A Randomized Controlled Comparison of Emotional Freedom Technique … · 2020-01-09 · ORIGINAL ARTICLE A Randomized Controlled Comparison of Emotional Freedom Technique and Cognitive-Behavioral

ORIGINAL ARTICLE

A Randomized Controlled Comparison of EmotionalFreedom Technique and Cognitive-Behavioral Therapyto Reduce Adolescent Anxiety:A Pilot Study

Amy H. Gaesser, PhD,1 and Orv C. Karan, PhD2

Abstract

Objective: The objective of this pilot study was to compare the efficacy of Emotional Freedom Techniques(EFT) with that of Cognitive-Behavioral Therapy (CBT) in reducing adolescent anxiety.

Design: Randomized controlled study.Settings: This study took place in 10 schools (8 public/2 private; 4 high schools/6 middle schools) in 2

northeastern states in the United States.Participants: Sixty-three high-ability students in grades 6–12, ages 10–18 years, who scored in the moderate

to high ranges for anxiety on the Revised Children’s Manifest Anxiety Scale-2 (RCMAS-2) were randomlyassigned to CBT (n = 21), EFT (n = 21), or waitlist control (n = 21) intervention groups.

Interventions: CBT is the gold standard of anxiety treatment for adolescent anxiety. EFT is an evidence-based treatment for anxiety that incorporates acupoint stimulation. Students assigned to the CBT or EFTtreatment groups received three individual sessions of the identified protocols from trained graduate counseling,psychology, or social work students enrolled at a large northeastern research university.

Outcome measures: The RCMAS-2 was used to assess preintervention and postintervention anxiety levels inparticipants.

Results: EFT participants (n = 20; M = 52.16, SD = 9.23) showed significant reduction in anxiety levelscompared with the waitlist control group (n = 21; M = 57.93, SD = 6.02) ( p = 0.005, d = 0.74, 95% CI [-9.76,-1.77]) with a moderate to large effect size. CBT participants (n = 21; M = 54.82, SD = 5.81) showed reductionin anxiety but did not differ significantly from the EFT ( p = 0.18, d = 0.34; 95% CI [-6.61, 1.30]) or control( p = 0.12, d = 0.53, 95% CI [-7.06, .84]).

Conclusions: EFT is an efficacious intervention to significantly reduce anxiety for high-ability adolescents.

Keywords: Emotional Freedom Technique, randomized controlled trial, adolescent anxiety, schools, gifted

Introduction

Of the approximately 50.5 million school-age chil-dren from pre-K through 12th grade in the United States,

over 5 million struggle with the negative effects of anxiety,1

including up to 2.5 million who refuse to go to school and/orparticipate in parts of their school day.2 Anxiety impedesconcentration, unsettles behavior, and interferes with per-

ception, frustrating the optimal functioning of students.3–8

Cognitive resources of those affected are diverted from in-formation processing and creative endeavors,9 which inhibitsdevelopment of abilities and talents. While research has in-dicated that the adverse effects of anxiety on performance canbe reduced or eliminated with the use of effective re-sources,10 excessively high caseloads of school counselors,psychologists, and social workers, as well as scheduling

1Department of Educational Studies, Counseling and Development Program, Purdue University, West Lafayette, IN.2Department of Educational Psychology, Counseling Program, University of Connecticut, Storrs, CT.

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINEVolume 00, Number 0, 2016, pp. 1–7ª Mary Ann Liebert, Inc.DOI: 10.1089/acm.2015.0316

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difficulties, limit the amount of time available for theseprofessionals to provide individual counseling support longterm.11–13

Cognitive-Behavioral Therapy (CBT) is the gold standardof treatment for adolescent anxiety; this therapy usesevidence-based techniques to help clients cognitively re-frame their interpretations and neutralize their psychologicaland emotional responses to present stimuli through aware-ness building and systematic desensitization processes.14

One meta-analyses on the use of CBT to treat adult anxietyreported moderate to large effect sizes for panic disorder(effect size range of 1.53–1.02), social anxiety disorder(effect size range of 1.75–0.89), and generalized anxietydisorder (effect size range of 0.92–2.26).15 Similarly, an-other meta-analysis examined CBT alone to treat anxiety(average effect size of 0.82 95% CI [0.63, 1.00]) comparedwith CBT with pharmacology (average effect size of 0.3395% CI [-0.02, 0.67]).16 Additionally, a meta-analysis in-vestigating the effectiveness of psychotherapy for childhoodanxiety revealed an overall mean treatment effect of 0.86.17

Conversely, while the use of CBT for anxiety is well es-tablished, research suggests that traditional interventionshave limited success in treating adolescent anxiety in the longterm.18–21 Studies have indicated that many treated patientscontinued to be symptomatic when sessions ended;22 at least50% of participants were nonresponsive to treatment,23 andan even greater percentage continued to need at least onepsychotropic medication trial and/or continued outpatienttherapy.24 Effective treatment interventions are needed toreduce anxiety and help students to develop effective man-agement strategies.

Concurrently, growing evidence supports EmotionalFreedom Techniques (EFT) as an efficacious treatment foranxiety in adults.25–28 Scholars have identified EFT, pro-gressive muscle relaxation, autogenic training, relaxationresponse, biofeedback, EFT, guided imagery, diaphragmaticbreathing, transcendental meditation, CBT, and mindfulness-based stress reduction as evidence-based techniques to ad-dress stress.29,30 Results of a meta-analysis investigating EFTas an intervention for anxiety revealed large effects sizescompared with controls in both adults and children. Thecombined pre–post effect size for the EFT treatment groupswas 1.23 (95% CI [0.82, 1.64]; p < 0.001), and the effect sizefor combined controls was 0.41 (95% CI [0.17, 0.67];p = 0.001).31 Research has examined diaphragmatic breathingand EFT interventions for anxiety and reported large posttestbetween-group effect sizes (Subjective Units of DistressScale, d = 1.11; Beck Anxiety Inventory, d = 0.94; BehavioralApproach Test, d = 0.89),32 as well as improvements in boththe diaphragmatic breathing and EFT groups with gainsmaintained on follow-up.33 Furthermore, a systematic reviewof EFT research in adults also indicated a significant reduc-tion of symptoms long-term with fewer required sessions thantraditional CBT.34

Initial studies examining EFT for adolescent anxiety havesupported EFT as an evidence-based intervention. This re-search has indicated that EFT reduces anxiety related tomathematics35 and significantly decreases test anxiety( p<0.05).36 Additionally, EFT significantly reduces the in-tensity of traumatic memories in abused adolescents (Impactof Event Scale scores: (preintervention mean = 36, SD – 4.74,postintervention mean = 3, SD – 2.60, p < .001).37 The current

quantitative study extends important research on the efficacyof EFT to treat adolescent anxiety, especially in school set-tings. Additionally, it contributes to the existing research onthe efficacy of EFT compared with CBT for treating anxietyby using standardized, research-based treatment protocols forboth CBT and EFT and by including a waitlist control groupto more fully assess treatment outcomes.

Materials and Methods

Participants

Sixty-three students (18 male, 45 female; age 10–18 years)who scored at moderate to high anxiety levels (i.e., 61–70 and‡ 71, respectively) on the Revised Children’s Manifest An-xiety Scale-2 (RCMAS-2)38 participated. All were engagedin high-ability education programs, in grades 6–12, in publicor private schools in two northeastern states. Participantscame from a total of 10 schools and were within the top 15%–20% of their peer groups academically. Of these schools, 8were public and 2 were private. Concurrently, 4 were highschools and 6 were middle schools.

Procedures

This study was designed to meet the American Psycholo-gical Association (APA) Division 12 quality control criteria39,40

and the Consolidated Standards for Reporting Trials (CON-SORT) criteria.41 Schools throughout one northeastern statewere invited to collaborate in the recruitment for this study.Ten schools from two northeastern states expressed interestand distributed the information forms to students from theirhigh-ability programs and these students’ parents. Additionally,the original state’s association for the gifted posted a studyrecruitment announcement on their website.

The pretreatment RCMAS-2 was administered to all in-terested students who, depending on age, consented or as-sented and received parent/guardian permission to participateafter they attended an informational meeting explaining thestudy. Through use of permuted randomized assignment,participants identified as having moderate to high levels ofanxiety on the pretreatment RCMAS-2 were randomly as-signed to one of three treatment groups: (1) CBT (n = 21), (2)EFT (n = 21), or (3) waitlist control (n = 21).

Permuted randomization allowed for restricted distributionof participants across the assignment of intervention groups,with equity maintained in the number of participants assignedto each group.42 Additionally, it ensured that the order inwhich groups were assigned each time was randomized tominimize assignment bias. A restricted assignment modelwas used to force equal sample sizes across groups as par-ticipants joined the study, as recommended for studies withfewer than 200 participants.43 To minimize potential re-searcher bias negatively affecting outcomes, RCMAS-2sadministered before and after the intervention were scored bya blinded independent assessor. Before participant assign-ment, graduate students taking upper-level classes on coun-seling, psychology, or social work and enrolled in graduateprograms at a large northeastern research university had beenrandomly sorted into the CBT or EFT interventions and trainedin their respective protocols. Training including 6 hours ofinstruction on the assigned protocol, and then individualpractice sessions supervised by certified practitioners until

2 GAESSER AND KARAN

mastery of the assigned protocol was achieved. These practi-tioners used mastery checklists to determine when the graduatestudents achieved mastery.

Measures

Outcome measure. The RCMAS-2 was used to assesspre- and posttreatment anxiety levels in study participants.The RCMAS-2 is a 49-item questionnaire and one of themost extensively used anxiety scales for children;44 it hasadequate to excellent reliability and excellent validity.38

RCMAS-2 scores are reported as T-scores. RCMAS-2scores of 60 or lower are considered in the normal to lowrange, scores of 61–70 are considered in the moderate range,and scores of 71 or higher are considered in the high range.

Scores on the RCMAS-2 exhibited adequate to excellentreliability on the basis of Cronbach a estimates of totalanxiety (TOT) = 0.92 for internal consistency with a stan-dard error of the mean of –3, and test-retest reliability forTOT of r2 = 0.76.38 RCMAS-2 was determined to be a re-liable measure for anxiety across sex, grade level, and eth-nicity,38,45,46 as well as for high-ability children.47,48

Construct validity of the RCMAS-2 was supported byextensive factor analysis.49,50 Reynolds51 further confirmedconstruct validity by comparing convergent and divergentvalidity between the RCMAS and the State-Trait AnxietyInventory for Children (STAIC) and found a large correla-tion between the RCMAS and the STAIC Trait scale(r = 0.85; p < .001). Reynolds52 found a score correlation ofr = 0.78 between the RCMAS and the STAIC Trait scale forhigh-IQ children, providing additional support for validitywith this group. Validity has been further established withcorrelations between RCMAS scores and teacher-observedbehavior.53

Intervention protocols. Both the CBT and EFT protocolsused in this study were manualized, specific, replicable, andhad been used in previous research.

CBT helps clients to cognitively reframe their interpretationsand neutralize their psychological and emotional responses topresent stimuli through awareness building and systematicdesensitization processes.14 With repeated practice, successfuluse of CBT is achieved when the individual no longer experi-ences anxiety related to the original trigger. A brief form ofCBT based on the Coping Cat54 and the C.A.T. Project55 forchildren was used as the CBT protocol for this study.

EFT is an easily implemented strategy that uses suchtechniques as awareness building, exposure, reframing ofinterpretation, and systematic desensitization, while teach-ing the participant to self-stimulate protocol-identifiedacupoints (i.e., acupuncture points) by tapping.56,57 Theeffectiveness of acupuncture for treating anxiety has beenwell documented.58–60 Rather than using acupuncture nee-dles, EFT relies on the manual stimulation of the acupoints.A recent meta-analysis indicated that interventions usingacupoint stimulation had a moderate effect size (Hedge’sg = -0.66 95% CI [-0.99, -0.33]) in reducing symptoms.61

In EFT, the client stimulates the protocol-identified acu-points by tapping on them. Preliminary studies have sug-gested that tapping and other alternative ways of stimulatingacupuncture points to be as effective as acupuncture nee-dling.62 The EFT protocol and identified acupoints that were

used in this study are the ones recommended for researchpurposes by the Association for Comprehensive EnergyPsychology63 and identified in Supplementary Appendix A(Supplementary Data are available online at www.liebertpub.com/acm).

Fidelity of intervention mastery and implementation wasmonitored throughout the study by practitioners certified inthe respective modalities (CBT or EFT) through regularreviews of session briefs and audiotapes.

Data analysis

Permuted randomized assignment of study participants totreatment groups was used to support unbiased estimates of theaverage treatment effect.64 Treatment outcomes were assessedby using the RCMAS-2 posttreatment (TOTf) scores. A one-way between-groups analysis of covariance (ANCOVA) wasused to assess outcome differences across treatment groups onposttreatment RCMAS-2 TOT scores (TOTf) by using thepretreatment RCMAS-2 (i.e., TOTin) as the covariate. Theindependent variable was the type of treatment modality (i.e.,CBT, EFT, or control) received by the participants. The de-pendent variable was the posttreatment RCMAS-2 total(TOTf) scores. Posttreatment RCMAS-2 was administered toeach participant after the participant underwent three individ-ual skill development sessions in the assigned modality. A one-way between groups analysis of variance on TOTin confirmedthat groups were equal before treatment and a between-groupsANCOVA confirmed a strong covariance (Z2 = 0.23) betweenTOTin and TOTf. The analyses were completed using IBMSPSS Statistics for Macintosh (Version 22.0, Armonk, NY).

Results

Implementation

Delivery of intervention sessions. Participants assignedto CBT or EFT treatment groups received three individualsessions of the identified intervention from trained graduatestudents. Attrition was minimal, with only one participantassigned to EFT withdrawing from the study before begin-ning her sessions because of scheduling difficulties with herextracurricular activities.

Intervention sessions with participants occurred over a 5-month period. Most individual sessions occurred not lessthan 1 week or more than 2 weeks apart. Participants in boththe CBT and EFT groups received regular, individual in-tervention sessions from their assigned graduate student forthree sessions. These sessions occurred at a time mutuallyagreed upon by the graduate student, participant, and, whereapplicable, school and participant’s parent/guardian.

At the first individual session, the assigned graduatestudent shared the appropriate intervention protocol with theparticipant. Participants’ parents/guardians also received acopy of the assigned protocol. The graduate student andstudy participant then followed the steps outlined in therespective protocols over the period of the three sessions. Noadverse events occurred within any of the sessions. CBT andEFT participants completed the posttreatment RCMAS-2after completing their third individual session.

Post-intervention sessions. All RCMAS-2s throughoutthe study were scored by an independent blind assessor. The

RANDOMIZED CONTROLLED COMPARISON OF EFT AND CBT 3

waitlist control group received no intervention throughout theduration of the delivery of the individual CBT and EFT ses-sions. Upon completion of all individual CBT and EFT ses-sions, the waitlist control group completed their secondRCMAS-2 before receiving any treatment themselves. Thewaitlisted control participants were then offered an EFT groupintervention session using the EFT protocol. Research hassupported the effectiveness of a single session of EFT.27,37

Analysis

Table 1 provides the within-group pre/post means andstandard deviations. Treatment outcomes were measured byadministration of the RCMAS-2 after treatment and ana-lyzed by using ANCOVA, with pretreatment RCMAS-2scores serving as the covariate. A one-way, between-groupsANCOVA was conducted to compare treatment effectivenesson participants’ posttreatment anxiety level scores. TheANCOVA was computed on posttreatment RCMAS-2 TOTfscores with TOTin and intervention and the interaction(TOTin*intervention). The interaction term was not signifi-cant (F[2, 56] = 0.094; p = 0.911) and was removed from themodel. Preliminary checks were conducted to ensure thatthere was no violation of assumptions of normality, linearity,homogeneity of variances, homogeneity of regression slopes,and reliable measurement of the covariate. The Levene testshowed equality of variance ( p = 0.058) for the resultingmodel. TOTin was a significant covariate (F[1, 58] = 17.47;p < 0.001;Z2 = 0.23), explaining 23% of the variance in TOTfscores. Intervention was a significant factor (F[2, 58] = 4.186;p = 0.020; Z2 = 0.13) with a large effect size.

Students in the EFT treatment group (n = 20; M = 52.16,SD = 9.23) had significantly lower posttreatment anxietyscores than students in the control group (n = 21; M = 57.93,SD = 6.02) ( p = 0.005; d = .74; 95% CI [-9.76, -1.77]) witha moderate to large effect size. Students in the CBT group(n = 21; M = 54.82, SD = 5.81) had decreased anxiety scores,but they did not differ significantly from students in the EFTgroup ( p = 0.18; d = 0.34; 95% CI [-6.61, 1.30]) or controlgroup ( p = 0.12; d = 0.53; 95% CI [-7.06, .84]). During thepost hoc analysis, a Bonferroni-corrected a of p = 0.016 wasused to maintain a group error rate of 0.05.

Discussion

Both the CBT and EFT groups experienced reduced anx-iety in this study, although only the EFT group had a statis-tically significant decrease compared with the controlgroup. Results indicated that EFT is an efficacious interven-tion in school settings for reducing adolescent anxiety withina few sessions. The significant reduction in anxiety levels forthe EFT intervention group is consistent with a growing bodyof research evidence indicating that EFT is an efficacioustreatment for adolescent anxiety.31,35–37

Clinical implications are significant. School counselors,psychologists, and social workers often have limited timeand resources to effectively assist students struggling withanxiety and/or teach them effective stress managementstrategies. EFT is an evidence-based protocol to more rap-idly address issues of anxiety and stress in school settings.Helping students to develop effective, easily incorporatedanxiety and stress management tools, such as EFT, early intheir lives can support maximum development of students’well-being and talent potential, as well as prevent persistentdifficulties with impairment due to anxiety into adulthood.

Several factors may account for the significant reduction inanxiety experienced by participants in the EFT group. Thera-pies that incorporate a somatic component in the treatment ofstress and trauma have been gaining traction within clinicalpractice.65 The somatic intervention used in EFT and investi-gated in this study (i.e., the stimulation of acupoints) hasreceived substantial investigation.31,61 For example, whenacupoint tapping was introduced to exposure therapy proto-cols, the extinction of fear memories was accelerated.66 Fur-thermore, biophysical markers indicating a reduction in stressafter acupoint tapping have included decreased expression ofgenes implicated in the stress response,67 normalization ofbrainwave patterns,68,69 and hormonal changes associated withstress reduction.26 Strengths of tapping protocols in facilitatingmemory reconsolidation and the resulting depotentiation ofneural pathways that maintain intransigent emotional learningshave also been proposed.70 These physiologic shifts afteracupoint tapping may help explain the significant reduction inadolescent anxiety evidenced in the present study.

Limitations

This sample was limited to high-ability students from thenorthwestern United States. Furthermore, a post hoc analysisof power using G*power software found that the study wasunderpowered (38%), indicating that treatment effectivenessmay have been underassessed because of low sample size.Further study is needed with larger, heterogeneous samplesizes to assess generalizability.

Because the RCMAS-2 was administered both before andafter treatment and does not have a parallel form, test bi-asing was a concern; however, randomized assignment ofparticipants helped to minimize this concern. Additionally,analyses completed and outcomes of the TOTf in the waitlistcontrol group suggested that test biasing was not an issue inthis study.

Future directions

To more comprehensively assess treatment outcomes, re-sults of this pilot study support further research related to

Table 1. Within-Group Comparisons by Revised

Children’s Manifest Anxiety Scale-2Full Scale Scores

Variable Mean – SD

CBT (n = 21)Pretreatment 64.05 – 6.82Posttreatment 54.82 – 5.81

EFT (n = 20)Pretreatment 63.75 – 6.73Posttreatment 52.16 – 9.23

Control (n = 21)Pretreatment 61.62 – 5.95Posttreatment 57.93 – 6.02

SD, standard deviation.

4 GAESSER AND KARAN

treatment effectiveness that includes the following: (1) largersample that consists of both high- and average-ability stu-dents, (2) more treatment sessions, (3) additional outcomemeasures, and (4) additional intervals to assess posttreatmentoutcomes (e.g., 1 month, 6 months, and/or 1 year after treat-ment) to more fully assess generalizability of results seen.Biophysical markers, such as neuroimaging findings andcortisol level indicators, should also be included. Further, asimaging technology becomes more refined and advanced,research should be conducted to more fully assess the mech-anisms involved in acupoint stimulation during counseling.Finally, a comprehensive comparison of EFT to all relaxationinterventions would be beneficial.

Conclusions

Results of this study are consistent with findings fromprevious research and a meta-analysis showing that EFT isan efficacious, evidence-based treatment for adolescentanxiety. Additionally, the results indicate that EFT can beeffectively used in school settings to significantly reduceadolescent anxiety within a few sessions.

