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T
HE
I
MMEDIATE
E
FFECT OF A
B
RIEF
E
NERGY
P
SYCHOLOGY
I
NTERVENTION
(E
MOTIONAL
F
REEDOM
T
ECHNIQUES
)
ON
S
PECIFIC
P
HOBIAS
:AP
ILOT
S
TUDY
Martha M. Salas, MA,
1,2
Audrey J. Brooks, PhD,
3#
and Jack E. Rowe, PhD,
2,4
Background: Specific phobia is one of the most prevalent anx-
iety disorders. Emotional Freedom Techniques (EFT) has been
shown to improve anxiety symptoms; however, their application
to specific phobias has received limited attention.
Objective: This pilot study examined whether EFT, a brief ex-
posure therapy that combines cognitive and somatic elements,
had an immediate effect on the reduction of anxiety and behav-
ior associated with specific phobias.
Design: The study utilized a crossover design with participants
randomly assigned to either diaphragmatic breathing or EFT as
the first treatment.
Setting: The study was conducted at a regional university in the
Southwestern United States.
Participants: Twenty-two students meeting criteria for a phobic
response to a specific stimulus (ⱖ8 on an 11-point subjective
units of distress scale).
Intervention: Participants completed a total of five two-minute
rounds in each treatment intervention.
Outcome Measures: Study measures included a behavioral ap-
proach test (BAT), Subjective Units of Distress Scale (SUDS),
and Beck Anxiety Inventory (BAI).
Results: Emotional Freedom Techniques significantly reduced
phobia-related anxiety (BAI P⫽.042; SUDS P⫽.002) and
ability to approach the feared stimulus (BAT P⫽.046) whether
presented as an initial treatment or following diaphragmatic
breathing. When presented as the initial treatment, the effects of
EFT remained through the presentation of the comparison in-
tervention.
Conclusions: The efficacy of EFT in treating specific phobias
demonstrated in several earlier studies is corroborated by the
current investigation. Comparison studies between EFT and the
most effective established therapies for treating specific phobias
are recommended.
Key words: specific phobias, energy psychology, Emotional
Freedom Techniques (EFT), anxiety, exposure treatment
(Explore 2011; 7:155-161. © 2011 Elsevier Inc. All rights reserved.)
INTRODUCTION
Specific phobia is the most prevalent anxiety disorder both
within the United States and in other countries.
1-4
A specific
phobia is characterized by a persistent and excessive unreason-
able fear in the presence of, or in the anticipated presence of, a
specific object, or situation. The Diagnostic and Statistical Manual
of Mental Disorders-Fourth Edition (DSM-IV) recognizes four pri-
mary subtypes of specific phobias: animals (eg, snakes), natural
environment (eg, heights), situational (eg, flying), blood-injec-
tion-injury (eg, injections, dentist), and an “other” category for
phobias that do not fit in one of the four subtypes.
5
Despite the widespread prevalence, it is the disorder for which
individuals are least likely to seek treatment
4,6
even though it is
an easily treated disorder. Two recent reviews found exposure-
based treatments, especially in vivo exposure (having the patient
come into direct contact with the feared stimulus), were very
effective.
7,8
However, it is unclear in most of the reviewed stud-
ies how many individuals dropped out or did not enter a study
due to the intense fear of being exposed to the feared stimulus.
8
In a survey of persons meeting clinical criteria for specific pho-
bias, a greater preference and lower refusal rate for virtual reality
over in vivo exposure was found with fear of confronting the
feared stimulus as the most frequent reason given.
9
In addition,
the ability to implement therapist-directed exposure treatments,
especially those involving in vivo demonstrations, in a clinical
setting limits its widespread adoption. Although several alternate
treatment approaches, for example, cognitive approaches or vir-
tual exposure, have been tried in treating specific phobias, they
are not as effective as in vivo exposure. A recent review found
positive results for One-Session Treatment (OST) of specific
phobias.
