* This is a preprint of an article published in
Journal of Clinical Psychology, Vol. 59 (9), p43-966 (2003). Published online
in Wiley Interscience: http://www.interscience.Wiley.com/
Steve Wells, Kathryn Polglase
and Henry B. Andrews
Curtin University of
Technology, Perth, Western Australia
Patricia Carrington
University of Medicine and
Dentistry of New Jersey, Robert Wood Johnson Medical School
A. Harvey Baker
Queens College of the City
University of New York
Corresponding
Author:
Patricia
Carrington
61
Kingsley Road
Kendall
Park, NJ 08824 U.S.A.
Phone: 732-297-2525
Facsimile: 732-297-0778
Email: welcome@pcarrington.com
This
study was partially funded by a grant from the Association for Comprehensive
Energy Psychology, San Diego, California.
The
authors also wish to thank Jon P. Austin, Dr. Phillip Ramsey, and Tracey
McGrath for their assistance.
Abstract
This
study explored whether a meridian-based procedure, Emotional Freedom Techniques
(EFT), can reduce specific phobias of small animals under laboratory-controlled
conditions. Randomly assigned
participants were treated individually for 30 minutes with EFT (n = 18) or a
comparison condition, Diaphragmatic Breathing (DB) (n = 17). ANOVAS revealed that EFT produced
significantly greater improvement than did DB behaviorally and on three
self-report measures, but not on pulse rate.
The greater improvement for EFT was maintained, and possibly enhanced,
at 6 - 9 months follow-up on the behavioral measure. These findings suggest that a single treatment session using EFT
to reduce specific phobias can produce valid behavioral and subjective
effects. Some limitations of the study
are also noted and clarifying research suggested.
Keywords
Specific phobia; Desensitization; Diaphragmatic Breathing;
Meridian-based techniques; Exposure Therapy; Emotional Freedom Techniques (EFT)
Specific phobias (previously
called “simple phobias”) rank among the most prevalent anxiety disorders, with
phobia of “bugs, mice, snakes and bats” the largest subgroup in this category
(Ost, Stridh, & Wolf, 1998). Until
the mid 1970’s systematic desensitization was the most widely used behavioral
treatment for this condition (Wolpe, 1958,1973), but subsequent research has
shown that in vivo exposure to the feared stimulus is even more
effective (Ost, Salkovskis & Hellstrom, 1991).
It seems that many phobic persons can be
taught to approach their dreaded object or situation by simply watching or
participating with an experimenter who demonstrates a confident non-anxious
interaction with that object, and therapist-directed exposure has outperformed
systematic desensitization in a number of research studies on treatment for
phobias (Hellstrom, Fellenius & Ost, 1996; Hellstrom & Ost, 1995; Ost,
1989, 1996; Ost, Brandberg, & Alm,
1997; Ost, Ferebee & Furmark, 1997; Ost, Hellstrom & Kaver, 1992). Ost and his colleagues report that they have
been able to shorten the treatment to a single intensive session averaging 2.1
hours with results equal to that of much more widely spaced and lengthier
programs for treating specific phobias, and suggest this treatment to be the
treatment of choice for specific phobias (Ost, Ferebee, et al., 1997).
There are
certain limitations to therapist-directed exposure, however. It demands in vivo exposure to
objects or situations frequently unavailable in clinical settings. To stay in the presence of the feared object
may be re-traumatizing for certain people which can result in undesirable
attrition rates in experiments and cause some people to refuse to participate
in treatment programs which use this approach.
Since therapist-directed exposure relies heavily upon successful
modeling, it also requires that the therapist be skilled at such forms of
modeling as handling snakes, spiders, roaches, etc. with genuine ease, a
requirement not always easily met.
Furthermore, the method is most effective if a therapist is present to
model the correct behavior, so it does not lend itself too readily to
self-directed exposure. Ost and his
colleagues do however report some success using manual-based exposure for
specific phobias (Hellstrom & Ost, 1995; Ost et al., 1991).
It would be
desirable to have a short, effective one-session treatment for specific phobias
which does not require either in vivo exposure or therapist modeling,
and which could also lend itself readily to self-treatment outside the clinical
setting. This paper explores one such
possibility.
Meridian-Based
Desensitization
Recently, a new group of behavioral interventions
known as “meridian-based therapies” or “energy psychology" methods have
been proposed as treatments for anxiety disorders based on clinical reports
which indicate that these approaches have produced rapid improvement in
negative emotional states (Callahan, 2001, Craig, 1995; Figley & Carbonell,
1995; Gallo, 1999). They are considered
to work by intervening in the same energy meridian system that is the claimed
basis for acupuncture.
These
methods typically require light manual stimulation of the end points of
traditional acupuncture meridians, or “energy pathways”, usually on the face,
upper body, and hands, while at the same time the person is mentally focusing
on the feared object. The parallel to
systematic desensitization is obvious – exposure (either actual or imagined) to
a feared stimulus is coupled with deep relaxation to neutralize anxiety.
Certain
points of difference exist between these meridian-based forms of
desensitization and the forms that have been used up until now in the behavior
therapies, however. Meridian-based desensitization
is reported to occur very rapidly in many instances - a few moments of tapping
lightly on a sequence of “acupoints” is reported to have a neutralizing effect
typically seen only after prolonged practice with other desensitization
procedures. Often one treatment session
using a meridian based technique and lasting no more than 30 to 60 minutes has been
reported as sufficient to substantially reduce or even eliminate a specific
phobia (Callahan, 1997; Craig, 1999; Gallo, 1999). Clinically, these meridian-based techniques have the advantage of
being extremely easy for patients to self-administer, and are reported to be as
effective when used only with imagery or repetitive verbal description of the
phobic object, as they are when applied in vivo (Craig, 1999).
As yet,
however, no adequately controlled studies have been conducted on these
methods. Acupuncture, however, from
which they were derived, has been quite extensively studied, with hundreds of
research reports published (Stux & Pomeranx, 1995). While the majority of studies have focused
on acupuncture’s analgesic properties (e.g. Levine, Gormley, & Fields,
1976), or its use in treating physiological conditions, needle acupuncture is
widely recognized by practitioners and researchers as a potent means of
inducing a sense of calm and tranquility.
In clinical practice needle acupuncture is frequently used as either a
sedative or an anti-anxiety agent depending upon the length of time the needles
remain in place (Apostolopoulos & Karari, 1996; Lo & Chung, 1979;
Roccia & Rogora, 1976). This tranquilizing
potential of acupuncture is consistent with the concept that the stimulation of
acupoints in the meridian-based therapies can lead to deep relaxation and, if
desired, to subsequent desensitization.
