1. Low self-esteem: cognitive behavioural approaches
Debbie Spain
Dept. of Mental Health
Florence Nightingale School of Nursing & Midwifery
King’s 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.

4. 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)

5. 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

6. 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)

7. 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

8. A link between self-esteem, affect and beliefs about voices ?
(Fannon et al., 2009)

9. 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 ?

10. 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

11. 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

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

13. LSE: a cognitive formulation (Fennell – see ref list)13

14. 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

15. 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’

16. 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)

17. 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 17

18. 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)

19. 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) 19

20. 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

21. 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)

22. 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 22

23. Behavioural experiments23

24. 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

25. 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 25

26. ‘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

27. 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)

28. 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), Fennell, M. (1997). Low self-esteem: A cognitive perspective. Behavioural and Cognitive Psychotherapy, 25, Fennell, M. (2004). Depression, low self-esteem and mindfulness. Behaviour Research and Therapy. 42(9), 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, McManus, F., Waite, P. and Shafran, R. (2009). Cognitive-Behavior Therapy for Low Self-Esteem: A Case Example. Cognitive and Behavioural Practice. 16, 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),