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Antidotes for Low Self-Esteem in Eating Disorder Recovery

By Michael E. Berrett

Introduction

I write this article as one having great interest in self-esteem and the impact of avoidance on one's sense of self. This interest has come from personal life experience growing up and professional experience as a clinician working with many different kinds of clients who have struggled with poor self-esteem. I write this article as one who has worked with many eating disorder patients over the last twenty years, most of whom suffered greatly from a poor sense of self and poor feelings of self-worth. They have taught me as I have made great effort to help them down that road to recovery. Those suffering from eating disorders most often have two things which are the common denominators of eating disorders. The first common denominator is poor self-esteem, the belief that they are not good enough, that they do not have much to offer the world, and the "felt need" to do something to "make up for that," which is partially acted out in the eating disorder. Secondly, the eating disorder truly is a disorder of avoidance. It becomes a way for those so addicted and so trapped in its grip to avoid painful emotions, painful beliefs about self, pain that comes from a lost sense of one's identity, and further, a way to avoid rejection and other painful experiences in life.

Why would I want to write about self-esteem? Firstly, understanding and remediating poor self-esteem is critical. Poor self-esteem is the thread of the deep woven fabric of an eating disorder. Regardless of failure or success, relationships or lack thereof, mental disturbance or mental health, poor self-esteem is a robber. It unconsciously puts a ceiling on the breadth and the depth of the joy in our lives and it puts an artificial and unnecessary limit on the depth or our experiences. Poor self-esteem erodes one's confidence and it is often a quiet, insidious, and invisible thief. We do not seem to understand enough about it and all the while, millions and millions suffer from it. Secondly, it is personal. It impacts my life. It impacts my children's lives. It impacts the lives of patients, clients, and employees with whom I work.

It breaks my heart to see those with eating disorders suffering from their poor self-esteem. This poor self-esteem is typified in the story of a patient who my friend, Dr. Frost, and I once worked with. This brief story typifies the poor self-esteem so often found in one suffering from eating disorders. Brenda came into a therapy session and described her previous night's dream.  She and her boyfriend were on an ocean beach. As they looked out to the ocean, there was a sign which read, "No swimming! Danger! Great White Sharks!" Despite the sign, her boyfriend grabbed her by the hand and took her ankle deep into the water. Brenda expressed her discomfort about being in the water and her boyfriend replied, "It's okay, the water is too shallow for a shark to come." Pretty soon the water felt so good and they were having such a great time in the sand, in the water, in the sun, and with each other, that they found themselves out to their knees. Again, she went away from the fun for a moment and remembered the sign. She expressed her fear of the sharks, to which her boyfriend said, "It's all right. Nothing is going to happen." Pretty soon they were up to their waists in the water.  Her expression of concern and his reply were repeated. Then finally, up to their necks in the water, her boyfriend reassured her that, all was okay, ignoring her fears and her pleas for them to go back onto the dry land. Hard to see at first, but then clear and sure, there came the fin of a Great White Shark. Within no time, the shark came up underneath her and took half of her body in one bite. The Great White snapped her off at the waist, and swam away with half of her riddled body. In this unrealistic, yet terrifying dream, her boyfriend turned to her and said, "Oh, I am so sorry about what happened," to which she replied, "Oh, it's okay. It's no big deal."

As you can see this young woman's low self-esteem was played out in this dream. It was her life to yield to the wants and desires of others and to ignore her heart, her sensibilities, her intuition, her mind, her best interest, and her feelings. To Brenda, her feelings did not count, were not worth listening to, were not worth following, and the only thoughts and feelings of worth were someone else's. The daily lives of those so similarly suffering is dramatically typified in this symbolic dream, which is about a chronic, poor, and destructive belief about themselves.

What Self-Esteem Is

First of all, let us talk about what self-esteem is not. Self-esteem is not about, and does not come from "externals." A model of self-esteem, according to many who are trapped in an addictive eating disorder, was conceptualized by a colleague of mine, Dr. Harold Frost. "Eating disorder patients most often become trapped in a belief about self which is: 'I am nothing more than my appearance, my achievements, and what others think of me.'" It is these beliefs about themselves that keep the eating disorder alive and well. Therefore, a step to recovery, and then ultimately one of the blessings of recovery, is to once again learn that esteem and worth are much more than appearance, so much more than achievements, and everything more than what others might think and feel.

Self-esteem has more to do with what one believes in, what one thinks, feels and desires, the intentions of one's heart, one's sensibility, intuition, capabilities, and more. It has to do with passion and how one lives their life. Self-esteem has more to do with the internal than the external. For the religious, it has to do with deity and divinity, the meaning of being a creation of God. For others, it may include ideas of connection with others, self-respect, good intention, talents, whether developed or not, a sense of being rather than doing. It is about who we are and the intentions of the heart.

According to Bednar Wells and Peterson (1989), self-esteem is:  "An enduring and affective sense of personal value based on accurate self-perceptions."

