Abstract
This article discusses the issue of using touch in psychotherapy and addresses the difficulties encountered in discussing the topic. These difficulties include confusion about the purpose of touch, lack of experience among psychotherapists in the use of touch, and misunderstandings about who actually uses touch in psychotherapy. The article then addresses the anxiety psychotherapists feel about using touch such as fears of sexual provocation or physical aggression. The importance of touch in emotional development and everyday life is emphasised and the benefits of using touch in psychotherapy detailed. Two cases of the beneficial use of touch are presented with comments from the clients, and the concept of “contactful touch” introduced. Finally, based on the author’s experience as a body psychotherapist, trainer and supervisor, some guidelines are suggested for how touch can be introduced into psychotherapy.
KEY WORDS: contactful touch, anxiety about touch, benefits, guidelines, vignettes, touch debate
Introduction
Much has been written on touch in psychotherapy and it comes around as a theme for conferences every few years. It is a popular subject for student dissertations within the humanistic and integrative psychotherapy field (see for example, Ball, 2002), but touch remains an uncomfortable issue to deepen into, and the professional debate moves relatively slowly given the evidence for its benefits. I was trained to touch and how to discuss it in psychotherapy. Touch was an integral part of my first individual psychotherapy, but not my second. I am comfortable with touch in the therapeutic endeavour, and include it fluidly as part of communication with clients. This article considers the reasons why the discussion of touch is so difficult and confusing and why the debate about whether to touch or not develops comparatively slowly. It discusses anxieties about touch in psychotherapy and society, why touch is so difficult, and the benefits of touch. Using vignettes from clients to illustrate how touch is essential for some clients, the author explains how she understands touch and offers guidelines on touching in psychotherapy
Some thoughts about why the touch debate moves slowly
Confusion about the purpose of touch
At conferences discussions about touch can be confused, even for body psychotherapists, as well as for humanistic psychotherapists and psychoanalysts. Often it is not clear whether we are thinking about touch as a symbol – perhaps of the mother and nurture, or something to be included for clients with developmental deficits, or as a tool for physiological calming with a goal like reducing anxiety or lifting depression, or a way of gratifying impulses, or as a tool to provoke catharsis. All of these are possibilities, but depend on different ways of viewing touch in the therapeutic endeavour. Often the discussion is adversarial with discussants defending their positions. These are often polarised as “to touch or not” to add interest, but this does nothing to engender a safe dialogue, where it could be truly possible to find some new insights about a difficult topic.
One way to cut through some of the muddle would be to map out the territory and the different ways that touch is used in each domain. Weber (1990) proposes one such model and identifies three perspectives from which to discuss touch. These are the physical-sensory, the psychological-humanistic, and the field. The physical-sensory view is reductive, mechanistic and medical. Discussion is dualistic, tends to look at the physiology and anatomy of touch, and techniques. The source of the touch is irrelevant i.e. who or what is touching. The psychological-humanistic perspective is closest to phenomenology and existentialism. It is concerned with subjectivity, and human feelings such as love and empathy. Interaction between individuals is purposive and self conscious. “I-Thou” relating is whole person relating and communing with another (Buber, 1947/2002). “I-Thou” touch involves one’s whole being touching another whole being. Touch is reciprocal. The field perspective fits with Eastern philosophy and incorporates the other two perspectives. Individuals are regarded as “localised expressions” of the energetic field. Intentionality is fundamental to relating; and the intention of the giver makes a difference to the touch, and how it is received. Intention is energy, which impacts on the other, and may be experienced before the actual physical touch occurs. This is because organisms resonate and attune with each other via non-sensory means. This is both literal and metaphorical. Touch as “reaching” the other, meets the other at deeper levels than the observable. In field theory everything is connected and meaning comes from the context. Structure and function are not separate and in therapeutic work the client and therapist co-create the field together. The contact between them organises the field and the relationship takes its particular shape (Parlett, 1991).
The lack of experience of touch in psychotherapy
A further difficulty in discussions is that participants may have no experience of touch in their training or individual psychotherapy, apart perhaps from “sparing” touch in a not very thought out way, or some social touching such as handshakes, or hugs at the ends of sessions, or in the gap between the consulting room and the outside door. Tune (2001, 2005) found in research interviews that therapists initially stated that they did not touch, but when he prompted them, they realised that they did touch mostly in the spontaneous social sphere.
