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An introduction for therapists, counselors, paraprofessionals, clergy, 12-step sponsors, or anyone in a helping role.
In a keynote address, Joan Borysenko, Ph.D., author of Minding the Body, Mending the Mind, made the statement that the common ground in the disciplines of medicine, psychology, and spirituality is healing, and that the healing relationship stands at the center of all healing.
The prevailing conceptualization of mental health and sobriety identifies them as having biopsychosocial, behavioral and spiritual dimensions, and posits that without addressing all of these dimensions, long-term success is far less likely. These two ideas lead to the conclusion that successful treatment requires deep inner healing to take place in the life of the client. Therapists and counselors offer a professional service, setting, and relationship for much of that healing to take place.
I offer the position that the presence the helper brings to the relationship is a major factor in the quality of the healing available to her/his client, and that there are general principles and specific methods to enhance -- in the moment and over time -- the quality of that presence.
This is not a primer on a school of therapy, and I offer no preferences to any particular strategy or technique for conducting therapy. In fact, any good therapist of any school of thought probably has developed their capacity to bring more of their awareness and goodwill to bear in the counseling encounter.
Presence defined: Presence and therapeutic presence, for the purposes of this talk, are best considered from three different perspectives:
From the perspective the individual who is present, the basic definition would be to be peacefully, receptively open to, aware and conscious of the internal environment (senses, thoughts, feelings) and immediate external environment (perceptions) in the present moment, with a minimum of distraction (through attraction or repulsion) of any particular element in awareness.
In addition to this definition, for the individual who is present in a relationship encounter, the definition would become to be fully engaged in a relationship encounter in full awareness of its real-time context, with a minimum of internal distraction by concepts; i.e. judgments of, objectification of or identification with the other; thoughts of past or future; other contexts, people or things; fantasy scenarios, strong emotions, sensations or perceptions.
From the perspective of experiencing someone who has a therapeutic presence, the definition would be someone who spontaneously fosters a felt-sense/feeling-tone of safety, connectedness, acceptance, goodwill, nonjudgment, healing, and compassion that is congruent with their nonverbal communication. This sense seems to surround the space around him/her, creating an atmosphere of serenity. It precedes and authenticates their behavior and speech.
There are several ways to develop ones capacity to cultivate presence: as a by-product of personal growth and healing; regular absorption, artistic expression, human encounter (e.g. art, music, sports, counseling, sponsoring, or ministry), communing with nature; or regular prayer, contemplative or meditative practices. Pursuing more than one of these endeavors tends to have an overall synergistic affect on presence cultivation.
Notably, all of these practices are also strong candidates as therapeutic activities for ones physical, emotional, mental, and spiritual health. It is a well-known fact that self-care on the part of the mental health professional not only enhances her/his personal life, but increases their mental, emotional, and energetic availability to provide a therapeutic for their clients.
Actively practicing and applying techniques common to some of the aforementioned activities can help optimize the therapists presence, both offline and during sessions: quieted mind, with relaxed & alert awareness of kinesthetic sensations, and the perceptual field, remaining focused on and open to every aspect of the client in the moment (physical body, behavior, verbal and nonverbal communications). I like to call this listening with your whole self.
Achieving and maintaining this kind of receptivity and openness, especially in the context of professional work, is challenging at first. It usually requires practice and years of experience to develop into a meaningful part of a therapists toolbox, but this is usually because practicing therapeutic presence is generally not taught. I am putting forth the argument that, not only can it be taught; it is a skill that can be taught and practiced simply and very effectively to drastically shorten the time it takes to develop into a powerful therapeutic tool.
Before we get into the technique Im going to teach you, there are some important principles I want to share with you upon which to base presence cultivation for therapeutic purposes:
1. Be in an attitude of total acceptance of the client and the clients present condition, including their beliefs, perspectives, attitudes, and perceptions. Acceptance of how the client experiences self and the world doesnt mean agreement with it. It simply means a total lack of inner resistance. This is the basic medium of the therapeutic encounter.
