‘Like diet and exercise, we need a daily dose of touch’ (p. 143).
Touch is simultaneously ‘the mother of the senses’, yet ‘the least researched of the senses’ (Montagu, 1986). This is surprising as skin, the organ of touch, comprises 18 per cent of our body and is approximately 18 square feet in area. Touch is the first sense to develop, at less than eight weeks in utero, and is the last sense to fade. In this second edition of ‘Touch’, Tiffany Field promotes the importance of touch, updating evidence from 2001, by drawing on a range of studies from psychology, anthropology, sociology, and biomedicine.
Field is concerned that North American society is at risk of losing touch. Schools have ‘no touch’ policies, and the growth of ‘touch-technologies’ such as mobile phones and tablets may, ironically, limit physical touch interaction with peers and with parents. To illustrate the consequences of reduced touching, Field presents data which supports the essential role of touch in child development, and contrasts this with her observation that in the U.S. children are socialized from an early age to limit touch. In observational studies comparing U.S. and French parent-children interactions, U.S. children were noted to play and touch their parents less, and show more aggressive behavior (p. 21). She describes a number of cultural studies to suggest that aggression is lower in touching than non-touching cultures (Chapters 2 & 3). In healthcare, despite a strong tradition of ‘hands on’ practice, the focus on treatment (particularly medications) and diagnostic technology has replaced the role of clinical touch, which is underused and neglected (p. 13).
To counter the ‘minimal-touch problem’ (p. ix), elaborated in the first four chapters, Field presents findings from studies to illuminate the benefits of touch, drawing on her work at the Touch Research Institute, University of Miami School of Medicine. In keeping with her research interests, which stems from her early experiences massaging her own premature baby, there is a strong focus on the role of massage and Field reports studies in infants, children, adolescents, adults and the elderly. A range of conditions are detailed: from asthma to attention deficit disorder, diabetes to depression, and a wide number of pain syndromes. The role of touch in health maintenance is also emphasized. There are light moments: rather than taking a coffee break, massage lunches and touch therapies to stimulate energy and feelings of well-being are advocated instead. Field details the physiological and biochemical effects of touch: lowering of blood pressure and heart rate, reduced levels of cortisol and increased oxytocin. A key message is that for massage to be a beneficial therapeutic modality moderate pressure is required, and this is explained by studies showing increased serotonin and decreased substance P, both of which ultimately play a role in pain relief. Attention is also given to present findings from brain imaging studies (using functional magnetic resonance imaging, fMRI) which show activation of different parts of the brain in response to different types of touch, such as pleasant touch activating reward pathways in the brain (p. 117) as well as those areas involved in social perception and social cognition (p. 116). Interesting questions are posed at the end of the text regarding the role of the internet and social media in propagating the culture of touch deficiency (p. 191), and provide fuel for future research.
The book has a clear structure, and individual chapters have extensive bibliographies which reference respected and accessible literature. The text is engaging and understandable: for example, Chapter 5 ‘Touch messages to the brain’ explains complex ideas and scientific terminology in accessible language, and Chapter 6 provides a useful overview of touch therapies, including energy methods (acupressure, acupuncture, reflexology, tai chi and yoga), manipulative therapies (massage, chiropractice, osteopathy, Trager methods) and combinations of these (Kinesiology, Chinese massage, Reichian massage). There is considerable cross referencing, which can be seen as useful, as it re-enforces key points but may risk irritation of other readers. Diagrams and images alleviate the text but are slightly dated which undermines the currency of the text.
The strength of this book is that it collates a wide range of material on a relatively neglected subject into a single resource. It integrates science with social commentary and draws on a range of resources from cultural studies, communication science, psychology and medicine. As such, it has wide appeal, from layperson to interested touch practitioner, clinicians and researchers. The text is a good primer on the topic, is thought provoking and provides resources for further inquiry. It could be particularly useful for people interested in learning more about touch therapies, particularly massage.
The challenge of appealing to a wide audience is that it is hard to keep everyone happy. We (MK, CS) explored its value wearing two hats: as family doctors and as doctors interested in the humanities. Like Field, we recognize the social tensions around touch. For example, doctors can be cautious to reach out and touch a distressed patient. Or they may avoid touching a patient when touch is indicated on health grounds, due to concerns of social propriety. For elderly patients physical examination can be their only experience of touch. As a result of reading this book, we feel more confident to discuss touch with our patients. As an example, Field’s descriptions of the benefit of touch on a child’s social development—where touch helps bonding with Mothers and Fathers, and touch deprivation is associated with unsocial behavior later in life—are moving, and re-enforcing that message may be reassuring to parents, who are sometimes anxious and intimidated by perceived social pressures. The text also bolstered our use of massage, not just for traditional things like back pain but also for the maintenance of well-being and as a tool to manage stress.
Overall, Field is measured in her interpretation of the evidence and she indicates inadequacies and weaknesses of touch research. However, Field doesn’t contrast the benefits of touch therapies with the negative aspects of touch beyond the ‘minimal touch problem’ that she advocates throughout the book—there is no mention of the reams of literature on physical abuse and its negative consequences. We also found that when Field discusses touch therapy for more specific illnesses, such as asthma and attention deficit disorder, we would have preferred more detail, rather than having to look up reference papers. For example, the case is made that nightly bedtime massage of asthmatic children would reduce the number of asthma attacks and improve pulmonary function tests, but the extent of improvement and the number of children studied isn’t elaborated. It is difficult to appraise study findings critically without descriptions of study details, methods, or absolute outcome data. We acknowledge that omitting this information makes the book more accessible for the average reader, and including them would result in a very different book with a different audience.
As doctors interested in the humanities we found that the book drew on familiar work and pointed us to new sources of information. The book could be strengthened by drawing on a wider literature, to extend our understanding beyond the obvious physicality of touch. At a basic level, touch can be defined as physical contact; this is the focus of this book. This text couches touch within a scientific paradigm and the author’s central premise is supported by quantitative data and serial measurements of biomedical parameters.
Touch is much more complex: the who, where, what, why and when of a single act of touch is gendered, contextually situated and socially regulated. Whilst Field draws on these ideas in the initial part of the book to support her belief that touch is belittled, she doesn’t expand on this literature in the second part of the book, where she presents her evidence. A range of studies, from healthcare practitioner and patient perspectives, have been conducted in nursing and—to a lesser extent—in other healthcare professions which substantiate the central role of touch as a vital part of human connection, particularly in healthcare.
These studies use a variety of approaches (ethnography, discourse) and could be used to corroborate her message more broadly in relation to the communicative and affective value of touch. Indeed one could extend the argument further by drawing on a rich philosophical tradition, which questions the very nature of touch (for example work by Jean-Luc Nancy, Derrida). By focusing solely on the benefits of touch as a biological process, the book will not, we suspect, provoke the critical reaction and change in clinical practice Field promotes. Engaging additional epistemologies would strengthen her argument, particularly in relation to the future direction of touch research and practice.
Reviewed by Drs Clark Svrcek and Martina Kelly. Svrcek is a family medicine resident, environmental engineer, explorer, husband, and father. He became interested in the area of touch in medicine as soon as he started his clinical experiences and quickly appreciated how much we communicate through hands-on connection. When he’s not working as a resident physician you can find him (or not) out in nature with his family.
Kelly is a family doctor and associate professor, in the Department of Family Medicine, University of Calgary. Martina is interested in medical education, particularly how we value and use different forms of knowledge in clinical practice and training. At present she is researching how we use our senses, including touch, in medicine.
Correspondence to Dr Martina Kelly.
Montagu, A. (1986) Touching: the Human Significance of the Skin. New York: Harper and Row.