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2021-08-02

Touch in Therapy

In this workshop, my intention is to provide an opportunity to explore what touch evokes. As the starting point of our own experience and thoughts about touch there is some guided experiments for how touch may be described and utilised in the therapy room.

Consider that touching elicits a sensation, a feeling, for both the one touching and the one touched.  How is this sensation experienced by each?  Already I am looking at the action of touching and being touched between person and person; because touching a chair, for example, does not illicit an experience between person and object in that the object does not experience the touch, the touch is not reciprocated.

Workshop:  Touch in Therapy

Introduction

In this workshop, my intention is to provide an opportunity to explore what touch evokes.  As the starting point of our own experience and thoughts about touch there is some guided experiments for how touch may be described and utilised in the therapy room.

 

Consider that touching elicits a sensation, a feeling, for both the one touching and the one touched.  How is this sensation experienced by each?  Already I am looking at the action of touching and being touched between person and person; because touching a chair, for example, does not illicit an experience between person and object in that the object does not experience the touch, the touch is not reciprocated.

 

Yet, in my experience there are situations where the client may well be numb to the extent that the person senses nothing at the body boundary.  Individuals will sometimes cut their skin for the purpose of wanting to feel.

Within the world of psychotherapy and counselling touch continues to be a topic of fierce debate and pronouncement in ethics. Yet, as Susie Orbach (2003) points out

Tell someone not in the field that touch is crucial to human psychological and physical development and you’d get a contemptuous daa and yet we …get singularly jittery and uneasy when touch comes to therapy … Unlike other psychoanalytic activities touch is just off limits. (p17)

 

As with all actions intentionality is significant.  The use of touch in therapy is guided by the intention of the action, and this in turn is guided by the context of the situation.  From a Gestalt perspective, the use of touch might be to nurture, facilitate, contain or repair (Hunter and Struve1998).  Touch need not be physically person to person, and sometimes will be.

Touch is about communication.  Touch is one aspect of our actions and as part of a situation of activity is to be seen as one part of many in the whole.  As such the absence of touch, and the resistance to touch, is also part of the situation and plays it part to form the whole action.  In keeping with the Gestalt position an absence is as valuable as a presence; and a resistance is as valuable as an acceptance.  As such each has a place in how the individual has adjusted to be in the world.  An absence or resistance of touch, therefore, is not something to be changed; it is something to be aware about.

To experience absence, an option is to experiment with its presence.  For touch, then there is the potential to experiment with touch where it is absent.  Along with any experimenting it is important to be able to grade the work for the client; and to have the client agree.  However, there is something else that is needed before any of that.  The therapist needs to be comfortable with touch.

The capacity of touch to heal and nurture is powerful.  Unfortunately, the abuse of touch is equally powerful.

Bluntly, touch is powerful.  In the right hands, it is a force for goodness, for healing, for nurturing.  To maintain touch in this healthy domain requires, as with those other domains of our experiences, the therapist to explore and work through their own history of touch.

Our Senses

We have five senses.  Touch, See, Hear, Smell, Taste.

Only one of these senses is reciprocated in its action, touch.  The other senses can be experienced without reciprocity.  You might smell another person; they may not smell you; you may see another person, they may not see you.

When you touch a person, they will feel touched.  There is a reciprocating experience.

A new born baby is not able to distinguish others by seeing; only varying shades of light and dark.  The first and foremost contact is touch, others senses are not developed to the same extent.

Through touching, stroking and handling the child’s body the mother conveys to the child on a sensory level a sense of the bodily self and its boundaries. This experience is internalized by the child as the basis of the body image.

People who are not touched as a child often have trouble with free movement and shame-ridden adults often have a childhood history in which there was very little touching, even in infancy.

Gilbert and Orlans 2011 p73

 

Touch is often referred to as the "mother of all senses" as it is the first sense to develop in the embryo.  (Zur and Nordmarken 2017)

In this essay, I have referred a number of times to the intentionality of our actions.  I want to take this further with respect to affect experience and Stern’s (1998) vitality affect.

Affect

Affect refers to our experiences of happiness and sadness, of anger, of fear, of disgust; and of surprise and interest.  So, to shake your hand with a feeling of happiness brings to the experience an affective experience.  Such action requires the conveyance of this affect to the experience and the quality of the affect can vary in intensity and duration.

Stern uses vitality affect to distinguish from categorical affect that is usually simply referred to as affect.

Vitality Affect

Here the vitality might be likened to the “dynamic, kinetic” (Stern 1998 p54) qualities of an experience.  So, you might, for example, be avidly reading this with interest.  You might be bursting with excitement.  In exploring or examining the vital processes of life, like breathing, being hungry, falling asleep, etc., and including the coming and going of thoughts and emotions attention needs to also be on the forms of feelings involved.

