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Journal of Aggression, Maltreatment & Trauma
ISSN: 1092-6771 (Print) 1545-083X (Online) Journal homepage: http://www.tandfonline.com/loi/wamt20
Emerging Trauma Therapies: Critical Analysis and
Discussion of Three Novel Approaches
Kjerstin Gurda
To cite this article: Kjerstin Gurda (2015) Emerging Trauma Therapies: Critical Analysis and
Discussion of Three Novel Approaches, Journal of Aggression, Maltreatment & Trauma, 24:7,
773-793, DOI: 10.1080/10926771.2015.1062445
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Emerging Trauma Therapies: Critical Analysis
and Discussion of Three Novel Approaches
KJERSTIN GURDA
School of Social Work, University of Wisconsin–Madison, Madison, Wisconsin, USA
Trauma-related disorders and treatment have gained increasing
attention in the last 3 decades, spurring the development of novel
treatment approaches. Many of these are incorporated into clinical
practice despite lacking a solid evidence base or unbiased analyses
to facilitate interpretation of existing information. Although treat-
ments might draw on elements from validated therapies, questions
regarding the incremental efficacy of new approaches persist. Three
novel therapies that might warrant further examination include
energy psychology, yoga, and brainspotting. The emergence of
novel, trauma-related therapies is examined, and the history, the-
ory, practice, and evidence base of these 3 specific therapies are
outlined. Directions for future work are discussed. Expositions such
as this might serve as a helpful resource for clinicians seeking
discernment regarding treatment for posttraumatic stress disorder.
KEYWORDS brainspotting, emerging therapy, emotional freedom
technique, novel treatment, PTSD, thought field therapy, trauma,
yoga
The concept of trauma has gained increasing attention in the last three
decades, both in the general population and among clinicians and research-
ers. Growing recognition of the impact of traumatic experiences—instigated,
in part, by increasing recognition of psychopathology associated with experi-
ences of military deployment, natural disasters, and terrorist attacks—has
perpetuated a greater focus on treatment of trauma-related disorders.
Although 60% to 90% of the population will sustain exposure to a traumatic
Received 20 February 2014; revised 24 February 2015; accepted 26 February 2015.
Address correspondence to Kjerstin Gurda, Early Childhood Initiative, 5810 Russett Rd. #3
Madison, WI 53711, USA. E-mail: Kjerstin.gurda@commpart.org
Journal of Aggression, Maltreatment & Trauma, 24:773–793, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 1092-6771 print/1545-083X online
DOI: 10.1080/10926771.2015.1062445
773
stressor at some point, 7%to 9% of individuals will go on to develop posttrau-
matic stress disorder (PTSD), the diagnosis most closely linked to traumatic
experiences (Foa, Gillihan, & Bryant, 2013; Kessler, Chiu, Demler, & Walters,
2005). This percentage can be more than twice as high for certain groups,
such as war veterans, women, and minorities (Kessler, Sonnega, Hughes, &
Nelson, 1995; Libby, Reddy, Pilver, & Desai, 2012). Further, PTSD has a high
comorbidity rate of 88% (Emerson, Sharma, Chaudry, & Turner, 2009), is
associated with increased risk of suicide (Kessler, 2000), and often signifi-
cantly inhibits normal functioning for individuals due to high levels of distress.
An increased focus on trauma has spurred research on PTSD as well as
development and refinement of treatment (Cukor, Olden, Lee, & Difede,
2010). There are various effective, evidence-based therapies indicated for
treatment of PTSD, including exposure-based therapies, trauma-focused cog-
nitive behavioral therapy (CBT), eye movement desensitization reprocessing
(EMDR), and limited evidence for psychopharmacological treatment (e.g.,
Bisson et al., 2007; Bradley, Greene, Russ, Dutra, & Westen, 2005; Foa,
Franklin, & Moser, 2002). Bradley et al.’s(2005) meta-analysis of 26 studies
with 44 treatment conditions concluded that treatment for PTSD is highly
effective, with 56% of those who received some measure of treatment and
67% of those who completed a treatment course no longer meeting criteria for
PTSD. However, a majority of individuals might continue to experience “sub-
stantial residual symptoms”after treatment (Bradley et al., 2005, p. 225), and
Cukor et al. (2010) reported that 33% to 44% of individuals do not benefit from
treatment for PTSD. Further, Bradley and colleagues found that two thirds of
those who initially experience recovery will relapse within 6 months.
It has been documented that PTSD is significantly difficult to treat;
symptoms can persist for decades, and a high number individuals never
seek or complete appropriate treatment, despite the chronic nature of the
disorder (Foa & Meadows, 1997; Libby et al., 2012). The combination of
increased focus and the unmet needs of the third of individuals who do not
respond to treatment have created space for innovation in this field. In
response, a growing number of novel therapies have emerged. Many of
these clinical interventions correspondingly draw on the body of literature
and theory that have emerged in trauma research and practice. Although these
novel therapies might be widely used, there is a paucity of data and a general
lack of understanding about a number of them.
