The place of touch in Counselling and Psychotherapy and the potential for healing within the therapeutic relationship

By Joanne McGuirk

Introduction

To touch or not to touch… that is the question! Some therapists find themselves wanting to reach out to a client and make physical contact at a crucial moment but hold back. Why so? I was one of those therapists. Although very drawn to the healing nature of touch, something had blocked and prevented me and others like me from touch intervention with clients. However, on completion of the research outlined in this article, I have since used touch intervention with some clients.

In these opening paragraphs, I will introduce the major themes of the article. We develop as tactile beings. I will explore the impact on later touch behaviour of an initial, inadequate, tactile experience, looking at how the individual will grow to become physically, psychologically, and behaviourally awkward in his relations with others and insensitive to their needs. This is where the need for love has not been met in the earliest and most basic component of touch. A most powerful form of communication throughout our lives, touch can be electric and high voltage. The way in which we are touched, or the lack of touch, leaves scars and wounds which impact on physiological and psychological health. The skin is the organ of embrace. When an infant feels insecure, and the maternal responses are acts of comfort, protection and reassurance, anxiety is reduced. “Within minutes or even seconds after attaching, the subject’s hands and body relax…” (Montague, 1971). Is it possible that touch may have a similar impact on the client within a therapeutic relationship, just like the small infant needing security to reduce anxiety?

Although touch has been scientifically proven to be essential for human development and relationships, there is, however, a sense that in counselling and psychotherapy it is inappropriate. I will look at how it is a topic that stirs a lot of controversy. Its absence in training courses perhaps suggests it should be avoided. This fuels my curiosity in relation to the meaning of touch and the power behind it. Almost like a taboo subject, there is a sense that when used, it should be minimal and kept to the most basic – a handshake, or touch on the shoulder. There is a tension. Ethical concerns exist. The client, for example, may interpret touch as having sexual intent, or therapists may misuse their power to sexually exploit clients. Touch is risky. It is a form of non-verbal com- munication. There are no witnesses. Touch can be nurturing, comforting and warm. It can also be invasive and violating. This paper examines what touch would mean within the therapeutic relationship for the client who, for example, has suffered traumas of commission in early childhood. Are there risks attached? It will also explore how the absence of touch within the therapeutic relationship communicates a powerful message. Could this replicate earlier experiences of touch deprivation such as in the imbalance of power between parent and child in traumas of omission, creating further wounding? Could touch avoidance lead to therapeutic experiences being missed, depriving the client of possible healing? I will also consider how the use of touch interventions and the facilitation of healing old touch wounds can be a challenging journey, particularly as it can evoke mixed emotions in the client around seeking touch – which in the past, for many, may have had dangerous consequences. The shame attached to that can be toxic. Could this be where the work lies; replacing bad touch with good touch, a corrective experience, simultaneously fulfilling the basic need to be touched?

Finally, I will discuss the role of the therapist. There are therapists who touch and those who do not. The relationship to touch can only be understood when considered in the context of the phase of therapy, the client’s gender, culture, presenting issues, personality and their history and relation to touch. What is clinically appropriate with one client could be clinically damaging to another. The work of touch is intimate. Parts of the self may be reached and accessed where other modes of relating may not be as effective – offering an opportunity to deepen the work and the relationship, with the potential to heal mind, body and spirit. Yes, boundaries are crossed – the boundary of the skin. However, must this necessarily always have negative connotations?

Prohibition, controversy and touch

“Physical contact with the patient is absolutely a taboo (since it may) mobilize sexual feelings in the patient and the therapist” (Wolberg 1972). A lot of controversy and opposition to touch in psychotherapy is based on the concept of the ‘slippery slope’. Although there is much research into the clinical and developmental aspect to touch, most op- position comes from the legal end of the spectrum, risk management experts, insurance companies, licencing boards, malpractice lawyers and traditional psychoanalysts. These professionals usually promote the concept that any physical contact beyond a handshake is unethical, a precursor to sexual exploitation. The opinion is that an innocent touch of a hand or pat on the back starts the ball rolling and, before you know, it has moved rapidly towards a sexual relationship. Boundaries are crossed, the client exploited, and the therapeutic relationship violated. Small boundary crossings lead to bigger boundary crossings. This fear can strongly influence therapists to avoid the use of touch and can adversely affect the therapeutic relationship in many ways. Therapists who have received training in risk management can be quite intimidated by the weight attached in that they either refuse to touch clients for fear of the consequences, realistic or otherwise, or if they do use touch, shy away from bringing it to the attention of supervisors or colleagues, and stay silent. Threats of lawsuits prompt therapists to put barriers in place between their clients and themselves. Could these physical barriers create psychological barriers blocking perhaps what could be deep work and limiting the healing potential?

