January/February 2016 Issue
Touch and Self-Disclosure With Clients — Into the Ethical Minefield
Sandy, a 68-year-old woman, is shaking as she talks about the death of her daughter. She's avoiding eye contact but looks at me momentarily. When I see the pain in her face I have an impulse to reach out my hand, nonverbally inviting her to place her hand in mine. I resist the impulse, question my resistance, and the moment is lost.
How could such a simple thing, an invitation to touch, to feel support from another human being during a time of pain be so fraught with complexity? The dictate was drilled into my head when I was training as a social worker: Never touch a client. Over the years, though, I've had a growing sense that such a broad injunction, though generally sensible, may be too categorical a proscription to encompass every single client situation.
It was one of two prohibitions I received, the other being never self-disclose anything to clients. I have modified the latter based on clinical experience suggesting to me that self-disclosure, under limited circumstances and when used responsibly and with discernment, can be useful to some clients. Although I have never initiated the use of touch with a client, I have also modified this prohibition in cases where a client requests a hug or a touch of the hand in situations where the context appears appropriate and boundaries seem clear.
There is no question that disclosing information about one's life to a client is a potential minefield. If done reflexively or for the wrong reasons it can easily confuse or undermine relationships, raise troubling ethical issues, blur important boundaries, and stir transference and countertransference in ways that can cause harm. Shifting the focus from a client to ourselves can call into question whether the client's needs and concerns are taking a backseat to our own and raise red flags about whether there is something about the nature of our client's struggles that is triggering us, or with which we are overidentifying.
The same cautions apply to touch, which is laden with the potential to confuse a relationship, trigger old wounds and defenses, or send unintended messages ("You can't handle this without me stepping in to soothe"; "I can't be trusted to respect your boundaries.") For clients with histories of physical or sexual abuse, or those who have challenges with physical or personal boundaries or confusion around issues of intimacy, touch can be especially charged.
Immovable Lines in the Sand?
Politely refusing to touch or answer questions about my life did make it less likely I'd get drawn into the minefield, but it also allowed me to see the potential drawbacks of an approach in which information that may be important to some clients, such as a time-limited, contextually appropriate moment of physical contact with a caring other, or an occasional willingness to share a personal experience with the intention of bringing insight or comfort, are viewed as automatic boundary violations, poor clinical practice, and even unethical.
As such drawbacks became apparent, I began to wonder if there were ever instances in which touch or self-disclosure, when offered with a focus on clients' needs, done with self-awareness and within the bounds of a specific and narrowly defined context, might be a source of healing and support.
Given the variety of settings and client populations served by social workers, touch and self-disclosure can seem infinitely nuanced and there are many who, understandably, defend the longstanding global prohibitions. Complicating this issue further is the fact that some agencies and institutions are so risk-adverse that little or no flexibility is available for even considering the potential clinical value of touch. I suspect that in some settings and clinical contexts, absolute prohibitions make sense. In the practice setting of hospice care, though, I have come to believe that if we are controlled and intentional about when, why, and how we use self-disclosure and limited client-initiated touch, and if we closely monitor our inner states to ensure that our motivation is focused on the well-being of our clients, these can strengthen the relationship without blurring boundaries and can lead to insight and enhanced coping, when done well and used sparingly.
Not surprisingly, these topics have been a source of reflection, conversation, and debate within our field, especially in recent years. Writing about self-disclosure in a January 2011 article in Social Work Today, Frederic Reamer, PhD, states: "Handled skillfully, judicious self-disclosure can enhance clients' sense of reciprocity in the clinical relationship, strengthen the therapeutic alliance, facilitate client trust, contribute to a more collaborative worker-client relationship, provide the client with a powerful role model, demonstrate the universality of human frailty, and normalize the client's challenges. Many social workers believe that carefully considered self-disclosure can be therapeutically useful and a key element in clients' clinical journey."
Regarding touch, a clinical update from the Zur Institute ("To Touch or Not To Touch") notes that mental health and counseling professionals using touch within the context of a therapeutic alliance must always carefully consider "clients' factors, such as presenting problems and symptoms, personal touch and sexual history, ability to differentiate types of touch, and the client's level of ability to assertively identify and protect his or her boundaries, as well as the gender and cultural influences of both the client and the therapist."
Though some might argue that there is always the possibility of psychological harm, the language illustrates receptivity to the ways that, when used responsibly, touch might occasionally make clinical sense, perhaps by helping a client stay grounded or feel less isolated or overwhelmed. Amidst the relentless individualism of our culture, touch can also send the potentially powerful message: "You don't have to do this alone."
There came a time in my practice when, for some clients, the potential benefits of sharing a story or disclosure from my life, or responding when a client asked for a hug, seemed to outweigh the potential risks. I began, cautiously and in close consultation with clinical peers and supervisors, to introduce flexibility in my responses to some clients among those who broached the subject by asking me a direct question about my life or reaching out for my hand. In select cases where I assessed the potential risk to be relatively low that a client would become confused about the meaning, content, or intention of touch or self-disclosure, and when it seemed these might bring connection or help a client gain perspective, normalize thoughts or feelings, or reduce a sense of aloneness, I responded.
