Gerald Vest: Risk Management Prevents Healthy, Skillful, Ethical & Nourishing Touch    
 Risk Management Prevents Healthy, Skillful, Ethical & Nourishing Touch1 comment
picture11 Oct 2009 @ 15:08, by Gerald Vest

In his seminal work, Touching: The Human Significance of the Skin, Ashley Montagu (1971) brings together a vast array of studies shedding light on the role of skin and physical touch in human development. He goes on to illuminate how the sensory system, the skin, is the most important organ system of the body, because unlike other senses, a human being cannot survive without the physical and behavioral functions performed by the skin. "Among all the senses," Montagu states, "touch stands paramount" (1986, p. 17).

Several years ago, I created a Global Touch Project here on the NCN and developed a website to inform and to discuss our progress with our students, participants, instructors and partners.

Currently, our 15-Minute StressOut Program is doing great as we are introducing our soldiers (wounded warriors)to our healthy touch program so that we can visit Veteran's Homes and interact with our brothers/sisters who served in previous wars. Our soldiers have given over 100 stressouts, during 3 sessions, in the Ambrosio Gullen Veterans Home, El Paso, TX with the cooperation and leadership of Mr. Willie Brown, Activities Director, Virginia and other staff. We have over 25 soldiers & staff, either certified, or in the process of completing their requirements following last week's workshop.

I can tell you, it is a very 'touching,' moving, and a remarkable experience observing and participating in this Warrior StressOut activity. Initially, I introduce our "Warrior StressOut Video - Coming Home", and our "Guidelines for Safe, Skillful, Ethical and Nourishing Touch"; followed, by Mr. Brown's, Integrative & Generative Exercise Program with the Elder Vets and our contingency assisting.

We then hook up our soldiers, staff and volunteers with the residents, all in wheel chairs, and give them a "StressOut." We have a big screen TV that shows our Instructional DVD (step-by-step instructions) while I take them through the process of our Best Practice Program.

Following our session, participants are invited to share their experience. One of the spouses of an elder Veteran spoke out, as tears came down her face,-- "God Visited Us Today--Thank you all so very much."

While we are getting great results from our work throughout the country, many professionals and health, education and social service programs are still reluctant and fearful to use physical interaction to empower, strengthen, and improve the opportunities for their patients, clients, students and residents to improve the quality of their lives, health and relationships. The following article will hopefully address these issues of Risk Management prohibiting safe touch.

Read Dr. Zur's Homepage and Blogs to learn about the Myths of Touch, discussions by other professionals, and Guidelines for professionals and other helpers such as integrative practitioners, social workers, teachers, therapists, and counselors. Many of us believe that it is unethical to withdraw essential methods and approaches from clients and patients, especially when they are identified as Best Practice, like our 15-Minute StressOut Program that is always done with guidelines that include permission, witnesses present,and follow-up evaluations.

Please comment on this important contribution to our use of physical interaction for primary prevention and for empowering and treatment for stress, anxiety and depression. We know that we can reduce lonliness, isolation, medication, anger for residents and care givers in aging programs, hospitals, veteran's homes, nursing centers with safe, healthy touch. We can also ask why so many children feel "left out" and "drop out" of schools and family life.

Our best practice research by the Ameican Diabetes Association also demonstrates the effectiveness of reducing blood sugar levels of Diabetes patients while increasing quality of life indicators. I wish to thank Dr. Zur and the late Dr. Ashley Montagu for their courage and outstanding work in advancing knowledge, wisdom, love and truth that will set us free from ignorance, prejudice, fear and doubt about the use of healthy touch by all sentient beings.



Risk management has become one of the most influential forces in medicine in general including psychotherapy. Risk management is the process whereby therapists avoid certain behaviors and clinical interventions--not because they are clinically ill advised, unethical, harmful or wrong, but because they may appear improper in front of judges, juries, licensing boards or ethic committees. (Gutheil & Gabbard, 1993; Williams, 1997). While the conscientious and ethical therapist carefully weighs the possible risk of any therapeutic intervention, including touch, against its potential benefits, risk-management frightens us into avoiding all "risky behavior" regardless of the likely positive results (Bonitz, 2008; Lazarus, 1994, 1998; Williams, 1997; Zur, 2007a).

