Motivation and emotion/Book/2015/Emotional Freedom Techniques

Overview


The aim of this book chapter is to investigate Emotional Freedom Techniques (EFT) by explaining what the practice involves and whether it has the ability to impact upon our emotional experience. The chapter defines emotions and explores psychological theories that assist us in understanding the cause and purpose of emotion. The chapter goes on to explore contemporary research to validate the effectiveness of EFT as a tool to improve the lives of those who use it.

The following questions will be addressed:
 * What is EFT, how does it work and can it alter the way we feel?
 * What psychological theories reinforce EFT?
 * Is there quality evidence to support the practice of EFT?

What are emotions?
In order to determine the capacity of EFT to improve emotional wellbeing, an individual must first understand emotions. Emotions are complex phenomena that are difficult to define and are often interpreted as a ‘feeling’ we experience. Reeve (2009) suggests that emotions are brief encounters with a number of different dimensions that exist together, including subjective experiences, physiological arousal, social-expressive responses and goal-directed behaviour.

Table 1.

Using an Example to Explore the Different Components of Emotion.

There are a number of theoretical frameworks that attempt to understand emotion, however, the debate is largely dominated by biological and cognitive perspectives (Reeve, 2009).



The biological perspective
The biological framework is based on the premise that emotions are inherently linked with evolution and are caused by physiological change (Fox, 2008). This theory asserts that emotions operate outside of our thoughts and perceptions, with the primary focus of enabling an individual to respond to life events and function adaptively in an environment (Fox, 2008). For example, the adaptive function of fear and anger is to assist survival by responding to a potential threat or harm (Reeve, 2009). The biological perspective concentrates on a restricted number of primary emotions that have biological foundations (Fox, 2008). Despite a lack of consensus over the exact number of basic emotions, theorists mostly agree that the six basic emotions include fear, anger, disgust, sadness, joy and interest (Reeve, 2009). The biological roots of emotions are supported by studies that have shown the ways in which basic emotions are recognised universally and sometimes across species (Ekman, 1992).

Table 2.

Two Theories to Assist Understanding of the Biological Approach.



The cognitive perspective
An alternative framework for understanding emotions is the cognitive perspective. This framework suggests that it is how an individual interprets or evaluates a stimulus, rather than the stimulus itself, that dictates and shapes the emotions they will encounter (Roseman, 1984). Although there are clear biological aspects of emotion, the individual appraisal of a situation causes an emotional experience. It is through these cognitions that an individual attaches significance to the event and subsequently feels a relevant emotion (Ekman, 1992). In contrast to the biological approach, the cognitive perspective proposes that there are a rich number of emotions caused by different formations of meaning (Reeve, 2009). This construct is depicted in Plutchik’s Wheel of Emotion, where each emotion belongs to a group of interrelated emotions that vary in intensity (Plutchik, 2001).

Table 3.

Two Theories to Assist Understanding of Cognitive Approaches.

What is EFT?
''“...the brain gets stuck in an ON position so that the person is continually experiencing the chemistry of being in mortal danger. EFT tapping turns it OFF!”'' - David Feinstein.

EFT is an emerging treatment which aims to alleviate underlying emotional distress that may be triggering particular conditions in individuals, by using both cognitive and somatic strategies (Stapleton, Porter, Sheldon & Whitty, 2011). The cognitive element of EFT involves concentrating on a traumatic memory and voicing thoughts or feelings related to this event (Craig, 2011). The somatic component of EFT stems from the traditional Chinese medicine practice of acupuncture (Feinstein, 2008). Acupuncture works by activating particular points on the body through needling (Feinstein, 2008). Instead of using needles, EFT utilises tapping, massaging or holding to stimulate the acupressure points located on the hands, face and upper torso, while simultaneously activating cognitions related to the psychological distress (Church & Feinstein, 2013). For this reason, EFT is often referred to as ‘psychological acupuncture’ or 'tapping' (Stapleton et al., 2011). The therapy does not attempt to understand or explain the psychological reasons behind the distress or physical illness. EFT simply acknowledges that there is a disruption to the energy system that can be realigned through tapping on the energy points (Feinstein, 2008).

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Energy psychology
Therapies that focus on bodily meridian systems or energy fields are referred to as energy psychology (EP) techniques (Feinstein, 2008). EP works on the premise that psychological disorders are caused by imbalances in mind-body energy patterns. EP procedures have been commonly applied in Eastern cultures for many years, but are a relatively new concept in Western societies (Meyers, 2007). EP stipulates that in addition to the energies that exist in the electromagnetic spectrum, there are three subtle energy systems that are difficult to detect (Feinstein, 2012). These are energy pathways, energy centre’s and energy fields, also referred to as meridians, chakras and biofield's or auras respectively. Although they are unable to be explained or understood with mainstream frameworks, many cultures around the world have identified and referred to these energy systems (Feinstein, 2012).

