Low self-esteem: cognitive behavioural approaches

Debbie SpainDept. of Mental Health

Florence Nightingale School of Nursing & MidwiferyKing’s College London

Learning outcomes

By the end of the session, students will be able to:

• Define (low) self-esteem • Discuss the limitations and advantages to formulation-

based treatment approaches • Outline the cognitive model of LSE• Be aware of interventions for LSE• Reflect on clinical practice implications

Wider reading

Fennell, M. (1997). Low self-esteem: A cognitive perspective. Behavioural and Cognitive Psychotherapy, 25, 1-25.

Fennell, M. (2006). Overcoming low self-esteem: Self help workbooks. 2nd ed. London: Constable.

Defining LSE• Negative representation of self:

- learned process- global (negative) judgement - shapes subsequent thoughts, feelings and behavioural responses; and information processing- negative sense of self (and schema) thereby perpetuated, and reinforced

(Fennell, 1998; Waite et al., 2012)

LSE: Impact and impairment

• How might LSE impact on daily functioning ?- can affect functioning across several domains e.g. work, social life- can be pervasive or occur in response to situations / perceived cues- features are not necessarily static; severity of features may wax and wane

• Not always an adverse experience

LSE and co-morbidity • LSE often found to occur alongside a range of psychiatric

disorders, in particular: - anxiety disorders e.g. GAD, social phobia, OCD- depression- eating disorders- psychosis

• (Fannon et al., 2009; Fennell, 2004; Freeman et al., 1998)

How can we explain the relationship between LSE and co-morbidity ?

• It has been hypothesised that LSE might be: - a component of other disorders- a cause of psychiatric disorder- a consequence / outcome of other difficulties- a vulnerability or predisposing factor for developing psychopathology (e.g. Fennell, 2004; McManus et al., 2009)

• Further research needed to understand relationship between symptoms

A link between self-esteem, affect and beliefs about voices ?

(Fannon et al., 2009)

CT for LSE: some considerations

• LSE is a transdiagnostic process, rather than a specific ‘diagnosis’

• Advantages and concerns about using a formulation-based approach, compared to a disorder-specific model of care ?

• Pathways to CBT for people who experience LSE- features may be overlooked entirely- may be referred for LSE-work directly- features may become evident during a course of therapy- may arise in the context of formulating ‘complex cases’- anything else ?

CBT assessment for LSE • RECAP: the remit of a CBT assessment ?

• Assessment includes consideration of: - current maintaining factors- developmental / longitudinal factors- specific triggers or modifiers- co-morbid psychopathology e.g. depression, anxiety- impact and distress

• Need to consider how LSE features may mediate responses, engagement during an assessment

Assessment: Rosenberg self-esteem scale

• 10 item self-report questionnaire; 4 point Likert scale

1. On the whole I am satisfied with myself2. At times I think I am no good at all3. I feel that I have a number of good qualities4. I am able to do things as well as most people 5. I feel I do not have much to be proud of6. I certainly feel useless at times7. I feel that I am a person of worth, at least on an equal basis with others8. I wish I could have more respect for myself9. All in all, I am inclined to feel that I am a failure10. I take a positive attitude towards myself

What thoughts, feelings or behaviours might contribute to

the development and maintenance of LSE ?

LSE: a cognitive formulation(Fennell – see reflist)

Formulation in clinical practice• Must be a collaborative process

• The formulation serves several purposes: to socialise to the model; clarify insight and understanding; inform treatment approach and goals for therapy

• May be easier to focus on maintaining factors in first instance

• Important to ‘pitch’ this at the right level for the individual

Formulation in clinical practice• What you ‘say’, and what the individual ‘hears’ may be two

different things e.g.:- “you are unacceptable to others” OR - “it seems that you believe that you are unacceptable to others”- “you seem to worry that you are unacceptable to others”

• Therefore, need to be mindful of, and accommodate information processing bias’

CT for LSE aims to … ?

• Reduce negative sense of self • Find a more balanced view of self• Accept (possibility) that have strengths and weaknesses• Increase awareness of positive qualities

(McManus et al., 2009; Fennell, 2006; Waite et al., 2012)

LSE: overview of treatment approach

• Goal-setting • Psycho-education and formulation to the model

- a shared formulation is critical for success• Overcoming maintaining factors e.g. avoidance• Exploring and re-evaluating dysfunctional assumptions /

rules for living• Exploring and re-evaluating core beliefs / the bottom line• Enhancing identification and awareness of positive

qualities

LSE: goal setting

• Goal setting is a fundamental component of CBT. Why might this prove complex when working with people who have LSE ?

