LEVELS OF THERAPEUTIC PRESENCE Stillness, insight, and wisdom arise only when we can settle into being complete in this moment, without having to seek or hold on to or reject anything. —Jon Kabat-Zinn (1994, p. 54) In describing the experience of therapeutic presence in Chapter 6, we explored the intensity of experience in those profound presence moments within the therapist. To arrive at the optimal depth of presence, therapists often have to go through a path of deepening in themselves and in relation- ship with the client, Once contact is made within one’s self, cherapists’ pres- ence can move outward toward the client and deepen at different levels of relational contact and sharing. In this chapter, we present an applied view with respect to becoming present before a session and toward deepening into presence when in session with a client. We first provide a four-step sequence to help therapists in preparing to become present prior to a session. We then apply a five-level model to relating with therapeutic presence in session, which includes mov- ing further into relational presence through a deepening in contact with the client and the presence process. While being present may start at the surface contact with the client, this state unfolds toa deepening of presence that allows for greater psychological and, pechaps, spiritual contact within the relationshi Toset the foundation for viewing levels of therapeutic presence, we frst discuss presence as a continuum. 135PRESENCE AS A CONTINUUM, Although we have spoken about presence asa state of being and relational stance, we do not view presence as.a concrete state that one either has or does not have throughout the course of a therapy session, For example, one thera- pist in our qualitative study stated: I think itis degrees also; it is not am I present or not. It's [the] degree to which Lam thece. I would say that it is almost an intensity continuum in terms of the presence ... the intensity of my connection, the intensity of my focus, the intensity of my concentration and empathy, and really the intensity of my lack of self-awareness. The opportunity to he in the varying intensities of presence is there all thd time, although as therapists we are not always aware of this within ourselves. ‘One therapist noted: I think presence is there all the time, it's just realizing it or experiencing it to different degrees. I think ic isa sensitivity that grows within the per- son, more than a skill. I’sa sensitivity to something that is there. In this perspective, presence is a state that we can experience at more of less different degrees of intensity as we open to greater sensitivity and relatedness with the other. LEVELS OF THERAPEUTIC PRESENCE IN PREVIOUS MODELS. There are various depths or levels of presence; for example, a greeting at the door would be a lighter version of presence than a profound interper- sonal experience with the client, which would reflect a relational depth of presence. We are inspired by the nursing literature here in teexamining pres- ence in levels. Gilje (1993) provided a model of presence that describes the deepening in the experience of presence itself as nurses go from managing patients’ rooms without making much contact or bringing much awareness of the person into their activities to making emotional or psychological contact dur- ing an exchange with their patients, As they deepened into the connection, a larger sense of transpersonal presence revealed itself. Nurses described transpersonal presence as going beyond the immediate connection with the patient to a larger sense of spirituality or vitality with all of life. Gilje (1993) described these three levels of presence as intrapersonal, interpersonal, and transpersonal presence. Osterman and Schwarte-Barcott (1996) extended that perspective to describe four levels of presence for nurses: physical presence (e.g., reading a 136 THERAPEUTIC PRESENCEbook in the room with a patient); partial presence (physical presence plus focus on a task relevant to patient; e.g, reading to the patient or changing an IV); full presence (partial presence plus attending and listening to the patient): and transcendent presence (beyond the two individuals and into the spiritual realm; i.e., having a mutual experience of “oneness"), in which both people experience peacefulness, calm, positive change, and transformation. Further- more, the authors argued that full nursing presence is anchoted in reality but that transcendent presence is devoid of boundaries and limitations and has the potential to transcend reality itself In this fourth level, the nurse recognizes a sense of oneness between the self and the patient. Invegrating the perspective of levels of presence from the nursing field with the current model of therapeutic presence creates a view of presence that deepens as contact is made in a psychotherapeutic context. In this vein, pres- ence can be viewed as a top-down process that occurs in two stages: prior to the session itself and in session with the client. An exploration of levels of therapeutic presence in psychotherapy provides an understanding of the dif- ferent degrees of presence that unfold as therapists deepen into the moment within and with their client. A FOUR-STEP SEQUENCE TO BECOMING PRESENT PRIOR TO THE SESSION Therapists can prepare for and deepen presence before the client walks through the door by L. arriving, 2. preparing the ground, 3. touching ground with self, and 4. preliminary contact with the client (notes, etc.). Artiving in the present moment means inviting or intending your whole being to be present as well as preparing the physical space to welcome the client. The former includes bringing yourself into the room, taking care of any physical needs (washroom, hunger, thirst, clothing for warrith, or air condi- tioning), and arriving in your body and mind as well as physically being in the room. The latter includes turning off telephones, adjusting temperature, removing clutter, and closing computers and any other devices that may act as distractions. Grounding in the body