Abstract

The current case report describes the assessment, formulation, and treatment of a patient with
low self-esteem using cognitive behaviour therapy. Cognitive case conceptualization was
constructed. The client was assessed before and after the therapy using Robson’s self-esteem
Questionnaire. The client showed significant change on the measure after five therapy
sessions. During the course of the therapy an attempt was made to help the client adopt more
functional beliefs through the use of Beck’s cognitive therapy.

INTRODUCTION:
Cognitive Therapy was developed by Aaron T. Beck at the University of Pennsylvania in the
early 19960’s as a structured, short-term, present-oriented psychotherapy for depression,
directed towards solving current problem and modifying Dysfunctional thinking and
behavior. This therapy has been adapted to diverse psychiatric disorders and populations.
Cognitive therapy is a unique system of psychotherapy with a unified therapy of personality
and psychotherapy supported by substantial empirical evidence.

Cognitive Behavior Therapy is one of the few forms of psychotherapy that has been
scientifically tested and found to be effective in hundreds of clinical trials for many different
disorders. In contrast to other forms of psychotherapy, cognitive therapy is usually more
focused on the present, more time-limited, and more problem-solving oriented. In addition,
patients learn specific skills that they can use for the rest of their lives. These skills involve
identifying distorted thinking, modifying beliefs, relating to others in different ways, and
changing behaviors.

The Cognitive Model proposes that distorted or dysfunctional thinking is common to all
psychological disturbances. Realistic evaluation and modification of thinking produce an
improvement in mood and behavior. Enduring improvement results from modification of
the patient underlying dysfunctional beliefs. The therapist seeks in a variety of ways to
produce cognitive change, changes in patients thinking and belief system-in order to bring
about enduring emotional and behavioral change. Treatment is based on both a cognitive
formulation of a specific disorder and its application to the conceptualization or
understanding of the patient.
Realistic Modification of Improvement in
Evaluation thinking mood & behavior

Persons, Burns and Perloff (1998) found that cognitive therapy is effective for patients with
different levels of education, income and background. Cognitive therapy for populations
other than psychiatric patients has been studied as well- prison inmates, school children,
medical

The therapy is tailored to the individual; the emphasis in treatment depends on patient’s
particular disorder, nevertheless, there are ten principles that underlie cognitive therapy for all
patients.

Cognitive therapy is based on the Cognitive Model, which hypothesizes that people’s
emotions and behaviors are influenced by their perception of events. It is not a situation in
and of itself that determine what people feel but rather the way in which they construe a
situation (Beck,1964: Ellis, 1962) or the way we interpret and think about a situation. One’s
underlying beliefs influence ones perception, which is expressed by situation specific
automatic thought. These thoughts in turn, influences ones emotions.

Core Beliefs

Intermediate Belief

Situation Emotion

Automatic Thoughts

Beliefs are the most enduring cognitive phenomena. Beginning in childhood, people develop
certain beliefs about themselves, other people, and their worlds. Their most central or core
beliefs are understandings that are so fundamental and deep that they often do not articulate
them, even to themselves. The person regards these ideas as absolute truths. When the core
belief for instance “I am unwanted” is activated the person interprets the situation through the
lens of this belief and tends to focus selectively on information that confirms the core belief.
The core beliefs are most fundamental level of belief; they are global, rigid and over-
generalized. Core Belief’s influence the development of an intermediate class of beliefs that
consists of (often unarticulated) attitudes, rules and assumptions. These beliefs influence
his view of a situation, which in turn influences how he thinks, feels and behaves. Automatic
thoughts are quick evaluative thoughts that spring up automatically without my deliberate
reasoning.

There are a number of Advantages and Disadvantages of CBT.

Advantages of CBT

1. It can be as effective as medication in treating some mental health disorders and may
be helpful in cases where medication alone has not worked.
2. It can be completed in a relatively short period of time compared to other talking
therapies.
3. The highly structured nature of CBT means it can be provided in different formats,
including in groups, self-help books and computer programs.
 4. Skills you learn in CBT are useful, practical and helpful strategies that can be
incorporated into everyday life to help you cope better with future stresses and
difficulties even after the treatment has finished.

Disadvantages of CBT

1. To benefit from CBT, you need to commit yourself to the process. A therapist can
help and advise you, but cannot make your problems go away without your co-
operation.
2. Attending regular CBT sessions and carrying out any extra work between sessions can
take up a lot of your time.
3. Due to the structured nature of CBT, it may not be suitable for people with more
complex mental health needs or learning difficulties.
4. As CBT can involve confronting your emotions an anxieties, you may experience
initial periods where you are more anxious or emotionally uncomfortable.
5. Some critics argue that because CBT only addresses current problem and focuses on
specific issues, it does not address the possible underlying causes of mental health
conditions, such as an unhappy childhood.
6. CBT focuses on the individual’s capacity to change themselves (their thoughts,
feelings and behaviors), and does not address wider problems in systems or families
that often have a significant impact on an individual’s health and wellbeing..

