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Current Research in Psychology 5 (1): 19-33, 2014
ISSN: 1949-0178
©2014 Science Publication
doi:10.3844/crpsp.2014.19.33 Published Online 5 (1) 2014 (http://www.thescipub.com/crp.toc)
Corresponding Author: Peta Stapleton, School of Humanities, Bond University, Gold Coast, Queensland, 4229, Australia
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A FEASIBILITY STUDY: EMOTIONAL FREEDOM
TECHNIQUES FOR DEPRESSION IN AUSTRALIAN ADULTS
1
Peta Stapleton,
2
Sharon Devine,
3
Hannah Chatwin,
4
Brett Porter and
5
Terri Sheldon
1,2,3
School of Humanities, Bond University, Gold Coast, Queensland, 4229, Australia
4,5
The Lakeside Rooms, Robina, Qld
Received 2014-06-20; Revised 2014-07-09; Accepted 2014-07-12
ABSTRACT
The purpose of this study was to investigate the feasibility of using Clinical Emotional Freedom Techniques
(EFT) to treat Major Depressive Disorder in an adult population by way of a therapeutic group setting.
Adults were assigned to EFT group treatment for a period of eight weeks. Diagnostic assessment was
completed immediately pre and post treatment using the Mini International Neuropsychiatric Interview. In
addition to this, self-report assessments measuring symptomatic evidence of depression were completed by
the participants before the treatment, after the treatment and at three month follow-up. Comparisons with a
community group were made at pre and post intervention and three month follow-up. The results indicated a
change in diagnosis in each of the participants, with data indicating an overall improvement for the
treatment group for depressive symptoms. Study implications and limitations are discussed.
Keywords: Depression, Adults, Emotional Freedom Techniques, EFT, Cognitive Behavioural Therapy, CBT
1. INTRODUCTION
Approximately 20% of Australians between the ages of
16-85 experience mental illness in each twelve month
period (ABS, 2009). Anxiety, depression and substance use
are the most frequently reported disorders and often co-
occur, due to anxiety possibly leading to depression, or
substances being used to self-medicate. In each 12 month
period, of the 20% of Australians with mental illness, 8.5%
have a minimum of two disorders (ABS, 2009). Moreover,
while it has been reported that approximately 45% will
develop mental illness in their lifetime (ABS, 2009),
treatment is accessed by less than half of those who
experience mental illness (CA, 2010; AIHW, 2007).
Depression is reportedly experienced by one in seven
Australians (ABS, 2009). Depression carries the third
highest impact of disease (WHO, 2008) including
Australia (AIHW, 2007), measured by several factors
such as financial burden to the economy and death.
Depression has also been reported as the highest source
of disability in Australia that does not lead to death
(AIHW, 2007). According to the WHO (2008), it is
estimated that depression will be ranked as the highest
health concern globally by the year 2030.
Depression has been found to have a high likelihood
of recurring throughout the lifetime once previously
experienced. According to Bolland and Keller (2002), a
single depressive episode will recur within a 12 month
period in 22% of the population. If three or more
episodes of depression have been experienced, a 90%
chance of recurrence has been reported (Bolland and
Keller, 2002). In addition to this, when depressive
episodes recur, the likelihood of suicide becomes
higher (Bolland and Keller, 2002).
1.1. The Diagnostic Features of Major
Depressive Disorder
The Diagnostic and Statistical Manual of Mental
Disorders, Fifth edition (DSM-5; APA, 2013) outlines
several diagnostic features an individual must meet to be
diagnosed with Major Depressive Disorder. The main
features of Major Depressive Disorder include a
depressed mood experienced almost every day,
diminished pleasure and difficulty sleeping. In addition
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to this, feelings of worthlessness and difficulty
concentrating are frequently experienced. For the
individual to meet diagnosis for Major Depressive
Disorder, they must have experienced five or more
symptoms over a two week period, as listed in the
DSM 5 (APA, 2013). These symptoms must have
caused distress or impairment in the individuals’ life
and are not due to substance use or any other medical
issue (APA, 2013).
Typical treatments for depression include
pharmacological, which has become the most popular
form of treatment (Beardslee et al., 2003),
psychotherapy, counselling and specific interventions
such as Cognitive Behavioural Therapy (CBT; WHO,
2004). CBTis considered a gold standard treatment
option and is a structured style of therapy requiring
direction from the clinician. It typically addresses
dysfunctional emotions, maladaptive behaviours and
cognitive processes through behaviour modification and
problem solving. CBT is thought to be effective for the
treatment of a variety of conditions, including mood,
anxiety, personality, eating, substance abuse, tic and
psychotic disorders. However, research has found that
the skill of the therapist is directly related to the
outcomes of CBT (Strunk et al., 2010) and at times
clients reportthey have felt under pressure to give
particular answers when receiving CBT, or that the
therapy was not flexible enough to match client needs
(Barnes et al., 2013). While meta-analyses find CBT
more effective than psychodynamic therapy and equal to
other therapies in treating anxiety and depression
(Cuijpers et al., 2008; Tolin, 2010), psychodynamic
therapy may provide better long-term outcomes (Shedler,
2010). Regular attendance to therapy sessions may
also prove difficult, as researchers have found that
consistent attendance by depressed individuals can be
limited (Barnes et al., 2003). Reasons for non-
attendance have been cited as difficulty dealing with
emotional issues and confusion regarding the
therapeutic process (Barnes et al., 2003). Therapies
such as CBT require a commitment from participants
to attend so that client receives adequate treatment.
