1 CHOOSING TO BE PRESENT AS COUNSELORS IN TRAINING: A GROUNDED THEORY By CHRIST INA TANNEN A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2009
2 2009 Christ ina Tannen
3 To Tyler, Cody, and Camilla
4 ACKNOWLEDGMENTS I am grateful for the support and inspiration given me by colleagues, mentors, friends and family. In addition, the support of the Presidential Fellowship awarded by the University of Florida enabled me to give my full attention to my doctoral program I want to acknowledge Dr. Harry Daniels, the Chair of my doctoral committee and a valued mentor. He has been a key sounding board and guide from the moment that being present was simply a personal fascination and through the many ways in which my ideas took form in the process of completing this dissertation. Dr. Daniels helped me develop my voice. He gave credence to my ideas which helped me not abandon them. When I thought my creative well had run dry our conversation stimulated new thinking. He often brought me back to my heart when I was afraid and went to my head. Dr. Mirka Koro -Ljungberg intro duced me to the world of qualitative research and expanded my understanding of post modern approaches to creating knowledge. She basically blew my mind. Dr. Mirka demonstrates a plasticity in her thinking as she can interpret from multiple theoretical pe rspectives, able to switch from one to another with clarity and apparent ease. Dr. Mirkas incisive questions and pithy statements guided me thought what seemed like a confusing sea of philosophical arguments. w ith all of her intellectual prowess, she al so showed herself to me as a whole person which made navigating these difficult waters seem more doable for me. I want to acknowledge the other members of my doctoral committee, Dr. Peter Sherrard, Dr. Sondra Smith, and Dr. Joseli Macedo for their encouragement and direction. Their questions and suggestions invigorated my work. Each of these people inspired me : Dr. Sherrard with his attention to meaning, process, and spirit, Dr. Smith with her zest for understanding and for jazzing her students to creativ ely engage with their own interests, and Dr. Macedo for her
5 eagerness to reach beyond her discipline to enrich my work and her own. I appreciated the lively conversations we had at key points in the dissertation process. I acknowledge Dr. Pat Korb for her contributions to my personal, academic, and professional life. I am thankful for her presence in my life. My encounters with Pat were my first experiences of powerful moments of connection in counseling and were the source of my fascination with being pr esent. She introduced me to Gestalt therapy which intersected with my experience in Buddhism and formed the theoretical and phenomenological basis for the topic of this study. My conversations with Dr. Michael Murphy while interning at the University of Florida Counseling Center revealed our common interest in mindfulness practice and clinical training for counselors. He provided encouragement for my study and arranged his schedule so he could lead the mindfulness meditation training group for the parti cipants in this study. I am grateful for his deep understanding of Buddhism, psychology, and training as well as for his generosity in sharing and exploring ideas with me. My parents value for education and their intellectual curiosity inspired a love o f learning that fueled this inquiry. They instilled in me a sense of commitment and drive that were necessary to my seeing this project to completion. I thank them for their unlimited confidence in my ability. My siblings, Marsha, Steven, and Lisa, and t heir spouses listened to innumerable conversations and complaints about my dissertation with great patience and I appreciate them for their optimism, reassurance, and of course, humor. My thanks go to my other family too, my friends. I thank Dena for phon e calls and beach trips and early morning coffee sessions that helped me stay connected to what is important in my life. Our friendship has thrived over 35 years and fertilizes my being on every level. I thank
6 Harriet for checking on me and sending me love and confidence over so many years. I thank Debbi and Dena for Friday afternoons that fed my heart and soul. I thank the yoga women for keeping me loose and feeling loved. Feeling known and loved by my family and friends allowed me to withstand and grow through significant changes in my life while continuing to work on this dissertation. Finally, I want to express my gratitude to my children, Tyler, Cody, and Camilla Tannen Barrup. They have taught me to love more deeply and to see myself more clearly, both fundamental aspects of being present
7 TABLE OF CONTENTS page ACKNOWLEDGMENTS .................................................................................................................... 4 LIST OF TABLES .............................................................................................................................. 11 LIST OF FIGURES ............................................................................................................................ 12 LIST OF TERMS ............................................................................................................................... 13 ABSTRACT ........................................................................................................................................ 17 CH A P T E R 1 INTRODUCTION ....................................................................................................................... 19 Overview ...................................................................................................................................... 19 The Therapist ....................................................................................................................... 19 The Therapeutic Relationship ............................................................................................. 23 Therapeutic Presence ........................................................................................................... 26 The Problem ................................................................................................................................ 30 Theoretical Foundations ............................................................................................................. 30 Constructivism ..................................................................................................................... 31 Phe nomenology ................................................................................................................... 31 Existentialism ....................................................................................................................... 32 Gestalt ................................................................................................................................... 32 Buddhism ............................................................................................................................. 33 Counselor Development ...................................................................................................... 34 Summary .............................................................................................................................. 36 Significance of Study .................................................................................................................. 36 2 LITERATURE REVIEW ........................................................................................................... 39 Therapeutic Effectiveness and Common Factors ...................................................................... 39 The Therapeutic Relationship ..................................................................................................... 40 Theories and Models ........................................................................................................... 40 Measurement ........................................................................................................................ 47 Client Characteristics and the Relationsh ip ....................................................................... 49 Summary .............................................................................................................................. 50 Therapist Characteristics and Development .............................................................................. 51 Therapist Characteristics ..................................................................................................... 51 Counselor Development ...................................................................................................... 54 Presence ....................................................................................................................................... 59 Presence: Conceptual Literature ......................................................................................... 60 Empirical Studies of Presence ............................................................................................ 64 Mindfulness Meditation .............................................................................................................. 71
8 3 METHODOLOGY ...................................................................................................................... 80 Overview ...................................................................................................................................... 80 Constructivist Theoretical Perspective ...................................................................................... 80 Purpose and Res earch Questions ................................................................................................ 82 Participants and Sampling .......................................................................................................... 82 Data Collection ............................................................................................................................ 89 Data Analysis ............................................................................................................................... 91 Overview of Grounded Theory ........................................................................................... 91 Data Analysis in This Study ................................................................................................ 94 Trustworthiness ......................................................................................................................... 100 Subjectivity Statement .............................................................................................................. 105 4 FINDINGS ................................................................................................................................. 108 Introduction ............................................................................................................................... 108 Overview of the Theory ............................................................................................................ 111 Being Present ............................................................................................................................. 114 Being Aware ...................................................................................................................... 115 Attending Inwardly and Outwardly .................................................................................. 117 Beginners Mind ................................................................................................................ 119 Trusting Self and Process/Letting Go ............................................................................... 120 Accepting Self, O ther, and What Is .................................................................................. 122 Staying With What Is ........................................................................................................ 124 Being Right Here in the Moment ...................................................................................... 125 Being Human/Being Authentic ......................................................................................... 126 Contexts Facilitating or Inhibiting Being Present ................................................................... 128 Being a Beginning Counselor ........................................................................................... 128 Navigating Conflicting Paradigms ................................................................................... 130 Academic Context ............................................................................................................. 132 Drawing on Spiritual, Theoretical, an d Family Support for Being Present ................... 133 Counseling Context Influencing Being Present ............................................................... 135 Acting to Contain Anxiety and Uncertainty ............................................................................ 137 Avoiding ............................................................................................................................. 137 Distracting .......................................................................................................................... 138 Controlling ......................................................................................................................... 140 Managing Image as Counselors ........................................................................................ 141 Awakening to Choices .............................................................................................................. 142 Distinguishing Being Present ............................................................................................ 143 Experiential Knowing ........................................................................................................ 145 Coming to Know Oneself .................................................................................................. 147 Recognizing Having a Choice .......................................................................................... 148 Choosing to Be More Prese nt ................................................................................................... 149 Taking a Stand on Being Present ...................................................................................... 150 Risking................................................................................................................................ 151 Weighing the Costs and Benefits of Being Present ......................................................... 153
9 Stepp ing Out of the Normal Way ..................................................................................... 155 Fostering, Cultivating ........................................................................................................ 157 Experiencing the Outcomes of Being Present and of Containing Anxiety and Uncertainty ............................................................................................................................. 161 Experiencing the Outcomes of Containing Anxiety and Uncertainty ................................... 162 Disconnecting .................................................................................................................... 162 Not Being Authentic .......................................................................................................... 163 Missing Therapeutic Opportunities .................................................................................. 164 Feeling Safe ........................................................................................................................ 165 Socially Acceptable ........................................................................................................... 166 Experiencing the Outcomes of Being Present ......................................................................... 167 Building Tolerance for Discomfort .................................................................................. 167 Counselor Feeling at Peace ............................................................................................... 169 Sustaining Counselor in Work .......................................................................................... 170 Being Better Instrument o f Therapeutic Process ............................................................. 171 Amplifying Connection ..................................................................................................... 173 Counseling in the Present Moment ................................................................................... 176 Facilitating Therapeu tic Process ....................................................................................... 179 Interpretation of the Theory ...................................................................................................... 181 Chapter Summary ...................................................................................................................... 192 5 CONCLUSION, IMPLICATIONS, AND FUTURE RESEARCH RECOMMENDATIONS .......................................................................................................... 194 Summary .................................................................................................................................... 194 Implications for Counselor Preparation and Practice ............................................................. 196 Implications for Theory ............................................................................................................ 204 Implications for Policy .............................................................................................................. 210 Limitations ................................................................................................................................. 214 Future Research Recommendations ......................................................................................... 218 Conclusion ................................................................................................................................. 221 APPENDIX A ALACHUA COUNTY CRISIS CENTER CLINICAL EXPERIENCE ............................... 223 B PRACT ICUM AND INTERNSHIP FIELD EXPERIENCES IN COUNSELOR EDUCATION ............................................................................................................................ 225 C PRACTICUM AND INTERNSHIP FIELD EXPERIENCES IN COUNSELING PSYCHOLO GY ........................................................................................................................ 227 D LISTSERV RECRUITMENT MESSAGE ............................................................................. 229 E INTERVIEW GUIDES ............................................................................................................. 230 F INFORMED CONSENT .......................................................................................................... 233
10 G DATA COLLECTION timeline ............................................................................................... 237 H MINDFULNESS MEDITATION GROUP ............................................................................. 238 I MINDFULNESS MEDITATION TRAINER VITA.............................................................. 250 J CODING TRAIL ....................................................................................................................... 259 K SAMPLE MEMOS ................................................................................................................... 266 LIST OF REFERENCES ................................................................................................................. 272 BIOGRAPHICAL SKETCH ........................................................................................................... 288
11 LIST OF TABLES Table page 3 1 Participant Demographics ...................................................................................................... 88 3 2 Elements of the Data Analysis Process ............................................................................... 100 4 1 Comparison of Prevailing Sociocultural Paradigm and the Alternative Paradigm of Being Present ........................................................................................................................ 185 H 1 Mindfulness Meditation Group Session 1 .......................................................................... 239 H 2 Mindfulness Me ditation Group Session 2 .......................................................................... 241 H 3 Mindfulness Meditation Group Session 3 .......................................................................... 242 H 4 Mindfulness Meditation Group Session 4 .......................................................................... 243 H 5 Mindfulness Meditation Group Session 5 .......................................................................... 244 H 6 Mindfulness Meditation Group Session 6 .......................................................................... 245 H 7 Mindfulness Meditation Group Session 7 .......................................................................... 247 H 8 Mindfulness Meditation Group Session 8 .......................................................................... 249
12 LIST OF FIGURES Figure page 4 1 Theoretical model: Choosing to be present as counselors in training .............................. 110
13 LIST OF TERMS Beginners mind Having an open mind, coming to experience as if for the first time. In the beginner's mind there are many possibilities, in the expert's m ind there are few (Suzuki, 1973). Being present Being all there in body, mind, and spirit in direct contact with the environment or person in moment to -moment felt experience. For the purposes of this study being present will be assumed to refer to therapists being present in the context of counseling. Buddhism A spiritual tradition in which enlightenment may be obtained through mindfulness meditative practices. Enlightenment means one has achieved direct knowledge and experience of well -being, happiness, and freedom from suffering. CIT Counselor in training. Client factors Factors that contribute to therapeutic outcome that include what clients bring to the therapy session and what influences their lives outside the therapy sessions, i.e. strengths, supportive elements in their environment (Hubble, Duncan, & Miller, 1999). Common factors Four factors that account for variance in therapeutic outcome: (1) client factors; (2) relationship factors; (3) hope, expectancy or placebo factors, and (4) technique factors (Hubble, Duncan, & Miller, 1999; Lambert, 1992). Concentration Concentration meditations train participants to focus on a single point, meditation such as a word (e.g., a mantra), sound, object, or sensation. (Kabat Zinn, Massion, Hebert, & Rosenbaum, 2002Constructivism : A theoretical orientation based on the following assumptions: The perspective of the observer and the object of observation are inseparable; the nature of meaning is relative; phenomena are context -based; and the process of knowledge and understanding is social, inductive, hermeneutical, and qualitative (Gergen, 1985) (Sexton, 1997, p. 8). Contact Contact in Gestalt therapy theory means being mindful of current reality at the boundary between me and not -me (Yontef, 1995). There may be contact bet ween a person and the environment that is not good, meaning the person is not mindful or there is something interfering with good contact. This is the focus of therapy in Gestalt therapy. Defense mechanisms are identified that get in the way of good cont act. There is also a healthy need to withdraw from contact. A cycling between contact and withdrawal is part of healthy functioning.
14 Counselor While counselor development model s (Loganbill, Hardy & Delworth, d evelopment 1982; Stoltenberg, McNeill, & D elworth, 1998) map development over the course of training and perhaps into early years of practice, the concept of counselor development used in this study also includes continued growth toward becoming a master therapist (Goh, 2005; Jennings, Sovereign, Bottorff, Mussell, & Vye, 2005; Jennings, Goh, Skovholt, Hanson, & Banerjee -Stevens, 2003). Counselors in Individuals enrolled in university graduate programs in either counselor t raining (CITs) education or counseling psychology. Criterion s ampling Including participants in a study based on their meeting some pre established criterion or criteria. (Kuzel, 1992) Embodied knowing The mind is not separate from the body. All conceptual understanding of the world is grounded in the bodys perceptual and motor systems. Truth and knowledge depend on embodied understanding ( Lakoff & Johnson, 1999, p. 555). Existentialism A philosophical and theoretical orientation that emphasizes four givens of existence: meaninglessness, isolation, freedom, and death. With this comes an emphasis on personal responsibility and authentic living in the world. Gestalt An existential, phenomenological, experiential, and experimental approach to psychotherapy and theory of change that emphasizes contact, self -support, here a nd now awareness, and respect. Hope/expectancy/ Factors that contribute to therapeutic outcome that include p lacebo f actors clients confidence in therapy and the therapist (Hubble, Duncan, & Miller, 1999). Implicit knowing . non -symbolic, nonverba l, procedural, and unconscious in the sense of not being reflectively conscious (Stern, 2004, p. 113). It is what we know before we are conscious of knowing it. Intersubjective Between two people; in contrast to intrasubjective, within one person. Master therapist A therapist considered an expert in psychotherapy by colleagues and by virtue of a record of positive therapeutic outcomes.
15 Meaning An interpreted goal, intent, purpose, or significance of a thing, event, relationship, or person. Meanin g, as used in the constructivist orientation of this study, is the understanding or sense an individual makes of his/her experience and the objects in his/her world. Meta analysis Quantitative statistical analysis that is applied to separate but similar e xperiments of different and usually independent researchers and that involves pooling the data and using the pooled data to test the effectiveness of the results. (Merriam Websters Dictionary) Mindfulness An operational working definition of mindfulne ss is: the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment (Kabat Zinn, 2003, p. 145). Mindfulness . highly refined practices aimed at systematica lly training and m editation cultivating various aspects of mind and heart via the faculty of mindfulness (Kabat Zinn, 2003, p. 145) which is done by (1) observing, noticing, bringing awareness; (2) describing, labeling, noting; and (3) participating. (1) nonjudgmentally, with acceptance, allowing;(2) in the present moment, with beginners mind; and (3) effectively (Dimidjian & Linehan, 2003, p. 166). Novice counselor A counselor within the first two or so years of training and clinical experience. P erson -centered A therapeutic approach developed by Carl Rogers that holds that people tend toward becoming fully functioning and emphasizes the therapists way of being rather than a set of techniques. Rogers identified six necessary and sufficient condit ions for therapeutic change which include therapist empathy, congruence and unconditional positive regard (Rogers, 1957). Phenomenology A philosophical and theoretical orientation that maintains that in direct experience of objects (people or the environme nt) through the senses and setting aside prevailing understandings of those phenomena people have the possibility for new understanding or meaning to emerge or to confirm existing meaning or understanding. Presence The quality of being all there in body, mind, and spirit in direct contact with the environment or person in moment -to -moment felt experience.
16 Primary knowing . arises by means of interconnected wholes, rather than isolated contingent parts and by means of timeless, direct, presentati on rather than through stored re -presentation. Such knowing is open rather than determinate, and a sense of unconditional value, rather than conditional usefulness, is an inherent part of the act of knowing itself, said Rosch. Acting from such awarene ss is spontaneous, rather than the result of decision making, and it is compassionate since it is based on wholes larger than the self. (Rosch quoted by Senge, Scharmer, Jaworski, & Flowers, 2005, p. 98) Qualitative inquiry Research emphasizing description and exploration of the qualities of phenomena or things, processes, and meanings rather than on measurement. Qualitative researchers stress the socially constructed nature of reality, the intimate relationship between the researcher and what is studied, and the situational constraints that shape inquiry (Denzin & Lincoln, 2005, p. 10). Reflection A therapists examination of the assumptions, beliefs, and values that inform his/her work with clients as well as reviewing and analyzing the cont ent and process of his/her work and interaction with clients. Relationship factors Factors that contribute to therapeutic outcome including therapist qualities as well as the alliance between therapist and client. System A set of parts or components that make up and function as a whole that has boundaries distinguishing it from its surroundings. Technique factors Factors that contribute to therapeutic outcome that include therapeutic or healing rituals that include a rationale, offer an explanation for the clients difficulties, and establish strategies or procedures to follow for resolving them (Hubble, Duncan, & Miller, 1999, p. 10). Therapeutic The connection, association, and involvement between therapist and relationship client. Working alliance Used interchangeably with therapeutic relationship and therapeutic alliance. When specifically tied to Bordins (1979) model, it includes the negotiation of goals, bond, and tasks between therapist and client.
17 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy CHOOSING TO BE PRESENT AS COUNSELORS IN TRAINING: A GROUNDED THEORY By Christ ina Tannen May 2009 Chair: M. Harry Daniels Major: Mental Health Counseling The purpose of this study was to examine how counselors in training (CITs) describe their experience of being present and the meaning they make of that experience. It focused on the counselors way of being as distinguished from their application of techni que. C onducted from a constructivist theoretical perspective this study assume d that knowledge is situational, that human subjectivity produces legitimate knowledge, and that meaning is constructed rather than discovered. Seven CITs, recruited from depart ments of counseling psychology and counselor education, participated in the study. They participated in a mindfulness meditation group as a way of cultivating being present and as a context in which they constructed the meaning of being present The tran scripts of interviews with the participants were analyzed using grounded theory method s which yielded a theoretical model of the process of choosing to be present as CITs The theory includes seven key elements : 1) Acting to Contain Anxiety and Uncertaint y, 2) Awakening to Choice s 3) Choosing to be More Present, 4) Being Present, 5) Contexts Facilitating or Inhibiting Being Present, 6) Experiencing the Outcomes of Containing Anxiety and Uncertainty, and 7) Experiencing the Outcomes of Being Present The theory acknowledges the inevitability of anxiety and uncertainty for CITs and portrays a dynamic process in which
18 they may at any one time move toward being more present or toward containing their anxiety and uncertainty, characterized as seeking connectio n or seeking safety. To choose, CITs first awaken to the experience of being present and thus to an alternative to acting to contain anxiety and uncertainty. They may then actively choose to become more present or they may go toward safety again. The cho ices they make take place in and are influenced by context. Being present and acting to contain anxiety and uncertainty both yield outcomes that shape their work as counselors in training. CITs negotiate the complexity of choice moment by moment and cumul atively influence their personal development by the choices they make. The theory offers new perspectives on being present in counseling, suggests a potential role for being present in the therapeutic relationship, and adds an unexplored dimension to the process of counselor development.
19 CHAPTER 1 INTRODUCTION Overview Psychotherapy is personal. This is often acknowledged to be the case for clients. Clients offer up their personal struggles, face into private experiences of trauma and loss, and bring their personal qualities and resources to contribute to the therapy process. But psychotherapy is also personal for the therapist. While objectivity is often prized and pressures exist for counselors to be experts who assess and treat with precision, therapists ultimately rely on their personal beings as the instruments o f therapy. Therapists not only draw on knowledge and skills, but also bring themselves into direct contact with the client and with themselves. For therapists to stay with their clients personal suffering, they come in contact with their own. Frequentl y, therapeutic change emerges from such a uniquely intimate encounter, when counselor and client sense a powerful connection to each other. How counselors develop the capacity to bring themselves to the therapeutic relationship so they can facilitate this connection is fertile but virtually unexplored ground. This capacity for connection will be taken up from the following perspectives: the person of the therapist, the therapist in relationship, and the therapists presence. The Therapist The counselors own being and experiencing in the counseling session need to be focal points in considering connection between therapist and client. As used here, being and experiencing are verbs that invoke the way the person of the therapist is alive and participating in the counseling session, awake to ones own being and to ones experiencing of clients. Being in contact with oneself means being aware of ones moment to moment experience of and adjustments to ones environment, including the client. According to Gest alt therapy tradition,
20 the self is a system of creative adjustments to what is encountered at the boundary between self and environment (Perls, Hefferline, & Goodman, 1951). The self evolves as it is continually constructed and reshaped in dialogue with the environment (Kincheloe, 2005). The self as a system constantly reorganizes and while there may be some recognizable patterns the path is not predictable. Similarly, Buddhists speak of no self with the idea that there is no firm entity that can be h eld onto as self, but rather continuous awareness and experience ( Hahn, 1990; Levine, 1979). Contact between client and therapist happens at the boundary between them where they each adapt and change in response to one another. If therapists keep themse lves away from that boundary, tucked behind a prescribed protocol or a preconceived idea about clients or their presenting issues, then a connection is not made between them and change does not happen. If therapists think of themselves as fixed entities se parate from their clients, true connection is more difficult. On the other hand, if therapists can be aware of themselves as perpetually evolving systems and can bring themselves fully to their personal boundary, the border that both separates and connects them to their clients, open to whatever they find there, then they and their clients have the possibility of growing and changing (Hycner, 1991; Perls, 1973; Perls, et al, 1951). A body of research on therapists regarded as experts offers a portrait of the master therapist that highlights personal qualities, abilities, and capacities (Skovholt, Hanson, Jennings, & Grier, 2004, Skovholt & Jennings, 2004, 2005), drawing attention again to the importance of attending to the therapist as a person. Not only ar e personal qualities emphasized, but the particular qualities seen as significant support the value of connection and of openness to novelty and unpredictability. For instance, the portrait of the master therapists includes tolerance for
21 ambiguity, anxiety, disorder, conflict, ambivalence, and paradox (Skovholt, Hanson, Jennings, & Grier, 2004, p. 19). These qualities also support the self adaptation and growth process identified above which in turn enables good contact between self and other. Good contac t in Gestalt therapy theory means being mindful of current reality at the boundary between me and not -me (Yontef, 1995). The therapist being congruent or fully oneself (Rogers, 1957, 1961; Skovholt, Hanson, Jennings, & Grier, 2004), along with the a bility to form relationships (Skovholt, Hanson, Jennings, & Grier, 2004, p. 27) are also associated with the master therapist. This body of work suggests that these qualities and capacities are developed over the career of a therapist who is graced with n atural relational abilities and who continually seeks personal and professional growth. While experience is a significant factor, it is not the determining one. What is unknown is how counselors in the beginning of their careers might make use of practic es aimed at developing these abilities and capacities. Loganbill, Hardy, and Delworth (1982) identify in novice counselors a nave sense of security based on black and white thinking and lack of awareness of problem areas in their work. Novice counselors a re also characterized by anxiety, dependency, and technique focus (Reising & Daniels, 1983; Ronnestad & Skovholt 1993). The term p remature foreclosure summarizes the novices tendency to latch on to one simplistic solution, theory, or frame of reference with which to view clients in order to avoid being cognitively or emotionally overwhelmed (Skovholt, Hanson, Jennings, & Grier, 2004, p. 20). This foreclosure on possibilities helps the practitioner, whether novice or seasoned, avoid the anxiety of am biguity and uncertainty but makes true contact with a client difficult if not impossible. The client is fit into a preconceived box rather than being experienced freshly. Supervisors of novice counselors are encouraged to provide structure and security i n response to this characterization (Stoltenberg, McNeill, &
22 Delworth, 1998) as opposed to encouraging them to embrace or tolerate their anxiety. If programs and supervisors provide direction and structures for novices to hold on to, it becomes a self -ful filling prophecy that novices will in fact rely on that direction and structure. Another way to address novice counselors needs is to train counselors to be present to be able to sit with anxiety, to increase their comfort with not knowing and not cont rolling, to be open. Cultivating presence can augment current structures in counselor preparation to enable novice counselors to make better connections with clients. Counselors in training (CITs) are taught to be aware of the behavior of the client, the feelings and thoughts of the client, as clues to the clients presenting issue or meaning making. Students of counseling are also advised to be aware of themselves, including their own behaviors, thoughts and feelings, cultural values, as clues to their ow n biases, personal history and meaning making. While some training is offered in how to interpret what they notice and how it fits with the content they have learned, students are not offered much assistance regarding the process of noticing itself (Hollom an, 2000). Noticing here means paying attention, being aware and seeing. Self awareness and accurate empathy show up in the qualities of master therapists and are held out as things to strive for. Novice counselors need a practice devoted to the developm ent of in the -moment awareness of self and other. Reflection is suggested as important in the process of becoming a master therapist ( Schon, 1987; Skovholt & Ronnestad, 1992) Reflection involves processing experiences in counseling. While reflection, ei ther in supervision or on ones own, may include a focus on both process and content aspects of counseling, it is an intellectual exercise about something that happened in the past (Ward & House, 1998). Primary knowing (Senge, Scharmer, Jaworski, & Flowers 2005), implicit knowing (Stern, 2004) and embodied knowing ( Lakoff & Johnson 1999) are ways of
23 describing a more inclusive kind of knowing, one that draws on the senses, emotions, and spirit in the present moment, as well as on thoughts about that expe rience. Present moment awareness (Stern, 2004) is a necessary companion of the reflection process. Present moment awareness provides the data upon which to reflect later. The quality of the awareness in the moment may determine the quality of the data f or reflection. Being present in the moment is a requirement for reflection to be effective and in turn strengthens the counselors skills. The Therapeutic Relationship After exploring the importance of the being of the therapist, this section turns to th e importance of the therapists being with the client in the therapeutic relationship. Common factors research sheds light on the significance of the therapeutic relationship (Hubble, Duncan, & Miller, 1999; Lambert, 1992). This line of research is devo ted to finding factors that contribute to therapeutic outcome regardless of theoretical orientation and has led to the identification of four common factors in client change: (1) client factors; (2) relationship factors; (3) hope, expectancy or placebo fac tors, and (4) technique factors (Hubble, Duncan, & Miller, 1999; Lambert, 1992). Relationship factors are of particular importance in the study of presence. These factors encompass therapist qualities as well as the alliance between therapist and client. According to Lambert (1992), Hubble, et al (1999) and others (Horvath, 2005; Mart in, Garske, & Davis, 2000; Norcross, 2002; Nuetzel, Larsen, & Prizmic, 2007; Stevens, Muran, Safran, Gorman, & Winston, 2007; Watson & Geller, 2005; Zuroff & Blatt, 2006) the therapeutic relationship is a substantial contributor to therapeutic outcome sec ond only to client factors in accounting for the variance in outcome. Investigation of the therapeutic relationship has focused primarily on two areas: (a) what factors make up the relationship (Bordin, 1979; Gelso & Carter, 1994; Norcross, 2002 ) and (b) what therapist qualities correlate with positive therapeutic relationships (Ackerman &
24 Hilsenroth, 2003; Clemence., Hilsenroth, Ackerman, Strassle, & Handler, 2005; Norcross, 2002 ; Watson & Geller, 2005). Conceptualizations of the therapeutic relationship have been provided most notably by Rogers (1957), Luborsky (1976), Bordin (1979), and Gelso and Carter (1985, 1994) and instruments to measure the relationship emanate almost exclusively from these models. In spite of the attention given to relationship factors in therapy, the following discussion will highlight critical limitations in the prof essions understanding of the therapeutic relationship. T he counseling field seems to have settled on the early models of the therapeutic relationship or alliance (Horvath & Luborsky, 1993 ; Norcross, 2002; Norcross, Beutler, & Levant, 2006). As a result, the research literature reflects a theoretical foreclosure that limits a full examination of this important phenomenon (Horvath, 2005; Elvins & Green, 2008). Studi es that identify therapist qualities that correlate with positive therapeutic relationships also use the same models and so are limited to contributing to an understanding of qualities that relate to those particular ways of conceptualizing the relationshi p. In addition, how therapists develop those qualities or develop the capacity to build positive therapeutic relationships has not been explored. In Horvaths (2005) review of the research on the therapeutic relationship, he refer red to projects designed to train therapists with the goal of developing better working alliances. He stated that more than half of the studies he reviewed showed no improvement in alliance ratings following training (2005). These findings appear to suggest that it is important to more clearly identify the interactive elements between therapist and client related to the alliance . (Horvath, 2005, p.5). Client ratings of the therapeutic relationship more consistently predict outcome than either therapist or observer ratin gs (Fitzpatrick, Iwakabe, & Stalikas, 2005; Horvath & Symonds, 1991; Hubble, Duncan, & Miller, 1999; Watson & Geller, 2005). T he discrepancy between client and
25 therapist ratings of the alliance has not been thoroughly investigated What is it that therapi sts are attending to that their appraisal of the alliance is so different from that of clients? It has been conjectured that therapists use their theoretical perspective as a reference point for making judgments about the relationship where the client may refer to other personal relationships (Hubble, Duncan, & Miller, 1999). If this is the case, then the therapists, especially therapists in training, are in a bind. On the one hand they are encouraged to adopt a theoretical orientation and on the other they need to find a way to set aside theory and be present enough in the encounter with the client to sense the state of their relationship. Research on the therapeutic relationship is also limited by the difficulty existing research structures have in accom modating the study of process -oriented and experiential phenomena (Norcross, Beutler, & Levant, 2006). As discussed above, the therapist and client adapt in response to each other and to their interaction, making the relationship a process and experientia l phenomenon. In addition, the relationship is a whole system, an understanding of which is limited, if not skewed, by taking it apart and studying the pieces as is required by existing research structures. For instance, adopting an atomistic rather than holistic approach, Ackerman and Hilsenroth (2003) Dunkle and Friedlander (1996), and Norcross (2002) separated the therapists contribution to the therapeutic relationship into discrete elements such as empathy, self -disclosure, honesty, flexibility, pos itive regard, and others, attempting to establish correlations of individual factors with ratings of the relationship. Extracted from the whole of the relationship, these variables may look different than when part of the gestalt. On a more global level, data generated by frequently used research methodology, such as the meta analysis, paints an impersonal picture of a personal encounter. The meta analysis has become the foundation for accepted knowledge claims about the therapeutic relationship
26 (Horvath & Luborsky, 1993; Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000; Norcross, 2002). In a review of the literature on the therapeutic relationship, including works from the years 2000 through 2006 as well as earlier classic works, the sources cited most often in the PsycInfo database were meta analyses. While drawing on a great deal of work, a meta analysis becomes removed from the phenomena of interest with the complexity of an entire research study reduced to a single data point in a meta analysis What is gained in breadth is lost in depth of understanding. What is an embodied experience becomes disembodied. The profession is left at a distance from the moment to moment experience of a relationship. These examples point to some key inadequacies in the professions understanding of the therapeutic relationship. The being and experiencing of the therapist in the moment of encounter with the client, what can be called the therapists presence, does not appear in the language or literature on the th erapeutic relationship. Being present, as both an intra -personal therapist factor (being) and as a co -constructed, inter -subjective experience (being with) fits intuitively in the realm of the therapeutic relationship and yet the topic is missing from the oretical models of the therapeutic relationship. Therapeutic Presence Presence has been suggested to be a process and/or quality inherent in positive therapeutic relationships but has been only marginally explored. The concept of presence distinguishes be tween a therapists way of being and the application of knowledge or technique. Psychotherapists from different theoretical traditions, i.e. psychoanalytic, existential, personcentered, and Gestalt, have written about therapist presence (Buber, 1970; Buge ntal, 1987; Freud, 1912/1961; May, 1958; Reik, 1948; Rogers, 1961) Freud recommended evenly hovering attention as opposed to selective or forced attention (1912/1961). Reik (1948) spoke of listening with the third ear meaning with ones whole being. For Bugental (1987), Presence
27 is the name for the quality of being in a situation or relationship in which one intends at a deep level to participate as fully as she is able (p. 27). When the therapist is present, he or she is relating to the client as one existence communicating with another (Binswanger, quoted by May, 1958, p. 81). In Martin Bubers (1970) I thou relationship, presence takes on the dimension of a meeting for [o]nly as the You becomes present does presence come into being (Buber, 1970, p. 63). In person-centered therapy the therapists function is being immediately present to his client, relying on his moment to -moment felt experience in the relationship (Rogers, 1989, p. 16). For Gestalt therapists, being present means making a uthentic contact either with oneself or with the environment which includes awareness at the sensory as well as the cognitive level (Korb, Gorrell, & Van De Riet, 2002). The few research studies on presence yielded qualitative descriptors such as recep tivity, inwardly attending, extending, being with and for the client, attentional ability, immersion in the moment, connected, authentic self and openness of being (Fraelich, 1989; Geller, 2001; Pemberton, 1977; Phelon, 2001). Presence as a holistic expe rience defies being pulled apart into pieces so it must be understood that each of these parts overlaps and intertwines with the others. Presence is also referred to as a continuum, expressed in terms of the intensity of the connection and the engagement of body, mind, and spirit (Geller, 2001; McDonoughMeans, Kreitzer, & Bell, 2004). Together these descriptors paint a picture similar to the conceptualizations of presence by therapists from various theoretical perspectives. Both Phelons (2001) and Gelle rs (2001) participants referred to kinesthetic aspects of presence. Connection between therapist and client, as for any two people, takes place at the boundary between self and other. From a phenomenological perspective contact is made through the sense s. Direct experience involves sensory data and awareness. For therapists to connect
28 with clients their attention cannot be solely occupied with cognitive functions that take them away from present moment experience (May, 1958; Reik, 1948; Stern, 2004; We lwood, 2000). They must involve their whole being. Awareness of sensory and kinesthetic data is not generally a focus of counselor preparation. Components of presence may be identified but in and of themselves do not resemble presence. And being present appears to encompass paradoxical aspects. For instance presence is described as requiring receptivity and action; concentration but not fixed attention, and heightened awareness of ones own being and also being unaware of ones own being. These paradoxi cal aspects appear mutually exclusive and yet each can be observed at different points. If only one aspect is identified as a variable in the study of presence, the appearance of its opposite confounds the findings. Meaningful study of the experience of p resence requires a holistic approach. Those who have studied presence propose conceptually that developing therapists skill in being present enhances their capacity to build a stronger alliance and a more therapeutic relationship (Geller, 2001; Pemberton, 1977; Phelon, 2001). There is also overlap in descriptions of the qualities of master/expert therapists (see above section) with descriptions of therapist presence. If the therapeutic relationship is considered critical to outcome in therapy, i t is reasonable to suggest that the qualities of these master therapists, including being present, have something to do with their ability to form therapeutic relationships that promote change. This line of reasoning supports the importance of increasing counselors ability to be present. To date, cultivating being present remains primarily the purview of spiritual practices and has not been thoroughly explored in the context of counseling.
29 In Buddhism, mindfulness forms the foundation of optimal presence, the combined working of the seven factors of awakening: mindfulness, investigation, energy, joy, tranquility, concentration, and equanimity (Morgan & Morgan, 2005). But mindfulness is not a Buddhist phenomenon. Mindfulness is a universal experience havi ng to do simply with the cultivation and refinement of our ability to be present and awake in our lives (Kabat Zinn, Massion, Hebert, & Rosenbaum, 2002, p. 287). Mindfulness meditation has been practiced for centuries as a way to develop mindfulness and t hus presence. Mindfulness meditation means sitting in intentional silence focusing attention on the breath, noting present moment experience as it unfolds without judgment. Psychotherapy research on mindfulness meditation has focused primarily on the eff ects of teaching mindfulness practice to clients as a therapeutic intervention (Baer, 2003). Results of various studies of the effects of mindfulness meditation practice show reduced anxiety depression eating disorders, and pain, and heightened pe rforman ce and life satisfaction (Brown & Ryan, 2003; Kabat -Zinn, Lipworth, Burney, & Sellers, 1 987; Kabat -Zinn, Massion, Kristeller, Peterson, Fletcher, Pbert, et al., 1992; Kristeller & Hallett, 1999; Shapiro, Schwartz, & Bonner, 1998; Teasdale, Williams, Souls by, Segal, Ridgeway & Lau 2000). In regard to therapists, mindfulness mediation has been explored as a method of self -care (Christopher, Christopher, Dunnagan & Schure 2006; Shapiro, Brown, & Biegel 2007). Fulton (2005) and Tremlow (2001) suggest conce ptually a number of benefits to mindfulness meditation as clinical training for therapists including fine tuning attention, listening and hearing skills; healthy experiencing of the here and now; developing nonattachment and optimal distance; and compassio n. Despite these potential benefits for the therapist, research is minimal in this area. Training counselor trainees in mindfulness meditation offers them the opportunity to develop
30 mindfulness as the foundation for being present and a context in which t o explore their experience of being present and the meaning they make of that experience in counseling. The Problem Despite the power and promise of presence in facilitating connection with clients, for therapist self awareness and growth, and for tolerating ambiguity and unpredictability, there is a dearth of systematic exploration of presence. The profession has not had the means to examine the meaning of being present in therapy and may have avoided the topic as it did not fit within the predomin ant research paradigm. In addition, research on counseling effectiveness has focused on the client or on specific theories and interventions (the therapists doing) rather than on the therapists being in counseling. What is understood about being present so far comes from the experience of seasoned therapists who have an interest in and a propensity to be present. Little is known about the meaning CITs make of the experience of being present or if they have the experience at all. The purpose of this stu dy was to examine how CITs describe and the meaning they make of their experience of being present in the context of counseling. Unless otherwise noted, being present implies being present as a therapist and in the context of counseling. Mindfulness is i ncluded as a way of cultivating the ability to be present. Theoretical Foundations Constructivism forms the theoretical perspective for my research. Phenomenological, existential, and Gestalt theories along with Buddhism each conceptualize the experience of being present and so contribute various perspectives to this study. In addition, theoretical propositions regarding counselor development furnish a context for this study as they structure existing expectations for counselors, particularly novice couns elors. I will briefly describe each of these as they inform my exploration of being present.
31 Constructivism Constructivism emerged from challenges to the modernist thinking and the limitations of logical positivism (Hayes & Oppenheim, 1997; Sexton, 1997). Constructivism suggests that the knower is inextricably entwined with what is known, and that knowledge is relative to context (Sexton, 1997). Reality exists in terms of the meaning constructed by the observer. Within constructivism, beliefs about the na ture of reality stretch along continua on two dimensions: (1) from realism to idealism, and (2) from individually constructed to socially constructed knowledge (Chiari & Nuzzo, 1996 ; Hayes & Oppenheim, 1997). At the extreme realist end of the continuum, constructivists believe that there is an absolute reality to be known but that it will never be truly and exactly known due to the limitations of the observers perceptual, cognitive, and emotional processes. At the other end of the continuum is the extreme idealist belief that reality is created entirely by the observer. Being present in counseling will be looked at in this study from a position on each of these dimensions: first, the experience of presence exists only as it is experienced by the counselor a nd second, the individual experience and the meaning made by the individual counselor is given primacy. The counselor enters into an intersubjective space with the client and constructs meaning from this interaction and as well as from his/her being in th e world. The meaning made by individual counselors is the interest of this study. An assumption I make is that being present in counseling acknowledges the uniquely constructed meanings of each individual and that opening to those different constructions of reality promotes a positive therapeutic relationship. Phenomenology Being present has been studied from a phenomenological perspective yielding rich descriptions of the experience by psychotherapists (Fraelich, 1989 ). Phenomenology is a branch of phil osophy that influenced psychotherapy theories such as existential and Gestalt as well as
32 research methodology in the social sciences. This philosophy called psychotherapists and researchers to go to the things themselves, and recognized the crucial val ue of returning to the self to discover the nature and meaning of things as they appear and in their essence (Moustakas, 1994, p. 26). The goal of phenomenology is to bracket off preconceived theories, concepts or categories so that one can make meaning of fresh experience, can see more clearly what is manifest (Moustakas, 1994). This is also a description of being present. Phenomenological experience is a present moment experience and being present is a phenomenological experience. Existentialism Accordi ng to existential theory, people experience anxiety due to the inevitability of the conditions of living: death, isolation, meaninglessness and freedom. It is in acknowledging their authentic experience of being in the world and connecting with that of o thers that people confront, accept and tolerate these conditions (Yalom, 1980). Human existence is seen as a process of emerging and becoming, of coming into being (May, 1958). Existential psychotherapy is based on . an understanding of what makes m an the human being; it stands for defining neurosis in terms of what destroys mans capacity to fulfill his own being (May, 1958, p. 35). Existential psychotherapy, then, encourages both therapist and client to inhabit their experience of living, to be p resent. Existential therapists have written eloquent descriptions of the value of presence in the therapeutic encounter. This approach to psychotherapy asks therapists to be present with their clients, connecting in their common experience of the givens of existence, authentically, one human being with another. Gestalt Gestalt therapy theory offers another frame for the therapeutic value of being present for both client and therapist. Gestalt therapy is described as phenomenological, existential,
33 experie ntial, and experimental (Korb, Gorrell, & Van De Riet, 2002; Yontef, 1989). It is phenomenological in that clients are encouraged to experience their lives directly through their senses rather than through their ideas about their experience. As in existe ntial therapy, the goal is to help clients remove what blocks them from this direct experiencing in order to make good contact with their environment and with themselves. This is accomplished by helping clients develop present moment awareness through experiential and experimental interventions. It is through experiencing themselves as they are in the present that clients come into their authentic being in the world. The paradoxical theory of change posits that people change by becoming who they are rathe r than trying to become something different (Beisser, 1970/2004).The human being is seen as a self regulating whole. People grow and adapt to relevant aspects of their environment at the boundary which both defines them as separate and connects them to th eir environment. As such, Gestalt therapy recognizes the self as interconnected with the context in which it comes to be moment by moment. The therapist is asked to be aware of self, others and the context or field; to be available for dialogue or relat ionship with the client; to use self as an instrument of therapy, and to focus on process rather than on content (Brown, 1997; Yontef, 2002). Gestalt therapy requires the therapist to be present to facilitate authentic, therapeutic dialogue in the immedia te moment and brings clients to their present experience to facilitate healthy organismic functioning and growth. Buddhism Buddhism provides a description of being present in the context of spiritual practice and points to potential therapeutic value in b eing present, for both therapist and client. Buddhism will be discussed here in the broadest of terms as diversity exists within the Buddhist world. In addition, the Buddhism presented here has been interpreted by western practitioners.
34 In Buddhism, as i n most Eastern spiritual traditions, well -being, happiness, and freedom are found within each person as part of his/her true nature. People suffer from believing that happiness lies outside them and from their attachments to things, people, and ideas, whi ch are in fact always changing (Fulton & Siegel, 2005). Buddhist mindfulness meditative practices are aimed at helping people achieve direct knowledge and experience of that essential nature that goes beyond the separateness of the individual self and the conceptual mind (Welwood, 2000). In striking similarity to constructivist and Gestalt thinking, Buddhism describes the construction of self as taking place moment to moment. In Buddhism, this construction of self results from attachment of the mind to pa rticular feeling states or thoughts (Levine, 1979) that are then claimed as ones identity. In meditation, attention is focused on each moment as thoughts and feelings pass through consciousness and over time the meditator learns not to hold on to any of them as proof of identify or self (Levine, 1979/1989). The effect is insight into the inevitability of change which in turn facilitates a letting go of needing to control life and an increase in compassion and love (Fulton, 2005). The emphasis on direct experience of what is in each moment and opening to compassion in Buddhist thought and practice offers another perspective on being present. For the therapist, being present and unattached to thoughts about the client, open to client changes, the therapis t would detach from the need to control and to know and would see more clearly and compassionately. Counselor Development Being present has been suggested to increase self awareness, tolerance for difficult emotions, and openness to complex and paradoxica l phenomena. In this study I listened to the meaning CITs make of their experience of being present in counseling against the backdrop of models of counselor development and expertise.
35 Stoltenberg and Delworth ( 1985) delineated a four -stage model of couns elor development for trainees. Increased autonomy and self awareness, along with knowledge of theory and technique, indicate progression from one stage to the next. More mature trainees also show more complete self understanding and are able to draw on a m ore complex view of the counseling process (Stoltenberg & Delworth, 1985). Loganbill, Hardy and Delworth (1982) used the terms stagnation, confusion, and integration to describe the stages in their model of counselor development. In the stagnation stage, counselors lack awareness of their blind spots, demonstrate a nave sense of security and black and white thinking (Loganbill, Hardy & Delworth, 1982). Although other models refer to anxiety at this stage and this model notes a sense of security, I conje cture that these are two sides of the same coin. Counselors rigidly cling to specific theory or interventions and feel anxiety when they are faced with challenges to those approaches or if they are forced to deviate from them. At later stages of both of these models (Stoltenberg & Delworth, 198 5 ; Loganbill, Hardy & Delworth, 1982), as well as in descriptions of master therapists (Goh, 2005; Jennings, Sovereign, Bottorff, Mussell, & Vye, 2005; Jennings, Goh, Skovholt, Hanson, & Banerjee Stevens, 2003), c ounselors demonstrate more self awareness, tolerate greater uncertainty and anxiety, and exercise more flexibility and complexity in conceptualizing client issues. Reising and Daniels (1983) demonstrated that a simple (linear) stage model of counselor dev elopment does not adequately depict this developmental process which is demonstrably complex. Counselors do not simply complete one stage and move to the next, but develop unevenly and perhaps cyclically. Therapist expertise has also been defined as knowi ng what happens moment by-moment during therapy sessions ( Orlinsky, Ambuhl, Botermans, Davis, Ronnestad, Willutski, Cierpka, & Davis, 1999). Regardless of to what extent
36 a counselor can be considered to be at a particular stage of development, moment to moment awareness seems crucial to performance. Summary In summary, this study focuses on the experience and meaning made by individual counselors of being present from a constructivist perspective. Phenomenology, existential, Gestalt, and Buddhist theori es explore presence and its meaning. Existential and Gestalt theories of human living, growth, and change influenced my own experience and thus my framing of the importance of being present. Both existential and Gestalt therapies center on authentic bein g in the present moment for therapist and client. How the meaning CITs make of their experience of being present overlays on existing conceptualizations of counselor development contributes to the analysis. Significance of Study CITs experience of being present and the meaning they make of that experience in counseling have not been the focus of previous systematic investigation. Therapists connection with clients has been shown to be crucial to positive therapeutic outcome (Horvath & Luborsky, 1993; La mbert & Catani Thompson, 1996; Norcross, 2002; Vocisano, Klein, Arnow, Rivera, Blalock, Rothbaum, et al, 2004) and yet little is known about the processes that enable therapists to make those connections. Without the study of being present in counseling, the profession is left at a distance from the very personal encounter between therapist and client, between one existence and another. It neglects what may prove to be an avenue for enhancing therapeutic relationships and the development of counselors. M ost examination of the therapeutic relationship has been atomistic and reductionistic and has centered on a circumscribed set of models and measures (Ackerman & Hilsenroth, 2003; Horvath, 2005; Clemence, Hilsenroth, Ackerman, Strassle, & Handler, 2005; Nor cross, 2002). A
37 qualitative analysis of therapists personal experiences and meaning making offers a holistic and inductive approach to looking at these complex processes. In particular, this study provides indepth descriptions of the meaning that people new to the practice of therapy make of the experience of being present, complementing the existing descriptions of presence by experienced therapists ( Fraelich, 1989; Geller, 2001; Pemberton, 1977; Phelon, 2001). Analysis of the experiences and constructed meanings of CITs regarding presence adds richness to the dialogue on therapist development on their way from novice to master. Novice counselors have been characterized as anxious, dependent, and technique -focused (Loganbill, Hardy, & Delworth, 1982; Reising & Daniels, 1983 ; Ronnestad & Skovholt 1993) while master therapists are portrayed as tolerant of ambiguity and uncertainty and focused on their relationships with their clients (Skovholt, Hanson, Jennings, & Grier, 2004; Skovholt & Jennings, 2004). Learning to be present can supplement other training experiences in addressing novice counselor anxiety thereby making room for flexibility in interventions and better contact with clients. The participants in this study, in learning min dfulness meditation, developed their capacity for being present and constructed meaning out of that experience in the context of counseling. In this study I highlight the therapists being and experiencing in the context of counseling, setting it apart fro m studies that have focused on discrete therapist interventions, client factors, and models and measures of the therapeutic relationship. The findings of this study help the profession know more of how therapists bring themselves to be present in the ther apeutic relationship and what they understand presence to mean in the context of counseling. In particular, this study sheds light on how new counselors understand and integrate the experience
38 of being present into their work as counselors. It also offers resources and encouragement for further exploration.
39 CHAPTER 2 LITERATURE REVIEW Therapeutic Effectiveness and Common Factors Psychotherapy helps bring about changes in clients symptoms and life functioning (Asay & Lambert, 1999; Seligman, 1995; Lamber t & Cattani Thompson, 1996; Lambert & Bergin, 1994). Testing different therapies using different methodologies and from different perspectives (client, therapist, observer), researchers have found support for the effectiveness of psychotherapy for a varie ty of presenting problems and diagnoses (Asay & Lambert, 1999; Hubble, Duncan, & Miller, 1999). Meta analyses of studies of specific therapies conclude that Everyone has won and all must have prizes meaning that therapies demonstrate reasonably equivale nt effectiveness ( Benish, Imel, & Wampold 2008; Lambert & Bergin, 1994; Ahn & Wampold, 2001; Wampold, Mondlin, Moody, Stich, Benson, & Ahn, 1997; Takuya, Wampold, Serlin, Hamilton, Brown & Kircher, 2008 ), although some therapies seem to work better for s ome problems (Bergin & Garfield, 1994; Ogles, Anderson, & Lunnen, 1999). Frank and Frank (1991, cited in Hubble, Duncan & Miller, 1999, p. 7) identified aspects of therapy that were held in common by effective therapies. They were followed by Lamberts (1992) work which proposed four common therapeutic factors. Building on Lamberts (1992) work, Hubble, Duncan and Miller (1999) reviewed the literature with the purpose of selecting the major components or ingredients of therapy that provided the best br idge between the various schools (p. 8) and emerged with labels for the big four factors that have become the language of the common factors literature: 1) client or extra therapeutic factors, 2) relationship factors, 3) placebo/hope/expectancy factors, and 4) technique factors. Lambert (1992) assigned percentages to each common factor to demonstrate its contribution to therapeutic outcome. Relationship factors (what Lambert called the common factors) were said to account for 30% of the
40 variance in t herapeutic outcome (with extratherapeutic factors contributing 40%, expectancy 15%, and therapy technique 15%)(Lambert, 1992, p. 97). While studies of the therapeutic relationship and the working alliance refer to these percentages regularly, Lambert himse lf cautioned that no statistical procedures were used to derive the percentages that appear in figure 3.1, which appears somewhat more precise than is perhaps warranted (1992, p.98). Nevertheless, researchers almost without exception maintain that the relationship is critical to positive therapeutic outcome (Lambert & Bergin, 1994; Horvath & Greenberg, 198 9; Nuetzel, Larsen, & Prizmic, 2007; Stevens, Muran, Safran, Gorman, & Winston, 2007; Zuroff & Blatt, 2006). This claim is predicated on empirical stu dies of the relationship as defined by various models of the therapeutic relationship and the working alliance. The Therapeutic Relationship Theories and Models Theorists conceptualize the therapeutic relationship in various ways to facilitate change. Fr eud recommended that therapists allow their analysands to develop a positive attachment to them by maintaining serious interest and sympathetic understanding of the client (Horvath & Luborsky, 1993, p. 56). This attachment was to allow clients to di splace onto the therapist aspects of relationships with significant people from the clients past. The processing of the transference, as this displacement is termed, forms the central thrust of the therapy (Gelso & Carter, 1994, p. 297). According to Ho rvath and Luborsky (1993), in Freuds later writing he indicated that beyond the transference relationship, by definition a distorted relationship, there may also develop a real or undistorted relationship. Beyond the transference relationship, this part o f the client, which is grounded in reality, helps the client to heal.
41 Determined to abstract from his therapy experiences the basic principles involved in change, Carl Rogers (1957) proposed six conditions that if present are not only necessary but suffic ient for therapeutic personality change. These conditions are as follows: 1. Two persons are in psychological contact. 2. The first, whom we shall term the client, is in a state of incongruence, being vulnerable or anxious. 3. The second person, whom we shall term the therapist, is congruent or integrated in the relationship. 4. The therapist experiences unconditional positive regard for the client. 5. The therapist experiences an empathic understanding of the clients internal frame of reference and ende avors to communicate this experience to the client. 6. The communication to the client of the therapists empathic understanding and unconditional positive regard is to a minimal degree achieved. (Rogers, 1957, p. 96) Many times the Person -Centered approac h is reduced, especially for research purposes, to what are called therapist offered conditions (TOC) and include only empathy, warmth, and genuineness. The more relationship-oriented conditions, in which the client and therapist are in contact and in whi ch not only does the therapist offer them but the client perceives the therapists empathy warmth and genuineness, are often left out. Nonetheless, they remain important aspects of this theory of change. Horvath and Luborsky (1993) note that Rogerss the ory does not address variability in client motivation or ability to take advantage of the conditions (p. 562), however, the first and last condition seem to take client perspective into account. They also report that in the majority of the studies on the T OCs it is the clients perception of the therapist rather than the therapists behavior that correlates most highly with outcome (Horvath and Luborsky, 1993, p. 562). Again, the sixth condition in Rogers theory of change demonstrates his acknowledgement of the importance of the clients experience and perception. From the necessary and sufficient conditions, it is clear that for Rogers, change only occurs in the context of a relationship. What sets Rogers PersonCentered Theory apart from most other t heories is this valuing of the relationship as the facilitative agent of therapy, rather than as a pre -condition for therapy techniques that bring about the change.
