Journal of Psychology & Psychotherapy
Open Access

Therapist's Sense of Low Self-Esteem

Rachel Bar-Yossef-Dadon^{* *}Correspondence: Rachel Bar-Yossef-Dadon, Department of Psychotherapy, Institute for the Standing Army and their Families, Ashdod, Israel, Email:

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Introduction

Although we may not have considered it, therapists, like all other people, can suffer from low self-esteem.

"Bar-Yochai, you sat in a good place, the day you fled the day you escaped, in the cave of rock you stood, there you obtained your majesty and glory" (From "Bar Yochai", a Piyyut of the 16th century).

The therapist's self-esteem is a subject that is not often discussed, yet it is quite common for a therapist to criticize his own work. Often, the therapist sits on the therapist's chair with a sense of low self-esteem, asking himself: "Am I doing the right thing? Maybe I'm wrong? When will the patient leave me?"

Literature Review

Low self-esteem and methods to cope with it

Freud, in his book "Mourning and Melancholia" vividly and painfully describes the experience of low self-esteem:

The patient represents his ego to us as worthless and morally despicable; he reproaches and vilifies himself and expects to be cast out and punished. He abases himself before everyone and commiserates with his own relatives for being connected with someone so unworthy [1].

With his literary talent, Freud demonstrates the extreme experience of a decline in one's self-esteem, which is often perceived by bystanders and even by the person himself as illogical.

Freud also coined the term "initial narcissism" and "secondary narcissism" [2]. The concept "initial narcissism" defines the basic and natural love of any baby and person of himself, which derives from a sense of omnipotence. During one's development, this sense of omnipotence is necessarily damaged due to the frustrations of reality and therefore the child, in normal development, turns his libido and self-love towards others. If there is a problem in the transfer of energy investment from the self to others, then "secondary narcissism" develops by which the person is preoccupied with himself as a result of not appreciating himself enough and thus being incapable of investing sufficient love and libido in others.

Rogers emphasizes the gap between the "ideal self" and the "actual self". This can be illustrated as a simple conditional logic equation: if a person expects more of himself than he actually is, his self-esteem will be damaged. An improvement in one's selfesteem will occur if a change occurs in one side of the equation:

One should strive for a more realistic position either by lowering the ideal self or by improving the actual self.

Kohut claims that during the process of self-development, the baby has a basic need in the self-object relationship of three types: mirroring, idealizing, and twin ship. Mirroring, which includes being admired, is necessary for the individual to experience himself as worthwhile and to be capable of admiring himself later in life. Idealizing is necessary for internalizing confidence and self-value. Twin ship is necessary for the baby to acquire a sense of being understood. The baby internalizes these relationships gradually, and thus the experience of self-esteem is created for him. When these needs are not satisfied, the individual will continue his entire life dealing with his selfesteem, trying to fill these voids. Such an individual is incapable of completely seeing other's needs because his unfilled needs become an obstacle.

Coping with the secondary narcissism, according to Kohut, can occur during psychotherapy when the patient's missing selfneeds become satisfied. The therapist needs to provide the patient with the various self-object needs in an emphatic manner, thus slowly and gradually assisting him in building a stable, complete, and vital self.

In addition, actual successes in external reality can help an individual feel good about himself and thus strengthen his sense of self [3].

Seligman claims that in the current Western culture, parents believe that they must improve their children's self-esteem by complimenting them. Parents do so because they have learned from popular psychology that it is inappropriate to raise children with over-criticism because criticism might damage their mental development. However, Seligman claims that such compliments will not help the child to develop a positive self-esteem. In order to raise self-confident children, they must experience success in the real world. The child must be capable of learning, investing, and persisting. Only when he achieves successes in the real world due to his own efforts will he believe his parents' praises and develop a positive self-esteem. As the data demonstrate, there is indeed a positive correlation between success and satisfaction after completing a task.

