All in the Head
Tuesday, June 29, 2004
by Sandra G. Boodman, Washington Post
Three Approaches to Mental Health Treatment That Stretch the Boundaries -- and, Sometimes, Credulity
Imagine being able to quickly banish phobias by rhythmically tapping on various body parts. How about a painless treatment that eliminates depression by exerting gentle pressure on a patient's shoulders or torso? What if it were possible to overcome attention-deficit hyperactivity disorder (ADHD) by having a child focus on a computer image that retrains his brain waves?
These are among the promises made by many practitioners of three alternative treatments -- thought field therapy (TFT), craniosacral therapy and neurofeedback -- that increasingly are being used to treat an encyclopedic array of psychological and behavioral problems.
Experts estimate that about 200 alternative mental health treatments are on the market, said Scott O. Lilienfeld, an associate professor of psychology at Emory University in Atlanta and an expert on unorthodox therapies. Some, such as relaxation exercises and yoga, are widely used as part of specific physical and mental health treatments and have been subjected to at least some scientific study. But others, including past life therapy and dolphin-assisted therapy, have little or no grounding in science.
While alternative psychological treatments have always existed, experts say, the Internet has been a boon to alternative practitioners, enabling them to reach vast audiences easily.
"The rapidity of marketing is unprecedented," said Lilienfeld, founding editor of the Scientific Review of Mental Health Practice, a semi-annual journal devoted to examining the theory and practice of both alternative and conventional therapies. Lilienfeld and other critics say the growth of many alternative therapies contravenes the move in psychology toward evidence-based treatments.
The majority of unorthodox therapies, Lilienfeld said, amount to pseudoscience; they are based on unvalidated theories and bolstered by anecdote. Few have been subject to peer review and most have never been validated by studies that randomly assign patients to receive different treatments and control for factors such as the placebo effect -- improvement not attributable to treatment -- that can skew the results.
Among the more notable examples, in the view of Lilienfeld, co-editor of Science and Pseudoscience in Clinical Psychology (Guilford Press, 2002), are eye movement desensitization and reprocessing (EMDR), a treatment for trauma in which a therapist waves his fingers in front of the eyes of a patient visualizing an event, and rebirthing or attachment therapy, which was implicated in the death four years ago of a 10-year-old girl in Colorado who suffocated while being held under a blanket by therapists trying to cure her behavioral problems.
Alternative therapies often sound convincing, observed James D. Herbert, an associate professor of psychology at Drexel University in Philadelphia, who has analyzed some of them. "They're packaged very nicely, there's a lot of psychobabble, a lot of jargon, and they sound impressive" to therapists who aren't well trained and to patients desperate for help.
Unlike conventional therapy, alternative approaches often claim to be useful or even curative for a huge array of unrelated problems. By contrast, conventional treatments typically have narrow applications.
John Upledger, the osteopath who developed craniosacral therapy, said in an interview that his hands-on treatment can vanquish depression, chronic pain, post-traumatic stress disorder, migraines, scoliosis, autism and colic -- among other ailments.
Roger J. Callahan, the clinical psychologist who invented thought field therapy, said his tapping treatment has a 98 percent success rate and works for "almost everything."
While many alternative mental health treatments do not appear to be harmful, some are costly. The expense and energy devoted to these treatments could prevent or delay the pursuit of more effective and less expensive therapies, Lilienfeld noted.
But experts concede that the popularity of alternative medicine stems in part from the shortcomings of traditional approaches.
A study by researchers at Harvard Medical School published in 2001 found that 66 percent of patients treated for anxiety and severe depression also used alternative therapies, including meditation, for these conditions -- and said they found alternative methods as helpful as conventional treatments.
"Alternative treatments all offer hope," Lilienfeld said. "They fill very important psychological needs, and many are used for conditions that have not responded to conventional treatment or for which there is no known cure. Quick fixes are very appealing."
Below is a discussion of three alternative therapies that both critics and proponents agree are increasing in popularity.
Neurofeedback, also known as EEG biofeedback, is being used to treat autism, depression, obsessive-compulsive disorder and anxiety, and even by those who want to improve their golf scores.
The therapy's best known and most hotly debated use is for ADHD. Some therapists say that neurofeedback can be used as an adjunct to stimulants such as Ritalin or can even eliminate the need for drugs; in combination with a behavioral program, medications have been shown to work in about 70 percent of cases.
