Psychotherapy Theory, Research, Practice, Training
2008, Vol. 45, No. 3, 391– 404
PRACTICE REVIEW
USE OF PHYSICAL TOUCH IN THE “TALKING CURE”:
A JOURNEY TO THE OUTSKIRTS OF PSYCHOTHERAPY
VERENA BONITZ
North Dakota State University
The present literature review examines
how physical touch has been used by
therapists with their clients in tradi-
tional verbal psychotherapy. Attitudes
and practices of therapists are pre-
sented in a historical context, starting
with physicians’ treatment of female
hysteria in the 19th century, and con-
cluding with current issues of debate.
The use of touch in therapy has been
highly controversial ever since Freud
stated his principle of abstinence. This
paper intends to give an overview of
the various positions of influential ther-
apists on the use of touch and their
rationale for touching or not touching
their clients, including the contextual
factors that have shaped the use of
touch over time. Furthermore, research
findings pertinent to the use of touch in
psychotherapy are included. The review
concludes with practical recommenda-
tions concerning the use of touch in the
contemporary therapeutic setting.
Keywords: psychotherapy, touch, his-
tory of psychology, ethics
Verena Bonitz, North Dakota State University.
Dr. Bonitz is now at Iowa State University.
The author would like to thank Jim Council and three
anonymous reviewers for their thoughtful comments on ear-
lier drafts of this article.
Correspondence concerning this article should be addressed to
Verena Bonitz, Department of Psychology, Iowa State Univer-
sity, W112 Lagomarcino Hall, Ames, IA 50010. E-mail:
vsbonitz@iastate.edu
Copyright 2008 by the American Psychological Association
0033-3204/08/$12.00 DOI: 10.1037/a0013311
Physical touch plays an important role in the
healing practices and religious ceremonies of var-
ious cultures (Hunter & Struve, 1998; Levitan &
Johnson, 1986; Miller, 1997), and many research
studies have validated the importance of touch
for our physical and emotional well-being. For
example, contact comfort rather than feeding has
been found to lead to affective bonding between
infants and their caregivers, consequently impact-
ing on a person’s relational style throughout the
life span (Ainsworth, 1989; Bowlby, 1969; Har-
low, 1958). Touch deprivation in infancy has
been linked to the infant’s failure to thrive (Field
et al., 1986), and to aggressive and antisocial
behavior in adults (Hunter & Struve, 1998). Mas-
sage therapy has been shown to have positive
effects on depression, immune system function-
ing, blood pressure, and state anxiety (Field,
1998; Moyer, Rounds, & Hannum, 2004).
However, in the Western tradition of verbal
psychotherapy the use of touch, despite its rec-
ognized therapeutic effects, has been highly con-
troversial ever since Freudian times. Touch is a
powerful means of nonverbal communication, ca-
pable of bringing about considerable healing ef-
fects when used in the psychotherapeutic setting
(Durana, 1998; Kertay & Reviere, 1993); its use
however is also associated with a potential for
harm, for example in form of sexual exploitation
of clients (Pope & Bouhoutsos, 1986; Stake &
Oliver, 1991), uncontrolled reenactment of trau-
matic material (Hunter & Struve, 1998), or the
imposition of societal power dynamics, for ex-
ample, in male therapist-female client dyads
(Brown, 1985; Major, Schmidlin, & Williams,
1990). The controversy surrounding the use of
touch in psychotherapy is fueled by a complex
interplay of theoretical rationale, cultural taboos,
and ethical and legal considerations.
The aim of this paper is to disentangle the
various threads interwoven in the debate on the use
of touch in psychotherapy by presenting the topic in
391
Practice Review
a historical context. I will start out with an illustra-
tion of the extensive use of touch by physicians
in the treatment of hysteria in the 18th and 19th
centuries, setting the stage for Freud’s reconceptu-
alization of the treatment of mental disorders. A
discussion of Freud’s psychoanalytic principles and
techniques will be included, as they had a pivotal
and far-reaching influence on consecutive theoriz-
ing and practice of the use of touch in psychother-
apy. An outline of different theoretical views on the
issue spanning the decades after Freud’s introduc-
tion of psychoanalysis will be followed by a sum-
mary of research efforts on the topic, with a special
emphasis on the alleged role of touch in the inci-
dence of sexual relationships between therapists and
their clients. In addition, an overview of current
attitudes and practices in the use of nonerotic touch
as well as current issues of debate will be presented.
The review concludes with a summary of major
sociocultural factors that are shaping the use of
touch in contemporary psychotherapy, followed by
a set of practical recommendations.
Women in a State of “Crisis”
Touch constituted a vital part in the treatment
of mental diseases in the 18th and 19th centuries
in Western societies. Often, as in the treatment of
female hysteria, touch was employed that was
more or less openly sexual in nature. Because of
the nonexistence of appropriate ethics codes and
poor understanding of female sexuality at the
time, these kinds of practices were not regarded
as problematic by a great number of medical
professionals (Maines, 1999). Two examples of
such dubious treatments, namely the practice of
mesmerism and the treatment of hysteria by phy-
sicians in the late 1800s, are presented.
Mesmerized!
Franz Anton Mesmer (1734 –1815), a Vien-
nese medical doctor, attributed illness (mental
and otherwise) to a misalignment of the magnetic
force field (“animal magnetism”) that he thought
to pervade the human body. The cure consisted of
the realignment of these magnetic forces with
help of magnets, passes over the body, intense
gazes, and touch of certain zones of the body, that
led up to a “crisis,” often involving convulsions
(Hart, 1896/1982; Hunt, 1994). Mesmer, a master
of self-promotion, soon opened a salon in Paris
where he hosted group sessions that soon became
392
the dernier cri among the city’s upper classes in
the late 1700s. A graphic account of such a ses-
sion, saturated with sexual overtones, has been
presented by Hart (1896/1982):
Mesmer, wearing a coat of lilac silk, walked up and down
amid this agitated crowd in company with Deslon and his
associates, whom he chose for their youth and comeliness.
