To Touch or Not To Touch? Physical Touch in the Therapeutic Relationship: A Deeper Look into the Ethical Dilemma
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To Touch or Not To Touch? Physical Touch in the Therapeutic Relationship: A Deeper Look into the Ethical Dilemma

An APA style article concerning the use of physical touch in the therapeutic setting.

Introduction

Physical touch, or skin on skin contact, can benefit one in a number of ways. For example, it has been shown in studies to decrease cortisol and stress levels as well as release serotonin and dopamine in the brain. These chemicals allow for us to either feel good or depressed if they are not balanced (unknown author, 2009). Studies have shown that touch deprivation in infants is correlated with failure to thrive in early development, along with future aggressive and antisocial behavior (Bonitz, 2008). There have even been studies and instances in orphanages in which infants who did not receive touch passed away. Physical touch is vital to our survival and even associated with healing in several cultures (Durana, 1998).

Some controversy surrounds the subject of physical touch when implementing it into the therapeutic setting. Many therapists recognize the benefits of touch and choose to administer it in controlled settings to clients as means of alleviating some of their personal suffering while offering a holistic approach to therapy. Other therapists have more conservative views about physical touch in the therapeutic role, in following with the teaching of Sigmund Freud, and have placed a taboo on the idea of using physical touch in therapy (Bonitz, 2008). This may be a safe move for those therapists worried about the possibility of lawsuits or developing sexual feelings between a client and therapist. Throughout this discussion and research, the ethical issues surrounding physical touch in therapy will be examined and addressed while weighing the pros and cons of this practice. Personal accounts from clients on the issue will be examined as well as therapeutic outcomes in determining if this is truly a safe therapeutic practice or something that should rightfully keep its taboo.

Historical Roots

The use of physical touch in psychotherapy received its first cultural taboo in the late 1800’s to early 1900’s when Sigmund Freud took a public stance towards abstinence from its use in his therapeutic practice. This was during a time of great sexual repression in which Freud had been labeled a “sexual pervert” (Bonitz, 2008). Freud did not want psychology to be scoffed at, but rather acclaimed and regarded as a science. He had originally been using physical touch himself in the treatment of hysteria. This was during a time in which he discovered his clients had been transferring important feelings felt for early authority figures onto him. In order for the most complete transference to develop, Freud thought it necessary to be as a “blank screen” which included abstinence from touch and self-disclosure (Bonitz, 2008).

Freud’s pleasure principle supports the idea that touch is used to indulge one’s most infantile sexual desires. He believed this kept a client at an infantile state when touch was administered in therapy. He believed that withholding touch from clients who were fixated at such a state would stimulate frustration at their infantile desires. Once a client was frustrated with their infantile desires, they were then given a chance to grow and understand their innermost subconscious struggles (Bonitz, 2008).

Through withholding touch and allowing his hysteric clients to develop full transference, Freud concluded that hysteria was rooted in childhood sexual trauma and/or fantasies. During this period of sexual repression he was labeled a sexual pervert for associating sexual fantasies with children (Bonitz, 2008). Children were not to be thought as sexual beings. This cultural taboo was formed out of research in supporting a desired outcome, and the sensationalism that received the essay resulting from said research.

Types of Touch

Controversy has arisen over what modern-day professionals label non-erotic touch. This is anything considered by those of western thought to be non-sexual. Some therapists have gone so far as to categorize all possible forms of touch; as Morris Goodman and Arthur Teicher noted in their research essay entitled To Touch or Not to Touch (1988). Nine categories of touch were recognized as occurring in interpersonal relationships. These categories were information pickup, movement facilitation, prompting, aggressive, nurturing, celebratory, sexual, cathartic and ludic. He also sees each category as beneficial to use by a professional with the exception of sexual touch (Goodman & Teicher, 1988).

