Clinical Case Studies

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A Cognitive-Behavioral Approach to the Enhancement of Self-Esteem in a Patient Suffering Chronic

Bipolar Disorder
Pauline L. Hall and Nicholas Tarrier
Clinical Case Studies 2005; 4; 263
DOI: 10.1177/1534650103259695
The online version of this article can be found at:
http://ccs.sagepub.com/cgi/content/abstract/4/3/263

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CLINICAL
10.1177/1534650103259695
Hall,
TarrierCASE
/ COGNITIVE-BEHAVIORAL
STUDIES / July 2005
APPROACH

A Cognitive-Behavioral Approach to the

Enhancement of Self-Esteem in a Patient
Suffering Chronic Bipolar Disorder
PAULINE L. HALL
University of Lancaster

NICHOLAS TARRIER
University of Manchester

Abstract: This report describes a novel cognitive-behavioral intervention aimed to increase

self-esteem, in a lady with a diagnosis of bipolar illness. It is argued that self-esteem is important to the development, maintenance, and relapse of the illness symptoms, being both a
vulnerability factor to, and a consequence of, illness episodes. The intervention involves
modification of the strength of positive beliefs about the self through the focus of attention
on specific behavioral examples of the patients positive attributes. The intervention is
described in detail and results over the longer term are reported. There were significant
improvements on measures of self-esteem, which was in the normal range at posttreatment
and follow-up. General psychotic psychopathology improved by 20% and there was an
improvement in social functioning over one standard deviation. Results at 3- and 12-month
follow-ups indicate that improvements were largely maintained although there was some
reduction in the magnitude of improvement.
Keywords: self-esteem; bipolar disorder; cognitive-behavior therapy

THEORETICAL AND RESEARCH BASIS

The impact of bipolar disorder on an individuals social and occupational functioning has been well documented in the literature. Coryell, Scheftner, Keller,
Endicott, and Klerman (1993) found that over 50% of bipolar patients experienced a
decline in occupational functioning in the 5 years following an illness episode. Gitlin,
Swendsen, Heller, and Hammen (1995) reported poor occupational and social outcomes in around 35% of individuals with bipolar illness over a similar follow-up period.
Other possible consequences of the illness have been found to include divorce and sepaAUTHORS NOTE: Correspondence concerning this article should be addressed to Professor N. Tarrier, Academic
Division of Clinical Psychology, School of Psychiatry and Behavioral Science, University of Manchester, Wythenshawe
Hospital, Manchester M23 9LT, United Kingdom; phone: (161) 291 5881; e-mail: nicholas.tarrier@man.ac.uk.
CLINICAL CASE STUDIES, Vol. 4 No. 3, July 2005 263-276
DOI: 10.1177/1534650103259695
2005 Sage Publications

263

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CLINICAL CASE STUDIES / July 2005

