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Therapeutic presence involves therapists using their whole self to be both fully engaged
This document is copyrighted by the American Psychological Association or one of its allied publishers.
and receptively attuned in the moment, with and for the client, to promote effective
therapy. In this paper, we present a biobehavioral explanation of how therapeutic
presence can facilitate a sense of safety in both therapist and client, to deepen the
therapeutic relationship and promote effective therapy. The polyvagal theory is used as
a guide to explain how specific features of therapeutic presence trigger a neurophysi-
ological state in both client and therapist within which both perceive and experience
feelings of safety. The polyvagal theory proposes that a state of safety is mediated by
neuroception, a neural process that may occur without awareness, which constantly
evaluates risk and triggers adaptive physiological responses that respond to features of
safety, danger, or life threat. According to the theory, when safety is communicated via
expressed markers of social engagement (e.g., facial expressions, gestures, and pro-
sodic vocalizations), defensiveness is down-regulated. Cultivating presence and engag-
ing in present-centered relationships can therefore facilitate effective therapy by having
both client and therapist enter a physiological state that supports feelings of safety,
positive therapeutic relationships, and optimal conditions for growth and change.
Effective therapeutic work is only possible client improvement (Norcross, 2011). Current
when the client feels safe and secure in the research has suggested therapeutic presence
therapy setting. Research has demonstrated that may be a core therapeutic stance that contrib-
the therapeutic relationship is central to positive utes to the development of a positive therapeutic
change for clients in psychotherapy and that relationship (Geller, Greenberg, & Watson,
differential therapeutic outcomes may only be 2010; Geller & Greenberg, 2012; Hayes &
minimally attributed to specific techniques Vinca, 2011; Pos, Geller, & Oghene, 2011).
(Duncan & Moynihan, 1994; Lambert & Ogles, Facilitating feelings of safety and security for
2004; Lambert & Simon, 2008; Martin, Garske, the client often emerges through therapists’
& Davis, 2000; Norcross, 2002, 2011; Orlinsky, ability to be fully present and engaged, which is
Grawe, & Parks, 1994). These observations core to the development of a healthy therapeutic
guided psychotherapy researchers to consider relationship (Geller & Greenberg, 2012; Lam-
common factors of therapy that are central to bert & Simon, 2008; Mearns, 1997; Rogers,
1957, 1980; Siegel, 2007, 2010). While clinical
observations affirm that presence elicits feelings
of safety in the client through the development
Shari M. Geller, Clinical Psychologist, Private Practice, of a positive therapeutic relationship, it is less
Toronto, Ontario, Canada, Department of Health Psychol-
ogy, York University, and Faculty of Music in association
clear how or why therapists’ presence leads to
with Music and Health Research Collaboratory, University clients’ safety and, hence, effective therapeutic
of Toronto; Stephen W. Porges, Department of Psychiatry, work. This paper explores this question through
University of North Carolina. the lens of neuroscience and biobehavioral
Correspondence concerning this article should be ad-
dressed to Shari M. Geller, 4-421 Eglinton Avenue West,
mechanisms as suggested by the well-re-
Toronto, Ontario, M5N-1A4 Canada. E-mail: drsharigeller@ searched and established polyvagal theory
gmail.com (Porges, 1995, 1998, 2007, 2011).
178
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Contemporary neuroscience offers the field scribed in the context of the polyvagal theory so
of psychotherapy a valid physiological frame- that a neurophysiological description of how
work for understanding how, through the oper- therapeutic presence results in the process of
ation of specific neurophysiological mecha- change can be illuminated. A clinical vignette
nisms, therapists’ presence activates clients’ will then be presented. Finally, a suggestion for
feelings of safety (Porges, 2011; Schore, 2003, training in therapeutic presence will be of-
2012; Siegel, 2007, 2010). The polyvagal the- fered— one that is supported by neuroscience
ory is one such perspective that provides the research, which argues for the integral value in
clinician with a neurophysiological explanation creating a sense of safety with and for the client.
