Conventional talk therapies often require multiple individual face-to-face sessions, led by highly trained psychotherapists. Such interventions are relatively expensive compared with common pharmaceutical treatments, and many therapy services are struggling to cope with existing referrals. Funding increases are unlikely to keep pace with demand. Hence, it is timely to consider other, potentially more cost-effective, approaches.
Emotional freedom techniques (EFTs) comprise a novel intervention that combines elements of exposure, cognitive and other conventional therapeutic techniques with the somatic stimulation of acupressure points (Feinstein, 2018). They are similar to acupuncture, but replaces the invasive use of needles with tapping or gently rubbing a series of acupoints on the face and body. It can be used as a self-help tool or as a face-to-face (one-to-one or group) therapeutic tool applied by trained therapists.
EFT was first introduced in the mid-eighties, but, due to the lack of evidence and apparently exaggerated claims of benefit, as well as the unconventional appearance of the technique, it was largely dismissed and even ridiculed by psychologists and others. However, a steadily growing body of research corroborates the existence of energy channels and the impact of somatic stimulation of acupoints on brain chemistry. It also demonstrates the speed, ease of use and efficacy of EFT in treating a wide range of conditions, such that some proponents consider it to be triggering ‘a paradigm shift in biomedicine’ (Feinstein, 2018).
Anatomy and function of energy channels and acupoints
The existence of ‘meridians’, or energy channels, is fundamental within traditional Chinese medicine (TCM), but has been largely dismissed by Western medicine until recently. It is believed that energy flow within the meridian network is improved through manipulation of acupoints, which are energy access points lying along the meridians (Feinstein, 2012).
An increased research focus over the past decade, together with modern imaging techniques, has provided support for the existence of meridians and fostered speculation regarding their anatomical and functional roles (Li et al, 2008). Some theories propose that meridians lie within the fascia network, the soft tissue component of connective tissue providing structural support throughout the body (Bai et al, 2011), and there appears to be close correspondence between the ‘meridians’ outlined in TCM and the body's interstitial connective tissue (Feinstein, 2018).
Recent evidence indicates that acupressure points have a significantly lower electrical resistance than other areas of the skin and a higher concentration of receptors sensitive to mechanical stimulation, as well as a range of other distinguishing biophysical properties (Li et al, 2012). It has been proposed that the semi-conductive properties of collagen within the connective tissue may allow signals produced by tapping on acupoints to be sent to the brain and within the body more rapidly and directly than via the nervous system (Feinstein, 2018).
Physiological impact of somatic techniques
Studies demonstrate that manipulation of acupoints results in rapid changes in brain electro-biochemistry, as measured by magnetic resonance imaging (MRI), single-photon emission computerised tomography (SPECT) and positron-emission tomography (PET) scans and electroencephalography (EEG) brain wave monitors (Hui et al, 2005; Lane, 2009; Feinstein, 2012). Research has also shown these changes to be associated with an increased release of endorphins, serotonin and γ-aminobutyric acid (GABA) and a reduction in cortisol levels (Lane, 2009; Church et al, 2012). This latter outcome has been repeatedly demonstrated, most recently in a 2019 study examining the impact of EFT intervention on a range of physiological indicators, including resting heart rate, blood pressure and cortisol levels, all of which significantly decreased during the intervention period (Bach et al, 2019). These neurochemical changes have the beneficial effects of reducing pain, decreasing anxiety, shutting off the fight/flight/freeze response, regulating the autonomic nervous system and creating a sense of calm.
It has been proposed that during an EFT session, the focus on a trauma-associated negative emotion, combined with acupoint stimulation, down-regulates the arousal response and reduces sensitisation to traumatic stimuli (Feinstein, 2012). Follow-up investigations of EFT interventions have consistently shown symptomatic improvements to be durable, even after short interventions. Ongoing research into the neural pathways that maintain negative affect and processes of memory integration and re-consolidation may explain the apparent long-term effectiveness of these techniques (Feinstein, 2018).
A recent meta-analysis of six dismantling studies examining the somatic (tapping) component of EFT confirmed its physiological significance in achieving rapid, lasting outcomes beyond a placebo effect or other nonspecific therapeutic effects (Church et al, 2018).
Intervention studies
There are now over 100 studies in peer-reviewed journals (Feinstein, 2018) indicating significant outcomes of EFT for anxiety disorders, depression, hostility, aggression, posttraumatic stress disorder (PTSD), addictions, phobias and food cravings. EFT has also been used effectively for a range of physical ailments, including headaches, joint pains, arthritis, chronic fatigue syndrome, irritable bowel syndrome and fibromyalgia and has been shown to positively impact on a range of biological markers (Bach et al, 2019).
EFT has been extensively investigated for treating anxiety and depression. A recent meta-analysis of 14 randomised controlled trials (RCTs) of EFT use for anxiety disorders (n=658) found a significantly greater treatment effect of 1.23 in reducing anxiety scores compared with the combined control effect of 0.41 (Clond, 2016). Examining EFT as a treatment for depression, a meta-analysis of 12 RCTs (n=398) and eight outcome studies (n=461) demonstrated an overall effect size of 1.85 (Nelms and Castel, 2016). A further meta-analysis of seven RCTs (n=247) investigating EFT for the treatment of PTSD found an exceptionally large treatment effect of 2.96 (Sebastian and Nelms, 2017).
To date, only one small RCT (n=20) has focused specifically on EFT interventions in older adults (Lee et al, 2015). This small study of women with insomnia (mean age=80 years) compared standard sleep hygiene education (SHE) with a form of EFT adapted for use with insomnia (EFT-I). Participants received eight 1-hour group sessions twice weekly for 4 weeks. Assessments at baseline and at 5 and 9 weeks post-intervention showed that EFT was more effective than SHE for improving sleep (Lee et al, 2015).
