UNCORRECTED PROO F 1 Cognitive-Behavior Therapy for Low Self-Esteem: A Case Example 2 Freda McManus, Oxford Cognitive Therapy Centre and University of Oxford 3 Polly Waite, University of Reading Medical Practice 4 Roz Shafran, University of Reading 5 6 7 8 Low self-esteem is a common, disabling, and distressing problem that has been shown to be involved in the etiology and maintenance of a 9 range of Axis I disorders. Hence, it is a priority to develop effective treatments for low self-esteem. A cognitive-behavioral 10 conceptualization of low self-esteem has been proposed and a cognitive-behavioral treatment (CBT) program described (Fennell, 1997, 11 1999). As yet there has been no systematic evaluation of this treatment with routine clinical populations. The current case report 12 describes the assessment, formulation, and treatment of a patient with low self-esteem, depression, and anxiety symptoms. At the end of 13 treatment (12 sessions over 6 months), and at 1-year follow-up, the treatment showed large effect sizes on measures of depression, anxiety, 14 and self-esteem. The patient no longer met diagnostic criteria for any psychiatric disorder, and showed reliable and clinically significant 15 change on all measures. As far as we are aware, there are no other published case studies of CBT for low self-esteem that report pre- and 16 posttreatment evaluations, or follow-up data. Hence, this case provides an initial contribution to the evidence base for the efficacy of 17 CBT for low self-esteem. However, further research is needed to confirm the efficacy of CBT for low self-esteem and to compare its efficacy 18 and effectiveness to alternative treatments, including diagnosis-specific CBT protocols. 19 20 L OW self-esteem has been associated with and cited as 21 an etiological factor in a number of different 22 psychiatric diagnoses (Silverstone, 1991), including 23 depression (Brown, Bifulco, & Andrews, 1990), obses- 24 sive-compulsive disorder (Ehntholt, Salkovskis, & Rimes, 25 1999), eating disorders (Gual, Perez-Gaspar, Martinez- 26 Gonzallaz, Lahortiga, Irala-Estevez, & Cervera-Enguix, 27 2002), substance abuse (Akerlind, Hornquist, & Bjurulf, 28 1988), chronic pain (Soares & Grossi, 2000), and 29 psychosis (Freeman et al., 1998). Silverstone and Salsali 30 (2003) report lower self-esteem in all psychiatric diag- 31 noses than in a comparison group, and that the effects of 32 psychiatric diagnoses on self-esteem may be additive in 33 that those patients with more than one diagnosis had the 34 lowest self-esteem, particularly when one of the diagnoses 35 was major depression. Low self-esteem has also been 36 associated with self-harm and suicidal behavior (Hawton, 37 Rodham, Evans, & Weatherall, 2002; Overholser, James, 38 Adams, Lehnert, & Brinkman, 1995). Furthermore, low 39 self-esteem has been shown to be a poor prognostic 40 indicator in the treatment of depression (Brown, 41 Andrews, Harris, Alder, & Bridge, 1986; Sherrington, 42 Hawton, Fagg, Andrew, & Smith, 2001), eating disorders 43 (Button & Warren, 2002; Fairburn, Peveler, Jones, Hope, 44 & Doll, 1993; Van der Ham, Strein, & Egneland, 1998), 45 and substance abuse (Kerlind, Hernquist, & Bjurulf, 46 1988), and to predict relapse following treatment (Brown 47 et al., 1990; Fairburn et al.). 48 While low self-esteem has been associated with many 49 psychiatric conditions, the nature of this relationship is 50 unclear: Some studies show that having a psychiatric 51 illness lowers self-esteem (Ingham, Kreitman, Miller, 52 Sashidharan, & Surtees, 1987) and other studies show 53 that low self-esteem predisposes one to a range of 54 psychiatric illnesses (Brown, Andrews, Harris, Alder, & 55 Bridge, 1986; Miller, Kreitman, Ingham, & Sashidharan, 56 1989). There is evidence that changes in either depres- 57 sion or self-esteem can affect the other (e.g., Hamilton & 58 Abramson, 1983; Wilson & Krane, 1980). Despite the 59 uncertainty about the direction of causality in the 60 relationship between self-esteem and psychiatric illness, 61 it is clear that the impact of low self-esteem is far reaching; 62 it is associated with teenage pregnancy (Plotnick, 1992), 63 dropping out of school (Guillon, Crocq, & Bailey, 2003), 64 mental illness (e.g., Brown et al., 1990), and self-harm and 65 suicidal behavior (Hawton et al., 2002; Kjelsberg, Nee- 66 gaard, & Dahl, 1994; Overholser et al., 1995). It also has a 67 negative impact on economic outcomes, such as greater 68 unemployment and lower earnings (Feinstein, 2000). In 69 summary, low self-esteem is common, distressing, and 70 disabling in its own right; it also appears to be involved in 71 the etiology and persistence of different disorders, and 72 attending to these processes may improve treatment 1077-7229/08/xxx-xxx$1.00/0 © 2009 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved. ARTICLE IN PRESS CBPRA-00212; No of Pages 10: 4C Available online at www.sciencedirect.com Cognitive and Behavioral Practice xx (2009) xxx-xxx www.elsevier.com/locate/cabp Please cite this article as: Freda McManus et al., Cognitive-Behavior Therapy for Low Self-Esteem: A Case Example, Cognitive and Behavioral Practice (2009), doi:10.1016/j.cbpra.2008.12.007