of core autonomic mechanisms that support
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
as open and receptive to the whole of the cli- et al., 2011). TPI-C has also been found to
ent’s experience. In moments of present- predict a positive therapeutic alliance across
centered engagement, therapists simultaneously person-centered, process-experiential, and cog-
are in direct contact with themselves, the client, nitive behavioral therapies (Geller, 2001; Geller
and the relationship between them. Effective et al., 2010).
therapists’ responsiveness and use of interven- Clients’ experience of their therapists’ pres-
tion or technique emerges from this attuned ence has also been found to relate to a positive
in-the-moment connection and resonance with session outcome (Geller et al., 2010) and symp-
the client’s experience (Germer, Siegel, & Ful- tom reduction (Hayes & Vinca, 2011). Further,
ton, 2005; Geller & Greenberg, 2012; Green- a recent study indicates that therapists’ prepa-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
berg, Rice, & Elliott, 1993; Goldfried & Davila, ration of presession presence relates to both
This document is copyrighted by the American Psychological Association or one of its allied publishers.
2005; Lambert & Simon, 2008). their in-session presence and positive session
outcome (Dunn et al., 2013).
Research on Therapeutic Presence There is a vast body of research indicating
that the therapeutic alliance results in positive
There is a growing body of research contrib- therapy outcome (Duncan & Moynihan, 1994;
uting to an understanding of therapeutic pres- Lambert & Ogles, 2004; Lambert & Simon,
ence (Geller, 2001; Geller & Greenberg, 2002; 2008; Martin, Garske, & Davis, 2000; Norcross,
Geller et al., 2010; Hayes & Vinca, 2011; Pos, 2002, 2011; Orlinsky, Grawe, & Parks, 1994).
Geller, & Oghene, 2011). A qualitative study in Now, emerging studies suggest that presence is
which therapists were interviewed about their a precondition to a positive therapeutic relation-
experiences of presence resulted in a model of ship and alliance. These studies contribute to
therapeutic presence that consists of three over- the validity of our theoretical assumptions that
arching categories (i.e., preparation: the pre- one possibility as to how presence contributes to
liminary intention and practice therapists en- effective therapy is by mediating and promoting
gage in to facilitate their being present; process: a positive therapeutic alliance (Geller & Green-
what therapists are doing when they are being berg, 2012; Geller et al., 2012).
present; and experience: what therapists’ in-
body experience of presence feels like; see What Is the Polyvagal Theory?
Geller, 2001; Geller & Greenberg, 2002, 2012).
A later study involved development of a mea- Polyvagal theory is an innovative reconcep-
sure of therapeutic presence, the therapeutic tualization of how autonomic state and behavior
presence inventory (TPI), which was based on interface. The theory emphasizes a hierarchical
the model noted above (Geller, 2001; Geller et relation among three subsystems of the auto-
al., 2010). Two versions of the TPI were created nomic nervous system that evolved to support
and studied: One from the therapist’s perspec- adaptive behaviors in response to the particular
tive (TPI-T) and the second from the clients’ environmental features of safety, danger, and
perception of their therapists’ presence (TPI-C). life threat (Porges, 2011). The theory has re-
The TPI-T can also be used as a self-audit tool ceived significant interest from researchers and
for therapists to reflect on their degree of pres- clinicians working with individuals, particularly
ence with a client (Geller, 2013b). Research those with a trauma history. This interest is
demonstrated that both versions of the TPI were based on how polyvagal theory articulates two
reliable and valid (Geller et al., 2010). defense systems: (a) the commonly known
Emerging research using the TPI suggests fight-or-flight system that is associated with ac-
that client’ reports of their therapists’ therapeu- tivation or the sympathetic nervous system
tic presence is predictive of the therapeutic re- (fight or flight) and (b) a less-known system of
lationship (Geller et al., 2010) and the therapeu- immobilization and dissociation that is associ-
tic alliance (Pos et al., 2011). These findings ated with activation of a phylogenetically more
support the propositions that presence provides ancient vagal pathway. The theory is named
a necessary foundation to develop a positive “polyvagal” to emphasize that there are two
working therapeutic relationship and is a nec- vagal circuits. One is an ancient vagal circuit
essary foundation for empathic responding associated with defense. The second is a phylo-
(Geller et al., 2010; Hayes & Vinca, 2011; Pos genetically newer circuit, only observed in
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(e.g., Ardizzi et al., 2013; Beauchaine, 2001; function of older circuits. Therefore, the newest
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Beauchaine, Gatzke-Kopp, & Mead, 2007; Egi- autonomic circuit associated with social com-
zio et al., 2008; Hastings et al., 2008; Perry, munication has the functional capacity to inhibit
Calkins, Nelson, Leerkes, & Marcovitch, 2012; the older involuntary circuits involved in de-
Schwerdtfeger & Friedrich-Mai, 2009; Travis & fense strategies of fight-or-flight or shutdown
Wallace, 1997; Weinberg, Klonsky, & Hajcak, behaviors.
