Running Head: A COMPARISON OF EMOTIONAL FREEDOM

A Comparison of Emotional Freedom Technique and Cognitive-Processing Therapy for the

Treatment of Posttraumatic Stress Disorder

Brenda Sebastian

Capella University: Integrative Project for Master’s in General Psychology

A Comparison of Emotional Freedom Technique

Abstract

The Department of Defense (DoD) and Department of Veteran Affairs (VA) have encouraged

training in cognitive behavior therapies CBTs like Cognitive Processing Therapy (CPT),

Prolonged Exposure (PE) and Eye Movement Desensitization and Reprocessing (EMDR) for the

treatment of Post-Traumatic Stress Disorder (PTSD), with CPT being one of the most commonly

used. However, Emotional Freedom Technique (EFT) is gaining recognition as a possible

treatment for PTSD. The current randomized controlled trial directly compares CPT and EFT

with PTSD clients. To do this, 225 participants will be randomly assigned to an EFT, CPT or

waitlisted group. The EFT and CPT groups will receive therapy twice a week for six weeks.

PTSD diagnosis, distressing psychological symptoms, and quality of life will be measured before

the intervention, after three weeks of treatment, at the end of treatment, and again after nine

months to analyze the effectiveness of EFT and CPT. This study is unique because of the direct

comparison between EFT and CPT. The results will provide needed information to practitioners

about what is effective for the treatment of PTSD. Methodological issues and recommendations

for future research will also be discussed.

A Comparison of Emotional Freedom Technique

Table of Contents
Chapter 1: Introduction....................................................................................................................1

Chapter Two: Literature Review.....................................................................................................3

Post Traumatic Stress Disorder...................................................................................................3

Emotional Processing Theory (EPT)...........................................................................................4

Cognitive Behavior Therapy (CBT)............................................................................................4

Prolonged Exposure Therapy (PE)..........................................................................................5

Cognitive Processing Therapy (CPT)......................................................................................5

Eye Movement Desensitization and Reprocessing (EMDR)...................................................6

Emotional Freedom Technique (EFT).........................................................................................7

Acupoint research....................................................................................................................7

Research in EFT......................................................................................................................8

Chapter Three: Methodology.........................................................................................................13

Purpose of Study........................................................................................................................13

Research Design........................................................................................................................13

Target Population.......................................................................................................................13

Participant Selection..............................................................................................................14

Procedures..................................................................................................................................14

Emotional Freedom Technique Group..................................................................................15

Cognitive Processing Therapy Group....................................................................................16

A Comparison of Emotional Freedom Technique

Measures....................................................................................................................................17

PSS-I......................................................................................................................................17

SA-45.....................................................................................................................................18

SF-36......................................................................................................................................19

Research Question and Hypotheses...........................................................................................19

Hypothesis 1..........................................................................................................................19

Hypothesis II..........................................................................................................................20

Hypothesis III........................................................................................................................20

Data Analyses............................................................................................................................20

Expected Results........................................................................................................................21

Chapter Four: Expected Findings..................................................................................................22

Chapter Five: Discussion...............................................................................................................24

Limitations and Future Directions.............................................................................................25

References......................................................................................................................................26
A Comparison of Emotional Freedom Technique 1

Chapter 1: Introduction

A concern over Post-Traumatic Stress Disorder (PTSD) in the United States grows as

military personnel continue to return from the Middle East. Approximately 1.9 million US troops

have been deployed to Afghanistan and Iraq in Operation Enduring Freedom (OEF) or Operation

Iraqi Freedom (OIF) since October 2001, and many of these troops have been deployed multiple

times (Institute of Medicine, 2010). Of the returning soldiers and marines, 303,905 have

reported mental health problems; 62,929 of which were diagnosed with PTSD (Institute of

Medicine, 2010). Even with such a large proportion of veterans seeking mental health support

and being diagnosed with PTSD, these numbers probably don’t fully represent the number of

veterans in need because of fear of being stigmatized.

PTSD interferes with functioning and quality of life for OEF and OIF veterans. One area

that suffers, relationships, can make life more difficult. Emotional numbing, one symptom of

PTSD, leads to a loss of intimacy in marriages and a withdrawal from parent/child relationships

(Institute of Medicine, 2010). Stress on interpersonal relationships with friends, coworkers, and

extended family can also occur and lead to the individual being isolated from his or her support

group. Work life suffers as well. Problems with flashbacks, anxiety, and lack of sleep can make

it difficult for veterans suffering with PTSD to complete tasks at work and can even keep them

from attending work for days at a time (Institute of Medicine, 2010). In addition, avoidance of

traumatic memories, another symptom of PTSD, has lead to an increase in alcoholism, alcohol

abuse, and substance abuse problems among OIF and OEF veterans (Institute of Medicine, 2010)

exacerbating problems in relationships and at work. As a result, an effective treatment method

that can provide healing for veterans and their families needs to be implemented.
A Comparison of Emotional Freedom Technique 2

Cognitive behavior therapy (CBT), considered the “treatment of choice” for PTSD by

many in the field (Bryant et al., 2008) celebrates an average success rate of around 40% after 12

sessions (Feinstein & Church, 2010). This percentage is promising because of the persistent

nature of PTSD, but more needs to be done to help our veterans. Emotional Freedom technique

(EFT) might be one possible solution.

