The Judicious Use of Touch in an AEDP Treatment: Responding to Developmental Need and Transformance Drive
By Hilary Jacobs Hendel, LCSW
Abstract. The use of touch in talk therapy has long been considered controversial and even taboo. However, touch when used thoughtfully and judiciously has the potential to facilitate healing. When confronted with the developmental and core need for touch, psychotherapists should have the ability to think through when it could be helpful and when it could be harmful. This paper considers the use of touch in a clinical case and the way it is negotiated by the patient-therapist dyad.
This paper discusses an AEDP treatment where touch was incorporated into the work. I discuss viewpoints from the literature; some considerations regarding the use of touch that are born from the sum total of my education and training both as a psychoanalyst and an AEDP psychotherapist; and my specific rationale for incorporating touch into this particular treatment. A verbatim transcript from a mid-treatment session illustrates clinical work with touch. At the end, I present some general guidelines for the judicious use of touch.
Touch in psychotherapy is a controversial topic. Freud used touch in his early work but later denounced it citing the dangers of touch where intense transference exists. Since then, psychoanalysts, lawyers, risk managers, and ethicists have advised psychotherapists to rule out touch as part of talk therapy with the main reason being that touch is a “slippery slope.” The slippery slope argument that has dominated current practice results from the lack of theoretical distinction in the psychoanalytic literature between nurturing touch and sexual touch. But, it is precisely that distinction which matters in a thoughtful discussion on the use of touch by a psychotherapist.In the early to mid 20th century, Object Relations theorists such as Rank, Klein, Fairburn and Winnicott, shifted the focus to pre-oedipal development and opened a door to differentiating between sexual touch and early developmental needs for soothing touch. Harlow and his famous research using wire and cloth monkey mother surrogates (Harlow, 1971), followed by a long line of infant-child and attachment research furthered our understanding of attachment and the need for physical touch to provide comfort and affect regulation in infants and babies. Attachment research, not to mention intuition, validates that touch is paramount to healthy development especially in infancy and childhood. Currently, body psychotherapies like the Alexander Technique unabashedly use touch. As Zur et.al. (2011) note, other body psychotherapies such as Reichian (Reich, 1972) and Bioenergetics (Lowen, 1958, 1976) use touch as their primary tool in psychotherapy, see its value, and endorse it as a therapeutic tool whole-heatedly. Additionally, experiential psychotherapists routinely touch patients as when they are tapping on a patient’s knees during EMDR processing, pressing on a patient’s stomach to “take over” physical tension as practiced in Hakomi (Kurtz, 1990), or having the patient push against the therapist’s hands to experience the physicality of setting boundaries as in Somatic Experiencing (Ogden et al., 2006). Furthermore, some talk psychotherapists will touch their patients when the patient initiates so as not to insult or embarrass them. Examples of this type of casual touch include a spontaneous hug, a handshake, a kiss on the cheek, or a “high five” as a show of support. Most psychoanalysts are highly opposed to any form of touch in therapy (Menninger, 1958; Wolberg, 1967; Smith et al., 1988). However, many other orientations support the clinically appropriate use of touch (Williams, 1997; Young, 2005; Zur, 2007a, 2007b). The literature is replete with pros, cons, guidelines and advisements on touch. Zur and Nordmarken (2011) have written an exhaustive paper on the clinical, ethical and legal considerations of touch in psychotherapy.
Touch, like all psychotherapeutic interventions, has the capacity both for harm and for healing. Rothschild (2000) believes that, in some cases, judicious touch is useful as long as client and therapist agree. It is crucial to think before acting; to understand the counter-transference and transference implications; to collaborate with our patients about potential benefit and harm, all of which will result in making wise clinical choices. Surveys of clients who have experienced touch in psychotherapy indicate that touch reinforced their sense of the therapist’s caring and involvement. The findings also “support the judicious use of touch with clients who manifest a need to be touched, or who ask for comforting or supportive contact” (Horton et al., 1995, p.455).