2009; Whitson & El-Sheikh, 2003). For exam- According to the polyvagal theory, effective
ple, the theory has been used as a core theoret- social communication can only occur during
ical explanation to explain the biobehavioral states when we experience safety, because only
shutting down that occurs following trauma then are the neurobiological defense strategies
(Bradshaw, Cook, & McDonald, 2011; Levine, inhibited. Thus, we suggest that one of the keys
2010; Ogden, Minton, & Pain, 2006; Quintana, to successful therapy is for the therapist to be
Guastella, Outhred, Hickie, & Kemp, 2012) and present and to promote client safety so that the
has also informed stress researchers of the im- client’s involuntary defensive subsystems are
portant role the parasympathetic nervous sys- down-regulated and the client’s newer social
tem and its component vagal circuits play in engagement system is potentiated. Functionally,
neurophysiological mechanisms related to de- during therapy, the repeated present-moment
fensive strategies associated with reactivity, re- encounters provide a “neural” exercise of the
covery, and resilience (Brown & Gerbarg, 2005; social engagement system. As these neural ex-
Evans et al., 2013; Kim & Yosipovitch, 2013; ercises enhance the efficiency and reliability of
Kogan, Allen, & Weihs, 2012; McEwen, 2002; the neural pathways inhibiting the defense sys-
Wolff, Wadsworth, Wilhelm, & Mauss, 2012). tems, the client acquires a greater accessibility
The polyvagal theory describes the neural to feelings of safety, openness, and self-
mechanisms through which physiological states exploration.
communicate the experience of safety and con- The polyvagal theory emphasizes the distinct
tribute to an individual’s ability either to feel roles of two distinct vagal motor pathways iden-
safe and spontaneously engage with others, or tified in the mammalian autonomic nervous sys-
to feel threatened and recruit defensive strate- tem. The vagus is a cranial nerve that exits the
gies. The theory articulates how each of three brainstem and provides bidirectional communi-
phylogenetic stages in the development of the cation between brain and several visceral or-
vertebrate autonomic nervous system is associ- gans. The vagus conveys (and monitors) the
ated with a distinct and measurable autonomic primary parasympathetic influence to the vis-
subsystem, each of which remains active and is cera. Most of the neural fibers in the vagus are
expressed in humans under certain conditions sensory (i.e., approximately 80%). However,
(Porges, 2009). These three involuntary auto- most interest has been directed to the motor
nomic subsystems are phylogenetically ordered fibers that regulate the visceral organs, includ-
and behaviorally linked to three global adaptive ing the heart and the gut. Of these motor fibers,
domains of behavior: (a) social communication only approximately 15% are myelinated. My-
(e.g., facial expression, vocalization, listening), elin, a fatty coating over the neural fiber, is
(b) defensive strategies associated with mobili- associated with faster and more tightly regu-
zation (e.g., fight-or-flight behaviors), and (c) lated neural control circuits.