Research on Cognitive Behaviour Therapy

In a study by D’Alelio and Murray (2015), cognitive therapy was administered in a group
format to test-anxious college students. Subjects were randomly assigned to groups meeting
for eight weekly sessions, groups meeting for four weekly sessions, or a waiting list control
group. The overall pattern of results suggested that the eight-session condition was superior
to the four-session condition, which was superior to the control condition in reducing self-
reported test anxiety. On the other hand, neither a task performance measure nor grade point
average showed any effect of treatment.

CBT for social anxiety disorder evidenced a medium to large effect size at immediate post-
treatment as compared to control or waitlist treatments, with significant maintenance and
even improvement of gains at follow-up (Gil, Carrillo, & Meca, 2001). Further, exposure,
cognitive restructuring, social skills training and both group/individual formats were equally
efficacious (Powers, Sigmarsson, & Emmelkamp, 2008), with superior performance over
psychopharmacology in the long term (Fedoroff & Taylor, 2001).
In a study by Hollon et al.,(1999) Forty-one unipolar depressed outpatients were randomly
assigned to individual treatment with either cognitive therapy (N =19)or imipramine (N
=22).As a group, the patients had been intermittently or chronically depressed. For the
cognitive therapy patients, the treatment protocol specified a maximum of 20 interviews over
a period of 12 weeks. The pharmacotherapy patients received up to 250 mg/day of
imipramine for a maximum of 12 weeks. Patients who completed cognitive therapy averaged
10.90 weeks in treatment; those in pharmacotherapy averaged 10.86 weeks. Both treatment
groups showed statistically significant decreases in depressive symptomatology. Cognitive
therapy resulted in significantly greater improvement than did pharmacotherapy on both a
self-administered measure of depression (Beck Depression Inventory)and clinical ratings
(Hamilton Rating Scale for Depression and Raskin Scale).Moreover, 78.9%of the patients in
cognitive therapy showed marked improvement or complete remission of symptoms as
compared to 22.7%of the pharmacotherapy patients. In addition, both treatment groups
showed substantial decrease in anxiety ratings. The dropout rate was significantly higher with
pharmacotherapy than with cognitive therapy.Even when these dropouts were excluded from
data analysis, the cognitive therapy patients showed a significantly greater improvement than
the pharmacotherapy patients. Moreover, while 68%of the pharmacotherapy group re-entered
treatment for depression, only 16%of the psychotherapy patients did so.

In a study by Davidson et al. (2006), the effectiveness of cognitive behaviour therapy for
borderline personality disorder was tested. The outcome of a randomized controlled trial of
cognitive behavior therapy in addition to treatment as usual (CBT plus TAU) was compared
with TAU alone (TAU) in one hundred and six participants meeting diagnostic criteria for
borderline personality disorder is described. Of the 106 participants randomized, follow-up
data on 102 (96%) was obtained at two years. Those randomized to CBT were offered an
average of 27 sessions over 12 months and attended on average 16 (range 0 to 35). We found
that the global odds ratio of a participant in the CBT plus TAU group compared with the
TAU alone group having any of the outcomes of a suicidal act, in-patient hospitalization, or
accident and emergency contact in the 24 months following randomization was 0.86 . In
terms of the number of suicidal acts, there was a significant reduction over the two years in
favor of CBT plus TAU over TAU, with a mean difference of −0.91 . Across both treatment
arms there was gradual and sustained improvement in both primary and secondary outcomes,
with evidence of benefit for the addition of CBT on the positive symptom distress index at
one year, and on state anxiety, dysfunctional beliefs and the quantity of suicidal acts at two
year follow-up. It was concluded that CBT can deliver clinically important changes in
relatively few clinical sessions in real clinical settings.

Cognitive behaviour therapy for low self-esteem

Low self-esteem has been associated with and cited as an etiological factor in a number of
different psychiatric diagnoses Some studies show that having a psychiatric illness lowers
self-esteem (Ingham, Kreitman, Miller, Sashidharan, & Surtees, 1987) and other studies show
that low self-esteem predisposes one to a range of psychiatric illnesses (Brown, Andrews,
Harris, Alder, & Bridge, 1986; Miller, Kreitman, Ingham, & Sashidharan). Despite the
uncertainty about the direction of causality in the relationship between self-esteem and
psychiatric illness, it is clear that the impact of low self-esteem is far reaching.

Low self-esteem is common, distressing, and disabling in its own right; it also appears to be
involved in the etiology and persistence of different disorders, and attending to these
processes may improve treatment outcome. Hence, it is a priority to develop effective
treatments for low self-esteem that can be applied across the range of diagnoses associated
with low self-esteem.

Cognitive therapy sessions for low self esteem follow a structure that includes a belief check
on mood, agenda setting, bridging from the previous session, reviewing homework (self-help
assignments that patient does between sessions), discussing issues on agenda, setting new
homework and summarizing and getting feedback from the patient about the session.
Cognitive therapists use a variety of strategies and techniques to help patients address their
thinking including psycho education, guided discovery, Socratic questioning, role playing,
imagery, etc.

