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Youarehere:ResourcesEssay&DissertaonSamplesBusinessEssayExamplesFreeCounselling
Dissertaon

FreeCounsellingDissertaon
rodrigo|October19,2011|0Comments


TableofContents[hide]
Abstract
1.Introducon
1.1Overview
1.2Importanceandrelevanceofthe
study
1.3Researchaimsandoverall
methodology
2.Bodyimage,selfesteemandtheimpact
ofmedia,genderandotherfactors.
2.1Overview
2.2Impactofpoorbodyimage
2.3Bodyimageandselfesteem
2.4Therelaonshipbetweenbody
imageandweight.
2.5Therelaonshipbetweenpoorbody
imageandotherfactors
2.6Gender,mediainuencesandbody
image
2.7Measuringbodydissasfaconand
poorbodyimage
2.8Theoriesofpoorbodyimage
2.8.1Objeccaontheory
2.8.2Othertheoriesincorporang
socialinuences
2.8.3TheDevelopmentaltransion
model
3.Bodydysmorphicdisorder.
3.1Denionsofbodydysmorphic
disorder
3.2Riskfactors
3.3Clinicalfeaturesanddiagnosis
3.4Prevalence
3.5Treatment
4.Counsellingtherapies
4.1Thedevelopmentofcounselling
4.2ThePracceofcounsellingforpoor
bodyimage
4.2.1Ethicalissues
4.3Typesoftherapyandtheir
usefulnessforBDDandbodyimage
problems
4.3.1Cognivetherapytechniques
(CT).
4.3.2Cognivebehaviouraltherapy
(CBT).
4.3.3Personcentredtherapy
4.3.4Prevenonprogrammes
5.Discussionofdierenttherapeuc
approachestobodyimagedisorders
6.Primaryresearchmethodology
7.Primaryresearchresultsanddiscussion
8.Conclusion
9.References

Appendix1:Quesonnaire
Related

Abstract
Thisstudylooksatthevalueofcounsellinginsupporngclientswithlowselfesteemandlowcondence
duetopoorbodyimage.Thecomplexnatureofpoorbodyimageanditslinkstolowselfesteemand
othernegavecondionsaretraced.Thenatureofthemoreseriouscondion,bodydysmorphic
disorder,issetout.Theroleplayedbythemediaisconsideredindetail,asisthedierencesbetweenmen
andwomenregardingpoorbodyimage.Inordertounderstandthebestapproachesincounsellingand
therapyforclientswithpoorbodyimage,varioustheorecalposionsaresetout.Thediscussionofthe
natureofbodyimageissuesinformsthediscussionofthreedierenttherapeucapproachestopoor
bodyimage.Dierentapproachesarecompared.Allhavevalue,anditissuggestedthatfurtherresearch
mightcompareapproachestobe ertailorprovisionofcareforsuerers.Ashortprimarystudyseemsto
conrmthesendings.

1.Introducon

1.1Overview
PoorbodyimageisacommonprobleminWesternandWesternisedsociees,parcularlyamongstgirls
andwomen,althoughincreasingly,also,inmen.Havingapoorbodyimagemayalsoleadtoother
psychosocialproblemsandclinicaldiculessuchaseangdisorders,depression,socialanxietyandlow
selfesteem(StrachanandCash,2002).Relavelyrecently,BodyDysmorphicDisorder(BDD)hasbeen
recognisedasaclinicalcondion.Inthis,individualshaveanextremelydistortedbodyimage,andare
preoccupiedbyarealorimagineddefectintheirappearance(InselInsel,TurnerandRoss,2009)

Thereisanimportantdisncontomakebetweenbodydissasfaconandbodydysmorphicdisorder
(BDD),withthela ermoreserious;howeverbothcanbetargetsforcounsellingandpsychotherapy
(Veale,2004).Therehavebeennumerousa emptstoplacebodyimagedissasfaconandBDDwithina
theorecalframework,withconicngandoverlappingexplanatorysystemsused,andthevarietyof
theorecalframeworksismatchedbyawidevarietyoftechniquesusedtotreatthesecondions.
Cognivebehaviourtherapy(CBT)speciallymodiedforbodyimageproblems,forexample,isan
emergingtherapyandisbeingulisedtohelpindividualswithbodyimagedissasfaconsanddysphoria.
Thistherapyhasbeenseentobeeecveinalteringbodyimagepercepondirecngamoreposive
outlookforobesepaents,aswellaspaentssueringfromBDD,andvariouselementsofCBThave
beenimplementedintothetreatmentofeangdisorderswithconsiderablesuccess(StrachanandCash
2002).DespitethesuccessandprevalenceofCBTandothercogniveapproaches,othertreatmentsdo
exist,forexampledissonancebasedprevenonprogrammeshavebeenusefullyapplied,parcularlyfor
universityagewomen.Othertherapeucperspecvesbasedaroundpersoncentredthemesarenotso
prevalent,butseemtooeranalternaveapproachtotreangbodyimageproblemsandBDD,although
areusedlesso ennowadaysandseemunderresearchedincomparison.

