Developmental Need, Transformance, and the Judicious Use

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Hilary Jacobs Hendel, LCSWDevelopmental Need, Transformance, and the Judicious Use of Various Forms of Touch in AEDP

Developmental Need, Transformance, and the Judicious Use ofVarious Forms of Touch in AEDP

Hilary Jacobs Hendel. LCSWJune 4, 2014

Private Practice of Hilary Jacobs Hendel, LCSW277 West End Avenue, Suite 3E

New York, New York 10023Tel: 917-239-7006

[email protected] Count: 7209

mailto:[email protected]

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Abstract

The use of touch in talk therapy has long been considered controversial and

even taboo. However, touch when used thoughtfully and judiciously has the

potential to facilitate healing. When confronted with the developmental and core

need for touch, psychotherapists should have the ability to think through when it

could be helpful and when it could be harmful. This paper considers the use of

touch in a clinical case and the way it is negotiated by the patient-therapist dyad.

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This paper discusses an AEDP treatment where touch was incorporated

into the work. I will discuss some viewpoints from the literature; some

considerations regarding the use of touch that are born from the sum total of my

education and training both as a psychoanalyst and an AEDP psychotherapist;

and my specific rationale for incorporating touch into this particular treatment. A

verbatim transcript from a mid-treatment session will illustrate clinical work with

touch. Finally, I will spell out some general guidelines for the judicious use of

touch.

Touch in psychotherapy is a controversial topic. Freud used touch in his

early work but later denounced it citing the dangers of touch where intense

transference exists. Since then, psychoanalysts, lawyers, risk managers, and

ethicists have advised psychotherapists to rule out touch as part of talk therapy

with the main reason being that touch is a “slippery slope.” The slippery slope

argument that has dominated current practice results from the lack of theoretical

distinction in the psychoanalytic literature between nurturing touch and sexual

touch. Eigen (1983) writes, “all physical needs were conceptualized as

essentially sexual drives needing to be sublimated,” but it is precisely that

distinction which matters in a thoughtful discussion on the use of touch by a

psychotherapist.

In the early to mid 20th century, Object Relations theorists such as Rank,

Klein, Fairburn and Winnicott, shifted the focus to pre-oedipal development and

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opened a door to differentiating between sexual touch and early developmental

needs for soothing touch. Harlow and his famous research using wire and cloth

monkey mother surrogates (Harlow, 1971), followed by a long line of infant-child

and attachment research furthered our understanding of attachment and the

need for physical touch to provide comfort and affect regulation in infants and

babies. Attachment research, not to mention intuition, validates that touch is

paramount to healthy development especially in infancy and childhood.

Currently, body psychotherapies like the Alexander Technique

unabashedly use touch. “Body psychotherapists' clinical orientation, such as

Reichian (Reich, 1972) or Bioenergetics (Lowen, 1958, 1976) use touch as their

primary tool in psychotherapy. They see the value of touch and endorse it as a

therapeutic tool whole-heartedly” (Zur, O. et. al, 2011). Additionally, experiential

psychotherapists routinely touch patients as when they are tapping on a patient’s

knees during EMDR processing, pressing on a patient’s stomach to “take over”

physical tension as practiced in Hakomi (Kurtz, 1990) or having the patient push

against the therapist’s hands to experience the physicality of setting boundaries

as in Somatic Experiencing (Ogden et al, 2006). Furthermore, some talk

psychotherapists will touch their patients when the patient initiates so as not to

insult or embarrass them. Examples of this type of casual touch include: A

spontaneous hug, a handshake, a kiss on the cheek, or a “high five” as a show

of support. “Most psychoanalysts are highly opposed to any form of touch in

therapy (Menninger, 1958, Wolberg, 1967, Smith, et. al. 1988). However, many

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other orientations support the clinically appropriate use of touch (Williams, 1997;

Young, 2005; Zur, 2007a, 2007b). The literature is replete with pros, cons,

guidelines and advisements on touch. A literature search and review offers a

wealth of articles on touch in psychotherapy. For an exhaustive paper on the

clinical, ethical and legal considerations of touch in psychotherapy see Zur, O.

and Nordmarken, N. (2011).

