GINA, A YOUNG WOMAN IN HER 20s, who had been in therapy for about a year, was rushed to the hospital for emergency abdominal surgery. In response to her distressed phone call, John, her therapist, visited her the next day. Gina was in a great deal of pain when John appeared in the doorway of her hospital room. Saying little, he came in, sat at her bedside, took her hand when she held it out to him, and offered a few reassuring words. After a short while, and after making sure that Gina had friends coming to see her, John left.
For Gina, John's visit meant that he cared about her and could appreciate the depth of her vulnerability and pain. She recognized the visit as an exception to the therapy frame and did not expect it to be repeated. Illness was not a means by which Gina ordinarily expressed her desires to be taken care of, so she did not fantasize, as some clients might have, about getting sick in order to receive John's ministrations. After Gina recovered, she and John discussed the hospital visit, what it had meant to her, and its place in the context of their relationship.
While some therapists would have avoided the hospital visit, arguing that it takes the therapeutic relationship outside the confines of the office and could promise more than therapy can deliver, many practitioners believe that the decision should be based on the individual circumstances and relationship.
What seems most important in this case is that John was not cavalier about his behavior. He carefully thought out the decision to visit, was deliberate in his actions while at Gina's bedside and later created a safe forum in which she could discuss the visits meaning with him. He did not make the mistake of thinking that his visit was equivalent to that of another friend; this was a professional visit that would have symbolic resonance.
Therapists who take their power seriously also take the boundaries of therapy seriously. When they bend the therapeutic frame, they do so carefully and explore the ramifications their action has for the client. They recognize that not all meanings may emerge at first, and that clients may be reluctant to acknowledge just how important a seemingly trivial exchange is to them.
Good therapists recognize, too, that the intense feelings that surface in sessions often gravitate toward the boundaries. And that touch, and other physical contact, may be the most emotionally laden and controversial boundary of all.
One of the problems is that a hug between two people of unequal power is not the same as a hug between equals. The person with greater power, in this case, the therapist, "rations" the hugs, and the client cannot "take" a hug whenever she wants one. This suggests to the client that the therapist's hugs are of tremendous value. Then, too, there is always the possibility that a hug will stir sexual desire. Hugs tend to become a taboo subject, not discussed during sessions even when they are routinely offered at the end, and practically never discussed while they are happening.
How therapists think about touch varies widely. Psychoanalytically oriented therapists are less likely to touch their clients because their theoretical model assumes that physical contact may gratify transference fantasies that need to be understood, not acted out. Therapists influenced by the humanistic and more recent recovery movements are more inclined to hug routinely at the end of sessions. Many therapists take a moderate position, offering a pat on the back or an occasional hug if the client asks for it or if a session is particularly grueling.
My research suggests that touch in this setting is seldom a simple social gesture. It is powerful, has mixed effects and far-reaching ramifications. A hug can easily become the locus for all of a client's unresolved feelings about authority, power, limits, the forbidden, deprivation and gratification.
If a client knows that a hug would mean too much or confuse her about the nature of the relationship, she should draw the boundary and simply let the therapist know that she would prefer not to be hugged. And if the therapist's hugs have become too important to her, she should be able to discuss their meanings with her therapist, without fear that the wrong answer will result in their being withdrawn.
Arlene is 49 and in training to become a therapist herself. She has been in therapy with Paul for three years. At the end of their first session, he asked ii she wanted a hug. After that, the hug became a regular part of each session's closing. Arlene became very attached to this ritual: "If I only see him once a week, that's one hug a week instead of two. I'm embarrassed to admit that I think about it in those terms, but I do. The hug means caring, acceptance, validation. I was raised to feel it was wrong or bad to have any needs of my own. The hug says that it's okay to give affection, it's okay to be vulnerable, I don't have to be ashamed."
Arlene's parents divorced when she was two, and she saw her father only on weekends. Arlene felt that her mother took things away from her if Arlene wanted them too much, or if they made her feel too special.
One afternoon, about a year and a half into Arlene's therapy, Paul was visibly upset when he came into the waiting room to get her for their session. She looked at him sympathetically, and he said, "I think I need a hug." Arlene was happy to oblige. "I was feeling very special and really good."
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