Becoming an emergency psychologist: Alterity and presence in a comprehensive not-knowing relationship

Pathways identified by an investigation of the relationship experience

According to the person-centered approach (PCA), one path to address the construction of a response to stimulate the debate is addressing the lived experience of the relationship between EPC provider and client.

Vieira and Dos Anjos (2013) emphasize that the need to control the process, exhibited by providers at the beginning of their careers, is replaced by an openness to experience the encounter with the client. The authors consider this to be an experience of openness to the unknown at the expense of the knowledge that techniques offer. This seeks to strengthen the engagement of both provider and client as the one parameter on which the former grounds their action.

At the other extreme of our subject of interest is what Rogers (1957) considered to be the primordial factor of the therapeutic relationship, that is, the client’s perception of the relationship proposed by the therapist. Although aware that emergency care should not be confounded with psychotherapy, Vieira and colleagues (2014), also employing phenomenological methods, interviewed five clients after EPC sessions to understand how they perceived the therapeutic relationship based on a single triggering question: What most called your attention during the encounter you just had?

According to those authors, the changes initiated during relationships established in the emergency psychological setting might only occur through a meaningful and strong, though brief, connection between provider and client, in which the latter feels that they are welcome, understood, and safe and can explore and build their relationship with the former.

Both abovementioned studies point to aspects that are relevant when reflecting on the condition of the EPC provider, among which we selected two for this discussion. One is their willingness to put themselves in a much more radical situation of not knowing than that experienced in psychotherapy, as the encounters sometimes end by themselves and there is no previous information about the client. The second factor to consider is the idea of the presence of the provider in the relationship, which has been indicated by clients receiving EPC as a truly significant aspect. Next, we present a more thorough analysis of these two aspects.

The displaced specialist: (Lack of) knowledge, recognition, and presence

Work at an EPC service presents providers with the challenge of recognizing that the other’s desire to seek help is what guides the entire process. In other words, the process begins with the client’s immediate search for help and the provider’s willingness to meet anyone arriving at the service. Thus, although all techniques and prescriptions for therapeutic action should not be dismissed, they must be put aside during the encounter with the client for their benefit. Attention and openness to the other are the initial and necessary challenges: “the emergency care provider’s basis for work is the effective movement, which favors the movement taking place at the time because the person is seeking care” (Mahfoud, 2013, p. 38).

It is the willingness to be with the other as a person, not merely as a technician, that moves the provider from their place as a specialist in relation to another person to that of an individual genuinely interested in being with them when their pain manifests as an emergency (or as close to this as possible). Indeed, Mahfoud (2013) and Vieira et al. (2014) emphasize that the possibility of the encounter in the emergency setting being unique significantly mobilizes and intensifies the processes that develop within the relationship.

On the provider’s side, those phenomena occur when they practice an approach to another individual that considers them to be an enigma (Schmid, 2018). Consequently, the provider understands that his or her initial ignorance values the client’s experience and the relationship in which the client is recognized as a person. We understand that Vieira and Dos Anjos’ (2013) study indicates that the EPC providers initially move from “I know” (certainty about what to do) to “I can” (willingness to create a relationship based on the present), upon developing the ability to be genuinely interested in the client’s narrative through a deep type of listening that cannot be mistaken for passivity.

To be an EPC provider is not to passively observe the other’s experience, but to participate in it and take it at face value, without interjections or suspicions between what an individual says and what they are. Based on Amatuzzi (2014), we understand that this is a stance of really listening to the other, in which the will to relate precedes what one tries to understand. This deep listening is only possible when providers recognize that their wisdom is based on ignorance, although this does not mean that knowledge plays no role. Knowledge, preceded by a genuine desire to be with the other and understand them, may be questioned by narratives without any correspondence to what the provider attempted to plan. As Schmid (2018) argues, before knowledge of the other is the recognition of the other as absolutely different and the attitudes that derive from this fact. Let us now give an example.

In one session, after a long silence and in full contact with what was happening, an EPC provider realized that the client had great difficulty describing what was troubling her. The provider decided to tell the client what he was feeling and told her that he had realized she was unable to speak—he did not make an assessment, did not judge, and did not speculate on possible causes. The client confirmed that perception and the provider asked whether it would be easier if she had some paper and pencil. The client accepted but, even then, she was unable to express herself and said it would be very difficult to do so with the care provider because she felt she was being analyzed. The therapist asked whether she would be able to express herself if he left the room; her answer was yes. Thus, he said he would leave the room and would wait until she called him back. Consequently, a relationship was formed within which the client was finally able to speak about what was making her suffer and provide some information about it.