The current proposal looks at a form of therapy called Emotional Freedom Technique

(EFT) which utilizes accepted methods within the field of psychology like cognitive

restructuring and exposure therapy with the added benefit of acupressure stimulation (Feinstein,

2012). Recent research by Church et al. (2013) shows EFT’s potential for helping veterans

suffering with PTSD. A recent study found an 87.5% reduction in the number of participants

who qualified for clinical diagnosis of PTSD after only six sessions of EFT (Church et al., 2013).

This study demonstrates that EFT has the potential to be more than twice as effective as CBT in

half the number of sessions. Although research is promising, more studies are needed to show

the potential of EFT.

A better understanding of EFT is necessary for it to become a widely accepted and

established form of therapy in the treatment of PTSD. As such, the proposed study directly

compares EFT and Cognitive Processing Therapy, a form of cognitive behavior therapy,

commonly used for the treatment of PTSD. With such a direct comparison, professionals will be

able to see the effectiveness of each form of therapy and make an informed decision about what

will work best for their clients.

A Comparison of Emotional Freedom Technique 3

Chapter Two: Literature Review

Post Traumatic Stress Disorder

According to the National Institute of Mental Health, Post Traumatic Stress Disorder

(PTSD) is a mental health disorder that impacts 3.5% of adults in the United States (National

Institute of Mental Health, 2013). The US Department of Veteran Affairs (VA) reports the

diagnostic criteria for PTSD, according to the DSM-V, to include a history of exposure to a

traumatic event either through personal experience, witnessing the event, or indirect exposure

(VA, 2014). As a result of this trauma, the individual with PTSD experiences symptoms from

each of four symptom clusters. Intrusion includes symptoms like intrusive thoughts, flashbacks,

and traumatic nightmares. Avoidance of thoughts, feelings, and reminders of the traumatic event

is another symptom cluster and diagnostic criterion for PTSD. Negative alterations in cognitions

and mood are also included and can involve negative feelings about oneself and the world as

well as feelings of isolation. Alterations in arousal and reactivity are the last symptom cluster

and can include sleep difficulties, self-destructive behaviors, irritability, and aggressiveness (VA,

2014). PTSD has been traditionally difficult to treat with the median recovery time of three to

five years (Polak et al., 2012).

One particular population of concern suffering with PTSD is veterans from Operation

Iraqi Freedom (OIF) in Iraq and Operation Enduring Freedom (OEF) in Afghanistan. Wilk et al.

(2013) reported that as many as 24% of infantry who have seen direct combat are diagnosed with

PTSD. The OEF and OIF soldiers and marines often have the added diagnosis of major

depression, traumatic brain injury, or physical injuries making treatment even more difficult

(Institute of Medicine, 2010). Fear of retraumatization or stigmitazation make veterans

A Comparison of Emotional Freedom Technique 4

treatment-resistant (Dinter, 2009) and the addition of physical injury to psychological concerns,

referred to as polytrauma, leads to even more difficulties (Institute of Medicine, 2010).

Emotional Processing Theory (EPT)

Emotional processing theory, developed by Foa and Kozak (1985; 1986), focuses on the

cognitive processes underlying anxiety disorders (Jaycox, Foa, & Morral, 1998). It suggests that

anxiety disorders are the result of fear structures that include pathological associations and

cognitions (Jaycox et al., 1998). With PTSD, an underlying pathological memory structure exists

(Foa & Jaycox, 1998; Foa & Riggs, 1993) along with distressing cognitions that the world is

unsafe, the self is incompetent, and that the symptoms associated with PTSD are dangerous

(Jaycox et al., 1998). The individual with PTSD sees the memory itself as dangerous; therefore,

it is proposed that treatment of PTSD needs to include exposure to the memory in a safe

environment so that a new association can be made through emotional exposure to the memory

without the feared response occurring (Jaycox et al., 1998). This theory helps explain what

occurs with PTSD as well as the common theme in most PTSD treatments today that include

exposure to the traumatizing memories.

Cognitive Behavior Therapy (CBT)

Cognitive Behavior Therapy (CBT) is currently the most widely used form of therapy for

PTSD (Wilk et al., 2013). Although different variations of CBT exist, the more common

elements used for PTSD include exposure and cognitive restructuring (Wilk et al., 2013). The

current therapies within the area of CBT that use these elements are prolonged exposure (PE),

cognitive processing therapy (CPT), and eye movement desensitization and reprocessing

(EMDR). The Department of Defense (DoD) and Department of Veteran Affairs (VA) have both

taken measures to increase the training in one or more of these modalities to improve care for
A Comparison of Emotional Freedom Technique 5

veterans suffering with PTSD (Wilk et al., 2013). PE was developed along with and is based

directly on emotional processing theory. Both CPT and EMDR contain similar elements in

treatment and support the concepts of emotional processing theory. Emotional freedom

technique, the focus of this proposal, also includes elements of exposure and cognitive

restructuring and further strengthens the concepts proposed by Foa and Kozak in 1985.

