Cognitive Behavioural Therapy/Metacognitive Therapy for Low Self Esteem
Phase: NA
Conditions: Psychological Disorders
Sponsor: University of Oslo

 
 
 
Title of the project: Cognitive Behavioral Therapy/ 
Metacognitive Therapy for Low Self Esteem 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Date of last revision: 01.12.24 
 

1 
 
Study protocol: 
 
 
 
 
 
 
 
 
 
 
In Norwegian: 
 
”Effekten av metakognitiv terapi og kognitiv atferdsterapi i behandling av lav selvfølelse: En 
pilot-studie” 
 
 
 
 
 
 
 
Department of Psychology 
University of Oslo 
 
In collaboration with: 
 
Department of Psychology 
NTNU, Trondheim 
  
&  
 
Metakognitiv Terapi Oslo (MKT OSLO)  
 
& 
 
Klinikk Neeta Myrseth Parmar  
 
 
 
Metacognitive Therapy or Cognitive Behavioral Therapy for Low Self-
Esteem: A pilot study.  

2 
 
SUMMARY  
The association between low self-esteem and psychiatric disorders indicates that low self-
esteem is an important transdiagnostic construct. People who report having a low self-esteem 
seem to experience more mental health problems and a reduction in quality of life.  
 
There have been a few trials considering the effect of Cognitive Behavioural Therapy (CBT) 
for low self-esteem, however, there are few randomized controlled studies. Recently, Meta 
Cognitive Therapy (MCT) has been introduced as a new, specific treatment for MDD, 
showing promising and lasting results. This treatment approach also has proven more 
effective than CBT for GAD or worry disorder. So far, no study has examined MCT for low 
self-esteem in a randomized controlled trial.  
 
For the present clinical trial, 20 patients with low self-esteem will be selected and distributed 
into two treatment conditions. The first group (n=10) will be treated with MCT, whereas the 
second group (n = 10) will be treated with CBT.  The patients will be assessed with different 
outcome measures at pre-treatment, at the end of treatment, and at six months follow up. In 
addition, they will also be assessed weekly using various measures.  
 
We aim in this study to (1) evaluate the accessibility and effectiveness of MCT and CBT in 
treating low self-esteem, (2) investigate the patterns of change and the mechanisms of action 
involved during treatment, and (3) examine the impact of meta-cognitions and 
neuropsychologial processes in the treatment response and any relapse prevention of low self-
esteem.  
 
 

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STUDY ORGANISATION 
 
 
Investigators:  
Roger Hagen, Ph.D., Professor, UiO, NTNU & Modum Bad (PI) 
Leif. Edward Ottesen Kennair, Ph.D., professor, NTNU  
Brage Kraft, Ph.D., Diakonhjemmet sykehus 
Sunniva K. Itland, Metakognitiv Terapi Oslo 
Neeta Myrseth Parmar, Oslo  
 
 
Sponsors: Department of Psychology, UiO;  
 
 
Contact information for the project: 
Roger Hagen, roger.hagen@psykologi.uio.no., phone: 0047-48109789 
 
 
 

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INTRODUCTION 
 
Self-esteem reflects how people feel about themselves and is a multifaceted construct related 
to other psychological constructs such as self-image, self-concept, self-perception, self-
confidence, self-acceptance, self-respect, and self-worth. Research suggests that self-esteem is 
related to psychological well-being and psychological problems (Sowislo &Orth, 2013).  
Healthy self-esteem has been described as holding a balanced view of oneself in which one 
recognizes and accepts human weaknesses and appreciates ones’ strengths and good qualities 
(Fennell, 1997). Small, but significant, sex differences have been found, with lower levels of 
self-esteem among women (Kling et al., 1999). Findings from prospective studies suggest that 
self-esteem is relatively stable throughout life (Orth& Robins, 2014).  It is generally believed 
that there are many benefits to having an accepting view of the self. It seems that high self-
esteem is related to success and well-being in different areas of life such as relationships, 
work, and health (Orth & Robins, 2014), however directionality is debated.  
Low self-esteem in adolescence, on the other hand, is associated with greater risk of mental 
health problems, substance dependence, and lower levels of life and relationship satisfaction 
in adulthood (Boden et al., 2008). However, the relationship between self-esteem and relevant 
outcomes (e.g., performance, interpersonal functioning, lifestyle, and happiness) 
is as mentioned not always straightforward (e.g., Baumeister et al., 2003). 
 
