Please note that this is an Archived article and may contain content that is out of date. The use of she/her/hers pronouns in some articles is not intended to be exclusionary. Eating disorders can affect people of all genders, ages, races, religions, ethnicities, sexual orientations, body shapes, and weights.

By: Randy K. Hardman, PhD

Please note that this is an Archived article and may contain content that is out of date.

It is apparent to me from years of work with women who suffer with anorexia and bulimia that they often have a great deal of confusion about who they are and their different aspects of self. Much too often, these clients believe that who they are is found only in what they do, and that what they do is the only indicator of their self-esteem or self-worth. This confusion about the different aspects of self can create a lot of problems in the recovery process because clients keep applying their externalized sense of self to the recovery process. The externalization of self prevents clients from working the internal and relationship shifts in their lives that are necessary components of healing and recovery. In addition, many clients lump together all three aspects of self and tie all of their self-esteem and self-worth to their ability to be perfect or to do things perfectly well. As their eating disorder has worsened, their esteem and worth have also been tied to how well they do their eating disorder.

In my study of writings on self-esteem and self-efficacy, I have come to recognize the value of helping my clients utilize a simple therapy model in clearly separating the three aspects of self so each is distinct and unique from the other. I also help them understand the important connections between self-confidence, self-esteem, and self-worth. In view of the literature on self-esteem and self-efficacy, I recognize that my therapy model is simplified and not complete, but it has proven to be very helpful to many eating disorder clients in the development of new approaches to themselves and in strengthening each aspect of self in their recovery.

Three Aspects of Self
Self-Confidence My sense that I can do something well.
Self-Esteem My inner relationship with myself.
Self-Worth My sense of belonging and uniqueness within my most important relationships.


Self Confidence

In this model, self-confidence is described as “I know I can do something well,” or “I have confidence in my ability to do a specific behavior, task, or activity well.” Low self-confidence is simply described as the opposite: “I don’t believe in my ability to do a specific behavior or activity well.” Either way, the focus of self-confidence is on something external, such as what they are doing or how they are performing specific behaviors. Examples of self-confidence are, “I know I can write well”; “I can speak to a group of people in an effective way”; “I can do well on school assignments”; or “I am good at a certain type of work I do at my job.” Unfortunately for too many women with anorexia or bulimia, this doing aspect has become their only evidence of whether they are okay or not okay, and thus they have distorted this simple notion of self-confidence. They often exert great internal pressures on themselves to perform, achieve, please, or accomplish goals at extremely high levels of behavior. Clients are often disappointed in their inability to reach their unrealistic goals or their very narrow and specific personal expectations. As a result, clients can suffer a great deal of low self-confidence, which is filtered and interpreted in their minds as low self-esteem or low self-worth. Many of the women that I work with in therapy, who I recognize as being extremely talented and capable individuals, are very good at doing many things, but because of their misunderstanding of the three aspects of self, they often end up feeling badly about themselves. They will perceive themselves as not good or not good enough, or believe they are failing at life, when in fact, those false internalized conclusions about themselves have nothing to do with self-esteem or self-worth. If clients do not keep self-confidence separate from self-esteem, then they will translate a lack of self-confidence in some specific behaviors as evidence that they are not okay as a person. This translation often leads to the avoidance patterns, so clearly described in Dr. Berrett’s article in this newsletter, or leads them to be negative with themselves for self-perceptions that are based in these external deficiencies.

One way to increase self-confidence is to help clients keep “who they are” separate from “what they do,” and then to help the client focus on experimenting, practicing, and risking at doing things better.

Clients can learn that who they are as people is much more than what they do or how they perform an activity. Doing is only one part of who they are as human beings. In the literature of the 1980’s, they are not “human doings” but rather “human beings.” So self-confidence grows as clients take risks. Risking is the key to strengthening self-confidence. It is impossible to take risks in behaviors if their personal “value” and “worthwhileness” are based on how well they do things and nothing else. Learning to separate “what they do” from “who they are” allows them to take the very risks that will lead to the development of the new skills and abilities they need in life and social settings. Their self-confidence will grow as they develop new talents and get better at what they are doing to help themselves in the recovery process. It is not uncommon for those suffering with eating disorders to believe that whatever new task is required of them, they need to immediately do it well or do it better than others, without any time or room to practice or improve at the task. So part of their refusal to take risks is to avoid feeling vulnerable or stupid, and this refusal is based more on their misunderstanding of self-confidence than it is on their natural abilities and talents. To feel vulnerable in new behaviors is a normal part of change and a normal part of building self-confidence.

