Self-esteem is tied into nearly everything, from career and relationship issues to anxiety and other mental health challenges, that bring clients through the counselor’s door. And if their self-esteem is unhealthy and out of balance, it hinders clients’ ability to grow and heal from their presenting issues — unless they first address how they feel about themselves.

“You need self-esteem in order to live a life that is really meaningful to you, and you won’t know what’s meaningful to you unless you know yourself,” says Katherine Hennessy, a licensed professional counselor (LPC) and certified alcohol and drug counselor at a group private practice in Lake Oswego, Oregon.

Hennessy views self-esteem not as a commodity to have in varying amounts but rather as an integral piece of working toward the therapeutic goal of self-actualization. She has seen clients who struggle with overconfidence or have difficulty recognizing their shortcomings, but that doesn’t mean they automatically have an overabundance of self-esteem.

“Self-esteem is an achievement; it’s not something you can have too much of. We are born with abundant self-esteem, and the world picks away at it as we get older, so it’s an achievement to get it back,” Hennessy observes. “Self-esteem is the foundation for mental health. Having healthy self-esteem means that we know that we deserve to be treated with respect by ourselves and by others. We must believe that our wellness and happiness are worth fighting for and that we are capable of making positive changes in our lives in order to work toward our therapy goals.”

On the surface

Self-esteem “definitely touches all of my clients in one way or another no matter their diagnosis, or even [in those with] no diagnosis,” says Ariel Cross, an LPC who owns a private practice in Denison, Texas.

Stagnation or lack of growth in counseling work and in life, such as career choices or relationship patterns, can be an indicator that a client’s self-esteem is out of whack, Cross notes. This can be the case both when an individual is overconfident (what Cross calls “insecure self-esteem”) and when they lack confidence and believe they are not good enough.

For clients with insecure self-esteem, lack of growth may include frequent job hopping, poor impulse control, an inability to accept or learn from criticism, irritability, anger or a pattern of blaming others (e.g., becoming angry at a boss who gives critical feedback in a performance review instead of recognizing it as an opportunity for growth or improvement). These clients often have a mindset that asserts, “It’s not me, it’s them,” Cross says.

Clients who struggle with low self-esteem, on the other hand, may be stuck in patterns that include staying in jobs or relationships that aren’t fulfilling, healthy or a good fit for them. They generally lack the confidence to seek or picture themselves in a better situation. Cross says these clients may have internalized the message “I’m not good enough.” 

Patterns of accepting and allowing others to treat them poorly can be a sign that a person has low self-esteem, Hennessy adds, as can behaviors that indicate they don’t trust themselves, such as asking a lot of questions or constantly seeking advice from others. When low self-esteem copresents with depression, it can manifest as listlessness or hopelessness. These clients simply may not know themselves well and struggle to find things that they enjoy or are good at, from hobbies to job skills, Hennessy says.

“If you have low self-esteem, you don’t know what you’re worth, what your value is or what’s important to you. You only know what others have told you,” she says. “You most likely don’t have a job that is meaningful to you or relationships with those who value you.”

Vanessa Wells is a licensed mental health counselor and school adjustment counselor for ninth and 10th graders at a charter high school in Salem, Massachusetts. She has past experience working at a residential clinic for clients with eating disorders. She says self-esteem challenges are often an underlying issue for students who come to see her because they are experiencing conflict with peers. This is especially true for individuals who are not (or who feel they are not) being valued or heard in their interactions. This can present as an inability to understand others’ perspectives or opinions without feeling devalued or retaliating in an unkind way.

Wells notes that self-esteem challenges in youth can also manifest as:

• Excessive apologizing
• Cognitive rigidity, inflexibility or perfectionism
• Isolating behaviors (staying home or not engaging
  with peers)
• Camouflaging (taking measures to hide their body, such as wearing overly baggy clothing or arranging their hair to cover their face)
• Negative tones or attitudes about others 
• Self-deprecating statements or humor

Boundaries and self-esteem

Shelby Turner, an LPC who counsels teenage and adult individuals at her solo private practice in the Greenville, South Carolina, area, helps clients work on creating and enforcing both physical and emotional boundaries. She finds this work is most often needed with individuals who struggle with low self-esteem.

