RE: SOCW6111 - Discussion Question 1 and Discussion Question 2 (WK7)

User Generated

znznornefpbhcbaf

Humanities

Description

Discussion Question 1 - Self-Reflection and Awareness

Exploring the reasons for wanting to be in social work and examining your motives for choosing a career of helping others is very important. Your background, including childhood experiences, may be instrumental in bringing you into the field of social work. Understanding the possible connection and working to resolve any underlying unresolved issues is essential to becoming an effective social worker. While working with a client, you must strive to be objective, but in the end we are all human with past hurtful experiences that can impact our ability to effectively work with clients. While complete objectivity is impossible and not expected, it is necessary to self-reflect and become aware of when a situation or a certain personality type causes you to react in an unprofessional manner. Understanding potential internal and external barriers you and your client bring to the room will assist you in balancing an appropriate empathetic response with proper objectivity.

For this Discussion, review the Geller & Greenberg (2012) article and the program case study for the Petrakis family, and view the corresponding video.


Post your explanation of the importance of identifying internal and external barriers of the client and social worker. Then describe the barriers experienced by Helen and the social work intern. Finally, suggest ways the intern could overcome these barriers.

Support your posts with specific references to the Learning Resources. Be sure to provide full APA citations for your references. Use subheading in response to included detailed response. PLease add 1 additional peer reviewed APA reference.

Reference

Geller, S. M., & Greenberg, L. S. (2012). Challenges to therapeutic presence. In Therapeutic presence: A mindful approach to effective therapy (pp. 143–159). Washington, DC: American Psychological Association.

Note: Retrieved from Walden Library databases.


*****************************************************************************************************************************************************************

Discussion 2 - Self-Disclosure

Knowing that clients might react negatively to your work with them may cause anxiety, frustration, and even anger. It is inevitable that you will work with a client who expresses anger or disappointment over working with you. This does happen in the social work field and is to be expected over time. Understanding how you might react to allegations of incompetence or anger over incomplete goals is essential to managing this type of exchange. While a negative interaction may be justified if either person did not fulfill responsibilities, often it is a result of the client’s personal reaction to the situation. The best response is to use these interactions to build the therapeutic bond and to assist clients in learning more about themselves. Stepping back to analyze why the client is reacting and addressing the concern will help you and the client learn from the experience.

For this Discussion, review the program case study for the Petrakis family. PLease use subheadings and be detailed. Cite references APA format.


Post a description of ways, as Helen’s social worker, you might address Helen’s anger and accusations against you. How might you feel at that moment, and how would you maintain a professional demeanor? Finally, how might you use self-disclosure as a strategy in working with Helen?

Support your posts with specific references to the Learning Resources. Be sure to provide full APA citations for your references.


Reference

Plummer, S.-B., Makris, S., & Brocksen, S. M. (Eds.). (2014a). Sessions: case histories. Baltimore, MD: Laureate International Universities Publishing. [Vital Source e-reader].

  • The Petrakis Family (pp. 20–22)

