The Ethics of Touch

Lecture in Wash DC, Oct 1999, via Common Boundary & DC Guild for Body Psych

I find it intriguing that I've been invited here tonight to talk about the ethics of touch in psychotherapy. After all, we dont hold lectures and debate controversies on the ethics of various verbal interventions in psychotherapy. Clearly, touch is a special case in the therapeutic relationship, and I hope to delve into some of the reasons for this tonight.

Modern Western psychotherapy has birthed itself just as

advances in technology are causing us to increasingly use our distance senses - sight & hearing

and use less our proximity senses - touch, taste, smell

In some ways, we are literally getting farther apart, and this potential for alienation is exactly what psychotherapy seeks to remedy. This increase in distancing has prompted physician & philosopher Ashley Montague to say: “The impersonality of life in the Western world has become such that we have produced a race of untouchables.”

Indeed, we now largely relegate our clients to the status of untouchables, using the rationalization that we are protecting them and ourselves from something harmful - our touch.

And to be fair, touch can be harmful, as I will point out in a minute. The question remains if we can clearly distinguish its potential for harm, and create training opportunities that avoid these possibilities. I'll give you the punch line from the beginning - I think touch skill is and should be trained in all psychotherapists, and that very teachable steps can be taken to avoid the potential harm in touch.

Before I talk about that, I cant resist a bit of singing the praises of touch. I suspect that I would be preaching to the converted if I say too much about the benefits of touch, so I'll refrain from being too over zealous, only glancing across a few of the more important recent findings.

As we turn more and more to neuroscience to validate what we do, we keep falling over a plethora of research that seems tailor-made for our longstanding clinical intuitions. In the realm of touch, we find that it stimulates nerve connections in our brain - this being largely true in infancy, but there is evidence this connection between touch and neural networking continues throughout our lifespan. As you may know, an abundance of nerve connections herald such heavy weights as intelligence, creativity, and behavioral plasticity.

Many of us know how this was first discovered - in orphanages - who at the turn of the century had in many instances 90% infant mortality rate - this condition was called merasmus.

There were similar findings in infant hospitals in situations of sensory deprivation, such as iron lungs.

After observing that touched and stroked infants had a less than 10% mortality rate, touch was instituted and mortality rates plummeted.

This benefit of touch has been likened to the instinct of most

mammals to lick their newborn infants - when this maternal behavior is prevented by experimenters, the same mortality rates occur in animal young, plus, the mother doesn't seem to mother well. It was later found that post-partum licking decreased stress hormones and stimulated the immune system in newborn mammals, and caused a release of oxytocin in the mother, the hormone of maternal bonding. This finding has been now replicated in both newborn humans and their mothers in our version of licking - holding and stroking.

A further update in the annals of animal torture has demonstrated that rats that were messed with medically - organs removed, given cancer, etc - that the handled ones survived at a 3:1 ratio and that

fondled rats develop more rapidly, and are more disease resistant.

Premature human infants who are touched at regular intervals gain more weight, are more responsive, are discharged several days earlier, & on their 8 mo follow up show continued greater weight gain, mental & motor development than low-touched babies

Cocaine-exposed newborns also show increase wt gain, decreased stress, and better motor development

Normal infants who receive a regimin of touch show

greater weight gain

less fussy

increased sociability and interaction with others

decreased stress hormones, increase of serotonin

In both babies and adults, touch has been shown to develop and to organize sleep/wake cycles - this may give us something to think about regarding our epidemic of sleep disorders in this culture, particularly insomnia.

Getting a bit closer to our psychological home, studies have found that 69% sexual abuse survivors felt touch fostered a bond with their therapist, trust, openess, communicated acceptance, & enhanced self esteem, and that they rated therapists touch more positively than non-survivors did.

Quite a few studies link a lack of childhood touch with violent and anitsocial behaviors.

