DEPRESSION AND ANXIETY 29:102110 (2012)

Research ArticleCOMPETITIVE MEMORY TRAINING (COMET)

FOR TREATING LOW SELF-ESTEEM IN PATIENTSWITH DEPRESSIVE DISORDERS: A RANDOMIZED

CLINICAL TRIAL

Kees Korrelboom,1 Maaike Maarsingh,2 and Irma Huijbrechts3

Background: Self-esteem is a major concern in mood disorders. Low self-esteemis a symptom of depressive disorders and is considered by some to be a predictorfor relapse, whereas high self-esteem seems to buffer against depression. Recently,Competitive Memory Training (COMET) has shown to be effective for the en-hancement of self-esteem in several psychopathological conditions. The currentstudy assesses whether COMET is also an effective intervention for patients withdepressive disorders.Methods: Sixty-one patients with depressive disorders whowere already in therapy in an outpatientmental health institution were randomlyassigned to either eight group sessions of COMET in addition to their regulartherapy (COMET + therapy as usual [TAU]: the experimental group) or to 8weeks of ongoing regular therapy (TAU only: the control group). These latter(control) patients received COMET after their TAU only period. All patientsin both groups that completed COMET were contacted 3 and 6 months laterto assess whether the effects of COMET had remained stable. Results: Com-pared to the patients who received TAU only, patients in the COMET + TAUcondition showed significant improvement with large effect sizes on indices ofself-esteem, depression, and depressive rumination. The therapeutic effects ofCOMET + TAU remained stable after 3 and 6 months on all outcome measuresor improved even further. Conclusion: COMET for low self-esteem seems to bean efficacious trans-diagnostic intervention that can relatively easily be addedto the regular treatment of patients with depressive disorders. Depression andAnxiety 29:102110, 2012. C 2012 Wiley Periodicals, Inc.

Key words: major depression; self-esteem; memory retrieval; RCT

1Head of Research & Innovation of PsyQ, Parnassia-Bavo Psy-chiatric Centre, The Netherlands2Department of Affective Disorders of PsyQ, Parnassia BavoPsychiatric Centre, The Netherlands3Research & Innovation of PsyQ, The Netherlands

Correspondence to: Kees Korrelboom, PsyQ, Research &Innovation, Stadhoudersplantsoen 2, Room 110, 2517 JLThe Hague, The Netherlands. E-mails: k.korrelboom@wxs.nl,k.korrelboom@psyq.nlReceived for publication 04 August 2011; Revised 02 November2011; Accepted 05 November 2011

DOI 10.1002/da.20921Published online in Wiley Online Library (wileyonlinelibrary.com).

INTRODUCTIONNot being a mental disorder in itself, low self-esteemis a formal symptom of several DSM-IV disorders. It ispart of the clinical picture of many patients and a mainreason for seeking psychiatric help. Moreover, low self-esteem is a risk factor for the development of and relapsein several disorders.[1,2]

From a theoretical viewpoint, negative biases inprocessing self-related information have been recog-nized as important factors in the development andmaintenance of depression.[3,4] Indeed, low self-esteemis empirically shown to be a risk factor for devel-oping depression,[5,6] and suicidal ideation.[7] More-over, positive self-evaluation supports recovery fromdepression.[810] The debate continues as to whether or

C 2012 Wiley Periodicals, Inc.

Research Article: COMET for Low Self-Esteem in Depression 103

not dysfunctional self-criticism is involved in relapse andrecurrence in depressive disorders.[1113]

Although controversy exists about its exact role, mosttherapists and researchers agree that self-esteem is animportant phenomenon in depressive illness. In clin-ical practice, it is often assumed that feelings of lowself-esteem will be automatically ameliorated when pa-tients have been successfully treated for their primarydisorder. However, although only few studies on de-pressive adult outpatient populations have incorporatedindices of self-esteem in their outcome measures, itis suggested that even after successful treatment, self-schema of many symptomatically remitted patients arestill vulnerable.[14] Indeed, one study that did employoutcomemeasures for depression and self-esteem simul-taneously resulted in large (within subjects) effect sizesfor depressive symptomatology (Cohens d = 1.26 and1.11, respectively), whereas (within subjects) effect sizesfor self-esteemwere only intermediate (Cohens d= 0.50and 0.64, respectively).[15]

