V. Discussion and Conclusions

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

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

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.

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

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

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.

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

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

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

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

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 mind-

body 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,

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

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

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

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 non-

physical 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

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,

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 action-

symptoms 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

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.

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

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 skin-

ego 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).

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

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

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

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

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.

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.