How to Document Low Self-Esteem to Pass Audits

Esther Perel's definition of self-esteem, "Seeing yourself as a flawed person, and still holding yourself in high regard," beautifully captures the complex nature of self-esteem. Clients often enter therapy with a profound sense of brokenness and hopelessness. They start by acknowledging their low self-esteem and struggle to envision a future where they could genuinely hold themselves in "high regard."

Documenting “low self-esteem” may not pass an audit.

Even though low self-esteem is a diagnostic criterion for Dysthymia, insurance companies do not cover or pay for sessions aimed at “improving self-esteem.” Our professional boards will question it as well. The reason is because this description lacks the specificity they require. Insurance companies and our boards, as well as our clients, and ourselves, want a client-centered approach that focuses on treating the individual rather than a general diagnosis or non-descript symptom.

Despite how common the experience of having lose self-esteem is, documenting low self-esteem is not as simple a process as one would expect. Self-esteem is such a commonly used word it seems that everyone should intuitively understand what it is. It might seem instinctive to set the therapeutic goal of "improving self-esteem." But it’s not the goal or destination of therapy. The reality of what low self-esteem is and how to document it is more nuanced and intricate than a simple quest for higher self-esteem.

If improving self-esteem is not the goal, why not? What is the goal?

Simply put, low self-esteem manifests differently from one person to another. To effectively document develop goals and measure progress for low self-esteem, it's important to identify and describe the specific behaviors associated with each client. This makes clinical sense because change doesn’t show up as a noun. Change shows up as a verb. Change shows up as a change in behavior!

During my 11 years of supervising clinicians at an agency, one of my supervisees often described several clients with low self-esteem. Upon reflection, she was able to describe what low self-esteem looked like for each one. She could articulate what it made each client do or not do. In other words, what behaviors illustrated their lack of confidence?

One client engaged in risky behavior, such as having multiple sexual partners with people he did not know. A different client refrained from risk taking by not applying for a job promotion due to a lack of self-confidence.

One person limits their life by taking too much risk. The other client limits their life by not taking risks. These are two vastly different descriptions of poor self-esteem and need to be documented as such.

Since there’s a big difference in presentation, there will be a big difference in goals, interventions, and progress. The corresponding goals for one client would be to reduce risky behaviors and for the other to increase the ability to take risks. Now we have behavior that can be measured and documented.

When documenting low self-esteem, don’t:

• Utilize "poor self-esteem" as the primary clinical problem description.
• Write "improve self-esteem" as a goal on a Treatment Plan.

Instead, follow these guidelines:

1. To both prevent any potential recoupment or clawback during an insurance audit and to empower clients in recognizing when their lives are improving, describe the negative behaviors associated with low self-esteem that will change as self-esteem improves. This approach aligns clinical practice with insurance standards and promotes the client's well-being and self-awareness.
2. Describe how low self-esteem presents in the client's Presenting Problem of the client’s treatment plan. You may ask your client questions like, "How does poor self-esteem affect you?" Or “What does poor self-esteem make you do or not do?” Get as specific as you can with frequency, intensity, and duration.
3. In the Goal section, specify the expected changes in these behaviors once the client's self-esteem has improved. This not only aligns with insurance requirements but also helps both the client and the therapist track progress effectively by observing positive changes in behavior over time. To help you and the client recognize appropriate goals, you may ask a question like, “If your self-esteem was better, what would you be able to do or not do?”

Thanks to Esther Perel for her insightful definition of self-esteem. The complexity of her definition helps us recognize how important it is to describe specific behaviors. This personalized and quantified approach helps describe a more accurate representation of the client's unique experience.

While insurance companies may not cover "low self-esteem" as a standalone treatment, they are more likely to support interventions aimed at reducing or eliminating risky behaviors and enhancing work performance. By focusing on these specific behaviors, we not only meet insurance requirements but also provide clients with concrete indicators of progress. We’re writing a useful treatment plan for a real person, not for a diagnosis. When the desired goals are achieved, like all of us, our clients may still have their flaws, but because of the changes they recognize, they can hold themselves in higher regard. (Goal Achieved!)

For a thorough explanation of what and how much to write in your progress notes, treatment plans and the other documentation essential for clinical practice, check out my PESI course, Mental Health Documentation & Medical Necessity: Simple, Clear Guidelines that Maintain Quality of Care and Protect Your Practice and the Documentation Wizard℠ Clinical Forms.

If you struggle with completing notes on time, download Beth's free 25 Tips for Getting Notes Done for quick completion recommendations from the Documentation Wizard.