(Cost-)Effectiveness of Drama therapeutic Self-esteem Intervention (DSI) as an add-on therapy for social anxiety disorders

Een onderzoek van:

Drs Manon Verdonschot

Social anxiety disorder

Social anxiety disorder (SAD) is the most common anxiety disorder with an estimated lifetime prevalence of 9,3% (Graaf, 2012). It is characterized by an intense fear and avoidance of social situations. The burden associated with this disorder is substantial (Ruscio, 2008). Persons with SAD report more problems with activities in daily life, more difficulties in forming relationships, lower health, and reduced wellbeing compared to the general population (netwerk kwaliteitsontwikkeling GGZ, in prep.; Dryman, e.a., 2016). Rates of unemployment and number of missed hours of work are higher compared to persons without AD (Wittchen, 2000). As a consequence, SAD results in a considerable economic burden (Konnopka, 2009). The course of SAD is chronic and debilitating, if untreated. Pharmacological, psychological, and self-help interventions are offered and studies showed reduced symptoms (Mayo-Wilson, e.a., 2014). However, these interventions aren’t effective for all patients, medication has side effects and some patients will continue to have symptoms and/or an increased probability to relapse (Mayo-Wilson, e.a., 2014). Therefore, there is a need to improve treatment effects for SAD.


It is proposed that effects of treatments for patients with SAD may be improved by focussing on self-esteem.  Self-esteem refers to a person’s overall emotional evaluation of his or her positive or negative attitude toward the self (Rosenberg, 1979). Low self-esteem is a main reason for seeking psychiatric help and it is a risk factor for the development of and relapse in several disorders (Stice, 2002; Wilson & Rapee, 2005; Orth, Robins, et.al. 2009). A meta-analysis showed that low self-esteem is a consequence of anxiety and also a predictor for developing anxiety symptoms (Sowislo & Orth, 2013), even when taking into account coping behavior, efficiency of social networks, stressful life events, and relational victimization (In-Albon, e.a, 2017; Orth, et.al., 2014). These results indicate that self-esteem is not just an epiphenomenon. On the contrary, self-esteem will have a strong impact, even stronger than factors as negative life events, coping, and efficiency of social networks. The clinical implication is that strengthening self-esteem in therapy for SAD is important, since strengthening self-esteem may act as a resource that buffers from negative experiences and may enhance the overall treatment effects in SAD.

Unfortunately, only few efficacy studies included self-esteem measures or focus on therapeutic interventions with an emphasis on self-esteem. Efficacy studies on interventions without a special focus on self-esteem revealed that symptoms may decline, whereas the effect on self-esteem was only intermediate or small (Watson, e.a., 2003). This may suggest that even after successful treatment, remittent patients may be still vulnerable. Studies on an intervention that target self-esteem in particular are promising to improve self-esteem. A meta-analysis on self-esteem interventions showed that interventions focussing on changing self-esteem were more effective in improving self-esteem compared to interventions with a broader focus (Haney & Durlak, 1998). In addition, interventions based on theories and empirical studies showed more effects than interventions without a theoretical or empirical ground (Bos, et al 2006). Using randomized controlled trials, improvement in self-esteem were shown in adult patients with depressive disorders (korrelboom, 2012), adults with personality disorders (korrelboom, 2011), adults with eating disorders (korrelboom, 2009) and persons with anxiety (Staring e.a., 2016).


In clinical practice, one of the interventions that focus on treating SAD and improving self-esteem is drama therapy. Drama therapy is an experiential form of treatment that uses expression techniques, role play, improvisation, and in vivo experiments (Hooren van e.a. , 2017). Interventions that have an experiential foundation and use in-vivo experiments are suggested to improve treatment for SAD, since recent results suggest that patients have an impaired sharing of emotions on an affective level, but not on a cognitive level of processing (Morrison e.a., 2016; , Buhlman e.a., 2015; ). Drama therapy has beneficial effects in anxiety disorders (AD; Dadsestan, 2008; Dehnavi, 2014; Anari, 2014). It is recommended in the Dutch multidisciplinary guideline and the Dutch Standard of Care for AD (netwerk kwaliteitsontwikkeling GGZ, in prep.) Recently, a drama therapeutic intervention is developed that primarily focus on improving self-esteem (Hilderink, 2015). This is called the Drama therapeutic Self-esteem Intervention (DSI). DSI is promising, since patient satisfaction is high (Hilderink, 2017), professionals in mental health care are enthusiastic on integrating DSI in treatment for SAD, and results from a pilot show very large effects (Hilderink, 2015). The integration of drama therapy in clinical practice may suggest it has a firm evidence base. Unfortunately, research using sound designs is missing and therefore there is a lack of solid evidence for effectivity.

Drama therapeutic Self-esteem Intervention

DSI is a group intervention to strengthen effects of usual care. DSI focuses on awareness of negative self-image, collecting evidence for positive self-image, and experiencing alternative behaviour in line with a positive self-image (Hilderink, 2016). DSI is based on drama therapeutic theories and principles derived from CBT. Based on effect research (Hilderink, 2015), DSI seems to significantly improving Self-esteem (Cohen’s d 1,5).

DSI makes use of working methods that match the model of Emunah and Selman and are adjusted to the individual development of the client. Consensus-based research (Doomen, 2010) reveals that the Emunah Five phase model (1996) is a useful guideline in dealing with anxiety disorders. The five phases of Emanuh are: dramatic game, fictional role play, realistic role play, psychodrama and farewell ritual. These five phases are in line with the phases of Selman (1980) for changing perspectives. The ability to changing perspectives is the ability to empathize in another, as well as move in a different perspective about the same situation. By changing perspectives, you can include new information about yourself, the other or the situation. Selman’s research brings forth five phases of the ability to change perspective: egocentric, subjective, reflective, reciprocal and social perspective. Within dramatic therapy, working with perspective is one of the active ingredients. Promoting the change of perspective helps to change a negative self-image. After all, one can switch from perspective and thus to role and consider a situation from multiple perspectives, assess whether cognitions are realistic and re-evaluate them.

The DSI is a protocol-based individual offered to a closed group of six clients and consists of six 75-minute sessions. Per session there is a fixed program with a purpose and related exercises and homework assignments.

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