42 Bordin (1979), troubled by the proliferation of psychotherapy theories in the 1960s and 1 970s, proposed a model of the working alliance. He saw the working alliance as a key element of the change process and one that can be generalized across theories to provide a focus for research on therapeutic change. The working alliance develops from th ree aspects of the therapeutic relationship: the goal, the task and the bond (Bordin, 1979). The alliance is enhanced to the extent that therapists and clients agree on the goals of their work together. While different theories focus on different kinds o f goals, the agreement on the goals is what is important. The client and the therapist collaborate on the content and conduct of their work together, including the assignment of homework, focusing on a particular behavior or how fees are paid (tasks). The bond resembles what might be called the affective or more intimate parts of the therapeutic interaction, including trust and attachment. Just as with goals, bonds may look different depending on the therapy approach, the role of the therapist and the length of therapy (Bordin, 1979, p. 254) but it is the strength, not the type, of the bond that is important to the overall alliance. In the early years of research on the relationship between working alliance and therapeutic effectiveness studies focused on t he use of psychodynamic therapies and Bordin (1979) called for more comprehensive confirmation of these results. The working alliance has been widely researched using many different therapeutic approaches since he made that call (Clemence, Hilsenroth, Acke rman, Strassle, & Handler, 2005; Dunkle & Friedlander, 1996; Horvath & Greenberg, 1989; Horvath & Luborsky, 1993; Watson & Geller, 2005; Horvath & Symonds, 1991; Bachelor & Salame, 2000, etc.). Gelso and Carter (1985/1994) advanced a model of the therapeutic relationship, put forth initially by Greenson (1967, cited in Gelso & Carter, 1994). Greensons model emanated from the psychoanalytic conceptualization of the relationship and initiated the use of the term
43 working alliance, further developed by Bor din (1979). Gelso and Carter outline the models three components: a working alliance, a transference configuration, and the real relationship (Gelso & Carter, 1994, p. 296). Transference has already been defined as the clients displacement onto the therapist of conflicts, feelings and attitudes from significant relationships in the clients life. In Gelso and Carters (1994) model, the transference configuration also includes countertransference, or the therapists transference to the clients issues or communication. The real relationship, similar to Freuds use of the term, is characterized by genuineness and realistic perceptions. Genuineness is defined as the ability and willingness to be what one truly is in the relationship to be authentic open, and honest. Here there is agreement with Rogers concepts of genuineness and congruence. Realistic perceptions refer to those perceptions that are uncontaminated by transference distortions and other defenses (Gelso & Carter, 1994, p. 297). Each of the components of this model interacts and overlaps with the others. The authors claim that these components of the therapeutic relationship exist in all forms of therapy. All of the theories and models of the therapeutic relationship and working al liance mentioned so far come from the perspective of the therapists. Bachelor (1995) examined the alliance from the perspective of the client in a qualitative study. Client ratings of the therapeutic relationship more consistently predict outcome than ei ther therapist or observer ratings (Horvath & Symonds, 1991; Watson & Geller, 2005; Fitzpatrick, Iwakabe, Stalikas, 2006) and tend to be higher than those of therapists ( Tryon, Blackwell, & Hammel, 2007). In Bachelors (1995) study, 66 descriptions were ga thered from 34 self referred clients over three phases of therapy at a university run community mental health clinic. The reports clustered around three types of alliances: nurturant, insight -oriented, and collaborative (p. 324). The nurturant type of al liance,
44 favored in 46% of the client protocols, was characterized by trust and was facilitated by therapist respect, nonjudgmental attitude, attentive listening, empathic understanding, and friendliness. The clients who wrote about the insight type of alli ance focused on self -revelation and therapist clarification type activities (39% of protocols). Only 15% of the clients in this study wrote about the alliance in terms of joint activity or collaboration with the therapist (Bachelor, 1995, p. 330). The co nclusion that all clients do not value the same kind of interaction with the therapist in building an alliance deserves attention. In a more recent study of 30 clients from three settings, Bachelor, Laverdiere, Gamache, and Bordeleau (2007) reported that of the therapist qualities deemed by clients as relevant to collaboration in therapy, the most prevalent was attentive listening. Bedi (2006) interviewed 40 outpatient clients who had received services at a university or community mental health clinic or f rom a private practitioner and reported a positive therapeutic relationship. Coding of the interviews yielded eleven common alliance formation factors: setting, presentation and body language, nonverbal gestures, emotional support and care, honesty, valida tion, guidance and challenging, education, clients personal responsibility, and session administration (p. 26). The inclusive nature of the list of factors makes it a somewhat unwieldy contribution to understanding the alliance. However, the findings sug gest that exploring how the therapist attends to these factors holds importance in establishing a positive therapeutic relationship. Ten therapists, identified as masters by their professional peers, were queried about their construction of the therapeuti c relationship (Sullivan, Skovholt, & Jennings, 2005 ). Their responses were organized into six relationship stances, three in the Safe Relationship Domain and three in the Challenging Relationship Domain. The therapists took these relationship stances at different points in therapy and with different clien ts. This constructivist approach to creating a
45 model of the therapeutic relationship from the therapists point of view contributes to the body of literature on the relationship but has not been adequately recognized. Attempts have been made to isolate factors that combine to make up the therapeutic relationship, and which correlate with outcome. Hatcher and Barends (1996) conducted a study over a five year period with 231 outpatient clients in which a factor analysis of client responses on three measure s of alliance isolated two constructs that were predictive of client improvement: confident collaboration and idealized relationship. Confident collaboration indicates clients confidence in the therapist, in the treatment and in their own ability to imp rove (p. 1330). This sounds remarkably like the definition of the expectancy/hope/placebo factor which Lambert (1992) and Hubble et al. (1999) separate from the therapeutic relationship in the common factor model. In a study of 125 individuals seeking tre atment at two university -based, community outpatient clinics Clemence Hilsenroth, Ackerman, Strassle, and Handler (2005) confirmed the importance of the confident collaboration and found consistency between client and therapist ratings, a rare finding (p 452). The idealized relationship factor addresses the degree to which clients feel they can speak up to their therapists when they disagree or have negative reactions to a therapist intervention. Hatcher & Barends (1996) study found no predictive value in the subscales of goal, bond, and task, but did in the composite alliance score. Watson and Geller (2005) examined the relationship between the TOC s and outcome as mediated by the working alliance in a study of 66 clients in a comparative treatment s tudy on depression They found that the clients ratings of the TOC (empathy, congruence, and positive regard) were predictive of improvement and concluded that these conditions facilitated the development of the working alliance (goal, bond, and task) (p. 30). In a meta analysis of clinician activities that relate to therapeutic alliance during the initial assessment and session, Hilsenroth and Cromer (2007)
46 extracted the following as some of the actions that contribute positively to the alliance: a dopt a collaborative stance toward client, s peak with emotional and cognitive content; u se clear, concrete, experience near language; f acilitate client affect and experience; e xplore uncomfortable feelings and e xplore in -session process and affect (p. 214). The measures used in these studies of the therapeutic relationship reflect the dominant models of the relationship described above. Within those models these studies suggest correlations with outcome. Working within existing frameworks allows the use of e mpirically supported instruments but also limits broader exploration of the relationship. Sexton, Littauer, Sexton, and Tommeras (2005) looked at the depth of the connection between therapist and client and how that related to ratings of the working al liance as measured by the Working Alliance Inventory In an in -depth analysis of therapy sessions between 34 clients at a Northern European outpatient psychiatric clinic and their therapists Sexton et al. (2005) found that connection was established earl y in the session and predicted the strength of the working alliance. The researchers state that therapist activities that seemed to develop connection were: (a) active focused listening, (b) keeping the topic largely centered on the client, (c) providing a relaxed warmth to the session, (d) allowing the client to become emotionally moved, (e) avoiding the provision of too much information or advice, and (f) not using a purely cognitive verbal style, a style that the client might perceive as indicating that the therapist was overly detached. (p. 114) The similarities between these activities of connection with aspects of bond TOC, nurturant alliance, and other terms used in defining the therapeutic relationship are obvious and the measure of the alliance fa miliar. The activities of connection may also be the activities of forming a relationship. Therapist self awareness may be helpful in developing an alliance as long as the therapists do not invest too much energy in managing th eir self awareness. Fauth and Nutt-Williams
47 (2005) examined the in-session self awareness of 17 therapist trainees in relation to their interpersonal involvement and the ratings of the alliance by volunteer student clients. The small sample size limits co nclusions from this study however raising self awareness as a potentially facilitative quality in developing a positive therapeutic relationship contradicted earlier findings (Williams, 2003; Williams, Judge, Hill, & Hoffman, 1997; Williams, Polster, Grizz ard, Rockenbaugh, & Judge, 2003, cited in Fauth & Nutt -Williams, 2005, p. 443) in which therapists worked to manage their self awareness so as not to interfere with their work with clients. Perhaps there are more nuanced terms for these different experien ces of self awareness, such as conscious awareness versus self -consciousness. This distinction bears relevance to this study of being present. Measurement The measurements of alliance derive from conceptualizations of the working alliance and relationsh ip. After conducting their own research in this area and reviewing decades of others research as well, Horvath and Luborsky (1993) concluded that Unfortunately, there has been no agreement across instruments as to the underlying structure of the alliance ; each instrument has different sub -scales, making such comparison impossible at this time (p. 565). Each scale emanates from a theoretical framework which dictates the variables to be rated. For instance the commonly used Working Alliance Inventory (WA I) (Horvath & Greenberg, 1989) measures three alliance dimensions outlined by Bordin (1979): goal, task, and bond. The Vanderbilt Psychotherapy Process Scale (VPPS) (Strupp and colleagues at Vanderbilt University, cited in Martin, Garske, & Davis, 2000, p. 440) appraises patient and therapist exploration, patient participation, patient hostility, therapist warmth and friendliness, negative therapist attitude and therapist directiveness (Bachelor & Salame, 2000). The Helping Alliance Questionnaire is base d on Luborskys (1976) model of alliance and assesses perceived helpfulness and support of
48 therapist as well as collaboration on goals. The Therapist Bond Scales (TBS) ( Saunders, Howard, & Orlinsky, 1989) include measures of working alliance, empathic resonance, and mutual affirmation. Here, working alliance is defined as the investment client and therapist make in their roles and the genuineness with which they bring themselves into the relationship (Saunders et al., 1989, p. 323). The other dimensions bear resemblance to Rogers empathy and positive regard, but focus more on the relational aspects rather than on therapist activity. The California Psychotherapy Alliance Scales (CALPAS) assess what the authors term therapeuti c alliance, working alliance, therapist understanding and involvement, and client -therapist agreement on tasks and goals (Gaston & Marmar, 1994). Gelso and colleagues recently developed a measure of the concept of the real relationship as defined by Gelso and Carters (1994) model of the therapeutic relationship, focusing on genuineness and realism (Gelso, Kelly, Fuertes, Marmarosh, Holmes, Costa, & Hancock, 2005). It makes sense that measures of a construct fit within a therapeutic framework and yet the variety of concepts being explored under the umbrella of the therapeutic relationship and the working alliance leads to some confusion as well as difficulty in replication and comparison. In addition, other ways of looking at the alliance, such as moment to -moment fluctuations in the quality of the patient therapist relationship might bear a different relationship to therapeutic outcome and paint a different picture of the alliance itself (Crits Christoph, Gibbons, & Hearon, 2006). The diversity in theory and measurement as well as the exclusive use of a few models and measures indicate that there is more work to be done in clarifying the complex interactions in the therapeutic relationship. In a review of the conceptualization and measurement of the th erapeutic alliance, Elvins and Green (2008) came to a similar conclusion. Therapeutic alliance constitutes a major variable in explaining the outcome of treatment. However, meta analytic, narrative, and theoretical reviews have all begun to comment on
49 sign i fi cant defi ciencies in both conceptualization and measurement of alliance. While the evidence on the overall impact of alliance on treatment outcomes is impressive, we know much less about its components, modeling and discrete measurement. (p. 1167). Clie nt Characteristics and the Relationship What the client brings to the relationship deserves mention in any review of literature on the therapeutic relationship. Client perspectives on the therapeutic relationship were explored above. Here I look at litera ture on client characteristics as they relate to the therapeutic relationship. In reviewing the empirical literature on client variables, Asay and Lambert (1999) reported that the most frequently mentioned are the severity of disturbance (including the number of physical symptoms involved), motivation, capacity to relate, ego strength, psychological mindedness, and the ability to identify a focal problem (Lambert & Anderson, 1996; Lambert & Asay, 1984) (p. 31). Strupp (1980, cited in Asay & Lambert, 1999, p. 32) analyzed a series of case studies of male college students and their therapists and concluded that client variables that influenced their ability to form relationships with the therapists made the difference in treatment outcome. Horvath and Lub orsky (1993) also reviewed the clients contribution to the working alliance and noted that clients who have difficulty with social or family relationships also have more difficulty establishing a strong working alliance (p. 567). On an intrapersonal leve l, clients with poor object relations, greater defensiveness, and less psychological mindedness have trouble entering into an alliance as well (Horvath & Luborsky, 1993, p. 567). Tryon, Blackwell and Hammel (2007) conducted meta analyses of client -therapi st alliance ratings in 53 studies published in refereed journals from 1985 through 2006. They reported that clients rated the alliance higher than therapists and that client disturbance was a significant moderator of rating differences between therapist an d client. These findings raise questions about the impact of the therapist offered conditions on the relationship. The interpretation of Rogers (1957) necessary
50 and sufficient conditions to be therapist offered conditions only, however, neglects the two that require involvement of the client: one, that the client and therapist must be in contact with one another, and two, that the client must perceive the therapists empathy and positive regard (Rogers, 1957). The client must be willing and able to ent er a relationship to some extent. The relationship is a co-created phenomenon so that each participant contributes to and influences the nature of that relationship. At the same time, there is something to be learned by exploring what therapists are attending to that their ratings of the alliance differ significantly from those of clients. Summary The therapeutic relationship, one of four factors in therapeutic change common across theoretical orientations, accounts for a significant percentage of change in therapy (Lambert, 1992). As ratings of alliance increase so do ratings of client improvement (Clemence Hilsenroth, Ackerman, Strassle, & Handler 2005). Meta analyses show a moderate but reliable and consistent association between working alliance a nd outcome (Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000). A variety of definitions and identifications of components of the relationship have been studied (Horvath, 2006; Horvath & Luborsky, 1993). Disagreement remains over how the alliance ope rates and what contribution each participant must provide for the development of a strong working alliance in therapy (Frieswyk et al., 1986; Gaston, 1990; Gelso & Carter, 1985; Hatcher, 1990; Horvath & Greenberg, 1987; Luborsky et al., 1985) (Horvath and Symonds, 1991, p. 147). The working alliance as a pan-theoretical construct, removed from its psychoanalytic context, has become isolated from a theoretical framework that would explain its part in therapeutic change (Horvath, 2005). Clients are not a h omogeneous group in terms of what they value in a therapeutic relationship (Bachelor, 1995). Therapist ratings of alliance are generally less predictive of outcome than clients, (Bachelor, 1995;
51 Bachelor & Salame, 2000; Asay & Lambert, 1999; Clemence et al ., 2005; Horvath & Luborsky, 1993; Lambert & Bergin, 1994). Therapist Characteristics and Development Therapist Characteristics With the understanding that the therapeutic relationship plays a significant part in the outcome of therapy, I turn now to the literature related to the contribution of the therapist to the relationship and to client change. In addition, I look at research findings on master therapists and models of counselor development as a developmental continuum. Ackerman and Hilsenroth (2003) conducted a meta analysis of twenty five studies of therapist qualities associated positively with the therapeutic alliance, as defined by Bordin (1979). Various theoretical orientations and level of therapist experience were represented in the studies included in their review. The following personal attributes of the therapist were reported to contribute positively to the alliance: flexible, experienced, honest, respectful, trustworthy, confident, interested, alert, friendly, warm, and open (Ackerman & Hilsenroth, 2003, p. 28). In a more recent metaanalysis of clinician interventions related to alliance, Hilsenroth and Cromer (2007) note the following therapist qualities and attitudes significantly relate to positive alliances: empathy s upport expl oration, activity, confident collaboration appreciation, trust warmth attunement potency competence respect attentive, engaged listening and appearing to understand the client without being judgmental Assigning causality, however, is questionable in either direction (therapist qualities predict alliance or alliance predicts qualities). In fact, the therapist qualities are treated as part of the alliance itself in several measures (The Vanderbilt Psychotherapy Process Scale, The Therapist Bond Scal es, California Psychotherapy Alliance Scales).
52 Contrary to Ackerman and Hilsenroths (2003) finding that experience is a facilitative therapist quality, Dunkle and Friedlander (1996) found level of experience was not predictive of positive alliance ratings in their study of 73 university counseling center therapists. Whether or not experience helps therapists build more positive therapeutic relationships is relevant to the definition and characterization therapist development and mastery. Master therapists tend to be experienced therapists and they tend to be relationally skilled (Skovholt & Jennings, 2004). Experience may correlate with therapist expertise and the formation of positive relationships however it does not apparently predict these outcomes. What Dunkle and Friedlander (1996) did find to b e predictive of the bond component of the alliance was the therapists level of self directed hostility, perceived social support, and degree of comfort with closeness in interpersonal relationships In her study of 34 outpatient clients perceptions of t he therapeutic alliance, Bachelor (1995) found that facilitative therapist qualities of respect, being nonjudgmental, and careful listening, including empathy as well as a climate of trust, were valued by most clients regardless of preferred type of allia nce (p. 330). Not surprisingly, Najavits and Strupp (1994) found that therapists who showed more warmth and friendliness, more affirmation and understanding, and a minimum of attack and blame had higher rating of the alliance. These findings come from a small sample of all white, experienced therapists trained in psychodynamic therapy who had similar caseloads and problem severity, but nonetheless have been widely generalized. Grunebaum (1986) interviewed 47 clients all of whom were mental health professi onals themselves who believed they had been harmed by psychotherapy. The study lacks methodological rigor but offers subjective accounts of therapies considered harmful by clients. Harmful therapy was characterized as distant, cold, unengaged, and lackin g in human quality in
53 addition to the more obvious ethical breeches of intensely emotionally or sexually involved therapy. Jennings, Skovholt and colleagues created what they called a portrait of the master therapist, or the Highly -Functioning Self base d on multiple analyses of longitudinal interviews with ten master therapists, selected by their professional peers for their mastery (Jennings, Goh, Skovholt, Hanson, & Banerjee -Stevens, 2003; Skovholt, Jennings, & Mullenbach, 2004). The authors organized the characteristics of the highly functioning self of the therapist into four types of characteristics paradoxical, word, identifying and central. Paradoxical Characteristics include Drive to Master and Never a Sense of Having Fully Arrived, Ability to be Deeply Present with Another and Often Preferring Solitude, Great at Giving Of Self and Nurturing Of Self. Examples of Word Characteristics are: congruent, intense, open, curious, reflective, and self aware. Central Characteristics were organized i nto cognitive, emotional, and relational domains. In the Cognitive Domain, the authors give as examples Embraces Complex Ambiguity and Profound Understanding of the Human Condition; under the Emotional Domain, deep acceptance of self, and Intense W ill to Grow, and finally in the Relational domain, Piloted by Boundaried Generosity and Able to Intensively Engage Others (Jennings et al., 2003, p. 66; Skovholt, Jennings, & Mullenbach, 2004, p. 135). Again, similarity exists between these character istics and those mentioned by other researchers, but these authors add a level of complexity by including paradoxical characteristics and by thickening the description of therapist characteristics. These studies were limited by the fact that the therapist s were all of European descent, all in private practice where they were selective in the clients they saw. These categories have not been examined in terms of how they contribute to therapeutic effectiveness other than the assumption that the therapists wh o generated the data were considered masters
54 by some consensus. If, however, these therapists are in practice effective therapists, which in turn implies that they have the capacity to establish positive therapeutic alliances, then this portrait of maste ry has relevance for this study. Counselor Development The qualities and abilities of the master therapist as outlined above contrast sharply with the characterization of novice counselors in various models of counselor development. In the early stages of each of the following theories or models of counselor development, the counselor trainee is characterized by anxiety, dependency, focus on technique, lack of awareness, and black and white thinking. As will be noted, most models encompass the development of counselors through training and in some cases also their early professional years. Targeting this period of counselor development may be due primarily to the need for models to serve as guides to supervisors. It may also be attributed to the accessib ility of this population for research and observation. Several of the predominant models are described below. Hogan (1964) proposed four stages in a model of counselor development, from beginning counselor through master psychologist. Counselors begin as dependent, neurosis bound, insecure, uninsightful, motivated and imitative and through the following stages develop greater autonomy, confidence, insight, and self awareness. The final stage, the master psychologist, represents seasoned therapists well b eyond their training years, although no time frame was suggested in the model. Hogans model stimulated other theorizing as well as research to test the model. Reising and Daniels (1983 ) study of 141 counseling psychology graduate students at twenty univ ersity counseling centers supported some of the factors related to Hogans model, however their findings suggested that counselor development is not a linear process, but a complex one. Such findings have implications for all the stage models of developme nt.
55 Hill, Charles, & Reed (1981) analyzed counseling sessions and interviews with 12 counseling psychology students through three years of doctoral training and derived a conceptual model of stages of counselor development over the training period. The f our stages in this model are labeled sympathy, counselor stance, transition, and integrated personal style. In these stages, the counselor trainee moves from over involvement and responsibility for client and difficulty setting limits and boundaries, to a stage in which the counselor learns techniques and adopts a model as part of looking to the supervisor or other experts for the right way to do counseling, to a transition stage involving disruption and anxiety and finally to the stage of integration when counselors have more confidence and trust in themselves, are more flexible and able to use personal reactions as tools in therapy. This model has not been thoroughly investigated however it is one of the few derived from empirical data. Loganbill, Har dy, & Delworth (1982) proposed a model of counselor supervision which included assessing counselors in terms of a stage model of development. The model is heavily influenced by the theories and assumptions of developmental psychology, in particular those of Erik Erikson and Margaret Mahler (Loganbill, Hardy, & Delworth, 1982, p. 14) and also derives from the literature and the authors experience in counselor education and supervision. According to this model, the three stages of development stagnation, confusion, and integration are distinct and sequential. Counselors may repeat the cycle numerous times throughout their life span each time at a deeper level and with more thorough processing of the issues in that stage. The initial stage, stagnation, is exemplified by narrow or rigid thinking, nave sense of security, dependency, low self concept in the counseling role, and lack of awareness. This stage is followed by the confusion stage which is characterized by instability, disorganization, confusi on, and an unfreezing of attitudes. This may result in some panic and grasping to regain
56 the security of stage one. The third stage, integration, involves reorganization, integration, flexibility, greater awareness, and personal security based on the awar eness of insecurity. Stoltenberg (1981) integrated Hogans (1964) stages and Hunts (1971, cited in Stoltenberg, 1981) Conceptual Systems Theory into what he named the Counselor Complexity Model. Stoltenberg maintained that counselor trainees develop in a predictable way through their training. Stoltenberg designed supervisory environments that he theorized based on Hunts conceptual development theory would be optimal in facilitating the counselors development at the different stages (see description o f Hogans theory above). He suggested that by the master counselor stage supervision if received at all is primarily collegial and the counselor can work independently. He also noted that not all counselors reach that stage of development. It can be ass umed that Stoltenberg intended that supervisors may impede counselors progress by not providing what Stoltenberg called optimal environments at the different stages. There may also be other counselor related factors that contribute to a lack of growth but these were not addressed. Wiley and Ray (1986) created an instrument to test the validity of an elaboration of Stoltenbergs model. After three pilot studies, data for this study were collected from 107 counselor trainee -supervisor dyads at university counseling centers. The authors reported that developmental stage was not predicted by training level and that matching the developmental level of the trainee with the environment considered optimal for that level did not predict satisfaction and learning r atings. The additional finding of a high percentage of trainees at the master counselor level challenged the conceptualization of that stage as one reached later in a counselors career. Replicating or further exploring this finding might help clarify the definition or meaning of the characteristics of this stage. Stoltenberg, McNeill, and Delworth (1998) put forth an integrated developmental model of supervision as an extension of Stoltenbergs earlier
57 work. Here again, the counselor moves from dependen cy toward greater autonomy, from anxious over -emphasis on self to greater ability to see the clients view, from simple explanations based on one framework to alternative and more complex conceptualizations. In the intermediate stages counselor is in a re organization process of giving up adherence to one framework but not having yet integrated others, and may experience confusion, overload, lack of motivation, or doubt about the profession. The models of counselor development reviewed above (Hill, 1981; H ogan, 1964; Loganbill, Hardy & Delworth, 1982; Stoltenberg, 1981; Stoltenberg, McNeill, & Delworth, 1998) are stage models and focus on development through the process of training and to some extent immediately after completion of training. There is no specification of how to evaluate or define the aspects of each stage and there is no indication of how students transition into the next stage. The relationship between experience and development is left unclear as well. And the complexity of the developmental process is not addressed. The models primarily attend to the kind of supervision best suited to counselors at the different stages. In a different approach, Jennings, Ronnestad, Skovholt, and their colleagues looked at the development of therapists over their life span in a series of qualitative studies and identified themes in therapist development and a model of the master therapist (see above section on Therapist Qualities) (Ronnestad & Skovholt, 2003; Skovholt & Jennings, 2005; Skovholt & Ronnesta d, 1992). Skovholt and Ronnestad (1992) analyzed interviews with 100 therapists ranging from first year in grad school to 40 years post grad school and identified twenty themes of therapist and counselor development. The therapists in the study were all from Minnesota and 96% of them were white. The findings must be viewed within the limitations of these contexts. The authors structured the data to provide description of the phases of development in the following
58 categories: experience and training, central task, predominant affect, sources of influence, role and working style, conceptual ideas, learning process, and measures of effectiveness and satisfaction. In a later reanalysis of the data from this study, Ronnestad and Skovholt (2003) reformulated the twenty themes into fourteen themes and six phases of development beginning with the lay helper and continuing to beginning student, advanced student, novice professional, experienced professional, and finally the senior professional. The authors note that the term phase, as opposed to stage, implies some fluidity in the boundaries of developmental processes. In this model as in others, the beginning student counselor is often plagued by anxiety when seeing clients such that it is difficult for them to concentrate, focus attention, cognitively process and remember what happened during the hour (Ronnestad & Skovholt, 2003, p. 12). The students seemed calmed by learning methods and skills and look to experts for guidance and validation. This character ization of novice therapists seems consistent across models. The same limitations regarding the homogeneity of the participant therapists apply to this study as to the earlier study. This study contributes a developmental model that follows the continued growth of the therapist through the life span which makes its scope unique among counselor development models (Goodyear, Wertheimer, Cypers, & Rosemond, 2003). Goodyear, Wertheimer, Cypers, and Rosemond (2003) in their response to Ronnestad and Skovholt (2003) note that some researchers had found that anxiety is not as prevalent in novice counselors as suggested by many of the earlier models along with this one. However, Skovholt and Ronnestad (1992 ) hypothesized that younger therapists are hesitant to t alk about their anxiety or are perhaps even unaware of it. They reported that the more senior professional therapists remember their novice years as anxious, especially in contrast to their experience as mature counselors.
59 What is missing from the dominant models of counselor development is exploration or theory regarding how counselors transition from one stage or phase to another (Worthington, 2006). In a review of theoretical and empirical literature on counselor development and supervision, Worthington (2006) did not report on the one exception. In addition to their model and themes of counselor and therapist development, Ronnestad and Skovholts (1993, 2003) offer a process model of development and stagnation. Just as with other developmental models, years of experience do not guarantee progress through all the phases of development. In contrasting stagnation and growth, the authors suggest that Openness to learning and an ability and willingness to recognize the compl exities of professional work is crucial for growth (Ronnestad & Skovholt, 2003, p. 13). Therapists who grow do not respond to challenge or anxiety by prematurely closing down, for instance by committing to one method or to one client age group or populati on. Instead therapists who grow are adaptive and remain open even in the face of uncertainty. These processes are relevant to the study of being present. Presence The term presence is absent from the language and research literature on the therapeutic relationship and the working alliance. However, therapists from various theoretical orientations have written about their experience with presence Although many of these therapists hail from humanistic traditions, studies have also shown the importance o f therapist offered conditions in therapies that focus more on technique than relationship (Watson & Geller, 2005; Lambert & Bergin, 1994). In spite of the number of writings on presence, a common language does not exist (Phelon, 2001). Writers have worked in relative isolation. Not only does this make the literature difficult to share among interested writers, but it testifies to the difficulty of putting into words the experience of presence. For these reasons, the authors own words are quoted often i n this section. The first part of this discussion of therapeutic presence reports the ways therapists
60 working within different theoretical frameworks have described their experience of presence. Then researchers efforts to study presence will be detailed Presence: Conceptual Literature In the psychoanalytic context, Freud advised therapists to use evenly hovering attention as opposed to selective or forced attention (Freud, 1912/1961). Theodore Reik (1948) wrote of listening with the third ear as his way of describing presence. It can be demonstrated that the analyst, like his patient, knows things without knowing that he knows them. The voice that speaks in him, speaks low, but he who listens with a third ear hears also what is expressed noiselessly what is said pianissimo. .The psychoanalyst who must look at all things immediately, scrutinize them, and subject them to logical examination has often lost the psychological moment for seizing the fleeting, elusive material. (p. 145) He went on to s ay that this third ear may be turned inward so that the therapist may hear voices from within the self that are otherwise not audible because they are drowned out by the noise of our conscious thought -processes (Reik, 1948, p. 146). These descriptions e voke a sense of what may be called presence and are reminiscent of the characteristics of the master therapist (Jennings, Goh, Skovholt, Hanson, & Banerjee Stevens, 2003; Skovholt, Jennings, & Mullenbach, 2004). In Martin Bubers (1970) I-thou relationshi p, presence takes on the dimension of a meeting not solely a presence coming from one person in the relationship. In addition, the present exists only insofar as presentness, encounter, and relation exist. Only as the You becomes present does presence come into being (Buber, 1970, p. 63). And in that relating, if we objectify anything, whether object or human, we relate to an it. True presence in direct encounter is the only way we know ourselves as an I and experience being alive (Buber, 1970, p 67). This view of presence as meeting contrasts with some of the more intrapersonal descriptions of presence explored later (Korb, 1988; Pemberton, 1977).
61 Rollo May (1989), an existential, humanistic psychotherapist, described presence in terms of empathy, meaning feeling into. The source of empathy is the ability to identify with another person and understand. It is what he called participation in oth ers that allows us to understand them. To know the meaning of beauty or love or any of the so -called values of life, we must let ourselves participate in them. Thus experiencing them, we shall know them on our pulse, as Keats puts it. It is sheer f olly to think that another person can be known by analysis or formulas; here understanding as participation comes into its own. (May, 1989, p. 67) He introduced the words experiencing and participation into the notion of being present. The existentiali st approach to therapy, as described by May (1958) relies on a real relationship between therapist and client in which the therapist is first a human being and second an expert in human existence. It is in being present with the client that the client may be sparked to be present in his/her own alive experience. As such, the therapist will need to be aware of whatever in him blocks full presence (May, 1958, p. 84). However, real confrontation between two people can be profoundly anxiety -creating (May 1958, p. 85) which makes understandable therapists temptation to protect themselves with the distance of technique or expertness. Crucial in the effort to be present is awareness of that temptation so as not to harm the client by denying connection and validation. Another existentialist, Bugental (1987) described presence as: .the quality of being in a situation or relationship in which one intends at a deep level to participate as full as she is able. Presence is expressed through mobilization of ones sensitivity both inner (to the subjective) and outer (to the situation and the other person(s) in it) and through bringing into action ones capacity for response. (p. 27) In existential theory, people experience anxiety due to the inevitability of the conditions of living: death, isolation, meaninglessness and freedom. It is the connection and presence of others that helps people confront, accept and tolerate these conditions.
62 Carl Rogers person -centered theory formed a key piece of the conve rsation about the therapeutic relationship. He maintained that significant positive personality change does not occur except in a relationship (Rogers, 1957, p. 96). The therapist offered conditions of empathy, congruence, and warmth also fit intuitivel y with the descriptions of presence by Buber (1970), May (1958, 1989) and Bugental (1987). In person-centered therapy the therapists function is seen as being immediately present to his client, relying on his moment -to -moment felt experience in the rela tionship (Rogers, 1989, p. 16). He added the qualifier accurate to the more common use of the word empathy in establishing his necessary and sufficient conditions for change. Being present in the clients world, in a moment -to -moment sensitivity in the here and now, in the immediate present (Rogers, 1989, p. 16), therapists are more likely to offer accurate empathy. In another approach from the humanistic tradition, Gestalt therapy, the concept of presence plays a central part in the therapy process. For Gestalt therapists, being present means making authentic contact either with oneself or with the environment which includes awareness at the sensory as well as the cognitive level (Korb, Gorrell, & Van De Riet, 2002). Authentic contact is not passive, something that just happens when in the presence of another. According to Laura Perls ( 1978/ 1992), contact is an activity; I make contact on the boundary between me and the other. The boundary is where we touch and at the same time experience separateness. It is where the excitement is, the interest, concern, and curiosity or fear and hostility, where previously unaware or diffused experience comes into focus, into the foreground as a clear gestalt. (p. 53, emphasis in the original) For both the rapist and client, being present and making contact with the environment facilitates satisfaction (completion of gestalten) and frees the person up for new growth (emergence of new gestalten). One goal of Gestalt therapy is maturation, or self -support and people are more able to be self -supporting by being present -centered which means being aware (Yontef, 1995, p. 278).
63 Being present in Gestalt therapy exists in the context of dialogue. The dialogic relationship is marked by three I thou characteristics : (1) inclusion and confirmation, (2) authentic presence and self -disclosure, and (3) a commitment to dialogue (Hycner, 1985, 1991; Hycner & Jacobs, 1995; Jacobs, 1989, 1992; Yontef, 1993) (Yontef, 1995, p. 282). Korb (1988) described her experience of presence this way. Material emerges in me that I have not thought, imagined or articulated in the way I do at that moment. .They [images and ideas] arise in me spontaneously; I am present in the words or images or ideas; any spoken language has a poet ic quality, any silence is affirmation without speech. I have no sense of time passing I am aware of nothing but the present; I see and hear clearly with no impediment or interruption; my perceptions do not alternate between figures for there is only on e figure, the whole of what is present. (p. 100) Korb characterized her experience as intrapersonal and at the same time this state of presence allows her to make more unimpeded contact with her clients (Korb, 1988, 101). Stern (2004) investigated the pre sent moment, a different angle of view of the experience of presence. He outlined features of a clinically relevant present moment (2004, p. 32): awareness or consciousness, not a verbal account of an experience; felt in the now; of short duration; psychologically significant to break through into consciousness; holistic happenings; temporally dynamic; unpredictable; involves a sense of self; and vary in importance (pp 32 40). He drew on neurological research for support for some of his conclusions. I n one example, he told of mirror neurons that fire in an individual observing another person doing something in the exact pattern as if the observer were performing the same action. We experience the other as if we were executing the same action, feeli ng the same emotion, making the same vocalization, or being touched as they are being touched (p. 79). Other mechanisms help synchronize one persons movements with anothers, allowing them to participate in each others experience. Stern added that im plicit knowing is part of the present moment, a knowing that is nonsymbolic, nonverbal, procedural, and unconscious in the sense of not being reflectively
64 conscious (p. 113), similar to Reiks (1948) listening with the third ear. In Sterns descripti on of the therapeutic present moment, boundaries between therapist and client become permeable, as in Korbs (1988) numinous ground, even as the selves remain differentiated: intersubjectivity rather than fusion (Stern, 2004, p. 77). In the intersubject ive present moment, You have your own experience plus the others experience of your experience as reflected in their eyes, body, tone of voice, and so on. Your experience and the experience of the other need not be exactly the same. They originate from different loci and orientations. They may have slightly different coloration, form, and feel. But they are similar enough that when the two experiences are mutually validated, a consciousness of sharing the same mental landscape arises. (Stern, 2004, p. 125) There are noticeable similarities between Sterns intersubjective present moment and Bubers (1970) Ithou meeting. Buddhist philosophy and practice is finding its way into psychotherapy (Welwood, 2000; Aronson, 2004; Anderson, 2005; Geller, 2003). Buddhist mindfulness practice is used to develop awareness and acceptance of what is, as opposed to what is wished to be, and to gain detachment from desire for particular outcomes. Welwood (2000) calls this unconditional presence (p. 141). This pres ence is open and humble. Suzuki Roshi, a teacher of Zen Buddhism, coined the term beginners mind to express this idea. In the beginners mind there are many possibilities, in the experts there are few ( Suzuki, 1973). Welwood (2000) described the va lue of open presence, or beginners mind, to therapy: . when they [therapists] operate from not knowing, they are more likely to embody authentic presence. Letting themselves not know what to do next invites a deeper quality of stillness and attentiveness into the work (p. 142). Empirical Studies of Presence It is stunning to juxtapose these powerful descriptions of presence with its absence from the research literature on the therapeutic relationship. Presence fits intuitively in the realm of the
65 relationship and thus studying this phenomenon holds importance for the counseling profession. Studying such a complex phenomenon presents a challenge. Several researchers have taken the challenge and contributed to an understanding of presence. The following is a look at studies of presence to date from the counseling and psychotherapy literature as well as from some other disciplines. Pemberton (1977) studied five psychotherapists purposefully selected for their reported effectiveness and presence. T he purpose of his study was to arrive at an operational definition of presence and develop a model of how presence is achieved, maintained and lost (Pemberton, 1977). His model of presence was derived from his observations of the therapists at work and from follow up interviews, however he did not delineate the coding or distillation process. The therapists in the study were well known in the field at the time of the study but no inclusion criteria were provided. The value of this study lies in three a reas. First, the language characterizing presence is broadened. Pemberton (1977) named the forces that enable or generate presence: focusing, extending, and enfolding (p. 4), defined in the following way. Focusing is the ultimate act of moving inward in order to fully be at one with oneself . Extending is the ultimate act of moving out ; opening, enlarging, and elongating boundaries . Enfolding is the ultimate act of taking in something that is exterior to oneself. Websters (1968) defines enfolding as, to fold inward or toward one another (p. 433), and The American College Dictionary (1964) adds, to clasp, embrace (p. 624). Enfolding is pure receptivity. (Pemberton, 1977, p. 45, emphasis in the original) Second, Pemberton (1977) concluded th at presence is an intrapersonal phenomenon rather than an interpersonal one. The coming together described by other writers, Pemberton suggested, happens when both people are individually present at the same time, in the relational realm. He called this meeting (Pemberton, 1977, p. 5). Third, he made the claim that healing is the immediate result of presence or meeting, (Pemberton, 1977, p. 6). Healing was described as a momentary process, happening over and over again, the outcome of which is
66 authen ticity, centeredness, purpose, clarity, and autonomy (Pemberton, 1977, p. 7). Further research needs to test the usefulness of focusing, extending, and enfolding in generating presence as well as the claim of the healing capacity of presence. Fraelich (1989) conducted a phenomenological study of presence in which he interviewed six practicing psychotherapists, three in private practice and three from a community mental health clinic. Fraelich analyzed the transcripts of the interviews using methodology delineated by Moustakas (1994) to identify the essential structures of the phenomenon of presence. He reported the following Thematic Structures of Presence: (1 ) p re sence as spontaneous occurrence, (2 ) i mmersion in the moment ( 3 ) o penness of being and ( 4 ) living on the cutting edge Fraelich concluded that his study substantiated the existence of presence, previously addressed only theoretically, and suggested presence as a powerful influence in psychotherapy. The theme of presence as spontaneous occur rence brings up the question of whether or not presence may be cultivated purposefully. Fraelich did not reference Pembertons (1977) study and noted that no quantitative or qualitative studies had been conducted up to that time on the nature of presence. This illustrates the marginalized status of the study of presence and lack of communication among researchers with presence as an area of interest. Phelon (2001) tackled the exploration of presence using several innovative methodologies. She began with a hermeneutic study of texts addressing presence from a wide variety of fields. Next a panel of experienced therapists, chosen because they had experienced a therapists presence and could discuss it, refined the categories derived from the hermeneutic st udy in two cycles of a process of sympathetic resonance (Phelon, 2001, p. 6) to arrive at the final distillation. The final distillation yielded nine elements (revised from the original nineteen) that Phelon (2001) grouped into three interactive categor ies: (a) development and growth, which
67 includes seasoning, commitment to personal growth, integration and congruence, and spiritual practice and belief; (b) qualities of awareness, including attentional ability, inner awareness, and kinesthetic aspects of presence; and (c) therapeutic alliance, including alignment with the client, and receptivity (p. 128). Phelon called this study an intuitive inquiry based on a process outlined by Anderson (1998, 2000, cited in Phelon, 2001, p. 5). This study demonstra tes an attempt to create methodologies that enable researchers to apply rigor while investigating complex, intangible phenomena. Presence in the context of medical healing takes on a more spiritual quality, although the spiritual dimension of presence also showed up in Phelons (2001) study. In a project by the New Creek Foundation, a nonprofit organization interested in healing, two components of a healing presence were agreed upon by participants: love and good intentions (Jonas & Crawford, 2004). Her e, love was described as a deep emotional connection with the spiritual or divine aspect of another person and rooted in the now (2004, p. 752). Nothing is known about the participants or the design of the project so its usefulness lies only in expa nding the languaging about presence. Literature from the nursing field attempting to define presence has been primarily theoretical and descriptive, just as it has in the field of psychotherapy. Two dimensions of presence emerge from that literature that McDonough -Means, Kreitzer, and Bell (2004) identify as physical and psychologic, or being there and being with. Physical presence involves bodyto -body proximity and the requisite skills of seeing, examining, touching, doing, hearing, and huggin g or holding. Psychological presence involves mindto -mind contact. To be psychologically present requires that the caregiver have skills of listening, attending to, caring, empathy, being nonjudgmental, and accepting. (p. S 25) A third dimension of therapeutic presence, the spiritual level, requires centering, intentionality, intuitive knowing, at -one -ment, imagery and connecting (McKivergen &
68 Daubenmire, 1994, cited in McDonough et al., 2004, p. S 25). All three dimensions compare with how presence h as been described in therapy. Structuring presence in a way that separates body, mind, and spirit, however, differs from a non -dualistic or holistic view. Also useful from the medical healing literature is the conceptualization of presence on a continuum rather than as dichotomous (one is either present or one is not) (Ost erman & SchwartzBarcott, 1996) The continuum model from presence to partial presence to full presence to transcendent presence -also operationalized presence to an extent and may be adaptable to research in psychotherapy. Drawing on other disciplines provides multiple viewpoints of perhaps a common experience that can be enriched by further study and is consistent with a constructionist way of knowing. Two other studies from outs ide the psychotherapy field focused on presence and not only provide additional points of view of presence but contribute other approaches to the study of presence. Kokinakis (1995) conducted a naturalistic study of yoga therapist training at a yoga train ing institute. Her findings suggested that loving presence is fundamentally important in the yoga therapists practice and thus is important as part of training. Loving presence was defined as knowledge of self (dual and non-dual), conscious awareness, an d an attitude of non attachment. As yoga is a practice that involves the body, there were important kinesthetic aspects of loving presence such as s ynchroniz ing breathing with client Kokinakis outlined training practices that promote or cultivate loving presence in the yoga therapist, beginning with cultivating loving presence toward oneself and then involving breathing and yoga postures done in connection with others and with an attitude of open, nonattachment. Kokinakis addressed the Eastern and Weste rn cultural values and beliefs that influence the meaning of loving presence. This is the only study to address multi -cultural considerations in exploring presence. This study
69 emphasized the place of the body in presence. Curry s (2003) study also highli ghted kinesthetic aspects of presence in looking at patients of naturopathic medicine and their experience of presence. Curry transcribed and coded interviews with the patients and with her co -researcher continually checked back with the patients as they w orked to create a synthesis of their experience. Currys analysis yielded components of healing presence in the following categories: predisposition to having healing presence experience, characteristics that promote healing presence, characteristics that block healing presence, characteristics about the interactive nature of healing presence, felt descriptors of the experience, mindful appraisals for meaning making, and lasting changes or transformations of heart & mind. Their final synthesis statement i ncluded the following characteristics of healing presence: m ind, body, spirit connectedness cocreated between client and practitioner ; c lients feel held and at ease ; c lients trust they will be heard and accepted for who they are ; f elt in the body and c lients feel a shift toward health Currys findings are in synch with Pembertons (1977) claim that presence is healing. In contrast to Pemberton (1977) but similar to many other descriptions of presence (e.g. Buber, 1970; Bugental, 1987; Rogers, 1989; Ste rn, 2004; Yontef,1995) is the description of presence as a cocreated or in between experience. Geller (2001) conducted a two-part study of therapeutic presence. First she interviewed seven therapists who had written about or were proponents of therape utic presence. From a five stage analysis of the interview data Geller constructed a model of therapeutic presence, which was then checked by a panel of experienced therapists and her supervisor (2001). This study employed a standard and rigorous qualita tive methodology. The resulting model of presence comprises three parts: (a) preparing for presence, (b) the experience of presence, and (c) the process of presence. Preparing for presence includes both practices in life that promote the
70 therapists ab ility to be present and pre -session preparation such as bracketing, clearing a space, and setting an intention to be present. Components of the process of presence are receptivity, inwardly attending, and extending. The experiencing of presence involve s immersion, expansion, grounding, and being with and for the client (p. 60). Presence as a holistic experience defies being pulled apart into pieces so it must be understood that each of these parts overlaps and intertwines with the others. The therapist s in the study also referred to presence as a continuum, expressed in terms of the intensity of the connection (p. 57). In the second part of Gellers (2001) study, she created a measure of presence, the Therapeutic Presence Inventory (TPI), based on the model of presence derived in the first part of the study (p. 117). The questionnaire reflects the therapists experience of presence during a therapy session with a client. A second version reflects the clients experience of the therapists presence. The author provided a thorough description of the measures taken to test validity and reliability of the TPI and the resulting data indicating adequate levels of both. This study makes four contributions to the study of presence. First, consistent with fi ndings that clients ratings of the working alliance are most predictive of therapeutic outcome (Horvath & Symonds, 1991; Bachelor & Salame, 2000; Clemence et al., 2005; Fitzpatrick et al., 2005) client ratings of therapist presence were more predictive of both the alliance and session outcome than therapists ratings (Geller, 2001, p. 182). Second, clients ratings of therapist presence correlated with their ratings of the working alliance and with session outcome, suggesting that presence contributes in some way to both. Third, the TPI offers a measure of therapeutic presence that opens a door to further research. And fourth, the preparation for presence part of the model of therapeutic presence offers guidance in beginning to think about training coun selors to be present. Every participant in Gellers study mentioned some form of
71 meditative practice as part of their preparation for being present. The next section reviews literature related to mindfulness meditation in particular. Mindfulness Meditati on In this section, I will define and describe some of the applications of mindfulness and mindfulness meditation. Mindfulness is a universal human capacity to pay attention in the moment without judgment. Mindfulness is said to be the foundation of being present (Morgan & Morgan, 2005) and mindfulness meditation is a practice to develop mindfulness and presence. Psychotherapy research on mindfulness meditation has focused primarily on the effects of teaching mindfulness practice to clients as a therapeuti c intervention (Baer, 2003). Results from various studies of the effects of mindfulness meditation practice show reduced anxiety (Kabat Zinn, Massion, Kristeller, Peterson, Fletcher, Pbert, et al., 1992; Shapiro, Schwartz, & Bonner, 1998), depression (Teas dale, Williams, Soulsby, Segal, Ridgeway & Lau 2000), eating disorders (Kristeller & Hallett, 1999), and pain (Kabat -Zinn, Lipworth, Burney, & Sellers, 1 987), and heightened pe rformance and life satisfaction (Brown & Ryan, 2003). These results must be co nsidered suggestive due to methodological limitations such as lack of control groups, small sample sizes, lack of evaluation of integrity of treatments (i.e. training of therapists to teach mindfulness meditation and evaluation of their performance). Mind fulness principles and practice have been incorporated into or combined with existing theoretical approaches to psychotherapy, e.g. Mindfulness Based Cognitive Therapy (Segal, Williams, & Teasdale, 2002), Dialectical Behavior Therapy (Linehan, 1993), and A cceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 1999). Empirical studies of the effectiveness of these approaches are emerging but are not the focus of this review as my interest is in mindfulness meditation as it relates to the therapists pr eparation and practice.
