Building self-esteem in therapy

Self-esteem is how we value ourselves. Typically, clients will come into therapy with low self-esteem: they may think of themselves as worthless or less than other people. Therapy can often boost people's self-esteem, whether that was the aim of coming to therapy or not.

In this article, I will discuss some possible methods of action for how different psychotherapies achieve this.

Person-centred counselling

Humanistic therapies like person-centred are non-directive, so the client sets the agenda in therapy sessions. The therapist plays a key role in guiding this exploration of the client's feelings and drawing attention to certain aspects.

As a client explores their feelings, the therapist will hold a mirror up to these: why does a client feel a certain way? Are there contradictions? Is there another perspective the client may be missing?

For example, a client turns down a job opportunity because it would mean more travelling. They may label their action as "cowardly" or "lazy". But maybe it could also be the action of someone who puts their family first and values being at home to spend time with their children.

Another key method is the core conditions. When a therapist treats a client with unconditional positive regard (UPR), the client sees some role modelling acceptance and begins to think "if this person can accept me, maybe I can accept myself, too".

This helps a client challenge their conditions of worth. They may believe that they are only a worthwhile person if they achieve certain things, work really hard or always put others first. But in the therapy room, they meet someone who treats them with positive regard even as they admit their deepest flaws.

Cognitive behavioural

CBT has multiple components. One is challenging cognitive distortions. A client may have a thought like "I'm worthless" and a therapist may encourage a client to examine the evidence for this claim. Typically it is driven by a feeling rather than a fact.

We can also look at what the consequences of this thought are. How does it make us feel? What does it make us do? Usually, the answer is to feel bad and maybe stay in bed. By examining this process, we can help a client understand what maintains these negative cycles and once they do, they have the choice to change it.

This then allows the client to do something different, which is at the heart of CBT. Our feelings are often driven by our behaviours so when we change the patterns of behaviour that led us to feel worthless, we change how we feel.

Different cognitive behavioural approaches tackle core beliefs slightly differently. For example, rational-emotive behaviour therapy (REBT) encourages clients to identify core beliefs such as self-devaluation and low distress tolerance.

It is also worth noting that CBT is goal-oriented. We agree on therapeutic goals with a client and then work towards achieving those goals. The act of achieving them may help challenge the client's belief that they cannot change and thereby alter the way they see themselves.

Solution-focused

Solution-focused approaches such as solution-focused brief therapy (SFBT) believe that the client already knows how to solve their problem and is already doing so some of the time.

A person may wake up 29 days a month thinking they are worthless and staying in bed. But one day a month they feel less bad, get up and do something that makes them feel better. This is known as an exception in SFBT.

By digging into these exceptions, we can help a client reveal knowledge that they already know. Maybe a client feels like a bad parent most of the time. What was different in the times when they did not feel this way? What could they do more of that would make them feel like a good parent more of the time?

Once a client sees that they are doing part of the solution some of the time, they can a) do more of it more of the time and b) challenge the idea that there is something inherently insufficient about themselves.

Mindfulness

Mindfulness develops skills around observing our thoughts without getting caught up in them.

Typically, low self-esteem arises from us having certain thoughts about ourselves ("I'm useless", "I should achieve more", "I'm not a nice person") and then accepting those thoughts as true. If we didn't believe them, they would not bother us.

By practising mindfulness, we learn to see these thoughts as mental events rather than a true representation of reality. This then robs the thoughts of their power. Once we stop buying into them automatically, they no longer have such strong emotional control over us.

As an additional benefit, the practice itself may represent a goal. Daily mindfulness practise can be hard to stick to. But it can also create a challenge: when a client sees themselves committing to something and following through with it, even when it is hard, it may challenge the way they see themselves.

Meditation

Meditation encompasses a broad range of techniques, of which open monitoring (mindfulness) is discussed above. But it is not the only technique that could help us here.

Loving-kindness meditation (metta) helps promote feelings of love and goodwill towards others, but also to ourselves, too. When practising loving-kindness, we start with ourselves as the object of concentration before expanding the circle outwards.

Similarly, we could see affirmations as a form of mantra meditation. In some ways, this is the opposite of what we would usually do in therapy. When we repeat a phrase like "I am worthy of love" over and over, we are encouraging the brain to accept the idea as a fact. In a sense, we're creating a cognitive distortion, but a positive one.

It is important to note that this tactic only works if we then back up this affirmation with action. This proves to ourselves that it is more than just words.

Summary

Self-esteem is a key part of leading a happy, fulfilling life. Different therapies use different approaches to building self-esteem but there are two key themes:

• As a therapist we can role model treating the client with acceptance and respect, thus encouraging them to treat themselves that way
• Challenging the negative ideas a client has about themselves and finding contradictions in their narrative that they are worth less than others

If we can consistently provide this environment for our clients, they are likely to leave us with improved self-esteem and a higher sense of self-worth.