Diana Guest & Jan Parker
Bioenergetic Analysis • The Clinical Journal of the IIBA, 2022 (32), 123–134
https://doi.org/10.30820/0743-4804-2022-32-123 CC BY-NC-ND 4.0 www.bioenergetic-analysis.comThe use of touch in psychotherapy has been a topic of discussion since Freud stopped touching his patients. Psychology in general has moved away from utilizing touch as a therapeutic intervention. However, several body-oriented clinical approaches, such as Bioenergetic Analysis, Neo-Reichian therapy, Core Energetics, Hakomi, and Somatic Experiencing, include touch as approved interventions. This article explores how touch can be used ethically in clinical practice. Types of touch and ethical considerations are discussed as well as the need for training and more research.
Keywords: use of touch in psychotherapy, somatic psychotherapy, ethical issues, types of therapeutic touch
Considerações clínicas sobre o uso do toque em psicoterapia (Portuguese)
O uso do toque na psicoterapia tem sido um tema de discussão desde que Freud deixou de tocar seus pacientes. A Psicologia, em geral, se distanciou do uso do toque como intervenção terapêutica. Entretanto, várias abordagens clínicas de orientação corporal como a Análise Bioenergética, Terapia Neo-Reicheana, Core Energetics, Hakomi e Experiência Somática (SE) incluem o toque como uma intervenção eficaz. Este artigo aborda como o toque pode ser utilizado de maneira ética na prática clínica. Serão abordados tipos de toque e considerações éticas, bem como a necessidade de maior treinamento e pesquisa.
Considerazioni cliniche sull’utilizzo del contatto in psicoterapia (Italian)
L’utilizzo del contatto in psicoterapia è stato oggetto di dibattito da quando Freud smise di toccare i suoi pazienti. La psicologia in generale si è allontanata dall’utilizzo del contatto come intervento terapeutico. Tuttavia, vari approcci corporei, come l’Analisi Bioenergetica, la terapia Neo-Reichiana, la Core-energetica, Hakomi e Somatic Experiencing includono il contatto tra gli interventi approvati. Questo articolo esplora il modo in cui il contatto può essere utilizzato in modo etico nella prassi clinica. Vengono discussi tipi di contatto e considerazioni di tipo etico e il bisogno di formazione e di più ricerca.
Considérations cliniques à propos de l’utilisation du toucher en psychothérapie (French)
L’utilisation du toucher en psychothérapie est un sujet de discussion depuis que Freud a cessé de toucher ses patients. La psychologie en général s’est éloignée de l’utilisation du toucher comme intervention thérapeutique. Cependant, plusieurs approches cliniques orientées vers le corps, telles que l’Analyse bioénergétique, la thérapie néo-reichienne, la Core-énergétique, le Hakomi et le Somatic Experiencing, reconnaissent le toucher comme faisant partie des interventions approuvées. Cet article explore comment le toucher peut être utilisé de manière éthique dans la pratique clinique. Il aborde les types de toucher et les considérations éthiques, ainsi que les besoins supplémentaires en formation et en recherche.
Consideraciones Clínicas sobre el Uso del Tacto en Psicoterapia (Spanish)
El uso del contacto físico en psicoterapia ha sido un tema de discusión desde que Freud dejó de tocar a sus pacientes. La psicología en general se ha alejado de la utilización del tacto como intervención terapéutica. Sin embargo, varios enfoques clínicos orientados a lo corporal, como el Análisis Bioenergético, Terapia Neo-reichiana, Corenergetics, Hakomi y Somatic Experience, incluyen el contacto corporal como intervenciones apropiadas. Este artículo explora cómo se puede utilizar el tocar de forma ética en la práctica clínica. Se discuten los tipos de contacto corporal y consideraciones éticas, así como la necesidad de formación al respecto y de más investigación.
Der Einsatz von Berührungen in der Psychotherapie wird diskutiert, seit Freud seine Patienten nicht mehr berührte. Die Psychologie im Allgemeinen hat sich von der Verwendung von Berührung als therapeutische Intervention entfernt. Mehrere körperorientierte klinische Ansätze, wie die Bioenergetische Analyse, die Neo-Reichianische Therapie, Core Energetics, Hakomi und Somatic Experiencing, beinhalten jedoch Berührung als anerkannte Intervention. In diesem Artikel wird untersucht, wie Berührung in der klinischen Praxis ethisch vertretbar eingesetzt werden kann. Es werden Arten von Berührungen und ethische Erwägungen erörtert sowie der Bedarf an Ausbildung und weiterer Forschung.
