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 then go deeper to build as full a picture as possible.
Watson, the founder of behaviorism started a long tradition of avoiding the question, why, declaring that it was inherently subjective and not fit for science. His avoidance of asking that question has cast a long shadow. Even today, most discussions focus on how to change low self-esteem or negative self-talk, but not why it is there. More recently, there has been a trend in CBT circles to follow curiosity and develop an individual case formulation, which might consider what lead to bad feelings about the self.
The trauma field and psychodynamics in general 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 one fact that seems to me to suggest otherwise. If we were dealing with simple learning, then why is low self-esteem so resistant to change? Why do sufferers have to work so hard to rid themselves of this seriously debilitating symptom?
Diving Much Deeper
The first early trauma patient I worked with suffered both from intense dread of remembering her traumas and from low self-esteem. To my surprise, processing the memories, once they were accessed, was very rapid and compete. Once thoroughly metabolized, we didn’t have to revisit those memories . (In a later post, I’ll explain how I know 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 did not change quickly and was subject to relapse. That was my first awakening to the fact that there are more than one change mechanism involved in psychotherapy. I Began to wonder why low self-esteem was so hard to change.
Shame and Values
The clue was shame. Along with low self-esteem went shame at being a person of such low worth. This might seem obvious, but a lot of thought about this (which I’ll again share in a later post) 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. This is radically different from other learning such as likes and dislikes. We don’t feel shame if we go against our usual 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 interesting family of mental contents, values, also includes attitudes, ideals, prohibitions. Self esteem is a member of the subcategory of attitudes. 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?
I would rather call these “internalized” instead of learned. They become part of the individual’s structure. 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), and an interesting book by XXX and XXX called “Snapping: ” led me to the belief that the trigger for internalization is what I would call “connection anxiety.” Children fear the loss of connection and internalize the values of toilet training, which lasts a lifetime. People who join cults tend also to 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 manifest values of their abusers, including their own lack of 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 “gratifying” their patients.
Implications of Relapse
The fact that low self-esteem and negative self-talk are particularly subject to relapse when conditions turn harsh means simply that these mental contents are something close to permanent. That may sound pessimistic, but I believe it is true. That doesn’t mean there is not a treatment. Treatment consists of internalizing new values or re-awakening old, positive ones in such a way as to override the negative ones.
Into the Unknown
When we begin to think about change, things get complicated. If values are, as they appear, essentially permanent, then change involves some mechanism by which one value takes precedence over another and a favored value can override the maladaptive one.
Clinical observation suggests that the mind works actively and powerfully to keep our behavior in line with our values. That is where self-talk comes in. Much of social conversation revolves around affirming our 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 try to do otherwise, as happens in general when we violate our own values, we can expect a shower of feelings of shame and general discomfort.
So it appears that here, we are hoping to foster the internalization of a healthier attitude towards the self and having it take precedence. Looking at how we might do this brings us back to how values are internalized. Here, perhaps because of intense resistance to change, the behavioral traditions seem to have the most to offer:
- Motivation: Much of what is commonly recommended is to be sure the patient is intellectually completely clear that the old attitude is maladaptive and wrong. This is necessary to counteract the mind’s inevitable efforts to rationalize staying with 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,” supporting 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.
- EMDR: One of the few therapies that actually addresses this issue apart 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 and 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 moving closer to full civil 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 new values is the goal is brainwashing and cult induction. While this is not generally proposed as treatment, opportunities for study abound. Here, hunger, sleep deprivation, and cognitive manipulation are combined to lead to dramatic internalization of new values attitudes, ideals, and prohibitions.
My general conclusion about 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 the patient’s willingness to expect and accept the inevitable backlash of shame and impulses to revert to old patterns.
Jeffery Smith MD
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