Years ago, during my analytic training, before I ever thought about actually using touch with a patient, I remember reviewing the NASW’s and APA’s guidelines on touch—mostly out of curiosity. I was surprised at the time, since the taboo felt so strong in my mind, that neither of them expressly prohibits touch. They do expressly prohibit sexual boundary crossings and imply the essential message for all caregivers and health professionals: Above all, do no harm!
Being held is a profound developmental need. If a patient has been deprived of this basic need, it makes intuitive sense that a therapist’s skillful use of touch could foster healing. There is also an argument that not using touch when needed might hamper healing or even cause harm. For patients who were denied adequate physical affection or were outright neglected, not tending to these developmental and basic needs for physical comfort and soothing, when needed and/or requested, could be construed as an enactment of the original trauma. Instead of a blanket rule against touch, I think a better way to think about touch is whether it could move someone toward transformance (Fosha, 2007) and healing, versus re-traumatization. I consider touch the way Ron Kurtz (1990) of Hakomi Therapy does, that it is a form of nourishment. He believes, and my observations concur, that if a therapist provides the right nourishment that the patient truly needs, the patient will accept only what is needed and when replete with nourishment will move from dependency to exploration of the world at large. In other words, supplying what is truly needed will lead natural development to continue.
My patient is a 29 year-old single, college educated, bi-sexual, woman of Russian Jewish descent who grew up in the southwestern part of the United States. Sara, as I will call her, was raised in an intact family by a verbally abusive mother, who relentlessly screamed at her for doing anything other than validating her mother’s own wants and needs. Ever since she can remember, Sara was yelled at for using the “wrong” tone, for saying the “wrong” things, even for having a flu or throwing up when she was sick. Sara never knew what would set her mother off and therefore had to constantly monitor her mother as well as her own verbal and non-verbal communications. She has a loving father who allowed the abuse to occur because of his own fears of the ramifications of intervening. The father, as well as Sara, suffers from Obsessive Compulsive Disorder (OCD). The father’s OCD led him to criticize Sara for being dirty and thereby left her with a belief that she is disgusting. Between her mother’s mental illness and her father’s aversion to natural body secretions and odors, I wonder if Sara was adequately held.
Some of her problems at the start of treatment include: OCD since age 6, fear of emotions, fear of assertion, intense focus on pleasing others to avoid anger at all costs, and difficulty knowing her own needs and wants. All of these problems make it hard for Sara to be in relationships and, consequently, leave her feeling isolated, alone, depressed, and anxious. She is extremely hard on herself and, when I first met her, engaged in self-harming behaviors such as cutting and head-banging. These behaviors seemed to act as self-punishment for her perceived badness, but also may be maladaptive attempts to regulate skin pain (pathogenic affect) caused by early neglect.
In our earlier work, Sara was terrified that she would anger me. Triggered by any sign she interpreted as my displeasure, I witnessed her plunge into frozen uncommunicative states. I was unable to do much for her in those moments except to reassure her that I was not angry (and I was not!) and remind her I was here. Inquiring after these episodes passed what I could do next time to be of more help, she would instruct me to just stay quiet and let her be still until she naturally calmed down on her own. Over time we experimented with other ways to help her “come back” such as grounding her feet on the floor, breathing, talking about light-hearted things like her favorite television shows, sharing with her what I thought she was experiencing in the moment, and finally extending a hand for her to hold on to if she wanted. All of these interventions helped yet it took her a while to recover. My thought was that the threat of my anger connected to the pre-verbal memory of her mother’s frequent emotional abandonments and the accompanying emotions of terror, rage, despair and massive amounts of anxiety.
The treatment has focused on helping her regulate anxiety, differentiate me from her mother, build her tolerance to the full spectrum of affects and their accompanying experiences including body sensations and impulses, and recognize and process core emotions to completion (Fosha, 2000). Additionally, I am helping her become familiar with and gain separation from younger selves or “parts” (Schwartz, 1995), also referred to in the literature as self-states, so she can listen to their needs and respond. In fact, a main theme in our work is managing the intense longings of these younger self-states, which I will refer to as “parts” or “selves.” Facilitating a dialogue between parts of the self makes it possible to manage internal conflicts and transform maladaptive coping strategies, such as self-harm, into adaptive ways of dealing with conflict (Lamagna & Gleiser, 2007). As internal parts come to understand and accept each other, self-compassion, not to mention self-awareness, grows exponentially.
