The Therapeutic Presence Issue, Geller/Cultivating Therapeutic Presence

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Cultivating Therapeutic Presence:

Strengthening Your Clinical Heart, Mind, and Practice

By Shari M. Geller

Shari M. Geller
Teaching Faculty in Health Psychology at York University
Adjunct Faculty at the Music and Health Research Collaboratory at University of Toronto
Centre for MindBody Health
250 Eglinton Avenue West, Suite 200
Toronto, On M4R 1A7
drsharigeller@gmail.com

I’ve learned that people will forget what you said, people will forget what you did, but people
will never forget how you made them feel.
Maya Angelou (as quoted in Booth & Hachiya 2004, p. 14)

Abstract. ​Working effectively in psychotherapy is only possible when clients feel safe and secure. To promote safety and optimal therapy, therapists need to focus more on how they are with clients than what techniques they do in the therapy session. Decades of research demonstrate that the therapeutic relationship is the most consistent predictor of change. Yet what contributes to a positive therapy relationship has been less clear. Emerging research suggests that therapeutic presence (TP) is a necessary and preliminary step to facilitating positive therapeutic relationships and more effective therapy. The therapeutic relationship is core to both Emotion Focused Therapy (EFT) and Accelerated Experiential Dynamic Therapy (AEDP). Intentional cultivation of TP is essential in both models and is trans-theoretical across various therapy approaches. TP facilitates an experience of safety for clients and therapists, which promotes effective therapeutic relationships and treatment.

A view to the neurophysiological dimensions of relationship informs how TP can create effective relationships and optimal therapists. One lens from which to view this is polyvagal theory (PVT). While we have an idea of what the benefits are of TP on the therapeutic relationship, PVT explains how TP strengthens the relationship, evokes safety for clients, and allows clients to engage in the deeper work of healing trauma and emotional difficulties.

This article will focus on (a) the definition and an empirically validated model of TP; (b) TP as a foundational and trans-theoretical approach, with a brief discussion on TP in EFT; (c) how presence elicits a neurological and physiological feeling of safety; and (d) cultivating skills of TP, which include attunement to self, to clients, and to the therapeutic relationship, as well as how to work with barriers to presence. A sample of TP practices concludes the article.

What is Therapeutic Presence?

Therapeutic presence is a way of being with client that optimizes the doing of therapy (Geller, 2017; Geller & Greenberg, 2012). It involves therapists bringing their whole self to the encounter and being present on multiple levels, physically, emotionally, cognitively, relationally, and spiritually. TP involves being grounded in one’s self, while receptively attuning to the verbal and non-verbal expression of client’s moment-to-moment experience.

TP is a way of preparing for therapy (Geller, 2017). When therapists bring intention to cultivate presence in their personal and daily lives and prior to session, it allows the experience of in-session presence to be accessed with greater ease. Ongoing self-care as well as taking a few minutes prior to session to center and invite a state of presence can support therapists to be in an optimal state to facilitate their clients’ healing.

TP is an embodied experience. Therapists’ experience includes feeling (1) grounded, centered and in contact with one’s self, while being (2) immersed in the moment with clients’ pain and suffering. There is a simultaneous experience of (3) expansion, in which there is a felt sense of a larger perspective and spaciousness; as therapists are (4) compassionately with and for the other, in service of their client’s healing process. This allows therapists whole self to be a safe and supportive other for clients, so they can explore their deeper emotional pain as well as have a corrective experience in a safe and secure attachment relationship with their therapist.

TP is also a process or way of doing therapy (Geller, 2017). This involves (1) being receptive to clients’ experience, attuning to their moment-to-moment verbal and non-verbal expressions. (2) Attuning inwardly to therapists’ own resonance with clients’ in-the-moment experience, which serves as a guide to (3) extend and promote contact through both verbal and non-verbal expression. This helps therapists sense and attune to how their client is receiving their responses and interventions and what is occurring moment-to-moment with their client and in the relationship (Geller, 2017). Being sensitively attuned to clients’ experience and sense of safety helps therapists recognize the optimal moments for responses or interventions so they are offered with the greatest impact and precision, and in resonance with what is emerging in-the-moment.

Therapeutic presence is highly relational. When clients perceive their therapist as present with them, they become more present within and in the relationship. A larger state of shared presence begins to emerge and therapists and clients bodies and brains become in synch. This supports an inter-subjective consciousness or sharing of the same emotional landscape (Stern, 2004), which deepens safety and leads to therapeutic change.

TP is growth promoting for therapists, clients, and the therapeutic relationship. It involves therapists’ self-care and balance and attention to present and healthy relationships in general. Clients feel heard, understood and safe, which is experienced on a neurophysiological level, and even outside of conscious awareness (Geller & Porges, 2014; Porges & Carter, 2014). Clients’ defenses then soften and natural growth and healing unfolds.

TP as a Foundation for Emotion Focused Therapy

Emotion Focused Therapy (EFT) is founded in the therapeutic relationship. The overall EFT approach involves both following and guiding (Greenberg, 2010). EFT therapists’ practice from a person-centered style (Rogers, 1957), which involves entering the client’s internal frame of reference and responding to it empathically, combined with a more guiding, process directive experiential and gestalt therapy style (Gendlin, 1996; Perls, 1969) to deepen clients’ experience. EFT is built on a genuinely valuing, affect regulating, empathic relationship in which the therapist is fully present, highly attuned, and sensitively responsive to the client’s experience.