Touch has often been placed at the top of the 'Do not do' list. "From the viewpoint of current risk-management principles" Gutheil & Gabbard stated, "a handshake is about the limit of social physical contact at this time" (1993, p. 195). Similarly, WebMD (1992) announces "A Hug-Free Zone: The threat of lawsuits, the already strong language in the APA code, and the general litigiousness of society have prompted many therapists to erect barriers between themselves and their clients when it comes to any physical contact. No more hugs for a sobbing client. No encouraging pats on the back" (section 2, Para. 1).

Like male preschool teachers who no longer hug young children, or camp counselor who would no longer hold a child in their lap for fear of being accused of inappropriate sexual behavior, many therapists, for similar reasons based on fear, have generally abandoned the practice of touching their clients. Defensive medicine, fueled by fear, is the defining forces behind risk management practices. The teaching of risk management principles seems to dominate ethics classes in graduate school and legal-ethical continuing education workshops. They are the foundation of endless attorneys' columns in our professional organization newsletters and a more recent breed of risk management presentations at our professional conferences. In all these formats, we are told never to hug, pat or hold our clients. Basically, we are told not to touch beyond a handshake and when possible even to avoid a handshake too. Beware! We are told, the slightest deviation from these ersatz commandments will set us on the 'slippery slope' to perdition. But even if one has not slipped uncontrollably down the slippery slope, the sheer idea that an action may appear suspicious to licensing boards, ethics committee members, or to administrative or civil courts' judges is adequate motivation to avoid touching clients, children or adults all the same.

When we listen closely to the risk management dogma, it is clear that no one really disputes the scientific fact, and the common knowledge, that touch is one of the most elementary human ways to relate and can be a powerful method for healing. Nevertheless, we have been frightened out of employing touch and most other forms of boundary crossings, such as self-disclosure, home visits, accepting gifts, bartering and many other behaviors frowned upon by the so-called "risk management" experts. These experts' advice often goes specifically against the practices of humanistic, cognitive-behavioral, family, feminist and group therapists. Ironically, these are also the orientations most practiced by psychotherapists.

Misleadingly, many of these attorneys, ethicists and so called risk management experts have mislead the therapeutic community, clients and licensing boards and courts to believe that non-sexual touch is unethical and below the standard of care. Unlike most commonly held beliefs, boundary crossings, such as touch are neither unethical nor below the standard of care. Ethics codes of all major psychotherapy professional associations (e.g., AAMFT, 2002; ACA, 1996; APA, 2002; NASW, 2001) neither prohibit boundary crossings in general nor do they prohibit the use of appropriate touch in therapy. All psychotherapy professional codes of ethics view sexual or violent touch with a current client as unethical. For specific details refer to the 'ethics codes' stance on touch in therapy ( Zur, 2004).

The obvious question then becomes, "Why are behaviors and interventions, such as touch, that are known to be clinically helpful, as well as very natural elements of human interaction, banned from our practices or, at best, driven underground?" The answer lies primarily in the concept, practice and teaching of defensive medicine or risk management.

In principle, nothing is wrong with managing risk if it is done thoughtfully by applying sensible clinical judgment and employing critical thinking rather than paranoid thinking. There must also be a sound knowledge of the professional codes of ethics and laws of states. All actions and clinical interventions involve some risk. For that matter, we often forget that inaction can be risky and even damaging to clients, as well. For example, I have been working with a woman who, 10 years prior to our first session, lost her infant son in an automobile accident. In an emergency appointment with a psychiatrist right after the death of her son, as she sobbed uncontrollably, she begged him to hold her. He refused, citing something about professional boundaries. Instead, he prescribed Valium. Eight years later, addicted to Valium and alcohol, she began therapy with me. After an intense few months of therapy, we visited her son's grave. It was the first time she had visited the grave. There we stood, holding each other and both weeping as she finally started facing her baby's death and grieving for him and for her years lost in drugged denial. While the psychiatrist followed risk management guidelines to perfection, he also may have inflicted immense harm. Did he sacrifice his humanity and the core of his professional being, to heartless protocol?

All therapists may, of course, with due consideration, attempt to reduce their own risks and the risks to their clients when employing touch in therapy. This is especially important when working with cases involved borderline or dissociative proclivities. This attempt to reduce risk goes side by side with clinical integrity, relevant training, and sound employment of treatment plans. Appropriate, risk-benefit analysis, requires that therapists ask themselves basic questions, such as, "What is to be gained by employing touch and what is there to lose? What do I risk if I do not touch and what do I risk if I do?" It is very important that such an analysis be made for each client and each clinical situation taking into account the specific client's mental state, presenting problem, history, culture, personality, communal support, class, gender, etc. (Complete guidelines for the use of touch in therapy will be found at the end of this article.)

