Hugs, Not Drugs?

Dear Dr. Roth,

I work in a small mental health unit of a large hospital. I am educated and trained and specialize in addiction therapy, group dynamics, and group therapy. The group model of treatment is used on the unit, and includes medication education, brief therapy, family education, recreation therapy, and life skills. The only times individual sessions are used are during the nurse's assessment and a psychosocial assessment by me, and of course the psychiatrist's daily progress evaluation and assessment.

The admission criteria are suicidal ideation, suicide attempt, or grave disability, and support crisis intervention. More than half of our patients are under the influence of a substance when admitted, and many have a mental illness diagnosis. The average length of stay is three to five days.

Our unit consists of 12 to 16 beds. We have two therapists (I am one). Our staff includes recreation therapists, mental health technicians, and RNs. None claims to have a personal experience with addiction or recovery; a few will claim to have depression. No one except me shares an experience of addiction, which I often do within the group therapy context, especially about the value of 12-Step groups and therapy.

The majority of staff, including the nurses, has learned about mental health and addiction and group therapy on the job. I mention this because I believe a lack of education and training regarding group dynamics exacerbates the therapeutic dilemmas that often arise. One of those dilemmas is this: When is hugging therapeutic for a patient?

I believe the issue of hugging in our mental health crisis unit has more to do with the philosophy of nurses who see it as healing touch. Is it therapeutically valuable to our patients within a group context to be hugged by staff?

Within 12-Step groups, hugging has taken on a new complexity. Thirty-five years ago, as I reflect, “not hugging” was looked upon unfavorably in 12-Step groups. (“Why in the world would you not want a hug, or give one?”) Today, privacy and boundaries have come of age as a right and choice.

As a psychotherapist I don't hug patients. Safety is one reason. The other is that I believe the therapeutic value of group experience is jeopardized when a patient is singled out by physical contact. I believe it blurs the boundaries essential for therapeutic alliance for all, and influences staff splitting.

Please offer your opinion, and any research that addresses this treatment issue. Thank you.

Ann Gassaway, PsyD

Dear Ann,

• the impact on group psychotherapy of working in a short-term, acute-care setting;

• the importance of examining staff group dynamics when engaging in conjoint psychotherapy (two or more therapists involved in treatment); and

• maintenance of a focus on boundaries and feelings in relation to any interpersonal interactions, particularly physical touch.

I am impressed that a small mental health unit is able and willing to dedicate its resources to hire a therapist of your caliber and experience in group therapy and recovery from addiction. In my experience, the greatest challenge to working in an acute-care setting is keeping it simple. If we are able to examine openly the dynamics of relapse that led the patient to require acute intervention, then we have been tremendously successful. This examination calls for a serious commitment to staying in the “here and now” with confrontation and interpretation of what the patient is doing in the group at the moment that mirrors the relapse behavior. From the point of view of addictions treatment, we are working with a group almost exclusively dedicated to working the First Step.

With those premises, I would like to make a bold suggestion. I believe, based on your description, that the unit is underutilizing your talents. You mention that you spend part of your time doing individual psychosocial assessments, which I suspect other staff could more efficiently perform. You do not mention whether the staff themselves meet as a group to monitor their own dynamics and work on their own recovery.

The upside of a staff group working on the First Step with the patients is the constant infusion of awareness of powerlessness and unmanageability to break staff denial. The downside of this work is the absence of explicit indications of a Higher Power (as manifest in the staff group conscience) to restore the staff to sanity. Therefore, I hope you are willing to consider expanding your sense of the role you might play in leading a staff group. I understand and accept that the unit may or may not be willing to authorize you in this manner; I ask only that you be willing to enlarge your own vision.

I introduce the two previous points to return us to your primary question about hugging. I wonder whether the staff members on the unit are the ones who want and need to be hugged. You are likely, with your depth of experience working with dysfunctional family dynamics, to be quite sensitive to parents who justify using their children to satisfy needs they are ashamed of with the rationalization that the children need to be treated this way. The pressure to hug patients may trigger powerful reactions in you against this hugging. Given the fragile nature of most patients entering an acute-care setting, I would recommend utmost caution in all transactions that cross boundaries.

That being said, let's address the central question: “When is hugging therapeutic for a patient?” While I am not aware of any rigorous studies that bear directly on this issue, my primary association is to the studies on infants who are orphaned and cared for in institutions with minimal to no human touch. If they do not perish from “failure to thrive,” they emerge profoundly scarred emotionally and spiritually. I view human touch as similar to oxygen; that is, it is essential for survival.

The key elements to answering this question are who is engaging in the hugging, what is the context, are boundaries in place (are the hugs occurring in public?), and is there an opportunity for the feelings mobilized by the hugs to be expressed and worked with. Group therapy is therefore an ideal forum in which to make hugs available, but only if there are no coercion or expectation, rigorous observation of sexual boundaries, and caution about any hugs that cross lines of authority. Hugs between patients who are not potential sexual partners and that occur with multiple witnesses (including staff) are therefore the least likely to be traumatic.

Perhaps the best way to end this column is to share my experience of receiving your request for support, which for me is like getting an e-hug. So please keep the questions, comments, and feedback coming to me at jrothmd@juno.com.