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To Touch Or Not To Touch:
Exploring the Myth of Prohibition On Touch In Clinical, Ethical & Legal Considerations
By Ofer Zur, Ph.D. & Nola Nordmarken, MFT To cite this page: Zur, O. and Nordmarken, N. (2008). To Touch Or Not To Touch: Exploring the Myth of Prohibition On Touch In Psychotherapy And Counseling. Retrieved month/day/year from http://www.zurinstitute.com/touchintherapy.html.
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INTRODUCTION In his seminal work, Touching: The Human Significance of the Skin, Ashley Montagu (1971) brings together a vast array of studies shedding light on the role of skin and physical touch in human development. He goes on to illuminate how the sensory system, the skin, is the most important organ system of the body, because unlike other senses, a human being cannot survive without the physical and behavioral functions performed by the skin. "Among all the senses," Montagu states, "touch stands paramount" (1986, p. 17). Before Montague published his classic book in 1971, Harlow (1958) set the stage for our understanding of the importance of touch for emotional, physiological and interpersonal development in human and non-human infants. In line with Harlow, Montagu concludes: "When the need for touch remains unsatisfied, abnormal behavior will result" (1986, p. 46). Primarily Euro-American cultures in general, particularly that of North American white-Anglos, have developed a set of unspoken taboos in regard to touch. Based on Cohen (1987) and Hunter and Struve's, (1998) work, following are short descriptions of these cultural, mostly unspoken, taboos:
Touch, in this article, refers to any physical contact occurring between a psychotherapist and a client or a patient in the context of psychotherapy. Touch is one of many non-verbal modes of communications (i.e., Fridlund, 1994; Young, 2005). This paper looks at touch as an adjunct to verbal psychotherapy. However, it also reviews the literature on body psychotherapies where touch is a key therapeutic tool. This paper explores the rich duet of talk and touch and articulates how such a duet can significantly increase a sense of empathy, sympathy, safety, calm, and comfort, as well as enhancing a client's sense of being heard, seen, understood and acknowledged by their therapist (Hunter & Struve, 1998). Touch is also likely to increase the sense of connection and trust between a therapist and a client (Smith et. al., 1998). The enhancement of the therapeutic alliance is of utmost importance, and as has been extensively documented, the quality of the relationship between therapist and client is the best predictor of therapeutic outcome (Lambert, 1992). Touch, in this paper, refers primarily to touch initiated by the therapist. However, when a client initiates or requests touch, the therapists must use his or her clinical judgment to ascertain whether providing or withholding touch is ethical and clinically advantageous in each therapeutic situation. Regardless of the vast scientific knowledge and data on the importance of touch for human development, communication, and its effectiveness in healing, the field of psychotherapy has generally shunned its use (Hunter & Struve, 1998; Smith et. al., 1998; Young, 2005; Zur, 2007). Starting with Freud, traditional psychoanalysis looks at touch as an obstacle to analysis and cure of neurosis (Fosshage, 2000). For a variety of reasons, the field at large has embraced the analytic hands-off stance. More recently, risk management guidelines, attorneys' advice columns and ethical and legal experts have joined the psychoanalysts to warn us about the perils of touch. Touch in therapy has joined the list of modern risk management-inspired taboos: do not leave the office, minimize self-disclosure and avoid dual relationships (Williams, 1997). Even those who endorse risk management reluctantly agree that a courteous handshake may be unavoidable. Viewing any non-erotic touch as the first step on the slippery slope towards sexual relationships is one of the major erroneous beliefs and obstacles to understanding the importance of touch in therapy. Such sexualization of all forms of touch is embedded in the culture at large and manifested in faulty beliefs prevalent in the field of psychotherapy (Lazarus & Zur, 2002). Some of the negative and frightening messages we have been inundated with come from prominent therapists, many of whom are psychoanalytically oriented. One example is Menninger, who asserts that physical contact with a patient is "evidence of incompetence or criminal ruthlessness of the analysts" (cited in Horton, et. al., 1995, p. 444). Simon, in a similar vein, instructs therapists to "Foster psychological separateness of the patient. . . interact only verbally with clients. . . minimize physical contact" (1994, p. 514). Wolberg (1972), agrees: "Physical contact with the patient is absolutely a taboo (since it may) mobilize sexual feelings in the patient and the therapist, or bring forth violent outburst of anger" (1967, p. 606). There are many different approaches to touch in therapy. One approach, often referred to as body psychotherapy, or somatic psychotherapy, sometimes uses touch as one of its primary tools while also employing verbal communication. It is a commonly misheld belief that all somatic or body psychotherapists utilize physical touch in psychotherapy. While many do, there are others who advise against touch. The concept that we are embodied beings, and the respect for the unity between psychological and bodily aspects of being, is common to all forms of somatic body psychotherapy. These schools of thought recognize the body as a vehicle of communication and healing. Another approach, and the focus of this paper, employs touch as an adjunct to verbal psychotherapy or counseling. Body psychotherapies include schools, such as Reichain (Reich, 1972) and its numerous branches, Bioenergetics (Lowen, 1976), Somatic (Caldwell, 1997) or Hakomi (Kurtz, 1990). These approaches focus on harnessing the healing power of touch. There are numerous other psychotherapeutic orientations that have embraced touch. These orientations formalized the use of touch in therapy as an adjunct to verbal therapy. They include Gestalt therapy (Perls, 1973), several variations of humanistic psychology (Rogers, 1970) and group therapy (Edwards, 1984). They also include some parts of feminist, child, family therapy and dance and movement therapy (Smith, et. al, 1998; Satir, 1972). In spite of the numerous therapeutic approaches, theories and practices that systematically and effectively use touch in therapy, touch has nevertheless been marginalized, forbidden, called a taboo, often sexualized and at times, even criminalized by many schools of psychotherapy and ethicists (Young, 2005; Zur, 2007). This article reviews the general importance of touch for human development, secure attachment, communication, the development and maintenance of physiological and psychological regulation, and the formation of therapeutic alliance. Types of touch employed in psychotherapy are discussed, as well as the main professional sources for the prohibition of touch in therapy. The western cultural context and its relationship to touch are also discussed as an additional source of the prohibition on touch. It then discusses the psychotherapeutic benefits of touch, and finally provides a summary and a set of guidelines for the use of touch in therapy. THE IMPORTANCE OF TOUCH
Touch is our first language. Long before we can see an image, smell an odor, taste a flavor, or hear a sound, we experience others and ourselves through touch, our only reciprocal sense. We cannot touch another without being touched ourselves, and it is in this sense that there is great positive potential in forming a strong therapeutic bond and a vehicle for healing injuries created by early touch violations or lack of necessary touch. Hunter & Struve, (1998) summarize the therapeutic effects of touch by suggesting that touch may help the therapist to provide real or symbolic contact and nurturance, to facilitate access to, exploration of, and resolution of emotional experiences, to provide containment, and to restore significant and healthy dimensions in relationships. Glickauf-Hughs, and Clance (1998) point to the role of touch in ego development. Of course, the potency of touch holds the potential for harm as well as healing. Because of this, touch in psychotherapy has long been held to be dangerous and taboo or at the very least, legally risky, or a threat to the integrity of the therapeutic process. Risk, however, is not a valid reason to avoid an important therapeutic modality. Not touching has powerful effects as well and this aspect of treatment is ignored by mainstream psychotherapy literature. However, not touching is also risky. "Absence of any physical contact is likely to cause transference distortions (i.e. the client may view the therapist as a cold, withholding parent figure" (Wilison & Masson, 1986, p.498). Wilson (1982) argues, "To disregard all physical contact between therapist and client may deter psychological growth" (p. 65).
