10.

1177/0898010104269242
JOURNALOF
Larden et al. / HOLISTIC
EFFICACYNURSING
OF THERAPEUTIC
/ December
TOUCH
2004

Efficacy of Therapeutic Touch

in Treating Pregnant Inpatients
Who Have a Chemical Dependency

Cheryl N. Larden, R.N., B.S.N.

British Columbia Women’s Hospital
M. Lynne Palmer, R.N., B.Sc.N.
British Columbia Women’s Hospital and
Surrey Memorial Hospital
Patricia Janssen, R.N., Ph.D.
University of British Columbia School of Nursing and
Department of Health Care and Epidemiology

Chemical dependency is known to complicate about 3.8% of pregnancies in Vancou-

ver, British Columbia, Canada. In this study, 54 English-speaking, hospitalized
women were randomly assigned to receive either (a) daily Therapeutic Touch over a 7-
day period for 20 minutes each day, (b) shared activity with a registered nurse for 20
minutes over a 7-day period, or (c) standard ward care. Anxiety was measured using
Spielberger’s State-Trait Anxiety Inventory. Withdrawal symptoms were measured
using a standardized Symptom Checklist. Anxiety scores were significantly less on
Days 1, 2, and 3 (p < .05) for the group receiving Therapeutic Touch. Therapeutic
Touch may be of value as an adjunctive measure in the treatment of chemical
dependency among pregnant women.

Keywords: anxiety; drug addiction; Therapeutic Touch; withdrawal symptoms

Chemical dependency is a growing problem among childbearing

women in North America (Woods, 1998). Intoxication using street
drugs followed by withdrawal has been associated with preterm

JOURNAL OF HOLISTIC NURSING, Vol. 22 No. 4, December 2004 320-332

DOI: 10.1177/0898010104269242
© 2004 American Holistic Nurses’ Association

320
Larden et al. / EFFICACY OF THERAPEUTIC TOUCH 321

labor and stillbirth (Kleber, 1999). The prevalence of illicit drug use by
pregnant women in Vancouver, British Columbia is approximately
3.8% (Perinatal Substance Use Guideline Committee, 1999). About 35
chemically dependent pregnant women are admitted annually to
British Columbia Women’s Hospital in Vancouver, a tertiary-level
teaching hospital that provides referral care for women throughout
British Columbia. It is not uncommon for these women to interrupt
their treatment to leave the hospital and return to street drug use.
During pregnancy, the treatment of choice for opioid addiction is
methadone. Titration of dosage to relieve symptoms associated with
withdrawal prevents the need to return to street drugs. Intoxication
and withdrawal symptoms from all classes of illicit drugs cause vari-
able patterns of mood and anxiety disorders (Schottenfeld &
Pantalon, 1999). Anxiety, fatigue, fear, and anger augment the percep-
tion of pain in individuals with a chemical dependency (Stimmel,
1999). Anxiety and pain management is, therefore, an integral part of
the overall treatment plan for pregnant women with addictions.
Therapeutic Touch (TT), developed in 1972 by Dolores Krieger and
Dora Kunz, is believed to reduce anxiety, the perception of different
types of pain, and to promote a sense of well-being. Driven by com-
passion, and with the intent to help or to heal, the TT practitioner
moves his or her hands over the individual’s body to consciously
redirect and modulate subtle human energy. Physical contact is not
required, as one of the underlying assumptions of TT is that the uni-
versal vital energy that supports all living organisms extends beyond
the skin (Krieger, 1993; MacRae, 1987). Martha Rogers’s (1970) holistic
framework of unitary human beings offers a theoretical perspective
that supports the fundamental assumptions of TT. Rogers postulates
that an individual is a unified whole within a permeable human
energy field. Both the individual and the environment are open sys-
tems that continually interact, resulting in constant repatterning and
reorganization of the energy field. Change occurs when resonating
waves of energy, in both man and the environment, produce disrup-
tive or enhanced rhythms.

AUTHORS’ NOTE: Appreciation is extended to Roberta Hewat, Ph.D., R.N., I.B.C.L.E.,

for her support and advice in writing this article. We would also like to extend our
appreciation to the study nurses who collected the data and performed the Therapeutic
Touch interventions: Carol Pearce, R.N., I.B.C.L.C., Diane Trovato, R.N., Wendy Latta,
R.N., B.S.N., M.N., and Brigid Ting, R.P.N. (Retired), B.S.N., M.Ed.
322 JOURNAL OF HOLISTIC NURSING / December 2004

The purpose of the study was to determine if women hospitalized

for treatment of their chemical dependency who were randomly
assigned to daily TT would have lower anxiety levels and levels of
withdrawal symptoms than those randomly assigned to receive daily
companionship by nurses or standard ward care.