There seems to be confusion however, as to what exactly constitutes the crossing of a boundary with a lack of differentiation between boundary crossing and boundary violation. As a result, confusion, false accusations and fear run rampant. Is crossing a boundary necessarily always harmful – or is it simply when boundaries are violated that harm is done? Boundary violations are related to sexualised touch which is harmful and always unethical. Boundary crossing can be something as basic as a handshake, a pat on the shoulder or holding of the hand – ethical, healing and therapeutic. Unfortunately, a lot of negative press in relation to touch comes from prominent therapists, many, traditional psychoanalysts. For example, Menninger (cited in Horton et al. 1995) believes that physical contact with a client is “criminal ruthlessness” and evidence of incompetence. Some suggest that therapists should only communicate verbally, remaining separate from the client, others suggest that boundaries need to be drawn between therapist and client as opposed to around them. Touch reaches across the professional space separating therapist and client.

Risk management is about the avoidance of certain clinical interventions not because they are clinically inappropriate but because they may appear inappropriate in front of judge and jury, ethical boards or licensing boards. That an action may appear suspicious in court is enough to motivate many therapists to avoid touch at all cost. Can we let licensing boards and ethical councils determine the course of therapy, practicing rigidly as opposed to caring and acting intuitively with our clients? Risk management recommendations need not be used as guidelines to how practising should be carried out – they are simply that, recommendations:

“The danger that risk management poses to clinical effectiveness can be clearly seen in its injunction against touch which obviously has a significant negative effect on the therapeutic alliance, the number one predictor of effective therapy.”

Lambert (1991)

We’re all very good at assessing the risk in touch interventions, but what about the need to assess the risk attached in not touching?

Attachment, touch and childhood development

Love is a basic factor in all needs, and is not something that rides above the satisfaction of needs, but is contained in such satisfaction. In satisfying the child’s needs, love is experienced. Field (1993) suggests that the limbic system, part of the brain governing emotions, responds positively to the chemicals released by loving touch, releasing oxytocin, often referred to as the ‘bonding hormone’. Bonding occurs as a result of an innate need for intimate contact, namely with the mother. Depending on the quality of the touch, the parent provides comfort and affirmation and a sense of self is derived from early experiences of the presence of touch. Sensitive, gentle loving touch gets imprinted, helping the infant as they grow, to reach out and touch others in that same way, throughout their lifetime. When mother and child have a close bodily relationship, it is the basis of good feelings about the self, a feeling of bodily connectedness and sociality, facilitating a feeling of self- esteem.

The source of self-esteem is love. However, parenting styles effect the quality of attachment and Heller (1997) states that what distinguishes a securely attached baby from an insecurely attached baby is the degree to which each could feel ownership of their mother’s body, and assurance of protection. Infants need to be reassured that when they make a signal requesting basic needs to be met, they will receive accurate feedback – that the effects of their behaviour will warrant a prompt soothing response, resulting in a sense of control over their lives. When one feels in control, there is a greater assurance of psychological survival. Feeling less need to control implies that closer relationships can be formed – it is not as risky. Could similar feelings apply to the client in therapy?

Touch, bonding and healing: the holding environment and the use of touch in traumas of omission
The need of the infant for body contact is compelling. When the individual is deprived of tactile stimulation it impacts on the way the individual relates to self and others – a feedback deficiency between skin and brain occurs, which may seriously effect development. Studies have demonstrated that the absence of touch can even kill. The satisfaction of tactile needs has not hitherto been considered a basic need. A basic need is defined as one which must be satisfied if the organism is to survive. “Touch is one of the most essential elements of human development, a profound method of communication, a critical component of the health and growth of infants, and a powerful healing force.” (Bowlby 1952 cited in Harlow 1971). Could it be suggested then that infant psychotherapy exists when tactile stimulation is practiced at the earliest stages of human development? Research indicates we are hard- wired to need touch in the earliest developmental stages. Could similar be true for the client in therapy who has not been ‘gentled’ as an infant, and has regressed to that early developmental stage? A window of opportunity is provided to re-parent, provide corrective experiences, meet unmet needs and facilitate the potential for healing. Montague (1971) suggests that one potential function of the therapist is to become more precious to the client than the internal parent(s) have been.

“The attempt to get physically closer and closer to a therapist provides a base of bonding which facilitates the introjection of a new parental substitute.” (Vereshack 1993). The nature of early contact and sensory experiences, received mainly through the skin, determines how the individual experiences the world and the kind of relationships he is able to have as he grows up, his sense of trust or mistrust. Montague (1971) suggests that failure to receive tactile stimulation in infancy results in a failure to establish contact relations with others. Loving, appropriate and adequate touch in infancy and beyond has been absent for many clients. As a result of childhood touch deprivation, developmental needs, essential in the regulation of physiological and psychological health, get compromised. Touch opens up old touch wounds – often non-verbal, that occurred in relationship. When the therapist does not or cannot meet the client in their touch needs and where they are at, can this also re-traumatise and repeat traumas of omission, flaming the transference, where the therapist is seen as unavailable, cold, unmoved, removed? Earlier unmet needs and deep longings are awakened and revealed, magnified through the transferential relationship, and the ‘distortion’ of the working alliance.

