Presence: The Core Contextual Factor of Effective Psychotherapy

Abstract

This article proposes that presence is the core contextual factor of therapeutic effectiveness. Presence is defined as a complex mix of appreciative openness, concerted engagement, support, and expressiveness, and it both holds and illuminates that which is palpably significant within the client and between client and therapist. While the therapeutic alliance, empathy, collaboration, and the provision of meaning and hope have been established as primary contextual factors in the facilitation of effective therapy, this article contends that presence is at their hub. Given that position, it is concluded that although presence is viewed favorably by leading practitioners, there are two major problems with how presence is actually being engaged: The first problem is the way some practitioners are " using " or " performing " presence rather than cultivating it as a therapeutic stance, and the second problem is how the training of therapists is becoming increasingly technical at the very time when the research (informing such training) is becoming contextual, relational, and nontechnical.

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Presence: The Core Contextual Factor of Effective Psychotherapy
[Existential Analysis, 26.2 (pp. 304-312) Copyright, July, 2015,
Society for Existential Analysis. This article is a draft that may not fully reflect the
published article of record.]
Abstract
This article proposes that presence is the core contextual factor of therapeutic
effectiveness. Presence is defined as a complex mix of appreciative openness, concerted
engagement, support, and expressiveness, and it both holds and illuminates that which is
palpably significant within the client and between client and therapist. While the
therapeutic alliance, empathy, collaboration, and the provision of meaning and hope have
been established as primary contextual factors in the facilitation of effective therapy, this
article contends that presence is at their hub. Given that position, it is concluded that
although presence is viewed favorably by leading practitioners, there are two major
problems with how presence is actually being engaged: The first problem is the way
some practitioners are “using” or “performing” presence rather than cultivating it as a
therapeutic stance, and the second problem is how the training of therapists is becoming
increasingly technical at the very time when the research (informing such training) is
becoming contextual, relational, and nontechnical.

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Introduction
The cultivation of presence is key to therapeutic healing. We’ve relied too long on the
verbal and procedural aspects of therapy, all the while overlooking the organic hub of
formally identified therapeutic factors (Geller & Greenberg, 2012; Schneider, 2008;
Schneider & Krug, 2010).
Presence is a potent yet highly delicate form of communication that has been
fostered for decades by existential-humanistic approaches to therapy (Elkins, 2007). It
has also been nurtured by many of the most masterful therapists—regardless of
orientation (Geller & Greenberg, 2012; Wampold, 2006 ). In this light, I contend that
presence is at the core of the so called contextual factors research (Wampold, 2006),
arguably, the most authoritative research on therapeutic effectiveness (Elkins, 2012).
This research shows that contextual (or “common”) factors account for far more of the
variance than techniques in the facilitation of effective psychotherapy, and that despite
decades of conventional thinking, it is the “nonspecific,” atmospheric, contextual factors
that demand our focus.
Among these factors are the therapeutic alliance (bond), empathy, capacity for
collaboration, and provision of meaning and hope (Elkins, 2012; Wampold, 2008). But
equally important, I contend, is that at the fount of each of these factors is presence.
Presence is a complex mix of appreciative openness, concerted engagement, support,
and expressiveness (Bugental, 1987; May, 1983). Furthermore, presence performs both a
holding, that is, containing function and an illuminating, that is, exploratory function; it
both holds and illuminates that which is palpably significant within clients and between
therapists and clients (Schneider, 2008). Hence if we look at each of the identified

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contextual factors, we can see vividly how presence is at their crux. Presence informs the
therapeutic alliance, for example, through the communication of attention, concern,
support, and availability. It is hard to imagine that clients can feel allied with their
therapists if their therapists do not embody (as distinct from merely enact) these above
qualities. Further, it is hard to imagine the salutary effects of such an alliance, such as the
sense of safety, of openness to disclosure, and of support for exploration, without the
steadfastness of abounding presence.
The appreciative openness, concerted engagement, support, and expressiveness
dimensions of presence are also key to the provision of empathy, collaboration, meaning,
and hope. Again, it is difficult to conceive of these latter offerings without the foundation
of presence.
Presence differs from related concepts like rapport and mindfulness. It differs
from rapport in that it refers to more than simple “harmony” or “accord” with another
person. While it certainly can include those dimensions, presence embraces a much
fuller and richer range of elements that may include a degree of discord and discomfort
with another person. The issue is not the degree of tranquility or even necessarily
agreeability within the therapeutic frame, but the sense that one is “there” for another,
appreciative of the opportunity, and available to work it through. Presence differs from
traditional concepts of mindfulness on several counts. First, it expands on the traditional
emphasis of mindfulness (or appreciative openness) within individuals to mindfulness (or
appreciative openness) within relationships. Second, presence, unlike traditional notions
of mindfulness, does not necessarily develop out of a specific set of religious or spiritual
practices; by contrast presence can evolve from a variety of secular experiences such as

