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Self-Esteem in Therapeutic Settings and Emotional Disorders
Self-esteem plays a key role in most formulations of psychopathological processes (Cooper, 1986) and in many models of therapeutic technique (Bednar, Wells, & Peterson, 1989). For several highly prevalent emotional disorders, such as depression and borderline personality, vulnerable self-esteem is a defining characteristic. For other disorders, such as narcissistic personality and eating disorders, fluctuations in self-esteem triggered by stressful interpersonal encounters prompt self-destructive behavior and maladaptive responses to others. We begin this brief chapter with an overview of the primary functions of self-esteem and the relevance of these functions to therapeutic efforts. We then illustrate how the dynamics of self-esteem are manifested in psychopathology through the lens of two emotional disorders, depression and narcissistic personality disorder. Next, we discuss how unconscious aspects of self-esteem pose a significant challenge to therapists. Finally, we offer daily process methodology as a promising way to examine self-esteem disturbances in emotional disorders and the therapeutic processes designed for their alleviation.
Self-Esteem in the Therapeutic Setting
Previous theorizing on the self posits that high self-esteem promotes positive affect, goal achievement, and interpersonal relationships (Leary, Tambor, Terdal, & Downs, 1995). We believe that each of these self-esteem functions plays an important role in the therapeutic process.
Promotes Positive Affect
Most people seek psychotherapy because they are experiencing distressing negative emotions. A good deal of evidence demonstrates that people with low self-esteem experience more negative emotions than their high self-esteem counterparts because of the way they respond to threatening information and how they regulate their moods. Whereas people with high self-esteem typically respond to threatening information by protecting or maintaining their positive beliefs about the self, people with low explicit self-esteem respond to such information by experiencing a diminished sense of self (Greenberg & Pyszczynski, 1985; Steele, 1988; Swann, 1987; Taylor & Brown, 1988; Tesser, 1988). Individuals with low self-esteem also recall fewer positive thoughts and memories in response to negative moods, and they dampen their positive moods compared with individuals with high self-esteem (Dodgson & Wood, 1998; Smith & Petty, 1995; Wood, Heimpel, & Michela, 2003).
Goal Attainment
Self-esteem is also linked to the therapeutic process in that individuals with higher self-esteem maintain higher goal expectancies and persist in the face of initial setbacks (Bandura, 1997; Maddux, 1995). Positive outcome expectancies are key to successful psychotherapy outcomes because clients’ assessments of the effectiveness of therapy are based mainly on their therapy expectations, rather than on therapist factors (Horvath & Luborsky, 1993). Because negative expectations about therapeutic outcomes presumably influence actual outcomes (Affleck, Tennen, & Rowe, 1991), these negative therapeutic expectancies are likely to become a self-fulfilling prophecy. In fact, psychotherapy clients with low self-esteem may be doubly challenged in psychotherapy: Their low expectations that therapy will be successful contribute to less effective therapeutic outcomes, and their lack of persistence in therapy when things are not going well make them likely candidates for premature treatment termination. Indeed, to the extent that their low expectations in therapy contribute to slow progress, low self-esteem individuals actually create a pessimistic therapeutic climate in which they are inclined to respond by disengaging from treatment.
Interpersonal Relationships
Clients’ and therapists’ self-esteem contribute to a positive therapeutic alliance, which in turn influences treatment outcomes (Bowlby, 1982; Horvath & Luborsky, 1993; Zetzel, 1970). Because people with low self-esteem have a history of feeling rejected, they are especially sensitive to signs of potential rejection (Leary et al., 1995; Murray, Holmes, & Griffin, 2000). For example, according to the dependency regulation model, relationship-specific expectancies of acceptance play a central role in regulating people’s perceptions of their relationship partners (Murray et al., 2000). In fact, the contingency between perceived acceptance and people’s regard for their relationship partners becomes overlearned and is elicited automatically (DeHart, Pelham, & Murray, in press). Therefore, individuals with low self-esteem may only be satisfied with their therapists when they believe that their therapists view them positively. Moreover, their perception of not being positively regarded may result in low self-esteem people derogating or challenging their therapists. These self-regulatory dynamics sow the seeds for negative therapeutic reactions and treatment failures, and thus represent another significant challenge for therapists.
