Utilization of Presence Awareness in Trauma Therapy

: Trauma can result in many long-term symptoms including emotional dysregulation, depression, addiction, and PTSD. When triggered by trauma, patients typically experience the world through a myopic lens. Helping clients observe and sense their trauma sequelae in the broader sensory awareness of Presence appears to help clients more easily process and resolve traumatic experience. The Presence Psychotherapy Trauma Protocol (PPTP) provides speciﬁc open-ended questions in session to help clients orient to Presence Awareness which can then be utilized to resolve trauma. Options to help clients sense their traumatic experience in the expansive awareness of Grounded Presence, Spacious Presence, Relational Presence, or Transcendent Presence create multiple regulating, processing, and attachment healing opportunities. PPTP’s concept of Reﬂective View is introduced which provides the clinician with prompts to help the client identify who they are as Presence Awareness early in session. This paper demonstrates, through a case example, how Presence Awareness and speciﬁcally Reﬂective View help clients access, tolerate, and process trauma in a broader sense of Presence Awareness.


Introduction
Psychological trauma can negatively affect physical health [1] and emotional health leading to many symptoms including emotional dysregulation, relationship issues, substance abuse, and post-traumatic stress disorder (PTSD) [2]. The Diagnostic and Statistical Manual of Mental Disorders defines PTSD as the result of witnessing or having direct exposure to either actual or threatened death, actual or threatened serious injury, or actual or threatened sexual violence with symptoms that can include experiencing unwanted upsetting memories of the trauma, nightmares, flashbacks or dysregulation when triggered by the event [3]. While trauma can be classified by confrontation with war, violence, disasters, sudden loss, or serious illness [4], what is traumatic to one person may not be traumatic to another so that trauma can be defined as an event that overwhelms the nervous system leaving the person unable to process and the experience [5]. In addition to cataclysmic events, neglect, betrayal and chronic relational ruptures in infancy can result in developmental trauma, and are at the root of many relationship issues and mood disorders [6]. Trauma symptoms can be multi-determined and may include relational trauma beyond infancy that exists during a cataclysmic event [7]. For example, a child experiencing physical abuse from one parent is shamed by the other parent for crying during the abuse.
The intensity and frequent complexity of trauma presents a challenge in treating trauma in that clients processing their traumatic experience can become dysregulated [5,8,9]. Lack of regulation can lead to states of overwhelm and even retraumatization during and between sessions [10][11][12].
Trauma can result from cataclysmic events such as car accidents, combat, natural disasters, violence, medical interventions, physical or sexual abuse, and these types of trauma are generally considered Big T trauma. Chronic relational ruptures, also called little T trauma, Relational Trauma, or developmental trauma, are at the root of many relationship issues, and mood disorders. However, many big T traumas include relational trauma such as when a client experiencing a traumatic injury felt alone during the incident and or a child experiencing physical abuse by a parent experiences the betrayal of the abuser and the abandonment from the parent who did not protect them.
It is increasingly common knowledge that mindfulness has psychological benefits and can be helpful with the effect of trauma: Mindfulness meditation has shown to provide regulation during intense emotion processing [13]. Mindfulness as defined by Merriam-Webster [14] is "the practice of maintaining a nonjudgmental state of heightened or complete awareness of one's thoughts, emotions, or experiences on a moment-to-moment basis". Mindfulness often involves attention to one's breath, body, or task at hand. In addition to facilitating regulation during trauma processing, many studies including the following, show that mindfulness decreases depression [15,16], decreases anxiety and stress [17][18][19][20][21] and decreases PTSD systems [22,23].

