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Cognitive-Behavior Therapy for Low Self-Esteem: A Case Example

Article  in  Cognitive and Behavioral Practice · August 2009

DOI: 10.1016/j.cbpra.2008.12.007

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Cognitive and Behavioral Practice 16 (2009) 266–275

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Cognitive-Behavior Therapy for Low Self-Esteem: A Case Example

Freda McManus, Oxford Cognitive Therapy Centre and University of Oxford
Polly Waite, University of Reading Medical Practice
Roz Shafran, University of Reading

Low self-esteem is a common, disabling, and distressing problem that has been shown to be involved in the etiology and maintenance of a
range of Axis I disorders. Hence, it is a priority to develop effective treatments for low self-esteem. A cognitive-behavioral
conceptualization of low self-esteem has been proposed and a cognitive-behavioral treatment (CBT) program described (Fennell, 1997,
1999). As yet there has been no systematic evaluation of this treatment with routine clinical populations. The current case report
describes the assessment, formulation, and treatment of a patient with low self-esteem, depression, and anxiety symptoms. At the end of
treatment (12 sessions over 6 months), and at 1-year follow-up, the treatment showed large effect sizes on measures of depression, anxiety,
and self-esteem. The patient no longer met diagnostic criteria for any psychiatric disorder, and showed reliable and clinically significant
change on all measures. As far as we are aware, there are no other published case studies of CBT for low self-esteem that report pre- and
posttreatment evaluations, or follow-up data. Hence, this case provides an initial contribution to the evidence base for the efficacy of
CBT for low self-esteem. However, further research is needed to confirm the efficacy of CBT for low self-esteem and to compare its efficacy
and effectiveness to alternative treatments, including diagnosis-specific CBT protocols.

L OW self-esteem has been associated with and cited as

an etiological factor in a number of different
psychiatric diagnoses (Silverstone, 1991), including
& Doll, 1993; Van der Ham, Strein, & Egneland, 1998),
and substance abuse (Kerlind, Hernquist, & Bjurulf,
1988), and to predict relapse following treatment (Brown
depression (Brown, Bifulco, & Andrews, 1990), obses- et al., 1990; Fairburn et al.).
sive-compulsive disorder (Ehntholt, Salkovskis, & Rimes, While low self-esteem has been associated with many
1999), eating disorders (Gual, Perez-Gaspar, Martinez- psychiatric conditions, the nature of this relationship is
Gonzallaz, Lahortiga, Irala-Estevez, & Cervera-Enguix, unclear: Some studies show that having a psychiatric
2002), substance abuse (Akerlind, Hornquist, & Bjurulf, illness lowers self-esteem (Ingham, Kreitman, Miller,
1988), chronic pain (Soares & Grossi, 2000), and Sashidharan, & Surtees, 1987) and other studies show
psychosis (Freeman et al., 1998). Silverstone and Salsali that low self-esteem predisposes one to a range of
(2003) report lower self-esteem in all psychiatric diag- psychiatric illnesses (Brown, Andrews, Harris, Alder, &
noses than in a comparison group, and that the effects of Bridge, 1986; Miller, Kreitman, Ingham, & Sashidharan,
psychiatric diagnoses on self-esteem may be additive in 1989). There is evidence that changes in either depres-
that those patients with more than one diagnosis had the sion or self-esteem can affect the other (e.g., Hamilton &
lowest self-esteem, particularly when one of the diagnoses Abramson, 1983; Wilson & Krane, 1980). Despite the
was major depression. Low self-esteem has also been uncertainty about the direction of causality in the
associated with self-harm and suicidal behavior (Hawton, relationship between self-esteem and psychiatric illness,
Rodham, Evans, & Weatherall, 2002; Overholser, James, it is clear that the impact of low self-esteem is far reaching;
Adams, Lehnert, & Brinkman, 1995). Furthermore, low it is associated with teenage pregnancy (Plotnick, 1992),
self-esteem has been shown to be a poor prognostic dropping out of school (Guillon, Crocq, & Bailey, 2003),
indicator in the treatment of depression (Brown, mental illness (e.g., Brown et al., 1990), and self-harm and
Andrews, Harris, Alder, & Bridge, 1986; Sherrington, suicidal behavior (Hawton et al., 2002; Kjelsberg, Nee-
Hawton, Fagg, Andrew, & Smith, 2001), eating disorders gaard, & Dahl, 1994; Overholser et al., 1995). It also has a
(Button & Warren, 2002; Fairburn, Peveler, Jones, Hope, negative impact on economic outcomes, such as greater
unemployment and lower earnings (Feinstein, 2000). In
summary, low self-esteem is common, distressing, and
1077-7229/09/266–275$1.00/0 disabling in its own right; it also appears to be involved in
© 2009 Association for Behavioral and Cognitive Therapies. the etiology and persistence of different disorders, and
Published by Elsevier Ltd. All rights reserved. attending to these processes may improve treatment
 Author's personal copy

