How Close do I get to My Clients?
The question of personal space, physical boundaries, personal space between people in close communication, and physical touch is something that has interested me for some time, and as a psychotherapist, supervisor, and trainer I am frequently confronted with the issue of how physically and emotionally I can or should place myself in relation to my clients, supervisee’s and trainees. Two of the main theoretical schools in counselling and psychotherapy take different positions in this regard, first the humanistic approach advocating qualities of genuiness, congruence, and at times an openness to self disclosure (Rogers, 1961), in order to build a stronger therapeutic relationship and a safe space for the client to explore themselves in. Secondly the psychoanalytic approach avoids such disclosure and takes a position of ‘abstinence’ by not gratifying the client in their efforts to get closer to the therapist. This position is justified by the theoretical concept of ‘transference’ in the relationship, whereby in the absence of a more equally open dialogue the client is offered the opportunity to transfer their significant inner conflicts onto the ‘blank screen’ of the therapist. Adhering to either position as an ‘article of faith’ does not necessarily include the client in the process, and in my view while the optimum space between people may be culturally as well as personally defined, in a therapeutic relationship the feelings and meanings associated with close emotional and physical contact, or a perceived absence of it, are an important part of the exploration of client’s histories and current dilemmas.
These theoretical positions highlight for me the pervasiveness of the significance of touch for psychological well-being. There is little in depth exploration of personal space and closeness in counselling theories, though the psychoanalyst (Winnicott,1965) was interested in the idea of a ‘potential space’ between mother and child where he believed creativity could develop. He emphasises the concrete relationship (where Freud focussed on the fantasy relationship) between the environment and the infant as the critical factor in determining the growth of creativity, which he saw (like many humanists), as essential to questions about the meaning of life. One of the key developmental tasks is to establish a sense of what Winnicott (1965) terms “psyche indwelling in soma” that is the awareness that our physical and psychological boundaries are interrelated. This interrelationship of the mind and body in human development was an important theoretical insight. In his practise Winnicott was not averse to using touch with his patients to facilitate this connection, and Margaret Little who was one of his patients who went on to train as a psychotherapist herself, commented;
literally through many long hours he held my hands clasped between his, almost like an umbilical cord.
(Little, 1990: 44).
John Bowlby (1969) has also made clear the importance of a close physical bond between children and their carers if they are to mature healthily. Mary Ainsworth who was a lifelong collaborator of Bowlby, discovered that it was the provision of a secure base, through a close attachment to the mother that enabled the child to go out and explore, safe in the knowledge that he/she can return to that secure base at any time. One major factor in the provision of a secure maternal base is of course touch. While the importance of touch in the provision of security and creation of a close bond has been mentioned by others (Harlow, 1971; Robertson, 1952), the most significant discoveries in attachment theory that indicate the role played by touch are recent developments in neuroscience, in particular the work of Alan (Schore,1994/1997; Panksepp,1998). these have confirmed such theories with evidence that as infants we need loving touch in order to develop our brains and thinking abilities. In other words, it is not just our emotional and psychological well being that needs close caring physical contact to thrive, but also our mental development as well.
At one extreme, for example within psychoanalysis touch has only been associated with the expression of adult sexuality, or with an unwanted interference in the therapeutic relationship. Elsewhere, developments in Humanistic approaches have actively sought to include the use of touch as an integral part of the therapeutic relationship, applying specific touch techniques to encourage the release of emotions or offer a nurturing and supportive environment. The subject still provokes controversy and debate however, the integration of mind and body as a topic worthy of discussion seems to be moving much more towards centre stage for many counsellors and therapists (Annual Conference of the United Kingdom Council for Psychotherapy, 2004; John Bowlby Memorial Conference, 2003; BACP Journal, 2005). The practice experiences of therapists with regard to the use of touch, the motivations behind their therapeutic decisions, and the extent to which they reflect upon and process these decisions, thoughts and feelings, are all areas of therapeutic interest to me.
I am particularly interested in what informs counsellors and therapists in their decisions about the use of touch, and if they are taking a reflective position to this issue or merely ‘following the rules’ whatever they may be and from whatever source. Continuous professional development is the catchphrase for all professions today, but in order to effectively reflect on these issues, counsellors and psychotherapists need to engage with their clients, supervisors and peers in meaningful dialogue, as well as look into their own thoughts and feelings about touch. Orbach succinctly makes this point:
leave the discourse and theorising about touch to body orientated therapists, and keep quiet about those hugs, the touch on the shoulder, the hand that needs holding, the kiss that got planted on us. In so doing we short circuit an attempt to think about when and why we should or should not touch.
