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
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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.
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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.
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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
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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
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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
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http://dx.doi.org/10.1037/13485-008
Therapeutic Presence: A Mindful Approach to Effective Therapy, by S. M. Geller
and L. S. Greenberg
Copyright © 2012 American Psychological Association. All rights reserved.
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
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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
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THERAPEUTIC PRESENCE
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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
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VanWagoner, Gelso, Hayes, and Diemer (1991) compared therapists
who were perceived as excellent by their peers with general therapists. They
found that master therapists were viewed as having greater self-insight,
empathic ability, anxiety management, and self-integration. Interestingly,
these qualities, which are a part of mastery, are also aspects of therapeutic 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
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created a blockade to that pain. I also felt overwhelmed with the notion
that I could not take away or lessen her pain in any way. With that 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
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process and allows the right technique or direction to emerge from this
level of openness. However, opening to the moment means opening to the
unknown and having periods in session that may feel entirely uncertain.
Therapists’ discomfort with uncertainty can lead them to respond in a way
that is out of sync with the client. In relational therapies, this may leave the
client feeling not heard or accepted and hence shut down. With manual-based
therapy, such as cognitive–behavioral therapy, this may result in speeding
through required steps without attuning to where the client is in the moment
and hence having less therapeutic impact. Therapists face a similar challenge
with silence. Tolerating the discomfort of silence or of the unknown is integral
to a good therapy process, as it is through uncertainty that one can allow for the
emergence of material or responses that could be important and relevant for the
client. Silence can also allow the client to work internally with what has been
offered through the therapist’s response or intervention, and the therapist’s 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
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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
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describe the time they spent just pausing, being still, or doing something they
love for themselves, one woman recalled the last time, which was 2 or so years
ago, she went on a walk in a park alone and felt refreshed . . . for that day! It
is no wonder that the benefits from these rare and precious self-nourishing
moments so quickly disappear.
The process of presence, or deepening into each moment, involves daily
time for preparing one’s own self to be in the moment. We can aspire to be
present and live a life in which we daily make a commitment to caring, 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:
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Pause, gently lowering your eyes and attending to your breath.
Reflect on the multiple roles you play or the demands you face
in your life. How many different people are you responsible for
(at work or at home, your children, parents, siblings, friends,
supervisees, administrative staff, colleagues, and of course your
clients)? Take a count of the people who need your regular
attention.
Reflect on how much time or what percentage of your day or
week is spent in fulfilling those responsibilities as well as in
meeting general daily demands (e.g., answering e-mails, phone
calls, taking care of the house).
Now note how much time or what percentage of your day or
week goes to fulfilling your own needs or self-nourishment.
Notice the gap between the amount of time spent in giving to
others and in attending to yourself.
Take a quiet moment to reflect on how that gap could be
reduced; that is, in what ways can you commit a little more time
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to your own self-care and personal growth or to the care of those
around you?
By becoming aware of the obstacles and stress in our lives, we can turn our
attention to clearing space regularly for presence in life and with clients.
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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
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therapeutic presence and that it is guided by an intention of being with and
for the client, in service of the other’s healing. Being aware of this intent is
essential for therapists to avoid misuse, becoming confused, or shutting down.
While we are distinguishing this energy from a countertransference 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.
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Witnessing a client in unbearably deep pain or grief is a challenge for
many therapists, as the pull to fix the pain can be strong, which is often a 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
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react to the therapist. Hence, there is a greater need for the therapist to
remain open, connected, and grounded yet nonreactive for his or her
approach to be effective.
An example of the acceptance that is necessary to facilitate technique
emerges from dialectical behavior therapy, a behavioral approach developed
by Linehan for patients with borderline personality disorder. With clients
with borderline personality disorder, the internal or affective world of the
therapist is vital in providing the basic acceptance that is needed to make the
behavioral techniques effective. Linehan (1993a) provided an interesting
commentary that speaks to the challenge and necessity of present moment
acceptance:
In relationship acceptance the therapist recognizes, accepts, and 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
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client’s experience of rejection. Similarly, if the therapist is overinvolved
in the dynamic of blame and defensiveness and reacts angrily or distances
himself or herself, it can overwhelm and damage the therapeutic 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
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life; at most we can help them to accept their terminal situation and come to
peace with any unfinished business in their lives or to live their final days with
acceptance of the reality of their life and their transition to death.
The most powerful therapeutic stance we can take with people who are
facing death is to be fully present with them, in their fear, their pain, and their
suffering. They need to be listened to and heard, as many people are fearful
of talking about death and so avoid the topic with the dying person. This level
of presence in end-of-life care demands that the therapist open up fully to the
other and the other’s pain, and likely to his or her own reality of dying and
death, and move through the painful suffering and loss that may be 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.
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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
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and our fear. It is not our expertise, but rather the exploration
of our own suffering that enables us to be of real assistance. This
precept reflects the importance of the exploration of our own
inner life in enabling us to be empathic and respond 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.
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Trauma
Riding the waves of uncertainty is acutely challenging when the client
is expressing or reexperiencing trauma. In particular, learning the details of
rape or abuse in a client’s childhood or seeing and hearing the effect of a 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
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overwork and that they do make sure that their leisure time really replenishes
their emotional reserve” (Lanyado, 2004, p. 13).
Working with trauma survivors, and the constant witnessing and fully
being there with some of the horrific experiences clients retell and 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
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