Psychological Trauma in Veterans using EFT (Emotional Freedom Techniques): A Randomized Controlled Trial

 

Dawson Church, PhD[1] Crystal Hawk, MEd,[2] Audrey Books, PhD,[3] Oliver Toukolehto,[4] Maria Wren, LCSW,[5] Ingrid Dinter,[6] Phyllis Stein, PhD[7]. Psychological Trauma in Veterans using EFT (Emotional Freedom Techniques): A Randomized Controlled Trial. This data was presented at the A4M American Academy of Anti-Aging Medicine conference, San Jose, California, Sep 9, 2009.

Abstract

A six session protocol of a brief and novel exposure therapy, EFT (Emotional Freedom Techniques) has been efficacious in reducing PTSD and co-occurring psychological symptoms in a within-subjects time series trial. The current study uses a randomized design and a wait list control group (n=13). Experimental group subjects (n=19) received six hour-long EFT coaching sessions, with pretest and posttest evaluations, as well as intermediate tests after three sessions. PTSD was assessed using the PCL-M (Posttraumatic Stress Disorder Checklist – Military), on which a score of <50 is clinical. The severity and breadth of psychological distress was measured using the SA-45 (Symptom Assessment 45), a short form of the SCL-90. Neither symptoms nor PTSD reduced in the wait list group during the passage of time. The breadth of psychological distress diminished highly significantly in the EFT group, as did the severity (both p<.001). After three EFT sessions, 72% scored PTSD-negative, with mean scores going from 62 pre to 44 (p<.001). After six sessions of EFT, 88% were PTSD-negative, with a mean score of 35 (p<.001). Thirteen subjects completed a 3 month followup, and all scored PTSD-negative (mean=31, p<.001). The results are consistent with other published reports showing EFTs efficacy at treating PTSD and co-morbid symptoms.

Keywords: veterans, PTSD, exposure therapy, trauma, EFT (Emotional Freedom Techniques).

Introduction

Some 300,000 US military personnel returning from the conflicts in Iraq and Afghanistan are estimated to be PTSD-positive (Institute of Medicine, 2006). PTSD is associated with co-occurring conditions such as depression, anxiety, and other mental health issues subsequent to deployment (Defense Health Board Task Force on Mental Health, 2007). Over 80% of PTSD sufferers meet diagnostic criteria for other psychological disorders (Breslau, 1990; Clancy et al, 2006). In addition to psychological symptoms, PTSD sufferers are more prone to physical diseases, increasing the cost and complexity of caring for this population (Boston University, 2008). This complex of conditions must be addressed for PTSD treatments to be effective (Tanielian et. al., 2008). Such problems have spurred efforts to find behavioral treatments for PTSD. A meta-analysis by Bradley (2005) found CBT (cognitive behavioral therapy), EMDR (eye movement reprocessing) and exposure therapies to be efficacious, while a meta-analysis by and Seidler and Wagner (2006) found efficacy for EMDR and CBT.

EFT (Emotional Freedom Techniques) is a brief exposure therapy with a somatic and a cognitive component. After recalling a traumatic incident, the subject gives it a score on a Likert-type scale from 10 (maximum) to 0 (minimum), referred to as Subjective Units of Distress or SUD (Wolpe, 1973). The subject pairs the traumatic memory with a self-acceptance statement, eg, “Even though I had to shoot the kid who ran toward my foxhole with the grenade…” (memory), “I deeply and completely accept myself” (self-acceptance statement). The subject then taps on a sequence of points on the body. Repeated sequences of EFT tapping may be performed till the subject’s self-report goes to a 0, indicating no emotional intensity associated with the traumatic memory. EFT was developed by Gary Craig and is described in The EFT Manual (Craig, 2008), which has been available as a free online download for over a decade, leading to standardized implementation. EFT for PTSD (Craig, 2009) reviews the clinical and research evidence applicable to this condition, and includes case histories and suggested protocols for implementing EFT with PTSD-positive clients. A research consensus method of EFT used in the present and previous studies is available online (www.SoulMedicineInstitute.org/EFT.pdf).

