[Adta] Annotated Bibliography on Touch

[ngoldov at gmail.com]

Here is a nice extensive bibliography on the use of touch in therapy. Enjoy.

Nancy Goldov, MA, ADTR, LMHC



References
Alyn, J. H. (1988). The politics of touch in therapy: A response to
Willison and Masson. Journal
of Counseling and Development, 66, 432-433. Retrieved January 21,
2005, from Academic
Search Elite database.
Alyn responds to the article, The Role of Psychotherapy: An adjunct to
Communication by Willison and Mason, cited at the end of this
bibliography. Alyn takes issue with their findings that nonerotic
touch is good. Alyn points out that the interpretation of erotic and
nonerotic touch is subjective and easily misinterpreted. Touch also is
complicated with issues of intimacy and power. Even nonerotic touch
may reinforce the unequal power relationship between the therapist and
client. Alyn concludes that touching clients carries great risk and
that the benefits are hypothetical, therefore, before touch is
included as a practice in therapy more studies are needed to determine
its effects on therapy outcome.

Boadella, D. (1997). Embodiment in the therapeutic relationship: Main
speech at the First
Congress of the World Council of Psychotherapy, Vienna [Electronic
version]. International
Journal of Psychotherapy, 2(1), 31-44. Retrieved January 19, 2005,
from Academic Search
Elite database.
Boadella discusses an integrated approach he calls biosynthesis.
Biosynthesis means integration of life and Boadella has defined seven
dimensions in his approach to a comprehensive and holistic
psychotherapy. 1) Movement 2) Breath 3) Emotionality 4) Image 5)
Channels of Contact (nonverbal communication 6) Touch (both contact
and no-contact forms – non-contact works with the energy field of the
body 7) Language. The note section of this article presents a
comprehensive overview of the history and development of integrative
methods of therapy from Freud to present day. In regards to touch
Boadella notes that boundaries must be respected, informed consent and
the clients awareness of relational transference and
countertransference in regards to touch must be addressed with the
client.

Brown, L. (1994). Concrete boundaries and the problem of
literal-mindedness: A response to
Lazarus. Ethics & Behavior, 4(3), 275-281.
Brown (1994) responds to Arnold Lazarus article "How Certain
Boundaries and Ethics Diminish Therapeutic Effectiveness." Brown
agrees that adherence to the "concrete, literal-minded" and rule-based
approach to ethical dilemmas that has become the cultural and legal
climate of our time can compromise the therapeutic effectiveness.
However, from a feminist therapy perspective Brown suggests a
different way of looking at the problem of how we resolve ethical
dilemmas and the responsibility of clinicians in making ethical
decisions. She argues that the problem is not about rigid adherence to
ethical rules that compromises clinicians therapeutic effectiveness,
but the failure of clinicians to consider the effects of power
dynamics in the therapist relationship, the failure to understand the
code of ethics as a guide that "allows for careful, informed
consideration of the meanings of our actions," and the failure to see
ethics as integrated into everything that psychologists do. She
advocates for a decision-making approach to ethical dilemmas that is
more focused on how we make ethical decisions taking into account the
client's best interests, the power dynamics, and the potential for
harm. She challenges therapists to be critical thinkers and integrate
the meanings and themes of the ethics code into the therapy
relationship. It is in this way that the therapist can remain
compassionate and effective and at the same time ethical.

Durana, C. (1998). The use of touch in psychotherapy: Ethical and
clinical guidelines [Electronic
version]. Psychotherapy: Theory, Research, Practice, Training, 35(2),
269-280. Retrieved
January 13, 2005, from PsycARTICLES database.
The article is primarily a literature review. Covers the Touch Taboo,
History of Therapeutic Touch, Research Studies, Ethical Guidelines,
Clinical Guidelines and two case studies. Durana concludes that touch
is a very complex form of communication and if used incorrectly can
cause harm to the client. Research so far indicates the benefits
outweigh the risks. However legal and ethical considerations and the
issues of transference and countertransference, make it a sensitive
issue. More study is needed.

Fisher, C. B., (2003). Decoding the ethics code: A practical guide for
psychologists. Thousand
Oaks, CA: SAGE Publications, Inc.
This book was used as a reference for the APA Ethical Principles of
Psychologists and Code of Conduct (2002).