Individuals with low self-esteem often agree to or put up with things they don’t like or aren’t comfortable with because they lack confidence or struggle to speak up for themselves. Boundary setting can be a powerful tool for these clients to begin breaking those patterns, Turner says.

For example, a youth who doesn’t like having their hair touched may just go along with this unwanted behavior from peers at school or in social settings. A counselor might help the client learn to voice their preference and set a physical boundary by saying, “I’d prefer a hug or high five, but please don’t touch my hair,” Turner suggests.

Setting an emotional boundary involves identifying ways that others hurt or dominate the client and then finding ways for the client to express their needs and ask for a different behavior. For instance, a counselor and a client might create a plan for the individual to ask their partner not to raise their voice or use insults during arguments. If the partner continues that behavior, the client would end the conversation and continue it only after the partner has de-escalated. If the partner violates the boundary again, the client could respond by leaving the room or otherwise separating themselves from the person, such as by ending a phone call or leaving a text message unanswered.

“I have to educate people a lot to help them see what they deserve, [emphasizing] that boundaries are helpful and OK and healthy, and that it’s OK to say ‘no’ sometimes,” Turner says. “It means ‘I respect myself too much to let you treat me this way.’”

(For more on boundary setting with clients, see the articles “When the behavior of others negatively affects clients’ mental health” and “The sensitivity of boundary setting in collectivist cultures.”)

Values: Getting to the root

The need for acceptance is part of who we are as human beings, Cross notes, so it is only natural for self-esteem to be central to decision-making and behaviors that counselors see in clients. Self-esteem often correlates to messaging and feedback that an individual received at a young age. Over time, those messages can become internalized as values.

“From zero to age 5, our self-worth and values are formed,” Cross notes. “If you grew up with neglect or within a traumatic household, it can affect your sense of self.”

Improving self-esteem then must involve exploring and dismantling unhealthy values and beliefs that clients have internalized — often unbeknownst to them, Cross says.

Turner agrees, citing an example: If a female client heard comments throughout childhood from a parent or other loved ones along the theme of “you need to watch what you eat; you’re getting chubby,” she may come to believe that her worth is based on her weight and clothing size. When messaging comes from people whom the client turned to for love and acceptance as a child, it can be difficult to think in a different way, Turner says.

Turner uses cognitive behavior therapy (CBT) to focus on unhealthy core beliefs that clients have internalized. She refers to these beliefs as “the roots of the tree.” 

“Cognitive distortions are the leaves; you can keep plucking the leaves off, but they’re going to keep growing until you address the root,” she says.

Cross pulls from several methods, including CBT, to explore clients’ beliefs and values “to the core,” she says. The ultimate goal is to have clients move toward self-compassion and acceptance of all the parts of themselves, including their flaws.

If a client makes a comment that reflects a negative self-belief (e.g., “I’m not good enough”), Cross will challenge their statement. She’ll ask, “Think back through your past. When was the first time you felt that way?” She doesn’t expect the client to answer immediately. She often has them think through this question on their own, and then they discuss it together at their next session.

Hennessy also works to guide clients to a place where they can recognize their thoughts without reacting or responding to them. They cultivate the ability to pause and ask themselves, “Where have I heard that before, and is it actually true for me?”

“It takes a lot of time [for clients] to become comfortable with the idea that we can be influenced by things, especially those we aren’t aware of,” Hennessy says. “We are individuals and don’t like the idea of outside things making us feel a certain way.”

Clients who struggle with self-esteem often don’t know what their values are, Hennessy notes. She uses mindfulness techniques to prompt clients to pay attention to their cognitive distortions and how they feel in their body when they discuss subjects such as body image that are tied to internalized beliefs. This technique teaches clients to identify cognitive distortions that are negative and in need of correcting. But it also can help them learn what thoughts and values do feel good so that they can begin to focus and emphasize those aspects in their life and decision-making.

