Effect of Touch in Therapy

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The healing and spiritual potential of touch in psychotherapy: is therapy better when we touch each other?

Abstract

This proposal addresses the potential of therapist initiated touch in psychotherapy to have deep spiritual significance for clients and therapists and to contain healing and sustaining elements needed for good psychotherapy. Psychological studies have demonstrated the importance of touch for human health and well-being across age ranges. (Sehlstedt, I., et al., 2016; Westland, G., 2001).  Psychology recognizes the human need for touch, yet nevertheless, since the time of Freud, psychotherapy has been uncomfortable accepting the use of touch within the psychotherapy room. At the same time, we know from surveys of mental health workers that touch has and does occur within psychotherapy. (Stenzel, C. L.,Rupert, P.A., 2004). This proposal suggests research to identify, quantify, and interpret the meaning of touch within the psychotherapy room. The project proposed will seek to verify through research, if as one researcher and clinician stated, “at its best, touch is a heartfelt expression of caring and love.” (Durana, 1998). Phenomenological studies suggest that clients and therapists who touch experience touch with psychotherapy as a deeply meaningful experience. (Phelan, J.E., 2009). (Leung, S.W., 2015). Some researchers draw direct connections to spirituality, such as the laying on of hands.(Phelan, J.E., 2009) Whether or not the implicit language of religious practice is employed, almost all phenomenological studies about the impact of touch describe the experience in language that echoes the language and descriptions of spirituality as described by researcher Kenneth Pargament. (Pargament, K.I., 2007). Of particular note to experiences of touch within psychotherapy is Pargament’s use of the term, “sacred moment,” which he says “refers to brief periods of time in which people experience spiritual qualities of transcendence, ultimacy, boundlessness, interconnectedness and spiritual emotions.” (Pargament, K. I., et al, 2014). In phenomenological studies clients  and therapists described touch within psychotherapy as healing, relational, helpful for attunement and a tool for reparation where a client’s body may have experienced abuse, trauma, or neglect. (Leung, S.W., 2015; Phelan, J.E. 2009). This proposal suggests a research project to explore whether or not touch is being experienced within psychotherapy as something potentially imbued with deep spiritual significance and at times as a pivotal, sacred  moment capable of tapping into a wealth of spiritual resources intrinsic to human beings.

Table of Contents

  1. Introduction
  2. Contextual Background
    1. Psychotherapist guidelines for touch of clients in Ontario and Canada
    2. Historical Background and Current Practice of Touch in Psychotherapy
    3. The Relevance of Spirituality to Mental Health
    4. My Context
  3. Statement of the Problem
  4. Research Questions
  5. Objectives
  6. Contributions to Knowledge
  7. Theoretical Framework
    1. The Importance of Human Touch
    2. Spiritually Integrated Psychotherapy
    3. Holistic Conceptions of the Human Person
  8. Application Framework
  9. Results and Discussion
  10. Recommendations
  11. Summary
  12. Bibliography
  13. Appendices

13.1 Annotated Bibliography

13.2 Beginning of Metadata Table

1. Introduction

The objectives of this study are to find and summarize articles and papers on non-erotic touch within traditional psychotherapy settings and to analyze experiences of touch for qualities of sacred moments or connection to spirituality.  Throughout this proposal the term touch will be used interchangeably with the term non-erotic touch (unless specified) because erotic touch is harmful to the client and therefore never therapeutically valid.  This study will examine why given the interconnected aspects of physical, mental, and spiritual within the human person, therapists choose to include or exclude touch in their practice. For therapists who do touch their clients, the study will investigate how frequently and in what way they touch, and for what therapeutic purpose they touch their clients. As well, the study will seek to determine how clients have experienced touch within psychotherapy and if the use of touch increases the number of sacred moments, as defined by Pargament, or the sense of the sacred within psychotherapy. Given the established risks associated with touch, the study will seek to discover if there are strategies and guidelines supported by research that would reasonably mitigate the risk of touch within psychotherapy and what that recommended training might look like. Lastly, given the established research between spirituality and improved mental health outcomes (Pargament, 2007), research will ask if analysis of existing data supports a link between increased physical touch and increased spirituality as Wardell suggests, and if so is there enough evidence to justify a significant shift in attitudes towards the use of touch as a healing tool for mainstream therapist. (Wardell, 2001).

The method for my project will be to review and compare academic articles and dissertations about touch within psychotherapy spanning more than sixty years as well as literature around the potential of spiritual significance embedded in touch and its relationship to mental health outcomes. Literature reviewed will explored the history of the use and misuse of touch, phenomenological intentions of psychotherapists who touch and do not touch their clients, phenomenological experiences of clients who are touched or not touched, impacts of touch on therapy, risks involved with touch, situations where touch is contraindicated, psychotherapy training around touch, and ethical considerations for its inclusion and exclusion from the psychotherapy room. Data regarding the potential for touch to increase or facilitate the occurrence of sacred moments or spiritual experiences between therapists and clients will be analyzed using a philosophical design model.

This research study will be predicated on a challenge to assumptions of the traditional western view of psychology and the human person as separated into three almost unconnected parts.  In many some traditions, human beings are seen as a composite of a physical self (the body), a mental self (the mind) and a spiritual self (the soul or spirit) all of which are deeply interconnected and cannot be understood as individual parts. ” In the Islamic view, body, emotion, soul, and mind have always complemented each other; treating one without the other is considered ineffective and useless. Islam views well-being as homeostasis that promotes inner tranquility and peace, including ethics (M’Amalat), spirituality (Rouh), emotion (Atefah), and the soul (Nafs).” (Carter, 2004).  According to Pargament, “Sacred moments in treatment represent a potentially important resource that may contribute to the well-being of providers, clients, and the therapeutic relationship. More generally, these findings point to the value of attending to the spiritual dimension of the relationship between providers and clients.”  (Pargament, K. I. et al, 2014). For some, including indigenous and Eastern traditions, the western division between body and mind is a false one, and one that ultimately estranges us from the innate wholeness of the spiritual realm. (Yeh, C.J. et al, 2004). The fragmentation that has defined western bias towards appropriate models of psychotherapy is therefore challenged by a more holistic conception of the human person.