Prolonged Exposure Therapy (PE)

Prolonged Exposure (PE) protocol for PTSD includes psychoeducation, in vivo exposure,

imaginal exposure, and emotional processing (Rauch, Eftekhari, & Ruzek, 2012). In the first

phase of therapy, the client discusses symptoms and learns the importance of confronting the

traumatic memories for healing. The second element, in vivo exposure, involves the client

confronting physical trauma reminders like people, places, and things. Imaginal exposure

involves the client recreating the memory in their mind in great detail and connecting to that

memory emotionally. As they visualize the memory, the therapist discusses the experience of the

memory and the exposure with the client and encourages them to describe both thoughts and

feelings.

Cognitive Processing Therapy (CPT)

Cognitive processing therapy (CPT), a specific form of CBT that occurs over a set 12

session process (Monson et al., 2006), was developed by Resick and Schnicke in 1992. It has

similar aspects of exposure therapy where the client thinks about the traumatic memory in great

detail and focuses on thoughts, feelings, and beliefs. It also involves the client learning about his

or her PTSD symptoms, developing skills to question or challenge those thoughts, and learning

to understand his or her changes in beliefs (Monson et al., 2006).

A Comparison of Emotional Freedom Technique 6

In a 2002 study, Resick, Nishith, Weaver, Astin, and Feuer, found CPT and EP to be

about equally effective in treating PTSD with CPT having slightly better results. In 2006,

Monson et al. found CPT to reduce the symptoms of PTSD enough that 40% of the participants

in the study no longer met the criteria for PTSD. These results provided “some of the most

encouraging results of PTSD treatment for veterans with chronic PTSD” (Monson et al., 2006, p.

898).

Eye Movement Desensitization and Reprocessing (EMDR)

Eye Movement Desensitization and Reprocessing (EMDR) was developed by Shapiro in

the early 1990s. Solomon, Solomon, and Heidi (2009) explained that during therapy, the

traumatic memory is brought to mind and the client is encouraged to focus on the images,

feelings, thoughts, and beliefs associated with the memory. Once a negative cognition about the

self connected to the memory is identified, the client selects a positive statement about the self

that could replace the negative one.

The addition of a physical element to therapy makes EMDR stand apart from PE and

CPT. During EMDR treatment, the therapist takes a baseline measurement of the physical

reactivity to the memory and then encourages the client to focus on the negative memory,

thoughts, feelings, beliefs, and current physical symptoms while an external bilateral stimulus is

presented (Solomon et al., 2009). Bilateral stimulation can be visual, tactile, or auditory and is

thought to aid in adaptive information processing which allows the client to integrate and

consolidate the memory as a narrative memory (Solomon et al, 2009). Throughout treatment, the

therapist rechecks physical reactivity and belief in the negative cognition. After the negative

physical symptoms and cognitions are reduced, a positive cognition about the self is reinforced
A Comparison of Emotional Freedom Technique 7

through bilateral stimulation and any residual body sensations are processed (Solomon et al,

2009).

Emotional Freedom Technique (EFT)

Like EP, CPT, and EMDR, emotional freedom technique (EFT), developed by Craig in

1995, also utilizes exposure and cognitive reprocessing (Lane, 2009); however, the addition of

acupressure stimulation gives EFT a unique element. During therapy, the client vividly recalls a

traumatic memory and pairs it with a reframe of self-acceptance (Church, 2012). During

exposure, the client taps, messages, or holds a series of nine acupressure points. The client and

therapist utilize the subjective units of distress (SUD) scale to measure the client’s anxiety level

before acupressure stimulation begins and again after each round to determine if more work

needs to be done on each specific memory (Lane, 2009). An additional round of exposure and

acupressure stimulation is completed until the emotional intensity of the memory reduces to a

comfortable level (Church, 2012).

Acupoint research

One of the negative claims about EFT is that it really isn’t any different from other forms

of CBT and that the stimulation of acupressure points does not make a difference (McCaslin,

2009). However, acupuncture, another form of acupoint stimulation, has been shown to produce

endogenous opioids, increased production of neurotransmitters like serotonin and gamma-

aminobutyric acid (GABA) as well as regulate cortisol, the main stress hormone in the body

(Napadow et al., 2007; Akimoto et al., 2003; Lee, Yin, Lee, Tsai & Sim, 1982; Ulett, 1992). Two

studies by Napadow et al. (2007; 2009) showed that there is a significant differences between

stimulating acupoints through acupuncture and “sham” points on the body using fMRI images

(Lane, 2009) and in other fMRI studies (Fang et al., 2009, Hui et al., 2000; Napadow et al.,
A Comparison of Emotional Freedom Technique 8

2007), acupuncture has been shown to downregulate hyperarousal of the amygdala and other

structures of the limbic system (Church, 2012).

Research in EFT

EFT’s use of acupressure points to reinforce its cognitive and exposure components is the

primary element making EFT different from other forms of CBT. Pressure on acupoints has been

found to be as efficacious as acupuncture needling (Cherkin et al., 2009). A recent double-blind

study by Takakura and Yajima (2009) compared acupuncture needling with nonpenetrating

pressure and found equivalent clinical improvements for both interventions (Feinstein, 2010).

Similar to acupuncture, research has been done with acupressure to confirm the importance of

the acupoints. Feinstein (2010) reported that several randomized controlled trials have shown the

superiority of using specified acupoints over “sham” points for reducing anxiety and pain (e.g.,

Barker et al., 2006; Kober et al., 2002; Lang et al., 2006; Wang et al., 2007).