A pilot study using a within-subjects, repeated measures design found six sessions of EFT to produce statistically significant reductions across the range of psychological symptoms, as well as PTSD, with gains maintained on follow-up (Church, Geronilla & Dinter, 2009). A one week EFT treatment intensive was also found to reduce PTSD and co-occurring conditions (Church, 2009a). EFT has been found efficacious for treating PTSD in non-military populations (Swingle, Pulos & Swingle, 2004), and other forms of energy psychology have been used for victims of human-caused and natural disasters (Feinstein, 2008a). Studies using EEG to note changes in the limbic structures of brain during the recall of traumatic incidents have also found energy psychology to result in downregulation of the stress response, with gains maintained on followup (Swingle, Pulos & Swingle, 2004; Diepold, 2008; Lambrou, Pratt & Chevalier, 2003). In addition to psychological symptoms, EFT has been used to treat a wide range of organic diseases (Feinstein, et. al., 2005).

A clinical dilemma found in evoking combat memories is the risk of retraumatization. Subjects asked to recall a traumatic incident may be retraumatized rather than desensitized by the experience (van der Kolk, 1996). This safety issue is typically minimized with EFT and other energy psychology techniques (Mollon, 2007). An absence of client distress, and the rapid reduction of self-reported emotional intensity, is reported by clinicians using EFT (Mollon, 2008). Reduced affect is observed even in studies that require war veteran clients to recall highly emotionally evocative combat memories (Church, 2009a; Church, Geronilla & Dinter, 2009). A survey of clinicians found that when the danger of retraumatization is present, energy psychology methods were preferred (Schulz, 2009). Flint, Lammers and Mitnick (2005) have found EFT to be a safe intervention for traumatized individuals, and describe group methods, as well as individual psychotherapy protocols, for applying EFT when retraumatization is a risk.

The mechanisms of action of EFT and other energy psychology techniques involve a variety of physiological systems. Lane (2009) posits increased regulation of the HPA (hypothalamus-pituitary-adrenal) axis. Oschman (2005) describes the semiconductive properties of connective tissue, and the transmission of stress-reducing signals through this matrix during energy therapy sessions. Sabban & Kvetnansky (2001) describe the regulatory functions of the Immediate Early Genes, especially genes such as C-fos and EGR-1, which reach peak expression during stress. Church (2009b) summarizes the evidence for the silencing of these and other specific stress genes during effective behavioral interventions for PTSD, and the increased reuptake of stress hormones such as cortisol and epinephrine during EFT treatment. LeDoux (2002) describes the threat-assessment neurological wiring in the brain, and how traumatic memories may condition the amygdala to respond, resulting in the “hostile takeover of consciousness by emotion.”

When successful counterconditioning occurs, memories are reconsolidated in these neuroplastic structures, but are now newly paired with proximate non-stressful cues (Davis, Bozon, & Laroche, 2003). Successful psychotherapy produces measurable changes in these brain structures (Felmingham, Kemp & Williams, 2006). Diepold and Goldstein (2008) used EEG to measure brain states, and found that as subjective emotional intensity of traumatic memories reduced following energy psychology treatment, the neural frequencies associated with stress also reduced.

Energy psychology appears to affect multiple physiological systems, especially the structures that regulate the stress response in the body. Craig (2008), as well as Gallo (1999), and other originators of energy psychology, suggest that its effectiveness is attributable to EFTs prescribed tapping points corresponding to the endpoints of the acupuncture meridians. fMRI measurement of the amygdala, hippocampus and other structures associated with fear and pain has noted decreases in activity associated with meridian endpoint acupuncture stimulation (Dhond, Kettner, & Napadow, 2007). Hui (2000) has found acupuncture to send signals directly to the amygdala and other emotional management structures in the brain, mediating hyperarousal. Studies examining the epigenetic effects of stress have found it to trigger expression of regulatory genes (Sabban & Kvetnansky, 2001; Davis, Bozon & Laroche, 2003; Thayer, 2000).

Because of its utility in reducing affect during the recall of traumatic events such as the flashbacks, nightmares and intrusive thoughts typical of PTSD, EFT is used in many outpatient facilities treating veterans, as well as some Veterans Administration hospitals and VA centers (Iraq Vets Stress Project, 2009). The efficacy of EFT in reducing symptoms that are often comorbid with PTSD, such as anxiety, depression and phobias, has been demonstrated in several studies (Rowe, 2005, Wells, Polglase, Andrews, Carrington & Baker, 2003; Church & Brooks, 2009). The brevity of treatment time frames in these studies, ranging from one to six sessions, as well as its general effect on psychological and physical symptoms, makes EFT a candidate for formal trials to determine efficacy for the complex of conditions that confront returning war veterans.

