Sheahan dissertation by ICSW

The Institute for Clinical Social Work

Touch and Countertransference in Psychodynamic Psychotherapy

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Michelle Sheahan

Chicago, Illinois January 28, 2022

Abstract Psychodynamic psychotherapy does not often involve physical contact between a therapist and patient; however, touch may occur either intentionally or incidentally during a psychotherapy session. When touch does occur, it can have significant impact on the client, the practitioner or both. The experience of touch for the practitioner, and the effect of touch on countertransference are important areas for exploration in contemporary psychodynamic psychotherapy research. In this mixed-methodology study of psychodynamically-oriented clinical social worker psychotherapists, 38 therapists completed an online survey, and seven therapists participated in three hour-long in-depth interviews. This research offers insight into the impact of physical touch within the psychotherapy session on the countertransference experience of psychodynamicallyoriented psychotherapists and is interpreted through a relational theory model.

Table of Contents

Page

Abstract..................................................................................................................ii List of Tables..........................................................................................................v List of Figures........................................................................................................vi Chapter I. Introduction................................................................................................1 General Statement of Purpose Significance to Social Work Relationship to Previous Research Statement of the Problem and Objectives to Be Achieved Research Tradition Theoretical and Operational Definitions of Major Concepts Statement of Assumptions Epistemological Foundation of Project Foregrounding II. Literature Review...................................................................................18 Countertransference Touch Touch and Countertransference Considerations Research Literature Survey iii

Table of Contents—Continued

Chapter

Page

III.

Methods.......................................................................................102 Research Questions and Major Approach Role and Background of the Researcher Research Sample Research Plan or Process Data Collection Data Analysis Ethical Considerations Issues of Trustworthiness Limitations and Delimitations

IV.

Results.........................................................................................102 Quantitative Research Qualitative Research

Discussion and Conclusions......................................................172 Limitations of the Study Conclusions Implications Conclusion

Appendices A.

IRB Approval.............................................................................198

References.....................................................................................................206

List of Tables

Table

Page

4.1 Characteristics of the Participants in the Qualitative Phase of the Study..........137

List of Figures

Figure

Page

1.1 Exploratory Sequential Design...............................................................................107 4.1 Occurrence of Unintentional Uninvited Touch.....................................................127 4.2 Therapist’s Opinion of Touch.................................................................................133

Chapter 1

Introduction General Statement of Purpose The purpose of this mixed methodology project is to study the effect of physical touch on the social worker’s countertransference in psychodynamic psychotherapy, using a relational theory lens. Therapist is broadly defined as the survey participant in this study and refers to a clinical social worker practitioner/clinician who is psychodynamically-oriented in their approach. Countertransference is broadly defined as the therapist’s experience in relation to the psychotherapeutic treatment with a particular patient. Touch is defined as any form of physical contact, intentional or unintentional, between therapist and patient. This study uses a mixed methodology design, which consists of a questionnaire to understand the scope of the use of touch in psychotherapy, and in-depth interviews to explore the meaning of touch within a relational theory lens and how it affects the psychodynamically-oriented clinical social worker psychotherapist’s experience of countertransference.

Significance of the Study for Clinical Social Work This research will contribute to the literature in a novel and critical way by examining the use of physical touch by clinical social workers in psychotherapy, as well as the way physical touch impacts the clinical social worker’s experience of countertransference in session with a patient. The existing data on this topic does not

generally consider the impact of touch on countertransference. While touch is not generally used in traditional psychotherapeutic treatment, it does occur: one older survey revealed that 87% of psychotherapists may touch their clients (Tirnauer et al., 1986), while another found that 95% of clinical social workers experienced some form of touch with clients with 29% using touch often or very often (Strozier et al., 1993). Whether touch is unintentional, intentional, or purposeful, it is known to occur in the context of psychotherapy but is often “left out of clinical conversation” (Rovers, et al., 2017, p. 237). This research attempts to expand the discussion of touch and its meaning in treatment. This study focuses specifically on the experience of the clinical social worker as a psychodynamically-focused psychotherapist. Clinical social workers have a unique perspective on the goals and practice of psychotherapy. The training and curriculum for licensure includes coursework not only on counseling and psychology, but on social change, equity and disparities, and recognizing the environmental context of psychopathology and mental health. The National Association of Social Workers defines the goal of the profession: “to enhance human well-being and help meet the basic human needs of all people” guided by a set of core values including service, social justice, dignity and worth of the person, the importance of human relationships, integrity, and competence (National Association of Social Workers [NASW], 2018, preamble). While not all social workers are psychotherapists, this set of values informs clinical social work psychotherapy practice. Social workers practice in diverse settings and use a wide range of modalities to achieve successful psychotherapy outcomes. A review article in 2018 found 418 social

workers on the internet advertising integrative or alternative therapies, including body psychotherapy modalities (Holden & Barker). The authors question whether these practices fall beyond the boundaries of the social work profession, suggesting that some of the advertised therapies may be “highly questionable” (Holden & Barker, 2018, p. 1). The use of touch in psychotherapy with clinical social workers is a timely issue to explore, especially in light of the “Me Too” movement and the increased focus on behavior that is aggressive or unintentionally sexually suggestive. The heightened awareness of abuse of privilege has implications for the psychotherapy situation, in which the power dynamic between patient and therapist, with its therapeutic intent, has the potential for exploitation. Experiences and anticipation based on past victimization may impact both therapist and patient’s experiences of touch in session as well as the fear of false accusation (Smith et al., 2019). Encountering a critical attitude regarding integrative and more eclectic approaches to clinical social work practice is not surprising in a field that is grounded in the principles of Freud’s original “talking cure.” Many clinical professionals, including psychodynamic social workers, may be wary of openly endorsing touch as an appropriate and therapeutic modality. In 2004, Orbach reflected that psychoanalytically- focused clinicians may believe that “touch is just off limits” (Orbach, 2003, p. 17). However, over the past several decades, advances in neuroscience and an understanding of the brain and body’s response to trauma have increased therapists’ attention to the physical body. Persistence of the traditional prohibition on touch may gradually be changing as psychotherapists from different disciplines begin to “maintain an active explorative

attitude towards somatic phenomena in the client and the therapist” (Ben-Shahar, 2018, p. 74). This change may be reflected in a seemingly-increasing range of available professional continuing education courses on the use of therapeutic touch, graduate education curricula that include nontraditional or complementary approaches, and a growing interest on the topic in the clinical literature. There are few statistics on certifications in body-based modalities or the actual use of body psychotherapy techniques by clinical social workers. The National Center for Complementary and Alternative Medicine (NCCAM) conducted a survey of patients in 2007 that demonstrated patients’ interest in receiving these treatments: in the previous year, 19.2% of adults and 4.3% of children 17 and younger in the United States had used a complementary mind-body therapy (NIH Fact Sheets, 2018). Patients’ interest in mind-body therapies and therapists’ incorporation of neuroscience into their treatment models has led to a shift in clinical practice, particularly with social workers. The social work profession was initially founded to help vulnerable populations escape “economic and social poverty” (National Association of Social Workers, 2020); this emphasis on person-in-environment and social justice endured as the field expanded and social workers became major providers of psychotherapy in the United States. By the 1980s, social workers were seeing twice as many therapy patients as psychiatrists (Goleman, 1985). As much of their training was rooted in psychoanalytic and psychodynamic traditions, many social workers adopted the traditional prohibition on touch. Now, however, with the rise of alternative therapies, more social workers may be incorporating psychotherapy modalities that may involve some degree of touch. Research

is needed to establish whether touch is occurring in psychodynamic psychotherapy with social workers, and to understand the effect of this touch on the treatment. Any occurrence of touch in session could affect the patient, the therapist, and the psychotherapeutic process. One way to try to understand the effect of touch in a psychodynamic relational theory model is to explore how touch affects the therapist’s experience and subjectivity through the lens of what is broadly called the countertransference.

Statement of the Problem and Objectives to Be Achieved Much has been written about the prohibition on touch, the ethics of touch, and techniques that involve touch in psychotherapy. There are fewer reports about the experience of the therapist when touch occurs and is thought about from a psychodynamic perspective. This may be due to a belief that mind-body techniques and the psychodynamic approach are incompatible, which could limit open exploration and discussion of the effect of touch on treatment. In the past, therapists may have been concerned about revealing that they are comfortable using touch in psychotherapy because of feared judgment from other psychotherapists based on the traditional taboo on touch (Orbach, 2003). Another possible reason for the limited literature on this topic is a necessary focus on the patient. In any therapeutic encounter where touch occurs, whether intentionally or incidentally, the primary issue to consider is its effect on the patient in the moment, the patient’s safety, and how that experience of touch affects the ongoing treatment. Much of the theoretical framework underlying mind-body psychotherapies is appropriately

focused on the pathophysiology, character structure and energetic presence of the patient. The therapist’s experience and the therapeutic relationship may be seen as less relevant, and not incorporated into a model of the effect of touch. However, I would argue that the therapist’s experience is an important aspect of the phenomenon of touch in therapy, and its exploration may yield valuable insights about both the patient and the treatment. Countertransference is an important aspect of psychodynamic theory and practice. Although the therapist’s observation of his reaction to the patient in treatment was initially considered an interfering, disruptive event that was “unconscious, neurotic, and adverse” (Norcross, 2001, p. 981), countertransference evolved to be understood as a rich source of information for the therapist about the patient’s interpersonal connections and communication. In addition, the therapist’s experience in session affects the patienttherapist relationship on many levels, including the neurobiological (Schore, 2010). The relational theory model posits that many factors, including countertransference, enter into the development and evolutions of the relationship between patient and therapist; and that it is the quality of this relationship that tremendously impacts the treatment. Relational theory also emphasizes the co-created space in treatment and the somatosensory experience, which could make it a helpful approach in thinking about the effect of touch in the psychotherapy session. The specific goal of this study is to research the scope of physical touch in psychotherapy, to understand the impact of this touch on the therapist’s countertransference, and to explore its meaning in the context of psychodynamicallyoriented clinical social work, from a relational theory perspective. There is a need for research in this area because past studies on touch in treatment have not emphasized the

therapist’s experience and the impact on treatment. With changing attitudes towards touch in clinical practice, therapists may be more willing to discuss their own experiences, making possible a deeper exploration of how the therapist’s countertransference is influenced by physical touch and how this then impacts the relationship and ultimately, the treatment. The research problem is focused on understanding the countertransference experience when psychotherapy involves physical touch. As more social workers consider using intentional touch in their work, there is a need for a better understanding of the scope of the practice and its effect on countertransference.

Relationship to Previous Research Several groups have published on the scope of the use of touch in clinical psychotherapy practice. While some of these studies focused on social workers (Borenzweig, 1983; Strozier et al., 2003), others surveyed psychologists and other mental health practitioners (Holroyd & Brodsky, 1977; Pope et al., 1987; Stenzel, 2002; Cassatly, 2003; Cook et al., 2010). This research demonstrated that therapists who use any kind of touch are most willing to use common forms of touch, including handshakes and hugs, and that clinicians who are less psychoanalytically-focused are more likely to engage in touch during a psychotherapy session (Strozier et al., 2003). Many of these studies did not specifically consider countertransference. The survey of social workers conducted by Strozier et al (2003) did reveal that a small number of therapists specifically cited the possibility of creating countertransference issues as a reason not to

use touch, although that research was not specifically designed to collect information on the therapists’ ideas about this belief. Researchers have examined the practitioner’s experience of touch through the lens of clinical psychology (Meland, 2017; Urbano, 2011), dance and movement therapy (Hochleutner, 2018), or nursing (Monetti, 2014, 2016). These studies and others include research on body countertransference, which explores the therapist’s physical reaction in session. Psychotherapists will benefit from this research because it offers insight into how physical touch affects the therapist’s countertransference. Exploring the narrative of several therapists in depth provides an opportunity to reflect on and make meaning of one’s own experience. As unintentional touch also happens in session, this research will be useful for those therapists seeking to understand how these unexpected interactions impact the clinical process by considering their impact on the countertransference.

Hypothesis or Research Questions to Be Explored The research question in this study asks how physical touch in psychotherapy affects the psychodynamic social worker’s countertransference. For the quantitative study, the hypothesis is that psychotherapists do experience touch in session, and that the therapists have ideas about its meaning and effect on countertransference. For the qualitative study, the assumption is that psychodynamically-oriented clinical social worker psychotherapists have ideas about the effect of touch in psychotherapy on the countertransference, which they can explain and explore in ways that reveal themes and concepts to extend the therapeutic understanding of this experience.

This mixed methodological study is designed to establish whether touch occurs in psychotherapy sessions with psychodynamically-focused clinical social workers, and to explore the therapist’s experience of countertransference in relation to this touch. The research questions are designed to test the quantitative hypothesis and explore the qualitative assumption by asking psychodynamically-oriented clinical social worker therapists about their own experience with touch in practice.

Quantitative research questions. The quantitative phase of the study asks: How widespread is the use of touch by psychodynamically-oriented clinical social worker therapists, and what therapist characteristics may be associated with use of touch in session? The hypothesis is that therapists who disclose using touch in session may have characteristics in common.

Qualitative research questions. The qualitative phase of the study asks about the meaning of touch in psychotherapy, specifically the therapist’s experience of its effect on countertransference. The assumption for the qualitative phase is that themes will emerge that may contribute to a greater understanding of the effect of touch on countertransference.

Research Tradition The research tradition is both quantitative and qualitative. The quantitative part analyzes a survey designed to learn about the scope of the use of touch in the psychotherapy session by psychodynamically-oriented clinical social work

psychotherapists. The qualitative component is based on a series of in-depth interviews in which psychodynamically-oriented clinical social work psychotherapists explore their own ideas about their experience of countertransference in psychotherapy sessions that involve touch. This mixed-methodology study addresses the research question about the scope and meaning of touch on countertransference in psychodynamic psychotherapy.

Theoretical and Operational Definitions of Major Concepts Touch, or physical touch is defined as intentional or unintentional contact between the therapist and patient. It includes appropriate, non-sexual touch initiated by either the therapist or patient. In addition, it could be either used as part of a specific modality that encourages touch or it could be a spontaneous expression by either the patient or the therapist. Psychotherapy is defined as traditional talk therapy in which a patient participates in a session with a trained clinical social worker for the purpose of alleviating a presenting issue. Psychodynamic psychotherapy is defined as a specific therapeutic approach incorporating the unconscious and is based on the psychodynamic frame of reference “that unconscious mental activity affects our conscious thoughts, feelings, and behavior” (Cabaniss, 2016, p. 4). Countertransference is defined as the therapist’s experience in the session in reaction to the patient, the material, or the interaction. This includes all reactions of the therapist, whether positive, negative, or neutral. It includes reactions located in the present as well as in the past.

Clinical Social Worker Psychotherapists are defined as professionals who have a master’s degree or doctorate in clinical social work, who are licensed at the independent level, and who practice psychotherapy with patients.

Statement of Assumptions •

Touch in the psychotherapy session can occur intentionally or

accidentally. •

Touch in the psychotherapy session can be therapeutic, neutral or

damaging for the patient. •

Touch in the psychotherapy session can be positive or negative for

the therapist. •

Touch in the psychotherapy session may have no clear meaning

assigned to it by either the patient or the therapist. •

Touch in the psychotherapy session is a topic that

psychodynamically-oriented clinical social worker therapists are willing to discuss. •

The information gathered will be useful whether the psychotherapy

sessions take place in an office, institutional setting, the patient’s home, or some other location. •

Therapist and patient characteristics of gender, age, history and

presenting issues are all useful sources of information that may be helpful in understanding the experience of how countertransference is affected by touch.

•

The type of touch discussed in this research is within the legal and

ethical framework for clinical social work practice. •

Therapists and subjects follow both the NASW Code of Ethics and

their local social work board’s guidance on the limits of touch in psychotherapy and they use touch in a manner they understand to be appropriate and therapeutic. As a clinical social worker psychotherapist studying at a psychodynamicallyoriented institute, I see a need for more research into the impact effect of physical touch in the psychotherapy session. I am specifically studying the use of touch in psychotherapy sessions that is practiced within the guidance from the Code of Ethics of the National Association of Social Workers: Social workers should not engage in physical contact with clients when there is a possibility of psychological harm to the client as a result of the contact (such as cradling or caressing clients). Social workers who engage in appropriate physical contact with clients are responsible for setting clear, appropriate, and culturally sensitive boundaries that govern such physical contact. (National Association of Social Workers [NASW], 2018, Standard 1.10)

Epistemological Foundation of Project Epistemology has been defined as “the study of knowledge, the acquisition of knowledge, and the relationship between the knower [research participant] and would-be knower [the researcher]” (Ponterotto, 2005, p. 127). The epistemological foundation of this project takes an objective approach for the quantitative phase of the study, which

uses data anonymously collected online through a questionnaire and analyzed using statistical software. The epistemological foundation of the qualitative phase is subjective and transactional: transcripts were analyzed thematically from interviews in which participants explored the interview questions in direct interaction with the researcher. A research paradigm is a set of beliefs, or philosophical assumptions that guides the researcher. This guiding philosophy includes ontology, the nature of reality; epistemology, what is considered knowledge and how it is justified; and axiology, the role of values in research; and methodology, or the process of research (Creswell, 2013). Both nomothetic and idiographic approaches are used in this study. This project seeks information about the use of touch by psychodynamically-focused clinical social workers as a cohort in the quantitative survey portion, while exploring individual ideas in the qualitative section, based on the experiences of several practitioners and the meaning they ascribe to touch in psychotherapy. This paradigm for the quantitative part of the study is postpositivist, seeking an objective reality to link phenomena (Ponterotto, 2005): the goal is to collect information through the survey, and analyze the data. The paradigm for the qualitative part is constructivist, meaning that there is not one single reality, as it is co-constructed and socially constructed; in this hermeneutical approach, “meaning is hidden and must be brought to the surface through deep reflection” (Ponterotto, 2005, p. 129). The goal of the qualitative phase is to encourage the participants to speak freely in their interviews, to explain their ideas about countertransference and touch, and to explore the themes and meanings that arise.

Axiology considers the researcher’s values and their effect on the scientific process. A qualitative researcher openly admits the value-laden nature of the study and the information gathered, revealing biases and values (Creswell, 2013). In the quantitative phase of the study, the researcher’s values are not disclosed, and an attempt is made to phrase the questions in a way that does not guide respondents to an answer affected by the researcher’s values. In the qualitative part of the study, the researcher’s own opinions, experiences, and ideas are bracketed and disclosed. The paradigm for both phases of the study is pragmatic, within a mixedmethodology framework. As described by Johnson et al., this offers an “epistemological justification” (2007, p. 125) for integrating results from both the quantitative and qualitative data, as well as the logic for weighing the value of different information in exploring the hypothesis and informing a new theory. This methodology also relies on Dewey’s warranted assertions, which alludes to a type of knowing in context (Johnson et al., 2007). It refers to an outcome of research that is not static and is “preferred to the terms belief and knowledge” (Dewey, 1938, p. 9). From this perspective, knowing about the experience is distinct from seeking knowledge as an end result. Combining data from both the quantitative and qualitative phases of this study will create the possibility of developing a new understanding of this phenomena, at this place and time, specific to psychodynamically-focused clinical social workers. Ultimately, use of touch in psychotherapy depends on the practitioner’s intent, goals, skills, training, and experience, as well as the patient’s availability and capacity to receive touch therapeutically. The clear need for sensible and rigid legal and ethical restrictions on inappropriate or abusive touch, as well as consultation and outside

professional clinical supervision, offers perspective and ensures understanding and compliance around the misuse of touch in clinical settings. There is also a need for a deeper understanding of the impact and meaning of touch in clinical practice. This study seeks to contribute some insight into this phenomenon.

Foregrounding This study focuses on the effect of physical touch on the psychodynamic psychotherapist’s countertransference. I have been reflecting on this question for the past several years as I have worked in private practice and studied in this doctoral program. For my first four years in social work, I was an oncology social worker and mind-body therapist at a cancer hospital. This involved training in mind-body practices and using touch, meditation and mindfulness techniques in conjunction with psychotherapy in counseling cancer patients. I believed that gentle, respectful, intentional physical touch was therapeutic for the patient; it was what I had learned in training and had become part of my occupational routine. Once I entered private practice and began to see a variety of psychotherapy patients, I became aware of my own nuanced feelings about any kind of physical contact. I paid attention to how touch changed things. Accidental contact and purposeful touch both had an effect on my own experience of the session and of the patient, whether it involved a handshake, hug, collision or gentle brushing of the skin while passing a pen or credit card. My previous experience researching this subject includes a poster presentation I gave at the National Institutes of Health in 2016 on the use of Reiki by social workers in palliative care. Although the topic is somewhat different from the focus of this doctoral

research, it was an opportunity for me to learn about and present the ethical and legal framework for touching patients in my licensed work; the considerations when incorporating touch into therapy; and the benefits and concerns raised by this practice. That research did not reveal many studies or explorations on how the therapist experienced physical contact with a patient. I became interested in learning more about what it might mean for the therapeutic process and the therapist’s emotional availability to the patient. My training in mind-body therapy includes certification in Reiki, a Japanese energy therapy; professional training and licensing as a massage therapist; and an intensive training program in the sensorimotor psychotherapy techniques of Pat Ogden (2015). This has led to an understanding that memory and emotion are encoded in the brain and are felt in the body. Effective psychotherapy must bring an awareness of and openness to the experience of the physical body as well as the inner psychic world. In Solms’ words, “Freud’s great contribution sprang from the recognition that mental life is unavoidably tethered to the body, and thereby to biology. There can be no mind without body” (Solms, 2015, p. 8). As I have trained in psychotherapy modalities that encourage physical contact between patient and therapist, I have been mindful about continuing to assess whether introducing the use of touch might be therapeutic for each individual, specific patient. I have become more and more aware that my own feelings provide useful information about the patient’s experience. However, when physical presence or touch feels difficult or intrusive to me, I wonder whether I am simply wishing to protect myself against an uncomfortable intimacy within the therapeutic interaction, or whether I am sensing

projected or introjected feelings of the patient. Traditionally, there has been a general prohibition against touch between therapist and patient. While this ideally limits abuse and exploitation, it may also have foreclosed a deeper understanding of our patients and ourselves, with a resulting dearth of research on the subject from a psychoanalytic and psychodynamic perspective. A 1983 survey revealed that clinical social workers showed openness to incorporating touch into their work and often used touch, but its author noted that a theoretical understanding of touch in modern psychotherapy was yet to be developed, suggesting a “germinal model about the utilization of touching by clinicians in the practice of clinical social work” (Borenzweig, 1983, p. 242). My hope for this doctoral research is further development of this model by contributing to the knowledge base on how the psychodynamically-oriented social worker experiences physical contact in psychotherapy and offering a relationally-focused perspective on how this countertransference impacts the treatment.

Chapter II

Literature Review This literature review is designed to synthesize an overview of what is known about the effect of touch in psychotherapy on the therapist’s countertransference, providing background information that informs an understanding of the research question and study design. Literature was selected based on its relevance from searches of Google and Google Scholar; PEP Web; the university library database; and PubMed. These articles and books included references to other sources in the literature which were then considered for the review. The goal of this literature review is to offer the reader of this doctoral dissertation background and context for the study. It sets a conceptual framework, or an integrated way of looking at the problem (Imenda, 2014). Although much has been written about touch and countertransference separately, their intersection and influence on one another is the focus of this chapter, synthesizing what has previously been learned about touch and countertransference in psychotherapy to reveal themes and concepts that are then further explored and developed in this mixed-methodology dissertation research project.

Countertransference Historical overview of countertransference in psychotherapy.

Freud presented the concept of countertransference in 1910, explaining: “We have become aware of the ‘counter-transference,’ which arises in him as a result of the patient's influence on his unconscious feelings, and we are almost inclined to insist that he shall recognize this counter-transference in himself and overcome it” (p. 144-145). This instruction to overcome the countertransference may have been a reaction to the threat psychoanalysts’ feelings posed to what was supposed to be a scientific discipline. A year earlier, Freud had used the term in a letter to Jung, encouraging him to avoid romantic involvement with patients after learning of Jung’s relationship with a female analysand. Freud wrote that these experiences “help us to develop the thick skin we need and to dominate ‘counter-transference,’ which is after all a permanent problem for us; they teach us to displace our own affects to best advantage. They are a ‘blessing in disguise’ (Freud et al., 1974, p. 230). These early descriptions of countertransference as a permanent problem indicate that Freud may have seen it as a distraction from treatment, a primarily nontherapeutic aspect of the therapist-patient relationship. His mention of its benefit to psychoanalysis is solely in the context of the analyst becoming more disciplined about his own feelings. While Freud focused on developing the idea of identifying transference as a useful psychoanalytic technique, calling it the strongest form of resistance (Freud, 1912), he did not describe a use for countertransference in treatment. Later, Freud reinforced his initial idea that countertransference relates specifically to the analyst’s personal emotions about the patient, explaining that allowing the countertransference to impact treatment would damage the truthfulness and abstinence on which analysis is based. He summarized: “we ought not to give up the neutrality towards

the patient, which we have acquired through keeping the counter-transference in check” (Freud, 1915, p. 163). In other words, countertransference weakens the objective stance that allows the analyst to be effective. Freud may have focused on this aspect of countertransference because of concerns about the behavior of early analysts that could detract from the public image of psychoanalysis as a scientific treatment. Ferenczi and Jung became personally and romantically involved with patients and their families, which may have been seen as a threat to the public image and even the existence of psychoanalysis (Jacobs, 1999). In addition, Freud may have been concerned that the analyst may become distracted by the patient’s erotic transference. The idea that “alien” feelings could disrupt or distract from a focused psychoanalytic treatment remained an influential concept in the early years of psychoanalysis (Racker, 1968). Some of Freud’s contemporaries began to explore countertransferential experiences as aspects of the psychoanalytic treatment. Brown (2011) notes an openness to countertransference from Freud’s colleagues, Ferenczi and Abraham, during the early development of psychoanalysis. In 1909, Abraham reported that his analytic treatment of patients was inducing “a symptomatic action in myself” that he describes as related to the patient’s infantile transference (p. 87). Ferenczi also implied that it may be an important aspect of the treatment. He stated that a “forgiving understanding” may cause the analyst to take a position influenced by the patient’s fantasy: “Besides monitoring the countertransference, one must therefore also pay heed to this ‘being induced’ by the patients” (Ferenczi, 1911, p. 253).

Reik, who was Freud’s student in Vienna, explored the impact of psychoanalysis on the analyst. His autobiographical description of the analyst’s inner process is not linked to a discussion of countertransference but suggests that there is the value in recognizing and exploring what he called “reciprocal illumination of unconscious happenings” that provide an opportunity for the therapist’s own growth and insight (Reik, 1998, p. 397). The idea that both patient and analyst may be reacting to one another in a generative manner reflects the sense that something beyond objective neutrality might contribute to effective interpretations. However, many early psychoanalysts continued to reinforce the idea of countertransference as a negative, nontherapeutic phenomena that involuntarily occurs in treatment and threatens the analyst’s neutrality. Stern, writing in 1924, felt that the patient’s transference could create the risk of the analyst “stepping out of the psychoanalytic situation, thereby falling into a trap that all patients set for the analyst,” (p. 168). As this attitude persisted, analysts were instructed to work out their countertransference in their own analysis so that it would not interfere with their treatment of patients. This began to change with the development of object relations and the exploration of projection and introjection. Balint and Balint challenged the “mirror-like attitude” and recognized that “the analytical situation is the result of an interplay between the patient’s transference and the analyst’s counter-transference” (1939, p. 228). Although Melanie Klein continued to define countertransference strictly as a distortion in psychoanalysis based on the analyst’s “unfinished business” in their own past (Mitchell & Black, 1995, p. 106), she contributed

to the development of understanding the analyst’s experience, particularly through her elaboration of the concept of projective identification. Klein noted in 1946 that countertransference could affect the session if the analyst’s early need for reassurance is communicated in a way that causes the patient to have an “urge to satisfy the analyst” (Klein, 1975, p. 226); and, like Freud, suggested that the response should be personal work on the part of the analyst, outside of the session, to facilitate integration in the patient. Despite Klein’s belief that the analyst’s emotional reaction to patients could lead to greater understanding of the patient’s material (Abend, 1989), she did insist that projective identification and countertransference were separate experiences, and that countertransference provided information only about the analyst. In 1958, she distinguished between the effect of the patient’s projections on the analyst and countertransference, stating: “I have never found that the counter-transference has helped me to understand my patient better; if I may put it like this; I have found that it has helped me to understand myself better” (Klein & Steiner, 2017, p. 103). Even with the development of these concepts in the first half of the twentieth century, countertransference was still largely understood negatively, as an experience that should be avoided rather than explored. Menninger (1958) saw countertransference as an interference in psychoanalytic treatment; Heimann wrote that she was “struck by the widespread belief amongst candidates that the counter-transference is nothing but a source of trouble” (1950, p. 81). Annie Reich acknowledged countertransference but minimized its value: “Counter-transference is a necessary prerequisite of analysis. If it does not exist, the necessary talent and interest is lacking. But it has to remain shadowy and in the background” (Reich, 1951, p. 31).

Heimann introduced a new way to look at countertransference, calling it “an instrument of research into the patient’s unconscious” (1950, p. 81) that demonstrated how “the analyst’s unconscious understands that of his patient” (1950, p. 82). This led to the development of ideas about how countertransference could be used as an additional source of information in session: “the analyst's awareness of his own responses can thus provide an additional avenue of insight into the patient's unconscious mental processes” (Sandler, Holder & Dare, 1970, p. 85). Heimann was associated with the British Independent or Middle Group, along with Winnicott; this school of thought came to emphasize the concept of countertransference as an important therapeutic experience (Caldwell, 2007). Winnicott also specifically explored countertransference, understanding the analyst’s reaction to the patient as a source of information for the treatment, and extending to feelings as strong as hate (Winnicott, 1949). Winnicott saw the psychoanalytic situation as “perfectly designed for exploring and regenerating personal subjectivity” (Mitchell & Black, 1995, p. 133). Winnicott later explored the idea of therapy in a transitional space and emphasized the importance of the analyst offering himself freely for use by the patient in providing missed experiences (Mitchell & Black, 1995). Winnicott recognized one way to understand countertransference as “the neurotic features which spoil the professional attitude and disturb the course of the analytic process as determined by the patient” (1965, p. 161). In illustrating this with the description of his reaction to a patient who hit him, Winnicott clarified that “a reaction is not countertransference” (1960, p. 21).