Acknowledgments

Implementation of this research was supported by fundingfrom two grants: one from the University of Connecticut($2000) and one from the Association for ComprehensiveEnergy Psychology ($8000). The content is solely the re-sponsibility of the authors and does not necessarily representthe official views of the University of Connecticut, theAssociation for Comprehensive Energy Psychology, or theNational Institutes of Health. The authors wish to thankthe Neag Center for Gifted Education and Talent Develop-ment for the use of their office space and assistance withrecruiting collaborating schools. They also gratefully ac-knowledge the guidance of Drs. Melissa Bray, Sally M.Reis, E. Jean Gubbins, James O’Neil, Joseph S. Renzulli,Lori Leyden, and Jaclyn Chancey during the design andimplementation stages; Catherine Ewing, LCSW, for herconsultation with the EFT training; research assistant Ste-phanie Murana for her assistance with data collection andentry; graduate students Mary Jane Bezares, Heather Casale,Marisa del Campo, Samantha Eisenberg, Kaitlin Gillard,Dawne Goodwin, Amanda Kanehl, Dina Menchetti, MayraReyes, Nilani Shankar, and Wen Zeng for their meticulousdelivery of the intervention protocols; the school and or-ganization contacts for their assistance with recruitment andcoordination of meetings at each school; and Yaping H.Anderson and Amy Yu for their assistance with manuscriptediting and formatting. Finally, they express their sincerethanks to the students and their parents who volunteeredtheir time to participate in this research.

Author Disclosure Statement

No competing financial interests exist.

References

1. Costello EJ, Mustillo S, Erkanli A, et al. Prevalence anddevelopment of psychiatric disorders in childhood and ad-olescence. Arch Gen Psychiatry 2003;60:837–844.

2. Anxiety and Depression Association of America. Schoolrefusal. Online document at: http://www.adaa.org/living-with-anxiety/children/school-refusal Accessed July 30,2015.

3. Bielock SL, Gray R. Why do athletes choke under pres-sure? In: Tenenbaum G, Eklund RC, eds. Handbook ofSports Psychology, 3rd ed. Hoboken, NJ: John Wiley &Sons, 2007:425–444.

4. Blanchette I, Richards A. The influence of affect on higherlevel cognition: a review of research on interpretation,judgement, decision making and reasoning. Cogn Emot2010;24:561–595.

5. Derakshan N, Eysenck MW. Anxiety, processing efficiency,and cognitive performance: new developments from atten-tional control theory. Eur Psychol 2009;14:168–176.

6. Eysenck MW, Derakshan N. New perspectives in atten-tional control theory. Pers Individ Diff 2011;50:955–960.

7. Hopko DR, Crittendon JA, Grant E, et al. The impact ofanxiety on performance IQ. Anxiety Stress Coping 2005;18:17–35.

8. Nieuwenhuys A, Oudejans RR. Anxiety and perceptual-motor performance: toward an integrated model of concepts,mechanisms, and processes. Psychol Res 2012;76:747–759.

9. Eysenck MW, Derakshan N, Santos R, et al. Anxiety andcognitive performance: attentional control theory. Emotion2007;7:336.

10. Eysenck MW. Attentional control theory of anxiety: recentdevelopments. In: Gruszka A, Matthews G, Szymura B, eds.Handbook of Individual Differences in Cognition: Attention,Memory, and Executive Control. New York: Springer, 2010:195–204.

11. Agresta J. Professional role perceptions of school socialworkers, psychologists, and counselors. Child Schools2004;26:151–163.

12. Carey J, Dimmitt C. School counseling and student out-comes: summary of six statewide studies. Profess SchoolCounsel 2012;16:146–153.

13. Lapan RT, Whitcomb SA, Aleman NM. Connecticut pro-fessional school counselors: college and career counselingservices and smaller ratios benefit students. Profess SchoolCounsel 2012;16:117–124.

14. Corey G. Theory and Practice of Counseling and Psy-chotherapy, 7th ed. Belmont, CA: Brooks/Cole, 2005.

15. Stewart RE, Chambless DL. Cognitive–behavioral therapyfor adult anxiety disorders in clinical practice: a meta-analysis of effectiveness studies. J Consult Clin Psychol2009;77:595.

16. Mitte K. Meta-analysis of cognitive-behavioral treatmentsfor generalized anxiety disorder: a comparison with phar-macotherapy. Psychol Bull 2005;131:785.

17. In-Albon T, Schneider S. Psychotherapy of childhoodanxiety disorders: a meta-analysis. Psychother Psychosom2006;76:15–24.

18. Compton SN, Walkup JT, Albano AM, et al. Child/ado-lescent anxiety multimodal study (CAMS): rationale, de-sign, and methods. Child Adolesc Psychiatry Ment Health2010;4:1.

19. Jansen M, van Doorn MM, Lichtwarck-Aschoff A, et al.Effectiveness of a cognitive-behavioral therapy (CBT)manualized program for clinically anxious children: studyprotocol of a randomized controlled trial. BMC Psychiatry2012;12:1–9.

20. Kessler RC, Chiu WT, Demler O, et al. Prevalence, se-verity, and comorbidity of 12-month DSM-IV disorders in

RANDOMIZED CONTROLLED COMPARISON OF EFT AND CBT 5

the National Comorbidity Survey Replication. Arch GenPsychiatry 2005;62:617–627.

21. Muris P, Broeren S. Twenty-five years of research onchildhood anxiety disorders: publication trends between1982 and 2006 and a selective review of the literature. JChild Fam Stud 2009;18:388–395.

22. Bernstein GA, Hektner JM, Borchardt CM, et al. Treatmentof school refusal: one-year follow-up. J Am Acad ChildAdolesc Psychiatry 2001;40:206–213.

23. Heyne D, Sauter FM, Van Widenfelt BM, et al. Schoolrefusal and anxiety in adolescence: non-randomized trial ofa developmentally sensitive cognitive behavioral therapy. JAnxiety Disord 2011;25:870–878.

24. Bernstein GA, Borchardt CM, Perwien AR, et al. Imipra-mine plus cognitive-behavioral therapy in the treatment ofschool refusal. J Am Acad Child Adolesc Psychiatry 2000;39:276–283.

25. Baker AH, Siegel L. Emotional Freedom Techniques (EFT)reduces intense fears: a partial replication and extension ofWells, Polglase, Andrews, Carrington, & Baker (2003).Energy Psychol Theory Res Treat 2010;2:13–30.

26. Church D, Yount G, Brooks AJ. The effect of emotionalfreedom techniques on stress biochemistry: a randomizedcontrolled trial. J Nerv Ment Dis 2012;200:891–896.

27. Rowe JE. The effects of EFT on long-term psychologicalsymptoms. Counsel Clin Psychol J 2005;2:104–115.

28. Wells S, Polglase K, Andrews HB, Carrington P, Baker EH.Evaluation of a meridian-based intervention, EmotionalFreedom Techniques (EFT), for reducing specific phobiasof small animals. J Clin Psychol 2003;59:943–966.

29. Varvogli L, Darviri C. Stress management techniques:evidence-based procedures that reduce stress and promotehealth. Health Sci J 2011;5:74–89.

30. Sojcher R, Perlman A, Fogerite S. Evidence and potentialmechanisms for mindfulness practices and energy psychol-ogy for obesity and binge-eating disorder. Explore J Sci Heal2012;8:271–276.

31. Clond M. Emotional freedom techniques for anxiety: asystematic review with meta-analysis. J Nerv Ment Dis2016;204:388–395.

32. Salas M, Brooks A, Rowe J. The immediate effect of a briefenergy psychology intervention (emotional freedom tech-niques) on specific phobias: a pilot study. Explore (NY)2011;7:155–161.

33. Jain S, Rubino A. The effectiveness of Emotional Free-dom Techniques (EFT) for optimal test performance: arandomized controlled trial. Energy Psychol J 2012;4:13–24.

34. Feinstein D. Acupoint stimulation in treating psychologicaldisorders: evidence of efficacy. Rev Gen Psychol 2012;16:364.

35. Aremu, A, Taiwo A. Reducing mathematics anxiety amongstudents with pseudo-dyscalculia in Ibadan through nu-merical cognition and emotional freedom techniques:moderating effect of mathematics efficacy. Afr J PsycholStudies Social Issues 2014;17:113–129.

36. Sezgin N, Ozcan B. The effect of progressive muscular re-laxation and Emotional Freedom Techniques on test anxietyin high school students: a randomized blind controlled study.Energy Psychol Theory Res Treat 2009;1:23–29.

37. Church D, Pina O, Reategui C, et al. Single-session re-duction of the intensity of traumatic memories in abusedadolescents after EFT: a randomized controlled pilot study.Traumatology 2012;18:73.

38. Reynolds CR, Richmond BO. RCMAS-2: Revised Chil-dren’s Manifest Anxiety Scale, 2nd ed. Los Angeles, CA:Western Psychological Services, 2008.

39. Chambless D, Baker MJ, Baucom DH, et al. Update onempirically validated therapies, II. Clin Psychol 1998;51:3–6.

40. Chambless DL, Hollon SD. Defining empirically supportedtherapies. J Consult Clin Psychol 1998;66:7.

41. Moher D, Schulz KF, Altman DG. The CONSORT state-ment: revised recommendations for improving the qualityof reports of parallel group randomized trials. BMC MedRes Methodol 2001;1, 2.

42. Friedman LM, Furberg C, DeMets DL. Fundamentals ofClinical Trials, 3rd ed. New York: Springer, 1998.

43. Shadish WR, Cook TD, Campbell DT. Experimental andQuasi-Experimental Designs for Generalized Causal In-ference. Belmont, CA: Wadsworth, 2002.

44. Silverman W, Treffers P. Bridging research and practice.In: Ollendick TH, March JS, eds. Phobic and AnxietyDisorders in Children and Adolescents. New York: OxfordUniversity Press, 2004:506–529.

45. Ang RP, Lowe PA, Yusof N. An examination of theRCMAS-2 scores across gender, ethnic background, andage in a large Asian school sample. Psychol Assess 2011;23:899.

46. Varela RE, Biggs BK. Reliability and validity of the Re-vised Children’s Manifest Anxiety Scale (RCMAS) acrosssamples of Mexican, Mexican American, and EuropeanAmerican children: a preliminary investigation. AnxietyStress Coping 2006;19:67–80.

47. Reynolds CR, Bradley M. Emotional stability of intellec-tually superior children versus nongifted peers as estimatedby chronic anxiety levels. School Psych Rev 1983;12:190–194.

48. Scholwinski E, Reynolds CR. Dimensions of anxietyamong high IQ children. Gift Child Q 1985;29:125–130.

49. Reynolds CR, Paget KD. Factor analysis of the revisedChildren’s Manifest Anxiety Scale for blacks, whites, males,and females with a national normative sample. J Consult ClinPsychol 1981;49:352.

50. Reynolds CR, Richmond BO. Factor structure and constructvalidity of ’What I think and feel’: the revised Children’sManifest Anxiety Scale. J Pers Assess 1979;43:281–283.

51. Reynolds CR. Concurrent validity of What I Think andFeel: The Revised Children’s Manifest Anxiety Scale. JConsult Clin Psychol 1980;48:774–775.

52. Reynolds CR. Multitrait validation of the Revised Chil-dren’s Manifest Anxiety Scale for children of high intelli-gence. Psychol Rep 1985;56:402.

53. Reynolds CR. Convergent and divergent validity of theRevised Children’s Manifest Anxiety Scale. Educat Psy-chol Measurements 1982;42:1205–1212.

54. Kendall PC, Hedtke KA. Cognitive-Behavioral Therapy forAnxious Children: Therapist Manual, 3rd ed. Ardmore, PA:Workbook Publishing, 2006.

55. Kendall P, Choudbury M, Hudson J, et al. The C.A.T.Project manual for the Cognitive-Behavioral Treatment ofAnxious Adolescents. Ardmore, PA: Workbook Publishing,2002.

56. Craig G. The EFT Manual, 2nd ed. Santa Rosa, CA: EnergyPsychology, 2011.

57. Feinstein D. Energy Psychology Interactive: Rapid Inter-ventions for Lasting Change. Ashland, OR: Innersource,2004.

6 GAESSER AND KARAN

58. Bussell J. The effect of acupuncture on working memoryand anxiety. J Acupunct Meridian Stud 2013;6:241–246.

59. Eich H, Agelink MW, Lehmann E, et al. Acupuncture inpatients with minor depressive episodes and generalizedanxiety: results of an experimental study. Fortschr NeurolPsychiatr 2000;68:137–144.

60. Bae H, Bae H, Min B, et al. Efficacy of acupuncture indeducing preoperative anxiety: a meta-analysis. Evid BasedComplement Alternat Med 2014;2014:850367.

61. Gilomen SA, Lee CW. The efficacy of acupoint stimulationin the treatment of psychological distress: a meta-analysis.J Behav Ther Exp Psychiatry 2015;48:140–148.

62. Cherkin DC, Sherman KJ, Avins AL, et al. A randomizedtrial comparing acupuncture, simulated acupuncture, andusual care for chronic low back pain. Arch Intern Med2009;169:858–866.

63. Association for Comprehensive Energy Psychology.EFT protocol. Online document at: http://energypsych.org/displaycommon.cfm?an=1&subarticlenbr=132 AccessedOctober 12, 2012.

64. Rosenbaum PR. Observational Studies. New York: Springer-Verlag, 1995:8.

65. Van der Kolk B. The Body Keeps the Score. New York:Viking, 2014.

66. Harper M. Taming the amygdala: an EEG analysis of exposuretherapy for the traumatized. Traumatology 2012;18:61.

67. Church D, Yount G, Rachlin K, et al. Epigenetic effects ofPTSD remediation in veterans using clinical EFT (Emo-tional Freedom Techniques): a randomized controlled trial.Paper presented at the Association for ComprehensiveEnergy Psychology (ACEP) Conference; Reston, VA; May30, 2015.

68. Diepold JH Jr, Goldstein DM. Thought field therapy andQEEG changes in the treatment of trauma: a case study.Traumatology 2009;15:85.

69. Lambrou PT, Pratt GJ, Chevalier G. Physiological andpsychological effects of a mind/body therapy on claustro-phobia. Subtle Energies Energy Med 2003;14:239–251.

70. Feinstein D. How energy psychology changes deep emo-tional learnings. Neuropsychotherapist 2015;10:39–49.

Address correspondence to:Amy H. Gaesser, PhD

Department of Educational StudiesCounseling and Development Program

Purdue University100 N. University Street

West Lafayette, IN 47907

E-mail: [email protected]

RANDOMIZED CONTROLLED COMPARISON OF EFT AND CBT 7

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Tapping for success: A pilot study to explore if

Emotional Freedom Techniques (EFT) can reduce

anxiety and enhance academic performance in

University students

E. Boath, A Stewart & A Carryer

Staffordshire University

Corresponding Author: [email protected]

Learning itself is an intrinsically emotional business

(Claxton, 1999, p15)

Abstract

Emotional Freedom Technique (EFT), also known as tapping, is an emerging psychological intervention that has been used to treat a variety of conditions, including exam stress and public speaking anxiety.

Participants were a convenience sample of 52 3rd year Foundation Degree level students undertaking a Research Methods Module. The module included an assessed presentation, which was known to generate anxiety among students. The students were given a 15 minute assignment workshop. They then received a 15 minute lecture introducing EFT and were guided though one round of EFT focussing on their anxiety of public speaking. The students were assessed using the Subjective Units of Distress (SUDs) and the Hospital Anxiety and Depression Scale (HADS) pre and post EFT. The students were instructed that they could continue to use EFT at any time to reduce their anxiety regarding their assessed presentation. Immediately following their presentation, the students were invited to take part in a brief face- to-face interview to identify those who used EFT to explore their use of and feelings about EFT and to identify those who had chosen not to use EFT and explore their reasons for not choosing to use it.

Forty Six of the total sample of 52 students (88%) participated in the research. There was a significant reduction in SUDS (p=p<0.001), HAD (p = 0.003) and HAD Anxiety Subscale (p<0.001). There was no difference in the HAD Depression Subscale (p=0.67). The qualitative data were analysed using a framework approach which revealed the following three themes: helpfulness of EFT in reducing anxiety and staying calm and focussed; Using other complementary therapy skills; and their reasons for not using EFT.

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Despite the limitations of the study, the results suggest that EFT may be a useful addition to curricula for courses that include oral presentations and that using EFT to reduce presentation anxiety may enhance academic performance.

Introduction

A range of pedagogic, medical and psychological strategies have been used to enhance academic performance. Strategies include peer tutoring (Lidren & Meier, 1991), assistive technology (Goldius & Gotesman, 2010; Parent & Del Rio-Parent, 2008), identifying student achievement goals, student self efficacy and reducing class size (Fonollar et al., 2007). Some students with a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) have used to ADHD drugs to enhance academic performance, whereas others without a diagnosis of ADHD have taken these drugs illegally to enhance their performance (Murray et al, 2011).

Fear of public speaking is the single most common fear and up to 75% of people suffer from it (Furmark, 2002; Pollard & Henderson, 1998). Many students report high level of public speaking anxiety levels around assessed presentations. While a slightly increased level of anxiety may enhance performance, too much anxiety can have a detrimental effect (Cherry, 2010).

Emotional Freedom Technique (EFT; Craig, 2011) is a gentle psychological intervention that can be easily taught and self-administered (Karatzias et al. 2011). Subjects gently tap with their fingertips on acupressure points on the head, torso and hands and relate this to the voicing of specific statements (Craig, 2011). Recent systematic reviews reveal that EFT is effective for a variety of psychological disorders including reducing presentation anxiety and test-taking anxiety and enhancing athletic performance (Boath et al., 2012a; Feinstein, 2012; Feinstein, 2008).

The emerging literature suggests that EFT is a feasible treatment for presentation and test anxiety in students. For example, Boath and colleagues (2012b) found that EFT significantly reduced presentation anxiety in University students. Sezgin and Ozgin (2009) investigated the effect of EFT and Progressive Muscular Relaxation (PMR) on test anxiety in Turkish students undertaking a University entrance exam and found that students scored higher on examinations post EFT. Benor and colleagues (2006) treated test anxiety in Canadian University students with EFT and found the EFT enhanced their performance and that these students also successfully transferred their EFT skills to other stressful areas of their lives. Schoninger (2004) used Thought Field Therapy (TFT; Callahan & Trubo, 2001 ), the precursor of EFT, to treat public speaking anxiety and found a significant reduction in anxiety, shyness, confusion, and physiological factors as well as increased poise and positive anticipation following one hour of TFT. In Australia, Jones and colleagues (2011) reported significant reductions in public speaking anxiety in a group of University students and lecturing staff randomised to receive EFT and concluded that EFT was a quick and effective treatment for public speaking anxiety.

However, to date none of the studies of presentation anxiety has linked the reduction in anxiety levels with enhancing academic performance and so this pilot study aimed to assess the impact on EFT on a cohort of students’ public speaking anxiety and to assess whether EFT had an impact on their grades.

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Methodology

A convenience sample of 3rd year students undertaking a Foundation Degree in complementary therapies were invited to participate in the project. Once written informed consent was obtained, the students were all given a 15 minute assignment lecture outlining the requirements for their assessed presentation. They were then asked to rate their anxiety levels using Subjective Units of Distress (SUDs; Wolpe, 1958) and the Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983). Higher scores on these scales mean higher levels of distress, anxiety and depression. Next, they received a 15 minute lecture introducing EFT, the theory behind it and the tapping points by TS who is a fully qualified and highly experienced Advanced EFT practitioner and trainer. Following this, they were guided though one round of EFT, focussing on their fear of public speaking and being assessed, by TS. The EFT protocol used followed the ‘basic recipe’ (Craig, 2011) and the one round included tapping on 12 acupressure points on the head, torso and hand, while tuning in to their anxiety about their presentation and being assessed. Following the introduction, where the students familiarised themselves with the tapping points, they were then guided through one full round of EFT, where they focussed on their own anxiety. The students were asked to complete the SUDS and the HADS scales immediately following this. This was approximately 30 minutes since they completed the previous outcome measures.

The students were instructed that they could continue to use EFT on themselves any time they wished during the intervening 8 weeks between the EFT training session and their assessed presentation. A reminder email was sent out one week prior to their presentation, with an attachment outlining the tapping points and reminding them about using EFT if they desired.

Immediately after giving their presentation, the students were invited to take part in a brief face to face interview in which they were asked if they had used EFT prior to their presentation, how effective they felt it had been, if they had used anything else to reduce their anxiety and if they would use EFT in future. Responses were captured verbatim in writing.