There is much controversy over what is actually considered beneficial touch and what is considered a boundary issue, and aggressive touch definitely sounds like the crossing of a boundary. Other psychologists have focused their view on what is considered non-erotic touch and considered the appropriate forms of touch to be used within a therapeutic relationship to be acts such as a hug, holding hands, hands on a shoulder or leg, a massage, holding one’s arms, a kiss on the cheek or lips and a restrain (Stenzel & Rupert, 2004). These are the types of touch we will be focusing on and discussing.

Touch in Modern-Day Therapy

After the sensationalism surrounding the research of Sigmund Freud and his public stance to abstain from the use of physical touch there has been a very strong cultural taboo surrounding its’ use in the clinical setting. Cheryl Stenzel and Patricia Rupert (2004) conducted a national study on 470 psychologists in current practice and their habits concerning physical touch. The results showed that nearly 90% either rarely or never offered touch to a client while in session. The most common form of physical contact was to occur during a salutation or farewell, and was never discussed upon occurrence (Stenzel et al, 2004).

Other researchers have found in a study among male therapists in the Los Angeles area that 59% admitted to engaging in non-erotic touch in their practices which included hugging, kissing and “affectionate touching” (Kertay & Reviere, 1993). Further research conducted on male and female therapists showed that nearly 50% believed that non-erotic kissing, hugging or “affectionate touching” could possibly be beneficial when used in moderation or occasionally in clinical practice (Kertay et al, 1993).

A pair of correlations has been observed between the ideas supporting or against physical touch with the school of thought and approach fueling the therapy practiced as well as the therapeutic dyad. For example, those who practice psychodynamic or behavior orientations to therapy employed a more conservative viewpoint towards the use of touch, and tended to abstain from it, while more new age forms of therapy tended to favor the use of touch and even surround their orientation and practice around its use (Stenzel et al, 2004). It has also been found that male-female dyads posed more of a threat for non-erotic touch to cross boundaries than in female dyads. The statistics surrounding misconduct complaints are strongly correlated with this as well showing most complaints to be made by females concerning a male therapist (Stenzel et al, 2004).

Carlos Durana (1998) observed several viewpoints from a diverse sample of therapists on their ideas surrounding non-erotic touch. Some therapists felt that it promoted an unequal power relationship between male-female dyads while others believed it to stunt growth and progress in the psychodynamic approach. Others simply believe anything beyond a formal handshake to be a boundary issue. In contrast, there were some therapists who believed touch to be an intervention and used it in conducting body work such as bioenergetics (Durana, 1998).

Personal Vignette

An assisted living program in San Diego, CA currently uses physical touch as a therapeutic tool in group therapy sessions. During any group therapy session clients may receive a massage from fellow clients and community staff. This is only encouraged during the group sessions and only in the presence of other clients and staff. Although there are strict guidelines in the use of touch in this therapeutic setting, one instance has caused discomfort among current clients and staff among the community. In addition to receiving a massage from a client or staff member, a client may also request to be held by a therapist. One afternoon during session a female client was held by her male therapist in the group setting. The room group therapy is conducted in is very cold and blankets are set around the room for the use of clients and staff. The male therapist and female client were in an embrace under a blanket for a large portion of the therapy session. This caused staff to feel uncomfortable and sparked rumors amongst clients that the female client and her male therapist were having an affair. The community as a whole was effected as a result, and soon after there were issues of sexual interaction between community members as well as boundary issues being reported amongst staff.

Ethical Considerations

The above story has sparked some ethical concerns that will be further discussed and explored. What exactly constitutes a hug or kiss as non-erotic? Could it be non-erotic for one person, and erotic to another? Also, is it ethical for physical touch beyond a handshake between male-female dyads?

One psychologist named Sandor Ferenczi believed that non-erotic touch was useful in his practice in helping those suffering from neglect or abuse from their family of origin. Ferenczi had studied under Freud, but abandoned his frustration technique in favor of implementing non-erotic touch into his own relaxation technique which included hugging and kissing his clients. Ferenczi made a very bold statement with this new controversial approach and coincidentally entered into sexual relationships with at least two of his female clients (Bonitz, 2008).