Клинические соображения по поводу использования прикосновений в психотерапии (Russian)
Использование прикосновений в психотерапии стало предметом обсуждения с тех пор, как Фрейд перестал прикасаться к пациентам. Психология в целом отошла от использования прикосновений в качестве терапевтического вмешательства. Однако некоторые телесно-ориентированные клинические подходы, такие как биоэнергетический анализ, неорайхианская терапия, сердцевинная энергетика, Хакоми и соматическое переживание, используют прикосновения в качестве одобренных вмешательств. В этой статье рассматривается вопрос, как этично использовать прикосновения в клинической практике. Обсуждаются виды прикосновений и этические аспекты, а также необходимость обучения и проведения дополнительных исследований.
关于在心理治疗中使用碰触的临床思考 (Chinese)
自从弗洛伊德停止碰触病人，在心理治疗中使用碰触就是一个需要讨论的话题，总的来说心理学中不再使用碰触作为一个治疗性的干预。然而，有几种身体取向的临床治疗流派，比如躯体动力分析，赖克神经治疗，核心能量，Hakomi 和躯体体验中，碰触作为被允许的干预方式。本文探索了碰触是如何在临床实践中被符合伦理的使用。讨论了碰触的类型和伦理的思考，也讨论了对培训和更多研究的需求。
This article was written before the pandemic occurred. Therefore, some of the material will only apply once the pandemic has been brought under control and the therapeutic use of touch is no longer contra-indicated for public health reasons. In our experience, the pandemic has increased people’s awareness of the need for touch and their desire for touch. However, as therapy returns to in-person sessions the conflict between the desire for touch and the fear of touch may be more active. Therefore, it is even more incumbent upon therapists to be aware of the impact of touch on the therapeutic process.
The importance of touch has been studied and discussed in the developmental psychology literature beginning with Harlow’s study and continuing into the development of attachment and object relations theories (Bonitz, 2008). An infant’s ability to thrive has been shown to be directly related to the degree and quality of physical contact with the primary caretakers.
“Touch is a fundamental, multilayered, and powerful form of communication thought to be essential to normative human development. No more and no less than other modalities of conveying both feeling and meaning, it can contribute to growth, and it can contribute to healing where growth has been disrupted” (Kertay & Reverie, 1998, p. 16).
However, since the development of modern psychotherapy, which began with Freud, the use of touch has been a controversial topic and many practicing psychotherapists are unaware of the group of body-oriented therapies where touch is an integral part of the work. These modalities include Bioenergetic Analysis, Core Energetics, Hakomi, Neo-Reichian therapy, Sensorimotor Therapy, Biodynamics, Somatic Experiencing and Biosynthesis.
“The use of touch can enhance the therapeutic experience for a client in many ways: to provide real or symbolic contact; to provide nurturance; to facilitate access to, exploration of, and resolution of emotional experiences; to provide containment; and to restore touch as a significant and healthy dimension in relationship. These features represent the actual clinical function of ethical touch when it is incorporated naturally into the process of a therapist-client relationship” (Hunter & Struve, 1998, p. 107).
Very few, if any, graduate programs in psychology teach anything related to the use of touch except that it is forbidden and even illegal, which it is not. Many “talk” therapists touch their clients spontaneously, for example shaking hands or a hand on the shoulder for comfort, without being conscious of the fact that this is a physical intervention or the potential impact on the client. In general, most therapists are reluctant to use touch as risk management and a lack of understanding regarding the efficacy of its use in psychotherapy.
Due to our litigious society and risk management for the therapist, the use of touch is controversial and misunderstood (Bonitz, 2008). Freud initially endorsed the use of touch as part of psychotherapy, but he changed his position in the early 1920s because he worried that it might tarnish the reputation of the new field of psychology, the talking cure. The main concern was that therapists would use their power and influence to sexually exploit their clients. Hence, touch in psychotherapy has been a hotly debated topic. This erupted further when Freud, in 1931, admonished Ferenczi, a star student, for letting a female client kiss him. Again, Freud felt that this would lead to sexual enactment and feared again for the reputation of psychoanalysis and therefore the subject of touch went underground. Ferenczi refused to stop touching his clients and was expelled from the psychoanalytic community. It was Wilhelm Reich, another of Freud’s students, who went on to link the functional identity of the psychic level to its corresponding physical muscular attitude and developed the most comprehensive method of clinical touch. In the 1950s Alexander Lowen, a student of Reich, and John Pierrakos further developed some of Reich’s principles fighting against this prohibition of touch. Additional therapeutic modalities such as Gestalt therapy, Psychodrama, and Satir’s family sculpting all began to utilize touch to some degree (Nolte, 2020; Polster & Polster, 1974; Satir, 1972).