By her own report, throughout her life she has sought out mother figures in the hopes of receiving some of the mothering that these younger selves need. I am the most recent of these maternal figures and the maternal transference she has towards me is strong. These strivings are adaptive and resilient in the sense that she is looking for something she truly needs. They are maladaptive in the sense that she can’t ultimately obtain what these child parts need from others as the demands are too high and healthy adults in relationships have limits. Only her present-day Self (Schwartz, 1995) is uniquely positioned to care for her younger selves. I explained this concept to her early in the treatment, i.e., in service to her being able to sustain an adult loving relationship, ultimately it is in her best interest to be her own good mother.
When we first began working, younger parts didn’t want comfort from within. They wanted it from me. This is something we still work actively together on shifting. As the treatment has progressed, internal parts are relating more and more to each other. As a result, her self-compassion is growing. In essence, we are slowly transferring the job of caretaker and soother of her younger selves from me to her.
Sara and I have always worked collaboratively. She is honest, hardworking, communicative (except in certain distressed states after which she can reflect on experience quite well), and we have a great appreciation for each other and the important work we are doing together. From the beginning, her longings for and access to me were major themes. Teaching and modeling boundaries is extremely important in our work, as her mother disrespected hers with verbal assaults and, as a result, setting boundaries was not modeled properly. Contact between sessions was discussed and at times I set limits. Having extensively discussed the importance of boundaries in good/safe relationships, I knew Sara had a sense of me as a well-boundaried therapist. She was aware that where boundaries were concerned, I considered and modeled taking care of myself as part of the equation. Consideration and establishment of boundaries is especially important when a treatment includes the use of touch so the patient feels safe accepting what she needs without fear of other boundaries being transgressed by the therapist.
Prior to first holding her, I had thoroughly examined my own thoughts and feelings about touching Sara. I thought through, both on my own and in supervision, my motives and goals for acting. I had thought through her possible responses. We had a history of being able to successfully process ruptures and metaprocess (Fosha, 2000; Prenn, 2009) our interactions together. We discussed my touching her before we acted and subsequently metaprocessed the experiences. We also discussed how others might judge my holding her (which was an issue she raised) and how she would feel and deal with those imagined judgments. Other issues we processed included her fears of becoming dependent on me, her fears of my feeling manipulated, and secondary sexual gratification she might obtain. These preliminary discussions were the foundation on which I allowed our work to expand into the realm of touch.
My decision to sooth Sara through holding her in my arms came after months of working together. Early in our work, Sara would be triggered into a very dysregulated freeze-like state whereby, among other signs and symptoms characterizing her distress, her skin would hurt, “It feels like I have no skin.” Inquiring into the sensation to see what it needed, the need to be held was the answer it gave. Sara’s body told the story of a developmental deficit which needed transforming. Being adequately held and soothed is a crucial state of development. Lipton and Fosha (2011) write, “Beginning at birth, right-brain-to-right-brain, contingent processes such as holding, touch, gaze sharing, face to face contact, entrained vocal rhythms, and spontaneous moments of play and delight are crucial for (i) the regulation of the autonomic nervous system, (ii) optimal brain development, (iii) the emergence of stress- and affect-regulation, and (iv) the creation of secure attachment” ( p. 5). When a baby or child is not adequately held and soothed, the child cannot bear the distress and the mind adapts the best way it can to survive.