Case History

In the first session the detailed case history of the client was taken

Identifying Information :

Name - Anwesha
Age - 22

Gender - Female

Educational Qualification - pursuing post-graduation

Chief complaint : She sought treatment for low self-esteem.

History of Present Illness : The client reported unable to perform well or engage in activities
in front of an audience and hesitation in approaching people she does not know. She has this
condition from class 11th. She reports that even though she would like to participate in such
activities, she is unable to convince herself to do so and her fear of being wrong in front of an
audience stops her from participating in a lot of things. Also her inability to do so, because of
her inherent fear, in turn makes her feel sad and remorseful.

Her symptoms also include the following -

Emotional Symptoms: Sadness, loneliness, despair and low self-esteem.

Cognitive Symptoms: Difficulty in concentrating, self-criticism and negativism.

Behavioral Symptoms: Social withdrawal, avoiding situations perceived as challenging.

Physiological Symptoms: loss of energy, inability to relax, gets easily tensed.

Psychiatric History : The client had no prior psychiatric history.

Personal and Social History : Anwesha is the younger of two siblings in a nuclear family. Her
brother is three years elder than her. She has been a good academically throughout her life.
Her parents were always and only focussed on her academic achievements. They were
supportive of her, but also very critical at the same time. She had always been a shy kid and
had a few friends in school. Her father had always been very strict and against any kind of
social outings with friends. Growing up, she has always feared being wrong at anything due
to the critical attitude of her parents, specially her father. She also believes her limited social
interaction has left her being clumsy in social situations and with feeling anxious at the
thought of meeting new people.
Medical History: The client does not have any medical problem that influenced her
psychological functioning.

Session 1

In this session the client was made comfortable and a rapport was formed with her. She was
educated about the cognitive therapeutic approach. After which her problems were discussed
in some more details.

(Therapist: T and Client: C)

Excerpts from the session

T: Hello. This is our evaluation session. Today, I will be asking you some questions so that I
can try to understand your problems and what is going on in your mind. Some of the
questions will be relevant and some won’t be, but I need to ask them in order to understand
what fits in for you and what not. Is that ok?

C: Yes. It’s alright with me.

T : (setting the agenda) Before we begin, I would like to tell you what I expect to cover
today. I would like to know about the problems that you have been experiencing. And also
about your history. Then, you could tell me anything that you think I have not asked and that
you think is important for me to know about you or your life. Is that fine?

C: Yes, it’s fine.

T : Is there anything you want to ask?

C : Nothing as of now.

T : Okay, feel free to ask anything whenever you want to.

C: Yeah sure.

T: So, now would you like to tell me what is the difficulty that you are facing?

C: I have difficulty in meeting new people, in public speaking. I can’t easily approach people
even when we are in familiar situation, like my new classmates in college or any institution.

T: Okay, so what happens in these situations? What do you feel/experience?

C: I feel scared and anxious. My heart starts beating very fast. My legs start shaking when
standing in front of an audience. I feel very nervous and tense. I start to fumble. My mind
stops working and I can’t think clearly what to say next.

T : Since when are you experiencing these difficulties?

C : Since school. I think class 11 th. It got really worse. Although, I think it was there before
that too. But I had done well in audience situations before that. I have won prizes in
declamation competitions in 6th and 8th class. But after that, yes I think after that I couldn’t do
it that well. And all these feelings got better of me.

T: Is there any specific reason behind why you started feeling like this?

C: Yes, could be. I mean, I have always been shy. And I’m still an introvert. Also, I have
always been just focussing on academics. My parents were always and only bothered about
that. They were very strict and critical about it. Ache marks lana was a priority. Aisa nhi hai
that they are not supportive, they are very supportive, provided whatever help I needed for
my studies. It’s just that it was always studies. My father was very strict and never permitted
social outings with friends. He thought it was a distraction. Toh isliye kabhi bahut social
interaction nhi hua, experience nhi hai logon se baat karne ka. And that is why I think I feel at
a loss when I meet or have to meet new people, I mean complete strangers.

T: Could you please explain what do mean by being at a loss when you meet new people?
How do you feel when you meet new people?

C: I meant that I don’t know what to say, how to talk, how to begin a conversation. I often
have this feeling that nobody would be interested in talking to me. That I’m such a worthless
person. I often can’t make an eye contact and talk. At times I feel I look funny, odd. Why
would anybody want to talk to me then. Or they will think that I’m interfering or getting close
unnecessarily. Basically I feel I’m unwelcomed. So I’m just scared to approach people. And
because of all this I try to avoid being in such situations as much as possible.

T : Okay, so these are the thoughts that run through your mind when you are in the company
of new people. (Psycho-education). In later sessions we will evaluate these thoughts. So when
you think that people will not like to talk to you, or think that you are funny and odd, how do
you feel? Happy, sad, angry…?

