Competitive memory training

1. Introduction

Version followed: adult COMET for low self-esteem (negative self-image) as described in the published four-step protocol of Korrelboom, de Jong, Huijbrechts & Daansen (2009), group format, 7–8 weekly sessions. Two published adaptations are added and labelled: COMET for depression in people who hear derogatory voices (van der Gaag et al., 2012) and the Dutch youth version (Kuin & Peters, 2014, as reported by Kwakman et al., 2022). The current therapist manual (Korrelboom, COMET voor negatief zelfbeeld, 2nd ed., 2023) and client workbook (Verbeter uw zelfbeeld in 7 stappen, 2023) are not drawn on; session-level detail that only they contain is marked [uncertain].

Competitive Memory Training (COMET) is a short, manualised, transdiagnostic CBT procedure developed by Kees Korrelboom in the Netherlands. It is usually run as an add-on to whatever treatment the client is already receiving. It rests on Brewin's retrieval-competition account of CBT: therapy does not erase or directly change negative self-knowledge. It changes which of the competing self-representations is more easily retrieved from memory. Clients usually already know they have some good qualities, but that knowledge carries no emotional weight and loses out to the negative self-image. COMET works on three things that decide this competition. First, it makes the positive self-representation emotionally salient. Second, it rehearses that representation repeatedly. Third, it links the representation, by counterconditioning, to the situations that normally trigger self-criticism. The authors sum up the aim as "making patients feel what they already know" (Korrelboom et al., 2009). [source: Korrelboom et al. 2009, reprinted in de Jong 2021, Leiden; van der Gaag et al. 2012 abstract, RUG portal]

2. Framework

Format and dose (by version).

Eating disorders version: 8 weekly group sessions of about 1.5 h, 6–8 patients, two co-therapists (a clinical psychologist and an art therapist with no prior CBT training), plus daily homework, alongside treatment as usual (TAU). [source: Korrelboom et al. 2009]
Personality disorders version: 7 weekly group sessions alongside regular treatment. [source: Korrelboom, Marissen & van Assendelft 2011, abstract]
Anxiety disorders version: 6 sessions, delivered in a crossover trial against EMDR. Format detail is not drawn on. [source: Staring et al. 2016, portal abstract] [uncertain]
Voices version: 7 sessions, four stages. [source: van der Gaag et al. 2012]
Youth version (ages 8–18): 7 individual sessions plus 1 parent session, using a workbook. [source: Kwakman et al. 2022]
COMET-Y: 7 weekly sessions plus a parent psychoeducation session. [source: NCT06343740 listing]
One Dutch service runs adult groups as 7 weekly 2-hour closed-group sessions plus a booster session about a month later. This is a local service format, not necessarily the manual's. [source: GGZ WNB flyer]

Phases (the four steps of the adult protocol). [source: Korrelboom et al. 2009]

Step	Goal	Typical timing
1. Identify the negative self-image	The client briefly states what they believe is wrong with them, so the target the positive image must compete with is explicit.	Session 1 [inferred from 2009 timing of steps 3–4]
2. Identify a credible positive self-image	The client considers whether the negative image is entirely true, then names personal characteristics and concrete experiences that contradict it. This brings forward positive autobiographical memories.	Session 1 (into 2) [inferred]
3. Strengthen the positive self-image	Make it emotionally loaded and easier to retrieve through four components: written stories and self-statements, imagery, posture and facial expression, and self-chosen music.	Sessions 2–5, plus daily homework
4. Counterconditioning	Link the activated positive self-image to cues that usually trigger insecurity and self-criticism: activate the positive state, then imagine a trigger situation while keeping it. Repeat in session and at home.	Final sessions (about 6–8)

Criteria for moving on.

From source: in step 4, the client extends practice to new trigger scenes once a difficult scene "can be tolerated" while keeping the positive state. [source: Korrelboom et al. 2009]
My synthesis for the other transitions [synthesis]:
- 1→2 when the negative self-image is stated in one short sentence the client recognises as "how I see myself".
- 2→3 when at least one positive quality is rationally credible to the client (they agree it is true, even if it does not feel true) and is backed by several specific memories.
- 3→4 when the client can reliably call up a noticeable positive feeling within a minute or two, using the combined routine.
Because the protocol is fixed-length, groups move on by session number even if some members lag. Individual work can slow down. [synthesis]

Session shape. The manual's per-session agenda is not drawn on [uncertain]. The published descriptions imply three parts to each session [synthesis based on 2009]:

review of the daily homework;
introduction and in-session practice of the next component;
assignment of daily home practice.