Method

Subjects were assessed using the PCL-M and SA-45. Inclusion criteria were a score of 50 or more on the PCL-M, which is the military cut-off point for a PTSD-positive assessment. Subjects were excluded if they scored more than 3 on two questions on the SA-45 related to physical violence. They also completed the ISI (Insomnia Severity Index), and a health history assessing TBI (traumatic brain injury) symptoms, addictions, pain, physical symptoms, drug and alcohol use, and prescription drug use. Subjects were required to be under the care of a Veterans Administration clinician or other licensed healthcare facility, since coaching in the present study was delivered as a complementary and supportive supplement to the Standard of Care (SOC). They were randomly assigned to a wait list (SOC) or experimental (EFT) group using permuted block randomization, with each EFT provider receiving a block.

Experimental subjects received six one hour sessions of EFT over the course of a month. Wait list subjects waited a month, and then received an identical six session intervention. Subjects completed an informed consent form. The study was reviewed for human subject protections, and approved by Copernicus IRB. Data analysis was performed blind and offsite by an independent statistician. Providers were required to possess an EFT competency credential, to complete human subjects protection training provided by the investigators, and to pass the CITI competency examination. Providers were also required to deliver EFT as client-assessed peer-to-peer coaching, to avoid the power differential implicit in a therapist-client relationship, and to support the therapeutic alliance between the client and their existing SOC healthcare provider. Implementation fidelity was monitored through written session plans and monthly teleconferences.

Subjects were asked to compile lists of traumatic combat memories prior to or at the first session. During sessions, subjects performed one or more sequences of EFT tapping on themselves until the SUD emotional intensity of each memory was 0, or as close to 0 as could be obtained given the limited time frame.

EFT sessions focus on specific combat incidents, rather than global generalizations. SUD is the primary measure of progress, rather than observer-rated measures. EFT is typically self-applied, and one focus of coaching is to teach the client to self-apply EFT during stressful events or memories that intrude between sessions. Rather than lengthly and detailed recapitulation of distressing incidents, EFT measures progress through the SUD score. EFT does not require the client to disclose the incident; a high SUD is sufficient to initiate intervention.

Subjects completed a set of assessments after three and six sessions. Follow-ups are being obtained after three and six months; this preliminary report contains enough data to report the three month follow-up of the first 13 subjects. A larger sample is being obtained, and the results of the entire sample and follow-ups will be reported subsequently.

The PCL-M self-assessment (Weathers, 1993) is used by the military. It has seventeen items, with a scale ranging from 1 to 5. The SA-45 is a short form of the SCL-90, and measures the same nine symptoms domains. It also has two general scales, the Global Severity Index (GSI) which measures severity of symptoms across all domains, and the Positive Symptom Total (PST) which measures the breadth of symptoms. It has been validated in various studies (Davison, M L, et al. 1997; Maruish, M E 1999). Subjects also completed the Insomnia Severity Index (ISI), since insomnia frequently co-occurs with PTSD (Lamarche & De Konick, 2007).

An ad hoc Confidential Health History form was created for the purpose of this study. Its goal was to gather data on several aspects of veteran health on a single page, rather than using multi-page forms which the pilot studies found resulted in decreased subject compliance. Data from this form included (1) a cluster of 9 symptoms drawn from criteria used by the National Center for PTSD; (2) a cluster of 17 risk factors for TBI; (3) how many times a week the subject exercised; (4) a scale based on the frequency of use in the previous month; (5) cigarette usage; (6) alcohol consumption; (7) alcoholism symptoms; (8) prescription and nonprescription medication use, and (9) physical pain. This data will be reported separately.

Results

Data was received for 32 veterans, 19 in the EFT treatment group and 13 in the wait-list SOC control group. The sample consisted of 29 males and 3 females.  Age ranged between 24-86 years old with an average age of 52 years old.  There was no difference in age or gender distribution between the two treatment groups. All participants met the criteria for a clinical diagnosis of PTSD (≥50) on the PCL-M (National Center for PTSD, 2008). PCL-M scores ranged from 50-75, with a mean of 61.7 (SD± 8.7). There was no statistically significant difference between the groups on the initial PCL-M score. 

A t-test was conducted comparing the days between initial assessment and pre-treatment assessment date for the wait-list control group vs. the initial assessment date and date of the assessment following the 6^th EFT treatment session.  There was statistically significant difference in the number of days between assessments, therefore days between assessments was included as a covariate in subsequent analyses.

	group	N	Mean - Days	Std. Deviation	Range - Days	t(df)	Significance
datedifft4	WL	13	29.00	6.10	14-36	-3.97 (21.47)	.001
	TX	19	51.21	23.27	9-102

Pre-6 Session Post waiting period analysis

A General Linear Model (GLM) repeated measures analysis of variance was conducted on on the SA-45 global scales, General Symptom Index (GSI) and Positive Symptom Total (PST), and the PCL-M. This model examined change over time between the pretest and posttest.