(Orbach, 2004: 36)
In a traditional psychoanalytic setting a number of different forms of contact are avoided. It is partly the roles, power differentials and also the physical positions of the analyst and patient that establish the boundaries. In such a hierarchical situation where it is usual for the analyst to determine distance and physical contact, for example the analyst sitting behind the patient on the couch, the patient may well feel they cannot initiate closer contact or touch under these conditions. Also where they are also unable to see the analyst’s face, it is difficult to cross-validate what he/she is hearing by other non-verbal means of communication. This can be experienced as disempowering by many patients (McLaughlin, 1994). It is difficult to justify a complete touch taboo in counselling and psychotherapy, and even Freud used to lay his hands on his patients head in his earlier career. More specifically it was gratification by physical contact that Freud prohibited, and this boundary was established by the expulsion of his colleague Ferenczi because of his over familiar style of using touch with his patients. It was the fear that touch would lead to sexual contact and the breaking of the incest taboo that worried Freud as much as any theoretical considerations. However there are some more recent indications that psychoanalysis is coming to accept that touch can be a nurturing expression, without the erotic necessarily taking primary position (Breckenridge, 2002; Bar-Levav, 1998).
An opposite view taken by some authors (Hunter and Struve, 1998; Breckenridge, 2000; Schlesinger and Applebaum, 2000), is that touch and the avoidance of touch are equally relevant factors in the emerging therapeutic relationship to be processed along with any other form of communication. In essence, the analyst’s action of sticking to the rule of abstinence by not making physical contact when the patient is reaching out to him/her could be seen as just as significant an intervention with a similar effect to holding the patient’s hand. As Hunter and Struve point out:
The therapist who chooses not to employ touch when such an intervention has the potential to facilitate therapeutic progress is just as accountable to claims of exercising poor clinical judgement as is the therapist whose touch interferes with therapeutic goals.
(Hunter and Struve, 1998: 151).
Breckenridge (2000) makes a similar point:
Not to touch, particularly not to touch prescriptively, also communicates; however, the communication is, I fear, about rigidity or even worse.
(Breckenridge in Casement, 2000: 164).
In my own research into the use of touch (Tune, 2001), I was interested in finding out whether or not counsellors and therapists were making physical contact with their clients and what their motives were to touch or refrain from touching. I interviewed twenty three therapists of different theoretical background. First, twenty out of the twenty three practitioners that I interviewed said that they did not use touch in their work, but when I mentioned the possible use of handshakes or hugs at the end of therapy they all said that they did touch. This raises the question as to why these experienced practitioners did not think the physical contact they had made was relevant to their work. Some of the answers to this issue lay in the observation that many therapists considered touch that happened at an ending of a session or of the therapy to be outside the ‘therapeutic space’, or as an everyday social interaction that had no influence on their practice. This finding confirms the view (Hunter and Struve 1998; Young 2004; Hilton 1996), that to touch someone at the end of therapy when you have not done so before, can surprise your client and carry many confusing meanings for them. Hilton emphasises the dangers of this in the following example which refers to a colleague who had come to the end of his training analysis:
As he was walking out of the office for the last time, the analyst for the first time put his arm on my friend’s shoulder and told him how much he enjoyed working with him. My friend said it was as if none of the therapy had happened. All of the feelings he thought he had worked through surfaced in his body as he felt the touch of the analyst. He said, here he was leaving when he felt for the first time he was beginning.
(Hilton, 1996: 177).
This issue of intention and possible misunderstanding of intent is seen by some (Young, 2004; Hunter and Struve, 1998) as a major contribution towards what is or is not ethical. One of my interviewee’s ‘T’ commented about the different ethical positions taken by organisational ethical codes and how they can be in contradiction to a counsellor’s own practice model:
The code of ethics is written in psychodynamic terms, and if she (colleague) had used her own code (humanistic) it would have been in some way denigrated.
As Young (2004) points out, few of the leading professional counselling and psychotherapy bodies in the United Kingdom have a clear ethical position regarding touch.
Another interviewee ‘C’, felt at odds with her spontaneity towards physical closeness:
Sometimes I feel like I would like to touch if they are in distress, but I’m cautious, I would ask a client, I have hugged clients.