Touch, like all psychotherapeutic interventions, has the capacity both for

harm and for healing. Rothschild (2000) writes, “In some cases, I think judicious

touch is useful when client and therapist agree.” It is crucial to think before

acting; to understand the counter-transference and transference implications; to

collaborate with our patients about potential benefit and harm, all of which will

result in making wise clinical choices. “Surveys of clients who have experienced

touch in psychotherapy indicate that touch reinforced their sense of the

therapist's caring and involvement. The findings also "support the judicious use of

touch with clients who manifest a need to be touched, or who ask for comforting

or supportive contact" (Horton et. al., 1995, p.455).”

Years ago, during my analytic training, before I ever thought about actually

using touch with a patient, I remember reviewing the NASW’s and APA’s

guidelines on touch—mostly out of curiosity. I was surprised at the time, since the

taboo felt so strong in my mind, that neither of them expressly prohibits touch.

They do expressly prohibit sexual boundary crossings and imply the essential

message for all caregivers and health professionals: Above all, do no harm!

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Being held is a developmental need. Therefore, It makes intuitive sense

that a therapist’s skillful use of touch could foster healing. There is also an

argument that not using touch when needed might hamper healing or even cause

harm. For patients who were denied adequate physical affection or were outright

neglected, not tending to these developmental and basic needs for physical

comfort and soothing, when needed and/or requested, could be construed as an

enactment of the original trauma. Instead of a blanket rule against touch, I think a

better way to think about touch is whether it could move someone towards

transformance1 (Fosha, 2007); and towards healing versus re-traumatization. I

consider touch the way Ron Kurtz of Hakomi Therapy thinks of touch, that it is a

form of nourishment (Kurtz, 1990). He believes and my observations concur that

if a therapist provides the right nourishment that the patient truly needs, the

patient will accept only what is needed and when replete with nourishment will

move from dependency to exploration of the world at large. In other words,

supplying what is truly needed will lead natural development to continue.

CLINICAL INFORMATION AND RELEVANT BACKGROUND

My patient is a 29 year-old single, college educated, bi-sexual, woman of

Russian Jewish descent who grew up in the southwestern part of the United

States. Sara, as I will call her, was raised in an intact family by a verbally abusive

mother, who relentlessly screamed at her for doing anything other than validating

1 “Transformance” is Fosha’s term for the “overarching motivational force, operating both in development and therapy, that strives toward maximally adaptive organization, coherence, vitality, authenticity and connection.”

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her mother’s own wants and needs. Every since she can remember, Sara was

yelled at for using the “wrong” tone, for saying the “wrong” things, even for having

a flu or throwing up when she was sick. Sara never knew what would set her

mother off and therefore had to constantly monitor her mother as well as her own

verbal and non-verbal communications. She has a loving father who allowed the

abuse to occur because of his own fears of the ramifications of intervening. The

father, as well as Sara, suffers from Obsessive Compulsive Disorder (OCD). The

father’s OCD led him to criticize Sara for being dirty and thereby left her with a

belief that she is disgusting. Between her mother's mental illness and her father's

aversion to natural body secretions and odors, I wonder if Sara was adequately

held.

Some of her problems at the start of treatment include: OCD since age 6,

fear of emotions, fear of assertion, intense focus on pleasing others to avoid

anger at all costs, and difficulty knowing her own needs and wants. All of these

problems make it hard for Sara to be in relationships and, consequently, leave

her feeling isolated, alone, depressed, and anxious. She is extremely hard on her

self and, when I first met her, engaged in self-harming behaviors such as cutting

and head-banging. These behaviors seemed to act as self-punishment for her

perceived badness, but also may be maladaptive attempts to regulate skin pain

(pathogenic affect) caused by early neglect.

