Monday, July 11, 2016

Self Esteem

Chapter Ten
Self Esteem
            Persistent mental illness, substance addiction, and trauma all negatively impact self-esteem.  Whether it is the struggle of overcoming difficult symptoms that limit functioning or facing the unfortunate stigma of a diagnosis, the view of self suffers.  This issue ultimately comes up in the ninth or tenth session if not before.  Low self-esteem is serious in that it can lead not only to depressed mood but at worst to self-harm including suicide.  People with low self-esteem often act in by withdrawing from social interaction or act out by creating conflict with others.  Targeting self-esteem starts with assessment.  Sometimes adults and children will express how they feel about themselves, “I can’t do anything right,” “I’m a bad kid.”  More often the feelings are expressed in behavior and demeanor such as slumping physical posture, downcast eyes, and short stilted speech.  One big sign of low self-esteem is the client’s inability or refusal to talk about their situation or desire to change the subject.  Whether the issue is mental illness or trauma, one common symptom is self-blame thus low self-esteem. 
            Several interventions can improve self-esteem.  The first is naming it and normalizing it.   Again, statements are more helpful than questions: “You feel bad about yourself,” or “It sounds like you blame yourself for your situation.”   Because it is a common feeling therapeutic joining is necessary.  That means agreeing with the feelings and not with the facts.  A return to the initial strengths-finding exercise can remind a client of their positive characteristics.  Once a therapeutic relationship is established a continuing attitude of unconditional positive regard and sincere pleasant human interaction set a tone from session to session that helps the client see themselves in a different light.  This is why, with families, I do not meet with children alone and, in fact, put the parent in charge of changing in a way that helps the child and the family.  I try not to make the child the subject of counseling or the target of intervention in a direct confrontational way.   Sometimes people with low self-esteem cannot tolerate hearing positive things about themselves.  A compliment or positive remark is likely to be knocked down or dismissed by a person with low self-esteem.  The child client and even adults can hear and take in more positive perspectives of themselves if they are delivered indirectly.  I encourage parents and partners to focus on and tell positive stories about the client.  At home, a parent saying something positive about the child to someone else within their earshot or in a way they will hear indirectly has much more influence and staying power than a compliment delivered directly to the child.  The positive statement feels more valid.  A good rule of thumb is 10 positive statements for every negative one.  This at least will reduce the number of negative comments made about a client if positive statements are hard to find.  It does mean we ignore negative behavior but balance the person’s experience.  Using narrative therapy, parents may construct a “success narrative”, a story putting the child in character with talents or “special powers” overcoming obstacles to survive and win.  I also use the book Don’t Feed the Monster on Tuesdays (Moser, 1991) and role play the child client “talking down” the big monster who spouts negative thoughts as a way of helping the child develop positive self-talk.  In this case, it is important not to go lightly but to state the child’s worst fears about themselves, “Your birth parents left you because you are too much trouble to love.”  When the child comes back with, “I am easy to love because my parents do,” you have hit pay dirt.
            It is imperative to distinguish between a person’s self-esteem and their core belief system because they require different kinds of interventions.  A person’s self-esteem is how they feel about themselves.  A person’s core belief system is how they see the world.  Negative self-esteem is serious but can be corrected.  A negative core belief system is more pernicious and less likely to change.  For example, a child who is wanted, cared for and celebrated feels they are important, adults are capable, and the world is safe.  A child who is rejected, hurt, and shamed feels they are bad, adults are scary, and the world is unsafe.  The first child can tolerate failure.  The second child expects it.  The same goes for adults who have experienced generally positive childhoods and those who have not.  Because we behave in ways that confirm our core belief systems, people with a positive view create, find, or interpret situations to fit this picture and people with a negative view do the same.  Almost no amount of strengths-finding, compliments, or positive self-talk will overcome a negative core belief system.  It requires a paradox intervention.  Confronting their negative view of the world with our positive view is counterproductive and will cause the person to dig in and feel unheard.  It is like a person who comes home at the end of the day complaining about their work and their spouse either tells them it is not so bad or how to fix it.  The person feels unheard, dismissed, and disconnected.  Instead, we agree with them and join in their view of themselves and the world.  This is very difficult for parents of traumatized children who see as one of their primary roles to raise happy children.  What gets in the way is the parents’ guilt and shame about the child’s trauma and their feelings of responsibility for the child’s feelings and the honorable desire to make “the bad stuff” go away or pretend it did not happen.  It is not easy, and can be quite aggravating, to be with a person who sees the world so darkly.  This is not the same as depression, but can feel like a bottomless pit of negativity.  We have to get down in the muck with the person and not stand on the edge of the hole calling down, “Pull yourself up!”
            What this looks like in practice is less talking and more experiencing.  That means creating pleasant playful experiences in session and out.  Play therapy and theraplay provide both.  Taking cues from the initial face mirroring and parallel drawing assessments in the first session with the child, I teach, model, and coach parents to lead the child into play and to follow the child through play.  I use multi-colored feathers for parents and children to blow off a table or to work together to keep one feather on the table.  I use play dough for a child to create or for parents to “decorate” their child.  Tin foil makes great hats, crowns, and bracelets.  Lotion can be used to play “slippery hands”.  Children and parents can create a mirror of their own family or an imagined future using a doll house with figures and furniture.  A sand tray provides a contained environment in which a child and parent may create a “world” representing themes from their own lives.  Blocks and Lego’s, crayons and paint, colored paper and pencils are all media for creative play WITH children.  A child or person with a negative core belief system needs help experiencing themselves and the people around them as protective and positive.  It is important to know that success in this area can be very fragile.  One setback, like a failing grade or the end of a relationship, can send a person back to what seems like square one.  Reversing a negative core belief system requires patience and perseverance.