72 In regard to therapists, mindfulness meditation has been explored as a method of self -care. Christopher, Christopher, Dunnagan, and Schure (2006) summarized the content of focus group discussion among eleven counseling students who completed a class in mindfulness practices which included yoga, mindfulness meditation, body scan, and qigong. The findings included reports of students being ab le to maintain focus and to stay more in the present as well as feeling better equipped, both emotionally and mentally, to deal with daily stress in their lives than before taking the class in mindfulness practices (p.506). Students chose from among a gr oup of practices that were all considered mindfulness practices and most students chose informal mindfulness practice or yoga as the most used methods. As such, the conclusions about what practices bring about these results must be somewhat vague. The met hods and analysis are not well documented so it is difficult to evaluate the rigor of the study. T he results suggest certain benefits of mindfulness for CITs but further research is needed. Shapiro, Brown, and Biegel (2007) studied the effects of Mindfulness Based Stress Reduction (MBSR) practice on several variables using a non randomized, cohort control group design with 54 masters level counseling students. The experimental group reported significant decreases in stress, negative affect, rumination, sta te and trait anxiety, and significant increases in positive affect and self compassion. The study participants were from one university, were self -selecting in participation in the study, and were from class groupings that may indicate motivational differe nces all of which influence the generalizeability of the findings. In addition, there was no true control group. Nonetheless this study provides more empirical support for the potential benefits of mindfulness training for the well -being of counselors. Mindfulness as clinical training, distinguished from clinical intervention and from counselor self -care, has been explored conceptually and to a limited extent empirically. Fulton
73 (2005) explored the therapists cultivation of mental qualities, well -desc ribed in meditation literature, that relate to the common factors underlying effective treatment (p, 58). He proposed that mindfulness meditation practice offers benefits to counselors in the following areas: paying attention, affect tolerance, practici ng acceptance, empathy and compassion, equanimity and the limits of helpfulness, learning to see, and exposing therapists narcissistic needs. Thomson (2000) suggested that Zen mindfulness practice facilitates in counselors the ability to be flexibly pr esent with clients and the natural growth of empathy and compassion. Twemlow (2001) proposed that training psychotherapists in Zen practice offers a way to develop important attributes: trained attention, the centrality of the here and now, nonattachment, and compassion. He referred to his use of Zen as divorced from its usual role as a form of Buddhism and/or a religious belief (p. 1) and described core principles emptiness of self and the non-dual nature of the universe, impermanence, and paradox. He suggested such training to prepare the person of the therapist to connect with clients, and to help clients hold contradictions and make meaning of their lives. Coming from the psychoanalytic tradition Twemlow accepted the expectation that therapists wil l undergo personal analysis but added that training the mind in the way of Zen fills gaps in preparing the therapist as instrument of connection and change. He integrated the philosophy of Zen and psychoanalytic/psychodynamic theory which may not make sen se to those outside that approach. Nonetheless Twenlow makes a convincing case for the value of the Zen philosophy as well as of mindfulness practice in transforming the therapist. Kur a sh and Schaul (2006) reported on the implementation of a program at t he University Counseling Center at Stony Brook University in 1999 in which mindfulness meditation training was offered to staff and predoctoral psychology interns. The authors outlined what they observed to be the benefits of the mindfulness practicum for counselor trainees. While in the beginning of mindfulness
74 training, trainees report anxiety, the authors note that mindfulness increases awareness of anxiety and with time mindfulness seems to reduce anxiety (p. 61). Meditation, on a physical level, help ed interns reduce stress (p. 62) and given the emphasis on doing in most counselor training programs the mindfulness practice helped provide balance in its focus on being in the moment in an open, non -doing state (p. 63). The authors maintain that min dfulness meditation promotes ego strength in the ability to be in touch with the body, experience emotions, strengthen attention and tolerance for ambiguity and paradox (p. 63). Meditation is generally practiced in silence which has the benefit of increas ing counselor trainees comfort with respecting and allowing for silence in session. Finally, the authors describe how the practice of meditation sitting and observing ones own experience with a non-judgmental, accepting attitude, over and over again cultivates the ability to be present and aware which they note as fundamentally important in the therapeutic relationship (p. 65). The benefits of mindfulness meditation practicum reported by the authors are based on anecdotal reports and the authors obs ervations. These conclusions must be interpreted in that context. Clearly the authors were predisposed to seeing these benefits by their own study and practice which is presumably why they developed the practicum in the first place. Did they simply see what they expected to see? This is likely but is tempered by the authors mindfulness practice which, also presumably, enables them to attend with an open, nonjudgmental mind to what is going on around them. There are few empirical studies of the impact of mindfulness meditation training for therapists on clinical outcomes. Two recent studies with contrasting results are reviewed next. Stanley et al. (2006) studied the effects of therapist mindfulness on client outcomes. The therapists were 23 doctora l level trainees and outcome measures were taken on 144 adult clients. The authors reported that higher therapist mindfulness as measured by the Mindfulness
75 Attention Awareness Scale (MAAS), predicted poorer outcome in clients as indicated by the Global A ssessment of Functioning and Clinical Global Impressions scores. They suggest that too much mindfulness distracts therapists from the greater agenda of adherence to manual based, empirically supported therapies (p. 332) because it does not allow thera pists to move into procedural memory, a sort of automatic pilot needed to perform a learned skill. Certainly these two processes are at odds. The conclusion that mindfulness interferes with effective therapy, however, should be questioned. The authors note that the variance in outcome attributable to the mindfulness of the therapist was limited (p. 333). The therapists were trainees in their first clinical placement and so may not have been at the point in their development as counselors where they coul d use mindfulness to access clinical judgment to improve outcome. The therapists were not trained in mindfulness practice but the MAAS is a self report rating of mindfulness in daily life. It is unclear if this instrument measures therapist mindfulness in counseling sessions or how MAAS measurement might differ with therapists trained in and practicing mindfulness meditation. In contrast to the above findings by Stanley et al. (2006), Grepmair Mitterlehner, Loew, and Nickel (2007) found more positive treat ment outcomes for 58 therapist trainees after they were trained in and practiced mindfulness meditation than prior to the meditation training. Outcome measures used were Session Questionnaire for General and Differential Individual Psychotherapy (STEP ), t he Questionnaire of Changes in Experience and Behaviour ( VEV ), and the Symptom Checklist ( SCL 90 R), which includes the GSI, on 113 patients in a psychosomatic hospital in Germany. On all measures, the patients of mindfulness trained therapists had more positive treatment outcomes. These results may differ from the Stanley et al. (2006) study in part because of the intensity of the mindfulness training and practice (daily for nine weeks) provided
76 to therapist trainees. No comparison of MAAS scores are available to evaluate the differences between therapists naturally occurring level of mindfulness as in the Stanley et al. (2006) study and the level of mindfulness of the mindfulness trained therapists in the Grepmair et al. (2007) study. One of the limitations of the Grepmair study is the fact that the control group consisted of the therapist trainees prior to mindfulness training so that the groups were distinguished during the experimental phase not only by the mindfulness training and practice but also because of being further into their clinical training. A true experimental design, including random assignment to groups would provide needed clarification of these results. Using a quasi -experimental design, Valentine and Sweet (1999) compared the ability to sustain focused attention, as measured by the Wilkins Counting Test, of 19 meditators and a control group of non -meditators. The meditators performed significantly bette r on the test of sustained focused attention than the controls. The limited sample and the nonrandomized design limit generalization of the results. The findings do point to a potential benefit for counselors in that the meditators were better able to ig nore distracting thoughts, an ability relevant to being present in the session with a client. Clearly a task more relevant to counseling than a counting test would better predict the benefit of meditation for counselors. In her dissertation study, Wexle r (2006) found significant positive correlation between therapist mindfulness, as measured by the Mindfulness Attention and Awareness Scale (MAAS) and the therapeutic alliance, as measured by the Working Alliance Inventory (WAI) and rated by 19 therapist -c lient dyads. The limitations of Bordins model of the working alliance, on which the WAI is based, were discussed earlier in this review however it stands as the most widely used measure of the alliance. Wexler also created and tested a measure of mindfu lness in psychotherapy, scores on which did not correlate with scores on the MAAS which imply that
77 more work needs to be done to sort out if these are two distinct experiences that do not correlate or if the mindfulness in psychotherapy scale needs reformu lation. The results of the study suggest that mindfulness and establishing a positive alliance in therapy are related. Bruce and Davies (2005) conducted a qualitative study of mindfulness in the context of hospice care. The participants were seven staff and two patients in a Zen Buddhist hospice care f acility, all of whom had practiced mindfulness meditation for at least six months. The authors referred to the difficulty in using language based in the subject -object duality to describe their experience a nd the experience of the participants. In summarizing their findings, the authors wrote : This inquiry points to in -between spaces of human experience wherein mindfulness fosters openness and supports letting go, and creating spaces for whatever is happen ing in attending the living and -dying process (p. 1329). Four themes were identified from interpretation of the data: meditation in action, abiding in liminal spaces (an in -between space where separation dissolves), seeing differently, and resting in groundlessness. These themes have relevance for psychotherapy practice and show similarity to writings about the experience of being present. In Buddhism, mindfulness forms the foundation of what Morgan and Morgan (2005) call optimal presence, the combined working of the seven factors of awakening: mindfulness, investigation, energy, joy, tranquility, concentration, and equanimity (Morgan & Morgan, 2005). But mindfulness is not a Buddhist phenomenon. Everyone has the capacity for mindfulness and experience s it in some way in their daily lives. Mindfulness is a universal experience having to do simply with the cultivation and refinement of our ability to be present and awake in our lives (Kabat Zinn, Massion, Hebert, & Rosenbaum, 2002, p. 287). Teaching mindfulness meditation
78 to counselor trainees offers them the opportunity to learn mindfulness as the foundation to being present, as a personal experience and in their clinical practice. But what exactly is mindfulness? In reviewing secular, professional research literature on mindfulness in an effort to point to future research directions, Dimidjian and L inehan (2003) identified the areas in which there was consensus in defining the practice of mindfulness. . t hree qualities related to what one doe s when practicing mindfulness: (1) observing, noticing, bringing awareness; (2) describing, labeling, noting; and (3) participating. It also identifies three qualities related to the ways in which one does these activities: (1) nonjudgmentally, with ac cept ance, allowing; (2) in the present moment, with beginners mind; and (3) effectively ( Dimidjian & Linehan 2003, p. 166) This is easier said than done. As Kabat -Zinn (2003), states it is unlikely that such process would be sustained or developed over tim e in most of us without some element of intentional practice . Mindfulness is not merely a good idea such that, upon hearing about it, one can immediately decide to live in the present moment . (p. 148). So mindfulness provides a foundation for being present and to develop and sustain mindfulness takes practice. What is mindfulness meditation? There exist highly refined practices devoted to developing mindfulness most well articulated and developed within the Buddhist traditions (Kabat Zinn, M assion, Hebert, & Rosenbaum, 2002). These practices may be done in secular or spiritual contexts. There are two basic types of meditation practices: concentration and mindfulness. Concentration meditations train participants to focus on a single point such as a word (e.g., a mantra), sound, object, or sensation. When the persons attention shifts away from the stimulus, it is directed back to the object of meditation (Baer, 2003; Kabat -Zinn, Massion, Hebert, & Rosenbaum, 2002) Although m indfulness medi tation shares with concentration meditation the use of a single object as a starting point, such as the breath, it asks the meditator to observe the constantly changing internal and external stimuli as they arise and to note the nature of those thoughts or sensations (Baer, 2003; Levine, 1979). The idea is not to become
79 absorbed or to shut out the world, but to pay attention and notice what is taking place, both internally and externally. Mindfulness meditation encourages the practitioner to come t o our senses through focusing on the body and on bodily sensations such as those associated with breathing . and to shift from being caught up in and carried away by the automaticity of our thoughts and feelings, to being aware of them, and being mor e grounded in awareness itself. (Kabat Zinn, Massion, Hebert, & Rosenbaum, 2002, p. 287) Mindfulness meditation practice means sitting in intentional silence focusing attention on the breath, noting present moment experience as it unfolds without judgment and then returning to the breath again.
80 CHAPTER 3 METHODOLOGY Overview In this chapter I outline how this study was conducted and the rationale and support for the methods. I begin with definition and implications of the constructivis t theoretical perspective. Next, I restate the purpose of the study and the research questions addressed and delineate the procedures and justification for sampling, data collection, intervention, and data analysis methods. Finally, I include a subjectivit y statement declaring my personal experience and interest in the topic of study to make transparent my biases and assumptions in approaching this study. Constructivist Theoretical Perspective This study emanates from a constructivist theoretical perspectiv e. Although multiple perspectives exist within the constructivist paradigm (Chiari & Nuzzo, 1996; Raskin, 2002) in general constructivism shares the follow assumptions: (1) that knowledge is relative and situational, that both the knower and the known cannot be removed from their context (Denzin & Lincoln, 1994); (2) that human subjectivity produces legitimate knowledge; (3) that human beings construct meaning rather than discover it (Schwandt, 2000), and (4) that no object can be adequately described in isolation from the conscious being experiencing it (Crotty, 1998, p. 45). Constructivism suggests that the knower is inextricably entwined with what is known, that the knower is both influenced by what is observed and influences it as well (Sexton, 1997). Reality exists in terms of the meaning constructed by the observer. Being present has been described in the literature from the perspective of experienced therapists. In this study it is the meaning of beginning counselors that is of interest. The cons tructivist perspective was chosen for this study to acknowledge and explore the meaning of being present as constructed by individual CITs as
81 one of multiple constructed meanings of being present. And because the constructivist perspective assumes that in dividuals construct meaning in context it is appropriate for analyzing the various contexts that impinge on CITs experience of being present and the meaning they construct of that experience. Discrepancies among the different constructivisms lie in beli efs about the nature of reality and how that reality becomes known. These different constructivis ms stretch along continua on two dimensions: (1) ontologically, from realism to idealism, and (2) and epistemologically from individually constructed to socia lly constructed knowledge (Chiari & Nuzzo, 1995; Hayes & Oppenheim, 1997). At the extreme realist end of the continuum, there is an absolute reality to be known but that it will never be truly and exactly known due to the limitations of the observers perc eptual, cognitive, and emotional processes. As such human beings construct meaning of the reality as they see it but that reality exists in an absolute sense. At the other end of the continuum is the radical idealist belief that reality is created entirel y by the observer. T he epistemological continuum is bounded at one end by the recognition of knowledge as it is constructed by individuals and at the other by recognition of knowledge constructed and reconstructed in the process of human social interaction I assumed that being present exists as it is experienced by the counselor. It takes on meaning only as it is constructed by individual counselors. T he theory generated by this study emanates from the experiences and the meanings constructed by the individual counselors as they are brought together by my interpretation and analysis. Denzin and Lincoln (2005) note that individual constructions may come together with those of other individuals in such a way as to create something of a consensus In this way, meaning that individual CITs make of their experience of being present may show agreement or share meaning with each other.
82 Purpose and Research Questions The purposes of my study are to examine how CITs describe their experience of being present and the meaning they make of being present in the context of counseling. Studying the experience and meaning of being present lends itself to qualitative inquiry. The following research questions guided this inquiry: 1 How do counselor trainees describe their experience of being present? How do counselor trainees understand and describe the personal and interpersonal qualities or aspects of being present? What proc esses do CITs experience in being present? 2 What meaning do counselor trainees make of being present in the context of counseling? What values and beliefs do CITs draw on in constructing meaning of the experience of being present in counseling? How do CIT s apply their constructed meaning of being present in counseling? Participants and Sampling The purpose of the study was to examine the description and meaning CITs make of their experience of being present in counseling. The purpose of sampling in qualit ative inquiry is to select participants who can provide rich data relevant to the research questions (Patton, 199 0). My intent is to probe deeply into the experience and meaning of CITs. The validity, meaningfulness, and insights generated from qualitat ive inquiry have more to do with the information -richness of the cases selected and the observational/analytical capabilities of the researcher than with sample size(Patton, 199 0 p. 185, italics in original). In qualitative study sampling may be done in a variety of ways to fit the theoretical orientation and purposes of the study. In general, sampling in qualitative inquiry is purposeful in contrast with the probability sampling of quantitative inquiry (Patton, 199 0 ) Where probability sampling derives i ts power from random selection of a statistically representative sample of the
83 population to which the researcher expects to generalize (Gay & Airasian, 2003), purposeful sampling derives its power from the selection of a sample targeted because of its lik elihood to offer rich, meaningful data related to what the researcher wants to know (Patton, 1990 ). Within the category of purposeful sampling researchers can choose from among different strategies to suit their research purposes (Kuzel, 1992). For this study, I initially used criterion sampling. Criterion sampling was done before the data is gathered (Kuzel, 1992) and ensured that all participants met criteria relevant to research questions. Consistent with the purpose of my study, the participants were recruited from graduate programs in counselor education and counseling psychology. Participants were recruited via announcements (See Appendix D) on the Counselor Education and Counseling Psychology listservs, through flyers posted in both departments and through presentations by the researcher in classes in counselor education.. The class presentations included the same information as the listserv announcement and provided the opportunity for interested students to ask questions. Participants included in the study were graduate students at a large university (approximately 51,000 students) in the southeastern United States. The university is situated in a medium -sized city with a population of approximately 115,000. Participants were volunteers and th erefore self -selecting. All participants met the following selection criteria: Participants were graduate students in counselor education or counseling psychology. Participants had experience counseling clients. This experience was in the form of one of t he following: Alachua County Crisis Center telephone counseling (See Appendix A), practicum or internship field experience at either masters or doctoral level (See Appendix B and Appendix C). Participants had completed or were currently working in one of these clinical placements. I recruited nine participants for the study and interviewed each of them one time prior to their beginning the mindfulness meditation training group. Two participants withdrew following the first interview stating their schedules were too full to accommodate participation in the study.
84 The remaining seven participants were each interviewed two more times and five of them were interviewed a fourth time. I assigned a pseudonym to each of the participants to protect their anonymity in reporting the findings. The participants included diversity in race/ethnicity, academic department, degree program, and, to some extent, theoretical orientation. Information provided by each of the participa nts will be described below (See also Table 3 1). The participants student status is reported as it was at the time of the study. Andrea is a fourth year doctoral student in Counseling Psychology in the Department of Psychology in a large southeastern university. She described herself as a white, first generation Polish American. Andrea reported having clinical experience working in a child abuse prevention program, a group home for adolescents, a university counseling center and an inpatient psychiatr ic unit in a hospital. At the time of the study she was not working with clients. Andreas integrative theoretical orientation included a strong influence of interpersonal and multicultural counseling theories and she indicated that she had used interventions from Gestalt, Cognitive -Behavioral And Solution Focused therapies. Andrea was interviewed four times for this study, over the course of eight months. Cathy is also a fourth year doctoral student in Counseling Psychology in the Department of Psycho logy in a large southeastern university. She identified herself as a biracial Asian American woman. Cathy gained her clinical experience working at a university counseling center and a community crisis center that offered both ongoing counseling and cris is intervention. She was not seeing clients the semester in which she participated in this study. Cathy listed her theoretical orientation as Integrative and noted the following contributing theories: Psychodynamic, Interpersonal, Feminist/Multicultural, A nd Client -Centered. Cathy was interviewed four times over the eight months of data collection and analysis.
85 Irene is a first year doctoral student in Mental Health Counseling in the Department of Counselor Education. She identified herself as Caucasian A merican. She completed three years of clinical training at a community counseling clinic working with couples and adolescents and worked as a substance abuse counselor for adolescents. She was not seeing clients the semester in which she participated in t his study. Irene said she conceptualizes her work with clients from a Wellness Counseling perspective. Irene was interviewed three times for this study. Jesse is in her final year as a doctoral student in Mental Health Counseling in the Department of Cou nselor Education. She identified herself as Arab American who practices from a Feminist, Relational Cultural, Eclectic theoretical orientation to counseling. She has seven years of clinical experience including at a university counseling center, a univer sity crisis intervention team, and ???? Jesse was actively seeing clients as part of the universitys crisis intervention team during the data collection period of this study. Jesse was interviewed four times for this study. Jill is a fourth year doctora l student in Counseling Psychology in the Department of Psychology. She identified herself as Caucasian. For her clinical training, Jill worked at a university counseling center and a university career resource center. Jill was one of three participants working with clients during the course of the study. She represented her theoretical orientation as Humanistic/Existential. I interviewed Jill four times for this study. Kelly is in her second year of working on her masters/specialist degree in both School Counseling and Mental Health Counseling in the Department of Counselor Education. She identified herself as White American. At the time of the study Kelly had worked for four years as a mental health technician at a psychiatric hospital and was conti nuing her work in that capacity during the study. She had not yet completed a clinical training experience as part of her
86 graduate program. Kelly identified her theoretical orientation as Solution -Focused Therapy (SFT) mixed with client -centered. I in terviewed Kelly once and she participated in the first week of the mindfulness meditation training group before she withdrew from the study. She indicated that she no longer had time in her schedule to participate in the study. Linda is in her third year working on a masters/specialist degree in both School Counseling and Mental Health Counseling in the Department of Counselor Education. She had completed school counseling placements in the public school system and a mental health practicum at an unnamed site. Linda was interning as a school counselor at the time of the study and she described her theoretical orientation as Client Centered and Cognitive Behavioral Therapy (CBT). I interviewed Linda one time. She missed two out of the first five meetings of the mindfulness meditation group and I determined that she was no longer a valid participant in the study. Pam is in her third year of study for a masters/specialist degree in Mental Health Counseling in the Department of Counselor Education. She ide ntified herself as White. Pams clinical experience consisted of training and work as a crisis phone line volunteer and three practicum and internship placements at the county crisis center providing individual and family counseling. At the time of the s tudy, Pam was seeing client as a staff member at the county crisis center. Pam identified her theoretical orientations as Humanistic, Person -Centered, and Gestalt. I interviewed Pam three times for this study. Teresa is a fifth year do ctoral student in the Counseling Psychology program in the Department of Psychology. She identified herself as Black and Latina and as a Panamanian American. She had completed training as a crisis phone line volunteer and for her practicum placement had worked as a counselor at the county crisis center and at a family medical practice.
87 Teresa described her theoretical orientation as Integrative combining Existential, Humanistic, Family Systems, Multicultural, and Cognitive Behavioral Therapy (CBT). I interviewed Teresa four times for this study .
88 Table 3 1 Participant Demographics Name Department Program Student Status Theoretical Orientation** Race/Ethnicity** Andrea 4 Psychology Counseling Psychology 4 th yr Doctoral Integrative (interpersonal, multicultural, CBT, Gestalt, SFT) White 1st Generation, Polish American Cathy 4 Psychology Counseling Psychology 4 th yr Doctoral Integrative (interpersonal, psychodynamic, feminist/ multicultural, client centered) Biracial Asian American Irene 3 Counselor Education Mental Health 1 st yr Doctoral Wellness Caucasian American Jesse 4 Counselor Education Mental Health 4 th yr Doctoral Feminist, relational cultural, eclectic Arab American Jill 4 Psychology Counseling Psychology 4 th yr Doctoral Humanistic/existential Caucasian Kelly*** 1 Counselor Education School & Mental Health 2 nd yr Masters Solution focused (SFT), client centered White American Linda*** 1 Counselor Education School & Mental Health 3 rd yr Masters Client centered, CBT Caucasian Pam 3 Counselor Education Mental Health 3 rd yr Masters Humanistic, person centered, Gestalt White Teresa 4 Psychology Counseling Psychology 5 th yr Doctoral Integrative (existential, humanistic, family systems, multicultural, CBT) Black and Latina (Panamanian American) *Number of Interviews ** As identified by participants ***Interviews not included in analysis .
89 Data Collection Data was collected from the participants through interviews. Interviews provide an opportunity to find out what is in and on someone elses mind . [and] to find out from them those things we cannot directly observe (Patton, 1990 p. 278). Interviewing as a data collection method is predicated on the assump tion that the perspective of others is meaningful, knowable, and able to be made explicit (Patton, 1990 p. 278). With the purpose of this study to examine the personally constructed meaning that CITs make of their experience of being present, interview s created an opportunity for the participants to articulate their experience and its meaning to them. These are not observable phenomena and so lent themselves to interviewing as an appropriate data collection method. Participants were interviewed using a semi -structured, in -depth formal interview format. The interviews were semi -structured in that, as the interviewer, I came prepared with guiding questions but did not stick to an interview script (Hatch, 2002). The questions were designed to allow respondents freedom to structure their responses to fit their way of making sense of their experience and to provide deep and rich descriptions of their experience and its subjective meaning (Hatch, 2002). The interviews were considered formal because they were planned and scheduled at a particular time rather than informal conversational interviews (Patton, 199 0 ). The interview guide (See Appendix E) was structured and flexible structured to keep the conversation focused on the research questions and flexible to allow for digressions and redirections by the respondents and probes for more depth by the interviewer. Participants were informed of the purposes of the study and that it was being conducted for my dissertation and possible later publication. All aspects of the consent process as required by the I nstitutional Review Board of the University of Florida were followed. Participants were not involved in any aspect of the study without signing an informed consent form (See Appendix F).
90 Three interviews were conducted with each of the seven participants and a fourth interview was conducted with five of the participants (See Outline of Data Collection, Appendix G). The first interview took place prior to the training in mindfulness meditation. The second interview was conducted during the seventh week o f the mindfulness meditation training. The third interview took place during two weeks following the completion of the mindfulness meditation training. The fourth interviews were conducted in the fourth month after the completion of the training as part of data analysis. The first and third interviews used the same interview guide (See Appendix E) which asked participants to describe their experience of being present and the meaning they make of that experience. The second interview involved processing the participants journals from the meditation training. The journals were copied and used as secondary data sources and were interpreted by the participants themselves in the interview. The interview was loosely structured to allow maximum flexibility to the participants in sharing the meaning they made from their journal entries (See Appendix E). I did not read the journals prior to the second interview so as to avoid coming to that interview with any preconceived ideas about meaning of the journals. Pr ior to the fourth interview, participants were sent the coding trail and proposed theory that had been produced by data analysis up to that point. The interview included member checking of the data analysis as well as theoretical sampling to fill out and probe the meaning of the existing codes. The participants were trained in mindfulness meditation as one way to cultivate being present. The mindfulness meditation training group was constituted for the purposes of this study and all members of the group were participants. P articipants ha d the opportunity to learn mindfulness meditation which has been shown to have benefits in stress and anxiety reduction in
91 addition to being a way to cultivate being present The mindfulness meditation training program ra n for eight weeks and included the following elements and methods: Weekly one and one -half hour group sessions Formal mindfulness meditation methods including sitting meditation, body scan meditation, and walking meditation Informal mindfulness meditation practices in everyday life such as awareness of routine activities such as eating, weather, driving, walking, and interpersonal communication. Daily home assignments including 5 20 minutes per day of formal mindfulness practice, 5 15 minutes per day of in formal mindfulness practice, one to three page daily readings, and daily meditation log. Weekly journal entries reflecting on practice (2 3 paragraphs). Group discussions centered around reactions and reflections on daily home practice. The eight session s of the mindfulness meditation training program are described in greater detail in Appendix H The mindfulness meditation trainer, Dr. Michael Murphy, is a licensed psychologist on the staff of the University of Florida Counseling Center (See Appendix I f or his vita). Dr. Murphy drew on his training in both Buddhist mindfulness meditation and Mindfulness based Stress Reduction to create this mindfulness meditation training program. Data Analysis Overview of Grounded Theory Grounded theory was developed by two sociologists, Barney Glaser and Anselm Strauss (1967) to provide an alternative to the predominant emphasis at the time on verification of theories. The purpose of grounded theory methodology was to discover in empirical data theories that would be m ore relevant and a better fit with the areas under study than theories created conceptually and then tested empirically. They devised a systematic and rigorous method of comparative analysis (Glaser & Strauss, 1967). The methodology has its roots in the p ositivist paradigm in that the assumption is that there is something to be discovered in the data.
92 As Strauss and Corbin (1998) state, . the researcher begins with an area of study and allows the theory to emerge from the data (p. 12). The theory can then be further tested in the service of better explaining and predicting behavior. Because of his interactionist background, Strauss acknowledged the interplay between researchers and data (Strauss & Corbin, 1998, p. 13) and Glaser and Strauss both art iculated the interpretive job of the analyst, emphasizing moving from the descriptive to the conceptual. However researchers are instructed to avoid allowing their biases to influence what is seen in the data. Researchers understanding of the area of stu dy gives them what is called theoretical sensitivity to the data. Theoretical sensitivity allows the researcher to understand what is in the data but the researcher is not to impose preconceived concepts or structures on the data. That the researcher can be objective in this way is a positivist notion that will not stand up in a study with a constructivist theoretical orientation such as this one. Kathy Charmaz (2000, 2005, 2006, 2008 ) and others (e.g. Bryant, 2002; Clarke, 2003) maintain that grounded th eory may be separated from its positivist roots and used as a tool by researchers from a constructivist theoretical orientation. Charmaz (2000) claims that constructivist grounded theory takes a middle ground between postmodernism and positivism (p. 510). Constructivist grounded theorists take a reflexive stance on modes of knowing and representing studied life. That means giving close attention to empirical realities and our collected renderings of them and locating oneself in these realities (Char maz, 2005, p. 509). In keeping with a constructivist theoretical orientation and in a departure from classic grounded theory, constructivist grounded theorists do not operate as objective observers of an objective world nor do they assume that data reflec t that world such that realities are there to be discovered. Interpretive theory calls for the imaginative understanding of the studied
93 phenomenon. This type of theory assumes emergent, multiple realities; indeterminacy; facts and values as inextricably linked; truth as provision; and social life as processual (Charmaz, 2006, p. 126). Charmaz emphasizes Strauss interactionist background as informing grounded theory and allowing it to be used outside of a strictly positivist realm (Charmaz, 2006). It can be argued that the participants in grounded theory studies have a voice in the data and that their voices interact with the researcher in the development of theories that are grounded in the data. Constructivist grounded theory focuses on actions and understanding processes involved in various phenomena which makes it an appropriate methodology for this study of being present as experienced and interpreted by CITs. In examining c onstructivist grounded theory Greckhamer and Koro Ljungberg (2005) sugges t that it is not so easy to extract grounded theory from its positivist origins, that the type of knowledge produced by the methodology is consistent with the ep istemology out of which it came These authors note the erosion of grounded theory as it is ad apted to the purposes of the researcher without regard for its epistemological implications. Others note that while grounded theory was developed in an era when positivism was the dominant paradigm, the founders never specified the theoretical orientation of grounded theory. This leaves room for disagreement on the kind of knowledge it may produce. In addition, grounded theory assumes that the social world, at some level, is orderly, patterned, and understandable and performs an ordering process on the data that justifies the interpretive practices of science and grounded theory (Denzin, 2007, p. 458). I attempt to address these criticisms as I use grounded theory methodology in this study by making transparent my own assumptions as the researcher, t o situate my interpretations of the constructed meaning of the participants in the study, and to allow complexity and disorderliness to remain a part of the constructed theory.
94 The two developers of grounded theory took the methodology in different direc tions over time (Kelle, 2007). Grounded theory researchers have sometimes aligned themselves with one or the other approach or have adapted the methods to suit their individual investigations. Some agree with this flexibility and contend that the methods are a set of principles and practices and not methodological rules (Charmaz, 2006, p. 9). Glaser on the other hand argued for the use of the methods as a complete package (Mruck & Mey, 2007). These differences of opinion leave the researcher to make choices in how and when to use procedures associated with grounded theory. Although not in this order, the process of grounded theory generation involves data collection, several levels of coding, and memo writing. In an iterative cycle the researcher com pares data to data, codes to codes, data to codes, and data and codes to memos, and interprets the comparisons and emerging theoretical implications in memos. These activities should blur and intertwine continually, from the beginning of an investigation to its end (Glaser & Strauss, 1967, p. 43). There seems to be general agreement with Glaser and Strauss (1967) that . the elements of theory that are generated by comparative analysis are, first, conceptual categories and their conceptual properti es; and second, hypotheses or generalized relations among the categories and their properties (p. 35). The researcher moves toward developing progressively more abstract concepts or categories and exploring the relationships among them. The comparisons b ecome more focused as the theory develops. Additional data collection is targeted to answer questions and fill out categories in what is called theoretical sampling. Data Analysis in This Study The original design for this study called for a narrative ana lysis of the data. During the data collection process and the transcription of the interviews, it became clear that grounded theory methods would be more appropriate to analyze the more abstract and conceptual nature of
95 the data. Grounded theory methods offered a means for interpreting the interaction of processes in the participants constructed meanings of their experience. In this section, I describe the specific steps and processes of the data analysis in this study. I provide an outline of the steps in Table 3 2 at the end of this section. In the analysis of the data, I followed Charmaz (2006) approach to constructivist grounded theory. She says I view grounded theory methods as a set of principles and practices, not as prescriptions or packages ( 2006, p. 9). Charmaz outlines two main phases of grounded theory coding: 1) an initial phase involving naming each word, line, or segment of data followed by 2) a focused, selective phase that uses the most significant or frequent initial codes to sort, synthesize, integrate, and organize large amounts of data (2006, p. 46). Each of the twenty three interviews with participants was transcribed verbatim. I first coded the transcripts in a detailed open coding process. Since the interviews spanned a period of several months and the participants were experiencing being present in different contexts over that period, I decided to open code all the interviews to get the full spectrum of their experience. In the initial coding process, Data are broken do wn in discrete incidents, ideas, events, and acts and are then given a name that represents or stands for these. The name may be one placed on the objects by the analysts because of the imagery or meaning they evoke when examined comparatively and in cont ext, or the name may be taken from the words of the respondents themselves (Straus & Corbin, 1998, p. 105). I first identified meaning units by going line by line through each interview transcript. Meaning units ranged from a few words to several sentence s. I then gave each meaning unit a code. The codes stayed close in the data (Charmaz, 2006), often using in vivo codes (Glaser & Straus s 1967), the persons own language, and attending to the nuances in what was expressed. Given the nature of the topic, nuances are
96 relevant in understanding how the participants experience being present and how they make meaning of that experience. Anothe r reason for using in vivo codes was to avoid imposing language from literature on being present and on mindfulness. In classic grounded theory, I would avoid using in vivo codes in order to move from the descriptive level and to the conceptual level (Holt on, 2007). However, much of the language of the participants in the study was already conceptual and reflective. In coding the data, I followed Glasers (1978) suggestion in asking the question, what is happening here? What are the processes at work and what accounts for those processes? (Glaser, 1978). From a constructivist perspective I was not discovering the processes but interpreting (constructing) what I saw as emerging from the data. Along with Glaser (1978), Charmaz (2006) also recommends looki ng for actions in the data to avoid applying preexisting categories. I followed this advice for both reasons -to focus on process and to avoid preexisting categories. As such I used gerunds whenever possible in coding my data but not to the point of for cing or creating awkward language. During the coding process, I stopped frequently to record my ideas about relationships between codes, the meaning of codes, questions about codes to look for in future interviews etc. These ideas were recorded in memos that were dated and labeled. The goals of memoing, according to Glaser (1978) are to theoretically develop ideas (codes) with complete freedom into a memo fund, that is highly sortible (p. 83, emphasis in original ). After coding the first interview f or all participants, the initial codes were reviewed to look for emerging relationships among codes and to note frequent and significant codes. The code list was extensive, detailed and close to the data at that point to allow for maximum fullness of categ ories. The constant comparative process involves comparing coded meaning units with each other and as categories grow, comparing categories or codes with each other, and
97 comparing emerging theoretical ideas in memos with the categories (Glaser & Strauss, 1 967; Charmaz, 2006). This is not a linear process but, as the name implies, a constant comparison of one aspect of the developing analysis to another and to the data. In keeping with this process, I frequently checked back with the data during the coding process, comparing codes with data. One particular focus of my attention was to try not to grab onto terms from existing literature out of convenience or to suit my familiarity with that language, unless a term from the literature seemed to be the best possible fit with my understanding of the data. Coded categories were compared with each other, seeking clarity while not sacrificing fullness. Memos informed the comparisons and pointed to evolving theor etical propositions about processes involving the d ifferent categories. Since I worked from a constructivist perspective, all of the coding and memoing is a cknowledged as interpretive. At the same time, I was looking for how the participants construct meaning of their experience as I constructed my unders tanding of that meaning and attempted to communicate that to a broader audience who will in turn construct their own meanings in their contexts. It was particularly challenging to maintain openness as the coding process continue d and a theory start ed to take shape. I tried to hold back on settling on a set of relationships and an organization of those relationships too soon in the process to allow new relationships to come into being. This process parallel ed the topic of my study as I tried to be present to the data in the analysis Refining of the initial codes moved into focused coding. According to Charmaz (2006) focused coding entails identifying the most significant or frequently occurring initial codes and using them to synthesize and explain larger segments of data (p. 57). Charmaz also suggests that in the focused coding process, the analyst is checking preconceptions about the topic as she acts on the data (p. 59). I defined relationships between categories drawing on my own
98 experience, my theoretical sensitivity to the area of study, and by repeatedly going back to the data and to the various levels of coding. If codes were not filled out enough to become categories and did not seem significant or relevant enough to the emerging theoretica l direction to warrant theoretical sampling, they were dropped. These codes provide possible directions for future exploration. Axial coding means . coding around the axis of a category, linking categories at the level of properties and dimensions (Strauss & Corbin, 1998, p. 123) and can be an approach to focused coding. The goal is to synthesize large amounts of data at a conceptual level (Charmaz, 2006). While not strictly applying Strauss and Corbins axial coding process, I did develop the rel ationships of subcategories around the axis of each central category. Clarke (2003) offered an alternative to axial coding, called situational mapping, which allows the researcher to explore relationships between the phenomenon under study with situation al influences in a less linear, causal arrangement of categories and subcategories. Early grounded theory studies stressed causal relationships but now many scholars aim for interpretive understandings. Such understandings remain contingent on contextual conditions. Situational mapping is another way to come to understand the data from a fresh perspective and one that acknowledges complexity and context. My codes highlight the actions involved in being present in counseling from the perspective of CITs. To form a theory, I needed to define how these actions relate to and influence each other. In my application of what Clarke (2003) called the messy situational map (p. 565), I wrote each category (action) on a post it note and laid the notes out rando mly. Then I followed Clarkes (2003) suggestion to systematically take each category and think about how it relates to every other one. Working with the situational map helped me identify the contexts which interact with the central process in the theor y and led into a final phase of coding, selective coding. Charmaz
99 includes axial, theoretical, and selective codes as optional additions to initial and focused coding, what she identified as the two main phases of coding (2006). S elective coding in Stra uss and Corbins (1998) approach represents the final step in grounded theory analysis and involves the integration of concepts around a core category (p. 236). Eventually a story emerges. Often, returning to the raw data and rereading several interviews or observations helps to stimulate thinking. This tends to work if one reads them not for detail but rather for the general sense, standing back and asking the following questions. What is the main issue or problem with which these people seem to be grappling? What keeps striking me over and over? What comes through, although it might not be said directly? (Strauss & Corbin, 1998, p. 148). Sele ctive coding yielded seven elements of the theory centered around the category of Choosing to Be Mor e Present. At this point in the analysis I revised the Internal Review Board protocol to add a fourth interview for the purposes of theoretical sampling, consistent with grounded theory methods. I conducted the theoretical sampling interviews (interview #4) with the following purposes: 1) to gather reactions to and feedback on the theory developed thus far, 2) to fill out categories that seemed significant but were not yet well developed, and 3) to inquire about unique outcomes (rarely mentioned but inte resting data), if appropriate. The participants were provided a diagram and overview of the theory in its form at the time. The theory was then revised and extended as I interpreted the data from these interviews.
100 Table 3 2. Elements of the Data Analysis Process Transcribed each interview ( 26 interviews) Identified meaning units in transcripts Open coded meaning units Reviewed and refined open codes Initial coding Focused coding Situational mapping using focused codes Selective coding Diagrammin g theory Theoretical sampling and member checking Refined focused and selective codes Refined d iagram and theory Throughout the process, kept log, wrote memos, and engaged in constant comparison to refine and clarify codes and check against the data. The selective coding and diagramming processes were not as linear as this list implies as there was an ongoing process of crafting and revising. Trustworthiness The epistemology and theoretical perspective that underpin a qualitative study determine how i t is to be evaluated for trustworthiness. The use of the term trustworthiness already implies a non -positivist epistemology in that the criteria do not include verifiability of a true reality or objectivity of the researcher. Nonetheless, evaluating the rigor of a study is equally important. This study used a constructivist approach to grounded theory and as such the findings are an interpretation of the constructed meanings of the participants. Constructivist grounded theory involves developing increas ingly abstract ideas about research participants meaning, actions, and worlds (Charmaz, 2005) while repeatedly checking the interpretation against data. From a constructivist theoretical perspective findings are acknowledged to be interpretative, propositional, and situational (Charmaz, 2006) consistent with the belief that there is no one absolute reality to be discovered. Establishing the trustworthiness of interpretations from this perspective means attending to credibility, confirmability, dependab ility, and transferability (Lincoln & Guba, 1985). Procedures have been identified to strengthen these aspects of the qualitative research. Creswell and Miller (2000) reviewed the literature on structures and criteria
101 for validity in qualitative studies and synthesized them into a matrix of nine validity procedures from post positivist, constructivist and critical theoretical paradigms as defined by Guba and Lincoln (1994). I will now address the procedures used to strengthen the credibility, dependabili ty and transferability of this study. Credibility roughly corresponds to the idea of internal validity or demonstrating the believability of the outcome of the study, in this case, the grounded theory. Rather than demonstrating how close the findings are to reality, the credibility of a studys outcomes are evaluated based on the plausibility of the interpretations (Glesne, 1999) and on having the findings approved by the constructors of the multiple realities being studied (Lincoln & Guba, 1985, p. 296). In my study credibility is established using member checking, prolonged engagement, disconfirming evidence, and peer debriefing procedures. Member checking, prolonged engagement in the field, and collaboration are the procedures that Creswell and Miller (2000) identify as within the lens of the study participants (p. 126). Since this study comes from a constructivist theoretical perspective, member checking is the most crucial procedure to establish credibility. In each of the interviews with the pa rticipants after the first one, I checked my understanding of what they had said in previous interviews and asked for their reactions and clarifications. The participants reactions, clarifications, and additions then became part of the transcripts of the interviews and guided subsequent coding. After the third interview, I sent all the participants the list and organization of codes and an overview of the theory as I had formulated it at that point. Five of the participants were available for a fourth i nterview per the revised protocol. In the fourth interview these five participants were asked to give feedback as to the fit of the theory with their experience and suggestions for changes. I then revised the theory based on their feedback. These were m ember checking
102 procedures but with a collaborative element as I was not only asking participants if the categories made sense or if their transcripts were accurate. They were collaborating to some extent on the theory development, although they were not f ully involved as coresearchers which would constitute true collaboration from a critical perspective. The procedure of prolonged engagement adds to the quality of the data by building trust with participants and inviting more comprehensive disclosure (G lesne, 1999). It also allows the researcher to better understand the contexts in which the phenomenon under study takes on meaning (Lincoln & Guba, 1985). Although the definition of this procedure applies it to field studies I think it is applicable for my study as well. I interviewed all seven participants three times over the course of three months and I interviewed five of the seven participants again fourth months later over which time we built rapport and comfort with one another thus increasing the potential for rich disclosure and adding depth to the data. Such data in turn increases the potential for credible interpretation. The participants kept journals during the eight -week meditation training. These journals were reviewed and interpreted by the participants and served as secondary data sources for triangulation. Disconfirming evidence resembles triangulation but where triangulation seeks convergence and confirmation, disconfirming evidence is a search for evidence that diverges from the preliminary themes or categories (Creswell & Miller, 2000). The initial focus of the analysis in my study was on the experience of being present and preliminary themes and categories were descriptive of that experience. As my engagement with the data continued, however, I began hearing the divergent messages that then led not only to the creation of new themes and categories (related to not being present and inhibitors to being present) but also helped clarify the initial themes and categories related to bei ng present. I then reexamined the
103 data with the divergent themes in mind and continued the search in the theoretical sampling interviews. Including both acknowledged the complexity and multiplicity of realities and supported the credibility of the theory. I used peer debriefing, described by Creswell and Miller (2000) as the review of the data and research process by someone who is familiar with the research or the phenomenon being explored (p. 129). Several people reviewed my work during the research process all of whom were familiar with the phenomenon of presence including my committee chair, colleagues at a university counseling center, and two doctoral students, one from Counselor Education at my university and one in Clinical Psychology from anot her university. The debriefing took place during several stages of analysis, first during the initial and focused coding phases, and then as the theory began to take shape. These people acted as sounding boards, as support, and they challenged my interpr etations which helped me clarify the meaning I was making from the data. Creswell and Miller state that using peer debriefing adds credibility to a study. In light of the constructivist perspective of this study, however, the peer debriefing was secondar y to member checking as the critical perspective is that of the participants. Dependability is made possible by the credibility of the study, paralleling the relationship between reliability and validity in conventional research (Lincoln & Guba, 1985). Si nce replication in search of the truth is not a goal consistent with constructivist research, dependability is evaluated by examining the rigor and appropriateness of the process that yields the outcomes and confirmability by evaluating the data, findings, and interpretation as internally coherent (Lincoln & Guba, 1985). It involves documenting the data collection and analysis procedures so that people outside the research study can review the documentation and evaluate the study, asking such questions as Are the findings grounded in the data? and Is the category
104 structure appropriate? (Schwandt & Halpern, 1988, cited in Creswell & Miller, 2000, p. 128). The audit trail is employed to support the dependability and confirmability of a studys outcomes. I documented the inquiry process in this study in a research log, memos, and a coding trail (Appendix J) I met frequently with my committee chair and several times with a grounded theory group and received feedback on questions such as the above that he lped refine my coding and the emerging theory. Examples of memos (Appendix K) excerpts from the research log, and the final coding trail (Appendix J) are included for review in this document as appendices. Researcher reflexivity is the procedure by which researchers disclose their assumptions, beliefs, and biases through which interpretation of the data has been filtered (Creswell & Miller, 2000). Again, this is consistent with a constructivist perspective that acknowledges that the researcher is constru cting meaning from the data and that the researchers constructions are situated in their values, beliefs, and historical context. In line with this criterion for trustworthiness, I have included a researcher subjectivity statement that allows the reader to frame of my subjective interpretations of the data. In addition, during the course of the inquiry, I recorded my thoughts on potential influences of my subjectivity on my interpretation of the data in memos. These memos also directed me to questions f or participants to clarify my understanding of their constructed meanings. Transferability in qualitative research from a constructivist perspective contrasts with external validity in quantitative research from a positivist perspective. External validity is concerned with representativeness for the sake of generalizeability. Transferability requires that researchers clearly delineate the contexts, conditions, and processes involved in the study so that those seeking to apply the findings may determine if sending and receiving contexts are sufficiently similar to allow one to entertain the possibility of transfer (Lincoln and Guba,
105 1985). The methodology for this study has been clearly recorded including the theoretical perspective, the data collection and analysis procedures, subjectivity of the researcher, and limitations. These descriptions offer readers data from which to determine the transferability of the findings. Subjectivity Statement It is important for me to openly delineate my relevant expe rience and assumptions as part of the constructivist approach to research. In constructivist research objectivity is not possible and knowledge is always created in and for a context by human beings as active agents. As a researcher I participated in the creation of knowledge as I interacted with the participants and with the data and therefore my assumptions and biases are inherent in my approach to the topic. Two streams of my life come together in this study. The first is my experience in therapy, as client and as CIT, and the second is my practice of mindfulness meditation. First, as a client of a Gestalt therapist, I experienced remarkable moments in therapy when I felt a timeless and powerful connection between us. I felt my therapist was right the re with me. I felt seen, known, and accepted in a way that transcended the content of the session. Those moments appeared to facilitate change. I wondered how it was that we become so available to each other. I have now experienced such moments in bot h chairs, as client and as counselor. I refer to that experience as being present. When I am present, I feel my awareness of my self heightened and at the same time I am not concerned with myself; I feel myself extending toward the client, listening with my full being; I let go; I reside in the present moment and linear time fades out. The overarching feeling in those present moments is compassion. This is my experience of being present, one that I have only fleetingly but invariably colored how I heard others descriptions of their experience.
106 During the course of planning and implementing this study I have been a CIT as were my participants. In my own preparation as a counselor, I want to develop my ability to be present both in myself and with clients. I first studied psychology in the prime of the existential, humanistic approaches to therapy and these views of the world shaped my understanding of the therapeutic process. My current fascination with being present fits with these theoretical framew orks. I resonated with Gestalt therapy, in particular, with its emphasis on here and now awareness and on making contact with the world not through the mind but more directly through the senses. I draw on these theories along with my experience as a CIT i n this study. The second stream contributing to my position in relation to this study is my experience in meditation. In my early twenties, over thirty years ago, I studied Buddhism and practiced mindfulness meditation. I became disenchanted with Buddhis m and in retrospect it was the religious precepts that were difficult for me to adopt, not the practice of mindfulness. In the last two years, I found myself returning to the practice of mindfulness meditation and see how it helps me cultivate my ability to be aware in the present moment. I find this in turn helps me be present in my work with clients. It is in meditation that I become aware of my own worry, fear, sadness, or grief, but learn to stay with them rather than try to control, distract, or avoid. It is this practice that helps me, when I am able to call on it, to stay with my clients in their painful places and not try to fix or rescue. Mindfulness meditation trains me to slow down, to acknowledge what is (rather than what should be, might be could be), and offer respectful acceptance to clients. It is my belief, then, that mindfulness, presence, and therapeutic change are part of a whole. Even further, it is my belief that learning to be present tunes me up as the instrument of therapy.
107 I viewed the data through my lens as a woman, as a CIT with a humanistic theoretical orientation to human growth and change, as a meditator, and as a person in my fifties. Each of these lenses influenced the meani ng I constructed from the data.
108 CHAPTER 4 FINDINGS Introduction The research questions for my study asked how counselors in training (CITs) describe their experience of being present and the meaning they make of being present in counseling. In analyzing the data I b egan to see that participants drew on their experience of not being present to help them in describing being present. In addition they described themselves as not present more often than present. In analyzing the data using constructivist grounded theory methodology, processes were identified that explain how CITs understand being present or not and what is at play in choosing to be more or less present. The point that differentiates being present or not is the point of awakening to choices CITs have in how to be. The theory derived focuses on the process of choosing to be present as CITs. The diagram in Figure 4 1 shows the seven key elements of the theory (selective codes): 1) Acting to Contain Anxiety and Uncer tainty, 2) Awakening to Choice s 3) Choosing to be More Present, 4) Being Present, 5) Contexts Facilitating or Inhibiting Being Present, 6) Experiencing the Outcomes of Containing Anxiety and Uncertainty, and 7) Experiencing the Outcomes of Being Present. Being Present, as defined by the CITs as they experience it, is depicted as one loop in a dynamic relationship with Acting to Contain Anxiety and Uncertainty, Awakening to Choice s and Choosing to be More Present. CITs, operating in what they described a s the normal way, seek the safety of containing their anxiety and uncertainty. When they awaken to choice s to be more present, they are at that point already more present. They are no longer unconsciously tied to one way of being. They may then move into actively choosing and being present or they may go toward safety again and contain their anxiety and uncertainty. Anxiety and uncertainty does not disappear if CITs choose to be more present but their experience of the
109 anxiety and uncertainty seems to change. CITs negotiate the complexity of choice s in both a moment to moment process and a personal developmental process. Their choices are also not made in a vacuum and so Contexts Influencing Being Present either facilitate or inhibit both the process o f containing anxiety and uncertainty and of choosing and being present. The final two elements of the theory define what develops out of choosing to go in either direction: Experiencing the Outcomes of Being Present and Experiencing the Outcomes of Contai ning Anxiety and Uncertainty.
110 Figure 4 1 Theoretical m odel: Choosing to be p resent as c ounselors in t raining
111 Overview of the Theory In this section I provide an overview of the processes and relationships in the theory that I derived from the meaning that the participant CITs made of their experience of choosing to be present. The descriptions are intended to be read as the researchers interpretations of the meanings made by the participants in this study of their experience. CITs face insecurity and uncertainty as they begin their work as counselors. T hey may suddenly find themselves alone in a room with a person experiencing significant pain. That person is looking to the counselor for he lp. CITs seem to have a choice then about how they work with the uncertainty and the anxiety that arises in them They make that choice not only in the counseling session itself, but also within a broader context that includes their academic departments, famil y and/or spiritual values professional standards, and prevailing cultural norms Defaulting to what seems to be the socially acceptable way (what is referred to in the data as the normal way ) they take steps to co ntain their anxiety in order to p erform well as new counselors. The word contain is used here meaning to hold or include within its volume or area; to keep under proper control; restrain; to succeed in preventing the spread of (Dictionary.com, 2008). Participants described doing this by trying to be in control (planning, researching and/or adopting a role); by distracting themselves from or avoiding uncomfortable emotions and by trying to maintain an image of competence. Those CITs who are exposed to the experience of being present in supervision, through mindfulness training, or in spontaneous personal experiences awaken to an alternative paradigm. This alternative paradigm, the paradigm of being present seems to ena ble them to connect with themselves and with their clients and as a by -product develop a different relationship with their anxiety. The concept of a paradigm is used in this analysis to mean A set of assumptions, concepts, values, and practices that constitutes a way of viewing reality for the community that shares them, especially in an intellectual discipline (The
112 American Heritage Dictionary, 2008). CITs in this study described being present as trusting and letting go; accepting what is; being human staying with what is and being aware Here anxiety is not contained but transcended or transmuted and CITs are more available for therapeutic connection with their clients. Choosing to be pr esent is not easy for CITs. For them choosing to be present m eans taking personal and professional risks in navigating these two conflicting paradigms It means revising priorities often in a way that contradicts their training. It means heightening awareness of themselves as persons, as well as of their clients, w hich puts CITs up against previously unacknowledged parts of themselves often creating new anxiety. What appears to move them to take these risks is their experience of being present In that experience, they recognize a fit with who they are, their belie fs and values, and their sense of purpose, and they see benefits to the therapeutic relationship and process. Paradoxically, once the choice is made and the CIT lets go into the present moment, anxiety dissipates, becomes less important, or is transmuted i nto feeling at peace. The CIT is more available to connect with herself and with her clients. That connection, whether with oneself or with clients, is seen by the participants in this study as fundamentally healing. Being present, CITs have conscious a ccess to their emotional reactions, their experience, their training, their intuition, their creativity, and their cognitive processing it is all there in the moment, which allows counseling to be alive in its complexity. Although presented thus far as something of a dichotomous choice, to be present or not, CITs are always present to some extent. Being present ranges from being safe in automatic mode to being fully present. Choosing to be present means consciously fostering and cultivating being pr esent so that one may move toward being fully present. The essence of the previous sentence is in the verbs choosing, fostering, cultivating and being. Each of the actions
113 associated with containing anxiety or being present are anchoring labels on a conti nuum, e.g. controlling and planning at one end and trusting and letting go on the other. There seems to be a threshold, though, at which CITs identify their experience as being present as opposed to not being present. That threshold is the point of aware ness or awakening. Acting to c ontain anxiety and uncertainty feels safe and familiar for CITs in this study but the fallout in counseling is disconnecting, being less available, missing healing opportunities, and not building relationship. Choosing to be present the CIT risks coming to know herself, rejection, loneliness, feeling uncomfortable emotions, and for some, religious censure. The benefits for counseling of choosing to be present weigh in heavily, though: amplifying connection, feeling at peace, be ing a better instrument of and facilitating the therapeutic process, counseling in the present moment, building tolerance for discomfort, and sustaining counselors in the work. Choosing to be present is both a moment to moment choice and a broader choice a bout living ones life. CITs may set the intention to be present and cultivate that ability through various practices and through coaching themselves. Caring for themselves as whole people, not confining themselves to their role as student or as counselor enhances their ability to be present. CITs may awaken at moments in life or in counseling when they become aware of their critical thoughts, their efforts to plan and control and other ways they contain their anxiety. At that moment with that awareness they become more present. They have awakened to the choice they have to foster that presence and connection or to hold on to the familiarity of containing their anxiety. With awareness comes the inevitability of choice. Choice replaces habit. Avoiding and distancing or being more present can no longer be unconscious acts.
114 Part of containing anxiety involves protecting ones vulnerability. When CITs choose to be more or less present they take into account the context. In some cases the context may not be a conducive or safe one in which to open oneself. So CITs may at times operate in the loop of safety and protection or they may flow into the loop of opening and letting go. Again, though, even in making an aware choice to protect themselves, they ar e more present. The more experience the CIT has being present, the more the choice is about connecting with others and with herself and less about negotiating discomfort. Choosing to be present is going toward something positive where containing anxiety i s going aw ay from something uncomfortable or negative. The two loops have a different quality. As moment to moment choices string together over time and the counselor or person spends more time in one loop or another, she develops and changes. The choos ing is part of a developmental process an d affects the kind of counselor or person she becomes. This overview of the theory delineated the part each of the selective codes plays in the theorized process. Each of the selective codes will be defined and ex amined in the sections that follow. The focused codes that make up each selective code are explored in the subsections of each selective code. Initial codes are bolded in the text under each focu sed code heading (See Appendix J for Coding Trail). The ex planations of the selective codes at the beginning of each of the next seven sections are the most conceptual and interpretive. As the focused and initial codes come progressively closer to the data, the explanations are more descriptive for those codes. I start with being present as a way of constructing a definition that informs the theory as a whole. Being Present Being present comprises a number of actions and attitudes that come together as a gestalt. The whole is different than the sum of the part s. Each action or attitude may look different when
115 taken out of the whole system. I took participants descriptions and defined these eight actions and attitudes of being present: 1) being aware, 2) attending inwardly outwardly, 3) beginners mind, 4) tr usting/letting go, 5) accepting self, other, and what is, 6) being right here in the moment, 7) staying with what is, and 8) being human/being authentic. These actions and attitudes will be examined individually keeping in mind their interconnectedness in the whole. They may be seen as nuances of the experience of being present, aspects of being present and requirements for being present. Being present is actually a continuum. The continuum has no end point if one is at least physically present, even if in automatic mode. There does seem to be a threshold, though, at which participants identified themselves as being present even if they recognized that they could become more or less present from that point. Being present is full of paradoxes that are u nresolvable in the logical mind. Being present is described as nondoing, simply being. At the same time actions are defined as part of being present, for example trusting/letting go and attending. Being present involves staying with and not avoiding what is in the moment even if what is feels uncertain or frightening. And yet, in being present, participants described feeling safe and at peace. Being present allows some distance from the object of awareness and at the same time participants described f eeling more alive and connected to others and to their own experience when they are present. Part of being present, then, is allowing complexity without deciding on one truth. Being Aware Being aware is the fundamental action of being present. Being aware to any extent moves the CIT out of automatic mode to being more present. The more aware CITs are, the more present they are. Awareness is meant in the sense of being conscious or cognizant through ones own perceptions. Awareness begins with waking up waking up to ones former lack of awareness, waking up to ones sensory and emotional experience, waking up to new insight.
