Touch was a subject that came up with some frequency in my psychology training. Namely, how much and when is it appropriate to share more than a handshake with a patient?

Clinical psychologists, although by and large are a touchy feel-y lot, also tend to be behaviorally conservative around their patients. We want to maintain good boundaries. We don’t want to confuse folks about the nature of our relationship with them.

This is particularly true of patients who are hospitalized for severe psychiatric disorders. I spent 3 1/2 years of my graduate school training working with adults at the local state psychiatric hospital, located amid tobacco fields in rural North Carolina. The hospital has since closed.

There are three situations that come to mind related to this topic, the first two occurred during my very first year of graduate school. The third occurred at the end of my 3rd year of graduate school.

#1 The two ladies sitting on the front porch incident

As part of my adult assessment course, I practiced interviewing skills with an elderly woman on the gero-psychiatry unit. She had dementia and a history of psychiatric illness. I was a 25 year-old at the time. She thought I was a young neighbor who had come to visit her and that we were sitting on her front porch. At one point we moved from one part of the ward to the other. She held my hand while we walked. Although I had a little thought of “Am I going to get into trouble for this, my supervisor is watching,” my gut told me that it was appropriate. This is something that I had done with my grandmother and great aunts. I didn’t see the harm in it. At one point in the interview, this sweet confused lady remembered that her husband had died, an event that had occurred years and years previously. But due to her memory impairments, it was as if she were learning the news again for the first time. I reached out for her hand as she cried and held it until she was feeling better. It seemed the kindest thing to do at the time and fortunately, my supervisor agreed and told me he thought I’d acted very appropriately.

#2 The what-are-you-doing-in-my-face incident

This incident is actually worthy of a post of it’s own because there is a lot more to it. But I will keep it to the topic at hand. I was doing an assessment with a 27 year-old man with paranoid schizophrenia, the latter of which I would later learn from his chart. I also learned later from his chart that there was a specific behavior plan on file to deal with his sexually inappropriate behavior. (The onsite psychologist did not allow students to review charts prior to meeting patients. That is one reason that this incident is worthy of a full post. Supervisors, don’t do that. It is called “hazing trainees” in the guise of giving us an unbiased experience.)

Looking back it is actually comical now that the chairs in the room had wheels on the bottom. There was no one else in the room with us. He kept scooting his chair closer and closer to me, while I kept scooting back. And they were those super old WWII-issue chairs that are really squeaky. So his squeaks would be followed by my series of squeaks. Suffice to say, I was keeping a good eye on him.  But I had to look over to pick up a new Thematic Apperception Test card (a.k.a the TAT and it is a projective personality measure) and when I straightened up I saw that his face was RIGHT IN MY FACE.

I quickly stood up while putting my hand on his shoulder, firmly guiding him back into his chair, and saying, “That is not appropriate!”

He said, “I was just trying to kiss you.”

I said, “I know and that is not appropriate. You stay in your seat over there and don’t try to kiss me again!”

I was able to finish testing and the rest of the story is for another day. The moral of this story is that while it is okay to grasp the hand of a sweet old lady who just remembered that her husband died it is not okay to return the kiss of a 27 year-old horn dog, even if he has paranoid schizophrenia and an extremely hard time with boundaries.

Incident #3: The case of the disorderly orderly

I spent year 3 of graduate school working 16 hours/week at the hospital for my practicum placement. I primarily did assessments but one of the social workers asked me to do psychotherapy with Doris, a 58 year-old patient who had been hospitalized for the 30th time in 30 years. He just wanted someone to give her some experience in normal interaction and not get too fancy. I thought he made a pretty good argument and agreed to do it. (My supervisor, an onsite psychologist was very entertaining during supervision but that was more about constant joking and outrageous personality. He did not object.)

Fast forward to the end of the academic year. I had seen Doris twice a week for many months. I would not be returning to see her. I gave her a hug and we said our goodbyes.

I walked into the nurses’ station to write a progress note in her chart. Danny, one of the health care techs (what we used to call an “orderly”) had witnessed this exchange. My guess is that he was in his early 30’s at the time. I don’t know how to write a rural North Carolina accent anymore, not to mention that Danny always spoke with a cheek full of tobacco, but what follows is my best shot.

“Elizabeth, when do I get mah hug? Mah life would be so good if Ah got a hug from you evrah day.” Then he spat into the plastic cup he always carried to use as a portable spittoon.

Now, I actually liked Danny. He was good-hearted, made 13K a year, and in the extremely rare event that a patient became assaultive, he would be the one to save my hide. Danny was also not the first health tech to bend the boundaries with one of the young female psych students. My friends had similar experiences on occasion. It was particularly obnoxious on the mens’ wards when it was done in front of patients, thereby setting a very bad example of how to treat us. But again, there were the good-hearted and would save our skins factors to consider.

I touched Danny but it was not quite what he had in mind. I smiled, picked up his left hand by his wedding ring, and said, “Danny, if you feel that you are lacking a daily hug, I believe it’s time that you had a talk with YOUR WIFE.”

Touch is something we all need. But as a psychologist, sometimes it’s okay and sometimes it’s not. And by the way, my comfort with the contact always figures in, even if I think that the contact would be okay for the patient. I’m not expected to be a therapeutically indicated hand holding, hugging machine. Working with children, it is usually less complicated. Although I never initiate hugs, I will return one that’s offered. And that’s one of the best parts of my job.