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Melanie J. V. FennellCognitive Therapy in the Treatment of Low Self-Esteem

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Advances in Psychiatric Treatment (Ì998),vol. 4, pp. 296-304

Cognitive therapy in the treatment oflow self-esteem

Melanie J. V. Fennell

Beck's cognitive therapy originally developed as ashort-term treatment for depression (Beck et al, 1979).It has been shown to be effective with a range ofother disorders including panic disorder, generalised anxiety disorder, social phobia, eating disordersand sexual dysfunction (Roth et al, 1996). It ispromising in the treatment of yet more disorders,many of which have traditionally been thoughtrelatively impervious to psychotherapy, for example,bipolar disorder, chronic fatigue and psychosis(Clark & Fairburn, 1997). However, not everyoneresponds well to short-term cognitive therapy. In

particular, it has been proposed that people withmultiple, chronic problems that are apparentlyexpressions of personality, rather than temporaryresponses to adverse life experiences, require moreextended therapy (Beckef al, 1990).

Low self-esteem (often a major focus of interest in

other psychotherapies) has been relatively neglectedin cognitive therapy. This is perhaps because it isneither a specific psychiatric disorder nor apersonality disorder. Rather, it emerges as an aspectof, consequence of or vulnerability factor for manypresenting problems. For example, a negative self-image is central to depression (aspect), but characteristically evaporates as mood lifts. Alternatively, self-denigration may occur only once a specific disorder,such as generalised anxiety disorder, has persistedover time (consequence) and may improve on its ownas the presenting problem is addressed. Low self-esteem may predispose to a range of other difficulties(vulnerability factor), such as depression andsuicidality, eating disorders and social anxiety. Hereit may hinder progress in treatment and persist evenafter presenting problems have been successfullyresolved.

I aim: (a) to introduce practitioners unfamiliarwith the approach to the concepts and methods of

cognitive therapy; (b) to show readers more familiarwith cognitive therapy how a cognitive model maybe helpful in understanding low self-esteem (Fennell,1997);(c)to outline a cognitive-behavioural treatmentprogramme, which follows logically from the modeland integrates methods from the treatment of specificdisorders with recent developments in cognitivetherapy for personality disorders; and (d) to providesome sense of how the model and related treatmentmethods may apply in practice, through anillustrative case example.

The model and treatment programme have notyet been empirically evaluated. However, as notedabove, research has repeatedly demonstrated theefficacy of the cognitive treatments for anxiety anddepression on which it draws, and has supportedthe proposed relationships between cognition, affectand behaviour in both anxiety and depression(Clark & Steer, 1996).

Cognitive model of emotionaldisorder

Beck's cognitive model of emotional disorder (Beck,

1976) suggests that, on the basis of experience,people form conclusions (beliefs and assumptions)about themselves, other people and the world(predisposing factors). When experience is negative,these conclusions are also negative. Some core beliefsare descriptions of how things appear in the eyes ofthe person, for instance, T am no good', 'peoplecannot be trusted' and 'life is a struggle'. These may

be experienced as statements of fact, rather thanopinions formed on the basis of experience. Otherbeliefs (dysfunctional assumptions) are more like

Melanie Fennell is Consultant Clinical Psychologist at the Department of Clinical Psychology, The Warneford Hospital, OxfordOX3 7JX, and has used cognitive therapy in clinical practice for many years. As Director of the Oxford Diploma in CognitiveTherapy, a one-year part-time course for qualified and experienced mental health care professionals, she is actively engaged intraining and supervision. She is also researching cognitive models and treatments for anxiety disorders.