Cognitive-Behavior Therapy for Low Self-Esteem 267

outcome. Hence, it is a priority to develop effective distress may result. The effort of behaving in accordance
treatments for low self-esteem that can be applied across with such rigid and extreme rules for living is consider-
the range of diagnoses associated with low self-esteem. able, and there is a strong likelihood that at some point in
A cognitive conceptualization of low self-esteem has the person’s life their terms will not be met. Needing to be
been proposed (see Figure 1) and a cognitive-behavioral liked by everyone, to be the best at everything, or to be
treatment (CBT) program described (Fennell, 1997, completely in control all the time, are likely to be
1999, 2004). Despite self-evaluative beliefs commonly unachievable in the longer term. When these rules are
being a target for intervention in CBT (e.g., Padesky, (or might be) broken, the bottom line is triggered. When
1991, 1994), the effectiveness of CBT for low self-esteem there is a threat that the rules might be broken (e.g., “I
has yet to be systematically evaluated. To date, the might not succeed”), anxiety results; once the individual
evidence base consists only of single-case examples with perceives that the rule has been broken (e.g., “I have
little or no empirical evaluation (Fennell, 1997, 2006) and failed”), the response shifts towards depression.
two evaluations of adapted versions of CBT for low self- Once the bottom line is triggered, the anxiety and
esteem applied to specific populations in group settings depressive symptoms are maintained by a range of
(Hall & Tarrier, 2003; Rigby & Waite, 2007). Although maladaptive behaviors such as avoidance, safety seeking,
results are encouraging, data are needed on the efficacy and interpreting positive events negatively (e.g., Alden,
of CBT for low self-esteem for individual outpatients Taylor, Mellings, & Laposa, 2008). Thus, the system more
presenting at psychotherapy services. or less guarantees that, whatever happens, the bottom line
Fennell’s (1997) cognitive-behavioral model of low will seem to have been confirmed (Fennell, 2004). For
self-esteem incorporates both longitudinal elements example, there is evidence from experimental studies
(early experience, “bottom line,” “rules for living”) as showing that believing that you are not liked is a self-
well as current maintenance cycles for the anxiety and fulfilling prophecy in that it leads you to change your
depressive symptoms that result from low self-esteem. This behavior, which in turns makes you less easily liked (Alden
model suggests that, on the basis of life experiences, & Bieling, 1998). This confirmation of the bottom line
which will typically but not always occur early in life, the leads to further depressive thinking. Hence, this model
person forms a fundamental “bottom line” about them- explains the co-occurrence of both depression and
selves. When this self-appraisal is excessively negative anxiety disorders in low self-esteem and accounts for the
(e.g., “I’m worthless” or “I’m not good enough”), the oscillation of patients with low self-esteem between
consequence is low self-esteem. In response to a negative anxious and depressed maintenance processes. The
bottom line, people develop strategies to negotiate their model helps us to understand how anxiety and depression
way through life in spite of their perceived inadequacies. can interact, and to find a possible common root in low
Fennell terms such strategies “rules for living,” and they self-esteem (Fennell, 2004).
map onto what Beck (1976) in his original cognitive The aim of this case report is to describe the
model of emotional disorders termed “dysfunctional assessment, treatment, and outcome of a patient treated
conditional assumptions.” The purpose of these “rules with CBT for low self-esteem based on Fennell’s (1997,
for living” is to allow the person to feel better about 1999) model. The effectiveness of the treatment is
themselves in spite of their negative bottom line—that is, evaluated on measures of self-esteem, depression, anxiety,
while the conditions of the rule are met, the person and general functioning.
escapes awareness of their negative bottom line. For Case Study
example, in response to a negative bottom line, “I’m
unlikable,” a patient may develop a rule to live by, such as Presenting Problems and Diagnosis
“I must not let people see the real me.” As long as the Jane1 was referred for CBT for depression and anxiety.
conditions of the rule are met, then they can avoid She sought help for depression and anxiety after
awareness of the bottom line and thus moderate their low experiencing increasingly low mood, struggling to cope
self-esteem. Rules for living generally relate to the with panic attacks, and spending increasing amounts of
domains of acceptance, control, and achievement— time checking and cleaning. The treating clinican (FM)
what the person believes they must do in order to be used the Structured Clinical Interview for DSM-IV-TR
liked/loved/accepted, to be sufficiently in control, or to (SCID; First, Spitzer, Gibbon, & Williams, 2002) to
be successful, and ultimately, to be happy. However, the establish diagnosis. Jane met criteria for the diagnosis of
rules for living that develop in response to a very negative major depressive disorder: She experienced persistently
bottom line tend to be excessive either in their content or
their application. Of course, it is nice to be liked, but if
you feel that you must always give being liked priority over 1
Names and identifying details have been changed to preserve
everything else, then common sense tells us psychological anonymity.
 Author's personal copy

