I’ve been a psychologist for almost 40 years, and I am constantly amazed at just how much neuroscience research is enhancing my clinical understanding of what psychotherapy clients may really need most. What I would like to talk about here is how the concept of presence—a state of grounded awareness of the present moment—can inform clinical practice and enhance the everyday lives of our clients.
Why Presence Is Important
Presence is a state of mind of selective and sustained attention where one is intentionally and nonjudgmentally receptive to one’s own senses, is active in reflecting on them, and is consciously directing their awareness to the present moment (1, 2). Presence first requires an awareness that we have, a capacity to experience it, and second, it requires the skills to make it happen. All clients—and clinicians—are on a continuum of both, so each client requires interventions tailored to their individual level of awareness and skills. But I am discovering more and more just how crucial it is to help clients learn how to be present with both difficult and life-affirming emotions. That is, how to sit with, better tolerate, and more fully embody those moments without reactively fighting them, distancing themselves from them, or becoming frozen by them.
Psychotherapy interventions are almost always chosen in the moment, because the timing of them is believed to be most helpful to the client. Cognitive-behavioral therapists may highlight a cognitive distortion, like all-or-none thinking; psychodynamic therapists may bring attention to a protective defense, like projection; Gestalt therapists may suggest the use of an I-statement to replace impersonal or blaming language. Even though the clinician’s application of their theoretical approach may be executed with textbook precision, the intervention can fall short.
For example, if a client repeatedly returns to a conditioned or protective response to difficult situations by jumping to unwarranted conclusions, by blaming themselves or others, or by characteristically pushing away or distancing themselves from their feelings, the best interventions of the clinician may not be enough. This is particularly true if developmental trauma or significant episodic injuries have occurred. When a client has difficulty taking in, processing, or applying the clinician’s intervention, or when emotional underpinnings of their symptoms may be so severe that access to the resources needed to make use of the clinician’s interventions are not available, building skills of presence may be needed.
The concept of presence is foundational to all psychotherapies but especially to somatic psychotherapies. From the early developers like Wilhelm Reich’s Orgone Therapy, Thomas Hanna’s Hanna Somatics, Alexander Lowen’s Bioenergetic Analysis, Moshé Feldenkrais’s Feldenkrais Method, and Ron Kurtz’s Hakomi Method to more modern approaches like Lisbeth Marcher’s Bodynamic Analysis, Pat Ogden’s Sensorymotor Psychotherapy, Peter Levine’s Somatic Experiencing, Raja Selvam’s Integral Somatic Psychology, and from the diverse work of Bessel van der Kolk, clinical practitioners have learned that using mind-body practices opens up new ways to strengthen their effectiveness—particularly for clients with chronic, unresponsive, recurrent, or refractory symptoms.
The Physiology of Presence
Modern neuroscience has provided a wealth of understanding of how presence operates and how it can be fostered. Being present in the moment causes neural and biochemical changes in the visual and prefrontal regions, causing increases in alpha and theta brainwave activity, reductions in autonomic nervous system activation, and changes in how information is processed and monitored. Research has shown that presence causes a cascading series of interactions between several identifiable regions of the brain, which sets in motion the activation of neurological and neurochemical changes that induce felt states of well-being.
More specifically, by setting our intention to be present, we activate a top-down process beginning in the dorsolateral pre-frontal cortex, which causes changes in two organizing cortical and subcortical superstructures known as the Default Mode Network (3) and the Salience Network (4). These superstructures coordinate distinct regions of the brain that are responsible for decreasing emotional arousal, reducing unpleasant self-referential thinking, and more effectively tolerating painful affect.
Merely intending to be present facilitates greater calm. When we begin to exercise greater presence, the Default Mode Network slows response reactivity. Additionally, substructures within the Salience Network (the anterior insular cortex and the anterior cingulate cortex) work synergistically with the Default Mode Network to a) detect mind-wandering to distressing thoughts and b) bring us back to a greater felt sense of calm and physiological homeostasis.
If our focus wavers, the Salience Network helps sustain our attention; it filters distractions; it slows our heart rate and breathing and decreases blood pressure and muscle tension; it increases heart rate variability; it downregulates the activation of our amygdala; and quite critically, it enhances our ability to monitor affective body states relative to actual occurrences in our external world. Stated somewhat differently, the neural circuit between the Salience Network and the amygdala allows us to accurately monitor the functional and dysfunctional interpretations we make about our outer world. For example, if we become frightened for no rational reason, presence triggers the Salience and Default Mode Networks that help bring us back to center.