116 Cathy said she was shocked becoming aware not only of how much pain her body was in but by the fact that she had not realized it until she became present in her body. Jesse described being present in counseling as awakening to the experience in the room. Waking up implies that one has been asleep, and to some extent being in automatic mode is that, but more waking up means becoming more conscious. Waking up has the quality of a boundary between consciousness and unconsciousness and at the same time there are degrees of both. Sometimes the CITs wake up as a result of their own efforts to cultivate being present and sometimes they are awakened by a moment of frustration in the session (Cathy) or by a clients expression of emotion (Teresa, Jill). Awareness has paradoxical qualities just as so many other aspects of the proces s of choosing and being present. On the one hand, as Pam describes it so well, when youre aware youre living and youre a part of the world and youre a part of life. And in another way awareness creates some distance between the person and the object of the awareness, whether the object is ones own thoughts or physical sensations or the emotional disclosures of another person. Irene referred to this property of awareness as realizing what my thoughts were and kind of not constricting around them The distance seems to bring a kind of clarity and calm that is not available when experiencing those same things in automatic mode. Cathy struggled for a way to describe this witnessing awareness or consciousness, In the moment there was a part of me, you know that, whatever that is, the third eye or whatever people want to call it, but, part of me that was, you know, thinking, oh, this is like, pretty crazy, I mean, this is pretty intense but pretty like and what s going on here is pretty neat. Aware ness of ones own thoughts, emotions and sensations seems to enhance counselors empathy for their clients thoughts, emotions, and sensations. The awareness allows CITs to focus on the processes in those thoughts, emotions, and sensations rather than on the content. Also once the counselor becomes aware of reactions, countertransference, physical discomfort,
117 worries, etc., she becomes less unconsciously distracted and can intervene or give feedback in the moment. Awareness builds on itself with each awa reness opening a door through which the person sees there is more to see. I feel like Im just [ makes sound like the cracking open of a door ] open ing my eyes a little bit to it and so I hope I can, you know, keep myself going and be cause it feels neat, lik e it feels like theres a lot here but I feel like, yeah, its just the first few steps of it. (Pam) As awareness builds, CITs notice more about themselves, about the world around them, and about their clients (heightening awareness ). For Teresa heightene d awareness means taking note of every, everything that Im doing at that moment and not, not taking it for granted (Teresa). Jill remembered her experience of being present this way I was very aware of details in the interaction, just very aware of ev erything that was happening, everything that was being said Although awareness too is on a continuum, once at the threshold at which CITs identify themselves as present there is a sense of heightened awareness. Attending Inwardly and Outwardly Attending t o ones inner experience and attending to ones perceptions of the outer world are actions that build awareness ( attending inwardly/outwardly ). A thought, event, or sensation may awaken a CIT and bring them into awareness, however using ones attention a ctively builds awareness and is part of being present. Attending inwardly involves paying attention to ones own sensory experience, emotional reactions, and thoughts. This self awareness is distinguished from self -consciousness in being present. Self -c onsciousness is part of the description of not being present as it involves anxious self -monitoring or self -criticism. Because I dont mean not self aware, but yeah, not self conscious, like t hats not where my thoughts are. And so much of the rest of the time they are. (Jill). Self awareness is also distinguished from self -centeredness as it is in the service of becoming more available and connected to the client or to the situation (or even to oneself if alone).
118 I keep on saying self awareness and I feel like it makes it sound like this whole experience has just been about me . but I really think that the more I am connected with myself, the more I understand about myself at a deeper level, it, it totally, how could it not impact my connections with other people and my interactions with other people ? (Cathy) The counselor attends outwardly to the process of the counseling session, to clients bodily reactions and emotional expression and to the content of their disclosures. Being present, the CIT must juggle attending inwardly and outwardly in bringing her fullest awareness to the moment. Teresa said when being present she is able to, to really attend to the visceral feelings that I have, w hat Im hearing from the person (Teresa). This is no t a balancing act as the attention is not equally inward and outward, but a more responsive interplay between them. Focusing too much on the client, counselors lose awareness of themselves and their own experience and therefore miss out on useful informat ion. Focusing inwardly too much, counselors lose connection with their client or the environment. I guess I would say that its a both and, so I, I am aware of myself and my own process and my own reactions to what clients are saying but Im also aware of wanting to meet them where theyre at, vali date their world as they see it. (Jesse) Focusing is a sharper use of ones attention than generalized awareness, what Cathy called zooming in. Being present prioritizes the focus of attention. Participants noted that their attention is at times focused so intently on their immediate interaction that outside noises and extraneous stimuli (Andrea, Cathy, Irene, Pam), along with their concept of time (Andrea, Jill) fall away out of their awareness. There are paradoxical aspects to attending. For instance forced focusing narrows and therefore compromises ones awareness. But too little intentional focus also limits awareness and therefore being present. It was more like I was demanding that, OK, forget every thing else just be right you know, like I was having a demanding approach to myself. It is different qualitatively, l ike you know I know how to, I can focus myself. I can, you know, even if Im worried xyz I can put it at the door, I can do all these things even when Im under huge stress. But maybe there is a difference between being able to focus and attend and give good
119 reflections and these things and then something, the presence being a little more open and deeper and where Im not having t hat sense of effort. (Irene) When CITs are successful in attending, they heighten their ability to remember what was happening at the time ( heightened memory) Zooming in on ones alive experience seems to be part of what imprints the moment. Pam said in this regard, As far as the, the sensory quality? Yeah, I mean I think its just like wow, you know that, that feeling of the magnitude of it and just um remembering that moment, specifically, like it had significance to it For some CITs their memory of details may be vivid (Jill) and others, like Teresa, remember more the feeling, I rememb er less about what specifically you know the specific details Beginners Mind The term beginners mind is borrowed from the Zen teacher Shunryu Suzuki (1973 ) who said, In the beginner's mind there are many possibilities, in the expert's mind there are few. With the attitude of beginners mind, CITs approach the client and the session with an open mind (approaching with open mind). Pam told of going on an emerg ency home visit and from what she was told about the client, she began to dread the encounter until she switched into a more open minded approach. Im just going to go and be there, and see what happens and who knows not having an expectation of wh at it is that Im, what it is that Im doing or what the plan is or whatever, but more of just going and being with the person and like it was really, really neat. (Pam) Going further, they approach the client and the session and as if for the first time (approaching as if new ). In my mind, I approach it kind of like Im just meeting them even if its one Ive worked with before (Jill). This attitude brings a freshness to the experience that opens up new possibilities. The CIT observes what is without applying previously held assumptions. This allowed Irene to connect with what is actually going on and be able to respond to whats actually going on instead of w hat I think is going on. From a constructivist
120 perspective what Irene refers to as what s actually going on is still her constructed meaning of what she perceives but it differs from a purely cognitive construction in drawing on multiple channels of perception. Not only is the Beginners Mind open but it is curious For Irene this means p ut my own concerns aside and really show interest and have a curiosity about where the other person is, f rom a genuine, like a genuine curiosity, like I wonder what yo ur experience is like right now. Jill also used the sense of wonder to describe being open and curious about her clients. With openness and curiosity, there can be no pre -set agenda for what will or what needs to happen in the therapeutic encounter. H aving preconceived ideas about the client or the work limits being present. In all these ways, CITs take the beginner stance rather than the experts, not because they are beginning counselors but to allow for unknown possibilities and connection with the client (not being expert ). This is particularly challenging because they are beginners and trying to appear competent to their clients as well as to their supervisors (see section on Acting to Contain Anxiety and Uncertainty). While challenging for the CIT, taking the stance of not knowing or not being an expert contributes to the openness of beginners mind and it encourages clients to tell more of their story. S o with the client I try to take more of that attitude, like I dont already know and it re ally does go a different direction be cause like if I already know like I might be a little bit right, b ut I think I get less from them they tell me less. (Jill). Trusting Self and Process/Letting Go Approaching clients and the counseling session with the openness of beginners mind requires trust in the therapeutic process and relationship and trust in oneself ( trusting self and process ). It is a struggle, though, for beginning counselors when they are under pressure in
121 graduate school and feeling their a nxiety and uncertainty. As they become present, though, CITs are able to be more trusting. For Cathy this means trusting her gut. I like when I listen to it. I like when it, it, when I notice, and Im connected with it because it might not even make a lo t of sense with whats happening, you know? It might seem really weird in that particular moment that Im feeling fear or Im feeling anger or Im just whatever, whatever my reaction is, but more times than not when Ive shared that with the client its b een feelings theyre experiencing, you know, and didnt for whatever reason werent conveying at the moment or hadnt shared up to that point or whatever, and it really marks moments of, of like great intervention time, I mean really great opening for the client times (Cathy) Irene noted that trusting herself allowed the conversation to deepen. And Pam trusts that the session will proceed in a productive direction if she stays present. With that trust, CITs let go into being present they let go of planning and controlling what happens and find themselves in the flow of the present moment. Not controlling and letting go means not controlling the pace of the counseling session (Jesse), not focusing on completing tasks (Jill), and most important, not bein g attached to particular outcomes (Andrea, Irene, Jesse, Pam, Teresa). Letting go of the desire for a particular outcome, even for what might be evaluated as a positive outcome, seems counterintuitive. And yet the alternative means trying to control the f uture which not only is impossible but it forecloses on possibilities in the present. Letting go is not fighting or trying to change the present moment (Jesse). Related to not controlling and letting go is not planning. Once the CIT gives up needing a p articular outcome, it follows that there is no place for a plan (not planning) Planning the present and the future is the opposite of letting go and not controlling. The counseling interaction is more alive, and youre not scripting yourself, youre no t figuring out what youre going to say next (Pam). Instead its OK, being, being messy and being not being sure of where its going to go (Teresa) and waiting for it to unfold (Jill). Although not controlling and not planning sound like non action, they are active in the sense that they open CITs to an unknown future. CITs also actively open themselves to what is and allow
122 themselves to be vulnerable as part of trusting and letting go ( allowing vulnerability ). Participants described having no preten se (Cathy) and their emotions being on display (Teresa), and allowing reactions to show (Andrea). Their feeling of vulnerability comes through in those expressions. Allowing themselves to be vulnerable is part of trusting themselves and the process and l etting go. Another action involved in trusting and letting go is drawing on intuition. Irene related an experience of being present in which she found herself approaching a client family in a different way than her normal approach. I felt an increased cap acity to be effectively responsive to the situation and I wasnt, I was very in the flow, like I was intuitively knowing what to do next rather than being like oh, gosh, what do I do next? This fathers being dominating again. How do I handle it So I wasnt in my head very much. I just was kind of like, speaking from like an intuitive place. She trusted her intuition and let go of her normal approach to allow it to come through. Participants used the expression in the flow in some ways synonymousl y with what is referred to as the process. Precise definitions for these terms are elusive with the limitations of language. Jesse referred to being present being in the flow of life and Irene seemed to agree in this passage. T heres like always an underlying current thats present in our lives T heres like, our blood is flowing as long as were alive, until our deaths, you know, our bodies are present right here, the ocean tides are flowing, the streams are flowing, the earth is present, so we can cho ose to connect with that Accepting Self, Other, and What Is Accepting oneself, accepting others, and accepting what is means giving up the fight with thing as they are. Accepting oneself means accepting personal limitations and needs (Irene), allowing myself, if I am sad, allowing myself to be sad, a nd allowing myself to be angry like if Im tired, its OK that Im tired (Andrea). There is a quality about accepting in the context of being present that is distinguished from resignation (Irene). A nd accepting also
123 does not mean condoning. Each of those has a value attached, either positive or negative. Accepting simply allows CITs to see things more clearly, without clouding them with what they should be or might be. Pam described meeting the cl ient described above. She had been told the client was having a psychotic episode and needed to be transported to a residential facility. In being open to and accepting of the client, Pam saw the client more clearly as a person and the situation changed character. I think it was just the simplicity, or like her seeing these things. And Id said that, I said Gosh I wonder if thats a lot like you, you know, that theres these really neat things about you but nobody really sees them. That they see, they just kind of t oss you aside or whatever, and that theres really like these pretty neat things about you that people just think are weird and so it was really cool to like have that conversation, and she was just this really sweet woman that, like her family lived in Arizona and she just didnt have anybody here And it wasnt, like we werent rushing to throw her in the car and take her to [the mental health facility] or anything like that. It was just like that time that we had. So it was neat. It was really neat. It was powerful Accepting oneself, others, and things as they are, not having to decide if something is good or bad, is freeing. There is no goal or endpoint to accepting. It is not for the sake of making anything happen. Accepting ones elf seems to be a prerequisite for truly being accepting of others. Participants noted the pervasiveness of their evaluation of themselves and their experience as good or bad, pleasurable or painful but that in being present they simply see themselves and their experiences as they are without judgment ( non-judging ). Judgment adds a story onto the experience itself. Being present means not adding the story but letting the experience be what it is. Teresa used her being late to our interview as an example I was thinking about Oh my god, what is she going to think about me being late its very easy to get caught up in that automatic thought of Im late, that means, that equals to ., i nstead of Im late and just put a period at the end, ri ght? Theres a little equal to. I do that. So the period would be, that would be being present. That would be like, Im late. Period. (Teresa)
124 There is a kindness to the self in accepting things as they are and not adding the evaluative story ( being kind to self ). The story that gets added to experiences and to ones behavior and feelings is often critical. As CITs become more present with themselves they discover their self criticism and see the connection between being kind to themselves and their ability to be kind to and connect with others. t hose things that I say to myself that I dont even realize that Im saying, that tend to be pretty critical, or even if theyre not directly saying oh, youre bad theyre saying you should whatever, I should be working more on this, I should be more productive I should be whatever, or you know, whyd you make that decision, that was stupid. you know, like, those things, and so mindfulness helps me be more aware of those things and then, and then being like OK, if it was somebody else saying this, what would I be saying to them and why cant I say that to myself. And so that, was, was such a different t hought to say that I should be kind to myself and to also recognize that I wasnt being, bec ause you just assume that you are, I think, at least I did. I just assumed I was, and I was so not. (Cathy ) Accepting oneself and others is validating It confirms the existence of peoples emotions and experiences and lets them be without trying to make them different. In being accepted as they are, clients feel heard and seen. This validation may help clients accept themselves. With the inevitability of change, what is in this moment will not be the same as in the next. So what is accepted in this moment will change without forcing the change. But one has to be present to notice. Accepting frees people from some of their critical internal dialogu e and from struggling against their experiences and reactions. CITs can then see their own experiences and their interactions with clients more clearly. Staying With What Is Accepting what is allows things to be as they are without trying to change them. Staying with what is means not trying to get away from things as they are As will be explored in the section on Acting to Contain Anxiety and Uncertainty, the default impulse for CITs is to somehow escape from uncomfortable feelings. In contrast, in be ing present, counselors stay
125 they stay with their feelings, they sit with their clients feelings, and they sit with ambiguity. Cathy sat with her client who wanted to kill himself. I just sat in the room with him and initially there wasnt very much c onversation it was just him, and me (Cathy). There is something respectful in sitting with what is being felt or experienced without trying to control it or make it be different, even if it is painful. I was sitting with what I imagined the emotions we re that she was experiencing so it was, it was not avoiding discomfort it was really embracing what was, whatever was coming up for her (Jesse). The staying is not forced but is part of opening to whatever is happening in the moment with beginners mind, acceptance and awareness (staying with) It is not waiting to go on to the next thing (Jill) but being there in the moment. In doing so, CITs become aware of constant change, which releases them into the flow of life. The feelings in the moment shift, perspective shifts, and the counselor or the client moves to the next experience more aware and alive. Being Right Here in the Moment Being present means being right here in the moment. It means being, not doing. It means being focused right here, not t hinking of other places, conversations, or tasks. It means being here now, not thinking of the future or the past. Jesse said being present is being in the here and now and not, and just being OK with being in the here and now a s opposed to thinking about the past or the future This has ramifications not only for the counseling session but in how CITs live their lives. T o be present youre looking at how youre feeling right now and youre not looking at just got to get through this semester and then thats it and just got to get through this year just got to get through this event or got to get through grad school and then my life will begin. (Andrea) The activities of graduate school or counselor training can be experienced in the present as that is the life being lived in the present. And in each moment, the focus of being present is
126 being, not doing Participants referred to being able to just be there (Jesse) or even to just be (Teresa). Not doing paradoxically does something. Cathy f elt so in her encounter with her client. I think that did something already without even doing anything. I think that might have made that first extension from me to him as a human being and so me just sitting there and not do ing that I think said so mething (Cathy). It validates and respects what is being experienced in the moment. Being right here in the moment locates being present in time and space. Paradoxically time and space are also not relevant in the present moment ( time becoming irrelevan t). CITs are particularly aware of the dimension of time given that their work is mostly spatially stationary. Being present, CITs experience time differently than when they are not. Participants described time slowing down (Jesse), time going by quickl y (Jill), and being unaware of time, as Andrea said I lose any concept of time. I dont think, oh, what time is it? Oh our session needs to end I dont think of these things (Andrea) Thinking about time, such as being aware of the ending time of the session, brings the CIT out of the present moment. I find like a lot of things are restrictive, the time, the amount of time you have and so sometimes, you know, it its hard for you to b e in that present moment be cause youre, if you have to think about all those restrictions (Teresa) The present moment is timeless as it is always right now. What is important is not action or the product of action, but simply being in the timelessness o f the present. Being Human/Being Authentic Being present, CITs are being human and authentic Not confined to their role as counselor, they are also daughters, friends, students, musicians, etc. Participants recognize that they are counselors in a profes sional setting but to be present in that role, they must be fully themselves. They respond to their clients as themselves and not just in their role ( not in counselor role). As Cathy said, And so for me, it wasnt like therapist client, it was, it was
127 hu man being to human being and at least I felt like, you know, right now its about the connecting of human beings (Cathy). Especially as beginning counselors, there is a temptation to add to the appearance of competency by staying in a role. But in being present, CITs venture out of the role. Not being in the counselor role means being authentic. Irene watched herself on a video recording during a part of a session when she felt present and she noticed herself gesturing naturally and said, OK Im, I fe el like myself. Like Im bringing my normal self in. Im not in a stilted, professional mode. And Cathy says simply, Im coming to you as I am. Being human in counseling means recognizing in oneself the vulnerability and emotions one sees in clients and not allowing the difference in roles to hide their common humanity. Im also human and have those kind of, I can have those kind of feelings too (Teresa). It means interacting with clients person to person with no pretense, not being guarded. Partic ipants described themselves when they were present as being human, with all their imperfections (Cathy, Irene, Pam, Teresa). Paradoxically, in the vulnerability of being authentic and human they also feel a sense of safety or peace as well. Pam described her experience this way: I feel that way about like genuineness, you know, be cause when youre genuine with someone, then you dont feel weird inside; it doesnt feel like youre hiding things. I t feels like youre being fully open with your clients or, and that you cant really get backed in a corner (Pam) Being a whole person acknowledges not only that the CIT is being human and not being in a counselor role, but they come to the moment aware of themselves as integrated wholes ( whole person) They have identities outside of being a counselor and being a student. Teresa said if I can see myself in different roles then I can see my client not just as my client but as a person. Being whole means not being fragmented as a person and not compartmental izing aspects of life. Being a whole human being with clients gives CITs access to all of themselves, not just their academic and clinical training. Irene said, To me, it means I have resources in the room with me
128 that I can draw upon, that I have access to because Im present with them. So I can access my humor. I can access my creativity and my intuition Participants indicated that being present, in particular being human and authentic, cannot be compartmentalized to the counseling session, nor can the stresses of outside life be compartmentalized there. As a whole person each aspect of ones life flows into other aspects. And I think the more stressed I get personally, just in my own life, like the less Im willing to let go of control Its, yo u cant do it part way, or at least I cant do it do it part way, very well, so I cant be like, OK, I just going to be really present with this client and then Im going to go back to being, you know, over controlling over the rest of my life. (Jill) The commitment it takes to be present and the effects that commitment has on the CITs whole life are explored more in Choosing to Be More Present. Contexts Facilitating or Inhibiting Being Present The choice to be more present is not made in a vacuum. I t is situated in the various contexts in which CITs live and study. Each of the following five contexts will be explored in this section: 1) being a beginning counselor, 2) navigating conflicting paradigms, 3) the academic context, 4) spiritual, theoretic al and family values, and 5) the counseling context. These contexts are the soil, the fertilizer, and the climate in which CITs open to being present or contain their anxiety and uncertainty. They neither determine nor predict being present and yet they have an effect on the choices CITs, facilitating or inhibiting. What is here is my interpretation of the meaning that CITs in this study make of their experience of these contexts. Being a Beginning Counselor People who are training to be counselors are b y definition beginners in doing counseling. In describing themselves as beginning counselors, participants highlighted their uncertainty and lack of confidence. . as a new counselor theres a lot of times when you dont feel confident, you feel like oh my god, I have no idea what Im doing (Pam). Not knowing what to do is one
129 thing, but even when CITs have skills and theoretical knowledge, they are unsure as to what will work with which client and when. Counselors rarely get direct feedback from t heir clients and without experience to guide them CITs are in the dark. Is the work youre doing with clients actually therapeutic and helpful (Jesse) ( not knowing what is therapeutic ). They look to others for the right way to be a counselor ( looking to others ). In my pre prac class we would watch tapes of other people doing therapy and so you figure, oh, that must be the right way. So then you try to emulate that or figure thats what Im supposed to be doing, so you kind of use stuff like that instea d of recognizing that its an individual way and theres things you can take from it but thats that person doing that persons thing. At the time, youre just thinking, thats the thing. Trying to dissect what theyre doing s o you can do it the same way b ecause that must be the right way. (Cathy). Using familiar skills, they bolster themselves with information ( information overloading). Cathys strategy was . get as much information as you can, read, get resources, get references, like writing a p aper you need to know what youre talking about. Not only do CITs load themselves up with information, but they are expected to take in a volume of theoretical and empirical information in their academic training. Beginning counselors rely on this theor etical knowledge and on the techniques they have learned ( relying on techniques and theory ), in some cases planning their sessions (see also Acting to Contain Anxiety and Uncertainty) Participants expressed feeling not authentic and at the same time not feeling ready to let go of control and trust themselves. Being evaluated contributes to the anxiety and uncertainty as well. That coupled with the fact that I was going to be on tape, people are going to see this, need to look professional (Cathy). The focus of their uncertainty may change as CITs gain experience, e.g. to being uncertain about the therapeutic process rather than being uncertain about how to seem competent, but it is always there ( experience changing nature of uncertainty ). Over time as you develop, it becomes more about the process n ot about technique. Still wonder if I can help the person (Cathy). The complexity and ambiguity of
130 counseling itself challenges CITs in sorting out what is in their control ( struggling with ambiguity of c ounseling ). Theres the uncertainty as to if the focus of therapy is whats mos t helpful for that client. A nd w ho decides, and how do you know? (Jesse). Being a beginning counselor creates a context of anxiety and uncertainty. By default CITs try to con tain that anxiety and uncertainty, processes that will be explored further in the section on Acting to Contain Anxiety and Uncertainty. At the same time, being a beginning counselor does not make containing anxiety inevitable, as will be explored in the s ection on Awakening to Choice s People who are in training to be counselors are also graduate students ( being achievers ). They have been accepted into graduate study programs by making use of what participants identified as their ability to think critical ly, to be organized, to gather and process information, and to fulfill the expectations of traditional education to achieve. When they begin their work as counselors, they draw on the skills that have helped them succeed in their academic life such as ga thering information and planning. The ground gets shaky under their feet when those skills do not guarantee success in counseling ( needing to be different as counselor than as student ). Navigating Conflicting Paradigms As CITs are exposed to the experience of being present they become aware of a paradigm that differs from the one that prevails in their academic and societal worlds. A paradigm is defined as A set of assumptions, concepts, values, and practices that cons titutes a way of viewing reality for the community that shares them, especially in an intellectual discipline (The American Heritage Dictionary). CITs find themselves in a developmental process of putting together their world view and their way of being within that world view, while acknowledging the existence and complexity of multiple world views. What participants called their normal way, the way of the prevailing sociocultural paradigm, is not being present ( normal way not being present ). Particip ants described their
131 normal way as being in automatic mode unaware, distracted, disconnected from their feelings. In addition to not tuning in to their experience, their default is to be judging of themselves and of others, to be ruled by time, and over all to try to be in control. These ways of being are indeed automatic and mostly unconscious because they are the norm. The norm becomes unnoticeable, unproblematic, and thus expected, to all those who agree it is the norm. The normal way, as described, stands in sharp contrast to descriptions of being present (See section on Being Present). Being present is not something that is typically modeled or taught in the prevailing paradigm which informs family, academic, and social norms ( being present not taught ). Participants noted that being present is not only absent from their training as counselors but in some ways contradictory to their training ( absent from training; contradicting training ). Its very at odds with what Im, the messages Im receiv ing from my academic, based on my academic training. So its interesting that I said that thats what, those things are whats feeling present to me, and thats, those are things that I, I feel like right now Im not always able to get or not communi cated as being a positive thing. (T eresa ) T here are so many other things that were told that are important, that are not, that have nothing to do with connection and, to a certain extent, some limited thing to do with relationships, but like we don t get reinforced for that stuff. (C athy) The notable exception is supervision. Participants credited significant supervisory relationships with introducing and encouraging being present. The incongruence between their academic training and this kind of input f rom their clinical supervisors presents CITs with additional complexity. I can remember, you know, first starting out in my prac and I have all these, you know, things that Ive heard professors say of you know you have to be intentional with everything you say and there has to be this, you know, plan what is your goal here in each of these and so I came in thinking that and then at the [practicum site] theyre saying, just, you know, the most important thing is to be, connect, and be genuine, and t his and that and so Im thinking A aah, what am I doing? (P am )
132 In this passage Pam gives one example of a conflict between the paradigm of being present and the prevailing sociocultural paradigm. As CITs become aware of conflicting paradigms they com e to a crossroads. They are faced with examining their own beliefs and taking stock of the courage they have to act on them in the context of conflicting paradigms. This is a developmental crossroads as a beginning counselor and as a person. The choices they make at that intersection have ramifications for how the person will work in counseling and in how she will live her life. Academic Context Counselors train and study within a demanding academic environment They are evaluated according to specific st andards and expectations, which often amplifies their self criticism ( amplifying critical voice ). If you dont know what youre doing, you should try really hard to at least look like you know what youre doing because youre in a really competitive envi ronment and people are watching (Cathy) And within the academic context, theres definitely that. You have to seem professional, you have to be meeting certain standards, you have to be show ing that we have certain skills (Jill). In the academic contex t, work and life interconnect. Although students and faculty are free from the confines of the nine to -five world, that freedom removes the boundaries between work time and personal time. W hen your advisor sends you an e -mail at 3:00 in the morning, its kind of hard to kind of set up your boundaries and be like, you know, well Im not going to do this (Andrea). People are reinforced for working harder and longer ( incongruence between personal and academic worlds ). In the academic context, problems seem t o be made concrete so they can be predicted and solved ( focusing on concrete problem solving ). CITs learn to gather and use knowledge to
133 solve problems. And even anxiety is looked at as a very concrete thing that can be managed, whether its through medi cation or through these cognitive or behavioral strategies (Jesse ) CITs feel encouraged to focus on future goals staying vigilant to ensure a desirable outcome. Its about future. Its about future, and sometimes a little bit the past, it, but its about your future, and its like, goals, and what you need to be doing in the next five years (T eresa ). Inherent in valuing a particular future outcome is a fear of the unknown consequences of things not going as planned, which in turn spawns greater diligence to ensure that outcome. Every aspect of the students academic life is part of a formula for success performance in knowledge acquisition, research production, and clinical practice. What happens if one deviates from that formula is not easy f or CITs to test ( promoting containing anxiety not being present ). Drawing on Spiritual, Theoretical, and Family Support for Being Present Setting the stage for the choice to be present are the spiritual, theoretical, and family values and beliefs that C ITs bring with them to their life and work. Although CITs participating in this study do not have identical beliefs and values, some aspect of their beliefs and values predisposes them to choose being present. What it takes to be more present fits with t heir notions of what kind of person they are or want to be or with their beliefs about how people change and about basic human nature (beliefs about change supporting being present). The participants in this study identified themselves as having a humanis tic, interpersonal or relational/cultural theoretical orientation which they felt supported the importance of being present in counseling ( finding theoretical support for being present ). Coming from a humanistic framework, I mean I think people can get through things, you know, I think people have resources and that theyre naturally, you know, life affirming, growth promoting organisms I really think that its like genuine human to human contact that is healing, its like the foundation of the, th e change that happens in therapy. (Jill)
134 Pam trust[s] that, that people, you know clients or whoever it is, that they have the capacity to, you know, figure things out on their own an d I trust that that they can get through things with support ( humanistic beliefs supporting being present ). Significant family members may pass on compatible values so that being present seems like the right thing to do ( influenced by family values ). The first thing Im thinking about is my father I dont know like the other day I was sitting and having coffee with him and he was like this is what is, what life is about for me, just being able to sit here and, and talk to you, you know, just being and being with my daughter. Its not about what happened bef ore, its just like that moment, that was precious for him and thats great you know, thats why I think that I cherish that, thats why I think I have that bias towards um being present (Teresa) Or family values may provide contrast with where the CIT ha s come in her own development. In Andreas family the value was, you know, education, the, the value was always education but through education fit in and through that Ive been able to influence my family as well I would say kind of countera cting my family values (Andrea). The contrast helps clarify the priority the CIT places on being present and therefore what she is willing to do to cultivate it. Spirituality, however known, plays a part in being present in the experience itself and in the motivation to choose to be more present ( influenced by spiritual beliefs ). CITs who experience being present and its importance in their work with clients probe beyond what they think is being a good student or good professional to their core belie fs. Again, their specific beliefs may differ but in some way their spiritual beliefs support and encourage these CITs to deeply connect with themselves and with their clients. The following statements from participants illustrate this. I guess my spiri tual background like I have an understanding of the sacredness of all beings I want to be present because I value the person (Irene) I think just believing t hat we are spiritual beings, just that basic belief influences how I deal with people, because Im not looking at them as like sacks of water, like Im a sack of water and youre a sack of water and were just talking to each other. Im thinking Im a spiritual being, youre a spiritual being. (Cathy)
135 but that ultimately what really matters is our life, our spiritual life after we leave this earth, and so you try to do the best you can and try to with, given that were human, try to do the best you c an here (Teresa) The more CITs understand their values to be supportive or at least compatible with being present, the easier it is to make the choice to be present. Sometimes, though, CITs may experience their values as conflicting. Perhaps they do not yet have an integrated value system or one that accommodates complexity or per haps the conflict comes in the more concrete manifestations of those values rather than from the values themselves. Family or religious guidelines may seem at odds with the counselors theoretical orientation in terms of how people grow and change or what the goal is for that growth and change. Does one look inward for guidance or seek guidance from a higher power? Does one value continuous striving for change or does one yield to a natural growth process? Reconciling or choosing among different values fo rm part of the context of choosing to be present. These value differences are also part of the conflicting paradigms that CITs navigate. Counseling Context Influencing Being Present On a more micro level, there are contextual factors in the counseling ses sion itself and in the counseling relationship that facilitate or interfere with being present for the CIT. Clearly the client is a key factor as the co -participant in the counseling relationship ( clients way influencing counselor being present ). Partici pants noted their ability or propensity to be more present was influenced by client openness to connection (Pam), client vulnerability and disclosure (Teresa), client interpersonal style (Irene), client expectations of the counselor (Andrea), and client si milarity to counselor, like their process of dealing with their own emotions was maybe kind of similar to mine (Jill). The nature of the relationship between client and counselor reflects these factors as well and as a whole contributes to the counseling context. It appears that being present for the CIT is influenced by but not dependent on these client
136 factors. And the effect seems to become less pronounced as CITs gain more experience in being present. The content of the counseling session emerges as part of the context for being present. Sessions with intense emotional content, such as the death of a family member or loss of custody of a child, heighten the counselors own emotional reactions. The intensity of the emotion sometimes helps awaken the c ounselor to their own present moment experience and at other times stimulates avoidance if the counselor feels overwhelmed by the story. In sessions with less emotional content counselors may be more susceptible to being distracted by unrelated thoughts an d plans or such sessions may set counselor and client at ease creating a context in which being present comes more easily. There is no recipe for being present or not, particularly in terms of the content of the session, however the content is part of the ground in which being present grows or not. Managing the counseling load involves such factors as the schedule of clients and kind of client interaction in previous sessions. Participants indicated that scheduling clients one right after another with little time in between gives counselors less time to prepare to be present and quickens their internal pace both of which can influence the counselors readiness to be present. It becomes harder, but not impossible, to keep from replaying earlier sessions an d planning future ones. A sense of feeling hurried also translates into the process of the session. In addition, the counselor may be affected by previous sessions, be they cathartic, difficult, or mundane. The counselors attention may remain with the previous session and be less available to the next client. Again these factors are part of the complex context in which counselors may choose to be present and are not predictors of being present.
137 Acting to Contain Anxiety and Uncertainty As participant s reflected on their experience of being present, they expressed that it was often easier to describe in terms of when they were not present. They articulated what it was like for them to not be present and what they described were actions taken to contai n their anxiety and uncertainty. To contain is to hold, restrain, and keep within boundaries. Anxiety is not used here as a diagnostic term for a disorder but as a common human experience of uneasiness from fear of unwanted outcomes. Uncertainty about th ese outcomes and about ones ability to manage them is a companion of anxiety. Some of the conditions for anxiety and uncertainty in CITs are found in the contexts examined in the section on Contexts Facilitating or Inhibiting Being Present, in particular the academic context and being a beginning counselor. Other conditions arise when CITs become aware of difficult emotions or unacknowledged parts of themselves, are faced with clients pain, confront conflicts in values, or when their experience contradic ts their training. CITs default to actions to contain their anxiety and uncertainty when seeking safety, even if unconsciously. Becoming aware of these automatic actions to contain anxiety and uncertainty is part of the awakening process that will be exp lored in Awakening to Choice s Four actions involved in containing anxiety and uncertainty for CITs are defined as 1) avoiding, 2) distracting, 3) controlling, and 4) managing ones image as a counselor. Each is detailed in this section. Avoiding Stron g emotions bring up anxiety and uncertainty in CITs which they may attempt to ameliorate. At one point in her interview Teresa described her difficulty being present in terms of difference in theoretical orientation and then realized, I think ultimately Im probably scared because of what Im feeling and my emotions just being fearful of what I might be feeling. But I dont think its I was saying, oh, its about the planning but its not Its really more about me.
138 Avoiding emotions is an attem pt to contain the anxiety that comes up. Avoiding involves finding ways to navigate around whatever is uncomfortable (Jill). Some CITs described keeping themselves distant from their emotional reactions as what they are used to (Teresa) and it is in cont rast to when they are present. If someones saying something upsetting or disturbing and Im not being affected in some way, then, that could be an indicator that Im not being present. Not meaning Im crying. But Im not connecting with the person or t uning in with what theyre saying if theyre telling me things that are very traumatic and theyre having no impact on me (Jesse) In daily life, avoiding and distracting can take many forms, which in their extreme form become addictive ways of containing anxiety, such as shopping, eating or working ( avoiding discomfort in outside life ). Describing what she saw as the hers and others normal approach, Jesse said, I dont like feeling uncomfortable so Im going to do everything I can in my power to avoid fe eling uncomfortable, whether its going shopping, or whatever it may be If avoiding is part of a counselors repertoire in their outside lives, it also becomes part of their counseling sessions. Avoiding in the counseling session may take the form of c hanging the subject when it triggers anxiety or uncertainty in the counselor or the client, or of rescuing the client with reassurance, advice, or problem solving ( avoiding discomfort in session ). In session, avoidance too. If its difficult for you as a therapist to talk about whatever your clients talking about then you can pick up on something else they said and make that the focus of the session, and so thats one way to avoid discomfort and anxiety in the session is to not talk about something that s uncomfortable or anxiety provoking, because really, I mean, depending on what the therapists approach is to therapy, they can have a lot of say in where the session goes and what is focused on and whats paid attention to. (Jesse) Distracting If CITs are successful in avoiding, they remain unaware that they are feeling at all. It is the normal way and remains unproblematic most of the time. If not successful in keeping anxiety out of awareness, then distracting oneself from the feeling helps contain the accompanying anxiety. Irene read from her journal where she wrote, I realize how much I distract myself from
139 the present moment. I wonder why Im so afraid of being myself in this moment and in this location with these feelings experiences and thoughts She was more present at that point from having realized that she was afraid and then distracted herself. In the moments of distracting, however, she had been unaware, and so successful in containing her anxiety and uncertainty. Some ways of distracting are subtle but also effective such as keeping ones mind occupied (Jill) and filling up ones time even if it is reading the cereal box each time it sits on the table at breakfast (Andrea). Staying predominantly in ones thoughts distracts from feeling (predominantly thinking ). In predominantly thinking, thoughts become the experience rather than the emotion that is being avoided. At times the thoughts may stimulate more anxiety which then starts the cycle again, especially since CITs described a pervasive internal dialogue or narration that was often self critical. Another way to distract oneself from present moment feelings is to plan the future or replay the past. Again, these thoughts have the potential to stimulate more anxiety but they distract the person from the immediate experience. I noticed that I am always, not always, most of the time in the future, which I told you earlier, and it felt like I was trying to brace myself against future experiences, so like get the most pleasure out of them or brace myself against anything thats not enjoyable, that might be painful or might make things not turn out the way I want them to and so I was always like rehearsing the future be fore I was there. I didn t even know I was doing that, but I think that's what I do, did all the time like I was trying to not feel things or not be affected by anything that happened. It was like almost strategically not being present to life. (Jill) Closely related is the acti on of tuning out The CIT may contain her anxiety and uncertainty by tuning out, and again remain unaware of her discomfort. Tuning out may involve not listening by drifting off or thinking of other things. In so doing, the CIT is unconsciously protecting herself (Jesse).
140 Controlling Controlling is a central action in containing anxiety and uncertainty. Controlling encompasses controlling oneself and trying to control what is happening now as well as trying to control future outcomes. Control is huge Controlling, desiring control, trying to be in control, and I think a lot of the problems people face is because theyre holding on so tightly to trying to control things and have things go a certain way. (Jesse) P lanning is way of trying to be in control of ones experience and it helps take away some uncertainty by making what will happen seem known. continuing to try to solve the problem or continuing to try to get ahead or continuing to try to plan everything out, whatever it is that Im trying to do thats causing the stress its just be comes addicting, but it doesnt actually make me feel any better. I always think it will I mean, initially, Im always like, once I get this fig ured out, then Ill feel better (Jill) Of course there is no way to really know how or what the future will be but planning helps the CIT feel that things are no longer uncertain. Anxiety and uncertainty both stem from anticipated future events or feelings. CITs make plans to keep th at future under some control, predictable, known, and therefore contain their anxiety and uncertainty. Open, unplanned space in time leaves the person uncertain which then brings up anxiety that prompts planning. Irene said when I thought about the futur e I just want to fill up the time so that there wont be any gaps, so I wont have to worry about what am I going to do with just being there Being beginning counselors and feeling uncertain about ones expertise is a particular kind of uncertainty. He re again, the default in dealing with that uncertainty is to control and plan. I think at the beginning of counseling I always came in with an agenda, thinking OK this person had said this during this session, OK let me look up these things, these are the, this is the list of things that were going to talk about (Andrea). There is a closing down on the counseling session, preventing unanticipated topics or issues from arising for which there is no plan ( controlling content in session ). The session b ecomes the
141 fulfillment of the counselors agenda. In a more subtle form of control, Jesse became aware that in her own discomfort with certain emotions she unconsciously manipulated the interaction in counseling so the client would not feel those emotions or would not trigger those emotions in her. I was just thinking of avoidance of uncomfortable emotions you know I mean, its not, its almost like, for me its not avoiding crying, cause I can sit with that all the time anytime, but it would be more avoidance of probably angering the client or saying something that could potentially hurt the clients feelings, or even just acknowledging whats coming up for me because its un, you know, its almost like Im trying to control the clients reactions in som e ways. Its not something that I c onsciously am like trying to do. Sometimes anxiety arises in sessions from worries about how the CIT will be seen on video tape or evaluated by supervisors. There is an almost constant internal narration of what is hap pening in the session knowing that the CIT will be reporting on the progress of the session to a supervisor. The counselor may then unconsciously try to guide the session toward a particular outcome that she will be happy to report ( controlling for specif ic outcome ). I feel like when I narrate it in a way like Im going to tell someone else about it, then you have a way you want it to end, too (Jill). Controlling for a specific outcome may not be related to evaluation by a supervisor. It may be simply to reduce the counselors uncertainty. The CIT makes the future more predictable by controlling or planning for a certain outcome. Managing Image as Counselors Being in training as a counselor means being evaluated which contributes to feeling anxiety and uncertainty and the desire to control how one appears. Some of what theyre looking for is very specific and so it seems like its something you should be contro lling and making sure happens (Jill). I defined this element of the acting to contain anxiety and uncertainty as managing image as a counselor Here participants described putting on a counselor person a that crea tes the image CITs believe they should have or the image that will
142 make them feel most secure. Cathy remembered trying to put on persona of what a therapist looks like, nodding head, looking serene . Not being present at all because I was playing with w hat I was supposed to look like . Self monitoring then makes sure the image is maintained. CITs monitor their posture, their language, their interventions, and their emotions. Andrea used the example of . self -monitoring be caus e I think oh what is the right word, what is the right statement to say (Andrea). Some monitoring might be considered self awareness but there is a point at which it takes over the consciousness and so blocks awareness in the attempt to contain anxiety and uncertainty. Wanting to appear competent CITs feel responsible to to provide some sort of solution (Jesse) or to hide personal background behind a professional image as Andrea expresses here: I come from a, a low socioeconomic class background, and I didnt, I kind of wanted to have that expert counselor role (Andrea). Although acknowledged to be new to their work as counselors, CITs still worry that they should somehow know more than they do, as Irene said Oh I should know all these DSM criteria or I should know the answer to the question they just asked me. The incompatibility of a CIT being a beginner and at the same time needing to have expert level experience and knowledge as a counselor (they may have expertise in other realms) does not st op CITs from trying to manage their image so they appear to be an expert beginner. The job of managing such an image takes energy and attention and participants noted that they did not feel present when they were monitoring how they appeared to their clie nts or to their supervisors. Awakening to Choice s Awakening to choice s is significant in the theory put forth here because it proposes that being present does not only occur fortuitously but is chosen. At any moment, CITs may seek safety or open to connect ion and they do this unconsciously until they awaken to the agency they
143 have in the process. Awakening to choices to be more present happens both in an instant and over time. The instant a person becomes aware, she is more present. Even if what she becom es aware of is having been in an automatic mode, the moment she awakens to see that she was in it, she is no longer there. For example, if a CIT becomes aware in session that her thoughts have wandered to the previous client she then can make a conscious choose as to where to place her attention. Awakening over time, the cumulative effect of moments of awakening, deepens the understanding of the choice to be more present with all that goes into that choice. The factors or processes involved in choosing t o be more present will be explored in the next section. This section details four conditions and actions of awakening to choice s to be more present: 1) distinguishing being present, 2) experiential knowing, 3) coming to know oneself, and 4) recognizing ha ving a choice. Distinguishing Being Present To awaken to the choice to be more present, CITs must distinguish when they are being present. The actions and attitudes that come together in what is defined as being present are examined in the section Being P resent. Here, those actions and attitudes are defined as experienced along a continuum. Being present has range and dimensions and there is no end point on these continua. If one is at least physically there, one can be said to be present. At the same time, participants implied a threshold at which they considered themselves to be present while acknowledging that they could become more or less present from that point. Being physically present but distracted, tuned out, or going through the motions is l abeled automatic mode I f Im preoccupied or feeling distracted, or just feeling like a spacey, where am I ? feeling, Im not available Im not totally there, like part of me might be there (Irene). In practice being in automatic mode is considered not being present. Being in automatic mode may be a predominant state of being in life or in counseling. Specifically in the counseling session, a
144 way of being that participants implied is less present is applying technique without connection This means applying interventions, body posture or interpretations in a mechanical or in some cases purely cognitive mode, as if performing an academic exercise (Cathy). A CIT performing in this mode m ay be evaluated positively on observable skills. But participants viewed skilled counseling (Cathy) as different and less present than counseling with heart (Irene) or with connection. Another dimension of applying technique without connection is appr oaching counseling as a chore, trying to get through it (Jill) or as a job to be done (Pam). Being in automatic mode and applying technique without connection are at the less present end of the being present continuum and can be associated with the actio ns of containing anxiety and uncertainty. At the other end of the continuum of being present, which again has no true end point, is being fully present. Being fully present requires the coming together of fertile conditions and the most expansive attitu des and actions of being present. The superlative experience of being present may be said to be at infinity on the continuum, a goal for CITs but not a reality most of the time. You know, if I could be truthful, if I could be honest about whats happening if I could be open to the individual, if I could be connected to the individual, oh, hey, if I could be non judgmental of the individual, all of those things, and then also being aware of what was happening in our dynamic together and also whats happeni ng with the client, just being in, in, moving I guess in the moments, moment to moment with the client, going along with them, seeing whats happening, and being, you know, kind of cognizant of all the things that, that are going on at any given time I mean if I could do all or most of that Id be pretty psyched. I think all might be a little bit much, but a little high for me, a little high goal. (Cathy). Clearly CITs are present in degrees of frequency and duration How often and for how long the y feel they are present varies, simply demonstrating these dimensions of being present. For CITs, being present is intermittent (Pam), uncommon (Jesse), fleeting (Jill), and fluctuating (Teresa). Distinguishing the quality of being present is part of awa kening to choice s to be
145 more present. This is meant in two meanings of the word, quality: first as an essential characteristic and second as the character or nature of the characteristic. For example, being present is distinguished qualitatively from be ing focused by Irene in these terms: the presence being a little more open and deeper and where Im not having that sense of effort. Its more like spon its happening and Im participating in it but I didnt have to like marshal all my forces to make it happen. Cathy noted that when she is present with another person their encounter has a meaningful quality rather than being purely academic and Andrea said not superficial. Pam contrasted the quality of clarity in being present with not being as present when . like I have a weight on my head or something . I t feels like theres like a shade or something that is there. Most participants described a particular quality to the energy of being present. In some cases this refers to the energy in the room and in others it is the counselors internal experience of energy (Jill, Pam). Articulating the distinguishing quality of being present tests the limitations of language. Distinguishing being present in its frequency, duration, range and quality is part of the awakening process. In their awakening participants expressed surprise that they were not present more given the importance they attached to being present (Jill, Pam, Jesse, Cathy, Irene). Experiential Knowing How do CITs k now what they know about being present, especially given the difficulty of using language to articulate what they experience? What I am defining as experiential knowing is a kind of knowing that does not require language to be known. Every participant commented on it being hard to describe the experience of being present and at the same time each one of them expressed knowing the experience and valuing the experience. They use expressions like knowing it was important (Cathy), knowing it was powerful (Andrea), and knowing the need for connection (Teresa). They distinguish between their preconceived idea of being
146 present and their experience of being present (Pam, Teresa, Irene). Recognizing their knowing is part of awakening to choice s to be more pr esent. In that recognition is also validation of the experience and of their knowing of that experience. Experiential knowing increases the CITs confidence in their knowing. They then attach significance to their experience and make meaning of that exper ience. Experiential knowing may either confirm or challenge the CITs previous beliefs. For example, Jesse described how being present with her own experience confirmed her trust in her Humanistic belief that people have within them the potential to grow and care for themselves. For Teresa, her experiential knowing of being present brought her to a crossroads in challenging her previous interpretation of her spiritual beliefs. In both cases, these CITs awoke to their choice to be more present or not. CITs describe being present as experiencing things as they are in the moment, feeling things as they are happening, not ignoring their own experience (Jesse, Pam, Jill, Teresa). As they talk about being present they consistently use words such as experienci ng, feeling, and sensing, words that connote in the -moment involvement. Teresa poetically portrayed her experiencing of emotion when she is present as pure, meaning no added judgment or evaluation. And in that pure emotion, she gains clarity. Ones body is the vehicle for present moment experiencing. In being more present, CITs are experiencing in the body : noticing bodily sensations or in some cases the bodily sensations grabbing their attention and helping bring them into the present, as Jill expresse d when I can like fee l my body, like from the inside. Most participants used the descriptor being in my body contrasted with being in my head when they are present (Cathy, Jill, Teresa, Jesse). And in being in their bodies, they become aware of phy sical reactions as information
147 information about their level of stress, tension, and anxiety in addition to how they are responding to their clients. I think that what I may have known cognitively but not actually experienced was the fact that, you know, these uncomfortable and very intense emotions are not this permanent state thats attached to me, thats going to follow me around o nce I have recognized that, which is something that is, that is newer for me, it helps me to realize that things aren t as disastrous as they might seem and it makes me feel more able to handle anything that comes my way and so I think that thats very valuable to instill in client s and I could have said that before, but, but now I know it, now I know it in a more physic al way, because Ive experie nced it in my own body and mind. (Jesse) Coming to Know Oneself As CITs inhabit their bodies and experience they build their self awarenes s. They watch themselves distance themselves from their emotions (Teresa) or hurt themsel ves with self criticism (Pam, Irene) or withdraw and disconnect (Cathy). In experiencing their emotions they become aware of how they avoid or tune out those emotions and this begins a process of exploring the self Teresa referred to herself in this pro cess as being a scientist observer learning about herself. Andrea noticed how her emotions are influenced by others judgments and some incongruities in her life. Jill recognized that when she is present she feels OK which highlighted how not OK sh e felt much of the time but also expanded the possibilities for feeling OK. Increasing self awareness and exploring the self, CITs recognize countertransference in sessions with clients. Once acknowledged, countertransference may be used for therapeutic benefit rather than interfering unconsciously. A cknowledging the truth to oneself is part of being present (Cathy, Andrea, Pam, Irene) in that it brings the whole person of the counselor into the present moment. Not doing so, as Pam noted, its like den ying a part of yourself or something, I mean its like not fully understanding yourself or fully understanding your experience (3.162) and leads to not being present. Acknowledging the truth to oneself seems frightening but becomes a relief and not only opens the way to being present but feels
148 right. As Cathy said, its actually made me stronger in some ways Im actually knowing myself. This is cool. This is the way it is supposed to be for me. All these processes of coming to know oneself are part of awakening to choice s to be more present. Recognizing Having a Choice One participant used the movie The Matrix (Silver, Wachowski, & Wachowski, 1999) as a metaphor for her awakening to the paradigm of being present. The Matrix portrays dual world s where one is decidedly evil (androids enslaved human beings and imposed an artificial world on them). The conflicting paradigms which CITs navigate may not be characterized in such a dualistic and evaluative way. Neither is the real world, especially from a constructivist perspective, but each is a way of seeing the world and being in it and in any one moment they are incompatible. Its exactly like the Matrix, like not everybody had this little view, or what I saw the last few weeks and so I have, a nd then what do I do now? Do I transform my life or, you know, do I transform what I, what I do, in a day by day, moment to moment, or do I just choose to go back and stay in the, the Matrix? You have to see that movie. Yo ull know. Its just like that (Teresa). As CITs come to know themselves and their direct experience of emotion, sensation, and connection in the present moment, they come to a crossroads as Teresa describes above ( being at a crossroads ). They are faced with a paradigm that may conflic t with either previously held values or with values that prevail in their environment. But once they are aware, they are already more present and thus immersed in awakening to choice s they now have (awareness distinguishing being present ). They recognize their existential choice to move either in the direction of the prevailing sociocultural paradigm, seeking the safety of containing their anxiety, or toward opening to connecting with themselves and their present moment experience. In the awakening proces s, there is a period where CITs question the agency of being present, wondering if what they experienced was random (Teresa) and unpredictable (Jesse, Irene), and if
149 they can really make it happen (Andrea). Once their ability to choose to be present is ac knowledged, it opens the door to noticing how they have constructed their lives and relationships that either facilitates or inhibits being present. As Cathy noted, I feel like when you start to go in this path of like mindfulness, connection, presence, I think sometimes you start to re -evaluate your relationships in some ways, ways of being in the world. The evaluation can present CITs with difficult choices. Pam wondered, What am I getting myself into? Sometimes, do you really want to know? bu t answered herself with Id rather be aware than unaware. Choosing to be more present is a moment by moment decision and participants found the moment to moment choice less overwhelming than choosing a change in their whole approach to life. But they a lso acknowledged that the choices they make moment to moment add up to a personal change journey Teresa understood the ramifications of choice when she said, I know its moment to moment but its also those moments build up. There is a broader change in your being, and in your, and so for me, I definitely understand how that is a decision -making process. Choosing to go toward being more present or toward acting to contain anxiety and uncertainty is part of a developmental process over time. The trajectory of the journey may feel more familiar and therefore more certain in one direction or the ot her depending on the persons history, context, and values. For some CITs the movement toward being present represents a bigger step into the unknown than for others. But for all there is no escaping the choice that is theirs to make once they become awar e of it. Choosing to Be More Present Once CITs awaken to the choice they have to move toward being more present they then can make that choice or not. Of course not choosing to be more present is still a choice, one that may become unconscious after a ti me but not in the moment of awakening and then choosing. Those CITs who choose to be more present are making a commitment that comes out of their
150 experiential knowing of what it is to be present and the meaning they make of being present, both as people and as counselors. Choosing to be present involves five processes: 1) taking a stand on being present, 2) risking, 3) weighing the costs and benefits of being present, 4) stepping out of the normal way, and 5) fostering and cultivating being present. Each o f these will be examined next. Taking a Stand on Being Present In choosing to be present, CITs are taking a stand on the value of being present. They take that stand when being present fits with their co unselor identity their sense of the kind of counsel or they are or are becoming Andrea said, I f Im going to be a professional, then Im going to be, have to, if Im going to be a professional, be a consultant, even, even counseling clients, like Im going to have to be honest an d direct and, and in the moment (Andrea). When asked to describe being a good therapist, Jesse responded with, Well, Im being present and went on to describe what that meant to her. Jill commented F or me, its really easy to shift into kind of an evaluative mode, when Im not present when Im just doing it as an exercise, you know, and Im going to move on to the next thing. And that really doesnt fit with my values as a therapist, you know, thats reall y, that doesnt feel good to me. The sense that being present feels r ight or resonates with counselors identity encourages them to take the risks involved in choosing to be more present. They draw the confidence to take a stand on being present from that resonance. Not only are counselors taking a stand in each moment th at they choose to be present but over time they are making a life altering commitment Each choice made in a moment contributes to the development of the CIT, although perhaps in small increments. Choosing to be present for even a moment, though, reflect s a broader commitment to the value of the paradigm of being present. Valuing being present for its therapeutic worth adds weight to taking a stand on being present. Participants
151 expressed valuing being present in emphatic terms, i.e. . if you aren t able to be present then you arent able to help (Jesse) as well as more generally saying it is significant to the therapeutic process (Jill, Pam, Cathy). Valuing being present comes from a passionate commitment to the client and to the therapeutic proc ess. I have an understanding of the sacredness of all beings . I want to be present because I value the person If theyve come to me, I want to be able to offer something to them, with as much as Im able to, with as much of mysel f as Im able to br ing to that moment. (Irene) People who do not share such a passion may minimize the complexity and intensity in being present. This challenges CITs to stand on the value they place on being present and may mean they are misunderstood. To be present with s omebody, another human being, I mean, it requires you to be giving of yourself in a way, and being, I mean it takes energy. It takes t takes commitment. But to say that, to say I go into therapy trying to connect with somebody, maintain that connec tion and use that connection to make change sounds so basic that sometimes it like its frustrating to me because Ill say that and, and depending on who I am talking to, I think they get it or they dont get it. (Cathy) CITs may not always find external support for choosing to be more present and so draw on their own values and sense of what it means to be a good therapist. Taking a stand becomes an important underpinning for choosing to be present given the risks. Risking Risking is part of choosing t o be present. CITs take risks in the momentary choice to be present as well as in the developmental process of being present over time. If acting to contain anxiety and uncertainty is moving away from the direction of being present, then what happens to the anxiety and uncertainty when choosing to be more present? And if being present is inconsistent with the prevailing sociocultural paradigm, then what do CITs risk in choosing another path? In general, being present brings CITs into direct contact with the present moment experience of their lives, with its uncertainties and impermanence, and with their whole selves.