2. Be confident in and conscious of your clients and your own essential and potential (i.e. spiritual) wholeness. It is enormously helpful not to approach clients with an attitude or belief that they themselves are broken, but that one or more aspects of their experiential and/or behavioral manifestation are out of synch with their essential nature. By focusing our attention on their pristine essence, we entrain our own consciousness to ours, and provide a wordless, energetic bridge from the clients experiential self to his/her pure potential.
3. Have faith and develop confidence in the fact that your client has all of the internal and external resources with which to heal and resolve their problems: they just arent aware of them or how to access them. It is your job to help her/him get out of his/her own way in order to do so.
4. Understand that presence is always a work in progress. Perfection is not required, because perfection requires critical judgment, and critical judgment is counterproductive to cultivating presence. Like meditation, once you learn an effective method, then regular practice, deliberate self-awareness and redirecting the attention back to focus will gradually improve your ability to restore, maintain, and deepen an inner state of being present.
While this list may seem long & a lot to think about when Im thinking and talking with my client, these 4 principles are more like the background scenery to the main subject of a photo or painting, or the orchestral accompaniment to the duet of the encounter. We put the most work into bringing these beliefs, attitudes, and perspectives outside the session, and just remind ourselves just before the session or whenever we notice having slipped out of being present.
The experience of being present is unmistakable. It is as nourishing to the practitioner as it is to the client. It carries a clear and palpable sense of sacredness, and seems to sanctify the space the encounter occupies. When you are in the zone youll feel/ recognize it, but you can be unconscious of slipping out of it because of mental or emotional distraction.
If you are experiencing your client as an object rather than the subject of your attention, if you are mentally or emotionally judging or reacting, if you are actively thinking about theories and therapeutic techniques, or if you are engaging an inner dialogue in short, if you are focused on anything other than your attention on your sensory input and your client in the here and now, you are not fully present in that moment.
Continuous, 100% presence is not possible, and this is part of why self-judgment is so unhelpful in its ongoing cultivation. Just relax, and gently return your awareness to I and Thou, Here and Now.
There is another side to being present. For clinicians, it is important to be on the ball with observing & assessing the client(s), observing & analyzing content & process, maintaining a theoretical perspective, remembering the treatment plan, developing new strategies & executing counseling techniques and interventions. It may seem as though attention to the quality of your awareness in the moment could interfere with this, or vice versa. On the contrary, cultivation of this capacity for presence seems to greatly enhance clinical thinking. It appears as though the filters to those areas of the unconscious which hold all of our knowledge and wisdom are removed when we are truly present.
It is nevertheless a challenge for a journeyman psychotherapist to develop this, and switching back and forth during a session is normal and acceptable. With continuing practice, both presence and our clinical expertise come more naturally and intuitively, and we can fall back on consciously accessing either or both as we need to.
One way I have found that helps me to keep the healing presence of my humanity and spirituality in the room while Im acting/processing as a therapist is to mentally place my sense of being present --empathy, kindness, compassion, acknowledgement of my clients pure essence and confidence in their ability to heal-- into my physical heart while my brain does the clinical work. I work to maintain a background awareness of my sensations, perception of the immediate environment, and especially my clients nonverbal communication. With practice, this is not as challenging as it sounds. In fact, in my opinion, it actually enhances the quality of my clinical intuition. If you realized how much thinking about other things you do during the course of a session and still keep track of whats going on, youd understand your mind is easily capable of this. Its just a matter of practice.
Here is a brief exercise together: 1. to sensitize you to the activities in your mind and emotions which cloud your full presence most of the time; and 2. to introduce /remind you of the glimpses of experience itself & offer one of the many means of cultivating it on your own and in sessions.)
