1. Kalla, Mahima
  2. Khalil, Hanan


Review question/objective: The purpose of this systematic review is to:


Identify, summarize and synthesize evidence on the uses and perceived benefits of a meridian-based energy psychology intervention, Emotional Freedom Techniques (EFT) for enhancing physical, mental and emotional health of people with chronic diseases and/or mental health conditions.


Specifically, this systematic review will examine the available Level 1 scientific literature in order to examine the effectiveness of Emotional Freedom Techniques, as a tool to assist with improving people's health. These will include:


1. Specific changes occurring in the physical body, as a result of administering EFT to a subject; for example, changes in cortisol levels, reduced clumping in blood cells, or a reduction in somatization.


2. Emotional and mental health benefits reported immediately and at a later follow-up time by subjects.


Background: Emotional Freedom Techniques (EFT), also known as tapping, is an energy psychology technique that combines stimulation of acupressure points on the face and upper body with exposure to a specific traumatic memory or trigger.1 EFT uses the meridian energy system of the body, similar to traditional acupuncture, but it differs in the way it is administered.2 In traditional acupuncture, needles are used to stimulate the end points of meridians. In EFT, the subject gently taps acupressure points with his/her fingertips. While tapping on acupressure points, the subject also focuses on the emotions triggered by a stimulus (e.g. spiders, in the case of phobias), or a particular traumatic event, and voices statements of self-acceptance. EFT combines cognitive strategies with systems such as acupuncture which leads to a shift in the "cognitive, behavioral and neurochemical foundations of the psychological problem".3(p2)


Similar to cognitive behavioral therapy, EFT's aspect of self-acceptance relies on the premise that acceptance, rather than resistance of a particular condition can reduce suffering.4


Stimulation of acupoints is believed to send a signal to the limbic system and reduce limbic hyper-arousal.5 This in turn, leads to "rapid reciprocal inhibition" and "long-term counter-conditioning".5(p3)


EFT appears to decrease activity in the amygdala, which is part of the brain's arousal pathway. It is also considered to have effects on the body's physiology in relation to stress regulation, emotional intensity and neural transmission.2


A randomized controlled trial (RCT) undertaken by Church et al. showed significant improvements in psychological distress symptoms and cortisol levels in 83 non-clinical subjects, who received one hour long EFT sessions.6 Participants were assigned to EFT, supportive interviews/psychotherapy, or no treatment groups. Salivary cortisol assays, which were undertaken prior to and 30 minutes post intervention, showed a reduction in cortisol level by over 24% in the group that received EFT, compared to a 14.25% decrease in the case of supportive interviews and about 14.44% in the case of no treatment.6 These decreases were in alignment with the perceived improvement in psychological distress symptoms. The EFT group demonstrated improvements in anxiety (58.34%), depression (49.33%) and overall symptom severity (50.5%).6


Another clinical study conducted by Church et al. involved 238 first year psychology students who were randomly allocated to either EFT or no treatment groups.7 Four 90-minute long group EFT sessions were administered to the EFT group.7 At the end of the four sessions, the EFT group showed statistically significant improvements in their depression scores, which were assessed using the Beck Depression Inventory (BDI).7 The mean score was in the non-depressed range.7


A number of studies have been undertaken to investigate the benefits of EFT for post-traumatic stress disorder (PTSD) patients, in particular veterans. In one RCT, veterans meeting clinical criteria for PTSD were randomly divided into EFT treatment and standard of care/wait list groups.8 Psychological distress and PTSD symptoms were compared after one month for the standard care group and after six EFT sessions for the EFT group. Not only were symptoms significantly improved, but also 90% of the subjects in the EFT group no longer met clinical PTSD criteria.8 At the end of the wait list period, the standard care group subjects received EFT.8 Sixty percent of the subjects became symptom free at the end of three sessions.8 Eighty six percent of the subjects were symptom free at the end of three months and 80% were symptom free at the end of six months.8 There have also been studies demonstrating some level of benefits of EFT for fibromyalgia,4 food cravings,2 and phobias.9


EFT in its current form emerged in the early 1990s.10 Whilst there have been a number of studies on various health conditions, as well as reviews of its evidence base, there seems to be only one review done systematically, which was a narrative review by Boath et al.1


The proposed systematic review will focus on summarizing and synthesizing evidence related to the perceived benefits of EFT for enhancing physical, mental and emotional health, in order to better understand how EFT can be used to support people suffering from chronic diseases and/or mental health conditions. A variety of scientific literature exists on the subject of EFT, ranging from RCTs to case reports. However, to ensure that studies falling in the higher ranks of evidence hierarchies are included in this review, only RCTs and cohort studies will be included.