Wishes, fears and experiences from the past – ‘unfinished business’ – carried over into the ‘here-and-now’ offer an opportunity for healing. The experience of inadequate, damaging parenting of earlier years means that now, in therapy, an opportunity is offered. A breathing in and internalising of this ‘new parent’ can provide a stronger foundation on which the personality can build and grow. It can help deepen the process enabling traumatic material to be experienced, perhaps for the first time, facilitating a stronger self to emerge. Can the therapist meet that void in adults, this time within a therapeutic relationship, facilitating that nurturing touch and holding, promoting the necessary growth that did not occur naturally in earlier years, or will it simply awaken a need that may never be fully met – open old touch injuries and retraumatise, increasing the depth of pain and distress?

Therapeutic Nurture

“Where human beings have not been satisfied by good nurturing in infancy, there remains an intense need for holding and touch.” (Vereshack 1993). The client’s emotional response to touch may take him by surprise as unmet needs which may well be below levels of consciousness begin to surface. Lack of touch, of contact and connection, is experienced as a separation anxiety and as adults causes us to become restless when alone for any durable length of time, wanting to be with someone who isn’t there. Loneliness has been defined as a feeling of deprivation caused by the lack of certain kinds of human contact, and is quite similar to the separation anxiety that infants and children experience when deprived for any length of time from contact with mother. Could this be what gets awakened in the therapy room?

Winnicott (1958), an object-relations theorist, talks about the ‘holding’ environment which a therapist can create for clients who did not receive ‘good enough’ mothering at that crucial early age. An individual may find tactile contact with others difficult, be it in the form of hugging, a simple handshake, or any form of bodily communication of affection. This is mainly due to the fact that his mother has failed him in her bodily relations with him; a failure in ‘motherliness’ of which a basic ingredient is “close physical contact, the hugging, cuddling, caressing, embracing, rocking” (Smith et al. 1998). Balint (1968), another object relations therapist, talked about the use of touch as part of therapy. He stated that this contact can be highly charged and always vitally important for the progress of treatment. He compared this technique with traditional psychoanalysts stating that in contrast to ‘insight’, which is the result of a correct interpretation, and correlates with seeing, the creation of a proper relationship results in a ‘feeling’ which correlates with touching. Object relations therapists try to facilitate new experiences as well as new thoughts. Touch can be a component of new experience: a door opens and there appears a window of opportunity for exploration, perhaps painful re-experiencing but with light and healing through touch. Where touch is avoided, new experiences may get missed and opportunities for healing lost. Body tensions and defences against emotions may remain held in and body work may be required.

When a client has regressed to earlier years, very often they are greeted with a ‘psychological wasteland’ – deprived of love, touch and empathy and possibly filled with neglect and damage. Without nurture, the central nervous system is wide open to feel pain. Direct touch can be called for, where the client is ‘held’ in close physical contact for long periods of time – as you would a child in pain. Vereshack (1993) calls this “direct therapeutic nurture”. The therapist being ‘good enough’ adapts to the need of the client. Over a period of time, this is perceived by the client as something that gives rise to the hope that the true self may at last be able to take risks in experiencing living, connecting and making contact with others. Although Winnicott (1965) didn’t talk much about his use of touch with clients in his own practice, there was an instance where he described the case of a client who had an absolute need to be in contact with him. She spontaneously came to have her head in his hands and a rocking rhythm developed. ‘We were communicating without words’. There is such potential in forming a strong therapeutic bond through touch, and a means of healing touch injuries created by early touch violations or touch deprivation – deepening the work.

Anna Freud (cited in Vereshack 1993) stated that “the intensity of the defence is equal to the intensity of the damage”. The more defensive a client is gives an indication to the intensity of the damage experienced. Thus there are times when intense reparative work must also occur. “One of the most profound neutralisers of adult terror is the placing of one abdomen against another.” (Vereshack 1993). This can be soothing and calming, as the abdomen is the centre of emotions. Let the emotions out, let them pass through, experiencing and containing, provoking and healing at the same time. The experience of being physically held, therapeutically, in a close and intimate way on a regular basis, can give rise to the young part of a client experiencing and feeling an embodiment of being held, perhaps for the first time. A foundation is laid, there is some sense of self, a mirroring of love and acceptance. If the therapist is in touch and completely present to the experiencing of the client then he feels what the client feels, getting to experience bodily also what it is like for the client. Empathy is increased but also the therapist’s understanding of what the experience is like for the client is heightened. It’s a way of communication – a profound way. The work is deep, body-mind healing.

Patterns of attachment and touch needs

Kreuger has argued that “the development of the psychological self depends primarily on parent-child interactions and attachments, which are governed by the physical contact that accompanies other forms of communication.” (Smith et al. 1998). How we experience ourselves is determined by early patterns of attachment – all of which we carry into adulthood. These patterns will influence the touch needs of different clients. Those of a securely attached client for example, will differ from the touch needs of the insecurely attached client. As has been discovered, touch is crucial for children’s growth, development and health. However, it may well be possible that touch is also critical for the physical and mental well being of adults.