Unformatted Attachment Preview

SOCIAL WORK CASE STUDIES: CONCENTRATION YEAR Working With Families: The Case of Brady Brady is a 15-year-old, Caucasian male referred to me by his previous social worker for a second evaluation. Brady’s father, Steve, reports that his son is irritable, impulsive, and often in trouble at school; has difficulty concentrating on work (both at home and in school); and uses foul language. He also informed me that his wife, Diane, passed away 3 years ago, although he denies any relationship between Brady’s behavior and the death of his mother. Brady presented as immature and exhibited below-average intelligence and emotional functioning. He reported feelings of low self-esteem, fear of his father, and no desire to attend school. Steve presented as emotionally deregulated and also emotionally immature. He appeared very nervous and guarded in the sessions with Brady. He verbalized frustration with Brady and feeling ­overwhelmed trying to take care of his son’s needs. Brady attended four sessions with me, including both individual and family work. I also met with Steve alone to discuss the state of his own mental health and parenting support needs. In the initial evaluation session I suggested that Brady be tested for learning and emotional disabilities. I provided a referral to a psychiatrist, and I encouraged Steve to have Brady evaluated by the child study team at his school. Steve unequivocally told me he would not follow up with these referrals, telling me, “There is nothing wrong with him. He just doesn’t listen, and he is disrespectful.” After the initial session, I met individually with Brady and completed a genogram and asked him to discuss each member of his family. He described his father as angry and mean and reported feeling afraid of him. When I inquired what he was afraid of, Brady did not go into detail, simply saying, “getting in trouble.” In the next follow-up session with both Steve and Brady present, Steve immediately told me about an incident Brady had at school. Steve was clearly frustrated and angry and began to call Brady hurtful names. I asked Steve about his behavior and the words used toward Brady. Brady interjected and told his dad that being 30 PRACTICE called these names made him feel afraid of him and further caused him to feel badly about himself. Steve then began to discuss the effects of his wife’s death on him and Brady and verbalized feelings of hopelessness. I suggested that Steve follow up with my previous recommendations and, further, that he should strongly consider meeting with a social worker to address his own feelings of grief. Steve agreed to take the referral for the psychiatrist and said he would follow up with the school about an evaluation for Brady, but he denied that he needed treatment. In the third session, I met initially with Brady to complete his genogram, when he said, “I want to tell you what happens sometimes when I get in trouble.” Brady reported that there had been physical altercations between him and his father. I called Steve in and told him what Brady had discussed in the session. Brady confronted his father, telling him how he felt when they fight. He also told Steve that he had become “meaner” after “mommy died.” Steve admitted to physical altercations in the home and an increase in his irritability since the death of his wife. Steve and Brady then hugged. I told them it was my legal obligation to report the accusations of abuse to Child Protective Services (CPS), which would assist with services such as behavior modification and parenting skills. Steve asked to speak to me alone and became angry, accusing me of calling him a child abuser. I explained the role of CPS and that the intent of the call was to help put services into place. After our session, I called CPS and reported the incident. At our next session, after the report was made, Steve was again angry and asked me what his legal rights were as a parent. He then told me that he was seeking legal counsel to file a lawsuit against me. I explained my legal obligations as a clinical social worker and mandated reporter. Steve asked me very clearly, “Do you think I am abusing my son?” My answer was, “I cannot be the one to make that determination. I am obligated by law to report.” Steve sighed, rolled his eyes, and called me some names under his breath. Brady’s case was opened as a child welfare case rather than a child protective case (which would have required his removal 31 SOCIAL WORK CASE STUDIES: CONCENTRATION YEAR from the home). CPS initiated behavior modification, parenting skills classes, and a school evaluation. Steve was ordered by the court to seek mental health counseling. One year after I closed this case, Brady called me to thank me, asking that I not let his father know that he called. Brady reported that they continued to be involved with child welfare and that he and his father had not had any physical altercations since the report. 32 SOCIAL WORK CASE STUDIES: CONCENTRATION YEAR 5. What were the agreed-upon goals to be met to address the concern? The goal was to find solutions to alleviate their frustrations and the discord in their relationship. 6. Did you have to address any issues around cultural competence? Did you have to learn about this population/group prior to beginning your work with this client system? If so, what type of research did you do to prepare? I was aware and sensitive to the fact that they were a gay couple. I was cognizant of the possible biased reactions they might have received from administrators at Jackson’s school and their surrounding community. I inquired into their interactions with the adoption agency and the school to get a sense of any negative interactions that might have impeded service delivery. I also suggested a support group for lesbian and gay couples who adopt. 