How Anxiety and Depression Can Affect Self-Esteem, Identity, and Self-Perception
A Conversation with Rebecca Peffer, LCSW, Associate Director, Adult Program, Compass Health Center – Silver Spring, about What High Functioning Anxiety and Depression Really Looks Like.
Anxiety and depression are easy to reduce to symptoms. The racing thoughts. The heaviness. The avoidance. The way everyday tasks start to feel more and more difficult.
The inner critic that gets louder.
What’s harder to name is what happens underneath: how your relationship with yourself can begin to change. Many people describe feeling like they’ve become a different version of themselves—more self-critical, less confident, less sure of who they are. Over time, negative self-talk can start to sound like truth.
In this Leadership Q&A, Britt Teasdale speaks with Rebecca Peffer, LCSW, Associate Director at Compass Health Center – Silver Spring, about how anxiety and depression shape self-esteem, self-worth, and self-perception, and what can help people rebuild a more accurate, flexible sense of self.
Rebecca explores how anxiety and depression can make negative self-talk feel convincing or even factual. She explains how these patterns influence identity, confidence, and everyday decision-making. She also discusses high-functioning anxiety and depression, and how structured treatment can help people rebuild a more compassionate view of themselves. Finally, she outlines signs that it may be helpful to consider a higher level of care when symptoms begin interfering with daily functioning.
The Connection Between Anxiety, Depression, and Self-Perception
Britt Teasdale: Rebecca, I’d love to hear more about you as a professional and what led you to Compass.
Rebecca Peffer
I’m a licensed clinical social worker. I’ve been in the behavioral health field for a little over 10 years now, both licensed and pre-licensed. I got my start in crisis intervention. I worked on an ACT team. I worked at a suicide hotline. And those experiences really were incredibly valuable to me, not only in teaching me very important skills, but also shining light on just how much need there is in the community, especially for folks with more serious mental illness.
After those experiences, I got my master’s degree and was able to practice clinical therapy. And I decided that I wanted to continue working with folks who are a little bit higher acuity.
I had the opportunity to work at some IOPs, some PHPs, for both mental health and substance use. And really, again, being drawn to being part of folks’ journey when they’re at their worst, I think, is a really special thing. The fact that people are able to come to you and trust you at the lowest points of their life is just really incredible.
And also, I love that level of care because we tend to see a lot of progress in a short period of time, and it’s really miraculous to witness. After I had that IOP and PHP experience, I did a short little stint in outpatient therapy. And it was a really great experience — again, a wonderful learning opportunity — but I decided that I missed the higher acuity level of care.
And so I had the opportunity to interview with Compass and I was really impressed by just how structured everything is. The curriculum is all evidence-based, which is something that’s really important to me. And also, with our KPIs and the fact that we’re a data-driven organization, knowing that we have evidence that this level of care and our treatment works was also something that was really important to me.
The love for this level of care, the great work that we’re doing at Compass, and also just a general passion for group therapy — that’s where I got a lot of my clinical start, and I think it’s something that is often undervalued.
Being able to be in the Associate Director role, where I would have the opportunity to help coach some of our group therapists and some of our other clinical staff to provide the best services possible, was really special and important to me.
Why Young Adults and Adults Are Vulnerable to Identity Shifts
Britt Teasdale: What is it about the young adult and adult population that interests you? Why did you decide to focus on that age group?
Rebecca Peffer
Especially with young adults, that is a very unique time in somebody’s life where they’re still working on identity formation — transitioning out of adolescence, where forming identity is kind of the main goal. They’re still working through that and also having to transition into some of those more adulting tasks and figuring out how to really function in society. And it’s just a very unique time where people tend to struggle a lot. I just saw a really great need for care there.
With the adult population as well, I think there’s kind of this sense that people are supposed to have it all figured out by the time they’re a certain age or they’re an adult. So being able to help de-stigmatize that mental health concerns or substance use can come up at any point in the lifespan — I think that’s a really important thing.
How Anxiety and Depression Affect Self-Esteem and Identity
Britt Teasdale: If we want to shift into this conversation around mood and anxiety disorders specifically: how do those challenges extend beyond what’s on the surface and into a person’s identity, feelings of self-worth, and self-esteem? I’m curious if we could jump into that for this young adult/adult population.
Rebecca Peffer
It’s pretty common for adults and young adults who are experiencing depression or anxiety or other mood-related mental illness to have their identity change in some ways as they’re struggling with those symptoms. There are a lot of different reasons for that, but typically how we see that showing up is:
Anxiety or depression really shift how we view the world. They shift our perception of the world. And that includes our self-concept. When we’re falling into patterns of thinking that we often see with anxiety and depression, it’s going to change how we see the world around us. It’s going to change how we see other people in our lives. And it’s also going to change how we think and view ourselves.
