Negative treatment of self in socially anxious clients

ABSTRACT

Exploring and working with the quality of a person’s self-relationship is central to the therapeutic process. Whilst research has often focused upon the measurement of concepts such as self-criticism, perfectionism and self-efficacy, there has been limited study of how the self-relationship, particularly as it relates to negative treatment of self (NTS), presents itself in discourse within therapy sessions. The current study was intended to examine the broader concept of negative treatment of self in socially anxious clients who participated in a research study on emotion-focused therapy for social anxiety (EFT-SA). Utilising a client self-report measure, four participants were selected based on high pre-therapy scores within the respective self-relationship domains of self-attack, self-control, self-neglect and self-affiliation. We carried out qualitative descriptive-interpretative analyses of session 2 therapy transcripts for each participant to identify the main themes of negative self-treatment. This investigation revealed both obvious and subtle client process indicators of different aspects of NTS: Objects (Being, Doing, Having), Directness (Direct vs Indirect), Modes (Self-Attack, Hostile Control, Hostile Neglect & Hostile Freedom), and Emotional Effects (Fear, Sadness, Anger, Shame). In addition to mapping nuances, the varying dimensions were incorporated into a comprehensive definition of negative treatment of self.

KEYWORDS:

• Emotion-focused therapy
• self-relationship
• negative treatment of self
• self-criticism
• social anxiety

Negative treatment of self (NTS) ranges from mild self-criticism to more severe forms of self-attack, creating possibly the most common type of misery, and limiting or destroying lives in both obvious and subtle ways (L. Firestone, 2010). This investigation intended to identify the range and scope of negative self-treatment because without awareness of what the possibilities are, one might overlook the more tacit processes. Much has been written on the importance of self-compassion (e.g. Germer, 2009; Neff, 2003), yet it seems clear that unless we can bring awareness to our self-critical thoughts, inimical self-actions, and their corresponding emotional effects, any attempts at developing self-compassion may be futile.

Observed in clinical practice, clients seeking help with persistent emotional difficulties occasionally assert their adeptness in the application of self-help techniques such as mindfulness meditation and positive psychology, sometimes even applying such tools against themselves. Highlighting the difficulties that can arise from focusing solely on positivity, and the importance of ‘so-called negative emotions and affective states’ (p. 111), Yakushko and Blodgett (2021) posited the vital connection between human distress, adaptive transformation and meaning-making. Although evidence supports the effectiveness of these self-help methods (e.g. Bolier et al., 2013), the misconception that one might circumvent emotional pain through actively concealing or overlooking negative treatment of self was the inspiration for this study.

Whilst detrimental self-treatment is often reduced to self-criticism processes, our starting point was the understanding that the inner critic is only part of a wider spectrum of intricate negative self-treatment that affects many aspects of a person’s experiencing, including self-attack, self-coercion and self-interruption (Elliott & Greenberg, 2021). For this reason, we set out to map and bring awareness to the full range and complexity of often subtle disaffiliating self-focused thoughts, behaviors and emotional reactions that drive people to therapy. It is our view that this mapping is essential for helping clients develop the self-awareness and self-acceptance necessary to support the movement from self-loathing to self-compassion.

Fluid by nature, emotions are valuable guides in our experience of life, yet ‘people are often taught to ignore or dismiss them’ (Elliott et al., 2004, p. 3). In doing so, people’s flow is disrupted, and an essential aspect of self and experiencing is blocked or denied. Rather than utilizing self-help techniques to cement the evasion, it is important to arrive at the deeper stuck emotions to transform them (Elliott et al., 2004) by bringing presence, acceptance and compassion to those parts of the self that we have otherwise sought to push down or even destroy. This ‘inability to integrate aspects of functioning’ is understood to be a ‘major source of dysfunction’ (Greenberg et al., 2003, p. 308) and the foundation of the conflict that can arise between various facets of self. Emerging from this friction are discrepancies between spontaneous lived experiencing and the conceptualized idea of self (Rogers, 1959). Thus, the question of self-awareness surfaces in connection with how well we know ourselves, together with how we may develop and expand recognition of self-sabotaging processes.

The assimilation framework (Stiles et al., 1990; Stiles, 2001) suggests that problematic internal voices (both those that criticize and are criticized) may be reconciled through the building of a meaning bridge. To encourage specificity and aid the resolution of their dysfunctional processes, two-chair dialogue (Elliott et al., 2004; Greenberg 1984) for conflict splits task, promotes contact and dialogue between inner critical voices and the experiencing aspects of self. In their reformulation of the assimilation model, Honos-Webb and Stiles (1998) emphasized the importance of the relationship between these inner voices. Linking conflicted self-aspects with unresolved problematic experiencing, they noted therapy involves developing awareness of, and assimilating ‘voices that determine behavior and attitudes’ (p. 25) of which the individual may be unaware.

Having experienced early social degradation, socially anxious (SA) clients are burdened by a pervasive and enduring sense of shame, deeply impacting self-identity (Elliott & Shahar, 2017). Developing a controlling hypervigilance driven by the intent to protect against further debasement, this ‘shame-ridden defective self’ (p. 145) adopts an injurious negative self-relationship. Iancu et al. (2015) reported a strong correlation between difficulties with self-esteem and self-criticism and the development and maintenance of social anxiety (SA). Underpinned by this personal sense of defectiveness and an enduring sense of shame, SA is characterized by both immediate and anticipatory fear of social interactions, and rumination that others might judge or scrutinize oneself (Elliott & Shahar, 2017). MacLeod et al. (2012) suggested that SA develops from experiences of being humiliated, criticized or abused by significant others about one’s character, appearance or social status, leading to ‘implicit over-generalized emotion schemes’ (p. 68). Representing introjected values and standards, such configurations produce a defective self-concept of oughts and shoulds, inducing a contemptuous and hostile way of relating with one’s self (Greenberg et al., 1993). Generating loneliness and isolation, the disabling and incapacitating effects of SA on a person’s ability to interact with others (Alden & Taylor, 2004) increases their risk of suicide (Cox et al., 1994). The multitude and complexity of the possible actions on self and resultant emotional processes highlight the debilitating and often challenging-to-treat nature of SA (Elliott & Shahar, 2017).