10
The OST technique employs hierarchical exposure,
1 Corpus Christi Independent School District, Corpus Christi, TX
2 Department of Psychology and Sociology, Texas A&M University-
Kingsville, Kingsville, TX
3 Department of Psychology, University of Arizona, Tucson, AZ
4 Private practice, Coweta, OK
1, 2, 4 This study was conducted as part of the first author’s Masters’
Thesis at the Department of Psychology and Sociology, Texas A&M
University-Kingsville, TX. Ms Salas is now a school counselor with the
Corpus Christi Independent School District, Corpus Christi, TX. Dr
Rowe is now in private practice in Tulsa, OK.
Portions of this data were presented at Energy Psychology Conference-
International 2001, San Diego, CA, and the Sixth Annual Energy Psy-
chology Conference, 2004, Toronto, Canada.
This study was funded in part by the Foundation for Epigenetic Medi-
cine, Fulton, CA, to A.J.B. The authors thank Dawson Church, PhD, for
comments on drafts of this paper.
#Corresponding Author: Addresss:
Department of Psychology, University of Arizona, P.O. Box 210068,
Tucson, AZ 85721
e-mail: brooksaj@email.arizona.edu
155
© 2011 Elsevier Inc. All rights reserved EXPLORE May/June 2011, Vol. 7, No. 3
ISSN 1550-8307/$36.00 doi:10.1016/j.explore.2011.02.005
ORIGINAL RESEARCH
participant modeling, cognitive intervention, and reinforcement
in a single session of up to three hours. However, due to the
intensity of the intervention, a sufficient degree of participant
motivation is required. Therefore, exploration of new treatments
is still needed.
Energy psychology techniques have been proposed as an al-
ternate treatment for anxiety disorders. The most widely used
form of energy psychology is the Emotional Freedom Tech-
niques (EFT).
11,12
EFT was developed by Gary Craig as an ab-
breviation of the methods used in Thought Field Therapy, an
earlier Energy Psychology method that used elaborate diagnostic
and treatment protocols.
13
EFT can be administered by a thera-
pist or taught to individuals for self-application. The technique
employs brief forms of certain components of other therapies
that have demonstrated efficacy, such as cognitive restructuring
and exposure; however, it also includes a somatic component.
The somatic component involves tapping on prescribed acu-
puncture points during the process. As described in Traditional
Chinese Medicine, the acupuncture points used are situated on
or near the endpoints of specific meridians or energy pathways
in the body. It is this use of “energy meridians” that Gary Craig
and other proponents of EFT attribute as one of the primary
mechanisms underlying the method’s effectiveness.
14
Support
for this contention was demonstrated in a recent study that
found the stimulation of acupuncture points by pressure alone,
without using needles, was as efficacious as needling in a ran-
domized controlled trial.
15
Hui and colleagues
16
found acu-
puncture to send fear-dampening signals directly to the
amygdala, the structure in the limbic system that scans the en-
vironment for threats.
Recent studies examining EFT have found evidence for EFT’s
ability to reduce psychological distress symptoms such as test
anxiety, general anxiety, depression, and trauma.
17-24
Wells and
colleagues,
25
for instance, examined the effect of a single EFT
session on specific phobia of small animals. In this study 35
individuals meeting DSM-IV criteria for specific animal phobia
were randomly assigned to either a 30-minute EFT or diaphrag-
matic breathing session. The EFT treatment produced an imme-
diate improvement in behavioral and subjective distress mea-
sures, but not in pulse rate. Twenty-one (60%) of the sample
completed a follow-up assessment six to nine months after the
intervention. Improvements in the behavioral measure were still
present at follow-up, even showing a slight increase from the
posttest. There was also evidence that the improvements in the
subjective distress measures were maintained at follow-up in
that, although they were lower than the posttest values, they did
not return to baseline levels. However, given the declines in
improvement on the subjective distress measures, the superiority
of EFT over diaphragmatic breathing had dissipated somewhat
at the follow-up point. The authors attribute the lack of statisti-
cal significance between the two treatment conditions in part to
the small sample size.
The purpose of the present study was to compare the imme-
diate effectiveness of a single session of EFT with that of a
comparison condition, diaphragmatic breathing, in the reduc-
tion of anxiety of specific phobias. Diaphragmatic breathing was
chosen as the comparison treatment, as it has been used both as
a stand-alone treatment as well as a component of interventions
designed for stress management and to reduce anxiety.