The screening assessment was the pretest, while the posttest assessment consisted of the assessment at the completion of the 6-session EFT treatment course for the treatment group versus the 30-day assessment at the end of the waiting period for the WL group.  The group by time interaction was significant for all three variables: GSI (F(1,29)=36.49, p<.001), the PST (F(1,29)=33.81, p<.001), and PCL-M (F(1,29)=30.02, p<.001).  Posthoc Tukey tests were conducted on the significant findings. In all cases, the EFT treatment group posttest was significantly lower than the WL posttest and the EFT treatment group pretest.

Table 1. GSI, PST, and PCL-M Pre-Post Means and Standard Errors by Group

Variable	Group	N	Norm	Pretest Mean ±SE	Posttest Mean ±SE	F(1, 29)	Sig
GSI	WL	13	38	70.79 ±1.53	71.90 ±2.31b	36.49	.001
	EFT	19		72.20 ±1.23b	56.97 ±1.85a
PST	WL	13	36	70.73 ±1.57	73.05 ±2.31b	33.81	.001
	EFT	19		70.87 ±1.26b	57.71 ±1.86a
PCL-M	WL	13	<50	63.48 ±2.56	61.42 ±3.83b	30.02	.001
	EFT	19		60.51 ±2.06b	36.82 ±3.07a

Posthoc Tukey tests a<b, p<.05

*Norm for the GSI and PST represent the best possible score. Scores above 60 are considered in the clinical range. According to military standards, scores on the PCL-M greater than 50 are considered a clinical diagnosis of PTSD.

Figure 1.  GSI, PST, and PCL-M Pre-Post Means by Group

* Clinical cut-off scores represent the criterion for a clinical diagnosis.  Score above 60 are considered in the clinical range for the GSI and PST. Scores of at least 50 are considered in the clinical range for PTSD on the PCL-M according to military standards.

The PCL-M was also recoded into a dichotomous variable to indicate whether the participant met the criteria for PTSD (≥50) or not. A chi-square analysis was conducted on the dichotomous variable at the posttest. Sixteen participants in the treatment group (84.2%) no longer met the criteria for PTSD, while none of the WL group had dropped below the PTSD cut-off score (χ²=21.90, p<.001).

Table 2. Meets PCL-M criteria at 6-session posttest by group

PCL-M criteria	WL N(%)	EFT N(%)	Total N(%)
< 50 no PTSD	0 (0%)	16 (84.2%)	16 (50%)
≥ 50 PTSD	13 (100%)	3 (15.8%)	16 (50%)

Treatment change over time – Pretest, 3-sessions, 6-sessions

A General Linear Model (GLM) repeated measures analysis of variance was conducted on the SA-45 global scales, General Symptom Index (GSI) and Positive Symptom Total (PST), and the PCL-M. The first model examined change over time between the pretest, after 3 EFT sessions, and after 6 EFT sessions.  A t-test was conducted comparing the screening (30-days before treatment) and the pre-treatment assessment for the WL group.  There was no difference between the two assessments; therefore the screening assessment was used as the pretest for the WL groups.  Treatment group was included as the between subjects variable in the model to determine whether the delayed start of the intervention for the WL impacted overall treatment effectiveness.  There was no difference between the two groups on the number of days between the initial assessment date and date of the assessment following the 6^th EFT treatment session (WL Mean ±SD: 61.3 ±10.5 vs. EFT Mean ±SD: 51.2 ±23.3). 

There was also no difference between the WL and EFT treatment groups in terms of mode of delivery, phone vs. in-person.  Overall, 68.8% of the sample received the EFT intervention by phone, 61.5% of WL and 73.7% of EFT received the intervention by phone. Two WL participants dropped out prior to the 3-session assessment so the sample size for the following analyses is 30 (WL N=11, EFT N-19).

The time effect was significant for all three variables: GSI (F(2,56)=48.6, p<.001), the PST (F(2,56)= 35.97, p<.001), and PCL-M (F(1.6, 45.8)=72.05, p<.001).  The time by group interactions were non-significant.  Posthoc Tukey tests were conducted on the significant time effects. For all 3 measures, the both the 3- and 6-session measures were significantly lower than the pre-test. In addition, the 6-session assessment was significantly lower than the 3-session assessment.