Beyond the issues surrounding male-female dyads and the boundaries of non-erotic touch there are issues of culture to be considered in evaluating the ethics behind this practice. Some cultures, for example, use physical touch more frequently such as European cultures. Other cultures such as Asian and Mediterranean vary extremely. Some Asian cultures place a high value on physical touch, while others value space and the abstinence from touching. Other cultural differences exist between sexes. Some males may abstain from touching other males where women are more open to non-erotic touch from other women (Phelan, 2009).

In addition to cultural influences towards using touch in therapy, one must be sensitive and aware of a client’s background. For example, a client who was sexually abused may be more sensitive to touch. The dyad between the client and therapist may also be extra sensitive if it is representative of the dyad in which the abuse occurred (Phelan, 2009). It is also a therapist’s duty to discuss the physical touch with the client to ensure there are no boundaries being crossed and to determine if there are cultural considerations or issues that may arise as a result of the physical touch (Stenzel et al, 2004).

With so many issues surrounding the topic of using non-erotic touch in therapy, cultural, ethical and dyadic issues, one must question what the clients views are surrounding the issue. Judith Horton and colleagues (1995) decided to research client’s impressions and experiences surrounding physical touch in the therapeutic setting. They surveyed clients in therapy who had experienced a significantly positive or negative experience with touch in therapy. Their studies found that a majority of clients reported positive experiences concerning touch in therapy. Studies showed that 69% said touch increased the bond between client and therapist. Furthermore, 47% noted that their self-esteem increased through the experience of physical touch in therapy (Horton, Clance, Sterk-Elifson & Emshoff, 1995).

Discussion

With the research and arguments presented, one must be very cautious about the use of physical touch in the therapeutic setting. Certain clients may not respond well to it, or may interpret it as erotic when it wasn’t intended as such. Ellen Toronto speaks of her discernment in the use of physical touch in therapy. She had been treating a client in her practice for intrusive sexual thoughts. Throughout the course of their therapy, he admitted having sexual fantasies about her and moved his chair close to her in therapy. In this instance she refused to touch him, and he did not touch her. She chose not to move her chair away, but remained neutral and professional. At termination the client thanked her for allowing him to “own” his sexuality. Having a woman he expressed sexual attraction to that neither rejected his expression nor acted upon it was healing for him in assisting him in exploring himself further until he felt in control of his own sexual urges (Toronto, 2001). Ellen did not express any sexual countertransference towards the client, however a therapist who did may have stunted the client’s breakthrough by encouraging his feelings through indulging him. Indulging him could have been a simple hand on his knee, hand or arm.

Just as the therapist Ellen was careful in discerning when to use touch on a case by case basis, modern-day therapists must do the same. One is led to believe based upon the evidence presented that factors such as diagnosis, dyad, history, culture and theoretical orientation of therapy must be taken into account before a therapist is to begin incorporating touch into a practice under proper ethical practices. In the case of the male therapist at the assisted living community, there should have been more discernment towards other clients, the therapist’s needs and the client’s needs. Perhaps it was as innocent as intended, however, it did not appear as such by some community members. It is grey area acts such as this that can create a downward spiral into inappropriate sexual behavior between therapist and client. The therapist should have asked himself how the act was benefitting him and how it could possibly affect his client and the entire group.

Based upon the research and vignettes, one is led to believe that there should always be clear cut boundaries when conducting therapy in the clinical setting. This protects the client and the therapist. When there are clear boundaries set and discussed about throughout the course of therapy there is more protection not only for the client, but the therapist as well. If a therapist has poor boundaries with a client they are, in a sense, making themselves more susceptible to instances of attraction, obsession, and improper conduct from a client such as a client acting out in physical violence towards the therapist, etc.

Personally, in one’s own future practice, the plan is to mostly abstain from physical conduct with clients. One aims to offer a safe haven of support for those in suffering and to keep the atmosphere professional and healing. Although the laying on of hands is seen as healing in religious culture (Durana, 1988), it will be kept out of the realm of one’s own personal practice as means of protecting clients and one’s self. Touching a client could spark past trauma of sexual or violent nature. Also, when working with a client, using touch could cause them to form an unhealthy attachment that is codependent. In instances of borderline personality disorder this is a greater risk. Also, believing to be an attractive woman, common sense tells one to dress appropriately, speak in a tone that cannot be interpreted as seductive and keep a professional distance with others, especially men in therapy.