The need for touch and holding, from an AEDP perspective, is considered an attachment striving, a core need, and an inter-subjective experience of pleasure (Fosha, 2008; Russell, 2014). But, being adequately held is also a developmental need that when left untended makes it hard for a growing child to feel confident enough to explore the world. Margaret Mahler wrote about a similar phenomenon when she described the rapprochement phase of development:
Previously fearless in action, the toddler may now become tentative, wanting his mother to be in sight so that, through action and eye contact, he can regulate this new experience of apartness. The risk is that the mother will misread this actually progressive need and respond with impatience or unavailability, precipitating an anxious fear of abandonment in the toddler, who does not yet possess the psychic capacities to function as an independent agent (as cited in Mitchell & Black, 1995, p. 47). Disruptions in the fundamental process of separation–individuation can result in a disturbance in the ability to maintain a reliable sense of individual identity in adulthood leading to chronic depression. So it is with a baby who innately turns to her mother for physical soothing and finds her unavailable. Overwhelming levels of affect and unbearable aloneness, stemming from this neglect, lead to the formation of pathogenic affect (Fosha, 2000).
Hugging and holding satisfy a developmental need. Sara reported she had a felt sense of that dysregulated part of her as very young. I imagined a distressed baby in need of soothing that neither words nor fantasy could calm. She could not self-soothe either. I wanted to experiment with holding to see if it might help to regulate this un-symbolizable affective experience wreaking havoc on her nervous system. And it did. Touch can intervene at the physiological level in the regulation of affective states and directly address dissociation and dysregulation (Shore, 2003). Sara’s newfound ability to recognize her need to be held and ask for it represents a moment of “transformance” (Fosha, 2007). Meeting that specific need is transformational and leads to healing.
A final word about sex as it pertains to this treatment. Sara felt guilty should she derive any sexual pleasure from being hugged. She is not to blame for having feelings. “Feelings just are,” I remind her frequently, “they are normal and natural.” Judging and acting on feelings and impulses is not helpful but noticing them and listening to them is. So it is with sexual feelings. Discussing her concerns and making my thinking explicit has allowed us to move forward in helping younger parts express their true needs for holding without too much conflict and shame from developmentally older parts that simultaneously experience different wants and needs than infant and child parts. When shame or conflict arise in the moment, we return to State One “Defense Work” (Fosha, 2000) until safety is restored.
I have used various forms of touch in my work with Sara, although the vast majority of our sessions are just talk. We hold hands; we explore fantasies together that include me holding her; and then there are times when I physically soothe her. The purpose of each form of touch is briefly reviewed as follows.
First, I offer my hand to hold during moments of both emotional processing and dysregulation, in order to help undo “unbearable aloneness” when words and my presence alone is not enough. Second, when child parts are distressed and want to be held, I invite us to first cultivate a fantasy, or portrayal, in lieu of actual holding. I do this to help her increase her self-soothing capacity. When we use fantasy, she is in charge, but I do guide her. I encourage her present-day self to relate to her younger parts if they are willing (Schwartz, 1995; Lamagna & Gleiser, 2008). When those parts want “only me” to comfort them, I encourage and invite the fantasy to become vivid imagining exactly what she needs from me and how she is experiencing it. I ask her to sense me holding her and how it feels on her skin and anywhere else she can notice. When I am comforting (in fantasy) the child parts, I typically invite the present day Sara into the scene in any way both she and her younger parts will be comfortable. Sometimes Sara sees herself standing on the periphery of the room in the scene or sometimes we are “group hugging.” This is integration in process! While technically not touch, these vivid portrayals are an extremely intimate experience and could be triggering in the same way that actual touch could be, so I consider it a form of touch.
Third, when I actually hold Sara, I typically join her on my sofa. She leans in to me and my arms envelop her. Sometimes I stroke her hair. When her skin burns raw, where words and fantasies are of no use, the actual physical contact is needed to undo the aloneness. More specifically, it supplies the development need that was lacking at a critical stage and thereby transforms its pathogenicity. Holding brings immediate relief, typically followed by “mourning-the-self” affects and gratitude as seen in State Three phenomenology (Fosha, 2000). When I do hold her, I let her release the hold first so she takes as much “nourishment” as she needs, unless we are out of time. We almost always metaprocess the impact of our physical contact, as we do with other relational interventions.