26,27
Breathing therapies are commonly used by healthcare practitio-
ners to reduce tension and arousal, as well as to treat specific
symptoms and disorders.
28
The present study was designed as a
partial replication of the Wells study.
METHOD
Participants
Participants were 22 volunteers recruited from a mass survey of
students in undergraduate Psychology classes at a regional uni-
versity in south Texas. More than half of the sample was female
(N ⫽15, 68%) with an average age of 20.8 years old. Participants
ethnic backgrounds included Hispanic (N ⫽16, 73%), in addi-
tion to Caucasian (N ⫽5, 23%), and other (N ⫽1, 4%). The
inclusion criterion for this study was a phobic response, equal to
or more than 8 on an 11-point subjective units of distress scale
(SUDS) to a specific stimulus (described below). Phobias in-
cluded fear of heights (n ⫽12), snakes (n ⫽5), cockroaches (n ⫽
2), darkness (n ⫽2), and syringes (n ⫽1). Participants with a
phobia that could not be tested directly, for example, fear of
flying, were excluded. Although a formal DSM-IV diagnostic
interview for specific phobias was not conducted; the SUDS
cutoff score was chosen to indicate that the participant had a
noticeable phobic response to one of the subtypes of specific
phobias. All participants received a detailed explanation of the
study and provided informed consent to participate. There were
no dropouts or adverse events in the course of the study.
Measures
Subjective Units of Distress Scale.
A list of six potential phobic
situations and objects that could be behaviorally tested was cre-
ated. The situations/objects were elevators, enclosed spaces,
heights, public speaking, small animals/insects, and other anxi-
ety-provoking stimuli that participants self-identified. Partici-
pants responded to each of these stimuli on an 11-point scale
ranging from 0 (no anxiety—would not avoid it) to 10 (extremely
anxious—would avoid it). This widely used scale is commonly
referred to as the SUDS popularized by Joseph Wolpe’s work in
systematic desensitization.
29
As described above, a score equal
to or greater than 8 on one of the six stimuli qualified the
participant for inclusion in the study.
Beck Anxiety Inventory (BAI).
The BAI
30-32
is a widely used,
well-validated measure of anxiety. The 21-item measure assesses
physiological and cognitive symptoms of anxiety on four-point
Likert scale ranging from 0 (not at all) to 3 (severe). Responses are
summed to create a total anxiety score ranging from 0 to 63.
Total scores distinguish between minimal (0-7), mild (8-15),
moderate (16-25), and severe anxiety (26-63). The instructions
were modified to apply to the identified phobic situation, “how
much are you bothered by each symptom when thinking about
being in the feared situation?”
Behavioral Approach Test (BAT).
The BAT is a commonly
used behavioral assessment for specific phobias and a popular
156 EXPLORE May/June 2011, Vol. 7, No. 3 The Effect of EFT on Specific Phobias
objective measure of clinical progress following treatment
such as exposure therapy.
7,33
Participants were assessed on
their ability to approach the feared stimulus without experi-
encing a SUDS level of equal to or more than 5. To assess
approach, the feared stimulus (eg, snake, cockroach) was pre-
sented and the proportion of comfortable distance (eg, feet)
from the stimulus was calculated with 100% representing the
closest distance to the phobic stimulus. In other words, a
higher percentage indicates a less phobic response or ability
to get closer to the feared stimulus. The approach test varied
for each phobic stimulus. In the test for fear of heights par-
ticipants were taken to the university stadium, which contains
38 bleachers. Participants were asked to go up the bleachers
next to the outside guardrail, where they could clearly notice
the height. The approach test for this particular phobia
ranged from 1 bleacher (3%) to 38 bleachers (100%). The
snake phobia approach test was conducted in the university
serpentarium with an observation room containing 20 terrar-
iums with live rattlesnakes. The approach test for snake pho-
bia ranged from being no less than seven feet from the obser-
vation room (14%) to being inside the observation room, two
feet away from the snakes (100%). In testing the darkness
phobia, the approach test was done in an adjacent office with
no light. The approach test ranged from walking toward the
dark room but stopping before standing in front of the closed
door (14%) to being inside the dark room, with the door
completely closed for at least five seconds (100%). The ap-
proach test for the injections phobia ranged from seeing the
researcher (sitting approximately five feet away) hold a syringe
inside the plastic package (14%) to seeing the researcher sim-
ulate an injection (rubbing alcohol on arm and placing the
needle right next to the arm; 100%). The approach test for
phobia of cockroaches was done in an adjacent office where a
live cockroach was kept in a jar. The test ranged from standing
three feet from the jar (20%) to holding the jar and opening
the lid (100%).
