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8 CHALLENGES TO
THERAPEUTIC PRESENCE
To optimize the moments of kairos (opportunity) in the therapy rela- tionship, in ourselves, and with our clients, therapists must be aware of and work through the potential barriers to relational therapeutic presence. A level of intimacy with the moment is needed for therapists to go deeper through the levels of therapeutic presence, which can be scary and make one feel vul- nerable. In particular, it can be more challenging to rely on one’s self and the deepest strata of one’s being to facilitate a response or choose a technique in resonance with what is most poignant for the client in the moment than to rely on a therapy plan or a particular technique. The challenges to engaging intimately in the moment in a psychotherapeutic encounter can arise from within the therapist (internal barriers) or from the client, the relationship, or other demands (external barriers). Although it is helpful to conceptually cat- egorize challenges as internal or external, even those that emerge externally (e.g., the client’s anger) are ultimately internal challenges to the therapist to be aware of and work through.
The challenges we examine in this chapter include internal ones such as countertransference, trust in the process, and personal barriers (stress, lack of self-care, appropriate use of energy) as well as external factors such as work- ing with challenging clients (e.g., clients with dual diagnoses or receiving
If you think you’re enlightened go spend a week with your family. —Ram Dass
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http://dx.doi.org/10.1037/13485-008 Therapeutic Presence: A Mindful Approach to Effective Therapy, by S. M. Geller and L. S. Greenberg Copyright © 2012 American Psychological Association. All rights reserved.
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end-of-life care, trauma survivors). However, first we invite you to pause briefly to uncover your own personal obstacles to being present with a client.
PAUSE MOMENT. Stop and notice any obstacles to presence:
� Take a moment to pause from reading and turn your attention inward. Close your eyes, soften your gaze in front of you, or jot down some notes.
� Focus briefly on your breath and allow yourself to bring your awareness to your bodily experience of breathing.
� What are you first aware of as you pause? Notice the busyness of your mind, judgments, or discomfort in your body that may pre- vent you from feeling centered or still. Notice any rushed feeling, as in wanting to get to the next page, the next moment, or the next task. Notice it without judgment, keeping awareness on your breath without following the thoughts about what you are expe- riencing, allowing each breath to take you back to the moment.
� Now reflect about the difficulties in being present with a client. What kinds of obstacles emerge in session with a client that hijack your focus or attention? Notice what they are. Then let them go.
� How do you know when you are not present with a client; what are the clues? How do you bring yourself back to the moment in session? What is one way you can work on noticing your barrier to being present and bringing your attention back in session?
INTERNAL CHALLENGES TO THERAPEUTIC PRESENCE
In this section, we explore some of the internal challenges that therapists can face as they open up to the contact that therapeutic presence entails. Being fully in the moment with a client requires having a level of self-awareness and inner health and integration. Presence is not just a passive state but an active engagement with one’s whole being, which demands a level of engagement with the other that requires that we take care of ourselves on a personal and professional level. Even so, we are human beings, and the challenges that can arise for us include countertransference, tolerance of uncertainty, the role of stress, and appropriate use of energy.
Countertransference
Countertransference is defined as “the therapist’s internal or external reactions that are shaped by the therapist’s past or present emotional conflicts and vulnerabilities” (Gelso & Hayes, 2007, p. 25). Although the notion of
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countertransference may have originated in the psychoanalytic tradition, the possibility of countertransferential reactions, or feelings in the thera- pist in relation to clients, can occur in any therapeutic modality. Note the perspective of Gelso and Hayes (2007):
Countertransference is universal in psychotherapy . . . by virtue of their humanity, all psychotherapists, no matter how experienced or emotion- ally healthy, do have unresolved conflicts and vulnerabilities, and that the relational intimacy and emotional demands of psychotherapy tend to exploit these conflicts and vulnerabilities, bringing them into play in the therapeutic work. (p. 133)
We believe that countertransference reactions, such as therapists’ emo- tional reactivity, are highly possible in present-centered work because thera- pists are open and in direct emotional, physical, cognitive, spiritual, and relational contact with their clients as well as present in these domains within their selves. In the presence process, the therapist is using the self as a sensor or an indicator. Therapists are taking in the depth of the client’s experience and accessing and attending to their own internal experience as a key indi- cator in understanding and responding or offering an intervention from moment to moment. We also believe that being aware of one’s self and the other, in the way that therapeutic presence evokes, allows therapists to rec- ognize countertransference reactions when they do emerge and either work with them internally to let them go and not act them out or use them in a positive therapeutic manner to reflect what the client is experiencing or may be evoking in the other.
