Development of Self-Esteem in CBT for Child
Frolli A1,2, D’Allocco G2, Orefice A2, Tortorelli FA2,3 and Ricci MC2,3
1Disability Research Centre, University of International Studies of Rome, Italy
2SPEE - Specialization School in Cognitive Behavioral Psychotherapy for Developmental Age Disorders, Italy
3FINDS- Italian Neuroscience and Developmental Disorders Foundation, Caserta, Italy
Submission: January 30, 2020; Published: February 21, 2020
*Corresponding author: Frolli Alessandro, Disability Research Centre of University of International Studies of Rome Via Cristoforo Colombo, 200, Roma, Italy
How to cite this article:Frolli A, D’Allocco G, Orefice A, Tortorelli FA ,Ricci MC. Development of Self-Esteem in CBT for Child. Psychol Behav Sci Int J. 2020; 14(3): 555890. DOI:10.19080/PBSIJ.2020.14.555890.
Abstract
Cognitive Behavioural Therapy brings together different psychotherapeutic approaches and techniques, integrating behavioral and cognitive therapies, which are used for the treatment of several psychopathological disorders. This therapy is considered a valid treatment modality and with scientifically demonstrated efficacy from the point of view of Evidence-Based. It explains the emotional disease of the “here and now” by working on thoughts, behaviors and emotions that emerge in everyone’s daily life. Patient and therapist actively collaborate to identify thoughts, behaviors and emotions that manifest in a psychopathological way, and to modify maladaptive and dysfunctional thinking habits. This therapy is indicated for the treatment of diseases such as anxiety disorders, mood disorders, personality disorders, pathological addictions etc. and in several cases, in association with pharmacological therapy. The main objective of Cognitive Behavioral Psychotherapy is to promote health at all levels and at all ages, through individual and group interventions, aware of the fact that the bases of adults are found just in childhood, a phase of life in which, today, given the dynamic society in which we live, it arises the need for increasingly specific and concrete methods of intervention.
Keywords: Cognitive behavioural therapy; Mindfulness; Coping power program; Schema therapy; Metacognitive therapy; Self-Esteem, Theory of mind
Introduction
At the end of the first twenty years of the 2000s, it had been evident to the exponents of Cognitivist Psychotherapy that the founding fathers, Aaron T. Beck and Albert Ellis had to be recognized, the merits of having marked an important transition in the evolution of Psychotherapy and a definitive separation from Psychoanalysis. Before arriving at an update of this evolution, it is necessary to remember where everything started. Almost in parallel, Beck and Ellis, between the late 1950s and early 1960s, took their first steps towards defining what clinical cognitivism will be, then declined into standard cognitive therapy (Beck) and rational emotional therapy (Ellis). Both psychoanalysts arrive at the same intuition by observing how, especially in depressed patients, conscious thoughts are mainly responsible for emotional suffering and are easily intercepted by the individual, unlike the unconscious thoughts on which the psychoanalytic method was deeply rooted. These thoughts, together with a determining component of cognitive distortions and irrational ideas, are recognized as the real responsible for the patient's suffering, and as a primary objective on which to intervene through techniques that refer to an only common denominator: disputing with the patient, then renamed Socratic dialogue. The fundamental objective is to conduct the subject to develop a more realistic vision of his surroundings. Standard cognitive therapy was definitively established between the 70s and 80s, not without having to defend itself from the attacks of the other orientations, up to a crisis that ended in the early 90s, when they began to question the results of the interventions, their durability and the percentage of relapses.
