Working with Self-Esteem in Psychotherapy

by Nathaniel Branden, Ph.D. (NathanielBranden@compuserve.com)
Copyright © 1994, Nathaniel Branden, All Rights Reserved
Copyright © 1994, The Hatherleigh Company, Ltd.


Background Information

When I began practicing psychotherapy in the 1950s, I became convinced that low self-esteem was a common denominator in most, if not all, of the varieties of personal distress I encountered in my practice (Branden, 1969). I saw low self-esteem as both a predisposing causal factor of psychological problems and also as a consequence. This lesson will briefly outline: (a) What self-esteem is; (b) why it is an urgent need; (c) what its attainment depends on; and (d) how the clinician can nurture it in psychotherapy.

Some clients' problems are direct expressions of an underdeveloped self-esteem. Examples include: shyness; timidity; fear of self-assertion, intimacy, or human relationships; and lack of participation in life. Other issues can be understood as consequences of the denial of poor self-esteem; i.e., as defenses against the reality of the problem. Examples of such defenses include: controlling and manipulative behavior; obsessive-compulsive rituals; inappropriate aggressiveness; fear-driven sexuality; and destructive forms of ambition. All of these consequences are driven by the desire to experience efficacy, control, and personal worth. Problems that manifest as poor self-esteem also contribute significantly to the continuing deterioration of self-esteem.

A primary task of psychotherapy is to help strengthen self-esteem. I believe that self-esteem can and should be addressed explicitly, and that it should set the context of the entire therapeutic enterprise. Even when the client is not working on self-esteem issues directly, even when therapy is focused instead on solving specific problems, problem solving can be accomplished by framing or contextualizing the process in such a way as to make it explicitly self-esteem-strengthening.

Almost all therapeutic orientations help clients confront previously avoided conflicts or challenges. My technique differs in that I typically ask questions like, "How do you feel about yourself when you avoid an issue you know, at some level, needs to be dealt with? And how do you feel about yourself when you master your avoidance impulses and confront the threatening issue?" In other words, I frame the process in terms of its consequences for self-esteem. I want clients to notice how their choices and actions affect their experience of themselves.

Definition of Self-Esteem

Self-esteem is the experience of being competent to cope with the basic challenges of life and of being worthy of happiness. It consists of two components: (1) Self-efficacy — confidence in one's ability to think, learn, choose, and make appropriate decisions, and, by extension, to master challenges and manage change; and (2) self-respect — confidence in one's right to be happy, and, by extension, confidence that achievement, success, friendship, respect, love, and fulfillment are appropriate for oneself (Branden, 1994).

To illuminate this definition, consider the following: If a client felt inadequate to face the challenges of life, if he or she lacked fundamental self-trust or confidence in his or her mind, a clinician would recognize the presence of a self-esteem deficiency, no matter what other assets the client possessed. The same would be true if a client lacked a basic sense of self-respect, felt unworthy of the love or respect of others, felt unentitled to happiness, or was fearful of asserting thoughts, wants, or needs.

Self-efficacy and self-respect are the dual pillars of healthy self-esteem; if either one is absent, self-esteem is impaired. They are the defining characteristics of the term because of their fundamentality; they represent not derivative or secondary meanings of self-esteem, but its essence. (For a critique of other definitions, see Branden, 1994.)

The Need for Self-Esteem

How people experience themselves impacts upon every moment of their existence. Their self-evaluation is the basic context in which they act and react, choose their values, set their goals, meet the challenges of life. Their responses to events are shaped in part by who and what they think they are — how competent and worthy they perceive themselves to be. Of all the judgments they pass in life, none is more important than the judgment they pass on themselves.

To say that self-esteem is a basic human need is to say that it makes an essential contribution to the life process; that it is indispensable to normal and healthy development; that it has value for survival. Without positive self-esteem, psychological growth is stunted. Positive self-esteem operates, in effect, as the immune system of consciousness, providing resistance, strength, and a capacity for regeneration.

When self-esteem is low, resilience in the face of life's adversities is diminished. Clients crumble before vicissitudes that a healthier sense of self could vanquish. They tend to be more influenced by the desire to avoid pain than to experience joy; negatives have more power over them than positives (Branden, 1984).

