Draft version 2.3 9/10/06. Paper submitted for journal consideration.

Please do not copy or cite wit out t e aut or!s permission at ener"y#innersource.net.

Energy Psychology: A Review of the Preliminary Evidence

David $einstein% P .D.
ABSTRACT

Energy psychology combines cognitive strategies with somatic procedures adapted from acupuncture and related systems for altering the cognitive, behavioral, and neurochemical foundations of psychological problems. While the number of adherents to this method has grown steadily within the professional community over the past two decades, so has the controversy surrounding the approach. Beyond being rooted in an unfamiliar paradigm, the field was early on confounded by claims of speed and effectiveness that were not adequately backed by empirical research. This paper identifies four stages in the establishment of an evidential basis for a new therapy, and it surveys the evidence for energy psychology within this framework, providing readers with the information that is currently available to both the fields advocates and its detractors. eurological mechanisms that may be involved in reported clinical outcomes are also considered. !ey words" acupuncture, amygdala, cognitive, desensiti#ation, hyperarousal, limbic system.

$omments on an earlier draft of this paper by %red &. 'allo, &h.(., )onald *. )uden, +.(., and )obert ,caer, +.(., are gratefully acknowledged. (avid %einstein, &h.(., is a clinical psychologist in *shland, -regon, and may be contacted at energy.innersource.net. /is website is www.innersource.net.

Energy Psychology: A Review of the Evidence

David Feinstein, Ph D

Energy psychology 0E&1 is a collection of psychotherapeutic modalities that have strong cognitive and somatic components. *s most commonly practiced 0more than two do#en variations can be identified1, E& combines cognitive interventions with methods derived from acupuncture and related systems. 2ts core strategy involves 31 the manual stimulation of specific points on the skin while a psychological problem is mentally activated which 41 sends signals to the brain that 51 are believed to facilitate desired changes in the neurochemical underpinnings of emotions, thoughts, and behavior. E& has been e6ceedingly controversial among psychotherapists. 2ts advocates have for more than two decades been claiming a level of clinical effectiveness that surpasses that of established

treatment modalities in its speed and power, but a robust body of research directly supporting these claims has yet to be produced. +eanwhile the approach has a strong popular following 0one e7newsletter that provides instruction on how to use E& methods had 489,888 active subscribers at the time of this writing and was increasing at a rate of 38,888 per month1 and its methods are also being increasingly utili#ed by mental health practitioners and in traditional health care settings such as /+-s and :eterans *dministration hospitals 0%einstein, Eden, ; $raig, 488<1. The 'reen $ross, founded in 3==< after the -klahoma $ity bombings to attend to the mental health needs of disaster victims uses E& as a standard protocol. *ccording to the organi#ations founder, $harles %igley, who also served as the chair of the committee of the (epartment of :eteran *ffairs that first identified &T,(" >Energy psychology is rapidly proving itself to be among the most powerful psychological interventions available to disaster relief workers for helping the survivors as well as the workers themselves> 0cited in %einstein, 488?1. +eanwhile, a review by the British &sychological ,ociety of one of E&s ma@or te6ts finds >the emerging research suggests that these methods are very effective indeed, e6tremely rapid, and thoroughly gentle> 0+olin, 488A1. *nother, in the online book review @ournal of the *merican &sychological *ssociation 0*&*1, describes energy psychology as >a new discipline that has been receiving attention due to its speed and effectiveness with difficult cases> 0,erlin, 488<1. *t the same time, another arm of the *&* has taken the unusual step of singling out E& as an area where its sponsors have been notified that they risk losing their sponsorship status if they offer psychologists continuing education credit for studying E&, reflecting and then amplifying the sensible distrust among professionals for unproven methods that make claims of strong efficacy. ,uch conflicting information leaves the clinician in a quandary. Beyond the familiar dilemma that there is a lag time between the introduction of a new therapy and its scientific evaluation, E&s broad popularity in the face of strong professional skepticism pressures the clinician to develop an informed opinion despite very limited scientific evidence that either establishes or refutes the methods putative therapeutic power. The purpose of this paper is to review the small body of established scientific evidence and present it along with preliminary evidence that has not been peer7reviewed, such as anecdotal reports, doctoral studies, and unpublished research. *n unusual amount of data of this nature has been produced. While individual studies that have not been peer7reviewed are difficult to interpret scientifically and cannot on their own establish efficacy, the data as a whole provides a sampling of a therapeutic phenomenon that has been difficult to interpret by any standard and can be used by clinicians to assess the information that is available to both the fields advocates and skeptics. The paper closes with a discussion of the kinds of research that would allow a more definitive assessment of E&.

A Brief !istory and "verview of Energy Psychology

Energy psychology introduces the principles of acupuncture into psychotherapy. *cupuncture has roots in the medical traditions of $hina, Bapan, and !orea, and evidence of its practice e6tends back at least <,888 years 0(orfer, et al., 3===1. Cnique electromagnetic properties of acupuncture points and pathways 0>meridians>1 have been postulated, with some empirical support 0*hn, Wu, Badger, /ammerschlag, ; Dangevin, 488<E Becker, )eichmanis, +arino, ; ,padaro, 3=F?E 'erber, 48831. The World /ealth -rgani#ation 0W/-1 lists over <8 conditions for which acupuncture is believed to be effective, including an6iety, depression, addictions, insomnia, hypertension, and other affect7related disorders. 2n the Cnited ,tates, the *merican *cademy of +edical *cupuncture has more than 3?88 physicians in its membership. E& has been evolving since the early 3=98s when Western mental health practitioners began formulating non7needle protocols for applying the principles of acupuncture to psychological issues 0'allo, 488A1. *cupressure, the prototypical non7needle form of acupuncture, dates perhaps as far back as acupuncture 0a Bapanese form is called ,hiatsu1, and is still widely