The idea of leaving the room cannot be found in any psychotherapy, counseling, or EPC manual but it was relevant to the provider–client relationship at that time and in a manner that gave new meaning to a relationship that was unable to become effective. What allowed the provider to do that? Certainly, his connection to what was going on between him and his client and his openness to hearing from her what being there meant to her. His ability to notice what was going on with himself at that precise time and to act based on such openness facilitated the provider–client relationship.

The openness established by the therapist allowed him to recreate himself in the face of the client’s unpredictability and to establish contact with an unknown individual emerging from within to express herself to another. This impelled her based on how the encounter was affected by the experience of the relationship established between the two (Gantt & Burton, 2012; Vieira & Pinheiro, 2013, 2015). Only by being open to listening to the imponderable aspects of the relationship, was the therapist able to assume an attitude that was attuned to the client’s desire, at first unimaginable, to be left alone, which she had expressed through her initial silence.

Together with the classic and sometimes standard question, “what brought you here,” the provider’s attitude in the above example includes another, implicit question, “what can I do to enable you to talk about it in the most meaningful way possible” or “I am very interested in listening to what you have to say, and I will do everything possible for this to happen.” EPC providers can allow themselves some indiscipline, in that the flexibility of “doing away with protocol” allows them to bring new possibilities into the therapeutic relationship or that the relationship shapes the specific actions.

We believe that the provider’s interest may be understood based on the notion of presence, which means “the immediate experience of (two or more) persons encountering each other in a given moment, in a moment-by-moment process in the respective present” (Schmid, 2002, p. 184). To be present, therefore, means to connect with what is happening moment by moment and to be available to recognize the client’s difference and respond in a way attuned to this difference. This involves assuming an ethical position according to which the other is considered a provocation and thus admitting the possibility of being transformed by them and that the other might also be changed somehow.

Therefore, this is a recognition relationship, which, according to Schmid (2018), means to accept and confirm what they are and what they might become within the encounter’s relationship. Recognition, as understanding, does not aim at anything but itself, that is, it is not a tool to trigger other processes beyond the recognition and understanding of the client as someone different; it is not a device to attain something else, although it is followed by after effects (Gantt & Burton, 2012; Vieira & Pinheiro, 2015).

In the example described above, the provider was able to signal that he was paying attention to what was happening, and he did not hurry to find or state a solution but offered the possibility to explore with the client what was going on between them at that moment. He recognized, accepted, understood, and simultaneously took a stance and responded based on his perception of what was going on between himself and the client and invited the client to participate in the construction of the intense process implied by their mutual relationship. Both individuals asserted the possibility of that moment being constructive to both persons and their relationship.

Upon assuming that position in the relationship, the provider established his place as the facilitator of the expression of the client’s experiences and his nonknowledge about her. In addition, he legitimized her feelings; offered her the opportunity to have an experience of autonomy and responsibility for herself; and concomitantly created an atmosphere of understanding, acceptance, warmth, and safety, within which the client could explore and be taken by her experiences and reorganize herself—even though this involved some degree of disorganization of what had already been established as true and crystallized.

Notably, this type of attitude should not be confused with some type of spontaneity. EPC providers who conduct their work based on PCA, for example, know it is not recommended to provide any interpretation to clients. Nor should they give any type of indication of what clients should do about the problem in question. They also know that if they succeed in being genuine and understanding in the relationship with their client, they will be close to what is desired from a therapist that is familiar with the PCA framework. The specific way to do this is necessarily linked to the relational context.

Therefore, there is a clear indication of principles and few prescriptions on how to actualize them. To act based on this logic is to transit between the unknown and the familiar, that is, to use the available tools as principles for action and simultaneously admit that these tools might be changed by the reality of a particular relationship. In other words, one must look at everything already established (techniques, for instance) from the strangeness of the moment that permeates the relational context (Gantt, 2000; Gantt & Burton, 2012).