152 Choosing to be present means risking that contact. The risks of choosing to be more present are defined as being vulnerable, feeling diffi cult emotions, scary to let go control into moment, facing uncertainty, risking rejection, and setting oneself apart from majority. Being present involves coming to know oneself and bringing ones whole self to interaction with others and as such means bei ng vulnerable It does feel risky to me to choose to be present because people will really see me, people will really know me, and what if I dont, what if in being natural and letting go you do something thats socially disapproved of or not what people want or youre just seen more clearly, you cant hide as much if youre letting go of control of what happens. (Jill) Risking rejection or making mistakes as the CITs true self feels more vulnerable than if adopting a persona or staying in role. Not only are CITs vulnerable in showing their authentic selves but they are vulnerable to feeling pain. Cathy said in remembering being present with a suicidal client that to sit with that pain was not easy. T o allow myself to be open with that and be vulnerable with him in that was not easy ., be cause it hurts you know. So I m allowing myself to be hurt. Feeling difficult emotions can bring up anxiety that adds to the original emotion and both are being experienced in the quieting down and slowing down process of being present. Teresa put is quite directly: I think ultimately Im probably scared because of what Im feeling and my emotions and not feeling like I can control myself or just, just being fea rful of what I might be feeling. Risking feeling difficult emotions is part of choosing to be more present. Participants expressed that it is scary to let go of control into the mome nt, not only with the potential to feel difficult emotion s and being vulnerable but also fearing the essential feeling of being out of control and as such fearing the letting go (Jill, Teresa, Andrea). Letting the moment unfold in counseling leaves the CI T with no external confirmation or comparisons, and no validation of the direction the counseling session is taking (Andrea). With no external props (Irene) and like when you just know something is happening and youre kind of waiting
153 for it to unfold (Jill) and recognizing that I dont feel like I have all the answers (Jesse) all put the CIT in the position of facing uncertainty I think that, that thats definitely a struggle to, to trust and let it kind of go where it needs to go, be cause theres not as much security (Pam). Choosing to be present in any one moment is risky in being vulnerable, feeling difficult emotions, letting go of control, and facing uncertainty. As the CIT chooses to be present multiple moments over time, even with those choices being intermittent, is risking transformation With all the uncertainty that comes with being present, comes the uncertainty of how a person changes over time as she lets go of control into the present moment. Personal change is often associated w ith some apprehension even when the path is felt to be more predictable. CITs, in choosing to be more present, risk transforming in ways they cannot control or predict. There are some ways in which CITs know that in the choosing to be more present they a re setting themselves apart from the majority, from the prevailing sociocultural paradigm. This is risking not only on a philosophical level but for some this may be risking losing support from their extended family or their religious fellowship or risking setting themselves apart within their academic departments. Weighing the Costs and Benefits of Being Present Choosing to be more present, just as most decision-making, entails weighing the costs and benefits. While CITs may take a stand on the value o f being present they are also aware of what they are risking in choosing to be present. As they experience the outcomes of both being present and acting to contain anxiety and uncertainty, weighing the costs and benefits changes but remains part of the ongoing process of choosing. Weighing the costs and benefits includes recognizing that choosing to be present is not easy and that there are conflicting emotions involved; balancing the need or desire for connection and protection; and ultimately choosing t o be present with the attendant risks for the sake of connecting with self and others. The specific
154 costs and benefits are explored more fully in the sections Experiencing the Outcomes of Being Present and Experiencing the Outcomes of Containing Anxiety a nd Uncertainty. In being present CITs trust and let go of control, make themselves vulnerable, and show their authentic selves and so have the potential to connect deeply with themselves and others. Participants described feeling heightened empathy for their clients (see Experiencing Outcomes of Being Present). In the process of choosing to be more present, CITs also attend to their own need to protect themselves from pain so that they can remain effective as counselors ( balancing connection and protect ion ). Jesse describes a d elicate balance, be cause you dont want to be so connected that you cant be a therapist. Theres a lso a self p rotective piece. It is i mportant for therapist s to take care of themselves, to not be traumatized. I think you can b e present in protecting yourself. And you can be not present in protecting yoursel f. The difference is awareness. Here she brings up again that the point of awareness distinguishes being present. Choosing to be present is not easy. Period. Particip ants repeatedly and in many different ways described the choice as not an easy one. CITs weigh their conflicting feelings in choosing to be more present, e.g. wanting connection and protection and feeling their clients pain and feeling satisfaction in the value of the interaction. Cathy refers to the vulnerability to pain as one way in which it is not easy to choose to be present. And, you know, thats not my life, you know, but I chose to sit you know, in a room with you and allow myself to be hurt and I mean pretty ultimate, thats pretty, pretty big stuff, you know. And so, its a lot easier not to do it, its just so much easier not to do it. (Cathy) Jill talked about her difficulty choosing to be present as she goes into her day. For her, setti ng the intention to be present with clients means putting aside the concerns of her outside life and she worried that she will lose control of all the things she is juggling in her life. The commitment to being present feels like putting being on top of t he rest of life at risk.
155 As they weigh the costs and benefits, those CITs who choose to be more present, knowing at least to some extent what they are risking, do so for the sake of connecting to themselves and to their clients ( choosing with the risk for the sake of connecting ). In talking with Teresa, I heard some anguish in her recognition that being present was something she felt she had to choose to fulfill her commitment to connecting with people. It seemed a difficult choice for her to make persona lly. The choice seems to accentuate the CITs personal value system beyond even their work as counselors. And its not to say that th at doesnt make your life hard like we dont get reinforced for that stuff. You know? So its kind of like I feel like when you connect with another person, truly connect with them, its a reminder of, of whats important, its a remi nder of, you know, like truth. so I think its completely worth it because its like every time I do it I feel like I get that gr ea t reminder and then I feel like Im closer to knowing myself (Cathy) Cathys comments again bring in the potential that context has to inhibit or discourage being present (See Contexts Facilitating or Inhibiting Being Present). CITs over and over seem to have to take a stand in risking and committing to being present. They weigh costs and benefits in the process of choosing to be more present. Stepping Out o f t he Normal Way The normal way is a way of being in the world that is automatic and mostly unc onscious because it is the norm in the prevailing sociocultural paradigm (see also section on Contexts Facilitating or Inhibiting Being Present for more on the normal way). The normal way is ones default. Choosing to be more present is stepping out of t he normal way and this requires reprioritizing. Attitudes and actions given priority in being present generally contradict priorities of the prevailing sociocultural paradigm in academic and social contexts in which counselors and training live at this po int in time (see also Navigating Conflicting Paradigms in the section on Contexts Facilitating or Inhibiting Being Present).
156 For CITs, reprioritizing seems most difficult and most necessary in choosing to be more present in the context of graduate school. Reprioritizing means placing greater value on having an identity outside of school and on what Irene described as being a little more lenient on myself l ike just being more real with myself about my en ergy level and kinder to myself. It means no t being as future oriented as in the normal way (Andrea ) and taking the time to prepare to be present before picking up a client even if it means being a few minutes late (Jill ). Choosing to be present means figuring out how you implement it with graduat e school and will you, we dont have to live these lives where we stay up late all the time and dont get enough sleep, and have to work hard all the time (Andrea) Shifting priorities in any of these ways may not please others and by definition differs from the norm, bringing the process back around to the risking involved. CITs typically approach counseling in ways consistent with the priorities of the normal way. Repeatedly participants noted as they remembered times when they felt they were being pre sent that they were stepping out of their normal approach. Jesse said being present is not my default and Pam said that w hen there are those moments that you feel just completely aware of whats around you that you really notice and it feels a lot dif ferent. Andrea noted that when she was being present she intervened with clients in the moment which was not typical of her behavior in session. Stepping out of ones normal approach requires courage and flexibility. And again it shows a commitment to clients welfare despite the personal challenges it presents. using myself at that moment to kind of be a part of that healing process for the client, so, and try to step out of my boundaries and even though its scary for me to do that, but bei ng able to step out there, too, and in the long run that I know that, that it might help in, in the healing process for the client. (Teresa)
157 Stepping out of ones normal approach to counseling, especially as a beginner, puts the CIT into unknown territory. Facing this uncertainty again is part of choosing to be more present. F ostering, C ultivating Choosing to be present involves commitment to fostering or cultivating the ability to be present. Philosophical, theoretical, or spiritual resonance with the value of being present is not enough to make it happen. While participants related being surprise d to realize they were present at times, they could in most cases trace conditions or actions that prefaced being present. If CITs take a stand on the value of being present and are willing to step out of their normal way of being to be present with the a ttendant risks, then it follows that fostering and cultivating being present becomes part of the choosing process. CITs foster and cultivate being present to increase the frequency, duration, and depth of that experience. The first part of fostering and cultivating being present is acknowledging that being present takes practice. Part of the process of Awakening to Choice s (see above) is recognizing ones agency in being present, that it is possible to influence ones state of awareness. Once this is r ecognized it follows that there are actions that facilitate or foster being present and that it takes practice to make those actions more effective in fostering being present. The practice is moment by moment and ongoing. Just as with practicing anything, it is possible to get better at it. As Jesse said, I think it takes practice, too, but the more often Im able to be present in session and the client is there with me I think that it just kind of sets the stage for being able to Actions that define fostering and cultivating being present include breathing, not predominantly thinking, slowing down, caring for self, coaching self to be present, stepping back, and preparing ones attitude and emotion to be aligned with being present. Each action relate s to the other actions and no one action stands alone to cultivate being present. Breathing
158 is a tool for bringing a person into the present moment and fosters relaxation, a state which fosters being present (Andrea, Irene, Jill, Jesse, Pam). I might noti ce my own discomfort or my own anxiety and then engage in some sort of deep breathing just to help relax myself so that I can continue to be present. So I feel like maybe thats kind of like a tool to get back on track (Jesse) Using breathing also brings CITs into their bodies, meaning they are aware of their bodily experience. Being in their bodies opens them to their feelings and then they are not predominantly thinking Their minds are not active and thinking falls away (Cathy). Every participant emph asized not being in my head as important in fostering being present. Stepping back from thoughts helps CITs not go emotionally up and down with their thoughts (Cathy, Pam, Teresa) and allows them to stay centered (Andrea). Focusing on breathing or deep breathing also helps the person slow down and take a few seconds to change frames of mind (Pam). CITs foster and cultivate being present by preparing their attitude and emotions. The preparation means reminding themselves to be present (Andrea, Cat hy, Pam) and setting an intention to be present (Irene). It means calming themselves (Andrea, Irene, Jesse) and fostering curiosity and openness (Cathy, Jill). S lowing down allows the counselor to choose to be present. I think that slowing down and h aving an awareness .a lso takes the focus off of the persons ego and once that happens theres a shift and I think that peopl e are able to be more present (Jesse) Conversely, participants noted that it is hard to be present when their lives are busy (Andrea, Irene, Pam, Teresa). When their lives are full and moving at a fast pace, CITs minds seem to be moving at a similar pace which takes them out of the present moment. Multi tasking, the hallmark of efficiency in the prevailing sociocultural p aradigm, is another pull away from slowing down. Cultivating being present is not just slowing down in session, but slowing their lives down. Slowing life down makes room for c aring for self The ability to be present is influenced by the quality of dai ly life and ones level of self care. If the CIT is depleted, being
159 present is more effortful and forced where if she cares for herself she is able to be more present for others. Being in their bodies, CITs attend to their needs sooner. For instance, Ji ll talked about noticing she was hungry or tired before she allowed herself to become ill. Participants mentioned numerous self care activities but most important seemed to be connecting with family and friends. I think what the connection with family a nd friends they remind me of different aspects of me different roles, that, for some reason that helps keep me grounded, And I think that frees me up in thinking, like if I was just like seeing myself as a therapist and what I need to do, my objecti ves in that setting or whatever, then Ill just be thinking about treatment plans. I need to do this and I need to do that, and then I find that that takes away from being present and being in that moment. (Teresa) Participants expressed surprise at reali zing the importance of caring for themselves in the big picture of their lives in fostering their ability to be present. This speaks again to how being present involves the whole person of the CIT (see Being Present). There are two additional activities that are powerful contributors to fostering and cultivating being present: supervision and mindfulness meditation. Participants told of supervision that influenced their being present both in introducing them conceptually to being present and fostering their being present. Not all supervisory relationships qualify as fostering or cultivating being present. Those that do offer permission to CITs to go into their counseling sessions without a plan, and to face unacknowledged parts of themselves, and the y validate CITs in being whole, being human. having supervision with B --, and in that point in my life I think I was ready for more than I was getting, or seeking, or se eing, or doing, whatever, a nd there was a whole part of me, that vulnerable part, whole parts of myself that I was not a cknowledging . I wanted more integrated sense of self and a more, a bette r understanding of who I am, and she challenged me and pushed me and worked with me to do that. (Cathy) The supervision relationship has the potential to awaken CITs to the experience of being present and as such is a powerful influence in the process of choosing to be present. Supervision also
160 offers a place for CITs to explore what triggers disconnection in them and what opens up being present. Supervision appears to be one of the only aspects of counselors training that fosters and cultivates being present. Participants in this study were trained in and practiced mindfulness meditation as a way of cultivating being present. Understandably mindfulness meditation showed up prominently in the data as a context for the attitudes and actions of being present, just as it was designed to do. Participants reported that in mindfulness practice they increased their awareness and acceptance of themselves and their emotional and bodily experience (Cathy, Jesse, Jill, Teresa), of what happens around them (Irene, Jesse, Jill, Pam, Teresa), of uncertainty (Andrea, Jill, Jesse), and the inevitability of change (Jesse, Pam). Mindfulness meditation is practicing being present so that one can then be more present outside of meditation. What participants reported of what they learned from practicing mindfulness meditation parallels processes of being pre sent in counseling such as staying with anxiety, trusting self, not needing to be an expert, not needing to control the direction of counseling, attending in the moment, being genuine, being aware, accepting what is. When Im not being mindful, like I ver y m uch want there to be movement, and I want there to be a certain direction. I dont always notice that Im doing that, that Im like trying to fill up the time or the space or whatever, but like having that space feels good to me now, which I think is so mewhat from doing this, from being more patient, more open to whatevers happening. (Jill) as far as sitting with uncomfortable emotion, I mean I know that thats something that is hard for me to do sometimes, but through this training and practice I ve really challenged myself to be better at it or to have more practice doing it, so I feel like the more that Im able to do that, the easier it will make the counseling process for me, the more Ill have to offer my clients . (Jesse) Participants d escribed mindfulness meditation as not easy in much the same way that they did choosing to be present, and as offering some of the same benefits with practice over time as
161 being present. Mindfulness meditation is a microcosm of being present in the broader spectrum of life. Experiencing the Outcomes of Being Present and of Containing Anxiety and Uncertainty Both in the moment and over time CITs reap the fruit and the fallout of their choices to go in the direction of being present or of containing their anx iety and uncertainty (see sections Being Present and Acting to Contain Anxiety and Uncertainty for definition of each). The processes encompassed by both being present and acting to contain anxiety and uncertainty are complex and paradoxical. These proce sses are complex in that they comprise interconnected actions and outcomes and they are paradoxical in that those actions and outcomes are sometimes contradictory. One of the motivations for and outcomes of acting to contain anxiety and uncertainty is fe eling safe. Avoiding, controlling, distracting, and managing image the actions of containing anxiety and uncertainty are all efforts to not experience fear or discomfort in what is. Distancing from ones experience accomplishes the goal of not feelin g the discomfort but in the process the CIT is left feeling disconnected, not authentic, and dissatisfied. Another of the fruits of acting to contain anxiety and uncertainty is that it fits with the prevailing sociocultural paradigm and as such is sociall y acceptable. At the same time, in acting to contain anxiety and uncertainty, CITs miss therapeutic opportunities, jeopardizing their safety and acceptance in their profession. In being present CITs go against their default impulses to seek safety and cer tainty. It feels risky and frightening to let go into an unpredictable present moment and be vulnerable as their authentic selves. They worry that they will be out of control and not competent when not working according to a plan. Paradoxically, once th ey are present, CITs feel safe and at peace and they find themselves skillful and connected in their work as counselors.
162 The outcomes of acting to contain anxiety and uncertainty and of being present will be explored in the next sections. Experiencing the Outcomes of Containing Anxiety and Uncertainty The complex and paradoxical processes of acting to contain anxiety and uncertainty lead to outcomes for the individual CIT and for their work with clients. Each of the five outcomes of containing anxiety and uncertainty will be examined next: 1) disconnecting, 2) not being authentic, 3) missing therapeutic opportunities, 4) feeling safe, and 5) socially acceptable. Disconnecting Acting to c ontain anxiety and uncertainty leads to disconnecting from oneself, fro m others, and from what is happening in the present. Disconnecting is by design as it fulfills the desire to create distance from discomfort. At the same time the disconnection often escapes awareness as it is part of an uncontested norm. Thats more l ike the normal way. Almost turning off any connection with yourself and the larger space (Jill). Judging oneself, others, and the world around is a more subtle form of disconnecting. Judging includes criticism, evaluation, self monitoring, and oth er wa ys in which experiences or people are not left to be what they are but compared to some predetermined standards. Graduate school and being a CIT are both contexts fraught with and encouraging of these forms of judging. CITs seem to come to their training as counselors with an internal self -critical voice that pushes them toward self improvement and also disconnects them from their present moment experience. This was mentioned as part of the requ irements of being achievers to the extent that they are accepted into graduate programs. As Cathy and Jill express in the following passages judging themselves leads to judging others, disconnects counselors from clients, and the interaction becomes inaut hentic.
163 So when bringing that back to my clients, Im thinking, you know, if I cant understand that process in myself, of being judgmental and wanting to be kind, one, how kind am I really, how kind am I really being genuinely with my clients ? (Cathy) W hen Im not present, you know s ometimes its being nice because I feel like I should be nice, you know, but its not being nice be cause Im really getting what the client is saying or really genuinely care about them and are honoring whats happening in the room. I think theres a difference there. (Jill) Both of these participants identify a hollow or going through the motions quality to disconnecting. It seemed to surprise participants to discover this lack of genuineness. Disconnecting means CITs ar e not available to others, most importantly their clients. Irene said, Im not available. Im not totally there, like part of me might be there, but, so theres less of me to connect with or thats attempting to make a connectio n. There seems to be a pro portional relationship between being unavailable and being disconnected. Not Being Authentic Disconnecting and not being authentic also interconnect. Jesse articulated the interconnection without identifying the nature of the relationship between the two when she said being inauthentic as a result of not being present, then youre not actually connecting and so for me part of that disconnection, so its, its d isconnection and inauthenticity. My interpretation is that disconnecting and in authenticity ar e each the condition for and the consequence of the other and both are fallout of the actions of containing anxiety and uncertainty. If one is disconnected one cannot be authentic and if not authentic, then one is disconnected. Managing image was inclu ded in the process of acting to contain anxiety and uncertainty (see section on Acting to Contain Anxiety and Uncertainty) so it follows that an outcome of that process would be staying in role Adopting behaviors consistent with what they understand to be professional or counselor like means not being authentic. In doing this, the CIT is protected from either making mistakes or feeling successful as her authentic self and does not bring her
164 whole self to the interaction with her clients. Irene found hers elf acting very formal be cause I thought, OK I got to prove that I know something Cathy noted that she stayed in the role of counselor to avoid being vulnerable but that it got in the way of connecting, which she also acknowledged was not something she was aware of in the moment. Missing Therapeutic Opportunities The actions that contain anxiety and uncertainty for CITs avoiding, controlling, distracting, and managing image lead to missing therapeutic opportunities. On the most basic level these actions mean to some degree not hearing, seeing, or understanding clients Pam described not really seeing the whole picture, only seeing with blinders on. which she went on to say has the potential for not only missing therapeutic opportunities but perhaps unconsciously hurting oneself or a client. Jill said, I act ually remember the clients less vividly, like I actually lose a lot of details of what they said Sometimes participants could only speculate on the comparison between being present because inherent in not being present is a lack of awareness. The specu lation also reflects insight from looking back on times when they were not present from the perspective of having been present. I think if I wasnt present it would have been really easy to kind of go my own way with it or not hear where she was at with it and maybe even like, you know, sometimes you just b ulldoze over people when youre not with them, you know so yeah, I think if I wasnt present I dont know that she would have felt as heard and felt as understood (Cathy) Related to not hearing, seeing, and understanding clients is missing healing opportunities CITs miss healing opportunities in not picking up on subtleties (Jesse) and details (Jill), by not sensing each other in the moment so new insight is not available (Teresa), and by preventing u nexplored material from emerging by sticking to an agenda or plan (Andrea). In containing their own anxiety and uncertainty, CITs fail to acknowledge anxiety and uncertainty as a normal part of life for their clients ( not acknowledg ing anxiety and
165 uncertainty ). CITs may feel a lack of confidence as beginners but with their clients they have power. In containing and not acknowledging anxiety and uncertainty, counselors model that choice for their clients. They may direct counseling sessions to cont ain the clients anxiety and uncertainty as well. In so doing CITs then perpetuate the prevailing sociocultural paradigm of acting to contain anxiety and uncertainty with their clients. This may be not only missing a therapeutic opportunity but doing som e detriment. I think that its a fine line to walk because being uncomfortable and having, and not knowing certain things is, is a part of life, and I feel like if we dont acknowledge that and teach clients how to sit with that, then they continue to, to suffer, and they continue to not be present, and not benefit from being present. And so, if were constantly trying to take that away from them, then I think it could do them harm, in a sense (Jesse) If CITs do not understand their clients, see them wi th blinders on, keep new insights or material from emerging, and do not acknowledge anxiety and uncertainty, clearly they miss therapeutic opportunities. This brings up potential ethical considerations in that not being present has the potential for couns elors to not provide adequate service or do harm to their clients. Feeling Safe An outcome of containing anxiety and uncertainty, along with the fallout of disconnecting, not being authentic, and missing therapeutic opportunities, is feeling safe a power ful feeling and a powerful reinforcer. Seeking safety underlies all the actions of containing anxiety and uncertainty. It feels safe because it is staying with the familiar. Theres a fear of the unknown. If your typical way is to avoid and thats wha t youve done all your life, like it takes a lot t o teach an old dog new tricks (Jesse). It feels safe to take action to avoid, distract or control rather than sitting with the discomfort of anxiety and uncertainty. Acting to c ontain anxiety and uncert ainty is experienced by CITs as protective ( p rotecting as self care). As Cathy said, i t doesnt require you to think, to question, to evaluate. T here are going to be aspects of yourself that you probably dont have to look at. There is a vulnerabi lity in that evaluation.
166 Its a little safer. Feeling safe is fundamental to the outcomes of containing anxiety and uncertainty because it is the feeling all the activities of the process are aimed at creating. Socially Acceptable Acting to contain anxiety and uncertainty is part of the prevailing sociocultural paradigm in which seeking safety is more common than seeking awareness and connection. It has become the standard mode of operating so to avoid is what is taught ( avoiding is what is taught) Jesse described how advertisers embody cultural norms and promote feeling inadequate while implying that improvement is possible with the right products. She implied that advertising reflects the prevailing sociocultural paradigm and also perpetuates i t. This overarching feeling of inadequacy generates anxiety which then must be contained to appear in control. Appearing to be certain and in control seems to be reinforced as the signal of professionalism and expertise. As the socially acceptable proce ss, acting to contain anxiety and uncertainty has the benefit for CITs of increasing not only their sense of security but others as well. Containing discomfort is understood by others. I think theres an evaluative component like by other people where it s more understood or accepted by other people to do that. So for me theres a social benefit. People understand when Im doing that. They approve when Im doing that. You dont rock the boat d ont make anyone else change the way theyre behaving or t heir assumptions. So I think theres a social component. (Jill) As the socially acceptable process, acting to contain anxiety and uncertainty also has the benefit of allowing CITs to fly under the radar, not call attention to themselves. It is easier to do or be what is expected They are not taking a stand or risking. Cathy also called attention to the power dynamics between dominant and minority perspectives. She described acting to contain anxiety and uncertainty as: easier because thats already what most people understand. I dont have to explain it. I do a lot of study with minority individuals and the idea that minority individuals have a better understanding of the dominant culture than sometimes the dominant culture does. I
167 could parallel that. Theres a dominant culture and as a person who feels sometimes outside of that, I have a pretty good understanding of what its about and I was pretty good at it. I get it. (Cathy) Doing what is expected contributes to the feeling of safety. It allows everyone to relax into an agreed upon way without overtly addressing the emotions involved. Experiencing the Outcomes of Being Present Outcomes emerge from being present both for the counselor as an instrument of change and for the therapeutic process. The counselor as an instrument of change refers to the impact the counselor as a person has on the process of change for the client, and includes counselors way of being and qualities as well as the counselors contributi ons to the therapeutic relationship. Seven outcomes of being present are defined here: 1) building tolerance for discomfort, 2) counselor feeling at peace, 3) sustaining counselor in work, 4) being a better instrument of the therapeutic process. 5) amplif ying connection, 6) counseling in the present moment, and 7) facilitating the therapeutic process. As in other processes in this theory, each outcome is in some way both the condition for and a consequence of the others. For example, building tolerance fo r discomfort helps the CIT feel at peace which then makes it possible for the her to build tolerance for discomfort. Each process interconnects with the others. The essence of the outcomes of being present is amplifying connection connection to self, c onnection to others, connection to ones experience of the moment. It is moving toward connection that distinguishes being present from seeking safety in acting to contain anxiety and uncertainty. Building T olerance for Discomfort Part of being present is staying with what is being felt and experienced in the moment rather than avoiding or distracting from it. The outcome is that CITs become more able to stay with what is being felt and experienced. This in turn allows them to stay present with themselve s and with their clients. In being able to stay with their own and their clients
168 experience, CITs are less likely to rescue clients from their discomfort. Therefore they do not rob clients of the opportunity to learn from that discomfort, to tolerate it and experience the transmuting of that discomfort themselves. Jesse said, [Being present] helps me to, to sit with whatever comes up in the counseling session for me or from the client It also, you know, in some ways, reminds me that I dont have to do anything, you know I definitely sometimes get caught up in wanting to take that discomfort away from my clients in some way but to remind myself that this isnt a permanent state for them either, and it will change, and shift and that thats a natural pro cess thats going to happen, and I dont have to make it happen. In being present, CITs acknowledge the uncertainty of life and raise their ability to stay with that awareness and not try to control what cannot be controlled. It frees them to be present and to tune in to their clients, to learn more about present conditions that sometimes go unnoticed in focusing on outcomes. Y eah, like Im more comfortable with the uncertainty, rather than in my head thinking like oh gosh, I hope they. for example th is was adolescent substance abuse, so man, I hope they pass their drug screen and they dont do this anymore and they dont you know like if Im thinking about, rather than just being with them and learning about them learning well what led them to use drugs in the first place or whats the situation in the family and like just providing them with the space to explore themselves (Irene) The counseling process itself is full of uncertainty as well. CITs may attribute their feeling of uncertainty to bein g beginners and try to contain the feeling by gathering information, planning, or adopting a counselor persona. But being present, CITs become more comfortable with uncertainty itself and can let it be. In doing so they notice more what is happening in f ront of them. CITs learn not only to stay with discomfort, they become more relaxed with discomfort as Irene said I feel a little more relaxed around it, like I have a little more space and awareness. Being in one moment with uncertainty, rather than thinking of all that is fantasized to lie ahead, pares the uncertainty down to a more manageable size. The issues or problems may remain unclear or unsolved, but they are bein g acknowledged as such rather than jumping forward to
169 future scenarios. Jill said sitting with that not knowing, it just makes the whole thing more OK . like facing that moment is manageable and I just feel calmer with that Counselor Feeling at Pe ace Participants named the emotions of being present as satisfied and happy within (Andrea), calm and centered (Irene), comfortable (Pam), feeling fine (Jill), relaxing (Cathy), feeling good (Cathy, Pam, Teresa), and feeling at peace (Andrea, Jesse). This feeling of peace is an outcome of being present. In awakening to the fact that that they have choice and then choosing to be more present, CITs have faced the fear of letting go, being out of control and vulnerable. Once they are present in the moment, they experience a different relationship to their anxiety and uncertainty and other discomforts. In the process leading up to being present, it seems like being present will be a scary proposition, but being present itself is not sc ary. Once present, worrying seems to have kind of dropped away (Irene) ( not worrying, not scar y). Jesse described a time when she was in session with a client who was upset about the uncertainty of her academic future. Jesse herself was sitting with t he uncertainty of her grandmothers imminent death. But in that moment, we were able to be there together and acknowledge that, I mean theres a lot of unknown in this world were kind of just letting go into the present moment and, and the benefit of that is a sense of peace, and a feeling of release and a feeling of calm, that we had both not been experiencing prior to that moment. While CITs may still be experiencing those discomforts, being present seems to create some space between those discomf orts and what can be called their aware consciousness or the authentic self, which brings a feeling of peace. At times the discomforts dissipate or are transmuted into a feeling at peace. Given her initial apprehension, Jill seemed continually surprised with this process. She said that once present in the moment, I think every time, you know, I just feel like, fine, and then I feel able to handle everything and no, it does not feel scary i n the actual experience. Being present seem s to feel natu ral, as if it is the natural state
170 of being once CITs let go into the present. Its just more natural. Its more of who you are (Pam). How CITs know this, that being present feels natural, seems to come from the experience they have in their bodies and in their hearts, more than in their cognitive processing. However they know it, the counselor feeling at peace as an outcome of being present becomes a strong reinforcer of choosing to be present. Sustaining Counselor in Work Being present in counseling is sustaining for CITs in their work. For one thing, being present contributes to making counseling enjoyable which sustains the CIT in what can be difficult work. Clients come with problems and distress which can wear down the CIT. As the CIT enjoys the fruits of being present, the process becomes more enjoyable and thus more sustainable. In the next passage, Jill describes her enjoyment in terms of time. This refers back to the timeless quality of being present (See section Being Present) as well as the common notion that time flies when youre having fun! Well, for me, its more enjoyable. A nd for me the time actually goes faster which is weird, actually. I was thinking it is kind of paradoxical, like you might think it would go slower, like but a couple of time s in the last few weeks Ive looked at the clock and Im like oh, we need to end. I think its because Im actually like engaged with what theyre saying, like I really want to know more, I really am like, its fun for me. (Jill) Not only does counseling become more enjoyable if being present, but CITs find it energizing Being present both costs and generates energy. CITs expend energy in choosing to be present with all that goes into that, i.e. risking, weighing costs and benefits, and t aking a stand. And when they become present, CITs gain energy. Thus it is a sustaining process, assuming there is a balance. I notice the sessions when I was much more present and really engaged with them, I usually end up leaving and having more ener gy or being more excited about like, wow look what happened (Pam). Feeling energized by ones engagement in the present moment is sustaining, not only in the counseling session but for the counselor as a
171 person. They seem to feel more alive and at peace in themselves. The benefits that CITs experience personally from being present contribute to their motivation to continue to choose to be present. Being authentic and being whole are elements of being prese nt which then sustains the CITs as whole people so the process is self reinforcing and sustaining. Along with the peacefulness of letting go into the present moment, the timelessness of the moment, and the increased comfort with uncertainty, being present amplifies the connection between people (see Amplifying Connection in this section). Connection seems to be at the heart of what makes being present sustaining in counseling, as Cathy articulates in this passage. feeling that true connection with a nother person I think is like really powerful and I think thats a great, I dont know, I think thats a great reward for me. And with other people, too. When I actually sit with somebody, Im like Wow, we just had something that was true. Thats like so sustaining. And so, I think thats really big. Being Better Instrument of Therapeutic Process The CIT becomes a better instrument of the therapeutic process in being present. In the process of choosing to be present, CITs come to know themselves and shift into a different paradigm. Having that experience seems to yield insight into the process of change for other human beings, specifically for their clients. Personal change brings with it some uncertainty as people move into the unknown territory of the new. There becomes a parallel between CITs cultivating being present, with the changes that brings, and the change process for clients in counseling ( parallel personal work with clients work ). Their parallel process of change increases the counselor s empathy for clients feeling resistant to or unsettled by change. I guess I sympathize with the struggle that my client would have with bringing on new practices into their lives. I definitely at one point I was like, oh my gosh, this is what clients g o through. Like Im giving them a new intervention to do and its totally different, like for me, this is very different than how I grew up. (Teresa) Coming to know themselves in being present, participants became aware of their own self criticism. This heightens their ability to tune into the clients self criticism. In working to accept
172 herself the CIT models self acceptance for the client. For example, as part of her pattern of self criticism Irene noted a tendency to blame herself when things that do not go well in session with a client. When she practices non judgment and self acceptance, she is more likely to tune into what is happening that may be of therapeutic use. In so doing, she models the practice for her clients. In being present, CITs are aware of themselves and of what is happening around them as their attention flows between their inner and outer experience. CITs then use themselves as a tuning fork in a sense as they react to what is in the room with a client. They are using self a s an instrument of counseling as Pam describes in this passage. I think that in that, in that type of interaction, sometimes I do tend to tune way into that person, so experiencing things myself and I can kind of go off of what Im, what Im feeling I t hink that, right, just tuning in with what, whats going on with me. Without being present, CITs miss what is going on inside them and the potential insight that offers for the therapeutic process. As CITs become more present as people, they become more p resent with clients. As they practice sitting with uncomfortable emotions, focusing in the here and now, accepting what is they can then translate their personal learning to their work as counselors and use themselves as instruments of the therapeutic process. Referring to the example mentioned earlier when Jesse sat with her client in uncertainty, she said it didnt make me uncomfortable because I had been practicing that in my own life as well CITs are also better instruments of the therapeutic process because a feeling of genuine caring seems to naturally flow from them when they are present ( caring emerging ). In opening nonjudgmentally to themselves and to their clients in the present moment caring and compassion emerges without effort, again as if it were the natural state of being. I dont think Ive ever been really present with someone without feeling that natural like interconnectedness, like were kind of the same, you know, like we re all of the same stuff, and we all have related experiences Were all in this life together. And I think when I
173 feel that, I truly do care about the other person. Yeah, so its not just like I have a sense of responsibility to this person or I like this person, its like like you really care. (Jill) The feeli ng toward others that CITs feel when they are present was described as feeling warmth in the chest (Andrea), a feeling of tenderness (Jill), authentically or genuinely caring (Irene, Jesse, Jill). This caring seemed almost surprising in its purity and in its effortlessness. In that caring CIT s connect with clients and create a safe context in which therapeutic change can happen. In tuning themselves as instruments of counseling, CITs increase their readiness and ability to apply their skills and knowledg e ( enabling keen application of skills and knowledge ). The openness, awareness, attention, authenticity and other aspects of being present support CITs in applying what they have learned and in astutely assessing the needs of clients. In their training, CITs are advised to be empathic, to notice client non -verbal communication, and to build a positive relationship with their clients. Participants noted that these qualities and skills come naturally with being present. Irene gave the example of assessing the client right from the beginning of a session like when somebody walks in the door if Im more focused and present I can kind of guess pretty fast how their day went, what theyre needing right now. In being present, CITs draw on a deeper and broade r level of awareness in an encompassing assessment of the client and of the relationship. These are considered basic skills of counseling but difficult to truly execute. And perhaps even more difficult to teach. Amplifying Connection Being present has the effect of amplifying connection with oneself, with others and with the world around. Connecting was defined by Random House Dictionary as joining or linking (1973) and these synonyms fit to some degree with this outcome of being pres ent. But joining and linking seem more fixed and less fluid than connecting. A more recent definition of to
174 connect, not included in the 1973 Random House Dictionary and considered informal by Dictionary.com (2008) is to relate to or be in harmony with a nother person, one's work, etc. This definition seems more appropriate in meaning and because the definition has come to be accepted during the lifetime of all the participants in this study. Like being present, there is a continuum of connection from les s connected to more connected. However, unlike the continuum of being present, connecting has is a end point, a point where one is disconnected. Cathy noted that suicide is the ultimate act of disconnecting and feeling disconnected. Being present facilit ates moving to the other end of the continuum, connecting at a spirit or energy level, beyond the confines of our constructed perception of the separation between people ( amplifying connection) If you can actually be with someone, like your whole person with another whole person, that reduces that isolation and maybe helps them get more in touch with the deeper, more spiritual part of them. (Jill) I almost have a visualization of opening myself up and I think the reason why is almost kind of opening up my body is be cause its kind of like lets get past this part, and lets get to the being part (Cathy). Being present seems to be a prerequisite for being connected and the degree or intensity of each influences the other. Connecting is an action and a outcome of being present and is not possible without the condition of being present. In other words, I cannot connect with you if I am not present and the degree of our connecting is influenced by the degree of my presence and the degree of yours. Once the self -perpetuating interaction between being present and connected is set in motion, it is difficult to separate the two processes and descriptions of them begin to resemble each other like two people who have lived together for a long time. Connecting is palpable, felt in the body, as well as in intangible ways that are sensed emotionally, energetically, or spiritually. Andrea describes her sense of connection as radiating
175 from my face and, and my chest and radiating between us The way I could descri be it I guess is wavelengths I felt like we really, were really very much were matching wavelengths (Andrea). Cathy describes connection below and she seems to struggle with the limitations of language in describing her experience. T he intensity of like that connection that was happening, and it was just, yeah, it was kind of like, it was, it was intense but neat that it was happening, be cause I, it was almost kind of like, like invisible kind of things, you know, kind of going o n and, and, you know, par ts of me kind of going out and parts of him going out and us meeting somewhere Andrea and Cathy articulated a quality of meeting that conjures up the sound of harmonic counterpoint. Matching may not be as important as the harmonizing of energy at the poi nt of meeting. Connecting, especially moving along the continuum has the same paradoxical processes or feelings associated with it as being present. And perhaps that is partly because the processes have merged at that point. The paradox again is that connecting, like being present, is not easy, involves risking vulnerability and loss of control, and yet it also brings a sense of peace and well being that is sustaining. In being present and connecting with the person in counseling, the counselor attunes to that person in a way that allows her to feel the clients emotions in heightened empathy and offer more accurate reflections to the client. Jill talked about using being present in this way: to be able to access any kind of intuition or like gut feelin g I have with a client, but also to be able to be more accurately empathic and communicate that too, so I think just, at an earlier level it would be a way to help form a relationship it also helps me to hear, when I am present helps me hear beyond w hats being said. The counselor is able to hear beyond the persons words not just the content but wha t are they communicating to me during the process, in their emotions, w hat are they communicating to me besides what the words theyre saying . (T eresa). In the section on Awakening to Choice s earlier in this chapter, I defined the CITs experiential knowing, or
176 knowing that comes from experiencing in the body and more inclusive than only cognitively understanding. This seems to relate to being abl e to hear beyond the persons words and to heightening empathy. For the client, being heard on a deep level, seems to feel validating and to further build connection and the relationship. Andrea said that being present produces that powerful connection, the feeling that the client says that oh wow, finally the co unselor gets me, really gets me (Andrea). Connecting requires two parties; it is connecting with. Two parties create connection and also are influenced by that connection in counseling ( recipr ocal influencing ). Cathy seemed to feel apologetic to some extent that she reaped the benefit of the connection when she said, Im robbin a little bit, be cause its not just a one way street, you know when youre fully, you know, Im getting something. As such, it is impossible to talk about connection between people without also talking about their relationship. Connecting builds the relationship between people (building relationship) and by definition this involves both people. The relationship becomes part of what sustains the counselor as well as the client in the work to be done in counseling. S ometimes I think that we both come out of the, well, most, many times I come out of a therapeutic relationship changed and, and the relationship stays wit h me (Jesse). Being present seems to be a condition for connecting. Connecting is an action the consequence of which is the building of a therapeutic relationship. The relationship becomes a condition for being present and for connecting as well. Conne cting is part of a system or process with being present. Counseling in the Present Moment When CITs are present they bring the counseling process into the present moment in the session : right here, right now (Andrea). Counseling in the present moment allows the unpredictable to surface, be noticed, and then exploited for the benefit of therapy. When containing their anxiety and uncertainty, CITs are more likely to miss what they have not primed
177 themselves to look for. Or they may stick to their agend a even when what materializes unexpectedly may have therapeutic value. Counseling in the present moment makes the work alive and fresh as the counselor and client are not talking about the past or the future but experiencing together at the moment. There is no hiding from or distancing from what is and so the experiences are powerfully felt. As such, there is risk involved and if the CIT remains present enough, she can attend to the clients reactions to that power. Counseling in the present comes out of the counselors awareness, attention, beginners mind, trust all the aspects of being present. The processes of counseling in the present moment include addressing what is in the moment, checking out assumptions in the moment and using counselor reactions and emotions in the moment. Addressing what is in the moment means stopping the session, perhaps stopping the client in the middle of a story or even a sentence, so as to not miss something potentially significant. It takes presence of mind to notice and then courage to bring the clients attention to what is happening in the moment. It is easier and safer to let the emotion or reaction pass by or to talk around it. Addressing what is in the moment heightens the clients awareness and allows new mate rial to emerge. L ike for example with the second client that I talked about there was an instance where he had referred to he had gotten angry and was at a party and had smashed a, a wall in, or had, no, had, had punched the wall and I said oh, OK and t hen I thought OK, well then Ill talk about like violent, violence, and violent backgrounds and what not later on but then I thought No, no, no. Stick with this right now and so I asked him like Well thats kind of strange. Was that normal behavior fo r you? and that brought a whole other issue up. (Andrea) In addition to addressing something significant in what the client is saying in the session, addressing what is in the moment also means having the courage to draw attention to the in the moment int eraction and relationship between the counselor and the client. These dynamics are rich in therapeutic potential and often go unacknowledged. In the counseling literature this is
178 often termed immediacy and is used to address ruptures in the therapeutic r elationship. In being present, CITs can without judgment observe their own contribution to the interaction with the client as well as what the cli ents contribution might be. Jesse mentioned that there are times when counselors are bored in session and t heir boredom is often attributed to the client. She said, I think that that certainly places all the blame on the client, which, you know, doesnt acknowledge the fact that, you know, maybe the therapist wasnt being present with, with the, what the clie nt was saying Part of counseling in the present moment that helps get at these dynamics between client and counselor is checking out assumptions in the moment Here again are rich possibilities in counseling because the dynamics are being experienced r ight then and can be more clearly known. Checking out assumptions in the moment also frees both CIT and the client from using energy in wondering or conjecturing, it shows that the counselor does not see herself as all knowing and it builds connection thr ough greater understanding of one another. Checking out assumptions in the moment demonstrates the CITs respect for the clients constructed meanings. To be able to address what is in the moment and check assumptions, the CIT draws on her reactions and emotions in the moment ( using counselor reactions/emotions in the moment ). Jesse felt goose bumps as her client told of the death of his girlfriend and used her reaction to connect with and validate her client. Cathy told of using her emotional reaction to her clients story and the cathartic effect it had for the client. The client described events in her relationship and Cathy disclosed her own strong gut feeling. The clients reaction seemed to signal change. A ll this emotion came out. Up to that point shed been a fairly emotionally controlled person except moments of being pretty tearful but anger had never been something, and it just, it just, pretty restricted, so for her to like sit back and then have that look of shock and then just like boom a ll this stuff come out. I was sittin g there going whoa, this is pretty
179 crazy but also like, you know, that was anothe r one of those moments saying OK this is stuff that you can trust, you know To facilitate that catharsis for the client, Cathy had t o be present. First she was aware of her emotional reaction and the image that emerged and then she had the courage to share with her client. She was being her authentic self as a counselor. And she accomplished all that in the moment. Facilitating Thera peutic Process The outcomes of being present facilitate the therapeutic process by expanding the therapeutic value of the encounter, by facilitating intensity, by clients benefitting from experiencing their counselors being present and from learning to be present themselves and by the healing properties of being present. Counseling can take many forms. CITs in the study indicated that counseling can take place with a counselor being less present and the client can still benefit. CITs who choose to be pre sent and work in the present moment seem to deepen the therapeutic encounter and as such expand the therapeutic value of the encounter. The counseling has a different quality to it. Often the qualitative difference is indicated by whether the encounter i s limited to interacting and problem solving on a cognitive level. As Jill said, You know, rather than just being in a room and talking and figuring out your stuff and getting insight into yourself, which is important, but, this is more than that How being present is more than that is not articulated but participants seemed to feel sure that it is, not only from the CITs perspective but also from the clients. Cathy said, But Im sure theres a difference from their perspective when Im really act ually connected and kind of like in my body and connected with my feeling, Im in my feeling space and when Im being directed by my gut One way that counseling with a CIT who is present is different is in the intensity of the encounter (facilitating i ntensity ). In describing times when they were present, participants used
180 descriptors such as intense (Cathy, Jesse) and powerful (Andrea, Pam). The emotions are being felt in their intensity in the moment and not avoided, even if they later dissipate or change. As discussed earlier in this section, the connection that is amplified in being present increases the intensity of the encounter. I think theres something respectful about being able to be present with your clients, you know that like there s this respect there of like, you know, that Ill be here with you unconditionally, give you my full attention, and that I think theres a lot of power in that (Pam) All the benefits that come to CITs in being present in the moment and over time are also available to the client. Clients benefit directly when CITs use being present to expand the value of the therapeutic process, and clients benefit indirectly through CITs modeling of being present as people ( clients learning and benefitting from being pr esent ). I think that by being really present with them, it helps them know themselves better, and helps them know their experience better, so that they can learn to trust that a little more, as opposed to kind of being on the outside and giving interpret ations (Jill) In this passage, Jill implies that if the CIT is present with her experience of her interaction with the client and uses that to bring the counseling process into the present moment for clients, clients get closer to their experience as well and through th at come to know themselves. Clients too build their awareness in the moment. Again this is a parallel process with CITs cultivating being present for themselves and coming to know themselves. Clients then awaken to their choice to be present in their liv es or not. Feeling choice is empowering so recognizing that they can choose to be more present in their lives empowers clients, as well as their counselors. Being present and connecting with clients has healing properties that facilitate the therapeuti c process (Jesse). Healing takes place in the connection and in the relationship that builds from that connection.
181 And I would imagine like the feeling I have leaving the session, of like wow, Im real, and this experience is real and all this, is made more possible for the client, too if Im present. And theres got to be something healing in that. (Jill) These are strong claims to make which may explain some of the tentative language in the next passage. Having chosen to be more present, CITs have taken risks, weighed the costs and benefits, and taken a stand, and they draw on the meaning they have made from that process in believing that being present is healing. And how present CITs are, how often they are present, and over how long a period of t ime places them in different places along the continuum of being present. The strength of their conviction in the healing power of being present may correlate with where they are on that continuum at that moment. I guess I feel like I strive to be present in sessions and thats one of the greatest gifts I have to offer the people who come to see me. So I feel really happy and like OK this is why Im doing t his when Im able to do that bec ause I feel like Im totally there with the person, and maybe they dont get that that much in their life, hopefully they do but like if I can do that for them around possibly sensitive, difficult, painful subject then th at may really help them heal, so I believe that it can t hat like it would. (Irene) Interpretation of the Theory In this section, I offer interpretation of the theory of choosing to be present as a whole and will connect my interpretations back to relevant literature. The major elements (See Appendix J for Coding Trail) of the theory were described in detail in the previous sections of this chapter: being present, awakening to choice s choosing to be more present, acting to contain anxiety and uncertainty, contexts facilitating or inhibiting being present, and outcomes of being present and of containin g anxiety and uncertainty. In this section the meaning of the major elements of the theory will be interpreted in a more holistic way, as part of the process as a whole outlined in the theory. My interpretation of how the participants in this study desc ribed their experience of being present seems consistent with what has been written in the conceptual and empirical literature on
182 being present to date. The focused codes (See Appendix J ) that label the processes and attitudes of being present in this stu dy are: being aware, attending inwardly/outwardly, beginners mind, trusting/letting go, accepting, staying with what is, being right here in the moment, and being human/being authentic. Beginning with Freuds recommendation of an evenly hovering attention (1912/1961), Reiks listening with the third ear (1948), continuing with Bubers (1970) I Thou encounter, the existentialists therapy as the meeting between authentic human beings (e.g. May, 1958; Bugental, 1987), Rogers necessary and sufficient c onditions for therapeutic change (empathy, warmth, genuineness, contact), and Gestalt therapys authentic contact (Korb, Gorrell & Van De Riet, 2002; Yontef, 2007) being present with clients resembles what appears in the data from this study. Empirical studies of being present also show similarity with these findings. Pembertons (1977) labels for the forces enabling presence focusing inward, extending outward, and receptivity, Fraelichs (1989) thematic structures of presence immersion in the moment, openness of being, and living on the cutting edge, Phelons (2001) qualities of awareness and the alliance, and Gellers (2001) processes and experience of presence receptivity, inwardly attending, extending, immersion, expansion, being with and for the client, along with the qualities of being present that come from explorations in nursing, yoga training, and naturopathic medicine, paint interconnected pictures of the phenomenon of being present. These descriptions of being present demonstrate the limi tations of language in expressing the complexity and the non -cognitive, nonlinear, timeless nature of the experience of being present. There is commonality in the definitions of being present regarding open awareness of oneself and of the other which bri ngs about connectedness. Pinning down an operational definition of being present does not fit within a constructivist epistemology but in the language used to describe the experience a socially constructed consensus seems to emerge.