Cognitive therapy in low self-esteem APT(1998), vol. 4, p. 297

guidelines for living, standards of performance orrules and regulations that allow the person tooperate in the world, given the perceived truth ofthe core beliefs (e.g. 'I must always do everything to

the highest possible standard, no matter what thecost'). All may be well until the person encounters

an event or series of events (precipitating factors orcritical incidents) in which he or she is unable tomeet the requirements of the dysfunctional assumptions (e.g. the perfectionist fails at a crucial task).This leads to activation of the belief system, givingrise to negative, distorted automatic thoughts. Theseare thoughts which pop into the mind rather thanbeing a product of reasoned reflection. They arenegative in emotional tone and contain biases orexaggerations (e.g. over-generalisation from specificincidents or jumping to conclusions). Negativeautomatic thoughts directly influence mood, bodystate and behaviour. The perfectionist who has failedmay feel anxious and depressed, experience physical signs of stress and begin working even harder.Unfortunately, changes in mood and body state andattempts to right the situation may feed back intocontinuing negative thoughts (maintaining factors).So the perfectionist's low mood makes him or her

more likely to think negatively, while attempts towork even harder result in increasing fatigue andstrain which may confirm the sense of failure. Avicious circle is established which becomes increasingly difficult to break without professional help.

Concepts and methods

In treating relatively acute disorders, such asdepression or anxiety, cognitive therapy is typicallyoffered for 6-20 sessions. Treatment is based on athorough assessment, normally using standardquestionnaires as well as a detailed clinical interview. Information is gathered on current thoughts,emotions and behaviours, living circumstances, theevents that precipitated the onset of the presentingproblems and, where possible, predisposing experiences and beliefs (these may not become evidentuntil later in therapy). An individual cognitive caseconceptualisation is drawn up (see Fig. 1), whichboth guides treatment and changes as new informationemerges and new understandings are reached.

The first objective is to help patients break out ofthe vicious circles which maintain their difficulties.Painful emotions and maladaptive behaviours arepresumed to result from negative biases in thepatient's thinking. The task is to help patients

become aware of thoughts or images that enter theirminds in upsetting situations ('What went throughyour mind just then?'), and to teach them to question,

re-evaluate and test the validity of those thoughts.The cognitive therapist's prime tool is 'guideddiscovery', a collaborative process of inquiry which

helps patients to explore evidence for and againsttheir ideas, to search for alternative perspectives,and to examine how realistic and helpful these areby carrying out experiments in the real world andobserving the results. It is not up to the therapist topoint out patients' errors of interpretation and to

suggest alternatives, but rather to teach self-observation, self-questioning and openness toexperimentation. These are skills which will allowpatients to discover alternative perspectives forthemselves. The objective initially is to bring aboutchanges in thinking on a day-to-day basis, withcorresponding changes in emotional state andbehaviour. At a later stage, attention turns todysfunctional assumptions and core beliefs. Asimilar process of guided discovery is used toquestion and reformulate dysfunctional assumptions, and to question the validity of core beliefsand arrive at more balanced views. Ultimately, theaim is not only to help patients to resolve currentdifficulties, but also to reduce their vulnerability tofuture problems (for further details on the practiceof cognitive therapy for emotional disorders seeHawtoneffl/, 1989).

Cognitive model of lowself-esteem

It is proposed that the cognitive model of emotionaldisorder, with some elaborations, is directly relevantto the understanding of low self-esteem (thefollowing account should be read in conjunctionwith Figure 1, and is illustrated in the case examplebelow). It is suggested that the essence of low self-esteem lies in global ('me as a person') negative core

beliefs about the self, which derive from an interaction between inborn temperamental factors andsubsequent experience, for example, neglect, abuse,bereavement or an absence of sufficient warmth,affection and praise. Dysfunctional assumptionsthen function as 'escape clauses' which allow the

person to feel more or less happy with him/ herself,so long as he or she is able to do as they require (beperfect, be loved, be in control, etc.). However, well-being and confidence remain fragile, because thedysfunctional assumptions and the behaviouralstrategies to which they lead 'wallpaper over'

negative core beliefs, rather than undermining andchanging them.