The association between low self-esteem and psychiatric disorders (Zeigler-Hill, 2011) 
indicates that low self-esteem is an important transdiagnostic construct. The association 
between low self-esteem and symptoms of mental disorders may be bidirectional. A meta-
analysis by Sowislo & Orth (2013) found that self-esteem predicted depression, whereas the 
direction was unclear for anxiety disorders. Self-esteem may represent a vulnerability to 
problems or disorders such as depression, social anxiety, eating disorder, and substance use 
(Vohs et al., 1999; Donnelly et al., 2008; Sowislo & Orth, 2013), but could also be 
the product of psychiatric disorders. Symptoms of depression for instance may reduce self-
esteem in persons with mental disorders (Shahar & Davidson, 2003; Burwell and Shirk, 
2006). 
 
A prior study of the underlying mechanisms that predict self-esteem (Hagen et al., 2020) 
lends support to a metacognitive model to explain the relation between metacognitive 
processes and self-esteem. Results showed that metacognitive beliefs influence the degree of 

5 
 
brooding, which again is associated with low self-esteem. The current findings dovetail nicely 
with recent metacognitive approaches to understanding self-esteem by Kolubinski et al. 
(2019). Together these studies suggest that rumination, self-esteem, and depression are 
closely linked (Hagen et al., 2020; Kolubinski et al., 2016), and that rumination mediates the 
prospective effect of low self-esteem on depression (Kuster et al, 2012). Rumination is a 
perseverative coping strategy in response to negative automatic thoughts. It typically consists 
of repeatedly contemplating past mistakes, one’s own shortcomings, negative mood, and 
pessimistic thoughts about the future (Wells, 2009).  
 
Low self-esteem has previously been conceptualized based on the cognitive model proposed 
by Fennell (1997), where core schemas and automatic thoughts maintain a low self-esteem. 
Cognitive-behavioral therapy (CBT) interventions are aimed at cognitive restructuring in 
order to modify schemas about oneself and self-critical thoughts. CBT based on the cognitive 
model proposed by Fennell (1997) has shown promising results (Kolubinski et al., 2018). 
However, there are few clinical trials that have examined increasing low self-esteem, and only 
three have used a randomized controlled design (Brown et al., 2004; Waite et al., 2012; 
McElhinney et al., 2016).  
 
The results of Hagen et al (2020) are potentially relevant for  new clinical interventions in 
treating low self-esteem. Metacognitive therapy (MCT; Wells, 2009) based on the S-REF 
model, represent a different treatment approach. In this approach, low self-esteem is 
conceptualized as being maintained by rumination, worry and unhelpful coping strategies. 
These strategies are driven by metacognitions, and treatment seeks to challenge and change  
these metacognitions and to reduce rumination, worry and unhelpful coping strategies (Wells, 
2009).  If treatment is successful, it would create more adaptable styles to encounter negative 
thoughts and emotions and thereby reduce low self-esteem (Fahramand,  2014).  
 
A meta-analysis by Normann & Morina (2018) showed that for depression and anxiety 
disorders, MCT had a better treatment outcome compared to CBT, and it would therefore be 
of interest to explore if these results are repeated when treating low self-esteem.  
 
To sum up; there are a limited number of clinical studies on psychological treatment for low-
self-esteem, and existing treatments given are largely based on cognitive therapy. Because 
both metacognitions and perseverant thinking could play a prominent role in low self-esteem, 

6 
 
a therapy such as MCT could be a promising new approach to treat such problems. To our 
knowledge no studies have so far examined the effectiveness of MCT in treating low self-
esteem,or compared the effect of this treatment approach to the more established CBT model.  
 
