Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2025 Jun 1.
Published in final edited form as: J Psychother Integr. 2024 Jun;34(2):190–199. doi: 10.1037/int0000315

Acupressure in Psychotherapy as an Unsinkable Rubber Duck: A reply to Feinstein (2023)

Cassandra L Boness a, Rory Pfund b, David F Tolin c,d
PMCID: PMC11244757  NIHMSID: NIHMS1934120  PMID: 39006869

Abstract

In a recent publication entitled “Integrating the Manual Stimulation of Acupuncture Points Into Psychotherapy: A Systematic Review with Clinical Recommendations,” appearing in this journal, Feinstein (2023) aims to aggregate the evidence on Emotional Freedom Techniques (EFT) across the “hierarchy of evidence.” EFT is based on the premise that tapping facilitates alterations in “energy meridians” and that these alterations reduce psychological symptoms or disorders. This commentary addresses several concerns with the Feinstein (2023) review including the pseudoscientific concept of energy meridians, the lack of evidence that tapping on acupressure points is the active ingredient that resolves psychological disorders, serious methodological flaws with EFT research, and the incompatibility of EFT with the ethical practice of psychology. Thus, we disagree with Feinstein’s (2023) conclusion that “The body of research on acupoint tapping that has emerged over the past two decades and the increasing quality of the study designs appears promising” (p. 61) and instead argue that EFT represents a pseudoscientific, “unsinkable rubber duck” (i.e., a belief that people continue to hold despite evidence to the contrary).

Keywords: Psychotherapy, meta-analysis, systematic review, emotional freedom techniques, thought field therapy

In the publication “Integrating the Manual Stimulation of Acupuncture Points Into Psychotherapy: A Systematic Review with Clinical Recommendations,” Feinstein (2023) aims to aggregate the evidence on Emotional Freedom Techniques (EFT) across the “hierarchy of evidence” (with meta-analyses at the highest level and anecdotal reports at the lowest level). EFT, which falls under the umbrella of “energy psychology,” is described by the author as a therapy that incorporates imaginal exposure and cognitive interventions with acupressure or tapping. EFT is proposed to ”…work with the body’s energy systems” (p. 48) or energy “meridians” (p. 49), which are allegedly disturbed in people with psychological disorders. Supposedly, working with these energy systems is a way to …(a) “methodically reduce the client’s sense of distress as deactivating signals are sent to areas of the brain associated with excessive fear, anger, or other problematic responses and (b) increase activation in executive brain regions associated with adaptive responses such as planning and stress management” (p. 50).

As the author correctly points out, EFT has faced criticism on multiple grounds. Although now packaged as EFT, this treatment is essentially equivalent to Thought Field Therapy (TFT) which also falls under “energy psychology”. TFT supposedly targets different energy fields, which become blocked through trauma or genetic vulnerabilities, and rebalances the autonomic nervous system through various tapping “algorithms”. EFT, in comparison, claims to use a single tapping algorithm to address all presenting problems (see Bakker, 2013 and McCaslin, 2009 for detailed discussions of TFT). The rebranding of TFT into EFT likely happened as a result of the TFT being viewed as discredited by experts due to the absence of scientific support for its effectiveness (Bakker, 2013; Norcross et al., 2006), sanctions brought against a therapist in Arizona practicing TFT, and later decisions by the American Psychological Association (APA) to consider TFT an inappropriate subject for Continuing Education courses (Lilienfeld & Lohr, 2000).1 Despite these actions, Feinstein (2023) notes that many therapists continue to use TFT (or EFT), representing what Randi (2012) referred to as an “unsinkable rubber duck” (i.e., a belief that people continue to hold in spite of evidence to the contrary).

Although Feinstein (2023) concludes: “The body of research on acupoint tapping that has emerged over the past two decades and the increasing quality of the study designs appears promising” (p. 61), we must disagree for several important reasons. First, EFT is based on the pseudoscientific concept of energy meridians which are neither evidence-based nor falsifiable. Second, EFT posits that tapping on acupressure points resolves psychological disorders, despite a lack of compelling research isolating this as the active ingredient. Third, the research on EFT is methodologically flawed. Fourth, EFT is not compatible with ethical practice. We describe each of these points in more detail below.

The Validity of Energy Meridians

The entire rationale for EFT is based on the premise that tapping facilitates alterations in “energy meridians,” which derived from traditional Chinese medicine, and that these alterations in turn reduce psychological symptoms or disorders. However, there is no reliable evidence that “energy meridians” exist, nor that these meridians are responsible for psychological symptoms or disorders (McCaslin, 2009). Indeed, energy meridians cannot be measured or quantified, which precludes rigorous scientific evaluation or falsifiability (Saraví, 1999). A lack of falsifiability is a common characteristic of pseudoscience (Lilienfeld, 1998; Lilienfeld et al., 2012; Olatunji et al., 2005; Popper, 2005), and it is perhaps unsurprising that research support for energy meridians is essentially entirely absent (Bakker, 2013). As such, it is difficult to consider energy meridians to be theoretically plausible or valid (Lilienfeld, 2011; Lilienfeld et al., 2012; Pignotti & Thyer, 2009).

