Getting in Touch with Touch: The Importance of Studying Touch in MDMA-Assisted Therapy and the Development of a New Self-Report Measure

Abstract

Background:

MDMA-assisted therapy (MDMA-AT) is an emerging treatment modality, with recent phase 3 trials indicating its potential for regulatory approval. Central to this therapy is the role of touch, yet its empirical evaluation in MDMA-AT, and psychotherapy in general, remains limited. The use of touch in combination with MDMA raises concerns about power imbalances and ethical boundaries.

Methods:

This article reviews existing literature on therapeutic touch and introduces the Touch Outcomes Measurement Inventory (TOMI). The TOMI is developed to assess client perceptions of touch in MDMA-AT, addressing a critical gap in the current research landscape.

Results:

The main outcome of this research is the creation of TOMI, a tool aimed at evaluating the impact of touch on clients in MDMA-AT. The review highlights the lack of empirical evidence in this area and the necessity for such a measure.

Discussion:

With the increasing likelihood of MDMA-AT becoming a widely used therapy, understanding how therapeutic touch affects clients is imperative. This article emphasizes the need for evidence-based and ethical guidelines for the use of touch in MDMA-AT. The development of TOMI is a step towards achieving this, providing a means for researchers and program evaluators to assess the implications of touch in MDMA-AT and psychedelic-assisted therapy more generally.

Introduction

3,4-Methylenedioxymethamphetamine (MDMA) is a monoamine-releasing phenethylamine that is posited to potentiate psychotherapy through enhancing fear extinction, modulating memory reconsolidation, altering self-experience such as self-compassion, and altering social functioning in adaptive ways.^1–4

MDMA-assisted therapy (MDMA-AT) has been tested for clinical use in multiple phase 2 and phase 3 studies where it demonstrated safety (although some safety concerns have been documented),⁵ tolerability, and initial efficacy in patients with post-traumatic stress disorder,^6,7 one phase 2 open trial with alcohol use disorder,⁸ and one phase 2 placebo-controlled trial with social anxiety disorder in autistic people.⁹ If MDMA-AT is approved by the United States Food & Drug Administration, this intervention could be more widely available in the United States and Europe within the next few years.

As part of the FDA approval process, the Multidisciplinary Association for Psychedelic Studies (MAPS) has created a detailed treatment manual for MDMA-AT¹⁰ that will presumably guide the dissemination of the therapy should it be approved for the treatment of post-traumatic stress disorder. According to this manual, the therapeutic use of touch is a key part of the therapy, with touch being described as

an important catalyst to healing during both the MDMA-assisted sessions and the follow-up therapy. Touch must always be used with a high level of attention and care, with proper preparation and communication, and with great respect for the participant's needs and vulnerabilities. Any touch that has sexual connotations or is driven by the therapist's needs, rather than the participant's, has no place in therapy and can be counter-therapeutic or even abusive. By the same token, withholding nurturing touch when it is indicated can be counter-therapeutic and, especially in therapy involving non-ordinary states of consciousness, may even be perceived by the participant as abuse by neglect. If the participant wants to touch one of the therapists, the therapist allows for and/or provides touch as long as it is appropriate and nonsexual.¹⁰

As such, therapists' ability and willingness to use touch are framed as an essential part of the ethical provision of MDMA-AT. The manual cites that the principles guiding the use of touch are based on those of Stanislov Grof, an early researcher of psychedelic psychotherapy.¹¹ Although the manual implies that therapists using MDMA-AT need to be capable of engaging in appropriate touch, it is also clear that clients have the right to decline the use of touch, except to ensure safety (e.g., to prevent a fall or to take vital signs), saying, “therapists should make it clear that there is no agenda or expectation that the participant be touched at all if they prefer not to be.”^{7, p.20}

MAPS also uses the 2019 MAPS MDMA-AT Code of Ethics¹² to outline basic principles for the use of therapeutic touch, such as the importance of informed consent and prohibitions against sexual forms of touch. Other authors have also written about the use of touch in psychedelic-assisted therapy more broadly,^13–16 but the MAPS guidelines are arguably the most important in guiding what will happen if MDMA-AT is approved and implemented in a legal context.