In this discussion, the field of emerging trauma therapies is examined,
including relevant questions regarding how these therapies seek substantia-
tion and how practitioners can discern between new treatment options. In a
more focused discussion, three specific emerging therapies are addressed:
energy psychology (including thought field therapy, emotional freedom tech-
nique, and Tapas acupressure technique), brainspotting, and yoga. Each of
these three emerging trauma therapies entails relatively foreign techniques or
mechanisms, and, thus, perhaps holds the greatest risk for misunderstanding
774 K. Gurda
or inappropriate implementation. Each treatment approach is discussed with
corresponding examination of existing literature and evidence.
CONTEXT AND TRENDS AMONG NOVEL THERAPIES
Emerging therapies for trauma span a broad range of approaches. A literature
search yielded a number of surveys that reveal a wide diversity of novel
therapies (see Bomyea & Lang, 2012; Cukor et al., 2010; Cukor, Spitalnick,
Difede, Rizzo, & Rothbaum, 2009; National Research Council, 2012; R. Sha-
piro, 2010; Welch & Rothbaum, 2007). Discerning which treatments might be
most worthy of consideration or attaining an adequate understanding of
individual approaches can be difficult. Although studies are being conducted
by private researchers, the Department of Veterans Affairs (VA), and the
Department of Defense—sometimes catapulting novel therapies into greater
use and access to research funding (Institute of Medicine, 2012)—few of the
large array of novel treatments have empirical support for application as
trauma treatments, failing to meet criteria for evidence-based practice (Foa
& Meadows, 1997). In place of empirical evidence, novel treatments might
rely on client and clinician reports of efficacy, pilot project case studies
(Institute of Medicine, 2012), and the “soundness of their theoretical rationale
and associated evidence”(Welch & Rothbaum, 2007, p. 475) to establish
credibility.
As noted by Foa et al. (2013), the difficulty of discernment regarding
treatment approach has been evidenced by the high percentage of clinicians
who use or rely on treatments for PTSD “of unknown efficacy”(p. 65) within a
clinician culture described as “antagonistic to evidence-based treatments”(p.
65) and training. This might be due in part to clinicians’aversion to subjecting
vulnerable clients to exposure therapy, which is a component of a majority of
supported treatments for PTSD (Foa et al., 2013). Pignotti and Thyer (2012)
reported that among Licensed Clinical Social Workers, who make up the
majority of psychotherapy providers in the United States, 75% endorsed use
of at least one “novel, unsupported therapy (NUST)”(p. 331). Of particular
interest, the authors found that female clinicians who specialized in trauma
were significantly more likely to use NUSTs, perhaps in part due to the
proliferation of novel therapies for trauma, which are discussed here. Regard-
ing usage of NUSTs, Pignotti and Thyer found that a majority of clinicians
rated clinical experience above published research as the rationale for treat-
ment selection. However, the process of discernment should entail clinicians
conducting careful analyses of available information and evidence to integrate
this with their clinical expertise—a practice that is often difficult to execute
while maintaining professional responsibilities. Consequently, translational
work and descriptive studies such as that presented here are needed to
facilitate the discernment process for clinicians.
Emerging Trauma Therapies: Critical Analysis 775
A large number of the emerging therapies for PTSD treatment seem, at
first examination, to be outliers in the clinical field. Use of unprecedented
techniques and nontraditional protocols might appear contrived and prevent
these therapies from gaining legitimacy or alienate practitioners from exam-
ination or use of these techniques. Conversely, with the constant recycling of
ideas and techniques in the therapeutic field, it is uncommon to find a practice
that does not integrate elements of a previously tested treatment or theory on
closer examination. These commonalities might, in fact, create a frame of
reference and greater understanding of those therapies that initially seem
unusual (Comas-Diaz, 2006).
EMDR, developed by Dr. Francine Shapiro, is of particular note in this
discussion because the treatment shares similar beginnings with many emer-
ging therapies for PTSD. At its inception, EMDR was a novel, untested practice
that was “discovered”by a clinician, entailed the unique and odd-seeming
practice of bilateral stimulation through eye movements, and was from the
very first reports linked with claims of rapid, enduring resolution of PTSD
symptoms (Greenwald, 1996; F. Shapiro, 2002). Over time, EMDR went from
being practiced under the label of an “experimental treatment”(EMDR Insti-
tute, 2011) to establishment as an “evidence based practice in the treatment of
trauma symptoms”(Lee & Cuijpers, 2013, p. 231) as indicated in guidelines
from both the VA and the American Psychological Association (APA).
Although many might still identify EMDR among the “emerging therapies”
listed here, its acceptance and evidence base, despite a still-dubious mechan-
ism, makes it a compelling case example (Lilienfeld & Arkowitz, 2008;F.
Shapiro, 2012). It has perhaps cracked open the door of acceptance for new
treatments, creating space for greater innovation and flexibility within the
field.
