"Intricate Tactile Sensitivity: A Key Variable in Western Integrative Bodywork." Saper, Clifford, and Mayer, Emeran, editors. The Biological Basis for Mind Body Interactions (Amsterdam: Elsevier, 2000); Prog Brain Res. vol.122: 479-90.


Intricate Tactile Sensitivity
A Key Variable in Western Integrative Bodywork

 

Summary

According to the founders and master teachers in major schools of Western Integrative Bodyworks, effective outcomes of the manipulative strategies characteristic of their schools cannot be attributed exclusively to any particular manipulative move or sequence of moves. The successful implementation of any specific therapeutic strategy is dependent on the degree to which an individual practitioner is able to learn and implement a kind of touch, Intricate Tactile Sensitivity ("ITS"), characterized by three qualities that are systematically taught in each of these schools: (1) discreteness; (2) pattern sensitivity; and (3) a sensitive contact between therapist and patient. Without demonstrating a proficiency in each of these skills, trainees are not considered ready to be authorized as practitioners of the individual method, and the applications of the methods themselves are not thought to be efficacious except randomly. Because these are learned tactile skills-not psychic, immaterial, or mental qualities-and because they are common to many therapeutic modalities, they are susceptible to outcome studies and to empirical investigations of their effects on the organism. Clinical examples of this kind of touch and its effects are presented from three different schools of bodywork: "Body-Mind Centering," "Rolfing," and"Continuum."

Western Integrative Bodyworks

During the past 150 years throughout the United States and Western Europe, there has been a widespread development and rapid proliferation of experiential approaches to the human body involving highly sophisticated methods of touch, body movement, and body awareness. They claim to have success with many kinds of symptoms, particularly chronic problems, that are impervious to mainstream therapeutic strategies. These schools of practical work have evolved largely outside the university and clinical worlds, in private studios and institutes. They include such methods as Rolfing, Feldenkrais, the F. M. Alexander Technique, Sensory Awareness, Craniosacral Therapy, Authentic Movement, Continuum, Body-Mind Centering, Rubenfeld Synergy, to name but a few. There are some ten thousand practitioners of these works seeing hundreds of patients each year. And yet, until recently, there has been little serious public information about these methods and, with few exceptions, virtually no research. (For a history of this movement and information about individual schools, see Johnson, 1995.) It is only in the recent years that there have been academic programs established to study these practices as a common field, along with international professional organizations, generalized standards of practice, a modest body of literature, and a collection of pilot studies (Austin, 1984, 1992; Bach-y-Rita, 1981; Barlow, 1952, 1955; Brown, 1991; Gutman, 1977; Hunt, 1977; Jones, 1963, 1965, 1970; Silverman, 1973; Weinberg, 1979; Wildman, 1986).

Outside investigators mistakenly lump these bodyworks together with other qualitatively different practices-massage, physical therapy, "laying on of hands"-leading to deficiencies in the design of studies to investigate them. The family of bodyworks analyzed here differ from these other kinds of practices in significant ways, one of which is the focus of this paper. Another common mistake on the part of outside investigators is to isolate an individual "move" or technique from the rich complex of a given method; for example, the Rolfing pelvic lift, or the Continuum knee micromovement. The application of that atomistic piece is subjected to outcome studies-for example, use of the pelvic lift in the treatment of chronic back pain. If successful, the atomized piece is investigated as to how it might be integrated into clinical medical practice. The problem with this approach is that it is constrained to an understanding of the narrowest range of efficacies. The focus on an isolated practice loses the wholeness of the method, and by doing so distorts the meaning and efficacy of the practice itself.

The groundbreaking work of the Touch Research Institute of the University of Miami Medical School has opened the door for the awareness of the significance of generalized attentive touch in addressing a wide variety of symptoms. In several studies, they have demonstrated the effectiveness of classical Swedish massage in the treatment of a wide range of problems, ranging from deficiencies in premature infants to stress in factory workers (Field, et al, 1996, 1997). This preliminary and pioneering work sets the stage for the design empirical studies that would make discernments among the many systematic methods of touch, and the wide range of skill developed by practitioners of touch.

