Almost 35 years ago I was a direct care worker in a state psychiatric hospital for children and adolescents. In those days, the length of time in care could be up to or even longer than two years. One of my favorite times to work was the 3-11 shift, working with children as young as 5 and as old as 10. During that shift, I was “on the unit” when they returned from school . My job was to facilitate afternoon activities, share and manage dinner, facilitate evening activities, and supervise clean up before bedtime.
My favorite time though, was after all the children had changed into their pajamas and were waiting in their rooms for us to tuck them in. Each child had an opportunity to choose a person from among the 2-3 staff working to be the person to tuck them in. When chosen, it was our task to respond to the bedtime request, which was limited to three choices: story, lotion, or powder.
All of us knew what that meant. A child could ask for us to read a bedtime story, to rub a back with lotion, or to rub a back with powder. Sometimes, if time allowed, there was a story and a before bedtime backrub. It was a ritual there, and bedtime seemed to be the most vulnerable of times for our children. It was, perhaps, the time we functioned most as parents, which included the requisite bedtime story, backrub and hug before turning off the lights. We heard some of our children’s scariest memories at these times, and received some of their most fierce hugs. If I dare say, it was the most magical of times in our role as direct service workers.
Touch In Today’s World
I can’t imagine sharing these same experiences in today’s world. There would be an instant throat clearing and calls for us to supervision. Administrators would ensure we understood the policies of the organization around touch, which in many instances would translate to: “Don’t touch clients.” The world has certainly changed in 30 years. We have much more knowledge and information about abuse, mandated reporting, and awareness around what we need to do to ensure that children—people—remain safe in our care. So much of what we know now, compared to what we knew then, makes us better clinicians. I’m afraid, however, that all we have learned about abuse that makes us better clinicians, has also come at the cost of losing some of what also makes us human.
Policies that exist now around touch, ethical guidelines around touch, and even some of our values around touch—in the name of safety—are sometimes more about liability and risk management. Even in working with adults, it is safer to have a policy of “no touch” than to leave any space open for the possibility of touch. It’s confusing to learn that our most powerful tool is our relationship with our clients, yet at the same time, we are conditioned to be overly cautious about touch. It’s almost as though we are encouraged to develop a therapeutic relationship that is as intimate as possible, as long as we don’t make physical contact.
I’ve consulted at child welfare and youth service agencies where the policy says hugging is allowed as long as it is a “side hug.” Or a variation of that is that “side hugging” is only allowed up to a certain age and then there should be no hugging. I’m wondering when there will be a policy that says we can only “Oprah Hug:” that strange front facing two handed holding of our hands shaking them up and down while maintaining a distance of 2-3 feet from one another. I smile as I think about the absurdity of that, while at the same time understanding the need for caution both legally and therapeutically.
Those Who Touch
In well-known psychiatrist Irvin Yalom’s book “The Gift of Therapy” he has one chapter that is entitled “Don’t Be Afraid of Touching Your Patient.” In this chapter, he says he makes a point of engaging in some sort of touch with each client at some point during each therapy appointment. He talks about the shaking of a hand, patting a back as someone leaves the office, holding a hand when asked, or hugging a person when asked. Of course he offers the caveat of not engaging in touch when there are concerns about sexual feelings, but says he is explicit in his decision not to touch in those situations.
Child trauma expert Bruce Perry, in his book “The Boy Who Was Raised as a Dog” also talks about the importance of touch. A specialist in childhood trauma, Perry discusses the misuse of therapies that force touch upon children, but also discusses the importance of allowing a young child to receive safe and comforting physical touch. He makes a point of stating how important this is and how much potential it has to expedite therapy and provide for corrective experiences. Of course, he too, like Yalom, has circumstances when he will not engage in touch, but these are more the exception than the rule.