Table 3.  GSI and PCL-M Pretest, 3-sessions, and 6-sessions Treatment Means and Standard Errors

Variable	Norm*	Pretest Mean ±SE	After 3 sessions Mean ±SE	After 6 sessions Mean ±SE	F(df)	Sig
GSI	38	71.78 ±0.93b	64.66 ±1.50b,c	58.56 ±1.76a	48.60 (2, 56)	.001
PST	36	72.70 ±2.08b	67.18 ±2.83b,c	60.25 ±3.87a	35.97 (2, 56)	.001
PCL-M	<50	61.51 ±1.63b	44.44 ±2.83b,c	35.32 ±2.68a	72.05 (1.6, 45.8)+	.001

Posthoc Tukey tests a<b, p<.05; a<c, p<.05

*Norm for the GSI and PST represent the best possible score. Scores above 60 are considered in the clinical range. Scores on the PCL-M of 50 or greater are considered a clinical diagnosis of PTSD according to military standards.

+Sphericity Assumptions not met, Greenhouss-Geisser F statistic

Figure 2. GSI, PST, and PCL-M Pre-During-Post Treatment

* Clinical scores represent the criterion for a clinical diagnosis.  Score above 60 are considered in the clinical range for the GSI and PST. Scores of at least 50 are considered in the clinical range for PTSD on the PCL-M according to military standards.

The PCL-M was also recoded into a dichotomous variable to indicate whether the participant met the criteria for PTSD (≥50) or not. A chi-square analysis was conducted on the dichotomous variable at 3- and 6-sessions. There was no difference between the two groups. After 3 EFT sessions, 23 participants (71.9%) no longer met the criteria for PTSD. This improved to 28 (87.5%) of the participants after 6 EFT sessions.

Table 4. Meets PCL-M criteria at 6-session posttest by group

PCL-M criteria	After 3 sessions N(%)	After 6 sessions N(%)
< 50 no PTSD	23 (71.9%)	28 (87.5%)
≥ 50 PTSD	9 (28.1%)	4 (12.5%)

Treatment change over time – Pretest, 3-sessions, 6-sessions, 3-month follow-up

Three-month follow-ups have been conducted for 13 of the participants; 5 WL and 8 EFT participants.  A General Linear Model (GLM) repeated measures analysis of variance was conducted on the SA-45 global scales, General Symptom Index (GSI) and Positive Symptom Total (PST), and the PCL-M.  The first model examined change over time between the pretest, after 3 EFT sessions, after 6 EFT sessions, and 3-month follow-up.  Treatment group was included as the between subjects variable in the model to determine whether the delayed start of the intervention for the WL impacted overall treatment effectiveness.  There was no difference between the two groups on the number of days between the initial assessment date and date of the 3-month follow-up assessment (WL Mean ±SD: 153.8 ±8.7 vs EFT Mean ±SD: 126.0 ±38.9). 

The time effect was significant for all three variables: GSI (F(3,33)=24.7, p<.001), the PST (F(3,33)= 22.8, p<.001), and PCL-M (F(3,33)=39.2, p<.001).  The time by group interactions were non-significant.  Posthoc Tukey tests were conducted on the significant time effects. For all three measures, the 3-session, 6-session, and 3-month follow-ups were significantly lower than the pretest. In addition, the 3-month follow-up was also significantly lower than the 3-session assessment.

Table 5. GSI and PCL-M Pretest, 3-sessions, 6-sessions, and 3-month Follow-up Treatment Means and Standard Errors

Variable	Pretest Mean ±SE	After 3 sessions Mean ±SE	After 6 sessions Mean ±SE	3-month Mean ±SE	F(3,33)	Sig
GSI	72.18 ±1.64b	61.68 ±1.57a,d	57.03 ±2.03a	54.55 ±2.68a,c	24.7	.001
PST	70.36 ±1.20b	63.13 ±1.73a,d	57.79 ±1.85a	53.26 ±2.53a,c	22.8	.001
PCL-M	61.96 ±2.72b	39.85 ±2.98a,d	32.19 ±2.71a	30.68 ±2.77a,c	39.2	.001

Posthoc Tukey tests a<b, p<.05; c<d, p<.05

Figure 2. GSI, PST, and PCL-M Pre-During-Post Treatment and 3-month follow-up

* Clinical scores represent the criterion for a clinical diagnosis.  Score above 60 are considered in the clinical range for the GSI and PST. Scores of at least 50 are considered in the clinical range for PTSD on the PCL-M according to military standards.