Measurement used in the trials. The Rosenberg Self-Esteem Scale (RSES) was the main outcome. COMET-Y used RSES ≤15 as its entry criterion. A self-esteem measure at start and end is a sensible routine. [source: Korrelboom et al. 2009; NCT06343740] [synthesis]

Who it is for.

Adults (or youth) whose low self-esteem is a problem across diagnoses: eating, personality, depressive and anxiety disorders, psychosis with derogatory voices. [source: trials above]
One service's criteria: the client partly recognises that the negative self-image is not fully accurate, and is willing to do homework. [source: GGZ WNB flyer]
The youth manual lists poor imagination or abstract thinking (for example lower IQ, autism) as a contraindication, because the imagery exercises need them. Kwakman et al. argue this did not hold in their autistic sample. [source: Kwakman et al. 2022]
COMET-Y excluded young people in acute crisis, with acute suicidality or with psychosis. [source: NCT06343740]

3. Guiding principles

Compete, don't dispute. COMET does not try to disprove the negative self-image. It builds a rival representation and makes it win retrieval. In practice: don't get drawn into Socratic debate about "am I worthless?"; move the client to recalling and feeling counter-evidence. [source: Korrelboom et al. 2009, which contrasts COMET with Fennell's challenge-based approach]
Make them feel what they already know. The target is emotional conviction, not intellectual agreement. In practice: a positive quality the client accepts rationally is enough to start; the work is making it felt. [source: Korrelboom et al. 2009]
Credibility first. The positive self-image must be believable to the client and grounded in their own experiences. In practice: choose modest, concrete qualities ("I am loyal to friends") over global ones ("I am wonderful"). [source: Korrelboom et al. 2009, step 2 "credible positive self-image"]
Emotional salience. Representations with emotional charge are retrieved more easily. In practice: every rehearsal should produce a felt shift, using imagery, body, voice and music, not just reading a list. [source: Korrelboom et al. 2009]
Repetition. Retrieval advantage comes from many repetitions. In practice: daily homework is part of the treatment, not optional; build short, repeatable routines. [source: Korrelboom et al. 2009]
Association (counterconditioning). The positive representation must be activated in the presence of the cues that usually call up the negative one. In practice: pair the positive state with imagined trigger situations, and in the youth version with real ones. [source: Korrelboom et al. 2009; Kwakman et al. 2022]
Personalisation. Scenes, stories and music are the client's own. In practice: never assign a "standard" uplifting song or stock scene; the client picks music that fits their positive self-image. [source: Korrelboom et al. 2009]
Old learning is outcompeted, not erased. This follows from the retrieval-competition account [inferred]. In practice: tell clients the old self-criticism will still show up, and that the skill is calling up the competitor when it does.
Structured, stepwise, manualised and brief. In practice: keep to the step sequence and session count; it is designed to fit alongside other treatment and be delivered by therapists with modest CBT background. [source: Korrelboom et al. 2009, 2011]
Transdiagnostic add-on. In practice: coordinate with the client's main therapist; COMET targets self-esteem, not the full disorder. [source: Korrelboom et al. 2009, 2011]
Voices variant: reappraise, then disengage. Target the voice's power by strengthening self-esteem, then practise accepting voices as mental events. In practice: the aim is less distress from the voices, not fewer voices; the trial found depression improved but hallucinations did not change. [source: van der Gaag et al. 2012]
Youth variant: enlist the environment. Parents act as co-therapists who support practice at home. In practice: hold the parent session early (after session 3 in Kuin & Peters) and give parents concrete tasks. [source: Kwakman et al. 2022; NCT06343740]

4. Intervention inventory

The interventions below come from the published descriptions: core adult protocol, steps 1–4, then the voices and youth adaptations. The manual's exact exercise wording and forms are not drawn on. All steps are paraphrased, and all example language is my own. [source: Korrelboom et al. 2009 unless stated]