Procedure
The present study utilized a crossover design with participants
randomly assigned to either breathing relaxation or EFT as the
first treatment. Half of the participants received the breathing re-
laxation treatment first followed by EFT, and the other half were
assigned to receive EFT first followed by breathing.
The anxiety intervention focused on the specific phobic stim-
ulus identified by the participant. As described above, the study
measures (SUDS, BAI) and intervention were conducted in a
separate area, adjacent to the location of the approach test. Partici-
pants received the intervention individually or in pairs. The study
self-report measures and approach test were conducted at baseline
and following each intervention.
Treatment Intervention
The treatment intervention was provided by the first author who
was a Master’s level graduate student in counseling psychology
under the supervision of a licensed psychologist (third author).
The interventionist was trained in and utilized both treatments
as part of her supervised clinical practice in the university coun-
seling center. Although the intervention was delivered under the
supervision of a licensed psychologist, no specific treatment
fidelity measures were collected. Participants completed a total
of five rounds (described below) in each treatment intervention.
Each treatment round was approximately 2 minutes, resulting in
a 10-minute treatment for each intervention. In both treatment
conditions participants were instructed to focus on the fear while
practicing either EFT or diaphragmatic breathing. In addition,
the intervention took place in proximity to the feared stimulus.
For example, the intervention for fear of heights was conducted
at the bleachers, while the intervention for the fear of snakes was
conducted in an area adjacent the observation room in the ser-
pentarium. After each round of treatment, participants were
asked to assess their anxiety level with a SUDS reading while
thinking about being in the feared situation. The last SUDS
reading after round 5 was considered the posttest.
Diaphragmatic Breathing. Diaphragmatic breathing, involving
the use of the diaphragm, is a standard procedure that has been
used for many years to reduce anxiety. For the present study, a
round of diaphragmatic breathing consisted of three deep
breaths, inhaling for a count of 4, holding for a count of 2, and
exhaling for a count of 4.
34
EFT. The EFT technique has both cognitive and somatic ele-
ments. The cognitive component pairs thinking about being in the
feared situation with a self-acceptance statement, while the somatic
component of EFT involves tapping specific points on the body
with the tips of the index and middle fingers. These points corre-
spond to the endpoints of traditional acupuncture meridians. The
present study employed a brief version of EFT
11
utilizing 8 of the 12
body points. The first point on the body, referred to as the “setup,”
consists of tapping on the side of the hand next to the little finger,
while repeating an affirmation statement three times, for example
“Even though I have this fear of heights, I deeply and completely
accept myself.” After the setup is complete, a “reminder phrase,”
such as “this fear of heights,” is repeated while tapping seven times
at each of the remaining seven body points. These body points
include the beginning of either eyebrow, the outside corner of the
eye, about one inch under either eye, under the nose in the center of
the upper lip, between the lower lip and the chin, just below the end
of the collarbone next to the sternum, and about four inches down
from the center of either armpit. A round of EFT consisted of the
self-acceptance statement and tapping the eight body points.
