Low self-esteem is characterized as a negative sense of the self and co-occurs with many other mental health problems. Although not formally represented in the diagnostic manuals it is nevertheless a distinct and treatable psychological difficulty. Negative self-evaluation is common, and low self-esteem can feature as a consequence of other primary conditions such as obsessive compulsive disorder (OCD) or post-traumatic stress disorder (PTSD). In these cases, negative self-beliefs are often addressed during the treatment of the primary difficulty. However, when negative self-beliefs feature as a primary difficulty, or as a vulnerability factor for other conditions such as in depression or social anxiety, then addressing the underlying low self-esteem is considered an important target for treatment.
Melanie Fennell’s Cognitive Behavioral Model of Low Self-Esteem (1997) is an adaptation of Aaron T. Beck’s (1976) generic model of emotional disorders. The model suggests that life experiences shape an individual’s beliefs about the self, others and the world. These ‘schema’ shape how a person perceives (filters) and understands their life experiences. Fennell characterizes schemas in low self-esteem as negative beliefs or images “of the self as a whole person rather than a differentiated flexible appreciation of varying qualities or aspects of the self.” The schema may be overtly articulated for example “I am unacceptable”, “I’m not good enough” or “I am worthless”, or it may be a more generalized ‘felt sense’ of inadequacy. Fennel describes such negative self-schema s persistent, enduring across time, situationally specific, and largely habitual and automatic.
The model is split into two parts. The top half of the model considers how an individual’s early experiences shape low self-esteem, and across which situations negative beliefs may be especially active. It describes a number of components and stages:
- Life experiences shape an individual’s core beliefs about the self, others and the world.
- The negative self-schema can be expressed as a ‘bottom line’: a fundamental negative global self-judgement.
- Intermediate beliefs which Fennel terms ‘rules for living’ are developed to safeguard and protect one’s self-esteem. “They specify the standards the person must achieve in order to remain relatively comfortable with him or herself”.
- In situations where one’s personal standards are not met, or might not be met ( triggering events, critical incidents), the negative self-schema (bottom line) is activated.
The bottom half of the model considers how maintaining mechanisms operate to perpetuate the low self-esteem schema. Once an individual’s ‘bottom line’ has been activated:
- Negative predictions about a triggering event (critical incident) lead to a state of anxiety. These anxiety symptoms in turn feed more negative predictions, subjectively confirming one’s bottom line and generating a vicious cycle of anxious preoccupation. For example: Invited to a party (critical incident) > “I’m worthless” (bottom line) > No-one will talk to me (prediction) > Feel anxious > Confirmation of bottom line: “I must be worthless or I wouldn’t be feeling so anxious”.
- Avoidance and safety behaviors aimed at reducing the anxiety: these prevent disconfirmation of the anxious predictions and further fuel the vicious cycle of anxious preoccupation. For example: Invited to a party (critical incident) > “I’m worthless” (bottom line) > No-one will talk to me (prediction) > Feel anxious > Avoid going (maladaptive behavior) > Confirmation of bottom line: “I knew it, I’m worthless, I can’t even go to a party like a normal person”.
- The bottom line is confirmed via parallel processes of perceptual bias (e.g. attending to one’s flaws and failures) and interpretational bias in which positive, neutral, or irrelevant data are ‘skewed’ to fit the negative schema (e.g. “they were only being kind”). The negative self-belief is reinforced, forming a vicious cycle.
Fennel draws attention to the possibility that in situations where there is the possibility that one’s rules (conditional assumptions) might not be met, both the anxious and depressive vicious cycles are activated. For example, if an individual holds a rule that “I must never let people down” and is confronted by a situation in which they might do so, then their underlying belief (e.g. “I’m useless”) is likely to activated. However, when there is no uncertainty – for example, when one’s rules are definitively broken – then the self-critical depressive cycle may be activated alone, without the anxious preoccupation. The model suggests individuals oscillate between the anxious and depressive cycles depending on the level of uncertainty.
