Thursday, October 17, 2013

Layers of Thoughts

In CBT, identifying, questioning, and challenging your thoughts is complicated by the fact that a lot of thinking happens below the surface of conscious awareness. In fact, the cognitive model describes layers of cognition that are sometimes compared to the layers on an onion: peeling back the outer layers reveals the layers underneath. Using this metaphor, your conscious thoughts make up the skin on the outside of the onion. These are the thoughts you are most aware of at any particular moment – the thoughts in the forefront of your mind that make up your ongoing stream of consciousness. They include things that you are paying attention to, focusing on, or choosing to think about. 

Just underneath your conscious thoughts is a layer of what are known as “automatic thoughts.” As the name implies, these thoughts happen automatically – without conscious deliberation. They are typically judgments or evaluations, and are generally brief – sometimes only a few words or a mental image. Automatic thoughts happen so quickly that we are barely aware of them; however, they are relatively easy to bring into conscious awareness because they often produce a shift in mood or emotion. You can become aware of your automatic thoughts by noticing changes in how you feel, and asking yourself: “What was just going through my mind?” 

Automatic thoughts, in turn, give us clues about the interior layers of the onion – our intermediate and core beliefs. Beginning in early childhood, we develop beliefs about ourselves, other people, and the world we live in. Some of these beliefs are so fundamental to how we view everything that we see them as absolute truths. We call these "core beliefs." Core beliefs are the basic assumptions that determine to what degree you see yourself as worthy/unworthy, safe/threatened, competent/incompetent, powerful/vulnerable, independent/dependently, and loved/unlovable. They also establish your sense of belonging and how you expect to be treated by others. 

Although we are often not consciously aware of our core beliefs, they have a significant impact on us: situations in daily life activate core beliefs, which then shape our perception and interpretation of the situation. The way that core beliefs influence our perception, interpretation, and response to a situation is through what are called "intermediate beliefs." These include our attitudes, assumptions, and rules. Attitudes are evaluative statements (e.g., "It would be terrible if..."), assumptions tend to be "if...then..." statements, and rules are "should" (or must, or ought) statements. Intermediate beliefs arise from core beliefs, either as logical extensions of them, or as attempts to cope or compensate for what we believe is true, for example: “I am inadequate so I need to work harder than everyone else.” “I am unlovable, so I should expect rejection.” 

Core beliefs can be combined in patterns called “schemas,” along with associated intermediate beliefs, and the emotions, body sensations, and behaviors they produce. Schemas serve as templates for processing and understanding life experiences, filtering incoming information so that we take in information that fits our existing core beliefs, while screening out anything that contradicts our beliefs. Schemas also shape the content of conscious and automatic thoughts. Automatic thoughts, in turn, strengthen and reinforce beliefs: the more you “hear” yourself think something, the more convinced you are that it is true. These processes together make core beliefs difficult to change. However, the time and effort needed to change them has a significant payoff: the resulting changes to intermediate beliefs and automatic thoughts can produce lasting emotional and behavioral benefits.

Wednesday, October 9, 2013

Core Beliefs and Schemas

We all develop beliefs about ourselves, other people, and the world we live in, beginning in early childhood. Some of these beliefs are so fundamental to how we view...everything...that we see them as absolute truths. We call these "core beliefs." Core beliefs are your basic assumptions about your value in the world. Core beliefs determine to what degree you see yourself as worthy, safe, competent, powerful, independent, and loved. They also establish your sense of belonging and basic picture of how you are treated by others.

We may not be consciously aware of our core beliefs - they are kind of like the water fish swim in. However, they have a significant impact (like water does for fish): situations can activate core beliefs, which then shape our perception and interpretation of the situation. In fact, we tend to filter incoming information to accept information that fits the core belief, while discounting anything that contradicts our belief.

The way that core beliefs influence our perception, interpretation, and response to a situation is through what is called "intermediate beliefs." This category includes our attitudes, assumptions, and rules. Attitudes are evaluative statements ("It would be terrible if..."), assumptions tend to be "if...then..." statements, and rules are "shoulds" (or musts, or oughts). These intermediate beliefs arise from core beliefs, either as logical extensions thereof, or as attempts to cope with a painful core belief (often that one is inadequate and/or unlovable): I am inadequate so I need to work harder than everyone else. I am unlovable, so I should expect rejection. Etc.
Both kinds of beliefs shape the content of your thoughts from moment to moment – your internal monologue, or “automatic thoughts.” Automatic thoughts, in turn, strengthen and reinforce your beliefs. For example, when you tell yourself constantly that you’re stupid, you convince yourself that this is true. By the same token, if your self-statements reflect a basic faith in your intelligence, this core belief will be confirmed and solidified.