No matter how great the intention to clear and manage the therapist’s own issues outside of session, therapists are human beings, and even resolved issues could rise to the surface in session. However, the level of self-insight, self-awareness, and commitment to one’s own growth that cultivating thera- peutic presence demands, such as attending to one’s own inner experience, serves both as protection from countertransference and as an antidote to countertransference reactions. Furthermore, the cultivation and experience of presence can help therapists to quickly distinguish intense countertrans- ference reactions from intense emotional reactions that may be therapeuti- cally useful.
Self-awareness and a continuous attending to one’s internal world are keys to recognizing and managing countertransference reactions. Gelso and Hayes (2007) described self-insight as a necessary precondition to connect- ing the therapist’s experience with the experience of the client. To use the self as a sensing instrument, “therapists must be able to see themselves, to understand their fluctuating needs and preferences and shortcomings and longings” (Gelso & Hayes, 2007, p. 108).
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VanWagoner, Gelso, Hayes, and Diemer (1991) compared therapists who were perceived as excellent by their peers with general therapists. They found that master therapists were viewed as having greater self-insight, empathic ability, anxiety management, and self-integration. Interestingly, these qualities, which are a part of mastery, are also aspects of therapeutic pres- ence, such as self-insight, self-integration (grounded and centered), attune- ment to the other, and ability to manage anxiety. These skills are central to mastery, as therapists who are perceived as excellent are better able to notice and manage countertransference reactions before they become problematic or manifest in therapy and potentially impede the client’s process. Hence, the practice of presence can also protect against countertransference reactions.
In addition, therapists’ insight, self-awareness, self-care, and psycholog- ical health as well as their training and professional experience, which are all a part of cultivating presence, will support the therapist in effectively using his or her own receptive openness to understand and facilitate the client’s thera- peutic process toward healing. In fact, openness to one’s own feelings has been associated with less countertransference behavior (Robbins & Jolkovski, 1987). It is often the therapists who have lost touch with what they are feel- ing or are unaware of their own experience in the moment who do not notice what is interfering with their ability to help or be there with their client.
To get out of the way of our client’s therapy, we need to get our own unresolved issues out of the way. Yet even when it is not possible or we are taken by surprise by a feeling (e.g., a sense of incompetence or frustration or anger), we need to develop agility in recognizing the source of that feeling and moving our awareness back into the moment and back to an open yet grounded place.
The following clinical vignette demonstrates how the therapist’s self- awareness helped her to recognize her own sense of detachment and counter- transference response and recoup her attention when she was struggling in session with a client:
Jane was discussing the loss of her son through an illness encountered when he was 8 years old. She was discussing the “deep hole” in her chest from the hurt and pain she felt at her son’s death. She expressed feeling over- whelmed by having to cope with everyday tasks, as she could barely “face each day.” As she spoke, I found myself cognitively responding to her pain by reassuring her, while my attention felt like it was moving further and further out of the room. I noticed my clipboard, which I rarely use, in my hand with my pen writing furtively. At that moment I recognized that the clipboard was almost acting like a shield to the overwhelming pain she was experiencing. I brought my attention to my present moment disconnec- tion and became aware that underneath the emotional distance I felt to Jane was a feeling of deep sadness and fear of loss. I realized that I had
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created a blockade to that pain. I also felt overwhelmed with the notion that I could not take away or lessen her pain in any way. With that aware- ness of my resistance to being present, for fear of being overwhelmed by sadness and incompetence, I noted and invited my attention back to pres- ence. I became aware of this vulnerability in me, and imagined putting these fears on a shelf, with an intention to return to these at a later time. I was then able to take a breath and invite my attention back to a sense of grounded presence, where I could feel once again my own inner stability yet open to a sense of support and the vastness of pain felt by Jane.
In this example, the therapist noted her nonpresent behavior of furiously writing and her distraction. She was able to quickly attend to her detachment and underlying pain and fear, notice and regulate her emotions, note these as something she needs to attend to at a later time, and return her attention to the moment. The inner dialogue and returning attention to the moment can be brief if therapists are skilled in their own self-awareness and ability to understand their emotional experience.
