Cognitive Reappraisal and Self Image
In the next few pages we will circle back to our old friend, Maslow's hierarchy of needs and explore how we can utilise cognitive reappraisal strategies for the treatment of deficits in each tier of the triangle. First, let’s take a look at the self image tier of the triangle:
If you've identified that the Self Image and self-esteem tier of the hierarchy of needs is your client's primary concern, there are two critical areas that require attention:
1. Current Thought Errors:
The types of thought errors that you are likely to encounter with a client experiencing self-image issues revolve around comparisons between oneself and others, manifesting in the following thoughts or core belief patterns:
I am LESS than others due to one or several weaknesses, failures or deficits. For example, I am less than others because I don't know how to suceed in life, I don't know how to fit in, I am physically unattractive, I am financially or educationally behind, I am weak or emotional and so on.
Other people view me as less favourable, less significant, less desirable, less interesting, less admirable than others due to one or several weaknesses, failures or deficits.
I am MORE than others due to one or several strengths, features or abilities. For example, I am more worthy, more exceptional, more unique, more admirable, more virtuous and so on.
Or a combination of these.
Please note: we are not talking about a client's constructive assessment of their abilities, stenghts or weaknesses. In fact, the ability to be self critical and be able to rationally assess one's challenges along with strenghts is indicative of a healthy self-image. The type of thoughts and core beliefs that we are referring to here are excessively negative, emotion ridden (e.g. feelings of inferiority, shame, anger, self blame, competetiveness, over excitement or euphoria associated with accessive pride) often accompanied by thinking errors such as emotional reasoning, catasrophising, over-generalising, magnification/minimisation etc.
The process of therapy involves carefully examining these thoughts with clients and exploring their accuracy against evidence, as the client is ready to engage in such exploration.
One more point to remember is, in keeping with the principles of emotion regulation and to avoid inadvertently encouraging experiential avoidance and toxic positivity, we also need to inform clients that once their thoughts are shifted, their emotions may or may not match their thoughts yet. This means that they could have a more rational and balanced view towards the situation, but underneath those thoughts, they may still feel shame, embarrassment, a sense of failure, inferiority, or a sense of defeat and helplessness. In other words, the process of cognitive shift isn't a magical wand that immediately erases underlying emotions. In fact, it's entirely normal for the emotions to lag behind the cognitive shifts. The purpose of cognitive reappraisal is not to diminish these emotions. Other techniques that we will explore in future sections can assist with alleviating emotions. So clients can stay true to their existing emotions, accept these emotions, and not try to fight or control them. While simultaneously, they can review their thoughts and adjust them to a more rational view.
Let's look at an example to illustrate these principles in action. Imagine working with Alex, a capable individual who tends to downplays his achievements in his career or personal life. Your conversation might unfold like this:
Therapist: Alex, you've mentioned feeling hesitant about your recent accomplishment. Can you share more about that?
Alex: Well, I kind of feel like I got lucky with it. Maybe it wasn't a big deal. Or maybe I'm a fraud and people will soon see that I'm really not very capable.
Therapist: Can you remember another time when you tackled a similar challenge and received positive feedback from your colleagues?
Alex gives several examples of his past accomplishments.
Therapist: That's a great. It seems like your skills often do come through when you face various challenges. Could it be that your recent accomplishment wasn’t just luck? What if we looked at your recent achievement through that lens?
Alex: I guess I could see it as a reflection of my skills.
If, as seen in this example, our client shows a willingness to embrace new perspectives and adjust their views with a level of ease, focusing on the present moment could be enough to achieve our goals. However, if the client's fundamental convictions seem to be deeply ingrained and resistant to change, or if we notice that the client consistently disregards current realities and evidence, it may be helpful to delve into client's past memories, particularly those from his middle childhood.