Feinstein’s (2023) argument for the existence of energy fields in the body rests on two premises: (a) the body is electrical, and (b) a belief in energy fields is prevalent in 97 cultures worldwide. This argument is entirely unconvincing; we note that while the body and brain are electric, and that the electricity in the body and brain are easily detected using reliable tools such as electroencephalography and electrocardiography, such tools have never, to our knowledge, detected the presence of energy meridians as espoused by proponents of TFT or EFT. As Beyerstein and Sampson (1996) noted, “It has always struck us as odd that proponents can accept that this mysterious energy is unable to interact with the physical matter in the sensors of measuring instruments (which could confirm its existence) while it is still able to interact with the physical matter of bodily organs to ‘read’ their state of health and produce a cure” (p. 22). Furthermore, the fact that a belief is old, or that it is cross-cultural, does not make it accurate (see, for example, the persistence of beliefs in racism, sexism, and flat earth). Indeed, pointing to such factors as “proof” has long been recognized as a hallmark of pseudoscientific persuasive techniques (Pratkanis, 1995). Other pseudoscientific tactics used by proponents of EFT including engaging novel paradigms that do not build on existing empirically supported concepts, misappropriating concepts from legitimate allied disciplines (e.g., neuroscience), and using obfuscatory language to give the appearance of meaningful or compelling content (Olatunji et al., 2005).

Acupressure or Tapping as the Active Treatment Ingredient

There is insufficient evidence to establish acupressure, or tapping, as the active ingredient in EFT. As others (e.g., McLean & Miller, 2022) have argued, when EFT is effective, this is likely due to its engagement of common therapeutic factors (e.g., rapport, goal setting) and reliance on imaginal exposure and cognitive interventions2, rather than through acupressure as proposed. Although Feinstein (2023) attempts to provide evidence for tapping as the active ingredient, including one randomized clinical trial and one meta-analysis, the actual evidence in support of acupressure as an active ingredient in EFT is still lacking. As such, we would argue that EFT represents what Rosen and Davison (2003) described as a “Purple Hat Therapy,” in which a practitioner uses otherwise valid therapeutic techniques while also instructing the client to wear a purple hat, and then incorrectly credits the client’s recovery to the purple hat rather than to the effective ingredients of the intervention.

Absent from Feinstein’s discussion is a review of studies that failed to find evidence of the efficacy of EFT or for the mechanism of tapping on acupressure points. As an example, Waite and Holder (2003) found that among college students with self-reported specific phobias, EFT was not superior (using the subjective units of discomfort scale while imagining the phobic object, which we acknowledge is not an ideal outcome measure) to a placebo condition in which alternative parts of the body (not associated with theoretical energy meridians) were tapped, and neither condition was superior to tapping on a doll (which has no credible connection to the purported energy meridians in the body). This omission, which has also been noted in previous reviews on EFT (see Pignotti & Thyer, 2009), is troubling and raises questions about the objectivity of the review.3

The meta-analysis presented as evidence of acupressure as an active ingredient (Church et al., 2018) has been heavily criticized, especially on methodological grounds (Spielmans et al., 2020; Spielmans & Rosen, 2022), and, contrary to Feinstein’s claim, the challenges with this meta-analysis have not, in our opinion, “been addressed” (Feinstein, 2023; p. 59). Here, we briefly summarize the original meta-analysis (Church et al., 2018) and subsequent critiques (Spielmans et al., 2020; Spielmans & Rosen, 2022) and responses (Church et al., 2020, 2022). In the original meta-analysis (Church et al., 2018), the authors examined whether acupressure was an active ingredient in EFT. Church and colleagues meta-analyzed three studies that purportedly isolated acupressure and concluded that acupressure was an active ingredient of EFT and that EFT outcomes were “not due solely to placebo, nonspecific effects of any therapy, or nonacupressure components” (p. 783), reporting an overall effect size of Hedges’s g = −0.45 (95% confidence interval [CI], −0.91 to 0.00).

Spielmans and colleagues (2020) challenged the results of this meta-analysis on numerous methodological and statistical grounds. For example, Church and colleagues (2020): 1) reported the overall effect as significant when the confidence interval included zero; 2) included two studies that failed to isolate the effect of acupressure; 3) included comparison groups that were not bona fide therapies; and 4) failed to control for researcher and therapist allegiances. To address the statistical concerns, Spielmans and colleagues (2020) reanalyzed the data from Church and colleagues (2018) and found Hedges’s g = −0.38 (95% CI, 0.10 to −0.87), p = 0.12, a nonsignificant effect for EFT.