MEDICAL AND PSYCHOLOGICAL EFFECTS OF MASSAGE Recent research done by the Touch Research Institute has demonstrated that touch triggers a cascade of chemical responses, including a decrease in urinary stress hormones (cortisol, catecholamines, norepinephrine, epinephrine), and increased serotonin and dopamine levels. The shift in these bio-chemicals has been proven to decrease depression (Field, 1998, 2003). Hence, touch is good medicine. It also enhances the immune system by increasing natural killer cells and killer cell activity, balancing the ratio of cd4 cells and cd4/cd8 cells. The immune system's cytotoxic capacity increases with touch, thus helping the body maintain its defense against pathogens (Field, 1998). Massage therapy has been shown to reduce aversion to touch and to decrease anxiety, depression and cortisol levels in women who have been sexually or physically abused (Field, et. al., 1997). It decreases diastolic blood pressure, anxiety and cortisol (stress hormone) levels (Hernandez-Reif, et. al., 2000). One study examined the effects of massage therapy on anxiety and depression levels and on immune function. The subjects received a 45-minute massage five times weekly for a 1-month period. The findings were that: 1) anxiety, stress and cortisol levels were significantly reduced; 2) natural killer cells and natural killer cell activity increased, suggesting positive effects on the immune system (Ironson, et. al., 1996). Bulimic adolescent girls received massage therapy 2 times a week for 5 weeks. Effects included an improved body image, decreased depression and anxiety symptoms, decreased cortisol levels and increased dopamine and serotonin levels. In a study of children with ADHD, touch sensitivity, attention to sounds and off-task classroom behavior decreased and relatedness to teachers increased after massage therapy (Field, et. al., 1997). Following five 30-minute massages, children/adolescents had better sleep patterns, lower level of depression and anxiety and lower stress hormone levels (Field, et. al., 1992). Massage therapy also decreased the anxiety, depression and stress hormone levels of children diagnosed with PTSD, who survived Hurricane Andrew. In addition, their drawings reflected less depression (Field, et. al., 1996). Recent research on pregnancy and infant massage documents benefits of touch that might allow us to consider this form of touch to be labeled as psychotherapy at the earliest stages of human development. Massaged babies show improved emotionality, sociability, soothability, temperament dimensions, and better face-to-face interaction behaviors (Field, et al., 1996). Many hospitals are now implementing Tender Touch parent education programs that promote the philosophy of developmental care in order to individualize infant care to maximize each baby's developmental potential. Other similar programs teach Tender Touch volunteers how to work with drug-exposed newborns. These programs were developed for at-risk infants and can be conceptualized as infant psychotherapy. Instruction begins by teaching a kind of attunement, training the caregiver to be observant of cues that indicate if the baby is being soothed or stressed by the type of touch. Caregivers are taught simple stroking techniques involving the amount of pressure, pace and consistency. Touch is adjusted as the caretaker responds to communication from the baby. Massaged preemies fare better than those in incubators on many counts: decreased stress hormones, temperature regulation, heart stability, sleep/alert cycles, and breathing regularity (Field, 1998, 2003). Touch attunement training is also beneficial for psychotherapists. Trial programs, which teach parents infant massage in an effort to reduce the incident of child abuse, show promising preliminary results. In 1994, the Children's Trust fund of Oregon awarded a two-year, $20,000 grant to the Perinatal Bonding Project. The project's 40 volunteers provided training in attunement and massage to parents who were identified by social service agencies as being at high risk to carry out abuse. From 1994 to 1996, when the program was in effect, the number of confirmed cases of infant abuse in Douglas County dropped from 104 to 15 (Menehan, 1996). "Everything that newborns and infants know about the universe they learn through their physical sensations." (Bar-Levav, 1998, p.53)Loving touch triggers the release of oxytocin, often referred to as the "bonding hormone" (Field, 1997). Studies in bonding also show that human babies who are held often and touched frequently in their earliest stages of development have higher scores on physical, emotional, and interpersonal scales (Klaus, Kennell, & Klaus 1976; Field et. al., 1986). The opposite is true of abusive touch or lack of touch. In fact, the absence of loving touch has been documented to have profound impact on the will to live. Death rates for under-touched infants less than one year of age, in institutes during the 1920's ranged from 30% to 100% (Hunter & Struve, 1998). During the early 30's, Bellevue hospital in New York challenged the prevailing norms and authorized staff to incorporate physical contact in their care protocols. The mortality rate dropped on that unit from 30% to 10%, and the caregivers proposed the name marasmus (wasting away) for this disease of institutionalized touch depravation (Cohen, 1987). Developmental specialists agree that primary caretakers' attunement and appropriate response to their child's communication of needs during the first few years of life is essential to adequate neurological and emotional development (Bowlby, 1952; Field, 1998, 2003; Harlow, 1971). They agree, as well, that deficits in the satisfaction of basic needs results in the development of defense structures that complicate and inhibit relationship to self and others. Ancient art depicts babies suckling at their mothers' breasts, held close against their skin, forming an intimate nurturing connection that communicates the promise of protection and immediate gratification of basic survival needs. These images of such earliest forms of communication depict our first language, the language of touch, as the essence of life (Montagu, 1971). For more than a million years mothers have held their infants close, responding to their basic needs with natural attunement and life affirming touch. We live in a fast paced, goal directed, multitask oriented world, but our limbic system, that part of the brain which governs emotions and responds positively to the chemicals released by loving touch, remains as ancient as cave images uncovered by anthropologists (Heller, 1997). Unfortunately, American babies and children are among the least touched on earth (Heller, 1997). We can look to developmental and evolutionary psychology to understand how social pressure and excessive valuing of early independence and self-sufficiency has resulted in American parents distancing themselves physically from their children (Mead, 1955). We can also look to the practices of parenting in higher touch cultures to appreciate the positive benefits of healthy psychological and emotional development. Research indicates that we are hardwired to need touch in the earliest developmental stages (Field, 1995, 2003). And yet, with the onset of the industrial revolution and related changes in childrearing practices, the way in which modern westerners cared for and connected with their babies was altered radically. Extended families were split up, depriving babies and mothers of the multi-generational, extended familial support system that had been the ground of childrearing in traditional communities for centuries. Childrearing advice of the 1920's cautioned parents about spoiling their children: "Never hug and kiss them. Never let them sit on your lap. If you must, kiss them on the head when they say goodnight. Shake hands with them in the morning. Give them a pat on the head if they have made an extraordinarily good job of a difficult task" (Watson, 1928, cited in Heller 1997 p. 104). Attachment and bonding, words that label the development of certain psychological processes, imply intimate touch, but it was not until the 1950's that the psychological community began to understand and appreciate the link between parent-child touch and attachment. We were familiar with Freud's concepts identifying the first year of life as the oral stage and for decades believed that our babies bonded with us because we fed them. Following World War II, psychologists John Bowlby (1969) and Mary Ainsworth (1978), conducted the first scientific study of love by exploring children's responses to separation and how parenting styles affect the quality of attachment. The foundation of attachment theory was developed by Bowlby in his book, Attachment, Separation, and Loss (1969). He concludes that bonding occurs, not only as a result of the reduction of primary drives, but also due to what he refers to as "primary object clinging," a need for intimate contact, which is