Hetherington, A. (1998). The use and abuse of touch in therapy and
counselling [Electronic
version]. Counselling Psychology Quarterly, 11(4), 361-364. Retrieved
January 13, 2005,
from Academic Search Elite database.
This review of research brings out the aspects of touch that are
abusing to the client and that replicate the prevailing power dynamics
of society in which women are devalued and disempowered. A good
argument against the use of touch as a genuine expression of feelings
towards a client is stated and the most relevant research is cited.
This review is a reminder that touch is not necessarily therapeutic
that therapists are in the position of self-role maintenance in
regards to clinical, ethical and moral codes and constraints.

Holroyd, J. C., & Brodsky, A.M. (1977). Psychologists' attitudes and
practices regarding erotic
and nonerotic physical contact with patients. American Psychologist,
32, 839-843.
Results of a survey sent to 1,000 Ph.D. licensed psychologists (500
male and 500 female). 706 surveys were returned, this was noted as
evidence of how much interest there is on this topic. Approximately
half thought hugging, kissing or affectionate touching might be
beneficial occasionally to both male and female clients. Most
nonerotic touch fell into four categories: 1) Touch for socially or
emotionally immature clients (children, schizophrenic) 2) for periods
of acute distress 3) for more general emotional support 4) for
greeting or termination. Males perceived benefits in nonerotic touch
for the opposite sex more often (53%) than females (40%). There was no
difference between males and females for same sex patients. More
Humanistic therapists (30%) than Psychodynamic (6%) therapists thought
nonerotic touching might be beneficial sometimes or always. The
majority of Psychodynamic Therapists felt the behavior might be
misunderstood frequently or always. The majority of Humanistic
Therapists though it would never or rarely be misinterpreted by
clients.

Holub, E. A., Lee, S. S. (1990). Therapists' use of nonerotic physical
contact: Ethical concerns.
Professional Psychology: Research and Practice, 21(2), 115-117.

Horton, J. A., Clance, P. R., Sterk-Elifson, C., & Emshoff, J. (1995).
Touch in psychotherapy: A
survey of patients' experiences. Psychotherapy, 32(3), 443-457.
Survey of 250 psychotherapy clients' that examined factors affecting
clients' perceptions of touch in therapy as positive or negative. The
authors found that the following factors were positively correlated
with clients' perceptions about touch: the client and therapist are
clear on the use of touch; the client feels in control of the touch,
the touch is congruent with the level of intimacy in the therapy
relationship; and there is a strong therapeutic alliance or bond. The
authors found that clients with history of sexual abuse or sexual
problems rated touch more positively and cited a "corrective or
educative role" (452). Very few clients' (only 10) had negative
experiences with touch. Of those that did, a common factor in the
negative experience was therapists' using too intimate a level of
touch. Many clients' described touch as creating a bond, as
communicating genuine caring and acceptance, as facilitating trust and
openness, and enhancing self-esteem,  (451). The authors discuss the
importance of protecting against exploitative touch as many clients
report difficulty asking to be touched or being able to express
negative feelings about touch with the therapist. They emphasize the
importance of clients being able to communicate with the therapist
about the therapy, including touch. The authors argue that we must use
sound clinical judgment within each therapy relationship, taking into
account the uniqueness of each client and the therapist's styles and
preferences. They argue that touch has many positive effects and argue
against rigid rules prohibiting its use. The results if this study may
not be applicable to all populations as sample was primarily white,
female, and highly educated.

Hunter, M., & Struve, J. (1998). The ethical use of touch in
psychotherapy. London: SAGE

Publications.

This book is based on the belief that touch is a basic human need.
Hunter and Struve are in favor of touch in psychotherapy and give
ethical guidelines for its use. Includes a solid overview of the
history of touch in Psychotherapy (Freud, Ferenczi, Reich, Adler),
Bioenergenics and Humanistic Psychology. Addresses the continuum of
touch, its power dynamics and the clinical use of touch in therapy.