In response to Spielmans and colleagues, Church and colleagues (2020) published a corrigendum in which they argue they clarified the methodological critiques and corrected the statistical errors (incorrect standard deviations) identified by Spielmans and colleagues (2020), reporting a new Hedges’s g value of 0.74 (95% CI = 0.34–1.13, p < 0.0001) and concluding “…the present revised analysis supports the original conclusion that the acupressure component of the EFT protocol is an active ingredient that contributes to the method’s favorable health effects” (p. 632). Importantly, in this corrigendum, Church and colleagues (2020) analyzed follow-up data rather than the original post-treatment end points used in Church and colleagues (2018). Thus, the concerns of Spielmans and colleagues’ (2020) were not directly addressed in this corrigendum nor later replies (Church et al., 2022).

Because Feinstein (2023) cites Church and colleagues’ (2018, 2020) meta-analyses as one of the main sources of evidence for acupressure as an active treatment component while omitting other studies challenging tapping as an active ingredient (Pignotti, 2005; Waite & Holder, 2003), we remain highly skeptical that there is evidence in support of acupressure as an active treatment component in EFT.

Quality of the Evidence

Given the hierarchy of evidence, we focus on the three meta-analyses included in Feinstein’s manuscript. Clond (2016) conducted a meta-analysis of EFT for anxiety (though many of the participants in the included studies did not actually have clinically significant anxiety or anxiety disorders) that included 14 randomized clinical trials. Nelms and Castel (2016) conducted a meta-analysis of EFT for depression that included 20 studies (12 randomized clinical trials, 8 outcome studies, though many of the participants in the included studies did not actually have clinically significant depression or depressive disorders and some were reportedly “workshop participants”). Sebastian and Nelms (2017) conducted a meta-analysis of EFT for PTSD (though they actually examined PTSD, anxiety, and depression) that included 7 randomized clinical trials.

We evaluated the quality of the evidence of these three meta-analyses using the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR 2; Shea et al., 2017) system (see Table 1). AMSTAR2 is a tool for critically evaluating systematic reviews and meta-analyses of randomized and nonrandomized studies of healthcare interventions across 16 domains. Each domain is coded “Yes” or “No,” and for some items, “Partial Yes.” “Yes” or “Partial Yes” indicates a positive result on the stated domain, and a code of “No” indicates a negative result. Consistent with previous work (e.g., Boness et al., 2020), six domains were deemed critical for the current evaluation (see Table 1). Coding “No” in any critical domain reflected a critical weakness.4 Overall confidence (critically low, low, moderate, and high) in the results of each meta-analysis was determined based on the pattern of results of AMSTAR2, including consideration of critical and non-critical domains. A rating of “High” was assigned if the meta-analysis had zero or one non-critical weakness, “Moderate” if no critical weaknesses and more than one non-critical weakness, “Low” if one critical weakness with or without non-critical weaknesses, and “Critically Low” if more than one critical flaw with or without non-critical weaknesses. All three meta-analyses were rated as having “critically low” quality of evidence and each suffered from the same critical weaknesses, several of which we highlight next, including inappropriate methods for statistical of combination of results, failure to account for risk of bias in interpreting results, and a failure to explain or discuss observed heterogeneity in effect sizes. There are numerous other methodological flaws as well which are described in Table 1.

Table 1.

AMSTAR2 Results

Item Clond 2016 Nelms & Castel, 2016 Sebastian & Nelms, 2017
1. Did the research questions and inclusion criteria for the review include the components of PICO? Y Y Y
2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol? N N N
3. Did the review authors explain their selection of the study designs for inclusion in the review? N Y N
4. Did the review authors use a comprehensive literature search strategy? N N N
5. Did the review authors perform study selection in duplicate? N N N
6. Did the review authors perform data extraction in duplicate? N Y N
7. Did the review authors provide a list of excluded studies and justify the exclusions? N N N
8. Did the review authors describe the included studies in adequate detail? PY PY PY
9. Did the review authors use a satisfactory technique for assessing the risk of bias in individual studies that were included in the review? N N N
10. Did the review authors report on the sources of funding for the studies included in the review? N N N
11. If meta-analysis was performed did the review authors use appropriate methods for statistical combination of results? N N N
12. If meta-analysis was performed, did the review authors assess the potential impact of risk of bias in individual studies on the results of the meta-analysis or other evidence synthesis? N N N
13. Did the review authors account for risk of bias in individual studies when interpreting/ discussing the results of the review? N N N
14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review? N N N
15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review? N N N
16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review? N N Y
Overall Rating Critically low Critically low Critically low
Open in a new tab

Note. Y = yes, PY = partial yes, N = no, NA = not applicable, PICO: (P = population, I = intervention, C = comparator group, O = outcome). Per AMSTAR2 guidelines (Shea et al., 2017), “Yes” or “Partial Yes” indicates a positive result on the stated domain, and a code of “No” indicates a negative result. An overall quality rating is assigned based on the pattern of ratings across those domains deemed critical versus noncritical. Those domains considered critical in this AMSTAR2 evaluation and others (e.g., Boness et al., 2020, 2023; Pfund et al., 2023) are bolded.

