Low self-esteem: co c gn g i n tive v e b e b h e a h v a iour u a r l app p r p o r ach c e h s e s

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1 Low self-esteem: cognitive behavioural approaches

2 Learning outcomes By the end of the session, students will be able to: Define (low) self-esteem 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, Fennell, M. (2006). Overcoming low self-esteem: Self help workbooks. 2 nd 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 and focus of attention -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 Can you think of any examples of situations or experiences that a person might find difficult if they have LSE?

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 CT for LSE: some considerations LSE is a transdiagnostic process, rather than a specific diagnosis

9 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

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

11 LSE: a cognitive formulation (Fennell see ref list)

12 A basis for treatment: Theory A / Theory B Theory A: Mark is inadequate and worthless; therefore he needs to work very hard to make sure that his work is good enough Theory B: Mark is as worthwhile as others, but his LSE and negative beliefs about himself cause him to engage in behaviours and thinking patterns that perpetuate anxiety and low mood (adapted from McManus et al., 2009)

13 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)

14 Self esteem Vs self acceptance Esteem means? Self acceptance exercise by Albert Ellis & Windy Dryden

15 Exercise Can you think of a situation where you might have judged yourself in this all or nothing way? Can you identify your beliefs, emotions and behaviour in this situation? If you apply the principles of self acceptance to this, what would your belief, emotion and behaviour change to?

16 LSE: overview of treatment approach Psycho-education and formulation to the model - a shared formulation is critical for success 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 Common interventions Identifying and challenging negative thoughts / beliefs Positive data logs: listing positive qualities, daily Increase engagement in enjoyable activities Behavioural experiments Acting on the new bottom line

18 Positive personal qualities

19 PPQ Surveys

20 Positive data log 1

21 Common interventions contd. Developing a therapeutic alliance; a safe and supportive environment Socratic questioning Evaluating the evidence (e.g. for specific beliefs / schema) Assertive defence of the self useful for dealing with criticism (Padesky, 1997)

22 Exercise Going back to the situation where you judged yourself : Can you remember the facts and/or evidence that you based your judgement on? If you had to defend yourself assertively ( be your own defence lawyer) what evidence or facts can you come up with?

23 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

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 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 Document examples of success; and helpful strategies

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. 2 nd 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),

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