Thought field therapy (TFT)
EP's original archetype is the thought field construct, which is described as an energy system in the human body that transports information (Callahan & Callahan, 2011). Based on this premise, Thought Field Therapy (TFT) encourages individuals to connect to their thought fields by thinking about the psychological problem. After stimulating the thought field, individuals are instructed to tap on acupoints to resolve energy imbalances caused by the psychological distress. Gary Craig (2011) developed EFT as a simplified form of TFT, claiming that a brief process would yield the same results as the longer sequence. Both TFT and EFT blend established cognitive perspective based interventions such as cognitive processing, imaginal exposure, systematic desensitisation and mindfulness with the physical stimulation of particular meridians or acupoints (Feinstein, 2008). Exposure therapy techniques subject the individual to real triggers or simulate an imaginal exposure that produces anxiety in a controlled environment, until the negative responses are weakened or no longer exist at all (Feinstein, 2010). A number of additional therapies can be used alongside exposure therapy, such as progressive muscle relaxation, diaphragmatic breathing, mindfulness meditations and other relaxation techniques to alleviate the physiological reactions to the stressor (Church & Feinstein, 2013).

Counterconditioning and consolidation
The goal behind concurrently using exposure with techniques to deal with physiological arousal is to decrease an individuals fear response to a particular stimulus or memory, also known as counterconditioning or desensitisation (Lane, 2009). Lane (2009) reports that during this process, stimuli that previously produced anxiety and triggered the sympathetic nervous system (SNS) response are changed to be associated with a parasympathetic nervous system (PNS) reaction. In EFT, the imaginal exposure evokes physiological arousal, whereas the acupoint tapping briefly deactivates arousal through electromagnetic signals (Oschman, 2003). This causes the brain to experience a mismatch of information, as the expected emotional reaction did not occur during the exposure to the triggering stimulus. Ecker, Ticic and Hulley (2012) report that mismatches challenge implicit learned responses and unlock neural synapses associated with the previous learning, allowing for modification of old memory pathways and new emotional learning. This process is referred to as consolidation or re-consolidation, whereby new information is translated into long-term memory. The effectiveness of re-consolidation can be influenced by the age and intensity of the existing emotional learning. Ecker et al. (2012) claim the individual is still able to recall and remember the events, however, the biological fear response is no longer associated with the stimulus.

What happens to the brain during EFT?
Understanding the neurobiological effects of exposure techniques combined with stimulating various acupoints stems from research into the efficacy of acupuncture needling (Feinstein, 2010). A study conducted by Fang et al. (2009) reported weakened responses in the limbic area through the activation of particular points during acupuncture. Although acupuncture needling and EFT techniques use different methods to activate acupoints, studies have indicated that EFT can produce similar results in regulating the brains fear response to environmental stimuli or traumatic memories (Feinstein, 2010). Takakura and Yajima (2009) conducted a double blind study to compare acupuncture needling with acupoint pressure that did not penetrate the skin and reported equal clinical benefits for both mechanisms.



EFT uses imaginal exposure to bring forward a trigger or memory in the individual, eliciting an anxiety response and increased activity in the amygdala. The amygdala is the part of the brain responsible for the fight, flight, freeze (FFF) response and primitive emotions such as anger and fear. It is activated by emotional stimuli and responds to learned events by storing emotional memories. Studies using functional magnetic resonance imaging (fMRI) have found that stimulating acupressure points through tapping, rubbing or applying pressure reduces hyper arousal in the amygdala, lowering the stress response produced by the exposure therapy (Hui et al., 2000).



Feinstein (2012) has also reported that opposing stress and relax signals allow the brain to retrieve memories without physiological arousal in the limbic area. Ruden (2010) suggests that tapping on acupoints during the procedure of memory recall causes memory and conditioned fear pathways to become open and fluid. During this process, the memory and pathways are re-recorded and repackaged in the hippocampus, by adding new information and rearranging the stress and emotions attached (Ruden, 2010).



Electroencephalography (EEG) has also been used to examine the effects of EFT on the brain. Diepold and Goldstein (2009) observed differences in brain wave patterns when individuals thought about neutral memories compared to traumatic memories. They found that individuals experienced statistically abnormal brain waves and emotional upset when recalling a traumatic memory. After being exposed to repetitive acupoint stimulation, the same individuals no longer demonstrated statistically abnormal brain wave patterns and their brain frequencies normalised. The study included an 18-month follow up, which found that the individuals continued to demonstrate normal brain wave patterns when recalling the trauma.

What is the evidence?
There is emerging evidence in the form of randomised controlled trials (RCTs) that supports the efficacy of EFT in treating a range of disorders including:
 * Athletic performance
 * Psychological distress
 * Food cravings and weight control
 * Post-traumatic stress disorder

Athletic performance


In one particular study, Church (2009) aimed to determine the impact of a brief EFT session on high performing male and female basketball players. 26 players were randomly allocated to a treatment group, which was exposed to a 15-minute EFT session, or a control group, which was subjected to a 15-minute placebo intervention. Performance was calculated based on vertical jump height and free throws before and after the intervention. The study found that players who were assigned to the EFT group had significant improvements in performance when measured against the control group (20.8% increase in improvement compared to a 16.6% decrease in improvement respectively). Based on these findings, Church (2009) reported that EFT is not only useful in improving performance but may also be helpful in preventing deteriorating performance in athletes.