initially associated with the mother (Harlow, 1958, p.3). Harlow took Bowlby's theory to the lab when he researched the importance of touch by conducting direct experimental analysis of the "affectional or love responses in neonatal and infant primates" (Harlow, 1958, p.3). He chose rhesus macaque monkeys as subjects for his analysis, as they share ninety-four percent of their genetic heritage with humans. The monkeys were offered access to two surrogate mothers: a "soft" terrycloth mother that was warmed by a light bulb that provided a positive tactile experience, and a wire mother with a bottle attached to it for feeding. The infants spent only the amount of time necessary for feeding with the wire mother and when left alone with her would cower in a corner. When given the choice of both mothers, they would cling to the "soft" mother for up to twenty-two hours a day and, in contrast, when left alone with her, would give her a few hugs and then felt secure enough to explore a strange object on their own. "These data make it obvious that contact comfort is a variable of overwhelming importance in the development of affectional response, whereas lactation is a variable of negligible importance" (Harlow, 1958, p.6). His observations of infant monkeys separated from their mothers at birth fundamentally changed our views. He discovered two very important things about development. Firstly, "comfort contact proved to be a more significant parenting quality than feeding... and... touch, not food, binds infant to caregiver" (Heller, 1997, p.55). The second finding was that even those monkeys that were reared on the soft mother, as adults, were neurotic, asocial, autistically self stimulating, self mutilating, and sexually inept. Subsequent studies involved providing the infants with a rocking surrogate. The infants in this study showed fewer abnormal developmental indicators. Normal functioning occurred, however, only in infants who were given contact with another live monkey for just one half hour a day. They needed interactive touch to support normal development. Developmental psychologist, Sharon Heller, writes that what distinguishes a securely attached baby from an insecurely attached baby is "the degree to which each could feel ownership of their mothers' bodies and therefore assurance of protection" (Heller, 1997 p.58). That feeling of ownership requires touch by sensitive, attuned parents. Through sensitive parental responding, infants receive accurate feedback about the effects of their behavior and they learn that, when they signal a need, they can expect a prompt, predictable, and soothing response. This makes it unnecessary to develop dysfunctional emotional defense systems. Infants who signal a need and are responded to by a sensitive, attuned parent feel a sense of control over their lives. The importance of this cannot be overemphasized. Feeling in control, one feels greater assurance of psychological survival. Feeling less need to control, one can more easily form closer relationships and benefit from the emotional satisfaction of bonding needs. One who feels in control is less likely to commit acts of violence, will have fewer physical problems, and live longer (Heller, 1997). The converse is true as well, just as sensitive, attuned touch gets etched in our developing neural pathways enabling us to reach out and touch in that same way throughout our lifetime, touch that is absent when necessary, inappropriately sexualized, cold or abusive, gets recorded in ways that cause us to draw inward or to strike out. Most abused children do not grow up to abuse their own children but those who do abuse their own children have almost always been abused in their own childhood: Violence begets violence. James Prescott (1975), a neuroscientist formerly with the U.S. Department of Health, Education, and welfare, reviewed forty-nine societies and concluded that a lack of bodily pleasure derived from touching and stroking during the formative periods of life was the primary cause of violent behavior in adults. Unfortunately, 93 percent of American parents use physical punishments therefore there is a higher incidence of child beatings and murders by parents in the U.S. than anywhere else in the world, and a classic study of American childrearing practices shows harsh and punitive touch to outweigh warm and affectionate touch (Wolfgang, 1969). Americans are considered by many other cultures to be independent to a fault, to be self centered, materialistic, lacking in reasonable social boundaries and somewhat abrasive. Why? Perhaps because we are a culture with a high population of insecurely attached persons. Object relations theory tells us that insecurely attached children often have a cool demeanor and focused involvement in activities that make them appear independent, although their independence may later become self-importance (Heller, 1997). John Bowlby (1969) sees this as pseudo-maturity and calls it compulsive self-reliance. Ambivalent or insecure attachment may or may not be the cause of our poor reputation but research indicates that the largest percentage of insecure infants are found in cultures that value and require the earliest self reliance, while those that value interdependence have the highest percentage of securely attached infants (Lamb, et. al., 1985). Anthropological data reveal mainstream American mothers as being less affectionate toward their children, more likely to touch their children in public mainly as a means of control, and to expect children to entertain themselves. They primarily reward their children with touch in response to acting out and generally tend to stimulate their children who, in response, become more active and vocal (Clay, 1966). They rely heavily on impersonal childrearing aids such as infant carriers, bottles, pacifiers, strollers, swings, playpens and cribs which limit the child's' experience of human, soothing touch (Heller, 1997). Montague (1971) postulates that this type of parenting would produce individuals who are able to lead lonely, isolated lives in the crowded urban world, with its materialistic values and its addiction to things. American children rate high in insecure coercive, negative behavior. Similar words could be used to describe adults in American culture. In contrast to American babies, 77 percent of Japanese babies are securely attached. Japanese mothers' attuned attention to their infants' needs is sited as the reason for these percentages. The bond between mother and infant is so intense that the Japanese literally call it "skinship." These mothers carry their infants on their backs for long periods, prolong breast feeding, co-sleep until their child is five years of age, co-bathe, and attempt to soothe their babies into a continual state of calm. Skinship makes a difference (Heller, 1997). Psychologist Elizabeth Ainsfeld (1990) of Columbia University tested this by distributing snuglies (soft, body baby carriers) to financially deprived American mothers whose infants were at high risk for insecure attachment. She gave the control group plastic infant carriers. Eighty-three percent of the snugli infants were securely attached at one year of age compared to only 38 percent of the babies carried in the plastic infant seats. Abused, neglected or touch deprived children learn not to trust touch. They tend to have great difficulty feeling of value, feeling truly powerful, or of forming reciprocally supportive relationships as adults. They are injured by lack of touch or by abusive touch (Heller, 1997). The above discussion of touch, culture and bonding has direct implications for psychotherapy and counseling. The cultural taboo against touch in psychotherapy encourages therapists to perpetuate the neglect that originally caused the injury. Therapists tend to avoid touch, to neglect consideration of touch in a well thought out treatment plan and to avoid talking about this with clients. Touching clients can hurt them if done in the wrong way but touch can also heal old touch injuries. Not touching can cause injury to certain clients in certain situations. The silence about this in our education and training programs of therapists, in supervision, or in actual therapy with clients often results in less effective therapy. A dialogue regarding touch should be expanded amongst therapists and between clients and therapists in general. The touch needs of a securely attached client will be different than the needs of a client who was attached in an insecure or avoidant way as an infant. Programs in attunement training, for parents and babies with attachment problems, have proven to be effective. Since babies lack language and conceptual skills, these parents are trained to "listen" to the body and to respond through appropriate touch. Although this is slowly changing, traditional training of therapists focuses very little on the body and hardly at all on touch. Touch attunement is a relatively neglected aspect of training and education for most therapists.