practiced. * review of A48 articles by /arvard +edical ,chools $onsumer /ealth 2nformation website 0www.intelihealth.com1 found at least preliminary evidence for the efficacy of acupressure with each of the mental health disorders for which the W/- found acupuncture to be effective 0including an6iety, depression, addictions, insomnia, and hypertension1. The points stimulated in E& generally correspond with points used in acupuncture and acupressure. The critical difference is the way that E& utili#es imagery, self7statements, and other cognitive interventions as part of the treatment, giving the approach greater ability to target psychological issues. The terms energy and psychology in >energy psychology> refer to the stimulation of electromagnetically distinctive acupuncture or energy points 0and the consequent activation of electrical signals that are sent to the brain1 for the purpose of bringing about psychological benefits. While the mechanisms by which this might occur are still a matter of speculation, a consortium of 4F leaders within the field formulated the following hypothesis 0%einstein, 488A1" * primary distinguishing contribution of E& is its ability to rapidly reduce hyperarousal in the limbic system by pairing" 3. a triggering image, thought, or situation 4. with the stimulation of specific points on the body which send signals to the limbic system that reduce the stress response. While $BT has established a strong research base 0Wright, 488A1, E& as such has not. *dding to E&s credibility problems, its techniques look patently strange 0e.g., tapping on the back of ones hand while moving ones eyes to activate different areas of the brain1, non7professional practitioners are utili#ing the methods without regulation, and even well7established professional practitioners disagree on its theoretical basis. While a substantial number of therapists representing a broad spectrum of professional backgrounds and orientations are utili#ing E& 3 and enthusiastically describing strong favorable outcomes, practitioner e6uberance is not known to be decisive evidence of efficacy. The psychotherapy field has in fact a long historyGdating back to phrenology and *nton +esmers magnetic rodsGof diagnostic and therapeutic approaches that were once widely touted and embraced but ultimately proved ineffective and often deceptive. Even the most sincerely promulgated methods are frequently shown to have less therapeutic benefit than initially reported when their use by practitioners who did not develop them are investigated over time. 2s E& another snake7oil phenomenon that will soon be universally recogni#ed as being clinically hollowE is it old wine in new skinGproducing positive results by repackaging established therapeutic modalitiesE or is it a genuine innovationH With the methods broad popularity, many clinicians are being forced to weigh in on this controversy, whether in answering the questions of a client who has heard about E& or sitting on a review board that is determining whether to institutionally support or e6clude the approach. While wide agreement e6ists that, all other things being equal, it is better to utili#e therapies whose efficacy is supported by research evidence, ways of assessing therapeutic innovations during the period between their introduction and their proper scientific evaluation are left largely to the individual practitioner. ,trong discretion and appropriate disclaimers certainly must be applied before an unproven approach can ethically be introduced. But professional ethics also requires clinicians to carefully evaluate all available therapies in selecting and applying the methods offered to the public, and e6isting clinical evidence for a new therapy warrants consideration even while the accumulation of e6perimental evidence is still in its early stages. The first stage in establishing the efficacy of a new approach is usually based on case reports. While such anecdotal evidence is sub@ect to practitioner bias 0sub@ective and sometimes ob@ective incentives for perceiving and reporting positive outcomes are always involved1 as well as selection bias 0negative outcomes are less commonly reported by the advocates of a method1, they do help determine whether a particular approach merits formal study, and if so, they help investigators formulate the questions that research needs to address. * second stage in establishing efficacy is systematic observation, where the outcomes of numerous individual cases are formally tracked and reported, though these outcomes are not compared to control conditions. * third stage is informal e6periment, often conducted by an individual practitioner or

in a single practice setting to gather data on a particular approach. 2nformal e6periments meet some but not all the criteria of formal e6periments or controlled clinical trials, the fourth stage of establishing efficacy, such as independent assessment of outcomes, blinded reviews, and a random assignment of sub@ects into e6perimental and control conditions. -f course these stages may unfold simultaneously, and in E&, evidence can be found at each of the stages, with the preponderance of it from the first three. While a substantial body of research from the fourth stage is required before a therapys effectiveness has been formally established, knowledge about the e6isting evidence in each of the stages is pertinent for evaluating a therapy such as E& before formal e6periments have affirmed or refuted its efficacy.