Thispaperwillcricallyevaluatevariouselementsofbodyimage,selfesteemandcondence,drawing
uponvariousstudiesmainlyemanangfromtheUK,EuropeandtheUS.Itfocusesuponstudies
incorporangweight,selfesteemandthemediainuenceinordertoreectanevolvingproblemthat
concernsbothmalesandfemales,fromadolescenceintoadulthood.Thestudywillrsttakeageneral
viewofthenatureofbodyimageanddissasfaconwithbodyimage,tracingitsimpact,diagnosis,
treatmentandvarioustheorieswhichhavebeendevelopedtoexplainit,andwilllookparcularlyatthe
conneconbetweenmediainuencesandbodyimage.ThecondionofBDDorimagineduglinesswill
alsobediscussed.Oncethenatureoftheproblemhasbeenestablished,dierenttreatmentpossibilies

willbeexplored,lookingparcularlyatcounsellingandpsychotherapy,andissuesassociatedwiththese.
Thedierenttherapeucapproacheswillbetraced,andtheestablishedsuccessofcognivebased
methodswillbeacknowledged.Whetherclientcentredapproaches,originanginObjecttheoryandin
workbyCarlRogers,oeraviablealternavewillalsobediscussed.Althoughtheprimaryfocusinthe
studywillbetounderstandthebenetsanddrawbacksofdierenttherapeucapproaches,aprimary
studywillalsobeincludedintheresearchtointerviewrecipientsofdierenttherapiesandanalysetheir
responsetotreatmentopons.Theprimarystudywillbeinformedbytheareasdiscussedinthe
secondaryreview.

1.2Importanceandrelevanceofthestudy
BDD,eangdisorders,excessdiengandexercisearedamagingtothehealthandareincreasinginboth
menandwomen,withtheprevalenceratereportedas0.7%inthegeneralpopulaon,5%incosmec
surgerysengs,and12%inadermatologyclinic(Veale,2004).Suchdisordersaredetrimentaltoboth
physicalandmentalhealth,andcanhavefurthereectsbyinuencingotherstomirrorthebehaviourof
suerers,parcularlyifthesubjectsareinaposionofauthority(YagerandODea2009).Theyare
highlydisrupveintermsofdailyfunconing(ChrislerandMcCreary,2010).Itisthereforeusefultolook
atthemosteecvemeasuresfortreangsuchdisordersandprevenngtheiroccurrence.

1.3Researchaimsandoverallmethodology
Themainpartofthestudywilltaketheformofacricalreviewofsecondaryliteraturegatheredfrom
academicdatabasesandulisinganumberofkeywordsearchesincludingthetermsbodyimage,body
imagedisorder,bodydysmorphicdisorder,eangdisorders,CBTCTpersoncentredtherapyand
clientcentredtherapy,bothaloneandincombinaon.

Thestudyaimsrsttounderstandthenatureofdisfunconsinbodyimageanditsrelaontoselfesteem,
andtolookatthecondionofbodydysmorphicdisorder,andtounderstandwaysinwhichthese
condionsaretheorised,parcularlyinregardstomediainuenceupontheirdevelopment.Italsoaims
touncoverthemostsuccessfulformsoftreatmentforpoorbodyimageandBDD,andtopresentthisin
thelightofthediscussionofthenatureofthecondions.Finally,itaimstocomparetreatmentopons
anddiscoverwhetherthereisaplaceforpersoncentredtherapiesalongsideeducaonprogrammesand
cognivetherapies.

Ashortprimarystudywillalsobeconducted.Thiswillgatherquantavedatafromanumberofpeople
whohavehadtherapytreatmentinthepast,tocollectdetailsabouttreatmentsundertaken,andto
assesshowsuccessfultherecipientsoftherapyfelttheirtreatmenttobe.Fulldetailsofmethodologyfor
theprimaryresearchwillbesetoutbelow.