Article Content

Inclusion criteria

Types of participants

Studies involving chronic disease/mental health patients of all age groups and backgrounds will be considered. This review will consider studies that involve people suffering from a mental or physical health condition, such as fibromyalgia, obesity, anxiety, depression and PTSD.


The Department of Health of the Commonwealth Government of Australia defines chronic health as a prolonged illness that cannot usually be resolved spontaneously or cured completely.11 Chronic diseases are usually complex and varied in both causality and impacts on patients. They may cause premature death or lead to long-term disability.11 Other common features of chronic diseases are as follows:


- Multiple complex causal factors;


- A long developmental period without any symptoms;


- Prolonged course of illness often characterized by other health complications; and


- Functional impairment or disability.11



Studies which clearly state that subjects are receiving other treatments apart from just EFT, i.e. EFT is used as a supportive care method, will be excluded. This will enable better insight into EFT's effectiveness as a treatment method for health conditions.


Types of intervention(s)/phenomena of interest

The intervention of interest is Emotional Freedom Techniques (tapping). Studies involving Thought Field Therapy, which is considered the predecessor of EFT, will be excluded from this review. Similarly, studies on traditional acupuncture and other forms of acupoint stimulation will also be excluded from this review.


EFT is a technique that can be self-administered by patients. However, for the purpose of this review, only studies which involve a minimum of four hours of intervention/training by a practitioner will be considered. Self-administered EFT has been excluded to reduce variability in the review. Four hours of minimum intervention time has been chosen because literature on other comparable interventions, such as Brief Interventions suggest four short counselling sessions by a trained interventionist.12 Currently, there is no literature suggesting minimum intervention time for EFT. Studies involving both individual and group therapy will be considered for this review.


The intervention will be compared to standard/conventional care methods for given health conditions; for example, Eye Movement Desensitization and Reprocessing (EDMR) for PTSD and Cognitive Behavioural Therapy for anxiety and depression.


Types of outcomes

The primary outcomes that will be considered are listed in the table below.


Types of studies

This systematic review will focus only on RCTs and cohort studies, with or without a control group, to ensure that studies ranking high in the hierarchy of evidence are included. This will ensure that the review is robust and of good quality. Other literature such as clinical demonstrations, case studies and expert opinion articles will be excluded from this review.


Search strategy

This review will incorporate published and unpublished studies written in the English language. The search will encompass electronic databases, direct contact with researchers, research listed on (research, training and certification body for EFT), as well as the Association for Comprehensive Energy Psychology (ACEP) website. Studies published between January 2000 and the present will be considered for this review. EFT emerged in the early 1990s.10 The starting date (2000) has been chosen arbitrarily to ensure a degree of currency in the chosen literature.


The following steps in the search strategy will be employed:


1. An initial search on the electronic database Medline, with the key word 'Emotional Freedom Technique*'. The results generated by this search will be scanned for additional key words.


2. Using those key words identified, a number of electronic databases will be searched.


3. Reference lists of identified papers will be scanned to search for additional studies.


4. and the ACEP websites will be searched for research.


5. Personal contact will be made with researchers to gain access to additional unpublished studies, as well as those studies whose full text is not found on the web.


6. Some journals publishing information on energy psychology are not yet indexed with major databases. One such journal which has a large amount of published literature on this topic is Energy Psychology.This journal will be hand searched separately.


The databases that will be searched include:


- Medline


- PsychINFO




- Embase


- Compendex


- Web of Science


Below is a list of the key words selected for the search. This list is not exhaustive and will be refined in the course of the search. The key words have been chosen using the PICO search method.


P: anxiety, stress, mental illness*, disease*, chronic disease*, psychosomatic disease*


I: Emotional freedom technique*, acupoint*, energy psychology, meridian-based, energy medicine


Assessment of methodological quality

Two reviewers will independently assess methodological quality prior to inclusion in the review using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Disagreements will be resolved through discussion and consultation with a third reviewer, if required.