Although MAPS promotes touch as an important part of MDMA-AT, other authors have expressed concern, fearing that it could intensify power imbalances, contribute to boundary crossings and unethical behavior.^5,13,14 There is a strong need for research on the use of touch in MDMA-AT given the emphasis on the use of touch in MDMA-AT, the possible heightened receptivity to touch because of its empathogenic effects,¹⁷ the heightened responsiveness to affective touch that occurs when people take MDMA,¹⁸ and the relative lack of evidence on the use of touch in psychotherapy in general.

One approach is to systematically evaluate how touch is perceived by participants in research trials and in clinical practice assuming the treatment is disseminated. Data on patient experience of touch and how this is related to therapist behaviors, client factors, processes of change, and outcomes can provide a more evidence-based framework for utilizing touch in the future.

Research on the use of touch in MDMA-AT is imperative to guide protocol development and training for ethical, safe, and appropriate application of touch in MDMA-AT. This article aims to initiate the empirical evaluation of the effect of therapist use of touch in MDMA-AT through first reviewing theory and research on the role of touch in ordinary talk therapy with the hope this will inform research on touch during therapy involving nonordinary states. We then describe the development process for a new self-report measure of reactions to touch that we are currently utilizing in a clinical trial of MDMA-AT for Social Anxiety Disorder.² We hope that by sharing this information and this new measure, we will encourage others to begin to more systematically assess the effects of touch in patients undergoing MDMA-AT.

The Role of Touch in Psychotherapy or Counseling

The empirical literature on the role and effects of physical contact (i.e., touch) between therapist and patient is surprisingly limited. With the exception of a handful of analogue and interviewing studies from >40 years ago,^19–21 there is essentially no research on whether touch is associated with better or worse outcomes from therapy. In addition, the empirical literature that does exist consists almost exclusively of surveys and interviews after therapy, often of providers rather than clients. In contrast, a number of theories have been proposed for how touch might function therapeutically, but little empirical evaluation of these theories has been conducted.

Below we outline the results of our literature search on the role of touch in psychotherapy in general. We first outline the breadth of theories that describe how touch may function in ordinary talk therapy. We then review some taxonomies on types of touch and relate empirical and theoretical perspectives with a focus on when touch may be experienced as helpful or harmful by patients.

Theoretical perspectives on touch in psychotherapy

There are many theories that may be useful in understanding how touch may function in a therapeutic context and when to use and when not to use it. At a fundamental level, touch is key to healthy development in most primate species. Touch is vital to the attachment process (attachment theory¹³) and early touch is crucial to positive development^22,23 and is a basic behavioral need.²⁴ At a psychophysical level, warm touch may increase oxytocin, as shown in couples,²⁵ or reduce cortisol, as has been seen with hand massages.²⁶ Thus, touch may gratify clients' innate need for touch, contact, and attachment and could thereby be therapeutic.^23,27

The therapeutic relationship is one of the most important general predictors of psychotherapy outcome,²⁸ and touch may strengthen the therapeutic bond by communicating care and empathy.²⁹ On a broad level, touch has been described as helping to release repressed affect³⁰ or regulate affect.³¹ Touch may also shift a patient's interpersonal focus from a competition-focused rank-order perspective (i.e., hierarchical, authority, and social rank perspective) to a more cooperation-based affiliative perspective (i.e., friendly intimate perspective²³).

From a behavioral perspective, touch within therapy may model healthy touch for the client.³⁰ For highly socially anxious individuals where one's discomfort with touch is a self-protection strategy against rejection,^32,33 touch could function as a form of exposure. Relatedly, for clients with a history of physical or sexual abuse or assault, the appropriate use of touch could help them learn that not all touch is inherently violent or sexual.³⁴

From a psychoanalytic lens, touch has a complicated history. Early psychoanalytic leaders exploring therapeutic touch were known to have committed major boundary transgressions with patients,³⁵ which ultimately contributed to the development of therapeutic concepts such as transference and countertransference. Today, touch is largely discouraged in the practice of psychoanalysis.³⁶ Historical accounts around the functions of touch in psychoanalytic and psychodynamic theory are myriad with some examples including the idea that touch can be appropriate if it is in the context of symbolic mothering³⁷ or helps the “patient to tolerate pain that was characterologically defended against.”^{29, p.21}

