Esther Perel’s definition of self-esteem is, “Seeing yourself as a flawed person, and still holding yourself in high regard.”
It’s a common occurrence that clients come to treatment feeling broken and hopeless, reporting low self-esteem, and not believing they will ever be able to hold themselves in “high regard.”
One of the criteria for Dysthymia is “low self-esteem”. So “improving self-esteem” seems like a reasonable therapeutic goal, right? Wrong!
Insurance companies do not authorize or pay for sessions to “improve self-esteem” because it is not descriptive enough.
Insurance companies want to know you are treating a person, not a diagnosis. One person’s low self-esteem looks different than another’s and measuring self-esteem is impossible without describing behavior. So it makes sense to find out the behaviors that demonstrate low self-esteem specific to the client. It also helps the client and the therapist identify when things are changing — because change shows up in behavior. So,
- include, “poor self-esteem” as a description of a clinical problem.
- use ‘improve self-esteem” as a goal on a Treatment Plan or Session Note.
- Describe how the low self-esteem looks in the Presenting Problem. You might ask your client, “What does low self-esteem make you do or not do?”
- Then, when describing the Problem, document that behavior. You can even use the client’s own words. (If you do, remember to put them in quotes.)
- In the Goal, document what will happen to the behavior when the client’s self-esteem has improved.
For example, when I supervised clinicians at an agency for 11 years, one supervisee told me that several of her clients had low self-esteem. When I asked her what that looked like, she reported that one client, “slept with a lot of guys”. Another client didn’t apply for a job because he didn’t think he could get it. These two very different presentations of low self-esteem need to documented as such.
An insurance company may not pay for low self-esteem. But they will pay to reduce or eliminate engagement in risky behavior and improve work performance! Plus, you and the client have now identified key behaviors that indicate when self-esteem is improving. When the goal is reached, the client, like the rest of us, is still flawed — but also still able to hold themselves in high regard. (Goal Achieve!)
Thank you, Esther Perel for a great definition of self-esteem. To prevent a recoupment or claw back from an insurance audit — and to support the client in knowing when life is getting better, describe specifically the negative behavior that will change when self-esteem improves.