This might mean that I held a person's hand when they reached for my own or gave them a hug when they extended their arms in what appeared to be a contextually appropriate gesture. It might mean that when a brokenhearted spouse looked at me and asked if I had ever experienced the death of a loved one, instead of deflecting or turning the question back on him or her, I responded honestly, communicating warmth and empathy, then moved away from any further self-focus.
As I gathered information, I compared those times I'd assessed that it was okay to use client-initiated touch or self-disclosure with the outcomes when I had done so, recalibrating or affirming the need for caution in instances when it appeared not to work, noting the many cases in which it did and the nature of the positive impact. As I improved at knowing when and how to engage clients in these areas, I began, in rare instances, initiating, rather than waiting for the client to initiate selective, brief self-disclosure. Before doing so I would always ask myself why I was doing it, what the potential risks were, how it might be misunderstood, how it might help a client, and whether there was any chance that my ego or an unconscious agenda might be at play.
An example of such a social worker-initiated disclosure involves a young couple I was working with who were providing home care for a terminally ill parent. They were at loggerheads with their 14-year-old son whose perceived irritability, isolation, and poor communication was creating tension and conflict. At one point I offered a short personal reflection on what it had been like for me being a teenage boy and how situations that were confusing and frightening could easily trigger the kinds of behavior patterns they were describing. I made it clear I was not rationalizing, excusing, or directly equating my experience with their son's, just offering the reflection. When the couple considered that fear might be beneath the surface behavior, they were able to feel empathy for the confusion and maturational challenges that often attend the teenage years and they were able to consider new ways of responding to what had appeared to be merely personal attacks from their son.
By then, my comfort level had also grown with contextually appropriate, client-initiated touch. Maybe there's something about death that opens people up to impulses to hug the social worker or hold his or her hand. Maybe it was the sad looks on the faces of those clients who had wanted hugs and not gotten them. These experiences showed me the potential value of touch to convey connection, warmth, empathy, strength, and accompaniment.
Though I've never initiated touch, recently, as in my session with Sandy, I've been sensing moments when offering physical contact without waiting for a client to initiate it might make sense. I know social workers who touch, and social workers—the majority—who don't. Some models of psychotherapy recoil from it; others, like Hakomi and somatic experiencing, encourage it in very specific situations if permission is given and it is done with mindfulness and respect.
As with self-disclosure, when it comes to touch, social workers seem divided between those who primarily see the risks and emphasize client protection, and those who, though they generally acknowledge the risks and the need to be cautious, believe that the possibilities in some instances outweigh the potential risks.
Critics could rightly point out that, even in cases when I'm convinced that limited self-disclosure or client-initiated touch will be productive, I do not know for sure; but neither do they know that it won't. This uncertainty is probably why global prohibitions can be so appealing. The problem is that these tend to view every client/social worker interaction from the perspective of what might be lost, who might be harmed, without considering what might be gained if the context, intention, and intervention all align in favor of taking the risk. I respect those who stand by these prohibitions as impermeable, but at least in some clinical settings, I believe that the potential benefits should be considered.
I don't know where my current questions about social worker-initiated touch will lead, but I do know the traditional warning against it is there for good reasons. Knowing if and when to engage clients on a more intimate and human level requires those elements our profession strives to embody—knowledge, respect, other-centeredness, sensitivity, ethics, skill, kindness, and a willingness to work hard to know ourselves so that when we serve others who have lost their way, we do not lose our own. It must also be said that using these dimensions with clients requires training and experience, something historical prohibitions have often made difficult to obtain. I constantly remind myself to move slowly and, when in doubt, err on the side of caution.
Self-disclosure and touch are not techniques I will ever use in anything but small doses. I still encourage new social workers to steer clear of them entirely, though we talk about how they may emerge in their practices as they gain knowledge and experience. When I do step into the minefield, it is not done impulsively, and the intention is always focused on the well-being of the client.
In the article by Reamer mentioned earlier, he offers excellent questions a social worker should always ask him- or herself prior to any self-disclosure—questions that should also be among those asked when considering touch: Why am I doing this? Whose needs are being met? What is the potential benefit and what are the potential risks to the client? How would a panel of my peers view this self-disclosure? How much should be shared? Should the self-disclosure be processed with the client? In addition to these, I always ask myself if there are any factors I'm aware of about the client's history that would preclude such interventions, and I assess the context for situational factors that could be problematic.
Sandy is wiping her eyes with a tissue. She puts the tissue in her lap. Her arms and hands move nervously as though looking for a place to land. My mind homes in on a few clinical questions it might be helpful to ask. She taps a hand on the arm of the chair. If I were a neighbor sitting in her kitchen, I would probably reach out my hand, but I'm her social worker. Even though I sense the potential usefulness of touch, we have not explicitly, and in advance, agreed on what those "clear, appropriate, and culturally sensitive boundaries" should look like. I lean forward, hands in my lap, and ask her a clinical question.
— J. Scott Janssen, MSW, LCSW, is a social worker with the Hospice and Palliative Care Center of Alamance-Caswell in Burlington, NC.