In our earlier work, Sara was terrified that she would anger me. Triggered

by any sign she interpreted as my displeasure, I witnessed her plunge into frozen

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uncommunicative states. I was unable to do much for her in those moments

except to reassure her that I was not angry (and I was not!) and remind her I was

here. Inquiring after these episodes passed what I could do next time to be of

more help, she would instruct me to just stay quiet and let her be still until she

naturally calmed down on her own. Over time we experimented with other ways

to help her “come back” such as: grounding her feet on the floor, breathing,

talking about light-hearted things like her favorite television shows, sharing with

her what I thought she was experiencing in the moment, and finally extending a

hand for her to hold on to if she wanted. All of these interventions helped yet it

took her a while to recover. My thought was that the threat of my anger

connected to the pre-verbal memory of her mother's frequent emotional

abandonments and the accompanying emotions of terror, rage, despair and

massive amounts of anxiety.

The treatment has focused on helping her regulate anxiety, differentiate

me from her mother, build her tolerance to the full spectrum of affects and their

accompanying experiences including body sensations and impulses, and

recognize and process core emotions to completion (Fosha, 2000). Additionally, I

am helping her become familiar with and gain separation from younger selves or

“parts” (Schwarz, 1995), also referred to in the literature as self-states2, so she

can listen to their needs and respond. In fact, a main theme in our work is

2 The term “self-state” or “part” refers to discrete experiences of subjectivity created when the brain links somatic, affective, cognitive, and behavioral representations into a cohesive, functional whole (Siegel, 1999).

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managing the intense longings of these younger self-states, which I will

heretofore refer to as “parts” or “selves.” Facilitating a dialogue between parts

of the self makes it possible to manage internal conflicts and transform

maladaptive coping strategies, such as self-harm, into adaptive ways of dealing

with conflict (Lamagna & Gleiser, 2007). As internal parts come to understand

and accept each other, self-compassion, not to mention self-awareness, grows

exponentially.

By her own report, throughout her life she has sought out mother figures in

the hopes of receiving some of the mothering that these younger selves need. I

am the most recent of these maternal figures and the maternal transference she

has towards me is strong. These strivings are adaptive and resilient in the sense

that she is looking for something she truly needs. They are maladaptive in the

sense that she can't ultimately obtain what these child parts need from others as

the demands are too high and healthy adults in relationships have limits. Only

her present-day Self (Schwartz, 1995) is uniquely positioned to care for her

younger selves. I explained this concept to her early in the treatment. That is: in

service to her being able to sustain an adult loving relationship, ultimately it is in

her best interest to be her own good mother.

When we first began working, younger parts didn’t want comfort from

within. They wanted it from me. This is something we still work actively together

on shifting. As the treatment has progressed, internal parts are relating more and

more to each other. As a result, her self-compassion is growing. In essence, we

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are slowly transferring the job of caretaker and soother of her younger selves

from me to her.

Sara and I have always worked collaboratively. She is honest, hard

working, communicative (except in certain distressed states after which she can

reflect on experience quite well), and we have a great appreciation for each other

and the important work we are doing together. From the beginning, her longings

for and access to me were a major theme. Teaching and modeling boundaries is

extremely important in our work, as her mother disrespected hers with verbal

assaults and, as a result, setting boundaries was not modeled properly. Contact

between sessions was discussed and at times I set limits. Having extensively

discussed the importance of boundaries in good/safe relationships, I knew Sara

had a sense of me as a well-boundaried therapist. She was aware that where

boundaries were concerned, I considered and modeled taking care of myself a

part of the equation. This is especially important when a treatment includes the

use of touch so the patient feels safe accepting what she needs without fear of

other boundaries being transgressed by the therapist.

Prior to first holding her, I had thoroughly examined my own thoughts and

feelings about touching Sara. I thought through, both on my own and in

supervision, my motives and goals for acting. I had thought through her possible

responses. We had a history of being able to successfully process ruptures and

meta-process3 (Fosha, 2000; Prenn, 2009) our interactions together. We

3 Meta-processing is an AEDP term and a cornerstone of AEDP theory. It refers to the process of reflecting on experiences of transformation. Fosha (2000) explains how meta-processing the

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discussed my touching her before we acted and subsequently meta-processed

the experiences. We also discussed how others might judge my holding her

(which was an issue she raised) and how she would feel and deal with those

imagined judgments. Other issues we processed included her fears of becoming

dependent on me, her fears of my feeling manipulated, and secondary sexual

gratification she might obtain. These preliminary discussions were the foundation

on which I allowed our work to expand into the realm of touch.