TOUCH AND ETHNICITY, REGION, CLASS, AND GENDER IDENTITY America in general is a low touch culture. Within the American culture there are differences regarding touch between different regions, ethnic or minority groups. For example, Californians touch each other more casually and more often than New Englanders (Mc Neely, 1987). California is an ethnically diverse state, however, and Californians whose heritage is linked to the Far Eastern cultures generally engage in less touching behaviors than do citizens of other Ethnic origins (Samovar, Porter, & Jain, 1981). Midwesterners who are strongly rooted in German and Scandinavian cultures are relatively restrained in their touch behaviors. In contrast, Americans of Latino heritage, a population found most often in southern regions of the country, touch easily and often. Americans of Mediterranean heritage touch and kiss freely (Mc Neely, 1987). Americans of Indian heritage are more likely to be sensitive to class distinction with regard to touch. Unspoken social taboos are reflected in touch behaviors. Persons of a higher class may touch persons of a lower class, but not vice versa. Despite alleged advances in civil rights for African Americans since the mid-1960s, many of the unspoken protocols and fundamental biases continue to inhibit touch between Caucasians and African Americans in modern U.S. (Hunter & Struve, 1998). It is believed that the unspoken rules regarding touch between different classes is related to the history of the master-slave relationship in the U.S. The relationship between ethnicity and touch has direct implications for touch in psychotherapy. While there is a growing body of literature on multicultural theory and counseling (Aponte & Wohl, 2000; Sue, Ivey, Pederson, 1996), little has been written specifically on the use of touch in psychotherapy with ethnically diverse populations. It is well documented that due to a history of oppression in the United States, as well as ongoing racism and discrimination, members of a minority group often experience therapy with a Caucasian clinician as a recapitulation of the power differentials that exist in society at large (Comas-Diaz & Green, 1994; Greene, 1997; Pedersen, et. al., 1996). Touch has layers of meaning, depending on one's culture, socialization and individual experience (Halbrook & Duplechin, 1994). How personal space is defined within a culture affects the interpretation of therapeutic touch. Cultural and sub-cultural power differentials, of both gender and class must be considered. Hence, as Smith (1998) points out, a therapist may be seen as "distant, respectful, or invasive" depending on the socialization and experience of the individual client. It is essential that clinicians inform themselves of their clients' cultural context before using the power of touch in session. SEXUALIZATION OF TOUCH Although Harlow's advice replaced Watson's, the legacy of these repressive attitudes continue to haunt us and may account for the reputation Americans have as being sexually obsessed and as having odd social customs related to touch. Within large portions of American culture, there is a propensity to either infantilize or sexualize physical contact (Hunter & Struve, 1997; Young, 2005; Zur, 2007). Most public displays of affection are held suspect, especially males touching males. While most boys learn that affectionate touch between males is taboo, they are granted acceptable touch in competitive sports and in military action. Many would find it embarrassing to kiss their fathers in public, but it is widely accepted for them to pat the buttocks of a male team member after a good play during a sporting event. Many Americans, embarrassed by nudity, cover their children's bodies so that they can't see each other naked and cover their own adult bodies so as not to over stimulate the children (Heller, 1997). These experiences are in direct contrast to the exaggerated, eroticized forms of nudity our children see on billboards, in the media, in unsolicited e-mails and on the Web. Madison Avenue knows, that which is taboo can be titillating and in this consumerist culture, eroticized nudity sells. Unfortunately, in addition to selling products, it sells young girls unrealistic physical images to which they compare themselves. It sells the notion of a superficial relationship to sexuality and acceptability of irresponsible choices. It sells the notion of bodies as objects rather than expressions of consciousness. In contrast, Margaret Mead (1967) taught that with normal exposure to nudity, children are more able to form a cultural script of their bodies. They compare their flat chests to a woman's rounded breasts, a flat tummy to a pregnant belly or a sagging one, a child's small penis to an elongated one in a crop of hair. This helps them to also develop a part of the cultural role for themselves and a relaxed attitude about the naked body. The uneasiness about child development related to healthy sexuality, nudity and touch is likely to escalate. Alarmingly, up to 30 percent or more of all children are sexually abused (Heller, 1999). The uncovering of institutional abuse of children, such as the church and the foster care system, has fueled our vigilance. We do need to protect our children. We also need to address the backlash. Innocent acts by parents, day care staff, and teachers are often falsely misinterpreted as sexual abuse. Although less than 1 percent of all reported child sexual abuse cases occur in childcare settings, fear of lawsuits has resulted in the institution of restricted touch policies (Heller, 1999). For example, the National Education Association advises teachers of elementary and high school children to "Teach but don't touch." In spite of this "hands off" policy, instances of child sexual and physical abuse are raising. Clearly, touch is not inherently dangerous to our children and it holds enormous positive potential for development and growth. It is the small minority of childcare workers who act out of their own pathology who are dangerous, just as it is the small minority of therapists who use touch to violate the boundaries of psychotherapy clients who are dangerous. As a culture and in the profession of psychotherapy it is important to reevaluate our protective interventions, not ban touch. Therapists, as this article articulates, also struggle with issues of touch in an increasingly adversarial legal and cultural environment. Because touch is often judged as generating from sexual motivation, therapist, like teachers, childcare workers and the American public in general, tend to avoid touching to minimize the risk of having their intentions misunderstood (Young, 2005; Zur, 2007). Because of that, our clients and society in general are deprived of the potential healing that a more open and permission-giving climate would facilitate (Fagan, 1998; Smith et. al., 1998). TYPES OF TOUCH IN PSYCHOTHERAPY
Therapeutic touch as an adjunct to verbal therapy
In summary, this article focuses on the forms of touch described in the first category, therapeutic touch. That is, touch that is intentionally incorporated as part of verbal therapy and most often includes a hug, light touch, stroke of head, rubbing of a client's back, shoulder or arm, rocking or hand-holding. The intent of these forms of touch, which are an integrated aspect of therapy, is to increase the sense of connection and relatedness with clients and/or to calm, sooth or reassure clients.