When I am teaching graduate students in social work, the subject of touch comes up often. My students are engaged in an internship (field placement) while they are taking classes so the policies of the field placement and/or their supervisor at the field placement are often brought into the classroom. Depending upon the placement and theoretical orientation of the supervisor, some students are taught that touch is never appropriate and is almost always a boundary violation. Others are provided with a little room to maneuver, though often the question of touch is so overanalyzed that the placement has ended before the decision has been reached whether or not touch might occur.
I understand why we have become so cautious about touch. And I think being able to support why any interaction is warranted, including touch, helps us learn and be more intentional about our work. At the same time, I am concerned when we are cautious solely because we are fearful about legal ramifications or cautious because we are concerned others will see us as unboundaried or unprofessional.
Touch As Corrective
Sherry was a 35-year-old woman with whom I had worked for a number of years. She had been brutally and repeatedly assaulted by an uncle as a child and adolescent. It wasn’t until young adulthood that the assaults stopped due to her uncle’s death. Her parents knew nothing of the assaults, and while Sherry held down a responsible job, her abilities to trust had been severely compromised.
Despite all of this, she slowly developed a sense of trust in her therapy. Still, she sat quite a distance from me in therapy, rarely made eye contact, and spoke softly—in an almost childlike voice. I distinctly remember the moment when she slowly scooted closer to me and asked if I would bring my hand closer to hers. I complied. Several times over several months she made the same request to which I always complied. After doing this a number of times, she asked if I would put my hand palm up and if she could put her hand on top of mine. I complied. And as she gently laid her hand on top of mine, tears streamed down her face. There was no conversation. We sat with her hand on mine, until toward the end of the session, she slowly removed it, quietly thanking me before she left my office.
I had been seeing Ron for almost 10 years and we had perhaps shaken hands on one or two occasions. He was also a survivor of childhood trauma and, like Sherry, struggled with trust and intimacy in relationships. At 40 years old, he had never had a long term or sustained relationship. He believed when things were going smoothly, something bad was sure to happen and rather than wait it out, he often ended the relationship before he could be hurt.
During one session, we talked more about this pattern and for some reason, during this particular session, he deeply connected with the part of himself that yearned for a relationship. As I walked him to the door he spontaneously hugged me and quickly left the waiting area. At the beginning of his next session, we talked about the hug. Ron seemed more distant than usual until I shared that the spontaneous hug at the end of his last session did not mean there was any expectation that he hug me again. It was entirely his decision. And as I spoke those words, he visibly relaxed.
I have had other clients over the years—men, women, gay, straight, survivors of abuse and those who have perpetrated abuse, who have at some point in our work together asked for a hug, have shaken my hand, touched my arm, or whose shoulder or back I have patted as they left my office. Like Yalom, we have intentionally discussed these moments of physical contact when they first occurred or when it has seemed like a pattern of handshaking might need to be interrupted based on the content of a session or when the therapeutic relationship had moments in which safety felt compromised for some reason.
The Metaphorical Back Rub
In some ways, I yearn for the innocence of 30 years ago, when I worked in that child and adolescent psychiatric hospital, and I could tuck a little boy or girl into bed at night, read a story, and offer lotion or powder or a brief back rub before bedtime. I understand why those moments don’t exist as they used to. I hope, however, that we can also recognize we can’t indiscriminately divorce touch from intimacy in our relationships in therapy. Not everyone will want or benefit from touch, but with those for whom it is soothing and even corrective, I hope the presumed benefit will outweigh our fear.
Even as I write this final paragraph, I am aware of my anxiety in posting this. I anticipate there are those who will challenge my thinking, ask if I am receiving supervision, or accuse me of meeting my own needs rather than my clients’ around issues of touch. Several things that are absolutely true: when Sherry placed her hand on top of mine and she cried, it was a huge step for her toward her ability to accept safe physical contact and I felt incredibly honored. I also felt better about myself and my work.
And your arm felt nice wrapped ‘round my shoulder, And I had a feeling that I belonged. I had a feeling I could be someone, be someone, be someone …
—Tracy Chapman (Fast Car)
Written by Jeff Levy, LCSW, CTRS