• Can we minimise difficulties ?

• Important to have open discussion about this early on• Further aims / goals may be added over time • Need to be realistic (and SMART)

A basis for treatment: Theory A / Theory B

Theory A: Jane is inadequate and worthless; therefore she needs to work very hard to make sure that she is accepted

Theory B: Jane is as worthwhile as others, but her LSE and negative beliefs about herself cause her to engage in behaviours and thinking patterns that perpetuate anxiety and low mood

(adapted from McManus et al., 2009)

Common interventions

• Thought records• Identifying and challenging negative thoughts • Use of continuums • Behavioural experiments • More behavioural experiments • Cue cards• Positive data logs: listing positive qualities, daily• Increase engagement in enjoyable activities • Acting on the ‘new bottom line’• Preparing for the future; relapse prevention

Common interventions contd.

• Developing a therapeutic alliance; a safe and supportive environment

• Socratic questioning• Downward arrow technique• Evaluating the evidence (e.g. for specific beliefs / schema)• “Assertive defence of the self” – useful for dealing with

criticism (Padesky, 1997)

Behavioural experiments: an overview

• A way to test out beliefs• Informed by a shared formulation

• Identify the specific belief to test• Rate the strength of belief• Devise a way of testing this out• Make predictions • Identify and problem-solve around any obstacles• Drop safety-behaviours• Conduct experiment• Rate outcome, belief

Behavioural experiments

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Homework: problems and pitfalls

• A shared formulation is vital

• Tasks need to be ‘pitched’ at the right level; be mindful of the impact of possible high expectations / perfectionism

• Important to problem-solve with the individual in advance

• Can be helpful to practice or role model in session

• Best to write everything down

Relapse prevention & therapy blueprints

• Importance of relapse prevention ?

• The end of formal therapy doesn’t necessarily mean that therapy has ended: CBT aims to support people to acquire strategies that they can continue applying

• Identify and explore risk factors • Document examples of success; and helpful strategies

‘CBT in practice’

• Provide handouts• Provide opportunity for reflection, and criticism / concern

about the formulation • Support people to generate their own examples• Be aware of thinking errors / bias’ in information

processing: accommodate these e.g. in homework • Pick up on cues in session: e.g. comments, self-talk

Summary and some considerations

• The evidence base for effective treatments for transdiagnostic processes is increasing

• But … it is important to keep therapy ‘simple’ and ‘straightforward’ i.e. focusing on specific goals, one step at a time

• CBT interventions for LSE aim to reduce a negative sense of self (and factors associated with this), and increase awareness of positives (and engagement in enjoyable tasks)

References and further reading

Bennett-Levy, J., Butler, G., Fennell, M., Hackmann A., Mueller, M. and Westbrook, D. (2004). Oxford Guide to Behavioural Experiments in Cognitive Therapy. Oxford: Oxford Uni Press.

Fannon, D., Hayward, P., Thompson, N., Green, N., Surguladze, S. and Wykes, T. (2009). The self or the voice ? Relative contributions of self-esteem and voice appraisal in persistent auditory hallucinations. Schizophrenia Bulletin. 112(1-3), 174-180.

Fennell, M. (1997). Low self-esteem: A cognitive perspective. Behavioural and Cognitive Psychotherapy, 25, 1-25.

Fennell, M. (2004). Depression, low self-esteem and mindfulness. Behaviour Research and Therapy. 42(9), 1053-1067.

Fennell, M. (2006). Overcoming low self-esteem: Self help workbooks. 2nd ed. London: Constable.Freeman, D., Garety. P., Fowler, D., Kuipers, E., Dunn, G., Bebbington, P. and Hadley, C. (1998).

The London-East Anglia RCT of CBT for psychosis IV: Self-esteem and persecutory delusions. British Journal of Clinical Psychology. 37, 415-430.

McManus, F., Waite, P. and Shafran, R. (2009). Cognitive-Behavior Therapy for Low Self-Esteem: A Case Example. Cognitive and Behavioural Practice. 16, 266-275.

Tarrier, N., Wells, A. and Haddock, G. (1998). (eds). Treating Complex Cases. The Cognitive Behavioural Therapy Approach. Chichester: John Wiley and Sons.

Waite, P., McManus, F. and Shafran, R. (2012). Cognitive behaviour therapy for low self-esteem: A preliminary randomized controlled trial in a primary care setting. Journal or Behavior Therapy and Experimental Psychiatry. 43(4), 1049-1057.