Introduction

Definition of cognitive behavioural therapy (CBT)

Cognitive Behavioural Therapy was developed from a cognitive way of interpreting mental illness. It addresses people’s emotions and behaviours that are influenced by their experiences, and how they perceive future situations.¹

Definition of low self-esteem

Self-esteem is a set of thoughts and feelings about their worth and importance. This can be a positive or negative attitude to their self.² Negative beliefs about the self create low self-esteem.³

Importance of addressing low self-esteem

Good mental health for children and adolescents helps raise their sense of identity, self-worth, and social functioning. It is also important in enhancing the ability to learn, be productive, and develop themselves.² By having higher self-esteem, individuals are more confident and friendly.

Overview of how CBT can help

CBT can challenge the way people perceive situations. This can help build a more positive mindset to problems, develop resilience and strength to tackle more conditions, and not break down if there is a negative setback.

Understanding low self-esteem

Highs and lows of self-esteem

Self-esteem fluctuates across life. Typically, self-esteem is high in childhood, then drops in adolescence, rises throughout adulthood, and then declines in old age.⁴ The stability of self-esteem is also important to note since it is low during childhood, increases in adolescence and adulthood, and then declines during older age.⁴ This suggests how vulnerable certain ages are and how responsive they would be to treatment - it is difficult to treat low self-esteem in children when they have many ups and downs. The level of stability, while it varies by age, did not change according to gender, ethnicity, or socioeconomic status.⁴ Positive relationship experiences, can lead to higher self-esteem across all age groups. Those with higher self-esteem had higher parental satisfaction, were more social, and had a higher rate of marital satisfaction.⁴

Signs and symptoms of low self-esteem

Other symptoms go hand in hand with low self-esteem, such as anxiety and depression.³ Signs such as low mood, low sociability, and anxious behaviours (such as nail biting) are just a few behavioural examples of those who have low self-esteem. 

In Fenn and Byrne, (2013)¹, there were some differences in gender across symptoms. When girls had low self-esteem in comparison to girls who had high self-esteem, the symptoms of depression and social anxiety were prominent. The same was shown in boys but also included social phobia as another symptom.

Causes and contributing factors

Psychopathological symptoms, for example, obsession-compulsion, interpersonal sensitivity, depression, anxiety, and hostility, have a negative relationship with self-esteem. For instance, if their self-esteem was high, their symptoms such as depression, and stress, were lower. Therefore, it also implies that those with higher self-esteem have fewer symptoms.⁴

Environmental factors can contribute to the level of self-esteem a person has. This includes bullying (at school or work); abuse; criticism; societal prejudice and adverse circumstances.³

Impact of low self-esteem on daily life

Those who have low self-esteem may have more mental health issues, weak physical health, unhealthy relationships (or no relationships), and low work/academic performance. 

Principles of cognitive behavioural therapy

Beliefs that are mentioned in CBT are about the self, others, and the world. They are usually learned earlier in life and are influenced by experiences.¹

A cognitive triad of negative core beliefs includes the self, the world/others, and the future.¹

Figure 1. The cognitive triad of negative core beliefs. This shows how each of the beliefs influence each other.¹

Basic principles of CBT

Self-made rules

People usually follow unconscious and conscious rules that they have adopted through experiences. These rules can be dysfunctional, such as a rule of “It’s better not to try than to fail.”. This negative outlook halts personal development as the person would not want to try anything new, and will become stunted.¹

Negative automatic thoughts

These are thoughts that unconsciously occur in certain situations. For example, in depression, these thoughts can stem from low self-esteem and can prevent a person from interacting with others, with thoughts such as “I will be rejected by the group.”. 

Formulations

CBT uses an individual's experiences and breaks them down to understand the person’s mental distress. This process is called a formulation and can be developed case by case.

Formulations for low self-esteem can start with an early experience in childhood (e.g. rejection by parents).  They can develop a core belief, which can lead to a rule (e.g. “Unless I am loved, I am worthless”) and is reinforced by other situations (e.g. more rejection by others). Thoughts, feelings, behaviour, and physical symptoms are interconnected, hence CBT needs to address them.¹

A cognitive model for low self-esteem 

In Freeman (2005),³ Fennell uses a cognitive model to show a basic understanding of the processes of low self-esteem. 

