Losing touch in social work practice.
Article Type: Report
Subject: Social workers (Ethical aspects)
Touch (Ethical aspects)
Psychotherapist and patient (Ethical aspects)
Therapist and patient (Ethical aspects)
Authors: McKinney, Kathleen G.
Kempson, Diane A.
Pub Date: 04/01/2012
Publication: Name: Social Work Publisher: Oxford University Press Audience: Academic Format: Magazine/Journal Subject: Sociology and social work Copyright: COPYRIGHT 2012 Oxford University Press ISSN: 0037-8046
Issue: Date: April, 2012 Source Volume: 57 Source Issue: 2
Topic: Event Code: 290 Public affairs Advertising Code: 91 Ethics
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 302403787
Full Text: Touch in social work practice may carry both positive and negative connotations. Although there are reasons to avoid the use of touch in practice, there are also reasons to address the topic of touch in working with clients. According to the NASW (2010) Code of Ethics (standard 1.10), social workers are not to engage in physical contact with clients if there is a risk of psychological harm. The use of touch needs to be exercised using "clear, appropriate, and culturally sensitive boundaries" (para. 1.10). It is possible that social workers may allow their fear of crossing professional boundaries (Reamer, 2003) to inhibit an important element of needed support, exploring with clients their recent experiences of gentle and respectful touch in their lives.

In an article addressing the debate over whether to touch young children in child care settings, Piper and Smith (2003) stated, "A moral panic has led to the production of guidelines that are concerned with protecting children from abuse and adults from false allegations, but where the needs of children are lost" (p. 890). This concern may inhibit work with adults as well. Given the basic necessity of touch in our lives, it seems important to ask our clients, "When is the last time you touched or have been touched with love and kindness?" This commentary explores the importance of touch in relationships and provides suggestions on integrating touch in social work practice.

IMPORTANCE OF TOUCH

The basis of much of our understanding of the importance of touch comes from research with animals. Montagu (1971) cited numerous animal studies demonstrating the importance of licking soon after birth. This licking seemed to elicit a necessary physiological response in newborn animals that promoted survival. For human infants, touch by caregivers may serve the same need (Feldman & Eidelman, 2007). The absence of touch in infancy has been shown to alter the physical structure of the brain and body, to lower IQ scores, and to increase abnormal types of behavior such as flat affect and stereotypical behaviors (Blackwell, 2000). "Stereotypical behaviors" are often seen when working with people diagnosed with autism. It is a repetition of behaviors that do not serve a purpose in a particular context (for example, clapping one's hands above one's head continuously without any apparent stimuli). Hammett (1921) and Harlow (1959) both discovered that if their experimental animals had been handled gently, as a mother might handle its young, the animals' abilities to handle stressful situations were far better than were those of animals not handled gently. Similar findings for human infants and young children who were orphaned have been found in observational studies (Skeels & Dye, 1939; Spitz, 1945).

TOUCH AS THERAPEUTIC

In recent touch research with humans, Dunbar (2010) has shown touch to be directly linked to the release of important neurochemicals in the brain, oxytocin and endorphins--both important in securing bonds and reducing felt pain. Tiffany Field (1998) (see also the Touch Research Institute Web site: http://www6.miami.edu/touch-research/) and her collaborators have published seminal findings on the beneficial effects of therapeutic massage on the growth of premature babies in neonatal intensive care (Field et al., 1986). The Touch Research Institute has conducted over 100 research studies on the therapeutic benefits of touch, and one of these benefits could be to recommend that clients explore whether massage might be indicated for their treatment goals. For a detailed description of the physiological response to massage therapy, see Field, Diego, and Hemandez-Reif (2007). In general, massage therapy has been shown to affect hormones and neurotransmitters in a positive, mental health-promoting way.

