Introduction

It may be assumed that the outcome of Haptotherapy (HT) is determined by an interplay of specific and nonspecific therapy factors, as will be the case with all therapies. Nonspecific therapy factors, as they apply to all therapy forms, have been described in detail: patient motivation and engagement (Kelders, 2015), confidence in the proposed treatment strategy (Vingerhoets, 2005), the expectation that the therapy will be beneficial (Bohart & Tallman, 1999; Bohart, 2000; Benedetti, 2013), an empathic therapist-patient relationship (Ackerman & Hilsenroth, 2003), a professional practice environment in which the therapy takes place (Mulder, Murray, Rucklidge & Common, 2017), clear explanations that the patient accepts (Mulder et al., 2017), and confidence-building rituals and procedures (Mulder et al., 2017).

HT-specific therapy factors are conversations that provide insight and understanding, experiential skills exercises, and affective contact-oriented therapeutic touch (Plooij, 2005; Klabbers, 2020, 2021). Patient ratings (N=640) for these HT-specific factors on a five-point Likert scale (1-5) are 4.4, 3.8 and 4.2, respectively (Klabbers and Vingerhoets, 2021a).

Specific therapy factors have been described for haptotherapy in fear of childbirth, particularly
experiential skills exercises (Klabbers, Wijma, Paarlberg, Emons, & Vingerhoets, 2014, 2017). As of 2023, however, we have yet to find any publications that explicitly describe the therapy factors of HT in general, nor does there appear to be a conclusive rationale for the presumed mechanisms.

The results of several initial studies into the effects of HT have been published. (1) In cancer patients HT contributes to: a reduction of pain, stress and other physical symptoms, a decrease in panic, anxiety and fear, an improvement of experienced social and cognitive function, well-being and quality of life (Van den Berg, Visser, Schoolmeesters, Edelman, & Van den Borne, B., 2006). A recent study (2021) showed that people with cancer primarily consulted a healthcare haptotherapist because they had the feeling that they had lost the connection with and trust in their own body. (Van Swaay, Vissers, Engels & Groot, 2021). (2) In pregnant women with severe fear of childbirth: HT has a positive effect on reducing fear of childbirth; moreover, maternal well-being increases after HT due to a decrease in prenatal distress and depression symptoms, there are fewer post-traumatic stress symptoms postpartum; and HT also has a positive effect on mother-child bonding (Klabbers et al., 2014, 2017). (3) HT for people with chronic pain has a positive effect on the increase of body-awareness, reducing stress and anxiety and a decrease in pain catastrophizing (Klabbers & Vingerhoets (2021b). It has been become clear that insight-providing conversations, experiential skills exercises and affective contact-oriented therapeutic touch are perceived by HT patients as a coherent whole and patients are very satisfied with the treatment (Klabbers & Vingerhoets, 2021a). However, although these aforementioned results are promising, it does not provide a conclusive rationale for the efficacy of HT.

The object of this article is then to provide more clarity regarding the presumed mechanisms of HT-specific therapy factors. With this article, the authors’ aim to contribute to clear communication regarding the presumed mechanisms of Haptotherapy (HT), as well as hope to contribute to future scientific research.

Haptotherapy

If HT is deemed a combination of specific and nonspecific therapy factors, the question is to what extent the various HT-specific therapy factors can be considered separately without compromising the whole of HT treatment, as the whole is more than the sum of its parts.

Where physiotherapy focuses mainly on ‘moving functionality’ and cognitive therapy primarily on ‘thinking’, haptotherapy is a person-centered therapy which focuses on the ‘the person’s ability to feel, assuming that a well-developed emotional life contributes to personal growth’ (Veldman, 2007).

Klabbers (2020): “People can be conscious of perceiving themselves, feel the space around them and have a sense of other people. People can empathize, intuit, imagine, sympathize and, above all, they can be aware and become aware of their own and other people’s inner feelings.”. Many people for example, no longer feel or recognise when they cross their own boundaries (Boot, 2004).

Symptoms of stress or burnout that can result from this are mentioned in the HT domain specification as one of the indications for haptotherapy (VVH, 2023). However, feeling, recognising and communicating boundaries is just a small part of HT.

One of the goals of haptotherapy is to make people aware of their ability to accept, experience, interpret and value their feelings. In other words, people learn to consciously open and close themselves to these feelings. (Plooij, 2005).