Whereas varied theories and elements of evidence-based treatments
serve to inform and ground novel therapies, certain themes can be found in
common within this expanding field and link to a rapidly growing body of
research on PTSD and trauma. Regardless of theoretical orientation or method
of practice, neurobiological research and understanding appear to be at the
cutting edge of therapy—and, therefore, many emerging trauma treatments—
as reflected by the work of researchers and writers such as Seigal, Perry,
Schore, Pollak, and Teicher. An element of the neurobiological focus is a
fundamental shift in how the mind–body connection is viewed. This has
incited increased integration of somatic elements into therapy and theory
regarding how trauma is encoded in the mind and physical body, with
corresponding implications for how to resolve its effects. Researchers and
writers, such as van der Kolk, Ogden, Levine, Rothschild, and Scaer, are at the
forefront of this movement from which dramatic implications for a shift in
PTSD treatment have come.
Respected yet controversial researcher van der Kolk has made increas-
ingly strong statements regarding the futility of talk therapy for those suffering
776 K. Gurda
from PTSD, arguing that trauma is experienced and stored in subcortical areas
of the brain, and resolution of PTSD, therefore, must happen through engage-
ment of subcortical processes—namely, engagement of the physical body—
rather than higher level cognitive processes engaged through talk therapy
(Wylie, 2004). Pronouncements like these, which call the function of therapy
as it has traditionally been conceptualized into question, are controversial
indeed. However, the incorporation of these elements into many emerging
therapies, including energy psychology, yoga, and brainspotting, could
explain their wide use, as discussed in the following section.
ANALYSIS OF THREE EMERGING THERAPIES
Energy Psychology
DEFINITION AND HISTORY
Energy psychology is not one technique, but a collection of similar therapies
that share the core strategy of combining physical interventions (related to
acupressure), which regulate energy fields and decrease hyperarousal, with
mental engagement of a target issue or emotion through imaginal exposure to
alter the distress response (Feinstein, 2008). These techniques include thought
field therapy (TFT), the emotional freedom technique (EFT), and the Tapas
acupressure technique. TFT was developed by Callahan, a psychologist who
drew on applied kinesiology and insights from Chinese medicine. Callahan
discovered the technique in 1979 when his client tapped with fingers on a
specific point on her body—which he later termed a meridian point—and a
long-held trauma was spontaneously released. By the 1990s, his techniques
were being practiced more widely and were even developed into other
named techniques, including Tapas acupressure technique. In 1995, Calla-
han’s mentee, Craig, simplified the protocol to a universal algorithm of mer-
idian points while focusing on a target, naming this approach the EFT. These
techniques were unified under the Association for Comprehensive Energy
Psychology in 1999, but are still practiced as distinct therapies (Mollon,
2007). Although the number of practitioners is unknown, the newsletter EFT
Insights has hundreds of thousands of subscribers (Feinstein, 2008).
THEORY AND LINKS TO OTHER MODALITIES
Both Callahan (1985) and Craig (2007) posited that the body has energy fields,
called thought fields, in which genetic or biological predispositions, trauma,
energy toxins, and other issues cause blockages—or perturbations—in the
body’s energy flow (meridian system), or qi. These, in turn, are identified as
the cause of all psychological problems (Karatzias et al., 2011; McCaslin,
2009). TFT and EFT mechanisms are linked to less acknowledged practices
Emerging Trauma Therapies: Critical Analysis 777
such as acupuncture, muscle testing procedures from applied kinesiology,
quantum physics, and paranormal concepts (e.g., morphic resonance), as well
as supported therapies, including EMDR, exposure-based treatments, and
building the therapeutic alliance (Mollon, 2007 cited by Feinstein, 2008).
EFT practitioners hold that by using manual stimulation at traditional
acupuncture points while focusing on an issue associated with emotional
distress, these blockages can be resolved permanently (Craig, 2009). Callahan
stated that the thought field is attuned when a person focuses on the source of
distress, permitting a clinician and client to identify and act on the correspond-
ing perturbations through tapping, which adds energy to the field and corrects
the imbalance (Callahan & Callahan, 2000). Although meridian points are
compared to acupressure points in the literature, there is little mention of
what separates them, aside from how they are acted on. It is noted that energy
psychology’s concept of subtle energies hails from an Eastern philosophy
framework. It holds that the body’s electrical systems and energy field exist
and are “readily verified”(Feinstein, 2008, p. 199). Detractors, however,
roundly refute this claim (e.g., McCaslin, 2009).
A secondary theory around EFT’s mechanism is that focusing on mem-
ories or issues that trigger the brain’s pathways of limbic hyperarousal (or fear
response, which sustains PTSD), paired with simultaneous acupoint stimula-
tion to disrupt arousal pathways in the amygdala and other areas of the brain,
reduces or interrupts hyperarousal (Feinstein, 2008; Ruden, 2007). This, pre-
sumably, allows memories to be reconsolidated, or lose their power to trigger
distress, and the pathway of elevated limbic response to be permanently reset.
Building on this theory, Ruden (2007) posited that abnormal glutamate func-
tioning in the amygdala is encoded with other neurochemicals in the triggered
response pattern, functioning to “re-load, the pathway . . . immortalizing it”(p.
