The cognitive components of Clinical EFT are drawn from CBT and exposure therapy. A typical sequence in the treatment of PTSD might be to have the client vividly recall details of a traumatizing event (exposure) while pairing the memory with emotionally neutral statements (cognitive reframing). To these cognitive and exposure elements, EFT adds the stimulation of a pre-established set of eight acupuncture points (acupoints) by tapping on them with the fingertips, a form of acupressure [34
]. For this reason, EFT is often referred to as simply “tapping”, and the EFT Manual [34
] outlines the process that has been validated in trials. The typical process involves, for example, a “Setup Statement” that consists of a reference to the traumatic event or related feelings combined with a self-acceptance statement and acupoint tapping. The wording of a typical Setup Statement might be: “Even though I vividly recall the horror of the bomb blast, I deeply and completely accept myself.” During the Setup Statement, the client taps on an acupoint on the side of the hand. For the remainder of the process, they gently tap with two fingers on the eight or more acupoints listed in the manual [34
] which include: start of the eyebrow, side of the eye, under the eye, under the nose, under the lips (chin crease), an inch under the collarbone, under the arm, and top of the head. During this time the client says a “Reminder Phrase” (typically a shortened version of the Setup Statement, e.g., one or two words such as “the horror”). To determine the impact of a given procedure, the intensity of the traumatic event is rated by the client using a Subjective Units of Distress (SUD) rating [35
], an 11-point Likert scale ranging from 0 (no distress) to 10 (maximum distress). These ratings, which may be taken numerous times during a single session, guide the therapist in determining the next treatment step.
Six comparative studies and a meta-analysis have addressed the question of whether acupoint tapping is an essential ingredient for the favorable outcomes reported following EFT treatments, or whether the cognitive, exposure, and non-specific therapeutic elements of the protocol are the primary active ingredients [36
]. Otherwise identical protocols with and without the acupoint tapping component were compared, and those which included tapping produced a significantly larger effect size than those with the other components but without tapping.
2.1. Changes in Biological Markers Following EFT Treatments
As might be expected from a therapy that includes a strong somatic component, measurable changes in biological markers have been found following EFT treatments. Hormonal shifts have been identified, including reductions in cortisol production that were statistically greater than cortisol reductions following a supportive counselling session [37
]. Changes in blood flow patterns within the brain have been identified in pre- and post-treatment fMRI readings [38
]. Studies examining the epigenetic effects of EFT treatment have found regulation of a range of genes related to health and mental health [37
]. For instance, a one-hour EFT psychotherapy session found that EFT was associated with the regulation of 72 genes, including those involved in learning and memory, regeneration of neural white matter, enhanced synaptic connectivity, neuronal survival after DNA damage, tumor suppression, insulin regulation, heightened immunity, inflammation, and antiviral activity [39
Evidence demonstrating the effectiveness of EFT and other acupoint psychotherapies has steadily increased in recent years. A systematic review of literature through April 2012 [41
] identified 51 outcome studies, including 18 randomized controlled trials (RCTs). Six years later, more than 100 clinical trials, with nearly half being RCTs, have consistently shown EFT to produce positive clinical outcomes (available from the online database maintained at www.Research.EFTuniverse.com
). The approach has also been the subject of more than 40 peer-reviewed concept papers and systematic reviews which have established it as an evidence-based treatment for a range of disorders [42
]. For instance, meta-analyses of EFT for anxiety [43
], depression [44
], and PTSD [45
] each found large effect sizes (Cohen’s d or Hedge’s g above 0.8).