Practice in presence and self-awareness can also help therapists to dis- cern the source of a countertransference reaction and to work with it effec- tively. For example, the therapist who is experienced in self-recognition may feel sleepy in session and discern that it is not fatigue per se but a sense of disconnect with himself or herself or with the client and hence bring their attention back to the moment. Another possibility for the source of that fatigue is the therapist’s resonance with the client’s disconnect from his or her own experience. Hence, it is a good opportunity to reflect this back, which would invite the client back to his or her own experience.
Therapists can also use the presence practice of in-the-moment bodily awareness to attain ease in recognizing the underlying needs that the counter- transference reactions, in the form of a lack of presence, could be indicating. For example, anxiousness may reflect a need for a break or a need for stretch- ing or exercise. Tiredness may be physical fatigue or may result from a lack of direction or connection in the session. Boredom may mean that the therapist is burnt out or perhaps that the client is avoiding and speaking about his or her surface experience. Becoming more aware of and attuned with one’s own bodily sensations can maximize the intention to be fully and optimally pres- ent in the room with the client. This self-attunement can also provide a map for inviting and returning one’s own awareness back to the moment.
Tolerating Uncertainty and Trusting the Process
One key aspect in preparing for therapeutic presence is to bracket theories, preconceptions, and therapy planning. Bracketing allows our receptive attunement to the uniqueness of the moment to guide the therapy
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process and allows the right technique or direction to emerge from this level of openness. However, opening to the moment means opening to the unknown and having periods in session that may feel entirely uncertain.
Therapists’ discomfort with uncertainty can lead them to respond in a way that is out of sync with the client. In relational therapies, this may leave the client feeling not heard or accepted and hence shut down. With manual-based therapy, such as cognitive–behavioral therapy, this may result in speeding through required steps without attuning to where the client is in the moment and hence having less therapeutic impact. Therapists face a similar challenge with silence. Tolerating the discomfort of silence or of the unknown is integral to a good therapy process, as it is through uncertainty that one can allow for the emergence of material or responses that could be important and relevant for the client. Silence can also allow the client to work internally with what has been offered through the therapist’s response or intervention, and the therapist’s dis- comfort with this and filling the silence could actually impede the client’s heal- ing and learning processes. To be able to trust in the unknown takes practice and the knowledge that tolerating discomfort can leave space for the emergence of poignant therapeutic material.
The challenge of trusting in the unknown occurs often near the begin- ning of a session, when the client begins to delve into his or her experience but what he or she is feeling or what might be needed is still unclear. Whether ther- apists are practicing from a relational or manual-based therapy perspective, there needs to be time for clients to develop comfort and safety in the relation- ship and hence bring their issues into full awareness. Therapists’ anxiety at this beginning stage can force a rushed sequence of interventions before their clients have had time to build trust or before the relationship has had time to develop. In particular, new students may lean on technique as a way of managing this anxiety and as a result minimize the therapeutic efficacy that they could bring to the therapeutic encounter because their interventions are not attuned with the client. Even with manual-based therapies, for optimal efficacy the therapist needs to adapt what he or she is doing in relationship to where the client is at the moment, which in certain moments requires a level of being with and tol- erating space and the unknown. It can be likened to an artist staring at a blank page. It is often the blank page that can be most intimidating and make even the most talented of artists cower. Yet it is through the artistic process that the artist learns to wait patiently for emerging material, to tolerate the unknown, so that what needs to take form or the actual technique that should be used can emerge in resonance with the moment.
It is the same in present-centered psychotherapy, in which we need to learn to be still and to listen, and perhaps even to tolerate the anxiety about not knowing how to help this person who is suffering, so that we can really
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listen to the other and to our deepest self and respond or intervene in reso- nance with the client in the moment. It takes a level of psychological resilience as well as understanding and trust that something healing can happen by being deeply present with clients in their suffering. From this unknown transition space, true healing can occur, as the therapist does not try to rush forward into an intervention or to fix the pain of the other. Rather, the responses and tech- niques that emerge from pausing in presence with the other turn out to be most facilitative for the client’s healing.
To manage anxiety about the unknown, therapists need to develop trust in the process, that by staying fully present in the moment and in the discom- fort of the unknown, what is revealed will allow for their responses or inter- ventions to be in the direction of healing. This comes through experience with relational therapeutic presence. However, there are some specific tools to manage that discomfort, such as returning to a focus on the breath, doing full abdominal breathing, or silently reminding yourself to stay in the present, to trust in the process, to trust in being in the moment. The therapist can also have an internal dialogue with himself or herself, including self-soothing or a gentle reminder to have trust or open fully.
