I woke up one morning thinking of the phrase I am not a robot, a phrase we see on the computer screen many times a day. As common as battery-powered scooters across urban landscapes, I am not a robot, is our new normal. Ironically, we are told to prove our humanness to a technological algorithm – a robot designed by a human that had to think like a robot to create an algorithm that could convince us to mechanically follow certain steps – and gain access to something we have been told is important. In other words, we are asked to prove to a machine that we are flesh and bones in order to be allowed to pass through the gate.
While I am not advocating the removal of captcha or two factor authentication, this metaphor is well-suited for illustrating an ideological dilemma we face in the mental health field: we know that the wellness of all beings depends on consistent, compassionate connection that unfolds over time and we are often met with the mechanical criteria of the medical-industrial complex that requires us to jump through clinical and administrative hoops just to be able to sit in a room with our patients. Sadly, much of our training and education is reflecting the same problematic criteria and misplaced power. We are told to adhere to approaches and techniques that are based on scientific evidence, yet despite the evidence that the therapeutic relationship is one of the most powerful determinants of successful outcomes, we are rarely encouraged to deepen our understanding and experience of therapeutic presence. This can be especially misleading and confusing for pre-professionals and new professionals who are trying to become effective clinicians.
Rather than guiding clinicians to become practiced in the nuances of each unique therapeutic relationship and allow answers to emerge through the relationship, we are increasingly funneled into systems that move us toward efficiency, productivity, and streamlined protocols that make it increasingly difficult to prioritize human connection.
In the guise of creating more accountability and increased quality of treatment, these protocols serve insurance companies, pharmaceutical companies, government criteria, marketing campaigns, and funding more often than they do our patients, not to mention the overlooked well-being of the clinicians who need healthy professional standards and conditions to be helpful.
Of course, it is our responsibility to do the best work we can to facilitate healing, but it is also important to recognize how our social conditioning, including professional conditioning, influences the clinical relationship.
It’s not that we haven’t been skeptical or pushed back. Many of us are concerned that mental health care and our profession is becoming more mechanical. Often minimizing or challenging the importance of practice-based evidence and phenomenological information from practicing clinicians, evidence-based protocols that privilege skewed scientific data from academic researchers are presented as the gold star standard of treatment. [1] Even therapeutic approaches and timelines are being deemed worthy or unworthy based upon criteria from selective science, billable hours, billable diagnoses, measurable outcomes, and mismanaged care. Our concern that best practices are being determined by researchers who are rarely experienced clinicians has led to expanding the scope of evidence-based practices to include consideration of patients’ preferences, actions, clinical state, and circumstances, [2] but this is not enough. Evidenced-based treatments can be problematic because they need to go beyond measuring progress strictly in terms of symptom reduction over the short term. They need to consider whether or not these treatments promote social and emotional well-being over the long term. [3]
Although I am not advising to turn our backs on science, I am concerned that we are in danger of turning a professional expertise into another cog in the capitalistic wheel while millions of people are shuffled into and out of healthcare systems that do not serve them. We have a valuable expertise whose success depends on a deeply nuanced understanding of relationship and the interpersonal spiral of impact that we diligently attend to with great care. The current rhetoric about our field dehumanizes the therapeutic process and underestimates human connection. It is a misguided ideology that promotes a level of conformity not unlike other systems of oppression. It defines health by measuring levels of functioning (i.e. whether or not people are able to work) and moves us toward a fast-paced mechanical existence that is unsustainable. It minimizes the power of relationship, phenomenology, and practice-based evidence and reinforces the very structures of dominance, control, and generational trauma that have likely contributed to our patients’ walking through our doors in the first place.
What is our role?
Certainly not to create more robots, consumers of conformity, or parrots for corporate ideologies. We are here to collaborate with individuals, families, communities, and professionals to connect with their truth in the midst of conditioning.
What can we do about it?
The Power of Presence in the Therapeutic Relationship
Here’s what I know from my practice that has also been documented in research.[4] In our profession, it takes time to develop a deep and nuanced understanding of the people we serve and create the trust needed for healing. It takes time to develop the therapeutic intimacy necessary for people to heal from past interpersonal challenges that caused many of the symptoms and situations to arise in their lives. It takes great diligence and self-awareness for a clinician to help people uncover and transform habitual patterns that did not emerge overnight. What is necessary for that long-term healing to occur is frequency, consistency, depth, compassion, and attention. In addition to our particular expertise, our clients need our therapeutic presence.
Presence might be described as “the experience of one’s whole self in an encounter with the client, intentionally and fully in the moment on a multitude of levels —including physical, mental, emotional, and energetic — from a grounded, spacious, and centered position within oneself.” [5] As we tap into presence, we find our flexibility, allowing whatever is arising in the moment with compassionate awareness, without judgment, or reactivity. [6]
Therapeutic presence emphasizes the intention to be fully with our patients in service of their healing. It involves a mindful balance of contact between our own experience and the client’s experience, while maintaining the self-awareness to be responsive to what is needed in the moment. Therapeutic presence is a process of shifting from internal to external, self to client, from receptivity to responsiveness. [7]
What we can do as clinicians is powerful.