Filling the touch gap
One way of filling the touch experience gap is to have massage or a body therapy such as craniosacral therapy alongside analysis or psychotherapy, or after completing initial training. When touch is split off in this way from the psychotherapeutic relationship it creates its own problems, and is quite a different experience from the possibility of having a range of ways of communicating in one relationship. So this leaves discussants speaking from everyday experiences, combined with theoretical ideas and rules. For the discussion on touch to progress, I believe that touch has to be experienced to enable talking from an informed position.
Assumptions about who touches therapeutically
The common assumption is that psychoanalysts do not touch, and indeed, are supposed not to touch – the rule of abstinence. The rule of abstinence appears to be more prominent amongst Freudians, but is also found amongst Jungians, although Bosanquet (2006) has observed that Jung made no clear prohibition on touching. Well-known examples of not touching are Patrick Casement’s (2002) work with Mrs B., who was severely scalded as a child, and also Joy Schaverien’s (2002, 2006) relationship with a dying patient.
However, we know that some analysts over the different decades do touch (see for example, Bosanquet, 1970; Woodmansey, 1986; Rosenberg, 1995; Toronto, 2006), but there is unease and ambivalence about it. Indeed, Ferenczi’s (Dupont, 1995) work with active methods and touch was largely ignored for years. Although Winnicott’s work with Margaret Little (1985) is held up as an example of work with a severely distressed person and touch seems legitimate, the current assessment of it is not clear-cut (see for example Kahr, 2006). Where touch has occurred in analysis it can be associated with shame, guilt and inadequacy. Something has been transgressed, which is hard to discuss with a supervisor (Pinson, 2002) or at a professional conference. Nevertheless, with the developments in neuroscience, trauma studies and research into child development, psychoanalysis has been required to reassess the abstinence rule and discussion on touch is coming out of the closet somewhat tentatively (For example, Orbach, 2003; Galton, 2006).
Contrary to popular belief not all body psychotherapists touch, or indeed have any training in touch. Some trained at the Chiron Centre for Body Psychotherapy have moved relatively more towards a psychoanalytic stance and do not use touch and active methods (Hartley, 2009). Rothschild (2000, 2002) does not use touch in her work with those who are traumatised. Young (2005) has also written on body psychotherapy without touch.
A recent step forward theoretically, is the discussion within the relational psychoanalysis – body psychotherapy debate. Asheri (2009), for example, orients her themes on touch around intersubjectivity and the therapeutic relationship. The common understanding on intersubjectivity seems to create a climate in which to reconsider touch.
Anxieties about touch within psychotherapy
The topic of touch does provoke anxiety. Authors who advocate touch in psychotherapy are emphatic that they are discussing “ethical touch” and are “thrifty” with their use of it. The most prevalent fear is that touch will provoke sexual acting out by both parties. Mintz responds to this and asserts:
To this writer it seems absurd that any qualified psychoanalyst should be so carried away by contact with a patient, however attractive, that he (or she) could not refrain from complete gratification. Such an impulsive person would not be safe on a dance floor. (Mintz, 1969, p.371)
Research has indicated that psychotherapists who touch are no more likely to act unethically than those who do not touch (Milakovich, 1998). Denman (2004) informs us that sexual boundary violation involves the “gradual erosion of customary boundaries” (author’s italics) (p. 298). Nevertheless there remains a tendency to link touch with sex both in psychotherapy and society more generally (see, for example, Davis, 1991).
Other fears are that touching a client may be aggressive or will lead to aggression.
Additional arguments against touch include that it may be manipulative; that it brings too much reality in and spoils the symbolic aspect of therapeutic work; that it keeps the client dependent in a pre-oedipal state with no room for envy, competition and the development of autonomy; and that it heightens the emotionality of the client.
Nowadays there is also the fear of false accusation and litigation making psychotherapists less adventurous. Nevertheless, the Health Professions Council consultation document for Dance Movement Psychotherapy (2009) includes touch as a differentiating factor from other creative arts psychotherapists. However, Popa and Best (2010) highlight the lack of detailed ethical guidelines and theoretical foundations for the use of touch in Dance Movement Therapy.