Critical incidents which lead the person to believethat he or she might not be able to meet the

APT(1998),vol.4,p.298 Peniteli

(EARLY) EXPERIENCETemperament

Events, e.g. neglect, abuse, bereavement, insufficient warmth/affection/praiseSlow starter at school, unfavourable comparisons with older sibling

CORE BELIEFSGlobal negative beliefs about the self

J am boring, I am stupid

IDYSFUNCTIONAL ASSUMPTIONS

Guidelines for living, standards of performance, rules and regulationsUnless I am the life and soul of the party, no-one will want to know me

I must work extremely hard all the time, or I will fail

ICRITICAL INCIDENT(S)

Events which precipitate overt difficultiesMove to a new city, losing touch with friends

High demands of professional training

ÕACTIVATION OF BELIEF

, SYSTEM

DEPRESSIONLow mood, loss of energy,lowered activity level, loss ofinterest and pleasure, suicidalthoughts

tSELF-CRITICISMI've done it again...I'm a fool. I'll never

fit in here

ANXIETYSweating, blushing,shaking, panic

NEGATIVE PREDICTIONS¡won't make a goodimpression, I won't be

up to the work

\

MALADAPTIVEBEHAVIOURAvoidance, safetybehaviours, disruptedperformance, discounting

CONFIRMATION OFCORE BELIEF

/ knew it, 1 am boring and stupid

Fig. 1 A cognitive model of low self-esteem

requirements of the assumptions (i.e. an element ofuncertainty), precipitate negative predictions, whichin turn lead to symptoms of anxiety. These may thenproduce further predictions (e.g. 'I am going to losecontrol'). Performance may genuinely be disrupted

(e.g. stammering, clumsiness). In addition, theperson may engage in a range of maladaptivebehaviours, including outright avoidance and moresubtle self-protective manoeuvres ('safety-seekingbehaviours'; Salkovskis, 1991). These are designed

Cognitive therapy in low self-esteem APT (1998), vol. 4, p. 299

to prevent the predictions from coming true, but infact contribute to the persistence of the problem. Evenif to the detached observer all has gone well, successmay be discounted as a product of luck, or a 'nearmiss' where disaster was only narrowly averted.

Thus, whatever the actual outcome, the person withlow self-esteem experiences the incident as confirmation of the original belief about the self. This oftenprovokes self-criticism (negative automatic thoughtsabout the self) and then depressed mood, sometimesintense and persistent enough to meet diagnosticcriteria for major depression. Depressed mood inturn maintains activation of the system, increasingthe frequency and credibility of negative predictionsand self-critical thoughts. The model suggests thatconfirmation and subsequent self-criticism anddepression may occur without preceding anxiety(the dotted line in Fig. 1), if the critical incident istaken to mean that standards set by the dysfunctional assumptions have definitely not been met,that is, no element of uncertainty is involved.

Cognitive therapy

Cognitive therapy for low self-esteem integratesconcepts and methods from well-validated short-term work with acute anxiety (Beck et al, 1985) anddepression (Beck et al, 1979), and more experimentalideas and interventions from recent developmentsin the treatment of personality disorders (Beckcf al,1990). Treatment is designed to target elements inthe cognitive model of low self-esteem (Fig. 1) in asystematic sequence, although the exact sequenceof events and the emphasis given to componentswill vary. Some key interventions are summarisedin Box 1.

As with anxiety and depression, therapy normallystarts with a focus on maintaining factors, identifying, questioning and testing the cognitions that drivethe vicious circle (i.e. negative predictions and self-critical thoughts) through a combination of cognitiveand behavioural methods. Focused cognitive-behavioural work provides a foundation forexamining how dysfunctional assumptions areboth unreasonable (asking more than can realistically be expected) and unhelpful. More realistic andhelpful alternatives are then formulated, and putinto practice in day-to-day situations. Finally,attention turns to modifying the negative core beliefsabout the self which the model suggests form theheart of low self-esteem.