My decision to sooth Sara through holding her in my arms came after

months of working together. Early in our work, Sara would be triggered into a

very dysregulated freeze-like state whereby, among other signs and symptoms

characterizing her distress, her skin would hurt, “It feels like I have no skin.”

Inquiring into the sensation to see what it needed, the need to be held was the

answer it gave. Sara’s body told the story of a developmental deficit which

needed transforming. Being adequately held and soothed is a crucial state of

development. Lipton and Fosha (2011) write, “Beginning at birth, right-brain-to-

right-brain, contingent processes such as holding, touch, gaze sharing, face to

face contact, entrained vocal rhythms, and spontaneous moments of play and

delight are crucial for (i) the regulation of the autonomic nervous system, (ii)

optimal brain development, (iii) the emergence of stress- and affect-regulation,

and (iv) the creation of secure attachment ( p.5).” When a baby or child is not

healing and transformational moments of a therapy session leads to ever-expanding spirals of deepening between patient and therapist and patient and self.

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adequately held and soothed, the child cannot bear the distress and the mind

adapts the best way it can to survive.

The need for touch and holding, from an AEDP perspective, is considered

an attachment striving, a core need, and an inter-subjective experience of

pleasure (Fosha, 2008; Russell, 2014). But, being adequately held is also a

developmental need that when left untended makes it hard for a growing child to

feel confident enough to explore the world. Margaret Mahler wrote about a similar

phenomenon when she described the rapprochement phase of development. “At

15–24 months the infant once again becomes close to the mother. The child

realizes that his physical mobility demonstrates psychic separateness from his

mother. The toddler may become tentative, wanting his mother to be in sight so

that, through eye contact and action, he can explore his world. The risk is that the

mother will misread this need and respond with impatience or unavailability. This

can lead to an anxious fear of abandonment in the toddler. Disruptions in the

fundamental process of separation–individuation can result in a disturbance in

the ability to maintain a reliable sense of individual identity in adulthood (Mitchell

and Black, 1995). So it is with a baby who innately turns to her mother for

physical soothing and finds her unavailable. Overwhelming levels of affect and

unbearable aloneness, stemming from this neglect, lead to the formation of

pathogenic affect (Fosha, 2000).

Hugging and holding satisfies a developmental need. Sara reported she

had a felt sense of that dysregulated part of her as very young. I imagined a

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distressed baby in need of soothing that neither words nor fantasy could calm.

She could not self-soothe either. I wanted to experiment with holding to see if it

might help to regulate this un-symbolizable affective experience wreaking havoc

on her nervous system. And, It did. Touch can intervene at the physiological level

in the regulation of affective states and directly address dissociation and

dysregulation (Shore, 2003). Sara’s newfound ability to recognize her need to be

held and ask for it represents a moment of “transformance” (Fosha, 2007).

Meeting that specific need is transformational and leads to healing.

A final word about sex as it pertains to this treatment. Sara felt guilty

should she derive any sexual pleasure from being hugged. She is not to blame

for having feelings. "Feelings just are," I remind her frequently, “they are normal

and natural.” Judging and acting on feelings and impulses is not helpful but

noticing them and listening to them is. So it is with sexual feelings. Discussing

her concerns and making my thinking explicit has allowed us to move forward in

helping younger parts express their true needs for holding without too much

conflict and shame from developmentally older parts that simultaneously

experience different wants and needs than infant and child parts. When shame or

conflicts arise in the moment, we return to State 1 “Defense Work” (Fosha,

2000) until safety is restored.

I have used various forms of touch in my work with Sara, although the vast

majority of our sessions are just talk. We hold hands; we explore fantasies

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together that include me holding her; and then there are times when I physically

soothe her. The purpose of each form of touch is briefly reviewed as follows: 1) I

offer my hand to hold during moments of both, emotional processing and

dysregulation, in order to help undo “unbearable aloneness” when words and

my presence alone is not enough. 2) When child parts are distressed and want to

be held, I invite us to first cultivate a fantasy, or portrayal, in lieu of actual holding.

