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Efficacy of Emotional Freedom Technique and Cognitive Behavioural
Therapy on Stress, Anxiety, Depression, Short-Term Memory,
Psychophysiological coherence and Heart Rate in Indian Adults
Shilpa Jasubhai,
Consultant Clinical Psychologist, Ahmedabad, Gujarat, India
Thoracic CT scan with a large collection of dorsal subcutaneous
scoliosis, pregnancy, gait disorders, motor crashes, falls, and joint
Studies showed that the majority of suicides are affected by
affected site. He refers that 4 months ago, he noticed weakness in
the left side that did not improve. He also associates slight
ipsilateral ocular proptosis.
ADITUM
Journal of Clinical Psychology and Mental Health Care
Open Access Review Article
Article Info
Received: March 19, 2021
Accepted: March 20, 2021
Published: March 24, 2021
*Corresponding author: Shilpa Jasubhai, Consultant
Clinical Psychologist, Ahmedabad, Gujarat, India
Citation: Shilpa Jasubhai. “Efficacy of Emotional
Freedom Technique and Cognitive Behavioural Therapy on
Stress, Anxiety, Depression, Short-Term Memory,
Psychophysiological coherence and Heart Rate in Indian
Adults”. Clinical Psychology and Mental Health Care, 2(4);
DOI: http;//doi.org/03.2021/1.10025.
Copyright: © 2021 Shilpa Jasubhai. This is an open access
article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is
properly Cited.
Abstract
World Health Organization reported depression as the fourth leading cause of
mental illness worldwide and one of the leading causes of disabilities among
adults. Living with depression may cause sleep deprivation, anxiety, stress and
short-term memory loss. This is because the individual’s mind may be occupied
with negative thoughts. Depression affects a person’s feelings, thinking, daily
functioning, processing speed, memory, and executive functions. National Mental
Health Survey of India in 2015-2016 reports that one in 20 Indians suffers from
Depression. Earlier research indicated that Cognitive Behavioural Therapy (CBT)
represents a superior approach in treating mild to severe depression symptoms, and
Emotional Freedom Technique (EFT) received increased attention. The present
study is in line with a study conducted in Australia in 2016 by Hannah Chatwin et
al. The objective of the current study is to evaluate the efficacy of EFT and CBT
in the treatment of stress, anxiety and depression, short-term memory loss,
psychophysiological coherence and heart rate in Indian young adults. Subjects (n
= 14), selected at random, from Ahmedabad (a metro city) in India, were screened
for stress, anxiety and depression using Depression, Anxiety and Stress scale
(DASS21) and Beck Depression Inventory (BDI2). They were also screened for
short term memory using Digit Span test, which allowed assessments of each
participant’s initial complaints of forgetfulness, difficulty in concentrating and
confusion. Their psychophysiological coherence score and heart rate were
recorded pre- and post- interventions using emWave system. These subjects were
randomly assigned to an 8 once a week CBT or EFT treatment program. All
participants were screened after 3 sessions, 5 sessions, 8 sessions and 6 months of
follow up using DASS21, BDI2 and Digit Span Test. They were also screened after
1 month for stress, anxiety and depression using DASS21 and BDI2. Findings of
the study depicted that both intervention approaches produced significant
reductions in stress, anxiety and depressive symptoms and concurrent
improvement in short-term memory (STM), psychophysiological coherence and
heart rate. The EFT treatment produced marked improvement in depression after 3
sessions. After 8 weeks of intervention, the CBT group reported significant
improvement in depression and short-term memory, while EFT intervention
therapy showed significant improvement in depression state after 1 month and 6
months of follow up respectively. Examination of individual cases showed,
clinically significant improvement in stress, anxiety, depression symptoms, short-
term memory and psychophysiological coherence across both interventions. The
results are consistent with the previous studies by Hannah Chatwin et al. (2016).
Present findings suggest that EFT would be an effective intervention therapy in
managing stress, anxiety, depression and STM and worthy of further investigation.
Keywords: CBT; EFT; stress; anxiety; depression; stm; psychophysiological
coherence; heart rate
Introduction:
Uncontrolled depression and anxiety cause significant impairment in daily
functioning, processing speed, memory, and executive function. Depression and
long-term anxiety are known to be associated with confusion, forgetfulness or lack
of concentration [81]. formation of a periosteal or intraosseous fistulous
arteriovenous connection; while the secondary lesion is formed by arteriovenous
fistula in a pre-existing benign primary bone pathology1.
The skull is a rare location and represents only 3% to 6% of all ABC10. Twenty-
one cases of ABC of the temporal bone have been described in the literature17.
ABC can affect any bone segment, with the long bones (67% of cases) being the
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J Clinical Psychology and Mental Health Care
of concentration [81]. World Health Organization (2020) reported
that depression is the leading cause of disability worldwide
affecting women more than men [86]. and 7.5% Indians suffer
from major to minor mental illness [55]. The National Institute of
Mental health and Neuroscience of India reported in a survey in
2016 that every 6th person needs mental health help and 1 in 20
suffers from depression [68,85]. When a person is in stress, stress
hormones are secreted in the brain and the amygdala and other
cerebral parts of the brain are activated. Lack of coping
mechanism can lead to physical and psychological consequences
and can be long-lasting, causing anxiety and depression [65].
The irony of mental health in India was reported by a survey done
in 2019 that there is still a stigma attached to mental illnesses.
Even educated people are loosely using term ‘Paagal’ with
depressed individuals [70]. Women primarily are less likely to
receive any help or are discouraged to seek help.
