Literature review

Therapeutic presence

Therapeutic presence is the therapist’s way of being present with the client, and impacts client outcomes and the therapist’s self-efficacy (Geller, 2017; Greason & Cashwell, 2009). Therapeutic presence has only been recently addressed in the literature, and how it impacts client outcomes specifically has not yet been established (Haley, 2014). Indications are that it can strengthen the therapeutic alliance through attunement to the moment, to personal experiences, and to the therapeutic relationship (Geller, 2017; Robbins, 1998; Rogers, 1980).

Central to a humanistic, client-centred approach, therapeutic presence is understood as a way of helping clients to become more attuned to their own personal experiences and those of others (Rogers, 1980). The moment-to-moment encounters involve bringing physical, emotional, spiritual, and cognitive attention to themselves and the client (Robbins, 1998). This degree of engagement and connection encourages the client to feel safe in exploring inner issues (Geller, 2017).

Research states that individual therapist factors and the therapeutic alliance are the strongest predictors of treatment success (Miller et al., 2013). A successful alliance is one that is highly attuned, open, connected, and safe (Geller, 2017). The therapist is required to observe and track thoughts, feelings, and sensations as they are happening in the moment (Gambrel & Keeling, 2010). Being present involves grounding as inward attending and self-regulating, while observing and attending to the client’s verbal and non-verbal cues and expressions (Geller, 2017). Thus, monitoring the therapist’s own therapeutic experience while attending to the client’s experience in a non-judgemental open way supports a positive relational space for healing.

Lambert and Simon (2008) suggest that opportunities to develop individual therapeutic attributes be a focus of psychotherapy training. They propose that therapists learn and internalise therapeutic attitudes and skills, such as therapeutic presence, for enhancing clinical outcomes. Geller et al. (2010) designed an empirically validated model of therapeutic presence as a practical framework to assist therapists in assessing and developing their presence. While limited evidence of its effectiveness exists, a self-auditing tool called the Therapeutic Presence Inventory (TPI) has been developed as part of this model. It has been used for assessing therapeutic presence in psychotherapy treatment training and in various mindfulness, self-compassion, art therapy, and osteopathy studies (Geller et al., 2010). The practical application of the TPI tool is evidenced by its use in four hospitals in Switzerland to monitor therapists’ effectiveness (Geller et al., 2010).

The importance of enhancing therapeutic presence as a skill is validated in theory and research (Hauser & Hays, 2010). There is, however, a lack of research into how different therapy modalities use therapeutic presence as a foundational approach (Geller, 2017). Research shows that learning therapy skills is essential, but therapists tend not to continue practising advanced skills once training has ended (Campbell & Christopher, 2012). Furthermore, Hauser and Hays (2010) assert there is little research to show how a therapist can develop a practice of therapeutic presence. Bridging this gap and finding ways to support therapists to practice therapeutic presence is germane.

Art therapy

Art therapy utilises the art-making process for expressing feelings, and working through issues and concerns (Case & Dalley, 2006). The tactile and creative interaction helps the therapist to recognise non-verbal communication, rhythms, and emotional responses (Malchiodi, 2018). Art-making is regarded as an intrinsic spiritual activity as old as human history, and offers a symbolic language and practical pathway for connecting with one’s spiritual self, unseen concepts, thoughts, and feelings (Kirca, 2019; Rubin, 2001).

The interaction between client, therapist, and art-making is recognised as a complex triangular relationship (Edwards & Wilkins, 2014). It demands the therapist to be present in the moment and pay close attention to non-verbal communication, material interaction, and the creative process, as well as developing a trusting relationship where the client can acknowledge and express strong emotions (Payne, 1993). The therapist makes connections between the therapist self, the client, and the art-making process with the aim for the connections to become aligned; this is known as therapeutic attunement, or ‘flow’ (Csikszentmihalyi, 1990). Attunement, or flow, involves an emotional sensing in “knowing their rhythm, affect and experience by metaphorically being in their skin” (Erskine, 1998, p. 236).