7. How would you advocate for social change to positively affect this case? I would advocate for better education for foster and adoptive parents on the resources they may be eligible to receive. 8. How can evidence-based practice be integrated into this ­situation? Using weekly scaling questions would be one way in which evidence-based practice could be implemented. Working With Families: The Case of Brady 1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation? I used structural family therapy, particularly the use of a genogram. I addressed issues of grief and loss and child d ­ evelopment. Finally, I used education to help them learn about services available and crisis intervention. 2. Which theory or theories did you use to guide your practice? I used structural family therapy. 3. What were the identified strengths of the client(s)? Brady’s bravery in disclosing the altercations between himself and his father showed great motivation and strength. 108 APPENDIX 4. What were the identified challenges faced by the client(s)? Steve was resistant to his own mental health needs and the effect on his relationship with Brady. Brady was not receiving proper evaluation and intervention for his presentation of developmental delays/disabilities. Brady and Steve were clearly dealing with unresolved grief due to the death of Brady’s mother. 5. What were the agreed-upon goals to be met to address the concern? The goal was to obtain a second evaluation and then provide suggestions of services to improve Brady’s behavior in the home and at school. 6. What local, state, or federal policies could (or did) affect this situation? The child abuse reporting laws were relevant to this case. 7. How would you advocate for social change to positively affect this case? I would advocate for more education and support for children with developmental disabilities and their parents. It was clear that Brady had an intellectual disability that had not been previously acknowledged nor properly addressed. 8. Were there any legal/ethical issues present in the case? If so, what were they and how were they addressed? While the reporting laws and ethics for clinicians are very clear in a case like Brady’s, there is always the concern that a parent might file a lawsuit against the social worker for making the report. These are cases in which the clinician’s documentation of the sessions needs to be accurate and thorough to justify the CPS report. 9. Describe any additional personal reflections about this case. I am often asked by students, “Do you find it difficult to make calls to Child Protective Services and does it get any easier?” My answer to that question is no, I do not find it hard to make calls to CPS because those institutions are there to help. However, I do continue to find it hard to hear stories of abuse from children. That will never get easier. I have learned a great amount of humility in these cases. If a child (or adult) finds my office space 109 SOCIAL WORK CASE STUDIES: CONCENTRATION YEAR safe enough and is able to disclose such complex issues as these to me, I feel honored. It is because a client trusts me enough to tell me these things that I feel responsible to do my job. Working With Families: The Case of Carol and Joseph 1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation? This case required extensive use of active and passive listening and patience to enable the client to become sufficiently comfortable with me and to arrive at a point where she could work on her issues. Initially she was very angry, hostile, resistant, and very much in denial. 2. Which theory or theories did you use to guide your practice? I work with people in their homes, which is their territory, not mine. I think it is very important to be aware of how I would feel if I were in their shoes. The person-in-environment perspective and Carl Rogers’ person-centered approach are crucial here. 3. What were the identified strengths of the client(s)? She was smart and had a good support system in her husband and mother, who were very supportive during her treatment. 4. What were the identified challenges faced by the client(s)? Carol was a severe alcoholic and had a drug problem to a lesser extent. She had psychological issues as well, including low selfesteem, depression, and anxiety. She also had transportation and legal problems as a result of losing her driver’s license after the DUI. 5. What were the agreed-upon goals to be met to address the concern? The primary goal was to protect her child by keeping Carol sober and finding the intervention method that would be most appropriate for her to do that. This took time due to the resistance to treatment. 6. How would you advocate for social change to positively affect this case? Treatment options and access to them need to be improved in rural areas. There were not many choices for this client, 110 The Petrakis Family Helen Petrakis is a 52-year-old heterosexual married female of Greek descent who says that she feels overwhelmed and “blue.” She came to our agency at the suggestion of a close friend who thought Helen would benefit from having a person who could listen. Although she is uncomfortable talking about her life with a stranger, Helen said that she decided to come for therapy because she worries about burdening friends with her troubles. Helen and I have met four times, twice per month, for individual therapy in 50-minute sessions. Helen consistently appears well-groomed. She speaks clearly and in moderate tones and seems to have linear thought progression; her memory seems intact. She claims no history of drug or alcohol abuse, and she does not identify a history of trauma. Helen says that other than chronic back pain from an old