In short, self-esteem influences the therapeutic process from beginning to end. Dysfunctional regulation of self-esteem and affect often brings the individual into therapy, may have a negative influence on the client-therapist relationship, and fosters a pessimistic therapeutic climate. Unfortunately, this is not the recipe for successful psychotherapy and may result in the client disengaging and eventually terminating treatment.
Self-Esteem and Psychological Disorders
As mentioned above, people’s overall feelings of worth and acceptance play an important role in their psychological functioning. However, the dynamics of self-esteem vary among emotional disorders. We have selected one disorder from DSM IV’s (APA, 1999) Axis I, major depressive disorder, and one from Axis II, narcissistic personality disorder, in which self-esteem plays an especially important role. We discuss how implicit (i.e., unconscious, relatively uncontrolled, and overlearned) and explicit (i.e., consciously considered and relatively controlled) self-esteem motives are related to each disorder, and we highlight potential difficulties that certain manifestations of implicit self-esteem pose for the therapeutic process.
Major Depressive Disorder
Major depressive disorder is characterized by a depressed mood, loss of interest or pleasure in activities, and disturbances in thought processes (APA, 1999, p. 327). Both psychoanalytic and cognitive formulations underscore the role of early relationships with significant others in the development of the disorder (Basch, 1975; Brown & Harris, 1989; Jacobson, 1975; Rado, 1968). For example, early psychodynamic perspectives asserted that depression is the result of unconscious anger felt toward the loss of an ambivalent attachment relationship, which is directed toward the self (Arieti & Bemporad, 1978; Basch, 1975). In addition, aggression is viewed as a defensive effort to ward off feelings of depression and to regulate self-esteem (Jacobson, 1975). On the other hand, cognitive formulations contend that early experiences create beliefs about the self that serve as vulnerability factors, which in turn interact with subsequent negative experiences to initiate and maintain depression (Bandura, 1997; Beck, Rush, Shaw, & Emery, 1979; Brown & Harris, 1978, 1989; Maddux, 1995; Pyszczynski, Holt, & Greenberg, 1987). In short, psychoanalytic and cognitive theories suggest that loss of self-esteem and poor self-esteem regulation in the face of adverse events are key features of depression.
Despite their many differences, psychodynamic and cognitive perspectives agree that self-esteem is a vulnerability factor for depression, and there is empirical support for the causal link between low self-esteem and depression (Brown & Harris, 1978, 1989). Recently, clinical and social psychologists have argued that it is not low self-esteem per se, but rather labile self-esteem, that is related to depression (Butler, Hokanson, & Flynn, 1994; Kernis, Grannemann, & Mathis, 1991; Roberts & Monroe, 1992, 1994). Presumably, negative events activate negative self-evaluations among individuals with labile self-esteem, which in turn compromises their ability to regulate depressed moods. However, most of this research has measured unstable self-esteem (the standard deviation of people’s self-esteem over time) rather than labile self-esteem per se (see Butler et al., 1994 for an exception).
Self-esteem may also be related to the belief that one can exercise control over dysfunctional thought processes, negative affect associated with depression, and behaviors that impair interactions with others (Bandura, 1997; Maddux & Meier, 1995). This line of reasoning, derived from self-efficacy theory, proposes that when individuals believe that they lack the ability to control their world and to repair the emotional damage elicited by negative events, feelings of hopelessness may develop (Abramson, Metalsky, & Alloy, 1989; Brown & Harris, 1978). In fact, many cognitive therapies enhance clients’ coping skills by fostering selfefficacy (Bandura, 1997; Maddux & Meier, 1995). Specifically, cognitive therapies increase people’s beliefs that they can control the outcomes of negative events, control and change negative thought patterns, and obtain desired goals. These therapies assume that clients have conscious control over and can easily change their dysfunctional thought patterns. However, beliefs that are overlearned and elicited automatically may not be amenable to conscious control.
