CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
MASSAGE AS ADJUNCTIVE THERAPY FOR INCEST VICTIMS:
A BODY-MIND APPROACH
A thesis submitted in partial satisfaction of the requirements for the degree of Master of Arts in
Educational Psychology, Counseling and Guidance
by
Mary Ann Denman
December, 1984 The Thesis of Mary Ann Denman is approved:
--.,1':.·~------~----;--~-r------Dr. Richard Thiel (Advisor)
-L------~------~------Barbara Farber, M.A. -v·~..::;"k'""""..£1..:4:::~.A.--'------'--=o~------ Dr. Bernard Nisenholz California State University, Northridge ii ACKNOWLEDGEMENTS This thesis is dedicated to my parents, for their continuous love. I would like to acknowledge: Patricia Ann Murphy; for inspiration, Eli Luria; 'for his generous monetary contribution and moral support, Ken Hubbard and Alison Call; for their support, patience and word processing know-how, Debra McKay for stirring up my gumption, The therapists, masseuses and subjects in the study for their contribution, Dr. James Prescott for the use of his questionnaire and help in planning the study design, My committee members and friends for their insight and continuing encouragement, and Michael Aronsohn for being by my side. iii TABLE OF CONTENTS ACKNOWLEDGEMENTS iii LIST OF TABLES vi ABSTRACT vii CHAF'TEF; 1 INTRODUCTION • 1 Purpose of the Study 2 Statement of the Problem • 2 L1mitations of the Study . 17 Summary 18 REVIEW OF THE LITERATURE 19 Documentation for the Necessity for Touch 19 History of Body-mind Approaches 27 Documentation by Massage Experts • 38 Research Precedents for this Study • . 47 Incest Description of the topic •• 52 Statistics Prevalence in the population 54 Character of the incestuous family. 55 Why is incest destructive?. 58 iv Chapter· Hypothesis • 60 Definition of Terms 61 Summary 62 3 1'"1ETHODOLOGY' 64 Reseat-ch Design 64 Subjects 65 Treatment Program 66 Instruments 67 Collection of Data • 72 Treatment of Data 74 4 RESEARCH RESULTS • 75 5 DISCUSSION 86 BIBLIOGRAPHY . 89 APPENDICES . 94 APPENDIX A . 95 APPENDIX B . • 102 APPENDIX C • 106 v LIST OF TABLES Table i: ANCOVA on Body-Related Self-Image . • 77 !able 2: ANCOVA on Profile of Mood States • 78 Table :.:; : ANCOVA on Index of Human Affection 79 Table 4: Means and Standard Deviations for B-R 5-I • • 80 lable 5: Means and Standard Deviations for POMS • 81 Table 6: Means and Standard Deviations for IHA . 8 -·? Table 7: B-R S-I Extra Items: Behavioral and Health-Related Measures; per cent Improvement . 83 Table 8: Observation Forms for Therapists: Number of "Points" Improvement . . 84 "i able 9: Observation Forms for Masseuses: Number of "Points" Improvement • • 85 vi . I ABSTRACT MASSAGE AS ADJUNCTIVE THERAPY FOR INCEST VICTIMS: A BODY-MIND APPROACH by Mary Ann Denman Master of Arts in Educational Psychology There is a growing need for powerful therapeutic modalities for the victims of sexual abuse. Incest is particularly damaging to the victim in terms of body image. The efficacy of massage as an adjunct to therapy was reviewed in the literature and studied with a quasi-experimental, pretest-posttest, comparative research design. Ten experimental subjects and six control subjects were drawn from two incest therapy groups of adult women, ages 24-40, who experienced incest as children. The control group received approximately four months of group work based on a particular format of incest therapy. The experimental vii group received the same as well as four individual, hour-long sessions with a trained masseuse. The measures used were the Body-Related Self-Image Questionnaire, the Profile of Mood States and the Index of Human Affection. Additional data was generated with observation forms completed by the therapists and masseuses. The results of an analysis of covariance of the major test scores showed no statistically significant difference between the two groups. Means and additional data indicated slight trend toward greater improvement among the experimental group. These results suggest that the research is headed in the right direction but that changes in the design would be in order. Major flaws were sample size, lack of random selection and assignment of subjects, and length of treatment program. viii Chapter- 1 INTRODUCTION AND STATEMENT OF THE PROBLEt1 Introduction Recent media attention has brought to light the problems and widespread incidence of child abuse, and incest in particular. It is becoming less of a risk to admit publicly to having been abused; therefore, many people are bringing their experiences from the past or present to medical, psychological and social work personnel. Some very effective treatment modalities have been and are being utilized, and yet more aid is needed in educating the helping professions to expand the range of available treatment for victims of sexual abuse. Coming from a background of individual, group and family counseling and from experience in bodywork therapies, this writer sees the combination of body and mind approaches as potentially very powerful. Child abuse is an abuse of power and a betrayal of trust which is inflicted physically as to-Jell as emotionally. It seems logical to approach such multi-level damage with well-integrated therapy. 1 2 Purpose of the Studv The purpose of this study is to provide information as to whether· the addition of massage, as individually and professionally applied, may speed or make more effective a particular group therapy process with victims of sexual abuse. Statement of the Problem Women who have been sexually abused can be found to have difficulties in many areas. The major devastating result is a lowering of self-esteem (Butler, 1978; Forward, 1979). The main defense against se::>~ual abuse is dissociation, which can cause distortion in body-image, barriers to trust, sexual dysfunctioni and somatization (Burgess, Groth, Holstrom & Sgroi, 1978; Herman & Hirschman, 1981). Some of the most common physical symptoms are severe headaches, nightmares, stomach problems, upsets in sleeping and eating habits, and various gynecological and/or sexual problems The ultimate purpose of this study is to increase the efficacy of treatment programs for victims of sexual abuse. Treatment programs that work will be examined and additional treatment in the form of bodywork will be suggested, if such is shown by the results of the study to be a beneficial adjunct. There are several well-known and published professionals and professional groups who have had a great deal of success working with victims and families of sexual abuse. Among these are Dr. Roland Summit and his group at UCLA, Dr. Suzanne Sgroi and her group in Suffield, Connecticut, Dr. Judith Herman with the Women,s Health Collective in Somerville, Massachusetts, Lucy Berliner at the Harborview Sexual Assault Center in Seattle, Washington, Dr. Susan Forward in Encino, California, Dr. Susan Kuhner of the Institute for Multiple Personalities in N. Hollywood~ and kee MacFarlane and others at Children's International Institute in Los Angeles. Probably best known is the Child Sexual Abuse Treatment Program Hank and Anna Giarretto in Santa Clara County, CA. The CSATP model has been used widely (and by some of the above -I groups) with a high degree of success. The Parents United (as well as Daughters and Sons United) groups were begun 4 along with this program and contribute greatly to the effective treatment. The CSATP purports to have a very low recidivism rate for perpetrators of incest who have been through the program. Part of the effectiveness of the program lies in the fact that the center works together with law enforcement and other social agencies. The offenders are usually mandated to attend the program as a diversionary program, instead of spending time in prison with no counseling. This aids greatly not only in community awareness and cooperation, but also in effecting powerful treatment plans with incest offenders who are typically hard to treat. Group therapy is well-known as probably the most effective therapeutic tool for treating families in which sexual abuse has occurred. It is especially potent in treating the victims. People learn quickly from peer response and honest confrontation how their behavior is per~eived by others. They learn to match that with their self-perceptions, and in the process of straightening out their identity, learn to interact more effectively with other people. In group they are supported, seen through by others yet still 1 oved, confronted., encouraged to share their deepest feelings, and challenged to grow. This is not to say that individual therapy is not needed; on the contrary, the individual therapy relationship creates the 5 foundation upon which the group experience may build. The group therapy portion of this study will follow the CSATP format of the groups. These deal with issues of adults who are now bringing up their childhood molestation The groups seem to work best when they are time-limited and have carefully delineated boundaries and structure. In this section are outlined four treatment issues in working with incest survivors, followed by a discussion of how group therapy works with each issue and what impact might be expected from massage work as adjunctive treatment. Please see Chapter 2, the Incest Section, for a more complete discussion of the literature on damage done by incest, and citation of the work of previous researchers on the subject. The perspectives on group work and massage come similarly from the literature discussed in Chapter 2 as well as from the experience of the researcher. 1. Disruption of trust a. Issue Incest victims typically have a very difficult time trusting. If molested by a father or other male figure, they do not trust men because their early, natural trust was violated. If the mother was either a participant or a "silent partner" against the daughter at the time of the disclosure, the daughter will have a great deal of anger, fear and feelings of betrayal toward her, and therefore, tend to mistrust women in general as well. Victims may be further traumatized by public knowledge of the situation and by public testimony which, although it is now being improved upon, can still be painful and embarrasing to the victim. As adults, this trust problem can be reflected in an enmeshment of the family of origin where there is too much fusion and not enough differentiation between· the members, or in an extreme severing of the family ties. Another pattern is ambiguity which can cause fluctuation between enmeshment and alienation. Similar difficulties can be seen in spousal relationships where trust is slow to form and the incest survivor may be pulled by fear to distance herself from her partner or feel a need to fuse with him in whatever way she knows how. b. Group work Group work with incest victims can have a very positive effect upon this lack of trust. Ideally, the woman first has a relationship with a woman therapist who is skilled and knowledgeable about incest dynamics. A woman therapist is commonly seen as preferable because she is usually more attuned to women's issues, does not represent the aggressor, 7 and may provide a safer atmosphere in which the client may reveal herself- The therapist builds a rapport with the woman, and then brings her into group. A group of women who are dealing with the issue of sexual abuse is especially effective because the women point out each other's coping patterns. Interestingly, they can become enraged at the experiences of the others even before they can feel anger at their own aggressors. This, coupled with the universality of the experiences of guilt, betrayal, feeling worthless and used, and the honesty with which the members relate, can build trust within the group very quickly. c. Body work . I Massage, in encouraging the differentiation between sensuality and sexuality, in promoting knowledge and awareness of one's body, and in the development of a trusting relationship that is enhanced by massive amounts of gentle touching, can aid greatly in the establishment of trust. lhe masseuse needs to be well-informed about incest as well as naturally open and compassionate herself. It is recommended that the massage be done by a woman and not a man to provide a safer atmosphere for the female incest victim. 