Furthermore, careful consideration needs to be given to the emotions evoked by the physicality of art materials, such as colours, textures, and forms (Salom, 2013). Material interaction involves complex levels of visual expression, and affective, sensory, and information processing; it is a truly in-the-moment expression of feelings, and mimics the way clients approach other things in life (Hinz, 2009; King, 2017; Salom, 2013). Art-making can be self-soothing, grounding, and self-regulating, as the kinaesthetic and sensory components of material interaction help to relax muscles, release tensions, and slow down heart rate and respiration (Hinz, 2009; Tucci et al., 2019).

Art therapy’s unique attributes play a pivotal role within the therapeutic relationship and convey information about the alliance, internal emotions, and unconscious processes (Case & Dalley, 2014). How the attributes affect therapeutic presence was investigated in a study by Schwarz et al. (2018). Fourteen art therapists were interviewed to describe their experience of therapeutic presence within the triangular art therapy relationship. The results found that the art process and art materials influenced therapeutic presence (Schwarz et al., 2018). Some participants found that art materials fostered therapeutic presence, while others found they hindered it. This was due to client factors; for example, a client said, “plaster is white, powdery and cold; it doesn’t give me a good feeling” (Schwarz et al., 2018, p.16). The interviewees identified attentiveness, openness, and flexibility as important factors for therapeutic presence in art therapy. They also developed a better understanding of how therapeutic presence assists in becoming more attuned to their clients, as well as strengthening the therapeutic alliance (Schwarz et al., 2018).

Mindfulness

Mindfulness practice is founded in Eastern Buddhist meditation traditions and philosophies, and involves bringing full attention to the present moment without judgment and with acceptance (Kabat-Zinn, 2003). It may prompt relaxation, but this is not the focus; mindfulness practice alters the conscious mind from a controlling mind to a mind that listens and observes thoughts, feelings, and physical sensations (Campbell & Christopher, 2012). A secular focus governs its practice elements on teaching skills such as conscious breathing, sitting meditation, daily-life mindfulness, awareness practice, and mindful speaking, listening, and moving (Geller, 2017; Weiss, 2004). Over the past 30 years, mindfulness-based practice in clinical interventions in medicine and psychology has been steadily growing (Campbell & Christopher, 2012). A recent review by Creswell (2017) of randomised controlled trials (RCT) of mindfulness-based interventions from the past two decades demonstrated that the interventions reduced symptomatology and showed long-term benefits.

A mindfulness perspective to art therapy is a recent approach and has not been widely researched (Malchiodi, 2018). However, promising research results in mindfulness-based art therapy with cancer patients are emerging (Rieger et al., 2020). A mindfulness approach to art therapy is seen as incorporating mindfulness techniques such as breathing, meditation, body scans, visualisation, and yoga into the art-making experience (Liebman, 2004). It has been shown to increase attention regulation and body awareness more than mindfulness techniques alone (Rappaport & Kalmanovich, 2014).

Positive results from mindfulness-based interventions have encouraged clinicians to investigate how mindfulness-based practice can be applied in other areas of clinical practice, such as improving the therapeutic alliance (Hick, 2008). Various authors have investigated the impact of mindfulness training on professional practice (Geller, 2017; Germer et al., 2013; Greenberg, 2012; Hick, 2008; Shapiro et al., 2007; Siegel, 2007).

Several researchers propose mindfulness-based training to help cultivate therapeutic presence (Bruce et al., 2010; Campbell & Christopher, 2012; Christopher & Meehan, 2010; Gehart & McCollum, 2008; Grepmair et al., 2007; Shapiro et al., 2007). A study by McCollum and Gehart (2010) found that mindfulness meditation training helped trainee counsellors to enhance therapeutic presence. Even though the study results are promising, research also suggests that a secular mindfulness approach does not support people to sustain a daily practice (Dimidjian & Linehan, 2003; Gause & Coholic, 2010; Rosch, 2007). Campbell and Christopher (2012) propose a more holistic application to develop deeper knowledge of oneself, and Rosch (2007), Dimidjian and Linehan (2003), and Gause and Coholic (2010) suggest an inclusion of spiritual viewpoints for a more inclusive and holistic approach.

