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Boundaries and Types of Touch In Psychotherapy

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(Photo from the Mother Love Bone’s album ‘Apple’)

By Jason Briggs, MA, LMFT

“Art…We are flesh and blood and full of faults. But we are also full of warmth. The world is full of confusion, but there is compassion in its midst. Communication via simple touch can transmit so much of us in just one minute. Like a painting or a piece of music. I want to touch your soul. I only wish I could be sure it was the right thing to do.”
– Jay Woodman, SPAN

In this piece we will explore ways to be boundaried when integrating touch in psychotherapy. Therapeutic touch is defined as any physical contact between a client and her therapist while participating in psychotherapy, which is non-sexual in nature. In this missive, we will address how therapists can use touch to help heal their clients.

Touch is often highly avoided by psychotherapists, partly because it’s rarely discussed in schools and training programs, and because of an over-arching lack of interest and understanding by gatekeepers in the field of psychotherapy, both historically and present. I will discuss how not using touch can be neglectful when a client needs exactly this type of support. Touch is an important and equally healing form of communication, possibly on par with words (i.e., Fridlund, 1994; Young, 2005). Given that touch, so often confused with sexual touch by therapists and clients alike, is so healing, we as therapists must no longer abandon considerations when using touch in psychotherapy and instead explore what using touch can do for our clients to facilitate a greater healing in the therapist-client relationship.

When using touch, one must always consider her rationale for why this adjunct type of support is being used, considering both client and therapist and the boundaries they share and are surrounded by. Touch enacted in therapy by the therapist in traditionally more rigid ways may stem less from an awareness of healthy boundaries and excellent standards of practice and instead from a lack of awareness or interest in the various standards of practice regarding touch and the benefits of the use of touch in psychotherapy. Maybe a therapist considering using touch hasn’t thought of what is barring their interest and ability to use touch as a viable form of communication in psychotherapy. Myths, as unchecked assumptions, are perhaps the most pervasive reason therapists don’t suss out how to use touch in their practice. Here is one such myth:

“There is a myth of the slippery slope that non-sexual touch inevitably leads to sexual touch, which is unfounded, scientifically unsupported and basically is paranoid. It’s pretty crazy actually if we just look at it. The assumption that soothing touch leads to sexual touch is nonsensical. In spite of numerous therapeutic approaches, theories and practices that systematically and effectively use touch in therapy, it has been marginalized, forbidden, called a taboo, often sexualized and at times criminalized by many schools and ethicists, licensing boards as well.” – Ofer Zur

What is the cost of a therapist’s lack of interest and awareness of touch in psychotherapy? Here is one possible outcome: “Indeed, touch deprivation has been consistently linked to aggression, delinquency, social isolation and depression in children and adults (Field, 2003).” Given this knowledge and the standards of practice in the field of psychotherapy, standards rooted in a larger philosophic service-based assumption known as the Hippocratic Oath (to always do no harm), it bears to reason that touch in psychotherapy cannot be ignored as a matter of the wellbeing of the clients we serve.

Boundaries that bar touch are likely to be too rigid and may prevent necessary information from being received by the client, possibly to sooth or calm, and prevent ongoing dissociation, etc. Touch that communicates harmful information to the client by her therapist needs to be withheld by the therapist, as this places her below the standard of care and practice and is illegal.

This harmlessness of using touch and assessing the potency of touch includes the therapist learning the client’s preferences, background, history, ability to stay in the present, power differentials and much more. Consent allows sharing of information, verbal or non-verbal (touch), to be given and received in ways that are experienced as healthy by client and therapist alike. It goes to say that negotiating boundaries around touch must be learned by therapists to raise touch into the realm of healing and that healing must be raised to unequivocal predominance. Boundaries allowing information to be shared in a defenseless way allows bonds to be felt between client and therapist. This sharing is like a cell whose nutrients are present and released, even when toxins exist. Toxins are contained for the time being and released when shame and fear can be let go of by the relational field found in the client-therapist relationship.

There are three types of touch in the literature on touch. The first is those adjunct forms of touch shared by psychotherapists, which complements verbal therapy and can take many forms. The second type of touch is therapeutic touch by body psychotherapists whom use their training in somatic psychotherapies to dictate what type of interventions may be used when considering touch for their client’s needs. The third type of touch is inappropriate or hostile touch and these are sexual, hostile or punishing touches and are illegal and unethical in the field of psychotherapy. With sexual touch the initiator intends to sexually arouse the therapist, client or both. In the first type of touch there are many forms and purposes for using touch with our clients.

