doi: 10.9769/EPJ.2012.4.1.DC
Dawson Church, PhD
Foundation for Epigenetic Medicine
Editorial
The History and Future of Trauma Treatment.
In the past few years, energy psychology has amassed a respectable research base. Many new studies have been published in peer-reviewed professional journals showing that methods using the stimulation of acupressure points combined with cognitive and exposure techniques Emotional Freedom Techniques (EFT) and Thought Field Therapy (TFT) in particular are efficacious for many of the most common mental health conditions.
They also show promise for physical problems such as pain. That is the milestone that the energy psychology field has recently passed. What is the milestone ahead? The most exciting development is the movement toward making these modalities available online, bringing the benefits of energy psychology to a large population.
There are many advantages to online delivery of a therapy, some of which are the following:
- Lowered service burden on mental health and primary care services;
- Frequent reinforcement of desired change;
- Avoidance of power differentials inherent in the therapeutic relationship;
- User access to 24/7 support, including at times they are having the most difficulty
- Rudimentary mental health tool placement in the hands of front-line service personnel (e.g., first responders, medics, aid workers, and physicians’ assistants);
- Help provided to rural populations lacking access to mental health services;
- Online treatment supplements to individual and group therapy sessions;
- Help obtained without disclosing one’s condition to others;
- Accessibility of self-help tools between office visits to a therapist;
- Rapid resolution of certain problems in compressed time frames;
- Greater user control of timing and duration of intervention;
- Embrace of online technologies by young people;
- Inexpensive and customized software user interfaces (“skins”) for special populations (e.g., preoperative patients, military personnel, university students);
- User customization of services selected (e.g., public speaking anxiety vs. test anxiety vs. needle phobia);
- Portable service provision on smartphones and other mobile devices; and
- Lowered cost burden to society.
These and other issues are discussed in new publications such as the Journal of Medical Internet Research (Griffiths, Lindenmeyer, Powell, Lowe, & Thorogood, 2006).
The most recent milestone passed was an analysis showing that existing published research meets established efficacy standards for treating several psychological conditions. The standards were developed by American Psychological Association (APA) Division 12 (Society of Clinical Psychology) in the 1990s as a way of identifying “empirically validated treatments.”
They define an empirically validated treatment as one for which there are two different controlled trials conducted by independent research teams. For a treatment to be designated as “efficacious,” the studies must have demonstrated that the treatment is better than a wait list, placebo, or established efficacious treatment.
To be designated as “probably efficacious,” a treatment must have been shown to be better than a wait list in two studies that meet these criteria or to have been conducted by the same research team rather than two independent teams.
The APA standards advocate that studies contain sufficient subjects to achieve a level of statistical significance of p < .05 or greater, which means that there is only one possibility in 20 that the results are due to chance. The current status of EFT as an “evidence-based” practice is summarized in this statement to be published in the APA journal Review of General Psychology:
A literature search identified 50 peer-reviewed papers that report or investigate clinical outcomes following the tapping of acupuncture points to address psychological issues.
The 17 randomized controlled trials in this sample were critically evaluated for design quality, leading to the conclusion that they consistently demonstrated strong effect sizes and other positive statistical results that far exceed chance after relatively few treatment sessions.
Criteria for evidence-based treatments proposed by Division 12 of the American Psychological Association were also applied and found to be met for a number of conditions, including PTSD. (Feinstein, in press)
As the status of energy psychology as an evidence-based practice becomes increasingly secure, the milestone that lies ahead is to extend the benefits of these practices through online delivery systems and test their efficacy when delivered in this format. Such testing can be faster and cheaper than traditional research.
The first online study of EFT was performed by Gunilla Brattberg, MD, of Lund University in Sweden (Brattberg, 2008). She conducted a randomized controlled trial of fibromyalgia published in the journal Integrative Medicine. She found a statistically significant improvement in fibromyalgia pain as well as depression and anxiety.
She expressed her results in the form of NNT, or Number Needed to Treat. This is a measure of how many patients have to receive a treatment in order for one to benefit. A high number means that many patients have to receive the treatment in order for one to benefit, and a low number means the opposite.
The most effective therapy possible would have an NNT of one; every person treated would benefit. The NNT for Lipitor (Pfizer, New York, NY), the most widely prescribed pharmaceutical drug in the United States, is 100. One hundred patients have to receive Lipitor in order for one to benefit. The NNT in the Brattberg study was 3 for depression and anxiety. For every three fibromyalgia patients receiving Brattberg’s online protocol, one would benefit. This is a very strong result when compared with most conventional treatments.