Anecdotal Evidence and Systematic "#servation

By the sheer weight of numbers, energy psychology may be unprecedented among unproven psychotherapies in its accumulation of systematically7collected and reported anecdotal outcome data. *n informal longitudinal study conducted over 3A years at 33 allied clinics in ,outh *merica 0detailed below1 tracked E& treatments with some 53,A88 patients 0*ndrade ; %einstein, 488A1. * /ealth +aintenance -rgani#ation 0/+-1 followed the treatment of F3A patients by seven therapists using Thought %ield Therapy 0T%T1, the earliest form of E&, and found that decreased post7treatment sub@ective distress was far beyond chance with 53 of 53 psychiatric diagnostic categories, including an6iety, ma@or depression, alcohol cravings, and posttraumatic stress disorder 0,akai et al., 48831. $ase summaries of T%T treatments with 55F post7disaster victims in !osovo, )wanda, the $ongo, and ,outh *frica indicated that 55A responded positively 0%einstein, 488?1, and organi#ations such as 'reen $ross and civil crisis management teams are increasingly incorporating E& procedures into their protocols for working with the mental health impact of natural and human7made disasters based on such reports from the field. * website that invites the submission of case studies from practitioners of Emotional %reedom Techniques 0E%T1, one of the most widely used forms of E&, has thousands of outcome reports based on self applications, peer applications, and professional applications of E%T. * search engine on the site 0www.emofree.com1 lists, at the time of this writing, 3?< entries for depression cases, A?8 for an6iety, 384 for &T,(, 3A3 for weight loss, 349 for addictions, =8 for sports performance, and 59= for physical pain, which often has an emotional component 0+eagher, *rnau, ; )hudy, 48831. The ma@ority of these entries present at least one case study. *s a group, the anecdotal reports give the impression of therapeutic outcomes that are both rapid and dramatic, though of course all the caveats about selective reporting, the bias of a methods advocates, and the sub@ective nature of such reports apply. $ase reports and systematic observation studies are on occasion published in peer7reviewed @ournals. The 384 participants of a weekend E%T workshop were given a well7established, standardi#ed symptom checklist 0the ,$D7=87), short form1 one month prior to the workshop, then immediately prior, then immediately after, and then si6 months after the workshop 0)owe, in press1. There was a highly significant decrease 0p I .888<1 in all measures of psychological distress as indicated by the checklist from pre7workshop to post7workshop, and these improvements held at the ?7month follow7up. While this is a significant effect, these are impressive findings whatever the intervention, the results could be attributed to the intensive group e6perience rather than to specific E%T procedures. Two earlier studies, however, involved individual treatments, so the power of an intensive group e6perience was not a factor in either case. Both studies were doctoral dissertations and were also based on the systematic observation of sub@ects who received E& treatments. 2n one of them, A9 sub@ects with public speaking an6iety, after one hour of treatment using T%T, demonstrated significant improvement on ob@ective measures such as standard an6iety inventories 0,choninger, 48831. %ollowing the treatment, the sub@ects also reported

decreased shyness and confusion and increased poise and interest in giving a future speech. Treatment gains were still present on four7month follow7up interviews. * second dissertation followed 48 patients who had been unable to receive necessary medical attention because of intense needle phobias 0(arby, 48831. While the study contains a number of methodological flaws, most notably that the e6perimenter both administered the treatments and collected the data, the sub@ects showed significant immediate improvement after an hour of T%T treatment and on one7month follow7up. either study, however, used a control group, so it is possible that the gains could all be traced to non7specific therapeutic factors such as the practitioners attention, caring, and conveying positive e6pectations.

$nformal E%&eriment

The largest study of energy psychology treatments to date combines systematic observation with a series of e6periments that employed moderate controls. 2t was conducted over a 3A7year period and involved some 53,A88 patients 0*ndrade ; %einstein, 488A1. The study was supervised by BoaquJn *ndrade, a physician and seasoned acupuncturist who introduced T%T to 33 allied clinics in *rgentina and Cruguay after he was trained in this technique in the Cnited ,tates. *ndrade had, as a young man, spent long periods of time in $hina, where he studied traditional acupuncture, and he had been applying it in his medical practice for thirty years. /e was struck with the apparent effectiveness of T%T, which focused directly on an6iety and other psychological disorders, and which did not use needles to stimulate the acupuncture points. The staff of the 33 clinics met this new procedure with both interest and skepticism. While the group had no funding for a formal research program, they decided to track the outcomes of treatments with these new methods and compare them with the treatments currently in place. ,tandard record7keeping already maintained a patients intake evaluation, the interventions used, and the treatment outcomes. *ndrades team added a simple procedure for briefly interviewing the patient, usually by telephone, at the close of treatment and then one month, three months, si6 months, and twelve months later. The interviewers had not been involved in the patients treatment. They had a record of the diagnosis and intake evaluation, but not of the treatment method. Their @ob was to determine if at the time of the interview the initial symptoms remained, had improved somewhat, or if the person was now symptom7free. -ver the 3A7year period, 5? therapists were involved in treating the 4=,888 patients whose progress was able to be followed after the completion of the therapy 0even after the initial question of whether the energy interventions were effective had been answered to the satisfaction of the treatment staff, the follow7up calls were continued because they seemed to have clinical value, sometimes leading to further treatment1. The impressions of the interviewers, supported by the data they collected, were that the energy interventions were more effective than e6isting treatments for a range of conditions. The clinics also conducted a number of substudies that allowed more precise conclusions. While the overall investigation did not use a control group, the substudies did use controlled, randomi#ed designs, comparing energy interventions with the methods that were already in use at the clinics. The largest of the substudies, conducted over a < 3K4 year period, followed the course of treatment of appro6imately <,888 patients diagnosed with an6iety disorders. /alf of them received energy psychotherapy and no medication. The other half received $BT, the treatment most often used at the clinics for an6iety disorder, supplemented by medication as needed. The interviews at the end of treatment, along with the follow7up interviews at 3, 5, ?, and 34 months, showed that the energy approach was significantly more effective than the $BTKmedication

protocol in both the proportion of patients showing some improvement and the proportion of patients showing complete remission of symptoms 0see Table 31.