Clearly, touch is beneficial, even required, but should psychotherapists be the ones to do it? To begin to play with that question, let's look at what some psychotherapists say:

Specifically, in a therapeutic context, some of the arguments for the use of touch are that:

1) touch is the treatment of choice to remediate touch wounds, such as:

deprivation & neglect

overstimulation, intrusion, violation or sexualization

parental narcissistic use of child via touch

a deadening of vitality & relating to ones body as an object

2) touch is important to boundary formation - our somatic yes or no

3) studies indicate it enhances the patients feelings of trust, safety reassurance, and self disclosure

4) increases perceptions of therapist as competent, trustworthy, caring

Various psychotherapists who use touch have speculated that it tends to be useful in instances of:

1. Symbolic mothering - esp when the patient is non-verbal - Holding time, autism

2. communicates acceptance during patient confusion or self loathing

3. strengthen reality contact when anxiety threatens

4. controlled expression of aggression (ie arm wrestling)

5. When natural expression of therapists feelings towards client, in situations when this is appropo to the clients progress

In order to touch someone, normal social distance lessened - both the patient and the therapist must lower their defenses to make contact. It can be this lowering of defenses that is behind some of the psychotherapeutic benefits of touch - in touch we become more permeable to love, caring, and positive regard, soaking up what we lack. The therapists power goes up, as would their ability to do good work. It also means that the patients vulnerability to coercion rises, and increases liklihood that powerful emotional content might be tapped that the client cant integrate

Let's look at why therapists have been classically reluctant to touch:

1. touch interferes with transference neurosis - the therapist needs to be a blank slate

2. touch gratifies patients desires - lessens patients energy & motivation

3. can easily be misinterpreted, especially erotically

4) can easily be misused - as in confering power, status, & hierarchy signals, esp between sexes

5) You can get your ass sued off

These are not empty criticisms - These are important issues that we must examine and work with very consciously and contientiously.

Ethical complaints often center on areas of psychotherapy that are controversial, & the use of controversial techniques requires even more stringent ethical guidelines. Touch is perhaps the most controversial issue I know of in psychotherapy today.

To begin to deal with these themes, I'd like to take a look at the ethics of touch from three levels - sex & power, the therapeutic relationship, and theoretical issues

1 st level - sex & power The Politics of Touch

This first level has to do with gender, status, hierarchy, power, and culture

We can look at various non-verbal communications research to study this level of issues

studies find that - in most cultures that have been studied:

males touch females more frequently

older people touch younger more frequently

hi status touches lo status more frequently

touching is often an attempt at dominance - is done when giving orders, giving advice, granting favors, giving info

the higher the class the less use of touch

Looking more closely at Gender issues:

women don't necessarily interpret a mans touch as sexual, but men often interpret a womans touch as sexual

we operate with the illusion (by assuming only affection w touch) that women touch more and have greater freedom to touch - reality is that that freedom only extends to other women.

Women touch women more than men touch men. Men touch women more frequently

Perhaps most telling is research from filmed interactions of parents with their children:

fathers touch daughters more than they touch their sons

before 6 months, boys get more touch from their moms than girls do, but after 6 months the girls start to receive more touch than boys by their moms, and the boys are moved to a greater interactional distance than girls

Females tend to discriminate others touch intentions from where it is placed on their body

Males discriminate types of touch more - whether it is a pat, a stroke, a brush, etc

Men tend to feel a lot of distress when they are forced to touch each other, women tend to get less anxious

When we examine perceptions that people have of negative touch motivations:

females categorize men as all hands

males categorize females as clingy

Cultural Issues In Touch

Americans are an extremely low touch culture (Jourard)

pairs of people in conversation in coffee shops for 1 hour:

Puerto Rico - 180

France - 110

England - 0

USA - 2

the longer imigrants are in US, the less frequently they touch

kinship system - learned & maintained thru touch

Some Thoughts that arise from studying these findings:

Men may be more touch deprived, and more likely to relegate touch to sexual behavior because of it

Women may be less touch deprived but more likely to be touch violated (re dominance) and to have more confusion re touch intent, especially from men

touch deprivation may lead to tactile defensiveness

touch violation may lead to poor touch boundaries

of course the primary issue in the ethics of touch is when it is sexualized - which is defined as any touch that arouses either the client or the therapist

11% of male therapists have had erotic touch with clients during therapy

2% female therapists have

5% male therapists have had sex with clients

.5% female had sex

The statistics on sex with clients rise a bit after termination

Besides the fact that sexual contact violates APA ethics, there is a lot of research evidence that its damaging to clients.