defensive immobilization (e.g., feigning death, Unlike other vertebrates, mammals have two
vasovagal syncope, behavioral shutdown, and functionally distinct vagal circuits. One vagal
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circuit is phylogenetically older and unmyeli- sympathetic nervous system, dampen the stress
nated. It originates in a brainstem area called the response system of the hypothalamic–pituitary–
dorsal motor nucleus of the vagus. The other adrenal axis (e.g., cortisol), and reduce inflam-
vagal circuit is uniquely mammalian and my- mation by modulating immune reactions (e.g.,
elinated. The myelinated vagal circuit originates cytokines). Second, through the process of evo-
in a brainstem area called the nucleus ambiguus. lution, the brainstem nuclei that regulate the
The phylogenetically older unmyelinated vagal myelinated vagus became integrated with the
motor pathways are shared with most verte- nuclei that regulate the muscles of the face and
brates and, in mammals when not recruited as a head. This integration of neuroanatomical struc-
defense system, function to support health, tures in the brainstem provide the neural path-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
growth, and restoration via neurally regulation ways for a functional social engagement system
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ther turn off defenses to engage others or pre- this bidirectional communication between areas
pare us for defensive strategies associated with in the right hemisphere promote adaptive inter-
either fight-or-flight behaviors or shutdown. personal functioning between therapist and cli-
Moreover, as this process shifts autonomic ent (Allison & Rossouw, 2013; Schore, 2012;
state, it may also bias perception of others in the Siegel, 2012). This right-hemispheric bias in
negative direction during states supporting behavioral state regulation is consistent with the
fight-or-flight or in a positive direction during profound impact of the “right” myelinated va-
states supporting social engagement. If our gus in the regulation of physiological state (see
physiological state shifts toward behavioral Porges, Doussard-Roosevelt, & Maiti, 1994).
shutdown and dissociation (i.e., mediated by the The attachment literature documents that
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
unmyelinated vagal pathways), we lose contact trauma and early lack of attunement (i.e., a
This document is copyrighted by the American Psychological Association or one of its allied publishers.
with the environment and others. caregiver not attuned to the needs of the child)
Our nervous system continuously monitors result in emotional dysregulation (Schore, 1994,
and evaluates risk in the environment. When 2003; van der Kolk, 1994, 2011). When one
features of safety, danger, or life threat are experiences lack of attachment to one’s primary
detected areas of the brainstem are activated caregivers, one can perceive oneself to be
that regulate autonomic structures. When fea- chronically in danger. As such, a person with a
tures of safety are detected autonomic reactions trauma background may have an autonomic
promote open receptivity with others, but when nervous system that chronically maintains a re-
features of threat are detected autonomic reac- action to danger that precludes the down-
tions promote a closed state limiting the aware- regulation of defense strategies. Perpetuation of
ness of others (Porges, 2003, 2007). For exam- these early experiences may then also result in
ple, in the presence of someone with whom an challenges in the social world of these clients to
individual feels safe, a person experiences the which they may respond defensively even when
sequelae of positive social engagement behav- there is no risk. This profoundly impacts the
iors consistent with a neuroception of safety. individual’s social world by removing them
Our physiology calms and our defenses are in- from naturally occurring reciprocal positive re-
hibited. Defensive strategies are then replaced inforcement implicit in supportive social inter-
with gestures associated with feeling safe and actions. Instead, a feedback loop is created, as
with this state of safety there is a perceptional others socially disengage from the reactive
bias toward the positive. Appropriately exe- trauma survivor, further heightening the trauma
cuted prosocial spontaneous interactions reduce individual’s sense of isolation. Such disengage-
psychological and physical distance. Thus, ac- ments may be as subtle as the lack of a contin-
tivating a sense of safety through being present gent facial expression, or speaking with a flat
with and for the client, can down-regulate the vocal tone, or as blatant as using a dominating
client’s defenses and promote positive growth voice or overtly turning away (e.g., to repeat-
and change. edly look at the clock in a therapy session or to
The polyvagal theory (Porges, 2011) explic- answer the phone in a session).
itly describes the mechanisms of bidirectional Consistent with the polyvagal theory, these
communication between the brain and the vis- potent regulators of our physiological state that
ceral organs in our body that occur during stress mediate emotional expression are embedded in
responses. This bidirectional influence between relationships (Cozolino, 2006; Siegel, 2012).