72). It might be possible to disrupt this reaction neurochemically; tapping is
believed to induce activation of seritonergetic pathways, which function to
inhibit or disrupt this response pattern, a phenomenon that has been used
successfully in studies on rodents. As such, TFT might activate serotonin
distinct from the function of a selective serotonin reuptake inhibitor (SSRI)
in the immediacy of its administration and its explicit link to trauma. Ruden
argued that this theory is testable, and infusion of other serotonin-releasing
agents should, therefore, produce similar results.
PRACTICE
Callahan (1985) called TFT “the five minute phobia cure,”originally using it to
treat anxiety disorders, but later indicating the therapy for treatment of PTSD
as well. Feinstein (2008) noted that energy psychology techniques can be
used “in independent psychotherapy, as an adjunct to other therapies, and as
a back home tool for emotional self-management”(p. 199). According to
778 K. Gurda
various authors (Callahan, 1985; Craig, 2007; Karatzias et al., 2011; Ruden,
2007), the basic practice of energy psychology entails eliciting the distress and
hyperarousal associated with a traumatic or disturbing memory or experience
and then tapping on various meridian points on the face, body, and hands
while experiencing this induced exposure; this works to reduce distress and
facilitate processing.
There are specific protocols associated with use of each energy psychol-
ogy practice, although all of them employ the basic technique noted earlier
and ask clients to rate their subjective units of distress (SUDS) using scaling
before and after tapping. Tapping could be done by the client, the therapist,
or both. Callahan’s procedure indicates specific sequences, called algorithms,
that vary in response to client presentation (as cited in McCaslin, 2009;
Pignotti, 2005). Craig’s protocol includes a “set up”(2007; Craig & Craig,
2014) of setting a focus and stimulating one meridian point, followed by
tapping six to eight times on a prescribed 12 points while reciting an affirma-
tion, such as, “Even though I have this problem, I deeply and completely
accept myself”(Craig, 2007; Craig & Craig, 2014); after this, clients might
count, roll their eyes, and hum a song. These practices following a client’s
affirmation are believed to engage both hemispheres of the brain in greater
processing (Gaudiano, Brown, & Miller, 2012). Rounds of tapping are con-
tinued to achieve reduction of SUDS and elimination of hyperarousal.
Because the basic technique is somewhat formulaic, it can be learned
and practiced by therapists or individuals with ease (Craig, 2007). There are
myriad training resources available for purchase and free online as well as
from trainers. The Association for Comprehensive Energy Psychology (ACEP)
encourages certification in either EFT or Comprehensive Energy Psychology
(CEP). Each certification process entails multiple levels of 2-day trainings and
optional certification, costing several hundred dollars for trainings to thou-
sands for certification. (ACEP, n.d.).
EVIDENCE OF EFFICACY
As even energy psychology proponent Feinstein (2008) noted, energy psy-
chology is “exceedingly controversial”and “relies on unfamiliar procedures
adapted from non-Western cultures, posits unverified mechanisms of action,
and early claims of unusual speed and therapeutic power ran far ahead of
initial empirical support”(p. 199). Energy psychology has not yet built the
body of empirical research required to scientifically establish its efficacy,
although an “unusual amount”(Feinstein, 2008, p. 202) of gray literature,
such as anecdotal reports, theses and dissertations, uncontrolled investiga-
tions, and unpublished research, exists in support of the technique (Feinstein,
2009). It would appear that interpretation of the existing body of literature can
bend two ways, with ardent supporters and vehement detractors calling on
Emerging Trauma Therapies: Critical Analysis 779
the same studies to support their claims in this debate between entrenched,
opposing sides.
Meta-analyses (Feinstein, 2008,2009,2012; Karatzias et al., 2011) have
found mixed preliminary evidence in this alternative body of literature sug-
gesting EFT and TFT might be effective treatments. Feinstein (2012) stated that
studies in the last 5 years have provided more significant evidence in support
of these treatments, including four randomized, controlled trials and five
outcome studies, as well as studies that found EMDR and EFT to have similar
efficacy and that use of EFT alongside CBT increases effect sizes. Other
findings have shown support for use of EFT with veterans (Church, 2010;
Church et al., 2013) and adolescents (Church, 2010). EFT has also been found
to shorten treatment time when used as an adjunctive therapy and as lacking
any evidence of harm (Flint, Lammers, & Mitnick, 2006).
In attempting to understand the mechanism of tapping, links have
been made to studies that show that coordination of visual and manual
tasks facilitates more vivid memory recall (Sapkota, Pardhan, & Van der
Linde, 2013) and studies substantiating the positive effects of acupuncture
and acupressure (Chung, Chen, & Yeh, 2012; Hollifield, Sinclair-Lian, War-
ner, & Hammerschlag, 2007). Linkages like these, Feinstein (2009) argued,
support the concept that individuals might benefit from tapping, regardless
of order, number, selection, or method of stimulating acupoints. Feinstein
noted additionally that EFT has reached the minimum threshold for desig-
nation as an evidence-based treatment, having met APA criteria through
the existing evidence, although this claim has not been met with such
designation by the APA.
