Rehabilitation patients with chronic, permanent or progressive disabilities present with myriad functional challenges. To progress in treatment, patients require creative solutions to their functional quandaries and to the difficult emotions that arise-anger, frustration, fear, anxiety or discouragement.

Focusing, a unique therapeutic technique formulated by psychologist and philosopher Gene Gendlin, PhD, may help patients work through such impasses. In his research and clinical work with patients, Gendlin identified a skill common among those who were successful in treatment: the natural ability to focus and access one's felt sense.

What is focusing? You have probably heard phrases such as gut reaction, getting in touch, getting in tune, and mind-body connection. Focusing goes deeper; it guides a patient to get in touch with his or her "felt sense" about a subject, problem or difficult emotion. During any given day, our bodies are reacting to the world around us-feeling tense, stressed, over-stimulated, relaxed and so on. The felt sense is the body's natural ability to register what is going on around us, a sixth sense so to speak, a capacity that is available to everyone.

"Our bodies are not just physical bodies," explains Dr. Doralee Grindler-Katonah, health psychologist and master trainer in focusing. "The felt sense accessed through focusing is deeper than a gut reaction. We each have a 'living body,' constantly sensing and experiencing things around us in a whole way. The body integrates this information on a level beyond our immediate thinking or feeling."

Teaching patients how to access their felt sense through focusing can be an invaluable tool in maintaining wellness. As part of my own coping toolkit and counseling work with patients, focusing enables me to manage my own disability challenges and also model for patients how to debrief themselves about distressing symptoms in a more integrated way. Some patients may already have a natural knack for "tuning in" to a felt experience about a problem; for others it would take practice. This ability can be learned and enhanced with practice and effort.

Steps of Focusing

In the focusing approach, Gendlin promotes learning from another vantage point: the body-mind connection. He encourages patients to discover self-care and self-awareness rooted in the felt sense.

For the purpose of learning how to focus, Gendlin has outlined the following steps:

1) clearing a space,

2) connecting to the felt sense,

3) getting a handle,

4) resonating,

5) asking, and

6) receiving (www.focusing.org/sixsteps.html).

With practice, one can gain confidence in focusing and may discover one's own process for focusing.

Let's look at an example of one session with a patient to illustrate the six steps.

Clearing a Space

First, ask the patient (or yourself) to take a moment to relax, be silent (seated, eyes closed) and ground herself in her body.

In this step patients are encouraged to draw their attention inward, and begin sensing their bodies. Patients can, one by one, identify all that concerns them-thoughts, feelings, physical sensations-without judgment.

The patient's response might sound something like this: "Well I feel exhausted (felt sense) right now, tense (felt sense), but also glad that I came to my appointment. But I'm worrying a lot about that math exam that's coming up, my knee. if it will get better, and then there's that argument with my boyfriend last night, and my father's latest medical results. I feel. I don't know, just overwhelmed. There is a lot now in my life. I feel tense (felt sense)."

Connecting to the Felt Sense

Second, the therapist invites the patient to focus on a concern and the physical sense of the problem. The patient is encouraged to "sit with" the unclear sense of feeling tense, overwhelmed or anxious. The felt sense often begins as a vague, unclear sense of a problem. In this step, the patient starts unpacking the felt sense, allowing herself to translate the bodily felt sense into words.

The patient might say something like the following: "I feel tense, stressed, a bit jittery (felt sense), and I don't know what it is, this week was not as bad as last week. There is a lot going on, but I feel tense in my hands, my chest, I just feel on edge. a low buzz in my upper torso (felt sense)."

Getting a Handle

Third, the therapist asks the patient to describe the felt sense. In focusing, a "handle" is an image, word or phrase which describes the felt sense, going from general to specific. Patients are encouraged to find a way to describe the quality of the felt sense until they find something-a handle-that describes the felt sense in a fresh way.

The patient might say something like the following: "I feel jittery, all wound up (felt sense). I am upset (felt sense). Yes, that's it. I am upset that I forget things. I get so anxious that I forget my medication. I forget appointments. I think of myself as a responsible person, that's it. I am responsible, and I forget sometimes (handle phrase)."