our brain and visceral organs explains how the Myron Hofer (1994) employed a similar con-
therapist’s social and emotional responses to the cept to explain the role of mother–infant inter-
client can potentially, by influencing the phys- actions in facilitating the health and growth of
iological state of the client, mediate either an infants. The core of the social engagement sys-
expansion or restriction of the client’s range and tem in mammals is reflected in the bidirectional
valence of socioemotional responding. Simi- neural communication between the face and the
larly, the client’s socioemotional responses can heart (Porges, 2012). Through reciprocal inter-
impact the therapist’s physiological state and actions, via facial expressivity, gesture, and pro-
potentially bias the therapist’s interpretations of sodic vocalizations, attunement occurs between
the client’s responses from support to reactive. the social engagement systems of two individ-
Recent neuroscience theory has suggested that uals. This attunement, consistent with Hofer’s
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insights, regulates behavioral states (i.e., emo- similar physiological states and psychological
tional regulation) and simultaneously promotes experiences, the polyvagal theory provides
health, growth, and restoration. plausible mechanisms to understand the phys-
While a lack of attunement in early relation- iological states that form substrates for a va-
ships may be the cause of current emotional riety of emotions and affective states. Rele-
dysregulation, attunement and connection in vant to the clinical setting, the theory also
current relationships can heal or, at minimum, provides an understanding of how to impact
exercise the neural circuits (i.e., the social en- physiological states via central pathways in-
gagement system) that support feelings of volved in neuroception of safety or via be-
safety (Allison & Rossouw, 2013; Grawe, 2007; haviors that signal safety. The occurrence of
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Porges, 2011; Siegel, 2010). From this perspec- neuroception of safety is detectable by phys-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
tive, physiological activation and/or emotional iological markers (e.g., open posture, soft fa-
dysregulation can be stabilized through social cial features, and breathing). We posit that
interactions, which would include, as described these emergent markers of safe reciprocal so-
below, warm facial expression, open body pos- cial interaction can reflect successful therapist
ture, vocal tone, and prosody (intonation and offering and client receiving of therapist pres-
rhythm of vocalizations). ence.
An understanding of how automatically
Therapeutic Presence and the physiological states are hierarchically regulated
Neuroception of Safety also informs clinicians of the potential of ther-
apeutic presence to therapeutically benefit the
Polyvagal theory helps us understand how client: by recruiting myelinated vagal circuits in
therapeutic presence can contribute to effec- the client through nondefensive social engage-
tive therapy by strengthening the therapeutic ment. Furthermore, the neural mechanisms of
relationship and enhancing the clients’ sense the newer vagal system offer an opportunity
of safety. The polyvagal theory posits a func- through which therapist presence can exercise
tional “neural love code,” which reflects the neural circuits in the client. By supporting the
evolutionary and biological quest for safety in client’s capacity for nondefensive social en-
relationship with others (Porges, 2012). From gagement, a client’s reactiveness can be trans-
this view, potent cues of safety or danger that formed over time. In the presence of someone
are detected by cortical areas and shift phys- who we perceive as safe, the client’s experience
iological states are communicated interper- of safety will result both in their defenses being
sonally from movements of the upper part of inhibited and their expressing nonverbal mark-
the face, eye contact, prosody of voice, and ers of feeling safe. Over time, this would result
body posture. These profound changes in in additional helpful clinical features such as
physiological state are mediated by features bodily softening and opening that support client
in the social interaction that are, in general, self-awareness. Hence, it is therapeutically ben-
outside the realm of our awareness. As such, eficial for therapists to communicate with their
an interaction with another (i.e., with client or clients using these nonverbal markers of their
therapist) can trigger a broad range of bodily own opening and softening, as these will help
changes that we can and do interpret. For turn off client defenses and communicate ther-
example, when seeing or talking to another apists’ neuroception of safety as well. Through
there may be feelings in the “pit of the stom- therapists’ warmth and prosody of voice, soft
ach,” a sense of urgency to get away, or a eye contact, open body posture, and receptive
desire to engage. Although reminiscent of the and accepting stance, the client experiences a
James–Lange theory of emotion (Cannon, calm and safe therapist and further opens in the
1927; James, 1884), polyvagal theory, with its therapy encounter. The therapeutic environment
constructs of neuroception and the social en- and clients’ growth is thus profoundly facili-
gagement system, emphasizes that there are tated.