Neff addresses the cultural-sociological aspect of self-esteem. She writes that in Western culture, due to its emphasis on the individual's centrality, we expect ourselves to excel even though statistically, the chances of excelling are low [4]. Neff found that people believe that they are very good in a variety of qualities, which, of course, is statistically unlikely. Thus, Neff demonstrates that the expectation to feel worthwhile is unrealistic and it is preferable to dare, as Barnes suggests, being "average".

Neff studied the cultures of Thailand, Taiwan, and the USA. In Buddhist Thailand, she found an emphasis on the values of modesty, consideration of others, compassion, and self-sacrifice. In this country, most people report that they have a high level in these values. In Taiwan, the culture of Confucius, she found an emphasis on self-criticism that helps the individual consider other's needs rather than focusing on him. This sociological examination demonstrates that in every culture, there is a different expectation regarding self-esteem. If in a Western clinic we would often hear the patients' desire to be of a high selfesteem as part of the need to develop the individual in Western society, then possibly in a meditation retreat in Taiwan, people would complain about their inability to be more giving.

Nevertheless, there are sociologically shared psychological findings: In all cultures, Neff found that high self-criticism is related to depression, anxiety, and an insecure attachment style. She also found that individuals with high self-criticism were raised in families or environments in which they were frequent recipients of criticism and therefore continued to criticize themselves throughout their lives. These individuals criticized themselves because they thought that by doing so, they were preventing criticism from others; thus, self-aggression became a defense against external aggression.

Neff writes that one of the difficulties generated by excessive selfcriticism is it being self-fulfilling. For example, in a romantic relationship, individuals with excessive self-criticism experience themselves as being criticized and ignore the supportive and loving aspects of their partners; a therapist with a low self-esteem might ignore the patient's approving and appreciating attitude towards him and thus generate a self-fulfilling prophecy, resulting in a patient who indeed does not appreciate him.

Interventions for low self-esteem

Neff suggests a variety of practices for coping with excessive selfcriticism. For example, she suggests that the individual write a letter to himself, which an individual who loves him would have written to him; or to initiate a Gestalt-like discourse between three chairs representing the criticizing self, the hurt self, and the compassionate self.

Finally, in a book dedicated entirely to the subject of burnout due to low self-esteem, Shahar addresses the mental and physical destructive aspects of low self-esteem. Shahar presents a variety of interventions that can be integrated into an integrative psychotherapy for a patient suffering from low self-esteem. Shahar writes that the purpose of the interventions is not to completely root out self-criticism and all its forms, but rather to generate a more constructive and healthier response to it.

Shahar introduces several interventions that have research validity. The following three are discussed here [5]. The first perceives self-criticism as a characteristic of several disorders of the C cluster (the avoidant personality disorder and the obsessive-compulsive disorder). One of its techniques derives from the short-term psychodynamic therapy of McCullough (1997) and includes a gradual exposure to feelings that were previously avoided. This intervention encourages patients to experience feelings such as anxiety, sadness, anger, and shame in order to enable them to gradually avoid the defensive position of self-criticism-that is, to shame themselves instead of experiencing the feelings, processing and digesting them.

An additional approach introduced by Shahar is the psychoeducational one, which was found to be efficient in a variety of disorders [6]. As part of this approach, Shahar explains to his patient that self-criticism is mentally and physically destructive, yet at the same time, he avoids an over authoritative approach: He is cautious not to provoke a too anxious attitude toward self-criticism and explains to the patient that the "trick" is to stop being angry with himself for the self-criticism.

The third approach is that of dereflection. The roots of this approach lie in the existential psychology of Sartre, Yalom, and Frankl [7-9]. It suggests that man should not deal too much with himself. According to this approach, going out into the world and finding self-fulfillment in the world according to one's authentic self helps one to forget internal aches and change the focus of one's thoughts to the other, to the interesting and significant. Shahar writes that this approach has not been validated by research yet it is similar to the Behavioral Activation (BA) approach, an approach that has been validated recently, especially with people suffering from depression. Shahar even mentions his wife, a clinical psychologist, who suffers from a chronic disease. He quotes her saying that there is nothing like her therapy sessions with others to help her forget and cope with her own difficulties.

