Therapeutic Presence in the Relational Field

One important dimension of therapeutic now moments is the quality of being which in Buddhism is called presence. Although hard to define, to be Present means to be aware in a way which is open, attentive, balanced, and flexible. Therapeutic presence is a quality of deep listening which has long been recognized in psychoanalytic work. It has been compared with Freud’s (1912) “evenly hovering attention” and Wilfred Bion’s (1967) idea of listening “without memory or desire” (Epstein, 1995).

The cultivation of presence is one of the hallmarks of Buddhist mindfulness meditation. As previously described, the core meaning of mindful awareness is the ability to be with what is; to be intimate with the present moment of experience. The practice of mindfulness cultivates this intimacy and depth of Presence. In the frame of inquiring deeply, the therapist lends his or her mindful awareness and presence to the purpose of illuminating the shared experience of the relational field.

As a therapist, to be Present means to be receptively and empathically aware both of self and other; non-defensive and curious about the experience of the present moment. Our Presence is part of the felt sense someone has in being with us. It is an essential aspect of the clinical atmosphere we provide, an important part of what allows the patient to feel deeply seen, felt, accepted, and understood.

As the therapist speaks from a state of Presence, s(he) has the opportunity to listen deeply to the patient, to be present with what the patient is saying and not saying, and to track the nuances of change in the interpersonal connection. As the patient speaks into the Presence of the therapist, s(he) has the opportunity both to listen more deeply to him or herself and to be transformed by the therapist’s listening. Often, as a patient narrates their experience in a therapeutic space of deep presence, a new sense of immediacy, freshness, and transparency is injected into experiences which had become repetitive, stale, and intractable. In this process of sharing, both people change.

Some idea of the impact of therapeutic presence is conveyed in the following brief vignette.

Clinical Illustration 5.2: Evan

Evan has tremendous difficulty communicating about his feelings with his life partner, William. Because William came into the relationship with a history of serious depression and several suicide attempts, Evan fears that to speak about his negative feelings honestly would cause emotional harm to William.

As a consequence, Evan defers to William’s preferences in most of the decisions in their relationship, from minor ones such as where to eat, to major ones such as how to spend vacations, what furnishings to buy, and so forth. The more he accommodates, the angrier Evan becomes, and the more difficult it is for him to feel comfortable expressing himself honestly.

Despite our repeated discussions of the importance of his speaking up, and despite very thorough analysis of the childhood reasons for his inability to do so, Evan remained frozen and unable to express himself. My clinical strategy was to call Evan’s attention to similar inhibitions that arose for him in our therapeutic relationship. All of this further frustrated Evan; now even in therapy he was finding himself jammed up and unable to express himself. He was mad at himself for the fact that he could see so clearly what he needed to do and yet felt so unable to “pull the trigger” [sic] by being honest and forthcoming with William. I pointed out that his language seemed to suggest that he was concerned about the damaging impact of his anger. From my side, I repeatedly noticed myself working way too hard.

One day, something occurred between me and Evan which surprised both of us: As I started to paraphrase something he was saying, he snapped at me in annoyance: “If you’d only let me finish without interrupting me,” he said, “you’d understand better what I’m trying to say!” Both of us sat in stunned silence as we absorbed what had just happened; the atmosphere of Presence in the room had palpably thickened. Immediately following, in a poignant “blood moment,” Evan says “Thank you. I can feel that you really heard me. This is what I most need from you: for you to hear what I am saying from here [pointing to his heart] and less what I am saying from here [pointing to his head].”5

The moment of spontaneity described above was one of intimacy, self-awareness, and growth for both Evan and myself: Evan expanded his capacity to be authentic and I saw more clearly how my own efforts to be therapeutic could get in the way.

Psychoanalytic work is based on the idea that as therapeutic interactions unfold over time, echoes of the patient’s history will inevitably begin to be enacted within the therapeutic encounter itself. Deeply embedded interpersonal patterns (or “transferences”) enter the therapy as elements of a lived emotional story which becomes the story of the psychotherapy. It can even be theorized that when we are very deeply present in the intimacy of the therapeutic encounter, the implicit (nonverbal) memories of interpersonal gaze and interpersonal resonance between mother and baby are evoked in the transference/countertransference. It is in this space of fertile mutuality that healing takes place.

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