BIOLOGY BSC1010 – Psychotherapy Theory, Research, Practice, Training

Psychotherapy Theory, Research, Practice, Training2008, Vol. 45, No. 2, 199 –213Copyright 2008 by the American Psychological Association0033-3204/08/$12.00DOI: 10.1037/0033-3204.45.2.199ENERGY PSYCHOLOGY: A REVIEW OF THEPRELIMINARY EVIDENCEDAVID FEINSTEINThis document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.Private Practice, Ashland, OregonEnergy psychology utilizes imaginaland narrative-generated exposure,paired with interventions that reducehyperarousal through acupressure andrelated techniques. According to practitioners, this leads to treatment outcomes that are more rapid, powerful,and precise than the strategies used inother exposure-based treatments suchas relaxation or diaphragmatic breathing. The method has been exceedinglycontroversial. It relies on unfamiliarprocedures adapted from non-Westerncultures, posits unverified mechanismsof action, and early claims of unusualspeed and therapeutic power ran farahead of initial empirical support. Thispaper reviews a hierarchy of evidenceregarding the efficacy of energy psychology, from anecdotal reports to randomized clinical trials. Although theevidence is still preliminary, energypsychology has reached the minimumthreshold for being designated as anevidence-based treatment, with oneform having met the APA Division 12criteria as a “probably efficacioustreatment” for specific phobias; anotherfor maintaining weight loss. The limitedscientific evidence, combined with extensive clinical reports, suggests thatDavid Feinstein, Private Practice, Ashland, Oregon.Comments on previous drafts of this paper by Fred P.Gallo, Douglas J. Moore, Ronald A. Ruden, and Robert Scaerare gratefully acknowledged.Correspondence regarding this article should be addressedto David Feinstein, PhD, 777 East Main Street, Ashland, OR97520. E-mail: df777@earthlink.neenergy psychology holds promise as arapid and potent treatment for a rangeof psychological conditions.Keywords: acupuncture, EFT, energypsychology, TAT, TFTEnergy psychology (EP) is comprised of a setof physical and cognitive procedures designed tobring about therapeutic shifts in targeted emotions, cognitions, and behaviors (Gallo, 2004). Ithas been used as an independent psychotherapeutic approach, as an adjunct to other therapies, andas a back home tool for emotional selfmanagement. In all three applications, althoughthe method is grounded in established psychological principles regarding affect, cognition, andbehavior, it also incorporates concepts and techniques from non-Western systems for healing andspiritual development. Specifically, EP, which isa derivative of energy medicine (Feinstein &Eden, 2008), postulates that mental disorders andother health conditions are related to disturbancesin the body’s electrical energies and energyfields.Many of the body’s electrical systems and energy fields are understood, readily verified, and afocus of established interventions. The application of lasers and magnetic pulsation, for instance, can be described in terms of specific,measurable wavelengths and frequencies thathave been found to be therapeutic (Oschman,2003). Other postulated energies are consideredto be of a more subtle nature and have not beendirectly measured by reproducible methods. Although such subtle energies are generally not recognized in Western health care frameworks, theyare at the root of numerous ancient systems ofhealing and spiritual development that are not onlystill in wide use throughout the world but increasingly being utilized in the West (Meyers, 2007).EP has been referred to as “acupuncture without needles” in treating mental health disorders.199This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.FeinsteinThe efficacy of acupuncture and acupressure (anonneedle form of acupuncture) is well established. The World Health Organization (WHO,2002) lists 28 conditions where scientific studiesstrongly support acupuncture’s efficacy and 63more conditions for which therapeutic effectshave been observed but not scientifically established. A review of 420 articles by HarvardMedical School’s Consumer Health Informationwebsite (http://www.intelihealth.com) found atleast preliminary evidence for the efficacy ofacupressure with many of the conditions listed inthe WHO report, including a variety of affectrelated conditions, such as anxiety, depression,addictions, insomnia, and hypertension.More than two dozen variations of EP can beidentified, with the most well-known beingThought Field Therapy (TFT), the Tapas Acupressure Technique (TAT), and the EmotionalFreedom Techniques (EFT). Many of the variations adapt practices and concepts from acupuncture and acupressure; others