A pilot study on “Effectiveness of Cognitive Behavioural Therapy
(CBT) and Emotional Freedom Technique (EFT) in reducing
Depression and Anxiety among Adults” was conducted by
Hannah Chatwin et al. in 2016 in Australia. The results revealed
clinically significant improvement in anxiety and depression with
both interventions. While CBT group reported a significant
reduction in depression post-intervention, which was not
maintained with time, the EFT group reported a delayed effect
with a significant reduction in symptoms after 3- and 6-months of
follow-ups. The individual cases revealed clinically significant
improvements in anxiety across both interventions [39]. After the
literature review, no past studies were found in line with Hannah
Chatwin et al study comparing CBT and EFT in reducing stress,
anxiety and depression in Indian population.
Literature Review
Ali H. Kizilbash, Rodney D. Vanderploeg, Glenn Curtissa (2002),
in a study on “The effects of depression and anxiety on memory
performance” reported that depression with comorbid anxiety had
an adverse effect on immediate recall, amount of acquisition and
on the retrieval of newly learned information [1]. Dotson VM,
Szymkowicz SM, Kirton JW, McLaren ME, Green ML, et al.
(2014) in study reported that depression and anxiety influence
cognitive and brain functioning [28]. A study by Louisa Burriss
et al (2008) showed positive association between PTSD and
general learning and memory impairment [54]. Katherine E. et al
(2013), in a study reported that anxiety disrupts both verbal and
spatial working memory [51]. Gary Christopher & John
MacDonald (2005), in a study on “The impact of clinical
depression on working memory” reported that depression affects
attention and working memory [38].
Benor et al (2009) conducted a study on effectiveness of CBT and
EFT in comparison with the treatment of test anxiety among
university students and concluded that WHEE (Wholistic Hybrid
Derived from Eye Movement Desensitization and Reprocessing)
and EFT showed significant effects in only 2 sessions as
compared to 5 sessions needed by the CBT [31]. Gaesser Amy H.
& Karan Orv C. (2016) in a pilot study on EFT and CBT to
Reduce adolescent anxiety, concluded that EFT is an effective
intervention technique to significantly reduce anxiety for high-
ability adolescents [36]. Zhang Y, Feng B, Xie JP, Xu FZ, Chen
J. (2011) conducted a comparative study on treatment of the
PTSD using CBT and acupoint stimulation. Results showed a
significantly stronger improvement in CBT with acupoint
stimulation [87].
Conal Twomey, Gary O’Reilly & Michael Byrne (2014) and
Hofmann S., Asnaani A, Vonk IJ., Sawyer A. and Fang A. (2012)
in their research on, effectiveness of CBT for anxiety and
depression, concluded multi-modal CBT is effective for anxiety
and depression symptoms in primary care and the evidence base
of CBT in general is very strong [22,44]. Ragnhild S. H. et al.
(2011) conducted a research on effectiveness of CBT on
depression and anxiety in primary health care unit and concluded
that CBT is potentially more effective for mild to moderate
depression and anxiety than usual care [69]. Saeid Pahlavanzadeh,
Samira Abbasi, and Nasrollah Alimohammadi (2017), conducted
a study on “The Effect of Group CBT on Stress, Anxiety, and
Depression of Women with Multiple Sclerosis” and found
significant improvement in stress, anxiety and depression after 8
weeks and 1 month [76].
Church et al (2010, 2012 & 2013) conducted various studies to
confirm the efficacy of EFT in bringing significant reductions in
the symptoms of depression and anxiety. They concluded that
Clinical EFT is an evidence based, stable, safe and reliable
treatment for psychological and medical diagnosis in primary care
settings [17,18,20]. Church et al (2012) in a study “The Effect of
Emotional Freedom Techniques on Stress Biochemistry”
observed significant improvement in psychological distress and
decrease in the cortisol level in one session in the EFT group [19].
Clond M (2016), Church et al (2012) conducted various studies
on efficacy of EFT in decreasing symptoms of stress, anxiety and
depression. Their conclusions were similar and all of them
reported improvement in symptoms, positive health effects and
increased mental well-being [21,18]. Donna Bach et al (2019), in
a study on “Clinical EFT (Emotional Freedom Techniques)
Improves Multiple Physiological Markers of Health”, reported
that a positive trend was observed for HRV (heart rate variability),
HC (heart coherence) and EFT. EFT combines both cognitive and
somatic elements and is effective for both physiological and
psychological symptoms [27]. Feinstein, D. (2012) in paper on
acupoint stimulation in treating psychological disorders got
positive result in few treatments of EFT [32]. In a study on
Efficacy of EFT in reducing public speaking anxiety, Jones, S.,
Thornton, J., & Andrews, H. (2011) concluded that the EFT
treatment group showed statistically significant decrease in
anxiety. [46]. Kalla Mahima et al (2017) in a study to find out the
experience of an EFT practitioner in using EFT technique to
support patients with chronic disease, concluded that EFT
technique can give promising results to health care practitioners
for the psychosocial aspect of chronic disease [48]. Karatzias et
al. (2011) investigated the effect of EFT on PTSD and the results
showed a positive outcome with voluntary termination of the
treatment after an average of 3.8 sessions [49]. Patterson SL.