TP is an essential stance in EFT therapy (Geller, 2019). A therapeutic relationship based in presence provides a powerful buffer to the client’s distress through the co-regulation of affect. The present and attuned therapist mirrors the client affective experience providing interpersonal soothing and this promotes the regulation of overwhelming, disorganizing, and painful emotions (Geller & Porges, 2014). Over time the interpersonal regulation of affect becomes internalized into self-soothing and the capacity to regulate inner states (Stern, 1985). In addition to being curative in and of itself, this type of therapeutic relationship also provides an optimal environment for promoting the therapeutic work of exploration and EFT task resolution. It also helps therapists to stay actively present while offering responses and interventions that are optimally timed for clients and in tune with their sense of safety.

For therapists, TP promotes a connection to one’s self and with clients that is both emotionally regulating and supportive of growth and wellbeing. Cultivating presence serves to increase effectiveness for EFT therapists (Geller, 2019). TP promotes clients to feel safe and engaged in the work of therapy. TP also allows therapists (a) to recognize and discern primary and secondary emotions; (b) effectively use EFT case formulation following the pain compass that will guide to the core emotion scheme and (c) the flexibility to read the moment so therapists can respond and intervene with the greatest impact.

Research on Therapeutic Presence

An empirically validated model of TP has been developed (Geller & Greenberg, 2002), which include three overarching qualities: (1) how we prepare ourselves to be present with our clients, both in life and in session, (2) the process or what we do in-session when we are present, and (3) the in-body experience (Geller & Greenberg, 2002, 2012).

Based on this model, a psychotherapy measure was developed, and was demonstrated to be reliable and valid in a larger psychotherapy research study (Geller et al., 2010). Two versions of the measure exist, one for therapists self-rated presence (therapeutic presence inventory – therapist; TPI-T) and one for clients perception of their therapists’ presence (therapeutic presence inventory – client; TPI-C).

Research with the TPI affirms that TP is related yet distinct from empathy (Pos et al., 2010; Geller et al., 2010); and presence precedes empathy (Hayes & Vinca, 2011). This finding suggests that TP is a necessary precondition to being empathic and sustaining a positive therapeutic relationship.

Research also suggests that TP is a positive predictor for the therapeutic alliance (Geller et al., 2010; Pos et al., 2011) across Emotion Focused Therapy (EFT), Cognitive Behavioral Therapy (CBT) and Person-Centered Therapy (PCT). It was found that clients’ experience of their therapists’ presence matters most, as those who experienced their therapist as present, had a positive alliance and a successful session outcome across all three modalities of therapy (Geller et al., 2010).

The findings above suggest that therapists need to learn how to embody and express/communicate presence for it to be optimally received by their clients. Polyvagal theory by Porges (2011) helps us to understand how to do this through prosody of voice, open body posture, and a face to heart connection that evokes connection and safety for clients.

How Does Therapeutic Presence Promote Effective Therapy?

Neurophysiological Underpinnings. To understand how TP activates safety and ultimately deepens the therapeutic relationship and effectiveness, it is helpful to look through the lens of Polyvagal Theory (PVT). In simplified terms, PVT is based on an evolved understanding of the autonomic nervous system. The old nervous system as we understood was a two-part system. It had a sympathetic nervous system (the fight or flight system), and the parasympathetic nervous system (the calming system). Polyvagal theory teaches us that the new nervous system is a three-part system, with an added social engagement system that developed as we evolved as mammals (Porges, 1995, 1998, 2003, 2011).

In the parasympathetic branch of the nervous system, there are two pathways travelling within the vagus nerve. The polyvagal (two vagal) system has a dorsal vagal pathway and a ventral vagal pathway (Porges, 2011). The dorsal vagal pathway reflects when we are shut down. It is unmyelinated, meaning the messages from this system transmits slowly. When a person feels overwhelmed or “in danger” in relationship or in general, their system shuts down, it goes into a freeze. It’s the equivalent of dissociation that trauma based clients may go through when they feel overwhelmed (a sympathetic nervous system or fight and flight system) and then shut off. I think many of us go through small dissociative moments a lot during the day. When we drift off or shut down to what is happening around us or within us.

The ventral vagal pathway responds to cues of safety in relationship (Geller, 2017; 2018; Geller & Porges, 2014; Porges, 2011). It is a myelinated system, transmitting messages in a faster conduction system. The ventral vagal has what is called a social engagement system (Porges, 2003). As social and relational beings, we regulate in our relationships (Geller, 2017; 2018). When the ventral vagal system is activated, through safe connection and relationship, we calm, and we can regulate our nervous system. Therapeutic presence can help optimize this ventral vagal pathway, through activating safety in relationship (Geller & Porges, 2014).

Bidirectional Attunement. PVT informs us of the bidirectional communication between the brain and the visceral organs (Porges, 2011). Cues of safety or danger outside of conscious awareness are detected by cortical areas, and can shift physiological states (Geller & Porges, 2014). Shifting physiological states are communicated from visceral organs to the brain via the vagus. These cues are also communicated from the regions to which the vagus nerve has projections, such as the striated muscles of the face and head (Porges, 2011). Because of these connections to the face which run all the way down to the sub-diaphragmatic region, the way that people use their faces, voices, breath, and bodies can say a lot about how calm or activated they are feeling in a given moment.

