Boundaries for Therapists: Why the Wall Model Fails in Pelvic Health
OTs in Pelvic Health Podcast · 60 min listen
Most of us were taught that a professional boundary is a wall. Something you put up between yourself and your client, to protect yourself and to keep them from knowing too much about you.
Lara Desrosiers never bought it. And watching clinicians who practiced that way, she noticed something: the stricter the wall, the more amplified the power difference between practitioner and client.
"How can we expect our clients to open up and trust us if we're not giving a little of our human selves to them as well?"
— Lara Desrosiers
Which puts anyone working in pelvic health in a bind. We need connection, because that's what makes trauma-informed care possible. And we need something to contain us, because without it we end up pouring everything into our clients and arriving home with nothing left.
This conversation is about finding the middle. Lara is an occupational therapist in Ontario who runs Pelvic Resilience, and she co-created the Trauma-Informed Pelvic Health Certification with me.
"Boundaries are the distance at which I can love myself and you simultaneously."
In this episode:
- Why the wall model of boundaries undermines trauma-informed care
- Two moments that forced me to rethink my own, one at home and one on a playground
- The signs you need boundaries, beyond simple exhaustion
- The difference between setting a boundary and trying to control someone
- Transitional routines that contain a session, and a phrase for the street
- What to do when a client's distress starts pulling your own nervous system with it
I learned boundaries by hitting rock bottom
I'm a people pleaser by nature, and I'd guess many of you listening are too. Boundaries weren't a conversation we had growing up in my house. I learned them by trial and error, and honestly, I had to hit rock bottom before I found the value in them.
I'd opened my private practice in New York City — I believe I was the first OT practitioner to have a pelvic health private practice there — and I was on cloud nine. I loved the work. I did house calls, running all over the city, from the Bronx down to the financial district.
And I was exhausted. I had a two-year-old and a two-month-old at home, and I showed up 100% for my clients. There was nothing left for my family at the end of the day.
I kept thinking, there has to be a middle zone. A way to keep thriving and loving what I do and still have something to give. I didn't want to lie on the couch every evening. I wanted to be part of my children's lives, to work out, to try a new coffee shop. There was so much I was leaving behind that mattered to me.
Being exhausted wasn't enough to change me, though. I was supposed to be exhausted — new entrepreneur, two small children, New York City. That was the whole picture. I was supposed to be hurried and tired.
It took two specific moments.
A wake-up call
We're a no-shoes-in-the-house family. Living in New York, you see the worst of the worst on those streets, and while I'm not a particularly neat or organized person, this one matters to me.
But every time someone new came over, I had a lump in my throat about asking. It was the timing — they'd just arrived, they might be handing me something, we're happy to see each other, and for me to interrupt that felt like a record scratching. Sorry, wait. Take your shoes off.
Then one year I got sick and ended up hospitalized with an infection in my foot that I'd picked up at my daughter's swim lesson.
That's when it shifted. Why was I floundering with this? It was now a health issue. I needed to feel at ease asking.
A wake-up call
My practice was a concierge service. We went to clients' homes, mostly pre and postpartum people, and my clients had my cell number — it was the business line. I spoke with every client before I saw them in person. There was no online booking; you booked through me. I texted with them about their exercises on that same phone.
I wanted their experience to be comprehensive, completely different from any other healthcare experience they'd had. So I invited them to text or call with questions.
Most people won't take you up on it. They don't want to bother you. Some overuse it.
One Saturday I was at the playground with my two-year-old and my two-month-old, answering texts. I wasn't present. My daughter Avery, who's eleven now, got hurt — and I didn't know, because I was on my phone. Another child's father had to bring her over to me.
How could I provide preeminent service and not be glued to my phone? How could I be there when my child is happy, sick, hurt? It felt like a dichotomy I couldn't solve.
So I kept giving clients my number, and I told them clearly: I'm available Monday to Friday, 9 to 4. That's when I pick up my kids, and I don't see clients on weekends. If you message outside that, it may be 24 or 48 hours, but I will get back to you during my next phone hours.
They loved it. Not one person pushed back. Nobody stopped working with me. And I felt so much better.
What boundaries actually create
When we have strong boundaries — when we make our own schedules — we end up creating space. For creativity, for health, for passion. And space for ourselves in relationship to the people we actually want to care for.
I wanted to care for my clients. I wanted to care for myself. I wanted to care for my children. It wasn't until I set boundaries that I could do all three at once.
A lot of the practitioners I support have a negative association with the word, and I understand why. It's a strange cultural gap. We learn to start businesses. We teach our children life skills. We can become the president of a company. But there's no class on how to become a person who prioritizes themselves by setting boundaries.
Without them, the compensation is simply fatigue — avoiding people and responsibilities because you're too tired.
A question I find useful, for myself and for the people I support: what is going to fit on your life plate? There's a finite amount of space there, energetic as well as temporal. I'd rather fill mine with food that sustains me than food that depletes me. That question shows me where the plate ends and everything else begins.
And people can't read our minds. Being direct about what you need doesn't push people away — it brings them closer. Instead of making them guess, you tell them. It saves time and energy, and it creates closeness.