This does not mean that they are necessarily incapable of achieving any real values. Some persons may have the talent and drive to achieve a great deal in spite of a poor self-concept — like the highly productive workaholic who is driven to prove his worth to say, a father who predicted he would amount to nothing. However clients who have low self-esteem will be less effective — less creative — than they potentially could be; it also means that they will be crippled in their ability to find joy in their achievements. Nothing they do will ever feel like enough.

Those who do exhibit a realistic confidence in their mind and value — who feel secure within themselves — tend to experience the world as open to them and to respond appropriately to challenges and opportunities. Self-esteem empowers, energizes, and motivates. It inspires persons to achieve and allows them to take pleasure and pride in their achievements. It allows them to experience satisfaction.

High self-esteem seeks the challenge and stimulation of worthwhile and demanding goals. Reaching such goals nurtures healthy self-esteem. Low self-esteem seeks the safety of the familiar and undemanding, which in turn further weakens self-esteem.

The more solid a client's self-esteem, the better equipped he or she is to cope with adversity in their personal lives or their careers. The higher a client's self-esteem, the more ambitious he or she will tend to be, not necessarily in a career or a financial sense, but in terms of what he or she hopes to experience in life — emotionally intellectually, creatively, spiritually. The lower the client's self-esteem, the less he or she aspires to; moreover, he or she is less likely to achieve set goals.

Either path tends to be self-reinforcing and self-perpetuating. The higher the client's self-esteem, the more open, honest, and appropriate his or her communications are likely to be, which reinforces a positive self-concept. The lower the client's self-esteem, the more muddy evasive, and inappropriate his or her communications are likely to be because of uncertainty about his or her own thoughts and feelings and/or fear of the listener's response. This, in turn, further diminishes self-concept.

The higher the client's self-esteem, the more disposed he or she is to form nourishing rather than toxic relationships. Vitality and expansiveness in others are naturally more appealing to persons of good self-esteem than are emptiness and dependency (Branden, 1981). The healthier their self-esteem, the more inclined they are to treat others with respect, benevolence, good will, and fairness — such persons do not tend to perceive others as a threat, and self-respect is the foundation of respect for others.

Those who have healthy self-esteem are not quick to interpret relationships in malevolent, adversarial terms. They do not approach encounters with automatic expectations of rejection, humiliation, treachery, or betrayal. Contrary to the belief that an individualistic orientation inclines one to antisocial behavior, research shows that a well-developed sense of personal value and autonomy correlates significantly with kindness, generosity, social cooperation, and a spirit of mutual aid (Waterman, 1981, 1984).

Finally, research reveals that high self-esteem is one of the best predictors of personal happiness (Meyers, 1992). Logically enough, low self-esteem correlates with unhappiness.

Roots of Self-Esteem

On what does healthy self-esteem depend? What factors have an impact?

There is reason to believe that we may come into this world with certain inherent differences that may make it easier or harder to attain healthy self-esteem — differences pertaining to energy, resilience, disposition to enjoy life, etc. I suspect that in future years we will learn that genetic inheritance is an important contributing factor in the ability to develop a healthy self-concept (Ornstein, 1993).

Upbringing, of course, is critical to self-esteem development. No one can say how many persons suffer ego damage in their early years, before the ego is folly formed; in such cases, it may be all but impossible for healthy self-esteem to emerge later, short of intense psychotherapy. Research suggests that one of the best ways to have good self-esteem is to have parents who model healthy self-esteem, as Coopersmith's The Antecedents of Self-Esteem (1967) demonstrates.

Children who have the best chance of acquiring the foundation for healthy self-esteem tend to have parents who:

However, no research has ever found the resold of healthy parenting to be inevitable. Coopersmith's work, for example, clearly showed that it is not. His study provided many examples of adults who appeared to have been raised superbly by the standards indicated above, and yet became insecure, self-doubting adults. And there are many who emerge from appalling backgrounds, but who do well in school, form stable and satisfying relationships, have a powerful sense of their own value and dignity, and, as adults, satisfy any rational criterion of good self-esteem.