Entwined with an expectation of self-perfection, at the core of negative self-treatment we find an unforgiving inner critic exhibiting varying forms and degrees of intensity, from mild castigation to despairing self-loathing and rejection. Expressed through exaggerated demands and demeaning of self, Whelton et al. (2007) defined self-criticism as ‘a consuming preoccupation with the establishment of a worthy sense of self’ (p. 136). G. Shahar (2015) described a critically intense self-relationship derived from ‘an uncompromising demand for high standards in performance’ underpinned by hostility when such standards are unmet (p. 5). Exploring the impact of intense levels of perfectionism on the treatment for depression, Blatt (1995) highlighted the ways in which self-criticism and problematic levels of perfectionism are engendered by harshly judgmental and punishing parents.

Firestone’s writings on self-attack processes provided important understandings of negative treatment of self (R. W. Firestone, 1997; R. Firestone et al., 2013). For example, to escape the pain evoked by the inner critic’s dysfunctional processes, avoidance tactics such as dissociation, depersonalization and a preoccupation with one’s fantasy world are often adopted (R. W. Firestone, 1997). Driving self-damaging behavior, the insidiousness of self-criticism directly correlates with conscious and unconscious patterns of self-harm (L. Firestone, 2010). Although the intent of the inner critic is understood to serve a protective function (Cornell, 2005), such belligerent self-abasement is the source of much maladaptive behavior and negatively affects emotional experiencing (Kramer & Pascual-Leone, 2015). Recognising the challenges faced in bringing compassion to an attacker, Cornell (2005) proposed that rather than perceiving the inner critic as a bad guy, viewing it as a part of the self that is fearful and trying to protect another self-aspect, better support its compassionate transformation. This recognition that the inner critic is criticizing something within the person rather than their whole self (Cornell, 2005), supports the assertion that differentiation is necessary to help clearly identify and aid the resolution of these often barely conscious or even unconscious attacks (R. Firestone et al., 2013; Stinckens et al., 2013a).

Acknowledging the array and complexity of self-critical narratives and self-damaging behaviors that present in therapy, and their emotional effects, this qualitative study sought to describe and classify the range of presentations at the beginning of therapy, to provide a broader account of NTS. Overall, the goal of this study was to explore: What kinds of obvious and subtle forms of negative treatment of self are present in session 2 therapy sessions with socially anxious clients? In the course of carrying out this study, a set of sub-questions emerged: (a) What are the objects of negative treatment of self (i.e. what do I dislike about myself?); (b) What are the various modes of detrimental behavior (i.e. what inimical actions do I take that are obstructing or harmful to me?); and (c) What are the emotional effects of NTS (i.e. what distressing emotions are activated?).

Method

Scrutinizing the within-therapy talk of socially anxious clients receiving emotion-focused therapy, this study sought to comprehend and classify their NTS discourse. Working with therapy session transcripts, we used generic descriptive-interpretive qualitative research (GDI-QR; Elliott & Timulak, 2021) as our method to elucidate how clients engaged in negative self-treatment early in therapy. Bringing together a range of qualitative research procedures to describe and categorize micro-processes in therapy, GDI-QR offers creativity and flexibility in representing, organizing and modeling qualitative data. Involving both careful description and interpretation (in the sense of bringing out implicit but not necessarily unconscious meanings), this approach also incorporated critical-reflective processes such as challenging emerging understandings against the data (auditing), and consensus through open dialogue among researchers (Elliott & Timulak, 2021). Its pluralistic and pragmatic analytical methodology was considered optimal for the overall aims of the project.

Participant information

Clients

We used data from the EFT arm of a larger study comparing EFT to person-centered therapy (Elliott et al., 2013). This larger study was approved by both university and national health service ethics committees. From this larger study, four participants varying demographically (see Table 1) were selected based on their pre-therapy scores on an experimental self-report measure, the Self Relationship Questionnaire (SRQ; Faur & Elliott, 2007), which assesses four types of self-relationship: self-attack, self-control, self-neglect and self-affiliation. To provide a range of experiences for study, the client with the highest pre-therapy score on each of these four subscales was selected for analysis. Each of these clients had a different EFT therapist, all of whom had in-depth post-qualifying experience in a variety of clinical settings and advanced EFT training. Based upon a range of outcome measures completed by each participant at the end of therapy, residual gain scores reflected two good, and two poor outcome cases.

Table 1. Participant data.

Participant	Sex	Age	SRQ Pre-Therapy Score
			S.Neg	S.Con	S.Att	S.Aff
1	M	35	2.13	2.20	1.29	0.20
2	M	18	0.88	2.80	0.43	1.50
3	M	46	1.88	2.60	2.57	0.10
4	F	29	0.25	1.40	0.14	1.90

S.Neg: Self-Neglect, S.Con: Self-Control; S.Att: Self-Attack; S.Aff: Self-Affiliation.

Researchers

At the time of this study, the first author and main researcher was undertaking MSc studies underpinned by a keen interest in better understanding and working with the self-relationship, particularly in relation to NTS. With 16 years in clinical practice, she expected to find both explicit and implicit process indicators of negative self-treatment, implementing an interpretive approach of deep reading of the data for implicit experiencing.