Winnicott defined a second concept of countertransference as an alteration in the therapist’s professional attitude by patients with antisocial tendencies, or those who require regression. Winnicott describes how analysts who recognize that a patient may need to pass through a phase of infantile dependence “will need to remain orientated to external reality while in fact being identified with the patient, even merged in with the patient” (Winnicott, 1965, p. 162). While this is a specific application of the concept of countertransference, it reflects a broader understanding of how the technique came to be used in psychoanalysis. Countertransference was understood as both a broad set of reactions to the patient, and a psychoanalytic tool: Winnicott suggested that his analysand, Margaret Little, understood countertransference as “the analyst’s total response to the patient’s needs” (1965, p. 163). Little saw transference and countertransference as “products of the combined unconscious work of patient and analyst” (1993, p. 49), central to the therapeutic effectiveness of psychoanalysis: “without unconscious countertransference there would be neither empathy nor analysis itself. It is a tool, and skill and satisfaction lie in using it fully, trusting in the safeguards that the ego supplies.” (1993, p. 133). Kernberg describes countertransference as the “total emotional reaction of the psychoanalyst to the patient in the treatment situation… although countertransference should certainly be resolved, it is useful in gaining more understanding of the patient. (1965, p. 38). Fairbairn further developed Winnicott’s concept of countertransference, seeing it as an aspect of the global relationship between patient and analyst (Stefana, 2017). In Bowlby’s model of attachment, parental relationships in infancy and childhood affect an

individual’s emotional development and influence his or her ways of interacting with others in adulthood (1977), which could be experienced in session in the interaction between therapist and patient. He noted the importance of observing the experienced interpersonal interaction in session: “when the language of feeling becomes an obstacle to recognizing that feeling entails action of particular sorts, it is best abandoned and replaced temporarily by a language of behavior” (Bowlby, 1969/1982, p. 123). Similarly, Bion et al. write that, in treatment with schizophrenic patients, “for a considerable proportion of analytic time the only evidence on which an interpretation can be based is that which is afforded by the countertransference” (1955/1985, p. 225). After Heimann’s reframing of the concept, countertransference became “a fact of analysis” (Little, 1960, p. 31). Mitchell and Black suggest that object relations theory and practice incorporated the use of countertransference “as a key device for gaining access to the repetitive self-object configurations of the patient’s internal world” (1995, p. 245). Sohn (2018) adds that in the object relations approach to countertransference, it was seen as an extension of the analysand, making the analyst a tool for use in treatment. Samuels recognized how countertransference conceptualized as subjectivity became important in the therapeutic dyad within psychoanalysis: “the countertransference experiences of the analyst are theorized as communications from the patient and hence as being of clinical utility. Analysis and therapy result from an interplay of subjectivities - they are intersubjective phenomena; there is no subjectivity (no subject) without an Other" (Samuels, 2016, Chapter 2).

Contemporary uses of countertransference in treatment. Recognizing that countertransference can be a powerful force in the psychodynamic and psychoanalytic interaction, theorists have proposed different ways of making use of the countertransference. Sandler, Holder and Dare describe “as a mean of gaining insight, through an examination of his own mental reactions, into the meaning of the patient’s communications and behavior” (Sandler, et al., 2018, p. 96). Gabbard writes that the countertransference is an “inevitable and useful as part of an exploration involving two spontaneous and responsive individuals engaged in an intense and emotionally taxing interaction” (1999, p. 12). Epstein and Feiner summarize their understanding that “countertransference is now seen as a normal, natural interpersonal event, rather than an idiosyncratic pathological phenomenon” (1979, p. 508). Countertransference has been used in treatment in specific ways. Spitz listed the necessary steps for proper use of countertransference. The analyst must: become aware of his own unconscious derivatives in response to the patient’s unconscious; infer the underlying unconscious processes in himself; and perform “a transitory identification with those processes in the patient which had provoked his own responses” (Spitz, 1956, p. 264). Balint also described a process for making use of countertransference in session: the analyst recognizes the positive countertransference and accepts it as reality; when there is negative countertransference it is used to identify “what is wrong is with the twoperson relationship developing between them” (1979, p. 115). Jacobs encourages a focus on subtle countertransference reactions as the most impactful in therapy. They are contained in “the way in which we listen, our silences and

neutrality, the emphasis we place on transference phenomena and interpretation of the transference, our ideas concerning working through, termination, and what constitutes a ‘correct’ interpretation” (Jacobs, 1986, p. 290). The patient may recognize hidden communications from the analyst, or almost imperceptible enactments; the interpretative process itself may become an enactment (Jacobs, 1986). Similarly, Field encourages observing expression of the countertransference as a kind of acting-out unconsciously evoked in the therapist (1989). In working with narcissistic individuals, Grayer suggests that beyond recognizing the countertransference, the therapist must “sustain the feelings and awareness, study them, cognitively examine them, search for the information they can yield up regarding the patient's internal objects” (1981, p. 170-171). Tansey and Burke suggest a method for a countertransference-based intervention in which “the therapist is inviting a patient to join in examining what the therapist is subjectively experiencing, because of the possible consequences which this collaboration might hold for understanding the patient himself” (1995, p. 146). Carpy also explores how to best use countertransference therapeutically, concluding that the analyst’s tolerance of the countertransference feelings may in itself help the patient and produce psychic change (1989). Gill emphasizes that “transference and countertransference do indeed constitute a transaction rather than countertransference being an occasional regrettable, even if in some ways, useful intrusion into a field essentially determined by the patient's realistic and transferential reactions” (1983, p. 218). Langs cautions that unrecognized countertransference may be the most frequent cause of therapeutic failure (1982), and

that not working with the countertransference could endanger the communication necessary for analysis (1979). Hoffman sees the countertransference as information for the patient, who as “interpreter of the analyst’s experience” (1983, p. 389) creates the complement of the transference and observes its effect on the analyst. The analyst then navigates balancing the interaction and the exploration of the countertransference experience and enactments. Bollas also addresses the countertransference state as the “not knowing-yet-experiencing” (1987, p. 203). He emphasizes that “the capacity to bear and value this necessary uncertainty defines one of our most important clinical responsibilities to the patient; and it enhances our ability to become lost inside the patient’s evolving environment, enabling the patient to manipulate us through transference usage into object identity” (Bollas, 1987, p. 203). Davies describes a process of making use of the countertransference: “in the context of exploring repetitive transference-countertransference paradigms, patient and therapist together weave a net of psychic fantasies within which to repair traumatically ruptured relationships and to contain, encode, and begin to experience previously overwhelming traumatic affect states” (1997, p. 255). Orbach and Carroll see countertransference as “a sophisticated relational response to the client” (2006, p. 67) including therapist perceptions of sensation, images and fantasies, and an observation of the client’s behavior, “sensitivity to relational cues” (2006, p. 67) that evoke a therapeutic response, a relational response, or a re-enactment.

The discussion of use of countertransference in session extends to whether the therapist should explicitly disclose any aspects of these reactions. Jacobs describes three types of self-disclosure: those outside the analyst’s awareness, including slips, errors, and nonverbal means; the sharing of phenomena that come to the analyst’s awareness within the session; and answering direct personal questions (1999a). While the first may reveal the analyst’s unconscious countertransference, the second is a verbal acknowledgement of the analyst’s experience in the moment: “an image, a fantasy, a memory, an affect” (Jacobs, 1999a, p. 160). Jacobs points out the risks and benefits of this approach and concludes that selective self-disclosure may contribute to analytic progress (1999a). Gill encourages some level of countertransference self-disclosure but cautions that “the analyst must recognize that his subjective experience may be as defensive on his own part as he believes the patient's conscious attitudes are” (1983, p. 228). Davies explored the issue of how her disclosure of erotic countertransference contributed to the clinical material. In her experience, “The analyst herself becomes both the magnet that draws out the reenactment of unconsciously internalized systems of self and object and the architect of the transitional arena where such self and object experiences become free to play and reconfigure themselves in more harmonious ways” (Davies, 1994, p. 157). Despite becoming generally accepted as a component of psychoanalytic psychotherapy, countertransference evokes caution and has continued to be a subject of debate. Sandler, Holder & Dare write that “it can be questioned whether the extension of the counter transference concept to cover all the feelings experienced towards a patient is useful” (1970, p. 85). While Casement appreciates the value of countertransference, he cautions to be mindful of what Racker calls “indirect countertransference” – when the

analyst or therapist is being affected by something that is not directly related to the patient or the treatment (2006, p. 134). Lemma calls countertransference the “fulcrum of therapeutic change” (2016, p. 224) with the potential to “both facilitate and potentially interfere with analytic work” (2016, p. 225). Racker warned that for the analyst, “there is danger of his ‘drowning’ in this experience” (1968, p. 164) if the analyst’s ego becomes involved in the countertransference and the projection is experienced as intense and real (a countertransference position) as opposed those that appear foreign to the ego and are understood as the analysand’s projections (a countertransference thought) (1968). While Segal describes a good type of countertransference as “a basic disposition which allows us to be receptive to projections without becoming identified with them” (2006, p. 94), she also warns that “counter-transference is the best of servants, but it must remain a servant because it is absolutely the worst of masters” (2006, p. 96). Kohut cautioned that the analyst should provide a matrix of “true neutrality” for undistorted transference that can be used only temporarily for work that leads to transmuting internalizations (Kohut, 1977, p. 263). When analyst and patient serve as selfobjects to one another, there may be positive countertransference; when the idealizing transference activates aspects of the analyst’s internal world that elicit a negative reaction towards the patient, aspects of the countertransference may present treatment challenges. Giovacchini describes idiosyncratic countertransference reactions that undermine the treatment: the analyst may feel anxious and make an interpretation that makes the patient feel betrayed; or the analyst may verbally attack the patient. In a confrontation

with the patient, Giovacchini reminds the clinician “we must never lose sight of the therapist’s probable participation” (1989, p. 33). Jacobs cautions: “some subjective reactions are so hurtful, so damaging, so powerful in their effect on patients and the analytic process that they cannot be analysed away. They create permanent scars in the treatment- and in the patient’s life” (1996, p. 273). Other risks include Tyson’s concept of countertransference collusion, where the analysand acts out in cooperation with a third party, and the action is met by cooperation from a complementary aspect of the analyst’s countertransference (1986). Poland writes that this collaborative ignorance, where an analyst fails to interpret acting out, is an example of false neutrality. He writes that countertransferential distortions result from “violations of the analyst's neutralization of his own underlying motivation” (1984). Awareness and caution about professional liability are reasons for therapists to consider and understand their participation in transference and countertransference processes. Gordon and colleagues (2016) point out that complaints to ethics committees and licensing boards often are related to “inaccurate or missed diagnoses, boundary violations and mismanaged countertransference” (p. 237). Similarly, Thomas (2005) noted that countertransference reactions may interfere with treatment after a licensing board complaint, indicating that insight around countertransference may be lacking in clinicians who received formal complaints. Education to increase awareness and clinical skill could be helpful in preventing transference and countertransference-related errors in psychotherapy practice. However, a survey of the effectiveness of risk management training for issues related to

countertransference found that “a large percentage of participants rated their graduate training as inadequate (i.e., nonexistent or poor)” (Pope and Tabachnick, 1993). More recently, Gordon et al (2016) wrote that they “feel that even today many practitioners are not exposed to sufficient (countertransference) education to help treat high-risk patients and also help them be more proactive to possible ethical dilemmas” (p. 243). Reamer explored the ethical implications of countertransference, noting that strong negative countertransferential reactions on the part of the therapist may make it challenging to maintain professional confidentiality, monitor for dual relationships and boundary issues, recognize and avoid conflicts of interest, secure informed consent, and complete documentation. His risk management approach includes the idea that “wise clinicians explore the clinical implications of such conflict and manage their countertransference very carefully” (Reamer, 2011).

Countertransference terminology. As theorists accepted countertransference as a useful component of psychoanalysis, they began to define specific types of countertransference or elements within the countertransferential experience that impact the experience and the treatment. Many of these theories delineate a type of countertransference originating in the therapist’s background and psyche from that originating in the patient, or the patient’s experience. Several theorists have connected countertransference to projection and introjection. Money-Kyrle offers a Kleinian distinction between types of countertransference. Introjective countertransference (counteridentification) is when the

analyst, the object receiving projection becomes identified with the patient to reproject and interpret. Projective countertransference is when the patient is a representation of the analyst’s damaged objects and formerly ill parts of himself (Money-Kyrle, 1956). Fliess also elaborated on counteridentification as a separate concept, calling it a regressive identification, “a response of the analyst to the patient's identifying with him, and repetitive in both patient and analyst of an early "constituent" identification” (Fliess, 1953, p. 279). Grinberg furthered the idea of projective counteridentification “to refer to a specific and differential aspect of countertransference, based on the unconscious analytic interaction between the patient and the analyst, and which is brought about by the particularly intense use of and psychopathic modality of the mechanism of projective identification of the patient” (1979, p. 226). In this experience, the analyst is a passive object of the patient’s projections and introjections and reacts either based on his or her own past experience or based solely on the patient’s projections. Grotstein notes that “the projecting subject’s image of the object and the object’s image of the subject are in active, communicative resonance” (2005, p. 1060). Grotstein uses Bion’s intersubjective model and builds on projective countertransference and projective counteridentification to explore the concept of projective transidentification, which is projective identification with the additional bodybased, hypnotic capacity to induce transformation in the object, and emphasizes that the object must have sensitivity, empathy and attunement for the emotional state of the subject (2005). Chediak classifies countertransference as a type of counter-reaction of analyst towards the patient, separate from the other reactions that emerge from the

analyst-analysand dyad of intellectual understanding, response to the patient as a person, analyst’s transference to the patient, and empathic identification with the patient (1979). Racker distinguished between what he called neurotic countertransference, which is when the analyst’s projections may damage the analysis, and countertransference proper. Countertransference proper is the analyst’s interaction with the patient’s transference and contains two different types of countertransference: concordant and complementary. Concordant identifications are “those that arise in the analyst by reason of the empathy achieved by the patient and that really reflect and reproduce the latter’s psychological contents” (Racker, 1968, p. 155). Complementary countertransference, in contrast, is an object relationship with a real transference, with “the patient representing internal objects of the analyst” (Racker, 1968, p. 156). Grayer and Sax extended Racker’s theory to create a model with two component aspects of countertransference. One is the transferred countertransference, which is the therapist’s relating that originates in an earlier time, including both neurotic and nonneurotic reactions. The non-neurotic relate to the therapist’s uniqueness as a human being, while the neurotic include direct forms, in which the therapist perceives the client as the object of the therapist’s transference, and indirect forms, where the therapist’s internal objects are projected onto an external target outside of the therapeutic dyad (Grayer & Sax, 1986). The second aspect of the model is the identification component, which encompasses Racker’s concordant and complementary identifications. The concordant identifications are similar to empathic identifications where the therapist may take on a feeling expressed by the patient, while complementary occur when the therapist feels as if he or she is acting like the patient’s original object (Grayer & Sax, 1986).

Ogden built on Winnicott's idea that there are aspects of the objective countertransference that represent “the therapist's mature, empathic response to the patient's transference” (1979, p. 370). Countertransference understood in terms of projective identification involves experiencing and processing feelings as the object of the projection; Ogden's understanding is that this involvement allows the therapist to participate therapeutically without losing the distance required to analyze the interaction. In the model conceptualized by Ogden, “countertransference offers clues to the patient’s unconscious fantasies” (Mitchell & Black, 1995, p. 108). Clarkson also extended Winnicott’s concept of countertransference, classifying objective countertransference as reactive or inductive countertransference, noting that the therapist is reacting to the patient’s projections. This is contrasted with proactive countertransference, reactions originating from the therapist’s unresolved conflicts (2003). In Clarkson’s model, complementary reactive countertransference is a reaction by the therapist that “would complete or be complementary to the real or fantasised projection of the patient’s historical past selves, ego states or historical epochs or the partner’s – the caretaker’s or parent’s – regressive states (2003, p. 95). Concordant reactive countertransference is the therapist’s reaction elicited by the patient “that seeks identification, confluence in Gestalt, empathy, fellow feeling, resonance or empathic attunement or its variants in the others” (Clarkson, 2003, p. 95); therapists feel overwhelmed by the same feelings that patients describe. Complementary proactive countertransference is a projection by the therapist onto the patient, based on the therapist’s own past; concordant proactive countertransference is a false identification by the therapist based on his or her unresolved issues and “can be destructive or facilitative

depending on whether the psychoanalyst or psychologist identifies with the projected identification or complies with the projective identification or induction to respond in a particular way (Clarkson, 2003, p. 96). Samuels differentiates countertransference into reflective countertransference, in which the analyst may take on aspects of the patient’s transference, and embodied countertransference, in which the analyst takes on an aspect of “someone or something in the patient’s internal world that has been active therein over time” (1993, p. 48). Samuels’ examples are that an analyst experiencing reflective countertransference may feel depressed because the patient is depressed, while an analyst experiencing embodied countertransference may feel depressed because the patient’s mother is depressed. Counterresistance is a term introduced by Schoenewolf to describe countertransference resistance to a specific patient’s transference; characterological counterresistance, related to the therapist’s defenses, and cultural counterresistance, created out of cultural biases. An example of counterresistance is when a therapist avoids meeting “subjective hate with objective hate” (Schoenewolf, 1993, p. 50). Robertiello and Schoenewolf also considered that countertransference and counterresistance errors play significant roles in therapeutic errors in the clinical setting (1987). Fordham distinguished between illusory, undesirable elements, and what he called useful syntonic elements: “Syntonic elements are basically different because, through introjection, an analyst perceives a patient's unconscious processes in himself and so experiences them long before the patient is near becoming conscious of them” (2003, p. 96). In this Jungian model, syntonic countertransference is an interaction with the

patient’s transference; countertransference in general relates to the unconscious as an “organ of information” (1960, p. 5) that is different from intuition. Kernberg differentiated abnormal and ordinary countertransference, acknowledging its usefulness in treatment (1965). In a 1987 paper, Kernberg lists components of the “global” concept of countertransference (p. 214) including the analyst’s unconscious reactions to the patient or to the transference; the analyst’s realistic reaction to the patient’s life; the analyst’s realistic reaction to his own life as affected by the patient; and the analyst’s realistic reaction to the transference. The concept of countertransference used in this research incorporates an understanding that feelings arising in the therapist during the session may be countertransferential experiences related to the patient, the material, the interaction, or the session itself. They may also be related to the therapist’s own private, “neurotic,” proactive, abnormal, characterological, cultural or illusory thoughts and reverie; even in this case, there may also be relevance for the treatment, as something in the patient’s narrative or physical presence may provoke a feeling in the therapist that affects the therapeutic interaction.

Countertransference from a relational perspective. The shift to appreciating a constructive role of countertransference in treatment was accompanied by the recognition of the two-person framework of contemporary analysis (Mitchell & Black, 1995). Relational psychoanalysis developed out of interpersonal psychoanalysis and object relations theories, incorporating aspects of self psychology, intersubjectivity, social constructivism, and gender theorizing (Mitchell &

Aron, 1999). In addition, transference and countertransference are emphasized in this school; the transitional arena they create is a space for enactments and reactivation of object relationships (Davies & Frawley, 1992). Relational theory was chosen as a framework for understanding this study on countertransference based on qualitative research. Many of the themes that surfaced across interviews explored presence, co-created space, and the effect of therapist and patient on one another. These themes are not unique to relational psychotherapy but are explored in depth by many theorists in both current relational writings and in older schools that inform relational thought. The relational model emphasizes the analyst’s participation and the mutual influence of patient and therapist on one another: “This increases his ability to use countertransference as an empathic tool… the relational model stresses respect for the intricacy of human relationships and for the impact which everything the analyst does (or does not do) inevitably has on his patient” (Greenberg & Mitchell, 1983, p. 398). In the interpersonal psychoanalytic approach, the analyst was seen as embedded in the analytic situation. Sullivan explained: “the actions or operations from which psychiatric information is derived are events in interpersonal fields which include the psychiatrist… events in which the psychiatrist participates” (1953, p. 14). Fromm emphasized the importance of mutuality in analysis, a situation in which the patient could learn from the analyst’s personal feelings and reactions to the patient, analyzing the patient by analyzing his own countertransference reactions (1994). Fromm writes: “The analyst analyzes the patient, but the patient also analyzes the analyst, because the analyst, by sharing the unconscious of his patient, cannot help clarifying his own unconscious

(1960, p. 112). Contemporary interpersonal analysis emphasizes creation of patterns of therapeutic experience between analyst and patient, and what is evoked in their interactions (Mitchell & Black, 1995). Intersubjectivity, as defined by Aron, is “the developmentally achieved capacity to recognize another person as a separate center of subjective experience” (1991, p. 30). A two-person model acknowledges a co-creation of countertransference. Therapist and patient each have a subjectivity and influence one another: “both transference and countertransference are jointly constructed based on the mutual influence of the two parties. In addition, within this point of view, transference and countertransference would be inextricably linked” (Gabbard, 2001, p. 988). Gabbard describes the interplay of subjectivities “as a jointly created phenomenon that involves contributions from both patient and clinician. The patient draws the therapist into playing a role that reflects the patient’s internal world, but the specific dimensions of that role are colored by the therapist’s own personality” (2001, p. 984). In this way, countertransference offers a means of deepening the analytic process with a specific analyst in a unique interaction with a specific patient. Stolorow, Brandchaft and Atwood note that intersubjectivity allows for countertransference to be understood as an aspect of the individual’s engagement with others, recognizing that the clinician “is himself implicated in the clinical phenomena he observes and seeks to treat;” intersubjectivity is affected by the transferencecountertransference interplay; and that “the analyst’s picture of the patient’s attributes crystallizes within the interplay between two personal universes” (1987, p. 3). Stolorow

and Atwood also note that “Transference and countertransference together form an intersubjective system of mutual influence” (1996, p. 186). Countertransference has also been conceptualized as a distinct component of the analytic third. As explained by Ogden, the analytic third is created out of the subjectivities of analyst and analysand through the process of projective identification (1994). Countertransference then relies on the dialectic between the analyst and the intersubjectivity of the analytic process (Gabbard, 1995). In terms of the analytic field, Baranger and Baranger write that the emotional situation rises from the analytic encounter, and countertransference is part of the intersubjectively constructed field. They explain that patient and analyst create a new type of communication “of doing or constructing something together or sharing a reparatory process. Insight is the integration of the transference and countertransference phantasies concerning analytic work” (Baranger & Baranger, 2008, p. 825). Within relational theory, Aron questions the use of the term countertransference. He writes: “referring to the analyst's total responsiveness with the term countertransference is a serious mistake because it perpetuates defining the analyst's experience in terms of the subjectivity of the patient. (1991, p. 32). He notes that in the traditional model of psychoanalysis, the analyst’s own psychic reality or subjectivity was relegated to an intrusion on the work, to pathological countertransference (Aron, 1995, p. 247). However, he believes that the modern definition of countertransference has not sufficiently broadened to consider the patient’s experience of the analyst’s subjectivity. McLaughlin also writes that “the term countertransference particularly cannot

accommodate the intrapsychic range and fullness of the analyst’s experiences vis a vis his patient (1981, p. 656). Aron also raises issues of power and influence within the therapeutic interaction: “The terms transference and countertransference too easily lend themselves to a model that implies a one-way influence in which the analyst responds in reaction to the patient. The fact that the influence between patient and analyst is not equal does not mean that it is not mutual” (1991, p. 32). He emphasizes the importance of enactments: “Transference-countertransference interactions are mutually constructed, are never simply talked about, but are always enacted as they are being discussed. The analyst must recognize her or his participation in the enactment and work her or his way out of it either through further inquiry or through interpretation” (Aron, 1995, p. 107). He also suggests analyzing participation rather than attempting to eliminate participation and notes that “countertransference is not an occasional lapse that intermittently requires investigation and elimination but rather is a continual and central element of the investigation” (1995, p. 125). In contrast to Freudian analysts, relational analysts assume that they will be drawn into enactments with the patient, and that analysis of the enactments will occur mutually. Greenberg and Mitchell echo the importance of the analyst’s participation and openness to countertransference reactions: “It is in the recognition of vulnerability and anxiety that the working through of countertransference occurs,” (Greenberg, 1991, p. 248). They describe the co-created experience of countertransference as “an inevitable product of the interaction between the patient and the analyst rather than a simple

interference stemming from the analyst’s own infantile drive-related conflicts” (Greenberg & Mitchell, 1983, p. 389). The relational model includes both process and embodiment. Sletvold (2014) writes: “working from a dyadic perspective, we could frame conceptions of quality within a relational model that stresses features of the process between two persons” (p. 165). Sletvold also notes that “transference and countertransference were indeed basically embodied communication of emotions” (2014, p. 139). Sohn describes the relational perspective on countertransference as the analyst’s countertransference belonging to the patient, the dyad, and the field rather than just the analyst (Sohn, 2018). In contrast, Grossman (2018) explores the concept that the patient’s ideas about the analyst are a creation of the analyst, and suggests that if countertransference as a concept is used to create distance from the patient, it implies that the mind of the analyst is different from that of the patient. In the context of the analyst-patient interaction around dysregulated behavior, Benjamin and Atlas note that “By analyzing both the countertransference and the transference the intersubjective dynamic can be seen even as the analyst maintains the asymmetry by her responsibility for self-reflection, her empathy, and her focus on regulating the patient” (2015, p. 20). Davies’ idea supports this concept: “we become the carriers of dissociated aspects of internalized self- and object representation, the patient's and our own, within the countertransference” (1996, p. 209). In the relational model, the analyst is a co-participant in the transference-countertransference space created from the interpersonal interaction. Benjamin describes the relational dyad as “a more advanced form of thirdness, based on a sense of shared communication about reality that tolerates

or embraces difference, one which is interpersonally realized as both partners feel freer to think about and comment on themselves and each other” (2018, p. 26). Davies names countertransference “simply one more route into the human experience” (1998, p. 748), and also relates countertransference to the idea of self-states. Her model of the transference-countertransference matrix explores its use as a basis for the “negotiated interpersonal process” (1997, p. 251) that allows for self-states to become elaborated in the therapeutic setting, particularly in trauma work. This matrix is also necessary for the therapeutic dissociation that Davies explains can counter traumatic dissociation: “I know of no better way to discover it than to ‘live with’ that aspect of the patient for a period of time, using my own countertransferential experience within that intersubjective space to begin to recognize and name the unknowable” (Davies, 1997, p. 253-254). In summary, the concept of countertransference has been developed and expanded since its first use by Freud in 1910. Its initial description as a distraction or hindrance in therapy has gradually evolved to a potential source of additional understanding about the patient. In Jacobs’ words, "by tuning in on ourselves, gaining awareness of our experiences in sessions, and grappling once again with the ghosts that haunt each of us, we rediscover not only forgotten aspects of our selves but the inner worlds of our patients as well” (1996, p. 275-276). The broader definition of countertransference considers all the ways in which the patient affects the therapist, which can be an important means of understanding the therapeutic dyad, the patient, and the treatment.

Touch

Historical overview of touch in psychotherapy. Psychotherapy is a treatment modality that was originally named the “talking cure” and relies on verbal and non-verbal communication between patient and therapist to effect change. A traditional prohibition on touch in psychoanalysis and psychodynamic psychotherapy has persisted, even while some non-psychodynamic modalities have incorporated touch into the clinical practice of psychotherapy. These modalities include a range of touch expression in psychotherapy to include “light contact with the hand or shoulder, full-body embraces, or direct and extended physical intervention in the body through massage or other manipulation” (Kertay & Reviere, 1993, p. 32). Throughout the history of psychotherapy, the question of using touch in treatment has been the subject of debate.

Early use of touch in psychoanalysis. The use of touch in psychotherapy started when Freud used massage and hypnosis in his early work with delirium, including with Frau Emmy von N. (Freud, 1893a). Later, he developed a method of touching the patient’s forehead, in theory to prevent the patient from monitoring or censoring thoughts, and asking what thought came to mind. Freud hypothesized: “What we have done is to make a path to an inner stratum within which the patient now has spontaneously at his disposal material that has an equal degree of resistance attaching to it” (Freud, 1893b, p. 292). Within ten years, Freud had stopped his experiments with touch and distanced his psychoanalytic procedure from what he called the cathartic method of treatment. Strachey

describes Freud’s method in 1904: “Without exerting any other kind of influence, he invites them to lie down in a comfortable attitude on a sofa, while he himself sits on a chair behind them outside their field of vision. He does not even ask them to close their eyes, and avoids touching them in any way” (p. 250). The concern that touch may be a distraction from the psychological work was not the only reason to discontinue physical contact between analyst and patient. Mintz suggests that Freud’s rejection of therapeutic massage was related to avoiding patients’ misinterpretation of touch in the context of investigating psychosexual development (1969, p. 367). In addition, Freud’s effort to situate psychoanalysis in the realm of science and medicine instead of religion or magic may have required abstinence from “the mystical implications of touching” (Mintz, 1969, p. 367). Freud saw psychoanalysis as a scientific process within the positivist model that was a scientific, rational exploration, contrasting with the religion, magic and hypnotic treatments of other popular healers (Fosshage, 2000). Freud continued to evolve his theories about the effect of the analyst’s actions on the patient, writing that “the treatment must be carried out in abstinence” to prevent the patient from acting out, to “preserve the erotic transference,” and to successfully treat the neurosis (1915, p. 165-166). He expounded on this in 1919, writing that abstinence refers not only to refraining from sexual activity, but from prematurely gratifying the patient or relieving her suffering without fully analyzing it or thoroughly treating it. In Freud’s words, “In analytic treatment all such spoiling must be avoided. As far as his relations with the physician are concerned, the patient must be left with unfulfilled wishes in abundance. It is expedient to deny him precisely those satisfactions which he desires most intensely and expresses most importunately” (Freud, 1919, p. 164). This idea of

nongratification persisted: touch could be seen as “an intrusion of the analyst that interferes with the free associational process and the unfolding of the intrapsychically generated transference” (Fosshage, 2000, p. 24). Several of Freud’s contemporaries were not as cautious about physical interactions with their patients. Ferenczi theorized about an analysis from below, in which unconscious material in the soma could be moved and manipulated (Smith, 1985). However, Freud’s theories predominated; Ferenczi’s methods and intent were also called into question by Freud and Jones, after which the theories were ultimately distanced from mainstream psychoanalysis (Fosshage, 2000). Wilhelm Reich, who trained with Freud and worked at the Polyclinic in Vienna, developed his own ideas that were not in line with mainstream psychoanalytic thinking. He believed in a “somatic core of the neurosis” (W. Reich, 2013, p. 13) and in a more tangible energetic force affecting psychological functioning. He created theories about character analysis and muscular armor, developing a vegetotherapy model that included an orgasm theory about the libido. Although Reich’s ideas and energy-concentrating devices were not scientifically validated, his theories impacted later somatic psychotherapy and bioenergetics (Shaw, 2003).