Other studies have found that in cases of sexual touch between therapist and client, the majority occur during a time when the therapist is experiencing personal difficulties - we often say that clients get confused about our touch intentions, but in this case we are clearly seeing a pattern of therapist confusion and incompetence - their inability to keep their personal issues from invading the session.

Let's take a look at some other research findings about the use and misuse of touch in psychotherapy:

1) Studies have found no relationship between erotic & nonerotic touch in therapists - this means that a therapist who touches their patients nonerotically is not more likely to also touch them erotocally - this good news points to the idea that we dont have to see any touch at all as leading to erotic behavior. The bad news is the inverse - there are therapists out there whose only touch with their clients is erotic.

2) therapists who differentially touched opposite sex clients but not same sexed clients were at significantly higher risk for sexual contact w patients

2 nd level - therapeutic relationship issues

Bill Cornell - each time a therapist touches a client their history and their affect/desire are evoked

Positive touch outcomes associated with:

•  patient & therapist discussing touch event & their relationship

•  patient feels in control of touch

•  touch is not experienced as demanding or need satisfying for therapist

•  overall expectations of treatment congruent w patient experience of treatment

emotional & physical intimacy congruent

this points to a few relational guidelines about touch - it works best when:

there is congruence with the therapists feelings

with the level of intimacy (physical not exceed emotional)

with the needs of patient

and the patient always feels in control of initiation & maintenance

Clients who are negative about touch from their therapists tend to have 4 themes:

•  feeling trapped in the gratification of being close

•  feeling guilty about being angry at a seemingly nurturing therapist

•  feeling responsible for therapists well being

4. recapitulating in therapy childhood dynamics

Notice that 3 of the 4 themes are about the therapeutic relationship

In our social worls, touch is a natural part of any close relationship. In some ways is seems strange that we can be in an extremely intimate relationship with our clients and NOT touch them. However, the issue is complicated by the fact that the therapeutic relationship is not a natural one in this sense - the intimacy is for many reasons one way - the therapist does not confide and share their personal lives or experiences unless it is therapeutically appropriate - so touch in this sense should obey the same boundaries.

Bill Cornell:

“I feel that in the name of protecting clients, therapists can all too readily infantilize them and deprive them of opportunities of contact, struggle, conflict, differentiation, and mastery thru the body. If its assumed that touching a client is always bad, unethical, sexually or countertransferentially motivated or simply too risky, clients are not invited forward into contact at a body level. I fear then that the psychological ego, the ego of the mind, must again substitute or compensate for an impoverished, fragile skin/body ego.”

Therapists need extensive training as to when self-disclosure is therapeutically appropriate with a client, and one of the primary ways this training is shaped is through the concept of projection, and its confusion with intuition. If we touch our clients, we must have ample training in discerning our projections from our natural intuitions.

By way of example, I'd like to read a quote from a book about touch in psychotherapy that disturbs me greatly:

Touching Dialogue quote

This highly interpretive monlogue is full of new agisms and presumptions about what the client is feeling. Whether these interpretations are true or not makes no difference - they set the therapist up as expert reader, as hi power. There is no need to invade a clients emotional body like this. Touch can heal without these assumptions.

To my mind, this is a clear example of projecting feelings onto a client via touch

It presumes we receive the signals from the patient that they are broadcasting - it further assumes that the patient sends clear signals, and that the therapist is a passive receiver of this clear message.

Non-Verbal Communications Researcher Sigfried Frey shows that we are not passive signal receivers - he shows that we interpret things as signals that aren't, and that we make up signaller intention from our own motivations and inclinations - head tilt data

When we touch someone we bring energy into the system of the relationship, stimulating a body response in both. This response may be threatening to their & your defense structure, which of course has advantages and disadvantages. We must be very thoughtful about touches power to increase the energy in the relational field, and be ready to work with the results.