A lot of times that looks like our internal narrative being a lot harsher and also more rigid. We’re less likely to take in information that goes against our beliefs about ourselves or the world or the people around us. And then all of those changes to our self-esteem can become very cyclical, where the depressive symptoms are reinforcing those beliefs about ourselves. And so it’s very easy for that to become a place where somebody can get stuck in feeling really poorly about themselves.
Why These Shifts Often Go Unnoticed
Britt Teasdale: I can imagine if you’re struggling with a mood disorder or anxiety disorder, you probably don’t notice that shift happening. Is that fair to say?
Rebecca Peffer
It’s certainly going to depend on the person, but in general it is pretty common for these thought patterns or changes to self-esteem or self-identity to go unnoticed.
A lot of the changes that happen in thought processes and in mood show up in what we call automatic thoughts, right? These are thoughts that we’re not necessarily trying to have. It’s just sort of the background noise that’s constantly running in our head.
Oftentimes we’re not even consciously aware that our narratives about ourselves have shifted. Maybe one day we wake up and we’re like, “Wow, I feel really terrible about myself. How did I get here?”
Why Anxiety and Depression Distort Self-Image and Self-Worth
Britt Teasdale: What is happening psychologically that causes people to see themselves more negatively?
Rebecca Peffer
There are a couple of different things going on. One of the big things is that our brain naturally evolved to be threat-focused. So we’re constantly on the lookout for danger or what we might perceive as threatening. In the past, this helped us survive as a species. But especially if we’re more prone to anxiety, it leaves us vulnerable to misattributing harmless stimuli in our environments as potential threat.
A lot of times in our current society, what that looks like is viewing social situations as threatening — which is where social anxiety can come in — or even labeling some of our own behaviors as potentially threatening to relationships.
And as humans, we’re social creatures. Forming relationships is one of the main things that we do. So when we see ourselves as being a threat to our ability to connect socially, we tend to get really hard on ourselves so that we aren’t making those same perceived mistakes.
With that, we also tend to be hardwired to prioritize or focus on negative experiences. I always use the example: if I’m one of my ancestors, I don’t need to remember the twenty bushes that are safe. I just need to remember the one bush where that tiger jumped out at me that one time.
Our brain is hardwired to remember things we perceive as threats — things that feel dangerous or give us anxiety — which leads to perseverating or ruminating. If we see our own actions or traits as bad or threatening in some way, and we start to ruminate on that, it further reinforces the beliefs we have about ourselves.
Negative Self Talk, the Inner Critic, and Mental Health
Britt Teasdale: Is this the idea of an inner critic? And what’s the line where it becomes a barrier and starts impacting someone’s sense of self?
Rebecca Peffer
Yeah, that’s a great question. Like you said, we all have an inner critic and it does have that evolutionary function.
I think where it crosses the line into potentially having negative outcomes is when we’re not able to differentiate between what is a fact and what is a feeling — what is based in reality and what is just a thought.
A lot of us have that inner critic and we’re able to take a step back and say, “Okay, maybe I’m being harsh on myself,” or we can think of examples where we did something right or showed a strength. Whereas when we’re really stuck in anxiety and depression, our self-concept becomes so rigid that we really believe all the things the inner critic says, and we’re not as open to noticing evidence that might go against those thoughts.
How Mood and Anxiety Disorders Shape Identity Across Age Groups
Britt Teasdale: How does this look different across age groups — kids, teens, young adults, adults?
Rebecca Peffer
Anxiety and depression and the effects on self-esteem look different in different age ranges.
In kids, it tends to look more like behavior-based labeling — defining identity or worth based on a single event. So let’s say I’m a child and I was mean to a friend at school and I feel bad. Instead of being able to say, “Okay, I did a bad thing,” it becomes, “I’m a bad person.”
For teenagers, that’s really when we start to form a solid sense of self. So when teens are experiencing anxiety or depression and it changes their perspective on themselves, it can look like a lot of self-doubt or not having a strong sense of self. That can look like conforming to peer pressure or difficulty setting goals for the future.
For young adults, as I mentioned earlier, we’re still forming a solid identity and navigating work or higher education. That’s when we tend to see a lot of comparing out. Young adults might look at peers and say, “Why am I not performing as well as they are? Why am I not where they are in their career?” That reinforces negative self talk or beliefs about the self.
And then in adults — older adulthood or throughout the lifespan after young adulthood — it often looks like a lack of confidence. Sometimes it looks like feeling we lack a purpose, or feeling we’re not competent, or not knowing our strengths and how to use them meaningfully.
When Low Self-Esteem Becomes a Barrier to Treatment
Britt Teasdale: How can these feelings and thoughts make it harder to seek or engage in treatment?