Challenging the anxieties
The training analyst, Braatöy (1954) writes of the “tremendous gift” to certain hysterical female patients of not touching and the message it gives of being interested in “me” and supported Freud’s ideas, based on his work with hysterical females, of shifting the focus to frustrating impulses and work with transference. Braatöy collaborated with the renown Norwegian physiotherapist, Aadel Bülow-Hansen, and studied with Reich, and also observed:
…persistent withdrawal, the absolute and holy rule, “never touch” may be reacted to as if it expressed a fear in the therapist similar to the patient’s own fear. In such cases, the absolute rule may paralyze the treatment. The patient will not let herself go because the therapist seems to be just as frightened of the essential thing, the body and its impulses, as she is herself. (Braatöy, 1954, p. 224 original italics)
He recalls defensively placing a table between himself and a female patient, and also observed that persistent verbalisation by the analyst can be interpreted quite rightly as defence.
Touch in society today
During the 1970s, along with many others, I met with friends to learn how to massage using Downing’s (1972) book on massage. Whilst there is now more ease in some parts of society with massage and touch, we have ambivalent feelings about touch and remain afraid of the intimacy involved (Leijjsen, 2006). With this comes uncertainty about pleasure and sexuality. The roots of this lie in how we were treated, and how we continue to treat children in our society. Intimacy between parent and child still gets regulated into feeding routines, carrying babies around in car seats like parcels, and not picking the child up for fear of spoiling. This leads to a deficit of touch experiences, and the lack of a continuum of touch communications and “understanding” of the nuances of playful touch, soothing touch, caring touch, and the pleasure of contact. Cornell (1998) has drawn our attention to Reich‘s (1983) paper on the origin of the human “No” and how painful it is for an adult to feel fully alive, when they had the “joy of life” crushed by a cold, unresponsive mother. This remains as pertinent as ever. The risk management culture in the U.S.A. has led to the avoidance of anything risky regardless of any benefits (Zur and Nordmarken, 2009). In Britain, mistrust has also been institutionalised (Furedi and Bristow, 2008) and rules are made to make everything safe and to dampen spontaneity.
How might touch help?
Touch is “chief” amongst the languages of the senses. “The communications we transmit through touch constitute the most powerful means of establishing human relationships, the foundation of experience” (Montagu, 1986, p.xv). Touch is vital in infancy for development (e.g. Spitz and Wolf, 1946; Bowlby, 1997/1969; Brazelton, T Berry, and Cramer, B.G., 1991; Schore, 1994; Trevarthen and Aiken, 2001; Travarthen, 2004). Sadly most of our clients will have had inadequate or inappropriate experiences of touch. Less is known about the touch needs of adults, including the elderly, but an awareness of ourselves through skin contact of some sort does seem to be important for an ongoing sense of self.
From a medical perspective touch including massage has numerous benefits. These include lifting mood in the treatment of depression, including post-natal depression, reducing anxiety, pain relief, reduction in muscle tension, decreasing raised blood pressure, enhancement of immune function, improving sleep, decreasing the symptoms of sexual abuse, reducing aggression in adolescents, and improving weight gain in preterm neonates (See for example, Field, 2003; Westland, 1993, 1993a).
Touch in psychotherapy
The literature on touch in psychotherapy describes a wide range of reasons for its inclusion therapeutically. Each position is underpinned by a theoretical stance and there is some consensus gradually developing across modalities. The categories below are an attempt to map the use of touch. The specific criteria fit in more than one grouping and are the author’s categorisations of the literature.
- For traumatised clients
Containment, facilitation of safety, holding, reorienting and reality testing in anxiety (Mintz, 1969; Hunter and Struve, 1998). Fear reduction (Liss, 1974). Dissipation of the transference and to make the symbolic concrete (author’s view). To learn to stay present and take charge and not dissociate (Showell, 2002). Reaching frozen clients (Jacoby, 1986). - For those who are emotionally and physiologically dysregulated
To soothe or enliven, and balance the autonomic nervous system. (Eiden, 1998). To restore the psycho-physiological repair systems of the organism as in Biodynamic Body Psychotherapy (Heller, 2007). Creation of a non-verbal form of safety and relationship where the client can make a stronger contact with themselves and their inner sensations and allow internal movement. (Eiden, 1998). - For those emotionally defended
To provoke catharsis, emotional expression and release. To reduce resistance and armouring (Reich, 1961, 1970; Lowen, 1975; Smith, 1985). - For those with childhood developmental deficits and traumas
Symbolic mothering when the client is incapable of verbal communication, perhaps where there has been a deficit in childhood (Mintz, 1969; Bosanquet, 1970; Toronto, 2006). Mirroring, (McNeely, 1987). Connection with the “child within” and its suffering (Jacoby, 1986). Nourishment of the physical connection to experience the presence of the therapist in non-developed patients (Goodman and Teicher, 1988). To explore, amplify and to give feedback (McNeely, 1987), and connect body sensations with touch, and to bridge physiological awareness with feelings (Eiden, 1998). To develop a stronger sense of the skin boundary to foster differentiation and separation (Cornell, 1998). To facilitate the client’s capacity for organisation and sustaining emotional and interpersonal structure (Cornell, 1998). - Embodiment of aggression and pleasure.