2.Bodyimage,selfesteemandtheimpactof
media,genderandotherfactors.
2.1Overview
ThetermbodyimagecanbetracedtotheEnglishwordbodywhichoriginallymeantperson,andto
theLanverbimaginari,whichmeanstorepresentthroughanimage.Thetermwasrstusedinthe30s
bySchilder,whodescribedapersonsbodyimageasthepicturetheymakeintheirmindrepresenngthe
waytheirbodyappearstothem(Flaming,1993).

2.2Impactofpoorbodyimage
Poorbodyimagehasbeenassociatedwithanumberofothernegavehealthissuesincludingdepression,
lowselfworth,poornutrionandeangdisorders(EldinandGolanty,2009).Poorbodyimageandhigh
levelsofdissasfaconwiththebodycanalsoimpactuponcareerchoice.HigherlevelsofBDDand
associateddisordershavebeenfoundamongstyoungpeopletrainingforprofessionsincludingnutrion
andothercareers(nutrionists,psychologists,diecians,homeeducaonteachers)associatedwith
eangandhealth.AnAustralianstudyforexamplefoundthathealthandphysicaleducaonteachershad
signicantlyhigherlevelsofoverexercising,exercisingdisorders,poorbodyimagesandincreased
dissasfacon(YagerandODea,2009).

2.3Bodyimageandselfesteem
Parcularlylinkedwithlowbodyimageareissuesofselfesteem.SelfesteemaccordingtoHarter(1990)
iscomposedoftwoaspects,rstlyhowapersonbelievesthemselvestobeperceivedbysignicantothers
andsecondly,howtheyviewtheirperformanceinareasconsideredimportant.Bodyimageisalso
characterisedasdividedintodierentcomponents.Somedisnguishtwoelements,perceptual
(evaluaonofonesphysicalbody)ontheonehandandaecve/cogniveontheother(apersons
atudestowardshisorherbody)(AllgoodMertonandLewinsohn,1990).Othersdisnguishathird
element,thebehavioural,lookingataconstowardandinvolvingthebody.Ineithercase,apoorbody
imagecanbethoughtofasafailureoffunconofoneormoreofthethreeconstuentcomponents
(Farrell,SafranandLee2006).

Therehasbeenalargeinterestoverthelast30to40yearsinthewaybodyimagepercepon,distoron
andselfesteemareconnected.Thebulkofthesestudieshavebeendirectedtowardsstudents,with
parculara enonpaidtofemalesandadolescents(Furnham,BadminandSneade,2002).Forexample,
Mellor,FullerTyszkiewicz,McCabeandRicciardelli,inanAustralianstudy,foundthathigherselfesteemis
associatedwithlowerbodydissasfacon,andthatwomenaremoredissasedwiththeirbodiesthan
men.AcomparavestudyofboysandgirlscarriedoutbyAllgoodMertonandLewisohn(1990)indicated
thatbodyimageisacricalcomponentofselfesteemwithintheagegroup13to18,parcularlyforgirls.
StudiesarenotconnedtotheUK,NewWorldandUSA,buthavebeencarriedoutacrosstheworld
includingHongKongandPoland,withwidespreadagreementthatpoorbodyimageisassociatedwitha
numberofnegaveoutcomesincludingeangdisorders.Theresearchintoaposivecorrelaon
betweensasfaconwiththebodyandenhancedselfesteemislessconclusive,butaconneconseems
tohavebeenestablishedinstudiesofbothmenandwomen(Furnhametal,2002).GriloGrilo,Maseb,
Brody,BurkeMarndaleandRothschild(2005),forexample,foundacorrelaonbetweenselfesteemand
bodyimagedissasfaconamongobesemenandwomenseekingsurgery.

2.4Therelaonshipbetweenbodyimageandweight.
Issuesofbodyimagehavebeencorrelatedwithweightissues.Adolescentgirlsandwomenarethetwo
groupsmostpredisposedtopoorbodyimageandmostlikelytousediengtoovercometheirissues
(Groesz2002).Anumberofstudieshaveunderlinedtheconneconbetweenweightandpoorbody
image,forexampleoneUSstudyfoundthatbetweenthoseindividualsclassiedasoverweightaremore
likelytohavelowerselfesteemandpoorbodyimage(Pesaetal,2000).Studiesalsofoundsucha
correlaonamongstmen(Silberstein,StriegelMoore,TimkoandRodin,1988).Beingoverweightisalso
associatedwithreducedemoonalwellbeing,assuggestedbyastudybyLoth,Mond,Walland
NeumarkSztainerofaround2,500adolescents.Inaddion,childrenwhoareoverweightareindangerof
beingsgmazedandisolatedfromtheirpeers.Theseresultsaremorenotableamongwomenthanmen,
althoughthisdierenceonlyappearsduringadolescence(Lothetal2010).