The second author was a Professor of Counseling at the University of Strathclyde, a principal developer of EFT, and an experienced qualitative researcher. They brought to this study an interest in self-relationship and NTS. Expecting that there would be explicit client process indicators of NTS, they challenged the deep, interpretive readings conducted by the first author. By proposing the confidence-rating scale (outlined in Data Analysis and indicating clearly or probably present examples) we were able to capture the different degrees of interpretation or explicitness of the categorization process of negative treatment of self. Being the research supervisor and auditor of the data, the second author sought to address this power imbalance by giving the first author the final decision on the analysis.

Data collection and preparation

The SQR was administered to clients as part of a larger set of outcome measures, after the conclusion of the intake process and before session 1; it was re-administered after session 8, and at the end of therapy, most commonly after session 20. We selected session two audio recordings for the study because the first therapy sessions contained varying amounts of client and therapist orienting discussions, whereas the second sessions were completely focused on clients and their presenting issues. Verbatim transcripts focused on content (rather than on interactional details) were then prepared, taking care to anonymize possibly identifying information. Transcripts were segmented first into client speaking turns and then into meaning units within speaking turns (Elliott & Timulak, 2021).

Data analysis

To analyze the data, the first author repeatedly listened to the recordings. The analytical approach used a combination of descriptive-interpretive and discourse analytic methods, including both process description and interpretative analytic modes (see Elliott & Timulak, 2005, 2021) for translating and categorizing client in-session discourse that revealed evidence of NTS. The main analyst attempted to bracket their preconceptions about NTS to allow the categories to systematically emerge from the data. The method involved explicating complex communications into their underlying components, including both explicit and implied meanings, attending to what the speakers would have understood each other to have meant in the context. The resulting method allowed for the microanalysis and unique categorization of each meaning unit specifically in relation to NTS. In short, the study employed an empathic process of entering and dwelling (Wertz, 1985), which led to the systematic emergence and classification of types, foci and modes of negative treatment of self. Due to the small sample size, and multitude and complexity of possible configurations of problematic self-relating, this study did not reach saturation as new categories continued to emerge with each session analyzed.

One of the emerging findings was that some instances of NTS were quite explicit and easy to see, whilst others were more implicit and harder to detect, requiring more inference. Therefore, to differentiate between these, we adopted a 4-point presence rating scale: 3 - Clearly Present; 2 - Probably Present; 1 - Probably Absent; 0 - Clearly Absent. ‘Probably absent’ and ‘clearly absent’ examples were excluded from the analysis. Lastly, we used a frequency scheme for designating themes as general, typical and unique (Elliott & Timulak, 2021).

Results

Although not originally planned, early in the analysis a hierarchy of four superordinate domains emerged: (a) Objects of NTS, (b) Directness of NTS, (c) Modes of NTS Behavior, and (d) Emotional Effects. Because of the conceptual overlap between the Directness and Modes domains, and to save space for this presentation, we have dropped the Directness domain. To explicate the related aspects of these phenomena, sub-domains, categories and sub-categories were identified within the emerging structure. The results indicating general, typical and unique themes are presented in order of frequency, together with participant quotes to illustrate the corresponding theme, followed by their explicitness/presence rating and unique identifier code (e.g. C1:29.1, indicating client number, meaning unit and speaking turn). The analysis is summarized in Table 2.

Table 2. Negative treatment of self: categories and frequencies.

Domains, Subdomains, Categories & Subcategories		Category
A.	Objects of Negative Treatment of Self – Being, Doing & Having (What I Dislike About Myself)
A.1.	Who I am (Being)
A.1.1.	Core-Self or Personality	General
A.1.2.	Self-Esteem or Self-Worth	Unique
A.1.3.	Body or Self-Image	Unique
A.2.	What I do (Doing)
A.2.1.	Self-Expression	General
A.2.2.	Self-Efficacy, Performance, Action or Inaction:
A.2.2.1.	Being Held Back by Limiting Emotion	General
A.2.2.2.	Falling Short of One’s Own Expectations of Self	General
A.2.2.3.	Falling Short of the Perceived Expectations of Others	Typical
A.2.2.4.	Inability or Incapacity to Act	Typical
A.2.2.5.	Incompetence/Non-Proficiency in Attempted Action	Typical
A.2.2.6.	Lack of Success or Progress	Typical
A.3.	What I Have (Having)
A.3.1.	Life Situation	Unique
B.	Modes of Negative Treatment of Self – Behavior (What I Do That Is Bad For Me)
B.1.	Self-Attack
B.1.1.	Negative Comparison of Self to Others	General
B.1.2.	Self-Derogation, Loathing or Rejection	Unique
B.1.3.	Self-Punitive or Hostile	Unique
B.2.	Hostile Control
B.2.1.	Pressurizing, Stressing or Overburdening Self:
B.2.1.1.	Expecting Attack, Threat or Danger	General
B.2.1.2.	Expecting Judgment, Criticism or Rejection	General
B.2.1.3.	Meeting One’s Own High Expectations	General
B.2.1.4.	Meeting the Perceived Expectations of Others	General
B.2.1.5.	Expecting Failure	Typical
B.2.1.6.	Expecting to be Ignored, Neglected or Overlooked	Unique
B.2.2.	Monitoring or Controlling Self – Restraining, Complying or Intruding	General
B.2.3.	Monitoring or Controlling Others – Enforced Propriety or Conformity	Typical
B.2.4.	Self-Doubt or Indecisiveness	Typical
B.3.	Hostile Neglect
B.3.1.	Minimizing, Negating or Avoiding One’s Feelings	General
B.3.2.	Self-Neglect or Abandonment	Typical
B.3.3.	Acquiescing or Affirming Negative Reactions from Others	Typical
B.3.4.	Undeserving of Positive Reactions from Others	Unique
B.3.5.	Reacting in a Flooded or Overwhelmed Emotional State	Unique
B.4.	Hostile Freedom or Separation from Others
B.4.1.	Isolating or Distancing Self from Others	Typical
B.4.2.	Self-Entitlement or Grandiosity	Typical
B.4.3.	Relinquishing Personal Responsibility	Unique
C.	Emotional Effects of the Negative Treatment of Self (What I Feel in Reaction to my Self-Dislike & Inimical Actions)
C.1.	Fear or Anxiety	General
C.2.	Sadness, Grief or Emotional Pain	General
C.3.	Anger or Frustration with Self or Other	General
C.4.	Guilt or Shame	General

Directness domain results are not reported here. Themes include both client self-report (acknowledging) and observational (expressing) data. General means that this phenomenon applied to all four participants; Typical means that this phenomenon applied to two or three of the participants; Unique means that this phenomenon applied to one participant.