The overall goal is to encourage realistic self-acceptance, 'warts and all'. It is proposed that

negative core beliefs about the self are maintainedby two complementary processes: biased perception

Box 1. Some key interventions

Overall treatment objectivesTo weaken old, negative core beliefs about

the selfTo establish and strengthen more positive,

realistic new beliefs about the self (abalanced view)

To encourage kindly self-acceptance, 'wartsand all '

Understanding the problemThe cognitive model - developing an individ

ually tailored case conceptualisation

Modifying the perceptual biasDirecting attention to positive qualities,

assets, skills, strengthsKeeping regular written records of examples

of positive qualities, etc. on a day-to-daybasis

Seeking evidence (past and present) whichis inconsistent with negative core beliefsabout the self

Recording incidents inconsistent withnegative core beliefs about the self

Acting against the old belief and observingthe results (behavioural experiments)

Modifying the interpretative biasRe-evaluating the evidence (past and present)

that apparently supports the old beliefQuestioning associated negative automatic

thoughts (e.g. self-criticism) on a daily basisTesting negative predictions through regular

and frequent behavioural experimentsBreaking down black-and-white thinking

through continuum workRe-evaluating dysfunctional assumptions

and formulating more realistic and helpfulalternatives

and biased interpretation (Padesky, 1994). Biasedperception means that information which is notconsistent with the pre-existing belief tends to be

ignored, screened out or forgotten. In contrast,information which is consistent with the preexisting belief is readily perceived, processed andstored. Biased interpretation means that incominginformation is distorted to fit the Procrustean bed ofthe pre-existing belief. So, a compliment is taken as

insincere and a practical problem is interpreted as asign of incompetence. The methods used to changecore beliefs are designed to help the patient to becomeaware of and correct these complementary processes,

APT(1998),vol.4,p.300 Fcnnell

both by actively directing attention to strengths,assets and qualities, and by examining past andpresent experiences held to support the old belief(work on specific self-critical thoughts lays afoundation for this). The end result is both to weakenand undermine old beliefs, and to establish andstrengthen more realistic and helpful alternatives.

Treating low self-esteem in thecontext of personality disorder

Even patients whose problems date back to childhood (as is common, for example, in social phobia)may work successfully within the limited timeperiod of classical short-term cognitive therapy,especially if they have the qualities summarised inBox 2. The interventions described above canproduce substantial change within a matter ofweeks. With more complex cases, however, it maytake some months for patients even to begin toperceive anything positive about themselves, or toconsider entertaining a more kindly view.

When treating low self-esteem in the context ofpersonality disorder, the objectives of cognitivetherapy are essentially the same, that is: to helppatients to bring about desired changes in theircurrent thinking, emotions and behaviour, and toundermine and find alternatives to underlyingdysfunctional assumptions and beliefs about theself. However, certain modifications to treatment are

Box 2. Characteristics in people likely torespond to short-term cognitive therapy

Acceptance of the cognitive model ofemotional disorder as relevant to theirown experience

Belief that change is at least theoreticallypossible, and acceptance of the possibility of alternatives to their negative views

Ability to recognise and describe thoughtsand feelings with minimal training

Low to moderate level of disabilityWillingness to tryout cognitive-behavioural

methods in practice, and to experimentwith new ways of thinking and behaving,both within therapy sessions and inbetween-session self-help assignments

Ability to form an equal, collaborativetherapeutic alliance

usually advocated (Beck et al, 1990) in response toproblems presented by these patients, some of whichare outlined below. These modifications are mainlybased on clinicians' attempts to overcome the

shortcomings of traditional cognitive therapy withthis difficult population, and have not as yet beensubject to systematic empirical testing.

Cognitive rigidity

Some patients believe their low opinion of themselvesreflects simple fact: that they really are useless,unlovable, etc. These beliefs are likely to be associated with intense emotion, and sometimes extensiveavoidance. Consequently, work at the level of specificpresenting problems may have minimal impact. Itmay first be necessary to help the patient to entertainthe possibility that beliefs are opinions, not facts, asa way of introducing some flexibility into the system.Even then, such patients will take longer to considerand work on alternatives to their negative views.

Multiple problems

Patients often present with a mass of problems, andfind it hard to define any of them precisely, establishpriorities or focus on one at a time. This makessystematic problem-focused work difficult and canleave both therapist and patient feeling overwhelmed. It may help to draw up a coherentconceptualisation at an early stage, to explain thedevelopment and maintenance of problems and howthey relate to underlying beliefs and to each other.