2.5Therelaonshipbetweenpoorbodyimageandotherfactors

Anumberofotherfactorsincludingrace,genderandsocioeconomicstatuscontributetoperceponsof
bodyimage:astudyintheUSAwithover1000olderadultsshowedraceandgenderandsocioeconomic
dierencessignicantfactorsinhowsubjectsperceivedtheirweight(Schieman,PudrovskaandEccles,
2007).Itshouldbenotedhoweverthatthisstudylookedatperceponsofbeingoverweightalone,
ratherthanbodyimageingeneral.Withinschoolchildren,ithasalsobeenfoundthatlowersocio
economicstatusiscorrelatedwithbeingoverweight,havingerracmealpa erns,disorderedeangand
bodyimageissues,whileselfesteemislowestamongstgirlsinmiddleorhighersocioeconomicstatus
(SES)Forboys,selfesteemislowestwithlowSES(ODeaandCapu2001).Otherstudieshavefoundthat
diengismostcommoninhigherSES(WaltersandKendler1995).

Racialfactorscanalsoplayapart:Xue,ZhouandZhou(2003)suggestthatChinesemalesaresuscepble
toidealizedbodyimages.Inaddion,thereissomesuggesoninresearchthatwhitewomenaremore
concernedwithbodyimageandweightthanaremenorblackwomen,withcorrespondinghigher
incidencesofbulimiaandanorexianervosa(HenriquesandCalhoun,1999).

Countryoforigincanalsomakeadierence.WhilemanystudieslookatthesituaoninWestern
countriessuchastheUKandUSA,otherstudieshavelookedatotherareas.BissellandChung(2009)
lookedatSouthKorea,ndingthattherearesignicantdierencesbetweenthewaypeopleinSouth
KoreaandUSAevaluatea racvenessinothers,andthewaythislinkstoselfesteemandothervariables
includingBMI.Thereissomesuggesoninresearchthatwhitewomenaremoreconcernedwithbody
imageandweightthanaremenorblackwomen,withcorrespondinghigherincidencesofbulimiaand
anorexianervosa(HenriquesandCalhoun,1999).

2.6Gender,mediainuencesandbodyimage
Onemajormediangfactorinpoorbodyimageisgender,andmanystudieshaveinvesgatedthisarea.
Genderisakeyfactorasitimpactssocialnormsandmeaningsassociatedwithappearance.Itisimportant
torecognisethatbothmenandwomencanbeeectedbybodyimageissues,inorderthatprevenon
andtreatmentbegivenwhereitismostneeded.

Whilethereareimportantinsightsintheoriesrootedinindividualiscandinternallyfocussed
psychoanalysisandtherapy,thepredominanttheorecalposiononpoorbodyimagetracesalink
betweensocialandculturalinuences,parcularlythosefromthemedia,anddysfunconalviewsof
onesbody.Thistheorecalbackgroundwillbeexaminedinmoredetailbelow.Thisinuencehasdisnct
characteriscsformenandwomen.Whereasitwaspreviouslyassumedthatonlywomenareinuenced
bymediaidealsofbodyimageandthinness,morerecentresearchshowsthatmenarealsosubjectto
intensepressuretoconrmtostereotypicalideals.However,forwomenparcularly,idealisedfemale
guresinmediahaveanegaveimpactonbodyimageandselfesteem.(Xueetal,2003).Upto19%of
USfemalestudentsarereportedtobebulimic,and61%havesomeformofeangdisorderbelowthe
clinicallevel(chronicdieng,binging,purging).Between70and94%offemalestudentswanttobe
slimmer,with80to91%dieng(YagerandODea,2008).Thereishigherpressureonwomentobethin
anda racve,andwomenaretradionallyexpectedtobemoreinvolvedwiththeirappearancethanare
men(Scheimanetal,2007).Thecorrelaonbetweenanegavebodyimageandapoorselfconcepthas
beenstudiedoverseveraldecades.Despitethisawarenessoftheproblem,womensllnditachallenge
toaccepttheirbodies,andthislackofcomfortwiththeirappearanceexpandsbeyondimmediate
dissasfaconwithlookstoeectotheraspectsoftheirlivesincludingtheirconceptofself(Dworkinand
Kerr,1987).