While there is bidirectional communication between brain (i.e., central nervous system) and body – there is also a bidirectional communication between the nervous systems of people who are in relationship with each other (Cozolino, 2006; Geller, 2018; Geller & Porges, 2014; Porges, 2011; Schore, 2012; Siegel, 2010). This communication is not necessarily in conscious awareness; it is more of a “gut” (visceral) sense that informs us of how we are feeling in an interaction.

Neuroception. A concept in PVT named neuroception by Porges (2011), describes how safety and unsafety are experienced and mediated by physiological states (e.g., bodily felt agitation when unsafe, internal sense of ease when feeling safe). Feeling scared when someone comes into the room screaming, is an accurate gut sense of unsafety in an unsafe situation. Feeling calm when relationships are calm and in synch, is an example of a neuroception of safety.

Emotional dysregulation and physiological reactivity to others (feeling unsafe even in safe situations) can develop in response to trauma or mis-attuned relationships. It is helpful to understand the potential neuroception of unsafety that particular clients may have as a result of trauma. If a client has an inaccurate system, the therapist may look down in reflection, and the client might feel abandoned in that moment. With presence, therapists can also be more attuned to their clients’ neuroception of safety or unsafety in their clients. This helps to read their state in the moment, to notice when they go into a freeze or unsafe place, and to activate safety through ventral vagal connection.

At the same time, present-centered safe relationships can heal and exercise the neural muscles of safety. Therapeutic relationships infused with presence can heal and exercise clients’ neural muscles of safety, and over time strengthen their ability to feel safe with others (Geller, 2018; 2019). The bidirectional nature of the social engagement system means that positive interactions between therapists and their clients can influence their vagal function to dampen stress-related physiological states, and support growth and restoration (Geller & Porges, 2014).

What Therapeutic Presence and Polyvagal Theory Teach Us in the Clinical Encounter

Therapists need to regulate to relate, we need to come into a sense of presence within ourselves and ground ourselves before meeting another in therapy. If a therapist enters into connection with someone when in a dysregulated state, it can be harmful. We all know what it’s like to get into a conversation with someone in a reactive way, such as pressing send on an email when you’re in a reactive moment. To be able to pause and regulate before we make any kind of connection, can make all the difference.

We also need to relate to regulate. This is the sense of co-regulation, that we’re constantly regulating ourselves through positive safe, present-centered relationships. When therapists cultivate presence and intentionally relate and tune into the moment, there is positive impact for clients and the relationship.

Co-Regulation: Creating Safety through Presence in Relationship

The regulators of emotions and physiology are embedded in relationship (Cozolino, 2006; Geller & Porges, 2014; Porges, 2011; Schore, 2012). When clients experience the attuned presence of their therapist, it can change their brain and experience. This occurs in part through co-regulation, which has been defined as the bi-directional linkage of oscillating emotions between different partners, contributing to the emotional stability of both (Butler & Randall, 2013). In clinical terms, if therapists are calm, then their clients will calm in resonance with their grounded presence, as emotions, bodies and brains are bi-directionally linked (Geller, 2017; Geller & Porges, 2014). Alternatively, if therapists are not grounded and present, then they can be thrown off or dysregulated by their clients’ emotional overwhelm.

The following brief explanation explains how this occurs in the psychotherapy process. First, (a) the therapist becomes present, prior to session, through grounding, centering, breathing, and attuning within their self in the moment; this then (b) allows therapists to openly receive and attune with their clients, which (c) causes clients to begin to feel safe from a neurological, physiological, and emotional perspective (Allison & Rossouw, 2013; Cozolino, 2006; Geller & Porges, 2014; Porges, 2011; Schore, 2012).

This process has four important effects (Geller & Porges, 2014).

  1. Clients’ defenses drop away and an optimal portal opens up to engage effectively in the work of therapy.
  2. Clients’ nervoussystem beginsto calm in resonance with their therapists’ calm grounded presence, and they feel more present and accepting within and more connected with their therapist.
  3. Therapists’ responses and interventions are offered in attunement with what is poignant in the moment for their clients, including their readiness to receive.
  4. Through repeated experiences of safety, clients can potentially generate a greater sense of safety in other relationships, which is central for wellbeing, growth and health (Geller & Porges, 2014).

Essence of Presence: Promoting Regulation and Growth Through Relationship

The essence of presence then is how therapists are with our clients, more than what they do in therapy. It is how therapists offer themselves with their receptive, connected, open, grounded, and attuned presence. As Maya Angelou said, people may forget what you said, yet they never forget how you made them feel.

There are ways that therapists can intentionally offer their selves, through their non-verbal expressions, to promote contact with clients. Being a calm and grounded presence can invite calm and safety within clients through the bidirectional communication that occurs in physiological and relational contact. Specific ways that therapists can express their nonverbal presence, activating a neurophysiological experience of safety (Geller, 2017), include:

  • Prosody (rhythm) in voice
  • Soft facial expression
  • Soft and direct eye gaze
  • Open and forward leaning body posture
  • Visual focus and attention attuned to clients

Research supports these non-verbal elements of safety in the clinical encounter. For example, therapists’ direct and attentive eye gaze results in clients feeling present and empathically attuned to (Marci & Orr, 2006; Marci et al, 2007). Marci et al., (2007) also showed that clients and therapists’ physiological arousal became in synch when therapists’ eye gaze was attentive and in contact with their client. In contrast, clinicians who shifted their eyes and attention away from the client left clients feeling distanced, less empathically attuned to, and in discord or out of sync with their clinician.