ration, legal problems, sexual risk-taking behaviors, and drug and alcohol abuse (Coryell
et al., 1993; Reinares, Colom, Martinez-Aran, & Vieta, 2002; Silverstone & RomansClarkson, 1989). The risk of suicide in bipolar patients is also high, 10% - 15%
(American Psychiatric Association, 1994).
In bipolar disorder, relapse is common, and therefore controlling the illness is of
great importance. This is especially significant as with each illness episode there is an
increased likelihood of future relapse (Coryell et al., 1995; Goodwin & Jamison, 1990).
Pharmacological approaches remain the first-line treatment for people with bipolar illness. There is evidence that supports the effectiveness of medication such as lithium carbonate (Silverstone & Romans-Clarkson, 1989); however, noncompliance rates are
high and this is one of the most important factors in determining relapse (Jamison &
Akishal, 1983). Of those who do not relapse, between 46% and 56% continue to experience periods of moderate manic or depressive symptoms (Gitlin et al., 1995; Harrow,
Goldberg, Grossman, & Meltzer, 1990). Moreover, relapse may occur in individuals
who remain compliant with pharmacological interventions. As many as 40% in 1 year
and 60% in 2 years were found to relapse despite adhering to prescribed medication
regimes (Miklowitz & Goldstein, 1997). Such observations have encouraged interest in
the treatment of bipolar illness using psychological therapies as adjuncts to medication.
A psychological treatment that has been found to be effective with various types of
mental disorders is cognitive behavior therapy (CBT). The perspective that our behavior
and actions are influenced by the way in which we perceive and interpret the world
underlies the cognitive model of psychopathology (Beck, Rush, Shaw, & Emery, 1979).
Cognitive-behavioral approaches in the treatment of psychological problems have been
supported by a vast array of clinical observations and empirical findings. However, studies to evaluate efficacy of CBT in the treatment of bipolar disorder are sparse. Of the few
studies conducted, a randomized controlled trial by Cochran (1984) evaluated a cognitivebehavioral intervention, which aimed to modify specific cognitions and behaviors that were
hypothesized to interfere with medication adherence and was successful in its aim to
improve medication compliance. More recently, in a review based on opinions of
respected clinicians, descriptive studies, and reports of expert committees by Parikh et al.
(1997), it was concluded that there was at this time fair support for the intervention to
be considered in clinical practice. Although much work still needs to be conducted to
establish whether CBT is efficacious for individuals with bipolar disorder, existing data
provide the foundations necessary for future development.
One area that generally has been well documented but not yet directly applied to
bipolar illness is the relationship between low self-esteem and mental health problems.
There is evidence to suggest that low self-esteem may be involved in a wide range of psychiatric conditions (Silverstone, 1991) and that self-esteem is significantly related to a
number of clinical disorders, particularly anxiety and depression (Freeman et al., 1998).
Self-esteem refers to evaluation that an individual makes regarding himself or herself; it

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reflects ones sense of individual competence and personal worth in dealing with the
challenges of life (Mruk, 1995). Fennel (2000) states that self-esteem is developed from
core beliefs about oneself. Negative beliefs about the self therefore form the essence of
low self-esteem. Research has shown that low self-esteem (lasting negative beliefs about
the self) may contribute to a range of difficulties, including depression, suicidal thinking,
eating disorders, and social anxiety (Fennel, 2000). Therefore, low self-esteem, rather
than solely being a consequence of mental disorder, may represent in itself a longstanding vulnerability factor for development of other problems: for example,
depression (Brown, Andrews, Harris, Adler, & Bridge, 1986) and seasonal affective
disorder (McCarthy, Tarrier, & Gregg, 2002).
McKay and Fanning (1992) propose that the relationship between self-esteem and
circumstances is most appropriately conceptualized as only indirectly related and the
intervening factor that determines self-esteem is the cognitive interpretation of events.
CBT may therefore offer an ideal approach for working with low self-esteem. As CBT
focuses on thoughts, beliefs, attitudes, and opinions, a persons opinion of himself or herself may lie at the heart of self-esteem. CBT provides a framework for understanding
development and maintenance of psychological problems. In low self-esteem, the cognitive representation of the self is assumed to be characterized by central negative characteristics. It is also suggested to be habitual and automatic and involve underestimations of strengths and qualities and overestimations of weaknesses and flaws. In terms of
self-esteem, Fennel (1998) conceptualizes low self-esteem as lying on a continuum. It is
suggested that for acute conditions, the patient may be helped to access an already existing positive and realistic self-view. However, for chronic conditions, the patient will
require help to create a more positive self-view. Fennel suggests that the latter will be
more difficult and time-consuming (Fennel, 1997).
Techniques suggested to overcome low self-esteem include cognitive restructuring
and identifying distortions and strengths, which gives rise to accurate self-assessment
(McKay & Fanning, 1992). Interventions that are derived from cognitive therapy for anxiety and depression and schema-focused work are also described by Fennel (1997, 1998)
as appropriate for use with low self-esteem. They include anxiety management, behavioral experiments (e.g., dropping of safety behaviors), and thought challenging.
Thus, a review of the literature generally presents a consistent finding that low selfesteem in individuals with psychosis is common (e.g., Bradshaw & Brekke, 1999). Furthermore, the importance of self-esteem in psychosis may have been previously understated, as there is evidence to show it is significantly related to level of distress as well as a
number of clinical variables, including total symptom severity, anxiety, hopelessness,
and depression (Freeman et al., 1998). As the aim of many cognitive-behavioral techniques is to reduce such measures, it may be that techniques directed toward increasing
self-esteem are multifunctional in that they also decrease corresponding symptom severity and other variables. This is supported by Lecomte et al. (1999), who found that an