There are a number of directions that might be taken in studying this significant therapeutic movement. The most obvious is outcome studies of claims made by each of the private institutes for the efficacy of their special techniques. For example, studies of the efficacy of Rolfing vs. other standard practices in the treatment of chronic low back-pain, or the efficacy of Feldenkrais vs. standard practices in the treatment of repetitive motion syndrome. These studies are indeed useful, and are going forward. There is nothing particularly challenging about that direction, aside from the daunting task of attracting funding necessary to do it.

And yet there is a potential for healing in the field viewed as a single therapeutic philosophy and system of technical methods. There are commonly held assumptions among these many schools, and thousands of practitioners, leading to common therapeutic strategies which have implications for health care and medical education beyond the specific contributions of any one school. Studies focused on these commonalities might lead to their dissemination among a much wider population than could be reached by any individual school of work.

This analysis has the goal of defining the unique characteristics of a peculiar kind of touch which is cultivated in these many different schools of Western Integrative Bodywork, identified here as Intricate Tactile Sensitivity (ITS). Because of its physical nature, and repeated use among a very large therapeutic community, ITS could serve as a more sophisticated focus for empirical studies. If this unique method of touch stands up to empirical scrutiny, it could prove to be of immense benefit not only to physicians and nurses, but to a wide population of informal caregivers, such as parents, and those who care for the aging and the dying.

The identification of ITS as a common and essential variable emerged during what is now an ongoing ten-year study seminar among founders or heirs of late founders of major schools of bodywork-Rolfing, F.M. Alexander, Feldenkrais, Continuum, Body-Mind Centering, Aston Patterning, Lomi Work, and Sensory Awareness. Despite differences of method and goals, sometimes radical and contentious, among these various schools, they share a claim that a particular kind of learned touch, described below, is essential to the efficacy of any of their particular methods of touching. Effective outcomes of the strategies characteristic of their schools cannot be attributed exclusively to any particular set of predefined manipulative moves. The efficacy of any particular move or sequence of manipulations is dependent on the presence of a specific kind of tactile sensitivity that is methodologically taught in each of these schools.

Because it creates a unique kind of intricate bodily connection between therapist and patient, ITS distinguishes this family of work from several other kinds of manipulative work-physical therapy, Swedish massage, Therapeutic Touch, chiropractic. At the same time, the physical quality of the skill distinguishes it from various forms of psychotherapy, which similarly aim at sensitive contact between therapist and patient, but with skills that are less susceptible to empirical analysis. The clinical and empirical investigation of this kind of touch provides a workable and promising access for studies of the efficacies and nature of these various approaches.

Clinical Descriptions of ITS

The kind of touch under analysis here is described in three excerpts from clinical narratives by members of the Somatics study group published in Groundworks: Narratives of Embodiment (Johnson, 1997).

Body-Mind Centering

"Body-Mind Centering" is a method of working with touch, body awareness, and movement created some thirty years ago by Bonnie Bainbridge Cohen (Cohen, 1993). The following excerpt is from a narrative written by Ms. Cohen about her work with a two-year-old infant, Robbie, who was brought to her by his parents in 1993. A year earlier, his baby-sitter dropped him down a flight of stairs. Both legs were broken, his right leg above the ankle in the growth center. It stopped growing. In the months of medical treatment that followed, he became terrified of doctors. His mother said that they could no longer even spell "d-o-c-t-o-r," without him becoming terribly upset. The family had driven from a great distance. When they came into the office, Robbie sat on his mother's lap, and Ms. Cohen put her hands gently on his foreleg. He screamed and kicked hysterically. She kept her hands gently on his leg and kept assuring him that she would not hurt him. After about five minutes he quieted down and Bonnie was able to work on him, as she describes here, and began to teach his parents how to work with him using this approach to sensitive touch:

I then began sharing with his mother and friend what I had been doing with my hands-on work with Robbie. It is extremely gentle and subtle. . . .

Changing the quality of touch in subtle ways can elicit different and equally subtle responses. The awareness of these intricate and complex interactions involves the perceiving of delicate changes in breathing, the expanding and condensing of the membranes of the cells in the different layers of tissues, and the flow of fluid between the cells. These activities establish the pathways of the micromovements throughout the body that create the blueprint for the movements of our body through space.

