Low Self Esteem
How to Treat Low Self Esteem with CBT
Some details of this case have been changed to protect the client’s identity.
One of the aims of this case report is to demonstrate that cognitive behavioural therapy, can bring a change in client’s presentation, a reduction in the symptoms experienced and can also provide the client with skills which will assist in coping with similar difficulties should they arise in the future, within a limited time frame.
The treatment of this client has been adapted to meet his particular needs and it was based on relatively recent research on low self esteem.
It took place within counselling service that can only offer a maximum of 9 months psychological treatment (including an interview, assessment, treatment plans and relapse prevention).
2. Client History
The patient is a 22 year-man from a small catholic town in Spain. He moved to London, with his parents and younger brother when he was about 10 years old. His parents are of coming from a strong religious background.
He was evidently a regular church goer and grew up under firm religious guidance. Things started deteriorating drastically when (at the age of 19) his mother discovered some gay porn magazines hidden away in his closet as well as pictures of himself with other men.
Soon after this discovery and after he admitted that he was gay, he was asked to leave the family home. At that point he became homeless, lonely and gradually depressed.
3. Further Developments
The patient indulged into his newly found freedom with drugs and alcohol, started taking prescribed medication in response to his depressive symptoms and practised male prostitution in order to survive.
Alcohol use became increasingly regular in order to combat loneliness, boredom and to sustain his life style. He has always been missing his family a lot and despite their rejection he still holds a lot of affection and respect for them and their values. But there is a recognised and obvious distance between his choices of lifestyle and those strongly suggested by his family.
These contradictions coupled with a strong sense of guilt and shame about “what or how he is” and “what he does”, as well as his young age precipitated and later perpetuated a loss of self-esteem and direction in life.
Three years after he left the family home, and after he moved in supported housing accommodation, he self-referred for psychotherapy further to an increase in his symptoms of depression and/or anxiety that at times lead to, and at other times were a consequence of, a loss of self esteem (as an in-depth assessment and formulation would later
4. Assessment and preliminary formulation
During the earlier sessions (the interview and assessment stage) it became clear that the patient was experiencing a variety of depressive and anxiety symptoms in response to different events.
He scored 29 on Beck’s Depression Inventory and 22 on Beck’s Anxiety Inventory which both suggest a moderate level of neurotic disorder. He has not been drinking for many years and on a daily basis and his life was not significantly affected by alcohol, thus he did not meet the criteria for alcohol dependence. However his drinking was in response to emotional distress (or sometimes celebration) and it was associated with symptoms relief.
Although to begin with, it was difficult for him to make connections between events, cognitions, moods and behaviour, relevant CBT and psycho-education, followed by drawing up (collaboratively) a preliminary (basic) formulation has facilitated just that.
The initial therapy focus was to highlight the vicious circles that the client often became trapped in, to help him start making connections between events, associated cognitions, behaviour and outcomes and finally to bring minor changes that would motivate the client to attend therapy on a regular basis.
It was recognised at an early stage that Vicente was new to psychotherapy, has never been in touch with any mental health service and his expectations were unrealistic and not clearly defined (‘alcohol is not a problem, nor is my family past, I just want things to be how they were, I am feeling lost and different, not sure that homosexuality is something I should be practising’).
Other priorities in the earlier sessions were to build trust with the client, to
collaboratively identify and operationalise the therapeutic goals and manage expectations from therapy and therapist.
The goals initially identified have changed throughout the therapeutic process and were continuously refined (just like the formulation was) but without losing sight of the initial overall aims.
For example when the client expressed during a session that he would like to feel normal again it was essential to clarify the specifics of ‘what does normal actually mean for him’ and where was he at that stage on a scale from 0 – 10 (0 – I am in a terrible place and 10- I am extremely happy). After Socratic questioning and sufficient guided discovery the client concluded that he wants to be at point on the scale (since he cannot realistically expect to be happy and anxiety or depression free all the time).
6. Continuing treatment - case formulation approach
Although the individual with a low self esteem has core beliefs reflective of one’s self-worth assessment and value as a person, in Vicente’s treatment it was equally important to consider his perception of others and his perceived position in the relationship with others.
Those specific self-evaluations and evaluations of others were generating a whole set of compensatory strategies. Hence introducing concepts such as Early Maladaptive Schemas (emotional deprivation or defectiveness & shame schemas) and schema coping styles (Schema Surrender, Avoidance or Overcompensation), have added value in the effective understanding and in the treatment of this case (Young, 1994).
It is worth noting at this point that more relevant history was added in this section than at the beginning of this paper (under Client’s History chapter).
That is in order to present how case unfolded in reality. The flow of relevant information about family, childhood, developmental history or significant life events, did not flow naturally as most therapists would hope, despite efforts to create the right atmosphere. In fact the therapeutic relationship was often hindered by client’s own schemas, which often pushed him to test the therapist.
The patient in this case example made significant progress over the course of therapy that lasted more than a year, to build a trusting relationships can take time, and although he had a lot of faith in his therapist he did not reveal painful experiences such as sexual abuse until his 8th session.
Through therapy he started to address his maladaptive schemas (core beliefs, assumptions rules, guidelines) and associated unhealthy strategies thus developing a more balanced view of self and others.