Feinstein (2010) pointed out that conventional protocols for PTSD often depend on the

vivid activation of and extended focus upon traumatic memories. Exposure can last for an entire

session with prolonged exposure therapy making retraumatization a potential risk. With EFT

however, only brief exposure is required, and rapid relief of distress is typical (Feinstein, 2010).

Church, Yount, and Brooks (2012) conducted a study where EFT was compared to supportive

interviews (SI) which are based on cognitive behavior principles. They found that after only one

fifty minute session, psychological distress symptoms were reduced by 50% with EFT compared

to the SI group that had a symptom reduction of only 23%. With symptom reduction occurring

so quickly with EFT, the risk of retraumatization is less of an issue.

A study of EFT that used electroencephalography (EEG) demonstrated a down-regulation

of brain frequencies associated with anxiety (Lambrou, Pratt & Chevalier, 2003). This can be
A Comparison of Emotional Freedom Technique 9

helpful during EFT sessions and outside of sessions too. One of the significant benefits of EFT is

its ability to be used outside of the therapeutic sessions to reduce distress. Symptoms like

flashbacks and nightmares often occur when healthcare providers are not available, and a

portable self-help method like EFT can be useful at such times. In addition to the client utilizing

EFT to reduce anxiety, it can be taught to the whole family to support the client and aid in

decreasing their own anxiety.

With the persistence of PTSD and the impact it has on returning veterans, their families,

and even their communities, it is important to find a treatment that will be effective in reducing

symptoms quickly and having long-lasting effects. Church et al. (2013) conducted a randomized,

controlled trial where individuals suffering from PTSD were treated using EFT. After six one-

hour sessions, 87.5% of the participants no longer qualified for clinical diagnosis of PTSD, and

after six months, 79.5% still did not meet the criteria. Clearly, these results, if repeatable, would

be desirable for use with individuals suffering with PTSD symptoms.

Research on the Underlying Mechanisms in EFT

Lane (2009) described how the brain reacts to stressful situations and how the reaction

can become programmed making it difficult to get past traumatic events. He explained that it is a

form of classical conditioning where the body’s autonomic nervous system becomes activated

when a trigger occurs. Solomon et al. (2009) explained that traumatic incidents are emotionally

charged and that they overwhelm the brain’s ability to process incoming information correctly.

Rather than being integrated and stored normally, the traumatic memory may be stored in the

limbic system indefinitely (Solomon et al., 2009).

Lane (2009) explained how counterconditioning, developed by Wolpe in 1958, can occur

by linking a difficult memory with relaxation techniques to create a new response in the body.
A Comparison of Emotional Freedom Technique 10

This form of therapy is also called desensitization and has become a more common addition to

CBT protocols. Lane (2009) described that the addition of acupoint stimulation in EFT helps

break the cycle of sympathetic nervous system hyperarousal more quickly than other forms of

desensitization allowing for quicker counterconditioning and has physical health benefits as well.

“The lateral nucleus of the amygdala is at once activated by memories or cues involving the

traumatic event and deactivated by the acupoint-generated signal. Such reciprocal inhibition is

the antecedent of extinction and may also bring about the depotentiation of neurological

pathways that were sustaining the fear response” (Feinstein, 2010, p. 395). Therefore, both

systematic desensitization and acupoint stimulation attempt to produce reciprocal inhibition, but

the signals acupoint stimulation sends to the limbic system reduce hyperarousal with markedly

greater speed and power than relaxation-focused interventions (Feinstein, 2010).

A randomized controlled trial (RCT) by Wells, Polglase, Andrews, Carrington, and

Baker, (2003) compared a single imaginal exposure/acupoint tapping session with a single

imaginal exposure/diaphragmatic breathing session in the treatment of specific phobias of insects

or small animals found the acupoint tapping to be statistically superior to the diaphragmatic

breathing on four outcome measures and another RCT conducted by Sezgin and Ozcan (2009)

compared self-applied exposure/ acupoint stimulation with progressive muscle relaxation and

found a significant decrease in test-taking anxiety for both approaches, but a significantly

greater one for exposure/acupoint stimulation (Feinstein, 2010). With regard to biological

explanations, Ruden (2005) proposed that the stimulation of the meridian points release

serotonin in the amygdala and the prefrontal cortex and therefore reduce hyperarousal quite

rapidly (Karatzias et al., 2011). Human brain mapping and neurobiological research support this

connection (Hui et al. 2000; Napadow et al., 2009; Ruden, 2010) and indicate that the process of
A Comparison of Emotional Freedom Technique 11

counterconditioning occurs in the human midbrain, principally in the amygdala (Lane, 2009).

This connection has also been supported through fMRI studies that show the impact of

stimulating specific acupoints on downregulating limbic system activity (Dhond, Kettner, &

Napadow, 2007; Hui et al., 2000).