From an object relations lens, there may be a relational importance to touch. Touch could function to support a corrective experience.^38–40 In Reichian theory,⁴¹ anxiety is held as muscular tension, noticeable in posture and movement, which touch could help address. Touch is also commonly seen as a boundary crossing and a slippery slope that may lead to boundary violations,⁴² although what little data exist suggest this is most often not the case.⁴³ Moreover, touch could interfere with transference,³⁷ function to gratify erotic desires on the part of the therapist or the sexual desires of the client, and may retraumatize clients with history of abuse.⁴⁴

Balint suggests that touch may also lead to “malignant regression,” where the client becomes dependent on the therapist.^38,43 Phelan⁴⁵ also notes that touch could foster dependent, infantile, or erotic transference. In contrast to these warnings, some psychoanalytic authors suggest touch is necessary to deal with periods of deep regression⁴⁶ or with psychotic anxieties and delusions that occur in the context of the patient–therapist relationship.⁴⁷

Humanistic theories tend to emphasize the need to experience emotions directly rather than distancing through cognitive analysis. Touch may, therefore, invite greater contact with feeling states and enhance communication.^48–50 Perls⁵⁰ used touch and body language as means of exploring the authenticity of patients' communication, whereas other humanistic counselors use touch as a means of communicating their own genuine feelings, thereby strengthening the therapeutic bond.²³

From the perspective of bodywork and many somatic therapies, touch makes body symptoms, sensations, feelings, energy, and spirituality accessible (e.g., touching a client's chest as a way “to help him embody the energy needed to get grounded in the treatment process.”^{23, p.101} Theories of embodiment⁵¹ suggest touch is a vehicle for reducing “feelings of separateness from one's physical presence, thus increasing psychological wellbeing.”^{23, p.140} The Alexander Technique conceptualizes the Mind & Body as “the self.”

Alexander Technique seeks to achieve “good use of self” through proper head, neck, and back alignment.⁵² However, it is important to note that the main premise of bodywork is not necessarily touching a client but helping the client be in touch with his or her feelings,⁴⁵ and that bodywork or somatic therapy includes a variety of theories from multiple fields (e.g., nursing, osteopathic medicine, and massage), some of which are not included above.

Taxonomies of touch in psychotherapy

Several writers have classified touch, as used in psychotherapy, into taxonomies or categories, with Smith⁵³ and Totton⁵⁴ among the most comprehensive. Smith⁵³ identified two forms of taboo touch (sexual and aggressive touch) as well as five forms of nontaboo touch: inadvertent touch, conversational markers (touch used to maintain someone's attention in a conversation or to emphasize a point), socially stereotyped touch (e.g., greetings such as hugs or handshakes), touch as an expression of the therapeutic relationship (e.g., giving physical comfort if someone is grieving), and touch as a technique (e.g., touch as bodywork or forms of somatic psychotherapy).

Totton⁵⁴ identified five different uses of touch: as comfort, to explore contact (e.g., placing a hand on a client's chest to allow him to stay with a feeling), as amplification (to help a client focus and bring attention to bodily sensations), as provocation (e.g., pressure on a rigid muscle to provoke discharge), and as a skilled intervention (e.g., osteopathy or acupressure). Phelan⁴⁵ identified the most frequent types of touch that occur in the therapist–client dyad to be socially accepted greetings and departures, consolation touch, reassuring touch, grounding or reorienting touch, touch to prevent self-harm or harm to others, and corrective experiences touch. Others have included categories such as playful touch and touch for purposes of instruction or modeling.⁵⁵

Common reactions to touch in psychotherapy

The sections above reviewed major theoretical perspectives on touch. This section below focuses on the limited evidence and theory specifically about how clients may perceive touch as either beneficial or harmful, as well as clinicians' and theorists' ideas of when touch is helpful or harmful. More research on positive and negative reactions to touch will hopefully help providers in the important work of tailoring the use of touch to client variables, such as demographic, diagnostic, or other factors.