The model enables clients to become aware of the processes that maintain their negative self-belief, including their cognitive biases and safety seeking and avoidance behaviors. The implications for treatment are that clients can learn to challenge and overcome these processes. Fennell (1997) describes a variety of therapeutic interventions for low self-esteem which include:
- Correcting perceptual bias by attending deliberately to strengths and achievements.
- Monitoring and challenging self-critical thinking and catastrophic predictions using thought records.
- Introducing Padesky’s prejudice metaphor (Padesky, 1990) as analogous to beliefs about the self.
- Developing alternative beliefs about the self by looking for counter-evidence, examining positive data logs, examining historical data.
- Using continuum work to weaken absolutistic thinking.
- Monitoring and testing anxious predictions (which often include components of overestimation of risk, and underestimation of ability to cope). One effective method for testing clients’ beliefs is the use of behavioral experiments.
- Changing behavior such as overcoming avoidance and safety behaviors, for example with exposure tasks.
- Analyzing and modifying dysfunctional assumptions: identifying and modifying the ‘rules for living’ (reviewing the advantages and disadvantages of rules, reviewing the historical helpfulness of rules, testing new rules for living).
“It would be helpful to explore and understand how your low self-esteem developed and what is keeping it going. I wonder if we could explore some of your thoughts, feelings, and reactions to see what kind of pattern they follow?”
- Early experiences: Help the client to explore important events from their childhood, and emotional memories and relationships with their caregivers (e.g. were they loving, critical, neglectful). Reflect on early life experiences, prompting for any adverse or difficult experiences. Consider using both open and closed questions:
- The environment we grow up in, the way others treat us, and the experiences we go through have a big impact on our self-esteem. Let’s explore the experiences you have had in life that have affected your self-esteem.
- What was growing up like for you? (prompt for family life, school life, friendships, relationships etc.). Did you go through any difficult times growing up? What impact did it have on you?
- What were relationships like as you were growing up? How were you treated by your mum and dad (and/or your siblings)? How did your parents care for you? Were there any negative experiences?
- We know difficult experiences in childhood can lead to low self-esteem. Did you have any of the following experiences?
- Abusive experiences for example physical, sexual or emotional abuse
- Other difficult events such as being bullied, losing someone you love, being in an accident, being seriously ill or being hurt or injured.
- Being rejected or hurt by others.
- Being discriminated against, or being the focus for prejudice.
- Being mistreated or punished frequently.
- Being different and not fitting in.
- Too much criticism from a parent or at school.
- Too little praise, warmth or affection from your parents.
- Being neglected physically or emotionally.
- Parents having unrealistic expectations.
- Difficult experiences as an adult can also impact on self-esteem. Have you had any stressful events as an adult that have affected how you see yourself? For example, an abusive relationship, being bullied at work or any traumatic experiences?
- The bottom line: Help the client to explore how their past experiences have shaped how they think and feel about themselves. It can sometimes be helpful to use a technique like ‘downward arrow’ to explore a client’s negative core beliefs.
- How have your past experiences shaped what you think of yourself?
- What kind of words do you use to describe yourself?
- Deep down what do you think and feel about yourself?
- If that were true, what would it say about you?
- Rules for living: Help the client identify any rules and assumptions they have developed to help them to function in the world. Rules for living can often be described in terms of “If … then …” statements, or absolute ‘shoulds’ and ‘musts’. Another way of thinking about rules is that they are ‘personal standards’ which keep self-esteem intact as long as they are met. A difficulty in low self-esteem is that rules often take the bottom line as a ‘given’ and inflexibly demand compliance. For example, “If I do what others want and please people all the time then they might not reject me” or “I must always do things perfectly [or else I am a failure]”. Questions to explore rules for living might include:
- When you’re in situation X, is there anything you feel you must do?
- When you feel anxious that you might be ‘found out’, what do you do to protect yourself?
