OVERCOMING LOW SELF ESTEEM: A Cognitive Behavioral Approach
Introduction
Cognitive Behavior Therapy is an ideal approach for working with low self- esteem. It provides an easily grasped framework for understanding how the problem developed and what the maintenance factors are. It offers a proactive, goal-oriented and pragmatic approach to improving the problem.
The first premise on which this model is built is this - you feel the way you think. Individuals with low self-esteem (LSE) are characteristically plagued by self-effacing thoughts. Self-criticism is a way of life and has a major impact on emotions and what people make of their lives. Common emotions associated with LSE are sadness, anxiety, guilt, shame, humiliation, frustration and anger. Individuals may also feel chronically discouraged and demoralized. In extreme cases LSE can lead to serious depression and suicide.
The second related premise and the targeted area for work - most of the bad feelings come from illogical thoughts or distortions. Through identification of the lie behind the thoughts and developing a strong, action-oriented methodology for change, the third premise of the model is addressed, i.e. you can change the way you feel.
The structure of thoughts
Cognitive Behavior (CB) theorists assert that thoughts are organized into a three-tiered hierarchy. These thoughts are at the core of maintaining the problem, and therefore each level needs to be addressed, analyzed, understood and modified.
1. NATS (negative automatic thoughts) are automatic, involuntary thoughts that reside just below the level of consciousness. Here cognitions are subject to greater control. They are easily accessible, malleable and distorted. NATS are triggered by external or internal events. People with LSE perceive many more events or situations in life as being threatening. With the result, the NATS may be triggered excessively.
2. Underlying conditional assumptions or rules - attitudes that is an intrinsic part of an individual's value system or personal philosophy. Some attitudes are positive and functional; however others are destructive and can increase vulnerability to painful mood swings and interpersonal conflicts. These rules have a number of characteristics :- they are cross-situational (unlike the NATS), are learned, culturally determined, idiosyncratic, rigid and resistant to change, linked to powerful emotional responses, are over-generalizations and guaranteed to perpetuate low self-esteem.
There are two categories of underlying beliefs
(1) the underlying assumptions which are the conditional beliefs (if…….then) and
(2) the rules or drivers (which are characterized by should and must statements) - these provide the guidelines for how we operate in the world and what we expect to happen to us. The rules are given credibility without being challenged and are derived from the core beliefs. These are almost always represented in a positive way e.g. if people liked me then they would be friendly towards me, as opposed to saying if people don't like me then they won't be friendly towards me and this will take thinking directly to the core issue. The positive slant is thus a defense, a means by which individuals hope to avoid coming face to face with the disturbing core negative beliefs. The more effective these rules are, the more one lives by them and the harder it is to access the core belief for modification.
3. At the heart of self-esteem lie central beliefs about oneself and one's core ideas about the kind of person you are. These beliefs are called schemata, are usually formed in childhood and normally regarded as a statement of fact by the holder. Negative core beliefs are merely distorted opinions, based on self-perception. They become instrumental in shaping our outlook on life and reverberate on all levels. A core belief is cross-situation ally activated. Once activated, it produces a cognitive shift away from positive and more realistic cognitions to the negative and the person begins to systematically interpret / distort incoming information to fit into the schemata (the core belief) structure. In this way its maintenance is secured. The person now feels emotionally disturbed or distressed. Once the disturbance has passed or ameliorated, the negative core belief becomes deactivated and returns to its latent state.
People also behave in ways that will support their core belief - e.g. my not sharing my thoughts regarding my ideas in groups for fear that I will be considered as intellectually inferior. I therefore take precautions to avoid the feared situation and consequently don't promote an opportunity to subject the belief to reality testing.
According to David Burns (Burns 1980) there are 10 common self-defeating core beliefs, viz :
- Emotional perfectionism - I should always feel happy, confident and in control of my emotions
- Performance perfectionism - I must never fail or make a mistake. Individuals feel that they never get to the top of the mountain as there is always another goal somewhere that needs to be achieved.