Mesmer carried a long iron wand with which he touched the
bodies of the patients, and especially the diseased parts. Often
laying aside the wand, he magnetized the patients with his
eyes, fixing his gaze on theirs, or applying his hands to the
hypochondriac region and to the lower part of the abdomen.
This application was often continued for hours, and at other
times, the master made use of passes. He began by placing
himself en rapport with his subject. Seated opposite to him,
foot against foot, knee against knee, Mesmer laid his fingers
on the hypochondriac region and moved them to and fro,
lightly touching the ribs. The master, raising his fingers in a
pyramidal form, passed his hands all over the patient’s body
(. . .) until the magnetized person was saturated with the
healing fluid, and transported with pain and pleasure. Young
women were so much gratified by the “crisis” that they
begged to be thrown into it anew. (pp. 31–32)
Mesmer’s activities soon attracted the attention
and disapproval of the French medical establish-
ment, who then launched a thorough investiga-
tion of Mesmer’s practices and his theory of
animal magnetism. Results from double-blind
studies were summarized in a report to Louis
XVI, the king of France (Franklin & Lavoisier,
1784). The committee members concluded from
their observations that the demonstrated effects
were because of imagination and imitation, and
that no such thing as animal magnetism ex-
isted. In a second report, the “Secret Report on
Mesmerism” that was not intended for publi-
cation, the commission commented on the
moral implications of Mesmer’s procedures
(Bailly, 1965). The authors point out that close
proximity and prolonged touch between the
male mesmerist and his female patients stirred
up sexual passions and sensations in both par-
ticipants, and they express their concern that a
continuation of such practices would necessar-
ily lead to a decline in decency and morality.
Hysteria: A Pathologized View of
Female Sexuality
Female hysteria (“womb disease”), known to
physicians since the time of Plato and peaking in
popularity in 19th century Western European so-
cieties, was a “disorder” that afflicted women
with a cluster of vague nervous symptoms such
as anxiety, irritability, fainting spells, sleepless-

ness, and sensations of heaviness in the abdomen
(Briggs, 2000; Maines, 1999). These ailments
were attributed to a “wandering uterus” filled
with “unexpended seed” as a result of sexual
deprivation. Another line of reasoning stemmed
from “reflex theory” that was popular among
physicians in the 19th century. This theory advo-
cated that every “irritated” organ in the body was
able to affect any other organ via neural connec-
tions (Shorter, 1992). The main culprit, again,
was the uterus, which was thought to be reflex-
ively connected with the brain and thus causing
all sorts of nervous symptoms in women.
In line with Galen’s humoral theory, the goal
of treatment was to redirect the “wandering” or-
gan into its normal position, accompanied by the
expulsion of “excess fluids” (Maines, 1999). As
Maines illustrates from archival sources, the cure
of choice was marital intercourse; if this was not
an option, “pelvic massage” was often adminis-
tered by a midwife or physician resulting in a
crisis called “hysterical paroxysm” (namely: or-
gasm) after which women felt much relief from
their symptoms. According to Maines (1999), there
was no evidence that physicians enjoyed the task; it
was tedious, skillful, and it could take up to an
hour of stimulation to induce the “crisis.” Hence,
physicians embraced the invention of the electric
vibrator, which reduced the time-to-orgasm from
up to an hour to a couple of minutes, enabling the
physicians to treat more patients (and multiply
their income). Maines argues that most physi-
cians who practiced this procedure did not con-
ceive of it as sexual, or the “crisis” as orgasm:
Little was known about female anatomy and sex-
uality, and an androcentric model of sexuality
(sex defined as penetration of the vagina by the
penis to male orgasm) dominated the medical
literature as well as society as a whole. By 1920,
the practice of clitoral stimulation had disap-
peared from physicians’ offices. Several reasons,
Maines argues, contributed to its decline: Vibra-
tors used for stimulation were available as house-
hold appliances, making it unnecessary to go to a
doctor’s office for treatment. Later, vibrators ap-
peared in erotic films, hampering the mainte-
nance of the clinical camouflage of the procedure.
In addition, increased knowledge of female sex-
uality exposed the procedure as a sexual act.
Finally, and most importantly, Freud had rede-
fined the origin of hysteria, arguing that it
stemmed from childhood sexual traumas rather
than from sexual deprivation.
Practice Review
Sigmund Freud: “Sexual Pervert”?
In his early years of treating hysterics Freud
routinely employed touch in the form of exerting
pressure on a patient’s forehead to stimulate the
surfacing of memories; he also stroked or mas-
saged a patient’s head or neck (Breuer & Freud,
1957; Hunter & Struve, 1998). However, later in
his career Freud abandoned the use of touch in
the therapeutic setting, holding up a strong stance
of abstinence. On what grounds did Freud recon-
sider his position on the use of touch? Two main
motives can be identified, one related to his social
environment, the other to changes in his psycho-
analytical technique.
After the publication of his essay “The Etiol-
ogy of Hysteria” in 1896 in which he located the
origin of hysteria in the occurrence of sexual
traumas (later: fantasies) in childhood, many of
Freud’s more prudish contemporaries were out-
raged by him referring to children as having
sexual feelings and fantasies, calling him a “sex-
ual pervert” (Fosshage, 2000; Jones, 1955). In the
aftermath, Fosshage (2000) argues, Freud did ev-
erything to avoid further misunderstandings re-
garding the nature of his treatment, seeking to
establish psychoanalysis as a respectable rational
science apart from mysticism, religion, and
quackery.