THE PROHIBITION OF TOUCH IN THERAPY Cultural-political-religious forces:
Professional psychotherapeutic forces:
BEYOND VERBAL COMMUNICATION Charles Darwin published the first scientific study of non-verbal communication in 1872 in, The Expression of the Emotions in Man and Animals. Since that time, thousands of research projects in a variety of fields, such as archaeology, biology, cultural and physical anthropology, linguistics, primatology, psychology, psychiatry, and zoology have been conducted. The results of this research have established a generally recognized body of knowledge of non-verbal cues and communication. Recent discoveries in neuroscience provide us with an even clearer picture of the importance of non-verbal communication. Because we now know how the brain processes non-verbal cues, body language has come of age in the 21st Century as a science to help us understand what it means to be human (Givens, 2004). Early theorists attended to non-verbal cues, but little was written regarding ways in which these elements could be brought into sharper awareness and focus until the pioneering works of Reich (1972) and Perls (1973). Few modern clinical training programs address this vital dimension in much depth (Blatner, 2002). Psychiatrists and psychologists have found that disturbances in non-verbal communication are more severe and often longer lasting than disturbances in verbal language (Bateson, 1979). From paleocircuits in the spinal cord, brain stem, basal ganglia, and limbic system, cues are produced and received below the level of conscious awareness. Non-verbal communication gives us the sense and the feel we remember long after words have died away (Givens, 2004). Many cultural influences involve an unspoken rule that people should ignore non-verbal elements of communication, so the task of incorporating conscious sensitivity and awareness to non-verbal communication is often limited. Generally speaking, women are superior to men in decoding non-verbal cues, most likely for biological evolutionary reasons.
Categories of Non-verbal Communication Somatic Expression: These "body voice" communications include: Blushing, perspiring, changes in breathing, flushing, muscle tension (constriction or expansion), moisture in eyes, blanching, flaring of nostrils, unconscious movement of body parts, visceral experience, numbing, and temperature changes (Blatner, 2002). Personal Space: Personal space is also a form of non-verbal communication. Many factors affect the distance in which individuals experience comfort in approaching or being approached by others. Power structures, role relations, gender, cultural factors, social relationships, location (e.g. public or private), personal and familial factors, and past experience with boundary violations are all included in this category. Eye Contact: Eye contact modifies the meaning of other non-verbal behaviors. For example, people on elevators or in crowds adjust their sense of personal spacial comfort if they agree to limit their eye contact (Scheflen, 1972). Paralanguage: "Non-lexical" vocal communications suggest emotional nuances. These include, but are not limited to, inflection, intensity, tone, pitch or pauses. Facial Expressions: Transient facial expressions may communicate emotions that are not intended or conscious. The face is an extremely developed organ of expression. Gestures: Gestures are also often unconscious or unintended modes of non-verbal communication. These might include, among many others: raised eyebrows, narrowing eyes, touching one's face, folding arms, pursing lips, self-hugging, or changes in breathing. Adornment: Semiontics is the science of the emotional and psychological impact of signs and appearances. These elements might include: clothing, makeup, pens, pipes, belts, pillows, etc. (Blatner, 2002). Therapeutic goals can be served when therapists increase their awareness of these forms of non-verbal communication and educate their clients about them as well. This self-knowledge is empowering to clients. People vary in regard to the mode they primarily rely on, whether it is auditory, visual, olfactory or tactile. It is essential to pay careful attention to the type of communication that is most effective which each client. A therapist who is sensitive to this issue might sit with a family and ask the father "Did you hear what was just said?" Then ask the mother "Did you see what just happened"? Then ask the son "Did you notice what just took place?" And finally ask the daughter "Did you sense what just happened?" Similarly, people will react to the same stimuli by using different terms, such "bad taste," "ugly looking," "stinks" or "sounds horrible." The intent to honor individual differences is compromised in an exclusive focus on verbal communication.
TOUCH IN CONTEXT Following, is an example of the importance of context. Imagine a 50-something male therapist who tells you that he spent a recent therapy session holding hands with a recumbent 24-year-old female client he had only just met. Of course in a "standard" therapeutic situation, such a scene is likely to evoke associations of an unethical, unprofessional, most likely illegal and inappropriate sexual mode. Now, imagine that this exchange takes place in a hospital room, the patient has cystic fibrosis, severe lung disease, and struggles mightily to breathe and speak despite the oxygen pressure mask she wears. The therapist asks how he can help and she grips his hand tightly saying, "Don't let go." (Koocher, personal communication, 2004). Gender issues are extremely important in understanding the context of touch. As noted above, men in general are more likely to sexualize touch unless it is hostile or aggressive (Smith et al., 1998). Along the same line, Abbey and Melby (1986) found that men are more likely to perceive sexual intent when women touch them, while women are less likely to perceive such sexual intent in men, especially when the situation is ambiguous or casual. In large part, clients' individual factors constitute the context of touch and therefore are of extreme importance. They include presenting problem, diagnosis, personality, history, and in particular, history of abuse, culture and gender. Timing is as important. While a handshake may be appropriate at the beginning of treatment, other forms of touch, such as a hug or a kiss on the cheek may not be. It is essential for the therapist to have explored his or her own relationship to touch issues as well. Even Pope and Vasquez (1998), with their major concerns about boundaries and dual relationships, have articulated the potential benefits of touch in psychotherapy: If the therapist is personally comfortable engaging in physical contact with a patient, maintains a theoretical orientation for which therapist-client contact is not antithetical, and has competence (education, training and supervised experience) in the use of touch, then the decision of whether or not to make physical contact with a particular client must be based on a careful evaluation of the clinical needs of the client at that moment. When solidly based upon clinical needs and a clinical rationale, touch can be exceptionally caring, comforting, reassuring, or healing (p. 170).
CLIENTS' PERCEPTION OF TOUCH Non-erotic or non-sexual touch in therapy, like any other form of non-verbal communication, can complement, negate, reinforce or alter verbal communication in general and in therapy (Geib, 1982; Horton et al., 1998; Smith et al, 1998; Young, 2005; Zur, 2007). Many of our clients, like people in general, are often more attuned to non-verbal cues such as body language and touch rather than to verbal communication (Givens, 2004). The quality of attunement between client and therapist is of utmost importance regarding the meaning of non-verbal cues and will determine the clients' response to touch. Geib (1982) conducted one of the first phenomenological studies of the meaning attributed by clients with regard to non-sexual touch and isolated four factors that are associated with a client's positive evaluation of touch in therapy: Congruence of touch; clarity regarding boundaries in therapy; client's perception of being in control of the physical contact, and client's perception that the touch was for his/her benefit rather than the therapist's. A study done by Horton et. al. (1995) supported Geib's finding that the degree of therapeutic alliance significantly influences the client's evaluation of touch.
TOUCH AND THE THERAPEUTIC ALLIANCE Therapists' congruent, invited, and appropriate non-sexual touch is likely to increase a sense of empathy, sympathy, safety, calm, and comfort for clients (Smith et al., 1998). It can also significantly enhance clients' sense of being heard, seen, understood and acknowledged by their therapists. As such, appropriate touch is likely to increase the sense of connection and trust between a therapist and a client. Research indicates that the clients' experience of touch in psychotherapy provides valuable information on assessing the therapeutic alliance and predicting therapy outcome (Gurman, 1977; Hartly & Strupp, 1983; Lambert, 1991; Marziali, 1984; Salvio, Beutler, Wood, & Engle, 1992). Hilton (1997) describes the importance of touch for transference and countertranferece analysis.