(2016) conducted a pilot study on the effect of stress and anxiety
in nursing students” and concluded that EFT can be an effective
tool in managing stress and reducing anxiety in nursing students
[63]. Meta-analysis of the past studies by Brenda Sebastian &
Jerrod Nelms (2016) showed that 4-10 session of EFT was an
effective treatment for PTSD [14]. Peta Stapleton et al. (2014)
investigated the feasibility of using Clinical Emotional Freedom
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Techniques to treat Major Depressive Disorder in an Australian
adult and positive results were found after eight weeks of therapy
[64]. Rowe, J. (2005) in a study on ‘The effects of EFT on long -
term psychological Symptoms’ using EFT and got promising
results with significant decrease in psychological distress post
workshop and after 1-month and 6-months of follow up [72].
Hartmann Ralf et al (2019) conducted a study on heartrate
variability as an indicator of clinical state in depression and
concluded that change in HRV parameter values correlated with
changes in the severity of depressive symptoms [40]. S.D.
Edwards (2016) investigated the influence of HeartMath quick
coherence technique on psychophysiological coherence and
feeling states and reported a significant change in percentages of
high psychophysiological coherence, decreased feelings of
sadness and increased feelings of peacefulness [74]. A study
conducted by Dan Malm et al. (2018), concluded that a
mindfulness-based CBT programme improved the health-related
quality of life and sense of coherence and reduced psychological
distress up to 12 months post atrial fibrillation [26].
However, there was not enough data available to compare EFT to
conventional treatment i.e. CBT for stress, anxiety, depression,
short-term memory, psychophysiological coherence and heart rate
in the Indian population. Further research is needed to establish
the relative effectiveness of EFT in the Indian context.
Present Study
The author chose to evaluate the efficacy of CBT and EFT on
stress, anxiety, depression, short-term memory and
psychophysiological coherence in Indian adults. Present study is
based on of her past research in 2018.
The participants were randomly selected and assessed for stress,
anxiety and depression. Participants who were screened positive
for stress, anxiety and depression were included in the present
study and further assessed for short-term memory loss and their
physiological coherence and heart rate were recorded. In the
initial interview most, participants complained of forgetting
names, misplacing things, forgetting specific words and difficulty
concentrating. According to past research findings, stress, anxiety
or depression could cause forgetfulness, confusion, difficulty in
concentration and other problems that disrupt daily mental
activities [56]. According to HeartMath research different
patterns of heart activity have discrete effects on emotional and
cognitive function. The heart rhythm pattern is erratic during
stress and anxiety and affects the brain’s emotional processes
[29]. The subjects were randomly assigned to an 8 once a week
CBT or EFT treatment program. All participants were screened
after 3 sessions, 5 sessions, 8 sessions and 6 months of follow up
using DASS21, BDI2 and Digit Span Test. They were also
screened after 1 month for stress, anxiety and depression using
DASS21 and BDI2. Their physiological coherence score and
heart rate were recorded pre- and post-interventions using
emWave system. The corresponding author has been using the
EFT therapy regularly to help clients with a variety of problems
like depression, anxiety, OCD, stress, etc. Thus, the author chose
to evaluate the effectiveness of CBT and EFT on stress, anxiety,
depression, short-term memory, psychophysiological coherence
and heart rate in Indian adults.
Stress:
The dictionary meaning of stress is “a state of mental or emotional
strain or tension resulting from adverse or demanding
circumstances.” [62]. In psychology, stress is
a feeling of strain, pressure or a type of psychological pain [81].
Baum, A. (1990) defined stress as any uncomfortable "emotional
experience accompanied by predictable biochemical,
physiological and behavioral changes [6]. Research by Baum, A.
& Polsusnzy, D. (1999), shows that stress can contribute to the
development of serious health issues, such as heart disease,
depression, obesity, anxiety, insomnia, muscle pain, high blood
pressure and a weakened immune system [7]. External stress or
internal perceptions can cause an individual to experience anxiety
or other negative emotions surrounding a situation, which they
believe is stressful [34].
Anxiety:
The dictionary meaning of anxiety is “a feeling of worry,
nervousness, or unease about something with an uncertain
outcome.” [60]. According to the American Psychological
Association (APA) “Anxiety is an emotion characterized by
feelings of tension, worried thoughts and physical changes like
increased blood pressure. People with anxiety disorders usually
have recurring intrusive thoughts or concerns. They may avoid
certain situations out of worry. They may also have physical
symptoms such as sweating, trembling, dizziness or rapid
heartbeat.” [2].
The essential features of generalized anxiety disorder according
to DSM V are “excessive anxiety and worry about a variety of
topics, events, or activities. Worry occurs often for at least 6
months and is clearly excessive. Excessive worry means worrying
even when there is nothing wrong or in a manner that is
disproportionate to the actual risk” [4].
Depression:
Dictionary meaning of depression is “feeling of severe
despondency and dejection.” [61]. According to APA
“Depression is more than just sadness. People with depression
may experience a lack of interest and pleasure in daily activities,
significant weight loss or gain, insomnia or excessive sleeping,
lack of energy, inability to concentrate, feelings of worthlessness
or excessive guilt and recurrent thoughts of death or suicide.” [3].
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According to DSM V Depression symptoms can vary from mild
to severe and a person may experience feeling of sadness, loss of
interest, changes in appetite, change in sleep, loss of energy,
feeling of worthlessness, suicidal thoughts, difficulty
concentrating and the symptoms should last for at least two weeks
[4].
Short Term Memory:
Short-term memory is the capacity for holding a small amount of
information in mind for a short period of time. Short-term
memory (STM) is the second stage of the multi-store memory
model proposed by Atkinson and Shiffrin [57]. According to
Atkinson and Shiffrin (1971) the duration of STM is between 15-
30 seconds [5]. According to the Miller’s Law (1956) the number
of objects an average human can hold in short-term memory is 7
± 2 [59].
