THE ROLE OF POSITIVE PHYSICAL TOUCH IN FAMILY THERAPY. and TRAINING FOR MARRIAGE AND FAMILY THERAPISTS ON THE ETHICAL USE OF PHYSICAL TOUCH IN THERAPY

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1 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 1 THE ROLE OF POSITIVE PHYSICAL TOUCH IN FAMILY THERAPY and TRAINING FOR MARRIAGE AND FAMILY THERAPISTS ON THE ETHICAL USE OF PHYSICAL TOUCH IN THERAPY A Two Paper Alternative Department Thesis Presented to the Faculty of California State University, East Bay In Partial Fulfillment Of the Requirements for the Degree Master of Science in Counseling By Sarah Lebeck-Jobe June 2010

2 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 2 Abstract This literature review explores the effects of positive physical touch on children and adults. Positive physical touch is defined as physical contact between two individuals that is mutually understood to communicate respect and care. Physical touch is a tool marriage and family therapists can suggest for families to reduce anxiety, improve relationships, and increase physical wellbeing. Patterns and the meaning of touch between heterosexual couples and between parents and children are reviewed. In addition, this literature review presents research regarding the effects of touch and of touch deprivation on individuals physical and mental health. It advocates examining the taboo against therapist-client physical contact that may prevent therapists from using touch as a therapeutic intervention and provides an ethical examination of the topic. Paper Two presents a training workshop for marriage and family therapists on the ethical use of physical touch in therapy.

3 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 3 THE ROLE OF POSITIVE PHYSICAL TOUCH IN FAMILY THERAPY and TRAINING FOR MARRIAGE AND FAMILY THERAPISTS ON THE ETHICAL USE OF PHYSICAL TOUCH IN THERAPY By Sarah Lebeck-Jobe June 2010 Approved: Randi S. Cowdery, Ph.D. Naveen Jonathan, Ph.D. Date Date

4 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 4 Table of Contents Abstract... 2 Paper One: The Role of Positive Physical Touch in Family Therapy... 5 I. Introduction... 5 II. Review of the Literature... 9 Patterns of Physical Touch in America... 9 Biopsychosocial Effects of Touch History of Touch in Psychotherapy Current Standard of Care Ethical Considerations III. Implications for Marriage and Family Therapists IV. Summary... 37

5 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 5 Paper One: The Role of Positive Physical Touch in Family Therapy I. Introduction Physical touch is a multifaceted component of nonverbal communication. Touch can convey anger, fear, love, sympathy, and other emotions to both the person being touched and to observers of the touch (Hertenstein, Keltner, App, Bulleit, & Jaskolka, 2006). This literature review explores the role of positive physical touch during individual and family therapy to evaluate its potential to foster healthy relationships, reduce anxiety, and improve physical health. Positive physical touch is physical contact between two individuals that is mutually understood to communicate respect and affection. This form of nurturing touch can take the form of hugging, holding, and touching a person s hand, arm, back, or shoulders (Aquino & Lee, 2000). This type of physical contact is not a sexualized form of touch. Marriage and family therapists are in a unique position to educate families on using positive physical touch to heal their disrupted relationships. Therapists can model appropriate touch in therapy sessions and encourage family members to practice giving and receiving positive physical touch (Fisher, 2002). This literature review presents the patterns and meaning of touch between heterosexual couples and between parents and children. In addition, this literature review presents research supporting the effects of touch and of touch deprivation on individuals physical and mental health. By understanding the attributes of healthy families, marriage and family therapists can better serve families who want to improve their relationships and deepen their communication skills.

6 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 6 In addition to exploring the role of touch between family members in therapy, this literature review examines the taboo against physical touch between the therapist and the client, which may stem from the failure to discriminate sexual from nurturant touch (Durana, 1998, p. 269). Despite this taboo, certain types of touch between therapists and clients continue to occur in sessions (Stenzel & Rupert, 2004). Therapists report touching female clients 55.8% of the time and touching male clients 47.1% of the time (Stenzel & Rupert, 2004). Other studies have shown that many therapists touch their clients in nonerotic ways to facilitate therapeutic alliance and to express nurturance (Nickell, Hecker, Ray, & Bercik, 1995). This review presents research on the way therapists and clients perceive the meaning and role of touch in therapy. It seems that most therapists are not adequately trained how to safely work through therapist-client touch should it arise in session (Durana, 1998). The use of touch as an ethical and clinical issue has not been sufficiently addressed in clinical training and supervision (Durana, 1998, p. 270). Since most therapists can expect to encounter situations in which they have some type of physical contact with clients, it is unwise to avoid discussing this topic. Although the therapist should follow the rules of the agency or private practice in which he or she works, training at the graduate level would improve the chance that new therapists will handle touch in an ethical manner that results in a respectful and safe environment for the client. In addition, despite explicit language forbidding sexual contact with current clients in the ethical codes of AAMFT, ACA, and CAMFT, some practitioners still make poor ethical choices. According to the California Board of Behavior Sciences, 13.5% of the disciplinary actions for licensed mental health professionals between 2003 and 2009