2~ Dissociation a. Issue Dissociation is one of the strongest defense 8 mechanisms~ and it is a very effective one. A friend talked of her conscious dissociative experience, saying that while she was being molested by her father, she mentally withdrew from her body and entered the wall. From there she watched what was happening to her body. In this way she could avoid the feelings her body was having and pretend it wasn't happening to her. approximately March 1982.> Dissociation is not always this conscious a choice; however, it is nearly always one of the defenses employed. Unfortunately, the separation between one's intellect and one s feelings, resulting in the repression of unacceptable emotions, seems clearly related to various physical as well as psychological ailments. (separating from reality) and can lead to severe dissociative disorders like fugue states and multiple personalities. Health problems that are typically understood as "psychosomatic .. (resulting more from psychological distress than from organic imbalances> betray dissociation also. This is also known as "somatization"; the enactment of psychological distress in physical, or "somatic", form. Especially common in incest victims are respiratory, 9 gastrointestinal, gynecological and musculoskeletal problems, migraines, nightmares, sexual dysfunctions, eating disorders (either overweight or anorexia/bulimia), anxiety, phobic behavior, lethargy, substance abuse, and depression- One busy clinician whose caseload consists primarily of work with sexual abuse claims that she has not yet worked with any incest survivor who does not have at least one gynecological problem and/or symptom Farber, personal communication, February 1, 1984-> b. Group work Group is a very difficult place to dissociate in secret. The climate of intimacy (in terms of honesty and tr-ansl uc.ence > which is fostered in group leads the participants not only to know one another well, but to recognize what's going on with one another- Incest survivors are also typically very good at reading people and extremely sensitive to mood and affect- Therefore., di !:?,soci at ion, be it as mild as taking a short mental trip, will be more noticed in a group like this than in more common social situations. This awareness., coupled with a great deal of loving support and compassion, can coax an incest victim to stay in the real world for greater lengths of time. She may then begin to experience her feelings and share them a bit more. The process within the group whereby the shared feelings lead to greater closeness and 10 understanding between the women may, although it is frightening, become more attractive since it fulfills a deep human need. Resistances are strong to feeling for quite awhile. The women usually fear that their emotions are intense enough to flood and possibly drown them, and so they are often careful to keep them dammed up. The group will help to retrain them to push past this fear and reap the benefits of closeness. The other women in the group will be able to share their experiences and insights with psychosomatic illness. Once the dissociation is lessened, the physical aspects should improve. c. Body work Massage is a wonderful tool to help a person get in closer contact with her body. People experiencing massage are frequently surprised to discover areas of tension, tenderness, and pleasure that had remained out of their conscious awareness. This closer knowledge of the body can lead to a higher degree of self~understanding and self-acceptance as well as insight into health and emotions. The masseuses' insights, observations and questions can help the client with relaxation and breathing skills, with reality-testing her body-image, and with simple body awareness. For example, let us imagine that a woman comes to a masseuse for her first massage. She may discover something about herself in several areas: ll 0 . Whether she allows herself to breathe deeply or only shallowly, or perhaps she finds that she often holds her breath. 2. Whether she has obvious patterns of tension in her body (i.e. the left side may be held chronically tighter than the right; she might not be able to stand to have her knees touched; her feet may be ticklish; her neck might feel ahungt-y" for touch, etc.) 3. Haw she experiences pain and pleasure; what happens if a spat is painful or pleasurable; does she relax and e>-lperience it, or tighten up against it? What feelings are associated with experiencing pleasure, and with pain? 4. Does she seem to want to know about her body, \<~hat the masseuse thinks, what connections might apply to health or emotions? 5. Does she like her body? Are there parts she likes or dislikes? These considerations are all ways of becoming more intimately involved with one's own body. The closer the association, the less dissociation is possible. It is difficult to be closely related to one's body without growing in tune with feelings as well. Touch, communicated by a gentle, compassionate and professional person can go a long way toward dissolving dissociation and clearing the way for self-knowledge and, ultimately, self-compassion. 12 ~1 ' :5. Self -esteem a. issue The dynamics within incestuous famililes create low self-esteem in the children. \This pattern is more fully explained in Chapter 2, the section on Incest.) The children feel starved for attention and approval of any sort, and therefore are set up to be victimized. They are not likely to turn down the offer of an adult or older friend to have "a special friendship" or "play a secret game". Once the Bbuse begins, they may feel incapable of ·taking a stand against it. The victimization then compounds their low self-esteem, and sets a precedent for repeated victimization. This can be evidenced in abusive marriage or work situations, rape, and transgenerational incest. The self-hatred which arises out of the low self-esteem is often acted out in self-destructive behavior such as substance abuse, suicidal ideation and attempts, battered wife syndt-ome, etc. The issues in therapy, then, are to aid the clients to realize that they continue to play the role of victim, and help them change that role. b. Group work Therapy in group is wonderful with victims because the members are quick to pinpoint each others· tendencies toward "martyr" behaviors and attitudes. Also., by simultaneously 13 understanding the symptoms and feelings behind them, they are very supportive and caring for one another. Nothing is better for self-esteem than for a person to show what she thinks is her worst side, and then, not only not to be rejected, but to be loved all the more for it! Also, in group the women learn to set reasonable, attainable goals for themselves, the fulfillment of which is another boost for self-appreciation and respect. The group leaders provide healthy role-modeling for self-determined, effective functioning which encourages each member to stay and continue her work on herself. Probably the most important step a woman incest victim can take is to redirect the rage she feels toward her aggressor and the people who didn't protect her from it. She has been turning this rage inward and feeling guilty for it, and now needs to put it where it belongs. This is the most important part of de-victimizing herself and will go a tremendous distance toward helping her feel better about herself. Watching other women go through this process and hearing their words of encouragement can help her through this wrenching and important experience. The process involves becoming aware of the rage, being realistic about the situation ~nd placing blame where it belongs through such techniques as letter-writing, role-play and actual confrontation within the family of origin. 14 c. Body work The power of body work with low self-esteem issues lies in the self-awareness which it fosters. The more a woman becomes familiar with her body's dynamics, the less a foreign force it is, the more it "fits" with the rest of her experience, and the more compassion she can gain for how her body has learned to deal with her life experiences. When she can feel in tune with her body and sensitive to its messages, she will feel better about herself in general. The massage work may be scary at first, because it begins to uncover what feels like a bottomless pit of neediness. ~Jhat she will discover, however, is that the pit has a bottom and that she can begin, by caring for herself in many gentle ways, to fill it up. 4. Control a. Issue Control is an important issue in treating victims of se~ believed, not the child; the child will be blamed; or that the child will be hurt or killed if she tells. So an essential concept for her to become in touch with as an adult is that she can learn to take control of her life in positive ways. Incest victims usually grow up having put forward a good facade all along, and idealizing their families, all the while feeling like worthless imposters. They seem to keep their lives together, to say and do all the right things, and to be very sweet, and yet are inwardly very angry and despairing. Many women spend their lives looking for the good parents they didn't have, for someone to take goad care of them. They cannot be fully functioning adults until the incest therapy is complete, since they still feel like needy children inside. b. Group work Group therapy provides probably the best place for one to drop one's facades. Although it feels unsafe at first, people learn over and over that their real selves, the parts they spend so much energy hiding, are lovable after