To Touch or Not to Touch

By Ofer Zur, Ph.D.

Our 6 CE credit online course Touch in Psychotherapy, fulfills the Law/Ethics Requirement:

A woman patient of mine lost her first and only infant son in a drunk driving accident. At the time of this tragedy, the pain of her loss was, of course immense; she could not stop crying and was contemplating suicide. At the insistence of her family, she agreed to an emergency appointment with a psychotherapist expert in loss. In this grief-stricken state, barely able to stand, she entered the office and sobbed uncontrollably. In her desperation and isolation she begged him to hold her. True to his most recent Ethics and Risk Management continuing education workshops, he explained to her that therapy is about talking, not touching and citing something about professional boundaries. At the end of the session, he suggested that she get a prescription for Valium from her GP and set an appointment for a couple of days later. Eight years later, addicted to Valium and alcohol, divorced and with two failed rehab programs behind her, she began therapy with me. After an intense and tearful few months of therapy and long conversations we went to her son’s grave. It was the first time she had ever visited the grave. There we stood, holding each other, and both weeping. We stood there for a long time as she cried and I cried. She had finally begun facing her baby’s death and mourning for him and grieving for the years lost in drugged denial. That therapist followed risk management guidelines to perfection. He took the “safe” path that forbids touch. However, by practicing risk management, adhering to the “no touch” dogma, he inflicted needless additional suffering on this woman. He sacrificed his humanity and the core of his professional being, to the demands of a heartless, paranoid and destructive protocol.

We have been told by ethics experts, attorneys, continuing education instructors and supervisors never to touch our clients. Touch has been increasingly perceived as a risk management issue to be avoided rather than as one of the most powerful tool of healing. Non-sexual touch, we have been told, is very likely to lead to sexual touch. In spite of the almost half century of knowledge of the emotional, physiological and behavioral benefits of touch, most therapists still shy away from appropriate non-sexual touch due to fear of boards, attorneys and lack of training. This Clinical Update summarizes the significant, ethical and clinical utility consideration of non-sexual touch in psychotherapy.

The General Significance Of Touch

  • Touch is one of the most essential elements of human development: a form of communication, critical for healthy development and one of the most significant healing forces.
  • In his seminal work, Touching: The Human Significance of the Skin, Ashley Montagu (1971) brought together a great array of studies demonstrating the significant role of physical touch in human development.
  • The effects of touch deficiencies can have lifelong serious negative ramifications.
  • Bowlby and Harlow, among many others, concluded that touch, rather than feeding, bonds infant to caregiver.
  • Touch has a high degree of cultural relativity. People of Anglo-Saxon origin place low on a continuum of touch while those of Latin, Mediterranean and third world ancestry place on the high end.
  • The general western culture and its emphasis on autonomy, independence, separateness and privacy have resulted in restricting interpersonal physical touch to a minimum. America is a “low-touch culture.”
  • In Western society, sex, love, power and dominance are dangerously confused.
  • Americans tend to sexualize or infantilize the meaning of touch and as a result tend to avoid touch. Watson, parenting expert of the early 1900’s, cautioned mothers not to sexualize their infants by kissing or hugging them affectionately.

Touch And Healing

  • The medicinal aspect of touch has been known and utilized since earliest recorded medical history, 25 centuries ago.
  • Touch unleashes a stream of healing chemical responses including a decrease in stress hormones and an increase in seratonin and dopamine levels.
  • Touch increases the immune system’s cytotoxic capacity thereby helping our body maintain its defenses.
  • Massage has been shown to decrease anxiety, depression, hyperactivity, inattention, stress hormones and cortisol levels.
  • Massaged babies are more sociable and more easily soothed than babies who have not been massaged.

Types Of Touch In Psychotherapy (See articles for details)

  • Ritualistic or socially accepted gestures
  • Conversational Marker
  • Consoling or reassuring
  • Playful touch
  • Grounding or reorienting
  • Task-Oriented
  • Corrective experience
  • Instructional or modeling
  • Celebratory or congratulatory
  • Experiential
  • Referential
  • Inadvertent
  • Preventing someone from hurting self or others
  • Self-defense
  • Therapeutic intervention – A bodytherapy medical technique
  • Inappropriate, unethical and mostly illegal forms of touch include sexual, hostile-violent and punishing touch.

Sources Of The Prohibition Of Touch In Therapy

  • The general western culture and its emphasis on autonomy, independence, separateness and privacy.
  • The cultural tendency in the USA to sexualize most forms of touch.
  • The traditional dualistic Western mind-body or mental-physical split.
  • Homophobia.
  • Some fundamentalist religious denominations that have a highly restrictive view of all forms of touch.
  • The litigious culture and the resulting risk management and defensive medicine practices.
  • Psychoanalysis and its emphasis on neutrality, distance and rigid boundaries.
  • Those feminist scholars who assert that most touch by male therapists of female patients is disempowering and injuring to the women.
  • The fear-based, illogical slippery slope idea that non-sexual touch inevitably leads to sexual exploitation.
  • The more recent crisis in the clergy and the not too distant day-care hysteria in regard to sexual exploitation.

