Efficacy of Emotional Freedom Techniques (EFT) or

Thought Field Therapy (TFT) forAnxiety: A narrative systematic

reviewAdam Boughey MSc, MBPsS, RN

Trainee Health Psychologist | Research Associate | Registered Nurse

A narrative what…!?

A ‘systematic review’ is a robust and detailed review of literature within a particular area of

interest.Why not just do a literature review?

A literature review may be open to bias in only identifying sources of information that are either

easily available or in highlighting only certain aspects of that information, e.g., positive

findings.

Key components• Focused on question.• Planned.• Exhaustive.

– Searches.– Reviewing studies.

• Impartial in presenting evidence.

• Synthesis of data/combining findings.

Let’s talk anxiety!

State of psychological uneasiness and

physiological tension focused on

apprehension (Colman, 2006).

Energy psychology for anxietyWe know that EFT (and TFT) is helpful (Feinstein, 2008, 2012) for conditions such as:• Post-traumatic stress disorder (PTSD).• Various phobias, and psychiatric diagnoses.• Anxiety.Of the above, most people would likely identify with anxiety

on some level.People might be unable to remove themselves from the

anxiety provoking situation/stimulus and so a self-management technique might appeal!

The challenge of reviewing anxiety systematically

• Anxiety is complicated!• Studies examining EFT/TFT often include outcome

measures such as Subjective Units of Distress Scale (SUDS).– Such measures might constitute a focus on components of

psychological anxiety, given the measure of disturbance/distress.

– Does one include studies with SUDS in the review?!

• Focus given to studies where there was a clear focus on a particular type of anxiety, which might have included SUDS.

My original plan• Focus on academic anxiety:

– Taking tests/examinations.• 3 papers: Benor et al. (2009); Jain and Rubino (2012);

Sezgin and Özcan (2009).

• Further research/consideration:– Academic anxiety may comprise ‘public speaking’:

• 4 papers: Boath et al. (2012, 2013); Jones et al. (2011); Schoninger and Hartung (2010).

• Only 7 papers!? More research:– 3 papers with anxiety measure at EFT conferences.

• Church and Brooks (2010); Palmer-Hoffman and Brooks (2011); Rowe (2005).

Story so far…

• 10 papers:– Test anxiety (3).– Public speaking anxiety (4).– ‘General anxiety’ (psychological distress) (3).

• More research revealed a further 4 papers also with outcome measures of anxiety:– WHEE (hybrid of EFT: EMDR + EFT) (Bair, 2008).– EFT on stress biochemistry (Church et al., 2012).– TFT for psychiatric disorders (Sakai et al., 2001).– EFT for dental anxiety (Temple & Mollon, 2011).

Challenges

The initial approach to systematic review was, at times, not as systematic as I would have hoped,

compounded by:• The lack of papers using EFT/TFT for a specific

form of anxiety (not best use of time to systematically review only 3 papers).

• My own lack of experience in systematic reviewing.– I did pass the work at doctorate level, however

ANXIETY

General Anxiety

Public Speaking Anxiety

Academic Anxiety

Challenge of being systematic

Methodology

• Inclusion criteria:– In English.– Aiming to investigate effect of EFT or TFT in

attenuating anxiety.– With both baseline and outcome measures of

anxiety (or psychological distress, e.g., SA-45).• Exclusion criteria:

– Commentaries, interviews, editorials, case studies, general information on EFT or TFT.

Methodology

• Search strategy:– All accessible (and relevant) online databases:

• Web of knowledge, ProQuest, ScienceDirect, SPORTDiscus, Swetswise, Cochrane, CINAHL, PsycARTICLES/INFO, Innovative Practice in Higher Education (IPiHE), Energy Psychology Journal, www.eftuniverse.com, www.tftfoundation.org.

– Consulted local experts in EFT (Liz Boath, Tony Stewart, and colleagues).