183 The descriptions in existing literature, both conceptual (e.g., Buber, 1970; Bugental, 1987; May, 1958; Welwood, 2000) and empirical (e.g., Fraelich, 1989; Geller, 2001; Pemberton, 1976; Phelon, 2001) come from seasoned therapists. The similarity in the descriptions by CITs in dicates that experience may not be the factor that determines a counselors ability to be present. At the same time, the participant CITs acknowledged that being present ranges on continua of frequency and duration and that all the actions and attitudes of being present also spread along continua. It may be that if counselors choose to be more present as they gain experience in their work they move toward being more fully present on the continuum. Here again the limitations of language appear, or perhaps it is language embodying the limitations of epistemology. If epistemology is the theory of knowledge which determines the kinds of knowledge that are possible (Crotty, 1998) and language structures that knowledge, then language can limit the meaning peopl e construct of their experience. The experience of being present is probably different along the continuum of presence and yet it bears the same label. Being more present hardly describes the qualities that develop in the experience of being present along the continuum. Participants were interviewed three times. At the first interview, every participant had experienced what they considered being present. Participants were interviewed again after seven and again after eight weeks of practicing mindfulnes s meditation as a way of cultivating presence. Their descriptions of the experience of being present did not change. What did change was their sense of agency in being present, their awareness of their choice to be present or not. They became aware of the power they had to treat themselves and approach the therapeutic encounter deliberately with openness, non judgment, letting go of control, in the present moment. In their initial interviews, the instances of being present that participants described
184 seeme d profound, spiritual, or deeply significant in some way. And those times seemed unpredictable, surprising, and unusual. In the latter interviews, people seemed to talk about being present in more everyday terms. Being present seemed demystified in some way, and the profundity of it was expressed differently, more along the lines of choosing mindfulness in the everyday moments than as a result of a force or power outside of them making presence happen. There is a Zen saying, "Before Enlightenment chop w ood carry water, after Enlig htenment, chop wood carry water that captures this idea. From the participants descriptions it seems clear that the experience of being present remains a significant one nonetheless. Although descriptions of being present in the existing literature resemble those in this study, what has not been addressed before in the literature on presence is the process of choosing to be more present. The theory presented here offers one explanation of that process and what facilitates and inhibits the process. The participants described their experience of being present as a desirable way of being, both for themselves and for their work with clients. They also expressed some frustration with the incongruence between their valuing of bein g present and the amount of time they actually are present. Some of their inability to be present may come from being beginning counselors but experience in the profession does not guarantee being present. Being present is not a matter of confidence or years under ones belt. The process of awakening, as described earlier in this chapter, is necessary for becoming present which is then followed by making a choice. And being present is not simply an intervention or activity but it is part of a paradigm shift. As participants identified elements of the contexts that tend to either facilitate or inhibit being present they seemed to be articulating an experience of conflicting paradigms, what I have labeled the prevailing sociocultural paradigm and the para digm of being present. In Table 41 I
185 have set the values of the prevailing sociocultural paradigm in counterpoint with the values of the paradigm of being present highlighting the contrast between them. In music, lines of counterpoint are composed to be combined with another melody to purposefully add depth to the piece of music. In the conflicting paradigms presented here there is no purposeful effort to add complexity but it is inherent in the situation in which CITs have placed themselves. These line s of counterpoint are end points on continua with infinite degrees of expression in between. Table 4 1. Comparison of Prevailing Sociocultural Paradigm and the Alternative Paradigm of Being Present Prevailing sociocultural paradigm Alternative Paradigm of Being Present Others most important (serving, pleasing) Self most important (enables serving better) Keep doing, be productive Stop, slow down, be Focus on change, improvement Accept what is Have a plan Let things unfold Be an expert Beginners Mind Work comes before personal life Person is instrument of work, take care of self Focus on inadequacies, improvement Kindness toward self Stay in control Let go of control Striving Non striving (letting go of drives) Reduce client pain Allowing client pain Some participants seemed excited to embrace the shift in paradigms but for others it presented more of a challenge. The former experienced less conflict with their previous beliefs and values than the latter. Regardless of how difficult the shift in paradigms was for these CITs, they described their experiences of being present similarly. Awakening to choice s CITs have to be more present is in part prompted and supported by what I have labeled their experiential knowing. As graduate students, CITs have been expected to put what they know into language. In this study, they reported knowing they were present and knowing it was a valuable or therapeutic experience and yet the language they used to express their knowing was often vague and they called on informal expressions such as whatever where the listeners are left to create their own meaning. Stern define d implicit knowing as part
1 86 of the present moment, a knowing that is nonsymbolic, nonverbal, procedural, and unconscious in the sense of not being reflectively conscious (p. 113) Primary knowing (Senge, Scharmer, Jaworski, & Flowers, 2005), implicit knowing (Stern, 2004) and embodied knowing ( Lakoff & Johnson, 1999) are other ways of describing a more inclusive kind of knowing, one that draws on the senses, emotions, and spirit in the present moment, as well as on thoughts about that experience. Part of the participants experiential knowing was a feeling in the body, a knowing through bodily experience. Robert Marrone (1990) states that . fundamentally, we are the body, we act through the body, and we perceive the world and each other through bodi es. We are lived -body and our experience of being -in -the -world is created and given form through our bodies (p. xi). Morrone used historian P. A. Sorokins term heart knowledge for knowledge grounded in the experience of lived -body (1990, p. 3). C ITs in this study drew on these holistic and phenomenological ways of knowing their experience of being present. Not only is experiential knowing part of awakening to being present it is also the source of new information unavailable if drawing only on co gnitive knowing. Although t ru sting this kind of knowing is part of being present it is often difficult for CITs. In the process of awakening in this theory, CITs become aware not only of their choice to be more present but they become aware of where they have been. They become aware of their internal voice that more often than not is judging them, reprimanding them, pushing them to do more. One participant described an almost constant internal narration of her experience as if prepari ng to report to som e authority. In the micro context, CITs report to supervisors or professors, but in the broader context of their lives this voice may be seen as the internalized voice of the prevailing paradigm. Perhaps the sense of having to report ones experience is a universal feeling of reporting to an archetypal parent or to god. There are at least two ways to
187 look at this reporting. In one way CITs may be reporting to an internalized critical authority in which case the constant inner dialogue may help CITs posit ion themselves well with that authority but it get s in the way of being present. This may be a more universal phenomenon among counselors and not just particular to counselors during their training. In their study of university counseling center therapis ts, Dunkle and Friedlander (1996) found therapists level of self -directed hostility correlated negatively with the bond component of the therapeutic alliance. Another way to frame the sense of reporting is in the service of the developmental process of cl aiming a stance. In this case, rather than being c ritical self -monitoring it becomes self awareness, which as defined as part of being present is a non judgmental awareness of self. These are aspects of being present occurring on two continua, one of awa reness and one of judgment. How these two interact with one another remains to be explored. For CITs to choose to be more present -to trust themselves, to let go of controlling and planning the future, to accept what is rather than push for change, to s low down and pay attention, to be authentic whole people in contexts that reward the other ends of those continua is a quiet act of rebellion. When it comes to the process of choosing to be more present, CITs have had an awakening to the experience of be ing present with themselves and/or with their clients. Those who find value in being present are in a bind. As participants described in this study, t hey have an experience of something profound that they have a sense makes them better therapists and even gets more to the heart of what they have been trained is important in therapy, but it goes against the grain of what is expected of them in their actual training as well as in the broader cultural context. If they choose to go the direction of being more present, CITs take risks. As students, CITs are in a power down position. Any group who is in a power down position pays close attention to the dominant group and knows it is risky to be different, to
188 question, to value their own interpretation of their experience if it differs from the dominant interpretation. There exist minority perspectives in which being present is encouraged. Fostering and cultivating being present has been a part of Buddhist practices (Fulton & Siegel, 2005) for centuries and in the psychotherapy field, existential (Bugental, 1987; Yalom, 2002) and Gestalt therapies (Gold & Zahm, 2008) in particular emphasize being present as a healing factor. These approaches offer CITs some guidance and encouragement in choosing to be more pres ent and in taking advantage of the benefits of being present for themselves and for their clients. The encouragement is needed not only because of going against a prevailing paradigm in CITs external contexts but also given their own anxiety and uncertain ty. All the participants in this study were reared in the prevailing paradigm to some extent and to some extent have internalized those values and beliefs. Some participants values and beliefs or their family or religious values and beliefs, were more s olidly in line with the prevailing paradigm and so the act of rebellion felt even more personally risky. Some participants in addition to being in a power down position as trainees also came from what they described as a lower socioeconomic group which ad ded to the feeling of risk involved. Also, all the participants in this study are female, another subdominant group, although none of them ever talked about their perspective as a female perspective. The acts of choosing to be present clearly do not take place in isolation but within various contexts. Charmaz (2005) suggests that focusing on both action and context deepens the analysis of the participants constructed meanings of their actions. The contexts that emerged from the data were the academic c ontext, the context of the counseling session, the prevailing sociocultural paradigm, and, on a more personal level, the contexts of the CITs being beginner counselors and
189 their family and spiritual values. The act of choosing to be more present takes on different meaning in particular combinations and qualities of these contexts. What emerged from the data in this study is that choosing to be present contrasts with what participants described as the normal way of handling anxiety and uncertainty which i s to seek safety in controlling, distracting, avoiding, and managing their image. It is consistent with models of counselor development that beginning counselors feel anxious, tend toward black and white thinking and dependency (Hill, Charles, & Reed, 1981; Hogan, 1964; Loganbill, Hardy, & Delworth, 1982; Stoltenberg, McNeill, and Delworth, 1998). It is also consistent with the existential philosophy that anxiety is a natural part of being human given that we will die, that we are alone, that we are free and responsible for our lives, and that life is meaningful only as we create that meaning. From an existential standpoint, the choice to contain anxiety and uncertainty or to be more present is not one that only faces novice counselors but one that in diff erent ways people face throughout their lives. Quantum physics and chaos and complexity theory moves the fundamental uncertainty in life from purely a philosophical notion to a scientific principle (Gelatt, 1995; Gleik, 1987; Zukav, 1979). It conflicts w ith the positivist scientific notion that predictability and control can be attained and is part of a revolution in scientific paradigms. That uncertainty is a fundamental principle of existence supports the interpretation of the experience of CITs descri bed in the theory presented here. CITs are indeed faced with a choice of how to live with that uncertainty, to move toward awareness, acceptance, trust, and connection or toward avoidance, distraction, and safety. While the choice to contain anxiety and uncertainty feels like the safe choice, there is a basic paradox here. Safety from uncertainty is an illusion so acting to contain anxiety and uncertainty in the hope of feeling safe is ultimately disappointing and leads to renewed efforts to increase the containment. Participants also acknowledged that the
190 outcomes of containing anxiety and uncertainty disconnecting, not being authentic, missing therapeutic opportunities while feeling safe and socially acceptable also left them with a sort of vague dissatisfied feeling, Im like oh I wasnt even really there (Jill) and it felt deadening (Irene). Whereas in choosing to let go into the present with all its uncertainty for the sake of connection seems to bring a feeling of safety nonetheless. Buddhists refer to resting in the present moment to capture this feeling. Gelatt (1995) proposed that counselors adopt an approach he called positive uncertainty which resembles being present as it involves acceptance of chaos and uncertainty, remaining flexible and open, aware, and being practical and magical. And Welwood (2000) states that counselors letting themselves not know what to do next invites a deeper quality of stillness and attentiveness into the work (p. 142) CITs are in a developmental process. They take in their experiences in context, moment by moment and day by day making choices in how to be. And in those choices, CITs construct a developmental path. If they choose the path of becoming more present they reap the benefits of being present. These benefits are identified in this study as amplifying connection, being a better instrument of the therapeutic process, facilit ating the therapeutic process, building tolerance for discomfort, counseling in the present moment, the counselor feeling at peace, and sustaining counselors in their work. These outcomes also become the conditions that support being present in a reinforc ing cycle. Choosing to be present is not a linear process. Although there are temporal and sequential aspects, these cannot be delineated in a generic form as with each moment the sequence might be slightly different. At the same time, general developmen tal trends can be identified. Just as in the Butterfly Effect of quantum physics (Gleik, 1987), from initial conditions it is impossible to precisely predict the developmental trajectory or end point and yet the process is not random. The potential for cha nge in choosing to be present over time
191 adds to the uncertainty that CITs face. It sends them into unknown territory as it is not their normal way. Of course, there is no end to this process, no end to the becoming, as in a finished self, but those moments add up and the CIT become s changed as a person The decision becomes bigger than j ust a moment to moment decision. The CIT must decide that is the kind of person she want s to be or that is the direction in which she w ant s to grow Or she can remain un aware of how she is changing over time by staying in the containing anxiety mode. According to the participants in this study, learning to be present gives beginning counselors a way to fulfill their aims in counseling, to put their beliefs into practice Each of them said they value trusting their clients and yet they realized they do not trust themselves. So cultivating being present allows them to start with themselves. It gives them experiential knowledge of what they believe intellectually and gives them confidence in trusting those beliefs. Cultivating being present is a path toward being the therapist these participants want to be. And the portrait of master therapists from the work of Jennings, Goh, Skovholt, Hanson, and Banerjee -Stevens (2003) and Skovholt, Jennings, and Mullenbach (2004) validates those desires. Master therapists are portrayed in the above studies as congruent, open, curious, reflective, self aware, deeply accepting of self, embracing complex ambiguity, and able to intensivel y engage others. In their analysis of growth versus stagnation through therapists developmental process, Ronnestad and Skovholt (1993l, 2003) suggest that therapists who grow are adaptive and remain open even in the face of uncertainty. While the outcom es of being present do reinforce the CIT in being present, there is no straight line path to becoming more present. CITs constantly weigh their need for self protection against their desire to directly experience their emotions, their sensory experiences, and their relationships. In a general sense they are weighing their need for
192 safety with their need to grow toward greater connection with themselves and others as they move back and forth between the experience loops depicted in the theory diagram (Figure 4 1). Through much of the analysis of the data for this study being a beginning counselor has been portrayed as an inhibitor in choosing to be present as illustrated by codes such as not ready to let go and trust, planning sessions, relying on techniques and theory, and struggling with ambiguity. These characterizations seem interconnected with acting to contain anxiety and uncertainty. But being a beginner also holds the possibility of beginners mind which is associated with being present. Not knowin g and not being an expert, may be turned into the advantage of beginners mind if CITs cultivate their ability to be present. It requires all the aspects of being present for this to happen awareness, trusting and letting go, acceptance, etc. The theory presented in this study proposes that an outcome of being present is a feeling of peace. I interpreted what the participants described to mean that when the aware consciousness or the authentic self is present, discomfort dissipate s or disappear s leaving the CIT feeling at peace. This raises the idea that being at peace is the natural state once one is present Some participants even used the word natural to describe the way being present felt to them (Pam, Jill). E vidence for this possibility at this p oint comes from spiritual practices that teach that inner peace is available to everyone. Chapter Summary The data collected for this study were analyzed using the methods of grounded theory from a constructivist theoretical perspective. The theory presen ted is grounded in the data as interpreted by the researcher. In three coding processes, initial, focused, and selective, meaning was constructed that produced a grounded theory of choosing to be more present as CITs. The theory proposes that there is a dynamic process in which CITs may choose to move toward safety by containing their anxiety and uncertainty or toward awareness and connection by being
193 more present and that the choosing takes place in multiple contexts that may facilitate or inhibit being present. The theory proposes that the choosing process takes place over and over again in momentary choices as well as in whole life choices. The outcomes of those choices contribute to the development of the CIT over time. The descriptions of being pres ent by CITs are consistent with those of seasoned counselors however there are most likely qualitative differences in the experience of being present depending on the locations on the multiple continua of presence. Also different from existing literature on being present is the definition of the processes of awakening to choice s to be present and choosing to be present. In those processes CITs come to know themselves better and move toward deeper connection with themselves and with others as they contend with the fundamental uncertainties of living. Implications of these findings for practice and future research are explored in the next chapter.
194 CHAPTER 5 CONCLUSION, IMPLICAT IONS, AND FUTURE RES EARCH RECOMMENDATION S Summary The purpose of this study was to examine how CITs describe their experience of being present and the meaning they make of that experience. It focused on the counselors way of being as distinguished from their application of technique. The therap eutic relationship has been found to be a significant contributor to therapeutic outcome (Hubble, Duncan & Miller, 1999; Horvath, 2005; Lambert, 1992; Martin, Garske, & Davis, 2000; Norcross, 2002; Stevens, Muran, Safran, Gorman, & Winston, 2007; Watson & Geller, 2005; Zuroff & Blatt, 2006) How counselors connect with clients in a way that fosters the therapeutic relationship has been minimally explored. While being present as counselors fits intuitively in the realm of the therapeutic relationship it is absent from the models of the relationship used predominantly in the conceptual and empirical literature (Bordin, 1979; Gelso & Carter, 1994) Aside from its potential role in the therapeutic relationship, little systematic exploration of therapist presence in its own right has been attempted al though therapists have written passionately about the importance of being present in their work (Buber, 1970; Bugental, 1987; May, 1958; Reik, 1948; Rogers, 1961; Perls, 1978/ 1992; Yontef, 2007). Positivist experi mental research, the dominant research paradigm until the last several decades, may have limited the exploration of complex and holistic experience such as being present. The research that has been conducted on therapist presence dra w s on the experience o f seasoned therapists (Fraelich, 1989; Geller, 2001; Pemberton, 1977 ; Phelon, 2001). The perspective of counselors in the training phase of development had yet to be explored. In this study seven CITs were interviewed about their experience of being prese nt and the meaning they made of being present in counseling. During the data collection period, the CITs
195 participated in an eight -week mindfulness meditation training group as a way of cultivating being present and as a context in which they constructed t he meaning of being present. All participants were interviewed three times, before, during and after the meditation group. A fourth interview was conducted with five participants. Since this interview took place five months after the completion of the meditation group two of the participants were no longer available The p articipant CITs provided rich descriptions of their experience and their constructed meaning of being present T he transcriptions of their inte rviews form the data of this investigation. I analyzed the data u sing grounded theory methods including four levels of coding, constant comparison memoing, diagramming, and theoretical sampling. From th e analysis of the data I have propose d a theor etical model of the process of choosing to be present In Chapter 4 I describe d and interpret ed the theory as a whole and the seven elements of that process : 1) Acting to Contain Anxiety and Uncertainty, 2) Awakening to Choice s 3) Choosing to be More Present 4) Being Present, 5) Contexts Facilitating or Inhibiting Being Present, 6) Experiencing the Outcomes of Containing Anxiety and Uncertainty, and 7) Experiencing the Outcomes of Being Present. The theory portrays a dynamic process in which CITs may at any one time move toward be ing more present or toward acting to contain their anxiety and uncertainty, characterized as seeking connection or seeking safety. To choose, CITs first awaken to the experience of being present and thus the fact that there is an al ternative to acting to contain anxiety and uncertainty They may then actively choos e to be come more present or they may go toward safety again and act to contain their anxiety and uncertainty. The choices CITs make in this regard take place in and are influenced by context. Being present and acting to contain anxiety and uncertainty both yield outcomes that contribute to the CITs development and their wo rk as counselors CITs negotiate the complexity of choice in a moment
196 by moment process and cumulatively influence their personal development by the choices they make. The theory offers new perspectives on being present in counseling suggests a potential role for being present in the therapeutic relationship, and adds an unexplored dimension to the process of counselor development. The implications of the theory for counselor preparation and pr actice, theory, and policy, limitations of the study, and futu re research recommendations will be explored in the following sections. Implications for Counselor Preparation and Practice Choosing to be present has implications for counselor preparation and practice in a number of ways, including these that will be dis cussed in this section: helping CITs be responsive in a postmodern world of situated and constructed meaning; humanizing and enhancing counselor competence and the therapeutic relationship; experiencing the paradigm of being present as an alternative to t he prevailing sociocultural paradigm (see Table 41), and finally, offering a path for connecting to oneself and to others that softens anxiety and uncertainty. The use of the term counselor preparation rather than the more commonly used training in this exploration of implications seems consistent with a constructivist perspective Counselor preparation t implies a less instructor -centered teaching (McAuliffe & Erikson, 2000) and is meant to inclu de multiple learning styles and methods of teachi ng (Fong, 1998) and to be less mechanistic and impersonal than what is connoted by training (Norcross, 2005, p. 840). Counselor preparation reflects the theoretical perspective of the profession. Neimeyer (1993) refers to a long tradition of realism in the mental health field (p. 222) which expects a direct correspondence between ones beliefs and observed reality. This perspective looks to experts to provide concrete direction and is externally located in conventional descriptions of phenomena (McAuliffe, 2002, p. 212). The belief in verification of reality leading to prediction and control has fostered the emphasis on empirically -based treatments.
197 From a constructivist perspective, on the other hand, reality is constructed by people in context, and is therefore relative and varied. Constructivism allows for complexity and paradox in understanding human experience. This view is consis tent with advances in science in the areas of chaos and complexity theories where universal Truth has been replaced with multiple and local truths (Hoskins, 2002, p. 227). From a constructivist perspective then, given the variety of individually constru cted realities rather than a solid ground of absolute truth, counselors can benefit from being ready for whatever comes as they encounter their clients. In his open letter to a new generation of therapists Yalom (2002) advises them to create a new ther apy for each patient (p. 33). The theory presented in this study implies that in choosing to be present CITs enable themselves to tolerate uncertainty and remain open to what is happening in the moment, which is consistent with a constructivist perspect ive of counselor preparation In being present CITs describe being aware and attending to themselves and to what is happening around them with an open and nonjudgmental attitude. As such they are open to phenomena or experiences that may not fit into pr eviously held beliefs or concepts. One of the outcomes of being present is defined in the analysis as counseling in the present moment which means addressing what is in the moment, checking out assumptions in the moment, and using counselor reactio ns/emotions in the moment. Each of these actions and abilities keeps the counseling interaction alive and responsive. There is further implication in the data that the capacity to be present can be purposefully cultivated and practiced. If counselor ed ucators help CITs learn to be present it would appear to facilitate their effectiveness in attending to the multiple truths of their clients. Attending to each clients truth has implications for multicultural counseling competency as well. Awareness is o ne of the three domains of multicultural competency identified by Sue,
198 Arredondo and McDavis (1992) and revised by Arredondo, Toporek, Brown, Jones, Locke, Sanchez and Stadler (1996). And awareness is a fundamental element of being present in this theory. In being present, CITs are aware of their internal dialogue and therefore their biases and assumptions and in taking a beginners mind (Suzuki, 1973) approach they acknowledge not knowing a nd open to multiple culturally-constructed ways of being. Particip ants in this study pointed to the influence of the academic context on their choice to be present. They noted that being present is not only absent from their preparation as counselors but in some ways contradictory to it They described the academic cont ext as amplifying their critical internal voice, focusing on concrete problem solving and future goals, and promoting the containing of anxiety and uncertainty in a demanding environment. It seems that the way participants interpret their academic context makes it difficult for them to contradict the socially accepted way of seeking safety by meeting the standards for performance, even if incongruent with their experiential knowing of the value of being present. The juxtaposition of the prevailing sociocu ltural paradigm and the alternative paradigm of being present seen in Table 4 1 sheds light on the complexity of what CITs navigate. Counselor preparation contexts might shift toward an environment more conducive to being present or toward more overt acknowledgment of both paradigms. From a positivist standpoint, shifting toward the paradigm of being present may create concern that the quality of preparation or of client progress may be compromised but it fits well with a constructionist/constructivist vie w. Participants described some supervis ory relationships and some approaches by their professors that were exceptions to the prevailing paradigm in their academic programs. These exceptions introduced CITs to the concept and in some cases the experience o f being present which became part of their process of awakening to choice s to be present. This suggests that t he relationships
199 between CITs and their supervisors and their professors are powerful in their potential to either be part of that awakening proc ess or part of perpetuating the prevailing paradigm that encourages CITs to seek safety. For example, some p articipants described professors who did not provide structure and predictability in their classes to rescue students from sitting with uncertainty Other participants told of their supervisors who acknowledged them as full human beings in supervision and encouraged them to be so with their clients. Th e impact of these relationships has implications for supervisors and professors to themselves cultivate their ability to be present. Supervisors and professors also work in the academic context that supports the prevailing sociocultural paradigm which in turn influences their choices to be present themselves and to encourage their students to be present Being present humanizes counselor competencies. Establishing competencies is part of the gate keeping role of counselor preparation programs and is especially valued by the movement toward empirically -supported treatments. Norcross (2005) warns that ho lding tightly to operationalized competencies has its costs. The pursuit of technical competency has much to recommend it, but it may inadvertently subordinate the value of the personal formation and maturation of the psychologist. The ongoing march towar d ESTs and EBPs tends to neglect the human dimension of the psychologist and the psychotherapy. It has created an environment where, as Thoreau (1854) complained in Walden, men have become the tools of their tools (p. 25). Professional training that addr esses only or primarily the techniques of psychotherapy quickly becomes arid, disembodied, and decontextualized. (Norcross, 2005, p. 840) Choosing to be present has implications for skills training for CITs. Among the skills on which counseling programs evaluate CITs are: establishing a working alliance, assessing clients, implementing targeted interventions, att ending to issues of diversity, and managing their own reactivity. Micro skills associated with the above macro level skills include monitoring self and client, noticing nonverbal communication, congruence, accurate empathy, feedback, and immediacy. The theory proposed in this study in dicates that CITs competence in these areas is
200 enhanced by being present. Participants expressed that in being present they are aware, empathic, accepting, and able to intervene in the moment. But more importantly in light of Norcross comments above, be ing present adds the dimension of connection to the more technical performance of counseling skills. Sexton, Littauer, Sexton, and Tommeras (2005) found that connection predicted the strength of the working alliance. The authors stated that t herapist s d evelop ed connection by (a) active focused listening, (b) keeping the topic largely centered on the client, (c) providing a relaxed warmth to the session, (d) allowing the client to become emotionally moved, (e) avoiding the provision of too much information or advice, and (f) not using a purely cognitive verbal style, a style that the client might perceive as indicating that the therapist was overly detached. (p. 114) Parallels can be drawn between this definition of connection and the outcomes of being p resent. For instance, one of the outcomes identified in the theory presented in this study is building tolerance for discomfort. In building their tolerance for discomfort, CITs allow their clients to reap the benefits of experiencing emotion in the pres ent because the CITs are not directing clients away from that emotion out of the CITs own discomfort. Other defined outcomes of being present are the counselor feeling at peace and caring emerging from being present which seem likely to contribute to providing a relaxed warmth to the session (Sexton et al., 2005) Beginners mind (Suzuki, 1973) and acceptance, both elements of being present, keep CITs from offering too much advice. Amplifying connection is a central code in my interpretation of the out comes of being present and choosing to be more being present is seen as choosing connection rather than seeking safety (see Figure 1). If in being present CITs amplify their connection with themselves and their clients and if connection predicts a stronge r alliance (Sexton et al., 2005) which in turn correlates with positive therapeutic outcome (Stevens, Muran,
201 Safran, Gorman & Winston, 2007), then cultivating being present seems fundamentally important for CITs Therapist qualities have been associated with positive therapeutic alliances. In a recent meta analysis Hilsenroth and Cromer (2007) note the following therapist qualities and attitudes significantly relate to positive alliances: empathy s upport exploration, activity, confident collaboration appreciation trust warmth attunement potency, competence respect attentive, engaged listening, and appearing to understand the client without being judgmental Skovholt, Hanson, Jennings, and Grier (2004) named the following as part of their portrai t of the master therapist: tolerance for ambiguity, anxiety, disorder, conflict, ambivalence, and paradox, being congruent or fully oneself, and the ability to form relationships. Are these qualities available only to those who are naturally favored with them or only come with experience? Or, can such qualities be developed deliberately? The findings of this study suggest that they can. Being present seems to allow counselors to be attuned to their clients, potent, caring, empathic, non judgmental, and e ngaged, all consistent with the qualities and attitudes related to positive therapeutic relationships (Hilsenroth & Cromer, 2007) as well as being open, increasing connection and tolerance for discomfort, consistent with qualities of master therapists (Skovholt, et al, 2004). There are practices such as mindfulness meditation that have been used in spiritual traditions for centuries (Welwood, 2000) and more recently as interventions in psychotherapy (Baer, 2003) through which people cultivate being present (Morgan & Morgan, 2005). There is no one path to becoming more present but helping awaken CITs to their choice to be more present and encouraging the cultivation of being present may promote the development of valuable counselor qualities.
202 Models of counse lor development characterize CITs as moving through varying levels of anxiety and uncertainty which are demonstrated by their level of dependency, technique focus and flexibility, self awareness, and cognitive complexity (Hogan, 1964; Loganbill, Hardy, & D elworth, 1982; Stoltenberg, McNeill, & Delworth, 1998). In the midst of their anxiety and uncertainty, novice counselors tend to latch on to one simplistic solution, theory, or frame of reference with which to view clients in order to avoid being cognitiv ely or emotionally overwhelmed in what Skovholt and colleagues called p remature foreclosure (Skovholt, Hanson, Jennings, & Grier, 2004, p. 20). Based on these models, supervisors are encouraged to provide structure for the anxious beginning counselor a nd to shift toward less structure and more collaboration as the CIT develops and presumably their anxiety and uncertainty lessen. Skovholt and Jennings (2005), drawing on their study of therapist/counselor development versus stagnation, address the CITs a nxiety and uncertainty and offer this caution: The beginner, faced with the heat of the ambiguous complexity of human life, needs help in doing counseling. However, our results strongly suggest that narrow skill training, although a part of becoming an expert practitioner, is not the essence. Being offered a ready to -wear method may relieve anxiety. This can be a good way to get into the harbor during the storm approach if it is only temporary. (Skovholt & Jennings, 2005, p. 15) In being present, CITs stay with their anxiety and uncertainty, accept what is without judgment and in the process their anxiety and uncertainty shifts or dissipates. Being present is a way for CITs to ride the waves of uncertainty and anxiety rather than trying to contain them. A s such being present offers a helpful companion to whatever structure may be provided to beginning counselors. Learning and choosing to be present may help keep CITs from prematurely foreclosing on possibilities and available information in their sessions with clients. The theory that emerged in this study proposes that CITs develop through active choices they make in how they respond to their anxiety and uncertainty rather than it being purely a function of experience and training. Studies have found tha t counselor experience is not a
203 predictor of outcome ( Beutler, Machado, & Neufeldt 1994; Dunkle & Friedlander 1996) which further supports the idea that development of effective therapists is not only a matter of experience and training. The implications of this acknowledgement of choice are significant for counselor education and supervision. Counselor educators hold the possibility of directing CITs attention to being present, to facilitate their awakening to their present moment experience and their choice to be more present, to validate the paradigm of being present in their approach to education and supervision. Counselor educators would also then be in the position to make their own choice to be more present with the risks involved for them in navigating conflicting paradigms. All of the above points have implications for practice as well. Enhancing the counselors ability to connect with clients, to attend to themselves and to their clients with open, non judgmental awareness, to inter vene in the moment, to tolerate their own and their clients discomfort, all contribute to authentic human encounters and empower clients to ride the waves of their own anxiety and uncertainty. Another implication of this study for practice is that CITs i n this study found being present sustaining to them in their work. Participants described a different kind of energy available to them when they were present and said that leaving sessions in which they were present they felt energized and satisfied. In contrast, when not present, when containing their anxiety and uncertainty by managing their image, distracting, avoiding, and trying to be in control, they described feeling deadened, disconnected, and dissatisfied. Counseling is a taxing profession as evidenced by the attention paid in the literature to burn out and compassion fatigue along with suggestions to avoid them (Marcus & Dubi, 2006, Rothschild, 2006; Skovholt, 2001).
204 How being present sustains counselors is yet to be explored Being present w as described as both using energy and energizing. This process may allow counselors to be sustained in their work as opposed to feeling only drained of energy. Another component of how being present is sustaining is the inherent satisfaction in direct ex perience of the present moment and in authentic communion with another human being. These experiences are seen as healing in the context of Buddhism and existential, person centered and Gestalt therapies and it makes sense that the counselor benefits as well as the client. If in choosing and cultivating being present counselors can sustain themselves in their work and enhance their competency as counselors, then these choices and actions deserve further attention in the profession. Implications for Theory In this section I explore the implications of this study for two domains of theory, counselor development and the therapeutic relationship I examine t he dominant models of counselor development and the therapeutic relationship in the Literature Review (S ee Chapter 2 ). When referring to existing counselor development models in this chapter, I am referring to models put forth by Hogan (1964), Hill, Charles, and Reed (1981), Loganbill, Hardy, and Delworth (1982), and Stoltenberg, McNeill, and Delworth (1998 ). The theory proposed in this study of choosing to be present adds what seems to be an important dimension to the professions understanding of the counselor development. Participants descriptions in this study of being beginning counselors generally correspond with descriptions of beginning level CITs in existing models of counselor development highlighting self consciousness, uncertainty, relying on technique and planning, struggling with the ambiguity of counseling and looking to others. However, according the my interpretation of the data in this study, as CITs bec o me aware of their choice to be present and experience being present and the outcomes of being present, they become more trusting of themselves, more able to tolerate
205 uncertainty and ambiguity, they judge themselves less and so move from self consciousness to self awareness and awareness of others. These may be seen as developmental shifts consistent with transitioning through the stages of counselor development proposed by existing models of counselor development. In another way they may be seen, as they are in the theory presented here, as resulting from deliberate action and commitment by CITs to be present in individual moments and over time The role of agency or cho ice on the part of CITs in their developmental process is not addressed in existing models no r is how CITs transition from one stage to another. Rather, t he implication seems to be that time, experience, and supervision tailored to the CITs stage of deve lopment facilitates growth. The theory proposed here describes a growth process that acknowledges the active role of the CIT. This process may be seen as facilitating CITs development through the stages outlined by existing models or it may be seen as a model of counselor development in its own right. E xisting counselor development models are decontextualized. T he theorists do not claim the specific contexts in which the models were created i n terms of the researchers theoretical perspective, the acad emic contexts in which the CITs were observed or the prevailing sociocultural paradigm in which those CITs came of age. If CITs were trained in a context that embraced the paradigm of being present (See Table 4 1) a model of their development might look different The participants in this study once awakened to the experience of being present, seem to be faced with conflicting paradigms as illustrated in Table 4 1 The paradigm of being present and the prevailing sociocultural paradigm are at any one m oment incompatible Take for instance the opposing values of having a plan and letting things unfold or focusing on change as opposed to accepting what is The data in this study suggests that the CITs choices are
206 influenced not only by their personal ex perience and values but by the values of the paradigm within which they live and train. A counselor development model based on the theory presented here, would show qualitative differences in the development of CITs depending on how much of the time they choose to contain their anxiety and uncertainty compared with choosing to be present. And such a model would include the influence of context In the participants description of being a beginning counselor it appears that they are navigating the transiti on from student to counselor, not only related to their level of experience in counseling but in the different requirements of the two occupations. What allows CITs to enter and succeed in graduate school, i.e. being an achiever, gathering information, cr itical thinking, is not apparently what allows authentic connection in the counseling encounter. Theories of counselor development have not addressed this transition from scholar to counselor. Although counselors may maintain their scholar identity in th e scientist -practitioner model, there appear to be very different ways of being that predict success in these different realms. This study suggests processes by which CITs move toward connection and engagement in the counseling process. E xisting counselor development models include differences in how c ounselor s conceptualiz e their work and apply interventions they have learned in their training. But other aspects of being a student also have an impact on how CITs develop through graduate school. At the same time that they are beginning clinical practice, they are also reading professional litera ture and writing scholarly papers. Identifying the differences in the ways of being as a scholar and as a counselor and how those ways of being may affect CITs development would add to existing counselor development models. Th e theory presented in this study highlights the choice to move towa rd connection or toward safety acknowledging the inevitability of uncertainty and anxiety. Anxiety has been
207 acknowledged to be part of the novice counselors experience and is expected to lessen with experience. Pa rt of why anxiety lessens seems to be that uncertainty lessens as CITs gain confidence that they know more. In the context of being present, expertise actually limit s possibilities. The concept of beginners mind (Suzuki, 1973) one of the elements of be ing present, states, In the beginners mind there are many possibilities, in the experts there are few. I f I think I know, I see what I expect to see, and I am less open to possibilities that do not fit with what I know. In not knowing, new possibilitie s can emerge The lessening of CITs anxiety may come from a growing feeling of certainty and control that is different than sitting with the anxiety and uncertainty, with not knowing. Loganbill, Hardy, and Delworth (1982) posit stagnation as one cycle of coun selor development and Ronnestad and Skovholt (2003) propose that there are processes in the development of counselors that facilitate growth or stagnation, e.g., Openness to learning and an ability and willingness to recognize the complexities of pro fessional work is crucial for growth (p.13). The theory of choosing to be more present demonstrates choices CITs make toward the openness that facilitates growth As CITs become more present, cultivat ing beginners mind, awareness, attention acceptance of things as they are, and the other features of being present, they begin to tolerate anxiety and uncertainty and to be able to stay open and grow as counselors. Contending with anxiety and uncertainty may also be relevant for counselors in their careers beyond their training For experienced counselors, the novices anxiety is likely replaced with more subtle or profound anxieties, as a sense of certainty in some areas gives way to new uncertainties Experienced counselors too may have the choice to move toward being present or toward contain ing their anxiety and uncertainty. Developmental models have looked at development over the years of training and shortly thereafter (Hill, Charles, & Reed, 1981;
208 Loganbill, Hardy, & Delworth, 1982; Stoltenberg, McNeill, & Delworth, 1998) given that their purpose was in part to guide supervision. The exception is the work of Skovholt, Jennings, Ronnestad and colleagues which examined development over the life span of the therapist (Je nnings, Goh, Skovholt, Hanson & Banerjee -Stevens, 2003; Ronnestad & Skovholt, 2003; Skovholt & Jennings, 2 004; Skovholt & Ronnestand, 1992) The master therapists in their studies were people well into their careers if not toward the end, wh ile the master therapist level in earlier models were counselors post training but early in their careers (Hogan, 1964; Stoltenberg, 1981) Master t herapists in the work of Skovholt and colleagues s howed a tolerance for ambiguity that indicates they did not allow anxie ty and uncertainty to keep them from being open to the unpredictable, to being vulnerable, and to authentic connection. E xperience as a counselor may not be the determining factor in decreas ing anxiety Experience can encourage a sense of certainty and c ontrol which is perhaps only a more subtle way of acting to contain anxiety and uncertainty. On the other hand, i f seasoned counselor s ha ve awakened to the experience of being present and to their choice to be present they may develop a different relation ship to anxiety. In the passage below, Carl Rogers as an experienced therapist demonstrates his experience of deeply opening t o the present moment connection. The vulnerability involved in being present seems just as frightening for him as for CITs. And now as I live these feelings in the hours with him, I feel terribly shaky, as though my world is falling apart. It used to be sure and firm. Now it is loose, permeable and vulnerable. It isnt pleasant to feel things Ive always been frightened of befor e. Its his fault. I dont know who I am any more, but sometimes when I feel things I seem solid and real for a moment. (Rogers, 1961, p. 68) Does the process of choosing to be more present for CITs and for experienced counselors look different on t he outside to the observer of counselor development? What is the difference in the subjective experience of the counselor? These are questions to be explored in future investigations that may add to theories of counselor development throughout the lifespan.
209 I turn now to implications of this study for the therapeutic relationship. Those who have studied presence propose conceptually that developing therapists skill in being present enhances their capacity to build a more therapeutic relationship (Geller, 2001; Pemberton, 1977 ; Phelon, 2001) Fulton (2005) maintains that mindfulnes s, a way to cultivate being present, cultivates numerous qualities that are highly suited to establishing a strong therapeutic alliance ( Fulton, 2005, p. 58) The findings in this study suggest that being present may be a factor in the development of positive therapeutic relationships. Just as with being present, there is no universal definition or model of the therapeutic relationship but the counseling profession seems to have primarily settled on Bordins (1979) model of the working alliance as the s tandard. Bordins model of the alliance has three components: goal, bo nd, and task. Gelso and Carter (1985, 1994) advanced a model that includes not only the working alliance but a components called transference and the real relationship (genuine and realistic relating between therapist and client ). Rogers (1957) outline d conditions for therapeutic change that center on the therapist s being in relationship with the client. These conditions are that two people are in contact with one another, that the therapist is congruent, and that the therapist experiences unconditional positive regard and empathic understanding and communicates them to the client (Rogers, 1957). Being present may be the fertile ground for Rogers conditions to come into being f or successful bonding between counselor and client and agreement on the goals and tasks of the alliance per Bordins (1979) model, and for the awareness and authenticity necessary in Gelso and Carters (1985/1994) model. For CITs in this study being pres ent means being aware, attending inwardly/outwardly, adopting beginners mind, trusting/letting go, accepting self and other, staying with what is, being right here in the moment, and being authentic. In being aware
210 and attending inwardly/outwardly, couns elors can notice the processes of transference and countertransference and use them for therapeutic benefit. Accepting self and other, staying with what is, being in the moment, openness and authenticity seem to facilitate the bond or affective aspect of the relationship. Amplifying connection with oneself and others emerges as one of the outcomes of being present and Sexton, Littauer, Sexton, and Tommeras (2005) found connection to predict a strong alliance in counseling. Another outcome of being presen t in this study is being a better instrument of the therapeutic process through the caring that emerges and from keen application of counseling skills and knowledge, which would seem to facilitate the bond and support the goals and tasks in the therapeutic alliance. Models of the therapeutic relationship may be made more comprehensive by showing the processes that facilitate the relationship. The findings in this study indicate being present may be one of those processes. Implications for Policy In this section I suggest implications for policy generated by this study I focus primarily on the effect of choices available to the counseling profession, specifically i n the preparation of counselors, which to some extent mirror the theory of choosing to be present I offer a brief look at the effect of epistemological differences on counselor preparation and suggest that being present for CITs calls for holistic education, or education of the whole self. Lastly I caution that movement toward predictability or toward efficiency and convenience in the profession are in conflict with a commitment to facilitating counselor presence in counselor education programs. Policies are based on what is considered legitimate knowledge, reflecting the science that created the knowledge and the epistemology embedded therein. An objectivist epistemology and a positivist orientation to science, with its emphasis on objectivity and predictability, has generated much of what is considered scientific knowledge in the counseling profession. Although fourteen years old, Scanlon and Baillie s (1994) statement below about counselor
211 education in this light seems as true today. They built on Schons (1983) contention that the greater the proximity to science the higher the profession al status and stated: If Schon's propositions are correct the increasing location of counselling courses into Departments of Higher Education may mean that, as a condition of their professional acceptance, there would be considerable pressure for them t o adopt curriculum models based on the technical rational paradigm. (Scanlon, 1994) The technical -rational paradigm comes from a positivist perspective. As post modern epistemologies have emerged to challenge objectivism, they have opened up new avenues of knowledge that create the need for policies to change as well. As counselor educators become aware of multiple ways of knowing they are faced with a choice similar to the one highlighted in the theory presented in this study. They can choose to deal with uncertainty by seeking the predictability and control promised by a positivist paradigm or they can choose to open to the complexity of multiple realities in a constructionist paradigm. The latter is consistent with the advances in science brought by chaos and complexity theory. Chaos and complexity theory suggests that objectivity is impossible and that outcomes cannot be predicted (Gleik, 1987). Each set of conditions in the present is a set of possibilities for the future with no guarantee d outco mes The pressure for accountability in the counseling profession that has spawned the movement toward empirically based practice comes from the choice to seek safety and certainty. It means educational policies that call for training counselors as techn icians and implies a predictability that does not exist according to chaos and complexity theory. From the standpoint of complexity theory, standardization of treatment cannot accommodate the endless possibilities of human behavior. Counselors may identi fy common patterns when certain conditions come together in a particular way but there is no possibility of accurate prediction of human behavior or relationships. So no matter how well counselors are trained in human behavior patterns and armed with theo ries and techniques to intervene when things are problematic, they need more
212 than that to be successful from a post positivist perspective. If counselor educators choose to set policy from the perspective of chaos and complexity theory and constructionism then policies would call for CITs to know how to adapt to what they encounter, to be open and receptive enough to notice the unpredictable, and to tolerate the anxiety that arises in uncertainty. The analysis of data in this study suggests that cultivat ing being present addresses this need for CITs. Participants descriptions of those professors and supervisors who helped awaken them to their choice to be present provide support for this contention and also highlight that these practices and values are n ot the norm. Table 4 1 highlights the differences between the prevailing sociocultural paradigm and the paradigm of being present and provides something of a map for how policies might need to change if a paradigm shift is to occur. In describing their e xperience of being present, CITs emphasized that it involved the whole, authentic self, not just a professional self. This suggests that the policies that govern counselor education support holistic education. It also raises questions about policy in est ablishing ethical boundaries in the relationships between CITs and their teachers and supervisors, as well as with their clients. Setting limits on professional relationships and focusing on content areas and technique provide a shield against the complex ity of human to human contact but at a price. CITs, especially if they have been introduced to the experience of being present, may vaguely sense that something far greater than objective knowledge and scientific distance is required. No method can teach the therapist how to be a person who can embody the relational qualities necessary for a genuine existential healing to occur. Therefore, the therapist is often condemned by his training to grope and wrestle with this in a personal existential da rkness, sensing the need for the infusion of his self, yet not certain as to how to accomplish this in a professional manner. (Hycner, 1991, p. 25) Setting policies for counselor preparation that promote the cultivation of being present creates a place fo r the person of the counselor in the therapeutic relationship. Kraus, Lutz, and
213 Saunders (2007) maintain that although randomized controlled trials attempt to isolate the effectiveness of treatments, it is therapists not treatment forms that actually tre at patients (p. 347). Skovholt, Jennings, and Mullenbach (2004) in their portrait of the master therapist stated: Expertise is not about narrow skill development. It is becoming, over a long time, fully human (p. 140). They went on to say Perhaps this is the most striking finding about the portrait (p. 140). Although Skovholt, Jennings, and Mullenbach note the contribution of time in this development process, they also point to the need for counselor preparation to promote optimal human developm ent if eventual expertise is the goal. With these ideas in mind, counselor preparation policies would reflect an interest in developing the whole person of the counselor along with content, ethics, and skills. Being present offers a way of being that seem s to sharpen the counselor as an instrument of therapy, to bring their whole persons to the therapeutic relationship, and to assess appropriate boundaries in those relationships by attending closely to themselves and to clients. Facilitating this kind of development means infusing the attitudes and actions of being present in coursework and clinical training for CITs, introducing and validating this way of being. Then CITs can make conscious choices as to how they will develop as counselors. Along with the pressure for accountability to a positivist standard of evidence based practice, there are other challenges to making the cultivation of being present a priority in counselor education. The advancing of computer -based technologies in the training of counselors is one. Consider the following scenario. A trainee e -mails an electronic portfolio with case notes, questions, and prepared segments of videotaped sessions to the supervisor. The supervisor replies to the portfolio by comments and suggestions to share the trainees experience with the whole supervision group. The group meets in the cyberspace using an Internet videoconferencing system. This kind of supervision, recently called cybersupervision (Coursal & Lewis, 2000) allows
214 the supervisors and trainees to talk to each other from the convenience of their desktop. (Berger, 2004, p. 303) A scenario such as this one offers financial, convenience, and efficiency benefits that make it attractive and yet makes learning to be more present less of a prio rity or at the very least, more difficult. If the counseling profession is to choose to go in the direction of promoting being present and connection in preparing counselors, the pull toward such convenience will have to be evaluated carefully. Consideri ng the paradigm of being present raises a number of policy related questions In addressing these questions, c ounselor educators mak e choices that will guide the development of CITs. What epistemology drives the policies of training? Is there flexibility in the academy to encompass the personal ? Can the curriculum expand to incorporate exposure to and cultivation of being present? Maki ng policy decisions with these questions in mind has implications for what kind of practice CITs are being prepared for and what kind of counselors CITs are being trained to be. This has implications for how CITs are assessed and on what competencies. Limitations From a constructivist perspective, people assign meaning to their experience through language. The research questions for this study asked how CITs describe their experience of being present and what meaning they make of that experience in cou nseling. Participants were challenged to articulate in language an experience they indicated is a nonverbal or no t a cognitive one such that it test s the ability of language to capture. Articulation of the meaning they make of their experience is created through language and so also limited by language. The kind of knowing that is described in the findings, experiential knowing, is difficult to translate into language, although still constructed by the individual. The task of constructing meaning is fu rther complicated by the act of interpretation. As a researcher coming from a constructivist
215 perspective, I am interpreting the meaning participants create from their experience of being present in my own knowledge construction process and through my own filters (see Subjectivity Statement in Chapter 3). Thi s study was originally designed to use narrative analysis but as the data were collected it became clear that grounded theory methods would enable better understanding of the participants constructed meanings. The first three interviews with all seven of the participants had been completed at that point. A fourth interview was then added for the purpose of theoretical sampling and member checking/collaboration consistent with grounded theory methodo logy. As the fourth interview took place five months after the third interview, five of the seven participants were available for this interview. Limited access to participants for additional interviewing curtailed additional theoretical sampling. Howeve r the categories included in the formation of the theory were considered saturated by Charmazs (2006) definition that categories are saturated when gathering fresh data no longer sparks new theoretical insights, nor reveals new properties of your core theoretical categories (p. 113). A limitation of the interview as a data collection method in this study is that the participants and the researcher were colleagues in the field of counseling at the same university. Coar and Sim (2006) investigated meth odological issues in interviewing medical professionals. They note that in interviewing colleagues, the researcher needs to be aware that the interviewees may feel the need to preserve or create an image in the interview (Coar & Sim, 2006). This may have been the case for the respondents in this study as well. I included a statement at the beginning of interview to the effect that I was interested in their experience and meaning and that there was no standard to which their answers were being held other than to be as true to their own experience and beliefs as they could.
216 All the participants in the study are female. Having all female participants was not a purposeful selection criterion. There was one male accepted into the study but he withdrew prior to the first interview due to scheduling conflicts. The findings are limited by having no data from male participants. At the same time, females make up a larger percentage of the student populations than males in the two counseling programs from which pa rticipants were recruited. Future research involving male participants can enlarge and enhance understanding of being present from the point of view of CITs. Participants all came from the same university which limits the heterogeneity of the sample and affects the transferability of the resulting theory. However having participants from both counseling psychology and counselor education, different programs and disciplines of counseling, offered multiple perspectives. The sample did include socioeconom ic, cultural, and racial diversity which strengthened the theory. While contexts were identified in the findings as facilitating or inhibiting choosing to be present, context was not the focus of the inquiry. Contexts appeared in the data to the extent th at they needed to be included in the theory but the processes involved in their influencing CITs in choosing to be present were not thoroughly explored. Choosing to be present is minimally situated in context in this study and deserves more examination. P articipants in the study were required to make a time commitment that may have discouraged some students from participating. In addition, people who agreed to be in the study knew they would be learning mindfulness meditation as a way of cultivating being present which also may have attracted a particular segment of the CIT population. It seems evident in the data that the participants in the study had a positive association with the experience of being present and an interest in mindfulness meditation whi ch makes them biased. However, their experience
217 of being present was necessary for the study in order for them to describe and make meaning of the experience. The criteria for participation in the study included the requirement that students had either completed or were currently in their clinical practicum or internship so that they would have had experience working with clients. Most participants were not seeing clients during the time that the study was conducted and in describing being present with clients had to rely on their memories. Although not seeing clients during the time of the study had the potential to influence their meaning making, participants had other experiences of being present that were current and at times the participants drew o n the immediate moment in the interview. In constructivist grounded theory the subjectivity of the researcher is overtly acknowledged rather than being masked as it is in objectivist research. In my subjectivity statement I outlined values, experiences, and contexts that informed my interest in the topic of the study and form the lenses through which I viewed the data. As I transcribed the first couple of interviews, I noticed points when I might have been leading the interviewee or communicating a desi red response. I recorded these times and processed them in memos. One comment I made in a memo indicated I was somewhat anxious about having good quality data and in a parallel process to the theoretical proposition in this study, I had tried to control the interview in subtle ways. In the memoing process I increased my awareness of this dynamic and was then able to be more present with my interviewees. I took pains in coding the data to stop myself from assuming the meaning of statements by the participants. Much of what they had to say sounded like what I had experienced myself or had read about in the literature on presence and on mindfulness meditation practice. I frequently use d in vivo codes because using participants language kep t me from imposi ng preconceived meanings. My prolonged engagement in the context and with
218 participants is part of what makes the study trustworthy. At the same time it has the potential to blind me as the researcher to taken -for granted aspects of the topic and context. Lincoln and Guba (1985) address this concern by saying t here are no techniques that will provide a guarantee against such influence either unconsciously or consciously; awareness is, however, a great step toward prevention (p. 304). Awareness of the p otential impact of my positions allowed me to be deliberate in how they affected my interpretations. In grounded theory it is important for the researcher to have what is called theoretical sensitivity to their topic, meaning the researcher must be knowle dgeable enough to interpret the data in a way that is relevant and useful to the field. My subjectivity is also my theoretical sensitivity. The extent of my awareness made the difference between bias and sensitivity. Future Research Recommendations A sm all number of studies have been conducted exploring therapeutic presence (Fraelich, 1989; Geller, 2001; Pemberton, 1977 ; Phelon, 2001) and a larger number of experienced therapists have written of their experience of being present (i.e., Bugental, 1987; May, 1958; Korb, 1988; Rogers, 1961) These sources provide the perspective of seasoned therapists on their experience of being present. This is the first known study on the experience and meaning of being present for CITs. Consequently there is signifi cant r oom for further investigation. The following recommendations represent a few of the possible directions for future research These include looking at the meaning of being present in counseling made by CITs in different contexts and with different de mographics; exploring further the connection between being present and the therapeutic relationship; investigating how presence may be cultivated, and analyzing the effects of mindfulness meditation training on counselor development and effectiveness. Whil e the participants in this study represented some diversity they all were studying in the same southeastern university. From a constructivist perspective, the experience and meaning
219 making of CITs from different parts of the country or the world would add complexity and depth to what is presented here. Specifically such exploration would shed further light on the effect of context as the findings presented here include on ly a general look at contexts that faci litate or inhibit being present for these CITs. It seems important to examine more closely the interaction between context and CITs choices to be present. From a Gestalt perspective, growth of the self occurs in the interaction between self and environment at the boundary between them. In addition, u nder standing the meaning made by CITs living and working in different contexts would help policy makers in creating counselor preparation programs that more thoroughly address factors facilitating being present. CITs in this study drew on spiritual, theor etical and family support for being present. I t would also seem important to study how different spiritual, theoretical, and family beliefs influence the meaning CITs make of being present as counselors, particularly the process of choosing to be present. The theory presented here is based on meaning made by CITs of being present over eight months. As such in the proposition related to counselor development, the dimension of time is represented to a limited extent. This is a single investigation and as such provides a snapshot of development from which I theorized a developmental process. It has been my argument for the significance of this study that being present fits intuitively in the realm of the therapeutic relationship whether as a common factor of or as a condition for the development of the relationship The qualities of therapists that correlate with positive alliances (Hilsenroth & Cromer, 2007) show similarity to descriptions of being present. Establishing c onnection has also been tied to s trong therapeutic relationships ( Sexton Littauer, Sexton, & Tommeras, 2005) and amplifying connection was found to be one of the outcomes of being present in this study. B eing present is implied in this study as an essential way of being for
220 relationship s to form that promote healing and change. Purposeful examination of the interaction between being present and establishing therapeutic relationships is needed. A nother next step in research would be further exploration of the cultivation of being present. In this study, participants were introduced to the practice of mindfulness meditation as a way of being present. Mindfulness meditation was not explored as an intervention itself but as a context for being present. Inve stigating mindfulness practice as part of clinical training for counselors is a promising area for future research. Grepmair, Mitterlehner, Loew, and Nickel (2007) conducted a study to examine the influence of promoting mindfulness in psychotherapists in t raining on treatment outcomes for patients in a 200bed -psychosomatic hospital and licensed training institution in Europe The group of 46 patients treated by the psychotherapists in training who practic ed mindfulness medi ta t ion showed significantly higher assessment of individual therapy on three self -report scales and showed significantly greater rate of change than the control group on five Symptom Checklist Scales The study has several limitations, including its historical control group design. Howe ver it is the first empirical study of how mindfulness meditation training might benefit CITs and promote positive therapeutic outcomes although o ther studies have examined mindfulness meditation as a clinical intervention and shown benefits for clients ( Baer, 2003). Kurash and Schaul (2005) implemented a n optional mindfulness meditation component to training psychology pre -doctoral interns at a university counseling center and argued the benefits of such a practice A meditation component means initiatin g nothing less than structured time for concentrated work on ones own being. A set time for meditation establishes a space just to be to see to be seen, to pause, to self -sense. It balances, even if just a little, the extraordinary amount of doing that is required during the training year. This correction in balance not only provides stress reduction but it also highlights, in action, the value of the being mode a state of openness, non-doing, in the -moment experience (Kurash & Schaul, 2005, p. 63)
221 Ex amination of a program of mindfulness medi t ation for CITs could elaborate on the Grepmair et al (2007) study in looking at counselor effectiveness from the perspective of clients in both qualitative and quantitative designs In addition, counselor compete ncies and counselor development during and after mindfulness training could be considered Existing counselor development models were created from observations of CITs in traditional academic programs, but the contexts were not identified at potentially having an impact on the way counselors develop. Would counselor development look different, in light of the outcomes of being present in the theory presented in this study, in CITs who cultivate their ability to be mindful and present? In addition, t he in strument that Geller (2001) created to measure therapist presence, TPI, could be used in a quant itative analysis of the effects of mindfulness training for CITs. The TPI offers both client and therapist forms for rating therapist presence. Such a study c ould expand our understanding of the effect of mindfulness meditation on the cultivation of being present. Conclusion Using grounded theory methodology from a constructivist theoretical perspective, I analyzed the descriptions and meaning of being present in counseling for CITs. The grounded theory presented in this study highlights the process of choosing to seek connection by being more present or choosing to seek safety by acting to contain anxiety and uncertainty. The theory also proposes outcomes of each of these choices that contribute to the development of the CIT and to their work as counselors. Being present is defined in the theory as being aware, attending inwardly -outwardly, beginners mind, trusting and letting go, accepting, staying with wha t is, being right here in the moment, and being authentically human. Being present seems to reflect a paradigm that conflicts with the prevailing sociocultural paradigm in ways outlined in Table 4 1. These findings have implications for theory, counselor preparation, and practice, and policy,
222 summarized as follows. For counselor preparation and practice the findings have implications related to preparing counselors for a post modern world of uncertainty, enhancing and humanizing counselor competencies, a nd for building positive therapeutic relationships. For theory the findings have implications related to counselor development and the therapeutic relationship. For policy the findings have implications related to post modern, holistic, connection-focuse d counselor education. And finally, future research might explore the meaning made of being present in counseling by CITs in different contexts and with different demographics; the connection between being present and the therapeutic relationship; how CITs can cultivate being present, and the effects of mindfulness meditation training on counselor development and competency.