Persistence of the taboo on touch in psychoanalysis. Anonymity, neutrality, and abstinence became fundamental principles of psychoanalysis, but “degraded into rules” as psychoanalysis developed (Schlesinger & Appelbaum, 2000, p. 126). The idea of abstinence as a tool to intensify the transference became an important aspect of psychoanalysis: “nongratification was an essential

principle of cure within a classical model” (Mitchell & Black, 1995, p. 162). Despite acknowledging that sensory contact is a basic human need, and that the analyst sometimes takes on the neglected functions of a patient’s development, Menninger believed that transgressions of the rule against physical contact were “representing prima facie evidence of the incompetence or criminal ruthlessness of the analyst” (1958, p. 40). Fromm-Reichmann cautioned analysts not to “be an obsessional denizen in our culture” by abstaining from touch, emphasizing that shaking hands with a patient may be indicated. In her suggestions for treating very disturbed patients, she suggested that an analyst could “touch him reassuringly or not to refuse his gesture of seeking affection and closeness. However, it is always recommended that one be thrifty with the expression of any physical contact” (Fromm-Reichmann, 1950, p. 12). She did not explore the countertransference aspect of physical contact but observed the possibility of inappropriate satisfaction of the therapist’s needs by encouraging the psychiatrist to “safeguard against a lack of alertness in listening due to this interference of his own unresolved needs” (Fromm-Reichmann, 1950, p. 12). Langs explained the need for the continued prohibition on touch, listing one of the fundamental ground rules of psychotherapy as not touching the patient, stating that “touching is contraindicated and anti-therapeutic” (1981, p. 200) because of the associated fantasies and desires that may gratify the patient in controlling the psychotherapist, as well as limiting the development of insight. Langs continued to believe that physical contact had no place in psychotherapy, even if in the context of keeping a female patient from falling when her foot fell asleep (Kahr, 2006); Kahr explains that Freudian practitioners “realize that any physical interaction between two

people can so easily trigger unconscious memories of earlier physical interactions, especially those of a provocative or abusive nature” (Kahr, 2006, p. 7). There is limited literature on the impact of touch on psychoanalysis, whether it occurs spontaneously or with planned intent. Galton speculates that although touch may be used in psychoanalysis and psychoanalytic psychotherapy, it is considered a “somewhat shameful secret… One widely held psychoanalytic viewpoint is that touching a patient serves either to relieve the anxiety of the patient or therapist and does not promote psychic change, or, at worst, leads to sexual relations between therapist and patient” (Galton, 2006, p. xx). Despite the traditional prohibition on touch, several psychoanalysts have explored the impact of touch on treatment. Winnicott’s experience as a pediatrician who conducted both adult and child analysis may have allowed him a greater openness to discussing the occurrence of touch. He was known to use non-sexual physical contact with his patients, although he did not include descriptions of these experiences in his formal writings. In a teaching seminar, Winnicott once described how he handled an analysand jumping into his lap during the session (Kahr, 2006). Kahr also writes that Winnicott “subscribed to the idea that physical holding might sometimes be required as a means of providing extra containment for the neediest of his patients” (2006, p. 2). Bowlby emphasized of the role of touch in the mother-child relationship, and the need for infants “to be in touch with and to cling to a human being” which is “as primary as the ‘need’ for food and warmth (Bowlby, 1969/1982, p. 178). Studying infants and

children, Bowlby also wrote that “there are occasions when it would be inhuman not to allow a distressed patient to make some form of physical contact” (1988, p. 154). Balint, who also studied the mother-infant relationship and had experience in the treatment of children, suggested that it is not only permissible to hold the hand of the analysand, but that this contact is “vitally important for the progress of the treatment” (1979, p. 145). Fosshage notes the importance of touch for the human experience, writing: “the avoidance of touch, just as touch, can have many different and profound meanings for analysands” (Fosshage, 2009, p. 331). In contrast, Schaverien, writing about her work with a dying patient, notes that her decision to resist physical contact “evoked a profound form of emotional touch, enabling the individuation process to continue to the end” (2006, p. 197). She summarizes this experience: “abstinence from physical contact maintains the emblematic nature of the transference” (Schaverien, 2006, p. 197). Kohut described the very rare experience of offering a severely depressed patient two fingers to hold after she said she felt as if she was lying in a coffin. Kohut writes that he immediately made an interpretation to himself that “it was the toothless gums of a very young child clamping down on an empty nipple” (Kohut, 1991, p. 535). Kohut was not encouraging the use of touch, but rather acting out of desperation, feeling that he could not reach the patient. Many years later, other theorists noted that “Through Kohut’s use of empathy and his theory of the self, he gleaned that the needed response was the wordless, physical extension of his fingers to his patient, who required the experience of life-affirming selfobject responsiveness at a simple, archaic, or, if you will, ‘lower’ level to aid her in healing her suicidal despair” (Bacal & Carlton, 2010, p. 138). This

interpretation of Kohut’s spontaneous actions has enhanced theory, but should not be understood as an endorsement of the use of touch. Casement wrote about his work with a patient who was requested she hold his hand (1985). In revisiting the case years later, he revealed that although he decided that it would not be therapeutic to hold the hand of the first patient, he did later hold the hand of a different patient, who was suicidal. He credited this touch with the second patient not taking her own life (Casement, 2000). Casement explained his approach to decide individually about the use of touch and its therapeutic value within the analytic dyad by describing not resisting the patient’s hand on his shoulder, while sustaining the handshake. He writes: “The sustained handshake here serves as a token boundary, which I continue to keep between the patient's body and mine, and I regard this ‘half embrace’ as unique to the consulting room. So, it serves both purposes. The patient is not rejected, and at the same time, the analytic relationship has not dissolved into something else at this moment of leaving, which needs to be a going on rather than a holding on” (Casement, 2000, p. 164). In discussing touch and countertransference, Maroda emphasizes her very human reaction to the patient’s suffering and how this has changed her work with later patients. She writes: “The guideline that I use in determining when to provide physical comfort is whether it seems inhuman not to” (Maroda, 2016, p. 150). She notes that in treatment, offering touch before the patient is desperately in need of it can be an error, and that deciding when to initiate physical contact can be difficult to assess. Maroda emphasizes the challenge of understanding of how physical contact impacts each patient in their individual treatment, with different positive reactions, as well as the perceived risk to the

patient and possibility of abuse. Her own preference in receiving touch from the patient is to accept hugs because “the narcissistic injury involved in refusing the spontaneous gesture of a patient’s hug can have a far worse outcome than accepting it. My preferred type of physical contact is touching the hand of the patient” (Maroda, 2016, p. 150). Maroda also briefly describes her own reactions to offering and refusing touch in session. Early in her career, a distraught 19 year old female patient asked her to leave the therapist’s chair and sit next her on the couch. Believing that providing her physical comfort would contribute to her pathological history and break the analytic process, she refused. Maroda said that it was “one of the most wrenching events I have ever witnessed” and “seemed absolutely inhuman” (Maroda, 2016, p. 152). After termination, she reevaluated the situation and came to understand that the patient wanted her to repeat the past up to a point, but with a different, possibly healthier, outcome.

Incorporating touch into psychoanalysis and psychotherapy modalities. During the 1960s, the human potential movement created therapeutic environments “in which touch was neither bad nor feared, but valued and encouraged” (Horner, 1968, p. 27). Therapists experienced these new kinds of psychotherapy both as patients and as clinicians, connecting the experience to attachment and object relations theory. Horner, a psychologist, describes how she had previously sought physical touch from her own psychotherapists and experienced their denial as a reinforcement of her own beliefs that she was untouchable, bad and dangerous. When she attended workshops led by Otto and by Satir, she participated in holding, nurturing touch exercises that she

described as healing and transformative, and opened her to the possibility of using touch with her own patients (Horner, 1968). Robertiello wrote in 1974 about his experience incorporating touch into his psychotherapy sessions. Holding his patients like a baby, he felt that those who were otherwise unable to develop a transference neurosis were now able to use therapy to develop the ability to achieve closeness in relationships. He connected this work to object relations theory: “one of the essentials to developing a very early kind of transference is the requirement of touching and holding, which is the essence of the relationship between mother and child in the first weeks and months of life” (p. 306). Despite these experiments with touch, many psychotherapists did not challenge the traditional rules against touching in the field. After achieving success in a family therapy session that involved holding a woman’s hand, Older demonstrated this technique for a supervisor and was told to “learn to touch without physical contact” (p. 199). He limited his own use of touch in session; later, when he began to speak about it again, he discovered that others also used touch but would not disclose the practice “for fear of misunderstanding or repercussions” (Older, 1977, p. 199). He summarized the state of touch in psychoanalysis in the 1970s with these thoughts: “We live in a strange time in which it is perfectly acceptable to induce convulsions in a person electrically, yet it may be illegal to hold that same person’s hand…. Touching is a technique. Not touching is a technique” (Older, 1977, p. 199). Bosanquet considered the use of touch in psychoanalysis and challenged the belief that “touching is acceptable as part of ‘management’ but not when ‘classical’ analysis is resumed” (Bosanquet, 1970, p. 42). Her understanding is grounded in a belief

that patient functioning and regression are not static. Citing Balint’s theory of benign and malignant regression, she notes the difference between a patient seeking consent to use the external world (benign) compared to the gratification of instinctual cravings (malignant), which would lead to the need for further gratification. In her model, the analyst receives and responds to communication both verbally and preverbally at the same time (2006). Cornell (2010) considers the intersection of psychoanalytic theory and bodybased treatment with his description of an approach rooted in script theory, part of the transactional analysis model conceptualized by Byrne. Integrating the ideas of Bollas, Winnicott, McLaughlin, and Mitchell at the time Cornell “began to learn how to work more effectively with affective and unconscious states through the transference– countertransference matrix” (2010, p. 181). He began to integrate this understanding with his somatic work, moving away from a cathartic model and towards a model based on Bucci’s code theory, a system for how humans experience and process the world that includes verbal symbolic, nonverbal symbolic, and sub-symbolic processing (2010). After the development of the humanist and encounter group movements, different types of physical contact were introduced into psychotherapeutic settings (Cowen, 1982). Borenzweig credited the sexual revolution with a movement within the psychotherapy community of “less concern about the libidinal components, and more concern about the therapeutic components, of touching in therapy” (1983, p. 240). In reviewing the literature on nonerotic touch in psychotherapy, Milakovich notes that the intention for touch was not from a psychotherapeutic theoretical perspective, and that the studies from

the 1960s through the 1980s failed to consider the therapeutic alliance, phase of therapy or intent of touch (1998, p. 75). As therapists have recognized the possibilities for incorporating touch therapeutically into psychotherapy, new modalities have emerged with their own theories, orientations and training for integrating body and mind. Broadly categorized as bodybased psychotherapy, this approach is defined as a branch of psychotherapy that “recognizes the continuity and the deep connections in which all psycho-corporal processes contribute, in equal fashion, to the organization of the person. There is not a hierarchical relationship between mind and body, between psyche and soma. They are both functioning and interactive aspects of the whole human being” (Young, 2004, p. 1). Body-based psychotherapies were developed that include core energetics, a spirituality and body-based psychotherapy developed by Pierrakos (Wilner, 1999); Hakomi, blending bioenergetics, Gestalt, Focusing, hypnosis, Reich’s theories, as well as Buddhism and Taoism, developed by Kurtz (Kurtz & Minton, 1997); the Rubenfeld Synergy Method, which was developed by Rubenfeld and combines the Alexander Technique, Feldenkrais, and Gestalt therapy (Haiman, 2004); and Eye Movement Desensitization and Reprocessing (EMDR), developed by Shapiro in the 1990s. Shapiro believed that there was an immune system-like process occurring in emotional healing, and that treatment allowed the body and mind to heal themselves (Haiman, 2004). Other body psychotherapy modalities include Reichian Therapy, Dance Movement Therapy, Primal Integration and Process Oriented Psychology; Totton notes that only a small number of body psychotherapists observe the prohibition on touch

(2003). There are also bonding psychotherapy, formerly called the new identity process; embodied psychotherapy; Gerda Boyesen’s Biodynamics, Lowen’s Bioenergetics, and Rolf’s Structural Integration, Thought Field Therapy, tapping, and the neuroemotional technique. Psychodramatic bodywork incorporates treating the body, using touch within the context of psychodrama to enact cathartic release (Phelan, 2009). Sensorimotor psychotherapy is a “body-oriented method that integrates physical, emotional and cognitive aspects of experience, within a framework supported by neuroscience, theories of attachment and dissociation” (Buckley, Punkanen & Ogden 2018, p. 225). It has a focus on grounding and returning to what is described as a window of tolerance, or a safe emotional range, in recovery from trauma. Somatic experiencing is also focused on the impact of trauma on the body: the therapist’s role involves “somatic resonance and subtle observation” (Levine, 2010, p. 139). It includes a method of tracking client experience called the “SIBAM model” which involves noticing sensation, image, behavior, affect and meaning (Levine, 2010, p. 139), all of which are understood and interpreted by the therapist.

Role of touch in psychotherapy. As more psychotherapy modalities involving touch have been developed, there has been more study of the types of body -based psychotherapy and its therapeutic use. In a review of different types of touch used in psychotherapy, Zur divides touch in therapy into three categories. The first, when touch is used as an adjunct to verbal therapy, includes light, culturally appropriate touch and gestures. These may be ritualistic

gestures, conversational markers, consolatory touch, reassuring touch, playful touch, grounding touch, task-oriented touch, corrective experience, modeling touch, experiential touch, referential touch, inadvertent touch, touch to stop self-harming behaviors, touch to prevent a person from hurting another, and touch in self-defense. The second type of touch is intentional touch by body psychotherapists who have specific training in the modality. The third type is inappropriate touch, which is unethical and often illegal (Zur, 2007). The functions of touch in psychotherapy have been described by Totton (2003) as comfort, exploring contact, amplification of body sensations, provocation for muscle discharge, and skilled intervention. Phelan (2009) divides use of touch in psychotherapy into ritually or socially accepted gestures, consolation touch, reassuring touch, grounding or reorienting touch, touch to prevent a client hurting oneself or others, and touch as corrective experience. Westland, a body psychotherapist, describes different purposes for using touch in psychotherapy. These include working with trauma, repairing emotional or physiological dysregulation, reducing emotional defenses, healing childhood developmental deficits and traumas, embodying aggression and pleasure, increasing energy flow, deepening experience in relationship, and creating a real relationship within the therapy (Westland, 2011). Westland’s application of touch, developed at the Chiron Centre in England, is called “contactful touch.” It is a relational, intentional means of communication. Goodman and Teicher reviewed the use of touch in psychotherapy and divided the practice into touch intending holding, which communicates safety, or a kind of provoking

touch, which is used to surface new content. The traditional rule of abstinence is seen as protecting the analyst from engaging in gratification and diminishing transferential material (Goodman & Teicher, 1988). They refer to Giovacchini, Winnicott, Little, and Robertiello in distinguishing between supportive psychotherapy and analytic psychotherapy, emphasizing that while the use of touch may be a successful tool in correcting missing emotional experiences, it does not necessarily contribute to progress in psychoanalysis (Goodman & Teicher, 1988). Goodman and Teicher also suggest that touching should be used only with a specific group of patients. Their model proposes that patients who have regressed to a state of employing primitive defenses or engaging in primitive or pathological processes may benefit from contact at the lower brain functions instead of the cortex. However, they maintain that through psychoanalytic talk therapy, rather than touch, psychoanalysis can contribute to the stimulation of brain activity and development of new neuronal pathways (Goodman & Teicher, 1988). Wolberg describes how physical contact can be used in transactional therapies “that advocate a free, spontaneous interaction between therapist and patient, characterized by unrestrained physical and symbolic communication” (2013, p. 542). The criticism of this psychoanalytically-oriented method is that both patient and therapist may regress, allowing “the therapist with neurotic problems a license for personal emotional catharsis and acting-out” (Wolberg, 2013, p. 543). Although the concept of countertransference is not discussed in this context, the implication is that the therapist does experience a reaction to the patient or the situation, and that this reaction may have a negative effect on the treatment.

Edwards (1981) names the types of touch in interpersonal relations as nurturant, sexual, information pick-up, movement facilitation, prompting, aggressive, celebratory, cathartic, and ludic touch. Edwards notes that even when the therapist does not intend these general experiences of touch in the psychotherapeutic relationship, the patient may have an internal reaction based on previous experiences outside of treatment. In Edwards’ model, this allows greater sharing of information and use of the transference and countertransference. Touch can be used as a form of communication. Family therapist Virginia Satir described her use of touch to work with families: “I was working to contact their spirits…my means of making contact was in my own congruent communication and the modeling that went with it” (1988, p. 340). Touch in psychotherapy, separate from any touch-based modalities, is understood in mental health nursing as a form of nonverbal communication (Wilson, 1982). Wilson cites Satir in explaining that verbal behavior serves as metacommunication and context for the nonverbal behavior: verbal behavior and touch elaborate and enhance one another as forms of communication (1982). Touch in therapy can be understood as a gift: Smolar considers touch one of several gifts a therapist can present to the patient in psychotherapy or psychoanalysis. These intangible gifts include a transitional object, self-disclosure, time, physical touch, and developmental presence; they present the possibility for therapists to “offer unusual parts of themselves as a viable therapeutic option” (Smolar, 2003, p. 321). Touch on the part of the therapist can be used to acknowledge meaning and make a connection with the patient. Jaenicke describes a relational approach to the use of touch,

and grounds it in Winnicott’s idea that receiving a correct interpretation is similar to being held. In this model, being held or being touched in some way can be experienced by the patient as a correct interpretation of what is being expressed (Jaenicke, 2008). The individual decision about touch depends on the state of the space between analyst and patient: “one human being can make the difference and can deeply effect change in the life of another if we are willing to enter into the intersubjective field, to take the risk to walk the line and let the line walk us” (Jaenicke, 2008, p. 142). Touch can also be used to effect change in treatment, as a force that deepens and intensifies work itself. Cornell writes: “The purposeful use of touch and movement in the therapeutic process is to enhance the understanding of how we know something, as well as what we know, to add experiential knowing to cognitive understanding” (2015, p. 51). While many relational psychotherapists and analysts do not use touch in treatment, relational theory makes space for taking the physical body into account. Aron writes that “we may still profit from the momentous legacy bequeathed us in Freud’s recognition that a person’s very self is constructed out of bodily experience” (2015, p. xxvii) and that “what is fundamental to the construction to the self is the body and its affects” (Aron, 2015, p. xx). Shapiro notes that traditional psychoanalytic theory “does not rely clinically on an experiential body” (1996, p. 298) and privileges the still body in the formal consulting room (1996). Gill suggests that Freudian analysts also listen explicitly and implicitly to the body (2000) and emphasizes the importance of moving away from a concrete understanding of the body to a metaphorical understanding, emphasizing “the body in

terms of its meanings” (Gill, 2000, p. 139). Aron connects the physical body and its experience of touch to attachment and intersubjectivity. He writes: “It is clear that in infancy our bodily sensations are greatly affected by the qualities of the “holding” and “handling” that we receive from caregivers, and so it is not much of an extension to suggest that our self is first and foremost a body-as-experienced-being-handled-and-heldby-other-self, in other words, our self is an intersubjective-bodily-self” (Aron, 2015, p. xx).

Touch and Countertransference How touch affects countertransference. Little has been written in the psychoanalytic literature about how countertransference is affected by the use of touch in treatment. Even as psychotherapies have evolved that do include components of touch, many analysts have continued to avoid the use of any touch at all. Burton and Heller noted that “psychoanalysts and psychoanalytic psychotherapists have a fear of touching their patients… they avoid any physical contact, no matter how minor, and actually have a horror of its possibilities” (1964, p. 124). They believe that the taboo about touch exists “because the psychotherapist does have a need to touch his patient…the fear and guilt involved are more often the psychotherapist’s than the patient’s and such attitudes constitute countertransference barriers to the relationship” (Burton & Heller, 1964, p. 124).

Types of physical countertransference.

When therapists do write about their countertransference in response to physical touch, they may describe their thoughts, feelings, reactions, subjectivity, or experiences. This is sometimes developed into specific descriptions of physical countertransference, with references to embodied countertransference, somatic countertransference, somatic resonance, touch countertransference, resonance, and embodiment. Hayes and Gelso divide countertransference manifestations into affective, cognitive, and behavioral reactions (2001). Affective manifestations include anxiety or boredom. Cognitive reactions may be distortions of the patient’s issues, misperceptions or misremembering the content of the session. Behavioral manifestations include avoidance or overinvolvement with patients. Soth points out that embodied countertransference is a unique concept (2005). It is distinguished from somatic resonance because it does not objectify embodiment, considers the countertransference, and uses the transference and projective identification. It is also different from somatic countertransference because it does not employ symbolization without embodiment, or “neglecting or overriding spontaneous processes with excessive reflection or verbalization” (Soth, 2005, p. 41). In the field of dance and movement therapy, Forester emphasizes the importance of somatic awareness, an embodiment, reaction or communication that is felt within the patient's body; and understands it as a prerequisite for somatic countertransference, which is “the effect on the therapist's body of the patient and the patient's material” (2007, p. 129).

While Field explores the meaning of physical feelings in the therapist as a manifestation of the countertransference (1989), Shaw cautions that there is a greater level of interaction and bi-directional communication. Shaw writes that while the therapist makes use of their body to monitor the therapeutic process, body-oriented communication and somatic emphasizing are “not merely aspects of countertransference” (2004, p. 285). Instead, they represent a profound connection “and are informative of the embodied therapeutic relationship” (2004, p. 285). In practicing body psychotherapy, Ben-Shahar describes the importance of recognizing somatic countertransference, or resonance: “It expands the psychoanalytic concept of transference (the way in which the therapeutic relationship acquires characteristics of the client’s previous relationships) into somatic spheres. Resonance is a complex therapeutic skill requiring understanding and exploration of therapist-client psychodynamics” (Ben-Shahar, 2018, p. xxii). In body psychotherapy, what is defined as habitual countertransference is based on the therapist’s construction of therapeutic position; situational countertransference is evoked between client and therapist (Marlock et al, 2015). Marlock describes how body psychotherapy integrates with relational work: “transference and countertransference are given as much attention as the genuineness and authenticity of the therapeutic contact” (Marlock et al, 2015, p. 743). In exploring how the physical body can be used to understand countertransference, Ross writes, “Somatic countertransference – soma meaning body – extends that definition to include the ‘physical’ as well as emotional responses aroused in the therapist” (2000, p. 453). Totton describes somatic countertransference or embodied transference as the “capacity for embodied relationship – including all of the irrational

and projective elements of relationship in general” (Totton, 2003, p. 87). Another model demonstrates how organic transference and countertransference cover “conscious and unconscious interactions and reciprocities between client and therapist on the nonverbal level” (Marlock et al, 2015, p. 458). Lemma writes that somatic countertransference is “a plethora of sensory and motoric experiences” (2016, p. 226). Spotnitz defines touch transference as the need to touch, which is identified with the patient, and touch countertransference as the reciprocal of that need, which include induced feelings only identified with the therapist in individual analytic treatment (1972). Applying these ideas to group therapy, he explains that group members may also experience touch countertransference; recognition of this phenomena is understood to be both a tool for decision making about touch in the group setting, and a source of therapeutic information.

Somatic countertransference as communication. Orbach summarizes three classes of countertransference in kinesthetic phenomena: the patient conveying an overwhelming physical sensation to the therapist, showing the therapist how the patient feels; a demand for provision, evoking the potential to identify with the therapist’s body; and a straightforward communication, in which the therapist is alerted of the presence of trauma or danger (2004b). Panskepp and Biven expand this to consider its therapeutic implications: “therapists need to be especially adept at using their cortical 'mirror-neuron' systems to promote affectively meaningful contacts and interpretations. In other words, their bodies need to resonate and harmonize with the motional states of their patients” (2012, p. 466).

Orbach uses Winnicott’s model of the false self to conceptualize the somatic, or body self as one that is a defensive structure, developed in order to survive a series of crises (1995). Winnicott’s idea that the “compliance on the part of the infant is the earliest stages of the False Self and belongs to the mother’s inability to sense her infant’s needs” (1965, p. 143) is expanded by Orbach to understand the “false body” (1995, p. 5). Similar to the development of a false self to defend against the true self, the false body may develop and prevent the expression of the authentic sense of self or subjectivity. Orbach connects this idea of a body self in the patient to the countertransferential feelings evoked in the consultation room, and the therapist’s experience of their own body (1995). Writing in 1969, Mintz described a method for integrating limited use of physical contact in psychoanalysis as a form of communication. In describing two cases, she writes: “with both [patients] I was aware of feelings of respect and warmth. If I had utilized touch merely as an impersonal therapeutic stratagem, or if I had actually experienced the sense of physical revulsion which both patients projected, I am sure that they would have perceived my gesture as false and responded with catastrophic mistrust and increased self-loathing” (Mintz, 1969, p. 374). Without using the term countertransference, she based her understanding of the therapeutic value of this practice on her own experience of the interaction. In Mintz’s experience, psychoanalysts who would offer patients a handshake, a touch on the shoulder, or a congratulatory embrace, may continue to consider such demonstrations incorrect “because they may contaminate the transference and block the development of its negative aspects altogether” (1970, p. 232). She countered this by explaining that withholding touch may be damaging for a patient, but that its use must be

carefully applied. The therapist’s own self-observation is an important piece of information: “Use of physical contact, then, seems to require not only an understanding of the patient's psychodynamics and an awareness of the probable effects of touch at that moment, but also a readiness for touch on the part of the therapist…” This understanding is based on “understanding of the patient, a reasonably-confident anticipation of the effect of the therapist's activity, and a reasonable degree of personal ease and comfort in the therapist” (Mintz, 1970, p. 234).

Using countertransference in deciding whether to touch. A therapist may become aware of a feeling in the countertransference that reinforces a plan to use touch or encourages the spontaneous expression of a touch gesture. Without specifically using the term, Brafman explores how countertransference may have played a role in Winnicott’s use of touch. He revisited the story of Winnicott visiting an ill patient at home, considering that Winnicott may have been responding to the patient’s ability to sense his need to care for her (Brafman, 2006). McNeely also explores how countertransference could affect the decision to use touch. She acknowledges that while the motivation to use touch may be related to the therapist’s internal issues, if done thoughtfully and carefully, it can be therapeutic within the psychotherapy session. McNeely writes, “This is no reason to eschew touching. It means, however, that the therapist’s goals and reasons must be absolutely clear and uncomplicated by his or her own personal needs” (1987, p. 78).

Countertransference feelings may also cause a therapist to limit their use of touch. Writing on the transference phenomenon with schizophrenic patients, Searles notes that the therapist’s own feelings about touch may affect its use or avoidance in session. He writes: “A therapist who is neurotically afraid of physical contact with people, including schizophrenic patients, to that degree complicates the recovery process in the patient; but so does the therapist who recurrently needs to reassure himself of his own living humanness, his own capacity for feeling, by a dramatically ' curative ' employment of physical contact with the patient” (Searles, 1963, p. 273). Bar-Levav, decades later, echoes this first point about avoiding touch because of the therapist’s concern about enactments or a perception of inappropriate conduct. He emphasizes that the therapist may be projecting this into the treatment, explaining that: “Forbidding touch on the basis of the possibility of stimulating an erotic transference essentially reflects the fears in the therapist” (Bar-Levav, 1993, p. 7). Searles elaborates on the second point, the danger of using physical contact to gratify the therapist’s insecurity: “In the latter instance, it is only ostensibly the trembling and frightened patient who is being helped by the therapist's reassuring touch; covertly the patient is thereby reassuring the therapist of the latter's own capacity for life and lovingness” (Searles, 1963, p. 273). Bosanquet believed that analysts may fear touch when the regressed patient has returned to the “as-if situation.” She asked: “Are we afraid of touching or being touched by our patients when they are not so regressed and infantile? Are we afraid that we might get too involved and unable to analyse?” (Bosanquet, 1970, p. 43). In order to understand her own question, she applied Fordham’s vision for countertransference: “The

analyst’s reactions, he says, must be included in all procedures; and ‘all valid techniques are personal interactions between analyst and patient’” (Bosanquet, 1970, p. 43, quoting Fordham, 1969). Spotnitz emphasizes the dangers of using touch for the therapist’s gratification, and also sees the “analyzing out” of subjective touch countertransference as a way to maintain an objective therapist’s role, to “respond purely in terms of the realistically induced feelings, the predictable and appropriate response of the emotionally mature observer and facilitator of meaningful change” (1972, p. 462). The therapist’s countertransference may be expressed in a negative type of touch. In their focus on the ethical use of touch in psychotherapy, Hunter and Struve (1998) define formulations of countertransference arising from therapeutic treatments involving touch. They describe perpetrator countertransference, which arises in reaction to a perpetrator transference from a client; victim countertransference, when the therapist feels victimized by the client; authoritarian countertransference, when the therapist may be nurturing or idealized; therapist as client countertransference, where the therapist may wish to be healed by the client; and sexual and voyeuristic countertransference. All of these are considered situations in which the use of touch in psychotherapy would be nontherapeutic and inappropriate (Hunter & Struve, 1998). Haiman offers an alternative interpretation of the transference-countertransference dynamic when physical touch is involved. What would be understood exclusively as a transference communication could be recognized as also serving as a direct communication to the therapist about the patient’s needs. This would then be

“accommodated, rather than analyzed” (Haiman, 2004, p. 78). In this model, the countertransference could be used to guide the therapist’s participation in that accommodation.

Countertransference in response to touch. Therapists who write about the use of body-based psychotherapeutic techniques do describe their own physical reactions to the patient. In his study of character and body movement, Reich defined a somatic countertransference experience: “The patient’s expressive movements involuntarily bring about an imitation in our own organism. By imitating these movements, we ‘sense’ and understand the expression in ourselves and, consequently, in the patient” (2013, p. 362). Reich names this the character attitude, which he defines as the total impression that the organism of the patient makes on the therapist (1972). Warnecke, a British relational body psychotherapist, writes that touch in therapy simultaneously involves biodynamics, working with the body, and psychodynamics, working with the transference (2011). Using touch is thought to intensify the relational interaction and offer information to both therapist and patient; what Warnecke calls body transference phenomena reflect internal states of both therapist and patient that may be “dissociated, unintegrated and disembodied” (2011, p. 238). In this type of work, the therapist relies on intuition to guide the use of touch and may experience therapeutic touch as a transitional phenomenon.

McCormick explores the idea of how physical contact in session affects the psychologist initiating the touch. He suggests that “the criterion of determination should be whether it was intended as a touching service or a taking” (McCormick, 1973, p. 200). He also explains how countertransference reactions can be useful, regardless of their content: valuing the information in itself as information, “Every shred of material regardless of its cultural ‘tag,’ is useable” (McCormick, 1973, p. 200). In exploring the role of physical touch in psychotherapy, Kupfermann and Smaldino (1987) emphasize its effect on transference and countertransference. They note that touch was not initially used in psychoanalysis because it would reify the analystpatient relationship, which could prevent expression of unconscious content by the patient. However, they also theorize that in a context of safety, touch can be used as an adjunct form of therapy that can help reintegrate a fragmented ego. Hunter and Struve, researchers on the ethical use of touch in psychotherapy, note that in incorporating touch into psychotherapy, it is imperative to deal openly with transference and countertransference as they "are inherently present in all human transactions and, therefore, they are natural and expected within any therapeutic relationship" (1998, p. 246). Ashton echoes this in her work on intentional touch in psychotherapy: “The main concern here should be how to work successfully and skillfully with these feelings that are brought up through touch, not to avoid touch because it brings up feelings” (1999, p. 4). Halbrook and Duplechin wrote a set of guidelines for practitioners on the use of touch in psychotherapy in 1994. They note that while touch can be a powerful therapeutic

intervention, therapists must be aware that impacts the therapist-patient interaction in that it “alters the content of the transference” (Halbrook & Duplechin, 1994, p. 43). Berendsen emphasizes the importance of awareness on the part of the therapist, emphasizing that the therapist “needs to be attentive to his/her own body” (2017, p. 96) in order to ensure that transference and countertransference processes do not threaten the therapeutic work. A 1986 article for counselors summarizing the role and use of touch in psychotherapy encourages therapists to use therapeutic touch “If the counselor is clear about the goal of touching and avoids countertransference feelings” (Willison & Masson, 1986, p. 499). Goodman and Teicher suggest that touch can be useful with patients who have not differentiated and integrated into “separate, related and autonomous human beings” (1988, p. 495). While not explicitly stating how touch affects countertransference, Gelso and Hayes discuss therapist self-disclosure of countertransference reactions, and its various effects in clinical treatment. They write: “self-disclosure may be considered akin to the use of touch in therapy: a double-edged sword that can be either of great benefit or damage, depending on its use” (Gelso & Hayes, 2007, p. 123). Countertransference can be impacted by the therapist’s observations about the patient’s body; Cash and Pruzinsky (1990) note that this can be helpful information about the patient’s emotional state, and that monitoring the therapist’s experience is important in the service of psychological change. Gabbard also notes how the therapist takes in observations of the patient’s reactions in treatment: "nonverbal correlates, such as tensing of muscles, changes in breathing, or shifts in body posture, often are used as illustrations” (2001, p. 988).