In contrast, Gaudiano et al. (2012) pointed out EFT’s lack of valid
scientific bias, efficacy, or superiority over other treatments and identified
many characteristics of pseudoscience in a literature review that was based
on several of the same studies reviewed in Feinstein’s(2009) analysis. Detrac-
tors, such as Pignotti (2005), McCaslin (2009), Waite and Holder (2003), and
Devilly (2005), also flatly refuted efficacy claims and pointed to conflicts of
interest as well as skewed interpretation of data and questionable source
material, including faulty study designs and a lack of rigorous peer review,
thus attributing the positive effects of energy psychology found earlier to
placebo or mechanisms from more proven treatments. Further, McCaslin
(2009) discredited down-regulation of the amygdala, stating functional mag-
netic resonance imaging (fMRI) studies have shown similar effects across
therapies and, as a result, findings are not attributable specifically to EFT.
McCaslin also challenged tapping, equating it with distraction, and the APA
went so far as to censor EFT as a valid therapy in 1999 and upholds this still
today (Feinstein, 2009).
Regardless of the controversy, it has been observed that large numbers of
practitioners implement energy psychology with clients, with 43% of clinicians
in one study reporting frequent use of these techniques (Gaudiano et al.,
780 K. Gurda
2012). However, these same clinicians were also found to be more reliant on
intuition and therapeutic eclecticism, supportive of alternative treatments, and
upholding of erroneous health beliefs, and to have lower scores on a test of
critical thinking. As the debate stands, clinicians might well be able to support
a decision for or against the use of these techniques dependent on clinical
expertise, although more generalizable and decisive data remain to be
published.
Yoga
DEFINITION AND HISTORY
Widely acknowledged in other contexts, yoga’s healing and transformative
potential have just begun to be studied formally in the United States. Although
yoga is a novel therapy for treatment of PTSD, as a tradition and practice, it
has a rich history across cultures and has been found to create improvement
in measures such as quality of life, emotional well-being, and stress manage-
ment (Spinazzola, Rhodes, Emerson, Earle, & Monroe, 2011). As indicated
earlier, growing recognition of the impacts of traumatic experiences on the
body and acknowledgment of the limitations of cognitively processing trauma
have created a need that yoga might be able to fill as an adjunctive treatment
(Emerson, as interviewed in Douglas, 2012). van der Kolk, the neurobiological
researcher who led this charge, described his research on the brain as having
led him to yoga as a trauma therapy. van der Kolk (interviewed in Wills, 2007)
explained that in looking for ways to help clients regulate hyperarousal, feel
safe within their bodies, and be more oriented in time and space, yoga
emerged as a therapeutic practice. This has guided his efforts to examine
and promote yoga as a trauma therapy.
THEORY AND LINKS TO OTHER MODALITIES
The theory of why yoga works as a therapy for PTSD is rooted in neurobio-
logical research that indicates traumatic experiences leave lasting “imprints”in
an individual’s sensory and hormonal systems. As van der Kolk (2009)
explained, this causes people to experience hyperarousal and become “terri-
fied of the sensations in their own bodies”(p. 12), continuously experiencing
a traumatic state, which causes them to lose their orientation to themselves
and the world. Living in this state of emergency triggers the release of
neurochemicals, which are meant to enable the body to engage in action,
but these overwhelmed individuals instead remain paralyzed and unable to
react. Yoga is believed to help traumatized bodies take effective action and
regain natural movement through physical practice.
Practitioners of yoga develop awareness and mastery of their bodies,
allowing them to reorient themselves and enabling them to tolerate distress
Emerging Trauma Therapies: Critical Analysis 781
through meditation and mindfulness; these increase awareness of the
impermanence of negative feeling states. This enlarged ability to observe
and tolerate discomfort while maintaining a feeling of safety is thought to
serve as a “positive imprinting process.”It also allows individuals to
“befriend”the bodies in which trauma has been experienced (van der
Kolk, 2009, p. 13). Researcher Khalsa (2007) stated that control of target
actions, such as the breath or body postures, generates changes in the
brain, limbic system, and hormone-related stress cycle, facilitating a focus
on the present. This is congruent with Levine’s(2010)somatictheory,
which indicates awareness of body memory and sensation in an integrative
approach to processing trauma.
PRACTICE
There are many schools of yoga. Kripalu yoga, Hatha (gentle) yoga, and Yoga
Nidra (yogic sleep—renamed iRest for implementation with veteran popula-
tions) are among those that have been adapted to provide trauma-sensitive
instruction (Pollack, 2010; Spinazzola et al., 2011). Although each might have
different components, most forms of yoga implement a combination of med-
itation and mindfulness, breath work, and physical postures of varying diffi-
culty with trauma-sensitive modifications.
