Cognitive Behavioural Approaches to Low Self Esteem
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Transcript of 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(?), /?*-/.+