LITERATURE REVIEW

Empirical research has demonstrated that TT has significantly re-

duced anxiety in cardiovascular patients (Heidt, 1981; Quinn, 1984),
the elderly (Lin & Taylor, 1998; Simington & Laing, 1993), middle-
aged psychiatric patients (Gagne & Toye, 1994), burn patients (Turner,
Clark, Gauthier, & Williams, 1998), people with terminal cancer
(Giasson & Bouchard, 1998), and female volunteers (LaFreniere et al.,
1999). TT has not been found to significantly lower anxiety scores in
two studies in which only healthy participants were recruited (Engle
& Graney, 2000; Olson & Sneed, 1995).
TT has also been found to significantly lessen a variety of types of
pain, such as tension headaches (Keller & Bzdek, 1986) and
musculoskeletal pain in the elderly. Two meta-analyses of TT (Peters,
1999; Winstead-Fry & Kijek, 1999) concluded that TT could produce a
moderate effect on physiological and psychological outcomes. Heter-
ogeneity of study methods, underreporting of data, and inadequate
description of study samples and the TT intervention limited the
validity of the conclusions from these studies.
Duration of administration of TT has increased in recent years
from 5 minutes or less (Heidt, 1981; Keller & Bzdek, 1986; Meehan,
1993; Quinn, 1984, 1989; Simington & Laing, 1993) to approximately
20 minutes, or until energy balance is restored (Giasson & Bouchard,
1998; Gordon, Merenstein, D’Amico, & Hudgens, 1998; Hagemaster,
2000; LaFreniere et al., 1999; Lin & Taylor, 1998; Peck, 1998; Turner
et al., 1998). A cumulative effect of TT over time has also been demon-
strated (Gordon et al., 1998; LaFreniere et al., 1999; Lin & Taylor, 1998;
Peck, 1998; Turner et al., 1998).
One small pilot study examining the efficacy of TT as a comple-
mentary therapy in prolonging periods of abstinence in people who
abuse alcohol and other drugs (Hagemaster, 2000) reported a trend
(p = .068) toward decreased depression among participants treated
with TT. There is no published research investigating the effect of TT
on pregnant women with chemical dependency.
Larden et al. / EFFICACY OF THERAPEUTIC TOUCH 323

METHOD

Design and Setting

A three-group randomized controlled design was chosen for this
study. A certificate of ethics approval was obtained from the British
Columbia Women’s Hospital Research Review Committee and from
the University of British Columbia Clinical Research Ethics Board
prior to commencing the study.

Sample
All English-speaking pregnant women admitted to the chemical
dependency treatment ward at British Columbia Women’s Hospital
during the study period, June 1, 2000 to June 1, 2002, were invited to
participate. Among 62 women approached, 54 agreed to participate.
Allocation to trial arm was determined by randomization software
and recorded on sequentially numbered cards placed in opaque enve-
lopes that were opened after each study participant was enrolled. Par-
ticipants were randomized to receive either TT; to have a nurse be
present with them in the room either talking, playing cards, making
puzzles, or coloring (presence group); or to have standard care. Writ-
ten, informed consent was obtained from all study participants.
Women participating in the study ranged from 15 to 38 years of
age, with a mean of 27 years (see Table 1). Forty percent were married
or in a common-law relationship. Ninety-eight percent were unem-
ployed. Sixty-seven percent did not finish high school, and only 12%
had postsecondary education. Forty-nine percent were Caucasian,
43% First Nations, and the remainder were Asian. Participants in the
three trial arms did not differ significantly according to age, marital or
employment status, ethnicity, or level of education completed. Prior
drug use was similar among the three groups. Twenty-one percent
were experiencing their first pregnancy and 61% had at least one liv-
ing child. Gravidity and parity were not significantly different among
the treatment groups.

