TYPE Clinical Trial

PUBLISHED 29 May 2024

DOI 10.3389/fpsyt.2024.1360388

Psychological intervention in
OPEN ACCESS women victims of childhood
EDITED BY
İbrahim Gündoğmuş,
Ankara Etlik City Hospital, Türkiye
sexual abuse: a randomized
REVIEWED BY
Derin Kubilay,
controlled clinical trial
Bahçeşehir University, Türkiye
Esra Yalım,
Gulhane Training and Research Hospital,
comparing EMDR psychotherapy
Türkiye

*CORRESPONDENCE
and trauma-focused cognitive
Marı´a Jesús Hernández-Jiménez
mariajesus.hernandez@ behavioral therapy
professor.universidadviu.com

RECEIVED 22 December 2023 Milagros Molero-Zafra 1, Olga Fernández-Garcı́a 1,

ACCEPTED 03 May 2024
PUBLISHED 29 May 2024 Marı́a Teresa Mitjans-Lafont 2, Marián Pérez-Marı́n 1
CITATION and Marı́a Jesús Hernández-Jiménez 2*
Molero-Zafra M, Fernández-Garcı´a O,
Mitjans-Lafont MT, Pérez-Marı´n M and
1
Faculty of Psychology, University of Valencia, Valencia, Spain, 2 Health Sciences Area, Valencian
Hernández-Jiménez MJ (2024) Psychological International University, Valencia, Spain
intervention in women victims of childhood
sexual abuse: a randomized controlled
clinical trial comparing EMDR psychotherapy
and trauma-focused cognitive Introduction: Childhood sexual abuse persists as a painful societal reality,
behavioral therapy. necessitating responses from institutions and healthcare professionals to
Front. Psychiatry 15:1360388.
prevent and address its severe long-term consequences in victims. This study
doi: 10.3389/fpsyt.2024.1360388
implements an intervention comprising two psychotherapeutic approaches
COPYRIGHT
© 2024 Molero-Zafra, Fernández-Garcı´a, recommended by the WHO and international clinical guidelines for addressing
Mitjans-Lafont, Pérez-Marı´n and short-, medium-, and long-term posttraumatic symptomatology: Trauma-
Hernández-Jiménez. This is an open-access
Focused Cognitive Behavioral Therapy (TF-CBT) and Eye Movement
article distributed under the terms of the
Creative Commons Attribution License (CC BY). Desensitization and Reprocessing (EMDR). Both approaches are adapted from
The use, distribution or reproduction in other group formats for implementation in small online groups via Zoom.
forums is permitted, provided the original
author(s) and the copyright owner(s) are
credited and that the original publication in Methods: The impact of both therapeutic approaches on trauma improvement
this journal is cited, in accordance with was assessed in a sample of 19 women who were victims of childhood sexual
accepted academic practice. No use,
distribution or reproduction is permitted abuse through a Randomized Clinical Trial comparing EMDR Psychotherapy and
which does not comply with these terms. Trauma-Focused Cognitive Behavioral Therapy after a baseline period. Intra and
inter comparison were made using statistics appropriate to the sample.

Results: Both therapeutic approaches significantly reduced symptomatology

across various evaluated variables, suggesting their efficacy in improving the
quality of life for these individuals. Following CBT-FT treatment, patients
exhibited enhanced emotional regulation, reduced reexperiencing, and
avoidance. The EMDR group, utilizing the G-TEP group protocol, significantly
improved dissociation, along with other crucial clinical variables and the
perception of quality of life.

Discussion: Although the limitations of this study must be taken into account due
to the size of the sample and the lack of long-term follow-up, the results align
with existing scientific literature, underscoring the benefits of trauma-focused
psychological treatments. The online group format appears promising for
enhancing the accessibility of psychological treatment for these women.

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Molero-Zafra et al. 10.3389/fpsyt.2024.1360388

Furthermore, the differential outcomes of each treatment support recent

research advocating for the inclusion of both approaches for individuals with
trauma-related symptomatology.

Ethics and dissemination: The study has been approved by the Ethics
Committee of the Valencian International University (VIU) (Valencia, Spain) (Ref.
CEID2021_07). The results will be submitted for publication in peer-reviewed
journals and disseminated to the scientific community.

Clinical trial registration: https://clinicaltrials.gov/ct2/show/NCT04813224,

identifier NCT04813224.

KEYWORDS

childhood sexual abuse, women, EMDR, G-TEP, TF-CBT, randomized clinical trial, group
psychotherapy, online psychotherapy

1 Introduction between ages 11 and 13, it influences the development of the

hippocampus, crucial in this developmental period; the impact at
Sexual abuse in childhood has been and continues to be a painful ages 14 to 16 affects the development of the prefrontal cortex (17).
reality in our society, demanding responses from institutions and The affected neural processes in individuals who have experienced
health professionals concerning its prevention and the treatment of abuse, neglect, and child maltreatment are primarily found in the
its severe long-term consequences for victims (1). Each year, tens of fronto-limbic networks, including the medial prefrontal cortex,
thousands of cases of child sexual abuse (hereinafter CSA) are orbitofrontal cortex, anterior cingulate cortex, hippocampus, and
reported (2). Pereda & Abad (3) indicate that CSA is one of the amygdala, with neglect related to changes in the development of
interpersonal victimization situations most strongly associated with insula activation during risk processing and abuse related to
psychological problems affecting all levels of an individual’s changes in fronto-parietal activation during cognitive control
functioning throughout life, leading to significant repercussions in (18). These studies also show that a smaller volume and altered
adulthood (4, 5) and attracting substantial research attention. In this activity patterns have been observed in the ventromedial region of
context, the analysis of sexual abuse contributes to a profound the prefrontal cortex in children with PTSD, suggesting the
understanding of the phenomenon, guiding practices more involvement of frontal lobe circuits in altered fear extinction
effectively to address it (6). characteristics, affecting fear conditioning and learning, with
It is documented that child maltreatment (specifically, physical, significant implications for subsequent development and
sexual, and emotional abuse, as well as physical and emotional consequences in adulthood.
neglect) exerts a high-impact influence on the development of the It is important to consider all these data from recent research in
child’s brain (7) and constitutes a significant risk factor for adult neuroscience, which even indicate differential effects between
psychopathology (8). The effects of this traumatic experience during neglect and abuse regarding risk processing. Neglect appears to
developmental stages often manifest in post-traumatic symptoms, impact more on neurodevelopment, harming the risk assessment
post-traumatic stress disorder (PTSD), sleep problems, anxiety, system, while the effects of abuse on neurodevelopment involve an
depression, substance abuse, difficulties in sexual functioning, low acceleration of the risk control system (18). Adult individuals who
self-esteem, and challenges in accepting one’s own body, among were victims of childhood sexual abuse have been exposed to both
others (9–16). However, there is limited literature on the the experience of abuse and neglect, potentially presenting this
implementation of specific psychological treatments with combined impact materializing in poor emotional regulation
randomization procedures for this population. strategies that generate difficulties at the relational level. When
Recent studies have shown a specific impact on brain this combination of neglect and abuse occurs, more disruptive
development due to abuse, maltreatment, and neglect during symptomatology in functioning has been found, associated with
childhood, with differential effects across developmental stages. hypoactivation in various higher-order cortical regions, as well as in
Specifically, when experienced between ages 3 and 5, there is a the amygdala (19). These neurocognitive functioning characteristics
greater vulnerability to subsequent dissociation and PTSD; influence their greater vulnerability to revictimization (20, 21),
exposure to abuse and neglect between ages 10 and 11 affects the representing a lifelong journey for them with a continuous stress
development of the amygdala; when these experiences occur burden related to abuse.