Stress and Multiple Roles
We are in an era in which we are bombarded by demands on our atten- tion, time, and emotional energy. Computers, faxes, cell phones, landlines, BlackBerries, e-mails, tweets, Facebook, and other technology-based commu- nications demand responses with an immediacy that was not expected even a decade ago. In addition, the multiple roles that many therapists play in their daily lives in the current reality carry their attention out of the moment and away from their own experience. The multiple demands in therapists’ lives and attention are stressful and can make the challenge of being fully present even greater than it is. The era of traditional roles is gone, and on one level this means a wonderful gain in equality and diversity in relationships and career choices, but on another level this has resulted in increased expecta- tions and demands to fulfill multiple roles.
The first author (S. G.) conducted a stress-reduction workshop for health care workers, with the intent of facilitating an understanding of the stress in their lives as well as ways of increasing presence in the workplace. She asked participants to name the different roles that predominate in their day-to-day lives. She was struck by the many roles each person described: health care practitioner, parent, caregiver for aging parents, supervisor, man- ager, professor, coworker, friend of someone with a terminal illness, caregiver for in ill sibling, driver for children, single parent, and so on. This is just a small list of what was expressed in this circle of 15 people. When asked to
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describe the time they spent just pausing, being still, or doing something they love for themselves, one woman recalled the last time, which was 2 or so years ago, she went on a walk in a park alone and felt refreshed . . . for that day! It is no wonder that the benefits from these rare and precious self-nourishing moments so quickly disappear.
The process of presence, or deepening into each moment, involves daily time for preparing one’s own self to be in the moment. We can aspire to be present and live a life in which we daily make a commitment to caring, com- passion, presence, learning, and practice. However, demands are made on us constantly by technology, by environmental stresses, and most profoundly by our multiple roles and the split attention that is created by a busy and stress- ful life. The subtle (and not-so-subtle) demands on our attention and time need to be countered by an awareness of the effects of stress and by managing stress and cultivating in-the-moment attention.
To allow for presence, we need to work to open to moment-to-moment awareness in our own selves, in our personal relationships, and in our relation- ship with what is true inside of us. To access that inner steadiness we have to commit to riding through our own inner terrain with greater ease and assurance, while being a part of a something larger, whether it be a sense of community or through spirituality. This can begin with a simple awareness of the multiple roles we hold as therapists in the 21st century.
PAUSE MOMENT. Take a moment to increase your awareness of the mul- tiple roles you play:
� Pause, gently lowering your eyes and attending to your breath. � Reflect on the multiple roles you play or the demands you face
in your life. How many different people are you responsible for (at work or at home, your children, parents, siblings, friends, supervisees, administrative staff, colleagues, and of course your clients)? Take a count of the people who need your regular attention.
� Reflect on how much time or what percentage of your day or week is spent in fulfilling those responsibilities as well as in meeting general daily demands (e.g., answering e-mails, phone calls, taking care of the house).
� Now note how much time or what percentage of your day or week goes to fulfilling your own needs or self-nourishment.
� Notice the gap between the amount of time spent in giving to others and in attending to yourself.
� Take a quiet moment to reflect on how that gap could be reduced; that is, in what ways can you commit a little more time
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to your own self-care and personal growth or to the care of those around you?
By becoming aware of the obstacles and stress in our lives, we can turn our attention to clearing space regularly for presence in life and with clients.
Misunderstood Energy
In moments of heightened connection that can occur at deep levels of relational presence, therapists can experience sexual feelings, not toward clients or toward anyone in particular but as a heightened sense of energy throughout the body. A master therapist interviewed in our qualitative study (Geller, 2001; see Chapter 2, this volume) described the energy experienced from presence:
There is an aliveness and it is very contactful . . . there is high excite- ment and it comes actually right from my genitals right up. I mean it is a very full, flowing feeling, right, and it’s very interpersonal. I mean they are all characterized by nothing else is going on. Everything is just whatever is in the moment.
This energy can be scary, threatening, or misplaced when it is not understood. The first author (S. G.) recalls when feeling a surge of energy in relation to a moment of relational contact and presence. She found it confusing and knew that she also had no physical attraction to this person. She had to sit with that feeling, curious about both it and her trepidation around it. In speaking to her supervisor at the time, she discovered that part of it emerged from the flow of being fully in the moment with this open and vulnerable human being and an openness within that ensued. The confusing part was that by closing down this feeling, she knew would have closed down to the client. Yet to be open to it fully felt inappropriate and wrong. Over time she experienced many other flow experiences in moments of relational therapeutic presence and realized it is not just emotional or sensory, it is energetic.