Potential use of EFT within health and care services
As EFT is a recently developed therapy, its evidence base does not yet compare in scale or quality with that of cognitive behavioural therapy (CBT) or other long-established talk therapies. However, in a recent evidence review of PTSD treatments, the National Institute for Health and Care Excellence (NICE) has recommended further research into the clinical and cost-effectiveness of EFT for the treatment of PTSD in adults (NICE, 2018). EFT has also begun to filter into some NHS trusts, such as Birmingham and Solihull Primary Care Mental Health Trust, Chesterfield Psychological Services and NHS Forth Valley. Two studies have evaluated EFT use within NHS settings (Stewart et al, 2013a; 2013b), and the Rotherham Institute for Obesity used to offer EFT treatment alongside other talk therapies until its closure following local council funding cuts.
EFT has been shown to be at least as effective as CBT and to deliver significant positive results in fewer sessions and with lasting results (Jasubhai and Mukundan, 1998; Stapleton et al, 2016; Gaesser and Karan, 2017). It can be used effectively and at low cost as a self-help tool for those with mild anxiety, low mood, pain and grief. Furthermore, practitioner training is not restricted to highly qualified health professionals but is relatively affordable in terms of time and financial investment. EFT can be applied in group as well as individual settings. It can also be easily learned by healthcare workers (Bertoux, 2017), which would equip them to apply it to calm upset, confused, anxious or aggressive patients and, thereby, work more effectively within their existing capacity. Moreover, EFT has been shown to be beneficial across a wide range of ages and demographic groups, including school children, college students, patients needing surgery, those with cancer and/or diabetes, victims of sexual violence and survivors of natural disasters (Bach et al, 2019). EFT can also be delivered effectively via online sessions (Stapleton et al, in press) and via telephone contact. The breadth of populations, settings and delivery methods indicates the generalisability and flexibility of the technique.
Relevance for older adults
Care providers and funding agencies face an increasing challenge in meeting the physical and mental health care needs of the rapidly escalating older adult population (generally defined as those over 65 years of age chronologically, although this is not always a good indicator of biological age/health, which is highly variable). The relative under-referral to talk therapies and much greater prescription of antidepressants for older adults than in younger cohorts has been highlighted (Harbottle, 2019). This is despite the fact that response to antidepressants tends to be lower in older cohorts, whereas the incidence of adverse side effects and drug interactions is greater. Further, adherence to antidepressant medication has been shown to be variable and particularly low among community-dwelling older adults (Raue et al, 2017).
Over-prescription of pharmaceuticals by practitioners treating older adults continues despite the fact that talk therapies have been demonstrated to be effective in reducing depression in this group (Raue et al, 2017). However, as Raue et al (2017) pointed out, not all approaches are equally beneficial, and, to be effective, psychotherapy should be adapted and tailored according to the specific needs of those with chronic or acute medical illness, cognitive impairment and/or suicide risk factors, which may prove expensive.
By contrast, EFT was designed so that the same tapping protocol could be applied to any physical or emotional condition. Therefore, it has the potential to be used effectively for older adults with multiple comorbidities and complex physical and mental health issues.
Bertoux's (2017) work indicates the potential scope of EFT use in older adults. Over the past 4 years, she has specialised in later-life care, and, at the end of 2015, she was contracted by the French healthcare service to provide an alternative to drug treatment for dependent older adults living in their own homes. This included those with sight, hearing and cognitive impairments, those with Alzheimer's and Parkinson's disease and those with long-term physical conditions, unresolved grief, fear of dying, depression and anxiety. The positive outcomes of this EFT trial (including reduced aggression and agitation, less confusion, improved mood, improved relationships with family and carers and greater compliance with nursing interventions) led to further funding to expand the intervention to several care homes. Bertoux has since continued to use EFT with older adults, within their own homes and care settings, to help them (and assist their carers) to better manage their physical and emotional symptoms. As a result of the rapid improvement in symptoms, mood and quality of life observed, and better compliance with care (improving cost-effectiveness and staff morale), Bertoux's contract was further extended to create a specially designed course for healthcare staff. Over the past 3 years, she has worked with doctors, psychologists and psychiatrists, and she has now trained over 100 nurses and healthcare assistants to use EFT within their daily practice (Bertoux, 2017). Unfortunately, plans to undertake an RCT to document the project findings have been stalled by lack of funding (personal communication), so her findings have not been available to academics. Further research in this area is called for.
Supporting older adults with EFT
Bertoux's work demonstrates some of the potential applications of EFT among older adults (2017). For example, it could be used by community nursing staff visiting anxious/confused patients in their own homes, or by healthcare assistants in care homes (and some day centres). EFT could be included by trained activity coordinators as an activity or, particularly in the case of those with cognitive impairment, it could be combined with music and singing sessions. Singing has been shown to improve mood and social interaction and to lower stress and agitation in people with dementia (Osman et al, 2014). For some time now, EFT tapping songs, combining acupoint stimulation with singing, have been used as a fun and effective mood enhancer for children. The combination of EFT and singing could prove a low-cost, enjoyable and highly effective intervention for older adults. Further research into the benefits of EFT in older cohorts and into the most cost-effective means of delivery is indicated.
Conclusion
Mood disorders significantly increase morbidity and impair quality of life in old age. EFT is an innovative somato-cognitive therapy shown to have significant beneficial effects on a range of physiological markers in addition to effectively modulating mood. EFT may offer an affordable, effective, easy and readily accessible tool to improve mood, moderate pain, manage a range of physical and emotional issues and enhance the quality of life of older adults across care settings, including those living in the community.