According to Forde et al. (2005), between five and eight
treatment sessions has been found to be the optimal number
when treating depression. Therefore if clients do not attend
regularly, treatment will be ineffective.
The use of alternative treatments by depressed
individuals is increasing, with research finding 54% used
some form of complementarys or alternative therapy to
treat depression in the United States (Kessler et al.,
2001). In addition to this, 66.7% of those receiving
standard treatment for depression, also used alternative
therapies (Kessler et al., 2001). However, only 19% of
these with severe depression sought out an alternative
therapy provider (Kessler et al., 2001), indicating a
preference of for self-administration.
Emotional Freedom Techniques (Clinical EFT) is an
approach that uses a tapping technique to heal
emotional discomfort (Gallo, 2004). Clinical EFT has
been found to be a fast and simple therapy technique,
which can be self-administered, or taught by a therapist
(Wells et al., 2003). It has been found to be effective
for many psychological disorders such as phobias
(Jones et al., 2011; Salas et al., 2011; Sezgin and
Özcan, 2009; Wells et al., 2003), anxiety (Rowe, 2005),
Posttraumatic Stress Disorder (PTSD) (Church, 2008a) and
stress (Church, 2008b).
Emotional freedom techniques. Emotional Freedom
Techniques (EFT or Clinical EFT) is based on Chinese
medicine and the theory of acupuncture, using the energy
meridians of the body (Feinstein, 2008). EFT includes
elements of cognitive therapy (Beck et al., 1979),
exposure (Wolpe, 1969), mindfulness and systematic
desensitization (Wolpe, 1958). The process of EFT is
completed by becoming aware of a problem, using a
setup statement to focus the mind on the issue and
tapping on eight specific acupressure points of the body,
while verbally stating the issue being addressed. The
issue is spoken as a short phrase while tapping.
Individuals are initially asked to rate their distress on a
subjective units of distress scale from zero to 10 (where
zero is no distress and 10 equals the most distress) and
after completing a round of each of the tapping points, to
re-rate their level of distress. They are then encouraged
to continue the rounds until their emotion has reduced.
The procedure of EFT begins by the individual
stating a difficulty they are experiencing, followed by an
opposing, but positive affirming statement. For example,
an individual may state “Even though I am overweight, I
deeply and completely love and accept myself”.
Researchers have found that when positive and negative
thoughts are combined, the individual experiences a
decrease of the negative experience (Kazdin and
Wilcoxon, 1976). This combination of positive
affirmation and negative thoughts is typically used in
Systematic Desensitization, a behaviour modification
therapy (Kazdin and Wilcoxon, 1976).
The practise of Clinical EFT appears to have
physiological effects, with one randomised trial
measuring cortisol levels related to depression and
anxiety, before and after one of three treatment
modalities: Clinical EFT, psychotherapy, or relaxation
(Church et al., 2012). The findings were that the being
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activated by fear, brain frequencies were found to
normalise after treatment (Church et al., 2012).
Brain frequencies have also been found to be affected
by Clinical EFT, where after being activated by fear,
brain frequencies were found to normalise after
treatment with Clinical EFT (Diepold and Goldstein,
2008). Researchers also found when participants were
asked to recall a traumatic memory, these frequencies
remained in the normal range (Diepold and Goldstein,
2008). The amygdala has been found to be unaffected by
stress after immediate use of Clinical EFT (Feinstein,
2008) and the ratio of serotonin and dopamine has been
found to balance after an individual has been treated with
Clinical EFT (Feinstein et al., 2005).
Neutral plasticity has been noted as a contributing
factor to the effects of Clinical EFT (Mollon, 2007).
According to Nader et al. (2000), when an individual
recalls an emotion inducing image, the memory becomes
fluid and further information may be added to the
memory. Mollon (2007) states that this is the opposite of
avoidance, where memories are shunned and new
information cannot be added. When tapping occurs during
memory recall, it appears to allow the emotional reaction
to be reset, due to this opening of the memory processes.
Clinical EFT has been found to be effective for
treating anxiety. In a study that took place over a 14 year
period Andrade and Feinstein (2004) measured 5000
individuals, from 11 clinics in South America, being
treated for anxiety. The design was double blind and
randomised. Two groups were allocated for the study,
the control group and the experimental group. The
control group was treated with both Cognitive
Behavioural Therapy (CBT) and medication, while the
experimental group was treated with Clinical EFT. The
findings were that 90% of the symptoms experienced by
the Clinical EFT treatment group were reduced and 76%
of the group were reported to no longer experience
symptoms of anxiety. The group receiving CBT was
found to have a 63% reduction in symptoms, with 51%
of the group found to no longer experience symptoms.
Although both the CBT plus medication and the Clinical
EFT treatments were effective, the Clinical EFT group
required only three sessions to achieve these results,
whereas the CBT and Medication group required 15
sessions. At twelve month follow-up, the CBT group
members were found to be more likely to experience
relapse than the Clinical EFT group.
Clinical EFT has been found to be effective when
treating food cravings in a randomised clinical study
(Stapleton et al., 2011). Ninety-six overweight or obese
individuals completed a four week treatment program,
with participants being measured pre and post the
program and also at 6- and 12- month follow-up.
