Energy therapies like Emotional Freedom Technique (EFT) and Thought Field Therapy (TFT) haven't gotten much respect from the American Psychological Association (APA). Currently the APA's Office of Continuing Education in Psychology refuses even to grant CE credits for workshops in TFT and EFT. In the June 2008 Psychotherapy Theory, Research, Practice, Training, psychologist David Feinstein of Ashland, Oregon, published the first review of the research on energy therapy in an APA refereed journal, and called for APA to accept energy therapy as an empirically supported treatment. However, in June 2009, two authors strongly critiqued Feinstein's review in the same journal.
Feinstein admits that the notion that clients who tap themselves on specific parts of the body to alter electrical pathways to the brain, thus producing rapid changes in feelings, cognitions, and behaviors, does invite skepticism—even though acupuncture, based upon the same principles, has gained mainstream respectability. In his paper, Feinstein based his case partly on the increasing amount of anecdotal evidence of success, videotapes of actual sessions, numerous single-case studies, and eight uncontrolled outcome studies. But such evidence falls far short of the replicable, randomized controlled trial (RCT) that the APA insists constitute empirical support.
"The plural of anecdote is not data," says Florida State University instructor Monica Pignotti, who coauthored one of the responses. The problem with the uncontrolled outcome studies, she and others contend, is that the positive effects could be due to placebo or some other element of treatment unrelated to the tapping. If energy psychology has an effective component, which has yet to be proven, they say it would most likely be exposure—the reexperiencing of trauma in a reassuring, controlled atmosphere.
Feinstein also included results from two RCTs, but his critics contended he ignored at least two other RCTs that didn't support his case. They added that the studies he used had imprecise outcome measures, inadequate selection and exclusion criteria, and faulty statistics that didn't compute effect sizes (considered the most meaningful statistical measure of clinical effectiveness), or ignored treatment dropouts.
Feinstein believes that critics of energy therapy demand a more rigorous standard of proof than for other treatments precisely because it challenges accepted notions of what therapy should be. This argument, his critics point out, has been used to defend fraudulent miracle cures for centuries. "Energy psychology has been around for 25 years," says Pignotti. "That's plenty of time to have accumulated good evidence."
Feinstein is now working on other reviews and articles, intent on bringing energy therapy into the psychology mainstream. It's frustrating and unconscionable, he says, that millions of people around the world are struggling with phobias and PTSD, when such a powerful, quick cure is so near at hand.
Therapy's Effect on Brain Cells
For the first time, a study has shown that effective psychotherapy with depressed clients is associated with changes at the brain's cellular level. While previous studies have found that psychotherapy affects the brains of depressed people, they've relied on brain imaging and scans—relatively crude instruments that some critics contend are akin to trying to determine details of the lunar surface by looking at the moon through an Earth-based telescope. After all, what does brain imaging really tell us when one area "lights up," beyond that there's some kind of increased activity in a relatively large area?
Now a study led by psychiatrist Jakob Koch of Christian-Albrechts University in Kiel, Germany, reported in the April Psychotherapy and Psychosomatics, has looked at a key brain protein called phosphorylated cyclic adenosine monophosphates (pCREB). While there's already some evidence that neurotransmitters like serotonin and norepinephrine are less available in the brains of depressed people, proteins like pCREB operate several rungs below neurotransmitters, helping to construct brain cells and nerve endings—in effect, creating the highways and byways along which neurotransmitters travel. They're also the basic ingredients of neurotransmitters themselves.
Koch's team found that people who responded positively to Interpersonal Psychotherapy (IPT), a therapy that addresses both cognitive and interpersonal issues, also had increased production of pCREB, raising the possibility that something about psychotherapy promotes the growth of brain cells. "In depression, brain growth in response to experience has been demonstrated to be slowed down," says psychiatrist Daniel Siegel, who's contended for years that the empathic attunement of relationships promotes the growth of new brain cells and neural connections. "Decreased protein production may be a result of such dampened neural growth."
Koch's study can identify only an association between IPT and increased pCREB production and can't definitively state that IPT caused the increased production. But those whose depression wasn't alleviated by IPT showed no increase in pCREB.
Do Therapists Perpetuate Myths?
What do these statements have in common? High levels of motivation help in solving difficult problems. Women have better social intuition than men. Positive self-affirmations boost self-esteem among people with poor self-concepts. Most people who were physically abused as children become physical abusers themselves. Venting anger in a safe, controlled manner is an effective anger-management tool. The answer, according to Emory University psychologist and researcher Scott Lilienfeld: they're all largely or entirely false.
Lilienfeld's new book, 50 Great Myths of Popular Psychology (which actually demolishes more than 250 myths), written with Steven Lynn, John Ruscio, and the late Barry Beyerstein, is intended for a general audience and psychology students, but Lilienfeld says therapists should read it, too. He argues that when therapists believe in them, even myths refuted by research can take on a life of their own.