Inducing Presence
There are literally hundreds of ways to induce presence in ourselves and in our clients. There may be several techniques that stand out and really work well for a particular client, and other clients may prefer using a wider variety of methods. Here are a few examples of ways clinicians have helped clients manage their physio-affective arousal by helping them make more consistent contact with the present moment.
Geller and Greenberg (5) believe that therapeutic presence is foundational to the therapeutic relationship, where the therapist’s whole self invites the client to become their whole self. The authors suggest the acronym P-R-E-S-E-N-C-E to organize a series of methods, where the client is asked to:
PAUSE (P)—stopping and creating a moment of stillness
RELAX/REST (R)
EMPTY (E) their mind of thoughts and judgements
SENSE (E) their physical and emotional state
EXPAND (E) their awareness of their external environment
NOTICE (N) the relationship or the connection between their inner and outer worlds
CENTER (C)—reconnecting with their core self and bodily groundedness,
ENTER (E) back into their immediate space or resume their actions or intentions prior to inducing the state of presence.
A method like this can be especially useful as an introduction to the notion of presence, as some clients may be quite unfamiliar with self-reflective and interoceptive processes.
In Somatic Experiencing (6), presence is induced when the clinician encourages the client to notice, observe, and become a witness to attendant body sensations, images, actions, impulses, emotions, or movements. If a calming or relaxing state is needed to temporarily offset the client’s overwhelming level of arousal, SE practitioners are encouraged to invite their client to slowly vocalize the sound “voooo,” which is reported to vibrate the vagus nerve, activating the parasympathetic (rest and digest) nervous system, and deactivating the dorsal vagal freeze response (7).
In addition to activating parasympathetic activity, the practitioner is also instructed to induce presence by prompting their client to notice their belly vibrating, to feel it do so, and to observe their overall physical reaction to making the sound. Levine also describes the use of Jin Shin Jyutsu, a Japanese mind-body system of self-regulation, where stronger states of presence and relaxation occur from better “energy flow” after performing a sequence of three body holds—placing one hand under the opposite armpit and placing the other hand over the opposite outer arm below the shoulder, placing one hand on the forehead and the other on the chest, and finally placing one hand on the chest and the other on the stomach.
For clinicians and clients who may be more familiar with interoception, Raja Selvam (8) highlights eight techniques for tolerating unpleasant emotions that also can enhance the experience of pleasant emotions. Each technique fosters greater presence with oneself and with one’s emotions:
a) breathing into and with the emotion
b) resonating with the emotion
c) heightening awareness of the emotion
d) visualizing the emotion dissipating, spreading more evenly in the body
e) vocalizing sounds that are congruent or resonant with the emotion
f) using self-touch to both support and make deeper contact with the emotion
g) enhancing one’s intention to make contact with, expand, or support the emotion
h) making very small body movements to release felt stuckness of the emotion
Applying these methods of presence to address an unpleasant emotion softens it and helps to better tolerate it. For clients with low tolerance for unpleasant emotions, the method is used in very shorts durations. At some point in the process, the client becomes aware they are tolerating the targeted emotion, when, at that point, they are prompted to notice the relief of having achieved it. Through the continued use of focused awareness and presence, the client is then guided to expand and make deeper contact with their relief. This typically results in a greater openness to and eventually a welcoming acceptance of the difficult emotion.
Other commonly employed presence inducing methods include inviting clients to:
a) name several things in their environment they can see, hear, smell, taste, and physically feel
b) scan and bring awareness to different parts of their body
c) take a long and audible sigh
d) gently stretch any part of their body
e) to look at something pleasurable in their environment and then to soften their eyes—relaxing their eyelids and facial muscles—while looking at it
f) simultaneously observe objects in their peripheral vision while focusing on a fixed point
g) toggle back and forth between looking at an object at a far distance—becoming curious about its nature, its history, its function—and then to notice how they are feeling about observing the object
Presence can also be fostered using the many forms of pranayama—a yogic breath control technique—an example of which is the mantra meditation So’ham, where on each in-breath one visualizes taking in all the positive energy of the universe and on each out-breath imagining expanding that positive energy to every part of the body. The very act of observing and reflecting on one’s internal states without judgement quiets the mind. Eastern philosophies and practices that emphasize living in the present moment are central to the many forms of meditation practiced throughout the world, which neuroscientific studies have shown similarly affect the brain superstructures discussed earlier (9).