As the culture shifted, and in particular the awareness of the potential harm to clients, more rigid parameters around touch developed (Stenzel & Rupert, 2004). To ensure the maintenance of adequate boundaries the profession moved to a prohibition against touch altogether. In addition, the emergence of discussing molestation publicly impacted the use of touch in society in general and psychotherapy in particular.
In more recent years an additional tension is between the scientific knowledge that touch is essential for healthy human development and human relationships, and the ethical concerns with exploitative and harmful sexual touching of clients by therapists. Because of this, the importance of touch in developing attachment and the recognition of the healing effect of touch in therapy has given rise to the legitimacy of touch used in body-oriented psychotherapy. This includes the need for training to educate therapists about appropriate touch.
Touch is very much a part of most cultures and yet the United States has become a touch phobic society due to the misuse of touch (Hunter & Struve, 1998). It is important to recognize that other cultures have different rules and rituals related to touch. There are various categories of touch which include: “accidental touch, task-oriented touch, attentional touch, celebratory/affectionate touch, emotional/expressive touch, aggressive touch, sensual touch and sexual touch” (p. 115). Accidental touch occurs without intention and is generally spontaneous in nature. An example could be when both the therapist and client stand up at the end of the session and accidentally touch. Although this type of touch occurs in daily life when people are in a small space or a crowd, within the therapeutic context clients may give it different meaning depending on their history, and therefore it is important to acknowledge both the touch and the lack of intention. The depth to which therapists respond to accidental touch may be related to their theoretical orientation, their assessment of the client’s reaction to touch in general, and their own comfort with discussing this type of touch with clients.
Task-oriented touch is self-explanatory (Hunter & Struve, 1998). It is touch that occurs during the performance of some activity. It can be purposeful or accidental. Examples in psychotherapy would be when the client hands you payment for the session or the client requires assistance to stand. “Psychotherapists often overlook that even these brief and seemingly innocuous, transactions involving physical contact may have a significant effect on a client” (p. 117). For example, the client with a history of molestation may interpret the touch as intentional and that you are trying to test them for their reaction.
Another type of touch is attentional touch designed to obtain a person’s attention (Hunter & Struve, 1998). This is more likely to occur at the beginning or end of a session. Touch that takes place at the beginning of an encounter is termed greeting touch. How the touch occurs can be influenced by age, gender, cultural background, and the situation. This could entail simply a handshake if initiated by the client. Touch that happens at the end of a session acknowledges the conclusion of the meeting. An example of touch that could happen at the end of the session could be a brief hug, a tap on the shoulder, or a handshake. Another type of attentional touch that is considered a form of social etiquette that might occur at the end of a workshop or group therapy would be the holding of hands during a closing circle.
“Celebratory/Affectional Touch usually occurs spontaneously and is an expression of joy, excitement, or pride … Affectional touch is an expression of friendly, helpful, or playful emotional energy” (Hunter & Struve, 1998, p 120). This type of touch is rarely utilized by therapists without adequate training in the ethical use of touch in psychotherapy as it is particularly open to misinterpretation by the client. For example, if a therapist hugs a client who has reported pride and a sense of accomplishment in completing graduate school, the client might confuse this action as one of friendship or a sexual overture. However, this form of touch could be significant if done within the context of a therapy group by one member to another. For example, a group participant expresses joy at becoming engaged and other members give him celebratory hugs.
Emotional touch is designed to communicate an emotional reaction or experience to another (Hunter & Struve, 1998). It is important to note that this form of touch is almost always initiated by the client and the therapist must judge how to respond. A therapist who is trained in the ethical use of touch might touch the client to assist emotional expression or communicate support.
Hunter and Struve (1998) discussed a form of touch they termed as aggressive. In the interests of clarity, we determined that touch between client and therapist is rarely aggressive but is more assertive in nature and planned. It is important that therapists assist their clients in expressing their anger in ways in which safety and appropriate boundaries are clear. This may include such actions as hitting a pillow, yelling during a Gestalt empty chair exercise, or stomping. Therapists who have been trained in the use of body-oriented techniques may touch clients during some assertive expressions such as pushing against each other.