In fact, Lilienfeld and his coauthors insist that the volume of dubious, potentially damaging psychological myths is increasing. The self-help industry publishes more than 3,000 books a year, often taking something with a kernel of truth and magnifying it into broader statements. For example, John Gray's Mars/Venus series flies in the face of research demonstrating that men and women have more similarities than differences in their emotional and cognitive styles. Books on self-esteem perpetuate the myth that high self-esteem inevitably leads to psychological health and low-self-esteem inevitably leads to unhappiness and failure. The Internet and popular media are also fertile breeding grounds for myths.
Therapists, says Lilienfeld, have an obligation to stay on top of research and to question and check the supporting data even—perhaps especially—on the things they assume they "know." The more we hear something, the more we tend to believe it; but just because we've heard something doesn't mean it's true.
Many myths come from confusing causation and correlation: the correlation between full moons and increased homicides, for example, seems due not to lunar gravitational power, but to the fact that over the periods studied, more full moons occurred on weekends, when assaults increase. Biased samples often breed myths: for years it was thought that AD/HD was much more prevalent among boys, when, in fact, it may be just as prevalent among girls, although girls usually have the inattentive type that leads to quiet daydreaming, while boys more often have the hyperactive kind that draws the attention of parents, teachers, and therapists. Some myths simply reflect outdated knowledge. Twelve-step programs were once the only widely available treatment for alcoholism and, as a result, many people still incorrectly believe they're the only effective treatment.
Googling Your Clients
Everyone is googling everyone these days, so it seems safe to assume that many therapists have googled their clients. But is it ethical? And even if it is, what are the therapeutic ramifications?
Suppose, for example, you google a client who's come in for something relatively innocuous, like loneliness or a relationship problem, and you find out he's on a sex offender registry list. Should you tell him what you did and what you know? Should you use this information, and if so, how? Can you do therapy effectively without revealing it?
Writing in Psychiatric News in May 2009, Linda Hughes, director of the American Psychiatric Association's Office of Ethics, advised that googling should be done "only in the interests of promoting the patient's care and well-being and never to satisfy the curiosity or other needs of the psychiatrist." Hughes points out that the "standard of practice" for obtaining information is face-to-face interviewing, with collateral information obtained from medical records and family members. "Standard of practice" is a specific legal term, and therapists who violate it are vulnerable to sanctions and lawsuits. Significantly, Hughes doesn't say psychiatrists shouldn't google clients; instead, she says, they should consider how the information will influence treatment and how the clinician will use the information.
Psychologist Ofer Zur, whose 2007 book, Boundaries in Psychotherapy, examines ethics issues in the context of today's technology and changing perspectives about therapy, points out that Gen-X and younger clients are less likely to consider it an invasion of privacy if their therapist googles them. From their standpoint, it's an accepted way of getting to know someone, and some might even be mildly surprised if their therapist doesn't think to google them, or at least check their Facebook profile. Many even may be more comfortable having information about themselves revealed in that way.
Nevertheless, says Zur, it's a good idea to obtain informed consent before you google. Doing that not only helps protect against sanctions, but it can prevent sticky situations in which the therapist finds out something so important that keeping it a secret can create unwelcome complications and twists in treatment.
The Worst Media Therapist Yet!
The depiction of therapy has made great leaps on television. Early sitcoms featuring Bob Newhart's Robert Hartley and Kelsey Grammer's Frasier were more about comedy than therapy, and gave little insight into what happened in sessions. Then came The Sopranos. Whatever Dr. Jennifer Melfi's flaws, she was a thoughtful clinician, and the therapy-wise scripts have inspired some provocative discussions of her methods. Psychiatrist Glen Gabbard wrote a book on the psychology of The Sopranos, and family therapist William Doherty has run ethics workshops using Melfi's sessions.
With the series In Treatment, HBO went even deeper into an examination of therapy. Gabriel Byrne's Dr. Paul Weston and Dianne Wiest's Gina are intelligent, committed, compassionate, and highly skilled, and the interplay of their personal and professional lives brings the complexity of therapy and therapists into sharp focus.
Now a comedy series, available only on webcasts and in its second season, gives us one of the worst therapists imaginable. Lisa Kudrow, known for her role in the network hit Friends and winner of a Webby Award for her portrayal of therapist Fiona Wallice, is a narcissist who's clearly in the wrong profession. The premise: Wallice conducts three-minute therapy sessions each week via webcam. Longer sessions are useless, she explains, because only three minutes of every therapy session contains anything important—the rest is about things like dreams, feelings and memories "which add up to a whole lot of nothing."
She begins each session by telling the viewer, "I'm Fiona Wallice, and this is Web Therapy," her smile coming just a beat too late to look sincere. The dialogue, mostly ad lib, serves as a primer for what therapists should avoid saying and doing. "You look bored," one client says, clearly identifying Wallice's lack of interest in him. "I'm not bored," she says. "I have enough of an inner life to keep me interested even in what you're saying." When a dissatisfied client announces that she's going to see another therapist, Wallice replies, "It's unethical for you to go see another therapist without discussing it with me," telling the client that's like "stealing intellectual property." When a client, sensing things aren't going so well, asks, "Your analytic training was where?" Wallice replies that for therapy to work, the client will have to give up his need for control.
