cognitive behavioural approaches to low self esteem

8/9/2019 Cognitive Behavioural Approaches to Low Self Esteem

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Low self-esteem:cognitive behavioural

approaches

Debbie SpainDept. of Mental Health

Florence Nightingale School of Nursing & Midwifery

King’s College ondon


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Learning outcomes

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

• Dene (low) self-esteem

• Discuss the limitations and advantages toformulation-based treatment approaches

• utline the cognitive model of L!"

• Be aware of interventions for L!"

• #e$ect on clinical practice implications


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%ider reading

&ennell, ' (**+) Low self-esteem: cognitiveperspective !eha"ioural and Cogniti"e

#sychotherapy , 25, -.

&ennell, ' (//0) $"erco%ing low selfestee%'Self help wor(boo(s nd ed London: 1onstable


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Dening L!"

• 2egative representation of self:

- learned process

- global (negative) 3udgement

- shapes subse4uent thoughts, feelings andbehavioural responses5 and informationprocessing

- negative sense of self (and schema) thereby

perpetuated, and reinforced

(&ennell, **65 %aite et al, /)


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L!": 7mpact and

impairment• 8ow might L!" impact on daily functioning 9

- can aect functioning across several domainseg

wor;, social life

- can be pervasive or occur in response tosituations < perceived cues

- features are not necessarily static5 severity offeatures may wa= and wane

• 2ot always an adverse e=perience


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L!" and co-morbidity

• L!" often found to occur alongside a range ofpsychiatric disorders, in particular:

- an=iety disorders eg >D, social phobia, 1D

- depression- eating disorders

- psychosis

• (&annon et al, //*5 &ennell, //?5 &reeman etal, **6)


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8ow can we e=plain therelationship between L!" and co-

morbidity 9• 7t has been hypothesised that L!" might be:

- a component of other disorders

- a cause of psychiatric disorder

- a conse4uence < outcome of other di@culties

- a vulnerability or predisposing factor fordeveloping psychopathology (eg &ennell, //?5'c'anus et al, //*)

• &urther research needed to understandrelationship between symptoms


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lin; between self-esteem, aect andbeliefs about voices 9

(&annon et al, //*)


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1A for L!": some considerations

• L!" is a transdiagnostic process, rather than a specicdiagnosisC

• dvantages and concerns about using a formulation-based approach, compared to a disorder-specic modelof care 9

• athways to 1BA for people who e=perience L!"

- features may be overloo;ed entirely

- may be referred for L!"-wor; directly

- features may become evident during a course oftherapy

- may arise in the conte=t of formulating comple= casesC

- anything else 9


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1BA assessment for L!"

• #"1: the remit of a 1BA assessment 9

• ssessment includes consideration of:

- current maintaining factors- developmental < longitudinal factors

- specic triggers or modiers

- co-morbid psychopathology eg depression,an=iety

- impact and distress

• 2eed to consider how L!" features may mediateresponses, engagement during an assessment


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ssessment: #osenberg self-esteem scale

• / item self-report 4uestionnaire5 ? point Li;ert scale

n the whole 7 am satised with myself

t times 7 thin; 7 am no good at all

E 7 feel that 7 have a number of good 4ualities

? 7 am able to do things as well as most people

. 7 feel 7 do not have much to be proud of

0 7 certainly feel useless at times

+ 7 feel that 7 am a person of worth, at least on an e4ualbasis with others

6 7 wish 7 could have more respect for myself

* ll in all, 7 am inclined to feel that 7 am a failure

/ 7 ta;e a positive attitude towards myself


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%hat thoughts, feelings orbehaviours might

contribute to thedevelopment and

maintenance of L!" 9


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L!": a cognitiveformulation(&ennell F see ref

list)


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&ormulation in clinicalpractice

• 'ust be a collaborative process

• Ahe formulation serves several purposes: to socialiseto the model5 clarify insight and understanding5inform treatment approach and goals for therapy

• 'ay be easier to focus on maintaining factors in rstinstance

• 7mportant to pitchC this at the right level for theindividual


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&ormulation in clinicalpractice

• %hat you sayC, and what the individual hearsCmay be two dierent things eg:

- Gyou are unacceptable to othersH OR

- Git seems that you believe that you areunacceptable to othersH

- Gyou seem to worry that you are unacceptableto othersH

• Aherefore, need to be mindful of, andaccommodate information processing biasC


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1A for L!" aims to I 9

• #educe negative sense of self

• &ind a more balanced view of self

• ccept (possibility) that have strengths and

wea;nesses• 7ncrease awareness of positive 4ualities

('c'anus et al, //*5 &ennell, //05 %aite et al,/)


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L!": overview of treatmentapproach• >oal-setting

• sycho-education and formulation to the model

- a shared formulation is critical for success

•

vercoming maintaining factors eg avoidance• "=ploring and re-evaluating dysfunctional

assumptions < rules for living

• "=ploring and re-evaluating core beliefs < the

bottom line• "nhancing identication and awareness of positive

4ualities


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L!": goal setting

• >oal setting is a fundamental component of1BA %hy might this prove comple= when

wor;ing with people who have L!" 9

• 1an we minimise di@culties 9

• 7mportant to have open discussion about this

early on

• &urther aims < goals may be added over time

• 2eed to be realistic (and !'#A)