As you can see, core beliefs are the very foundation of your self-image: they largely dictate what you may and may not do (your rules), how you present yourself (your attitude) and how you interpret events in your world (your assumptions and automatic thoughts). Therefore, holding negative beliefs takes a significant toll on your mood, relationships, and overall functioning. Changing your core beliefs requires time and effort; and yet changing them will fundamentally alter your view of yourself and your environment.
Schemas

Core beliefs are also combined in patterns that are referred to as schemas. Schemas include beliefs about yourself, the future, other people and the world, along with associated intermediate beliefs (now called schema processes), which produce emotions, body sensations, and behaviors. Schemas form templates for processing and interpreting life experiences.

Dr. Young and his colleagues have identified 18 “early maladaptive schemas:” schemas that develop very early in life and can produce distress and difficulties throughout one’s life. Read through their list of schemas and rate how strongly you think each one applies to you, from 0-100%.
Emotional Deprivation
This schema refers to the belief that one’s primary emotional needs will never be met by others. These needs can be described in three categories: Nurturance – needs for affection, closeness and love; Empathy – needs to be listened to and understood; and Protection – needs for advice, guidance and direction. Generally parents were cold or removed and didn’t consistently care for the child in ways that would adequately meet the above needs.

Abandonment/Instability
This schema refers to the expectation that one will soon lose anyone with whom an emotional attachment is formed. The person believes that, one way or another, close relationships will end imminently. As children, they may have experienced the divorce or death of parents. This schema can also arise when parents have been inconsistent in attending to the child’s needs; for instance, there may have been frequent occasions on which the child was left alone or unattended to for extended periods.

Mistrust/Abuse
This schema refers to the expectation that others will intentionally take advantage in some way. People with this schema expect others to hurt, cheat, or put them down. They often think in terms of attacking first or getting revenge afterwards. In childhood, these people were often abused or treated unfairly by parents, siblings, or peers.

Defectiveness/Shame
This schema refers to the belief that one is internally flawed, and that, if others get close, they will realize this and withdraw from the relationship. This feeling of being flawed and inadequate often leads to a strong sense of shame. Generally parents were very critical and made them feel as if they were not worthy of being loved.

Social Isolation/Alienation
This schema refers to the belief that one is isolated from the world, different from other people, and/or not part of any community. This belief is usually caused by early experiences in which children see that either they, or their families, are different from other people.

Dependence/Incompetence
This schema refers to the belief that one is not capable of handling day-to-day responsibilities competently and independently. People with this schema often rely on others excessively for help in areas such as decision-making and initiating new tasks. Generally, parents did not encourage children to act independently and develop confidence in their ability to take care of themselves.

Vulnerability to Harm and Illness
This schema refers to the belief that one is always on the verge of experiencing a major catastrophe (financial, natural, medical, criminal, etc.). It may lead to taking excessive precautions to protect oneself. Usually there was an extremely fearful parent who passed on the idea that the world is a dangerous place.

Enmeshment/Undeveloped Self
This schema refers to a pattern in which a person experiences too much emotional involvement with others – usually parents or romantic partners. It may also include the sense that one has too little individual identity or inner direction, causing a feeling of emptiness or of floundering. This schema is often brought on by parents who are so controlling, abusive, or overprotective that the child is discouraged from developing a separate sense of self.

Failure
This schema refers to the belief that one is incapable of performing as well as one’s peers in areas such as career, school or sports. These clients may feel stupid, inept or untalented. People with this schema often do not try to achieve because they believe that they will fail. This schema may develop if children are put down and treated as if they are a failure in school and other spheres of accomplishment. Usually the parents did not give enough support, discipline, and encouragement for the child to persist and succeed in areas of achievement, such as schoolwork or sport.

Subjugation
This schema refers to the belief that one must submit to the control of others in order to avoid negative consequences. Often these people fear that, unless they submit, others will get angry or reject them. They therefore ignore their own desires and feelings. In childhood there was generally a very controlling parent.

Self-Sacrifice
This schema refers to the excessive sacrifice of one’s own needs in order to help others. When these people pay attention to their own needs, they often feel guilty. To avoid this guilt, they put others’ needs ahead of their own. Often people who self-sacrifice gain a feeling of increased self-esteem or a sense of meaning from helping others. In childhood the person may have been made to feel overly responsible for the wellbeing of one or both parents.

