Psychology struggles with self-esteem. It’s a will o’ the wisp – chased around all the time but never pinned down: everyone’s sure self-esteem is important but no-one can work out what to say about it with a great deal of conviction. The NHS and Mind think it’s significant enough in terms of mental health to deserve its own topic on their websites but when it comes to explaining why, the best they can come up with is statements like Having low self-esteem isn’t a problem in itself but they are closely linked[1] and Living with low self-esteem can harm your mental health and lead to problems such as depression and anxiety.[2] It would be difficult to say anything at all and be more circumspect and tentative.
Part of the problem is defining terms. Experimental psychology tends to take self-esteem at face value, relying on self-reporting in the form of graded responses to statements like I feel I do not have much to be proud of or I take a positive attitude towards myself.[3] But those tests aren’t intended to be used for diagnostic purposes and they aren’t. In a clinical context, the evaluation would be likely to be quite different: over-emphatic responses aren’t a sign of genuine self-esteem but a betrayal of underlying insecurities. Yet in research those same questionnaires are routinely used to explore associations between self-esteem and various disorders.
And often people aren’t using the same terms. Self-esteem is a very expansive concept: there are dozens of different ways of talking about the same kinds of ideas without ever saying ‘self-esteem’. ‘Shame’, ‘narcissistic’, ‘shy’, ‘anxious’, ‘guilt’, ‘arrogance’, ‘internal bully’, ‘self-persecution’, can all touch on very similar territory and there’s any number of other ways of doing it. So, it’s easy to miss when people are actually talking about the same thing or saying something similar (or contradicting each other) and the result is countless separate streams of work which in some way relate to self-esteem but which get conducted and considered in isolation from each other.
It seems obvious what’s missing: lots of dots and not much to join them up. The problem can be spotting the dots; here’s a few.
There are two separate systems of psychiatric diagnosis: DSM-5 (developed in the US) and ICD-10 (developed by the World Health Organisation). Each identifies feelings of ‘worthlessness and guilt’ as key markers of depression (in fact those are the only ‘ideas’ mentioned in either – so far as the other symptoms, like lethargy, lack of appetite or inability to sleep are concerned, you could be suffering from flu). ‘Worthlessness and guilt’ are the only mental elements included in the diagnostic classification of this core mental illness.
Depression has very high co-morbidity rates with other disorders – if you suffer from another mental health condition, it’s very likely you’ll experience depression too. So much so that ICD-10 has to tell clinicians not to diagnose depression in a number of different situations so that other diagnoses can get a look in. You have to tell clinicians not to diagnose depression because otherwise they would.
At the same time, geneticists have reported that there is no evidence of a different genetic basis for depression from any other mental health disorder. Some have suggested that depression shouldn’t be thought of as a discrete entity at all but something that crosses borders between different psychiatric conditions, that is itself a hallmark of mental illness.[4]
So, ‘worthlessness and guilt’, as the signature ideas associated with depression begin to look very significant, not just to whole range of different psychiatric diagnoses but maybe to the whole idea of mental illness itself.
Which might explain some of the generic features of how we respond to mental health issues. It’s rarely explicitly spelt out why, but, from the influence of ideas around ‘good enough’ parenting in the last century to self-forgiveness and learning to love yourself today, there’s a consistent theme around challenging perfectionism, self-acceptance and being kind to yourself.
That ties-in with leading theories about the origins of depression – social rank theory (speaks for itself), the vulnerability model (low self-esteem creating a vulnerability to depression) and the cognitive triad (negative thoughts about the self, cycling into negative thoughts about the world and the future).
All of which is consistent with a scattergram of research suggesting strong associations between self-esteem and various different disorders (though, of itself, association doesn’t reveal causation – is it people with low self-esteem developing depression,[5] anxiety,[6] OCD,[7] eating disorders,[8] bipolar disorder,[9] schizophrenia[10] and personality disorders[11] or is self-esteem reduced as a result of suffering mental health issues?).
Parenting gurus, Instagram influencers, counsellors and psychotherapists, theorists, and experimental psychologists all seem to saying and doing the same thing here and it’s about self-esteem and its relationship with mental health.
So are criminologists, who report significant associations between self-esteem and criminal and delinquent behaviour.[12] And forensic psychiatrists, with low self-esteem conjectured as a trigger for sexual offending[13] and mechanisms such as ‘narcissistic decompensation’ (severely depleted self-esteem coming out in lethal rage) offered as an explanation for mass shootings, like the 2011 attacks by Anders Breivik in Norway. [14] Even when the consequences take the most extreme forms of behaviour, the roots seem to be the same.