Yoga as a PTSD therapy is accompanied by an expectation that the yoga
specialist is a part of the clinical team and should be integrated and supervised
accordingly (Emerson, cited in Douglas, 2012). As such, The Trauma Center in
Boston has spearheaded a movement to provide specific preparation for
specialists, entailing a 110-hour trauma-sensitive yoga teacher training, costing
around $4,000 (The Trauma Center, 2007), with similar programs springing up
nationwide (Sparrowe, 2011). Other offerings include a 3-day training on
integrating yoga as a somatic-based psychotherapy into practice using chair
yoga, breathing, and meditation; these often cost several hundred dollars and
include a certification option (Lutz, 2010).
As identified by Emerson et al. (2009), who have implemented the yoga
program at The Trauma Center under Van der Kolk’s direction, adaptations
of common yoga practices fall under the five domains of environment,
exercises, teacher qualities, assists, and language. The environment could
be modified to limit distractions and increase a sense of safety (e.g., students
are not asked to practice with their backs to the door). Exercises are paced
carefully and given with modification options to avoid triggering students
and to increase personal awareness and choice. Teachers practice slowly
and clearly to create a feeling of safety, and assists (physical modifications of
others’poses) are rarely done, and then only with prior permission. Lan-
guage is significantly modified from normal instruction to reflect a paradigm
of choice and to engender a sense of community and support among
782 K. Gurda
participants. Practice is often weekly or more frequent, with indication for
personal practice at home (Emerson et al., 2009).
EVIDENCE OF EFFICACY
Like energy psychology techniques, a rigorous evidence base has yet to be
established for the use of yoga as a PTSD treatment. This evidence base might
be emergent, however, as program development and data collection are
underway. Preliminary studies and meta-analyses have overwhelmingly
found that yoga as an adjunctive intervention has significant effects on alle-
viating PTSD and could be provisionally considered consistent with defini-
tions for evidence-based practices (Brown & Gerbarg, 2011; Cukor et al.,
2009; Emerson et al., 2009; Kirlin, 2010; Libby et al., 2012; Sparrowe, 2011;
Spinazzola, Rhodes, Emerson, Earle, & Monroe, 2011; Telles, Singh, & Balk-
rishna, 2012). The mechanisms of yoga have been independently studied, and
a meta-analysis conducted by Spinazolla et al. (2011) found wide support for
the positive impacts of various components. These benefits include the posi-
tive effects of breath work in improving emotional and biological regulation;
the influence of meditation and mindfulness in decreasing ruminations, anxi-
ety, depression, stress, and substance abuse; and the impact of asanas (pos-
tures) associated with positive changes in the neurocognitive aspects of PTSD,
such as present-focus, safety, and equalization of the body’s biochemical
systems (Spinazolla, 2011; Kirlin, 2010).
Efficacy for yoga as a treatment has been found among specific client
populations, including veterans (Brown & Gerbarg, 2011; Johnston, 2011;
Stankovic, 2011); survivors of natural disasters (Descilo et al., 2010); adoles-
cents (Lilly & Hedlund, 2010); and women who suffer from complex, treat-
ment-resistant PTSD (Sparrowe, 2011). In fact, because diagnosis of PTSD in
U.S. veterans is increasing, the VA has initiated implementation of yoga and
funded research on its effectiveness (Lutz, 2010; Zimmerman, 2010), with one
study finding that the majority of VA PTSD programs implement yoga and
mindfulness practices as part of therapy (Libby et al., 2012). Research has not
stopped there; 13 yoga research trials are listed on the governmental trials
funding page alone (see www.trials.gov), and there are multiple dissertations
and theses on yoga treatment of trauma as well (e.g., Dixon-Peters, 2007;
Gulden, 2012; Johnston, 2011; Kirlin, 2010; West, 2011). These studies are not
without flaws; many trials have small participation numbers, and van der Kolk
(cited in Wills, 2007) reported his yoga studies have had had the highest
dropout rates of any studies he has conducted. This might be linked to the
commonly held bias toward yoga as alternative, spiritual, or new-age,
although efforts like that of the VA could contribute to normalization of
yoga as an accessible practice (Libby et al., 2012).
Emerging Trauma Therapies: Critical Analysis 783
A need for methodologically sound empirical studies persists, as does the
need for dismantling studies to determine the most effective practices among
the wide variations between schools of yoga (Kirlin, 2010). Although the
literature seems to indicate general and fairly unified support for use of
yoga as an adjunctive treatment for PTSD, the lack of critical controversy
over yoga’s efficacy might be largely due to its recommendation as an
adjunctive rather than primary treatment modality. Indeed, much of this
support is based on “gray literature”similar to that used to establish efficacy
of energy psychology; if this emphasis was to shift toward yoga and other
body-focused therapies as primary therapies (as Van der Kolk seems to
support), the consensus might well move away from support of yoga as a
treatment.
Brainspotting
DEFINITION AND HISTORY
Among the newer of novel therapies for treating PTSD is brainspotting (BSP),
a brain-based dual-attunement model of treatment (Grand, 2013). Originally a
practitioner and great proponent of EMDR, in 2003, Dr. David Grand discov-
ered BSP while conducting slowed eye movements with a trauma client.