The general intuition that instilled doubt about the validity of the standard model was that it was necessary to focus more on the thought processes rather than on the contents, educating the patient to have a less involved relationship with his own knowledge. New approaches have begun to assert themselves on this idea that, although still included in the macro-area of cognitive therapies, they are united by other theoretical assumptions and by a more complex reading of psychopathological functioning. Mindfulness breaks into the panorama of cognitive psychotherapy thanks to the American doctor Jon Kabat-Zinn who, starting from the need to integrate Buddhist meditation practice with medical-psychological one, develops the MBSR protocol (Mindfulness Based Stress Reduction) which finds consensus and empirical validity in the reduction of stress and suffering in patients with chronic pain. The theoretical assumption of mindfulness is articulated in a series of rules or, as the author calls them, pillars (not judgment, patience, the beginner's mind, trust, not seeking results, acceptance, letting go), which will help to give a definition for all subsequent third wave orientations: "mindfulness is the awareness that emerges from paying attention, in the present moment and in a non-judgmental way, to the flow of experience, moment after moment" (Kabat-Zinn, 2003). Starting from the imprinting given by Kabat-Zinn and from mindfulness in general, different approaches have emerged that, to date, have definitively found their stable place in the broad and ever-changing panorama of cognitive behavioral disciplines. One of these is definitely the ACT (Acceptance and Commitment Therapy) by Steven C. Hayes. What particularly characterizes this approach is the introduction of the Relational Frame Theory, a theory that supports the centrality of the individual's attitude towards thought in determining psychic suffering rather than the content of it and of beliefs in general. Interventions such as ACT don’t have as main objective the resolution of symptoms, that was strengths but also weaknesses of previous approaches, but a more general acceptance and openness to experience (cognitive flexibility), foundation of almost all mindful approaches. Marsha Linehan's DBT (Dialectical Behavior Therapy) is a more symptom-oriented approach and considered relevant for the intervention for serious personality disorders (such as Borderline Disorder).
By integrating the principles of mindfulness and cognitive behavioral psychotherapy, DBT focuses on reducing emotional dysregulation and impulsive and self-injurious behaviors through a very structured and articulated intervention, divided into modules that yield individual psychotherapy and social skills of group. Adrian Wells’ Metacognitive Therapy instead proposes to intervene on the thought process by questioning the "metacredit", and seems to be a tribute to the progenitors Beck and Ellis, but the curiosity to experiment with the technique of Kabat Zinn, renaming it Detached Mindfulness, leaves us glimpse a coherence with the idea that what really needs to change in the individual is the relationship with thought, which should not be suppressed but observed and let go. Our country too can boast a significant contribution in the evolved overview of cognitive behavioral therapies: Interpersonal metacognitive therapy, which also includes modules based on mindfulness as regards the part of emotional regulation. It arises from the great intuitions of Giovanni Liotti [1] who, with his motivational systems, has defined key points within which to move to understand the functioning of the patient and to enhance the patient's ability to reflect on his own inner life, and to regulate it in order to achieve an emotional and interpersonal balance. On this basis many authors, including Antonio Semerari and Giancarlo Dimaggio, have structured a model that is still evolving whose results leave good prospects for a definitive affirmation of this fascinating and complex form of psychotherapy.
The idea that the patient is moved in relationships by a maladaptive interpersonal scheme that arises from a desire (characterized by the relative motivational system) that inevitably clashes with the expectation of the other's response which, almost always, will frustrate the previous one, determines a negative self-image (known as core belief) and hence the patient's emotional suffering and the use of dysfunctional coping strategies, responsible for activating interpersonal cycles. The attention given to the different metacognitive deficits that make the patient unable to read the intentions of others within the relationship, and which inhibit his ability to take a critical attitude towards thoughts makes this model fascinating in its complexity, and it seems almost confirm the premise from which our analysis started on the birth of the third wave of cognitive behavioral psychotherapy: the limit of standard cognitive therapy is the quality of the patient's metacognitive functioning.
Discussion
The combination of adult and developmental therapy is an expression of a vision that sees the person through a model that connects the continuity and discontinuity of the different existential phases and related psychopathological problems. Already Fonagy discussing some epidemiological data, stated that the high prevalence of childhood mental disorders represents a relevant mental health problem, considering also the fact that serious childhood psychiatric disorders don’t spontaneously regress, and many of them are associated with a subsequent low adaptation in adolescence and adulthood, including high risk of developing psychopathology further on. The intervention therefore seems justified in all stages of development, including very early childhood. Psychoanalysis initially proposed different explanatory models based on the theory of instinctual development and object relations, up to the most recent relational developments. The Relational Systemic Approach has instead focused on the communicative meaning of the symptom in the context of the family system, overcoming the narrow confines of the individual setting. The behavioral approach focused on the development of rigorous behavioral assessment procedures in the child and techniques based on the paradigm of operant conditioning (Applied Behavior Analysis) and classical conditioning (Behavior Therapy).