Objects of negative treatment of self

The objects of NTS (what I dislike about myself) fell within three broad sub-domains of being (who I am), doing (what I do) and having (what I have):

Being:

The first object in terms of who I am differentiated between dislike or a negative appraisal of the internal self (including the core self or personality, sense of inherent value, and self-esteem or self-worth) vs the external self (body or self-image).

A general phenomenon across all participants was the negative appraisal of core self or personality, indicating a universal belief that there was something fundamentally wrong with self. The target of self-criticism varied in range between owned and projected expression: from disliking the core of who they were, feeling abnormal and flawed due to finding things difficult, to the projection that others will see and judge their character negatively. Interestingly, most examples appeared to contain an expression of the client’s doubt, expressed through statements such as ‘I don’t even know if it’s’, ‘it’s almost as if’ and ‘I think it’s’, challenging their belief that they were flawed, albeit slightly:

Therapist:

What is the part of yourself that you don’t like?

Client:

It’s more internally, it’s almost as if it’s like me, it’s who I am, who I am as a person, but it’s like an I or the me (3, C1:29.1).

The negative evaluation of self-esteem or self-worth, feeling of negligible value with little to offer was unique to one participant. The expression of insufficiency, worthlessness and expendability was tentatively cited in the justification of one’s insignificance and a source of condemnation. Again, this particular client qualifies their self-critical assertions with a slight expression of doubt:

Client:

It’s almost as if I don’t have any value or I can’t bring any value, or I don’t have a lot to add or a lot of value to give (3, C1:5.1).

Appearing as a source of antipathy and humiliation, critical statements about body or self-image were again unique to the same participant, at times being tentatively expressed with an uncertainty of its role in the client’s distress. Having little faith in terms of one’s appearance, doubts were clearly expressed concerning physical image, for example:

Therapist:

How specifically could you be humiliated, regarding what?

Client:

Well to a certain extent it’s my body image, I know I could lose weight and look better (3, C1:3.1).

Doing:

The second object of self-dislike, in terms of what I do, was further differentiated into negative appraisals of self-expression vs self-efficacy, performance, action or inaction.

Self-criticism relating to self-expression was a common target with all participants, highlighting a struggle with communication, ranging from the initial experience of wondering what to say about one’s self or a particular subject, to fearing having little to contribute to a conversation. Additionally, the projected fear of how others might receive what was said and the judgments that might form as a result, included concern about the quality and appropriateness of any given response or saying something offensive or out of context. Whilst desiring to be more articulate, the ensuing impact on behavior was communicated through the avoidance of conversing, particularly in groups, expressing what needed to be communicated quickly so that one could fall silent, or rehearsing and censoring conversation in the hope of avoiding judgment:

Client:

It’s always difficult it’s, I wish I could sort of open up more and be more articulate, but I’m just not used to talking (3, C3:50.1).

The next category about doing included a set of general and typical subcategory themes relating to the process of taking action or doing an intended task, lack of belief in one’s ability to produce a desired result, and the quality of one’s endeavor.

Being held back by limiting emotions was a general object of self-criticism restricting behavior due to experiencing a difficult emotional state, often co-occurring alongside avoidance strategies to circumvent anticipated or ensuing distress. This included descriptors of being held back by anxiety or fear, and feeling constrained or immobilized due to discomfort or awkwardness:

Client:

I had a chance to kiss somebody, and I just didn’t take it because I could feel the fear in me, it’s fear of humiliation and rejection (3, C1:2.2).

Underpinned by impeccable and idealistic aims, falling short of one’s expectations of self described a general process of berating self when unable to achieve or perform to one’s ideal. This was a source of anxiety, shame and self-directed anger when the client perceived that they had been unable to offer a high or even adequate standard, or achieve flawless results:

Client:

When I realize I’m just not doing what I would like to do in a perfectionistic sense the kind of anger toward myself and frustration comes afterward (3, C1:13.1).

Falling short of the perceived expectations of others was underpinned by projected, overblown ideas of perfection, a process of berating one’s self when feeling unable to meet the imagined or real expectations of others. A typical theme expressed through the seeking of approval or the projected belief that they simply didn’t measure up to other people’s expectations:

Client:

They would see from the inhibitions I have, I wouldn’t dance for example, so I just can’t fulfil what’s necessary in order to get into a deeper relationship with them (3, C2:60.4).

Feeling incapable of doing what the person would like to do was the theme of the category inability or incapacity to act, in which condemnation and self-reproach were expressed as disappointment through utterances such as ‘I just can’t do that’ and ‘if I were able to confront these situations’:

Therapist:

What [is it that] this part exactly doesn’t like?

Client:

My inability to cope with life, my inability to handle these situations (2, C1:30.1).

Incompetence/non-proficiency in attempted action described a typical object of self-dislike that any action taken was simply not good enough. This was often driven by unrealistic expectations of perfection that were expressed through fear of inadequacy and a deep-seated belief of not measuring up. It reflected a sense of not being up to the job or not having what it takes to get it right or achieve success:

Therapist:

And do you like yourself?

Client:

The majority of time I don’t because I’m just kind of struggling through trying to find solutions but I’m just not kind of getting them (3, C1:27.1).