Difficulties in the therapeuticalliance

Patients often report significant interpersonaldifficulties, based on beliefs about themselves, othersand relationships (e.g. 'I must never allow anyoneto see my true self, or 'people are out to attack andexploit me'). Patients may therefore be reluctant to

discuss their difficulties openly and prone tomisinterpret the therapist's behaviour. This, in turn,may result in activation of the therapist's own

negative beliefs and dysfunctional assumptions,and thus prevent the development of a warm, equalcollaborative alliance. Relationship issues mustthen be addressed in their own right, using the samecognitive theoretical framework that is used toaddress any other problems in the patient's life

(Safran & Segal, 1990). Therapy can then functionas a 'laboratory' in which the patient may safely

experiment with new ways of relating, beforetransferring learning to the outside world.

Cognitive therapy in low self-esteem APT(1998), vol. 4, p. 301

Non-verbal meanings

Patients with long-standing problems often havevivid, painful memories of childhood experienceswhen beliefs about themselves, others and the worldare crystallised out. Perhaps because they wereformed early in life, these beliefs may not have anyreadily definable verbal content. This has twoimplications for therapy. First, it may be necessaryto work on changing meanings assigned to experiences in the distant past. Second, imaginai andexperiential methods, often drawn from Gestalttherapy, can supplement more purely verbal andbehavioural techniques to identify and changemeanings that the patient may never have put intowords (Hackmann, 1997).

Chronicity

Patients whose difficulties are lifelong have oftenaccumulated a substantial body of experience whichapparently supports their negative beliefs aboutthemselves. This is especially so where the beliefshave resulted in extreme disability (multiple episodes,absent or unsatisfactory personal relationships,failure to establish a successful working life, etc.).In this case, hopelessness about the possibility ofchange may be intense, undermining willingnessto engage actively in the process of therapy and evencontaminating the therapist. Treatment may alsoneed to include teaching interpersonal and workskills from the most basic level.

The existence of long-standing, strongly heldnegative core beliefs does not necessarily indicate aneed for long-term treatment (Fennell, 1998). Manypatients with such beliefs respond well to 6-20sessions of competently administered cognitive therapy. This is of practical importance, given limitedresources. However, taken together, the difficultiesoutlined above sometimes mean that cognitive therapy must be extended over a longer time period (18-24 months is sometimes advocated). For a population which makes heavy use of services, this may bean acceptable investment, provided it can be shownto be more effective than more short-term alternativesboth after treatment and over long-term follow-up.

Case example

Peter was referred by his general practitionerbecause of his social phobia, of several years'

duration. Peter had not responded to anxiolytic medication. He had recently developed panic attacks andwas becoming increasingly depressed and suicidal.

The cognitive conceptualisation of Peter's problems

is presented in italics in Fig. 1. In childhood, he wasseen as slow and dull in comparison to his bright,socially adept elder brother. This led to two corebeliefs about himself: Tam boring' and 'I am stupid'.

His dysfunctional assumptions, adopted duringadolescence and reflecting his strategies formaintaining self-esteem, were: 'Unless I am the lifeand soul of the party, no one will want to know me'

and T must work extremely hard all the time, or Iwill fail'. These allowed him to feel more or less

happy with himself in his final years at school andat university, so long as he could do as his strategiesrequired. However, they left the underlying beliefsabout himself intact. Problems arose when he movedto a new city to pursue a professional career. Thework was very demanding, and at the same time helost contact with old friends. This combination ledto activation of his core beliefs about himself.

Self-monitoring helped Peter to identify thenegative predictions fuelling his anxiety sociallyand at work, for example: T won't make a goodimpression' and T am going to make a mess of thisassignment'. These triggered a range of anxiety

symptoms, including sweating, blushing andshaking. He was certain that his anxiety wasobvious, and predicted that others would thinkbadly of him because of it. To prevent his predictionsfrom coming true, Peter engaged in a variety of self-protective manoeuvres. Sometimes he avoided socialsituations altogether. At other times, he would readthe newspaper so as to have something interestingto say, drink heavily before going out in order torelax and spend hours perfecting work assignments.Sometimes he had genuine difficulties, for instance,his mind would go blank when his boss asked hima question. On other occasions, he in fact performedperfectly well, but in retrospect would discount this(e.g. 'they were just being polite' or 'well, I manageda good cover-up there, but next time...'). The end