Another way of looking at how to promote regulation in relationship is through attuned right-brain to right-brain communication (Schore, 2009; 2012; Quillman, 2012). Right-brain to right-brain refers to these nonverbal ways that promote regulation, as highlighted in PVT, such as body posture, vocal expressions, facial expressions, and gestures.

In interactions with therapeutic presence, therapists listen with their body and senses (right brain) to what is expressed via the body of their clients (their right brain’s communication). Informed by PVT, it is important that therapists are actively using non-verbal communication to communicate that they are listening, connected and wanting to understand their clients and help them to feel safe.

Polyvagal Theory proposes that cues of safety or danger are communicated interpersonally from the upper part of the face, eye contact, prosody of voice, and body posture (Geller & Porges, 2014; Porges, 2011). The therapeutic encounter is filled with nonverbal messages that are outside the realm of our awareness, yet clients are interpreting their therapist’s way of relating with them in a physiological or gut sense way. The neuroception of safety is detectable by physiological markers.

Research suggests that a safe therapeutic environment facilitates the development of new neural pathways for the client, which contributes to the repair of attachment injuries and provides the positive social interactions essential for health and growth for the client (Allison & Rossouw, 2013). When clients feel their therapist is present, open and centered and willing to hear, feel, and hold their pain with a caring and grounded presence, it can actually deactivate the trauma response and over time give their brain an experience of safety that eventually extends to other relationships

Even in a difficult conversation or therapeutic rupture, how therapists approach the rupture with makes all the difference. For example, I had to confront my client about the multiple ten-minute voicemails she left on my voice mail, as it was stressing and burning me out. I needed to share how this was taking me away from being present in session, yet in a way that my body posture communicates openness, my voice was prosodic, so they felt the difficult yet authentic communication with acceptance and kindness. This kind of attuned presence also helped myself, regulate my own reactivity so I could maintain an authentic connection with my client.

Clinical Skills for Therapeutic Presence

Being skillful at TP involves a commitment to cultivating presence in therapists’ personal lives and relationships. This includes strengthening the in-body and relational qualities of TP such as grounding, immersion, expansion and being with and for the other. Summarized below are the skills of approaching the session with presence as a part of the preparation phase, as well as in-session skills that reflect the process of presence in-session, as informed by the TP model. This process reflects what occurs throughout the session as therapists are (a) receiving from and attuning with their client and (b) attuning within themselves; and (c) responding and making contact with their clients to activate a sense of safety and deepen the relationship. This process involves tracking clients’ moment-tomoment experience; both how their client is feeling, and how they are receiving their therapist’s interaction with them (Geller, 2017).

Starting with Cultivating Presence in the Therapist

Presence starts within the therapist, in their personal lives and prior to session. Practice strengthens the neural pathways of that which we wish to cultivate (Hanson & Mendius, 2009). Practice in real life expands therapists’ capacity to access presence when in session. A variety of practices can be found in my book, A Practical Guide to Cultivating Therapeutic Presence (Geller, 2017): diaphragmatic breathing with long exhalations, relaxation practices, yoga, music, mindfulness, grounding or centering exercises, and deep listening.

Preparing Prior to Session

Therapists benefit from the intentional cultivation of presence prior to session, as it allows them to be in a grounded and receptive place, with a safe and regulated nervous, to best meet and offer their attuned and compassionate presence to their clients. This is supported by research that suggests just five minutes of centering prior to session improves session outcome and reduces clients’ psychological distress (Dunn, Callahan, Swift, & Ivanovic, 2013).

This preparation can start before the therapist even arrives at the office. It includes allowing time to open up the space, gather thoughts, get nourished, and center inside, vs filling the space with checking voice messages, texts, and emails. A couple of practices to cultivate presence through preparation are offered below.

1. Intention. Setting intention for presence prior to session, can be simple and powerful. Standing in a grounded posture, feeling the soles of the feet as they touch the floor and taking a few deep and slow breaths can facilitate this process. Therapists can engage in a tree pose or a centering practice to activate a sense of presence in the body. It also helps to take a brief pause between clients, to take a few full breaths and intentionally let go of the last client and open to meeting the next person.

2. Presence Practice: PRESENCE Acronym. The PRESENCE acronym was developed to reflect the qualities of TP, such as being in contact with yourself and your client simultaneously (Geller & Greenberg, 2012; Geller, 2017). With practice, it can then be utilized efficiently before each session to invite the experience of presence. Practice is essential in supporting access to the experience of presence, so explore this acronym at different times both outside and prior to session so activation of presence prior to session is more easily felt.

  • Pause (put aside what you are doing to just rest in this moment)
  • Relax into this moment (soften your facial and body muscles)
  • Enhance awareness of your breath (take 3 deep inhalations and exhalations)
  • Sense your inner body (bring awareness to what you are feeling in your physical and emotional body)
  • Expand sensory awareness outwards (seeing, listening, touching, sensing what is around you)
  • Notice what is true in this moment (both within you and around you, without judgment).
  • Center and ground (feel your feet on the ground and the center of your body)
  • Extend and make contact (open your eyes and ready yourself to approach the next moment or open the door for your client, while staying connected to your self and your breath).