all. When a person can lay out all her faults and what she calls her weaknesses Control over herself becomes less important. She is then 16 able to concentrate more on taking good care of her own needs, becoming actually her own good parent, and allowing herself the healing experiences of expressing her deepest feelings to other people. In this way she can free her energies to deal more effectively with her life. c. Body work Control is one of the more noticeable issues dealt with by massage work. During a massage, it becomes evident how much tension a person is experiencing physically. Through increased self-awareness and the feedback from the masseuse, a woman learns how much and where she holds herself in checJ~. She may have certain resistances in areas that were touched during incestuous contact, such as belly or inner thighs, that are no longer necessary. She may have a fantasy that to relax is somehow to invite danger. She may think that to breathe in deeply is to somehow give her environment too much influence over her, and she wants to shut out influence rather than to let it in. She will learn how much she controls her breathing and whether she allows herself as much air as her body wants. A gradual learning process is possible wherein she begins to control more consciously the degree of relaxation she allows herself. This loosening up of her body has gradual and sometimes even immediate results both in her feeling states and in her physical health. This connection, if explained only in a 17 physiological framework~ lies in the increased blood flow to all areas of the body including the brain, which encourages more complete function mentally and physically. Increased metabolic function aids the body in preventing and fighting disease, and increases the freedom of mental processes as well. It can only be surmised the extent of the positive emotional benefits that massage offers. lhis study is limited in several ways. First, the sample is small. The experimental group consists of ten subjects, and the control group has six subjects. The research design is simple, the length of treatment is short, and the measure of body-related self-image is previously untested. The sample was chosen, and not randomly, from the two groups oriented around sexual abuse operating in a small town, and therefore may not be generalizable to a larger population. The results could be affected by other influences from the community, since it is impossible to control for effects had on the subjects by books, TV, media, classes and other life experiences during the time of the experiment. The masseuses were chosen subjectively by their skill 18 r . and personal qualities. All were trained at the same school and used a standardized massage sequence, but there is no way to control for the effects of different personalities on the subjects or to standardize any conversation taking place during the treatment program. Women who have been sexually abused as children display a range of symptoms which cuts across the board diagnostically. Of special importance is their body image~ as it correspondingly affects their mental, physical and emotional well-being. The use of bodywork is seen by this writer as a powerful adjunct to present treatment procedures. This study attempts to explore the possible efficacy of just one mode of body therapy as an adjunct to group counseling. The group counseling has been shown to be highly effective in itself, as is evident from the work of Judith Herman (1981), Susan Forward (1979), Jean Good~"'lin (1982>, and others, yet perhaps there are ways to expand and speed that effectiveness. If bodywork could be shown to help people learn to trust their bodies again, to help counter some of the dissociation, and to teach that touch can be given in a healing, non-demand way, and speed the effective treatment of incest victims. ,, . Chapter 2 REVIEW OF THE LITERATURE Introduction This chapter will cover five general areas of background interest to this study. The areas are: Doc.~m~n!.~ti oQ__fo.!:_ nec~ssi ty of touch !jj. s_tory_E.f_ body-mind the~ approache!§i_ Doc.~::_fl_l~nt.:kti_on by massage experts Research Precedents for this study Incest The literature covering each area of interest will be briefly summarized due to the vast amount of material on each subject. Ashley Montagu, a well-known and prolific anthropologist, wrote an entire book called Touching: the Human Significance of the Skin. (1971). In it he outlines the tremendous importance of cutaneous stimulation to the physiological and behavioral health of mammals and other 19 20 animals. Lack of bonding, immediately after birth of the offspring in many mammals (involving licking, nuzzling and nursing behaviors> disrupts normal physical and behavioral development. He cites several fascinating studies with animals; a few are the following: Denenberg and Whimbey, with rats, 1963; McKinney, with collies, 1954; Maier, with hens, 1962; and, of course, Harlow and his co-workers with monkeys(i963>, which point up the tremendous biological need mothers and their offspring have for great amounts of tactile stimulation. Professor Harry Harlow's famous experiments with monkeys are very enlightening. In a book written with Clara Mears, entitled The Human Model: Primate Perspectives (1979>, he collects and comments on various experiments done by himself and his colleagues. The study in which baby monkeys were separated from their mothers and given their choice of the wire lactating surrogate mother and the terrycloth nonlactating mothers showed some particularly interesting results. Harlow's conclusions: "The wire mother is biologically adequate but psychologically inept." "These data make it obvious that contact comfort is a variable of overwhelming importance in the development of affectional responses, whereas lactation is a variable of 21 negligible impor-tance." (p. 108) In another chapter he observes: Another extremely important variable is the conveyance through the mothers to the child of a sense of security and trust which creates self-confidence within the infant to face the future of the outer world. As the baby initiates the first forays away from the mother, feat- of the st~ange and unknown are foremost and any sudden or intense stimulation sends him hurtling back to rub new contact and comfort from mother's brave, bounteous and beautiful body. Maternal contact eliminates the fear and each experience adds additional confidence. .In addition to contact comfort, all maternal ministrations during early mother-baby behavior beginnings-- warmth, rocking, nursing and protection-- contribute to the confidence build-up. (p. 142) In studies conducted jointly by Suomi, Harlow and t·'icl (they would not engage in normal sex play> and became mothers. The result: "Motherless monkeys could be a model for only the most regrettable human mother of all, the child abusive maternal model." (Suomi, Harlow ~< Mcl 170) 22 Monkeys raised in partial isolation, where they were allowed to see and hear other monkeys but not touch or interact with them were retarded in age-appropriate and sex-appropriate social behaviors. They also showed signs of many abnormal disturbances during their first year. If the isolation were protracted for one to three years, they also developed self-directed behaviors such as clutching, mouthing and self-aggression. Six-month old isolate monkeys who were severely retarded in social behavior finally were able to respond when placed with three-month old normal, surrogate-raised "therapist" monkeys. "They Ethe 'monkey psychiatrists'] broke the self-directed isolate behaviors through the initiation of contact; they initiated the first playful interactions and provided a social medium conducive to the recovery that was acheived." (Suomi, et al., 1972, p. 931) The therapists would gently approach and cling to the troubled monkeys. Play behavior was developed within one month, and by one year later the two groups were indistinguishable. Harlow (1979) also cites Spitz' <1945) and Bowlby's (1960> reports of orphaned children in institutions. The children had been separated from their mothers early in life; Spitz' children were six months to one year and Bowlby's were two to five years old. They both found the 23 following patterns of behavior. When first separated, the children increased in active protest including anxiety, crying, screaming and agitation. After a time of separation, depression set in which Spitz termed """Ji thdl~awai" and Bawl by called "despair." The children became developmentally retarded, dejected, and withdrew from stimulation. Spitz coined the term "anaclitic depression," meaning the depression caused by the separation of the infant from the mother. The children Spitz observed, when reunited with their mothers, recovered quickly and almost completely" Bowlby's, however, perhaps because of the age difference, remained detached and hostile when returned to their mothers. In a similar vein, Montagu (1971> states that in the 19th century and even into the early 20th century, it was discovered that up to 100% of infants in foundling institutions under one year of age were dying. They developed marasmus, a Greek term for "wasting away," and did better only when the idea of TLC, "tender~ laving care," was instituted into the hospital settings by Dr. Fritz Talbot of Boston. Talbot found that, even without breastfeeding, babies will do well if they are handled, cuddled, cooed to, rocked and carried. The affectional bonding is necessary in addition to the meeting of food and cleanliness needs or babies will not survive. {in Montagu, 1971) 24 Montagu continues to delineate the need for tactile stimulation throughout the process of human development in the drive for contact with mother, with peers, sexual contacts~ and as old people. As we have seen, in our brief summary 7 different cultures vary in both the manner in which they express the need for tactile stimulation and the manner in which they satisfy it. But the need is universal and is everywhere the same. .Adequate tactile satisfaction during infancy and childhood is one of fundamental importance for the subsequent healthy behavioral development of the individual. The e: animals, as well as those on humans, shows that tactile deprivation in infancy usually results in behavioral inadequacies in later life. (p. 318) Touch is needed throughout life as well, as can be seen in the responses of older people to a caress, embrace or ...... pat. "Tactile needs do not seem to change with aging- ... ' anything they seem to increase." Dr. James Prescott, a developmental neuropsychologist formerly with the National Institute of Child Health and Human Development animals showing that pleasure and violence are inversely related; when one is present, the other is inhibited. Stimulation of pleasure centers in the brain of a raging animal by the use of electrodes will immediately