Client Specific Mindfulness Meditation
Presence Psychotherapy maintains that there are ever-present phenomena that appear to be implicitly regulating and helpful in resolving trauma-induced emotions and beliefs: compassion/love, grounding, spaciousness and transcendence [24]. Each has unique benefits: Compassion decreases loneliness [25][26][27], Grounding increases calmness, [24,28]; I have observed anecdotally that awareness of Spaciousness seems to help client quickly and calmly observe and sense their traumatic pain and Transcendent mindfulness practice appears to mitigate terror during trauma processing. It may be helpful for clinicians to be familiar with at least one brief mindfulness practice that corresponds to each of four regulating phenomena to best address the client's presenting symptom.
Additionally, the clinician's familiarity with these four phenomena can help ensure the clinician can offer a brief practice with which the client is comfortable and can experience well-being. I have found that some clients respond well to some kinds of mindfulness meditation and not others and that having options to offer clients is important to increasing the usefulness of mindfulness meditation. For example, some clients with complex relational trauma are distrustful of compassion from others the therapist and may also be unable to feel compassion for themselves, particularly early in treatment. These clients may become agitated, rather than regulated, when experiencing the therapist's compassion or when doing a compassion-based mindfulness practice. These clients may initially be regulated with a grounding or spaciousness mindfulness practice. Alternatively, these particular clients may benefit from Presence Psychotherapy's Expanded Relational Presence practices and may be able to comfortably receive compassion from a mindfulness practice that includes a non-threatening attachment figure to help such as a pet, or in some cases a spiritual being [24]. Other traumatized clients are uncomfortable bringing attention to their bodies and can initially benefit from a spaciousness or transcendent practice rather than bringing attention to their breath or focus on the body in grounding practices mindfulness. I maintain that clients will experience the most benefit from mindfulness meditation in psychotherapy if we are familiar with a compassion, grounding, spaciousness and transcendent practice, and offer the client the one (s) that will be most helpful for their presenting problem, that they are comfortable doing, and enjoy. Presence Psychotherapists typically offer a brief guided mindfulness meditation orienting the client to one of the regulating dimensions near the beginning of session. As Presence Psychotherapists, we have found that with four categories available, we can offer one that clients enjoy and from which they can experience immediate benefit.

Presence Awareness
Presence is subtle energy that can be sensed as a result of mindfulness [24,29]. It is ever-present energy, as opposed to a state of mind, independent of thoughts, feelings, and sensations, that can be experienced by sensing and being present with the positive effect of mindfulness practice [24].
Presence Awareness has unique therapeutic benefits: Empirical evidence suggests clients benefit clinically from the Therapist's Presence in the treatment setting [13,30]. Presence has been used to help with affect regulation in trauma therapy and can help parents build secure attachment with their children [31]. As a result of the therapeutic benefits of mindfulness and Presence awareness, it is useful for clinicians to integrate mindfulness and Presence Awareness while working with trauma in the clinical setting.
PPTM offers specific open-ended prompts offered after guided mindfulness practice to help clients sense and become present with the subtle benefits of mindfulness.
Presence Psychotherapists are finding anecdotally that through specific open-ended questions following mindfulness meditation, clients are able to sense the subtle energy of Presence, not as a feeling or state but as energy that exists in and around them independent of their thoughts, feelings and sensations. PPTM applies the concept of Felt Sense, coined by Eugene Genlin [32] described as bodily felt emotions, sensations, emotions, memories, images, meanings, beliefs, needs, and actions. Felt Sense can be utilized to help clients perceive the subtle energy, not only of feelings, thoughts and sensations, but also of Presence in them and around them. The Presence Psychotherapist helps the client sense their beingness, not as a state, but as the fundamental energy of who they are in which thoughts, beliefs, actions, and sensations arise. After guiding the client through a brief mindfulness practice focused on compassion/love, groundedness, spaciousness, or transcendent oneness. Presence Prompts are offered to help the client orient to Presence Awareness. The final Presence Prompt is an invitation for the client to sense themselves in the current moment as the energetic qualities of Presence that they spontaneously sense through the Presence Orienting Process. This helps clients create a shift in identification from who they are as an intense emotion or a negative self-concept to a broader identification of themselves as Presence able to observe their trauma related emotions, beliefs and sensations. PPTP provides techniques to help clients to create a shift in identification from who as less then, too much, bad, anxious, depressed, or other trauma-induced self-concepts, to a sense of the Presence of who they are beyond their trauma.