The Process of Presence Within a Session:

Attunement to Clients, Self and the Relationship

Once the session begins, therapists go through a circular process to optimize their presence in relationship with their clients. They are (a) receiving, reading and attuning to clients’ moment-to-moment experience (b) attuning within one’s self to what is being received, and (c) allowing this blend of experiences to inform their understanding and response, while activating promoting contact in the moment between them. This includes tracking their moment-to-moment clients’ experience and the relationship; as well as assessing when clients feel safe or unsafe; and what is needed to promote safety if needed.

(A) Receiving, reading and attuning with clients. Therapists’ attunement with clients invites an experience of feeling heard, felt, and seen (Geller, 2017). Therapists are open, receptive, and actively listening to clients’ verbal and non-verbal experience; listening to what their clients are saying, as well as how they are saying it. For example, they are attuning to clients’ body posture, vocal tone and pace, breathing rhythm, and facial expressions (see Geller (2017) for a more detailed account of what different expressions may indicate).

Therapists are using their self as an antenna to empathically attune to the emotional world of their client, which includes listening for their core pain by attending to both primary and secondary emotions. In this presence process, there is an empathic attunement to unfolding the relationship between narrative, internal experience, and body language. Attuning to verbal cues as well as gestures can be a guide to understanding clients’ experience. For example, Sally was clutching her chest while she spoke about her exhusband, a gesture that may indicate that she was experiencing the grief around the ending of her marriage.

Clients’ vocal quality (pitch, tone, rhythm) can also be a portal into their experience (Rice & Kerr, 1987). For example, an increase or change in vocal pitch and frequent pauses may indicate a client is feeling anxious about what is being shared (Laukka et al., 2008) or disconnected from their experience (Geller, 2017). An increased pitch along with volume and speed, can reflect that a client is experiencing anger (Scherer, Johnstone, & Klasmeyer, 2003). Attuning to clients’ vocal quality in context of what they are sharing can guide therapists to understand their current emotional state. From the start, EFT relied on the client vocal quality scale (Rice, Wagstaff, Koke & Greenberg 1979) which specified vocal features of productive vocal qualities (focused and emotional) and unproductive ones (external and limited) voice.

Attuning to clients’ breathing patterns also can inform therapists on their clients’ experience. For example, deep and slow breathing may indicate that the person feels relaxed, heard and met by their therapist. Shallow breathing may signal anxiety and irregular breathing; short exhalations may suggest the client is feeling unsafe, triggered, or threatened. A sigh can indicate a wide variety of emotions and mental states ranging from relief, to boredom, fatigue, or dismay; or it can indicate a physiological re-set allowing individuals to regain respiratory control after something has dysregulated them (Vlemincx et al., 2013). Given the cultural differences of nonverbal gestures and expressions, understanding clients’ nonverbals (e.g., a sigh) in that context helps to decipher the meaning (Geller, 2017).

Therapists can attune to clients’ body posture to listen to their experience. For example, a client’s crossed arms may indicate that the client is held back, defensive, and disconnected. An upright yet open posture, with a relaxed vitality in the body suggests clients feel open and engaged. Attuning to facial expression and eye gaze is also informative. For example, a downward cast could indicate shame, or eyes widened may reflect fear. A soft eye gaze can indicate that client feels safe and at ease.

Reading bodily cues also may indicate when a primary emotion holds greater emotional charge and meaning than the words alone are conveying, or when there is discord between what clients are sharing and what they are feeling. For example, my client Laura (client’s name and details changed) shared “I am happy that my daughter is moving into her own home,” yet her leg was shaking, and her eyes were glazed and looking downward. I reflected to Laura that her body was expressing something discordant from what she was saying, wondering if it was sadness or fear. This allowed for further unfolding of her grief and fear at this pivotal life change.

To strengthen the ability to attune with clients, therapists can try the following:

1. Watch a therapy tape (or foreign movie) with the sound off (or on a slower speed). Try to identify the client or actor’s emotional experience. Then turn the sound or subtitles on to see how close your understanding was to their actual experience.

2. Mirror a partners’ facial expression, eye gaze, body posture, breathing patterns to try to get a felt sense of their experience from the inside out. From a neurophysiological experience, this is said to activate mirror neurons in yourself, with your partner, to give you a sense from the inside out of their experience (Iacoboni, 2009a; 2009b; Siegel, 2007).

(B) Attuning inwardly. As therapists receive clients’ moment-to-moment experience, they are also attuning within to understand what is being received. Therapists use their body as an autonomic resonance to sense and listen to clients’ experience, and then listening internally to understand what is received and to determine how to respond (Geller, 2018). Therapists can also tune in to how they may not be present (i.e. distraction or countertransference reaction) and invite their attention back to the moment. This scanning of therapists’ inner experience can occur quickly in session, once the ability be present strengthens through practice out of session.

Emotions, body sensations, breathing patterns, images, and insights are all sources to attend to within the therapist. For example, a quiver in therapists’ chest or moisture in their eyes may be a resonance from their clients’ sadness. An accelerated heart rate or tight anxious feeling may be an autonomic resonance with their clients’ anxiety. Attending to therapists own breathing patterns also provides cues of what is occurring in the session. Therapists’ restricted breath may reflect their own absence or disconnection, or may be a resonance with their client indicating they are unsafe or emotionally disconnected. Therapists can actively use their breath to entrain with their clients breathing patterns, to deepen the connection and to more astutely read their experience. When therapists are present, the body acts as an empathic indicator of clients’ experience.

