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Body Dysmorphic Disorder Techniques for Treating Obesessions with Body Perfection
Body Dysmorphic Disorder: Diagnosis & Treatment - 10 CEUs

Section 21
Using Self-Esteem Assessments with BDD Clients

CEU Question 21 | CE Test | Table of Contents | Body Dysmorphia
Social Worker CEUs, Psychologist CEs, Counselor CEUs, MFT CEUs

Self-Esteem Assessment
However precisely they may use its definition, counselors and other helping professionals need to be sure they do not make statements about self-esteem, nor plan interventions, without some basis for having assessed it as accurately as possible. It is important to note that there are problems inherent in assessing self-esteem. Mruk (1999) stated that self-esteem is an impure phenomenon closely related to other self-phenomena, all of which are problematic to assess. Some instruments purported to measure self-esteem are, in actuality, measuring a sum of various self-descriptions that may be a different concept than self-esteem (Skaalvik, 1986) Poor quality instruments are also a problem (Street & Isaacs, 1998). Nevertheless, if counselors target self-esteem enhancement as a goal in treatment planning, using assessment instruments, even if not perfect, and other assessment techniques to measure levels of self-esteem is preferable to no assessment at all.

Achieving a sound degree of scientific validity is difficult. This sets the limits within which we can realistically expect certainty in our assessment results, and the counselor is well advised to use more than one resource before coming to any conclusions about their clients' levels of self-esteem. Considering "multiple and repeated measures to obtain ‘snapshots’ of an individual's self-esteem in different social situations" (Demo, 1985, p. 1491) allows the counselor to better ascertain more realistic and accurate approximations of the construct.

Methods of Assessing Self-Esteem
In their landmark review of self-concept methodologies, Wells and Marwell (1976) stated that all instruments have biases and that relying on a single form of measurement is inadequate. Counselors have several options before making decisions about self-esteem levels in their clients: pencil-and-paper self-reports, ratings by others (e.g., teacher, school counselor, or parent), behavioral observation (e.g., participant observers and peers), and interview methods.

However, assessment of any kind does not begin with administering an assessment instrument but by observations made as soon as the client meets the counselor. The counselor asks why the client is there and not only attends to content but also observes the client process and style (Bednar & Peterson, 1995). Assessment can be described as a process that requires participation from and interaction between both counselor and client. Counselors are responsible for taking information gathered from an assessment and developing a treatment plan based on individual needs (Fong, 1993; Seligman, 1996). The same principle should apply before making judgments about self-esteem levels if interventions targeted toward self-esteem enhancement are to be incorporated into treatment planning.

The use of standardized pencil-and-paper self-report instruments is the primary and most reliable means of ascertaining self-esteem levels and is discussed in greater detail in the following section. Ratings by others, behavioral observations, and interview methods are subjective means of assessment. The use of these methods as alternatives to traditional paper-and-pencil tests can clarify distinctions between experienced and presented self-esteem (Demo, 1985; Savin-Williams & Jaquish, 1981). Estimates of experienced self-esteem, indicated by self-reports, and presented self-esteem, most often assessed through observation, may vary (Demo, 1985). Although self-ratings can capture meaningful personal information unavailable to others (Hamilton, 1971), they are an inherently fallible source of data in which minor changes in questions, wording, format, or context can result in major differences in results (Schwarz, 1999). On the other hand, observer ratings provide information about the level of self-esteem communicated to others (Demo, 1985), but ratings by others by their nature must infer information, making them susceptible to obscuring and distorting perspectives of an individual's self-esteem (Demo, 1985). Vaac and Juhnke (1997) stated that counselors have used the interview as a powerful assessment tool and, although this is certainly true in the assessment of self-esteem, this method is subject to interviewer bias. However, despite the fact that many useful structured and semistructured interview formats are available (see Vaac & Juhnke, 1997), none specifically target self-esteem.

These alternatives to standardized assessments may be useful in yielding corroborative evidence but are susceptible to distortion became of a lack of consistency and agreement on manifest characteristics of self-esteem. To date, although few researchers have addressed the characteristics of low and high self-esteem per se, one multiple regression study indicated that interviewer ratings were congruent with respondents' self-reported self-esteem (Tran & O'Hare, 1996). In a study of perceptions of self-esteem by teachers, counselors, and school administrators (Scott, Murray, Mertens, & Dustin, 1996), all groups were uniform in how they perceived indicators of high self-esteem but were not uniform about indicators of low self-esteem. One viewpoint of low serf-esteem indicates the opposite and holds that its characteristics consistently involve a high level of maladaptive behaviors and include anxiety and depression (Harter, 1993; Watson & Clark, 1984). Another viewpoint holds that high self-esteem can be maladaptive and characterized by an overinflated sense of self (Hoyle et al., 1999). Characteristics of low or high self-esteem can be in the eye of the beholder. My tentative and exploratory research survey that asked counselors to describe self-esteem characteristics indicates little agreement and in some cases diametrically opposed perceptions (e.g., aggressiveness is perceived as a characteristic of both high self-esteem and low self-esteem).

Clearly, assessing self-esteem is an imprecise but necessary activity. Findings to date suggest that no single assessment procedure will accurately pinpoint self-esteem levels and that no one individual rater can consistently make accurate judgments regarding self-esteem in any one client. Thus the best avenue to assess self-esteem is triangulation. Triangulating results by using multimethod, multirater, and multisetting assessment procedures will yield richer results. It is recommended, therefore, that counselors use one or more standardized assessment instruments and supplement the information with one or more of the aforementioned subjective, qualitative methods.