Data analysis

The quantitative data were entered into SPSS. Data were screened for normality using the Shapiro-Wilk test. SUDs and total HAD were found to be normal and were analysed using the paired t-test. Anxiety and depression data were found to be non-normally distributed and therefore the non-parametric equivalent, the Wilcoxon Signed Rank Test was employed. Before and after mean scores (SUDS and total HADS) were compared using paired t-tests and the anxiety and depression subscale were compared using the Wilcoxon Signed Rank Test. Where P-values were <0.05, the differences were considered statistically significant.

The qualitative data was analysed using thematic framework analysis to identify emergent patterns and themes (Ritchie and Spencer, 1994). Interview transcripts were read independently by LB and AC who devised an index of key concepts and themes drawing on a priori issues linked to the study objectives as well as issues raised by the students. LB and AC agreed on a final framework and subsequently data from the transcripts were applied systematically to the framework followed by mapping and interpretation.

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Ethical approval

Ethical approval was obtained from Staffordshire University Research Ethics Committee.

Results

Fifty two 3rd year students were invited to participate in the project and 46 (88%) agreed and gave written informed consent. All students were female and aged between 25 and 55 (mean = 37.5). Many students were ‘returning to learning’ and studying for a career change.

SUDS data and the Hospital Anxiety and Depression Scale (HADS) scores were collected immediately before and immediately after the EFT training. A total of 46 complementary therapy students participated in the research. Table 1 shows the students’ anxiety scores pre and post EFT. It demonstrated that the means for the SUDS, the Anxiety Subscale of the HADS and the total HADS were significantly lower after the EFT intervention. However, there was no significant difference in the depression subscale of the HADS.

Table 1. Results of inferential analysis pre and post EFT

Measure Time Mean (SD) P-value Significant?

SUDS Before

After

5.68 (2.79)

3.80 (2.93)

<0.001 Yes

Anxiety Subscale

Before

After

10.22 (4.78)

7.83 (5.17)

<0.001 Yes

Depression Subscale

Before

After

4.81 (4.45)

4.56 (4.40)

0.67 No

Total HADS Before

After

14.97 (8.24)

12.44 (8.46)

0.003 Yes

Students in the study were followed-up, to see whether there was a difference in grades points achieved for the presentation, between those in the cohort who had used EFT prior to their presentation and those who had not.

“Marks” were expressed as assignment grades, based on Staffordshire University’s grading system at the time of the study. In this system, grades for Foundation Degrees are

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awarded between 1-15, where 1-3 represents a fail; 4-6 represents third class, 7-9 is a lower second, 10-12 is an upper second and 13-15 is First class.

Follow-up data were received for a total of 46 students, 19 of whom had used EFT for their presentation anxiety and 27 who had not. Data were found to be non-normal using the Shapiro-Wilk test; nonparametric statistical tests were therefore used.

Students who had used EFT attained significantly higher grades (mean 10.63, SD=2.872, range 4-14) than those who had not (mean 7.70, SD=2.771, range 4-13). Means were compared using an Independent-samples Mann-Whitney U test, which was significant (p<0.01).

The qualitative data produced a rich insight about the student’s experience of EFT. The students gave positive feedback about their experience of EFT and these were characterised by three overarching themes: theme 1 relating to the effectiveness of EFT in reducing their anxiety and helping them to remain calm and focused; a second theme relating to their use of other complementary approaches and a final theme outline their reasons for not using EFT. Quotes are presented to illustrate the themes. Names have been changed to maintain confidentiality.

Theme 1: Helpfulness of EFT in reducing anxiety and staying calm and focussed

It was evident from the quotes that EFT had a calming effect on students which helped to reduce their pre-presentation anxiety and helped to keep them calm and focussed, as illustrated by the following data extracts:

Yes. I did it [EFT] in the car. It helped. I didn’t sleep well last night – got a dry mouth and feel shaky, but not as bad as I usually am when doing a presentation. My legs are normally going, but they are alright today. It definitely took the edge off. I would definitely use it again. Used it for helping me to sleep and will use it again in future. (Kelly)

Yes I usually go blank, I forget. And I used it to keep me focussed today. I also used it when I first sat down and looked at the assignment. It did actually work. (Jacky)

Yes, I done it before I came in and yesterday. It really helped me actually. It helped me to calm down. Helped my emotions – my anxiety, nervousness. Helped me to calm down really. It took the edge off the presentation (Roberta)

I have done it a few times for other things, for example when I am feeling a little bit worried. ...It was something to do while waiting outside. Tapped in the corridor! (Anne)

Theme two: Using other complementary therapy skills

The students were undertaking a Foundation Degree in Complementary therapy and had a range of complementary skills, including aromatherapy and reiki to reduce their anxiety and many made good use of these instead of EFT to help them relax and reduce their anxiety prior to their presentation:

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Not used EFT, but did visualisation and used hypnotherapy on myself. (Ruby)

No, used reiki and yoga techniques and my own aroma treatment. (Georgia)

No, not used it today, but used calming oils. I have been using it and found it really helpful. Used it to help when I meet people and to have my photo taken. (Anita)

Theme three: Reasons for not using EFT

Five students indicated that they although they had used EFT successfully for anxiety following the session, they had not carried out any EFT immediately prior to the presentation. Reasons for not using EFT included forgetting, feeling silly tapping it in public, uncertainty that they were doing it right and not being able to tap due to obsessive compulsive disorder (OCD):

Tapped in the morning and before driving in to do the presentation and it helped bring down my anxiety levels, but I didn’t tap immediately before the presentation, as I was in a busy corridor and felt daft doing it. That would have really helped. (Cathy)

I did not use it on the day of the presentation as I was not sure I was doing it ‘right’ (Lynne)

I struggled with EFT as I have OCD and I kept counting the number of taps, rather than focussing on my anxiety. (Lee)

Two students, who forgot to use EFT, reported their regret at not using it:

No. Didn’t. I should have [used EFT]... I think if I’d used it, it would have been a good idea. I would have done better. Can’t believe I didn’t actually. (Amanda)

Yes, used it in the past, but not today. I didn’t even think about it. That would have been a good idea! I just forgot I was in such a panic. Have used it for headaches and stuff in the past and it worked . (Alison)

Discussion

This small study explored the feasibility of using group EFT in reducing presentation anxiety in University students and enhancing academic performance. The results suggest that group EFT is an effective intervention in reducing presentation anxiety as measured using SUDS and HADS and that EFT can be used to reduce anxiety and enhance performance. Indeed, the anxiety reducing effects of EFT reported in this study are consistent with the findings of previous research that has used EFT to reduce exam stress and presentation anxiety in high school and university students (Boath et al., 2012b; Schoninger, 2004; Sezgin & Ozgin, 2009; Feinstein 2008).

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The qualitative data analysis revealed three overarching themes. Students on the whole felt that EFT was very useful in reducing their presentation anxiety.

There was no significant difference in pre and post depression scores on the HAD depression subscale. This is in line with previous research (Boath et al., 2012b) and reflects the focussed nature of EFT and that the tapping was aimed at reducing anxiety and not depression.

Eight is the cut- off point for caseness for both the anxiety and depression subscales of the HAD. A score above 8 on either subscale suggests a clinical level of depression or anxiety. The depression scores pre and post EFT were substantially below 8, suggesting that students were not depressed. However, the mean anxiety scores pre EFT of 10.22 were well over the clinical cut-off point for anxiety and this highlights the high level of anxiety students felt in relation to their presentation. The mean anxiety levels following the EFT intervention reduced to 7.83, which suggests that their anxiety had reduced to a non-clinical level. It is feasible that a further round of EFT may have resulted in even greater reductions in anxiety levels (Craig, 2011) and future research should explore this.

In line with other EFT research, there were no ethical or safety issues identified during the study. Only one student with obsessive compulsive disorder (OCD) highlighted that she could not perform EFT properly as her OCD involved counting and meant that she concentrated on counting the number of taps and not her anxiety. This may be a limitation of EFT, however the literature suggests that EFT can be a useful treatment for OCD and offers solutions to this issue including varying the order and number of tapping points (Moran, 2012; Bressler, 2011).

Research has questioned the validity of using self-report scales alone (Carrell & Williamson, 1996 cited in jones). The HADS and SUDS scales were not repeated on the day of their presentation. Further research is currently underway that will do this. However the qualitative results suggest that the students who used the EFT on the day of their presentation found it extremely helpful.

Although the results suggest that EFT is an effective group treatment for presentation anxiety and to enhance performance, these are tentative due to the limitations of the study outlined below,

The use of a convenience sample of complementary therapy students may have meant that many were more inclined towards the use of a psychological intervention than students studying for other courses. The authors have carried out a similar intervention with Sport Science students and many of them were initially very sceptical. Indeed the authors’ clinical experience suggests that many people find the idea of EFT absurd, let alone the idea that this can also have an impact on their psychology and other research supports this assertion (Burkeman, 2007; Gaudiano & Herbert, 2000).

Public speaking anxiety is often reported to be greater in women that in men (Furmark, 2002; Pollard & Henderson, 1998). The students were all women and so further research is currently underway with a cohort of male and female students to assess if there is a gender difference. The present study did not obtain demographic informational such as age, ethnicity or disability future research will include these variables.

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There was a long period (8 weeks) between the EFT training session and the presentation. Students were sent a reminder email. However they were not directly instructed to continue tapping, but were told that they could use EFT if they wished prior to their presentation. Although 8 weeks seems long other EFT research has demonstrated that a single brief EFT session is effective and that the results are maintained for up to 6 months when EFT is used for weight loss or phobias (Stapleton et al., 2011; Wells et al., 2003). However, it may be that the acute, situational nature of presentation anxiety, requires further intervention.

This study did not take into account factors such as personality and learning styles that have been shown to play significant roles in influencing academic achievement (Komarraju et al., 2011; Richardson et al., 2012). Furthermore, the use of learning and study skill in enhancing performance (Hamblet, 2012) was not addressed. Future research could consider exploring these traits.

Overall the students who used EFT had a mean grade of 10.73, equating to an upper second, whereas those who did not use EFT had a mean grade of 7.7, which equates to a lower second. However, students’ prior academic performance in presentations was not assessed, as previous presentations had been group presentations and this was the only individual presentation they had during their course. It is therefore impossible to conclude that EFT enhanced their performance, as it may be that students who used EFT were less anxious, or were simply more adept at using mechanisms at their disposal to enhance their performance. Future research should compare outcome with marks on previous presentations. I

The sample size in the current study was small (n=46), they were all women and there was no control group. The question therefore arises as to whether the findings from this small select group of female university complementary therapy students could generalise to a wider population of students. In order to explore this an RCT of EFT versus a lecture on presentation skills using larger cohort of male and female students doing a sports science degree is currently underway. (Boath et al., ongoing).

27 out of the 46 students (59%) did not carry out any further EFT and this is higher than rates of ‘dropout’ in other studies that have used EFT (Karatzias et al 2011(39%); Brattberg, 2008 (40%). This higher rate may be due to the fact that this cohort of complementary therapy students had other complementary skills, such as aromatherapy that they could call on to reduce their anxiety, as highlighted in the qualitative analysis. The most common reason for not using EFT was that they had forgotten about it, or had forgotten how to do it. Many of those who forgot also added that they wished that they had remembered and felt that their performance would have been enhanced if they had used it.

For the 19 students who did continue tapping, the frequency and duration of tapping was not assessed. Future research could employ a diary method to record this and also explore the duration of treatment effects.

Although there was an immediate effect on SUDS and the anxiety subscale, the evidence for long term effects was not addressed in this study as the HADS and SUDS were not repeated on the day of the presentation. Future research should consider assessing students immediately prior to and after their presentation.

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The HADS assesses feelings of depression and anxiety over the past week. A scale such as the Spielberger State-Trait Anxiety Inventory (STAI; Speilberger et al.,1983), that has been used in other anxiety research, and distinguishes between the temporary condition of ‘state anxiety’ and the more general, long–standing ‘trait anxiety’ may have been a more appropriate choice of outcome measure.

The scales used were both self-report and although the results highlighted high levels of anxiety in both groups, the sample was not therefore derived from a clinically diagnosed anxious population.

The HAD and SUDS scales do not address presentation anxiety per se and so scales designed to assess apprehension, confidence in public speaking and communication competence such Personal Report of Communication Apprehension, Personal Report of Confidence as a Speaker and Self-Perceived Communication Competence ( Hancock et al., 2010) would be valuable future outcome measures.

The outcome measures used were both self-report and although the results highlighted high levels of anxiety in the students, the sample was not derived from a clinically diagnosed anxious population. Future research would benefit from the use of a clinician assessed scale, such as the Structured Clinical Interview for DSM Disorders.

Research has also shown that EFT is effective with large groups of people (Rowe, 2005) and so has the potential to offer very efficient and cost effective interventions to student groups. However, it would be interesting to explore if individual sessions with students were more effective.

The lead researcher (EB) was not blind to treatment group. The researchers who collected the data and interviewed the students (EB and AC) were also the module lead and award leader for the group and were therefore known to the students.

The students were aware that the authors were highly experience advanced EFT practitioners and that all have a strong allegiance to EFT. This may have influenced students’ responses via verbal or non-verbal cues and may well have strengthened the ‘client-therapist’ relationship which is known to have a positive effect on treatment outcome.

Conclusion

Despite the limitations of the study, the results suggest a potential role for EFT as a group intervention in reducing presentation anxiety and potentially enhancing academic performance in University students. In addition, given that it takes a very short time to train students to use EFT, and that once learned, EFT can be very effectively self-administered suggests that EFT may be a useful addition to curricula for courses that include oral presentations. Furthermore, EFT can easily be transferred to other aspects of student life, for example exam stress and so could be used to reduce anxiety around exams and potentially enhance exam performance. Further research is planned to address this.

Funding

Staff time was provided by the Faculty of Health, Staffordshire University

Conflict of interest

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None

Ethical approval

Ethical approval was obtained from Staffordshire University.

Acknowledgements

The authors would like to thank the students who participated in the research and gave their time to be interviewed. We also thank Staffordshire University for facilitating staff time in carrying out the research.

References

Benor,D. J; Ledger, K; Toussaint, L; Hett, G; Zaccaro, D. (2006). Pilot Study of Emotional Freedom Techniques, Wholistic Hybrid Derived From Eye Movement, Desensitization and Reprocessing and Emotional Freedom Technique and Cognitive Behavioural Therapy for Treatment of Test Anxiety in University Students. Explore: The Journal of Science and Healing. (6) p. 338-340.

Boath, E., Stewart. A. & Carryer, A. (2012a). A Narrative Systematic Review of the Effectiveness of Emotional Freedom Technqiue (EFT). CPSI Monograph [online] Available at http://www.staffs.ac.uk/assets/A_Narrative_Systematic%20_Review_of_the_Effectiveness_of_Emotional_Freedoms_Technique_(EFT_tcm_45300.pdf. [Accessed: 16th August 2012].

Boath, E., Stewart, A. & Carryer, A (2012b). Tapping for PEAS: Emotional Freedom Technique (EFT) in Reducing Presentation Anxiety Syndrome (PEAS) in University Students. Innovative Practice in Higher Education [online] 1 (2). Available at http://journals.staffs.ac.uk/index.php/pihe/article/view/19. [Accessed: 16th August 2012].

Brattberg, G. (2008). Self-administered EFT (Emotional Freedom Techniques) in Individuals with Fibromyalgia: A Randomized Trial. Integrative Medicine: A Clinician's Journal. 7 (4) p. 30-35.

Bressler, H, P. (2011). When is it safe to use EFT with OCD? EFT, MIT and Tapping Therapy Articles [online]. Available at http://www.eft-articles.com/eft-articles.taf?_function=articledetail&article_ID=342.[Accessed: 14th August 2012].

Burkeman, O. (2007). The Guardian [online]. Available http://www.guardian.co.uk/lifeandstyle/2007/feb/10/healthandwellbeing.features 3 [Accessed : 9th August 2011].

Callahan, R.J. & Trubo, R. (2001). Tapping the Healer within: Using Thought Field Therapy to Instantly Conquer Your Fears, Anxieties and Emotional Distress. London. Piatkis.

Carrell, L. J. & Willmington, S. C. (1996). A Comparison of Self Report and Performance Data in Assessing Speaking and Listening Competence. In Jones, S, J., Thornton, J, A & Andrews, H, B (2011). Efficacy of Emotional Freedom Techniques (EFT) in Reducing Public

Innovative Practice in Higher Education Boath, Stewart, Carryer Vol.1 (3) April 2013 Tapping for PEAS

Innovative Practice in Higher Education 11 © IPiHE 2013 ISSN: 2044-3315

Speaking Anxiety: A Randomized Control Trial. Energy Psychology: Theory, Research and Treatment. 3 (1) p.33 - 42

Cherry, K. (2010). The Everything Psychology Book: An Introductory Guide to the Science of Human Behaviour. Adams

Claxton, G. (1999). Wise up to the Challenge of Lifelong Learning. London. Bloomsbury.

Craig, G. (2011). The EFT Manual (2nd Ed.). Energy Psychology Press.

Feinstein, D. (2008). Energy Psychology: A Review of the Preliminary Evidence. Psychotherapy: Theory, Research, Practice, Training. 45 (2) p. 199-213.

Feinstein, D (2012). Acupoint Stimulation on Treating Psychological Disorders. Evidence of Efficacy. Review of General Psychology. In Press.

Fenollar, P., Román, S.& Cuestas,P J. (2007). University students' academic performance: An integrative conceptual framework and empirical analysis. British Journal of Educational Psychology. 77 4, p. 873-891.

Furmark,T.(2002). Social Phobia: Overview of Community Surveys. Acta Psychiatrica Scandinavica. 105 p. 84-93

Gaudiano, G.A. & Herbert, J.D. (2000). Can We Really Tap Our Problems Away? A Critical Analysis of Thought Field Therapy. Skeptical Inqurer. 24(4) [on-line]. Available from http://www.csicop.org/si/show/can_we_really_tap_our_probles_away_critical_analysis_of_thought_field_th/ [Accessed: 3 August 2011]

Goldius, C & Gotesman, E (2010) The Impact of Assistive Technologies on the Reading Outcomes of College Students with Dyslexia. Educational Technology. 50 (3) p 21-25.

Hamblet, EC (2012). Teach students strategies to improve academic performance. Disability Compliance for Higher Education. 17 (9) p6

Hancock, A.B., Stone, M.D., Brundange, S.B., Zeigler, M.T (2010). Public Speaking Attitudes: Does Curriculum Make a Difference? Journal of Voice. 24 (3) p. 302-7.

Jones, S, J., Thornton, J, A & Andrews, H, B (2011). Efficacy of Emotional Freedom Techniques (EFT) in Reducing Public Speaking Anxiety: A Randomized Control Trial. Energy Psychology: Theory, Research and Treatment. 3 (1) p.33 - 42

Lidren, D M. & Meier, S E. (1991). The effects of minimal and maximal peer tutoring systems on the academic performance of college students. Psychological Record. 41 (1), p 69.

Karatzias, T; Power, K; Brown, K; McGoldrick, T; Begum, Millia, B; Young, J; Loughran, P; Chouliara Z; Adams, S (2011). A Controlled Comparison of the Effectiveness and Efficiency of Two Psychological Therapies for Posttraumatic Stress Disorder. Journal of Nervous and Mental Disease. [On-line] 199 (6) p 372 – 378. Available from: http://journals.lww.com/jonmd/Abstract2011/06000/A_Controlled_Comparison_of_the_Effectiveness_and.3.aspx. [Accessed 23 September 2011].

Innovative Practice in Higher Education Boath, Stewart, Carryer Vol.1 (3) April 2013 Tapping for PEAS

Innovative Practice in Higher Education 12 © IPiHE 2013 ISSN: 2044-3315

Komarraju, M., Karau, S J., Schmeck, R R., & Avdic, A (2011). The Big Five personality traits, learning styles, and academic achievement. Personality & Individual Differences. 51 (4) p.472-477.

Moran, C. (2012) Introducing emotional freedom techniques. Speechmark Publishing, London

Murray, D. W., Rabiner, D.L., & Hardy, K (2011). Teacher Management Practices for 1st Graders with Attention Problems. Journal of Attention Disorders. 15 p639-646

Parent, D W.& Del Rio-Parent, L (2008). Introducing TCAD Tools in a Graduate Level Device Physics Course. IEEE Transactions on Education. 51 (3), p. 331-335.

Pollard, C. & Henderson, J. (1998). Four types of social phobia in a community sample. Journal of Nervous Mental Disease. 176 p.440-445.