The 3 rd level - theoretical issues

this level has to do with the type of patient, the timing of touch, and the type of therapeutic issue being worked on

some authors have looked at 2 types of patient that we tend to get in touch trouble with:

the understanding one - wants to gratify you

the innocent one - childlike quality that seduces therapist to drop boundaries

another way to look at it is the difference between the

regressed patient - who is repressing developed capacities - not good to touch - may regress further

and the non-developed patient - trouble communicating due to low capacities - good to touch, may help transmit verbal communications, develop ego strength, positive parenting

Let's consolidate the various themes that have been introduced here, and move on to what we can do as clinicians with regard to touch.

Its my belief that touch is underused in most therapeutic encounters. The primary reason for this is that due to its immense power, it can cause harm. As a society we fear this power/harm combination. We have feared it so deeply, and in many cases so correctly, that we legislate laws, cultural mores, taboos and conventions to control it. The ability to do harm with touch will always exist as long as there is a power differential between individuals, sexes, classes, and races. What we also are beginning to realize as a society is that touch is so necessary to human existence that there are times in our lives that we would die without it.

Psychotherapy is often seen as a remedial return to the unmet needs of our formative years. What we now know is that one of our most primary and basic needs is touch. Both lack of touch and innapropriate touch can permanently warp our being. We also know that our need for touch never goes away - it simply becomes more self-directed.

At the same time, our other most primary need is for safety, particularly physical safety. It has only been recently that as a world culture we are calling into question the age-old practice of the physical punishment of children. As we look at the rampant misuse of touch as a tool for coercion, domination and control in our culture, we can begin to understand why we are fearful of retraumatizing our clients by touching them.

How then do we use touch as an effective and nourishing tool in psychotherapy, particularly in forms of psychotherapy that value and address the body as a crucial factor in healing? What is called for is a thorough method of training in touch for helping professionals that will address the needs of our clients for both safety and physical nourishment.

The first component of touch training is ethics, and the factors that create ethical behavior concerning touch are what we

are focusing on this evening. At some other time, I'd love to talk more specifically about touch training itself, but I'll only sneak in a bit of that now, as it relates to ethical issues.

Most states do not have specific laws about touch in psychotherapy. In the broadest sense, we can generalize that in order to violate civil or criminal law, touch must be unwarranted, unwelcome, unnecessary, and have the potential to cause physical or psychological harm. In the fields of psychotherapy and counseling we have ever so slightly more specific guidelines. Within the process of psychotherapy, any sexual touch is rightly considered unwarranted and is strictly censured, even if it is invited by the client. But this is where guidelines tend to stop. Beyond these important strictures, we have very little ethical or technical guidance about how to touch our clients in only healing ways. It's as if there's a hole in our field of vision - we know touch is important and powerful, yet we fail to do much of anything that would help us use this power.

It is my belief that this hole in our visual field occurs for some interesting reasons. In a standard Oxford dictionary, the word touch takes up 14 colums - close to a record for the numbers of meanings for one word. Clearly, touch can mean many things, and it can convey many different intentions, including nurturance, support, punishment, dominance, affection, intimacy, sex, and so on. It's no wonder we can get confused about it.

One way we could begin to work with this confusion is to take a good look at the fact that as Americans the overwhelming majority of us are still hitting our children as a form of culturally sanctioned punishment. This form of touch is completely unnecessary, and the sooner we stop using it, the sooner we will remove that particular shadow from touch motivations. I am not sure that spanking harms children in the classic ways we think, but I suspect that its abiding trauma is that we grow up confused about what touch can mean. So, even though as adults we are protected by law from any physical violence done to us, this same basic right is not extended to children, who are more vulnerable and in need of protection. Parents have the right to inflict physical pain on their children at any time that is deemed appropriate by the perpetrator of that pain. Granted, we have become more alert to the most henious excesses of the abuse of children, and will remove children in extreme cases, but we still guarantee, protect and even value the hitting of children in our society. It would be unthinkable as adults for us to allow a person to hit us, even if we had done something to bring it on. We would have a tidy little civil law suit in our hands, one which could bring us monetary reward.