Although we may not know all the biological or developmental factors that influence self-esteem, we know a good deal about the specific (volitional) practices that can raise or lower it. We know that an honest commitment to understanding inspires self-trust, and that an avoidance of the effort has the opposite effect. We know that people who live mindfully feel more competent than those who live mindlessly. We know that integrity engenders self-respect and that hypocrisy does not. We "know" all this implicitly, although it is astonishing how rarely psychologists discuss such matters.

Clinicians cannot work on self-esteem directly because self-esteem is a consequence — a product of internally generated practices. If clinicians understand what those practices are, they can work with others in such a way as to facilitate or encourage their actualization. Interventions can be designed with that end in view. But the practices themselves can arise only within the client and can only be caused by the client.

The Six Pillars of Self-Esteem

What, then, are these practices? More than three decades of study have convinced me that six practices are crucial and fundamental:

When these practices are absent, self-esteem necessarily suffers. When and to the extent that they are an integral part of a person s life, self-esteem is strengthened.

THE PRACTICE OF LIVING CONSCIOUSLY:

If clients lives and well-being depend on the appropriate use of their consciousness, then the extent to which they honor "sight over blindness" is the single most important determinant of their self-efficacy and self-respect. One cannot feel competent in life while wandering around (at work, dealing with superiors, subordinates, associates, customers, or in marriages or in relations with one's children) in a self-induced mental fog. Those who attempt to exist unthinkingly and evade discomforting facts suffer a deficiency in their sense of worthiness. They know their defaults, whether or not anyone else does.

A thousand times a day, each person must choose the level of consciousness at which to function. Gradually, over time, a person establishes a sense of the kind of person he or she is, depending on the choices made and the degree of rationality and integrity exhibited. If, at the end of therapy, a client functioned no more consciously than at the beginning, we would have to question the efficacy of the therapeutic enterprise. In therapy, one can encourage consciousness by:

Tom, age 44, who was the CEO of an insurance benefits business, said that his business was growing rapidly, that he needed to hire a new high-level consultant, and that he was afraid of hiring someone who might be more brilliant than himself. Rather than work on the problem in my office, I gave him a home-work assignment: for the next two weeks, he was to write six to ten endings everyday for the incomplete sentence, "If I bring a higher level of consciousness to my fear of hiring a brilliant consultant — ." At the end of two weeks, he reported that he had resolved the issue to his complete satisfaction; he proceeded to hire a brilliant consultant with whom he continues to have an outstanding working relationship.

The exercise I gave Tom, by its repetitiveness, and by the implications of the words in the stem, stimulated his creativity and problem-solving abilities. A further benefit was that the solution was entirely his own, which enhanced his self-esteem.

THE PRACTICE OF SELF-ACCEPTANCE:

At the deepest level, self-acceptance is the virtue of commitment to the value of one's own person. It is not the pretense at a self-esteem one does not possess, but rather the primary act of self-value that serves as the basis for dedication to achieving self-esteem. It is expressed, in part, through the willingness to accept — to make real to oneself without denial or evasion — that we think what we think, feel what we feel, have done what we have done, and are what we are.

Self-acceptance is the refusal to regard any part of ourselves — our bodies, our fears, our thoughts, our actions, our dreams — as alien, as "not me." It is the willingness to experience, rather than disown, whatever may be the facts of one's being at a particular moment. It is the refusal to engage in an adversarial relationship with oneself. It is the willingness to say of any emotion or behavior, "This is an expression of me — not necessarily an expression I like or admire — but an expression of me nonetheless, at least at the time it occurred." It is the virtue of realism — of respect for reality — applied to the self. Thus, if I am confronted with a mistake I have made, in accepting that it is mine, I am free to learn from it and do better in the future. I cannot learn from a mistake I cannot accept having made. Self-acceptance is the precondition of change and growth.

Mary, age 39, a lawyer, became indignant at the idea of self-acceptance and said, "I've got lousy self-esteem! And you're asking me to accept that?" I responded, "If you don't accept that you have the problem, how do you plan to solve it? Self-esteem begins with respect for reality."

Can therapy can be called successful if the client fails to grow in self-acceptance? One of the ways we can teach self-acceptance in therapy is by dealing with total acceptance — no condescension, no sarcasm or ridicule, no quarreling with clients' feelings — absolute, relentless (and unsentimental) respect.