Therolethemediaplaysinwomenspoorbodyimagehasexpandedgreatlywiththeadventofnew
communicaonpossibilies,buthasbeenaroundforcenturies.Objeccaonofwomensappearance
hasoccurredsinceearlyculturewithastandardofbeautyportrayedthroughart,literatureandmusic.
Nowadays,however,theexplosionofaccessibilityanduniversalitythroughelectronicandprintmedia
havebeenhighlightedbybodyimageandeangdisorderexpertsasincreasingpressureonwomentobe
concernedwiththeirappearance(ThompsonandHeinberg,1999).
Repeatedexposuretomedia,bothdirectlyandindirectly(bothbyexperiencingimagesofwomeninthe
newspapersoronTV,forexample,butalsothroughconversaonswithpeers,familymembersandother
membersofsociety)meanthatpressurestobethinaretransferred,andyoungerwomenareparcularly
vulnerableHowever,therelaonshipisnotastraigh orwardone,butismediatedbyfactorsincluding
extentoftheinternalisaonoftheideal,socialcomparisonandtheextenttowhichaschemaforthinness
isacve(LopezGuimeraLopezGuimera,Levine,SanchezCarracedoandFauquet,2010).Numerous
studieshavelookedatvariouselementsofspecicmedia;televisionexposure(GonzalezLavinand
Smolak,1995;Sce,SchupakNeuberg,ShawandStein,1994);typeofprogramviewed(Tiggemannand
Pickering,1996),andexposuretoprintmedia(Sceetal,1994)forexample.Thereiswidespread
agreementthatthemediaoverallportrayidealizedimagesofwomenandthuscontributetonegave
feelingsaboutbodyimageandthedevelopmentofpathologicalbeliefsinsomewomen.Thesestudies
havebeenreinforcedbymorerecentinvesgaons(TucciPeters,2008).

Ofparcularimportanceinidealisingwomensappearanceandleadingtonegavebodyimageare
womensmagazines.Thesehaveplayedthispartoverseveraldecades.Womensmagazineshaveplayed
anambiguousrole.Asearlyasthe1980swomensfashionmagazinessuchasCosmopolitanandElle
begantopublisharclesreporngwomenseangdisorders,andduringthe90sanewtrendfortness
magazinesheraldedanewstylewithanemphasisonposiveselfesteemandselfacceptance.Aposive
atudeaboutyourownbodywaspublicised,andportrayedasbeingaprerequisiteforoverallself
condence.Further,duringthemid90sacondionknownbodyimagedistoronorBID,wasalso
highlightedbyfashionmagazineswhoemphasisedtheirsocialconscienceandrelevancetorealwomen.
SuchmagazinesrecognisedBIDasaseriousillness,threateningmanywomenandlinkedwithlowself
esteem,somemesreportedtobemorecommonthananorexiaandbulimianervosa.Ontheotherhand,
whilepromongtheircaringcredenalsthroughdiscussingeangdisordersandproblemsofpoorbody
image,magazinesconnuedtoportrayidealisedimagesofwomen,parcularlywiththedevelopmentof
digitalimagingtechniquesandtheenhancedpossibiliesforpresenngaconasphotorealiscreality.
Womenarebombardedthroughfashionshootswiththemessagethatpre ywomenequalthinwomen
(Markula,2001).Researchinthisareaconrmsthatexposuretoeditorialandadversementsinwomens
magazinesimpactuponbodyimagethroughpromoonofstandardsofbeauty(Groesz,2002).Therst
metaanalycalstascalreviewofmediaimpactupongirlsandwomenfrom25previousstudies
revealedthatindividualsexpresseddierencesintheirmovesforsocialcomparisonwiththeirown
imageandthatthiswasassociatedwithdiversemeasuresofnegavebodyimage.Resultsinthisstudy
supportedtheinverserelaonshipofbodyimagea erparcipantsviewedimagesonthinmodelsin
comparisonwithimagesofaveragesizemodels,plussizedmodelsandinanimateobjects(Groesz,2002;
StormerandThompson,1996).Inaddion,suchmagazinespromoteaneedforendlessconsumponof
lifestyleaccessoriesandgarments,withtheunderlyingmessagethatwomenneedtopurchasethelatest
stylestobeacceptable.Somealsoarguethatmagazinestherebysupportcapitalismandpatriarchy
(GoughYates2003).