Part of helping clients in the process of building and strengthening self-confidence is to approach changes as an ongoing learning curve or as practice time to develop new skills and talents. Practice and risk are normal parts of growth, learning, understanding, and improvement in life, and are better than focusing on the constant negative evaluations, criticisms, or assessments of their performance. The therapy question, “What did you learn from this experience?” rather than “How well did you do?” will support clients in pursuing activities that they avoided in the past because of their fear of failure. Doing new things or doing old things differently are very important parts of recovery, but recovery from an eating disorder is also much more than what clients do on the outside.


Self-esteem is described as “My inner sense of self” or “How I am inside of me.” It is helpful to point out to clients that they have a relationship with themselves in which they make sense of who they are by the way they respond to and treat themselves on the inside through internal dialogue or internal communication. Clients will readily recognize an inner relationship with themselves but often perceive their negative mind, their self-rejection, and their self-disapproval as a natural consequence of their poor behavioral performances, imperfections, or inabilities to do things as perfectly as they need to in order to be “okay.” The concept I am trying to help them understand is that the manner in which they treat themselves internally is the key to a gradual shift in the development of positive self-esteem. The therapy questions are, “Are you kind to you, or are you mean to you?” “Are you self-rejecting, or are you self-accepting?” “Are you critical of yourself on the inside, or are you compassionate of yourself?” “Are you self-respectful, or are you self-demeaning?” As clients go through these inward-focusing questions, it becomes apparent to them that the majority, if not all, of their internal messages to themselves are on the negative side of rejection, punishment, and other self-critical forms of communication. Self-esteem can be based on internalized messages they may have heard or received from their significant others as they were growing up, but now they have internalized those same beliefs as their own and turned these core messages into “how-I-am beliefs” about themselves. Self-esteem can be seen on the continuum between positive and negative self-messages that say a whole lot less about “who I am,” and say a whole lot more about “how I am” with myself. Self-esteem is about being okay. Low self-esteem is about not being okay. Self-esteem is about being enough, whereas low self-esteem is about not being enough. No matter how well a client can do things or how positive other people think of them, it is still their view or their sense-of-self that determines whether they feel acceptable or unacceptable within themselves.

In the extensive literature on Shame, it is obvious that shame, which creates a sense of being unacceptable, flawed, or broken, has a great impact on these internal communications and relationship with self. An important effect of healing shame in eating disorder recovery is that it greatly strengthens self-esteem. Shedding the false self messages of shame can begin to open the possibilities of self-forgiveness and self-acceptance. As described in Dr. Berrett’s article, avoidance patterns can do great damage to self-esteem. Living out of harmony with the strongly held internal beliefs, commitments, and values that a client has will greatly contribute to negative self-esteem. Living congruently with what they believe, their values, and what matters to them most will strengthen self-esteem because it strengthens the internal messages that say, “I am okay,” or “I’m congruent with myself,” or “I feel good about me and how I’m living my life.” Eating disorder clients, it seems, at times, only hear those extremely negative, deprecating, and accusatory messages of self that tell them they are not okay. The problem is that almost all of those messages are again tied to the externalized confusion of self-esteem. I want to help clients recognize that self-esteem is internal, and because self-esteem is internal, they have the power to make new relationship choices within themselves that are very different than the old negative messages from the past. Positive self-esteem can grow, improve, and develop by changing and correcting the internal messages given to one’s self to messages that are much kinder, more validating, and more accepting toward themselves. In this pursuit of self-esteem, clients look to themselves to be the source of strength, and look less to the externalized “other esteem” evidences of value.

In my work with eating disorder clients, it is often evident that there are loving people in their lives who send them positive and affirming messages to no avail, because these messages are not well accepted or quickly become twisted and transformed into some kind of negative evidence against themselves because of the painful internalized messages of self. I typically put more emphasis on self-kindness and self-compassion than any other concept in working with strengthening self-esteem, because typically, eating disorder clients are very kind and compassionate with others and I want to find a way to translate this relationship approach back to themselves. Self-acceptance is more about how well they treat themselves than how well they do (self-confidence), more about the truth that all people have pluses and minuses, strengths and weaknesses, and that self-acceptance means they accept all parts of themselves and not just the great parts. It is essential that they are kind internally to themselves in their weaknesses, struggles, and in their deficiencies, so that out of that kind and compassionate relationship within themselves they can strengthen and build their self-esteem and self-respect. It helps clients to recognize that what is true about others is also true for them. They can learn that what makes them okay is what also makes other people okay. Clients can begin to accept that the difference between them and someone else who struggles with the same insecurities, fears, and doubts, but who seems more content, satisfied, and happy with themselves, is not their ability to do things better but their internal self-kindness. It is not that somehow they are better in comparison, but rather it is simply that this other person is kinder and more self-accepting in their relationship to themselves. Criticism, harshness, shaming messages, and perfectionism encourage clients to relate negatively to themselves and lead to a great deal of internal conflict, pain, and patterns of avoidance in life. The connection between self-confidence (in doing well) and self-esteem (in being okay) is that clients can learn to trust themselves in both aspects of self. It is important for them to learn that who they really are is much more than what they do, how they look, or how well they perform. Doing well is an important value. Working hard, achieving, and accomplishing positive things are good qualities that can support positive self-esteem. Self-confidence can be very helpful in their lives, but being self-accepting, self-kind, and at peace with themselves (self-esteem) is an important and powerful aid in the road to eating disorder recovery. Forgiveness, heartfelt verbal expressions, honest emotions, creativity, positive self-feedback, validation of personal qualities and attributes, love, gentleness, validation of self, giving, recognizing good motives and intents in one’s self, are all quiet but powerful ways to strengthen and build self-esteem in the recovery process.