Initial Search(n = 381)

Duplicates (n = 97)

Non-applicable papers (n = 92)

Reviews (n = 40)

Everything else(n = 71)

Other than anxiety (n = 65)

Remaining papers (n = 16)(unable to obtain 2 papers)

Commentaries (n = 14)Interviews (n = 2)Editorials (n = 9)General information (n = 35)Case studies (n = 6)Other than EFT or TFT (n = 5)

Methodology

Phew! I’m glad that’s over!

3 RCTs1 NRCT2 CBAs1 HCT7 BAs

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MediumLowLow & MediumLowLow

Research designsBased on Reeves et al. (2008) – Cochrane Collaboration

Analysis

Narrative review

What’s that?

Reviewing the studies and summarising the findings in words, rather than statistically

combining the findings (average differences) and reporting a statistical effect/result.

Analysis

No meta-analysis? Tut-tut • Studies had not only different measures of

anxiety but also different types of anxiety.• Too much variation in the study

design/method.• Questionable results?

– Danger of statistically pooling results from diverse non-randomised studies (Sterne, Egger, & Moher, 2008).

Synthesis

• 1358 participants.– 1112 non-clinical sample volunteers.

• 525 attendees at EFT conferences.

• 216 patients receiving mental health/behavioural care.

• 30 participants receiving dental treatment presenting with dental anxiety.

Synthesis• Remaining 587 participants.

– Test anxiety:• High school students (n = 70).• College and university students (n = 183).

– Public speaking anxiety:• Third year university students (n = 67).• University students and staff (n = 36).• General public (n = 48).

– Graduate research:• General public (n = 100).

– Free cortisol test:• General public (n = 83).

ResultsTest anxiety (TA)

• Significant decrease in TA for WHEE and EFT (more so than CBT).

• TA significantly decreased for EFT and progressive muscular relaxation but more so for EFT.

• TA significantly decreased for both EFT and diaphragmatic breathing compared to no treatment.

(p < 0.05, i.e., less than 5% chance of the result occurring by chance)

ResultsDental anxiety

• Significant decrease in subjective distress (reduction of ≥ 4 points [moderate distress] on scale).

• Were not allowed to tap on face!

ResultsPublic speaking anxiety (PSA)

• Significant decrease in PSA for groups using EFT or TFT.

• EFT significantly more effective than control (wait-list).

• EFT improves speaker confidence but does not affect communication apprehension (nerves still remain).

• TFT increases ‘positive anticipation’ prior to public speaking.

ResultsOther studies

• EFT conferences:– Significant effects of EFT in reducing psychological

distress.• Heart rate synchronisation (similar heart rates

of participants to the therapist):– Possible indications of energy work.

• Salivary cortisol:– Significant reductions in salivary cortisol for EFT

use.

Discussion• Both EFT and TFT appear effective in

attenuating anxiety.• EFT has given rise to other modalities (e.g.,

matrix reimprinting [MR]).– Stewart et al., (2013a) conducted a service

evaluation for MR on the NHS, finding significant decreases in psychological anxiety and increases in well-being and self-esteem.

Discussion• Cost-effectiveness:

– The reduced clinical time required to help people with anxiety is beneficial. EFT on the NHS requires ~5 sessions to be effective (Stewart et al., 2013b), compared to the average of 6-20 sessions of CBT, depending on condition/severity (NICE, 2008).

Final thoughts and reservations• Energy flow throughout the body is a hotly debated

topic between both academics and clinicians!– McCaslin (2009) states the basis of energy flow is

unsubstantiated.– Pignotti (2005) highlights, from using TFT-VT (Voice

Technology) no significant differences between two groups subjective distress even when ‘true’ and sham TFT points were used.

• Issues of “proprietary trade secrets” (Pignotti, 2005, p. 72) leaving any researcher sceptical of extraordinary claims.

– Issue of small sample sizes and poor research designs.

Final thoughts and reservations• 39% (525 of 1358) participants were attendees at EFT

conferences.– If a person has an interest in a therapy and has committed

their working life to that therapy, one may not be surprised if that therapy is of benefit to that person.

• Could the positive effects of energy psychology techniques be due to:– Contact with another human in one’s time of distress?– Reassurance?– Psychological affirmation.– Affecting the flow of energy?