Energy is discussed more often in Eastern traditions or in relation to somatic practices such as yoga, qigong, or tai chi. In tantric practices, it is under- stood that energy is a life force that can travel throughout the spine and the body. Energy can be called sexual when it is directed toward another human being in a genital-based way. However, therapists who are not familiar or comfortable with these energy concepts could either shut their feelings down, and therefore shut down presence, or direct their feelings inappropriately toward the client.
Therapists must have an understanding of energy from different per- spectives, as well as a healthy relationship with themselves and their profes- sional ethics, to avoid misusing or becoming distracted by this feeling when it emerges. It is also important to understand the relational dimensions of
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therapeutic presence and that it is guided by an intention of being with and for the client, in service of the other’s healing. Being aware of this intent is essential for therapists to avoid misuse, becoming confused, or shutting down.
While we are distinguishing this energy from a countertransference feel- ing of attraction to a client, when misunderstood, this energy can lead to countertransference reactions. The few therapists who have not taken the steps to understand what is occurring, whether it be a heightened energy that accompanies presence or a countertransference attraction, develop personal and intimate relationships with their clients. Some are good therapists from a clinical perspective, yet they crossed a personal boundary and then termi- nated therapy too soon, after engaging in sexual and intimate relationships with their clients. It is not just completely misguided, highly inappropriate, and an ethical violation, but also an easy line to cross if one is not aware of the powerful feelings that can accompany relational connection and how to have appropriate and clear intentions or to access supervision.
Personal practices with energy work, such as qiqong, tai chi, or other somatic practices, could help in gaining comfort with the experience and the appropriate use of energy. Supervision is also important when the energetic responses emerge and become confusing or create the danger of an ethical vio- lation. The self-awareness that is essential in cultivating presence as well as the awareness that therapeutic presence is about being in service of the client’s heal- ing can help therapists to stay open and behave in ethical and appropriate ways.
EXTERNAL CHALLENGES TO THERAPEUTIC PRESENCE
There are certain patients, whether because of their personality styles or their diagnoses or their overwhelming pain, who can be more challenging for therapists to be open to and present with. Examples include an angry or defensive client (especially if fear of confrontation or anger is part of the ther- apist’s core issue) or a client diagnosed with borderline personality disorder who may suffer significant inner pain and suicidal ideation or may use the relationship to manipulate for his or her needs. Certain clients can also hook therapists into reactivity more than others. Other examples of challenging clients could include those in tremendous inner or outer pain, such as clients facing dying and death. Therapists can feel overwhelmed in these situations because they cannot fix the client and can at most bear witness to the client’s pain. The challenge in these moments is not only in staying receptive, open, and present but also in not being so open and enmeshed that we lose our- selves. A related challenge in these moments is to not create distance or manipulate the client into shutting down or closing up without becoming aware of the driving force behind that distancing or feeling of enmeshment.
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Witnessing a client in unbearably deep pain or grief is a challenge for many therapists, as the pull to fix the pain can be strong, which is often a self- protective response to witnessing pain or grief. The ultimate acceptance that being present provides may be healing for many clients, and it is the most challenging of clients that can benefit the most. In fact, this level of presence can be a lot more challenging, and perhaps emotionally draining, than being half present or partially focused. Some examples of presence with challeng- ing clients are explored next.
Personality Disorders
Dual diagnoses are common, and such clients can be challenging for many therapists. For example, in working with someone who has sought ther- apy for depression but who also displays narcissistic tendencies, cultivating a present attitude and working with one’s self are helpful in not feeling as if you are drowning in an ocean of protective reaction. On the one hand, narcissism is a disorder based on a lack of love; on the other hand, narcissism is expressed through arrogance, anger, and selfishness. This can create difficulties in the responses of therapists, who can sometimes experience the shame that nar- cissists create or a reactive and aversive response in the face of arrogant self- ishness. In the face of such ingrained behavior, therapists can find themselves feeling angry, defensive, and hopeless.
Narcissism stems in part from parents’ inability to attune to their children at a time when the child needed that for self-development, and therapists’ attunement is essential in the healing. The tricky balance for the therapist is between being aware of and nonreactive to the outward expression of arrogance or the demands these clients make to have their greatness reflected and attun- ing to the deeper shame or sadness underlying these behaviors yet are highly protected by the client.