LaTorre describes how taking in the whole system and experiencing consciousness within the entire body “enhances the exchange and deepens rapport” (2000, p. 68). Durana, in researching the use of touch in psychotherapy, defines countertransference narrowly, as a distorted perception about the client that is based in unresolved parental attachments on the part of the therapist (1998). He writes that touchrelated transference and countertransference experiences can arise that become nontherapeutic. Cautioning that a lack of therapist congruence can contribute to negative feelings in the patient, Durana emphasizes that therapist self-knowledge and clear ideas about physical contact are critical. To mitigate the risk of the therapist’s personal reaction negatively impacting the treatment, Durana suggests that the therapist receive touch in their own therapy, in order to “integrate somatic, feeling, countertransference, and energetic cues, using his or her countertransference reactions (perceptions, feelings, fantasies) as cues to guide his or her work with touch” (1998, p. 276). Bonitz (2008) echoes this caution, encouraging the therapist to become comfortable with touch and explore his or her own issues surrounding physical contact, before using it clinically. Karbelnig warns that physical contact may cause the concretizing of countertransference, in which therapists may interpret romantic feelings towards patients as real, as opposed to symbolic (2008, p. 33). In contrast, Carere-Comes actively uses physical touch in the service of the transference-countertransference matrix development, confident that catalyzing the erotic transference-countertransference matrix results in

“deep formation or transformation work” (2007, p. 107). without risking a sexual enactment. McGuirk also explores how using touch in treatment may affect the therapist. Noting that touch in psychotherapy presents risks, she emphasizes that “it is not possible to touch and hold a client without exploring the impact on the therapist and his own attitudes, motives and perceptions towards touch (2012, p 11). She acknowledges the possibility of the therapist experiencing pleasure at physical contact with the patient, writing: “though this may not be the objective of the therapist at the outset, as it is the client’s process and healing that must be facilitated, the therapist also receives, unintentionally perhaps, but simultaneously” (2012, p. 11).

A relational understanding of the effect of touch on countertransference. Stone describes an experience of connection in the intersubjective space created by the therapeutic dyad, describing the interaction in terms that seem biophysical: “Resonance occurs when the analyst’s bodily tuning fork vibrates with the patient’s psychic material through the unconscious” (Stone, 2006, p. 115). Charles sees countertransference as empathetic resonance, writing that “our primary instrument for encountering and reading these nonverbal elements is our own affective responsiveness; our countertransference” (Charles, 2004, p. 102). The therapist may experience the patient in a way that offers nonverbal information about the patient. Rumble describes the "intersubjective nature of the body image" that offers the therapist a sense of the other's body, and of the function of the body for housing thought and for containment (Rumble, 2010, p. 138). Orbach sees the

utility of reminding the clinician of the “intersubjective aspect of the therapist’s body” and continues that “it allows us to further the work so that we can use the powerful body countertransferences to help transform the very anguished bodies that are our patients’ experience of their corporeality” (Orbach, 2004b, p. 149). Samuels explores the division between the interpersonal relationship and the interpsychic image, suggesting that integrating imagery and relationship serves to enhance the understanding of the internal world (1989/2016). Instead of separating images and communications, Samuels suggests that “the coin is three-sided: to body and image can be added relationship” (1989/2016, p. 174). In considering the evolution of modern psychoanalytic treatment, Toronto emphasizes that the breadth of psychoanalytic thinking requires consideration of the impact of physical contact. While handshakes and hugs occur in practice, they had not been as openly discussed as other aspects of the therapeutic interaction. She explains how the model of two-person relational psychoanalysis had led to the redefinition of the analyst’s role: “the clinician's responses to the patient have come to be viewed as important pieces of data that must be explored and understood as vital parts of the treatment process” (Toronto, 2001, p. 38). McLaughlin also addresses the fact that touch does occur, even in psychoanalysis. He explores the generative possibility of touch in psychoanalysis, concluding that an openness to its use may be therapeutic, and related to the countertransference. He writes: “this work of retrieval is more readily addressed when the ongoing analytic stance

enhances a synergism by which both may transcend old expectations, and find expanded dimensions of themselves” (McLaughlin, 2005, p. 181). Asheri explores the use of touch from a relational psychoanalytic perspective. Referring to Benjamin’s definition of intersubjectivity, she emphasizes the need for recognition and a capacity to recognize others in return. Asheri writes: “We cannot deal with the question of touch without taking into account our understanding of the therapeutic encounter as an embodied intersubjective engagement. As such, we have to consider the question of ‘touch’ as an integral part of negotiating the paradoxical tension between attending to the intrapsychic dynamic within both participants and the interpersonal dynamic between them” (2009, p. 108). Also understanding touch as communication, Diamond considers touch a form of language. She emphasizes the importance of exploring the analysand’s tactile attachment relations as well as the analyst’s relation to touch “so that countertransference experience can be reflected upon continuously” (Diamond, 2006, p. 91). In her conceptualization of the body in psychoanalysis, Diamond writes that she agrees with Fonagy that non-verbal memory cannot be accessed verbally in analysis, but “that non-verbal memory reveals itself in bodily expression and in enactments of transference or countertransference” (2013, p. 195). Relational theorists who do not use touch, but consider the body, use similar language in processing the countertransference experience. Knoblauch describes the use of “expanded therapeutic attention on the part of the analyst” that results in an “embodied nonsymbolic level of countertransference experience” (2008, p. 200). This creates space

for the session to reach a tipping point, a “micromoment” which represents the catalysis resulting in a shift in the therapeutic process (Knoblauch, 2008, p. 207). Aron emphasizes that the relational focus “implicates bodily interaction and somatosensory experience” and “deconstructs the dichotomy between verbal (mental) and preverbal (bodily) experience; it recognizes the ongoing interaction of language and the body in constructing human subjectivity and intersubjectivity” (2015, p. 24) McDougall writes that countertransference can be used when the analyst feels that the analysand’s speech “is a meaningless communication at all levels, or he may be aware of being invaded with affect that does not seem directly attributable to the content of the patient’s communication” (McDougall, 1993, p. 100). This sense of invasion could be understood through the countertransference.

Considerations Cultural and gender considerations. Cultural considerations are critical for understanding and evaluating the use of touch and its impact in psychotherapy. Pallaro writes: “cultural transference and countertransference are co-created by both the patient and therapist, reflecting not only each of their internalized self-object relationships, but also their sociocultural heritage, diverse family-of-origin environment, and membership in a dominant or minority group” (2007, p. 180). Socialization and culture influence views of bodies and bodily practices; social class also impacts mobilization and movement (Carey & Green, 2013). White (2002) notes that in comparison to European cultures, Americans tend to abstain from

touch in general, and professionals including teachers avoid touch due to fear of litigation. Countertransference itself has long been discussed in relationship to the characteristics of both patient and therapist: Strauss wrote that “fundamental problems and conflicts of the patient will emerge and be worked through in the course of analysis, irrespective of the analyst’s sex” (1960, p. 26). Sandler, Holder and Dare note that gender of the analyst plays a role in transference-countertransference in child analysis, and that analysts working with older patients may experience a countertransference manifestation equating them with their parents (2018). In her summary of the use of touch in psychotherapy, McGuirk writes: “the relationship to touch can only be understood when considered in the context of the phase of therapy, the client’s gender, culture, presenting issues, personality and their history and relation to touch. What is clinically appropriate with one client could be clinically damaging to another” (2012). Cultural differences may also play a role in the effect of touch in psychotherapy on countertransference. Soth calls the therapeutic relationship “an intersubjective, culturally contextualized system of complex parallel body/mind processes” (2005, p. 40). In a 2013 doctoral dissertation, Ruiz describes a qualitative study based on interviews with six Latina women whose female therapists used non-erotic touch in the psychotherapy session. This grounded theory research contributed an understanding of the client’s perspective to the literature; the author emphasizes that “culture plays an important role when it comes to norms related to touch” (Ruiz, 2013, p. 5).

Touch practices vary by geographic region, relationship, context, age and social class, gender and sexuality (Green, 2017). Green also emphasizes the effect of stereotypical gender roles, homophobia and constructions of masculinity, and notes that “gender and linked (perceived) sexuality may affect both a willingness to touch and differential intentions and receptions” (2017, p. 780). Touch by male therapists with female clients may have implications that it may not have with male clients, or with female therapists; feminist authors attribute much of women’s psychological distress to discrimination and sex-role stereotypes (Stenzel, 2002). A study of attitudes toward touch in therapy among psychologists in India revealed that female therapists were more comfortable with touch and more likely to use touch in therapy; the researchers hypothesized that this may be influenced by traditional Indian gender roles and attitudes about homosexuality, power and social position (Joshi, Almeida & Shete, 2010). The social construction of touch in social work involves class, culture, understanding of the body and of private space, habits and rituals; “Cultural and historical norms, and personal preferences and experiences, alongside physiological predispositions, therefore all intersect and impact upon how touch is applied, intended and received (Green, 2017, p. 782).

Use of touch with vulnerable populations. In addition to the general considerations about use of touch in psychotherapy, there are additional concerns when working with vulnerable populations. In treating

trauma survivors, Aposhyan (2004) emphasizes that embodied transferencecountertransference reactions are a critical component of using touch therapeutically. Novak (2018) writes that with traumatized populations, therapeutic touch can serve as a nonverbal, physical anchor, and a relational body experience. Novak (2018) presents a model of informed physical contact in psychotherapy that is designed to be appropriate for patients with a history of trauma and dissociation. Suggesting that transactional analysis could be used to overcome the challenge of privileging the mind over the body in psychotherapy, he suggests four categories of touch that could be considered as therapeutic: pass-by touch, completion touch, containinginforming touch, and somatic mastery and modulation. Pass-by touch includes social rituals such as handshaking that may be incongruent with the session or mask emotions. Completion touch could also be a social ritual, but “creates a physical connection between the therapist and client that integrates the physical body into the work” (Novak, 2018, p. 21). Containing-information touch provides information about the patient’s emotions and somatic sensations, while somatic mastery and modulation refers to the specific forms of physical contact used in body work and body psychotherapy. In considering the use of touch, Kamradt suggests a decision-making model that considers the four issues of legal, clinical, ethical and risk-management (2017). She reminds the reader that “’informed’ consent explicitly implies that the client has a comprehensive understanding of all aspects of the treatment in which they will engage, and in this case, the therapist may choose to reiterate and confirm that the client indeed is

comfortable with the use of touch” (Kamradt, 2017, p. 29). This understanding could be a challenge for patients with cognitive challenges, with populations who have experienced trauma, or when a patient is not empowered to ask for clarification. A review of lawsuits against social workers insured through the National Association of Social Workers over the previous twenty years showed that 18.5% alleged some form of sexual impropriety (Reamer, 2017). Reamer distinguishes boundary violations that could result in legal action from boundary crossings involving touch that are not necessarily unethical. Cautions raised by Reamer include situations when clinicians are not specifically trained in touch and lack competence; or when their use of touch is not based on evidence and may be harmful to the client (2017). Guidance for social workers using touch in therapeutic situations includes keeping in mind the principles of autonomy, beneficence, nonmalificience, and virtue ethics; asking about the presence of physical and sexual abuse in their histories is also critical (McKinney & Kempson, 2012). Because of the power differential in the therapeutic situation, patients in general are considered vulnerable; “a negligent intervention by the clinician can cause lasting injury to the emotionally exposed client” (Smith & Fitzpatrick, 1995, p. 501).

Research Research approaches to understanding countertransference and touch in psychotherapy. Because the use of touch had traditionally been discouraged in psychotherapy, therapists may have been reluctant to disclose whether they use touch in their practices.

This could have limited the number of research studies that explore the effect of touch in the psychotherapy session. In addition, some of the earlier research focused on students and was not generalizable to therapist-patient relationships (Milakovich, 1998). Much of the earlier research explored the use of erotic or non-erotic touch, especially in relationship to intimacy and power (Alyn, 1988). This research often focused on boundary crossings rather than on the therapist’s experience of therapeutic, appropriate touch. While there are few studies that specifically explore how the therapist’s countertransference is affected by physical touch in the session, several research projects have considered the therapist’s subjective experience of touch in psychotherapy. Researchers using qualitative methodologies have studied countertransference by analyzing patterns (Eizirik, 1991), and comparing session summaries (Windholz & Skolinkoff, 1985). Qualitative research methods for studying body countertransference have included grounded theory (Shaw, 2004); qualitative research methods on the use of touch in psychotherapy has included critical incident technique (Moy, 1980), and interviews and exploring common themes (Geib, 1982, Milakovich, 1993, Tune, 2001). Qualitative methods for exploring the therapist’s experience with body-based psychotherapy have included interviews (Webster, 2002, O’Hearne, 1972, Pinson, 2002, Clance & Brown, 2001, Grant, 2007, Fox, 2009), pragmatic case studies (Kaplan, 2006), phenomenology (Perlman, 2012), and grounded theory (Haiman, 2004). Quantitative studies evaluating the countertransference experience were generally based on questionnaires and scales that were sent out as paper surveys to specific groups of therapists; more recent studies use surveys that are completed online. These have

included questionnaires on attitudes (Tirnauer, 1996), trait inventories and empathy scales (Hayes & Gelso, 1991), countertransference factors inventory (Gelso, 2002), specific countertransference (Harmell, 1987), impact message inventory (Kiesler, 1996), a countertransference checklist (Holmqvist & Armelius, 1996), and an assessment of countertransference scale (de Moura Silveira et al, 2012). Quantitative tools to study body countertransference have included the body awareness measure (Forester, 2000), Egan and Carr Body-Centered Countertransference Scale (Booth, Trimble & Carr, 2010), the Need for Interpersonal Touch questionnaire (Nuzbaum et al, 2014), and the Body Consciousness Questionnaire (Miller, Murphy & Buss, 1981). Quantitative data on the use of touch in psychotherapy has been collected through questionnaires (Holroyd & Brodsky, 1977, Stenzel, 2002, Cassatly, 2003, and Cook et al, 2010). Quantitative studies on attitudes toward the use of touch in psychotherapy have used the Mind-Body Therapies Beliefs and Practices Survey (Schwartz, 2008), as well as specifically designed questionnaires (Suiter & Goodyear, 1985, Gartrell et al, 1986, Clance & Petras, 1998, Fosshage, 2000, Schultz, 1975, Norcross, 1987, Borenzweig, 1983, Strozier et al, 2003, and Waddell, 2010). Mixed-methodology studies in this area have generally used questionnaires and a thematic analysis of in-person or distance interviews (Kearney, 2016, Horton et al, 1995).

Quantitative surveys on attitudes towards countertransference. Previous research on countertransference includes a number of quantitative surveys about attitudes towards countertransference in psychotherapy. The American Academy of Psychotherapists conducted a membership survey in 1995 and included a

question about countertransference. In a randomly selected sample of 128 independently practicing, experienced psychotherapists from various fields, almost three-quarters of the therapists “were of the opinion that there are no inappropriate feelings for therapists to experience” (Tirnauer et al., 1996, p. 90). Hayes and Gelso (1991) observed 35 psychotherapy trainees in session and found that state anxiety, which includes feelings of apprehension, nervousness and physiological sequelae, was related to countertransference in male trainees, as measured on the Trait Anxiety Inventory (STAI; Spielberger, Gorsuch & Lushene, 1970) and BLRI Empathy Scale (Barrett-Lennard, 1962). One of the authors later designed the Countertransference Factors Inventory (CFI) and evaluated the relationship between countertransference scores and therapy outcome by considering five characteristics: selfinsight, self-integration, anxiety management, empathy, and conceptualizing skills (Gelso et al, 2002). A specific countertransference scale was used by Harmell for doctoral research on the correlation between countertransference, therapist experience, theoretical orientation, and therapist self-awareness. The countertransference subscales explore unpleasant feelings, dislike of patient, and detachment of patient (Harmell, 1987). This 70-item questionnaire, developed by Reifsnyder, was completed by 113 practicing PhD-level psychologists; one of its findings was that psychoanalytically-oriented therapists had most awareness of desire to be directed and controlled by others, and least dislike-ofpatient countertransference (Harmell, 1987). Harmell does note that the subscales contain only negative countertransference items, and that positive countertransference may be an important factor to evaluate in studying therapist self-awareness.

Kiesler suggests using an Impact Message Inventory to quantify a patient’s objective (generalizable) countertransferential reaction. For subjective countertransference, Kiesler writes that the focus has been on inventories that can capture aspects of the “occurrence within therapy session of moments of therapist anxiety, of a therapist’s rigid approach or avoidance behavior in regard to certain topics being discussed by the patient, or of a therapist’s continual avoidance of transference interpretations in response to various aspects of the patient’s discourse” (Kiesler, 1996, p. 231). Holmqvist and Armelius created an empirical model to understand sources of therapists’ countertransference feelings by developing a “feeling words” checklist and assigning feelings to the therapist’s personal style, reciprocal feelings, or the unique emotional interaction (1996, p. 71). Multiple staff members working with individual patients completed a questionnaire about their reactions to those patients, and data was analyzed using a principal components model. They found that helpfulness and other generally valued feelings emanated from patients, while closeness and other feelings were connected to the style of the therapist. De Moura Silveira et al expanded on this research with the development and validation of an Assessment of Countertransference Scale with Brazilian psychiatry residents who work with trauma victims. The scale clusters feelings into three categories: closeness, distance, and indifference; these were then modified for the updated scale to rejection, closeness and sadness (de Moura Silveira, 2012, p. 203).

Qualitative research on attitudes and experiences of countertransference. Eizirik et al. (1991) analyzed patterns of countertransference reactions in brief dynamic psychotherapy and created a list of countertransferential feelings. Therapists recorded their sessions with six individual therapy patients, evaluating their own countertransferential feelings both individually and in a group discussion setting. Another approach to measure countertransference was developed by Windholz and Skolinkoff. They compared how a listener understood verbal reports on daily analytic sessions with the analysts’ written summaries of the sessions, believing that discrepancies between the two reports revealed the analyst’s countertransference (1985).

Quantitative research on body countertransference. Body countertransference has also been specifically studied. In terms of quantitative tools, there are several validated scales that relate to countertransference. However, many of the body awareness scales have not been demonstrated to show high levels of reliability or validity, and existing self-report instruments do not cover the range of adaptive and maladaptive aspects of body awareness (Mehling et al., 2009). A quantitative scale that could be used to assess understanding of touch is the Need for Interpersonal Touch questionnaire (NFIPT) (Nuzbaum et al., 2014). This scale connects confidence with physical touch. Another scale is the Egan and Carr Body-Centered Countertransference Scale, which assesses the therapist’s bodily or somatic reactions to patients within the therapy session (Booth, Trimble & Carr, 2010).

In a doctoral dissertation project, Forester (2000) developed two measures for assessing use of body awareness as a way of measuring countertransference: The Body Awareness Measure and Frequency of Practice (of body awareness) measure. Ninety-six clinicians responded to questionnaires and completed the measures; the author concluded that factors affecting management of countertransference were body awareness, frequency of practice of body awareness, years of personal psychotherapy, and hours and years in supervision (Forester, 2000). Occurrence of touch in the session was not a focus of the study. In another doctoral dissertation project (Schwartz, 2006), three scales were used to measure countertransference: the Inventory of Altered Self-Capacities (IASC) (Briere, 2002), the Body Awareness Measure (Forester, 2000), and the Private Body Consciousness subscale of the Body Consciousness Questionnaire (Miller, Murphy, & Buss, 1981). One hundred ten therapists and psychology interns seeing clients in therapy were recruited on websites, listservs, email and in person. Approximately half the therapists identified themselves as psychodynamic, and almost one-fourth were cognitive-behavioral; 52% of the therapists reported using somatic techniques (Schwartz, 2006, p. 66). The study did not find the predicted inverse correlation between levels of body awareness, externalization of emotion and affect dysregulation, which the author points out could be due to problems with self-disclosure and self-report, or the instruments themselves, rather than a true lack of relationship between the variables (Schwartz, 2006, p. 66). Although therapists endorsed using somatic techniques, it was not clear whether these modalities included touch.

Qualitative research on body countertransference. Shaw (2004) explored somatic experiences during the therapeutic encounter in a qualitative study of psychotherapists. Participants were studied in discussion groups, interview groups, and professional scrutiny discussion groups using a grounded theory approach. Themes that arose from the interviews included physical reactions, communication, styles and techniques, body empathy, body as receiver, and body management. Shaw found that “It is by interpreting their own lived experience through a psychotherapeutic lens that therapists produce claims to knowledge about their clients” (2004, p. 284). Several social work masters’ thesis research projects have studied embodied countertransference. A qualitative analysis of written responses revealed that clinicians aware of embodied countertransference used their bodies "as sites of inquiry and guidance” (Clarke, 2007, p. 76). Similarly, clinicians were interviewed in another project, in which it was found that therapists use their physiological reactions to patients as a clinical tool (Jakubowski, 2012). Neither project asked about physical touch in session. The European Association of Body Psychotherapy surveyed its members and found that body psychotherapy research is most often presented as case studies, but that the qualitative research is sometimes considered insufficiently objective (Young & Grassmann, 2019). It was also recently found that body psychotherapists generally work in private practice so that research is conducted by smaller groups of individuals than in large studies, and that an area of focus is “relational embodiment” (Jokic et al, 2019, p. 82).

Quantitative research on the extent of use of touch in psychotherapy. Research on the use of touch by psychotherapists has mainly consisted of anonymous surveys and case studies. In an early study, Holroyd and Brodsky conducted a nationwide survey of 666 PhD psychologists practicing psychotherapy by postal mail. About half the respondents believed that non-erotic physical contact may be beneficial to patients; this differed greatly by theoretical orientation. Only 6% of psychodynamic psychotherapists thought that non-erotic physical touch might be beneficial to patients frequently or always; 68% felt it would rarely or never benefit patients (Holroyd & Brodsky, 1977). In a 2002 doctoral dissertation, Stenzel investigated the use of touch in verbal psychotherapy by psychologists. This project used a mailed questionnaire that was completed by 470 psychologists in the United States; its results revealed that touch in psychotherapy could be categorized into “Touch as an Expression of the Relationship, Socially Stereotyped Touch, and Touch as Technique” (Stenzel, 2002, p. x). Gender of therapist and client was shown to play a role in whether touch was used; most frequent types of touch were handshakes, accepting a hug, and touching a client’s shoulder, arm, or upper back (Stenzel, 2002, p. 78). Although Stenzel does not discuss countertransference specifically, 3.8% of respondents reported ending psychotherapy with a client “because of discomfort with physical contact in therapeutic relationship” (Stenzel, 2002, p. 80). In a later publication of the same data, the conclusion is that frequency of touch in session is low, but occurs enough to warrant greater attention (Stenzel, 2004).

Cassatly also researched the use of touch in psychotherapy by psychologists in a 2003 doctoral dissertation. A questionnaire was filled out by 650 licensed psychologists across the United States; 90% of respondents stated that they ever had used touch with clients (Cassatly, 2003, p. 64); 73.1% stated that they believed it could be therapeutic and 85.7% believed it to be ethical (Cassatly, 2003, p. 65). Countertransference was not explored in this study. Although they did not specifically ask about the use of touch in psychotherapy, Cook et al conducted an internet study of psychotherapy modalities in 2010 that revealed how infrequently practitioners indicate that they use body-based treatments. In a survey of 2,739 subscribers to the Psychotherapy Networker magazine, only about one percent said they used body therapy techniques half or more of the time. The question, however, only allowed respondents to choose among the categories of none/some; half; or most/all (Cook et al, 2010). It may be that this questionnaire did not capture the actual use of touch in session because of the wording of the questions and intent of the survey.

Quantitative research on attitudes towards the use of touch in psychotherapy. Beliefs about mind-body therapies among psychologists were studied in quantitative dissertation research by A. Schwartz in 2008. The survey of 96 professional psychologists in the United States was conducted by postal mail and consisted of four questionnaires: a Mind-Body Therapies Beliefs and Practices Survey; a Theory of Planned Behavior Questionnaire; the Marlowe-Crowne Social Desirability Scale-Short form 1; and a Background Information Questionnaire (Schwartz, 2008, p. 86). Results

indicated that only a small percentage of psychologists used techniques that involved touch (Schwartz, 2008, p. 145); most of the mind-body techniques considered involved breathing, meditation, or other mindfulness practices not requiring physical contact. One measure specifically examined touch but did not explore therapists’ countertransference surrounding touch practices. In an exploratory study with 120 counselors in 1985, Suiter and Goodyear found that physical contact through semi-embraces led to negative perceptions of the therapeutic interaction. Gartrell, Herman, Olarte, Feldstein & Localio surveyed psychiatrists in 1986 and found that 68% of them were willing to hug patients (1986). Clance and Petras collected data on the decision-making process for therapists about which patients they would touch (1998). Fosshage conducted an informal survey in 2000 of psychoanalyst peers, and found that of 30 surveyed, all 30 were willing to hug patients. Psychotherapists may have different perspectives on touch based on their disciplines. Schultz surveyed clinical social workers in 1975 and found that 65% approved the use of touch in psychotherapy. A survey of 319 psychologists in the 1980s found that existential psychotherapists were more likely to use physical contact than behavioral or psychodynamic therapists (Norcross, 1987). Hypothesizing that adherence to Freudian position limited the use of touch in therapy, Borenzweig investigated the factors that influence the use of touch by the clinician in 1983. He sent 196 questionnaires to a random sample of clinical social workers from the California Registry of Social Workers and analyzed the 87 responses. The theoretical orientation of over half the respondents was given as eclectic (53.5%); he

also found that 50% used touch in their practice, while 83% were positively oriented to touching (Borenzweig, 1983, p. 240). The respondents were asked about their own feelings: 58.8% disagreed with the idea that clinicians should avoid touch “to avoid stimulating erotic feelings in themselves” (Borenzweig, 1983, p. 240). Borenzweig attributed this shift from earlier research to the cultural shift surrounding sexuality in the 1980s. Borenzweig also asked about therapists’ perception of clients’ attractiveness and whether that impacted their tendency to touch clients. Of the clinical social workers, 84.4% reported touching clients “regardless of their attractiveness” which Borenzweig describes as in line with the overall tone of answers favoring “use of touching based upon differential diagnosis, in behalf of the needs of the client, not the needs of the therapist” (Borenzweig, 1983, p. 240). Reasons for using touch included reducing tension in a crisis, and moving therapy in a positive direction (Borenzweig, 1983, p. 240). Psychodynamically-oriented social workers Strozier, Krizek and Sale conducted a snowball survey of 91 clinical social workers by postal mail, asking them 30 questions about their use of touch in psychotherapy. In addition to the general question about how often they used touch in therapy, the survey included questions about the type of touch that revealed that the most common were a handshake (82 of 91 participants) and touching on the arm, shoulder or back (74 of 91 participants), followed by hugging (57 of the participants). Fewer therapists used hand holding, holding/cradling, stroking, or patting; psychoanalytic or object-relations oriented psychotherapists were least likely to report using touch frequency (Strozier et al, 2003).

In exploring the reasons for and against using touch in this study, participants mainly considered the effect of physical touch on the client. However, some write-in answers included a fear that touch would be in response to the therapist’s need, rather than the patient’s need; that it may lead to sexual feelings in the therapist; and that it may create countertransference issues (Strozier et al., 2003). Waddell conducted a quantitative study on how attachment style is associated with mental health professionals’ use of touch in practice with adult clients. An internet survey was used to query 63 full-time, master’s level psychoanalytically-oriented social workers. The results did not find a relationship between touch behavior and attachment style, but did reveal that 87.3% had used touch at some point within the therapeutic relationship, while one-third regularly engaged in touch with clients. Touch was initiated by the client in 27% of the cases, by the client exclusively in 19% of the cases, but was not initiated by the therapist exclusively in any of the cases. A qualitative question in the survey asked about the types of situations where touch was used with clients. It revealed themes about the type of touch used, the timing of touch, reasons for touching, and factors relating to gender and length of time working together (Waddell, 2010).

Qualitative research on the use of touch in psychotherapy. Conducting doctoral research in the 1970s, Moy sought to fill a gap in qualitative information about “how [the therapist] uses touch, the circumstances surrounding it, or the criteria present indicating appropriateness of touch” (1980, p. 8). Social workers, psychotherapists, marriage and family therapists, psychologists, physicians and nurses

were interviewed and data was analyzed using a 1954 instrument called the Flanagan Critical Incident Technique. Moy’s questions included: “conscious use of touch, origin of the development of the philosophy of touch, when touch is initiated, on what part of the person seeking help touch is likely to occur, intentions likely to be conveyed through touch, context factors making a difference in the decision to touch, physical setting in which touch would likely occur, circumstances when purpose of touch was misinterpreted, critical incidents involved when touch had a negative effect, and critical incidents involved when touch had a positive effect” (Moy, 1980, p. 67). In Moy’s study, all respondents stated that they make a policy to use touch consciously; 29% reported that neither positive nor negative incidents with touch in session had any effect on their philosophy of touch. For positive experiences, 54% reported that their philosophy was reinforced; for negative experiences, 14% reported that they changed behavior. Although the study was designed to answer questions and identify critical incident effects, rather than to generate themes, it included segments of interview transcripts that offer some insight into the countertransference experience of the therapists. In her doctoral dissertation research, Geib (1982) conducted a qualitative study on patients’ experience of touch in therapy, interviewing thirteen women and analyzing common themes that emerged from the analyses. One of the findings was a perception that touch may be meeting the therapist’s needs, rather than the patient’s (Geib, 1982). Horton, Clance, Sterk-Elifson and Emshoff studied patient experiences of touch in psychotherapy in 1995. In the mixed-methodology study, they used a questionnaire to capture information about the patient-therapist demographics, had participants fill out the

Working Alliance Inventory (Horvath & Greenberg, 1989), and included open-ended questions. Patients were eligible if they had a significant positive or negative experience of touch in therapy beyond accidental contact or a formal handshake. The researchers noted that it was not possible to know whether their sample was representative of the larger outpatient therapy population; in addition, participants were recruited through advertisements, therapists, and support groups (Horton, Clance, Sterk-Elifson, & Emshoff, 1995). Milakovich (1993) explored how psychotherapists made decisions about whether to use touch. Personal and professional characteristics of those therapists who use touch as an intervention within the context of their therapeutic relationships were studied. In interviews with 84 therapists, she discovered that many therapists used touch but that ‘the practice is largely hidden from the public and professional forum” (Milakovich, 1993, p. 220). In a later discussion of the same data, she cautions that teachers, supervisors and therapists impact the next generation of clinicians and “need to consider carefully whether their values stem from their own unmet needs, or from their having acknowledged and met those needs” (Milakovich, 1998, p. 90). Tune, a psychodynamic psychotherapist who initially trained in body-therapy, interviewed six British psychotherapists of different theoretical orientations, asking their perspective on whether touch is a valid therapeutic intervention (Tune, 2001). One of the major themes that emerged was the difficulty of discussing touch in session, in supervision, or in training (Tune, 2001).