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These pieces of evidence regarding the impact of childhood TF-CBT has increasingly been used in a group format,
sexual abuse on adult life functioning and its implication at the extending its application to adults who have experienced
neurodevelopmental level provide valuable information for childhood sexual abuse. Authors like Deblinger, Pollio & Dorsey
effectively intervening in symptoms resulting from this neuro- (45) and Bass et al. (46) assert that its application in adults and
emotional interference caused by trauma. Therefore, the therapies group therapy is appealing because it can be highly effective and
of choice for these individuals must address the impact of the event potentially reach a larger number of individuals simultaneously.
in a way that can effectively repair the post-traumatic impact, such Furthermore, group TF-CBT therapy can be particularly valuable in
as Eye Movement Desensitization and Reprocessing (EMDR) (22– reducing feelings of shame, isolation, and stigma experienced by
25) and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) victims after traumatic events (47).
(26–28). As for the second chosen therapeutic modality, Eye Movement
Given all this, the design of an intervention is proposed that Desensitization and Reprocessing Psychotherapy (EMDR), it
includes these two main psychotherapeutic approaches was developed by Shapiro (48, 49). As has already been indicated,
recommended by the WHO and other international clinical EMDR is one of the transdiagnostic therapy models recommended
guidelines for the treatment of short-, medium-, and long-term in international guidelines for addressing the aftermath of traumatic
post-traumatic symptomatology (29), International Society for the life experiences. Recently, positive impacts on the neurobiology of
Study of Trauma and Dissociation (30): Trauma-Focused Cognitive post-traumatic stress disorder have been studied (50). This trauma-
Behavioral Therapy (TF-CBT) and EMDR, both adapted from focused psychotherapeutic approach is recognized by various
group formats to be carried out in small groups through telematic clinical associations and international guidelines for treating
intervention via Zoom. This group and telematic format offer the trauma, life adversities, and psychological stressors (30, 44). The
possibility of reaching more people, being easily accessible, and World Health Organization (WHO) includes EMDR among the
less costly. recommended treatments for post-traumatic stress disorder (51).
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an EMDR is currently a psychotherapeutic model that allows
evidence-based treatment model designed to address post- access to disturbing and traumatic life events, along with current
traumatic symptoms. It can be implemented in group settings triggers and future projected experiences. These are reprocessed
and online, offering substantial assistance to patients (children, with adaptive resolution (52). This approach is based on working
adolescents, and young individuals) and their families in with the processing of traumatic experiences contributing to the
overcoming symptoms resulting from exposure to traumatic patient’s symptoms, with memory being the central element of
experiences (31). With extensive research supporting its efficacy, therapy. It involves working with all aspects of the traumatic
TF-CBT is now widely acknowledged as a well-established experience, including imagination, beliefs, affect, and bodily
intervention for treating post-traumatic stress and associated sensations, using dual attention stimulation through eye
symptoms (28, 32–38). movements or bilateral tactile or auditory stimulation.
TF-CBT integrates components from various theoretical The standardized basic protocol consists of eight treatment
perspectives, including attachment theory and humanistic phases: Phase 1 for assessment and conceptualization, Phase 2 for
approaches. The influence of attachment theory is evident in the preparation, Phase 3 for assessing the target event, Phase 4 for
emphasis on involving a supportive caregiver, such as a partner, processing, Phase 5 for installing an adaptive belief for the event,
another family member, or a friend. This approach results in stress Phase 6 for body check, Phase 7 for closure, and Phase 8 for
reduction for the victim and improved recovery. Additionally, the reevaluation. Phases 1 and 2 begin in the initial sessions and
humanistic approach in the clinician-child relationship is valued continue throughout the treatment process, allowing for the
and essential for successfully implementing TF-CBT techniques completion of case conceptualization as the selected events are
(39, 40). worked on, using stabilization tools to manage emerging issues in
The TF-CBT approach aims to: (1) explore the impact of the therapy process. Phases 3 to 8 are conducted with each event
intrafamilial childhood sexual abuse, (2) develop the victim’s (traumatic memories or those related to symptoms and present
sense of self-efficacy (empowerment), and (3) understand the situations triggering them), following a working sequence
repercussions on the behavior of minors and their social and established after Phases 1 and 2 based on the diagnostic
family relationships. This therapy assists individuals in hypothesis and the individual’s specific clinical needs.
questioning and modifying dysfunctional cognitions associated Although EMDR relies on the basic protocol described above, it
with trauma (41). can be modified and adapted to particular situations. Specific
Central components of TF-CBT include Psychoeducation, protocols have been developed for working with different clinical
Relaxation, Affective Regulation (affective analysis and emotional conditions and addressing complex traumatization and dissociation
modulation training), Cognitive Processing of trauma, Trauma in recent years. Of particular interest for this study is the adaptation
Narration, Desensitization of experiences associated with trauma for recent traumatic events, crises or emergencies, and ongoing
memories, and Enhancement of safety and future development stress. The Recent Traumatic Event Protocol (52) was adapted and
(39). Psychoeducation about common reactions to trauma is a key further improved by Elan Shapiro (53) to address the differences in
feature of all TF-CBT therapies, aiming to normalize individual post-traumatic symptom expression when the event has not yet
symptoms and justify subsequent interventions (42–44). consolidated in long-term memory. Subsequently, versions of this

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approach have been developed to enhance the effectiveness of Phase 2) Preparation for the treatment of the traumatic event,
treatment for post-traumatic stress in group interventions. including psychoeducation and regulation strategies. Resources to
Elan Shapiro developed the Group Traumatic Events Protocol be used in later reprocessing phases are also prepared. The 4
(G-TEP) to formulate a group protocol incorporating the strengths Elements exercise is introduced, along with drawing a resource or
of EMDR and the AIP model, containing key elements of the symbol of a calming place, and installing positive feelings with EBL.
individual protocol. G-TEP is an adaptation of the Recent Phases 3-6: Conducted following the G-TEP worksheet,
Traumatic Event Protocol (R-TEP) for use with groups of adults, providing safety (safe place, past resource, desired future, timeline
older children, and adolescents who have had recent traumatic structure), control, order, and differentiation between past danger
experiences or events that have long-term life-changing and present safety. The EMD strategy establishes containment
consequences that are not necessarily recent. It requires a limits for the present T Episode.
simplified and structured worksheet format suitable for quick Phase 7) Closing the session period: A group debriefing of the
assimilation and effective use with groups or individuals (54). experience is conducted, and some of the stabilization exercises
In response to a surge in requests for mental health care prepared in Phase 2 (4 Elements and the container) are performed.
following natural disasters, Jarero and Artigas developed the This facilitates the patient’s transition from associative channels
EMDR-Group Trauma Protocol (EMDR-IGTP) (55). EMDR- activated by focusing on the traumatic event to the closing phase.
IGTP has been used with children and adults worldwide, with Phase 8) Reevaluation: This phase takes place immediately after
numerous studies reporting its effectiveness in response to disasters, the group intervention. It assesses which participants may require
ongoing war trauma, ongoing geopolitical crises, war refugee additional individual attention and which may need further
displacement, workplace accidents, and severe partner violence evaluation to identify the nature and scope of their symptoms.
(56). These authors have subsequently developed adaptations of The literature highlights several effective psychological
these group protocols for the treatment of pathogenic memories, therapies for post-traumatic stress disorder (PTSD), including
such as childhood sexual abuse, resulting in chronic long-term various exposure therapy modalities, trauma-focused cognitive-
symptoms related to the impact of the accumulation of stressors behavioral therapy (TF-CBT), and eye movement desensitization
over time, hindering the consolidation of such memories into long- and reprocessing (EMDR) (66–68). These therapies share central
term memory (57, 58). elements aimed at assisting individuals in processing traumatic
The impact of trauma exposure is cumulative in nature (9). The memories, cognitions, and attributions, collectively known as
accumulated effects of a previous trauma may be associated with trauma-focused psychological therapies (42, 44, 66, 69). Both TF-
more severe emotional responses to subsequent trauma (59, 60). For CBT and EMDR are recommended by the UK National Institute for
Stevens, Eagle, Kaminer, & Higson-Smith (61), the existing Health and Care Excellence (NICE) guidelines for treating PTSD in
conceptualization of traumatic stress, such as PTSD and complex child and adult populations, with a common form being a cycle of
PTSD, may have limited utility for continuous danger and threats, eight to 12 individual outpatient sessions of TF-CBT or EMDR (44).
given the notion that trauma exposure is localized in the past. The general objective of this study is to assess the effectiveness
Therefore, it does not capture the daily experiences of continuous of trauma-focused treatments in adult women who are victims of
traumatic stress without safe spaces for protection and childhood sexual abuse. Specifically, it addresses the impact of
recovery (62). trauma related to childhood and adolescent sexual abuse in adult
In recent years, studies have been published on the application victims, proposing the design and implementation of two group
of these protocols initially developed for recent events in treatment programs based on EMDR and Trauma-Focused
populations with post-traumatic symptoms related to Cognitive Behavioral Therapy. The study provides evidence of the
developmental trauma and chronic sequelae that retraumatize the benefits of both therapies in reducing symptoms that hinder
individual (63). There is also evidence that women who have functioning in various areas of adult life, along with a
experienced CSA benefit from these interventions, improving comparative analysis of their effectiveness in this population.
their symptoms of post-traumatic stress, anxiety, and depression Based on this general objective, the following hypotheses
(63, 64). are proposed:
For the current study, the G-TEP (54) and the individualized
Protocol for Stabilization for Acute Stress (EMDR-PESEA) (65)
were implemented. The individual application addressed potential 1.1 Intrasubject hypotheses
destabilization within the group dynamic, necessitating
personalized regulatory sessions for subsequent reintegration into 1) Between T1 and T2, considering only the temporal progression,
the collective setting. it is expected that there will be no change in the overall analyzed sample
The implemented intervention is outlined as follows: or in the two treatment groups analyzed separately regarding health
Phase 1) Client history before Session 1: An online assessment and well-being indicators in the studied variables (life satisfaction, self-
session is conducted using the LimeSurvey assessment tool, esteem, psychopathological symptoms).
encompassing all subsequent measurement variables. This was 2) Between T1 and/or T2 and T3, after receiving one of the two
executed on Zoom in small groups to account for potential study intervention protocols (EMDR or TF-CBT), an improvement
destabilization during trauma-related questioning. is expected in health and well-being indicators in the studied