calm it. He aisa notes that, as was discovered in primates, 1 ack of sufficient sensory stimulation causes electro-physiological abnormalities of the brain. The pleasure systems of the brain become damaged. "There in fact is brain damage at the structural level. There is abnormal neurochemical development and functioning, and abnormal neuroelectrical activity of the brain." (see Howell, 1983, P· 3> This can lead to failure of the pleasure centers to inhibit the violence systems in the brain, can lead to impaired sexuality and ability to form affectional bonds, and can increase the desire for compensatory behaviors such as alcohol and drugs. Prescott's cross-cultural study involving 49 cultures shows a high correlation between what he called !;somatosensor-y affection" The deprivation of body touch, contact and movement are the basic causes of a number of emotional disturbances which include depressive and autistic behaviors, hyper-activity, sexual abberation, drug abuse, violence and aggression. We should seek not just an absence of pain and suffering, but also the enhancement 26 ,, of pleasure, the promotion of affectionate human relationships, and the enrichment of human experience. In conclusion, there seems to be strong evidence that affectional bonding., or warm cuddling and touching is essential in the infancy of humans and other animals, and continues to be important in maintaining health throughout one's life. ~istory of Body-Mind Approache~ Beginning about the time of Freud 7 a line of people interested in the healing of the mind began to incorporate concepts of the connections between body and mind into their theories and techniques. This section will trace the documented histories of these movements and show their areas of similarities and differences. Josef Breuer and Sigmund Freud contributed to the development of the body-mind connection in their Studies in !:!ysteria (1937), whet-ein they described women patients with physical ailments apparently caused by experiences that they called "psychic trauma"; intense experiences of fear, anxiety 7 shame, or pain. The physical symptoms that they decided were likely to be psychosomatic were neuralgia and pain, epileptiform convulsions and tics, partial paralysis, persistent vomiting and anorexia nervosa. They found that chronic or recurring symptoms of this nature were tied to earlier trauma which was subsequently forgotten or repressed. This formed the theory of "hysteria." The physical symptoms would disappear if the patients were able to stir up the traumatic memories along with the accompanying affect. When the affect was discharged, the patient would experience spontaneous energy releases, such 27 28 as crying, shaking and physical aggression. Freud and Breuer called this "the act of giving vent in speech or action to repressed experiences," or "abreaction." Therefore we know that they were aware of physical components of both ailment and cure, and used mental techniques of hypnosis and free association to help elicit abreaction. Georg Groddeck, a colleague of Freud, used massage in his medical and psychoanalytic practice. In a paper entitled " Massage and Psychotherapy" presented to the Psychotherapeutic Congress at Dresden in 1931 and previously published, he discussed the importance of bodily contact between doctor and patient. He used massage as a way to assess and treat his patients. Although for centuries literature had been available proclaiming the therapeutic benefits of massage to body and soul, Groddeck was probably the first to document its use within the practice of psychoanalysis. One of the most important factors in the use of massage, he thought, lay in the tightening of the bond between the therapist and patient. We can say with full justification that massage, in whatever way it is carried out, must have some psychical influence upon the unaccustomed organism, and that it is an important, though incalculable weapon for psychotherapy. What we call transference and resistance appear during the course of the massage to 29 help or hinder. (Groddeck, 1931, p. 47) He described benefits for diagnosis and treatment, noting how the refinement of the physician's sense of touch increases his or her investigative efficacy. Also he said that vis1on., hearing and sense of smell are sharpened by massage, changes in form and color can be noted, and the patlent·s hidden secrets can be revealed in changing facial e} \p 48) As a direct benefit to the patient, Groddeck noted that rather than being labeled with a diagnosis, At the first touch the patient's thought and attention are diverted into other channels. He gets more insight into his own condition and wants to find out something more about himself. . as day by day he is faced by new problems arising aut of his changing sensations in massage., his awakening desire to learn then becomes so intense that. . soon. • he is exploring new physical and mental fields which would otherwise only be discovered by the greatest of good luck. Therefore the patient receives not only the many physiological benefits of massage, but an increase in his or her confidence in the doctor and II also the healing 30 power of his own organism" and can receive "a transformation of conscious, unconscious and vegetative characteristics of great consequence to psychotherapy." (p. 52) Groddeck ended the paper with a conservative statement: "All things considered, we may perhaps be allowed to contend that massage and psycho-therapy can be usefully employed together." (p. 53) It should be mentioned that Groddeck's views are quite controver-sial. Those who are concerned with the utilization of massage in a psychotherapeutic practice often express warnings against sexual entrapment and the tremendous transference implications that such intimate touch can bring up. It is well to be aware of and heed such warnings. Wilhelm Reich <1949), a well-known therapist in the early 190()s, also began as a Freudian, but developed a theor-etical structure which combined physiological and psychological assessment and treatment. Reich is known as the father of the body-mind theory leading to such integrative approaches as bioenergetics, Rolfing, Alexander technique, Radix work, etc. He was particularly interested in the physical manifestations of early repression (mainly se};ual, as in Freud's theories) and he therefore wor-ked towar-d releasing repressed emotional memories through psychotherapy and direct manipulation of the body. His term "character armour" serves to describe both psychic and 31 physical defensiveness which shows up as chronic muscular tension and extremely diverse subsequent physical symptoms. He found that in working directly with the chronic tensions~ such as in the jaw area~ the armor or resistance was loosened and the repressed memories and affect could then -flood out. Reich discovered that the muscular armor could be traced to seven "rings," or areas of the body. His techniques to release these areas, each of which had concurrent effects on the next area progressing downward, included deep breathing exercises and massage of the area of focus. He, l1ke Freud, discovered that repressed memories and emotions would be released along with movements and sensatjons such as shivering, tics, prickling, spasms, etc. Reich's work, although not subject to published scientific research, has made a lasting impression on both psychotherapy and body-oriented therapies. Following right behind Reich was his student, Alexander Lowen recognized Reich as one of the greatest contributors to the analytic understanding of man. "Reich's formulation of the functional identity of muscular tension and emotional block was one of the great insights developed in the course of the analytic therapy of emotional disturbances." (1958, p.13} He went further than Reich, however, in explaining his theories, techniques and 32 ~1 • observations simply and clearly. The character of the individual as it is manifested in his typical pattern of behavior is also portrayed on the somatic level by the form and movement of the body. The sum total of the muscular tensions seen as a . I gestalt, that is, as a unity, the manner of moving and -t-• ac~1ng, constitutes the "body expression" of the organism. The body expression is the somatic view of the typical emotional expression which is seen on the psychic level as "character". It ·is no longer necessary to depend on dreams or the technique of free ·I association to disclose the unconscious impulses and their equally unconscious resistances. Not that such techniques have no proper place but a more direct approach to this problem is provided by the attack upon the block in motility or the muscular rigidity itself. (Lowen~ 1958, p. 14} Lowen especially noticed emotional holding patterns in the breathing patterns of his patients: Analysis on the somatic level had revealed that patients hold their breath and pull in their belly to suppress anxiety and other sensations. In situations I which are experienced as frightening or painful, one sucks in the breath, contracts the diaphragm and tightens the abdominal muscles. (1958, p. 14> 33 He discussed how this becomes a chronic pattern, summarizing: "The final result is a loss of affect and a lowering of the emotional tone." (p. 14) His techniques involved "actJ.vities" and direct work upon the muscular rigidity. The activities are designed to bring into the patient's conscious awareness that he/she has muscular tension and a lack of motility. Once the patient is aware, then he/she can gain conscious control over the rigidity and its accompanying blocked emotional impulse, and begin to dissolve them. In a more recent book, The Betrayal of the __ Boqy ( 1967), Lawen concentrated his focus on the split between the body and the ego. This, he said, is the basic identity split and is the root of schizoid disturbances. He noted that human beings defend themselves against feeling terror and the expression of terror in one of two ways. The more common defense is the formation of a rigid barricade, in the form of muscular contraction and tension. The second'J more drastic way, is with what he called the "schizoid retreat". In this type of person he noted superficial bodily flabbiness and lack of tone, little expression, and a sense of deadness. This defense is a retreat not only from feeling but also from the field of action. This type of person remains submissive rather than active in all situations. Both defenses he attempted to break through by 34 way of motility exercises and direct muscular manipulation. An example of this: he would have a patient who was losing expression and tone hit the couch with a tennis racket to elicit an anger response and awaken physical sensation. The alive connection between body and mind is necessary to health. Lowen developed the · system of bioenergetics out of Reich's theories, adding to the body of work exploring character