Touching is a physical act, yet it is appropriate within the psychotherapy room only if the act of touching engages or interacts with therapy in a way that improves mental health. This study will explore the impact of touch on the therapeutic process and will ask questions about how physical touch engages not only the body, but the mind, emotions, and spirituality of a client. If the act of human touch between client and therapist has elements of a spiritual experience, this is significant for establishing best practice, not to mention expanding our understanding of human healing on a psychological and spiritual level. This proposal suggests that research needs to be reviewed carefully to establish reasonable grounds for evaluating the potential connection between touch and spirituality as well as examining research for the implications of a verifiable connection should one exist.

A number of the articles reviewed draw parallels between a holistic understanding of the person, the need for touch, and the ensuing connection to spirituality that a holistic understanding allows. An article on indigenous healers underscored the fact that for many clients, healing on a holistic and ultimately spiritual level is more coherent with their perceptions of health and relief from suffering. (Yeh, C.J., et al, 2004). Some literature suggests that the use of touch has an intrinsically spiritual component, both from a historical as well as cultural perspective. (Phelan, J.E., 2009). Further research is needed to explore differences in perception, experience, and meaning (in giving and receiving touch and the potential connection to spirituality) based on ethnic, religious, or other forms of culture.

The wariness of traditional models of psychology surrounding touch between therapist and client is twofold. The first stems largely from concern about potential for sexual indiscretion. This concern has been born out in the historical record of psychology’s well known pioneers as well as lesser known practitioners who became sexually involved with clients. Sex between a psychotherapist and client is forbidden today, but it remains a primary reason for lawsuits against therapists. One hundred years plus into the field of psychotherapy there is ample evidence that therapists are at times attracted to their clients, clients are at times attracted to their therapist, and each can misunderstand the intent or feelings of the other. (Bonwitz, V., 2008; Durana, C., 1998). As a result, many in the field have followed a maxim of “better safe than sorry,” in regards to touch.

The second concern around touch is voiced most strongly from the psychoanalytic tradition which is concerned about dependency and or meeting clients’ immediate desire for gratification and comfort in a way that ultimately prevents them from achieving the growth and independence they need for psychological health. (Leung, S.W., 2015). Ultimately, the question of this research will be a question of what the best and safest way to do psychotherapy might be. If sacred moments sustain, inspire, and promote healing, and if touch is experienced as a sacred moment, is not touching our clients safer than touching? Or does a touch phobic psychotherapy represent a different kind of danger, where hyper concern for risk management means a profession misses the rich possibilities for healing available in simple human touch, a power which might give us a key, not just to our clients spirituality but to our own? The proposed research project will examine the history of touch, the prevalence of touch, the arguments for and against touch, the potential connection between touch and the sacred, the implications of the inclusion of touch in non-body oriented psychotherapies, the observed gaps in the literature and the preliminary conclusions which require further research to verify.

 

2. Contextual background

2.1  Psychotherapist guidelines for touch of clients in Ontario and Canada.

According to established national and provincial guidelines, sexual contact is the only touch expressly forbidden between therapists and current or recent clients. There is nothing describing touch as beneficial or outlining what safe touch would look like. The CRPO guidelines for professional practice state, “Touching may be easily misinterpreted, particularly where removal of clothing is involved. For example, a client may view an act of encouragement by an RP, such as a hug, as a crossing of client therapist boundaries or even a sexual gesture. When it comes to touch between a therapist and client, Members are encouraged to act prudently and with extreme caution.” (CRPO, 2011).

2.2   Historical background and current practice of touch in psychotherapy

The father of psychotherapy, Sigmund Freud, initially used touch in a number of treatments with patients. After receiving much public criticism of psychoanalysis, Freud reversed his position on touch and declared it at odds with good psychoanalytic practice. While some notable colleagues disagreed, Freud’s edict essentially set the stage for a profession wide discomfort with touch that exists to this day. While many have questioned the prohibition on touch, the profession has largely distanced itself from open acceptance of touch, pointing to the unfortunately high number of sexual indiscretions between therapists and their clients and the negative consequences for the client in such cases. There has been an attempt in the last sixty years to quantify what is happening with touch within psychotherapy rooms and if the prevailing discomfort with touch is for various reasons wrongheaded.

There has been significant advancement in our understanding of human physiology and the interconnected impact of trauma, for example, on both the mind and body. Trauma work in particular has used touch to helpful effect in healing minds and bodies. The question I propose to address in my project is if the interconnectedness of spirits, minds, and bodies is applicable to questions about the efficacy of touch within mainstream psychotherapy for potentially non-trauma related work.

Research about the impact of non-erotic touch within psychotherapy has grown a great deal in the half century. (Bonitz, V., 2008). The potential of touch within psychotherapy to increase human connection, meaning, healing, and a connection to the sacred has been recognized in academia to some extent, yet the hesitance to accept its use in most clinical practices remains. (Phelan, J., 2009). Some research suggests that more therapists use touch than talk about it. (Stenzel, C.L.; Rupert, P.A., 2004). More research is needed to determine if therapists  therefore recognize an intrinsic value in touch for their clients, but are not be willing to risk the disapproval of their peers.

Touching within psychotherapy without talking about it is problematic irrespective of its merits or shortcomings. If touch it is happening within psychotherapy based on perceptions of its benefits, but stigmas around its use prevent open dialogue, we enter a potentially dangerous space where we are using an intervention that is not trained for, discussed with peers, brought to supervision, or adequately studied with the intent of due diligence to protect our clients. (Leung, S.W., 2015). Given these concerns, this proposal hopes to analyze literature useful to suggesting a path forward in terms of appropriate training and supervision models.

