The Ethical Use of Touch in Psychotherapy

Mic Hunter, Jim Struve

• Publisher: SAGE Publications, Inc
• Year: 1997
• Print ISBN: 9780761903611, 9780761903604
• eBook ISBN: 9781506320717
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Is ethical touch an oxymoron? Is the bias against touch in psychotherapy justified? Can the recovery process be complete without healing touch? Mental health professionals are entrusted with the awesome responsibility of providing appropriate treatment for clients in a safe environment that nurtures trust, a necessary ingredient for optimum movement through the therapeutic process. Though treatment approaches vary, most modalities are verbally based and, in theory, exclude physical contact. Fearing that any form of touch would likely lead to sexual feelings or interaction, clinicians tend to shy away from the topic. In The Ethical Use of Touch in Psychotherapy, however, authors Mic Hunter and Jim Struve skillfully demonstrate that touch--a most basic human need--is intrinsic to the healing process along with talk-therapy, regardless of the practitioner?s theoretical orientation. While the use of touch is a given in other health care settings, it remains a benefit denied as taboo in psychotherapeutic relationships, due to transgressors whose unscrupulous use of a valuable technique have marred its reputation. This book encourages readers to conduct a meaningful self-reflection and explore possible misconceptions related to touch in order to rejuvenate its acceptance. Based on years of sound research and clinical experience, The Ethical Use of Touch in Psychotherapy promises to enrich clinical discussion and stimulate further empirical research. This insightful and progressive presentation is a must read for clinicians, interns, and advanced students, as well as lay readers interested in the dynamics and innovations in psychotherapy.

Part I

Foundations and Historical Background

As we undertake our venture into the realm of exploring the ethical use of touch in psychotherapy, we begin by examining the foundations and historical background of this issue. For the use of touch to be truly ethical, its application must be grounded in a solid philosophical and theoretical framework. In addition, it is important to learn from those who have preceded us. Therefore, it is helpful to take the time to understand the historical roots that have created the current context in which we will attempt to employ touch within our own clinical settings.

We have included this section of the book because we believe that theory and context are essential to determining when the use of touch is ethical. Although much of the material contained in Part I is not inherently clinical in nature, we believe that a solid understanding of the issues surveyed in this part will directly affect the degree to which any clinician is effective in employing therapeutic techniques of touch.

Much of the information in this part provides an underpinning that determines the validity and effectiveness of using touch within therapeutic settings. We encourage readers to take their time with these chapters in Part I before rushing on to Part II, which will address issues more directly related to the clinical application of touch within the setting of psychotherapy. We have synthesized highly technical and research-oriented material to make it more readable for those who may approach this issue from more clinical than scientific interest. Adequate references have been included to guide those readers who seek more detailed exploration of specific issues related to the foundations and historical background of touch.

Chapter 1

The Physiology of Touch

As Peloquin (1989) noted, “If length of entry in the dictionary communicates the importance of a word’s function, then the fourteen full columns on ‘touch’ in the Oxford English Dictionary affirms the significance ascribed to touch” (p. 299). Touch is a primary process by which humans gather information about the world.

It may seem odd for a book that is written primarily for psychotherapists about psychotherapy to begin with a nonclinical discussion of the physiology of touch. We believe, however, that the information about physiology is important—and worthy of consideration. One of our intentions in writing this book is to offer an overview of the various dimensions of the ethical use of touch in psychotherapy. Therefore, any comprehensive presentation needs to include a discussion of physiology. More important, however, much of the impact of touch on people occurs at the physiological level.

In many respects, touch is primarily a visceral experience, especially when it is paired with intense emotions. Within this context, practitioners who choose to use touch as a therapeutic tool should have at least an overall working knowledge of how physical contact affects people’s bodies. We hope that awareness of the basic physiological dimensions of touch will provide a more solid foundation to explore ways to apply touch within individual frameworks of psychotherapy.

The Evolution and Mechanics of Skin Sensitivity

The principal sensations of touch, pressure, temperature, and pain are realized through the skin. Most knowledge about how the skin functions has been learned relatively recently, since the 1940s. The skin is the largest sensory organ and may actually be regarded as the largest organ of the body. We can easily suggest that the skin is the second most significant human organ system, surpassed in importance only by the brain.

Montagu (1971), in his landmark book, Touching, noted that “the sense most closely associated with the skin, the sense of touch, ‘the mother of the senses,’ is the earliest to develop in the human embryo” (p. 1). The skin is already highly developed even before the embryo has either eyes or ears. Although the fetus is less than 1 inch long during the 8th week of gestation, it is already capable of responding to touch. Montagu noted that a light stroking on the face of the fetus even at this early stage of development could cause a reflexive turning away from the source of the stimulation.