It is my belief that children have at birth, as infants and toddlers, a positive sense of self. It is not until circumstances, experiences, and interactions which teach differently, that beliefs about self change and poor self-esteem "raises its ugly head."Then, children begin to forget and disbelieve how wonderful they are. Part of overcoming poor self-esteem is to "come back to" that which you once knew about your value and worth before life's negative experience began to teach falsehoods about the value of yourself.

Traditional Models of Self-Esteem

A person's belief about where poor or positive self-esteem comes from depends on their model of human growth and development, and their model of personality and learning theory. It is the "filter," the "sunglasses" we look through, which helps us find meaning in the world and also dictates our model of self-esteem. I present only a few of many traditional models of self-esteem, ways to help build self-esteem in each model, and finally, I will discuss some unanswered questions and concerns which remain after traditional models are rendered.

Philosopher / Behavioral Scientist

Interventions Based on Model

Interventions Based on Model

William James

Setting goals and realizing them.

Baby steps structure for success, then generalize to other situations.

Sullivan

Reflected appraisals of significant others.

Cognitive restructuring.

George Herbert

Winning approbation from significant others.

Seek positive feedback from trusted loved ones.

Gordon Allport

Coping with difficulties versus avoiding difficulties.

DBT: Dealing with different emotional states, "Feel the fear and do it anyway."

Rollo May

Courage to allow all of oneself to exist.

Existential therapy and acceptance of being.

Scott Peck

Face adversity head on.

Grandma's rule, face things first, play or enjoy later.

Rosenberg

Self-confidence, the expectation of success amid challenges.

Plan to goal setting and success.

* Information adapted from Bednar Wells and Peterson's (1989).

In reviewing these traditional models and theories about self-esteem, and the consequent interventions needed to overcome poor self-esteem, it is seen that traditional models have many strengths, and luckily, many of these models have been utilized in the current therapies, including cognitive/behavioral therapy and the "positive mental attitude" programs that people have used in self-growth, psychotherapy, and business consulting. But despite the good that has come out of these and other traditional models, many questions remain unanswered. That leaves room for new theories, hopefully more useful and practical in helping people overcome poor self-esteem and make gains in their journey of recovery from emotional and mental illness and from addiction. One of these new models will be presented later in this article.

Questions Remain from Traditional Models

Difficult and unanswered questions remain from traditional models such as these:

1. What if young people growing up are treated well within family and social circles, and they still have poor self-esteem? What does that mean about the old theories?

2. What about those with loving and attentive parents who would give everything and anything for their children, and who have done their best, have done well, and still their children suffer with poor self-esteem?

3. What about the resilient who suffer horrendous trauma, abuse, neglect, and abandonment, but yet seem to feel good about themselves?

4. If self esteem is based on the appraisals of significant others, then why is it that all too often, our positive and expressed appraisals do not seem to make much difference?

(Questions were adapted from Bednar, Wells, and Peterson 1989).

The New Model of Self-Esteem

A new and practical way of looking at self-esteem is that no matter the source of low self-esteem, it is avoidance that maintains it. The ideas presented here come from my twenty plus years of clinical experience, personal life experience, and from the book Self-Esteem: Paradoxes and Interventions in Clinical Theory and Practice, APA, 1989, by Bednar, Wells, and Peterson.

The basic philosophy in this model is this: "One's overall evaluation of self is the natural consequence of a person's tendency to consistently cope with or avoid that which he or she fears. Low self-esteem is, therefore, both a cause and a consequence of disordered behavior"(pg. 4).   Bednar et al., propose that "When there is a consistency in one's tendency to cope or avoid conflict, there is a continuous basis for internal feedback from the self about the adequacy of the self."

In other words, it is believed that there is interpersonal(external) and inter psychic (internal) feedback which we all receive in life, which is ongoing, and there are basic truths about that feedback:

1. Everyone is going to receive, and might as well expect, plenty of negative feedback from the social environment.

2. Many people receive a lot of favorable feedback socially, but tend not to believe it.

3. Self-evaluative processes are ongoing for most, if not all of us.

4. Self-evaluation is impacted by either coping or avoidanc, and that choice impacts one's sense of the adequacy. (pg 13)

In other words, we have two choices: We can cope, which is growth oriented, personal development oriented, and increases understanding. Coping involves facing and resolving life's dilemmas. Or we can avoid. Avoiding means we stay away and hide from internal risk taking, or interpersonal risk taking.

"Whether people cope or avoid dictates the positive or negative nature of the personal psychological experience," and "Avoidance leads to negative self-evaluations, while coping or facing leads to favorable self-evaluations" (pg. 14). In other words, it is not what ultimately happens in a situation, or how well someone does, but rather it is the understanding and the sense of self that one has either chosen to avoid or chosen to cope and do the best that they can that really someone's their sense of self-worth and esteem. (Bednar et al.)

