Guidelines for Using EFT with Serious Mental Disorders

We were fortunate to have a few experienced practitioners who have contributed to parts of the EFT Level 3 Comprehensive Training Resource.  One of those is Tracey Middleton, LCSW-C (, who has been working in Baltimore, MD with people who have psychotic disorders and Dissociative Identity Disorder (formally known as Multiple Personality Disorder), and selectively uses EFT with marked benefits.

This is certainly a population that falls under the caution Gary Craig often stated “don’t go where you don’t belong.” Tracey has the training and experience to be able to assess the appropriateness (or not) of using EFT with this population. Since this is the population I worked with many years ago in the mental health system in Georgia, I particularly admire the work she is doing and the caution she is exhibiting. Tracey shares excellent criteria to determine appropriateness of EFT use with this population – because, reality is, sometimes we should not use EFT.

Tracey writes:

It is my responsibility as the Therapist to determine if using EFT as an alternative intervention is appropriate and safe for my client and that I have their permission to use it. [Italics added for emphasis.] This can get complicated if my client is experiencing psychotic, delusional and/or dissociative states.  I have developed the following questions to help me discern this:

  • Is the client able to develop and articulate clear and concise goals for using EFT? Can the client repeat back to you the goals of EFT as an intervention in order to demonstrate true understanding?
  • Is the client able to give informed consent to the use of EFT on those specific issues and goals? Is the client able to understand its benefits, limitations and possible abreactions? It is important to get the client’s consent at different points in the session while using EFT. They may give consent to start using EFT and in the middle of its application decide to stop. Are you giving the client opportunities to change their mind and reassuring them that it is ok?
  • Is there a strong therapeutic alliance already established with the client that could tolerate a new intervention like EFT? Do you know your client well enough to know when a yes to using EFT really means yes? Some clients may say “yes” to EFT to please you, but really don’t want to do it. This kind of interaction could lead to harm. Ask open-ended questions thoroughly to determine true consent.
  • Have you assessed whether tapping on any of the acupoints might cause a stress response? Show the client a diagram with the EFT acupoints on it and ask which points they would like to use for EFT. Don’t assume.
  • When using EFT as an intervention for delusions and/or auditory/visual/olfactory hallucinations and/or dissociative states, it is important to assess if the client is competent to consent to their goals and possible benefits. If their goal is to reduce or stop delusions and/or hallucinations, can they verbalize and conceptualize what their life would be like without them? Ann’s note: If not, this means don’t use EFT in this case. If they are unable to do this, it could increase the likelihood of an abreaction and thus cause possible harm.
  • Does the client have enough ego-strength[1] to adjust to the cognitive shifts that come with EFT, or could the cognitive shifts cause a decompensation in mental stability?
  • Have you received permission from your clinical supervisor to use EFT with your client who has severe chronic mental illness and discussed ways to decrease the likelihood of causing harm?  Although EFT is an evidence-supported technique, there is limited research regarding its efficacy and limitations for the treatment of delusions, psychosis, hallucinations and/or severe dissociative states.

Tracey goes on to say, “My experience has taught me that if I can answer yes to the above questions, then I proceed to use EFT on general and global symptoms. Have the client use EFT on non-threatening issues FIRST to learn how it feels to use the technique and to become familiar with its benefits.  Be sure to observe how the client responds to general cognitive shifts. This will give you and the client time to see how EFT is tolerated. This will also allow more time for trust and rapport to develop between you and the client around using EFT. The client will rely on this until s/he has trust in EFT.”

[1] Ego-strength is used to describe individuals who are able to maintain their sense of identity and self in the face of adversity, distress, and conflict and can approach problems with the sense that he or she can not only overcome, but also grow as a result.  Low ego-strength refers to individuals who struggle to cope with problems, are overwhelmed by reality, and may avoid challenges and conflict.

The term ego-strength comes from Sigmund Freud’s psychoanalytic theory of personality, in which the personality is composed of three elements: the id, the ego, and the super-ego.  Put simply, the id is comprised of primal urges and is present at birth, the super-ego is comprised of standards and rules acquired from one’s parents and society, and the ego is the part of the personality that mediates among the demands and standards of the id, the super-ego, and reality.

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Ann Adams