Traditional psychoanalysis is Oedipal-oriented, with touch seen as mostly sexual. However, object relations places emphasis on the pre Oedipal issues relating to very early mother-child interactions. One of the goals of object relations therapy is mastering unresolved developmental issues – basic trust, dependency, autonomy. Helping the client develop a flexible interpersonal style, a cohesive sense of self and a strong ego that is good at reality testing. The object- relations school of therapy looks specifically at the role of nurturance and empathy both in the early history of the client and in the therapeutic relationship. Thus in deciding whether or not to touch a client depends on ego development and developmental deficiencies along with the client’s attachment style.

Attachment and bonding, as highlighted in Harlow’s (1958) experiments with infant monkeys, occurs through touch and contact, not nutrition. When physical needs are met but emotional needs neglected, the child becomes detached and emotionally unrelated to others. Without corrective experiences, the adult in therapy may be highly functioning but fail to make meaningful connections and attachments in his life to other people. This developmental failure often results in adults with schizoid characteristics – people were not a source of nurturance. Fairbairn (1952) described schizoid individuals “as people whom love has made hungry; because they fear devouring the object with their hunger, they consequently shut their hunger off”. These people live in their heads, making contact intellectually rather than with their bodies. Thus for these clients, nonverbal forms of relating, of which touch is one, can be powerful and possibly even a necessary form of treatment.

One therapist for example observed that when his client talked about difficulties, she increasingly intellectualised and became withdrawn. After six months of treatment, with permission, the therapist suggested the client place her head on the therapist’s lap whilst talking about these difficulties. Important to note – touch was not introduced in this instance until a good understanding of the client’s level of ego development was established, and it thought to be fairly certain that touch intervention, such as the client placing her head on the therapist’s lap would not cause an unsafe regression. The client expressed more emotion and cried, at the end of the session felt much better and asked for a hug, where she particularly felt connected to her therapist. Amongst other factors, the use of touch greatly increased the client’s attachment to the therapist, and subsequently attachment to others in her life. Touch in this case helped the client bond, perhaps for the first time in her life, and did not result in an unhealthy dependence or self-destructive acting out. Touch with unbonded clients can facilitate the development of attachment.

With neurotic or overly cognitive clients, the use of touch can increase spontaneity and the ability to live in the present. Glickauf-Hughes and Wells (1995, 1997) suggest that clients who have a neurotic level of ego organisation and object relations development do have a clear sense of self, and do not feel engulfed by close relationships with others. They have an object constancy – an internal positive object they can rely on for feelings of comfort and security, and when lonely do experience extreme separation anxiety or emptiness. However, the obsessive-compulsive personality for example is rigid with a sense of formality in relationship. “We have found that the use of touch in a playful way helps bypass defences and increases obsessive clients’ sense of spontaneity.” (Smith et al. 1998). Talk can be limiting. The use of touch and introducing playfulness can be beneficial, evoking laughter, dissipating the defences, and the struggle for control.

Using touch with counter-dependent clients can facilitate dependence needs to be egosyntonic. For some character types, normal dependence needs are shameful. Although parents responded to the needs of their infants enabling attachment to others to occur, they were undependable with for example, alcohol addictions, bipolar or borderline disorders. The needs of the parents took precedence over the needs of the children. Children parented. As a result, they were then shamed for their needs which weren’t met and told that they were in some way ‘too much’ for the parents. However, they were reinforced for looking after their parents’ needs and so, in the process, got their own needs met, albeit vicariously. Parenting and caretaking for others then becomes a pattern throughout life; clients aware of the needs of others, but seldom their own needs, and when they are, feeling shamed because of it. The use of touch with these clients can highlight their resistance to feeling their needs, and the resistance to dependency on others. Dependency can be dangerous. Part of the process is for the individual to give themselves permission to attach, to trust, become dependent – for as long as it is therapeutic. Thus, for many clients “touch can be a powerful tool for increasing awareness; overcoming resistance and rigid defences; and mastering the developmental phases of attachment, dependence and trust.” (Smith et al. 1998)

The healing potential of touch in traumas of commission

“Touch like fire, can be a provider of light, warmth, nurturing and movement, or of damaging and destructive consequences.” (Smith et al. 1998). Assessing whether or not to use touch interventions with adult survivors of sexual abuse can prove to be extremely complicated. Diff- erent debates exist – is it useful, appropriate or contraindicated at all times? Some believe that touch in any form should never be used with clients working on these issues, however, others believe that clinically and ethically, the use of touch with survivors of childhood abuse can be invaluable in the healing process. Touch can feel safe and nurturing – counteracting the betrayal by and loss of trust in primary caregivers who failed to protect and nurture. Some therapists do take the stance however, not to use touch interventions at all. This must be explained to the client at the outset. Otherwise old messages the client received in early years and carried into adulthood may get played out again in the therapy room, for example, ‘you’re too dirty or contaminated to touch’, or ‘if the therapist touches me, he will lose self-control and abuse me’. Cole and Schaefer (1986) suggest that this is not only good therapeutic practice, it is imperative with survivors of sexual abuse.

