What do we mean when we say NICE has found EFT to be clinically- and cost-effective for PTSD? What was the process?
In the UK, the National Institute for Health and Care Excellence (formerly National Institute for Clinical Excellence – NICE) is responsible for the evaluation of all treatments and therapy to be recommended for use in the UK’s National Health Service (NHS). NICE produces guidelines by condition. This article concerns the NICE Guideline for Post-traumatic stress disorder (PTSD), NG116 (1).
Approximately every five years, NICE considers whether a guideline needs to be revised and updated and, if necessary, conducts a review process that takes one–two years, involving extensive literature review and stakeholder consultation. EFT International (at the time of last review of NG116 known as AAMET) is registered with NICE as a stakeholder for the PTSD Guideline and has participated in the last two reviews; this was in 2011 just a consultation whether full review were needed. Then a full review of NG116 (1) was initiated in 2016 and published in December 2018. The NICE review process is well ordered and mostly transparent – their literature reviews, analyses, discussions and documented decisions are available to download from their website. You can find these relating to the 2018 revision here:
The information showing how NICE came to recommend further research into EFT for PTSD is available within the 1326-page: Post-traumatic stress disorder [D] Evidence reviews for psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in adults (2), and explained and summarised below, so you won’t need to trawl those 1326 pages.
NICE starts the process of review with a literature search, then decides for each research paper found whether it is to be included and analysed. At this stage many papers are excluded. The process is explained in Post-traumatic stress disorder [D] Evidence reviews for psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in adults (2), pages 9-13 and Appendices A-C.
Unfortunately, in the 2018 revision, the majority of published papers on EFT for PTSD, including a systematic review and meta-analysis showing high effect sizes, were excluded at this stage. However a handful of papers did make it through. It will be important for future EFT researchers to consider when planning research into EFT for PTSD, or indeed other conditions for which NICE evaluates literature, what are the NICE criteria for inclusion of papers. This can be gleaned by careful study of evidence reviews such as the one considered here (2).
The included EFT papers were grouped together with a couple of papers on Thought Field Therapy (TFT) for PTSD and considered together as ‘combined somatic and cognitive therapies’ (CSACTs). They omitted the paper that compares EFT to EMDR (Karatzias et al, 2011) (3) in their analysis of EFT, instead using this paper in their review of the literature for EMDR – whereas the paper was researched and written as a study of EFT.
Based on the papers they decided to include for each therapy, NICE then completed their own Network Meta Analysis (NMA) and compared 18 psychological interventions for PTSD for efficacy and of these, 11 interventions were considered in an economic analysis. Combined somatic and cognitive therapies were rated respectively 2nd and 4th most effective in two slightly different analyses (4).
Based on this evidence analysis, only Trauma-focussed CBT (TF-CBT), when completed in 8 sessions could be considered better than the CSACTs. Of the CSACTs, it was acknowledged that larger effect sizes were observed in the NMA for EFT than for TFT. There was "some promising evidence for clinical benefits of EFT" (5) and thus a research recommendation for EFT was included in the final guideline when published in December 2018. This recommendation was not included in the draft guideline that NICE put out for consultation in June 2018 and is likely the result of EFT International’s (at the time AAMET’s) detailed response to the consultation (6). EFTi made the case that the evidence for patient benefit from use of EFT for PTSD was so strongly promising that it would be morally wrong not to include it in the reviewed guideline.
This evidence was good, even based alone on the papers NICE had included in its NMA, even without all the additional papers that had not made it through to the final analysis. These can be found by searching by condition (PTSD) on EFT International’s database here.
Based on the NICE NMA only, the guidance development group committee for this guideline decided "that a recommendation could not be made for combined somatic and cognitive therapies based on the evidence for clinical and cost-effectiveness when weighed up against [these] additional considerations" (7). They instead took a first step of recommending further research (5,7). These additional considerations were as follows:
- The research papers they considered related exclusively to PTSD in military veteran populations. They wanted to consider papers relating to civilian populations before recommending EFT outright. However it must be noted here that Karatzias et al (3), the team that had compared EFT to EMDR, had collected data in a civilian NHS setting working with patients with various types of PTSD in NHS Fife, and found EFT similarly effective to EMDR, which is recommended in the NICE PTSD guideline as a treatment for PTSD, on the basis of this and other studies
- There were too few papers on EFT that used clinician-assessed measures such as Clinician-Administered PTSD Scale for DSM–IV (CAPS) or DSM-V (CAPS-5). NICE favoured this measure, because "this outcome can be blinded" (5). The majority of CSACT studies used self-report instruments of PTSD symptoms, which NICE found less adequate, presumably as they might be considered more subjective and more open to bias since outcome data collection cannot be blinded
- There was some follow-up data provided in most of the studies considered. Unfortunately, NICE found it to be too limited.
EFT International Research Team would like to encourage those researching EFT for PTSD, or indeed other conditions, to consider these points when planning and undertaking future research projects.