borrow from yoga,meditation, qigong, and other traditional practices. Some conceive of their distinctive therapeutic mechanism as the activation of electricalsignals that purportedly influence brain activity(Ruden, 2007); others as catalyzing shifts in putative energy fields, such as the body’s biofield(Rubik, 2002). TFT, TAT, and EFT, each utilizing techniques derived from acupuncture andacupressure, have received by far the most attention and investigation, and they will be the focusof this review.A Shared Core StrategyNearly all the therapies and emotional selfmanagement approaches that fall under the heading of EP, however, share a common core strategy. They combine physical interventions forregulating electrical signals or energy fields withmental involvement in a feeling, cognition, orbehavior that is a target for change. This simultaneous pairing of the physical activity and mental activation is believed to therapeutically alterthe targeted response.In brief, beyond whatever unfamiliar methodsit may incorporate, EP is an exposure-based treatment. The effectiveness of exposure therapieswith posttraumatic stress disorder (PTSD) andother anxiety disorders is well established. Exposure is, in fact, the single modality for which theevidence is sufficient to conclude, according to200stringent scientific standards (National Instituteof Medicine’s Committee on Treatment of Posttraumatic Stress Disorder, 2007), that the methodis an efficacious treatment for PTSD. Other treatments that have strong empirical support in treating PTSD, such as cognitive-processing therapy,stress inoculation training, and eye movementdesensitization and reprocessing (EMDR), alsogenerally incorporate substantial exposure components (Keane, Foa, Friedman, Cohen, & Newman, 2007).In EP, as with other exposure-based treatments,exposure is achieved by eliciting—through imagery, narrative, and/or in vivo experience—hyperarousal associated with a traumatic memoryor threatening situation. Unique to EP is that extinction of this association is facilitated by (a) the manual stimulation of acupuncture and related pointsthat are believed to (b) send signals to the amygdalaand other brain structures that (c) quickly reducehyperarousal. When the brain then reconsolidatesthe traumatic memory, the new association (to reduced hyperarousal or no hyperarousal) is retained.According to practitioners, this leads to treatmentoutcomes that are more rapid (less time; fewerrepetitions) and more powerful (higher impact;greater reach) than the strategies used by otherexposure-based treatments that are available tothem, such as relaxation, desensitization, mindfulness, flooding, or repeated exposure. Another clinical strength reported by practitioners is increasedprecision, and thus less chance of retraumatization.By being able to quickly reduce hyperarousal to atargeted stimulus, numerous aspects or variations ofa problem may be identified, precisely formulated,and treated within a single session.A survey of several major EP textbooks(Callahan & Trubo, 2002; Diepold, Britt, &Bender, 2004; Feinstein, 2004; Gallo, 2004;Hartung & Galvin, 2003; Mollon, 2008) revealsfour typical foci of EP interventions: immediatereduction of elevated affect, extinguishing conditioned responses, addressing complex psychological problems, and promoting optimal functioningor peak performance. For instance, the stimulation of specified acupuncture points (acupoints)has been shown to decrease activation signals inthe amygdala (Hui et al., 2000), and holding suchpoints has been shown to rapidly decreaseanxiety in people who sustained minor injuriesduring an accident (Kober et al., 2002). Anotherexample of EP reducing elevated affect is thatindividuals required to describe recent traumaticThis document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.Special Section: Energy Psychologyexperiences to government officials evidenced lessanxiety and greater accuracy in their reports whenthey tapped a specified set of acupoints while recounting the event (Carrington, 2005). By addingimaginal exposure, this core strategy has beenshown to extinguish a range of maladaptive conditioned responses, such as specific phobias (Wells,Polglase, Andrews, Carrington, & Baker, 2003) and¨test-taking anxiety (Sezgin & Ozcan, 2004). Elaborations on it have been applied to a spectrum ofpsychological problems and goals (Gallo, 2002).Relatively easy to learn, the method is most frequently integrated into the clinician’s existing repertoire when treating complex issues.ControversiesEP has been exceedingly controversial amongpsychotherapists. Its advocates have for morethan two decades been claiming a level of clinicaleffectiveness for a range