Therapists who learn more about their clients and their own relationship to touch and how to use it effectively have advantages over those therapists who don’t have touch at their disposal as an important healing intervention. Raising our voice and awareness regarding touch, as therapists, means embracing the simplicity of touch, its complex applications, and preparations on how to use it in therapy. Doing this means raising touch to its rightful and helpful place in psychotherapy, not only as a valid form of communication but one that embodies a combination of silence, caring and connection, which words simply fail to communicate.


References

O. Zur , Nordmarken, Nola (2015) Touch and Boundaries in Psychotherapy: To Touch Or Not To Touch, Exploring the Myth of Prohibition On Touch In Psychotherapy And Counseling, Clinical, Ethical & Legal Considerations, Online Education.

O. Zur (2007). Touch In Therapy and The Standard of Care in Psychotherapy and Counseling: Bringing Clarity to Illusive Relationships. United States Association of Body Psychotherapists Journal (USABPJ), 6/2. 61-93. Copyright USABP www.usabp.org

Mozilla Firefox, Google search, (2018, July 15, 9:10 pm). https://www.goodreads.com/quotes/tag/touch

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Touch and Considerations of Touch In Psychotherapy

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therapeutic touch

(Photo Credit: ESB Professional)

By Jason Briggs, MA, LMFT

“In the seventy-three seconds prior to the explosion that killed the seven astronauts aboard the space shuttle Challenger in 1986, one was recorded saying to another, ‘Let me hold your hand.’”
– Born to Serve, The Evolution of the Soul Through Service by Susan Trout, PhD

Therapeutic touch is defined as any physical contact between a client and her therapist, while participating in psychotherapy. Psychotherapists often avoid touch in their practice, mostly because it is rarely discussed in schools and training programs. There are also unchecked assumptions about public attitudes of the role therapeutic touch has in the field of psychotherapy, counseling and other licensed clinical fields, as an important and equal healing form of communication, possibly on par with words. Touch is one of many non-verbal modes of communications (i.e., Fridlund, 1994; Young, 2005).

Many psychotherapy practitioners use therapeutic touch to advance healing in relationship with their clients. These clinicians must be broad-minded, informed by boundaries, skillful about its applications, and understand what happens in its absence. “In line with Harlow, Montagu concludes: ‘When the need for touch remains unsatisfied, abnormal behavior will result” (986, p. 46). However, many attitudes inform this ‘separating out’ of using touch in psychotherapy and so legal and ethical mandates need to be regulated, codified and put in to law. Alongside these boundaries and limits, we can also do much as clinicians to learn about and normalize touch, freeing its healing effects to allow it to be helpful and mutually beneficial for therapist and client alike.

Legally, when thinking of using therapeutic touch in psychotherapy, for many clients and clinicians alike, sexual touch may often be confused with therapeutic touch. Therapeutic touch is a touch on a person’s body that may be on skin or clothes and isn’t sexual. This article’s focus isn’t to pour over the entirety of what informs this confusion and how this cultural sanctioned, unchecked assumption came to be, research points to some of these reasons, why such confusion arises when the use of therapeutic touch is used in psychotherapy. To be clear, therapeutic touch or as Mason categorizes it, affectional sharing, is both legal and ethical to use with clients in the field of psychotherapy. Legally, this must be expressed as non-sexual touch, meaning, no touching of the genitals or sexual touching of any kind. Sexual touching is a form of sexual misconduct. Sexual misconduct covers a broad range of activities, including verbal suggestions, innuendoes or unwanted advances. This kind of sexual behavior by a therapist with a client is considered sexually exploitive, illegal and unethical and isn’t therapeutic touch:

“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. 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. 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.”

We have let our clients down as therapists who throw the proverbial baby of therapeutic touch out of the bath tub of their own repressed sexual feelings, and often withhold meaningful help and healing touch.

