Training Students on the Ethics of Touch in Psychotherapy

D. Kim Fuller, Ph.D., ABPP
 

How many times has a student or supervisee asked you how they should respond to a client’s spontaneous hug?  Do students ask about the ethics of touching children during play or family therapy?  Have you included information about the ethics of touch in your case conferences? Since touch is such a fundamental, powerful and potentially healing form of communication, yet one that contains so much risk of client exploitation, it is important for training programs and clinical supervisors to include information about how and when to use touch in an ethical and therapeutic manner. It is unethical to practice outside one’s areas of expertise or training, yet few training programs even mention touch let alone provide training in the ethical use of it.  Training programs should provide a context for psychologists to think about touch in an ethical manner.  Consultation should be encouraged.  As Pope et al (2006) remind us, therapists grow and develop best in an atmosphere of openness, respect and encouragement to tackle difficult subjects.      

Although most therapists do touch their patients, at least occasionally (Hunter and Struve, 1997; Pope et al, 2006), few of us received any training or guidance about how and when touch might be therapeutic, when it might be neutral or when harmful.  The 2002 Ethics code of the American Psychological Association says very little about touch, and does not even use the word ”touch” anywhere in the code.   Sexual touching is of course prohibited and is always unethical (sections 10.05 – 10.08).  Psychologists are also prohibited from engaging in behavior that might constitute sexual harassment (3.02), conflicts of interest (3.06) or exploitation of clients (3.08).  But there are many instances in which nonsexual touching might occur in psychotherapy, and lack of training or guidance presents an ethical dilemma that many of us resolve by refraining from touching clients at all.
The ethical concerns that are raised by questions about therapeutic touch are too complex to be fully explored in a brief article, but I will attempt to outline some of the issues that merit consideration in our work. Physical touch is a powerful and emotional form of communication.  It is always reciprocal—that is, one cannot touch without being touched. It therefore has the potential of facilitating the emotional connection between therapist and client. Human beings are “hardwired” to need loving touch in order to grow and develop.  The extensive literature on attachment and parent-infant bonding, as well as studies of the physiological and psychological effects of massage document the potential healing and soothing impact of touch (cited in Zur and Nordmarken, 2006). Therapists may use nonsexual touch in psychotherapy for many reasons:  to greet clients, to console them in grief or despair, to ground them in the present moment, to restrain a violent or assaultive client, to express understanding or to provide encouragement (Zur and Nordmarken, 2006).  Touch may also occur in play therapy with children, in certain family therapy techniques such as psychodrama or family sculpture, or in therapeutic interventions using EMDR or hypnosis.    

In considering how and when to touch a client, it is helpful to examine the question in light of the broad general principles that organize the 2003 APA ethics code.  The principles of beneficence and nonmaleficence remind us to do no harm to clients and to choose interventions most likely to benefit them.   Because touch is deeply emotional, it can trigger powerful negative as well as positive feelings in clients.  Clients who have been victims of violence or abuse, or those with paranoid or borderline personality characteristics can experience touch as intrusive or threatening.  Touch should never be used unless the therapist knows the client well and is certain that touch is in the client’s interest.  Hunter and Strube (1997) ask “Who is likely to benefit from this?  In all cases, the answer must be the client.  If touch is being considered for the therapist’s needs rather than for the client’s needs, then it should not be used” (p.141).   These authors caution that clients should consent to touch before it is used. Consent can be written or verbal. Verbal consent can be obtained by asking a client, “Is it OK with you if I touch your hand?” A formal written consent should be used if touch is a primary tool in the therapy as in exposure and response prevention therapy for OCD or tapping a client’s hands in EMDR.  Verbal consent is sufficient if touch is an adjunct to verbal psychotherapy as in the use of touch to communicate empathy during an emotional verbal therapy session (Zur and Nordmarken, 2006).   Model language for a formal written consent form can be found in Hunter and Struve’s 1997 book (p.154).  These authors also recommend that information about the use of touch, including the client’s assent to it, should be documented in the client’s chart.  For any consent to be freely given, however, clients need to feel comfortable saying no. They need to feel secure that the therapist will not be offended and that the therapeutic bond will remain intact regardless of their response. Consent should include the proviso that the client can change his or her mind about the use of touch at any time, for any reason.