of conditions that surpasses that of established treatment modalities inits speed and power, but a robust body of researchdirectly supporting these claims has yet to beproduced. Confounding this basic credibilityproblem, EP is rooted in an unfamiliar paradigmadapted from non-Western health care practices,its techniques look patently strange (e.g., humming or counting while tapping on the back ofone’s hand), and even its most committed practitioners disagree about the mechanisms thatmight explain the results they report.The approach has, nonetheless, gained a strongpopular following. EFT Insights, an e-newsletterthat provides instruction on how to utilize EFT ona professional as well as self-help basis, had368,000 active subscribers at the time of thiswriting, and this number was showing a net increase of more than 7,000 per month (G. Craig,personal communication, December 27, 2007).The media has been intrigued by claims made byEP practitioners and their clients. Numerous EPphobia treatments have, for instance, been airedon TV talk-shows, including dramatic pre- andposttreatment clips. In one such program, awoman who convincingly described a terror ofspiders appeared calm, following a brief TFTsession, as she permitted a tarantula to crawl onher hand (Coghill, 2000).EP protocols are also increasingly being utilized in traditional health care settings such asHealth Maintenance Organizations (HMOs; Elder et al., 2007), disaster relief efforts (Feinstein,2008), and Veteran’s Administration (V.A.) hospitals. Lynn Garland, a social worker with theVeterans’ Health care System in Boston, for instance, reports that she, along with numerouscolleagues using energy psychology in the V.A.,are having “dramatic results in relieving bothacute and chronic symptoms of combat-relatedtrauma” (Feinstein, Eden, & Craig, 2005, p. 17).An international professional organizationwith more than 1,000 members, the Associationfor Comprehensive Energy Psychology (www.energypsych.org), was incorporated in theUnited States in 1999 and has developed a comprehensive certification program and ethics code.EP is increasingly recognized in Europe, with“Advanced Energy Psychology” qualifying ascontinuing education for psychologists,physicians, and related professions in severalcountries, including Germany, Austria, and Switzerland. A review of one of EP’s major texts(Energy Psychology Interactive; Feinstein, 2004)in the online book review journal of the American Psychological Association (APA) noted thatbecause EP successfully “integrates ancientEastern practices with Western psychology [itconstitutes] a valuable expansion of the traditional biopsychosocial model of psychology toinclude the dimension of energy” (para. 5). Thereview, by a former APA division president, described EP as “a new discipline that has beenreceiving attention due to its speed and effectiveness with difficult cases” (Serlin, 2005, para. 2).Professional gatekeeping organizations and forums in the United States have not, however,been persuaded. The APA itself singled out EP asan unacceptable topic for its sponsors to offerpsychologists for continuing education credit, apolicy still in effect at the time of this writing. Ascathing commentary by Harvard psychologistMcNally (2001), in a special issue of the Journalof Clinical Psychology focusing on TFT, arguedthat the methodological flaws in existing studiesof the approach render their data to be uninterpretable, ultimately suggesting that until TFTfounder Callahan “has done his homework, psychologists are not obliged to pay any attention toTFT” (p. 1173). In one of the few standard psychology texts to mention EP, Corsini (2001),editor of an anthology of innovative psychotherapies, explained his choice to include a chapteron such an “outlandish” approach by noting thatTFT “is either one of the greatest advances inpsychotherapy or it is a hoax” (p. 689).201This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.FeinsteinBeyond the familiar dilemma of lag time between the introduction of a new therapy and itsscientific evaluation, assessing the viability of EPposes several additional challenges. Its purportedactions cannot be explained by conventional clinicalmodels and some of its methods do not appear to bebased on any rationale accepted by Western science. In addition, despite strong popular interest anda quarter century of efficacy claims by growingnumbers of credible therapists, neutral investigatorshave not carried out comparison studies between EPand conventional modalities. Although the relatively few studies that have been conducted by thefield’s adherents tend to support the new approach,clinicians, insurance providers, and the public arerequired to make the