Presence Orienting
The combined process of offering one of the mindfulness categories followed by Presence Prompts is called Presence Orienting. It is generally, but not always facilitated while the client's eyes are closed, or with a soft gaze. This two-fold process allows for a deepening of awareness of the subtle energy of Presence. We as Presence Psychotherapists have found that almost all clients are able to Presence Orient. (An alternative Presence Orienting method, which is beyond the scope of this paper, is utilized for the few clients that do not want to do this practice.) As Presence Psychotherapists, we have found that many clients report feeling amazed or awed after Presence Orienting. The following is a chart with more detail about the Four Frequencies of Presence. The following is a table showing Presence Psychotherapy Presence Prompts.

Presence Prompts
Presence Prompts are offered after a therapist-led brief Grounding, Spaciousness Compassion/Love or transcendent/oneness, mindfulness meditation practice.
"As you bring your awareness to ____ (fill in the blank with the focus of the previous mindfulness meditation practice), tune to any subtle qualities, feelings, sensations you are aware of as you bring your attention to (depending on what mindfulness practice was facilitated) perhaps a sensation, color, temperature, movement, in or around your body". "Let me know what you are aware of as you tune in . . . ". "Rest and Reside in _____ (repeat the client's sensory words)". "Take a sensory picture of yourself as (repeat the client's words) ______ in this moment". Reflective View: "Sense who you are as ____" (repeat the sensory words the client named).

Reflective View
Reflective View is the final Presence Prompt and is a Presence Psychotherapy concept based on the supposition that at our essence, we are energy that is connected, calm, aware and compassionate, without fear. Reflective View is the Felt Sense awareness of oneself as calm, compassion, spacious, connected. Reflective view is an invitation for the client to sense themselves in the current moment as the energetic qualities of Presence that they spontaneously sense through a guided mindfulness practice followed by Presence Prompts.
Reflective View appears to create a rapid shift from over-identification with gripping emotional experience or difficult thoughts to a Felt Sense awareness of the beingness of who they are able to calmly be with their experience.
Presence Psychotherapy helps clients experience the essence of who they are as Resource. Resource, the regulating element of somatic-trauma models, is generally experienced as something separate from the client. Examples of resource in body-based trauma models include, but are not limited to, grounding, a nurturing or compassionate figure, a safe place, the therapist's compassion or the client's compassion for themselves, often experienced by the client as an aspect of their personality. When the client experiences an identification shift from resource as peripheral, to who they are fundamentally as Resource throughout the session, a large broad container or safety exists to fully access and process trauma.
Reflective View provides increased resource and thereby increases clients' capacity to discover and remain process without becoming overwhelmed while processing trauma related memories, feelings and trauma-induced beliefs.
There is value in helping a client create a shift in identification with gripping emotion experience or identification with a trauma-induced belief, such as or a negative self-concept to a broader identification of themselves as Presence Awareness. PPTP provides techniques to help clients to create a shift in identification from a self-belief as less then, too much, bad, anxious, depressed, or other trauma-induced self-concepts, to a sense of the Presence of who they are beyond their trauma. It is helpful in trauma work to help clients create a shift in identification from the grips of a negative trauma-induced belief such as "I am bad; I am not enough. I am weak. I worry all the time." Instead, spontaneously report "I am solid. I am safe. I am love." Reflective View provides clients with the awareness of the beingness of who they are able which then allows them to calmly be with their trauma experience. Presence prompts provide a process for inviting clients to experience a Broad sense of awareness that can view and calmly process the part of mind trapped in trauma.
From this broader vantage point, clients can then calmly and compassionately observe and reprocess the parts of the mind that continue to hold trauma-related experience. Reflective View provides increased resource and thereby increases clients' capacity to discover and remain process without becoming overwhelmed while processing trauma related memories, feelings and trauma-induced beliefs. Table 1 shows anecdotal responses from clients after Presence Prompts are completed:

Shifting Identification to Provide Symptom Relief Early in Treatment
Introducing Presence Orienting within the first couple sessions provides the clients with the opportunity to experience the benefits of mindfulness and Presence early in treatment. This technique to help clients differentiate who they are core negative beliefs of being not enough, bad, too much, not loveable, to a sense of who they are as valuable, loveable, capable, and calm. Anecdotally, clients report a reduction in symptoms and express feeling relieved to experience themselves positively so early in therapy. Frequently clients say things like "This is amazing. I never experienced like this before." When the client senses who they are as subtle energy that is flowing, compassionate, anchored, and/or expansive, they are often then able to Include and have a Felt Sense of trauma-related material inside the broader energy of who they are as Presence.