Varvogli and Darviri (2011) noted that acupoint stimulation, used in EFT, produces

opioids, serotonin, and gamma-aminobutyric acid (GABA) shutting off the fight/flight/freeze

(FFF) response and reducing pain, slowing heart rate, and decreasing anxiety. They also point

out that acupoint tapping helps to regulate cortisol, also known as the stress hormone. Church,

Yount and Brooks (2012) conducted a clinical trial of EFT to measure cortisol levels through

saliva. The trial compared an EFT group with a supportive interview (SI) group as well as a no

treatment (NT) group. The results showed that the drop in cortisol was the same (14%) for both

the SI and NT groups but 24% for EFT.

Limitations of EFT Research

McCaslin (2009) claimed, “A review of the evidence provided by Feinstein (2008) and

other available research on energy techniques show that neither of these therapies [EFT and

Though Field Therapy (TFT)] meets the criteria of empirical support or the scientific basis

necessary to be considered a viable style of psychotherapy” (p. 250). However, McCaslin’s

review was based on early pilot studies that were unfortunately developed on minimal budgets

(Feinstein, 2012). The early results have since been repeated and expanded upon within the past

few years. Clinical trials showing the effectiveness of EFT as well as the physiological evidence

supporting the efficacy of acupoint stimulation demonstrates the potential for EFT in helping

those with PTSD. The evidence that now exists on the efficacy of EFT has lead to the APA’s

approval of EFT training for continuing education credit in 2013.

A Comparison of Emotional Freedom Technique 12

Recommendations for Future EFT Research

Feinstein (2010) suggested that, although randomized controlled trials exist, more

research is needed to confirm the results. Studies with a large sample size that are repeatable are

also needed. The current proposal intends to use a sample size big enough to show a large effect

size and be representative of the population needing help for PTSD. Reliable and valid tests and

measures will also be utilized to make the study more accurate and repeatable. Studies that

compare EFT to other forms of efficacious psychotherapy are also needed (Feinstein, 2010;

Church, 2013). The current study will compare EFT with a commonly used form of CBT

therapy (CPT) used for people with PTSD. Church et al. (2013) also suggested that looking at

drug therapy alone or in combination with EFT would be helpful. The current proposal would

fulfill this recommendation by including data analysis comparing the impact of psychotropic

medications on EFT, CPT, and a no treatment group to look at the impact of drug therapy on

treatment. The current study proposal asks, is EFT a more effective treatment for PTSD than the

more commonly used CPT?

A Comparison of Emotional Freedom Technique 13

Chapter Three: Methodology

Purpose of Study

The purpose of the current proposed study is to compare the effectiveness of Emotional

Freedom Technique (EFT) and Cognitive Processing Therapy (CPT) in the treatment of Post-

Traumatic Stress Disorder (PTSD). It is also the purpose of this study to see if one of these

approaches is more effective than the other at reducing the symptoms of PTSD, psychological

distress, and improving quality of life for the target population. The effect of drug therapy will

also be looked at in isolation and in conjunction with both EFT and CPT. The results of this

study could help inform practitioners as well as those suffering from PTSD on what is the most

effective route for treatment.

Research Design

For this randomized, controlled trial, using a between groups experimental design, adults

diagnosed with PTSD will be randomly assigned to one of three groups. One of the experimental

groups will provide EFT, a second will provide CPT, and the last will be a wait list group that

will serve as a control. Measures of PTSD, psychological distress, and quality of life will be

administered before treatment begins, half way through the intervention, at the end of treatment,

and again nine months later.

Target Population

The target population will include adults between the ages of 18 and 80 who have been

diagnosed with PTSD. A subpopulation of interest includes veterans with PTSD, especially those

who served in Operation Iraqi Freedom (OIF) in Iraq and/or Operation Enduring Freedom (OEF)

in Afghanistan. A separate analysis will be conducted for this subpopulation to see if there is a

difference in effectiveness of EFT and/or CPT.

A Comparison of Emotional Freedom Technique 14

Participant Selection

Participants will be recruited through postings at local mental health practices and

facilities. Because of the special requirements involved in conducting research with active

military personnel, only retired or discharged veterans will be included in the current study with

the goal of conducting a similar study with active military at a later date. Since comorbid

psychological issues and coocurring mental and physical concerns, called polytrauma, are

common with veterans (Institute of Medicine, 2010), the study will aim to include a wide range

of individuals with PTSD alone or with other psychological diagnoses or physical injuries. The

level of significance for the proposed study is p=.05, two-tailed with a power of .80. The

predicted effect size is 35 as determined by the results from the studies by Resick, Nishith,

Weaver, Astin, and Feuer (2002) and Church et al. (2013). Based on the calculation (Kadam &

Bhalerao, 2010) of this significance level, power, and effect size, the estimated sample size will

need to be 68 people per arm of the study. To account for potential drop-out, the total sample

size for the study will be 225.

Procedures

Participants will be recruited through postings at local mental health practices and

facilities including hospitals, mental health facilities, and the local VA. The recruitment form

will indicate that participants must currently be diagnosed with PTSD and must not be active

military. The diagnosis of PTSD needs to come from a doctor or therapist and will be confirmed

using the PTSD Symptom Scale-Interview Version at the beginning of the study. The form will

have contact information on it so that potential participants can get in touch with a researcher to

find out more about when and where the study will be held.
A Comparison of Emotional Freedom Technique 15

The study will follow guidelines from the American Psychological Association for

working with human participants and approval from an institutional review board (IRB) will be

obtained. The study will be described to participants and informed consent will be acquired. The

test battery, described in the measure section below, will be administered to participants and

demographic data will be collected. Information about OIF and OEF veteran status as well as any

current drug therapy usage will be collected.