This was the approach that Hennessy took with an adult client who was unhappy at her job as a medical receptionist. Hennessy guided the client to be mindful of how it felt as she thought and talked about which aspects of her job did and did not align with her personal values and traits.

After some introspection, the client discovered that what she hated about the job — and what made the position a mismatch for her — was scheduling tasks and data entry. Because she disliked those aspects, she often made mistakes when entering data, which led to a cycle of feeling bad about the job and herself.

However, what she did enjoy was talking with patients to understand their medical history and connecting them to the appropriate help. This realization led her to seek a position that would align with her values and allow her to engage with people more. She eventually transitioned into a job as a case coordinator.

“She came to realize that she shouldn’t be behind a desk at all,” Hennessy recalls. Not only was she happier and more fulfilled in her new job, but the client’s self-esteem lifted because she finally felt that she was good at something, Hennessy notes.

Wells does values exploration with almost all of the high school students she counsels, most of whom have never been in a therapy setting before. Not only are they unfamiliar with their values, but many do not have the language to express what they are feeling or thinking in
this realm.

Wells uses mindfulness techniques and a number of worksheets and tools to equip them with vocabulary and prompts to identify their core beliefs. This includes a values “card sort” activity that uses a deck of 50 cards, each with a value such as honesty and an explanation of that value. Students arrange the cards into categories based on how important the value is to them (e.g., most important, least important). Wells talks with the students while they sort the cards and prompts them to think about their values by asking questions such as “What decisions might you make in your life based on this value?”

It’s developmentally appropriate for teenagers to struggle with making healthy choices, Wells notes. Values work can be an empowering way for young clients to hone these skills. 

This was the case with one student who had previously done the card sort activity with Wells and identified honesty and friendship as the values that were most important to them. The teenager came to see Wells again after experiencing friction in their friend group. The student had made a conscious decision to tell a lie to “create drama” among her friends, which resulted in relational struggles and negative reactions from her peers, Wells recalls. As a result, the student experienced feelings of guilt and an increase in depressive symptoms. Wells helped the student realize that the decision to lie was incongruent with the values they had originally identified in counseling, and together they brainstormed ways that the student might make different choices in the future. 

Thought patterns and self-talk

The self-talk that people hear is based on their core beliefs, and when those values are unhealthy, they may be bombarded with messages such as “I’m not good enough,” “I’m ugly,” “The rest of the world is the problem,” “I’m unworthy” and other problematic thoughts. It is imperative that counselors help individuals with unhealthy self-esteem to address and repair both their core beliefs and the self-talk that stems from them.

Humans are very good “rehearsers,” Cross notes. We often can’t stop ourselves from rehearsing and hearing in our minds what we assume others will say or feel about us. A large part of the work in counseling often involves “reality checking” these patterns with clients, she says.

Cross advises counselors to gently challenge clients’ negative thought patterns rather than abrasively confronting messages that clients may have internalized and lived with for so long. She once heard a counseling colleague describe this approach as “care-frontation” rather than confrontation. Cross often uses Socratic questioning and CBT to gently “care-front” her clients about their unhealthy thinking. 

For example, a client may express that they’re unhappy at their job. They are anxious and have a low mood, and they hate the thought of going to work. Cross would prompt the client with a question: “What makes you stay at that job?”

The client may respond by expressing fear: “I don’t even know how I got this job,” “I’ll never get another job” or “I don’t feel worthy of another job.”

The client is stuck in a pattern of rigid thinking, and the root is that they don’t feel they are good enough to be in a different situation, Cross says. From here, she would deploy “care-frontation” and challenge their thinking by pointing out past successes.

“You got this job,” Cross would tell the client. “You may feel it was lucky, but is that true? Usually people don’t stumble into jobs — they earn them.”

She finds Socratic questioning can be especially helpful for clients who struggle with cognitive distortions related to self-esteem. She often gives these clients printed questions on a piece of paper or notecard that they can keep with them and refer to when needed. Cross once counseled a client who experienced panic attacks. He kept a list of Socratic questions in his wallet and would pull it out when he began to feel triggered, she recalls.