Lara: I love thinking about self-love and the drive to take care of ourselves as the foundation that supports connection. The fear is always that it will drive disconnection. But when people understand us and what we do and don't have capacity for, it eases the relationship in so many ways.
The signs, beyond exhaustion
I've been reading Nedra Glover Tawwab's Set Boundaries, Find Peace, and she lists signs that you need boundaries. Lara and I both recognized ourselves in more than one.
You may need boundaries if you notice:
- A sense of being overwhelmed
- Resentment toward people asking for your help
- Avoiding phone calls or interactions with people who might ask for something
- Making comments about helping people and getting nothing in return
- Frequent burnout
- Daydreaming about dropping everything and disappearing
- Hearing yourself say "I have no time for myself"
She also has a quiz for self-assessing your boundaries, with three types: porous, rigid, and healthy. I like that framing, because we tend to think only in extremes. Sometimes we imagine ourselves being rigid when we're actually being healthy.
Lara: Those are huge signposts, because so much of learning about boundaries comes from trial and error, or from finding ourselves in depletion and only noticing in hindsight.
One of my favorite books on this is Emily Nagoski's Burnout. Something I've learned, and keep working on, is that my body and my nervous system are such a good source of information about where my boundaries lie. Getting curious when uncomfortable sensations come up — when someone asks me to do something, or during a client interaction. If my gut is tingling, I try to get curious about that, because it tells me where the boundary is.
We live in our heads so much that we don't check in with our bodies enough. I think of the foundation of strong boundaries as — to use Deb Dana's term — befriending our nervous systems.
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Sign up for freeWhy the wall model fails trauma-informed care
Lara: The first time I really learned about boundaries was in school, before our mental health placements. What was instilled in us was that a boundary is a wall you put between yourself and your client — to protect yourself, and to avoid giving clients too much personal information. There was a rule around disclosure.
That never sat well with me. Once I was in my placement, and then working, I started observing colleagues with far more experience than I had. I could see the clinicians with really strict boundaries. And I could see the others, who were willing to walk alongside their clients and build personal connections. That second approach resonated with me so much more.
I worked with a few psychiatrists who had very strict walls with their clients, and what I noticed was that the power dynamic difference was just amplified. How can we expect our clients to open up and trust us if we're not giving a little of our human selves to them as well? How can we expect them to feel safe with us — which is the essence of being trauma-informed?
Trauma experiences stem from someone feeling disempowered and disconnected. To be the container that promotes healing, we need to find a middle ground: flexible enough to connect in a human way, while still containing where we end and the client begins.
So healthy boundaries are critical, because we have our own nervous systems. We're human. We need to know where our boundaries lie, or get curious and discover them. But we need to balance that with connection.
Containers, not walls
Lara: Instead of thinking of a boundary as a wall, I think about creating safe containers — for the different parts of my life, and for the different components of my day. Then I bookmark them with a transitional routine. The kind of thing that works so well with our kids can be really helpful for us too.
Before a session, I'll do something like tapping or rubbing the boundaries of my body, just to remind myself that I am a distinct being. I can be here, I can hold space for this person, and I'm a separate person with my own stuff.
Afterward, depending on what came up — because our nervous systems are inevitably affected by the people we work with, that's the nature of being human — I tune into what my body is looking for. Maybe some movement, shaking it out, to bookend that session and give the next client some space.
And I love doing it at the end of my day too, to bookend the day and transition to being fully present with my family.
Lindsey: I do something similar. I learned it from a practitioner named Galina Denzel, and it mattered most when I was living in Paris, though I could have used it in New York.
Before going out onto busy streets — which would sweep me up, and I'd end up absorbing what people around me were experiencing — I'd put my hands on my skin and say: everything inside is mine, everything on the outside is someone else's.
It became almost like a jacket. Something that let me realize I didn't have to be so porous. I did the tapping version before clients, but walking down the street I needed something more, and that touch combined with the phrase really helped.
Lara: Anything we can do. Even the imagery of a container helps me be willing to be more open — maybe even more porous — within a session, and then close those pores at the end, so I can let that experience move through me before moving on.
Boundaries are about your response, not their behavior
This is the distinction that changed how boundaries felt to me, because it stopped feeling like I was getting out a whip and telling someone what to do.
When you set a boundary, you're either stating a need, making a request, or saying no. And crucially, you are not trying to control the other person. You're telling them what you will do.
Trying to control:"You can't have more than one drink tonight."
A boundary:"If you have more than one drink, I'm going to call an Uber."
Trying to control:"Please don't write to me outside my working hours."
A boundary:"I answer emails and texts within 48 hours, Monday to Friday. If you write in the off hours, I'll reply during my open hours."
Trying to control:"Please don't stop by unexpectedly."
A boundary:"If you stop by unexpectedly, I may not answer the door."
That last one was a real neighbor, when I was working from home and genuinely needed that time. Reframing it from what I wanted them to stop doing into what I would do made it possible to say.
Lara: It also communicates what to expect from us, which again drives connection. It builds trust when we're transparent and clear.