Inappropriate Methods for Statistical Combination of Results

When combining results from primary studies in a meta-analytic investigation, it is critical to use appropriate methods and make appropriate statistical decisions to ensure the robustness of the resulting effect size estimate(s). All three meta-analyses estimated the overall, weighted effect of EFT based on pre-post measures within a single treatment condition. This combination of pre-post effect sizes does not provide reliable, unbiased information about treatment effects and instead represents overestimated, uncontrolled treatment effects that cannot rule out spontaneous recovery, regression to the mean, or other threats to internal validity (Cuijpers et al., 2016).

The use of pre-post effect sizes was identified through the following information. Clond (2016) reports the formula used to calculate effect sizes as the difference between scores on a pretest and scores on a posttest divided by the standard deviation of the pretest score (p. 390). Nelms and Castel (2016) write that “all effect sizes were calculated directly using the following formula: d = (M1-M2)/S, where M1 is the pretest mean, M2 the posttest or follow-up mean” (p. 419). Sebastian and Nelms (2017) state that “mean differences were calculated from the reported means before and after treatment” (p. 20).

The use of pre-post effect sizes is not only problematic for statistical and methodological reasons, but they are also used to make apples and oranges comparisons. That is, the authors used these inflated pre-post effect sizes (d = 1.23 in Clond, d =1.31 in Nelms and Castel, d = 2.96 in Sebastian and Nelms) to claim that the effect of EFT was substantially higher than the more statistically sound and methodologically rigorous post versus post effect sizes from meta-analyses of pharmacotherapy (e.g., d = 0.20 in Fournier et al., 2010) and other psychological treatments (e.g., d = 0.22 in Cuijpers et al., 2010).

Failure to Account for Risk of Bias in Interpreting Results

Accounting for potential risk of bias is critical given bias in the form of confounding, sample selection bias, bias in measurement of exposures and outcomes, and selective reporting of outcomes can greatly impact the resulting effect sizes of the primary studies included in a meta-analysis. None of the three included meta-analyses formally evaluated or accounted for risk of bias. In what may have been an attempt to account for risk of bias, each of the three meta-analyses inappropriately applied the Chambless Empirically Supported Treatment Criteria (Chambless & Hollon, 1998). Of note, the Chambless criteria were never intended to be used in this way and instead are intended to evaluate the evidence required to determine whether a treatment is empirically supported.

Although this is an erroneous use of the Chambless criteria, if these criteria are to be used as an indicator of bias, it is unclear how some of the studies included in these meta-analyses met the Chambless criteria. For example, one criterion is “Adequate sample size—the study must include a sufficient number of subjects (sufficient power) for statistical analysis to determine a significant difference between the treatment and control conditions (p < 0.05)” (Clond, 2016, p. 390). Several of the manuscripts included in the Clond (2016) investigation had less than 15 participants per condition which, in the absence of a formal a priori power calculation, seems unlikely to be sufficient for meeting the criterion of “adequate sample size.” Feinstein himself, in describing adequate sample sizes, states “The number most frequently cited as the demarcation between a small study and a large study was 30 participants for each treatment condition,” (p. 57). The determination of an adequate sample size is much more complex than rule-of-thumb cutoffs, and it is unclear how exactly the sample sizes of studies included in these meta-analyses were considered “adequate” (per the Chambless criteria) by Feinstein’s own comments on sample size. However, some of the meta-analyses included by Feinstein offer insight into how sample sizes were determined to be adequate. For example, Sebastian and Nelms (2017) wrote, “Two of the included studies have only eight subjects in each treatment group. While this number is very small, treatment effects were nonetheless highly significant. The APA [Chambless] criteria advocate sample size sufficient to obtain a statistical significance of P < .05 or greater, which both studies achieved. While it is not one of the criteria, studies with at least 30 in each group are preferred” (p. 20). By this rationale, the authors considered sample sizes adequate if the results were statistically significant. This demonstrates a serious misunderstanding of statistical power.