Self-Esteem Assessment Instruments
There are over 2,000 self-esteem-related assessment instruments (Mecca, Smelser, & Vasconcellos, 1989; Mruk 1999). Most are self-report questionnaires and exhibit those problems inherent in all self-report measures, such as semantic understanding, question format, social desirability, and self-presentation (Schwarz, 1999). In a review of self-esteem assessments, Blasocvich and Tomaka (as cited in Robinson, Shaver, & Wrightsman, 1991) stated,"neither a firm body of evidence nor a convincing definitional rationale to justify many of the ‘self-esteem’ measures exists" (p.119).When reviewing any assessment instrument—and this is especially critical in self-esteem assessment—counselors should follow some basic steps in determining its appropriateness for their particular situation.

Study the technical manual. When choosing any self-esteem instrument, as with any instrument, the counselor needs to evaluate its utility, reliability, and validity. This means it is important to consider how the test developer has defined self-esteem and to use the assessment only within that context. Is the instrument suitable in assessing global self-esteem only? Are there areas of selective self-esteem that can be assessed by this instrument? If so, are these areas indicative of global self-esteem levels or are they measuring only transitory characteristics?

Read test reviews. Reviews of available instruments can be found in the professional literature (Bracken & Mills, 1994; Chiu, 1988; Demo, 1985; Robinson et al., 1991), in Test Critiques (Keyser & Sweetland, 1998), in Tests in Print (Murphy, Conoley, & Impara, 1994), and in Buros Mental Measurements Yearbook (Conoley & Impara, 1995). Readers are directed to these sources of information.

Continually ask a set of questions:
A. Does this instrument measure what it purports to measure? The technical manual should give an operating definition of self-esteem. Does this definition fit the questions asked in the assessment? Does it indicate strong empirical support for its validity?
B. Does this instrument measure what I need to know about this client? Is it normed on a population appropriate for this client? Does the instrument in fact measure the general or specific trait or characteristic in question? Does it have utility? Can its results be used to indicate a direction for intervention?

This article has called for accountability in the use of the self-esteem construct, presented a review of its development, offered definitions of the self-esteem system grounded in the professional literature, and discussed its assessment.

To work toward accountability and systematically address issues associated with self-esteem in their clients, counselors and other helping professionals can benefit from these principles:

Be familiar with self-esteem definitions and terms. Consistency in the use of the concepts of global and selective self-esteem is a first step. Counselors need to understand that competence, sense of accomplishment, and feedback are critical elements in developing and maintaining self-esteem. Counselors should keep in mind that self-esteem varies across characteristics and situations and its constituent elements are weighted differently by different clients.

Use multiple assessment methods. Accountability means not only using definitions appropriately but also being careful not to prejudge behavior or overt characteristics as indicating self-esteem problems. Accountability means assessing levels of self-esteem and using more than one approach whenever possible. Use of qualitative methods are critical and necessary. When standardized self-esteem instruments are used, choosing the most reliable, valid, and useful instrument to fit the needs of the individual should be common practice.

Become well versed in differences in behavior style across cultures and contexts. Varying family dynamics and environmental factors may account for attitudes and behaviors assumed to be related to self-esteem problems when no such problem may exist. Deference to authority, for example, can be misconstrued as low self-esteem when, in fact, it may be a culturally bound phenomenon. Whereas most counselors continue to become culturally aware and sensitive, the manifestations of self-esteem across cultures is underrepresented in the research literature.

Be aware of personal self-esteem issues. Counselors need to consider their own reactions to low self-esteem manifestations. They may wish to consider participation in peer counseling groups attending to their own self-esteem needs. As with other concerns, peer supervision is also recommended.

Attempt to use suitable intervention strategies. Greater precision in the use of the self-esteem construct will enable the counselor to discriminate effective versus ineffective strategies among the abundance of self-esteem resources so easily available to them. Interventions aimed at enhancing self-esteem can be developed that are appropriate and meaningful and grounded in its definition and assessment.
- Guindon, Mary H.; Toward Accountability in the Use of the Self-Esteem Construct; Journal of Counseling & Development, 07489633, Spring2002, Vol. 80, Issue 2

Personal Reflection Exercise #7
The preceding section contained information regarding using self-esteem assessments with BDD clients.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Newman, S. (2020). Review of Clinical evolutions on the superego, body, and gender in psychoanalysis [Review of the book Clinical evolutions on the superego, body, and gender in psychoanalysis, by J. S. Lieberman]. Psychoanalytic Psychology, 37(1), 86–87.

Summers, B. J., & Cougle, J. R. (2018). An experimental test of the role of appearance-related safety behaviors in body dysmorphic disorder, social anxiety, and body dissatisfaction. Journal of Abnormal Psychology, 127(8), 770–780.

Wilver, N. L., Summers, B. J., & Cougle, J. R. (2020). Effects of safety behavior fading on appearance concerns and related symptoms. Journal of Consulting and Clinical Psychology, 88(1), 65–74.

Online Continuing Education QUESTION 21
Why can it be more useful to address selective self-esteem with a BDD client, than addressing the client’s global self-esteem? Record the letter of the correct answer the CE Test.

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