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"I'm Unlovable": Changing Your Client's Lifetraps
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Section 16
An Integrated Approach toThe Psychotherapy of Self-Esteem
Anne C. Fisher, PhD ADTR

CEU Question 16 | CEU Answer Booklet | Table of Contents | Couples
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Introduction
Mimi hesitates to accept an invitation to spend the weekend with new acquaintances at the beach, thinking that she is not an interesting person. Jared often treats others angrily assuming, in advance, that they think poorly of Self-Esteem Im Unlovable Changing Your Clients psychology continuing edhim. Sheila worries about applying to a university to study landscape architecture, because she believes she can’t possibly succeed. Jay becomes so concerned about what his boss thinks of him that it interferes with his performance at work. Whinny cries that she stays home alone on the weekends because she believes that no one she knows truly likes her. Nana remains married to an abusive husband who is paranoid and alcoholic, because she thinks, “He is the best I can do.”

These are just a few clinical examples, from my private practice as a psychologist, demonstrating the debilitating effects of the difficulty in regulating self-esteem on the inner, relational and professional lives of my patients.

The Importance of Self-Esteem
“The need to feel that one possesses value and worth, at least in Western cultures, is a kind of psychic bedrock, essential to the existence of the person, analogous to the body’s need for air or water” (Mack & Ablon, 1983, p. 4). Since the earliest reference to self-feeling by William James in 1890, there have been more than 7000 articles and books published about self-esteem and 20,000 articles published that are indirectly related to it (Mruk, 1995). Additionally, more than 2000 measures of self-esteem have been identified (Kitano, 1989). Theory and research regarding self-esteem spans the disciplines of psychology, sociology and education.

There is one outstanding theme in the literature of self-esteem. It is that positive self-esteem is a crucial aspect of well-being. Difficulties with self-esteem have been linked to all manner of psychopathologies, for example: thought disorders such as schizophrenia, affective disorders such as depression, neuroses/anxiety disorders, substance addictions, and personality disorders, such as narcissistic and borderline. Based on this information, the importance of the ability of the psychotherapist to effectively influence self-esteem cannot be underestimated.

Dimensions and Definition of Self-Esteem
Overlapping and yet distinctive perspectives are offered for naming, locating, defining and conceptualizing self and self-esteem and the relationships between them. Also, there are a variety of explanations related to their origins, meanings and functions, and their development. For the purposes of this work, self-esteem is defined as the emotional, cognitive, behavioral, physical, and social evaluation a person makes of himself or herself. The ability to balance positive and negative aspects of that evaluation is termed the regulation of self-esteem and is considered the goal of self-esteem development and of the psychotherapy of self-esteem.

An Integrated Approach to the Psychotherapy of Self-Esteem
The comprehensive treatment of self-esteem involves detailed conceptualization, effective clinical assessment, careful process monitoring and sensitive intervention, all in the context of the therapeutic relationship.

Therapist Conceptualization of Self-Esteem
“...self-related phenomena...coexist in an intricate, multidimensional, interlocking network of structures...” (Mruk, 1995, pp. 25-26). Conceptualizations of self-esteem run the gamut of theoretical orientations. As self-esteem is such a complex and foundational aspect of human being, it is challenging to address it in psychotherapy. Hence, detailed study of self-esteem is recommended. The following is a quick reference to categories in the literature of self-esteem and their continua which can be used to gauge your knowledge and to identify your preferences.

1. Labels: There are a variety of names that are applied to self-esteem, for example: self-regard, self-love, self-acceptance, and self-respect.
2. Perspective: Self-esteem may be viewed as residing in individual processes, social processes, or both.
3. Nature: Self-esteem may be viewed as motivational, cognitive, affective, experienced, or all.
4. Temporality: Self-esteem may be viewed as stable over time, fluctuating, or both.
5. Awareness: Self-esteem may be considered to be conscious, preconscious, unconscious, habit, or as a combination.
6. Values: Self-esteem may be viewed as value-based, imbued with values from many sources within the culture such as social institutions including religion, education, family, and significant individuals such as parents, siblings, teachers, clergy, and peers.
7. Development: Self-esteem may be viewed as maturational and as developmental products and processes.
8. Survival: Self-esteem may be viewed as defensive, adaptive and as a regulatory mechanism, or as a combination.
9. Origin: Self-esteem may be viewed as evolutionary, innate, learned, or as a combination.
10. Specificity: Self-esteem may be viewed as global, specific (for example, including aspects such as physical, moral-ethical, personal, familial, social, aspects, etc.), or as a combination.
11. Mastery: Self-esteem may be viewed as related to success, efficacy, competence, strength, mastery, and superiority.
12. Historicity: Self-esteem may be viewed as indistinguishable from one’s life historical context and/or from one’s present lived experience.
13. Uniqueness: Self-esteem may be viewed as a unique personal construction and/or as shared with one’s larger groups.
14. Authenticity: Self-esteem may be viewed as the extent to which one is living authentically, rather than falsely.
15. Self-actualization: Self-esteem may be viewed as an important constituent of a human potential for self-realization or self-actualization.

Clinical Assessment of Self-Esteem
The following areas are important to consider in the assessment of self-esteem. Careful assessment will help you to formulate interventions.