structures and concentrating more an physical exercises and techniques to elicit abreaction. He focused less on physical healing than Reich and more on psychological freeing and its components in physical structure. Will Schutz, a prominent group leader and promoter of the encounter group which came to the forefront at Esalen Institute in the 60s, discovered many physical connections to emotional blockages. In his 1971 volume, entitled Here Comes Everybody; Bodymind and Encounter Culture, he described certain emotional states as they are reflected chronically in the body. He also emphasized the importance of body awareness and advocated massage as an adjunct to therapy. He was especially aware of specific patterns of psychological conflict as they are manifested in the body. An example is a left-right split, which is usually characterized by an imbalance between the male and female 35 components of a person, as he discovered it in one young woman: The overall appearance was of the tough, male right side protecting the soft, feminine, fragile left side. This matched her position in the world, where she was a professionally successful woman of great femininity. She turned on one side or the other. A freeing of her body can help her build toward an integration of the two parts. (Schutz, 1971, p. 79) Schutz was closely associated with Ida Rolf Elaine Siegel <1973) worked with touch and movement therapy with schizophrenic children and adolescents in the 1970s. With four children diagnosed autistic and schizophrenic, she used physical contact and movement, eventually contacting them and aiding them in the discovery of their own body boundaries and of a world outside their ot'1!n. "In summary, we used strongly rhythmic exercises and dances coupled with music and body contact as stimuli to provide impetus toward body-image building and the formation of a sense of separate self." ( 1973' p. 148) The understanding of body boundaries is essential to the sense 36 of self and the ability to form a body image; the added awareness brought by movement and touch can make that self-understanding a positive one. Jeri Salkin (1973) 7 a dance and movement therapist, worked at Camarillo State Hospital and Cedars-Sinai Medical Center. She brought her expertise to bear with many emotionally distur-bed patients. "The fragmented ego experience of severely disturbed children may be the pathological manifestations of an early disturbance in the rhythm of tactile stimuli." <1973, p. 32) She found the development of body boundaries essential to ego development. The movement therapy served to help her patients become aware at various bodily tensions and movements, and encouraged them to initiate postures which symbolized or represented certain psychological conflicts. Her work, emphasizing body awareness, body-image building, reality-testing and communicatiion by means of movement and body contact, was highly successful and well-received. Rolfing could also be considered one of the main body-mind approaches, although it is primarily oriented to freeing physical structure. Emotional releases \Freud's abreaction) sometimes come about from the spontaneous unfolding of past emotional experiences as trapped in the musculature, but Ida Rolf <1977, 1978) did not focus on this. Rather she allowed it as a natural part of the course 37 of events leading to physical alignment; a by-product of restructuring the body. Therefore, space will not be spent outlining her methods, but her work is mentioned as noteworthy and very important to the history and development of bodywork modalities. Moshe Feldenkrais (1972) and F. Matthias Alexander ( 1941} have developed systems of bodywork which also are well-known and effective. They focus on postural and movement re-education and not on the body-mind connection and emotional work. They would make very valuable adjuncts, however, to psychotherapy~ as they would help an individual increase understanding of one's body and possibly encourage insights into one's personal dynamics. From Sigmund Freud through the present, a growing interest in holistic healing has pervaded the thinking of psychologists. Presently there are many branches of therapy which take the complexity of human situations into account and work toward balancing the whole person. p ' This sect1on will focus on massage experts who have research, personal experience and successful practices to report on. These authors present written histories of massage, then add to the body of literature with their own insights and technique. John Harvey Kellogg, a surgeon and superintendent of the Battle Creek Sanitarium in Michigan, researched and wrote one of the most complete texts on mas$age that has ever been written. In his 1895 volume, The Art of t:1assag~, he gave special attention, after testing methods of massage learned in this country and in Europe~ to massage of the abdominal region and its vital organs. "The physiologic research which has been applied to the method of massage with1n recent years has clearly demonstrated the effectiveness of external manipulations as a means of influencing metabolic and other processes in the deeper parts of the organism." (1895, p. iii) His understanding of the efficacy of massage lay in its mechanical and physiological effects, and no more as far as is discernable from his writing. He does recommend massage for a variety of illnesses. Gertrude Beard, compiling a review of the literature on massage in her 1973 volume, Beard's Massage_, notes that "massage is mentioned as a form of treatment in the earliest 38 Y:J 11 ' medical records., and its use continues down through histary."(p. 5) She quotes Hippocrates (460-380 B.C.) and Avicenna (980-1037) as they describe massage practices to be used by physicians. She also comments on the lack of detailed descriptions of massage technique in the early medical literature, and an the variations among definitions of the term "massage". Beard offers kernel ideas on massage by nine medical people, whose work dates from the late 1800s and early 1900s. Douglas Graham of Boston, writing from 1884-1918, defined massage as: a term now generally accepted by European and American physicians to signify a group of procedures which are usually dane with the hands, such as friction, kneading~ manipulations, rolling, and percussion of the external tissues of the body in a variety of ways, either with a curative, palliative or hygienic abject in view." Beard's own definition of massage is: the term used to designate certain manipulations of the soft tissues of the body; these manipulations are most effectively performed with the hands and are administered for the purpose of producing effects on the nervous, muscular and respiratory systems and the local and general circulations of the blood and lymph. (p. 6) She gathered terminology of massage from the time of 40 the ancient Greeks and Romans, seeing similar terms carried through to the 4th and 5th centuries A.D. and then picked up again in the literature of the 14th through 17th centuries. We have very little literature describing medical practices during the Dark Ages. In the early 19th century, the terminology began to include French words and some newer language apparently inco~porated by Per Henrik Ling of Sweden. Ling is known as the originator of Swedish Massage. Discussing the effects of massage, Beard cites a few studies showing physiological changes in response to massage. She also notes that some practitioners also claim psychological effects resulting from massage. She is especially interested in the perception of pain and how massage can alter those perceptions. Frances Tappan wrote Healing Massage Techninques, a 9tudy of Eastern and Western Methods in 1978. She, also, delineates a history of massage, noting that massage was well known in the east, particularly in China where it probably originated. Egyptian, Persian and Japanese medical 1 i terature is also replete with references to massage and bath treatments. She names Hippocrates, Herodicus and Asclepiades as eminent Greek physicians who left behind them instructions about treatment with massage and exercise. Asclepiades even abandoned all use of medicines and relied solely on massage for curing the sick. Such well~known figures as Julius 41 Caesar, Pliny and Arrian showed great trust in and respect for massage in their own lives. Again we see a history of massage which is blank during the Middle Ages. Until the 16th century 7 interest in or at least record of massage work was nearly nonexistent. I Tappan writes about a man named Ambroise Pare who wor·ked, in the 16th century, to build a case for what he called "mechanotherapy", citing physiological and anatomical needs for it. This began a good deal of writing on the subject which reached a high point in the work of Per Henrik Ling. In the 1880s, the acceptance of Ling's work showed in the development and adoption of the "Swedish Movement Treatment" or the "Ling System" which became Swedish massage. Shortly thereafter, Germany, France and Austria became the sites for many reputable institutions famous for healing through massage and cleansing. Tappan continues her history by citing fifteen men and women who championed the use, documentation and teaching of effective massage from 1880 to 1977. Tappan then discusses the mechanical, physiological and ref le>-~ effects of massage, emphasizing the positive attitudes toward healing which a masseuse can share with her patient. While giving massage one can encourage the patient to understand the potential source of healing in his own consciousness. He can be encouraged not to be 42 helpless~ passive., depressed or desperate, but rather capable and active in his own treatment. Skillful encouragement can stimulate the human body's own defense and healing mechanisms. <1978, p. 28) She is also particularly intrigued by the recent research on endorphins for pain relief, relaxation techniques for healing, and massage for premature and newborn babies for quicker development and less possibility of emotional disturbance. Robert Henley Woody (1980) is a psychologist who is well-versed also in massage and hypnosis. In his book, The Use of t·lassage in Facilitating Hol_~stic Hea.lth, he discusses holistic health concepts, bodymind and massage, and his awn style of integration which he calls "hypnomassage." The list of massage benefits which he highlights begins with the tremendous affect massage can have in reducing anxiety. Discussing psychosomatic disease, he states: The autonomic nervous system is vitally linked to holistic health. Problems like substance abuse, high blood pressure, skin disturbances, diarrhea, headaches, sexual dysfunctions, peptic ulcers, various forms of colitis,. bronchial asthma, insomnia, and an array of psychosomatic conditions may be impacted upon through the autonomic nervous system. The integral factor is, of course, the anxiety, and the objective is to bring the autonomic nervous system into opposition of the 43 anx1ety. <1980., p. 5) He refers here to Pelletier's well-known booktHind as !