 
AIMS OF THE STUDY 
The purpose of this pilot trial is to investigate the efficacy of MCT may be beneficial in 
treating low self-esteem, in comparison with CBT, which has some support as an intervention 
for low self-esteem.  The outcome of this pilot trial is also specifically intended to inform the 
planning of any future randomized controlled studies. 
 
RESEARCH QUESTIONS 
 
Questions that will be addressed: 
(1) Evaluate the accessibility and effectiveness of MCT and CBT in treating low self-
esteem? 
(2) Is change in metacognitions or cognitive content most predictive of treatment 
outcome?  
(3) Is treatment change also associated with changes on neuropsychological measures? 
 
 
STUDY DESIGN 
We will use a  multiple baseline single case design, involving 12 patients all of whom will either 
receive MCT or CBT and act as their own control. Such a design are recommended for 
preliminary evaluation of novel psychological interventions as they allow for examination of 
treatment-related changes within and between participants in small samples whilst allowing 
experimental control. Before commencing MCT or CBT, patients will complete baseline 
periods of three weeks, including three measurements. The baseline period will enable us to 
determine any possible effects of other factors such as history, maturation, statistical regression, 
or spontaneous remission, which may be responsible for symptom improvement. This design 
can increase confidence that any observable changes are likely to be attributable to the 
interventions. The therapy will take place at the out-patient clinic at the Department of 

7 
 
Psychology, NTNU, at the outpatient clinic at the Department of Psychology, UiO, at 
Metakognitiv Terapi Oslo and at Neeta Myrseth Parmar in Oslo.    
 
 
ELIGIBLE CRITERIA 
Inclusion criteria 
Patients meeting all inclusion criteria listed below will be included in the study: 
1. Signed written informed consent obtained prior to entry in the study. 
2. Scores below 15 on the Rosenberg Self-esteem Scale (RSE) 
3. 18 years or older. 
 
Exclusion criteria 
Patients presenting with any of the following will not be included in the study: 
1. Psychosis  
2. Bipolar type 1 
3. Current suicide intent  
4. PTSD 
5. Cluster A or cluster B personality disorder  
6. Substance dependence 
 
MEASURES 
A battery of measures will be administered at multiple baseline (pre-treatment), at post-
treatment (at 8 weeks) and at six months follow-up. These measures include a combination of 
self-report instruments, neuropsycholoigal tests,  and assessor administered ratings. All 
patients must sign a written consent for participating before they will be included. The 
instruments to be included are as follows: 
 
Assessment of patients: 
 
I. Symptom measures (self-report): 
1. Rosenberg Self-esteem Scale (RSE; Rosenberg, 1965) 
2. Robson Self-Concept Questionnaire (RSCQ; Robson, 1989). 
3. Ruminative Response Scale (RRS; Nolem-Hoksema & Morrow, 1991) 

8 
 
4. Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger & Borkovec, 1990) 
5. Metacognitions Questionnaire-30 (MCQ-30; Wells & Cartwright-Hatton, 2004) 
6. Automatic Thoughts Questionnaire-8 (ATQ-8, Netemeyer et al, 2002) 
7. Patient Health Questionnaire -9 (PHQ-9; Spitzer, Kroenke & Williams, 1999) 
8. Generalized Anxiety Disorder-7 (GAD-7; Spitzer, Kroenke, Williams & Lowe; 2006)  
9. Inventory for Interpersonal Problems (IPP-64, Horowitz et al, 1988) 
 
II: Neuropsychological measures:  
1. Behavior Rating Inventory of Executive Function – Adult Version (Roth et al, 2005) 
2. CANTAB: Intra-Extra Dimensional Set Shift (CANTAB, 2009) 
3. CANTAB: Spatial Working Memory  (CANTAB, 2009) 
4. CANTAB: Rapid Visual Information Processing (CANTAB, 2009) 
5. CANTAB: One Touch Stockings of Cambridge (CANTAB, 2009) 
 
THERAPISTS COMPETENCE AND SUPERVISION 
The four therapists have received training and are licenced in either meta-cognitive therapy or 
cognitive behavioral therapy. The supervision of the therapists will take place biweekly, 
where the CBT group and metacognitive group will meet up to discuss their patients and 
supervise each other. All therapists will receive equal amount of collegial supervision and 
support during the study period.  
 
