How Does Therapeutic Presence Promote Real Change?

How Polyvagal Theory and neurophysiological safety enable growth through therapy

Written by: Dr. Shari Geller, Ph.D., C.Psych.

Key points:

• Therapeutic presence can strengthen the therapeutic relationship.
• Bidirectional attunement evokes clients’ sense of safety.
• Therapists’ presence and a neurophysiological experience of safety allows for clients’ engagement in therapy.

Being fully present with a client requires you, as a therapist, to bring your whole self to the encounter: physically, emotionally, psychologically, spiritually, and relationally (Geller & Greenberg, 2022). Your clients will feel safe and more secure with you, supporting the difficult work of therapy. Sounds straightforward enough. Keep in mind, it asks you to focus on how you are with your client, rather than just what you do in the therapy session.

Safety emerges from a therapeutic relationship with a present and grounded therapist. As you attune to your clients’ moment-to-moment experience, as well as your own, with awareness and compassion, clients can feel you with them. This allows clients to feel heard, felt, and seen, and ultimately safe to open and share their intimate experiences and challenges. So, a part of how to evoke change in therapy is through a neurophysiological experience of safety.

This neurophysiological experience of safety through therapeutic presence can be understood in part through the lens of Stephen Porges’s Polyvagal Theory (PVT) (Geller & Porges, 2014). In simplified terms, PVT is based on an evolved understanding of our autonomic nervous system. The old nervous system was viewed to have two parts: a sympathetic nervous system (fight or flight) and a parasympathetic nervous system (rest and digest). Polyvagal Theory teaches us that the new evolved nervous system has three parts, with the parasympathetic consisting of two parts (two for poly): the dorsal vagal (shut down) part of the polyvagal nervous system and the ventral vagal (regulation through relationships) system, which is an evolved system in mammals and includes a social engagement system (Porges, 2011).

While there is bidirectional communication between the brain (central nervous system) and the body, there is also bidirectional communication between the nervous systems of people in relationships with one another (Cozolino, 2006; Geller, 2018; Geller & Porges, 2014; Porges, 2011; Schore, 2012). This communication is not necessarily in conscious awareness; it is experienced as a “gut” sense that informs how we are feeling in an interaction. When therapists are offering their presence and grounded attunement to their clients, the nervous system of clients can receive this calming, grounded state, evoking safety and calm within their own nervous system.

A related concept in PVT, neuroception (Porges, 2011), describes how safety and unsafety are experienced and mediated by physiological states (e.g., bodily felt agitation when unsafe, internal sense of ease when feeling safe). Feeling scared when someone comes into your therapy room screaming fire is an accurate gut sense of unsafety in a potentially unsafe situation. Conversely, feeling calm when relationships are calm is an example of a neuroception of safety.

A neuroception of unsafety or emotional dysregulation and physiological reactivity to others (feeling unsafe even in safe situations) can develop in response to trauma or misattuned relationships. It is helpful to understand the potential neuroception of unsafety that your particular clients may have as a result of trauma. If a client has an inaccurate system, a therapist looking down in reflection may provoke the client to feel abandoned in that brief reflective moment. With presence, however, therapists can be more attuned to their client’s neuroception of safety or unsafety. Therapeutic presence helps to read a client’s state in the moment, notice when they go into an unsafe place, and then activate safety through their ventral vagal connection.

At the same time, present-centered safe relationships can help to heal a client’s neuroception of unsafety developed from trauma. Therapeutic relationships infused with presence can exercise your client’s neural muscles of safety. Over time, this can strengthen a client’s ability to feel safe with others (Geller, 2018). The bidirectional nature of the social engagement system means that positive interactions between a therapist and client can influence their vagal function to dampen stress-related physiological states and support growth and restoration (Geller & Porges, 2014).

Bringing your therapeutic presence to a client is not only a necessary foundation for effective therapy, but it is also an offering and a gift that helps your client and their nervous system feel calm and safe. In this way, your clinical skills and therapeutic presence are tools that support you and your clients and deepen the therapeutic relationship. And they can allow your presence to be a buffer to a client’s painful emotions through a safe relationship, so they can work through their difficult emotions and trauma and repair these experiences. This can ultimately empower clients to live more fully, extend self-compassion to their painful emotions and themselves, and cultivate deep, meaningful relationships (Geller, 2025).

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