CBT for Appearance Anxiety

Alex Clarke is a clinical and health psychologist specializing in disfigurement and altered appearance.Andrew R. Thompson is Reader in Clinical Psychology at the University of Sheffield NHS Clinical Psychology Doctoral Training Programme.Elizabeth Jenkinson is a registered Practitioner Health Psychologist, Chartered Psychologist and Senior Lecturer in Health Psychology at the University of the West of England.Nichola Rumsey is Vocational Training Charitable TrustProfessor of Appearance Research at University of the West of England and is Co-Director of the Centre for Appearance Research.Rob Newell is Emeritus Professor of Nursing Research at the University of Bradford.

• Foreword xvPreface xvi1 Background, Clinical Problems, Common Presentation and Treatment Considerations 1Physical and Treatment-Related Factors 3Socio-Cultural Factors 3Psychological Factors and Processes 3Body Image Disturbance 3Clinical Problems and Presentation 4Common Features in Referral 8Visibility of Condition 8Shame 9The Meaning of Visible Difference 9The Experience of Loss 9Physiological Responses 10Culture 10Gender 11Age 11Expectations of Treatment 11Association of Physical Change with Psychological Outcome 12Fix It Solutions 12Treatment Considerations 132 A Stepped-Care Approach to Psychosocial Intervention 15The PLISSIT Model 16Level 1: Permission 16Level 2: Limited Information 18Level 3: Specific Suggestions 18Level 4: Intensive Treatment 193 Models and Frameworks: Expanding the Conceptual Approach to Managing Appearance-Related Distress 21Explanation for Choice of Therapeutic Approach 22Behavioural Approaches: Fear Avoidance and Social Skills Training 22Building an Evidence Base 25Cognitive Approaches: Comparison of Appearance Anxiety and Social Phobia 26Use of Safety Behaviours 28Anticipatory and Post-Event Processing 29The Role of Assumptions and Schema in Appearance Anxiety 32Summary 33Deriving a Cognitive Behavioural Treatment Model: Identifying Factors and ProcessesContributing to Successful Adjustment to Disfiguring Conditions 34Working Framework of Adjustment to Disfiguring Conditions 34The ARC Framework of Adjustment to Disfiguring Conditions 34Predisposing Factors 35Intervening Cognitive Processing 36Socio-Cognitive Processing 37Outcomes 41The ARC Research Programme Findings 43The Studies 43Summary of Findings 43Key Messages from the Research Programme 45Implication of These Findings for Design of Interventions 45Summary 474 Clinical Assessment 48Eliciting the Problem 49Summarizing 51Motivation and Self-Efficacy 52Readiness for Change 53Measurement Tools 55Generic Measures of Psychological Constructs (as used in the ARC Study) 55Measures of Psychological Constructs Specifically Related to Appearance 57Measures of Body Image 58Measures of Psychological Constructs Specifically Related to a Condition Type 58Body Dysmorphic Disorder (BDD) 59Core Clinical Dataset 59Regular Subjective Measures of Frequency for Events, Thoughts and Feelings 60Goal Setting 61The SMART Acronym 61Challenges in Treatment for Appearance-Related Problems 62Introducing a Biopsychosocial Model 62Treatment ‘buy-in’ 635 Social Skills and Coping Strategies 64Staring, Questions, Comments and Loss of Anonymity 66Making the Most of Appearance 66Developing a Positive Approach to Visible Difference 67Posture, Smiling and Eye Contact 67Developing Verbal Skills 68Learning to Have a Conversation 68Answering Questions About Appearance 68Managing Staring 70Putting it into Practice 71Taking the Initiative in Social Encounters 72Managing Anger and Developing Assertiveness 73Anger 73Managing Intimacy 75Disclosing a Disfiguring Condition to a Partner 75Summary 776 Cognitive Behavioural Therapy 78Techniques in Cognitive Behavioural Therapy 79Socratic Dialogue 79Eliciting Negative Automatic Thoughts 82Unhelpful Beliefs Record Form 84Negative Automatic Thinking Styles Associated with Anxiety 84Triple Column Technique 87Pie Charts 87Manipulating Safety Behaviours 88Anxiety management techniques 88Target, Tools, Troubleshoot, Test 89Cost–Benefit Analyses 90Some Techniques for Dealing with Appearance-Related Self-Criticism and Shame 93Functional Analysis of Self-Criticism 94Identifying the power of self-criticism 94Summary 977 Planning Treatment and Sessional Guides 98Introduction 102Working at Level 1 102Working at Level 2 104Working at Level 3 105Session 1 106Structure Outline 106Working at Level 3 Using FaceIT (www.faceitonline.org.uk) 108Working at Level 4 using CBT 108Planning Treatment and Sessional Guides 108Clinical Examples 112Example 7.4 112Session 1 112Session 2 116Review Data 116Set Agenda 116Restatement of Formulation 117Elicit Patient Understanding 118Session 3 118Review of Homework and Reformulation 118Set Agenda 119Introduction to Answering Questions About Her Face 119Role of Self-Focused Attention Discussed 119TTTT 119Homework 119Session 4 119Review of Homework and Reformulation 119Set Agenda 120Reattribution of Beliefs 120Design Behavioural Experiments 121Homework 