: Dawson Church, PhD and Darlene Downs, DD

ABSTRACT

Purpose: To determine whether a single session of EmotionalFreedom Techniques (EFT) could reduce the emotional impact of traumatic memories related to sports performance and lead to increased confidence levels in athletes.

Background: A relationship has been noted in other studies between sports performance and psychological factors such as confidence and anxiety levels. Critical incidents, which are experienced as traumaticmemories, are associated with increased levels of psychological distress acrossa variety of symptom domains. Brief EFT sessions have been demonstrated toimprove sports performance and reduce anxiety.

Methods: Female college athletes (N = 10) withtraumatic memories were assessed on three self-reports and one objectivemeasure (pulse rate). Subjective measures were the State Sport ConfidenceInventory, Subjective Units of Distress (SUD), and the Critical Sport IncidentRecall (CSIR) questionnaire, which measured both emotional and physical formsof distress. Subjects received a single 20-min EFT session. Baseline valueswere obtained, as well as pre-, post-, and 60-day follow-ups.

Results: Significant post-intervention improvements werefound in SUD, for both emotional and physical components of CSIR, and forperformance confidence levels (p = .001). The change in pulse rate wasmarginally significant (p = .087). All participant gains weremaintained on follow-up.

Conclusions: EFT may increase sport confidence levels byreducing the emotional and physical distress associated with the recall ofcritical incidents.

Applications in Sport: A brief application of EFT employedimmediately prior to competition may increase confidence and mediate anxiety

INTRODUCTION

Research investigating the linkage between psychological factors and sportsperformance reveals complicated relationships among anxiety, stress,self-confidence, and achievement. Although researchers have observedsignificantly higher levels of confidence alongside lower levels of cognitiveand somatic anxiety in elite versus non-elite athletes (1,2), or even withinthe same athlete in practice versus competition (3), predicting performancebased on variations in those measures has proven more difficult.

Findings on the relationship between self-confidence and performance havebeen more consistent, with reports of high self-confidence predicting highperformance among a variety of athletes. These include young female gymnasts(4,5), high school long-distance runners (6), singles tennis players (7), andbaseball players (8). Research into the predictive power of anxiety onperformance has yielded less stable results, however. Jones et al. for example(4), found no significant differences between the somatic anxiety ratings givenby high- and low-performing gymnasts; and Sanchez, Boschker, and Llewellyn (9)actually found an inverse relationship: that higher levels of pre-competitionsomatic anxiety in elite male climbers were related to higher performanceduring competition. Whether somatic anxiety improves or harmsathleticperformance may depend on athletes’ perceptions of theiranxiety, that is, whether they regard it as something more likely to befacilitative or debilitative of performance (4,10). Anxiety is also mediated bywhether the athlete is competing in a team or individual sport (11), theperceived level of support provided by a coach (12), and whether the setting isat the athletes’ home venue (13).

This summary of findings suggests that athletes seeking mental conditioningin an effort to improve their performance in sport should look to methods withthe potential to maximize their self-confidence while diminishing the effectsof anxiety (or reorienting the athlete to perceive this anxiety, particularlysomatic anxiety, as facilitative toward performance). Interventions designed totarget these psychological factors have ranged from relaxation-based techniquesto cognitive-behavioral therapy (CBT), and reviews have found them efficacious(14,15). It is worth noting, however, that many of the therapeuticinterventions under examination involved numerous treatment sessions. Twostudies on CBT to improve vertical jump height and free throw percentage inbasketball players prescribed anywhere from 6 to 12 hours oftreatment(16,17)—which while useful as part of an athlete’s long-termtraining regimen is hardly an expedient method for use in high-pressure,competitive situations. The ideal therapy for these situations would be brief,economical, reliable, and easy to administer or self-administer.

These characteristics have led to increased use by athletes of EmotionalFreedom Techniques (EFT). Developed by Craig (18), and referred to elsewhere as“acupressure assisted psychotherapy” (19), thispsychophysiological intervention pairs exposure to a traumatic memory with acognitive element involving self-acceptance. To these established methods itadds a somatic element, in the form of stimulating 12 specific points on thebody. These locations are regarded in traditional Chinese medicine as theendpoints of acupuncture meridians. The EFT client provides a self-assessmentof the degree of emotional distress before and after stimulating these pointswith the fingertips, and repeats the process until the distress is reduced. Theprotocol can be performed in less than a minute.

Published studies have found evidence for the efficacy of EFT in thelong-term reduction of psychological distress (20,21). EFT has been tested fora range of psychological conditions including phobias (22-24), posttraumaticstress disorder (PTSD) (25-28), test anxiety (29,30), and physical symptoms(31,32). EFT remains effective when delivered as an online intervention (31)and when adapted to a group format (33).

