Novice Counselor's blog

Abstract
This project describes the treatment of a low-income client suffering with low self-esteem. The primary treatment mode utilizes Rational Emotive Behavior Therapy (REBT). Background and causes of low self-esteem are explored, followed by steps taken to identify and dispute the client’s irrational thinking, utilizing REBT’s ABC Model. Suggestions for addressing client’s economic and quality of life issues are also given.

Final Project Case Description
The Novice Counselor is hypothetically working at Community Mental Health Center where she is treating a low income client struggling with low self-esteem. The client is a thirty-two year old African American female with two children. She is divorced and is having trouble finding a job while receiving public assistance. Her husband is not paying any child support and has had a history of verbally abusing the client. She is struggling to make ends meet and blames herself for not being able to find a job and for the failure of her marriage. The client has a negative view of herself, feeling she is not attractive enough to find a mate, and does not have any useful skills that would enable her to find a job. She also feels that she is not a good mother to her children. Her low self-esteem also keeps her from applying for jobs as she feels she doesn’t have anything to contribute to society.
The therapist will be using Rational Emotive Behavior Therapy as the primary intervention for this client. One reason for selecting REBT is its efficacy for changing irrational thinking and beliefs which may play a role in issues of self-esteem. Another reason for selecting REBT is the learner’s interest in researching intervention modes for self-esteem issues. Such issues play a role in many clients’ profiles.

The Nature of Self-Esteem
Among psychosocial resources, higher levels of self-esteem have been shown to predict fewer stressors over time. Self-esteem has been associated with the use of problem-focused and active coping, lesser use of avoidance coping, and greater persistence in the case of failure or setbacks. Self-esteem may inhibit stress proliferation indirectly through its effect on choice of coping strategy, in particular, the positive association with problem-focused coping and negative association with avoidance (Barker, 2007).
Causes of Low Self-Esteem
Why self-esteem is Important
According to Dr. Sorensen of the Self-Esteem Institute, low self-esteem is actually a thinking disorder in which an individual views himself as inadequate, unworthy, unlovable, and/or incompetent. Once formed, this negative view of self permeates every thought, producing faulty assumptions and ongoing self-defeating behavior. Cognitive symptoms and consequences of low self-esteem include faulty self-image (the inaccurate view of oneself as inadequate, unlovable, unworthy, and/or incompetent). Emotional Symptoms and consequences of low self-esteem include discouragement, fear and anxiety of making mistakes, being rejected, or looking foolish or inadequate, and hypersensitivity (Sorensen, 2009). Low self-esteem serves as a risk factor for depression, especially in the face of major life stressors. Higher levels of self-esteem have been shown to predict fewer stressors over time. Self-esteem has been associated with the use of problem-focused and active coping, lesser use of avoidance coping behaviors, such as behavioral disengagement and emotional venting, and greater persistence in the face of failure or setbacks . Self-esteem seems to buffer or moderate the impact of negative events. Conversely, low self-esteem opens a door of vulnerability to negative outcomes associated with exposure to stressful experiences, such as depressive symptoms, which in turn generate further stressful experiences. (Barker, 2007)

How Low Self-Esteem Will Be Treated
A key aspect of REBT is that people are not disturbed by events per se but by the views and beliefs they have of the events. Irrational beliefs are illogical, rigid and inconsistent with reality whereas rational beliefs are logical, flexible and consistent with reality. As a consequence of holding irrational beliefs, people develop unhealthy emotions, dysfunctional behaviors and psychological disturbance. By disputing their irrational beliefs, people can acquire more rational and realistic ways of thinking that will produce greater acceptance of the self and greater satisfaction with life (Davies, 2006).
REBT is an active-directive, persuasive approach to therapy. (Ellis, 2000). Thus, the therapist will use an educational model when utilizing REBT. The therapist will explain to the client the basic nature of REBT and give examples of irrational beliefs. These include:
It is a dire necessity for one to be loved and approved by virtually every significant other in one’s community.
One absolutely must be competent, adequate, and achieving in all important respects or else one is an inadequate, worthless person.
People absolutely must act considerately and fairly and they are damnable fools if they do not.
It is awful and terrible when things are not the way one would very much like them to be.
Emotional disturbance is mainly externally caused and people have little or no ability to increase or decrease their dysfunctional feelings and behaviors.
If something is or may be dangerous or fearsome, one should be constantly and excessively concerned about it and should keep dwelling on the possibility of its occurring.
One cannot and must not face life’s responsibilities and difficulties and it is easier to avoid them.
One must be quite dependent on others and need them and cannot mainly run one’s own life.
One’s past history is an all-important determiner of one’s present behavior and because something once strongly affected one’s life, it should indefinitely have a similar effect.
Other people’s disturbances are horrible and one must feel very upset about them.
There is invariably a right, precise, and perfect solution to human problems and it is awful if this perfect solution is not found.