Lack of success or progress emphasized unfavorable results and an absence of accomplishment, often alongside a comparison with the perceived triumphs of others. This was expressed through acknowledging stuckness, or an appraisal of others as more successful, and ‘if only’ statements reflecting a sense of disappointment and regret:

Client:

They dress quite similarly [to me], they act quite similar, but still they have much more success, they’re much more successful (3, C2:50.1).

Having:

The third object in terms of what I have was a small category unique to one participant: self-dislike relating to life situation referring to disappointment, regret or shame about scarcity or lack of possessions or achievements:

Client:

I don’t have a sort of normal life, I don’t have a job, I don’t have a partner, so (3, C3:24.2).

Modes of negative treatment of self

Distinguishing between the various modes of inimical behavior, that often served a protective function yet caused unintentional obstruction or harm (not the commonly understood intentional self-injury), the broad categories of self-attack, hostile control and hostile neglect emerged. In addition, we found one mode of self-damaging interpersonal behavior: hostile freedom or separation from others.

Self-attack:

Self-condemnation was a milder, yet direct form of self-attack than that traditionally understood as self-harm or self-injury. It could be differentiated into three main categories: negative comparison of self to others; self-derogation, loathing or rejection; and self-punitive or hostile.

The general theme of negative comparison of self to others described the comparative process of unfavorably weighing one’s self up against others with subsequent feelings of inferiority. A source of envy, this was a form of downgrading and diminishing one’s self, expressed and compounded through the belief that others are superior, can perform more effectively, or are in a more favorable position:

Therapist:

You’re just gonna not be good enough (C: uh-huh), right? What hurts the most in that?

Client:

That other people can do it effortlessly (3, C4:177.1).

Unique to one participant, self-derogation, loathing or rejection contained the clear expression of one’s dislike or hatred for one’s self, communicated through a self-directed antipathy, rejection and lack of approval:

Client:

I don’t know if it’s self-loathing I don’t know if it’s that bad (3, C1:10.1).

Again, unique to one participant and whilst similar to the category above, self-punitive or hostile compounded the clear expression of one’s self-rejection and loathing, embodied or enacted through a more severe form of self-directed hostility and punishment, being highly critical and hard on one’s self, or turning anger and aggression inwards:

Client:

It’s only after maybe two or three weeks a lot of time that I might get any sense of myself being angry at myself or frustrated with myself (3, C1:20.1).

Hostile Control:

We found four categories of hostile control: pressurizing, stressing or overburdening self; monitoring or controlling self; monitoring or controlling others; and self-doubt or indecisiveness.

A major form of hostile control was pressurizing, stressing or overburdening self, which contained numerous subcategories of various NTS modes or fear-based expectations. Making oneself feel unsafe and apprehensive ranged from angst about an actual physical threat or danger to the more subtle expectation that others will judge, criticize, ignore or reject them. This included striving for perfection or to feel enough, pressurizing self to meet one’s high expectations or the perceived expectations of others. This often led to high levels of stress or even burnout, thus creating a hostile self-sabotaging stance underpinned by a need for control. We list the main forms this pressurizing took, providing an example of each:

Expecting attack, threat or danger:

Therapist:

Ok so tightening up, is it telling you anything?

Client:

I suppose it’s still the fight or flight sort of thing just preparing the body really for what’s to come ahead (3, C3:13.1).

Expecting judgment, criticism or rejection:

Client:

I could approach one of these people. Now the one problem I have obviously is I’m afraid of facing rejection that immediately they make some sort of move that would mean they don’t like me (3, C2:61.2).

Meeting one’s own high expectations:

Client:

I didn’t feel that I particularly, I didn’t have the resources there that I could go to, because it was all just meant to be in my head (3, C4:104.1).

Meeting the perceived expectations of others:

Client:

It’s almost as if I don’t want to put a foot wrong with people, I want to behave in such a way that everybody will like me so I don’t want to make mistakes in company (3, C1:14.1).

Expecting failure:

Therapist:

Afraid that you are a failure?

Client:

Yeah or potentially could fail at this (3, C4:180.1).

Expecting to be ignored, neglected or overlooked:

Client:

What I contribute must be of extremely high value even to stand a chance of being heard and listened to (3, C1:9.1).

Another form of hostile control was monitoring or controlling self, a general theme that reflected the harmful aspect of restraining or repressing one’s self and needs, often to comply with the needs or demands of others or to intrusively push one’s self forward. This was expressed through closely monitoring and filtering one’s behavior and responses, trying to imitate others or behave in a particular way to gain their approval, or reluctantly yet forcibly pushing one’s self into action:

Client:

I can’t really outlive myself as I think I am because basically everything I do would have to go through that filter whether I can present it to them (3, C2:38.1).

Two of the clients exemplified the concept of monitoring or controlling others reflecting the desire to enforce upon others a sense of propriety or conformity to one’s own needs, standards of behavior, opinions or moral code. This need to rectify perceived external conflict was underpinned by fear and a desire for others to comply. It was expressed through monitoring and seeking to modify the behavior or opinions of others when at odds with them, or modifying one’s own to manipulate a desired outcome. Whilst this more explicitly reflects a form of interpersonal behavior rather than negative treatment of self, it was included within the analysis due to its implication of a deep sense of intrapersonal unease:

Client:

It implies that I make the choice for the others not to be interested in me [so I don’t face the rejection] (3, C2:41.2).

Self-doubt or indecisiveness reflected uncertainty about self or experiencing, focusing on a self-perceived lack of awareness or ability to comprehend meaning, accompanied by low confidence in one’s choices and actions. This was a form of self-handicapping, seeking to control or avoid responsibility for outcome by obscuring or protecting against potential mistakes or errors of judgment, or reactions from others. Often manifesting through hesitancy and passivity, this indicated inner conflict underpinned by fear, arising between different aspects of self, or between self and others:

Client:

I don’t really know what’s better because on the one hand, I would like to have more contact with people, but on the other hand I like the level that I’ve got, so I think that’s quite exemplary for the challenges that I face in deciding this (3, C2:52.3).