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basis for treatment: Aheory < Aheory B

Theory A: Jane is inade4uate and worthless5therefore she needs to wor; very hard to ma;esure that she is accepted

Theory B: Jane is as worthwhile as others, buther L!" and negative beliefs about herself causeher to engage in behaviours and thin;ingpatterns that perpetuate an=iety and low mood

(adapted from 'c'anus et al, //*)


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1ommon interventions

• Ahought records

• 7dentifying and challenging negative thoughts

• Kse of continuums

• Behavioural e=periments• 'ore behavioural e=periments

• 1ue cards

• ositive data logs: listing positive 4ualities, daily

• 7ncrease engagement in en3oyable activities

• cting on the new bottom lineC

• reparing for the future5 relapse prevention


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1ommon interventionscontd

• Developing a therapeutic alliance5 a safe andsupportive environment

• !ocratic 4uestioning

• Downward arrow techni4ue

• "valuating the evidence (eg for specic beliefs< schema)

•

Gssertive defence of the selfH F useful fordealing with criticism (ades;y, **+)


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Behavioural e=periments: anoverview

• way to test out beliefs

• 7nformed by a shared formulation

•

7dentify the specifc belie to test• #ate the strength of belief

• Devise a way of testing this out

• 'a;e predictions

• 7dentify and problem-solve around any obstacles• Drop safety-behaviours

• 1onduct e=periment

• #ate outcome, belief


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Behavioural experiments

E


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pitfalls

shared formulation is vital

Aas;s need to be pitchedC at the right level5 be

mindful of the impact of possible high e=pectations< perfectionism

7mportant to problem-solve with the individual inadvance

1an be helpful to practice or role model in session

Best to write everything down


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#elapse prevention M therapyblueprints

• 7mportance of relapse prevention 9

• Ahe end of formal therapy doesnCt necessarily

mean that therapy has ended: 1BA aims tosupport people to ac4uire strategies that theycan continue applying

• 7dentify and e=plore ris; factors

• Document e=amples of success5 and helpfulstrategies


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1BA in practiceC

• rovide handouts

• rovide opportunity for re$ection, and criticism <concern about the formulation

•

!upport people to generate their own e=amples• Be aware of thin;ing errors < biasC in information

processing: accommodate these eg inhomewor;

• ic; up on cues in session: eg comments, self-tal;


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!ummary and someconsiderations

• Ahe evidence base for eective treatments fortransdiagnostic processes is increasing

• But I it is important to ;eep therapy simpleCand straightforwardC ie focusing on specicgoals, one step at a time

• 1BA interventions for L!" aim to reduce a

negative sense of self (and factors associatedwith this), and increase awareness of positives(and engagement in en3oyable tas;s)


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#eferences and further reading

Bennett-Levy, J, Butler, >, &ennell, ', 8ac;mann , 'ueller, ' and %estbroo;, D

(//?) $)ford *uide to !eha"ioural +)peri%ents in Cogniti"e ,herapy =ford:=ford Kni ress&annon, D, 8ayward, , Ahompson, 2, >reen, 2, !urguladNe, ! and %y;es, A (//*)

Ahe self or the voice 9 #elative contributions of self-esteem and voice appraisal inpersistent auditory hallucinations Schi-ophrenia !ulletin 112(-E), +?-6/

&ennell, ' (**+) Low self-esteem: cognitive perspective !eha"ioural and Cogniti"e#sychotherapy , 25, -.

&ennell, ' (//?) Depression, low self-esteem and mindfulness !eha"iour esearchand ,herapy 42(*), /.E-/0+

&ennell, ' (//0) $"erco%ing low selfestee%' Self help wor(boo(s nd ed London:1onstable

&reeman, D, >arety , &owler, D, Ouipers, ", Dunn, >, Bebbington, and 8adley, 1(**6) Ahe London-"ast nglia #1A of 1BA for psychosis 7P: !elf-esteem andpersecutory delusions !ritish /ournal of Clinical #sychology 3, ?.-?E/

'c'anus, &, %aite, and !hafran, # (//*) 1ognitive-Behavior Aherapy for Low !elf-"steem: 1ase "=ample Cogniti"e and !eha"ioural #ractice 1!, 00-+.

Aarrier, 2, %ells, and 8addoc;, > (**6) (eds) ,reating Co%ple) Cases. ,heCogniti"e !eha"ioural ,herapy 0pproach 1hichester: John %iley and !ons

%aite, , 'c'anus, & and !hafran, # (/) 1ognitive behaviour therapy for low self-esteem: preliminary randomiNed controlled trial in a primary care setting /ournalor !eha"ior ,herapy and +)peri%ental #sychiatry 43(?), /?*-/.+

cognitive behavioural approaches to low self esteem

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