The client will be taught how to identify her own self-defeating ideas, thoughts, beliefs and actions and replace them with more effective, life-enhancing ones. In order to accomplish this, the therapist will focus on a specific problem which the client brings up and identify the irrational beliefs associated with this problem. The client will be encouraged to use REBT self-help forms (Weinrach, Ellis, et.al., 2007), during her spare time and during sessions to identify and dispute her irrational beliefs. Once irrational beliefs are identified, the therapist along with the client will begin the process of disputing these beliefs.

The ABC Model
This model is the essence of REBT and is used to detect irrational beliefs and ideas, to debate and discuss them, and to create new ideas, attitudes, and beliefs (Capuzzi and Gross, 2007).
(A) Stands for the activating event. Before the individual experiences behavioral and emotional consequences (C), he or she interprets and judges the activating event by his or her own system of ideas, attitudes, and beliefs, (B). It is in (B) that one must look for phrases like “must, should, need, ought to, have to”, which tend to be irrational and need to be disputed. (C) are the behavioral and emotional consequences of the irrational beliefs. These three steps are explained to the client.
The method for dealing with the client’s issues can be broken down into the following steps (Dryden, 2009):
Obtaining basic information and utilizing initial impressions
Developing a problem list
Identifying goals for therapy
Developing a list of problem emotions (Cs)
Developing a list of problem critical activating event (A)
Identifying core irrational beliefs (Bs)
Identifying dysfunctional behavior (Cs)
Identifying the purposive nature of dysfunctional behavior
Identifying the cognitive consequences of core irrational beliefs (Cs)
Identifying the client’s health and medication status
Developing an understanding of relevant predisposing factors
Predicting the client’s likely responses to therapy

Examples of Specified Problems
The client’s ex-husband is verbally abusive by putting the client down, telling her she is fat and lazy, an unfit mother, and will never amount to anything. The client responds by feeling bad about herself, not attempting to get a job, and having a low self-esteem.
The client is very discouraged about the prospect of finding a job and has essentially given up on that goal.

Examples of Specified Goals
When the client’s ex-husband is being verbally abusive she may want to get away from him and realize that his words mean nothing, do not necessarily reflect reality, and do not change how she feels about herself. She wants to feel unconditional self-acceptance no matter what happens in her life.
Although the client has practically given up on finding suitable work, the client’s goal is to realize that just because a job hunt has been unsuccessful in the past, it does not mean that it will forever remain so. The goal is to get the client to keep trying and perhaps get her involved in vocational counseling.

Why Unconditional Self-Acceptance is More Important Than Self-Esteem
According to Ellis, self-esteem is anathema to self-acceptance. Any evaluation of one’s self on a global measure of self-worth is unhealthy and dysfunctional. First, it is irrational because there are no objective bases for making global evaluations of one’s self. Second, focusing on one’s self-esteem will make a person vulnerable to life’s little setbacks, rejections or mistakes, so that even people with generally high self-esteem may be predisposed to blow these out of proportion with resultant negative consequences. Third, a concern about self-worth can lead to a preoccupation with comparing oneself with others at the expense of engaging in healthy and productive endeavors and pursuits. It is well known that low self-esteem is associated with psychological dysfunction, such as depression, but even high self-esteem can be associated with psychological dysfunction, such as emotional vulnerability to criticism (Davies, (2006). According to a study by Chamberlain, David, and Haaga, (2001), people with high unconditional self-acceptance (USA) were more objective when evaluating themselves and also less apt to denigrate those who negatively evaluated their performance. Thus, the client will be advised to unconditionally accept herself whether or not she behaves competently or correctly and whether or not others are likely to express approval or respect.

Group Therapy
The client will be recommended for group therapy. The group’s aim will be to achieve a shift in negative perceptual bias. Clients in the group are encouraged to actively search for counter-evidence, question and reinterpret experiences, gather information through behavioral experiments, question the validity of previous standards and formulate alternatives (Rigby and Waite, 2006). The group situation provides clients with the opportunity to observe patterns of thinking in others, to recognize biases and their negative impact and thereby gain insights into themselves. It provides a safe place to consider alternative, more realistic ways of interpreting and evaluating experiences. Another important element is the opportunity to directly challenge negative beliefs and fears about social acceptability and to promote a sense of belonging. Rigby and Waite, (2006), believe that improvements in self-esteem as a result of the group experience are attributable to cognitive changes, such as shifts in negative biases towards the self and a reduction in negative automatic thoughts, which are primary in maintaining low self-esteem.