Attuning to this delicate process is the key. This process takes place within the cells of our bodies and is not easily obvious to others observing from the outside, because there is minimally perceptible change between us in either the practitioner's hands or in the client's body. . . . Deep transformation of tissue takes place when there is an ongoing dialogue between the practitioner and the client at the subtle level of the cellular matrix.

Ms. Cohen goes on to describe the kind of touch she has developed, and here uses with Robbie, with the help of two metaphors. First, she describes it as like the resonance created by two musicians playing in harmony:

From this underlying resonance, I then begin to exert microforces with my hands into the bone and feel how they are relayed through the bone. I notice if they are reflected back into my hand, carried forward into the same direction as my force, or shunted into another direction. My response is always in relationship to my sensation of the microforces reflected from the bone back to me.

She uses a second analogy of a bat's echolocation, by which the bat navigates by sending out an auditory signal that bounces back and guides its direction:

I both follow the present lines of flow in the bone and suggest through touch alternative pathways as possibilities, always with effortlessness of movement as a guiding principle. In the case of bone repatterning, my perception is that I am exploring the subtle pathways through which minute lines of force flow through the bones.

Because the family lived so far away, they were not able to work with Ms. Cohen for more than a few sessions. For that reason, she put particular emphasis on teaching his parents how to work with him at home. This is a significant point, because a central conclusion of this paper is that the kind of touch described here is not esoteric. Like the practice of mindfulness meditation disseminated so successfully by Jon Kabat-Zinn, described elsewhere in this volume, this touch can be widely taught to people who might benefit from employing it.

Three years later, x-rays indicated normal growth in the leg. Robbie continues to ask his parents to work on him in this way, and his parents report that he has become more gentle and loving since they have begun working with him in this way. (This paper does not have the intention of supporting efficacy claims of these narratives, but to elucidate the workings of each method so that such claims might be more accurately assessed.)

Rolfing

Rolfing is a well known and well documented method of deep connective tissue manipulation with roots in the old osteopathic community, named for its founder, Dr. Ida P. Rolf, who died in 1978 (Rolf, 1977; Johnson, 1977). Michael Salveson is one of the two original heirs of Ida Rolf's teaching heritage, the senior teacher for the Rolf Institute. In this narrative, he gives a lengthy description of how he went about his work in a session with a long-term patient, a middle-aged psychologist and author, who had sprained her right knee.

Hands on flesh; I put my hands above and below her right knee and I am filled with the sensations of her skin, the changes in density and temperature, the bias in the way the flesh subtly pulls my hands toward the outside of her knee joint, the way she is moving in there, the way she is not. I know that any displacement of a joint will create asymmetrical pulls in the tissues around the joint, especially in the ligaments, and that if I am attentive I will feel this. My hands hold her knee and I sink inside myself, moving confidently into my own experience of the inner, comfortable, nourishing silence. Now, I feel her more accurately, in more detail. Her knee is displaced. It is too open on the medial side, the inside of her knee. The femur has moved back, posterior, in relationship to the tibia. I am listening with my hands, without intention. My hands follow the direction of the strain in Tara's knee.

According to the standard manipulative tests for ligamentous integrity of the knee joint, Tara's knee is normal. There is no structural damage to the ligaments of her knee. Nothing is torn. But her knee is painful enough that she is not comfortable resting her weight on it. She sprained it and her knee has not returned to its previous "normal" condition. Although the ligaments and meniscus are intact, they are twisted out of place. I can feel this displacement in her knee joint. This is a subtle perception and something I have trained myself to feel.