Failure to Explain or Discuss Observed Heterogeneity in Effect Sizes

It is critical to discuss how observed heterogeneity may impact the overall effect sizes reported by the meta-analysis to ensure effect sizes are adequately contextualized in light of this information. All three meta-analyses reported significant heterogeneity among the included effect sizes (Clond: Q=75.8, I2=82.8; Nelms and Castel: Q=22.39; Sebastian and Nelms: I2=87.5). Although Clond (2016) appeared to have conducted a moderator analysis by diagnosis and treatment dose, the author failed to provide a strong rationale for evaluating these moderators over others and also failed to provide a satisfactory explanation for or discussion of this heterogeneity beyond stating that the heterogeneity may “…reflect variation in the samples studied and variation in the conduct of the studies themselves” (p. 393). Similarly, Nelms and Castel (2016) conducted no formal investigation of the sources of the observed heterogeneity nor was a satisfactory explanation for or discussion of this heterogeneity provided beyond postulating, “…factors that might have contributed to this were the large number of studies, the diversity of populations from clinic clients with major depressive disorder to veterans with PTSD to non-clinical workshop participants, and the varied treatment time frames ranging from 1 to 10 sessions.” (p. 424). Sebastian and Nelms also failed to formally investigate the sources of the heterogeneity nor was a satisfactory explanation for or discussion of this heterogeneity provided.

In summary, all three meta-analyses included in Feinstein (2023) as the highest level of evidence suffered from serious issues related to their methodological quality which is not made readily transparent by the author in summarizing the evidence for EFT. The lack of transparency is concerning given most treatment trials, even those considered methodologically rigorous, suffer from some methodological limitations (e.g., in a meta-analysis of 115 randomized clinical trials on depression, only 11 were very high quality; Cuijpers et al., 2010). Low quality of evidence and a lack of transparency about the limitations of the evidence greatly undermines the confidence in, and conclusions drawn, from these meta-analyses with respect to the efficacy of EFT in the treatment of anxiety, depression, and PTSD. These results also point to the need for a closer evaluation of the methodologic quality of the other meta-analyses (e.g., Gilomen & Lee, 2015) and manuscripts described by Feinstein (2023). Of note, we are not the first to critique the quality of the methodology used in EFT research (e.g., Bakker, 2013; McCaslin, 2009; Olatunji et al., 2005; Pignotti & Thyer, 2009; Spielmans et al., 2020; Spielmans & Rosen, 2022) and some of the errors raised by these authors are repeated in Feinstein (2023). Indeed, according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, which is mentioned by the author but not applied to the current investigation due to it being “beyond the scope of this study” (p. 61), the quality of the evidence for EFT, specifically in the treatment of PTSD, anxiety, and depression, is considered low given the fact that the meta-analyses all have major flaws (Atkins et al., 2004; Guyatt et al., 2008).

EFT and Ethical Practice

The APA’s ethics code (American Psychological Association, 2002) holds integrity as critical to the practice of psychology. For example, Principle C states, “Psychologists seek to promote accuracy, honesty, and truthfulness in the science, teaching, and practice of psychology” (pp. 3-4). One of the major concerns about EFT, and energy psychology more generally, is its presentation as a “miracle cure” (McLean & Miller, 2022; Pignotti, 2005) in the absence of compelling empirical evidence. As one example, the Association for Comprehensive Energy Psychology notes “Get breakthrough results with energy psychology” and “Thousands of professionals throughout the world, and a robust body of research show these methods work, time after time, in a wide variety of situations” on the homepage of their website (Association for Comprehensive Energy Psychology, n.d.). As we have demonstrated, to present EFT in this way is failing to promote accuracy, honesty, or truthfulness. These claims are not surprising, however, given that EFT is a proprietary or trademarked treatment which may be especially prone to confirmation bias and other cognitive errors and biases (Lilienfeld, 1998; Lilienfeld et al., 2012; Olatunji et al., 2005). This is further complicated by EFT being a rebranding of TFT which, as previously described, has been discredited (Lilienfeld & Lohr, 2000; Norcross et al., 2006). This rebranding shows an attempt to push the practice of meridian-based therapies forward, often at a steep cost to prospective practitioners, despite larger concerns about their legitimacy and empirical support.

The APA ethics code also requires that “psychologists’ work is based upon established scientific and professional knowledge of the discipline” (p. 5, Standard 2.04). Though not mentioned explicitly, we would argue that this principle requires good science, based not only on well-conducted outcome trials, but also on plausible, testable, and efficacious mechanisms of action. EFT meets neither of these criteria. In particular, we note that the practice of EFT requires telling patients things about their condition and its remediation that are either untestable or are demonstrably false (e.g., that there are energy meridians in the body, that these meridians are responsible for psychological problems, and that tapping on acupressure points can resolve psychological problems). As such, EFT is not compatible with ethical practice in behavioral health (Olatunji et al., 2005).

Conclusions

Although Feinstein (2023) has attempted to summarize the hierarchy of evidence for EFT in the treatment of various psychological disorders, there is insufficient evidence for energy meridians and their relevance to psychological disorders in the first place, and the shortcomings of the evidence presented were not thoroughly transparent to provide the reader with sufficient context for interpreting the state of the evidence on EFT, which is severely lacking. Indeed, a) the validity of energy meridians is dubious, b) there is little to no credible evidence of acupressure as an active treatment ingredient, c) meta-analyses of EFT for a variety of psychological disorders fall short methodologically, rendering the state of the evidence for EFT as an efficacious treatment for psychological disorders inconclusive at best, and d) EFT is not within the realm of ethical behavioral health practice. Despite this, EFT has yet to self-correct and thus continues to be an unsinkable rubber duck.