Vocational Training
The client will be recommended for vocational counseling and training to aid in her job search and development of marketable skills.

Stress Reduction
The client is experiencing stressors related to securing basic needs (e.g., trying to make ends meet; unable to afford dinner or entertainment), parenting stress related to child rearing/or the parenting role (e.g.,unsure in the way you discipline your child, getting children ready in the morning), marital stress related to marital problems or conflicts with a significant other, and job-related stress related to the job search, vocational training, or schooling. The reduction of stress may be a strategy for preventing many of the health issues that disproportionately affect African American clients (Townsend, Hawkins, Batts, (2007). The therapist will attempt to focus the discussion on the many relevant aspects of African American women’s lives, including spirituality, motherhood, and intimate relationships to name a few. For African American women, self appreciation and the ability to value the African American culture can be empowering. Feelings and appraisal associated with marginality, tokenism, role entrapment, multiple role responsibility, prejudice, sexism, and racism need to be explored as they relate to coping and stress management. The client is taught to identify her stressors and determine those that could be changed (e.g., conflicts due to a lack of appropriate time management), versus those that are uncontrollable (e.g., racial discrimination on the job). Once the stressors had been identified, the client is encouraged to select the appropriate coping strategy to manage the identified stress. The use of a Journals can be suggested to help the client track her daily stressors and the strategies she finds most effective in handling them. In addition, the use of social support and spirituality as stress management techniques will be encouraged (Townsend, Hawkins, Batts, (2007).

Summary
The client’s self-esteem issues will be addressed by education in the basics of REBT while focusing on disputing irrational beliefs, attitudes, and behaviors as they relate to specific problems in the client’s life. The client will be taught the concept of unconditional self-acceptance, which seems to be more important than self-esteem. The client will attend group therapy to gain a sense of belonging and further identify distorted thinking. The client will also attend vocational counseling to address carrer issues and engage in culturally sensitive stress reduction sessions with the therapist to address quality of life issues.

References
Barker, D. B., (2007); Antecedents of Stressful Experiences: Depressive Symptoms, Self-Esteem, Gender, and Coping; International Journal of Stress Management, Vol. 14, No. 4, 333–349

Capuzzi, D., Gross, D. R. (2007). Counseling and psychotherapy: Theories and interventions (4th ed.). Upper Saddle River, NJ: Prentice Hall. ISBN: 0131987372.

Chamberlain, J. M., David, A., Haaga, F., (2001); Unconditional Self-Acceptance and Responses to Negative Feedback; Journal of Rational – Emotive & Cognitive – Behavior Therapy. 19, 3; ProQuest Psychology Journals, pg. 177.

Davies, M. F., (2006); Irrational Beliefs and Unconditional Self-Acceptance. I. Correlational Evidence Linking Two Key Features of REBT; Journal of Rational-Emotive & Cognitive-Behavior Therapy, Vol. 24, No. 2.

Dryden, W., (2009). My Idiosyncratic Practice of REBT, http://www.psychotherapy.ro/index2.php?option=com_content&do_pdf=1&id=30;Retrieved on 3/5/2009

Ellis, A.,(2000); Rational emotive behavior therapy (REBT). Encyclopedia of psychology, Vol. 7. Kazdin, Alan E. (Ed); pp. 7-9. Washington, DC, US: American Psychological Association;  New York, NY, US: Oxford University Press, 537 pp.

Rigby, L., Waite, S., (2006). Group Therapy for Self-Esteem, Using Creative Approaches and Metaphor as Clinical Tools; Journal of Behavioural and Cognitive Psychotherapy, 35, 361–364.

Sorensen, M. J., (2009); http://www.theselfesteeminstitute.com/AboutSelfEsteem.htm; Retrieved 3/5/2009

Townsend, T. G., Hawkins S. R., Batts, A. L., (2007). Stress and Stress Reduction among African American Women: A Brief Report. Journal of Primary Prevention, 28:569–582

Weinrach, S. G., Ellis, A., MacLaren C., Wolfe, J., DiGiuseppe, R., Vernon, A., Malkinson, R., Backx, W., (2007). Rational Emotive Behavior Therapy Successes and Failures: Eight Personal Perspectives. Journal of Rational-Emotive & Cognitive-Behavior Therapy, Vol. 24, No. 4.