In his book, Shahar presents interesting findings. He found that patients with a low self-esteem find it difficult to maintain the therapeutic alliance, resulting in damage to the existence of the therapy and its success. At the beginning of the therapy, interventions that offer various active techniques are perceive as criticism against them and even beneficial remarks can be perceived as negative because they are interpreted as criticism. From this, Shahar concluded that therapy with such patients will be of long duration. The therapist's attitude in the first weeks of therapy should be emphatic, examining, warm, and cautious. Shahar suggests that only later should more active techniques be introduced. In any event, the therapist must pay attention to transference and countertransference and to addressing raptures that occur during the therapy.

A short, fictional case study follows that demonstrates several of the points presented above

Sarah tried to turn to various psychotherapies when she was in her mid-twenties. Her relationships with men were problematic and she was often moody. In the past, she had received psychotherapy at a public clinic, yet did not feel it had contributed much. At the present period of her life, Sarah, subconsciously, did not appreciate herself. She was not satisfyingly successful with her studies, she was unsuccessful at forming a stable relationship with a man, and she remembered a prestigious course during her army service which she had left untimely as a shaming stain. Several months after she had left the course, she had started suffering frequently from those moods. These moods were of the attacks upon herself and on her unsatisfying life.

Sarah understood from her friends that because she was receiving psychotherapy privately, she could go "shopping" and choose a therapy that suited her. She found this advice to be empowering.

The first clinical psychologist she approached was recommended by an appreciated clinical psychologist who knew Sarah. The therapist seemed to Sarah to be an impressive woman, thin and serious. In response to Sarah's hurting words, this psychologist said a few sentences, which Sarah experienced as intelligent yet cold. She also did not look at Sarah. Sarah‘s sensitive self was hurt. She did not schedule another session. Then she turned to a clinical psychologist who had treated certain members of her family. This closeness seemed problematic to her and already during their first session, the therapist suggested she begin a psychoanalysis session with him. Sarah became scared and withdrew. It could be concluded that Sarah used subconscious projective identification toward these therapists, projecting her injured self-esteem onto them.

Like the story of Goldilocks, Sarah visited another clinical psychologist and remained with him. Leah asked, “Why did she stay with the third one?” Frist of all, before the first meeting, Sarah understood that this therapist was nice, and happily married with three children. These facts subconsciously appealed to her because she desired a mate, a family and a harmonic relationship with them. Idealizing the therapist helped from the beginning to internalize his virtues, thereby strengthening her own self-esteem.

This therapist remained very quiet during the meetings, hardly offering advice or tools. Rather, she mostly used reflections. But she always listened intently and with great interest. The term “containing” is too banal in the parlance of psychology, so I would write that she was simply there, present in a light and non-intrusive manner, for years. Like a peaceful rock on seashore, that doesn’t change.

Sarah continued with this therapy, which turned out to be a Kohutian therapy, for six and a half years, at first twice a week. Even though Sarah found the therapist’s interventions disappointing and empty, the therapist did not narcissistically damage her self-esteem, enabling her to express herself authentically. After about three years, Sarah started communicating authentically with other people as a result of being able to express herself again and again in front of the attentive therapist. For years, no one had given her the opportunity to talk in a non-judgmental atmosphere. Of course, this long period of therapy required genuine commitments of both time and money.

Before this, Sarah felt bitterly about not be able to grow in many aspects of the life, like a small tree in a huge tropical jungle, blocked from the sunshine by the taller trees all around, stunting its growth. The taller trees basked in the sunshine that it could never experience. Perhaps the psychotherapy was like a fallow field; where now, after so many years of quiet anger toward all of the other trees that towered over her and toward the hierarchy of the jungle, this was a place where she could feel the sunshine and grow from her present stunted form and finally blossom. This was finally a curative for Sarah’s aching self-esteem.