These types of questions can include:

• What is the evidence for this thought, and what is the evidence against it?
• Am I basing this thought on a fact or a feeling?
• Could I be misinterpreting the evidence or making assumptions?

Turner suggests a first step in counseling clients who struggle with self-esteem may be to introduce them to the idea that their feelings and thought patterns can be challenged or changed. An important aspect of this work, Turner adds, is to help clients learn to respond to their self-talk with accuracy, not necessarily positivity. For example, a client who is hesitant to seek a raise at work may feel that there’s no point in asking because they won’t get the raise and their boss will laugh or think they’re stupid for bringing it up. Instead of making positive statements such as “Oh, that won’t happen,” “You’ll be fine” and “Don’t worry,” a counselor could prompt the client with questions that separate feelings from fact:

• Does my job performance support a raise?
• Has my boss ever laughed at me or called me stupid before?
• Are my co-workers getting raises?
• Is the raise amount I’m asking for reasonable?

“It’s not ‘good vibes only’; it’s thinking accurately,” Turner says. This work is “reframing and learning how to think more accurately, not just more positively.”

Wells agrees, emphasizing that positive affirmations are one tool that is not appropriate for clients who are working on self-esteem in counseling. She urges practitioners to keep their statements and questions as neutral as possible, especially when working with teens.

Perhaps a client mentions a belief with the theme of “everyone hates me” while talking in session. Wells says the counselor could respond neutrally by asking the client to name examples of influences in their life, such as a parent or a loyal pet, who have expressed that they don’t hate the client. She often emphasizes to her young clients that we are “not mind readers” and don’t actually know what others are thinking or feeling about us.

“Trying to do positive affirmations is not helpful in the grand scheme of things because they [clients] won’t believe it. But what they can’t push back against is neutral facts,” Wells stresses.

Instead, Wells uses CBT as well as acceptance and commitment therapy, motivational interviewing, narrative therapy, Socratic questioning and role-playing to talk through and explore clients’ experiences and self-beliefs that influence their thought patterns and behaviors. 

Group work can also be a powerful setting for clients to work on social skills and self-esteem in tandem, Well notes. Sometimes she gives her student groups prompts — such as “What would you do if X scenario happened?” — to role-play together or to write about in their journals at home and discuss at the next group session.

A sense of self

Jon Soileau, an LPC and managing partner at a small private practice in downtown Kansas City, Missouri, estimates that roughly half of his clients enter counseling acknowledging that self-esteem is something they need and want to work on. Soileau counsels from a contemporary psychoanalytical approach. So, self-esteem, as it relates to clients’ ego or sense of self, is central to his work, he says, and many clients seek him out for that reason.

Soileau explains that a person’s sense of self involves their level of comfort with who they are. Self-esteem is just one component of a person’s sense of self, along with their personality traits, moral code, belief systems, likes/dislikes and other aspects that make them unique.

Self-esteem struggles, including lack of confidence, concern over what others think about them, and the inability to process emotions, are often a sign that a client’s sense of self is underdeveloped or “soft,” or that the client is simply unaware or out of touch with it, Soileau says.

He takes a two-part approach — a process he calls “holding and uncovering” — when helping clients to develop and improve their sense of self. In the primary, holding stage, Soileau focuses on listening to the client and remaining curious. He also uses free association to prompt clients to talk about things they are struggling with, their life history and what brought them to counseling. While the client speaks, he invites transference, taking in the many nonverbal cues that the client is expressing in addition to their spoken words. For example, a client’s tone may rise or change when they talk about a certain topic. This provides him with more information and gives him an opportunity to ask for additional details, he says.

“The cognitive pieces are very important, but [so are] the affect in the room and what we can hear, see and feel from the patient,” he says. “I let all the details of what’s going on with the patient wash over me.”

During the second phase of therapy (uncovering), Soileau guides the client to understand and dig into why they feel the way they do. “Rather than targeting self-talk, I focus on what’s influencing the self-talk — the very root of what’s going on,” he says.