Evidence
showing a marked difference between acupuncture points and nonacupuncture
points in terms of electrical resistance of the skin (Bergsmann &
Woolley-Hart, 1973; Cho, 1998; Cho & Chun, 1994; Syldona & Rein, 1999)
is, in turn, consistent with the notion that the meridian-based therapies may
derive their special therapeutic properties from stimulating specific acupoints
(Callahan, 1995; Gallo, 1999).
Because of
the invasive nature of needle acupuncture and the level of expertise required
to administer it, this intervention has not lent itself readily to the
treatment of emotional disorders, however.
By contrast, the meridian-based therapies are noninvasive and easily
administered by those untrained in acupuncture. They are therefore potentially appropriate for treating a wide
variety of emotional disorders.
Emotional Freedom Techniques (EFT)
The two
leading meridian-based therapies are Thought Field Therapy (TFT) (Callahan,
1987) and Emotional Freedom Techniques (EFT) (Craig, 1995, 1999). TFT was developed by Roger Callahan from his
study of the energy meridian system of acupuncture which he applied to the
treatment of emotional problems, combining this approach with treatment
techniques developed by George Goodheart (1987), and John Diamond (1985). TFT utilizes light tapping of meridian
points in a protocol which involves the use of specific sequences of these
points (called "algorithms"), each of which addresses a specific
emotional problem or category of problems.
While its
followers claim to have applied TFT clinically with great success (Callahan,
2001a), the few published studies on TFT (Bray & Folkes, 1999; Carbonell,
1997; Figley & Carbonell, 1995; Johnson, Shala, Sejdijaj, Odell and
Dabishevci, 2001; Leonoff, 1996; Wade, 1990; Callahan, 2001a, 2001b, 2001c; Pignotti
& Steinberg, 2001; Sakai, Paperny, Mathews, Tanida, Boyd, Simons, Yamamoto,
Mau, & Nutter, 2001) all suffer from a number of methodological
weaknesses. One of the most prominent
of these is the consistent lack of a comparison control condition in all except
the Carbonell (1997) study, which employed both a control condition, and random
assignment of participants, but unfortunately only a brief preliminary report
of this study was ever published. The
other studies suffer variously from a range of methodological weaknesses
including lack of experimental controls, sampling biases, and an over-reliance
on subjective measures (for a summary of criticisms see in particular: Gaudiano
& Herbert, 2000; Herbert &
Gaudiano, 2001; Lohr, 2001).
EFT,
presently the most widely used of the meridian-based therapies, is an offshoot
of the TFT method which, unlike the latter, uses only a single
"all-purpose" algorithm to treat every emotional problem, and
therefore does not require any diagnostic procedures, whereas TFT uses muscle
testing for this purpose. For this
reason, it can easily be self-applied.
EFT also has a detailed manual which allows for well-controlled
research.
To date,
however, despite clinical anecdotal evidence which suggests that EFT can be effective
in reducing anxiety (Carrington & Craig, 2000; Craig, 1999; Hardistry,
1999; Hartmann-Kent, 1999a, 1999b) there have been only a few studies exploring
its clinical potential. In a pilot
study on the effects of EFT on auto accident victims suffering from PTSD,
Swingle, Pulos & Swingle (2001), found significant changes in these
patients’ brain waves and self-reported symptoms of stress three months after
they had received two 1-hour sessions of EFT treatment. In a study of children diagnosed with epilepsy,
Swingle (2001) found significant reductions in seizure frequency in this group
as well as extensive clinical improvement in the children’s EEG readings after
exposure to two weeks of daily in-home EFT treatment. However, neither of these studies included a control comparison
condition and both had very small numbers of participants.
Comparison Condition
A number of
clinicians, including three of the authors (S.W., P.C., and A.H.B), have
observed EFT to be effective in the treatment of specific phobias, and thus it
appeared useful to test the efficacy of this method for this clinical
condition. The question then arose as
to what might be a suitable procedure to use as an attention-comparison
condition, to assess the possible contribution made by placebo effects. Because the authors, as well as others
(Craig, 1995; Gallo, 1999), have observed that a frequent result of EFT is to
produce a state of calm in the user, we decided to employ as a comparison
condition another method known for its specific calming effects, namely
controlled diaphragmatic breathing. It
was thought that both of these techniques might hold promise as desensitization
procedures because of their common calming properties.
While most
of the research on diaphragmatic breathing has studied this practice as an
adjunct to other anxiety-reducing techniques, the practice has been repeatedly
associated with creation of a state of deep calm and tranquility, which state
can apparently be voluntarily reversed so that anxiety can be intentionally
produced by manipulation of the breathing pattern (Peper & MacHose,
1993). In a review of research on
breathing retraining for treatment of Hyperventilation Syndrome and panic
disorder, Garssen, de Ruiter, and van Cyck (1992) concluded that breathing
retraining and related procedures are therapeutically effective, and Lehrer,
Sasoki, and Saito (1999) have demonstrated that slowing the respiration results
in demonstrable physiological changes consistent with deep relaxation. It seems logical therefore that
diaphragmatic breathing might be useful for desensitization.
While an
attention-comparison condition which did not possess active treatment
ingredients would have presumably enhanced the likelihood of finding
significant effects for EFT, we chose to create a more stringent test, by
employing a diaphragmatic breathing condition which may well have some active
treatment ingredients which serve to counteract anxiety.
Hypothesis
The present
study compared EFT to a specific form of Diaphragmatic Breathing (DB) designed
to include verbal elements similar to those of EFT. In an informal survey of colleagues in the psychological field,
we found that many clinicians who had used EFT in their practice claimed to have
obtained a rapid and dramatic decrease in anxiety using this method, with the
anxiety often lessening markedly within one session. Clinicians who were familiar with diaphragmatic breathing also
reported a decrease in anxiety with that intervention, but this was usually
observed to occur over a longer period of time. Accordingly, we formulated a hypothesis to the effect that EFT
would produce greater reductions in self-report and physiological indicators of
anxiety and in avoidance behavior than would DB in a single 30-minute treatment
session, and that these changes would be maintained over time.
Method
Participants
Participants were recruited
through advertisements placed in the newspaper and on community radio seeking
people with spider, mouse, rat, or roach phobias. An extensive, highly structured interview based on the DSM IV
criteria for Specific Phobia was administered to each participant over the
telephone when participants responded to the advertisement.
Participants were selected for
inclusion in the study using the following criteria. Participants had to be:
(l) over 18 years old, (2) have symptoms matching the DSM-IV criteria for
specific phobia (American Psychiatric Association, 1994), (3) not be currently
receiving treatment (psychological or medical) for their phobia, and (4) agree
to be contacted for follow-up testing. On the Behavioral Approach
Task, any participants able to stand at the closest point to the feared animal
and still report a SUDS level (Wolpe, 1958) of less than 5 were also excluded
from the study.
