Low self-esteem: a refined cognitive behavioural model

Melanie Fennell's (1997) seminal cognitive approach to low self-esteem was published in Behavioural and Cognitive Psychotherapy. The current paper proposes a refined model, drawing on social theories, and research with people with socially devalued characteristics. This model emphasises how self-esteem relates to perceptions of one's value in the eyes of others. It is proposed that core beliefs typical of low self-esteem relate to one's value in relation to personal adequacy (e.g. having worth or status) and/or to social connection (e.g. being liked, loved, accepted or included). In each of these value domains, beliefs about both the self (e.g. 'I am a failure', 'I am unlovable') and others (e.g. 'Others look down on me', 'Others don't care about me') are considered important. The model suggests that everyone monitors their value but in people with low self-esteem, cognitive biases associated with underlying beliefs occur. In the context of trigger situations, this results in a greater likelihood of negative appraisals of perceived threat to one's value. Such appraisals activate underlying negative beliefs, resulting in negative mood (e.g. low mood, anxiety, shame, disgust) and other responses that maintain low self-esteem. Responses which can be used excessively or in unhelpful ways include (a) corrective behaviours; (b) compensatory strategies; (c) increased value monitoring; (d) safety-seeking behaviours; (e) rumination; (f) unhelpful mood regulation responses. These responses can adversely impact daily functioning or health, having the counterproductive effect of maintaining negative beliefs about one's value. Examples are provided for low self-esteem in lesbian, gay and bisexual individuals.

Acceptability, feasibility and preliminary efficacy of a compassion-based cognitive behavioural intervention for low self-esteem in sexual minority young adults

Low self-esteem can impair daily functioning and is a risk or maintenance factor for several mental health problems. Sexual minority young adults, for example, those identifying as lesbian, gay or bisexual, on average have lower self-esteem than their heterosexual peers. Compassion-based interventions for low self-esteem might be especially beneficial for sexual minority young adults, whose higher levels of shame and self-criticism are likely to be contributing to maintenance of their low self-esteem. This study explored the acceptability, feasibility and preliminary efficacy of a new compassion-based cognitive behavioural intervention for low self-esteem tailored to sexual minority young adults. Participants were a community sample of 24 sexual minority young adults aged 16-24 experiencing clinically significant low self-esteem. An uncontrolled pre-/post-design was used with qualitative feedback and quantitative outcomes. Self-report standardised measures were completed at baseline, pre-intervention, intervention mid-point, post-intervention and 2-month follow up. Preliminary efficacy was examined through post-intervention changes in self-esteem, functioning, anxiety and depression. Potential mechanisms of change were examined through changes in self-compassion, self-criticism and unhelpful coping responses to minority stress. Results showed good acceptability and feasibility and preliminary evidence of intervention efficacy for improving self-esteem, functioning, depression and anxiety. There was evidence for improvement in self-compassion and reduction in self-criticism, and these constructs could be investigated in future studies as treatment mediators. Randomised controlled studies are needed to further examine efficacy of the intervention.

Sexual minority young adults' perspectives on how minority stress and other factors negatively affect self-esteem: a qualitative interview study

Sexual minority young adults (lesbian, gay and bisexual), are at increased risk of experiencing mental health problems than their heterosexual peers. On average they also have lower self-esteem which may contribute to the development or maintenance of mental illnesses. Interventions to improve self-esteem could improve well-being and reduce mental ill-health risk in sexual minority young adults. It is important to understand the processes that contribute to lower self-esteem in this population. The present study aimed to explore these processes. Semi-structured qualitative interviews were conducted with a sample of 20 sexual minority young adults (age 16-24 years) with a range of self-esteem levels. Using thematic analysis, three overarching areas were idenitified: 'Negative social evaluations and reduced belonging', 'Striving and failing to meet standards', and 'Negative sexual orientation processes'. These findings have theoretical implications for minority stress models of mental health inequalities, highlighting the potential interaction between minority-specific and more general risk factors for mental health problems. Findings also have clinical implications for the development of tailored interventions to help improve low self-esteem in sexual minority young adults.

Self-esteem in sexual minority young adults: a qualitative interview study exploring protective factors and helpful coping responses

Research on mental health inequalities between sexual minority and heterosexual young adults has historically focussed on the additional stress processes that might explain this disparity. However, more recently there has been a shift towards research focussed on resilience factors that might promote mental health in sexual minority young adults. Self-esteem is one such proposed resilience factor. This study aimed to explore the factors that promote or protect self-esteem itself in sexual minority young adults. A semi-structured interview study was conducted with 20 sexual minority young adults (aged 16-24) to explore their perspectives on the factors, responses and strategies that have helped to protect or promote their self-esteem. Six themes were identified from thematic analysis: helpful responses to minority stress; sexuality acceptance; positive LGBTQ + social connections and representations; positive social relationships and evaluation; successes and positive qualities and general coping strategies for low self-esteem. Findings are discussed in terms of their theoretical implications.