The PCL-M was also recoded into a dichotomous variable to indicate whether the participant met the criteria for PTSD (≥50) or not. All 13 participants no longer met the criteria for a clinical diagnosis of PTSD (≥50).  PCL-M scores ranged from 17-45, with a mean of 30.9.

There were 7 dropouts in the experimental group, and 3 dropouts in the control group. The 3 reasons given by participants for dropping out included, in order of frequency, (a) uncomfortable levels of emotion when being asked to recall old memories, (b) unwillingness to fill out forms, such as the PCL-M (which is also used by the Veterans Administration) which require recalling potentially retraumatizing incidents, and, (c) “not enough time.” No adverse events, or increase in participant distress, were reported in the present study.

Case Histories

The following informal anecdotal accounts represent a range of the experiences encountered by the investigators, and treated with EFT, in the course of the present study.

Case History 1: Vietnam Nurse

Subject’s body was so sensitive that she was unable to tolerate EFT tapping on any part of it without getting violently nauseous. Subject reported many incidents of physical abuse starting in early childhood, and was so physically sensitive that she was easily triggered by physical stimuli. She couldn’t wear socks or shoes, and couldn’t tolerate physical touch by others. Her companion, reporting that their life situation was “unbearable,” and that she was “in complete desperation,” arranged for coaching.

Subject’s intolerance to touch presented a challenge to finding a way to let her apply EFT. She found that she was able to tolerate tapping between her eyebrows, so that was the only point used in the first session, which focused on fear and safety issues.

Half way through the second session, she noticed that she could now tap on every EFT point, including the collar bone point, which had previously been her most sensitive spot. During this and subsequent sessions, the client worked with three specific war memories, and two physical symptoms, among other issues.

(1) Subject had rescued some Vietnamese village people, elderly and children and was treating them in her field hospital. A US Army sergeant came in and ordered her to discharge them immediately because the space was required to treat American service personnel. The subject outranked the sergeant, and refused. A that point, he withdrew his service revolver from its holster and put the barrel to her head. He said he was going to kill the villagers one way or the other, and her only choice was whether or not she was going to die first.

Realizing the rage he was in, she knew she had no choice, and rescuing the villagers was completely out of her control. She knew that the only thing she could do was to allow for them to go in peace and with dignity, with no fear or panic, in the tradition of their culture. To insulate them to the violence of the sergeant, she very gently pulled the IVs out of their arms, allowed the children to gather around the elders for support, and encouraged them to leave the hospital as a group. Once outside, they were shot by the sergeant.

The nurse never recovered emotionally from the experience. She blamed herself for being responsible for the killing. She continued to have nightmares about the incident even decades later.

During the EFT session, subject tapped on the separate scenes of this traumatic event. She began to feel a sense of connection with the villagers, and come to an understanding that they were actually grateful for her. They had witnessed the gun at her head and they knew that there was nothing more she could do. They didn’t blame her but appreciated that she did the best she could. After this cognitive shift, the nightmares about the incident did not recur.

(2). The subject lives close to a military base. Helicopters frequently fly overhead, and she would go into involuntary panic at the sound. After several rounds of EFT, subject said that she now simply noticed the sound of the helicopters, without panic or agitation.

(3). One of the subject’s most traumatic memories was of an incident in which the hospital she was working in was bombarded by friendly fire and collapsed on her. At the time the bombardment began, she had been walking down a corridor. Two children were present, and she grabbed them and threw herself over them, protecting them with her body while the hospital roof collapsed. She was the only person pulled out alive from the rubble. She spent many months in hospital and rehabilitation following the incident. She had frequent nightmares about the scene. After EFT, the memory no longer held emotional triggers. She was able to recount the incident calmly, without the emotional upheaval that she reported before.

(4) Subject had an allergic reaction whenever she consumed ice cream. She self-applied EFT for the substance itself, and for her symptoms. Subject recounted that, in Vietnam, there were two things that wounded men requested: steak, and ice cream. Both were difficult to obtain, and represented the comforts of home. When subject would eat ice cream, she was connecting with the pain she had seen. After EFT, the allergy subsided.

(5) Subject had a hearing impairment, due to scar tissue from various injuries. She identified shutting off her hearing as a defense mechanism, and repeated application of EFT was required. After EFT, her hearing improved to the point where she could hear the clicking of the keys on her computer keyboard.

