Six Sessions of Emotional Freedom Techniques Remediate One Veteran's Combat-Related Post-Traumatic Stress Disorder

Abstract

Background: Reports show high rates of post-traumatic stress disorder (PTSD) in Veterans who served in the Gulf Wars. Emotional Freedom Techniques (EFT) comprises an evidence-based practice that is highly effective at reducing symptom severity in Veterans with PTSD. The case report here is of one of the Veterans who participated in a replication study of the first Veteran Stress Research Study conducted by Church et al. Results of that study demonstrated that EFT was highly effective at treating the psychologic symptoms of PTSD. Similar results have been found in the replication study conducted by Geronilla et al.

Case: RM is a young Marine Reservist who served in Iraq and returned with PTSD. He participated in the Veteran Stress Project replication study wherein he received 6 sessions of EFT. EFT is explained and a sample treatment session is described. A discussion of some of the changes that have occurred for RM is included.

Results: The patient's PTSD scores dropped from a high clinical score of 60 before treatment to 40 after 6 sessions and to a clinical score of 22 at 6 months follow-up. His insomnia, which had been at a clinical level, reduced as did his pain and measures of psychologic distress, as measured in the Symptom Assessment–45 instrument.

Conclusion: Six sessions of EFT reduced PTSD scores dramatically and improved RM's life. He continues to use EFT to manage any stress in his life.

Introduction

The U.S. Department of Veteran's Affairs website reports that 11%–20% of the Veterans who served in Operations Iraqi Freedom and Enduring Freedom, ∼12% of Desert Storm Veterans, and ∼15% of Vietnam Veterans have post-traumatic stress disorder (PTSD) in a given year.¹ The Rand report cites studies that show that rates of PTSD rose from 9% shortly after deployment to a 31% a year after deployment.²

To address this problem, the Veteran Stress Project was initiated in 2008 by Dawson Church, PhD, of the Soul Medicine Institute, now the National Institute for Integrative Healthcare. In both the pilot study³ and the study by Church et al.,⁴ Veterans were screened with a Health History Questionnaire, the Symptom Assessment–45 (SA-45), the Insomnia Severity Index (ISI), and the Post traumatic disorder Checklist–Military (PCL-M). After 6 sessions of Emotional Freedom Techniques (EFT), 86% of the participants in the study no longer met the clinical criteria of PTSD as measured by the PCL-M.⁴ In 2013, a replication study was initiated and RM, the Veteran in this case report, participated. In this study, 169 Veterans were assessed for eligibility. Those who scored 50 points or higher on the PCL-M,⁵ the threshold for PTSD diagnosis, were invited to participate in 6 free sessions of EFT. Fifty-eight Veterans were enrolled. At the end of the 6-month follow-up, 95% of the Veterans who completed the replication study no longer scored >50 on the PCL-M with a mean score of 34 (P < 0.001).⁶ The current author was one of the coach/researchers for the replication study and this case report describes the EFT 6-session process with RM is an example of the research process.

Emotional Freedom Techniques

The Veteran Stress Project research described EFT as a brief exposure therapy combining cognitive and somatic elements.⁶ The EFT protocol used in the study followed the procedural components of Clinical EFT.⁶ Participants identified key traumas that contributed to their symptoms. The participants were also asked for their thoughts, emotions, and beliefs about both the symptoms and the traumas. The intensity of the emotions was assessed by each client, using the subjective units of distress score (SUDS).⁷ Observations about body sensations associated with both the symptoms and the memories of the trauma were also addressed. The Veteran was asked to recall a specific trauma memory as the coach guided him or her to tap on select acupoints that have been found to have a calming effect. A statement of self-acceptance was paired with the precise words that the client had used to describe the memory, including the thoughts, beliefs, physical sensations, and emotions. A sample session round is included below. Intensity level was assessed after each round and tapping continued until the SUDS level was a 0 or 1 on the traumatic memory. The experienced EFT practitioners in the study knew how to address the memory gently so that there was rarely an abreaction. Participants were given the Handout of EFT points and asked to continue to tap between sessions (see Appendix A).

Case

RM was a 27-year-old Marine Reserve Veteran who had served in Iraq as a Corporal. He had spent a total of 9½ years in the Service. He went in the Marine Reserves right after high school, with the intention of pursuing Officer Candidate School and was deployed to Iraq 2 years later, during his sophomore year in college. He was a radio operator on supply and recovery missions during deployment. He was able to finish college on his return to the United States. His anxiety and emotional distress had sent him to numerous doctors with little or no results. He was referred by his father, who had been using EFT, and had seen the movie “Operation Emotional Freedom: The Answer.”⁸ RM was willing to try anything, even though he was skeptical. He saw it as a “last resort.”