The session below demonstrates touch using a fantasy portrayal followed at the end by physical soothing. During a moment when the longings of a young part arise with intensity, I guide her to tune into her body, to notice what she is experiencing, to bring attention to what she notices, and to hear what her body is telling her. Then when she recognizes a desire to be held, we honor it and work with it so see if she can sooth it internally with fantasy. It is only at the end of the session that I actually hug her to help her relax and regulate even more before she goes back out into the world.
This transcript is from a recent session of a 2x/week treatment currently approaching its 4th year. We begin 13 minutes into a session before she is going away on vacation for a week. Comings and goings, needless to say, are fraught and always triggering of fears and insecurities.
Pt: Whenever I go away, not only do I worry about you dying, but I also worry that I will die and you’re not going to know that I’m dead. I don’t know…I just want you to know that if I die, thank you for everything and I love you. And hopefully you’ll find out somehow. [abandonment anxiety coming up.]
Th: I hear that you want me to know that you love me and are grateful for me.
Pt: Yes. (nodding)
Th: And I think the chances are very, very good we will both be ok and we’ll see each other next week but– is there someone you can ask to let me know if anything happens to you? Would that be a comfort to you? [honoring her experience; “going beyond mirroring” to problem solve]
Pt: Yes, I think I can tell Flo—she knows I see you [Sara hasn’t told her parents she is in therapy for fear of repercussions and judgments.]
Th: So if you tune in and notice what’s coming up now…
Pt: (tension around her mouth which she squeezes tightly shut.)
[Squeezing her mouth closed is always a signal to me that she’s having an emotion and working to hold it down.]
Pt: (silence)…A bit of sadness…like…just sort of maybe hearing you talk about comings and goings from zero to 3…(puts hands over her eyes)…yeah
[We had discussed earlier in this session how current comings and goings resonate with early abandonments like when “connected” mom would switch into “angry” mom and how terrifying that abandonment was.]
Th: That touches something…let’s stay with physical sensations? [Previously she has told me that when affect overwhelms her, it is helpful to stop everything we are doing and focus strictly on her body sensations. Helping her regulate affect is the purpose of my suggestion to stay with her body.]
Pt: (labored breathing—some tension in chest—then a relaxing upon recognition.) It’s like a physical sensation of wanting to be held.
Th: Can you make some room for that…and maybe get a sense of how old that part is…or even get an image of that part?
Pt: (eyes closed) Like two years old maybe…(eyes more scrunched closed, labored breathing, increasing distress)
Th: See if you can separate from that part more and make it further away so its feelings don’t overwhelm you as much. [I’m hoping my suggestion will help her regulate a bit, but it doesn’t.]
Pt: (more distressed) It’s crushing me!!! [pathogenic affect]
Th: Where is the crushing feeling inside?
Pt: (points to chest)
Th: What does it need? What does it need to make the experience a little less intense so it stops crushing you? What is this crushing tell us? I’m right here. I’m not going anywhere. (lots of silence)…Scary, huh!
Pt: It’s telling me that I want…(squeezing lips to hold down the feeling)…it’s telling me that I want physical contact.
Th: Which part? How old? [I may be too cautious here but I always want to know the age of the part before I act on physically holding her—if she said the part was 16 years old, we would have done something different.]
Pt: (nods yes) Two years I think but maybe the six-year-old too.
Th: Yeah…can you check in exactly how it needs the contact and imagine it just the way it needs it. Is that ok? [I move to do a fantasy portrayal.]
Th: Let’s see if we can take care of that sweet, sweet little girl first and see if we can help her be less distressed.
Pt: It would help if I hugged the pillow.
Th: Great! Feel free. (She flops sideways on couch and grabs my pillow and hugs it, which is something she’s done many times before.) Is that a bit better? (Her body relaxes a little.)
Th: Can you get more of a sense of her and where she is?
Pt: Alone in the living room floor crying her eyes out and confused and alone?