Following this trend, Beck and Ellis' first clinical cognitivism emphasized the importance of distorted thinking and related schemes, which however initially showed limits of applicability to the child if we consider his procedural and emotional expression, in addition to the request for linguistic and thinking skills which aren’t particularly developed in school and even less preschool age. Since the 1980s there has been a "relational shift" characterized by an evolutionary current of cognitive research linked to the analysis of motivational systems, and in particular to Bowlby's attachment theory, and a constructivist current linked to a consideration wider than metacognitive and interpersonal processes. This perspective originates in the quality of primary attachment relationships, in which the human being is seen as a complex system that evolves over time, maintaining an organization and a sense of himself that influence the perception of reality. From these perspectives new theories emerged also in the developmental age, in which the symptoms in every phase of the life cycle aren’t seen longer as behaviors acquired through learning mechanisms or manifestations of guiding conflicts, but as ways to maintain a meaningful relationship with the other and a sense of consistency and stability over time. Among the contributions from the third wave, in the evolutionary scope we can mention an intervention that is gaining greater importance, specific for the control of aggression: the "Coping Power Program". Originally intended to be applied in schools in the United States, it then spread widely in Europe in clinical settings. The program, a structured course for children and families with Parent Training sessions, is based on the Contextual Social Cognitive Model of Lochman and Weels and identifies five risk areas whose combination during the child's development can increase the chances to experience a behavior disorder.
The areas concerned are area of biological and temperamental factors moderated by the area of the family context, area of the environmental context and school factors, area of the context of peers and area of the child's skills about processing of social information. In particular, the interaction between cognitive evaluation (appraisal), physiological activation (arousal) and behavioral response is emphasized. The cognitive assessment of the situation can be influenced by difficulties in coding social signals, which can influence physiological activation, which can depend on a biological predisposition and activate aggressive behavioral responses. All that interferes with the search for possible and effective solutions to the problem and is reflected in social interaction. In recent years there has been a growing interest in the theoretical study and clinical applications of Mindfulness even in developmental age: its effectiveness as a therapeutic approach in adulthood has been demonstrated in numerous clinical conditions both of an organic nature, such as for example in the fibromyalgia, both psychological in nature, such as in anxiety disorders, but positive effects have also been found in populations of children, especially starting from 5 years of age. There is much evidence to support the fact that the administration of mindfulness-based protocols in children is associated with an increase in both social and emotional skills, as well as in executive functions. Also, in the school system, numerous techniques and exercises have been adopted that serve to increase awareness in the child, inspired by previous currents such as that of Montessori.
Another proposed technique is the "Schema Therapy", an integrative therapy that combines concepts of psychodynamics, systemic relational, Gestalt therapy and cognitive behavioral. It focuses more on emotions, on the therapeutic relationship, on the biography of the patient, integrating psychoeducation and coaching scheme for parents, and many techniques suitable for children. At the base there is the concept of "scheme" by which we mean a set of memories, emotions, physical sensations that belong to the individual and to the relationship he has with the other. Early maladaptive patterns are formed from unmet primary needs in the early years of life. Each of us faces these patterns and responds to the chronic frustration of primary needs by implementing survival strategies, that is coping style. These reactions, in response to crisis situations, become problematic if used for most of the time, and continue to activate early maladaptive patterns. Schema Therapy also introduced the concept of Mode: this is configured as a momentary, perceptible and observable state which is a habitual reaction to a given stimulus. Modes can be functional or dysfunctional: when it is dysfunctional, a Mode can include intense unpleasant emotions, avoidance responses or self-destructive behaviors. Working on observable modes also involves modifying early maladaptive patterns, which aren’t observable as they are part of our Nervous System. The study of constructs and therapeutic methodologies at the basis of Schema Therapy is constantly evolving: the progressive evolution of a practical theoretical model in the developmental age simultaneously represents a conceptual challenge and a clinical urgency. In recent years, the progress of Cognitive Behavioral Psychotherapy, as we have seen, has favored a real specialization in the scope of development and developmental age in general. Childhood and adolescence are phases of life characterized by continuous changes, both on physical, cognitive and interpersonal levels: these changes, threatening balance and requiring the development of continuous forms of adaptation, could be hardly tackled, compromising functioning in all areas of life, from relational to family to school.