Dealing with the therapist's low self-esteem psychodynamic attitude

Turning to Rogers’s work, when in addressing a therapist with low self-esteem, suggesting that the therapist try to lower his perfection level is in order. For example, if the therapist expects that the patient will not quit the therapy sessions, his expectations can be modified by presenting the fact that patients quitting therapy happens quite frequently [10]. Alternatively, the therapist should take steps to improve his therapeutic abilitiesthat is, improve his actual self as a therapist.

According to Kohut, therapists obsessing over their self-esteem is a narcissistic vulnerability derived from narcissistic childhood deficiencies and perhaps also from narcissistic damage at the stage of their professional apprenticeship. Often, such therapists might not see their patients' needs because they are concerned with their own self-esteem and might use them as the self-object. In Kohut’s view, the therapist should turn to sources that will strengthen his personal and professional self. Such sources can be personal psychotherapy, which will fulfill lacking or hurting self-needs, and personal guidance, whose role is to fill personal and professional narcissistic voids. A twinship relation with colleagues, who can identify with the therapist's difficulties, can help the therapist build a stronger and more vital self. Actual professional successes can also improve the therapist's selfesteem.

Achievement based attitudes

According to Seligman, the first method to raise the therapist's self-esteem is the understanding that his self-esteem derives from his abilities. His self-esteem will rise, therefore, if he improves his professional abilities: He can read professional literature, write and think about his countertransference, receive guidance, or join a group of colleagues [11,12]. Research on "Super-Shrinks", that is therapists who were found to be especially effective, found that these successful therapists spent twice as much time on every case. In addition, they coped well with difficulties in the therapeutic alliance and regularly collected feedback about the results of the therapy.

Bion’s contribution to the subject of the therapist's self-esteem is especially interesting: He perceives the weakening of the therapist's self-esteem as a positive phenomenon. He believes that if there aren't "two scared people" in the therapy room, then the psychotherapy is insignificant. Why bother to know what is already known? According to Bion, the psychoanalyst's need to know and feel confident contradicts the therapist's basic state of existence, that of the therapist being "without memory or desire" [10].

"In psychoanalysis there is no place for desire; there is no place for memory, as it is based on and inseparable from desires related to past activities different from psychoanalysis. A desire to be a good analyst obstructs being an analyst".

Instead of memory and desire, Bion recommends holding on to an act of faith represented by an 'F' [13]. In such a state, the mind is open to absorb what is really happening between the therapist and the patient. Is it possible that this 'F' state is actually the therapist's relatively balanced self-esteem? Indeed, the 'F' state enables a certain type of confidence in what is happening in therapy. Even if the therapist is scared, he feels confidence in the process he is holding and using.

Case study (Fictitious narrative)

In order to demonstrate the implementation of the various approaches, presented below is a fictional case study of a patient, Yoav, who is also a therapist preoccupied with the issue of his professional self-esteem.

Yoav, a clinical social worker, came to me for therapy at the age of 58. He had received therapy for many years. He came to therapy to cope with symptoms of anxiety which he had been experiencing since his brother's death many years ago. In addition, he wanted to talk about his professional career. He felt he needed some change, despite having a relatively flourishing clinic.

During the sessions, it became clear that Yoav did not appreciate himself as a therapist. He stated that he grew up in a critical family but did not want to elaborate on his parents. According to what he said, he had already spoken about them in two previous therapies he had gone through. At his age, he was less angry at them and understood them more. Nevertheless, it was clear that he lacked an experience of mirroring, and not only in the professional field. In addition, his inner demands were high and it was obvious that he was suffering from a strict super-ego. During therapy, Yoav spoke about his lack of self-confidence as a therapist: "I know I'm okay", he said in one of our sessions, "but I have this constant need to flatter the patients, to please them. If the patients quit the therapy after several sessions, I think it is because of me, that something isn't right with me, something that repels people. When will I feel comfortable in the therapist's chair? When will I stop living in fear that the patients will leave me, you know, private clinic and everything".

Yoav told me about an acquaintance he met through Facebook, younger than him and a therapist like him: "She", he said, "Told me something once and I envy her for it. She told me: ‘I feel comfortable on the therapist's chair.’ She feels comfortable and she is so young, and me?" Yoav said that the young therapist used to receive private guidance frequently.