Emotional Inhibition
This schema refers to the belief that one must suppress spontaneous emotions and impulses, especially anger, because any expression of feelings would harm others or lead to loss of self-esteem, embarrassment, retaliation or abandonment. These people may lack spontaneity, or be viewed as uptight. This schema is often brought on by parents who discourage the expression of feelings.

Approval-Seeking/Recognition-Seeking

This schema refers to the placing of too much emphasis on gaining the approval and recognition of others at the expense of one’s genuine needs and sense of self. It can also include excessive emphasis on status and appearance as a means of gaining recognition and approval. People with this schema are generally extremely sensitive to rejections by others and try hard to fit in. Usually they did not have their needs for unconditional love and acceptance met by their parents in their early years.

Unrelenting Standards/Hyper-criticalness

This schema refers to the belief that whatever you do is not good enough, that you must always strive harder. The motivation for this belief is the desire to meet extremely high internal demands for competence, usually to avoid internal criticism. People with this schema show impairments in important life areas, such as health, pleasure or self-esteem. Usually these clients’ parents were never satisfied and gave their children love that was conditional on outstanding achievement.

Entitlement/Grandiosity
This schema refers to the belief that one should be able to do, say, or have whatever one wants immediately, regardless of whether that hurts others or seems reasonable to them. These people are not interested in what other people need, nor are they aware of the long-term costs of alienating others. Parents who overindulge their children and who do not set limits about what is socially appropriate may foster the development of this schema. Alternatively, some children develop this schema to compensate for feelings of emotional deprivation or defectiveness.

Insufficient Self-Control/Self-Discipline

This schema refers to the inability to tolerate any frustration in reaching one’s goals, as well as an inability to restrain expression of one’s impulses or feelings. When lack of self-control is extreme, it may lead to criminal or addictive behaviors. Parents who did not model self-control, or who did not adequately discipline their children, may predispose them to this schema as adults.

Negativity/Pessimism

This schema refers to a pervasive pattern of focusing on the negative aspects of life while minimizing the positive aspects. Clients with this schema are unable to enjoy things that are going well in their lives because they are so concerned with negative details or potential future problems. They worry about possible failures no matter how well things are going for them. Usually these people had a parent who worried excessively.

Punitiveness

This schema refers to the belief that people deserve to be harshly punished for making mistakes. People with this schema are critical and unforgiving of both themselves and others. They tend to be angry about imperfect behaviors much of the time. In childhood these clients usually had at least one parent who put too much emphasis on performance and had a punitive style of controlling behavior.

Based on:

Thursday, September 12, 2013

The Therapeutic Paradox of Self-Invalidation

If validation is one of the core skills for fostering a therapeutic alliance, it may be even more important for clients who grew up in an invalidating environment, may have little prior experience of validation, and habitually invalidate themselves. However, it's also important to consider and plan for how a particular client is likely to experience and react to validation. Some respond positively: validation improves rapport, diffuses pain, and over time helps clients become better able to self-validate and self-regulate. Others find validation itself to be distressing.

While such a reaction may seem counterintuitive, it makes sense in the context of the client's experience. For someone who has been chronically invalidated, the experience of validation is foreign and uncomfortable. The client may feel thrown off balance by the unexpected response.

At a more complex level, a client who habitually self-invalidates may find validation itself...invalidating. This presents quite the therapeutic paradox: I can validate my client's experience, which invalidates their self-invalidation of that experience; or I can validate the self-invalidation, which invalidates the experience.

Both of these options are likely to dysregulate the client. Perhaps this is why clients with Borderline Personality Disorder are so often labeled "difficult clients." However, that's also invalidating of the genuine and understandable distress these clients experience living inside this paradox day in and day out.

The challenge for therapists is to find a way to lessen a client's suffering by gradually lessening the internal dissonance of self-invalidation - which happens in part through the experience of validation. How, then, can we make validation less invalidating?

I believe the answer is that validation itself must be dialectical. We need to name and reflect both the client's initial internal experience, and their self-invalidation of this experience. In this way, by simultaneously validating the experience of invalidation, and the experience that is invalidated, the client may finally be able to experience genuine validation.

Monday, August 26, 2013

Two Kinds of Supervision

Supervision is at the heart of teaching and learning how to be a mental health professional. Therapy brings about change through a special kind of "helping" relationship, and we learn to foster and harness that kind of relationship through our relationships with supervisors.