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personal struggle, profound interpersonal relationships, reflective and philosophical
education, and depth psychotherapy. Furthermore, unlike conventional mindfulness,
presence does not concertedly aim to dissolve the identity of self (if that is even
achievable), but to expand, deepen, and redefine the identity of self. Finally, unlike
conventional conceptions of mindfulness, presence aims to coexist with and integrate not
necessarily detach from suffering. This latter tenet has key implications for therapy,
because if the aim is to coexist with as distinct from detach from or “pass through”
dysphoric states then there may be more room to linger over, struggle with, and even
potentially benefit from the experience of those states. To be clear, nothing that I say
here about presence precludes the incorporation of mindfulness practice—or
philosophy—within its purview. Indeed, in my view, mindfulness practice is a form of
presence. However, what is at issue here is whether the practice is applied in the context
of a living, evolving relationship, or as a more or less isolated technique with strictly
proscribed aims. (See Geller and Greenberg, 2012 for an elaboration on several of the
above points).
The Current Threats to Therapeutic Presence
Perhaps the chief threat to therapeutic presence today is the attempt to relegate it
to a technique. This tendency can be seen in the so called evidence-based practice
movement as well as in some formulations of mindfulness as a component of effective
treatment. In the evidence-based practice movement, presence is too often viewed as
something one performs in order to comply with quantitatively determined protocols.
However, as Kriz and Langle (2012, p. 476) point out there is a striking difference

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between “making use of” humanistic applications of presence and “being” and
embodying those applications. They provide the following vignette to illustrate:
(a) the therapist is trained to behave according to a manual to give
(preformulated) remarks of understanding toward a client (e.g., verbalizing
understanding words and performing understanding gestures) and (b) the
therapist genuinely has the sensitivity to and experience of understanding and
expresses his or her own feelings. (p. 476)
“Accordingly,” the authors “insist on the difference between a therapist (a) behaving as if
he or she can be understanding and (b) being understanding (p. 476).
On the other hand, even theorists such as Steven Hayes (2012) who are supportive
of the centrality of therapeutic presence insist that it must be a “manipulable” variable.
He states that to optimize therapeutic effectiveness psychological science will need to
“formulate rules about how to manage experiential processes. For example
[psychological science] may have to operationalize the training that gives rise to
sensitivity to experiential processes and show experimentally that this training
matters”(p. 463). He goes on to explain “that clinicians can then be taught how best to
establish strong working alliances, which means that the manipulable aspects of the
therapeutic relationship need to be known” (p. 463).
John Norcross, another exponent of the necessity for therapeutic presence, also,
like Hayes, argues for its experimental manipulability. He bases his approach on the
“transtheoretical model” of client-therapy matching (Prochaska & Norcross, 2009),
which pairs empirically supported therapeutic strategies, e.g., relationship-building or