result, to his mind, was confirmation of his beliefsabout himself that he was stupid and boring. Thisled to streams of self-criticism. Combined withhopelessness about improving his situation, thistriggered clinical depression including not only lowmood but also loss of energy, lowered activity levels,loss of interest and pleasure, and suicidal thoughts.This state was sometimes reached without intervening anxiety, for example, when his boss criticiseda report he had written.

Peter received 16 weekly sessions of cognitivetherapy, and three, monthly follow-up 'booster'

sessions. Treatment began by identifying linksbetween anxious predictions and safety behaviours,and considering how these operated together inspecific situations to maintain his anxiety (Clark,1997). He predicted, for example, that unless he

APT(1998),vol.4,p.302 Fennell

made every effort to be bright and witty, people wouldnot want to know him. He was asked to considerwhether this idea was generally true (review of theevidence), or whether in fact he knew people whowere not particularly bright and witty, but none theless had an active social life. Even though he did, hestill believed that for him personally being brightand witty was essential. However, he agreed to carryout a behavioural experiment. He went out withfriends and, instead of striving to be the life andsoul of the party, listened quietly to the conversation.There was no sign that people did not want to knowhim, and in fact one friend commented that she hadenjoyed his company. This became the first of a seriesof experiments which gradually undermined bothhis specific predictions about what would happenin particular situations, and also his overallassumption that to be acceptable he must alwaysact in this way. This gave him confidence to conductsimilar tests on his predictions that unless he spenthours perfecting every assignment at work, hewould be unable to do his job. He agreed to adopt a'good enough' standard, and discovered to his

surprise that he was able to work more efficientlybecause the time taken to complete assignments wasreduced. Again, this changed his feelings andworking practices on a day-to-day basis, and alsodiminished the assumption that he must workextremely hard all the time in order to succeed. Peteralso learned to identify self-critical thoughts, and toquestion them CWhat's my evidence for that?', 'Whatwould I say to another person in that situation?').

Once he had mastered these skills and could seechange occurring, his depression lifted.

The combination of changes in thinking andbehavioural experiments showed how strategiesPeter had adopted to meet the requirements of hisdysfunctional assumptions and improve his self-

esteem actually had an adverse impact, confirminghis poor opinion of himself. This observation formedthe basis for formulating more realistic and helpfulalternatives: 'being relaxed and spontaneous bringsme closer to people', and 'enough is as good as afeast'. These were consolidated over treatment andthroughout follow-up through further behaviouralexperiments (acting in accordance with the newrules, and observing the outcome). At the same time,work began on modifying Peter's negative core

beliefs about himself. The idea that he was stupidwas tackled by reviewing supporting and contraryevidence. Most of the evidence in favour of the beliefwas located in the distant past, though he stilltended to see failure to perform exceptionally as afurther sign of stupidity. Detailed explorationrevealed that, while he had undoubtedly been slowto develop at school, a combination of specificdifficulties with reading (which was resolved), poor

teaching and shyness were a better explanation forthis than stupidity. Changing this belief alsoinvolved some imagery work, as Peter had vivid,painful memories of feeling stupid as a little boywhich emerged in similar situations in the presentand were not affected by purely verbal interventions.Peter imagined himself speaking to his child self,telling him that his difficulties were not his fault,and that he was actually intelligent and would dofine in the end. This reduced the pain of thememories, and they became less powerful and lessfrequent.