Overall, 70
potential participants responded to the call for volunteers. Of these, 24 were ruled out as ineligible,
leaving a total of 46 participants in the study. Thirty-five of these were assigned directly to one of the two
experimental conditions. Because
experimenters were no longer available to treat them individually, the 11
additional respondents who replied to the call for volunteers after the two
treatment groups had already been formed were assigned to a Group EFT treatment
and their results are reported separately.
Thirty-five participants thus participated in the individual treatments,
and 11 in the group treatment.
Of the 46
participants overall, 43 were female and 3 male. These figures are consistent with previous studies of specific
phobias, which have reported the overwhelming majority of participants to be
women (Ost 1987). The mean age of the
participants in this study was 39.6 years (Range = 19 – 72). With respect to the duration of their
phobia, 23 participants reported that they had suffered from it as long as they
could remember (or an equivalent phrase), and the remaining 23 reported having
had the phobia from 3 to 50 years (M = 20 years).
Design
Participants
were randomly assigned to either the EFT treatment condition (n = 18) or
DB treatment condition (n = 17).
All eligible volunteers who responded to the advertisements after the
individual treatment sessions had already been allocated were assigned to the
Group EFT treatment condition (n = 11).
No participants were assigned to a Group DB treatment condition because
of the very small number of these additional participants. All participants were reimbursed for any
parking and travel expenses incurred but received no compensation for their
participation in the experiment.
The
experimenters consisted of a male and a female psychologist who administered
standardized treatment protocols for each of the treatment conditions. Each experimenter conducted roughly one half
of the individual treatments, the male treating 18 participants (11 EFT, 7 DB),
and the female treating 17 participants (7 EFT, 10 DB). The assessments were
made by two research assistants who were intentionally kept totally uninformed
with respect to the experimental condition of each of the participants they
assessed.
Behavioral Approach Task (BAT). The Behavioral Approach Task was designed to measure the
participants’ level of avoidance of the feared animal. Participants were assessed on how close they
would allow themselves to get to the feared animal. There were 8 measurement points, with a SUDS rating (Wolpe &
Lang, 1964) taken at each point: The
first two points were: (i) outside the room, door closed, and (ii) outside the
room with door open (6 meters from stimulus animal). The next 6 points were inside the room, at the following
distances away from the feared animal: (iii) 5 meters; (iv) 4 meters; (v) 3
meters; (vi) 2 meters; (vii) 1 meter; (viii) directly in front. The BAT was scored from 1 to 8 according to
the point reached by the participant.
Experimenter demand during the BAT was kept purposely low, with the
participants not encouraged to move closer to the animal at any time.
Fear
Questionnaire. A modified form of the Brief
Standard Self-Rating for Phobic Patients (Marks and Matthews, 1979) was used to
measure phobic symptoms and change. The
version used here included 3 of Marks and Matthew’s original 4 measures -- Main
Target Phobia, Global Phobia, and Anxiety-Depression. Marks and Matthew’s
(1979) report (a) that test-retest correlations for these three measures range
from .79 to .93, and (b) that the measures sensitively reflect clinical
improvement of phobic patients following treatment.
Subjective Units of Distress (SUDS) when
imaging the animal (SUDS Imagined). This SUDS measure (Wolpe,
1958) consisted of an 11-point scale ranging from 0 = No fear/distress, to 10 =
Intense/unbearable fear/distress. Participants were asked to give a SUDS rating
indicating how they felt when they imagined their phobic animal “here, right
now.” They were asked to rate how they
felt at this moment, not how they imagined they would feel.
SUDS
During BAT. SUDS ratings were
also recorded at each step taken on the Behavioral Approach Task, and a SUDS
average was calculated for each participant by averaging the SUDS scores for
each step taken in common between pre- and post-assessments, for that
participant’s behavior test. The SUDS
average on the BAT thus reflected levels of distress evidenced while
approaching the feared animal.
Pulse
Rate. A research assistant took pulse rate manually
following completion of demographic data, and once again at the point at which
the client voluntarily stopped on the Behavioral Approach Task.
Confidence
Rating. Expectancy effect was measured by asking
participants to indicate during the pre-treatment assessments how confident
they were that their as yet unidentified treatment would work on an 11-point
scale, from 0 = not at all confident, to 10 = absolutely confident. The participants’ ratings thus provided a
global rating of confidence that any treatment would work for their
condition.
Procedure
On attending their scheduled
session, participants were met by a research assistant who was unaware of which
treatment they would receive (except in the case of the group treatment where
it was obvious that all were receiving the same intervention) or of the
treatments being offered.
Pretest data was collected as
described and participants were then taken to another room for the BAT. Outside
the room, with the door closed, they were asked to report their SUDS level
knowing that the feared animal was inside.
They were then asked if they wished to have the door opened, and if so
the door was opened and another SUDS rating taken. The feared animal was housed in a transparent container on a desk
inside the room. Participants were then
asked if they wished to move closer, and at each of the subsequent steps on the
behavior test their SUDS rating was requested.
At the point at which the participant did not want to move any closer,
their pulse rate was recorded and testing was discontinued. Those participants who failed to meet
criteria for inclusion in the study on the BAT were either given EFT treatment
if they wished, or were included in the group EFT treatment, but their results
were not included in the analysis.
Participants
were re-contacted for follow-up 6 months after completion of the first part of
the study, but fourteen of them did not return for retesting. Many of them had moved to other locations, a
few were simply reluctant to participate further. Twenty-one participants in all, 12 in the EFT condition and 9 in
the DB condition, took part in the follow-up study. Due to procedural difficulties, it was three months before
retesting of all 21 participants was completed.
Treatment
Treatment
was conducted immediately following pretesting. At the beginning of each treatment session, the experimenter
provided a rationale for the intervention, which was constructed to reflect a
similar low level of demand for each experimental condition. Individual treatment sessions were limited
to 30 minutes, including both rationale and treatment procedures. Group
treatment sessions were 75 minutes. At
the end of the allotted time, the treatment was stopped and posttesting
proceeded in the same order as pretesting, using identical measures.
EFT condition. The EFT treatment protocol followed the
EFT “Basic Recipe” outlined by its developer (Craig 1995, 1999), which consists
of having a person tap on a series of acupuncture points on his or her own body
while remaining “tuned into” - or focused on - her fear by repeating a
standardized "Reminder Phrase" (e.g. “this fear of spiders”, “ this
fear of cockroaches” etc.) as each acupoint is contacted. A round of EFT consists of tapping 5 to 7
times in prescribed sequence, at the end points of each of the 12 traditional
acupuncture meridians (5 located on the head, 2 located on the upper trunk of
the body, and the remaining 5 on the hand), thus theoretically avoiding any
requirement to "prescribe" specific sets of acupoints. A self-accepting statement (e.g. “Even
though I have this fear of spiders roaches, rats etc., I deeply and completely
accept myself”), combined with rubbing on a reflex point in the upper chest
known as the "neurolymphatic reflex point" (Callahan, 1987) is used
prior to each sequence of tapping in EFT.
