The goal of this study was to examine the role of self-esteem variability in a sample characterized by longstanding inflexibility and in a therapeutic context designed to perturb entrenched patterns and foster change. We used an observational method to measure self-esteem and its variability over a ten-week period of treatment, and then examined this early variability as a predictor of treatment outcome (personality disorder and depressive symptoms) measured up to one year later. Although the current literature suggests that greater self-esteem variability is associated with worse mental health outcomes, we explored the possibility that variability in a personality-disordered sample could instead be a predictor of better posttreatment functioning.
It is interesting that average levels of self-esteem did not predict posttreatment outcomes. In contrast, self-esteem variability predicted improvement in both personality and depression symptoms after a course of CT-PD, even after controlling for average levels of self-esteem. Further, variability in BDI scores did not significantly predict treatment outcomes. These findings extend research associating self-esteem variability only with negative outcomes (e.g., Butler et al., 1994
; Roberts & Kassel, 1997
; Roberts & Monroe, 1994
) and suggest that variability in the context of therapy might be helpful, as was also reported by Roberts et al. (1999)
. A lack of fluctuation might reflect entrenched maladaptive patterns, whereas increases in variability might represent readiness or flexibility for change (Hayes et al. 2007
; Hayes & Strauss, 1998
Our study examines self-esteem variability in a new context and time frame: Cognitive therapy for personality disorders that was conducted for up to 52 weeks. Previous research conducted over a one to two week period of everyday life (e.g., Greenier et al., 1999
; Roberts & Monroe, 1994
) suggests that self-esteem variability in reaction to negative events is associated with negative outcomes. In contrast, the variability in our study reflects, at least in part, reactivity to a therapy that is designed to facilitate change. Our findings suggest that it might be important to consider the populations included in studies of self-esteem variability, the context in which they are studied, and the source of the disturbance. Such information might be relevant to whether variability is associated with negative or positive outcomes, as Roberts et al. (1999)
Our findings have several theoretical and practical implications. These results contribute to research on the importance of variability in the process of change during treatment for personality disorders. Strauss et al. (2006)
reported that in this same sample, variability in the therapeutic alliance, if handled well, can be associated with significant improvement in cognitive therapy. Similarly, the current study suggests that variability in self-esteem is associated with change in this difficult-to-treat population. Variability in self-esteem might not always be undesirable or something to be avoided in the context of treatment, but rather some variation might be a necessary part of therapeutic change. It is possible that the early variability that we captured marks an opening of the patterns of dysfunctional self functioning that the DSM-V work group (APA, 2011
) propose contribute to personality disorders. This disturbance can then facilitate later change.
This study also addresses several weaknesses in previous research on self-esteem variability. Specifically, our use of a clinical sample, the context of a therapy designed to perturb and improve self-esteem, observational codings of verbalizations of positive and negative view of self, and the assessment of self-esteem over a longer period of time, all represent improvements upon previous methods.
However, there are some limitations that warrant discussion. First, although this sample is typical of those reported in clinical trials of long-term treatments for personality disorders, the sample size is small, and the need for replication is important. Second, some personality disorders, such as borderline personality disorder and narcissistic personality disorder, are characterized by self-esteem lability (Rhodewalt, et al., 1998
; Zeigler-Hill & Abraham, 2006
), and therapy often focuses on stabilizing the concept of self rather than destabilizing it. Thus, our results might not generalize, or might even be contrary, to treatment for other personality disorders. These results speak to the importance of treating personality disorders based upon their specific symptom profiles and recognizing clinical differences between clusters. In addition, a self-report measure of self-esteem was not included in this clinical trial, so it is not clear that the Positive View of Self and Negative View of Self items of the CHANGE measure (Hayes et al., 2006
) are measuring the same construct as the RSES (Rosenberg, 1965
). Furthermore, this is the first application of the CHANGE to the study of self-esteem, and future research is needed to support its validity as used in this manner. Additional measures of self-esteem would have strengthened this study, but were unfortunately not available in this archival dataset. However, our finding that more self-esteem variability predicted better treatment outcomes converges with Roberts et al.’s (1999)
finding that more variability using yet another measure, the Stability of Self Scale (Rosenberg, 1979
), predicted improvement in depressive symptoms.
We also sampled from the first 10 sessions of this 52-session treatment, and thus we cannot address the role of self-esteem variability later in therapy, nor can we empirically speak to any comparisons between early and later self-esteem variability. These early sessions were chosen because this phase of therapy could capture readiness for change before symptom change had already occurred. This study does not address, however, how self-esteem variability might function over the remainder of CT-PD (i.e., sessions 11 to 52), or the state of self-esteem variability at the end of treatment. Given the labor-intensive nature of coding with the CHANGE measure (Hayes et al., 2006
), it also was not feasible to code up to 52 sessions for each participant. Future research in this area might examine the stability of self-esteem across the full course of CT-PD, as well as at posttreatment, and compare the strength of variability in different stages as a predictor of treatment outcome.
In addition, we did not assess self-esteem variability in the week or two-week period before therapy began, as Roberts et al. (1999)
did, so we cannot specify whether self-esteem variability during sessions one through ten represents perturbations as a result of CT-PD, or whether these patients began treatment with already variable self-esteem. However, it is important to consider that AVPD and OCPD are characterized by entrenched and negative views of self (APA, 1994
) and that many tools of CT-PD are designed to perturb the maladaptive patterns that contribute to personality disorders, especially one’s view of self. Through collaborative activities such as gathering evidence for and against core beliefs, generating alternative balanced thoughts, or testing predictions and expectations via behavioral experiments, the therapist is asking patients to consider information that might challenge and perturb their entrenched belief systems.
In summary, our findings suggest that, as in other systems in nature, some variability might be adaptive in the context of therapeutic change. There is a broad literature on the importance of a stable sense of self in mental health, but when individuals are locked in pathological patterns, as is the case with personality disorders, too much stability can impede change. With some openness, new experiences and corrective information can be introduced to destabilize the old patterns and facilitate movement to a new, more adaptive organization (Hayes et al., 2007
; Hayes & Strauss, 1998
). This new organization would be relatively stable, but also open to feedback from the environment. Our findings take the self-esteem variability construct to a different context - that of therapy for personality disorders that are characterized by pathological self-criticism, avoidance, and rigidity - and illustrate a different side of variability that we think might enrich this line of research.