Controlled exploration of aggression as in arm wrestling (Mintz, 1969). Bringing energy into the body to experience pleasurable streamings (Boyesen, 1976); Liss, 1974, Southwell, 1988). Exploration and re-awakening of pleasurable sensations in the body and re-connection with the sensual and sexual self; or the exploration of the revulsion of pleasurable body sensations (Staunton, 2000; Cornell, 1998). To deepen the level of intimacy and to differentiate emotional and sexual intimacy (Cornell, 1998). - Increasing energy flow
To free energy flow and to allow breathing to deepen (Older, 1982; Totton, 2005). To revitalise a client cut off from feelings (Tune, 2005). Putting information into the organism and creating energy flow throughout the body and increasing self sensation (Davis, 2001). Connecting energetically with the spiritual as described by Carroll (2002). - Deepening experience in relationship
To focus attention (Older, 1982). To emphasise a verbal statement (Older, 1982), and increase self exploration (Pattison, 1973). To explore relatedness and closeness and to discover that this does not have to be sacrificed for autonomy; To deepen the client’s experience and relational needs (Cornell, 1998). - Real relationship
Conveying a sense of self worth and communicating acceptance (Mintz, 1969; Eiden, 1998). Relating to the client as an adult in post-oedipal states (Asheri, 2008). Spontaneous and natural expression of the therapist’s feelings (Mintz, 1969; Smith, 1998)
Examples of touching therapeutically from the client’s perspective
There are clients for whom touch is an essential part of the therapeutic relationship. A Jungian analysand describes (permission given) how the history of receiving touch from her analyst has taken her to the beginnings of sensing relationship without touch. She writes:
My therapist had often talked about the space between us as if it were alive with feelings, and that there could be contact across this space. I had always felt it to be an empty nothingness … We explored where my therapist might be in the room in relation to me. A problem I have had is that when I lie on the couch and close my eyes, I often lose all sense of my therapist being present. She sits a little behind me and I can find it hard to keep any awareness of her unless she is touching me. In this exploration, I found that there was an area in front of me where I could sense her strongly with my eyes closed, but as she moved to the side, and more behind, she would disappear. As a result, we have varied our spatial relationship, with her sometimes sitting more in front of me as I lie down. In that way I can both have the relaxed space that comes when lying down but without dropping right into an empty place where I feel alone and abandoned unless I am physically touched.
Similarly a body psychotherapy client (permission given) writes:
… my psychotherapist respects and honours my boundaries, my insecurities and the space that opens up when I am unable to verbally express what is going on for me (author’s italics). We are in relationship to one another, and as such, my experience of him and the therapeutic space is one of safety.
She continues from her diary:
I am touching a well of grief: a long hollow place that is empty and I keep falling and falling. This is not the emptiness of dissociation; this is inside, a place deep inside that goes on and on. It sits underneath the anxiety, the anxiety always there to keep me apart from this emptiness, from the depth of the aloneness, from this dark fetid hollow. Here I am excluded, and separate – solitude. I am touching the dark void, the abyss I am falling into the darkness alone. I touch this well of dead grief – I am dead grief, and I howl and long to be contacted and held. As I curl up, my therapist is there, and carefully, gently he places his hand on my back, he is a witness to my grief, he is there with me, in my grief he makes contact – he holds my grief without taking it from me, without fear he holds it alongside me, there are no words, there is the contact. I feel the warmth of his hand on my skin, but it does not interrupt my grief, it lets me know he is with me, it lets me know he can take this pain, that he recognizes the aloneness and without wanting to fix, cure or interrupt he sits there with it and me … I am alone but with someone, a benign someone, and it all feels a little more bearable.