Waters, in a 2010 doctoral dissertation, interviewed six therapists about their use of touch. Using a grounded theory approach, she explored influences on the therapist’s decision to use touch “when a client, explicitly or implicitly, asks to be touched or in those moments when the therapist experiences an inner urge to touch the client” (Waters, 2010, p. 47). Using the categories of personal and professional approaches to touch, emotional tenor of the sessions, and reflecting and realizations, she found a “dynamic interplay of the multilayered, multifaceted influences” (Waters, 2010, p. 112) within the therapist’s overall attitude towards touch. She concluded that “talking about their decisions to touch or not to touch resulted in increased self-awareness, knowledge, and change for the participants and the researcher, and it revealed that even the participants in the study who do not touch – touched” (Waters, 2010, p. 112). Sheret explored the use of touch among clinical psychologists in a 2015 doctoral dissertation. She used a grounded theory methodology, interviewing eleven therapists about their experiences of touch behavior in therapy. She identified variables that therapists consider in weighing whether to use touch in session, including individual characteristics of both therapist and client, and “the intended and perceived meaning of either touching or not touching and how the chosen behaviour fits within a wider professional and societal context” (Sheret, 2015, p. 142).

Qualitative research on the effect of touch on the therapist’s countertransference. Several research studies have examined the therapist’s experience of body-based psychotherapies or the use of touch in talk therapy. While not addressing countertransference directly, the research contributes to an understanding of the impact on the therapist and the clinical interaction. In the late 1960s, O’Hearne recognized the healing impact of touch in his own experience, while acting as if touch was taboo in his outpatient psychiatric practice. He interviewed over 25 group psychotherapists about their use of touch in therapy. To his surprise, most of them actually used touch in practice, and more in group therapy than with individuals (O’Hearne, 1972). In integrating his results with the literature, O’Hearne concluded that “the result of touching depended upon the metacommunication about the touch” (O’Hearne, 1972, p. 448). Webster used her own experience as a therapist who would sometimes physically hold clients as material for doctoral research on the subject. She revisited recordings of therapy sessions, talked with clients and former clients, and explored her own feelings about the work. She narrates moments in supervision where she questions her use of touch in therapy: “maybe the physical contact was an intuitive response that I allowed to be expressed” (Webster, 2002, p. 30.). This therapeutic strategy included but did not emphasize the countertransferential aspects: “In addition to acknowledging the symbolic aspects, both the transferential and countertransferential aspects of the therapy

relationship, the therapy worked with the real aspects involving the warm and personal exchange from the therapist to each client” (Webster, 2002, p. 197). Kaplan, in a 2006 doctoral dissertation, used the pragmatic case study method to study verbal and somatic interactions with clients in body-centered psychotherapy with a dually-trained practitioner (Kaplan, 2006, p. iii). She observed twelve video-recorded sessions each of three clients who were in body-centered psychotherapy with a therapist licensed in both counseling and massage therapy. This practitioner recruited three new clients specifically for the study and engaged them in psychotherapy and techniques from Rubenfeld Synergy, Hakomi, and Somatic Experiencing (Kaplan, 2006, p. 36). The focus of this research was on integrating the two modalities therapeutically for the client, rather than on the experience of the practitioner herself. Perlman used a phenomenological approach to study the experience of clinical social workers and psychologists practicing psychotherapists using therapeutic touch in a 2012 doctoral dissertation; twelve therapists were interviewed about their decisionmaking processes. Six themes were developed; “the value of touch, therapist-client relationships, function of touch in therapy, power differential, misunderstood intentions, and preparedness, highlighted the complexities surrounding the decision-making processes of therapists” (Perlman, 2012, p. ii). Five of the 12 participants felt that touch should not be used. Countertransference emerged in the discussion of decision-making, particularly in understanding whether comforting clients with physical contact would gratify the client or the therapist. Countertransference was also mentioned as a reason for avoiding touch in session (Perlman, 2012).

In a 2002 study on how therapists conceptualize touch in psychotherapy, Pinson interviewed four psychoanalysts who used touch in session with adults to explore how they decided to use touch and whether they felt it was therapeutic. The analysts acknowledged using supportive touch, or “contact that is made with the intent to comfort or strengthen ego functioning” (Pinson, 2002, p. 184). Analysts disclosed their feelings about touch in the therapy hour and gave case examples; although three of the four therapists generally disapproved of touch in session, they were able to describe cases in which the use of touch had a positive impact on the treatment. Clance interviewed psychomotor psychotherapists about their personal experiences of using touch in psychotherapy while conducting research for a book chapter on the subject. They explained how they decide whether to use touch and how to process the touch with the patients. One therapist described countertransference in this context as a means of distinguishing whether touch would be therapeutic. Several referred to Virginia Satir, who would explicitly ask the patient permission for specific physical contact (Clance & Brown, 2001). Grant conducted master’s thesis research on social workers using Reiki by interviewing six social workers or counselors trained in Reiki and three organizational representatives on their opinions about integrating Reiki and social work. Representatives from the College of Social Workers and Social Service Workers, the Canadian Reiki Association, and The Ontario Health Department were interviewed, recorded and transcribed; the researcher then summarized participants’ views on the benefits and limits of incorporating a touch energy practice into social work. Although participants “found Reiki to be a natural complement to social work” (Grant, 2007, p.

127), they also recognized the limits of integrating alternative therapies into an established health care framework. In another Master’s thesis project, Fox (2007) pursued similar research by conducting 60-90 minute interviews with four Ontario social workers who were also trained in Reiki. Therapists highlighted themes of professional identity, connecting with a patient, and enhancing their practice as social workers. Countertransference was indirectly addressed as “benefit for social workers” and included comments about deepening understanding, self care, and “sitting with not knowing” (Fox, 2007, p. 55). Haiman’s grounded theory doctoral research on the integration of psychodynamic and body-centered therapies consisted of interviews with dually-trained psychotherapists (2004). Haiman recruited eight psychodynamic or psychoanalytic psychotherapists who were trained in psychotherapy and a body-based therapy. Haiman describes each of the eight participants in a narrative; some began as psychotherapists, while others trained first in mind-body methods. The interview themes presented center on reasons for integrating the body methods with psychotherapy, the patient’s experience, and the therapist’s countertransference. In interviews, participants who felt their body-centered work supported psychodynamic theory and practice told Haiman that “they felt that transference and countertransference reactions were amplified in body-centered work.” (Haiman, 2002, p. 75). The clinicians also said that they made use of somatic countertransference “listening for and interpreting their own bodily reactions as relevant to the clinical encounter” (Haiman, 2002, p. 75). Participants who differed with psychodynamic theory did not

acknowledge expressing or working with somatic countertransference, indicating that the psychodynamic orientation may play a role in the therapist’s assessment of the importance of countertransference in the treatment. Haiman also notes that instead of interpreting the patient responses as transference, they were taken as direct communication to the therapist about the patient’s needs.

Theoretical concepts of the meaning of touch in psychotherapy. Researching therapists’ understandings on how touch impacts countertransference invites subjective interpretations about the process, the therapist’s motivation, and the perceived results. Pope et al. (1987) conducted a survey of psychologists’ practice patterns which revealed that hugging a client happened rarely or sometimes, and that offering or accepting a handshake happened fairly often or very often. The researchers suggest that this could be related to the struggle to express respect to the client. They cite a theory proposed by Thompson in 1950: that therapists’ behaviors are unnaturally formal because of a fear that the analyst might show countertransference (Pope et al., 1987). In his 1983 study exploring the use of touch among social workers, Borenzweig found that clinicians with a Freudian orientation “refrained from using touch to establish

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basic trust” (p. 241), while those with other orientations believed that touching clients was unrelated to countertransference reactions (p. 241). From the perspective of contemporary interpersonal analysis, the analyst engages in the interaction: “The analyst is regarded as having interpersonal needs, anxieties, and security operations that are inevitably evoked in interactions with the patient. Because the present is given relatively more weight than the past, the analyst seen less as a semidetached observer of the patient’s operations and more as a full participant in interpersonal patterns they create and maintain together” (Mitchell & Black, 1995, p. 79). Touch can also be seen as diagnostic in therapy, assessing the capacity to give and accept affection; it can also be used as a somatic listening tool (Hedges, 1983). Touch has been described as a change agent (Older, 1977), and as a means of decreasing space (Fagan & Silverthorn, 1998). It is thought to provoke an increase in client self-disclosure (Pattison, 1973). Westland cites Weber’s model for understanding touch in psychotherapy. The physical-sensory perspective focuses on the physiological, technical use of touch. The psychological-humanistic perspective relies on phenomenology and existentialism, and takes into account subjectivity and feelings, and is reciprocal. The field perspective is an energetic understanding of how intention, energy, and attunement impact the interaction of two individuals (Westland, 2011, p. 18). In summarizing the use of touch in psychoanalysis and psychotherapy, Schlesinger and Appelbaum look to the future with the idea that “Those who will develop analytic technique for the expanding population to be served in the coming millennium

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will have to recognize that sometimes words alone are not enough” (2000, p. 140). On the motivation to research this topic, Borenzweig wrote: “The conventional wisdom- the psychoanalytic theoretical base-would predict against touching being practiced in clinical social work. But-given its importance to growth, trust, and therapeutic love-I knew it had to be there” (1983, p. 239).

Literature Review Summary This research project is designed to expand the theoretical understanding of the clinical phenomena of countertransference in response to touch. An extensive review of the literature reveals that traditional psychoanalytic and psychodynamic psychotherapy has evolved from a strict prohibition on touch and disavowal of countertransference to a more nuanced understanding. Some theorists have developed ideas to understand the role of countertransference in session, while others explore the therapeutic value and risks of incorporating physical touch into psychotherapy. The literature on the intersection of these concepts is still developing. This work aims to add information about the particular subject of the impact of touch on countertransference in both a quantitative and qualitative way.

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Chapter III

Methods Research Questions and Major Approach This mixed-methodology study asks: how does intentional physical contact or touch within the psychotherapy session impact the psychotherapist’s countertransference? The quantitative phase of the research, an anonymous web-based questionnaire, is designed to assess the scope of the use of touch in session among psychodynamically-focused clinical social worker psychotherapists. The qualitative phase is a phenomenological study of the experience of touch in session, its meaning for the therapist, and its effect on the therapist’s countertransference. Quantitative Research Questions: 1.

How widespread is the use of physical touch in the psychotherapy

session among psychodynamically-oriented clinical social work psychotherapists? 2.

What characteristics are associated with attitude towards the use of

touch in the psychotherapy session by psychodynamically-oriented clinical social work psychotherapists?

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Qualitative Research Questions: 1.

How will the experience of touch in the psychotherapy session be

described by psychodynamically-oriented clinical social work psychotherapists? 2.

What meaning is ascribed to the experience of touch in the

psychotherapy session by psychodynamically-oriented clinical social work psychotherapists? 3.

Does touch in session impact countertransference as understood by

psychodynamically-oriented clinical social work psychotherapists?

Rationale for research design. A mixed methodology design was chosen for this study to explore the problem from multiple perspectives using different sources of data, and to create context for potential contributions to psychodynamic theory. The focus of this research is psychodynamically-oriented clinical social work practice: a mixed-methodology design offers the opportunity to explore the scope of the occurrence of touch in psychotherapy, and to understand the experience and the meaning therapists ascribe to touch in session. This mixed methodology framework, in which quantitative and qualitative sources of data are integrated, increases insight into the research question and strengthens the study (Rubin & Babbie, 2016). In mixed methodology studies, distinct sets of data are collected and analyzed using different approaches, which results in a perspective on the research problem that is

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both broad and deep in its exploration. The use of mixed methodology to study the countertransference effect of intentional physical touch by the psychodynamic psychotherapist within the therapy session creates an opportunity for more meaningful understanding than either approach alone. The congruence and completeness that are more possible with this design may lead to a “multidimensional understanding” (McLafferty et al., 2010, p. 59). By integrating findings from the quantitative questionnaire and the qualitative interviews, this project contributes to understanding an aspect of psychodynamically-focused clinical social work that is frequently not discussed or acknowledged. Mixed methodology research invites multiple worldviews, beliefs and values (Creswell & Plano Clark, 2018). Participants were included in this study not for their stance on the use of touch in psychotherapy but based on their identification as psychodynamically-oriented clinical social worker therapists open to discussing the topic. They expressed a range of ideas about touch and attitudes towards touch in the psychotherapy session. The research process was intended to capture commonly held ideas as well as unique perspectives on the experience of touch in psychotherapy to develop an understanding of this phenomenon. The study was designed to explore diversity in responses and countertransference reactions to the experience of touch in psychotherapy, offering complex and meaningful possibilities that contribute to an understanding of the phenomenon. In selecting a mixed methodology design, “there is room in ontology for mental and social reality as well as the more micro and more clearly material reality” (Johnson & Onwuegbuzie, 2004, p.

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15). This material reality is captured in the quantitative questionnaire. The mental and social reality is described and explored in the qualitative interviews. Mixed methodology is more than simply a combination of quantitative and qualitative designs: it offers multiple approaches to the research problem. Both phases are integrated into the research study (Johnson & Onwuegbuzie, 2004) so that the qualitative and quantitative viewpoints, as well as the data itself, contribute to answering the research questions (Johnson et al, 2007). In the quantitative phase of this study, participants were asked about their practices and ideas in a questionnaire format, while in the qualitative phase, participants spoke at length about their experiences in one-on-one interviews. The two parts of the study examine different aspects of the question of how touch occurs in the psychotherapy session, leading to ideas about how it might impact the therapist’s countertransference. These different approaches to the research question make use of the strengths of both quantitative and qualitative research. Qualitative work identifies categories that may change throughout the project, while quantitative parts of the research define categories and goals (McCracken, 1988).

Rationale for specific methodology. In mixed methodology research, quantitative findings are used to establish a framework for the scope of the research and its impact and may also be explored in the qualitative interviews. The conceptual framework establishes the relevance and importance of the topic (Duckworth, 2017). Often this structure is established before the data collection, interpretation and evaluation; qualitative research questions and the

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research process contribute to the conceptual framework. The framework itself informs and justifies the research (Maxwell, 2005). Qualitative-dominant research, symbolized as quan+QUAL, is a design in which the qualitative component is emphasized. Epistemologically, this design is defined as “the type of mixed research in which one relies on a qualitative, constructivistpoststructuralist-critical view of the research process, while concurrently recognizing that the addition of quantitative data and approaches are likely to benefit most research projects” (Johnson et al, 2007, p. 124). Researchers choose this design when the research question demands quantitative data and approaches be integrated into otherwise qualitative research (Johnson et al., 2007, p. 124). In this study, the quantitative piece is a critical component that sets expectations for the relevance of this research question to clinical social work practice. It provides insight into the scope of the use of touch and to factors that influence therapists’ attitude to touch in session but it is not the primary focus of the study. The main approach to answering the research question is an exploration of themes, concepts and ideas from the qualitative interviews. This design is meaningful in the study of countertransference, which itself is a concept that is difficult to define in concrete terms. The practice of intentional touch within a session, and the rationale for its use, could be quantified and explicitly defined; the concrete experience of unintentional touch could also be described and understood objectively. The feelings within the therapist that are evoked relative to touch are less straightforward. Using a qualitative, free-form interview approach to explore the

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therapist’s countertransference may be more informative in elucidating a concept that includes multiple realities of experience in response to the objective experience of touch. This mixed methodology study has an exploratory sequential design, in which the qualitative interviews were completed before the quantitative online survey was conducted. This sequence was chosen to help the researcher enter the qualitative survey without the bias of answers from the quantitative study. This also addresses a concern about validity in mixed methodology research: each component of the research is addressed so that the whole is greater than the sum of the individual parts (Onwuegbuzie & Johnson, 2006). The following figure describing the exploratory sequential design is adapted from Creswell & Plano Clark, 2018, p. 66:

Figure 1.1 Exploratory Sequential Design The collection instrument and research processes in this study are designed to seek information on a topic that has traditionally not been as openly discussed as other aspects of psychodynamic or psychoanalytic psychotherapy. The emphasis on

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anonymous and confidential data collection reflects previous research challenges with therapists’ willingness to discuss the use of touch in session (Orbach, 2004a). The quantitative survey in this project is an internet-based questionnaire. The goal of this phase of the research was to establish the scope of the use of touch in psychotherapy and explore whether there are factors in common among psychotherapists with similar experiences of touch in session. It was developed based on studies in the literature, ideas and questions that arose in the qualitative interviews, and my own experiences as a psychotherapist. The qualitative phase of this study is phenomenological in nature: it aims to contribute to an understanding of the phenomenon of the experience of touch in session, and its effect on the therapist’s countertransference. Phenomenology, based on the philosophical thinking of Husserl, is used to explore common meaning for several individuals through their lived experience, creating a composite description of the experience itself and how they experienced it (Creswell, 2013). In this work, different therapists shared their individual ideas and experiences to contribute to a synthesis of perspectives on the phenomenon. One of the main goals of phenomenology is to understand an experience, which Rubin and Babbie note corresponds to the social work concept of empathy in clinical practice (2016). In the qualitative phase of the research, one-on-one interviews were designed to create a space for ideas to emerge about the meaning of touch in session. In addition to the words spoken by the participants, the researcher’s subjectivity becomes part of the data: qualitative researchers themselves are considered instruments for collecting and

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analyzing data (McCracken, 1988). Qualitative researchers acknowledge their roles as participant-observers (Elliott, Fischer & Rennie, 1999). In this case, with one therapist interviewing another therapist about their experience of touch in psychotherapy, the interviews became a collaborative, co-created space for exploration. In relational psychoanalysis, “analysts recognize their own embeddedness as participants in the very field that they are simultaneously observing. Participantobservation, the study of transference and countertransference, is inherent in this model” (Aron, 1995, p. 140-141). As a psychodynamically-focused social worker psychotherapist who uses touch in the psychotherapy session, I was both an observer and an embedded participant in the interviews. My research on this subject is directly meaningful to my work and an extension of the personal reverie, exploration and discovery that result from my hands-on work with psychotherapy patients.

Research Sample The research samples for the both the quantitative study and qualitative phases of the study consist of psychodynamically-oriented clinical social worker psychotherapists in North America who were willing to share their experiences with the use of touch and ideas about touch in their professional psychotherapy practices. They were recruited in a snowball and convenience method via email, social work listservs, and word of mouth. The initial goal for recruiting participants was 40-100 participants for the quantitative phase, and at least six participants for the qualitative phase. In qualitative research, 6-10 participants may be enough to reach data saturation for a phenomenology study (Morse, 2000). Data saturation is reached when no new information seems to be emerging from

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the interviews. This occurs when “the study provides maximum information on the phenomenon” (Moser & Korstjens, 2018, p. 11). Theory is central to social research, as it guides and provides context for observations (De Vaus, 2014). In constructing a theory, it is important to ensure that the theories are empirically based, and that they are then tested by evaluation against empirical reality (De Vaus, 2014).

Research Plan or Process Quantitative phase (online survey) research plan. In preparation for creating the quantitative survey, previous research was examined in the areas of touch in psychotherapy, body psychotherapy, and countertransference. Possible questions and approaches for the interview questions were drawn from various studies, including four on body awareness, eight on body psychotherapy, ten on countertransference, five on somatic countertransference, and thirty on touch in psychotherapy. These studies used a range of quantitative and qualitative approaches to understand the experience and practices of clinical psychotherapists. Questions for the quantitative phase of the study covered several areas: the occurrence of touch in session, and how it was handled; therapists’ intentional touchrelated practices; therapists’ opinions about touch in session; therapists’ training in other modalities; and therapists’ personal background and professional experience. In light of the sensitivity of the topic of touch in psychotherapy, careful attention was paid to any

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text that could be perceived as emotionally loaded words or leading questions (Pallant, 2016). As I was conducting interviews for the qualitative section of the study, ideas that arose out of the interviews influenced the addition of questions to the survey. These included exploring the impact of the COVID-19 pandemic and the dramatic increase in the use of teletherapy; asking about the effect of a patient’s sexual orientation on the therapist’s willingness to touch; considering the therapist’s experience of personal therapy and supervision as a place to explore the use of touch; and asking about cultural differences and whether a therapist had lived in places other than the United States. The survey was piloted to evaluate the feasibility of this research and to improve on study design (Bloomberg & Volpe, 2019); the questionnaire was then further refined based on information from the pilot study.

Qualitative phase (interview) research plan. The qualitative section of the research is structured around answering the research questions: how do therapists describe the experience of touch in session, what meaning does it have for them, and does touch in psychotherapy affect countertransference? Some of the assumptions of this study are that touch in psychotherapy is an experience that therapists will discuss and explore, and that there may be an effect of touch on countertransference. The interviews seek to explore these assumptions, and to discover whether the assumptions are valid for the studied population. In preparation for the interviews, I read through other researchers’ studies on touch in therapy or on countertransference; of the 57 studies I found in the literature,

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about half were qualitative, with approaches that included exploratory, grounded theory, phenomenological, pragmatic case study, and heuristic. The interview guide was based on these studies and other literature, as well as my personal experience. The semistructured interview guide (Zohrabi, 2013) offered a framework for the direction of the interviews but was not used to limit the topics or range of the interview. It included the following questions: 1.

Think about times when touch was used in the therapy

room. What comes up for you? 2.

As the therapist, in what way, if any, does touch change

your experience of the client? 3.

As the therapist, in what way, if any, does touch change

your experience of the session? Countertransference is defined here as the therapist’s experience in the session in reaction to the patient, the material, or the interaction. This includes all reactions of the therapist, whether positive, negative, or neutral. It includes reactions located in the present as well as in in the past. As the therapist, in what way, if any, does touch affect your countertransference? Interviews explored the four questions; participants’ responses led me to ask more specific questions based on their answers and on what I picked up on in their language, in their voices, or in their faces that made me curious and eager to have a better understanding of their perspectives.

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Memoing and bracketing were important components of the research process, from the beginning of research design, through conducting the study, analyzing the data, and writing. Smith and Flowers emphasize that positive engagement with the participant facilitates bracketing prior concerns (2009). Bracketing is a process of becoming aware of my own biases, ideas and hunches about the role of touch and its effect on countertransference in psychotherapy; owning that these thoughts may not be shared by my participants; and labeling them as my own so that I do not inadvertently only hear what I want to hear or ask questions in a way that leads participants to agree with me rather than generate their own ideas. I attempted to address this by disclosing my bias in a general way, keeping track of my own feelings during the interviews, and noting in my memoing document when an answer felt disappointing or incomplete. This felt like a clue to me that that my own beliefs or biases were strong and could potentially keep me from hearing the participants’ own important, complex, and different ideas. My goal in the interviews was to pay attention and create a space to welcome new thoughts; bracketing facilitated this effort as “questioning at this phase of the project should all be generated by attentive listening to what your participant has to say” (Smith & Flowers, 2009, p. 64). In the qualitative phase of this research, each of the seven therapists participated in three individual one-hour interviews over a video conferencing platform. One participant delayed the third interview due to illness, but the other six participants completed the process within about three weeks.

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Data Collection Quantitative (survey) data collection. The quantitative survey was posted on Survey Monkey. Participants clicked on a website address to access the survey and completed the surveys anonymously. Participants’ answers were downloaded as data files.

Qualitative (interview) data collection. Each interview was audio recorded. Interviews were transcribed by me, typed verbatim into Microsoft Word. Although it was time consuming, this was a method of immersing myself in the data (Bloomberg & Volpe, 2019). I then checked for accuracy by listening to the recordings a second time. I copied each interview into a separate tab of Microsoft Excel, adding line numbers and creating columns for my initial analysis and notes.

Data Analysis Quantitative (survey) data analysis. The quantitative data was analyzed using SPSS, a statistical analysis software platform that allows the researcher to perform analysis and build visualizations and reports (IBM, 2020). SPSS was used to obtain descriptive statistics to summarize the results of the questionnaire.

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Qualitative (interview) data analysis. In order to understand how the interview material suggests possible answers to the research questions, the interviews were coded and analyzed. A code is a construct that symbolizes data (Vogt, 2014); it classifies similar information to move towards consolidated meaning (Saldana, 2016). In addition to common words and ideas that emerge, the coding process highlights “incoherencies, paradoxes, ambiguities, processes” (Alvesson & Kaerreman, 2011). This analysis moves from the raw data to initial coding, focused coding, and thematic analysis. It was conducted in the order of the interviews, once transcription of all 21 interviews was complete. Qualitative data analysis was conducted using an approach similar to that of interpretative phenomenological analysis, which looks to “interpret the meaning of the content of the participant’s account” (Smith, Flowers & Larkin, 2009, p. 74) and was completed in different phases. One goal in the process is to organize what the participants experienced and how they experienced it (Moustakas, 1994). The first step in the coding process is pre-coding. As I transcribed the interviews, I highlighted significant passages, made notes next to the lines of text, and kept track of my thoughts and ideas in my memoing document. The pre-coding process took place as I was transcribing and continuing to interview the participants. This first step of free textural analysis includes observations, summarizing and associations (Smith & Osborn, 2007). This level of analysis remains grounded in participant words and meanings; these comments were the initial basis of the analysis of the next stage.

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After the interviews were transcribed, first cycle coding began. First cycle coding is an in-vivo coding process. In this step, the participants’ own words were copied to a column beside the line of transcript. These first impression notes are taken directly from the participant’s language, which is important in studies that “prioritize and honor the participant’s voice” (Saldana, 2016, p. 106). In this research, where the therapist’s countertransferential experience is the focus, the participant’s own words are important in developing an understanding of the meaning of the experience. In addition, by coding each line in detail, the initial phase of analysis “reduces the likelihood of imputing your motives, fears or unresolved personal issues to your respondents and to your collected data” (Charmaz, 1995, p. 37). Second cycle coding is a form of focused coding, which is also called selective coding or intermediate coding (Saldana, 2016, p. 239). It is more directed than line-byline coding, applying a smaller number of interesting codes to large amounts of data (Charmaz, 1995). In-vivo codes from the first cycle were given focused codes, and often labeled as phrases or sentences instead of lines. As I continued to code the interviews, I would rename codes, combine codes, split codes, or change codes, going over the transcripts several times. Saldana emphasizes that coding is organized by classification reasoning plus “tacit and intuitive senses” (2016, p. 9). The coding process involved operationalizing the codes, creating a growing list of codes that had emerged from the interviews, and intuitively applying the ones that fit best, or creating a new code if an idea was emerging for the first time. Once this coding was completed, I sorted the codes by interview, by participant, and for the entire set of interviews to reveal which themes appeared most often, and which might be outliers. This

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process resulted in further consolidation of several codes, and revisiting interview transcripts to confirm that the codes captured the meaning of the participants. A qualitative codebook evolved as the codes were copied onto a separate list with detailed information about what each code means, which helps organize the data (Creswell & Plano Clark, 2018). An intermediate coding process included taking the many codes from the second cycle and consolidating them into slightly broader categories. This was distinct from operationalizing; I wanted to see if more specific themes were revealed before assuming that they were one theme. Themes that appeared less frequently are also thought to be important and possibly meaningful in their uniqueness. Some of these may be called orphans, relevant text segments that are not repeated. At this level of analysis, they are kept as separate terms: “because qualitative research is not focused on quantity, individual places [terms] have an important place in this paradigm” (Auerbach & Silverstein, 2003, p. 59). In addition, there were terms that I considered combining, but decided to keep separate at this point in order to evaluate whether there were enough meaningful distinctions between their use to consider their categories separately. The process then moved into the third level of qualitative data analysis in this study, thematic analysis. In this phase, topics are grouped with repeating ideas in common into coherent categories (Auerbach & Silverstein, 2003). Saldana (2016) notes that themes themselves are not coded, but that a theme is instead an outcome. Categories of meaning are collapsed into themes, and eventually synthesized in a way that might suggest possible answers to the research questions. Particular attention was given to how the theme illuminates other aspects of the accounts (Knight et al., 2003) and how the

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themes contribute to a developing model of how social workers experience countertransference in relation to touch in the psychotherapy session. The themes were connected back to the specific quotes identified by line number in the transcript. This ensures that the themes are connected to primary source material; some themes were expanded, while others were removed (Knight et al., 2003). The unit of analysis in this research is not the individual therapist, but the phenomenon of the therapist’s experience of touch in therapy. The significant statements are the initial units of analysis that branch out to broader units of what is experienced, and how it is experienced, so that its essence is the “culminating aspect” of the phenomenological study (Creswell, 2013, p. 77).

Ethical Considerations The ethical considerations in this study included ensuring that participants understand that they would not expect to receive any benefit for their participation and offering resources if any part of their participation caused them distress. In addition, confidentiality and disclosure were maintained with the participants’ rights as human subjects the highest priority (Creswell, 2013). This study has no known benefits to participants other than the positive feelings resulting from contributing to the field’s body of knowledge and application to clinical work. There are no costs to participating. Possible risks to the participants included the inconvenience of being interviewed several times and possible negative emotional responses to discussing personal reactions to professional interactions. The risks were considered reasonable since this is an adult population of licensed therapists.

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Participation in this study was voluntary. All participants received and completed an informed consent document (Appendix A) prior to participation in the study. The form follows the Institute of Clinician Social Works’ IRB protocol and includes: a.

Explanation of the study including type of topics to be discussed

Inclusion and exclusion criteria

Duration of participation

Description of procedures

Description of foreseeable risks (minimal) and benefits (no compensation)

Limitations of confidentiality (i.e., raw, unedited data seen by the

research team and professional transcriber), and a description of how confidentiality of records would be maintained g.

My direct contact information in the event of a research-related

injury h.

A statement confirming that participation was voluntary, and could

be withdrawn at any point in the research process without penalty or loss of benefits i.

Any anticipated circumstances whereby participation may be

terminated

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A statement that findings developed through the research will be

provided to the participant upon research completion Informed consent was approved by the Institute of Clinical Social Work’s Internal Review Board, as per standard protocols, prior to the commencement of research. Following IRB guidelines, and The National Association of Social Workers’ Code of Ethics (2018), anonymity and confidentiality of all participants and data obtained, including backup copies, were rigorously maintained in password protected digital files. Participants were informed that the final product of the research is a permanent and public record that would be further edited for anonymity. In addition, they were informed that the data will be maintained for period of five years in a secure location, after which all files would be destroyed.

Issues Of Trustworthiness For the qualitative part of the study, credibility was ensured by member checking and triangulation. Member checking consists of sending participants their transcripts or a summary and asking them to review whether they are accurate. Triangulation includes asking the same question in a different way at different points in the interview. Dependability was ensured by confirming that the analysis process meets accepted standards for the research design (Korstjens & Moser, 2018). In this study, the literature was searched for mixed methodology research design, and its recommendations followed. Confirmability refers to neutrality; it was important to observe inter-subjectivity of the data, and to conduct interpretation based on the data, and not on the researcher’s opinion.

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The audit trail includes notes on decisions made during the research process (Korstjens & Moser, 2018). For both the quantitative part of the study and the qualitative part, transferability is both limited and useful. This study is applicable to a specific set of psychotherapists but will yield information on the effect of physical touch on the therapist’s countertransference in session. A description of the participants’ characteristics may assist readers in judging whether the results are transferable to another population.