Depressed individuals also experience relationship difficulties (Brown & Harris, 1978; Davila, Bradbury, Cohan, & Tochluk, 1997; Fincham, Beach, Harold, & Osborne, 1997). For example, wives who are depressed act in ways that elicit rejection from their partners, which results in them feeling more distressed (Davila et al., 1997). A client’s depression can also influence the therapeutic relationship. Because people’s beliefs about the self can influence the imagined appraisals of others (Kenny, 1994; Shrauger & Schoeneman, 1979), the negative self-appraisals of depressed individuals make them inclined to anticipate, and perhaps even evoke signs of rejection from the therapist that interfere with the therapeutic alliance.
Narcissistic Personality Disorder
Narcissistic personality disorder is characterized by a grandiose sense of self-importance, constant need for admiration from others, lack of empathy, and interpersonal exploitativeness (APA, 1999, p. 661). Most psychodynamic perspectives on narcissism point to the important role of early object relations in the development of the disorder (Cooper, 1986; Kernberg, 1975; cf. Laseh, 1979, Nemiah, 1973). That is, early relationships with parents who are rejecting, neglectful, disapproving and do not meet the child’s needs are internalized into negative feelings about others as well as feelings of inferiority and insecurity (Nemiah, 1973). Therefore, a vulnerable self-structure develops, and narcissistic individuals try constantly to compensate for their insecurities by exaggerating their accomplishments, preoccupying themselves with thoughts of success, and seeking excessive admiration from others.
Clinical conceptions depict narcissistic individuals as demonstrating emotional instability, despite their grandiose sense of self (Kernberg, 1975; Kohut, 1986; Nemiah, 1973). Narcissists’ excessively positive self-views are believed to be defensive and mask underlying insecurities (Kernberg, 1975), which is consistent with research and theory on subclinical levels of narcissism among young adults who have high explicit and low implicit self-esteem (Brown & Bosson, 2001; Jordan, Spencer, Zanna, Hoshino-Browne, & Correll, 2003; Kernis, 2003). In addition, people with high explicit and low implicit self-esteem respond defensively to self-concept threats (Bosson, Brown, Ziegler-Hill, & Swann, 2003; Jordan et al., 2003). This inconsistency between explicit and implicit self-views may contribute to the narcissist’s emotional instability (Emmons, 1987; Reich, 1986) and aggression in response to self-threat (Bushman & Baumeister, 1998).
Another reason why narcissistic clients experience emotional instability is because they set excessively high goals for themselves that they fail to meet (Kernberg, 1975; Kohut, 1986; Lasch, 1979; Nemiah, 1973). In fact, it has been argued that narcissistic individuals may be especially well suited for bureaucratic institutions because of the ambition and confidence they exude (Lasch, 1979). However, their vulnerable self-esteem makes them particularly sensitive to criticism or setbacks, and their awareness of this sensitivity makes it difficult for narcissists to take risks. Excessively high personal goals, an impoverished sense of self, and extreme sensitivity to criticism converge in individuals with pathological narcissism to engender unstable self-esteem (Rhodewalt, Madrian, & Cheney, 1998), which in turn generates affective instability.
Narcissistic individuals also have impaired interpersonal relationships. They are caught in an approach-avoidance dilemma. On the one hand, they must rely on the admiration of others to combat the negative appraisals they maintain about themselves—appraisals that they are unable to regulate (Stolorow, 1986). At the same time, however, they are terrified of becoming emotionally dependent on others because others are viewed “as without exception undependable” (Lasch, 1979, p. 84). Problems relying on others make it difficult for the narcissist to form a productive client-therapist relationship (Bromberg, 1986; Cooper, 1986; Lasch, 1979). A major goal in the psychodynamic treatment of narcissistic individuals is to make their unconscious insecurities more consciously available (Kernberg, 1975; Kohut & Wolf, 1986; White, 1986). Then, their insecurities may be more fully integrated into conscious beliefs.
