Low self-esteem:

cognitive behavioural
approaches
Debbie Spain
Dept. of Mental Health
Florence Nightingale School of Nursing & Midwifery
Kings College London

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

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.

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)

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

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)

How can we explain the

relationship between LSE and comorbidity ?
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

A link between self-esteem, affect and

beliefs about voices ?

(Fannon et al., 2009)

CT for LSE: some considerations

LSE is a transdiagnostic process, rather than a specific
diagnosis
Advantages and concerns about using a formulationbased 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 ?

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

Assessment: Rosenberg selfesteem 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

What thoughts, feelings or

behaviours might
contribute to the
development and
maintenance of LSE ?

LSE: a cognitive
formulation
(Fennell see ref
list)

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

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

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)

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

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)

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)

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

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)

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

Behavioural experiments

23

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

Relapse prevention & therapy

blueprints
Importance of relapse prevention ?
The end of formal therapy doesnt 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

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, selftalk

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)

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), 174-180.
Fennell, M. (1997). Low self-esteem: A cognitive perspective. Behavioural and Cognitive
Psychotherapy, 25, 1-25.
Fennell, M. (2004). Depression, low self-esteem and mindfulness. Behaviour Research
and Therapy. 42(9), 1053-1067.
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, 415-430.
McManus, F., Waite, P. and Shafran, R. (2009). Cognitive-Behavior Therapy for Low SelfEsteem: A Case Example. Cognitive and Behavioural Practice. 16, 266-275.
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 selfesteem: A preliminary randomized controlled trial in a primary care setting. Journal
or Behavior Therapy and Experimental Psychiatry. 43(4), 1049-1057.