While the technique that therapists use with personality disorders such as narcissism is valuable, whether it be emotional regulation, increas- ing interpersonal skills, self-soothing practices, enhancing empathy, or cognitive–behavioral techniques, what is most valuable is how the thera- pist is in the room with the client. The technique does not matter if the client is not met with a warm, accepting, open, and grounded presence in the therapist. On the flip side, although people with narcissism need the presence and compassion of the therapist, they are not enough. For exam- ple, only when the narcissistic mirror is challenged can people with nar- cissism start to heal. However, to know how and when to challenge these clients is highly dependent on the therapist’s inner steadiness, compassion, and attunement to the client in the moment, as the client can initially
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react to the therapist. Hence, there is a greater need for the therapist to remain open, connected, and grounded yet nonreactive for his or her approach to be effective.
An example of the acceptance that is necessary to facilitate technique emerges from dialectical behavior therapy, a behavioral approach developed by Linehan for patients with borderline personality disorder. With clients with borderline personality disorder, the internal or affective world of the therapist is vital in providing the basic acceptance that is needed to make the behavioral techniques effective. Linehan (1993a) provided an interesting commentary that speaks to the challenge and necessity of present moment acceptance:
In relationship acceptance the therapist recognizes, accepts, and vali- dates both the patient and himself or herself as a therapist with this patient as well as the quality of the patient–therapist relationship. Each is accepted as it is in the current moment; this includes an explicit accept- ance of the stage of therapeutic progress or lack thereof. Relationship acceptance, like all other acceptance strategies, cannot be approached as a technique for change—acceptance in order to get past a particular point. Relationship acceptance requires many things, but most impor- tantly it requires a willingness to enter into a situation and a life filled with pain, to suffer along with the patient, and to refrain from manipu- lating the moment to stop the pain. Many therapists are not prepared for the pain they will encounter in treating borderline patients, or for the professional risks, personal doubts, and traumatic moments they will encounter. The old saying “if you cannot stand the heat, don’t go into the kitchen” is nowhere more true than in working with suicidal and borderline patients. (pp. 515–516)
A therapist who is skilled at acceptance and presence has the ability to be with the deep pain and to provide support from within where the client is at. Furthermore, the skilled presence therapist can recognize the source of the anger or manipulation that could be directed at him or her and not react to or ignore the anger or manipulation.
Gabbard (2001) noted that in working with a patient with borderline personality disorder, the therapist can be placed in the role of “bad object,” with anger being directed toward him or her as a projection of the patient’s abusive parent. An optimal state in the therapist is a state of being even, in the “middle ground,” experiencing some of that anger inside but maintain- ing a capacity for empathy and helping the other. Gelso and Hayes (2007) supported Gabbard in rejecting the traditional psychoanalytical model of being nonreactive when pulled by a patient’s rage by creating an objective distance from the client, as this can anger the client further and deepen the
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client’s experience of rejection. Similarly, if the therapist is overinvolved in the dynamic of blame and defensiveness and reacts angrily or distances himself or herself, it can overwhelm and damage the therapeutic relation- ship. This optimal state that Gabbard (2001) described reflects the experi- ence of therapeutic presence, the state of being deeply connected, in the moment, authentic, in connection with self, yet expansive in holding both the emotional authenticity and the intention for healing with and for the patient.
The therapeutic process with people with personality disorders is often long and difficult. Although presence allows for deeper attunement, non- reactivity, and inner steadiness, it is sometimes hard for therapists to sustain these states during the long therapeutic process. In addition, allowing a sense of closeness and interpersonal connection with someone with narcissism or borderline personality disorder can at times create within the therapist a state of shakiness and lack of confidence in his or her own self. The challenge here is for therapists to discern their experience of lack of confidence and not knowing how to help from an inner interpersonal reaction to the client that can be clinically useful.
The therapist’s own personal practice becomes essential in enabling him or her to remain open yet hold steady when faced with a client’s potential aver- sive reactions. A colleague recently discussed how she felt more drained of energy in relation to her patients with personality disorder when she became more present with them, instead of just partially attentive, which is how she pre- viously practiced. She realized that the demands of being open and connected in some ways were greater and required balancing her schedule and life practices so that she had healthy ways to take care of herself (e.g., time between sessions, debriefing, and mindful walking) to release any residual tension. Maintaining this inner state of openness, grounding, and nonreactivity, a state that is essen- tial in working with personality disorders, takes a great deal of inner commit- ment on the part of the therapist. Presence is a significant underlying state that can help people with personality disorders, yet cultivation and commitment are essential in sustaining it.