223 APPENDIX A ALACHUA COUNTY CRISI S CENTER CLINICAL EX PERIENCE Applicants who possess the necessary initial qualifications (see below) commit to a six week training program. The training program is designed to provide each person with adequate skills to perform effectively on the phone. Two four -hour observation shifts are also required. Here, trainees have the opportunity to experience the realities of telephone counseling. It is a time for learning about community resources, of actual phone room activities, and for observation and listening. Additionally, three supervised shifts follow, which allow trainees to perform the duties of the Phone Counselor with the support and coaching of experienced Volunteers. Once training is completed, Volunteer Telephone Counselors make a commitment to working regular hours ( one four -hour shift per week ) for at least 6 months ( 24 shifts). During this time, they are also encouraged to attend in -service training sessions. An annual event combines training, recreation, fellowship and reward. The Counselor is expected to respond with confidence in an empathetic, caring manner. Secon dly, the Counselor is expected to be sufficiently knowledgeable of the referral information and references utilized by the Center. By the time a Volunteer becomes a Phone Counselor, (s)he has been deemed capable of performing these duties with minimal assi stance from the Staff. This is not to say, however, a Counselor should feel hesitant in consulting with others (Staff or CARE Team). In fact, there are circumstances (such as when there are duty -to -warn considerations) under which the Counselor should cons ult the person on -call (Staff or CARE Team) as a matter of course. Volunteer Pre Requisites Prior to training, a potential trainee must fall within the following guidelines : Minimum age 20 preferred Within six months prior to beginning the training pr ocess, preferred that trainee not have made a suicide attempt, had a major crisis in his/her life or been a client of the Crisis Center Must have a genuine desire and willingness to help people who are in need; Does not require a high school diploma or special training. Immediately following training, the potential volunteers will be: Required to have successfully completed the Alachua County Crisis Center Phone Training, including Observation and Supervised shifts Sign the Confidentiality Agreement Commit to 24 regularly scheduled volunteer phone counselor shifts (usually over a period of approximately six months), Attend three In Service sessions per 12 months;
224 Must follow Code of Ethics adopted by the Alachua County Crisis Center; Must put effort into following all Phone Room and Scheduling procedures.
225 APPENDIX B PRACTICUM AND INTERN SHIP FIELD EXPERIENC ES IN COUNSELOR EDUC ATION Site and Direct Service Hour Requirements Practicum and Internship experiences require students complete minimum number of hour requirements. Hour requirements include hours in which the student is required to be onsite and hours in which the student provides direct client contact. Students may be asked to complete additional hours as part of their negotiation with clinical site hosts. Students are required to maintain an Activity Log, tracking their hours, and submit a signed copy to the Clinical Coordinator on the last day of classes. Listed belo w are hour requirements for each program specialization. Students are expected to begin work on the first day of class and are required to be onsite until the last day of class. Students are demonstrating professional misconduct when leaving a clinical si te prior to the end of term and are subject to department disciplinary action, which may include receiving an Unsatisfactory (U) for the clinical experience requiring the student to register again for the clinical experience. Mental Health and Marriage and Family Counseling Programs Practicum Onsite Hours 400 Hours (27 hours per week during Fall & Spring semesters; 34 hours per week during Summer C semester) Direct Client Service Hours 100 Hours Internship Onsite Hours 600 Hours (40 hours per week during full time, one -semester internship; 20 hours hours per week during split, two -semester internship) Direct Client Service Hours 250 Hours (Students seeking Marriage and Family licensure must demonstrate, within their practicum and internship clinic al experiences, they have completed 180 hours of direct service with couples and families.) School Counseling and Guidance Program Practicum Onsite Hours 225 Hours (15 hours per week; approximately 3 school days per week) Direct Client Service Hours 65 Hours Internship Onsite Hours 600 Hours (40 hours per week) Direct Client Service Hours 180 Hours Course Preand Corequisite Requirements Prerequisite courses must be completed prior to registration for clinical experiences. Corequisite courses may be completed either prior to or during the same semester as registered for clinical experience. The following sections detail the specific pre and corequisite requirements for each program specialization.
226 Mental Health and Marriage and Family Couns eling Programs Prerequisite Courses for Practicum MHS 5005 Introduction to Counseling (3 cr.) MHS 6401 Counseling Theories & Applications (4 cr.) MHS 6720 Professional Identity & Ethics (3 cr.) MHS 6200 Assessment in Counseling & Development (3 cr. ) MHS 6500 Group Counseling: Theory & Practice (3cr.) Corequisite Courses for Practicum MHS 6071 Diagnosis & Treatment of Mental Disorders (3 cr.) MHS 6430 Introduction to Family Counseling (3 cr.) MHS 6420 Multicultural Counseling (3 cr.) Prerequ isite Courses for Internship MHS 6020 Counseling in Community Settings (3 cr.) MHS 6450 Substance Abuse Counseling (3 cr.) School Counseling and Guidance Program Corequisite Courses for Practicum MHS 5005 Introduction to Counseling (3 cr.) MHS 6401 Counseling Theories & Applications (4 cr.) MHS 6720 Professional Identity & Ethics (3 cr.) MHS 6421 Play Counseling and Play Process with Children (3 cr.) SDS 6411 Counseling with Children (3 cr.) SDS 6413 Counseling Adolescents (3 cr.)
227 APPENDIX C P RACTICUM AND INTERNS HIP FIELD EXPERIENCE S IN COUNSELING PSYCHOLOGY Required Practica/Internship Training [7 hours required] (1) PCO 7944 Practicum in Counseling Psychology at the University Counseling Center (1) PCO 7944 Practicum in Counseling Psychology at the University Counseling Center (1) PCO 7945 Advanced Practicum in Counseling Psychology at a student -selected, Program approved site (1) PCO 7945 Advanced Practicum in Counseling Psychology at a student -selected, Program approved site (1) PCO 7949 Int ernship in Counseling Psychology Part I (1) PCO 7949 Internship in Counseling Psychology Part II (1) PCO 7949 Internship in Counseling Psychology Part III Practicum Structure Pre -practicum All first year students are enrolled in a professional training sequence. During the Spring semester of the first year students enroll in the pre -practicum (entitled Ethics and Skills, PCO 7217) in which they establish carefully monitored contact with clients through the University Counseling Center. Group sup ervision is provided for pre -practicum students by the Counseling Center psychologists, and the core Counseling Psychology Program faculty provide individual supervision for this experience. The objective of the prepracticum is to develop proficiency in ba sic communication and interview skills, including the ability to establish therapeutic rapport, regulate therapeutic interaction, and terminate the counseling process. Overview of Practicum and Advanced Practicum Training Practicum training is required to develop broad -based counseling competencies that are tailored to the students subspecialization interests (e.g., vocational, family, assessment). This training involves a sequence of graduated practica experiences. During the Fall and Spring semesters of students second year, following the successful c ompletion of the Pre -practicum experience (PCO 7217), students enroll for a two semester Practicum (PCO 7944) at the University Counseling Center. Practicum students are provided midpoint and final evaluati ons during each of the two semesters to maximize feedback regarding their progress and professional development. The successful completion of this two-semester practicum sequence qualifies students to enroll for an Advanced Practicum (currently listed as P CO 7945) in their third year. Successful completion of two Advanced Practica is required with enrollment in the second contingent upon successful completion of the first. Successful completion of the second Advanced Practicum must occur prior to the inter nship experience. The program requirements for the practicum sequence are designed to insure that each student accumulates in excess of 900 pre doctoral, pre internship practicum hours. Supervision should be conducted by licensed or license eligible psycho logists in individual or group supervision contexts, or by other licensed mental health professional subject to review and approval by the Director of Training. In addition to the supervision provided during the pre practicum, each student receives two hou rs of normally scheduled supervision per week as part of the two semesters of Practicum and as a part of the two semesters of Advanced Practicum, resulting in a total of approximately 120 hours of
228 formally scheduled supervision across these four semesters of practica experiences, excluding the Pre -Practicum experiences that precedes them. Counseling Center Practicum Requirements During the two -semester practicum at the Counseling Center, students are expected to see an average of 4 to 5 clients per week. T here is a minimum expectation of 40 client contact hours for the Fall semester, and a minimum of 55 hours during the Spring semester. Other criteria for obtaining a satisfactory course grade include adherence to the Counseling Center administrative policie s and recommendations for professional behavior, attendance and participation at group and individual supervision meetings, and completion of all assigned work within the supervision settings. The practicum requires an average of 11 hours per week of on-si te time. The typical distribution of time is as follows: 4 to 5 hours of client contact, 1 to 3 hours of case management, consultation and preparation of supervision, 2.5 hours for group supervision, 1 hour of individual supervision, and 1.5 hours of parti cipation in clinical team meetings. Advanced Practicum Requirements Each student will spend between 12 and 15 hours per week at their required two semester Advanced Practica. Allowing for time spent getting started during the first week of each semester, s tudents will log approximately 225 on-site hours (15 weeks x 15 hours) per semester of each of their two required Advanced Practica. Consequently, each student should accumulate approximately 450 hours of Advanced Practica. Students are expected to maintai n a minimum service load of approximately 5 client contacts per week (including contacts with individuals, families, and groups), resulting in 75 client contact hours per semester, minimally (15 weeks x 5 clients). Over the course of the required two semes ter Advanced Practicum, no fewer than 150 client contacts will be logged. The two semesters of Advanced Practicum may be completed at one or more of the approved practicum agencies (see the Manual Appendices Section) or at an alternative Advanced Practicum site for which approval is requested by a student and then approved by the core program faculty, the students advisor and the Director of Training.
229 APPENDIX D LISTSERV RECRUITMENT MESSAGE Hello, Are you curious about mindfulness and the experience of being present as a counselor? Do you want to learn how to meditate? Therapist presence has been associated with positive therapeutic relationships and with the qualities of master therapists. Mindfulness meditation has been said to be the foundation pr esence and has been shown to have benefits in reducing stress and anxiety as well as pain, headaches, and other physical problems. I am conducting a qualitative study for my dissertation with the purpose of increasing understanding of how counselors in tr aining describe their experience of being present and what that means to them in the context of counseling. Participants in the study will learn mindfulness meditation in an 8 -week training group as a way to cultivate being present. The mindfulness medit ation training will be lead by Dr. Michael Murphy, clinical Associate Professor at the UF Counseling Center and experienced meditator and therapist, and will take place at the Counseling Center. I will interview participants about their experience and appl ication of being present. The study will begin in the spring semester of 2008 and is IRB approved. Participants must be students enrolled in Counselor Education or Counseling Psychology and must have experience working with clients, either in current or completed practicum or internship or through volunteering at the Alachua County Crisis Center. If you are interested in participating in the study or just want more information, please contact me at firstname.lastname@example.org at your earliest convenience. I will be excited to talk with you about the project. Thanks for your attention and interest, Tina Tina Tannen, Ed.S. Doctoral Candidate, Counselor Education UF Counseling Center Associate FL State Registered Intern, Menta l Health Counseling
230 APPENDIX E INTERVIEW GUIDES Interview #1 Guide Demographic Information (to be filled out by the participant) 1. Number of years of counselor training (in what year are you now?) 2. Clinical Experience: Crisis Center Training Practicum, Internship, Doctoral Internship (Please specify which you have completed and where you are currently working.) 3. Racial/ethnic/cultural background or identification 4. Theoretical orientation Interview Questions 1. During this part of the interview, I would like you to immerse yourself as much as you can in your subject ive experience of being present. Being present has been described as being all there (body, mind, emotions, spirit) and aware i n the present moment. I am going to ask you to remember a time when you were present, preferably in a counseling session. I am going to ask you to describe this experience as thoroughly and as richly as you can. I may prompt you to consider the experienc e from various perspectives but I mostly want to hear your personal description. I want to know what being present is like for you. By experience, I mean your subjective awareness of thoughts, feelings, body sensations or possibly things that do not fit into any of those categories but are part of your experience how you know you are present. So I am going to allow a few minutes of silence now so you can bring an experience of being present in counseling to your awareness. (Allow silence). Please describe your experience. 2. How did you prepare yourself to be present, before and during the session? 3. What else would you add to give the most complete description of what being present was like for you? 4. Now I want to move from description of you r experience to exploring how you make sense of that experience. What does your experience of being present in counseling mean to you? 5. How do you connect your experience of being present with your training? beliefs or values theoretical orientatio n sense of yourself as a therapist?
231 6. How did you use or apply being present in the counseling process or encounter? 7. What else could you add to help me understand what being present in counseling means to you? 8. Do you have anything more you w ant to bring up or ask about, before we finish the interview? Interview #2 Guide Questions I would like you to read over your journals from the last seven weeks to immerse yourself as much as you can in your subject ive experience of mindfulness practice and being present in counseling. 1. As you look over it now, what stands out to you as significant or meaningful in what you wrote? 2. What changes do you notice in you as a counselor? 3. What changes do you notice in how you pra ctice counseling? Interview #3 Guide Questions 1. During this part of the interview, I would like you to immerse yourself as much as you can in your subject ive experience of being present. Being present has been described as being all there (body mind, emotions, spirit) and aware in the present moment. I am going to ask you to remember a time when you were present, preferably in a counseling session. I am going to ask you to describe this experience as thoroughly and as richly as you can. I may prompt you to consider the experience from various perspectives but I mostly want to hear your personal description. I want to know what being present is like for you. By experience, I mean your subjective awareness of thoughts, feelings, body sensations or possibly things that do not fit into any of those categories but are part of your experience how you know you are present. So I am going to allow a few minutes of silence now so you can bring an experience of being present in counseling to your awa reness. (Allow silence). Please describe your experience of being present. 2. How did you prepare yourself to be present, before and during the session? 3. What else would you add to give the most complete description of what being present was like f or you?
232 4. Now I want to move from description of your experience to exploring how you make sense of that experience. What does your experience of being present in counseling mean to you? 5. How do you connect your experience of being present with yo ur training? -beliefs or values -theoretical orientation -sense of yourself as a therapist? 6. How did you use or apply being present in the counseling process or encounter? 7. What else could you add to help me understand what being present in counseling means to you? 8. Do you have anything more you want to bring up before we finish the interview?
233 APPENDIX F INFORMED CONSENT Protocol Title: A narrative analysis of the meaning counselors in training make of their experience of being present in counseling Please read this consent document carefully before you decide to participate in this study. Purpose of the research study: The purpose of the study is to increase understanding of how counselors in training describe their experience of being present and the meaning they make of being present in the context of counseling. Therapist presence has been correlated with the therapeu tic relationship, a significant contributor to therapeutic outcome, and with qualities of the master therapist. What you will be asked to do in the study: Y ou will be asked to participate in an 8 -week mindfulness meditation training group as a way to cultivate being present. This training involves daily practice (5 20 min utes) during the 8 weeks and writing brief (1 2 paragraphs) journal entries each week. In addition, y ou will be asked to participate in three interviews, answering open -e nded questions regarding your experience of being present and the meaning you make of that experience in the context of counseling. The interviews will be conducted by the principle investigator and will be audio taped and transcribed. If you consent to pa rticipate in this study, you will be asked to fill out a brief Client Information Form which is required of anyone receiving services at the UF Counseling Center. Then you will meet with the trainer, Dr. Murphy, for a group screening. Where the mindfulnes s meditation training will take place: The mindfulness meditation training will take place at the University of Florida Counseling Center. The mindfulness meditation trainer: Michael Murphy, Ph.D. will be the mindfulness meditation trainer. He has cond ucted this 8 week training at the University of Florida Counseling Center for the past 5 years and has been a meditator himself for the past twenty years. Dr. Murphy is also a licensed psychologist. Time required: Three interviews up to 1 hours each, e ight 1 hour mindfulness meditation training sessions, daily 5 20 minute practice of meditation and weekly journal entries during the 8 weeks of the mindfulness meditation training.
234 Risks and Benefits: There is no more than minimal risk anticipated in participating in this study. The benefit of the study will be its contribution to scientific knowledge regarding therapist presence. Participants may benefit from learning mindfulness meditation which has been shown to help reduce stress and anxiety. Co mpensation: No compensation is offered for participation. Participants will be offered a brief written analysis, from the perspective of the principle investigator, of the participants cultivation of presence. Confidentiality: Identifying information w ill be removed from the transcript of your interview. Your identity will be kept confidential to the extent provided by law. Your name will not be used in any report. The audiotape of the interview will be destroyed following analysis. Although the meditation group is a psychoeducational group and not a therapy group, you will be a client of the Counseling Center and accorded the same confidentiality protection. Voluntary participation: Your participation in this study is completely voluntary. There is no penalty for not participating. You may choose not to answer any question in the interview without consequence. You may choose not to participate in any aspect of the mindfulness meditation training without consequence. Right to withdraw from the study: You have the right to withdraw from the study at anytime without consequence. What will be done with the results of the study: The results of the study will be analyzed as part of the doctoral dissertation of the principle investigator and may also be su bmitted for publication. Participants may request a copy of the results. Who to contact if you have questions about the study: Christina Tannen, Ed.S. Doctoral Student, Department of Counselor Education, College of Education, University of Florida. 371 9719. email@example.com Harry Daniels, PhD, Department of Counselor Education, College of Education, University of Florida, 3920731.
235 Who to contact if you have questions related to Counseling Center clinical services : Rafael Harris, Psy.D., Clinical Services Director, Counseling Center, University of Florida. 392 0575. Who to contact about your rights as a research participant in the study: UFIRB Office, Box 112250, University of Florida, Gainesville, FL 326112250; ph 392 0433. Agreement: I have read the procedure described above. I voluntarily agree to participate in the procedure and I have received a copy of this description. Participant: ________________________________________Date: _________________ Princi pal Investigator: _______________________________ Date: _________________ Addendum to Informed Consent Protocol Title: B eing present in counseling as counselor s in training : A grounded theory Please read this consent document carefully before you decide to participate in this part of the study. Purpose of the research study: The purpose of the study is to increase understanding of how counselors in training experience being present and the mea ning they make of being present in the context of counseling. Therapist presence has been correlated with the therapeutic relationship, a significant contributor to therapeutic outcome, and with qualities of the master therapist. What you will be asked to do in the study: You will be asked to review a draft of the provisional theory generated from data analysis and provide feedback to the primary investigator. Reviewing the written materials will be followed by one interview of up to one hour with the pr imary investigator either by telephone or in person. The interview may be audio recorded. Time required: Up to one and a half hours may be required to review the written material and participate in the interview.
236 Risks and Benefits: There is no more than minimal risk anticipated in participating in this part of the study. The benefit of the study will be its contribution to scientific knowledge regarding counselor presence. Compensation: No compensation is offered for participatio n. Confidentiality: Your identity will be kept confidential to the extent provided by law. Your name will not be used in any report. Voluntary participation: Your participation in this part of the study is completely voluntary. There is no penalty for not participating. Right to withdraw from the study: You have the right to withdraw from the study at anytime without consequence. What will be done with the results of the study: The results of the study will be analyzed as part of the doctoral disserta tion of the principle investigator. Participants may request a copy of the results. Who to contact if you have questions about the study: Christina Tannen, Ed.S. Doctoral Student, Department of Counselor Education, College of Education, University of Flo rida. 3719719. firstname.lastname@example.org Harry Daniels, PhD, Department of Counselor Education, College of Education, University of Florida, 3920731. Who to contact about your rights as a research participant in the study: UFIRB Office, Box 112250, University of Florida, Gainesville, FL 326112250; ph 3920433. Agreement: I have read the procedure described above. I voluntarily agree to participate in the procedure and I have received a copy of this description. Particip ant: ________________________________________Date: _________________ Principal Investigator: _______________________________ Date: _________________
237 APPENDIX G DATA COLLECTION TIMELINE Table G 1. Data Collection Timeline Week Dates Activity Content Pre Nov Dec 2007 Recruit participants, Group screens, Schedule interview #1 Informed Consent, Preparation for study 1 Jan 6 13 2008 Pre Interview (#1) Interview protocol 2 Jan 14 20 Session #1 MM Training Training & journaling 3 Jan 21 27 Session #2 MM Training Training & journaling 4 Jan 28 Feb 3 Session #3 MM Training Training & journaling 5 Feb 4 10 Session #4 MM Training Training & journaling 6 Feb 11 17 Session #5 MM Training Training & journaling 7 Feb 18 24 Session #6 MM Training Training & journaling 8 Feb 25 Mar 2 Session #7 MM Training & Interview #2 Training & journaling. Journal Processing 9 Mar 3 9 Session #8 MM Training Training & journaling 10 Mar 10 16 Spring Break 11 Mar 17 28 Post MM Training Interview (#3) Member checking Repeat interview protocol August Member checking Interview ( #4) Member checking and feedback on theory
238 APPENDIX H MINDFULNESS MEDITATI ON GROUP
239 Table H 1. Mindfulness Meditation Group Session 1 Activity Description Purpose Welcome. Review contract and guidelines for participation. Participation in research is voluntary however participants encouraged to commit to attending all training sessions and to daily practice to get full benefit of the group. Group members are asked to keep what is shared in the sessions confidential. This training group is not a therapy group but a skill acquisition group. To clarify the expectations of participants. Introductions Trainer will introduce himself including his qualifications to lead the group. Participants will be asked to share name, department, what brought them to the group. To begin to build a safe atmosphere in the group and engender confidence in group leader. Raisin eating exercise Participants are given a raisin and asked to: Close eyes and feel raisin on fingers. Touch the raisin to lips Observe at each step of putting raisin in mouth, chewing, and swallowing. Low risk activity designed for participants to focus awareness and atte ntion on the experience of eating a raisin. Used as a metaphor for mindfulness meditation.
240 Table H 1 Continued Activity Description Purpose Overview of mindfulness and description of the mindfulness meditation training program Based on Mindfulness Based Stress Reduction Program (MBSR) (Kabat Zinn, 1990) Overview of mindfulness: Moment to moment non-judgmental awareness, being awake instead of on autopilot; not a technique, but a way of being; not trying to improve yourself; simple but not easy, take s practice. Benefits may include emotional/psychological (calmer, less anxiety, less stress, improved concentration), physical (reduced headaches, blood pressure, insomnia, fatigue). Risks are minimal but sometimes sad or traumatic memories surface in me ditation. Over time, with practice, meditation can also be therapeutic in these areas. 8 week program, 1.5 hours each week of group sessions and up to 25 minutes per day of home meditation practice, reading, and journaling. Difficult to learn and maintain practice alone. Coming to group helps support practice and reinforce learning. To provide overview of mindfulness. To explain the mindfulness meditation training program. To review possible benefits as reported in research literature. To warn of possib le difficulties participants may encounter. To provide information counseling services on campus and in the community. Mindfulness meditation practice: Sitting meditation Referring back to raisin eating exercise, participants are directed this time to obs erve their breath in the same way. Participants are instructed to sit comfortably upright in their chairs and notice the feeling of the abdomen rising and falling as they inhale and exhale, paying attention in moment -to -moment awareness, coming back to the breath and to the present moment whenever they notice their minds wandering, maintaining a non judgmental awareness. (10 minutes) A low risk activity designed to build awareness in the present moment and to learn to observe thoughts and feelings as they pass through awareness without judging or controlling them. Homework Assignments 5 minute daily mindfulness meditation practice Daily reading (see manual) Daily meditation log (see manual) Weekly journal entry on reactions to meditation practice Eat one meal mindfully. To reinforce the learning in the group session, to practice meditation skills, to reflect on meditation practice for increased understanding.
241 Table H 2. Mindfulness Meditation Group Session 2 Activity Description Purpose Sitting meditation Participants are instructed to sit comfortably upright in their chairs and notice the feeling of the abdomen rising and falling as they inhale and exhale, paying attention in moment to -moment awareness, coming back to the breath and to the prese nt moment whenever they notice their minds wandering, maintaining a non -judgmental awareness. (10 minutes) Process the experience of the sitting meditation. A low risk activity designed to build awareness in the present moment and to learn to observe thoughts and feelings as they pass through awareness without judging or controlling them Didactic Importance of breath as anchor line to the present moment. It is always there, and it connects the body and the mind. No need to control it. Learning to do one thing at a time. Helps in stilling the mind. To expand participants understanding of the principles of mindfulness and mindfulness meditation. Check in on home practice and reading Participants may volunteer to share their impressions and experiences of their home practice of meditation and of the readings. Use participants experience in practice to reinforce principles of mindfulness meditation. To offer validation and support to participants regarding their meditation practice. To reinforce learning o f principles of mindfulness meditation. Body Scan Participants are instructed to lie down on the floor on their backs in a comfortable position. (They may stay in their chairs if they wish.) Participants are asked to direct their attention first to the br eath as in sitting meditation, and then to each part of their body, starting with the feet, moving to calves, thighs, etc. up to the head, paying attention in moment -to -moment awareness to the sensations in each part of the body, coming back to the to the present moment whenever they notice their minds wandering, maintaining a non judgmental awareness. To introduce an alternative way to do mindfulness meditation. Participants can experiment to find a form of mindfulness meditation that appeals to them. Homework Assignment 5 minute daily mindfulness meditation practice and 60 second mindfulness breaks during the day. Daily reading (see manual) Daily meditation log (see manual) Weekly journal entry on reactions to meditation practice. Do one small routine activity this week mindfully (e.g. brush teeth, tie shoe, do dishes). To reinforce the learning in the group session, to practice meditation skills, to reflect on meditation practice for increased understanding.
242 Table H 3. Mindfulness Meditation Group Se ssion 3 Activity Description Purpose Sitting meditation Participants are instructed to sit comfortably upright in their chairs and notice the feeling of the abdomen rising and falling as they inhale and exhale, paying attention in moment to -moment awareness, coming back to the breath and to the present moment whenever they notice their minds wandering, maintaining a non judgmental awareness. (10 minutes) Process the experience of the sitting meditation. A low risk activity designed to build awarenes s in the present moment and to learn to observe thoughts and feelings as they pass through awareness without judging or controlling them. Didactic Witness Mind, meaning the part that can observe your thinking or acting. Slowing or stopping incessant thi nking brings calm and focus. Do one thing at a time. See emotions and thoughts as like the weather, sometimes sunny sometimes gray and always temporary. To expand participants understanding of the principles of mindfulness and mindfulness meditation. Check in on home practice and reading Participants may volunteer to share their impressions and experiences of their home practice of meditation and of the readings. Use participants experience in practice to reinforce principles of mindfulness meditatio n. To offer validation and support to participants regarding their meditation practice. To reinforce learning of principles of mindfulness meditation. Sitting meditation Participants are instructed to sit comfortably upright in their chairs and notice the feeling of the abdomen rising and falling as they inhale and exhale, paying attention in moment to -moment awareness, coming back to the breath and to the present moment whenever they notice their minds wandering, maintaining a non judgmental awareness. (1 0 minutes) Process the experience of the sitting meditation. A low risk activity designed to build awareness in the present moment and to learn to observe thoughts and feelings as they pass through awareness without judging or controlling them. Homework A ssignment 10minute daily mindfulness meditation practice and 60 -second mindfulness breaks during the day. Daily reading (see manual) Daily meditation log (see manual) Weekly journal entry on reactions to meditation practice. Do a driving meditation. Driv e/ride from one place to another with total mindfulness To reinforce the learning in the group session, to practice meditation skills, to reflect on meditation practice for increased understanding. To bring mindfulness into daily living.
243 Table H 4. Mindfulness Meditation Group Session 4 Activity Description Purpose Sitting meditation Participants are instructed to sit comfortably upright in their chairs and notice the feeling of the abdomen rising and falling as they inhale and exhale, p aying attention in moment to -moment awareness, coming back to the breath and to the present moment whenever they notice their minds wandering, maintaining a non -judgmental awareness. (10 minutes) Process the experience of the sitting meditation. A low risk activity designed to build awareness in the present moment and to learn to observe thoughts and feelings as they pass through awareness without judging or controlling them. Check in on home practice and reading Participants may volunteer to share their s uccess and problems in their home practice of meditation and reactions to the readings. Use participants experience in practice to reinforce principles of mindfulness meditation. To offer validation and support to participants regarding their meditation practice. To reinforce learning of principles of mindfulness meditation. Didactic Importance of the present moment, befriending the present moment, being in the present moment. Working on being instead of doing. Can you tell the difference? To expand participants understanding of the principles of mindfulness and mindfulness meditation. Walking meditation Participants are instructed to walk slowly and mindfully across the room, paying attention to the shifting of the weight from one foot to another a nd to the breath, with eyes gazing a few feet ahead but not focused on anything. As with other forms of meditation, the idea is to observe what is in each moment without judgment. (10 minutes) Process the experience of the walking meditation. To introduce an alternative way to do mindfulness meditation in addition to following the breath and the body scan. Homework Assignment 10minute daily mindfulness meditation practice and 60 -second mindfulness breaks during the day. Try walking meditation either instead of or in addition to sitting meditation. Daily reading (see manual) Daily meditation log (see manual) Weekly journal entry on reactions to meditation practice. One time this week, walk from one class to another mindfully. To reinforce the learning in the group session, to practice meditation skills, to reflect on meditation practice for increased understanding. To bring mindfulness into daily living.
244 Table H 5. Mindfulness Meditation Group Session 5 Activity Description Purpose Sitting meditation Participants are instructed to sit comfortably upright in their chairs and notice the feeling of the abdomen rising and falling as they inhale and exhale, paying attention in moment to -moment awareness, coming back to the breath and to the prese nt moment whenever they notice their minds wandering, maintaining a non -judgmental awareness. (20 minutes) Process the experience of the sitting meditation. A low risk activity designed to build awareness in the present moment and to learn to observe thoughts and feelings as they pass through awareness without judging or controlling them. Check in on home practice and reading Participants may volunteer to share their success and problems in their home practice of meditation and reactions to the readings. Use participants experience in practice to reinforce principles of mindfulness meditation. To offer validation and support to participants regarding their meditation practice. To reinforce learning of principles of mindfulness meditation. Didactic Judgment. Makes us feel superior and reinforces a solid self, and creates suffering. What is it like not to judge. Generosity. The opposite of judgment and self centeredness. To expand participants understanding of the principles of mindfulness and mindfulness meditation. Outside exercise Participants are instructed to go outside, to walk mindfully in silence to a busy area and observe (just be). Observe without judgment; let the scene unfold on its own, with no preference. Come back to the breath or body if mind gets caught up or judges. A low risk activity designed to build awareness in the present moment and to learn to observe thoughts and feelings as they pass through awareness without judging or controlling them. To expand the practice of m editation. Homework Assignment 20minute daily mindfulness meditation practice (can alternate sitting and walking or outside). 60second mindfulness breaks during the day. Daily reading (see manual) Daily meditation log (see manual) Weekly journal entry o n reactions to meditation practice. Do one act of generosity each day (keep it small). Set aside one period of the day when you dont judge. To reinforce the learning in the group session, to practice meditation skills, to reflect on meditation practice for increased understanding. To bring mindfulness into daily living.
245 Table H 6. Mindfulness Meditation Group Session 6 Activity Description Purpose Sitting meditation Participants are instructed to sit comfortably upright in their chairs and notice the feeling of the abdomen rising and falling as they inhale and exhale, paying attention in moment to -moment awareness, coming back to the breath and to the present moment whenever they notice their minds wandering, maintaining a non -judgmental awareness. (2 0 minutes) Process the experience of the sitting meditation. A low risk activity designed to build awareness in the present moment and to learn to observe thoughts and feelings as they pass through awareness without judging or controlling them. Check in o n home practice and reading Participants may volunteer to share their success and problems in their home practice of meditation and reactions to the readings. Use participants experience in practice to reinforce principles of mindfulness meditation. To o ffer validation and support to participants regarding their meditation practice. To reinforce learning of principles of mindfulness meditation. Didactic Practice is not getting carried away with out thoughts and emotions. Dont create a story out of a t hought or feeling, just let it be. New way to relate to thoughts and emotions, observing them, not grabbing on to them, and they melt away. To expand participants understanding of the principles of mindfulness and mindfulness meditation. Loving Kindness Meditation Participants are instructed to extend to each of a series of people four sayings by repeating them silently. May you be safe (free from danger) May you be happy (free from mental suffering) May you be healthy (free from physical suffering) May you live in peace. To be said to: a mentor, a friend, a neutral person, a person mildly disliked, an enemy, self, people in the room, people in the community or in the world. To he lp participants build compassion and open -heartedness, both for oneself and for others; to focus outside oneself on the connectedness with others.
246 Table H 6 Continued Activity Description Purpose Homework Assignment 20 minute daily mindfulness meditation practice (can alternate sitting and walking or outside). 60second mindfulness breaks during the day. Daily reading (see manual) Daily meditation log (see manual) Weekly journal entry on reactions to meditation practice. One time this week when something arises that you dont like, watch what your mind does (non attachment to getting what we want. To reinforce the learning in the group session, to practice meditation skills, to reflect on meditation practice for increased understanding. To br ing mindfulness into daily living.
247 Table H 7 Mindfulness Meditation Group Session 7 Activity Description Purpose Sitting meditation Participants are instructed to sit comfortably upright in their chairs and notice the feeling of the abdomen rising and falling as they inhale and exhale, paying attention in moment to -moment awareness, coming back to the breath and to the present moment whenever they notice their minds wandering, maintaining a non -judgmental awareness. (20 minutes) Process the experien ce of the sitting meditation. A low risk activity designed to build awareness in the present moment and to learn to observe thoughts and feelings as they pass through awareness without judging or controlling them. Benefits of Mindfulness Meditation Review main points of chapter included in manual called Introducing Medical Meditation (Khalsa, 2001). Ask participants what has changed in their lives. To inspire participants to continue practicing. To reinforce learning of principles of mindfulness meditati on. Sending/Receiving Practice (Tonglen) Didactic Receiving (Breathing in): A new attitude toward unwanted (painful) experience. Rather than try to escape it or make it go away, hold your seat and move closer to that pain. willing not just to endure it but also to let it awaken your heart and soften you. (Chodron, 1994, p. 7) Sending (Breathing out): A new attitude toward pleasurable experience. Rather than try to hold onto it, think of other people and wish for them to feel that. Be generous with your joy. (Chodron, 1994, p. 7) Both pleasure and pain are opportunities to be aware. Can be used as part of daily meditation. To expand participants understanding of the principles of mindfulness and mindfulness meditation. Outside Meditation Exercise Participants are instructed to go outside and d o a walking meditation in which they are like two year olds, seeing things with fresh eyes and having no destination. Addition instruction is to open your heart to each person you meet, look them in the eye, see them with the spirit of loving kindness (compassion, nonjudgmental, open, connected). (15 minutes) Process the exercise. A low risk activity designed to build awareness in the present moment, to build open heartedness, and to expand the practice of meditation.
248 Table H 7 Continued Activity Description Purpose Homework Assignment 20 minute daily mindfulness meditation practice (can alternate sitting and walking or outside). 60second mindfulness breaks during the day. Daily reading (see manual) See if you can notice your first thought in the morning. Final journal: What has changed in your life; how do you plan to continue practicing and the principles of mindfulness meditation (address obstacles to practice). To reinforce the learning in the group session, to practice meditation skills, t o reflect on meditation practice for increased understanding. To bring mindfulness into daily living. To support participants in planning for future practice of mindfulness meditation.
249 Table H 8. Mindfulness Meditation Group Session 8 Activity Descri ption Purpose Sitting meditation Participants are instructed to sit comfortably upright in their chairs and notice the feeling of the abdomen rising and falling as they inhale and exhale, paying attention in moment to -moment awareness, coming back to the breath and to the present moment whenever they notice their minds wandering, maintaining a non -judgmental awareness. (15 minutes) Process the experience of the sitting meditation. A low risk activity designed to build awareness in the present moment and to learn to observe thoughts and feelings as they pass through awareness without judging or controlling them. Check in on home practice and reading and final writing assignment. Participants may volunteer to share regarding their home practice, reactions to the readings, and from the final writing assignment. Use participants experience in practice to reinforce principles of mindfulness meditation. Discuss obstacles to continued practice. To offer validation and support to participants regarding their medit ation practice. To reinforce learning of principles of mindfulness meditation. Review and resources Review principles of mindfulness meditation, techniques, and potential benefits. Provide handout with opportunities and resources related to mindfulness m editation. To reinforce the learning in the group session and to support participants in planning for future practice of mindfulness meditation.
25 0 APPENDIX I MINDFULNESS MEDITATI ON TRAINER VITA MICHAEL C. MURPHY EDUCATION Ph.D. Counseling Psychology, 1984 University of Texas at Austin (APA approved) M.A. Counseling Psychology, 1982 University of Texas at Austin (APA approved) B.A. Cum Laude, Major in Political Science, 1976 Knox College, Galesburg, Illinois. LICENSURE Approved by the State of Florida to practice psychology, License #PY0003594. PROFESSIONAL EXPERIENCE August 1984 Clinical Associate Professor and Staff Psychologist to Present Counseling Center, University of Florida Gainesville, Florida Full tim e position with the following duties: Counseling/Psychotherapy Director of Practicum and Internship Training (19871992, 2007present) Training and Supervision Group Counseling and Psychotherapy Consultation and Outreach Crisis Intervention Coordinator of Practicum and Specialist Internship Training (2005present) Director of Clinical Services (1984 1987) Faculty Appointment Coordinator, Couples Clinic (1993 Present) Coordinator, Staff Development Series (1997present) Committee and Ad ministrative Assignments August 1983 to Psychology Intern, APA Approved Internship August 1984 Counseling and Psychological Services Center University of Texas at Austin 19761979 Director of Student Activities and International Student Advisor Knox Col lege; Galesburg, Illinois TEACHING EXPERIENCE
251 Contemplative Psychology/Psychotherapy: Counseling Psychology Program; fall 2006. Practicum class: Counseling Psychology Program, University of Florida (2005present) Death and Dying: Department of Counselor Education, University of Florida; taught each fall semester (2000 2005). Will resume teaching this class fall 2007. Spiritual and Transpersonal Issues in Counseling: Department of Counselor Education, Univer sity of Florida: taught each spring semester (2001; 2002; 2005) Spiritual Issues in Multicultural Counseling: Department of Counselor Education, University of Florida; Spring 2000 and 2001. Spiritual Issues in the Health Sciences: team taught class; Un iversity of Florida Honors Program; Spring 2000. Group Psychotherapy: Counseling Psychology graduate program, University of Florida. Taught each spring semester, 1985 1989 and 19941999. Advanced Practicum Class: Counseling Psychology graduate program, University of Florida, 1997 1999. Couples Therapy: Taught to Predoctoral Psychology Interns at the U.F. Counseling Center, 1993 Present. Intern Special Topics Seminar: Taught Predoctoral Psychology Interns on variety of topics Professional Identit y Development; Working with sexual identity issues in counseling; Dream Interpretation; Gender Issues; Pornography addiction; etc. Supervision of Supervision Seminar: Taught to Psychology Interns; 1985 1990 and 19961999. Human Growth and Development: Sante Fe Community College, Psychology Department. Summer 1985. Self Hypnosis for Professional and Personal Improvement: University of Florida Community Education Program. Winter 1992. OUTREACH AND PRESENTATIONS Police Intervention with the Emotionally Disturbed Person. Training programs for university police department, University of Florida, January 2005. Unintentional Classism: The Challenge of Understanding Social Class. Presentation for the Diversity Lunch Series, University of Florida Counseling Center, Spring 2005. Spirituality and Cultural Diversity Presentation for the Diversity Lunch Series, University of Florida Counseling Center, Fall 2004. GLBT Consciousness Raising. University of Florida Police Department; June 2004. Ne w Student Orientation: Talking with Parents About Their Kids Leaving Home University of Florida; 2003 -present. Death and Dying Workshop presented to the UF Center for Spirituality and Health; May 2003. Dream Interpretation. Class presentation to transpersonal psychology class; January 2003. Critical Incidents in Supervision Continuing Education Workshop; University of Florida; June 12, 2002.
252 Pornography Addiction: Etiology and Treatment Considerations. Presented to Ps ychology Interns, University of Florida Counseling Center; Spring 2002; Summer 2003. Sex and Power in Therapy. Presented to Psychology Interns, University of Florida Counseling Center; Spring 2001 and 2002. Meditation and Mindful Movement. Weekly grou p offered to University of Florida students; Fall 2001 and Spring 2002. E -mail in Clinical Practice: Professional and Ethical Issues and Duty to Warn Requirements in the University Setting. Continuing Education Workshop presented to University of Flori da Counseling Center, Student Mental Health and Private Practice Psychologists. December 7, 2001. Death and Dying. Workshop presentation to the University of Florida Spirituality and Health Faculty Group. December 3, 2001. Violence Against Women and C hildren: Treatment Considerations. Television interview on WCJB in Gainesville, FL; May 7, 2001. Dream Interpretation Training. Professional staff at Peaceful Paths (domestic abuse shelter); spring 2002. Dream Interpretation 6 8 workshops per seme ster presented to residence living units, Counseling Center Peer Counselors, and other campus groups (1992 -present). Mental Imagery for Performance Enhancement and Relaxation National Collegiate Health and Wellness Week; March 24, 1998. The Lies Men Are Told: Un -doing the Male Stereotype UF Mens Leadership Conference; March 23, 1996. Male Sex Role Changes and Stresses Script developed for Counselnet; University of Florida Counseling Center self -help tape series; August 1999. Coping With Anxiety. Script developed for Counselnet; University of Florida Counseling Center self -help web page; June 2000. The Academic Success Group: Helping UF Students Succeed In The Classroom. Article written for the Student Affairs Update ; Fall 1999. Spirituality and Psychotherapy Presented to local/regional mental health professions. Gainesville, FL, May 1993 Professional Identity Issues Presented to psychology interns, University of Florida Counseling Center. (1985Present) Time Management In -service training workshop for Alachua County Supervisor Development Training Program. (June 1990) Fighting Multiple Oppressions Presented to the Lesbian, Gay, and Bisexual Student Union. (October 1993) Sex and Power in Therapy Presented to psychology interns, U.F. Counseling Center. (every year since 1993) Mind -Body Issues Presented to psychology interns, U.F. Counseling Center. (August 1993) Consultation and Outreach in a University Counseling Center Presented to Counseling Psychology class. (April 1994) Cultural Diversity Training Presented in College of Education. (October 1993) Cultural Awareness Training Presentation to Athletic Training class, University of Florida. (Fall 1992)
253 Crisis Intervention and Counseling Presentation to practicum class, University of Florida Counseling Psychology Program. (Spring 1992) Sexual Harassment Workshop Facilitator for university -wide sexual harassment workshop, University of Florida. (January 1992) Journal -Writing Workshop Workshop for psychology interns, University of Florida Counseling Center. (1992, 1993) Gay and Lesbian Counseling Issues Presentation to psychology interns, University of Florida Counseling Center. (June 1992) Men's Issues Presentation to psychology interns, Un iversity of Florida Counseling Center. (September 1992) Clinical Assessment and Note Taking Presentation to graduate level class in Counselor Education, University of Florida. (Fall 1992) Using Self Hypnosis and Mental Imagery to Promote Psychological and Physical Health Presentation to mental health professionals as part of The Gainesville Family Institute's continuing education workshop series; Gainesville, Florida. (1989) Group Facilitator Student Affairs Cultural/Racial Awareness Training Prog ram University of Florida; Gainesville, Florida. (1989) Male Gender Role Issues Presentation to the United Church of Gainesville; Gainesville, Florida. (1987) Crisis Intervention and Referral Presentation to the University of Florida Peer Counselor s. (1987) Ethics in Professional Psychology Presentation to the University of Florida graduate psychology students. (1986) Male Gender Role Confusion Presentation to University of Florida Campus Organized Against Rape (COAR). (1986) Sexual Harassmen t Workshop Group Leader Presentation to University of Florida administration and faculty (1986). Short Term Group Psychotherapy In -service staff development, University of Florida Counseling Center (1985). Stress and Being a Professional University of Florida College of Journalism (1984). Issues in Counseling Men In -service staff development, University of Florida Counseling Center (1984). Have also developed and/or presented programs on the following topics: Assertive Living The Wellness Workshop Time Management Relaxation Training Self Hypnosis Sexual Decision Making Career Exploration and Planning Stress Management Adjustment to College Gender Role Issues Imagery Training The Male Experience Pathways to Health
254 CONSULTATION PROJECTS University of Florida Athletic Department (1993 Present). University of Florida Residence Life Liaison Program (2001-present). University of Florida Women's Basketball Team (19921993). Univer sity of Florida School of Nursing (19901992). University of Florida College of Law (19861989). University of Florida Baby Gator Nursery and Daycare (1988). University of Florida Division of Residence Life (19861987). PROFESSIONAL DEVELOPMENT Using Imagery in Psychotherapy. Two day training provided by the Florida Society of Clinical Hypnosis. Stuart, Florida. May 2006. EMDR Training. Three day, Level One training. Austin, Texas; August 2005. Hypnosis Training ; Spring workshop of the Flori da Society of Clinical Hypnosis; Topics: smoking cessation and irritable bowel syndrome; Captiva Island; April 2004. Mindfulness Based Stress Reduction: A Seven Day Training Program. Jon Kabat Zinn and Saki Santorelli; Austin, Texas. September 17 24, 2003. Being With Dying. Upaya Zen Center; March 14 21, 2003 Multicultural Considerations in Crisis Intervention and Trauma Work. University of Florida, October 30, 2002. Counseling Gay and Lesbian Couples. University of Florida, February 2003. Imagery and Healing Presented by Dr. Jean Achterberg. Hilton Head, SC; December 10 12, 2002. Energy Medicine. Presented by Donna Eden. Phoenix, Arizona, May 2002. Gainesville Commission on the Status of Women Annual Conference and Workshop May 6, 2003. International Conference on Energy Psychology. Phoenix, Arizona; Spring 2002. Advanced Hypnosis Training in Ego State Therapy : Florida Society of Clinical Hypnosis; Melbourne, Florida; May 2000 (10 hours of CE credit). Spirituality and Health Harvard Medical School 3 day workshop; Orlando, FL; May 2000. Meditation and Psychotherapy : Institute for Meditation and Psychotherapy; Santa Fe, New Mexico; Fall 1999 (five day conference/training workshop). Hypnotic Regression : Brian Weiss; Chica go, Illinois; Fall 1998 (5 five training workshop). Bioenergetic Therapy Training Prgram : 5 4 day training sessions; 1996 1997; Institute for Bioenergetic Analysis; Alachua, FL. Spirituality and Psychotherapy : 2nd annual conference/workshop; Kripalu Cen ter; Lenox, MA. (April 15 22, 1995) Brief Therapy Conference Milton Erickson Foundation; Orlando, FL. (December 8 12, 1993) Meyers Briggs Type Indicator Three day intensive workshop on the MBTI; Center for the Applic ation of Personality Type, Gainesville, Florida. (November 1922, 1992) Issues in Clinical Supervision Training workshop by Dr. Helen Roehlke; University of Florida. (May 1993)
255 Understanding Black Families Training workshop by Dr. Nancy BoydFranklin; Gainesville, Florida. (May 18, 1990) Updating Skills in Sexual Abuse Treatment University of Florida. (April 24 26, 1987) Training in Clinical Hypnosis Training workshop by Dr. James Morgan; University of Florida, 12 hours. (Fall 1986) Gestalt Therapy Training Training workshop by Dr. Pat Korb, Gestalt Center of Gainesville. (Spring 1986) Marathon Group Therapy Training Led by Dr. Earl Koile; University of Texas, Austin, Texas. (Apr il 1981) Massage Therapy Training Austin Wellness Center, Austin, Texas; 24 hours of training. (Fall 1982) GRANTS "Male Gender Role Confusion." Grant received from the University of Florida Committee on Sexual Exploitation. Awarded twice, 1986 an d 1987. PROFESSIONAL AFFILIATIONS American Psychological Association (APA): Division 29 (Psychotherapy); Division 32 (Humanistic) (1984present) American College Personnel Association (ACPA) (19831996) Commission VII (Counseling Centers) Dir ectorate Body Member 19901992) Program Reviewer for national conference (1991, 1992) Standing Committee for Men Co -editor, SCFM Newsletter (19861989) Florida Society of Clinical Hypnosis (FSCH) (1994-present) Association for Humanistic Psyc hology (1995-present) HONORS Recipient of the University of Florida Superior Accomplishment Award (Student Affairs Faculty Service), 1996. PRIVATE PRACTICE 1985 to Present Engaged in private practice, providing individual and couples psychotherapy to broad -based clientele. CONFERENCE PRESENTATIONS Murphy, M.C., Varnes, J., Rogers, A., McClosky, J., Patrick, C., Doering, P., Goldberger, B., Carodine, K., and Kuldau, J. Drug Testing: An Important Element in Substance Abuse Prevention Presented at the AAHPERD annual meeting, March 23, 2000.
256 Murphy, M. C., and Perez, R. (1993). Dream Interpretation Workshop Presented at APA Division 17 Southeast Regional Conference, Gainesville, Florida. Murphy, M. C., Probert, B., Funderburk, J., Desmond, F., a nd Whitchard, K. (1991). Shared Leadership In Response To Tragedy: Serial Murders In A College Community. Presented at the American College Personnel Association (APCA) annual conference, Atlanta, Georgia. Murphy, M. C., Vidaurreta, B. L., and Bellamy, D (1991). Training in Ethnic Issues at the Internship Level: Results of a National Survey. Presented at the American College Personnel Association (ACPA) Annual Conference, Atlanta, Georgia. Murphy, M. C., and Jensen, R. J. (1988). Gender Role Flexibi lity among Male College Students Presentation at the American College Personnel Association Annual Conference, Miami, Florida. Braberman, D., Cochran, A., Murphy, M., and Rabinovitz, F. (1988). Men's Centers on the College Campus Presentation at the American College Personnel Association Annual Conference, Miami, Florida. Schauble, P., Murphy, M., Paterson, C., and Archer, J. (1987). Cost Effectiveness of Internship Training Programs: Clinical Service Delivery through Training Paper presented at the American Psychological Association Annual Convention, New York City. Schauble, P., Murphy, M., Paterson, C., and Archer, J. (1987). Cost Effectiveness of Internship Training Programs: Clinical Service Delivery through Training Paper presented at t he Association for Counseling Center Training Agents Annual Conference, Monterey, California. Murphy, M. (1987). Countering Sexist Media Images Presentation at conference on the Impact of Violence on Women and Children, sponsored by the Gainesville Com mission on the Status of Women, Gainesville, Florida. Jensen, R. J., Travaglioni, L., Murphy, M., and Paterson, C. (1987). Special Counseling Services for Male College Students Paper presented at the Southeastern Psychological Association Annual Convent ion, Atlanta, Georgia. Murphy, M., and Jensen, R. (1987). The Effects of the College Experience on Men Presentation at the American College Personnel Association Annual Convention, Chicago, Illinois. Murphy, M., and Jensen, R. (1987). Special Counseling and Programming Services for Male College Students: Are There Too Many or Not Enough ? Presentation at the American College Personnel Association Annual Convention, Chicago, Illinois. Roberson, K., Murphy, M., and Powell, J. (1987). M en and Friendship: New Perspectives for the Student Personnel Professional Presentation at the American College Personnel Association Annual Convention, Chicago, Illinois. Stevens, M., Good, G., Murphy, M., Rabinovitz, F., Sappington, S., and Valdes, L. (1987). An Office of men's Services by 1990: No Small Task Presentation at the American College Personnel Association Annual Convention, Chicago, Illinois. Murphy, M., Archer, J., and Foos, J. (1986). Role Conflict in College Males: Implications f or Preventive Mental Health Programs Presentation at the American College Personnel Association Annual Convention, New Orleans, Louisiana. Archer, J., Morgan, J., Murphy, M., and Foos, J. (1985). Role Conflict in College Males: Implications for Preven tive Mental Health Programs Paper presented at the American
257 Association for Counseling and Development Annual Convention, New York City, New York. Murphy, M. (1984). The Adjustment of Rural High School Students to a Large, Urban University: The Identi fication of Stressors and Coping Behavior Presentation at the American College Personnel Association Annual Convention, Baltimore, Maryland. Clack, R. J., Hanson, G., and Murphy, M. (1984). Dropouts and the Mission of Student Affairs Presentation at the American College Personnel Association Annual Convention, Baltimore, Maryland. Murphy, M., and Long, K. M. (1983). Getting at the Fundamental Issues: Defining Professional Identity Paper presented at the American Psychological Association Annual C onvention, Anaheim, California. Clack, R. J., Hanson, G., and Murphy, M. (1983). Exiting Students: An Untapped Resource Presentation at the American College Personnel Association Annual Convention, Houston, Texas. Murphy, M., and Bienko, D. (1981). Can New Ideas Be Made More Accessible through Text Engineering ? Paper presented at the National Reading Conference, Dallas, Texas. Goetz, E., and Murphy, M. (1981). Helping Students Learn from Informative Text Paper presented at the National Reading C onference, Dallas, Texas. RESEARCH AND PUBLICATIONS Murphy, M.C. The intimacy rating scale: A therapy instrument for helping clients evaluate relationship health. Submitted for publication Murphy, M.C. Taming the Anxious Mind: An eight week meditation group. Submitted for publication. Murphy, M.C. Taming the anxious mind: A mindfulness meditation group at a university counseling center. Journal of College Student Psychotherapy Fall 2006, Vol. 21, No. 2. M.C. Murphy, & Martin, T. (2004). Introducing a t eam -b ased c linical s ystem at a u niversity c ounseling c enter : A good method for handling client demand. Journal of College Student Psychotherapy 19(2), 312. Murphy, M.C. (2004). My barn having burned to the ground, I can now see the moon. In G. Howard and E.A. Delgado -Romero (Eds.). When things begin to go bad (pp. 9398). Lanham, Maryland:Hamilton Books. Fukuyama, M., Murphy, M., & Siahpoush, F. (2003). Bridging t he gaps: Weaving multicultural and humanistic perspectives into transpersonal education. The Humanistic Psychologist 31(23), 182191. Murphy, M.C. (1998). Progressive m uscle r elaxation t raining In C.C. Clark (Ed.). The Encyclopedia of Complem entary Health Practices (pp. 202204). Springer Publishing Co. Murphy, M.C. (1998). Autogenic Training. In C.C. Clark (Ed.). The Encyclopedia of Complementary Health Practices (pp. 184186). Springer Publishing Co. Murphy, M. C., & Archer, J. (1996). Stress on the college campus: Changes over the past eight years Journal of College Student Development 37(1), 2028
258 Murphy, M. C., Vidaurreta B., & Bellamy, D. (1995). Training in ethnic minority issues at the internship level: Results of a national survey. Journal of Multicultural Counseling & Development 23 (3), 170180. Stress, Anxiety, and Depression in Males (July 1992). University of Florida Counseling Center Self Help Brochure. The Counseling Center After Dark (Fall 1991). University of Florida Student Affairs Quarterly Schauble, P., Murphy, M., Paterson, C., & Archer, J. (1989). Cost effectiveness of internship training programs: Clinical service delivery through training. Professional Psychology: Rese arch and Practice 20(1), 1722. Murphy, M. C. The adjustment of rural students to a large, urban university: The identification of stressors and coping behaviors Unpublished doctoral dissertation, University of Texas at Austin, Austin, Texas (1984). S challert, D., Goetz, E., Murphy, M., Tierney, R. (1982). Mapping as an aid in helping students learn from their textbooks, in Learning from expository text: The interaction of text structure with reader characteristics N.I.E. Final Report, Grant No. NI E G -790667. Schallert, D., Goetz, E., Murphy, M., Tierney, R. (1982). The learnability of ideal texts derived from maps, in Learning from expository text: The interaction of text structure with reader characteristics N.I.E. Final Report, Grant No. NIE -G 790667.