Indeed, most cultures have historically sanctioned physical violence against any person in a low power position. Thus, we see institutional violence perpetrated against women, political protesters, racial minorities, inmates, and old people, as well as children. This implicit message, that we can get away with hurting someone who is subordinate to us, is a fundamental feature in most societies, and may be part of the root of all the furor around the ethics of touch. From this perspective, it behooves us to work actively for peace and social justice for no other reason than to help us all return to the unequivocal nurturance of touch in all our lives.

Until peace and justice prevail, we do therapy.

Given that any client who walks into our offices is likely to have been touch deprived and touched innappropriately in the past, how do we help to remediate this? Ethically, here are a few guidelines I'd like to suggest:

1) Get touch training. This gives you a framework for reading the body in terms of energy and tension patterns, defensive blocks, tissue structure, and touch technique. It gives you clinical information that can inform your decision to touch, where to touch, and how to touch. It can in some instances empower you to touch legally, from the framework of having legitimate background and skill. Many bodywork systems provide this type of training. The time and energy output to become certified in a bodywork form can be formidable, though I highly recommend it. However a good old fashioned massage license will also do. As a somatic psychologist, I include touch training in all my training programs.

2) Take a touch history with all clients. Ask them to describe touch in their family growing up, from the stand points of affection, control, punishment, sexuality. Ask them to report both touch they received, touch they gave, and touch they witnessed. Ask if they have ever been touched innapropriately as adults and if touch has been nourishing for them. Also ask if they have any concerns about touch in their current lives.

3) Pre-contract with clients for touch as a possibility in the sessions. Explain your philosophy of touch in writing in your intake forms. Give examples of when touch would be innapropriate, and when it might be called for. Explain that touch does not have to be part of your work together, and that at any time they can ask that touch be stopped and it will immediately be stopped. If you have any incling that the client might not have good touch boundaries - for instance the inability to sense or express their NO, overriding their NO in order to feel loved, safe or in control, or using touch as a bartering tool), touch is not appropriate until this is thoroughly worked with as a therapeutic issue. Other mutual protections are to only use touch in group settings, where members can all witness the touch, and videotaping sessions, in which the client has unrestricted access to the tape. I have brought a copy of my touch contract to share with you if your are interested

4) dont touch until therapeutic relationship is established

Studies have shown that most therapists get in trouble with their clients for a misinterpreted noterotic touch when the therapeutic relationship is new, or not well established.

5) When in doubt, don't touch. When in doubt, bring up the doubt as a clinical issue. An example of this would be when you have an urge/intuition to hold a client, but you are also feeling a sense of trepidation about it. Don't do the action, but trust that the urge and the trepidation arose for a clinical reason. You may want to say at that moment "Were you ever held or comforted when you felt this feeling as a child?", or "I had an urge to hold you just now, along with a worry about doing that. Does this feel relevant your experience?"

6) Understand your motivations for touch. Particularly, do you clearly see the client at that moment, and do you have a precise vision about where and how to touch? Or are you feeling an urge to hold or touch that is coming from you? The deciding factor can come from a knowing of where your attention is located. Is it client-centered or is it arising from your own feelings? If you don't have a clear and client-centered vision, pause a minute and get curious about the feelings the client may be stimulating in you. Rather than touching, ask yourself about the relevance of your feeling to the clients experience. One of the most frequent innapropriate therapeutic touches is one that rescues the client from whatever uncomfortable state they are feeling. Running a close second is touch that rescues the therapist from uncomfortable feelings. If we examine these urges we can get an interesting look into how the client may be enrollong us into their life scripts, and we are enrolling the client in ours. We can also make conscious our own needs to be appreciated, liked, or touched.