Case History 2: Vietnam Combat Veteran

Subject had a violent, alcoholic father. He was drafted to Vietnam. He worked on two specific memories, among others:

(1). The first night in Vietnam, he woke up horror, realizing he was in imminent danger, when an enemy artillery bombardment began at 2:30 am. The camp was completely unprepared, with plywood floors and no security, and the draftees had not yet been issued weapons with which to defend themselves. Their anger at the army for not being prepared for them and keeping them safe was enormous. The subject remembered drinking a bottle of scotch whiskey and smoking a pack of cigarettes the first night, while a friend of his, newly married, sobbed helplessly. The recruits slept uneasily under their beds. The artillery fire resumed every night at 2:30 am. Before the first EFT session, subject would wake up every morning at this time. After EFT, he was able to sleep through the night.

(2). Some of the workers in the camp were Vietnamese. They pretended to be friendly, but their families were connected to the enemy, and the subject discovered that they were secretly passing information about the base to the Vietcong. So he and the other recruits were never safe. Subject felt a sense of betrayal, and being unsafe, ever since, and was able to reduce his SUD score around these issues with EFT.

Other Combat Memory Examples

EFT is effective at reducing SUD score for specific memories rather than global issues. The following are examples of specific memories on which EFT reduced SUD scores to 0:

(1) An Iraq veteran described an incident in which the Humvee in which his best friend was the driver, hit an Improvised Explosive Device or IED, and was unable to extricate himself. He burned to death. The veteran used EFT for the incident. He then began to spontaneously recall the funerals of other people who had loved him. After reducing his SUD score for each one, he began to relax.

(2) Another Iraq veteran was the driver of a transport truck, and in charge of transporting the men inside safely. At night, he had a very limited field of vision through the vehicle’s armor. The lack of peripheral vision made the drive very stressful for him. His passengers yelled at him for his inadequate driving, and he felt overwhelming anger for their resentment while he was so stressed, and trying to do a good job. He performed EFT for these memories, as well as for finding forgiveness, and tapped while imagining the other soldiers asking for forgiveness, using phrases like, “Sorry man for yelling at you. It wasn’t personal,” coupled with the EFT self-acceptance statement.

(3) A former Vietnam officer described ongoing threats from his subordinates. He described huge tension between white and black soldiers. He had stood up for a Vietnamese woman who was about to be raped, and prevented the rape by his comrades. As a result, he was harassed by his compatriots for months.

One of his ethnic soldiers went into a rage after drinking heavily and picked pointed his rifle through the tent door at the soldier while he was asleep. The officer handcuffed his opponent outside the bar until he sobered up. From that moment on, the soldier tried to shoot the officer wherever his back was turned. The  officer did not have a safe moment until the subordinate was killed in a firefight.

(4) Another Veteran shot a 9 year old girl who was pointing a rifle on him. He said, “I only saw the rifle! I was trained to shoot when somebody point a rifle at me! I found out later that it wasn’t loaded. She is always with me, smiling, and she never says a word. I have asked for forgiveness, I have asked my life to be taken for hers, but it hasn’t. I have to live with this memory every day, and I always see her. I wish I’d never come back from Vietnam.” The little girl was with him as a flashback for 44 years, quietly smiling at him. After EFT, she now disappeared. Most veterans report severe childhood trauma in addition to combat trauma. Issues include sexual abuse, parental alcoholism, physical abuse, poverty, and neglect. Some reported that releasing childhood trauma was more effective than releasing war memories in producing a reduction in emotional distress levels.

Discussion

A six session protocol of EFT, as well as other brief treatment protocols, has been efficacious in previous trials with statistically significant results (Church, Geronilla & Dinter, 2009, Church 2009a). The present report is part of a larger randomized clinical trial (RCT) of EFT with combat veterans. The RCT will analyze data for which the current sample is too small, and monitor whether or not EFTs effects hold over longer follow-up periods. In all studies of energy psychology that included long term follow-up, results held over time (Feinstein, 2008a). Long term improvements were also observed in trauma victims in disaster areas (Feinstein, 2008b), and in healthcare workers who self-applied EFT (Church & Brooks, 2009). Besides the long-term improvements found in previous EFT studies noted above, Rowe (2005) found that participant gains were maintained over time in a general population, and Wells (2003) found that phobias, after being extinguished by a single EFT treatment, remained so on follow-up. Of particular interest is whether TBI symptomatology changes with reductions in PTSD, since PTSD has been associated with neurological changes that are resistant to treatment (Vasterling & Brewin, 2005).