&able 1 Outcome-Comparisons with 5,000 Anxiety Patients at Close of Therapy

'(& / )*D+',&+-. Some Improvement Complete Remission of Symptoms ?51 <31

*P -./0 =81 F?1

While conducting telephone interviews to place people in one of three categories 0>no improvement,> >some improvement,> >complete remission of symptoms>1 is not the most stringent way to measure clinical outcomes, various other measures supported these findings, such as pre7 and post7treatment scores on standardi#ed psychological tests, including the Beck *n6iety 2nventory, the ,pielberger ,tate7Trait *n6iety 2nde6, and the Lale7Brown -bsessive7 $ompulsive ,cale. &re7 and post7treatment brain scan images also matched the interviewer ratings. /owever, while these more ob@ective measures did corroborate the interviewers ratings, they were not consistently applied or tracked. 2n another substudy, the length of treatment was dramatically shorter with with an E& approach than with $BT supplemented with medication, as shown in Table 4.

&able 2 Length of TreatmentComparisons within a ampling of !"0 Anxiety Patients

'(& / )*D+',&+-. Typical Number of Sessions Average Number of Sessions = to 48 3<

*P -./0 3 to F 5

*nother question that is relevant for anyone e6perimenting with the methods presented in this paper is whether tapping the acupoints is as effective as the traditional method of placing needles in them. *s an acupuncturist, this was of particular interest to *ndrade. * third substudy, while

very small, had a surprising outcome, suggesting that tapping the points in the treatment of an6iety disorders may actually be more effective than inserting needles into them 0see Table 51.

&able 3 Tapping #s$ AcupunctureComparisons in the Treatment of %& Anxiety Patients

.**D/*2
0 M591

&,PP+.3
0 MA81

Positive Response

<81

FF.<1

The question of the >indications> and >contraindications> for an E& approach was also asked by the investigators. %or what conditions was this approach the most effective and for what conditions was it the least effectiveH $linicians who were not involved in the treatment assessed the outcome of E& interventions with a sample of patients that represented a wide spectrum of clinical disorders. They gave each case a sub@ective score of 3 to <, estimating the effectiveness of the energy interventions in contrast to the conventional treatments that might have been used 0a ><> indicated that the rater believed the energy approach was far more effective than the conventional treatment would have beenE a >3> indicated that the rater believed it was far less effective than the conventional treatment would have been1. While highly sub@ective, these ratings were designed to help the ,outh *merica clinics generate clinical guidelines as they introduced energy techniques. The staffs reported that the resulting guidelines were valuable in matching patients with treatment approach 0B. *ndrade, personal communication, Buly =, 48841. This is, of course, still largely impressionistic, and the degree that the ratings might generali#e to other settings is also unknown. But the ratings at least give an early glimpse into the conclusions that one group of practitioners has been drawing. +ost an6iety disorders received a >A> or ><.> These included panic disorders, agoraphobia, specific phobias, social phobias, separation an6iety, &T,(, acute stress disorders, obsessive compulsive disorders, and generali#ed an6iety disorders. The raters believed that the energy interventions were more effective or far more effective than other available treatments for these an6iety conditions. *lso receiving a ><> were many of the emotional difficulties of everyday life, from unwarranted fears and anger to e6cessive feelings of guilt, shame, grief, @ealousy, re@ection, isolation, frustration, or love pain. -ther conditions that were rated as more likely to respond to an energy approach included ad@ustment disorders, attention deficit disorders, elimination disorders, impulse control disorders, problems related to abuse or neglect, and communication disorders. $ases receiving a >5> indicated that the rater believed that the energy intervention produced a result that would be about the equivalent of other available psychological treatments. This would suggest that ma6imum clinical advantage would be gained by combining the energy approach with the more conventional treatment. $onditions in this category included mild to moderate reactive depression, learning skills disorders, motor skills disorders, Tourettes syndrome, substance abuse7related disorders, and eating disorders. $ases where a conventional treatment approach was rated as being likely to have been more effective than the energy treatment included ma@or endogenous depression, personality disorders, dissociative identity disorder, bipolar disorders, psychotic disorders, delirium, and dementia. ote that these conditions tend to have a strong biochemical foundation. ,ubsequent reports should be mentioned, however, which suggest that people within these diagnostic

categories have been helped by energy treatments with a range of life problems that are secondary to their condition 0'allo, 48841. The investigators also tracked changes in brain wave frequency ratios over the course of treatment with a number of patients in each of three treatment conditions for generali#ed an6iety disorder" E&, $BT, and medication. The ratio of alpha, beta, and theta waves in various parts of the brain can be measured using a digiti#ed electroencephalogram 0EE'1, and the individual profile can then be compared with the profiles in databases. 'enerali#ed an6iety disorder, for instance, has a distinctive brain wave ratio >signature> as compared with a non7clinical population. *s patients symptoms decreased over the course of treatment, their brain wave ratios normali#ed. *n e6ample of this normali#ation in one patients treatment over 34 sessions can be viewed at www.innersource.netKenergyNpsychKepiNneuroNfoundations.htm. This brain wave normali#ation and reduction of symptoms also corresponded with norepinephrine levels dropping to normal reference values and low serotonin rising. While these preliminary scans have not been published, the investigators observed that patients who were successfully treated with E& and $BT showed similar normali#ation in their brain wave ratios. $BT, however, required a greater number of sessions and, on one7year follow7up, the brain wave ratios for patients who received $BT were more likely to have returned to their pre7treatment levels than they were for the patients who received the energy treatments 0B. *ndrade, personal communication, Buly 3=, 488A1. &atients in the medication group, like those in the E& and $BT groups, showed a reduction in symptoms, but their brain scans did not show a normali#ation of the brain wave ratios 0B. *ndrade, personal communication, +arch 4<, 48851. This suggests that the medication was suppressing the symptoms without addressing the underlying wave frequency imbalances. $onsistent with this interpretation is that, in addition to the side effects reported by many in the medication7only group, symptoms tended to return when the medication was discontinued. While the overall results of the ,outh *merican study as well as the various substudies seem to lend support for an energy psychology approach, it must be emphasi#ed that in terms of scientifically establishing the methods of energy psychology, these findings are highly preliminary. The study was initially envisioned as an e6ploratory in7house assessment of a new method and was not designed with publication in mind, nor were the findings ever submitted to a peer7reviewed @ournal. ot all the variables that need to be controlled in robust research were addressed, not all criteria were defined with rigorous precision, the record7keeping was relatively informal, source data were not always maintained, and the degree to which any valid conclusions would generali#e to other settings is unknown. onetheless, the sub7studies did use randomi#ed samples, control groups, and >blind> assessment. While it is important not to over7interpret the striking clinical outcomes that were reported, it is also shortsighted to ignore them. When understood within the conte6t of a si#able practitioner group whose training was several generations down the line from the methods originators and who were conducting an in7house investigation over a substantial period of time, these findings are suggestive that E& merits serious attention. The research approach used is also heuristic for the design of further investigation.