A second motivation to shift his perspective on
touch grew out of Freud’s daily work with pa-
tients. Freud discovered that patients transferred
their feelings they had experienced toward early
authority figures onto the analyst (including sex-
ual wishes and aggressive drives), hereby reen-
acting the dynamics of previous important rela-
tionships (Freud, 1912, 1915). The analysis of
transference became a cornerstone of psychoan-
alytical technique, facilitating the exploration of
unconscious motivations and conflicts. For a full-
fledged transference to unfold it was therefore
necessary for the analyst to remain as neutral as
possible, a “blank screen” onto which the trans-
ferential feelings could be projected; this princi-
ple of abstinence included the prohibition of self-
disclosure on the part of the analyst as well as
physical touch (Freud, 1912, 1915, 1919; see also
Mintz, 1969, for a discussion).
Touch, in congruence with Freud’s pleasure
principle, was seen as a means of gratifying a
patient’s infantile sexual wishes, hereby keeping
the patient fixated at an infantile level. Fixation,
in turn, precludes the emergence of these primi-
393
Practice Review
tive urges into conscious awareness, hereby rob-
bing the patient of the opportunity to eventually
work through them. Hence, abstinence from
touch was seen as an important way of frustrating
the patient; only through frustration of their in-
fantile wishes the patients were thought to be
motivated to change and gain insight into their
unconscious struggles. An important implication
was that touch of any sort was now seen as
inherently sexual and therefore taboo (Fosshage,
2000), promoting misconceptions about the use
of touch in therapy for decades to come.
Freud’s Legacy: Touch in Psychotherapy in
the Aftermath of Freud
In the time period after the establishment of
psychoanalysis up to the 1970s, the controversy
that unfolded about the use of touch was mainly
based on theoretical grounds and anecdotal evi-
dence. The early psychoanalytic movement was
more or less polarized into two camps: The ma-
jority of orthodox psychoanalysts such as Men-
ninger (1958) and Wolberg (1954) strongly ob-
jected to any form of touch, whereas others, such
as Ferenczi (1953), Reich (1945), or Balint
(1968) experimented with touch to varying de-
grees, some breaking away from traditional psy-
choanalysis and even founding their own schools.
Therapists belonging to schools of thought
other than psychoanalysis, such as humanistic
orientations including Gestalt therapy, were
much more in support of using touch as an ad-
junct to verbal therapy, often even formalizing its
use (Perls, 1973). In the following, the theoretical
positions regarding the use of touch of these
schools of psychotherapy will be illustrated.
Freud Versus Ferenczi: Why Stop With a Kiss?
It did not take long until Freud’s principle of
abstinence was challenged. Sandor Ferenczi, one
of Freud’s most beloved disciples, soon pro-
foundly disagreed with Freud’s technique. He
realized in his work with patients that in overly
frustrating them he reenacted the early neglect
and abuse some of them had suffered in their
family of origin (Hoffer, 1991). He then aban-
doned the technique of frustration in favor of a
“relaxation technique,” which included gratifica-
tion of his patients’ demands by hugging and
kissing them (Ferenczi, 1953). Unfortunately, Fe-
renczi also got romantically and sexually in-
394
volved with at least two of his female patients
(Masson, 1988), which drew a scornful reply
from Freud, who was concerned about the repu-
tation of psychoanalysis and the (mis)application
of analytic techniques by novices in the field
(Roazen, 2001). In a famous 1931 letter to Fe-
renczi, Freud wrote:
There is no revolutionary who is not knocked out of the field
by a still more radical one. So-and-so many independent
thinkers in technique will say to themselves: Why stop with a
kiss? Certainly, one will achieve still more if one adds “paw-
ing,” which, after all, doesn’t make any babies. And then
bolder ones will come along who will take the further step of
peeping and showing, and soon we will have accepted into the
technique of psychoanalysis the whole repertoire of demivi-
ergerie and petting parties, with the result being a great
increase in interest in analysis on the part of analysts and
those who are being analyzed. The new ally will, however, lay
too much claim to this interest for himself, the younger of our
colleagues will be hard put, in the relational connections that
they have made, to stop at the point where they had originally
intended, and Godfather Ferenczi, looking at the busy scenery
that he has created, will possibly say to himself: Perhaps I
should have stopped in my technique of maternal tenderness
before the kiss. (cited in Roazen, 2001, p.771)
These disagreements between Freud and Fe-
renczi were never resolved. Instead, they opened
up one of the major battlegrounds of psychoana-
lytic technique: Does frustration promote change,
or is it counterproductive to healing by reenacting
old traumas of deprivation?
When Pendulums Begin to Swing, They
Commonly Swing Too Far
Within the psychoanalytic camp the majority of
analysts were more or less opposed to the use of
touch, following Freud’s lead. Extreme views of the
prohibition of touch were held by Menninger
(1958) and Wolberg (1954), who looked upon any
type of touch (even a handshake) as “incompetent”
or even “criminal.” Unfortunately, Menninger did
not make any distinction between touch that is
therapeutic, aggressive or sexual in intent (Hunter
& Struve, 1998)–with far-reaching consequences,
because Menninger was actively involved in shap-
ing the field and the training of analysts.
Through anecdotal accounts and informal sur-
veys we have evidence that not all analysts were
as abstinent in their clinical work as theory pre-
scribed (e.g., Mintz, 1969; Pinson, 2002). Some
analysts noted in their publications, that nurturing
touch could facilitate the analysis of certain pa-
tients: Balint (1968), for example, advocated that
touch was a valuable if not necessary component

in the work with deeply regressed patients. Win-
nicott (1965), known for his concept of the “hold-
ing environment,” reported literal holding of psy-
chotic patients.