Noticing any images that arise internally can help as empathic indicators to what clients’ experience is. For example, I noticed an image of my client alone on an island when he spoke about caring for his disabled son and aged father. When I reflected to him this feeling of being alone and isolated, a tear formed in his eye and he and nodded saying “no one is ever there for me.” Combined with knowledge of his family history, I recognized this was a marker for an EFT empty chair task with his mother who he described as cold and demanding that he be the one that cares for his younger siblings.

TP requires that therapists have an embodied sense of self-awareness and capacity for interoceptive (sensing inwardly) awareness. Embodied self-awareness is the ability to pay attention to ourselves, including our experience, bodily sensations, movements, and inner sensory world, in the present moment (Fogel, 2009). Presence requires therapists’ willingness to trust what they sense and feel. Therapists’ immediate sensory experience, when in presence, can reflect what is most poignant in their clients’ experience and then guide them in facilitating growth and change.

Practices that focus on embodied self-awareness, helps to strengthen the capacity for self-attunement. These include yoga, qi-gong, and meditation. A couple of sample practices are:

1. Mindfulness Meditation (MM), Body Scan, or Mindful Walking. These practices help to attune inwardly to your experience. A basic MM practice is below:

  • Sit in an upright, yet relaxed position.
  • Invite your awareness to your breath. Find a place in the body, the belly or the chest, where you can experience your breathing.
  • Notice the rise and fall of the belly or chest in rhythm with your inhale and exhale
  • When the mind goes off /distracts (which it will), name one descriptive word (thinking, worrying, remembering) and gently invite your attention back to the breath.
  • Practice for 10 minutes to start, slowly increasing to 20 then 30 minutes.
  • Be gentle with yourself around the level of distraction, knowing that you are building your neural muscles for focus and attention each time your invite your awareness back from distraction to the breath.

2. Listening to Your Body in Relationship – When you are in a dialogue with someone or they are sharing their experience with you, practice listening to your own body at the same time (Geller, 2019). What do you notice in your emotions? Breathing pattern? Posture? Images or guiding words that arise?

Responding and Promoting Contact

We have been exploring the first two parts of the cyclical process of therapeutic presence. The third reflects extending and maintaining contact with clients, such as with an empathic understanding or silent gesture.

Responding with TP means actively using the information that is attuned to in the client and in one’s self, in order to facilitate the therapeutic process while maintaining contact and connection in the therapeutic relationship. When attuning within to what is received from clients, there is a process therapists can go through to assess internally what is being experienced and how to respond. For example, if therapists notice tension or shut down within themselves, they are assessing:

(a) If it is their own issue that is triggered and then what is needed to return their attention to the moment (e.g., self-regulate, put aside personal issues)

(b) If it is therapeutically important and they are either sensing something occurring in the client that needs attending to, such as with an empathic gesture or a marker for an intervention, or a relational repair in the case of a rupture.

Therapists can also assess the following from external cues in the client:

(c) Their emotional experience in the moment and how to respond to deepen their experience, regulate, or offer an intervention (e.g., downward cast and tear forming, while talking about their sister, may be a possible marker for an EFT empty chair task);

(d) If the client is feeling safe and open to receiving a response or intervention, or if they are in a closed or unsafe state and need something in the relationship or within to generate safety (e.g., relational repair or contact or an emotional regulation skill).

With therapeutic presence, therapists are constantly using their body to read the emotional state of the client and the relationship, which inform their responses.

Therapists also maintain contact with a strong focus on maintaining a positive therapeutic relationship. Contact includes the way therapists approach and relate with their clients (the “essence of presence” as discussed earlier). Promoting contact begins with attunement, yet is expressed verbally through empathy and congruence, as well as non-verbally through synchronization.

Earlier we talked about gestures to support this non-verbal right brain to right brain connection. Other specific ways that therapists can non-verbally express to their clients that they are with them and promote contact include the following.

Entrainment in body, brain and relationships. Entrainment is based on a physics phenomenon of resonance. Independent rhythms (or oscillating bodies) join in synchronized movement as one speeds up while the other slows down. One example is how the second hands of clocks that are placed side by side, eventually move in unison. Entrainment helps us understand the psychological, physiological, and neuronal synchrony in TP promotes regulation and growth in therapeutic relationships.

Entrainment promotes a subjective sense of synchrony between people. Purposely entraining body movements with someone else’s can increase a sense of unity (Behrends, Müller, & Dziobek, 2012; Geller, 2017). Like the hands of the clock, bodies tend to naturally fall into these synchronistic rhythms as well (Marsh, Richardson, & Schmidt, 2009). When therapists use their presence to autonomically attune and resonate with clients’ physiology and experience, synchrony emerges as their bodies come into rhythm with each other. The body moves in temporal coordination and vocal rhythms reflect each other (Ramseyer & Tschacher, 2014; Imel et al., 2014). Coming into sync on a physiological level builds a sense of trust and safety. Movement synchrony at the start of psychotherapy has predicted client ratings of the alliance at the end of each session, as well as symptom reduction (Koole & Tschacher, 2016; Ramseyer & Tschacher, 2011).

The following suggestions can strengthen therapists’ ability to self-regulate, sustain contact with clients, and express presence non-verbally.

  1. Entrainment breathing. Therapists can intentionally mirror their breath with their clients as a way to read their experience and to promote connection and contact.