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psychodynamic exploration, with client stages of readiness, such as those of
precontemplation or preparation (Schneider, 2013).
The problem with these “evidenced based” approaches in my view however is
that they can become wooden, contrived, and appropriate to data, but not necessarily the
living, breathing individual sitting across from one.1 The cultivation of presence, in other
words, just as with any of its offshoots, such as empathy, become reducible to in-session
enactments, rather than the experiential, organically cultivated stances that appear to
endure (e.g., see Shedler, 2010). Such stances are not merely learned from a data base,
but through hard-won personal and supervisory experience, through much that one
experiences outside of the classroom, and through exposure to rich experiences of living.
It is no accident in this vein that a recent study in Science showed that concerted exposure
to literary fiction (as distinct from popular fiction, nonfiction, and no reading) promoted
enhanced capacities for imagination, sensitivity to others, and attunement to others’
subtle emotional expressions (Comer, Kidd, & Castano, 2013).
Presence as a Personal Cultivation
While contextual or common factors theory initially emerged through the failure
of techniques to correlate with therapeutic effectiveness (Wampold, 2001), this finding
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1I want to be clear that my concern about basing therapeutic presence and other
contextual factors on essentially experimental evidence does not mean that practitioners
who prioritize such evidence are wooden or mechanistic in their approach to clients.
Quite the contrary in many instances; however, my contention is that their present-
centeredness when optimized is probably not the result of their efforts to directly
replicate experimental research findings, but is the result of a rich and complex
cultivation that is in many ways incidental to and quite likely superior over such
replication, and that this is in fact what is borne out by the contextual factors research on
therapeutic outcome.
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has morphed in recent years into a recognition that personal dimensions of therapy are
most salient. The contemporary literature is replete with this shift in emphasis (see
Bohart & Tallman, 2010; Duncan, 2015; Norcross & Lambert, 2011; Wampold, 2006).
In my view, Wampold and others who developed the contextual factors theory of
therapeutic effectiveness are now advocating that the factors should be cultivated,
integrated with existing clinical knowledge, and personally engaged; not on the basis that
they should be performed, enacted, or mechanically manipulated. We are moving
headlong into an efficiency oriented, quick fix, and appearance oriented society.
Virtually everything we have learned from the depth psychologies over the last one
hundred years raises alarming questions over these contemporary developments. People
learn least about themselves when they are hurried, when they multitask, and when they
are consumed by pat or simplistic formulae (Carr, 2011). They learn most on the other
hand, when they are sensitively heard, when they can explore, and when they can open to
their most intimate desires (May, 1981; Yanchar, Spackman, & Faulconer, 2013). Is this
not what a substantive therapy should provide? Why would we support a therapy that
recapitulates the very problems that bring many people into therapy in the first place—
the wooden, the mechanical, and the manipulated? Why not devise a science that can
distinguish “best practices,” that is a contextually centered, intimate point of view from
an “exacting,” aggregated point of view? This is a point of view that mindfully blends
quantitative and qualitative research with long term, in depth training; personal training
that emulates a mentorship model and that betokens the intimacy and discernment of an
optimal therapeutic relationship.

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Consider the recent findings of Fauth, Vinca, Gates, Boles, & Hayes (2007). In a
comprehensive review of the psychotherapy training literature they concluded that
“traditional psychotherapy training practices which emphasize didactic teaching methods,
adherence to manual-guided techniques, and/or applications of theory to clinical work via
supervised training cases, do not durably improve the effectiveness of psychotherapy” (p.
384). They went on highlight the “heretofore overlooked organizational/treatment
culture in the ultimate success of psychotherapy training,” and demonstrated how this
culture can be enhanced through the development of present-centered skills. These skills
consist in what they call (1) “responsiveness,” or the capacity of clinicians to “recognize,
attend, and empathically respond to clients’ needs , as expressed implicitly or explicitly
within the psychotherapy session;” (2) “pattern recognition,” or the expansion of the
capacity to “respond to the most important events and experiences within a given
psychotherapy session;” and (3) “mindfulness,” or the deepening of “moment-to-moment
awareness and acceptance of one’s experience” (pp. 385-386). To facilitate these
capacities, the researchers recommended a training environment that shifts from an
emphasis on didactic-verbal learning to one that stresses individual and social (or
“comindful”) meditation practices, role play exercises, and critical observation of video
demonstrations (pp. 386-387).
The researchers summarize: “we propose that future psychotherapy training focus
on a few “big ideas,” such as therapeutic responsiveness;..the development of
psychotherapist meta-cognitive skills (i.e., pattern recognition and mindfulness) via
experiential practice and constructive feedback, and [close attention] to the
organizational/treatment context” (pp. 389-390).

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The findings of these more traditional researchers have been powerfully affirmed by an
emerging set of qualitative investigations. Arguably, these qualitative inquiries are superior
to the quantitative at articulating the power of therapeutic presence to affect the entire
therapeutic enterprise. This was certainly the point of view of Geller and Greenberg (2012),
who made a strong case for presence as a core dimension of practice.
Drawing from a qualitative study they did in 2002 as the centerpiece of their formidable
research on therapeutic presence they elaborate four dimensions that are key to therapeutic
presence—“the sense of being grounded, which includes feeling centered, steady, and
integrated inside one’s own body and self;” the sense of being immersed “in the moment
with the client;” the sense of “spaciousness or an expansion of awareness and sensation
while being tuned into the many nuances that exist at any given moment with the client;”
and the sense of “intention for presence to be with and for the client’s healing process” (p.
109).
Geller and Greenberg go on to consider the implications for training such therapeutic
presence and conclude:
Training…needs to include relational practices (e.g., group drumming, relational
mindfulness) to help therapists remove the barriers to meeting another with
presence as well as to deepen the ability to be fully open with another while in
contact with their own experience, the foundation for relating with presence.
Rather than minimizing the value of intervention, we are strongly
suggesting that the cultivation of therapeutic presence of the person and his or
her personal growth should be an equal adjunct in psychotherapy training and can