A few psychoanalytic practitioners swung to the
other extreme, incorporating touch as a formal tech-
nique into their repertoire. Wilhelm Reich, a student
of Freud and Ferenczi’s, did not agree with the
traditional mind-body distinction. Reich had a par-
ticular interest in understanding the patient’s resis-
tance in therapy. He noticed in his clinical work that
patients did not only show resistance by dismissing
the analyst’s interpretations, but their defensiveness
also manifested itself in their body posture, breath-
ing pattern, and muscle tension (Kepner, 1993;
Reich, 1945). The task of the therapist was to deal
with this “character resistance” by locating the “ar-
mor” that hindered the free flow of (sexual) energy
and prevented the emergence of the underlying con-
flicts. The removal of the defensive “armor” was
achieved through a variety of techniques. These
included breathing exercises, expressive move-
ments of limbs, or direct pressure on certain muscle
groups. These activities were hypothesized to allow
energy to flow freely, leading to the resolution of
the underlying instinctual conflicts.
As a consequence of this practice, Reich was
expelled from the orthodox psychoanalytic circle
(Hunter & Struve, 1998). However, Reich’s
body-centered approach attracted numerous fol-
lowers, and many different extensions of this type
of therapy have been developed. Lowen (1976),
for example, used his approach of bio-energetic
analysis to gain a better understanding of how
specific disturbances (e.g., depression, or differ-
ent personality disorders) are manifested in char-
acteristic bodily postures and tensions. In addi-
tion, Lowen refined Reich’s therapeutic
techniques, including the use of physical touch.
Others in the Reichian tradition (e.g., Pierrakos,
1976) focused on how disturbances in psycholog-
ical functioning negatively impact our physical
health, hereby pointing out the importance of
studying disease in a holistic way.
On Being a Good Parent
In the 1960s, psychologists became interested
in the development of attachment patterns be-
tween a mother and her child, pointing out the
impact of a lack of attachment on the child’s devel-
opment (Ainsworth, 1967; Bowlby, 1969; Harlow,
1958). A therapist working from an attachment
Practice Review
framework sees his role analogue to that of a
mother who provides a “secure base” for their
child from which it can explore the world. In the
therapeutic relationship, by functioning as a “se-
cure base” for the client, the therapist responds to
the client in a reliable, attentive and empathic
way that enables the client to explore painful
experiences and feelings (Bowlby, 1988). In this
context, physical contact can be a powerful
means of facilitating this secure attachment for
the client.
An outgrowth of this framework constituted
the “reparenting” movement in psychotherapy
that sought to literally provide the good parenting
and attachment the patients never had obtained in
the first place. This included holding and rocking
of deeply regressed patients, or even letting the
patient suck on the therapist’s thumb (Moser,
1992; Whitaker, Warkentin, & Malone, 1959).
Have you had your “peak experience” yet?
Humanistic therapists place great emphasis on
genuineness and spontaneity in the therapeutic
relationship, as they value the free expression of
feelings. In line with this philosophy, nonerotic
touch is seen by many humanistic therapists as a
means of communicating genuine affection and
authenticity (Hunter & Struve, 1998; Stenzel &
Rupert, 2004).
Fritz Perls, the founder of Gestalt therapy, was
an analysand of Wilhelm Reich. This relationship
heavily impacted Perls’ notion of the therapeutic
process, and he incorporated many of Reich’s
views into his own approach, including the em-
phasis on eliciting powerful emotions, and a di-
rect confrontational style (Smith, 1975). Most
importantly, Gestalt therapy greatly stresses the
integration of the body and its sensations, and the
use of touch was somewhat formalized as a
means of establishing contact between therapist
and client (Imes, 1998; Perls, 1973).
Techniques centered on touch were particu-
larly valued in the human potential movement’s
encounter groups that became popular in the
1960s and 70s; common group exercises included
back rubs, group hugs, and massage (Howard,
1970; Rogers, 1970). The permissive and rebel-
lious Zeitgeist of the time also fashioned a more
nonconformist offspring of these groups such as
advanced “Nude Sensitivity Training Work-
shops,” where participants could “actively try
new ways of relating” (Howard, 1970, p. 86).
Sometimes, in search of “peak experiences,” en-
counter group practices led into uninhibited sex-
395
Practice Review
ual orgies between group members or even in-
volving the therapist (Perls, 1969; Shepard,
1972). Fritz Perls candidly recounted his own
indulgences at the Esalen Institute (Perls, 1969).
For professional gatherings or encounter groups,
sexual activities were frequently on the agenda,
gaining him the reputation of a “dirty old man,”
as he liked to call himself.
Götterdämmerung
Up to the late 1970s, the debate over the use of
touch in psychotherapy was mainly based on
theoretical rationale. Report of touch in scientific
publications was anecdotal; systematic research
studies on the practice, meanings or repercus-
sions of touch were nonexistent, and the topic
was taboo among professionals, their organiza-
tions, and journal editors (see Pope, Sonne, &
Holroyd, 1993 for an in depth discussion). In
particular, physical contact in conjunction with
sexual intimacies between therapists and clients
was regarded as a “problem with no name” (Da-
vidson, 1977).
This situation was about to change when sev-
eral researchers, starting with Holroyd and Brod-
sky (1977), began publishing the results of sur-
veys conducted among mental health
professionals of various disciplines, investigating
therapists’ attitudes and practices regarding dif-
ferent types of touch. In Holroyd and Brodsky’s
survey, 12.1% of male and 2.6% of female psy-
chologists reported having had a sexual relation-
ship with at least one client (sample size: 1,000,
return rate: 70%). Eighty percent of the offending
therapists did so repeatedly, and 4% of the total
sample rated therapist-client sexual contacts as
potentially beneficial for the client. These shock-
ing numbers were confirmed in subsequent stud-
ies conducted during this time frame (e.g., Pope,
Keith-Spiegel, & Tabachnick, 1986; Pope, Lev-
enson, & Schover, 1979). More recent surveys
(Pope, 1990; Stenzel & Rupert, 2004) indicate
that sexual contacts between therapist and client
have been reported significantly less frequently
over time. However, it is not clear whether this
trend is primarily because of an actual decrease
of such occurrences as a result of increased eth-
ical awareness. Because of a heightened threat of
litigations and other professional consequences,
many cases might go unreported, even in an
anonymous survey (Pope & Vasquez, 2003).