268 McManus et al.

Figure 1. Cognitive Model of Low Self-Esteem.

low mood, loss of interest and pleasure in activities that several hours a day cleaning or checking, and at the
she normally enjoyed (e.g., socializing), weight loss, sleep time of assessment was unable to leave the house
disturbance, fatigue, feelings of worthlessness and guilt, unaccompanied. Jane was also subthreshold for the
poor concentration, and suicidal thoughts (but no plan or diagnosis of a number of other disorders. She experi-
current intent to act on the suicidal thoughts). enced occasional out-of-the-blue panic attacks in relation
Jane also met criteria for obsessive-compulsive disorder to times of stress (e.g., having to leave the house without
in that she experienced recurrent intrusive thoughts that somebody else to check for her), but she did not show
caused marked anxiety about being responsible for harm persistent avoidance in relation to these attacks. Jane was
(e.g., her home catching fire), and she responded to excessively concerned about how she appeared to others
these intrusive thoughts by attempting to suppress the and was avoidant of social situations. However, this
thoughts and by engaging in cleaning and checking appeared to be more of a result of her depression and
rituals. Her rituals were excessive and caused marked low self-esteem (not wanting others to ask about her [lack
interference and distress (e.g., being late for work as she of] career and discover what a worthless person/failure
spent several hours checking everything in the house was she was) than a true fear of embarrassment or humiliation
switched off, unplugged, and/or locked). She spent as in social phobia. Related to this overconcern about how
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Cognitive-Behavior Therapy for Low Self-Esteem 269