To investigate the physiological mechanisms of action of EFT, Church, Yount& Brooks (34) undertook a randomized controlled trial measuring thecortisol levels of 83 participants before and after an hour-long intervention.Cortisol was selected as a target since it is a multi-systemic endocrinehormone, regulating many of the body’s stress-response systems. Pre- andpost cortisol levels were measured for three groups: the first group receivedEFT coaching; the second group received a supportive interview by a therapist,while the third group rested. The study found that psychological symptoms suchas anxiety and depression were significantly improved after EFT when comparedto the other two groups, and that cortisol declined significantly (p <.03). Anxiety in the EFT group declined by 58% (p <.05). Theimprovement in psychological symptoms was significantly associated with thedecline in cortisol, indicating a simultaneous psychological and physiologicaleffect for EFT.

The potential for use of EFT in sports psychology became apparent due topress reports over the last decade began to note its increasing popularityamong baseball, soccer, and basketball players, and among golfers (35-37),though evidence for its effects on performance were largely anecdotal untilChurch (38) undertook a randomized controlled trial to study its impact on freethrow performance and jump height in elite (i.e., Division 1 college)basketball players. Church compared a 15-min EFT intervention with a placebotreatment delivered to performance-matched men’s and women’sbasketball teams. He found that following a 15-min EFT intervention,players’ free throw percentages improved significantly. In a subsequentcritique and re-analysis of Church, Baker (39) argued that Church understatedthe effectof EFT due to the ceiling effect: players with perfect scores couldnot improve more whether they were in the control or experimental groups. Byre-analyzing results for the lowest-scoring athletes, Baker found thatlow-performing players improved disproportionately. A second randomizedcontrolled trial measured EFTs efficacy at improving soccer free kickperformance when compared to a placebo, and also found significant improvement(40).

The present study sets aside the question of performance outcome to look atthe impact of EFT on athletes’ levels of confidence and distress. Itseeks to elucidate the psychological mechanisms underlying the positiveassociation between EFT and improved athletic performance by examiningEFT’s potential for increasing confidence and reducing anxiety. Weexpected that these outcomes would be evidenced in changes in bothpsychological measures, via self-reported levels of confidence and distress,and physiological measures, via recordings of participants’ pulserates.

Method

Participants

Participants were members of a women’s university volleyball team.Permission was obtained from the university’s ethics committee toconduct the study, and all participants signed informed consent forms. Elevenpotential participants were initially assessed for inclusion in the study. Theonly exclusionary criterion was a score of less than 3 on a Likert scale(ranging from 0 = minimal distress to 10 = maximum distress)that assessed participants’ distress when asked to recall either anemotionally troubling memory in which their “team did not win” ortheir “worst experience with a coach.”

One potential participant was excluded based on this criterion. The dataanalysis is therefore based on the recordings for the remaining 10 women.Participants ranged in age from 18 to 21, with a mean age of 19. All hadobtained academic scholarships based on their sports abilities, and 8 hadobtained Most Valued Player status. They had played volleyball prior to thestudy for periods ranging from 6 to 11 years, with a mean value of 9 years, andreported playing between 0 and 6 other sports, with a mean value of 2 othersports.

Design and Intervention

Participants completed the Subjective Units of Distress (SUD) scale, theState Sport Confidence Inventory (SSCI), and the Critical Sport Incident RecallSurvey (CSIR). Assessments were performed at the following intervals: 30 dayspre-intervention, 15 days pre-intervention, immediately pre-, immediatelypost-, and 60 days post-intervention. Participants’ pulse rates werealso measured at these same intervals. Measures are described in detail below.Participants were competing with other teams throughout the assessmentperiod.

The intervention, delivered by a certified EFT practitioner, consisted of a20-min EFT session with each athlete individually. Under thepractitioner’s direction, each participant paired her description of thetraumatic memory (i.e., of her team not winning or of her worst experience witha coach) with a statement of acceptance: for example, “Even thoughI’m angry that my coach embarrassed me by yelling at me in front of theentire team, I fully and completely accept myself.” The practitioner orparticipant then activated the somatic component of the intervention by tappingon the prescribed acupoints (for a thorough description of the EFT tappingsequence and acupoints, see Church & Brooks (41)). After the 20-min sessionwas complete, the participant provided another SUD score.