- Perceived perfectionism - people will not love and accept me as a flawed and vulnerable human being.
- Fear of disapproval or criticism (approval addiction) - I need everybody's approval to be a worthwhile person. Here the health of a person's self esteem is dependent upon how people respond to and what they think of him or her.
- Fear of rejection (love addiction) - If I am not loved, then life is not worth living. Love is seen as a survival need, and whether or not one is loved will influence the health of self-esteem.
- Fear of being alone (hopelessness) - if I am alone, then I'm bound to feel miserable and unfulfilled. An inability to find happiness within oneself.
- Fear of failure (achievement addiction) my worthwhileness depends on my achievements (or my intelligence or status or attractiveness).
- Conflict phobia - people who love each other should not fight.
- Emotophobia - I should not feel angry, anxious, in inadequate, jealous or vulnerable.
- Entitlement - people should always be the way I expect them to be. One expects and demands that needs and wants are met by others.
- Methodology
How can low self-esteem be improved? For the sake of simplicity, I have broken the approach down into three generalized stages.
STAGE 1
Becoming more aware of one's own negative thought patterns is not as easy as it may sound. If someone has been plagued by a lack of self-esteem for a long time the negative thoughts will have become an unrecognizable weave in the fabric of consciousness, a habitual way of thinking. The first step is to learn to notice what situations trigger the thoughts and to observe the impact that these thoughts have on emotions and behavior. Negative shifts in emotional states are often indicative of the activation of self-critical thinking.
(a) Identifying those NATS
Uncovering NATS can be a difficult process. There are a number of tools that can be used to elicit these effectively. These include the following :
Guided discovery. This is teasing out more of the client's thinking through use of Socratic (open-ended questions) probing questioning. This facilitates accessing the NATS through encouraging the client to open up and thereby bring the negative thoughts into awareness.
Images - This is an effective technique to use if the client finds it difficult to articulating what the problem is. They are asked to conjure up an image as to how they see themselves. For example, I see myself shrinking.
Role Play - this is used when clients have problems uncovering their NATS / salient cognitions regarding problematic relationships with others. The therapist plays the role of the person that the client is experiencing problems with. The closer the role-play is to the information the client supplied about the specific person, the more effective the technique. Use of chair-work as in Gestalt Therapy can also be a very powerful tool to elicit NATS.
Use of moments of strong emotion in the sessions can help reveal to the client and therapist the important automatic thoughts. Hot cognitions will emerge here.
Therapist-driven possibilities. Here the therapist uses his creativity and initiative by stimulating cognitive processing. This helps the client get out of a cognitive loop.
Working with the personal meanings that the client attaches to events / situations. For example, what does it mean to the client when their boss talks to them in a disparaging manner.
Suggesting the opposite. A technique that is useful to help stimulate a client's NATS awareness is to suggest something that is the opposite of what their response or thinking might be. This stimulates an "oh no, not like that at all…." response.
In-session experiments - if the client has a problem e.g. is feeling very anxious or starting to feel the onset of a panic attack, the therapist can initiate an in-session exercise to do with the client, to take their focus away from the body. After a while, it can be brought to their attention that they are fine and that nothing awful happened. The thoughts that triggered the anxiety can be examined.
Also in vivo exposure - i.e. taking the client to the feared place / situation that will activate the NATS. E.g. John thought he was particularly unattractive and struggled with low self-esteem as a result. He felt very anxious when in the presence of other people. The therapist decided to accompany John to the local café, where he hoped the hot cognitions would emerge. The experiment yielded crucial assessment data that could have remained untapped whilst in the consulting room.
DTR - Daily thought record - working with this table allows the client to monitor the kinds of thoughts that they have, makes the NATS explicit, and facilitates a degree of objectivity. By gaining some distance from the thoughts insights into the impact that thinking has on emotions can be gained. It also serves as an important between-session record of what has been happening.