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intervention aimed to promote self-esteem gave rise to an increase in the use of active
coping strategies and a decrease in positive symptoms in the experimental group. However, these researchers found no direct effect of the intervention on levels of self-esteem.
They concluded that this may have been due to a problem with the measure they used to
assess self-esteem. The Rosenberg Scale (Rosenberg, 1965) used in this study may have
been insensitive for the measurement of self-esteem in a schizophrenic population.
However, the intervention used by Lecomte et al. was adapted from Reasoners (1992)
Building Self-Esteem module, which was originally intended for use with normal
schoolchildren. Therefore, it may have been the intervention itself that was inappropriate
for use with individuals with psychosis.
In a clinical trial of CBT for psychosis carried out by Kuipers et al. (1997), the Self
Concept Questionnaire (Robson, 1989) was administered to measure self-esteem at
baseline and at the 9-month follow-up. However, the CBT intervention failed to show
improvement on this and several other outcome measures (e.g., social functioning). It
therefore appears that existing treatment interventions are inadequate, indirect, and
equivocal in terms of effects on low self-esteem. It is clear that the development of a simple and effective treatment relevant to individuals with low self-esteem and psychosis
would yield considerable benefits for patients as well as organizational resources.
The use of a simple, time-limited, cognitive-behavioral technique to promote feelings of self-worth in the treatment of psychotic symptoms is described in a case report by
Tarrier (2001) with anecdotal positive results. The technique has also been evaluated in
a pilot project by Hall and Tarrier (in press 2003) with encouraging results.

CASE INTRODUCTION

This report shall describe the background, treatment, and outcome of the cognitivebehavioral intervention for low self-esteem with a 52-year-old woman with a diagnosis of
bipolar affective disorder. For reasons of confidentiality, the client will be referred to as
A.P.

PRESENTING COMPLAINTS

A.P. had not complained of low self-esteem as a problem until directly asked for the
purpose of the research. The admission to hospital was precipitated by psychotic
symptoms and poor self-care. On admission, A.P. shouted negative and derogatory
self-statements in the corridor of the ward. She was extremely distressed and would
spend days isolated lying on her bed.

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267

HISTORY

A.P. had a long history of severe mental illness dating back more than 20 years.
During her first depressive episode, she had killed her baby while suffering psychotic
symptoms. She also made two serious suicide attempts. There is no record of any criminal prosecution case made against A.P. but she was detained in hospital following the
infanticide. Because this time she has had numerous involuntary admissions to hospital
under sections of the Mental Health Act (1983), treatment had included electroconvulsive therapy (ECT) and different types of pharmacotherapy, including various
neuroleptics and mood-stabilizing medications.
A.P. has been divorced twice and now lives alone in a council house. She has an
adult daughter who is deaf and severely handicapped. Prior to her last hospital admission, her daughter lived at home and she cared for her with help from local social services. Her daughter was placed in residential care when A.P. was admitted to hospital. In
view of the previous infanticide, social services had always monitored the situation with
regards to risk factors for her daughters safety; however, this was less of an issue now that
she was an adult.
A.P.s illness history is characterized mainly by depressive episodes with psychotic
features. She had experienced episodes of paranoid thoughts when she believed her
neighbors knew all about the past and she was reluctant to go out because she felt persecuted. A.P. felt extreme guilt at having killed her child. When psychotic, she would
shout that she was evil and deserved to be punished. It seemed that the guilt had affected
her considerably to manifest in a negative self-concept. Even when well, A.P. never
spontaneously talked about herself in a positive manner at all.