Hostile Neglect:

We were able to differentiate five forms of hostile neglect: minimising, negating or avoiding one’s feelings; self-neglect or abandonment; acquiescing or affirming negative reactions from others; and reacting to these in a flooded or overwhelmed emotional state.

The general theme of minimizing, negating or avoiding one’s feelings described the participants’ style of neglectful emotional processing, reflecting a strong desire to protect from and avoid emotional distress. Effort was directed into blocking, erasing or denying one’s feelings to evade fear, anxiety, pain or anger, often coinciding with modifications to behavior to avoid triggering further emotional reactions. Experienced internally, emotions were often concealed from the outside world, as the person was preoccupied with efforts to control or escape any discomfort and potential judgment from others. Impatience and puzzlement were occasionally expressed as to the reason and meaning of the experienced emotion, and inner conflict surfaced when one’s emotional response deviated from what might be expected in a given situation:

Client:

I’m so occupied with sort of getting my attention away from the fear of it, so I spend all the time distracting myself from the strain that this puts on me (3, C2:65.3).

Self-neglect or abandonment described a typical process of overlooking or relinquishing one’s needs, being selfless in a way that was neither beneficial nor commendable. Failing to notice and take care of one’s self or to act upon what was necessary or desirable created a state of passivity that often led to a related theme: reacting in a flooded or overwhelmed emotional state, a state of tension developing to the point that it could no longer be contained. The combination of these categories led to a familiar process:

Self-neglect or abandonment:

Client:

They do annoy me and criticize me a lot, I’m quite easy going so I kind of don’t retaliate or be assertive (3, C1:21.2).

Reacting in a flooded or overwhelmed emotional state:

Client:

But then after a while I just kind of explode at them (3, C1:21.2).

Two other related themes, feeling undeserving of positive reactions from others and acquiescing or affirming negative reactions from others described processes of either shunning positive responses or colluding with negative responses from others. Feeling undeserving or unable to accept positive regard together with a lack of protest when faced with bad behavior from others appeared as hostile neglect in the form of indirect self-punishment. This was underpinned by a belief that the self was not worthy of praise or respect, together with the familiar feeling of being poorly treated; this often involved condoning or overlooking negativity whilst feeling responsible for the aggression of others.

Undeserving of positive reactions from others:

Client:

I get this reaction that they are really sorry for me, and I don’t feel that I deserve that (3, C2:18.2).

Acquiescing or affirming negative reactions from others:

Client:

She’s never violent but it’s that kind of psycho terror that then goes on and which makes you as a person then feel bad for what you apparently did to her (3, C2:27.1).

Hostile Freedom or Separation from Others:

This main category involved three interpersonal categories of isolating or distancing self from others, self-entitlement or grandiosity, and relinquishing personal responsibility.

The typical theme of isolating or distancing self from others reflected an inherent distrust of people, underpinned by a style of relating that kept others at bay, seeking safety in one’s isolation. Whilst this was likened to a form of solitary confinement, sometimes driven by either an expectation of rejection or a genuine fear of people, it was most often accompanied by a conflicting desire for greater contact and connection. Yet care was taken to avoid meaningful or extended contact through behaviors that held people at a distance, imprisoning one’s self through fear, and maintaining loneliness and seclusion:

Client:

I don’t think my behavior triggers other people to proactively approach me. The way I behave protects me from others reacting negatively to me, but it also stops people from behaving positively (3, C2:47.2).

Self-entitlement or grandiosity reflected a sense of superiority and dispensation that viewed others as lesser beings. Feeling privileged and deserving of something based on entitlement rather than merit appeared as a source of discontent. Negatively impacting experiencing, it was expressed through feelings of unfairness and injustice when perceiving others as possessing what one desired:

Therapist:

There’s a sense of unfairness?

Client:

Yeah, I was the secretary general. A lot of the people who were just delegates, student officers below me are now going to all these Ivy League schools or Oxbridge or similar, so it feels really unfair (3, C2:64.1).

Passing the responsibility for one’s shortcomings or difficulties to another through the action of blame, relinquishing personal responsibility reflected a perceived absence of personal authority, control or power over one’s life and experiences:

Client:

They sent me to this school which was very small, and it’s much more difficult to get a higher grade. Had I been able to go to a different international school, I would have been able to go to a much better university now. That’s the thing I blame on my parents (3, C2:64.2).

Again, while it can be argued that these examples more clearly express varying forms of interpersonal behavior, they also indicate various inimical intrapersonal actions, ranging from insecurity and fear of rejection to disempowerment, isolation and indignation.

Emotional effects of negative treatment of self

Directly linking objects of self-dislike and modes of NTS, we found it useful to distinguish among the various types of distressing emotions that appeared to result from, or be activated in the negative treatment of self: fear or anxiety; sadness, grief or emotional pain; anger or frustration with self or other; and guilt or shame.

Participants within the EFT-SA protocol sought help with social anxiety and therefore as expected, fear or anxiety was the most frequently expressed emotional response, communicated through direct unequivocal statements such as ‘it’s fear’, ‘I’m kind of anxious and tense’ and ‘I’m really scared’. One participant expressed feeling fearful at the thought of having to speak in front of a group. Panicking that she would not meet their expectations, she imagined others being bored and negatively judging her:

Therapist:

Scared of?

Client:

I don’t know if it’s about being judged and them thinking god you know this is so boring (3, C4:121.1).

Less frequently expressed, sadness, grief or emotional pain was communicated through utterances such as ‘it’s going to hurt’, ‘it makes me feel down’, ‘raw’ and ‘heavy’. For another participant, acknowledging the difficulties they faced in relating and conversing was a source of emotional pain:

Client:

I don’t quite remember what her arguments were, but it was a very irrational response meaning that I was obviously crying for the rest of the evening (3, C2:26.4).