Findings indicated a significant improvement in food
cravings, the subjective power of food and craving
restraint when compared to waitlist controls (p<0.05)
(Stapleton et al., 2011). In addition to this, the
improvement in food cravings was maintained at 6-
and 12- month follow-up, with a craving restraint
appearing to have increased effects after time and
average weight loss at 12-months was 5.5 kg (11
pounds) (Stapleton et al., 2011).
1.2. Clinical EFT and Depression
Two Randomised Controlled Trials (RCT) found
Clinical EFT to be an effective treatment when treating
symptoms of depression. After completing an eight week
online Clinical EFT course, 36 fibromyalgia patients
receiving treatment for PTSD were found to have a
significant reduction of depressive symptoms (Brattberg,
2008). The second RCT focussed on 59 war veterans
who were experiencing clinical levels of depression
(Church et al., 2013). After six sessions of Clinical EFT,
there was a significant change in their depressive levels
which decreased to a subclinical level. These
improvements were also maintained at three and six
month follow-up (Church et al., 2013).
A randomised control trial was completed comparing
Eye Movement Desensitisation and Reprocessing
(EMDR) with EFT in 46 participants (Karatzias et al.,
2011). Both of these interventions were found to
effectively treat PTSD after four sessions, leading to a
full reduction of symptoms (Karatzias et al., 2011).
When specifically reviewing the symptoms of
depression, both therapies were found to be equally
successful, utilising the same amount of time to improve
symptoms (Karatzias et al., 2011).
EFT has been found to be effective when treating
students with depression. A randomised control trial was
conducted on 238 college students with depression, who
each participated in four 90 min group sessions of
EFT (Church et al., 2012). When compared to a non-
treatment control group, the EFT group had
significantly less depressive symptoms than the
control group (Church et al., 2012). Limitations to this
study include; the EFT sessions were not administered
by a trained professional, a small number of sessions
were utilised and no formal diagnosis was made of the
participants (Church et al., 2012). It was proposed that
a larger number of treatment sessions, administered by
a trained Clinical EFT professional may provide
further effects (Church et al., 2012).
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Clinical EFT has also been found to be an effective
treatment when self-administered. A study of 216
health care professionals using Clinical EFT to treat
Major Depressive Disorder and anxiety used computer
based interventions where the participant was required
to follow directions, rather than being taught by a
Clinical EFT professional in person (Church and
Brooks, 2010). This study found that post treatment, a
significant decrease in pains, cravings, emotional
instability and traumatic memories was reported
(p<0.001) (Church and Brooks, 2010).
Large group intervention has also been found to be
effective with 102 participants in a three day EFT
workshop being measured at the beginning and end of
the workshop, as well as at one month and six month
follow-up (Rowe, 2005). A significant decrease in
symptoms such as anxiety, depression, phobias,
somatization, hostility, paranoia and interpersonal
sensitivity occurred, as measured by a self-reported
symptom checklist (Rowe, 2005). These changes were
maintained at three and six month follow-up (Rowe, 2005).
While Clinical EFT has been found to be an effective
treatment modality for many disorders (Brattberg, 2008;
Church 2008c; Stapleton et al., 2011), its limitations
include small sample sizes, lack of professional
instruction and lack of formal diagnosis (Church et al.,
2012). The benefits of using Clinical EFT include the
simplicity of administration (Church and Brooks, 2010)
and the reduced financial costs due to the reduced
number of treatment sessions required (Wells et al.,
2003). Once taught the tapping points and procedure of
administration, Clinical EFT can be self-administered.
Previous studies have found self-administration of Clinical
EFT to be a successful form of therapy (Brattberg, 2008),
with effects noted after minimal sessions such as a single
session when treating phobias (Wells et al, 2003), or four
sessions for successful treatment of PTSD (Church, 2010).
Thus, Clinical EFT is a simple therapy, which may be
administered at anytime. As depression is a growing
concern amongst the population and current therapy is
not universally effective, this may be an alternative
therapy for those who are unmotivated, fatigued and
experiencing financial hardship.
The significance of this study is its exploration of the
use of Clinical EFT in the clinical setting for the first
time with adults suffering Major Depressive Disorder.
Clinical EFT has been shown to be effective in the
treatment of stress (Church, 2008b), anxiety (Rowe,
2005), phobias (Jones et al., 2011; Wells et al., 2003)
and PTSD (Church, 2010). While symptoms of
depression have been found to improve when other
psychological conditions have been treated with EFT
(Brattberg, 2008; Church et al., 2011), no study has
measured the effect of EFT solely on Major
Depressive Disorder in an adult population, using a
diagnostic tool as evidence for treatment effects. The
current study aimed to develop an eight week Clinical
EFT program and test its effectiveness in treating
adults with diagnosed Major Depressive Disorder.
Each of the 120 minute Clinical EFT treatment
sessions would be conducted by a trained Clinical
EFT professional. A formal DSM-IV (APA, 1994)
diagnosis of Major Depressive Disorder would be
assessed prior to the commencement of treatment and
reassessed at the conclusion of treatment. Self-
reported symptomatic levels of depression and any co-
morbid conditions would be measured at the
commencement of treatment and again at the
conclusion of treatment and three month follow-up.
It was hypothesised that Clinical EFT would prove to
be a successful treatment modality in this feasibility study
for reducing Major Depressive Disorder in an adult
sample, as measured by the Mini International
Neuropsychiatric Interview (MINI; Sheehan et al., 1998),
Beck Depression Inventory II (BDI-II; Beck et al., 1961)
and the Depression, Anxiety and Stress Scale 21(DASS
21; Lovibond et al., 1993). It was also hypothesised that
Clinical EFT would have sustained benefits at the 3-
month follow-up period.