During a typical neurofeedback session, which lasts about 45 minutes, electrodes are attached to a child's forehead and connected to a small EEG machine linked to a computer. The child sits in a comfortable chair watching a video display that resembles a video game. The operator watches the EEG readout to determine whether the child is emitting brain waves indicative of an alert, focused state or a drowsy, inattentive state. The alert brain waves are rewarded by beeps, augmented by the encouragement of the tester to the child to keep producing them.
The use of a non-drug alternative appeals to many parents who are leery about putting their children on medications and say they prefer a more "natural" approach.
Research on epilepsy has demonstrated that biofeedback can reduce seizures by altering brain waves. The goal for children with ADHD is to filter out mental activity associated with slower brain waves that is believed to be related to impulsivity and inattention.
By remaining relaxed but focused, proponents say, the child learns through repeated sessions to produce brain waves that demonstrate sustained attention, thereby diminishing the hyperactivity and inability to concentrate that are the hallmarks of ADHD.
"We're finding most people are done after about 30 or 40 sessions," said Deborah Stokes, a psychologist who three years ago opened Neurofeedback Consultants in Alexandria. Stokes charges about $125 per session, which she said most insurance plans don't cover. Many of her clients learned about the treatment from Internet support groups or chat rooms for parents of hyperactive children, she said.
But critics say that the evidence that neurofeedback works for ADHD is shaky.
Psychologist John Kline, an EEG expert and professor at the University of South Alabama in Mobile, said studies over the past decade have been marred by poor research design or compromised by other factors, such as the use of multiple treatments simultaneously and a lack of randomization.
"The literature that ties brain wave changes to treatment outcomes is really tentative," Kline said.
A study published in 2001 by psychologist Jeffrey Lohr of the University of Arkansas in Fayetteville echoed Kline. "Despite 20 years of research on neurofeedback," Lohr and his co-authors concluded, "it appears that nearly all of the experimental tests published in peer-reviewed journals are surprisingly weak."
To Lilienfeld, the rationale for the use of neurofeedback for ADHD is "not completely implausible." But, he added, "there's a danger in confusing correlation with causation." In Lilienfeld's view, brain wave abnormalities may not be the cause of attention problems. "Changing brain wave patterns may have no effect," he said.
"What's disturbing about neurofeedback," he added, "is how widely promoted it is in the face of mixed evidence."
Other experts say neurofeedback works for ADHD. A small study by Joel F. Lubar at the University of Tennessee published in 1995 found improvements in behavioral ratings by parents of 23 children who underwent a summer program of intensive neurofeedback.
Stokes said she isn't swayed by the skepticism of critics.
"I don't care about that," she said. Maybe, Stokes added, the improvement parents report "is due to the counseling I give or the toy I give [children] at the end of the sessions. I'm more outcome-based. I'm a clinician and I want them to get better."
That was Margit Paulding's goal for her 6-year-old son, who has undergone more than 60 sessions in the past six months at Stokes's center. Paulding said she hoped to wean her little boy off a high dose of Concerta, a stimulant his pediatrician prescribed to treat his severe case of ADHD.
"Until we started this, he was getting worse, even on the meds," Paulding said recently, as her son stared at the computer screen in Stokes's office, playing what he calls "brain games."
"Almost immediately we saw a decrease in hyperactivity, and we got feedback from other people who didn't know he was doing this treatment that he was better," Paulding said.
"We were spending every penny and then some on this," she noted, adding that she and her husband decided the financial sacrifice was justified by his improvement. Her husband's parents, she said, were so impressed by what they saw that they now pay for the sessions.
Before neurofeedback "I spent a lot of nights really upset that he was never going to be able to do things like other kids, go to a sleepover or to summer camp," she said. Now, Paulding said, she is convinced her son will be able to enjoy as normal a childhood as his 2-year-old sister, who shows no signs of ADHD.
In the 19 years since osteopath John Upledger opened his eponymous institute in Palm Beach Gardens, Fla., more than 50,000 therapists from 50 countries have taken courses he devised to treat dozens of ailments. Treatment is simple: Craniosacral therapists exert gentle pressure on various parts of the body where they detect pulse points in order to release what they say are blockages of cerebrospinal fluid that cause problems.
Upledger, now 72, dismisses the importance of randomized, controlled trials and the views of his critics. Proof of the effectiveness of his treatment, he said, lies in the testimonials of grateful patients who tell him they feel better -- like the woman who had sought treatment at 83 other places before a single visit with Upledger cured her temporomandibular joint disorder.
