Six-Month Follow-Up Comparing AIT and EFT in the Reduction of Negative Emotions Associated with a Past Memory ()
1. Introduction
Treatment resistance significantly increases the cost associated with psychiatric conditions, with expenses often as much as ten times higher when compared to more-treatment responsive cases (Howes et al., 2022). Despite estimates that up to 60% of patients with mental illness exhibit poor response to standard treatments, only 1% of research has focused on developing novel effective strategies for conditions such as treatment resistant depression (TRD) (Howes et al., 2022; McIntyre et al., 2023). Therefore, research on both pharmacological and non-pharmacological treatment modalities for treatment resistant psychiatric conditions is crucial for advancing behavioral health care.
Energy psychology, which arose from a combination of Eastern and Western traditions, is a hybridized psychotherapy approach that melds verbal and somatic components to decouple troubling emotions from specific memories (Gallo, 2009). Roger Callahan developed a technique he called Thought Field Therapy (TFT) that combined concepts from modern (at the time) kinesiology with ancient Chinese acupuncture meridian-based stimulation to help patients find relief from the troubling emotions associated with specific memories (Callahan & Callahan, 1996). While this early form of energy psychology used a detailed algorithm to select acupuncture points in a specific order, it lacked the verbal component that became a critical part of later iterations of energy psychology (Pignotti, 2007).
Energy psychology posits that psychological issues can be addressed by engaging the body’s energy systems, including meridians and chakras. Its effectiveness may stem from direct biological mechanisms, such as influencing bioelectrical and biochemical processes through techniques like tapping, which impacts neural pathways, stress regulation, and gene expression (Feinstein, 2023b). Memory reconsolidation offers another explanation, suggesting that techniques like Energy Freedom Techniques (EFT) reduce emotional responses by altering neural connections associated with learned fear or anxiety (Ecker, 2015). Tapping is thought to deactivate the limbic system’s response to an emotionally activating memory, facilitating neural integration, altering implicit memory while preserving autobiographical memory and enhancing coping strategies (Feinstein, 2015).
Multiple forms of energy psychology, including EFT and Advanced Integrative Therapy (AIT), have been developed since the days of Callahan’s earlier work, most of which include both somatic and verbal components. Of the various forms, EFT has been the most often studied. EFT combines a repeated verbal phrase with tapping on or near a series of acupuncture points to help relieve the negative emotions related to a single memory (Craig & Fowlie, 1995). The efficacy of the technique for a variety of psychiatric conditions has been evaluated many times via RCT against gold-standard treatment modalities such as cognitive behavioral therapy (CBT) (Feinstein, 2023a). A recent systematic review of 70 randomized control trials by Church et al. (2022) found that EFT was an effective treatment for a wide variety of conditions and was particularly effective in treating PTSD symptoms as compared to standard therapy. A study by Bach et al. (2019) demonstrated that EFT could improve various physical health markers such as heart rate, blood pressure, and cortisol levels, which suggested that significant physical health benefits may also be derived from EFT in addition to the previously described mental health benefits. The evidence supporting the clinical use of EFT for additional psychiatric pathologies continues to grow. For example, in 2023, Feinstein provided data to support the concept that EFT was highly effective in the treatment of the negative emotions associated with elevated scores on the adverse childhood events questionnaire (ACE).
1.1. Common and Varied Elements between EFT and AIT
AIT, developed by Asha Clinton in the late 1990s, is another form of energy psychology that incorporates elements from Ayurvedic traditions and focuses on manipulating the body’s energy flow through chakras (Clinton, 2010). EFT also finds Eastern influence in the altering of the flow of Qi through the 12 energy meridians of Chinese antiquity (Church et al., 2022). Energy centers along the 12 meridians are “tapped” on while a phrase is repeated. AIT, in contrast, directs the patient and practitioner to hold a hand in place over each chakra in turn, while repeating a specific phrase (Clinton, 2010). Although the phrasing of the verbal component differs as well, the baseline goals of EFT and AIT are identical; the clearance of negative, unpleasant emotions tied to a specific memory. In the cases of both AIT and EFT, the emotional distress associated with the memory often spontaneously clears as the patient progresses through the treatment process, sometimes with only a single cycle of either protocol (Brown et al., 2023).