According to past research findings, stress, anxiety or depression
could cause forgetfulness, confusion, difficulty in concentration
and other problems that disrupt daily mental activities. (56) S.
Nolen-Hoeksema et.al, concluded that a person with depressed
mood spends more time on processing negative or depressive
information than other forms of information which may affect
cognitive functioning and working memory [75].
Psychophysiological Coherence
Doc Childre (1991) is the founder of the HeartMath Institute.
Heart rate variability (HRV) is a measure of the beat-to-beat
changes in heart rate. The HRV helps to understand the
interactions between physiological, mental, emotional and
behavioural processes. According to HRV analysis the heart is a
sensitive marker for emotional changes, which is reflected in heart
rhythm patterns. It reflects a person’s capacity to adapt effectively
to stress and environmental demands and is an important indicator
of both physiological resilience and behavioural flexibility.
Different patterns of heart activity have different effects on
cognitive and emotional function of the brain. During stress,
anxiety or negative emotions, the heart rhythm pattern is irregular
and erratic. HeartMath scientists call this an incoherent heart
rhythm pattern. This restricts the ability to think clearly,
remember, learn and it affects emotions. When positive emotions
are experienced the heart rhythm pattern becomes smooth and
harmonious called coherent heart rhythm pattern. According to
Rollin McCart, coherence is an optimal physiological state when
the heart, mind and emotions are in alignment and which prevents
and reduces stress, increases resilience and improves emotional
wellbeing. This is called psychophysiological coherence because
there is an increased harmony in both the psychological and
physiological processes. [29,40,41,54,71].
EFT:
The basic EFT technique was developed in 1995 by Craig and
Fowlie as a simplified form of thought field therapy (Callahan,
1985). He described the unique feature of EFT in one statement,
“The cause of all negative emotions is a disruption in body’s
energy system.” EFT is a blend of Acupuncture and Mind-Body
Medicine, both of which have been supported by scientific studies
for decades [23].
In simple words EFT is an alternative therapy for emotional
distress and physical pain. EFT is the most well-known form of
“energy psychology” which combines cognitive and exposure
techniques by stimulating the selected acupuncture points
(acupoints) by tapping on them. It works by gently tapping on the
acupoints while focusing on emotional trigger and repeating a
statement of self-acceptance [23,33,47]. This helps in releasing
blockages within the energy system which causes negative
emotions and physical disorders. These blockages in our energy
system cause limiting beliefs and behaviours, various physical,
emotional and psychological syndromes, such as low confidence,
stress, anxiety or depression [83].
A cognitive approach with acupuncture leads to a change in the
behaviour, subconscious thought process and neurochemical
bases of the psychological problem. Stimulation of these meridian
points is believed to send signals to the limbic system, decrease
the activity in amygdala and balance the secretion of stress
hormones. Like CBT, EFT thrives on the fact that rather than
resistance of a condition, self-acceptance will reduce the suffering
[47]. EFT seems to balance disturbances in the meridian system
which in turn balances the negative emotions and the physical
discomfort attached to it at conscious and sub-conscious level.
Thus, EFT reduces the time spent by conventional therapy
procedures [23].
The American Psychological Association (APA) in a review in
2012, stated that EFT therapy met the criteria for evidenced-based
treatments, but the mechanisms behind EFT are not understood
[73].
CBT
Aaron Beck (1960) is considered the father of CBT and his
theories are widely used in treating depression and anxiety [10].
Beck Institute states CBT as a time-sensitive, structured, present-
oriented psychotherapy directed toward solving current problems
and teaching skills to modify dysfunctional thinking and
behaviour [66]. Based on the CBT concept, CBT helps an
individual to understand the connection between thoughts,
feelings and behaviour, and teaches the effective coping strategies
for dealing with different problems throughout life [16].
According to the National Health Service (NHS) of England,
“CBT is based on the concept that your thoughts, feelings and
behaviour are interconnected, and constantly influence one
another.” CBT deals with current problems, rather than focusing
on past issues [67]. This is another common factor between EFT
and CBT.
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The cognitive Model [12].
Our pattern of thinking makes us perceive the world in a specific
way. According to Aaron Beck the perceptions and interpretations
of depressed persons are distorted. Depressed individuals are
occupied in "cognitive errors," (50) such as negative and fearful
thoughts and biased information processing. (69) These errors in
thoughts are automatic and the individual believes them to be true.
CBT focuses on altering these automatic thoughts. In simple words
CBT is a focused, short term and structured method to treat a
variety of mental health disorders. (33)
Hypothesis:
• Ho 1 -There is no difference in the efficacy of EFT and
CBT intervention therapies after 3 weeks, 5 weeks, 8
weeks, post 1 month and 6 months of follow up in
reducing stress, anxiety and, depression in Indian adults.
• Ho 2 - There is no reduction in stress, anxiety, depression,
short-term memory span, psychophysiological coherence
and heart rate post interventions in Indian adults.
• Ho 3 - There is no improvement in short-term memory
span post 6 months of follow up in Indian Adults.
• H1 - There is a significant difference in EFT and CBT
intervention therapies after 3 weeks, 5 weeks, 8 weeks,
post 1 month and 6 months of follow up in reducing
stress, anxiety, and depression in Indian adults.
• H2 2 - There is a significant reduction in stress, anxiety,
depression, short-term memory span,
psychophysiological coherence and heart rate post
interventions in Indian adults.
• H3 3 - There is a significant improvement in short-term
memory span post 6 months of follow up in Indian adults.