7 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 7 were for sexual misconduct (2009). Between 1983 and 2009, 28.7% of the reported disciplinary actions for psychologists were for sexual or dual relationships with clients (Monitor on Psychology, 2009). There is clearly a need for additional training for marriage and family therapists on the topic of appropriate, non-erotic physical touch. Perhaps if the topic of touch in counseling were no longer a taboo, therapists could more freely discuss using positive physical touch with clients as a technique. By bringing the topic into the professional arena, therapists could gain experience sorting through ethical challenges that confront them when working with clients. This literature review investigates the following questions regarding physical touch: 1) What are the patterns of physical touch between heterosexual couples in America? 2) What are the patterns of physical touch between parents and children in America? 3) What are the biopsychosocial effects of touch on children and adults? 4) What is the history of the use of touch in the field of counseling/marriage and family therapy? 5) How do practicing therapists use touch in counseling sessions and what are their attitudes toward touch in counseling? 6) What are the beliefs of clients who have been touched in therapy about the usefulness and ethics of touch in counseling? 7) What are the ethical recommendations regarding touch in counseling from a standard of care perspective?

8 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 8 This literature review will serve as a framework for evaluating the usefulness and ethics of incorporating positive physical touch into counseling sessions.

9 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 9 II. Review of the Literature Patterns of Physical Touch in America It is important to understand what is considered culturally acceptable physical touch between family members and couples in relationships in America. Therapists should have knowledge of culturally normative behaviors so they can better understand the background of families and couples they see for counseling. The therapist s office has elements of both a private and a public setting, so the therapist should be aware of studies carried out on in both private and public arenas and of the way the environment may influence their clients. Several studies have examined touch: one provides a snapshot of touch patterns between fathers and their preadolescent sons, another uncovers beliefs regarding the perceived appropriateness of various types of touch among family members, and a third examines the influence of relationship status on touch patterns between couples in public settings. The last two studies examine gender influences patterns of touch and how touch is viewed in different cultures. These studies are not an exhaustive survey of attitudes toward touch that clients may practice. Therapists should endeavor to learn about the touch patterns and normative behaviors of their clients cultures and family units. The first study investigated the touch patterns between 39 dyads of fathers and preadolescent sons who played games together in a laboratory setting. The study revealed that fathers and sons share more nurturing touch than researchers anticipated (Salt, 1991). In fact, most observed interactions were not roughhousing, but were instead positive types of touch such as placing a gentle hand on the son s leg or back. In a written questionnaire, fathers reported more affectionate types of interactions such as hugging

10 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 10 and kissing their sons in the privacy of their homes than the researchers observed in the laboratory. Sons attitudes about touch appeared to change as they entered preadolescence. They were less likely to desire touch with their fathers, especially if their peers were in attendance. The study concluded that the amount of touch fathers initiate with their sons decreases as their sons age (Salt, 1991). The results from this study are questionable for the following reasons. First, the sample size of 78 participants is small (Salt, 1991). Second, 56.4% of fathers had postcollege education, which was higher than the national average at the time of the study (Salt, 1991). Third, the study was conducted in a laboratory setting, and the observed interactions were not congruent with the reported types of touch between the fathers and sons in their homes (Salt, 1991). Therefore, the results of this study cannot be generalized to the wider population or to all settings. It does provide a good foundation for examining father-son touch patterns, and should be replicated with additional dyads from different educational backgrounds and in a more homelike environment. Another study asked 204 individuals to rate the appropriateness of certain types of touch between fathers and mothers with their daughters and sons at different ages (Harrison-Speake & Willis, 1995). The researchers hoped to uncover normative attitudes about familial touch in America. They asked about the appropriateness of children sitting on their parents laps, kissing, bathing, and sleeping in the same bed. They hypothesized that the appropriateness rating of all of these types of touch would decrease as the children aged. The hypothesis was supported when results indicated that respondents felt that the appropriateness of touch decreased as children got older for all groups and all types of