Mr. Salveson's narrative is particularly instructive about the problems that arise when outcomes research is done too quickly without understanding the unique nature of the therapeutic modality under study. Rolfing is widely understood in terms of what is actually a recipe for novices, a formulaic sequence of manipulations typically implemented over a ten-session series, somewhat in the manner of a specific method of physical therapy. But, as Mr. Salveson accurately points out, it is not only, or even primarily, an objectivistic analysis of body structure and specific moves that characterized Dr. Rolf's teaching, but an intricacy of touch, trained to "listen" for clues from the patient's body as to how to move one's hands. He continues describing how this works:

Additionally, I am able to feel several slight motions under my hands. In order to feel this, I touch without any intention to change anything. I just listen with my hands. In order to do this, I become quiet and rest in my own inner silence. I need this silence in order to feel these subtle motions. What is most interesting is that my perception increases in acuity as my hands match the subtle forces that express the strain in her knee joint. I know the underlying anatomical structures, so I am able to interpret the slight distinctions my hands feel. I am familiar with the landscape.

Without my even noticing it, a movement starts up in Tara's knee. Slowly, almost imperceptibly, the bones of her upper and lower leg move further into the direction of the displacement created by the injury. I follow. Her knee moves to an extreme position and stops. I wait. After a few seconds, her knee moves out of the pattern of injury and toward normal. I follow. Another hesitation at the other extreme and the unwinding continues. After a few of these rhythmical movements, I feel the bones of her upper and lower leg move into a more normal relationship. The knee joint settles onto the table and the strain of the injury eases. It seems that my attention and my willingness to match the pattern of the injured knee joint have mobilized an inherent force that makes it possible for Tara's knee to return to a more normal position. Her knee seems to know where it belongs. It needed only a bit of intelligent attention and gentle urging to break the pattern of injury and trigger the release.

Italics are added in this paper to emphasize how different is the attitude Mr. Salveson embodies here, both from stereotypes of Rolfing as a therapy that "moves" body parts in often forceful ways into the "right" position, and from mainstream physical therapies that also have a more objectivistic attitude. The therapists in the tradition under analysis all share an assumption that the body has its own organic healing intelligence, which will reveal itself if given the proper stimulation. In that sense, ITS shares with other modalities, like psychotherapy, a deliberate and systematic use of the placebo effect in the sense of a studied attempt to evoke and enhance the self-healing capacities of the person under treatment. But it needs to be emphasized that "deliberate," "systematic,"and "studied" differentiate this kind of effect from the non-specific effects elicited by a kindly pat on the back or a sugar pill, more commonly associated with placebo. In the final section of this paper, it is argued that the repetitive and empirical nature of these strategies offers the possibility for advancing research design in the area of this kind of systematic appeal to self-healing mechanisms.

Salveson concludes:

I soften my touch, searching for her rhythm, the pulse in her knee joint. My left hand rolls inward. Her femur stirs again and starts the minute rocking that I know will lead to greater motility. The tibia moves slowly away from the femur, rolls in the other direction, and moves back toward the femur. A pulse starts up. Slowly the bones move away from each other. Slowly they move back toward each other. I follow this. The sensation in my hands is magnified in my awareness. Sensation flows in my arms and hands. I bring my attention to my belly. I dissolve everything that emerges in my experience. I wonder, I worry about depleting myself, using too much of my own energy. I have three more sessions to do today. I go down into the earth. Tara's knee pulses symmetrically along the longitudinal axis of her leg and twitches occasionally. I feel a flow, sensations moving under my hands down into her lower leg and ankle. We have reestablished the normal connections. The rhythmical motion in her knee continues on its own. Time to move on." (39f)

Continuum

Continuum is a school of body awareness developed thirty years ago by Emilie Conrad (Da'oud, 1995). In the excerpts below, Ms. Conrad describes her work with Barbara who had an auto accident in mid-1960s when she was eighteen years old. An extreme fracture of the 7th thoracic vertebra left her immobilized from there down. She met Ms. Conrad eleven years later in 1975, and has worked with her until now. At the outset of their work, Barbara was living in isolation, barely able to care for herself. Ms. Conrad describes her early work:

Besides teaching Barbara how to expand her breath and find a wealth of internal richly textured, subtle movements, I held my hands over her spine, sometimes actually touching her, and sometimes holding my hands a few inches above her spine, allowing for a more subtle energy flow. I knew from the research with Dr. Hunt that subtle movements can be transmitted from one person to another, particularly when rapport or empathy is present (Hunt, 1995). Through years of exploring, I was able to communicate these subtleties by touch. Our contact allowed Barbara to feel more discrete, intricate modalities of movement, as well as an abundance of new sensations. Her ability to feel herself moving from the inside was a revelation. She told me it was the first time she felt herself as whole. . . .