Material:
• Depression, Anxiety and Stress Scale 21 (DASS 21)
• Beck Depression Inventory II (BDI II)
• Digit span (Jacobs, 1887)
• Emwave System
• Consent Form
• Demographic Information Form
Method:
Participants:
19 participants in the age group of 25 to 40 years were randomly
selected from general population in Ahmedabad, India and were
screened for stress, anxiety, depression, short-term memory and
their psychophysiological coherence scores were recorded using
Beck Depression Inventory - second edition (BDI-II) (8),
Depression, Anxiety, Stress Scales 21 (DASS-21) (53), Digit Span
Test (45) and emWave Pro system respectively [29].
Due to personal reasons some of the participants dropped out and
few were not eligible for inclusion. Ahmedabad being a
conservative city there is a stigma attached to seeing a
psychologist. Male don’t volunteer for research work so easily,
especially when a researcher is a female. Thus, there was a
difference in the gender equality.
BDI II (Aaron Beck, 1996) is a revised version of BDI is designed
for individuals aged 13 and over. Based on DSM 5 it measures the
severity of depressive symptoms such as hopelessness and
irritability, feeling of guilt or feelings of being punished, as well as
physical symptoms such as fatigue, weight loss, and lack of interest
in sex. BDI II contains 21 questions. Participants were asked to
specify on a 4-point Likert scale the extent to which they had
experienced negative emotional states of depression during the
past week [10].
The DASS 21 scale (Lovibond, S.H. & Lovibond, P.F., 1995) is a
set of three self-report scales designed to measure the negative
emotional states of depression, anxiety and stress. ‘Participants
were asked to specify on a 4-point scale the extent to which they
had experienced negative emotional states of depression, anxiety,
and stress during the past week. Each of the three DASS-21 scales
contains 7 items, divided into subscales with similar content. The
development of DASS-21 was based on the assumption that
difference between the stress, anxiety and depression experienced
by normal subjects and clinical patients is mainly of degree [53].
Digit span was originally devised by Jacobs (1887). Short term
memory span has been measured through the recall of digit
sequences. The span indicates an ability to retain meaningless
material that appears to be unrelated to thinking [45]. Digit-span
task measures working-memory's number storage capacity.
Participants are presented with a series of digits (e.g., '8, 3, 4') and
must immediately repeat them. The longest list of numbers a
person can remember is that person's digit span. The participants
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were asked to repeat the digits in the given order in the forward
digit-span task and in the backward digit-span task the participant
had to reverse the order of the numbers [80].
EmWave system was developed by Doc Childre in 1991. Emwave
system accurately records the heart rhythms and heart rate
variability and translates coherence information into graphical
display on the computer screen. The ear sensor was attached to the
earlobe of each participant. The ear sensor detects the pulse easily.
They were asked to keep their eyes closed and not to move or talk
while the recording was going on. The recording was done for 4
minutes. The psychophysiological coherence score and heart rate
were recorded pre- and post- interventions. [29,77].
14 participants (10 female and 4 male) who were screened positive
for stress, anxiety and depression were included for the study. They
were asked to sign the consent form and provide demographic
information. Then they were tested for short term memory using
digit span and their psychophysiological coherence score and heart
rate were recorded. The participants were then randomly assigned
to 8 once a week EFT (N=7) or CBT (N=7) therapy program. They
were screened for stress, anxiety and depression after 3 sessions, 5
sessions, 8 sessions, after 1 month and 6 months using DASS 21
and BDI II. Participants were screened for STM using digit span
test post interventions and after 6 months. Their
psychophysiological coherence score and heart rate were recorded
pre- and post- interventions. The results were analysed using ‘t’
test.
Procedure:
Eight, once a week individual therapy session was conducted for
both EFT and CBT programs by the researcher. A similar structure
was used for both the interventions. Participants were contacted
after 1 month and 6 months post intervention to complete the same
questionnaires.
EFT Intervention:
The procedure involved participants to focus on a distressing
thought, create an intensity rating, initiate a setup phrase, and then
complete the tapping sequence using acupressure points.
Psychological Reversal means energy in the body is disturbed. It
is self-defeating, negative thinking which often occurs
subconsciously and may be outside one’s awareness. It should be
neutralized with affirmative statement for cognitive shift.
At the beginning of each session participants were asked to rate
their subjective level of discomfort on the scale of 1 to 10. Then
based on emotional difficulty being experienced a setup phrase
was initiated. The affirmative statement of acceptance of the
difficulty was repeated 3 times while tapping on "Karate Chop"
point, as per Craig’s EFT manual. e.g. “Even though I have this
Problem, I deeply and completely accept myself”. The sequence of
tapping points- TH, EB, SE, UE UN, UL, CB, UA, Gamut
procedure and WR was taught and the participants were asked to
get tuned into emotional discomfort while tapping on the meridian
point and repeating the affirmative statement. The whole cycle was
repeated till the subjective level of discomfort reduced to zero
level. After the 1st round the setup phrase was rephrased as, “Even
though I still have some of this remaining problem. I deeply and
completely accept myself”. [24].
At the end of each session, they were given home plan and asked
to give feedback for the session. Home plan included tapping
sequence, thought journal, affirmation statement and breathing
exercise.
CBT Intervention:
The CBT session was conducted using conventional CBT
program. The aim of the intervention was to modify distorted
thinking, dysfunctional behaviour, and distressing feeling by
teaching coping strategies. In simple words the goal was to replace
negative thoughts with productive behaviour.
