Intervention: Approaches and sources

of support

Goals of this module

• To be able to:• Recognise the continuum between normative

discontent and extreme body image anxiety• Identify excessive concern• Discuss this sensitively & give helpful advice• Understand treatment approaches • Recommend sources of support

ACTIVITY ONE

• write down one thing that you really LIKE about your appearance

• write down one thing that you really DISLIKE about your appearance

Thinking about the feature that you DISLIKE:

• On a scale of 0 – 10

• How noticeable is it to others? /10• How much do you worry about it? /10

Noticeability

Distress

Plot your score below:

0

10

10

Noticeability

Distress Plotting noticeability and worry

A

B

C

D

A: highly noticeable & causing high distress

B: highly noticeable but not distressed

C:not very noticeable but very distressed

D: not very noticeable and not very distressed

How did you score?

• Most people are a ‘D’. We describe this ‘normative discontent’

• A would be typical of someone who has had a recent appearance altering injury

• B is someone who looks unusual but is positive and confident

• C is someone whose anxiety is disproportionate to their actual appearance

Is concern about appearance normal?

• How would you answer this question? Think about what you have learned from earlier parts of this course

Is concern about appearance normal?

• How would you answer this question? Think about what you have learned from earlier parts of this course

• Interest in appearance is normal. Appearance anxiety becomes a problem when it significantly impacts and disrupts a persons day to day life

ACTIVITY TWO

• How does your appearance impact on your life?

• The following are the kinds of questions that we ask to see how Body Image investment impacts on day to day life (NB: there are no ‘right’ or ‘wrong’ answers! )

• See how you score:

Fill in the gaps….

• How long does it take you to get ready each day?.................

• On how many occasions do you look in the mirror each day?........... For how long?........

• Are you ever late for an event because are not happy with your appearance? Yes/No

• Do you ALWAYS wear make-up: at home?.....• At work?........... On holiday? ……………

ACTIVITY THREE (a)

• Write down all the ways that you regularly modify or adapt your appearance

Here are just some:

• Make-up, hair style, hair extensions, hair colour, dieting, tattoos, piercing, nail extensions, nail polish, manicure, pedicure, facials, non-invasive beauty treatments, skin care, hair removal, skin lightening, tanning, Botox, fillers, plastic surgery, orthodontics, etc

• Clothes

ACTIVITY THREE (b)

• Thinking about the ways in which you modify your own appearance: how do you think excessive appearance concern would impact on these behaviours?

• What effect might this have on behaviour in general?

Impact of Body Image anxiety on related behaviour

• Repeated mirror checking or avoidance

• Excessive grooming and use of make-up

• Take ages to get ready• Keep changing/buying clothes• Seeking plastic surgery or

expensive treatments• Seeking reassurance from

others• Using clothes or make-up as a

‘disguise’

Negative impact of Body Image anxiety on general behaviour

• AVOIDANCE AND CHECKING • Avoiding social situations• Limited involvement in other

activities• Avoiding situations where

likely to feel the centre of attention

• Avoiding having photos taken• Avoiding sex and intimacy

Comparisons with ‘ideal’ images can increase appearance anxiety

Most of us have a less than ‘ideal’ appearance!

ACTIVITY THREE (c)

• What affect might excessive Body Image anxiety have on beliefs about appearance?

• How might this effect your beliefs about the self generally?

Impact of Body Image anxiety on beliefs about appearance?

• I am abnormal or inferior• Other people are more attractive than me• I have to always look my best• If other people saw me without my make-up

they would not want to be with me• I don’t look feminine/masculine….• I need plastic surgery• etc

Impact of Body Image anxiety on beliefs about the self?

• LOW SELF ESTEEM &SELF CONFIDENCE• I am abnormal or inferior• Other people are better than me• No-one is ever going to want to be with me• I am useless• I am no good at anything• Etc

ACTIVITY THREE (d)

• What affect might excessive Body Image anxiety have on mood and emotion?