Limitations and Delimitations The limitations of this study are that it is focuses on a specific subset of psychotherapists, which may limit its transferability. The study focuses on any psychodynamically-oriented clinical social work psychotherapists, regardless of whether they use touch in practice. The small voluntary sample size may provide a result that is not representative of therapists in general. It was limited in terms of gender and age: all seven of the therapists who agreed to participate in the qualitative interviews identified as female and were between the ages of 50 and 77. In addition, it is also possible that therapists who were willing to respond to an invitation to participate in a study on touch and countertransference already had ideas about touch that were not representative of psychodynamic psychotherapists as a whole.

The Role and Background of the Researcher I am a licensed clinical social worker in private practice, trained in a number of psychotherapy modalities involving touch, including Reiki psychotherapy and

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sensorimotor psychotherapy and I am comfortable using touch in psychotherapy sessions. Primarily, this touch includes Reiki energy work during the talk therapy sessions. Occasionally, I practice craniosacral therapy or light touch massage. I am interested in understanding the effect of physical touch on the therapist’s countertransference; this study seeks to clarify that effect from the psychotherapist’s perspective.

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Chapter IV

Results This research project seeks to explore the scope and experience of the use of physical touch among psychodynamically-oriented clinical social work psychotherapists, and to understand their lived and reported experiences about characteristics associated with their attitude towards the use of touch in the psychotherapy session.

Quantitative Research Description of quantitative survey. The quantitative phase of this study seeks to establish the scope of touch occurring in session, whether accidentally or intentionally, as well as practices surrounding the occurrence of touch, and the meaning therapists might ascribe to the experience. It also explores psychodynamically-oriented psychotherapists’ beliefs about the appropriateness, usefulness and role of touch in psychotherapy. In preparation for creating the quantitative research survey, previous research was examined in the areas of touch in psychotherapy, body psychotherapy, and countertransference. Possible questions and approaches for the interview questions were drawn from 57 studies, including four on body awareness, eight on body psychotherapy, ten on countertransference, five on somatic countertransference, and thirty on touch in

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psychotherapy. These studies used a range of quantitative and qualitative approaches to understand the experience and practices of clinical psychotherapists. As I was conducting interviews for the qualitative section of the study, ideas that arose out of the interviews were included in survey questions. These included the impact of the COVID-19 pandemic and move to teletherapy; the effect of a patient’s sexual orientation on the therapist’s willingness to touch; the therapist’s experience of personal therapy and supervision as a place to explore the use of touch; and cultural differences and whether a therapist had lived in places other than the United States. A questionnaire was prepared in Survey Monkey and piloted with student volunteers to informally solicit feedback on ease of use, interest, and functionality of the survey. A link to the final version of the survey was included in a recruitment email posted on two national listservs for social workers: the American Association for Psychoanalysis in Clinical Social Work and the National Association of Social Workers, as well as my local Greater Washington Society for Clinical Social Work. I followed up with a reminder email and asked social workers to forward the link to psychodynamically-oriented colleagues who may be interested in participating.

Participants in quantitative survey. There were 38 participants who completed the entire questionnaire. Of 58 participants who began the questionnaire and met eligibility criteria, twenty did not reach the end of the survey and their data was not analyzed. Most of the participants selfidentified as white, cis-gendered female, and straight/heterosexual. Ages of the 38 participants ranged from 32 to 77, with a mean age of 57.03 and standard deviation of

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12.01. Thirty-two participants identified as female (84.2%), four male (10.5%), one gender non-conforming (2.6%), and one (2.6%), specified “non-binary genderfluid.” For sexual orientation, 28 (73.7%) identified as heterosexual; four as bisexual (10.5%); and two as homosexual (5.3%). Three people wrote in the other category: “Lesbian (I find the word homosexual pejorative);” “Lesbian;” and “hard to say.” One person selected “choose not to answer.” For race and ethnicity, one participant chose two categories, Hispanic, Latinx or Spanish Origin and White (2.6%); two participants selected “other” and entered “Middle Eastern” and “Biracial European.” Of the remaining participants, one chose not to answer (2.6%); one entered Hispanic, Latinx or Spanish Origin (2.6%); two entered Black or African American (5.3%); and 31 entered White (81.6%). For national origin, 20 listed European countries, two listed Latin America or Latin America and Europe, and one listed the Middle East; not all participants answered this question. Of the 38 participants, only two (5.3%) were born outside the United States; 11 (28.9%) have spent time living in countries other than the United States as adults. Three therapists (7.9%) conduct some of their psychotherapy sessions in languages other than English; these languages are French, Russian, and Farsi. Participants described their spiritual or religious identities with a range of answers. Participants were able to select as many descriptors as applied to them; 25 participants (65.8%) described themselves as spiritual; six as religious (15.8%); four as atheist (10.5%); eight as agnostic (21.1%) and two chose none (5.3%). Thirty-two participants (84.2%) were raised with some kind of religious or spiritual identity. In terms of social work education, 25 participants have an MSW, 10 have a doctoral degree in

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social work, one is a PhD candidate, and two did not answer. Students graduated with an MSW between 1975 and 2016. Because the sample size for the survey is small, the data reported are not statistically significant inferential findings but can be understood as descriptive statistics. However, there are interesting patterns and trends among the results, which are described below.

Quantitative answers to research questions. 1. How widespread is the occurrence of physical touch in the psychotherapy session among psychodynamically-oriented clinical social work psychotherapists?

Most participants acknowledged that at some point, touch has occurred between themselves and a patient. Thirty-three participants (87%) acknowledged that touch in some form has happened in psychotherapy and only five participants (13%) said that touch had never occurred with a patient. This includes both unintentional touch and intentional touch.

How much unintentional touch occurs in psychotherapy? Of the 33 participants who said that touch has occurred at some point in therapy, the most common situation where touch occurred was during payment exchange, which was acknowledged by 24 participants. Seventeen participants acknowledged that touch occurred when therapist and patient brushed against one another or bumped into one another. It was least likely that patient and therapist touched to keep a patient from falling or during a medical emergency, but a medical emergency is thought to be a rare

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occurrence during therapy. Over half of the participants, 20 of the 38 respondents, acknowledged that they had been touched by a patient without consent.

Figure 4.1. Occurrence of Unintentional Touch in the Psychotherapy Session. This figure illustrates several different situations in which touch might occur in psychotherapy.

How many therapists use intentional touch in psychotherapy? Intentional touch used by therapists includes gestures such as handshakes or hugs, as well as touch that is incorporated into the treatment with the intention of being therapeutic. This includes formalized modalities that deliberately incorporate touch and the spontaneous use of touch. Most participants acknowledged that they may shake hands, hug, or accept a hug. Only 16% said that they never shake hands, and 29% said that they never hug. Participants were unlikely to initiate a handshake or hug. Most said that they would only

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hug if the patient initiated the hug (63%), while some also said that they would only shake hands if the patient initiated the handshake (41%). Most therapists felt that it was not possible to generalize who initiates a handshake. Participants who shake hands or hug or allow hugs were asked when and where these practices happen. Most acknowledged shaking hands at the first session (79%); very few acknowledged hugging at the first session (only one participant of the 27 who would ever hug). Participants were about as likely to shake hands or hug before termination or a break in treatment (37% would shake hands, and 44% would hug). Few participants would hug in the waiting room (4%), while more would hug in the consultation room (19%). Of the 32 participants who are willing to shake hands with a patient (84%), most say it is not possible to generalize who initiates the touch (56%). When in the course of treatment touch occurs, 79% say it occurs at the first session (as opposed to every session).) Of the 27 participants who said that they would ever hug or accept a hug from a patient (71%), they were more likely to do so before termination or a break (44%), least likely to do so at the first session (4%) and in the waiting room (4%), more likely to do so if the patient is terminally ill or had a recent loss (56%) and less likely to do so if the patient is a child or teen (22%). In terms of age of the client, participants are more likely to do so with patients who are elderly (34%), and less likely to do so if the patient is a teen (25%). Of the 38 participants in the study, 22 (58%) endorsed using some kind of informal touch practices; this might include a supportive gesture or a symbolic movement to be with the patient. Of those 22 participants who use touch in session, 17 (45%) endorsed using touch in response to a particular clinical moment. These types of touch

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included taking a distressed patient’s hand (11%), accept a patient reaching for their hand (18%), or placing a hand on the patient’s back or arm (21%). Interestingly, 24% endorsed that they would move to sit by a patient at a particular moment of therapy, which is not explicitly touching, but may have meaning within the psychotherapeutic situation. When asked if they used techniques or modalities in addition to psychodynamic psychotherapy, 22 participants (57.9%) wrote in the other modalities that they routinely use. Of these, 15 participants listed modalities that might, at times, involve touch techniques or direct work with the body, or modalities with a focus on body-mind integration, as opposed to a strictly analytic approach. These included seven who used EMDR; three who used yoga therapy; two who used somatic experiencing; and one each who used sensorimotor psychotherapy, body image therapy, or EFT (tapping).

Patterns that emerged from the data. Overall, therapists indicated that they were more inclined to use more formal touch at the beginning of treatment, as indicated by their use of handshakes, and more intimate touch later in treatment, as shown by their use of hugs. Therapists were generally more likely to use touch with elderly patients, and less likely with children or teens. They were also more likely to use touch in a particular clinical moment, for example, with a patient who had recently experienced a loss. In addition, a way therapists might react to a particular moment in psychotherapy was to move closer to the patient, which is not physical touch, but is a physical movement towards the patient. Of formal modalities therapists incorporated into their clinical work, EMDR was endorsed more frequently, with seven participants indicating that they use EMDR in their practice.

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2. What characteristics are associated with attitude towards the use of touch in the psychotherapy session by psychodynamically-oriented clinical social work psychotherapists? In this mostly female-identified sample (84%), a higher percentage of participants, who were all psychodynamically-oriented clinical social work psychotherapists, endorsed several specific attitudes and characteristics. When deciding whether to use touch, therapists are influenced by length of time they have worked with the patient (5 participants, or 17%, said often and 17, or 59%, said always), but not by whether the patient has a disability. Most participants who might use touch would ask verbally for permission (21, or 84%, said always, and one, or 3%, said often). Most participants agreed that if they had an employer, the employer’s policies would impact their decisions about touch in session: 20, or 53% agreed, and 6, or 16% strongly agreed. Most participants would not interact differently with patients if sessions were video recorded: 10, or 26% strongly disagreed with a statement that they would interact differently, and 20, or 53% disagreed. Whether and how participants process or talk about touch yielded a split response. Therapists were split on how they processed the experience of touch. Participants were asked if they talk about touch with the patient, with other therapists or professionals, and whether they document touch that happens intentionally or unintentionally in session. The only instances in which most of the participants would discuss non-intentional touch with patients was when patients touched them without consent (11 of 20 to whom this happened, or 55%); or if they touched during a medical emergency (6 of 10 to whom this happened, or 60%). Although 24 participants said that touch happens during payment

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exchange or when handing the patient something, only one (4.2%) brings this up to discuss with a patient. Touch is sometimes explored with the patient and is sometimes processed with someone else, most often a consultant or supervisor. Most participants indicated that they also process the occurrence of touch on their own, whether they also discuss it with others, potentially as a part of self-inquiry and self-processing. This included six who would not discuss touch with anyone and also would not process it on their own; five who only processed it with others; and six who would only process it on their own but would not discuss with others. Most therapists discuss the occurrence of touch with others and process it on their own; touch is more likely to be discussed if it occurred during a medical emergency or if touched by a patient without consent. Touch is most often documented by the therapists surveyed when it is related to the therapeutic process. Less than a third of participants would document handshakes, hugs, unintentional touch, intentional, informal use of touch, intentional use of touch as part of an established body-based treatment modality, or touch related to a therapeutic revelation, shift in treatment, or unusual clinical thinking. Participants expressed their beliefs about whether touch crosses a boundary, whether it can be appropriate or therapeutic in session. A quarter of the participants who had been touched by a patient without consent (5 of 20 participants) felt that it transgressed a boundary in psychotherapy. Of the 20 participants who had been touched by patients without the therapist’s consent, ten (50%) felt that it had an impact on treatment, while eight (40%) felt that it affected countertransference. Other types of nonintentional touch interactions, including bumping into one another or touching during exchange of payment, were not generally perceived as transgressing a boundary.

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The vast majority of respondents believe that it is possible for touch (intentional or unintentional) to have a positive impact (92%) on the therapeutic process; an equal number believe that it is possible for touch to have a negative impact (92%) on the therapeutic process. The majority believe that intentional touch can benefit the patient (92%), while fewer participants believe that touch can benefit the therapist (71%). Most of the participants also responded by saying they agree or strongly agree that there may be certain situations where touch may be appropriate in psychotherapy (86%). At the same time, most of the participants also believe that the same therapeutic outcomes could be achieved without physical contact (89%). Many participants consistently agreed that therapists should be very clear on their state’s licensing board’s regulations (84%). They also endorsed the statement that touch should be allowed if the patient requests it, and the therapist is trained or certified in a touch-based modality (69%); slightly fewer participants agreed that touch should be allowed if the patient requests it but the therapist is not formally trained or certified in a touch-based modality (64%). Participants in this study, all of whom identified as psychodynamically-oriented clinical social workers, were asked about their perceptions of other therapists’ opinion of the use of touch in therapy. They believed that other psychodynamic therapists may be more critical of the use of touch than non-psychodynamic psychotherapists: participants endorsed different scenarios in which therapists might be critical 67 times for psychodynamic psychotherapists, compared with 38 times for non-psychodynamic therapists.

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Figure 4.2 Therapist’s Opinion of Touch Psychodynamic psychotherapists are generally thought to be more critical of the use of touch. This figure illustrates what participants believe about psychotherapists’ attitudes towards touch practices in psychotherapy. In terms of the transition to telehealth during the pandemic, most respondents stated that they missed sharing physical space with patients (82%), while only 16% agreed with the statement that they missed being able to use touch. No participants strongly agreed that they missed being able to use touch with patients.

Quantitative Summary The quantitative portion of this study addressed the research questions by establishing that, in this small sample, touch does occur in psychodynamic psychotherapy

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between social workers and their patients. Touch occurs when the therapist or patient unintentionally touch, or when a patient touches a therapist without consent. A therapist may also intentionally touch the patient as part of a formal touch modality, or at a particular clinical moment. This research also addressed the question of psychodynamically-oriented psychotherapists’ beliefs about the appropriateness, usefulness and role of touch in psychotherapy, with most participants agreeing that touch could be appropriate or helpful in psychotherapy, but also showing caution in their approach to touch and to how other therapists may perceive the use of touch in session.

Qualitative Research Description of qualitative interviews. For the qualitative phase of this mixed-methodology study, seven psychodynamically-oriented psychotherapists were interviewed about their experiences of their encounters with patients during therapy sessions and the impact these encounters had on their countertransference with these patients. Interview transcripts were analyzed thematically, as described in Chapter III, into several broad categories. From these categories, sub-themes emerged regarding therapists’ ideas about the role of touch in session and how it may relate to countertransference. The themes and subthemes that emerged from 21 hours of interviews with seven psychodynamically-trained therapists were synthesized in order to address the research questions. In general, participants wanted to talk about much more than just touch. They wanted to talk at length about their felt sense of their patient based on the non-verbal communication that occurs between them. They also wanted to talk about the patient’s

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physical presence during the session and how that impacts their therapeutic responses. In describing that felt sense of the patient in these other non-tactile ways, the participants talked about the experiencing of an embodied other. They also talked about what they themselves experience in the presence of the patient, as well as how they think about and understand the countertransference experience, particularly when intentional or unintentional touch occurs. They also explored the influence of their own background and training on their countertransference around the issue of touch in psychotherapy. These discussions would lead to valuable exploration under any circumstances. Additionally, the discussion was particularly meaningful to participants and researcher because the interviews coincided with the time period shortly after the COVID-19 pandemic broke out in the United States. During this time, all participants were temporarily holding sessions only by phone or video. Even without being in the actual presence of the client, the participants described a keen awareness of the patient’s physical presence in session and how they experience the patients’ embodiment of emotion. The sense that the patient was present in distance therapy sessions, but not physically, highlighted for participants the loss of a critical resource for therapeutic meaning making. From a relational point of view, they also felt the impact of virtual therapy on some aspects of the therapeutic relationship.

Participants in qualitative interviews. Participants were not pre-screened for their ideas about the use of touch in psychotherapy. Of the seven participants, four stated that they do use touch occasionally, sometimes inadvertently, and sometimes deliberately as part of their somatic or

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bioenergetic therapy practice. Three participants stated that they do not use touch intentionally at all. All participants wanted to take part in the study because of their interest in the topic and their wish to contribute to the emerging body of knowledge about the subject. Two said that they were motivated to participate because of their own experiences writing a dissertation. It is important to note that the focus of the interviews was not the question of whether touch should be used, but of the experience of touch in session; those who would not generally use touch did connect with memories of how it felt when touch had occurred in session, and those who are generally open to touch also gave examples of times when they would specifically not use touch in session. The qualitative section of this study included seven participants who responded to an email posting inviting participation in the research. All seven identified as psychodynamically-oriented clinical social worker psychotherapists who were willing to discuss their ideas about touch and countertransference in session. Their ages ranged from 50 to 77; they had been in practice between two and over 45 years. Their selfdescribed ethnic or racial identities include European and African descent, Mediterranean, white, and Jewish. Those who chose to disclose a sexual orientation identify as heterosexual or bisexual; they practice in throughout the United States. Four have trained as psychoanalysts; other theoretical interests and orientations include Freudian, Jungian, Ego Psychology, Relational, Object Relations, Self-Psychology, Intersubjective, Somatic, and Bioenergetic therapy. Characteristics of participants are listed in Table 4.1.

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Gender

Age

Ethnicity (self defined)

Human race of mixed European and African descent White/Jewish

Caucasian

Not given

White

Mediterranean

Ashkenazi Jew

Professional clinical orientation (selfdefined) Object Relations, Jungian

Years in practice

Current Practice location

Previous practice locations

Group practice

Relational, Self Psychology, Jungian, Intersubjective, Somatic Relational, Self Psychology

45+

Group private practice Private practice

Private practice

Object Relations, Ego Psychology, Self Psychology Freudian

30+

Private practice and institute’s clinic Private practice

Somatic Experiencing, EMDR, Winnicott, Bowlby, Lacan, Jung, Shore Bioenergetic Therapy

30+

Community mental health

Private practice Private practice

School, community mental health Community mental health Community mental health

Private practice

Community mental health

Table 4.1. Characteristics of the Participants in the Qualitative Phase of the Study Initially, the interview script did not include my self-disclosure that I am a therapist who occasionally uses touch in practice. However, at the start of the first interview, I realized that participants may be hesitant to discuss their use of touch without some context about why the researcher was curious about touch and countertransference in psychotherapy. Ultimately, I decided to disclose my experience, telling participants that I use and teach the Japanese energy practice Reiki, that I have trained in somatic and sensorimotor therapy, and that I am open to using touch in psychotherapy sessions with patients. Participants shared their responses to this disclosure about the use of touch in practice and discussed their own experiences of touch in session.

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Qualitative answers to research questions. 1. How is the experience of touch in the psychotherapy session described by psychodynamically-oriented clinical social work psychotherapists? There were four main findings about participants’ experience of touch in the psychotherapy session. Participants acknowledged that touch occurs in session; actual physical touch is not required for contact and connection, shared energy and presence; touch practices change over time; and therapists consider the perceived clinical benefit in deciding whether to use touch.

Touch occurs in session. All seven participants agreed that touch does occur in the psychodynamic psychotherapy session. Some have intentionally trained in touch-based modalities, while others practice talk therapy that does not incorporate any form of touch. From a relational perspective, touch may represent a concrete interaction of two subjectivities, whether it is intentional or accidental. Harris writes: “As in so much conceptual work on the body and body ego, one is always slipping along a continuum of symbolic and material phenomena” (2015, p. 51). Participants acknowledged the experience of touch in session and their experiences with touch. Participants talked about touch in psychotherapy by describing it as intentional, unintentional, initiated by the therapist, or initiated by the patient. In addition to these categories, participants also talked about different definitions and conceptualization of touch in psychotherapy. These included the informal use of touch by the therapist, as well as touch as part of a formal mind-body psychotherapy modality. Influences on therapists’ understanding of touch in therapy and the presence or absence of it in their

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practice included training, the cultural and religious background of their patient and of themselves, the setting in which they are practicing and the beliefs they have about the function and use of touch. Whether or not participants intentionally incorporate touch in their work, they all noted that touch happens. Three participants intentionally abstain from any kind of touch in session; one was a bodyworker before training as a psychotherapist (participant 1), and two take a more traditional psychoanalytic approach (participants 4 and 5). However, they have experienced patients shaking their hands, spontaneously hugging them, or invading their personal space. Two participants described their use of touch within the session as informal, purposeful placement of a hand or moving closer to the patient (participants 2 and 3), or using Somatic Experiencing techniques, either directly using touch or using those practices without making physical contact (participants 2 and 6); or using Bioenergetic techniques (participant 7). Participants described how various observations of physical, physiological, and energy-based components combine to give the therapist an overall experience or felt sense of the patient; and how it contributes to their understanding of their own inner experience in session. They spoke to how this inner experience, which informs the countertransference, influences their response to the patient in session.

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Actual physical touch is not required for contact and connection, shared energy and presence. In her discussion of the relational approach to the body, Wrye writes: “One may indeed touch another’s body with one’s mind” (2015, p. 101). This theme was echoed by participants in interviews as they related touch-like experiences or a sense of connection without physically touching the patient. Several participants brought up the idea that actual physical touch is not required for contacting a patient. In speaking to this issue, participants described how their senses come into play when interacting with and observing the patient, whether or not touch is an intended component of the session. Participant 4 explained: “There’s different ways to touch people” (Interview 18: 124); participant 1 said: “Connection is a form of touch” (Interview 15: 177). These therapists, who do not intentionally use touch, described an understanding of how to make non-physical contact with the patient that may have some of the same functions and opportunities as actual physical touch. Similarly, silence and withdrawal were connected to touch by Participant 3. Speaking of one case, she said: “Basically, we touch, even without thinking we’re touching people. We are touching people. Even in our silence. And our withdrawal. It’s even more powerful” (Interview 17: 101-103). Participant 6 described transitioning from hands-on somatic experiencing treatments to a practice with similar methods, but where she would not actually touch the patient. Her perception of the patient, and the patient’s experience of the near-touch interaction, revealed the sense of an almost visceral interaction without physically interacting.

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This touching-without-touching experience echoes a relational idea about the cocreated space: “Gradually, patient and analyst mutually regulate each other’s behaviors, enactments, and states of consciousness such that each gets under the other’s skin, each reaches into the other’s guts, each is breathed in and absorbed by the other. For a while, patient and analyst share a jointly created skin-ego/breathing self” (Aron, 2015, p. 25).

Touch practices change over time. While many psychotherapists were trained to “hug with words” and offer talkonly treatment, they acknowledged that over time, their practices adapted to their patient population, their understanding of treatment, and their comfort with the physical body in session. Cornell describes the impact of physical presence during a session: “It is not uncommon, in the midst of deep relational psychoanalysis, for the body – be it that of the client or the therapist – to present itself in the therapeutic playing field, often unbidden and unsettling in its arrival” (2010, p. 31). This idea that the body can show up in session was described by several participants, who noted that their reaction in session has changed over time. Participants described how their practices had changed over time, emphasizing that in addition to their practices, their attitudes towards touch have changed over time. Several started with very rigid ideas about touch prohibition, and have become a little more flexible, while always adhering to their sense of what is professional and ethical; others have spontaneously experimented with offering touch and decided that it was not an effective technique in their practice.

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Overall, participants expressed caution about the intentional use of touch in session. Several cited a prohibition on touch as an integral feature of the psychodynamic/psychoanalytic tradition (participants 1, 4, 5), while others endorsed the judicious use of informal, purposeful touch (participant 3) and formal touch-based psychotherapy modalities (participants 2, 6 and 7). One respondent spoke of the negative attitude towards touch by the therapist in psychotherapy. “There was no touch. Touch was taboo. And then life happens. And patients happen. And then you’re confronted with - I guess, moments that inevitably require something more.” (Interview 3: 91-92). Touch happens, and this decision to use touch was often described as based on an active assessment of the client’s needs, whether following their formal training or occurring as a spontaneous felt experience. Participants spoke about the variety of factors that entered into their attitudes towards touch and decision about using touch with clients. Among these were the client’s clinical condition, trauma history, and cultural background.

Perceived clinical benefit affects decision to use touch. In exploring the decision to use touch in session, therapists may consider how it impacts the patient with their presenting issue, history, and experiences, as well as the therapist-patient relationship. Therapists also consider their own theoretical orientation and ideas about touch, which affect their ideas about whether a practice is therapeutic. Participants described how the perceived therapeutic benefit of using touch in session affected their decision to use an informal or formal touch practice. Participants primarily described assessing the action’s therapeutic benefit to the patient, both when

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they are using a touch-based modality as part of the treatment, or when they occasionally use informal, intentional touch at a specific moment in session. Several therapists described reaching out to touch the patient in what felt like a moment of need, in a particular therapeutic moment. Participant 3 said: “When a patient is in deep despair, I will move forward, and I have moved forward, and touched their knee...to really contain, kind of to show them that I am with them” (Interview 3: 96-98). Participant 2 draws on her training in Somatic Experiencing and a background in processoriented psychology to complement her psychodynamically-oriented treatment. She described how she uses her hands-on skills in response to the patient: “It’s more the sense that I have some repertoire, or resources for being able to offer that or be able to reach out, in a moment in a session, or if it’s right, with somebody” (Interview 9: 52-53). In understanding the purpose and the potential function of touch in the moment, participants described relying on intuition and a sense that the purpose is therapeutic. Participant 2 explained that her decision not to use touch with a particular patient was based on a sense, a “subtle signal” (Interview 2: 377). Participants said touch was problematic when it did not have the desired effect, or when it led to a sense of misattunement between therapist and patient. Often, participants described an experience that was not explicit touch, but a sense of a shared energy or presence. Participant 2 also described observing the emotional state of the patient and how her physical contact with the patient at that moment might change the experience for the patient. She gave an example of a case where she felt that abstaining from using touch would be therapeutic with a particular patient: “It’s not a decision, it’s an awareness as I’m talking to you that this person comes to mind, where the feeling towards the end of

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certain sessions, where she’s upset, I wish I could do something to comfort, but I know she has to go away and cry by herself, or, you know, work it through on her own” (Interview 2: 383-386). Participant 7 described how her training and experience in bioenergetic therapy has led her to examine the purpose of using touch before incorporating touch techniques into a session with a patient. She explained how she decides to use touch based on the specific context of the patient in the moment: “I use physical techniques and touch in my practice. As with any intervention, the most important thing is that the therapist needs to be conscious of what they are doing. If you touch somebody, what is the purpose?” (Interview 7: 63-66). Several participants described an awareness of the potential negative impact of touch at a particular clinical moment. Participant 6 reflected on a hands-on Somatic Experiencing session that had left her feeing unsettled, and refrained from continuing with the modality with that particular patient as she thought through whether it might not be therapeutic for the patient. Participant 4 described reaching out to a patient in distress, and recognizing that her touch was not received as supportive. The recognition that her action may not have been the most therapeutic in the moment made her more cautious about trying to use touch spontaneously with other patients. Although her practice often includes touch, participant 7 will also intentionally not use touch when she has a sense that not touching would be more therapeutic for the patient. She explained: “There are times when it would be inappropriate to touch, and it’s intrusive, and what I look for to pay attention to is: is touching - sometimes a person will

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dissociate, get more disconnected. So you have to really see what is going on for that person. And why are you doing it” (Interview 7: 219-222). These explorations of the decision to use touch or to abstain from touch with a patient reveal an openness to adapting theory and practice to the individual, observing signs in the patient and in the therapist as touch is offered or withheld, as presence is felt and connection is maintained. Davies describes a “psychic dehomogenization requiring both patient and analyst to be able to hold, contain and play with a multiplicity of states of mind” (1996, p. 566) with multiple levels of conscious and unconsciousness. The offer or rejection of touch as interpersonal events during the session are held and experienced by patient and therapist alike.

2. What meaning is ascribed to the experience of touch in the psychotherapy session by psychodynamically-oriented clinical social work psychotherapists? Participants explored the meaning they ascribe to touch in psychotherapy. The findings included common ideas about the functions of touch, particularly scaffolding, grounding, regulating and connecting. Participants also described how they understand touch as a source of communication about the unconscious, and how touch can be a form of interpersonal communication, especially of gratitude or aggression when initiated by the patient. From an attachment perspective, touch in treatment may be both a corrective emotional experience and an enactment (Wallin, 2007). Participants described their experiences using touch in session, explaining the meaning they intended the touch to convey, and the multiple meanings they discovered as they processed the experiences.