Based on Amatuzzi (2016), we understand the provider’s and client’s response as authentic speech, to wit, “a synthesis speech, which actualizes an individual’s present state of being. For this reason, it reveals [the individual] in all his/her possibilities. It does not merely state: it performs, it does” (p. 127). Both the emergency care provider’s and the client’s authentic speech do away with the stereotypes that either one of them might engage with at the onset of their relationship and updates their contact with each other’s alterity. This means that even when both individuals already know the content of experience (which is often the case), the way of expressing it is fully new, as it emanates from the present time and the relationship with the other. Therefore, the individual’s position in the face of such experience is what changes, rather than the content of the experience as such.

Both the provider and the client enter into a relationship in which they need to learn, ideally, to evaluate what is more significant for themselves, that is, what seems to be full of meaning and involves them when it is said. Therefore, all efforts made, particularly by the provider, are for the sake of being attentive to the other and to how they are affected by what is received from the other.

From the perspective of training, mechanisms are necessary for EPC providers to learn how to evaluate the present time in a receptive manner for both themselves and the other. Rogers (1983) said that it is necessary to stimulate a type of knowledge that involves professionals in the process of knowing—meaningful learning. This is only possible when they are allowed to question themselves about the sense of what they learn and, consequently, how they position themselves in the face of such knowledge and their willingness to receive it.

In our experience, the path we found for a provider to approach the experience of EPC involves the use of sense versions, an instrument developed by Amatuzzi (2014) that provides a sort of “affective radiograph” of the encounter with the client. It essentially consists of a short narrative in the first person written soon after the encounter with the client (such as an EPC session) in which the professional attempts to describe what they found to be most meaningful. It is quite far from a linear, detailed, and exhaustive narrative because our interest is in understanding what aspects of the relationship with the client have particular value for providers so that we can, together with the professional, explore their experience of the relationship in its dynamic aspects. We believe that the more providers write and read about their experience to colleagues and supervisors via this model, the higher their odds of being present in the relationship with clients.

Within this context, both content and techniques—as well as learning related to training providers—affect the relationship, and value is given to feelings. This is because supervision aims to provide room to reflect on the provider–client relationship and to strengthen the bond between providers and their supervisors so that beginners can improve their ability to be touched by the affection involved in a relationship of openness with a client (Vieira & Dos Anjos, 2013). In turn, supervisors should, instead of merely instructing, invite EPC providers to be part of a relationship in which the presence of those forming it—a pair or a group—is emphasized (Vieira et al., 2018). Supervision might occur when EPC providers experience and ask themselves about their willingness to open themselves to establish contact with their own and the other’s dimension of strangeness.

Therefore, this is a type of learning that involves affection and feelings associated with a theoretical comprehension (Rogers, 1980/1995). This process involves the entire individual, and thus, the more cognition and affection walk together, the higher the odds are for EPC providers to be present in the relationship with their clients (Rogers, 1983). The more “teaching” situations create conditions for individuals to perceive themselves as present and whole, the higher are the odds that they will appear as such to the clients who seek their help at EPC services.

Supervision, in this context, acts like a space that invites the providers not only to report their and their client’s behaviors but, especially, to make sense around the interpersonal relationship between them and the person seeking help. It is, therefore, a step ahead of what Rogers (1983) called significant learning, as it occurs in a context of sense production around a certain relational experience with a clear phenomenological inspiration (Amatuzzi, 2014).

Unconditional positive regard and empathic understanding: Conditions of (not) knowing to make alterity present

Based on the previously described aspects, all of which are interwoven in the process of becoming an EPC provider, we considered the existence of two primary attitudes that appear as sources to access the other: unconditional positive regard and empathic understanding. Rogers (1951/1965) postulated, in his theory of personality and behavior, that “the best vantage point for understanding behavior is from the internal frame of reference of the individual himself” (p. 494). In this proposition, we consider every behavior of the client as a reaction to their phenomenological field, which manifests to the provider the expression of their experience in organismal nuances. It is the provider’s work to do their best to enter the experience world that the client presents in their expressions during the encounter.

Rogers (1957) postulated the condition of unconditional positive regard as necessary and enough to be sustained together with empathic understanding—and other conditions that are not the focus of this reflection. We understand that the attitude of unconditional regard must be sustained by the therapist to perceive how the expressions of the client’s experience affect them. To consider the client is to recognize their experience as a valid area in which to know what they experience. To appreciate this is to sustain an action of not imposing a value (price) on what the client experiences, not judging them, but recognizing the values that emerge from them regarding their needs.