she came across to others, Jane met some criteria for the she felt that these interventions had helped her during
diagnosis of anorexia nervosa—she had a Body Mass that particular crisis, she recognised that her low self-
Index of 18 and restricted both the quantity and range of esteem remained unchanged and felt that this left her
foods eaten for fear of gaining weight. She had a distorted vulnerable to experiencing further episodes of anxiety
impression of her body size and perceived herself to be and depression in response to life events. At the time of
“disgustingly fat” and “a fat pig.” However, she did not assessment Jane was taking 20 mg/day of fluoxetine and
meet DSM-IV-TR (American Psychiatric Association, 2000) she was advised to keep this does stable.
criteria for the diagnosis of anorexia nervosa because her
BMI was not sufficiently low, and because she had not Relevant Personal History
experienced persistent amenorrhea. In addition, as with
the social anxiety, Jane felt that her need to be “thin” had Jane reported a happy childhood. Having grown up in
to do with wanting to make herself acceptable to others a high-achieving family, she was an academic high
and to compensate for her “unacceptability” by being achiever herself and attended a prestigious university. It
thin/pretty/funny/successful—she reported that in the was while at university that Jane first experienced
past when she had felt better about herself as a person she significant symptoms of anxiety and depression. Pre-
had been comfortable with a body weight in the normal viously she had always managed to excel academically but
range. Finally, Jane was also subthreshold for the diagnosis this became more onerous as she progressed through the
of posttraumatic stress disorder (PTSD). She had been academic system and she found that she had to work
the victim of an acquaintance rape approximately 7 years extremely long hours, and even that didn’t guarantee her
previously. For a period of time after the rape, Jane had position at the top of the class. She also found it difficult to
met full criteria for PTSD, but since leaving the situation be successful socially, as well as academically, and felt that
in which the rape occurred, she no longer experienced she no longer knew “how to get it right for people.”
frequent enough intrusive symptoms to meet criteria for During her time as an undergraduate Jane was raped by
the diagnosis of PTSD. However, she still engaged in an acquaintance. Following the rape, Jane engaged in
significant avoidance behaviors (avoidance of sex, parti- risky sexual behaviors, which she later regretted. In
cular sexual acts and positions, and extreme caution response to these perceived failures she became
regarding safety). depressed and began a broad range of checking behaviors
(e.g., that she had not forgotten something, that she had
not offended someone, as well as checking electrical
Psychometric Measures
appliances, water sources, and locks). These symptoms
Jane completed the Beck Anxiety Inventory (BAI; Beck persisted, at a higher or lower level in response to life
& Steer, 1993), Beck Depression Inventory (BDI; Beck, stress, for the next 5 years. During the 5 years since
Steer, & Brown, 1996), and Robson Self-Concept Ques- graduation, Jane had failed to establish herself in a career,
tionnaire (RSCQ; Robson, 1989). The BAI and BDI are and at the age of 27 she was referred for CBT for
widely used 21-item measures of anxiety and depression depression and anxiety.
(respectively) that have been shown to have acceptable or
high internal consistency, validity, and reliability (e.g., Treatment
Beck, Steer, & Garbin, 1988). Total scores range from 0 to
Jane attended 12 sessions of individual CBT spread
63, with higher scores indicating more severe anxiety or
over a 6-month period, with 3 follow-up appointments in
depression. At assessment, Jane scored in the severe range
the following year. Sessions were scheduled at the
on both the BAI and BDI.
convenience of the patient and therapist’s work sche-
The RSCQ (Robson, 1989) is a 30-item self-report scale
dules and were generally weekly for the first 6 weeks,
measuring self-esteem. Statements are rated on an 8-point
with longer gaps between sessions as treatment pro-
scale from “strongly disagree” (0) to “strongly agree” (7).
gressed. Treatment was carried out by a clinical
Scores range from 0 to 180 with higher scores indicating greater
psychologist (FM) who is accredited by the British
(more positive) self-esteem. Robson reported a Cronbach alpha
Association of Behavioral and Cognitive Psychotherapists
coefficient of 0.89 and test-retest correlations of 0.87. At
as a CBT therapist, supervisor, and trainer, and who has
assessment Jane scored 94 on the RSCQ, which is below the
experience providing CBT for low self-esteem. Treat-
mean for psychiatric outpatients and more than 2 standard
ment was based on Fennell’s (1997, 1999, 2004, 2006)
deviations below the mean for nonclinical groups.
CBT for overcoming low self-esteem. The four phases of
treatment were:
Prior and Current Treatment
Jane had had several courses of counseling/ 1. Goal-setting, individualized formulation, and psychoe-
psychotherapy and medication in the past and although ducation (Sessions 1–2).
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270 McManus et al.