4.1 Rationale and psychoeducation (retrieval competition)

Purpose / when: Session 1, before step 1. It explains why the treatment trains feelings and memory access rather than arguing about the facts, and why daily practice matters. [source: rationale in Korrelboom et al. 2009; that it is delivered as explicit psychoeducation is inferred] [synthesis]
Steps:
1. Ask the client to notice that, when they think of themselves, the negative verdict comes to mind first and fast.
2. Explain that the mind holds more than one "file" about the self. The file that wins is the one that is most emotionally charged, most practised and most linked to everyday situations.
3. State the plan: build and charge up the positive file, practise it daily, then hook it to the situations that usually bring up the negative one.
4. Set expectations: the old view will not vanish; the aim is that it no longer always wins.
Example language (illustrative): "You already know a few good things about yourself; they just don't feel true. We're not going to argue with the critical voice. We're going to train the other side until it can compete."
Watch for: Hearing this as "think positive". Stress concrete memories and practice, not slogans. A client who rejects any positive file needs more time in step 2.

4.2 Formulating the negative self-image (step 1)

Purpose / when: Session 1. It names the target the new representation must compete with.
Steps:
1. Ask the client to describe briefly what they think is negative about themselves. Keep it short; this is not a full history.
2. Condense it into one or two short self-statements in the client's own words (e.g. "I'm a failure", "I'm not worth caring about").
3. Optionally rate how strongly it feels true (0–100) as a baseline [synthesis].
4. Youth version: phrase it as a fitting automatic negative thought and take stock of strong and weaker sides. [source: Kwakman et al. 2022]
5. Voices version: identify which aspects of negative self-esteem the voice content reinforces. [source: van der Gaag et al. 2012]
Example language (illustrative): "If the critical part of you summed you up in one sentence, what would it say?"
Watch for: Long problem narratives (redirect: "we only need the headline"). Distress on saying it aloud (validate, then move on). The statement should be self-evaluative ("I am…"), not situational.

4.3 Identifying a credible positive self-image (step 2)

Purpose / when: Session 1 (into 2). It produces the content of the competing representation: qualities that contradict the negative image, backed by real memories.
Steps:
1. Ask whether the negative image is entirely and always true.
2. Help the client name personal characteristics that contradict it. Choose qualities they can accept as at least partly true.
3. For each quality, collect specific experiences (when, where, what they did) that show it.
4. In a group, other members may contribute observations; the client decides what they accept [synthesis; group facilitation detail not in sources].
5. Formulate one to a few positive qualities to work with. Fewer, credible ones beat a long list [synthesis].
Example language (illustrative): "Is there any time, even small, when that 'I'm useless' story didn't fit? What did you actually do then?" / "Which of these would you sign as true, even if it doesn't feel it right now?"
Watch for: Disqualifying ("anyone would do that"). See section 5. Qualities that are really performance standards ("I'm perfect at work") can backfire in perfectionistic clients [synthesis]. Signs it is working: the client can name at least one quality plus two or three concrete episodes.

4.4 Self-referent stories (step 3a)

Purpose / when: Sessions 2–5 and daily homework. Written, specific episodes build retrievable, emotionally anchored evidence for each positive quality.
Steps:
1. For a chosen quality, the client writes a short story about a specific time it showed: setting, what they did, what happened, how it felt.
2. Write in the first person and in detail, so the episode can be relived rather than summarised [synthesis].
3. Collect stories daily as homework, adding new ones from the day (for example, "today I showed this when…") [synthesis based on daily homework in source].
4. Read stories back in session and help the client add sensory and emotional detail.
Example language (illustrative): "Write it as if you're replaying it: where were you, what did you say, what did you notice in yourself afterwards?"
Watch for: Stories that are lists of virtues, not episodes. Stories that end with a self-put-down ("…but it was nothing"); ask the client to stop at the point the quality showed. Signs it is working: stories get easier to write and more vivid.

4.5 Positive self-statements and self-verbalisation (step 3a)

Purpose / when: Alongside the stories. Each story is distilled into a short, believable self-statement that serves as a portable retrieval cue, later spoken aloud during activation.
Steps:
1. From the stories, the client distils one short self-statement per quality (e.g. "I'm someone who stands by people").
2. Check credibility; soften it if it is too grand ("I can be…", "I often…") [synthesis].
3. Practise saying it aloud with a convinced tone, linked to recalling one story [synthesis; youth version names "positive self-talk", Kwakman et al. 2022].
Example language (illustrative): "Say it like you're telling a friend something you know about yourself, not like you're reading a poster."
Watch for: A flat, mechanical delivery; add posture and imagery. A statement that triggers "yes, but" every time needs rewording.