RESULTS
Statistical Analysis
A General Linear Model repeated-measures analysis of covari-
ance was conducted on each of the dependent variables, SUDS,
Table 1. Baseline t-Test Results by Treatment Order Means and
Standard Deviations
Variable
Breathing-EFT
Mean ⫾SE
EFT-Breathing
Mean ⫾SE t(20) Sig
SUDS 9.45 ⫾0.82 8.91 ⫾0.94 1.45 0.16
BAI 38.82 ⫾13.20 31.64 ⫾7.62 1.56 0.13
Approach 39.91 ⫾27.86 35.55 ⫾14.29 0.46 0.65
157
The Effect of EFT on Specific Phobias EXPLORE May/June 2011, Vol. 7, No. 3
BAI, and BAT, controlling for the baseline value. The between-
subjects variable was the order of therapy presentation (breath-
ing first/EFT second versus EFT first/breathing second) and the
within-subjects variable was time of measurement (after the first
treatment, and after the second treatment). Post hoc Tukey tests
were conducted on significant findings.
Results
The t-tests were conducted on the baseline SUDS, BAI, and BAT
variables comparing the two treatment order groups and no
significant differences were found (see Table 1). In the models
examining intervention effects over time, the time by treatment
order interactions were significant for each dependent variable.
In the post hoc Tukey analyses the SUDS, BAI, and BAT breath-
ing first posttest was significantly higher than the EFT presented
first posttest, the EFT presented second posttest, and breathing
presented second posttest (Table 2). When presented first,
breathing therapy is significantly less effective in reducing sub-
jective distress, anxiety, and ability to approach the feared stim-
ulus than EFT. In addition, when EFT is presented following the
breathing intervention a statistically significant reduction in sub-
jective distress, anxiety, and ability to approach the feared stim-
ulus occurs above any effect the breathing may have had. No
additional reduction in subjective distress, anxiety, and ability to
approach the feared stimulus occurs when breathing is presented
following EFT (Figures 1,2and 3).
Effect sizes were calculated for the first posttest between
groups for the three dependent variables. Cohen’s dwere ob-
tained for SUDS, BAI, and BAT (1.11, 0.941, and 0.893, respec-
tively). According to Cohen values of dgreater than 0.80 are
considered a large effect
35
indicating a large treatment effect for
EFT.
DISCUSSION
The present study demonstrated the ability of EFT to reduce
anxiety related to a specific phobia in comparison to diaphrag-
matic breathing. EFT significantly reduced phobia-related anxi-
ety and behavior whether presented as an initial treatment or
following the comparison treatment, diaphragmatic breathing.
When presented as the initial treatment, the effects of EFT re-
mained through the presentation of a second comparison inter-
vention. The use of a comparison condition that is often an
element of many exposure, desensitization, and relaxation treat-
ments, suggests that EFT is not merely a placebo, and therefore,
worthy of additional research for the treatment of specific pho-
Figure 1. Subjective Units of Distress Scale treatment pretest and posttests adjusted means by treatment order.
Table 2. First and Second Treatment Adjusted Posttest Means and Standard Errors by Treatment Order
Variable Treatment Order
First Treatment Posttest
Mean ⫾SE
Second Treatment Posttest
Mean ⫾SE F(1,19) Sig
SUDS Breathing-EFT 5.719 ⫾0.77
a
2.890 ⫾0.74
b
12.30 0.002
SUDS EFT-Breathing 2.872 ⫾0.77
b
2.792 ⫾0.74
b
BAI Breathing-EFT 27.872 ⫾3.82
a
15.278 ⫾3.75
b
4.75 0.042
BAI EFT-Breathing 15.946 ⫾3.82
b
11.995 ⫾3.75
b
Approach Breathing-EFT 51.153 ⫾5.88
a
79.255 ⫾6.40
b
4.58 0.046
Approach EFT-Breathing 68.574 ⫾5.88
c
79.472 ⫾6.40
b
Posthoc Tukey test a ⬎b, P⬍.001; a ⬎c, P⬍.03.
158 EXPLORE May/June 2011, Vol. 7, No. 3 The Effect of EFT on Specific Phobias
bias. Furthermore, statistically significant effects were found
with a small sample indicating a robust treatment effect.
The results of this study should be interpreted in light of the
following limitations. This study is limited by the lack of a
follow-up. The first author provided the treatments and col-
lected the data. However, although it was hypothesized that EFT
would yield superior results; both treatments were used by the
first author in clinical practice with positive results.
The present study confirmed the immediate effect of EFT
found in the Wells study. In addition, the present study exam-
ined multiple subtypes of specific phobias, not just small animal
phobias as in the Wells study.
