Touching may be the most intimate type of self-disclosure and is one of the most controversial subjects discussed by analysts.  Whether a pat on the back, a hug, a handshake or a comforting touch, therapists have a varied opinion about what is appropriate.

For many analysts, any physical interaction between analyst and patient is off-limits.  A handshake initiated by the patient is usually considered the most acceptable form of physical interaction while erotic interaction, at the other end of the spectrum, can result in the forfeiting of a professional license and possibly more. But what about physical interactions that fall between the two poles?  While some therapists consider that even a pat on the back exceeds acceptable professional boundaries, others tend to be more flexible about physical encouragement.

As analysts, comfort can serve as a barometer when we are faced with any form of physical interaction with a patient.  A physical response by the analyst that’s tentative, awkward or uncomfortable may cause a rupture in the treatment.  When I am presented with a physical request by the analysand that makes me uncomfortable, I explore the meaning of the overture with the analysand to disarm the awkwardness.  Although I do not feel uncomfortable with a handshake, if I did, I would articulate my hesitation rather than reveal any tentativeness in an awkward action.

With a physical overture, I always follow the patient’s lead.  Handshakes, initiated by male patients as a gesture of thanks, are not uncommon at the end of a session. Typically, I refrain from responding physically to other physical overtures or requests and instead tend to explore them in the course of the analysis.  One exception was when I worked with terminally ill patients in their homes.  In these instances, my therapeutic boundaries become much more fluid since any rigidity can feel unnatural and be experienced as non-empathic.

I once had a patient who for many years talked about the distance between us and about his strong desire to hold my hand.  He claimed that my holding his hand would help him feel connected and comforted.  At some point I realized that my declining his request was stalling the treatment.  One session, after talking again about the request, I agreed to take the risk.  I came and sat next to him and gently took his hand, but when I took his hand I immediately felt awkward and hesitant about how long to hold it.  When should I pull my hand away? Should I wait until he pulled his hand away?  I suddenly realized there would be a rupture when I took my hand away.  After about 30 seconds, I gently pulled away and sat back down in my chair.  What I thought would fulfill an aching need turned into rejection.  Although for years we had talked about and explored the need, the decision I made to satisfy that need, with the best intentions, backfired.  Eventually we recovered from the rupture the handholding had caused and I learned about the power and risk of satisfying even the most basic of physical requests.

The experience with my patient was illuminating.  And while I still have set ideas about the role physicality plays in treatment, I am open to the power of touch in the therapeutic setting.

When I started my private practice I rented an office from a colleague only one day a week and saw all my patients on that day. My colleague’s office conveyed much about her tastes and interests and had a very strong personal look and feel.

Because I had no say in how the office looked, I wondered how my patients would feel and respond to a space that gave such a particular and strong impression. I, in fact, was questioned about the many wall hangings and knick-knacks on display. While I explored this with my patients, I continued to offer as little self-disclosure about my own tastes and preferences as I possibly could.

When my colleague gave up the office and I took it over full time, I had the opportunity to redo it from top to bottom. I wanted the space both to have a neutral quality and a feeling of warmth and safety. I wondered how much of me should be put into the space without self-disclosing more than I wanted to.

Because I wanted my office to be a warm “holding environment”, I found many decisions challenging – the color of carpeting and paint; the look and comfort of the furniture; what hung on the walls; the books on the bookshelves; and what was displayed on the desk, ledges, and bookcase.

I was surprised by how many details I needed to consider during this project – details I wouldn’t have had to deal with in a space dedicated to another purpose. I took the most time and put the most thought into how I would decorate the walls. While I wanted the room to reflect my personal tastes – unavoidable anyway – I was intent on keeping a sense of overall neutrality.

The office had a color scheme of bright red. I chose a very pale gray for the walls and carpeting which radically changed the feel of the room to a light neutral. Decorating the walls however, was more complicated. While I wanted to eliminate what might be disruptive, I still wanted there to be some personality. After many internal debates, I decided against pictures that seemed too stimulating or interesting and went with photographs and paintings of Italy. They were beautiful and at the same time contributed to the overall neutrality of the room.

Going through this process was illuminating because it revealed to me how difficult it is to avoid self-disclosure and how much we inevitably disclose to our patients before treatment even begins.

Appearance is a significant form of self-disclosure.  When I first started my practice 16 years ago, I put a lot of thought into how I would dress.  Because I was renting an office only one day a week at the time, I had no say in its appearance.  I was left with no way to make an impression except by the way I dressed.

Being new to the profession, I thought that looking the most neutral required me to dress in slacks, dress shirt, and tie.  This business look was not typical of the way I normally dressed, but because I followed the blank screen approach, I believed this presentation best fit with that theoretical stance.

As I look back on that decision now – I still dress the same as I did then – I realize that while dress always tells a story, I have little control over how people see me, given that their view is likely to be imagined, projected, or assumed.  Patients will form an impression independent of how I want them to perceive me.

While I once thought that dressing in business attire would elicit respect and enhance my status as an analyst, I came to realize that no matter how I dress, my appearance is “grist for the mill”.  In fact the way this impression colors the treatment helps to shine light on the patient’s psyche and on his/her relationship with me. 

A related issue is the affect of my “real life” way of dressing – unintended self-disclosure – would have on patients who encountered me outside the office.  I had once feared that this might shake my patients’ view of me, of my neutrality and professionalism.  Instead, I found that those few patients I have encountered outside my role of analyst have registered negligible effects. On the contrary, these encounters seem to appeal to their desire to see me as “human” or as “having a life”.

Although I haven’t altered the way I dress in my practice, I imbue it with far less importance than in times past.