SURVEYS ON TOUCH IN THERAPY Pope, Tabachnick, Keith-Spiegel (1987) report the following from their survey of psychotherapists: About one fourth of our respondents reported kissing their clients, either rarely (23.5%) or more often (5.0%). About half viewed this practice as unethical. An additional 36.6% believed it to be unethical in most circumstances. The study of attitudes towards touch in therapy primarily involves issues related to sexual feelings, sexual touch and sexual boundary violations. Most of these surveys present several methodological concerns either because they seem to lack clear differentiations between sexual and non-sexual touch or assume that, in most cases, non-sexual touch inevitably leads to sexual touch. The bias against boundary crossing in general and touch in particular, combined with sampling limitations have also been a concern with the validity of the surveys. Holroyd & Brodsky (1980) titled their article regarding their survey "Does touching patients lead to sexual intercourse?" Not surprisingly they also concluded that it "is difficult to determine where 'non-erotic hugging, kissing, and affectionate touching' leave off and 'erotic contact' begins" (p. 810). Similarly, Pope and various colleagues (Pope & Bouhoutsos, 1986; Pope, Schover, & Levenson, 1980; Pope & Vasquez, 1998) have conducted several surveys that gave much more weight to the potential dangers of touching and how it is likely to lead to sexual intimacy rather than the more inquisitive balanced stance of looking at the positive and negative potentialities and unique complexities that touch introduces into therapy. The bias of Pope, Tabachnick and Keith-Spiegel (1987) in regard to touch is apparent as soon as one notices that under the heading "Do Not Exploit" they discuss the topics of "Sexual issues and physical contact" under one subtitle. In their conclusion, citing several of their colleagues, they state, "The focus on erotic contact in therapy has raised questions about the legitimacy and effects of ostensibly nonerotic physical contact" (p. 1001). In their national survey, Pope & Tabachnick (1994) were admittedly surprised to find that nonsexual physical touch in the form of being cradling or held by their therapists was reported by about one fourth of client-participants. They also found that about 1 in 20 (6%) reported that the therapist touched the client in a sexual way. These researchers' bias in regard to the issue of touch in therapy becomes apparent when one reads their following reflection and their alarm at the their finding: That so many participants had been cradled or held by their therapists was surprising, in part, because of the attention paid, by both the public and the profession, to sexual contact. In light of the harm and penalties associated with sexual violations, it might be hypothesized that therapists would tend to avoid forms of physical contact such as holding and cradling (i.e., those beyond a handshake, reassuring touch, and other brief and limited forms of making contact). The finding is also somewhat surprising given the relevant lack of therapy research literature on the effects of nonphysical touch. That at least one fourth of the participants reported having been cradled or held by their therapists suggests that this form of therapist-client relationship deserves increased attention in systematic studies, graduate training programs, and continuing education courses (Pope & Tabachnick, 1994, p. 257) The prevalent biased view in the field has, in part, been perpetuated by these writers who do not consider touch as an important and basic healing method, or recognize it as one of the most basic forms of human communication. Like so many others in the field, they associate or link non-sexual touch with sexual touch. Additionally, their statement that there is a 'lack' of research of the healing effect of touch is as surprising as it is inaccurate. This attitude goes along with Pope's (1982) and his followers' assertion that non-sexual dual relationships often lead to sexual dual relationships. Perhaps one of the more important significant findings is reported by Holroyd and Brodsky (1980). Their study relates to the differential treatment of female and male clients with regard to non-erotic touch, which was systematically related to therapist-client erotic involvement. This has been interpreted by most researchers to mean that therapists who differentiate between those with whom they will employ touch in therapy are sexualizing touch and are also more likely to violate the sexual boundaries of therapy. The same study did not find any correlations between non-sexual touch and sexual touch when therapists touched men and women equally. The important conclusion of these finding is that therapists' own attitudes towards touch and their tendency to sexualize touch are the key factors in contributing to sexual misconduct rather than the touch itself. A more balanced view of touch and its potential benefits and risks is found in surveys of therapists and clients, presented in a series of chapters found in Smith et. al.'s (1998) book. As was cited above, several factors have been found to significantly correlate with a client's positive evaluation of touch, such as clarity regarding boundaries, congruence of touch, client's sense of being in control and the client's perception that touch is for his/her benefit (Geib, 1982; Horton, 1995). Positive functions of touch, as expressed by clients who have experienced touch in psychotherapy, include providing a link to external reality, increasing self-esteem, and inviting the experience of new modes of relating. Other surveys of clients who have experienced touch in psychotherapy indicate that touch reinforced their sense of the therapist's caring and involvement. The findings also "support the judicious use of touch with clients who manifest a need to be touched, or who ask for comforting or supportive contact" (Horton et. al., 1995, p.455).
CLINICAL ORIENTATIONS ON TOUCH Most psychoanalysts, as noted earlier, are highly opposed to any form of touch in therapy (Menninger, 1958, Wolberg, 1967, Smith, et. al. 1988). However, many other orientations support the clinically appropriate use of touch (Milakovitch, 1993; Williams, 1997; Young, 2005; Zur, 2007). Very few modern analysts, such as Fosshage (2000) have differed with the main line analytic doctrine and advocate a clinically responsible use of touch in psychoanalysis. The human potential movement and the humanistic movement of the 1960s introduced a whole new approach to touch and boundaries in therapy. This movement endorsed appropriate non-erotic touch and viewed it as an enhancement of the therapist-client connection (Hunter & Struve, 1998). Rogers (1970) discusses the value of touch and describes specifically how he has soothed clients by holding, embracing and kissing them. Gestalt therapy incorporates numerous forms of touch as an integral part of therapy (Perls 1973). Gestalt practitioners place a special importance on non-verbal communication and non-verbal intervention. Unfortunately, Gestalt practices in the 60's and early 70's, under Perls' leadership went too far and at times, included unethical sexual touch in conjunction with therapy (Hunter & Struve, 1998). Lazarus and Zur (2002) note how the promiscuous practices in the 1960s around touch, nudity and sexuality have resulted in some form of backlash, where touch and other boundary crossings have since been viewed as harmful. Family therapists, including Satir (1972) often utilize touch as an element of engaging clients in therapy (Holub & Lee, 1990). Behavioral and cognitive behavioral therapists are likely to incorporate touch or any boundary crossing into therapy if it fits with their interventions, such as modeling or reinforcement (Lazarus & Zur, 2002). Feminist therapists seem to have two camps when it comes to issues of boundaries, including touch. The more vocal, politically and professionally active faction focuses on issues of power, male dominance, sexuality, and oppressive patriarchal values. Predictably, they take a strong stance against most boundary crossings and dual relationships and advocate for the protection of, what they see as, vulnerable female clients sexually exploited by powerful male therapists. Borys, Bouhoutsos, Brown, Keith-Spiegel, Jorgenson, Kitchener, Sonne, and Vasquez are some of the authors who tend to align with this ideology (Zur, 2005). Alyn (1998) describes a kind of touch hierarchy in which it is more likely for a person of higher status to touch someone of lower status than the converse. In this context any touch, even non-sexual touch by male therapists of women clients is seen as disempowering and therefore harmful to women. The much less vocal faction of feminist therapy focuses on essential issues of inclusion, connection, mutuality, self-disclosure, and equality. The focus of these writers, as manifested in the important work of Greenspan (1995) and some contributions by The Stone Institute and The Feminist Therapy Institute (1987), relate how healing often entails tearing down rigid, arbitrary, professional boundaries rather than erecting them. Along these lines, appropriate touch, which is congruent with the therapist-client relationship, is seen as potentially healing. In their survey of therapists, Pope, Tabachnick and Keith-Spiegel (1987) report that therapists of differing theoretical orientations have very different beliefs about the effect and practice of touching clients. They report that 30% of humanistic therapists indicated that nonerotic hugging, kissing and affectionate touching might frequently benefit clients in psychotherapy. In contrast, only 6% of psychodynamic therapists indicated the same. While most psychodynamic therapists thought touch could be easily misunderstood, humanistic therapists did not share this view. Milakovitch (1998) compares therapists who touch and those who do not touch. The following are some of his findings:
SEXUAL AND NON-SEXUAL TOUCH IN THERAPY Part of the problem with differentiating sexual and non-sexual touch in therapy stems from the lack of differentiation between sexual feeling and sexual activity. While about 90% of therapists report being sexually attracted to their clients at some time (Pope & Vasquez, 1998), less than 10% have ever violated their clients sexually. Lazarus and Zur (2002), Smith et al, (1998), like many other writers, emphasize that the problem of such lack of differentiation is rooted in insufficient professional education. They view the problem as starting with graduate schools, which focus on rigid, restrictive ethical education and the teaching of risk management practices rather than providing a focus which will assist students in recognizing and processing their sexual feeling towards clients; something, which most would agree, is a common element in the therapist/client dynamic (Pope, Sonne, & Holroyd, 1993). Such lack of education undoubtedly exacerbates the problem, resulting in untrained therapists who tend to deny difficult or unacceptable feelings in a process, which is likely to increase their vulnerability to violate their clients.
BODY-CENTERED PSYCHOTHERAPIES The United States Association For Body Psychotherapy (USABP) asserts "All experiences, as well as distortions and denials of reality and other defensive maneuvers, are reflected not only in peoples' thoughts and feelings but also in the way they move, how they breathe and how the structure of their bodies has evolved over the years. . . "(United States Association For Body Psychotherapy, 2003, Par. 1). Body psychotherapy assists people in healing and developing not only through the use of verbal interventions, but also through guiding them to a deeper awareness of their bodily sensations, images, behavior and feelings. There are many approaches to body psychotherapy just as there are multiple approaches in psychotherapy and a variety of techniques are employed. "These forms seek to resensitize our clients to their birthright of healthy and optimal functioning by using the direct physical experience of the body as a healing tool. These systems also advocate our continued growth and transformation as humans through reclaiming our integrative being" (Caldwell, 1997, p. 26). Techniques common to most body-centered psychotherapies include attention to somatic awareness, breath, movement, imagery, and touch which can vary from deep manipulation used to release body blocks to supportive hugs or holding. Humanistic, Existential and Gestalt psychology, as well as dance and movement therapy, family therapy, systems theory, biology, and Far Eastern philosophy have all contributed to body psychotherapy approaches. All attempt to integrate the body and mind and take into account when problems began and how they effect a person's development over the years.
The History of Body Psychotherapy Ferenczi, originally trained in the psychoanalytic model, at one point spoke out as a proponent of hugging, holding, kissing and non-erotic fondling of clients, believing that the use of such therapeutic touch would provide corrective parenting to clients with early injuries. Initially, Freud was supportive of his experiential experiments but withdrew his support when he became aware that Ferenczi had become sexually and romantically involved with more than one of his clients. Ferenczi refused to discontinue his use of touch and was subsequently expelled from the ranks of orthodox psychoanalysis (Fosshage, 2000).
Reichian Therapy
Bioenergetics
Radix Somatic Experiencing (SE) According to the Foundation for Human Enrichment Somatic Experiencing is not considered as a form of psychotherapy, it stands on its own as an approach to healing trauma. The Foundation is clear that SE is neither a psychotherapy nor a bodywork technique, but lends itself well to being integrated into these and other treatment modalities.
Additional approaches to body psychotherapy New forms of body-centered psychotherapy are evolving which apply softer techniques and less analytical methodology. These forms use less exploitive, stressful postures, invasive touching, or breathing to extreme states. There is less of a focus on analysis as the client takes more responsibility for finding meaning in the communication from their body voice. These new forms, yet to be thoroughly researched, include Kurtz's (1990) Hakomi Therapy, Gay and Kathy Hendricks' Radiance Method, Amy and Arnold Mindells' (1983) Process Therapy, and Christine Caldwells' Moving Cycle (1997) and Rubenfeld Synergy System (Rubenfeld, 2000) among others.
Biochemical Links between Consciousnesses, Mind & Body Energy Pert postulates "The limbic system, and it's neurons have axons that extend into the pituitary gland, these axons secrete a neuropeptide called CRF. . . We could say that CRF is the peptide of negative expectations, since it may have been stimulated by negative experiences in childhood. . . Autopsies almost always show a tenfold higher level of CRF in the cerebrospinal fluid of those who killed themselves compared to those who died from other causes" (1997, p. 270). Animal studies show that monkey babies deprived of maternal nurturing, neglected or abused have high levels of CRF. These baby animals were cured by an older 'monkey hug therapist' who simply cuddled and hugged the stressed out baby monkeys causing their chronically elevated CRF levels to go down. "In the case of treating mood disorders and other mental unwellness, the mainstream misses a lot by excluding touch, by ignoring the fact that the body really is a gateway to the mind, and by refusing to acknowledge the importance of emotional release as a mind-body event with the potential to supplement or even sometimes replace talk cures and prescription pills" (Pert, 1997, p. 274). Feeling is healed through somatic experience because our minds and our feelings reside in our bodies. Pert (1997) writes of accessing ones' psychosomatic network and entering the bodymind's conversation and redirecting it as a way to keep information flowing, feedback systems working, and natural balance maintained. She asserts that we are literally able to consciously and intentionally intervene at the level of our molecules, making significant changes in our physiology, releasing certain biochemicals into our systems. The well-known tools of traditional psychotherapeutic trade, such as dreams and the symbolic meaning of words, as well as touch do, in fact, access the psychosomatic network. There is no doubt that these traditional tools have their place and their effectiveness but it is necessary to acknowledge other effective points of entry as well: the skin, spinal cord, and organs are all nodal points of entry into the system. The deepest oldest messages are stored and must be accessed through the body. "Your body is your unconscious mind, and you can't heal it by talk alone." (Pert, 1997, p. 306).