1.2. Evidence Base for the Efficacy of AIT
Despite its promise, AIT has limited empirical research. Three case studies have been published with reports showing AIT’s effectiveness in treating complex PTSD and depression. Pace (2021) reported on a case where a patient was treated for recurrent Major Depressive Disorder (MDD) and complex PTSD using AIT in combination with other modalities such as Eye Movement Desensitization Reprocessing (EMDR). The author noted that AIT was particularly effective in addressing the emotions attached to the root traumas that had occurred in the patient’s childhood. PTSD scale scores showed significant reduction. Bird Weaver (2021) likewise presented a case where a patient with a primary diagnosis of complex PTSD was successfully treated primarily using AIT, with objective PTSD scales showing marked improvement. Both authors suggested that AIT was both effective and produced positive results faster than many other treatment modalities. A third case study, also authored by Pace, is in pre-publication at the time of this writing but is expected to support the efficacy of AIT, with changes in standard PTSD scale measurements used to evaluate patient improvement.
More recently, two studies conducted by the Department of Psychiatry and Behavioral Health at the Kerkorian School of Medicine at UNLV have been completed in an effort to add to the empirical evidence regarding the successful use of AIT. An initial survey-based study was completed in 2022 with the objective of collecting the observations of providers who use AIT in their daily practice (Brown et al., 2022). Respondents to the survey (N = 76) reported that in 92% of cases where AIT was used, Subjective Units of Distress (SUD), a proxy metric for the measurement of emotional discomfort described by Wolpe (1973), dropped from an elevated score to a 0 or a 1 (no or very little emotional distress) after a single AIT therapy session.
Based on the promising results of the provider survey, a follow-up randomized control trial (RCT) (N = 72) comparing the efficacy of AIT versus EFT in clearing the negative emotional content attached to a specific memory was conducted from January to May of 2023 (Brown et al., 2023). Using SUDs to measure emotional distress, both EFT and AIT were reported to produce a significant decrease in the intensity of negative emotions attached to the selected memory. In the study, a pre-intervention SUD mean of 4/10 was reported to drop to a mean of 1/10, post intervention. Importantly, the study found no significant difference in post-intervention mean scores of SUD (1.03 ± 1.10 vs. 1.29 ± 0.71, p = 0.2) between the two modalities (Brown et al., 2023, p. 1868). AIT was found to be non-inferior to EFT, and notably had a higher percentage of first-round reductions of the SUD score to zero or one.
1.3. Purpose
Although the initial results of the Brown et al. (2023) RCT are promising, the long-term efficacy of AIT’s effects remains unknown. This survey-based study aims to evaluate whether memory reconsolidation, as hypothesized to play a role in AIT’s effectiveness, is sustained over a six-month period. Specifically, the study will assess whether the alteration of implicit emotional responses persists over time without altering core autobiographical memories, as expected under memory reconsolidation phenomenon (Ecker, Ticic, & Hulley, 2013).
2. Methods
2.1. Study Design, Setting and Participants
This follow-up aimed to assess the long-term efficacy of interventions used in 2023 (Brown et al., 2023) through a post-intervention questionnaire after 6 months. Inclusion criteria required participants to have been subjects in the original RCT. All 72 participants of the RCT consented to participating in a follow-up questionnaire at or six-month after the initial intervention. More details of this RCT can be found in the previous study (Brown et al., 2023).
2.2. Ethical Considerations
The follow-up questionnaire was included in the IRB approval granted by the UNLV Institutional Review Board (IRB) on September 26, 2022 (UNLV-2022-455). Both the original study and the follow-up questionnaire adhered strictly to ethical guidelines, ensuring that no personally identifiable information (PII) was collected or stored at any point, whether through physical or electronic means. Data was anonymized completely, maintaining participants’ confidentiality and protecting their privacy throughout the research process.