ASSESSMENT

A wide range of assessments was administered to A.P. at baseline, postintervention,

and at 3- and 12-month follow-ups. All assessment scales have acceptable psychometric
properties of reliability and validity. Most of the scales were self-administered questionnaires. In the case of interviews, assessments were conducted by one of the authors (PH)
and checked for objectivity by an independent rater from audiotapes of the interview.
The assessments used were as follows.
The Self Concept Questionnaire (SCQ) (Robson, 1989). This is a 30-item selfadministered questionnaire for measuring self-esteem. The scale provides a composite
measure of self-esteem based on the dimensions of self-worth and significance, attractiveness, competence, and ability to satisfy aspirations. A score above 132 is regarded as
within the normal range. The mean score in a nonclinical population is 137.

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CLINICAL CASE STUDIES / July 2005

The Hospital Anxiety and Depression (HAD) Scale (Zigmond & Snaith, 1983).
This scale consists of 7 alternate items for measuring anxiety and 7 for depression. The
maximum score is 21 for both anxiety and depression. Scores below 8 are considered
within the nonclinical range.
The Positive and Negative Syndrome Scale (PANSS) (Kay, Fiszbein, & Opler,
1987). This is a measure of psychotic symptoms and consists of 30 items and is administered as a semistructured interview. The PANSS is composed of three subscales, which
consist of items to measure positive symptoms such as hallucinations, conceptual disorganization, excitement and grandiosity, and negative symptoms such as passive/apathetic social withdrawal. The third subscale measures general psychopathology (e.g.,
depression, anxiety, poor impulse control, guilt). All items are scored between 1 (symptom not present) and 7 (symptom severe). The three subscales are combined to provide a
total score.
The Social Functioning Scale (SFS) (Birchwood, Smith, Cochrane, Wetton, &
Copestake, 1990). This is designed to assess various aspects of social performance, which
is summarized as a total score and is administered as an informal interview. The scale has
been standardized on a population of chronic schizophrenic patients living in the community so that a population mean score is 100, with a standard deviation of 15.
A self-constructed questionnaire was also administered postintervention to assess
satisfaction with the intervention and subjective effects.

CASE CONCEPTUALIZATION

The conceptualization was based on a case formulation (for a discussion of case

formulations, see Tarrier & Calam, 2002) in which self-esteem is hypothesized to have
an iterative association with life experiences and psychosis (see Figure 1). Thus, selfesteem had a central role to play, both as an antecedent and as a consequence, in the
development, maintenance, and relapse of A.P.s bipolar illness. Lowered self-esteem
following exposure to adverse experience in early life, in combination with a biological
vulnerability to develop bipolar disorder, had led to an increased vulnerability for A.P. to
develop other problems, such as repetitive psychosis, depression, hopelessness, and suicidal ideation. The traumatic life events of infanticide and divorce, which then followed
the onset of her illness, served to strengthen feelings of low self-worth and perceived selfvalue. A.P. was also referred for medical assistance because of being overweight. This
factor again acted as reinforcement for her low self-esteem.
When A.P. began to struggle to look after her daughter at home with recurrence of
psychotic symptoms, this led to a vicious cycle of negative thoughts, feelings, and behaviors. This appeared evident in the negative and derogatory content of A.P.s psychotic

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269

LOW SELF-ESTEEM
Resulting from early adverse life experience

Life experiences
Onset of psychotic illness
Killed baby
Breakdown of marriages
Struggled with weight

LOW SELF-ESTEEM

Critical Incident
Recurrence of psychotic symptoms
Unable to cope with looking after daughter

LOW SELF-ESTEEM

Thoughts
Im no good
Im evil
Everybody knows my past

Feelings
Hopelessness
Guilt
Paranoia

Behaviors
Withdrawal
Social avoidance
Self declaration

LOW SELF-ESTEEM
Figure 1. Case Conceptualization: The Effect of Life Experience and Chronic Psychotic Illness on
Self-Esteem

self-statements on admission to the ward. As with most, if not all, psychotic ideation,
there was a rational link to reality; the psychotic statements often had relevance to the
infanticide and associated beliefs of being evil. Therefore, it may be that negative self-

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CLINICAL CASE STUDIES / July 2005

worth and untreated low self-esteem were iterative with the illness process. In addition to
this, low self-esteem was also a consequence of the overall level of severity of clinical
symptoms. Low self-esteem may therefore have also played a role both as an aggravating
consequence of A.P.s illness and as a persistent vulnerability to the exacerbation of her
symptoms.