For participants to qualify for the study, they will need to meet the minimum score for

PTSD on the PTSD Symptom Scale-Interview Version (PSS-I). Once data is collected, the

included participants will be randomly assigned into one of the three groups previously

mentioned. The waitlisted control group will be told of their role in the study and offered

treatment after 6 weeks, at the conclusion of the intervention portion of the study. The EFT and

CPT groups will receive treatment for fifty minutes, twice a week for 6 weeks. The clinicians

providing EFT will be certified EFT practitioners and those providing CPT will be trained and

experienced in administering CPT. All of the clinicians will be licensed professional counselors,

licensed marriage and family therapists, licensed social workers, or licensed doctors of

psychology (PsyDs).

Emotional Freedom Technique Group

EFT will be delivered using the standardized method described in The EFT

Manual (Craig, 2008). During the first session, the participant will learn how blocks in energy

can lead to both physical and emotional suffering. Acupressure points will be identified and the

EFT coach will explain how tapping on or stimulating them can help unblock energy and relieve

distress. The participant will be asked to make a list of his or her most traumatic memories

during the first session. Once the list has been made and the individual feels comfortable with
A Comparison of Emotional Freedom Technique 16

where the acupressure points are, the client will choose a memory to begin with. The EFT

practitioner will encourage her/him to visualize the event and focus on the physical response the

memory induces. The client will then be asked to rate the overall distress experienced on a SUD

scale. The EFT coach will help the participant come up with the set-up phrase/statement that

identifies the stressful event and combines it with a self-affirming/accepting statement. The

coach will lead the individual through the sequence of tapping/stimulating of acupressure points

while encouraging the client to repeat a reminder phrase. At the end of each round, the EFT

coach will check in with the participant to see where they are on the SUD scale. The rounds will

continue until the client reports a SUDS of zero or as close as possible. Throughout the

remaining sessions, the goal will be to work through as many of the memories initially listed as

possible and reduce the anxiety level associated with each to a minimal level. The participants

will also be encouraged to use EFT outside of treatment.

Cognitive Processing Therapy Group

CPT would follow the manual, written by Resick and Schnicke in 1993 (Resick, 2002).

Session one would begin with an education about PTSD and an overview of treatment. An

assignment would be given to write an impact statement about the personal meaning of the

primary traumatic event. Clients learn about the relationship between events, thoughts, and

emotions during session two and are given the assignment of writing a detailed account of the

primary trauma at the end of session three. Therapy begins in session four with Socratic

questions regarding self-blame and other distortions related to the event after the client reads

their detailed account to the therapist. The memory is reprocessed again in session five. At this

point, clients are taught to challenge and change their beliefs about the event and the implications

of the trauma for their lives. Clients are first taught to challenge a single thought and then to
A Comparison of Emotional Freedom Technique 17

identify problematic patterns of thinking. Worksheets are used, beginning with Session seven, to

develop and practice more balanced self-statements. For the remainder of treatment, clients focus

on one theme each week and correct any overgeneralized beliefs that come up. During session

eleven, clients rewrite impact statements about the primary trauma allowing them to evaluate the

gains they have made during the last session.

Measures

PSS-I

PTSD criteria will be measured using the PTSD Symptom Scale-Interview Version (PSS-

I). In addition, psychological distress will be measured using the SA-45 and the SF-36 will be

utilized to measure quality of life. The battery of tests will be administered at the beginning of

the study, after three weeks of treatment, at the conclusion of treatment after six weeks, and

again at a nine month follow-up. So that long-term data can be collected on the effectiveness of

EFT and CPT without delaying treatment for the no-treatment group, the individuals in the

waitlist group will be offered treatment after the 6 week treatment portion of the study is

completed. The results of the study to date will be provided to the waitlisted participants and

they will be given the choice of treatment method. As a result of these individuals no longer

being waitlisted however, only the EFT and CPT participants will complete the testing battery

during the nine month follow-up.

The PTSD Symptom Scale-Interview Version (PSS-I) developed by Foa et al. in 1993 is

a semistructured interview that assesses current symptoms of PTSD as defined by DSM-IV

(American Psychiatric Association, 1994) criteria (Foa & Tolin, 2000). It has 17 questions that

match the 17 symptoms of PTSD and results in a PTSD severity score as well as a

reexperiencing, avoidance, and arousal subscore. The PSS-I uses a 4 point Likhert scale ranging
A Comparison of Emotional Freedom Technique 18

from 0, not at all to 3, very much. Internal consistency coefficients for PSS-I subscales range

from .65 to .71 and test-retest reliabilities range from .66 to .77. Interrater reliabilities range from

.93 to .95. It shows good concurrent validity, as indicated by significant correlations with

measures of PTSD symptoms, depression, general anxiety (Foa et al., 1993) and CAPS (Foa &

Tolin, 2000). The PSS-I was chosen over the more commonly used Clinician Administered

PTSD Scale (CAPS) for two reasons. First, the PSS-I can be used with a civilian population,

whereas CAPS is used more for military personnel (Foa & Tolin, 2000). Secondly, the PSS-I

takes half the time to administer having 17 questions rather than 34 like CAPS, but yields similar

results (Foa & Tolin, 2000).