injury, which she manages with acetaminophen as needed, she is in good health. Helen has worked full time at a hospital in the billing department since graduating from high school. Her husband, John (60), works full time managing a grocery store and earns the larger portion of the family income. She and John live with their three adult children in a 4-bedroom house. Helen voices a great deal of pride in the children. Alec, 27, is currently unemployed, which Helen attributes to the poor economy. Dmitra, 23, whom Helen describes as smart, beautiful, and hardworking, works as a sales consultant for a local department store. Athina, 18, is an honors student at a local college and earns spending money as a hostess in a family friend’s restaurant; Helen describes her as adorable and reliable. In our first session, I explained to Helen that I was an advanced year intern completing my second field placement at the agency. I told her I worked closely with my field supervisor to provide the best care possible. She said that was fine, congratulated me on advancing my career, and then began talking. I listened for the reasons Helen came to speak with me. I asked Helen about her community, which, she explained, centered on the activities of the Greek Orthodox Church. She and John were married in that church and attend services weekly. She expects that her children will also eventually wed there. Her children, she explained, are religious but do not regularly go to church because they are very busy. She believes that the children are too busy to be expected to help around the house. Helen shops, cooks, and cleans for the family, and John sees to yard care and maintains the family’s cars. When I asked whether the children contributed to the finances of the home, Helen looked shocked and said that John would find it deeply insulting to take money from his children. As Helen described her life, I surmised that the Petrakis family holds strong family bonds within a large and supportive community. Helen is responsible for the care of John’s 81-year-old widowed mother, Magda, who lives in an apartment 30 minutes away. Until recently, Magda was self-sufficient, coming for weekly family dinners and driving herself shopping and to church. But 6 months ago, she fell and broke her hip and was also recently diagnosed with early signs of dementia. Through their church, Helen and John hired a reliable and trusted woman to check in on Magda a couple of days each week. Helen goes to see Magda on the other days, sometimes twice in one day, depending on Magda’s needs. She buys her food, cleans her home, pays her bills, and keeps track of her medications. Helen says she would like to have the helper come in more often, but she cannot afford it. The money to pay for help is coming out of the couple’s vacations savings. Caring for Magda makes Helen feel as if she is failing as a wife and mother because she no longer has time to spend with her husband and children. Helen sounded angry as she described the amount of time she gave toward Magda’s care. She has stopped going shopping and out to eat with friends because she can no longer find the time. Lately, John has expressed displeasure with meals at home, as Helen has been cooking less often and brings home takeout. She sounded defeated when she described an incident in which her son, Alec, expressed disappointment in her because she could not provide him with clean laundry. When she cried in response, he offered to help care for his grandmother. Alec proposed moving in with Magda. Helen wondered if asking Alec to stay with his grandmother might be good for all of them. John and Alec had been arguing lately, and Alec and his grandmother had always been very fond of each other. Helen thought she could offer Alec the money she gave Magda’s helper. I responded that I thought Helen and Alec were using creative problem solving and utilizing their resources well in crafting a plan. I said that Helen seemed to find good solutions within her family and culture. Helen appeared concerned as I said this, and I surmised that she was reluctant to impose on her son because she and her husband seemed to value providing for their children’s needs rather than expecting them to contribute resources. Helen ended the session agreeing to consider the solution we discussed to ease the stress of caring for Magda. The Petrakis Family Magda Petrakis: mother of John Petrakis, 81 John Petrakis: father, 60 Helen Petrakis: mother, 52 Alec Petrakis: son, 27 Dmitra Petrakis: daughter, 23 Athina Petrakis: daughter, 18 In our second session, Helen said that her son again mentioned that he saw how overwhelmed she was and wanted to help care for Magda. While Helen was not sure this was the best idea, she saw how it might be helpful for a short time. Nonetheless, her instincts were still telling her that this could be a bad plan. Helen worried about changing the arrangements as they were and seemed reluctant to step away from her integral role in Magda’s care, despite the pain it was causing her. In this session, I helped Helen begin to explore her feelings and assumptions about her role as a caretaker in the family. Helen did not seem able to identify her expectations of herself as a caretaker. She did, however, resolve her ambivalence about Alec’s offer to care for Magda. By the end of the session, Helen agreed to have Alec live with his grandmother. In our third session, Helen briskly walked into the room and announced that Alec had moved in with Magda and it was a disaster. Since the move, Helen had had to be at the apartment at least once daily to intervene with emergencies. Magda called Helen at work the day after Alec moved in to ask Helen to pick up a refill of her medications at the pharmacy. Helen asked to speak to Alec, and