The Handshake

Being of Austrian-Jewish extraction, I grew up in a family in which everyone hugs and kisses when we meet. Indeed, in my private life, I would regard myself as a rather physically affectionate person. But in the consulting room, during my working day, I adopt a very different stance. Although I endeavor to be at ease within my body during analytic sessions, I do maintain a certain physical distance from my patients, and I keep myself seated in my leather chair, perched behind the couch. I do so for the obvious reasons. I regard psychotherapy and psychoanalysis as cognitive-affective relationships in which one provides healing through compassion, reliability, and understanding—not through cuddles. Furthermore, I know only too well that the vast majority of my patients, if not all of my patients, will have experienced noxious physical contact during infancy and childhood, and many of them maintain a phobic reaction to actual touch; therefore, like most psychoanalytically inclined mental health professionals, I adopt a hands-off policy in order to refrain from retraumatizing the men and women who come to work with me.

In fact, in more than twenty-five years of practice, I can recall only one instance when I had to touch a patient. Some fifteen years ago, while working in the mental handicap field with clients who had suffered from brain damage, and who would, therefore, often manifest various forms of "challenging behavior," I received a referral request from a psychiatric colleague to assess a woman afflicted with compulsive head-banging—a most distressing presenting symptom. This lady—also suffering from mutism—would slam her head vigorously against a wall many times during the day, and she caused great distress to the nursing staff who had to work with her throughout frustrating and exhausting eight-hour shifts.

In view of her primary symptom, I thought it likely that she would try to bang her head in my presence, and indeed, within minutes of arriving in my office, she did so. No sooner had I introduced myself—"Hello, I'm Brett Kahr, and I . . ."—than my new patient instantly hurled herself against the far wall and began to thwack her cranium against the plaster, creating a huge thud. She did this twice in rapid succession, and I desperately interpreted, "You're really showing me how distressed you are, and how you want to knock some terrible thoughts out of your head." Sadly, this remark, which I assumed to be a reasonably well-phrased interpretation, and one that had worked like a charm for one of my senior colleagues who had treated head-bangers herself, seemed to have had little impact on my new patient. This troubled woman, in fact, continued to bang. I became increasingly agitated, both by the loud noise and by the fear of the patient inflicting further brain damage. "Please stop," I cried. "I am deeply concerned that you are hurting yourself." This more directive remark did not achieve the desired effect either, and the lady continued to bang her head. Eventually, in blind terror that she would eventually bloody herself, I stood up from my seat and gently placed my hands on the lady's shoulders, steering her away from the wall, and veered her into a comfortable chair. This episode remains a very stark exception to my long-standing "hands-off" policy in the consulting room.

Virtually every clinician that I know could regale an audience with comparable stories of extraordinary, unexpected physical contact. During the course of researching my book D. W. Winnicott: A Biographical Portrait (Kahr 1996), I had the pleasure of interviewing Dr. John Padel (1991), now deceased, a distinguished member of the Independent Group of British psychoanalysts who had taken seminars with Winnicott in the 1950s, during his studentship at the Institute of Psycho-Analysis in London. Padel recalled that, on one occasion, Winnicott shared a clinical vignette about an acrobatic female patient who, in the middle of a session, managed to perform a backwards roll while still on the couch, and had ultimately landed up in Winnicott's lap! Winnicott turned to the students and asked...