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variables, both in the overall analyzed sample and in each of the two TABLE 1 Procedure timeline.
treatment groups analyzed separately. A statistically significant
T1 Initial symptomatology assessment: 1st Baseline
increase (p <0.05) is expected in life satisfaction and self-esteem,
and a statistically significant reduction (p <0.05) is expected in 8 Randomized distribution in the two treatment conditions: CBT
weeks - EMDR
psychopathological symptoms.
T2 Symptomatology assessment: 2nd Baseline

8 CBT vs. EMDR Treatment

1.2 Intersubject hypotheses weeks

T3 Post-treatment assessment
3) At T1 and T2, it is expected that both groups (EMDR and TF-
CBT) will exhibit similar scores (no statistically significant differences)
in health and well-being indicators related to the studied variables (life approved by the Ethics Committee (CEISH) of the Valencian
satisfaction, self-esteem, psychopathological symptoms). This ensures International University (VIU) (Ref. CEID2021_07).
that both groups are homogeneously comparable. Each participant receives information about the study’s purpose
4) At T3, differences are expected based on the type of treatment and procedures and provides written consent. The psychologist
received, either EMDR or TF-CBT psychotherapy. It is expected specialist researcher obtains consent and assent. The data is
that one of the two treatments will result in a significantly greater confidential and anonymous and is used solely for the study.
improvement in health and well-being indicators than the other Numeric codes will link each participant’s identifying
treatment group (higher life satisfaction and self-esteem, lower information. Data collected is stored in a locker at the principal
psychopathological symptoms). investigator’s workplace, and the electronic data is password-
protected on the university network computer. Any modifications
to the protocol will be recorded on ClinicalTrials.gov (accessed on
2 Methods 16th June 2022). Clinical Trial registration number: NCT04813224.
Informed consent is available at Clinical Trial registration. https://
2.1 Design clinicaltrials.gov/ct2/show/NCT04813224.
For women’s participation in the study, connections were
Following the CONSORT guidelines (70), which offer evidence- established with organizations, particularly the non-profit entity
based recommendations for randomized trials, a Randomized ACASI (Association against Childhood Sexual Abuse). ACASI
Controlled Trial (RCT) is proposed, without a control group, with offers support and psychological assistance to adults who are
participants assigned to two types of treatment: 1) TF-CBT, 2) EMDR. victims of childhood sexual abuse.
Following the initial assessment (T1), participants are randomly Participants are informed of the evaluation and intervention
assigned to one of the two treatment groups. Subsequently, after an protocol, provided informed consent, and committed to
interval equivalent to the duration of the intervention protocols, a re- confidentiality. Therapy sessions for both intervention protocols
evaluation is conducted to measure changes in participants who have were conducted in a group and online format (via the Zoom video
not yet received treatment (T2). Following this second evaluation, conferencing platform). Sessions lasted approximately 60 minutes,
participants receive the assigned treatment protocol based on the earlier occurring weekly. Each therapy protocol comprised eight treatment
randomization. Upon completion of the initial treatment, participants sessions with groups ranging from a minimum of 2 to a maximum
undergo a final reassessment (T3). This approach allows for the of 4 participants.
evaluation of both the overall benefit of applying trauma-focused To be part of the final study sample, participants needed to
psychotherapy (analyzing intrasubject changes in the overall sample complete at least 6 out of 8 treatment sessions for each intervention
between T1, T2, and T3 without distinguishing the type of treatment) protocol (75% of sessions). All women in the study sample received
and an analysis of the effect of each treatment protocol separately treatment. This study did not include a control group without
(conducting an intrasubject analysis, this time for each treatment treatment or a waiting list because symptoms in adult victims of
condition, TF-CBT on the one hand, and EMDR on the other). childhood sexual abuse tend to become chronic, and the likelihood
Similarly, the level of effectiveness is analyzed by comparing both of spontaneous recovery is low.
treatment groups (intergroup comparison after applying each type of Regarding participant randomization, it was conducted using
intervention in the post-treatment assessment at T3). Evaluation time the Randomizer.org program before recruitment through permuted
points are at 0 months (T1), after eight weeks (T2), and eight weeks block randomization. Interested participants who met inclusion
after receiving treatment (T3) (Table 1). criteria (with no exclusion criteria) were assigned spaces in one of
the two interventions in the order of their enrollment.
Participants are kept unaware of the two experimental
2.2 Procedure conditions and are not informed about the specific procedures for
implementation and assignment to each treatment group.
The study protocol was submitted for approval and Therefore, the details are undisclosed to the participants.
endorsement before its implementation. The study has been However, it’s important to note that associations involved in