C : Sad, I feel very sad and bad. I feel lonely and I want the event/thing to get over fast.
T: I want to make sure I understand. This situation you described here is that you feel tensed
and anxious in a situation where there are new people or complete strangers and you have to
interact with them or give a presentation in front of them. You feel that others feel that you
are funny, odd, worthless. And because of these thoughts you are scared to approach people
and avoid such situations. Is that correct?

C : Very much.

T : These thoughts led you to feel sad and lonely, Did I get that right?

C: Yes, that’s right.

T : I understand Anwesha that certain kind of social situations are difficult for you and you
feel very uncomfortable in them. So, you and I will work together to resolve your problems.
Is there anything else you would like to share with me?

C : No, I can’t think of anything as such right now.

T : Okay. That’s fine. Now, I would like to tell you how the therapy sessions will go. We will
meet at regular intervals for the sessions. In each session, we will work on an agenda that we
need to decide together. We will take up your problems one by one in the sessions and work
towards resolving them and helping you overcome your difficulties. Also, I will be giving
you homework assignments which you need to complete before your next scheduled visit. Is
it okay?

C : Yes it is okay.

T : Please don’t hesitate to ask anything you are not able to understand?

C : Yeah sure. I’ll ask if that is so.

T : Okay. Would you like to give any feedback?

C : Umm…no nothing really. It is fine till now.

T : Okay, so may I ask you to maintain a dairy or some writing where you record when you
are feeling sad or lonely. And you could also write down about when you are in a situation
you want to avoid - what are your thoughts and how do you feel at that time? What did you
do or what was your reaction to the situation? Would you be able to do it? Is it alright?
C : Yeah I will try to do it.

T : Good. Okay then. Take care. See you for the next session.

Case Conceptualisation –

Core belief : “I’m worthless”, “it’s embarrassing to be wrong in front of a lot of people”

Intermediate beliefs

Attitude : it’s difficult to approach new people, talking in front of an audience is difficult

Rule : avoid social situations, avoid presentations/stage activities

Assumption : others think I look funny, odd ; I get clumsy in social situations

Situation : meeting new people in a new setting, presentation/talk in front of an audience

Automatic thoughts : nobody would really like to talk to me, I am not welcomed, I might be
interfering, I should not say anything wrong in front of an audience

Reaction :

Emotional : sadness, worried

Physiological : feeling low, pressurized, tense, anxious.

Behavioural : does not talk to anyone, avoids challenging social situations

Session 2

The session began by greeting the patient, setting the agenda and providing rationale for the
same and reviewing her homework assignment. I asked her how she had been feeling the past
whole week. I asked her to rate her mood on a Scale of 1-10, with 1 being extremely bad/sad
to 10 being extremely happy/good. She responded with a 5. She told me that she said she had
been feeling okay for the most part except that in one of the papers, a professor has
announced a group presentation and she had been feeling a little worried about it already.
Excerpts from the session –

C : One of the professors have just given us a group presentation, in which every member of
the group has to speak. And I am worried about it.

T : What were your immediate thoughts when you heard about it?

C : I will not be able to give a good presentation.

T : Why do you think so? What is the evidence for the same?

C : It has happened before. I get really nervous in front of people or an audience.

T : What has happened before?

C : A bad presentation.

T : I would really appreciate if you could share an instance of the same.

C : Well I have had a few experiences in which the presentation did not go well. The teacher
was not happy with my or rather our work.

T : Okay. What were her complaints?

C : It could have been better.

T : Better in terms of?

C : Content, topics covered, time taken. At times it has been very lengthy or we have missed
a few topics.

T : Okay, I can understand that very well. anything else?

C : No. That’s it.

T : Okay, in the above few experiences did the teacher had any specific complaint directed
towards you?
C : ummm…no not as such. Although I feel I did not speak very well as I was nervous, I
forgot some parts and then became more nervous. So that led to a bad presentation.

T : What makes you nervous? What are the thoughts that came to your mind that make you
feel nervous?

C : What if I make a mistake? What if I forget? I would end up saying something wrong.

T : Okay, let’s take those up one by one. We are talking about a presenting a topic through
power-point presentation (ppt). Correct me if I am wrong, but in a ppt one has certain
pointers/cues to help you or guide you. Am I right?

C: Yes that’s right

T : And how do you think those pointers can help you or any presenter, per say?

C : Pointers help one in remembering the content to be spoken of.

T : That’s right. So do you think that can help you with your forgetting difficulty?

C : Yes, it can.

T : So, can we tick off one worry from the list? The forgetting worry.

C : Yes we can.

T : Does it make sense? How are you feeling now?

C : Yes it does very much. I feel much better.

T : Next, you also mentioned about making a mistake, about saying something wrong. Right?

C : Yes I did. I am really worried about that part.

T : Okay. What will happen if you say something wrong?