This exercise, a form of meditation or mind-clearing, methodically develops the capacity for presence. Practicing it will provide an intimate familiarity with being present, as well develop and reinforce ones ability to quickly become present in the context of a relationship.
The exercise is a circuitous progression of centering ones attention on experience in the moment. Each shift of attention, from perception through being, adds a dimension of experience in the here and now. The mind becomes absorbed in the present moment, along with the inner space and immediate environment, until all merge into undifferentiated being. This last step may take time to experience even for fleeting moments, and it is advisable not to judge at all whether, for how long, or how often the mind achieves that state. The critical mind is the opposite of the present mind.
Also, the heart tends to activate when we are present, you may notice warm sensations in the middle of the chest: this is a welcome development, but is not sought out in this practice. Simply practice becoming and being present, and all will fall into place.
Position: seated on a chair with feet planted; on the floor or a meditation bench with legs crossed Indian-style, half-lotus, full-lotus; or on the floor with legs together, calves folded under thighs and sitting on heels. (Lying down if no other position is feasible; however, this is not an optimal position for this practice)
Posture: Back straight and relaxed (not ramrod); belly relaxed (not held in); shoulders upright and comfortable (not shrugged, slumped nor pulled back as if at military position of attention); head facing straight forward; eyes (whether open or closed) directed to a softly gazing at a point on the floor about three feet in front of you. (Note: do not direct your eyes upward to your third eye, as this induces a type of trance that does not promote being present)
Breathing: the breath is through the nostrils, soft, slow (12-16 full breaths per minute), and low into the, relaxed, expanding and contracting belly. The chest and shoulders should be relaxed and relatively still throughout the breathing. If the chest is visibly moving in and out, and/or the shoulders up and down, correct this by perceiving yourself inhaling down to your navel, crotch, and buttocks. Another way to correct chest-breathing is to first lie down on you back and notice how your belly naturally expands and contracts rather than your chest and shoulders when you breathe. The next step is to sit with your back at a 45-degree incline and breathe into the belly. Then reproduce this kind of breathing while sitting upright and standing. Once you get the hang of the sensation and mechanics of diaphragmatic (belly) breathing, remind yourself to breathe that way several times a day.
Mental focusing technique: This technique is a simple and powerful way to practicing bringing your attention to the present moment. It can be used as a meditation in its own right, but can also be applied to the therapeutic setting to help you refocus and bear witness in the therapeutic relationship.
Beginning Start with the diaphragmatic breathing, focusing your attention on the process and sensation of the breathing; the subtle movement in your abdomen; the sensation of the airflow through your nostrils; the sensation the breathing causes throughout your body.
After about a minute, you will start shifting your full attention to each of these experiences, about a minute each, one after the next. Whenever you notice your awareness wondering outside or only on a portion of the intended focus, gently redirect it. If you are paying close attention to your awareness, youll most likely need to refocus your mind many times in just one minute. Keep the breathing steady.
1. Perception - Rest your awareness on the entire range of your visual field and auditory input; try not to single anything out just consciously receive all the visual and auditory input coming into your eyes and ears. Whenever you find yourself focusing only on one or the other, gently expand your awareness to encompass both. To help you stay focused, you can mentally repeat the word perception as a periodic reminder of what you are doing.
2. Sensation Shift your awareness to focusing on the sensations within your entire body; try not to single out any area(s) of the body or type(s) of sensation(s) out: see if you can feel and notice everything your nervous system is communicating to your brain from the rest of your body. Notice how the sensations shift as you inhale or exhale. Whenever you notice attention drifting, gently refocus to sensation.
3. Awareness Shift your awareness to focusing on BOTH perception and sensation while you continue the gentle, slow belly breathing. Try to take it all in at once, encompassing every perception and sensation with your mind, singling nothing out. Be gentle with this, however. Just allow your attention to expand as far as it will to receive all of the input from your body and your environment. Whenever you notice yourself focusing on just one or the other (breathing, perception, or sensation), gently expand your awareness as far out as you can to embrace it all again.