Dadirri

Dadirri is Australia’s ancient Indigenous practice of deep listening, and may provide a more holistic, spiritually inclusive approach to developing deeper knowledge and connection to self, others, and nature. Spirituality is a universal concept that embraces many perspectives, being a human experience that involves searching for meaning and connecting to something that is bigger than life (Spencer, 2012). Dadirri is an all-embracing concept of mind, body, spirit, and place awareness in which everything is interconnected (Brearley, 2014). The meditative practice connects people to the spirit within themselves as well as within the land (O’Gorman, 2019). Dadirri is central to Dr/Aunt Miriam-Rose Ungunmerr-Baumann and her people (Kohn, 2016). Ungunmerr-Baumann is an Aboriginal Elder who became the Northern Territory’s first Indigenous teacher and school principal (Kohn, 2016). She is a renowned artist, writer, activist, and public speaker; in 1998 she was made a Member of the Order of Australia (Kohn, 2016), and in 2021 she was awarded Senior Australian of the Year (Colbeck, 2021). The Miriam Rose Foundation was established in 2013 in response to many youth suicides in her community (Ungunmerr, n.d.). The foundation supports young people by providing education, culture, arts, and opportunities (Ungunmerr, n.d.). Over the years, Ungunmerr-Bauman has endeavoured to share her teachings with non-Indigenous Australia in cultural connection immersion retreats and Christian practices as part of the reconciliation process (Kohn, 2016; O’Gorman, 2019). In the education curriculum, dadirri is incorporated as a mindfulness teaching resource (Atkinson, 2012).

The mainstream Western mental health services often fail to meet Aboriginal mental health needs, as they treat specific problems rather than the person holistically (Vicary & Bishop, 2005). A dadirri perspective has helped to create a more holistic treatment (Atkinson, 2012). For example, dadirri is used as part of dialectical behaviour therapy to treat chronic suicidal ideation in Indigenous peoples diagnosed with borderline personality disorder (Atkinson, 2012). Dadirri also formed the foundation for the development of the Deep Listening Project in 2003 (Brearley, 2014). This is a project in which dadirri practice has enhanced genuine and respectful connections at cross-cultural exchanges between Australia and Canada (Brearley, 2014). At the events, the leaders invite attendees to participate in dadirri to become fully present to oneself and each other, identify what is happening and emerging in the moment, and open a space in which genuine connections can be made (Brearley, 2014). While there are unique attributes of dadirri, Morris et al. (2022) identify important similarities between dadirri, Buddhist philosophies and Western psychology, including aspects such as deep awareness of the present moment; it could be elucidated that dadirri embodies a depth of presence akin to the Western concept of therapeutic presence.

Therapeutic presence involves paying attention to the physical therapeutic space with awareness to sound, place, and other outer sensations (Kossak, 2009). In dadirri practice, Ungunmerr-Baumann (n.d.) urges everyone to sit still and wait quietly in nature. The beneficial effects on health and well-being of experiencing the natural environment have a growing body of research to support them (Robbins, 2020). These same principles are also evident in ecopsychology, or ecotherapy, as an emerging approach to mental health practice (Bessone, 2019). Nature-Based Therapy (NBT) also applies the natural environment within a therapeutic relationship to promote mental health and well-being (Bessone, 2019). Studies by Kaplan (1995) found experiencing or viewing nature improved the ability to focus and concentrate, but how the natural environment specifically affects therapeutic presence is unknown.

Secular mindfulness training has been described as helpful in enhancing therapeutic presence. However, the research has documented a lack of mindfulness training opportunities that have spiritually inclusive approaches, and calls for further studies of practices that can be sustained daily. The literature describes art therapy and dadirri as holistic practices, both sharing a mind, body, and spirit approach. However, there is no specific literature connecting the use of dadirri with art therapy in mental health practice in general, in developing therapeutic presence skills more specifically, or in supporting sustained practices. To address these gaps, this research aimed to explore the experience of a daily dadirri-inspired art therapy practice on therapeutic presence.