11 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 11 touch. The respondents thought it was more appropriate for most types of touch to occur between same-sex pairs. The rating scale was one to five, where five represented very appropriate touch. For example, the mean approval rating of daughters sitting on their mothers laps at age 2 was 4.83, and the mean approval rating of boys sitting on their fathers laps was similar at 4.79 (Harrison-Speake & Willis, 1995). In contrast, the mean approval rating of sons sitting on their mothers laps at age 2 was 4.78, and the mean approval rating of daughters sitting on their fathers laps also dropped to However, maternal touch was usually seen to be appropriate with their children to an older age than paternal touch. For example, the appropriateness of girls sitting on their mothers laps at age 14 was 3.33, while boys sitting on their fathers laps at the same age was rated 2.52 (Harrison-Speake & Willis, 1995). In this example, we can see the decline of the perceived appropriateness of touch between parents and children as the children age, even between same sex dyads. This study revealed a certain cultural norm in America for parents to touch their children less as they age. However, the sample contained only Caucasian and African- American respondents, and the researchers found some effects of race on perceptions of appropriateness of touch. In general, Caucasians approved of touch between parents and children more than African-Americans (Salt, 1991). Specifically, touch that was initiated by fathers was found to be less appropriate by African-Americans (Salt, 1991). Therefore, additional research should be conducted to better ascertain the touch trends in different cultural groups. Therapists should be aware that touch norms vary by culture, age, gender, and race.

12 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 12 Another study investigated the effect of both gender and culture on touch patterns. The touch interactions of 120 people were observed in dance clubs in Rome, Prague, and Boston (Dibiase & Gunnoe, 2004). The participants, who were in their twenties, did not know they were being observed. The researchers attempted to identify differences between hand touches and non-hand touches by gender. They expected to find differences in touch patterns between the three cultures observed. They predicted the least, yet most equitable, amount of touch between American couples. Two observers recorded touches over a five-minute time period per individual observed. The results showed that the men observed initiated hand touching more frequently than women. However, women used non-hand touching significantly more than men. The hypothesis that Americans would touch less than the other two cultural groups was upheld by the data. These results indicate that touch behaviors are likely to be the product of socialization and thus will differ by culture (Dibiase & Gunnoe, 2004, p. 58). This study could be improved by increasing the sample size, including different age groups, and expanding to other cultural groups. Also, the relationship status of each couple could affect the results in unknown ways. The next study presented in this literature review adds information about the impact a couple s relationship status has on their touch patterns. Willis and Briggs (1992) investigated the meanings men and women attribute to touch and the effect relationship status has on touch patterns and the frequency of touch. The researchers observed 500 heterosexual couples in public recreational settings and counted the number of times each partner intentionally touched the other with his or her hand. The researchers approached each couple after observation and attempted to gain

13 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 13 information about the couple s relationship status. The three categories of relationship status were 1) dating or engaged, 2) married or cohabitating for less than one year, and 3) married or cohabitating for one year or more (Willis & Briggs, 1992, p. 58). Willis and Briggs (1992) discovered that couples who were dating/engaged or married/cohabitating for less than one year were more likely to touch each other than couples who were married/cohabitating for more than one year. Also, they uncovered differences in touch patterns between men and women that seemed to be related to their relationship status. Men were more likely to initiate touch in the engaged/dating and married/cohabitating for less than one year groups (Willis & Briggs, 1992, p. 59). However, in the group of couples who were married/cohabitating for more than one year, the women initiated the touch more frequently. Another result showed that the lowest frequency of touch occurred between the couples that had been married/cohabitating more than one year. This study could be improved if it took into consideration each partner s level of satisfaction with the relationship. The researchers did not ask the couples their age or any additional questions about their relationship. If the researchers had asked the couples for more details, richer conclusions could have been derived from this study, including possible correlations between relationship satisfaction, age, and the amount of touch between the partners. These studies have shown that these touch patterns are not constant, but that they tend to change over time and are influenced by cultural traditions and relationship status. Parents in the United States tend to touch their children less as they mature, and men have been shown to tend to touch their female companions less after marriage than during

14 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 14 their early courtship. These changes in touch patterns may influence the way individuals perceive their relationships and themselves. For example, the adolescent girl who is cuddled less than her younger sister may feel rejected by her parents. Many Americans seem to accepted as natural the adorable cuddly child growing into the sulky, rebellious, noncommunicative adolescent. However, much of this change in a teenager s personality is biologically based, and how much of this transformation might rather reflect the dramatic decrease in physical contact that is available between adults and children following the onset of puberty? (Hunter & Struve, 1997, p. 144). The wife whose husband reaches out to her less and less over the years may become inexplicably depressed. It is important for therapists to be aware of the acceptable touch patterns in their clients culture. Each cultural group has different norms related to touch, and the therapist would be remiss if he or she did not respect those norms when interacting with clients or when suggesting physical interactions between family members. This literature review will not present details on the cultural variations of touch patterns, and instead the recommendation is made to any therapist working in a multicultural setting to learn about each client s specific attitudes toward touch. Biopsychosocial Effects of Touch Research has demonstrated that the influence of touch reaches beyond mere communication of emotions. In the next section of this literature review, the biopsychosocial effects of touch, or lack thereof, will be explored. By understanding the mechanisms by which touch affects the mind and the body, marriage and family therapists can pinpoint techniques to help clients who are struggling with mental illness and relational difficulties. Research reveals the positive effects of touch therapy on the

