It all begins with therapeutic presence…

Daniel Siegel, child and adolescent psychiatrist and author of multiple books on child development, makes a strong case throughout his work for using neurobiological findings to inform clinical or therapeutic practice. He has a particular interest in mindfulness practice and how it may enhance therapeutic technique and also facilitate the therapist in developing therapeutic presence. He states:

‘The way we help others grow will be shaped by our own mindful presence.’ (2007)

Developing therapeutic presence I believe is so fundamental to our work with young people, that I felt it had to be the first topic on which I blogged. As our development as a therapist progresses, it is so easy to forget this most essential of therapeutic elements. To become caught up in finding the right words, the right intervention, the right theory to apply. Yet to truly find a way to the child we must begin with ourselves. We must create a space inside ourselves which is ready to receive them. This is not just a mental space.   It is a space which is fully embodied. It is -as Dora Kalff, Jungian Sandplay pioneer referred to as a, ‘temenos,’ meaning  a safe and protected space.  We reach it through attuning to ourselves and to our own inner body-brain-mind state.  As we grow in our development as a therapist this space becomes more familiar and easy to find, despite the outer turmoil which may going on. Yet when new to the profession, we need to grow this space, nurture it and in time, trust it. Personal therapy of course is essential to growing this space.  We are received (hopefully) by our therapist with therapeutic presence and in turn we learn to provide this for our clients.

Shari Geller has researched therapeutic presence extensively. Her work has focused on adult therapists and their clients, but I feel much of what she shares is relevant to us as child psychotherapists.  She states that therapeutic presence is a ‘relational stance’ and has 3 components:

• availability and openness to all aspects of the client’s experience
• openness to one’s own experience in being with the client
• capacity to respond to the client from this experience

When we are with our very first clients it can feel impossible to hold all 3 of these components in mind. Often we are struggling to separate what belongs to the client and what to us and then feeling frozen in how to respond. I often think of it rather like a two snow globes with their snow shaken up obscuring the image inside. If we are like a shaken up snow globe as is our client, how can we have space inside to receive our client’s communications? Over time, as our own therapy and supervision progresses we begin to sift between what belongs to whom and we experience the snow settling, so that our own experiences no longer eclipse our clients’ and our presence begins to feel therapeutic.

Both Geller and Siegel argue the practice of mindfulness can help in the development of therapeutic presence.  That through mindfully attending to oneself we can begin to create that inner space which can receive and mindfully attend to another. There is now a growing body of research which demonstrates how mindfulness does in fact change the brain and in particular the pre-frontal cortex which has been associated with empathy and attunement (Lazar 2005). Lazar argues as does Siegel, that these changes in brain architecture, may mean that these mindful ‘states’ eventually become more easily accessible ‘traits’.  Recent research also is considering how different types of mindfulness practices impact the brain differently and so can be leveraged for developing more theory of mind, empathy or presence (Valk 2017).

Siegel states that:

‘The availability and empathy of the therapist that emerges with the therapist’s own mindful presence, maybe a common source of healing in psychotherapy across the various schools and specific orientations.’ (2007)

So here we come to integration. Therapeutic presence is not specific to any one modality of psychotherapy but may be a common factor in all effective psychotherapies.  Freud spoke of ‘evenly hovering/suspended attention’ (1912), Bion of reverie and containment, Winnicott of ‘holding’ (see Ogden 2004).  Whilst I think each of these concepts is different and something more than therapeutic presence, I wonder if any of them would be possible without it?

We therefore begin with ourselves. In future posts I shall consider how we can cultivate our therapeutic presence.  It may be something as simple as taking a few minutes between clients to sit in a chair and watch our breath, making our exhale slightly longer than our inhale to activate our parasympathetic nervous system. To feel our feet grounded solidly against the floor/the earth, to have our chest open to allow easy breathing and to feel with each breath that we are nurturing or growing our therapeutic space inside, our temenos, ready to receive our client with presence.

References/Further Reading

Freud, S (1912) “Recommendations to Physicians Practising Psycho-Analysis”.

Geller, S and Greenberg, L (2012) Therapeutic Presence. A mindful approach to effective therapy.  American Psychological Society

Lazar et al (2005)Meditation experience is associated with increased cortical thickness Neuroreport. 2005 November 28; 16(17): 1893–1897.

Ogden, T (2004) On Holding and containing: being and dreaming. In International Journal of Psychoanalysis. Issue 85

Siegel, D (2007) The Mindful Brain in Human Development: Reflection and Attunement in the Cultivation of Well-being. New York: Norton