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participant recruitment, as well as therapists and members of the 2.4 Outcome measures
research ethics committee endorsing the study, are aware of the
existence of the two treatment groups. 2.4.1 Ad hoc registry for general
The sessions were conducted by two therapists, who were sociodemographic and clinical variables
present in each session and conducted both protocols Participants will be asked for information about age, gender,
simultaneously to avoid any potential interference. Additionally, nationality, marital status, coexistence, educational level,
having both therapists present was beneficial in case some employment status, and family socioeconomic status.
participants exhibited dysregulation reactions, as one therapist
could then proceed to a Zoom room to assist in stabilizing the 2.4.2 Measurement of dependent variables
situation. Both therapists are experts in EMDR and CBT-TF models Table 4 compiles the psychological variables studied along with
and have extensive experience in teaching and conducting clinical the corresponding measurement instruments used.
sessions in these treatment protocols for trauma.Sample. It is widely known that difficulties in emotion regulation are
As illustrated in Table 2, the sample consisted of 19 women who closely related to the presence of previous traumatic experiences,
were victims of childhood sexual abuse. They ranged in age from 18 particularly those endured during childhood, such as sexual abuse,
to 53 years (M = 38.42; SD = 10.34) and held Spanish nationality and this association plays a key role in explaining the development of
(89.5%), except for one American and another Portuguese. The subsequent psychiatric disorders (74). Research provides evidence
majority had university education (57.9%), 31.6% had higher that chronic exposure to stress in early life leads to molecular
education, and 10.5% had basic education. Additionally, at the mechanisms affecting the neuroendocrine regulation of stress,
time of the intervention, 63.2% were employed. Regarding their chronic inflammation, and alteration of central neural networks
marital status, the majority were married or in a relationship (75, 76). These alterations, possibly related to epigenetic changes
(52.6%), followed by single participants (36.8%) and separated or (77), may hinder the normal mental development necessary for
divorced individuals (10.5%). Thus, 57.9% lived alone with their healthy emotional regulation and trigger difficulties in attachment
nuclear family (partner and children), 15.8% lived alone with their (78, 79). Indeed, a history of childhood abuse is associated with
family of origin (parents, siblings, etc.) or shared a residence with increased avoidance of negative emotions, emotional dysregulation,
non-family members (friends or acquaintances), and only 5.3% and psychological distress (79–84). Neuroimaging literature indicates
lived alone or alone with their child. In terms of household income, that post-traumatic stress disorder is associated with dysfunction in
18.2% of participants reported income levels ranging from €45,000 brain areas (prefrontal cortex, insula, amygdala, hippocampus)
to €99,999, 9.1% reported incomes between €25,500 and €44,999, involved in fear conditioning or controlling emotional response
another 18.2% reported incomes between €16,000 and €25,499, (85). This is supported by a strong association between post-
18.2% reported incomes between €1,000 and €15,999, 27.3% traumatic stress disorder and emotional dysregulation (86). Specific
reported incomes between €6,500 and €9,999, and 9.1% reported difficulties in emotional regulation could exacerbate PTSD
incomes below €6,499. symptoms, hinder the emotional processing of trauma, and
The inclusion criteria for sample selection were as follows: (1) perpetuate a cycle of dysregulation (87–89).
being female, (2) aged 18 years or older (no limits in the maximum Therefore, alongside the measurement of post-traumatic stress
age for the participants), and (3) having experienced childhood sexual through the EGS-R (90), two other relevant measures are
abuse. Additionally, the exclusion criteria were: (1) severe mental introduced: emotional regulation measured through the DERS
illness, indicated by extreme scores on measures such as personality (Difficulties in Emotion Regulation Scale) and dissociation
dimensions (71) (assessed by the DSM-5 personality questionnaire) measured through the DSS (Dissociative Symptom Scale).
(72), dissociation (measured by the DES), or psychopathology Regarding the assessment of post-traumatic symptomatology, the
indicators (measured by the SCL-90 global severity index, paranoid Posttraumatic Stress Disorder Symptom Severity Scale according to
ideation, or psychoticism subscales); (2) problematic substance use DSM-5 (EGS-R) is used, which has been employed for measuring
(alcohol, cocaine, etc.) based on DSM-5 criteria; and (3) ongoing PTSD symptoms in contexts of violence and sexual assaults (90) as well
regular psychological therapy specifically addressing the traumatic as in adult victims of childhood sexual abuse (91). It is a 21-item scale
experience of childhood sexual abuse (CSA). based on DSM-5 diagnostic criteria, assessing the presence and severity
of symptoms. The scale serves as a structured evaluation instrument in
Likert format (from 0 to 3 based on the frequency and intensity of
2.3 The intervention symptoms) with four domains: re-experiencing, avoidance, negative
alterations in cognition and mood, and hyper-arousal, and an
Out of the total 19 women evaluated, 8 underwent treatment additional section on dissociation and dysfunctionality. The EGS-R
using the CBT-TF protocol, while 11 received treatment through has demonstrated adequate psychometric properties in the sample with
the EMDR protocol. Descriptions of both treatment protocols are high internal consistency (a = 0.91).
available in our previously published clinical trials (73), registered The Difficulty in Emotion Regulation Scale (DERS) is commonly
under Clinical Trial number NCT04813224. Summaries of both used to assess dimensions of emotion dysregulation, including non-
protocols are presented in Table 3. acceptance of emotions, interference in daily life, emotional

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TABLE 2 Demographic characteristics of the sample. TABLE 3 Treatment protocols.

% (n) /M (SD) Treatment protocols

Age (years) 38.42 (10.34) Trauma-Focused Trauma-Focused
CBT-based treatment EMDR treatment
Nationality
Adaptation of the protocol of Cohen for Adaptation of Elan Shapiro's
Spanish 89.5 (17) complex trauma. Group Traumatic Episode
TF-CBT is an evidence-based therapeutic Protocol for adults with
Portuguese 5.25 (1)
approach for treating traumatized patients. childhood adverse experience
American 5.25 (1) Generate an improvement of symptoms of and complex trauma.
PTSD, dissociative, affective, or cognitive and EMDR is an evidence-based
Sexual orientation behavioral problems. therapeutic approach for
Eight weekly one-hour online group sessions treating traumatized patients.
Heterosexual 63.2 (12) per week. Generate an improvement in
Three phases of 2–3 sessions each. PTSD symptoms, dissociative,
Homosexual 21.1 (4)
Phase 1: TF-CBT Coping Skills for Complex affective, or cognitive and
Bisexual 15.8 (3) Traumas. Objectives: Establishing a trusting behavioral problems.
relationship and self-regulation skills; Eight weekly one-hour online
Educational level reinforcing safety; psychoeducation; group sessions per week.
relaxation skills, mindfulness affective and Eight-phase EMDR protocol.
Primary Education 10.5 (2) cognitive coping. Phases 3 to 7 will be conducted
Phase 2: Trauma Narration and Complicated during sessions 3 to 8.
Higher Education 31.6 (6)
Trauma Processing. Objectives: The Phase 1: Objective: Client
University Degree 57.9 (11) development of the trauma narrative; identify history before session 1.
and examine the impact of core beliefs; Phase 2: Objectives:
Employment status development of a hierarchy of feared stimuli Preparation for the treatment
and a gradual exposure schedule. Live of the traumatic event, with
Working 63.2 (12) exposure to trauma memories. psychoeducation and
Phase 3: Consolidation and completion of regulation strategies, calming
Not working 36.8 (7)
treatment. Objectives: After processing the place, and setting up positive
trauma, share the individual progress feelings with EBL.
Marital status
achieved with others; follow-up sessions; Phases 3–6: Objectives:
Married or in partnership 52.6 (10) ensure safety and develop appropriate performed following the G-
relationships in real-life situations. TEP worksheet. Sense of
Single 36.8 (7) security (safe place, past
resource, desired future,
Separated or divorced 10.5 (2)
timeline) control structure,
order, differentiation of past
Cohabitation
and present.
With the family of origin (parents, siblings, etc.) 15.8 (3) Phase 7: Closing of the session.
Objectives: A group debriefing
With the nuclear family (partner and children) 57.9 (11) of the experience and
conducting some of the
With friends or acquaintances 15.8 (3) stabilization exercises.
Phase 8: Objectives: Re-
Alone or alone with child 10.6 (2)
evaluation. After the group
Annual household income intervention, assess any need
for individual attention.
Between 45000€ and 99999€ 15.8 (3)

Between 25500€ and 44999€ 10.5 (2)

Dissociative symptoms have been assessed using the Dissociative
Between 16000€ and 25499€ 15.8 (3) Symptom Scale (DSS) for decades in adults who experienced
Between 10000€ and 15999€ 15.8 (3) childhood sexual abuse (9, 94). The DSS (95) is a self-administered
scale with 28 items designed to measure dissociative
Between 6500€ and 9999€ 31.6 (6)
symptomatology. Items are scored based on the frequency of each
Below 6499€ 10.5 (2) dissociative experience on a scale from 0 to 100, where 0 represents
“never” and 100 represents “always.” The DSS has good psychometric
dyscontrol, limited strategies, and difficulty with goal-directed properties, with a Cronbach’s a of 0.91 in the Spanish validation (96).
behavior, impulse control, and emotional clarity (92, 93). The Dissociative Symptom Scale (DSS) was developed to assess
Emotion regulation difficulties are common in people with PTSD. moderately severe levels of depersonalization, derealization, gaps in
The final adapted version used in this study comprises 28 items. The awareness or memory, and dissociative re-experiencing that would be
DERS scale exhibits good psychometric properties with a relevant to a wide range of clinical populations, especially those who
Cronbach’s a of 0.91 for the total scale. have been victims of childhood sexual abuse and post-traumatic