I do this to help her increase her self-soothing capacity. When we use fantasy,

she is in charge, but I do guide her. I encourage her present-day self to relate to

her younger parts if they are willing (Schwarz, 1995) (Lamagna and Gleiser,

2008). When those parts want “only me” to comfort them, I encourage and invite

the fantasy to become vivid imagining exactly what she needs from me and how

she is experiencing it. I ask her to sense me holding her and how it feels on her

skin and anywhere else she can notice. When I am comforting (in fantasy) the

child parts, I typically invite the present day Sara into the scene in any way both

she and her younger parts will be comfortable. Sometimes Sara sees herself

standing on the periphery of the room in the scene or sometimes we are “group

hugging.” This is integration in process! While technically not touch, these vivid

portrayals are an extremely intimate experience and could be triggering in the

same way that actual touch could be, so I consider it a form of touch. 3) When I

actually hold Sara, I typically join her on my sofa. She leans in to me and my

arms envelop her. Sometimes I stroke her hair. When her skin burns raw, where

words and fantasies are of no use, the actual physical contact is needed to undo

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the aloneness. More specifically, it supplies the development need that was

lacking at a critical stage and thereby transforms its pathogenicity. Holding brings

immediate relief, typically followed by “mourning-the-self” affects and gratitude

as seen in State 3 phenomenology (Fosha, 2000). When I do hold her, I let her

release the hold first so she takes as much “nourishment” as she needs, unless

we are out of time. We almost always meta-process the impact of our physical

contact, as we do with other relational interventions.

The session below demonstrates touch using a fantasy portrayal

followed at the end by physical soothing. During a moment when the

longings of a young part arise with intensity, I guide her to tune into her

body, to notice what she is experiencing, to bring attention to what she

notices, and to hear what her body is telling her. Then when she

recognizes a desire to be held, we honor it and work with it so see if she

can sooth it internally with fantasy. It is only at the end of the session

that I actually hug her to help her relax and regulate even more before

she goes back out into the world.

The following transcript is from a recent session of a 2x/week treatment

currently approaching its 4th year. Parentheses contain my own private

unspoken process, thoughts, feelings and comments. We begin 13 minutes into

a session before she is going away on vacation for a week. Comings and goings,

needless to say, are fraught and always triggering of fears and insecurities.

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TRANSCRIPT

E: Whenever I go away, not only do I worry about you dying but I also worry that I

will die and you’re not going to know that I’m dead. I don’t know…I just want you

to know that if I die, thank you for everything and I love you. And hopefully you’ll

find out somehow. (Abandonment anxiety coming up)

H: I hear that you want me to know that you love me and are grateful for me

E: Yes (nodding)

H: And I think the chances are very very good we will both be ok and we’ll see

each other next week but-- is there someone you can ask to let me know if

anything happens to you? Would that be a comfort to you? (Honoring her

experience)

E: Yes, I think I can tell Flo—she knows I see you (Sara hasn’t told her parents

she is in therapy for fear of repercussions and judgments)

H: So if you tune in and notice what’s coming up now…(I notice tension around

her mouth which she squeezes tightly shut. This is always a signal she’s having

an emotion and working to hold it down)

E: (Silence)…A bit of sadness…like...just sort of maybe hearing you talk about

comings and goings from zero to 3…(puts hands over her eyes)…yeah

(Previously, we had discussed how current comings and goings resonate with

early abandonments: when her “connected” mom would switch into “angry”

mom and how terrifying that abandonment was)

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H: That touches something…let’s stay with physical sensations? (I ask her to

stay with physical sensations to regulate the affect, which often overwhelms her

—previously she has shared that it is helpful to stop everything we are doing and

focus strictly on her body sensations. Helping her regulate affect is the purpose

of my suggestion)

E: (Labored breathing—some tension in chest—then a relaxing upon recognition)

It’s like a physical sensation of wanting to be held.

H: Can you make some room for that…and maybe get a sense of how old that

part is…or even get an image of that part?

E: (Eyes closed) Like 2…(eyes scrunched close, labored breathing, increasing

distress)

H: See if you can separate from that part more and make it further away so its

feelings don’t overwhelm you as much.