Presence Orienting and PPTP
PPTP is the full trauma processing protocol that begins with Presence Orienting and integrates Presence Orienting while processing trauma.
Because the details and nuance of psychological trauma often exist in implicit memory [33], while accessing and processing trauma it is helpful to provide treatment interventions that helps clients access and process implicit traumatic memory. Implicit memory can be accessed through body awareness [33] EMDR (Eye Movement Desensitization Reprocessing (EMDR), (IFS) Internal Family Systems, (SE) Somatic Experiencing Body, and (AEDP) Accelerated Experiential Dynamic Reprocessing are all somatic-based treatments that have shown to be effective in treating the effects of implicit memory [34][35][36][37][38].
These evidenced-based models share several common underpinnings: Resource, something that the client experiences as calming to prevent dysregulation during the remembering and relaying of traumatic experience [39] guidance for the client to sense trauma related emotions, beliefs, images in or around the body, techniques for titrating the amount of trauma related thoughts, feelings and sensations that emerges, and finally, techniques to process and release trauma related feelings and reprocess trauma-induced negative beliefs [24].
Presence Psychotherapy helps clients experience the essence of who they are as Resource. Resource, the regulating element of somatic-trauma models, is generally experienced as something separate from the client. Examples of Resource in body-based trauma models include, but are not limited to, grounding, a nurturing or compassionate figure, a safe place, the therapist's compassion or the client's compassion for themselves, often experienced by the client as an aspect of their personality. When the client experiences an identification shift from resource as peripheral, to who they are fundamentally as Resource throughout the session, a large broad container or safety exists to fully access and process trauma.
The Presence Psychotherapy Trauma Model incorporates Resource, as well as regulating and body centered trauma processing techniques. Additionally, it integrates mindfulness and Presence Awareness with Reflective View to provide a treatment that offers techniques for mood improvement and shift of identification early in treatment as well as robust Resource for regulating and processing trauma.

The PPTM Protocol: Presence Orienting with Reflective View Including
Felt sense of the suffering part of the mind in or around the body viewed by the client in bigger, wider field of Presence Awareness.

Zooming In
Bringing awareness to the specific feelings, sensations, negative beliefs, images of trauma within larger container of any of the Four Dimensions of Presence.