SUDS level is checked at the outset and following each round of the
Basic Recipe. Treatment continues
ideally until all aspects or separate issues of the problem identified have
been dealt with (i.e. until SUDS is reduced to 2 or below), as related issues
as well as the original identified stimulus can sometimes trigger fear. For example a rat in motion, the sound of it
scurrying, a rat's tail, etc. could still trigger a fear response even after
the general issue ("rats") had been treated. Craig (1995) refers to these additional
components of the total fear as "aspects". In the current study, treatment continued until the end of the
time limit for the session.
For the individual sessions,
the full version of EFT (covering all 12 meridian endpoints as specified above)
was used for the first three rounds of treatment, and a shortcut version as
prescribed in Gary Craig's manual (Craig, 1999) (using only the first 7
meridian endpoints) was used for the remainder of the session.
DB condition. The deep breathing condition was designed
to parallel as closely as possible the EFT condition, the difference between
the two being mainly the fact that EFT participants tapped on meridian end
points and DB participants used controlled breathing as their intervention, and
the fact that the participants in the DB condition did not use a
self-acceptance statement.
In the DB treatment,
participants were instructed to “tune into” or focus on their fear throughout
the treatment (exactly as in EFT) by repeating a similar Reminder Phrase (e.g.
“This fear of spiders”) between each breath.
An initial SUDS level was obtained and participants were instructed in
deep diaphragmatic breathing. The two
main elements in the breathing training were to breathe low into the diaphragm
(demonstrated to them), and to use a count (4 for inhale - 2 for hold breath -
4 for exhale) to slow down the inhalations and exhalations. Participants did the breathing in “rounds”
of 10 deep breaths, with each complete breath taking approximately 10-12
seconds. In between each separate
breath they were asked to repeat their "Reminder Phrase" or focus on
an image representing their fear, thus paralleling the way the person focuses
on the problem while tapping on each meridian point in the EFT treatment. After each “round” of 10 breaths, the
participant was asked for a SUDS rating.
Each separate aspect or issue related to the problem was then addressed
by additional "rounds" of the breathing technique in exactly the same
fashion as separate aspects or issues are addressed in the standard EFT
protocol (Craig, 1995, 1999).
Group
Treatment. Group EFT sessions were
conducted with 11 additional participants who could not be accommodated in the
individual treatments. Since there was
no control group used, the group treatment procedures and data are reported in
Appendix A.
Follow-up
When
participants came for follow-up they were retested on all measures, following
which they were given an opportunity to discuss their experiences with the
researchers.
Statistical
Procedures
Intervention. Five separate
2 x 2 split plot ANOVA’s 1 were used to measure the effect of two levels of the repeated
measures variable of Time (pretest vs. posttest) and two levels of the between
group treatment variable (EFT vs. DB) on the 5 dependent variables.
Follow-up. Four converging sets of information were computed for each
dependent variable where significant effects of EFT vs. DB were observed during
the original intervention session in order to assess whether or not the effects
predicted for EFT (if such did appear) had dissipated by the time of the
follow-up. These included: (i) repeated measures t tests
comparing data from the pretest with data from the follow-up; (ii) repeated
measures t tests comparing data from the posttest with data from the
follow-up; (iii) separate 2 x 2 split
plot ANOVA’s measuring the effect of two levels of the repeated measures
variable of Time (pretest vs. follow-up) and two levels of the between group
treatment variable (EFT vs. DB); (iv) finally, Cohen’s (1988) d was
computed for each of these four dependent variables.
All statistical tests were
two-tailed, and performed using the statistical package SPSS for Windows
version 10.0.
Results
The
results are presented in terms of several interrelated issues.
Comparability of
Conditions
1. t-tests showed no significant difference between EFT (M
= 40.5, SD = 13.09) and DB (M
= 36.24, SD = 11.37) conditions in terms of participants’ age (t
(33) = 1.00, ns).
2. t-tests showed no significant difference between the mean
confidence level that any treatment would work for those later included in the
EFT condition (M = 5.00, SD = 1.68) as compared to those later
included in the DB condition (M = 5.18, SD = 2.60) (t (33)
= -.24, ns).
3. t-tests comparing the pretest values
of EFT and DB conditions showed no significant differences on any of the
measures used.
Assessment
of Hypothesis: Is There an Immediate
Effect of EFT?
Results from ANOVAS
Separate ANOVAs were undertaken for each of the five
dependent variables. If EFT showed
significantly greater improvement from pretest to posttest than did DB, this
would result in a significant Time (pretest vs. posttest) x Treatment (EFT vs.
DB) interaction.
Behavior Approach Task (BAT).
Participants in EFT showed greater improvement from pretest (M =
4.5, SD = 2.5) to posttest (M = 6.8, SD = 1.7) than did
participants in the DB condition, who showed lesser improvement from pretest (M
= 5.6, SD = 2.5) to posttest (M = 6.4, SD = 1.8). This interaction was significant (F
[1,33] = 6.63, p < .02).
SUDS Imagined.
Participants in EFT showed a greater decrease in fear from pretest (M
= 7.6, SD = 2.4) to posttest (M = 3.8, SD = 2.3) than did
participants in the DB condition who showed a lesser decrease in fear from
pretest (M = 7.1, SD = 2.2) to posttest (M = 6.0, SD
= 2.4). This interaction was
significant (F [1,33] = 8.84, p < .005).
SUDS During BAT. Participants in EFT showed a greater decrease in fear from
pretest (M = 6.2, SD = 2.1) to posttest (M = 2.5, SD
= 2.0) than did participants in the DB condition who showed a lesser decrease
in fear from pretest (M = 6.5, SD = 2.1) to posttest (M =
4.7, SD = 2.8). This interaction
was significant (F [1,33] = 7.34, p < .02).
Fear Questionnaire.
Participants in EFT showed a greater decrease in fear from pretest (M
= 31.9, SD = 7.3) to posttest (M = 15.1, SD = 9,7) than
did participants in the DB condition, who showed a lesser decrease in fear from
pretest (M = 32.2, SD = 10.6) to posttest (M = 25.2, SD
=12.2). This interaction was
significant (F [1,33] = 10.53, p < .005).