The forms of experience are always present, whilst the affect, for example, happy, will come and go.  The forms of the experience are what vitality affect refers to.

What Touch

There are a number of definitions for the varieties of touch we experience.  These would probably be useful in examining and researching the action of touch.  However, for the purposes of these emerging thought essay there is clarity in defining the touch being explored is the varieties of non-sexual touch.

However, as with all of our experiences and actions, this is not clear cut in that a certain touch may be sexual or non-sexual.  In conjunction with the action is the intentionality of the toucher, i.e., (mostly) the therapist.

Most physical touching is with the hand and fingers.  Other physical touch will be via the arms and upper body, e.g., a hug.  There are guidelines for touching the body.  Obviously, the sexual regions are not to be touched.  Traditionally, safe areas are (Hunter and Struve 1998):

  • The hand

  • Upper back

  • Shoulder region

  • Middle back

  • Lower back

 

However, these areas may not be safe, for example, a client physically abused across the middle back may find it traumatising to be touched on the back.

The guideline for touch has clarity in:

Never touch a client anywhere unless and until you have first identified a “map” of those physical locations that are connected to subjective meaning – such as abuse experiences and erogenous zones – for that client.

Never – under any circumstance – touch the breast, buttock, or genital areas of a client

Hunter and Struve 1998 p112

 

Sometimes the prospect of touch seems like facing a minefield.  How is it possible to cross safely and successfully?  Well, this workshop is not about ‘don’t cross the field’, it’s about how to navigate as safely and as successfully as possible; how to be good enough so when/if a mine is stepped on the situation does not blow you up!

Navigating the use of touch requires your attunement (Erskine et al 1999) to the client, to yourself and to the relationship.  The better your attunement the less prospective of getting your actions wrong. 

How to Touch

Simple: how to touch is to touch appropriately.

Exploring this involves attunement to the client.  Consider the developmental age the client is expressing.  What touch, if any, would be appropriate for the ‘child’ (Berne 1969) the client is expressing?

Kepner ((2001) describes touches in terms of its quality.  I want to add a word of caution here in respect of this text is describing work with the body which is more than the use of touch.  His book is worthy of reading and keep sight of the difference of the use of touch in psychotherapy and body work in psychotherapy.  That said Kepner offers interesting perspective on the kinds of touch and their possible therapeutic benefits, some of which are:

Feather touch        acts as a reminder – focus here, notice this part of your body.  And this might be considered sensual…

Laying on hands    action of contact, stimulating perception and affect.  And this might be considered coercive …

Simple touch          not the feather touch, more firm, acting as presence; “I am here”.  And this might be considered a test, a grooming, for abuse

Light stroking         acts to sooth, with direction of energy.  And this might be considered sexual, or condescending, petting …

Rocking                  acts to comfort, soothe and loosen tightness.  And this might be considered controlling, destabilising, pushing, pressing …

Vibrating                 acts to enliven.  Holding and imparting the sense of excitement.  And this might be considered violent and attacking ...

(P78) (text in red added)

 

By far the most common ways in which touch is used in therapy is shaking a client’s hand; touching the arm, the shoulder and touching the back.  Hugging follows as the next most common touch. (Strozier et al 2003).  How we initiate and fulfil the touching of the arm, or back, or the handshake is a behavioural action and is guided by our intention towards the client.  So, the intentionality is important to know and understand.  This raises transference and counter transference scenarios.  The therapist needs to be clear with their self as to the motivation, intent and intervention being undertaken. 

 

We internalize the manner in which we are handled and responded to as babies which informs our bodily self experience and our embodied sense of self in the world.

Gilbert and Orlans 2011 p73

 

So, how to touch is not simply a mechanistic action, it involves our intentionality and attunement and affective being.

 

Shaking Hands

In Western society, there is an acceptance of shaking hands as a greeting.  In commerce and business shaking hands is significant for introduction, affirmation, agreement and for contracting.

When I work with professional business clients I am concerned and curious with being offered a hand to shake.  My concern is the purpose from the client in terms of the handshake – is this the habitual greeting or finishing of a meeting.  My curiosity is what meaning, if any, has this for the client.  For me to continue the handshaking with the client I might enquire what it means for the client.  More so I tend to ensure that my handshake is accompanied by my intentionality and my in-the-moment appreciation of the client.  I do this by embracing within my own being the sense of appreciation, or concern, or joy, etc., and also accompany the handshake with the words and expression to support my vitality and intentionality.