If I generalise about these client examples with their unique differences, they might be considered in terms of development trauma and/or deficit, possibly alexithymia. When the client’s system becomes overwhelmed with arising sensations and feelings, there is no language capacity to articulate what is occurring. At a certain point, “there are no words” and the client no longer feels/does not feel the presence of the psychotherapist. For clients who can accept touch it can be a rapid way of bringing them back into relationship (Eiden, 1998). This is skilled work and not to be undertaken lightly. Clients who are more traumatised have less capacity to differentiate the touch communications of others (Fagan, Silverton, and Smith, 1998). Ford (1993) has developed a structured protocol for therapists to employ to explore touch, when the client has been sexually abused – one of the major areas of trauma.
Contactful touch
When I worked at the Chiron Centre (1983-1995), we adopted the term “contactful touch” for the way we related to clients through touch. We acknowledged touch as a language in its own right that does not always easily translate into words. Touch contact can be much deeper than any verbal communication, and is informed by presence, intentionality and congruence between other forms of communication (Westland, 2009). Touch is relational and part of a range of ways of communicating. Contactful touch always happens in the here and now, moment by moment. In the moment of touching, I am also touched and out of that communications occur. When I touch I do not have a predetermined goal. This form of touch is more a bottom-up, than top-down approach.[1] Technical knowledge about different types of touch may give some idea of how the touch might be received, but I can never really know. Contactful touch is underpinned by Weber’s (1990) field perspective. Touch is not a technique or an intervention. Touch becomes technique when the client becomes object and I am subject as in “I do bodywork”. When touch is exploratory, awareness is placed in the hands and there is movement into the unknown with curiosity. I cannot explore what I already know. So whatever form the touch takes, contact is fundamental to it. Carroll sums this up as “Touch is a multiplicity of possibilities each with context in the specific relationship at a specific moment”. (Orbach and Carroll, 2006, p. 66)
Guidelines on touching (or not) in psychotherapy
After 30 years of clinical experience, I have come to the following thoughts about touch:
- Touching in the therapeutic relationship requires experiential training. This includes knowledge of how to touch contactfully, having a coherent theoretical perspective, knowing how to monitor both one’s own and the client’s responses, being able to discuss touch as an aspect of the ongoing relationship, and having adequate supervision from someone who has also had touch training.
- Touch has to be discussed at the initial contracting stage and explanation given about why it is included in the psychotherapy, and mentioned again with first “touchings”. This initial discussion should be matter of fact. It cannot be assumed that someone seeking body psychotherapy will want to communicate partly via touch.
- The client and the therapist at this moment and with this client should be comfortable with touch. This is an ongoing issue and has to be considered regularly as part of a process review. The touch should be considered as an aspect of the relationship and its discussion from a meta-perspective can strengthen the therapeutic alliance. The relationship is the main focus for informing the touch.
- Social forms of touching such as handshakes and hugs around the edges of sessions are to be avoided. These may have a place in the actual session, where they can be discussed.
- Relationships are complex. We are multi-faceted and any communication including touch can be multilayered in meaning. Feelings about touch communications can emerge later. The therapist may have to initiate this discussion, preferably in terms of the ongoing relationship.
- The touch has to be spoken about. The spontaneous “fatherly hug” given without bidding at the end of a session to a client sexually abused in childhood may not be perceived as a “fatherly hug”.
Conclusion
Touch is intrinsic to communication, and without it relationship is partial. Whilst there is some slow progress towards the acceptance of touch for clients who are emotionally deprived, more has to be done to further its more widespread inclusion. For this to happen, dialogue about touch in relationship has to move from adversarial debate to discussion that can hold both the universal (or general) and the particular (or specific) and not confuse them. The problem with touch is that it is not easy to pin down and make safe. Any touch in psychotherapy will be multi-layered with meanings and experiences that cannot be pre-determined. It is not possible to be prescriptive about touch without losing some of the richness of its possibilities. Touch reminds us that we are human and are embodied. Touch can lead us into the deepest realms of intimacy and mystery. It is not surprising that we are frightened of it.
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[1] Processing of information can be seen as “top-down” i.e. relatively more cognitive or “bottom up” i.e. relatively more sensorimotor and emotional. These three levels of processing must be balanced and integrated in psychotherapy. See for example, Ogden, P., Minton, K, and Pain, C. (2006). Trauma and the Body, a Sensorimotor approach to Psychotherapy. London: W.W. Norton.