Taken together, these ndings suggest that an inter-vention specically targeted at the enhancement of self-esteemmight benet the usual treatment of patients withdepressive problems. Empirical support for such specicinterventions, however, is scarce. Although probably be-ing the most practiced self-esteem intervention in adultpsychiatry, to date the efcacy of Melanie Fennells pro-tocol has not yet been studied.[16] At the moment, NickTarriers self-esteem intervention has been proven suc-cessful only in a psychotic population.[17] CompetitiveMemory Training (COMET) is considered to be an-other intervention that specically targets self-esteem.In line with Brewins notion of a memory retrieval com-petition in long-term memory between the differentmeanings attached to the same concept,[18] COMETtargets the strengthening of functional concepts in thiscompetition, by using self-esteem promoting imagery,self-verbalizations, facial and bodily expression, andmu-sic. COMET for low self-esteem is set up as a trainingprogram and consists of eight treatment sessions. TheCOMETprotocol for treating low self-esteem appearedto be effective in randomized clinical trials as an add-onintervention among eating disordered patients[19] (largebetween subjects effect size on self-esteem; intermedi-ate between subjects effect size on depression) and per-sonality disordered patients[20] (large between subjectseffect sizes on both self-esteem and depression). Thecurrent study is aimed at the efcacy of COMET forlow self-esteem for patients with a depressive disorder.Main research questions are whether COMET for lowself-esteem enhances self-esteem and depression in de-pressed patients and whether these effects remain stableover time.

METHODSOVERVIEW OF THE STUDY

The study was carried out between January 2008 and August 2009at the Department of Affective Disorders (DAD) of PsyQ and was

approved by an independent medical-ethical committee. PsyQ is a di-vision of the Parnassia Bavo Psychiatric Center, a large mental healthorganization in the Netherlands. Patients who were already in outpa-tient treatment for depression and who fullled the criteria for inclu-sion, could be referred for the study by their therapists. After inclusionand informed consent, patients were randomized into either 8 weeksof COMET + (ongoing) TAU (the experimental group) or 8 weeksof (ongoing) TAU only (the control group). After the rst random-ized phase of the study, patients in the control group also receivedCOMET. Both groups completed follow-up measurements 3 monthsand 6 months after the end of their respective COMET therapy.

PATIENTSAt theDAD, several treatment lines aredifferentiated. Patients aged

1865 years could be referred for the present study. These patientswere then screened for eligibility by the second author (MM). Inclu-sion criteria were (1) currently having depressive symptoms due to adiagnosis of a depressive disorder or an adjustment disorder with de-pressed mood, as established in a semi-structured interview with theStructured Interview for DSM Disorders-I (SCID-I), in combinationwith (2) feelings of low self-esteem as established in a clinical interviewduring screening and as conrmed by the referring therapist. Exclu-sion criteria were: (1) insufcient knowledge of the Dutch languagethat would hamper participation in the group treatments and com-pleting the measurements, or (2) having a severe addiction, (3) bipolardisorder, or (4) other serious co-morbid psychopathology. In addition:(5) patients who followed another treatment that was specically tar-geted at enhancing self-esteem were excluded. Finally, all participantshad to provide informed consent.

Based on earlier ndings, large effect sizes were expected.[19,20]

Therefore, with a power of 0.80 and two equally sized groups, a min-imum of 52 patients were needed. Enrolment was performed in veblocks. Finally, 75 patients were referred for the study. Of these, sixdid not fulll the criteria for inclusion (they all lacked sufcient de-pressive symptoms at the time of referral) and were excluded. Of theremaining 69 patients, eight declined to participate for various reasons(most were unable to attend the group treatments at the designatedtimes).

Finally, 61 patients entered the study (Table 1). Mean age was 40.9(SD= 10.2) years; 12 (20%)weremale and 49 (80%)were female.Ninepatients (15%) were diagnosed with amajor depressive disorder, singleepisode (two mild, ve moderate, two in partial remission), 36 (59%)with a major depressive disorder, recurrent type (three mild, 12 mod-erate, two severe without psychotic features, 19 in partial remission)and 15 (25%) with other depressive disorders (13 with a dysthymic dis-order, whereas two had an adjustment disorder with depressed mood).Figure 1 and Table 1 present the results of the inclusion and random-ization procedures.

INSTRUMENTSThe depression and adjustment disorders sections of the SCID-

I[21,22] were administered to assess whether patients fullled the diag-nostic criteria for inclusion.