We all receive supervision throughout our training, in graduate school, and leading up to licensure. However, ethical guidelines require that we continue to make use of supervision - or consultation, supervision's less hierarchical cousin - throughout our careers. Unfortunately, not all agencies that employ mental health professionals make supervision a priority, and not all supervision is created equal.

Indeed, there are two main categories of supervision that professionals receive once they have graduate and are out in the field:

1) Administrative Supervision

Administrative supervision is perhaps the most readily-available kind of supervision. It focuses on ensuring that workers are meeting requisite standards and following established protocols. An administrative supervisor is concerned with how programs are operating, whether workers are showing up on time, presenting themselves professionally, and completing all the paperwork needed to keep the agency in business. Administrative supervisors are also typically responsible for things like performance evaluations.

2) Clinical Supervision

Clinical supervision is what most of us think of when we think about supervision. This is the kind of supervision that focuses on the clinical work: how we understand what is going on for our clients, how we can connect with and help them, and what might be getting in the way. It helps us recognize and think about what may be going on underneath the surface of our clinical encounters. It gives us a place to express our own feelings, identify our own biases and issues that may be triggered in our work, so that these things don't "leak out" when we're with a client. It may help us recognize a need for more self-care, or our own therapy. It helps us develop a deeper understanding of theory and practice so that we can intervene more skillfully.

Most agencies provide administrative supervision as a matter of course. Whoever is your "boss" is probably technically providing administrative supervision. When licensed supervisors are available, many agencies will provide clinical supervision for employees working toward licensure. After all, agencies typically benefit from this arrangement, both because they are more competitive when vying for the best new graduates, and because they stand to receive added reimbursement for services provided by licensed professionals. Of course, there is not always a supervisor available who has the kind of license an employee needs for their own licensure. When this happens, the employee may be able to negotiate with their employer for an appropriate supervisor to be found in another program, department, or even outside the agency. However, sometimes it is necessary for newer graduates to find and pay for their own outside clinical supervision.

Logistically, it is easiest when your administrative supervisor (your "boss") also provides clinical supervision. Practically, however, this is not always possible...or even desirable. It may be that your boss has a different kind of license than you need, or that the agency does not prioritize clinical supervision, or that your boss's area of expertise is not quite what you need. You may have reservations about revealing difficulties to the person who will be completing your performance evaluation. Or you may benefit from the perspective of someone who has a little more distance from the program or agency setting.

I was grateful in my early years of practice to have a clinical supervisor who was removed from the program where I worked, who could stand outside the politics, and who was supportive of me, rather than another agenda. I left a different job because my supervisor took expression of emotion during supervision as a reflection of my sessions with clients, rather than as a healthy way of ensuring my emotions did not enter into my work with clients. Currently, I have a supervisor who is better able to blend administrative and clinical. Thus, my experience suggests that much depends on the supervisor, and the setting.

What has your experience been? How have you experienced supervision at its best and at its worst? How have administrative and clinical supervision been combined or separated for you? What recommendations would you make to agencies and the profession as a whole?

Friday, August 2, 2013

Cutting Does NOT Make You "Borderline:" Understanding Non-Suicidal Self-Injury

All too many clinicians (and sometimes the general public) hold stereotyped and inaccurate assumptions about self-injury, based on outdated "clinical data." In particular, there are some who automatically assume anyone who "cuts" has Borderline Personality Disorder (BPD) - arguably the most stigmatized diagnosis among mental health professionals. It's time to set the record straight about self-harm.

Non-suicidal self-injury is defined as intentional tissue damage that:

  1. does not have suicidal intent (in other words, self-injury, by definition, is not a suicide attempt or suicidal gesture; however, if the self-injury is serious enough, it can lead to accidental death.
  2. is not culturally-sanctioned (in other words, tattoos, piercings, ritual scarring in certain cultures, and things like that aren't included). 

Forms of self-injury are wide-ranging, and include scratching, cutting, skin-picking, hair-pulling, burning, bruising, even breaking bones.

Several decades ago, self-injury was pretty much only seen in individuals with serious mental illnesses, including BPD and psychosis. That was then. This is now: it is estimated that 20% of all adolescents and young adults will at some point engage in self-injury, and the number has been rising. In fact, a study by Cornell Research Program on Self-Injurious Behavior found that almost half of college students who self-injure do not have a diagnosable mental disorder. Those who do have a mental health condition are in fact most likely to have eating disorders, but self-injury is also seen in conjunction with anxiety disorders, depression, bipolar, substance abuse, and PTSD. More severe (e.g., deeper) and more frequent injury may be linked to more serious mental illness, and to later suicide attempts, in contrast to infrequent and/or superficial injury, which does not have the same links.