"Maybe therein lies the secret?" Yoav said. "I don't know…"

Yoav himself was an autodidact. He learned much from professional books.

I asked: "What can help make you feel better with yourself during your therapies?"

"I don't know", Yoav said.

"Nevertheless", I said, "think of something intuitively, even if it's not true". Maybe if the patients remained longer in therapy? If I receive an award for how I work?" he said and smiled when he mentioned the award. "Award…" I said, and smiled, too.

"I think I need the recognition of the professional community, maybe? You know, I work in the deep darkness of my private clinic and no one knows how I work".

"And the fact that a respected state institution sends you cases, that people succeed in their therapy with you, does not help you feel more comfortable?"

"Now that you mention it, then, maybe yes? Maybe if you said it over and over again, it would get into my mind? But no, it's like I don't even want it to happen, you know … it's like I don't want to be resting on my laurels. Maybe I'm afraid that such rest will cause me not to work well. that I'll take my work lightly. It’s like it wards off the evil eye. That is, I prefer thinking that I'm 'not something', and then I'll be better. If I think I am 'something' then maybe I'll become arrogant and take my work lightly. Do you understand what I'm saying? It's like I was sentenced to being so insecure, with all this self-criticism, do you understand? I don't want to feel good with myself, I don't. I prefer remaining low, at the 'height of grass' as they say."

I nodded, not knowing what else to say. I smiled, looking slightly sorrowful. "And you know what; I remember this as a child. You know, I grew up in a quite critical house and all that, so if I criticize myself, then I will be less criticized". I continued to smile and nod. I looked at him and probably narrowed my eyes. "I understand", I said. I trusted my facial expressions to tell him what I felt. I know that my facial expressions are relatively dramatic and didn't want to utter some sophisticated interpretation. In addition, I didn't have anything to say.

I took a deep breath. I looked to see whether Yoav was also breathing.

"In my eyes", he said, "I should be a great theorist like Winnicott or Eigen.

Someone likes that …" My eyes opened wide.

"Difficult right?" He said, "Well, I published several articles, but you know, in Hebrew, and it's … and I'm not connected to any university to sit and write and go to symposiums and lecture in seminars and all that. I'm just, I'm a simple therapist… and what is sad is that I worked hard to get to the dream I am in now, and now I want more and more. What am I, the fisherman's wife from the story about the golden fish? Everything I get, I'll want more and more? Can’t I be satisfied with what I have? I hope I won't be returned to my pitiful wooden shack because I'm so ambitious.”

Yoav has high expectations of himself. Facing such high expectations, it is almost impossible not be disappointed [14]. In Yoav's super-ego, there is a too high ideal self. On the one hand, this super-ego gives Yoav's life its meaning and purpose; yet on the other, it leaves him professionally dissatisfied with himself.

"And you know", Yoav added in one of our sessions, "I'm sometimes sorry that I wasn't born in an English-speaking country. They at least write in the most spoken and communicated language in the world, and that's it, they have an article, a book, a blog. This Hebrew, who understands it at all? ”

And then he told me awkwardly about another of his thoughts:

"You know", he said, "about a year and a half ago I had this thought that I would have liked to win a Nobel …" I smiled, and again, opened my eyes wide.

He continued: "Do you understand how problematic I am? Nobel? At the time, I was energetically writing my professional blog, I wrote it in English, too. I felt wonderful. Really! Some great joy, ‘elated’, as you say in English. Do you understand what it takes for me to feel well?

It doesn't make sense. I have a Facebook friend-I think she is fifteen years older than me-and she writes: ’The trick is to love what you have, not to focus on what you are lacking.’ Yes, it sounds like some bullshit of positive psychology, but she is presumably right. At noon, before taking a break, I too, say to myself ‘thank you' sentences for what I have, but I don't feel that way. Once, in a Lacanian therapy, the therapist taught me to discover where my 'desire' is, not to be satisfied with too little. And I over-adopted this mode of thinking. So something is always lacking, you know? At home, in my clinic, in my 'career'. At my age, I already need to accept what there is. Enough grinding such things, what do I want from myself? This mindset suits someone who is thirty plus. Man, the so developed 'self' culture of the western world in the previous century and now, you know, is tiring, and not so good. Self-knowledge, selffulfillment such worn words. The Buddhists are right: be part of the public; enjoy the group; stop trying to stick out."

