SETA trial

Cognitive behavioural therapy will cure about 40% of patients of their anxiety disorder, yet 30% will still be left with a severe anxiety disorder. In anxiety disorders, low self-esteem often plays a role, especially when the disorder is more complex or in the case of a co-morbid depression. Based on underlying theory about the working mechanisms of cognitive behavioural therapy, it has been assumed that negative and positive memory representations compete with each other in determining a person’s responses to stimuli in terms of thoughts, feelings, and behaviours (competitive memory retrieval account). However, it is unclear which works better for self-esteem treatment: enhancing positive memory representations or reducing negative memory representations. Also, it is not known whether both approaches exert a complementary effect, or what the effect is on anxiety symptoms. We aim to answer these questions by treating 60 patients with an anxiety disorder with two self-esteem treatments: one to reduce negative memory representations (’EMDR second method approach’) and one to enhance positive memory representations (COMET). Patients will be randomly allocated to treatment A or B, and after six sessions these treatments will be swapped (randomized controlled trial with a cross-over design). Self-esteem, including its positive and negative aspects, and also anxiety symptoms are the primary outcome measures and will be measured at three time points. Secondary outcomes are depression and general psychopathology.

We want to answer the following research questions (we do not know the direction of effect (which of the two methods works better) and therefore have no hypotheses):

- Which of the mentioned treatment approaches is more effective for improving self-esteem?
- Do both approaches have additive value (does a patient benefit more after receiving both treatments, in comparison to receiving just one?)
- Does the order of conducting these two treatment approaches matter for the total effect?
- How do the treatment approaches exert their effect on positive and negative self-esteem as separate constructs? Are the expected specific effects confirmed by the data?
- What is the effect of an improved self-esteem on anxiety symptoms?
- Do subjective positive personal characteristics and experiences predict the success of COMET? Or if these factors are not present, does EMDR work better than COMET?

At baseline (T0), halfway (T1), and after end of the 12 session complete treatment (T2), measurements will take place using self-administered questionnaires.

The two study allocations will receive this order of treatment modules:

1. First EMDR second method (6 sessions in 6-8 weeks) and then COMET (6 sessions in 6-8 weeks)
2. First COMET ((6 sessions in 6-8 weeks) and then EMDR second method (6 sessions in 6-8 weeks)

‘EMDR second method’ is a well defined therapy, manuals existing in books and tought by the Dutch EMDR Association. EMDR stands for Eye Movement and Desensitization Reprocessing. It is an effective treatment for Posttraumatic Stress Disorder (Balkom van et al., 2013; Engelhard 2012; van den Hout, Rijkeboer, Engelhard et al., 2012). EMDR desensitizes vivid mental representations with negative emotionality (Shapiro n.d.). By using EMDR, these representations get reduced in their vividness and emotionality, and the memory content gets less accessible (van den Hout, Bartelski, & Engelhard, 2012). An underlying principle is that negative events leave their tracks in the memory of an individual in such a way that it causes symptoms, including dysfunctional beliefs about oneself (e.g. ‘I am a bad person’) or the world (‘I am in danger’) (de Jongh, ten Broeke, & Meijer, 2010). By desensitizing negative memory content, low self-esteem can probably be treated, and this approach is known as ‘EMDR second method’ (Broeke ten, Jongh de, & Oppenheim, 2012).

COMET stands for Competitive Memory Training and has in various studies proven to be effective in reducing low self-esteem as well as depression (Korrelboom, de Jong, Huijbrechts, & Daansen, 2009; Korrelboom, Maarsingh, & Huijbrechts, 2012; Korrelboom, Marissen, & van Assendelft, 2011; van der Gaag, van Oosterhout, Daalman, Sommer, & Korrelboom, 2012). COMET uses positive memories that encompass ‘counter-themes’ of the current negative self-image. For example: if someone thinks of himself ‘I am incompetent’, then the counter-theme will be: ‘I am competent.’ Representationts of this theme within that person’s autobiographical memory will by selected and then repeatedly relived as vividly as possible. This way the positive counter-theme becomes more active in the actual memory, inhibiting the negative memory representations, and improving self-esteem.