4.6 Positive imagery (step 3b)

Purpose / when: Sessions 2–5 and daily. Imagining personalised scenes in which the positive qualities are present raises emotional salience.
Steps:
1. Pick a scene from a story, or a vivid image of oneself showing the quality.
2. Guide the client, eyes closed if comfortable, to enter it in the present tense and first person: surroundings, own actions, others' reactions, bodily feeling.
3. Help them dwell on the moment of feeling good about themselves; ask for a feeling rating [synthesis].
4. Practise until the client can call up the scene on their own in a minute or two; set daily home practice.
5. Youth version: activate a "proud" memory or image together with positive self-talk. [source: Kwakman et al. 2022]
6. Voices version: retrieve and relive memories linked to positive self-esteem. [source: van der Gaag et al. 2012]
Example language (illustrative): "Step back into that moment. What do you see around you? What are you doing? Notice what it feels like, right now, to be someone who did that."
Watch for: Negative memories intruding, or the scene turning into an evaluation. Gently return to the chosen moment and shorten it. Clients who cannot form images can use the written story read aloud plus music and posture (see section 5). Signs it is working: a visible affect shift, and the client reports a felt sense rather than "I know it happened".

4.7 Posture and facial expression (step 3c)

Purpose / when: Sessions 2–5 and daily. Deliberately adopting a posture and facial expression that fit the positive self-image adds a bodily retrieval cue and amplifies the feeling.
Steps:
1. Ask the client how someone who truly believed the positive statement would sit or stand, hold their head, look and breathe.
2. Have them adopt it: for example, upright, shoulders open, head up, steady gaze, a slight smile if it fits [synthesis on specifics].
3. Contrast it briefly with their usual "self-critical" posture so they feel the difference [synthesis].
4. Combine it with the self-statement and imagery; practise daily.
5. Youth version: link the positive posture and music to a memory. [source: Kwakman et al. 2022]
Example language (illustrative): "Let's try the posture of the person in that story. Sit the way you sat when you were proud of that. Now say your sentence from there."
Watch for: Embarrassment, especially in groups. Normalise it, have everyone do it at once, and let people start small. Physical limitations: adapt to what is comfortable.

4.8 Self-chosen music (step 3d)

Purpose / when: Sessions 2–5 and daily. A personally chosen piece of music that fits the positive self-image acts as an emotional amplifier and a cue the client can carry anywhere.
Steps:
1. Between sessions, the client picks a piece of music that, for them, fits the positive self-image (makes them feel capable, worthwhile, proud).
2. Play it in session (or the client plays it on their phone) while they hold the posture, picture the scene and say the statement.
3. Use the same piece consistently so it becomes a conditioned cue [synthesis].
4. Youth version: also photos that bring a good feeling. [source: Kwakman et al. 2022]
Example language (illustrative): "Choose a track that sounds like the 'you' in your stories, not just one you like. Bring it next week."
Watch for: Music tied to loss, a former partner or rumination. Ask what memories it brings and switch if needed. Lyrics that clash with the self-statement.

4.9 Combined activation routine

Purpose / when: End of step 3 and the start of every step-4 exercise. All components are stacked to produce the positive state quickly and reliably.
Steps:
1. Start the music.
2. Adopt the posture and facial expression.
3. Bring up the imagery scene.
4. Say the self-statement(s) aloud.
5. Stay with the feeling for a short while and rate it.
6. Rehearse daily until the client can enter the state in a minute or two [synthesis on timing]. (The component list is from the source; the order is my synthesis.)
Example language (illustrative): "Music on, sit up, step into your scene, and tell yourself your sentence. How strong is that feeling now, 0 to 10?"
Watch for: Activation that stays weak. Go back to the strongest single component. Signs it is working: a rising, reproducible feeling rating.