Entrainment breathing communicates to clients’ that they are not alone in their experience, promoting a neuroception of safety and activating the social engagement system (Geller & Porges, 2014). Entrainment breathing involves therapists mirroring their clients breathing rhythm. It creates a neurophysiological synchronization of rhythm in the brain and body between people (Cozolino, 2006; Siegel, 2010; Porges, 2011, 2014). This can support empathic attunement with clients’ emotional experience, as well invites clients to feel safe as their breath comes into rhythm with their therapists’ calm and grounded presence.

2. Long exhalations to activate a calm presence. Long exhalations are efficient ways of turning off therapists’ (and clients’) sympathetic nervous system and vagal pathways of defense, inviting a sense of calm, openness and trust (Geller & Porges, 2014; Porges, 2011). Through long exhalations therapists can invite their own body into presence and invite clients to attune to their therapists’ calming presence. It is also a helpful practice for clients to do directly to activate greater calm and safety.

Clinical Vignette: Using Cues to Inform Your Understanding and Response

The following is an example of both cues from myself and cues from the client in a couples’ session can promote an empathic understanding and response (Geller, 2019).

              Sam and Syd were seeing me for the fourth session of couple’s counseling after Sam had spent some of the couple’s savings in an investment. Syd angrily yelled at Sam in a high and sharp tone for not consulting with him. I noticed in my own body that I was pulling back, my body was leaning away from the client, my back against the chair, my breath was restricted and I felt a sense of agitation. I first checked in to assess whether I was personally triggered or reactive in some way but quickly discerned that this was not the case. I realized my body was telling me that Syd was cut off from his more vulnerable (primary) emotions of hurt and low self-worth. I took a long exhalation to bring myself back into connection, and then validated his upset and then asked him to check inside to what he was really feeling, perhaps hurt or not valued in some way? A tear formed in Syd’s eyes as he took a breath, he said “Ya it hurts me that you don’t care about what I think and feel, and it makes me feel worthless, like I don’t matter.” I could feel my body open, soften and move forward in a caring gesture.

Reflection. Our bodies’ reactions in the moment offer vital sources of information. The tight and pulled-back feeling that my body was expressing helped affirm my read that Syd was not yet at his primary emotions. Assessing that my pull back was a response to the secondary emotion of anger allowed me to register and reflect his primary hurt. The first step was to regulate through long exhalations. The second was to use my awareness to recognize the resonance of disconnection that was occurring with Syd’s secondary emotional response of anger. The third was to use this awareness by inviting him to make contact with his deeper emotional experience. My resonance with Syd’s emotional disconnection was validated by the way my body softened and naturally moved forward in a caring stance, once he expressed his hurt. His core emotional experience pulled care and compassion from me.

Barriers to Therapeutic Presence

Being intimately engaged in the way that presence requires can be challenging for therapists. It requires a sustaining of attention and connection and being with the painful and often traumatic emotions and experiences of clients, staying close to their experience, while maintain an inner steadiness and contact with one’s own experience.

To notice barriers to presence requires a strong capacity for interoceptive (inner sensing) awareness. This includes an ability to quickly recognize when therapists are disconnected or triggered, so they can work with it in the moment and invite their presence and awareness back to their client.

To assess presence more globally post-session, the TPI-T scale (Geller et al., 2010) can be used as a self-auditing too. This can help to identify particular areas that are stronger or weaker in general with respect to presence or with particular clients (Geller, 2017). Observable markers of presence can also allow therapists to assess presence or absence. By watching videotapes of sessions, therapists can recognize the areas that need attention, both in the moment and overall in their therapeutic stance.

Therapists may think they are present, yet when guided through a self-assessment, notice that their bodies are tight, arms crossed, fists clenched, which can send the message to clients that they are not there. Our ability to notice clients’ sense of safety or shut down, can also be recognized through video tape review and markers. See Appendices A-B in (Geller, 2017) for a list of markers of therapists’ presence and clients’ safety. They can also be used to observe every day interactions to assess when therapists are present or not, and if others feels safe and connected with them.

Some examples of internal barriers in the therapist include self-doubt, distraction tolerating uncertainty, and countertransference. They may arise from therapists’ own triggers, lack of self-care or from vicarious traumatization. Relational challenges can also occur including therapeutic ruptures. As well as client challenges such as hopelessness, emotional dysregulation, rage, suicidality, dying and death. A more elaborate discussion of the barriers to presence can be found in Geller (2017) and Geller & Greenberg, (2012). For now, a couple strategies to work with challenges will be discussed.

Working with Self-Doubt: Self-Compassion

Self-doubt and feeling like an imposter is common among early (and experienced) therapists. Self-doubt can take many forms. It can emerge in subtle moments when clients are talking about difficult issues. For example, I recall listening to a client talk about the ritual rapes she experienced growing up and the voice in my head saying “you’re in over your head, you have no idea how to help.” Doubt can occur more broadly, such as feeling incompetent as a helping professional at all. It can take the form of over-working to establish or “prove” competence and credibility, and hiding behind busyness to avoid being “found out.”

Being present means being with all that arises, including moments of anxiety and doubt. Self-doubt can infiltrate therapists’ ability to be balanced or focused. It can interfere with therapists’ ability to meet their clients in the depths of their experience. Some strategies include accepting imperfection; acknowledge your own strengths and achievements; supervision; boosting education in modalities or areas that feel less strong; personal counselling or psychotherapy. A powerful antidote to self-doubt can be found in selfcompassion practice.

Self-compassion practice. The following exercise is adapted from Neff (2011) and Germer (2012). This practice can help therapists find a different relationship with the underlying experiences that contributed to self-doubt. With continued self-compassion practice, there is greater ease in working with this in session if doubt arises including the ability to re-direct attention back to the moment.