The CBT program involved identifying and challenging the
harmful automatic thoughts, restructuring negative automatic
thoughts, core beliefs and scheduling and monitoring activities.
Participants were given different worksheets like Alternative
Action Formulation, Functional Analysis and Longitudinal
Formulation and were asked to maintain a thought journal as home
plan. [66].
At the beginning of each session participants were asked to rate
their subjective level of discomfort and describe their feelings of
this week, compared to earlier weeks. They were, then, asked to
name the main problems they faced during the week and the plan
for the session was discussed. To create a bridge between the last
and present session they were asked whether anything unusual
happened during the week which they would like to share. This
was followed by discussing self-help assignments. After
prioritizing the issue, the problems were discussed one by one. The
truthfulness of their thoughts and beliefs in the difficult situation
were assessed. New skills to modify their negative thinking and
behaviour and solving problems on their own were taught. They
were asked to summarize and write down important points in their
own words and home plan activities were scheduled until the next
session. At the end of the session, they were asked to give a
feedback for the session and were asked to rate their subjective
level of discomfort. Home plan activities included affirmation
statement, thought journal, breathing exercise and worksheets like
Alternative Action Formulation, Functional Analysis and
Longitudinal Formulation.
In each consecutive session at the beginning the home plan was
reviewed for both the intervention therapies. After 8 weeks of
intervention participants were asked to continue home plan
activities.
Statistical Methods:
The statistical analysis was done using small samples t test and
within subject t test. A statistical significance in t test indicates
whether the difference between the averages of two groups most
likely reflects a “real” difference in the population from which the
groups were sampled. We are interested in finding out (i) changes
in subjects’ scores before the treatment and after the treatment (ii)
whether there was any significant difference between the two-
intervention therapies (iii) whether there was an improvement in
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stress, anxiety, depression, memory, psychophysiological
coherence and heart rate post intervention [37,79].
Results:
Graph 1 Pre-Intervention
The total sample size was 14, consisting of 1o women and 4 men
between the age group of 25 – 40 years. Pre-test results show no
statistically significant difference in both intervention groups.
Average depression score in both the groups on BDI II scale was
24.57 (EFT) and 25.57 (CBT) respectively, which is in the
moderate range and on DASS 21 scale was 22 (EFT) and 22.57
(CBT) respectively, which is in the severe range. Average anxiety
score in both the groups was 16.29 (EFT) and 15.43 (CBT)
respectively, which is in the severe range. Average stress score in
both the groups was 26.29 (EFT) and 26.57 (CBT) respectively,
which is in the moderate range. The forward digit span score in
both the groups was 5.14 (EFT) and 5.29 (CBT) respectively. The
backward digit span score in both the groups was 4.86 (EFT) and
4.71 (CBT) respectively. The psychophysiological coherence
score in both the groups was 1.10 (EFT) and 0.99 (CBT)
respectively and heart rate was 119 in both the groups.
Graph 2 After 3 weeks of Intervention
After 3 sessions, average depression score in both the groups on
BDI II scale was 22 (EFT) and 22.9 (CBT) respectively, and on
DASS 21 scale was 14 (EFT) and 13.4 (CBT) respectively, which
is in the moderate range. Average anxiety score in both the groups
was 17.7 (EFT) and 19.7 (CBT) respectively, which is in the
moderate range. Average stress score in both the groups was 14
(EFT) and 13.4 (CBT) respectively, which is in the moderate
range. There was no significant difference found in reduction of
stress, anxiety and depression between both intervention therapies
after 3 weeks.
Graph 3 After 5 weeks of Intervention
Average depression score after 5 sessions in both the groups on
BDI II scale was 17.14 (EFT) and 18.57 (CBT) respectively,
which is in the range of borderline clinical depression and on
DASS 21 scale was 15.43 (EFT) and 17.14 (CBT) respectively,
which is in the moderate range. Average anxiety score in both the
groups was 11.43 (EFT) and 11.14 (CBT) respectively, which is
in the moderate range. Average stress score in both the groups was
17.14 (EFT) and 18 (CBT) respectively, which is in the mild
range. There was no significant difference found in reduction of
stress, anxiety and depression between both intervention therapies
after 5 weeks.
Graph 4 After 8 weeks of Intervention
Average depression score after 8 sessions on BDI II scale in both
the groups was 14.6 (EFT) which is in the range of mild mood
disturbance and 10.7 (CBT) which is in the normal range. The
result is statistically significant at 0.05 level. Participants who
received CBT therapy showed better results than participants who
received EFT therapy. On DASS 21 scale average depression
score was 13.7 (EFT) which is in the moderate range, and 10.9
(CBT) which is in the mild range. Average anxiety score in both
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the groups was 8.0, which is in the mild range. Average stress
score in both the groups was 11.4 (EFT) and 12.9 (CBT), which
is in the mild range. Average forward digit span score in both the
groups was 8.0 (EFT) and 9.4 (CBT) respectively. The result is
statistically significant at 0.05 level. Average backward digit span
in both groups was 7.4 (EFT) and 7.7 (CBT) respectively.
Average psychophysiological coherence score in both the groups
was 3.4 (EFT) and 4.3 (CBT) respectively. The result is
significant at 0.05 level. Average heart rate in both the groups was
84.1 and 80.9 respectively. There was a significant reduction in
depression and improvement in forward digit span and
psychophysiological coherence in CBT group post intervention.
There was no significant difference found between two therapies
in reduction of stress, anxiety, heart rate and improvement in
backward digit span.