E: (more distressed) It’s crushing me!!! (Pathogenic affect)

H: Where is the crushing feeling inside?

E: (points to chest)

H: What does it need? What does it need to make the experience a little less

intense so it stops crushing you? What is this crushing tell us? (Lots of

silence)...scary, huh!

E: It’s telling me that I want…(squeezing lips to hold down the feeling)…it’s

telling me that I want physical contact.

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H: Which part? How old? (I may be too cautious but I always like to have her let

me know the age of the part before I act on holding her—if she said the part was

16 years old, we would have done something different)

E: (nods yes) Two years I think but maybe the six-year-old too.

H: Yeah…can you check in exactly how it needs the contact and imagine it just

the way it needs it. Is that ok?

E: Yes

H: let’s see if we can take care of that sweet sweet little girl first and see if we

can help her be less distressed.

E: It would help if I hugged the pillow.

H: Great! Feel free (she flops sideways on couch and grabs my pillow and hugs it

which is something she’s done many times before.) Is that a bit better? (I noticed

her body relax a little)

E: Yes

H: Can you get more of a sense of her and where she is?

E: Alone in the living room floor crying her eyes out and confused and alone?

H: Where did everybody go? You don’t know? (She seems to be also in the part,

which I can tell by her childlike voice) What does she need?

E: She needs you!

H: Can you bring me in to be with her? (suggesting we use fantasy)

E: (nodding head)

H: Am I with her? What’s happening? (I ask her to elaborate on the fantasy)

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E: You pick her up and take her away to your house, you’re sitting together on

your sofa and she’s on your lap.

H: Can you describe more of what you see?

E: she’s on your lap, holding onto your torso and crying into your neck.

H: Beautiful…can you tell her I’m with her for as long as she needs me and just

the way that feels right?

E: (visibly relaxing)

H: What do you notice now …just in your body…

E: The crushing is gone…

H: And in its wake, what do you notice?

E: An emptiness…(still lying down and holding a pillow)

H: What’s it like—that feeling...like how big is it, what shape is it, can you take

lots of time to get to know it just for the sake of getting to know it.

E: it’s like 8” oval down my chest…

H: How is it to make contact with it while we’re together? Is it ok?

E: Uh huh

H: Is there a color associated with it…like if we stand on the perimeter and look

in together and I’m holding you securely so you can’t fall in…like we’re holding

hands and I’m tethered to a big tree so we can’t fall in… Just anything you notice

even a glimmer…

E: Its just kind of black

H: Just kind of black

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E: uh huh

H: Can I get you curious about that blackness or is your instinct to stay far away

from it or anything in between. I think it’s meaningful. And I only want to look at

this together, never alone.

E: I just want to pretend it’s not there.

H: is it something you know was there or is this a new discovery?

E: I felt it before (lying quietly then pops up a bit)...I’m sorry.

H: For what?

E: I don’t know…I’m being pathetic.

H: I don’t think you’re pathetic at all. We are touching on very deep and profound

experiences that have huge meaning.

E: Ok

H: I think you’ve done amazing today!! (Affirmation) What’s your sense about

how we have such a different take on the experience we’ve been sharing today?

(Seizing the opportunity to practice being all right with two different subjectivities,

something that her mother could not tolerate)

E: (Big smile--Pops all the way up—sitting up now looking happy and regulated)

I’m not surprised (laughing) by now I know how we differ in that way.

H: Is it possible that when you label something as pathetic, what you’re actually

feeling is incredible vulnerability. We don’t have a lot of language in our culture

praising vulnerability—just the opposite, in fact.

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E: It feels like…to me pathetic means that I wasn’t able to overcome something.

Like I wasn’t able to…like I gave in to the feeling or something…instead of like

trying to cover it up and go on as if nothing was happening.

H: you mean right here right now today?

E: Yeah. Like I should have umm you know…tried not to feel that way…

H: Really?? Why is that?

E: I don’t know.

H: That seems like it would be more of doing what you had to do throughout your

life to survive in your family.

E: Yeah!

H: is it your sense that that would be helpful?