The studies on the frequency of therapist-client
396
sexual contacts elicited mixed reactions; disbelief
and denial (Sonne & Pope, 1991), fiery debates,
but also more concerted research efforts on the
topic of touch. In the following section, the major
research findings and threads of discussion will
be presented, spanning the time period between
the late 1970s up to today. Three major theme
clusters will be discussed, namely the difficulty
of differentiating between nonerotic and erotic
touch, the concept of boundaries, and research on
important variables affecting the use of nonerotic
touch.
How Do You Know It’s Sexual?
Fritz Perls, the founder of gestalt therapy, once
stated candidly (Perls, 1969):
And if I comfort a girl in grief or distress and the sobbing
subsides and she presses closer and the stroking gets out of
rhythm and slides over the hips and over the breasts (. . .)
where does the grief end and a perfume begin to turn your
nostrils from dripping to smelling? (p. 100)
This quote fittingly illustrates one of the major
dilemmas surrounding the use of touch in psy-
chotherapy: What kind of touch interaction is
appropriate and ethical, and where does one have
to draw the line? Research indicated that most
therapists at the time were somewhat in the dark
when it came to judging the meaning or nature of
types of touch (Holroyd & Brodsky, 1980; Stake
& Oliver, 1991). The origin of common miscon-
ceptions (e.g., that all touch is inherently sexual)
can be attributed to cultural taboos (Cohen, 1987;
Heller, 1997) as well as a strong influence of
Freudian doctrine (Durana, 1998) as described
earlier.
In Western societies, especially in the U.S.,
touch among adults is often used either to signal
sexual intentions or as an indicator of power
dynamics in a patriarchal society (Hunter &
Struve, 1998). These cultural traditions have been
exemplified in research studies: men are more
likely to perceive touch as sexual in intent (Ab-
bey & Melby, 1986), and the highest frequency
of touch occurs between friends of the opposite
sex (Jourard & Rubin, 1968). In terms of power
dynamics, Major et al. (1990) reported that a
person high in status is more likely to touch
someone of lower status, rather than the reverse.
Feminist therapists in particular are concerned
that these dynamics are repeated in the therapeu-
tic relationship if touch is used by a male thera-
pist with a female client, potentially contributing

to further disempowerment of women (Alyn,
1988; Brown, 1994).
Further factors that exacerbate the distinction
between appropriate and inappropriate physical
contact are the lack of agreement on the features
and characteristics of sexual touch, and ambigu-
ous wording of questionnaire items in surveys
(Stake & Oliver, 1991). In addition, although all
major professional organizations nowadays de-
clare sexual relationships (including sexualized
touch) between therapists and current clients as
unethical (see Pope et al., 1993 for the wording of
ethics codes of various organizations with regard
to sexual relationships), no concrete ethical
guidelines exist on the use of appropriate and
therapeutic forms of touch (Durana, 1998).
On the Way Down the “Slippery Slope”
Whereas in the early days of psychotherapy the
disagreements centered primarily on differences
in theory and technique, the focus has shifted
throughout the 1980s and 1990s to ethical con-
cerns and risk management considerations. As a
result, the concept of boundaries became a topic
of heated dispute. Boundaries, “the “edges” of
appropriate behavior” play an important role in
the maintenance of a safe and predictable thera-
peutic relationship (Gutheil & Gabbard, 1993,
1998). Boundaries include, for example, the
length of sessions, fee arrangements, multiple
relationships, therapist self-disclosure, gifts, and
physical contact. It is always the ethical respon-
sibility of the therapist (not the client’s) to main-
tain and enforce these boundaries. Boundaries are
not a strict one-size-fits-all concept; whether a
certain behavior is categorized as a benign cross-
ing of boundaries (i.e., constructive departures
from the usual therapeutic framework), or
whether it is viewed as a boundary violation that
leaves the client harmed and exploited depends
on the therapist’s theoretical orientation, client
pathology, gender, and, most importantly, the
situational context (Gutheil & Gabbard, 1998;
Lazarus, 1994). Because of these factors, the
distinction between boundary crossings and
harmful boundary violations can often be difficult
to make in everyday practice. This is further
complicated by the possibility of one leading to
the other: The “slippery slope” argument states
that, although infrequent boundary crossings can
enhance the therapeutic outcome, repeated
stretching and blurring of boundaries might be a
Practice Review
precursor to more serious boundary violations,
such as therapist-client sexual relations (Gabbard,
1994, 1996; Simon, 1989; Strasburger, Jorgen-
son, & Sutherland, 1992). For example, sexual
attraction between therapists and clients seems to
be a common phenomenon; nearly every male
therapist (95%) and 76% of female mental health
professionals reported having felt sexually at-
tracted toward a client at least once in their career
(Pope et al., 1986). This experience left most
therapists in a state of guilt, anxiety, and confu-
sion. In addition, only half of the respondents
reported having had adequate supervision on this
topic, and only 9% said that their graduate train-
ing had addressed these concerns (Pope et al.,
1986, 1993). Unresolved sexual feelings, along
with the inability to recognize and handle erotic
transference reactions from the client, can thus
trigger an “acting out” of these feelings, which is
further facilitated by the intimacy and confiden-
tiality of the therapeutic relationship (Strasburger
et al., 1992). As a result, boundary crossings,
such as frequent use of nonsexual touch, are then
thought to initiate the descent down the slippery
slope toward full-fledged sexual intimacies
(Hunter & Struve, 1998; Pope et al., 1993).
