Introduction
Self-esteem is an important factor in the development and maintenance of good psychological health. Self-esteem is the degree to which people accept and value themselves, thus achieving a basic feeling of self-worth. To have low self-esteem means that the individual has a negative image of the self, which tends to be global, persistent and enduring (Fennell, Reference Fennell1997). Low self-esteem can be integral to numerous mental health difficulties where old negative views of the self are believed rather than new and more helpful perspectives.
Fennell (Reference Fennell2006) proposes that negative life experiences, particularly early in life, lead to the development of the “Bottom Line”, a global negative belief reflecting sense of worth. Specific life events or situations can activate this Bottom Line, which leads to an upsurge of negative automatic thoughts about the self, unhelpful behaviours and painful emotions, in turn seeming to confirm the Bottom Line (Fennell, Reference Fennell1997). A person with low self-esteem will process incoming information in accordance with their view of themselves; overemphasizing their weaknesses and underestimating their strengths.
Based on the above model, Fennell has produced a set of guided self-help workbooks entitled Overcoming Low Self-Esteem Self-Help Course (Fennell, Reference Fennell2006). The books use CBT as a framework for understanding how low self-esteem developed and how it is maintained. It focuses on thoughts, beliefs, attitudes and opinions about the self that lie at the heart of low self-esteem. Importantly, it offers effective strategies for questioning and changing these cognitions in order to permanently enhance self-esteem.
Research evaluating the effectiveness of CBT based interventions for low self-esteem lags behind the volume of research on CBT for mood disorders such as depression and anxiety. The evidence base to date consists of a mixture of single case studies, studies in specific populations (such as schizophrenia) and adapted group interventions, using a variety of different models and approaches within CBT. McManus Waite and Shafran (Reference McManus, Waite and Shafran2009) report a single case study of cognitive behavioural treatment of a young woman with low self-esteem, depression and anxiety symptoms. The client initially met the diagnostic criteria for major depressive disorder and obsessive-compulsive disorder, and was in the subclinical range for several other disorders, including panic disorder, anorexia nervosa and post-traumatic stress disorder. The assessment, formulation and intervention followed the model and treatment described by Fennell (Reference Fennell1997). At the end of 12 sessions of CBT over 6 months and at one-year follow-up, the client showed reliable and significant change on measures of depression, anxiety and self-esteem, and no longer met the criteria for any psychiatric diagnosis.
Rigby and Waite (Reference Rigby and Waite2006) report a group CBT intervention based on Fennell's approach (Fennell, Reference Fennell1997) with the addition of narrative and imagery techniques. Seventy-two participants completed 10 weekly sessions, with a 2-month follow-up. Significant improvements were found post-treatment on anxiety, depression and self-esteem scores and maintained at follow-up.
In light of the need for further research into the treatment of low self-esteem and the strong evidence base for CBT, we describe a service evaluation of a self-esteem group intervention based around Fennell's (Reference Fennell2006) workbooks, delivered for women with low self-esteem. Here we describe the outcome of this evaluation.
Method
The group
We recruited women, aged 18 or over, with low self-esteem (defined as a score of less than 120 on The Robson Self Concept Questionnaire (RSCQ) (Robson, Reference Robson1989), who consented to participate in a CBT group addressing low self-esteem. Participants were referred from within the Fife (Scotland) Adult Psychology Service either during treatment or following a triage assessment by a psychologist. Participants were referred with a variety of common mental health problems (mostly co-morbid depression and anxiety). Inclusion criteria included that any other predominant problems had already been addressed in therapy and that the client would be likely to respond well to a group setting. Each participant was invited to a further assessment appointment with a group facilitator; during which the format and evaluation of the group was explained, and they had the opportunity to ask questions. Pre-intervention measures were completed at this stage. Generally, participants did not receive any other therapeutic input whilst attending the group, although we do not have exact data regarding this.
A single sex women's group was chosen rather than a mixed sex group as some writers feel that women may feel a “lack of unconscious sexism”, and may feel more able to talk openly, feeling an increased sense of warmth and closeness (Burden and Gottlieb, Reference Burden, Gottlieb and Brody1987; Walker Reference Walker and Brody1987). Although these claims are not supported by empirical data, Herman and Schatzow (Reference Herman and Schatzow1984) found that women who had experienced incest or sexual abuse felt more comfortable and freer to express their feelings and tell their stories within a single sex group. They also felt that the same could be said for women who had been abused by men. Due to the nature of the unknown genesis of low self-esteem with individual group members, the authors felt that a single sex group for women would provide a safer environment for openness and discussion.
The group began approximately 2 weeks after the assessment, and consisted of eight weekly 2-hour sessions. It was facilitated by two clinicians, at least one of whom was qualified to a post graduate level. As such the clinicians were either: a Chartered Clinical Psychologist, a Cognitive Behavioural Therapist, a Clinical Associate of Applied Psychology (this is a post unique to Scotland that requires training in psychology to a postgraduate level), or a Trainee Clinical Psychologist. The group followed the format of the Overcoming Low Self-Esteem Self-Help Course workbooks (Fennell, Reference Fennell2006), covering chapters one and two in the first week, and thereafter a chapter per week. It was expected that some participants might feel daunted at the prospect of speaking in front of a group and so it was explained that there would be no requirement to speak if they did not wish to do so. The clinicians read aloud from the books, providing further examples, inviting questions and encouraging discussion. The balance between discussion versus didactic psychoeducation varied between sessions and groups depending on the individuals involved, and clinicians tailored this accordingly. However, an attempt was made to read aloud all of the material from the course books to ensure all topics were covered. At the final session, post-intervention measures were completed. The referring clinicians arranged individual follow-up appointments to determine whether individuals should be discharged or whether they required further psychological input. Unfortunately, data on how many participants attended such appointment or required further input are not available.