Malpractice insurance carriers represent the primary force behind risk management, or what some attorneys call "healthy defensiveness". While the actual likelihood of a lawsuit or of licensing discipline for psychotherapists is extremely low (Williams, 1997), in the rare event that it takes place, it can be very costly to the insurance company and emotionally and financially devastating to the practitioner. The rare, but nevertheless outrageously costly, judgments drive the malpractice insurance companies to advocate strict risk management practices and the avoidance of any behavior that may give a jury reason to suspect inappropriate behavior and levy an expensive penalty. Ironically, this strategy, as will be discussed later, is more likely to backfire on the insurance companies.

Aiding and abetting the insurance companies and attorneys has also fueled the risk management fire, inspiring paranoia and widespread instruction in risk avoidance behavior. Attorneys' advice columns seem to have become a regular feature in our professional journals. Scheduled sessions with legal professionals abound at our professional conferences. Often, without any clinical training whatsoever, they sternly give us long lists of what we should avoid. At the top of the list is, of course, "Do not touch!" Obviously the list does not stop there. They tell us never to leave the office even though going to an open space with an agoraphobic client, as part of a systematic desensitization is the appropriate, if not mandated, clinical intervention. They tell us never to socialize with clients even though it is often impossible to avoid doing so in rural areas and in small communities. They tell us never to share a meal with a client even though an "anorexic lunch" can be part of a perfectly executed family system-based treatment plan. When it comes down to it, risk management can be also defined as attorneys' advice overriding clinical judgment.

Risk management and the fear it induces effects not only mental health, but also our entire society. It is part of a bigger and more complex phenomenon: the American litigation explosion and the rights movement. Even though, as has been stated, litigation is rare in our profession, the mere possibility of such a consequence is daunting and affects us strongly. We have become a culture where everyone tramples everyone else in the fight for his or her rights and entitlements (Etzioni, 1987, Zur, 1994). While accountability is an important civic quality, this lawsuit-happy culture, combined with the culture of victims, creates an atmosphere of dread that changes the way we do (or don't do) business, play or healing. We all know about the playgrounds across the country that have been stripped of monkey bars, high slides and fun swings due to the thousands of lawsuits filed by parents after their children have 'gotten hurt' while playing. Ministers, teachers, and youth counselors avoid touching - especially children or women. People have actually sued McDonald's for the obesity resulting from too many Big Macs! Litigation gone wild, indeed.

Flowing directly from this trend, fear-induced risk management has driven physicians to practice defensive medicine' and to routinely order a huge number of diagnostic tests, such as lab and radiology investigations, not because they believe they are medically necessary but as part of their risk management strategy. The rationale is that the physician will not be accused of not having done everything in his power to rule out even the most unlikely diagnosis. Some estimate that doctors waste between $50 to $100 billion annually on defensive medicine. Shockingly, some also estimate that this is the amount that could buy health insurance for the 40 million uninsured Americans. While attorneys laugh all the way to the bank, our risk management-intoxicated, phobic culture ends up settling for inferior care of every kind; children are deprived of touch and opportunities for play; and spiraling medical costs continue to bankrupt the country.

One of the major concerns inherent in risk management is that fear induced, defensive behaviors, and the systematic avoidance of many behaviors have gradually stolen in through the back door to become the perceived standard of care in medicine and mental health (Zur, 2007a). The standard of care is not anything that can be found in a textbook; it evolves as more and more professionals adopt certain practices, which then achieve acceptance as the "standard" in the community. A prime example of how risk management affects the standard of care is the requirement that a woman chaperone be present during a gynecological pelvic exam. Besides providing some comfort to the female client, the chaperone's primary role is to protect the physician from false accusation, criminal complaint or lawsuit. The witness also reduces the risk that misconduct may occur. Before chaperoning became part of the standard of care, some women preferred not to have such a witness, especially if they had a long, trusting relationship with their physician or if the physician was a woman. However, today, not having a witness is considered practicing below the standard of care. The danger that we face in mental health these days is that more and more risk management proscriptions may metamorphose into the standard of care.