2.3. Recruitment and Study Procedures
Participants from the original 2023 RCT consented to take part in a follow-up, email-based questionnaire at the time of the initial study. In the first quarter of 2024, a total of eight follow-up emails were sent to all 72 participants. Each subject received a link to the Qualtrics survey through their preferred email. Of the 72 participants, 51 completed the follow-up questionnaire, resulting in a response rate of 70.83%.
2.4. Questionnaire
The follow-up questionnaire, administered through the Qualtrics platform, asked participants to recall the specific memory identified during the original RCT and report the current intensity of their emotional activation using the Subjective Units of Distress (SUD) scale. The SUD scale, first introduced by psychologist Joseph Wolpe (1973), is a widely used subjective measure of emotional intensity. It is commonly employed in assessing changes in unpleasant emotions when evaluating the effectiveness of Energy Psychology protocols, such as EFT, and other modalities like EMDR. It functions similarly to the verbal or graphic pain scales used in general medicine.
Participants accessed the Qualtrics survey through a unique link sent via email, with the system designed to prevent multiple submissions. The survey first collected basic demographic information, then prompted participants to recall the memory and intervention from the original study. They were then asked to provide their current SUD score and indicate any associated bodily sensations they were still experiencing, if applicable. A copy of the survey instrument can be found as [IMAGE TABLE].
2.5. Data Analysis
First, data were cleaned and re-coded for running the analytical procedures to investigate the long-term equivalency of the two energy psychology modalities (EFT vs. AIT). The univariate tests were used to describe the data as frequencies, proportions, and measures of central tendencies. The 95% confidence interval of proportion were calculated by the normal approximation to the binomial distribution. The bivariate group comparisons were conducted through Chi-square and independent-samples-t-tests. There were two groups’ criteria used in the analyses. First, by intervention modality that received either EFT or AIT intervention (primary objective). Second, to compare three groups categorized by emotions’ resolution. In the absence of unique identifiers, linkage of the previous RCT individual-level data with the follow-up data was not possible. Therefore, historical aggregate SUD scores (Brown et al., 2023) were used as the comparison/baseline to investigate the persistence in the emotional freedom. All analyses were conducted using SPSS version 26.
3. Results
Of a total 72 participants, 51 completed the six-months follow-up survey (response rate = 70.8%). The sample was predominantly females (65%), non-Hispanic (80%), and employed (84%) (Table 1). Whites constituted over 40% of the people in the sample, followed by Asians (29.4%), Blacks (9.8%), and other races (9.8%), which includes multi-racial, Native Hawaiians, Middle Eastern, or another Pacific Islander). More than 4/5th of the people in the sample were heterosexual or straight (Table 1).
Table 1. Socio-demographic characteristics of the sample (N = 51).
Variables |
Categories |
Frequency n (%) |
95% CI
(LCL, UCL) |
Age (M ± SD) |
- |
32.1 ± 8.3 |
(29.8, 34.5) |
Gender |
Male |
17 (33.3%) |
(20.8, 47.9) |
Female |
33 (64.7%) |
(50.1, 77.6) |
Genderqueer |
1 (2%) |
(0.1, 10.5) |
Hispanic or Latino |
Yes |
9 (17.6%) |
(8.4, 30.9) |
No |
41 (80.4%) |
(66.9, 90.2) |
Race |
White |
22 (43.1%) |
(29.4, 57.8) |
Black or African American |
5 (9.8%) |
(3.3, 21.4) |
Asian |
15 (29.4%) |
(17.5, 43.8) |
Others |
5 (9.8%) |
(3.3, 21.4) |
Sexual Orientation |
Heterosexual or Straight |
42 (82.4%) |
(69.1, 91.6) |
Dual sexual |
4 (7.8%) |
(2.2, 18.9) |
Others |
4 (7.8%) |
(2.2, 18.9) |
Marital Status |
Married |
20 (39.2%) |
(25.8, 53.9) |
Unmarried (Never
married/Unmarried couple) |
28 (54.9%) |
(40.3, 68.9) |
Divorced |
3 (5.9%) |
(1.2, 16.2) |
Working
(Employment Status) |
Yes |
43 (84.3%) |
(71.4, 93) |
No |
8 (15.7%) |
(7, 28.6) |
Annual Gross
Income |
0 to $10,000 |
6 (11.8%) |
(4.4, 23.9) |
$10,001 to $25,000 |
7 (13.7%) |
(5.7, 26.3) |
$25,001 to $50,000 |
7 (13.7%) |
(5.7, 26.3) |
$50,001 to $100,000 |
14 (27.5%) |
(15.9, 41.7) |
$100,001 to $250,000 |
12 (23.5%) |
(12.8, 37.5) |
Above $250,000 |
2 (3.9%) |
(0.5, 13.5) |
M = Mean; SD = Standard Deviation; CI = Confidence Interval; LCL-Lower Confidence Limit; UCL = Upper Confidence Limit.