25
Although the Wells study em-
ployed a 30-minute intervention, the present study demon-
strated a reduction in phobia-related anxiety and behavior fol-
lowing a 10-minute intervention. Given the lack of a follow-up
in the present study, it is not possible to determine durability of
the effects with a 10-minute intervention. Further research is
needed to determine the optimal intervention period. Although
the present study only examined the immediate effect of EFT on
phobia-related anxiety, the Wells study on which this study was
based, found some evidence for the long-term benefit of EFT in
treating specific phobias. A study conducted as a partial replica-
tion of the Wells study found EFT to be superior to a supportive
interview treatment and no treatment in treating small animal
phobias.
36
Similar to Wells results, evidence supporting the
long-term effect of EFT was found. Effect sizes obtained in these
two studies, as well as the present study, indicate a large effect for
EFT on specific phobias. Furthermore, the effect sizes obtained
Figure 2. Beck Anxiety Inventory treatment posttests—adjusted means by treatment order.
Figure 3. Approach treatment posttests—adjusted means by treatment order.
159
The Effect of EFT on Specific Phobias EXPLORE May/June 2011, Vol. 7, No. 3
in these studies is consistent with those obtained in a recent
meta-analysis of OST of specific phobias.
10
Accordingly, these
studies provide support for EFT as a well-established treatment
in that the studies used a between group design comparing EFT
to a psychological treatment;
37
however, the comparison treat-
ments in these studies were not specifically designed to treat
specific phobias and had relatively small sample sizes. Therefore,
a comparison of EFT with other current treatments of specific
phobias is needed to establish EFT as an efficacious treatment
for specific phobias.
Certain elements of EFT are comparable to other specific
phobia interventions, which may explain the positive results
observed in this study. Namely, imaginal exposure, cognitive
restructuring, and relaxation associated with tapping are all pres-
ent in EFT. However, unlike other techniques, EFT is hypothe-
sized to intervene on the body’s energy system through the
mechanism of tapping specific energy meridian endpoints. The-
ories based on the body’s energy system hypothesize that energy
blockages or imbalances, often due to trauma or psychological
conditioning as in phobias, cause emotions to persist and block
the flow of energy.
38,39
Removing the blockage and rectifying
the flow of energy is believed to alleviate symptoms, such
as those experienced in a phobic situation. Preliminary support
for this hypothesis was found in a pilot study of EFT for claus-
trophobia. Changes in electrical conductance between acupunc-
ture points were observed following a single EFT treatment.
22
Although further studies are needed to determine whether EFT
is as, or more, efficacious as the existing specific phobia treat-
ments, the contribution of tapping to the common treatment
elements warrants further study. Both the present study and the
Wells study utilized diaphragmatic breathing as the comparison
condition as a control for EFT’s ability to reduce anxiety; how-
ever, a control for the cognitive component of EFT was not used
in the diaphragmatic breathing intervention in either study.
Therefore, future dismantling studies of EFT should examine
the contribution of both the cognitive component and tapping.
In addition, verifying the unique contribution of tapping will
provide further support for the principles of not just EFT, but
energy psychology in general.
Clinical Implications. A strength of the present study is that
positive results were observed after a very brief 10-minute EFT
intervention. The single-session intervention (OST) employed
to treat specific phobias can take up to three hours. Furthermore,
EFT is particularly amenable to self-administration as well as
instruction in group settings further enhancing its use in either
the direct treatment of specific phobias or to augment an exist-
ing treatment. For example, significant improvements in psy-
chological distress were found following both brief (four-hour
workshop including two hours of self-application,
40
two weekly
two-hour sessions
17
) and intensive (three-day) instruction in
EFT.
23
Improvements were maintained at both 90-day
40
and
six-month follow-ups.
23
In contrast to other anxiety disorders,
specific phobias are particularly responsive to self-administered
or minimal therapist contact interventions,
41
thus enhancing
EFT’s value as an intervention for this type of disorder. The short
intervention time frame required and ability to administer the
treatment in a group format suggests that EFT may be a cost-
effective treatment for specific phobias.
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