1. Thought: What does your patient communicate about what he or she thinks of himself or herself, of you, and of others? Each area offers information about self-esteem.
2. Emotion: When your patient communicates about what he or she thinks of himself or herself or others, what affect is attached?
3. Behavior: What anecdotes do you hear from your patient about his or her behavior or the behavior of others that gives you information about self-esteem? How does your patient behave toward you that gives you information about self-esteem?
4. Physical: How does your patient evaluate himself or herself physically? What does his or her posture and nonverbal communication say to you about self-esteem?
5. Social: What does your patient communicate to you about how you and others view him or her and treat him or her?
6. Regulation: How well does your patient balance positive and negative aspects of self-esteem? What defensive forms do attempts take to accomplish a balance? How sensitive is your patient to disruptions in self-esteem? How resilient is your patient when disruptions occur?

Process Monitoring of Self-Esteem: “I had a really good day at work, but when I went home, I kept thinking to myself, ‘Who do you think you are? You’ll never amount to anything,’” David said, feeling defeated. At all times during each session we must monitor our patient's self-esteem and their attempts to regulate it. Aspects of self-esteem vary from moment to moment. Therapeutic interventions of any nature must be coordinated with these variations, as receptivity to interventions varies with self-esteem. At times, it will be necessary to intervene specifically in relation to self-esteem.

Interventions
“I’m afraid that I will never be able to have a good relationship,” Jack sighed, discussing his fears related to the ending of his relationship with his girlfriend. “Throughout your relationship, you have shown that you have learned much of what it takes to have a good relationship. You will be able to continue to learn anything else that is needed,” I responded, helping him to regulate his thoughts and feelings about himself.

What follows are five major areas of intervention in the treatment of self-esteem. It is important to remember that self-esteem is a primal aspect of being, and, as such, you will be challenged, but can succeed, in working through considerable resistance to change.

1. Enhancing Awareness of Self-Esteem: This is accomplished through reflection to your patient of your observations of him or her regarding thought, emotional, behavioral, social, and physical aspects of self-esteem. Awareness of self-esteem is the foundation for further intervention.
2. Exploration of the Origins of Self-Esteem: Linking your patient’s experience of self-esteem with his or her personal history provides a relational context and allows for interventions that support the separation of your patient’s original difficulties from new learning.
3. Reworking and Practicing New Thought and Feeling Concerning Self-Esteem: Creating and practicing new thoughts about the self and about others, in collaboration with your patient, supports a shift in self-evaluation. It is also useful to bring attention to how new thinking may affect feeling.
4. Practicing New Behaviors Related to Individual Self-Care and Taking Care of Self in Relationship: This is accomplished through the exploration of positive self-care and through developing strategies for taking care of the self within relationships.
5. Addressing Physical Manifestations of Self-Esteem Difficulty: Bodies and nonverbal behavior that reflect problems with self-esteem will not leave space for new possibilities in your patient’s behavior or in the perception and behavior of others toward your patient. Movement-based activities such as dance, yoga, massage, Pilates, or exercise will create and support shifts in self-esteem and help with its regulation through shifts in body armoring and physiology.

Enhancing Self-Esteem Regulation Through Shifting Perspective: Many experiences occur that are painful to the patient with self-esteem difficulties. Understanding the imperfections and limitations of the self and others, past and present, practicing self-acceptance, and learning that such experiences aren’t a result of personal fault or inadequacy in your patient can support a shift in perspective. This allows for less hurt and improved resilience.

The Therapeutic Relationship: “You think a lot more of me than I think of myself,” William confessed. Much of the work of developing a well-regulated self-esteem occurs indirectly within in the experience of the therapeutic relationship. It is accomplished through the everyday interactions you have with your patients, by treating them respectfully and with acceptance and communicating carefully and positively, both verbally and nonverbally.

A Postscript for the Therapist
Throughout the course of our work as therapists, we inevitably will encounter patients who will challenge our self-esteem. Furthermore, over the course of a career, we will certainly experience inner states or personal situations that may affect our self-esteem, hence, potentially affect our work. As the same time that we are monitoring our patient's self-esteem, it is important to monitor and to attend to our self-esteem through our own self-care and with the support of accepting and supportive others.

Anne C. Fisher, PhD ADTR is a licensed clinical psychologist and a registered dance/movement therapist in private practice in Washington, DC. For the past 20 years, she has had a general psychotherapy private practice involving the long-term, developmentally-based treatment of adults, individually and in couples, involving verbal and nonverbal techniques.

Throughout her career, Dr. Fisher has had particular interest in the areas of the development of self and, within that, the development of and the treatment of difficulties with self-esteem. Her interest in self-esteem culminated in her work Self-Esteem: Theory, Assessment and Clinical Practice (1996). The goal of this work is to provide guidelines for the psychotherapist regarding the conceptualization of self-esteem for use as a foundation for the assessment and treatment of self-esteem-related difficulties.

Personal Reflection Exercise #5
The preceding section an integrated approach to the psychotherapy of self-esteem. Write three case study examples regarding how you might use the content of this section of the Manual in your practice.

Online Continuing Education QUESTION 16
What are five major areas of intervention in the treatment of self-esteem? To select and enter your answer go to CEU Answer Booklet.

 
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