C : People will think I am stupid.

T : And how would you feel?

C : I will feel bad.

T : Do you think all the people are correct all the time. For example, take your teachers or
your friends. Do you think all the things they say to you are 100% correct. Or do they also
make mistakes?

C : Yeah they do make mistakes, a lot of mistakes. At times, teachers also make mistakes.

T : So do you think it is really possible to be correct all the time?

C : No..(laughs) its practically not possible.

T : And what do you think about people who make mistakes? Do you think they are stupid?

C : No, I don’t really.

T : Okay. So why do you think when you will make a mistake or say something wrong,
people will think of you as stupid? Is there any evidence for the same? Has anyone ever said
that to you?

C : aaaaa…..(thinking for a while) no not really. (pause) actually never. No one has said that.

T : Okay, so why do you think so, then?

C : I don’t know. It’s just a thought in my head. It’s always there.

T : Okay, so we can say that it is an assumption you have made up for yourself.

C : Yeah, maybe you are right.

T : Okay. I would really appreciate if you could tell me what is it like in everyday situations.
Do you often make mistakes? Or is it rarely? Or somewhere in between?

C : No, I don’t often make mistakes. I am usually correct on the things I say.

T : That’s good. And what about in presentations? You must have been part of it before too.
You told me earlier that it has happened in the past that your presentation did not go well. But
there would be some good experiences as well? Aren’t there?

C : Yes there are. The last presentation I did really went well. I did not make any mistake. I
remembered everything. In fact in the one before that, which was not a ppt one and an
individual one, at that I also did well. I was a little nervous, but still they went quite well.
T : That’s brilliant Anwesha. So if you could try and recall, what made it a good presentation
for you? What are the reasons that you think it went well?

C : It was good as I remembered everything, did not forget a single thing. I was less nervous.
And that could be because I was very well prepared.

T : So does being well-prepared makes you less nervous?

C : Yes it does. I feel more sure.

T : And also if you are well-prepared, chances are less that you will forget anything and make
mistakes.

C : Yes, absolutely.

T : So, in that case, if you try and start preparing from now, you will be well-prepared for this
presentation and subsequently remember everything and will not make mistakes. Do you
think this can be a possibility? Does it makes sense?

C : Yes it is, completely.

T : You see Anwesha, you have given good presentations in the past. And you now if you are
well prepared you will be able to give a good presentation. Your past experiences are causing
you to form dysfunctional beliefs about yourself leading to the worried and low state you are
in right now. Okay, how about if we make a diagram? We just discussed a good example of
how in a specific situation your thoughts influence your emotions.

T : Can you realize how your thoughts and emotions are linked? See, how you viewed the
situation led to the automatic thought that then influenced what you felt.

C : Yes! (suprised). I never thought like that before. But what you say is actually kind of true.

T : Now, can you tell me in your own words about the connection between thoughts and
feelings?

C : Well, it seems like my thoughts are affecting my feeling and they lead me to feel low
about myself.

T : Very good. Yes that is what is happening to you. You have developed dysfunctional
thoughts which are making you feel low and sad.
C : Yes I can see that now.

T : Now, do you think with this awareness you can watch your mood now and see when you
are feeling low, ask yourself “ what’s going through my mind”. You can jot down the
thoughts and evaluate them to see whether they are true or not. Would you be able to do it?
Do you think this technique will help you?

C : Yes, I can give it a try for sure. It seems to me that it might work.

T : How are you feeling, right now?

C : I am feeling much better already. I think I just assumed that the presentation may go bad.
But like in the past, if I work hard, I’ll be able to do a good job.

T : Very nice. It seems to me that you have already learnt to evaluate your thoughts. Very
good. And rightly as you said, another thing that you can do is start preparing for it from
today only.(stating goal in behavioural outcomes) let us make this a homework for this week.
Is that okay?

C : Yes, sounds great.

T : And next week, you could give me a demo presentation for practice to test your
preparation. Will that be fine with you?

C : Yeah, that would be great help.

Session 3

Agenda – working on the hesitation to meet new people.

In this session, the agenda was to help the client overcome the hesitation in meeting new
people in a new setting. Before beginning with the new agenda, I asked the client how she
had been doing the past whole week. The client reported feeling much better having shared
her thoughts with me and had learnt how her thoughts were affecting her emotions and
behaviour. After this, we together decided to work on her hesitation problem with new people
she meets.
Excerpts from the session -

T : You had told me in the evaluation session that you feel hesitant in approaching new
people. One of the automatic thoughts we identified earlier was “others will not like me”. Is
that correct?

C :Yeah its true. I think people will not like me.

T : And how does that make you feel?

C : Terrible. Very sad.

T : So you have a thought that people will not like you and that makes you feel terrible and
sad. Can you give me any evidence which makes you so sure that others will not like you?

C : umm…(after thinking a lot)… actually no. I can’t think of anything.

T : Has anyone done something or said something to you that made you think and feel like
this?