Th: Where did everybody go?
Pt: (shaking her head back and forth)
Th: You don’t know? [Her childlike voice suggests that she seems to be in the “part.”] What does she need?
Pt: She needs you!
Th: Can you bring me in to be with her? [suggesting we use fantasy]
Pt: (nodding head)
Th: Am I with her? What’s happening? [asking her to elaborate on the fantasy]
Pt: You pick her up and take her away to your house, you’re sitting together on your sofa and she’s on your lap.
Th: Can you describe more of what you see? [I want the portrayal to light up the neural network as much as possible thereby fostering integration.]
Pt: She’s on your lap, holding onto your torso and crying into your neck.
Th: Beautiful…can you tell her I’m with her for as long as she needs me and just the way that feels right to her?
Pt: (visibly relaxing)
Th: What do you notice now …just in your body…
Pt: The crushing is gone…
Th: And in its wake, what do you notice?
Pt: An emptiness…(still lying down and holding a pillow)
Th: What’s it like—that feeling…like how big is it, what shape is it, can you take lots of time to get to know it.
Pt: it’s like 8” oval down my chest…
Th: How is it to make contact with it while we’re together? Is it ok?
Pt: Uh huh
Th: Is there a color associated with it…like if we stand on the perimeter and look in together and I’m holding you securely so you can’t fall in…like we’re holding hands and I’m tethered to a big tree so we can’t fall in… Just anything you notice even a glimmer…
Pt: It’s just kind of black….
Th: Just kind of black.
Pt: uh huh.
Th: Can I get you curious about that blackness or is your instinct to stay far away from it or anything in between? I think it’s meaningful. And I only want to look at this together, never alone.
Pt: I just want to pretend it’s not there.
Th: Is it something you know was there or is this a new discovery?
Pt: I felt it before (lying quietly then pops up a bit)…I’m sorry.
Th: For what?
Pt: I don’t know…I’m being pathetic.
Th: I don’t think you’re pathetic at all. We are touching on very deep and profound experiences that have huge meaning.
Th: I think you’ve done amazing today!! [affirmation] What’s your sense about how we have such a different take on the experience we’ve been sharing today? [metaprocessing. I seize the opportunity to have her practice being all right with two different subjectivities, something that her mother could not tolerate.]
Pt: (big smile–pops all the way up—sitting up now looking happy and regulated) I’m not surprised (laughing) by now I know how we differ in that way.
Th: Is it possible that when you label something as pathetic, what you’re actually feeling is incredible vulnerability. We don’t have a lot of language in our culture praising vulnerability—just the opposite, in fact.
Pt: It feels like…to me pathetic means that I wasn’t able to overcome something. Like I wasn’t able to…like I gave in to the feeling or something…instead of like trying to cover it up and go on as if nothing was happening.
Th: You mean right here right now today?
Pt: Yeah. Like I should have umm you know…tried not to feel that way…
Th: Really?? Why is that?
Pt: I don’t know.
Th: That seems like it would be more of doing what you had to do throughout your life to survive in your family.
Th: is it your sense that that would be helpful?
Pt: (shakes head no)
Th: That’s why I am so proud of you for doing something so brave. It’s hard to touch on these very deep old, old, old experiences that basically don’t have language—they get stored viscerally just in these black spaces we all have. They feel like holes but they are markers for lonely, overwhelmed, in the darkness feelings. [I do some psycho-education here by bringing on the left-brain to organize right brain experience. Fosha (2008) refers to this as “platforming.” Saying “we” lets her know that this is a normal experience, mitigating shame and aloneness.]
Pt: Yes! [recognition] I feel lonely and overwhelmed like all the time.
Th: Yeah so maybe that’s this part when it comes to the front.
Pt: (nodding yes) Maybe…
Th: And maybe we could spend some time here getting to know this place and what it is telling us about what happened and maybe it would heal a bit and you wouldn’t have to keep feeling as overwhelmed and alone. That it’s just a feeling memory in a way…
Pt: Yeah…(looking down and shaking head yes)
Th: I guess I’m curious what it is like, if you just check me out for just a second…is that ok for you? [Mid sentence, I invite her to shift from a downward gaze to look at me, which she does.]