7) In touch, timing is crucial. If done too soon, it will sedate the clients deepening experience, and potentially give them a message that its not OK to feel intense feelings, or that they need to be protected from intense feelings. If done too late, it can be reinforcing of old imprints of control or deprivation. Supervision in this area can be very beneficial in fine tuning ones sense of timing.

8) Never touch a sexual area, or an area that the client considers private. This is obvious, but needs to be stated. Pay particular attention to cultural differences. For example, many Asian cultures consider the head a private area. Cultures can have different mores about touch between men and women.

9) Take your intuition seriously, but not literally. It is important to know the difference between intuition and projection. Intuition can very accurate in its sensing of a clients primal need for touch. Relying on cognitive analysis to shape touch will rob it of its most vital energies. It is crucial in this case to get training in transference/countertransference. If we cant tell the difference between our genuine responses and our reactiveness, we will soon be lost, and getting lost in touch can be horrific.

10) Use touch boldly and sparingly. Once we value and trust our intuition, we can become exquisite bearers of nourishment in our clients lives. For this same reason, we want to make sure we are challenging our clients to proactively and appropriately find other sources for this nourishment. The therapeutic relationship cannot for long be the only place a client is touched. Otherwise, we foster a deeper dependency than would be useful.

To recapitulate some of the ethical consideration about touch, we can say that:

We should never touch when it is not genuine - this retraumatizes

Even when touch is genuine, it may not be indicated in terms of the type of client, the timing, and the status of the therapeutic relationship

Don't use touch when to do so helps the client avoid therapeutic material

Avoid touch when the patient is manipulating

Never touch when it would support the clients sense of helplessness

There is evidence that touch is most often misinterpreted when client doesnt want it, or when he or she is feeling paranoid, hostile, or sexual

Some other Considerations are that:

1) touch issues are different with adults than with teens (less) and children (more)

2) different for different cultures

3) different with the 2 sexes

Touch Technique

When we are willing to use the tremendous power to heal that touch represents, we also commit to providing the best and most accurate form of touch for the various needs of our clients. In this light, we can look at our various conscious and unconscious touch intentions, some specific forms that touch comes in, and some general tips for how to use touch.Here I will draw from my own touch training manual.

Touch Intentions

- There are 5 conscious intentions involved in touching our clients, and 5 unconscious ones. They reflect whether we are acting in service to our clients, or acting to enroll them in our personality strategies. The conscious intentions are to support, to nurture, to challenge, to reflect, and to provide space. The unconscious intentions are mindlessness, codependency, sedation, aggression, and abandonment.

Support - A supportive touch can literally provide physical backing for a clients experience. My intention is to contribute a stabilizing influence. A supportive touch intention allows a client to practice a new body movement sequence with my initial help. It can also provide physical encouragement. It mirrors a developmental stage when we needed our parents direct intervention in order to progress, and supplies us with a sense of a basically benevolent and caring world. When done well, and at the appropriate point in the clients process, supportive touch actually supports the clients emergent progress.

Sedation - When we are confused or unaware of our own unresolved support issues, we have a tendency to touch our clients in a sedating way. This is often accomplished by unconsciously taking responsibility for the clients experience, and looks like a taking over the clients movement for them. It may involve touching too soon, so that an emerging movement sequence is not allowed to develop on its own. The result is that any charge or energy that a client has to move through an experience is lost, either through distraction or disempowerment. It gives the client the message that she can't do it herself, or that he doesn't have to do anything to get through life.

Nurture - Just as we were (hopefully) held and greeted and loved when we were born, so a nurturing intention conveys a sense of love and acceptance. It is a holding of the clients body after they have completely and deeply expressed. It comforts and shelters. It literally nurtures a clients breakthrough into physical truthtelling and accurate expression. It signals them that their essence is welcome here, when it may not have been originally.

Codependent - When I need to touch you to reassure myself that I am alright, I am being codependent. We often touch codependently in the disguise of nourishing others. This type of touch often has a look to it like the frightened parent nervously patting the child while saying "There, there, you'll be alright." This move actually smothers the emergent essence of the client, and alerts us to our unconscious need to seek approval outside ourselves, at the expense of essence.