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TABLE 4 Psychological Variables studied and assessment low (scores ≤ 25), medium (26–29), and high (≥30) self-esteem. The
instruments used.
alpha coefficient for internal consistency is very high, a = 0.92.
Several studies reveal that individuals who experienced
Variable Assessment instruments
childhood sexual abuse not only had significantly less satisfying
Post- Post-traumatic Stress Disorder Symptom Severity Scale
lives but also exhibited other symptoms, such as suicidal ideation,
traumatic Stress according to the DSM-5 (EGS-R)
impaired social functioning, distorted body perception, and
Emotional Scale of Emotional Regulation Difficulties (DERS) psychosomatic illnesses (104). Consequently, a measure of overall
Regulation
life satisfaction is incorporated as a variable for assessment, utilizing
Dissociation Dissociative Symptom Scale (DSS) the Satisfaction with Life Scale (SWLS) (105). This 5-item scale
Psychopathology Symptom Checklist-90-Revised (SCL-R) prompts participants to express their agreement with each question
on a Likert scale from 1 to 7, resulting in scores ranging from a
Self-Esteem Rosenberg Self-Esteem Scale (RSE)
minimum of 5 to a maximum of 35, where higher scores indicate
Satisfaction Satisfaction with Life Scale (SWLS) greater life satisfaction. The SWLS is recommended for use
with Life
alongside scales focusing on psychopathology or emotional well-
being because it evaluates the conscious evaluative judgment of
symptomatology. The DSS has good psychometric properties, with a individuals about their lives based on their own criteria. The
Cronbach’s a of 0.95 in our study. reliability analysis of the scale indicated that this Spanish version
Additionally, considering that this study will evaluate the exhibits good internal consistency (a = 0.85).
effectiveness of two therapeutic approaches, meaning it will
examine whether the level of insight differs between trauma-
focused cognitive-behavioral therapy and EMDR, it is deemed 2.5 Data analysis
appropriate to use the Symptom Checklist-90-R (SCL90-R; 97–99).
This instrument assesses nine specific psychopathological The assessment instruments and the study variables collected
dimensions. Mental health professionals commonly use the SCL- through them will be coded and captured in databases. The results
90-R to assess psychological symptoms and monitor patient progress obtained from this intervention will be analyzed using the Statistical
during and after treatment. Symptomatology in several areas of Package for the Social Sciences (SPSS version 28).
function is common in people who were sexually abused in The following statistical procedures have been employed for the
childhood. Therefore, an instrument such as the SCL-90-R is useful data analysis, considering the nature of the analyzed variables and
to classify symptoms by clusters, especially if there is no clear pattern the estimated sample size:
of post-traumatic stress, but there is significant symptomatology • Descriptive Analysis: Descriptive statistics were employed to
resulting from the trauma. The SCL-90-R consists of three global provide a comprehensive understanding of the distribution of key
indices of distress: Global Severity Index, Positive Symptom Distress variables. The data information was conveyed using frequencies
Index, and Positive Symptom Total. Additionally, the SCL-90-R (Fr) and percentages (%), with means (M) utilized to indicate
consists of nine primary symptom dimensions: somatization, central tendency and Standard Deviations (SD) obtained to
obsessive-compulsive, interpersonal sensitivity, depression, anxiety, highlight the degree of data dispersion.
hostility, phobic anxiety, paranoid ideation (PAR), and psychoticism. For the remaining analyses of variables within the study sample,
This self-administered questionnaire presents 90 items describing non-parametric hypothesis testing techniques were employed. This
symptoms and requires the individual to indicate on a Likert scale approach was primarily due to the limited size of each protocol
between 0 (not at all) and 4 (significantly or extremely) to what extent group, considering the focus on a clinical sample. The following
they feel bothered by each of the symptoms described. Reliability analyses have been conducted using these techniques:
showed a high Cronbach’s alpha for the scale (a = 0.98).
The Rosenberg Self-Esteem Scale (RSS) is the most widely used • Intrasubject Analysis: Non-parametric tests to compare two
instrument to measure this element (100). An increasing number of or more dependent or related samples have been applied.
studies suggest that self-esteem is significantly associated with the These tests are used for before-after group designs to
aftermath of childhood sexual abuse (101). Additionally, it is compare differences in results in a sample (in the total
estimated that self-esteem may play a mediating role in mental sample and, separately, in the EMDR group and the TF-
health problems (102). Therefore, self-esteem is considered to serve CBT group) measured on the same dependent variables
as a dimension of positive functioning and help this clinical before and after the treatment (independent variable). The
population manage, regulate, and minimize psychological distress, Friedman test was applied for this purpose.
thereby generating higher levels of subjective happiness, which is • Intersubject Analysis: Non-parametric tests have been used
beneficial for mental health (103). Hence, it has been one of the to compare two independent or unrelated samples. These
dimensions evaluated in this study. The RSS assesses the feeling of tests are used to assess differences in results between two
satisfaction that a person has about himself/herself. It consists of ten groups (the EMDR group and the TF-CBT group)
items focusing on general feelings of self-respect and self-acceptance. measured on the same dependent variables at the same
The total score ranges from 10 to 40 points, with a distinction between time points (both at T1 and T2 to validate the homogeneity

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of both samples, ensuring their comparability, and at T3 for contrasts resulting in statistically significant differences with a
conducting the comparative analysis post-treatment of both probability equal to or less than 0.05, 0.01, or a trend (probability
psychotherapy protocols). The test applied for this purpose equal to or less than 0.10) will be displayed (See Table 5).
is the Mann-Whitney U test.
• Internal Consistency Analysis (Reliability): The Cronbach’s
alpha coefficient (a) was calculated for each of the 3.2 CBT-TF protocol sample
instruments used in the study to estimate their reliability.
This information is provided along with an explanation of Upon examining emotional regulation, significant differences in
each measurement instrument. scores between T1 and T3 are observed in the factor that assessed
Limited Access to Emotion Regulation Strategies. This indicates that
the treatment has had an impact on improving participants in this
aspect, which is an important outcome as difficulties in emotional
3 Findings regulation are relevant in adults who have experienced childhood
abuse (106). This result aligns with the reviewed literature, indicating
3.1 Intrasubject analysis (comparison that the impact of trauma is associated with dysfunction in areas of
T1-T2-T3) the brain involved in fear conditioning or the control of emotional
response functioning (107). It is also consistent with some results
In this section, given the numerous analyses conducted in both from the application of trauma-focused CBT, where it seems effective
the inter and intra processes of mean comparisons, only those mean in reducing emotional dysregulation (108).

TABLE 5 Variables with significant differences between pre- and post-treatment data as a function of treatment protocol.

Variable Friedman test p Dunn-Bonferroni post-test

Treatment protocol: TF-CBT

2.38 (0.018) T3<T1

Re-experiencing 7.76 0.021
1.75 (0.08) T2<T1
Post-traumatic Stress Disorder
2.38 (0.018) T3<T2
Symptom Severity Scale Avoidance 11.04 0.004
2.5 (0.012) T3<T1

Dissociative symptoms 4.73 0.094 1.75 (0.08) T3<T1

Additional Items 4.67 0.097 1.88 (0.061) T3<T1

Global Severity Index 4.71 0.095 2.13 (0.034) T3<T2

Symptom Checklist-90-Revised
Positive Symptomatic
4.71 0.095 2.13 (0.034) T3<T2
Distress Index