Disclosures:

Dr. Tolin receives consulting fees from Mindyra LLC and Oui Therapeutics; book royalties from Guilford Press, Oxford University Press, Cambridge University Press, Springer, John Wiley & Sons, and New Harbinger Publications; and research support from the National Institute of Mental Health and the American Foundation for Suicide Prevention. Dr. Boness receives research support from the National Institute of Health. Dr. Pfund receives research support from the Tennessee Department of Mental Health and Substance Abuse Services and the International Center of Responsible Gaming.

Investigator effort partially supported by NIAAA K08AA030301 (PI: Boness).

Footnotes

This commentary addresses a previously published manuscript in this journal on energy therapies, and specifically emotional freedom techniques. We raise concerns with the plausibility of the treatment’s mechanism, doubts about tapping as an active ingredient, problems with the methodological quality of the research, and additional ethical concerns.

1

This is arguably more serious than Feinstein’s characterization of TFT as being “…met with strong professional skepticism” (p.48).

2

However, a close look at the EFT manual (Church, 2017) demonstrates that EFT’s supposed “cognitive” interventions do not necessarily resemble common empirically supported cognitive interventions. Instead, EFT proposes that tapping while using a self-acceptance statement (e.g., “Even though [problem], I deeply and completely accept myself”; Church, 2017, p. 272) produces cognitive shifts “toward feelings of being at peace, of having moved on, of being safe” (Church, 2017, p. 185). Thus, EFT does not engage common empirically supported cognitive techniques such as evaluating and testing thoughts or challenging cognitive distortions, for example (see Spielmans et al., 2020 for a more detailed discussion of this issue).

3

Such omissions are also evident in other sections of Feinstein’s review, including the section on acupuncture which cites a non-peer reviewed manuscript as the most rigorous source of evidence for acupuncture’s effectiveness (McDonald & Janz, 2017). Both McDonald and Janz (2017) and Feinstein fail to capture more rigorous Cochrane reviews which have failed to find high quality support for acupuncture’s effectiveness in treating a range of conditions (e.g., low back pain [Mu et al., 2020], depression [Smith et al., 2018]).

4

More detailed information on what is considered a “yes” versus a “partial yes” versus a “no” for each AMSTAR2 item can be found in the original AMSTAR2 documentation (Shea et al., 2017).