Rebecca Peffer
After a while of that really negative self talk and those negative beliefs being reinforced, we unfortunately see that people can feel undeserving of help. That might sound like, “My problems aren’t big enough,” or “I don’t deserve to feel better about myself.”
There can also be hopelessness about the ability to change. When you’ve had a negative sense of self for so long, and it’s rigid and not open to being challenged, it can be easy to get stuck in the place of, “These things I think about myself are true, and there’s no hope of that changing.”
And especially with social anxiety, there can be fear of being judged. When you have a harsh inner critic already, you assume other people are thinking about you the same way you’re thinking about yourself. That can be really disheartening, especially when you’re thinking about going into a group space.
What You Can Say to Someone Who’s Hesitating to Get Help
Britt Teasdale: What would you say to someone who’s having these feelings — deciding whether to seek treatment or having trouble engaging in treatment?
Rebecca Peffer
The main thing I would say is that we do know — we have evidence — that it is possible to change our inner critic or our relationship with ourselves.
We have neuroplasticity, which is the brain’s ability to adapt and change throughout our lifespan. Both emotionally and on a neurological level, we know it’s possible for our relationship with ourselves to change.
I’ll be the first to admit that going to a program or getting help can feel scary. But from what I’ve seen, a lot of people have really good experiences. They learn a lot about themselves, make connections with others, and learn skills that help them manage anxiety and depression.
The number one thing I would say is there’s no harm in trying — and we are all deserving of love and care from others, and deserving of love and care for ourselves.
How Treatment Can Rebuild Self-Worth and a More Accurate Self-View
Britt Teasdale: When someone is engaging in treatment, what aspects of self-esteem and self-image tend to shift as symptoms improve?
Rebecca Peffer
Typically, the more somebody engages in treatment, the more we see their sense of self or identity become more flexible.
They’re able to shift some of the negative self talk and challenge some of the harsh things the inner critic says. They also recognize and accept that we’re complex and dynamic — we’re not one thing. We can hold multiple truths about ourselves at once.
With that comes the ability to be less judgmental — to say, “This is who I am,” and that’s neither a good nor bad thing. It just is.
Another thing we see is that people, after leaving programming or getting help to manage anxiety and depression symptoms, feel more confident in their ability to do hard things and tolerate discomfort. Whereas before, it’s easy to tell yourself, “I can’t do that.” So a big thing we see is willingness to try, and willingness to do things that otherwise might feel too scary.
Therapy Skills That Support a Healthier Relationship With Yourself
Britt Teasdale: What are some specific coping skills we teach at Compass that help people relate to themselves differently?
Rebecca Peffer
I could talk about this for ages. I’m a big believer in the skills. There are quite a few — I’ll choose the main ones.
Any skills related to challenging and reframing our thoughts are important. We all experience cognitive distortions, which are thinking errors — traps we fall into. We’re especially prone to believing them when we’re experiencing anxiety or depression because they reinforce how we feel and how we think about ourselves.
Cognitive reframing teaches people how to catch those errors and check the facts — decide, is this a fact or a feeling? And how can I reframe this thought to be more evidence-based or more neutral rather than overly negative?
There’s also cognitive defusion, which is not trying to change the thought itself, but changing how we relate to our thoughts. The idea is that we can recognize our thoughts are just thoughts. That doesn’t mean they’re necessarily true. And we can have those thoughts without engaging in them or letting them change how we feel about ourselves.
Another important category is identifying values and talking about values-based actions. Values are a huge part of self-identity, and most of us don’t spend a lot of time thinking about them. Being able to identify “Here are my values, here’s what’s important to me,” helps us work through discomfort.
For example: if one of my values is connection, but I have social anxiety, I’ve probably been avoiding social situations. Values-based actions allow us to say, “I’m going to sit with the discomfort of this anxiety in service of this value,” because that’s what I want my life to be filled with — connection.
And then the last broad category is emotion regulation skills. These help us identify and label what we’re feeling — because sometimes we know we feel something, but we can’t put our finger on it. Emotion regulation skills help us label emotions and manage them in ways that aren’t avoidance-based.
They focus on doing things aligned with our values, and on healthy ways to acknowledge and feel feelings without our feelings overtaking us.
Emotion Regulation Skills That Help With Anxiety and Self-Esteem
Britt Teasdale: Could you provide an example of one of those emotion regulation skills?
Rebecca Peffer
A lot of our emotion regulation skills involve mindfulness.
One that I think is really valuable is a body scan, or taking the next step into progressive muscle relaxation. That skill is essentially sitting down and scanning your body — noticing what’s happening physically and emotionally in each part of your body — to gain greater awareness of what you’re feeling, and what might be helpful in tolerating or changing those feelings.
How Group Therapy Builds Confidence, Skills, and Self-Worth
Britt Teasdale: How does group therapy specifically help with building these skills and rebuilding self-worth?