Hence, as a precautionary measure, some thera-
pists believe that it would be safer to avoid any
boundary crossings, such as therapist self-
disclosure or the use of nonerotic touch in favor
of risk-management considerations, regardless of
the therapeutic potential of these interventions
(Gutheil & Gabbard, 1993; Simon, 1989): “From
the view of current risk-management principles, a
handshake is about the limit of social contact at
this time” (Gutheil & Gabbard, 1993).
This position soon came under attack by ther-
apists who feared that adherence to ethical guide-
lines in a restrictive and inflexible way would
limit them in their creativity and ability to tailor
their therapeutic approach to each client, reject-
ing the notion that malpractice attorneys take
over in determining the standard of mental health
care (Gutheil & Gabbard, 1998; Lazarus, 1994;
Older, 1977; Zur, 2001). Lazarus published this
position in a provocative and controversial paper
(Lazarus, 1994) that drew many replies ranging
from supportive to openly hostile (Bennett,
Bricklin, & VandeCreek, 1994; Brown, 1994;
Gabbard, 1994; Gutheil, 1994), and the debate is
likely to continue in the future.
397
Practice Review
Who Uses Touch With Whom, When, and Why?
Despite a major emphasis in the literature on
problematic therapist-client sexual relationships,
research in recent years has shifted toward the
exploration of factors involved in the application
of nonsexual nurturing touch (such as hand-
holding, a hug, or stroking or patting of the back).
Whereas the percentage of therapists involved in
a sexual relationship with their client is quite
consistent across different studies, this is not the
case for the proportion of professionals who
touch their clients in a nonsexual way. The esti-
mates for the percentage of therapists touching
their clients range from close to 100% down to
10% (Milakovich, 1998; Pope, Tabachnick, &
Keith-Spiegel, 1987; Stake & Oliver, 1991; Sten-
zel & Rupert, 2004; Strozier, Krizek, & Sale,
2003). Reasons for these inconsistent findings
include the therapist population under study (e.g.,
social workers vs. psychologists), sampling tech-
niques, point in time, and differing definitions of
what types of touch were included (e.g., a hand
shake vs. hugging). Those studies that explicitly
reported the frequency of occurrence of different
types of touch, however, showed some consis-
tency. Generally, nearly all therapists would ac-
cept or offer a handshake, but the percentage of
those who would hug their clients was much
lower, and even fewer therapists reported holding
their clients’ hands. Behaviors such as kissing on
the cheek, or holding the client on the therapist’s
lap, in contrast, were very rare occurrences.
Regarding those therapists who do touch their
clients, it is of great interest to learn about their
decision-making process. Researchers are therefore
studying which characteristics distinguish between
therapists who touch their clients from those who
do not. Further, it is under investigation for which
type of clients and in what situations the use of
touch might be most beneficial. How a client per-
ceives the experience of being touched by his ther-
apist, and the meanings he assigns to the physical
contact is also being explored.
Therapists Who Touch Versus Those Who
Do Not
There are a number of differences between
therapists who touch their clients and those who
do not: Therapists who touch are more likely to
practice a humanistic form of therapy rather than
a psychodynamic one, and female therapists use
398
touch more often than their male counterparts
(Milakovich, 1998; Stenzel & Rupert, 2004; Stro-
zier et al., 2003). Further, therapists who touch
are more likely to consider touch to be healing,
they have made positive experiences with touch
in their own therapies, received training on the
use of touch, and had supervisors that supported
its use (Milakovich, 1998).
“Touch a paranoid and risk losing a tooth, touch a seductress
and risk losing your license. Touch a violent patient with a
short fuse and risk losing everything.” (Older, 1977, p. 201)
Therapists who use touch with their clients
report that not all types of clients are equally
suited for this intervention. Touch has been found
to have therapeutic effects with schizoid individ-
uals with bonding and attachment deficiencies,
clients that are highly functioning (but only on a
primarily intellectual level), clients who perceive
the need for closeness as shameful, and clients in
acute distress (Glickauf-Hughes & Chance, 1998;
Holroyd & Brodsky, 1980). Therapists are also
more prone to touch children or older clients
(Strozier et al., 2003). Clients for whom touch is
not advised are those with engulfment issues or a
history of poor boundary control, those who ex-
hibit borderline functioning, and those who act
overly seductive (Glickauf-Hughes & Chance,
1998; Older, 1977).
The use of touch with clients who have been
physically or sexually abused is controversial, as
touch was often involved in causing the original
trauma (Imes, 1998). Therefore, touching these
clients might result in dissociation, and violent or
seductive behavior (Glickauf-Hughes & Chance,
1998; Hunter & Struve, 1998). However, abuse
survivors who experienced touch in a respectful
and appropriate way, attributed great therapeutic
benefits to it: they reported that touch improved
their self-esteem, trust, and it gave them the op-
portunity to set limits, and to learn that not all
touch is inherently violent or sexual (Imes, 1998).
At the Receiving End
Until recently, touch was mainly seen as either
sexual, aggressive, or nurturing in intent. Nowa-
days, theorists and researchers alike seem to pay
more attention to the differentiation of the possi-
ble meanings that touch can convey. This is par-
ticularly noticeable in the publications by psy-
chodynamically oriented authors. Many
psychoanalysts seem to rethink their stance on

the use of touch: touch is not only seen as an
obstacle to a successful analysis by gratifying
libidinal impulses, but it can serve as resistance
solver, convey symbolic mothering, and commu-
nicate acceptance or a sense of reality (Durana,
1998; Fosshage, 2000). Further, touch has been
used by therapists to reach the client when verbal
communication broke down, as a conversational
marker, to establish safety, to express toward the
client that he is lovable, or to explore aggressive
feelings in a controlled way (e.g., arm wrestling)
(Hunter & Struve, 1998; Kertay & Reviere, 1993;
Pinson, 2002). Clients who were touched by their
therapists, tended to relate more information, and
they perceived the therapist as more trustworthy
(Willison & Masson, 1986).