Some of the discrete elements of EFT, such as cognitive restructuring, and exposure to traumatic memories, have been shown to be efficacious in other examinations of PTSD, such as one conducted by the American Psychiatric Association (Benedek, Friedman, Zatzick, & Ursano, 2009). In a study of 24 combat veterans diagnosed with PTSD, subjects received 12 sessions of cognitive restructuring and exposure. After treatment, 40 percent of subjects no longer met the criteria for PTSD. However, half showed no reliable improvement, and co-morbid symptoms such as behavioral avoidance did not improve significantly (Monson et al, 2006). In examining studies of PTSD for efficacious treatments, the IOM (Institute of Medicine), cited the Monson et al study as one of the most encouraging for long-term PTSD sufferers.

To this established foundation of exposure and cognitive challenge, EFT adds the somatic signal of tapping. This signal is incongruous with a hyperarousal of fight-or-flight physiology. It pairs the traumatic memory with a physiologically incongruous input of tapping, sending a confounding signal to the body. Current research in the mechanisms of memory retrieval during stress suggest that memories are reconsolidated in conjunction with proximate cues from the current environment (Davis, Bozon & Larouche, 2003; LaDoux, 2002). In the language of evolutionary biology, “you would not be tapping if you were being chased by a tiger.” This interrupts activation of the body’s HPA stress axis. EFTs pairing of a combat trauma with a self-acceptance statement plus a physiological stimulus indicating safety is hypothesized to reconsolidate the memory in such as way to as render it non-traumatic.

EFT was delivered as a supplement to the care provided to these subjects by their primary caregivers, usually a Veterans Administration hospital. EFT coaching was overtly supportive of the therapeutic alliance between the subject and the primary caregiver. Coaches did not diagnose or treat any condition, or attempt to diagnose PTSD according to DSM-IV criteria. Most subjects were recruited based on referrals by VA psychiatrists and psychologists. Often, after seeing one treatment-resistant client successfully treated, such clinicians referred additional difficult cases to the study.

There are many good reasons to treat PTSD proactively with EFT. Unresolved emotional trauma correlates highly with physical diseases, including cancer, heart disease, diabetes, and hypertension. These risk factors are not alleviated by the passage of time (Felliti, et. al. 1998). A study of apparently health Vietnam veterans found that anger, depression and hostility predicts a rise in protein risk markers for cardiovascular disease (Boyle, et. al. 2007). Dysregulation of the autonomic nervous system has been linked to both psychological and physiological disorders; Thayer (2005) regards it as “the final common pathway linking negative affective states and conditions to ill health.” By reducing emotional traumas using EFT coaching, these later health consequences can be modified or avoided. The benefits of PTSD treatment can spread far beyond the traumatized individual; families and communities that might otherwise be disrupted (McFarlane & van der Kolk, 1996/2007) can be spared the consequences of transferred PTSD (Church, 2009a). Treating Iraq war veterans with PTSD effectively pays for itself in under two years (Tanielian, et. al. 2008).

The benefits of EFT treatment for PTSD are therefore considerable. EFT can be used to treat many veterans quickly, using limited resources. EFT presents a low risk of retraumatization; it can be learned by a client in a few minutes; it can be delivered by a physician’s assistant, life coach, or auxiliary personnel, and it can be self-applied by the client for traumatic memories that intrude between therapeutic session. EFT is also efficacious when applied in groups (Rowe, 2005; Church & Brooks, 2009), suggesting further research on group EFT as a proactive resilience-building resource for veterans prior to deployment, and an effective post-deployment strategy, before the conditioned response of traumatic recall can take neurological root.

Conclusions

The current study utilized a randomized controlled design, contrasting a wait list control group with a group treated with six sessions of EFT (Emotional Freedom Techniques) coaching. The wait list group’s results were unchanged over time, while the EFT group demonstrated statistically significant drops in PTSD, from clinical to subclinical scores, as well as improvement in the severity and breadth of a range of comorbid psychological problems such as depression and anxiety. A high degree of statistical significance in a small number of participants (n=32) indicates a robust effect. The results of the present study are consistent with previous within-subjects trials showing that brief EFT treatments produce large drops in PTSD as well as co-occurring conditions, with gains maintained over time. A six session protocol of EFT warrants clinical application in institutions that treat large numbers of veterans. Further research will determine if group EFT interventions produce the effects similar to those noted in one-to-one delivery.

Acknowledgments

The authors thank the many volunteers in the Iraq Vets Stress Project, especially Crystal Hawk for study coordination, Deburah Tribbey for data entry, and Audrey Brooks for data analysis.

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