"In the self-evaluation process, people usually notice what they do, and they often notice how they feel. What they do not often enough notice is how they feel about themselves as a result of their choices and as a result of how they live their lives. If one gets in the practice of becoming aware of how they feel about themselves for doing, acting, facing, and "following through," then they can develop a tool for improving their self-esteem. Feelings about oneself are deeper, more important, and more connected to the core, to the heart, and to the individual's actual sense of self.

Steps Toward Improved Self-Esteem using the "Avoidance Model"

1. Determine the level of preoccupation with peer approval and acceptance.

2. Help identify and label significant avoidance patterns used in anxiety arousing conflict situations.

3. Help identify and label the self-evaluative thoughts and feelings associated with those avoidance patterns.

4. Learn to realistically break avoidance patterns.

5. Learn to face and cope with intrapersonal conflicts.

6. Identify new behavioral responses to conflict.

7. Become aware of feelings about self which are associated with the new behaviors versus feelings about self stemming from old avoidant behaviors.

*(Adapted from Bednar et al. (1989) (pg. 127).

In the process of these seven steps, the following principles can help increase the chances of success:

  • Ask hard questions which cause reflection.
    • "How do you feel about selling yourself out?"
    • "What was it like to go against what you felt was right?"
    • "How did you feel about yourself after you said that?"
    • "If you continue to act in life as you did today, what will your life be like and how will you feel?"
    • "How do you feel about being able to face that hard situation?"
    • "Even though you are upset with yourself, how does it feel to be honest with yourself?"
    • "Have you noticed that you have been acting differently in the last few hours?"
  • Help clients learn to ask themselves how they feel and how they feel about themselves.
  • Help clients notice and feel the emotion associated with negative and positive patterns which they enact in their lives.
  • Focus on the process, not so much on the outcome.
  • Hold up the mirror. Help them see the process that we see, and help them see the person that we see.
  • Use the therapy session and the therapeutic relationship, along with the client's patterns within the relationship, as a microcosm for the rest of life.
  • Do not prematurely save them from negative emotion and negative meaning in their recognition of avoidance.
  • Teach them through their own self-reflection that avoidance validates the fear of failure, and that it has a negative impact on self-esteem.
  • Quit trying to convince clients that they are great. Instead: 
    • Help them see their goodness and notice the small evidences of their courage, their progress, and their willingness to avoid avoidance.
    • Correct the incorrect and move on. In other words, if an eating disorder patient says, "I am fat," say, "I see you as beautiful, and additionally you are in a normal weight range. I am sorry you cannot see that." We correct and then move on instead of trying to convince.
    • Help them change the approval management façade since they will not accept positive feedback from us on the outside, until they become more honest and real with themselves on the inside.
  • Teach clients to give positive feedback and positive recognition to themselves. Encourage clients to validate themselves first, and then if we validate their positive self-appraisal, they may begin to accept ours as well.

Avoidance: Research Survey

In September 2005, I walked into a therapy group I was running and asked eleven women to help me prepare to teach other professionals about the impact of avoidance on self-esteem and on the process of recovery. They wanted very much to help.  The women in this group ranged in age from sixteen to twenty-four years of age, were struggling with anorexia or bulimia, and were receiving intensive care in our residential treatment program.

In the survey I asked each patient to respond in writing to the following six questions:

1. What are the most important things you have avoided during your life and during your process of recovery?

2. Why did you, or are you, avoiding those most important things in your life?

3. What has been the cost of avoidance in the past or the present?

4. When you have overcome the pattern of avoidance, and how did you do that?

5. What has helped you stay out of avoidance the most?

6. What, if anything, does avoidance have to do with your personal feelings of self-worth?

After the survey questions were completed, responses were reviewed. Much can be learned from these women about the role of avoidance in their self-esteem, and the role of avoidance or non-avoidance in the process of recovery from an eating disorder. In the following paragraphs, I give a summary of the conclusions which I derived from the participants' responses. With each of the conclusions are one or two direct quotes associated with each item to illustrate firsthand one direct comment which led to each drawn conclusion.

Summary of Conclusions from Avoidance and Self-Esteem Survey

Click the (+) next to each topic to learn more.

+ 1) Patients will recognize and take ownership for their own avoidance patterns when given a common language and a safe opportunity to talk about it.
+ 2) Common areas for avoidance in life generally and in the process of treatment include:
+ 3) People embrace avoidance in an attempt to control others' responses, especially in areas of acceptance or rejection.
+ 4) Pretending is a common form of dishonesty with self and a common avenue for avoidance.
+ 5) The price paid, or the cost of avoidance is high.
+ 6) Some of the patients have at least some recognition and understanding that one of the highest costs of avoidance is loss of feelings of self-worth.
+ 7) People can overcome the tendency and pattern of avoidance.
+ 8) Patients have many tools and methods for overcoming avoidance, and thereby increasing their self-esteem.
+ 9) Patients can learn to notice and utilize negative and positive affective states related to coping and avoiding.

Courtesy of Center For Change, Orem, Utah