Geib (1998) interviewed clients about their
touch experiences in psychotherapy and she
concluded that there are four recurrent themes
associated with a client’s perception of the
touch as being highly beneficial: Touch is most
likely to be perceived as therapeutic if the
client has a sense of being in control of the
contact, for example, the therapist asked for
permission before touching. Touch was seen as
helpful when it seemed to be a response to the
need of the client rather than the therapist’s. It
was also rated positively when the touch expe-
rience was processed verbally afterward. Fi-
nally, touch was perceived as most helpful
when the intervention was congruent with the
level of emotional intimacy in the therapeutic
relationship.
Horton, Clance, Sterk-Elifson, and Emshoff
(1995) came to similar conclusions in their sur-
vey of psychotherapy patients’ experiences with
touch in psychotherapy. Almost all participants
rated the touch they received from their therapists
as positive. Patients found touch most helpful
when the intervention was congruent with their
presenting issues (e.g., loneliness, self-esteem is-
sues), when the patients had asked to be touched,
and when they were able to openly communicate
their feelings toward the therapist. Patients who
reported sexual problems, sexual abuse, or fears
and phobias as their presenting issues were sig-
nificantly more likely to rate touch as positive
than those who did not report these problems.
Overall, positive ratings of touch were associated
with the patient’s positive perception of the
working alliance. In addition, respondents indi-
cated that the touch experience created feelings
of closeness and being cared for, and it enabled
Practice Review
them to feel safe enough to explore more threat-
ening material or to work at a deeper level.
Another factor that can define the meaning of
touch is the cultural background of both therapist
and client. For example, in Clance and Petras
(1998), a Latina therapist reports that not touch-
ing her Latino clients would appear quite foreign
and emotionally cold to them. In Germany and
Switzerland, shaking hands is the standard greet-
ing and departing ritual, and a refusal to shake
hands with a client at the beginning and end of a
session could be highly insulting (Holder, 2000).
How Times Have Changed!
Freud’s stance on the use of touch in psycho-
therapy was shaped by both theoretical rationale
and sociocultural considerations. Whether touch
should be used in psychotherapy remains a topic
of debate today. What changed, however, is the
context in which the issue is embedded. Similar
to Freud, many clinicians are still guided by
theoretical considerations when it comes to the
use of touch [e.g., psychodynamically oriented
therapists are much less likely to make physical
contact with their patients than their colleagues
that endorse a humanistic orientation (Stenzel &
Rupert, 2004)]. However, it appears that posi-
tions on either side of the theoretical spectrum
have become more flexible and diverse, resulting
in the establishment of a more pragmatic middle
ground.
Besides the focus on theoretical rationale, the
larger sociopolitical context has substantially
shaped the place and meaning of touch in contem-
porary psychotherapy. First, we now have a better
understanding of how ill-timed or sexual touch neg-
atively affects a client’s well-being. Second, there is
a heightened awareness of how gender issues, cul-
tural issues, and power dynamics are reflected in the
therapeutic relationship. Further, contemporary psy-
chotherapy is guided to great extent by ethical con-
siderations as well as risk management practices.
These important factors will be illustrated in the
following sections.
The Problem Got a Name
Whereas up to the 1970s the existence of ther-
apist sexual misconduct was officially either ig-
nored or denied (see Pope et al., 1993 for an in
depth discussion), therapists and professional or-
ganizations alike are now stepping up to the chal-
399
Practice Review
lenge, and concerted efforts are being made to
understand the dynamics of therapist-client sex-
ual relations. According to Pope, several factors
might render therapists susceptible to entering
these kind of relationships; among these are in-
sufficient recognition of sexual behaviors as they
occur, training issues (no open discussion of sex-
ual feelings, professors serving as inadequate role
models by getting romantically involved with
their students), denial of the problem, and miss-
ing awareness of the damage done to clients
(Pope, 1988; Pope et al., 1993). Pope (1988)
consequently coined the term Therapist Client
Sex Syndrome, pointing out the harmful effects
these encounters produce in clients, namely
feelings of ambivalence, guilt, rage, confusion,
and increased suicidal risk. Furthermore, in-
creased anxiety, depression, substance abuse,
and trust issues could be observed (Stake &
Oliver, 1991). Therefore, strategies are being
developed that are aimed at the reduction of the
prevalence of therapist sexual misconduct. This
includes ethics training workshops (Pope et al.,
1993; Vasquez, 1988), identification of profes-
sionals at risk (Strasburger et al., 1992), ade-
quate screening of graduate school applicants
(Strasburger et al., 1992), and education of
potential clients (e.g., through brochures) that
therapist-client sex is never justified (Thorn,
Shealy, & Briggs, 1993).
Ethics Are Paramount
In contrast to Freud’s era, ethical consider-
ations are paramount in the contemporary prac-
tice of psychotherapy. Yet, there are currently no
explicit guidelines that regulate the use of phys-
ical touch in psychotherapy. Nonetheless, there
are general ethical principles that clinicians
should consider in their ethical decision-making
process when it comes to the use of touch.
Whereas the prohibition of sexual relations be-
tween therapist and client is probably the most
obvious ethical imperative (see Hunter & Struve,
1998 for a compendium of the exact wording in
various ethical guidelines), other relevant stan-
dards include the principles of beneficence and
nonmaleficence (promotion of the welfare of the
client, avoidance of harm and exploitation), au-
tonomy (e.g., lack of coercion), fidelity (e.g.,
fully informing the client about treatment modal-
ities, including the potential use of touch), and
400
competence (American Psychological Associa-
tion, 2002).
