How to Document “Low Self-Esteem”

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 anothers 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,

DO NOT…

• 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.

INSTEAD…

1. 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?”
2. 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.)
3. 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.

Beth Rontal, LICSW, a private practice therapist and the Documentation Wizard® is a nationally recognized consultant on mental health documentation. Her Misery and Mastery® trainings and accompanying forms are developed to meet strict Medicare requirements. Beth’s Documentation Wizard® training program helps clinicians turn their clinical skill and intuition into a systematic review of treatment that helps to pass audits, protect income, maintain professional standards of care, reduce documentation anxiety and increase self-confidence. Beth’s forms have been approved by 3 attorneys and a bioethicist and have been used all over the world. She mastered her teaching skills with thousands of hours supervising and training both seasoned professionals and interns when supervising at an agency for 11 years. Her newest initiative, Membership Circle, is designed to empower psychotherapists to master documentation with expert guidance, efficient strategies, and a supportive community.