References

  1. American Psychological Association. (2002). Ethical Principles of Psychologists and Code of Conduct. American Psychologist, 57(12), 1060–1073. 10.1037/0003-066X.57.12.1060 [DOI] [PubMed] [Google Scholar]
  2. Association for Comprehensive Energy Psychology. (n.d.). Retrieved March 15, 2023, from https://www.energypsych.org/
  3. Atkins D, Eccles M, Flottorp S, Guyatt GH, Henry D, Hill S, Liberati A, O’Connell D, Oxman AD, Phillips B, Schünemann H, Edejer TT-T, Vist GE, Williams JW, & The GRADE Working Group. (2004). Systems for grading the quality of evidence and the strength of recommendations I: Critical appraisal of existing approaches The GRADE Working Group. BMC Health Services Research, 4(1), 38. 10.1186/1472-6963-4-38 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Bakker GM (2013). The current status of energy psychology: Extraordinary claims with less than ordinary evidence. Clinical Psychologist, 17(3), 91–99. 10.1111/cp.12020 [DOI] [Google Scholar]
  5. Beyerstein BL, & Sampson W (1996). Traditional Medicine and Pseudo-science in China: A Report of the Second CSICOP Delegation (Part 1). Skeptical Inquirer, 18–26. [Google Scholar]
  6. Boness CL, Hershenberg R, Kaye J, Mackintosh M, Grasso DJ, Noser A, & Raffa SD (2020). An evaluation of cognitive behavioral therapy for insomnia: A systematic review and application of Tolin’s Criteria for empirically supported treatments. Clinical Psychology: Science and Practice, 27(4). 10.1037/h0101780 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Boness CL, Votaw VR, Schwebel FJ, Moniz-Lewis DIK, McHugh RK, & Witkiewitz K (2023). An evaluation of cognitive behavioral therapy for substance use disorders: A systematic review and application of the society of clinical psychology criteria for empirically supported treatments. Clinical Psychology: Science and Practice. 10.1037/cps0000131 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Borenstein M, Hedges L, & Rothstein H (2007). Introduction to Meta-Analysis. [Google Scholar]
  9. Chambless DL, & Hollon SD (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66(1), 7–18. 10.1037/0022-006X.66.1.7 [DOI] [PubMed] [Google Scholar]
  10. Church D (2017). The EFT Manual. Vearsa: : Hay House, Inc. [Google Scholar]
  11. Church D, Kip K, & Stapleton P (2022). Corrigendum Supports Therapeutic Contribution of Acupoint Tapping to EFTs’ Observed Effects: Response to Spielmans (2021). The Journal of Nervous and Mental Disease, 210(2), 143. 10.1097/NMD.0000000000001439 [DOI] [PubMed] [Google Scholar]
  12. Church D, Stapleton P, Kip K, & Gallo F (2020). Corrigendum to: Is Tapping on Acupuncture Points an Active Ingredient in Emotional Freedom Techniques: A Systematic Review and Meta-Analysis of Comparative Studies. Journal of Nervous & Mental Disease, 208(8), 632–635. 10.1097/NMD.0000000000001222 [DOI] [PubMed] [Google Scholar]
  13. Church D, Stapleton P, Yang A, & Gallo F (2018). Is Tapping on Acupuncture Points an Active Ingredient in Emotional Freedom Techniques? A Systematic Review and Meta-analysis of Comparative Studies. Journal of Nervous & Mental Disease, 206(10), 783–793. 10.1097/NMD.0000000000000878 [DOI] [PubMed] [Google Scholar]
  14. Clond M (2016). Emotional Freedom Techniques for Anxiety: A Systematic Review With Meta-analysis. The Journal of Nervous and Mental Disease, 204(5), 388. 10.1097/NMD.0000000000000483 [DOI] [PubMed] [Google Scholar]
  15. Cuijpers P, Van Straten A, Bohlmeijer E, Hollon SD, & Andersson G (2010). The effects of psychotherapy for adult depression are overestimated: A meta-analysis of study quality and effect size. Psychological Medicine, 40(2), 211–223. 10.1017/S0033291709006114 [DOI] [PubMed] [Google Scholar]
  16. Cuijpers P, Weitz E, Cristea IA, & Twisk J (2016). Pre-post effect sizes should be avoided in meta-analyses. Epidemiology and Psychiatric Sciences, 26(4), 364–368. 10.1017/S2045796016000809 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Feinstein D (2023). Integrating the manual stimulation of acupuncture points into psychotherapy: A systematic review with clinical recommendations. Journal of Psychotherapy Integration, 33(1), 47–67. 10.1037/int0000283 [DOI] [Google Scholar]
  18. Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, & Fawcett J (2010). Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-analysis. JAMA, 303(1), 47. 10.1001/jama.2009.1943 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Gilomen SA, & Lee CW (2015). The efficacy of acupoint stimulation in the treatment of psychological distress: A meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 48, 140–148. 10.1016/jjbtep.2015.03.012 [DOI] [PubMed] [Google Scholar]
  20. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, & Schünemann HJ (2008). GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ, 336(7650), 924–926. 10.1136/bmj.39489.470347.AD [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Lilienfeld SO (1998). Pseudoscience in contemporary clinical psychology: What it is and what we can do about it. The Clinical Psychologist, 51, 3–9. [Google Scholar]
  22. Lilienfeld SO (2011). Distinguishing Scientific From Pseudoscientific Psychotherapies: Evaluating the Role of Theoretical Plausibility, With a Little Help From Reverend Bayes. Clinical Psychology: Science and Practice, 18(2), 105–112. 10.1111/j.1468-2850.2011.01241.x [DOI] [Google Scholar]
