“Real freedom is the ability to pause between stimulus and response, and in that pause, choose which direction to throw our full weight—mind, body, emotions, and spirit.” — Rollo May, Ph.D.
We often hear about the importance of “being present” as an employer, employee, colleague, parent, spouse, or friend; while making art, conversation, dinner. While this seems over-recommended, vague, or intimidating to some, cultivating presence makes work as a therapist more effective.
A friend glances a beat too long at their smartwatch (or straight-up reads an e-mail on it) while we talk to them. On the phone with our partner, we attempt to convey an important experience from our work day and notice their attention drift. Our kids are more interested in TikTok than our existence.
We have all experienced similar instances of lack of presence from important others, and we suspect we check out and tune out pretty often ourselves. And yet, we have all experienced someone whose fully present attention made us feel deeply seen and heard. What is all that about, really?
What do we experience when our therapist is fully present in the therapy room with us? Is it safety? Calm? Emotional connection?
How do we know our therapist is present? Is it their eyes, expression, posture, or how they repeat back accurately what we have said? Do they know just the right moment to intervene?
Presence is Central in Therapy
Source: SDI Productions/Unsplash
How do we know when our therapist is not present, and what does that feel like to us? Do their eyes droop? Do they look away, fidget impatiently in their seat, or misfire in their comments? Do they clumsily intervene in a way that feels jarring? Do they talk at us versus to us?
Presence Is Central to Effective Therapy
Large meta-analyses by leading psychotherapy outcome researchers Bruce Wampold, Ph.D., and Zac Imel, Ph.D., found certain “common factors” predict good outcomes from therapy, regardless of what method of therapy (e.g., CBT, DBT, psychodynamic, etc.) is used. These factors include the therapeutic relationship (the bond between client and therapist), empathy, collaboration (agreement on tasks and goals), instilling meaning and hope, and repairing ruptures (breaks in the therapeutic relationship).
Kirk Schneider, Ph.D., a leading existential-humanistic psychologist, writes that therapeutic presence is the hub of the common factors wheel. Presence allows the common factors to thrive.
An Existential Definition of Presence
Schneider defines therapeutic presence as: “…a complex mix of appreciative openness, concerted engagement, support, and expressiveness, and it both holds and illuminates that which is palpably significant within the client and between client and therapist.”
Presence involves sanctuary, sacred space, courage, strength, and safety (holding) while simultaneously showing what is physically, emotionally, imaginatively, and intuitively felt as important in the present moment (illuminating). The present therapist helps the client feel how they block themselves from what is significant and, thus, from their freedom and growth possibilities.
Presence Holds and Illuminates What Is Significant
Source: George Desipris/Pexels
Presence and the Real Relationship
People often come to therapy because of issues with how they connect with the present moment, with themselves, with others, and with the world. Presence invites the client into the felt moment of their experience of the therapeutic relationship, showing new ways of connecting and relating.
Presence fuels what we call the real relationship. That is, an authentic working with the unspoken, and often unacknowledged, sensations, emotions, and processes going on between therapist and client beneath what is said and done. In existential therapy, this process is often more important than the content of therapy. Content refers to the surface of what is said and done—what we are ostensibly “working on.”
There are moments when I’m so attuned with the client that time shifts, slows down, or disappears. I’m thinking but not overthinking. I’m aware of how my body registers the sensory experience in the room.
I’m empathizing with the emotional poignancy underneath and in between the client’s words. There is an energetic connection and an intuitive understanding building between us. I am fully here now.
In other moments, it’s a struggle to keep my attention from wandering. Time drags. I over-analyze a client’s words, and we lose emotional connection. The client dryly intellectualizes their problems, and we lose what is palpably significant.
What is my client’s experience of me in those very different moments?
Their answer to the above question is often the most important part of therapy and supercharges our relationship and work together.
Interpersonal Neurobiology
Daniel J. Siegel, M.D., a psychiatrist, professor at UCLA, and leading writer in interpersonal neurobiology, writes:
“When not integrated, systems tend to move toward chaos, rigidity, or both. A reinterpretation of mental distress revealed in the symptoms of the various syndromes of mental disorder is that these each can be viewed as an example of chaos or rigidity. In this perspective, helping those with mental suffering is carried out through the process of cultivating integration. How can we achieve this? We cultivate well-being and integration through our relationships that are filled with therapeutic presence. Presence is the portal for integration to arise.”
Presence is likely a process of “neural integration” where the limbic region of the brain (emotion and fear) integrates well with the pre-frontal cortex (rational, executive) region of the brain.
Existential psychology and psychotherapy have long discussed the importance of therapeutic presence: the integration of polarities such as acceptance and change, freedom and limits, constriction and expansion, meaning and mystery, isolation and belonging, safety and growth, calm and vigilance, the mundane and the transcendent, the rational and emotional.
Further, areas of the brain that seem to reflect the experience of presence, according to Siegel, also involve attuned communication, emotion regulation, response flexibility, empathy, fear modulation, intuition, morality, and insight into oneself.
A Disconnect Between Clients and Therapists
Shari Geller, Ph.D., an expert on presence and self-compassion, created the Therapist Presence Inventory (TPI) for clients and therapists to measure presence after a therapy session.
The client version (TPI-C) consists of three questions on a Likert scale ranging from 0 to 7: “My therapist was fully there in the moment with me,” “My therapist’s responses were really in tune with what I was experiencing in the moment,” and, “My therapist seemed distracted.”
The therapist version consists of 21 questions exploring the process of presence, the experience of presence, and the absence of presence. A few examples from the TPI-T: “I was aware of my own internal flow of experiencing,” “I felt tired or bored,” “I felt fully immersed in my client’s experience and yet still centered within myself.”
Geller determined the questions in the TPI scales based on a qualitative study where she interviewed therapist experts about presence.
Geller’s later study showed that clients who experienced better outcomes rated their therapist as higher in presence. These session outcomes consisted of clients’ insights into themselves, others, the world, and positive behavior changes.
However, clients did not experience better outcomes when therapists rated themselves as higher in presence. It was how the client saw the therapist, not how the therapist saw themselves, that mattered.
This begs the question: What do clients actually experience of therapeutic presence in their own words? And does this tool need to be revised to include questions derived more from the client experience?
New Research Exploring the Client Experience
I am conducting a study to explore what clients say and experience about therapist presence. I will use the TPI scale and conduct in-depth interviews with clients, comparing what clients say in interviews with the TPI results.
I will make observations and ask follow-up questions to help clients, for example, discover what they felt physically and emotionally in session at certain moments with their therapist. I will keep a journal of these observations.
If presence is as important in therapy as it is in life, then therapists need a better understanding of when we express presence in a way that resonates with clients and produces better outcomes and when clients do not find us present. We need clients to teach us how to be present in a way that works. What “works” in therapy, at the end of the day, is what works for the client.
To find a therapist near you, visit the Psychology Today Therapy Directory.
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