An important aspect of my work, unfortunately beyond the scope of this lesson, is the identification and integration of the client's subpersonalities (Branden, 1994). This can be viewed as a field within the broader field of self-acceptance, but is actually something of a specialty in its own right. Many clinicians have observed that whenever one learns to own and integrate a previously unrecognized or denied "part," one feels stronger and more complete; self-esteem is strengthened.

THE PRACTICE OF SELF-RESPONSIBILITY:

To feel competent to live and be worthy of happiness, the client needs to experience a sense of control over his other existence. This requires that the client be willing to take responsibility for actions and the attainment of goals — which means that he or she takes responsibility for his or her life and well-being. The practice of self-responsibility entails these realizations:

In my opinion, one of the most important moments in therapy occurs when the client finally realizes (however this is achieved) that no one is coming: No one is coming to redeem their childhood; no one is coming to make them happy; no one is coming to rescue them. If they wish their life to improve, they will have to do something different themselves. One day in group therapy, a client with a sense of humor challenged me: "You always say that no one is coming. But you came!" "Correct," I admitted, "but I came to say that no one is coming."

THE PRACTICE OF SELF-ASSERTIVENESS:

Self-assertiveness is the virtue of appropriate self-expression — of honoring one's needs, wants, values, and convictions, and seeking rational forms of their expression in reality. Its opposite is the surrender to timidity, which consists of consigning oneself to a perpetual underground where everything that one is lies hidden or still born. The client who is not self-assertive usually seeks to avoid confrontation with someone whose values differ, or wants to please, placate, or manipulate someone, or is trying simply to "belong."

Healthy self-assertion entails the willingness to confront rather than evade the challenges of life and to strive for mastery. When the client expands the boundaries of his or her ability to cope, he or she expands self-efficacy and self-respect. A continuing refrain in my work with clients is: "Your wants are important. Your life is important. Whether or not you are happy is important."

This message (like everything else I do) is always underscored and amplified by sentence-completion exercises. (I explain this process in detail below.) The sentence stem, "If someone had taught me my wants were important —" typically elicits such endings as: "I'd care more about them; I'd take them more seriously; I'd think about them; I'd exert more energy on my own behalf; I'd be more assertive; I'd treat myself with more respect."

Repetitive exercises of this kind stimulate shifts of consciousness and behavior that are experienced by the client as originating entirely from within. Clients are helped to identify what their most important wants are and then to develop action plans for their attainment (if possible).

A typical group therapy exercise that I use asks all members of the group to identify some important desire in their life. Sitting in groups of three, they are asked to work with the question, "If I were to convert this desire into a conscious purpose, what would I need to do?" Action plans develop out of the group's brainstorming.

THE PRACTICE OF LIVING PURPOSEFULLY:

Life has been defined as a process of self-sustaining and self-generated action (Rand, 1961). Purpose, then, is the very essence of the life process. Through our purposes, we organize our behavior, giving it focus and direction. Through our goals, we create the sense of structure that allows us to experience control over our existence. To live purposefully is to use your powers for the attainment of goals we have selected, such as: studying, raising a family, earning a living, starting a business, bringing a new product into the marketplace, solving a scientific problem, or building a vacation home. Our goals lead us forward; they call for the exercise of our faculties and energize our existence.

To observe that purposefulness is essential to folly realized self-esteem should not be understood to mean that the measure of a client's worth is his or her external achievements. We admire achievements — in others and in ourselves — and it is natural and appropriate for us to do so. But this is not the same thing as saying that achievements are the real measure (or grounds) of self-esteem. The root of self-esteem is not tangible achievements, but those internally generated practices that, among other things, make it possible to achieve.

By way of teaching purposefulness, I typically ask clients to explore the following ideas:

If you were to operate 5% more purposefully on the job — or in your marriage — or in your relationship with your children — or in therapy itself — what do you imagine you might do differently? Would there be advantages for you in doing that? What might the obstacles be? Would you be willing to experiment for, say, 30 days with operating more purposefully in order to discover what happens and whether you like it?

(Why 5%? Because it is not intimidating. Anyone can accomplish 5%!)