The basic principle is that emotions are physical reactions to threats and opportunities in life that we become aware of in our brain, and then we call them feelings (Damasio, 2004).

Gaining awareness of what is felt in the body offers the possibility to learn from emotions and feelings, to get to know ourselves better and to cope with the demands of life. Self-knowledge increases the sense of confidence, self-confidence and the feeling of being able to stay true to yourself under varying circumstances.

Philosophy on the body and corporality distinguishes between the ‘body-object’, which refers to the body as an object that can be examined for medical purposes, or which must conform to the prevailing ideal of beauty, and the term ‘body-subject”, which refers to the manner in which the body is experienced subjectively (Merleau-Ponty, 1945; Ter Meulen BC, Van Woerkom, 2009).

Haptotherapy works with the body that is experienced – the body-subject. Clarifying the difference between the body-object and body-subject can be created through insight-providing conversations, experiential skills exercises and affective contact-oriented therapeutic touch to create body awareness and self-awareness.

Insight-providing conversations

In the HT treatment room, the therapist and patient talk to each other during getting acquainted, intake, theoretical explanation of HT, introduction and explanation of an experiential skills exercise, introduction and explanation of affective contact-oriented therapeutic touch, performance of an experiential skills exercise, performance of affective therapeutic touch, evaluation of the skills exercise, evaluation of touch, and discussion of how this affected the patient.

In short, although the healthcare haptotherapist, in principle, has a non-verbale attitude and there is likely to be less talking during an experiential skills exercise or affective contact-oriented therapeutic touch, there is still conversation. Talking is done to name, recognise, acknowledge and to understand emotions and feelings, and to learn from the past that is captured inside the body, and to learn for future behaviour and action.

HT is an experiential therapy and must be primarily felt and experienced. Nevertheless, it is important to provide language for what happens in therapy, firstly, to teach the patient the language to express what they have experienced, and also to be able to communicate about HT, both with haptotherapists between themselves and others (Plooij, 2005).

Experiential skills exercises

People can talk about feeling, can think about what feeling is, and they can imagine what it feels like. However, talking about feeling is still mostly thinking, even though words and thoughts can trigger an emotion.

HT skills exercises are designed to actually experience feeling and bring it to consciousness. Initially, it is focused on discovering (or rediscovering) and developing touch, and then making contact with one’s own body and what can be felt there, as well as making contact with others and the environment.

“Together with your healthcare haptotherapist, you discover through the experiential skills exercises your behaviour in certain situations. Are you driven by your convictions and ideas, for example, or by emotions? Do you stay in touch with yourself and the other person? Ingrained patterns and new ways of acting emerge and provide insight into yourself. Together with your healthcare haptotherapist, you look at how you make choices and explore other options to get more in touch with yourself and the other person” (VVH, 2023), where ‘the other person’ in this case is initially the therapist.

Touch

For the intervention of touch, Leijssen (2006) distinguishes between the following kinds of touch:
encouraging, protective, evoking emotion, reassuring, affirming, uncovering and confrontational. The last three in this list are mentioned by Plooij (2014) as being applicable to haptotherapy.

Klabbers (2021) assumes that all forms of touch can be applicable to haptotherapy and he adds another form, educative touch (hapto-education), that is, a form of touch that provides insight.

This does not involve an objectifying judgmental touch, but always an affective contact-oriented therapeutic touch aimed at methodically familiarizing the patient with opening and closing themselves to emotional impressions, becoming aware of their feelings, being present in their feelings, perceiving the space around them and perceiving others in that space around them.

In HT practice, it will differ per indication and per situation whether encouraging, protective, evoking emotion, reassuring, affirming, uncovering, confrontational and/or teaching touch is used. The authors are not aware of any publications on this subject.

Presumed mechanisms

In practice, the authors have observed that ‘not feeling and/or not listening to your feelings’, as a basis on which physical and mental/emotional symptoms can arise, is becoming more well-known. “If you have symptoms, you first want to get rid of them as soon as possible. However, they can be a signal to work on yourself and offer the opportunity for growth.” (VVH, 2023).

According to the authors, as of 2023, people are increasingly coming directly with the underlying question: ‘Can you help me to access my feelings? Also, the statement, “I think I could make better choices if I could better access my feelings” is heard.