COURSE OF TREATMENT AND ASSESSMENT OF PROGRESS

TREATMENT APPROACH

The aim of the intervention was to focus the patients attention on her positive
qualities and to demonstrate if her belief in her having these qualities would increase if
she attended to specific evidence to support the belief. Thus, belief strength was a product of attentional focus, and low self-esteem often resulted from inappropriate focus
rather than from an accurate representation of reality. The intervention as described by
Tarrier (2001) consisted of working with A.P. to identify a total of 10 positive self-attributes.
The intervention consisted of seven sessions of 1-hour duration, with two positive qualities
noted in five of the seven sessions. Following identification of a positive self-attribute,
A.P. was asked to rate how much she believed each quality to be true on a scale of 0 to 100
(0 = not at all true; 100 = completely true). Evidence was collected to support each positive quality. The positive qualities noted were rehearsed by verbal description and mental imagery and the conviction level was rerated. In all cases, the patients rating of her
belief strength increased. Considerable emphasis was placed on the demonstrated fact
that she increased her belief in her possession of a positive attribute if she focused her
attention of collecting evidence in support of that belief. Homework tasks were set to
note further examples of evidence for the attributes. This served the purpose of maintaining positive attentional focus and also increased the chances of reactivity. That is, the
more a person monitors his or her behavior for positive qualities the more probable it is
that he or she will behave in such a way. Examples of the positive qualities noted and supporting evidence are shown in Table 1. Throughout the intervention, A.P. was asked to
reflect on the effect of paying increased attention to specific behaviors and evidence.
Emphasis was placed on the process that self-beliefs change with focus of attention, and
as self-esteem can be affected by beliefs it therefore is amenable to change. A simple
technique to evaluate evidence supporting thoughts was also taught. If A.P. came up
with negative self-evaluations, they were addressed by defining the attribute and evaluating the evidence. Care was taken not to dwell on negative aspects, however, but to turn
the focus to positive ones.
Finally, plans were established for continuing self-therapy on termination of the
intervention. This resulted in a basic idiosyncratic staying well plan, which adhered to
the techniques of the intervention as well as general strategies to help A.P. stay well (e.g.,

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271

TABLE 1

Examples of Positive Qualities and Supporting Evidence

Im determined
I insisted that I needed to see the doctor on Thursday to get my medication
Im determined to stay well
Im determined to stay out of hospital
Im going to the community mental health centerIm determined to keep it up
Im hoping to get involved in a college courseIm interested in history and am determined to use my interest
I try to understand people
I read the notice boards in the hospital
I want to understand different types of mental illness
I try to put other people at their ease by listening to them and answering their questions
I ask people questions to try to understand their point of view
Im thoughtful
Ive helped my elderly neighbors
I used to go down and visit my neighbor
I invited her up for a meal
When I was at the shop, I bought some throat sweets to help someone on the ward with a cold
I sent a letter to my mum because I wanted her to feel good and accept how well Im doing

record and rehearse positive qualities about herself; evaluate the evidence for and
against any negative thoughts; keep taking medication).
EVALUATION