2. Breaking into maintenance cycles: learning to reeval- meant that her colleagues thought she was a fat, greedy
uate thoughts/beliefs through cognitive techniques pig. Jane was able to see that no matter what the situation,
and behavioral experiments (Sessions 3–6). she tended to interpret it to mean that she was in some
3. Reevaluating “rules for living”: developing alternative, way not good enough. The formulation was used as a basis
more adaptive rules (Sessions 5–9). for psychoeducation and normalization. It was suggested
4. Reevaluating the “bottom line”: formulating an alter- that treatment would involve gathering and reviewing
native, more helpful “bottom line”; combating self- evidence for the validity of the following two theories:
criticism and enhancing self-acceptance; and planning
for the future (Sessions 7–12). Theory A: Jane was an inadequate person who
needed to compensate for her worthlessness by
Sessions 1–2
achieving especially highly and being especially nice
Goals, formulation, and psychoeducation. In terms of her to others, in order to ensure that she was acceptable
goals for therapy, Jane wanted to be able to value herself as a person.
more, to reduce the time she spent checking and Theory B: Jane was as worthwhile as any other
cleaning, to be less rigid about diet and exercise, to be human being but her low self-esteem/believing that
able to be more open and honest with people close to her, she was not good enough caused her to get stuck in
and to be less upset by perceived failure or rejection. An vicious circles of maladaptive thought and behavior
initial formulation was drawn out collaboratively with Jane that led to her experiencing symptoms or depres-
in the second session. Further detail was added across the sion and anxiety.
course of therapy, and this is included in the version
shown in Figure 2. For example, not trusting her own judgment/memory
Jane felt that her self-worth had always been dependent led to her spending a lot of time checking, and thus not
on achieving externally validated high standards (e.g., having enough time to complete the work she wanted to
reaching the top of the class, receiving a first-class degree complete. This inability to get as much as she wanted
from a top university, having lots of friends, having a good done further confirmed her low self-esteem.
job, praise from important others, being thinner than her
peers, having male admirers, being witty and fun). Most of Sessions 3–6
her life she had been able to regularly achieve these
standards. However, in her early twenties the costs of Learning skills to reevaluate thoughts/beliefs through
achieving these standards (i.e., having to work all the time) cognitive techniques and behavioral experiments. Jane was
became too high and she began to feel that she was failing able to complete daily thought records (Greenberger &
and was not good enough as a person. The symptoms of Padesky, 1995) in order to challenge her negative thinking
depression and anxiety that she developed in response to on a day-to-day basis. For example, Jane reevaluated such
these feelings of failure further prevented her from meeting thoughts as, “I’m a bad friend,” “I look ugly in photos, I
the high standards she aspired to and confirmed her feeling don’t know how to dress properly,” and “They think I’m a
that she was somehow not good enough. For example, the failure because I haven’t got a successful career, and won’t
fact that her excessive checking caused her to be late for want to know me.” Behavioral experiments (Bennett-Levy
work confirmed her “bottom line” that she wasn’t good et al., 2004) were collaboratively devised to enable Jane to
enough. Her difficulties were further exacerbated when she test out her negative predictions (e.g., answering her
was raped by an acquaintance. She blamed herself for not phone when she wasn’t feeling very entertaining or
preventing the rape and for being unable to “just put it out of disclosing her perceived failings to others). She also used
my mind and move on” and was critical of herself for her behavioral experiments to test out the consequences of
sexual behavior following the rape. Dealing with the rape reducing her cleaning and checking (e.g., leaving her
and its aftermath made it even more difficult for Jane to meet mobile phone charger plugged in to see if it did catch
her high standards for achievement and, consequently, she fire). She was also able to survey the opinions of others to
felt even more of a failure and not worthwhile as a person. find out their standards for safety and cleanliness, and to
Jane felt that the formulation as shown in Figure 2 was find out what they thought of other people who had
a good account of her current difficulties and she was able different standards from themselves. This work was
to identify situations in which her interpretation of the continually linked back to the formulation and used to
event had exacerbated her distress. For example, one day reevaluate her bottom line that she wasn’t good enough.
at work, she felt upset over not being offered cake, which
she interpreted as meaning that her colleagues didn’t like Sessions 5–9
her/want to include her; yet, on another day, Jane felt Reevaluating rules for living: Developing more adaptive
upset upon being offered cake, because she believed it rules. The formulation in Figure 2 identifies several rules
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Cognitive-Behavior Therapy for Low Self-Esteem 271