For therapists who do use and are comfortable with touch interventions, the client’s developmental stage and ego strength must be taken into consideration – does the client have the ability to process material with the therapist, or check out assumptions they disagree with? Hence, touch is not recommended with clients who have poor levels of ego development and object relations development as they may be unable to say no to touch in the therapy room and unconscious regression can occur. Worth noting is that clients with such a history have a higher probability of being re-victimised by their therapists. There are contraindications to touch in the early phase of therapy, as the client’s readiness is difficult to assess. A power imbalance exists also. The client may be in awe of the authoritative and ‘expert’ stance of the therapist, similar to when the survivor was a child with little or no power or control over what was happening. Contact was dangerous, touch a powerful communication of something beyond words, beyond comprehension of a young cognitively undeveloped brain and body. Compliance maintained survival; basic needs got met. Now in the therapy room, touch, or the lack of it inevitably opens old touch wounds, sends out old messages. Cornell (1977) stated that “once a strong therapeutic alliance has been formed, the use of touch will evoke, address and hopefully help correct such historical experiences and distortion”. In traumas of commission, very often there are no words to describe what happened, particularly when trauma was pre-verbal. Could it be possible that a way of communicating in the therapeutic relationship is through touch – just as it was in the pre-verbal stage? The wounding was in the touch, therefore could the healing be in the touch?

Touch with caution

Hunter and Struve (1998) suggest that:

“touch may help the therapist to provide real or symbolic contact and nurturance, to facilitate access to exploration of, and resolution of emotional experiences, to provide containment, and to restore significant and healthy dimensions in relationships.”

Within the framework of the client’s need for nurturance, touch can be seen as essential and most importantly, non-erotic, although this does not dispute the case that sexual overtones (which I will mention later) can still exist. Although permission must always be sought before touch interventions made, this may not be sufficient. Many clients want to please their therapist, fearing the consequences of, for example, rejection and abandonment. With adult survivors of sexual abuse, there may be ‘multiple ego states’. The adult professional may be well able to say no to unwanted touch interventions, however, if it is the child self whom the therapist is in contact with, there may not be sufficient ego strength to say no to a symbolic, powerful and authoritative therapist figure. Thus, it may be more appropriate to address the least developed ego state. If there is an effective working relationship and the quality of contact and connection is good, the therapist may be able to spot when ego states are shifting, and bring this into the client’s awareness. This way, touch intervention aimed at a particular ego state is received by that same ego state it was intended for.

Forer (1969) suggests that verbal contact alone leaves the individual in a limbo of isolation from their own body and indeed from other people. Touch can provoke an eruption of emotion – an unfreezing of something that never got experienced – it brings the client into the experience, brings people in touch with themselves and in touch with others. “Both truth and communication begin with a simple gesture: touch, the authentic voice of feeling.” (Montague, 1971). There may be no words, however there is understanding – communication is via the energies transmitted from body to body. It is a deep and often intimate form of contact; a powerful form of non-verbal communication.

However, if the client is experiencing episodes of dissociation, de-personalisation, flashbacks, or body memories, there is no way to assess the impact of touch and whether or not it is being experienced traumatically. The client may not even be aware of body sensations or feelings, if numbing out. So how will they know if touch is okay or not? Contracting before interventions of touch are made can be agreed on so that if the client is in a place where they are unable to speak or say no, or indeed yes, to touch, that some type of non-verbal signal be agreed on. Although the urge to reach out to a client and touch their shoulder, back or hand may be heightened at this moment, this has the potential to be experienced as restraining or re-traumatising in some way. Eye contact can be a powerful way of bringing a client back if the therapist can get the client to look at them and connect in the safety of the here and now. The connection that occurs when the eyes meet often interrupts dissociation and other altered states. This is one way of staying ‘in touch’ and has been proposed to be related to the incompatibility between shame and connection.

Hand power back – counteract shame

“Love is like air and water and sunlight. Without it we will die. When we soak it up, we feel intense pleasure. We grow.” (Caldwell 1966). If love is conditional upon how we act, then we perfect the act to get the love we need. This is pleasurable but also forms part of an addiction. However, love is both a need and a pleasure. So what happens when this need for pleasure is sought in the presence of love but the love is harmful, abusive and intrusive? Touch that is abusive or simply insufficient, or lacking when appropriate, gets recorded and imprinted. The adult may be left with the inability to regulate touch. There may be shame in seeking love and guilt in receiving pleasure. Confusion between love and pleasure and needs can be created – needs shamed. Touch opportunities for connection and bonding were doubted in the past, loving contact missed out. So could the space between therapist and client now present an opportunity to experience what was missing, lost or abused – safe contact and bonding?