4.10 Counterconditioning in imagination (step 4)

Purpose / when: Final sessions (about 6–8) and daily homework. It associates the positive self-image with the cues that normally trigger insecurity and self-criticism, so that those cues start to call up the competitor.
Steps:
1. Build a short list of personal trigger situations, ranked from mildly to strongly insecure [synthesis: the source implies grading by "once a difficult scene can be tolerated"].
2. Activate the positive state fully with the combined routine (4.9).
3. While still in that state, picture a trigger situation (for example, being criticised, entering a room of strangers, looking in a mirror) and try to keep the positive posture, statement and feeling.
4. If the negative state takes over, stop the scene, re-activate the positive state, and return to the scene, shortening it or making it milder if needed [synthesis].
5. Repeat several times in session and daily at home.
6. Once a scene can be tolerated while staying confident, move to the next, more difficult scene.
Example language (illustrative): "Keep the music and the posture. Now, as that confident 'you', walk into the meeting where you usually shrink. Stay in your body and your sentence. What happens?"
Watch for: Overwhelm or flooding with old shame. This is not trauma exposure; step down the hierarchy. Signs it is working: the scene evokes less self-criticism, and the client reports the positive feeling holding, or recovering faster, during the image and then in real situations.

4.11 Daily home practice

Purpose / when: Every week. Repetition is one of the three active processes; homework covers steps 3 and 4.
Steps:
1. Agree a short daily routine: write one new story or add to an old one, and run the combined activation once or twice.
2. In step 4, add one or more counterconditioning rehearsals.
3. The client keeps a simple log (done/not done, feeling rating) [synthesis; Korrelboom et al. 2009 note that homework compliance was not formally checked, a limitation].
4. Review the log at the start of each session.
5. Optional client support: the client workbook. [source: Korrelboom 2023 workbook listing; its contents are uncertain]
Example language (illustrative): "Ten minutes a day is the dose. What time and place will make it happen?"
Watch for: Non-adherence; see section 5.

4.12 Relapse prevention and booster

Purpose / when: The last session and an optional follow-up. It prepares for future self-critical moments and keeps practice going.
Steps:
1. Anticipate high-risk situations.
2. Write a short personal plan: the cues that signal the old self-image, the activation routine to use, and the counterconditioning practice to resume.
3. Youth version: "EHBO" (first aid) session. The young person keeps practising counterconditioning and talks through expected difficult moments. [source: Kwakman et al. 2022]
4. Some services add a booster session about one month later. [source: GGZ WNB flyer]
- The adult manual's relapse-prevention content is not drawn on. [uncertain]
Example language (illustrative): "When the old sentence shows up next month, what's your first-aid routine?"
Watch for: Stopping all practice once the client feels better [synthesis].

Adaptation: COMET for depression with derogatory voices (van der Gaag et al. 2012)

This version has seven sessions in four stages:

Identify the aspects of negative self-esteem the voices confirm (as in 4.2).
Retrieve and relive memories of positive self-esteem (as in 4.3–4.9).
Bring the positive self-esteem in to compete with the voice content (4.13).
Learn to disengage from voices and accept them as mental phenomena (4.14).

The trial found depression improved, mediated by self-esteem and acceptance of voices; hallucination severity did not change. Session-by-session wording was not available (the full text is embargoed). [source: van der Gaag et al. 2012 abstract, RUG portal] [uncertain on detail]

4.13 Competing with voice content

Purpose / when: Stage 3 of the voices version. It weakens the link between what the voice says and the client's self-evaluation.
Steps:
1. Activate the positive self-esteem state.
2. Then bring to mind (or wait for) typical voice content, and hold the positive state while hearing it.
3. Repeat, as in 4.10.
- This is my reconstruction from the stage description. [synthesis]
Example language (illustrative): "From that steady place, let the voice say its usual line. You don't need to answer it; notice whether it still has the same grip."
Watch for: Increased voice activity or fear. Keep practice short, and check safety and command content. Signs it is working: the client rates the voice as less powerful and less believable.

4.14 Disengaging from and accepting voices

Purpose / when: Stage 4 of the voices version. It reduces the voices' emotional impact by relating to them as mental events rather than authorities.
Steps:
1. Normalise voices as products of one's own mind.
2. Practise noticing a voice, labelling it ("there's the voice again"), and returning attention to the current task or the positive state, without arguing or obeying.
- The specific method is not described in the sources; these steps are my synthesis. [synthesis] [uncertain]
Example language (illustrative): "It's a voice, not a verdict. Notice it, name it, and bring your attention back."
Watch for: Distress when the client attempts acceptance. Coordinate with their psychosis care team.