THE PRACTICE OF INTEGRITY:

As a person matures and develops his or her own values and standards (or absorbs them from others), the issue of personal integrity assumes increasing importance in self-assessment. Integrity is the integration of ideals, convictions, standards, beliefs, and behavior. When behavior is congruent with professed values (when ideals and practice match), a person is said to have integrity. Those who behave in ways that conflict with their own judgment of what is appropriate lose face in their own eyes. If the policy becomes habitual, they trust themselves less or cease to trust themselves at all.

When a breach of integrity wounds self-esteem, only the practice of integrity can heal it. At the simplest level, personal integrity entails such questions as, "Am I honest, reliable, and trustworthy? Do I keep my promises? Do I do the things I say I admire, and avoid the things I say are despicable?"

To understand why lapses of integrity are detrimental to self-esteem, consider what a lapse of integrity entails. If I act in contradiction to a moral value held by some one else but not by me, I may or may not be wrong, but I cannot be faulted for having betrayed my convictions. If, however, I act against what I myself regard as right, if my actions clash with my expressed values, then I act against my judgment. I betray my mind. Hypocrisy, by its very nature, is self-invalidating. A default on integrity undermines me and contaminates my sense of self. It damages me as no external rebuke or rejection can damage me.

Rebecca, age 40, was a physician with a suburban practice affiliated with a small local hospital. If the combined days her patients spent in the hospital annually passed a certain number, Rebecca and her husband were rewarded by the hospital with a luxurious cruise. When she knew their insurance was adequate, she often found her self recommending a longer hospital stay for her patients than was strictly necessary. She came to therapy because of mysterious bouts of anxiety and depression. "I've got a wonderful husband — we've got a great home and a great life — I don't know what's the matter with me."

When I learned of Rebecca's arrangement with the hospital, I inquired how she felt about it. Instantly, she became defensive, and, in fact, canceled her next two appointments. When she returned to my office, she complained of a new problem: insomnia. When I reopened the question of her dealings with the hospital, she said angry, "Well, I suppose I do feel a little guilty, it's stupid to feel guilty. I mean, who am I really hurting?"

Although symptoms such as Rebecca's could have many possible causes, I suspected her anxiety, depression, and insomnia were mostly rooted in this issue. She was violating her deep sense of right and wrong, and no rationalization could protect her self-esteem. Therapy did not proceed easily.

At one point, Rebecca wondered aloud if perhaps she should drop therapy and attack her problem with tranquilizers and antidepressants. The break through occurred when I proposed an experiment: "Would you be willing — for the next 2 months — to prescribe only hospital stays you're convinced are medically necessary? And let's see what happens." She agreed. Within 10 days, her symptoms began to disappear.

Psychologists do not talk much about integrity. In today's world, many people find the word incongruously old-fashioned. It does not sound "scientific." And yet, we do need principles to guide our lives, and the principles we accept must be reasonable, because if we betray them , our self-esteem will suffer. Integrity is one of the guardians of mental health.

The Self-Esteem Sentence-Completion Program

Central to all of my work is a self-esteem-building program I designed, which integrates the six pillars and which is given to most of my clients. Sentence-completion work is a deceptively simple yet uniquely powerful tool for raising self-understanding, self-esteem, and personal effectiveness. It rests on the premise that all of us have more knowledge than we normally are aware of — more wisdom than we use, more potentials than typically are displayed in our behavior.

Sentence completion stimulates insight and integration, and can be used for many different purposes. The purpose here is to use a 30-week program to build self-esteem — and, concurrently, to improve overall effectiveness at work and in relationships (click here to see the program). A rather complex set of premises and assumptions about motivation are embedded in this exercise; during the course of therapy, most of these are made explicit sooner or later.

The procedure essentially consists of the client writing an incomplete sentence (a "stem") and adding different endings; the sole requirement is that each ending be a grammatical completion of the sentence. The client should work as rapidly as possible, with no pauses to "think." The therapist should tell the client that any ending is fine. The client can work with a notebook, typewriter, or computer.