Womenarealsomoresubjecttogenderrelatedharassmentinpublicthanaremen,perhapsasaresultof
widespreaddisseminaonofidealisedimages.Arecentstudyhassuggestedthattheseexperiencesof
harassmentsandwomensemoonalreaconstosuchincidentscanplayapartinfeelingsoflowself
esteemandpoorbodyimageaswellasfeelingsofshameanddisliketowardsthebody(Lord,2010).Low
bodyimage,whencombinedwithhighselfesteem,hasalsobeenlinkedtoindirectaggressivebehaviours
amongstyoungwomen(Young,2008).

Whiletheimpactofmediauponbodyimagehasbeen,unlrecently,predominantlystudiedinwomen,it
isgraduallybeingrecognisedthatmenarealsopronetobodydissasfaconthroughmediainuence.
Mensconcernstendtodierfromthoseofwomen,mostnotablyinthatmensmainconcernismuscle,
withmenreporngmoredesireforincreasedmusclemassthanwomen(Krayleretal,2007).Higher
levelsofmuscledissasfaconhavebeencorrelatedwithhigherlevelsofdepression,lowerselfesteem,
pathologicaleangpa ernsandhigherlevelsofsocialanxiety.Bodyfatisalsoanareaofconcernfor
men,andthishasalsobeenassociatedwithothercondionsincludingeangpathology,socialanxiety
anddepression.Heightdissasfaconhasbeenstudiedless,butalsoappearsasacauseofbodyimage
dissasfaconinmen(Blashill,2010).Gaymenarelessstudied,butwouldappeartoreporthigherlevels
ofmuscledissasfaconanddesireforthinnessthanheterosexualmen.

Researchintomensissueswithbodyimagestartedinthe80s.Anearlystudyrevealedalmost100%of
collegeagedmenweredissasedwithapartoftheirbody,and70%thoughtadiscrepancyexisted
betweentheircurrentandidealbodyshapes(Mishkin,1986).Morerecentstudieshaveconrmedthe
existenceofarangeofeangdisordersanddysfunconsinbodyimageinmen,includingdisordered
eang,bodydysmorphicdisorderandexcessiveexercising(Drummond,2002).Between17and30%of
undergraduatemendiettoloseweight;thereisalsoincreasingadaptaonofweightli ing,bodybuilding
andsteroiduse.510%ofindividualswitheangdisordersaremale(YagerandODea2008).

Inially,itwasassumedthatmenwouldnotbeinuencedbyimagesofidealisedbodiesinthemediaas,
itwashypothesised,menarelessaectedbyvisualimagesthanwomen.Laterinvesgaonfound,tothe
contrary,thatmenndvisualmaterialmoreevocavethanfemalesandthereforearefacedwitha
greaterdegreeofbodyimageconcernsthanwasoriginallythought(Barthel,1992).Astudycarriedoutby
AgliataandTantleDunn(2004),incorporangseveralpreviousstudies,suggestedthatwhenmenare
exposedtomediaimagesoftheidealmalebody,whichisdenedasleanandmuscular,itcanleadto
negaveeectupontheirmoodandtheirsasfaconwiththeirbody.Therehasalsobeenanexplosion
ofmensmediaoverthelast20years,withmagazinesdevotedtohealthandtness,ladsculture,and
themetrosexualman,concernedwithhislooksandphysicalimpactuponothers.Thedevelopmentof
thesefashionablemasculiniescanbeseenasabyproductofcapitalism,ascorporaonsa empttosell
newandprotablemarketsegmentstobothadversersandconsumers.Whilethetradionalmarketsfor
imagerelatedproductswomenismoreorlesssaturated,andwhilethegaymarketwillalwaysforma
minoritygroup,thetargetgroupofheterosexualmenisunderdeveloped(Cova,KozinetsandShankar
2007).Itisunsurprisingthereforethatthelast2decadeshaveseenanexplosioninthevolumeand
varietyofidealisedmaleimages.Asaresult,menarebeginningtofacethesamepressuresaswomento
possessphysicalcharacteriscsconsidereda racveandmasculine.Therearespecicdierences
betweenthewayadesirablebodyiscommunicatedtoeachgender.Maletargetedmagazineo en
adverseexerciseandweightli ingtoagreaterextentthaninfemalemagazines,whichfocusondieng.
Printmediaencouragesmalestomouldtheirbodiesintotheiridealshape,throughexerciseandsubject
themtoacultureofmasculinity(AgliataandTantleDunn,2004).Inaddion,ithasbeensuggested
thatexposuretoLadMagazines,suchasthe90sUKpublicaonLoaded,whichfeaturehighly
sexualisedimagesofdesirableandseeminglyavailablewomenparadoxicallyincreasesawarenessofmale
readersownbodies.Astudyamongstundergraduatemenfoundthatsuchmagazinescanleadto
increaseddissasfaconwithbodyimageinmen,perhapsduetoassimilaonandsubsequentprojecon
totheirowncaseofmessagesaboutwomenandidealizedimages(AubreyandTaylor,2005).