SA-45

Psychological distress will be measured using the Symptom Assessment-45 (SA-45). It

measures a person's psychological distress over the previous week. It has 45 questions that are

scored on a Likert-type scale ranging from 0 “not at all” to 4 “extremely (Rowe, 2005). It has

two global scales, the Global Severity Index (GSI) and the Positive Symptom Total (PST) as

well as nine subscales that measure symptoms ranging from anxiety to psychoticism (Rowe,

2005). T-scores that are based on sex-normed data for nonclinical populations are calculated

with any score greater than 60 considered in the clinical range (Church, 2012). The reliability of

the SA-45 has been validated through numerous studies (Davison et al., 1997; Maruish, 1999 as

reported in Church 2010). The SA-45 was chosen for the current study proposal as a way to

show the difference between EFT and CPT in reducing psychological distress for those suffering

from PTSD.
A Comparison of Emotional Freedom Technique 19

SF-36

The Medical Outcome Study Short Form-36 (SF-36), developed by Ware and Sherbourne

in 1992, is a quality of life survey regularly used in the medical field today. The SF-36 measures

eight health concepts ranging from physical functioning, and bodily pain to social functioning,

and mental health (Ware, 2011). Reliability studies from the late 1980s to the present report

reliability coefficients on the subtests generally above .70 for most sample groups (e.g., Garratt,

Ruta, Abdulla, Buckingham, & Russell, 1993; Jenkinson, Coulter, & Wright, 1993; Brazier et al.,

1992 as reported by Ware, 2011). Shiner et al., 2011 reported that the SF-36 has demonstrated

ability to assess psychosocial functioning in trauma survivors (Schnurr, Lunney, Bovin, & Marx,

2009) and be used as an outcome measure in posttraumatic stress disorder (PTSD) treatment

studies (e.g., Rapaport, Endicott, & Clary, 2002; Schnurr et al., 2003). Shiner et al., (2011) also

extended prior findings (Ramchand et al., 2008; Schnurr et al., 2006; Vasterling et al., 2010)

showing that the SF-36 is sensitive to changes in PTSD. The SF-36 was chosen for this study

because of its ability to give information about functioning and overall quality of life that can’t

be measured by the SA-45 or the PSS-I.

Research Question and Hypotheses

Is emotional freedom technique as or more effective than cognitive processing therapy at

treating post-traumatic stress disorder is the research question for the current proposal.

Hypothesis 1

H1: EFT will be more effective at reducing the number of participants who qualify for PTSD,

reducing distressing psychological symptoms, and increasing quality of life more than the

waitlisted group for both veteran and non-veteran participants.

A Comparison of Emotional Freedom Technique 20

Ho1: EFT will not be more effective at reducing the number of participants who qualify for

PTSD, reducing distressing psychological symptoms, and increasing quality of life more than the

waitlisted group for both veteran and non-veteran participants.

Hypothesis II

H2: CPT will be more effective at reducing the number of participants who qualify for PTSD,

reducing distressing psychological symptoms, and increasing quality of life more than the

waitlisted group for both veteran and non-veteran participants.

Ho2: CPT will not be more effective at reducing the number of participants who qualify for

PTSD, reducing distressing psychological symptoms, and increasing quality of life more than the

waitlisted group for both veteran and non-veteran participants.

Hypothesis III

H3: EFT will be more effective at reducing the number of participants who qualify for PTSD,

reducing distressing psychological symptoms, and increasing quality of life than the CPT group

for both veteran and non-veteran participants.

Ho3: EFT will not be more effective at reducing the number of participants who qualify for

PTSD, reducing distressing psychological symptoms, and increasing quality of life than the CPT

group for both veteran and non-veteran participants.

Data Analyses

A MANCOVA will be performed on the data gathered from the initial test battery and

again on the test battery administered at the end of week three and at the conclusion of treatment

after six weeks. The MANCOVA will show any differences between groups prior to the

intervention, at the half-way point and again at the conclusion of treatment. A univariate

ANOVA will be used to compare EFT and CPT at the nine month follow-up. Individual t-tests
A Comparison of Emotional Freedom Technique 21

will be used to identify differences between veterans and non-veterans as well as to look for

differences between individuals receiving drug therapy and those who are not.

Expected Results

Based on previous research, it is expected that both EFT and CPT will reduce

psychological distress symptoms, decrease the number of individuals diagnosed with PTSD, and

improve overall quality of life. However, it is predicted that EFT will be more effective than

CPT in these regards. For the additional analysis to see if psychotropic medications make

treatment more or less effective or if there will be a difference between military vs. non-military

individuals is not known.

A Comparison of Emotional Freedom Technique 22

Chapter Four: Expected Findings

Before treatment begins, demographic data will be collected for all participants including

age, gender, race, and education information. In addition, data will be collected about current

psychotropic medication usage and OIF/OEF veteran status. T-test and chi-square will be used to

see if there is a significant difference between the EFT, CPT, and NT groups on demographic

data. Since participants will be randomly assigned to a group, a significant difference in

demographic data is not expected.

