March 29, 2011
David Fawcett, Ph.D., L.C.S.W., is a substance abuse expert, certified sex therapist and clinical hypnotherapist in private practice in Ft. Lauderdale, Fla.
When I was going through clinical supervision before licensure, my mentor pointed out that one's particular therapeutic modality, be it cognitive, behavioral, psychodynamic, Gestalt or whatever, is often not as important for good clinical results as simply being present with the patient. Because at that time I was very focused on mastery of particular skills, I was somewhat incredulous. But I have since come to understand that beneath good technique there is indeed a realm of energetic exchange with a patient that is often non-verbal and that has great power for healing. I call it being present at both physical and emotional levels.
This has become most obvious for me in doing heart-centered hypnotherapy, which is basically psychotherapy while the patient is in regression. It is powerful and challenging for both the patient and therapist, because deep emotions are released, which can easily trigger strong reactions. It is essential, therefore, for the therapist to know himself or herself and to be able to remain emotionally present for the patient during this work. The therapist needs to remain a constant, grounding force and contain the patient's psychic energy while the patient is in this vulnerable state.
I believe the ability to remain present and engaged has powerful application in any kind of health care provider/patient relationship. People need to know that they are safe, being heard and, hopefully, being understood as well. In some cases there may not be an easy (or any) solution for a clinical problem, but the experience of expressing feelings and having someone genuinely receive that message, even if no solutions are forthcoming, is empowering.
Patients are sensitive to this dynamic. I work extensively with gay men who have experienced multiple stigmas: homosexuality, being HIV positive, and frequently, addictions. Many others also have a significant history of trauma and emotional, physical, or sexual abuse. A lifetime of hypervigilence, in which mind and body remain exquisitely alert to potential danger, has gifted them with a highly developed skill for reading the non-verbal, energetic exchange in the room, particularly with regard to shame. A health care worker's ability to avoid distractions and simply be emotionally present with the patient can, by itself, be therapeutic, because it provides, at its most basic, a human connection that may be the only such meaningful interaction that person experiences that day or that week.
This awareness of a consistent presence relates to several other concepts that have found their way into traditional psychotherapy from the study of mindfulness, a calm awareness of one's body, feelings, and consciousness. One of them is curiosity, which can be defined as a playful interest in what one notices while being mindful. Actively engaging curiosity while speaking with a patient frequently not only reveals relevant data for the clinical concern, but also conveys a meaningful human interest and models a technique that can be used by the patients themselves to improve insight and gain awareness.
A second concept is acceptance, which involves acknowledging and accepting the presence of problematic difficulties, struggles, or symptoms and thereby improving chances of gaining some mastery over them. A clinician has ample opportunities to work with a patient at such acceptance, not necessarily to surrender to the problem or symptom, but rather to assist the person in moving past a reactive struggle and clarifying the real issues or concerns that need to be addressed.
At a deeper level, the clinician can also employ acceptance to reinforce his or her emotional presence in the encounter. With heavy caseloads and chronic illness, it can be easy to objectify and categorize patients as a set of symptoms or diagnoses. Practicing acceptance of, as well as curiosity about, that patient in front of you can keep the experience grounded in a way that not only benefits the health of patient, but the satisfaction and resilience of you as the clinician.
I facilitate a gay men's drop-in group each week that focuses on a variety of topics. Over time, I have realized that whatever the subject matter on a given night, the benefit for the attendees is not the particular knowledge or information I present, no matter how fascinating or wonderful my delivery might be. Rather, the benefit is an opportunity to interact with each other with laughter and tears and genuine caring. I focus simply on being present and engaged, sometimes with provocative curiosity and sometimes just acceptance alone, and never fail to be impressed by the hearts and wisdom of those men.
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