Controlled Clinical Trials

*mong the questions that need to be asked when investigating the benefits of a new therapy, as reported in anecdotal accounts and systematic observation, include" Would the patient have gotten better without the treatmentH Would the benefits be as strong if the patient received a >placebo> treatmentH

Would other therapies have led to greater benefitsH What are the critical ingredients for producing the observed benefitsH ,ome controlled research, either directly from the energy psychology literature or from studies of its procedural parent, acupuncture, bears upon each of these questions. *cupuncture draws from the same pool of electromagnetically7active points as E& but does not generally include focused cognitive interventions.

'o(ld the &atient have gotten #etter witho(t the treatment)

* doctoral dissertation that used a controlled, randomi#ed design investigated the effects of T%T on the presenting problem as well as on the self7concept of 49 phobia patients 0Wade, 3==81. Two self7concept inventories were administered a month prior to the treatment and then two months after the treatment. The T%T treatment reduced the phobias substantially, and significant improvement was also found in self7acceptance, self7esteem, and self7congruency two months after the treatment. * wait7list control group of 4< sub@ects did not show improvement in either their phobias or their self7concept. While standardi#ed instruments were used to measure self7 concept, a weakness of this study was that assessments regarding reduction of the phobias were based solely on verbal self7reports. *lthough this is the only purely wait7list study in the E& literature, comparison studies between a therapeutic approach and a >placebo> treatment also address the issue of whether ingredients specific to the treatment in question are producing the observed clinical outcomes.

'o(ld the #enefits #e as strong if the &atient received a *&lace#o* treatment)

&lacebo treatments do not, in themselves, have characteristics that would be e6pected to remedy the condition being investigated. They are used rather to e6amine whether factors such as caring attention, e6pectation, and suggestion can account for a therapys success, or whether the treatment being compared to it yields benefits beyond these generic factors. * study published in the Journal of Clinical Psychology e6amined whether the effects of E& procedures were due to non7specific factors or placebo effects with individuals who volunteered to receive help with strong irrational fears of insects or small animals, including rats, mice, spiders, and roaches 0Wells, &olglase, *ndrews, $arrington, ; Baker, 48851. The E& treatment was compared with a rela6ation technique that used diaphragmatic breathing. ,ignificantly greater improvement was found, based on standardi#ed phobia scales and other measures, in the group that received the E& treatment. -n follow7ups, ? to = months later, the improvements held. * study conducted at Oueens $ollege in ew Lork to see if these findings could be replicated produced similar results 0Baker ; ,iegel, 488?1.

'o(ld other thera&ies yield greater #enefit)

While highly preliminary, the comparisons of E& and $BT in the ,outh *merica study suggest that E& with an6iety patients may be superior in effectiveness, speed, and durability. * comparison study conducted at %lorida ,tate Cniversity and published in 3=== evaluated the effectiveness of four approaches that were in use at the time for the treatment of posttraumatic stress disorder 0$arbonell ; %igley, 3===1. The approaches investigated included T%T, eye movement desensiti#ation and reprocessing 0E+()1, traumatic incident reduction 0T2)1, and visualKkinesthetic dissociation 0:K!(1. The study employed detailed evaluative measures and follow7up assessments. *ll four approaches yielded sustained reduction in sub@ective units of distress during follow7up evaluations conducted within the A7 to ?7month range. The greatest reduction of reported distress was produced by the T%T treatment 05.5 on a scale of 381, with T2) at 5.3, E+() at 5.8, and :K!( at 3.<. The differences among the first three approaches were not statistically significant, but the differences in the amount of time required to produce the improvement were substantial, with T%T averaging ?5 minutes per patient, E+() averaging 3F4 minutes per patient, and T2) averaging 4<A minutes per patient. *mong the studys weaknesses are that it had only 49 sub@ects, the number of sub@ects across treatment conditions varied considerably, and the timeframes on follow7up evaluation were not uniform.