I listened and could connect with what Yoav was saying. I, too, thought that often we, and especially those in therapeutic professions, are tired of the occupation, tired with ourselves, and tired of our 'self'.

"Nevertheless", I said, "these values of self-fulfillment and progress are embedded in us. I understand that you are fed up with discussing them, but there is an advantage to a man who fulfills himself, even if it is through professional fulfillment. There is no need to annihilate the need to progress." I forgot to be emphatic, I told myself. I am again in a Socratic dispute. Did I have a certain decrease in my self-esteem at that moment?

A week later, Yoav came and we discussed the same subject again.

"I’m just discouraging myself. I … I'm tired. I'm taking the wind out of my sails. I'm probably good at it. A shame and anyway", he said, "I read a new study. There's this Miller, ever heard of him?"

I said I hadn't.

"Yes", Yoav said, "he's not so familiar in Israel. In short, this Miller wrote a post about the concept of ‘super-shrink’. Do you know what that is?"

"No", I said.

"In short", Yoav continued", "super-shrinks are those therapists who are really and truly great. The results of their therapies are much, much better than those of others. And what characterizes them, if I remember, is that first of all, they spend twice as much time on every therapy they do, presumably writing, reading, and guidance? And they monitor the patient's state, you know, what's his state in every phase. And I think they also manage the therapeutic relationship in a good manner.

Something like that I don't remember exactly. In short, I decided to spend more time reading to write much more. I anyhow write and I decided to write down things for myself before a session, about what I feel towards the patient".

"It sounds interesting", I said appreciatively.

Several months passed. Yoav continued his sessions with me. From time to time, he skipped a session.

In the meantime, he found a solution that satisfied him: Beside the fact that he spent more time on each of his patients, he decided that his English blog will be where he fulfills himself— his source of pride. He continued writing on his blog his thoughts, experiences, and knowledge on psychotherapy.

Yoav felt, as he said: "Drops are starting to drop into my empty pot. There is already some water in the bottom, in the pot". Yoav was still not completely satisfied but he was less frustrated.

In one of our sessions, several months after he understood that the blog is his "display window", he said: "You know, it seems to me that I always need something to boost my professional selfesteem. When I was thirty-something, I wanted to have a private clinic. That was my goal. Then I wanted to have a large library in my clinic and now this blog, the writing but why? Why do I not know how to be satisfied with what there is?"

I smiled and said: "You know, a year ago I had quite a normal patient. He had this life-philosophy that I liked. He said of himself: ‘I constantly pursue a different goal. When I achieve this goal, I set myself another one, which I find important. This way I'm happy.’ This man simply accepted his need of pursuing his important goals."

Yoav smiled with certain bitterness: "But what else will my professional self-want? What else will I need?"

"You never rest", I said, and added with a smile, "well, let's not exaggerate. There was a woman who said, ‘I'll rest in my grave’, and she died suddenly. She was quite successful, well-known in Israel. Maybe you can rest during the Ashkenazic Siesta?” I smiled. Yoav smiled back at me: "I taught myself this just recently, actually. And I rest facing the safari and animals on T.V. Me and nature. Do you understand?" we both smiled. A little humor never hurts, in therapy and in general.

Discussion

The therapist has many opportunities to suffer from a low selfesteem: processes of devaluation by patients, times when the private clinic is relatively empty, criticism from supervisors or professional colleagues, and patients quitting unexpectedly the therapy. In such moments, the therapist might sometimes wonder if, when facing his patients, he is reconstructing the experience of being rejected as a child.