2.3  The relevance of spirituality to mental health

The inclusion of spirituality as a relevant aspect of psychotherapy is relatively new within the traditional psychology, which has traditionally limited its scope of inquiry to the mental landscape. Pargament’s work to develop validity for the existence of sacred moments and the inclusion of spirituality as relevant to psychological assessment, health, and treatment has now been reinforced now by substantial numbers of studies corroborating his findings of the relevance between spiritual health, belief, and coping and positive mental health outcomes. (Pargament, K.I., 2013). One successful study included the integration of yoga with somatic and western psychology. (Jaquet, K., 2011). Further research review is required to establish how prevalent this kind of holistic approach is becoming or what the implications might be for the future of psychotherapy, but spirituality is recognized as a relevant aspect of mental health treatment.

2.4 My context

While the design of my study is philosophical, requiring me to discover the connections between existing studies and literature, it is important to locate myself as a researcher of observed data and a potentially biased searcher for meaning, gaps, and conclusions. In terms of spirituality, I grew up in a church and have lived a life full of both healthy and unhealthy intersections with religious practice. Throughout the ups and downs of human existence, my life has been one blessed with a number of significant sacred moments. The first time I heard Kenneth Pargament speak about sacred moments, I felt my heart practically leap within me to have a name for my experiences. Approaching this research, I have a pre-existing comfort with spirituality and personal familiarity with sacred moments and their potential for carrying us through suffering.

My relationship with touch is more complicated. I grew up in a family where touch was neither frequent nor safe. I fancied myself not a hug person and avoided the kinds of safe physical affection I knew little about. Home life was unpredictable and horrifically long. I kept a turtle on my dresser and moved it slowly inch by inch as the years went by until I could leave. In my grade 10 year something truly remarkable happened. A new teacher came to our school with her arms literally open wide. Many of us found ourselves swept up in a joyful or comforting embrace, sometimes four or five of us in a row. My life did not suddenly become joyful, but I did everything I could to be present where those hugs might be given. The holding I received from her the day  I told her my family was dispensing to the four winds to exist no more, was something I went back to in my mind for years.

My other biases are as follows. When my children were little and got sick I would hold them for as long as possible, believing that somehow the holding might help to heal them. Even as they threw up on me, I held them. I took them to the doctor, gave them juice and toast and medicine, but in my heart I felt that as their mother, my touching them, was another healing thing that I could do for them.

Further to this, I believe in therapy. I am in therapy. I am training to be a therapist. The most beautiful, important, and sacred moment I ever had with my current therapist was the day I wept and she held my hands and let me lean against her. If I can be that present for another person as a therapist myself, I want to learn how to do that.

Lastly, I have lived long enough to observe that wanting to help people and helping them is not necessarily the same thing. I am wary of cowboy style psychotherapy or therapists misguidedly attributing their own needs to their clients. I believe strongly in the merits of research and study. Hence my deep curiosity about what the research as to say about the intersection of touch, psychotherapy and sacred moments.

Good research will require reflexivity. I must be reflective, aware, and cautious about my own bias and its ability to impact my choice of what to read and review most carefully or how to interpret what I read. Good research will require me to work actively against the human tendency for bias by seeking literature which does not support my pre-existing thoughts and conceptualizations. As well, it will be important to discuss and consult with peers and professors about my ongoing research direction in order to spread my inquiry as widely as possible and further guard against bias.

3.  Statement of the Problem

While, therapist initiated touch between therapist and client has been suspect since the time of Freud, we know that touch is happening. The ensuing ethical conversation has seemed to range from a position of no touching in psychotherapy to a position that if we can quantify it and guard against abuses, touch might be okay. (Phelan, J.E., 2009). This proposal suggests a research project to address the possibility that touch might not just be ethically admissible, but an unheralded bridge to the depths of a person’s psyche and spirituality, a tool needed to the extent that it may be unethical not to offer touch to some clients as part of psychotherapy and a bridge to the sacred act of healing. The essential problem to be addressed is therefore this: based on existing studies, is there justification for the inclusion of non-erotic touch between psychotherapist and client as an accepted therapeutic intervention in mainstream psychotherapy with the potential to create or enhance sacred moments?

3.1  Applicable terms:

Non-erotic touch is defined as touch intended for non-sexual purposes.  It occurs on a spectrum ranging from a simple pat on the shoulder, or a hand on the knee, to a therapist actually holding a client on their lap. My paper will not attempt to decide which kinds of non-erotic touch should or should not be included. Different therapists and clients will have different levels of comfort. My paper will address non-erotic touch as a category and acknowledge that a continuum of comfort within the inviolable parameter of non-erotic exists.

Therapeutic intervention is an action initiated by the psychotherapist in psychotherapy for the express purpose of benefiting the client and increasing their potential for growth and healing.

Mainstream psychotherapy is defined as psychotherapy recognized by licensing bodies, but not specific to body work or touch related psychotherapies. Body psychotherapy, somatic psychotherapy, and others already have a specific focus on the body and employ touch. Relevant studies from these disciplines will be reviewed, but the purpose of the paper is to ascertain whether findings about touch are relevant and useful to psychotherapists who did not specialize in specifically body or somatic psychotherapies.

Sacred moments are defined as “brief periods of time in which people experience spiritual qualities of transcendence, ultimacy, boundlessness, interconnectedness, and spiritual emotions.” (Lomax, Kripal, & Pargament, 2011).

4.  Research Questions

Given a holistic conception of the human person, what the best way to do psychotherapy in regards to the non-erotic touch? (Best is defined as what is in the best interest of the client and what is useful for the therapeutic process, respecting that a therapist can only use a tool effectively if they are comfortable with it.) Is not touching safer (if safer is defined as the pathway most likely to prevent or alleviate further suffering)?  Does a touch phobic psychotherapy represent a kind of danger, where hyper concern for risk management means a profession misses the rich possibilities for healing available in simple human touch? (Danger is defined as anything that increases the suffering of the client in intensity or duration.) Can touch used appropriately be a link to sacred moments? When is touch not indicated and what are the arguments against its inclusion in psychotherapy?