Impact of Body Image anxiety on mood

• Depression• Anxiety• Anger/aggression• Shame• Disgust• etc

Summary: Body Image Anxiety

• Focus on inappropriate ‘ideals’ of appearance can lead people to feel inferior and abnormal

• Appearance takes up too large a part of self concept

• People experience low self esteem and low self confidence

• Social anxiety can lead to social avoidance and a reluctance to take part in activities

Body dysmorphic disorder

• Extreme Body Image anxiety is classified as a psychiatric condition (BDD) often associated with Obsessional Compulsive Disorder(OCD)and Depression

• BDD occurs in about 3 in 100 people and up to 15 in 100 people who request cosmetic surgery

• BDD is treated by a specialist psychologist using Cognitive Behaviour Therapy (CBT) and medication

Summary: When should we be concerned?

• We become concerned when people are taking hours to get ready, check their appearance in the mirror on multiple occasions, repeatedly ask for reassurance from other about their looks, are late or miss events, feel compelled to wear make up and behave in ways that prevent them acting spontaneously or living a normal life

Treatment approaches: what needs to change?

– Biomedical approaches aim to improve appearance by medical or surgical means

– Psychological approaches aim to reduce the impact of appearance anxiety, by modifying beliefs and behaviour

A Cognitive Behavioural model of Body Image anxiety

• Cognitive behavioural therapy (CBT) is a systematic treatment that aims to identify and challenge unhelpful beliefs (cognitions)and change behaviour

• In Body Image anxiety, this means examining beliefs about appearance, examining the evidence that supports them and reducing associated social anxiety and avoidance behaviours

BELIEFS

BEHAVIOURS

FEELINGS

PHYSIOLOGY

A COGNITIVE BEHAVIOURAL MODEL

Maintenance cycle

BELIEFS

BEHAVIOURS

FEELINGS

PHYSIOLOGY

A COGNITIVE BEHAVIOURAL MODEL

I must always look immaculate, I don’t look like other people, I am deformed, to be successful I must be beautiful…

Maintenance cycle

BELIEFS

BEHAVIOURS

FEELINGS

PHYSIOLOGY

A COGNITIVE BEHAVIOURAL MODEL

I must always look immaculate, I don’t look like other people, I am deformed, to be successful I must be beautiful…

Mirror gazing, social avoidance, avoid intimacy ; safety behaviours: big jackets, make up, excessive grooming, asking for reassurance

Maintenance cycle

BELIEFS

BEHAVIOURS

FEELINGS

PHYSIOLOGY

A COGNITIVE BEHAVIOURAL MODEL

I must always look immaculate, I don’t look like other people, I am deformed, to be successful I must be beautiful…

Mirror gazing, social avoidance, avoid intimacy ; safety behaviours: big jackets, make up, excessive grooming, asking for reassurance

Anxious, lonely, despairing, unhappy, disgusted, ashamed, angry

Maintenance cycle

BELIEFS

BEHAVIOURS

FEELINGS

PHYSIOLOGY

A COGNITIVE BEHAVIOURAL MODEL

I must always look immaculate, I don’t look like other people, I am deformed, to be successful I must be beautiful…

Mirror gazing, social avoidance, avoid intimacy ; safety behaviours: big jackets, make up, excessive grooming, asking for reassurance

Anxious, lonely, despairing, unhappy, disgusted, ashamed, angry

Heart races, palpitations, rapid breathing, faintness, sweaty, blushing

Maintenance cycle

What does a specialist psychologist do?

• Works within a clear evidence based framework

• helps to identify and modify unhelpful beliefs (by examining and challenging the evidence that supports them)

• helps to dismantle unhelpful behaviours and replace them with more helpful alternatives

Levels 0-2 of a stepped care approach is ideal for vocational trainers

• Raise the subject; have a sensitive discussion; offer support

• Advice: introduction to information and self help materials, on-line intervention, onward referral to health professional support

• (Level 3,4&5: Specialist –led)

Stepped Care Interventions

Levels 0 – 2 relevant for vocational trainers

Levels 3 – 5 require health professional support

Activity Four(a)

• Thinking about the impact of Body Image anxiety on behaviour: write down four things that might cause you to be concerned about someone

Activity Four(a)

• Thinking about the impact of Body Image anxiety on behaviour: write down four things that might cause you to be concerned about someone

• Late or absent, excessive attention to appearance, mirror checking, seeking reassurance, social avoidance etc

Activity Four(b)

• Raising the subject

• Write down some ideas about what you might say to raise the subject with someone you are concerned about

Activity Four(b)Raising the subject

• I notice that you are often late for activities: why do you think this is a problem for you?

