First do no harm: don't counsel to increase self-esteem

I sit with another unhappy patient with low self-esteem and a catalogue of problems about which I am powerless to do anything. I wonder quite what I can do that the individual in front of me might find helpful. Of course I can listen and empathise, and I'm sure that this helps to an extent, but what would really make a difference? So, stuck with anything to suggest, I ask a question ‘What do you want from life?’. And the reply that comes back is, ‘I just want to be happy’. Blaise Pascal wrote: ‘All men seek happiness. This is without exception. Whatever different means they employ, they all tend to this end. The cause of some going to war, and of others avoiding it, is the same desire in both, attended with different views. This is the motive of every action of every man, even of those who hang themselves.’1

If Pascal is right, my next question must be, ‘Of course you do, but what will make you happy?’. And it follows that we need to be sure that that which is ‘the motive of (our) every action’ really will make us happy. Otherwise our lives will remain unhappy. So what do we pursue to make us happy? In the medical setting for many it is ‘As long as I've got my health’. Elsewhere, for some it is money, for others it is status. For others it may be food, or alcohol, or sex, or relationships, or holidays, or possessions, or success, or acclaim, or all manner of other minor pleasures with which we seek to reward ourselves, to stroke our egos, to affirm our worth, and boost our self-esteem by gently whispering to ourselves ‘You're worth it, you're somebody’. But the effect is short lived and, once again, we seek one more shot of self affirmation.

Michael Horton in his book Too Good to be True writes: ‘The demand for glory, power, comfort, autonomy, health and wealth creates its own industry of therapists and exercise, style and self-esteem gurus — and churches — to massage the egos wounded by this hedonism. When crisis hits, the soul is too effete to respond appropriately. We become prisoners of our own felt needs, which were inculcated in us in the first place by the very marketplace that promises a ‘fix’. We become victims of our own shallow hopes. We are too easily disappointed because we are too easily persuaded that the marketplace always has something that can make us happy.’2

Could it be that our obsession for self-esteem is actually counterproductive? Could it be that happiness is found outside of ourselves? And so I ask another question: ‘Have you ever climbed to the top of a mountain and admired the view, or looked up into the night sky and been amazed by the stars, or stood on the coast when the waves are crashing against the rocks? And when you have been in that place have you thought “I could stay here and enjoy that view forever”?’. Most people I ask readily agree that they have. At that moment they have felt happy, satisfied, not because of who they are or what they have, but because of what they are experiencing — that is, they are standing on the edge of greatness and are satisfied simply by witnessing that greatness. John Piper asks: ‘Do people go to the Grand Canyon to increase their self-esteem? Probably not. This is, at least, a hint that the deepest joys in life come not from savouring the self, but from seeing splendour.’3

He is right. We go to the Grand Canyon not to boost our self-esteem, but to go ‘Wow!’.

CS Lewis, perhaps best known as the author of The Chronicles of Narnia, in his essay The Weight of Glory commented that our desires are: ‘… not too strong, but too weak. We are half-hearted creatures, fooling about with drink and sex and ambition when infinite joy is offered us, like an ignorant child who wants to go on making mud pies in a slum because he cannot imagine what is meant by the offer of a holiday at the sea. We are far too easily pleased.’4

So what should be the advice to my unhappy patient? Of course listen and empathise. Of course provide them with any help I can, or direct them to those better positioned to do so. But should I try to boost their self-esteem? Could it be that to do so would be to give yet one more fix of ‘You're OK’ and deepen my patient's addiction to self? We must first do no harm. Could it be better to encourage them to look outside of themselves and search for that which is truly great? Of course my patient wants to be happy. I want them to be happy, infinitely and eternally happy. For that they don't need high self-esteem but to esteem highly the infinitely and eternally great.

• © British Journal of General Practice, 2007.