5.  Objectives

My research will find and summarize articles and papers on non-erotic touch within traditional psychotherapy settings from a holistic perspective viewing the human person as composed of complex interconnected parts, including physical, mental, and spiritual aspects. The research will seek to understand why therapists choose to include or exclude touch in their practice and to reflect clearly (for therapists who do touch) an understanding of how frequently they touch their clients, how they touch their clients, and for what therapeutic reasons they choose to touch their clients. Research will further examine how clients and therapists have experienced touch within psychotherapy and to a limited extent how clients and service providers within other wellness contexts have experienced touch as a potential connection to the spirituality. The research will seek to discover if there are strategies and guidelines supported by research that would reasonably mitigate the risk of touch within psychotherapy and to see if the research supports justification for increased use of touch by psychotherapists in the best in the promotion of sacred moments and or the best interest of the client. Lastly, the research will seek to provide an overview of recommended training for psychotherapists around the use of therapeutic touch, appropriated indications for its use and non-use, and suggestions for opening the dialogue on the potential benefits of the intersection between healing, spirituality, sacred moments, and non-erotic touch within psychotherapy.

6.  Contributions to knowledge

Research could be used to inform practicing psychotherapists about the evidence for touch as a means of strengthening the therapeutic alliance, reducing anxiety, promoting increased healing, and inviting the potential for sacred moments.  Further, this research could be used to inform schools of psychotherapy and supervisors about the need to educate new interns, not just the dangers of touch, but about the potential for touch to heal, comfort, ground, and connect clients with themselves, others, and the sacred. (Westland, G. 2011). Research could also be used to suggest populations (such as elderly clients) that may benefit from touch more frequently than others as well as to suggest ways that touch may need to be moderated in reference to certain populations.  (David Edvardsson, J., et al., 2003). Research may also be used to educate clients about the benefits of touch in psychotherapy so they are better able to advocate for effective treatment.

Research could be used to inspire others to design studies about the use of touch in psychotherapy and the connection between physical touch between therapists and clients and connection to emotional and spiritual healing. (Schoop, E.M., 2006). Hopefully this research will inspire others to design studies or research projects to provide more clear evidence for the link between human touch and spirituality.

As research already indicates that touch is being used in research, further research conclusions can be used to support the development of an educated code of ethics around touch. This exists currently within body psychotherapy, but not elsewhere. The spoken and unspoken taboo against touch in psychotherapy has meant a surprising lack of guidance on the subject. Currently, the only imperative is the injunction against sexual relationships between psychotherapists and their clients. No guidelines exist to guide non-erotic touch such that it is used only for the benefit of the client, in ways that leave the client in control of how much touching occurs, or even that touch and the reasons behind it be made clear to clients so that informed consent is possible. With adequate research to support the use of touch, appropriate guidelines might be developed to decrease the risk and strengthen the potential of touch that is already occurring in psychotherapy or that might occur in the future.

7. Theoretical framework

7.1  The Importance of Touch

Touch is intrinsic to human communication . It is also necessary for human well being and happiness. (Sehlstedt, I., et al., 2016).  The nursing profession has increasingly recognized the importance of touch for healing, even linking it to the spiritual dimension.  Human touch, according to one nursing researcher, “promotes healing for the individual’s highest good, meaning that cure is not the focus but rather individual facilitation of self-healing and growth. It is proposed that this is accomplished by restoring balance and harmony in the human energy system. One of the outcomes of both the practice and receiving of HT (human touch) is thought to be increased spiritual awareness.” (Wardell, D. 2001). Psychology’s wariness about touch as an intentional psychotherapy tool is at odds with its own overwhelming evidence that humans need the physical touch of other humans.

7.2  Spiritually integrated psychotherapy

Spiritually integrated psychotherapy is a term coined by Kenneth Pargament to refer to mental health practice that assess for spiritual wellness and dysfunction along with standard psycho assessments.  Pargament argues that spirituality belongs in the therapy room for discussion and treatment as well as a potential source of strength and resilience. (Pargament, K.I., 2007).   According to researchers, “Sacred moments in treatment represent a potentially important resource that may contribute to the well-being of providers, clients, and the therapeutic relationship. More generally, these findings point to the value of attending to the spiritual dimension of the relationship between providers and clients.”  (Pargament, K. I., et al, 2014).

7.3 Holistic conceptions of the human person

The modern western conceptualization of separating health and well being into mental and physical compartments is one way of thinking. “Eastern Asian civilizations integrate theory and treatment of the mind and body. In contrast, since the 17th century, Western healthcare has retained a world view theory highly influenced by Descartes’ philosophy of body-mind dualism. In the Islamic view, body, emotion, soul, and mind have always complemented each other; treating one without the other is considered ineffective and useless.” (Carter, D. J., & Rashidi, A., 2004).  In an increasingly multicultural, multifaith world connected globally through technology, it is appropriate and necessary to cull wisdom and perspective from a variety of sources and to question a solely western dominated model of wellness.

8.  Application framework

This research project will proceed from a philosophical design model. The philosophical model attempts to challenge existing beliefs or models by examining existing research. (http://libguides.usc.edu/writingguide/researchdesigns).  Through my research, I hope to challenge the widely accepted taboo about the use of touch within psychotherapy, however, the results of my research must be subjected to pragmatism. I hope through a comprehensive investigation to reflect what works and what does not for the use of touch within psychotherapy.

Serena Wai-Jing Leung’s dissertation about client’s “lived experience of touch,” was a compelling work that shared from the client’s perspective the benefits of touch (and in a few cases the harm perceived from the lack of touch in previous psychotherapy). (Leung, S.W., 2015).  As well, the Jones/Glover article about touch as experience by clients using the Alexander Technique underscored the positive emotional impact that people experienced from healthy experiences with touch. (Jones, T., Glover, L., 2014). This proposal suggests that a further review of literature analyzing the spiritual impact of touch is promising but requires more research to effectively challenge our current culture of touch aversion within psychotherapy.

James Phelan’s work, which focuses on the therapeutic reasons for which touch is being used by those who choose to include it, also suggests a questioning of the current models of thinking around touch. Many of the articles reviewed to date suggest that insurance companies and a risk management approach to psychotherapy are driving practice more than actual research. (Leung, S.W., 2015).