A core clinical dilemma when treating PTSD is that traumatic memories need to be addressed and processed in order for recovery to occur, but approaching these memories runs the risk of re-traumatization and resulting exacerbation of symptoms [47
]. Moreover, traumatic memories are stored differently from autobiographical memory, being more in the form of sensory-motor reliving of the traumatic experience, and often in an unintegrated mode that is not yet mediated via language [17
]. Clinical EFT contains inherent procedural elements that are designed to minimize the danger of re-traumatization by approaching the traumatic memory in graduated steps and reducing arousal at each step, making EFT unusually gentle and safe. The approach leads clients into a position from which the traumatic memory can be narrated without emotional distress. A review of studies involving more than one thousand subjects found no “adverse events” to have been reported ([42
], p. 650). Based on the extensive research demonstrating Clinical EFT’s efficacy and safety for treating PTSD, the VA has designated it as a “generally safe therapy” [51
2.6. Group Treatment
In addition to individual treatment sessions, group EFT has also been found to be effective [52
]. A unique dynamic within EFT group sessions is called “Borrowing Benefits” (Church, 2013b). Borrowing Benefits refers to the way that a group member’s SUD level on a pre-selected personal issue can be lowered by simply watching and tapping along as another group member is guided by the therapist in front of the group. Several studies show that Borrowing Benefits produces significant clinical gains in participants [53
]. For instance, in a study of 218 veterans and their spouses, PTSD symptomology was evaluated before and after a seven-day retreat in which group sessions that utilized Borrowing Benefits were one of the core therapeutic activities [55
]. Prior to participating in the retreat, 83% of the veterans were above the PTSD cutoff on a symptom checklist; following the retreat, this had been reduced to 28%. For the spouses, 29% were in the PTSD range prior to the retreat; 4% following the retreat.
2.7. Online, App, and Telemedicine Treatment Sessions
In a study of individuals suffering from fibromyalgia, participants were treated entirely online using an EFT protocol [56
]. Significant improvements were found in anxiety, depression, and pain. Another study compared EFT delivered via face-to-face sessions with EFT delivered via telephone with a group of veterans reporting clinical symptoms that fall above the PTSD threshold [57
]. The in-person sessions produced significantly stronger outcomes (91% symptom reduction to below the PTSD range vs. 67% for the telephone sessions). While a 67% recovery rate might not be optimal, it is superior to recovery rates identified in meta-analyses of psychopharmacology and in-office talk therapy studies. For instance, a comparison of meta-analytic reviews showing large effect sizes in treating PTSD for cognitive therapies (Hedge’s g = 1.63), exposure therapies (1.08), EMDR (1.01), and the medication Topiramate (1.20) [45
]. In contrast, six of the seven studies they reviewed of EFT treatments for PTSD exceeded each of these effect sizes, and all seven showed a large effect. In any case, the preliminary evidence from online and telephone applications of EFT indicates that psychological improvement appears to result from such remote interventions.
Self-guided online programs for applying EFT in the treatment of PTSD are also available. In addition to providing veterans with access to practitioners of Clinical EFT, the web site of the Veterans Stress Project (www.StressProject.org
, a program of the National Institute for Integrative Healthcare) hosts a virtual interactive therapy program called Battle Tap [58
]. Battle Tap allows veterans to log on and conduct tapping sessions at the time and place of their choosing and with complete anonymity. After entering the site, they describe their concerns, which the software then integrates into a customized Setup Statement. They are then guided via video sessions recorded with other veterans in which they use Borrowing Benefits to reduce PTSD symptoms. Battle Tap is supplemented by a variety of PTSD apps and other resources recommended by APA Division 56 (Trauma Psychology, https://www.apatraumadivision.org/793/veteran-resources.html#apps
). The Battle Tap web site will also refer veterans to EFT apps which are currently under development.
2.8. Simultaneous Treatment of PTSD and Comorbid Conditions
Post-traumatic stress disorder is typically comorbid with other diagnoses, most often depression, anxiety, substance dependence or abuse, or chronic pain [15
]. Emotion Freedom Technique studies examining the relationships among PTSD and co-morbid conditions have found that reductions in PTSD symptoms correlate with reductions in anxiety, depression, and pain [54
]. When veterans have been successfully treated for PTSD, levels of traumatic brain injury (TBI) symptoms have also been reduced [60
]. Emotion Freedom Technique group treatments of PTSD using the Borrowing Benefits method also found simultaneous reductions in depression and anxiety [53