In utero, the skin is continually stimulated by the amniotic fluid as well as by the touch and pressure of the womb. Responsiveness and sensitivity to touch can be seen during the earliest stages of infancy. Even before an infant can demonstrate active gestures of alertness, he¹ is highly responsive to touch. With ever-increasing speed, the newborn infant exhibits a number of reflexes that indicate a growing sensitivity to touch. For example, early in the developmental process, a gentle stroke on the cheek alerts the baby to turn his head in the direction of the stroke. When a finger is placed on a baby’s lips, he responds instinctively with a sucking motion. Even before it is clear that a child can visually discern a mother’s breast, physical contact with a breast prompts an automatic sucking response. Holding a young child firmly or wrapping him in a soft blanket tends to reduce crying and fussing.

Touch can be active or passive. Brown (1984) clarified some of the important features of passive and active touch. Passive touch (being the recipient of touch) functions in several ways, including (a) to stimulate an organism to an alert state to allow for responsiveness, (b) to facilitate the control of excessive input and hyperresponsiveness, (c) to experience pain, (d) to communicate emotional responses, and (e) to warn an organism to protect itself. Active touch (being the initiator of touch) also functions in distinct ways, including (a) to facilitate communication with another; (b) to divert, calm, or modify the response of another; (c) to alert another; (d) to facilitate exploration; and (e) to enhance or solidify a word or a communication.

Another type of touch is self-touch. Self-touch has several important functions, including to support self-control, to assist exploration, and to facilitate self-stimulation.

The Structure of the Skin

The skin constitutes almost 20% of the total body weight in humans, and skin contains more than a half million receptors scattered across all regions of the body (Collier, 1985). Skin serves as the interface between the body’s internal structures and the external environment, functioning as a protective armor against mechanical injury. The thickness of the skin varies throughout different regions of the body, with its thickness ranging from 1/50 of an inch on the eyelid to ⅓ of an inch on the palms of the hand and the soles of the feet. Despite these variations in thickness, most areas of skin are inhabited by a cumulative total of about 15 feet of blood vessels and about 72 feet of nerves (Cohen, 1987).

From an evolutionary perspective, the skin and the nervous system both develop from the same layer of embryonic tissue, the ectoderm. This shared lineage provides a critical link between the skin and the nervous system. As the fetus develops, the nervous system folds into the body’s interior and fastens itself shut, and the skin continues to function as a type of external nervous system. The skin forms a myelin sheath that provides the necessary protective encasement for nerve fibers, which communicate sensory messages along the spinal cord to the brain.

The skin maintains a constant state of readiness to receive messages. Five sensations can arise from stimulation to the nerve endings in the skin: touch, pain, heat, cold, and pressure. The human body is especially sensitive to stimulation that is activated by tactile contact.

Conscious sensations of specific stimuli depend on the functioning of certain brain areas. Physiological damage to particular regions of the brain that result from a stroke, infection, injury, or a tumor may contribute to selective loss in the ability to process certain types of sensory data. Similarly, injuries to receptor areas in the skin may cause difficulties in receiving or transmitting certain sensory experiences. Through accumulated life experiences, humans also have the capacity to learn skills that allow them to dissociate or distort perceptions of sensory stimuli as they are processed.

For example, it is common for athletes to dissociate certain distracting physical stimuli as they pursue specific training regimens to promote their abilities, thereby increasing their pain threshold and enhancing their performance. Elite athletes may even accomplish phenomenal feats while “ignoring” an otherwise debilitating injury. Likewise, many victims of prolonged trauma, such as political torture or physical/sexual abuse, are able to survive overwhelming and seemingly intolerable pain because of their ability to dissociate from physical and/or emotional aspects of their experience. Unfortunately, survivors may often continue such dissociative coping responses well beyond the actual circumstances of their trauma.

Physiological Responses to Touch

A wide array of research demonstrates that measurable physiological changes may be produced when touch is applied under the proper circumstances. Krieger (1975) reported a significant change in hemoglobin values after patients on a medical unit were touched by health care staff. Knable (1981) documented identifiable changes in blood pressure, heart rate, and respiratory rate in severely ill patients when nurses held their hands for up to 3 minutes. Lynch, Thomas, Mills, Malinow, and Katcher (1974) found similar results, documenting significant changes in heart rate during hand-holding or pulse taking for a sample of patients in a shock-trauma unit.