The philosophical design is applicable because the research (around non-erotic touch as it relates to psychotherapy and an increased sense of the sacred) raises the kinds of ontological, epistemological, and axiological questions that the model suggests. Ontologically, the research needs to establish what is already happening in terms of touch within the psychotherapy room. What is happening in terms of how much touch and what kind of touch, but also, what is happening in terms of impact on the therapy from the therapist as well as the client’s perspective?

Epistemologically the research needs to determine and explain how and why many practitioners have come to decide that touch is dangerous . The research also needs to determine and explain how some have come to decide that touch might be safe, healthy, needed and imbued with sacred potential. By what measures have they reached these conclusions? How can researchers be certain that unbiased evidence exists to support the increased inclusion of touch? What is evidence based on that suggests the opposite – that touch can be counter-productive to good therapy?

From an axiological perspective, the research needs to address attitudes towards interconnectedness between aspects of the human person (physical, emotional, spiritual). How do psychotherapists view the connection? How do spiritual leaders within the community view the connection? How do clients or North American culture at large view the connection?  Do eastern perspectives or those of native healers have something important to contribute to the dialogue about the connection between human touch and psychological healing? What is their perspective? Do marginalized groups have a different perspective than traditional Western society? What values do they bring to the conversation and how might this influence the need for culturally informed and sensitive psychotherapy training?

For all these reasons, a philosophical approach is suggested by the research to date as an appropriate method for establishing the efficacy, relevance, and risk of touch as a potential therapeutic tool within mainstream psychotherapy.

9.  Results and Discussion

Preliminary results indicate that the research may support the use of touch to deepen or increase the presence of sacred moments in therapy. (Westland, G., 2011; Wardell, D.W., 2001; Tzarfaty, K., 2015; Matherly, N., 2013; David Edvardsson, J., et al, 2003). The working hypothesis of the proposed project is not yet supported by the necessary education and training to enact the standard use of touch within the psychotherapy sphere. It is hoped that sufficient calls for research and reflection will stimulate the kind of intellectual interest required to remove some of the stigma attached to the use of touch in psychotherapy, and to begin developing training that is both academic and experiential within accredited programs.

It is important to note that I have read more literature in favour of the inclusion of touch within psychotherapy, than I have read literature opposed to it. An academically sound and more richly developed argument will require rigorous review of more disapproving voices in the modern context. While a much greater percentage of literature found through databases spoke in favour of touch, I am also aware of the need to guard against my own bias and not potentially overlook or dismiss important criticism of various forms of touch or its connection to spirituality in psychotherapy.

10.  Recommendations

The recommendations developed from the study of my major research project are as yet unknown. I hope it will include recommendations for how to both inspire and provide permission for practicing psychotherapists to open their minds the possibility of human touch as an intervention with potential for emotional and spiritual significance in the therapy room. I also hope recommendations will include models of relatively low commitment, short term training that might allow therapists to safely and effectively incorporate some elements of touch in clinical practice, as well as models of extensive training and the differences between the two in both training and outcomes.

11. Summary

Preliminary research suggests that touch may be beneficial to relieve suffering, and promote personal growth, healing, and positive change. The taboo against touch is increasingly difficult to defend from an evidence based perspective. Given the risk of hurting by attempting to help in a not fully informed way, practitioners should take the need for training seriously, however, review of the literature to date suggests that the incorporation of touch as a standard part of a psychotherapist’s tool set merits serious consideration as a way of inviting sacred moments into the psychotherapy room.

12. Bibliography

Bonitz, V. (2008), Use of physical touch in the “talking cure”: A journey to the outskirts of psychotherapy. Psychotherapy: Theory, Research, Practice, Training, Vol 45(3), Sep 2008, 391-404. http://dx.doi.org/10.1037/a0013311

Carter, D. J., & Rashidi, A. (2004). East meets west: Integrating psychotherapy approaches for muslim women. Holistic Nursing Practice, 18(3), 152-9. Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/232544221?accountid=14701

College of Registered Psychotherapists of Ontario (2015). Professional Practice and Jurisprudence for Registered Psychotherapists. Retrieved from http://www.crpo.ca/wp-content/uploads/2013/10/Professional-Practice-Jurisprudence-Psychotherapists-Oct-13-FINAL.pdf

David Edvardsson, J., Sandman, P., & Rasmussen, B. H. (2003). Meanings of giving touch in the care of older patients: Becoming a valuable person and professional. Journal of Clinical Nursing, 12(4), 601-609. doi:10.1046/j.1365-2702.2003.00754.x

Durana, C. (1998), The use of touch in psychotherapy: Ethical and clinical guidelines.

Psychotherapy: Theory, Research, Practice, Training, Vol 35(2), 1998, 269-280.http://dx.doi.org/10.1037/h0087817

Jaquet, K. (2011). Wholistic group therapy for women: An integration of mind, body, and spirit (Order No. 1503825). Available from ProQuest Dissertations & Theses Global. (916755044). Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/916755044?accountid=14701

Jones, T. and Glover, L. (2014), Exploring the Psychological Processes Underlying Touch: Lessons from the Alexander Technique. Clinical. Psychology. Psychotherapy., 21: 140–153. doi:10.1002/cpp.1824

Kalkreuth, K. L. (2014). The body as the unconscious mind: An exploratory study of christian psychoanalytic psychotherapists’ perspectives on embodiment (Order No. 3630895). Available from ProQuest Dissertations & Theses Global. (1564231904). Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/1564231904?accountid=14701

Kertay, L., & Reviere, S. L. (1993). The use of touch in psychotherapy: Theoretical and ethical considerations. Psychotherapy: Theory, Research, Practice, Training, 30(1), 32-40. doi:http://dx.doi.org.proxy.bib.uottawa.ca/10.1037/0033-3204.30.1.32

Latorre, M. A. (2000), A Holistic View of Psychotherapy: Connecting Mind, Body, and Spirit. Perspectives in Psychiatric Care, 36: 67–68. doi:10.1111/j.1744-6163.2000.tb00693.x