Hunter, M., & Struve, J. (1998). Challenging the taboo: Support for
the ethical use of touch in
psychotherapy with sexually compulsive/addicted clients. Sexual
Addiction & Compulsivity,
5, 141-148. Retrieved January 20, 2005, from Psychology and Behavioral Sciences
Collection database.
Hunter and Struve propose that the use of touch in psychotherapy
leading to sexual contact is due to the unethical behavior of a few
therapists and not a general finding. They state that nonsexualized
touch has decreased in all interactions because of the American
cultural view that touch has very sexual overtones and this has led to
a nation starved for touch. They feel the clients (especially those
sexually compulsive/addicted) exposed to touch in therapy will have a
model of appropriate ways of being intimate without being sexual.
Hunter and Struve also address guidelines on the appropriate use of
touch.

Kertray, L., & Reviere, S. L. (1993). The use of touch in
psychotherapy: Theoretical and ethical
considerations. Psychotherapy, 30(1), 32-40.
This literature review brings to light theoretical arguments and
historical developments in regards to the use of touch. The new
contribution it adds to the discussion is a three-step decision making
strategy supported by theoretical arguments and justifications to
determine the considerations when using touch. Given the complexity of
the issue the point is made that there are times when theoretical
justification would not ever be a guarantee that a decision to touch
is ethical. Opinions highlighted against the use of touch included,
that a client lowers defenses and is vulnerable to coercion, and that
even when sexual contact is not an issue an increase in the power
differential occurs. Concern for regressed patients whose capacities
would be blocked and ignored is discussed. Ongoing supervision or peer
consultation is recommended for therapists who utilize touch as a
significant part of the psychotherapeutic process.

LaTorre, M. A. (2000). Integrative perspectives [Electronic version].
Perspectives in Psychiatric
Care, 36(3), 105-107. Retrieved January 13, 2005, from Academic Search
Elite database.
As an advocate for use of the medium of touch in acupressure and
therapeutic touch, LaTorre poses many questions to consider with this
decision. Questions having to do with clients coping, client's ego
boundaries, perceived benefits and other relevant concerns are asked.
A clinical example is given demonstrating the ways that acupressure
supports one client's well being.


McNeil-Haber, F. M. (2004). Ethical considerations in the use of
nonerotic touch in
psychotherapy with children. Ethics & Behavior, 14(2), 123-140.
The author discusses how touch occurs frequently in psychotherapy with
children and can be very beneficial in healing and nurturing. The
different types of touch that occur when working with children are
discussed, including touch initiated by the therapist (protective
touch) and touch initiated by the child (playful touch) and the
potential ethical dilemmas that arise with these different types of
touch. The author reminds us that children are often not the ones
giving informed consent nor are they deciding on appropriate
boundaries for therapy. The therapist is responsible for setting the
boundaries for the use of touch. Therapists should be guided by the
principals of beneficence and nonmaleficence in determining when it is
beneficial to allow touch, when it may be harmful to allow it, and
when it may be harmful to reject touch by a child. The author suggests
that the child's perception of touch as positive may be for the same
reasons adults find it beneficial (i.e., acceptance and connection)
and under the same conditions (client is in control of touch, touch is
for benefit of client, and touch is openly discussed). The author
proposes a set of guidelines and other considerations for deciding
when touch is appropriate with children, including among other things
the benefits and risks, the child's safety, and practical
considerations.

Montagu, A. (1986). Touching: The human significance of skin. New
York: Harper & Row.

Montagu makes fine points about the intricate meaning of the skin and
defines touch as the mother of the senses. Skin's function as the
second most important organ of our body, after the brain, is depicted
as an exposed portion of the nervous system. The book speaks of the
external nervous system in which the outside world is felt through the
conduct of the tactile functions. Discovery is made in the inquiries
of understanding skin stimulations for the healthy development of the
organism both physically and behaviorally. The effects are of
insufficient skin stimulation in the developing human being, is
informed. The skin related activities of many mammals are discussed
such as in the self-licking behavior of apes. Touching and its
relationship to sex, growth, development, culture and contact is
thoroughly enumerated, with many references offering study.