Methods

This research used a mixed-methods single exploratory case study (AB design) with the researcher as participant. The case study is a commonly used method in art therapy research as it allows for a personal narrative (Edwards & Wilkins, 2014). This was particularly significant for this inquiry as the researcher’s own perception of therapeutic presence was the basis for study. It allowed a personal exploration while maintaining a clinical context of the question asked. The single-subject AB design was an appropriate art therapy research approach, as it provided a means of looking at cause-and-effect relationships by comparing the researchers’ response patterns to their own pre-intervention response pattern (Carolan, 2011). The researcher served as the source of data for both the experiment and the control condition.

Dadirri-inspired art therapy intervention

Daily dadirri-inspired art therapy was programmed across 21 consecutive mornings. Each session consisted of listening to dadirri recordings and silent contemplation outside the researcher’s studio, in the garden. Art-making was completed inside the studio, looking out to the garden, followed by reflection on the experience.

The practice aimed at creating a daily routine that could be maintained for the duration of the study. The study’s duration of 21 days was based on the popular 21/90 rule that asserts that it takes 21 days to make a habit and 90 days to make a lifestyle change (O’Brien, 2020). There are various ways to form routines, and what is most helpful is to develop a set time-structure so that fewer decisions need to be considered (Arlinghaus & Johnston, 2019). For this reason, daily practice aimed to be at the same time each morning.

Each session followed Allen’s (1995) art therapy principles of intention, attention, and witness. This process was chosen as it allowed therapeutic presence to be actively anticipated and the art-making process to tap into creative energies and inner symbolism.

• Intention – art therapy interventions started with grounding in dadirri practice as inner deep listening and quiet still awareness. The researcher listened to a six-minute recording adapted from Ungunmerr-Baumann’s reflections (n.d.), followed by quiet contemplation (see Appendix 1). There was no set time for contemplation

• Attention – following quiet contemplation, a non-directive art approach with a choice of art materials offered an opportunity for selecting a material that closely reflected how dadirri was experienced. McNeilly (1983) describes a non-directive approach to encourage a more subtle and intuitive response, which suited dadirri’s focus on simply being, sitting in stillness and waiting to let something appear (Ungunmerr, n.d.).

• Witness – involved capturing the experience in written journal reflections.

Data and measures

Qualitative data consisted of 21 daily artworks, pre-therapy and post-therapy questionnaire reflections, and daily journal entries documenting starting time, session, art medium, style, process, and written reflections (see Appendices 2 and 3).

Quantitative measures consisted of a pre-therapy and post-therapy questionnaire gauging the researcher’s experience of therapeutic presence before and after the dadirri art therapy sessions (see Appendix 2). The questions were composed based on similar themes emerging in the literature review and A practical guide to cultivating therapeutic presence by Geller (2017). The questions assessed the experience of preparing to be present and practising therapeutic skills for cultivating presence.

A further quantitative measure was the evidence-based Therapeutic Presence Inventory (TPI), which self-assessed the degree of therapeutic presence following individual art therapy interventions with three clients at clinical art therapy placement (Geller et al., 2010) (see Appendix 4). These therapeutic relationships were chosen as the clients exhibited stable alliances with the researcher. The purpose was to measure positive or negative changes in the therapeutic presence over 21 days. The quantitative and qualitative data helped to identify and understand what aspects of, and how, dadirri-inspired art therapy interventions affected therapeutic presence.

Results

The researcher participated in daily dadirri-inspired art therapy over 21 consecutive days. For art responses, see Table 1; for starting times, choice of art materials, style, and process see Table 2. All art responses featured nature as a topic. Fourteen art responses used dry materials, eight used wet materials and one used both. Seven art responses were abstract and figurative, and seven were a mixture of both. Eight art processes were regulation focused, one was focused on symbolic meaning-making, and 12 were a combination of both.