Richardson, M., Abraham C.& Bond, R (2012). Psychological Correlates of University Students' Academic Performance: A Systematic Review and Meta-Analysis. Psychological Bulletin. 138 (2) p.253-387. .

Ritchie,J. & Spencer, L. (1994). Qualitative data analysis for applied policy research. In Bryman and Burgess (eds). Analysing Qualitative Data. Routledge, London.

Rowe, J. E. (2005). The effects of EFT on long-term psychological symptoms. Counselling and Clinical Psychology. 2 (3) p.104-111.

Schoninger, B. (2004). Efficacy of thought field therapy (TFT) as a treatment modality for persons with public speaking anxiety. (Unpublished).

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, & Treatment. 1 (1) p. 23-30.

Spielberger C.D, Gorsuch R.L, Lushene P.R, Vagg P.R, Jacobs A.G.(1983). Manual for the State-Trait Anxiety Inventory. Consulting Psychologists Press.

Stapleton, P.,Sheldon, T & Porter, B (2011). Clinical Benefits of Emotional Freedom Techniques on Food Cravings at 12 Month Follow-Up. A Randomised Controlled Trial. Energy Psychology Journal. 4 (1) p. 1-11

Wells, S., Polglase, K., Andrews, H. B., Carrington, P. & Baker, A. H. (2003). Evaluation of a meridian-based intervention, emotional freedom techniques (EFT), for reducing specific phobias of small animals. Journal of Clinical Psychology. 59 p. 943-966.

Wolpe, J. (1958). Psychotherapy by Reciprocal Inhibition. Stanford: Stanford University Press.

Zigmond A.S & Snaith R.P (1983). The hospital anxiety and depression scale. ActaPsychiatrica Scandinavica, 67. ( 6) p. 361-370.

Innovative Practice in Higher Education Boath, Stewart, Carryer Vol.1 (3) April 2013 Tapping for PEAS

Innovative Practice in Higher Education 13 © IPiHE 2013 ISSN: 2044-3315

Nurse Education Today 40 (2016) 104–110

Contents lists available at ScienceDirect

Nurse Education Today

j ourna l homepage: www.e lsev ie r .com/nedt

The effect of emotional freedom technique on stress and anxiety innursing students: A pilot study

Susan Librizzi Patterson ⁎Carolinas College of Health Sciences, Charlotte, NC, USA

⁎ Tel.: +1 704 355 3464; fax: +1 704 321 5833.E-mail address: [email protected].

http://dx.doi.org/10.1016/j.nedt.2016.02.0030260-6917/© 2016 Elsevier Ltd. All rights reserved.

s u m m a r y

Article history:Received 28 June 2015Received in revised form 31 December 2015Accepted 2 February 2016Available online xxxx

Background: Stress and anxiety have been identified as significant issues experienced by student nurses duringtheir education. Some studies have suggested that the stress experienced by nursing students is greater thanthat experienced by medical students, other non-nursing healthcare students, degreed nurses, and the femalepopulation in general. A recently introduced energy type therapy, emotional freedom technique (EFT), hasshown some success in reducing symptoms of anxiety, stress, and fear in a variety of settings.Objective: The purpose of this studywas to determine the efficacy of EFT in decreasing anxiety and stress as a po-tential intervention to assist students in stress management.Design: The study used amixedmethod design of both qualitative and quantitativemeasures. Quantitatively, in aone grouppretest–posttest design, participants received group instruction in the technique andwere encouragedto repeat it daily. Self-reported anxiety was measured at baseline, and thenweekly for four weeks using the Per-ceived Stress Scale (PSS) and the State–Trait Anxiety Inventory (STAI). The qualitative survey was completed byparticipants at the end of the study in order to capture a more subjective experience.Setting: The pilot study was conducted in a two-year college in the southeastern region of the United States.Participants: All enrolled nursing students in an associate degree nursing programwere invited to participate. Par-ticipation was voluntary, resulting in an original convenience sample of thirty-nine nursing students (N= 39).Methods:Data collection instruments included a demographic questionnaire, pretest State–Trait Anxiety Inventory(STAI) and Perceived Stress Scale (PSS). A qualitative questionnaire was also administered at the end of the fourweeks. STAI and PSS were administered weekly. Data analysis using RMANOVA was performed at the second,third and the fourth week.Results:Decreases in anxiety asmeasured on both the STAI and PSSwere statistically significant (p= .05). For PSS,STAI state and trait data, the reduction in self-reported stress was statistically significant with a mean differencebaseline to week 4. Qualitative data suggested that nursing students experienced a decrease in feelings of stressand anxiety including a decrease in somatic symptoms.Conclusions: Overall, findings suggested that EFT can be an effective tool for stress management and anxiety reliefin nursing students.

© 2016 Elsevier Ltd. All rights reserved.

Keywords:Emotional freedom techniqueStressAnxietyNursing students

Introduction

Psychological stress has long been identified to be an unfortunateconsequence of a career in nursing. Conditions which contribute tothis are increased job demands, inadequate staffing, increased acuityof patients, lack of administrative support, a rapidly changing healthcareenvironment, and the emotional challenges of working with the sickand dying. Stress and anxiety have also been identified as significant is-sues experienced by student nurses during their education. In fact, somestudies have suggested that the stress experienced by nursing students

is greater than that experienced bymedical students, other non-nursinghealthcare students, degreed nurses, and the female population in gen-eral (Baldwin, 1999; Beck et al., 1997; Rhead, 1995). Nursing studentshave identifiedmajor areas of stress as coursework, clinical experiences,and personal issues (Jones and Johnston, 1997, 2000; Lindop, 1999;Timmins and Kaliszer, 2002; Elliott, 2002; Rhead, 1995; Jimenez et al.,2010).

A variety of stress management approaches for nursing studentshave been suggested and tested. Jones and Johnston (2000) made astrong endorsement for a multifaceted approach to stress reductionusing problem solving, time management, relaxation techniques, aswell as other interventions. This same study also emphasized the needfor interventions that dealt with the interface between student nursesand the healthcare organization. Galbraith and Brown (2011), in theircomprehensive literature review of successful interventions for

105S.L. Patterson / Nurse Education Today 40 (2016) 104–110

managing stress, identified that themost successful interventions had astrong theoretical basis and included, “cognitive reappraisal ofmaladap-tive cognitions, as well as relaxation”(p. 718).

Although the role of complementary therapies in the treatmentof stress and anxiety is not new, there has been increased interestin the role of energy or biofield therapies in reducing anxiety and pro-moting feelings of well-being. Biofield therapy is described by theNational Institutes of Health's National Center for Complementary andAlternative Medicine (2012) as “the manipulation of various energyfields to affect health” (p.1). A recently introduced energy type therapyis emotional freedom technique (EFT). While similar to other energybased therapies such as Reiki and Healing Touch, EFT may have morein common with acupuncture, a well-known Chinese medicine tech-nique (Church, 2010). EFT combines the tapping of meridian pointswith a focus on the feared object or negative emotion to provide desen-sitization to the fear. In addition, there is repetition of a statement ofself-acceptance, suggested to contribute to cognitive restructuring, awell-known psychotherapeutic technique, where the individualidentifies and corrects negative thoughts (Church, 2010). Tappingthe meridian points relieves stress, and through the application ofthis non-traumatic physical stimulus while also introducing thefear with self-acceptance, the negative somatic response that is as-sociated with that memory and all similar memories is interrupted(Craig, 2010).

EFT is currently receiving much attention in the treatment of com-pulsive behavior, phobias, anxiety, and post-traumatic stress disorder.Therapeutic results and relief of symptoms are often quick and dramat-ic, demonstrating rapid improvement in the participant's ability to tol-erate stress.

Review of the Literature

An examination of the literature was performed to better under-stand the prevalence of anxiety reported by nursing students and the ef-fectiveness of a variety of interventions. The review focused on threemain questions: (1) Has anxiety been identified as a significant issuefor nursing students? (2) What particular interventions have been suc-cessfully applied to reduce anxiety? and (3) Has EFT been identified as apotential intervention for decreasing anxiety in nursing students orother groups?

A literature search was performed using the Cumulative Index toNursing and Allied Health Literature database (CINAHL) for the periodof October 2000 through 2011. This database was chosen due to its ex-tensive coverage of nursing, biomedicine, health sciences, and alterna-tive/complementary medicine. Search elements included anxiety,stress, nursing students, complementary therapies, energy therapies,and emotional freedom technique (EFT). In the case of EFT, since onlya scant number of articles were recovered from the CINAHL search, anEFT website, http://www.eftuniverse.com/was also used to identifypeer reviewed articles.

A limited number of articles were generated regarding stress andanxiety in nursing students requiring an expansion of the search to1995. This may reflect current lack of interest in this topic as a researchfocus even though in the contemporary nursing education environmentstudents report stress and anxiety as concerns. Deary et al. (2003) ex-amined a cohort of nursing students to better understand causes ofstress, burnout, and attrition using six different instruments and con-cluded that stress and the use of negative coping skills increased asthe nursing program progressed and psychological symptoms in-creased.Watson et al. (2008) found that life changes and stress contrib-uted to distress, and that newly qualified nurses had a higher reportedstress than nursing students. Gibbons et al. (2008) identified sourcesof distress to include new clinical experiences, lack of support fromstaff, and a number of stressors regarding coursework demands andgrades. Jimenez, Navia-Osorio and Diaz. (2010) uncovered three kinds

of stressors in nursing students, clinical, academic, and external, withclinical rotations the most intense source of stress.

Interventions for relieving the stress and anxiety usually focused ona multifaceted approach. Charlesworth et al. (1981) evaluated a fiveweek stress management program for nursing students and foundthat those enrolled in the program experienced a reduction in test anx-iety. Boutin and Tosi (1983) compared the effects of hypnosis and thecombination of hypnosis and cognitive restructuring against a controland placebo group and noted better results from the group receivingthe combined approach. Jones and Johnston (2000) designed a six ses-sion stress management intervention, which included a presentationon coping skills, problem solving strategies, cognitive techniques, timemanagement skills, and relaxation techniques, showing anxiety wasless in those students receiving the intervention. Hamrin et al. (2006)reported that a peer-led support group demonstrated self-reported re-ductions in anxiety and improved coping. Hsiao et al. (2010) foundthat spiritual health was negatively associated with clinical practicestress and depressive tendency.

Although there was no information available regarding the use ofEFT in nursing students, the literature did suggest that EFTmight be suc-cessful in decreasing anxiety and feelings of distress in a variety of pop-ulations and settings. Wells et al. (2003) found that EFT was moreeffective in reducing human phobias of small animals than a compara-tive group using deep breathing. Waite and Holder (2003) comparedEFT against other methods and a control group and found EFT to bejust as effective at reducing fear as the other interventions, but more ef-fective than the control group. Rowe (2005) compared a group usingEFT pre-treatment to post-treatment, finding a statistically significantdecrease in all components of psychological distress. Brattberg (2008)demonstrated a statistically significant improvement in pain, anxiety,depression, vitality, social function, and performance in a group ofwomenwithfibromyalgiawho received EFT. Church et al. (2009) exam-ined the effects of EFT on psychological symptoms in a sample ofveterans finding a statistically significant improvement in symptoms.Church (2009a) studied the effect of EFT on athletic performance inbasketball players,which demonstrated an improvement in the numberof free throws, but not jump height. Additional studies by Church(Church, 2009b; Church et al., 2010), on small groups of veterans suffer-ing from post-traumatic stress disorder (PTSD) indicated significantlyless psychological symptoms when compared to control groups.Church and Brooks (2010) investigated the effects of multiple roundsof EFT with healthcare workers on physical discomfort, emotionalchildhood experiences and substances craved finding a reduction insymptoms. Church et al. (2012a, 2012b) undertook a study on EFT andits effect on depression among college students with lower depressionscores for those using EFT. Church et al. (2012a, 2012b) investigatedthe effect of EFT on the salivary production of cortisol and found thatthe EFT group had significantly less production of cortisol than otherstudy groups.

To summarize the literature, stress and anxiety have been identifiedas areas of concern for nursing students. A variety of stress managementapproaches have been suggested and tested with the most successful in-terventions having a basis in cognitive reappraisal and relaxation. EFT hasbeen recently introduced and is currently receivingmuch attention in thetreatment of compulsive behavior, phobias, anxiety, and post-traumaticstress disorder.With the gap in the literature on the use of EFT in nursingstudents, the purpose of this project was to determine the efficacy ofemotional freedom technique (EFT) in decreasing anxiety and stress innursing students enrolled in an associate degree nursing program.

Methods

The research proposal, study design and all participant related con-tent was reviewed and approved by the university and healthcare sys-tem Institutional Review Boards (IRB). In observance of IRB guidelines,all participants were provided a description of the study and how

106 S.L. Patterson / Nurse Education Today 40 (2016) 104–110

privacy and confidentiality would be maintained; written, informedconsent was obtained. All participants selected a unique confidentialidentifier to further provide confidentiality.

Study Design

This study was a mixed design with both quantitative and qualita-tive approaches. Quantitatively, a quasi-experimental, time series,pretest-posttest design was selected and qualitatively, a post-study,short answer questionnaire was chosen.

Setting

The setting was a hospital based associate degree nursing programin the southeast region of the United States with a nursing studentbody of approximately 250 students. Only nursing students wereincluded. Group sessionswere held in classrooms at the collegewith ac-cess only to those participants admitted to the pilot in order to provideparticipants with confidentiality.

Sample/Recruitment

Participants in the pilot study were a convenience sample of associ-ate degree nursing students recruited by a variety of means includingcollege newsletter announcements, email invitation, electronic, andpaper poster displays. Exclusion criteria included those currentlybeing professionally treated for anxiety and those who were alreadyregular users of EFT. The rule of 30was applied to determine the samplesize for the pilot study. Burns and Grove (as cited in White, 2012) sug-gest that in quantitative research at least 30 participants are needed ineach group being studied. Melnyk and Cole (2011) also state that pilotstudies are conducted with smaller sample sizes of perhaps 30–40 par-ticipants. The initial sample size was 39 participants, one participantdropped out of the study the second week and a duplicate case wasidentified in the demographic data sample and was removed. This re-sulted in a final demographic sample of 37. During data analysis it wasnoted that there were additional duplicate cases and that some partici-pants did not complete the PSS, STAI trait and state survey every week.Additional duplicate cases were removed and cases without full datasets for week 0, week 2 and week 4 were also removed. This resultedin an sample size of n = 31 for PSS and a sample of n = 30 for STAIstate and trait.

Study Intervention

The EFT technique, The Basic Recipe (Craig, 2010; Church, 2010)wasused as an intervention in the study. EFT involves the light manual tap-ping of traditional acupressuremeridianpoints (acupoints) on the head,face, neck, chest and hands while verbally confronting the feared objector stressor and repeating a phrase of reassurance. Participants are askedto repeat the phrase, “even though I have this feeling of stress and anx-iety, I deeply and completely accept myself” while simultaneously tap-ping the acupoints. After the initial round of tapping accompanied bythis phrase, the participants are instructed to shorten the phrase to‘this feeling of anxiety, stress’ or some other short phrase that focuseson the fear. Participants are then encouraged to repeat rounds of thisprocess until they note their anxiety to be decreased.

Measurement Tools

Three instruments were used in this project, the State–Trait AnxietyInventory (STAI) (Speilberger et al., 1983), the Perceived Stress Scale(PSS) (Cohen et al., 1983) and a qualitative questionnaire developedby the researcher. The STAI, is a 40 item self-report instrument thatmeasures both state and trait anxiety using a four-point Likert scale.State anxiety is defined as a temporary condition of anxiety while trait

anxiety is a longstanding anxiety trait. Reliability has been establishedat .92 for state anxiety) and .90 for trait anxiety (Speilberger et al.,1983). Cohen et al. (1983) developed a 14-item self-report, one-dimen-sional tool for measuring perceived stress called the Perceived StressScale (PSS) which uses a 5-point Likert scale and has an established re-liability of 0.84, 0.85, and 0.86 for three samples. The14-item instrumentwas revised to a 10-item instrument with a reliability of 0.78 (Cohenand Williamson, 1988). The 10-item PSS was used for this project.

Basic demographic data including age, gender, marital status, race/cultural background, years of previous college, current course enroll-ment, previous experience with EFT, and current involvement withother anxiety/stress reduction interventions were also collected.

The pilot began with an introductory session (week 0) followed byfour follow-up sessions, each a week apart. Three introductory sessionswere offered in order tomeet student schedulingneeds. In the introduc-tory session, the researcher provided participants with step by step in-structions for the technique using the EFT technique as described inThe Basic Recipe (Craig, 2010), a demonstration and the opportunityto practice. Participants were encouraged to practice the techniquedaily. During the first follow-up session (week 1) and the second fol-low-up session (week 2), participants met as a group. Multiple sessionswere offered each week to meet student schedules. During these ses-sions, the techniquewas practiced and PSS, STAI instrumentswere com-pleted via SurveyMonkey linked to a study website. No group sessionwas held during week 3 and participants practiced the technique inde-pendently and were instructed to complete surveys remotely. In thefinal group session (week 4), in addition to the PSS, STAI surveys, a qual-itative questionnairewas completed and a debriefing statement provid-ed. A gift certificate for $20.00 was provided for participants whocompleted the study.

Data and Results

Through SurveyMonkey, demographic and quantitative data wasexported to the Statistical Package for the Social Sciences, version 20(SPSS) for data analysis. Four participant files were excluded from thedata sample because ofmissing EFT log or duplicative project IDnumbers.

Sample Demographics

There were thirty-nine (n = 39) initial participants in the pilotstudy. One participant dropped out before the second week of thestudy due to increased anxiety and desire to seek professional help.The remaining 38 participants continued in the pilot through its dura-tion of four weeks. A duplicate case was identified in the demographicdata sample adjusting the final demographic data sample data to 37.The demographic sample consisted of 33 females and four males withan average age of 34.Marital status reflected 37.8%married and 62% sin-gle. Most (62%) were employed, with 40.5%working 16–30 h per week.Highest level of education varied, with the majority of the sample al-ready having a baccalaureate degree (54%), 16.2% with a graduate de-gree, 8% with an associate degree, and 16.2% with previous college andno degree. Only 5.4% listed their highest level of education as a highschool diploma or GED. Themajority of students were in the intermedi-ate level of the nursing program (51.3%), with 37.8% in the fundamentallevel, and 10.8% in the advanced level. Average GPA range was self-reported and results were 3.5–4.0 (54%), 32.4% in the 3.0–3.5 range,10.8% in the 2.5 to 3.0 range, and 2.7% in the 2.0–2.5 range. A summaryof the sample's demographic data can be found in Table 1.

Quantitative Analysis

A repeated-measures, analysis of variance (RMANOVA) was per-formed comparing baseline, week 2, and week 4 for each of the quanti-tative instruments, PSS, STAI-state, and STAI-trait. Although data wascollected at baseline and then weekly for 4 weeks, when data was

Table 1Demographic data.

Gender Marital status GPA Employment Program level Highest education

33 F4 M

37.8% married 3.5–4.054%

62% employed 37.8% F51.3% I

54% bachelors8% associate

62% single 3.0–3.5 32.4%2.5–3.0 10.8%2.0–2.5 2.7%

40.35% at 16–30 h/wk 10.8% A 16.2% graduate16.2% previous college5.4% HS/GED

107S.L. Patterson / Nurse Education Today 40 (2016) 104–110

examined and cleaned for missing cases, duplicate cases, and verifica-tion that the same participants were represented in each repeatedmea-sure, some cases were present in the PSS data set for week 1 and 3,which were not present in week 1 and week 3 STAI data sets. Addition-ally, after data examination and cleaning, week 1 and week 3 had a de-creased sample size of N = 28 for STAI state and trait. To maintain thesample size at the N = 30 minimum recommendation for a pilotstudy (Melnyk and Cole, 2011; Burns and Grove, as cited in White,2012), data analysis was performed on baseline, week 2, and week 4data which after cleaning had adequate sample size.

RMANOVA assumes that the dependent variable is continuous, is ap-proximately normally distributed, has sphericity, and has one indepen-dent variable. The sphericity assumption was met in the STAI-stateresults but violated in both the PSS and STAI-trait results. To rectifythis violation, an adjustment to degrees of freedom was made throughGreenhouse–Geisser correction and sphericity was met. A traditionalalpha level of .05 was chosen as the indicator of statistical significance.

Data analysis supported the hypothesis that nursing students willhave reduced anxiety relative to baseline as measured by the PerceivedStress Scale, the State–Trait Anxiety Inventory.