The hours that Barbara had spent so willingly learning to expand and diversify her breath had finally brought resilience to her brittle skeletal structure. The breaths and movements seemed to stimulate the fluids inside her bones. As she lay on her back, the movement would radiate from her hips into her seemingly frozen legs. When I touched her externally, I felt the rock-solid hardness of her leg, but inside, I could feel a warm and deep pulsation. As she breathed in a variety of ways, I pulsed her legs very gently, with just the slightest touch of my hands. I experimented with different pressures; interestingly, it was the lightest touch that seemed most effective. One day radiating wave motions could be felt in her legs -- not just pulsations, but rich undulations.

It was about a year into our process that her knees began to move-micro-movements encircling her entire knee area. . . Seemingly, they emerged from a deep source, modulating the skin and leaving it iridescent. Her knee had not flexed yet, but it moved, no doubt about that. I saw small quivers permeating her calf.

 

As Barbara gained strength, after weeks of micro-movements in her knees, we experimented with having her sit up and move her knees exclusively. (69,70)

 

1996. Barbara no longer qualifies as a paraplegic. Although she is not quite ambulatory, she has flexion in all her joints, she has quadricep articulation, and she has continuing strength and innovation in her legs, ankles, and feet. What was once an overly rigid spine poised like a bow continues to melt into refined and glorious mobility. Though not exactly walking, she has full movement capacity when not fully erect. We keep in mind that there was eleven years of atrophy before she began her healing process. We can also reflect on the fact that I never worked with the actual site of her injury. (78)

 

Ms. Conrad attributes the success of her work with Barbara to a kind of touch that evokes unsuspected, previously underutilized capacities for movement from an extremely damaged organism. Like Ms. Cohen's metaphor of two musicians working towards resonance, Ms. Conrad uses her highly sensitized touch to call forth new movements from Barbara's spine that are not affected by the damage.

 

Barbara's paintings flourish and grow. She has become a full-fledged artist. Her vibrant paintings. . . .have found an appreciative public. Barbara has been leading movement groups on her own, as well as working with clients privately, taking them through the process that she has been exploring. (78)

 

Definition of Intricate Tactile Sensitivity

The kind of touch described by these and other bodywork innovators encompasses three aspects that shape the training of practitioners of all of these methods:

 

1. Discreteness:

The learned ability to discriminate tactilely the intricate kinds of information being communicated from the patient to the toucher's hand:

micromovements in the patient's body,

variations in connective tissue densities from one region to another, and from one layer of the body to another deeper layer,

differences in tone at different levels of tissue,

temperature variations,

different pulsations,

ranges of reaction to differences in touch: resistances, vulnerabilities, excitations, receptivity, etc.

This skill is not unusual by comparison to more traditional healing systems: Taoist, Ayurvedic, Indigenous. Practitioners in those older traditions devote long years to the development of intricate sensibilities through meditation, martial arts, and various bodily practices. Their methods are based on highly skilled diagnosis of subtle information discerned through trained touch, smell, sight, and listening. They need to be able to distinguish a variety of pulses, the significance in changes in fingernails, tongue, hair, eyes. It is no accident that all of the founders and leading teachers in the schools under analysis here have engaged in long-time studies of one or another of these older traditions, and acknowledge their debt to their radical empiricism. In fact, many of these traditions in being digested by Western culture, have been abstracted and reduced in many cases, while these bodyworks preserve the old intricate empiricisms. For example, Taoist medicine, which includes herbal and dietary prescriptions, manipulative techniques, meditation practices, martial arts, and ethical practices, as well as needles and moxibustion, has been reduced in Western laboratory research to the use of needles. Teachers of these bodyworks, by contrast, acknowledge and incorporate the older multivariate understanding of healing systems.

 

2. Pattern sensitivity:

A pre-conceptual, pre-verbal tactile sensitivity to movements throughout large segments of the body.