Youth adaptation: Kuin & Peters (2014) "Werken aan je zelfbeeld" (ages 8–18)

This version has 7 individual sessions with a workbook, plus a parent session after session 3. Session topics [source: Kwakman et al. 2022]:

Formulate the negative thought and take stock of strong and weaker sides.
Break the negative attention bias and strengthen positive traits.
Activate a proud memory with positive self-talk.
Link posture and music to the memory; exposure to tense situations by acting confident.
Negative comparison with others, followed by positive recall.
Stay self-assured while feeling a negative memory.
"EHBO" (first aid).

The youth-specific techniques follow.

4.15 Positive attention training (youth)

Purpose / when: Session 2. It breaks the habit of noticing only negatives.
Steps:
1. Search exercises: find positive pictures in magazines or newspapers, positive words in a text, and positive traits hidden in a negative story. [source: Kwakman et al. 2022]
2. Then turn the same search onto oneself ("find three good things you did this week") [synthesis].
Example language (illustrative): "This story sounds all bad. Can you be a detective and find the good qualities hidden in it?"
Watch for: The child treating it as a test. Keep it playful.

4.16 Positive diary (youth)

Purpose / when: From session 2, daily. It records what went well each day, supported by positive memories. [source: Kwakman et al. 2022]
Steps:
1. Each evening, write one to three things that went well and which quality they show [synthesis on the format].
2. Parents can add compliments they gave (see 4.17).
Watch for: Entries that are only about external events ("it was sunny"). Prompt for the child's own part.

4.17 Parent session and parents as co-therapists (youth)

Purpose / when: After session 3 (Kuin & Peters); an added psychoeducation session in COMET-Y. It explains the treatment and how parents influence self-esteem, and recruits them to support practice at home. [source: Kwakman et al. 2022; NCT06343740]
Steps:
1. Explain the treatment course and what to pay attention to at home.
2. Ask parents to give specific compliments that name a quality and write them down.
3. Ask them to support homework without taking it over.
Example language (illustrative): "Name the quality, not just the result: 'That was kind of you to wait for your brother' rather than 'good job'."
Watch for: Parental criticism undermining the work [synthesis]. If it continues, address it in family work.

4.18 Acting confident in real tense situations (youth)

Purpose / when: Session 4 onwards. It transfers the posture and music link into real life through exposure to tense situations while "pretending" to be self-confident. [source: Kwakman et al. 2022]
Steps:
1. Choose a mildly tense real situation.
2. Activate the positive state beforehand (posture, music, memory).
3. Enter the situation and act as if confident.
4. Review it afterwards.
- Grading and review are my synthesis.
Example language (illustrative): "You don't have to feel brave; just act as if you are for five minutes, and we'll see what happens."
Watch for: Situations with real bullying risk. Choose safe ones and involve school if needed. [synthesis]

4.19 Comparison followed by positive recall (youth)

Purpose / when: Session 5. It practises recovering from negative social comparison by calling up positive memories. [source: Kwakman et al. 2022]
Steps:
1. Briefly evoke a typical unfavourable comparison with someone else.
2. Then deliberately switch to a positive memory and the activation routine.
- The details of the switch are my synthesis.
Watch for: The comparison step running long. Keep it brief; the training target is the switch.

4.20 Staying self-assured while feeling a negative memory (youth)

Purpose / when: Session 6. This is the youth counterconditioning step. [source: Kwakman et al. 2022]
Steps: As in 4.10. Activate the positive state, then hold it while bringing up a mildly negative memory; grade upward. [synthesis on grading]
Watch for: Traumatic memories. Do not use these. [synthesis]

Other published applications (procedures not drawn on)

COMET has also been applied to obsessions (Korrelboom et al. 2008 pilot; a self-help format by Schneider et al. 2015), to panic (compared with applied relaxation, Korrelboom et al. 2014), to rumination in depressed older adults (Ekkers et al. 2011), to cancer-related PTSD (7 weekly sessions, Farahimanesh et al. 2021), and as a single-session imagery procedure for positive memories in experiments (Utrecht, NL-OMON46647). Their specific competing representations and steps are not drawn on here; do not adapt them from this guide without the original papers. [uncertain]

5. Handling problems

The sources give little guidance on problems. Unless a source is tagged, everything below is my synthesis, derived from COMET's retrieval-competition logic. [synthesis]

