The effect of EMDR and CBT on low self-esteem, a randomized controlled trial

Numerous people experience repetitive negative thoughts about themselves
resulting in a *low self-esteem*. Recent definitions of self-esteem describe
that it represents the affective, or evaluative, component of the self-concept;
it signifies how people feel about themselves (Leary & Baumeister, 2000). This
affective self-evaluation is subjective at its core and is not based on
specific behaviors (Robins, Hendin & Trzesniewski 2001). According to Rosenberg
(1989), high self-esteem *expresses the feeling that one is good enough*. The
individual simply feels that he is a person of worth. Although *low
self-esteem* is not in itself a disorder, it is found in several disorders as
described by the DSM-IV-TR, i.e. depression, obsessive compulsive disorder,
eating disorders, chronic pain, substance abuse and psychosis (Brown, Bifulco,
& Andrews, 1990, Ehntholt, Salkovskis, & Rimes, 1999, Gual et al. 2002,
Akerlind, Hornquist, & Bjurulf,1988, Soares & Grossi, 2000, Freeman et al.,
1998). A low self-esteem negatively effects these disorders and increases the
chance of relapse after treatment. Several studies even indicate that low
self-esteem is a causal factor in some of these disorders (Silverstone, 1991,
Sowislo & Orth, 2013). Treatment is often primarily aimed at the DSM-IV
disorder and not directly at changing low self-esteem whereas the latter might
be more effective due to causality or at least will prevent patients from
relapsing.

Interventions that focus on changing low self-esteem are primarily cognitive
interventions that stimulate patients to investigate their negative thoughts
and try to replace them with more realistic, positive thoughts. A much heard
complaint from patients however is that after treatment with these
interventions they rationally believe that their low self-esteem is not so much
true but that it doesn*t feel like that (Sanders & Ten Broeke, 2011, Young,
Zangwill & Behary, 2002). In other words they still feel bad about themselves
although knowing that this isn*t true.

Fennel (1997) developed a cognitive model of low self-esteem and describes that
especially early childhood experiences lead to certain assumptions and beliefs.
These beliefs are the basis for interpreting present experiences and gain in
strength when these beliefs are again confirmed. These beliefs grow out to be
fundamental and rigid beliefs that people have about themselves, others and the
world and are called *core beliefs* (Beck, 1995). These core beliefs are mostly
dysfunctional. They are not based on facts and do not match reality and lead to
psychological distress.
Because the core beliefs find their origin in past experiences perhaps
treatment interventions should focus more directly on these past experiences.
It is suggested that Eye Movement Desensitization and Reprocessing (EMDR) might
be an effective treatment method for changing core beliefs and therefore
changing low self-esteem. EMDR has been developed by Francine Shapiro in 1989
and has grown out to be a protocolled psychotherapeutic treatment method that
can be used to treat symptoms caused by disturbed and unprocessed life events.
With EMDR natural processing of these experiences is enhanced and symptoms
diminish (Shapiro 2001, Shapiro 2002, Solomon & Shapiro 2008).

Several case studies have shown a positive effect of EMDR on low self-esteem
(Dziegielewski & Wolfe 2000, Shapiro 2001, Maxwell 2003, Sanders & Ten Broeke,
2011). Furthermore
Wanders et al. (2008) did a randomized control trial using EMDR and CBT in 26
adolescents with self-esteem and behavioural problems. They compared 4 sessions
EMDR with 4 session CBT and found that both methods where effective but that
the EMDR condition resulted in more behavioural changes. The current study is a
randomized controlled trial in adults with low self-esteem. EMDR will be
compared to CBT.

The aim of the present study is to investigate whether EMDR is an effective
method to treat low self-esteem and if this is more effective than CBT.