Readministration of measures following the intervention and at follow-up are presented in Table 2. These showed that on the primary outcome of self-esteem, A.P. had
increased from a well-below-average score in the pathological range (85) on the Robson
self-esteem scale to one well above the threshold for the normal range (166). This represented an almost doubling of her score on this measure. In terms of the measures of
psychopathology, her total PANSS score, although not initially high, did show a reduction of 20%. Although there was an absence of any anxiety or depression, most notably
there had been an improvement in her level of social functioning of nearly 20 points,
increasing by well over one standard deviation on this measure from a score that was
almost exactly the mean score for a chronic psychotic patient living in the community.
A.P.s feedback of the intervention offered important qualitative information. She
reported finding the intervention very helpful and was confident that she would continue to use the technique. By the end of the intervention, A.P. was discharged from hospital and looking forward to reestablishing her life at home. She started to attend group
and social activities at the local community mental health center and made several good
friends. A.P.s goal at this time was to be able to care for her daughter again. A.P. now also
reported that she believed she was not inherently to blame for the infanticide as she had
been gravely ill at the time. This did not detract from the sense of loss but eased the sense
of self-blame and ameliorated the feelings of intrinsic evilness.

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COMPLICATING FACTORS

Using psychological treatments with psychotic patients has often been thought of
as inappropriate because of severity of their disorder and its putative biological cause.
However, there is increasing evidence that this pessimism is unfounded, and although
there are a number of potential difficulties (for a discussion of these, see Tarrier, 2001;
Tarrier & Haddock, 2002), psychological treatments may be very effective with this
population (Tarrier, 2001).
Identification of positive self-attributes was a very difficult task for A.P. Initially, she
could not think of any, which is not unusual when commencing this technique with psychotic patients. This required suggestions and prompts with open questions (e.g., What
would your mum say it was she liked best about you?). However, by the third session,
A.P. knew what was expected and self-esteem appeared to be beginning to increase, as
she found the task of noting positive qualities slightly easier.
The intervention though was not designed solely for individuals with a diagnosis of
bipolar affective disorder. As such, some of the scales were not specific tools for measuring symptoms of this disorder. This may lead to limitations of the data as effects may have
been present but not measured or false effects noted by using inappropriate instruments.
Finally, as emphasis was placed on changing focus of attention to positive selfattributes and thus improving self-esteem between sessions, the work with A.P. needed to
be supported by members of the multidisciplinary team. With A.P.s consent, the content
of the session and assessment results were shared with members of the care team. A.P.
herself also discussed the intervention and her home tasks with other staff.

MANAGED CARE CONSIDERATIONS

This case study was carried out within the U.K. National Health Service (NHS), a
free at the point of contact public health service. The intervention described was a
time-limited CBT program, but was delivered within the context of a multidisciplinary
approach to this patients continuing treatment delivered by the local NHS mental
health services. However, reference to the follow-up results will indicate that there is
some drop-off of improvement over time, and it is probable that continuity of care involving reestablishment of intervention or booster sessions on a regular basis may be
required with chronically psychotic patients. Psychological treatments do not cure
psychosis but they do help patients cope better with their chronic illness.

10

FOLLOW-UP

Assessment scales were readministered at 3 and 12 months following completion

of the intervention (see Table 2). Self-esteem scores across all assessment points are pre-

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273

TABLE 2

Assessment Scores Over Treatment and Follow-Up

Scale
Robson SCQ
PANSS total score
HAD anxiety
HAD depression
Social Functioning Scale

Baseline

Postintervention

3-Month
Follow-Up

12-Month
Follow-Up

85
39
7
3
100.3

166
31
0
0
119.7

166
37
0
4
121.4

137
34
5
3
109.5

NOTE: SCQ = Self Concept Questionnaire; PANSS = Positive and Negative Syndrome Scale; HAD = Hospital Anxiety
and Depression.