PSS Results

Mauchly's test of sphericity, an important assumption for RMANOVA,was violated (significance of the approximate Chi-square of 9.18 is .010,a significance level b0.05) and so aGreenhouse–Geisser correction to de-grees of freedom was applied. Greenhouse–Geisser correction valuesdemonstrated that themean scores for PSS week comparisons were sig-nificantly different (F(1.6, 47.2) = 24.59, P b 0.0005, partial eta squared.45).

The Bonferroni pairwise comparison tests demonstrated that themean difference of 3.16 was significant (p = .05) from week 0 (base-line) to week 2; the mean difference of 2.52 was also significant fromweek 2 to week 4 (p= .05) and the mean difference of 5.68 was signif-icant from week 0 (baseline) to week 4. Descriptive statistics for thesample (n=31)demonstrated a decrease in PSS scoremean frombase-line of 23.87 (std. deviation 6.51) to 20.71 (std. deviation 6.17), in week2 and 18.19 (std. deviation 6.86) in week 4 (p= .05). This represents a23.8% decrease in anxiety as measured by PSS. Descriptive statistics re-sults are presented in Table 2. A profile plot demonstrates the differencein means over the 4-week period in Fig. 1.

STAI State Results

Mauchly's test of sphericity for STAI state, with in subjects effect(P = .860) was not found to be statistically significant (p N .05) andthe sphericity assumption was not violated. The observed F value was

Table 2Descriptive statistics PSS baseline, week 2 and week 4, p= .05.

PSS score Mean Standard deviation N

Baseline 23.87 6.51 31Week 2 20.71 6.17 31Week 4 18.19 6.86 31

statistically significant, F(2, 58) = 22.22, p b .001, partial eta squared =.434. Bonferroni pairwise comparison tests suggested that althoughthere was a decrease in anxiety from week 0 (baseline) to week 2(mean difference 3.33) this change was not significant. However, whencomparing week 2 to week 4, a mean difference of 9.7 was found to besignificant (p = .05). Furthermore, when comparing week 0 (baseline)to week 4, the mean difference of 13.03 was significant (p = .05).

Descriptive statistics for the sample (n = 30) demonstrated a de-crease in mean from baseline of 38.13 (std. deviation 10.03) to 34.8(std. deviation 10.78) in week 2 and 25.1 (std. deviation 7.42) in week4 (p = .05). This represents a 34.2% decrease in anxiety as measuredby STAI state. Descriptive statistics results are presented in Table 3. Aprofile plot demonstrates the difference in means in Fig. 2.

STAI Trait Results

Mauchly's test of sphericity was found to be significant (p = .009)and the sphericity assumption had been violated. With a correctionaladjustment made to degrees of freedom through Greenhouse–Geisser,mean scores for anxiety were significantly different (F(1.56, 45.19) =20.48, p b 0.0005). Bonferroni adjustments for multiple comparisonsdemonstrated a decrease in anxiety from week 0 (baseline) to week 2(mean difference 3.13) and this change was significant (p = .05). Acomparison of week 2 to week 4 also demonstrated a decrease in traitanxiety (mean difference 4.4) and this change was statistically signifi-cant (p = .05). The comparison of week 0 (baseline) to week 4 alsodemonstrated a decrease in trait anxiety (mean difference 7.53) andthis change was also significant (p = .05).

Descriptive statistics for the sample (n=30)demonstrated adecreasein mean from baseline of 37.87 to 34.73 in week 2 and 30.33 in week 4(p= .05). Overall, this represents a 19.9% decrease in anxiety when com-paring baseline to week 4. Descriptive statistics results are presented inTable 4. A profile plot demonstrates the difference in means in Fig. 3.

Qualitative Results

Qualitative data, as measured by the self-report of nursing studentsin a six-itemquestionnaire developed by the researcher, reported a per-ceived reduction in anxiety and stress. Questions covered the following

Fig. 1. Estimated marginal means of PSS from baseline through week 4 (p = .05).

Table 3Descriptive statistics STAI state, baseline, week 2, and week 4 (p= .05).

STAI state score Mean Standard deviation N

Baseline 38.13 10.03 30Week 2 34.8 10.78 30Week 4 25.1 7.42 30

Table 4Descriptive statistics of STAI trait, baseline, week 2, and week 4 (p= .05).

STAI trait score Mean Standard deviation N

Baseline 37.87 11.69 30Week 2 34.73 10.67 30Week 4 30.33 8.12 30

108 S.L. Patterson / Nurse Education Today 40 (2016) 104–110

themes: ease of technique, changes in mood or feelings, immediate re-duction in stress, changes in anxiety or stress after 4 weeks, changes inmood after 4weeks, and other feelings or experienceswith EFT. Responseratewas 100% on all six questions. A text analysiswas performed throughSurveyMonkey on qualitative data to identify frequently used words andphrases. In addition, qualitative data was manually reviewed for individ-ual comments, and repeated themes were identified and categorized.

For the question, “Did you experience any changes in mood or feelingsimmediately after using the technique” a text analysis revealed that 87% ofthe students felt calmer, more relaxed after using EFT. Commentsincluded:

“I felt a decrease inmoods of tension and anxiety, and an increased feel-ing of control over the present situation I was in.”, “I was not as anxiousand it transferred to not being in a bad mood.” and “EFT did calm medown when I used it 15–30 minutes before a test.”

In addition to the feelings of increased calm and relaxation, 17% re-ported that the technique helped them sleep:

“This techniqueworked especially well when I woke up during the night(which happens rarely, but is annoying.). I would do EFT and go rightback to sleep.”, “Yes. I felt calm, sleepy, and relaxed. Most of the time,when I use EFT at night, I fall right asleep afterwards.”

For the question, “Did you experience any reduction in anxiety or stressimmediately after using EFT? If so, how did you experience the change(decreased heart rate, less agitation, etc.)?”, most participants (82%) de-scribed an immediate calming, relaxing, or less tension:

“I feel a sense of calm and relaxation after using the technique as manytimes as it took to take my mind off of the stress and anxiety.”, “Rightaway. It was very effective in reducing my stress in minutes.” and“Yes, I was almost always instantly calmer after 1 or 2 rounds of doingit.”

Many participants (51%) also reported a decrease in somaticsymptoms:

“Yes, decreased heart rate and decreased ‘tightening’ orweight in the pitof my stomach.”, “Yes. Less pressure in my chest.” and “I could feel thisrelief with the reduction of tension in my jaw,my heart rate would de-crease, and I could feel the tension leave my shoulders and neck.”

Fig. 2. Estimated marginal means of STAI state, from baseline through week 4 (p = .05).

For this same question, some (10%) also reported an increased feel-ing of control:

“More in control, breathing slowed.”, “Yes, I felt calmer andmore in con-trol of the current situation immediately after doing EFT.” and “I felt thatusing EFT gave me a perceived feeling of control and security.”

For the question, “After the four weeks of using EFT, did you experienceany overall change in mood or feeling?” A total of 38% reported that theirmood had not changed but they did find EFT to be an effective tool fordecreasing anxiety:

“Not really. I feel it worked better for me as an acute therapeutic tool.”,“Not particularly, I felt the technique worked to temporarily relievestress; I don't think I experienced an overall change inmood.” and “I stillexperience worries and nervousness; however, EFT has provided a wayto relieve those feelings, at least temporarily and provides a way to bet-ter control and manage those feelings.”

In contrast, 33% reported that EFT might have impacted their mood:

“I believe that my mood has improved since beginning EFT.”, “Yes, I felthappier. I feel that I am an easier going person.” and “I changed to moreof a positive mood/feeling while using EFT”. Some 20% of the partici-pants were not sure: “My overall mood has not been drasticallychanged, although I would say that my overall attitude has improvedgreatly and I ammore successful at being positive on a daily basis sincepracticing EFT.”, “It is really hard to say because I have so many otherthings going on right now. I have had some personal issues this pastmonth and I have a final coming up.” and “I feel great, but I don't knowif that is because of EFT.”

In the next inquiry, “After four weeks of using EFT, did you experienceany overall change in feelings of anxiety or stress? If so, how did you expe-rience the change (decreased heart rate, less agitation, etc.), 56% of partic-ipants admitted to experiencing less stress and anxiety after four weeksof using the technique. Comments included:

“I would say overall I am somewhat less anxious and stressed becausethings don't seem tomakeme upset quite as easily or quickly.”, “Slightly.

Fig. 3. Estimated marginal means of trait, from baseline through week 4 (p = .05).

109S.L. Patterson / Nurse Education Today 40 (2016) 104–110

I feel calmer.” and “Levels of anxiety have gone down to amore tolerablerate.”

A large number of respondents (43%) also reported that they werebetter able to cope after 4 weeks:

“I feel more empowered to tackle my stress level and confident that go-ing forward Iwill use the tool to keepmy stress levels at amore comfort-able level.”, “I felt like I still had stress but it was better controlled usingEFT.” and “EFT enabledme to experience a temporary relief of stress andanxiety.”

Some participants (12%) reported no change in stress and anxietyover the four weeks:

“I don't believe so. My heart rate and breathing become increased whenI get anxious.”, “No change. I do not wrestle with anxiety very much.”and “I don't think overall but I was able to use EFT to reduce my stressin immediate situations”.

For the question, “Are there any other feelings or experiences youwould like to comment on regarding your practice of EFT?” A total of 82%of participants provided positive comments about their experiencewith the technique; some of these include:

“I would say it's definitelyworthwhile to have in ‘your tool bag’ as awayto lessen anxiety as it's quick& easy to incorporate into one's daily rou-tine.” and “I feel much more able to manage my anxiety. Even though Istill feel anxious at times, I calm down more quickly.”

Discussion

Both qualitative and quantitative statistical analysis supported thepilot hypotheses, that nursing students participating in EFT wouldhave reduced anxiety relative to baseline as measured by the PerceivedStress Scale, the State–Trait Anxiety Inventory, and a qualitative survey.The qualitative data provided participant feedback rich in expression ofimproved feelings of calm, relaxation, and diminished agitation and ten-sion. Notably, some participants also identified a decrease in negativesomatic symptoms, as well as an improved ability to fall asleep. Mostparticipants also described that the technique provided them with afeeling of control over stress and anxiety, another tool for stress man-agement and coping.

For PSS data, the reduction in self-reported stress was statisticallysignificant with a mean difference baseline to week 4. PSS data support-ed claims in the literature that the stress experienced by nursing stu-dents is greater than that reported by the female population in general(Baldwin, 1999; Beck et al., 1997; Rhead, 1995). This is strongly reflectedin PSS results where baseline PSS measurement of stress in this samplewas considerably higher than Cohen andWilliamson's (1988) reportedPSS normative means for women (mean 13.7, std. deviation 6.6). The el-evated perceived stress reported by nursing students in this samplemayreflect a greater perception of stressful events, the need for better copingstrategies, and perhaps personality attributes that are particular to thosewho chose the nursing profession.

Conversely to PSS, STAI state results for baseline anxiety were justbelow Speilberger et al. (1983) normative values for females (mean38.76, std. deviation 11.95) and did not reflect the claim in the literaturethat the stress experienced by nursing students is greater thanmembersof the general female population.Most importantly and similar to PSS re-sults, for STAI state data, reduction in anxiety when comparing baselineto week 4 was also statistically significant. STAI trait results for baselineanxiety are also just below Speilberger et al.’s (1983) normative valuesfor females (mean 40.40, std. deviation 10.15). Similar to PSS and STAIstate results, the reduction in STAI trait scores baseline compared toweek 4 was also considerable. This result is surprising and differs with

expectations and results in the literature, since trait anxiety is reflectiveof one's personality trait for anxiety and is expected to be stable overtime. This may reflect that although the explanation to students com-pleting the STAI trait tool was to comment regarding their usual orlongstanding level of anxiety, students may have been commenting ontheir current level or state of anxiety.

Although the exact mechanism behind EFT has not been identified,Church (2010) suggests that tapping of meridian points while focusingon the fear or negative emotion decreases the associated feelings of anx-iety. Repeating of a statement of self-acceptance may contribute tochanging ones thinking or appraisal of the fear. Lane (2009) proposedthat acupressure tapping might produce “a biochemical relaxation re-sponse that counter conditions anxiety producing stimuli and traumaticmemories” (p. 11). Both of these explanations support Galbraith andBrown's (2011) suggestion that cognitive reappraisal and relaxationplay a key role in effective stress management techniques.

The literature suggests that EFT has been shown to significantlydecrease anxiety, and feelings of distress in a variety of populationsand settings. These settings and conditions included veterans, pho-bic individuals, athletes, individuals diagnosed with fibromyalgiaand others. Both qualitatively and quantitatively, the results of thispilot study support that EFT may also decrease the feelings of stressand anxiety experienced by nursing students as well as offer thema means for coping or give them some measure of control overexisting anxiety.

The study did have a number of limitations, one of which is its smallsample size (n = 39), which limits the ability to apply study results tothe general population. There was also potential for selection bias dueto convenience sampling. This selection or sampling bias, inherent to con-venience sampling, was accepted in this studywith the knowledge that italso decreased the ability to apply the study results to the general popu-lation. In addition, the nature of nursing being a profession dominated byfemales, persons of male gender were diminished from the sample. Thisagain represents a selection bias and limits the ability to generalizestudy results across genders. Attention biasmay also have been a limitingfactor since participants were aware of their involvement, and the studyhypothesis. As a result of this bias, participantsmay have given amore fa-vorable response when responding to the instruments. Participants wereall familiar with the researcher as a current or former instructor. Thiscould potentially influence participants providing a more favorable re-sponse to instrument questions. However, the 98% study retention ratesuggests that the efficacy of the EFT was instrumental in keeping partici-pants engaged.

Conclusions and Implications for Nursing

EFT can be another tool for successful stress management and anxi-ety relief in nursing students. Beyond efficacy, the simplicity and imme-diacy of EFT make it especially attractive. The technique can be taughtquickly and then practiced by the individual with no need for frequenttherapist intervention or the associated costs. Even more important,therapeutic effects have been reported to occur quickly, perhaps eveninstantaneously after performing the technique. Stress reduction andthe resulting feelings of well-being and self-efficacy promote psycho-logical health and hardiness. The psychologically hardy individual isbetter able to cope and endure the certain stressors of academics andlater, the professional environment. Improved academic and profes-sional retention is critical in nursing and in healthcare.

With the predictions for an unprecedented nursing shortage loomingin the next ten years, attracting and retaining competent candidates fornursing is imperative. Furthermore, to succeed in today's healthcareenvironment, the nursemust be resilient. Arming studentswith effectivecoping techniques increases their chances for successful health mainte-nance and professional longevity as they move from academics topractice.

110 S.L. Patterson / Nurse Education Today 40 (2016) 104–110

References

Baldwin, P., 1999. Stress and the nurse. Nurs. Stand. 13 (16), 22–24.Beck, D., Hackett, M., Srivastava, R., McKim, E., Rockwell, B., 1997. Perceived level of and

sources of stress in university professional schools. J. Nurs. Educ. 36 (4), 180–186.Boutin, G., Tosi, D., 1983. Modification of irrational ideas and test anxiety through rational

stage directed hypnotherapy. J. Clin. Psychol. 39 (3), 382–391.Brattberg, G., 2008. Self-administered EFT (emotional freedom techniques) in individuals

with fibromyalgia: randomized trial. Integr. Med. 7 (4), 2008.Charlesworth, E., Murphy, S., Beutler, L., 1981. Stress management skill for nursing stu-

dents. J. Clin. Psychol. 37 (2), 284–290.Church, D., 2009a. The effect of EFT on athletic performance: a randomized control blind

trial. Open Sports Sci. J. 2, 94–99.Church, D., 2009b. The treatment of combat trauma in veterans using EFT: a pilot proto-

col. Traumatology 16 (1), 55–65.Church, D., 2010. The EFT Mini-Manual. Energy Psychology Press, Fulton, CA (Retrieved

from http://eftuniverse.com/index.php?option=com_subscribe&Itemid=17%3).Church, D., Brooks, A., 2010. The effect of a brief emotional freedom techniques self-

intervention on anxiety, depression, pain and cravings in health care workers. Integr.Med. (Encinitas) 9 (5), 40–43.

Church, D., Geronilla, L., Dinter, I., 2009. Psychological symptom change in veterans aftersix sessions of emotional freedom technique (EFT): an observational study. WholisticHealing Publ. 9 (1), 1–13.

Church, D., Hawk, C., Brooks, A., Toukolehto, O., Wren, M., Dinter, I., Stein, P., 2010. Psy-chological trauma in veterans using EFT (emotional freedom technique): a random-ized controlled trial [Special section]. Society of Behavioral Medicine, Seattle, WA.

Church, D., De Asis, M.A., Brooks, A.J., 2012a. Brief group intervention using EFT (emotion-al freedom techniques) for depression in college students: a randomized controlledtrial. Depress. Res. Treat. 2012, 1–7.

Church, D., Yount, G., Brooks, A., 2012b. The effect of emotional freedom techniques (EFT)on stress biochemistry: a randomized controlled trial. J. Nerv. Ment. Dis. 200 (10),891–896.

Cohen, S., Williamson, G., 1988. Perceived stress in a probability sample of the UnitedStates. In: Spacapan, S., Oskamp, S. (Eds.), The Social Psychology of Health. Sage,Newbury Park, CA, pp. 31–66.

Cohen, S., Kamarck, T., Mermelstein, R., 1983. A global measure of perceived stress. J. HealthSoc. Behav. 24, 385–396 Retrieved from http://www.psy.cmu.edu/~scohen/.

Craig, G., 2010. The EFT Mini Manual. Energy Psychology Press, Fulton, CA.Deary, I., Watson, R., Hogston, R., 2003. A longitudinal cohort study of burnout and attri-

tion in nursing students. J. Adv. Nurs. 43 (1), 71–81.Elliott, M., 2002. The clinical environment: a source of stress for undergraduate nurses.

Aust. J. Adv. Nurs. 2 (1), 34–38.Galbraith, N., Brown, K., 2011. Assessing intervention effectiveness for reducing stress in

student nurses: quantitative systemic review. J. Adv. Nurs. 67 (4), 709–721. http://dx.doi.org/10.1111/j.1365-2648.2010.05549.x.

Gibbons, C., Dempster, M., Moutray, M., 2008. Stress and eustress in nursing students.J. Adv. Nurs. 61, 282–290. http://dx.doi.org/10.1111/j.1365-2648.2007.04497.x.

Hamrin, V., Weycer, A., Pachler, M., Fournier, D., 2006. Evaluation of peer-led supportgroups for graduate nursing students. J. Nurs. Educ. 45 (1), 39–42.

Hsiao, Y., Chien, L., Wu, L., Chiang, C., Huang, S., 2010. Spiritual health, clinical practicestress, depressive tendency and health promoting behaviors among nursing students.J. Adv. Nurs. 66 (7), 1612–1622 (http://nccam.nih.gov/health/whatiscam/ 2010.What is complementary and alternative medicine).

Jimenez, C., Navia-Osorio, P., Diaz, C., 2010. Stress and health in novice and experiencednursing students. J. Adv. Nurs. 66 (2), 442–455.

Jones, M., Johnston, D., 1997. Distress, stress and coping in first year nursing students.J. Adv. Nurs. 26, 475–482.

Jones, M., Johnston, D., 2000. Evaluating the impact of a worksite stress management pro-gramme for distressed student nurses: a randomized trial. Psychol. Health 15,689–706.

Lane, J., 2009. The neurochemistry of counter conditioning: acupressure desensitization inpsychotherapy. Energy Psychol. 1 (1), 1–14.

Lindop, E., 1999. A comparative study of stress between pre- and post-project 2000 stu-dents. J. Adv. Nurs. 29 (4), 967–973.

Melnyk, M.B., Cole, R., 2011. Generating evidence through quantitative research. In:Melnyk, B., Fineout-Overholt, E. (Eds.), Evidence-Based Practice in Nursing andHealthcare. Wolters Kluwer Heath/Lippincott Williams & Wilkins, Philadelphia, PA,pp. 397–448.

National Center for Complementary and Alternative Medicine, 2012,. What is Comple-mentary and Alternative Medicine. http://nccam.nih.gov/health/whatiscam.

Rhead, M., 1995. Stress among student nurses. J. Clin. Nurs. 4, 369–376.Rowe, J., 2005. The effects of EFT on long-term psychological symptoms. Couns. Clin.

Psychol. J. 2 (3), 104–111.Speilberger, C.D., Gorsuch, R.L., Lushene, R.D., Vagg, P.R., Jacobs, G.A., 1983. The State–Trait

Anxiety Inventory for Adults. Manual and Sample, Manual Instrument and ScoringGuide. Consulting Psychologists Press: Mindgarden Inc. (www.mindgarden.com).

Timmins, F., Kaliszer, M., 2002. Aspects of nurse education programmes that frequentlycause stress to nursing students—fact finding sample survey. Nurse Educ. Today 22,203–211.