Pulse Rate. The main effect for Time (pre- vs. posttest)
on this variable was statistically significant (F (1,33) = 16.84, p
< .001) with participants’ pulse rates being reduced when EFT and DB
conditions were pooled (pretest M = 87.43. SD = 16.75; posttest M
= 80.03, SD = 14.12) but the Time x Treatment interaction was
non-significant (F (1,33) = .01, ns). Contrary to the hypothesis, the amount of decrease for the EFT
condition did not differ from the amount of decrease for the DB condition.
The
hypothesis of greater effect of EFT than DB treatment was thus supported for
four of the five measures used in this study. 2
Effect Sizes
As indicated above, the
hypothesis here focuses on the interaction between Time (pre- vs. posttest) and
Condition (EFT vs. DB), thus involving four means for each variable. For descriptive (but not inferential)
purposes, we reduced each of these four means to two means by subtracting the
posttest mean from the pretest mean. In
this manner it became possible to assess the effect size of each significant
interaction in terms of Cohen's d, which is the mean difference between
two conditions expressed in standard deviation units. Cohen (1988) has suggested, as a rough rule of thumb, that in the
behavioral sciences a difference of 0.20 SD is a small effect, a
difference of 0.50 SD is a medium effect and a difference of 0.80 SD
is a large effect (for example, the very noticeable difference in height
between 13 and 18 year old females is 0.80 SD units).
For the four significant interactions, BAT, SUDS
Imagined, SUDS During BAT and the Fear Questionnaire, the values of d were
1.24, 1.42, 1.30, and 1.54 respectively.
In terms of Cohen's suggested criteria these are very large effects.
Graphic Presentation
The posttest-minus-pretest change scores used in
computing the d's are presented in Figures 1-A through 1-D for the above
four significant interactions. Since
Pulse Rate showed no difference between conditions at either posttest or
follow-up and thus is not relevant to the issues which underlie this study, it
is not depicted. For BAT, the
hypothesis predicted that EFT participants would walk closer to the feared
object (and thus obtain higher scores on posttest vs. pretest) than
would DB participants. Figure 1-A
depicts this greater positive change for EFT.
For the remaining three dependent measures, the hypothesis predicted
that EFT participants would show a greater decrease in fear (and hence
obtain lower scores at posttest) than would those in the DB condition. Thus, lower scores are reflected in larger
negative numbers in figures 1-B through 1-D.
Figure 1. Comparison of the immediate
effect of EFT vs. DB intervention: Amount of change (posttest minus pretest) on
the four dependent measures with significant results.
Insert Figure 1 about here
Assessment of Hypothesis: Is There a Long-Term Effect of EFT?
The mean
time that elapsed between initial testing and follow-up was 7.58 months (N
= 12, range = 6-9 months) for EFT participants, and 8.11 months (N = 9,
range = 7-9 months) for DB participants.
Comparability of Follow-Up and
Nonfollow-Up Participants
For each of
the four variables where there was a significant outcome from pre- to posttest
we undertook a t test in which we compared pretest scores for those who
came back with pretest scores for those who did not return. None of these were significant.
Do the Effects of EFT Endure?
There are
four kinds of information that are relevant to this question. Two examples may make this clearer.
Case 1 supposes that the effects of EFT
totally dissipate over time. In this
event means for EFT subjects at follow-up would approximate means at pretest on
each variable, with t values approximating zero. However, for these subjects, means of the
posttest would differ dramatically from the means of the follow up, with the t
values being highly significant. When
EFT and DB are compared, none of the 2x2 ANOVAs would be significant and the F's
would approximate zero. And finally, d
values describing the effect sizes of these interactions would also approximate
zero.
Case 2
would fall at the opposite extreme.
Here there would be total and complete persistence of the effects; the t
tests comparing pretest and follow-up means would show very large and significant
values, whereas t tests comparing posttest and follow-up would be
nonsignificant since here it is assumed that the effects persisted. The interaction between Condition (EFT vs.
DB) and Time (pretest vs. follow-up) would also be highly significant and the
values of d showing the effect size of these interactions would be
substantial.
As will be seen, our outcome fell between
these two extremes.
Follow-up for BAT. EFT participants walked further toward the feared animal
during the follow-up (M = 6.67, SD = 1.56) than on the pretest (M
= 4.17, SD = 2.72), (t [11] = 3.23, p < .008). This observed effect showed no evidence of
dissipating between posttest (M = 6.42, SD = 1.98) and the
follow-up (M = (6.67, SD = 1.56) (t [11] = 0.41, ns). An ANOVA revealed a
significant Treatment x Time interaction (F [1, 19] = 6.81, p < .02) (for DB: pretest M
= 6.11, SD = 2.52; follow-up M = 6.22, SD = 2.64; for EFT:
see above). Defining effect size for
BAT exactly as was done above, d =
1.63 SD units when EFT is
compared to DB, a very large value according to Cohen's (1988) criteria. This represents a substantial increase in d. Thus, four converging lines of evidence
indicate no dissipation in the effects of EFT.
Descriptively speaking, when Figures 1-A and 2-A are compared, there is
a substantial increase in the effects of EFT on the BAT as compared to DB at
the time of the follow-up as compared to the time of the pretest.
Figure 2. Comparison of the long-term
effect of EFT vs. DB intervention: Amount of change between pretest and
follow-up on the four dependent measures with significant results.
______________________________________________________________________________
Insert Figure 2 about here
Follow-Up
for SUDS Imagined. EFT participants showed less fear at
follow-up (M = 4.83, SD = 3.07) than at pretest (M = 7.58,
SD = 2.23) (t [11] = 2.63, p < .02). This effect showed no evidence of
dissipating between the posttest (M = 3.83, SD = 2.52) and the
follow-up (M = 4.83, SD = 3.07) (t [11] = 0.99, ns). There was however no significant Treatment x
Time interaction in the ANOVA (F [1,19] = 0.11, ns) (For DB:
pretest M = 6.67, SD = 2.00; follow-up, M = 4.33, SD
= 2.96. For EFT: see above.). The
effect size here showed d = 0.20 SD. Although the effect of EFT did not dissipate, the outcome is at
best ambiguous, and evidence that EFT produced a long-lasting effect greater
than that for DB is lacking (See Fig. 1-B and 2-B).
Follow-Up
for SUDS During BAT. EFT participants showed less fear at
follow-up (M = 3.23, SD = 2.13) than at pretest (M = 6.11,
SD = 2.51) (t [11] = 3.21, p < .008). This effect showed no evidence of
dissipating between the posttest (M = 2.23, SD = 2.08) and
follow-up (M = 3.23, SD = 2.13) (t [11] = 1.31, ns). There was however no significant Treatment x
Time interaction in the ANOVA (F [1,19]
= 1.43, ns) (For DB: pretest M = 5.67, SD = 1.75;
follow-up M = 4.08, SD = 1.71.