E: (shakes head no)

H: That’s why I am so proud of you for doing something so brave. It’s hard to

touch on these very deep old old old experiences that basically don’t have

language—they get stored viscerally just in these black spaces we all have. They

feel like holes but they are markers for lonely, overwhelmed, in the darkness

feelings. (I am doing some psycho-education here and bringing on the left-brain

to organize right brain experience. Fosha (2008) refers to this as “platforming.”

By saying “we” it let’s her know that this is a normal experience, mitigating

shame and aloneness)

E: Yes! (Recognition) I feel lonely and overwhelmed like all the time.

H: Yeah so maybe that’s this part when it comes to the front.

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E: (nodding yes) Maybe…

H: And maybe we could spend some time here getting to know this place and

what it is telling us about what happened and maybe it would heal a bit and you

wouldn’t have to keep feeling as overwhelmed and alone. That it’s just a feeling

memory in a way…

E: Yeah…(looking down and shaking head yes)

H: I guess I’m curious what it is like, if you just check me out for just a second...is

that ok for you? (I’m inviting her to shift from a downward gaze to look at me

when I ask her the following and she does)

E: Yeah (smiles)

H: What it is like…to touch on a feeling that is full of such aloneness but to do it

when we are connected. How that changes the experience or what it is like…

E: (deep breath) It is good to have you share in it and know about it umm…it is

hard because I know we are together but like sometimes I need…

H: feel free…

E: sometimes I need the physical contact and its not… just being here together is

being good but it is not the same and it doesn’t feel…(really struggling)…like…

(lots of affect and anxiety coming up. I notice her hands rubbing together, deep

sighing, mouth clenched, all of which signify that emotions are pushing up in

response to her trying to express her needs)

H: it’s hard…it’s ok. I would imagine it would bring up lots of feelings maybe of

sadness and maybe some anger. (She is nodding yes) And if we just make

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room…(I gesture with my hands the idea of making lots of room) just to label—

and we’re not going to be with them today because we don’t have time. But just

to label and let them be. And if you still want a hug goodbye from me today, I

would love to (she’s nodding yes). And if you feel angry (nodding no with a smile)

and don’t want a hug, that would be ok too.

E: (nods yes) No, I don’t feel angry. I just feel this intense longing. And I’m not

angry because I know it’s important to try and take care of that without actually

needing it but its so incredibly painful.

H: So painful! Just keep trying to keep that young part separate so she doesn’t

overwhelm you. If you can keep the young part separate (I gesture separating

with my hands)…like really keep her far away and then just talk to her or sit with

her so she’s not alone. And even if it’s not perfect, it may be better than nothing.

E: (nodding yes with big smile) yeah

H: Play with that and let me know.

E: ok...

H: And I’m right here---take me with you to Paris. (I mean in fantasy—entraining

object constancy and undoing aloneness)

E: and maybe I’ll send you a nice picture.

H: I’d love that. We have a few minutes, do you want me to sit with you and have

real physical contact before you go?

E: yes

H: (I sit next to her on couch, she leans into me and I put my arms around her)

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E: it feels so good…

H: Everything’s going to be ok. I think you’ll have a great time…the beauty; the

food…and then you’ll come back. And it is not like it was when you were a little

girl. Now as a grown up you have all these skills and tools in your toolbox to

reach out and cope with what comes. When you were little, you had none. That’s

why it is important to stay in touch with little Sara in any way she’ll have you and

any way you are willing…even if it is just being in the same room and sitting

quietly with her so she knows she’s not alone any more.

E: Sounds good.

H: I love how you are more and more getting to know and share exactly what you

need. (affirming her, loving her up)

E: And sometimes the fantasies help and sometimes not.

H: Yes and as we keep working together, it will get easier and easier to recognize

little Sara and satisfy her needs just as we’ve been noticing all along. And you’ll

feel better and better just like you have been. And maybe even this latest shift

that you shared today about the OCD part having two settings now instead of

one is really a testament to the fruits of our labor. (She shared that some days

she doesn’t have to do the entire washing ritual if she has to get out of the house

for an important reason—that she negotiates with the OCD that she’ll do the

ritual the next day…and it listens!!)

E: Its true. I’m being kinder and more compassionate to myself.