Several methods for delivering EFT other than individual therapy have been tested. In a controlled trial of veterans with PTSD, Hartung and Stein (2012) compared telephone coaching with office visits. Two thirds of the veterans receiving telephone coaching showed a significant symptom reduction within six EFT sessions.
For office visits, the results were even stronger, with 91% of veterans going from above to below PTSD thresholds on standardized inventories within six EFT sessions. The superiority of office visits in reducing symptoms should not, however, obscure the strong results obtained over the telephone. The telephone sessions still produced a better result than most other therapeutic methods can offer, along with the expanded accessibility and other advantages of a nonoffice option.
Another way of delivering energy psychology interventions is in group therapy sessions. This has been reported in several studies. A study of 216 healthcare workers receiving a day of group EFT found a 45% reduction in psychological symptoms such as depression and anxiety (Church & Brooks, 2010).
A randomized controlled trial of depression in college students found that most participants in the moderate to severe depression category normalized after four group therapy sessions (Church, De Asis, & Brooks, in press). Rwandan orphans who received TFT group therapy experienced significant reductions in PTSD symptoms (Stone, Leyden, & Fellows, 2009).
Taken together with similar published studies, this research has demonstrated that delivery methods other than personal counseling can improve mental health. The next logical step is to make them available online and test them against other delivery methods that have already demonstrated their efficacy.
Research is often driven by the availability of technology. The human genome project was accelerated by the development of fast and inexpensive gene sequencers. Brain research made huge strides when MRIs became available. In a similar way, the electronic delivery of energy psychology will be driven by the availability of new online content delivery systems.
Several of these have become available recently, and more will follow. Three are Moodle, Learnexa, and Articulate Storyline. These online content delivery systems combine many of the components one would expect to find in a university course into an online class. They provide a rich user experience that flips seamlessly between a wide variety of media.
They can serve up PDFs, HTML web pages, videos, spreadsheets, word processing documents, PowerPoints, live streaming video, quizzes, certification programs, live instruction from a teacher, instant feedback from students, chat forums, social networking, and live video images of participants.
Hardware is interacting with software to accelerate this progress. Today’s smartphones have more computing power than the laptops of 10 years ago and are able to perform more functions using less bandwidth. With data stored on cloud services, and applications such as spreadsheets and word processors increasingly accessed from online servers rather than local hard drives, powerful data processing operations are possible from remote locations.
Some organizations, such as the U.S. Department of Defense, have already written applications that use smartphones to deliver psychological services. One called PTSD Coach, released by the Defense Department in 2011, is a free mobile app that allows users to track their symptoms, discover local support services, identify personal strategies for managing PTSD, and receive anonymous assistance.
There are already at least four EFT applications available in the iTunes store. They range from a simple application that recaps EFTs Basic Recipe to a sophisticated application offering virtual coaching for specific mental health problems like anxiety and depression.
It is also conceivable that mental health interventions can be built into online games. Many children’s games combine play and learning.
A tapping game might reward users who lower their stress levels; a multiplayer world modeled on an interface similar to World of Witchcraft, which allows thousands of simultaneous users worldwide to band together for battles, quests, and treasure hunts, might instead create a virtual world in which users could offer energy psychology relief services to disaster victims, educate children, or mediate in geopolitical conflicts.
The iTunes store includes scores of games that use nontherapeutic tapping, in some form or other, as part of the user interface. They include Tapping Ants, Toddler’s Tapping Zoo, Tap of War, Speed Tapping, and many others. Applications could be developed that combine acupoint tapping with game play for therapeutic gain.
There is no guarantee that only roses will bloom in this new world. It is also possible that research will discover potential dangers in the online delivery of energy psychology methods. There are certainly high risks with many drug-based conventional therapies. The flip side of NNT is NNH, or Number Needed to Harm. This is a measure of the potential risks of a therapy.
With the NNH, the lower number is the undesirable one; that is, an NNH of 5 means that it only takes five people taking it for one person to experience harmful effects. Pregabalin (brand name Lyrica; Pfizer, New York, NY), an antiseizure medication touted for use in reducing the pain of fibromyalgia, has an NNT of 5, which might not be so bad, but its NNH is reportedly close to 1.