TREATMENT  
The meta-cognitive treatment program is based on Wells’s metacognitive therapy (Wells, 
2013). The patients receiving meta-cognitive therapy will be treated for 8 sessions, with 
weekly session of 45-60 minutes duration. A detailed description of the content of each MCT- 
session could be found in appendix A in the study protocol. The CBT is based on the 
treatment manual written by Fennell (1997). The patients receiving CBT will be treated for 8 
sessions, with weekly session of 45-60 minutes duration. A detailed description of the content 
of each CBT- session could be found in appendix B in the study protocol.  
 
TREATMENT CONDITIONS AND ADHERENCE 
The treatment will be administered according to the originators published treatment manuals 
for MCT and CBT as  described above under treatment.  Using checklists session-by-session 
will ensure adherence of the therapy (see appendix A and B for a further description for this)  

9 
 
 
SCHEDULE OF ASSESSMENTS 
 
See appendix C for a further description related to the schedule of assessments.  
        
PROCEDURE 
1. All patients referred to the study will be asked to fill out the Rosenberg Self-esteem Scale 
in order to participate in the trial.  A RSE score below 15 will result in a further 
assessment in order to examine whether they fulfil the inclusion and exlusion criteria. If 
they fulfill these criteria the participants be asked to take place in the study.  
2. Patients will be distributed to one of the two treatment conditions (MCT or CBT) 
3. Patients will be asked to self-rate symptoms on a battery of self-report questionnaires 
three times before start of therapy (multiple baseline for three weeks).  
4. Patients will be assessed at neuropsychological tests after the multiple baseline (before 
start of therapy).  
5. Meta-cognitive therapy will be given to patients in group 1, while patients in group 2 will 
receive CBT.  
6. The patients will be assessed prior to treatment, at post-treatment at 8 weeks, and at six 
months follow-up.  
 
GENERAL CRITERIA FOR RECOVERY/IMPROVEMENT 
The criteria for improvement and recovery will be estimated based on the primary outcome 
measure on RSE. Other outcome measures will include: Reduction of symptoms of anxiety 
and depression as measured by self-report questionnaires, in addition to a reduction in worry 
and rumination.   
 
PRIMARY EFFICACY VARIABLES 
The primary efficacy variables would be related to change in self-esteem at post-treatment 
and by six months follow-up.  
 
SECONDARY EFFICACY VARIABLES 
The secondary efficacy would be related to symptom measures of anxiety, depression, 
rumination, worry, metacognitions, cognitive content and interpersonal problems at post-
treatment and by six months follow up.  

10 
 
 
ANALYSIS OF EFFICACY DATA 
A comparison between the two groups of patients will be conducted at post-treatment and at 
six months follow up. The null hypothesis is assumed. A within group analyses will be 
conducted in order to estimate effect sizes and significant clinical change estimates. 
                                                                         
DROP-OUT RATE 
A treatment dropout will be defined as any patient receiving less than three sessions. If the 
patient withdraws from the trial with less than three sessions, he or she will be defined as a 
dropout patient and will not be included in the statistical analyses. Results from the study will 
be based on per protocol completers.  
                                     
PATIENT POPULATION FOR ANALYSIS 
The per protocol completed treatment patients (PP patients) consist of all patients who 
completed treatment or received at least six sessions as prescribed in the protocol.  
       