The future…

Establishing mechanisms of action.

To adhere to evidence-based practice, not really ethical to offer a treatment purported to be effective, and not

addressing the mechanics of that treatment.

The future…• Gilomen and Lee (2015) meta-analysis:

– 18 RCTs: psychological distress | EFT, TFT, or acupoint tapping.

– Quality: Used Gold Standard (GS) Scale (7 quality categories).

– Hedge’s g (standardised mean difference): difference in average score (post-test) between intervention and control group, then dividing this into the standard deviation (the spread of scores).

• Similar to Cohen’s d, but better estimate in smaller samples.

The future…• Gilomen and Lee (2015) meta-analysis:

– Results: • Moderate effect size (difference in average score between

treatment and control): Hedge’s g = -0.66.• No significant relationship between treatment time and

effect size.– Discussion:

• Issues with randomisation methods and assessors being blind to treatment conditions (bias).

• EFT appears to have some moderate effect.• Future studies need to compare tapping vs. no tapping!• Test mechanisms of action – do not just offer in the hope of

it being effective to service more people.

Conclusions and future directions• EFT/TFT appear effective for anxiety.

– If a person finds a technique effective, does it really matter how that technique works?

Yes! No!

Who’s going to pay? Great Not

me

Further research/cr

edibility

Discovery of action

References• Bair, C. C. (2008). The heart field effect: Synchronization of healer-subject heart rates in energy therapy. Advances in Mind-

Body Medicine, 23, 10-21.• Benor, D. J., Ledger, K., Toussaint, L., Hett, G., & Zaccaro, D. (2009). Pilot study of Emotional Freedom Techniques, wholistic

hybrid derived from eye movement desensitization and reprocessing and Emotional Freedom Technique, and cognitive behavioral therapy for treatment of test anxiety in university students. Explore: The Journal of Science and Healing, 5, 338-340. doi:10.1016/j.explore.2009.08.001

• Boath, E. H., Stewart, A., & Carryer, A. (2012). Tapping for PEAS: Emotional Freedom Technique (EFT) in reducing presentation expression anxiety syndrome (PEAS) in university students. Innovative Practice in Higher Education, 1(2), 1-11.

• Boath, E. H., Stewart, A., & Carryer, A. (2013). Tapping for success: A pilot study to explore if Emotional Freedom Techniques (EFT) can reduce anxiety and enhance academic performance in university students. Innovative Practice in Higher Education, 1(3), 1-13.

• Church, D., & Brooks, A. J. (2010). The effect of a brief Emotional Freedom Techniques self-intervention on anxiety, depression, pain, and cravings in health care workers. Integrative Medicine, 9, 40-43.

• Church, D., Yount, G., & Brooks, A. J. (2012). The effect of Emotional Freedom Techniques on stress biochemistry: A randomized controlled trial. Journal of Nervous and Mental Disease, 200, 891-896. doi: 10.1097/NMD.0b013e31826b9fc1

• Colman, A. M. (2006). Oxford dictionary of psychology. New York: Oxford University Press Inc.• Feinstein, D. (2008). Energy psychology: A review of the preliminary evidence. Psychotherapy Theory, Research, Practice,

Training, 45, 199-213. doi: 10.1037/0033-3204.45.2.199• Feinstein, D. (2012). Acupoint stimulation in treating psychological disorders. Evidence of efficacy. Review of General

Psychology, 16, 364-380. doi: 10.1037/a0028602• Gilomen, S. A., Lee, C. W. (2015). The efficacy of acupoint stimulation in the treatment of psychological distress: A meta-

analysis. Journal of Behavior Therapy and Experimental Psychiatry, 48, 140-148.