Power and Other Differentials
Today, there is a heightened sensitivity within
the therapeutic community with regard to how
larger societal problems such as discrimination
and power dynamics might manifest themselves
in the therapeutic relationship. Physical touch in
particular can signify anything from sexual ha-
rassment to the reinforcement of societal power
dynamics, and additional layers of meaning are
added when this is happening in a multicultural
context (Abbey & Melby, 1986; Major et al.,
1990; Zur, 2007). Therefore, many clinicians
have become cautious in their use of touch be-
cause of the possibility of misperception of their
interventions by their clients or the general pub-
lic. Thus, in response to these issues, clinicians
today often operate from a standpoint of risk
management to avoid the threat of litigation for
professional misconduct (Gutheil & Gabbard,
2003; Zur, 2007).
How You Should Do It When You Do It:
Practical Recommendations
As outlined above, the decision to use physical
touch in traditional verbal psychotherapy is depen-
dent on a variety of clinical, ethical, and cultural
considerations. The following section is intended to
provide tentative guidelines for using types of phys-
ical touch (e.g., hugging or holding) in the contem-
porary practice of psychotherapy that exceed cul-
turally sanctioned greeting rituals such as a
handshake. Based on the literature (Durana, 1998;
Holub & Lee, 1990; Hunter & Struve, 1998; Kertay
& Reviere, 1993; Zur, 2007) the following recom-
mendations can be made: When using touch, it is
important that the therapist have a clear rationale for
using this intervention. The rationale could be the-
oretical (e.g., touch as a means of providing a cor-
rective emotional experience), or based on other
considerations (see Smith, 1998, for a decision-
making model). It is imperative that the touch be for
the client’s benefit rather than the therapist’s. Ther-
apists should closely examine their own motivation
for touching a client to prevent detrimental out-
comes. Use of touch should be embedded in a larger
therapeutic context and be used rather cautiously;
alternative, less risky interventions should be con-
sidered that might bring about the same result.

Further, the clinician should ask the client for
permission to touch and state clearly that the
client has the right to say “no”. In addition, touch
that exceeds a simple handshake should only be
used if a strong therapeutic alliance has already
been established. In addition, it is important to
monitor the client’s reactions (both verbal and
nonverbal) to being touched by the therapist, and
the subjective meaning the experience holds for
the client should be explored. The particular
meaning of touch also greatly depends on the
context in which it occurred (e.g., a single instant
in a crisis situation vs. ongoing body-oriented
work). In particular, it is important to assess
whether erotic transference and countertransfer-
ence reactions are present; in this case, use of
touch should be discontinued.
Based on the reviewed literature, it is clear that
touch is more beneficial for some clients than
others. Therefore, client characteristics (e.g., di-
agnosis, developmental history, prior experience
with touch, or sexual abuse history) should be
considered when deciding whether to touch a
client.
The therapist needs to be comfortable with touch
and should be aware of his or her own issues around
physical contact. Further, the therapist should have
adequate training and background knowledge about
the various issues that might become salient when
using this intervention (e.g., knowledge about im-
pact and functions of touch), and should make ap-
propriate use of supervision or consultation when in
doubt. In addition, the therapist should be familiar
with relevant professional ethical guidelines that
might apply to the use of touch, as well as with
specific rules and regulations at his or her practice
site.
The clinician can implement additional safe-
guards to minimize the risk of exploitation and
harm. These might include the referral of the
client to a colleague who subscribes to a body-
oriented school of therapy, or the enlistment of a
massage therapist who closely cooperates with
the primary psychotherapist. In addition, touch
might be used in a group setting rather than in
individual sessions to minimize the risk of mis-
conduct within the secrecy of the one-on-one
relationship. From a risk management standpoint,
it would be wise to obtain the client’s formal
informed consent before using touch, followed by
clear documentation of the actual interventions in
the treatment records. Finally, the clinician
should be familiar with how his or her malprac-
Practice Review
tice insurance policy is applicable to the use of
physical touch when encountering litigation.
The goal of the guidelines presented above is to
maximize the potential benefits of touch while
maintaining appropriate safeguards to protect the
welfare of both the client and the therapist. It is
hoped that these guidelines might help clinicians to
increase their therapeutic efficacy so that their cli-
ents can receive the full benefits of this intervention.
Summary
The present paper reviewed how physical
touch has been used in psychotherapy over the
last century. Although 19th century physicians
used touch extensively in an unconcerned man-
ner, the situation changed drastically when Freud
introduced his principle of abstinence, banning
physical contact from the analytic setting mainly
for technical reasons. In the aftermath of Freud,
the use of touch elicited much controversy among
practitioners. Whereas up to the 1970s the battle
was fought primarily on theoretical grounds, the
emphasis shifted toward an argumentation based
on ethics and risk-management considerations.
This development was catalyzed by the emer-
gence of empirical studies on the use of touch in
the scientific literature; especially the ones con-
cerned with therapist-client sexual contacts led to
a spectrum of responses, bringing the topic out of
the closet.
Studies on the frequency of the use of nonsex-
ual touch (e.g., hugging, shaking, or holding
hands) yield mixed results, but these kinds of
behaviors seem to occur quite frequently, at least
among therapists adhering to more humanistic
schools. Even some members of the psychoana-
lytic community now have started to rethink their
stance of total abstinence, trying to create a more
humane treatment environment. Therapists who
advocate the use of touch often cite the numerous
therapeutic effects attained by this intervention,
whereas those who oppose it point out the inher-
ent potential for harm, including the role of touch
in therapist-client sexual contacts, the danger of
misinterpretation, the risk of fostering depen-
dency, and the reinforcement of societal power
dynamics.
Ongoing efforts are being made to study fac-
tors that bear significance in the therapist’s deci-
sion to use nonerotic touch, such as therapist
personality, client characteristics, and the percep-
tion and meaning of different forms of touch. In
401
Practice Review
addition, ethical guidelines for the use of noner-
otic touch are being developed. Other attempts
are being directed toward the reduction of the
frequency of therapist-client sexual intimacies:
Raising awareness through training, establishing
standards on how to deal with impaired profes-
sionals and identifying common features that pre-
cede these relationships are some of the top cur-
rent concerns.
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