The followingmeasureswere administered at all speciedmoments:Rosenberg Self-Esteem Scale (RSES).[23] This self-referent 10-item

rating scale (range 1040) assesses global self-esteem and was consid-ered the primary outcome measure. A high total score means higherself-esteem. The scale is sufciently reliable and valid.[24]

The Self-Esteem Rating Scale (SERS SF-20).[25] This self-referent20-item rating scale taps two dimensions of self-esteem separately,being positive and negative self-esteem. High scores (range 1070)are favorable on positive self-esteem and unfavorable on negative self-esteem (range 1070). Reliability and validity are good.[25]

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TABLE 1. Pre-treatment status for the two treatmentgroups

Experimental Controlgroup groupCOMET + TAU TAU only(N = 31) (N = 30) Signicance

Age in years: mean 39.0 (10.7) 42.9 (9.5) n.s.(SD)

Gender n.s.Male 7 5Female 24 25

Diagnosis n.s.MDD single 4 5MDD recurrent 18 18Other 8 7Missing 1

Global self-esteem 21.4 (3.7) 20.1 (3.9) n.s.(RSES)

Depression (BDI) 27.3 (9.9) 29.9 (10.8) n.s.Positive self-esteem 41.9 (10.2) 38.1 (12.8) n.s.

(SERS-pos)Negative self-esteem 47.5 (11.0) 48.9 (10.9) n.s.

(SERS- neg)Rumination (RSS) 42.8 (6.4) 42.9 (8.6) n.s.

COMET,CompetitiveMemoryTraining;TAU, therapy as usual; n.s.,not signicant; MDD, major depressive disorder; RSES, RosenbergSelf-Esteem Scale; BDI, Beck depression inventory; SERS-pos, Self-Esteem Rating Scale, positive; SERS-neg, Self-Esteem Rating Scale,negative; RSS, Rumination on Sadness Scale.

Beck Depression Inventory-II (BDI-II).[26,27] Low scores on this self-referent rating scale (range 063) are favorable. The Dutch translationis reliable and valid.[27]

Rumination on Sadness Scale (RSS).[28,29]

This 13-item self-referent rating scale assesses cognitive responsesto sadness and has a range from 1365. A low score is favorable.Its psychometric properties are well established.[29,30] The RSS wastaken since self-esteem can be related to specic modes of self-focusedrumination.[31]

THERAPISTSCOMET groups were led by two therapists. Seven therapists par-

ticipated in the study. All were psychologists and had ample experi-ence in treating patients with depressive disorders in groups. All werespecically trained (1 day) according to the manual and were regularlysupervised in COMET by the rst two authors (KK and MM).

Psychiatrists and psychologists specialized in treating depressed pa-tients performed TAU.

PROCEDUREAt the start of their treatment at the DAD, all patients are diag-

nosed according to the DSM-IV criteria, established during a clini-cal interview. During their regular treatment (TAU) patients couldbe referred to the study by their therapists, if the criteria for inclusionseemed to be fullled. During assessment for eligibility, the depressionand adjustment disorders sections of the SCID-I were taken. When allcriteria were checked and informed consent was given, measurementswere taken and patients were randomized into two treatment condi-tions. Randomization was performed in ve separate blocks of 1018

patients, by opening blinded envelopes in which both treatment condi-tions had been concealed in advance. Although TAU for both groupscontinued, COMET for the experimental group startedwithin 2weeksafter inclusion. COMET was performed in small groups consisting of59 patients. TAU was practiced in both groups during all phases ofthe study.

The rst measurements (M1) were taken during recruitment. Sec-ond measurements (M2) were taken 8 weeks later, at the end ofCOMET+TAU(experimental group) andTAUonly (control group).Since COMET for the control group started immediately after M2,thesemeasurements were also the pre-COMETmeasurements for thisgroup. The control group was assessed again after they had nishedtheir COMET (post-COMET measurement for the control group:M31). Finally, all patients who had completed COMET (whether inthe experimental groupor later in the control group) completed follow-up measurements 3 months after the completion of either COMET(FU 1) and again 3 months thereafter (FU 2). Thus, the experimentalgroup had their measurements taken four times (recruitment/start ofCOMET (M1), end of COMET (M2), FU1; and FU2), whereas thecontrol group was assessed ve times (recruitment/start of TAU only(M1); end of TAU only/start of COMET in control group (M2); endof COMET in control group (M3); FU1; and FU2).

TREATMENTSTherapy as Usual (TAU). TAU was not further specied.