Waite, W., Holder, M., 2003. Assessment of the emotional freedom technique. Sci. Rev.Ment. Health Pract. 2 (1), 1–17.

Watson, R., Gardiner, E., Hogston, R., Gibson, H., Stimpson, A., Wrate, R., Deary, I., 2008. Alongitudinal study of stress and psychological distress in nurses and nursing students.J. Clin. Nurs. 18, 270–278.

Wells, S., Polglase, K., Andrews, H., Carrington, P., Baker, A.H., 2003. Evaluation of ameridian-based intervention emotional freedom technique for reducing specific pho-bias of small animals. J. Clin. Psychol. 59, 943–966.

White, A., 2012. Using samples to provide evidence. In: Schmidt, N., Brown, J. (Eds.),Evidence-Based Practice for Nurses. Jones & Bartlett Learning, Sudbury, MA,pp. 246–271.

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BRIEF REPORT

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 STUDENTSDaniel J. Benor, MD,1 Karen Ledger, RN, BScN,1 Loren Toussaint, PhD,2# Geoffrey Hett, PhD,3

and Daniel Zaccaro, BA2

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bjective: This study explored test anxiety benefits of wholisticybrid derived from eye movement desensitization and repro-essing and Emotional Freedom Techniques (WHEE), Emo-ional Freedom Techniques (EFTs), and cognitive behavioralherapy (CBT).

articipants: Canadian university students with severe or mod-rate test anxiety participated.

ethods: A controlled trial of WHEE (n � 5), EFT (n � 5), andBT (n � 5) was conducted. Standardized anxiety measures

ncluded the Test Anxiety Inventory and Hopkins Symptomhecklist-21.

esults: Despite small sample size, significant reductions in test

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38 © 2009 by Elsevier Inc. Printed in the United States. All Rights ReserISSN 1550-8307/09/$36.00

HEE and EFT achieved the same benefits as CBT did in fiveessions. Participants reported high satisfaction with all treat-ents. Emotional freedom techniques and WHEE participants

uccessfully transferred their self-treatment skills to other stress-ul areas of their lives.

onclusions: Both WHEE and EFT show promise as feasiblereatments for test anxiety.

ey words: Test anxiety, exam anxiety, emotional freedomechnique (EFT), wholistic hybrid derived from eye move-ent desensitization and reprocessing and Emotional Free-

om Techniques (WHEE), cognitive behavioral therapyCBT)

Explore 2009; 5:338-340. © Elsevier Inc. 2009)

NTRODUCTIONhis study investigated the feasibility of two “Energy Psychol-gy” techniques and cognitive behavioral therapy (CBT) in re-ucing test anxiety. Both emotional freedom techniques (EFT)1

nd wholistic hybrid derived from eye movement desensitiza-ion and reprocessing and Emotional Freedom TechniquesWHEE)2 are potent self-treatment methods for dealing withild to severe stress, are safe for use outside the therapist’s office,

nd do not produce heavy emotional abreactions.Emotional Freedom Techniques is a mental/emotional ver-

ion of acupressure that can be self-applied for a wide range ofmotional, health, and performance issues. Emotional Freedomechniques is based on the connection between a person’s

houghts and emotions and the body’s subtle energies, neuro-ogical activity, and cellular function. Emotional Freedom Tech-iques treatment gently removes unconscious blocks to healingith a statement about the negative issue while repeating a self-ffirmation and massaging neurolymphatic points on the chest

Association for Comprehensive Energy Psychology, Haverford, PADepartment of Psychology, Luther College, Decorah, IAUniversity of Victoria, Victoria, British Columbia

Corresponding Author. Address:epartment of Psychology, Luther College,

00 College Drive, Decorah, IA 52101

r hand. This is followed by tapping or rubbing a specific se-uence of acupuncture points on the face, upper body, andands while repeating a reminder phrase about the negative

ssue. Emotional Freedom Techniques acupuncture points inter-ace with the person’s neurophysiological systems to increasehysical, emotional, and neurological stability.1

The methodology for WHEE combines the alternating rightnd left body stimulation derived from EMDR, with affirma-ions modified from EFT as a person focuses on their anxieties.gain borrowing from EMDR, WHEE installs positive cogni-

ions and feelings to replace the negative ones that have beeneleased. Anxieties are reduced by WHEE very rapidly and

HEE is used by people on their own to reduce recurrentnxieties as needed.2 Eye movement desensitization and repro-essing, from which WHEE is partly derived, has four studiesemonstrating efficacy for test anxiety3-6 and many studies dem-nstrating efficacy for treating severe emotional trauma. In fact, themerican Psychiatric Association has acknowledged EMDR as hav-

ng the same efficacy as CBT in treatment of both acute and chronicosttraumatic stress disorder.7

Generally speaking, energy psychology research is still in itsarly days.8 Energy psychology has demonstrated efficacy inreatment of generalized anxiety disorder,8 weight control bysing the Tapas Acupressure Technique,9 and specific phobiasy using EFT.10 Clinical observations by D.J.B. and K.L. indi-ate that test anxiety responds rapidly and well to WHEE and

ved EXPLORE November/December 2009, Vol. 5, No. 6doi:10.1016/j.explore.2009.08.001

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re easily learned, rapidly effective, can be administered inroups, and are safe to use on one’s own.Cognitive behavioral therapy can include a variety of modal-

ties. In this study, muscle relaxation with systematic desensiti-ation, individualized to each student’s anxieties about theirests, were used.11 Effectiveness of CBT has been demonstratedor test anxiety.12 We have found no studies exploring the rate ofhange of anxiety over the course of CBT therapy or of particu-ar components of CBT that are effective in addressing test anx-ety, which are some of the issues explored in this study.

resent Study Objectivesiven the encouraging early findings in energy psychology tech-iques, the purpose of this study was to evaluate the efficacy ofHEE and EFT in treating test anxiety in college students by

sing CBT as a control group. This study examined closely theate of improvement in test anxiety resulting from each treat-ent. We expected that WHEE and EFT would be equally

ffective as CBT in bringing about relief from test anxiety, andhat these benefits could be realized in fewer treatment sessionshan with CBT.

ETHODarticipantsrom an initial pool of 27 volunteers, 15 students met the inclu-ion criterion and completed the study. The inclusion criterionas that the student had to demonstrate moderate (�37 forales, �41 for females) to severe (46 for males and 51 for fe-ales) test anxiety on the Spielberger Test Anxiety Inventory.se of major tranquilizers or a history of psychosis were exclu-

ion criteria. Ethics review and approval was granted through thenstitutional Review Board of Luther College and all studentsrovided informed consent for the study and treatment.

herapistsaniel Benor, MD, is the developer of WHEE. He is a psychi-

tric psychotherapist with training in EMDR and EFT and eightears’ experience in using WHEE. Karen Ledger, RN, BScN, is aealth educator and nurse-counselor with 13 years of experienceeaching and working with EFT in groups and one-on-one ther-py. Geoffrey G. Hett, PhD, retired from the University of Vic-oria in 2008 and specialized in teacher education and counsel-ng psychology. Much of his career was directed toward teachingnd supervising MA and PhD students in the use of CBT.

esign and Procedureur intent was to randomly assign all participants to one of three

reatment groups. Due to a poor response to multiple recruit-ent efforts and conflicts with class schedules, we were not able

o randomly assign participants to the treatment groups. Stu-ents were assigned to treatments on the basis of scheduling andvailability. Both WHEE and EFT interventions were conductedn two weekly sessions lasting two hours. Cognitive behavioralherapy consisted of five approximately two-hour sessions fo-

motional Freedom Techniques

ents were made at baseline (ie, recruitment), one day beforexams, and one day after exams.

easurestandardized assessments included the Test Anxiety Inventory13

nd the Hopkins Symptom Checklist-21.14 Qualitative demo-raphic and personal history data were also collected.

ESULTSuantitative Analysesest Anxiety Inventory data were submitted to a 3 (EFT vs CBTs WHEE) � 3 (base vs preexamination vs postexamination)ixed model repeated measures analysis of variance (ANOVA).he main effect for time of testing was significant (F � 32.4; P �

001). There was a decrease in anxiety from base (mean � 62.3,D � 7.9) to preexamination (mean � 52.5, SD � 7.1) to pos-examination (mean � 42.7, SD � 9.4). All pair-wise differencesere statistically significant (P � .001). There was no treatmentroup � time interaction (F � 1.6, not significant). Hence, theate of decrease in anxiety across the three treatment conditionsas similar.Because of nonparallelism present in graphical plots of theeans of the three treatment conditions across the three time

oints and concerns about type II error involved in testing in-eractions with small samples, we further examined decreases innxiety separately for each treatment condition. For the EFT and

HEE treatment groups, all decreases in anxiety across timeere statistically significant (P � .05). For the CBT treatmentroup, there were no statistically significant decreases in anxietyt any time point. Hence, although the omnibus test of thenteraction was not significant, decreases in anxiety did appear toiffer quite dramatically across treatment conditions. Wholisticybrid derived from EMDR and EFT treatments yielded statis-ically significant decreases in anxiety in only two sessions.

Hopkins Symptom Checklist-21 data were also submitted to ahree (EFT vs CBT vs WHEE) � three (base vs preexaminations postexamination) mixed model repeated measures ANOVA.gain, the main effect for time was significant (F � 8.7; P �

001). There was a decrease in distress from base (mean � 50.3,D � 12.9) to preexamination (mean � 39.4, SD � 9.5) toostexamination (mean � 35.3, SD � 9.0). Decreases in distressrom base to preexamination and base to postexamination weretatistically significant (P � .05), but distress scores at preexami-ation and postexamination were the same (not significant).here was no treatment group x time interaction (F � 0.3, not

ignificant). Hence, the rate of decrease in distress across thehree treatment conditions was similar.

ualitative Analyseshe qualitative responses of students who completed the studyere uniformly favorable regarding treatment benefits related to

heir test anxiety, (qualitative data is available upon request).mportantly, students in the WHEE and EFT groups were moreikely to have used these skills to also reduce stress responses in

339EXPLORE November/December 2009, Vol. 5, No. 6

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ISCUSSIONoth WHEE and EFT are promising new methods for the treat-ent of test anxiety. They produced effects in only two sessions,

s compared with five CBT sessions. Students reported usingach of the methods frequently and transferring the use of EFTnd WHEE to reduce stressors in other areas of their lives, withood effect. These findings, in essence, confirm others showingromising benefits of energy psychology in treating many psy-hological conditions.

imitationshis pilot study has some key limitations. First, random assign-ent was not possible. Second, our sample size was small, lim-

ting the power of statistical tests. Although these factors limithe generalizability of the results of this pilot study, they suggesthat further, more rigorous studies may be warranted, and les-ons learned from this study will be helpful to other researchersn planning their studies.

ONCLUSIONShe limitations of the present study notwithstanding, this is therst known study to demonstrate the efficacy of WHEE and EFT

n the treatment of test anxiety in college students, and the firstomparison of these methods with CBT. Our data are prelimi-ary, but with continued attention to the importance of com-lementary/alternative energy psychotherapies, larger-scale rep-ications of this work will provide additional evidence of thefficacy of these techniques. Future studies will no doubt offer aocused lens in which to view the impressive and efficient effectsf energy psychology techniques for use with a broad array ofsychological maladies.

EFERENCES1. Waite LW, Holder MD. Assessment of the emotional freedom tech-

nique: an alternative treatment for fear. Sci Rev Ment Health Pract.

40 EXPLORE November/December 2009, Vol. 5, No. 6

2. Benor DJ. 7 Minutes to Natural Pain Release: WHEE for Tapping YourPain Away–The Revolutionary New Self-Healing Method. Fulton, Calif:Energy Psychology Press; 2008.

3. Bauman W, Melnyk WT. A controlled comparison of eye move-ments and finger tapping in the treatment of test anxiety. J BehavTher Exp Psychiatry. 1994;25:29-33.

4. Gosselin P, Matthews W. Eye movement desensitization and repro-cessing in the treatment of test anxiety: a study of the effects ofexpectancy and eye movement. J Behav Ther Exp Psychiatry. 1995;26:331-337.

5. Maxfield L, Melnyk WT. Single session treatment of test anxietywith eye movement desensitization and reprocessing (EMDR). Int JStress Manag. 2000;7(2):87-101.

6. Stevens MJ, Florell DW. EDMR as a treatment for test anxiety.Imagin Cogn Pers. 1998-1999;18:285-296.

7. American Psychiatric Association. Practice Guideline for the Treatmentof Patients with Acute Stress Disorder and Posttraumatic Stress Disorder.Arlington, Va: American Psychiatric Association Practice Guide-lines; 2004.

8. Feinstein D. Energy psychology: a review of the preliminary evi-dence. Psychotherapy: theory, research, practice. Training. 2008;45:199-213.

9. Elder C, Ritenbaugh C, Mist S, et al. Randomized trial of twomind-body interventions for weight-loss maintenance. J Altern Com-plement Med. 2007;13:67-78.

0. Wells S, Polglase K, Andrews HB, Carrington P, Baker AH. Evaluationof a meridian-based intervention, emotional freedom techniques(EFT), for reducing specific phobias of small animals. J Clin Psychol.2003;59:943-966.

1. Cormier S, Nurius PS, Osborn CJ. Interviewing Change Strategies forHelpers: Fundamental Skills and Cognitive Behavioral Interventions. Flo-rence, Ky: Brooks Cole; 2008.

2. Wachelka D, Katz RC. Reducing test anxiety and improving aca-demic self-esteem in high school and college students with learningdisabilities. J Behav Ther Exp Psychiatry. 1999;30(3):191-198.

3. Test Anxiety Inventory. Mind Garden. Available at: http://www.mindgarden.com/products/tsans.htm. Accessed August 21, 2008.

4. Green DE, Walkey FH, McCormick IA, Taylor AJW. Developmentand evaluation of a 21-item version of the Hopkins SymptomChecklist with New Zealand and United States respondents. Aust

Emotional Freedom Techniques

ORIGINAL RESEARCH

EMOTIONAL FREEDOM TECHNIQUES IN THE TREATMENT OF UNHEALTHY

EATING BEHAVIORS AND RELATED PSYCHOLOGICAL CONSTRUCTS IN

ADOLESCENTS: A RANDOMIZED CONTROLLED PILOT TRIAL

and Terri Sheldon, BA (Hons)2,*

Context: In Australia and throughout much of the world, ratesof obesity continue to climb as do the prevalence of eating dis-orders, particularly in adolescents. Psychological consequences ofchildhood obesity include low self-esteem, depression, body dissa-tisfaction, and social maladjustment (Young-Hyman et al., 2012).

Objective and Intervention: This feasibility study sought toexamine the impact of a six-week Emotional FreedomTechniques (EFT) group treatment program upon eatingbehaviours, self-esteem, compassion, and psychological symp-toms. Design: Forty-four students were randomly allocated toeither the EFT group or the waitlist control group.

e-mail: [email protected]

1 School of Psychology, Bond University, Gold Coast, Queensland4229, Australia2 The Lakeside Rooms, Gold Coast, Queensland 4229, Australia

#Corresponding author.

* Mailing address: Suite 9, North Building, 34-36 GlenferrieDrive, Robina, QLD 4226.

& 2016 Elsevier Inc. All rights reserved.ISSN 1550-8307/$36.00

Results: Results revealed a delayed effect for both groups atpost-intervention, with improved eating habits, self-esteem,and compassion at follow-up. Findings provide preliminarysupport for EFT as an effective treatment strategy for increas-ing healthy eating behaviours and improving associatedweight-related psychopathology.

Key words: EFT, obesity, self-esteem, psychological distress,eating behaviours, compassion

(Explore 2016; 12:113-122 & 2016 Elsevier Inc. All rightsreserved.)

The global obesity epidemic has been accelerating for fourdecades, with limited prevention efforts being instigated duringthis period.1 Recent research conducted by the (WHO) reportsthat obesity represents the fifth leading cause of global deaths.Additionally, the eating behaviors of adolescents has receivedwidespread attention in recent years, with alarming predictionsthat children today will be the first generation to die earlierthan their parents if sufficient preventative measures are nottaken.2

Vast amounts of research indicate these disturbing forecastsare largely due to eating behaviors.3,4 There are also a numberof eating behaviors that develop during the period of child-hood and adolescence that can manifest into eating-relatedpsychopathology.5 These disordered behaviors have a myriadof long-term physical and psychological consequences,including increased risk of chronic health conditions.3 This

highlights the importance of designing effective strategies forthe prevention and management of this global epidemic.

FOOD CHOICES AND EATING BEHAVIORSThe Australian Nutritional Survey6 indicated that the dietaryconsumption of Australian adolescents is inadequate. A broadrange of factors have been identified that influence the eatingbehaviors of youth.7 These factors include social modeling,access to healthy food, exposure to food advertising, negativeemotions, and parental influence.7,8 Ackard et al.9 found thatin a school-based sample of approximately 4700 students,57% of girls and 33% of boys reported using unhealthy weightcontrol behaviors in order to lose weight. Additionally, thestudy found that 17.3% of girls and 7.8% of boys reportedthat they had engaged in overeating in the past year.Participants who reported overeating were more likely to beoverweight or obese, currently dieting, and scored significantlylower on measures of self-esteem and body satisfaction.Nutritionally sparse diets, cravings for readily accessible

unhealthy foods, and overeating are implicated in theetiology of unhealthy eating habits among adolescents.10

These unhealthy habits are associated with poor healthoutcomes, such as a higher risk of developing chronicdisease as adults, increased risk of obesity in adulthood,increased susceptibility to psychological distress, and poorer

113EXPLORE March/April 2016, Vol. 12, No. 2http://dx.doi.org/10.1016/j.explore.2015.12.001

overall quality of life.11 Paradoxically, pressure to fit an idealbody shape can lead to unhealthy weight loss endeavors suchas fasting and dietary restraint, which may increase thepropensity to binge eat.9,12 Previous studies have establishedthat fasting or restricting dietary intake is linked to bothweight gain/obesity and disordered eating/eatingdisorders.13,14

PSYCHOLOGICAL FACTORS ASSOCIATED WITHOBESITYStudies exploring the role of psychological factors in obesityhave revealed several important findings, including variousconstructs being implicated in the etiology, maintenance, andprevention of obesity. A study by Young-Hyman et al.15

showed a clear association between psychological distress andobesity, whereby overweight and obese children reportedhigher levels of psychological distress.

Self-EsteemStudies have consistently demonstrated self-esteem, specifically,as a factor implicated in the etiology and maintenance ofchildhood and adolescent obesity.16 French et al.17 reviewed35 outcome studies investigating the link between self-esteemand obesity in children and adolescents. Findings of this meta-analysis revealed that obese adolescents consistently reportedlower self-esteem in comparison to their non-obese counterparts,which was in turn associated with greater body dissatisfaction,negative perceptions of body image, and other psychologicalsymptoms. Similar findings have been established in otherstudies of the relationship between self-esteem, obesity, andother psychological constructs.17,18

Randomized controlled trials have also revealed that beingoverweight or obese can lead to a number of mental healthoutcomes, including depression, anxiety, reduced self-esteem,self-compassion, and self-worth, and in extreme cases, sui-cide.4,14,19 Overall, these findings indicate an urgent need formore holistic interventions that also take into accountpsychological and mediating variables of health.20

Researchers in the area of prevention and treatment ofobesity have previously sought to target certainpsychological factors in order to counteract the deleteriouspsychological consequences of obesity.21,22

Self-CompassionMore recently, empirical literature has established self-compassion as a construct associated with improved eatingbehaviors.23 Self-compassion refers to an individual having anunderstanding for the self instead of being judgmental orcritical.24 Previous studies suggest that self-compassion is alsostrongly linked to psychological and physiological health,with individuals higher in self-compassion being more likelyto exercise regularly25 and maintain a healthy diet.23 Foradolescent populations, studies indicate that higher ratings ofself-compassion are associated with increased ability toidentify and modify unproductive behaviors.26 Kelly et al.27

found that, among clients diagnosed with an eating disorder,increases in self-compassion were associated with decreases inpoor eating behaviors including binge eating.