Although this quality is difficult to describe in accurate language, and even more difficult to see how to construct designs for its empirical investigation, it is a common experience in ordinary living. Skill in the use of sports equipment, for example, requires the development of sensitivity to felt lines of connection between one's body, the instrument, and what the instrument contacts. The fly fisherman has to develop a felt, non-conceptual, non-visual sensitivity to the movements from the handle through the flexible rod, line, lure, cast, water, strike. Tactile sensitivity to this long chain of stimuli is crucial to land the trout. Similarly with tennis, golf, skiing, and a variety of activities, including working with tools like hammers and screw-drivers, where the skillful use of equipment, which extends the physical body, requires more than a sensitivity to the surface of contact. In a similar fashion, practitioners in all of these schools are trained to sense through their hands long chains of events. In lifting a patient's head, for example, one is sensitized to reactions throughout the torso and shoulder-girdle, even into the hips and legs.

 

3. A sensitive contact between therapist and patient:

This quality is a function of the first two in that the peculiar kind of contact between therapist and patient that occurs in these works is due to the intricacy of tactile contact between the two: it is not primarily psychological, psychic, or emotional-although it may include any of these. It creates a unique humane sense of connection between the two people that many claim has a profound effect on the sense of alienation caused by the effects of mind/body dualism on child-rearing and education. As such, it is related to the placebo effect in that it physically, sensually evokes a positive connection of the patient with the work of the therapist. Despite its redundance with the other two qualities, it deserves a place of its own to underline its unique role in this work, and because the founders and master teachers of these works all refer explicitly to this quality of contact.

Because ITS generates a unique kind of intricate bodily based contact between patient and therapist, a grounded and sane contact, it has often been contextualized within a psychological model. But many teachers of bodywork resist this move because they feel more affinity with biomedicine's focus on the physical body, which is often etherealized in clinical psychology. In this regard, the humanizing quality of this very physical skill responds very directly to the widely recognized need to humanize the climate of medical treatment. In the event that the efficacy of this kind of touch were more widely established, its introduction into medical education might have important results in creating a better climate for healing.

 

"Schools" and Method

It would be misleading to give the impression that ITS is taught as a separate item from the particular method that characterizes each school. Each school of work is characteristically different, partly in the way that practitioners are introduced to ITS. They each embody a particular range of the infinite possibilities of touch, both on the part of the toucher's potentials, and on the part of the enormous amount of data manifested in the touched client. Better known examples of this reality are found in the long training of practitioners of Chinese medicine who must learn to sense the five pulses; or the training of classical osteopaths who are trained to sense the pulsing of the cerebrospinal fluid. In the case of the three schools represented in the descriptions of ITS above, one finds these differences:

Rolfing: practitioners focus on learning to discern gradations in the fascial planes of the body at different depths of penetration; patterns in muscular and fascial fibrous webs, and resistances evoked from the patient as they are being touched in specifically different regions and depths.

 

Body-Mind Centering: highly analytical in its "listening" to different layers of the body: organs, fluids, bones. But its discernment does not involve "penetration."

 

Continuum: A more pure "listening" touch, non-analytic in attitude. It is similar in form to certain traditional systems of meditation which direct one's attention to whatever it is that is arising from moment to moment, without attempts to change it. In the case, instead of focusing on breath, thoughts, or feelings, the practitioner is focusing on the moment to moment sensations arising from touching the other person.

 

Despite these differences of focus, the shared basis is clear enough to make it possible to envision teaching this shared approach to touch to large populations of people, if it were experimentally validated as efficacious.

 

Intricate Kinesthetic and Proprioceptive Sensitivity

 

The systematic cultivation of sensitive touch in training practitioners of Western Integrative Bodyworks is accompanied by a parallel cultivation of intricate awareness of one's own body in moving, listening, feeling, and sensing. This training in overall bodily sensitivity is another factor that distinguishes these works from traditional massage training where the focus is exclusively on touch.