Leung, S. W. (2015). The lived experience of touch in psychotherapy: A phenomenological study (Order No. 3714877). Available from ProQuest Dissertations & Theses Global. (1700412482). Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/1700412482?accountid=14701

Lomax, J. W., M.D., Kripal, J. J., PhD., & Pargament, K. I., PhD. (2011). Perspectives on “sacred moments” in psychotherapy. The American Journal of Psychiatry, 168(1), 12-8. Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/839307275?accountid=14701

Matherly, N. (2013), Navigating the Dance of Touch: An Exploration into the Use of Touch in Dance/Movement Therapy. American Journal of Dance Therapy 36(1):77-91 · DOI: 10.1007/s10465-013-9161-2

Moreau, G. A. (2009). Touch and psychotherapy: A journey to the depths of the unconscious and back again (Order No. 1472651). Available from ProQuest Dissertations & Theses Global. (305151675). Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/305151675?accountid=14701

Pargament, K. I. (2013). Conversations with eeyore: Spirituality and the generation of hope among mental health providers. Bulletin of the Menninger Clinic, 77(4), 395-412. doi:http://dx.doi.org.proxy.bib.uottawa.ca/101521bumc2013774395

Pargament, K.I. (2007). Spiritually Integrated Psychotherapy: Understanding and Addressing the Sacred. NewYork: Guilford Press.

Pargament, K. I., Lomax, J. W., McGee, J. S., & Fang, Q. (2014). Sacred moments in psychotherapy from the perspectives of mental health providers and clients: Prevalence, predictors, and consequences. Spirituality in Clinical Practice, 1(4), 248-262. doi:http://dx.doi.org.proxy.bib.uottawa.ca/10.1037/scp0000043

Peifer, D. E. (2008). Adolescent experiences of touch in psychotherapy (Order No. 3322264). Available from ProQuest Dissertations & Theses Global. (304818067). Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/304818067?accountid=14701

Phelan, J. E. (2009), Exploring the use of touch in the psychotherapeutic setting: A phenomenological review. Psychotherapy: Theory, Research, Practice, Training, Vol 46(1), Mar 2009, 97-111. http://dx.doi.org/10.1037/a0014751

Sehlstedt, I., Ignell, H., Backlund Wasling, H., Ackerley, R., Olausson, H., & Croy, I. (2016). Gentle touch perception across the lifespan. Psychology and Aging, 31(2), 176-184. doi:http://dx.doi.org.proxy.bib.uottawa.ca/10.1037/pag0000074

Shoop, E. M. (2006). Exploring how four master body psychotherapists came to adopt body psychotherapy and how they approach their practice (Order No. MR15158). Available from ProQuest Dissertations & Theses Global. (304986227). Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/304986227?accountid=14701

Stenzel, C. L. (2002). Psychologists’ use of touch in individual psychotherapy (Order No. 3039308). Available from ProQuest Dissertations & Theses Global. (305520768). Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/305520768?accountid=14701

Stenzel, C. L.; Rupert, P. A. (2004), Psychologists’ Use of Touch in Individual Psychotherapy. Psychotherapy: Theory, Research, Practice, Training, Vol 41(3), 2004, 332-345.http://dx.doi.org/10.1037/0033-3204.41.3.332

Tzarfaty, K. (2015). Integrative psychotherapy: Somatic, transpersonal, and western psychology in the practice of psychotherapy (Order No. 3726291). Available from ProQuest Dissertations & Theses Global. (1728319412). Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/1728319412?accountid=14701

Wardell, D.W. (2001). Spirituality of healing touch participants. Journal of Holistic Nursing, 19(1), 71-86. Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/196416980?accountid=14701

Westland, G. (2011). Physical touch in psychotherapy: Why are we not touching more? Body, Movement and Dance in Psychotherapy, 6(1), 17-29. doi:10.1080/17432979.2010.508597

Yeh, C. J., Hunter, C. D., Madan-Bahel, A., Chiang, L. and Arora, A. K. (2004), Indigenous and Interdependent Perspectives of Healing: Implications for Counseling and Research. Journal of Counseling & Development, 82: 410–419. doi:10.1002/j.1556-6678.2004.tb00328.x

13. Appendices

13.1 Annotated Bibliograpy

Bonitz, V. (2008), Use of physical touch in the “talking cure”: A journey to the outskirts of psychotherapy. Psychotherapy: Theory, Research, Practice, Training, Vol 45(3), Sep 2008, 391-404. http://dx.doi.org/10.1037/a0013311

In this article, Bonowitz attempts to provide an overview of the use of touch within psychotherapy and attitudes towards its inclusion or exclusion from practice. Bonowitz begins with Freud and continues to the time of her publication, providing enough example of the misuse of touch within psychotherapy to explain clearly the reticence of the profession to get too close. Bonowitz does a careful job presenting not only the uses of touch within psychotherapy, but also the arguments for and against it and the conclusions of various studies over the years. Bonowitz ends by suggesting the literature supports touch in some cases and offers some suggestions as to under what conditions this might ethically and most helpfully occur.

Carter, D. J., & Rashidi, A. (2004). East meets west: Integrating psychotherapy approaches for muslim women. Holistic Nursing Practice, 18(3), 152-9. Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/232544221?accountid=14701

This article seeks to validate worldviews held by many Muslim female clients as specific to faith and culture but open to misinterpretation by a largely Christian western worldview. The authors provide basic background on Muslim faith and middle eastern culture as well as common sources of misunderstanding for Muslim clients and non-Muslim practitioners.

David Edvardsson, J., Sandman, P., & Rasmussen, B. H. (2003). Meanings of giving touch in the care of older patients: Becoming a valuable person and professional. Journal of Clinical Nursing, 12(4), 601-609. doi:10.1046/j.1365-2702.2003.00754.x

This article was unique in its focus on the impact of touch for the health provider (as opposed to the client). The authors studied caregivers of older patients with dementia and analyzed the impact that providing touch to patients had on the caregivers. Prior to touch, caregivers expressed feelings of hopelessness and frustration at their inability to help their clients. After incorporating touch, providers felt they saw their patients as more human. Providers also felt an increased sense of worth, and satisfaction in their ability to meet and help their client. (Clients experienced benefits as well but were not the focus of the study.)