Self-worth is described as “My understanding of my valuable and important place in life in relation to God, family, and friends,” or “My sense of belonging and uniqueness within my most important relationships.” Self-worth grows out of a personal sense of belonging, fitting in, being included and wanted in relationships, and a knowledge they are truly loved and valued by others. Self-worth is tied to a sense of being worthwhile and meaningful in the context of personal, spiritual, and social relationships. Self-worth is often expressed as a spiritual connection that clients can feel in their relationship with God. It is also their sense of being important, connected, and having a sense of belonging to family members, friends, and other worthwhile social connections. They know in their hearts that they matter within the context of those relationships. They have a feeling of purpose, meaning, and value within their enduring relationships. They know their presence makes a difference in these relationships, and when they are absent, they are truly missed. They feel appreciated and recognized as their own, separate selves. These relationship connections are what build self-worth. Self-worth is oftentimes a sense of heart. It is an intuitive sense of knowing and understanding beyond thoughts and even beyond feelings that “who I am is important to God and to others, and that their love, concern, and involvement in my life are some of the evidences of that worth.” Self-worth is not about pleasing or winning approval from other people but instead it is a cherished connection of love, acceptance, and inclusion.

Since self-worth is tied to the heart, I encourage clients to let love out and let love in, and to accept other people’s acceptance of them. I encourage them to be willing to come from this place of belonging in their relationships instead of hiding in isolation, loneliness, and emptiness while being surrounded by people who truly care about them and who have a place for them in their hearts. Since being important and valuable is not about performance or ability, but rather about a sense of being needed and valued in a significant relationship, it is often part of the process of strengthening self-worth to resolve and heal from some of the past damaging relationships among family, peers, God, or religious and spiritual leaders in which they felt they were undervalued, demeaned, or unimportant. It helps clients to recognize that as painful as those past experiences have been for them, they do not have to remain permanently stuck in that place for the rest of their lives. They can strengthen and change their self-worth by opening their hearts again to the love, acceptance, and personal involvements that are available now in their relationships with God, family, and others. They can learn to become better receivers of those valuing messages in their lives. It is difficult at first, for many women suffering with eating disorders, to let those messages of love and acceptance in from God and others, but when they do, and as they become better at receiving love and valuing messages from their important relationships, this is what I would describe as a change of heart, a blossoming within, or an enlarging effect which strengthens their self-worth. Self-worth is its own separate aspect of self, but it interacts powerfully with self-esteem and self-confidence.

If a person has a clear sense of belonging and importance within the context of a relationship, they will then approach other relationships with confidence and positive energy because they have already developed a felt sense of self-worth. Their ability to relate positively to others significantly grows because they have opened the doors to the love coming to them within the context of these significant relationships.


In conclusion, these three aspects of self are uniquely different from each other, but they also interact powerfully with each other. Again, the focus of self-confidence is on the outside or external evidences of behavior. Self-esteem focuses on the inside or internal relationship within one’s self. In the broader context of relationships, self-worth is both an internal and an external experience. Being aware of and including these three aspects of self allows clients to emphasize different approaches and strategies in their healing and recovery from an eating disorder. I have observed this powerful shift over many years as I have seen clients operate more from the inside out in the way they live their lives in terms of self-esteem and self-confidence, and operating better from the outside in, in terms of love and self-worth, developing a full sense of self. As clients experience all three aspects of self, they can continue to actively develop and strengthen their self-confidence, their self-esteem, and their self-worth as part of their recovery. Many clients have found this simple model to be helpful to them in their journey of recovery.