The authors believe that it is essential to include a discussion about the use of touch in all clinical training programs. It is important for therapists to be comfortable discussing sexual issues with their clients, however sensual and sexual touch should never be used within the context of the client-therapist relationship.
Touch is an inherent need for survival of the infant (Kertay & Reviere, 1998). As the person develops the need changes but remains necessary for secure attachment in most people.
Harlow (1958) demonstrated the importance of touch in the development of the young monkey, noting that the infant monkeys he studied required touch as much as food for their normal development. In fact, at times the monkeys preferred the comfort of tactile stimulation to food, even when they were hungry. Spitz (1945) extended these findings to humans in studies of the effects of touch deprivation on infants and children in orphanages. He demonstrated that infants deprived of physical contact failed to develop normally and became physically ill, despite adequate attention to their other physical needs (p. 17).
Lowen (1972) likewise reported the correlation between the lack of contact with the mother in infants frequently led to depression in adults. “The predisposing event in the past is the loss of the love object … The infantile depression that results from separation is not a psychological reaction but is the direct physical consequence of the loss of this essential contact” (p. 135–136).
It is clear that touch is an integral part of the infant and child’s ability to form an attachment with first the primary caregiver and then others (Glickauf-Hughes & Chance, 1998). Attachment is formed by the attunement of the relationship between parent and child through non-verbal communication. This includes touch that is nurturing, not mechanical; and that includes eye contact, smiling, and attention to the cues between parent and infant. As people grow older the use of touch in relationships with greater emotional distance may not include touch. However, in healthy intimate relationships, including friendship, touch is part of the connection. This can be as simple as two people high-fiving each other during a sports event or putting a hand on another’s shoulder. Consequently, the prohibition against touch in the psychotherapeutic relationship may inhibit the strength of the connection.
In therapy, touch can assist in developing new spontaneous actions (Ogden, Minton & Pain, 2006). Touch that is used in a playful manner can help reduce rigid defenses, especially in clients with an obsessive organization (Glickauf-Hughes & Chance, 1998). Additionally, it can assist in developing spontaneity and strengthening the connection between the client and therapist. “The effective use of touch in therapy can anchor the client to the here-and-now and to the relationship with the therapist” … (Ogden, Minton & Pain, 2006, p. 20). Therefore, in addition to increasing the connection, the use of touch can assist the client in being more present in both the therapy session and everyday life.
Like any other therapeutic intervention, the use of touch may affect the client’s transference to the therapist (Ogden, Minton & Pain, 2006). It is important for the therapist to ask clients to become aware of their body prior to using touch, and for both clients and the therapists to notice the effects of the contact. This can help heighten the client’s awareness of the impact of the touch once it occurs. Processing the client’s reaction is essential to preventing misinterpretation of the contact or the therapist’s intentions. It can open up previously undisclosed material for future work. Other issues regarding transference can be related to the absence of touch in therapy. This could increase the likelihood of transference distortions. For example, the therapist could be considered as lacking warmth and being seen as a withdrawing figure by the client (Hunter & Struve, 1998).
Horton et al. (1995) reported that 69% of the respondents in a sample of 231 clients who were actively participating in psychotherapy indicated that touch fostered a stronger bond, facilitated deeper trust, and contributed to greater openness to the therapist, and 47% indicated that the use of touch by the therapist enhanced their self-esteem. This study noted that clients identified touch as a contributing factor that helped them to feel valued and that this subsequently contributed to their feeling better about being in therapy (p. 105).
Based on the study cited above, it is clear that touch or lack of touch needs to be considered in psychotherapy so that the use or nonuse is a conscious decision, rather than a reaction to the current cultural prohibition in many therapeutic modalities outside of body-oriented psychotherapy.
While the authors believe that the use of touch can facilitate deeper healing, it is important that a careful assessment be part of the decision of when and how to use touch with each client and within each session. Factors such as clients with poor boundaries or fear of engulfment, clients with a history of childhood physical or sexual abuse, sexual assault, physical violence, or violent acting out, clients with PTSD from war or torture, clients with erotic transference, clients with cultural or religious prohibitions against touch, and clients with a psychotic disorder all require careful consideration about how any one of the above factors may influence the response from the client and the transference issues that may arise from the incorporation of touch. Another important consideration is the development and strength of the therapeutic alliance. Except with clients who have a psychotic disorder, touch is not contraindicated but requires conscious consideration and training in the use of touch.