Strozier, Krizek, and Sale (2003) suggested that touch facilitates "getting in touch" with emotions that are not readily available to clients in psychotherapy, and they mention five situations in which touch is indicated: (1) for "symbohc mothering" when clients are not attuned to their ability to communicate verbally, (2) to encourage acceptance when clients are excessively self-depracating, (3) to bring clients back to reality when their feelings of anxiety are too overwhelming, (4) to explore aggressive feelings in a safe manner (for example, screaming obsenities in a pillow), and (5) to express genuine concern for and acceptance of clients. One need only scan the literature briefly to find recent work on the therapeutic effect of massage and healing touch in areas ranging from reducing the negative symptoms associated with cancer (Post-White et al., 2003) to helping older adults sleep when they are stressed (Nelson & Coyle, 2010). In addition, Kempson (2001, 2007) has shown that body work and touch modalities may be more beneficial than traditional psychotherapy (talk therapy) in working with complex posttraumatic stress disorders. Talk may be unavailable as a method for dealing with such disorders, or it may be retraumatizing; touch bypasses the need for engaging the brain in a cognitive process.

UNHEALTHY TOUCH

Although the therapeutic benefits of touch are extensive, one needs to consider the issue of unhealthy touch. Therapists and other professionals entrusted to work with clients have occasionally been implicated in sexual abuse (Disch & Avery, 2001; Kumar, 2000) and physical abuse (Hinshaw, 2007). Given this notoriety, it is not surprising that professionals broach the topic of touch with trepidation. However, recent data indicate that the majority of people receiving mental health treatment have experienced trauma during their lifetime (Cusack, Frueh, & Brady, 2004) and that one indicated treatment for trauma sufferers is massage (Macintosh & Whiffen, 2005). Thus, it is imperative to address touch in one's work with clients.

IMPLICATIONS FOR PRACTICE

Although touch can and has been used in unhealthy ways with clients, one must not overlook the value of touch in creating positive bonds or attachments (Ainsworth & Wittig, 1969; Bowlby, 1988) and how these attachments affect the kind and quality of relationships people experience throughout their lives (Bretherton, 1996). The integration of touch within the psychotherapeutic context is obviously fraught with multiple concerns. In spite of inherent complexities, a reconsideration of some clinicians' practice behaviors of "do not touch" is warranted. The social work profession could perhaps incorporate the biomedical ethical framework as a starting point for consideration of the use of touch within therapeutic situations. Under this framework professionals are required to keep foremost in their minds the principles of autonomy (self-determination), beneficence (promoting well-being), and nonmaleficence (doing no harm), with an emphasis on virtue ethics (character of the moral agent) (Wardell & Engebretson, 2001). We offer four suggestions regarding touch for practitioners to incorporate in their work regarding touch:

1. Think about your clients and reflect on how to explore with them whether they live part of their life being physically isolated from significant people in their lives and key attachment relationships.

2. Examine with your clients, if therapeutically possible, the set of circumstances that might explain the isolation and withdrawal from others they experience. It could be that unhealthy touch has affected their willingness to reach out to healthy people in their lives and resume healthy touching practices.

3. Work with your clients in establishing healthy touch in their lives. Intuition and clinical judgment are important guides in deciding whether to use self-reflection as a therapeutic technique. One of the deciding factors would be clients' life circumstances, such as the presence of physical and sexual abuse in their histories.

4. Explore as a professional how touch has affected your own life and how this may affect your willingness to discuss or recommend therapeutic touch with your clients. Fox (2007) outlined some excellent self-reflective questions that social workers can use in beginning to think about their own personal history of touch.

"Reaching out" carries a new connotation when we apply some of these suggestions to social work practice. Working to promote the holistic health of our clients invites us to place a keener focus on touch so as to promote the continuation of healthy attachment relationships.

Original manuscript received February 10, 2011

Accepted February 15, 2011

Advance Access Publication August 3, 2012

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Kathleen G. McKinney, PhD, is a mental health therapist, Touchstone Health Partners, Fort Collins, CO. Diane A. Kempson, PhD, is associate professor, Division of Social Work, University of Wyoming, Laramie. Address correspondence to Kathleen G. McKinney, 4217 Wellington Drive, Fort Collins, CO 80526; e-mail: mckinneykathy6@gmail.com.

doi: 10.1093/sw/sws036
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