Magda said he had gone out with two friends the night before and had not come home yet. Helen left work immediately and drove to Magda’s home. Helen angrily told me that she assumed that Magda misplaced the medications, but then she began to cry and said that the medications were not misplaced, they were really gone. When she searched the apartment, Helen noticed that the cash box was empty and that Magda’s checkbook was missing two checks. Helen determined that Magda was robbed, but because she did not want to frighten her, she decided not to report the crime. Instead, Helen phoned the pharmacy and explained that her mother-in-law, suffering from dementia, had accidently destroyed her medication and would need refills. She called Magda’s bank and learned that the checks had been cashed. Helen cooked lunch for her mother-in-law and ate it with her. When a tired and disheveled Alec arrived back in the apartment, Helen quietly told her son about the robbery and reinforced the importance of remaining in the building with Magda at night. Helen said that the events in Magda’s apartment were repeated 2 days later. By this time in the session Helen was furious. With her face red with rage and her hands shaking, she told me that all this was my fault for suggesting that Alec’s presence in the apartment would benefit the family. Jewelry from Greece, which had been in the family for generations, was now gone. Alec would never be in this trouble if I had not told Helen he should be permitted to live with his grandmother. Helen said she should know better than to talk to a stranger about private matters. Helen cried, and as I sat and listened to her sobs, I was not sure whether to let her cry, give her a tissue, or interrupt her. As the session was nearing the end, Helen quickly told me that Alec has struggled with maintaining sobriety since he was a teen. He is currently on 2 years’ probation for possession and had recently completed a rehabilitation program. Helen said she now realized Alec was stealing from his grandmother to support his drug habit. She could not possibly tell her husband because he would hurt and humiliate Alec, and she would not consider telling the police. Helen’s solution was to remove the valuables and medications from the apartment and to visit twice a day to bring supplies and medicine and check on Alec and Magda. After this session, it was unclear how to proceed with Helen. I asked my field instructor for help. I explained that I had offered support for a possible solution to Helen’s difficulties and stress. In rereading the progress notes in Helen’s chart, I realized I had misinterpreted Helen’s reluctance to ask Alec to move in with his grandmother. I felt terrible about pushing Helen into acting outside of her own instincts. My field instructor reminded me that I had not forced Helen to act as she had and that no one was responsible for the actions of another person. She told me that beginning social workers do make mistakes and that my errors were part of a learning process and were not irreparable. I was reminded that advising Helen, or any client, is ill-advised. My field instructor expressed concern about my ethical and legal obligations to protect Magda. She suggested that I call the county office on aging and adult services to research my duty to report, and to speak to the agency director about my ethical and legal obligations in this case. In our fourth session, Helen apologized for missing a previous appointment with me. She said she awoke the morning of the appointment with tightness in her chest and a feeling that her heart was racing. John drove Helen to the emergency room at the hospital in which she works. By the time Helen got to the hospital, she could not catch her breath and thought she might pass out. The hospital ran tests but found no conclusive organic reason to explain Helen’s symptoms. I asked Helen how she felt now. She said that since her visit to the hospital, she continues to experience shortness of breath, usually in the morning when she is getting ready to begin her day. She said she has trouble staying asleep, waking two to four times each night, and she feels tired during the day. Working is hard because she is more forgetful than she has ever been. Her back is giving her trouble, too. Helen said that she feels like her body is one big tired knot. I suggested that her symptoms could indicate anxiety and she might want to consider seeing a psychiatrist for an evaluation. I told Helen it would make sense, given the pressures in her life, that she felt anxiety. I said that she and I could develop a treatment plan to help her address the anxiety. Helen’s therapy goals include removing Alec from Magda’s apartment and speaking to John about a safe and supported living arrangement for Magda. (Plummer 20-22) Plummer, Sara-Beth, Sara Makris, Sally Brocksen. Sessions: Case Histories. Laureate Publishing, 02/2014. VitalBook file. The citation provided is a guideline. Please check each citation for accuracy before use. Petrakis Family Episode 3 Petrakis Family Episode 3 Program Transcript FEMALE SPEAKER: And you're sure Alec is stealing from her? Pills. From his own grandmother. FEMALE SPEAKER: I can't call the police. He's still on probation! Possession. FEMALE SPEAKER: Have you spoken to him about it? FEMALE SPEAKER: He denied it. But I found them. He got her oxy prescription refilled so he could take them himself. How old are you? FEMALE SPEAKER: Excuse me? FEMALE SPEAKER: I said, how old are you? FEMALE SPEAKER: I don't see what that has to do with anything. FEMALE SPEAKER: You're too damn young to be doing this job. That's it. You don't know what you're doing! None of this would have happened! It was your bright idea! You're the one who told me to have him move in with her and take care of her! FEMALE SPEAKER: I did tell you to do anything! I only suggested it. And we talked about it together. FEMALE SPEAKER: No, no. That's not true. I followed your advice. You're going to have to fix this. You have to do something. I don't know what else to do. I can't call the police. He can't go back to jail. Awful things will happen to him. I can't let that happen. I won't! Petrakis Family Episode 3 Additional Content Attribution MUSIC: Music by Clean Cuts Original Art and Photography Provided By: Brian Kline and Nico Danks ©2013 Laureate Education, Inc. 1 Copyright American Psychological Association. Not for further distribution. 