The first session was in the current researcher's office. RM presented with high anxiety and “white coat” hypertension. The blood pressure (BP) issue was critical, because he was scheduled for surgery within the week for a shoulder injury. The doctors refused to operate on him when his BP was so high. He brought his BP cuff with him and took his BP after he had completed the first round of assessments, before treatment started. His BP was above normal. He was asked to imagine going in for surgery and his BP increased. The researcher guided him through several rounds of tapping, and, at the end of the session, RM took his BP again as he imagined the surgery. His BP had dropped to near normal. Throughout the course of the 6 total treatments, several deployment-related traumas, current and past relationship issues related to his PTSD, and beliefs about himself were addressed. Five of the treatments were carried out over SKYPE videoconferencing because he had had his surgery after the first session and could not drive. After the research study was over, he said that he was more comfortable doing the session on video in the safety of his own home.

Sample EFT Session

RM chose to work on a trauma in which one of his convoy commanders was killed on a mission that RM was supposed to be on. RM was a radio operator, and he said that he found it highly effective to remain calm and stoic no matter what he had to report outside the wire because it would affect people listening to him. As a result of his constant preoccupation with this story, he realized that he had never grieved the loss of his commander, who was also a friend. His SUDS level was an 8 when the treatment began.

The following phrases were repeated as RM tapped through the series of acupoints:

Round One

Tapping on the outside fleshy part of his hand:

“Even though I was supposed to go on the mission, and I didn't, I love and accept myself.” He repeated this three times.

Tapping 6–7 times on each of the points below:

Eyebrow: “I was supposed to go on the mission.”

Side of eye: I was supposed to go (emphasis on “supposed to go”).

Under eye: “But I didn't go on the mission.”

Under nose: “I didn't go.”

Chin: “I was supposed to go, but I didn't.”

Collarbone: “I was supposed to go, but I couldn't.”

Under arm: “I was supposed to go on the mission, but I didn't go.”

His SUDS stayed the same. When he was asked: “What emotions are coming up?” he replied: “Shame, guilt, grief.” He shed many tears.

The same pattern continued with more emphasis on guilt. Part of the way through, he said “I could have died!” so he then tapped on that statement. On the third round through he added: “I had to remain stoic, I never allowed myself to grieve for him.” He tapped several rounds on that as his tears flowed.

After a break for water, when asked for his SUDS level, he said it was down to a 5 and he was feeling it in his chest and his heart. As he tapped for the physical sensations, he said: “I was supposed to go, and I didn't, and I was relieved I didn't go, but I felt so guilty for feeling relieved.” After several rounds using these words his SUDS was at a 2 and he was then asked if he was ready to forgive himself for not going on the mission and for feeling relieved. After tapping through the points again using his words, he said the pressure in his chest was gone. He said that he felt embarrassed that he cried but was relieved to “get it all out.”

In a later session he talked about how having to be stoic caused him to lock up all his feelings and that he was learning to feel again. In the most recent interview with him, 3 years after the end of the research, he said that he is happier than he has ever been in his life, he is doing very well as an Operations Manager in a job that he loves, he rarely has anxiety, and he taps when he does feel anxious.

Measures

The replication study⁶ used the same measures as in the first study,⁴ which have been shown to be valid and reliable.

The PCL-M⁵

This is a self-administered questionnaire with 17 questions that correspond to stressful combat experiences; it is a government document. Respondents are asked how much they have been bothered by previous stressful military experiences in the previous month. Scores of 50 of higher are considered to be in the clinical range for PTSD. Scores can range from 17 to 85.

The ISI¹⁰

The ISI has 7 questions rating from 0 to 4 (very severe). Scores are totaled, and scores of 15–28 are considered in the clinical insomnia range. Respondents are asked to rate their insomnia problems for the previous month.

The SA-45⁹

The SA-45 lists 45 symptoms that are rated on a 1–5 scale. Respondents are asked to rate how much the problem has bothered or distressed them in the previous 7 days. There are 9 conditions that are measured, including phobic anxiety and depression. The clinical range is shown in T-scores over 60.

The Health History Questionnaire

This questionnaire was designed for the first study⁴ to track demographic and health information, and includes a question asking the Veteran for current experience of pain on a 0–10 Likert scale.

Results

RM tapped with the researcher every week for 6 weeks, and he took the assessments again after 3 sessions, after 6 sessions, and at 3- and 6- month follow-up dates.

RM Inventory Results (Table 1)

Table 1.