- What rules do you live by that make you feel better about yourself?
- Do you recognize any ‘musts’ and ‘shoulds’ that you live by?
- Do you have any mottos that you live by?
- Do you recognize any of these rules in yourself?
- I must always put others first
- If I don’t succeed then I’m a failure
- I must do things perfectly all the time
<li”>Everybody should always like me
- I must never let people down
- Critical incidents: These are ‘trigger situations’ in which one’s rules are definitely broken, or might be broken (ambiguous). Help the client to identify common types of situations that trigger activation of their bottom line. These might be situations when their rules for living are definitely broken (e.g. failed a test) or situations when there is the threat that the rules might be broken (e.g. sitting a challenging test that could be failed).
- Can you tell me about some situations that you normally find quite challenging? What is it about those situations that bothers you most?
- You told me that it’s often situations where there’s a deadline that you find challenging. What rule do you think might be under threat in that situation?
- What kinds of situations trigger your bottom line? When do you tend to feel, for example, not good enough?
- Can you tell me about a recent time when one of your rules were broken?
- Can you tell me about a recent time when one of your rules was at risk of being broken?
- What are the typical situations when your standards and rules may not be met?
- Activation of bottom line: Help the client to understand that the trigger situation activates their bottom line.
- What happens when you can no longer maintain your rules and standards?
- How do you feel when your rules are broken or at risk of being broken?
- What kind of ‘bottom line’ might be activated in situations like that?
- How does this make you feel?
- Predictions: Using specific examples, explore the kind of negative predictions that the client makes when the bottom line is active. Help the client to understand that negative predictions lead to symptoms of anxiety, which in turn generate further negative predictions, forming a vicious cycle.
- What kind of predictions did you make in that situation?
- What were you worried would happen?
- What is your worst fear?
- What would be the worst-case scenario?
- How do these predictions make you feel?
- Unhelpful coping strategies: Help the client to identify how they behaved in response to their anxious preoccupation. Focus on avoidance and safety-seeking behaviors. These might include seeking reassurance, keeping quiet, making excuses, or other compensatory behavior.
- What do you do to cope with the anxiety?
- What do you to prevent the worst from happening?
- Is there anything you do which makes you feel better in this situation?
- If you can’t avoid or escape, what do you do to cope?
- Do you avoid anything or take any extra precautions?
- Confirmation of the bottom line: Help the client to understand how unhelpful behaviors can inadvertently serve to confirm the bottom line.
- What happens to your belief in your bottom line when you feel anxious? Do you think it gets stronger or weaker?
- What happens to your belief in your bottom line when you avoid or use safety behaviors?
- Self-critical thinking: Help the client to elicit the self-critical thoughts they experience when their bottom line is active.
- What kinds of things do you say to yourself when you are feeling …?
- What kind of thoughts go through your mind at times like these?
- How do you criticize yourself in these situations?
- What thoughts go through your mind?
- What kinds of names do you call yourself?
- Low mood/Depression: Help the client to understand the link between their thoughts and mood.
- How do you feel when you speak to yourself like that?
- Interactions between components: Self-criticism and depressed mood continues to keep the bottom line active, feeding into further negative predictions and anxiety. Unexamined or unchallenged rules for living continue to present many potential opportunities for standards to be broken. This continues the vicious cycle of low self-esteem.
- Exploration of treatment targets: Once the model has been developed using specific examples clients can be encouraged to reflect on potential areas for intervention. Typical early targets are anxious predictions, unhelpful behaviors, self-critical thinking.
- If we could make a change in any part of this cycle, where would be a good place to start?
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International University Press.
Fennell, M. J. (1997). Low self-esteem: A cognitive perspective. Behavioural and Cognitive Psychotherapy, 25(1), 1-26.
Padesky, C. A. (1990). Schema as self-prejudice. International Cognitive Therapy Newsletter, 6(1), 6-7.