Data collection

The data extracted from the studies will pertain to participants, intervention logistics and implementation, and outcomes. Data that will be extracted includes, but is not necessarily limited to:


* Sample size


* Demographic distribution of participants


* Other personal attributes or qualifying characteristics of chosen participants


* Medical condition of participants


* Process of randomization


* Intervention details (e.g. duration, one-on-one or group session, year, qualification of facilitator, other logistic or descriptive details related to implementation)


* Findings from accompanying questionnaires/interviews, where applicable


* Results (Statistics, changes in subjective units of distress, reported perceived benefits, measured changes in health parameters, etc.)


* Comparison between results from EFT and other techniques/modalities, where applicable.


The standardized data extraction tool from JBI MASTARI will be used for data extraction (Appendix II).


Data synthesis

With quantitative data results, the overall effect of similar single studies can be combined to calculate a summary of effect of the intervention, which may have statistical significance. Where possible, data will be pooled in statistical meta-analysis using JBI-MAStARI.


Effect sizes may be expressed as odds ratios (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.


Conflicts of interest

None to declare.



This systematic review is part of a PhD research project, currently underway at Monash University's School of Rural Health, supported by the Australian Post-Graduate Award scholarship. The project is supported and supervised by Dr Anske Robinson, Dr Hanan Khalil and Dr Peta Stapleton (Bond University).




1. Boath E, Stewart A, Carryer A. A narrative systematic review of the effectiveness of Emotional Freedom Techniques (EFT). Staffordshire University, CPSI Monograph, Centre for Practice and Service Improvement. 2012. [Context Link]


2. Stapleton P, Sheldon T, Porter B. Practical application of emotional freedom techniques for food cravings. The International Journal of Healing and Caring. 2012; 12(3): 1-8. [Context Link]


3. Stapleton P, Sheldon T, Porter B. Clinical benefits of emotional freedom techniques on food cravings at 12-months follow-up: A randomized controlled trial. Energy Psychology. 2012; 4(1):1-12 [Context Link]


4. Brattberg G. Self-administered EFT (Emotional Freedom Techniques) in individuals with fibromyalgia: A randomized trial. Integrative Medicine. 2008; 7(4): 30-35. [Context Link]


5. Feinstein D. Rapid treatment of PTSD: why psychological exposure with Acupoint Tapping may be effective. Psychotherapy: Theory, Research, Practice, Training. 2010; 47(3): 385-402. [Context Link]


6. Church D, Yount G, Brooks A. The effect of emotional freedom techniques on stress biochemistry: A randomized controlled trial. The Journal of Nervous and Mental Disease. 2012; 200(10): 891-896. [Context Link]


7. Church C, De Asis M, Brooks A. Brief group intervention using emotional freedom techniques for depression in college students: A randomized controlled trial. Depression Research and Treatment. 2012;(Article ID 257172): 1-7. [Context Link]


8. Church D, Hawk C, Brooks A, Toukolehto O, Wren M, Dinter I, et al. Psychological trauma symptom improvement in veterans using emotional freedom techniques: A randomized controlled trial. The Journal of Nervous and Mental Disease. 2013; 201(2): 153-160. [Context Link]


9. Wells S, Polglase K, Andrews H. Evaluation of meridian-based intervention, EFT for reducing specific phobias of small animals. Journal of Clinical Psychology. 2003; 59(9): 943-966. [Context Link]


10. Carrington P. History of Meridian Tapping and EFT [Internet]. New Jersey: Pace Educational Systems Inc.; 2012 [cited 2014 Jan 5]. Available from:[Context Link]


11. Department of Health. Chronic Disease [Internet]. Canberra ACT: Commonwealth of Australia; 2012 [cited 2014 Jan 4]. Available from:[Context Link]


12. National Institutes of Health. Brief Interventions [Internet]. Alcohol Alert. 2005; (66). Rockville MD: US Department of Health and Human Services. Available from:[Context Link]

Appendix I: Appraisal instruments


MAStARI appraisal instrument[Context Link]

Appendix II: Data extraction instruments


MAStARI data extraction instrument[Context Link]


Keywords: Emotional freedom technique; acupoint; energy psychology; meridian-based; anxiety; stress; mental illness; disease