Research on touch in psychotherapy is showing that those who were abused in childhood, particularly sexually abused, generally evaluate touch in therapy as positive and beneficial in the process of working through the resultant legacy of shame, fear, self-loathing and mistrust. However, therapeutic holding can both provoke and heal trauma – like a dual process. The holding can bring up past traumatic experiences however, this time the client can get to distinguish that this is not abusive holding and break through and be nurtured in the holding – ‘a warm and safe hearth in a desperate storm’. Providing ‘therapeutic nurture’ through touch and holding to a client in a regressed state, at this crucial point, can repair damage done in earlier years as the central nervous system is wide open. By being touched gently, appropriately and timely, a primitive reaction can be triggered – one of bodily relaxation, soothing and a feeling that one is not alone. Appropriate touch conveys the therapist’s emotional relationship to the client: that he is willing to be more in touch with him, that he wants to try and understand more of what is happening for him, that he sees him, and accepts him. There is nothing required or demanded in return except for the client to give himself permission to receive. Based on the concept of the Zen Buddhist of ‘no-mindedness’, the therapist facilitates the opening of the doors of the mind, but must then step aside, and allow the client’s process to unfold. Their own minds must be empty or void of their own conflicts as they remaining with the client. A ‘knowledgeable’ therapist will only get in the way of the client’s process.

Injunctions to be silent are particularly potent for survivors of sexual abuse. Interventions of any nature, including touch, can be ill-timed or misunderstood. Errors in touch may trigger an injunction to stay silent as the abused has experienced in earlier life. The silence in the therapy room may perhaps re-enact the threat given to stay silent in the abuse. Even sobs can be inward, silent. Thus, it is imperative that the relationship is strong enough to tolerate processing any errors the therapist may make or get wrong in his humanness, and sufficiently open to allow the client to use their power to contradict the therapist and put things right, when required. Closely monitor the client’s response to touch. Continually watch for non-verbal cues in case touch in certain areas, or generally, is indeed unwanted but the client cannot say no, either because he fears the outcome, or because he is locked or frozen in a ‘silent’ place and simply cannot speak. The therapist must remain hyper-vigilant.

Processing afterwards is essential, healthy, and aids integration. In a study of touch in psychotherapy with adult survivors of childhood abuse (both physical and sexual), clients reported that touch interventions “repaired self-esteem, trust and a sense of their power or agency, especially in setting limits and asking for what they needed.” (Horton et al. 1995). What better way to empower the client in touch interventions than to give them choice, and the freedom to express their needs. Rather than leaving it to the therapist to decide what is the best way to approach touch interventions with the client, hand power back. Encourage the client to take more of an active role in how they want to be touched, as opposed to remaining passive – as they have had to be before, when it may well have been dangerous any other way. Explore for example, whether the client would like the therapist to come over to them or, whether the client would like to go over to the therapist, what way the client would like to be held or touched, where on the body feels safe to be touched, what’s useful or positive and what isn’t. Leave everything open and hide nothing as touch was hidden before. Asking for needs to be met and having them met can be powerful, combating and counteracting of deep and often toxic shame. The client is in control and taking charge. It is touch on the client’s terms.

Sexualisation of the relationship

In any therapeutic relationship, there is always potential for the client to be attracted to the therapist, even more so with a survivor of sexual abuse. The attraction must be processed as touch interventions can be seen as the therapist reciprocating the client’s feelings. Letting the client know that he (the therapist) values him too much to let it become a sexual relationship will help the client feel more in control, and able to process what’s happening. Talking openly about the attraction and setting up clear boundaries leaves the therapist in a much better position to use touch interventions. Some adult survivors have no experience of intimate relationship or nurturance other than a sexual one, and at some point may try to sexualise the therapeutic relationship. Non-erotic touch can help the client work through the sexualisation of touch, and can be an opportunity to break through the client’s defences, facilitating separation and tolerance of the two kinds of experiences – erotic and non- erotic. However, if a client is seeking sexual gratification, then touch interventions are not therapeutic for the client as he cannot receive touch in the non-erotic manner intended.

The client may avoid all touch or sexualise all touch. In working with the transference, the client may also feel he/she will be abused by the therapist. This is a fear to be processed and worked through and it is beneficial to do so as the client will see that not all touch needs to be sexual or threatening or abusive. When using touch in a nurturing way, great care must be taken as sexuality can emerge. The adult can choose this sexual side to dominate or can go with the nurturing affect. If touch crosses over into sexual arousal, it is important that both client and therapist can work through this together. It can be a wonderful opportunity to look at sexuality and touch and that there is no need to act on sexual feelings and fantasies. The nurturing aspect can override the sexuality piece and in fact become like oxygen to the lungs, breathing new life into the client, giving rise to a stronger internal self – a foundation and secure base from which to go forth.

Therapists who touch and those who don’t

Although boundaries are crucial within the therapeutic relationship, the boundary of the skin, which contains the organism and separates it from an other, is crossed when contact is physical. To touch someone involves coming into their space. What influences the therapist’s decision to touch or not to touch? How do we recognise an opening for appropriate touch and what were the intentions of the affect in the first instance? Was it simply impulsive, spontaneous and natural or was it the agenda of the therapist, to gratify his own needs, to get close and intimate with the client, or to make him feel powerful and God-like perhaps?

Clients are vulnerable; therapists in a powerful position. Body ego develops according to how we were touched in early life. The therapist must be aware and work in depth, on his own attitude to touch, and his comfort zone in relationship to touch with a client. Like the insecure infant, the adult client will pick up on the therapist’s lack of confidence, and this may well trigger that insecurity again.