2. MATERIALS AND METHODS
2.1. Participants
Eleven adults were recruited using Face book pages,
university notice boards, word of mouth and community
classified pages in both local newspapers and on the
internet. The criteria to participate in the trial included
being over 18 years of age and having a diagnosis or
probable diagnosis of Major Depressive Disorder.
Volunteer participants were required to contact the
researcher and an appointment was made to complete the
MINI (Sheehan et al., 1998). The MINI was used to
confirm diagnosis of Major Depressive Disorder.
Participants’ were given the option to either meet with
the researcher to complete the MINI at the University
where the study was held, or complete the MINI over the
telephone. Each adult was emailed contact details of
alternative services, such as Lifeline, to be used if they
became distressed by completing the MINI, or if they did
not meet criteria for Major Depressive Disorder.
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After completing the MINI, it was found that ten of
the eleven participants met criteria for Major
Depressive Disorder (additional diagnoses can be
viewed in Table 5). The additional participant did not
meet diagnostic criteria for either Major Depressive
Disorder, or an alternate disorder, however, was
accepted into the treatment group due to self- reported
depressive symptoms. Once the participants had met
diagnostic criteria for Major Depressive Disorder,
they completed an online questionnaire package
including demographic questions such as age range,
gender, education level, number of people in
household, current education level, as well as the
Beck Depression Inventory II (BDI-II; Beck et al.,
1996) and the Depression, Anxiety and Stress Scale
21(DASS 21; Lovibond et al., 1993).
The final depressed sample consisted of two males
and nine females who participated voluntarily after
providing informed consent (see Table 1). Of the males,
one was in the 25-29 year old age range and one was in
the over 55 age range. Of the female participants, three
were in the 18-24 year old age range, one was in the 30-
35 year old age range, two were in the 40-45 year old
age range, one was in the 46-49 year old age range and
two were in the 50 and over age range.
A comparison community sample of non-depressed
adults was recruited through Facebook pages,
university noticeboards and community classified
pages in both local newspapers and on the internet.
The community sample consisted of 34 individuals,
sevenmales and 27 females each of whom participated
voluntarily after providing informed consent (Table
2). Of the males, one was in the 30-35 year old age
range, one was in the 40-45 year old age range and
five were in the 50+ age range. Of the female
participants, two were in the 18-24 year old age range,
one was in the 25-29 year old age range, three were in
the 30-45 year old age range, two were in the 36-39
year old age range, eight were in the 40-45 year old
age range, three were in the 46-49 year old age range
and eight were in the 50 and over age range.
2.2. Intervention and Materials
This study was reviewed for human subject
protection by the Bond University Research Ethics
Committee (BUHREC). Protocol Number: RO1518 and
was registered with The Australian New Zealand
Clinical Trials Registry (ANZCTR).
The Clinical EFT instruction was provided by a
certified professional EFT practitioner who acted as
group facilitator and a student researcher acted as a
support facilitator. The group intervention took place at
the Bond University Psychology Clinic.
The Clinical EFT program was developed by the
supervising and student researcher and two certified
EFT therapists, was based on standard Clinical EFT
protocols as outlined in the EFT manual (Craig, 2010)
and was then peer reviewed. In addition, this program
was modelled on a previous EFT food craving
program developed by the supervising researcher
(Stapleton et al., 2011). The program included a
treatment fidelity plan, requiring completion of an
intervention checklist after each treatment group by
the treatment professional and the co-facilitator.
The EFT program was designed to increase
participants’ understanding of Major Depressive
Disorder, as well as provide instruction regarding
thoughts and their effects on feelings, the benefits of
increased activity levels, psycho-education regarding
EFT and its associated tapping points, how to
construct appropriate EFT statements and to
experience the effects of using EFT.
The process of Clinical EFT involves thinking of
adistressing event, emotion, or memory, ratings its
intensity, initiating a setup statement, then completing
the tapping process on a sequence of 7 specific points
on the upper body (Brattberg, 2008). The setup phrase
focuses on the difficulty being experienced and is
spoken aloud, adding a voiced statement of
acceptance. For example, if anxiety is experienced, a
setup phrase could be “Even though I have this
anxiety, I deeply and completely accept myself.” The
setup phrase is stated while tapping either the “karate
chop” point below the little finger of either hand, or a
specific area on the chest below the collar bone,
termed the sore spot in EFT protocols (Craig, 2010).
After repeating the setup phrase three times, the
tapping process is followed, using a shortened version
of the setup phrase. In the example above a phrase
such as “All this anxiety” would be appropriate and
would be voiced while each point is tapped
approximately seven times each. Acupressure points 1
to 7 (Craig and Fowlie, 1995) were taught to each
participant to use when self-administering EFT. These
points are the inner eyebrow, the side of the eye,
under the eye, under the nose, the chin, the collar bone
and under the arm. See diagram in Appendix A.