First thing in the morning, before proceeding with the day's business, the client should sit down and write the first stem. Then, as rapidly as possible, without pausing for reflection, the client should write as many endings for that sentence as he or she can in 2 or 3 minutes. The therapist should instruct the client not to worry if the endings are literally true, make sense, or are "profound"; the purpose is to write anything...but write something. The client should complete the remaining stems in the same fashion.

The therapist should instruct the client to proceed with the day's business after all stems have been completed. The exercise should be completed every day, Monday-Friday for the first week, always before the start of the day's business. The client should not read what was written the day before. Naturally, there will be many repetitions, but new endings inevitably will occur.

In doing this exercise, the client should empty his or her mind of any expectations concerning what will happen or what is "supposed" to happen. The therapist should instruct the client to invent an ending if his or her mind goes absolutely blank, but not to stop with the excuse that he or she cannot do the exercise. An average session should not take longer than 10 minutes. If it takes much longer, the client is "thinking" (rehearsing, calculating) too much.

At some point each weekend, the client should reread what has been written for the week, and then write a minimum of six endings for this stem:

If any of what I wrote this week is true, it might be helpful if I —

If the client finds this program helpful, it is often useful to start it over again. Some of my clients use this program three or four times, always with new results.

DISCUSSION OF SENTENCE COMPLETION:

When a client is given a sentence stem and asked to keep repeating it (either orally or in writing), the process tends to act as a stimulant to new associations and integrations, both of which lay the groundwork for subsequent shifts in feelings and behavior. It is not uncommon for a client to say something like, "My pattern became so clear to me — and its futility or destructiveness so devastatingly obvious — that I found I could no longer continue it. I had to try something different. I found myself driven to experiment with these new learnings."

The value of having a client work with the same set of stems for a week (or longer) is that the repetitiveness helps to counteract the inclination to dismiss unpleasant realities; it also encourages and facilitates absorption of the insights that "spontaneously" tend to surface. When working with sentence completion with the client in the office rather than as a homework assignment, the therapist should offer new stems that are inspired by significant endings to previous ones, so that the client develops an awareness that goes progressively deeper. (Branden, 1983, 1987, 1993).

For example, exploring the influence of a client's mother in his or her development, the therapist might offer a chain of stems as follows:

Mother was always —
With Mother I felt —
Mother always seemed to expect —
One of the things I wanted from Mother and did not get was —
Mother speaks through my voice when I tell myself —
One of the ways I'm still trying to win Mother's love is —
If it turns out I am more than my mother's child —
I am becoming aware —

This last stem often is used at the end of a chain to facilitate integration and the articulation of insights. Alternates to accomplish the same end include:

I'm beginning to suspect —
If any of what I'm saying is true —
What I hear myself saying is —

Conclusion

If a therapist perceives the building of self-esteem as central to his or her work, specific issues must be addressed. They can be summarized in the form of questions:

If one's aim is to build self-esteem in psychotherapy, perhaps the first step is to become aware that these are questions the therapist needs to ask — and answer.

References

Branden, N. (1969). The Psychology of Self-Esteem. Los Angeles: Nash Publishing.

Branden, N. (1973). The Disowned Self. New York: Bantam Books.

Branden, N. (1981). The Psychology of Romantic Love. New York: Bantam Books.

Branden, N. (1983). If You Could Hear What I Cannot Say. New York: Bantam Books.

Branden, N. (1984). Honoring The Self. New York: Bantam Books.

Branden, N. (1987). How to Raise Your Self-Esteem. New York: Bantam Books.

Branden, N. (1993). The Art of Self-Discovery. New York: Bantam Books.

Branden, N. (1994). The Six Pillars of Self-Esteem. New York: Bantam Books.

Coopersmith, S. (1981). The Antecedents of Self-Esteem (2nd ed.). Palo Alto, CA: Consulting Psychologists Press, Inc.

Ornstein, R. (1993). The Roots of the Self. San Francisco: Harper Collins Publishers.

Meyers, D. C. (1992). The Pursuit of Happiness. New York: William Morrow.

Rand, A. (1961). For the New Intellectual. New York: Random House.

Waterman, A. S. (1981). Individualism and Interdependence. The American Psychologist, 36(7), 762-773.

Waterman, A. S. (1984). The Psychology of Individualism. New York: Praeger Publishers.