Milakovich (1992) compared therapists who touch with those who do not. Therapists who use touch interventions also had supervisors who believed in the legitimacy of touch, and advocated it as a therapeutic tool, unlike therapists who do not touch. Being given permission by those in positions of authority, like trainers or supervisors paves the way for touch interventions. Therapists come to learn what is therapeutic and will facilitate growth for the client, and what will not. These therapists learned to value gratification of the need to be touched as important, as opposed to those who believe that to do so would be detrimental to the client and the therapy and so do not use touch with clients. She also discovered that those who were more likely to have received touch from their own personal therapists and liked it, were significantly more inclined to use touch with their own clients than those who rarely received or liked touch from their own therapists.

Thus, experiential understanding of the benefits of touch can motivate a therapist to use touch with their own clients. For example, many therapists who reported using touch with clients had themselves been physically or sexually abused in their own childhood. They had a heightened sensitivity around touch and its impact on others, were considerably aware of power issues, and when it is not okay to touch – boundaries were observed. Having experienced non-abusive touch in their own therapy was very healing and they wanted to facilitate healing also for their clients through the use of safe touch. In fact, in Milakovich’s study, a therapist’s choice not to touch clients was significantly linked with not having experienced sexual abuse as a child. “Therapists’ experi- ences with personal therapy thus appear to serve as a model for their own therapeutic practices.” (Smith et al. 1998).

It would appear also that therapists who touched had different values and beliefs to those who did not use touch. Those who touched thought it to be therapeutically beneficial and in some cases, therapeutically necessary for healing to occur. Many therapists thought clients who had been sexually abused needed to experience ‘safe touch’, demonstrating that touch can occur within boundaries, and is not always sexual. Some believed that touch can be used as a physical anchor when clients revisit past traumas, especially with clients who, as children, had adults stand by watching, without doing anything. These clients had a need for nurturing touch, and had experienced touch deprivation. In fact, some believe that it is actually unethical not to touch in some of these cases. In comparison, therapists who did not touch their clients had a different set of beliefs and values – that touch is detrimental therapeutically. They believed that touch was confusing and boundaries became blurred between themselves and their client. They believed touch with abused clients would only serve to further traumatise them. These therapists spoke of clients’ ‘wishes’ for touch, never calling these ‘needs’.

The most common reason for not using touch, however, is theoretical orientation. Traditional psychoanalysts, for example, oppose any form of touch in therapy. Incidentally, in contrast, William Reich (1972) was actually ousted by the International Psychoanalytic Association (IPA) for his professional stance on touch. Depending on which therapeutic orientation a therapist works from is relevant in the clinical usefulness of touch in therapy. For example body psychotherapists who work from a Reichian, Bioenergetics or Hakomi approach use touch as a tool in their practice. Therapists who are swaying towards touch interventions are more inclined to seek further training in body-oriented psychotherapies which can enhance their competency in this area. Worth noting however, is that extensive and systematic use of touch may require signed, written, informed consent, and a rationale given in the clinical records, particularly in body-oriented psychotherapies where touch is the regular intervention. “Generally, humanistically-oriented therapies are more likely to endorse appropriate, non-erotic touch as they view it as an enhancement of the therapist-client connection.” (Hunter & Struve, 1998; Williams, 1997). These therapists believed and also experienced touch to be ‘healthy, healing and natural’.

Therapist pleasure

“The speaking aloud of deep personal truths always nurtures the listener.” (Vereshack, 1993). When we touch an other, we are touched ourselves, just like touching a relic, we experience and are touched by it. There are two people in the relationship, each impacted by the other. When there is contact of the skin, intimacy increases and intensifies, sharing is occurring, experiencing is deep. It is inevitable that nurturing and healing will flow both ways. Though this may not be the objective of the therapist at the outset, as it is the client’s process and healing that must be facilitated, the therapist also receives, unintentionally perhaps, but simultaneously. It is similar to a parent receiving when in close physical and intimate contact with its young child. Vereshack (1993) suggests that all psychotherapy brings pleasure to therapists, the pleasure and healing of being within an intimate relationship. This intimacy however, is safe for the therapist as he is not laying himself bare, he does not have to take a risk, unlike the client who risks lots in sharing the most intimate parts of himself. Therapists can get emotional satisfaction from being a part of this intimacy. What Vereshack is saying is that therapists can and do nourish themselves on this intimacy whether they (we) admit it or not. Could this be a closeness that we do not have in our outer world? Clients take risks when meaning is paramount. When therapists seek their own personal interests within the therapeutic relationship, meaning ends, with no point to the client sharing intimate parts of himself – no hope, only despair.

However, there are suggestions that touching a client might easily lead to eroticism and the collapse of therapy. When holding someone closely, it is more than likely impossible not to be aware of the other’s body, as touch is body-centred. During the ebb and flow of the therapeutic process, both client and therapist will experience difficulties at times. Soothing reassurance, which is important, can however pass into “an excited erotic or sensual experience which may at first appear to be disintegrative.” (Montague, 1971).