4. Being This is the most challenging step. Shift your awareness beyond your individual self as the locus of awareness so that you no longer differentiate yourself from the sensory and perceptual input or their source, and no longer differentiate them from each other. Every point in your immediate environment, as well as the totality of the space you occupy and the boundaries of your perception are now your primary frame of reference. Whenever you notice yourself spacing out, return your attention to your immediate environment.
Return to step 1 and cycle through again until complete. This exercise can generate a great deal of mental power and chi energy in and around the body, regardless of how well or poorly executed you may think your session was. Therefore, it is always important to ground yourself to close the session, regardless of where you end in the sequence.
Grounding It is important to ground yourself after even just a few minutes of this exercise. To do so, plant your fleet on the ground while standing or sitting in a chair with your hands clasped in your lap or flat on the sides of your thighs. Focus your attention on the sensations in your feet and the feeling of ground or floor beneath them. When you stand, stretch and bend your legs. Drink some water afterwards.
You may want to limit yourself to a 4-minute period of this exercise at first, and gradually work your way up to 10 minutes. Any more than 20 or 30 minute a day is not really necessary. Some find the 4th step too challenging and prefer to only cycle through steps 1-3, and this works just fine.
Other activities to promote presence:
Psychophysical and psychospiritual practices that cultivate presence: i.e. exercise, hatha yoga, tai chi, some sports, breathing and relaxation exercises, visualization, massage, the focusing technique; the various forms of prayer, sitting/standing/walking meditation, chanting; and inner work which reduces neurosis and its manifestations in mental activity, emotions, interpersonal communication, and behavior.
Its important to remember that simple presence, while powerfully therapeutic, is neither a replacement for nor a type of psychotherapy. It should be considered a base for the therapeutic encounter from which any therapeutic intervention can be greatly facilitated.
By tending our presence as an important aspect of our inner development, we directly cultivate an atmosphere of healing in all of our relationships.
From a spiritual point of view, presence can be considered bringing forth the pure spirit we were created as to bear witness in every encounter, thereby inviting the spirit of the other in communion, which in turn is an invitation to the Spirit we were created from to be present.
Below are some reading references to learn more about and/or practice the cultivation of a healing therapeutic presence.
Clinical Literature:
The Therapeutic Self: Developing Resonance--Key to Effective Relationships - John G. Watkins
The Art & Practice of Compassion & Empathy (Margot Lasher, Ph.D.)
How to Meditate (Lawrence LeShan, Ph.D.)
The Relaxation Response (Herbert Benson, M.D.)
The Book of Meditation: The Complete Guide to Modern Meditation (Patricia Carrington, Ph.D.)
Eastern References:
Zen Mind, Beginners Mind (Suzuki Roshi)
Peace is Every Step (Thich Nhat Hanh)
Tao Te Ching (translation by Stephen Mitchell)
Meditation in Action, Chogyam Trungpa Rinpoche
Ordinary Magic: Everyday Life as Spiritual Path (John Welwood, Ed.) (Collection of articles on aspects of presence -excellent resource)
Christian Authors:
The Interior Castle (Saint Theresa of Avila)
Learning to Dance Inside: Getting to the Heart of Meditation (George Fowler)
Thomas Merton
Meister Eckhart
Jewish References:
I and Thou (Martin Buber)
Meditation and the Bible (Rabbi Aryeh Ben Kaplan)
Sufi (Islamic mysticism) References:
Living Presence (Kabir Edmund Helminski)
(Article adapted from the authors December, 1997 November 2000 articles and presentations to mental health professionals and graduate interns at Prince William County Community Services Board - "Cultivating Presence in Substance Abuse Therapy"; and a periodic seminar provided to Prince William County Substance Abuse Unit Detention Center detainees: Sought through Prayer and Meditation: A Simple Meditation Technique for Cultivating Sobriety)