  23. Lilienfeld SO, Ammirati R, & David M (2012). Distinguishing science from pseudoscience in school psychology: Science and scientific thinking as safeguards against human error. Journal of School Psychology, 50(1), 7–36. 10.1016/j.jsp.2011.09.006 [DOI] [PubMed] [Google Scholar]
  24. Lilienfeld SO, & Lohr JM (2000). Thought Field Therapy Pracitioners and Editors Sanctioned. Skeptical Inquirer, March/April, 5–9. [Google Scholar]
  25. McCaslin DL (2009). A review of efficacy claims in energy psychology. Psychotherapy: Theory, Research, Practice, Training, 46(2), 249–256. 10.1037/a0016025 [DOI] [PubMed] [Google Scholar]
  26. McDonald J, & Janz S (2017). The Acupuncture Evidence Project: A Comparative Literature Review. https://agopunturaintegrata.it/onewebmedia/The-Acupuncture-Evidence-Project.pdf
  27. McLean CP, & Miller M (2022). Energy Psychology and Therapy. In Hupp S & Wiseman R, Investigating Pop Psychology (1st ed., pp. 139–149). Routledge. 10.4324/9781003107798-16 [DOI] [Google Scholar]
  28. Mehdipour A, Abedi P, Ansari S, & Dastoorpoor M (2022). The effectiveness of emotional freedom techniques (EFT) on depression of postmenopausal women: A randomized controlled trial. Journal of Complementary and Integrative Medicine, 19(3), 737–742. 10.1515/jcim-2020-0245 [DOI] [PubMed] [Google Scholar]
  29. Mu J, Furlan AD, Lam WY, Hsu MY, Ning Z, & Lao L (2020). Acupuncture for chronic nonspecific low back pain. Cochrane Database of Systematic Reviews, 2020(12). 10.1002/14651858.CD013814 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Nelms JA, & Castel L (2016). A Systematic Review and Meta-Analysis of Randomized and Nonrandomized Trials of Clinical Emotional Freedom Techniques (EFT) for the Treatment of Depression. EXPLORE, 12(6), 416–426. 10.1016/j.explore.2016.08.001 [DOI] [PubMed] [Google Scholar]
  31. Norcross J, Koocher G, & Garofalo A (2006). Discredited psychological treatments and tests: A Delphi poll . Professional Psychology-Research and Practice - PROF PSYCHOL-RES PRACT, 37. 10.1037/0735-7028.37.5.515 [DOI] [Google Scholar]
  32. Olatunji BO, Parker LM, & Lohr JM (2005). Pseudoscience in contemporary psychology: Professional issues and implications. The Scientific Review of Mental Health Practice: Objective Investigations of Controversial and Unorthodox Claims in Clinical Psychology, Psychiatry, and Social Work, 4(2), 19–36. [Google Scholar]
  33. Pfund R, Ginley MK, Boness CL, Zajac K, Rash C, & Witkiewitz K (2021). Evaluation of Contingency Management (CM) for Substance Use Disorder (SUD) [Preprint]. Open Science Framework. 10.31219/osf.io/zme9n [DOI] [Google Scholar]
  34. Pignotti M (2005). THOUGHT FIELD THERAPY VOICE TECHNOLOGY VS. RANDOM MERIDIAN POINT SEQUENCES A Single-blind Controlled Experiment. Scientific Review of Mental Health Practice, 4(1), 38–47. [Google Scholar]
  35. Pignotti M, & Thyer B (2009). Some comments on “Energy psychology: A review of the evidence”: Premature conclusions based on incomplete evidence? Psychotherapy: Theory, Research, Practice, Training, 46(2), 257–261. 10.1037/a0016027 [DOI] [PubMed] [Google Scholar]
  36. Popper K (2005). The Logic of Scientific Discovery. Routledge. [Google Scholar]
  37. Pratkanis A (1995). How to sell a pseudoscience. Skeptical Inquirer, 19(4), 19–25. [Google Scholar]
  38. Randi J (2012). The Unsinkable Rubber Duckies. https://www.wired.com/2012/05/opinion-randi-frauds/
  39. Rosen GM, & Davison GC (2003). Psychology Should List Empirically Supported Principles of Change (ESPs) and Not Credential Trademarked Therapies or Other Treatment Packages. Behavior Modification, 27(3), 300–312. 10.1177/0145445503027003003 [DOI] [PubMed] [Google Scholar]
  40. Saraví FD (1999). Energy and the brain: Facts and fantasies. In Mind myths: Exploring popular assumptions about the mind and brain (pp. 43–58). John Wiley & Sons Ltd. [Google Scholar]
  41. Sebastian B, & Nelms J (2017). The Effectiveness of Emotional Freedom Techniques in the Treatment of Posttraumatic Stress Disorder: A Meta-Analysis. EXPLORE, 13(1), 16–25. 10.1016/j.explore.2016.10.001 [DOI] [PubMed] [Google Scholar]
  42. Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, Moher D, Tugwell P, Welch V, Kristjansson E, & Henry DA (2017). AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ, j4008. 10.1136/bmj.j4008 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Smith CA, Armour M, Lee MS, Wang L-Q, & Hay PJ (2018). Acupuncture for depression. Cochrane Database of Systematic Reviews, 2018(3). 10.1002/14651858.CD004046.pub4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Spielmans GI, & Rosen GM (2022). Corrigendum Compounds Errors and Again Fails to Support the Specificity of Acupoint Tapping. The Journal of Nervous and Mental Disease, 210(2), 139. 10.1097/NMD.0000000000001376 [DOI] [PubMed] [Google Scholar]
  45. Spielmans GI, Rosen GM, & Spence-Sing T (2020). Tapping Away at a Misleading Meta-analysis: No Evidence for Specificity of Acupoint Tapping. The Journal of Nervous and Mental Disease, 208(8), 628. 10.1097/NMD.0000000000001181 [DOI] [PubMed] [Google Scholar]
  46. Waite WL, & Holder MD (2003). Assessment of the Emotional Freedom Technique: An Alternative Treatment for Fear. The Scientific Review of Mental Health Practice: Objective Investigations of Controversial and Unorthodox Claims in Clinical Psychology, Psychiatry, and Social Work, 2, 20–26. [Google Scholar]

RESOURCES