During my first experience working in the field, I encountered a dually-diagnosed client who tested my limits during our first session together. (This was an active support position at an assisted living community for severely mentally ill and dually diagnosed clients). Some limits included admitting attraction to me, trying to hold my hand, grabbing my side and jokingly tapping or shoving me. This was his first day in the assisted living community and he was newly sober. I did not want to make the client feel unsafe, or unwelcome in his new community, but I knew that I needed to set some strict boundaries with him, or he would be putting his therapy at risk as well as our therapeutic relationship. I took him aside and explained to him that in the therapeutic community we must keep respectful boundaries. I explained to him that it made me feel uncomfortable to be involuntarily touched on the hand, side or back and that he should ask and communicate to me any kind of physical exchange. As a woman this was a personal boundary that represented a matter of respect. This approach worked great with the client as he had been testing me to see if he was safe in the community. Overall, the exchange caused the client to feel safe and know he was in competent care. A month or so later I spent Christmas with the clients who did not travel home. This client was present and asked me for a hug on the holiday. Due to the situation I saw no problem with this and gave him a hug. There were no further issues within this therapeutic relationship.

Conclusion

The personal experiences, research findings, and expert opinions have greatly contributed towards the notion that one must act with extreme caution over using touch in therapy. If a client asks for a hug during a difficult time one may or may not oblige depending on the nature of the dyad and therapeutic relationship. However, touching a client who has sexual transference towards a therapist has the ability to encourage the client’s sexual feelings, thus stunting the possibility for personal growth. Also, a therapist should not engage in touching a client they may be experiencing sexual countertransference towards. This could manipulate the judgment and objectivity of the therapist. Although physical touch is highly beneficial and healing, one may elect to refer a client to see a massage therapist, rather than risk the client’s personal growth.

References

Bonitz, Verena. (2008). Use of physical touch in the “talking cure”: A journey to the outskirts of psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 45(3), 391-404.

Durana, Carlos. (1998). The use of touch in psychotherapy: ethical and clinical guidelines. Psychotherapy, 35(2), 269-280.

Goodman, M.,Teicher, A. (1988). To touch or not to touch. Psychotherapy, 25(4), 492-500.

Horton, J., Clance, P., Sterk-Elifson, C., Emshoff, J. (1995). Touch in psychotherapy: A survey of patients’ experiences. Psychotherapy, 32(3), 443-457.

Kertay, L., Reviere, S. (1993). The use of touch in psychotherapy: theoretical and ethical considerations. Psychotherapy, 30(1), 32-40.

Phelan, James. (2009). Exploring the use of touch in the psychotherapeutic setting: A

phenomenological review. Psychotherapy Theory, Research, Practice, Training, 46(1),

97-111.

Stenzel, C., Rupert, P. (2004). Psychologists’ use of touch in individual psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 41(3), 332-345.

Toronto, Ellen. (2001). The human touch: An exploration of the role and meaning of physical touch in psychoanalysis. Psychoanalytic Psychology, 18(1), 37-54.

Unknown author. www.sedona.com. (2009). The remarkable power of touch and hugs…especially in times like these. Retrieved July 29, 2009. http://www.sedona.com/hugging-is-good.aspx.

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Comments (2)

I read this article because I work this students in a private setting and this issue definitely arises. I tend to be somewhat unemotional and unexpressive, and so some of my attempts and support and approval are wasted. I have been working on "the least amount of touch to communicate support and approval", which has included lots of high fives and occasional backpatting when a student cries. This seems to help communicate support and approval more than I did previously.

That sounds like the perfect use of touch in a controlled environment with clear boundaries. That is wonderful and a perfect example of what is beneficial and acceptable. Thank you.

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