"I have no good qualities" (stuck in step 2).
- Lower the bar: ask for behaviours, not traits ("times you helped someone"), and for small, partial or past examples.
- Use informants: the group, or a trusted person's view, which the client then tests against memory.
- Accept a quality the client agrees with only "rationally". The protocol aims to make felt what is already known, so felt belief is not required at the start. [source for that point: Korrelboom et al. 2009]
- If nothing is credible after two sessions, review suitability. One service requires partial recognition that the negative image is inaccurate. [source: GGZ WNB flyer]
"Yes, but" disqualification. Don't debate it; COMET competes rather than disputes. Note the "but" as the old file speaking. Return to sensory detail of the episode and to the bodily components. Make the statement more modest so it survives the "but".
Feels fake or silly (posture, music, saying statements aloud).
- Explain that it is meant to feel unnatural at first, like practising a new skill.
- Model the exercise yourself, and have the whole group do it at once.
- Start privately at home, or use a smaller version (sitting upright, music on headphones).
Imagery difficulties.
- The youth manual treats poor imagination or abstract thinking as a contraindication; Kwakman et al. found the youth version feasible in autistic children. [source: Kwakman et al. 2022]
- Workarounds: concrete cues (photos, objects, the written story read aloud), more emphasis on music, posture and self-talk, and short, eyes-open practice.
Negative intrusions during positive imagery. Common, and consistent with the model. Label the intrusion as "the old file competing", re-engage the strongest cue (music, posture), shorten the scene, and choose a safer memory. Avoid memories tied to people who later hurt the client.
Overwhelm in counterconditioning. Stop the scene and re-activate the positive state. Drop to a milder scene, and use shorter exposures with more repetitions. Move up only once a scene is tolerated. [grading principle from Korrelboom et al. 2009]
Trauma memories surfacing. COMET is not trauma processing. Contain the material, ground the client, and refer to or coordinate with trauma-focused treatment.
- In anxiety patients, COMET outperformed EMDR on self-esteem, and doing EMDR first reduced the later benefit of COMET. [source: Staring et al. 2016 abstract]
- This is a trial finding, not a sequencing rule. Its clinical implication (consider COMET first when the target is self-esteem rather than trauma) is my inference. [uncertain]
Non-adherence to daily practice. Problem-solve when and where it will happen; shrink it to a two-minute minimum version; use phone reminders and keep music and a statement card on the phone. Check the log every session. If practice is never done, discuss whether now is the right time. Low self-esteem itself ("it won't work for me") often drives non-adherence: treat that as content for the exercises.
Group difficulties.
- Social comparison ("others have better qualities"): name it as the same mechanism and use it as practice material (compare youth session 5). [source for the session topic: Kwakman et al. 2022]
- Dominant members, or members who reassure too much: set a rule that only the person decides what is true of them.
- Absences: give a catch-up handout or brief phone call so the member can rejoin the step sequence.
Ruptures (client feels dismissed: "you just want me to think positive").
- Validate the pain behind the negative self-image.
- Re-explain the rationale: the aim is not denial but access to an existing, balanced picture.
- Invite the client's view of which qualities are realistic. Acknowledge any pace mismatch, and slow down within the structure.
Perfectionism and conditional worth. Qualities framed as achievement can strengthen "I'm only OK if I perform". Steer toward relational and character qualities (kindness, loyalty, persistence) and toward "good enough" episodes.
Depression, suicidality and risk. COMET runs alongside regular care. Screen for suicidal ideation at intake and routinely, following your service's standard risk assessment and safety-planning procedures. COMET-Y excluded acute crisis and acute suicidality, and these call for crisis care first. [source for the exclusions: NCT06343740]
Voices variant problems.
- Voices may escalate, or threaten, when the client attempts competition or acceptance. Keep exercises brief, check for command hallucinations and risk, and coordinate with the psychosis team.
- Set the expectation that the goal is less distress and depression, not fewer voices. [source: van der Gaag et al. 2012 findings]
Youth-specific. Low motivation, or parents who criticise: involve parents early. Keep exercises playful and short. Ask the school to collaborate on real-life confidence practice when bullying is involved.
Relapse after treatment. Resume the daily routine and counterconditioning for the new triggers. Offer a booster session (one service routinely schedules one at about one month). [source: GGZ WNB flyer]

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