For this reason, it becomes a central element of Third Wave Cognitive Behavioral Therapies to promote, especially with children and adolescents, a change of thinking style that allows, in a more positive and functional way, a more adaptive assessment of oneself, the world and the future. Exactly against this background, the construct of Self-Esteem comes into play, which plays a central role not only for adult psychotherapy but becomes crucial in intervention in the developmental age. Recent studies suggest that self-esteem, understood as feeling more or less well with oneself, develops in preschool age, an age in which children already have a positive or negative idea of themselves: it therefore plays a critical role in education of social identity. As a result, a high or low self-esteem can determine the quality of interpersonal relationships, coping and problem-solving strategies, but mostly it translates into awareness and control of one's own mental states (ToM). Low self-esteem is often considered an essential element in the symptomatological-clinical picture of many psychological problems such as anxiety, depression, eating disorders, behavioral disorders and problems related to academic or work performance. Low self-esteem can lead to a vicious cycle called "learned helplessness": devaluing oneself and one's own effectiveness inevitably leads to the creation of negative expectations, which condition thoughts and behaviors through cognitive distortions, which complicate the success of the task. This failure will reinforce initial thinking and the development of avoidance strategies, thus promoting the stabilization of a bad self-image. Good self-esteem, on the other hand, means having the ability to accept and understand both strengths and weaknesses and to support more adaptive strategies to deal with stressors and problems.
This results in a deep interest from Third Wave Cognitive - Behavioral Psychotherapy, in building a good self-image, and therefore a good self-esteem, through a work focused on awareness of one's mental and emotional states, promoting interventions since the age of childhood. The Cognitive-Behavioral Psychotherapeutic intervention allows to work on the obstacles that contribute to the development and maintenance of a good level of self-esteem: irrational fears, dysfunctional thoughts and ineffective communication style: irrational fears lower the level of self-esteem and negatively affect style of relationship that becomes passive. Over time, the accumulation of dissatisfaction and frustration over the failure to achieve the desired goals, which favors low self-esteem, can lead to an impulsive manifestation of anger with aggressive relationship methods. Both of these behaviors appear to be dysfunctional with respect to the objective of developing healthy, assertive and functional relationships to achieve goals. It is possible to trace a union between adult psychotherapeutic and developmental age interventions precisely on self-esteem, given the longitudinal development of this construct. A fundamental theoretical approach is provided by Mindfulness, which, by promoting awareness of one's thoughts and behaviors, teaches us to live in the "here and now" without conditioning.
Mindfulness is based on the idea that self-esteem depends exclusively on the Self and not on what happens in the external world: through self-acceptance, it maintains that the way in which we place ourselves in the world is much more important, rather than to what happens. Over the years this perspective has appeared absolutely revolutionary, thanks to the integration of meditation techniques and psychotherapy techniques in order to improve the self-image, for a more adaptive approach to the outside, enjoying great success especially in relation to the developmental age. Wells' Metacognitive Therapy is also linked to Mindfulness theories on strengthening self-esteem which, mainly created to deal with the problems related to anxiety and depression, focuses on the "how" we think of ourselves rather than the "what", thus working on what are called "metacognitive beliefs", ideas and theories that each person has of their own thoughts and their cognitive and behavioral efficiency. Evaluating in a "detached" way, or as objective way as possible, the thoughts associated with one's self not only helps the construction of a realistic image of the person but helps adaptive and less harmful self-regulation in terms of psychological distress. Although it seems difficult to associate the concept of metacognition with children, Bruner's studies are famous, which conclude that children already have a metacognition nucleus at 18 months: therefore it is easy to imagine how early interventions, aimed at raising awareness of this type of thought, may in the course of development bring positive results in terms of emotional management and well-being. Another approach that has achieved good results with adolescent subjects is the Acceptance and Commitment Therapy, which sees self-esteem closely linked to the quality of the relationship with oneself. Poor management of emotions, understood as avoidance, control or compensation is a sign of rigidity, which has negative effects on one's values by distorting self-esteem.