Positive reactions to touch

With regard to the phenomenology of touch and how it may be perceived positively by clients, Horton et al.²⁹ identified 10 functions of touch based on a thematic analysis of client-reported experiences:

• 1.Provide a link to external reality.
• 2.Communicates “You are not alone.”
• 3.Communicates acceptance and enhances self-esteem.
• 4.Models a new way of relating.
• 5.Helps client get in better contact with bodily sensations.
• 6.Creates a bond, feeling of closeness, that therapist really cares.
• 7.Strengthens, reassures, comforts, or heals.
• 8.Facilitates a breakthrough in therapy.
• 9.Provides a sense of containment, safety, or closure.
• 10.Meets a current deprivation (a need).

Other writers have identified additional, and sometimes overlapping, positive functions of touch. In a comprehensive multidisciplinary literature review of the research on touch, Kelly et al.⁵⁶ also identified touch as communication and an affective language that can communicate care, genuine and positive emotion, connection to one another and a wider community, and lead to deeper intimacy. Jones and Glover⁵² note that touch can be perceived as nurturing. Touch can also calm and focus clients during high arousal or when re-experiencing trauma^23,31 and assist in affect regulation,³¹ presumably by calming or grounding the client.

Negative reactions to touch

Touch is perhaps likely to result in negative effects on clients when linked to concrete forms of therapist boundary crossing and abuse, such as sexual contact with clients or the initiation of relationships involving coercive physical interaction or violence toward clients. In addition, authors have described subtler ways in which touch may be iatrogenic or interfere with therapy.

For socially anxious individuals with increased self-consciousness in social situations, touch could be awkward and strained.⁵⁷ Being touched creates an immediate expectation for a response, usually in the form of reciprocal touch, which is a more extreme form of social presence that may be upsetting to some clients.⁵⁸

Touch also has potential to be perceived negatively and represent a boundary violation. Some clients may perceive touch as harmful when it is perceived as a violation of a cultural norm or expectation. For instance, touch may be understood as sexual,^45,59,60 as touch in Western cultures often is used to signal sexual intentions. Touch is also an indicator of power dynamics⁶¹ and, as such, touch may reinforce an imbalance of power in therapy, leading to even greater vulnerability in clients or increasing the possibility of exploitation.⁶²

Touch might evoke experiences of societal oppression, feelings of inferiority related to power discrepancies, or one's minority status.^23,63 Touch has the potential to be particularly harmful to women or other people with societally oppressed identities. Touch may implicate broader societal dynamics related to patriarchy⁶¹ or white supremacy⁶⁴ and could reinforce harms related to those societal structures. For example, touch used by a male therapist with a female client could further disempower the client based on gender dynamics.⁶⁵ Empirical research on gender dynamics in relation to touch in psychotherapy demonstrates a complex patterns of findings, suggesting more research is needed around these factors.^66,67

Touch may leave clients feeling unsafe^68,69 and may be stigmatized in certain settings (e.g., the military⁵⁸). Clients with a trauma history may feel as if the touch has recreated their trauma.⁷⁰ Outside of the therapeutic context, uninvited touch from a stranger is often experienced as offensive, intrusive, or threatening.⁷¹ It is plausible that touch could, in certain contexts, communicate to a client that he or she needs to calm down or be less emotional.⁷² Similarly, untimely touch may distract by bringing a client out of his or her internal experience when staying internally directed would be more helpful.

If the meaning behind touch is unclear⁶⁰ or if touch is unwanted, it could make a client feel nervous or unsure how to respond. The lack of touch could also appear foreign and emotionally cold to certain populations (e.g., Latino clients⁶⁰). In Germany and Switzerland, shaking hands is standard when greeting and taking leave, thus not shaking hands could be insulting or hurtful.⁷³ In general, not reciprocating expressions of touch is likely to be seen as a rejection.⁴⁵

Development of a New Measure of Reactions to Touch in MDMA-AT

As reviewed above, there has been very little research on the use of touch in psychotherapy in general and no research that we could find on the role of touch in MDMA-AT specifically. In response to this need, we developed a measure of participant reactions to touch in MDMA-AT that we call the Touch Outcomes Measurement Inventory (TOMI) for use in our clinical trial on MDMA-AT for social anxiety disorder (clinicaltrials.gov/ct2/show/NCT05138068). Some reasons to have a measure that focuses on the perceptions of participant-clients are multiple.