15 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 15 behavior of children diagnosed with autism or attention deficit hyperactivity disorder, infant development, and responses to stress. Before delving into these studies, there will be a review of the biological development that is activated by physical touch. These specific studies measure the effects of experience-dependent growth, where synaptic growth occurs as a direct result of exposure to more individualized kinds of environmental events (Broderick & Blewitt, 2006, p. 73). Life experiences determine which synapses are maintained and which neural pathways are reinforced. Use it or lose it seems to be the mantra of neural pruning, which is the normal process of eliminating redundant or unused connections in the brain. Research has shown that physical stimulation has an influence on certain aspects of brain development. In an investigation of the behavior of female rats and their newborn pups, researchers measured the number of times each mother licked or groomed each pup (Diorio & Meaney, 2006). The babies of mothers whose grooming behavior was at least one standard deviation higher or lower than the median were compared in two ways. First, the startle response of each group was tested to see how the pups reacted to unexpected noises as well as how quickly the animals returned to the activities they were engaged in before they were startled. Researchers found a significant difference in the behavior between the two groups. The rats whose mothers were deemed high licking and grooming were less startled and more quickly returned to their previous activities, such as eating. These pups produced less of the stress hormone cortisol when confronted with stressful events. In contrast, the pups whose mothers licked and groomed less were much more startled. Sometimes these pups did not return to their activities for ten minutes or more and they produced much more of the stress hormone cortisol.

16 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 16 The researchers also assessed the biological causes of the different levels of cortisol production in these two groups. They found that the stimulation of the mothers licking and grooming actually changed the gene expression of the pups. The pups were born with approximately the same NGFI-A gene structure, which controls the growth and differentiation of cells in the hippocampus, but the two groups had different amounts of methylation at day six depending upon the grooming behavior of their mothers (Diorio & Meaney, 2006). The change in this gene impacts the pups startle response in later life. The hippocampus is involved in the stress response and is affected by cortisol. These findings suggest that sustained effects of maternal care on gene expression are caused by alterations of DNA methylation and chromatin structure at relevant promoter sites (Diorio & Meaney, 2006, p. 280). This study provides evidence linking the relationship between maternal care and infant brain development and behavior later in life. Infants who are held and caressed more by their caregivers may have less pronounced reactions to stress as adults because their hippocampi have different receptors for cortisol. Turning now to human studies, premature infants who are massaged by caregivers are more likely to gain weight and thrive than infants who are not massaged. Weight gain is critical for newborn health and it is one indicator that the baby is developing normally. Field (2001), the director of the Touch Research Institutes at the University of Miami School of Medicine who has contributed a great deal to the study of touch, has shown that premature infants who are massaged can gain 31-47% more weight than premature infants who are only held or lightly stroked. Several other physiological attributes were measured in the infants to determine if massage therapy had any additional effects. Again, a notable difference was the decrease in cortisol levels in the massaged infants.

17 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 17 The current social climate that allowed the preterm infant massage experiment to occur is much different than the zeitgeist that governed how children were treated in orphanages a century ago. Although institutions were benevolently created with the aim of helping poor children, they operated under the medical and social norms that forbade physical contact of any type between staff and children (Hunter & Struve, 1998). These practices lead to high mortality rates of institutionalized children. An investigation into the mortality rate of children in orphanages in America and Germany between the late 1800 s and the early 1900 s uncovered a link between high mortality and touch deprivation (Hunter & Struve, 1998). Retrospective studies found mortality rates between 32% and almost 100% for children during their first two years of life (Hunter & Struve, 1998). Even popular child rearing manuals of that era instructed parents to create more formal relationships with their children. Watson s 1928 guide entitled Psychological Care of Infant and Child advised: There is a sensible way of treating children. Treat them as though they were young adults Never hug and kiss them, never let them sit in your lap. If you must, kiss them once on the forehead when they say goodnight. While the formality of the recommended interaction may strike one as quite unfeeling, this was the child rearing advice many parents were reading in the 1920s and 1930s. However, in the 1930s, New York s Bellevue Hospital decided to break these societal conventions and began to allow staff to touch the children. Staff were encouraged to pick up, hold, and physically nurture every hospitalized baby several times each day. Miraculously, the mortality rate of children on the pediatric wards at Bellevue plummeted dramatically, dropping from well over 30% to under 10% (Hunter & Struve, 1998).