sented graphically in Figure 2. Scores on the measure of self-esteem remain within the
normal range even after 12 months posttreatment. Scores on the PANSS total are lower
than baseline although there is instability in improvement. Similarly, with the HAD anxiety and depression scores, there is a minor resurgence of symptoms, especially after 12
months. The social functioning scale demonstrated good maintenance of gains at the 3month follow-up but with some loss at 12 months, although even at 12 months after the
completion of treatment a gain of over one half a standard deviation had been achieved.
Complementary to the quantifiable measurements were the comments reported
by A.P. in appreciation of the work and observable changes she made in her life.
She reported, The esteem course . . . has helped me a great deal. Over the past few
months I have learned so much that helps to keep me well, mentally and psychically. . . . I read the notes regularly. I find that I am aware of situations and can make my
mind up without any trouble.
A.P. had also implemented strategies on her staying-well plan. She was taking her
medication regularly, eating and drinking well, and had re-homed two cats, which gave
her a great deal of pleasure. Most important though, A.P. had achieved her overall goal.
She had successfully increased the amount of time she was able to have her daughter
home and at the time of the 12-month follow-up assessment was caring for her on weekends. A.P. now exercised active involvement in the decisions concerning her life and was
satisfied with the arrangement of her care. She felt stable and sufficient that she was
home with her on weekends. A.P. did not experience a relapse in illness or readmission
to hospital during the follow-up period.

11

TREATMENT IMPLICATIONS OF THE CASE

The treatment intervention described was administered with good outcome to a

client with a long and chronic illness history. However, the intervention was brief, with a
focus on positives. Such characteristics are similar to those of Solution Focused Brief
Therapy, most commonly used with work with children or mild to moderate adult men-

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CLINICAL CASE STUDIES / July 2005

score

Robson SCQ
175
150
125
100
75
50
25
0
Pre

Post

3 month
FU

12 month
FU

Figure 2. Self-Esteem Scores Over Treatment and Follow-Up

NOTE: SCQ = Self Concept Questionnaire; FU = follow-up.

tal health problems. It may be the case, however, that changing the focus from problems
and illness to positive aspects about oneself may empower the individual mentally and
promote recovery from symptoms.
The intervention is also simple to teach and share with other professionals. It does
not require intensive or expensive training or resources and thus could be easily replicated and offered to a large number of clients with low self-esteem. Although we have
developed and used this approach to enhance self-esteem mainly with psychotic
patients, this is not the exclusive utility of this approach. Because lowered self-esteem is a
common factor in many psychological disorders, this approach has wide utility. The second author has also used this approach with patients suffering from social phobia and
anxiety, and a current pilot project is investigating its efficacy with chronic and
treatment-resistant depression.
Sufferers of psychotic illnesses endure the negative societal responses and stigma
as well as the handicapping effects of their chronic illness. It is important that patients
suffering severe mental illnesses have access to psychological treatments from which
they will benefit and that psychological interventions to reduce the burdensome consequences of the illness and social stigma be developed and made more widely available.

12

RECOMMENDATIONS TO CLINICIANS AND STUDENTS

Several issues are raised by the development of this treatment approach. First, that
patients suffering from bipolar illnesswhich most probably has a strong biological
foundationwill still respond to psychological interventions; this is true of all psychotic

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disorders. Second, interventions should be developed to target specific clinical problems, such as lowered self-esteem, that are common to many disorders, rather than
exclusively at treating Diagnostic and Statistical Manual of Mental Disorders (4th ed.)
(DSM-IV) diagnostic groups (see also Tarrier, Wells, & Haddock, 1998). Last, effective
evaluation of treatments is not a luxury but a clinical imperative, and should progress
through innovative case studies, case series, preliminary trial to large-scale randomized
controlled trials (Tarrier & Wykes, 2004). Whether this method proves to be a useful
adjunct or a stand-alone treatment and with which patients still requires investigation.

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Pauline L. Hall originally obtained an honors BSc degree in psychology in 1994. She then went on to train
and work as a psychiatric nurse and cognitive-behavior therapist before completing her clinical psychology
doctorate (D Clin Psy) from the University of Lancaster in 2004.
Nicholas Tarrier completed his MSc in experimental psychology from the University of Sussex in 1973 and
his PhD from the Institute of Psychiatry, University of London in 1977. He worked as a clinical psychologist
in the NHS from 1981, as senior lecturer at the University of Sydney from 1989 to 1991, and he has been
professor of clinical psychology at the University of Manchester since 1991.

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