Hypothesis:

1. Participants will improve on measures of self-esteem, psychological symptoms
and social interaction after treatment with EMDR
2. Participants will improve on measures of self-esteem, psychological symptoms
and social interaction after treatment with CBT
3. Participants will show a larger improvement on measures of self-esteem,
psychological symptoms and social interaction
in the EMDR condition compared to the CBT condition
4. Participants will show a more rapid improvement on measures of self-esteem,
psychological symptoms and social
interaction in the EMDR condition compared to the CBT condition
5. Participants will show a larger improvement on measures of self-esteem,
psychological symptoms and social interaction
at 3 month follow-up in the EMDR condition compared to the CBT condition*

This study is a randomized controlled trial with two parallel groups i.e. an
EMDR condition and a CBT condition. Participants are measured on self-esteem,
psychological symptoms and social interaction before treatment, after 10 weeks
of treatment and at 3 month follow up after finishing treatment. They will be
treated at Dimence, a specialized mental health care facility, located in
Zwolle.

Procedure:
- Patients are referred by their therapist for self-esteem treatment
- Patients are assesed with the Rosenberg Self Esteem Scale (RSES) ((Rosenberg,
1965) and part of the MINI-plus and will be included in the study when they
score below the cut-off point on the RSES and do not meet the criteria for PTSD.
- Patients will be assesed with two other questionnaires, i.e. the Brief
Symptom Inventory (BSI), to measure psychological symptoms, and the
*Inventarisatielijst Omgaan met Anderen* (IOA) to measure social interaction.
In an interview using the downward arrow technique the patient formulates a
negative core belief starting with *I am..* that represents their low
self-esteem. Also a positive core belief is formulated indicating what the
patient would want to believe about himself. The patient will indicate the
credibility of these core beliefs on a visual analogue scale (VAS) ranging from
0-100 (0= not at all true 100=absolutely true).
- At least 30 patients will be included in either the EMDR or the CBT condition
after randomization
- Participants will receive 10 weekly treatment sessions in each condition
- Participants rate the negative and positive core beliefs on a visual analogue
scale (VAS-score core beliefs) after each session
- Participants fill in the RSES after each session
- After finishing the treatment condition participants are assessed with the
RSES, BSI, IOA and VAS-score core beliefs and again after 3 months.

Subjects are randomly assigned to either the EMDR or the CBT condition.

EMDR condition
Subjects receive 10 weekly sessions of 60 minutes each. Using the *Second
method* of case conceptualization described by De Jongh et al. (2010), 5
memories are identified that have led to the formation and perpetuation of the
selected core belief. These memories so to speak subjectively *prove* that the
belief is true. Subjects are asked to write down these memories in a few
sentences. The memory that gives the most proof for the belief according to the
subject will be selected first. The basic EMDR protocol will be started using
this memory (De Jongh & Ten Broeke, 2003). When efficiently treated the next
memory that gives the most prove will be selected and treated with the EMDR
protocol. The duration of effectively treating one memory differs between
individuals which means that it is possible not all of the 5 memories will be
effectively treated or that all 5 memories are treated before ending the 10th
session. All sessions are videotaped and evaluated by an independent EMDR
supervisor.


CBT condition
Subjects receive cognitive behavioral group therapy based on a method described
by De Neef (2010). The group consists of 10 participants maximum. They receive
10 weekly sessions of 120 minutes each including a 15 minute break. They
receive information about low self-esteem and keep a diary where they write
down positive events and positive qualities of themselves. Cognitive
interventions are used to help subjects recognize positive events and to
recognize and change negative and disfunctional thoughts. They further receive
information and training about receiving critism, investigate pro*s and cons of
negative thoughts and discuss how to prevent relapse. All sessions are
videotaped and evaluated by an independent CBT supervisor.

Participants will be treated according to one of two methods, i.e. EMDR or CBT,
during 10 weekly sessions. Participants will be asked to fill out the RSES,
BSI, IOA and the VAS before and after treatment and after 3 months. It takes
approximately 30 minutes to fill out the questionnaires After each session they
are asked to fill in RSES and the VAS which will take approximately 5 minutes
each time. Patients receive 10 euros for participating in the study.