Figure 2. Formulation of Jane’s Current Difficulties According to Fennell’s (1997) Cognitive Model of Low Self-Esteem.

for living (dysfunctional assumptions) that Jane agreed new rule. For example, Jane used this technique to
were unrealistic and left her vulnerable to experiencing reevaluate the rule, “I need to complete tasks quickly and
low self-esteem, anxiety, and depression. She used the perfectly in order to get anywhere in life.” She reflected
“flashcard technique” (Fennell, 1999) to reevaluate her that this rule was unrealistic in that nobody completed
dysfunctional assumptions. This involved the following everything quickly and perfectly yet most people got
stages: specifying the old rule; considering the origins of somewhere in life, and it was unhelpful in that it caused
the rule and looking at the impact it has had on her life; her to feel pressured and to spend more time on tasks
specifying in what ways the rule is helpful and in what ways than she wanted or needed to. She decided that a more
it is unhelpful; considering how the rule is unreasonable/ helpful alternative would be, “While there is satisfaction in
doesn’t reflect the way that the world is; specifying a new carrying out tasks well, you can’t do everything well so it is
rule that has most of the advantages of the old rule but necessary to prioritize what you will invest time in doing
fewer of the disadvantages; and specifying what needs to well and which tasks you will do to a lower standard.” Her
be done in order to work towards living according to the plan for living according to the new rule involved
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272 McManus et al.

choosing some tasks to do to a lower standard (e.g., up with a general strategy; activity scheduling for
cleaning, menial tasks at work, buying presents for people managing her mood; and behavioral experiments for
she wasn’t especially close to) and testing out the testing anxious predictions. She particularly thought that
consequences of doing these to a lower standard, whether she needed to continue to review the progress she was
or not it does in fact stop her from getting anywhere in making towards living according to her new rules on a
life. What she found was that it helped her to go where she weekly basis. Jane also mentioned that she had stopped
wanted as it freed up her time for the things that were taking her antidepressant medication some weeks pre-
important to her. Jane used the same technique to viously. She explained that once she began to feel better
reevaluate the other dysfunctional assumptions in the she had so frequently forgotten to take her medication
formulation shown in Figure 2. that it didn’t seem worth it when she did remember.

Sessions 7–12 Results

Combating self-criticism and enhancing self-acceptance. Jane The questionnaire scores shown in Figure 3 reveal that
was able to reflect on her self-criticism and recognize that it Jane’s progress in treatment fluctuated in response to life
was not helpful in that it more often undermined her events and stressors. The events that prompted increases in
motivation than enhanced it, and it certainly undermined anxiety and depressive symptoms (e.g., the death of her
her enjoyment of life. She was very aware that she would aunt and guilt at not attending the funeral, ending her
not judge another person so harshly or think that it would relationship with her boyfriend) were utilized in therapy not
be helpful to them to be treated in such a way. She was able only to practice Jane’s CBT skills (e.g., challenging the guilt
to record her self-critical thoughts and link these to self- about not attending her aunt’s funeral, checking out
defeating behaviors. She used a list of key questions (e.g., anxious predictions about not being able to manage without
How would you view someone else in this situation?) to try her boyfriend), but also for developing the formulation
to challenge her self-critical thinking. Despite this insight, (i.e., about Jane’s “bottom line” and “rules for living,” and
she found it very difficult to remain unaffected by self- also about her typical responses to stressful life circum-
critical thoughts. Jane decided that she would aim to work stances). By the end of treatment Jane felt that she had
towards the basic philosophy that the point of life is not to made significant progress towards her goals. More specifi-
get top marks as often as possible, but to enjoy the ride as cally, she had stopped excessive cleaning and checking and
much as possible. With this aim in mind she was able to was able to eat and exercise as she wanted. She felt that she
overcome her high standards and self-criticism in order to was less affected by perceived failures or rejection and was
be able to work on enhancing self-acceptance. This work better able to value herself, even in the absence of objective
included making a list of her positive qualities and tracking measures of success. She also felt that she had made
them on a daily basis (e.g., instances where she was friendly progress in being more open and honest with those around
or helpful to others, or completed a task to a satisfactory her—for example, she now answered her phone rather
standard) and using an activity schedule to increase the than vetting calls until she could “put on a good show.”
range and frequency of activities that she engaged in that Figure 3 shows Jane’s response to treatment on the BAI
gave her a sense of pleasure and/or satisfaction (e.g., and BDI during the course of her treatment and at 1-year
walking to work instead of getting the bus, visiting an art follow up. Effect sizes (Cohen’s d) at the end of treatment
gallery, spending time with friends whose company she were 1.70 on the BAI and 3.61 on the BDI. At 1-year
genuinely enjoyed). Over time, Jane reported that these follow-up, effect sizes (Cohen’s d) were 2.64 on the BAI
methods were effective in undermining her negative and 3.92 on the BDI.
bottom line and strengthening the alternative (“I am a
person of equal worth to others and, thus, deserve to have a
balanced life with some achievement of what is important
to me and some enjoyment”).
Ending treatment. Jane constructed a relapse manage-
ment plan by summarizing what she had learned from
therapy and reviewing what she had found most helpful in
bringing about change. Possible risk factors for relapse
were identified as stress at work, comparing herself
unfavorably to her peers, interpersonal rejection, and
any perceived failure. Jane reported that the techniques
that she had found particularly helpful were: thought
records for dealing with specific situations; the flashcard Figure 3. Jane's scores on the Beck Anxiety Inventory (BAI) and
technique for reviewing her rules for living and coming the Beck Depression Inventory (BDI).
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Cognitive-Behavior Therapy for Low Self-Esteem 273