Bear in mind, though, that risk management is neither part of the ethics codes nor part of any treatment standard. Risk management is merely a set of precautions advocated by malpractice insurance vendors and attorneys, supposedly to minimize the chances of being sued. When it comes to touch, good treatment and good risk management may sometimes call for mutually exclusive decisions regarding a given client. For example, it would probably be good risk management never to touch children and for male therapists never to touch female clients. Most of us would agree that such risk management advice is utter nonsense, since helping those in need is a fundamental ingredient of the psychotherapy professions. This example, like the case of the psychiatrist who refused to hold the grieving mother, illustrates the faulty logic and drawbacks of risk management and its single-minded devotion to avoiding lawsuits and its equally single-minded lack of regard for the primary goals of our work.

We have seen how, over time, a new standard of care insinuates itself into psychotherapy. This results in a continuous rising of the risk management bar as to what constitutes acceptable clinical behavior. Expert witnesses have often encountered testimonies by prominent experts that boldly and falsely asserted that touch, like gifts, extending a session beyond the allotted time or bartering always fail to meet the standard of care (Williams 1997). Similarly and dangerously, many licensing boards have uncritically accepted risk management recommendations as their guidelines. Paradoxically and ironically, as the bar is raised and more interventions seem frowned upon by the boards, courts and attorneys, there is increased likelihood that insurance companies and therapists will be sued or sanctioned. Risk management, without any doubt, has come to haunt the insurance companies, an unforeseen retribution for their shortsighted, cost-saving strategies. Sadly, it also impacts our profession negatively and often reduces our creativity and effectiveness, thus depriving our clients of the fullest measure of care.

The fear campaign by the insurance carriers, attorneys and many ethicists and "risk management experts" has too often succeeded in paralyzing therapists and forcing them to restrict themselves to rigid and constipated ways of relating to clients and avoiding any physical contact with their clients. As a result, clinical effectiveness is compromised. The danger that risk management poses to clinical effectiveness can be clearly seen in its injunction against touch which obviously has a significant negative effect on therapeutic alliance, the number one predictor of effective therapy (Lambert, 1991). We cannot think of any more effective ways to enhance therapeutic alliance then a reassuring or comforting hug, pat or hand holding. All of this may not be effective 'risk management', but it is basic good therapy.

Very regrettably, most professional organizations have jumped on the bandwagon and joined the fear campaign. They promote the practice of defensive medicine through their own risk management workshops and seminars. Some, as we see monthly, have given attorneys a regular column in their newsletters or journals where this paranoiac thinking is disseminated. As risk management becomes more prevalent, its effect is clearly seen on new therapists. In the numerous Ethics with Soul workshops I have conducted across the country, I (O.Z.) have noted that older (non-analytically oriented) therapists seem to be less concerned about risk management practices. The opposite is true of the new graduates. Alarmingly, through the fault of most graduate schools and their ethics professors, many of the newer therapists believe that risk management practices are part of the standard of care.

In summary, a risk managed practice may sound as if it adheres to practical or pragmatic advice but, in fact, it is a misnomer for a practice in which fear of attorneys and boards, rather than feeling, caring and intelligent clinical considerations, determine the course of therapy. As therapists, we are trained, hired and paid to provide the best care possible for clients. We are not paid to act defensively. This fear of board investigations and malpractice lawsuits pushes therapists to take protective measures. Consequently, we lower the quality of care for our clients.

Arnold Lazarus (1994) appropriately claims, "One of the worst professional or ethical violations is that of permitting current risk management principles to take precedence over humane interventions." Clinical interventions must be determined by empirically-based treatment plans, clinicians' intuitive and creative sensitivities, and specific client factors, such as the client's problems, situation, personality, degree of functionality, history, and culture -- never by fear of boards and courts. We must remember that the therapeutic effect of touch has been scientifically and clinically proven. We must also remember that we are hired to help rather than being hired to practice risk management. Therefore we must touch clients when appropriate in a way that will help them grow and heal.

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1 comment

5 Nov 2009 @ 13:57 by jerryvest : Our Warriors appreciate it when people
thank them for the service to our Country. When you see a man or woman in uniform let them know that you appreciate the sacrifice that they have made. I work in a trauma center and know first hand how injured and wounded our soldiers are. It is a miracle that many of their marriages have made it as most of those I know have served 2-5 tours of duty. One of my warriors mentioned that during the past 3 years he has only been with his family for a few months. These wars have been just as invisible as we rarely see any news related to them--just body counts.  

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