In a phenomenological implication (Stein, 1917/2007) to rethink the condition of unconditional positive regard (Rogers, 1957), we understand that this attitude is a management of the affections (pathos) triggered by the expression of the experience of the client to the provider. These affections vary as follows: if the client’s expression affects the provider so that the provider legitimates it according to their own experience, the result is sympathy (represented, for example, by esteem reactions); if the provider contests the client, the result is antipathy (e.g., a reaction of disgust or prejudice); if the client has no sufficient impact to provoke sympathy or antipathy in the provider, the result is apathy (indifference toward the other). Therefore, depending on how the provider’s experience was affected by the client’s expression, the result may be sympathy, antipathy, or apathy. From these affections, value judgments emerge from the provider and are expressed and perceived in terms of impressions about what the client expressed.

It is worth highlighting that the contents that arise from the provider’s experience and that are developed from what the other presents are related to value judgments. This is why the provider has a constant state of attention toward how the client affects them and what comes from this. By becoming aware that these value judgments come from the provider’s experience and are not natural, coming by themselves from the client, the provider makes an effort to suspend them, remove them momentarily, and to make an effort to focus on the experience of the other, which is central to the relationship. However, what was suspended and comes from the provider’s experience must be recalled and analyzed during the supervision to assess how these affections and judgments are building the provider’s experience and whether they are limiting or hindering their access to the other’s experience. Thus, one recognizes what belongs to the client’s experience and the provider’s experience, and which elements allow the (dis)agreement in the relationship.

The unconditional positive regard implies a search in which the provider fights to place themselves before the other from their own experience but making an effort to consider the client’s experience from what they show. Positive regard does not necessarily imply agreeing with the other and its absence does not imply disagreeing or being neutral. It means attention and an ethical attitude to take the other’s experience as a place of truth and valuable knowledge, even if it causes strangeness in the provider. Unconditionality implies that the provider does not establish, from their affections and value judgments, conditions to engage with the client.

From the attitude of empathic understanding, the provider makes themselves present and available to enter the client’s experience. However, to make this relational attitude present, “the various meaningless and strange behaviors are seen to be part of a meaningful and goal-directed activity” (Rogers, 1951/1965, p. 494). Although recognizing an attitude of strangeness in the face of the other and an attempt to make this experience knowable, the provider will always oscillate between a place of knowing (nonstrangeness) and not knowing (strangeness) in front of the client. This oscillation is essential and present in the process of becoming an EPC provider due to two factors: the limits/possibilities of empathic understanding and the dimension of alterity.

Empathic understanding by itself is a condition/attitude that contains at its core a constitutional limitation since “To point out the advantages of viewing behavior from the internal frame of reference is not to say that this is the royal road to learning” (Rogers, 1951/1965, p. 495). What is experienced and denoted by the client to constitute the phenomenological (perceptual) field that makes up their personality and behavior can only be accessed in its entirety by themselves. There are, therefore, two factors that limit the empathic understanding of the provider regarding the client.

Empathy is a dimension of affection (pathos) that is basic to human beings (Costa & Telles, 2017; Fontgalland et al., 2018; Goto et al., 2016; Moreira & Torres, 2013). It is an ordinary (daily) act of becoming aware of the presence (coexistence) of another as someone with the same basic processes that make up a person (Stein, 1917/2007). Like the provider, the client has sensations, emotions, feelings, perceptions, thoughts, personality, and behavior. However, each one uniquely accesses these experiences according to how these processes are activated and elaborated (represented) as meaning. Thus, the dimension of the sense of experience connects the provider to the client as a living being with the same psychological processes; the dimension of what is meant and represented from this experience makes up the contents and makes every experience unique.

A client, for example, who seeks help expressing sadness (sense) because their father died in a car crash and they regret having had a fight with him and being unable to say goodbye (meaning) is received by a provider who does not necessarily have the same experience but connects to the other because the provider knows how it is to be sad based on other sources of experiences. Experiencing what the other feels, that is, its sense (sadness) and content (death of the father and regret about fighting with him) is accessible to both, so that, in short, both client and provider are affected by their contact with each other.

Thus, the act of contact is enough to establish the act of empathy toward the other, that is, becoming aware that a client is a person, a living being, just as is the provider (Stein, 1917/2007). Both are similar by being individuals with the same psychological processes but not equal because these experiences vary in their content and sources. The provider has to recognize not only that empathy establishes their relationship with the client but also, from their experience, what interferes with the expression of the client’s experience and what from it affects them. When the provider finds themselves showing sympathy, antipathy, or apathy toward the client, they must perceive this judgment flow as the source of their experience regarding the client and pay attention in order for it not to interfere in the client’s expression.