Others worried that touch could be counter - therapeutic in some way. ‘F’ commented as follows:
I risk taking them out of themselves….. (this is) the main reason, backed by my own therapy, being allowed to make my own journey and given my space.
Another interviewee ‘A’, thought it could only be ethical if it was situational and spontaneous. He had been influenced by his own experience as a client:
I had a therapist who hugged me. I didn’t like it, so I would feel I was manipulating if I hugged someone. If I felt intuitively, I would. It would have to come out of the situation. I finished with one client, saying goodbye I gave her a kiss on both cheeks, then worried about it afterwards. I worry about my spontaneity. I did hug one of my male clients but he asked for it.
Many of the interviewees said their use of touch was spontaneous and arose naturally from the interaction. This was not motivated by theory or experience nor was it thought through in terms of the therapeutic process:
At the end with a hug, working with children it comes in more, it’s a natural part of communication…….to encourage parents, to invite them to hug their children.
One interviewee ‘H’, saw her use of touch as specifically outside the theoretical domain of the therapeutic process:
When a ‘meeting’ has occurred, something very real has happened, not necessary to process…..at an ending when you meet “person to person” without any transference or whatever. Not part of a theoretical model or routine, more spontaneous.
So, for some interviewees who seemed to have not given much thought to their use of touch, words like “natural”, “spontaneous” and “intuitive” were used to either permit the use of touch or argue against it as counter-therapeutic or contrary to training and experience. As already noted Schlesinger and Appelbaum (2000) and Breckenridge (2000) have commented on this point about the possible negative therapeutic effects of repressing spontaneity in the therapeutic use of touch. Clearly, in my own research a lack of confidence in following intuition and spontaneity was an issue for counsellors and therapists and a source of some confusion within their practice.
Some major themes emerged from my research which relate to training, supervision and discussing physical contact with the client (processing). These are presented in the table 1 below for subsequent discussion.
Table 1: Major themes that emerged (from 89 examples of touch given)
Number of examples of the major theme of why therapists touch
Training-incorporating touch as a legitimate area for discussion in training
1 therapist reported touch being discussed in training, another said it was mentioned briefly. The remainder stated the issue was only mentioned in terms of a warning not to do it.
Number of examples of the major theme influencing why therapists touch and what they do about it
Supervision-discussions about issues of touch in therapy
33 of the 89 incidents of touch mentioned were discussed in supervision, though 17 of these were by the same 3 therapists.
Number of examples of the major theme of what therapists do about issues of touch
Processing-touch within the therapeutic relationship
19 examples of touch were processed with clients in the session, 8 of these by the same 2 therapists.
Touch and closeness in training
The influence of both the interviewee’s respective training organisations theoretical models as well as the attitudes of the trainers themselves towards close physical contact, emerged as a major influence on the decisions the therapists made about how close to get to their clients. The following quotes were some of the comments made by interviewees on the attitudes within their training programmes towards the ethical use of therapeutic touch:
We were warned off touch in training.
It’s to do with being human and caring, it should be part of our training-to look at touch rather than just say no you mustn’t.
This links to Pinson’s (2002) findings that make a connection between the level of comfort experienced by therapists who are contemplating or using touch in their practice and the extent to which it was covered in their training. More than just a lack of preparation or omission, another interviewee emphasised a negative attitude towards touch in her training organisation:
We were warned off it in training. It could be ambiguous, or dangerous and should be avoided. That was it really.
Importantly Hunter and Struve believe that this is a serious omission in training:
This collective failure to incorporate discussions of touch onto course curriculum is an underlying factor that contributes to professionals entering the field of psychotherapy ill equipped to deal with touch in an appropriate and ethical way.
(Hunter and Struve,1998: 70).
The findings in my research revealed that the debate about close proximity in the therapeutic relationship was lacking in the training of all but three of the practitioners I interviewed who were already using or considering using touch in their work. I draw the same conclusions as Young (2004) in this respect, which is that the therapeutic profession would generally benefit from a wider discussion of touch and how close we get to our clients and calls for a greater depth of additional training and personal development in this area.