Rebecca Peffer
There are a lot of really awesome things about group therapy. One is that it provides a space for people to hear they’re not alone in what they’re experiencing.
When we have anxiety or depression — or negative self talk that changes how we view ourselves — it’s not uncommon for people to feel, “I’m the only one who feels this way.” Connecting with others who are experiencing something similar is really helpful and can automatically start to change that perception.
It also provides opportunities for patients to give feedback to others and prove to themselves that they have valuable things to share — valuable experiences for others. That sense of altruism matters: “I am able to help somebody else.”
And the group space is wonderful because it provides opportunities to practice skills daily — both in structured ways (“Today we’re working on this skill”) and informal ways.
If I’m struggling with social anxiety, I’m in a group of people, and I can use my skills to connect with others or feel more comfortable talking in front of a group. It’s direct exposure to some of the things that might feel anxiety-inducing.
What to Know If You’re Nervous About Group Therapy
Britt Teasdale: What would you say to someone who’s apprehensive about group therapy?
Rebecca Peffer
I think it can sound intimidating. But everybody in that group is there for the same reason — maybe not the same specifics, but they’re all there to feel better, to work on themselves, and to learn skills.
We tend to find it’s a very open-minded and welcoming place because we share that common goal of wanting people to feel their best and live their best lives.
Something I’ll say to patients on their first day is: we’re not expecting you to come into group and answer every question and pour your heart out in front of everybody. It’s okay to take time to acclimate. Nobody expects you to share anything groundbreaking or make huge strides in front of the group right away.
When to Consider a Higher Level of Care for Anxiety or Depression
Britt Teasdale: When would you say symptoms signal the need for a higher level of care?
Rebecca Peffer
Anytime somebody is experiencing chronic or consistent thoughts about harming themselves or potentially harming other people as a result of depressive symptoms — that would be a point where I would encourage folks to talk to current providers about exploring a higher level of care.
Outside of immediate safety concerns, if anxiety or depression symptoms are impacting someone’s ability to live the life they want to live, that can be a signal.
That might look like difficulty getting out of bed and taking care of activities of daily living — showering, brushing teeth, eating. Or if someone is depressed or anxious to the point they’re not able to go to work consistently, or care for their children or pets or parents — those would be signals that someone might need more support than what they’re currently getting.
High Functioning Anxiety, Depression, and Hidden Symptoms
Britt Teasdale: You hear terms like “high functioning anxiety.” Can that mask what’s really going on?
Rebecca Peffer
Yes. There are a lot of people who struggle with anxiety and depression and are still able to get up and go to work every day. From the outside, we might not recognize they’re struggling.
For those folks, I’d look at: one, is this sustainable? How feasible is it to continue living this way long-term?
And going back to values: maybe I’m able to do what I have to do, but am I able to find pleasure and enjoyment in my life? Is this the life I dreamed I would have?
High functioning anixety or depression can feel like going through the motions and not being able to enjoy life because of symptoms — even if other people can’t see it — that can be an indicator someone might need more support.
Key Takeaway: Thoughts Aren’t Always Truth
Britt Teasdale: If you could leave readers with one message about self-esteem and mental health, what would it be?
Rebecca Peffer
Anxiety and depression really change the way we view ourselves and the world around us by changing our perspective and how we interpret the world around us.
If there’s one thing I hope folks take away from this interview and from our programming, it’s that not everything you think is true. Not all feelings are facts. It’s important to question what we’re thinking about ourselves and recognize that not everything we think about ourselves is 100% accurate.
Britt Teasdale: Yeah, I think that’s huge. If you’re having a thought, it’s easy to assume it must be true, and then it can spiral. Is there anything we haven’t touched on that you think would add value?
Rebecca Peffer
No, I don’t think so. I would just reiterate that if depression, anxiety, or a mood disorder is something somebody is struggling with, they’re not alone — and change is possible.
It takes bravery to get help and tenacity to stick with it. Taking that step is a really huge and wonderful thing.
Bios
Rebecca Peffer, LCSW
Rebecca Peffer is an Associate Director at Compass Health Center and a Licensed Clinical Social Worker with over a decade of experience in behavioral health. She graduated with a BA in Psychology from Salisbury University and a MSW from the University of Maryland, Baltimore. Rebecca has worked across crisis intervention, ACT teams, suicide prevention, IOP, and PHP levels of care. Rebecca is passionate about evidence-based treatment, group therapy, and helping people build a more flexible and compassionate relationship with themselves.
Britt Teasdale, MFA
Britt Teasdale is Associate Director of Brand & Content at Compass Health Center and co-host of You Only Know What You Know, Compass’s mental health podcast for parents and caregivers. With a background in journalism and creative nonfiction, Britt specializes in translating complex clinical insights into accessible, human-centered storytelling for families, clinicians, and communities.