Previous research on both CPT and EFT make it possible to predict the outcome of these

treatment methods. Resick, Nishith, Weaver, Astin, and Feuer (2002) found that PE and CPT

yield similar results when working with PTSD clients. In their study, 53% of the participants in a

CPT group and 53% in the PE group were negative for PTSD after treatment. After nine months,

55% of the CPT group and 50% of the PE group were still negative for PTSD.

In another comparison, Karatzias et al. (2011) found a large effect size for both EFT and

EMDR treatment methods. From pretreatment to posttreatment, effect sizes on the Clinician

Administers PTSD Scale (CAPS) were d= 1.1 for EMDR and d= 1.0 for EFT groups (anything

bigger than .80 is considered large, Cohen, 1988 as reported in Karatzias et al., 2011). On the

PTSD Check List (PCL), the effect sizes were d= 1.0 for EMDR and d= 1.1 for EFT groups from

pretreatment to posttreatment. At follow up, both EMDR and EFT groups still had a large effect

size on both the CAPS and PCL (Karatzias et al., 2011).

For the current proposed study, a repeated measures pretreatment to posttreatment

MANOVA will be conducted for the groups EFT, CPT and NT groups to see if there is a

significant difference present. Based on research by Resick et al. (2002) and Karatzias et al.

(2011) described above, a significant difference is expected to be found between both the EFT
A Comparison of Emotional Freedom Technique 23

and CPT groups compared to the NT group. The significant reduction in PTSD symptoms found

by Resick et al. (2002) when using CPT and the significant effect size found by Karatzias et al.

(2011) when using EFT indicates that both EFT and CPT will have a significant impact on PTSD

symptoms in the proposed study.

The study by Resick, Nishith, Weaver, Astin, and Feuer (2002) can be compared to the

study by Church, Hawk, Brooks, Toukolehto, Wren, Dinter and Stein (2013) where after six one-

hour sessions of EFT, 87.5% of the participants no longer qualified for clinical diagnosis of

PTSD, and after six months, 79.5% still did not meet the criteria. This comparison, while not

direct, does explain the expectations of this study that EFT will be a more effective treatment for

PTSD than CPT. This will be analyzed in the current study with another MANOVA which will

be done for the EFT and CPT groups across the four assessment periods, including the nine

month follow up (Church et al., 2013). A significant difference is expected between the EFT and

CPT groups for the last three assessment periods with EFT being significantly more effective.

Two additional analyses will be conducted in the current proposal. The EFT, CPT, and

NT groups will be further separated between OIF/OEF veterans and others to see if there is a

difference in treatment effectiveness for veterans than for everyone else. With the large

population of military veterans being diagnosed with PTSD, it’s important to know which form

of treatment is best. Lastly, an analysis will be done to better understand the influence of

psychotropic medications on treatment methods. It is imperative to know if EFT or CPT works

better in conjunction with psychotropic medications or without it. The results of these two

additional analyses would give providers more information to base their treatment strategies on

so that the best aid is provided to people suffering from PTSD.

A Comparison of Emotional Freedom Technique 24

Chapter Five: Discussion

This proposed randomized, controlled trial aims to compare a commonly used form of

therapy (CPT) with EFT to determine their effectiveness for treating PTSD. Although both have

been shown to be effective forms of treatment for PTSD (Resick, Nishith, Weaver, Astin, &

Feuer, 2002; Church et al., 2013; & Karatzias et al., 2011), these two methods have not been

directly compared. Based on previous studies, (Resick, Nishith, Weaver, Astin, & Feuer, 2002;

Church et al., 2013; & Karatzias et al., 2011) it is predicted that scores will be reduced on the

PSS-I and SA-45 for both the EFT and CPT groups and remain the same for the NT group with

the scores being significantly lower for the EFT group. Likewise, scores on the SF-36 are

expected to improve for the EFT and CPT groups but remain the same for the NT group with the

EFT group being significantly higher. In a small randomized trial, Brattberg (2008) found an

increase in quality of life scores, as measured by the SF-36, after an EFT intervention for women

suffering with fibromyalgia. This study demonstrated that EFT has the potential to not only

reduce psychologically distressing symptoms, but improve overall quality of life as well.

With PTSD being such a difficult diagnosis to treat (Polak et al., 2012), integrating a

treatment like EFT that has the potential to reduce PTSD symptoms, psychological distress, and

improve overall quality of life could improve the lives of so many suffering today. If the current

study finds that EFT is truly 35% more effective at reducing PTSD than the most commonly

used form of treatment, the implications could be tremendous for clients and their families.

Because of this potential, it’s important that more be learned about EFT and its possible uses for

people with PTSD.

A Comparison of Emotional Freedom Technique 25

Limitations and Future Directions

A possible limitation of this study is allowing only non-active military to participate.

With the high population of veterans returning from Iraq and Afghanistan with PTSD, it is

crucial to find out what can help this population. It is highly recommended that this study be

repeated in the future with a military population to see if the results are consistent with active

military personnel so that the most effective form of treatment is being used. Another possible

limitation is the lack of a tangible physiological measure like cortisol level or amygdale

activation. With EFT still being considered an “alternative” form of therapy, it is important for

individuals to understand the underlying mechanisms in action with EFT. For that reason,

repeating this study with a physiological measurement is also recommended.

 A Comparison of Emotional Freedom Technique 26

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