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By Mitch Abblett, Ph.D.
I remember him well: my first therapy patient during my graduate
school training. He was a man in his thirties with an anger control
problem. Tired of holes in their walls, the man's girlfriend told
him she would leave if he didn't get therapy. So there he sat across
from me in that first session. During that 90 minutes, I stared
down at the outline of intake questions I had painstakingly crafted.
I was nervous and clung to that clipboard as if it was a life raft.
Needless to say, my patient never came back. Was it my fault? Perhaps
not, but I did fail to make a connection with him. I failed to engage
this patient with the clinical "presence" that I believe is crucial
to effective psychotherapy.
In our training, psychologists are taught to consider the patient's
presenting problem, clinical history, current functioning, testing
results, our theoretical perspective and evidence-based techniques
and methods in designing our treatment plans. All of these things
are necessities. What seems less likely is receiving any in-depth
training in the role of our own behavior in the outcome of therapy.
Perhaps you've learned to monitor counter transference reactions,
but how much have you considered the impact of your interpersonal
behavior patterns as to whether patients make progress? Psychotherapy
is an extended, change-oriented conversation between two (or more)
people. How limiting is it to assume that the therapist's self-presentation
is irrelevant to the outcome of the conversation?
Psychotherapy process and outcome researchers (such as Lester Luborsky,
Larry Beutler and Leslie Greenberg) have provided a body of evidence
that the relationship between patient and therapist (the "therapeutic
alliance") is one of the most predictive variables for successful
therapy outcome. With the relationship being so important, what
the therapist brings to the table in terms of expectations, assumptions,
feelings and actions appears crucial.
I like to think of the therapist contribution as clinical "presence."
Any concept needs to be empirically scrutinized, but as a start,
I would say the therapist's presence is an aggregate of various
components of behavioral, emotional and cognitive skill, some more
amenable to training and change than others, but all requiring attention
and understanding.
A therapist's presence is more than charisma. Politicians, car
salespeople, pickup artists at bars and sociopathic cult leaders
all may exude charisma, but fall short when it comes to the presence
required for others to find themselves moved toward action and change.
There's an aspect of authenticity. Confidence can border on narcissism
and arrogance, but therapeutic presence results from therapists
accurately and assertively connecting their true selves with the
patient's wants, needs and perspective. It calls for empathic skill.
Authenticity is caring, reaching out, but in an assertive yet respectful
way. Here's where the Hitlers, Ted Bundys and some politicians of
the world fall short.
There are certain mechanics of presence that can be harnessed and
honed. Posture, tone of voice, use of gestures and movement are
all crucial to the impact you make on patients. Think of the distinction
between "process" and "content" and remember that people focus much
more on how you say things than what you're saying. We lose our
grip on presence by failing to use our voice and movements to convey
caring and confidence regarding a positive outcome to therapy. A
study of physicians who used a gruff, abrupt tone of voice during
their exams with patients found they were much more likely to subsequently
get sued for malpractice. Therapeutic presence? Not so much.
Presence arises from an optimistic mindset. Research has shown
the benefits of responding to adversity as though it's a bump in
the road and not the result of poor character or personal shortfalls.
We shouldn't downplay our patients' problems, but if we project
a hopeful, yet feasible vision of change, this will resonate within
therapy. When patients struggle with loss, setbacks and failure,
our ability to confidently, yet compassionately, reframe the situation
toward adaptive changes is key.
There's an aspect of spontaneity; that presence is rooted in aliveness
in the moment and creative production. Many of us fall short here.
Perhaps we were trained to give patients a "blank slate"; that any
spontaneous self-disclosure is dangerous. While there are hazards
to excessive and thoughtless self-expression, it's also important
to know that therapists self-disclose whether they want to or not.
Our inability to control every nonverbal behavior makes this the
case. Humor is an avenue to spontaneity that can create aliveness
and increase a therapist's presence and impact. The data suggests
that we're drawn to others' use of humor because it eases our anxiety
and uncertainty in social situations and it helps us see the world
differently. Humor has been repeatedly linked to positive, healing
outcomes. It can go a long way to strengthening the bond of the
therapy relationship. We need to be thoughtful about our self-expressions
in therapy, but we shouldn't be overly rigid either.
Across all the presence skill domains, there is a necessity of
timing; that the clinician did or said exactly what the moment required.
Based on your intensive assessment of your patients, you learn when
to project confidence and when a more compassionate tone is required.
When do you nudge a patient to use a cognitive-behavioral change
strategy and when do you give them emotional space to express their
distress? Using supervision to fine tune one's intervention timing
appears important to developing clinical presence.
Much like a fire, clinical presence is the coming together of spark
and fuel in the proper atmosphere. It builds and spreads when conditions
are right, dissipates when they are not. Authenticity, mechanics,
optimistic mindset, spontaneity, timing, and a receptive patient
are the raw ingredients. Progress in treatment is the final product.
I wish I could go back in time to that first patient. If so, I'd
set the clipboard aside.
Mitch R. Abblett, Ph.D., is clinical director of Manville School,
Judge Baker Children's Center in Boston, Mass.
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