The belief about being boring was tackled in adifferent way. Peter believed initially that anythingless than '100% scintillating' was boring, with no

intervening stages. On a continuum with 0%scintillating (i.e. boring) at one end and 100%scintillating at the other, he initially rated himself atclose to 0%. However, after exploring what 100%and 0% scintillating actually meant (always havingjokes and funny stories and never being unconfidentor at a loss what to say, versus never having anythingto say and being unable to join in any conversations),he realised that he was probably nearer 50%, evenwhen making no attempt to shine. He also concludedthat being with someone who was scintillating 100%of the time would be exhausting. This reminded himof a university friend who appeared genuinely closeto 100% and made him feel more like an audiencethan a participant in conversations, and of agirlfriend who broke up with him because she felthe never took anything seriously and she could notget close to him. Peter then began to recollectinstances where he was able to be himself withoutany negative responses from others, and where hebehaved in a way that showed intelligence andcommon-sense. This combination of re-thinking theold beliefs and day-to-day change led to theformulation of new beliefs, which he saw as moreaccurate once all the evidence was taken intoaccount: 'I am likeable just as I am' and 'I am an

intelligent person who sometimes does stupidthings'. By the end of treatment, Peter rated his

confidence in his old core beliefs at 0%, and the newalternatives were close to 100%. He no longer metcriteria for social phobia or major depression, andreported that he was handling his work and sociallife with confidence and pleasure.

Referring patients forcognitive therapy

Low self-esteem is associated with a wide range ofpresenting problems. Additionally, the model and

Cognitive therapy in low self-esteem APT (1998), vol. 4, p. 303

associated treatment programme contain elementsfrom cognitive therapy of anxiety, depression andpersonality disorder. Ideally, referrals should bemade to therapists with knowledge and supervisedexperience of working cognitively with a range ofpsychological problems, including long-termdifficulties associated with high levels of distressand disability. Unfortunately, at present very fewpsychiatrists (particularly at consultant level) haveenough training and supervised experience incognitive therapy to work effectively with thesepatients. However, cognitive therapy is widelyavailable from clinical psychologists. Also, increasing numbers of nurse behaviour therapists workingin hospital and community settings now receivetraining in the approach. The British Associationof Behavioural and Cognitive Psychotherapies(BABCP; inquiries to Howard Lomas, ExecutiveSecretary, 23 Partridge Drive, Baxenden, Accrington,Lancashire BBS2RL), a multi-professional organisation, holds a register of accredited cognitive-behavioural practitioners, including therapistsoperating in private practice. Patients with lesssevere problems may also benefit from cognitivetherapy self-help texts which address low self-esteem (McKay & Fanning 1992; Young & Klosko,1993; Butler & Hope, 1995; Greenberger & Padesky,1995). A 'homework' assignment of reading a

relevant chapter from one of these, and perhapsmonitoring and making a note of situations,thoughts and emotions relating to low self-esteem,can be a helpful rough-and-ready way to assess howlikely a patient is to respond to cognitive therapy.Broadly speaking, patients who complete theassignments and who feel the cognitive model ofemotional disorder has direct personal relevance tothem are likely to take to cognitive therapy and makegood use of it. Conversely, patients who have seriousdoubts about the relevance of the model and/or failto complete the assignments may be less suitable, atleast for a short-term focused approach.

References

Beck, A. T. (1976) Cognitive Therapy and Emotional Disorders.New York: International Universities Press.

—, Rush, A. }., Shaw, B. F., et al (1979) Cognitive Therapy ofDepression. New York: Guilford., Emery, G. & Greenberg, R. (1985) Anxiety Disorders

and Phobias: A Cognitive Perspective. New York: BasicBooks.

—, Freeman, A., and associates (1990) Cognitive Therapy ofPersonality Disorders. New York: Guilford.

Butler, G. & Hope, T. (1995) Manage Your Mind. Oxford:Oxford University Press.

Clark, D. A. & Steer, R. A. (1996) Empirical status of thecognitive model of anxiety and depression. In Frontiers ofCognitive Therapy (ed. P. M. Salkovskis), pp. 75-96. NewYork: Guilford. "

Clark, D. M. (1997) Panic disorder and social phobia. InScience and Practice of Cognitive-Behavioural Therapy (edsD. M. Clark & C. G. Fairburn), pp. 119-153. Oxford:Oxford University Press.

— & Fairburn, C.G. (1997) Science and Practice of Cognitive-Behavioural Therapy. Oxford: Oxford University Press.

