TIFT #4 A Deeper Look at Low Self-Esteem

One of the most common problems patients struggle with is low self-esteem and negative self-talk. In this TIFT, I want to bring psychodynamics together with CBT and more to go deeper into the subject.

Why People develop Low Self-Esteem

Watson's declaration that why was necessarily subjective and not fit for science has cast a long shadow. Even today, most discussions from a behavioral orientation focus on how to change low self-esteem or negative self-talk, but not on why it is there. More recently, there has been a trend in CBT circles to develop an "individual case formulation," which might consider what lead to bad feelings about the self.

Psychodynamics was built on the question of why. Along with work in the field of trauma, explanations from this orientation tend to look at low self-esteem as something learned as a result of abuse and neglect. If one is treated poorly, then it makes sense that the victim would conclude that they were of little worth, especially in childhood or adolescence. This simple explanation seems to fit the facts. However, there is an additional element that suggests otherwise. If we were dealing with simple learning, then why is low self-esteem resistant to change? Why do sufferers have to work so hard to rid themselves of this seriously debilitating symptom?

Diving Deeper into Why

The first early trauma patient I worked with suffered both from intense dread of traumatic recall and from low self-esteem. To my surprise, processing the memories, once they were accessed with full emotion, was rapid and compete. After they had been brought to light, the dread was gone and we didn’t have to revisit them again (In a later post, I’ll explain why I am convinced that the mechanism was Memory Reconsolidation). While I was surprised by the rapidity and completeness of the healing of those memories, I took note that her low self-esteem was much harder to treat. It did not change quickly and was subject to relapse. That was my first awakening to the fact that psychotherapy involves more than one change mechanism.It was also the beginning of along search to understand why low self-esteem is so hard to change.

Shame and Values

The clue was shame. Accompanying low self-esteem was shame at being a person of such low worth. This might seem obvious, but a lot of thought and reading led to a surprising conclusion. Shame and guilt are what we feel when we fail to live up to our values. Low self-esteem belongs in the same category as a value. Just as one might value self-control or honesty, a person might negatively value the self. Values are radically different from other learning such as likes and dislikes. We don’t feel shame if we go against our preference, nor do we feel proud of our likes and dislikes. But we fee pride about our values. In the end I concluded that this distinct and interesting family of mental contents also includes attitudes, ideals, and prohibitions. To generalize, I refer to them all as values. Self esteem is, more precisely, an attitude towards the self. All are capable of generating pride, shame, or guilt. When pathological, all are subject to relapse, and all are exceedingly hard to change.

How are Values Acquired?

In recognition of this distinction, I would propose saying that values are “internalized”rather than learned. They become part of the individual’s lasting structure and form the basis for judgments. So how does this happen? Freud was helpful with the concepts of identification with the lost object and his theory of the development of the superego (though I am not in agreement with all he said about the latter). I also learned from an interesting book by Conway and Siegelman called Snapping: America's Epidemic of Sudden Personality Change. Together they led me to the belief that the trigger for internalization is what I would call “connection anxiety.” Children protect themselves against the loss of connection by internalizing the values of their family such as toilet training, which lasts a lifetime. People who join cults tend also to crave a sense of belonging. They, too, have connection anxiety. During the induction ceremony, they internalize (sometimes suddenly) the values of the cult. Those who are poorly treated in childhood or abused are afraid of being rejected and alone. They internalize the implied and sometimes explicit values of their abusers, including their own low worth. I’ll even suggest that young professionals, in the early phases of their training and anxious to belong, may internalize powerful values such as not asking "why" or being sure not to “gratify” their patients.

Relapse Implies a Different Mechanism of Change

When we begin to think about change, things get complicated. The fact that values are subject to relapse confirms that, even with successful treatment, they remain intact, stored somewhere in memory. Unlike other mental contents, where change can involve modifying existing information, change for values appears to require internalizing new values or re-awakening old, positive ones in such a way as to override the effects of negative attitudes towards the self.

[Note: Since writing the above, I have become convinced that values can be modified through memory reconsolidation, though this does not happen easily or often. See TIFT #98 The implication is that resistance to change in values is an active process of maintenance.]

The Function of Self-Talk

Clinical observation suggests that the mind works actively and powerfully to maintain consistency between behavior and values, perhaps to avoid shame. That is where self-talk comes in. Much of social conversation revolves around affirming values. Similarly, self-talk is a natural way to reaffirm an internalized attitude. Whatever the mechanism, intuitively, it appears that we are compelled to do this. If we do otherwise, as happens when we violate our own values, we can expect a shower of feelings of shame and general discomfort. This is no less true even when values are dysfunctional.

Behavioral Treatment

Here, the goal is to foster the internalization of healthier attitudes towards the self and to have them take precedence. Looking at how we might do this brings us back to how values are internalized.Verbal exploration and expression of negative attitudes tends to make them stronger. Interpretation is often too weak to yield significant change. The behavioral tradition seems to be the source of many of the most effective treatment strategies.

• Motivation: A first principle is to be sure the patient is completely clear, intellectually, that the old attitude is maladaptive and wrong. This is necessary to counteract the mind’s inevitable and strong efforts to rationalize and reinstate the old attitude.
• Adoption of New Thoughts: Purposefully repeating positive self-talk is one of the mainstays of behavioral intervention.
• Behavioral Disobedience: Behaving in ways counter to the maladaptive value, such as holding one’s head high instead of slouching, often brings on a powerful “backlash” of shame, discomfort, and impulses to return to “normal,” tending to confirm its effectiveness in helping the individual to adopt new values. Recent interest in somatosensory therapies emphasizes the importance of working with the body in addition to the mind. [Later note: Clients appreciate when I call this "Civil Disobedience."]
• EMDR:One of the few therapies that actually addresses values differently from other mental contents, EMDR prescribes “installing” the new value by holding the trauma memory and the positive cognition in mind at the same time then performing alternating stimulation.
• Psychedelics and Ceremony: Ayahuasca Ceremonies and other psychedelic experiences are being researched as treatment for depression, where negative attitudes towards the self represent an important component of the symptomatology. I recently worked with a man who was stuck in his growth because of an internalized attitude that was blocking his considerable creativity. As we were progressing toward full behavioral disobedience, he decided to attend an Ayahuasca weekend, using a psychedelic substance surrounded by ceremony. He came back unblocked and soon discontinued therapy. I had one follow up a few months later and he was doing well.
• Brain Washing and Cult Induction: Another area where installation of values is the goal is brainwashing and cult induction. While this is not generally proposed as treatment, opportunities for study abound. Hunger, sleep deprivation, and cognitive manipulation are combined to lead to dramatic internalization of new values attitudes, ideals, and prohibitions.

Conclusion

My general recommendation for this problem is “the kitchen sink.” That is, when patients are hampered by negative attitudes towards the self, it is well to use any and all appropriate approaches, starting with intellectual conviction and motivation for change. The job is hard and requires consistent effort over time, along with preparing the patient for the inevitable backlashes of shame and impulses to revert to the old patterns. 

Jeffery Smith MD