Pope, K. S., & Tabachnick, B. G. (1993). Therapists' anger, hate,
fear, and sexual feelings:
National survey of therapist responses, client characteristics,
critical events, formal
complaints, and training. Professional Psychology: Research and
Practice, 24(2), 142-152.
Retrieved February 1, 2005, from PsycARTICLES database.
National survey sent to 300 female and 300 male Psychologists (50%
return rate) listed in the APA membership register. Therapists'
self-reports of anger, hate, fears and sexual feelings towards clients
were the basis of the survey. Survey was in two parts: 1) The
therapist's feelings towards clients and 2) The therapist's view of
the client's behaviors toward them. The authors pointed out that these
feelings might be difficult for therapists to acknowledge and when
unacknowledged have negative consequences to the client. They also
point out that if these feelings are appropriately acknowledged and
addressed they can be a resource in therapy leading to more trust and
honesty in the relationship. One troubling finding was the difference
in interaction between therapist and client based on gender. More
therapists notice that their female clients are physically attractive.
Female clients receive more hugs and more cradling or holding in their
therapist's lap. It was reported that 11.6% of the therapists
responding had a complaint filed against them. Male therapists were
three times more likely than female therapists to have a complaint
filed. Another finding was that many therapists felt their graduate
training in regards to feelings was inadequate.

Pope, K. S., Tabachnick, B. G., & Keith-Spiegel, P. (1987). Ethics of
practice: The beliefs and
behaviors of psychologists as therapists. American Psychologist,
42(11), 993-1006. Retrieved
February 1, 2005 from PsycARTICLES database.
National survey of 456 practicing psychotherapists self-reports of the
degree to which they used 83 different behaviors in their practices
and their attitudes about whether these behaviors were ethical.
Results indicated that almost all (91.7%) reported offering or
accepting a handshake from a client from rarely (3.3%) to very often
(48.2%), and 72% believed it unquestionably ethical to do so. Majority
reported hugging either rarely (45%) or more frequently (41.7%) and
41.2% thought it ethical under rare circumstances, while 45% believed
it was ethical in many circumstances. As for more kissing, the vast
majority (94%) never or rarely kissed clients; however, over one-third
believed kissing was ethical under rare circumstances. Again the vast
majority did not engage in sex with clients nor did they believe it
was ethical. In fact, the findings of sexual contact and erotic
activity were significantly lower than other studies have found (1.9%
and 2.6% respectively), which may represent an actual decline in
sexual misconduct or that psychologists are not less willing to admit
when they do it. Female psychologists were more likely to hug their
clients. Behaviors involving touch were evaluated in terms of the
ethical standards prohibiting exploitation of clients. Respondents
indicated that informal networks of colleagues were the most effective
source to guide their behaviors, followed by the APA Ethics Committee
and Ethical Principles, with state and local ethics committees and
published research given the lowest ratings. The authors highlight the
need to gather data on psychologists' use of and ethical beliefs about
their use of these behaviors in therapy, not only to help guide
professionals in practice but also to help create formal standards of
practices and standards by which the APA Ethics Committee can evaluate
complaints against its members.

Rabinowitz, F. E. (1991). The male-to-male embrace: Breaking the touch
taboo in a men's
therapy group. Journal of Counseling and Development, 69, 574-576.
The author provides anectodal evidence of the use of male-to-male
touch in his men's therapy group and the benefits touch provides in
offering support among members and facilitating communication and
deeper processing. The author provides some background on the taboo of
male-to-male touch in our society and the resultant complexity of
social and personal issues surrounding male-to-male hugging. The
author discusses the research that touch can benefit clients by
increasing self-exploration and improving positive perceptions of
counseling and therapist and the differential findings in the research
that men perceive touch more negatively and benefit from it less than
women do. The author's description of the male to male hug touches on
the complexity of the meanings the hug carries with it and the
potential for it to arose strong feelings, which seems in keeping with
other literature on this topic that to be appropriate the touch must
be congruent with the level of intimacy that the client is comfortable
with and that the client is in control of the touch. Discusses the
arguments for (offers support and grounding) and against (potential
for sexual exploitation and interference with transference) the use of
touch and some guidelines proposed by others for the use of nonerotic
touch. Conclusion is that touch can be beneficial to the client and
the therapy process when used appropriately.