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Table 1. Age range and sex distribution of depressed sample
Age 18-24 25-29 30-35 36-39 40-45 46-49 50+
Male 0 1 0 0 0 0 1
Female 3 1 0 0 2 1 2
Table 2. Age range and sex distribution of community sample
Age 18-24 25-29 30-35 36-39 40-45 46-49 50+
Male 0 0 1 0 1 0 5
Female 2 1 3 2 8 3 8
Two main types of instructional materials were used
during the intervention; instructional material
administered in the form of PowerPoint slides and client
handouts developed by the lead author were handed out
at the beginning of each session. The session topics for
the EFT intervention consisted of the following:
Week 1: Psychoeducation regarding treatment
Week 2: Behaviours that help manage depression
Week 3: The Thinking-Feeling connection
Week 4: Cognitive Restructuring
Week 5: Core Beliefs
Week 6: Stress and Relaxation
Week 7: Goal Getting
Week 8: Self Management
Social validity data was gathered in each group on
a weekly basis, by way of participants completing
self-report measures regarding the effectiveness of
treatment. Participants were able to remain
anonymous in order to obtain the most accurate
feedback. The participants were asked to nominate on
a Likert scale from 1 to 6, with 1 indicating not useful
at all and 6 indicating very useful, how useful the
treatment information and skills learnt were to their
symptoms of depression. Participants were then asked
to nominate how easy the treatment information was
to understand, with 1 indicating very difficult and 6
indicating very easy. Participants were also asked to
indicate how confident they felt in using the
information and skills covered, with 0 indicating not
confident at all and 6 indicating confident. Finally,
participants were asked if they would recommend
using these new skills to others, with 1 indicating not
recommended and 10 indicating highly recommended.
Participants were also asked to provide a rating
regarding the facilitator, with 1 indicating not at all and
5 indicating very much. Participants were asked how
approachable the facilitator was, how well the
facilitator explained skills and ideas, how well
questions and concerns were addressed, how
appropriate handout materials were and how much the
program met their needs. They were also invited to
make comments at the end of the form.
The current study was a pilot study using a small
sample of 11 participants, being compared to a non-
clinical community sample.
2.3. Measures
The Mini International Neuropsychiatric Interview
(MINI; Sheehan et al., 1998) is a short structured clinical
interview, based on the Structured Clinical Interview for
DSM IV (SCID; First et al., 1997) which enables
researchers to make diagnoses of psychiatric disorders
according to DSM-IV or ICD-10. Taking approximately
15 min to complete, the MINI has been found to have
good validity and reliability (Sheehan et al., 1998).
Sheehan et al. (1997) indicated the MINI has been found
to have a high correlation with the Structured Clinical
Interview for DSM Axis I Disorders, as well as having
both strong sensitivity (0.96) and specificity (0.96).
The Beck Depression Inventory II (BDI; Beck et al.,
1996) was used to assess symptom severity in clients
with probable Major Depressive Disorder. Each item
contained a statement which the client then rates in
relation to themselves, with higher total ratings indicating
higher levels of depression. Total scores less than 10 are
considered to reflect no or minimal depression, while
scores ranging between 10 and 18 are considered to reflect
mild depression. Moderate depression is indicated by
scores between 19 and 29, while severe depression is
indicated by scores greater than 29. The BDI II has
convergent validity with observer-rated measures
diagnosing depression (Marton et al., 1989). Internal
consistency of the BDI-II has been shown to be
consistently high, with measures of Cronbach's alpha
ranging from.88-0.95(Beck et al., 1996).
The Depression, Anxiety, Stress Scale 21 (DASS
21; Lovibond and Lovibond, 1995) is a self-report
questionnaire consisting of 21 items, which provides a
measure of depression, anxiety and stress (Atkin and
Cetin, 2007). The DASS 21 has been found to have
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good internal consistency, with interscale correlations
being Depression-Anxiety (0.45-0.71), 0.50 or below in
all English-speaking samples, Anxiety-Stress (0.65-0.73)
and Major Depressive Disorder-Stress (0.57-0.79)
(Antony et al., 1998; Brown et al., 1997; Clara et al.,
2001). Convergent validity has also been found to be
good for both clinical and non clinical samples
(Brown et al., 1997).
2.4. Participant Flow
Twenty individuals expressed interest in the
program. Of these individuals, 13 agreed to be
assessed (Fig. 1). Two participants did not attend
assessment, however, each of the 11 participants who
were assessed, participated in the treatment program.
Of those members, 2 males and 3 females did not
return after 2 weeks due to several factors. Two
withdrew due to illness, 2 had a lack of confidence in
the program and 1 participant did not return due to
death in the family and resultant grief (Fig. 1). Of the
remaining members (n = 6), each completed the final
assessments and 3-month follow-up. The withdrawn
participants did not appear to differ from completers
by visual inspection of pre-treatment scores or
demographic characteristics.
Eight Clinical EFT group therapy sessions were
administered over eight consecutive weeks. Each
session lasted 120 min. Participants were not included
in the data analysis if they discontinued attendance
after the first two weeks (n = 5). Treatment was
provided through a group setting, with information
being presented by the certified EFT professional,
using the PowerPoint slides as a treatment tool, as
well as modelling tapping points, as previously
described. Participants were given handouts, pens and
a clipboard and encouraged to stop and complete areas
in the handouts regarding symptoms, thoughts and
feelings as needed.
Participants who provided consent to do so, were sent
text messages on a weekly basis by the certified EFT
therapist, reminding them to use their Clinical EFT
techniques daily, which was designed to strengthen
motivation and adherence. Participants were able to
withdraw from this service at any time and were asked
periodically throughout the study if the frequency of
contact was appropriate and if there were any concerns
regarding this practise.
The post-test was administered at the conclusion of
the final session. Three month follow-up was completed
by an email being sent to each participant, containing a
link to the measures.
