Author's note: The following article is adapted from The Ethics of Touch: The Hands-on Practitioners Guide To Creating a Professional Safe and Enduring Practice, by Ben Benjamin and Cherie Sohnen-Moe.

A client seeks treatment believing the practitioner knows best. Clients defer to the practitioner's judgment because they desire to be helped by an authority figure that possesses greater knowledge, healing ability and, therefore, power. Since a power differential exists in any health care relationship, the client may be inclined to respond to the practitioner as he or she would other authority figures, and in doing so, may recreate elements of similar past relationships. This situation is known as transference, a normal, unconscious phenomenon that appears during a therapeutic process. Professional helping relationships usually have a strong transference element in which the parent-child relationship is unconsciously re-established. In transference, unresolved needs, feelings and issues from childhood are transferred onto the helper. Whenever there is a power differential in a relationship, there is a strong potential for transference and counter-transference to arise. Transference also may occur in other relationships in which there is a real or perceived power differential, such as with a boss, teacher or clergy.

The power of touch in stimulating transference hasn't been formally studied, but anecdotal evidence suggests that touch, especially when it's intentional and done with care, can create regressive experiences. Clients frequently disclose personal information, talk about their emotional problems or demand special treatment. On an unconscious level, clients often expect practitioners to help them emotionally and in other areas, as well. These are transference reactions. Practitioners need to understand and deal with these situations in a gentle, appropriate manner. In mature adult clients, these feelings will likely be recognized and not control their behavior; however, in individuals incapable of handling these feelings, transference may become the dominant reality and cause frequent disappointment and feelings of rejection, often followed by anger and withdrawal. Maintaining clear boundaries is crucial for handling transference and ensuring it does not negatively impact the therapeutic relationship.

Signs of Transference

• The client frequently asks you personal questions.
• The client calls you at home, knowing that calls should be placed to your office.
• After only one or two treatments, the client is overly complimentary of you and your work.
• The client tries to bargain with you for a reduced rate.
• The client regularly requests that you change your schedule to accommodate his or her schedule.
• The client brings you gifts.
• The client repeatedly invites you to social engagements and feels rejected when you explain your policy of separating your work and social life.
• The client asks you to do "a little bit more" at the end of most treatment sessions and expresses disapproval if you don't comply.
• The client asks you to help him/her solve personal problems.
• The client frequently asks you questions in areas that you've previously explained aren't within your scope of practice.
• This client often mentions that you remind him/her of someone.
• The client has difficulty maintaining a physical boundary and attempts to inappropriately hug or touch you at the end of each session.
• The client has difficulty leaving after the session and tries to engage you in conversation.
• The client gives you intimate details about his or her personal life.

The Blending of Transference and Counter-Transference

Together, transference and counter-transference form a potentially volatile mixture within power differential relationships. Transference and counter-transference affect the answers to the questions we posed before: How is the person who holds the power using that power, and how is the person with less power responding? When both individuals in a relationship are psychologically mature, there is greater assurance that they will use or handle power in a healthy way; nevertheless, such maturity doesn't ensure that transference and counter-transference won't occur.

The practitioner working with psychologically immature clients has a serious responsibility, because such clients may be unaware of the transference they bring to the therapeutic relationship. The practitioner must cultivate his/her own awareness of both transference and counter-transference and consciously mitigate against their effects. Individuals more prone to transference include children or adolescents, needy clients, and clients that have been referred by mental-health professionals to assist in the processing of psychological issues.

A good goal for practitioners is to minimize the potential for unconscious "acting out" of power issues in the therapeutic relationship; nevertheless, the person who holds the power in a relationship may have difficulty recognizing transference and counter-transference. Getting supervision on a regular basis gives the practitioner the opportunity to explore these issues, gain clarity and learn methods for dealing effectively and ethically within the situation.