Pt: Yeah (smiles)
Th: What it is like…to touch on a feeling that is full of such aloneness but to do it when we are connected. How that changes the experience or what it is like…[metaprocessing and undoing aloneness]
Pt: (deep breath) It is good to have you share in it and know about it umm…it is hard because I know we are together but like sometimes I need…
Th: Feel free…
Pt: Sometimes I need the physical contact and it’s not… just being here together is being good but it is not the same and it doesn’t feel…(Really struggling)…like…[lots of affect and anxiety coming up. I notice her hands are rubbing together, deep sighing, mouth clenched, all of which signify that emotions are pushing up in response to her trying to express her needs.]
Th: It’s hard…it’s ok. I would imagine it would bring up lots of feelings maybe of sadness and maybe some anger. (she is nodding yes) And if we just make room? [gesturing with my hands the idea of making lots of room.} Just to label the feelings coming up—and we’re not going to be with them today, because we don’t have time. But just to label them and let them be. And if you still want a hug goodbye from me today, I would love to (she’s nodding yes). And if you feel angry (nodding no with a smile) and don’t want a hug, that would be ok too.
Pt: (nods yes) No, I don’t feel angry. I just feel this intense longing. And I’m not angry because I know it’s important to try and take care of that without actually needing it but it’s so incredibly painful.
Th: So painful! Just keep trying to keep that young part separate so she doesn’t overwhelm you again. If you can keep the young part separate… [gesturing separation with my hands]…like really keep her far away and then just talk to her or sit with her so she’s not alone. And even if it’s not perfect, it may be better than nothing.
Pt: (nodding yes with big smile) Yeah.
Th: Play with that and let me know.
Th: And I’m right here—take me with you to Paris. [I mean in fantasy—entraining object constancy and undoing aloneness.]
Pt: And maybe I’ll send you a nice picture.
Th: I’d love that. We have a few minutes, do you want me to sit with you and have real physical contact before you go?
Th: [I sit next to her on couch, she leans into me and I put my arms around her.]
Pt: It feels so good…
Th: Everything’s going to be ok. I think you’ll have a great time…the beauty; the food…and then you’ll come back. And it is not like it was when you were a little girl. Now as a grown up you have all these skills and tools in your toolbox to reach out and cope with what comes. When you were little, you had none. That’s why it is important to stay in touch with little Sara in any way she’ll have you and any way you are willing…even if it is just being in the same room and sitting quietly with her so she knows she’s not alone any more.
Pt: Sounds good.
Th: I love how you are more and more getting to know and share exactly what you need. [affirming her, loving her up]
Pt: And sometimes the fantasies help and sometimes not.
Th: Yes and as we keep working together, it will get easier and easier to recognize little Sara and satisfy her needs just as we’ve been noticing all along. And you’ll feel better and better just like you have been. And maybe even this latest shift that you shared today about the OCD part having two settings now instead of one is really a testament to the fruits of our labor. [She had shared that some days she doesn’t have to do the entire washing ritual if she has to get out of the house for an important reason—that she negotiates with the OCD that she’ll do the ritual the next day…and it listens!!]
Pt: It’s true. I’m being kinder and more compassionate to myself.
Th: Yes you are.
Pt: (hugging me tight) Thank you so much! You are so soft and warm.
Th: You’re so snuggly! A good snuggler! [using evocative words of nurturing]
Pt: Thank you. When’s your birthday? [Feeling safe engenders curiosity.]
Th: September 18th. When is yours?
Pt: October 5th. I’ll be 30.
Th: Very respectable age. What makes you think of this now?
Pt: I have actually been wondering for a long time. Not that I couldn’t ask, it just felt particularly safe to ask now.
Th: Hmmm it feels very safe right here right now.