Scale of Emotional Limited access to emotion 2.25 (0.024) T3<T2

6 0.05
Regulation Difficulties regulation strategies -1.88 (0.061) T2<T1

Treatment protocol: EDMR

Post-traumatic Stress Disorder

Dissociative symptoms 5.515 0.063 2.025 (0.043) T3<T1
Symptom Severity Scale

Somatization 4.67 0.097 2.03 (0.043) T3<T1

3.09 (0.002) T3<T1

Obsessive-Compulsive 9.81 0.007
1.71 (0.088) T2<T1

Interpersonal sensitivity 5.69 0.058 2.24 (0.025) T3<T1

Depression 5.71 0.058 2.24 (0.025) T3<T1

Symptom Checklist-90-Revised
Psychoticism 6.53 0.038 2.35 (0.019) T3<T1

Additional Items 5.42 0.067 2.24 (0.025) T3<T1

Global Severity Index 5.44 0.066 2.24 (0.025) T3<T1

Positive Symptomatic 1.81 (0.07) T3<T1

5.07 0.079
Distress Index 2.03 (0.043) T3<T2

Depersonalization/
Dissociative Symptom Scale 2 0.041
Derealization

Satisfaction with Life Scale Total score 6.87 0.032 -2.5 (0.012) T3>T1

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A trend of increased distress between T1 and T2 is also 3.3 EMDR protocol sample
observed. This may stem from the group of women confronting
their avoidant tendency regarding trauma (109, 110) while In the evaluation of Post-traumatic Stress Disorder Symptom
addressing aspects of it during the response to the assessment Severity, after EMDR treatment, there is a trend of improvement in
protocol and being aware that it will be addressed later. the dissociative symptoms subscale between T2 and T3 (p<0.06).
In the measures of Post-traumatic Stress Disorder Symptom This difference becomes statistically significant (p<0.043) when
Severity, a trend of improvement is seen in the Reexperiencing comparing T1 and T3, indicating an improvement in this variable
subscale after trauma-focused CBT treatment. There is a significant compared to the initial assessment. This result aligAting group
difference between T1 and T2 (p<0.08), as well as a greater EMDR protocols (63).
significant difference between T1 and T3 (p<0.18) after the eight Regarding the results in the broad-spectrum psychopathological
treatment sessions. The trend of improvement between T1 and T2 clinic measured by the SCL-90, changes are observed in the
(baseline without treatment) could be attributed to the group of following aspects:
women gathering for the initial evaluation in a Zoom session where In the obsession and compulsion subscale, a significant
they all respond to the questionnaire through LimeSurvey, facing difference is noted between T1 and T2 (p<0.088), as well as a
the intrapsychic exposure to the traumatic episode in a supportive greater significant difference between T1 and T3. This suggests clear
group context. This hypothesis would need to be confirmed in improvement after the eight treatment sessions (p<0.002). The
further studies with a more significant sample. The significant improvement during the baseline in this symptomatic subscale
improvement in this variable after treatment aligns with findings could be attributed to the group of women confronting their
in other research, such as that of Tichelaar et al. (1). avoidant tendency regarding trauma (109, 110) when addressing
In the Avoidance scale, there is a trend of improvement between aspects of it while responding to the assessment protocol and
T2 and T3 (p<0.18), but a greater significant difference is observed knowing that it will be addressed later. With these results, it can
between T1 and T3 (p<0.12). This may be because as therapy be concluded that the applied EMDR treatment appears to improve
progresses, avoidant symptoms decrease. This result is very relevant ruminative and compulsive symptoms significantly. Although more
as the avoidance strategy is characteristic of this population, as research is needed, this result is in line with a systematic review
revealed by some studies, making it challenging to address and conducted in 2021 on the improvement of obsessive
integrate the emotional imprint of trauma (109, 110). symptomatology with EMDR treatment (111).
The Dissociative Symptoms subscale displays a positive trend in The items measuring somatization show a trend toward
response to the treatment, revealing significant differences between significance (p<0.097), with an improvement in these symptoms
T1 and T3 (p<0.08), with no observable change between T1 and T2. throughout the treatment from T1 to T3. Notably, this variable has
This outcome is consistent with findings in limited studies on this no significant differences between T1 and T2, indicating that the
topic (1). While extensive evidence supports this therapy in the change becomes evident after treatment administration in this
child population, additional research is warranted in the specific subscale. Based on these findings, it can be inferred that
adult population. the implemented EMDR treatment appears to alleviate somatic
In the evaluation of psychopathological symptoms through the symptomatology significantly. This is particularly relevant as
SCL-90, improvement is observed in aspects evaluating additional somatization is linked to childhood sexual abuse in both men and
items: Poor appetite, Sleep problems, Thoughts about death or dying, women (112).
Overeating, Waking up very early, Restless sleep, and Feelings of Concerning interpersonal sensitivity, a significant difference is
guilt. A significant difference is observed (p<0.06) between T1 and observed (p<0.05) between T1 and T3, possibly explained by the
T3, possibly explained by the positive effect of treatment, as there positive effect of treatment, as there are no significant differences at
are no significant differences at baseline. The value of these items, baseline. Here again, relevant symptomatology for this population is
even though they are not central to psychopathological severity, significantly improved after treatment, contributing to self-
represents a significant clinical change. confidence and trust in oneself and others.
In the Global Severity Index, a good indicator of the current level In the domain of Depression, a notable difference is noted
of distress severity that combines the number of symptoms (p<0.05) between T1 and T3, possibly explained by the positive
recognized as present with the intensity of perceived distress, effect of treatment, with no significant differences at baseline.
there is also a clear significant improvement due to the treatment Depressive symptomatology is highly present in this population
effect between T2 and T3 (p<0.03). (113, 114), and it has significantly decreased after EMDR treatment,
In the index evaluating response style, indicating whether a in line with the early research on EMDR with this population (115),
person tends to exaggerate or minimize the distress they are and more recent studies (63).
experiencing, the Positive Symptom Distress Index, there is again a For aspects related to Psychoticism, a significant difference
significant improvement due to the treatment effect between T2 and (p<0.01) is observed between T1 and T3, potentially attributed to
T3 (p<0.03). the positive impact of treatment, with no significant differences at
These improvements noted after receiving the CBT-TF baseline. The noteworthy decrease in scores on this scale,
treatment protocol are clear indicators of the overall efficacy of encompassing items related to guilt, perception of sex, and
this psychological intervention, as indicated by research such as that feelings of being different, is highly positive. This reduction could
of Tichelaar et al. (1). indicate a trend supported by other studies: EMDR may lead to a

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decline in psychotic symptoms and the risk of crises in patients relevant since it is a type of symptomatology that is difficult to
(116). In a similar vein, Valiente et al. (23) have found preliminary reduce, as patients have been regulating coping with this traumatic
evidence suggesting that EMDR therapy improves both psychotic episode using dissociative and avoidant strategies for years
and affective symptoms. (109, 110).
In the additional items referring to poor appetite, sleep problems, For the “Negative Cognitive Alterations/Negative Mood”
overeating, thoughts about death, feelings of guilt, and restless sleep, a subscale, a trend of improvement after treatment is observed
significant difference is also observed (p<0.05) between T1 and T3, (p<0.07) between T1 and T3, with no significant differences
possibly explained by the positive effect of treatment, as there are no between baseline times (T1 and T2).
significant differences at baseline. Therefore, their improvement The same trend of improvement (p<0.06) is found for the total
also represents a significant clinical change. score on this scale of post-traumatic symptoms, both between T1
Regarding the Global Severity Index, providing information on and T3 and between T2 and T3.
the current level of distress severity, a significant difference (p<0.05) Beyond these trends, significant differences are found in
is observed between T1 and T3, possibly explained by the positive dissociative symptomatology measured by this questionnaire
effect of treatment, with no significant differences at baseline. (p<0.06), with this difference occurring in the dissociative
On the other hand, the Positive Symptom Distress Index, a symptoms subscale between T1 and T3.
measure that indicates whether a person tends to exaggerate or In the context of the broad spectrum psychopathological clinic, it
minimize the distress they are experiencing, shows a trend of should be noted that:
improvement both between T2 and T3 and between T1 and T3 Concerning the Obsession and Compulsion clinic, there is a
(p<0.10), with no significant differences at baseline, and a reduction significant difference in these symptoms (p<0.018) between T3 and
in symptom presence after treatment. T1 and between T3 and T2. No significant differences are observed
These last three subscales related to the overall impact of in the baseline results.
symptomatology show a significant improvement after EMDR Regarding Interpersonal Sensitivity, there is a significant
treatment, an improvement that is also seen in the CBT-TF difference in these symptoms (p<0.025) between T3 and T1. No
group, in line with the overall improvement that both treatments significant differences are observed in the baseline results.
seem to produce in this population (1). When addressing aspects related to Depression, there is a trend
In the context of the Depersonalization-Derealization clinic, of improvement with p-values of <0.066 both between T3 and T1
significant differences (p<0.05) are observed between T1 and T3. and between T3 and T2.
This positive outcome, signifying a notable reduction in dissociative Similarly, in the Anxiety clinic, a trend of improvement is
symptoms like depersonalization and derealization, is well- observed with p<0.93 between T2 and T3.
documented in earlier studies on EMDR in this population (115) Finally, in the aspects related to the assessment of Psychoticism,
and more recent research (63), as observed in our sample. a significant difference is observed (p<0.05) between T1 and T3 and
Finally, in terms of life satisfaction, differences are found between between T2 and T3, which can be explained by the positive effect of
T1 and T3. Consistent with the outcomes observed in the previous treatment, as there are no significant differences in the baseline. As
symptoms, EMDR significantly improves life satisfaction, which is an mentioned earlier, this change is positive because this scale includes
important indicator of overall improvement. items related to guilt, perception of sexuality, and feeling different.
These findings are in line with other studies indicating positive
outcomes in women who are victims of CSA with both EMDR and
TF-CBT treatment, yet with a more substantial reduction in PTSD 3.5 Intersubject analysis
symptoms in the EMDR groups (117).
3.5.1 Pre-treatment comparison between EMDR
and CBT-TF protocols
3.4 Total sample - analysis of the effect of Before delving into a detailed comparison of the results
receiving trauma-focused treatment obtained in the study variables after applying both treatment
protocols, it is essential to highlight the homogeneity of both
A thorough intrasubject assessment has been undertaken, treatment groups at T1 and T2. No significant differences were
concurrently evaluating both treatments to observe the integrated observed between the two treatment groups at these two temporal
outcomes of trauma-focused intervention (See Table 6). Previous points. This indicates that concerning health and well-being
analyses have already demonstrated the effectiveness of both indicators in the studied variables, both groups are homogeneous
treatments, resulting in significant changes that contribute to and can be reliably compared. The consistent baseline across groups
improving these women’s quality of life and mental health. makes the intergroup results reliable and meaningful for
Regarding Post-traumatic Stress Disorder Symptom Severity, comparison after treatment.
measured through the EGS scale:
There is a trend of improvement after treatment (p<0.07) 3.5.2 Post-treatment comparison between EMDR
between T2 and T3 in the behavioral/cognitive avoidance scale, and CBT-TF protocols
with no significant differences between baseline times (T1 and T2). The analyses conducted, which differentially compared post-
This result is consistent with previous research findings and is treatment results (T3) across analyzed variables based on the applied