Fennell, M. J. V. (Ì997)Low self-esteem: A cognitiveperspective. Behavioural and Cognitive Psychotherapy, 25,1-25.

— (1998) Low self-esteem. In Treating Complex Cases: TheCognitive-Behavioural Therapy Approach (eds N. Tarrier, A.Wells & G. Haddock). Chichester: Wiley, in press.

Greenberger, D. & Padesky, C. A. (1995) Mind Over Mood: ACognitive Therapy Treatment Manual for Clients. New York:Guilford.

Hackmann, A. (1997) The transformation of meaning incognitive therapy. In The Transformation of Meaning inPsychological Therapies: Integrating Theory and Practice(eds M. Power & C. R. Brewin), pp. 125-140. Chichester:Wiley.

Hawton, K., Salkovskis, P. M., Kirk, ]., et al (eds) (1989)Cognitive-Behavioural Therapy for Psychiatric Problems.Oxford: Oxford University Press.

McKay, M. & Fanning, P. (1992) Self-Esteem (2nd edn).Oakland, CA: Harbinger.

Padesky, C. A. (1994) Schema change processes in cognitivetherapy. Clinical Psychology and Psychotherapy, 1, 267-278.

Roth, A., Fonagy, P., Parry, G., et al (1996) What Works forWlwin? A Critical Review of Psychotherapy Research. NewYork: Guilford.

Safran, J. & Segal, Z. V. (1990) Interpersonal Process in CognitiveTherapy. Northvale, NJ: Jason Aronson.

Salkovskis, P. S. (1991) The importance of behaviour in themaintenance of anxiety and panic: A cognitive account.Behavioural Psychotherapy, 19, 6-19.

Young, J. E. & Klosko, J. (1993) Reinventing Your Life. NewYork: Dutton.

Multiple choice questions

1. From a cognitive perspective, low self-esteem is:

a a personality disorderb an acute psychiatric disorderc an aspect of, consequence of or vulnerability

factor for a range of psychological problemsd a product of unconscious conflicts.

2. Negative core beliefs about the self are:a irrelevant to the successful treatment of low

self-esteemb a result of previous experience and influence

current thoughts, feelings and behaviourc a bi-product of biochemical disturbancesd the end product of behavioural deficits and

excesses.

3. Low self-esteem is perpetuated by:a a vicious circle comprising cognition,

affect and behaviour, which results inpersistent activation of negative beliefsabout the self

b behavioural avoidance strategiesc symptoms of anxiety and depressiond interpersonal and environmental Stressors.

APT(1998),vol.4,i).304 fennell

4. Cognitive therapy for low self-esteem aims to:a help patients to break out of the vicious circleb undermine old negative core beliefs about the

selfc establish a new, more positive and realistic

view of the selfd understand how the problem developed and

what keeps it going.

5. Cognitive therapy for low self-esteem:a can be done by anyone with basic book

knowledge of cognitive therapyb is not available within the National Health

Servicec should only be given by therapists with sound

knowledge of the approach and supervised

experience of working cognitively with a rangeof psychological problems

d should always be carried out in combinationwith psychotropic medication.

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FORTHCOMINGFROMGASKELL

Clinical Topics in PsychotherapyEdited by Digby Tantam

The focus of this book is on specific conditions in which psychotherapy is the main treatment currentlyin use. Common syndromes which patients present to the psychotherapist and to general psychiatristsare covered. Contributors provide a succinct review of what treatment works in each condition, andhow it works. Some of the chapters have been published previously in the British journal ofPsychiatry.Clinical Topics in Psychotherapy will prove an invaluable guide to all clinicians.

Readership: Psychotherapists, general psychiatrists, general practioners, and all those whoseprofession involves the provision of psychological treatment

October 1998, £30.00,304pp., Paperback, ISBN1 901242226

ROYALCOLLEGEOFPSYCHIATRISTS,17 BELGRAVESQUARE,LONDONSW1X 8PGTEL:+44 (0) 171 235 2351, EXT146 FAX:+44 (0) 171 245 1231

http:llwww.rcpsycii.ac.uk