114 EXPLORE March/April 2016, Vol. 12, No. 2

INTERVENTION PROGRAMSA number of multi-disciplinary and population-based treat-ment programs have been recommended.28 In a meta-analysisof 131 published studies, Russell-Mayhew et al.14 reportedthat the majority of programs that have attempted tointervene in childhood or adolescent obesity have focusedon food intake, nutrition, and physical activity. The rate ofefficacy in these types of approaches is estimated at 20%.According to an Australian study by Williams et al.,29

successful preventative measures for unhealthy eating mustinclude encouragement of healthy food choices, provision ofeducation, and increased availability of healthy food. Meta-analysis and follow-up studies indicate that any gains fromprevention and intervention programs are generally notmaintained,30 which suggests the need for more holisticinterventions that also take into account other variables,including psychological constructs.20

EMOTIONAL FREEDOM TECHNIQUESEmotional freedom techniques (EFT) is a relatively new,meridian-based technique that is gaining acceptance as anevidenced-based, clinically useful tool within the realm ofenergy psychology.31,32 EFT is a group of exposure therapiesthat consist of somatic and cognitive elements, which aredesigned to target emotional discomfort.33 Sojcher et al.34

review found that energy psychology strategies havepromising outcomes for obesity and binge eating disorder-related difficulties. Other randomized controlled trials havedemonstrated that EFT is effective in reducing food cravings,resulting in reduced weight, craving restraint and psycholog-ical coping in adult trials.35,36

In a randomized controlled trial37 of 96 overweight/obeseadults, participants were allocated either to an EFT-basedtreatment or to a four-week waitlist condition. Compared towaitlist participants, the EFT group reported significantimprovements in food cravings, craving restraint, and thesubjective power of food. These effects were maintained at 6and 12 months, with additional reductions in BMI and bodyweight. Researchers concluded that EFT demonstrated effi-cacy in reducing cravings, and led to a reduction of weight inoverweight and obese individuals.36 Evidence suggests thatparticularly positive aspects of energy psychology treatmentsare the often-enduring results displayed within short time-frames of between one to six weeks.38-40 The process of EFTinvolves focusing on the situation identified as causing thedistress and tapping on specific meridian points on thebody.33

More recently, Stapleton et al.41 compared the effectivenessof EFT and Cognitive Behavioral Therapy (CBT) in thetreatment of food cravings among 88 overweight and obeseadults. Both the EFT and CBT groups reported significantdecreases in food cravings, craving restraint, and subjectivepower of food from pre-treatment to six-month follow-up.The EFT group lost on average 6.79 kg from pre-treatment tosix-month follow-up, while the CBT group lost only 4.33 kgfrom pre-treatment to six-month follow-up. Dawson andWilde examined the effectiveness of a six-week online weightloss program in achieving weight loss among adults. Results

EFT in the Treatment of Unhealthy Eating Behaviors

Table 1. Weekly Program Content

Brief Overview of Content

Week 1 Explanation of EFT; confidentiality and program rulesWeek 2 Body image, resilience, and self-compassionWeek 3 Dietary requirements, water intake, and taking care of

yourselfWeek 4 Importance of exercise and of getting sufficient sleepWeek 5 Information about takeaway/junk foods and how to beat

cravingsWeek 6 Making goals and sticking to them; debriefing of

program; questions and comments.

EFT ¼ emotional freedom techniques.

of the study showed that participants reported an averageweight loss of 5.44 kg from pre- to post-treatment and afurther 1.36 kg in the six-month period following the inter-vention program. In an outcome study42 of 216 healthcareworkers attending a single, full-day EFT group workshop,participants reported significant reductions (i.e., to a non-clinical level) in addictive cravings for chocolate, food ingeneral, alcohol, and tobacco. Moreover, the study of Churchand Brooks43 indicated that participants' completing an EFTweekend workshop targeting addiction reported significantlyreduced psychological distress post-treatment, which mayimply that EFT may be an effective adjunct to addictiontreatment such as food cravings, by reducing the severity ofindividuals' general psychological distress. However, there is adistinct lack of research exploring the effectiveness andclinical utility of EFT for targeting eating behaviors,psychological distress, or physical activity among childrenand adolescents, specifically.

CURRENT STUDYThe overarching goal of the study was to develop a clinicalprotocol and framework for an effective, enduring, and low-cost intervention program for increasing healthful lifestylepractices among 14- and 15-year olds. The current studyaimed to assess whether frequency of eating behavior, self-esteem, self-compassion, and psychological distress improvedfollowing completion of the six-week EFT program. Thestudy also aimed to evaluate the impact of EFT across time,including between pre-treatment, post-treatment, and 10-week follow-up. Finally, the study aimed to compare theresults of the EFT group participants to the waitlist group. Itwas hypothesized that, at post-intervention, the EFT groupwould report increased positive eating behaviors, decreasednegative eating behaviors, increased self-esteem, increased self-compassion, and decreased psychological distress, comparedto the WL group. Moreover, it was hypothesized that thesetreatment effects would be maintained at 10-week follow-upfor the EFT group, in comparison to the WL group.

METHODProcedureEthical approval was obtained from the Bond UniversityHuman Research Ethics Committee prior to the commence-ment of the study. Approval for conducting research atQueensland schools was obtained from the Department ofEducation, Training and Employment. The principal of Helen-svale State High School was provided with this documentation.A letter was sent to participants' parents including an explan-atory statement of the current study. Participants were providedwith a list of local counseling services to ensure that participantsand their parents had sufficient contact options if participantsexperienced any psychological distress throughout the study.Treatment fidelity plans for the EFT groups were formed prior

to the trial commencing. The primary investigator and the EFTintervention practitioners developed and reviewed the treatmentmanuals to ensure the active ingredients of the intervention wereadequately operationalized. Fidelity was not monitored using

EFT in the Treatment of Unhealthy Eating Behaviors

audio or video recording, but rather facilitators completedintervention checklists, and participants completed weekly socialvalidity scales (described below). EFT treatment delivered wasbased on standardized treatment protocols44 and provided byEFT practitioners via a group setting. One facilitator was acounselor and certified at level 2 by EFT Universe, with 30 yearsof prior counseling experience in critical incident stressdebriefing. The other facilitator was a level 3 AAMET certifiedcounselor with a Masters of Counseling degree. A Masters ofClinical Psychology student and a Registered Nurse completingher Honors in Psychology supported facilitators. Each sessionconsisted of 70 min of treatment per week, every Tuesday at thesame time. Table 1 briefly outlines weekly program topics andcontent. Note that each of the topics introduced in each sessionwere addressed using the EFT tapping sequence; as such, EFTwas a component of each session.At the end of each session, participants were given take-

home EFT information and activities to complete. In order toprotect participant privacy, fidelity was not monitored viaaudio or video recording; however, intervention checklistswere used and optional social validity scales in the form of aweekly evaluation (described earlier) were distributed uponsession completion. The post-intervention questionnaire wasadministered at the conclusion of the final session in week 6.The 10-week follow-up questionnaire was completed via hardcopy in a classroom on the school premises.

RecruitmentPotential participants were recruited from a local State HighSchool to take part in a six-week pilot study consisting of70 min of treatment per week. The recruitment process wasnot limited to participants who were self-identifying as havingdifficulties with weight or eating behaviors, but rather wasoffered to any adolescent wishing to “to inspire healthyeating, increased physical activity, and improved resilience.”Inclusion criteria specified that participants should bebetween 12 and 18 years old and have parental consent toparticipate in the treatment. Exclusion criteria includedstudents not capable of physical activity, known sufferers ofdiabetes (types 1 and 2), and adolescents with hypoglycemic.Initially 60 students currently attending grade 9 were

approached to take part in the study. Appropriate parentalconsent forms were returned by 28 students. These students

EXPLORE March/April 2016, Vol. 12, No. 2 115

completed their own participant consent forms, except fortwo individuals who declined to take part in the study. Dueto limited participant availability and the requirement to fitthe program around normal school curriculum, participantswere randomly allocated (via a computerized random numbergenerator system) to two intervention groups. A statistician,unconnected to the study and blind to its aims, at the leadauthor's previous institution completed the computer ran-domization and subsequent data analyses. The first group, theEFT group, consisted of 12 participants and was run duringterm 2 of the school year. The second group, the WL group,consisted of 14 participants and was conducted in term 3.Outcomes for the WL group will be analyzed and presentedin a separate study. The format of the intervention did notchange between groups. In total, 26 participants took part inthe six-week intervention. All 26 participants completed the

WL Group Baseline Measurement(N = 12)

Analysed (n

Expressed interest(N = 6

Given consent formsignatu

Analyse(n = 22

10-week fol

Lost to follow-up (n = 0)

Returned participa(N = 2

WL Group Declined to Partake in Study(N = 1)

WL Group Post Measurement(N = 11)

Figure 1. Consort participant flow di

116 EXPLORE March/April 2016, Vol. 12, No. 2

program. However, four participants from the EFT group didnot complete their final assessments and their data could notbe used in the study analyses. Other reasons for drop outsincluded study commitments and school absence on treat-ment days. There were no adverse events to report. Attend-ance rate average was 4.85 sessions (out of a total six) for thetotal sample. Refer to Figure 1 for consort diagram andcomplete details of participant flow.

ParticipantsIn total, pre/post-intervention data was collected from 22participants (11 males and 11 females). Of the 22 participantswho completed pre/post study questionnaires, 18 completedthe follow-up questionnaire at 10-weeks to establish if out-come variables were maintained. Participants ranged in agefrom 14 to 15 years. The participants were predominantly

=18)

in participating 0)s for caregivers’ re.

EFT Group Baseline Measurement(N = 14)

d)

low-up

Lost to follow-up (n = 4)

nt consent form 6)

EFT Group Declined to Partake in Study(N = 3)

EFT Group Post Measurement(N = 11)

agram of EFT feasibility program.

EFT in the Treatment of Unhealthy Eating Behaviors

white with 78.8% of participants identifying their ethnicity asCaucasian, 9.6% Asian, 3.8% Maori/Pacific Islander, 3.8%Middle Eastern, and 3.8% European.

MeasuresThe participant questionnaire included a battery of self-reportmeasures (described below), which comprised a total of 212items. Although measures were merged, this did not affect thereliability or validity of individual scales. To ensure con-fidentiality of responses, each participant used a uniquerespondent code. An explanatory statement and consent formwere included to inform respondents of the purpose of thestudy and included details regarding confidentiality andprivacy. The entire questionnaire took approximately 35–45 min to administer.

Demographic variables. Demographic information sur-rounding gender, age, grade, ethnicity, marital status, numberof people within the household, and household income levelwas collected.

Eating behaviors. The Youth Adolescent Food FrequencyQuestionnaire–Short Version (YAQ)45 is a self-report measuredesigned to assess the frequency of eating behaviors inindividuals on a seven-point scale ranging from 1 ¼ never/less than once a month to 7 ¼ more than five times a day. TheYAQ has demonstrated adequate internal consistency, test–retest reliability, and validity, in previous studies.46,47

Self-esteem. The Rosenberg Self-Esteem Scale (RSEQ) is 10-item self-report measure of global self-esteem. Participantswere required to indicate their agreement with items on afour-point scale ranging from 1 ¼ strongly agree to 4 ¼strongly disagree. Previous studies have shown the RSEQ topossess good internal consistency and construct validity.48,49

Psychological distress. The Depression Anxiety Stress Scale—21 (DASS-21)50 is a self-report inventory designed to assessnegative emotional states of depression, anxiety, and stress

Table 2. Means and Standard Deviations of Dependent Variables BetweDrinks, Unhealthy foods, and Self-Esteem

WL Group (n ¼ 11)

Pre Post FollowVariable M (SD) M (SD) M (SD

Healthy drinks 9.73 (1.95) 9.73 (1.95) 10.91Unhealthy drinks 16.27 (6.72) 16.27 (6.72) 11.82Healthy foods 29.18 (7.81) 29.18 (7.81) 33.27Unhealthy foods 34.55 (5.80) 34.55 (5.80) 25.55Self-esteem 23.82 (4.29) 23.82 (4.29) 24.73Psychological distress 35.57 (16.31) 35.57 (16.31) 33.79Self-compassion 35.50 (8.22) 35.50 (8.22) 38.21

Using Wilk's λ, a significant multivariate main effect was revealed for group F (6,24.73, P o .001, partial η2 ¼ .97, power ¼ 1.00. A significant interaction betwe.90, power ¼ .98, therefore, further analyses focused primarily on interaction edeviations

EFT in the Treatment of Unhealthy Eating Behaviors

over the past week. The DASS-21 includes seven items perscale, and items are rated on a four-point scale ranging from 0¼ never to 3 ¼ almost always. The DASS-21 has adequatereliability and validity, as evidenced in a number of outcomestudies.51,52

Self-compassion. The Self-Compassion Scale (SCS—ShortForm53) is a 12-item self-report inventory used to assess majorcomponents of self-compassion, including mindfulness, self-kindness, and humanity. All items are rated on a five-pointscale from 1 ¼ almost never to 5 ¼ almost always. The SCS-SF has been found to be a psychometrically sound measure ofself-compassion, with high internal consistency and conver-gent validity with scales measuring self-compassion andacceptance.53

Weekly evaluation forms. Evaluations were distributed at theend of each session as a means of collecting social validitydata and assessing participants' subjective perceptions of theintervention. Evaluations were voluntary and could be com-pleted anonymously. Participants were asked to nominate ona Likert scale ranging from 1 ¼ not useful at all and 6 ¼ veryuseful, how beneficial they believed the skills and treatmentdelivered to have been.

ResultsData was analyzed using the Statistical Package for SocialSciences 22.0. A one-way repeated-measures MANOVA wasconducted to compare scores across time, to determine if theintervention had an effect on the dependent variables.Table 2 displays the means and standard deviations for thedependent variables between groups at pre-intervention, post-intervention, and follow-up.

Healthy drinks. Refer to Figure 2 for mean scores for healthydrinks, for both groups at each measurement point.Univariate analyses revealed a significant interaction effecton healthy drinks F (1.40, 27.93) ¼ 55.86, P ¼o .001, partialη2 ¼ .74, power ¼ 1.00. Simple effects analyses for group

en Groups at Pre, Post and Follow-Up for Healthy Drinks, Unhealthy

EFT Group (n ¼ 11)

-Up Pre Post Follow-Up) M (SD) M (SD) M (SD)

(2.59) 11.64 (1.50) 12.45 (1.81) 17.64 (2.38)(2.79) 13.18 (3.09) 10.45 (1.86) 7.91 (2.12)(6.51) 32.73 (6.75) 31.55 (4.25) 38.55 (4.63)(4.63) 36.75 (4.97) 28.45 (4.44) 23.73 (3.95)(4.73) 27.73 (2.28) 28.64 (2.98) 31.45 (3.91)(15.54) 46.25 (14.68) 39.13 (12.89) 28.73 (8.49)(5.87) 31.75 (7.92) 34.50 (9.47) 37.94 (7.67)

15) ¼ 3.98, P ¼ .014, partial η2 ¼ .61, power ¼ .87, and time F (12, 9) ¼en time and group was also shown F (12, 9) ¼ 6.39, P ¼ .005, partial η2 ¼ffects. EFT ¼ emotional freedom techniques; M ¼ means; SD ¼ standard

EXPLORE March/April 2016, Vol. 12, No. 2 117

Figure 2. Mean healthy drink scores, as measured by the YAQ.

revealed there was no significant difference between groups atpre-intervention F (1, 20) ¼ 6.60, P ¼ .118, partial η2 ¼ .25,power ¼ .69. At post-intervention F (1, 20) ¼ 11.54,P ¼ .003, partial η2 ¼ .37, power ¼ .90, there was a significantdifference between groups with the EFT group consuming agreater number of healthy drinks compared to the WL group.A significant difference between groups was also observed atfollow-up F (1, 20) ¼ 40.32, P ¼ o.001, partial η2 .67, power¼ 1.00, that is the EFT group consumed a significantly greaternumber of healthy drinks than the WL group.

Simple effects analyses for time revealed there was asignificant difference in the number of healthy drinks con-sumed by the WL group over time F (1, 10) ¼ 20.12,P ¼ .001, η2 ¼ .67, power ¼ .98. Pairwise comparisons withSidak adjustment revealed the number of healthy drinksconsumed by the WL group increased significantly (P¼.004) from pre-intervention to follow-up. For the EFTgroup, significant differences in the number of healthy drinksconsumed across time were observed, F (2, 20) ¼ 110.43,P o .001, η2 ¼ .92, power ¼ 1.00. Pairwise comparisons withSidak adjustment revealed, although the number of healthydrinks consumed by the EFT group increased from pre-intervention to immediately post-intervention, this increasewas not significant (P ¼ .059). However, there was a significant(Po .001) increase in the number of healthy drinks consumedfrom post-intervention to follow-up, and this increase wassignificantly greater than pre-intervention levels (P o .001).

Figure 3. Mean unhealthy drink scores, as measured by the YAQ.

118 EXPLORE March/April 2016, Vol. 12, No. 2

Unhealthy drinks. Refer to Figure 3 for mean scores forunhealthy drinks, for both groups at each measurement point.The results revealed a significant univariate interaction effecton unhealthy drinks F (1.53, 30.56) ¼ 2.24, P ¼ .013, partialη2 ¼ .10, power ¼ .37, indicating that the consumption ofunhealthy drinks differed as a function of time and group.Simple effects analyses for group revealed there was nosignificant difference between the EFT group and WL groupat pre-intervention F (1, 20) ¼ 1.92, P ¼ .181, partial η2 ¼ .09,power ¼ .26. At post-intervention, there was a significantdifference between groups F (1, 20) ¼ 7.65, P ¼.012, partialη2 ¼.28, power ¼ .75, with the EFT group consuming fewerunhealthy drinks compared to the WL group. A significantdifference between groups was also observed at follow-upF (1, 20) ¼ 13.72, P ¼ .001, partial η2 ¼ .41, power ¼ .94,that is, the EFT group were consuming a significantly lowernumber of unhealthy drinks than the WL group.

Simple effects analyses for time revealed there was asignificant difference in the number of unhealthy drinksconsumed by the WL group over time F (1, 10) ¼ 10.17,P ¼.010, η2 ¼ .50, power ¼ .82. Pairwise comparisons withSidak adjustment revealed the number of unhealthy drinksconsumed by the WL group decreased significantly (P ¼ .029)from pre-intervention to follow-up. For the EFT group,significant differences in the number of unhealthy drinksconsumed across time were observed, F (2, 20) ¼ 31.20,P o .001, η2 ¼ .76, power ¼ 1.00. Pairwise comparisons withSidak adjustment revealed the number of unhealthy drinksconsumed by the EFT group decreased significantly(P ¼ .015) from pre-intervention to immediately post-inter-vention, with an additional significant decrease (P ¼ .003)from post-intervention to follow-up.

Healthy foods. Refer to Figure 4 for mean scores for healthyfoods, for both groups at each measurement point. Resultsrevealed a non-significant univariate interaction effect onhealthy foods F (2, 40) ¼ 1.33, P ¼.275, partial η2 ¼ .06,power ¼ .27, indicating that the consumption of healthyfoods did not differ as a function of time and group.

Unhealthy foods. Refer to Figure 5 for mean scores forunhealthy foods, for both groups at each measurementpoint. Univariate analyses revealed a significant interaction

Figure 4. Mean healthy food scores, as measured by the YAQ.

EFT in the Treatment of Unhealthy Eating Behaviors

Figure 5. Mean unhealthy food scores, as measured by the YAQ.

effect on unhealthy foods F (2, 40) ¼ 13.40, P ¼ o .001,partial η2 ¼ .40, power ¼ 1.00, indicating the consumption ofunhealthy foods differed as a function of time and group.Simple effects analyses for group revealed there was nosignificant difference between the EFT group and WL groupat pre-intervention F (1, 20) ¼ .75, P ¼ .395, partial η2 ¼ .75,power ¼ .13. At post-intervention F (1, 20) ¼ 7.65, P ¼ .012,partial η2 ¼ .28, power ¼ .75, there was a significantdifference between groups with the EFT group consumingsignificantly less unhealthy food compared to the WL group.No significant difference was observed between the EFT andWL group at follow-up F (1, 20) ¼ 18.55, P ¼ .334, partialη2 ¼ .05, power ¼ .16.

Simple effects analyses for time revealed there was asignificant difference in the number of unhealthy foodsconsumed by the WL group over time F (1, 10) ¼ 35.08,P o .001, η2 ¼ .78, power ¼ 1.00. Pairwise comparisons withSidak adjustment revealed the number of unhealthy foodsconsumed by the WL group decreased significantly(P o .001) from pre-intervention to follow-up. For the EFTgroup, significant differences in the number of unhealthyfoods consumed across time were observed F (2, 20) ¼ 92.84,P o .001, η2 ¼ .90, power ¼ 1.00. Pairwise comparisons withSidak adjustment revealed the number of unhealthy foodsconsumed by the EFT group decreased significantly (P o.001) from pre-intervention to immediately post-intervention,

Figure 6. Mean psychological distress scores, as measured by theDASS-21.

EFT in the Treatment of Unhealthy Eating Behaviors

with an additional significant decrease (P o .001) from post-intervention to follow-up.