Regular treatment at the DAD is based on the Dutch Multidisci-plinary Guidelines for Depressive Disorders.[32] In line with interna-tional standards, these guidelines indicate cognitive behavioral ther-apy (CBT) and interpersonal psychotherapy (IPT) as psychologicalinterventions of rst choice, and SSRIs and tricyclic antidepressantsas medications of rst choice in the treatment of depressed patients.There was no formal integrity check in this condition.

Competitive Memory Training (COMET). COMET lastedeight sessions of 2 hr each and consisted of several steps, all aimedat strengthening the patients positive self-opinions and making themmore competitive. All steps were repetitively practiced during therapysessions and in homework assignments. The following steps could beidentied: First, the negative self-image was identied. Next, a credi-ble but incompatible and more positive self-image, based on personalcharacteristics, acts, and experiences, was formulated. This positiveself-imagewas strengthenedbywriting small self-referent stories aboutreal-life instances in which these positive personal characteristics hadbeen active. During the next few sessions, these instances were mademore emotionally salient by imagining these scenes, backing them upwith positive self-verbalizations (session 3), body posture, facial expres-sion, (session 4), and music (session 5); all these were selected by thepatients themselves and believed to promote the experience of positiveself-esteem. Then, in the next two sessions (sixth and seventh) counterconditioningwas introduced in order to formnewassociations betweencues that formerly activated low self-esteem and the newly enhancedrepresentations of positive self-esteem on the other hand.[33] In the -nal (eighth) session, after discussion of the latest homework, COMETwas evaluated.

To assess the treatment integrity in COMET, two informed but in-dependent assessors checkedwhether these treatmentswere performedaccording to the manual. During live observations of a sample of treat-ment sessions, pairs of assessors (independently of each other) tickedon a (dedicated) form whether prescribed elements were handled, andwhether elements were introduced that were not in the manual.

1Note that the experimental group did not ll in M3.

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Research Article: COMET for Low Self-Esteem in Depression 105

Figure 1. Flowchart of the study.

STATISTICAL ANALYSESA regression analysis was performed to assess whether random-

ization was successful. Age, gender, diagnosis, and pre-treatmentscores on all outcome variables were taken as predictors forgroup.

Themain analyseswere on an intention to treat basis.Missing valueswere imputed by the LOCF (last observation carried forward) proce-dure. After imputation, ANCOVAs were calculated for each outcomevariable separately, with each score at M2 as the dependent variables,the scores on the same variable at M1 as covariates, and group as

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106 Korrelboom et al.

Figure 2. Rosenberg Self-Esteem Scale.

xed factor. The size of signicant differences between groups wasdetermined by calculating Cohens d for each of these differences.[34]

Finally, in this randomized phase of the study, in each group the per-centage of patients who realized a clinical signicant change (CSC)on the RSES and the BDI-II in the direction of normal functioning

was determined.[35] Normal self-esteem was dened as functioningcloser to the mean of a functional group than to the mean of the pa-tient group. The cut-off score was established at 26, which was halfwaybetween the mean score of the study population at M1 (M = 20.8;SD = 3.8) and the mean score of a functional group of Dutch

Figure 3. Self-Esteem Rating Scale.

Figure 4. Beck Depression Inventory.

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Research Article: COMET for Low Self-Esteem in Depression 107

Figure 5. Rumination on Sadness Scale.

citizens (M = 31.6; SD = 4.5).[36] Based on a reliability coefcientof 0.87, found in that same study, a change on the RSES of minimally6 points between M1 and M2 was considered necessary to realize areliable change (RC). A similar procedure was applied with regard tothe scores on the BDI-II. Taking 14 as the cut-off score between nor-mal and depressed functioning (013 are the limits of the Dutch normgroup with minimal depressive symptoms),[27] and a change of atleast 5 points (based on SD = 6.1 and testretest reliability = 0.93)[27]as the criterion for an RC. Patients who surpassed the cut-off score andrealized an RC were considered to have achieved a CSC. Secondaryanalyses were on an observed cases basis. At follow-up, results werecalculated for all patients who completed their COMET (whether inthe experimental group, or later in the control group) with ANOVAsfor repeated measures for all separate outcome measures and with fourfactors for time (start of COMET2; end of COMET3; FU1 and FU2).

Except for the regression analysis where a p-value of .1 was applied,p-values of .05 were considered signicant.Wheremultiple testing wasan issue, a Bonferroni correction was employed.

RESULTSSince there were no predictors of group, it was con-

cluded that randomization had been successful. BetweenM1 and M2, one patient in the experimental group andone in the control group dropped out. Their missingpost-treatment scores at M2 were substituted by theirscores at M1.