While most of the medical research published in non7Western cultures is not translated for English7language @ournals, vigorous scientific investigation of acupuncture is being carried out in $hina. *ndrade, the principle investigator in the ,outh *merican studies, reports that in the ma@or hospitals, researchers with doctorates in physiology, biochemistry, and related fields have been scientifically scrutini#ing the traditional healing methods 0B. *ndrade, personal communication, Bune 38, 488A1. /e estimates that specific, measurable functions have been identified for at least 3< percent of the acupuncture points 0stimulating point * releases chemical B, sends impulses to brain area $, etc.1. %or instance, he describes having personally witnessed a meticulously designed study at one of the ma@or hospitals in Bei@ing with twelve patients diagnosed with severe panic disorder. :arious drug and acupuncture interventions were used over a two7week period. Each patients biochemistry 0based on blood and urine samples1 as well as emotional responses were carefully tracked. (uring a three7day period, the primary intervention was to stimulate si6 acupuncture points that are believed to increase serotonin, a neurotransmitter involved with depression and other mood disorders. (uring this period, the intensity and frequency of the panic attacks decreased for all twelve patients 0eight of them became asymptomatic1, their serotonin levels increased 0this is the clinically desirable direction1, and their norepinephrine levels decreased, again the desirable direction. The acupuncture was superior to the drug treatments in all of these measures. o published studies, and no formal or informal studies reported on several E& practitioner e7lists followed by the author, have compared E& to another therapy in the treatment of an6iety and shown E& to be inferior. umerous individual reports, however, suggest that by prudently combining E& with other therapies for treating a range of disorders, the effects of both approaches were, in the therapists estimation, enhanced. 2n summary, the early studies that have attempted to compare E& with other therapies, generally focusing on an6iety or phobias, have found E& to be more effective. Because each study is in its own way highly limited, and the number of studies is very small, no definitive conclusions can be drawn, but these early e6plorations do beckon more robust comparative studies.

'hat are the critical ingredients within an EP a&&roach for &rod(cing the o#served clinical #enefits)
While it may require many years for this question to be fully answered, an interesting procedural quandaryGand one that has become a topic of considerable debate among practitionersGis the relationship between treatment outcomes and the specific acupoints used in the treatment. 2f future studies support the preliminary evidence that E& treatments are effective, is there something, for instance, about simply tapping the body while mentally activating a psychological problem that has a curative effect, or do the points that were identified in ancient $hina really have special qualitiesH /ere the evidence is mi6ed. *n early investigation of this question suggested that in treating A= people with height phobias, those who tapped points typically used in a T%T protocol showed significantly more improvement than those who tapped non7T%T >placebo> points 0$arbonell, 3==F1. These findings were confounded because some of the >placebo points> turned out to be points that are also sometimes used in acupuncture, though that should have reduced rather than e6aggerated the differences between the two groups. 2n a subsequent tightly7designed study, published in Anesthesia & Analgesia, treatments that involved manually stimulating acupoints were applied by the paramedic team after a minor in@ury and compared with treatments that stimulated areas of the skin that do not contain recogni#ed acupuncture points 0!ober, et al., 48841. *gain, the treatments that used the traditional points were more effective, resulting in a significantly greater reduction of an6iety, pain, and elevated heart rate. * third study, investigating acupuncture for depression, used a randomi#ed, controlled, double7 blinded design in treating 59 female patients diagnosed with clinical depression 0*llen, ,chnyer, ; /itt, 3==91. The researchers compared the use of acupuncture points 0during twelve treatment sessions over an eight7week period1 specifically selected for the treatment of depression with acupuncture points usually used for other ailments 0also twelve sessions over eight weeks1 and a wait7list control group that received no treatment. %ollowing the acupuncture treatments, <8P of

patients who received the depression protocol showed no sign of the disorder while only 4FP of the patients in the other two groups e6perienced symptom relief. *fter the initial clinical trial, the women from the other two groups were administered acupuncture using the points associated with the treatment of depression over an eight week period. ,eventy percent of them e6perienced a drop in depressive symptoms, with ?A percent showing complete remission according to DSM IV criteria. These findingsGbeyond demonstrating that placebo or e6pectation effects that might be associated with acupuncture treatment were not the decisive factors in the clinical outcomesGsuggest that the targeting of the proper points was an important element of the treatment. * fourth study, however, did not detect a difference between tapping standard >Emotional %reedom Techniques> 0E%T1 points and tapping non7E%T points in treating fear, though both tapping procedures were more effective than no treatment 0Waite ; /older, 48851. While serious questions have been raised about some of the conclusions reached by the authors of this study 0Baker ; $arrington, 488<1, other clinical evidence suggests that stimulating certain points not identified in traditional acupuncture may indeed have a therapeutic effect. 2n a large7scale 'erman study investigating medication vs. acupuncture 0(iener, 488?1, and also traditional vs. sham points within the acupuncture group, 95< migraine patients 0of 34=< initially screened1 completed treatment after having been randomly assigned to receive 31 prophylactic medication 0beta blockers, calcium7channel blockers, or antiepileptic drugs1, 41 traditional acupuncture 0ten sessions over si6 weeks1, or 51 sham7point acupuncture 0also ten sessions over si6 weeks1. The treatments decisively reduced the occurrence of migraines 0pI.88831, with the traditional acupuncture and the medication having about equal success 0reduction by 4.5 symptom7days vs. a reduction of 4.3 days, respectively over a si67month period1 and the sham7 point acupuncture leading to a reduction by 3.? symptom7days. The difference between the traditional acupuncture points and the sham points did not reach statistical significance 0pI.8=1, which suggests that sham points also have a therapeutic impact. But the greater effect of the traditional points leaves open the possibility that they have special therapeutic properties the sham points do not. While this is an area where further study is clearly needed, acupuncture pointsGwhich are distinguished by having lower electrical resistance and a higher concentration of receptors that are sensitive to mechanical stimulation 0Dangevin ; Landow, 48841Gare believed by practitioners to produce stronger electrochemical signals than random points. )esearch in $hina, such as at the Bei@ing hospital discussed above and numerous other studies, also suggests that the stimulation of many of the traditional acupuncture points have specific effects, such as to increase serotonin levels or to strengthen or sedate the energy flow to a particular organ. ,ome light on the question is shed by an e6periment where researchers used positron emission tomography 0&ET1 scans to see what was occurring in the brains of 3A people having acupuncture treatment for painful osteoarthritis 0&ariente, White, %rackowiak, ; Dewith, 488<1. *ll 3A underwent each of three treatment conditions in a random order. 2n one condition, blunt needles touched the patients skin, but the patients were aware that the needle would not pierce the skin and were told that it would not have any therapeutic value. 2n a second condition, specially developed >trick> needles were used. They gave the impression that the skin was being penetrated even though the needles never actually pierced the skin. )ather, like a >stage dagger,> the tip of the needle moved up into the body of the needle. The third condition was conventional acupuncture. The &ET scans revealed marked differences in brain activity for each of the interventions. When the patients were touched with the blunt needles, only the brain areas associated with the sensation of touch were activated. With the trick needle treatment, an area of the brain associated with the production of natural opiates was also activated. atural opiates act in a non7specific way to relieve pain, so their production following the trick needle treatment may have constituted the neurological dimension of a placebo effect. With the real acupuncture, the part of the brain which produces natural opiates was also activated, but another region, known as the insular, and thought to be involved in pain modulation, was activated as well. ,o while the belief that acupuncture was being administered did produce non7specific therapeutic effects, the real acupuncture produced additional, more specific effects.

