One day several years ago, I spontaneously hugged a patient of mine, Gretchen.
It was during a moment in which her despair and distress were so intense that it seemed cruel on a human level not to reach out my arms to her, in the event that she might derive some relief or comfort from an embrace. She hugged me for dear life.
Months later, Gretchen reported to me that hug had changed her. “The motherly embrace you gave me that day,” she said, “lifted the depression I have had all my life.” Could a hug really have such an effect? The notion has stayed with me ever since.
Freud used touch in his early work but later denounced it, citing its dangers in cases of intense transference. Since then, psychoanalysts, lawyers, risk managers, and ethicists have advised therapists to avoid touch as part of talk therapy, arguing that it is a “slippery slope.”
The slippery slope argument is well-intentioned; no one wants to sanction or encourage inappropriate touching. But the argument arises only because of the lack of a firm theoretical distinction in the psychoanalytic literature between nurturing touch and sexual touch. That distinction is precisely what matters in any thoughtful discussion of the therapeutic use of touch, be it by a psychoanalyst or anyone.
I started thinking about hugs during my psychoanalytic training. Every so often I was assigned a patient who would hug me without warning, either at the beginning or the end of a session. When I talked about this with my supervisors, some suggested that I stop the hug and instead analyze the meaning of it with the patient. Other supervisors suggested the opposite: that I allow it and accept it as part of a cultural or familial custom. Bringing it up, they suggested, could shame the patient.
I remember consulting the ethical guidelines from the National Association of Social Workers and the American Psychological Association. I assumed “Do not touch” was overtly spelled out. I was surprised to discover that those organizations, while expressly prohibiting sexual boundary-crossings, did not expressly prohibit touch.
The nurturing touch is hardly a new idea. In the early to mid-20th century, object relations theorists like Otto Rank, Melanie Klein, Ronald Fairbairn and D.W. Winnicott helped shift the focus of psychoanalysis from Oedipal development to pre-Oedipal development — that of infants and very young children — in which soothing touch plays a critical role. Later on, psychological researchers furthered our understanding of how essential physical touch is to providing comfort and emotional regulation in adults as well as children.
Today, neuroscientists have learned that when humans get emotionally upset, our bodies react to manage the increased energy. These physical reactions bring discomfort at best and at worst are unbearable. What can we do to obtain immediate help when we are distressed so that we don’t have to resort to superficial balms like drugs or psychological mechanisms like repression? What kind of relief is affordable, efficient, effective and nontoxic?
The answer is touch. Hugs and other forms of non-sexual, physical soothing, like hand-holding and head stroking, intervene at the physical level to help the brain and the body calm down from overwhelming states of anxiety, panic, and shame.
This insight was driven home for me when I underwent training in trauma psychotherapies such as Accelerated Experiential Dynamic Psychotherapy (A.E.D.P.) and Eye Movement Desensitization and Reprocessing (E.M.D.R.). These therapies, which are somatic, or body-related, in emphasis, taught me to make use of my patients’ fantasies and imaginations to help them satisfy unmet needs or regulate their rattled nervous systems. Those fantasies, I have found, are often rooted in physical comfort. I frequently guide my patients’ present-day adult selves to act as their own nurturing mother or father, to offer solace to any suffering “parts” of themselves that need or want hugging and holding.
I also encourage my patients to learn to ask for hugs from their loved ones. A therapeutic hug, one designed to calm the nervous system, requires some instruction. A good hug must be wholehearted. You can’t do it halfway. Two people, the hugger, and the “huggee,” face each other and embrace each other with their full bodies touching. Yes, it is intimate. The hugger should be focused on the huggee with purposeful intention to offer comfort. It is literally a heart-to-heart experience: The heartbeat of the hugger can regulate the heartbeat of the huggee. Lastly and very important, the hugger must embrace the huggee until the huggee is ready to let go and not a moment before.
The paradox of hugs is that though they are quintessentially physical, they can also be enacted mentally.
I often invite my patients, if it feels right for them, to imagine someone they feel safe with, including me, holding them. This works because the brain does not know the difference between reality and fantasy in many ways.
Gretchen, for example, sometimes feels small and scared. I know her well, so I can tell just by looking when she is being triggered into shame. To help her feel better, I intervene using fantasy. “Gretchen,” I say, “can you try to move that part of you that’s feeling shame right now to the chair over there?” I point to a chair in my office. “Try to separate from that part of you,” I continue, “so you can see it from the eyes of your present-day calm and confident self.”
I gesture with my hands to convey a part of her coming out of her body and joining the two of us on the chair a few feet away. Gretchen visualizes in the chair the shame-filled part of her — in her case, her 6-year-old self. In this fantasy, Gretchen hugs and soothes the 6-year-old. Sometimes, however, that 6-year-old wants me, not Gretchen’s adult self, to hug her. I invite Gretchen to imagine that I am hugging the girl. In this way, I “pretend hug” many of my patients without actually touching them.
I still have my Freudian-trained self, sitting over my shoulder, judging the use of “real” hugs in treatment. So, even when I think a physical hug would be therapeutic, I continue to rely on fantasy. And ultimately, I believe it better for the patient to learn to self-soothe, and that is an ability that fantasy cultivates.
But sometimes, as in Gretchen’s case, actual touch changes something deep. It seems, at those times, that there is no substitute for the real thing.
(Details and names have been altered to protect patient privacy.)