This ensures I am grounded in my own experience; that I am attuned in the situation; and I am imparting my sense and my being with the client.

Touching: Arm, Shoulder, Back

A hand to the shoulder or back, or to the arm is potential for healing and potential for harm.  A client experiencing violence might take this as another violent act so it is very important to be familiar and cognizant of the client’s situation and history.  The permission to work in this way can allow the experience of touch to be welcomed as something other than a violation.  A gentle laying of the hand can be an antidote to previous experience.  The power of this is supported when the therapist has embraced – embodied – the healing, comfort, and care for the client and this transfers with the physical touch to the client.

Hugging

A hug is described as clasping, or holding close, with the arms and with affection.  Amongst its many benefits a hug can dispel loneliness, simply feel good, open doors to feelings, and overcome fear.  (Keating 1983)

Again, intentionality is important, and transfers with the hug.  To offer a supportive hug is accompanied by the intentions to support and the vitality – dynamics of supportive -  affect.  So, you need to be attuned and present supportively and authentically.

The cost of authenticity is your vulnerability to be impacted in the situation and therefore knowing your own needs is important so that you are meeting those of the other, not yours.

The gift of authenticity is your willingness to share, to show and give compassionately.

Bear Hug

The generic hug might be considered to be the bear hug.  Arms wrapped around the other that through its powerful hold (not squeezing) gives comfort, strength and security; and transmits through this hold the feeling and thoughts from the hugger.  This hug might illicit thoughts of childhood snuggling hugs with mother – if such hugs took place; so often our clients are those that did not get much snuggle hugs.

Snuggle Hug

As indicated, this type of hug is received in infancy and early childhood.  Often this stops too soon for the child.  There is question about when hugs stop being given and what is happening that hugs even have to stop.  With the bear hug possibly giving memories of snuggle hugs there is an opportunity to work this into the therapy alongside therapeutic work with the ‘child’ (Berne 1969).  When you consider the work of Richard Erskine (Erskine et al 1999; Erskine and Moursund 2011; Erskine 2010; Erskine 2015) then working with the ‘child’ provides for snuggle hugs.  I have been fortunate to witness the work of Richard Erskine and working with body process and the client’s ‘Child’ is amazing to see and a very worthwhile experience.

A Frame Hug

This hug reduces the physicality of contact and is so named for the shape produced as each hugs the other around the shoulders with a distance between of the feet position creating the A frame shape.  This hug provides a detached warmth and usually is briefer than other hugs.  Popular stance for hello and goodbye.  This type of hug is generally much less of a threat for those not familiar or comfortable with hugging contact.  Therefore, it also has more formality, like handshaking, and as such might be considered the classic type of hug.

When to Touch

In looking for articles I realised that missing in my research results was touch from the client perspective.  This was highlighted in reading an article from the Cambridge Body Psychotherapy Centre (CBPC 2017) that include

the client perspective

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.  CBPC 2017

 

There are many people that I would welcome into my home.  There are times when these same people are not welcome to into my home.  There are a few people that are welcome to turn up at any time however I might not be overly welcoming if they do, and still they are welcome.  The important differences with these people is the relationship I have.

In therapy, we build an alliance and a relationship with our clients.  The relationship is what will grow the trust and strength of client and therapist to work together.  Building the relationship will involve working, challenging, and exploring the myriad of interventions that will enable the client to be aware and know their way of being.  Part of this can include the use of touch.  In itself, the question and permissions about touch allow for an exploration of the meaning of touch for the client.  As such, without any physical touch occurring, much might come to light in its exploration.

Having broached the question of touch the therapist needs to hold to the client’s wishes and respect the client’s position.  Every article on touch will affirm the permission from the client; ask first.

Yet, or perhaps more correctly, also, there are times when I have touched without first checking or asking for permission.  These are times when I feel the touch is appropriate and to interrupt the situation would interfere with the process in we are both involved in and is supported by our therapeutic relationship.  A time such as a deep upset and my hand on the shoulder, or upper arm, speaks more of presence and attunement than words.  Yet, words may have sufficed, possibly.  Touch can indicate worth, that the person is worthy of touch.

Mintz (1969) citing Kertay & Reviere, (1993) suggests when touch is appropriate:

  1. when the patient is incapable of verbal communication touch may act as symbolic mothering.

  2. when the patient's self-loathing is overwhelming touch can communicate acceptance.

  3. when anxiety provokes panic or dissociation touch can help reground the client.

  4. Touch can strengthen and restore the client’s being.

  5. To explore aggressive feelings touch can be used as a resistance to push against or touch may be used to tussle with the client.

