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 him. Sheila worries
about applying to a university to study landscape architecture,
because she believes she cant 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.
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.
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 bodys 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
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.
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.
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
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,
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 ones life historical context and/or
from ones present lived experience.
13. Uniqueness: Self-esteem may be viewed as a unique personal
construction and/or as shared with ones 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
Assessment of Self-Esteem
The following areas are important to consider in the assessment
of self-esteem. Careful assessment will help you to formulate
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
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
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? Youll 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.
Im 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.
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
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
patients experience of self-esteem with his or her personal
history provides a relational context and allows for interventions
that support the separation of your patients 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 patients
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
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 arent a result of personal
fault or inadequacy in your patient can support a shift in perspective.
This allows for less hurt and improved resilience.
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.
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.
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.
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.
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
What are five major areas of intervention in the treatment of self-esteem?
To select and enter your answer go to .