2.7Measuringbodydissasfaconandpoorbodyimage
Anumberofscaleshavebeenintroducedtohelpassesstheextentofbodydissasfacon,includingthe
PictorialBodyImageScale(PBI),BodyDissasfaconsubscaleofEangDisordersInventor(EDI),Visual
AnalogueScale(VAS)amongstothers.TheBodyEsteemScale(BES)incorporatesweightsasfacon,and
canalsobeusedasameasureofphysicala racvenessassessment(Groesz,2002).

2.8Theoriesofpoorbodyimage

Researchhassuggestedthatthereisaninvestmentinanidealofthinnessingirlsasyoungas3(Harriger
Harriger,Calogero,WitheringtonandSmith2010),soitisimportanttolookathowsuchidealsare
ingested,andtheoriesofhowpoorbodyimagecomesabout.Byunderstandinghowthishappens,and
parcularlywhetherpoorbodyimageisprimarilycausedbyexternalinuencesinsocietyorcultureorby
traumastothepsycheatkeydevelopmentalperiods,itiseasiertoselectappropriatetypesoftherapyor
counsellingtoaddresstheproblem.Equally,byunderstandingthatdierenttheoriescanhavevaluefor
explainingbodyissues,itispossibletoseethevalueofdierentwaysoftreangthedisorder.Theoriesof
poorbodyimagecanbeplacedinthecontextofideasabouthowbodyimageingeneralcomesabout.
Somesuggestthatthedevelopmentofbodyimagehasfourcharacteriscs.Itisrstanintegraonof
physical,psychologicalandsocialfactors,seconditchangesoverme,thirditisalearnedbehaviour,and
fourthithasbothconsciousandunconsciouscomponentsThephysicalelementconcernsthewayin
whichsomeonerelateshisorherbodytotherestoftheenvironment.Psychologicalissuesconcernthe
valuesa ributedtodierentpartsofthebodyandthewayinwhichtheselfisdenedintermsofthese.
Thesevaluescanchangeofme,anddierentpartsofthebodybecomemoreorlessimportantat
dierentlifestages.Finally,sociologicalaspectsincludethewayotherpeoplereacttoapersonsbody,
andhowthesereaconsareprocessedbythesubjectBodyimagechangesoverme,asaresultof
changesinthethreefactorsdescribedabove.Developingtheabilitytousedierentsenses,forexample,
triggersbodyimagechanges.Inaddion,changesintheenvironmentimpactuponbodyimages.Finally,
bodyimageispsychologicallycomplexcontainingbothelementsinconsciousawarenessandelements
whicharehiddenfromawareness(Flaming,1993).Suchanunderstandingofthemulfaceted
developmentofbodyimagecouldbeseentolendweighttothevalidityofdierenttreatment
programmestoaccountforthecomplexnatureofthecondionwithconsciousandunconscious
elementsandwithcausesbothinternalandexternal.

Thereareanumberoftheorieswhichsuggestwaysinwhichapoorbodyimagedevelops.Thesedivide
broadlyintotwotypes,thosewhichlinkpoorbodyimagetosocialandculturalfactorsprimarilythe
objeccaonofthebodyinthemedia,andthosewhichdevelopfromapsychoanalycalmodelwhich
priorisesinternalprocessesofthepsyche.Eachtypeoftheorycanbeusedtosupportadierent
treatmentapproach.Ithasbeenseenabovethatthemediaplayanenormousroleincreangand
maintainingidealisedbodyimageandawarenessofindividualshor allsinbothmenandwomen.This
roleisconrmedbythersttwotheoriesdiscussedbelow.