The other thing I've noticed in myself, as a fellow people pleaser, is the drive to over-explain. If someone invited me to an event I didn't want to attend, I felt I needed a reason — so I'd come up with a little white lie, or a long-winded explanation.
Now I just say: unfortunately, I don't have the capacity for that right now. Clear about the boundary, and acknowledging that when I get into over-explaining, people don't typically care. They want to know yes or no.
It's the same with clients. They want to know what to expect from me. They don't need the ins and outs of why I have these limitations. So I check myself: is this explanation going to help the client, or is it about me and my guilt? If it's my guilt, I put a pin in it and tell them only what helps them.
Lindsey: This one still hits home for me. I always feel there's a reason I'm supposed to explain. There's something so easeful about simply saying, I don't have the capacity for this.
Where to start
If you want somewhere concrete to begin, pick one category and try it there. Get a small success, then look at the others.
Family and domestic
Dividing household tasks. My husband Doug is an amazing cook and I am not, so for the eighteen years we've been married, he cooks and I clean.
Children
Bedtimes for small children. Monitoring screen and online time. Interruptions — letting them know which physical spaces are off limits when I'm recording or taking mentorship calls.
Professional
Emails and texts outside working hours. What happens on vacation, including the out-of-office. And there's a lot to unpack around accepting unpaid work, especially for students.
Personal
Time for exercise, volunteering, social events, romantic time with your partner.
Electronic
News and social media. During COVID I reached a point where I simply couldn't listen to the news any more. That was a boundary.
Emotional
People pleasing. Difficult coworkers. And rehashing past failures in your mind — noticing when you've thought about something repeatedly without making progress, and finding a way to tell yourself you no longer need those thoughts.
Finances, time management and self-care
Including the treatment you allow from others, and your own thoughts. You can stop talking to yourself unkindly, the same way you'd stop someone else being mean to you.
At a recent OTs in Pelvic Health Summit, Susie Gronski shared her boundaries form with us. She works with a lot of clients who have penises, and she enters every therapeutic relationship with a form that both she and the client sign, after talking it through. It defines her role and theirs. She finds it comforting and beneficial, for her and for them.
I love seeing concrete examples like that in pelvic health specifically. We can read about all of this and be inspired, but a form you can put into practice tomorrow is what lets you walk in with confidence.
Lara: When someone has a trauma history related to attachment and relationships, a lot of push and pull can come up in the power dynamic. If one of their protective responses is fawning, or wanting to please you as the clinician, they might take a passive approach and look to you as the expert.
So one of the things I include in my contract and my early discussions is this: my role is to be your guide. You are the expert in your lived experience. Making that dynamic explicit means we can anchor back to it later — when those protective responses surface, or when there's frustration that I don't have a magic fix. We can return to that early conversation about this being a trial-and-error process we're working through together.
When your client's distress pulls you with it
Lara: This comes up a lot. What do we do when a client is heightened or overwhelmed in session, and we start to feel heightened and overwhelmed alongside them?
Lindsey: That happens to me fairly often, because I tend to meet the energy of whoever I'm with.
What I do comes from something Marty Smith said in her keynote at the summit. When I feel myself matching an upregulated energy — the client getting anxious, nervous, tense — I don't apologize for needing a moment to downregulate. And I articulate what I'm feeling out loud.
I'm building interoception into my work, and a lot of my clients struggle to detect those signals early. When they can build that sense, it's a game changer.
So I stop, I name what I'm experiencing, and I use a tool. Extended exhalation is a favorite: I'll visibly take a minute or so making my exhale longer than my inhale, to regulate myself. Then I check back in. How are you feeling? What are you noticing in your body?
The point is that I'm modeling, and — as Marty talked about — I'm not meeting their energy. Rather than doing it covertly, excusing myself to the bathroom, or quietly breathing under the conversation, I verbalize it. Which also invites them to check in with what they've got going on.
Lara: You're giving them the gift of being mirrored, which helps people feel seen and heard. And you're giving them language for how it sits in the body, which builds their skill at checking in with themselves.
You're also giving them a container. It interrupts the spiral, helps us get grounded, and then we can decide together how to use the time we have.
The same approach helps with trauma disclosures. If a client is telling us about their birth experience, we can monitor their capacity to stay present. If they're becoming overwhelmed, we can gently press pause and validate: it sounds like this was an incredibly overwhelming experience for you.
And then something I find helpful is asking: I wonder whether going into all the details of what that was like would be helpful right now? What about the experience do you really need me to understand?
They don't have to share everything. But they get to share what's most important to them about what they want you to understand.
Modeling it is part of the work
One more thing worth saying. Setting these boundaries, and letting clients see you do it, is itself beneficial to them.
So much of what we're trying to support clients with is taking care of themselves and their own nervous systems. A big part of that is helping them find their own plate — the balance that works for them. Being clear about what we have capacity for models exactly that.
I learn far better by example than by being told something. Lara, you do this in your own life — in over a year of working together on this certification you've been consistently clear and kind and direct about when you need space and when you don't have capacity. And that gives me the confidence to do the same back.
It ripples into other areas of my life, because I've seen the grace it can be done with, and I felt closer to you every time. That was living proof of how effective and how beautiful it can be.