  6. Sometimes touch accompanies the natural expression of the therapist's feelings toward the client.

 

When I initiate any touch without seeking permission I risk not just being wrong, I risk accusations of anything from being unprofessional, too familiar, up to being abusive.  I trust in my own sense of ethics; my own sense of attunement; and I trust in the strength of the relationship with my client.

This American writer Older (1977), sums the risks…

Touch a paranoid and risk losing a tooth,

touch a seductress and risk losing your license.

Touch a violent patient with a short fuse and risk losing everything (1977, p. 201).

 

Risk is mitigated with professional learning, supervision and support.

Not Touching

I am talking here in the context of the use of physical touch that does not have the therapist and client actually touching.  There is a school of thought that would include the handing over of a cheque, or giving a tissue is touching in the sense that both are touching the same object.  For me the sense of this is more to do with degrees of proximity and levels of intimacy.  There is a closer-ness between therapist and client in the handing of a tissue, as there is in handing over the cheque.  The situations have a different level of intimacy and pretty much the same degree of proximity (and differing intentionality).

There is therapeutic value in going with this common touch and as such is easily categorised under the exploration of touch in therapy.  So, maybe, reflect on clients that avoid common touch.  The client that might always leave the cheque on the table; will always take their own tissue – even bringing their own.  Perhaps your interest is perked to notice more with your clients now.

However, in this section I am interested in considering how the client might experience touch without the therapist physically touching the client, or the client touching the therapist.

The understanding of one’s self and biases is a prerequisite for any therapeutic application, but is even more essential for such intimate and directly contactful work as touch.

Kepner 2001 p.74

 

First and foremost, not touching, is the way to work until you have explored fully, in your own therapy, your own needs and desires and favours with touch.  So, touching without physical contact is a way to work with the client.

Touch provides for an immediate bodily sensation of being present and being in the world.  For a lot of clients there is a minimisation of awareness to such body sensations that is utilised to avoid feelings that are too uncomfortable and often traumatising.

The work regarding body sensation of touch is about bringing the client to the awareness of their desensitised position.  This allows, then, an exploration of the experience of being desensitised in a situation of some sensitivity in the body.  For example, a client may remark on feeling nothing.  To explore this ‘nothing’ alongside the feeling of the chair being sat on, or feet on the carpet provides for a difference the client might then use to expand on feeling.

Use of objects

Exploring of touch in this way can be useful for those clients that have desensitised.  With the intention of the client having greater awareness of their being-in-the-world one aspect of this is to notice the world acting on them.

Sitting

Starting with the object being sat on.  For the client to explore the sensations and bodily tensions of being in the chair is a concentration of the client’s awareness of what is, here and now.  And easily falls under ‘this-new-thing-called’ mindfulness.  The purpose here is to have the client be aware of their physicality through bringing to mind what is being sensed; then how this feel, and then what is brings to mind.

Material

Have the client explore objects with differing texture, shape, and  size that can be stroked and touched; can be felt on different parts of the skin – the back of the hand, the cheek, the lips.  The use of stones, or buttons, is a common technique.   Consider using pieces of material and sponge, clay, playdoh; consider shredded paper, wool strands; consider what might be less common to touch such that a different experience is provided.  The purpose is to explore the differences in the experience of touching, and this will include touching with either hand – the different sensation experienced, as possibly touching to the right and left side of the face.

Sand tray

More sensitising work can be done that may involve a closer proximity of the therapist.  The use of a sand tray allows for the client to experience varying sensations of pouring sand; dry sand, wet sand and so on.  This might include the therapist pouring the sand.

Cushions

Cushions may be used as objects described above, or in experiments with the client to feel the presence through their hands and the cushion of your hands on the other side of the cushion.  The experience of sinking into cushions, surrounded and swaddled can be explored.

Self touch

The client can experiment with using each hand to touch, for example, their forehead, or their cheek.  Sensations in the hand and the cheek can be described along with what is different.  Indeed, pay attention to your client for actions such as stroking their hand with a finger, or placing the hand on their cheek. 

Retroflected Behaviour

These might well be indicators of a retroflected action where the client performs the action that was not given and wanted.  You might enquire as to who would you have wanted to be stroking your hand, or pressing their hand to your cheek?  Notice you might soothe yourself by holding your hand with the other; by stroking the back of your hand, or stroking your upper arm …

Attending to the Senses

 

 

 

 

 

 

 

Working from a holistic position with therapy provides for the possibilities of engaging all the senses.  The Gestalt cycle of experience is a foundation for considering the emergence of interest and attention to this interest through to its assimilation of the person’s lived experiences.