Discussing closeness in supervision
Out of eighty nine examples of touch given during the interviews thirty three were discussed in supervision. However, of those thirty three examples, seventeen were by the same three therapists. In addition, very few of these examples of the use of touch were recounted without some feelings expressed in the telling -verbally and non-verbally; sometimes indicated by the tone of voice, demeanour, expression, or a sigh. Often the feeling was anxiety about the supervisor’s reaction, or uncertainty about the intervention. Sometimes it was regret that touch had not been employed more therapeutically, and frequently it was accompanied by a sense of warmth and empathy towards the client when it was. This is in accord with Geib (1998), regarding the sensitivity but also defensiveness felt by many therapists who report using touch in supervision. Lawton makes a connection between the avoidance of certain issues being discussed in supervision and power in the supervisory relationship.
Three quarters of the subjects said they found it difficult to view their supervisors as equals, and half felt, or expected to feel, somewhat intimidated by them. This was evident in that some subjects were unable to challenge their supervisors or raise contentious issues.
(Lawton, 2000: 34).
One interviewee ‘C’, explained her avoidance of discussing touch as being due to her supervisor’s orientation and her belief that she would disapprove, though this was untested as ‘C’ did not mention touch even when it was frequent:
Actually there is one client, a man; there is a lot of touch. I see him at the centre. Funny I hadn’t thought of this before, there is a lot of touch.
A female therapist also avoided the issue of a hug that she initiated:
It never really happened in supervision. The man I hugged… it kind of self resolved… he sort of worked it out about the touch thing.
While ‘L’ another counsellor, did take an incident to her supervisor of a client wanting some physical contact. She was told it was only acceptable on the last session. This was an interesting piece of supervisory advice given that this supervisor was against the use of touch at any other times:
Yes, but my supervisor wasn’t able to help me. She took the view that it should be no touch unless on the last session the client wants a hug from you.
The theme of discussing issues related to the use of touch in supervision raises a number of professional issues for counsellors, psychotherapists, supervisors and trainers. First, the findings indicate that for the majority of the respondents, discussion about touch and issues related to touch were not a normal part of their supervisory debate, unless the touch was exceptional in some way, and as in the majority of examples it affected the therapist. Less attention was paid to effects upon the client, in particular when the touch was therapist-initiated. Secondly, there was considerable evidence that supervisors took a negative attitude to the use of touch, or that supervisees perceived that they might do, if they reported using touch in their work. Thirdly, though a reluctance to disclose incidents or issues of touch to supervisors might have originated in training, it persisted long after the practitioners were qualified, indicating a persistent ‘external locus of evaluation’ in the respondents work. Fourthly, with those respondents who had been pro-active in finding supervisors who were open to discussing the use of touch, examples and issues of touch were not omitted from the supervisory discussions. These findings support those of other studies related to supervision issues already mentioned, in that those topics that are perceived as ‘difficult’ or contentious are frequently avoided in supervision.
Discussing physical closeness within the therapeutic relationship.
The theme of processing touch with the client forms part of the question about what the therapist does in regard to his/her decisions about using or abstaining from using touch in deciding how close to be with a client. This theme is closely linked to the preceding one about supervision, but while messages from supervisors were seen to affect both the counsellors and therapist’s decisions about using touch and their openness to discussing it within supervision, the decision to openly discuss touch within therapy did not show evidence of affecting the therapist’s decisions to use it or not. In addition to messages from training and supervision another significant influence on the interviewee’s openness or ability to discuss touch with their clients was the context in which the touch occurred. Endings were one situation in which further processing was clearly impossible.
Young is unequivocal about the avoidance of processing the use of touch within the therapeutic relationship:
However it seems that here is also a taboo about talking about touch in psychotherapy, and thus for many it is a touchy (sic) subject.
(Young, 2004: 24)
One client a counsellor reflected that by not avoiding uncomfortable feelings about touch in the session, it helped her client to move forwards in the work:
The fact that I asked her meant that we didn’t get stuck in that little collusive place. She was able to say a bit about what she was feeling, and her anger came out.
One further issue that arises from my research about the discussing of client’s needs for physical contact or the therapist’s use of touch, is what this may mean to either of them. If, for example the client initiates touch, a question arises as to how the therapist responds to that request. Some of the interviewees welcomed the invitation to touch the client in so much as it resonated with their own intuitive sense at the time, but they did not discuss this with their client. Others did not want to get physically close, but went along with the request anyway, and again did not talk about this with the client. A minority were clear immediately that for a variety of reasons, this was something they did not want to do and declined, but then failed to discuss this decision in the therapy session. These findings are similar to those of Geib (1998) and Wilson (1982) which indicate that while the taboo around touch may not be preventing counsellors and therapists from getting physically close to clients in their work, it often makes them feel sufficiently guilty to avoid processing it in the session.