Pre- and post-intervention measures comprised, The Robson Self-Concept Questionnaire (RSCQ) (Robson, Reference Robson1989), The Beck Depression Inventory (2nd edn.) (BDI-II) (Beck, Steer and Brown, Reference Beck, Steer and Brown1996) and The Beck Anxiety Inventory (BAI) (Beck, Epstein, Brown and Steer, Reference Beck, Epstein, Brown and Steer1988). Ethical approval was granted (by the University of Edinburgh and East of Scotland Ethics Advisory Service) to analyze these scores. Advice was also sought from the East of Scotland Ethics Advisory Service who approved the project and advised that full ethical approval was not necessary.
Results
Forty-nine women participated in seven groups; however, due to a drop out rate of 24% only 37 completed sets of outcome measures were available. Power calculations indicated that with 37 participants and an alpha level of 0.05, this study had 77% power to detect a large effect size. The mean age of the participants was 38, ranging from 20 to 58 years. Information on group attendance was only recorded for 24 participants. The mean number of sessions attended for these participants was 6.3, ranging from 1 to 8 sessions. Using a within-subjects design, quantitative data gathered in this study were analyzed using dependent t tests.
Independent t tests indicated that there were no significant differences in age or pre-intervention scores between those participants who dropped out during the group, and those who completed the group. Mean scores of participants who completed the course on the RSCQ, BDI and BAI pre-intervention and post-intervention are shown in Table 1. Paired samples t tests were used to compare the means. This analysis showed a significant increase in self-esteem and a significant decrease in depression and anxiety after completion of the group. An intention to treat analysis was also completed, assuming the same pre and post-intervention scores for participants who dropped out of the group. The results still showed an increase in self-esteem (21 points) and a decrease in depression (11 points) and anxiety (7 points) post-intervention, all of which are significant at p < 0.001.
Mean and mean change for participants who completed the group in self-esteem, depression and anxiety scores pre- and post-intervention
* indicates significant at p<.001.
The clinical significance of the self-esteem group was determined by examining the change in percentages of clinical categories on measures of depression and anxiety. Of the 37 participants who completed the groups, 81% dropped one or more clinical categories on the BDI, and 57% dropped one or more clinical categories on the BAI.
Discussion
These findings indicate that a CBT group, based on the Fennell workbooks (Fennell, Reference Fennell2006) is effective at increasing levels of self-esteem and at reducing levels of depression and anxiety. More specifically, we found a mean increase of 28 points on the RSCQ, a mean decrease of 15 points on the BDI and 9 points on the BAI. These results support earlier findings by Rigby and Waite (Reference Rigby and Waite2006) whose CBT group for low self-esteem was also found to be effective. Moreover, the results demonstrated clinical significance as the proportion of participants who were in the moderate or severe categories for depression and anxiety (as measured by the BDI and BAI respectively) were significantly reduced after the intervention. Although scores were not restored to non-clinical levels, it is hoped that the skills learnt during the group would lead to further change over time. However, given that there are no follow-up data, this needs to be established via further investigation. It should also be noted that these findings are limited by a lack of control data. Furthermore, due to attrition only 37/50 complete sets of data were available, which again limits these findings.
Although the specific mechanism for change has not been examined in this study, it can be hypothesized that given the negative bottom line is central in Fennell's (Reference McManus, Waite and Shafran1997) model of low self-esteem, the experience of being accepted within a group and meeting other people who share similar difficulties would be therapeutic for individuals with low self-esteem, as it may start to undermine common bottom lines, such as being unlovable or inferior. Equally, through developing new skills and changing perspectives, the foundations may be laid for a new bottom line, for example one of being competent or lovable. Anecdotally, it seemed that both individuals with low self-esteem problems triggered by depression and individuals with longstanding low self-esteem appeared to benefit from this group, but this would be something worth further research.
Since the group encourages participants to formulate how their low self-esteem developed and how it is maintained, this often triggered traumatic memories and painful emotions. Validating and containing this emotion within a group setting, while respecting participant confidentiality within limited time, was often challenging for clinicians. Participants were given the option to talk to clinicians individually before or after each session and this seemed beneficial. At times, participants had to be guided towards processing these emotions (e.g. by writing a letter or keeping a diary) using strategies that were not included in the workbooks. Perhaps, inclusion in the workbooks of how to deal with these difficult emotional memories would be beneficial.
In summary, the initial results are promising, and encourage further research in this area. A controlled trial is currently underway to evaluate the effectiveness of this intervention and will include a 2- and 6- month follow-up of participants, giving some measure of the stability of effects found. If this intervention is found to be effective, an evaluation of its cost-effectiveness would be important to ensure that clinical resources are used efficaciously. It would also be useful to study the efficacy of the group for men or mixed sex groups in the future.
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