Through recent studies, more has become known about the mechanisms of HT in several areas, namely, in people with chronic pain (Klabbers & Vingerhoets, 2021b), in pregnant women with fear of childbirth (Klabbers et al., 2014, 2017), in people with cancer (Van Swaay, Vissers, Engels & Groot, 2021), and in HT for child and parent (Pollmann, M., Rooij, F., & Rodenburg, R., 2018).

HT for people with chronic pain

The presumed mechanism of HT in people with chronic pain is described as follows. “Through conversation, experiential skills exercises and contact through affective therapeutic touch, the HT sessions make tangible what is at play physically and emotionally. How the body responds and how a person handles this (reflexes and behavioural patterns) become tangible. Haptotherapy contributes in this way to raising awareness of the body and emotional consciousness. The objective is that thinking, feeling and acting come into balance with each other (again). This makes boundaries, possibilities and impossibilities easier to feel and resilience increases.

As a result, a person develops a stronger and more vital outlook in life and can find themselves again.” (Chronic Pain Workgroup (Werkgroep Chronische Pijn), 2022).

HT for pregnant women with fear of childbirth

The presumed mechanism of HT in pregnant women with fear of childbirth is described as follows. “The central idea of HT is to make the pregnant woman aware of her ability to open herself up to (allow and experience) and to close herself off to sensory impressions. This key concept forms the theme throughout the entire treatment (Fear of Childbirth Workgroup (Werkgroep Bevallingsangst), 2022). Changes in mindset, as well as the increase in body awareness and self-awareness, are mentioned as supposedly active mechanisms for the proven positive effect of HT (Klabbers et al, 2014, 2017).

HT for people with cancer

In HT for people with cancer, the most distinguishing feature of HT is that the body is considered to be a carrier of emotions. “Emotions always have a physical component; they are felt somewhere in the body. This recognition has implications for treatment in that the affective contact-oriented therapeutic touch of the healthcare haptotherapist is intended to help the patient get in touch with their body and emotions. It is believed to promote emotional processing.

Compared to the more objectifying touch of medical examination, affective contact-oriented therapeutic touch carries an affirmative meaning and an emotionally supportive effect. This can be extremely helpful in repairing the disruption of body connection and the emotional or psychological damage caused by cancer and/or its treatment.” (Van Swaay, Vissers, Engels & Groot, 2021).

HT for child and parent

“HT for child and parent consists of the following components which can be adapted to the child’s age: practice and example situations in which the healthcare haptotherapist demonstrates a form of interaction based on affective affirmation, and where necessary, then discusses it; affective play, aimed at affirming affective contact and communication between child and parent. This play can be light-hearted and playful, but can also be intensified as soon as possible. ‘Play’ means exercises aimed at finding a comfortable position in close proximity contact, such as sitting or lying on or beside, or standing next to each other; using affective therapeutic touch of the child by the healthcare haptotherapist and, where possible, by the parent, in which the child becomes more comfortable in their body; and haptotherapeutic psycho-education of the parent following the treatment situations.” (Pollmann, M., Rooij, F., & Rodenburg, R., 2018).

Summary of mechanisms

The authors note that the aforementioned descriptions of the presumed mechanisms of HT for people with chronic pain, for pregnant women with fear of childbirth, for cancer patients and in HT for child and parent, do show similarities, even though sometimes different words are used and the emphasis may be different. ‘Through insight-providing conversations, experiential skills exercises and affective contact-oriented therapeutic touch, body consciousness and awareness of the body are developed (as referred to in body-subject, thus the experienced body), increasing self-knowledge, self-esteem and insight into patterns of action and creating self-confidence, resilience and emotional capacity’.

Discussion

Veldman (2001, 2007) believed that he had found an explanation for the mechanisms of HT. Among other things, he studied the change in muscle tension during affective contact-oriented therapeutic touch. He observed that affective contact-oriented therapeutic touch led to more openness, more well-being and more vitality, and observed that people demonstrated a more relaxed and resilient muscle tension. The authors concur with this observation based on observations made in HT practice, i.e., they state: “It happens right under your hands”. However, Veldman’s (2007) theoretical explanation for this has not (yet) been scientifically confirmed. Furthermore, the authors are not familiar with any publications on the physiological aspects of HT, as is the case with massage, for example (Müller-Oerlinghausen, Eggart, Norholt, Gerlach, Kiebgis, Arnold & Moberg, 2022). Müller-Oerlinghausen et al. (2022) have described the role of afferent nerve fibers, oxytocin and interoception. Massage is something different from HT, but afferent nerve fibers, oxytocin and interoception probably also play a role in HT, although the authors consider it unlikely that only physiological aspects can explain what exactly occurs at the physical, psychological and emotional levels in HT.