A cognitive behavioural intervention for low self-esteem in young people who have experienced stigma, prejudice, or discrimination: An uncontrolled acceptability and feasibility study

OBJECTIVES

Stigma has been found to be associated with lower self-esteem, which increases the risk of difficulties across life domains including vulnerability to mental health problems. There are no previous studies of interventions for people experiencing low self-esteem in the context of different stigmatized characteristics. This study evaluated feasibility, acceptability, and preliminary outcomes of an intervention targeting low self-esteem in stigmatized people aged 16-24 years.

DESIGN

An uncontrolled study with repeated measures.

METHOD

People with a range of stigmatized characteristics, who had low self-esteem and associated impaired daily functioning, were recruited from the general population. The individual six-session cognitive behavioural intervention had modules chosen according to participants' formulations. The CBT included compassion-focussed therapy methods and was informed by stigma research. Feasibility was assessed in relation to recruitment, retention, and protocol adherence. Acceptability was assessed through participant feedback. Questionnaires assessing self-esteem, functioning impairments, depression, anxiety, self-criticism, self-compassion, and responses to prejudice and discrimination were administered at baseline, pre-, mid-, post-intervention, and two-month follow-up.

RESULTS

Forty-four people completed screening; 73% were eligible. Of these, 78% consented and 69% (N = 22) started the intervention. Eighteen (82%) participants completed, and four dropped out. Follow-up measures were completed by all treatment completers. Treatment completers reported the intervention was useful, improved their self-esteem and coping, and would recommend it. Ratings of usefulness and frequency of use of intervention components were high at post-treatment and follow-up.

CONCLUSIONS

The intervention was feasible and highly acceptable to treatment completers. This suggests the intervention warrants investigation in a randomized-controlled trial.

PRACTITIONER POINTS

Young people with low self-esteem whom have been negatively affected by stigma may wish to access support and be willing to engage in psychological interventions. Cognitive behavioural therapy may be helpful for young people with low self-esteem who have experienced stigma, prejudice, or discrimination. Cognitive behavioural techniques such as self-compassionate thought records and behavioural experiments were considered acceptable and helpful by young people whose self-esteem has been affected by stigma. Addressing responses to stigma in therapy, such as rumination, avoidance, and perfectionism, appears to be feasible and acceptable.

123 Quality Improvement Project on Completion of Respect Form in the Community At Jean Bishop Integrated Care Centre (ICC)

Background

ReSPECT (Recommendation Summary Plan for Emergency Care and Treatment) form was designed to communicate a personalized set of recommendations for a patient’s clinical care in an emergency situation and priorities over other aspects of future care. AIMS & OBJECTIVE 1)To measure ReSPECT Form completion rates at ICC and proportion of forms uploaded on the system and this compared with the published data 2 to improve performance where possible through QI process 3) Re-auditing after interventions.

Methods

All patients who attended the ICC from 1st October 2019 to 21st October 2019 were audited. Altogether 80 patients’ notes on system 1 and Lorenzo were reviewed. After initial results, interventions such as displaying the poster of salient results and recommendations in ICC clinic rooms, giving feedback to key team members were performed by the audit team.

Results

9 patients already had ReSPECT forms. From the remaining 71 patients, 57 discussions (80%) were taken place and 29 forms (41%) were completed while 28 were not for definite reasons. ReSPECT discussion was not initiated for recorded reasons in 9 cases and without reason in 5 cases. Out of 29 completed forms, 24(82%) were uploaded on the system. After the interventions, the re-audit cycle with 16 cases in which 13(94%) had ReSPECT discussions and 6 forms were completed.

Discussion

In comparison with NHS forth valley ReSPECT report, we had a better figure in completion forms (41% Vs 39%) and the number uploaded on system (82% vs 79%). After interventions, 81% had either ReSPECT forms completed or discussion which is much improved.

Conclusion

From this study, the overall improvement in performance was seen with simple interventions but further spot check QIPs and regular training sessions to team member will be essential for sustainability.

Improving Mental Health Service Utilization Among Men: A Systematic Review and Synthesis of Behavior Change Techniques Within Interventions Targeting Help-Seeking

Compared to women, men are less likely to seek help for mental health difficulties. Despite considerable interest, a paucity in evidence-based solutions remains to solve this problem.

The current review sought to synthesize the specific techniques within male-specific interventions that may contribute to an improvement in psychological help-seeking (attitudes, intentions, or behaviors). A systematic review identified 6,598 potential articles from three databases (MEDLINE, EMBASE, and PsycINFO). Nine studies were eligible. A meta-analysis was problematic due to disparate interventions, outcomes, and populations. The decision to use an innovative approach that adopted the Behavior Change Technique (BCT) taxonomy to synthesize each intervention’s key features likely to be responsible for improving help-seeking was made. Of the nine studies, four were engagement strategies (i.e., brochures/documentaries), two randomized controlled trials (RCTs), two pilot RCTs, and one retrospective review. Regarding quality assessment, three were scored as “strong,” five as “moderate,” and one as “weak.” Key processes that improved help-seeking attitudes, intentions, or behaviors for men included using role models to convey information, psychoeducational material to improve mental health knowledge, assistance with recognizing and managing symptoms, active problem-solving tasks, motivating behavior change, signposting services, and, finally, content that built on positive male traits (e.g., responsibility and strength). This is the first review to use this novel approach of using BCTs to summarize and identify specific techniques that may contribute to an improvement in male help-seeking interventions, whether engagement with treatment or the intervention itself. Overall, this review summarizes previous male help-seeking interventions, informing future research/clinical developments.