-fealer, A Holistic Approach to Preventing §tre?s_Disorders, for contributing to his ideas. In support of massage as a valid therapeutic intervention, Woody observes: t'lassol ogy, the scientific study of the manipulation of the body, finds supportive research from all of the major medical and behavioral science areas. There are both physical and mental effects from massage. Massage is so fundamental to rehabilitation that it is often the first technique taught in a physical therapy curriculum. As will be presented, there seems to be no question about how massage influences the body. It can reach the autonomic nervous system to transmit a message counter to anxiety. To try to explain to his readers what massage is and what effects it has, Woody quotes George Downing (1972) and Alexander Lowen (1977>. First, Downing: When receiving a good massage a person usually falls into a mental-physical state difficult to describe. It is like entering a special room until now locked and hidden away; a room the very existence of t'lfhich is likely to be familiar only to those who practice some form of daily meditation. By itself this state is a gift. However, he who is g1ving the massage need not 44 stop there. The more he can tune into his friend's heightened awareness, the more he can convey something of his own inner self and experiences as well. The least touch becomes a statement, like drawing with a fine pen on sensitive paper. Trust, empathy and respect, to say nothing of a sheer sense of mutual physical existence, for this moment can be expressed with a fullness never matched by words." p. 1; in Woody, 1980, pp. 12-13) And this less abstract description follows: Massage serves several purposes. We all need to have something done for us and to us. Massage partly fulfills this deep oral need, is one of its attractions. But we also have an adult need to be touched in a pleasurable way without any se>:ual undertones, and massage meets this need, too. The hands of a masseuse can get at tensions that are inaccessible to our own hands and not directly affected by the exercises." 1980, p. 13) Woody also describes the physical and physiological effects that massage has. These are well-known and less important to this discussion than the psychological effects which massage provides. Woody has developed a construct called the "body quotient" which stands for a quota of body stimulation that is necessary to a person to prevent 45 negative consequences from occuring. He quotes Harlow's "contact comfort" theories and Montagu (1971) and Desmond Morris· <1971) works on touching and intimate behavior respectively. He summarizes, Of consequence to holistic health~ it would appear that a deficit in body stimulation, which includes an 1ntimacy component, promotes the development of neurotic conditions, such as anxiety reactions and inappropriate affect. .It seems clear-cut that massage holds the potential of offering the person immediate and rather massive remediation for any deficit in his/her body quotient. (Woody, 1980, p.18} Woody is convinced that massage is a vital 1 ink in enhancing and maintaining holistic health. A recent volume (1981} called Therapeutic Touch: a Book contains some avante-garde research and articles of opinion on the subject of touch. Of particular importance is the work of Dolores Krieger, Ph.D., R.N. and professor of nursing at New York University. She knew of a study in which a man known for his healing abilities, Mr. Estabany, held flasks of water in his hands which were subsequently used to water barley sprouts. The control sprouts received untreated water, and the chlorophyll level in the treated water-sprouts was significantly higher. (l ' w~th a simple laying-on of hands treatment. Based on this intriguing research, Krieger developed a research design which established that laying-on-of-hands, or what she ter·med "therapeutic touch," raised the hemoglobin values in blood samples of her exper1mental group to a point wh1ch was significant at the 0.01 level of confidence. This experiment was repeated in slightly d1fferent form with very similar results. Therapeutic touch is different from massage, but the main element--touching w1th the intent to heal--is the same. These writers have been motivated by their own personal experience and research with massage to document their observations and thoughts. All agree that massage is beneficial and that these benefits are far-reaching. This section will deal with research that has already been done which sets precedent for the experiment to be discussed in this thesis. Thomas Shostak, Laurie Eisler and Keith W1tt are the scholars whose work will be represented here. Thomas A. Shostak <1979) wrote his Ph.D dissertation for F.:.urleigh Dickinson University on The Comparative Effects of Varied Human Sexuality E: Goldfarb and Lowen, mm:.t of which have been discussed above, Shostak draws a conclusion about somatosensory stimulation: In the form of warm human contact and body movement, somatosensory stimulation is necessary to the development of a healthy personality, and., further, to the development of a humanistic outlook. To test this concept, his research compared the effects on authoritarianism (as measured by the Personality Orientation Inventory, the Edwards Personal Preference Schedule and the Index of Human Affection) of human sexuality classes taught in four different ways. One group received only cognitive instruction., a second cognitive plus visual stimulation (films) , the third group received somatosensory stimulation in the form of simple hand and face massage in addition to 47 48 (l ' the cognit1ve instruction., and the fourth group a combination of all four modes of instruction. He discovered that only the groups receiving touch as an integral part of learning about human sexuality showed positive changes in terms of authoritarianism. Laurie Eisler (1982) wrote a master's thesis for UCLA entitled T he__ ...ci_n____c::t....:.e~goz__r_a_+-:::..~.c..:.i-=o::..:n~ _ _;::o'-'f---'e:::....:..::>~-"p'-'e=-r.:.....;::i'-'e=-n~t-"i=-=a:.::l__ movement She did empirical research into the possibilities of this integration, applying it to pregnant women and writing up her case studies. Tracing the history of therapists who believed that body and mind are interconnected, she discusses the work of Freud, Groddeck, Reich and Rolf. The practices of Gerda Boyeson with Bioenergetics and Penny Bernstein with Gestalt Movement Therapy are introduced as examples of bodywork as primary psychotherapy; as affecting every level of a person's being and aiding change on each level. Eisler also covers the topic of massage as adjunctive therapy~ which is closest to the orientation of this study. She cites the work of several psychologists and psychiatrists who employ the use of massage or acupressure themselves or who use a mutual referral system to provide warm contact stimulation for their clients. All report a high incidence of improvement from the tactile stimulation. Not only do the patients receive touching which may help to fill an early deficit, but they grow in body awareness and 49 1nsight, make connections between their emotions and their bodies, and some reach out from an autistic or schizophrenic level of defensiveness to a healthier, more personally involved relationship with the therapists. Waal, 1955; McKinnon, 1980; in Eisler, 1982) Eisler's own work emphasizes the powerful possibilities of connecting movement therapy, which can stimulate so much in terms of spontaneous., nonverbal connections to life meanings, and massage, which permits a naturally intimate, impactful and direct relationship. In order for therapy of any kind to be at its most effective, she asserts, it needs to be inner-directed rather than outer-directed (issuing from the desire and motivation of the client rather than a technnique being applied to the client). Eisler describes her empirical study as a pilot project and discusses cases of pregnant women that she worked with using massage and movement therapy. Her work seems promising as a treatment modality and it provides concepts and precedent for future research. A doctoral dissertation in Psychology entitled An ~nves~~~ation into the Effectiveness of Treatment Involving Talk~ plus Touching in Enhancing Health was written for The Fielding Institute by Dr. Keith Witt. Dr. Witt"s 1982 work is a more closely related precedent to this investigator's concept and research style, although his research design is more complex. Witt took three groups of 50 normal subjects and applied talk therapy (counseling> to one, massage therapy to the second, and an integrative style of therapy called "Symbol Linking Therapy" to the third. His results indicated that the integrative therapy did not seem to show distinguishably more powerful positive effects on its group s health than the therapy of either of the other- groups. All groups did show more positive health profiles after treatment than before. Witt lists some possible reasons for the outcome. As part of the theoretical basis for his study, Witt list:. several previous research studies in which talk therapy and some form of body therapy are combined. In se>~ therapy as done by Kaplan in 1974 and by Masters and Johnson in 1970, touch and talk are both employed as therapeutic technique. Nicholi in 1978 combined medication and psychotherapy in the treatment of psychosis and neurosis. Medication and group therapy were integrated in 1980 by Rosenman with the intent to aid patients with heart disease. And in treating cancer patients, Simonton et. al. ( 1978) utilized medication, visualization exercises, group therapy and surgery and/or radiation treatments. The research results of all the studies mentioned showed that the combination of treatments is more effective than separate treatment procedures. Witt's work is thorough, thoughtful and unprecedented. One of his most reflective comments is this: 51 For all practical purposes, clinical either/or formulations popular in the 60s and 70s, with cognitive behavioral extremists on the right and humanistic extremists on the left, may be seen in the light of these implications to be inadequate either/or constructs that do not reflect the possibility that most, maybe all, helping treatments, may have some healing effect in common. Witt is suggesting that those in the helping professions maintain an open, inquiring mind with an emphasis on recognizing human self-healing abilities, rather than a closed, suspicious, pessimistic and competitive spirit which could actually stand in the way of health and healing. lhese authors have all visualized and put into practice forms of treatment that seek to address the entire person, hoping to affect health in a more integrative and more