For EFT: see above.). The effect
size for this interaction showed d = 0.74 SD, a large value
according to Cohen’s (1988) criteria.
Descriptively speaking, when Figs. 1-C and 2-C are compared, there is a
less striking difference between the effects of EFT vs. DB at time of follow-up
as compared to time of posttest, but a substantial effect is nevertheless
present at follow-up.
Follow-Up for Fear
Questionnaire. The
pattern of findings here is somewhat complex. As indicated earlier, at pretest
the EFT
participants scored relatively high (M = 30.92, SD = 8.28) and at
posttest they showed a very substantial decrease (M = 13.08, SD =
8.20), however by the time of the follow-up a significant part of this decrease
had been lost (M = 22.75, SD = 7.46) (for posttest vs. follow-up,
t [11] = 3.11, p< .01).
It is noteworthy however that in terms of the issue at hand, these
scores at the time of the follow-up had not returned to their original
value: the follow-up value was still significantly smaller (t [11] =
2.59, p < .025) than the original pretest value. Regarding the ANOVA, there was no
significant Treatment x Time interaction (F [1,19] = 0.86, ns)
(For DB: pretest M = 30.89, SD = 11.63; follow-up M =
26.78, SD = 15.64. For EFT: see above.). The effect size for this interaction showed d = 0.58 SD,
a medium value according to Cohen’s (1988) criteria. Descriptively speaking, when Figures 1-D and 2-D are compared,
there is a less striking difference between the effects of EFT vs. DB on the
Fear Questionnaire at the follow-up as compared to the posttest, but a moderate
effect is still seen at follow-up.
Discussion
The findings are largely consistent with the hypothesis that EFT does reduce phobias of small animals, and that this reduction is enduring, at least in terms of behavioral change. However, as we shall presently outline, inferences drawn from these findings must be considered tentative due to certain methodological limitations of the current study.
The results of our analyses indicate that EFT treatment had an immediate effect of reducing specific phobias of small animals in a single 30-minute treatment session conducted under controlled conditions. On 4 of the 5 measures employed, EFT-treated participants improved significantly more from pre- to posttest during the original intervention session than did those in the DB condition. On the single physiological measure used, Pulse Rate, both conditions showed a significant decrease from pre- to posttest but there was no difference between conditions in this respect.
This
immediate effect of EFT appears to be long lasting. This is especially clear in terms of improvement in avoidance
behavior. For BAT the evidence was
clear-cut; the follow-up showed (a) substantial improvement compared to the
pretest and (b) no evidence of dissipation relative to the posttest. The significant results from the ANOVA
indicate that EFT participants showed greater improvement in how far they
walked toward the feared animal from pretest to follow-up than did DB
participants. The effect size
associated with this interaction actually showed a considerable increase (d
= 1.24 for the immediate effect and 1.63 for the long-term effect). Thus, converging evidence from four
interrelated sources leads to the same conclusion, namely that, on the
important behavioral task, EFT produces an effect which lasts at least 6 to 9
months.
For SUDS
During BAT and for the Fear Questionnaire, however, the evidence is only
suggestive of a long-term effect for EFT.
The immediate effect on both of these measures was a decrease in
reported fear from pretest to posttest.
For both measures the level of fear was significantly smaller at
follow-up than at the time of the original pretest, indicating that these
effects persisted, although for the Fear Questionnaire some significant
dissipation of the original decrease in fear was also observed. The d values (0.75 and 0.58)
associated with the amount of decrease in fear from pretest to follow-up for
EFT as compared to DB participants can be described as “large” and “medium”
respectively, in terms of Cohen’s (1988) suggested criteria. Although the interactions between Treatment
(EFT vs. DB) x Time (pretest vs. follow-up) for SUDS During BAT and for Fear
Questionnaire were not significant, these negative findings can be arguably
attributed to low statistical power, given the small sample sizes involved in
the follow-up. For example, according
to Cohen (1988), if the true population value of d were 0.75, one would
need a sample of approximately 30 in each condition to have an 80 per cent
chance of observing an outcome which was significant at the .05 level
(two-tailed test). Although a firm
conclusion cannot be drawn here, evidence that (a) the observed decrease had
not disappeared at follow-up and (b) the between-treatment conditions effect
sizes are substantial, suggests that a long-term effect may well obtain for
these two measures.
The
evidence for a long-term effect of EFT on the other subjective measure,
Imagined SUDS, is weak. Although the
immediate effect of a decrease in fear from pretest to posttest did not
disappear at the time of the follow-up, the effect size associated with this
measure was small (d = .20) and the interaction between Treatment x Time
was not significant. For this measure,
therefore, no claim of a long-term effect for EFT can be made based on the
present data.
Intent of Study
The main question the study
addressed can be stated as — does EFT produce any effects on specific phobias
of small animals? We did not attempt to
find out whether EFT is the preferred mode of therapy for such phobias. To do this we would have had to include in
our design the best available current procedure for such treatment — Therapist
Directed Exposure Therapy. Rather, we
were asking a more preliminary question — are the effects observed for EFT real
or can they be dismissed as artifacts?
The answer to this question depends in large part on how appropriately
the comparison condition, DB, was designed.
Comparability of Interventions
The two treatments closely
paralleled each other except for the experimental variables. In both interventions, experimenters
introduced the treatment with a similarly worded rationale designed to minimize
the demand characteristics of the experiment.
In both, the length of the treatment sessions was limited to 30 minutes. EFT participants were instructed to stay
attuned to the issue at hand by repeating a standard Reminder Phrase at each
acupoint, DB participants repeated a similar standard Reminder Phrase between
taking each deep breath. EFT
participants used 12 Reminder Phrase repetitions for each round of their
treatment during the first 3 rounds and 7 Reminder Phrase repetitions during
the remaining rounds, and DB participants used 10 Reminder Phrase repetitions
per round (roughly the numerical midpoint for the EFT repetitions) for the
duration of the DB treatment. EFT
participants’ SUDS ratings were retaken after each round of that treatment, and
DB participants’ SUDS ratings were taken after each round of DB. During EFT, each separate aspect or issue
related to the problem was addressed by adding more rounds of EFT, and in DB
they were addressed by similarly adding more rounds of DB.
The factors
that differentiated these treatments were that (a) during EFT specific
acupoints on the body were contacted with light tapping, while during DB,
participants practiced a specific form of deep breathing, and (b) only EFT
participants repeated a self-acceptance statement at the commencement of each
round. From the perspective of
answering the question, "Does EFT work?” the fact that EFT and DB differed
in two ways is not relevant. From the
perspective of determining why EFT may have worked, future dismantling
studies are needed to determine the relative contribution of each of these
variables.