References• Jain, S., & Rubino, A. (2012). The effectiveness of Emotional Freedom Techniques for optimal test performance. Energy

Psychology: Theory, Research, and Treatment, 4, 15-25. doi: 10.9769.EPJ.2012.4.2.SJ• Jones, S. J., Thornton, J. A., & Andrews, H. B. (2011). Efficacy of Emotional Freedom Techniques (EFT) in reducing public

speaking anxiety: A randomized controlled trial. Energy Psychology: Theory, Research, and Treatment, 3, 19-32. doi: 10.9769.EPJ.2011.3.1.SJJ

• McCaslin, D. L. (2009). A review of efficacy claims in energy psychology. Psychotherapy Theory, Research, Practice, Training, 46, 249-256. doi: 10.1037/a0016025

• National Institute for Health and Clinical Excellence (NICE). (2008). Cognitive behavioural therapy for the management of common mental health problems: Commissioning guide. Retrieved from http://www.nice.org.uk/media/878/f7/cbtcommissioningguide.pdf

• Palmer-Hoffman, J., & Brooks, A. J. (2011). Psychological symptom change after group application of Emotional Freedom Techniques (EFT). Energy Psychology: Theory, Research, and Treatment, 3, 33-38. doi: 10.9769.EPJ.2011.3.1.JPH

• Pignotti, M. (2005). Thought Field Therapy Voice Technology vs. random meridian point sequences: A single-blind controlled experiment. The Scientific Review of Mental Health Practice: Objective Investigations of Controversial and Unorthodox Claims in Clinical Psychology, Psychiatry, and Social Work, 4, 38-47.

• Reeves, B. C., Deeks, J. J., Higgins, J. P. T., & Wells, G. A. (2008). Including non- randomized Studies. In J. P. Higgins and S. Green (Eds.). Cochrane handbook for systematic reviews of interventions (pp. 13.1-13.34). Chichester, UK: John Wiley & Sons, Ltd.

• Rowe, J. (2005). The effects of EFT on long-term psychological symptoms. Counseling and Clinical Psychology Journal, 2, 104-111.

• Sakai, C., Paperny, D., Mathews, M., Tanida, G., Boyd, G., Simons, A., ... Nutter, L. (2001). Thought Field Therapy clinical applications: Utilization in an HMO in behavioral medicine and behavioral health services. Journal of Clinical Psychology, 57, 1215- 1227.

References• Schoninger, B., & Hartung, J. (2010). Changes on self-report measures of public speaking anxiety following treatment with

Thought Field Therapy. Energy Psychology: Theory, Research, and Treatment, 2, 13-26. doi: 10.9769.EPJ.2010.2.1.BS• Sezgin, N., & Özcan, B. (2009). The effect of progressive muscular relaxation and Emotional Freedom Techniques on test

anxiety in high school students: A randomized controlled trial. Energy Psychology: Theory, Research, and Treatment, 1, 23-29. doi: 10.9769.EPJ.2009.1.1.NS

• Sterne, J.A., Egger, M., & Moher, D. (2008). Addressing Reporting Biases. In J.P.T. Higgins and S. Green (Eds.). Cochrane Handbook for Systematic Reviews of Interventions (pp. 10.1-10.33). Chichester, UK: John Wiley & Sons, Ltd.

• Stewart, A., Boath, E. H, Carryer, A., Walton, I., & Hill, L. (2013b). Can Emotional Freedom Techniques (EFT) be effective in the treatment of emotional conditions? Results of a service evaluation in Sandwell. Journal of Psychological Therapies in Primary Care, 2, 71-84.

• Stewart, A., Boath, E. H, Carryer, A., Walton, I., Hill, L., Phillips, D., Dawson, K. (2013a). Can matrix reimprinting be effective in the treatment of emotional conditions in a public health setting? Results of a U.K. pilot study. Energy Psychology: Theory, Research, and Treatment, 5, 1-6. doi: 10.9769.EPJ.2013.5.1.AS.EB.AC.IW.LH.DP.KD

• Temple, G. P., & Mollon, P. (2011). Reducing anxiety in dental patients using Emotional Freedom Techniques (EFT): A pilot study. Energy Psychology: Theory, Research, and Treatment, 3, 53-56. doi: 10.9769.EPJ.2011.3.2.GPT

Thank you for listening

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