259 APPENDIX J CODING TRAIL Initial Codes Focused Codes Selective Codes Awakening Awareness Being aware Heightening awareness Attending Inwardly Outwardly Focusing Attending Inwardly Outwardly Heightened memory Approaching as if new Approaching with open mind Beginner's Mind Curious Not being expert Allowing vulnerability Drawing on intuition In the flow Not controlling, letting go Trusting self and process/Letting go Not planning Being present Trusting (self, process) Accepting (self, other, what is) Being kind to self Non judging Accepting (self, other, what is) Validating Sitting with Staying with what is Staying with Being right here in the moment Being, not doing Being right here in the moment Time becoming irrelevant Being human Not in counselor role Being human/Being Authentic Whole person
260 Initial Codes Focused Codes Selective Codes Being an achiever Being evaluated Experience changing nature of uncertainty Feeling not authentic Information overloading Lacking confidence Looking to others Needing to be different as counselor than as student Being Beginning Counselor Not knowing what's therapeutic Not ready to let go and trust Planning sessions Relying on techniques & theory Struggling with ambiguity of counseling Amplifying critical voice Demanding environment Contexts Facilitating or Inhibiting Being Present Focusing on concrete problem solving Focusing on future goals Academic Context Influencing Being Present Incongruence between personal and academic worlds Promoting containing anxiety not being present Beliefs about change supporting being present Finding theoretical support for being present Humanistic beliefs supporting being present Drawing on spiritual, theoretical, and family support for being present Influenced by family values Influenced by spiritual beliefs
261 Initial Codes Focused Codes Selective Codes Client's way influencing counselor being present Content of session influencing being present Counseling context influencing being present Managing counseling load Absent from training Aware of conflicting paradigms Being present not taught Caring for self is selfish vs necessary to help others Contradicting training Contexts Facilitating or Inhibiting Being Present Distracting vs tuning in cont. Focusing on doing Focusing on future outcome vs present process Navigating Conflicting paradigms Focusing on inadequacies vs being kind to self Focusing on what needs to change vs accepting what is Normal way is not present Predicting & controlling vs letting go into uncertainty Avoiding discomfort in session Avoiding discomfort in outside life Avoiding emotions Avoiding Distancing from own emotional reactions Controlling content in session Controlling for specific outcome Controlling Acting to Contain Anxiety and Uncertainty Planning Distracting Predominantly thinking Distracting Strategically not present
262 Initial Codes Focused Codes Selective Codes Putting on counselor persona Acting to Contain Anxiety and Uncertainty cont. Self monitoring Managing image as counselor Wanting to appear competant Acknowledging truth to oneself Experiencing own emotions Exploring self Coming to know oneself Knowing oneself Self awareness Applying technique w/o connection Automatic mode Being fully present Being present has frequency & duration Distinguishing being present Being present has range and dimensions Awakening to choice s Distinguishing quality of being present Experiencing Experiencing in body Experiential knowing Experiential knowing Awareness distinguishes being present Being at a crossroads Recognizing personal change journey Recognizing having a choice Questioning agency in being present Recognizing existential choice
263 Initial Codes Focused Codes Selective Codes Counselor identity Making a life altering commitment Taking a stand on being present Valuing being present Being vulnerable Facing uncertainty Feeling difficult emotions Risking rejection Risking Risking transformation Scary to let go control Setting oneself apart from majority Balancing connection and protection Choosing to be present, not easy Weighing costs and benefits of being present Choosing with risk for the sake of connecting Choosing to be more present Going against the tide Reprioritizing Stepping out of normal way Stepping out of normal approach Being present takes practice Breathing to prepare to be present Caring for self Mindfulness meditation cultivating being present Not predominantly thinking Fostering, cultivating Preparing attitude and emotion Slowing down Supervision influencing being present
264 Initial Codes Focused Codes Selective Codes Disconnecting Judging Disconnecting Less available Containing anxiety feels safe Feeling safe Protecting as self care Staying with the familiar Missing healing opportunities Not acknowledging anxiety and uncertainty for client Missing therapeutic opportunities Not hearing, seeing, understanding Experiencing the Outcomes of Containing Anxiety and Uncertainty Not being authentic Not being authentic Staying in role, not genuine Avoiding is what is taught Socially Acceptable Easier to do/be what's expected Containing discomfort is understood by others Building relationship Connecting Hearing beyond words Amplifying Connection Heightening empathy Reciprocal influencing Caring emerging from being present Experiencing the Outcomes of Being Present Enabling keen application of counseling skills & knowledge Being Better Instrument of Therapeutic Process Parallel personal work with clients' work Using self as instrument Being able to stay with Gaining comfort with uncertainty Building tolerance for discomfort Relaxing with discomfort
265 Initial Codes Focused Codes Selective Codes Addressing what is in the moment Checking out assumptions in the moment Counseling in the present moment Using counselor reactions/emotions in the moment Counselor feeling at peace Natural Counselor feeling at peace Experiencing the Outcomes of Being Present cont. Not worrying, not scary Client's learning & benefitting from being present Expanding therapeutic value Facilitating therapeutic process Facilitating intensity Healing Making counseling enjoyable Energizing Sustaining counselor in work Sustaining
266 APPENDIX K SAMPLE MEMOS 7/4/2008. Levels of Presence; Being present has range and dimensions; See also Properties and processes I am beginning to construct multiple dimensions of being present from the data. The dimensions go horizontally and vertically. For instance the dimension of frequency, referring to frequency of being fully present could be a vertical dimension that intersects with the dimension of being present itself that spans from physically present (applying technique without connection) to fully present, which seems to be a horizontal dimension. Another vertical dimension is the layers of properties or aspects of present that come together in different ways to impact the character of that moment of being present. These layers might include awareness of countertransference, deep breathing, connecting to clients emotions, etc. Anxiety is on a dimension as well. Too much anxiety cant be prese nt. However, anxiety/tension is part of the picture when there is danger involved, like an adrenalin -laced presence. Calm and peaceful at the other end. Frequency Automatic mode to fully present Anxious to calm Quality of therapy 7/18/2008 Searching for the best word for this category Range: the extent to which or the limits between which variation is possible the extent or scope of the operation or action of something range. (n.d.). Dictionary.com Unabridged (v 1.1). Retrieved July 18, 2008, from Dictionary.com website: http://dictionary.reference.com/browse/range An area within which something or someone exists, acts, or has influence or power Synonyms: ambit, compass, extension, extent, orbit, purview, reach, realm, scope, sphere, sweep, swing.
267 Dimension: a property of space; extension in a given direction Level: an extent, measure, or degree of intensity, achievement, etc Range seems the best fit for this code or category. Being present has a range on a number of dimensions: duration, frequency, intensity/??? Frequency: rate of occurrence Duration: the length of time something continues or exists Aspect: nature; quality; character; a way in which a thing may be viewed or regarded; interpretation 7/19/2008 First point is that there is a range of being present, as we are always present to some extent (P 1). Being on automatic mode may be one end of the continuum (C 1, JJ -2). Applying technique in without connecting to the client (see Connecting) is closer to the automatic mode end of the continuum of presence. Being fully present is seen as a somewhat unattainable goal and requires all aspects of presence to come together at once. What people generally describe as being present i s somewhere on the continuum between these two extremes. While not saying exactly where they fall on the continuum, participants could identify some periods in which they were present. The extent of being present that qualifies in that way is not constant The frequency and duration of those periods fluctuates. Most participants agreed that being present to the extent that they would name the experience as such is a rare occurrence. 7/17/08 Theoretical Memo Connecting means joining or linking to some deg ree with oneself, with other people, and with the world around. Although used as synonyms for connecting, joining and linking do not fit as well in describing the experience. Joining and linking seem more fixed and less fluid than connecting. Like being present, there is a continuum of connection from less connected to more connected. However, unlike the continuum of being present, where there is no zero point unless
268 you are dead, and some might argue not even then, with connecting there is a zero point, a point where one is disconnected. One person noted that suicide is the ultimate act of disconnecting and feeling disconnected. The other end of the continuum is connecting at a spirit or energy level, beyond the confines of our constructed perception of the separation between people. I almost have a visualization of opening myself up and I think the reason why is almost kind of opening up my body is cause its kind of like lets get past this part, and lets get to the being part (C 1, 238) If you can actually be with someone, like your whole person with another whole person, um, that reduces that isolation and maybe helps them get more in touch with the deeper, more spiritual part of them (JS 1, 173) Definition: to join, link, or fasten togethe r; unite or bind 5. to associate mentally or emotionally. 10. Informal to relate to or be in harmony with another person, one's work, etc.: connect. (n.d.). Dictionary.com Unabridged (v 1.1) Retrieved July 17, 2008, from Dictionary.com website: http://dictionary.reference.com/browse/connect Random House. Did not include the informal definition.Since the Random House dictionary of 1973 did not include the informal definition, this meaning has come to be in the last thirty years, the lifetime of all of the participants. This is a notion that they have grown up understanding. Being present seems to be a prerequisite for being connected and the degree/level/intensity of each influences the ot her. Being present is a condition, an action and a consequence of connecting. Connecting is an action and a consequence of being present but is not possible without the condition of being present. In other words, I cannot connect with you if I am not pr esent and the degree of our connecting is influenced by the degree/level of my
269 presence and the degree/level of yours. Once the self -perpetuating interaction between being present and connected is set in motion, it is difficult to separate the two processe s and descriptions of them begin to resemble each other like two people who have lived together for a long time. Connecting is palpable, felt in the body, as well as in intangible ways that are sensed emotionally, energetically, or spiritually. I would just say just radiating from, um, from my face and, and my chest and radiating between us The way I could describe it I guess is wavelengths . I felt like we really, were really very much were matching wavelengths (A 1, 36) T he intensity of like that connection that was happening, and it was just, yeah, it was kind of like, it was, it was intense but neat that it was happening, cause I, it was almost kind of like, um, like invisible kind of things, you know, kind of going o n and, and, you know, pa rts of me kind of going out and parts of him going out and us meeting somewhere (C 1, 88) Connecting increases/deepens when people come together as whole people, as human beings, less so when people stay confined to their roles as counselor or client. Pa radoxically, as connecting increases/deepens the individual person becomes less important. Im genuinely being me, and I dont think Ive ever been really present with someone without feeling that natural like interconnectedness, like were kind of the s ame, you know, like were all of the same stuff (JS 3, 187) W hen youre connected on that level sometimes all those differences is not as relevant, or, I know its there, you know [Mhmm] still there, but its not as relevant, its just being human at that moment, two human beings exchanging um a moment uh or an emotion or something that can connect us in some way. (T 1, 379) N ot self conscious, like thats not where my thoughts are. And so much of the rest of the time they are. So its like minimizing the importance of self, seems to be part of the present. (JS 3, 208) As connection increases/deepens/intensifies (moves along the continuum) in counseling, people seem to feel a sense of belonging and safety that facilitates disclo sure, self acceptance, and the facing of difficulties personal experiences. Connecting in counseling gives people and
270 experience on which to draw in making connections in the rest of their lives. . and then with, having that connection and they rea lize that they can have that with others, well hopefully they realize they could have that with others. (A 1, 383) At the same time that being connected eases the confronting of personal difficulties, it also provides some distance from those difficulties in fulfilling basic human need that then reorganizes the priority of those difficulties. So its kind of like I feel like when you connect with another person, truly connect with them, its a reminder of, of whats important, its a reminder of, you kno w, like truth. (C 3, 137) Connecting, especially as you move along the continuum has the same paradoxical process or feelings associated with it as being present. And perhaps that is partly because the processes have merged at that point. The paradox i s that it is not easy, it involves risking vulnerability and loss of control, and yet it also brings a sense of peace and well being that is sustaining and not scary at all. Connecting requires two parties; it is connecting with. Connecting with some people in counseling is easier than connecting with others. Come emotions seem to facilitate connection. Both client and counselor vulnerability are conditions for connecting. Two parties create connection and also are influenced by that connection in counseling. It just feels, I mean, its almost kind of for me I feel a little bit like, you know, Im robbin a little bit, cause its not just a one way street, you know when youre fully, you know, Im getting something, and, you know, sometimes its hard w ith, but just feeling that true connection with another person I think is like really powerful and I think thats a great, um, I dont know, I think thats a great reward for me. And with other people, too. When I actually sit with somebody, Im like Wo w, we just had something that was true. Thats like so sustaining. And so, I think thats really big. (C 3, 130) In being present and connecting with the person in counseling, the counselor attunes to that person in a way that allows her to feel the cli ents emotions in heightened empathy and offer more accurate reflections to the client. The counselor is able to hear beyond the persons words
271 as well as communicate even in silence. The client feels validated and understood further building connection a nd the relationship. it produces that powerful connection, the feeling that the client says that oh wow, finally the cou nselor gets me, really gets me (A 1, 377) The client feels very understood by you, um, and feels comfortable in order to be much more honest with you then and um, yeah, to use I guess clinical knowledge, establishes rapport (A 1, 382) It is impossible to talk about connection between people without also talking about their relationship. sometimes I think that we both come ou t of the, the, well, most, many times I come out of a therapeutic relationship changed and, and the relationship stays with me (JJ 1, 235) the more that I can encourage the client to be present and the more Im able to be present and the more that were able to connect with one another, um, (3) the more beneficial I think that is for the therapeutic relationship (JJ 1, 156) Being present may be seen as a condition (following having been an action), connecting is a action the consequ ence of which is the building of a therapeutic relationship. The relationship becomes a condition for being present and connecting as well. This makes connecting part of another self -perpetuating process. The phenomenon of entrainment may help in descri bing the interplay among being present, connecting, and the relationship. Entrainment is a principle in physics and is defined as the synchronization of two or more rhythmic cycles. (http://www.transparentcorp.com/products/np/entrainment.php. Accessed 1/28/08) When in each others presence, pendulums come to synchronize with each other. There is some support for the idea that over time people synchronize with each other, with nature, with musical vibrations, and so on.
272 LIST OF REFERENCES Ackerman, S., & Hilsen roth, M. J. (2003). A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Review 23, 1 33. Ahn, H., & Wampold, B. E. (2001). W here oh where are the specific ingredients? A meta analysis of co mponent studies in counseling. Journal of Counseling Psychology, 48, 251258. Anderson, D. T. (2005). Empathy, psychotherapy integration, and meditation: A Buddhist contribution to the common factors movement. Journal of Humanistic Psychology, 45, 483502. Aronson, H. B. (2004). Buddhist practice on western ground: Reconciling eastern ideals and western psychology Boston: Shambhala. Arredondo, P., Toporek, R., Brown, S. P., Jones, J., Locke, D. C., Sanchez, J., & Stadler, H. (1996). Operationalization of the multicultural counseling competencies. Journal of Multicultural Counseling and Development 24, 42 78. Asay, T. P., & Lambert, M. J. (1999). The empirical case for the common factors in therapy: Quantitative findings. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The Heart and soul of change: What works in therapy (pp 3356). Washington, DC: American Psychological Association. Bachelor, A. (1995). Clients perception of the therapeutic alliance: A qualitative analysis. Journal of Counseling Psychology 42, 323337. Bachelor, A., & Horvath, A. (1999). The therapeutic relationship. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The Heart and soul of change: What works in therapy (pp 133178). Washington, DC: American Psychological Association. Bachelor, A., Laverdire, O., Gamache, D, & Bordeleau, V. (2007). Clients collaboration in therapy: Self perceptions and relationships with client psychological functioning, interpersonal relations, a nd motivation. Psychotherapy: Theory, Research, Practice, Training, 44, 175192. Bachelor, A., & Salam, R. (2000). Participants' p erceptions of dimensions of the therapeutic alliance o ver the c ourse of therapy. Psychotherapy Practice and Research, 9 39 5 3. Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125143. Bedi, R. P. (2006). Concept mapping the clients perspective on counseling alliance formation. Journal of Counseling Psychology, 53, 26 35. Beisser A. (2004). The paradoxical theory of change. International Gestalt Journal 27, 103107 (original work published 1970).
273 Benish, S G. Imel, Z E. & Wampold, B E. (2008). The relative efficacy of bona fide psychotherapies for treating post traumatic stress disorder: A meta analysis of direct comparisons Clinical Psychology Review 28, 746758. Berger, T. (2004). Computer -based technological applications in psychotherapy training. Journal of Clinic al Psychology, 60, 301215. Bergin, A. E., & Garfield, S. L. (1994). Handbook of psychotherapy and behavior change (4th Ed). New York: John Wiley & Sons, Inc. Beutler, L. E., Machado, P. P. P., & Neufeldt, S. A. (1994). Therapist variables. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 229269). New York: John Wiley. Bohart, A. C., & Tallman, K. (1999). How clients make therapy work. Washington, DC: American Psychological Association. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice 16, 252260. Brown, J. (1997). Researcher as instrument. Gestalt Review 1 71 84. Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well -being. Journal of Personality and Social Psychology 84, 822 848 Bryant, A. (2002). Regrounding grounded theory. Journal of Information Technology Theory and Application, 4, 2542. Bryant, A., & Charmaz, K. (Eds.) (2007). The SAGE handbook of grounded theory. Los Angeles, CA: SAGE Publications. Bryceland C., & Henderikus S. J. (2005). E mpirical validation and professional codes of ethics: D escription or prescription? Journal of Constructivist Psychology, 18, 131 155. Bruce, A., & Davies, B. (2005). Mindfulness in hospice care: Practicing mindfulness in action. Qualitative Health Research 15, 13291344. Buber, M. (1970). I and thou. (W. Kaufman, Trans.) New York: Charl es Scribners Sons. Bugental, J. F. T. (1987). The art of the psychotherapist. New York: W. W. Norton & Company. Cameron, J. (1992). The artists way: A spiritual path to higher creativity New York: G. P. Putnams Sons Publishers. Charmaz, K. (2000). Gro unded theory: Objectivist and constructivist methods. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of Qualitative Research, (2nd e d ., pp. 509 535). Thousand Oaks, CA: SAGE Publications.
274 Charmaz, K. (2005). Grounded theory in the 21st century: Applications for advancing social justice studies. In N. K. Denzin & Y. S. Lincoln (Eds.), SAGE Handbook of Qualitative Research (pp. 507 535). Thousand Oaks, CA: SAGE Publications. Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis Thousand Oaks, CA: SAGE Publications. Charmaz, K. (2008). Grounded theory as an emergent method. In S. N Hesse Biber & P. Leavy (Eds.) Handbook of emergent methods (pp. 155 170). New York, NY: Guilford Press. Chiari, G., & Nuzzo, M. L. (1996). Psychological constructivisms: A metatheoretical differentiation. Journal of Constructivist Psychology 9 163184. Chodron, P. (1994). Start where you are: A guide to compassionate living. Boston, MA: Shambhala Publications. Chr istopher, J. C., Christopher, S. E., Dunnagan T., & Schure M. (2006). Teaching self -care through mindfulness practices: T he application of yoga, meditation, and qigong to counselor training. Journal of Humanistic Psychology 46, 494509. Clarke, A. E. (2 003). Situational analyses: Grounded theory mapping after the postmodern turn. Symbolic Interaction, 26, 553 576. Clemence, A. J., Hilsenroth, M. J., Ackerman, S. J., Strassle, C. G., & Handler, L. (2005). Facets of the therapeutic alliance and perceived progress in psychotherapy: Relationship between patient and therapist perspectives. Clinical Psychology and Psychotherapy, 12, 443454. Coar, L., & Sim, J. (2006). Interviewing ones peers: M ethodological issues in a study of health professionals Scandinavian Journal of Primary Health Care 24, 251256. Creswell, J. W. & Miller, D. L. (2000). Determining validity in qualitative inquiry. Theory into Practice, 39, 124130. Crotty, M. ( 1998). The foundations of social research: Meaning and perspective in the research process. Thousand Oaks, CA: SAGE Publications. Crits Christoph, P., Connoly Gibbons M. B., & H earon B. (2006). Does the alliance cause good outcome?: Recommendations for future research on the alliance. Psychotherapy: Theory, Research, Practice, Training, 43, 280 285. Csikszentmihalyi, M. (1997). Finding f low: The psychology of engagement with everyday life. New York: Basic Books. Curry, D. (2003) Healing presence: Experiencing the medicine of the naturopathic relationship. An organic in quiry. (Doctoral dissertation, Saybrook Graduate School and Research Center. 2003) Retrieved December 11, 2008, from Dissertations & Theses: Full Text database.
275 Damasio, A. R. (1999). The Feeling of What Happens New York: Harcourt Brace. Denzin, N. (2007). Grounded theory and the politics of interpretation. In: A. Bryant & K. Charmaz (Eds.) The SAGE handbook of grounded theory (pp. 454 471) Lo ndon : SAGE Publications. Denzin, N. K., & Lincoln, Y. S. (Eds.). (1994). The handbook of qualitative researc h Thousand Oaks, CA: Sage Publications. Denzin, N. K., & Lincoln, Y. S. (Eds.). (2000). The handbook of qualitative researc h (2nd ed). Thousand Oaks, CA: Sage Publications. Denzin, N. K., & Lincoln, Y. S. (Eds.). (2005). The SAGE handbook of qualitative rese arch (3rd ed.). Thousand Oaks, CA: Sage Publications. Dimidjian S. & Linehan M. M. (2003). Defining an agenda for future research on the clinical application of mindfulness practice Clinical Psychology: Science and Practice, 10, 166171. Dunkle, J. H., & Friedlander, M. L. (1996). Contribution of therapist experience and personal characteristics to the working alliance. Journal of Counseling Psychology, 43 456460. Eisner, E. W. (2003). On the art and science of qualitative research in psychology. In P. M. Camic, J. E. Rhodes, & L. Yardley (Eds.), Qualitative research in psychology: expanding perspectives in methodology and design (pp. 17 30). Washington, DC: American Psychological Association. Elvins, R. & Green, J. (2008). The conceptualization and mea surement of therapeutic alliance: An empirical review, Clinical Psychology Review 28, 1167 1187. Fauth, J., & Nutt Williams, E. (2005). The in -session self awareness of therapist -trainees: Hindering or helpful? Journal of Counseling Psychology 52, 443447. Fitzpatrick, M R. Iwakabe, S ., & Stalikas, A (2005). Perspective divergence in the working alliance Psychotherapy Research Special issue: The Therapeutic Relationship. 15, 69 79. Fong, M. L. (1998). Considerations of a counseling pedagogy Co unselor Education and Supervision, 38, 106112. Fraelich, C. B. 1989). A phenomenological investigation of the therapists experience of presence. Dissertation Abstracts International, 50(4B), pp. 1643. (UMI No. 8904935). Freud, S. (1961). Recommendations to physicians practicing psychoanalysis. In J. Strachey (Ed. And Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 21). London: Hogarth Press. (original work published 1912).
276 Fulton, P. R. (2005). Mindfulness as clinical training. In C. K. Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mindfulness and psychotherapy (pp. 55 72). New York: The Guilford Press. Fulton, P.R. & Siegel, R. D. (2005). Buddhist and western psychology. In C. K. Germer, R. D. Siegel, & P. R. Fulto n (Eds.), Mindfulness and psychotherapy (pp. 28 51). New York: The Guilford Press. Gaston, L. & Marmar, C. R. (1994). The California Psychotherapy Alliance Scales. In A. O. Horvath and L. S. Greenberg (Eds.), The Working Alliance (85 108), New York: John Wiley & Sons, Inc. Gay, L. R. & Airasian, P. (2003). Educational research: Competencies for analysis and applications. Upper Saddle River, NJ: Pearson Education, Inc. Gelatt, H. B. (1995). Chaos and compassion. Journal of Counseli ng and Values, 39, 108117. Geller, S. M. (2001). Therapists presence: The development of a model and a measure (Doctoral dissertation. York University, 2001). Dissertation Abstracts, 63(2-B), 1025. Geller, S. M. (2003). Becoming whole. Journal of Person-centered and Experiential Psychotherapies, 1 -4 258273. Geller, S. M., & Greenberg, L. S. (2002). Therapists experience of presence in the psychotherapy encounter. Person -centered and Experiential Psychotherapies, 1/1&2 Gelso, C. J., & Carter, J. A. (1 985). The relationship in counseling and psychotherapy: components, consequences, and theoretical antecedents, The Counseling Psychologist, 13, 155244. Gelso, C. J., & Carter, J. A. (1994). Components of the psychotherapy relationship: Their interaction and unfolding during treatment. Journal of Counseling Psychology, 41, 296306. Gelso, C. J., Kelley, F. A., Fuertes, J. N., Marmarosh, C., Holmes, S. E., Costa, C. & Hancock, G. R. (2005). Measuring the real relationship in psychotherapy: Initial validation of the therapist form. Journal of Counseling Psychology 52, 640649. Glaser, B. G. (1978). Theoretical sensitivity. Mill Valley, CA: The Sociology Press. Glaser, B. G. & Strauss, A. L. (1967). The discovery of grounded theory. Chicago, IL: Aldine Publishing Company. Gleick, J. (1987). Chaos: Making a new science New York: Penguin Books. Glesne, C. (1999). Becoming qualitative researchers: An introduction. New York : Longman.
277 Goh, M. (2005). Cultural competence and master therapists. Journal of Mental Health Counseling, 27, 71 81. Gold, E. K. & Zahm, S. G. (2008). Gestalt therapy. In M. Hersen & A. M. Gross (Eds.), Handbook of clinical psychology (Vol. 1) (pp. 585616). Hoboken, NJ: John Wiley & Sons. Goodyear, R. K., Wertheimer, A., Cypers, S., & Rosemond, M. (2003). Refining the map of the counselor development journey: Response to Ronnestad and Skovholt. Journal of Career Development 30, 73 80. Greckhamer, T. & Koro -Ljungberg, M. (2005). The erosion of a method: Examples from grounded theory. International Journal of Qualitative Studies in Education, 18, 729750. Grepmair, L. Mitterlehner, F., Loew, T., & Nickel, M. (2007) Promotion of mindfulness in psychotherapists in training: Preliminary study. European Psychiatry 22, 485489. Grunebaum, H. (1986). Harmful psychotherapy experience. American Journal of Psychotherapy XL 165176 Guba, E. G., & Lincoln, Y. S. (1994). Competing paradigms in qualitative research. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of quali tative research (pp. 105 117). Thousand Oaks, CA: SAGE Publications. Hanh, T. N. (Speaker). (1990). Mindfulness and psychotherapy. (Cassette Recording). Boulder, Colorado: Sounds True. Hatch, J. A. (2002). Doing qualitative research in educational settings. Albany: State University of New York Press. Hatcher, R. L., & Barends, A. W. (1996). Patients view of the alliance in psychotherapy: Exploratory factor analysis of three alliance measures. Journal of consulting and clinical psychology 64, 13261336. Hayes, R. L. & Oppenheim, R. (1997). Constructivism: Reality is what you make it. In T. L. Sexton & B. L. Griffin (Eds.), Constructivist thinking in counseling practice, research and training (19 40). New York: Teachers College, Columbia University. Hayes, S. C., Strosah l L., & Wilson, K. G. (1999). Acceptance and commitment therapy. New York: Guilford Press. Hill, C. E., Charles, D., & Reed, K. G. (1981). A longitudinal analysis of changes in counseling skills during doctoral training in counseli ng psychology. Journal of Counseling Psychology 28, 428436. Hilsenroth, M. J. & Cromer, T. D. (2007). Clinician interventions related to alliance during the initial interview and psychological assessment Psychotherapy: Theory, Research & Practice 44, 205218.
278 Hogan, R. A. (1964). Issues and approaches in supervision. Psychotherapy: Theory, Research, and Practice, 1 139141. Hollomon, D. (2000). The I of the therapist: Eastern mindfulness and the skillful use of self in psychotherapy. (Doctoral disse rtation, The Union Institute, 2000) D issertation Abstracts International, 61(6 B), 3279. Holton, J. A. (2007). The coding process and its challenges. In K. Charmaz & A. Bryant (Eds.) The SAGE handbook of grounded theory. (pp. 265290). Los Angeles, CA: SAGE Publications. Horvath, A. O. (1994). Research on Alliance. In A. O. Horvath & L. S. Greenberg (Eds.), The Working Alliance (259286). New York: John Wiley & Sons. Horvath, A. O. (2005). The therapeutic relationship: Research and Theory. Introduction to the Special Issue. Psychotherapy Research, 15, 3 7. Horvath, A. O. (2006). The alliance in context: Accomplishments, challenges, and future directions. Psychotherapy: Theory, Research, Practice, Training, 43, 258263. Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the working alliance inventory. Journal of Counseling Psychology, 36, 223233. Horvath, A. O., & Luborsky, L. (1993). The role of t he therapeutic alliance in psychotherapy. Journal of Consulting and Clinical Psychology, 61, 561573. Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta analysis Journal of Counseling Psychology, 38, 139 149. Hoskins, M. (2002). Towards new methodologies for constructivist research: Synthesizing knowledges for relational inquiries. In J. D. Raskin & S. K. Bridges (Eds.), Studies in Meaning: Exploring Constructivist Psychology (pp. 225244). New Yo rk: Pace University Press. Hubble, Duncan, & Miller (1999) The heart and soul of change : What works in therapy. Washington, DC: American Psychological Association. Hycner, R. (1991). Between person and person: Toward a dialogical psychotherapy Highland, NY: The Gestalt Journal Press, Inc. Jennings, L., Goh, M., Skovholt, T. M, Hanson, M., & Banerjee Stevens, D. (2003). Multiple factors in the development of the expert counselor and t herapist Journal of Career Development 30, 59 72. Jennings, L., Sovereign, A., Bottorff, N., Mussell, M. P., & Vye, C. (2005). Nine ethical values of master therapists, Journal of Mental Health Counseling, 27, 32 47.
279 Jonas, W. B., & Crawford, C. C. (2004). The healing presence: Can it be reliably measured? Journal of Alternative and Complementary Medicine, 10, 751756. Kabat Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and Ill ness. New York: Dell Publishing Kabat Zinn, J. (2003). M indfulness -based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10, 144156. Kabat Zinn, J., Lipworth, L., Burney, R., & Sellers, W. (1987). Four year follow up of a meditation based program for the self -regulation of chronic pain: Treatment outcomes and compliance. Clinical Journal of Pain, 2 159 173. Kabat Zinn, J., Massion, A. O., Hebert, J. R., & Rosenbaum, E. (2002). Meditation. In Tagliaferri, Co hen, Tripathy (Eds.), Breast Cancer: Beyond Convention (pp. 284 314). New York: Simon & Schuster. Kabat Zinn, J., Massion, M. D., Kristeller, J., Peterson, L. G., Fletcher, K. E., Pbert, L., et al. (1992). Effectiveness of a meditation -based stress reducti on program in the treatment of anxiety disorders. American Journal of Psychiatry 149, 936 943. Kelle, Udo (2007). The development of categories: Different approaches in grounded theory. In K. Charmaz & A. Bryant (Eds.) The SAGE handbook of grounded theory (pp. 191 213). L ondon : SAGE Publications. Khalsa, D. S. (2001). Meditation as medicine: Activate the power of your natural healing force New York: Fireside. Kincheloe, J. L. (2005). Critical constructivism: Primer New York: Peter Lang Publishing, Inc. Kokinakis, C. L. (1995). Teaching professional standards: Training yoga therapists in loving presence. (Doctoral dissertation, Michigan State University, 1995). Retrieved December 11, 2008, from Dissertations & Theses: Full Text database. Korb, M. P (1988). The numinous ground: I -thou in gestalt work. The Gestalt Journal, XI, 97106. Korb, M. P., Gorrell, J., & Van De Riet, V. (2002). Gestalt therapy: Practice and theory, (2nd e d ). Highland, New York: The Gestalt Journal Press, Inc. Kraus, M. S., Lutz, W., & Saunders, S.M. (2007). Empirically certified treatments or therapists: The issue of separability. Psychotherapy : Theory, Research, Practice, and Training, 44, 347353. Kristeller, J. L., & Hallett, C. B. (1999). An exploratory study of a medita tion based intervention for binge eating disorder. Journal of Health Psychology 4 357 363.
280 Kurash, C. & Schaul, J. (2005). Integrating mindfulness meditation within a university counseling center setting. Journal of College Student Psychotherapy, 20, 53 67. Kuzel, A. J. (1992). Sampling in qualitative inquiry. In B. F. Crabtree & W. L. Miller (Eds.), Doing Qualitative Research (pp. 31 44). Newbury Park, CA: Sage Publications. Lakoff, G. & Johnson, M. (1999). Philosophy in the flesh: The embodied mind and its challenge to western thought New York: Basic Books. Lambert, M. J. (1992). Implications of outcome research for psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (p p 94 129). New York: Basic Books. Lambert, M. J., & Bergin, A. E. (1994). The effectiveness of psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook Of Psychotherapy And Behavior Change (143 189). New York: John Wiley & Sons, Inc. Lambert, M J. & Cattani Thompson, K (1996). Current findings regarding the effectiveness of counseling: I mplications for practice. Journal of Counseling & Development, 74, 601608. Levine, S. (1979). A gradual awakening. New York: Anchor Books. Lincoln, Y. S. & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills, CA: SAGE Publications. Linehan, M. M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press. Loganbill, C., Hardy, E., & Delworth, U. (1982). Supervision: A c onceptual model. The Counseling Psychologist 10, 3 42. Luborsky, L. (1976). Helping alliances in psychotherapy. In J. L. Claghorn, (Ed.), Successful psychotherapy: Proceedings of the ninth annual symposium, November 19-21, 1975, Texas Research Institute of Mental Sciences (pp 92 116). New York: Brunner/Mazel. Marcus, S. & Dubi, M. (2006). The relationship between resilience and compassion fatigue in counselors In G. R. Walz, J. D., & Bleuer, R. K. Yep (Eds.), Vistas: Compelling perspectives on counsel ing 2006 (pp. 223225), Alexandria, VA: American Counseling Association. Marrone, R. L. (1990). Body of knowledge: An introduction to body/mind psychology Albany, NY: State University of New York Press. Martin, D. J., Garske, J. P., & Davis, M. K. (2000 ). Relation of therapeutic alliance with outcome and other variables: A meta analytic review. Journal of consulting and clinical psychology 68, 438450.
281 May, R. (1958). Origins of the existential movement in psychology. In R. May, E. Angel, & H. F. Ellenb erger (Eds.), Existence: A new dimension in psychiatry and psychology (pp. 3 36). New York: Basic Books. May, R. (1958). Contributions of existential psychotherapy. In R. May, E. Angel, & H. F. Ellenberger (Eds.), Existence: A new dimension in psychiatry and psychology (pp. 37 91) New York: Basic Books. May, R. (1989). The art of counseling. New York: Gardner Press. McAuliffe, G. J. (2002). Student changes, program influences, and adult development in one program of counselor training: An exploratory ind uctive inquiry. Journal of Adult Development 9 205216. McAuliffe, G. J. & Eriksen, K. (2000). Preparing counselors and therapists: Creating constructivist and developmental programs. Virginia Beach: The Donning Company/Publishers. McDonough -Means, S. I., Kreitzer, M. J., & Bell, I. R. (2004). Fostering a healing presence and investigating its mediators. Journal of Alternative and Complementary Medicine, 10, S25 41. Miller, M. V. (2002). The aesthetics of commitment: What gestalt therapists can learn from Cezanne and Miles Davis. International Gestalt Journal, 25, 109122. Morgan, W. D., & Morgan, S. T. (2005). Cultivating attention and empathy. In C. K. Germer, R.D. Siegel, & P. R. Fulton (Eds.), Mindfulness and psychotherapy (pp. 7 5 -90). New York: The Guilford Press. Moustakas, C. (1994). Phenomenological research methods. Thousand Oaks, CA: SAGE Publications. Mruck, K. & Mey, G. (2007). Grounded theory reflexivity. In A. Bryant & K. Charmaz (Eds.) The SAGE Handbook of Grounded The ory (pp. 515538). London: SAGE Publication.s Najavits, L. M., & Strupp, H. H. (1994). Differences in the effectiveness of psychodynamic therapists: A process outcome study. Psychotherapy 31, 114 123. Naranjo, C. (1993). Gestalt therapy: The attitude and practice of an atheoretical experientialism. Nevada City: Gateways/IDHHB Publishing. Neimeyer, R. A. (1993). An appraisal of constructivist psychotherapies. Journal of Consulting and Clinical Psychology, 61, 221234. Norcross, J. C. (Ed). (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients New York: Oxford University Press.
282 Norcross, J. C. (2005). The p sychotherapists o wn p sychotherapy: Educating and developing p sychologists American Psychologist 60, 840850. Norcross, J. C., Beutler, L. E., & Levant, R. F. (Eds.) (2006). Evidence-based practices in mental health: Debate and dialogue on the fundamental questions Washington, DC: American Psychological Association. Nuetzel, E. J., Larsen, R. J., Prizmic, Z. (2007). The dynamics of empirically derived factors in the therapeutic relationship. Journal of the American Psychoanalytic Association, 55, 13211353. Ogles, B. M., Anderson, T., & Lunnan, K. M. (1999). The contribution of models and technique s to therapeutic efficacy: Contradictions between professional trends and clinical research. In M. A. Hubble, B. L. Duncan, and S. D. Miller (Eds.). Heart and Soul of Change Washington, DC: American Psychological Association. Orlinsky, D., Ambuhl, H., Bot ermans, J., Davis, J., Ronnestad, M. H., Willutski, U., Cierpka, M., & Davis, M. (1999). Psychotherapists' assessments of their development at different career levels. Psychotherapy, 36, 203215. Osterman, P. & Schwartz Barcott, D. (1996) Presence: Four w ays of being there. Nursing Forum 31/2, 23 31. Patton, M. Q. (1990). Qualitative research and evaluation methods. Thousand Oaks, CA: SAGE Publications. Pemberton, B. K. (1977). The presence of the therapist. (Doctoral dissertation, Georgia State University, 1976). Dissertation Abstracts International 38, 373374. Perls, L. (1978/1992). Concepts and misconceptions of Gestalt therapy Voices: The Art and S cience of Psychotherapy, 14/3. Reprinted in Journal of Humanistic Psychology, 32, 50 56. Perls, F., Hefferline, R., & Goodman, P. (1951/1994) Gestalt Therapy: Excitement and Growth in the Human Personality Highland, New York: The Gestalt Journal Press. Phelon, C. R. (2001). Healing presence: An intuitive inquiry into the presence of the psychotherapist. (Doctoral dissertation, Institute of Transpersonal Psychology, 2001). Dissertation Abstracts International 62(4B), 2074. Piers, C. (2005). The minds multiplicity and continuity. Psychoanalytic Dialogues, 15, 229254. Random House d ictionary of the English l anguage (The Unabridged Edition). (1973). New York: Random House. Raskin, J. D. (2002). Constructivism in psychology: Personal construct psychology, radical constructivism, and social constructivism. In J. D. Raskin & S. K. Bridges (Eds.) Studies
283 in Meaning: Exploring Constructivist Psychology (pp. 1-15). New York: Pace University Press. Reik, T. (1948). Listening with the third ear. New York: Farrar, Straus and Company. Reising, G. N. & Daniels, M. H. (1983). A study of H ogan's model of counselor development and supervision Journal of Counseling Psychology 30, 235 244. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology 21, 95 103. Rogers, C. R. (1961). On becoming a person. Boston: Houghton -Mifflin. Rogers, C. R. (1989). Client -centered therapy. In H. Kirschenbaum & Henderson, V. L. (Eds.), Carl Rogers : Dialogues (9 40). Boston: Houghton Mifflin Company. Ronnestad M. H. & Skovholt T. M. (1993). Supervision of beginning and advanced graduate students of counseling and psychotherapy. Journal of Counseling & Development 71, 396405. Ronnestad, M. H., & Skovholt, T. M. (2003). The journey of the counselor and therapist: Research findings and perspectives on professional development. Journal of Career Development 30, 5 44. Rosenfeld, E., & Wysong, J. (1982). An oral history of Gestalt Therapy : Interviews with Laura Perls, Isadore From, Erving Polster, and Miriam Polster. Highland, NY: The Gestalt Journal. Rothschild, B. (2006). Help for the helper: The psychophysiology of compassion fatigue and vicarious trauma. New York, NY: W. W. Norton & C o. Santorelli, S. F. & Kabat -Zinn, J. (Eds.) (2003). Mindfulness -based stress reduction professional training resource manual: Integrating mindfulness meditation into medicine and health care. Wooster, MA: Center for Mindfulness in Medicine, Health Care, and Society. Saunders, S M. Howard, K. I & Orlinsky, D E. (1989). The Therapeutic Bond Scales: Psychometric characteristics and relationship to treatment effectiveness. Psychological Assessment 1, 323330. Scanlon, C. & Baillie, A. P. (1994). A prep aration for practice? Students experiences of counseling training within departments of higher education. Counselling Psychology Quarterly 7/4 Schon, D. A. (1983). The reflective practitioner. New York: Basic Books. Schon, D. A. (1987). Educating the ref lective practitioner San Francisco: JosseyBass
284 Schwandt, T. A. (2000). Three epistemological stances for qualitative inquiry: Interpretivism, hermeneutics, and social constructionism. In N. K. Denzin & Y. S. Lincoln (Eds.), The handbook of qualitative researc h (2nd ed.). Thousand Oaks, CA: Sage Publications. Segal, Z. V., Williams, J. J. G., & Teasdale, J. D. (2002). Mindfulness -based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press. Seligman, M. (1995). T he effectiveness of psychotherapy: The Consumer Reports Study. American Psychologist 50, 965974. Senge, P., Scharmer, C. O., Jaworski, J., & Flowers, B. S. (2005). Presence: An exploration of profound change in people, organizations, and society. New Yor k: Currency/Doubleday. Sexton, H., Littauer, H., Sexton, A., & Tommeras, E. (2005). Building an alliance: Early therapy process and the client therapist connection. Psychotherapy Research, 15, 103116. Sexton, T. L. (1997). Constructivist thinking within t he history of ideas: The challenge of a new paradigm. In T. L. Sexton & B. L. Griffin (Eds.), Constructivist thinking in counseling practice, research and training (3 17). New York: Teachers College, Columbia University. Shapiro, S., Brown, K. W., & Biegel G. M. (2007). Teaching self -care to caregivers: E ffects of mindfulness -based stress reduction on the mental health of therapists in training Training and Education in Professional Psychology 1 105115. Shapiro, S. L., Schwartz, G. E., & Bonner, G. (19 98). Effects of mindfulness -based stress reduction on medical and premedical students. Journal of Behavioral Medicine 21, 581 599. Silver, J. (Producer), Wachowski A. & Wachowski L. (Writers/Directors) (1999). The matrix [Motion picture]. United States: Warner Brothers. Skovholt, T. M. (2001). The resilient practitioner: Burnout prevention and self -care strategies for counselors, therapists, teachers, and health professionals Needham Heights, MA: Allyn & Bacon. Skovholt, T. M., Hanson, M., Jennings, L., & Grier, T. (2004). Expertise in therapy and counseling. In T. M. Skovholt & L. Jennings (Eds.), Master therapist: Exploring expertise in therapy and counseling (17 30) Needham Heights, MA, US: Allyn & Bacon. Skovholt, T. M. & Jennings, L. (Eds.) (2004). Master therapist: Exploring expertise in therapy and counseling. Needham Heights, MA, US: Allyn & Bacon. Skovholt, T. M. & Jennings, L. (2005). Mastery and expertise in counseling. Journal of Mental Health Counseling, 27, 13 18.
285 Skovhol t, T. M., Jennings, L., & Mullenbach, M. (2004). Portrait of the master therapist: Developmental model of the highly-functioning self. In T. M. Skovholt & L. Jennings (Eds.), Master therapist: Exploring expertise in therapy and counseling (125 146) Needh am Heights, MA, US: Allyn & Bacon. Skovholt T. M., Ronnestad, M. H. (1992). Themes in therapist and counselor development. Journal of Counseling & Development 70, 505515. Stanley, S., Reitzel, L. R., Wingate, L. R., Cukrowicz, K. C., Lima, E. N., & Joiner, T. E. (2006). Mindfulness: A primrose path for therapists using manualized treatments? Journal of Cognitive Psychotherapy: An International Quarterly, 20, 327335. Stern, D. N. (2004). The present moment: In psychotherapy and everyday life. New Yo rk: W. W. Norton & Company. Stevens, C. L., Muran, J. C., Safran, J. D., Gorman, B. S., & W inston, A. (2007). Levels and patterns of the therapeutic alliance in brief psychotherapy American Journal o f Psychotherapy 61, 109129. Stoltenberg, C. D. (1981). Approaching supervision from a developmental perspective: The counselor complexity model. Journal of Counseling Psychology 28, 59 65. Stoltenberg, C. D. & Delworth, U. (1985). Supervisees Perceptions of Their Development: A test of the counselor complexity model. Journal of Counseling Psychology 32, 630633. Stoltenberg, C. D., McNeill, B., & Delworth, U. (1998). IDM supervision: An integrated developmental model for supervising counselors and therapists. San Francisco: Jos sey Bass Publishers. Strauss, A. & Corbin, J. (1998). Basics of qualitative research Thousand Oaks, CA: SAGE Publications. Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. J ournal of Counseling & Development, 70, 477483. Sullivan, M. F., Skovholt, T. M., & Jennings, L. (2005). Master therapists construction of the therapy relationship. Journal of Mental Health Counseling, 27, 48 70. Suzuki, S (1973). Zen mind, beginners mind New York: John Weatherhill, Inc Takuya, M., Wampold, B. E., Serlin, R. C., Hamilton, E. G., Brown, G. S. & Kircher, J. C. (2008). Benchmarking the effectiveness of psychotherapy treatment for adult depression in a managed care environment: A prelim inary study Journal of Consulting and Clinical Psychology 76, 116124. Teasdale, J. D., Williams, J. M., Soulsby, J. M., Segal, Z. V., Ridgeway, V. A., & Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by mindfulness -based cogniti ve therapy. Journal of Consulting and Clinical Psychology 68, 615 623.
286 Thomson, R. F. (2000). Z azen and psychotherapeutic presence American Journal of Psychotherapy 54, 531548. Tryon, G. S., Blackwell, S. C., & Hammel, E. F. (2007). A meta analytic exa mination of client therapist perspectives of the working alliance. Psychotherapy Research 17, 629642. Twemlow, S. W. (2001). Training psychotherapists in attributes of mind from Zen and psychoanalytic perspectives, Part II: Attention, here and now, nonattachment, and compassion. American Journal of Psychotherapy 55, 22 39. Valentine, E. R., & Sweet, P. L. G. ( 1999). Meditation and attention: a comparison of the effects of concentrative and mindfulness meditation on sustained attention Mental Health, Religion & Culture 2 59 70. Vocisano, C., Klein, D. F., Arnow, B., Rivera, C., Blalock, J., Rothbaum, B., et al. (2004). Therapist variables that predict symptom change in psychotherapy with chronically depressed outpatients. Psychotherapy: Theory, Res earch, Practice, Training, 41, 255265 Wampold, B. E., Mondlin, G. W., Moody, M., Stich, F., Benson, K., & Ahn, H. (1997). A meta analysis of outcome studies comparing bona fide psychotherapies: Empirically, all must have prizes. Psychological Bulletin 122, 203215. Ward, C. C,. & House, R. M. (1998). Counseling supervision: A reflective model. Counselor Education & Supervision, 38, 23 34. Watson, J. C., & Geller, S. M. (2005). The relation among relationship conditions, working alliance, and outcome in both process -experiential and cognitive -behavioral psychotherapy. Psychotherapy Research, 15, 25 33. Welwood, J. (2000). Toward a psychology of awakening: Buddhism, psychotherapy, and the path of personal and spiritual transformation. Boston: Shambhala. Wertz, F. J., & Aanstoos, C. (1999). Amedeo Giorgi and the project of a human science. In: D. Moss (Ed.) Humanistic and transpersonal psychology (287300). Westport, Connecticut: Greenwood Press. Wexler, J. (2006). The relationship between therapist mindfulness and the therapeutic alliance (Doctoral dissertation, Massachusetts School of Professional Psychology, 2006). Dissertation Abstracts International 67, 2848. Wiley, M. O. & Ray, P. B. (1986). Counseling supervision by developmental level. Journal of Counseling Psychology, 4 439445. Worthington, E. L., Jr. (2006). Changes in supervision as counselors and supervisors gain experience: A review. Training and Education in Professional Psychology, 5 133160. Yalom, I. D. (1980). Existential psychotherapy. New York: Basic Books.
287 Yalom, I. D. (2002). The gift of therapy: An open letter to a new generation of therapists and their patients New York: Harper Collins. Yontef, G. (1989). Gestalt therapy. In R. J. Corsini & D. Wedding (Eds.), Curren t psychotherapies (4th ed.). Itasca, Illinois: F.E. Peacock Publishers. Yontef, G. (1995). Gestalt therapy. In A. S. Gurman, & S. B. Messer, (Ed), Essential psychotherapies: Theory and practice (pp. 261303). New York, NY: Guilford Press. Yontef, G. (2002). The relational attitude in Gestalt therapy theory and practice. International Gestalt Journal 25, 15 35. Yontef, G. (2007). The power of the immediate moment in Gestalt therapy. Journal of Contemporary Psychotherapy, 37, 17 23. Zukav, G. (1979). The d ancing Wu Li masters: An overview of the new physics New York: William Morrow and Company, Inc. Zuroff, D. C., & Blatt, S. J. (2006). The therapeutic relationship in brief treatment of depression: Contributions to clinical improvement and enhanced adaptive capacities. Journal of Consulting and Clinical Psychology 74, 130140.
288 BIOGRAPHICAL SKETCH Christina Tina Anne Tannen grew up in Miami, Florida She spent her first year of college at Oberlin College in Ohio. T he cold winter sent her back to Florida where she graduated from Eckerd College with a Bachelor of Arts degree in psychology in 1974. Following her variety of curiosities and responding to unpredictable life events led Tina to several careers over her adult life. In 1980, Tina received a Master of Arts in c ommunity arts m anagement from the University of Illinois at Springfield S he then became the Managing Director of the Hippodrome State Theater in Gainesville, Florida. From 19842005 Tina codirected a summer camp for adolescents in Plymouth, Vermont whi ch allowed her to spend the summers outdoors in the mountai ns with her family and 100 other adventurous and creative people of all ages During those 22 years Tinas other career was raising her three children. Tinas first child was diagnosed with autism which also launched Tina on a self -directed study of the autism spec trum disorder. She worked for a short time as a parent advocate and support person for the Center for Autism and Related Disabilities at the University of Florida. Tinas second child was born prematurely which led to Tinas work as Parent Supp ort Coordinator for the neonatal intensive care unit at Shands Hospital in Gainesville, Florida. F inally, Tina chose counseling as the career to take her through the last chapter in her professional life in honor of her lifelong fascination with how people grow and change She earned a masters/s pecialist degree in mental health counseling from the Department of Counselor Education at the University of Florida in 2005. In addition to the requirements of her academic program, Tina pursued additional clinical training and completed professional training in Gestalt therapy at the Gestalt Center of Gainesville. She is a National Certified Counselor and a Registered Mental Health Counseling Intern working toward licensure in the State of Florida. Her special interests
289 include training and development of counselors, Gestalt therapy approaches to change, and mindfulness meditation as clinical training as well as clinical intervention.