Procedures
Prior to the initial treatment, sociodemographic and pregnancy-
related data were collected from each participant, as well as initial
scores on the Symptom Checklist and the State-Trait Anxiety
324 JOURNAL OF HOLISTIC NURSING / December 2004

TABLE 1
Demographic and Pregnancy-Related Characteristics
of Participants by Treatment Group

Therapeutic Presence Standard Care

Touch (n = 18) (n = 16) (n = 20) p Value*

Age Mean ± SD 26.7 ± 1.42 28.0 ± 5.86 27.11 ± 5.73 .81

Marital status
single: n (%) 9 (50) 10 (62.5) 13 (65) .61
a
Unemployed: n (%) 17 (100) 15 (93.8) 20 (100) .31
Ethnicity: n (%)
First Nations 7 (38.9) 8 (50) 8 (40) .51
Caucasian 11 (61.1) 10 (37.5) 11 (50)
Other 0 2 (12.5) 2 (10)
a
Education completed: n (%)
Grade 7 or less 8 (50.1) 10 (62.5) 11 (55) .68
Grade 12 5 (31.3) 5 (31.3) 7 (35)
Postsecondary 3 (18.8) 1 (6.3) 2 (10)
Prior drug use:
Cocaine 11 (61.1) 13 (81.3) 17 (85) .19
Heroin 10 (58.8) 9 (56.3) 12 (60) .97
Ativan 5 (27.8) 5 (31.3) 2 (10) .25
Methadone 5 (27.8) 5 (33.3) 2 (10) .25
Cigarettes 14 (87.5) 13 (81.3) 14 (77.8) .76
Other 7 (41.2) 5 (33.3) 9 (45) .78
a. Missing data for some participants.
*p ≤ .05.

Inventory (STAI-X). In the experimental group, TT was administered

by one of six nurses in a standardized fashion according to Krieger’s
(1993) technique. Each nurse had received formal training and had
practiced as a TT practitioner for a minimum of 2 years. Treatments
were given daily for 7 consecutive days for a period of 20 minutes. If a
participant left the ward without medical leave and returned, the
treatments were continued daily until seven treatments had been
given. The same nurses who administered TT to the experimental
group spent 20 minutes in the presence of women in the first control
group (presence group) daily. Participants chose an activity as previ-
ously described. In the group receiving standard care, contact with
the study nurses was limited to daily collection of study data. There
was no scheduled time during which nurses spent one-on-one time
with participants. Outcome measures included anxiety and
symptomatology related to withdrawal from substances.
Larden et al. / EFFICACY OF THERAPEUTIC TOUCH 325

Instruments
The STAI-X (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983)
is a 20-item scale asking participants to rate how they feel at the time
of completing the questionnaire, on a 4-point response scale. The Trait
subscale on this tool measures anxiety as an emotional state. This
scale has been validated in a number of studies and across a variety of
ethnic groups (Iwata et al., 1998). Factor analysis has indicated that
anxiety is represented as a unidimensional construct. Possible scores
range from 20 to 80, with 80 indicating high anxiety. Ayers (2001)
found that internal consistency for the State subscale ranged from .86
to .95 in pregnant and postpartum women. Test-retest reliability was
.35, which is expected as state anxiety changes over time. In the cur-
rent study, internal consistency (Cronbach’s alpha) for the STAI-X
was 90.5%, consistent with reliability indices previously published
for pregnant women (Ayers, 2001).
The Symptom Checklist was used to reflect participants’ experi-
ence of withdrawal symptoms in the prior 24-hour period. This tool
was developed at the Aurora Centre, a residential treatment center in
Vancouver, British Columbia, for women recovering from chemical
dependency (Poole, 1998). It consists of seven questions about with-
drawal symptoms, including drug cravings, physical symptoms
(headaches, shakes, sweats, body aches, nausea, and diarrhea), sleep
disturbances, anxiety, depression, concentration, and energy level.
Participants rate their perception of the symptom severity on a visual
analogue scale ranging from 0 (representing none/never) to 10 (mean-
ing severe/always). Internal consistency (Cronbach’s alpha) for this
scale in the current study was 86.2. Construct validity was demon-
strated by the ability of the tool to discriminate between women with-
drawing from substances who were exposed to acupuncture versus
no treatment. Qualitative reports from participants supported the
efficacy of acupuncture in congruence with the checklist (Poole,
1998).
The Symptom Checklist was completed prior to each TT or pres-
ence session. The STAI-X form was completed immediately following
the encounter to measure state anxiety after the intervention. Women
receiving standard ward care completed study data forms and placed
them in sealed envelopes collected daily by the study nurse. If partici-
pants left the hospital for any reason and returned, the study was
resumed. The treatments, therefore, were not provided on consecu-
326 JOURNAL OF HOLISTIC NURSING / December 2004

tive days but were interrupted for variable periods for most of the
study participants.
Demographic and pregnancy-related characteristics of the partici-
pants were analyzed using chi-square for categorical data and analy-
sis of variance for continuous data. Anxiety and withdrawal symp-
tom scores were compared among the three groups on each of 7 days
of treatment using repeated-measures linear regression (general lin-
ear modeling). This approach measures differences between groups
while taking into account change within participants over time. An
alpha level of .05 was adopted as the criterion for rejection of a null
hypothesis.