C : No, no one has said or done something.

T : Okay, and do you have any evidence that people may actually like you?

C : Yes maybe but I am not very sure though. But I have really good friends and now after
almost a year with my classmates, a lot of people talk to me in the class and yeah I also talk
to them. and we have nice conversations.

T : That’s really good. So you have quite good evidence that people like you as they talk to
you and no evidence that people don’t like you.

C : aaaa…(smiles slighlty) ya right.

T : And how do you feel now?

C : Better.

T : Good. And what’s going through your mind?

C : I am thinking that maybe I was wrong. I do have friends and I talk to a lot of people. So it
can’t be that they don’t like me.
T : Can you see what the effect of your original thought was?

C : It made me sad.

T : And what is the effect of changing your thinking?

C : I feel much better.

T : Anwesha, a lot of times you will find that your thoughts are not accurate. just because you
think something, does not meant it is actually true. I want you to question your thoughts from
next time and find evidence for your thoughts. See if you have any evidence to prove if your
thoughts are completely true, partially true or not at all true. Can you try to do that?

C : Yes, I will definitely try.

Session 4

Agenda – to evaluate client’s assumption - “others think I look funny and odd”.

In this session, the agenda was to help the client evaluate the assumption “others think I look
funny and odd”. Before beginning with the new agenda, mood check was done and the
previous session revisited in brief. The homework was reviewed.

After this, we together worked on the agenda of the session and gathered evidence for and
against it to help her do realistic appraisal of her thoughts.

Excerpts from the session -

T : Anwesha, one of the automatic thoughts that we had identified was “ others think I look
funny and odd”. Is that right?

C : Yes, it bothers me a lot.

T : Has anyone told you so?

C : Not directly. But yes.

T : What did they tell you? I would really appreciate if you share some details about this
experience.
C : In my school, I have received lots of remarks from friends and classmates. My friend has
told me that I look very bad. Actually it wasn’t like that I asked her about it. My best friend
and some other classmates of ours were having a conversation about what boys think about
the girls of the class. I was really naïve back then. As I had told you earlier, my parents were
very strict and hence my only focus was studies. I knew very little about other stuff that peers
used to talk about. I was never part of any such conversation ever. Nobody used to talk to me
about these things. People only approached me for studies related stuff. On that day as well, I
just happened to stand there. I wasn’t really interested in the conversation, but I stood there
just because of my best friend. As you know in school we roam around in the morning and in
the recess time with our friends and just go everywhere together. So like that only we were
standing and some classmates joined and this conversation started. So I was just standing
there, quietly, as I hardly knew anything about this thing and was a mute spectator to all that
they were saying. And then out of nowhere, my best friend tells me, that - you are not even a
sisterly stuff. I had not even asked her to tell about the opinion people had about me. I guess
that really hurt my self-esteem. I still remember that whole instance vividly. Ever since I
think I am very ugly. (the client got a little emotional while telling this. She did not cry, but
her eyes swelled up a little towards the end.)

T : Are you okay? (I paused for a while and offered her water)

C : (her eyes are lowered, she is looking at the ground, takes a deep breath, sips a little water,
takes a while to gain her composure and then smiles faintly making a brief eye contact)
Yeahh, I am fine.

T : Please feel free if you wish to change the topic or if you are not feeling comfortable with
answering my questions?

C : No no its okay. It feels good to share this with someone.

T : Okay, so should we continue? If you are fine…

C : Yes please.

T : I can understand what serious impact the statement would have had on your tender mind
then. But you see that was just one person’s opinion. There could be a lot of reasons why she
said that to you. And if you remember, in the last session we talked about how to question
and test the accuracy of our thoughts. Similarly, we can do so with other people’s statements.
We will do that in a while. But before that, you told me above that many people said such
things. I would really appreciate if I get a clearer picture of all those things that make you feel
and think about yourself in that particular way.

C : Ya my best friend was never encouraging of me in most aspects. I realized that quite late.
And specially she never said anything good too. Also one of my classmates used to call me
Jassi- the character of a serial Jassi Jaisi Koi Nahi. Although I never took it quite seriously
initially because I did not really like that boy. He was such a mischievous and naughty
student, very bad, never studied in class. So in my head I took it as because Jassi is very
intelligent and so was I. I was a topper. And he also gave this same reason once - giving
explanation why he called me so, now I don’t know he said that to save his skin or he actually
meant it, though I think now he said that to only save his skin. Later on, I started interpreting
the name Jassi in a negative way, that I look funny, ugly, odd. There’s one more incident, but
I can’t tell you that, sorry.

T : Its okay, Anwesha. Absolutely fine. My purpose is to help you and not to make you
uncomfortable. Yes I also watched that programme and Jassi was an intelligent girl indeed.
And so are you? Ain’t you? If you were a topper in your school, you must be scoring good
marks in university as well? Isn’t it so?

C : Yes, I am still very focussed on my studies. Though I am not a topper here but yeah I
score good marks.

