Low self-esteem: cognitive behavioural approaches

1
Low self-esteem cognitive behavioural
approaches

• Debbie Spain
• Dept. of Mental Health
• Florence Nightingale School of Nursing
  Midwifery
• Kings College London

2
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

3
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.

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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)

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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

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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)

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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

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

• (Fannon et al., 2009)

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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 ?

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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

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Assessment Rosenberg self-esteem scale

• 10 item self-report questionnaire 4 point Likert
  scale
• 1. On the whole I am satisfied with myself
• 2. At times I think I am no good at all
• 3. I feel that I have a number of good qualities
• 4. I am able to do things as well as most people
  
• 5. I feel I do not have much to be proud of
• 6. I certainly feel useless at times
• 7. I feel that I am a person of worth, at least
  on an equal basis with others
• 8. I wish I could have more respect for myself
• 9. All in all, I am inclined to feel that I am a
  failure
• 10. I take a positive attitude towards myself

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• What thoughts, feelings or behaviours might
  contribute to the development and maintenance of
  LSE ?

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LSE a cognitive formulation(Fennell see
reflist)
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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

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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

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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)

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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

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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)

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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)

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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

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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)

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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

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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

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Relapse prevention therapy blueprints

• Importance of relapse prevention ?
• The end of formal therapy doesnt 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

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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

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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)

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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.