Durana, C. (1998), The use of touch in psychotherapy: Ethical and clinical guidelines.

Psychotherapy: Theory, Research, Practice, Training, Vol 35(2), 1998, 269-280.http://dx.doi.org/10.1037/h0087817

This literature review is quite dated. It is included here because it corroborates existing data in other papers and because of a few critical studies it cites that are not discussed elsewhere. Studies such as large anonymous surveys where clinicians self report on experiences of erotic and non-erotic touch yield data that suggest there may not be a correlation (as is often feared) between non-erotic touch and erotic touch. Surveys found a much greater percentage of non-erotic touch within humanistic schools as opposed to psychodynamic, however the percentage of reported sexual relationships with clients was the same. Durana does not discuss technique, however concludes from his review of literature spanning more than thirty years that there is validity for the inclusion of touch under certain parameter. Again, the breadth of years covered by Durana, who is himself removed in his writing almost twenty years from the present, provided a greater historical foundation and understanding of the trajectory of the arguments within the field over a significant time period.

Jaquet, K. (2011). Wholistic group therapy for women: An integration of mind, body, and spirit (Order No. 1503825). Available from ProQuest Dissertations & Theses Global. (916755044). Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/916755044?accountid=14701

This study involved an eight week therapy group for women that involved a combination of traditional group therapy, yoga, and meditation. The author proposes considerations for models of holistic therapies and critiques weaknesses in the model.

Jones, T. and Glover, L. (2014), Exploring the Psychological Processes Underlying Touch: Lessons from the Alexander Technique. Clinical. Psychology. Psychotherapy., 21: 140–153. doi:10.1002/cpp.1824

This is a fascinating study that by design, moves the conversation around touch in psychotherapy from ethics to actual technique and theory about what touch is and how it is experienced. In this two part study, Jones and Glover have surveys completed by AT clients as well as in-depth interviews of 6 AT clients. (AT, or the Alexander Technique, is not a specifically psychotherapy technique but involves a trained instructor who responds to and touches the head and neck of clients in an attempt to relieve stress, improve posture, etc.) Using coding techniques, Jones and Glover uncover themes around the experience of touch. Clients find it meaningful, healing, and a source of connection and being seen. As well, the clients find the experience so profound that they express the difficulty of putting to words the experience of being touched. Results from the surveys, which worked to assess in detail clients level of comfort or discomfort with various forms of touch, provoked more than one client to complain that the surveys were trying to stigmatize something (touch) that was healthy.

Kalkreuth, K. L. (2014). The body as the unconscious mind: An exploratory study of christian psychoanalytic psychotherapists’ perspectives on embodiment (Order No. 3630895). Available from ProQuest Dissertations & Theses Global. (1564231904). Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/1564231904?accountid=14701 

This doctoral dissertation uses a qualitative study to assess the attitudes and practices of Christian psychoanalytic psychotherapists towards embodiment. The author writes from a bias of personal experience with psychotherapy attuned to notions of embodiment that she found helpful and necessary for her own journey. Interestingly, while she finds a common language and acceptance for ideas about embodiment, multiple psychotherapist self select to note that they feel touch to be inappropriate within the psychotherapeutic setting. So her findings support the language of embodiment and the language of interconnectedness between our physical, mental, and spiritual selves, however there she found discomfort with moving beyond talking about bodies to actually touching them.

Latorre, M. A. (2000), A Holistic View of Psychotherapy: Connecting Mind, Body, and Spirit. Perspectives in Psychiatric Care, 36: 67–68. doi:10.1111/j.1744-6163.2000.tb00693.x

This article was selected because of its holistic view of the human person. The inclusion of the body and the spirit as part of what enters a psychotherapy room is relevant for any consideration of touch. The author’s approach includes ideas about certain emotions residing in certain parts of the body and the potential for holistic psychotherapy to untap emotion in a new (or perhaps more ancient) way.

Leung, S. W. (2015). The lived experience of touch in psychotherapy: A phenomenological study (Order No. 3714877). Available from ProQuest Dissertations & Theses Global. (1700412482). Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/1700412482?accountid=14701

This dissertation reviewed the literature around touch in psychotherapy as a whole but designed a study focused exclusively on the experience of touch for the client in psychotherapy. Participants were found by referral from experienced psychotherapist with previous training in touch and who used touch within psychotherapy for therapeutic purposes. Data was collected in 90 minute semi-structured interviews and produced a wealth of interesting material. One interesting point that developed in more than one interview (of which there were 11) was that for some clients, not only was the inclusion of touch in psychotherapy transformative, but the lack of touch in previous psychotherapies was something they experienced as negative, distancing and somewhat dehumanizing. The author concluded that while more study was needed (and her study method had selected for clients with a positive experience of touch) for some clients, touch is experienced at a profoundly deep level that allows psychotherapy to be greatly enhanced by its inclusion.

Matherly, N. (2013), Navigating the Dance of Touch: An Exploration into the Use of Touch in Dance/Movement Therapy. American Journal of Dance Therapy 36(1):77-91 · DOI: 10.1007/s10465-013-9161-2

Although not conclusive, this article raises interesting questions about the possibility of Dance/Movement Therapy to play a leading role in exploring the value of touch as well as common missteps to avoid with the inclusion of touch. Unlike most other therapy’s, DMT has employed touch for a long period of time and uses a number of tested techniques to reduce the threat of touch and gradually acclimatize clients to its use. The author’s measured and knowledgeable approach invites the reader to learn about some of the strengths (and weaknesses) of DMT without feeling like the author is trying to sell you something.

Pargament, K. I., Lomax, J. W., McGee, J. S., & Fang, Q. (2014). Sacred moments in psychotherapy from the perspectives of mental health providers and clients: Prevalence, predictors, and consequences. Spirituality in Clinical Practice, 1(4), 248-262. doi:http://dx.doi.org.proxy.bib.uottawa.ca/10.1037/scp0000043

This article reviewed a study of psychiatric nurses and their experiences of sacred moments with clients. The authors sought to understand predicting factors of sacred moments as well as to understand their meaning for clients as well as health care providers. The study concluded that sacred moments impact therapeutic alliance and increased the providers sense of meaning in their work.