The lack of tolerance of one's mental states, thoughts and emotions, does not allow a realistic and adaptive evaluation of oneself. Consequently, a more flexible and healthier attitude is promoted for the recognition of the thought and emotional activity, distinguishing it from the assessment of reality, in order to achieve a more harmonious self-esteem capable of directing the person towards values and healthier and more realistic goals. Finally, we mention Young's Schema-Focused Cognitive Therapy which, both with adults and children, aims to work on innovative self-esteem. Through the definition of universal needs, such as security, autonomy, play, etc., it leads individuals to develop awareness of their own needs and behaviors put in place to satisfy them. Psychological well-being and a good self-image are the result of satisfying these needs in an adaptive way, considering emotional and relational states and coping responses. In conclusion, we have seen that in order to achieve balance and mental and physical well-being it is essential to develop a good self-image from childhood. In today's world, where changes are increasingly rapid, and need continuous and versatile adaptation strategies, being aware of what you are worth, of your strengths and weaknesses, becomes essential to manage emotions and mental states in a way adequate. And this is exactly one of the main objectives of Cognitive Behavioral Psychotherapy which, through individual and group interventions, promotes health at all levels and at all ages, aware of the fact that the bases of adults are found just in childhood, a phase of life in which, today, given the dynamic society in which we live, it arises the need for increasingly specific and concrete methods of intervention.
Conclusion
The construct of self-esteem implicitly involves the ability to attribute to oneself and other mental states that are desires, intentions, thoughts and beliefs, and to explain and predict behaviors on the basis of these inferences (ToM): the esteem a child has of himself depends on his thoughts, his expectations, his awareness of himself and others [2], therefore on his interactions. The first-order ToM consists in acquisition of the ability to recognize one's own and other’s emotions and thoughts (I think you think) [3], and in understanding of false belief that child acquires at four years of age. When a child, at about four years of age, is able to understand that the way in which other acts is guided by his beliefs about the world, and that these beliefs aren’t necessarily the faithful mirror of reality, but are just referentially opaque with respect to it, that subject "possesses" a ToM, or has achieved "understanding of subjectivity" [4]. Fonagy [5-10] uses the term meta-representation meaning the intersubjective ability to understand oneself and others, which is also evident in the primary relationship with caregiver. Mentalization helps to understand other people's behavior by making sense of actions observed even if others don’t directly explain them. In fact, human behavior is guided both by knowledge of reality and by a metacognitive monitoring that has recursive thinking as its tool, that is, a thought that implies meta-representation, or representation of a mental representation (I think you think he thinks, Second-order ToM) [2, 11-15].
The age of four is therefore considered a sort of watershed between an evolutionary phase in which the child isn’t yet able to reason at a meta-representation level on the belief - so much so as to commit what in the tasks of false belief is called "realistic error" (i.e. extending one's own knowledge of reality to the other)- and a subsequent phase in which he reaches this ability that will allow him, in the following years, to articulate increasingly complex levels of recursion of thought (second and third order recursive thinking). Therefore having a good awareness and self-esteem and being able to understand one's own and others' thoughts and beliefs, becomes fundamental to manage emotions and mental states in an adequate way: reaching a metacognitive restructuring is one of the main objectives that Cognitive Behavioral Psychotherapy of the Third Wave based on Self-Esteem aims to achieve. On these bases, our experimental research group proposes to work on a new rehabilitation treatment, which has as its presupposition a metacognitive and metarepresentational restructuring as a cure for psychopathological situations in developmental age [16-25].