2. Past Memories:
An essential first step is to determine key events that may have contributed to an unhealthy self-image. As we learned in the previous module, by working together with your client to delve into their history, you can pinpoint specific moments that hold emotional weight. For instance, let's go back to the case of Alex. Through exploring his history, you may come to realise that he first experienced feelings of inadequacy in primary school (middle childhood) due to a yet to be diagnosed case of dyslexia, which made him feel like he wasn't adequate, as well as a schoolyard bully that made him feel like he didn't fit in with his peers.
Therapist: Can we take a minute and explore something? It's a technique called imagery work. I'll guide you to use your imagination to travel back in time to specific moments from your past and then, by imagining things a bit differently, you can gain new insights and perspectives. Of course the past is the past and we can't really change it, but through imagining it differently, we can change the way that we are impacted by it today. Close your eyes if you're comfortable, and imagine you're traveling back in time to your childhood. Can you remember a time when your carefree childhood feelings were replaced by the ideas of self doubt and feeling not good enough? Do you remember any memory like that?
Alex: I remember struggling a lot with reading and writing at school. All the other kids seemed to get it, but I kept struggling. I had dyslexia, and it made me feel like I wasn't as smart as the other kids in my class.
Therapist: I'm sorry to hear you experienced that. Can we try something now? Imagine if your adult self, or some else you trust, was to step into the story and support your younger self through this experience? What do you think he needed to hear? What would you like to do for him?
Alex: I'm not sure. Maybe somehow making his dyslexia disappear?
[Note: Often clients opt for imagery solutions that involve changing external circumstances in their past. The issue with this type of strategy is that, in reality the client has still experienced what they have experienced, and the imagery work has not addressed the need for the experience to be reframed. Hence, usually, the best use of these imagery exercises is to assist the client to still go through the experience, but try to make sense of the experience or reshape their thoughts around it.]
Therapist: We can try that. But in reality, this child will still have a memory of what it felt like to have dyslexia and feel inadequate in class. So maybe instead of making the dyslexia disappear, we could help him understand that his dyslexia doesn't make him less worthy than other kids. We could tell him that his dyslexia is just a specific challenge in a specific area, and that all people will experience their own challenges in life. Having challenges doesn't make you less worthy. You could practice the things that are a little hard, like your spelling, and eventually become better at them. Or you could shine even brighter in the things that you're already good at, like sports or science. It's all about having fun and learning new things! Every kid's journey will be different, so you don't have to compare yourself to the other kids around you.
[Note: The purpose of this dialogue with Alex is partly to convince adult Alex why his child self wasn't inferior than his classmates. Once he is convinced of this, he can use imagery to convince the child in his imagination as well. For some clients this step may take a bit more time as their self worth is so deeply scarred, that they can’t even accept that as a child they were worthy or deserved better. For such clients, you may need to focus on broader cognitive restructuring aimed at improving their self work a bit longer before they are ready to delve into childhood imagery work. A good strategy would be to try to detect any maladaptive core beliefs that may cause them to have such poor self image.]
Alex: I guess I can see your point. The dyslexia was just a challenge. I didn't need to form such a negative self image around it.
Therapist: Exactly, can you imagine if someone had told little Alex about all of this back then? Can you close your eyes again and talk to him about it?
Alex: I would tell myself that dyslexia doesn't define my worth. I'd say that I have strengths and abilities that go beyond just reading and writing.
Therapist: That's great! How does your younger self feel after hearing these words?
Alex: He feels a bit lighter, like there's more to him than just his struggles. But he's still worried about the schoolyard bully. He still feels like there is something wrong with him if the bully picks on him.
Therapist: Shall we use the same technique to support him through the bullying as well? What did the bully say or do that was hurtful?
Alex: He kept telling me that I was annoying and no one wanted to play with me.
Therapist: And you believed him?
Alex: I'm not sure. I mean, there were times when I was alone during breaks and no one was playing with me. So yes, I did believe him.
Therapist: What about at other times? Were there times when things were different?
Alex: I do remember playing and having fun with the other kids at times.
Therapist: So what do you think caused you to fit in one day, and not fit in another day?