  • Take a moment to pause, breathe, and go inward.
  • Become aware of a doubt that you have in your therapy practice or alternatively in your life – this could be in the form of a doubting inner voice.
  • See if you can float back in time to a difficult period or relationship that may have contributed to this inner doubt.
  • Notice the difficult feelings and sensations that are present in your body as you do this. • Take your hand and put it on the place in your body where you feel this doubt and/or this earlier difficulty – offering kindness to the suffering you are experiencing.
  • Become aware of the shared suffering that is a part of being human.
  • Find some gentle and kind words to offer to that suffering such as “I am here for you,” “I know how much pain is there,” “I understand,” or “I love you”.
  • Continue to offer your suffering compassion and love with your words and gestures.
  • Allow your hand to drop away as you close this practice, while staying connected to the feeling and words of self-compassion.

activity (Gilbert, 2009; Stellar, Cohen, Oveis, & Keltner, 2015).

Working with Distraction and Disconnection with Clients

Distraction and disconnection are challenges to therapeutic presence. This could include internal distractions such as judgments or thoughts, or external from noise or demands on attention. Disconnection with clients can also occur if therapists are triggered by clients’ emotions, self-doubt or countertransference issues. The risks in not working with distractions is that therapy proceeds at a more surface level, and potential opportunities to promote deeper connection and change are missed, with clients left feeling alone in their suffering. Breathing compassion in and out is a one way of sustaining connection with clients when therapists experience themselves drifting or shutting down.

Being With and For Practice: Breathing Compassion In and Out

This practice involves breathing compassion for yourself and others. This was adapted by Germer (2012) from traditional Tonglen practice, based in Tibetan Buddhism (Rinpoche, 1992).

  • Invite yourself into a comfortable, relaxed yet upright siting posture. • Take a few relaxing breaths as you settle yourself into the moment.
  • As you inhale, offer compassion to your stress and difficult emotions inside.
  • As you exhale, offer compassion to the challenges this other person is experiencing.
  • Continuing breathing compassion in and out with a natural and relaxed breathing rhythm. Scan your body for any distress inhaling compassion for yourself, while exhaling compassion for the other person(s) who need it.
  • Allow the words to accompany your breath if it is helpful: one for me, one for you.
  • When that feels complete, invite your awareness back by slowly opening your eyes.

This practice can activate a feeling of compassion, and allow for a return to presence when therapists feel overwhelmed with emotion, blocked or shut down from their clients. When disconnection is noted, therapists can briefly focus taking an in-breath while offering compassion to themselves, and on the outbreath offering compassion for their client; until they find a natural state of re-connection (Germer, 2012). A brief model for optimizing therapy with therapeutic presence is presented in the Appendix.

The Fertile Ground of the Present Moment

Across therapy traditions, the greatest opportunities for growth and healing emerge in the fertile ground of the present moment (Geller, 2017; Stern, 2004). Both EFT and AEDP value relationship as the core to deep and effective therapeutic work. Through intentional attention to this quality in therapists’ personal lives and in therapeutic training, the ability to activate presence in session becomes more possible, and the healing potential in clients and the relationship unfolds with greater rapidity.

How can therapists optimize the fertile ground of the present moment in session? Stern (2004) described the ancient Greeks’ notion of kairos, which is a moment of opportunity. Events come together and there is opportunity to act or respond that could change the course of your destiny, either for the next moment or a lifetime. In psychotherapy, attunement to the fertile ground of the present moment, and both the visible and invisible expressions of client’s experience, allows clients to feel deeply felt, seen and understood.

Practice makes presence. Therapists’ commitment to engage in the work of presence and working with barriers to presence is an ongoing life process. Cultivating and strengthening the ability to be present and attuned with others, in my view, is the greatest gift therapists can offer their clients..

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Appendix

A Model for Optimizing Therapy with Therapeutic Presence

The following is a quick guide for therapists in how to optimize sessions with therapeutic presence. An elaboration of these steps can be found in Geller (2017, 2019).

  • Pre-session – Before clients arrive, engage in a 5 minute practice such asthe PRESENCE acronym
  • Begin the session by:
    • Approaching clients with openness and receptivity, bracketing preconceptions judgments and therapy plans.
    • Attuning with clients, inviting a brief mindfulness practice to arrive into the session together.
  • In Session
    • Receptively listening and attuning with the body to clients emotional experience.
    • Reading clients moment-to-moment experience, verbally and non-verbally what they are expressing, their vocal quality, gestures, breathing patterns, noticing what is poignant for them or when they are shutting down.
    • Attuning inwardly to how the clients’ issues are resonating inside, what is arising in resonance with what they are sharing. This includes checking in when you are not present and inviting yourself to reset your attention and return to the moment
    • Responding or offering an empathic (or EFT intervention) based on markers that you are receiving from your client and what you are attuning to within yourself.
    • Reading and attuning with clients as to how responses/interventions are being experienced by them.
    • Entraining your breath to theirs to read their experience and promote contact.
  • Closing session – Have a mindful moment together with your client to absorb what clients have learned.
  • Transition to the next session or part of your day
    • Taking a few minutes to intentionally close the session internally (finish notes, take a walk, stretch) to release residual emotions that may be carried from the session.
    • Re-center/ground; engage with the PRESENCE acronym before approaching the next client or moment in the day.