Dying and Death
Being with someone who is dying, or with someone facing a terminal ill- ness, is one of the greatest challenges for therapists as nothing can be done to fix or relieve this reality for the other. As therapists we like to see relief, we like to feel we can help someone navigate through intolerable feelings or sit- uations into a new life with peace and wholeness. Yet that is not the case when facing persons who are dying. We cannot help them to live a healthier
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life; at most we can help them to accept their terminal situation and come to peace with any unfinished business in their lives or to live their final days with acceptance of the reality of their life and their transition to death.
The most powerful therapeutic stance we can take with people who are facing death is to be fully present with them, in their fear, their pain, and their suffering. They need to be listened to and heard, as many people are fearful of talking about death and so avoid the topic with the dying person. This level of presence in end-of-life care demands that the therapist open up fully to the other and the other’s pain, and likely to his or her own reality of dying and death, and move through the painful suffering and loss that may be experi- enced without shutting down or feeling overwhelmed. This requires facing fear and the barriers to opening to generate a level of inner resiliency, and it requires skill in being open yet grounded and emotionally stable.
The compassionate care movement has brought attention to the impor- tance and value of presence in end-of-life care (Halifax, 2009). This runs counter to our Western orientation, which involves fear and avoidance of death and any discussion of dying. We cannot avoid our own fear of death when we work with people who are dying. Facing a life-threatening illness calls us to a place inside that is raw, vulnerable, and real, and if we avoid deal- ing with that reality then we avoid life, and we avoid offering our pure pres- ence to the client who is facing death.
Roshi Bernie Glassman, as discussed in Halifax (2009), teaches three tenets of compassionate care for the dying as helpful when being with some- one facing death. The first tenet, not knowing, reflects giving up fixed ideas of ourselves or others and opening to the spontaneity of the beginner’s mind. The second tenet, bearing witness, reflects being present with the suffering and joy in the world, without judgment and without attachment to outcome. The third tenet, compassionate action, reflects a commitment to free others and ourselves from suffering.
Frank Ostaseski, founder of the Zen Hospice Project in San Francisco and the Metta Institute in Sausalito, California, developed five precepts of service as companions on the journey of accompanying the dying (Ostaseski, n.d.). He described these as bottomless practices that can be continually explored and deepened and have to be lived and communicated through action.
� The first precept: Welcome everything. Push away nothing. In wel- coming everything, we may not like what is arising, but it is not our work to approve or disapprove, but just to listen deeply. This is a journey of continuous discovery; we have no idea how it will turn out, and it takes courage and flexibility.
� The second precept: Bring your whole self to the experience. In the process of healing others and ourselves, we open to both our joy
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and our fear. It is not our expertise, but rather the exploration of our own suffering that enables us to be of real assistance. This precept reflects the importance of the exploration of our own inner life in enabling us to be empathic and respond compas- sionately to the other person.
� The third precept: Don’t wait. This precept calls for patience and an honoring of present-moment experience, rather than wait- ing for death. When we wait for the moment of death, we miss so many moments of living. This allows for the awareness of the precarious nature of this life to reveal what is most important, that calls us to enter fully.
� The fourth precept: Find a place of rest in the middle of things. Rest is often something people look forward to that arrives when we are at the end of the day or going on holiday. We imagine that we can only find rest by changing the conditions of our life. But it is possible to discover rest right in the middle of chaos and dif- ficult emotions. This rest reflects the experience of presence, which is always accessible to us and emerges from bringing our full attention, without distraction, to this moment.
� The fifth precept: Cultivate don’t-know mind. This describes cul- tivating an open and receptive mind that is not limited by agen- das, roles, or expectations. From this open receptivity we allow the situation itself and the relationship with the other, in the moment, to inform our actions. This aspect of presence involves listening openly to the other, as well as listening to our own inner voice, sensing and trusting our intuition. We learn to see, feel, and look with fresh eyes.