It's also often assumed that only females self-injure. While it is true that females report more self-injury than males, about 30-40% of those who self-injure are male. The actual numbers may be even more balanced than that, however, because male self-harm is more likely to outwardly resemble externally-focused aggression. Boys and men are more likely to fight, punch or kick things, etc., as an intentional form of self-injury, seeking to bruise or break something. Males are also more likely to begin self-injuring through a group or social context (i.e., where multiple boys or men self-injure together).

Self-injury functions as a coping mechanism, in a way similar to substance use and other addictive behaviors: it releases endorphins that reduce physiological arousal. In other words, it mitigates feelings of agitation or distress, and helps people calm down and feel better. It can also give people a sense of control, and means of expressing intense emotions. For people with trauma histories, it can be grounding.

Treatment, then, focuses on developing healthier coping skills to regulate emotions, tolerate distress, express feelings effectively, experience control and mastery, and ground oneself. At the same time, once self-injury has become a habit, managing urges and thoughts about injuring without injuring are crucial skills. Dialectical Behavioral Therapy, Acceptance and Commitment Family, and other mindfulness-based approaches, sometimes in conjuction with Motivational Interviewing and/or Cognitive Behavioral Therapy, are promising approaches to treatment and recovery.

However, none of these approaches can be effective if people don't engage in treatment - something that can be strongly influenced by their initial interactions with professionals. Responses that are biased and stigmatizing are only likely to drive people away from treatment, and back to self-injury. In contrast, a non-judgmental, empathic approach characterized by unconditional positive regard (i.e., Rogers' "facilitative conditions") opens the door - literally and metaphorically - for people who self-injure to engage in treatment and move forward into recovery.


Monday, July 22, 2013

Breadth or Depth?

Working at a partial hospital program, I spend time thinking about program development - specifically, how to best structure a psychoeducational curriculum. Since we opened 18 months ago, we've generally organized the weekly schedule on what I'll call a "breadth" model. Groups are generally offered once a week. Each group tends to go through a rotation of material, and may build on what is covered in previous weeks, but don't typically tie into other groups happening in the same week.

Since the length of stay in partial is relatively short (3-4 weeks is average, but some patients can be there much longer, or leave right away), and admissions and discharges happen on a rolling basis, the population is always in flux. In practice, that means it's hard to build upon previous weeks. If groups do build on a prior week's group, it's necessary to start with a recap for those who weren't present for the prior group. Each group session has to function, in some respects as a stand-alone, single-session intervention.

The primary rationale for the breadth model is to provide clients with a range of basic information and coping skills. Since not every skill works for every client, nor in every situation, it is hoped that a breadth of options will allow everyone will find something beneficial.

Recently, however, we've been thinking about a different approach, which I'll call a "depth" model. In contrast to the breadth model, the depth model would include sequences of groups that build on each other within the same week, focusing in depth on a particular skill before moving on to a new skill. There would still be some breadth (not every group in the week would address the same topic - that would be overkill!), but not to the same degree.

The rationale for the depth model is that coping skills are skills, requiring practice and repetition to reach the point of truly being useful. Providing only a superficial overview of a skill may not make it accessible to clients, and if a client does try to use a skill to cope, the skill may not be well-developed enough to be helpful. The client may then reach the unfortunate conclusion that the skill "doesn't work" (and maybe none of them work!).

DBT can serve as a useful illustration of breadth vs. depth. DBT includes four skill modules (mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance). The breadth model would be to have one group each week for each module, and cover the material in each module sequentially over several weeks. Thus, a client would be exposed to all four modules and would learn some, but likely not all, of the material from all of the modules. In contrast, the depth model would devote all four weekly groups to the same module until all of the material has been covered, and then move on to the next module. A client would likely learn most or all of the information in at least one module, but may only learn about one or two modules during the length of their stay.

So, what do you think: is it better to focus on breadth or depth? Is it better for clients at this level of care to be introduced to a wider range of possible skills (and perhaps learn more in individual or outpatient therapy about the particular skills they find helpful), or to become more comfortable and skillful at one or two skills (which may not be the most useful to them, or may leave them without skills for some situations they face)?