The Role of Implicit Self-Esteem in the Treatment of Emotional Disorders
Many people are unable to articulate self-concept vulnerabilities as a part of their conscious belief systems (Pelham, DeHardt, & DeHart, 2003; Wenzlaff & Bates, 1998). This, we believe, poses a thorny problem for cognitive therapists. Specifically, how does one go about consciously restructuring a set of overlearned beliefs that are elicited automatically? The integration of the psychoanalytic concept of the unconscious with advances within cognitive psychology in measuring implicit beliefs (Epstein, 1994) holds considerable promise for our understanding of how unconscious self-concept vulnerabilities might contribute to emotional disorders. For example, investigators have recently begun to use indirect methods to determine whether people at risk for depression engage in biased information processing (Alloy, Abramson, & Francis, 1999; Hedlund & Rude, 1995; Wenzlaff & Bates, 1998). These findings indicate that the accessibility of negative self-relevant thoughts may provide a way to assess vulnerability to depression. That they were derived from experimental investigations guided by cognitive psychological theory should make such findings palatable to cognitive therapists.
Psychoanalytic approaches to psychotherapy have long acknowledged the importance of unconscious working models. In fact, one of the cornerstones of psychoanalytic therapy is its attempt to change people’s unconscious beliefs about self and others by having the client project these beliefs onto the analyst. Then, the analyst helps recondition these implicit beliefs by repeatedly responding to the client in ways that do not replicate childhood interactions with significant others. However, people’s implicit self-evaluations appear to be most informative when assessed under conditions of threat or cognitive load (Bowlby, 1982; Jones, Pelham, Mirenberg, & Hetts, 2002; Koole, Dijksterhuis, & van Knippenberg, 2001; Pelham, Koole, Hardin, Hetts, Seah, & DeHart, 2005). For example, self-concept threat seems to activate beliefs that are typically not available to conscious reflection (Jones et al., 2002; Pelham et al., 2005). Therefore, we encourage therapists to begin using additional techniques that evoke self-concept threat or induce cognitive load, to help uncover and change self-concept vulnerabilities that lie outside of conscious awareness.
A Daily Process Approach to Self-Esteem in Emotional Disorders and in Psychotherapy
A growing literature now demonstrates the unique potential of daily process designs—commonly referred to as daily diary recording (Stone, Lennox, & Neale, 1985), ecological momentary assessment (EMA; Stone & Shiffman, 1994), or experience sampling methodology (ESM; Csikszentmihalyi & Larson, 1984)—to capture hypothesized psychological processes in situ. Indeed, several investigations described in this chapter used daily process methods (Butler et al., 1994; Kemis et al., 1991; Rhodewalt et al., 1998; Roberts & Monroe, 1992). Yet, only rarely have investigators addressed temporal associations depicted in the clinical literature and in theories describing self-esteems role in emotional disorders (Tennen & Affleck, 1996; Tennen, Affleck, Armeli, & Carney, 2000; Tolpin, Gunthert, Cohen, & O’Neill, 2004).
Invariably, clinical and social psychological theories of disturbances in self-esteem posit if-then contingencies in daily life, and how a particular disorder alters these contingencies. As described in this chapter, these theories depict responses to self-threatening information, thoughts and memories evoked by negative moods, behavioral responses to setbacks, and self-regulation efforts in response to negative emotions. We believe that the inherently idiographic nature of these if-then contingencies is exceptionally well suited to study through daily process designs. Fortunately, the behavioral, cognitive, and emotional contingencies described throughout this chapter fit well with the ways people portray their everyday lives in recounting experiences in psychotherapy sessions and in daily social exchanges. This natural tendency should serve as a resource to therapists.
Finally, daily process methods can provide unique implicit and explicit self-esteem related outcome indicators in studies of the psychotherapy’s effectiveness. Rather than comparing pretreatment and posttreatment levels of self-esteem as indicators of effective treatment, daily process methods would allow clinical researchers to examine changes in how low self-esteem clients respond to self-threatening information, whether after treatment they are better able to evoke positive memories when they experience negative moods, and if treatment made them more resilient to setbacks in their daily lives. These are the very processes described by traditional clinical theory and current social psychological models of self-esteem.
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