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TABLE 6 Variables with significant differences between pre- and post-treatment data.

Variable Friedman test p Dunn-Bonferroni post-test

Avoidance 5.92 0.052 1.78 (0.074) T3<T2

Negative alterations in cognition

5.25 0.073 2.11 (0.035) T3<T1
and mood
Post-traumatic Stress Disorder
Symptom Severity Scale
1.7 (0.089) T3<T2
Dissociative symptoms 10.15 0.006
2.68 (0.007) T3<T1

Total score 5.62 0.06 2.27 (0.023) T3<T1

1.99 (0.052) T3<T2

Obsessive-Compulsive 8.08 0.018
2.68 (0.007) T3<T1

Interpersonal sensitivity 7.37 0.025 2.51 (0.012) T3<T1

1.78 (0.074) T3<T2

Depression 5.44 0.066
2.11 (0.035) T3<T1

Anxiety 4.76 0.093 2.11 (0.035) T3<T2

Symptom Checklist-90-Revised 1.87 (0.062) T3<T2

Psychoticism 7.31 0.026
2.27 (0.023) T3<T1

1.95 (0.052) T3<T2

Additional Items 9.88 0.007
2.92 (0.004) T3<T1

2.27 (0.023) T3<T1

Global Severity Index 8.22 0.016
2.59 (0.009) T3<T2

Positive Symptomatic 1.95 (0.052) T3<T1

9.08 0.011
Distress Index 2.92 (0.004) T3<T2

Scale of Emotional Limited access to emotion

6 0.05 2.19 (0.029) T3<T2
Regulation Difficulties regulation strategies

2.1 (0.036) T3<T1

Absorption 6.04 0.049
2.01 (0.045) T2<T1
Dissociative Symptom Scale
Depersonalization/Derealization 8 0.015

treatment protocols, did not reveal significant differences in the absence of treatment effects on these variables may be attributed
post-treatment variables (see Table 7). This evidence supports the to the small sample size of this study or the need for more extended
notion that both treatment approaches are equally beneficial for this or personalized treatments to induce the desired changes in
population. This is evident both in the general sample of women who these aspects.
are victims of childhood sexual abuse, considering the overall treatment
effect, and when separately analyzing the effects of each
therapy protocol. 4 Discussion
Consistent with existing research, such as studies by Van den
Berg (118) and Mueser (119), the findings indicate that patient Within the broader context of this study’s general conclusions
outcomes did not significantly differ between those who received and in alignment with the overarching objective—to address the
TF-CBT or EMDR across various PTSD symptom-centered impact on adult trauma victims related to childhood sexual abuse
outcomes. Likewise, concerning neurophysiological changes, the and to assess the effectiveness of two trauma-focused treatments for
study aligns with others, suggesting a comparable and beneficial these women—it is essential to note that, based on the obtained
psychological impact of EMDR and TF-CBT in patients with post- results, the first intragroup hypothesis between T1 and T2, where
traumatic stress disorder. Neuroimaging data imply a similar only the effect of time was applicable, anticipated no change in both
neurophysiological substrate for clinical improvement after both groups in health and well-being indicators in the studied variables.
EMDR and TF-CBT, involving changes affecting bilateral This expectation aligns with Gesteira et al. (120), who assert that
connectivity of the temporal pole (26). spontaneous recovery does not occur over time.
While describing these results, it is worth noting that no Concerning intragroup hypothesis 2, between T1 and/or T2 and
differences were found, either within or between subjects, in the T3, after receiving one of the two intervention protocols under study
data related to self-esteem or in the Anxiety, Hostility, Phobic (EMDR or TF-CBT), improvement in health and well-being indicators
Anxiety, and Paranoid Ideation subscales of the SCL-90. These in the studied variables was expected. This hypothesis manages to find
findings warrant further in-depth analysis in the future, with an evidence in its favor, as the results show the benefits of both trauma-
increased study sample to achieve more conclusive data. The focused psychotherapies in reducing symptomatology and impairing

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TABLE 7 Results of post-test (T3) differential analysis according to TABLE 7 Continued

treatment protocol implemented.
Mann–
Mann– Variable Whitney p
Variable Whitney p U test
U test
Emotion regulation 46.5
Re-experiencing 54 0.442 problems 0.84
(total score)
Avoidance 59 0.238
Amnesia 30 0.272
Negative 55
alterations in Dissociative Absorption 36.5 0.762
0.395
cognition Symptom Scale
Post-traumatic Stress and mood Depersonalization/ 35
0.492
Disorder Symptom Derealization
Severity Scale Hyper-arousal 40 0.778
Rosenberg Self- 49
Total score 0.717
Dissociative 41 Esteem Scale
0.84
symptoms
Satisfaction with 42.5
Total score 0.904
Dysfunctionality 48 0.778 Life Scale