In today's impatient world, when the wisdom of therapy sometimes seems in danger of being reduced to one-liners and quick solutions, Web Therapy is a comedic nightmare vision of short-term therapy taken to an extreme.
The Effects of Client Feedback
Research consistently shows that asking clients how they think therapy is going, especially during their first five sessions, significantly improves outcomes. Moreover, feedback seems to work best with clients identified by the evaluation process as being at risk of dropping out or of not benefiting from therapy. So why don't more therapists place client feedback on a par with their own clinical judgments?
That question is even more clinically relevant in light of a new study by psychologists Morton Anker and Barry Duncan and marriage and family therapist Jacqueline Sparks reported in the August Journal of Consulting and Clinical Psychology, which extends the effect of feedback research to couples therapy. Couples who told their therapists in every session how they evaluated their therapy were significantly more likely to show improved marital satisfaction than couples who didn't offer feedback. Six months after therapy ended, just over 81 percent of the 126 couples who gave feedback were still together, as opposed to about 66 percent of the 119 couples who didn't.
Soliciting feedback from clients is surprisingly uncomplicated. The study used a simple, four-question form, on which clients marked a spot on a continuum indicating how heard and respected they felt in the session, how much the session addressed their goals, how good a fit the therapist seemed, and how the session seemed overall. (The form, the Session Rating Scale, and its companion, the Outcome Rating Scale, which also uses just four questions to assess how clients are doing on their goals outside of session, are available for free at www.heartandsoulofchange.com.)
Duncan suspects that it's the collaborative, conscious process that therapists and clients go through in discussing the feedback that improves outcomes, and not necessarily the forms themselves. Soliciting feedback in each session on the therapeutic alliance and clients' goals focuses everyone on these two highly reliable predictors of successful therapy.
So if soliciting feedback is so easily integrated into each therapy session and takes under five minutes, why don't more therapists do it? Duncan and Sparks find that while many therapists believe they already do this informally, few of them actually do it. In addition, they speculate, the dismissal of client input has been "hardwired" into therapists' thinking and practice. Many clinicians may prefer to believe that if therapy works, it's because of their skill and insight, and if it doesn't, it's due to clients' lack of motivation or other deficits. But as the research on the power of feedback continues to accumulate, along with the growing self-recovery and informed-consumer movements among clients, deliberate, regular, formalized feedback is likelier to become a standard feature of treatment.
When New Clients Interview Therapists
The old model of the therapist as the expert parental figure taking care of the client has been evolving for some time toward a more egalitarian view of the relationship. More clients have begun viewing themselves as informed consumers who wish to interview their potential therapist. But as a recent discussion on a therapists' listserv indicates, authority is sometimes a difficult thing to give up.
A therapist on the listserv asked for collegial advice about dealing with an increasingly common occurrence: clients who want to meet with her and several other therapists before choosing one. She reported that virtually none of these clients ended up choosing her, and she wondered whether her discomfort about being interviewed had something to do with it.
Therapists on the listserv who reported the highest success rate in the group-interview process used a technique long familiar to anyone who's looking for a date: don't act too hungry. San Diego therapist Lew Mills compliments the other therapists who are on the list if he knows and respects them. When Chicago therapist Lauren Miller finds that a client isn't a good fit for her, she often unexpectedly ends up seeing them. "The harder I try to refer out, the more persistent clients tend to be," she says. New Jersey therapist Michael Gindi informs such clients that his first session is always a brief, free consult because he himself retains the right to choose whether to work with someone, and that he takes on only one in four new clients.
Although many therapists routinely give three referrals, some are uncomfortable when they find that they themselves are one of three candidates. Although San Francisco therapist William Henkin thinks this kind of shopping is a good idea for clients, he has reservations about going through the selection process himself. "I never like to be part of this experiment because I invest myself in the first meeting and want to feel it's likely to continue." Some psychodynamically-inclined therapists refer to it as a job interview or running a gauntlet, and believe that potential clients who let the therapist know they're interviewing candidates are probably anxious, hostile, or ambivalent. But therapist Alice Graubart of Chicago takes a different view. Although such clients may be trying to gain mastery over an inherently insecure situation, she tries to understand what the client feels he needs and whether the client feels that she understands him.
Graubart's approach illustrates an important point. Therapists who feel uncomfortable about selling themselves might remember that an important technique of successful selling is also one of the basic techniques of therapy: first find out from clients what they want or need.
Energy Therapy: Psychotherapy Theory, Research, Practice, Training 45, no. 2 (June 2008): 199-213, and 46, no. 2 (June 2009): 262-69. Brain Cells: Psychotherapy and Psychosomatics 78, no. 3 (April 2009): 187-92. Web Therapy: episodes may be purchased at www.lstudio.com. Some older episodes are available for free at www.hulu.com. Feedback: Journal of Consulting & Clinical Psychology 77, no. 4 (August 2009): 693-704.
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