Among these 51 participants, 43 (84.3%) recalled their intervention arms they were assigned to in the previous RCT. Twenty-eight of these 43 participants, 28 (65%) reported being in the EFT arm, while 15 (35%) recalled receiving the AIT intervention (Table 2). There were no significant differences noted between these two arms in terms of emotions’ resolution following the attached memory recall (p > 0.05, Table 2). The SUD scores among participants in both arms remained low even after the 6-months (78.6% in AIT vs. 60.0% in EFT arm, p > 0.05, Table 2) and no significant differences were noted. Except for marital status, there were no statistically significant differences in the demographic characteristics of the groups with emotional resolution, improved and worsened (Table 3).
Table 2. SUD and specific memory recall in both interventions.
Variables |
Categories |
AIT (15, 34.8%) |
EFT (28, 65.1%) |
p-value |
Effect size |
Chi-Square |
SUD Score reduced |
Yes |
11 (78.6%) |
12 (60%) |
0.255 |
0.195 |
1.298 |
No |
3 (21.4%) |
8 (40%) |
|
|
|
Specific memory recall |
Emotions Resolved |
14 (93.3%) |
22 (78.6%) |
0.435 |
0.197 |
1.667 |
Emotions Improved |
1 (6.7%) |
5 (17.9%) |
|
|
|
Emotions Worsened |
0 (0%) |
1 (3.6%) |
|
|
|
Please note that SUD scores were self-reported by the participants, which may subject to a recall bias acknowledged in the limitation section.
Table 3. Comparing demographic characteristics of groups by emotional status (N = 51).
Variables |
Categories |
Emotions
Resolved
(41, 80.4%) |
Emotions
Improved
(9, 17.6%) |
Emotions
Worsened (1, 2.0%) |
p-Value |
Effect Size |
Chi-Square |
Gender |
Male |
14 (34.1%) |
2 (22.2%) |
1 (100%) |
0.136 |
0.262 |
7.002 |
Female |
27 (65.9%) |
6 (66.7%) |
0 (%) |
|
|
|
Genderqueer |
0 (0%) |
1 (11.1%) |
0 (0%) |
|
|
|
Hispanic or Latino |
Yes |
8 (19.5%) |
1 (12.5%) |
0 (0%) |
0.800 |
0.095 |
0.447 |
No |
33 (80.5%) |
7 (87.5%) |
1 (100%) |
|
|
|
Race |
White |
17 (43.6%) |
4 (57.1%) |
1 (100%) |
0.875 |
0.161 |
2.444 |
Black or African American |
5 (12.8%) |
0 (0%) |
0 (0%) |
|
|
|
Asian |
13 (33.3%) |
2 (28.6%) |
0 (0%) |
|
|
|
Others |
4 (10.3%) |
1 (14.3%) |
0 (0%) |
|
|
|
Sexual Orientation |
Heterosexual or Straight |
33 (82.5%) |
8 (88.9%) |
1 (100%) |
0.867 |
0.159 |
1.268 |
Dual sexual |
3 (7.5%) |
1 (11.1%) |
0 (0%) |
|
|
|
Others |
4 (10%) |
0 (0%) |
0 (0%) |
|
|
|
Marital Status |
Married |
16 (39%) |
4 (44.4%) |
0 (0%) |
0.002 |
0.406 |
16.852 |
Unmarried (Never married/Unmarried couple) |
25 (61%) |
2 (22.2%) |
1 (100%) |
|
|
|
Divorced |
0 (0%) |
3 (33.3%) |
0 (0%) |
|
|
|
Working
(Employment Status) |
Yes |
33 (80.5%) |
9 (100%) |
1 (100%) |
0.314 |
0.213 |
2.314 |
No |
8 (19.5%) |
0 (0%) |
0 (0%) |
|
|
|
Annual Gross Income |
0 to $10,000 |
5 (12.8%) |
0 (0%) |
1 (100%) |
0.198 |
0.375 |
13.484 |
$10,001 to $25,000 |
5 (12.8%) |
2 (25%) |
0 (0%) |
|
|
|
$25,001 to $50,000 |
4 (10.3%) |
3 (37.5%) |
0 (0%) |
|
|
|
$50,001 to $100,000 |
13 (33.3%) |