most informed assessmentspossible amid strong conflicting opinions and despite very limited scientific evidence for either establishing or refuting claims about the method’stherapeutic power.The purpose of this paper is to consider theexisting evidence that bears on the efficacy ofTFT, TAT, and EFT, the most widely used formsof EP (a review of literature, websites, and professional organizations suggests that upward of95% of EP treatments are provided by a practitioner trained in one of these modalities). Subsequent investigations are needed to compare theseapproaches with one another, but their sharedstrategy of stimulating acupoints whereas mentally activating a targeted psychological concernis the present focus. Although waiting for thebody of peer-reviewed, replicated, randomizedcontrolled trials (RCTs) that would be required toscientifically confirm or disconfirm the claims ofEP practitioners, this review considers the limitednumber of existing RCTs as well as a hierarchyof evidence that has not been peer-reviewed, suchas anecdotal reports, uncontrolled investigations,master’s and doctoral studies, and other unpublished research. An unusual amount of data ofthis nature is available. By considering each rungof this hierarchy of evidence on its own meritsand within an understanding of its limitations, aninformed preliminary assessment is possible.The ReviewAnecdotal Reports, Systematic Observation, andCase StudiesAn anecdotal report, in itself, carries a lowlevel of scientific credibility. Besides not offering202a comparison condition to control for placebo andother nonspecific therapeutic elements, anecdotalevidence is subject to both selection bias (negative outcomes are less commonly reported by theadvocates of a method) and assessment bias (subjective and sometimes objective incentives forperceiving and reporting positive outcomes maybe substantial). However, when reports coming inlarge numbers from a range of sources quiteremoved from the method’s originators are consistently corroborating one another, a differentlevel of evidence may be accumulating. Stronganecdotal validation of EP is being offered in awide variety of settings by second, third, andfourth generation practitioners, as contrasted withthe method’s developers, who are characteristically biased in evaluating their own approach.Anecdotal evidence.EP maybe unprecedented in the amount of systematically collectedanecdotal outcome data it has accumulated. Theprimary EFT website (http://emofree.com), forinstance, posts thousands of anecdotal reportsbased on self-help, peer-help, and professionalapplications of EFT. A search engine on the sitelists, at the time of this writing, 165 entries fordepression cases, 460 for anxiety, 102 for PTSD,141 for weight loss, 128 for addictions, 90 forsports performance, and 389 for physical pain(which often has an emotional component). Although the descriptive detail and quality of theseentries varies considerably, most of them presentat least one report of a treatment session with asuccessful or partially successful outcome asjudged by the recipient and/or practitioner. Themain TAT website (http://www.tatlife.com) andits newsletter archives include 93 brief practitioner reports of the successful use of TAT with avariety of presenting problems.Treatment sessions are increasingly beingrecorded on video and made available for criticalexamination. Video tapes of sessions with diagnosable disorders, particularly when follow-upsessions are included, allow a more detailed assessment of a method than other types of anecdotal evidence. More than 200 EFT sessions arepart of DVD training programs offered athttp://emofree.com. Among these are rapid anddramatic improvements shown in six inpatients atthe V.A. Hospital in Los Angeles suffering fromprolonged, severe PTSD.Systematic observation of EP in disaster relief.Numerous case histories illustrating theclinical uses of EP are described in the publishedThis document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.Special Section: Energy Psychologyliterature (e.g., Bray, 2006; Gallo, 2002), and asEP has been increasingly applied in disaster reliefsettings, a body of anecdotal and field reports hasbeen accumulating suggesting the method is effective in some of the most challenging situationsmental health practitioners can face. TFT treatments by international teams working with postdisaster victims in Kosovo, Rwanda, the Congo,and South Africa tallied the treatment outcomeswith 337 individuals (Feinstein, 2008). Treatmentfocused on reducing severe emotional reactionsevoked by specific traumatic memories, whichoften involved torture, rape, and witnessing lovedones being murdered. Following the EP interventions, 