First, it seems likely that participants are in the best position to report accurately on the ways touch affected them. Second, a participant-reported measure can also serve a gatekeeping function in future trials or in psychedelic medicine clinic where it could potentially detect therapists who are crossing boundaries or creating negative reactions in touch with their clients, thereby facilitating intervention and hopefully learning. Third, it could be that therapist personal needs/emotions might affect participant objectivity in reporting touch.⁷⁴

The development of our measure was based on widely used guidelines from COnsenus-based Standards for the selection of health-based Measurement Instruments (COSMIN^62,75) to guide our item development process and to assess content validity. We began with a comprehensive literature review on the role of touch in psychotherapy generally and MDMA-AT specifically, much of which is reviewed above. We also sought relevant literature in allied fields that utilize touch extensively such as nursing or physical therapy. Specifically, we sought to identify theoretical frameworks to guide measure development, the most commonly reported client reactions to touch in therapy, facilitative or iatrogenic effects of touch, published guidelines on when to use touch, and theoretical taxonomies of types of touch in therapy.

After the literature review, we created an interview guide and interviewed three experts on MDMA-AT, including two who had experience specifically with the use of touch in therapy. The interview included questions about (1) the most common kinds of reactions clients have to touch in MDMA-AT, (2) the negative reactions they had experienced or heard of, (3) their ideas of why touch is important and helpful in MDMA-AT, (4) their thoughts on what would occur if touch was restricted, and (5) what needs to be different in using touch in MDMA-AT versus in other forms of psychotherapy. We also asked them to suggest particular questions we might want to consider for the questionnaire.

Based on this literature review and expert input, we defined the construct we were attempting to measure, the intended use of the measure, and the intended target population. The measure is atheoretical and intended to characterize the amount and types of touch that occur in MDMA-AT sessions, as well as client perceptions of how touch was helpful or unhelpful. The intended population for use are clients receiving MDMA-AT, and it is intended to be used after sessions in which MDMA is administered. The primary measurement properties of interest are predictive and convergent validity.

We next brainstormed a set of items using a multistep process. To assure we had good content validity and had covered the full range of possible responses, we first identified the most common themes from the literature on what had been observed as negative and positive aspects of touch. Themes related to positive aspects of touch identified from the literature included that touch created a sense of containment, safety, or closure; was strengthening, reassuring, comforting, or healing; created a link to an external reality, was grounding, or calming; put clients in contact with bodily sensations; helped them feel cared for, close to the therapist, or strengthened the therapeutic bond; communicated that they were not alone; indicated acceptance or enhanced self-esteem; met a current need; facilitated a breakthrough in therapy; and reminded clients of earlier experiences.

Themes related to negative experiences with touch that we attempted to generate assessment items for included touch making clients uncomfortable, intrusiveness, touch feeling sexual, distracting them from something more important, occurring without permission, creating confusion, and being startling. We then generated multiple items for each theme, reviewed them and narrowed them down to one item representing each theme we identified from the literature.

The result of this process was a measure consisting of 18 items. The first is a multiple answer (select all that apply) item that allows participants to indicate the types of touch (e.g., a hug) or locations of touch (e.g., forearm) that occurred during the session. We also included one item on client perceptions of the amount of touch in the session. The final 16 items ask participants about positive and negative aspects of touch that occurred in the session. After the initial generation of items, we recontacted the three experts and had them rate each of the 18 items we generated in terms of relevance, comprehensiveness, and comprehensibility as recommended by COSMIN.

Furthermore, we asked for feedback on the response options, instructions, whether any important experiences were left out, whether items were redundant, and on any other elements of the survey. Based on these responses, the questionnaire was revised again with items being revised or rejected and some new items being written to respond to reviewer feedback. The final measure has 16 items that attempted to assess these domains of positive and negative effects of touch, plus the 1 item about location of touch and 1 on amount of touch (see osf.io/qm7bk/for the final measure). Finally, we included a qualitative item where respondents are invited to write about “any feelings or experiences that were not captured in this questionnaire.”