TERMINATION OF THE STUDY AND PATIENT SAFETY 
In accordance with the Helsinki Declaration, patients have the right to withdraw from the trial 
at any time for any reason. Additionally, any patient may be discontinued from the study at 
any time if the investigator feels it is in the best interest of the patient.  Patients may be 
discontinued for the following reasons: 
 
1. By request of the patients or investigator whether for health risks or other reasons. 
2. By severe adverse experience that may place the patient at risk. 
3. Severe non-compliance with therapy, protocol deviations or behaviour putting the 
patient himself at risk. 
4. Intercurrent illness. 
 
If the participants experience negative adverse effects under or after treatment (which is not 
expected), the therapist treating the patient would refer the participant for suitable 
psychological treatment.  
                       
VARIATIONS TO THE PROTOCOL 

11 
 
Variations or violations to the protocol are prohibited unless where the patient is in a situation 
of hazard. In case of deviations from protocol the nature and rationale for the deviation must 
be documented. The comment should be signed and dated by the investigator. The primary 
investigators (Roger Hagen and Leif Edward Ottesen Kennair) will decide whether the 
violation of the treatment condition disqualify the collected data.    
  
COMPLIANCE WITH GOOD CLINICAL PRACTICE (GCP) 
The study will be conducted in compliance with good clinical practice (GCP), including the 
recent version of the declaration of Helsinki (2000) and the laws and regulations of Norway.  
 
CONFIDENTIALITY AND PATIENT DATA 
All patient data collected for the purpose of the study should be handled by the investigator 
and his staff with precautions, to ensure the safe confidentiality of the patients and related 
data. Confidentiality of the patients is based on the laws and regulations by national health 
authorities and the declaration of Helsinki. The patients’ confidentiality will be secured in any 
presentation of the study. The data and identity of the participant will be securely saved in a 
secure database at the University of Oslo (TSD), to Norwegian law and regulations. On 
request the national health regulatory authority will be granted access to the study patient’s 
journal. 
 
ETHICAL ASPECTS 
The study will be conducted in accordance with the principles outlined in the “Helsinki 
declaration” (5th version, 2000). Patients will be informed and asked to sign a written consent 
before they participate in the study. It will be clearly stated for the patient that participation is 
absolutely voluntarily and confidential, and that the patient may withdraw from participation 
in the trial at whenever point he or she chooses.  
 
 
 
APPROVAL FROM ETHICAL COMMITTEE 
The study will be submitted for the Norwegian Ethical Committee (REK) and Norwegian 
Center for Research Data (NSD) in order to get approval from these before the study starts.  
 

12 
 
PUBLICATION AND DISSEMINATION OF THE RESULTS 
Publications based on the data from this study proceed from the group headed by the primary 
investigators, with specification of the participating clinics and contacts. Authors of the 
publications will be those who actively participate in producing the protocol, compiling the 
results and writing the articles. 
 
REFERENCES 
                         
Baumeister, R. F., Campbell, J. D., Krueger, J. I., & Vohs, K. D. (2003). Does High Self-
Esteem Cause Better Performance, Interpersonal Success, Happiness, or Healthier 
Lifestyles? Psychological Science in the Public Interest, 4(1), 1–44. 
 
Boden JM, Fergusson DM, Horwood LJ. (2008) Does adolescent self-esteem predict later life 
outcomes? A test of the causal role of self-esteem. Developmental  Psychopathology;20, 319-
39.  
 
Brown J,S., Elliott, S.A., Boardman, J., Ferns, J., Morrison,  J. (2004) Meeting the unmet 
need for depression services with psycho-educational self-confidence workshops: preliminary 
report. British Journal of Psychiatry, 185, 511-515. 
 