Considerations of ethical standards of practice and care, when a therapist is considering using touch in psychotherapy, are that informed consent to use touch must be written and can take many forms. Whatever way the written informed consent is being offered when intending to use touch with clients in psychotherapy, whether in the standard informed consent for treatment or a completely separate informed consent statement, should be discussed, reviewed together and fully understood prior to being signed. Once signed, verbal consent should be the ongoing default for whether touch is wanted by a client. Subtle forms of coercion, such as asking about a client’s wish for touch after a client has said “no” to an invitation from her therapist to receive some form of touch, is sexual exploitation. The nature of consent to experience therapeutic touch in psychotherapy is ongoing moment to moment and can change at the client’s whim, meaning without an explanation and without external coercion (overt and covert) and fear of punishment by the therapist. The skilled, judicious and attuned ethical therapist tracks verbal and non-verbal communications to learn how to use therapeutic touch with his client’s complete and unequivocal consent. Uncertainty expressed by a client is still viewed by the therapist as an implied “no” and warrants validation and support.

Sometimes a robustly honored “no” can lead to a client accepting therapeutic touch later, emphatically altering the trajectory of their healing process. Once a colleague told me of a client he had who went from initially saying, “I don’t like touch,” to saying, “I think I’m ready for a hug,” after a year of therapy. This prompted him to ask her the question, “how do you think touch can help you in our psychotherapy sessions?” They reviewed some of the research on the value, importance and help one gains through therapeutic touch and together they established a gradually longer hug, always allowing the client to end at her convenience. Once I observed my colleague and his client sharing one of these longer hugs, and upon one of his other colleagues waiting for their hug to end, said to her client, “I’d like to offer you a hug but not that long.” They all laughed and knew that this was her comfort level as a clinician, and this was to be honored and respected, as well the therapeutic touch shared by her colleague and his client.

What are the benefits of the use of touch in psychotherapy? The benefits aren’t just anecdotal, just as much harm is done with words in relationships, so too does the logic follow that touch can be used to harm or heal. We know that touch is instantly reciprocal; we touch and are touched by the other, in one instant when touch is shared, regardless of the intent. We often forget about the innocence we had in ourselves and our clients had in themselves, when harmed by another’s reckless use of touch. In those moments, we forget about what we gave and focus on what we lost. Let us remember, with love and innocence we touched those who harmed us, and it this that remains.

Thus let us always remember, the therapists’ rationale for the use of touch in psychotherapy is essential, to help ourselves and our clients recover their healing. This rationale, should always include the clinicians knowing the ego strength of the client they serve, their propensities toward transference of dissociating when experiencing touch, being over compliant, being inclined to sexualize touch, while having conspicuously absent feelings (either positive or negative) about experiences around touch (black and white thinking and behaving is one of the guises under which projection may occur), etc. The needs of the client must always be uppermost in our minds as therapists. One way to inoculate ourselves against the possibility of putting our needs above our clients’ is by finding ways to have our own physical touch needs met in our communities. Confronting the question of how to touch in psychotherapy, and meeting the complexity of issues that arise when thinking about how to operationalize it, can seem daunting. With the myriad of professional and personal, legal and ethical issues surrounding using touch in therapy, and with a grasp of the complex issues and powerful sensations and feelings that may arise, there can be an amnesia and silence that buries the healing. Healing is a much better reason to begin to understand how to embody right relations to touch we can accept, while learning to not only give touch to our clients in therapy, but to see them be more embodied, whole, connected and free.


References

Fridlund, A. (1994). Human Facial Expression: An Evolutionary View. San Diego, CA: Academic Press.

Pope, K. S. (1990-b). Therapist-patient sexual contact: Clinical, legal, and ethical implications. In Margenau, E.A. The encyclopedia handbook of private practice. pp. 687-696. New York: Gardner Press, Inc.

Pope, K.S., & Vasquez, M.J.T. (1998). Ethics in therapy and counseling: A practical guide, 2nd edition. San Francisco: Jossey-Bass.

Trout, Susan, S. (1997). Born to Serve, The Evolution of the Soul Through Service. Alexandria, VA: Three Roses Press.

Young, C. (2005). About the ethics of professional touch. Retrieved from http://www.eabp.org/pdf/TheEthicsofTouch.pdf and

Young, C., and Westland, G. (2014). Shadows in the History of Body Psychotherapy: Part I. International Body Psychotherapy Journal: The Art and Science of Somatic Praxis. Retrieved from http://usabp.org/wp-content/uploads/2013/10/IBPJournal-Vol-13-1-Spring-2014.pdf

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