means making contact with a steadiness in one’s self. This could be done through a few moments of feeling one’s feet on the ground in a standing position or perhaps one of the centering techniques we presented in Chapter 6. It could also include taking a few breaths to calm your nervous LEVELS OF THERAPEUTIC PRESENCE 137system and to enhance equanimity within. A gentle body scan could also sup- port grounding: scanning your awareness through your body, starting from the toes up through each body part, and allowing the awareness of each body part to support a gentle release and softening of any tension. Being in contact and fully in your own self and center can help to prepare to open to the depth of whatever the client brings in, without attachment or feeling overwhelmed or shut down. Grounding in the body also helps to create contact with your own self and sensations so that attending inwardly and using the self as a sensor of what the other is experiencing flows naturally and easily Clearing aspace means putting aside any personal issues or preconceptions the therapist is experiencing. This can occur through consciously visualizing putting one’s issues or needs on ajshelf, knowing that you can retum to them at another time, Clearing a space can also involve letting go of rension in the body and mind as well as creating a greater sense of spaciousness in one's self through deep breathing or expanding one’s awareness to the space in and around the body. Clearing a space, along with grounding, can help to support a state of nonteactivity and prepare an open, receptive place to take in whatever experi- ence or emotion the client brings into the session. Preliminary contact with the client could include looking at notes from the previous session or just imagining ot visualizing the client on a physical, emo- tional, and energetic level and preparing to meet this unique other before he or she walks in the door. This does not mean creating plans or preparing what to speak about in session. Instead, ic means connecting with a sense of the person before meeting him or her, pethaps by recalling a past conceptualization of the person that can be triggered in consciousness and let go of when this person is actually met. Preliminary contact can create an awareness of prior experience with this individual (or ifthe client is new, a recall of a phone contact you may have had) so that itis accessible in session ifsomething emerges in the moment that is relevant. After this preparation process, there is a readiness to walk to the door and greet this other unique being, with a focus on the present, open- ing and connecting with the other. The path to becoming present prior to the session allows for presence to begin with the other moments before actually meeting him or her so that the therapist is ready and accessible to the client. This process does not need to be Jong—it can take just 5 minutes—but what it gives back in terms of the ability to be present with the other is tremendous. These gentle pauses allow for pres- ence to emerge more easily. FIVE LEVELS OF DEEPENING INTO PRESENCE IN SESSION Drawing on the Osterman and Schwartz-Barcott (1996) model of pres- ence, we present a model of five levels of presence contact that occurs from 138 ‘THERAPEUTIC PRESENCEthe moment of meeting the client, which begins from opening the door to this unique person in this unique moment: 1. physical presence (light presence) . contact with other—light presence (superficial or small talk) settling into the toom/chairs . awareness of own body (present moment awareness, contact with chair) 2. psychological presence (partial presence) a. hearing the story, checking in b. listening, attending, attunement, caring, openness, and interest 3. emotional presence (presence with and for the other) a. understanding, compassion, acceptance, empathy, uncondi- tional positive regard b. responding or providing intervention or empathic response in resonance to what the client is sharing 4, transpersonal presence (presence with spirit) a, body as a vessel b. contact with deeper connection between therapist and client . contact with deeper intuition d. contact with spirituality (vitality, enhanced sensation, and perception) 5. relational therapeutic presence (all the levels) a. vacillating (dancing) between what is needed in the moment of deep contact with self, with the client, and with a deeper spirituality and intuition b. being fully with and for the other yee filled with energy, vital- ity, and a spiritual transcendence. oe When we greet aclient at the door, welcoming the other in through direct physical contact and exchange of hellos, we enter into the first level of in-session presence, which we call physical presence or light presence. Physical pres- ence refers to the moment of initial contact with the client. It is not a time to go deep into issues but rather to check-in with a hello and greeting. It includes the initial welcoming of the client into the therapy space and may include gen- eral talk about the weather, traveling to the session, and so on. This isan impor- tant part of the process of arriving and heing present with each other in that there isa human warmth and contact that lets the client know you are happy to see him or her, you are interested in his or her day-to-day life, and that you are two human beings in contact with each other. Physical or light pres- ence includes settling into a comfortable sitting position and just generally settling into the room together. This physical or light presence can also 139 LEVELS OF THE! APEUTIC PRESENCinclude therapists’ awareness of their physical body by being aware of the body on the chair and feeling that contact place as another invitation to show up, be present, and to have a general awareness of one’s own sensory tool, the body. The next level of presence is psychological presence or partial presence, which includes beginning to check-in and hear the content of the client's expe- rience. Checking in with the client includes hearing the client's initial story about what has been going on