*s researchers sort out the active ingredients of acupuncture, the mechanisms of E&s application of the principles of acupuncture to cognitive processes will also become clearer. /owever, enough is already known from related fields to formulate some early hypotheses.

+echanisms

Energy psychology, by adopting from other cultures methods that are outside the scope of standard mental health care practices, poses a paradigm challenge to conventional psychology, much as the field of energy medicine, of which E& is a specialty, poses a paradigm challenge to conventional medicine 0%einstein ; Eden, 488?1. onetheless, mechanisms that can be understood within accepted e6planatory frameworks are being postulated. Work by )uden 0488<1, for instance, points to evidence that acupoint stimulation releases serotonin in the amygdala and the pre7frontal corte6 and describes neurological mechanisms that plausibly underlie the clinical effects reported by E& practitioners. The e6planation that reducing limbic system hyperarousal is a primary mechanism of E& was the consensus of the consortium of 4F E& leaders mentioned earlier 0%einstein, 488A1. )epresenting a spectrum of clinical backgrounds and theoretical orientations, the group postulated that E& interventions for reducing fear, an6iety, and other effects of trauma are effective because" 3. When a memory, image, or other stimulus that triggers limbic system hyperarousal is mentally activated while 4. specific areas of the skin that are electrically sensitive are simultaneously stimulated 5. shifts in neurochemistry are brought about that reduce the hyperarousal. Two lines of research provide an empirical basis for this hypothesis" The stimulation of specific acupoints can deactivate areas of the brain that are involved with the e6perience of fear and pain. Bringing a stressful memory to mind makes it susceptible to being >reconsolidated> so that the conditioned emotional link to the stressful memory is e6tinguished.

Acupoint Stimulation and Areas of the Brain Involved with Fear and Pain. * study published in the Proceedings of the ational Academy of Science in 3==9 used functional +agnetic )esonance 2maging 0f+)21 to demonstrate that stimulating a toe acupuncture point used in Traditional $hinese +edicine to treat eye disorders activates the occipital lobes of the brain 0$ho, 3==91. When the investigators stimulated non7acupoints that were 4 to < cm away from the vision7related points, activation in the occipital lobes was not observed. This demonstration of a correlation between acupoint stimulation and the activation of specific areas of the brain as anticipated by ancient acupuncture literature gained considerable notice. 2n a subsequent study at /arvard +edical ,chool, stimulation of a particular acupoint on the hand 0Darge 2ntestine A1 produced prominent decreases of f+)2 signals in the amygdala, hippocampus, and other brain areas associated with emotion 0/ui, et al., 48881. The investigators speculate >that modulation of subcortical structures may be an important mechanism by which acupuncture e6erts its comple6 multisystem effects> 0p. 351. * series of reports specifically investigating E& treatments using electronic instruments showed decreased right frontal corte6 arousal in treating trauma following motor vehicle accidents 0,wingle, &ulos, ; ,wingle, 488A1, normali#ation of brain wave patterns upon activation of a traumatic memory 0(iepold ; 'oldstein, 48881, and changes in the electronic conductance along the acupuncture meridians after treatments for claustrophobia 0Dambrou, &ratt, ; $hevalier, 48851. These laboratory findings suggest that the