This is already a very compelling picture. Vague references to links between self-esteem and mental health or the potential for low self-esteem to lead to problems really don’t look as if they’re doing justice to the situation any more. Mental health and self-esteem seem to be pretty much inseparable from each other and self-esteem is looking like a very active ingredient in mental health issues.
Which also makes sense when you look at some of the circumstances commonly associated with increased rates of mental health issues – like socio-economic disadvantage, trauma, discrimination, prejudice, bereavement, relationship breakdown, bullying, stress[15] – circumstances you would expect to affect how people feel about themselves, to affect their self-esteem.
And, really, we do know this; we do know that self-esteem is an absolutely vital dynamic in mental health. We know it intuitively and practically in the way we respond as individuals to people who are suffering from mental health problems. It’s implicit in our efforts to destigmatise mental illness and it comes out unfiltered in self-help and well-being guidance – ‘the most important relationship is with yourself’.
But because we don’t recognise that we know it, our responses to it are fairly unsophisticated. If we were clear about it, there would be an opportunity to be more deliberate and considered about what we did with it. Once you see how pervasive and powerful the connections are when you start to pull some of these threads together, it’s hard not to believe that ought to involve some changes to how we think about mental health and try to treat mental illness.
[1] https://www.mind.org.uk/information-support/types-of-mental-health-problems/self-esteem/about-self-esteem/
[2] https://www.nhs.uk/mental-health/self-help/tips-and-support/raise-low-self-esteem/
[3] These questions are from the Rosenberg Self-Esteem Scale
[4] Wray, N.R., Ripke, S., Mattheisen, M. et al. Genome-wide association analyses identify 44 risk variants and refine the genetic architecture of major depression. Nat Genet 50, 668–681 (2018). https://doi.org/10.1038/s41588-018-0090-3
[5] Orth, U., & Robins, R. W. (2013). Understanding the link between low self- esteem and depression. Current Directions in Psychological Science, 22, 455- 460. http://dx.doi.org/10.1177/0963721413492763
[6] Affective and self-esteem instability in the daily lives of people with generalized social anxiety disorder ntonina S Farmer, Todd B Kashdan Clinical Psychological Science 2 (2), 187-201, 2014
[7] A systematic review of obsessive-compulsive disorder and self: Self-esteem, feared self, self-ambivalence, egodystonicity, early maladaptive schemas, and self concealment Tess Jaeger, Richard Moulding, Yoon Hee Yang, Jonathan David, Tess Knight, Melissa M Norberg Journal of Obsessive-Compulsive and Related Disorders 31, 100665, 2021
[8] The impact of self-esteem on eating disorders F Mora, S Fernandez Rojo, C Banzo, J Quintero European Psychiatry 41 (S1), S558-S558, 2017
[9] Social adjustment and self-esteem of bipolar patients: a multicentric study S. Blairya , S. Linottea , D. Souerya, G.N. Papadimitrioub , D. Dikeosb , B. Lerer , R. Kanevad , V. Milanovad , A. Serretti , F. Macciardi , J. Mendlewicza Journal of Affective Disorders 79 (2004)
[10] Barrowclough, C., Tarrier, N., Humphreys, L., Ward, J., Gregg, L., & Andrews, B. (2003). Self-esteem in schizophrenia: Relationships between self-evaluation, family attitudes, and symptomatology. Journal of Abnormal Psychology, 112(1), 92–99. https://doi.org/10.1037/0021-843X.112.1.92
[11] Self‐esteem in patients with borderline and avoidant personality disorders LI Lynum, T Wilberg, S Karterud Scandinavian Journal of Psychology 49 (5), 469-477, 2008
[12] Does self-esteem negatively impact crime and delinquency? A meta-analytic review of 25 years of evidence Carrie Mier, Roshni T Ladny Deviant behavior 39 (8), 1006-1022, 2018
[13] Natural born killers?: The development of the sexually sadistic serial killer Bradley R Johnson, Judith V Becker Journal of the American Academy of Psychiatry and the Law Online 25 (3), 335-348, 1997
Self-esteem, shame, cognitive distortions and empathy in sexual offenders: Their integration and treatment implications, William L Marshall, Liam E Marshall, Gerris A Serran, Matt D O'Brien Psychology, crime & law 15 (2-3), 217-234, 2009
[14] Mass violence in individuals with Autism Spectrum Disorder and Narcissistic Personality Disorder: a case analysis of Anders Breivik using the “Path to Intended and Terroristic Violence” model – L. Faccini, C.S. Allely: Aggression and Violent Behaviour volume 31, November-December 2016
[15] McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. https://www.mind.org.uk/information-support/types-of-mental-health-problems/mental-health-problems-introduction/causes/
You write clearly and emphatically, Jonathan. Have you come across the books of James Davies on the DSM etc?
And it looks like Mounty has crossed over, too!