Burwell, R. A., & Shirk, S. R. (2006). Self Processes in Adolescent Depression: The Role of 
Self-Worth Contingencies. Journal of Research on Adolescence, 16(3), 479–490 
CANTAB (2009). The Cambridge Neuropsychological Test Automated Battery. Cambridge 
Cognition Limited: Cambridge, UK. 
Donnelly, J., Young, M., Pearson, R., Penhollow, T. M., & Hernandez, A. (2008). Area 
Specific Self-Esteem, Values, and Adolescent Substance Use. Journal of Drug 
Education, 38(4), 389–403 
 
Farahmand V, Hassanzadeh R, Mirzaian B, Fayyazi Bordbar MR, Feizi J (2014). The efficacy 
of group metacognitive therapy on self-esteem and mental health of patients suffering from 
major depressive disorder. Iran J Psychiatry Behav Sci, 8, 4-10. 
 

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Fennell, M. J. V. (1997). Low self esteem: A cognitive perspective. Behavioural and 
Cognitive Psychotherapy, 25(1), 1–25 
 
Hagen, R., Havnen, A., Hjemdal, O., Kennair, L.E.O., Ryum, T., & Solem, S. (2020). 
Protective and Vulnerability Factors in Self-Esteem: The Role of Metacognitions, Brooding, 
and Resilience. Frontiers in Psychology, 11, 1447 
 
Horowitz, L.M., Rosenberg, S.E., Baer, B.A., Ureno, G., & Villasenor, V.S. (1988). Inventory 
of Interpersonal Problems: Psychometric properties and clinical applications. Journal of 
Consulting and Clinical Psychology, 56, 885–892. 
 
Kling, K. C., Hyde, J. S., Showers, C. J., & Buswell, B. N. (1999). Gender differences in self-
esteem: A meta-analysis. Psychological Bulletin, 125, 470–500. 
 
Kolubinski, D. C., Nikčević, A. V., Lawrence, J. A., & Spada, M. M. (2016). The role of 
metacognition in self-critical rumination: An investigation in individuals presenting with low 
self-esteem. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 34, 73–85 
 
Kolubinski, D. C., Marino, C., Nikčević, A. V., & Spada, M. M. (2019). A metacognitive 
model of self-esteem. Journal of Affective Disorders, 256, 42–53. 
 
Kroenke, K., Spitzer, R. L. & Williams, J. B. (2001). The PHQ-9: validity of a brief 
depression severity measure. Journal of General Internal Medicine, 16, 606–613 
 
Kuster F, Orth U, Meier LL (2012). Rumination mediates the prospective effect of low self-
esteem on depression: a five-wave longitudinal study. Pers Soc Psychol Bull, 38, 747-59.  
Spitzer RL, Kroenke K, Williams JBW, Lowe B. (2006). A brief measure for assessing 
generalized anxiety disorder. Archives of Internal Medicine. 166: 1092-1097. 
McElhinney, R., Reid, H., & Morton, L. (2016). A controlled trial of a CBT group for women 
with low self esteem. Clinical Psychology Forum, 287, [287]. 
 

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Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and 
validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28, 487–
495. 
 
Netemeyer, R. G., Williamson, D. A., Burton, S., Biswas, D., Jindal, S., Landreth, S., Mills, 
G., & Primeaux, S. (2002). Psychometric Properties of Shortened Versions of the Automatic 
Thoughts Questionnaire. Educational and Psychological Measurement, 62(1), 111–129. 
 
Nolen-Hoeksema, S., & Morrow, J. (1991). A prospective study of depression and 
posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta 
earthquake. Journal of Personality and Social Psychology, 61, 115–121. 
 
Normann, N., & Morina, N. (2018). The efficacy of metacognitive therapy: A systematic 
review and meta-analysis. Frontiers in Psychology, 9, Article 2211 
 
Orth, U., & Robins, R. W. (2014). The Development of Self-Esteem. Current Directions in 
Psychological Science, 23(5), 381–387. 
Robson, P.J. (1989). Development of a new self-report questionnaire to measure self-esteem. 
Psychological Medicine, 19, 513–518 
Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton 
University Press 
 
Roth, R. M., Isquith, P. K., & Gioia, G. A. (2005). Behavioral Rating Inventory of Executive 
Function—Adult version. Lutz, FL: Psychological Assessment Resources, In 
 
Shahar, G., & Davidson, L. (2003). Depressive symptoms erode self-esteem in severe mental 
illness: A three-wave, cross-lagged study. Journal of Consulting and Clinical Psychology, 
71(5), 890–900 
 
Sowislo, J.F., & Orth, U. (2013) Does low self-esteem predict depression and anxiety? A 
meta-analysis of longitudinal studies. Psychological Bulletin. 139, 213-240. 
 