Additionally, according to Rogers (1951/1965), the knowledge of the internal reference frame of the other is linked to a communicational manifestation. Communication is the act of making something common. It is, therefore, a conjoint apprehension (com-prehension) of senses and meanings that emerge in the relationship. When the client expresses their experience to the provider, the provider apprehends (captures) it from their own experience but always considering the other unconditionally. However, this capture remains in the provider’s experience in terms of impression and the provider needs to assess, ethically, whether their apprehension was accurate and respectful regarding the manifestation of the other’s experience. This is why the provider is concerned with sharing their apprehension and impression with the client so that they can clarify which sense and meaning of the expression were captured. It is the moment of presenting the perception and knowing how close it is from what occurs in the client’s experience. The client will confirm whether such apprehension was accurate or not. In this mutuality, the apprehension is shared and validated in its sense and meaning by both, establishing comprehension (conjoint apprehension between provider and client).

When the client manifests a situation that upsets them, this expression occurs through the current flow of their experience. Thus, the expressive manifestation is perceived by the provider and they try to apprehend the sense and meaning of the experience, which is not, anymore, current to the flow felt by the client. What is current and present in the client’s experience flow will never be completely current and present in the provider’s experience. What happens is a search for the approximation of senses and meanings to what emerges from the provider–client relationship. Thus, although limited, empathic understanding is an essential source to entering the client’s experience, respecting it, and recognizing and considering the emotional impacts that it has on the provider’s experience. The understanding sphere of senses and meanings of the client’s experience is what makes the empathy in EPC something extraordinary (beyond daily life) and special in this type of interpersonal relationship.

The factor that triggers the oscillation between knowing and not knowing in the process of practicing EPC and becoming an EPC provider is the dimension of alterity that is present in the act of empathically understanding the other. Rogers (1980/1995) understood that society consists of multiple realities from different perceptive fields created by people’s experiences. As long as there is a reality component that is shared and allows the same access to perceptions and ideas/judgments about the same object, there are endless unique elements of reality that are immersed in the way each individual experiences the world. Thus, Rogers (1980/1995) emphasizes a position of commitment with each person in their uniqueness and distinctions. In Rogers’ opinion, it is not about becoming fond of the other through what they have in common with me but becoming fond exactly through what in them is different from me. There is a teleology in the person-centered approach that is stretched in EPC and comes closer to the recognition of the alterity dimension that is present in human experiences.

The effort to unconditionally consider and empathically understand the client is to enter the unit that organizes one’s experience in its potential and search for self-fulfillment, with the difference that it presents and represents to the providers their condition as a person. By internalizing what the client expresses, the provider breaks up with what is neutral and assesses the affective impact of their experience. As the provider moves their interiority to the client-directed exteriority, the client, in turn, reabsorbs themselves and elaborates what was expressed. It is through the presence of the other in the provider–client relationship that every apprehension and sharing or sense and meaning rises toward a relational totality that is present in the encounter and idealizes an infinity, that is, the relationship always reveals something that is not proper of either the provider or the client but of the relationship that arose from the encounter (Vieira & Pinheiro, 2013).

One can notice, therefore, that there is an ethical implication in the analyzed conditions because the provider’s practice occurs through the orientation of dealing with the unknown, by making it known, and of seeing as strange everything that is known and does not generate changes and movements in the relationship. It is the provider’s duty not to remain attached to their own standards since they must avoid trying to fit the client into such standards. Effectively, the other’s ipseity in the relationship is highlighted, allowing an encounter with the unrelatedness.

Final considerations

To conclude the present reflection on the condition of becoming an EPC provider, we observe that the dimension of alterity in the empathic understanding in EPC evokes the idea that all understanding of the other’s experience is an understanding of oneself. This dimension is crucial to broaden the emergency care providers’ experience in the sense of increasing their presence and availability to encounter the client. Finally, the practice of EPC expects the described training and intervention trajectory to be extended to other types of relationships, without clinging to protocols, techniques, or diagnoses. Therefore, we consider that an attitude of openness to any type of demand during a certain period, regardless of the subsequent referrals or clinical developments, radicalizes the professional–client encounter according to the qualities indicated in this article.