Saturday, July 20, 2013

3 Steps to Improving Self-Esteem

Part of developing self-esteem is reframing and restructuring negative thoughts and beliefs about ourselves. However, at the same time, it's important to increase our awareness and attention to positive things about ourselves - to not only decrease negative thoughts and beliefs, but also to actually increase positive thoughts and beliefs.

This can be pretty challenging for people who have low self-esteem, because our minds naturally filter information through our existing beliefs and expectations. If we have negative beliefs and expectations, we are likely to notice and remember everything that might support these beliefs and expectations, but we probably don't even notice all the things that contradict our negative beliefs and expectations. In other words, the positive things exist, but we may not see them because we don't expect them to be there!

To help you become more aware of your positive aspects, follow these three steps:

Step 1: Make a List of Positive Qualities

Because it's hard to notice the positives, it is important to start writing them down. This first step is the most difficult of the three. Make a list of positive aspects of yourself, including all your good characteristics, strengths, talents, and achievements. Set aside a specific time to do this, and write the list somewhere you will be able to find it again.

Write as many positive things about yourself as you can think of…there is no limit. Include everything no matter how small, insignificant, modest, or unimportant they are! Exhaust all avenues and brainstorm as many ideas as possible (there are some suggestions below to help). If you run out of ideas, take a break. Come back to it over the course of a few days, until you have a substantial list of your positives.

Some questions that might help you come up with things include:
  • What do I like about who I am?
  • What characteristics do I have that are positive?
  • What are some of my achievements?
  • What are some challenges I have overcome?
  • What are some skills or talents that I have?
  • What do others say they like about me? What do people say my strengths are?
  • What are some attributes I like in others that I also have in common with?
  • If someone shared my identical characteristics, what would I admire in them?
  • How might someone who cared about me describe me?
  • What do I think are bad qualities? What bad qualities do I not have?
Enlist the help of a trusted friend or family member – someone you know would be supportive of you doing this, rather than someone who may be critical or contribute to lowering your self-esteem. Two heads are better than one and an outsider might have a more objective perspective of you than you do of yourself. Who knows what nice things you might discover about yourself with their help?

Watch out for negative self-evaluations or discounting positives as “small” or “no big deal” or “not worth writing.” You tend to remember detailed negative things about yourself, therefore do the same with the positives – it is only fair! Also remember, you don’t have to do these positive things absolutely perfectly or 100% of the time – that is impossible. So be realistic about what you write down - something that you generally are or do is a true positive, even though there will always be exceptions to any positive - for all of us!

Once you have a list, re-read the things you write, over and over. Reflect on what you have written - and resist critical or doubtful thoughts about it. Let the positive qualities pile up and ‘sink in.’ This is important so that you learn to notice these things and feel more comfortable acknowledging them, rather than just giving them lip-service.

Step 2: Identify Past Examples of Your Positive Qualities

Once you have a list of your positive qualities, the next step is to recall specific examples of how you have demonstrated each of the positive attributes you listed. Fold a piece of paper in half. On the left, write the first item on your positive qualities list. On the right, list as many examples as you can come up with to provide evidence of that positive quality. Consider events, experiences, successes, achievements, feedback you've gotten, etc., both recently and throughout your life up to this point.

Leave plenty of space to add examples as you remember them, then move on to the second item on your list, and so on, until you have examples for each of your positive qualities. By doing so, you will make each attribute more than just meaningless words on a page. Instead, each attribute will become a real, specific, and detailed memory of something that actually happened. In the process, you may also recognize additional positive qualities that your examples suggest. Add those to your first list, too!

This process will take some time, but is worth the effort. Remembering specific incidents that illustrate your positive qualities will allow the list to have an impact on your self-esteem.

Step 3: Notice Examples of Positive As They Happen

After spending time recalling past examples of your positive qualities, it's time to recognize examples of your positive attributes on a daily basis. This should be an ongoing exercise – something to do every day. Each day, try to record three examples from your day that illustrate certain positive qualities you have. Write exactly what you did and identify what positive attribute it shows in you. Start with noticing three a day if you can (you can always start with fewer if necessary), but try to build from there, increasing it to 4, or 5 or 6. By doing this, you will not only be acknowledging your positive qualities as things you did in the past, but also acknowledging them as things you are every day. 


This process will take time. Don't try to rush through it. Instead, give yourself time to actually experience and come to believe the things you are writing down. Over time, taking these steps will help you develop a positive self-image that is connected to your past, embedded in the present, and carries forward into the future.