1 (12.5%) |
0 (0%) |
|
|
|
$100,001 to $250,000 |
10 (25.6%) |
2 (25%) |
0 (0%) |
|
|
|
Above $250,000 |
2 (5.1%) |
0 (0%) |
0 (0%) |
|
|
|
p values less than 0.05 are considered statistically significant.
At the time of RCT, there were no statistically significant differences found in the mean SUD scores across two intervention arms (1.03 ± 1.10 vs. 1.29 ± 0.71, p = 0.2, Table 4). Similarly, at the 6-months follow-up, people who recalled being in AIT and EFT had no significant differences in the SUD scores across both arms (1.7 ± 0.5 vs. 1.3 ± 0.6, p = 0.1, Table 4), which demonstrates long-term equivalency of these interventions in the reduction of negative emotion associated with the particular memory. No statistically significant differences were evident in the mean SUD scores at these two points (intervention vs. Six months follow-up). In the absence of unique identifiers, we could not account for both within-subject (after the intervention vs. six months follow-up) and between-subject factors (AIT vs. EFT), therefore, only descriptive comparison was made, which indicated no differences in the means and variance.
Table 4. Comparing SUD scores at the baseline and Six-months follow-up.
Variables |
AIT (15, 29.4%) |
EFT (28, 54.9%) |
p-value |
SUD score (Six months follow-up) |
1.7 ± 0.5 |
1.3 ± 0.6 |
0.1 |
SUD score following the intervention in the original RCT |
1.03 ± 1.10 |
1.29 ± 0.71 |
0.2 |
4. Discussion
These results suggest that the participants who were separated into one of two interventions, Advanced Integrative Therapy (AIT) or Emotional Freedom Technique (EFT), maintained reductions in Subjective Units of Distress (SUD) after a 6 to 12-month follow-up survey. This study investigates the long-term emotional resolution six months after the original intervention, which was conducted using standardized training sessions led by the first author, a psychiatrist certified in Advanced Integrative Therapy (AIT) by the AIT Institute. The author also completed extensive training in Emotional Freedom Techniques (EFT), including basic, intermediate, and advanced levels through Gary Craig’s video modules and further certification through The Association for Comprehensive Energy Psychology (Levels 1 and 2). All investigators were trained and assessed for competence in following standardized protocols for Quick AIT and basic EFT through four 90-minute sessions. The EFT protocol aligned with those used in studies by Bond University. Further details are available in the original intervention study (Brown et al., 2023).
Historical SUD scores from the previous randomized control trial (Brown et al., 2023) were used for comparison to determine the level of emotional distress. The previous trial’s results suggested the general equivalence of AIT and EFT; these additional data suggest that both intervention arms may provide the same degree of long-term (durable) reduction of negative emotions associated with single traumatic memories.