In the authors’ experience, whether therapists use touch as an integral part of their therapeutic modality or merely touch the client with a handshake or pat on the shoulder, it is important that ethical guidelines always be considered. This includes knowing clients’ histories, especially related to any traumatic touch; their current functioning level; asking clients about their reaction to touch when it occurs in therapy; cultural norms related to touch; and any characterological issues that might influence the use of touch with that client.
Ethically and practically, it is essential that all body-workers spell out the boundaries of their work with each client … The legal and ethical challenges to our profession have served to educate us about our responsibilities. There is an inherent imbalance in the therapeutic relationship that demands our constant awareness … We as therapists must constantly be aware of the effect our touching is having (Conger, 1994, pp. 11, 13).
Contrary to popular belief, non-sexual, non-erotic touch in psychotherapy is not inherently unethical (Zur, 2007). Additionally, there is no law of which the authors are aware that prohibits non-sexual touching with clients in the therapeutic setting. Although as stated above, most students are taught not to touch their clients. This results in new therapists having no training in how to use touch with clients and perpetuates the belief that touch is dangerous in therapy (Parker & Guest, 2011).
As discussed in the introduction, there are several types of body-oriented psychotherapy, all of which have training programs. Although we are not familiar with the specifics of most of those programs, the authors were both trained in the use of touch during their post-graduate training in Bioenergetic Analysis and utilized these interventions during our years of practice as psychotherapists. Of utmost importance before using touch is the strength of the therapeutic alliance and the disclosure of how one uses touch in the therapeutic process. For example, in Bioenergetic Analysis we have a standard consent form describing how, when, and for what purpose touch may be used. It is also explicitly noted that there will never be any contact with breasts, genitals or sexually charged part of the client’s body. Additionally, it is important to ask permission and describe the type of touch to be used prior to any move towards the client. It is also important to be acutely aware of the non-verbal communication from the client, especially when there is a disconnect between the verbal compliance and body language about the use of touch.
Most body-oriented training programs are two to four years of post-graduate work. This indicates the need for extensive education in the use of touch by psychotherapists.
In our experience, as therapists who utilize touch as an integral intervention, it is essential that written consent is obtained from the client prior to the use of touch at all. The consent form should define how touch will be used, can be helpful, the purpose of using touch, that touch can evoke strong emotions, and how to rescind consent once given. The form should be written in language that is easily understood by most people, not in therapeutic jargon. Additionally, it is important to ask permission immediately before using touch.
It appears from both the authors’ experiences as Certified Bioenergetic Therapists and the research studied, that touch occurs in the therapeutic environment more often than is currently discussed in the literature. This ranges from a casual handshake to body-oriented interventions. It is unclear the extent to which therapists who use touch, at least occasionally, are adequately educated in all the ramifications of its use. The authors believe that the use of touch should be incorporated into psychotherapist educational programs to decrease the misunderstanding of the laws and efficacy regarding the use of touch, and how to obtain the training necessary to utilize it as a therapeutic technique. For example, the curriculum from the International Institute for Bioenergetic Analysis integrates training on the use of touch throughout the four-year academic program. Other somatic modalities require different lengths of training but all include a discussion on the use of touch. This training is essential to avoid the misapplication of touch in ways that can be harmful to the therapeutic alliance or to the client.
Most somatic training programs do not engage in quantitative research. Part of this is that the training programs are post-graduate and not associated with a university so that the faculty are solely clinicians and not researchers. As body-oriented psychotherapy becomes more mainstream and discussed in graduate educational programs hopefully this will change. The authors believe this research is essential to understand more fully the impact and efficacy of this work.
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Diana Guest, MFT, CBT, is a member of the IIBA faculty and is coordinating trainer for SCIBA, the New Zealand society and the first two training groups in China. She is currently on the BoT and was the president of the IIBA from 2017-2020. She leads workshops and teaches in Latin America, the USA and China. She has written several books and articles with her co-author Jan Parker. They recently published Becoming Grounded: a detailed guide for bioenergetic therapists which has also been translated into Italian. They also wrote A Guide to Becoming Grounded: for somatic therapist and individuals. All are available at Amazon.com.
Jan Parker, PhD, LMFT, has written multiple articles and books with her co-author, Diana Guest, for over 27 years. She is a CBT and the Executive Director, Interim Treasurer, and NANZIBA representative for the Southern California Institute for Bioenergetic Analysis. She is a professor at National University in San Diego, California, where she has taught for 30 years.