That means that nearly every person taking it will experience harmful effects. Xanax (Pfizer,New York, NY), an antianxiety drug often prescribed for fibromyalgia patients, has an NNT of 6 (six people treated before one benefits) and an NNH of 3 (three people treated, one harmed).
By way of contrast, in the thousands of subjects treated in the dozens of energy psychology studies published to date, no adverse events have been reported. That does not mean that, as its use spreads and unsupervised online delivery increases, dangers will not become apparent.
Some possible source of harm might be:
- Overenthusiastic users might employ online energy psychology as a substitute for proper medical or mental health treatment.
- Users might attempt inappropriate self-treatment of severe mental health diagnoses like schizophrenia or bipolar disorder.
- Early success might encourage users to employ energy psychology alone, instead of using it within a suite of other methods that can support progress.
- Psychological abreactions that a user, alone in a room with a computer, cannot manage might occur.
- Users might display a lack of control over how much time is spent on resilience-building before undertaking potentially retraumatizing psychological exploration.
- Beneficial initial experiences might spontaneously open up deep-seated traumatic wounds that the user is not equipped to deal with.
- se of energy psychology might undermine therapeutic alliances with trained mental health professionals.
- Novice users might attempt to use freely accessible online tools to treat other persons without obtaining training or licensure.
- Clients may lack discrimination as to the quality of available web therapies.
For reasons such as these, it is important that online projects incorporate a research component whenever possible. This might include an informed consent statement that includes a description of potential harms, plus an online version of a simple assessment such as the Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983), which can be completed by the user online in less than a minute.
A high score could alert both user and provider of the enhanced possibility of risk, and steps could then be taken to reduce this risk before it becomes substantive.
Despite these drawbacks, the online delivery of mental health services is likely to increase dramatically in the coming years, driven by technology and user demand. Brattberg’s study (2008) opened the eyes of many clinicians to the possibility of treating large numbers of sufferers using online treatment programs.
At present, online EFT research has been proposed or is in progress for prostate cancer, depression, interpersonal relationships, and PTSD, as well as a replication and extension of Brattberg’s study. The next few years will see the publication of these data.
The many desirable characteristics of online delivery of energy psychology methods are unlikely to mean that they will completely replace traditional methods. Clients will still visit psychotherapists and life coaches.
No computer program, no matter how sophisticated, can interpret the millions of sensory and energetic cues provided by one-to-one human interaction. However, the advent of online delivery systems will make energy psychology available to vastly greater numbers of people at greatly reduced cost. If the 45% reduction in psychological distress found in the healthcare workers study were applied to millions of people rather than 216, the online delivery of energy psychology could make a serious reduction in aggregate human suffering.
References
Brattberg, G. (2008). Self-administered EFT (Emotional Freedom Techniques) in individuals with fibromyalgia: A randomized trial. Integrative Medicine: A Clinician’s Journal, 7(4), 30-35.
Church, D., & Brooks, (2010). The effect of a brief EFT (Emotional Freedom Techniques) self-intervention on anxiety, depression, pain and cravings in healthcare workers, Integrative Medicine: A Clinician’s Journal, 9(4), 40-44.
Church, De Asis, & Brooks (in press). Brief group intervention using EFT (Emotional Freedom Techniques) for depression in college students: A randomized controlled trial. Depression Research and Treatment.
Feinstein, D. (in press). Acupoint stimulation in treating psychological disorders: Evidence of efficacy. Review of General Psychology.
Griffiths, F., Lindenmeyer, A., Powell, J., Lowe, P., & Thorogood, M. (2006). Why are health care interventions delivered over the internet. A systematic review of the published literature. Journal of Medical Internet Research, 8(2), e10.
Zigmond, A.S., & Snaith, R.P. (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandanavia, 67, 361-370.
Hartung, J., & Stein, P. (2012). Telephone delivery of EFT (Emotional Freedom Techniques) remediates PTSD symptoms in veterans: A randomized controlled trial. Energy Psychology: Theory, Research, and Treatment, 4(1), 33-42.
Stone, B., Leyden, L., & Fellows, B. (2009). Energy psychology treatment for posttraumatic stress in genocide survivors in a Rwandan orphanage: A pilot investigation. Energy Psychology: Theory, Research, and Treatment, 1(1), 73-82.
U.S. Department of Veterans Affairs (VA). (2011). PTSD coach (Version 1.0.1) [Mobile application software]. Retrieved from http://itunes.apple.com