As clinicians monitor their clients’ presence in sessions, they may already be well acquainted with when and how it fluctuates, and they may already be creatively using effective but less structured methods than those I have suggested. For example, I recently observed one of my client’s arousal level waxing and waning throughout a session, influenced by small things that were said by either them or me. By tracking these remarks along with correlated changes in their breathing, movements, and muscle tension, I was able to get subtle clues about what may be fostering or inhibiting presence. Monitoring my client’s real-time physio-emotional arousal, I was able to determine when the client was sufficiently present or needed support to do so—that is, whether they needed to build tolerance for a difficult emotion, rest from the unpleasant emotion, better regulate their arousal level, or expand their resources to address the emotion.
Lin: A Case Study
Lin had been my long-time client, who experienced significant developmental trauma from his father. At one point in our work together, he went through an extended period of unemployment in a vapid job market. Despite his considerable insight about his father’s impact on him and the substantial progress he had made with this issue, the stress of his unemployment was producing exacerbated and pronounced anxiety, which had brought him to the point of helplessness, exhaustion, and withdrawal. Lin’s precipitous overwhelm was also making it extremely difficult to calm him in the sessions, as he became more prone to unending ruminations about his difficulties, almost as if I were invisible to him. He was intellectually aware that his pondering was crippling him, but he could not relent from compulsively engaging in it while shaming himself for doing so. Despite my best efforts and those of his psychiatrist, something more was needed.
I decided to better employ the methods I have been discussing here to enhance Lin’s self-attunement. Although some aspects of what I was witnessing in Lin were related to his childhood, he was not in a resourced enough state of mind at that time to process interpretations about it. He was also not resourced enough to process feedback about cognitive distortions he was caught in, so I proceeded to address his immediate moment-to-moment, physio-emotional dynamic. He needed to become better present with how he was fanning his own flames, shutting me out as a support, and cutting himself off from his own psychic resources.
Because Lin seemed to need the simplest, most easily understood and tolerated intervention, I decided to begin the next session by encouraging him to take his time and look around the room, letting his eyes move the way they wanted to. . . and name five things he could see, then asking him to name two things he could hear, then one thing he could smell. Then I asked him how it felt to do so, to which he responded, “a little better.” I said, “That’s good, Lin.” He then quickly changed the focus and began characteristically ruminating on his troubles.
After empathizing with how tough a time he was having, I asked him how it felt at that moment in the session, and he responded, “Upset.” I then asked him if he noticed the shift he made, which he was able to acknowledge. I replied to him, “It’s excellent that you observed that, Lin.” Then I asked him to take a long, slow, audible sigh, where I could see him begin to settle. I could also feel myself settle a bit, which, in the resonance, helped me confirm I was on a good path in that moment with him. Although he soon began to agitate himself again with self-shaming accusations, it took him a little longer to start doing so. I’ve seen these delays occur with other clients, so it confirmed my intuition that his resilience for, and tolerance of, his troublesome emotions were growing.
I try to continuously monitor in real time my clients’ presence and their tolerance for unpleasant feelings. I think it helps me make better decisions about whether I should help them better tolerate their arousal or help them become better aware that they are tolerating it on their own. Sometimes clients need us to be their resource when they are having trouble maintaining access to their own inner resources. Sometimes it’s more important for them to see and feel our pride in them when they are handling their arousal just fine without us.
Gale: My Experience with Therapeutic Presence
This essay would not be complete without discussing the variety of ways clinicians wax and wane in maintaining their own steady presence with clients. Every day I work on learning how to be with my clients—to be awake, to how I repeatedly lose and regain attunement to them, to vacillations in my own internal emotional and physiological states, and to the subtle effects my degree of presence has on them. Being present is relationally essential: it facilitates empathic resonance, it prevents interpretive and empathic errors, and it makes my work and my life more enjoyable.
Like many, I grew up without being taught about emotions. It wasn’t until my late thirties that I realized I had feelings that I could identify and discuss. Through the study of academic psychology, through my clinical practice, and through my personal psychoanalysis, I have met many emotional mentors, some of whom, paradoxically, have been my clients.
Gale was a middle-aged, divorced client of mine, who regularly attended his sessions but who was highly reactive and talked incessantly without reflecting on his words or actions. Managing my own unpleasant internal reactions to him took some time. Although I recognized my countertransference reaction was stemming from my relationship with my father, this insight alone didn’t provide enough real and lasting emotional relief.