It is of particular interest to note that NICE observed, in respect of Cognitive Behavioural Therapy (CBT), which generally has been favoured as the treatment of choice for PTSD:
Although the evidence for trauma-focused CBT was overwhelmingly positive, the committee discussed the evidence suggesting a potential harm of trauma-focused CBT in terms of a significantly higher rate of drop-out relative to waitlist, and a small but still statistically significant higher drop-out where trauma-focused CBT augmented treatment as usual or medication relative to treatment as usual/medication-only. The committee discussed potential reasons for this higher rate of discontinuation, and speculated that trauma-focused CBT may be less acceptable to people who are not ready to directly confront traumatic memories, are not able to engage due to functional impairment from associated symptoms, and/or have difficulties in building a trusting therapeutic relationship. As existing recommendations for non-trauma-focused symptom-specific CBT interventions, modifications of trauma-focused therapies for those with additional needs (including complex PTSD), and engagement strategies for those with difficulties in building trust in the therapeutic relationship (based on the qualitative evidence [see evidence review H]) have the potential to address some of these reasons for discontinuation, the committee agreed that the potential for benefit was greater than the potential for harm.….Furthermore, offering EMDR as an option for those with non-combat-related PTSD, or supported computerised trauma-focused CBT as an alternative lower intensity intervention, allows people who may not find trauma-focused CBT acceptable to access another psychological intervention if they prefer. (7)"
EFTi’s Trainers and Practitioners who are experienced in treating trauma with EFT are aware of EFT’s advantages over CBT in respect of the patient groups described above. EFT’s particular strengths are the gentleness and safety of the approach and the extent to which it resources patients to support themselves between sessions. We also heard anecdotally from the researchers who undertook the comparison study of EMDR and EFT in NHS Fife (Karatzias et al) (3) that patients preferred EFT to EMDR. We know anecdotally from other NHS services where EFT has been made available that it has featured strongly in patient choice of therapy.
There is a fast-growing and promising evidence base for EFT, suggesting both clinical- and cost-effectiveness. In meta-analysis papers consistently show clinically significant improvement with EFT. A method used of determining the clinical significance or ‘effect size’ between two groups, Cohen’s d, is explained by Dr Peta Stapleton in The Science behind Tapping (8). A meta-analysis of 7 randomised controlled trials of EFT for PTSD (9) uses Cohen’s d to show the treatment effect size for the trials that compared EFT to treatment as usual or waitlist. Stapleton explains that the value Cohens d = 0.2 denotes a “small” effect size, one in which there is a real effect (something is really happening), but which you can only see through careful study (8). Cohen’s d = 0.8 denotes a “large” effect size, an effect that is big enough and consistent enough to be plainly obvious, one that is “very substantial” (8). In meta-analysis of EFT for PTSD (9), Cohen’s d = 2.96, clearly a remarkably large effect size. Effect size is used to inform us about the effect of one treatment over another; in this case the very large effect of EFT for PTSD was in favour of EFT compared to normal care.
NICE, even based on a small selection of papers from all the research available, in its own NMA found EFT to be the second most effective and cost effective therapy for PTSD. The emerging evidence base for EFT for PTSD shows huge promise and potential, including with patient groups where previous therapies of choice have been found insufficient. We await further research and further review by NICE.
In the meantime, we find it true to say that NICE has found EFT to be effective for PTSD (2,4,6).
Given that, alongside the NICE approach of considering only gold-standard research evidence there is a mass of anecdotal and other levels of evidence and clinical experience of positive benefit from the use of EFT for PTSD, many more treatment centres for PTSD need to be looking at how they start to include EFT in their offer to patients, also looking for opportunities to initiate the further research that NICE recommends.
Given the lower number of sessions needed and the much reduced risk of re-traumatisation with EFT compared with other treatments (notably CBT and EMDR), insurance companies also need to consider how they support this work, which, ultimately, will reduce their costs as well as having beneficial effect for their customers on Quality of Life Years (QALY).
Jacqui Footman, Chair of EFT International
With special thanks to Professor Elizabeth Boath of Staffordshire University, UK and Dr Peta Stapleton of Bond University, Australia for checking and suggestions.
- Post-traumatic stress disorder, NICE Guideline NG116, published 5 December 2018
- Post-traumatic stress disorder [D] Evidence reviews for psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in adults. NICE guideline NG116, Evidence reviews. December 2018
- Karatzias T, Power K, Keith Brown, McGoldrick T, Begum M, Young J, Loughran P, Chouliara Z, Adams S. A controlled comparison of the effectiveness and efficiency of two psychological therapies for posttraumatic stress disorder: eye movement desensitization and reprocessing vs. emotional freedom techniques. Journal of Nervous & Mental Diseases 2011 Jun 1;199(6):372-8.
- Post-traumatic stress disorder [D] Evidence reviews for psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in adults. NICE guideline NG116, Evidence reviews. December 2018. Page 267.
- Post-traumatic stress disorder [D] Evidence reviews for psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in adults. NICE guideline NG116, Evidence reviews. December 2018. Page 1286.
- Post-traumatic stress disorder: management. Consultation on draft guideline - Stakeholder comments table. 11/06/2018 to 23/07/2018. 5 December 2018
- Post-traumatic stress disorder [D] Evidence reviews for psychological, psychosocial and other non-pharmacological interventions for the treatment of PTSD in adults. NICE guideline NG116, Evidence reviews. December 2018. Pages 285-6.
- Stapleton P, The Science behind Tapping, 2019, Hay House. Page 54
- Sebastian B, Nelms J. The Effectiveness of Emotional Freedom Techniques in the Treatment of Posttraumatic Stress Disorder: A Meta-Analysis. Explore 2017 Jan 1;13(1):16-25.