Glassman’s three tenets and Ostaseski’s five precepts reflect the whole experience of therapeutic presence, from the need to be receptive and open to the unknown and to others to be fully present and nonjudgmental to what is being expressed or experienced without attachment to outcome, to the need to be present with and for the client with the intention to be with the other in a way that is healing. This offering of presence and compassion requires therapists to look deeply at their own attitudes and fears in relation to illness and death as well as to recognize the cultural and family attitudes that they may have internalized, and to open fully to the multiple dimensions of the experience of dying and death. To face and move through their own potential fear of death and to have or strengthen a level of inner resiliency and stability require deep inner work on the part of therapists, so they can offer the gift of being present and bearing witness to the client’s suffering, without shutting down, holding back, or becoming overwhelmed.
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Trauma
Riding the waves of uncertainty is acutely challenging when the client is expressing or reexperiencing trauma. In particular, learning the details of rape or abuse in a client’s childhood or seeing and hearing the effect of a sex- ual or physical violation on a child or adolescent is heartbreaking. Yet the reality is equally hopeful because that person has made it to the therapist’s office. There is nothing more profoundly healing than offering a traumatized child, adolescent, or adult your complete self, with the capacity not only to hear and feel but also to stay steady and hold that pain.
The presence of the therapist allows the trauma survivor to feel under- stood and supported, as trauma survivors often feel alone in their suffering and believe that no one can understand what they may be experiencing. A trauma survivor could feel that even the therapist, not having experienced the trauma that he or she went through, is outside of the wall that the survivor has cre- ated for protection and survival. Hence, therapists’ presence may include an acknowledgment of the truth of not having the shared experience of trauma, but a willingness to be there, to listen, and to take in the experience with open- ness, compassion, and a capacity for understanding.
The risks are complex for a therapist who has not experienced the trauma of the survivor (or survivors, as it could be a community trauma or disaster) and is trying to be as present as possible. The resonance with feeling the tragic experience can create in the therapist either an urge to rescue and protect the client from further distress or a deep emotional upset or horror in knowing too much about what the survivor has experienced (Lanyado, 2004). Exposure to the details of the trauma may create an internal defense to protect one’s self from the effects of witnessing the horrific through the verbal account of the event. Even the most present and skilled therapists are not immune to this response in the face of trauma. Hence the agility to recognize this state for what it is (a mirror response or defensive reaction) and to work with it through inner recognition, and perhaps a calming of one’s own anxiety, is central to remaining or returning to being fully present with the client.
Nothing is more potentially challenging to the strata of one’s being than to witness the sheer expression of pain associated with trauma. Furthermore, there is an occupational hazard of becoming overwhelmed, depressed, defen- sive, and burnt out in the face of trying to help people process or cope with trauma (Lanyado, 2004). However, if therapists begin to feel overwhelmed and lose hope in the face of trauma, they are more inclined to attempt to fix, distance themselves from, or overidentify with the client’s experience, which can result in a failure in the ability to be present and helpful, and the client will be at risk of not feeling safe and likely shutting down. In working with trauma, it is essential that “therapists ensure that they do not consciously
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overwork and that they do make sure that their leisure time really replenishes their emotional reserve” (Lanyado, 2004, p. 13).
Working with trauma survivors, and the constant witnessing and fully being there with some of the horrific experiences clients retell and reexperi- ence, can create a shutting down or vicarious traumatization in therapists if they are not taking care of their needs and finding a release for that which is carried in their own emotional bodies after session. Here the danger of not being pres- ent as a way to self-protect is higher. This is where peer supervision, self-care, and time after session or the workday are imperative. Some therapists find it helpful to talk to a colleague, meditate, play music, engage in artistic or creative activities, walk or exercise, or have some time at the end of the day to decom- press by walking home from the office or going to a park or somewhere else calm. Cultivating and sustaining a nonreactive yet open state, which is essen- tial in working with challenging clients, is equally important for therapists in training as well as expert therapists.
CONCLUSION
Although the potential for healing with therapeutic presence is great, the challenges are equally great. Being fully open and engaged with the client brings internal challenges such as countransference reactions and managing busyness, multiple roles, and stress, as well as external challenges such as meet- ing or being with difficult clients or clients experiencing great pain, trauma, or loss. This speaks to the increased requirement for therapists to take care of their own internal worlds and mental health, cultivate and maintain self- awareness, as well as leave time during the day and between sessions to release and be connected to their own needs for self-care and relation to release emotional residue and to minimize compassion fatigue.
Next we look at the neurobiological correlates of presence and how shifting one’s own biology in the direction of calm and openness can help to cultivate presence and work through the challenges that accompany presence.
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