RESULTS

As expected among this population of women, there were high

rates of attrition (see Figure 1). In the TT arm of the trial 12/18 (66%)
completed all 7 days of treatment as planned; in the presence group
this proportion was 7/16 (44%), and in the standard care group 11/20
(55%). Among 30 participants completing treatment, only 16 partici-
pants, 5 (28%) in TT, 3 (19%) in presence, and 8 (40%) in standard care,
completed their seven treatments on consecutive days. Participants
who withdrew left without explanation, and it is assumed, as is com-
mon among this population, that they returned to use of street drugs.
Among these, 5 out of 6 returned for subsequent treatment in the TT
and presence groups compared to 2 among a total of 7 in the ward
group. Women returning to the ward did so because of an ongoing
desire to manage their drug use in a way that was safest for their
babies. Two women who were randomized to the TT group withdrew
from the study prior to receiving a TT treatment. One stated that she
had changed her mind about participating in the study and the other
did not provide a reason but left the ward against medical advice the
following day.
Among 42 women who received three treatments, those in the TT
group (n = 16) had statistically significantly lower anxiety scores com-
pared to the presence (n = 11) and standard care groups (n = 15) fol-
lowing the first, second, and third treatments, F(2, 42) = 3.96, p = .027
(see Figure 2). After the first day of treatment (Day 2 of the study),
mean scores in the TT group were significantly lower than the pres-
ence group and on Days 3 and 4, significantly lower than either the
presence or standard care group. After Day 5, when the number of
Larden et al. / EFFICACY OF THERAPEUTIC TOUCH 327

54 Women Randomized

TT (18) Presence (16) Standard Care (20)

No
Treatment (2) Discharged Self-discharged
(5) (6) Discharged
Discharged (3)
(5)
Returned (5)

Self-discharged Self-discharged
(6) (7)

Returned (5) Returned (2)

Completed 7 Days
Completed 7 Days Of Treatment (7) Completed 7 Days
Of Treatment (12) Of Treatment (11)

Treatment
Treatment Uninterrupted Treatment
Uninterrupted (3) Uninterrupted
(5) (8)

Figure 1: Participation and Attrition of Sample Participants.

60

50

40
TT
30 Presence
Ward
20

10

0
1 2 3 4 5 6 7 8

Figure 2: Mean Anxiety Scores of Participants, Days 1-8.

NOTE: TT = Therapeutic Touch. Mean anxiety scores for TT group are significantly
lower than either the presence or standard care group on Days 2, 3, and 4. p < .05.

women remaining in the study dropped as a result of discharges or

leaving the hospital against medical advice, the differences in anxiety
scores were no longer statistically significant, although anxiety scores
remained lower in the TT group. There were no significant differences
328 JOURNAL OF HOLISTIC NURSING / December 2004

40

35

30

25
TT
20 Presence
Ward
15

10

0
1 2 3 4 5 6 7 8

Figure 3: Mean Symptom Scores of Participants, Days 1-8

NOTE: TT = Therapeutic Touch.

between the half whose treatment was not interrupted compared to

those for whom it was.
There were no statistically significant differences in groups with
respect to mean symptom scores (see Figure 3). Mean symptom scores
referred to a summary score for drug cravings, physical symptoms,
(including shakes, sweats, headaches, body aches, nausea, diarrhea),
sleep disturbances, anxiety, depression, concentration, and energy
level. It was noted that women often fell asleep after the treatment.
Subjective data from women who had received TT included the fol-
lowing comments: “I had the best sleep I have had in months”; “I feel
less twitchy.”
There were no statistically significant differences in total symptom
scores between groups over the 7 days of the study. When assessed
individually, there were no significant differences in symptom levels
among groups.