 

This cultivation of intricate sensitivity is not only a methodological element in the training of practitioners: it is also a quality elicited by the practitioner in the client, considered a basic element in healing. In any further analyses, this dimension, which touches on a much more sophisticated understanding of the placebo effect, would have to be elaborated. For a basic assumption of these various schools is that the education of the patient in more intricate levels of sensitivity provides the basis for healing, as in the case of Barbara working with Ms. Conrad.

 

Contrasts:

 

The nature of ITS is further illuminated by contrast with other kinds of touch with which it is often confused:

 

oPhysical therapy and chiropractic: the focus in these systems of manipulation is not on the development of tactile sensitivity as described here, but on the ability to detect deviations from normative anatomical structures, and tension patterns in the musculature of the patient. The training has a mental and analytical focus.

 

oTherapeutic touch and related methods put the emphasis on spiritual and moral attitudes. If one examines the explanations of therapeutic touch or various other hands-on healing practices, often originating within spiritual traditions, there is more focus on mental thoughts and images held by the practitioner than on the sophisticated refinement of physical and sensitive skill.

 

oSwedish massage . Swedish massage, still widely practiced and taught in its pure form, focuses on the implementation of specific kinds of moves in a formulaic sequence. In its classical European form, the emphasis is not on responding to the intricate data non-verbally communicated by the patient to the therapist's hands, but on the repeated sequence of predetermined strokes. From the standpoint of advances in research, it also needs to be recognized that "massage" is becoming increasingly difficult to define with any specificity. Newer massage schools have incorporated many other bodywork practices, some described here, into their work to such an extent that the work of any given massage practice is now often, like California cuisine, a blend of many hard-to-discern elements-traditional, new, and from many cultures.

 

oOrdinary touch of any kind combined with certain kinds of intention, visualization, mental imagery. Here again, the focus is attitudinal rather than on physical skills refined by long practice.

 

Confusions about these various modalities are leading to a misunderstanding of the nature of these works as they are submitted to outcome research protocols that neglect the key defining variables.

 

Challenges for Research Design

 

If one examines various studies of touch, both in animals and humans, there is a striking imbalance. On the side of empirical analysis, there is a brilliant intricacy of statistical reasoning, imaging techniques, mapping of mechanisms throughout the organism, and the analysis of the systemic interactions within the organism. But on the side of stimuli under investigation, one finds two factors that are disproportionately simplistic:

 

1. Only crude stimuli are being investigated: pinching, pinpricks, feathering, hot and cold strips, touch vs. withdrawal of touch, "attentive" vs "non-attentive" touching.

 

2. There is a tendency to lump all manipulative practices into overly simplistic categories-massage, "laying on of hands," physical therapy-which tend to blur significant differences, and distort an understanding of effects of these various kinds of practices on the organism.

 

From this perspective, it would seem that breakthroughs in research might happen if the intricacies of empirical analysis were matched by similarly intricate distinctions among qualitatively different systems of touch.

 

Methodical Cultivation

The seemingly intractable problem that confronts research design is that the kind of touch defined here is not formulaic, like the sequence of strokes in Swedish Massage or a particular method of physical therapy. Accomplished practitioners do not, in principle, follow predictable sequences of pre-established moves that can be put into a protocol. It is often said that these dimensions of bodywork are indeed valuable, but in the way that poetry is valuable, outside the realm of empirical study. The objection is also raised that the effects of these various works are due to idiosyncratic charisms of the founders, many of whom are indeed larger-than-life figures. Yet, each of the teachers in question claim that they learned this kind of touching contact between therapist and client, and that it is a teachable skill. Development of that skill occupies a large part of the training methods in each school. The kinds of touching described above are considered an essential component of the methods in question. Trainees in these schools of work are not authorized to practice until they give evidence of these qualities.

 

The response to charges that the kind of sensibility described here falls beyond the scope of empirical science lies in the nature of its methodical cultivation. What is at issue here is a classic instance of a phenomenon not yet fully accessible to empirical investigation, but potentially accessible to ingenious methods of research design. ITS is a widely repeated phenomenon that is embedded in the pedagogical methods of many training schools, utilized to judge the successful training of thousands of practitioners, and to evaluate the efficacy of working with particular kinds of human problems. This learned tactile skill is not in its essence psychic, immaterial, or mental. It involves hand-to-body contact, with careful attention to the sensible reactions that accompany the touching. It is an empirical reality, involving physical movements, susceptible-in principle at least, if not by currently accessible technologies-to instrumental detection. Although current methods of research design may not work for the kinds of phenomena described here, the existence of such a repetitive and widely recognized empirical reality certainly hold out the promise of breakthroughs in research methodology, as has always been the case in the history of science, where new phenomena were originally resistant to the old methods. It seems inappropriate to the scientific mentality to give up the attempt to study this phenomenon as it actually occurs.