Measures

Subjective Units of Distress. SUD uses an11-point Likert scale ranging from 0 (minimal distress) to 10(maximum distress) to assess the emotional impact of criticalincidents (42). Increased SUD has been found to be associated with heightenedarousal of the sympathetic nervous system (43). SUD also correlates with heartrate, respiratory rate, and galvanic skin response (44). When interventionslower SUD, physiological signs of stress are also reversed (45).

State Sport Confidence Inventory. The SSCI is a validatedinstrument that asks the question “How confident are you right now aboutcompeting in the upcoming contests?” across 13 categories (46). For eachcategory, athletes report their confidence level on a scale from 1 (lowconfidence) to 8 (high confidence). The SSCI is designed to measure confidencelevels at a defined point in time, such as prior to a future series of athleticevents, and relative to “the most self-confident athlete” theparticipant knows.

Critical Sport Incident Recall Survey. The CSIR wasdeveloped for this study by the second author (47), as a means of assessingPTSD symptoms in athletes, after a literature search determined a lack ofsuitable validated assessments. It measures emotional distress (ECSIR) andphysical distress (PCSIR) associated with the recall of a critical incident. Ithas 16 questions, scored by participants on a scale from 0 (verycomfortable) to 4 (very distressed).

Pulse rate. Participants’ pulse rates were measuredwith the Instapulse 107 (Bio Sign Instruments, Champlain, NY). The Instapulseis a portable handheld device that measures electrocardiogram rhythm anddisplays a four-heartbeat average. We selected the Instapulse as one of theleast invasive methods of obtaining pulse rate values. Athletes held the devicefor 30 seconds while at rest, and the mean of the values obtained was used inthe study.

Statistical Analysis

We conducted paired t tests to compare the first and secondpretests. One participant was missing the second pretest; therefore, wecalculated a mean substitution (mean of the first and third pretest) for thisparticipant. All t tests were nonsignificant; therefore an average ofthe two pretests was calculated and used in subsequent analyses (see Table 1).A general linear models repeated measures analysis of variance was conducted onall dependent variables across four time points: average of the first twopretests, pretest immediately preceding the intervention, posttest, andfollow-up. We then conducted post hoc paired t tests on all significant models.Because of the number of possible comparisons (6), we applied the Bonferronicorrection, setting the alpha level to p < .008 for thepairedt tests.

Table 1. Paired t-test results for first and second pretests.

Measure

First pretest:
M (SD)

Second pretest:
M (SD)

t(9)

p

SUDS

6.10 (2.4)

6.00 (1.9)

0.25

.811

ECSIR

34.45 (8.0)

27.20 (5.8)

-1.0

.343

PCSIR

27.20 (5.8)

25.35 (6.3)

1.26

.240

SSCI

74.10 (21.6)

73.0 (19.8)

0.62

.550

Pulse

90.50 (13.4)

102.55 (15.4)

-2.05

.071

Note. SUDS = Subjective Units of Distress; ECSIR = emotional distress as measured on the Critical Sport Incident Recall (CSIR) survey; PCSIR = physical distress as measured on the CSIR; SSCI = State Sport Confidence Inventory.

Results

The main effect for time was significant for SUDS, ECSIR, PCSIR, and SSCI(p = .001). Time was marginally significant in the model for pulserate (p = .087). In the post hoc analyses, the pretest average wassignificantly higher than the posttest for SUDS, ECSIR, and PCSIR, suggestingan improvement in these variables. Similarly, the pretest average was lowerthan the posttest for SSCI, indicating an increase in sports confidence. Thepretest average was also significantly different than the follow-up for all ofthe variables, including pulse rate, indicating maintenance of the improvementsobserved at the posttest. Similarly, the pretest immediately prior to theintervention was significantly different than the posttest and the follow-upfor all variables, with the exception of the pulse rate, indicatingan immediateimprovement on these variables following the EFT intervention. There was nodifference between the posttest and the follow-up for any of the dependentvariables. Change data are displayed in Table 2.

Table 2. Change over time.

Measure

Pretest average:
M (SD)

Immediate pretest:
M (SD)

Posttest:
M (SD)

Follow-up:
M (SD)

F(3, 7)

p

SUDS

6.05 (2.1)a

5.10 (2.4)c

0.70 (1.6)b,d

2.30 (1.7)b,d

28.73

.001

ECSIR

34.28 (8.0)a

27.40 (7.0)c

20.0 (8.8)b,d

19.80 (7.1)b,d

11.85

.001

PCSIR

26.28 (5.6)a

24.10 (7.2)c

16.70 (7.4)b,d

18.70 (7.1)b,d

11.55

.001

SSCI

73.55 (20.5)a

74.60 (20.3)c

90.70 (15.8)b,d

87.50 (21.5)b,d

10.38

.001

Pulse

96.53 (11.0)e

91.70 (21.5)

84.90 (13.8)

81.30 (9.0)e

2.43

.087

Note. Changes between scores denoted “a” and scores denoted “b” yielded reductions that were statistically significant at the p < .003 level; changes between scores denoted “c” and those denoted “d” yielded reductions that were statistically significant at the p < .006 level.
a > b p < .003; c > d p < .006; e > f  p = .002.