TOUCH WITH SPECIAL POPULATIONS
Survivors of Childhood Trauma Studies done in the context of post-traumatic stress disorder have explored the relationship between trauma and memory (Allen, (1995; Herman, (1992; Van der Kolk, McFarland & Weisaeth, 1996). The concept of memory and trauma is highly controversial. A balanced view is provided in a monograph published by The International Society for Traumatic Stress Studies (Childhood Trauma Remembered (ISTSS, 1998). Many studies document that traumatic memories are encoded in our sensorimotor system as kinesthetic sensations and images. Herman (1992) reports that "in states of high sympathetic arousal, the linguistic encoding of memory is inactivated, and the central nervous system reverts to the sensory and iconic forms of memory that predominate in early life" (p. 39). This results in the client having great difficulty reconstructing a narrative of their traumatic memories as they experience them instead as emotional and sensory recall (Van der Kolk et. al., 1996). Due to the somatosensory experience of trauma, new forms of treatment are offered by body-oriented therapies (Hovdestad & Kristiansen, 1996). Bar Levav, (1998) reports that physiological patterns in the body can be changed by touch to correct early injurious experiences. Since the nature of the original injury, physical and/or sexual assault, involved boundary violation, the therapist must be particularly careful to structure a foundation of client safety and empowerment. Most authors agree that a client must want to touch or be touched and understand the concepts of empowerment before it is clinically or ethically appropriate to begin the use of touch in session (Hunter et. al., 1998). To this end, clients should be encouraged to express their preferences, to practice boundary-setting exercises, and to participate in creating a treatment plan. Studies suggest that there is a positive correlation between a clients' perception that they are in control of touch and their positive evaluation of touch in psychotherapy (Geib,1998; Horton, et. al., 1995). Many abuse survivors respond to anxiety by having difficulty in protecting their boundaries. Therefore, it is helpful for the therapist to state clearly that he or she accepts full responsibility for ensuring that there will be no sexual contact with the client, and to be clear about the process and type of touch that will be involved. Hunter and Struve suggest that it is helpful to draft written ground rules as many survivors are highly dissociative and have difficulty retaining verbal information in stressful situations. Helfer (1978) developed a program, which includes a series of graduated exercises through which a client can address developmental tasks, which were missed in childhood as a result of abusive or neglectful parenting. Since most survivors of abuse have learned to mistrust touch, he begins by helping the client get in touch with his or her five senses that may have been undeveloped, underdeveloped, or overdeveloped. These exercises explore the distinction between good touch and bad touch and help the client to enjoy the benefits of soothing supportive touch. The therapists may then guide the client in nurturing, supportive self-touch such as self-massage or self-stroking. Another approach is to direct the client in the use of imagery to reconnect with his body, to recognize bodily sensations and to name them. It can also be less threatening for a client to experience safe, nurturing, non-erotic touch through the use of imagery. Clients might further be instructed to deliberately engage in various types of touching activities, such as touching trusted friends or animals, massage, or contact sports. Any touching in therapy should be solely for the benefit of the client and great caution must be taken if the client is dissociated. The hypocampus, amygdala, hypothalamus and thalamus function by laying down memory traces that are subsequently regulated by stress hormones. Flashbacks can occur when a current stressor activates traumatic memory traces and the client dissociates and loses full contact with essential details in the current environment. Positive therapeutic results have been demonstrated in the cognitive-behavioral treatment of psychological trauma survivors. Touch, used in a non- structured, organic manner can yield results similar to those of cognitive-behavioral interventions (Bremner, 2002), with the added benefit that most survivors of abuse report that touch in therapy helps them to feel "touchable" and that appropriate touch in psychotherapy helps them identify appropriate, connective, non- violating forms of touch. "The client can relearn to assimilate sensory data about physical contact only if they are processed concretely and with an intense focus on reality-testing feedback loops" (Hunter & Struve, 1998, P. 217). It is essential that the therapist be familiar with the dynamics of dissociation before working with a trauma survivor. (See Steele & Colrain, 1990, for an extensive list of dissociative signs.) When working with clients who have a history of abuse, it is of crucial importance that the client's permission be requested prior to making any physical contact. Asking communicates respect for her and her body; it says that her preference will be respected and that no intrusion (however slight) will occur against her will (Courtois, 1998). Many therapists consider touch of any kind to be inappropriate with clients who have been abused through violations of the body. Many therapists and all somatic therapists believe that a client will have great difficulty in fully recovering from such trauma if only verbal or cognitive approaches to therapy are used. "...therapeutic efforts to help a client heal from touch-related wounds ultimately ought to include experiential approaches that directly access the body and that provide the client with real-life opportunities to feel nonabusive touch" (Hunter & Struve, 1998, p. 218). Clients traumatized in childhood are often unable to make distinctions between affectionate touch and sexual touch (Ball (2002). "Healing is unlikely to occur if this positive and appropriate touch remains only an idea or intellectual concept" (Hunter & Struve, 1998, p. 218). In a study done by Horton et. al. (1995), it was found that sexually abused clients were more likely to attribute a corrective or educative role to touch in therapy, and to report feeling "touchable", "lovable" or generally better about themselves as a result of touch than were non-abused clients. Of the clients in this study who reported a history of sexual and/or physical abuse and neglect, 71% wrote that touch repaired self-esteem, trust, and a sense of their own power or agency, especially in setting limits and asking for what they need. Durana (1998) states that touch is usually contraindicated for clients who are paranoid, actively hostile or aggressive, or who implicitly or explicitly demand touch. Hunter and Struve (1998) suggest that special care should be taken using touch with populations that have experienced assault, neglect, attachment difficulties, sexual addictions, eating disorders, and intimacy issues. Rothschild (2000), suggests that a better strategy for these clients is to assist them in learning how to perceive and respect his or her own boundaries and to teach how to meet the needs of touch among close friends and family due to the complication of the possible provocation of transference and countertransference.
Children and Adolescences Adolescents may be particularly sensitive to dimensions of control with regard to touch and may react negatively to touch that could be interpreted as patronizing or unduly familiar (Smith, et. al., 1980; Jones, 1994). A growing body of literature has linked aggressive, violent, and antisocial behaviors to early childhood touch deprivation (Mitchell, 1979; Older, 1982). These children grow up with a diminished ability to feel, and a reduced ability to initiate or receive touch (Hunter & Struve, 1998). In one study, the staff of an adolescent treatment program modeled nonsexual, nonviolent touch to incorporate physical contact as an acceptable aspect of the milieu. They found that the adolescents demonstrated a marked decrease in violent and sexual behaviors (Dunne, Breggen, & O'Brian, 1982).
Touch with Elders
Gender issues Research shows that women respond more positively to touch than do men (Whitcher & Fisher, 1997). From birth, American women receive more affectionate touch from males and females and are given greater permission to touch either gender and be touched by either gender. They are more likely to have and expect a broader repertoire of touch. American males are given less affectionate touch in infancy and early childhood and this has been linked with higher rates of violence and aggression in later life (Redleaf, 1998). For most men in our soc | |