Anger or frustration with self or other was expressed through direct or indirect statements: direct in relation to self (appearing as an enactment of the self-criticism or an effect); ‘a sort of low-level aggression or anger toward myself’; indirect in relation to others and often expressed in a milder form; ‘I was getting quite annoyed’. One participant experienced self-directed anger because their anxiety prevented them from conversing the way they would like:

Client:

I do experience anger toward myself just because I can’t converse like other people can in situations because of my anxiety (3, C1:10.1).

Although described at some point by all four clients, the least commonly expressed emotion was guilt or shame, communicated through comments such as ‘I feel humiliated’ and ‘I can’t face knowing’. For one participant, this was concerning regrets about their lack of achievement in life, reflected in embarrassment and shame when having to interact with others:

Client:

That was a bit awkward and embarrassing because I had sort of revealed a lot about myself (3, C3:3.1).

Defining negative treatment of self: an integrative summary of our findings

Negative treatment of self was observed as a synergistic activity comprising the dimensions of objects of NTS, inimical actions and their emotional effects. Operating as an interconnected gestalt, these domains emerged from the analysis, presenting as a cyclical process. Creating problems and interfering with personal goals, each aspect of negative treatment of self contained a self-sabotaging aspect that appeared to directly affect and sustain the others.

1. Objects of Negative Treatment of Self exhibited varying forms and degrees of intensity, whereby a person deemed an aspect of self as flawed in terms of who they are, what they do, or what they possess. It resulted in preoccupation with how others might perceive or judge one’s flaws together with how one may obtain an acceptable or worthy sense of self. Self-dislike or self-criticism was expressed through inflated demands and idealistic expectations of self, together with a tendency toward belligerent self-derogation, abasement or rejection when such standards were unmet.

2. Modes of Negative Treatment of Self appeared most often as self-critical process, understood as a behavioral reaction to, or enactment of NTS, exhibiting varying forms and degrees of intensity, whereby an action was taken either momentarily or habitually, that was consciously or unconsciously obstructive or detrimental to self, whether by attacking or distancing, controlling or neglecting. Appearing to negatively affect emotional experiencing and sustain the self-critical process, strategies for carrying out the behavioral reactions included direct (through self) or indirect (through others) action.

3. Emotional Effects of the Negative Treatment of Selfinvolved a bodily feeling that was activated due to the effect, or as an enactment of the NTS actions that negatively impacted a person’s homeostasis or experiencing, sustaining pessimistic thinking and detrimental behavior or action whilst causing multiple forms of emotional pain.

Discussion

We set out to explore the wider spectrum of negative self-treatment, including its targets and ramifications (Werner et al., 2019), along with its emotional processes and implicit effects (B. Shahar et al., 2011). Seeking to uncover more subtle forms of NTS and self-damage, we have offered examples of direct and indirect, obvious and underlying processes, including inimical actions on self. Aiming to move beyond the exploration of self-criticism as it relates to perfectionism and personal effectiveness (G. Shahar, 2015; Whelton et al., 2007), and its impact on personal goal achievement (Powers et al., 2011), this investigation revealed a heterogeneous collection of problematic self-processes. When we started to organize the specific modes of negative actions on self, we found that they naturally grouped themselves into categories found in Benjamin’s (1996) introject model, which is part of her Structural Analysis of Social Behaviour (SASB) interpersonal circumplex, which developed in parallel with and informed EFT theory (Elliott et al., 2004). Although often implicit, the examples of self-sabotage contained in our findings carry important implications for the self-relationship, providing evidence for inclusion within our understanding and definition of NTS.

On reviewing the literature, it was apparent that some definitions of self-criticism placed greater focus on what I do alongside persistent expectations of high standards of performance and accomplishment (G. Shahar, 2015), with a tendency to berate and demean oneself when failing to achieve such inflated goals (Whelton et al., 2007). This study supports expanding this understanding to incorporate aspects of people’s being (core self) and having (life situation), together with clearly defined strategies for NTS. Unlike most previous studies reviewed, we have incorporated the behavioral and emotional effects integrated under the broader concept of negative treatment of self.

In their mapping of the inner critic’s underlying process markers, Stinckens et al. (2013a) offered their clinical impressions of the inner critic, by way of degrading, punitive, controlling, neglectful, distancing and domineering styles of self-relating, all of which were evident in our analysis. The classification of negative self-treatment narratives presented here differs in that it provides a set of client examples portraying an array of possible presentations, thus offering a useful adjunct to assist identification and understanding of the varied and subtle ways NTS can occur and be expressed in therapy. In recognizing and working with the inner critic, Elliott et al. (2004) reiterated the need to be mindful of both its content and mode of enactment. By viewing emotion as a variable of the self-critical process, Whelton and Greenberg (2005) asserted that it produces a unified experience by synthesizing ‘affective, cognitive, motivational and motoric information’ (p. 1584). Similarly, our integrative summary of negative treatment of self captured the variables of objects (targets), behaviors and emotional effects.