Total score 53 0.492

Somatization 49.5 0.657 functioning in different areas of adult life. The findings make a
Obsessive- 43.5
significant contribution to research on the treatment of individuals
0.968
Compulsive who have experienced childhood abuse, potentially fostering the
development of specific protocols for this clinical population. This
Interpersonal 44
1 aligns with studies asserting the effectiveness of trauma-focused CBT
sensitivity
protocols, implemented over eight weeks, not only in reducing chronic
Depression 49.5 0.657
posttraumatic stress disorder and depressive symptoms but also in
Anxiety 51.5 0.545 addressing more insidious symptoms such as dissociation and
Hostility 52 0.545 emotional dysregulation (108). Moreover, recent studies by Brown
Symptom Checklist- (27) and Grady et al. (28) affirm the highly positive implications of TF-
90-Revised Phobic anxiety 38.5 0.657
CBT in the treatment of childhood sexual abuse. These results are
Paranoid ideation 45 1 consistent with other research supporting the effectiveness of both
Psychoticism 47.5 0.778 psychotherapeutic approaches, making them preferred models for
treating patients with trauma-related symptoms (121).
Additional Items 47.5 0.778
Regarding intergroup hypotheses, the first, at T1 and T2,
Global 48 expected both groups to have similar scores in health and well-
0.778
Severity Index
being indicators in the studied variables. The evidence supports this
Positive 41 expectation, considering that the passage of time alone does not
Symptomatic 0.657
improve well-being.
Distress Index
In the second intergroup hypothesis, at T3, differences based on
Nonacceptance of 35
the type of treatment received, either EMDR psychotherapy or TF-
emotional 0.492
responses CBT, were expected. Regarding this hypothesis, both treatments
have proven effective but each of them contributes to improvement
Difficulty engaging 30
in goal- 0.351
in different aspects of symptomatic clinical presentation, supporting
directed behavior recent research advocating for the combination of these two
approaches to enhance the treatment’s impact on patients who
Impulse 52.5
0.272 have experienced trauma. These results indicate a consistent
control difficulties
Scale of Emotional reduction in many posttraumatic symptoms, aligning with prior
Regulation Difficulties Lack of 32
emotional 0.492 research (23, 122–125) demonstrating a sustained decrease
awareness following sessions of trauma-focused CBT and EMDR treatment.
Limited access to 50.5
Considering the limited specific studies related to TF-CBT
emotion intervention for childhood sexual abuse in adult women, evidence
0.6
regulation supporting the efficacy of TF-CBT exists in studies focused on post-
strategies
traumatic stress management in educational settings (36, 37, 126,
Lack of 54.5
0.395
127), general healthcare (120), and victims of terrorist attacks (128).
emotional clarity
These authors argue that patients’ improvement is due to TF-CBT’s
(Continued) effectiveness, not spontaneous recovery processes.

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It is also worth noting that these results support the Although this study has considerable promise, it is important to
appropriateness of online intervention (MHealth) (129), which is consider some of the limitations that must be addressed. One such
particularly relevant since the explosion of its use during the limitation is the small size of the sample. A larger number of
COVID-19 pandemic (130). Recent research indicates a positive participants would enable more rigorous analyses of demographic
treatment effect in online EMDR therapy using the G-TEP group variables. It is also important to recognize that accessing this type of
protocol (131). clinical population is challenging, and there is also a high experimental
Several interesting results suggest avenues for further investigation mortality. In this context, the initial call for participation in the study
in this type of intervention. For example, in the emotional regulation attracts a greater number of individuals who meet the specified profile.
scale, improvements occur after applying the TF-CBT protocol, but no However, upon initiating contact, it is not uncommon for individuals
significant differences are observed after applying the EMDR protocol. to exhibit avoidant patterns and subsequently decline to continue. This
This observation could be related to studies indicating that different phenomenon has been observed and will require further assessment to
trauma-focused therapy approaches improve different types of determine if there are strategies that can enhance the participation of
symptomatology (1). Similarly, the differential changes produced by this specific clinical population. Although victims of CSA exist in both
both trauma therapy models can be interpreted. With TF-CBT, there is men and women, it is evident that the majority of victims who seek
a trend of improvement in emotional regulation and re-experiencing, assistance from social and health organizations specializing in the
as well as significant reductions in avoidant and dissociative symptoms treatment of these traumatic experiences are women. It can be
of post-traumatic stress. This aligns with the study by O’Doherty et al. hypothesized that men are less visible in this context, as it is more
(5), which concluded that improved mental health and PTSD challenging for them to share their experiences and seek help. This is
symptoms after TF-CBT intervention. However, these authors reflected in the profile of the individuals who have participated in our
acknowledge the lingering question of whether the treatment’s call for pilot studies through an association of victims of CSA, who have
benefits persist over time. On the other hand, EMDR intervention been exclusively women.
stands out for the significant reduction in dissociative symptomatology, A further limitation of this study is the lack of long-term follow-
as well as significant improvements in obsessive-compulsive up, which would provide greater assurance regarding the
symptoms, interpersonal sensitivity, and psychoticism. Both therapies interpretation of these findings. However, the reality of these
yield significant general improvement measures, but only EMDR women has made follow-up beyond the end of the therapeutic
shows a significant increase in life satisfaction. sessions challenging. In the future, it will be necessary to identify
Continued evidence suggests that different therapeutic more effective strategies to overcome this limitation. The study’s
approaches can yield improvements in various types of principal strengths lie in its methodological rigor, particularly the
symptomatology, as indicated by Tichelaar et al. (1). Another use of a randomized controlled trial design and detailed treatment
intriguing line of interest following this study is to investigate protocols for EMDR and TF-CBT. Furthermore, the innovative
whether the combined effect of TF-CBT and EMDR can offer approach of delivering therapy in an online group format adds a
greater advantages in symptom improvement and the optimal unique dimension to the field. It is therefore evident that further
order of application. A recent meta-analysis (121) found that the extensive randomized clinical studies are required in order to
best results in reducing post-traumatic symptoms were achieved ascertain the efficacy of these programs and to enhance the
with CBT approaches with exposure and EMDR therapy. They generalizability of their results. Additionally, there is a paucity of
recommended incorporating both into PTSD protocols. Studies research on psychotherapy interventions for women who are
show that applying TF-CBT followed by EMDR yields significant victims of childhood sexual abuse, which serves to highlight the
improvements in health and well-being values. This could be necessity for further exploration in this area.
explained by TF-CBT dedicating a significant phase to
stabilization, which may benefit participants more (132, 133).
Another study also addresses the importance of the order of both Data availability statement
interventions (133, 134), showing evidence of improved EMDR
intervention by first adding TF-CBT. Future research could delve The data that support the findings of this study are available
into whether a specific order of applying both therapies (group TF- from the corresponding author, upon reasonable request.
CBT and G-TEP EMDR) enhances intervention outcomes.
In conclusion, this study provides evidence of the effectiveness
of trauma-focused treatments in adult women victims of childhood Ethics statement
sexual abuse. An interesting avenue for future research would be to
continue providing evidence on the efficacy and benefits of The studies involving humans were approved by Ethics
consecutively applying two protocols, allowing both types of Committee of the Valencian International University (VIU)
psychotherapy to combine and enhance their efficiency and (Valencia, Spain) (Ref. CEID2021_07). The studies were
effectiveness. Additionally, it would provide insights into the conducted in accordance with the local legislation and
potential beneficial contribution of receiving a more extended institutional requirements. The participants provided their written
treatment (both consecutive interventions) versus a single one. informed consent to participate in this study.

Frontiers in Psychiatry 14 frontiersin.org

Molero-Zafra et al. 10.3389/fpsyt.2024.1360388

Author contributions 2021”. The funding institution did not have any role on the
selection of journal nor analysis or method.
MM: Writing – review & editing, Writing – original draft,
Validation, Supervision, Resources, Methodology, Investigation, Acknowledgments
Formal analysis, Data curation, Conceptualization. OF: Writing –
review & editing, Writing – original draft, Software, We would like to acknowledge and sincerely thank the
Methodology, Investigation, Formal analysis, Data curation, nonprofit association (Asociación Contra los Abusos sexuales en
Conceptualization. MM: Writing – original draft. MP: Writing la Infancia, ACASI) and the women who participated in the study.
– review & editing, Writing – original draft, Supervision,
Resources, Methodology, Investigation, Formal analysis, Data
Conflict of interest
curation, Conceptualization. MH: Writing – review & editing,
Writing – original draft, Resources, Project administration,
The authors declare that the research was conducted in the
Methodology, Investigation, Funding acquisition, Formal
absence of any commercial or financial relationships that could be
analysis, Data curation, Conceptualization.
construed as a potential conflict of interest.

Publisher’s note
Funding
All claims expressed in this article are solely those of the authors
The author(s) declare financial support was received for the and do not necessarily represent those of their affiliated organizations,
research, authorship, and/or publication of this article. This work is or those of the publisher, the editors and the reviewers. Any product
supported by a specific funding “Grants for internal research that may be evaluated in this article, or claim that may be made by its
projects at the Valencian International University (VIU), 2020- manufacturer, is not guaranteed or endorsed by the publisher.

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