 

Like mindfulness meditation, the cultivation of this touch involves a sustained practice of learning how to pay attention to specific realms of human experience. There is enormous body of anecdotal evidence, and a collection of pilot studies, that give promise that such a practice has unique therapeutic efficacy. Kabat-Zinn's model of applying mindfulness meditation in clinical settings, described in this volume, is applicable to the cultivation of ITS, which could be taught to large segments of the population: parents and caregivers of many kinds. Likewise, the pioneering work of Dr. Tiffany Field and her colleagues at the Touch Research Institute suggest ways of moving ahead in these areas.

 

Attentive-Inattentive Touch vs. ITS

 

The direction of moving into empirical studies of ITS are illuminated by its contrast between what investigators have already noted as differences between "attentive" and "inattentive" touch. Dr. Saul Schanberg, whose paper appears in this volume, told an illuminating story of an event that occurred at the Touch Research Institute during a study of the effects of touch on premature infants. At one point, they were finding anomalies in the results for which they could not account. He flew down to observe the actual work going on in the clinic and found that one of the nurses was distractedly touching her charges while chatting with other people. Upon investigation, it was her charges that were showing up with the anomalous results. What is particularly revealing about this story from the point of view of the methods under analysis in this paper is that a division between nurses who are "distractedly" touching, as contrasted with those who are not, is too crude a distinction, failing to take account of an long spectrum between full attention and complete distraction. Teachers of mindfulness meditation recognize that because so many variations exist in people's ability to be present, methods must be designed to educate people to become more mindful. In the same way, teachers of ITS recognize the enormous variations in a practitioner's ability to be attentive in touching his or her patients. There is a touch in which the person is so depressed or absorbed in his or her own troubles that even though an outside observer would think the person was attentively touching the other, the actual experience of the touch is one of distraction. Another person is so occupied with mentally assessing the patient, that he is paying virtually no attention to sensations in his hands.

 

There are, of course, many physicians, nurses, and psychologists who embody a kind and sensitive touch in their practice. But it is important, for the sake of understanding the significance of this analysis, to recognize that they come upon this touch randomly, because they had kind parents, were raised in an ethically grounded spiritual values, had good teachers, etc. These qualities are not preconditions for excellence and authority in the Western models of practice and education. A desensitized person is often more successful in this model than the kind and sensitive person, because medical training demands such individual aggressivity. To argue that it is enough to teach health practitioners to be "gentle" or "kind" in their touching is like saying that it is enough for a person untrained in scientific method simply to become more thoughtful in order to engage in science without acknowledging the enormous body of skills that need to be learned.

 

Future Possibilities for Research

 

The historical stage of understanding this large family of bodyworks is like the early stages of any of the natural sciences where the first stages require careful ferreting out and description of the phenomenon, trying to discern exactly what is here that deserves study. The hope of this paper is that the description of one phenomenon, ITS, that is characteristic of these many works opens the door for more illuminating and accurate empirical studies. Some designs might study the efficacy of this kind of touch as contrasted with other tactile systems-traditional Swedish massage, chiropractic, and specific methods of physical therapy-in relation to a widely studied chronic disease entities such as chronic low back pain, irritable bowel syndrome, or repetitive motion syndrome. If, in fact, the singular efficacy of this kind of touch can be established, other studies might be designed to ferret out the nature of the effects of this kind of touch on the organism itself. Most especially, it is the hope that any such studies will take seriously the conceptual frameworks of the experts in these strategies-more generously including them in the research design teams and using their work to break new conceptual ground-instead of attempting to fit empirically derived non-medical concepts into current medical categories.

 

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