both top-down (i.e., brain to body) and bot- It is for this reason that offering the client a
tom-up (body to brain) signals regulating our consistent presence that is open, grounded, spa-
physiological state. However, because both cious, and with the intent of being with and for
top-down and bottom-up pathways can trigger the client, is essential to the development of a
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well as how to recognize and regulate their own logical regulation that enables an inhibition of
This document is copyrighted by the American Psychological Association or one of its allied publishers.
reactivity to maintain authentic consistency defense and supports the responses that reflect
with their client. calm, openness, and trust. Therefore, we sug-
gest that feeling met and heard by a present
therapist capable of being attuned and respon-
The Face and Voice sive to clients’ experience and physiology al-
lows clients to drop their defenses and to them-
According to the polyvagal theory, the face selves feel open and present. We assert that this
and voice are powerful conduits through which shared biobehavioral state is not only healing in
safety is communicated to another. This is con- and of itself, but allows for the possibility of
sistent with the clinical notion that the face is deeper therapeutic work conducted in the safety
where presence is communicated to the client of the relationship.
(Geller & Greenberg, 2012). In the view of The therapeutic presence theory of relation-
Levinas (1985), faces are information centers ship proposes that therapeutic presence is an
that offer encounters with the other that are essential component underlying any effective
direct and profound. Looking at the face of the therapeutic relationship. Regardless of theoret-
other and listening to voice are central to human ical orientation, or type of therapeutic approach,
relating, dialogue, and presence (Geller & presence promotes good session process and
Greenberg, 2012). outcome, as well as enhances the therapeutic
The importance of facial connection and alliance (Geller, 2013a, 2013b; Geller & Green-
prosody of speech is affirmed in the polyvagal berg, 2012; Geller et al., 2012). This theory
theory. From this perspective, the neural con- suggests therapists’ presence provides the ther-
nection between face (and voice) and heart apy relationship with the type of depth and
provides a portal through which neural regu- connection needed to help clients feel safe
lation of physiological states can be exercised enough to access their deepest feelings, mean-
through social engagement. In offering ther- ings, concerns and needs, and to share these
apeutic presence the therapist’s warm facial with the therapist. Therapeutic presence pro-
connection, receptive posture, open heart, and vides the type of environment in which these
listening presence help the client to feel safe feelings and needs can be most effectively at-
and further precipitates neural regulation of tended to, explored, shared and transformed.
the client’s physiology. Over time, consis- From this perspective, present-centered en-
tently offered present-centered encounters gagement with the client also originates in the
with the therapist can strengthen the client’s therapist through an internal preparation and
emotional regulation. This occurs as the cli- intention for presence. This preparation in-
ent’s physiology begins to entrain with the cludes the therapist’s cultivation of a capacity
therapists’ presence. Consistent therapist for presence both in life and prior to meeting the
presence shifts the client to more frequently patient (Geller & Greenberg, 2002, 2012). Ther-
experience safety in social interactions. apist presence with self or internal attunement
Hence, effective therapy requires repeated facilitates a sense of calm and safety within the
present engagement by the therapist, which therapist as he or she prepares to meet the client
would include the therapist being able to self- (Siegel, 2010). There is evidence that attuning
regulate, and to be open and available in the to one’s self and one’s “felt sense” (Gendlin,
face of the client’s defense and pain. 1978) of another, as therapeutic presence en-
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tails, is the basis for attuning to and understand- 2010). Through relationally attuning, there can
ing the other (Siegel, 2007, 2010). We posit that be what has been termed “brain-to-brain cou-
this experienced attunement, the client “feeling pling” (Hasson, Ghazanfar, Galantucci, Garrod,
felt” by the therapist (Siegel, 2007), impacts the & Keysers, 2012), which results in a resonance
client’s physiology through the calming feel- from one brain to another. We believe that as
ings of safety that is evoked when one feels met the therapist is self-attuned and approaches the
and understood. client with a calm and engaged presence, an