The beauty of this field is that we can question and reflect upon how we might best sit with each patient in each session to facilitate the emergence of self-awareness and authentic expression. We can take the time to listen deeply to what is said and not said, whether it is with words, pauses, facial expressions, and somatic changes. We can slow down processes to help clients deeply listen to themselves and hear the wisdom that arises out of stillness, often because we have taken the time to build enough trust to be in vulnerable, uncomfortable, and intimate spaces together.
It begins with our commitment to being as present as we possibly can.
While I recognize the level of difficulty in overhauling a problematic system, we can and do make a difference by staying close to our integrity and patient-centered care. Inasmuch as psychotherapy is about helping people free themselves from conditioning and blind obedience to the past, we too, have an opportunity to free ourselves from the internalized constructs of imposed systems that ultimately do not serve us or the people we aim to help. When we begin to become more fully present with ourselves and our patients, we are able to create opportunities for healing to occur through the quality of the therapeutic relationship and discern how we will approach treatment of each person, based on what we learn from that relationship.
Our therapeutic presence invites authentic human connection and compassion and buffers the disembodied, disconnected, mechanical coldness encouraged by oppressive systems that put productivity and profit over people and planet.
Our therapeutic presence honors each individual’s unique path for healing and the time it takes to attune to what is needed.
Our therapeutic presence models that we privilege healthy and respectful connection based on awareness and clinical discernment, rather than cookie-cutter or contrived solutions.
How do we deepen our therapeutic presence?
3 Key Ways to Deepen Therapeutic Presence
Increase Your Awareness about Therapeutic Presence
When we consider more deeply the influence we have on our clients and renew our intention to explore how our presence impacts the clinical relationship, it is a great first step. By expanding our awareness, we engage with our ethical responsibility to deepen our understanding of the complexities and subtleties of each interaction. Rather than implementing interventions from manualized treatment plans and insurance-influenced protocols, we can pause and tune into what best serve a patient’s needs. We can also tune into our unconscious assumptions, reactions, triggers, and/or habits. When we do this, we have the opportunity to become more aware of our motivations, learn to respond therapeutically, and model a relationship that honors the dignity of the people in our care. Imagine the profound transformative experiences we might have the privilege to facilitate when working from the deep spaces of self-awareness and interpersonal awareness.
Set an Intention to Prioritize Therapeutic Presence
When we make a resolve to prioritize being as fully present as possible, we begin to create a safe and supportive container to allow whatever is arising in the session to exist without judgment. We make it a point to become receptive and open to the organic process (as much as is possible within our particular work environments), with a mixture of attentiveness and reflection.
When we welcome the space to discover the uniqueness of each clinical relationship, we then have an opportunity to slow down, avoid reductionism, hold opposites and contradictions, and imagine multiple possibilities that go beyond the evidence-based criteria and/or professional guidelines while still upholding a high standard of care.
Commit to Cultivate Therapeutic Presence
When we make a commitment, we take active steps that reflect our intention to be present with ourselves and the people we serve. Whether that means incorporating psychoeducation about the therapeutic relationship into intake sessions, writing articles, challenging manualized approaches in groups or agencies, taking courses that focus on self-awareness, mindfulness, and/or the clinical relationship, do what feels best for you. Every gesture, no matter how small, is a reflection of your commitment and a generative response to the rise in mechanical systems in the mental health field.
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[1] Jurist, E. (December 01, 2019). Saving Talk Therapy: How Health Insurers, Big Pharma, and Slanted Science Are Ruining Good Mental Health Care. Journal of the American Psychoanalytic Association, 67, 6, 1083-1088.
[2] Cook, S.C., Schwartz, A.C., Kaslow, N.J. (2017). Evidence-Based Psychotherapy: Advantages and Challenges. Neurotherapeutics, 14(3), 537-545. doi:10.1007/s13311-017-0549-4.
[3] Gnaulati, Enrico. (2019). Saving Talk Therapy: How health insurers, big pharma, and slanted science are ruining good mental health care. Boston, Massachusetts: Beacon Press.
[4] Orlinsky, D., Grawe, K. and Parks, P. (1994), “Process and Outcome in Psychotherapy – Noch Einmal” in Handbook of Psychotherapy and Behavior Change, 4th Edition, Eds., Bergin, A. and Garfield, S., John Wiley & Sons, New York, p.267.
[5] Geller, S. M., & Greenberg, L. S. (2012). Therapeutic presence: A mindful approach to effective therapy. Washington: American Psychological Association.
[6] Welwood, J. (2000). Toward a psychology of awakening: Buddhism, psychotherapy, and the path of personal and spiritual transformation. Boston: Shambhala.
[7] Geller, S. M., & Greenberg, L. S. (2012). Therapeutic presence: A mindful approach to effective therapy. Washington: American Psychological Association.
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Did You Know?
Inner Science Institute is built on a strong belief that self-awareness can lead to deeper levels of authentic, compassionate presence and connection with ourselves, each other, and all beings. We hope that what we teach here helps you deepen your wisdom and expand your skillset so that you can offer your expertise with the contactful, heart-based, and compassion-filled presence that the people we serve depend upon to heal. Feel free to check out our courses to find out more or sign up for our email list at the bottom of our home page, where you will receive the latest updates.
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