RM Inventory Results

Assessments	PCL-M	ISI	Phobic Anxiety (SA-45)	Depression (SA-45)	Pain (Health History Questionnaire)
Pretreatment	60	14	70 (t-score)	68 (t-score)	7
After 3 sessions	50	13	68	64	5
After 6 sessions	40	17	68	63	4
3-month follow-up	26	2	60	59	3
6-month follow-up	22	4	53	57	0

PCL-M, Post traumatic stress disorder Checklist–Military; ISI, Insomnia Severity Index; SA-45; Symptom Assessment–45.

PCL-M⁵

Scores above 50 are in the clinical range for PTSD.

Insomnia Index⁹

Scores of 15–28 are considered to be in the clinical range.

SA-45 Symptom Assessment,⁹ Phobic Anxiety, and Depression scales

Clinical range is shown in T-scores over 60.

Pain (from the Health History Questionnaire)⁴

RM's PCL-M score dropped to 50 after 3 sessions and to 40 after 6 sessions. However, the results truly began to show at the 3- and 6-month follow-up. His PCL-M score dropped to 26 at 3 months and to 22 at 6 months. The lowest possible score is 17. His insomnia was slightly better after the third session, but it spiked after the sixth session. When asked why this might have been, he said that after he had cleared away some of the traumas, he was able to move forward in his life, and that was the week he was interviewing for better jobs, one of which involved moving away from his family. At 3- and 6-month follow ups, his insomnia was very low. The anxiety and depression scale scores reduced slowly as well, as did his pain scores, which were recorded on the Health History Questionnaire.⁴

Discussion

RM was one of 58 veterans who participated in the Veteran Stress Replication Study.⁶ Although at the end of 6 sessions, his PCL-M score of 40 was not as low as the mean scores of the combined EFT and control groups, which had declined to a mean of 34 (−52%; P < 0.001), his scores continued to drop as he continued to tap and move on with his life. The mean score of 34 was maintained at the 3- and 6-month follow-up points for the Veterans in the study, whereas his scores dropped to 22 at the 6-month follow-up date. Although he had not been having nightmares that he could recall, his sleep was often disturbed by a prevailing sense of anxiety and he would awaken feeling as though something bad had happened or was going to happen. As he dealt with his anxiety, his sleep improved. He had been suffering from “survivor guilt,” which is often part of PTSD. Research has shown that unresolved survivor guilt can “increase the distress load of Veterans”¹⁰

In a recent follow-up with RM on the life changes as a result of participating in the research, this is what he had to say when the current author asked if she could use his experience in the Stress Project:

I still use EFT during stressful days and meetings, and it always brings me back to center after enough tapping. Tapping gave me a free therapy that I could do myself. Oftentimes, I don't even speak about the situation when tapping now. I let my ‘monkey’ mind wander and tap as my thoughts wander. It seems to work on calming the automatic responses and stories my mind makes up. Relief like no other for sure.

Thanks for coming into my life during the right season, which allowed for [a] much-desired shift in my way of being in this world.

I'm now Operations Manager of my current company, putting deals together with ‘bigwigs’ I never thought possible. Inch by inch, life gets easier and easier. … Or is it because I get better and better? All I know is EFT was a game-changer for me. What makes it easily forgettable is that it doesn't cost anything. (RM, personal communication, October 8, 2016)

Conclusions

A case was reported in which 6 sessions of EFT not only reduced this Veteran's PTSD scores to below the clinical threshold but also gave him a tool that he continues to use 3 years after the completion of his participation in the study. EFT helped reduce the hyperarousal that he felt as a response to both external and internal triggers. He was able to reframe the beliefs he was holding about himself and his place in the world. His experience was not unique, as 97% of the participants in the replication study no longer scored in the clinical range for PTSD. For the study participants, the mean Insomnia Index scores dropped to 9 points, and most of the scales on the SA-45 showed a reduction as well (P < 0.001).⁴ EFT appears to be a highly effective intervention for the treatment of PTSD in combat veterans.

Appendix A

FIG. A1.

Handout of Emotional Freedom Techniques (EFT) Points.¹² Participants were asked to continue to tap with this chart between sessions.

Table A1.

EFT 8-Point Treatment Chart

EFT point	Meridian	Acupuncture point
Side of hand	Small Intestine	SI 3
Eyebrow	Bladder	B 2
Side of eye	Gall bladder	GB 1
Under eye	Stomach	ST 1
Under nose	Governing Vessel	GV 26
Under lip	Conception Vessel	CV 24
Collarbone	Kidney	K 27
Under arm	Spleen	SP 21

Table of EFT Points adapted from ref. 13. The table shows EFT points and corresponding acupuncture points and meridians.

EFT, Emotional Freedom Techniques.

Acknowledgments

The author acknowledges RM for his service, for his participation in this study, and his assistance with this article.

Author Disclosure Statement

Lorna Minewiser, PhD, receives compensation from training and coaching EFT, but received no compensation for her participation in this study.