• Prompt: does it take you long to get ready?• I notice that you often ask other people if you

look okay: do you find yourself worrying about this?

• I notice that you check your appearance a lot – do you think you worry more than other people?

What to say….

• Do……• Reassure that some concern is

normal & that help is available when concern is excessive

• Ask if they are being teased or bullied by someone else

• Suggest that they read more about appearance anxiety

• Offer the chance to talk to you more

• Don’t……….• Tell them that they look fine to

you• Tell them that there are lots of

people who have ‘proper’ disfigurements

• Suggest they are silly or making a fuss about nothing

• Get drawn into a discussion about their appearance or whether they need surgery

Offering advice

• What comparisons are they making? Are there more suitable role models they could use?

• Encourage social activities with other students• Recommend reading and websites for more

information• Explain that help is available via: counselling

(at college), via their doctor, or via online or telephone support

Accessing further support

These are good self help texts which explain body image concern and help people to understand and change their behaviour

Websites• Changing Faces is a charity set up to help people with visible

difference in appearance. They have useful resources and ideas for everyone concerned about what they look like.

• www.changingfaces.org

Online interventions are becoming available for adults and children

On-line interventions

Summary Activity: (please answer yes or no)

• If I think someone might have a Body Image problem I should:

• Explain that concern about appearance is normal• Recommend plastic surgery• Reassure them that they look beautiful to me• Tell them they are making a fuss about nothing• Encourage them to read more about Body Image

problems• Encourage them to participate socially

Summary activity (cont)

• Encourage them to spend less time in front of the mirror

• Encourage them to research surgery on the Internet• Encourage them to go out without make-up from

time to time• Encourage comparison with a wider group of people• Discuss sources of support• Explain how to access help

Summary Activity: yes / no

• If I think someone might have a Body Image problem I should:

• Explain that concern about appearance is normal• Recommend plastic surgery• Reassure them that they look beautiful to me• Tell them they are making a fuss about nothing• Encourage them to read more about Body Image

problems• Encourage them to participate socially

Summary activity (cont)

• Encourage them to spend less time in front of the mirror

• Encourage them to research surgery on the Internet• Encourage them to go out without make-up from

time to time• Encourage comparison with a wider group of people• Discuss sources of support• Explain how to access help

Conclusion

You can help identify and offer support:

• Observe behaviour• Raise the subject and ask questions• Listen, normalise and support• Recommend information• Advise sources of further help

Managing disfiguring conditions

What are the problems?• Negative impact on self perceptions (self esteem/worth)• Encounters with others (self consciousness;

social anxiety)• Reactions of others (unwanted attention,

stereotyping, avoidance)

The impacts of a visible disfigurement

“in their attempt to go about their daily lives, people are subjected to visual and verbal assaults, and a level of familiarity from strangers (including) naked stares, startled reactions, ‘double takes’, whispering, furtive looks, curiosity personal questions, advice, manifestations of pity or aversion, laughter, ridicule and outright avoidance”. (MacGregor, 1962)

In a job interview, the following are important (for people with a disfigurement and for those with other appearance concerns)

• Good social skills• Dress smartly• Good eye contact• Appear relaxed • Smile!• The goal is to put other people at ease: “if you are

positive about your appearance, other people will be too”

Should appearance be mentioned?

• This is entirely up to the individual. A positive statement can be helpful such as:

• “you will notice I have a facial difference: I think that managing this has helped me to develop my social skills and put the customer at ease”…………

• But no-one should feel pressured to talk about their appearance

What if the employer asks?

In the UK this is illegal. However, people are often curious. Answers include:• I don’t think my appearance is relevant to this job• It is not a problem for me so I don’t think it needs

to be a problem for others• The advantage of looking distinctive is that

people can always remember who they spoke to! (Humour can often be really helpful!)

Managing disfigurement

• The key is putting other people at ease so that the social interchange between them is relaxed and positive – a key skill in the workplace.

• Techniques for managing job interviews are illustrated in the online programme www.faceitonline.org.uk