2.5. Data Analysis
Data was analysed using the Statistical Package for
Social Sciences 22.0 (SPSS). An independent samples t-test
was conducted to compare the self-reported baseline DASS
21 scores between the depressed and the non-depressed
group. There was significant difference in scores between
the depressed (M = 28.66, SD = 9.41) and the non-
depressed group (M = 6.11, SD = 4.63; t (38) = 9.25, p =
0.00 (two-tailed). The magnitude of the differences in the
means (mean difference = 22.54, 95% CI: 17.61-27.48 was
large (eta squared = 0.69).
An independent samples t-test was conducted to
compare the self-reported DASS 21 scores at the
completion of treatment between the depressed and the
non-depressed group. There was a significant difference
in scores between the depressed (M = 28.16, SD = 14.56)
and the non-depressed group M = 6.11, SD = 4.63; t (38)
= 3.67, p = 0.01 (two-tailed). The magnitude of the
differences in the means (mean difference = 22.04, 95%
CI: 6.78-37.31 was large (eta squared 0.26).
An independent samples t-test was conducted to
compare the self-reported DASS 21 scores at three
month follow-up between the treatment group and the
community sample. There was significant difference in
scores between the depressed (M = 21.16, SD = 9.49)
and the non-depressed group (M = 6.11, SD = 4.63; t
(5.42) = 3.80, p = 0.01). The magnitude of the
differences in the means (mean difference =15.04, 95%
CI: 5.11 to 24.98) was large (eta squared =0.27).
An independent samples t-test was also conducted to
compare the self-reported baseline BDI II scores
between the depressed and non depressed group. There
was a significant difference between the depressed (M =
30.66, SD = 11.00) and the non-depressed group (M =
5.08, SD = 5.41; t (38) = 8.97, p = 0.00 (two tailed). The
magnitude of the differences in the means (mean
difference = 25.57, 95% CI: 19.80 to 31.34) was large
(eta squared = 0.67).
An independent samples t-test was conducted to
compare the self reported post BDI II scores between
the depressed and non-depressed group. There
remained a significant difference between the
depressed (M = 21.83, SD = 14.86) and the non-
depressed group (M = 5.08, SD = 5.41, t (5.23) =2.72,
p = 0.039 (two tailed). The magnitude of the
differences in the means (mean difference = 16.74,
95% CI: 1.17 to 32.31) was large (eta squared = 0.16).
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Fig. 1. Participant flow diagram of clinical EFT treatment group
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Table 3. Descriptive statistics for DASS 21 administration Time 1, Time 2 and Time 3
Time Period N Mean Standard deviation
Time 1 (Pre-intervention) 6 28.66 9.42
Time 2 (Post intervention) 6 28.16 14.56
Time 3 (3 month follow-up) 6 21.16 9.50
Table 4. Descriptive Statistics for BDI II for Time 1, Time 2 and Time 3
Time Period N Mean Standard deviation
Time 1 (Pre-intervention) 6 30.66 4.49
Time 2 (Post intervention) 6 21.83 6.07
Time 3 (3 month follow-up) 6 18.66 7.20
An independent samples t-test was conducted to
compare the self-reported BDI II scores at three
month follow-up between the treatment group and the
community sample. There was a significant difference
in scores between the depressed (M = 18.66, SD =
10.93) and the non-depressed group (M = 5.08, SD =
5.41; t (5.44) = 2.97, p = 0.028). The magnitude of
differences in the means (mean difference 13.57, 95%
CI: 2.14 to 25.01) was large (eta squared = 0.18).
The means and standard deviations of the administration
of the DASS 21 and pre treatment, post treatment and three
month follow-up are presented in Table 3.
The means and standard deviations of the administration
of the BDI II, at pre intervention, post intervention and three
month follow-up are indicated in Table 4.
A Wilcoxon Signed Rank Test revealed no
significant reduction in symptoms as measured by the
DASS 21when comparing the pretest scores and the 3-
month follow-up, z = -1.68, p = 0.093. However, a
Wilcoxon Signed Rank Test revealed a significant
reduction in depressive symptoms as measured by the
BDI II when comparing the pretest scores and the 3-
month follow-up, z = -2.20, p = 0.028.
3. RESULTS
3.1. EFT Treatment
Eleven individuals were recruited through university
notice boards, Facebook pages and word of mouth. Ten
of these individuals met criteria for Major Depressive
Disorder, which was assessed by the administration of
the MINI. One participant did not meet criteria for Major
Depressive Disorder, however, participated in the group
due to depressive symptomology.
The first hypothesis asked whether Clinical EFT
resolved Major Depressive Disorder as a diagnosis. The
data revealed that while the diagnosis of Major Depressive
Disorder was not completely resolved immediately after
treatment, two members no longer met criteria. In addition,
each member of the group no longer met diagnosis for
one or more disorders they had met criteria for when
completing the MINI.
The second hypothesis asked whether Clinical EFT was
effective at reducing the symptoms of Major Depressive
Disorder. While scores on the DASS 21 indicated no
significant difference, in several cases individual
participants reported clinical differences in symptoms. That
is, the difference was enough so that if measured in a
clinical setting, it would indicate treatment was successful.
Therefore a clinically valid difference was achieved. The
BDI II indicated a significant difference in the pre, post and
3-month follow-up measures in the symptoms of Major
Depressive Disorder.
The third hypothesis asked whether the treatment
effects of Clinical EFT were sustained at follow-up. The
data suggests that not only are the effects of Clinical EFT
sustained at follow-up, but there appeared to be
continuous effects.
