her 18-month-old daughter toddles in and out between our knees.

Two years ago, my client was alone, homeless and pregnant when she agreed to participate in a pilot project. The intervention is long-term home visits from a public health nurse. During the first year, the provincial ministry responsible for child protection kept an open file until my client proved she could provide the basics: food security, a drug-free home and a stable environment. In the beginning, our home visits took place in parking lots, under a bridge and at McDonald’s. Once she started to receive monthly social security cheques, we worked on how to budget and access food banks. After several months, with me as her advocate, she qualified for subsidized housing.

On many days the odds seemed stacked against her, but I’ve grown to admire her resilience and perseverance, tackling each challenge with intelligence and wisdom beyond her years. It’s been exciting to live those concepts in the nursing literature that describe the positive changes that happen within the context of meaningful nurse-client relationships.

Relational practice directs nurses to challenge the notion of nurse-as-expert and to experience families’ fullness and depth, to be authentic. As this brave young woman waits for my answer, I wonder, Can authenticity include loving my client?

The home visits covered the basics of pregnancy, labour and delivery, and we explored how violence and addiction can interrupt the healthy emotional responses that establish attachment and bonding. Over time, we developed a trusting relationship within which she became willing to accept that going outside day after day to smoke while her infant cried it out damages the neural networks for attachment. That smoking marijuana (more culturally acceptable than smoking cigarettes in B.C.) creates a barrier to bonding, because being impaired means she’s missing her infant’s cues. She learned how her mother’s addictions and her father’s violence became embedded in her own neurophysiology. She connected that knowledge with how her actions today affect her child’s development. She has embraced the hard work of self-examination. Motivated by her heart’s desire to be a good mother, she continues to learn the skills of loving wisely. Yet when she offers me her love, I choke. Why?

“Don’t cross professional boundaries,” cautions the voice of B.C.’s RN regulatory body in my inner ear. On the organization’s website is a diagram of a continuum of professional behaviour, with rigid boundaries at one end and weak boundaries on the other. Neither extreme fosters therapeutic relationships. On the one hand, I’m directed to be authentic and engage in relationships; on the other, I’m cautioned to maintain a professional distance. Conversations with my client have often turned to boundaries, as she searched for healthy ways to love members of a dysfunctional family who continue to hurt her.

Her determination inspires me to delve deeper into what professional boundaries mean to me. It would be easy to interpret the depth of the feelings she’s expressed for me as validation of my skills in relational practice — as proof I’m a good nurse. But that would be transference.

Transference can feel and look like love, but nurses who don’t understand the difference because therapeutic clarity is compromised by a lack of awareness of their own needs can inadvertently re-traumatize a vulnerable client.

The thought of hurting this woman and her child, even unintentionally, leaves me suddenly dizzy. I sit down beside the toddler, on the floor. They trust me. Is fear of doing harm reason enough to disengage from relationship and shrink away from being authentic?

I studied boundary and transference in postgrad work in integrative body psychotherapy (IBP). Part of my attraction to this approach is the requirement that students walk the talk. Each candidate for IBP certification must undergo 100 hours of somatic counselling with a practitioner qualified in the discipline. I grew to know myself through subtle but clear somatic signals. Self-knowledge is the key to understanding needs — met and unmet — and the difference between love and transference. I’ve grown to regard self-awareness as an integral component of professional competency and lifelong learning. My commitment to authenticity is why I’m confident my client can trust me. But could her expression of love be countertransference, a projection of her unmet needs onto me?

Perhaps. All humans are hard-wired to seek love. After working five years in this program, I now know that relational practice takes root in our mutual humanity. I’ve learned that I don’t need to fear countertransference; I must anticipate and honour it. My client’s feelings are hers alone to define. Trust is her privilege to share, if she so chooses. My job is to meet her at the place where our boundaries intersect. My professional responsibility is to be emotionally mature and ethically aware and to always, always act in her best interests.

The health authority can track and study outcomes of the project and can pay me for my time, skills and nursing knowledge. I can observe and chart the percentiles of bonding behaviours. But what cannot be measured is the distance travelled on the sacred path we have walked together, nurse and client, hand in hand.

Returning her gaze from her toddler’s height, my professional answer comes into focus.

“I love you, too.”

Dianne Clarence, BScN, IBP, RN(C), is a public health nurse with Vancouver Island Health Authority.