The theory of therapeutic relating based on entrainment process ensues that invites the cli-
presence also suggests that although the expe- ent’s brain to regulate into a safe presence-
rience of presence by the therapist and its com- centered state.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
munication to the client is important, it is heal- We propose that the cultivation of safety
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ing only if the client experiences the therapist as through the emergence of a relational presence
being fully there in the moment (Geller & promotes therapeutic effectiveness and client’s
Greenberg, 2012). This is based on research positive growth and change through three
suggesting that it is the clients’ experience of mechanisms. Relational presence facilitates (a)
their therapists’ presence, not the therapists’ clients’ openness to engage in therapeutic work,
experience, which promotes positive therapeu- (b) strengthening of the therapeutic relationship,
tic process and change as well as a strong ther- and (c) therapists’ being more attuned to the
apeutic alliance (Geller et al., 2010; Pos et al., readiness of the client and more able to opti-
2011). There are also reciprocal relationships mally offer effective and attuned interventions
among the therapist’s felt and communicated or responses (see Figure 1). Further, over time, F1
presence, clients receiving and feeling thera- from the perspective of the polyvagal theory,
pists as present with them, and both parties the client’s capacity for neuroception of safety
developing greater presence within and between is encouraged through repeated encounters in
each other. This presence growing within and the presence of a safe present therapist.
between therapist and clients contribute to the In summary, a relationship theory based on
development of relational presence. Relational therapeutic presence suggests that therapeutic
presence provides the conditions for an “I– presence will lead to the development of a
thou” encounter and, ultimately, this mutual synergistic relationship in which the client
relational presence also promotes relational develops greater presence, while the deepen-
depth, safety, and therapeutic change (Buber, ing of relational presence between therapist
1958; Cooper, 2005; Geller, 2013a; Geller & and client occurs simultaneously. This has
Greenberg, 2012). been articulated through the lens of the poly-
Emerging theories from several scientific dis- vagal theory. As the client, via neuroception,
ciplines including neuroscience research invites reacts (without cognitive awareness) to the
us to recognize our inherent relational nature present-centered therapist as safe, the client’s
(Cozolino, 2006; Porges, 2011; Siegel, 2007, physiology becomes regulated and calm, al-
Figure 1. ! Note: Repeated engagement and presence from therapist also exercises neural
regulation of the muscles involved in the client’s experience of safety in self and in
relationship.
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lowing for more openness and presence in the therapist withdrawal). My anxiety grew as I began
client. As such, we believe that presence is a to hear my own internal voice say, “you can’t help
him . . . you fought with your own mother before she
relational stance fundamental to evoking a died and you still feel guilty . . . who do you think
sense of safety in the therapist, in the client, you are?” (Therapist’s sympathetic nervous system
and in the relational therapeutic environment. is activated and a relational disconnection occur-
This sense of safety in turn can further pro- ring). My responses to him were concrete and flat
and my facial features tightened as I battled with my
mote a positive therapeutic alliance and ef- own critical voices (loss of myelinated vagal tone
fective clinical work across different thera- reflected in a loss of neuromuscular tone to upper
peutic approaches. part of the face with a resultant flat face—voice
would also lose prosody, and likely muscle tone
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
I experienced as open and feeling understood. My client engage in therapeutic work. Further, the
prior practice in presence primed me to silently capacity of the brain to develop new neural
imagine putting my doubts and my unresolved issues
with my mother aside for the moment. I noticed how connections leading to calmer and healthier
Michael’s distance and shutdown reflected my own emotional states is facilitated when a safe ther-
internal distancing. I invited my attention back to the apeutic environment is promoted through the
moment and was able to return with my full aware- cultivation and expression of therapists’ pres-
ness to my client. As I looked in Michael’s eyes I
reflected in a soft and warm voice, “The pain is so
ence (Allison & Rossouw, 2013; Cozolino,
deep . . . pain and regret at wishing it could have 2006; Geller & Greenberg, 2012; Porges, 2011).