DISCUSSION

Anxiety was significantly lower in the TT group compared to the

presence and standard care groups during the first 3 days of treat-
ment. These results are meaningful in recognition of the high inci-
dence of anxiety found in women with a chemical dependency
(Schottenfeld & Pantalon, 1999). Reduction in anxiety scores concurs
Larden et al. / EFFICACY OF THERAPEUTIC TOUCH 329

with findings from previous research demonstrating that TT signifi-

cantly lessened anxiety in other populations (Gagne & Toye, 1994;
Giasson & Bouchard, 1998; Heidt, 1981; LaFreniere et al., 1999; Lin &
Taylor, 1998; Quinn, 1984; Simington & Laing, 1993; Turner et al.,
1998). On Day 7, there is a small rise in mean anxiety for the TT group
noted when scores are plotted (see Figure 2). Anticipation of ending
contact with the TT practitioner may have contributed to this finding.
Alternatively, there may be poorly understood reasons related to sub-
stance dependency that lead to an increase in anxiety during the
hospitalization period.
A harm-reduction approach to treat chemical dependency during
pregnancy attempts to minimize withdrawal symptoms to persuade
women to abstain from street drug use (Kleber, 1999). There were no
significant findings related to withdrawal symptoms measured on
the Symptom Checklist. It is possible that a 7-day period is too short to
realize the benefits of TT for symptom relief. Examination of with-
drawal symptoms over a longer period of time in a larger study is
warranted. Alternatively, the Symptom Checklist may not have been
a sufficiently sensitive measure.
The study was limited by a small sample size, which limited our
ability to identify causal relationships. A priori sample size calcula-
tions were not undertaken due to the absence of published or baseline
data on which to base such calculations. Additional limitations
include attrition among study participants who left the hospital for
variable periods of time against medical advice, inability to blind
study participants, and a single study site. A strength of this study is
the randomized three-group experimental design, which facilitated
homogeneity of participant characteristics within groups. It is the first
study conducted to evaluate if exposure to TT can result in lower lev-
els of anxiety and withdrawal symptoms for pregnant inpatients who
have a chemical dependency.
This study suggests that TT may promote lower levels of anxiety in
pregnant inpatients with a chemical dependency compared to nurs-
ing presence alone or standard care. A harm-reduction approach for
pregnant women with chemical dependency entails nonjudgmental
care that aims to reduce risks to these women and their fetuses
(Kleber, 1999). An intervention that reduces anxiety fits with a harm-
reduction approach and could be a valuable adjunct to the care of
chemically dependent women. In this study, exposure to TT resulted
in significantly lower levels of anxiety over the first 3 days of treat-
ment. The body comprises complex and interconnected systems.
330 JOURNAL OF HOLISTIC NURSING / December 2004

When there is a problem in one system, it may adversely affect others.

Conversely, when a problem in one system is resolved, it affects the
whole organism positively (May, 2001). TT is a simple and inexpen-
sive way to deal with the complex, multifaceted issues of chemical
dependence. It uses a holistic approach that may have the potential to
improve compliance with chemical dependency treatment protocols.
A larger sample and continuation of TT treatment for more than 7
days is indicated to test the effect on withdrawal symptoms. Qualita-
tive data from pregnant women hospitalized with drug addiction
could be useful in determining additional measures of efficacy.

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Cheryl N. Larden, R.N., B.S.N., is a perinatal nurse at British Columbia Women’s

Hospital in the antepartum and postpartum clinical areas and is a perinatal clinical
educator. Cheryl has practiced Therapeutic Touch since the 1980s. She has studied un-
der Delores Krieger and Dora Kunz, the originators of Therapeutic Touch. She is an
instructor and a founding member of the British Columbia Therapeutic Touch Net-
work. Cheryl makes use of her skills in Therapeutic Touch in her hospital-based nurs-
ing as well as in private practice.

M. Lynne Palmer, R.N., B.Sc.N., is the coordinator of the Antepartum Care Pro-
gram in Surrey Memorial Hospital, and at the time of the study, she was affiliated
with British Columbia Women’s Hospital. For her master’s in nursing thesis, she is
conducting a qualitative study exploring the experience of women receiving
antepartum care at home in identifying preterm labor. Recent publications include
(with C. West and T. Tier) “No Place Like Home (Canadian Nurse, 2000).

Patricia Janssen, R.N., Ph.D., is an assistant professor in the Department of

Health Care and Epidemiology at University of British Columbia and an associate
faculty member in the School of Nursing. Her work focuses on maternal/newborn
health. Recent publications include (with E. Weibe, A. Henderson, and I. Fung) “Eth-
nic Chinese Women’s Perceptions About Condoms, Withdrawal, and Rhythm Meth-
ods of Birth Control” (Contraception, 2004), (with P. Janssen, and S. Lee) “Out-
comes of Planned Hospital vs. Planned Home Births in British Columbia (Journal
Salude (i) Ciencia, 2003), and (with P. Janssen, C. Iker, and E. Carty) “Early Labour
Assessment And Support At Home: A Randomized Controlled Trial” (SOGC Jour-
nal, 2003).