The treatment integrity data showed a high level ofagreement between the observers on most issues (8089%). Of the 10 rated COMET sessions (25%), 88%was performed according to the manual. The treatmentintegrity data showed a high level of agreement betweenthe observers on most issues (8089%). Of the 10 ratedCOMET sessions (25%) 88% was performed accordingto themanual.Then, concluding that treatment integrity

2This was M1 for the experimental group and M2 for the controlgroup.3This was M2 for the experimental group and M3 for the controlgroup.

in COMETwas good, analyses of covariance were cal-culated for all outcome measures separately.

Then, concluding that treatment integrity inCOMET was good, analyses of covariance were cal-culated for all outcome measures separately. Patientsin COMET + TAU performed signicantly betterthan patients in TAU only on all measures: RSES:F(2, 58) = 23.56, p < .000; BDI-II: F(2, 58) = 40.06,p = .001; SERS-pos: F(2, 58) = 49.87, p = .001; SERS-neg: F(2, 58) = 21.22, p < .000; RSS: F(2, 58) = 40.06,p = .001. All differences remained signicant after cor-recting for multiple testing. The sizes of all differencesbetween COMET + TAU and TAU only were large.Table 2 presents an overview.

Next, for both groups, the percentages of patientswere calculated that had realized aCSCon theRSES andthe BDI-II. At the RSES, two patients (7%) in the con-trol group changed from problematic to normal func-tioning during TAU, whereas 12 patients (39%) did soduring COMET. In TAU, three patients (10%) realizedan RC for the better, whereas two patients (7%) in thisgroup deteriorated 6 points or more. In COMET, nopatients deteriorated, whereas 14 (45%) realized an RCin the positive direction. In total, two patients in TAU(7%) and nine in COMET (29%) realized a CSC at self-esteem.

At the BDI, four patients (13%) in the controlgroup changed from problematic to normal function-ing during TAU, whereas 12 patients (39%) did soduring COMET. Moreover, one patient (3%) changedfrom normal to problematic functioning during TAU,whereas no patient in COMET did so. In TAU, 12patients (40%) realized a positive RC, and 23 patients(74%) did so in COMET. Moreover, in TAU, three pa-tients (10%) deteriorated more than 4 points at the BDI,whereas none did in COMET. Taking these results to-gether, 12 patients (39%) in COMET and two patients(7%) in TAU realized a CSC at depression.

After the rst phase of the study, patients in the con-trol group also receivedCOMET.Twenty-nine patients

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108 Korrelboom et al.

TABLE 2. Interaction effects between pre- andpost-treatment: intention to treat

Mean (SD) Mean (SD)95% CI 95% CI Effect size

Variable/ Pre- Post- (between)group N treatment treatment (Cohens d) Signicance

RSESExp: 31 21.4 (3.7) 27.1 (6.0)

(20.022.8) (24.929.3) 1.3 .000TAU: 30 20.1 (3.9) 21.2 (4.5)

(18.721.6) (19.622.9)BDI

Exp: 31 27.3 (9.9) 16.8 (12.8)(23.630.9) (12.121.5) 1.2 .001

TAU: 30 29.9 (10.8) 26.0 (10.1)(25.933.9) (22.229.8)

SERS-posExp: 31 41.9 (10.2) 48.8 (8.7)

(38.245.7) (45.652.0) 1.3 .001TAU: 30 38.1 (12.8) 40.4 (10.4)

(33.342.8) (36.544.3)SERS-neg

Exp: 31 47.5 (11.0) 35.3 (13.8)(43.451.5) (30.240.4) 1.2 .000

TAU: 30 48.9 (10.9) 47.1 (9.7)(44.853.0) (43.450.7)

RSSExp: 31 42.8 (6.4) 35.6 (8.8)

(40.545.2) (32.438.9) 0.9 .002TAU: 30 42.9 (8.6) 41.2 (8.1)

(39.646.1) (38.244.2)

95% CI, 95% condence interval; RSES, Rosenberg Self-EsteemScale; BDI, Beck depression inventory; SERS-pos, Self-Esteem Rat-ing Scale, positive; SERS-neg, Self-Esteem Rating Scale, nega-tive; RSS, Rumination on Sadness Scale; Exp, experimental group(COMET + TAU); TAU, control group (TAU only).