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Vohs, K. D., Bardone, A. M., Joiner, T. E., Jr., & Abramson, L. Y. (1999). Perfectionism, 
perceived weight status, and self-esteem interact to predict bulimic symptoms: A model of 
bulimic symptom development. Journal of Abnormal Psychology, 108(4), 695–700 
 
Waite, P., McManus, F., & Shafran, R. (2012). Cognitive behaviour therapy for low self-
esteem: a preliminary randomized controlled trial in a primary care setting. Journal of 
Behaviour Therapy and Experimental Psychiatry, 43,1049-1057. 
 
Wells, A., (2009). Metacognitive Therapy for Anxiety and Depression. The Guilford Press. 
 
Wells, A., & Cartwright-Hatton, S. (2004). A short form of the metacognitions questionnaire: 
Properties of the MCQ-30. Behaviour Research and Therapy, 42, 385–396. 
 
Zeigler-Hill, V. (2011). The Connections Between Self-Esteem and Psychopathology. J 
Contemp Psychother 41, 157–164  
 
 
 
 

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Appendix A: Metacognitive therapy manual for low self esteem  
 
Session 1 
·  Review CAS-1 and generate case formulation based on the generic model  
·  Socialize to the model 
·  Identify and label rumination and worry episodes (increase meta awareness) 
. Introduce rationale of attention training. 
·  Practice attention training (use sounds in the room-5 minutes) 
·  Homework: ATT practice in everyday settings  
Session 2 
·  Review homework and CAS-1, especially related to rumination and worry time and 
beliefs related to uncontrollability 
·  Introduce and practice detached mindfulness 
·  Introduce rumination and worry postponement as an experiment to modify 
uncontrollability belief 
·  ATT practice 
·  Homework: ATT + form, apply DM to triggers, rumination and worry postponement. 
Session 3 
·  Review homework and CAS-1, especially related to rumination and worry time and 
beliefs related to uncontrollability 
·  Identify triggers for rumination and worry and practice DM (compare active rumination to 
DM and postponed rumination in session) 
·  Challenge uncontrollability metacognitions (verbally and experientially) 
·  Explore unhelpful coping (avoidance and activity levels) and threat monitoring 
·  ATT practice 

17 
 
·  Homework: ATT, apply DM to triggers, rumination and worry postponement, increase 
activity levels. 
Session 4 
·  Review homework and CAS-1, especially related to rumination and worry time, beliefs 
related to uncontrollability, and unhelpful coping strategies  
·  Check that rumination and worry postponement and detached mindfulness is being 
applied to at least 75 % of the triggers, and that rumination and worry episodes last no 
longer than 2 minutes 
·  Challenge unhelpful coping and threat monitoring using experiments in the session 
·  ATT practice 
·  Homework: ATT, apply DM to triggers, rumination and worry postponement and ban 
unhelpful coping and threat monitoring + plan activities 
Session 5 
·  Review homework and CAS-1, especially related to rumination and worry time, positive 
beliefs, and the use of unhelpful coping 
·  Check the DM is widely applied to triggers 
·  Challenge positive beliefs about rumination and worry and other CAS activities such as 
threat monitoring 
·  Review unhelpful coping and threat monitoring and suggest other way to cope with 
triggers 
·  ATT practice 
·   Homework: ATT, apply DM to triggers, rumination and worry postponement + plan 
activities 
Session 6 
·  Review homework and CAS-1, especially related to rumination and worry time, positive 
beliefs, and the use of unhelpful coping 