been different. . . .” Michael’s tears began to well up In this vein, we view therapeutic presence
again as he looked to me and said, “yes, I feel deep and the creation of safety that it supports as a
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
I shared with Michael the sense of helplessness in the (Geller et al., 2012). Powerful in and of itself,
face of grief, and this open and compassionate sharing therapeutic presence can also promote the great-
not only allowed him to open and express his layers of est efficacy when accompanied with modality
grief and despair, but also deepened the bond between
us. (As long as therapist’s social engagement system specific techniques (Geller, 2013b; Geller &
was ‘online’, she was present and could support Mi- Greenberg, 2012). If, instead, a scripted and
chael with the appropriate cues to trigger in his ner- nonreflective response or intervention is pro-
vous system a neuroception of safety that would enable vided to clients without present awareness of
him to process his profound grief.)
the client’s in the moment experience, by a
The therapist’s present-moment awareness therapist who is detached from the humanism of
served to notice the disconnection while her the person-to-person encounter that psychother-
prior “presence practice” allowed her to self- apy entails, the client may feel defended and the
regulate (through deep breathing and aware- intervention will be limited in its efficacy. Al-
ness), put aside self doubt and unresolved is- ternatively, offering the intervention in a way
sues, and return with full open presence to the that is infused with therapeutic presence and
client. In this example, the therapist’s inward attuned to the readiness of the client, promotes
attending and contact with her experience, client’s safety and optimizes the window
which is a part of the practice of therapeutic through which effective therapeutic work can
presence, allowed her to notice her own barriers occur.
and her distancing from the client. She was then We propose that cultivating presence and un-
able to return her attention back to the client and derstanding the neurophysiological underpin-
open to the difficult feelings that he was expe- nings of creating safety needs to be an essential
riencing, both of which allowed for a repair in component in therapist training programs across
the relational disconnection. This reconnection modalities. Psychotherapy training typically fo-
invited the client back to a place of safety with cuses on intervention and techniques without
the therapist where he could then grieve fully attention to how the therapist can cultivate the
the loss of his wife. state of being present to support the client’s
neuroception of safety. We have argued here
Final Remarks that therapeutic presence is foundational to pro-
moting client’s safety, a core prerequisite for
Using empirical neurophysiological support effective therapeutic work regardless of the
provided by the polyvagal theory, it appears that therapeutic approach. As such, we also argue
feeling safe is a necessary prerequisite to estab- that understanding and cultivating therapeutic
lishing strong social bonds (i.e., a therapeutic presence should be viewed as an essential foun-
relationship), that are potentially helpful or dation in psychotherapy training. It is important
healing for a client. We propose that through for therapists to maintain a calm presence in the
present-centered relating that includes eye con- face of pain or struggle. Hence, training can
tact, softening and warmth in voice, vocal pros- include ways of supporting this state through
ody, emotional attunement and in-the-moment attention to bodily and emotional regulation as
engagement, the client perceives safety. This well as barriers to positive relating. Findings
experience of neuroception of safety eventually from neuroscience that reflect the neural corre-
shuts down the client’s defenses, which is heal- lates that occur between therapists’ presence
ing in and of itself and also helps therapist and and clients’ experience of safety can help ther-
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tapraid5/int-int/int-int/int00314/int2217d14z xppws S!1 9/5/14 7:02 Art: 2013-0154
apists understand how to promote greater ther- engagement system during sessions (i.e., vagal
apeutic attunement. regulation of the heart by quantifying the respi-
Therapist’s cultivation of presence can also ratory sinus arrhythmia component of heart rate
contribute to a necessary part of the therapist’s variability) as clients receive therapists pres-
ongoing self-care. Clients also may benefit in ence may help to illuminate the neurophysio-
and out of session with neural exercises that logical regulation and healing that present-
promote experiences of inner safety. Such neu- centered therapeutic relating can evoke.
ral exercises that promote the neuroception of
safety for both therapist and client can include
slow exhalations following deep abdominal 1
See www.rhythmandmindfulness.com.
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.2013.07.003.Epub2013Jul31 Accepted May 7, 2014 !