Psychological distress. Refer to Figure 6 for mean scores forpsychological distress, for both groups at each measurementpoint. Univariate analyses revealed a non-significant univari-ate interaction effect on psychological distress F (2, 40) ¼ .94,P ¼ .398, partial η2 ¼ .05, power ¼ .20, indicating thatpsychological distress did not differ as a function of timeand group.

Self-esteem. Refer to Figure 7 for mean scores for self-esteem,for both groups at each measurement point. Results revealed asignificant interaction effect on self-esteem F (1.42, 28.47) ¼3.81, P ¼ .047, partial η2 ¼ .16, power ¼ .55, indicating self-esteem differed as a function of time and group. Simpleeffects analyses for group revealed there was no significantdifference between groups at pre-intervention F (1, 20) ¼7.13, P ¼.095, partial η2 ¼ .26, power ¼ .72. At post-intervention, there was a significant difference between groupsF (1, 20) ¼ 9.38, P ¼ .006, partial η2 ¼ .32, power ¼ .83, withthe EFT group demonstrating a higher level of self-esteemcompared to the WL. A significant difference between groupswas also observed at follow-up F (1, 20) ¼ 13.21, P ¼ .002,partial η2 ¼ .40, power ¼ .93, that is, the EFT group reportedhigher self-esteem scores than the WL group.

Simple effects analyses for time revealed there was nosignificant change in self-esteem scores for the WL group overtime F (1, 10) ¼ 1.72, P ¼ .219, η2 ¼ .15, power ¼ .22. Thatis, self-esteem scores did not significantly change from pre-intervention to follow-up. For the EFT group, significantdifferences in the self-esteem scores across time were observedF (1.16, 11.55) ¼ 9.86, P ¼.007, η2 ¼ .50, power ¼ .85.Pairwise comparisons with Sidak adjustment revealed thatthere was no significant change in self-esteem scores from pre-intervention to immediately post-intervention (P ¼ .642), butthat a significant increase in scores was observed from pre-intervention to follow-up (P ¼ .031), and from post-intervention to follow-up (P o .001).

Self-compassion. Refer to Figure 8 for mean scores for self-compassion, for both groups at each measurement point. Resultsrevealed a significant univariate interaction effect on self-

Figure 7. Mean self-esteem scores, as measured by the RSEQ.

EXPLORE March/April 2016, Vol. 12, No. 2 119

Figure 8. Mean self-compassion scores, as measured by the SCS.

compassion, F (2, 34)¼ 7.24, P¼ .002, ηp2 ¼ .299, power¼ .913,

indicating that self-compassion scores differed as a function oftime and group. Simple effects analyses for group revealed therewas no significant difference between the EFT group and WLgroup at pre-intervention F (1, 20) ¼ 1.09, P ¼ .310, partial η2 ¼.75, power ¼ .13. Moreover, there was no significant differencebetween the EFT group and WL group at post-intervention, P ¼.267, or at follow-up, P ¼ .242.

Simple effects analyses for time revealed that, acrossmeasurement points, there was a significant difference inthe self-compassion scores of EFT group participants, F (1,19) ¼ 11.41, P o .001, ηp

2 ¼ .643, power ¼ .997. Pairwisecomparisons with Sidak adjustment revealed that self-compassion scores increased significantly from pre-intervention to immediately post-intervention, F (1, 21) ¼11.22, P ¼ .003, ηp

2 ¼ .348, power ¼ .891, with no additionalimprovements made from post-intervention to 10-week fol-low-up, F (1, 15) ¼ 2.32, P ¼ .116, partial η2 ¼ .311, power ¼.472. Simple effects analyses for time revealed there was nosignificant difference in the self-compassion scores of WLgroup participants over time F (1, 10) ¼ 35.08, P ¼.301, η2 ¼.78, power ¼ 1.00.

WEEKLY EVALUATION RESULTSA total of 66 completed participant evaluation forms weresubmitted for review. For the EFT group, results indicatedthat 78% of participants found the program useful, 68% ofparticipants indicated they would be confident in using theinformation and skills covered, and 86% of participantsresponded that the content was easy to understand.

DISCUSSIONThis study was conducted to examine the feasibility of a six-week EFT intervention program on adolescents and to extendunderstanding of the relationship between eating behaviors,self-esteem, self-compassion, and psychological distress.Results of the current study revealed a number of significantfindings. Firstly, results indicated that the EFT group con-sumed a significantly higher number of healthy drinks at post-intervention, compared to the WL group. However, resultsrevealed that this effect was not maintained at follow-up. For

120 EXPLORE March/April 2016, Vol. 12, No. 2

unhealthy drinks, study findings demonstrated that the EFTgroup consumed a significantly lower number of unhealthydrinks at post-intervention, compared to the WL group.Results also revealed that the EFT group reported significantdecreases in consumption of unhealthy drinks at pre- andpost-treatment, which were maintained at follow-up.Results revealed a non-significant interaction effect for

healthy foods, which implied that participants' consumptionof healthy foods did not differ between groups and over time.The EFT group consumed a significantly lower number ofunhealthy foods at post-intervention, compared to the WLgroup. Results also indicated that the EFT group reportedsignificant decreases in consumption of unhealthy foods at pre-and post-treatment, which were maintained at follow-up. Thisfinding, in particular, is consistent with previous research,36,37

which indicates that EFT-based intervention has the potentialto improve negative eating behaviors among adolescents.Results revealed a non-significant interaction effect for

psychological distress, meaning that there was no significantdifference in psychological distress between groups and overtime. However, it is important to note that there wereclinically valid decreases in the means of both groups interms of psychological distress scores. One reason for this lackof statistically significant finding may be that group facili-tators did not instruct participants to apply the EFT tappingsequence to various psychological symptoms. Although therewas no statistically significant finding, further examination ofdescriptive statistics indicated clinically valid changes in theEFT group from pre-intervention to follow-up.In terms of self-esteem, results indicated significantly higher

self-esteem scores from pre- to post-intervention and follow-upfor the EFT group. Although the EFT group exhibited asignificant increase in self-esteem from pre- to post-treatment,this effect was not maintained at follow-up. With respect toself-compassion, study findings indicated significantly higherself-compassion scores from pre- to post-intervention for theEFT group. This is consistent with previous studies demon-strating significant increases in self-compassion scores followingan eight-week psychological intervention,24 and may furthersuggest that self-compassion can be taught and enhanced.However, this effect was not maintained at follow-up.

IMPLICATIONS OF THE CURRENT STUDYThe current study has a number of strengths, includinghaving expanded on the limited research examining theimpact of EFT on eating habits, self-esteem, self-compassion,and psychological distress in adolescents. Moreover, thisstudy provided preliminary evidence for the effectiveness ofadopting a more multifaceted intervention approach thatexamines not only dietary intake and physical output butalso other psychological variables such as self-esteem and self-compassion, in targeting weight-related behaviors.14

LIMITATIONS AND RECOMMENDATIONS FORFURTHER STUDYAlthough results of the current study demonstrate a numberof important findings and was originally intended as a pilot

EFT in the Treatment of Unhealthy Eating Behaviors

study, the small sample size is likely to affect the general-izability of research findings. Future replication studies mayseek to examine the effectiveness of EFT-based interventionwith larger sample sizes, in order to ensure power of studyconclusions. A priori analyses for a MANOVA indicated thatto achieve a power level of 0.80, while setting the level ofsignificance α ¼ .05, at least 32 participants per group wouldbe needed to detect significant change on primary andsecondary outcome measures and to achieve a mediumeffect size.Moreover, a thorough program evaluation may be neces-

sary needed to more specifically assess how interventionmaterials are implemented or practiced by participants. Afurther limitation of the current study was the reliance uponself-report data, which is a common methodological concernwithin psychological research. As such, it is important toconsider whether the study findings may have been affectedby variables such as social desirability bias.Although the current study was aimed at changing eating

behaviors rather than achieving weight loss, participants'weight may affect how they responded to the intervention.In particular, adolescents that are overweight or obese mayhave a greater need to change eating behaviors and engage inphysical activity and may be affected by their difficulties withself-image. Future replication studies should seek to incorpo-rate BMI as a variable, in order to evaluate the impact thatweight has on the outcome measures assessed.

CONCLUSIONSNonetheless, the results of the current study are promising,and tentatively suggest that EFT is useful in promotingimprovements in eating behaviors and self-esteem, withinsome adolescent groups. In the absence of a clear andconsensual causal pathway to disordered eating, a focus onpositive psychology and EFT may provide an opportunity tofacilitate healthier eating in adolescents. Participants inreported that the EFT program was useful and simple tounderstand, and that they would be confident in using theskills taught and information learned outside of the contextof therapy. Future research should focus on expandingalternative intervention styles that is readily available toadolescents, in order to reduce the international obesityepidemic.

REFERENCES1. Gortmaker SL, Swinburn BA, Levy D, et al. Changing the

future of obesity: science, policy, and action. Lancet. 2011;378(9793):838–847. http://dx.doi.org/10.1016/S0140-6736(11)60815-5.

2. American Heart Association. Understanding Childhood Obesity.USA: American Heart Association; 2014; http://www.heart.org/HEARTORG/GettingHealthy/HealthierKids/ChildhoodObesity/What-is-childhood-obesity_UCM_304347_Article.jsp#.VoyVoMB96qB.

3. Buttitta M, Iliescu C, Rousseau A, Guerrien A. Quality of life inoverweight and obese children and adolescents: a literature. QualLife Res. 2014;23:1117–1139. http://dx.doi.org/10.1007/s11136-013-0568-5.

EFT in the Treatment of Unhealthy Eating Behaviors

4. Pulgarón ER. Childhood Obesity. A review of increased risk forphysical and psychological co-morbidities. Clin Ther. 2013;35:A18–A32. http://dx.doi.org/10.1016/j.clinthera.2012.12.014.

5. Ackard DM, Neumark-Sztainer D, Story M, Perry C. Overeatingamong adolescents: Prevalence and associations with weight-related characteristics and psychological health. Paediatrics.2003;111:67–74. http://dx.doi.org/10.1542/peds.111.1.67.

6. Australian Government, Department of Health, 2008. NationalHealth and Medical Research Council: Department of Healthand Ageing. (2013). Australian Dietary Guidelines: Providing thescientific evidence for healthier Australian diets. Available from:⟨https://www.nhmrc.gov.au⟩.

7. Levitan RD, Davis C. Emotions and eating behaviour: implica-tions for the current obesity epidemic. Univ Toronto Q.2010;79:783–799. http://dx.doi.org/10.3138/utq.79.2.783.

8. Landis AM, Parker KP, Dunbar SB. Sleep, hunger, satiety, foodcravings, and caloric intake in adolescents. J Nurs Scholarsh.2009;41(2):115.

9. Ackard DM, Neumark-Sztainer D, Story M, Perry C. Overeatingamong adolescents: prevalence and associations with weight-related characteristics and psychological health. Paediatrics.2003;111:67–74. http://dx.doi.org/10.1542/peds.111.1.67.

10. Neumark-Sztainer D, Story M, Falkner N, Beuhring T, ResnickM. Sociodemographic and personal characteristics of adolescentsengaged in weight loss and weight/muscle gain behaviors: Who isdoing what? Preventive Medicine. 1999;28:40–50.

11. Vander Wal JS, Thelen MH. Eating and body image concernsamong obese and average-weight children. Addictive Behaviors.2000;25(5):775–778.

12. Abraham S. Dieting, body weight, body image and self-esteem inyoung women: doctors' dilemmas. Med J Aust. 2003;178(12):607–611.

13. O’Dea JA. Evidence for a self-esteem approach in the preventionof body image and eating problems among children andadolescents. Eat Dis. 2004;12:225–239. http://dx.doi.org/10.1080/10640260490481438.

14. Shelly Russell-Mayhew, Gail McVey, Angela Bardick, AlanaIreland. “Mental Health, Wellness, and Childhood Overweight/Obesity”. J Obes. 2012;2012:9. http://dx.doi.org/10.1155/2012/281801.

15. Young-Hyman D, Tanofsky-Kraff M, Yanovski SZ, et al. Psycho-logical status and weight-related distress in overweight or at-risk-for-overweight children. J Obes. 2006;14(12):2249–2258. http://dx.doi.org/10.1038/oby.2006.264.

16. Strauss R. Childhood Obesity and Self-Esteem. Pediatrics.2000;105:1.

17. French SA, Story M, Perry CL. Self-esteem and obesity inchildren and adolescents: a literature review. Obes Res. 1995;3(5):479–490.

18. Braet C, Mervielde I, Vandereycken W. Psychological aspects ofchildhood obesity: a controlled study in a clinical and non-clinical sample. J Pediatr Psychol. 1997;22(1):59–71. http://dx.doi.org/10.1093/jpepsy/22.1.59.

19. Swallen KC1, Reither EN, Haas SA, Meier AM. Overweight,obesity, and health-related quality of life among adolescents: theNational Longitudinal Study of Adolescent Health. Pediatrics.2005;115(2):340–7.

20. Goodspeed Grant P. Food for the soul: social and emotionalorigins of comfort eating in the morbidly obese. In: Buckroyd J,Rother S, eds. Psychological Responses to Eating Disorders andObesity. New Jersey: John Wiley & Sons; 2008;121–138.

21. Bell C. Cultivating resiliency in youth. J Adolesc Health. 2001;29:375–381. http://dx.doi.org/10.1016/S1054-139X(01)00306-8.

EXPLORE March/April 2016, Vol. 12, No. 2 121

22. Gordon Rouse KA, Ingersoll GM, Orr DP. Longitudinal healthendangering behaviour risk among resilient and non-resilientearly adolescents. J Adolesc Health. 1998;23:297–302. http://dx.doi.org/10.1016/S1054-139X(98)00019-6.

23. Claire E. Adams, Mark R. Leary. Promoting Self–CompassionateAttitudes Toward Eating Among Restrictive and Guilty Eaters. JSoc Clini Psychol. 2007;26(10):1120–1144. http://dx.doi.org/10.1521/jscp.2007.26.10.1120.

24. Neff KD1, Germer CK. A pilot study and randomized controlledtrial of the mindful self-compassion program. J Clin Psychol.2013;69(1):28-44. http://dx.doi.org/10.1002/jclp.21923. Epub2012 Oct 15.

25. Magnus C, Kowalski K, McHugh T. The role of self-compassionin women’s selfdetermined motives to exercise and exercise-related outcomes. Self and Identity. 2010;9:363–382.

26. Neff KD, Pommier E. The relationship between self-compassionand other-focused concern among college undergraduates, com-munity adults, and practicing meditators. Self and Identity. http://dx.doi.org/10.1080/15298868.2011.649546.

27. Kelly AC, Carter JC, Zuroff DC, Borairi S. Self-compassion andfear of selfcompassion interact to predict response to eatingdisorders treatment: A preliminary investigation. PsychotherapyResearch. 2013;23(3):252–264.

28. National Health and Medical Research Council. Clinical practiceguidelines for the management of overweight and obesity in adults,adolescents and children in Australia. Melbourne: National Healthand Medical Research Council. 2013. Available from: ⟨https://www.nhmrc.gov.au⟩.

29. Williams P. Monitoring the affordability of of healthy eating: acase study of 10 years of the Illawarra Healthy Food Basket,Nutrients, 2(1):1132–1140.

30. Mann T, Tomiyama AJ, Westling E, Lew A, Samuels B, Chatman J.Medicare's search for effective obesity treatments: diets are not theanswer. Am Psychol. 2007;62(3):220–233. http://dx.doi.org/10.1037/0003-066X.62.3.220.

31. Church D, De Asis MA, Brooks AJ. Brief group interventionusing emotional freedom techniques for depression in collegestudents: a randomized controlled trial. Depress Res Treat.2012;2012:257172. http://dx.doi.org/10.1155/2012/257172.

32. Feinstein D. Acupoint stimulation in treating psychologicaldisorders: evidence of efficacy. Rev Gen Psychol. 2012;16:364–380. http://dx.doi.org/10.1037/a0028602.

33. Craig G. The EFT manual. Santa Rosa, CA: Energy PsychologyPress; 2010.

34. Sojcher R, Perlman A, Fogerite S. Evidence and potentialmechanisms for mindfulness practices and energy psychologyfor obesity and binge-eating disorder. Explore. 2012;8(5):271–276.http://dx.doi.org/10.1016/j.explore.2012.06.003.

35. Church D. Clinical EFT as an evidence-based practice for thetreatment of psychological and physiological conditions. Psychol-ogy. 2013;4(8):645.

36. Stapleton P, Sheldon T, Porter B. Clinical Benefits of EmotionalFreedom Techniques on food cravings at 12-months follow-up: arandomized controlled trial. Energy Psychol. 2012;4(1):1–12.

37. Stapleton P, Sheldon T, Porter B, Whitty J. A randomizedclinical trial of a meridian-based intervention for food cravingswith six-month follow-up. Behav Change. 2011;28:1–16. http://dx.doi.org/10.1375/bech.28.1.1.

122 EXPLORE March/April 2016, Vol. 12, No. 2

38. Baker AH, Siegel MA. Emotional Freedom Techniques (EFT)reduces intense fears: A partial replication and extension of Wellset al. Energy Psychology: Theory. Research & Treatment. 2010;2(2):13–30.

39. Church D. The treatment of combat trauma in veterans usingclinical EFT (emotional freedom techniques): a pilot protocol.Traumatology. 2010;16:55–65. http://dx.doi.org/10.1177/1534765609347549.

40. Rowe. The effects of EFT on long-term psychological symptoms.Counseling and Clinical Psychology. 2005;2:104–111.

41. Stapleton P, Porter B, Bannatyne A, Urzi K-C, Sheldon T. Foodfor Thought: Randomised Controlled Trial of Emotional Free-dom Techniques and Cognitive Behavioral Therapy in theTreatment of Food Cravings. Obesity. 2016, in press.

42. Church D, Brooks AJ. The effect of a brief EFT (emotionalfreedom techniques) self-intervention on anxiety, depression,pain and cravings in healthcare workers. Integr Med. 2010;9(4):40–44. Retrieved from ⟨http://www.academia.edu/⟩.

43. Church D, Brooks AJ. The effect of EFT (emotional freedomtechniques) on psychological symptoms in addiction treatment: apilot study. Int J Sci Res Rep. 2013;2(2):315–323. http://dx.doi.org/10.9734/JSRR/2013/3500.

44. Craig G, Fowlie A. Emotional Freedom Techniques: The Manual. SeaRanch, CA: Author. 1995.

45. Rockett HR, Wolf AM, Colditz GA. Development and reprodu-cibility of a food frequency questionnaire to assess diets of olderchildren and adolescents. J Am Diet Assoc. 1995;95(3):336–340.http://dx.doi.org/10.1016/S0002-8223(95)00086-0.

46. Lukens CT, Linscheid TR. Development and validation of aninventory to assess mealtime behavior problems in children withautism. J Autism Dev Disord. 2008;38(2):342–352. http://dx.doi.org/10.1007/s10803-007-0401-5.

47. Martinez MF, Philippi ST, Estima C, Leal G. Validity andreproducibility of a food frequency questionnaire to assess foodgroup intake in adolescents. Cad Saude Publica. 2013;29(9):1795–1804. http://dx.doi.org/10.1590/0102-311X00055512.

48. McMullen T, Resnick B. Self-esteem among nursing assistants:reliability and validity of the Rosenberg Self-Esteem Scale. J NursMeasure. 2013;21(2):335–344.

49. Supple AJ, Plunkett SW. Dimensionality and validity of theRosenberg self-esteem scale for use with latino adolescents.J Behav Sci. 2011;33(1):39–53. http://dx.doi.org/10.1177/0739986310387275.

50. Lovibond SH, Lovibond PF. Manual for the Depression AnxietyStress Scales. (2nd ed). Sydney: Psychology Foundation; 1995.

51. Antony MM, Bieling PJ, Cox BJ, Enns MW, Swinson RP.Psychometric properties of the 42-item and 21-item versions ofthe Depression Anxiety Stress Scales in clinical groups and acommunity sample. Psychol Assess. 1998;10:176–181. http://dx.doi.org/10.1037/1040-3590.10.2.176.

52. Henry JD, Crawford JR. The short-form version of the Depres-sion Anxiety Stress Scale (DASS-21): construct validity andnormative data in a large non-clinical sample. Br J Clin Psychol.2005;44:227–239. http://dx.doi.org/10.1348/014466505X29657.

53. Raes F, Pommier E, Neff KD, Van Gucht D. Construction andfactorial validation of a short form of the Self-Compassion Scale.Clin Psychol Psychother. 2011;18:250–255.

EFT in the Treatment of Unhealthy Eating Behaviors