3.2. Participant Evaluation and Subjective Ratings
Each participant in the study was asked to
complete a worksheet containing social validity
questions at the end of each session. This was on a
voluntary basis and could be completed anonymously.
The answers provided indicated that throughout the
program 88% found the Clinical EFT program
information and skills to be useful. In addition, 100%
found the information easy to understand and 88%
indicated they felteither okay, confident, or higher in
using the information and skills covered.
Feedback regarding the facilitator was given using a
Likert scale from 1-5, with 1 indicating Not at all and 5
indicating Very much. When asked how approachable
the facilitator was 4% indicated a score of 4, whereas
96% gave the maximum score of 5. When asked how
well the facilitator explained skills and ideas, 24%
indicated a score of 4, while the remainder of the
participants gave a score of 5. When asked how well the
facilitator addressed questions and concerns, 17% gave a
score of 4, whereas 83% gave a score of 5. When asked
how appropriate the handout materials were, 2% gave a
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score of 3, 33% gave a score of 4, with 65% giving a
score of 5. The final question asked at what level the
program met the individuals’ goals. 7% gave a score of
3, 30 % gave a score of 4 and 63% gave a score of 5.
Each participant was re-administered the MINI at the
completion of the program. As indicated in Table 5, of
all EFT the participants, both participant 2 and 5 no
longer met criteria for Major Depressive Disorder
(MDD). Participant 1 maintained the diagnosis of MDD
and General Anxiety Disorder (GAD), however, no
longer met criteria for Agoraphobia, Social Anxiety
Disorder (SAD) and Obsessive Compulsive Disorder
(OCD). Participant 4 maintained the diagnosis for MDD,
however no longer met criteria for GAD. Both
participant 5 and participant 2 attended the entire eight
week program and had the greatest results. Participant 5
no longer met criteria for MDD, Panic Disorder with
Agoraphobia, OCD Current, or GAD. Participant 2 no
longer met criteria for MDD, Panic Disorder and
Bulimia Nervosa. At the initial administration,
participant 3 met criteria for MDD, Panic Disorder and
Agoraphobia, SAD, OCD, PTSD, Bulimia and GAD,
whereas, when the interview was readministered, the
participant no longer met criteria for OCD.
Although the changes in DASS 21 scores were not
significant, some changes were at a level to be clinically
remarkable and to have indicated change at a clinical
level (Table 6).
Table 5. EFT Pre and post diagnosis from structured clinical interview
Participant Pre Diagnosis Post diagnosis
1 Major depressive disorder Major depressive disorder
Agoraphobia General anxiety disorder
Social anxiety disorder
Obsessive compulsive disorder
General anxiety disorder
2 Major depressive disorder No diagnosis met
Panic disorder
Bulimia nervosa
3 Major depressive disorder Major depressive disorder
Panic disorder Panic disorder
Social anxiety disorder Social Anxiety Disorder
Obsessive compulsive disorder Post traumatic stress disorder
Post traumatic stress disorder Bulimia nervosa
Bulimia nervosa General Anxiety disorder
General anxiety disorder
4 Major depressive disorder Major depressive disorder
Generalised anxiety disorder
5 Major depressive disorder No diagnosis
Panic disorder
Obsessive compulsive disorder
General anxiety disorder
Table 6. The depression scale of the DASS 21
Participant DASS 21 pre DASS 21 post DASS 21 3mth follow-up
1 15 20 14
Extremely severe Extremely Severe Extremely severe
2 5 4 4
Mild Normal Normal
3 15 4 9
Extremely severe Normal Moderate
4 15 12 9
Extremely severe Severe Moderate
5 8 7 6
Moderate Moderate Mild
6 14 20 17
Extremely severe Extremely severe Extremely severe
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Table 7. The anxiety scale of the DASS 21
Dass 21 Dass 21 Dass 21
Participant Anxiety pre Anxiety post Anxiety 3 mthfollow-up
1 5 10 9
Mild Extremely severe Severe
2 1 0 0
Normal Normal Normal
3 5 3 3
Mild Normal Normal
4 12 8 5
Extremely severe Severe Mild
5 11 9 0
Extremely severe Severe Normal
6 6 7 6
Mild Moderate Mild
Table 8. The stress scale of the DASS 21
Participant DASS 21 DASS 21 DASS 21
Stress pre Stress post Stress 3 mthfollow-up
1 16 18 11
Severe Extremely severe Moderate
2 6 8 7
Normal Mild Normal
3 7 4 5
Normal Normal Normal
4 12 12 9
Moderate Moderate Mild
5 11 12 6
Moderate Moderate Normal
6 8 11 7
Moderate Moderate Normal
The symptoms of anxiety as measured by the
DASS21 generally continued to reduce after treatment
with Clinical EFT had concluded (Table 7). The Stress
scale of the DASS 21 indicated a mild improvement at a
clinical level in some cases (Table 8).
4. DISCUSSION
The current study was a feasibility pilot study of a
Clinical EFT program that was developed to treat Major
Depressive Disorder in an adult population. The results
confirmed that Clinical EFT is an effective treatment
modality when treating symptoms of depression. Firstly,
each participant treated with Clinical EFT found their
depressive symptoms were reduced at some level. This is
consistent with previous reports of reduced depression
when using Clinical EFT as a primary treatment
modality (Church et al., 2012; Feinstein, 2008).