Conclusions and Future Research Directions on MDMA-AT and Touch

The TOMI has several strengths. First, it was developed using all the steps outlined in COSMIN standards for assessing development and content validity. It allows researchers and clinicians to begin systematically assessing common client reactions to touch as they occur during dosing sessions and associate these variables with outcomes. The TOMI could also be used as a quality assurance device, to provide a standardized and easy means to assess whether therapists may be engaging in touch in ways that are distressing or iatrogenic to clients.

This could both be useful in clinical training around touch, as shown in the literature on feedback-informed treatment,⁷⁶ as well as used as an oversight function to detect clinician behavior that could be harmful. This measure is currently being utilized in our study of MDMA-AT for social anxiety disorder,^2,3 which will allow us to collect initial quantitative data and also qualitative data that could inform further item development. Responses on this measure will be associated with other client variables, process variables, and outcomes to begin to evaluate convergent validity.

The TOMI is also limited in its scope. It is not intended to assess the antecedent conditions or context of touch during MDMA sessions, such as what kind of consent to touch was sought by the therapist beforehand or whether touch was discussed afterward, but only how touch was perceived by the client. Although we acknowledge that consent is important and that the context of touch is key to understand how it functions, this is simply not the focus of this particular questionnaire. In addition, any assessment at a single point in time has limitations; the meanings and functions of touch may change over the course of therapy.

For example, touch may not be something that only occurs during drug administration but may also be incorporated into nondrug sessions and may relate to the quality of the therapeutic relationship. In addition, perceptions of past touch could change over time with touch being perceived positively at one point being seen as harmful at a later point. We encourage the field to develop additional lines of research related to touch in MDMA-AT.

Other potential topics include developing methods to assess therapist comfort with various types of touch, including training background and scope of practice; negotiation of touch during preparation and protocols for renegotiation of touch during MDMA sessions; as well as alternatives or stepwise approaches to touch, such as working with the participant's breath, participant self-touch, the use of weighted blankets, or methods of indirect touch (e.g., applying pressure through a pillow).

In conclusion, much more research is needed on the use of touch in MDMA-AT and in psychedelic-assisted therapy more generally. Regularly assessing responses to touch could potentially detect iatrogenic adverse effects of touch or could be utilized as a monitoring system for detecting boundary violations or therapists who are using touch in a problematic manner. In addition, since the use of touch is a prominent component of MDMA-AT, this modality, compared with other psychotherapeutic contexts, presents a unique opportunity to collect a large amount of data quickly to characterize the breadth of reactions to therapeutic touch.

In addition, we believe this measure could easily be modified for use in other forms of psychedelic therapy or even for ordinary talk therapy, as the process for identifying the items was not specifically based on research relating to MDMA-AT. Although empirical research is clearly important, qualitative research is also needed to further explore the nuances of how touch is experienced in MDMA-AT and to answer the kinds of questions that cannot be answered using self-report scales. We offer this measure to researchers in the hope that they start to use it to achieve these aims and offer more evidence-based guidelines for how and when to use touch in MDMA-AT and in psychedelic-assisted therapy more generally.

Authors' Contributions

J.L. played a primary role in conceptualizing the study, defining its methodology, collecting data, analyzing data, and drafting and revising the article. L.R.A. played a primary role in reviewing the literature relevant to the study, conceptualizing the study, defining its methodology, collecting data, analyzing data, and drafting and revising the article. V.G. assisted in conceptualizing the study, provided data for the study, and assisted in revising the article. C.S. assisted in conceptualizing the study, provided data for the study, and assisted in drafting and revising the article.

Author Disclosure Statement

V.G. and C.S. have received payment to conduct MDMA therapy educational and training events focused on the psychotherapy aspect of MDMA-assisted therapy through the Multidisciplinary Association for Psychedelic Studies. The other authors have no relevant disclosures.

Funding Information

This research was funded internally by Portland Psychotherapy through its social business model.