Turning the View
Facilitates clients' awareness of various vantage from which to view and process and resolve trauma. Examples include client viewing trauma from Presence Awareness, Part of the mind in a trauma scene orienting to Presence Awareness facilitated at the beginning of the session, clients simultaneous awareness of Presence and trauma induced feelings, beliefs and symptoms.
A case example is provided to demonstrate utilization of one of the four categories of mindfulness followed by Presence Prompts with Reflective View. This Presence Orienting process continues through the rest of the PPTM model.
The therapist began the session with a compassion-based mindfulness practice. This particular compassion/love mindfulness-meditation practice was designed by the author. It is followed by Presence Psychotherapy Prompts with Reflective View to help the client sense who she is as compassion before turning attention to the issue of the day, in this case, trauma-induced anxiety.
Case Example: The therapist utilized a compassion-oriented mindfulness meditation for this session. This particular compassion/love mindfulness practice was designed by the author to easily facilitate Reflective View. It is followed by Presence Psychotherapy Prompts with Reflective View to help the client sense who she is as compassion before turning attention to the issue of the day, in this case, trauma-induced anxiety. Client: "I am feeling so anxious about my upcoming surgery. I haven't been able to sleep." Therapist: "If you like I can guide you in a process to try and help you with this." Client: "Great." Therapist: " It can be helpful if we first help you to feel calm and observe the anxiety from a calm place. How does that sound? " Client: " I can't do that. I can't get calm." Therapist: "Would you like me to guide you in a brief mindfulness practice to help you experience calmness?" Client: "Please." Therapist: "Do you feel comfortable closing your eyes or if that's not comfortable to have a soft gaze looking down at your lap or the floor?" Client nods and closes her eyes. Therapist: (starting compassion/love mindfulness practice) "Bring to mind someone or something for whom you have love or compassion. Pick someone that you easily feel love or compassion without other mixed feelings. If can be a child, a pet, a friend, or even a spiritual being. If you choose a person, choose someone who is living." Client: nods. "I have something." Therapist: "You can keep who or what it is private, or you can share it with me. It's up to you." Client: "It's my cat." Therapist: "Go ahead and see or sense your cat in your mind's eye in a way that feels particularly endearing to you." Client: smiles Therapist: "What's your cat's name?" Client: "Meow." Therapist: "As you see meow in front of you . . . (after a couple moments) bring awareness to the love or compassion you feel Toward her." Client smiles with a warm countenance. Therapist: "Now turn your attention now to your body and sense where you feel the sensation of your love or compassion in or around your body." Client: "In my heart." Therapist: "Does it feel more like love or compassion?" Client: "Love" Therapist: " . . . Take some time to be present with love." Therapist: "How is it to feel this?" Client: "Really nice. I feel calm and loving." This is the end of the compassion/love mindfulness practice. The therapist now begins the Presence Prompts with Reflective view to help the client create a shift of identification with herself as love.
Therapist: Beginning Presence Prompts: "Bringing your attention to the loving feelings and calmness in you, (using the words the client identified in the compassion/love mindfulness practice) . . . tune into and sense love as you feel it in your heart. (This is the prompts to experience the Felt Sense of the effect of mindfulness) Notice the subtle qualities." Client: "It feels warm and good and calm." Therapist: "Rest and Reside (Presence Prompt) in the warm, good, calmness of your love as you sense it in your heart." Client: "face looks relaxed and open with a slight smile." Client: "The warm love is moving from my heart out in front of me." Therapist: "Sense yourself in this moment as warm, loving and calm." Client: nods slowly. Therapist: (Reflective View) "Sense who you are as warm, loving and calm energy . . . " Client: "The warm energy . . . love of me is inside . . . and around me." Therapist: (Reflective View continues) "Take a sensory picture of you are warm, loving energy . . . " "How it is to sense yourself in this way?" Client: (Opens eyes) "Really good! It's true that this is me. It's good to get this is me." Therapist. Closing your eyes again so that you can sense the warm loving energy of you in and around . . . And in this expansive of warm love, INCLUDE in your awareness the part of you that feels anxious. Sense that part inside this field of warm love. Client: "It's a ball of anxiety. But it's only a ball. I can see and feel it inside the warmth and love of me." (Client experiences anxiety in the broader awareness of the warmth of love of her Presence.) The session continues with the client now regulated with a shift in identification able to observe herself as Compassionate Presence that can include and observe the anxiety she is experiencing. Therapist:(Beginning trauma access and processing) "Does it feel ok to zoom in and discover more about the anxiety from this broader field of calm, love?" Client:(calmly with eyes closed) "Yes, I am curious about it . . . after a moment It actually feels pretty little, like young. I remember being five and having to get a cavity filled. My mother wasn't in the room with me and I was really scared." (Trauma memory emerges spontaneously in the safe container of the session with Reflective View.) Client opens eyes: "That's really interesting. The anxiety is really coming from memory of being five." Presence Orienting helps client to be very resourced which results in access to the corresponding traumatic memory of an early dental procedure triggered by the current life event of her upcoming surgery. High resource can reveal trauma (Levine). Because the client is identified with herself as Presence, the emerging memory is met with curiosity and wonder rather than feeling overwhelming to the client. The session continues: Therapist: (joining client in her sense of wonder) "Yes it is interesting! You are aware of the young part of you that felt scared and wanted mom when getting your cavity filled . . . Does it feel ok to close your eyes again and take a moment to sense your heart center that is filled with warm love that is in and emanates our from you? If it helps to bring your cat to mind, you can do that if it helps you sense the love of who you are." Client: nods. "Yes, I feel the warm flowing energy of my love." Therapist: "Does it feel ok to see or sense the scared five-year-old you in this field of your warm loving energy?" Client: "Yes, I see her in the dentist office and my warm loving energy is all around her and the room." Therapist: "Would you like to see if she wants to Turn her View to sense your Loving Presence all around her?" Client: "She already is and she feels calm with me there."