8 CHALLENGES TO THERAPEUTIC PRESENCE If you think you’re enlightened go spend a week with your family. —Ram Dass To optimize the moments of kairos (opportunity) in the therapy relationship, 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 vulnerable. 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 categorize 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 working with challenging clients (e.g., clients with dual diagnoses or receiving 143 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. 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: 䡲 Copyright American Psychological Association. Not for further distribution. 䡲 䡲 䡲 䡲 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 prevent 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 experiencing, 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 144 THERAPEUTIC PRESENCE Copyright American Psychological Association. Not for further distribution. countertransference may have originated in the psychoanalytic tradition, the possibility of countertransferential reactions, or feelings in the therapist 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 emotionally 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’ emotional reactivity, are highly possible in present-centered work because therapists 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 indicator 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 recognize 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 therapeutic 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 countertransference reactions from intense emotional reactions that may be therapeutically 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 connecting 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). CHALLENGES TO THERAPEUTIC PRESENCE 145 Copyright American Psychological Association. Not for further distribution. 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 presence, such as self-insight, self-integration (grounded and centered), attunement 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 psychological 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 therapeutic 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 feeling 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 selfawareness helped her to recognize her own sense of detachment and countertransference 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 overwhelmed 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 disconnection 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 146 THERAPEUTIC PRESENCE Copyright American Psychological Association. Not for further distribution. 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 awareness of my resistance to being present, for fear of being overwhelmed by sadness and incompetence, I noted and invited my attention back to presence. 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 discern the source of a countertransference reaction and to work with it effectively. 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 countertransference 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 stretching 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 present 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 CHALLENGES TO THERAPEUTIC PRESENCE 147 Copyright American Psychological Association. Not for further distribution. 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 discomfort with this and filling the silence could actually impede the client’s healing 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 beginning 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 therapists are practicing from a relational or manual-based therapy perspective, there needs to be time for clients to develop comfort and safety in the relationship 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 tolerating 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 148 THERAPEUTIC PRESENCE Copyright American Psychological Association. Not for further distribution. listen to the other and to our deepest self and respond or intervene in resonance 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 techniques 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 discomfort of the unknown, what is revealed will allow for their responses or interventions 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 attention, time, and emotional energy. Computers, faxes, cell phones, landlines, BlackBerries, e-mails, tweets, Facebook, and other technology-based communications 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 expectations 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, manager, 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 CHALLENGES TO THERAPEUTIC PRESENCE 149 Copyright American Psychological Association. Not for further distribution. 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, compassion, 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 stressful 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 relationship 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 multiple roles you play: 䡲 䡲 䡲 䡲 䡲 䡲 150 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 THERAPEUTIC PRESENCE 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. Copyright American Psychological Association. Not for further distribution. 