18 
 
·  Explore and challenge negative beliefs about feelings and low self esteem 
(danger/blocking beliefs) 
·  ATT practice, increased difficulty 
·  Homework: ATT, widen application of rumination and worry postponement, and reduce 
unhelpful coping and threat monitoring, maintain increased activity levels 
Session 7 
·  Review homework and CAS-1, check for residual beliefs, unhelpful coping and threat 
monitoring 
·  Begin work on therapy blueprint 
·  Challenge residual beliefs 
·  Explore and challenge (?) fear of fallback 
·  ATT practice 
·  Homework: ATT, finish writing the therapy blueprint (Old plan/new plan), implement 
new plan 
Session 8 
·  Review homework and CAS-1 
·  Finish the new plan & summarize therapy 
.  Challenge residual beliefs 
·  Discuss likely future triggers how the new plan should be implemented in the future 
·  Homework: Implement the new plan 
 
 
 

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Appendix B: Cognitive behavioural therapy for low self-esteem 
Session 1 
Review Rosenberg 
Generate case formulation based on CBT-model for low self-esteem 
Socialize to the model 
Identifying anxious predictions and negative automatic thoughts 
Identifying self-critical thoughts 
Identifying the bottom line 
Homework: Recognize trigger situations where anxious predictions (NAT) or self-critical 
thoughts appear. 
 
Session 2 
Review Rosenberg 
Review homework 
Testing anxious predictions: 
Identifying trigger situations where anxious predictions (NAT) appear. 
Questioning NAT through Cognitive diamond and ABCD-model 
Formulating more realistic thoughts  
Homework: Behavioral experiments addressing avoidance and safety seeking behaviors 
 
Session 3 
Review Rosenberg 
Review homework 
Working with self-criticism: 
Identifying trigger situations where self-critical thoughts appear. 
Questioning self-critical thoughts through cost-benefit analysis and ABCD-model 
Formulating more realistic and kinder thoughts  
Homework: Behavioral experiments treating oneself as if worthy of respect and affection 
  
Session 4 
Review Rosenberg 
Review homework 
Identifying and questioning cognitive distortions 

20 
 
Formulating more realistic thinking patterns. 
Homework: Behavioral experiments questioning cognitive distortions  
 
Session 5 
Review Rosenberg 
Review homework 
Identifying and questioning rules of living 
Formulating more realistic and helpful standards and rules 
Homework: Behavioral experiments trying out a more realistic rules of living 
 
Session 6 
Review Rosenberg 
Review homework 
Directing attention to qualities, assets, strengths, skills 
Homework: Gathering data to support new perspective 
 
Session 7 
Review Rosenberg 
Review homework 
Questioning the bottom line 
Creating a new self-representation, a balanced view 
Homework: Behavioral experiments trying out a balanced view 
 
Session 8 
Review Rosenberg 
Review homework 
Summarize therapy and formulate a new plan 
Homework: Implement the new plan 
 
                                                                                                                                                                               
                                                                                                                                   
 
 
 

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Appendix C: Schedules of assessments   
 
 
 
 
Week 
Entry 
BS1 
BS
2 
BS3 
(Pre) 
S1 
S2 
S3 
S4 
S5 
S6 
S7 
S8 
Post 
6 
m 
FU 
Inclusion/exclusion criteria 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent)  
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Socio-demographics  
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
RSE 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
RSCQ 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
X 
RRS 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
X 
PSWQ 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
X 
MCQ-30 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
X 
ATQ 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
X 
PHQ-9 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
GAD 7 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
IIP-64 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
X 
BRIEF 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
X 
C-IED      
 
 
 
X 
 
 
 
 
 
 
 
 
X 
X 
C-SWM 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
X 
C-SST 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
X 
 
 
 Note. Abbreviations: BS = Baseline, S= Session, Post= Post-treatment; FU= follow-up