One way the client may manage this is to alienate the self in order to deal with shame and guilt, turning off acceptance of the body to deal with the transition from reassurance to sensual or erotic feelings. However, the therapist may also feel guilt and shame in relation to experiencing erotic feelings simply because they have not worked through their own unresolved guilt and shame. If this escapes the therapist’s awareness, it can communicate to the client that talk is good and touch is bad, fueling the source of prohibition of touch. Montague (1971) would suggest that this erotic psychosomatic arousal and the fantasies associated with it are crucial therapeutic raw material, with significance for both client and therapist. If boundaries are muddied, it can offer an opportunity to explore how boundaries in the client’s outside world may also get muddied. However, the relationship must be strong enough to withstand an awareness of physiological arousal. If and when this did arise, wouldn’t it be wonderful if the therapeutic relationship were strong enough for client and therapist to work through together, acknowledging that it is just that, a physiological arousal and not to get involved in it and continue with a healthy and therapeutic moment – sexual arousal will fade as it has no purpose, no goal. There is potential for learning and growth for client and therapist alike – tolerance and acceptance of what is and what will pass – excitement, and that no action need be taken in relation to their fantasies.

A particular level of growth within the therapist must be present as it is not possible to touch and hold a client without exploring the impact on the therapist and his own attitudes, motives and perceptions towards touch. This is not something that can be read up on but comes from experience. As in gaining experience, errors will be made. It is essential that touch or holding is wanted or requested by the client. The nurture of the client must always be primary, not the nurture of the therapist. Touch and intimacy with a client must not feed the ego of the therapist – it must always be client-centred. Traumatic experiences may be relived. Intimate details of sexual encounters – abusive or otherwise – may be recounted and shared. The therapist must be aware of the difference between the purpose of healing and voyeuristic interest. The competent therapist will remain responsible. The client must have a self that is strong, resilient, with sufficient ego and must want to and have an ability to work through deep and sometimes overwhelming emotional upsurges. Both client and most definitely therapist must be aware of what’s happening with them in this close and most intimate mode of communicating.

Conclusion

In psychotherapy, the spoken word is probably the most common and favoured form of communication. It is safe, with little risk attached. Touch, on the other hand, speaks its own language, conveys how we are perceived, received. It is the first form of communication from conception, right up to the moment we are born and onwards. When touch is inadequate, absent or abusive, it gets recorded and imprinted mani- festing in psychosomatic and psychological disorders. Patterns of relating are established, impacting and distorting relationships – with issues of trust, self-esteem, difficulty in getting basic needs met, shame and a whole host of other interpersonal and intrapersonal issues. In the therapeutic relationship, old touch injuries, traumas of omission and commission must get worked through in a healing ‘holding’ environment. Sometimes the only way forward to healing such deep and core wounds is through touch, as the original wounding was. Crossing the boundary of the skin, the organ of embrace, when appropriate, can promote bonding and attachment, increasing depth of connection and trust between therapist and client. Touch can also increase client self-disclosure, provide containment, communicate empathy, increase the client’s interpersonal risk taking, and enhance the therapeutic alliance – the best predictor of therapeutic outcome. Hunter & Struve (1998) suggest that the rich duet of talk and touch can significantly increase a sense of empathy, safety, calm and comfort, as well as enhancing a client’s sense of being heard, seen, understood and acknowledged by their therapist. In fact, there are instances where touch is not simply a recommendation, it is essential – offering an opportunity for corrective experiencing and re-parenting. The ‘bodymind’ speaks, it aches, screaming out to be heard, for its needs to be recognised – for healing to occur, for movement to flow.

A lot of the controversy attached to touch in counselling and psychotherapy settings revolves around risk assessment experts, licencing boards and lawyers, along with the concept of the ‘slippery slope’. However, is the crossing of a boundary necessarily always unethical, or only when boundaries are violated? Could it at times, due to fear of courts and judiciary elements, be unethical to avoid the use of touch, flaring up old touch wounds and flaming the transference, where the therapist is seen as cold and uninvolved, just as in the original wounding? Lapierre (2003) suggests that from this perspective, the touch taboo and the resulting touch illiteracy limit our psychotherapeutic horizons and rob us of effective, perhaps critical, forms of clinical reparation interventions.

Using risk management recommendations as the basis of how to carry out counselling and psychotherapeutic practice is unethical. Therapists are concerned with helping and healing, meeting the client’s needs, as opposed to protecting themselves and avoiding their own fears – a human approach, client-centred. If risks are not taken in providing nurture we may lose our sense of being ‘therapeutically alive’. Clients may miss the opportunity for growth, a leaving behind of childhood devastations, and a rebuilding of their defences. Are the risks attached to touch sufficient reason to avoid a very powerful method of communication with all its potential? Ethical touch, based on ethical decisions is appropriate and healing. Touch and life are SYNONYMOUS.

Joanne McGuirk, B.Sc Psychology (Hons), graduated as a psychotherapist in 2012 from Dublin Counselling and Therapy Centre. She continues to see clients there and also at The Monaghan Wellness Centre. The Centre was originally set up for people recovering from cancer so there is a gorgeous healing energy wafting throughout the building. Her email address is jomcguirk30@hotmail.com

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