These findings indicate an immediate positive effect of EFT on the SUDSrating, emotional and physical competition experience ratings (ECSIR, PCSIR),and sports confidence level (SSCI). However, there was no immediate effect onpulse rate. In addition, all significant changes were maintained at thefollow-up, indicating maintenance of the effects observed immediately followingthe intervention. A decrease in the pulse rate was found at the follow-up.However, given that the decrease in pulse rate was nonsignificant immediatelyfollowing the intervention, it is unclear whether the observed difference atthe follow-up can be attributed to the intervention.

Discussion

The present study extends research by Church (38) and Llewellyn (40) to showfurther evidence of the potential of EFT for use by athletes. WhereasChurch’s randomized controlled trial found significant improvement inbasketball free throw performance, and Llewellyn found significant improvementsin soccer free kicks, these were both outcome studies that did not attempt toinvestigate the psychological or physiological mechanisms of action of EFT. Thecurrent pilot study examines a number of plausible psychological mechanisms,and suggests that EFT can maximize athletes’ confidence while reducingthe distress they experience when recalling sport-related trauma. Furthermore,EFT’s effects on confidence and distress were long-lasting, remainingsignificant even 60 days after application of the brief, 20-minintervention. Alarge effect size in a small population receiving a brief intervention isconsistent with a robust treatment effect.

A limitation of the present study is its small sample size, though the useof t tests was designed to mitigate against individual variance. Replication isnecessary in larger populations, with different sports and age groups, and withactive control groups, before these results can be generalized. EFT’slow cost, ease of use, and quick application, argue strongly for its furtherstudy.

We found only a marginally significant effect of EFT on athletes’pulse rates in this study, and therefore, although psychological measuressupported the efficacy of EFT, our single physiological measure provided onlylimited support for our hypothesis. In their study of the effects of EFT onphobias, as measured by behavioral, self-report, and physiological measures,Wells et al. (22) similarly found only marginally significant changes inparticipants’ pulse rates. They noted, however, that this was notuncommon in the arena of behavioral interventions, which “tend to yieldchanges on physiological measures with less regularity than they do onbehavioral and self-report measures” (48, 49).

A similar disparity between the size of physiological and psychologicalmeasures was found in the cortisol study (34). While both cortisol andpsychological distress decreased significantly, a significant effect was notedin psychological measures after testing only 30 subjects. Almost three timesthat number were required to demonstrate significance on the physiologicalmeasure of cortisol. A replication of the present study with a larger N mightsimilarly produce confirmatory data.

Additionally, pulse rate may be too imprecise a measure, since it istypified by rapid fluctuations. Church et al argue that salivary cortisol testsare a more sensitive physiological measure of stress, since cortisol levelsadjust slowly relative to most other hormones and neurotransmitters. Thecircadian cycle of cortisol is stable month after month, and ultradianfluctuations are small. Salivary cortisol assays can elucidate the hormonaleffects of EFT, and by extension its genetic effects as well, since the genesthat code for cortisol must of necessity be expressed in order for cortisollevels to rise. For this reason, a review of the experimental evidence for EFTstates that: “Exposure [and] acupoint treatments modulate, with unusualspeed and power, gene expression for specific as well as systemictherapeuticgains,” (50). Not only does EFT therefore offer sportspsychology a technique that is ripe for exploration; sports psychology offersenergy psychology a fertile field for the further elucidation of itsmechanisms.

Conclusion & Applications in Sport

Because of the complexity of relationships between psychological factors,such as confidence and anxiety, and athletic performance, the challenge forsports psychology is to find interventions that simultaneously improveathletes’ confidence levels, reduce the stress of sport-related trauma,demonstrate efficacy in game-appropriate time frames, and yield measurableimprovements in performance. Although a range of techniques has been assessed,few have demonstrated the results apparent in the preliminary research withEFT. This pilot study found significant improvements in confidence, reductionsin the intensity of sport-related traumatic memories, and reductions inself-reported stress. Further research is required to determine whether theseresults can be replicated in a randomized controlled trial against anactivetreatment group, whether physiological measures correlate reliably withpsychological improvement, and whether EFT demonstrates similar effects whentested with larger sample sizes.

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