Interpretation training to target repetitive negative thinking in generalized anxiety disorder and depression

OBJECTIVE

Repetitive negative thinking (RNT) for example, worry in generalized anxiety disorder (GAD) and rumination in depression, is often targeted during psychological treatments. To test the hypothesis that negative interpretation bias contributes to worry and rumination, we assessed the effects of inducing more positive interpretations in reducing RNT.

METHOD

Volunteers diagnosed with GAD (66) or depression (65) were randomly allocated to one of two versions of cognitive bias modification for interpretation (CBM-I), either with or without RNT priming prior to training, or a control condition, each involving 10 Internet-delivered sessions. Outcome measures of interpretation bias, a behavioral RNT task and self-reported worry, rumination, anxiety and depression were obtained at baseline, after home-based training and at 1-month follow-up (self-report questionnaires only).

RESULTS

CBM-I training, across diagnostic groups, promoted a more positive interpretation bias and led to reductions in worry, rumination, and depressive symptoms, which were maintained at follow-up. Anxiety symptoms were reduced only in the GAD group at follow-up. There were no differences between CBM-I versions; brief priming of RNT did not influence CBM-I effectiveness. Level of interpretation bias post training partially mediated the effects of CBM-I on follow-up questionnaire scores.

CONCLUSIONS

In contrast to some recent failures to demonstrate improvements following Internet-delivered CBM, we found that self-reported RNT and negative mood were reduced by CBM-I. This is consistent with a causal role for negative interpretation bias in both worry and rumination, suggesting a useful role for CBM-I within treatments for anxiety and depression. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

An investigation of the shielding characteristics of computed radiography cassettes

Computed radiography (CR) systems are rapidly replacing film screen techniques. Previous estimates have been made of the degree of attenuation that occurs as a primary diagnostic X-ray beam passes through a film-screen cassette at different tube potentials. Cassette attenuation is commonly stated in terms of equivalent thickness of lead, which can be calculated using lead attenuation curves. These values can then be subtracted from the shielding requirements calculated for diagnostic X-ray rooms. Since the introduction of CR, no comparison has been made between the attenuation of the old film-screen and the new CR cassettes. In order to perform such a comparison, transmission factors for two CR cassettes and one film-screen cassette were measured, in addition to experimental lead attenuation curves. Lead equivalent thickness values were calculated for all three cassettes using both a semi-theoretical model and measured data. Although there was some discrepancy between the two methods, both found that the new cassettes provided a similar or greater degree of attenuation as the film screen cassette.

The role of nitric oxide in endothelial cell damage and its inhibition by glucocorticoids

Incubation of vascular endothelial cells with S.typhosa endotoxin and interferon-gamma caused a time- and concentration-dependent reduction in the viability of the cells. The cytotoxic effect was inhibited in a concentration-dependent manner by NG-monomethyl-L-arginine, an inhibitor of nitric oxide (NO) synthesis, and by the glucocorticoids dexamethasone and hydrocortisone, two inhibitors of the induction of NO synthase. These findings indicate that in these cells the cytotoxic effect of endotoxin is mediated by the NO synthesized by an inducible NO synthase. This induction of NO synthase in vascular endothelial cells may represent a mechanism of local endothelial damage during endotoxin shock and other immunologically based conditions.

Social support, self-esteem and depression

A prospective study of 400 largely working-class women with children living at home has used measures of self-esteem and 'social support' to predict the risk of depression in the following year once a stressor had occurred. Actual support received at the time of any crisis in the follow-up year was also measured. Self-esteem was correlated quite highly with some of the measures of support. A core tie was defined as a husband, lover or someone named as very close at first contact. Negative evaluation of self (i.e. low self-esteem), and various indices of lack of support from a core tie at the first interview, were associated with a greatly increased risk of subsequent depression once a stressor occurred. Lack of support from a core tie at the time of the crisis was particularly highly associated with an increased risk. There was also a high risk among those who were 'let down' - that is, for those who did not receive the support which they might have expected in terms of the first interview material. It is concluded that it is essential for prospective enquiries to take account of the actual mobilization of support in the follow-up period.

Life stress, chronic subclinical symptoms and vulnerability to clinical depression

Prospective enquiries of the role of social factors in the aetiology of depression are faced with the problem of who to exclude from the enquiry in terms of psychiatric symptomatology present at first contact. With this problem in mind the role of subclinical symptoms among women not cases of depression has been examined in terms of their relation with a subsequent onset of caseness depression. Psychosocial factors of particular importance in the development of such depression were low self-esteem, marked long-term difficulties and severe life events arising out of (or 'matching') these difficulties. These psychosocial factors were also correlated with the presence of subclinical symptoms. It is concluded that although subclinical symptoms relate to a raised risk of subsequent depression at a caseness level there is no evidence that there is inherent vulnerability stemming from such subclinical symptoms over and above that explained by the psychosocial correlates.