Generalizability of Results
Since
in the present study recruitment of participants was through ads in newspapers
and on radio, the generalizability of these findings to a strictly clinical
population carries with it some uncertainty.
However, since specific phobias of small animals and insects are seldom
incapacitating and the usual way of handling them is by simply avoiding the
phobic object, clinicians only rarely receive referrals for treatment for this
type of phobia (although they may incidentally work with a small animal phobia
if presented by a multiphobic patient or a patient with some other psychiatric
diagnosis). In this context, Ost has
observed that although people with specific phobias might very well constitute
the single most prevalent anxiety disorder, at the same time it is the group
that apply for treatment the least (Ost, 2002).
A
review of the research on small animal phobias shows that in the overwhelming
majority of studies –– we did not find a single exception to this rule in our
sample of major studies in this area –– researchers used ads in local
newspapers to recruit, as well as, in some cases, some physician referrals (see
Bandura, 1969; Ost et al, 1991; Hellstrom & Ost, 1993; Ost, 1996; Ost et
al.1997; Ost et al. 1998; Muris,
Merckelbach, Holdrinet, & Sijsenaar 1998; Muris et al.,
1998). Obtaining subjects with specific
phobias of small animals is so difficult, in fact, that we do not believe the
researchers cited above could have conducted their studies had they not gone
beyond clinical populations for their subject pool, an assumption in agreement
with that of Ost who has expressed the opinion that if researchers had to wait
for subjects to be referred for such studies "a study of 40-50 subjects
would certainly take 5 years or more to complete" (Ost, 2002).
With
respect to whether the findings in our sample of nonclinically recruited
subjects with small animal phobias will generalize to a clinical population
with similar phobias, it should be noted that when screening applicants for
participation in the present study, the experimenters gave special attention to
assessing the degree to which the phobia was interfering with the person's
life. They searched carefully for
specific evidence that the phobia was very distressing to the person and/or
affecting his or her life negatively in an important manner, rejecting all
those who did not provide evidence to support this criterion. A moderate degree of disruption was not
sufficient; it had to be either moderate-to-severe or severe for the person to
be admitted to the study. In addition,
even after being initially admitted, a participant was eliminated from the
study if at pretest she went all the way up to the feared animal on the
behavioral test and did not at least report a fear level of 5 or higher. All of our participants would have easily
exceeded the minimum criteria of phobia severity advised by Ost, the principal
researcher in this area, for a study of specific phobias (Ost, 2002), who
specifies that participants must fulfill all DSM IV diagnostic criteria for
this condition (the "interference" criteria in particular), but also
that the severity of their symptoms is, as a minimum, "moderate; life is
disturbed, but symptoms are not considered disabling in any way" (Ost,
1991). In fact, subjects who indicated
that their symptoms were not disabling in any way would normally have been
eliminated from this study.
Also
relevant may be the observation of the present authors who use EFT regularly in
their practice (Wells, Carrington and Baker), that the clients whom we have
treated in a clinical setting for specific phobias incidental to more severe
problems, have experienced the same rapid and lasting relief from these phobias
when EFT was applied to them, as the participants in the present study.
Possible Processes
Contributing to Results
Although the present research was not designed as a dismantling study, it may nevertheless be useful to consider what factors might have produced the results.
Imaginal Exposure
One factor contributing to the results might be the high
level of imaginal exposure used in both conditions. Participants were repeatedly asked to focus on the object of
their fear by repeating a Reminder Phrase which made specific reference to that
object. While it is possible that this
element of imaginal exposure contributed towards the overall results,
participants in the EFT treatment used a similar amount of imaging as in the DB
condition. The fact that EFT produced
superior results to DB despite the similarity of the imagery used in both
conditions, suggests that there are additional elements in EFT that contributed
to the outcome in this condition.
Energy System Hypothesis
In light of the fact that it
is derived from acupuncture theory, it is possible that EFT may have obtained
its results through intervening in the body’s so-called “energy system”, i.e.
through its meridian end points, as suggested by its originator (Craig, 1993;
Craig, 1995, 1999). One factor that
supports this hypothesis is that one of the two primary differences between EFT
and DB conditions in our study was that EFT participants contacted the meridian
end points while focusing on their feared object while DB participants did
not. Future dismantling studies will
need to be conducted, however, to determine the contribution of the various
components of EFT to the results.
Desensitization
Another explanation, which is
closer to the concepts of traditional psychology, is that EFT constitutes a
novel form of desensitization. A common
report from participants in this study as well as from clinical patients is
that they feel very “relaxed” after tapping on the meridian points, and EFT
seems to bring about such relaxation very quickly. Since each round of EFT requires focusing of attention upon a
feared object, this combination of repeated focusing on the feared object while
one is simultaneously relaxed fits well into the paradigm of
desensitization. In fact, certain
desensitization elements seem to be present during both EFT and DB. Just how great a part they may play in
determining the final results remains to be investigated.
Distraction
Even though EFT specifically
directs a person to stay tuned-in to his/her fear (by repeating a phrase such
as "fear of rats") while tapping on the meridian points, a procedure
which on face value appears to be the opposite of distraction, perhaps the most
common question directed at EFT is whether the tapping process works because it
distracts the person from focusing on the fear. With respect to this concern we would point out that any
"distraction" possibly present seems to be equally involved in the DB
condition where participants focused on a count for the duration of each
breath, yet the DB condition showed less improvement from pretest to posttest
than did the EFT condition, suggesting that if such distraction played a role
in the results, it was a minor one.
Some might argue
that focusing on deep breathing may not be as "distracting" as
focusing on tapping. To clarify this
point, further studies involving introduction of a variety of distraction
conditions would be needed. However,
extrapolating from daily life, where momentary distraction from a phobic fear
leads at best to momentary improvement, the robustness of these results ––
assessed after the allegedly distracting treatment was completed ––argue
against "distraction" being a key factor in the outcomes
observed.
It is
also noteworthy that the issue of distraction touches upon why EFT works, while the central point of the present study
was "does it work?"
Comments on the
DB Condition
Although EFT produced significantly
greater improvement than did DB on 4 of the 5 measures, within the DB condition
itself there was a significant improvement from pre- to posttest (cf. Footnote
2). Unfortunately, the design of this
study precluded our being able to interpret this substantial improvement. On the one hand, it is possible that there
are true effects of diaphragmatic breathing on the measures studied. On the other hand, without an appropriate
comparison condition, we cannot rule out the many possible alternative explanations,
such as placebo effect, regression to the mean, etc. In the case of EFT, DB served as an appropriate comparison
condition and therefore conclusions could be reached regarding EFT. If an appropriate third condition had been
included to which we could have compared the DB results, then there would have
been a basis for reaching conclusions regarding the effectiveness of DB. Future studies would do well to include such
a condition.