(b) Identifying the underlying assumptions and rules
People with LSE set stringent and unrealistic general rules that serve as a dictate as to who they should be and how they should behave, what is acceptable and what is not, and what is necessary to establish and maintain satisfying relationships. If a minor transgression is inadvertently made, LSE sufferers attack themselves for not being good enough, for not doing all the things they should be doing.
When tackling the assumptions and rules, a first step could be to determine where they come from and then look at why the rules are unreasonable. Look at the disadvantages of holding onto the rules and exploring what alternative rules would be more helpful. Looking at the payoffs of obeying the rules is important as this links directly to the core beliefs.
(c ) Working with the core issue of self-esteem, the core beliefs
This is where the vital work of improving self-esteem lies. If only the NATS, underlying assumptions and rules are addressed, it is rather like chopping the weeds off at grass level rather than digging deeper to the root and then pulling them out (Fennell 1999). It is therefore imperative that these beliefs are accessed to enable them to be analyzed, understood and modified. The core beliefs are at the lowest level of cognitive activity and consequently the most challenging and difficult to access. There are a number of effective techniques that enable this.
» The downward arrow technique
This is a process used to move through the cognitive layers to the 3rd level, where the core beliefs reside. It brings the beliefs into the client's awareness, where they are accessible to the therapist. The starting point in the process is a question from the therapist to elicit a NAT. The therapist follows this with a series of economical questions that slowly move the awareness to the core belief.
Example :
Client : I was so nervous about sharing my ideas with my psychotherapy group.
Therapist : Why did you feel this?
Client : I was so anxious that I would come across as intellectually inferior to the group members and the tutor.
Therapist : And if you did come across like this?
Client : I would be devastated
Therapist: Why? What would this mean to you?
Client : That I was simply not good enough
Therapist : And this would mean ?
Client : That I was not worthwhile as a human being - I have no value!
« David Burns suggests an approach for identifying self-defeating or core beliefs that may be easier for someone who is not in therapy to use. He has developed a questionnaire that focuses on the 10 common beliefs. (Burns 1993). In my personal experience, it certainly is a very effective alternative tool for accessing the core beliefs!
STAGE 2
In Stage 2 the negative thoughts are subjected to scrutiny, to determine whether they are healthy or unhealthy. It is important to know when to change negative feelings. Do the thoughts serve you in any way that is positive? Are they all bad? Are they healthy or neurotic? When should I not change them and when would it be better for me to change them? Cognitive distortions are present in neurotic thinking patterns and once these are identified and the thoughts are seen to be unrealistic and irrational, it is much easier to work on changing them. The types of distortions that are commonly present are :
- All or nothing thinking - looking at things in absolute terms
- Over-generalization - view an event as a never-ending pattern of defeat, rather than seeing it as an isolated incident
- Mental filter - filtering out all the positives and focusing only on the negatives
- Discounting the positives - downplaying or ignoring accomplishments or positive qualities, in favor of the negative aspects or failures
- Jumping to conclusions (mind reading and fortune telling)
- Magnification or minimization - blowing things out of all proportion or shrinking their importance
- Emotional reasoning - reasoning based not on logic but rather on emotions
- Should statements - looking for the drivers and the rules
- Labeling - attaching self-effacing labels to oneself
- " Blame - blaming yourself for something that you were not entirely responsible for or blame others and overlook your part in the issue
STAGE 3
The hard-at-work inner critic has a very corrosive effect on self-esteem. It needs to be revealed as a charlatan, proved wrong and silenced! Individuals are therefore encouraged to view their thoughts rather as hypotheses that need to be subjected to empirical testing (reality testing) to determine their accuracy. They take on the role of the personal juror, weighing up the evidence. Through developing a strategy for change (questioning, refuting and replacing thoughts with rational, realistic and healthy ones based on fact rather than "internal fiction"), the hold on these old and well-worn habitual patterns are weakened and more adaptive thoughts and responses are introduced into a person's thought and behavioral repertoire. Self-acceptance is enhanced too. In this way the perpetual attacks on self-esteem reduce significantly to the point where healing can take place and the person can lay claim to a healthy self-esteem that is rightfully theirs!