Soileau sometimes uses enactment to help clients work through a troubling pattern or scenario with which they are struggling. For example, a client may not do well in romantic relationships but doesn’t understand why. Their relationships typically go well for a while, but they always end badly and the client’s feelings are hurt.

Soileau would invite a similar scenario to happen in counseling so that he could process it with the client. Perhaps the client misses a session and Soileau charges a no-show fee, causing the client to respond in anger — as they do in all their relationships. “From there, we can process it and work through it together,” Soileau says. “In session, I … would allow it [the angry blowup] to happen in a way that’s controlled and healthy.”

This deeper work on the roots of a client’s feelings and patterns should happen only after a strong and trusting therapeutic bond has been established, he says. Delving into these issues before a client is ready can damage the client-counselor relationship and cause the client to stop coming to appointments, he explains.

Soileau takes a relational approach in his work with clients and says this therapeutic connection is central to fostering the level of comfort that clients need to open up and work on their self-esteem and underlying issues. Fostering the therapeutic relationship is a focus “from the first minute I interact with a patient,” he says. “The therapeutic relationship is fundamental. We need to make them feel at home and able to be themselves — their true self — and not the person that they feel they have to be outside of the therapy room.”

Empathy without reassurance

When working with clients who have unhealthy self-esteem, it can be heartbreaking to hear them use statements such as “I’m not worthy” or “I’m not good enough.” Counselors must suppress the urge to respond with reassurance, however.

Clients with low self-esteem often seek reassurance, but at the same time do not fully believe others when they respond positively and contradict the clients’ self-beliefs. Turner says the crux of counseling work in this realm is to break these patterns so that clients can identify their beliefs as inaccurate and something that is within their power to change.

It is a natural human urge to contradict clients when they say something like “I am ugly,” Turner acknowledges. But “rescuing” a client from this thought is both inappropriate (because counselors should not be commenting on a client’s appearance) and subverts the very skills that the client needs to develop on their own.

“My opinion does not matter; my job is to help them do the work,” Turner emphasizes. “I have to remember that it’s not my job to reassure; it’s my job to help that person identify and challenge inaccurate ways of thinking. That goal is not going to be accomplished if I just reassure them that they’re not ugly.”

Hennessy agrees and urges counselors to respond to clients who are seeking advice (which is common among people who second-guess themselves) with more questions, not suggestions. An important part of this is acknowledging and honoring that the client is in the process of making a difficult decision and has made good choices in the past.

Hennessy uses mindfulness to prompt clients to assess how they feel in their body when they think about a tough decision. She might ask the client, “What does your intuition feel like? What does your gut tell you? What does it feel like when you think about doing A versus doing B?” 

“It can feel cold to respond with questions [such as] ‘What do you think about that?’” Hennessy admits. However, clients “have to validate themselves. It doesn’t help them grow to get validation from an external source [the counselor]. … Counselors will have a reflex to reassure and comfort clients, and we have to put our therapy hats on really snug to stop ourselves from doing that.”

Turner says she often reminds clients that “healthy self-esteem is something that we all have to work at; it doesn’t come naturally.”

She also emphasizes to clients that dismantling long-held beliefs requires hard work and repetition. “There’s no quick fix,” she says. Training your brain to learn new thought patterns is like blazing a trail in the woods, Turner asserts. You have to visit it and walk over it repeatedly for it to become established, worn and comfortable. 

Turner also emphasizes that clients are welcome to return to therapy at any point after they conclude their work together. This message is important for all clients, but especially those who struggle with their self-esteem, she says. She stresses to clients that it is normal for struggles to ebb and flow throughout the course of a person’s life and that it is not a sign of failure to seek a “refresher” with a counselor when their current tools and coping techniques are no longer meeting their needs.

“Clients often need to hear things over and over again, [as] we all do,” Turner says. “I have seen people come out of these really deep patterns [cognitive distortions] once they know how to identify them and open their minds to thinking a different way. It opens a world of possibility to realize how negative and inaccurate thinking affects all aspects of our lives.”

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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