Challenge - Touch can also challenge, much as the birthing process challenges a fetus. This touch intention arises from the clients need to have something to push against, someone who can hold up under their weight. Oftentimes, we need some boundary in order to feel met by life. An intention to challenging involves helping to intensify a clients experience so that he/she can fully participate with it. Often a challenge intention arises in the presence of the clients addictive process.

Aggression - When we have not completed our issues around being challenged, primarily because we have challenge confused with control, we will unconsciously aggress with touch. Here we will use touch for purposes of domination, power, or authority, and will unwittingly retraumatize our clients. This is rarely obvious, however, and we need to look for subtle ways in which we are using touch to control rather than facilitate a clients process.

Reflection - The intention to reflect manifests through our interest in a clients' seeing themselves accurately, and is often called mirroring. We want to reflect back to them; we want to let them know we see them. It is a statement of "I see you, I see this shape of you, this size of you, this energy in your body." Reflection allows a client to form safe and healthy relationships with the outside world.

Mindlessness - We unconsciously engage in mindlessness when we have not been adequately reflected. If we do not have a history of being seen, deeply seen, we are not able to stay present to ourselves. We literally cannot see ourselves. When we cannot observe our own process, we go asleep to others. We touch without thought or reason. We touch out of a lack of anything else to do.

Provide Space - Sometimes the best intention is to simply bear witness. In this case, the touch intention comprises a conscious act of not touching. Paradoxically, this can be very "touching." By not touching our clients, we can foster a sense of separation, of autonomy, of distinctness that can be an exquisite. It is important to see that both touching and not touching are active interventions, and are used consciously to further the process of the client.

Abandonment - An intention to abandon occurs without our knowing it, and is a reenactment of our own issues in this area. If, just when touch is needed, we don't touch, we can be acting out of our own loneliness in the world. We unknowingly abandon the fledgling work the client is engaging in, and give them a message that they must do it alone, always alone. Sometimes we do this, thinking that we are providing space, but sometimes space can be absence rather than permission.

Types of Touch

There are 4 types of touch, which are generally used as the session progresses through 4 organic stages of development. In the initial stages of a session awareness touch is usually the touch of choice. In the second stage of a session, where the client tends to struggle with owning their physical and behavioral patterns and sequencing through them, a working touch is appropriate. As the client enters the third stage, where they have completely felt and expressed the incomplete realities of the old patterns, where the possibility for true experience arises, a nurturing touch is often called for. And lastly, when a client works to integrate their new sense of authenticity into going out into the world and their daily lives, a teaching touch can be used.

Awareness - In the first stage of a session, the client is opening up to him or herself. The client is exploring sensation, feeling and energy, in an attempt to access the fuel for their transformational journey. It is at this point where awareness touch can be used. Awareness touch is a light resting of the hand on or above some part of the clients body. The purpose is to focus or magnify the attention the client gives to this spot. It is important to allow the hand to be soft, and to relax it onto the shape of the area underneath it. This touch does not "do'" anything per se, but is more about a being, an attentional witnessing presence that assists the client.

Working - This type of touch is highly specialized in bodywork, and can be transfered to body-centered psychotherapy. It's a touch that actually uses directed pressure to change the tissue, in order to free blockages, promote energy flow, or exaggerate a holding pattern. I often call it an intensifying touch, in that it provides the clients energy system with more input and more direction to move in. It frequently involves either a doing more of what a client is already doing (like squeezing a gripped hand), or providing a physical boundary or limit that the client can push against or along. Either way, this touch can deepen the clients experience. It is not recommended that any therapist engage in this touch form unless he or she has had specific touch or bodywork training.

Nurturing - When a client has fully moved through a feeling, has fully committed to and engaged in a complete movement sequence, nurturing techniques are in order. These are perhaps our most familiar forms of touch. They involve holding and stroking, and allow the client to rest all or part of their body into a nourishing field. Because this is also often the most deprived form of touch, it can also be the most misunderstood. In a sexual abuse survivor, this is the touch form that will tend to be the most confusing. For this reason, I sometimes will stroke a clients hair very gently, in lieu of holding him or her more fully. And I let the client decide if and when he or she is ready for a full hug or complete holding.