The present culture regarding the use of touch is not therapeutically beneficial. There was a general level of anxiety in most of the people I interviewed around the issue of touch in therapy, and this showed itself in the following ways;
This level of anxiety and the taboo about discussing closeness and touch evident in current literature and my own findings, still has an influence on training and psychotherapy today, and contributes towards an unhealthy lack of awareness about the benefits, risks, and implications of touch in psychotherapy, that puts both clients and therapists at risk. To abstain does not offer a solution either, as Hinton points out:
Avoiding touch is not the answer; understanding and integrating the meaning of touching for you personally will give you the solid basis from which you can be the “stable adult parent-substitute” that is needed. But first your own needy little child must have been acknowledged and allowed to grow up
Implications for practice.
The implications for practice that emerge from my study fall under four general headings, which are:
Many interviewees also commented on the lack of a set of guidelines regarding closeness in their training or professional organisations. One such list of guidelines for the ethical use of touch in psychotherapy has been drawn up by Hunter and Struve (1998) and is repeated below. They suggest these guidelines as a base line for the use of ethical touch.
It is appropriate to use touch in psychotherapy when:
Š the client wants to be touched
Š touch is intended for the clients benefit
Š the client understands concepts of empowerment ( and they can say no)
Š the therapist has a solid knowledge base about touch
Š boundaries are clearly understood by both client and therapist
Š there is enough time in the session to process touch
Š the therapeutic relationship has developed sufficiently
Š touch is offered to all types of clients (there is no differentiation on the basis of gender, age, sexual orientation for instance)
Š supervision is available and used
Š the therapist is personaly comfortable with touch.
(Hunter and Struve, 1998: 138).
Whether practitioners or trainees see such guidelines as helpful or not I believe that the following questions are important considerations for all those working therapeutically, irrespective of how close or distant they place themselves within their therapeutic relationships:
These questions arise from the general lack of clarity and inconsistency around the use of touch which my own research and current literature reveals, and the increasing need from an ethical point of view to confront ambiguity and anxiety in the promotion of safe practice.
Practitioners and trainees would also do well to consider how they intend to negotiate physical contact with their clients, if indeed they are thinking about using it. As the findings suggest, in order to be sufficiently aware of the potential power of such interventions and to practise them ethically, then further professional development to explore the issue of touch would be advised. The findings also strongly suggest that personal self development about the whole issue of closeness is a pre-requisite for working therapeutically with touch. The haphazard introduction of powerful physical interventions without any knowledge of their effects, a theoretical and experiential grounding in their use, or an absence of processing their effects, is not to be recommended.
If touch is to be used for instance as a form of support during a difficult session, as a means by which the therapist nurtures a client in a regressed stage, as a symbolic way of celebrating or acknowledging progress made, as a welcome or goodbye, or more subtly as a means by which the therapist ‘tunes into’ the space between him/her self and the client, then practitioners would do well to reflect on the following points:
Š Is the touch consensual? If it was not (because it was spontaneous for instance), have you checked afterwards that it was alright with the client.
Š Do you feel the same about touching this client as you do about them touching you, if not why not?
Š Have you reflected on what touch meant to you and the client in this session?
Š What opportunities have you created for you to process your feelings about touch in therapy with peers, supervisor or trainer?
Š Have you taken the opportunity to inquire how the client felt about touch in the session?
Š Have you explored what touch might mean to this client in the context of their culture, gender and history?
Š Have you sought to develop your own awareness of your bodily sensations in your personal development?
If practitioners are considering these questions and seeking to find answers to them, then my findings and current literature would indicate that much understanding and benefit to the client can be gained by the creative integration of ethical touch as a therapeutic intervention. For those practitioners who intend simply to offer a supportive hand or a hug at certain times, then research data would indicate that while this spontaneous expression is not uncommon and frequently welcomed, it would be better if it was not left to the last session, and was talked about with the client at the right moment. If on the other hand counsellors and therapists are using touch in a haphazard way without a conscious awareness of its possible meanings, or not in a co-operative manner, or in secrecy and without open discussion, then they would be better advised to avoid its use.
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