There are a number of excellent tools in the Cognitive Behavioral Practitioners toolbox, to help someone with LSE smash their old destructive beliefs and create new, self-supporting beliefs. They include :
Examine the evidence approach
- The survey method
- The acceptance paradox. This is based on the philosophies of Buddhism.
- The experimental method. Here the individual takes on the role of the scientist. " The double standards technique
- The pleasure-predicting method
- Thinking in shades of grey
- Defining terms
- The semantic method (using words that are more objective and less emotional)
- Reattribution- looking at other factors that could have contributed to the issue so reducing self-blame
- Bringing positive qualities into focus. People with low self-esteem tend to discount their positive attributes or achievements. By making a list of all the positive qualities, talents, skills and strengths this can help to build and strengthen a positive view of oneself.
- A cost-benefit analysis
- Externalization of voices
- Tackling perfectionism
- Working with positive continua. Changing an old negative belief (schema) into a positive, more realistic belief through use of continua to help measure progress. There are a number of steps that are taken:
- Identify the new core belief.
- Define the behavioral activities that need to be performed to enable the person to strengthen this new and healthy core belief.
- Gather evidence to support this new belief, related to each of the behavioral criteria. In this way evidence is methodically collected to strengthen the new belief.
- Historical review and modification of the core belief
The client is asked to examine a core belief using a historical review. The belief is subjected to scrutiny based on the reasoning ability of the client's adult mind in contrast to the child's mind when the core belief was initially formed.
Intrinsic to the practice of this model is the use a number of worksheets to enhance the process. The action of writing thoughts down, keeping a written record of progress is a powerfully effective supportive process.
Conclusions
The CBT model offers a very effective method for tackling the widespread issue of low self-esteem, the proportions of which could be considered epidemic. The strength of the approach lies in the fact that it is proactive, tacking the source of the problem to promote healing rather than administering something (e.g. talking about the problem) that may provide short-term symptomatic relief. The pathway towards realization of the goal, improved self-esteem, is clearly mapped out. As a result it is possible to monitor progress and qualify it in real changes in thinking and behavior. It is a process of building or rebuilding a positive foundation of self based on realistic, sound and unbiased beliefs. This requires an investment in time and effort on the part of the afflicted person, promising no quick fix. It is unrealistic to believe that the product of many years of compounded negative experiences will be eradicated in a short period of time. The changes that the CB intervention will affect take place on a number of levels. Firstly, structural changes take place. The faulty self-schemata (core beliefs) are remodeled based on evidence of the now, as opposed to the interpretations of the past. This will help to remove the negative biases in the person's thinking patterns, thereby assisting in the alteration of perceptions and subsequent interpretation of events. Secondly, this will, in turn, be translated into behavioral modifications, congruent with the reworked schema.
Once self-esteem is on the mend, the individual becomes less vulnerable to self-attack. Neutral events are less likely to be negatively misinterpreted. Negative events may not impact as powerfully. For example, if someone doesn't like you it won't be the end of the world, losing one's job may be seen as an opportunity rather than as something devastating, failing at a task will be manageable, an aborted relationship will be difficult but not insurmountable and wont' mean that you are undesirable or unlovable.
Developing healthy self-esteem can be seen as the key to discovering joy in everyday living, empowering people to make the most of their lives!
References
Burns, D. (1993) 10 days to great self-esteem p150. Vermillion.
Burns, D. (1980) Feeling Good. The new mood therapy. Avon Books.
Fennell, M. (1999) Overcoming Low Self Esteem. Robinson Publishers.
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