The measures used to assess the symptoms of
depression produced differing results. The BDI II
indicated a significant difference between the three
administrations, whereas the DASS 21 indicated there
was no significant difference. The second administration
of DASS 21 post-treatment, indicated many of the
participants had a greater number of symptoms, or
experienced greater severity of their symptoms, than was
experienced pre-treatment. There may be several
reasons for this. As both post measures question how
the participants felt over the past week, this may
change on a week to week basis. While there may be
an improvement in one week, this may change to an
increase in symptoms in an alternate week. Moreover,
the second administration of both the DASS 21 and
the BDI II, were completed at the conclusion of the
final EFT session, while the participants were still in
the treatment room. Clinical EFT, by its nature brings
into consciousness any negative thought or feeling the
participant had been experiencing and as this second
administration was completed immediately after a
treatment session, it could be hypothesised that each
individual was more focussed on their difficulties
from the prior week, than they would have been when
initially completing the survey. Therefore it may have
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been that an awareness of depressive symptoms had
increased throughout the course of treatment, which
led to an increase of reporting, over what was initiated
in the initial assessment. However, this does not
explain the results of the BDI II.
The BDI II administered immediately post-treatment
provided an overall indication that participants
experienced less symptoms, at a lower severity level,
than had been indicated pre-treatment. The variance in
the results of the DASS-21 and the BDI II may have
been due to studies on the DASS-21 which have found
that rather than the depression, anxiety and stress
scales measuring symptoms in those specific areas,
many of the items appeared to be measuring general
distress (Osman et al., 2012). Osman et al. (2012)
have suggested that several items of the DASS do not
fit specifically in the anxiety, stress or depression scale,
leaving the researchers to state that the scales of the
DASS 21 appear unreliable. Therefore, the results of the
DASS 21 appear to be questionable in a study
specifically measuring the symptoms of depression.
The results taken at 3-month follow-up of both the
BDI II and the DASS 21 indicated there may have been a
progressive improvement effect. Many of the group
members experienced a continuous improvement in their
symptoms. As previously noted, members of the group
were sent periodic supportive text messages to remind
them to continue tappingduring the treatment program,
although it is uncertain how many members completed
this exercise, or how often it was completed. However, if
it was ascertained that the gradual improvement occurred
without further intervention, this would make it a very
powerful treatment modality. A delayed effect was also
found by Stapleton et al. (2011), where EFT used to treat
food cravings appeared to have continuous effects, with
feelings of restraint over food having been found to increase
at 6-month follow-up. Alternatively, if these effects were
due to the supportive messages, they further indicate the
effectiveness of self-administered Clinical EFT.
There were several limitations to this study. The large
number of drop outs from the group meant that it
effectively halved in size after recruitment. In addition,
recruitment proved difficult with a depressed population.
While many enquiries were made regarding the program,
the group modality of treatment appeared to be a negative
factor for enrollment as many initial enquirers stated they
would not feel comfortable attending a group setting.
Completing the structured interview provided a
difficulty for some members who failed to attend their
appointment to complete the interview. Of the participants
that did complete the study, difficulty was experienced in
receiving completed follow-up questionnaires. As depressed
individuals usually have difficulty with motivation and
concentration, this is an aspect that would need to be
considered for future studies.
5. CONCLUSION
Three major conclusions can be made from this
study. The first conclusion is that Clinical EFT as a
treatment modality appears to resolve symptoms a client
is experiencing, which may in turn resolve a disorder that
has been diagnosed. In the current study, each participant
was asked to practise Clinical EFT on any difficulties
they were experiencing over the week and were
reminded of this through text messages sent by the
Clinical EFT professional on a weekly basis. Although
the program was targeted toward depressed individuals,
they were encouraged to used Clinical EFT to deal with
any issues, which could range from self-esteem issues to
anger, difficulties with their partner, or any other
difficulties that were experienced. This may account for
the change in diagnosis for each participant.
The second conclusion was that Clinical EFT
appeared to reduce depressive symptoms in each
participant. Although there were no significant
differences in the self-report measures of the DASS 21,
the self-report measures of the BDI II indicated a
significant difference. The MINI also, reported a change
in diagnosis of Major Depressive Disorder in several
participants and a change or reduction in the number of
comorbid disorders in other participants.
Each participant indicated to the researcher that they
felt better and visually appeared to have an altered
demeanour and outlook as the sessions progressed. It
could be concluded that as improvements were made
between the final session and the 3-month follow-up,
changes were in a transient state and that 6-month
follow-up measures could ascertain whether there is a
stronger effect in this area.
The third conclusion was the results were not only
sustained at follow-up, but appeared to improve. In
addition, participants’ appeared to require the full eight
weeks of treatment to no longer meet criteria for Major
Depressive Disorder. As both participants who attended
the entire eight week program no longer met criteria for
Major Depressive Disorder it appears that attendance for
shorter amounts of time, although effective, did not
produce the same results. Further consideration may be
that each participant met criteria for several disorders,
therefore, as each participant experienced resolution
from one of these, they may have required further
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treatment sessions to work through each of their
diagnoses to reach the cause of their difficulties and
resolve their Major Depressive Disorder.
Future studies could complete longitudinal follow-up
assessments on participants to ascertain if the treatment
method has long term effects. In addition, due to many
enquirers stating they found the group aspect of the
treatment daunting, future treatment could focus more on
individual treatment on a one on one basis. The current
study lends support for a larger trial. Future studies could
use more comparison treatment when treating
depression, such as relaxation and CBT, as well as
utilising a larger sample size.
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