(Sara gets up, cheerfully exits to leave on her vacation)
In addition to the immediate relief and affect regulation that holding provides, there have been many overall shifts in her Self (Schwarz, 1995) and internal organization. Sara reports sensing a lifting of her depression that she attributes to the moment I held her for the first time when she was experiencing the painful skin sensation I referred to earlier. She no longer self-harms, she no longer berates herself for small infractions like being late for a session. She rarely freezes in session and when she gets dysregulated she comes back quickly. Her capacity for self-compassion is growing almost from each week to the next. Sara feels like dating again and traveling and, in general, she is more adventurous. Her growing assertiveness is evident both in session with me and out of session with her friends and colleagues.
Several days after this session, I received an email from Sara who was on vacation. I have quoted it below because it was significant:
I’m having a very pleasant time here so far! The weather is great and I’m feeling pretty relaxed. Monday’s session was a huge help in making me feel safe and secure about being away – thank you so much! Below is a picture of ______ , which we visited today. I hope you’re having a great week. I miss you and can’t wait to see you on Tuesday!
I was moved by this communication. It beautifully illustrates how she is moving through the process of individuating and separating. This growth has allowed her to begin to explore the world safely and happily with the knowledge that she has a secure base to which she can reliably return (Bowlby,1988).
In conclusion, touch when used judiciously and mindfully is a healing and transformational experience. Sara reports that the holding has helped her feel worthwhile as a human being, and deserving of love, attention and connection. Her sense of being disgusting and bad is diminishing rapidly. Additionally, she is becoming more and more compassionate to herself. She is far less dysregulated, with a growing tolerance for core affective and core relational experiences that can be processed to completion thereby releasing adaptive action tendencies (Fosha, 2000). The request or need for holding has not increased; in fact, it has decreased. I anticipate that with these early needs nurtured, her desire to explore the world will grow, as will her capacity to navigate the trials and tribulations of adult relationships.
General Guidelines for Touch When Requested by the Patient
- Experiment with fantasy holding first—it is generally all that is needed and it facilitates self-soothing capacities in the patient.
- If therapist feels an impulse to hold patient or patient request it, think through why this is coming up now and about counter-transference. Think about motivations for wanting to touch patient. Think through transference implications and how various parts of the patient might react.
- If the therapist has a sense that the patient could benefit from actual touch, discuss first with the patient. If patient is interested, go to step 4. If not, drop it. Metaprocess the therapist’s inquiry and how the patient feels about it.
- Think through alone and together potential reactions to actual touch, using fantasy for a dress rehearsal.
- Have patient sign “Consent to Touch” form before using touch.
- In future sessions, when touch seems appropriate, remember to check with patient if they want to be touched in a particular moment.
- Metaprocess the experience afterwards.
Sample Consent to Touch Form*
(Name of therapist) may incorporate non-sexual touch as part of psychotherapy. Sexual touch of clients by therapists is unethical and illegal. (Name of therapist) will ask your permission before touching you, and you have the right to decline or refuse to be touched without any fear or concern about reprisal. Touch can be very beneficial but can also unexpectedly evoke emotions, thoughts, physical reactions or memories that may be upsetting, depressing, evoke anger, etc. Sharing and processing such feelings with the therapist, if they arise, may be a helpful part of therapy. You may request not to be touched at any time during therapy without needing to explain it, if you choose not to, and without fear of punishment.
* It’s best to consult with your malpractice insurance on any forms they might endorse.
 “Transformance” is Fosha’s term for the “overarching motivational force, operating both in development and therapy,that strives toward maximally adaptive organization, coherence, vitality, authenticity and connection.”
 The term “self-state” or “part” refers to discrete experiences of subjectivity created when the brain links somatic, affective, cognitive, and behavioral representations into a cohesive, functional whole (Siegel, 1999).
 Metaprocessing is an AEDP term and a cornerstone of AEDP theory. It refers to the process of reflecting on experiences of transformation. Metaprocessing the healing and transformational moments of a therapy session leads to ever-expanding spirals of deepening between patient and therapist and patient and self (Fosha,2000).
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