Low self-esteem may be linked to a childhood experience that negatively affects the person at a young age. It develops over time and shapes our way of living and operating. 

CBT techniques for low self-esteem

CBT changes how a person thinks (cognitively) and what they do (behaviour).

Cognitive restructuring

Guided discovery technique 

Guided discovery helps to understand the patient's point of view, and in turn, helps to expand their thinking. Awareness of the patient's assumptions helps the therapist offer other perspectives and solutions. Questioning their assumptions can help the patient conclude without directly telling them. This leads to a 4 part series to address the patient's concerns:

1. “Identify and understand their assumption”¹
2. “Question the reasons and evidence for their beliefs”¹
3. “Highlight other perspectives”¹
4. “Explore implications”¹

Such questions can include “What else could we assume?’, “What do you think causes …?”, ‘What alternative ways are there of looking at this?” and “Why is … important?”.¹

This addresses low self-esteem by breaking down a patient's concern into 4 parts. For example, with low self-esteem, the patient may not believe they are worth having a relationship with others. The therapist needs to identify why the patient believes this, perhaps a negative experience created this belief, and then question why they are unworthy We find evidence, either by disputing evidence or corroborating evidence to suggest that they are worthy, can help to change the perspective of the patient.

Target core beliefs technique

A personal, positive data log of all observations that go against a negative belief can be written by the patient, for example, observing themselves being useful to people, can raise their self-esteem.¹

Target assumptions technique

They provide evidence that supports and does not support their assumption, which can challenge the patient's belief system.¹ This can break the rigidness of the rules, for example, a patient may believe that they are not interesting enough to talk to other people, but a therapist talks them through what they like and dislike to apply in future conversations. This build-up of information can then be used in a real-life situation, to show the patient they are interested. CBT techniques can be used together to ensure the patient has a variety of techniques to suit their processing.

Behavioural activation

Encouraging engagement in positive activities

Activity scheduling to plan each day. The therapist and patient work together to reduce larger tasks into smaller, more easily attainable tasks. Adding a grading element can reinforce the productive experience of completing the tasks and help to overcome procrastination. Doing small activities to target low self-esteem raises confidence in achieving the tasks.¹

Fighting against their predictions

Behavioural experiments can be used to challenge what the worst outcome would be. For example, an individual with low self-esteem,  may not feel confident, in exploring social situations. A prediction that a patient may make is that in a group setting, when the individual approaches, the group members do not talk to them. The patient would then apply this to the real world, by going up to a group of people, and can see whether the prediction will come true or not. Over time, the patient would re-evaluate their negative thoughts in this situation.

Hierarchy

Therapists would work with the patient to develop tasks in a hierarchy.¹ This applies to self-esteem to encourage the promotion of self-worth and can instil confidence. For example, where there is a low anxiety task (such as messaging a friend online), and scales up to a high anxiety task (such as approaching a group of people they don't know and interacting with them).

Self-compassion exercises

By using relaxation training and breathing exercises, the individual can reduce anxiety levels by trying a behavioural experiment. This provides a sense of control over the body and can increase confidence to try and dispute their other predictions.¹

Conclusion

Aims of CBT

CBT is a therapy that uses cognitive ways to process and address people's behaviours.

CBT helps improve self-esteem and the goal of CBT in treatments includes: identifying and challenging negative thoughts and their patterns, developing a healthier sense of perception towards the self, and enhancing coping skills.

Drawbacks of low self-esteem

Having low self-esteem can increase the risk of mental and physical health, have unhealthy relationships, and result in low performance in work or academics. 

Techniques of CBT and treatment application

Cognitive CBT techniques of guided discovery, targeting core beliefs, and assumptions address the beliefs that result in low self-esteem. Behavioural CBT techniques include engagement in positive activities and behavioural experiments. At every stage, the therapist should use behavioural exercises to demonstrate examples to show the patient what they could experience.³