Teaching - As a client completes a session and seeks to integrate the work done into their daily life, a teaching touch is often called for. This touch assists the client in the practice of new movement behaviors, and the application of occurrences in the session to their everyday body. It can look like holding my hands on the front and back of a clients rib cage and asking them to breathe into the pressure of my hands, thus promoting increased breath capacity. Here again, bodywork training can prove valuable, as it can give the clinician a framework for how to proceed.

Coming from thes touch intentions and types of touch, I'd like to add a few more General Touch Guidelines

- Remediate our own touch wounds first. I cannot stress enough the need for us as therapists to have plenty of nurturing and appropriate touch in our lives. Get regular bodywork and massage. Touch and stroke your own body regularly. Live sensually in your skin, rubbing it with lotions, carressing it with hot water, nourishing it with different textures. Be sexually active, whether you have a partner or not. Touch your loved ones often and consciously . By leading lives rich in nourishing touch, we reduce our unconscious motivations to seek our own gratification through client touch, while at the same time becoming a clear advocate for the exquisite power to heal and grow via touch.

- Do not touch until your clinical intention is clear. This is not to say that we have to have an intentional analysis complete before we begin. Touch is highly intuitive and often spontaneous, and as long as we consciously check in and feel clear, our intentions are also clear.

- Always stop touching when the intention is complete, or if your attention goes elsewhere. It is actually clinically toxic if I leave my hand resting on someones body for no reason, especially when my attention has gone elsewhere.

- Touch obeys laws of synchrony . If I am touching mindlessly, it likely has its roots both in my history and in the history of my client. By being alert and commited to my own healing around touch, I can see more clearly my clients scripts for touch and avoid getting enrolled in them. I can also glean information from moments of my unconsciousness. These moments can actually reveal details of who the clients abusers or neglectors might have been. If I find myself unwittingly playing a knight in shining armor, I can begin to get alert to issues of rescuing in the relational system I am in with the client.

- Touch works best when I combine training with trust. Training secures our abilities. And the more I trust that my ability to touch effectively will arise, the more my abilities are supported and cultivated. Trust actually fosters conscious creativity, and the more I trust myself, the more trustworthy I am to my clients.

- If I make a touch mistake, I fess up, and reveal everything that I am aware of . I have seen this one move be more healing than any other intervention I have made with a client. By becoming totally visible, I transform my unconsciousness into conscious relationship. I once realized in a session that I had touched a client in a controling manner. I revealed this, and described to her my embarrassment, and when and how I felt the urge to touch her that way. She began to cry, and told me that it was exactly at these moments that her mother used to grab her and shake her when she was growing up. We both marveled at how compellingly we had both reinacted that moment, and she was then able to see how she would set herself up to get that familiar result by allowing herself to lose control and expect others to provide it. And after the session I was able to unravel an unconscious intention to aggress as a way to validate my sense of authority in the face of out of control situations.

It's my strong belief that healthy touch intentions and skillful techniques can have profound and lasting benefits in psychotherapy. At the same time, we seem to be in the midst of a Dark Age for touch in our culture, where we may be shamed and persecuted for using it, much like the witches were in those Dark times, many of whom were healers. We cannot stand idlly by while any culture persecutes its citizens for being healers. We can take part in a great social healing around the issue of touch by training ourselves thoroughly and consciously to use this primal act as a means of healing and transformation, taking nothing for granted. Touch may be something that everone does, but it is not something that everyone does well. It's time we raised the standards. I encourage all of us to keep this powerful tool alive for our future generations through highly conscious and nourishing touch. The poet Mary Oliver has enjoined us that we do not have to be good, we only have to let the soft animal of our body love what it loves. Our bodies love touch. Let us do what we love, and be agents for that love to bring us together again; to decrease the distance between us, and increase the interconnectedness of all life.