How to Fully Apply the CBT Approach to Treating Low Self-Esteem
Your client has crippling self-esteem.
Every week you sit with them and go over old ground. You challenge thoughts, and they nod in agreement, but week in week out nothing seems to change.
You feel as if nothing will ever work. Self-views will never shift.
Soon you'll be one client less, and everyone will be all the poorer.
Is there no tip, trick or approach that will work?
While CBT is known for treating anxiety and other panic disorders, it's not known for being useful with self-esteem. And while it's fast becoming the approach of choice for health services around the world, not everyone agrees it should.
Maybe you have your doubts. Maybe CBT hasn't worked well in the past. Maybe you feel it's approach is all the same. And I sympathise.
But in its approach to self-esteem, it at least offers an interesting perspective.
One that could help turn your client around. That could give them the self-esteem they deserve.
Understand Your Clients Pain
CBT regards beliefs about ourselves and other people as learnt and having their roots in experience.
This learning can come from many sources:
- Direct experience
- The Media and Social Media
- The thoughts and behaviours of people around you
The thoughts and behaviours of people around you
Often a person's sense of their self-worth is a result of how they were treated in early life.
If caretakers mistreat children, they often assume this reflects something terrible in themselves - they must have somehow deserved it.
Over time these views can become entrenched.
While they may have made sense at one time, and while they may have served a purpose, now they don't.
These experiences can emerge from systematic punishment, criticism, neglect and abuse, to a mild sense of being an odd one out at school. And they're not just restricted to early experiences.
Workplace intimidation or bullying, abusive relationships, stress, and exposure to traumatic events can all affect later life.
Understanding your clients' background, where they might have picked up their self-beliefs from, is the start of the healing journey.
Healing Starts Here
Smash Apart the Bottom Line
The bottom line is the conclusions the client has formed about themselves based on their experience.
It's their assessment of their worth and value as a person.
- “I am bad.”
- “I am worthless.”
- “I am stupid.”
- “I am not good enough.”
Different clients have different bottom lines:
- “I am fat and ugly.”
- “I am all wrong.”
- “I am unlovable.”
- “I am inferior.”
They will fully believe the bottom line is correct. It can be hard to make clients realise that it's just an outdated idea. One they picked up long ago.
One way to help them smash through the Bottom Line is to read case stories of others. When looking at someone else, it can be obvious where faulty thinking is.
Another way is to work with clients, so they come to understand their bottom line. How it might have developed and what patterns keep it going.
It's essential to help clients see that their negative beliefs about themselves are opinions, not facts. Habits of thought that can change.
The glass half empty can become the glass half full.
Half empty, or half full?
Systematically Destroy All Biases
It's useful to educate clients on the biases that serve to keep their bottom line active.
- Biased Perception is when clients only notice what is wrong. Misperception can relate to aspects of physical appearance (Their eyes are too small), character (They're not outgoing enough), or simple mistakes (They're so stupid). Moreover, it involves filtering out what is positive. Anything that doesn't fit the bottom line gets ignored.
- Biased Interpretation is when the meaning of what is seen gets distorted. Trivial mistakes and failings reflect their self-worth. Dissatisfaction with one aspect of themselves takes on all-consuming importance. Eyes are too small; therefore, they're ugly. Compliments get discounted and thinking always favours self-criticism.
Exercises can help clients understand what biases they may use.
As their therapist, you can help them:
- Catch Self Critical Thoughts as they happen - the first step is noticing.
- Question self-critical thoughts - is this necessarily true?
- Practice treating themselves more kindly - are there alternative views?
- Develop and act from a new perspective - is this just the voice of low self-esteem?
A critical part of the healing process is when clients realise their thoughts about themselves are open to question.
They can learn to observe and record them and their impact on their feelings, body state and behaviour. And they can re-think them and search for more balanced and kindly perspective on themselves.
Is this just the voice of low self-esteem?
End the Destructive Cycle
Your ultimate goal as a therapist is to get your client to end the destructive cycle of thinking that fuels their low-self esteem.
One way that cycle is maintained is anxious predictions.
Low self-esteem makes it hard to make realistic predictions or to act on them with an open mind.
When clients with low self-esteem make predictions about themselves (e.g. 'I won't be able to cope', 'Everyone will think I am an idiot'), they tend to treat them as facts, rather than hunches that may or may not be correct.
And the problem?
To prevent the predictions coming true, they take precautions.
Doubt and uncertainty mean they act out a whole range of strategies designed to prevent the worst from happening.
Unfortunately, in the long run, these strategies rarely work.
As a therapist, you can educate the client on the biases behind anxious thinking. Including:
- Overestimating the chances that something terrible will happen - I'm always bad at presentations.
- Overestimating how bad it will be - everyone will laugh at me.
- Underestimating personal resources - I'm no good at these things.
- Underestimating external resources - No one will help me prepare.
You can also help your client become aware of what they are predicting when they become anxious. Educate about the bodily symptoms of anxiety, so they become aware of the trigger - thought - anxiety cycle.
Encourage your clients to experiment. To face situations, they would typically avoid and to take the risk of dropping unnecessary precautions.
The most powerful way they can build confidence is to do things differently. To face their fears and realise they're not real.
Discovering that you can
Break All the Rules
To act in the world while maintaining the bottom line, clients will have developed specific rules that allow them to get by.
If someone believes they are wrong, they won't allow anyone close to them. If that same person believes they are unacceptable, they will always keep themselves under control. If the person on your chair believes they are unlovable, they will never ask for what they need.
These rules can usually express themselves in one of three ways:
Assumptions are ideas about the connections between self-esteem and other things in life. They usually take the form if, then statements.
- If I allow someone close to me, then they will hurt and exploit me.
- If someone criticises me, then it means I have failed.
- Unless I do everything people expect of me, then I will be rejected.
Drivers are the ‘shoulds’, ‘musts’, ‘oughts’ that compel us to act in particular ways or be particular kinds of people, to feel good about ourselves.
- I must never let anyone see my true self.
- I must always keep myself under tight control.
- I should be able to cope with anything life throws at me.
Value Judgements are statements about how it would be if clients acted (or did not act) in a particular way, or they were (or were not) a particular kind of person.
- It’s terrible to make mistakes.
- Being rejected is unbearable.
- It’s vital that I stay on top of things.
Rules are not like anxious predictions or self-critical thoughts.
They do not pop into client's heads under specific circumstances and at particular moments.
They are much broader, more general in their impact. Rules may influence how clients think, feel, and act across a whole range of situations.
Helping clients identify their rules, challenging them, and working with them to create new ones is at the core of the CBT approach.
Changing all the rules
Create a Superstar
It's not easy to see people attack themselves. Or resist well-meaning attempts to change their core beliefs.
And while the CBT approach may not be a panacea, it does have some things to teach us.
When a client talks of a point where they can't get past, you can refer to the bottom line. When they speak of negativity or share some of their critical thoughts, you can see to biases. And when they talk of getting anxious, you can help them work out what it is they are predicting.
You can mix exploratory work with psycho-education, uncovering the root cause of their bottom line and rules for living, giving assignments and homework that involve recording thoughts and analysing beliefs.
Building up self-acceptance and creating a positive bottom line.
The goal is to change the rules.
To turn a negative cycle into a positive one. To let a more confident, assertive, self-respecting client emerge. To use CBT for low self-esteem to create a triumphant superstar, get counselling in Peterborough now.
- Premature Termination in Psychotherapy: Strategies for Engaging Clients and Improving Outcomes by Joshua Swift and Roger Greenberg
- All that Remains: A Life in Death, by Sue Black