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Functions of touch in session include scaffolding, grounding, regulating, and connecting. Body-centered therapists are often trained with specific goals and purposes for using techniques that involve touch; those who also take a psychodynamic approach may also incorporate an understanding of the unconscious. One author describes integrating these two approaches: “In both psychoanalytic and body-centered work, my focus is those elements of experience that are not part of the patient’s conscious memory and sense of self, yet which deeply shape his experience of his world…As analysts, we do this via our associations, affective states, and dawning awareness of enactments. As body centered therapists, permitted the possibility of two-way communication between our physical beings, other channels are amplified and enlivened” (Bass, 2010, p. 152). Participants who acknowledged that they used touch in session described touch as a critical source of information and affirmation in their clinical work. In talking about their actual use of touch in psychotherapy, participants spoke about the function of touch in the treatment. Whether touch initiated by the therapist was intentional or unintentional, participants identified various functions of touch, using words and phrases such as “working through something,” “containing,” “being together,” “scaffolding,” “regulating,” and “grounding.” While their training and attitudes toward touch varied, participants reported that touch informed meaning making for all the subjects in this study. They also noted that the discussion of touch helped them to clarify the function and purpose of touch in the particular way they practiced therapy. Participants described various meanings of touch in psychotherapy in addition to the words above. These include bringing attention to the physical body, teaching a new

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experience, containing, connecting, building trust, resonating, regulating, and gaining information about the patient and the therapeutic process. Clearly, it seems that participants who used touch intentionally found it to be a very helpful way of connecting with their patient, a way of enhancing the relationship. It was also described as a way for the patient to become more connected with themselves and their emotions that may be disavowed. In addition to the touch experience itself, processing and exploring that experience is significant. Participant 7 said: “One thing I think that’s really important in working with touch is that it not just be used as something where you’re just trying to make somebody feel better. Sometimes comfort is important in therapy, but therapy really is a process where you are helping a person grow. And the point is maturation, growth. And so you’re not just trying to touch somebody to make them feel better. And it’s also important for whatever a person comes in contact with, for it to be processed in a conscious way” (Interview 7: 152-157). Several therapists described touch in session as a means for the patient to reconnect with their physical bodies and with themselves. Participant 1 said that her verbal guidance helped with reconnecting, “Or connecting in a new way, if they’re not used to it, or forgot about how” (Interview 1: 330). She described this process: “The first step is to just help them notice. It’s a kind of frightening enterprise. And for some people, it’s frightening to be in their body” (Interview 1: 312-315). Connecting with the physical body may be a new experience for patients and may open new space for emotional growth in psychotherapy. Participant 7 explained: “Let’s say a person has never been touched in their whole life, that’s an extreme, but as a therapist, if you’re trying to ask

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them to imagine that they’re being held or touched, if you’ve really never experienced that, how are you going to know? To be able to embody that, experience that.” (Interview 7: 119-122). Touch was described as creating boundaries and a sense of containment. Participant 1 described how the therapist can “act as a container, like Winnicott talks about, the holding environment. I think that my background in somatic training, touch therapy, helped me prepare a better holding environment for my clients” (Interview 1: 207-209). Participant 4 described this experience in her work with a child patient: “She needed a holding environment. She needed - she really needed more soothing than words could be. Because she was just so all over the place. And she was very amenable to that. I think she needed that” (Interview 4: 140-143). The therapist’s ability to feel and recognize may be important for working with a patient who does not have as clear a sense of self and other: “The whole point is, you want to help them develop a sense of containment and boundaries. And not be acting out and moving” (Interview 7: 314-315). Participant 2 described a containing function when hugs are part of the frame for the end of the session with certain patients: the hugs are an “important part of closing the contact” (Interview 2: 102). Touch was also described as increasing connection and trust in the psychotherapeutic relationship. Participant 6 described the therapist’s body as a channel (Interview 13:63), and participant 3 explained that even when touch practices are not used in treatment, “It is about touch. How do we touch people who are different to ourselves” (Interview 10: 383). Participant 2 explored how using touch modalities in psychotherapy requires a level of trust, both for the patient to trust the therapist and for

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the therapist to trust her own skills and intuition. She said: “there’s something profound about being allowed to be - when somebody is offering, out of need, a degree of trust, allowing you to put your hands on them in some way, hold them, and see what happens, because you don’t know. And I think there’s something meaningful about that level” (Interview 2: 333-337). Accompanying the patient through the therapeutic process was described by participant 7: “The therapist isn’t saying, you’re not going to feel any pain, they’re saying, I’m in the journey with you. As you process it and go through it” (Interview 21: 122-123). Participants explained how touch has a regulating function in psychotherapy, with the therapist and patient resonating with one another: Participant 3 described how a sense of feeling connected can be used to resonate with another and to regulate: “There’s the twinship part, there’s the kind of regulating, I’m with you, which is - you know, in silence, and then there’s the hugs” (Interview 3: 98-103). Participant 6 described a similar use of how her own body’s sensations in the moment guide her to work with the patient, especially for tasks of regulation: “When I feel like I’m not clear about which direction to go, I’ll either have a gut feeling or whatever, but if I’m not able to access my gut feeling, that gives me information about what’s going on here right now, and that it’s time for us to calm our nervous systems” (Interview 6: 319-322). Many of the ideas expressed by participants about the purpose of touch in session reflect their training and experience in purposely using touch. The sense of creating boundaries and demonstrating containment is reminiscent of Winnicott’s limiting membrane, the infant’s surface of the skin, through which the infant “comes to have an inside and an outside, and a bodyscheme. In this way meaning comes to the function of

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intake and output; moreover, it gradually becomes meaningful to postulate a personal or inner psychic reality for the infant.” (1965, p. 44) Kupfermann described how touch could be used to assist the patient “in gaining a physical sense of her own being… a failure to respond means that the unintegrated self falls forever.” (Kupfermann, 2015, p. 166)

Touch is a source of information about the unconscious. The idea of using touch and the body as a source of information about the patient was explored by several participants. From a theoretical perspective, this could be understood as an example of Asheri’s “embodied intersubjective engagement” in which two subjectivities interact at an interpersonal and interpsychic level (2009, p. 108). Touch provides information to the therapist that is experienced as a physical sensation, and possibly not immediately connected to the spoken material. Participants described touch as a source of information in therapy, generally about unconscious processes or experiences that are not verbalized. Participant 6 said: “Now I think I respect my sensations and intuitions a lot more. And I think that feeling gives us different information.” (Interview 20: 392-393). She also explained: “I think it gives the client a lot more room, when there’s shame involved, to not have to, you know, spill their guts, but move through it…part of the problem with more psychoanalytic-psychodynamic therapy is that - a lot of trauma is stored in the body, and you’re reinforcing this idea of staying in your head” (Interview 6: 249-252). The idea that one body can understand unspoken information from another body was echoed by participant 2: “It’s an interest in the body that isn’t always necessarily that I’m touching a body, but an interest in the

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body to body and embodied experience” (Interview 9: 391-394). Another purpose of touch was described by participant 6 as validating unsynthesized or unconscious knowledge held by the therapist: “Touch might be just a way that we legitimize, again, something that we know, but we allow ourselves to concretely acknowledge it through touch” (Interview 6: 546-547). Considering the meaning of touch in the therapeutic moment informs therapists’ decisions about whether to use touch with a particular patient. Participant 1 described her process of evaluating whether accepting a hug or guiding a patient into their body is therapeutically useful by relying on her intuition. She said: “I do a lot of things intuitively, and so just assessing, did I do that intuitively right. Did it seem ok for the client?” (Interview 1: 94-95). Participant 2 described observing a reluctance to invite the therapist to come closer, which discouraged her from using touch in that moment. She explained how she picks up this information as she decides whether to use touch with “People who are bringing some sort of struggle or suffering, but who I’m not feeling are inviting touch, or holding” (Interview 2: 354-358). From a theoretical perspective, this unconscious communication could be inducing an understanding in the therapist that is perceived as a feeling. In the words of McDougall: “Rather than seeking to communicate moods, ideas and free associations, the patient seems to aim at making the analyst Feel something or stimulating him to do something” (1978, p. 179).

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Touch is a form of communication of gratitude and aggression. Therapists also explored the meaning of touch initiated by the patient: most understood touch initiated by the patient, or refused by the patient, to be a form of communication. This nonverbal communication could be processed and explored but conveyed something different to the therapist that complemented the verbal material of the session. Therapists who used intentional touch practices also found that they gained information from these interactions that could then be used therapeutically. Participant 1 described how she understood her patient’s hug at the end of session as an expression of gratitude. She recalled: “something in her body language said that she wanted to hug. And she was saying it with gratitude” (Interview 1: 90-91). She continued: [The hug] “solidified for me that she appreciated our time together. And that that was a way of showing it” (Interview 1:99-100). Participant 3 also described handshakes with the potential of communicating gratitude and a sense of closeness. She recalled one patient in particular who would regularly shake her hand at the end of the session: “I’m the only one in the world he talks to about so many things. So - and yet, I know it was meaningful. It was him really saying “Thank you.’” (Interview 3:134-135). This same participant also noted the value of regular handshakes as a physical connection that might symbolize an emotional connection and highlighted an aspect of the patient’s development that might have implications for treatment. She described one patient in particular: “It kind of feels like some kind of umbilical cord, kind of, just something he needs more that he never got. And that I’m comfortable to give” (Interview 3: 110-111). Participant 5 described a patient who refused the once-a-year hug, interpreting the meaning of that refusal in the context of her case history: “I have one for instance, who

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doesn’t like to be touched. And doesn’t like me to talk a lot. She likes to talk because she never was allowed to talk as a child” (Interview 5: 91-93). The enactment of this patient refusing a hug could be used by the therapist to increase her understanding of this patient. Several participants described their reactions to aggressive touch by the patient in session, which participants often related to enactments. Participant 2 spoke of a male patient who would reach for hugs provocatively. When she did not accommodate his requests for more sexualized touch, he expressed his dissatisfaction at her refusal: “He started kind of teasing and saying that I was giving 'duck hugs'” (Interview 2: 296). Other participants described avoiding physical contact with those whose behavior felt aggressive. Participant 4 described a patient who verbally provoked her with stories and requests to the point that she sometimes felt: “that was actually a very hostile act” (Interview 11: 305). She described how the patient reacted to her refusal to engage in his sexual fantasies: “He thought it would be much better - that I would be a more open, better therapist if I didn’t have my hang-ups” (Interview 11: 312-313). With aggressive touch, therapists described monitoring their own reactions both to protect themselves and to continue to engage in the treatment. Participant 2 described managing her personal reaction to the aggressive patient while continuing to treat him for issues related to the aggression and relationship issues: “My dealing with it was really a combination of energetically meeting him and holding boundaries and they were not easy boundaries to hold…allowing a little bit of touch, you know, was quite challenging” (Interview 2: 302-305). The difference between ritualized touch, and spontaneous or planned touch with a therapeutic intention, was also brought up by several participants. Handshakes and hugs

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may seem more rote or relatively meaningless to some therapists or to some patients; however, they could also have significant meaning, which may not be appreciated or acknowledged we often don’t know unless we ask or intuit from body language. Such socially ritualized gestures may not carry the same meaning to the therapist or patient as more spontaneous expressions of touch. The meaning of these gestures can vary enormously in the meaning intended or how it is interpreted by the recipient. There are hugs, for example, that may convey tenderness, wishes to comfort, or signs of attachment. A hug or handshake may be intended or experienced as distancing, aggressive or provocative, but also as a type of connection or sign of respect. Most therapists seek to clarify the meaning of a particular word or phrase that a patient may use in discussing their feelings or an event; they could also explore touch in the same way, whether intentional or unintentional. From a theoretical perspective, this touch communication by patients may be understood as representing unformulated experiences, meanings and emotions for which the patient’s words are not yet sufficient, or not trusted to communicate the depth and intensity of the patient’s feeling. Aron describes: “For patients who have not achieved an ability to symbolize, un-formulated experiences can be experienced only vicariously by intersubjectively communicating them to another, a process that some analysts describe by speaking of projective identification” (2015, p. 25). 3. Does touch in session impact countertransference as understood by psychodynamically-oriented social work psychotherapists? The third set of qualitative findings are related to the impact of touch on countertransference. Participants described how touch, physical changes in the patient,

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and somatic and energetic aspects of treatment have an effect on the therapist’s experience; they described how therapists recognize body and somatic countertransference as an important aspect of the psychodynamic interaction; and they discussed how countertransferential reactions increased understanding about their responses to the patient. The concept of countertransference is an area of psychodynamic clinical work that has long captured clinical interest. Here, countertransference is defined as the range of feelings, reactions and associations a patient evokes in the therapist. These internal responses can be used as sources of clinical information about the patient that affect how the therapist understands and responds to the patient.

Touch, physical changes in the patient, and somatic and energetic aspects of treatment have an effect on the therapist’s experience. From a relational perspective, the therapist’s physical reaction to the patient’s subjectivity informs and affects treatment. Aron writes: “Much of what we pick up from our patients we may first feel in our bodies and perhaps most immediately in our breathing. Our bodies are the primary arena for the psychophysiological processing of affect” (2015, p. 28). In this same paper, Aron writes: “Affect regulation takes place on a bodily level – we feel in our bodily reactions something of what the other person feels, and we convey this recognition through bodily responses. These are often instantaneous and not processed explicitly in language” (2015, p. 28). Many participants touched on issues of countertransference with their patients in a theoretical sense and by giving examples from their clinical practices. Participants

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explained how they understood countertransference, which they also connected to their explanations of their use of touch and how they feel about using touch in session. Countertransference was presented as a source of information in session that could increase empathy and identification with patients (Participant 4, Interview 4: 147) or create distance in the therapeutic relationship. Countertransference was also described as a conscious and unconscious experience (Participant 5, Interview 19: 92) and an explanation for the therapist’s strong emotional reactions to the patient, which could affect the therapist’s actions in session. In addition to the cognitive awareness of countertransference evoked by the patient’s material and presence, therapists described a physical experience within themselves that often illuminated some kind of countertransferential reaction to the patient. At times, participants also discussed affective attunement to the patient and sometimes used the two terms interchangeably. While countertransference could be defined as the therapist’s inner experience of what the patient evokes in them, affective attunement could be a way to increase empathy with the patient’s felt experience. Participants spoke at length about the value of the patients’ felt experience. Participant 1 described using the countertransference: “I know how she feels, what might help her make a connection and become grounded. So I think I probably do use that feeling sensation even though I can’t physically touch her. It’s like stepping into her shoes, so to speak” (Interview 15: 158-160). Participants described their use of their own bodies and internal experience during the session to connect with and contact the patient in a therapeutic way.

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Harris describes how this use of the therapist’s physical experience co-creates the therapeutic space and affects the therapeutic experience: “The analyst’s body becomes one of the points of registration or representation of experience not verbally symbolizable but nonetheless powerfully dominant in intrapsychic life and therefore projected into interpersonal space” (2015, p. 39).

Therapists recognize body and somatic countertransference as an important aspect of the psychodynamic interaction. Somatic countertransference, in the words of Lemma, is “a plethora of sensory and motoric experiences such as the analyst feeling discomfort in the body, alterations in breathing, feeling tired, sleepy or restless, feeling itchy or nauseous and so on” (2014a, p. 14). Participants describing their own countertransference are engaged in a process of experiencing and observation, an aspect of self-reflexivity. Aron describes this concept as “the dialectical process of experiencing oneself as a subject as well as of reflecting on oneself as an object. It is not, therefore, exclusively an intellectual observational function, but an experiential and affective function as well.” (2015, p. 4) Therapists described how touch and their own physiological and emotional reactions related to their understanding and recognition of countertransference in their work with particular patients. Participant 6 described her experience: “I became much more attuned to how there is this force field between the client and the clinician. And if you’re open and receptive to it, and this is part of what’s interesting about how you might define countertransference” (Interview 6: 268-270).

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Touch affected countertransference in in several main ways, as explained by participants. They incorporated somatic and energetic aspects into a broad understanding of the concept: Participant 6 said: “This idea of countertransference hooks into something much bigger. We use it in psychotherapy, and we can use it in lots of different ways, and in a Freudian way, it was much more limited to emotional reactions and thoughts. We’re expanding into somatic experiences related to the energy and the exchange, but I think we’re also talking about something maybe a little bit bigger” (Interview 20: 17-22). Participant 3 connected countertransference to intuition, as well as to feelings of love for the patient, which she often experienced physically as well as emotionally. Though these responses did not always involve actually touch interactions between therapist and patient, they often evoked in the therapist an urge to touch the patient in a supportive or affectionate way. Describing her experience in session, she observed how the therapist’s feelings are integral to the work. Relating this to theory, she mentioned that there have been psychoanalysts: “Who talked about love, and who talked about their warm feelings, and their intuitions…But it was always there” (Interview 3: 292-296). Participant 7 emphasized that countertransference was operating continuously during treatment, and that the therapist monitors it internally: “consciousness or awareness of countertransference is important throughout the whole session” (Interview 7: 112-113). Participant 6 expressed a similar understanding about countertransference: “It’s just a specific manifestation of something that we need to be much more conscious of and respect all the time. And not even just - even just in a quantum way, you can’t observe something without changing it” (Interview 20: 86-88).

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Several participants described countertransference as a tool to make sense of observations taken in by the therapist’s senses about the patient’s body, for example is the patient is conveying a sense of fear, anxiety or dependency towards the therapist: For the therapist who is paying attention to the body [hers and the patient’s] in psychotherapy, the therapist may require a different kind of engagement, one which could possibly be understood through a lens of countertransference. Participant 6 said that she appreciated: “not having to know intellectually, or analytically” (Interview 6: 248). Countertransference was specifically mentioned by participant 2 in observing her own reactions to a patient’s response to touch, in the context of the interaction between patient and therapist: “that’s probably a more subtle and complex transferencecountertransference thing from someone who has probably learned to contain their vulnerability, to not rely on others for comfort” (Interview 2: 360-362). She continued, explaining that the patient may be sensing a reaction from the therapist that is not cognitively processed. “There’s something I would say in the transferencecountertransference happening. That feeling, she’s not expecting it, she’s either going to find a way to self-soothe, or leaving distressed, and then cope with it. But there’s some way that I don’t sense an invitation or something for me to soothe” (Interview 2: 367371). Participants described recognizing a physical aspect of the countertransference that was experienced as touch, vision, or hearing; this often occurred when the therapist picked up a sense from the patient’s experience when there was an exchange of touch, although touch was not necessary for this kind of experience. Participant 3 said: [It was] “a river kind of flowing” (Interview 3: 315-316), “Almost like touching points, but

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they’re not touching, physical touching points, but these touching points, whether it be words or an image” (Interview 3: 319-320). She expanded on this theme to connect the flow to synchronicity and connection: “it has this sort of natural flowing up, something gets said or an image gets said and it just seems to just touch” (Interview 3: 326-330). Participant 3 also described her observations of the patient’s physical presence in contrast to teletherapy: “You can actually feel it physically” (Interview 17: 25-26) Participant 3 related this experience to the energetic observation, extending it to a sense of magic or telepathy in her own inner experience. She said that certain therapeutic experiences “led me to understanding so much more about - that there’s so much more happening in the room than one can ever know, that transference-countertransference could even explain” (Interview 3: 277-279). Participants spoke a great deal about paying attention to the physiological responses within their patients, as well as within their own bodies during therapy. This was described as a source of information that may come from the therapist touching or observing or listening to the patient, or it may come from ways in which the patient touches or responds nonverbally to the therapist. While participant 1 said that, generally, “I feel energized almost after every session,” (Interview 1: 509), she described one patient that evokes a different reaction in her. In this same vein, some participants talk about tuning into their own visceral somatic experiences during the session to help assess and better understand what the patient is experiencing. For example, participant 7 said of her patients: “I feel like I register them in my own body” (Interview 7: 279). Participant 3 also noted her own reaction to a patient: “I feel like I resonate with her. “She’s full of life. The deadness hasn’t come in

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yet” (Interview 17: 277-278). In addition to noticing and taking on how the patient might feel during the session, participants explored the idea that some things they might feel offer insight into the patient’s lived experience. Participants explained how they also observe physical and energetic changes in the patient that then affects their internal experience as the therapist. These therapists described being sensitive to perceiving a type of information from patients that the therapists themselves may be experiencing as a feeling within themselves. Participant 2 described: “some really, really deep, traumatic, tragic stuff we are working with. And I really felt, you know, that desire to touch or hold” (Interview 2: 151-152). Therapists described the importance of being aware of their countertransference towards the patient because of boundary concerns. The therapist’s awareness of his/her own emotional and physical reactions may move the therapist towards or away from the patient. This can be a helpful signal and help the therapist determine how to maintain boundaries that are in the best interest of the patient. Participant 1 said: “I still think it’s important to use the body, your own self” (Interview 1: 64). With the patient who made her feel less energized than other patients, she added: “I notice a lingering feeling” (Interview 1: 509). Participant 7 echoed this theme by noting: “The therapist is using themself in a lot of different ways” (Interview 14: 403). She speaks monitoring her internal experience: “I can feel it in my body…like I take somebody’s temperature with my body” (Interview 21: 170-172). In explaining the importance of recognizing countertransferential feelings, participant 3 described how her internal sense affects the negotiation of physical and emotional space with a patient: “In terms of embodied and being together, but not too

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much together, and trying to find that place with her, it’s exquisitely sensitive” (Interview 3: 431-433). Participant 6 also described relying on what she feels within herself in relation to the patient. She explained: “I’ve come to the point where I trust what I feel more than what I know… I’ll just be much more aware of what I’m feeling physically” (Interview 6: 308-311). Participant 3 also described the effect of the patient’s transferential actions on her internal state. She told of an experience of deciding to sit next to one young female patient during a session and, in a different session with a different patient, deciding not to move closer: “There’s something in the countertransference, something in the transference being, you know, she was more drawing in. So the fact that I went to sit with her was not a coincidence. Yeah, there was something easy about her to sit with her, to be near her. Whereas, other patients, they have a much more - a force field of, you know, just comfortable distance. Yeah. As well as the emotional part of it. Because that can bring down all sorts of boundaries and attachment styles, I think, once you’re in despair. But also, if you’re in despair. There’s in despair and in your cave, and there’s in despair and just kind of loosely bounded, and say, I guess there’s different ways in which people draw you in or don’t” (Interview 3, 231-239). A theoretical understanding of this use of countertransference in response to touch includes the concept of the “analytic third”, which is the relationship itself. Ogden explains: “The concept of the analytic third provides a framework of ideas about the interdependence of subject and object, of transference–countertransference, that assists the analyst in his efforts to attend closely to, and think clearly about, the myriad of intersubjective clinical facts he encounters, whether they be the apparently self-absorbed

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ramblings of his mind, bodily sensations that seemingly have nothing to do with the analysand, or any other 'analytic object' intersubjectively generated by the analytic pair” (Ogden, 1994b, p. 17). In this model, countertransference and bodily sensations are included in the co-created space generated by interaction of the therapist and patient’s subjectivities. Ogden describes a case in which “a somatic delusion experienced by the analyst, and a related group of bodily sensations and body-related fantasies experienced by the analysand, constituted a principal medium through which the analytic third was experienced, understood, and interpreted” (1994b, p. 13). He continues by explaining that conducting the analysis “depended on the analyst's capacity to recognize and make use of a form of intersubjective clinical fact manifested largely through bodily sensation/fantasy” (Ogden, 1994b, p. 13).

Countertransferential reactions are used as a source of information about the patient. Participants described how they used their own countertransferential experiences to understand more about the patient and the patient’s experience. There are several different types of countertransference experiences participants described that ranged from the most traditional ideas of countertransference to more expansive themes of body countertransference and feeling projections or identifications with the patient. At times, they interpreted their internal feelings as their own personal issues that arose in response to a patient’s presentation or transference, which is aligned with the earliest understanding of countertransference. In addition, many participants spoke of their body

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countertransference, an awareness of physical feelings that arise in response to the patient. Participants also spoke of recognizing feelings within their internal experience that were evoked by the patient, but could represent how the patient feels, how the patient makes others feel, or even how the patient wishes to be treated. When the therapist’s internal experience felt like an appropriate reaction to the patient, the countertransference could be used to reinforce a therapist’s working hypothesis or model. Participant 6 used hands-on Somatic Experiencing techniques in this way: “The touch, just verified something that I knew. And I no longer doubted myself. And it was amazing, the things that emerged. That you could literally feel in somebody else’s body, the connection” (Interview 6, 84-86). Changes in the patient’s and therapist’s response to touch can often reveal subtle or not so subtle changes in the patient’s defenses and relatedness. Participant 5 describes her practice, where she offers her patients hugs once a year. One particular patient refused the hug year after year. When she finally accepted the therapist’s hug, this was seen as both a symbolic representation and an enactment of something changing in the patient. With the hug, the therapist could actually feel and experience this change. Participant 5 recalled: “I said, ‘This is the first time you have ever initiated a hug. And I’m very glad you did.’” (Interview 5: 110-114). She continued: [This shift in behavior was “an extension of her better, active relationships all around” (Interview 5:122-123). Body countertransference is a term that a number of participants used. This was a term participants used term as an indicator of a reaction to the patient; therapists described recognizing physical feelings in their own bodies in terms of both positive and negative body countertransference. At times these visceral body reactions seem to have

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meaning for the therapists themselves, based on their own histories; at other times, their reactions seem connected more to the patient’s experience. Participant 5, in describing a challenging client, said: “My stomach sometimes gets up set before she [my client] comes in. I think I’m a little afraid of her anger” (Interview 12: 188). Fear of the patient is another response to which some participants became aware. Participant 2 described how she experienced anger in a telehealth couples’ session: I was quite activated during that session. She said: “I was actually also calming myself as I was helping her. If I had been in the office with them, [rather than meeting virtually], it would have been much harder for me.” (Interview 2: 209-210). A countertransferential response in the therapist that feels maternal, or protective, could be evoked by a projective identification or introjection from the patient. Several therapists related their use of touch to maternal feelings, connecting to a possible maternal role as the therapist. Participant 3 explained: “With some of my younger female patients, it’s just felt right, maternal, to say goodbye with a hug” (Interview 3: 103-104). She noticed that several patients who seemed to be eager for physical contact had mothers they described as neglectful (Interview 3: 119-120) or alcoholic (Interview 3: 230). Therapists also relied on their countertransference to understand which transferential roles may be therapeutic, particularly in treatment involving touch. Participant 7 described using Bioenergetic therapy techniques with a patient who sought to begin to separate from the intrusive mother of her childhood: “In that sense, I’m the positive mother to her. Like to that person in that moment, I am a positive mother. That’s how I would think of it. Positive mother, father, parent figure” (Interview 7: 218-219).

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She also cautioned that the therapist does not only take on positive roles: “You don’t want to be just present yourself and have this demand that you be seen just as the positive mother. Because you know, the person may have a need to feel their negative feelings. And to be able to have a relationship, with that negative expression of feeling and have the therapist be able to process and tolerate that” (Interview 21: 110-114). Participants spoke of feeling something different and interpreting it as feeling what the patient is feeling. This is different from attunement in that it is an experience felt by the therapist, not a technique used in treatment. They described this as a type of physical countertransference of understanding what it might feel like to be the patient; touch seems to intensify this experience but is not necessary. For participant 6, this was generally helpful in exploring what the patient might be feeling: “when you talk about countertransference, I love that you’re viscerally tuning in to your body simultaneously, to know what’s going on with the other person” (Interview 6: 161-162). Participant 1 described working with a patient with paranoid schizophrenia and experiencing what seemed to be the same state the patient described about his own life: “When I’m engaged with this particular client, I feel like, a fog. I feel - at times, it’s hard to focus” (Interview 1: 220-221). Participant 7 also described an aspect of attunement with the patient that overlaps with her use of countertransference. She explained how she uses her body as an instrument in therapy to understand and share the experience of the patient, recognizing that she may notice feelings in her own physical body that may inform her about how it feels to be the patient. She said: “when I meet somebody and they’re telling me, I feel

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like I register them in my own body. Somehow my own body - somehow starts getting a feeling of what they’re living, in their body” (Interview 7: 278-280). Some participants described a sense that what they were picking up on how the patient makes others feel and saw this as another type of countertransference. Speaking of the patient who made her feel foggy in session, participant 1 suggested that instead of feeling what the patient was feeling, “I might be feeling how other people in his world feel, when they engage with him” (Interview 1: 222-224). Participant 6 described her reaction to a patient that gave her more information about how people in his environment might experience him. Noticing her own reaction when she is with the patient, she described what it might mean for the treatment: “I like him very much and I find him boring. When you feel like you’re bored, to my mind, it’s because we’re colluding in some way, or we’re missing something, or what’s this resistance in the dyad that - he seems monotonous” (Interview 13: 416-419). In describing her body reaction to what she called “deadened” patients, participant 3 explained how her own body unexpectedly offers information about the patient’s experience in the world: “Yawning usually comes when they’re not present. They might just be chattering away, and it’s like, where are you…You just want to distract yourself” (Interview 17: 294-299). Countertransference that occurs in the patient-therapist dyad also has an effect on the treatment, according to several participants. Several themes emerged related to the concept of a therapist feeling something that belonged to the co-created space, as opposed to something in her own experience or within the patient. Participant 6 described how she would rely on her countertransference to assess whether to continue offering a touch

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technique to a patient in session. Recalling the feeling that gave her pause in continuing with tablework with a particular patient, she recognized that what she was feeling was not specifically her own experience, but not necessarily the patient’s experience. She said: “There was something there that I felt I need to attend to before I would feel comfortable doing that. And I couldn’t tell if was mine or his” (Interview 6: 164-166) Later, she continued: “It was in the dyad” (Interview 6: 281-282). Participant 6 also described how the physicality of the countertransference made use of her own nervous system to attune to the patient and help regulate the patient in the moment: [The countertransference] “gave me permission to be completely present. In fact, it made me aware of the necessity of being completely present, physically, and how I would use my nervous system to calm the other person’s nervous system” (Interview 6: 277-281). In using bioenergetic practices, participant 7 described how the shared experience allows a kind of embodiment for the patient that does not require actual physical touch but serves as a connection between therapist and patient: “Between the therapist and the client, between the client and the therapist, how the person is embodied in her own experience… that goes on whether we’re touching or not touching” (Interview 14: 367370). Participant 3 explored working in a space between patient and therapist, coexperiencing with the patient: “And I think I’ve always worked between the two in the room, obviously, you kind of work between those two positions. Totally immersing as if you were them, so that you could feel their world” (Interview 17: 268-270). Therapists described using countertransference to connect to knowledge outside the patients’ conscious awareness. This idea of understanding and using

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countertransference relates to the concept that psychodynamic therapy helps bring attention and understanding to aspects of the psyche that are not consciously registered. Participant 6 said that the therapist’s role “Is to help people become more embodied. I tell everybody, ‘You know things, you know in a way that’s not just an intellectual knowing.’ And we’re taught to not pay attention to what we know” (Interview 6: 351-354). This technique includes paying attention to physical embodiment as new information, with the therapist partly using her own countertransference to identify feelings and sensations and to bring them to conscious awareness. Therapists also described their own intuition about patients: Participant 5 described how a year after termination, a patient came into her mind. She described the feeling of knowing that a patient was in distress: “It was so strong and it pulled me, it pulled on me the whole day” (Interview 12: 332). Participant 3 described her experience of energy in the psychotherapy session and how it felt different in teletherapy sessions than in person. She said: “It’s just like a magnet field. Like either drawn in or drawn out. Literally. Like a magnet. You know, you feel it. Yeah, it’s this invisible energetic field between two human beings that we’re missing right now [during the pandemic]” (Interview 3: 242-244). This sense of the connection, of the invisible magnetic echoes the observations of clinicians who say: “a feeling of the uncanny seems best described as a bodily held, lowgrade anxiety, a sign of the press of unconscious material, suspended just out of awareness” (Harris, 2015 p. 40). Participant 7 also ran through a list of questions in her mind as she observed the patient’s physical body and the patient’s presence. As she heard the patient talk, she

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thought to herself: “Who is this person sitting in front of me? What are they living with? In their body? What are they experiencing? How do you understand what they're living with? And that has to register” (Interview 21: 249-251). Some participants described sometimes feeling aware of the patient seeming to be disconnected. Participant 7 said: “It could be totally disembodied, also…it’s as if they’re talking about somebody else. They’re not even sharing some way that’s something of their own experience” (Interview 21: 464-466). This sense that the patient may be speaking about emotionally laden content with an incongruent affect may make the therapist feel disconnected or concerned; these feelings within the therapist are a signal that there is something happening between the patient’s internal thoughts and feelings and the patient’s expression. Participants talked about one of the ways countertransference can be used therapeutically to recognize when a patient’s reaction or feeling differs from what the therapist feels, sitting with the patient in session. Participant 7 explained how she makes use of the recognition that something has shifted: “we feel something and then we disconnect and dissociate… someone might be talking about something, and I - you know, starts getting painful, and I can see that they’re not - they disconnected. I can say, what just happened just there. You lost connection. And I think that helps build a ground, and also a sense that I’m attuned to them” (Interview 21: 468-473). Participant 3 explored how taking in in and using this body countertransference can contribute to the therapeutic work: “You’re being touched. You felt something. And they would use it to help them understand what happens in the world with other people.

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With other people who are not able to work with that consciousness to be able to feed it back” (Interview 17: 329-331).