Sakiyama, Y., & Koch, N. (2003). Touch in dance therapy in Japan.
American Journal of Dance
Therapy, 25(2), 79-95.
This article discusses the mind-body relationship in Japanese culture
and the fact that social rules govern and regulate the use of touch in
Japan. Western views towards touch with its emphasis on separation of
mind and body and "touch taboo" is compared to the attitude towards
touch in Japanese culture with its emphasis on connection of mind and
body and how those views in the larger social cultures have
implications for therapists in the use of touch in therapy.
Contrasting views about touch in psychoanalysis, psychotherapy, and
dance therapy in Japan and western cultures, is highlighted. Japan is
a culture with a high tolerance for crowding where touch is generally
understood as a fundamental human need and a way of healing. The Japan
Dance Therapy Association wrote into their ethical code of practice a
code regarding touch. This code is consistent with the perspective
that touch is a natural part of life in the Japanese culture.

Smith, E. W. L., Clance, P. R., Imes, S. (Eds.). (1998). Touch in
psychotherapy: Theory,
research, and practice. New York: Guilford Press.
This book is a compilation of various authors' perspectives on the use
of touch in psychotherapy and includes a brief history of the use of
touch in psychotherapy and the influences and biases that have lead to
its current state of controversy; classifications of different types
of touch and the meanings of different types of touch; research on
clients and therapists experiences with and perspectives on touch; and
case studies illustrating the use of touch. Different theoretical
perspectives are presented on the use of touch and general and ethical
guidelines for when and how to use touch (or not use touch) in various
contexts are offered. Arguments are presented for the "judicious" use
of touch taking into consideration the meanings and context in which
touch occurs (p.17). Guidelines for the use of touch with various
populations are discussed.

Stack, J. E., Oliver, J. (1991). Sexual contact and touching between
therapist and client: A survey
of psychologists' attitudes and behavior. Professional Psychology:
Research and Practice,
22(4), 297-397.
Survey of 320 Missouri psychologists examining their experiences with
and beliefs about the nature of varying types of touch, from
nonerotic, to suggestive, to clearly sexual touch, and how they
defined sexual misconduct, taking into account the effects of gender,
years of experience, and degree. What gets defined as sexual
misconduct depends on how it is defined. Also looked at how they
handled sexual attraction to clients and client reports of sexual
misconduct by previous therapists. The results indicated that most
psychologists defined clearly sexual contact as sexual misconduct such
as genital touching and over half identified kissing as misconduct.
Most identified touch of shoulder, arm or hand as rarely misconduct.
There were no gender differences in reports of overtly sexual
behavior, but males reported more sexually suggestive behaviors, and
females reported less attraction to clients. The authors suggest that
results indicate female therapists, and therapists with higher degrees
and therapists with more recent training, may be more sensitive to
sexual misconduct issues (less permissive attitudes towards and less
sexually suggestive behaviors). The majority reported being sexually
attracted to clients at some point in their career, and many reported
this attraction to clients. Authors argue the need for more research
on sexually suggestive behaviors, for training in how to handle sexual
attraction, and for more information on psychologists' opinions and
experience regarding touch and sexual behavior to help establish
guidelines for the use of touch.

Stenzel, C. L., & Rupert, P. A. (2004). Psychologists' use of touch in
individual psychotherapy.
Psychotherapy: Theory, Research, Practice, Training, 41(3), 332-345.
National survey of 470 practicing psychologists in private practice on
their use of touch in psychotherapy, the types of touch used, and
when, how, and why touch was used. The types of touch are examined
using Smith's (1998a) seven categories of touch that focus on purpose
and intention of therapist; nonerotic touch was classified as
relationship touch (hugging – for therapeutic purposes) and social
touch (handshake). Authors discuss the arguments around the use of
touch within theoretical and ethical considerations with the primary
goal of avoiding harm or exploitation. Results indicated that few
report the more erotic, suggestive, or potentially sexual types of
touch or aggressive touch, but many reported use of the traditionally
defined nonerotic forms of touch such as holding hand, touching
shoulder, and accepting and offering handshakes at least sometimes.
Most touch occurred at greeting or termination, rarely during
sessions. Female clients are touched more often than male clients by
both female and male therapists. Female therapists, humanistic
therapists, and therapists with more training and/or experience with
touch more often used touch and touch used primarily at greeting or
termination and rarely during sessions. Over one-third reported asking
permission to touch, but half reported not discussing it in therapy.
Primary reasons for using touch were empathy, comfort, support, and
nurturance. Authors conclude touch does occur for therapeutic reasons,
but most psychologists are highly cautious about the use of touch.