Justice and integrity refer to treating clients fairly and being honest.   Zur and Nordmarken (2006) raise the interesting suggestion that the rigid avoidance of touch, especially if it is avoided primarily out of risk management concerns is unethical.  If touch is withheld from clients for whom it could be healing, helpful or therapeutic (for example, shaking the hand of an AIDS patient, hugging a grieving client who is well-known to the therapist) it is unethical to do so.  These authors remind us that “therapists are not paid to protect themselves; they are hired to help, heal, etc”. It is unethical to avoid touch purely out of fear.  On the other hand, decisions about the use of touch should be mutual. Just because a client desires the therapist’s touch does not mean that the therapist is obligated to provide it. Therapists may experience a client’s request for a hug or other nurturing touch as intrusive or sexualized. Or they may be uncertain of whether or not touch would be beneficial because they have not carefully considered it and are untrained about how and when to use touch in therapy. Being honest with the client about one’s reservations can provide a therapeutic opportunity to discuss touch, intimacy and other issues pertaining to close emotional relationships.  Hunter and Struve (1997) encourage therapists to remain attuned to their own boundaries and comfort level with clients and to seek consultation as necessary to clarify them.     

The general principles of fidelity and responsibility further reinforce the centrality of trust in therapeutic and other professional relationships. An important component of taking professional responsibility with clients is to maintain awareness of the power differential between therapist and client in which the therapist holds inherent power. Because the therapist holds more power than the client, there is always the risk that a client may acquiesce to a therapist’s suggestion even when it makes her or him uncomfortable (Welfel, 2002). Much of the opposition to the use of touch in psychotherapy is related to concern that the power differential between client and therapist invariably means that touch is exploitive or dangerous.  But having power does not necessarily mean using it to exploit.  Instead awareness of the inevitable power differential in therapeutic relationships means that it behooves the therapist to be cautious about introducing touch into the therapeutic relationship until the relationship is well-developed.  At a minimum the therapist should have a clear understanding of the client’s history, especially vis-à-vis previous experiences of physical touch.  In addition therapists should fully attend to nonverbal as well as verbal indications from the client about his or her response to touch.  Any indication from the client that touch is unwelcome should be respected and discussed.  This too can be a therapeutic opportunity to validate and empower the client.     

The principle of respect for the rights and dignity of our clients suggests that a therapist must understand the meaning of touch from the perspective of the client’s culture, personal history and personality. Touch, like other forms of nonverbal communication, is easily misinterpreted if client and therapist have different assumptions about its meaning. In the United States, touch often has a sexualized meaning, especially for men.  Nonsexual touch is initiated by men less frequently than it is by women, and males may experience touch as a sexual overture more readily than women do. In general, North Americans are less likely to touch each other than individuals from South America or the Mediterranean. And within the United States there are regional as well as ethnic differences in the use of casual touch and in expectations regarding personal space (Zur and Nordmarken, 2006). Clinicians must carefully examine their own cultural norms regarding touch.  For example, as a straight Caucasian woman whose family of origin was verbally affectionate but low on the touch continuum, I am quicker to touch children than adults, women than men, and White clients than African Americans. If a therapist is unfamiliar with the client’s cultural assumptions regarding touch, these assumptions should be verbally explored before the use of touch is considered in therapy.  Hunter and Struve (1997) caution that client expectations are a critical factor in determining whether or not touch is appropriate.  “Expectations should fall within the range of what is actually possible within the therapy relationship” (p. 139). They recommend having a set of written guidelines for clients to clarify the boundaries of the therapy relationship and to elaborate the basic rights and responsibilities for both therapist and client.

References
American Psychological Association (2002). Ethical Principles of Psychologists and Code of Conduct. Washington, D.C.
Hunter, M. and Struve, J.(1997). The Ethical Use of Touch in Psychotherapy.  Thousand Oaks CA:  Sage.
Pope, KS, Sonne, JL, and Greene, B. (2006).  What Therapists Don’t Talk About and Why:  Understanding Taboos That Hurt Us and Our Clients. Washington, D.C.: APA
Welfel, E.R. (2002). Ethics in Counseling and Psychotherapy. Pacific Grove CA:  Brooks/Cole.
Zur, O. and Nordmarken, N (2006) To touch or not to touch:  Rethinking the prohibition on touch in psychotherapy and counseling. In http://www.zurinstitute.com/touchintherapy.html.