Graph 5 After 1 Month of Follow Up
Average depression score after 1 month of follow up in both the
groups on BDI II scale was 8.1 (EFT) which is in the normal range
and 10.7 (CBT) which in the range of mild mood disturbance. The
result is significant at 0.05 level. On DASS 21 scale average
depression score was 9.4 (EFT) which is in the normal range and
10.6 (CBT) which is in the mild depression range. Average
anxiety score in both the groups was 5.7 (EFT) and 6.6 (CBT),
which is in the normal range. Average stress score in both the
groups was 10.6 (EFT) and 12.3 (CBT), which is in the mild
range. Participant who had received EFT therapy showed
significantly better result in reduction of depression on BDI II
scale after 1 month of follow up. Both the groups were asked to
continue the home plan.
Graph 6 After 6 Month of Follow Up
Average depression score after 6 months of follow up in both the
groups on BDI II scale was 8.1 (EFT) and 10.4 (CBT) which is in
the normal range. The result is significant at 0.05 level. On DASS
21 scale it was 9.1 (EFT) which is in the normal range and 10
(CBT) which is in the mild depression range. Average anxiety
score in both the groups was 5.7 (EFT) and 7.4 (CBT), which is
in the normal range. Average stress score in both the groups was
10.0 (EFT) and 11.1 (CBT) which is also in the normal range.
Average forward digit span score in both the groups was 9.7
(EFT) and 9.9 (CBT) respectively. Average backward digit span
score in both groups was 7.7. After six months, the average scores
on BDI II, DAS 21 and digit span remained more or less same
across both the groups.
Graph 7 Pre and Post Intervention
There was a statistically significant improvement at 0.05 level in
stress, anxiety, depression, forward digit span, backward digit
span, psychophysiological coherence and heart rate post
interventions in all the participants.
Discussion:
Observationally, after 3 weeks of intervention, there was a
reduction in depression on BDI II scale in EFT group from
moderate to borderline clinical depression. The result support the
past studies by Benor et al. (2009) where EFT showed significant
effects in only 2 sessions as compared to 5 sessions for the CBT
and by Church et al (2012) where EFT showed a significant
improvement in psychological distress and decrease in the cortisol
level in one session. [13,19]
Observationally, after 5 sessions there was a reduction in stress,
anxiety and depression across both the groups. The Results
support the findings of Zhang Y et.al. where CBT with acupoint
stimulation showed significantly stronger improvement [87].
One of the subjects who was 34 years old Female, had severe
stress, anxiety and depression pre intervention, showed noticeable
improvement with EFT intervention therapy after 5 weeks. Her
stress score came down in the range of mild, anxiety score and
depression score on DAS 21came down in the moderate range and
on BDI II depression came down in the range of mild mood
disturbance. Results support the study done by Benor et al (2009)
where EFT showed significant effects in only 2 sessions as
compared to 5 sessions needed by the CBT to reduce anxiety in
university students [1]. The subject did not show much
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improvement after 8 sessions of EFT but after one month of
follow up the subject became normal and the score across all the
tests were in normal range i.e. < 10. Her scores on BDI II, DAS
21 and backward digit span remained same after 6 months of
follow up. There was an improvement in forward digit span after
6 months of follow up compared to a score after 8 sessions. Her
psychophysiological coherence was 1.2 and heart rate was 122 pre
intervention. According to the HeartMath Institute our feelings
and emotional stress affect our heart rhythm pattern and make it
appear erratic and irregular. After the 8 sessions her
psychophysiological coherence was 4.6 and heart rate was 92.
Higher heart-coherence levels indicate positive emotional state
which is reflected in the pattern of the heart’s rhythm. This shift
in the heart rhythm plays an important role in promoting higher
cognitive functions and emotional stability. The result supports
the study done by Hartmann Ralf et al (2019) where he concluded
that change in HRV parameter values correlated with changes in
the severity of depressive symptoms [40, 41, 71]
E.g. Heart Rhythm pattern of the participant mentioned above.
Pre-Intervention - Coherence-1.2 Heart rate-122
During stress, anxiety and negative emotions, the heart rhythm
pattern is irregular and erratic. This restricts the ability to think
clearly, remember or learn and it affects emotions [71].
Post-Intervention - Coherence-4.6 Heart rate-92
When the positive emotions are experienced the heart rhythm
pattern becomes smooth and harmonious. This is called
psychophysiological coherence state [71].
At 8 weeks, the CBT intervention group reported significant
improvement in depression on BDI II scale, forward digit span and
psychophysiological coherence. Depression score came down
from borderline clinical depression to mild mood disturbance on
BDI II scale and from moderate to mild depression on DASS 21
scale. Findings are highly consistent with prior studies like
Hannah Chatwin et al. (39), Hofmann et al [44], Ragnhild S. H. et
al [69], Conal T. et al [22] and Saeid Pahlavanzadeh et al [76]
where they concluded that CBT is potentially more effective for
mild to moderate depression and anxiety than the usual primary
care treatment.
After 8 weeks of therapy the range of depression in EFT group
came down from borderline clinical depression to mild mood
disturbance. The results support the findings of Peta Stapleton et
al. [64], where they reported improvement in the participants
having major depression with 8 sessions of EFT. The stress score
in both groups was in the mild range.
There was significant improvement in forward digit span with
CBT intervention. Result supports the study by Fatemehsadat A.
et al (2015) [31]. There was a significant reduction in depression
and improvement in psychophysiological coherence in CBT group
post intervention. Results support the study by Hartmann Ralf et al
(2019) which concluded that change in HRV parameter values
correlated with changes in the severity of depressive symptoms
and Dan Malm et al. (2018) which concluded that a mindfulness-
based CBT program improved the health-related quality of life,
sense of coherence and reduced psychological distress up to 12
months [40, 26].