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 excitement 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 understood 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 perspectives, as well as a healthy relationship with themselves and their professional ethics, to avoid misusing or becoming distracted by this feeling when it emerges. It is also important to understand the relational dimensions of CHALLENGES TO THERAPEUTIC PRESENCE 151 Copyright American Psychological Association. Not for further distribution. 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 feeling 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 terminated 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 violation. 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 healing 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 therapist’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 ourselves. 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. 152 THERAPEUTIC PRESENCE Copyright American Psychological Association. Not for further distribution. 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 selfprotective 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 challenging 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 therapy 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 narcissists create or a reactive and aversive response in the face of arrogant selfishness. 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 attuning 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, increasing interpersonal skills, self-soothing practices, enhancing empathy, or cognitive–behavioral techniques, what is most valuable is how the therapist 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 example, only when the narcissistic mirror is challenged can people with narcissism 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 CHALLENGES TO THERAPEUTIC PRESENCE 153 Copyright American Psychological Association. Not for further distribution. 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 validates 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 acceptance 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 importantly 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 manipulating 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 maintaining 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 154 THERAPEUTIC PRESENCE Copyright American Psychological Association. Not for further distribution. 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 relationship. This optimal state that Gabbard (2001) described reflects the experience 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, nonreactivity, 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 aversive 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 previously 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 essential in working with personality disorders, takes a great deal of inner commitment 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 illness, 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 situations 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 CHALLENGES TO THERAPEUTIC PRESENCE 155 Copyright American Psychological Association. Not for further distribution. 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 experienced 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 importance 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 dealing with that reality then we avoid life, and we avoid offering our pure presence 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 someone 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. 䡲 䡲 156 The first precept: Welcome everything. Push away nothing. In welcoming 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 THERAPEUTIC PRESENCE Copyright American Psychological Association. Not for further distribution. 䡲 䡲 䡲 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 compassionately to the other person. The third precept: Don’t wait. This precept calls for patience and an honoring of present-moment experience, rather than waiting 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 difficult 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 cultivating an open and receptive mind that is not limited by agendas, 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. CHALLENGES TO THERAPEUTIC PRESENCE 157 Copyright American Psychological Association. Not for further distribution. 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 sexual 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 understood 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 created 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 openness, 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, defensive, 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 158 THERAPEUTIC PRESENCE Copyright American Psychological Association. Not for further distribution. 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 reexperience, 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 present 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 decompress 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 essential 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 meeting 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 selfawareness, 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. CHALLENGES TO THERAPEUTIC PRESENCE 159
Purchase answer to see full attachment
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.

Explanation & Answer

...


Anonymous
Really helpful material, saved me a great deal of time.

Studypool
4.7
Trustpilot
4.5
Sitejabber
4.4

Related Tags