effective way. Their research, hopefully, will pave the way for more thorough studies on the subject of body and mind integrative therapies, to further our progress in improving human life. 52 lncest Qes~c.if:?tipn of the toeic. Incest is legally defined as sexual intercourse between two people too closely related to marry. Many people who work with sexual abuse of this kind have broadened the meaning of the term, finding that a whale range of psychological difficulties can arise from sexual contact which varies from exhibitionism to intercourse. The degree of trauma does not necessarily follow proportionately from the degree of sexual contact • Susan Forward, Ph.D defines incest broadly as. • "any overtly sexual contact between people who are either closely related or perceive themselves to be closely related." The abuse of power is the most significant factor. Incestuous conduct may be as insidious as subtle comments on a child's budding sexuality or as blatant as incestuous rape, and often takes such forms as oral-genital contact and manual genital manipulation. The child is used to satisfy the needs of the adult. Statistics. The statistics on age of onset, age at discovery, prevalence in the population and sex ratio vary from study to study. de Young (1982) discusses the contradictory research conclusions and the difficulty in finding good research, and notes that seldom are control groups used. It is unanimously agreed that female victims report se~<:ual abuse much more often than male victims. Forward \1979) reports that 90/. of the victims are female. Butler <1978> reports that 80-90/. of the offenders are men, while Sanford's (1980) and DeFrancis' <1969) figure is 97%. It should be mentioned here that recent research is bringing to light more incest perpetrated on bays and more perpetrated by women. The use of male pronouns referring to offenders and female pronouns to victims in this report is not to offend anyone; rather it is an attempt to simplify the writing and reading task. Forward <1979) notes that the victims' dynamics are very similar whether they are male or female; this writer would surmise that the offenders' 54 ,, ' motivations are also similar regardless of gender. Most of presently reported incest cases (75/~) involve -father and daughter 1979} The average age of initiation of the incest is when the child is seven to eight years, and most often the disclosure, if the incest is reported, happens six months to one year later. (Justice and Justice, 1979; Tormes, 1968) Most sexual abuse against children is committed by someone the child knows and trusts 27% of the perpetrators lived with their victims. These statistics would impress upon us that the traditional warnings to children not to accept candy from strangers and to watch out for old men in school playgrounds are grossly inadequate as protective, preventive measures. For preventive techniques, see Sanford (1980> and Herman and Hirschman (1981). Prevalence in the population. Incest crosses all social, economic, and racial lines. The early research used cases brought in by social agencies 55 such as police departments, welfare offices~ etc., and so the samples were largely of people from lower economic brackets who had few alternatives. This set up a skewed profile of the incestuous family. Now it is seen that incest occurs equally among all types of people. It is also grossly underreported (Forward., 1979) c Butler estimates that 50-90% of the cases of sexual assault on children goes unreported~ and Burgess et al. <1978J believe that incest occurs in one out of every ten families. Henry Giarretto treated 1000 families in one county (Santa Clara., C.A.> in the first eight years of his Child Sexual Abuse Treatment Program. This alone puts Weinberg's optimistic estimate of one in a million (1955) into the status of wishful thinking. Forward notes that there is a social impact resulting from incestuous abuse; the victim becomes self-punishing if not self-destructive, and this can lead to alcoholism, prostitution and/or drug abuse. (1979) The character of the incestuous family. Incestuous families quite often fit a pattern of rela.ting. The family usually lives in a patriarchal atmosphere communication~ and o~ten sexually as well. de Young's study (1982) shows that 75% of her interviewed families reported 7•j having experienced at least one affair, and 4 -.) .. reported sexual alienation preceding the incest. The mother (using nott-J a "typical" father-daughter incest pattern as an e>~ampl e) in the family is usually absent in some way; she may be sick, institutionalized~ away at work a lot, or simply emotionally distant (Forward., 1.979; Justice and Justice, 19"79). The daughter-mother relationship has broken dov-m, often with a role reversal. The daughter takes over the mother's role of caring for the other children, cooking and cleaning powerful at home, while harboring a great deal of anger, frustration and insecurity. He is usually of at least average intelligence, goes to church regularly~ and maintains a steady work history 1979). Both mother and father have a childhood history including abuse, usually at least emotional and physical, and often sexual as well. (deYoung, 1982) An important point: the involvement between father and daughter is not so much a sexual need fulfillment as it is the father·s distorted attempt to find nurturing, acceptance and closeness. The daughter is discouraged from social contacts CHerman & Hirschman, 1981} ' and has as a role model a mother who is not capable of surviving emotionally or financially without her husband. Florence Rush cites the Bible and the Talmud as setting up the ancient ideas of women as property, and of all heterosexual relationships as financial transactions to be arranged by men. She notes that father-daughter incest is not prohibited anywhere in the Bible and is even generally (although not specifically> condoned. Judith Herman's study (1981) of 40 women who shared their incest stories portrays the incestuous family as conventional, churchgoing, financially stable, often a large family, with a patriarchal father and a submissive mother. The mother often suffers depression, illness, alcoholism, or psychosis and, again, the daughter fills her 58 shoes. Schlesinger \19821 notes two family types: (1) the "classic" family in which the pathology is confined within the home, so that it looks stable, and the family is not known to social agencies; and <2> the multi-problem family in which incest is only one aspect of its disorganization, and it is known in the community on other issues. Weinberg (1955) also notes two family types: the ingrown family, with few outside relationships, and the family which is so loosely organized that sexual attitudes are not constrained or well-taught. In any case, the incestuous family fears disintegration and is seeking to maintain a balance. Unfortunately, it chooses a means which is unhealthy and destructive. Why~s incest destructive? There are several reasons why incestuous contact is harmful. "The father, in effect, forces the daughter to pay with her body for affection and care which should be freely given." submit to him. Another double bind is pointed out by Knittle and Tuana ( 1980) ' working with adolescent incest victims: These children are in a double bind: if they make any attempt to stop the abuse, they are betraying their fami 1 ies; if the abuse continues, their feelings of self-revulsion and rage increase. They are helpless, and the anger turns inward. Researchers have documented a high incidence of self-destructive and antisocial behavior among victims of sexual abuse 7 for example, suicide, drug abuse, and prostitution. The role change is an important factor too; suddenly the young girl becomes her father's partner and is thrust into an adult role for which she is by no means prepared. Then she automatically takes guilt upon herself, and her home becomes an unsafe place. Add to this the tremendous stress of having to keep a terrible secret, and the cultural reactions of horror and condemnation which she almost surely encounters, and the situation can be unbearable. Sanford <1980) notes that the disparity of power, knowledge and resources between an adult and a child is the damaging factor. Due to the adult's greater size and strength, emotional power, knowledge of sexuality and its consequences, and ability to threaten and bribe, it is impossible for him to avoid exploiting the child if he 60 indulges in sexual contact. The child can in no way be considered to "consent" as we consider adults able to consent \Finklehor, 1979)., and therefore sex between children and adults can only be considered as victimization. Possible harms listed by Herman and Hirschman are these: (i981) a. The child may be rendered more vulnerable to pathological deviations in later life, especially if the incest involved force b. Impairment of "se>:ual self-esteem" c. Sexual difficulties later (i.e. disgust for sexual subjects, se~<:ual "flashbacks" especially if the assault was a rape trauma, orgastic dysfunctions, etc.) d. Tendencies toward repeated victimizations e. Severe disturbances Self-esteem is easily harmed in childhood as it is, and to be the guardian of a terrible secret can confirm in the child a negative identity which can surpass even the trauma of the incest itself. t!YJ~othesi s. The experimental group, experiencing body massage in addition to group counseling for incest issues, will show a greater degree of health as measured by the Profile of Mood States, the Body-Related Self-Image measuret and the Index of Human Affection as well as by subjective observation 61 terms filled out by the masseuses and therapists, than the control group which receives only group counseling. Definition of terms. 1. "Body-related self-imageu, as used in the title of one o~ the questionnaires, refers to a person's feelings and attitudes about herself drawn from experiences of herself physically. This includes several components: (a) degree of body awareness (b) degree of satisfaction with one's body (c) degree of comfort with one's (d) basic self-acceptance (e) ability to let go of control (f) ability to accept pleasure (g) ability to care for physical health ••• "1 L... "l'"lassage" in this study, except as otherwise noted in the body of chapter 2 describing forms of and history of massage, will refer to a specific style of Swedish massage. This style provides a thorough, non-sexual body massage, using oil, done with the subject nude or partially clad, and employing a basic, flowing sequence which can be varied to accommodate work on specific tight or resistant areas. Massage may also be called ubodywork". 3 .. "Group therapy" or <"group counseling") in this study will follow the model for group work developed for incest victims by Henry Giarretto in Santa Clara County. It will consist of therapist, co-therapist and a group of women and focuses on the issues brought up by the common 62 experiences of the group. 