To regroup, I decided to take my own advice—that is, to apply to me and my own process with Gale, the recommendations I was making to my clients. In fact, this essay is a reaffirmation of what I continue to learn—how to authentically embody a better moment-by-moment attunement to “me” when being with my clients;how to give myself flashes of time to breathe, a moment to be with myself, to attend to me, to care for me, and to have an instant where I can honor and affirm my own existence.
As I permitted myself to focus on my needs while with Gale, a variety of methods to be more fully present spontaneously emerged. My next thought with Gale was to experiment with my own movement, so I consciously authorized myself to change my posture. Because I was so intent on focusing my attention on Gale, I realized that I wasn’t aware enough of my muscle tension and joint discomfort. As I crossed my legs, stretched my back, shifted my weight, I found myself quietly sighing. At first, it felt like a release, but it soon evolved into a wondrous return to a safe and grounded place—a place where I could give myself room to be with Gale’s loquacious tangentiality, without judging it or reacting to it.
From this place of peaceful inner calm, I started feeling more genuinely grateful for the relational space Gale and I were co-creating, and with it arose a greater sense of compassion and appreciation of his struggle. As I described in the earlier section on the physiology of presence, I could experience my arousal level diminishing, my dysfunctional interpretations of my outer world with Gale quieting, my capacity to accurately monitor my own body states increasing, and my tolerance for enduring my illusion that I was being ignored strengthening.
As if divinely inspired, my brain’s higher-order functions suddenly kicked in, and I realized at a visceral level that, not unlike myself growing up, Gale had no one in his childhood he could talk to about the things he wanted, for as long as he wanted. He never had anyone who wanted to be with him in the way he needed, to play with him on his terms, who conveyed to him that he was important, that he mattered. So, I sat with Gale, sometimes for whole sessions at a time, intently listening, staying present, breathing with intention, unobtrusively sighing, shifting my posture. . . until one day he began to slow and settle and finally voice, “I’ve had a lot to say,” to which I simply smiled and nodded.
At that moment, I could feel the resonance of his attunement with me and mine with his. Paradoxically, I became aware of what I believed I really wanted with Gale all along—not only for him to be aware of himself, but for me to be truly present with him, to connect with him, and to feel his connection with me.
References
(1) Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10, 144–156. https://doi.org/10.1093/clipsy/bpg016
(2) Koch, C., & Tsuchiya, N. (2007). Attention and consciousness: Two distinct brain processes. Trends in Cognitive Sciences, 11, 16–22. https://doi.org/10.1016/j.tics.2006.10.012
(3) Malinowski, P. (2013). Neural mechanisms of attentional control in mindfulness meditation. Frontiers in Neuroscience, 7, Article 8. https://doi.org/10.3389/fnins.2013.00008
(4) Philip, N. S., Barredo, J., van ‘t Wout-Frank, M., Tyrka, A. R., Price, L. H., & Carpenter, L. L. (2017). Network mechanisms of clinical response to transcranial magnetic stimulation in posttraumatic stress disorder and major depressive disorder. Biological Psychiatry, 83, 263-272. https://doi.org/10.1016/j.biopsych.2017.07.021
(5) Geller, S. M., & Greenberg, L. S. (2012). Therapeutic presence: a mindful approach to effective therapy. American Psychological Association. https://doi.org/10.1037/13088-000
(6) Levine, P. A. (2010). In an unspoken voice: how the body releases trauma and restores goodness. Berkeley, CA: North Atlantic Books. https://www.northatlanticbooks.com/shop/inanunspoken-voice
(7) Porges, S. W. (2011). The polyvagal theory: neurophysiological foundations of emotions, attachment, communication, and self-regulation. New York: W. W. Norton & Company. https://wwnorton.com/books/9780393707007
(8) Selvam, R. (2022). The practice of embodying emotions: a guide for improving cognitive, emotional, and behavioral outcomes. Berkeley, CA: North Atlantic Books. https://www.penguinrandomhouse.com/books/673734/the-practice-of-embodying-emotions-by-raja-selvam-phd
(9) Bauer, C. C. C., Cabral, J., Stevner, A. B. A., Kirchhoff, D., Sousa, T., Violante, I. R., … & Kringelbach, M. L. (2022). Mindfulness meditation increases default mode, salience, and central executive network connectivity. Scientific Reports, 12, 13219. https://doi.org/10.1038/s41598-022-17325-6