H: Yes you are.

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E: (hugging me tight) Thank you so much! You are so soft and warm.

H: You’re so snuggly! A good snuggler! (I use evocative words of nurturing)

E: Thank you. When’s your birthday? (feeling safe engenders curiosity)

H: September 18th. When is yours?

E: October 5th. I’ll be 30.

H: Very respectable age. What makes you think of this now?

E: I have actually been wondering for a long time. Not that I couldn’t ask, it just

felt particularly safe to ask now.

H: Hmmm it feels very safe right here right now.

(Sara gets up, cheerfully exits to leave on her vacation)

In addition to the immediate relief and affect regulation that holding

provides, there have been many overall shifts in her Self (Schwarz, R., 1995) and

internal organization. Sara reports sensing a lifting of her depression that she

attributes to the moment I held her for the first time when she was experiencing

the painful skin sensation I referred to earlier. She no longer self-harms, she no

longer berates herself for small infractions like being late for a session. She

rarely freezes in session and when she gets dysregulated she comes back

quickly. Her capacity for self-compassion is growing almost from each week to

the next. Sara feels like dating again and traveling and, in general, she is more

adventurous. Her growing assertiveness is evident both in session with me and

out of session with her friends and colleagues.

26


Several days after this session, I receive an email from Sara who was on

vacation. I have quoted it below because it was significant:

“I'm having a very pleasant time here so far! The weather is great and I'm feeling pretty relaxed. Monday's session was a huge help in making me feel safe and secure about being away - thank you so much! Below is a picture of ______ , which we visited today. I hope you're having a great week. I miss you and can't wait to see you on Tuesday!”

I was moved by this communication. It beautifully illustrates how she is moving

through the process of individuating and separating. This growth has allowed her

to begin to explore the world safely and happily with the knowledge that she has

a secure base to which she can reliably return (Bowlby,1988).

In conclusion, touch when used judiciously and mindfully is a healing and

transformational experience. Sara reports that the holding has helped her feel

worthwhile as a human being, and deserving of love, attention and connection.

Her sense of being disgusting and bad is diminishing rapidly. Additionally, she is

becoming more and more compassionate to herself. She is far less dysregulated,

with a growing tolerance for core affective and core relational experiences that

can be processed to completion thereby releasing adaptive action tendencies

(Fosha, 2000). The request and/or need for holding has not increased, in fact it

has decreased. I anticipate that with these early needs nurtured, her desire to

explore the world will grow, as will her capacity to navigate the trials and

tribulations of adult relationships.

HILARY’S GENERAL GUIDELINES FOR TOUCH WHEN REQUESTED BY THE

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PATIENT:

1) Experiment with fantasy holding first—it is generally all that is needed and

it facilitates self-soothing capacities in the patient.

2) If therapist feels an impulse to hold patient or patient request it, think

through why this is coming up now and about counter-transference. Think

about motivations for wanting to touch patient. Think through transference

implications and how various parts of the patient might react.

3) If the therapist has a sense that the patient could benefit from actual

touch, discuss first with the patient. If patient is interested, go to step 4. If

not, drop it.

4) Think through alone and together potential reactions using fantasy for a

dress rehearsal.

5) Have patient sign “Consent to Touch” form before using touch.

6) In future sessions, when touch seems appropriate, remember to check

with patient if they want to be touched in a particular moment.

7) Meta-process the experience afterwards.

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Sample Consent To Touch Form

(Name of therapist) may incorporate non-sexual touch as part of

psychotherapy. Sexual touch of clients by therapists is unethical and

illegal. (Name of therapist) will ask your permission before touching you,

and you have the right to decline or refuse to be touched without any fear

or concern about reprisal. Touch can be very beneficial but can also

unexpectedly evoke emotions, thoughts, physical reactions or memories

that may be upsetting, depressing, evoke anger, etc. Sharing and

processing such feelings with the therapist, if they arise, may be a helpful

part of therapy. You may request not to be touched at any time during

therapy without needing to explain it, if you choose not to, and without fear

of punishment.

Name

Date

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Documents

Developmental Need, Transformance, and the Judicious Use