Standard scientific studies of his technique "can't be done," he said, because "no two patients are exactly alike and no two therapists are exactly alike. I decided that what I was feeling was what I could believe."
Stephen Barrett, a retired psychiatrist who maintains the Quackwatch Web site, has described Upledger's beliefs as being "among the strangest I have ever encountered." Barrett said craniosacral treatment is based on "fanciful claims" such as the notion that manipulation of the skull can affect levels of cerebrospinal fluid in adults or that blockages cause the problems Upledger describes.
A 1999 report by officials at the British Columbia Office of Health Technology Assessment found insufficient evidence to support the effectiveness of craniosacral therapy.
Physical therapist Ronald Murray of the Asclepeion Center of Silver Spring said he ardently believes in the treatment, which has a large following in the Washington area.
Murray, who was trained by Upledger, said that 80 percent of the people he treats tell him they feel better afterward. "The people I see have been to everyone else," said Murray, who charges about $110 per session and has a three-month waiting list.
Gail Zech, a 76-year-old writer in Gaithersburg, said she consulted Murray several years ago at the suggestion of a friend. Zech said three doctors, including a neurosurgeon, told her she needed spinal surgery to prevent possible paralysis caused by a deteriorating vertebrae that was causing constant pain.
After several months of weekly treatments performed by Murray, Zech said, her pain disappeared. A neurologist told her that the deterioration had also stopped; Zech said she never underwent surgery.
"At the risk of sounding like a goofy enthusiast, I am so grateful to Ron," she said, adding that she is now pain-free and able to move normally. "I consider this to be lifesaving treatment."
Upledger said that as word of his treatment's success has proliferated, so have patients. Currently, he said, he has a five-year waiting list.
The institute, which has 80 employees and grossed $10 million several years ago, according to Upledger, also treats repeat clients.
Among them, he said, is a U.S. senator (whom he declined to identify) who for the past six years has spent two weeks annually in Palm Beach receiving craniosacral therapy.
"He gets cleaned out from all the stress he has," Upledger said. "He told me that once he retires, he'll let me use his name."
Thought Field Therapy
Clinical psychologist Roger J. Callahan of La Quinta, Calif., said he discovered thought field therapy 25 years ago, when he tapped once under a patient's eye, instantly curing her of a severe fear of water. The tapping cleared a blockage of energy in her "thought field" which, in Callahan's view, is similar to an electrical field. Thought fields occur in the body, according to Callahan, and psychological problems and environmental toxins can cause blockages, also referred to as "perturbations," which proper tapping can eliminate.
"It certainly appears ridiculous," Callahan said in an interview, "but if you try it you'll see it's the most important treatment in history."
Here's how it is said to work: A therapist uses a series of prescribed rhythmic finger taps called "algorithms" on various points on the body. The taps and body parts vary according to the problem being treated. During the tapping, the patient engages in a repetitive activity: repeating the alphabet or humming snatches of "Mary Had A Little Lamb" while thinking about a distressing situation.
These repetitive activities are supposed to correct disturbances in the thought fields that cause myriad psychological problems, including phobias, depression and post-traumatic stress disorder. The cost of sessions varies, but many thought field therapists charge between $75 and $150.
Several published studies have found that thought field therapy, or TFT, was useful in treating trauma, depression and other problems, but none of the studies was subject to standard peer-review.
To Drexel's Herbert, TFT is "silly" and a classic example of pseudoscience. "Despite extraordinary claims to the contrary, there is absolutely no scientific evidence for any of this," he said.
In 1999 the Arizona Board of Psychologist Examiners reprimanded a psychologist for using TFT in his practice, according to the Quackwatch Web site. The American Psychological Association has also announced that thought field courses are not approved for continuing education credits.
Callahan said that his treatment works and that he believes his critics have a "power problem" and are worried that TFT will rob them of business.
Washington social worker Deborah L. Taylor said that for the past five years she has been performing the treatment during sessions with phobic or anxious clients. "There's more proof that it's helpful than that it's not helpful," said Taylor. "It's a tool."
In some cases, it can be an expensive tool.
The most advanced TFT courses for therapists involve the purchase of a "voice technology" machine coupled with three days of individualized training with Callahan at a cost of $100,000. Voice technology enables therapists to diagnose and treat patients sight unseen, over the phone by analyzing their voices.
"A TFT Voice Technology practitioner has the potential for the whole world as their clients," Callahan's Web site notes.