Figure 4. Jane's scores on the Robson Self-concept Questionnaire (RSQ).

Figure 4 shows Jane’s response to treatment on the is comprised of standard CBT techniques, and is
RSQ over treatment and at 1-year follow-up. Effect size formulation driven. Also, it may be typical of the kinds
(Cohen’s d) on the RSQ at posttreatment was 1.22 and of CBT that are carried out in routine clinical practice
was 1.68 at 1-year follow-up. By the end of treatment and where patients often show high levels of comorbidity and
at 1-year follow-up Jane was scoring in the nonclinical where there is little or no evidence base to guide clinicians
range on all measures. There are three methods for in choosing how to structure, sequence, or combine
calculating clinically significant change (Jacobson, Foll- interventions for patients who meet criteria for more than
ette, & Revenstorf, 1984; Jacobson & Truax, 1991). Using one disorder (Harvey, Watkins, Mansell, & Shafran, 2004).
a clinical mean of 99.8 (SD = 24) and a nonclinical mean of However, what is unusual is that the treatment is driven by
137 (SD = 20) (Robson, 1989), Jane’s change on the RSQ a formulation of the patient’s low self-esteem, rather than
from 94 at pretreatment to 121 at posttreatment meets the of her diagnosis/diagnoses. Fennell’s (1997, 1999, 2006)
criterion for clinically significant change by methods B cognitive approach to low self-esteem may offer the
(being within 2 SD of the nonclinical mean at the end of clinician a way of conceptualizing and treating patients
treatment) and C (being on the “normal side” of the with low self-esteem that incorporates elements of both
halfway point between the clinical and nonclinical means, symptom-focused CBT and schema-focused CBT, and can
but not by method A (being more than 2 SD from the be applied to patients whose problems fall into or
clinical mean). This change on the RSQ also meets between several diagnostic categories. The key element
Jacobson, Follette, and Revenstorf’s (1984) criteria for of this approach is combining standard CBT interventions
reliable change (RSC alpha = .83). Similarly, her changes to break maintenance cycles with more core-belief
on the BDI and BAI also met criteria for reliable change focused work to change basic beliefs about the self and
and for clinically significant change (by methods A, B and the dysfunctional ways in which the person interacts with
C). At the end of treatment and at 1-year follow-up, Jane the world. Standard CBT techniques are used not only to
no longer met diagnostic criteria for any psychiatric break the maintenance cycles of anxiety and depression,
disorder, as assessed by the SCID. but also to look at changing the rules and strategies that
leave the person vulnerable to responding to life stress
Conclusions with similar symptoms in the future. In the later stages of
CBT for low self-esteem was effective in helping Jane to treatment the clinician may also utilize more schema-
meet her therapy goals and in reducing her symptoms of focused techniques in order to combat the “bottom line.”
depression and anxiety. At the end of treatment, and at 1- How this approach compares to diagnosis-led inter-
year follow-up, she no longer met diagnostic criteria for ventions is yet to be established. The approach yielded
any psychiatric disorder and scored in the nonclinical large effect sizes that were maintained at 1-year follow-up.
range on measures of anxiety, depression, and self-esteem. However, it is hard to draw any firm conclusions on the
As far as we are aware, there are no other published case basis of one case. One obvious advantage of this approach
studies of CBT for low self-esteem that report pre- and is that it would have taken longer than 12 sessions to carry
posttreatment evaluations or follow-up data. Hence, this out CBT protocols for both depression and OCD, and
case provides an initial contribution to the evidence base these would not have addressed her other problems
for the efficacy of CBT for low self-esteem. directly (subthreshold panic disorders, social phobia,
In many ways the treatment described in the current PTSD, and eating disorder), so it may be that intervening
case report could be considered to be “standard CBT”—it directly on self-esteem is a more efficient route. However,
 Author's personal copy