A likely explanation for the comparable effectiveness of both AIT and EFT in maintaining reductions in SUD up to six months post-treatment may be attributed to memory reconsolidation theory (Ecker et al., 2013). During this process, negative emotions associated with specific events can be altered through a specific mismatch process. The mismatch may occur in cognitive domains, such as challenging and reframing a deeply held belief about the event; physiological domains, like changes in heart rate or relaxation responses triggered during the intervention; or emotional domains, such as eliciting feelings of safety or calmness that contradict the original distressing emotions (Ecker et al., 2013). The goal is to develop new emotional associations with previously encoded implicit memories through a mismatch of the expected stimuli. The unchanged autobiographical memory is thus re-encoded with an altered emotional tone, the effects of which should be long-lasting (Feinstein, 2015). In other words, the autobiographical memory is separated from the original, distressing, emotional tone and then re-encoded with a neutral emotional tone. Future recall of the memory includes only the re-encoded emotional tone and thus is no longer distressing. This concept may be supported by the data from this follow-up study.
An interesting outlier was observed in both the original RTC and this follow-up, in that one participant reported an elevated SUD score of 8. One participant reported an 8 SUD in both the RTC and this follow-up; which suggests that the reconsolidation of the memory into long-term memory store may remain whether the emotional tone improved or worsened. The clinical implications of this observation are significant, and support interventions that successfully allow the reconsolidation of memory with a reduced emotional tone.
The lasting impact of the therapeutic effects observed from this study can easily be applied to clinical practice. High levels of emotional distress can be seen in many common psychiatric illnesses, including depressive disorders, anxiety disorders, personality disorders, and trauma disorders. Both AIT and EFT are non-invasive and relatively simple to perform in session and teach patients for self-care. The rapid and sustained reduction in emotional distress reported in this and preceding studies suggests that these techniques may be valuable as primary or adjunctive treatment for many patients suffering from emotional disruption secondary to troubling memories (Church et al., 2022).
There are multiple limitations to this study to consider. Out of 71 participants in total, 51 completed the six-month follow-up survey (a response rate of 70.83%), which may represent a response bias. Additionally, the participants from the previous randomized controlled trial were relatively limited in demographic range; the sample was predominantly female, non-Hispanic, employed, and heterosexual. The lack of individual-level data linkage limits our ability to assess within-group differences, which affects the confidence in interpreting the results as true indicators of long-term efficacy. Without being able to track participants directly from the original RCT to the follow-up, we relied on historical aggregate SUD scores as the baseline, which introduces the possibility that the observed outcomes could be influenced by random variation or unmeasured confounding factors. This limitation prevents a deeper understanding of how individual characteristics or responses to the interventions may have influenced the results. Despite this constraint, the overall consistency in SUD reductions across the sample over the six-month period suggests that the interventions likely had a meaningful impact. However, future studies that incorporate unique participant identifiers will be essential to enable within-group analyses and provide a clearer picture of the interventions’ long-term efficacy. Only 84.3% of participants recalled the intervention arm to which they were previously assigned. Although it is unclear what effect this may have had on the durability of symptom improvement, it further limits comparisons between the two interventions. Recall bias and self-reporting bias are a consideration which could not be eliminated in a study of this design. Finally, the limitations discussed in the original RCT also by definition apply to any further studies based on that data.
5. Conclusion
In conclusion, this study provides preliminary evidence that both AIT and EFT are effective in reducing emotional distress with sustained improvement in a six to twelve-month follow-up period. These findings contribute to a growing body of literature that supports the use of energy psychology to reduce emotional distress associated with single traumatic memories. However, further research with a larger sample size, more diverse subject population, and intervention with specific diagnoses will need to be conducted to establish AIT as equivalent to the more studied EP variant, EFT.
Acknowledgements
We would like to thank Martha Norheim, of the Department of Psychiatry, who coordinated the scheduling of all participants for the study. The Department of Psychiatry provided the time and support for this project, as well as the Department of Research.