Smith (1989) reported that premature infants who were massaged for 15 minutes three times a day gained weight 45% more rapidly than those infants who were left alone in their incubators. Smith noted that “the massaged infants did not eat more than the others. Their weight gain seemed to be related to effects of touch on their metabolism” (p. 199). Montagu (1971) noted research studies that demonstrated positive effects on a person’s immunological system, including enhanced resistance to infections and other diseases, when that person had received stimulation of the skin during early childhood.

Distinct and measurable physiological responses can be noted following physical contact with the skin (Collier, 1985). These responses tend to be expressed through changes in one or a combination of three related phenomena: changes in temperature, changes in the amount of perspiration on the skin (usually seen as sweating), and changes in muscular tension. These physiological changes are essentially involuntary in their nature and, therefore, beyond conscious control.

Variations in Touch Perception

Like most nonverbal behaviors, touch rarely has a definitive or singular implication. Rather, a variety of qualitative factors influence the variability and meaning of touch, including duration, frequency, intensity, scope of contact, sequence of action, degree of reciprocity, body parts involved, context or setting, relationship or roles of the individuals involved, and relationship of touch to other stimuli (Thayer, 1982).

Touch as Validation of Reality Through Integration With Other Senses

Adults, as well as children, use touch to corroborate information that is gathered by our other senses, facilitating the process by which we validate the accuracy of what we hear, smell, see, or taste. Generally, in those situations in which we doubt the reliability of touch, most sighted persons call first on vision for validation. On the other hand, touch is frequently used to verify the reliability of vision, as sometimes occurs in the purchase of fabrics in which tactile contact to evaluate the texture may serve as a significant factor in deciding whether that material really is as appealing as it visually appears.

Touch is a more dominant modality than vision for younger children, ages 3 or 4. As children mature, vision seems to become of equal importance or more dominant than touch (Itakura & Imamizu, 1994). This distinguishing factor becomes significant in working with adult survivors of childhood trauma or people who suffered abuses that involved violations of touch, because the age(s) at which that trauma occurred may determine the degree to which memories have been stored predominantly through a visual or tactile modality. Interpreting presenting symptomatology and implementing intervention strategies may more appropriately focus on visual or tactile modalities, depending on the age that a touch-related trauma occurred.

The Relationship of Touch to Memory

We focus next on the ways in which touch relates to the process by which humans experience memory. For many people, touch has potent emotional meaning—positive or negative—because of its linkage to memories. Furthermore, not all memory that is linked to touch is accessed consciously. Relevant to our discussion here are two concepts: a working definition of memory and clarification of the process of state-dependent learning.

For most people, touch triggers a multitude of emotional and physical associations. The mind and the body seem to release a rush of memories whenever physical contact is made with another person or object: Touch may be accompanied by a feeling of familiarity that guides us through a routine task; touch may alert us to a stance of alarm, as we are signaled to remember that a particular physical sensation is a precursor to danger or harm; touch may be a new experience and may increase our feelings of anxiety because we have no memory associations with which to link particular physical sensations; touch may provide an immediate calming response, as when we experience a physical contact that has strong associations with previous encounters of being nurtured or protected.

Memory is not simply a result of or a specific phase of consciousness. Rather, as Prince (1995) noted, memory is more accurately concep tualized as a process. Prince further clarified that “conscious memory is only a particular type of memory. The same process may terminate in purely unconscious or physiological effects, or what may be called physiological memory to distinguish it from conscious memory” (p. 29; italics in the original). In addition, recall of memory—whether at the conscious or physiological level—is influenced by whatever events have transpired between the actual time an event occurs and the time it is recalled as well as by whatever previous knowledge about that event is available at the time of recall (Ornstein, 1991).

The physical body frequently becomes the “storage container” for physiological memory, wherein prior associations with touch are deposited. We can often speculate about persons’ histories with touch simply by observing their body demeanors. Many people who have been severely traumatized by physical and/or sexual abuse learn to carry their bodies in a rigid or constricted manner, whereas people who have been appropriately nurtured may be visibly more open and fluid in their manner of physical presentation. People who have received judgmental or shaming messages about their physical appearance tend to focus considerable energy on hiding their b...

Table of contents

• Cover Page
• Dedication
• Title
• Copyright
• Contents
• Preface
• Acknowledgments
• Part I Foundations and Historical Background
• Part II Clinical Application of Touch in Psychotherapy
• Part III Materials and Training Aids
• References
• Index
• About the Authors