Converging evidence from a replication study now in progress
Baker and Siegel (2001) undertook a
replication of the present study using two different comparison conditions –– a
supportive interview and a no intervention condition. The pattern of their findings provides a basis for speculating
about the effectiveness of DB. For EFT,
they found similar reduction in fear of small animals to that found for EFT in
the present study. If it had been by
virtue of a placebo effect alone that in the present study the attention
comparison condition (DB) produced significant (albeit less than EFT) reduction
in fear, one might expect that the Baker-Siegel results for the supportive
interview condition would be similar to those found for DB in the present
study. However this was not the
case. The latter researchers found no
change whatsoever from pretest to posttest in either their no intervention
condition or the supportive interview.
Alternative explanations such as placebo effect and regression to the
mean can therefore be ruled out in their study. Because their replication study is very similar to the present
one, one can parsimoniously account for the findings of both the Baker-Siegel
study and the present one in terms of the following hypothesis: EFT and DB both
produce a true effect due to their common feature of rapid relaxation
and this shared feature led both conditions to produce reduction in fear when
experimentally studied, presumably by a desensitization process. However, since EFT produced significantly
greater reduction in fear than DB, it would seem that there must be something
additional occurring within the EFT condition.
Possible
Sources of Error or Bias and Limitations of the Study
There are several possible
sources of error or bias which could have affected the findings. Practice
Effect
Since both the EFT and DB
conditions had identical exposure to practice, this explanation can be
considered unlikely.
Regression to the Mean
Since participants in both
conditions were randomly assigned to treatments and showed no significant
difference at time of pretest on any of the measures used, the findings appear
inconsistent with an explanation based on regression to the mean.
Expectations, Demand
Characteristics and Other Possible Sources of Bias.
Here, we consider the possible
role of expectancy effects, demand characteristics and other sources which
might have biased our results. To rule
out such sources of bias, the “gold standard” design in medical research is
both double blind and placebo-controlled.
Because in psychotherapy research it is not usually possible to have
participant or experimenter blind as to what treatment is being administered, a
double-blind design is at best infrequently possible in such studies. However, it is possible to approximate such
a design and thus minimize sources of bias and artifact.
Blind data collection.
The Research Assistants who collected the data were kept totally blind
as to which experimental condition a given subject was assigned during both the
pre- and posttesting. Because of this
strategy, there is no way that they could have biased the data collection.
Participants’ a priori expectations. Prospective participants were given no specific information
whatsoever about either the EFT or the DB condition before the start of the
study. Materials used in recruiting people
simply stated that the study would be exploring ways of reducing phobic
reactions to small animals, without specifying the "ways". There was thus no way that participants
could have had any differential expectancy regarding either DB or EFT.
Participants’ expectations during first part of treatment. Of necessity, participants did learn about the conditions to
which they were assigned, at the start of the study. Therefore once a given condition was started, each participant
had her own impressions of the procedure being administered to her. Could these initial impressions have given
rise to a placebo effect which favored EFT?
Clinical
experience of the authors indicates that upon first being exposed to such an
unusual procedure as EFT, many people are initially skeptical and may even
regard the idea that tapping on one’s body could produce a psychological effect
to be quite absurd (see also observations by Craig, 1995, 1999). This argues against a positive placebo
effect, at least for the EFT condition.
In fact, a placebo effect is probably more likely to be present in the
DB condition because deep breathing is at face value more plausible as a stress
reduction technique than EFT. If so,
presence of a placebo response here would have worked against the hypothesis.
Possible
experimenter allegiance or expectation effect. One important source of possible bias in
psychotherapy research is found when the experimenter has an allegiance or
expectation for one, but not the other, form of therapy being studied. Particularly when the experimenter is administering the
treatment(s), the potential exists that he/she may inadvertently shape the
participants’ outcomes via various verbal and non-verbal cues.
A
standard way to control for such a possible source of bias when two well-known
forms of therapy are being compared is to have each form of therapy
administered by practitioners who have an allegiance to that particular form of
therapy. It was not possible to apply this strategy
in the present study, however, because we felt it advantageous to construct a
comparison condition which included certain key elements of the EFT
condition. We also felt it desirable to
select an attention-comparison condition which shared the feature of fostering
a state of calm. Accordingly, we
constructed an entirely new condition, DB.
Precisely because DB was new and experimentally constructed, there was
no possibility of recruiting therapists who had any pre-existing allegiance to
it. Given our choice of comparing EFT
and DB, one common means of controlling for experimenter expectancy or
allegiance effects was therefore ruled out.
Since we
cannot rule out experimenter allegiance effects the findings of the present
study, although clearly positive and in keeping with the hypothesis, must be
interpreted tentatively. Perhaps they
are due to some true effect of EFT, or perhaps they simply reflect a therapist
allegiance effect. Only future research
can clarify this issue.
Need for
Additional Controls
It would have been useful if a
no-treatment or waiting list control condition had been included and we hope to
see this in future research. However,
when Ost (1997) reviewed previous research on specific phobias with respect to
the inclusion of no treatment controls, he found that of 21 studies in which an
active treatment was compared with a no treatment or waiting list condition,
the active treatment achieved significantly better results in 90% of the
studies. Additionally, as he notes, the
few studies to date that have followed untreated phobias for a long period of
time have found a low proportion of spontaneous remission after 5 years (Agras,
Chapin & Oliveau, 1972) and also after 7 years (Wittchen, 1991).
The BAT Procedure
With
respect to the measurements used in this study, the Behavioral Approach Task
did not include having the participant actually touch the feared animal, as has
been done in some other studies (e.g. Ost, 1989), and therefore the
participants may not have recovered from their phobic avoidance as fully as is
suggested by our measures. On the other
hand, it is possible that certain participants would have shown even greater
improvement than they were able to demonstrate here had these additional
instructions been included. It may be
relevant that pretest-posttest comparisons showed significant improvements in
avoidance behavior for both of the treatment conditions despite this limitation
in the measure.
Pulse Rate
In the current study, pulse rate was the only measure that did not show any differences between conditions at time of intervention, a finding consistent with findings by Turpin (1989) and Ost (1991) who note that behavioral interventions tend to yield changes on physiological measures with less regularity than they do on behavioral and self-report measures. In the present study, the pulse rate measure was taken by hand at different points of time during the pre- and posttest, and also at the point when participants voluntarily stopped the BAT. Considering that in both treatments the majority of participants approached closer to the feared object on posttest than on pretest, it is encouraging to note that their pulse rate was actually lower on average when doing so. It would be useful in the future to compare pulse rates at the identical approach point, or at several different points, in