Qualitative summary. The participants’ immersion in the issues of this research led to a greater understanding of their patients, their own countertransference and the impact of this synergy on the therapeutic interactions and relationship. Through the quantitative survey and qualitative interviews in this research, psychodynamically-oriented clinical social worker psychotherapists acknowledged that touch does occur in psychotherapy. They ascribe meaning to the unintentional occurrence of touch, and to the intentional use of touch in session. They also consider the effect of touch through a countertransference lens, exploring the impact of physical touch on their own internal experience, and, at times, use this as information about the patient and about the therapeutic process. Additionally, they acknowledge the difficulty of talking openly about their use of touch in consultation, and the realization of the importance of doing so.

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Chapter V

Discussion and Conclusions This study looked at the role of touch in psychodynamic psychotherapy, asking specific research questions and exploring them through both a qualitative and a quantitative methodological approach. For the quantitative study, the working hypothesis was that psychotherapists do experience touch in session, and that the therapists have ideas about its meaning and effect on countertransference. For the qualitative study, the researcher’s pre-study assumption was that touch in session has an effect on the countertransference experienced by psychodynamically-oriented clinical social worker psychotherapists, and that themes and concepts emerging from a discussion of this experience can be used to develop a greater understanding of the effect of touch on the therapist’s countertransference and on the therapeutic relationship. The project included collecting data directly from psychodynamically-oriented clinical social worker psychotherapists, analyzing the quantitative data using statistical methods, analyzing the qualitative data using phenomenological research methods, and suggesting possible answers to the research questions as well as implications for clinical practice and ideas for future research. Based on my review of the literature and much of the commentary on touch in psychodynamic psychotherapy, I anticipated that psychotherapists who agreed to

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participate in the research would have opinions about the use of touch in psychotherapy. What I found was that they had a deep understanding of psychodynamic thought and had interesting and varied ideas about touch. There were several surprising results. From the literature review, it appeared that psychodynamic psychotherapists might be disinclined to use touch in treatment, or even reluctant to discuss it, possibly with a supervisor, consultant, or directly with the patient. This may be because of the generally cautionary tone of much of the literature on the use of touch in psychodynamic psychotherapy, which contains numerous theoretical justifications for not using touch in treatment, as well as examples of therapists crossing boundaries and taking actions that are seen as nontherapeutic. While there is research on touch in psychotherapy, many proponents of using touch do not take a psychodynamic approach. Of the seven psychodynamic therapists who were eager to talk about their ideas about touch and countertransference, three initially said that they never use touch in session. During the interviews, those who did endorse using touch recalled times when patients had touched them, or when they had deliberately used touch with a therapeutic intention. Therapists spoke less about their own bodily reactions or about their feelings towards the patient; they spoke more about their experience of touch itself in the therapeutic encounter. The topic of touch gratifying the therapist and the topic of erotic countertransference were also mentioned by participants but not discussed in depth. It is possible that participants may have felt that these topics were too close to boundary violations and felt uncomfortable exploring them in our brief time together. Several participants mentioned the prohibition on touch and on how even talking about touch was

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uncommon among psychodynamic psychotherapists. This increased my awareness of the challenges of discussing this topic; in retrospect, it might have been more useful to ask more direct questions or interview each participant them more than three times.

Limitations of the Study

The quantitative portion of this study has several known limitations. The research only focuses on psychodynamically-oriented clinical social workers in North America who practice psychodynamic psychotherapy, which is not as large a group as the entire population of clinical social workers. The study group was limited in this way to seek a psychodynamic understanding of the research problem, but it also resulted in challenges in recruitment of a large quantitative sample. The 38 respondents to the survey may not be representative of the estimated population of psychodynamically-oriented clinical social workers in North America. The qualitative research study also has limitations. Of the seven therapists who agreed to participate, all identified as female; no therapists of other gender identities offered to be in the study. The lack of gender diversity could be a limitation to this research. Finally, this mixed-methodology study was conducted from the perspective of a clinician who does use touch in psychodynamic clinical practice; despite bracketing and following standard qualitative research methods, it is likely that this may have had an effect on the data that was collected and the way it was analyzed.

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Conclusions Conclusions on how the experience of touch in the psychotherapy session is described by psychodynamically-oriented clinical social work psychotherapists. The quantitative research resulted in several main findings about the use of touch in session. Most participants acknowledged that touch does occur in psychodynamic psychotherapy, and most also discussed intentional and unintentional instances of touch with the patient. There may be a reluctance in general to openly acknowledge the occurrence or perhaps the importance of touch during sessions, as evidenced by only a small percentage of survey participants acknowledging that they document the occurrence of touch in session. However, there is a recognition by many therapists of the need to process touch when it does occur, as evidenced by responses showing that many participants do discuss touch experiences with peers, supervisors, personal therapists or others. An even higher percentage indicate that their mode of processing touch in sessions is by self-inquiring and processing touch in session on their own. In the qualitative study, participants described their experience of touch in very concrete ways by enumerating specific situations and contexts when touch occurred, rather than beginning by talking about the experience of touch itself. For example, participants recalled past therapy sessions and described how touch had impacted the interaction between patient and therapist, the treatment, or the patient or therapist themselves. This may have been due to the way questions were structured by the researcher. Over the three interviews, participants talked somewhat more in depth about

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their ideas about the experience and meaning of touch. This could be a reflection of the rarity of opportunities to discuss touch openly in a psychodynamic context. The quantitative section revealed that touch does occur in psychotherapy and explored characteristics that might make a therapist more likely to use touch, as well as therapists’ ideas about touch. In the qualitative section, participants focused both on how touch would occur in session, and the meaning they made of that experience. In many cases, it was the researcher’s prompts that shifted respondents back to the question of their own experience and how they would describe it. Several said that at times they found that touch gave them information about the patient that went beyond verbal communication, such as patients spontaneously and unconsciously flinching away from touch or leaning into it. They were able to make an interpretation of what this response, and their feelings about it, might mean for the treatment. Interview participants also began to explore what might cause a therapist to lean in or move back from their patient, possibly a reflection of their non-verbal response to patients’ discussion of painful material, influenced by their own countertransference They reflected on how they were aware of these non-verbal responses as they begin to examine them in discussions with colleagues. This heightened awareness could help therapists become more attuned to their own responses to touch-related occurrences in session, including unanticipated touch from the patient, and the use they might be able to make of these spontaneous experiences. Participants also considered how deliberate or spontaneous touch, either by patient or therapist, can serve many functions, as a therapeutic tool or as an expression or source of information itself. Connecting to theory, participants demonstrated careful attention to the patient’s body, whether they were using

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touch or not. Aron writes: “In clinical psychoanalysis the analyst needs to attend to all sorts of direct and symbolic expressions of the patient’s experience of the body” (2015, p. xvii). This attention to the somatic experience was integrated into an understanding of the patient by participants, and understood, at times, through their own somatic reactions. One of the unexpected findings related to this research question was that several participants described an experience that was not explicitly touch at all, but was an experience of presence, or of a shared energy. They described a connection with the patient that resembled touch but did not involve physical contact. Some used language of energy work, while others described a kind of presence or a specific feeling. Another unexpected and important finding was how often participants used touch or physical sensations as a way of being more attuned to what the patient might possibly be thinking or feeling, particularly when the patient was not able to fully articulate those thoughts or feelings in words. Attachment theory could explain how physical sensations and feelings in the countertransference communicate what cannot be verbalized, with patients seeking representations of mental states through the body (Aron, 2015). Fonagy and Target write: “the child finds out about other minds through generating ‘countertransference’ responses from attachment figures, particularly parents and friends: sending probes and waiting for a reaction” (2007a, p. 929). Respondents also talked about other influences that impacted their experience of touch in the psychotherapy session. These included the relational models of co-created space, interacting subjectivities, and the influence of therapist and patient on one another.

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Conclusions on the meaning that participants ascribed to the experience of touch. Participants’ responses about the meaning of touch in therapy were more limited than their vignettes about the occurrence of touch in therapy. Participants spoke about the meaning of touch in psychotherapy from several different perspectives. One perspective was what meaning the touch seemed to have to the patient; another perspective was focused on the therapist’s experience and spoke to their own exploration of countertransference. The distinction between intentional and unintentional touch is an issue that many participants mentioned; it may be that they felt that this distinction was also meaningful to their patients. The therapists interviewed seemed to reflect on their motivation for using intentional touch, or abstaining from intentional touch, and sought to understand it. While they felt that intentional touch by patients served as a form of communication, unintentional touch could also be interpreted within the context of the psychotherapy treatment. Participants in the quantitative survey responded to questions about their beliefs about the use of touch in psychotherapy. In general, they expressed a much higher level of comfort about touch that was unintentional than that which was intentional. This may confirm and conform to the previously discussed ideas about the prohibitions and biases against touch in psychotherapy, in which intentional touch is seen as transgressing a boundary. Most respondents felt that non-intentional touch does not transgress a boundary. The anonymity of the quantitative survey may have made it easier to express

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ideas about touch and personal biases more succinctly, while the intimacy and discussion format of the qualitative interviews may have encouraged more careful wording and less formulated ideas. Overall, the participants’ responses reflected the tenor of earlier writings and studies on touch in psychotherapy, in that participants indicated a reluctance to talk about it, and a reluctance to explore the subject fully. However, when respondents were eventually willing to explore the use of touch in psychotherapy, more were likely to acknowledge its existence and its impact on the work. Participants acknowledged that the use of touch did, at times, enhance their understanding of and attunement to the patient. It also seemed, at times, to enhance the patient’s perception of the interpersonal connection with the therapist. However, most participants were very much aware of and closely tied to the constraints against the use of touch and the potential pitfalls of using intentional touch in psychotherapy, which limits this type of exploration in everyday practice. One of the take-aways from these findings that is of most value to the future practice of clinical social work and other types of clinical practice is the value of and need for keeping discussions about touch in the forefront of clinical work. When clinicians feel they cannot talk about touch, whether intentional or unintentional, there is much more of a danger of misinterpretation, shame and closure on a potentially important avenue of exploration. When touch is considered an important dimension of clinical work, and is openly discussed with supervisors, consultants, colleagues, and most of all, patients, it opens avenues for exploration that can only deepen the therapy and

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therapeutic connection. Such discussions also guard against transgressions that can occur when clinicians are steeped in shame, protectiveness and fear of “being discovered.”

Conclusion on how touch in session impacts countertransference. Some of the central findings in this study centered on the research question of how touch in session might impact countertransference as understood by psychodynamically-oriented social work psychotherapists. In the quantitative portion of the study, most survey participants felt that touch might impact countertransference, although accidental touch was seen as having less of an impact on the countertransference by some therapists than intentional touch. Most participants also said that they miss sharing space with their patients when the Covid-19 pandemic led to many only doing teletherapy; fewer said that they missed using touch during this time. The qualitative research also resulted in findings about therapists’ attitudes towards touch and about their understanding of countertransference. In the interviews, countertransference was described by the participants as a source of information about the patient, the treatment, and the therapists themselves. They explained how touch affects the treatment, and how it impacts their internal experience. They also discussed the process of deciding to use touch in session; several connected the concept of countertransference to somatic experiences and intuition. Participants talked primarily about their experience of feeling more attuned to their clients when touch occurred in an intentional way. With prompting, several were able to talk about how this attunement affected their interactions with their patients. Touch was thought to help therapists feel more empathetic or express a connection or

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attunement to the patient. When touch did occur that elicited for the participant a more neutral or negative feel, participants said that they ended up feeling more wary, or cautious of using touch at all. Surprisingly, participants did not explore their own countertransference feelings of anger, or of feeling hurt, when clients used touch in a more aggressive way. Therapists demonstrated that their understanding of countertransference affects their experience of touch in session: they make sense of their own reactions through a countertransference lens to understand whether to offer or withhold touch with a patient, and to assess the benefit of touch on the treatment in the moment. They reflect on their own feelings and use models of countertransference to assess whether what they are feeling belongs to the patient, the therapist, or the dyad. What the therapist knows or perceives about the patient also affects touch-related countertransference in session. Therapists brought up themes of age, gender, sexuality and culture in describing the effect of touch on their countertransference. A shared background was seen as an opportunity for greater connection with a patient and as creating the possibility of misunderstanding or misattunement. Therapists’ ideas about categories of people also influenced their decision to use touch, and assumptions about what the touch might mean for a particular person may foreclose discussion with patients on the impact of touch. Therapists described noticing the patient's physical body, processing that information, and considering it through a countertransference lens. They also described being attuned to noticing physical and energetic characteristics of the patient, monitoring how what they noticed changed with the use of touch. Therapists noted that they

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observed therapeutic growth as well as disconnection or disembodiment in their patients' bodies, and some sensed a kind of force field, regardless of whether they were using touch in session. A therapist's own background, training, personality and experiences were described as affecting the countertransference in relation to touch. Therapists discussed their changing attitudes to touch in session, the importance of supervision and personal therapy, and the ability to contain one's own feelings in the service of the treatment. Therapists discussed both positive and negative body countertransference in session and how they understood what it might mean about the patient or the treatment. Psychoanalytic training, its lack of openness towards touch in treatment, the analytic couch, and concerns about other therapists' opinions of the use of touch in session were also described as affecting the therapist's countertransference. Among the most cogent findings in this research were the preconceived ideas participants had about touch, including prohibitions. For this reason, when conducting the interviews for the qualitative research, I decided to disclose my experience as a mindbody practitioner who uses touch in psychotherapy. The finding that touch does impact countertransference contributes to the understanding of how to work within a psychodynamic model while using mind-body techniques in session. Drawing on the field of neurobiology, for example, patients’ anxiety can be understood from the perspective of infantile experience and touch may be understood as providing reassurance and increasing a sense of safety. That could pertain to clinical work and the choices a clinician makes about using touch with particular patients. Focusing on the physical body or the “sensate experience” (Eldredge and Cole,

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2010, p. 80) could contribute to an understanding of the patient’s experience and needs in treatment; the therapist’s perception and visceral reaction to the patient provides additional information in offering psychotherapy treatment.

Implications Clinical implications . This research has direct implications for psychodynamically-oriented clinicians. Touch, thinking about touch, and talking about touch are useful sources of information. There is a range of ways to do psychotherapy; under any circumstances, the clinician serves themselves and the client best by receiving supervision and consultation about the way they practice psychotherapy. It is critical for psychotherapists to be thoughtful and informed when considering the experience of touch in clinical practice and whether to use touch intentionally within the psychotherapy framework. Countertransference issues around touch are a particularly important area to bring into supervision and consultation because of the various legal messages and constraints, because of the current climate around sexual harassment, and to ensure that nothing is misinterpreted. Some participants described an awareness of their countertransference in relation to touch in the psychotherapy session, explaining how they became aware of it and make use of it when touch is used diagnostically and therapeutically. In interpreting the diagnostic meaning of touch, therapists rely on their countertransference. They consider whether what they are feeling is their own reaction, something the patient is feeling, or how the patient makes others feel. They also consider whether what they are feeling is something in the dyad. In using touch therapeutically, therapists use their

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countertransference to assess whether touch would be appropriate and generative. They monitor the effect of touch on increasing embodiment, sustaining grounding, and creating connection during times of intense suffering. In the relational model, this may be a kind of induced countertransference, as described by Harris: “a communication from and for each of us created an imaginative inhabiting of the patient’s experience” (2015, p. 59). Feeling what the patient feels is an example of countertransference that does not require physical touch, but touch may provide an additional source of information. The therapist’s countertransference is also used to evaluate regression and to avoid creating a situation of dependency. The traditional psychodynamic or psychoanalytic framework therapists describe is ultimately a construct of deprivation. Therapists describe an awareness of monitoring their use of touch to ensure that it facilitates feeling and exploration, instead of smoothing over difficult feelings or keeping them out of emotion. They also monitor their own countertransference to ensure that touch is precise and intentional, and specifically different from the kind of touch a patient might experience with a friend or family member. Touch practices and touch experiences increase the therapist’s felt sense of countertransference. Therapists described an increased ability to note what they physically feel in the countertransference and separating their feelings from the feelings they attribute to the patient. They described touch as increasing the experience of embodiment, sensing boundaries, and entering the other's world while remaining anchored as the therapist. Themes related to the understanding of touch through a

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countertransference lens in session are a greater ability to sense the resonance, increase attunement, use affective empathy, and mentalize. This experience of using the body as an instrument in therapy is described in the literature with parallels to an artist creating art (Bady, 1984) or to a dancer: “We can attune ourselves more to the body-mind in the analytic dance, if we not only listen with the third ear but consciously feel with our skin, our bones, and our viscera our patient’s narratives of desire” (Wrye, 2015, p. 114). Bady describes how this awareness facilitates countertransference in therapy “Sensory awareness enables the therapist to be in a fine tune with his or her unconscious and facilitates an awareness of countertransference – once viewed as a sign of weakness in a therapist, presented here as a valuable tool the mature therapist welcomes into the treatment situation” (1984, p. 539). As the body and sense of touch are used as clinical instruments, countertransference can also be used as a tool to determine the appropriate diagnostic or therapeutic use of touch. Therapists who generally do not use touch may rely on their countertransference in deciding how to react to a request for touch, or to the rituals of hugs or handshakes. Therapists who use touch intentionally in session use their countertransference throughout the process of planning, offering, and processing the experience of touch. It is significant to note that regardless of whether a therapist uses touch regularly in session, countertransference can be an important tool to evaluate whether touch might be therapeutic and how it might feel to the patient. Therapists acknowledged that touch in the psychotherapy session, including handshakes, hugs, and intentional touch practices, may have a positive impact of touch on the therapist. This in itself was not given as a reason not to use touch but is an aspect to

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consider in understanding the therapist’s countertransference. Therapists emphasized while that they do not use touch to comfort the patient or to comfort themselves, they recognize that it can potentially benefit the therapist. This was particularly pronounced as several therapists described missing the in-person interaction, and the hugs, while doing teletherapy-only during the COVID-19 pandemic. Therapists emphasized using countertransference to monitor that any use of touch is based on the needs of the patient and relying on supervision and consultation to ensure appropriateness. The discussion of the effect of touch on countertransference led to another clinical implication of this research: actual physical touch is not always needed to make use of touch-related countertransference observations. Therapists talked about their attention to the patient’s breathing, doing energy work without actually touching the patient, guiding the patient's body movement using words, using the voice to touch the patient, and working with the aura or the sensations around the patient. Often therapists who are open to touch develop a sensitivity or heightened ability to work with something that cannot be seen or heard. This observation also extends the usefulness of this research to practitioners who choose not to use touch in practice. Becoming aware of their own bodies, learning body-based practices, and observing how they touch the patients in nonphysical ways can be understood in the countertransference in a similar way to touch. Therapists’ examples of touch experiences that were detrimental to the treatment or made the therapist or patient uncomfortable lead to another clinical implication: therapists need to practice within their own limits of safety and comfort, but not so far inside that they are not viscerally aware of the countertransference experience. Therapists disclosed their own reasons for being comfortable or uncomfortable with touch in

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session; what may work with one therapist would be inappropriate with another. Therapists emphasized how patients understand and take in the therapist’s reaction. They emphasized that there are many ways of contacting patients psychodynamically, energetically, or empathically, without actual physical touch. A final clinical implication is the benefit of talking about touch, with patients or with other clinicians. In this series of interviews therapists acknowledged that touch in session does happen and explored the experience with the curiosity and openness. Simply being able to discuss touch opens new possibilities and generates new ideas about the patient, the therapist, and the treatment. Using countertransference as a monitor and a tool to explore the use of touch gives therapists a way to recognize that their reactions and feelings have an important role in the treatment. Therapists remarked that they were able to think about their case examples in a different way and understand their own feelings about touch better simply from having a conversation about touch in therapy. Being able to talk with other therapists and supervisors about touch in session may facilitate open communication with patients about touch as well. Discussing the experiences of touch with a patient is critical for the therapeutic use of touch and non-touch means of incorporating the physical body in session. Wallin writes: “Beyond the nonverbal behavior that signals our indispensable resonance and attunement, patients…almost always need contingent responses that are conveyed in spoken language. When patients can read our mind in our words as well as in our face, they are helped to experience their relationship with us as one that can accommodate what they may previously have felt the need to dissociate” (Wallin, 2007, p. 155). McDougall echoes this thought: “All that has been silenced becomes a message in-action,

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and it is this action-communication language that may install itself within the analytic situation, there to express itself through signs and secret codes. It is then possible for the analyst to aid his patients to stop the psychic hemorrhage created through continual acting out and the direct discharge of tension, pain, and confusion; to render the actionsymptoms expressible through language, and to enable the patient to undertake his analytic adventure (1993, p. 132-133). Therapists described how the thought process of deciding not to use touch with a patient because it would not be therapeutic at that moment in therapy is different from not using touch simply because it is taboo. The traditional prohibition against touch seems to also have become a prohibition against thinking about touch; this limits the therapist’s creativity and curiosity. When therapists feel comfortable discussing the possibility of using touch with supervisors or colleagues, they create a more generative environment for understanding the patient and the treatment. Acknowledging and discussing the countertransference is also important in the context of therapy that involves touch. Maroda, in exploring how countertransference is expressed through physical contact, notes that “Failure to express or analyze the countertransference, particularly at critical moments in the treatment process, can result in long impasses, untimely terminations, and treatments that run their course dominated not by the transference, but by the countertransference” (Maroda, 2016, p. 156).

Theoretical implications. This research has implications for psychodynamic theory in extending the understanding of countertransference, how it is felt physically, and how it is affected by

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the use of touch in session. In psychodynamic and psychoanalytic psychotherapy and psychoanalysis, patients find words to represent mental activity and feelings of the soul. This process of learning to use language to communicate thoughts and feelings offers clues to the unconscious. While the therapist may intermittently offer a thought or interpretation, the therapist is reacting to the patient throughout the session and might understand the reaction through a countertransference lens. When touch occurs in session, the therapist’s countertransference is impacted by physical sensation, biofield energy, and emotions as well as words. Psychodynamic theory emphasizes that patients work to explore the unconscious over time, and that comforting a patient may prevent the patient from discovering or understanding something painful. Therapists in this research emphasized that it is important to hold this concept in mind and use touch when it is complementary. At times, touch may lead to finding and forming words. Touch is described as a bridge from the nonverbal and unformulated but meaningful understandings to a description in language that can be communicated to the therapist and held in the patient’s mind. Countertransference as a theoretical concept has evolved from being seen as an intrusion on the session that should be eliminated to a broader understanding that it can be a useful tool in working with the patient. Touch has also traditionally been understood as a practice that does not belong in the session. Even when therapists do not intentionally practice touch, it does happen with handshakes, hugs, and other spontaneous actions where the patient and therapist come into contact. Developing a theory to make sense of this experience and its impact on the treatment is important.

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The issue of countertransference related to touch elicited many different reactions in the respondents. Some felt as if they were very aware of their countertransference in relation to touch and paid attention to what they were thinking and feeling; this then helped them diagnostically and therapeutically. Some of the therapists interviewed in this research described how physical touch is not always needed to take in the countertransference experience that contributes to informing the therapist about the patient and the session. From this perspective, touch and presence are an extension of the transference-countertransference interchange, the interaction of the patient and the therapist, and additional input for the therapist to use in understanding the patient. Surprisingly, none of the interviewees talked about countertransference in the most traditional (historical) way, as something exclusive to the therapist’s personal experience that should be eliminated to prevent it from impacting the treatment. Another theoretical implication is that touch can be explored and understood rather than excluded from psychodynamic theory. Experienced through the therapist’s senses and countertransference, touch could be connected to theory. Touch could be related to attachment, enactments, grounding, object relations or the relationship between therapist and patient. Touch occupies a different space in therapy when it can be talked about; therapists are able to create models and hypotheses about their cases when they are encouraged to think about touch, about the possibility of touch, and about the meaning of touch in treatment. This includes expanding theory to include both touch itself and the capacity to talk about touch. It also recognizes that nonverbal information can be important in session and can be communicated to the patient and received in the countertransference. The therapist may take in this information, recognizing that the

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patient’s interpretation, understanding, or experience of the moment may be different from what they are able to articulate in words. From a relational perspective, the bodies are in the session and the subjectivities inhabiting those bodies mutually affect and influence one another. Aron writes: “The analyst must be attuned to the nonverbal, the affective, the spirit (breath) of the session, the feel of the material, to his or her own bodily responses, so that these may be gradually utilized to construct metaphors and symbols that may be verbally exchanged by the analytic pair, gradually permitting the differentiation of the more primitive shared skinego and the construction of a more developed, articulated, and differentiated personal attachment and interpersonal connection” (2015, p. 26). Fonagy and Target use an attachment model to link countertransferential experience to information about object attachments: “since the mind never, properly speaking, separates from the body, the very nature of thought, the very nature of adult symbolic processes, will be influenced by characteristics of the primary object relation” (2007b, p. 432). Linking this idea to the experience of the body in session, a therapist could understand more about a patient’s earliest experiences of attachment and develop a feeling-sense about their effect on current relationships. Target and Fonagy also emphasize how countertransference can not only lead to a greater understanding of the patient, but it is in itself a generative process. They write: “Many psychoanalytic theories of development assume that the self develops transcendentally, from within the individual. We take the view that it is, instead, an interpersonal process requiring interaction with the minds of others” (Target & Fonagy, 1996, p. 474).

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Looker emphasizes that including the body in treatment is critical for the connection to affect and cognition: “The touch taboo and the fixed postures of patient and analyst that we have inherited from the classical model inhibit not only what we do and say with our patients, but even what we are able to imagine and feel. We have been taught to be quick to reflect interpretively, to impose rational order on bodily experience. We foreclose our opportunity to learn from the body and to connect it to both affect and abstract thought (Looker, 2015, p. 239). Harris connects the body to countertransference, in a discussion about the analyst’s vulnerability and analytic bodies: “Whatever you do about and with your countertransference, its presence is irreducible” (Harris & Sinsheimer, 2013, p. 257).

Social and policy implications.

This research has implications for policymakers and licensing boards. The qualitative interviews reveal how carefully therapists think about the use of touch in therapy. When therapists feel that touch is allowed in the psychotherapy session, they may be more willing to talk about touch that is happening but not discussed. Licensing boards, social work organizations and malpractice companies should recognize that therapeutic, intentional touch does happen in session and should be both allowed and clearly defined. Implications for society include the recognition that it may be important to address the continuing effect of the prohibition on touch that originated with the older psychoanalytic tradition. Even when touch is allowed in session, therapists may fear judgment or criticism if they acknowledge that touch happens both intentionally and

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spontaneously. Therapists’ reluctance to disclose the use of touch to other therapists may prevent them from fully exploring the experience, limiting the patient’s treatment, and continues the perception that touch is not occurring in psychotherapy. Implications for education include the idea that the topic of touch in psychotherapy should be discussed in social work schools. Many therapists said that the topic of touch was not addressed or presented as a taboo and a mistake in treatment. Social work schools could update their curriculum to reflect how state boards of social work address touch, the benefits and risks of using touch, and how to manage, process, and talk about unexpected touch in session. Social work education could also be expanded through approved continuing education courses on touch in the fields of ethics, therapist-patient communication, and neurobiology. Increased discussion of the ethical, and generative use of touch may create an environment in which therapists are more willing to disclose the actual occurrence of touch in session. If therapists feel safer discussing touch in supervision and consultation, there may be more opportunities to intervene in nontherapeutic use of and possibly prevent instances of abusive or unethical touch. There are also implications of this research for leaders in the social work field. Social work leaders and advocates should recognize that touch does occur in session, and that social workers invest in training and practice to use touch therapeutically with patients. They should refrain from making the assumption that the use of touch leads to ethical violations, and instead raise the level of dialogue about the ethnical use of touch. Social work leaders should also respect the rich history of touch research and encourage investment in future research, incorporating touch research into the creative, dynamic

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thinking about how clinical social worker psychotherapists practice and work towards healing and growth. This research has implications for individual therapists and supervisors. It is important to have a more open discussion of how appropriate touch might work in psychotherapy, signs of when touch is nontherapeutic, and how therapists might learn to use their countertransference to monitor the helpfulness and appropriateness of the use of touch in session. Individual therapists may feel that they should not disclose accidental or intentional touch in session because of their colleagues’ judgment. This may create an environment in which therapists do not seek guidance or consultation on a complex and important topic. Talking openly about touch and using the countertransference to monitor the touch experience could facilitate therapists’ ethical practice, and promote dialogue There may also be implications for social workers effecting change in social and racial justice. Some of the interviews took place during the protests of the police killings of George Floyd and Breonna Taylor, and the discussion of countertransference expanded from therapists’ experience in session to a larger exploration of difference, othering, and therapists as effectors of social change. Countertransference questions that therapists asked themselves about touch and countertransference included: How is this making me feel? Why am I feeling this way? Does it mean something about me or about the patient? Is this how the patient feels? Is this how the patient makes others feel? How can I use what I am feeling to understand the patient’s experience? If social workers could lead the way in asking these questions in everyday life, they could possibly play a larger role in creating greater understanding and eventual social change. The context of societal unrest highlights the importance of recognizing countertransference as a tool to tolerate

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difference and discomfort, to sort out reactions, to recognize transference, projections, and introjections, and to promote increased mentalizing inside and outside the consulting room.

Research implications. This study adds information to the literature about the effect of touch on countertransference and highlights further questions and areas for future research. Interviewing non-female-identified therapists from more diverse ethnic backgrounds may provide more insight into the role of gender and internalized assumptions. Meeting with therapists more than three times may create a greater degree of trust and lead to greater insight about topics that were not accessible during the three interviews. This may include an exploration of the benefit of touch to the therapist, or a discussion of erotic countertransference. Another area of future research may be seeking out more psychodynamically-oriented therapists who regularly use touch in treatment and exploring the models they may create to understand the experience of countertransference in relation to touch.

Personal implications.

This project allowed me to research a topic of great personal and professional interest. I practiced mind-body therapy as an oncology social worker, but as I moved into a psychodynamically focused individual psychotherapy practice, I wondered about the meaning of touch in session and how I could use my countertransference to understand the experience. Interacting with the participants, my classmates, my professors and my

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colleagues in a focused discussion was enriching and exciting. I was surprised at the diversity of experience and different interpretations of countertransference and the effect of touch. I was encouraged by the openness and curiosity of the participants and grateful for their time and support. This research strengthened my idea that countertransference might be a psychodynamic concept to help understand the effect of touch in session. Countertransference can be used both as a tool to monitor the use of touch and as a sensor to understand the patient’s experience; this mixed methodology study has answered some questions and created more questions for me.

Conclusion This study highlighted the fact that despite a lingering traditional prohibition on touch in psychodynamic psychotherapy, social workers do sometimes use touch in session, and have ideas about its meaning and effects on countertransference in psychotherapy treatment. Ultimately, this study reveals ways in which therapists and analysts can be sensitive to nonverbal communication, sometimes through the sense of touch, and process it through a filter that assesses countertransference. Certain aspects of traditional Freudian psychoanalysis have reinforced the tendency to ignore the physical body, privileging verbalized content and reaffirming the cartesian split between body and mind. With the traditional taboo on touch and physical separation of body and gaze created by the placement of the patient on the couch, the frame of psychoanalysis creates an opportunity to perpetuate that aspect of privilege that is blind to the physical reality of the patient.

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Orbach wrote: “When something becomes off limits without being much thought about or rather thought about anew from time to time, we are in danger of fossilizing. Our field, our collective and individual practice diminishes” (2003, p. 17). It is my hope that this research contributes to greater openness and increased willingness to talk about touch in psychotherapy and to understand its meaning through the concept of countertransference.

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V. Discussion and Conclusions