Pointing to the way in which research often links self-criticism to various client presentations such as depression (Blatt et al., 1976; Gilbert et al., 2006), Werner et al. (2019) highlighted the lack of research into self-criticism as a commonly occurring aspect of personal functioning. Investigating experiences of eating difficulties through EFT group therapy, Brennan et al. (2015) observed self-criticism as a salient concern. Capturing some behavioral and emotional aspects of self-criticism, they observed broad themes reflecting participants’ difficulties in distinguishing or addressing inner critics: recognizing its destructive effects; understanding its protective function; processing emotions; accepting needs; and valuing support. While the current investigation relates to SA, the overlap suggests that the taxonomy of NTS may offer useful insight into the self-relationship regardless of presenting difficulties. As proposed by Elliott and Shahar (2017), EFT for SA addresses assumed personal defectiveness derived from earlier degrading interpersonal experiences. The resultant anxiety that one will be recognized as deficient produces an enduring sense of shame and fear. Deeply woven within, are reactive self-critical processes in addition to aspects of self that seek to coach and guard. Pointing to the centrality of the role of negative self-treatment in the EFT understanding of SA, several aspects of our analysis clearly reflected this recognizable clinical picture. Considered both a strength and limitation of this study, it is likely that somewhat different results might be obtained for other clinical presentations such as depression or eating difficulties. With a small sample size involving analysis of four socially anxious clients’ within-therapy discourse, the negative treatment of self model presented here may not be representative of other clients, issues or approaches.

Instances of hostile freedom or separation from others supported Elliott and Shahar’s (2017) assertion that SA is a type of experiential and behavioral avoidance causing social isolation and deep unhappiness, with sufferers often having ‘greater than average needs for social contact’ (p. 143). Although a type of interpersonal behavior, it was considered pertinent to retain these findings due to the negative impact on the individual. According to Stinckens et al. (2002), the process of the inner critic in therapy is not necessarily stable. Although our findings supported this assertion, we noted that instances of NTS were not equally distributed across participants, at times reflecting distinctive patterns within each case. While space limitations prevented us from presenting such case-based readings of themes, this is a useful topic for future research. Stinckens et al. (2013a) suggested it might not be necessary to address all of the inner critic’s forms and manifestations to effect a therapeutic change. The varied and complex inner workings of negative treatment of self certainly support a more flexible therapeutic approach, consistent with Stinckens et al.’s (2013b) conclusion that successful therapy requires more adaptive active engagement with the critic in all of its forms and presentations. Acknowledging the correlation of harsh self-criticism with depressive difficulties, and self-compassion with psychological resiliency (Ehret et al., 2015), it feels pertinent for future research on NTS to also consider client levels of self-affiliation as well as their inimical self-processes.

Regardless of their SRQ self-report, all participants’ discourse provided a rich array of negative treatment of self, featuring both convergence and divergence with their self-appraisal. Meriting further study, these emerging inconsistencies suggested that the client’s self-report is not always a valid tool for understanding their self-relationship; conversely, the within-therapy discourse may not expose it either coherently or succinctly. Pointing to the importance of utilizing multiple methods for exploring and understanding the self-relationship, such inconsistencies support the use of methodological pluralism in research on psychotherapy and counseling (e.g. Klein & Elliott, 2006). Revealing and working with such discrepancies may be a crucial factor in understanding the self-relationship, particularly in the area of self-neglect, which due to its less obvious nature, tends to be overlooked. Notable is the scope for further study and development of EFT theory in relation to self-neglect, an area that can be difficult to effectively identify, measure and process as, stated by Elliott et al. (2004), ‘silenced self-aspects are typically implicit, undifferentiated, or inadequately symbolized’ (p. 38). Similarly, in their study of emotion-focused two-chair dialogue for self-criticism, B. Shahar et al. (2011) argued for more observational process research in association with the clients’ self-report, stating the importance of examining emotional processing and more implicit outcomes to more effectively address self-criticism. Additionally, this need for further research is reflected in the lack of negative treatment of self literature beyond the more physical and violent aspects of this phenomenon and self-criticism in general.

The development of this study enabled the deeper reading of the clients’ discourse, enhancing awareness of tacit processes and how they may present in therapy. This interpretative approach to reading and describing data is strongly underpinned by the researchers’ observation and perceptual styles, and in particular, by the theoretical understandings they bring to the research (Elliott & Timulak, 2021), thus different researchers might find somewhat different findings. Additionally, the limitation on the number of observations that were available for categorization due to the small sample size, may further contribute to variance when attempting any repeated classification of the data. While analyzing the data, it was often taxing to accurately classify due to similarities and subtle differences appearing across categories. Distinguishing between self-criticism and behavioral effects required repeated readings and was sometimes difficult because their expressions are so closely connected. Furthermore, the method applied in the microanalysis of the data was very labor-intensive, a potential disadvantage for its wider use.

This study is possibly the first investigation into the subtleties of negative treatment of self that amalgamates the variables of NTS objects or targets, modes or behaviors and emotional effects. Replicating and further developing the model is recommended in order to elaborate and refine the category structure and support the recognition of the various facets of NTS. Exploring the framework in relation to other presenting issues may assist the further development of specific clinical representations and interventions. In line with Elliott et al’.s (1994) Comprehensive Process Analysis, moving beyond the classification of negative self-treatment by scrutinizing any precipitating triggers and subsequent events may broaden understanding of the process of NTS. Moreover, whilst we observed and categorized what appeared to be the emotional effects of negative treatment of self, it is recognized that it may also be preceded or accompanied by other more general emotions and feeling states.

Conclusion

Broadening the definition and our understanding of negative self-treatment, this study highlighted the relevance of subtle and implied processes viewed in association with self-damaging behavior and its emotional effects. Paying closer attention to a client’s self-appraisal in conjunction with their within-therapy discourse may assist therapists in better understanding their clients’ NTS and can support more finely tuned therapeutic work. In the confusion of being both the attacker and the attacked, it is common for the inner critic and the ensuing suffering to evade awareness, resulting in conflicts between more conceptual, externally-originated aspects of self and the person’s in-the-moment lived experiencing. Perhaps it is within this discrepancy, the space in between, that we find the doorway to opening up self-neglect and other silenced aspects of self. Supporting and developing awareness of self-sabotaging patterns creates both a framework for understanding and the fertile ground for the introduction and application of a more self-compassionate way of being, learning to be fully present in one’s lived experiencing with an open heart toward all aspects of who we are.

Disclosure statement

No potential conflict of interest was reported by the author(s).