Zooming in and Broadening Awareness
The session continues with the client regulated and able to remember and process the early dental trauma alternating between "Zooming In" on to process the thoughts, feelings, and sensations of the trauma and healing client "Broadening her Awareness" to Loving Presence around the 5-year-old experience. Zooming in to the trauma material and frequently Broadening Awareness to Presence and/or the present moment is central to Presence Psychotherapy and provides an opportunity for traumatic experience to be held within the bigger container or Presence Awareness.
At the end of the session, the therapist asked the client how she felt about her upcoming surgery. The client responded, "I'm a little nervous but the ball of anxiety is gone." The results of this session are reflective of typical PPTM sessions and are not unique to this client.
When the client senses who they are as subtle energy that is flowing, compassionate, anchored, and/or expansive, they are often then able to Include and have a Felt Sense of trauma-related material inside the broader energy of who they are as Presence.

Discussions
The case example above shows the full PPTM protocol. The full model can be utilized to fully process Big T as well relational trauma. Alternatively, Presence Orienting with Reflective View can be offered alone, without the full protocol, to provide regulation and help people sense their distress inside a wider expanse of well-being.

Shifting Identification to Provide Symptom Relief Early in Treatment
Generally speaking, it is through the therapeutic process of resolving a traumatic event, or events, that the client can experience a positive core belief about themselves and who they are. These core beliefs and identification with these beliefs as who the client is can be particularly embedded with chronic relational trauma. Many somatic-based trauma models seek to help clients create differentiation by helping them to observe sensations related to trauma-induced beliefs and feelings in the body from a curious calm position (EMDR, IFS, SE, and Sensory motor, to name a few.). For many clients, particularly for those who experienced complex relational trauma, it can traditionally be a long therapeutic process to heal trauma-induced feelings and beliefs and to create a shift in identification of who they are Introducing Presence Orienting within the first couple sessions appears to provide the clients with the opportunity to differentiate who they are from core negative beliefs of being not enough, bad, too much, not loveable, to a sense of who they are as valuable, loveable, capable, and calm. Anecdotally, clients report a reduction in symptoms and express feeling relieved to experience themselves positively so early in therapy. Frequently, clients say things like "This is amazing. I never experienced who I am in this way before.". The shift in identification that Reflective View offers, appears to increase clients' resilience, creating a robust resource for trauma processing.

Utilization of Presence Awareness in Various Settings and within Other Treatment Models
As a result of the therapeutic benefits of mindfulness and Presence awareness, medical and mental health clinicians may consider offering guided grounding, spaciousness, compassion or transcendent mindfulness followed by Presence Prompts to regulate patients who are distressed. Presence orienting has many promising applications for psychiatry, and medical practitioners meeting with patients experiencing anxiety regarding procedures, diagnosis and prognosis.
Presence Orienting with Reflective View alone, without knowledge or utilization of the complete PPTM protocol, can be utilized and integrated with other modalities. Presence Orienting can be integrated by trauma therapists into other trauma models. Therapists who do not work specifically with trauma may also benefit from including Presence Orienting in their work.
Globally, the COVID 19 pandemic has resulted in an increase in and trauma. In the West, individuals with higher narcissism scores appear to have had more trauma symptoms and PTSD as a result of the COVID pandemic [40]. PTSD in a Tunisian community is estimated in 33% of the population [41]. Depression, insomnia People struggling with COVID-related trauma might benefit from Presence Orienting and the full Presence Psychotherapy model. A systematic review has found that COVID-19 has increased anxiety, depression and stress in Mexico [41]. The US has seen a COVID related increase in insomnia and depression [42]. Presence Orienting and PPTP may prove to be useful for mitigating these effects.
Anecdotally, Presence Orienting helps clients sense their trauma-induced feelings, sensations and negative beliefs in a broader awareness. Presence appears to provide differentiation from trauma symptoms, robust regulation for trauma processing, attachment healing possibilities, and symptoms relief early in treatment. A growing body of clinicians trained in Presence Psychotherapy's' full trauma processing protocol, PPTP, are reporting a significant reduction in trauma symptoms through a very regulated process.
A limitation of this paper is the lack of empirical research to support anecdotal findings. As a Presence Psychotherapy community, we look forward to research that can further test these findings.