entered COMET for the control group, of which fourdropped out. To assess the stability of the COMET re-sults over time, ANOVAs for repeated measures withfour factors for time (start COMET, end COMET,FU1, andFU2)were performedon all outcomemeasuresfor all patients who had completed COMET (whetherin the experimental group or control group) and hadcompleted measurements during the two specied FUmoments. Fifty-one patients met these criteria and wereentered in these calculations. The results are illustratedin Figures 25. Changes over time were signicant on allvariables: RSES: F(2, 56, 125.53)= 29.38, p< .0004 (onepatient missing); SERS-pos: F(3, 150) = 9.84, p < .000;SERS-neg: F(2, 45, 122.44) = 27.67, p < .000; BDI-II:F(2, 69, 129.04) = 28.57, p < .000 (two patients miss-ing); RSS: F(3, 147) = 23.89, p< .000 (one patient miss-ing). As appeared from contrasts (repeated), in all in-stances but one (RSS), all signicant changes took place

4Where the assumption of sphericity was violated, Huynh-Feldt cor-rections were applied.

during COMET. At the RSS, although the initial (pre-COMET to post-COMET) change had already beensignicant (F (1, 49) = 21.94, p< .000), there was an ad-ditional signicant change between the end of COMETand FU1 (F (1, 49) = 11.77, p = .001).

DISCUSSIONIn line with previous studies,[19,20] COMET for low

self-esteem proved effective in enhancing self-esteemin a clinical population, at least when applied in com-bination with TAU. Patients with depressive disordersimproved signicantly and with large effect sizes afterCOMET + TAU when compared with TAU only. Theparticipants gains duringCOMETremained stable overa period of 6 months and pertained to several indicesof self-esteem, depression, and depressive rumination.Moreover, both on the RSES and the BDI-II, manymore patients treated withCOMET thanwithTAUhadan RC, and changed from the problematic functioninggroup to normal functioning. Approximately four to vetimes more patients in COMET + TAU than in TAUonly realized a CSC on these indices.

Some aspects of the study warrant closer considera-tion.

First, it should be noted that by performing the studyin a regular mental health institution, its ecological va-lidity was highly promoted. Second, there was very littleattrition. Only one patient in COMET and one in thecontrol group dropped out during the controlled phaseof the study. Thereafter, four patients did not completeCOMET in the control group, whereas four other pa-tients were lost to the rst follow-up, and two to the sec-ond follow-up. A last potentially important nding is theeffect on depressive rumination. Apart from improve-ments on self-esteem and depression, COMET patientsalso improved on rumination. This differential effectwas observed directly after COMET, and also duringfollow-up. Depressive rumination is considered a strongpredictor of relapse in depressive illness.[37] As faras depressive rumination involves worries about self-worth,[31] it is conceivable that enhancing self-esteemwill reduce this kind of depressive rumination in an in-direct fashion.

The study has several limitations. First, patients hadto be referred by their regular therapists. Therefore,it is unknown whether some patients who would havefullled criteria for inclusion were not referred, andwhether those not referred patients would have per-formed differently. Moreover, the regular mental healthsetting necessitated a crossover design in which patientsfrom the control group also received COMET at a laterpoint of time. Therefore, it is impossible to establishhow patients in the control group would have faredduring follow-up without ever receiving COMET. Thethird limitation concerns TAU. It is not known how ad-equately TAU was applied. The fourth and most im-portant limitation concerns the amount of therapy thatpatients in both groups received. Although it was impos-

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Research Article: COMET for Low Self-Esteem in Depression 109

sible to control for this aspect during the trial, the totalnumber of therapeutic contacts (TAU and COMET)between M1 and M2 was calculated post hoc for bothgroups. The experimental group received more therapy,i.e. 10.5 (SD = 5.1) versus M = 4.6 (SD = 4.8) in thecontrols. This is a signicant difference (t (56) = 4.5;p< .000). Even when allowing for the possibility that thedifferences between TAU alone and COMET + TAUshould be attributed to a difference in the total amountof therapy received instead of to the COMETprocedureitself, this possibility is not very likely. Many patients inboth groups had a relatively long history of (TAU) treat-ment. Simply adding ve extra sessions of similar TAUto this total amount does not seem an adequate explana-tion for the observed differences between the groups.

CONCLUSIONSDespite these limitations, COMET for low self-

esteem seems to be an effective trans-diagnostic inter-vention. It is currently the most empirically supportedspecic intervention for the enhancement of self-esteemin adult psychiatric populations. Further research isneeded to assess the effects of COMET in other pop-ulations, on other aspects of self-esteem, and during aneven longer follow-up period.

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