Stockwell, S. R., & Dye, A. (1980). Effects of counselor touch on
counseling outcome. Journal
of Counseling Psychology, 27(5), 443-446.
Study using undergrad and graduate students as clients and counselors
to test whether counselors touch had any significant effects on how
client's evaluated the counseling session and on client's
self-exploration behaviors. Touch was defined as "physical contact
between the hands and wrists of a counselor and the hands, arms,
shoulders, and upper back of a client." The design included one
50-minute highly structured interview that followed specific protocol
for touch and no-touch scenarios. The authors found no significant
effects of touch on client's evaluations of the counseling session or
on self-exploration. In fact, the results showed more of a trend
towards higher satisfaction for client's who were not touched. Females
scored higher on self-exploration generally regardless of touch or no
touch. The results of this study were compared to previous studies
that found touch to have positive impacts on client's exploration of
self (Pattison, 1973) and client's evaluation of counseling (Alagna et
al., 1979). Given the disparate results of this study and previous
studies of this nature, the authors discuss the possibility that the
difference might have been due to the degree to which the different
studies were controlled.

Strozier, A. L., Krizek, C., & Sale, K. (2003). Touch: Its use in
psychotherapy. Journal of Social
Work Practice, 17(1), 49-62. Retrieved January 13, 2005, from
Psychology and Behavioral
Sciences Collection database.
This social work perspective is a reminder that therapeutic
relationships are not social relationships but rather professional
ones. This literature review offers supportive comments on both sides
of the discussion. A vital point made reveals the trial and error
method that clinicians end up faltering through due to a shortage of
guidelines and rules about touching in psychotherapy. A questionnaire
instrument is used applying the snowball method to gather study
participants. Ninety-one surveys were returned and exploratory data
was analyzed using descriptive statistics. Results presented a
comparison with frequency of touch and social workers theoretical
orientation along with other comparison tables. Results showed that
the because of the general definition given to touch in this
questionnaire, data analysis was difficult. Results raised questions
about deficiencies in social worker education and clinical
rationalization. Without a clear mandate in the use of touch in their
practices, social workers and others will continue to self-education
through research, study, and trial and error.

Suiter, R. L., & Goodyear, R. K. (1985). Male and female counselor and
client perceptions of
four levels of counselor touch. Journal of Counseling Psychology,
32(4), 645-648.
Study using actual clients and counselors rated counselors who used
different types of touch that varied by degree of intimacy. Four
different scenarios of touch were examined: no-touch, touch of
client's hand, touch of client's shoulder, and semi-embrace. The
methodology involved the use of videotaped vignettes of counselors
(all male counselor/female client) using different types of touch
(these vignettes used actors and actresses). The clients and
counselors rated the counselors in each vignette on the counselors'
expertness, attractiveness, and trustworthiness. The authors found
that the clients and counselors did not rate the counselors any
different in the less intimate levels of touch (hand or shoulder), but
they did rate the counselors using the most intimate level of touch
(semi-embrace) as less trustworthy. The authors suggest this may have
been because this level of touch was more than what would have been
appropriate in that context. No gender differences in rating were
found, but there were differences between clients and counselor
ratings, with clients rating counselors generally as more expert,
attractive, and trustworthy.

Willison, B. G., & Masson, R. L. (1986). The role of touch in therapy:
An adjunct to
communication. Journal of Counseling and Development, 64(8), 497-500.
Retrieved January
21, 2005, from Academic Search Elite database.
This article is a literature review defining touch and offering
perspectives both for the use of touch and against the use of touch.
The authors present a review of the research clients' perceptions of
touch and conclude that some level of touch can be beneficial as means
of communication for infants, children, and adults, and touch seems to
increase clients' self-disclosure and clients' positive evaluations of
the therapist and the counseling process. "Women are more comfortable
being touched than are men and that all clients are more accepting of
touch from women than from men" (p .498). Factors that affect the
clients' perceptions of touch are discussed; when touch might be
beneficial (clients experience of touch (appropriateness in the
situation); when touch might be beneficial (client experiencing grief;
clients with history of sexual abuse); when touch might be harmful
(client does not want touch); when it may be harmful to withhold touch
(re-created rejection); and the positive effects of touch (conveying
acceptance, reconnect with reality). Guidelines are offered for the
use of touch. The authors conclude that touch is a positive form of
communication that can be beneficial in psychotherapy.


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