stimulation of specific acupuncture points, with or without needles, can bring about precise, intended outcomes. Activated Memories Need to Be Reconsolidated. Even if the stimulation of specific acupoints can decrease activation signals in the amygdala and related brain structures, a second process that must be e6plained regarding the mechanisms involved in E& is how the stimulation of acupoints can cause targeted changes in affect, cognition, and behavior. 2n virtually all formulations of E&, the mental activation of a situation the client finds problematic, such as an intrusive memory, is done simultaneously with >energy point> stimulation. Whenever a memory is accessed, it must then be reconsolidated into the persons cognitive system. While consolidation, the process by which newly learned information is stored, was at one time believed to occur only at the time of the e6perience, a research program at ew Lork Cniversity headed by Boseph De(ou6 has shown that >considerable evidence now indicates that consolidated memories, when reactivated through retrieval, become labile 0susceptible to disruption1 again and undergo reconsolidation> 0(ebiec, (oyere, ader, ; Dedou6, 488?, p. 5A491. That is, when a memory is retrieved, it can then be altered before it is stored again. %or instance, rats conditioned to e6pect an electric shock when a particular tone was played would free#e in fear upon hearing the tone. But when administered a medication that prevents the amygdala from producing the proteins that are needed for memory storage, the response to the tone was permanently e6tinguished 0 ader, ,chafe, ; De(ou6, 48881. The memory needed to be reconsolidated if the fear response to the stimulus was to be sustained. To restate the above hypothesis in terms of these two lines of research" When a memory or image that triggers hyperarousal is brought to mind, and acupoints that decrease activation signals in the amygdala and other brain areas are simultaneously stimulated, the memory or image is delinked from the stress response. When the memory is then reconsolidated, the strength of its ability to trigger hyperarousal has been reduced, leading 0after repeated e6posures to the procedure1 to the e6tinction of the elevated limbic response. While this hypothesis, even if confirmed, will not tell the whole story since numerous reports suggest that E& has an effect with a range of emotional conditions, from those involving hyperarousal to those involved with peak performance, it seems to account for much of the e6isting E& data in the treatment of an6iety7 related disorders. 2t also provides a preliminary framework for future research. *dditional neural pathways that can be targeted by acupoint stimulation for the purpose of shifting dysfunctional cognitions and emotional patterns have been mapped, including the brain chemistry that undergirds relationship style 0,iegel, 48831, addictions 0)uden, 48851, and other clinical concerns 0$appas, *ndres7/yman, ; (avidson, 488<1.

Concl(sions

Energy psychology represents a convergence of methods rooted in acupuncture with cognitive techniques that are well established within contemporary clinical practice. While both sources are backed by substantial empirical support, the composite format has not yet been adequately tested. *necdotal reports and data based upon systematic observation and preliminary e6periments are promising, but peer7reviewed controlled clinical trials are only beginning to appear. While E& properly builds upon empirical findings from acupuncture and cognitive behavior therapy, it must at this point in its development investigate specific E& protocols. *mong the questions and issues that beg for further empirical investigation" 3. (oes the stimulation of selected acupoints while an6iety7arousing thoughts are mentally activated reduce limbic system hyperarousal and an6iety as measured by brain imaging technology, symptom assessments, and self7reportsH

4. %or what conditions is E& effective, ineffective, or contraindicatedH 5. While virtually all E& protocols combine the stimulation of specific points on the skin with the mental activation of scenes, thoughts, or emotions related to the clinical goal, which points and which physical procedures are the most effectiveH A. 2n addition to mental activation and the simultaneous stimulation of points on the skin, various approaches to E& utili#e additional elements Q which of these are necessary to produce desired outcomesH <. 2n light of RA, how should E& protocols be formulated for specific conditionsH This paper has reviewed evidence about E& according to the four stages by which a new therapys efficacy is established. $onsiderable supporting data was found within the first three stages, but the long leap into the fourth stageGpeer7reviewed controlled clinical trialsGis for the most part yet to be accomplished. onetheless, by discounting findings from the early stages, the psychotherapy establishment has put itself at odds with growing numbers of therapists who are determining that the methods increase their clinical effectiveness, as well as large numbers of laypeople who are reporting having benefited from E& and are pu##led by the acrimony it seems to have caused within the mental health profession. (uring the period between the introduction of a method and a scientific verdict on its efficacy, sources of information that in themselves are insufficient to establish that verdict can nonetheless be informative. %aced with this situation, each clinician makes an independent @udgment, by informed choice or by default, on each entry within the latest batch of therapeutic innovations that some fellow practitioners have found to be promising. This paper has been an attempt to provide findings that might help therapists come to as informed a decision as possible at this point about E&. 2n brief, basic E& techniques are non7invasive, relatively easy to learn, and backed by substantial clinical observation. *t the same time, very few controlled clinical trials directly supporting the approach have been produced, and its mechanisms of action are not well understood. While further empirical evidence is clearly needed before any definitive @udgments can be made, the use of acupuncture points as a central part of the treatment adds to the conceptual challenge. *cupuncture and acupressure are rooted in an unfamiliar paradigm, yet the efficacy of each in addressing mental health needs does have empirical support 0e.g., *llen, ,chnyer, ; /itt, 3==9E !ober, et al., 48841. +any ancient healing practices, in fact, from acupuncture to yoga to meditation, are >withstanding the test of time . . . because, not only does anecdote testify to the practices benefits to patients . . . emerging technology can demonstrate ob@ective effectiveness> 0Bobst, 488A, pp. 3 7 41. These ancient practices are increasingly being adapted into conventional care health settings. $onsider, for instance, the tra@ectory of meditation in relationship to Western psychotherapy, where clashing paradigms, according to an article in the American Psychologist, have developed into a >mutually enriching dialogue> 0Walsh ; ,hapiro, 488?, p. 44F1. Even before E& has been fully validated, the ways it combines somatic and cognitive interventions has initiated another enriching dialogue. * growing number of Western psychotherapists believe the approach enhances their clinical effectiveness by rapidly bringing about targeted changes in the neurochemical foundations of psychological problems.

References

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