4. "Incest victim" or "incest survivor" is a person who has experienced at some time a sexual molestation as defined by various mental health professions. Here is a definition by Dr. Susan Forward: Incest is II . any overtly sexual contact between people who are either closely related or perceive themselves to be closely related." (Forward, 1979, pp.3-4> Summa.!:X. To review~ we have covered in this chapter a great deal of information relating to two main areas; that of the importance of touch in general and massage in particular, and that of incest and its ramifications. We began with a review of anthropologist Ashley Montagu's work on touch, continued with the fascinating tales of research with animals and foundling infants, and some recent neuropsychological information on the importance of somatosensory stimulation to the health of the brain. Then came a history of psychologists from Freud on who were interested in approaching psychology from a holistic frame of reference, including Freud, Groddeck, Reich, Lowen, Schutz, Siegel, and Salkin. Next, we perused the history of massage, noting its beginnings in the Orient, its establishment in Greece and Rome, its more recent developments in the 19th century with 63 the development of Swedish massage, and the relative flourishing of "new age" holistic health approaches of today. Gertrude Beard, Frances Tappan, Robert Woody and Dolores Krieger represent some of the current thinking on the effectiveness of massage in many areas of health treatment. The topic of incest was covered~ including information from statistical sources on recent research as well as clinical information from many sources dealing with etiology, characteristics of the incestuous home, and damage to the victims. Incest is a topic growing in importance to our culture 1n general and the healing arts in particular. Whatever modes that can be found to encourage healing of the damage done is well worth exploring. Touch is recognized as an essential element to health, and may be tapped into as a healing modality in concert with the therapy that already is known as effective. Chapter .::- METHODOLOGY Introduction In this chapter, the procedure that was followed in arranging and executing the research study will be presented. The design of the study will be discussed, as well as the procedures followed in finding and recruiting subjects, developing the treatment program, choosing and developing the instruments., and the data collection and anal ys1 !:'•• This study is an example of research based on theory. The thoughts and experiences developed during the writer's work with massage and study of psychology over a number of years have led to the theory that an integrative approach using both could be a very powerful tool in working with people. Current interest in the topic of incest has encouraged the channeling of the theories into a study working with incest victims. The study has a quasi-experimental, pre- and post-test., comparative research design. The term "quasi-experimental" is used because the subjects were not randomly chosen and assigned to groups; rather., the availability of subjects was limited and most of the easily available subjects were 64 65 . utilized. \This is the biggest flaw in the design.) The control group of ten women received group therapy alone, and the experimental group of ten women received group therapy plus four one-hour massage sessions with a trained masseuse. Each woman was evaluated by pre- and post-test questionnaire, as well as by pre- and post-test evaluation forms filled out by masseuses and the group therapists. All women were to be concurrently in group therapy or have been recently in group therapy, the groups centering their concerns on issues of incest. Subjects The subjects were drawn from therapy groups dealing vnth issues of adult women incest survivors in a small city on the coast of Southern California. The therapists of a few groups were approached and asked to participate in the study. They in turn asked the women in their groups to participate. In the case of the control group, some discretion was used by the therapists in their initial screening. They chose women whom they thought would be willing to participate and then asked them to be involved. Five experimental subjects were gathered from each of two groups and ten control subjects agreed to participate who were involved in another group, although only six of the control subjects completed the study. Each woman is identified by her birthdate for a code; 66 therefore the writer does not know them by name and does not know which set of data belongs to which participant. Inasmuch as the subjects do not know whether they were participating in an experimental or control group, these procedures amounted to a double-blind format, thus reducing experimenter bias. TI:_ea"l:_~~nt F~~o-'l!:~m The treatment program consists of group therapy for the control group and group therapy plus massage for the experimental group. The groups chosen to supply the subjects are modeled after the Child Sexual Abuse Treatment Program in Santa Clara County, described in the Introductory Chaptet-. The masseuses are graduates of the Institute for Holistic Studies where they all took the Holistic Massage Specialist training course. Two of the three were trained by the researcher in Swedish massage, and the third was very similarly taught. The massage they learned follows a specific sequence and is a one-hour Swedish massage which uses oil, is very thorough and non-sexual, and can be somoewhat adapted to accommodate individual areas of tension and resistance. The masseuses were gathered before the study began to give them instructions, give them information about incest and its results, and to air their feelings about sexual abuse and any experiences any of them might have had with 67 (l ' seductive or molesting adults. The masseuses were not told how the study was being run, in order to cut down on bias in their viewpoint. It is a concern that they could probably guess the aim of the study. They were encouraged to be as objective in their observations as possible. The criteria for choosing the masseuses were their skill in massage, their sensitivity and compassion, and their professionalism. The masseuses, therapists and subjects all received letters of orientation and instruction. The letter to the e>;peri mental subjects is included in the appendix as an e>{ample. Instruments The writer originally wanted to measure body-image, and set about researching instruments to do that. The couple that were found were very limited and not appropriate to the study. Therefore, a questionnaire was written. It was a long process, involving a pilot study of a few people, including two incest survivors, who filled out the questionnaire and gave their personal reactions as well as suggestions for additional items. In order to back up the untested questionnaire, two other measures were chosen; the IHA, or Index of Human Affection, written by Dr. James Prescott who is quoted in Chapter 2., and the PONS., or Profile of Mood States, by McNair, Lorr & Droppleman. If 68 il ' all the questionnaires show changes in similar directions, this should lend credence to the developed instrument. This questionnaire, entitled Body-Related Self-Image, has a biographical section to gather information about the incest and a second section with 79 statements representing 8 categories. The items have responses on a Likert-like scale of 1-6 ranging from "strongly agree" to "strongly disagree." The 8 categories are these: 1. basic self-acceptance 2. somatization/dissociation 3. degree of comfort with sexuality 4. degree of satisfaction with body 5. ability to accept pleasure 6. ability to care for physical health 7. ability to let go of control 8. degree of body awareness Each subject receives a score in each area as well as a "total health" score. The Body-related Self-Image Questionnaire will be found in the Appendix. The Index of Human Affection, by Dr. Prescott, "evaluates a variety of values, attitudes and behaviors involving parent-child relationships, human se>~ual i ty, alcohol and drug usage, ethnic and racial prejudice, and the morality of pain and pleasure in human relationships." (Prescott, 1978., p.38) It now includes 103 items as well as a biographical section, and has a set of 6 possible 69 responses ranging from "agree strongly" to "disagree strongly." The questionnaire has been administered to attendants of Prescott's lectures; college students (both East and West coasts); high school students; alcoholics, drug abusers and incest offenders in treatment; members of professional societies and "growth communities" in California; lesbian women and women who have had abortions. The data collected was analyzed in a particular way; that is, to correlate agreement or disagreement with a particular personality profile; that of authoritarianism. Prescott's main interest so far in analyzing the data has had to do with attitudes on abortion. Unfortunately, the measure does not have national but has shown high correlation in terms of profiles on authoritarianism. The authoritarian personality, as shown in this study, is characterized by punitive, repressive attitudes toward physical pleasure and sexual expression, attitudes valuing pain, violence and punishment, and belief in authoritarian control over individuals. This is also the profile that corresponded very significantly with an anti-abortion stance. The IHA includes sections on psychosomatic ailments and substance abuse, as well as on attitudes toward sexuality, pain and pleasure, etc. The Profile of Mood States scale of feeling and affect. It is also a measure derived from factor analysis, like the IHA., and measures 6 identifiable mood states. These are: 1. Tension-Anxiety 2. Depression-Dejection 3. Anger-Hostility 4. Vigor-Activity 5. Fatigue-Inertia 6. Confusion-Bewilderment. The scales have proven to be effective in assessing the emotional states of psychiatric outpatients and their responses to therapies of differing sorts. It has also been shown to work well with normal subjects. Norms have been derived from a sample of 1000 psychiatric clinic patients at their initial visit, and also from 856 college students who agreed to participate either in psychopharmacological experiments or in taking test batteries for standardization purposes. The internal consistency of the POMS rates highly. "All these indices of the extent to which the individual items within the six mood scales measure the same factor are near .90 or above.'' (Poms Manual. p.9) Test-retest reliability is a difficult measure for a mood scale; in fact, high-stability coefficients might actually show lack of construct validity because a measure like this needs to be sensitive to any change in affect or mood. "For the 150 VA 71