274 McManus et al.

more research is needed to determine whether interven- Fennell, M. (1999). Overcoming low self-esteem: A self-help guide using
cognitive behavioral techniques. London: Robinson.
ing directly on self-esteem is more (or less) effective than Fennell, M. (2004). Depression, low self-esteem and mindfulness.
using diagnosis-led formulations, either in sequence or in Behavior, Research and Therapy, 42, 1053–1067.
combination, to guide CBT. Fennell, M. (2006). Overcoming low self-esteem: Self-help program. London:
Constable and Robinson.
A limitation of the current study is that the assessment First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (2002).
relied heavily on patient self-report. Such self-report Structured Clinical Interview for DSM-IV-TR Axis 1 Disorders, Research
questionnaires are usually fairly transparent and thus Version, Patient Edition. (SCID-I/P). New York: Biometrics Research,
New York State Psychiatric Institute.
could be susceptible to being biased by the patient’s Freeman, D., Garety, P. A., Fowler, D., Kuipers, E. K., Dunn, G.,
desire to please the therapist by appearing to improve. Bebbington, P., & Hadley, C. (1998). The London-East Anglia
Future studies may wish to consider including observa- randomised controlled trial of cognitive-behaviour therapy for
psychosis IV: Self-esteem and persecutory delusions. British Journal
tional data from video or audio transcripts of sessions. For of Clinical Psychology, 37, 415–430.
example, a relevant index of improvement for the current Greenberger, D., & Padesky, C. (1995). Mind over mood: A cognitive
patient could have been the frequency of self-critical therapy manual for clients. Changing the way you feel by changing the way
you think. New York: Guilford Press.
statements made during the therapy sessions. Such Gual, P., Perez-Gaspar, M., Martinez-Gonzallaz, M. A., Lahortiga, J., &
observational data may give a broader repertoire of Cervera-Enguix, S. (2002). Self-esteem, personality, and eating
assessment and help to identify whether any changes disorders: Baseline assessment of a prospective population based
cohort. International Journal of Eating Disorders, 31, 261–273.
made in therapy are having an impact on the patient’s Guillon, M. S., Crocq, M. A., & Bailey, P. E. (2003). The relationship
behavior both within and outside of the sessions. between self-esteem and psychiatric disorders in adolescents.
European Psychiatry, 18, 59–62.
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Psychiatry, 2, 2. Therapy Centre, Warneford Hospital, Headington, Oxford, OX3 7JX,
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of Occupational Therapy, 7, 87–95. Accepted: December 3, 2008
Van der Ham, T., Strein, D. C. V., & Egneland, H. V. (1998). Personality Available online 16 June 2009

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