Ethical Consideration Of Non-Sexual Touch In Therapy

  • Touch in therapy is not inherently unethical.
  • None of the professional organizations code of ethics (i.e., APA, ApA, ACA, NASW, CAMFT) view touch as unethical.
  • Touch should be employed in therapy when it is likely to have positive therapeutic effect.
  • Practicing risk management by rigidly avoiding touch is unethical. Therapists are not paid to protect themselves, they are hired to help, heal, support, etc.
  • Avoiding touch in therapy on account of fear of boards or attorneys is unethical.
  • Rigidly withholding touch from children and other clients who can benefit from it, such as those who are anxious, dissociative, grieving or terminally ill can be harming and therefore unethical.
  • Sexual, erotic or violent touch in therapy is always unethical.
  • Stopping therapy in order to engage in sexual touch or sexual relationships is unethical and often illegal.
  • Ethical touch is the touch that is employed with consideration to the context of the therapeutic relationship and with sensitivity to clients’ variables, such as gender, culture, history, diagnosis, etc.
  • Seeking ethical consultation is important in complex and sensitive cases.
  • Ethical therapists should thoroughly process their feelings, attitudes and thoughts regarding touch in general and the often, unavoidable attraction to particular clients.
  • Critical thinking and thorough ethical-decision making are most important processes preceding the ethical use of touch in therapy.
  • Documentation of type, frequency and rationale of extensive touch is an important aspect of ethical practice.

Clinical Considerations For Touch In Psychotherapy

  • The meaning of touch can only be understood within the context of who the patient is, the therapeutic relationship, the therapist and the therapeutic setting.
  • Touch, like any other therapists’ behavior and interventions should be employed if they are likely to help clients.
  • Touch increases therapeutic alliance, the factor found to be the best predictor of therapeutic outcome.
  • Touch can help therapists to provide real or symbolic contact and nurturance, to facilitate access to, exploration of, and resolution of emotional experiences, to provide containment, and to restore significant and healthy dimensions in relationships.
  • Clinically appropriate touch must be employed with sensitivity to clients’ variables, such as history, gender, culture, diagnosis, etc.
  • Sensitive, attuned touch gets etched into our developing neural pathways enabling us to feel of value, and to connect emotionally with others. As such, touch can be a powerful method of healing.
  • Language never completely supersedes the more primitive form of communication, physical touch. As such it can have a significant therapeutic value.
  • The unduly restrictive analytic, risk management or defensive medicine emphasis on rigid and inflexible boundaries and the mandate to avoid touch interferes with human relatedness and sound clinical judgment.
  • Due to the absence of attention to touch in most training programs, clinical supervision, research and testing, the majority of therapists tend not to incorporate the use of touch in therapy.
  • Fear, misguided beliefs and lack of training often lead to therapists employing an approach of “touch but don’t talk.”
  • Touch that is inappropriate, sexual, cold or abusive can be harmful.
  • Traumatic memories are encoded in our sensorimotor system as kinesthetic sensations and images, while the linguistic encoding of memory is suppressed. Therefore, appropriate touch can have a significant therapeutic value.
  • Disturbances in non-verbal communication are more severe and often longer lasting than disturbances in verbal language. Using touch in therapy may be the only way to heal some of these disturbances.
  • To disregard all physical contact between therapist and client may deter or limit psychological growth.

Guidelines For Clinically Appropriate And Ethical Touch In Therapy

  • Touch should be employed in therapy if it is likely to be helpful and clinically effective.
  • Avoiding touch due to fear of boards and attorneys is unethical and a betrayal of our clinical commitment to aid clients.
  • Touch in therapy must always be employed with full consideration to the context of therapy and clients’ factors, such as presenting problems and symptoms, personal touch and sexual history, ability to differentiate types of touch, the clients level of ability to assertively identify and protect his or her boundaries as well as the gender, and cultural influences of both the client and the therapist.
  • Touch should be used according to the therapists training and competence.
  • Extensive touch should be incorporated into the written treatment planning.
  • The decision to touch should include a thorough deliberation of the clients’ potential perception and interpretation of touch.
  • Therapists must be particularly careful to structure a foundation of client safety and empowerment before using touch.
  • Factors that are associated with congruence are; clarity regarding boundaries, patients’ perception of being in control of the physical contact, the patient’s perception that the touch is for his/her benefit rather than the therapists.
  • The therapist should state clearly that there will be no sexual contact and to be clear about the process and type of touch that will be used.
  • Extensive use of touch, as utilized in some forms of body psychotherapy, is likely to require a written consent.
  • Touch is usually contraindicated for clients who are highly paranoid, actively hostile or aggressive, highly sexualized or who inappropriately, implicitly or explicitly demand touch.
  • Special care should be taken in the use of touch with people who have experienced assault, neglect, attachment difficulties, rape, molestation, sexual addictions, eating disorders, and intimacy issues.
  • Therapists should not avoid touch out of fear of boards, attorneys or dread of litigation. Therapists are paid to provide the best care for their clients not to practice risk management.
  • Consultation is recommended in complex cases.
  • Therapists have a responsibility to explore their personal issues regarding touch and to seek education and consultation regarding the appropriate use of touch in psychotherapy.

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