334 of the 337 individuals were able tobring to mind their most traumatic memories fromthe disaster and report no physiological/affectivearousal. Twenty-two traumatized Hurricane Katrinacare givers participated in a 30-min group orientation and followed by an individual TFT session ofapproximately 15 min. They reported an averageSUD (a 0 to 10 Subjective Units of Distress selfreport scale, after Wolpe, 1958) reduction from amean of 8.14 to 0.76 on 51 problem areas they hadearlier identified (http://www.innersource.net/energy_psych/articles/ep_energy-traumacases.htm).Reported improvements after postdisaster application of EP methods have frequently beencorroborated by local health authorities who hadno affiliation to a particular treatment approach(Feinstein, 2008). The Green Cross (The Academy of Traumatology’s humanitarian assistanceprogram), founded in 1995 after the OklahomaCity bombings to attend to the mental healthneeds of disaster victims, has begun to use EP asa standard protocol for working with disastervictims. According to the organization’s founder,Charles Figley, who also served as the chair ofthe committee of the Department of V.A. thatfirst identified PTSD: “Energy psychology is rapidly proving itself to be among the most powerfulpsychological interventions available to disasterrelief workers for helping the survivors as well asthe workers themselves” (C. Figley, personalcommunication, December 10, 2005).Case studies using brain scans.Case studies are distinguished from anecdotal reports by theinclusion of objective outcome measures, and theyalso frequently supply greater clinical detail thatcreates a stronger context for interpreting findings. Several case studies have examined physiological shifts following EP treatments. A seriesof digitized EEG scans, for instance, examinedchanges in the ratios of alpha, beta, and theta frequencies distributed throughout the brain prior toTFT treatment for an individual diagnosed withgeneralized anxiety disorder (GAD) and after 4, 8,and 12 sessions (posted at http://innersource.net/energy_psych/epi_neuro_foundations.htm). Overthe 12 sessions, the symptoms of GAD abated according to self-reports and SUD ratings. The brainwave patterns, correspondingly, normalized, ascompared with profiles in databases.A second single-case study, by Diepold andGoldstein (2000), evaluated quantitative electroencephalogram (qEEG) measures before a TFTsession, immediately following the session, andon an 18-month follow-up. Statistically abnormalbrain wave patterns were observed when the participant thought about a targeted personal traumaprior to the session, but not when a neutral (baseline) event was brought to mind. Reassessment ofthe brain wave patterns following a TFT treatment that focused on the traumatic memory revealed no statistical abnormalities when thetrauma was again mentally activated. Subjectivedistress, based on self-report, was also eliminated. On 18-month follow-up, the brain wavepatterns were still normal when the trauma wasbrought to mind. Two other brain scan studies(Lambrou, Pratt, & Chevalier, 2003; Swingle,Pulos, & Swingle, 2004), with four claustrophobic participants and nine traumatized participants,respectively, also revealed normalized posttreatment brain wave patterns.In brief.As a group, the anecdotal reports,field observations, and case studies give an impression of therapeutic outcomes that are bothrapid and dramatic, as summarized in Table 1.Although caveats about selective reporting andthe power of nonspecific therapeutic factors suchas placebo must still be taken into account, thisbody of evidence is too large and consistent to bedismissed a priori, as it provides context for evaluating longstanding claims of strong clinical benefits that are mired in controversy.Uncontrolled Outcome StudiesEight uncontrolled outcome studies of EP havebeen conducted, four of which have been publishedafter peer review. Uncontrolled outcome studiesmeasure the effects of a treatment interventionwith a sample of subjects according to specifiedoutcome criteria. No attempt is made to control203FeinsteinTABLE 1. Summary of Anecdotal Reports, Systematic Observation, and Case Studies of EPSourceTreatmentEFThttp://www.tatlife.comThis document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.http://emofree.comTATBray (2006)http://www.innersource. net/energy_psych/articles/ep_energy-traumacases.htmFeinstein (2008)See “Case studies using brainscans” on previous pageTFTTFT or EFT GroupEFT TFTTFTTFT or EFTConditionType of evidenceRange of problemsand goalsRange of problemsand goalsPTSDPostdisaster traumaAnecdotal report; tapedsessionAnecdotal report; tapedsessionAnecdotal reportAnecdotal report;systematic obs…