Another study by Llewellyn-Edwards and Llewellyn-Edwards (2012) included 15 female soccer players who were randomly allocated to either the treatment group, which included a short EFT session, or the control group, which involved a coaching session of similar time. The findings supported the results of the basketball study, showing substantial improvements in rates of successful penalty kicks in the group who received the EFT treatment when compared to the group who received coaching.

Psychological distress


Rowe (2005) reported improvements in psychological symptoms after an 18-hour EFT workshop, as measured by a shortened version of the Derogatis Symptom Checklist (SA-45). 102 participants were required to complete the checklist a month prior to the workshop, at the beginning and end of the workshop and six months after the workshop. Psychological symptoms including paranoia, psychoticism, obsessive-compulsive, somatization, phobic anxiety and hostility were all found to significantly decrease in severity after the EFT workshop, with the six-month follow-up confirming that the changes in psychological distress levels were enduring. Andrade and Feinstein (2004) also conducted a RCT that examined 5000 participants who had previously been diagnosed with anxiety. Participants were randomly allocated to either a control group (N=2500), that received Cognitive Behavioural Therapy (CBT) and medication, or an experimental group (N=2500), which received clinical EFT. The study found that the control group reported significant improvements in 15 sessions, whereas the clinical EFT group obtained significant results in three sessions. The EFT treatment group reported a 90% reduction in symptoms, with 76% of the group reporting complete cessation of symptoms. The CBT group reported a 63% decrease in symptoms, with 51% of the group reporting no symptoms at all. Andrade and Feinstein (2004) also found that EFT group participants were resilient to relapse after a twelve-month period.

Weight control and food cravings


Stapleton et al. (2011) conducted a RCT to assess the effectiveness of clinical EFT in treating food cravings. 96 overweight or obese participants were randomly allocated to a treatment group, which received a four week EFT treatment program (N = 49) or a waitlist control group (N = 47). The study reported statistically significant findings in the degree of food cravings, perceived power of food, psychological symptoms and restraint capabilities in the EFT group in comparison to the control group. It was reported that at the 12-month follow-up, the original findings had persisted as well as additional improvements in weight and BMI, with an average weight loss between five and six kilograms. The authors suggested that many current obesity management programs emphasise cognitive and behavioural approaches in the form of keeping distracted, reforming thought patterns, eliminating tempting foods and increasing physical activity. Research has suggested that any efforts to control or reduce food cravings through suppression of unwanted thoughts can actually lead to more regular and extreme craving thoughts and higher levels of distress (Marcks & Woods, 2005). Stapleton et al. (2011) argued that EFT encourages individuals to accept their thoughts and experiences and consequently lowers the levels of distress.



Post-traumatic stress disorder (PTSD)
Church et al. (2013) conducted a RCT that assessed the effectiveness of EFT in treating war veterans with PTSD. 54 participants were randomly assigned to a treatment group (N = 29), which received six EFT sessions that ran for one hour each, or a control group (N = 25). The study found that participants experienced significant improvements in psychological distress after the sessions, reporting that the results persisted at the three and six month follow-up. At the beginning of the study, the standardised mean PTSD scores were 61.4 for the treatment group and 66.6 for the control group. After the sessions the mean score for the treatment group was 34.6, while the mean score for the control group remained unchanged. The authors noted that mean scores of the EFT treatment group had decreased well below the military PTSD threshold of 50 and the veterans no longer met the criteria for PTSD.

What is the quality of the evidence?
Studies that have demonstrated the efficacy of EFT have also been criticised for their methodological rigour, including:
 * Inconsistent selection criteria.
 * Small sample sizes.
 * Variations in the EFT versions utilised.
 * Classified as RCTs without evidence of randomisation.
 * Discrepancies in the level of experience of the EFT practitioners included in the studies.
 * No formal diagnosis of psychological conditions.
 * Lack of acknowledgement of potential placebo effects or subjectivity of outcomes.

Pignotti and Thyer (2009) have suggested that in order to improve the overall quality of the evidence supporting EFT, studies should utilise standardised procedures and measures to eliminate any potential for bias and reporting of inaccurate findings. Furthermore, it was advised that results from EFT studies must be interpreted with caution and further quality research is needed to determine the effectiveness of the technique (Pignotti & Thyer, 2009).

Conclusion
Emotions pervade almost all aspects of our lives. People desire to improve the quality of their emotional well-being by managing and dealing with unwanted emotional experiences. This process begins by using various psychological theories to enhance our knowledge and emotional awareness, as well as becoming familiar with techniques that can be utilised to alleviate or lessen the severity of these emotions. Exploring new techniques such as EFT adds to our understanding of the ways in which emotions impact on our experiences. EP techniques are relatively new constructs in Western cultures, despite being practiced in Eastern societies for many years. EP and EFT principles are not able to be explained with traditional psychological theories, however, they are becoming increasingly accepted around the world to improve health and well-being. Although the research is immature, there is emerging evidence to support the usefulness of EFT in treating a variety of conditions. The current level of evidence justifies further research to support the role of EFT in influencing negative cognitions, emotions and physiological responses, as there is potential for EFT to be an effective technique that improves the lives of those who use it.