Klabbers (2018) has classified affective contact-oriented therapeutic touch in HT as a specific therapy factor. The therapist-patient relationship as described by Ackerman and Hilsenroth (2003), which is considered a nonspecific therapy factor in other therapies, could also be seen as a specific therapy factor in HT.  Within the therapist-patient relation, the patient likely follows the same patterns as in daily life. By making the therapist-patient relationship central, the patient learns to recognise their own patterns within the relationship and HT can help in understanding and expressing them.

Gradually in the search for a rationale, the authors realised that the summary of the mechanisms formulated in the article, for the time being, may perhaps be the best option to use as a description of HT: ‘‘Through insight-providing conversations, experiential skills exercises and affective contact-oriented therapeutic touch, body consciousness and a growing body awareness are developed (as referred to in body-subject, i.e. the experienced body), increasing self-knowledge, self-esteem and insight into patterns of action and creating self-confidence, resilience and emotional capacity’. The underlying assumption is that the experience of the body-subject plays a crucial role in the efficacy of haptotherapy.

To further understand the mechanisms of HT, the Haptotherapeutic Well-being Scale (HWS) can provide a perspective (Klabbers & Vingerhoets, 2021b, 2022). The HWS contains fourteen questions and five subscales: psychological well-being (1, 9, 11, 14), physical well-being (2, 3), autonomy (4, 7, 10), relationships with others (5, 6, 8) and touch and being touched (12, 13). If the effect of HT is compared across various indications for HT, then an analysis of the difference scores on the HWS subscales could maybe show what the results of HT are based on.

Restrictions

The therapy factors and the potential mechanisms described in this article, could provide insight into and plausibly demonstrate how HT works. However, this does not mean that ‘how HT works’, has been scientifically proved, i.e., it has not yet been determined what exactly occurs at the physical, psychological and emotional levels.

Strengths

The HT-specific therapy factors and the mechanisms discussed in this article make it clear that HT takes the body-subject as its starting point and connects to the human capacity to feel. This clarity can potentially contribute to determining when and for whom HT would likely be a useful therapy.

Recommendations for future research

Quantitative research focuses on statistically significant effect differences. It is advisable for HT to continue with this research. In addition, qualitative research is also needed to answer the question of how and why HT works.

The authors recommend demonstrating the importance of the body-subject experience. HT may possibly induce behavioural change, because the client can experiment with vulnerable behavior within the safety of the HT-patient relationship, which could be an interesting research question for HT.

Conclusion

In addition to the insightful conversations, the experiential skill exercises and the affective contact-oriented therapeutic touch, the therapist-patient relationship in HT can also be seen as a specific therapy factor. Although this article does not yet provide a conclusive rationale for the efficacy of haptotherapy, it offers a good overview of the specific and nonspecific therapy factors in haptotherapy and the presumed mechanisms of haptotherapy.

Acknowledgment

We would like to thank Monica Pollmann MSc, healtcare haptotherapist, also lecturer at the Academy of Haptonomy and board member of the Association of Haptotherapists (VVH), for her advice.

Authors’ contributions

All those involved are considered co-authors, because they have all made important contributions to this article. All authors have read and approved the final manuscript.

Information about the authors

¹Dr. Gert A. Klabbers, Haptotherapy practice, Ietje Kooistraweg 25, 7311 GZ Apeldoorn, the Netherlands and Postdoctoral researcher at Tilburg University, Warandelaan 2, 5037 AB Tilburg, the Netherlands. ²Bob Boot MSc, Haptotherapy practice, Texelstraat 80, 1181 ES Amstelveen, the Netherlands. ³Marjolein Dekker, Haptotherapy practice, Noorderplein 7, 7412 VS, Deventer, the Netherlands. ⁴J. Willem Hagg, Haptotherapy practice, Kozakkenlaan 21, 7231 DK Warnsveld, the Netherlands.