18 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 18 In addition, regular physical touch has been found to improve certain behaviors that are characteristically found in children with autism (Field, et al, 1997). The study consisted of a control group comprised of children who were held for 15 minutes twice each week by an adult volunteer and an experimental group composed of children who were routinely massaged for the same amount of time. The study found that either form of touch had the following effects on autistic children: improved attention span, less touch aversion, decreased off-task behavior, less orienting to irrelevant sounds, and decreased stereotypic behavior. Although massage was not shown to have an increased positive effect on the children as it did in the infant study, the conclusion points to touch therapy as a means of reducing certain behaviors associated with autism. These positive results may predict further improvement if the touch sessions were extended either by duration or frequency. The study could have used a larger sample size to strengthen its conclusion. It could also be expanded from the school where the experiment took place to the homes of the autistic children to see if parents could be taught similar techniques to help their children. The study could also be improved by assessing the progress of the children more frequently. The researchers observed the children s behavior on the first and last days of the study, but did not record observations of the children in the intervening four weeks. Many other things could have affected the children s behavior on the days the researchers observed for example, perhaps children typically behave differently on Mondays after a weekend at home than on other days of the week. The researchers did not provide enough detail for the reader to ascertain whether these situational variables were controlled. However, another study of children who were diagnosed with attention deficit hyperactivity disorder and received massage

19 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 19 therapy showed similar results (Field, 1998). The children who were massaged, in contrast to the control group who experienced relaxation therapy, had less fidgeting, were more on-task, and were more attentive in the classroom (Field, 1998). Studies investigating whether physical touch can mediate the effects of stressors on autonomic nervous functioning in adults have also been conducted. The autonomic nervous system is the part of the brain that unconsciously controls heart rate, blood pressure, and breathing, and it is responsive to environmental stressors (Broderick & Blewitt, 2006). Ditzen, et al, tested the effects of positive physical partner contact (neck and shoulder massage) on the levels of cortisol and heart rate in response to psychosocial stress in 67 heterosexual women (2007). The research hypothesized that women who experienced physical contact with their partners immediately preceding a stress test would have significantly lower cortisol and heart rate responses than women who received only positive verbal support from their partners or no partner interaction (Dietzen, et al, 2007, p. 565). The study also expected the participants reported feelings of anxiety and perception of the stressfulness of the test would be lower in the group that received physical contact with their partners. The results supported the hypothesis because the group that had positive physical contact with their partners had significantly lower cortisol levels and lower heart rates in comparison to the control group and the group that received verbal support. The hypothesis regarding anxiety and perception of the stressfulness of the test was not supported because all groups reported feeling less anxious after the test in comparison to their anxiety level before the test. The results indicate that physical touch as a couplespecific behavior might prevent higher cumulative overall health risk (e.g.,

20 The Role of Positive Physical Touch in Family Therapy Lebeck-Jobe 20 cardiovascular disease) caused by daily stress over time (Dietzen, et al, 2007, p. 570). These findings are significant to the marriage and family therapy field because they indicate that therapists may encourage positive physical contact between partners to help alleviate a client s anxiety. A similar study investigated the relationship between partner physical contact and heart rate and blood pressure levels. Cohabitating couples (74 women and 109 men) either held hands for 10 minutes and watched a romantic video and gave each other a 20 second hug or rested quietly for 10 minutes and 20 seconds. After the contact or rest, one partner performed a task of public speaking, which was considered stressful enough to raise a person s blood pressure. Researchers measured blood pressure and heart rate levels before, during, and after the public speaking event. They evaluated the data using unpaired t tests and ANCOVAs and determined that the partners who had held hands with their mates had significantly lower increases in blood pressure and heart rate than the non-contact group (Grewen, Anderson, Girdler, & Light, 2003). The heart rate and blood pressure of the participants who did not have positive physical contact with their partners was almost double those of the other group (Grewen, Anderson, Girdler, & Light, 2003). An important finding from this study is that men and women both benefited from positive physical contact from their partners. These results revealed that men derive a similar benefit from the touch of their partners. Other research has shown that women are more likely to derive a positive benefit from partner contact. The study could be improved if the researchers could demonstrate a protective effect of physical touch between couples after a significant delay between physical contact and a stressor.

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