T : That’s great Anwesha. You see it’s not easy to secure admission in a university. You have
done that. And now you are competing with some of the best students of India and scoring
good marks. How does that make you feel?

C : Really good.

T : What is going through your mind right now?

C : Nothing.

T : Okay. If I were to tell you that there is an individual who got admission in a top university
and is now obtaining good marks in studies there, what would you say about such a person?
Is he/she worthwhile or worthless?

C : Definitely worthwhile. (smiles faintly)

T : Okay and since you share the same things with her I just described above, what kind of a
person are you – worthwhile or worthless?

C : Worthwhile. (smiles)

T : Good. Anwesha, now let us examine the counter-evidence to all those statements. You
must have received some compliments as well. Tell me about those.

C : Yeah, I have. But in college. In an activity that we were doing as part of our class,
actually it was a workshop, everyone in the group had to give every other member a genuine
compliment. That is when two of the most beautiful girls of my class said that I am very good
looking. I couldn’t really believe it. So I thanked them a lot. I also told them no one has ever
said such things to me. And after that I have got quite a few compliments which have boosted
my morale and makes me feel good. Also one really good friend with whom I shared all this,
said that I am pretty and I somehow just know that she was not lying. She has never ever lied
to me. Sometimes I think maybe that the things people said in school are not really true. Like
you said evaluate your thoughts. But I still can’t get those experiences out of my head so
easily.

T : That’s good. You have had good experience in college, right?

C : Yes. Much better than school.

T : Okay, take a while to think and tell me , thinking realistically, have you received more
positive views or more negative views in your cumulative experiences?

C : I think more of good lately.

T : So do you think your thought about “ others thin I look funny,odd” could be a bit over-
generalized?

C : hmm..may be.

T : Again you need to see that some past experiences are causing you to form dysfunctional
beliefs about yourself leading you to ignore all your positive experiences and evidence that
contradict your belief system. Is it so?

C : Yes, it does seems so.

T : Can you see how your dysfunctional thoughts are making you feel?
C : Yes they are making me feel low and bad about myself.

T : So would you like to change something about the way you think?

C : Yeah , I should evaluate my beliefs and thoughts and give due weightage to each
experience.

T : That’s good decision. And how do you think it might help you?

C : I will feel better about myself, think less negatively.

T : Okay. Now I know it may be hard for you initially to evaluate your thoughts and consider
your experiences fairly, but if you try you will be able to do it. Here I am going to suggest
you an activity. Whenever you feel low or sad, write down your thoughts and try to figure out
your belief. Then try and think of some positive experiences related to your thought/belief.
This will help you do a realistic appraisal of your thoughts and beliefs. Would you like to
give it a try?

C : Yes, definitely.

Session 5

Agenda – Eliciting feedback and termination of therapy.

The session began by greeting the patient. I asked her how the past whole week went. She
reported it as being good. She had that presentation and it went very well. she told me that
she did not forget anything, did not feel anxious or worried before it like she used to before
and felt very little nervous. She reported that many automatic thoughts crossed her mind the
previous week but she used the techniques she learnt in the sessions to keep them in check
and did not let them affect her emotions and behaviour. Then she and I set the agenda of the
session. I elicited the client’s feedback. I enquired whether she had benefitted from the
therapy and did she learn anything and would she be able to use what she has learnt in future
too. I asked her what changes she felt in herself.

Excerpts from the session –

(deciding the agenda of the session)
T : Okay, Anwesha so let us set the agenda of the session. What would you want to talk about
today? Well, you have already told me that it was a pretty good week for you. Still, are there
any problems that you would like to talk about?
C : No, nothing. I did not face any issue last week.
T : Are you sure? It can be anything though, not necessarily from last week only. Any other
issue/thought that might have bothered you?
C : No actually I feel so much better now. Ever since the therapy sessions started I have been
feeling so good, more good gradually. Initially I thought a lot, but now with the things I have
learnt here, I don’t let them bother me. I feel I have found a solution to all my problems.
T : So would you like the sessions to continue?
C : umm…no I don’t think ab zarurat hai. (laughs) I mean it was really good talking to you
and these sessions have helped a lot and I could actually go on and on talking to you. It feels
just so nice to share, but considering the fact that this is a structured therapy so you know that
formal thing so yeah I think now is the point to stop it as I have discussed my issues and
found my solutions.
T : Okay, Anwesha as you are so sure, so this will be our last session now.

[ As per the client’s wishes, I decided to turn it into the last session and moved the
conversation towards termination of the therapy. I alongwith her collaborative effort
summarized the previous sessions and revisited the techniques employed to make sure she
remembers them and have understood them properly. Then I elicited her feedback about the
therapy and her overall experience.]