Although bilateral eye movements are a central aspect of EMDR therapy,
Grand was modifying the normal pace of this practice when he stopped
motion and had his client hold her gaze in a spot where he noticed a wobble
movement in her eyes. Witnessing the resultant rapid processing reaction,
which cleared his client’s previously inaccessible trauma, Grand felt he had
made a breakthrough in discovering a new therapeutic technique (Grand,
2013). Grand developed the treatment model from there, calling it brainspot-
ting. Psychologist Lisa Schwarz trained with Grand, later becoming a colla-
borator and developing Grand’s BSP model beyond its original form, naming
it resource brainspotting for treatment of clients with severe attachment and
dissociative disorders (D. Grand, personal communication, May 2013). The
resultant fully articulated resource model BSP incorporates techniques applic-
able for all clients. Although BSP does not enjoy the body of research EMDR
has amassed—in fact, there remain to be any formally evaluative studies
published on this treatment—many EMDR practitioners and other clinicians
have “enthusiastically adopted”the treatment, reporting high rates of success
(R. Shapiro, 2010, p. 119). To date there are more than 6,000 clinicians trained
in the model worldwide (Grand, 2013).
THEORY AND LINKS TO OTHER MODALITIES
BSP claims a brain-based mechanism and emphasizes the importance of dual
attunement of the therapist with the client and the client’s neurological
784 K. Gurda
processes (accessed through location of and work with relevant eye posi-
tions). Similar to other therapies, clients are asked to initiate activation around
a problem issue. The therapist then locates an associated eyespot with the
client in which the client processes while listening to bilateral music.
The theoretical explanation of BSP is that brainspots, or relevant eye
positions, are physiological subsystems related to the energetic and emotional
activation of a trauma and facilitate “direct access to the autonomic and limbic
systems”(Grand, n.d., para 4). Processing in these brainspots in a supported
context is thought to facilitate rapid discharge and resolution of traumatic
experiences. Work with brainspots and bilateral stimulation of the brain are
posited to down-regulate the amygdala, facilitate homeostasis (Scaer, cited in
Schwarz, 2013), and result in deconditioning of maladaptive response pat-
terns, thus enabling the body’s innate tendency toward self-healing and
release of traumatic capsules (Schwarz, 2013). The technique “processes
and dismantles the symptom, the underlying trauma, the somatic distress,
and the dysfunctional beliefs at the reflexive core”(Brainspotting Interna-
tional, 2009, para 5). Further, BSP has been described as utilizing internal
resources of strength and groundedness, allowing pendulation between posi-
tive states and trauma states to contain the processing of trauma (Grand, 2013;
L. Schwarz, personal communication, May 2013).
Additional theoretical perspectives have been drawn on to support this
proposed mechanism; a recent article published in Medical Hypotheses
presented a highly complex descriptive model for BSP’sneurologicalpath-
way (Corrigan & Grand, 2013). Research of the notion that minute eye
movements—called microsaccades—are associated with focus and internal
processing has been presented as support for the concept that attunement
to physical cues, such as eye movements, is a way to access stored trauma
in specific eye positions (Martinez-Conde & Macknik, 2007). Research
regarding the adaptive orienting responseinrelationtoeyemovements
has also been drawn on, bolstering the theory that eye movements are
implicated in the processing of significant events and, therefore, a means
of access as well (Corrigan & Grand, 2013).
Although many comparisons have been made between BSP and
EMDR, D. Grand (personal communication, May 2013) asserted that,
aside from engagement of the eye as an element of treatment, the mechan-
isms of BSP are essentially different from that of EMDR. BSP has instead
been identified as drawing more heavily on theories such as Levine’s
somatic experiencing, due to BSP’s engagement of and attunement to the
body and the concept of pendulation between trauma and resource states
(called vortexes;Levine,1997). Corrigan and Grand (2013)positedthatBSP
is the most “subcortical”(p. 760) of all treatments, allowing clients to
access deeply stored trauma and for action to “anchor at the midbrain”
(D. Grand, personal communication, May 2013) without disruption from
more cortical processes incited by many other treatments In this way BSP
Emerging Trauma Therapies: Critical Analysis 785
hasbeenadditionallyalignedwithcurrenttheoriesandresearchregarding
neurological, body-oriented, and somatic engagement in trauma therapy.
PRACTICE
BSP has been established as an integrative model, with the expectation that
clinicians will incorporate the therapy into their modality of practice. As such,
there currently is no prescriptive treatment protocol. Rather, clients are asked
to focus on an issue and “activate”themselves regarding that issue, allowing
themselves to engage difficult emotions or affect. Clients then identify where
they feel the activation in their bodies, provide an associated SUDS rating, and
are guided through steps to locate a relevant eye position for processing.
There are several methods for locating, or mapping, brainspots on the x,
y-axis, including outside window, in which a finely attuned therapist looks
for any physical cues while sweeping across the client’s gaze with a pointer,
and inside window, where a client is able to determine location of the eyespot
through his or her own identification of increased distress (Grand, 2013).