Peifer, D. E. (2008). Adolescent experiences of touch in psychotherapy (Order No. 3322264). Available from ProQuest Dissertations & Theses Global. (304818067). Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/304818067?accountid=14701

This dissertation analyzed a study on perceptions of touch in psychotherapy for adolescents. The study was a qualitative study involving twelve adolescents, half male, half female. Adolescents expressed more caution around touch than adults typically do.

Phelan, J. E. (2009), Exploring the use of touch in the psychotherapeutic setting: A phenomenological review. Psychotherapy: Theory, Research, Practice, Training, Vol 46(1), Mar 2009, 97-111. http://dx.doi.org/10.1037/a0014751

In  this article, Phelan explores the meaning behind the use of touch within psychotherapy. While he takes time to discuss the ethics as well as efficacy of touch, his main focus, as his title suggests is about for what purpose touch is being used, what meaning is attached to it, and what message is trying to be conveyed. From the research, Phelan identifies six thematic meanings for touch as well as the kinds of touch used to convey the meaning. (For example, when touch is used for reassurance, it often involves a pat on the back or shoulder.) Phelan balanced approach offers examples of studies that support the efficacy of touch and a few that have found it not unethical, but simply not significant. Towards the end of the article Phelan draws parallels between the longstanding tradition in some religious of laying on of hands for healing purposes and the potential of touch within psychotherapy. He sees not only existing cultural context for touch as a vehicle for healing, but also the possibility that healing touch has spiritual implications.

Sehlstedt, I., Ignell, H., Backlund Wasling, H., Ackerley, R., Olausson, H., & Croy, I. (2016). Gentle touch perception across the lifespan. Psychology and Aging, 31(2), 176-184. doi:http://dx.doi.org.proxy.bib.uottawa.ca/10.1037/pag0000074

This article shared findings from a study of 120 person ages 13 – 82 in response to gentle stroking.  The authors attempted to compare physiological response and ratings of pleasantness in response to the stroking by age. Participants were half male, half female. The article is relevant to my study as it underscore the importance of touch across age spans.

Stenzel, C. L. (2002). Psychologists’ use of touch in individual psychotherapy (Order No. 3039308). Available from ProQuest Dissertations & Theses Global. (305520768). Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/305520768?accountid=14701

This dissertation was helpful to read in its entirety as it give much more detail about the reasons behind the study, the literature reviewed, the method of the study, as well as the data collected. The conclusions and main themes however, are the same as the article of the same name, by the same author, noted below.

Stenzel, Cheryl L.; Rupert, Patricia A. (2004), Psychologists’ Use of Touch in Individual Psychotherapy. Psychotherapy: Theory, Research, Practice, Training, Vol 41(3), 2004, 332-345.http://dx.doi.org/10.1037/0033-3204.41.3.332

While this survey was completed in 2002, it nevertheless represents a helpful update from earlier work on the what is happening in psychotherapy rooms in regards to touch. Surveys were sent to 1200 members of the APA and completed by 470 people, so while the surveys represent a somewhat limited populations, the results also represent a large number of separate practitioners.

Results indicate that frequency of touch within psychologists surveyed is low, but that touch is nevertheless occurring within the context of psychotherapy. Because of this, and because various codes of ethics fail to address touch beyond the prohibition against sexual touch, the authors make a strong case of more studies and proposed guidelines based on existing knowledge to date.

Tzarfaty, K. (2015). Integrative psychotherapy: Somatic, transpersonal, and western psychology in the practice of psychotherapy (Order No. 3726291). Available from ProQuest Dissertations & Theses Global. (1728319412). Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/1728319412?accountid=14701

This dissertation uses grounded theory to study the possibility of integrated psychotherapy using somatic, transpersonal and western psychology. Eight clinicians who incorporated somatic or transpersonal theory into their practice were interviewed. This study is relevant to my research as it attempts to integrate theories in pursuit of a holistic wellness model, however, the study is fairly technical and specific in its aims and harder to extrapolate applications for mainstream practitioners.

Wardell, D.W. (2001). Spirituality of healing touch participants. Journal of Holistic Nursing, 19(1), 71-86. Retrieved from https://search-proquest-com.proxy.bib.uottawa.ca/docview/196416980?accountid=14701

This study analyzed participants in healing touch training for spirituality. Study revealed an increased spirituality correlated with increased levels of training in touch. This study potentially validates the hypothesis that there is a direct link between touch and spirituality.

Westland, G. (2011). Physical touch in psychotherapy: Why are we not touching more? Body, Movement and Dance in Psychotherapy, 6(1), 17-29. doi:10.1080/17432979.2010.508597

This article represents the only voice of an experienced, long term practictioner within psychotherapy who is trained to use touch and has done so decades. Westland assumes a supportive audience, so unfortunately does not provide extensive outside sources to corroborate her views. However, it is helpful to hear collected wisdom and advice from a working practitioner. Westland is a talented communicator and invites with gentle passion. Psychotherapists as readers may come away inspired to read more or even take a class on the use of touch. Researchers may also leave hungry to see if what Westland promises is true.

Yeh, C. J., Hunter, C. D., Madan-Bahel, A., Chiang, L. and Arora, A. K. (2004), Indigenous and Interdependent Perspectives of Healing: Implications for Counseling and Research. Journal of Counseling & Development, 82: 410–419. doi:10.1002/j.1556-6678.2004.tb00328.x

This group authored article argues for a more open approach to psychotherapy and research than Western perceptions typically allow. Authors suggest that indigenous and Eastern understandings of a human being are much more holistic than a Western approach and that the Western idea of hiving off mental health into a specific realm for healing apart from the rest of the person (physical and spiritual) is not congruent with indigenous conceptions of health. The article attempts to educate as well as inspire counsellors to recognize the healing function of shamans and native healers and to consider a holistic approach to therapy that might include collaboration or referral to religious healers.

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