References
- Liotti G, Monticelli F (2008) I sistemi motivazionali nel dialogo clinico, Raffaello Cortina Editore, Italy.
- Frolli A, La Penna I, Cavallaro A, Ricci MC (2019) Theory of Mind: Autism and Typical Development. Acad J Ped Neonatol 8(4): 555799.
- Ballerini A (2002) Autismo e schizofrenia: una proposta. In: Patologia di un eremitaggio. Uno studio sull’autismo schizofrenico. Bollati Boringhieri, Torino, Italy, pp. 136-154.
- Battistelli P (1995) Io penso che tu pensi . Le origini della comprensione della mente, Franco Angeli, Milan, Italy.
- Fonagy P (1989) On tolerating mental states: theory of mind in borderline patients. Bulletin of the Anna Freud Centre 12(2): 91-115.
- Beck J (2013) La terapia cognitivo comportamentale, Astrolabio, Italy.
- Boldorini AL, Spagnuolo P (2009) Chiavi dell’autostima. Stare bene con se stessi, stare bene con gli altri, Ecomind, Italy.
- Bruner J (2000) La ricerca del significato, Bollati-Boringhieri, Torino, Italy.
- Dimaggio G, Montano A, Popolo R, Salvatore G (2013) Terapia metacognitiva interpersonale dei disturbi di personalità, Raffaello Cortina Editore. Italy.
- Ellis A (1989) Ragione ed emozione in psicoterapia, Astrolabio, Italy.
- Fabbro F, Muratori F (2012) La Mindfulness: Un nuovo approccio psicoterapeutico in età evolutiva, Giornale di Neuropsichiatria dell’Età Evolutiva 32.
- Fonagy P (1996) Attaccamento, sviluppo del Sè e sua patologia nei disturbi di personalità, Psychomedia.
- Fontana D, Slack I (1999) La meditazione per i bambini. Roma, Astrolabio, Italy.
- Hayes SC, Stroshal KD, Wilson KG (2013) ACT. Teoria e pratica dell’acceptance and commitment therapy, Raffaello Cortina Editore, Milan, Italy.
- Kabat-Zinn J (2018) Vivere momento per momento, Tea Editore, Milan, Italy.
- Lambruschi F (2014) Psicoterapia cognitiva dell'età evolutiva: procedure di assessment e strategie psicoterapeutiche. Bollati Boringhieri, Italy.
- Linehan MM (2015) Dbt Skills Training. Manuale, Raffaello Cortina Editore, Italy.
- Lochman JE, Wells KC (2002) Contextual social–cognitive mediators and child outcome: A test of the theoretical model in the Coping Power program. Dev psychopathol 14(4): 945-967.
- Meltzoff AN, Prinz W (2002) The imitative mind: Development, evolution, and brain bases. Cambridge, England.
- Orth U, Trzesniewski KH, Robins RW (2010) Self-esteem development from young adulthood to old age: A cohort-sequential longitudinal study. J Pers Soc Psychol 98: 645658.
- Sebastiano SS (2002) Psicoterapia integrata per bambini e adolescenti. Sovera Edizioni.
- Semerari A (2000) Storia e tecniche di psicoterapia cognitiva. Roma, Laterza, Italy.
- Wells A (2012) Terapia metacognitiva dei disturbi d’ansia e della depressione, Eclipsi.
- Young JE, Klosko JS, Weishaar ME (2007) Schema Therapy. La terapia cognitivo-comportamentale integrata per i disturbi della personalità. Edizione italiana a cura di A. Carrozza, N Marsigli e G Melli. Editore Eclipsi: Firenze, Italy.
- Zeigler Hill V (2011) The connections between self-esteem and psychopathology. Journal of Contemporary Psychotherapy 41: 157-164.