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enhance the efficacy of therapeutic technique. It is essential to balance the doing
mode of therapy with the being mode for greatest efficacy in the client’s
healing.” (p. 260)
Finally, a qualitative study by Pierson et al. (2015) relates how presence was
key to the experience of an existential-humanistic therapy training program conducted by
the Existential-Humanistic Institute located in San Francisco. An “overarching
assumption” of the program “is that it is the client’s in-the-moment-experiencing that
forms both the underlying and the actual process in therapy” (p. 644). This assumption, in
turn, led to the corollary emphasis on trainee attunement to “process,” that is,
preverbal/kinesthetic dimensions of practice, as much if not more than “content,” or
verbal/analytical dimensions. Trainees engaged this process emphasis through a “mix of
didactic presentations, relevant videos, faculty demonstrations, experiential exercises, and
role play practice” (p. 644).
Citing the survey data compiled by Krug and Piwowarsky concerning trainees’
experience with the program, the authors note that five major themes emerged: (1) the
enhancement of trainees’ relationships to the unknown; (2) the enhancement of trainees’
personal growth and shifts in personal identity; (3) the incorporation of trainees’ skills into
their professional environments; (4) the deepening of trainees’ relationships with
existential-humanistic concepts, from a “dryer, more theoretical knowing to a livelier,
embodied kind of knowing; and (5) a striking degree of trainee appreciation for the
“personal touch” of the training environment.

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Some of the trainee comments that were gathered included: “The awareness of how
much more growth I have ahead is no longer intimidating, and I am more willing to take
risks;” and “I think I have…dropped some of my own protections….My heart is
more open;” and “It would not be a stretch to say I am a completely different person than I
was before…more secure, present, willing, and mostly alive;” and finally “The [trainings]
were reflections of true encounters among like-minded people…willing to relate to one
another at a much deeper level” (pp. 646-647).
In a special issue of the APA journal Psychotherapy, eight leaders from
diverse areas of therapeutic practice—including the aforementioned Stephen Hayes
concluded that “the authentic personal relationship is fundamental to effective practice”
(Schneider & Langle, 2012, p. 481). They also went on to suggest that the enhancement of
therapeutic presence is dependent upon “the person of the therapist….
This means that not only should training focus on the cultivation of personal
skills, such as empathic listening and forming an alliance, but it should also
concentrate on the therapist’s own life, his or her own emotional and intellectual
growth and his or her own responsiveness to clients’ needs. These elements may
be stimulated by relevant reflections on psychology, culture, and the arts, but they
may also be explored by personal therapy, meditation, and experiential exercises
(e.g., dyadic role play). The intent here should be on helping trainees to become
well-rounded (engaging-empathic) people, not just competent technicians (p.
481).

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What these reformers of training advocate for then is a renewed focus on
presence, the core of effective therapy, and an abiding focus on the experiential skills
required to facilitate such presence, both in the instructor and in the student. They
advocate for a fresh focus on process as distinct from content-rich emphases in
conventional clinical training programs; and they encourage a revamping of the
cognitive-behavioral hegemony in clinical graduate education (see also Levy &
Anderson, 2013).
To put it more squarely, it is simply unconscionable that a profession that prides
itself on fidelity to its own research persistently countermands that research with its
support of clinical graduate programs that emphasize technically driven, formulaic
curricula (see Heatherington et al, 2013). I understand perhaps the political and economic
bases for that support, but this should not prevent us as a profession from taking stands
that accurately reflect the research—and in this case, the research compels a major shift
in emphasis toward humanistically and relationally oriented training.
Let me conclude then where I began: The cultivation of presence is integral to the
contextual factors associated with effective psychotherapy; the current emphases on the
verbal and procedural aspects of therapy, while notable, are secondary; finally, the
optimization of presence is neither “performed” nor “enacted.” It is lived.

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