121Session 5 121Review of Homework 121Set Agenda 121Strategies for Attentional Training 122Development of Personal Coping Approaches 122Homework 122Session 6 122Review of Homework 122Measure Noticeability and Worry 122Reattribution of Beliefs 122Feedback from Behavioural Experiments 122Development of Personal Coping Approaches 123Homework 123Session 7 123Review of Homework 123Set Agenda 123Schema-Focused Reattribution 123Preparation for Ending 123Homework 123Session 8 124Review of Homework 124Schema-Focused Reattribution 124Planning for Ending 124Homework 124Session 9 124Homework 124Agenda 124Outcome 125Example 7.5 126Session 1 126Summary 129Session 2 130Review Data 130Introduction to Social Comparison Processes 130Restatement of Formulation 130Elicit Patient Understanding 131Introduction to Compassionate Thinking 132Homework 132Session 3 132Review of Homework and Reformulation 132Set Agenda 132TTTT 132Introduction to NATs 132Section 4 133Review of Homework and Reformulation 134Set Agenda 134Reattribution of Beliefs 136Design Behavioural Experiments 136Session 5 137Review of Homework and Reformulation 137Set Agenda 137Session 6 137Review of Homework and Reformulation 137Set Agenda and Review Progress 138Measure Noticeability and Worry 138Reattribution of Beliefs 138Feedback from Behavioural Experiments (Disclosure) 138Homework 138Sessions 7, 8 and 9 138Review of Homework and Development of Final Reformulation (See Figure 7.13) 138Set Agenda 139Focus on Schema-Focused Reattribution 139Session 10 140Outcome 140Example 7.6 140Session 1 140Summary 144Session 2 144Review Data 144Noticeability and Worry Graph 145Set Agenda 145Introduction to Social Comparison Processes 146Self-Efficacy 146Safety Behaviours 146Restatement of Formulation 146Homework 147Session 3 147Review of Homework and Reformulation 147Set Agenda 147TTTT 147Anxiety Management 148Introduction to NATs 148Homework 148Session 4 148Review of Homework and Reformulation 148Set Agenda 148Design Behavioural Experiments 149Homework 149Session 5 149Review of Homework 149Set Agenda 149Homework 149Session 6 150Review of Homework 150Set Agenda 150Measure Noticeability and Worry 150Design of Behavioural Experiments 151TTTT: Role Play Her Response If Her Breasts Are Mentioned 151Homework 151Session 7 151Review of Homework 151Set Agenda 151Focus on Reattribution 151Preparation for Ending 152Homework 152Sessions 8, 9 and 10 152Session 11 152Homework 154Agenda 154Outcome 154Example 7.7 154Session 1 154Summary 157Session 2 157Review Data 157Plan Homework 158Therapeutic Buddy 158Homework 158Session 3 158Review of Homework and Reformulation 158Homework 159Session 4 160Review of Homework and Reformulation 160Set Agenda 160Set Homework 160Session 5 160Review of Homework 160Set Agenda 160Homework 161Session 6 161Review of Homework and Reformulation 161Set Agenda 161Completion of Rating Scales and Outcomes 161Sessions 7 and 8 161Set Agenda 161Session 9 162Completion of Rating Scales and Outcomes 162Summary and Feedback 162Outcome 162Long-Term Outcome and Maintenance of Change 162Complete Maintenance 162Partial Maintenance 163Slip-Back and Sub-maintenance 163Slip-Back and Failure 163Social Support and Therapeutic Partners 164Summary 164Additional Resources 1658 The Emerging Adult: Facilitating Transition from Child to Adult Service 166Introduction 167Introducing the Problem of Transition 167Transition from the Young Person’s Perspective 168Transition from the Parents’ Perspective 168Transition from the Health Professionals’ Perspective 168Guidance for Improving Transitional Care 169Issues Pertinent to Caring for Young People with Appearance Concerns 170The Salience of Appearance to Young People 170Reluctance to Seek or Accept Support 171Factors that Can Promote Adjustment to a Visible Difference among Young People 171Romantic Issues 173Transition as an Opportunity for Those with a Visible Difference 174Concluding Remarks 1759 Psychological Assessment for Cosmetic Surgery 176Introduction 177Is Cosmetic Surgery Effective? 177Access to Surgery in the NHS 178Psychological Screening by the Surgeon 179NICE Guidelines 179Onward Referral 179What Does the Surgeon Want from a Psychological Assessment? 180What Does the Patient Want from a Psychological Assessment? 181A Framework for Psychological Assessment 181Case Examples 183Common Problems in Referral 189Liaising with the GP 189Health Professionals’ Knowledge of Cosmetic Procedures 189Summary 190Additional Resources 19010 Models of Service Delivery 191Lay-Led Support 192Specialist Services 192Outlook 192Embedded Services 192Royal Free Hospital, London 192Access to Psychology Services 192Access to Mental Health Services 193Mapping Service Models onto Stepped Care 193Appendix 194Resources 272References 280Index 293

“This book is perhaps most useful for those working with individuals where appearance anxiety is the result of an observable visible disfigurements as this is clearly the main focus of the book.”  (Behavioral and Cognitive Psychotherapy, 1 May 2014)