This works on the premise of an organism sensing and therefore responding and reacting.  The sensing is the initiating stimulus.  For example, I sense an emptiness in my stomach and become aware that I haven’t eaten for a while and so I interrupt what I am currently doing and apply energy to my need to move to opening a packet of biscuits and action the consumption of said packet, fulfilling my contact of the sense of hunger and its solution (yum, yum) leading my satisfaction of hunger.  Now I might withdraw from this experience and notice the sensation that is an anxious feeling leading to my awareness of my thoughts telling me to get back to writing; and here I am now …

Sensation

This is the initiating point, sense the moment.  From here there follows the meeting of needs.  Often the sensation and its subsequent cycle of experience is interrupted, often of necessity.  Shutting down sensing leads to our desensitisation to our organismic needs not being met, or not being fulfilled satisfying.

Having a sense of annoyance, for example, may often be ignored, or deflected away, so as to maintain some sense of harmony.  In doing this, though, the source of the annoyance has not been acted on and therefore not satisfied.  This lingers as unfinished business; lingers and possibly stored in the body as muscular contractions; possibly stored mentally as resentment, or shame.

Therapy is the opportunity to be in touch with unfinished business.  An opportunity to be back in touch with the sense of annoyance, for example, and finish that which was not finished.

For clients that have particularly desensitised their feeling, there will be a numbing of their physical being to the extent that sensations are no longer in awareness.  An example coming to mind is a young man that would rarely wear warm clothes in the winter and insist that he did not feel the cold.  His skin was cold; this was not being felt as he had numbed himself overtime not to the cold, but to feeling anything at the skin boundary.  I noticed he would at times put a flame to his palm.  Was this a way to feel?

Mostly the desensitisation is about keeping internal sensations limited.  I am referring to those feelings in the stomach, the chest.  The ignoring of tensions in muscles, shutting out the soreness, or discomfort in the body.  There are consequences for these actions, some supportive, others not.

Touch in therapy is more than a physical contact of therapist and client; it is the touching of the spirit, the soul; the touching of thoughts with feelings.

References
Berne, E., 1969 Games People Play. Vintage Books, New York
CBPC 2017 Physical touch in psychotherapy Why are we not touching more. Available from Cambridge Body Psychotherapy Centre Limited at http:// www.cbpc.org.uk/ TouchInPsychotherapy.htm Accessed 21 March 2017
Clarkson, P. (2000) Gestalt Counselling in Action, 2nd Edition, London, Sage
Erskine, R. and Moursund, J. P., 2011 Integrative Psychotherapy in Action. Karnac Books, London
Erskine, R., 2010 Life Scripts Karnac Books, London
Erskine, R., 2015 Relational Patterns, Therapeutic Presence: Concepts and Practice of Integrative Psychotherapy Karnac Books. Kindle Edition.
Erskine, R., Moursund, J, Trautmann, R. 1999 Beyond Empathy: A Therapy of Contact-in Relationships. Routledge
Gilbert, M. and Orlans, V., 2011 Integrative Therapy: 100 Key Points and Techniques. Taylor and Francis. Kindle Edition.
Hunter, M. and Struve, J. 1998 The Ethical Use of Touch in Psychotherapy. Sage London
Kepner J. I., 2001 Body Process: A Gestalt Approach to Working with the Body in Psychotherapy. Gestalt Press Cambridge MA.
Kepner, J. 2001 Touch in Gestalt body process psychotherapy purpose, practise and ethics. Gestalt Review, Vol 5 No 2 pp 97-114
Kertay, L. and Reviere, S. L., 1993 The use of touch in psychotherapy: theoretical and ethical considerations. Psychotherapy Vol 30 No 1 pp32-40
Mintz, E. E., 1969 On the rationale of touch in psychotherapy. Psychotherapy: Theory, Research, and Practice. Vol6 No4 pp232-234
Older, J., 1977 Four Taboos that may limit the success of psychotherapy. Psychiatry Vol 40. p197-204
Orbach, S., 2003 Part II Touch, Psychoanalysis’s Discomfort with Touch. British Journal of Psychotherapy vol20 No1.
Stern, D. N., 1998 The Interpersonal World of the Infant. Karnac Books, London.
Strozier, A. L., Krizek, C. and Sale, K., 2003 Touch: its use in psychotherapy. Journal of Social Work Practice. Vol17 No1
Zur, O. and Nordmarken, N. (2016). To Touch Or Not To Touch: Exploring the Myth of Prohibition On Touch In Psychotherapy And Counseling. Retrieved 29 March 2017 from http://www.zurinstitute.com/touchintherapy.html

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