Resonating

Next, the therapist has the patient check in with the handle, and see if it resonates with her in her body. In this step, the patient is encouraged to "sit with" the felt sense and "give it friendly attention."

The patient might say something like the following: "Yes, I am responsible and I forget. That is it. I am really upset about this disconnect (felt sense), I don't know why. I don't want it to be this way. I feel lighter, a little bit of a release in my chest (felt sense). I felt so tense before, but now that I connected to that phrase, 'I am responsible and I forget sometimes,' that changed things for me on the inside. I feel relieved (felt sense)."

Asking

To go deeper into focusing, the therapist can then have the patient ask her felt sense a question, such as, "What is it about the whole problem that makes you feel this quality?" In this step, the patient is allowing herself to debrief with her new felt sense about the problem to gain more insight.

The patient might say: "I am responsible and I do forget things. That feels right, that feels better (felt sense). Maybe I can accept both things, that forgetting things does not mean that I am not responsible. I can get better at trying to not forget or if I forget, I can learn from it. I am relieved (felt sense). The other way I was thinking about it made me so anxious (felt sense)."

Receiving

The last step is to have the patient take in whatever new idea, insight or piece of information came and sit with it for a moment. Depending on the nature of the problem, patients are advised that they may have to come back to unpack the subject further or, if they feel the issue is resolved, to "welcome what came."

The patient might say: "I feel relieved (felt sense) to feel that I am responsible, and I also do forget things sometimes, that I am human, and that I need to take care of myself so I don't get stressed to the point of forgetting."

Therapeutic Uses of Focusing

Focusing can be utilized on many levels. Patients can use it daily, as a coping strategy to check in with oneself, or as a structured time set aside to unpack a problem. Grindler-Katonah, one of the founding members of the Focusing Institute, has specialized in the uses of focusing in health and wellness. There is a growing body of research on focusing in health care (see Resources) and across various populations, but applications essentially fall into two main areas.

Managing Difficult Emotions or Physical Symptoms: When patients are stuck, emotionally focusing can help get to the heart of the problem.

"Felt sense is not the same as a feeling or craving," says Grindler-Katonah. "When we bring our attention to what is underneath-the grief, fear, anxiety-we are going into the whole of the problem."

This sensibility is critical for chronic patients who may not feel they have a way out of their recurrent symptoms. Katonah notes that focusing is not about curing problems, but about expanding our experience of a problem to all parts of it-our hunger, fears, hopes, expectations, desires, etc.

In her work applying focusing with cancer patients, Katonah explains that focusing has expanded patients' emotional experience in the moment.

"Many patients undergoing cancer treatments were used to disassociating. With focusing, they were able to reconnect to how they felt before they became sick and made room for other parts of themselves-the whole of who they are."

Integrating Focusing into Therapeutic Sessions: For practitioners, a focusing approach can offer an alternative mode of therapeutic inquiry for patients and practitioners to mutually process problems. It is not uncommon for patients to feel burnt out from the chronic cycle of symptoms.

Grindler-Katonah notes that focusing can be empowering to patients. When they are prone to chronic stress, they can lose their sense of discriminating what is going on in the body. Some possible focusing-oriented questions OT practitioners could include in sessions include:

Taking time to focus: "Let's take a moment and stop to break down this recurrent problem. I can ask some questions and you can let me know what sounds right to you."

Supporting patients to process difficult physical symptoms on a felt-sense level: "Let's take a moment together and keep this physical discomfort company. Do any words or images come to you when you describe this difficulty?"

Guiding patients to stay curious: "What is it about all of that stress in your knee that you are noticing? Take a moment, and sense everything that comes up for you."

Coping with chronic medical conditions presents ongoing challenges to patients. Focusing is an invaluable tool that can be integrated into any modality.

Dr. Reji Mathew is a psychotherapist/clinical instructor at New York University. She is a disability advocate and freelance writer. The main focus of her work is to promote coping skills education for persons with chronic illness and disability. Her clinical expertise is in integrative psychotherapy, particularly cognitive-behavioral skills training. Reach her via e-mail at her website: rejimathewwriter.com.