Alex: I remember standing on the side of the schoolyard and keeping to myself a lot. Not really mixing with the other kids. I was too shy or anxious to mix with them.
Therapist: Do you remember why you were shy or anxious?
Alex: Because I kept remembering the words of the bully kid. I thought I was annoying and no one wanted to play with me. So I pulled myself away.
Therapist: And while you were pulling yourself away, naturally the other kids left you alone. And in your mind, that must have confirmed what the bully was telling you.
Alex: Exactly. It kept firming up the belief that no kid wanted to play with me.
Therapist: Sadly bullies often tell us that there's something wrong with us and it's understandable that you believed what the bully was telling you. But it's good to remember that the purpose of a bully is to make you feel bad about yourself. If their purpose was to tell you the truth, they could have done it in more gentle ways. So it's wise to not believe all the negative things that a bully tells you about yourself. Do you think we could tell the younger you to not believe the bully?
Alex: Yes, he now realises that if he just went back into the playground, other kids would play with him. He feels like he fits in.
The Domino Effect of Memories
One thing to keep in mind here is a principle referred to as the cascading effect or the domino effect of memories. As we know, early memories act as a foundation for interpreting later events in life. During the process of therapy, if we change a client’s perception of an earlier memory, a cascading shift can ripple through time, influencing how they perceive subsequent experiences. In Alex's case, for example, the core belief "I'm not good enough and I don't fit in" was maintained as part of his identity and once he hit adolescence, a combination of challenges like puberty, increased peer pressures and highschool bullying caused this belief to exacerbate even more. Later, adulthood experiences such as employment challenges or searching for a partner further cemented this belief in. As you can imagine, once the belief “I’m not good enough” or “I don’t fit in” is there, life would create a myriad of scenarios to confirm this existing belief.
Once therapy had helped Alex develop a new understanding of his middle childhood experiences, not only was his self-perception in the present moment transformed, but a ripple effect was initiated whereby he began reframing his memories of adolescence and adulthood too. At times you may find that this ripple effect happens automatically, as your client starts pondering all the subsequent memories and developing a new view of them. At other times, you may need to manually help your client apply their new understanding to the subsequent events of their life.
In contrast, you may find that if you first attempted to shift Alex’s view of his adolescence and adulthood, his views would be more resistant to change as he would still remember the events of his adolescence and adulthood through the lens of a child who was less than his peers as he couldn’t spell or fit in. That earlier belief needed to have been shifted first. After addressing the earlier memories, the intense emotional charge connected to later events, such as high school difficulties, also began to diminish. Transforming the core, foundational memories can gradually reshape the entire narrative of Alex’s sense of self-worth.
Another way to view this principle is that early memories can serve as templates or reference points for how we interpret and respond to later life events. Thus, modifying our perspective on these foundational memories can potentially have a positive influence on how we view and process more recent experiences.
So from a practical standpoint, we are suggesting that a rule of thumb is to commence the exploration with the event that occurred at the youngest age and progressively work through to more recent memories. However, therapists may encounter situations where clients display resistance to revisiting earlier memories and instead prefer to focus on later-life events. This inclination can be attributed to the escalating intensity of negative emotions as clients navigate through life's challenges. For instance, a memory from age 7 might seem less emotionally charged than one from age 18, as years of challenging experiences would have eroded client’s self-worth even further. Clients often express that while the origin of their self-esteem issues dates back to middle childhood, these issues didn't gain prominence until later stages of life. This is where psychoeducation comes into play. It's crucial for therapists to help clients comprehend the significance of revisiting earlier memories, even if the associated emotions appear less intense, as it lays the groundwork for untangling the web of self-perception. Below is an analogy that I like to provide to clients about this principle, to help them understand the logic:
"Just like a big tree starts as a small seed, our feelings about ourselves also begin when we are very young. Even though those early feelings might not seem as big as the ones we have now, they are like the roots that grow into the big tree. To understand the big tree, we need to look at how it started as a little seed and grew. In the same way, to understand how you feel about yourself today, we need to go back and see how it all began when you were younger."