Another excerpt -
C : I have realized that my thoughts and beliefs were so rigid that they were screening out all
positive experiences and evidence and I focussed on all negative outcomes that reinforced my
beliefs. Its amazing how I did not see that. I always thought of myself as an aware and
rational person. But it seems now how little I knew about my own self and my thoughts.
T : I am glad that you are more aware about yourself now. How does this make you feel
now?
C : Very good. And at peace.
T : Do you feel any changes in yourself after these sessions?
C : Yes. I am not afraid of presentations anymore. I can realistically thin about such
situations now. I know if I prepare myself good and everything will probably go fine. I
question my own assumptions and I realised through the homework tasks that I have so
many. So I check the evidences now like we did in the session and I realised so many of them
were so over-generalized. Now if anytime I have the thought that they don’t like me or I am
not looking good, I check with myself why I am thinking that, what made me feel that,
instead of just feeling low and sad all the day and consequently missing out on all the fun
moments that have had followed. Earlier if I had one of these thoughts I used to feel sad and
low the whole day for it. Now I stop myself pretty soon.
T : That is very good to hear Anwesha that it has helped you so much. You should continue
writing your thoughts and questioning them. Keep the learning from the sessions alive and
use them in your everyday life and you’ll see how you are able to deal with the various
situations, worries in a much better way. And in this way you can become your own therapist.
C : (smiles) Yes, that would be wonderful. I’ll definitely continue doing this. Thank you so
much.

Result

The client showed considerable improvement in her self-esteem at the termination of the
therapy.

Discussion

In the present study an attempt was made to apply Cognitive Behaviour Therapy(CBT) to a
client who was having low self-esteem. the client was a 22 years old female who reported
feeling low and sad due to her dysfunctional thoughts about her worth(I am worthless),
apprehensions about her looks (others think I look funny) and doubts about her abilities(I
cannot give a good presentation).

Based on cognitive Triad model, it can be the client had negative views about herself or we
can also say a negative bottom line, which was extreme in some aspects that she wanted to
avoid challenging situations. Beck’s cognitive help the client question and change her
dysfunctional thoughts and beliefs. A total of 5 sessions were conducted.

In the sessions, the client’s core beliefs, automatic thoughts and intermediate assumptions
were identified, evaluated and modified using various techniques such as cognitive
restructuring, Socratic questioning/guided discovery, homework assignments etc.
Reflections of the therapist – As a therapist, it was my first experience at conducting a
cognitive behaviour therapy on an individual (client) dealing with an issue (here, low self-
esteem) that needed to be addressed. It was definitely not an easy task. Reading the theory
from book and gaining an understanding of the techniques is whole together different thing as
compared to attempting to apply that understanding in a practical setup to a human being who
is need of some help. More than a practical, it was a huge responsibility – as a ‘to be’
psychologist, as a human being. I was a little scared, hesitant, and doubtful of myself before
beginning my first session with my client. I rehearsed like a hundred times in my mind as to
how to go about it. Fortunately, my client was very open and shared her problems very
lucidly which made my job as a therapist somewhat easy. In the therapy sessions, at times I
had to remind myself that I was a therapist and I have to interact in a certain way. Because at
times I found myself wanting to offer the client a solution as opposed to what I was supposed
to do – eliciting it from the client by Socratic questioning/guided discovery. In some aspects,
I benefitted too as my client was a receptive and quick learner and took smoothly to the
techniques I employed. Even in her descriptions and the data she provided, she seemed to be
somewhat aware of the fact that she has certain kind of thoughts that bother her. So the part
of explaining her the link between her thoughts/cognitions affecting her emotions and
behaviour did not seem as difficult.

Due to time constraints the therapy had to be terminated within a limited number of sessions,
however in ideal scenario, the sessions should have been spaced out and follow-ups must be
done after four-six months to ensure that the client is fine, is using her psycho-education from
the sessions and has not relapsed.

Conclusion

Cognitive behaviour therapy for low self-esteem proved to be effective for the client.

References
1. Beck, J.S. (2011). Cognitive Behaviour Therapy : Basics and Beyond. New York :
Guilford Press.

2. McManus, F. , Waite, P. , Shafran, R. (2009). Cognitive-Behavior Therapy for Low

Self-Esteem: A Case Example. Cognitive and Behavioral Practice, 16, 266-275.

3. McEvoy, P.M. , Nathan, P. (2007). Effectiveness of cognitive behavior therapy for

diagnostically heterogeneous groups: A benchmarking study. Journal of Consulting
and Clinical Psychology, 75, 344-350.

4. Butler, A.C. , Chapman, J.E., Forman, E.M. & Beck, A.T. (2006). The empirical
status of cognitive-behavioral therapy: A review of meta-analyses. Clinical
Psychology Review, 26, 1-31.

5. Davidson, K. , Norrie, J. Tyrer, P. , Gumley A., Tata, P. , Murray, H. & Palmer, S.

(2006). The effectiveness of cognitive behavior therapy for Borderline Personality
Disorder: Results from the borderline personality disorder study of cognitive therapy
(boscot) trial. Journal of Personality Disorder, 20, 450-465.