Another method, one-eye BSP, is used with specialized goggles that block a
portion of the field of vision and allow clinicians to find the more activated
eye and the resource eye, or the side that feels more calming and stable to the
client. Gaze spotting entails identification of brainspots clients naturally grav-
itate toward while processing emotional content (Grand, 2013). Additional
methods include z-spotting, which engages a “third dimension”through mod-
ulating the client’s brainspot on a near–far, or “z-axis”; and rolling BSP, which
is employed by slow movement of the pointer or finger that a client tracks
with his or her eyes, stopping at each identified brainspot for processing
(Grand, 2011,2013). Work with resource eyespots has also been fully inte-
grated into treatment.
Once this process is initiated, clients listen to bilateral music on head-
phones at a low volume while in their eye position, and they often experience
an intense flow of memories, emotions, and associations. This process can take
place without extensive verbal exchange, and clients are asked to remain open
and without expectation, which Grand called focused mindfulness (Grand,
2011). Clients process until their SUDS score is lowered, and then are asked
to reinitiate activation as much as possible, called “squeezing the lemon,”to
process to completion. Length of treatment is dependent on the extent of
traumatic experiences (Grand, 2011).
Although this represents the basic methodology, many other techniques
are used in BSP. BSP instruction entails 2-day trainings (or using a training
DVD) for each of three phases, with an option to pursue certification through
supervision. Each training costs several hundred dollars (less for DVDs), with
additional costs for certification (EMDR International Association, n.d.; Grand,
n.d.).
786 K. Gurda
EVIDENCE OF EFFICACY
As there are not yet any studies supporting or rejecting BSP’s efficacy, anec-
dotal evidence, treatment information, and soundness of theory constitute the
available material for discernment regarding this therapy. BSP practitioners
report that their clients experience “fast, deep response and move quickly
through issues”(R. Shapiro, 2010, p. 119), and some EMDR practitioners have
described BSP as a “greater precision tool than EMDR”(J. Ryan, personal
communication, April 2013) and “more containing and stabilizing for trauma-
tized clients”(L. Schwarz, personal communication, May 2013). Additionally,
several research studies regarding BSP are currently underway, including a
randomized trial involving fMRI imaging in relation to BSP and another
randomized study comparing EMDR with BSP; results are forthcoming (D.
Grand, personal communication, May 2013).
In the Corrigan and Grand (2013) article, the authors highlighted research
that provides evidence for BSP mechanisms. These included studies that
indicated that blinking, which is one cue used to locate brainspots, has
been associated with altered brain function and processing. The tendency
toward spontaneous eye movement during searching thought processes,
followed by gaze fixation when information is found, have appeared to
further support proposed connections between eye movements and internal
processing (Corrigan & Grand, 2013).
As evaluations and critiques of this therapy are yet to be published,
identification of detractors is not possible. Confounding consideration of
BSP at this stage is the fact that all material regarding treatment comes from
its originators and collaborators, implying inherent bias. It remains to be seen
if this therapy will persist to establish a solid evidence base.
CONCLUSION
New emerging therapies and novel techniques will certainly continue to exist
at the periphery—and, indeed, in common practice—of trauma treatment.
The process of gaining acceptance as an evidence-based treatment is inten-
sive and can be further inhibited by the fact that scientific research institutions
seldom fund unproven treatments, limiting opportunity for expansion in the
field (van der Kolk, cited in Wylie, 2004). However, innovative treatments
persist and are implemented with legions of clients, amassing anecdotal and
clinical evidence of relative efficacy.
Unfortunately, the opportunity costs inherent in emerging treatments are
not only born by clients, but considerable financial cost associated with training
for many of these therapies is covered by clinicians looking to expand their
expertise (McCaslin, 2009). The limited time and funds available to clinicians
only increase the importance of committing to well-chosen treatment modalities.
Emerging Trauma Therapies: Critical Analysis 787
As clinicians face the daunting task of discerning which treatments warrant
implementation and which might be best renounced, translational studies and
aggregation of existing sources are needed to tip the balance in favor of treat-
ment selection based on information rather than intuition. Still, with many
treatment options, including those in this analysis, clinicians will be hard-pressed
to discover a definitive evaluation of efficacy and might need to rely on clinical
judgment ultimately to reach their own verdict.
In regard to research and development of new approaches, critical discus-
sion is needed to address the process by which treatments gain legitimacy and
the validity of outcome measures that carry the most weight in consideration of
efficacy in this field. Dismantling studies are more broadly prescribed to enlarge
our understanding of what common elements serve particular populations and
diagnoses, and greater attention to generalizability, including application of
treatment with diverse populations and cooccurring disorders, is of increasing
importance. Finally, let Pignotti and Thyer’s(2012) findings of widespread, but
unexamined, use of novel treatments by trauma therapists serve as a cautionary
note. The field of trauma specialization might necessitate innovation, diversity,
and the willingness to straddle conflicting findings pertaining to controversial
treatments. However, unstudied application of untested treatments ought not to
supplant critical judgment in work with this most vulnerable of populations.
ACKNOWLEDGMENTS
The author gratefully acknowledges support from the University of Wisconsin
Madison School of Social Work and Dr. Tally Moses.
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