for them during the week or pethaps what focus they have for this session. As therapists invite themselves to show up for the client, they begin to listen and attend to clients’ sharing of their experience with caring, openness, interest, and acceptance. This is the beginning stage of the therapists’ presence: allowing for an attunement to what the client is bring- ing into this particular session. A third level involves being emotionally preseneto the client, or present with and for the other. This deepening into presence on an emotional level occurs as the therapist begins to experience an emotional resonance with and empathy for the client. The therapist begins to gather a level of understanding, accept- ance, and compassion for the client’s concerns and may offer an empathic response that reflects that understanding. The therapists’ responses as they deepen into emotional presence, with and for the client, emerge in ditect res- conance with what the client is sharing. The therapist is simultaneously listen- ing and absorbing the content and nonverbal gestures or processes that the client is experiencing and looking within his or her own sensory body for infor- mation on what the client may be experiencing. Listening, understanding, and responding are held with the intent to be with and for the client. A fourth level that may emerge in the therapist as the session unfolds and the relationship deepens in the moment is a ranspersonal presence or pres- ence with spirit or presence with something larger. Although therapists can, with practice, enter into the session with a sense of this larger presence, they also gather this larger sense of spaciousness and transcendence from being in physical, psychological, and emotional contact with their client. In transpersonal presence, therapists recognize theit body as a vessel for healing that is taking in che depth of experience of the client yet is connected toa langer state of energy or support. The contact between the therapist and the client is felt on a deeper level by the therapist, where there is a palpable presence between the two people. Therapists also experience greater contact and access to their own intuition as they take in the depth of experience of the other and access their own inner wisdom, professional knowledge, ot appro- priate response technique, which stem from this resonance with the other and with a larger felt sense of energy. As the deepening between therapist and client occurs, the therapist feels in contact with a larger sense of spirituality as well as a high-level sense of vitality and an enhanced sensory and perceptual experience in direct relationship with the client. Tran personal presence can 140 THERAPEUTIC PRESENCEemerge in special presence moments or through deep intersubjective sharing (Stern, 2004). The fifth and final level of therapeutic presence is when all of these lev- els are integrated and occurring simultaneously, which reflects a relational therapeutic presence. Relational presence involves holdingall of the levelssimul- taneously and vacillating among what is emerging and poignant in the moment, which may include contact with self (ie., checking in inwardly with what is being experienced), deep contact with the client (i.., felt experience of being with and for the other, attuned deeply to the other's present moment experience), and contact with a deeper sense of intuition, spirituality, ora tran- scendental force. This relational presence includes being fully with the other yet filled with energy, vitality, and a spiritual transcendence as emerging from the direct present-centered relationship with the client. Ieis this profound rela- tional presence that allows for the emergence of flow, riding the waves of the unknown, yet trusting in the process and in the therapist's own intuition and responses when they emerge from that place of deep connection. In relational presence there exists great opportunity for deep healing to emerge from the level of multiple present moment connections (with self, other, and transcen- dence or spirit) and from the quality of what unfolds in the depth of the rela- tionships between these connections. The emergence of healing in therapeutic relational presence reflects Rogers's (1980) experience, quoted in full in Chapter 1, where he spoke of being close to his “inner intuitive self" and “transcendental core” and the moments that “our relationship transcends itself and becomes a part of something larger. Profound growth and healing and energy are present” (p. 129). CONCLUSION We propose that therapeutic presence can occur at multiple levels and can be experienced in different depths and at different moments, depending on where the client is and what he or she needs to stay in contact. Some clients need more time in physical presence to settle into the session and the encounter in a deeper way. Other clients have greater comfort with their own experience and with the relational encounter, so physical presence is only a momentary experience as they prefer a deeper emotional opening and encounter early in the session. Our ability as therapists to tune in to the multiple levels of therapeutic presence, as well as to where the client is and needs to be to stay in contact, serves as the ultimate guide in the unfolding of the therapeutic encount While the dance of present-moment awareness and deepening into rela- tional therapeutic presence with clients is healthy and desirable, there are LEVELS OF THERAPEUTIC PRESENCE 141challenges to becoming and being in presence with clients, both within the therapist and with particular clients, which we explore in Chapter 8. The recognition of these challenges in the present moment is essential to deepen- ing in the therapeutic relationship. As Stern (2004) noted, all moments of present moment experiences, when recognized and given attention, are moments of kairos, or a moment of opportunity in the moment, in which we can act or respond in a way that could change the course of one’s destiny, either for the next moment or for a lifetime. 142 THERAPEUTIC PRESENCE