In addition to a personality tendency of over-self-criticism, which also contributes to the therapist's low self-esteem, usually, in the first stages of professional progress, a therapist does not receive guidance that can improve his self-esteem.

In the case study of Yoav the psychotherapist, his low self-esteem derived from a childhood in a critical house and a strict superego. In addition, Yoav had real subjective needs of selffulfillment, needs that he found difficult to validate and therefore, he painfully attacked himself [15]. In the therapy sessions, these needs were validated.

In addition to acknowledging the need for real achievements, Yoav also lowered the high demands of his super-ego, which required that he be like Winnicott or win a Nobel Prize. In this sense, he adjusted his ideal self to his real self, by being temporarily satisfied with the English blog that he wrote.

This case study also demonstrates that the therapist should be contained and protected by an additional figure, just like a baby held by his mother is contained and protected [16].

Nevertheless, although it is easy to be drawn into an empathetic understanding of the therapist and his needs for an undamaged self-esteem, it is also important to set limits to the therapist's need for maintaining his self-esteem. The technique of dereliction demands that we address others or other matters, and not only ourselves. Thus, it is important in therapy to differentiate between an occupation with ourselves and our selfesteem, which is significant and contributes to the therapy, and an over-occupation with the self, such as the inclination to view responses in Rorschach [17]. The inclination to view such responses in Rorschach is related to extra self-reflection, depression, and even suicidal tendencies. Similar to the ACT approach, often, we must live with the suffering within us and in spite of it and at the same time, be committed to the values of the patient's interest [18].

This work should not be perceived as overly moral or as obstructing processes of significant reverie exploration of selfesteem, yet it should be emphasized that there is a limit to being occupied with one's self-esteem and we must be able to move on a continuum between self-observation and focusing on other matters. The therapist must also be aware of when the occupation with his self-esteem becomes non-productive for the therapy. Thus, for example, during therapy, the therapist can be in a state of "floating attention", occupied with the question “Will the patient persist with the therapy?” The contents of his "floating attention", as Bion writes, are important and relevant to the therapeutic alliance: Yet often, the patient will experience such a question as the therapist having an exaggerated occupation with him and maybe even preoccupied with other matters such as payment, all the while preferring that the therapist focus on him and his sequence of associations. This is a dilemma the therapist lives with and needs to be aware of.

The present article joins a previous article by the same author about finding the therapist's true self [19]. This discussion of the subject of the therapist's self-esteem expands the discussion of sensitive issues related to the therapist's development. Just as it has become legitimate to discuss a mother's personal development and welfare and not only her baby's, so it is legitimate to deal with the therapist's personal development and welfare, to understand and validate his needs [20-25]. Writing about these issues might help one to cope with the sense of loneliness in the private clinic. Similar issues that should be discussed in this context are the attitude to money in therapy, the therapist's dependence on his patient, the therapist's recharging, and the aging therapist [26-29].

On a more personal note

It takes courage to write about the therapist's self-esteem: A person who is overly occupied with himself is perceived as problematic and tends to suffer more from depression [17]. But as therapists, we have been taught to face our difficulties, even if the process is shameful or embarrassing. On the contrary, those shameful difficulties only call us to put our finger on the pain, since that pain contains a new truth, a discovery [30-32]. And of course, sometimes you need to put your finger, other times; you need simultaneously to listen to the patient's concerns as well as to our own pain. Not all of us are capable of going through a beneficent therapeutic process. Sometimes, we must go through shameful processes with ourselves and with our colleagues before reaching the understanding that we need to develop our professional needs.

Conclusion

Interventions for self-esteem enhancement are presented, followed by a case study from the literature and a fictional case study. Finally, there is a call for recognition of the psychotherapist’s difficult position that requires reflection upon his self-esteem while always risking being drawn into an exaggerated reflection that can interfere with or even damage the patient’s needs.

Disclosure

The writing of the article fulfills my need to professionally progress and receive mirroring from my community. Like all of us, I too want to succeed, help others succeed, and find my true professional self while being aware of the egocentric facets of reflection; facets that we need to live with and be aware of.

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