Another subject, who was a 40 years old male, had severe stress
and anxiety and moderate depression pre intervention. He showed
noticeable improvement with CBT intervention therapy after 8
sessions. His stress score came in the range of normal and anxiety
and depression in mild range. There was a marked improvement in
STM span after 8 sessions. Even after continuing the home plan
there was no further improvement seen in the subject after 1 month
and 6 months of follow up. A mild anxiety and mild mood
disturbance were observed after 6 months of follow up. There was
no further change in STM span.
Pre-Intervention - Coherence-1.1 Heart rate-120
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Post-Intervention - Coherence-4.6 Heart rate-82
His psychophysiological coherence was 1.2 and heart rate was
120 pre intervention. After the 8 sessions his psychophysiological
coherence and heart rate improved drastically. It came down to
4.6 and 82 respectively. The result supports the study done by
Hartmann Ralf et al (2019) where he concluded that change in
HRV parameter values correlated with changes in the severity of
depressive symptoms [40,71,84]
After 1month of follow up, the EFT group significantly showed
further improvement in depression and scores across all the tests
were within normal range. The CBT group reported a significant
reduction in depression after 8 sessions, while EFT group reported
a delayed effect. Results support the study conducted by Hannah
Chatwin et al [39].
After 6 months of follow up, the results were more or less similar
to 1 month of follow up where EFT group showed significantly
better results in depression score and scores across other tests
were within the normal range in EFT group. There was no further
improvement in CBT group.
The individual cases revealed clinically significant improvements
in stress, anxiety and depression across both the interventions.
Results support the study conducted by Hannah Chatwin et al
[39]. There was a significant improvement in the short-term
memory post interventions. There is limited research available on
the effect of depression, anxiety and stress on short term memory
and corelation between psychophysiological coherence, heart
rate, depression, stress and anxiety. In a study Tallie Z. Baram and
UC Irvine, reported that acute stress activated selective molecules
called corticotropin, which disturbed the processing of receiving
and storing memories [82]. It may be concluded that reduction in
stress, anxiety and depression symptoms can improve the STM
memory loss. The finding needs further validation.
The overall results indicated that a slightly greater effect was
achieved by the CBT group in terms of depression scores post-
intervention. Findings are highly consistent with prior studies that
confirmed efficacy of CBT, such as Hannah Chatwin et al [39].
and Hofmann et al [44]. The results are also consistent with past
studies that confirmed the efficacy of EFT, such as Church D [20],
Jones, S. et al [46], Kalla Mahima et al [47, 48], Patterson SL [63],
Sebastian et al [77] and Rowe J [72].
Thus, we can conclude that both the intervention therapies showed
significant improvement in managing stress, anxiety, depression,
STM span, psychophysiological coherence and heart rate. EFT
intervention therapy can be an effective tool as a primary care
treatment. The participants were able to build mental resilience
and were able to cope with the life situations post EFT
intervention.
Thus, we can conclude that EFT can be a promising tool for
treating stress, anxiety and depression and improving STM,
psychophysiological coherence and heart rate in the Indian
population. Scientifically established comparative studies
between EFT and CBT in Indian population for treating stress,
depression, anxiety, STM, psychophysiological coherence and
heart rate are yet to be conducted.
Conclusion:
The current study is in line with the pilot study by Hannah
Chatwin (39) to examine and compare the effectiveness of CBT
and EFT in reducing depression and anxiety among adults. The
results indicated that a significant (p<0.05) effect was achieved
by the CBT group in terms of depression, forward digit span and
psychophysiological coherence scores post-intervention, while
EFT group reported a delayed effect with a significant (p<0.05)
reduction in symptoms after 1 and 6 months of follow-up. The
results are consistent with the previous study by Hannah Chatwin
et al [39]. The analysis of individual cases in both intervention
groups revealed clinically valid improvements in depression,
anxiety, and stress scores, STM span, heart rate and
psychophysiological coherence scores post-intervention. Our
emotions and thoughts can impact our brain. Stress, anxiety and
depression can overload our minds and cause distraction and
disinterest in your surroundings. This interferes with day-to-day
activity and affect memory and concentration. Identifying and
treating emotion triggers, stress, anxiety and depression by
support, counselling and lifestyle changes, can significantly
improve a quality of life, memory, psychophysiological
coherence and heart rate [30].
The present study showed that a highly standardized CBT
program had a favourable influence on stress, anxiety, depression,
STM, psychophysiological coherence and heart rate, as compared
to EFT group post interventions. The findings of the present study
indicate that EFT may be an effective treatment approach for
anxiety and depression and supports the finding of Patterson SL
[63]. After the above study the researchers strongly recommend
that EFT is of paramount importance as a pivotal tool in managing
stress, anxiety, depression, STM, Psychophysiological coherence
and heart rate in the Indian population. A direct control of
emotional state or its control through cognitive processing are
both indeed useful and have equally strong effect in correcting
behaviour, physiological symptoms and improving memory.
Limitation and Recommendation:
Had the sample size been large enough, the effectiveness and
variability of EFT and CBT interventions would have been more
apparent. Further research on efficacy of CBT and EFT in
reducing depression, anxiety and stress symptoms in a larger
sample from varied cultures would provide more valuable inputs.
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A research on the relationship between stress, anxiety and
depression with STM and the cognitive function, would provide
more insight.
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