2.8.1Objeccaontheory
ObjeccaontheorywasdevelopedbyFredricksonandRoberts(1997),butisrootedinearlierfeminist
theorysuchasworksbyDeBeauvoir,Itdescribesaprocesswherebythesexualisaonofwomensbodies
isthenorm.Womencometoseethemselvesasobjectstobelookedatcrically.Womenlearnearly,both
directlyandthroughindirectinuence,thatlooksareacurrency,andthathowpeopleassesslooks
determineshowanindividualistreated.Thishasaneectuponsocialandeconomiclifeoutcomes.
Womendevelopathirdpersonperspecveupontheirbodies,inordertoancipatecricismandcontrol
howtheyaretreated.Thissupplantsamorehealthyrstpersonperspecveorinsideviewoftheir
body.Theprocessofobjeccaon,thetheorysuggests,leadstoavarietyofnegaveemoonaland
behaviouralconsequencesincludingincreasedselfconsciousnessandincreasedpreoccupaonwiththe
outwardappearanceofthebody,ratherthanwithitseciencyorhealth.Objeccaoncanalsoleadto
shame,disgustandanxietyasthebodyfailstocorrespondtodesiredideals,andalsotoarangeof
behaviouralandemoonaloutcomesincludingeangdisorders.Objeccaontheoryalsopredicts
dierentstagesofobjeccaon,fromthestartoftheprocessatpuberty,whenthematuringfemale
startstoexperienceexternala enonandcrical,sexuallyrelatedevaluaonfromothers,throughto
midlife,whenwomenaremoreableandwillingtostepoutofthearenaofbodyassessment(Chrisler,
2004).Themediaplaysacentralpartintheprocessofobjeccaonwhichresultsinindividualstaking
theperspecveofanoutsiderontheirphysicalself,andtoconstantlymonitortheirappearance(Aubery
2006).Theinialdevelopmentofobjeccaontheorysuggestedthatwomenaremoresuscepbleto
objecfyingtheirbodiesandtothefeelingsofshameandanxietygeneratedwhentheyfeeltheirbodies
asobjectstobeviewedandevaluatedbyothersarelessthanperfect.However,ithasmorerecently
beensuggestedthatmenalsocanbeaectedbytheprocess,witharecentstudy,forexample,nding
thatincreasesinbodysurveillancea erexposuretosexuallyobjecfyingmediaoccuronlyinmen

(Aubrey,2006).Inaddion,morerecentexploraonshavepointedoutthatnotonlyismuchthis
researchamongstmencarriedoutonlywithheterosexualmen,butalsothatgaymenseemtohave
higherlevelsofbodydissasfaconthanheterosexualmen.Thisisanareawhichdemandsexploraon,
andtherehavebeensomea emptstoexplainitrootedindevelopingobjeccaontheorybysuggesng
thatgaymenareundermorepressuretohaveabodythatisdesirableanda racve,astheyare(like
heterosexualwomen)tryingtoa ractmenaspartners,andmenplacemoreemphasisuponphysical
a racveness.Inaddion,gaycultureandmediahighlightsmalea racveness,thusincreasingthe
pressureongaymen(Blashill,2010).

Othertheories,lessdirectlyrelatedtoobjeccaontheory,includethefemininityhypothesis,which
suggeststhatgaymenhavehigherlevelsoffemaletraitsthanheterosexualmen,andthatthesetraits
areassociatedwithhigherbodydysmorphia.(Lakkis,Ricciardelli,andWilliams,1999).

2.8.2Othertheoriesincorporangsocialinuences
OthertheoriesincorporangmediainuencesincludetheDualPathwayModel,withfoundaonsoflow
selfesteem,andtheSocialComparisonModel,whichtracesarelaonshipbetweenmediaexposureto
pressuresandelevatedinternalisaonofmediavalues.Thesemodelsallaimtoexplainspecic
mechanismsbywhichthemediageneratenegaveeects(ThomsonandHeinberg,1999).

TheDualPathwayModeldevelopsoutofobjeccaontheory.OriginallysuggestedbySceandAgras
(1999),itholdsthatbodydysmorphiaiscreatedbyasocialandculturalpressuretobethin,o enthrough
mediainuences.Athinidealisinternalisedbythissocialpressure.Thedysfunconalbodyimagethus
createdcanleadstoeangdisordersandothernegavebehaviouralpa ernsthroughtwopathways,
eitherofwhichissucienttocausethesepa erns.ThetwopathwaysaretheRestraintandthe
Aecvepathway.Withtherestraintpathway,dissasfaconwiththebodyleadstoa emptstorestrain
eangwhichinturncausespressureupontheindividual,leadingtoeangbehaviourssuchasbinging.
Theaectpathwayseesbodydysfunconalviewsprovokingnegavefeelingsabouttheselfasnegave
assessmentsofappearanceleadtonegaveemoons.Inaddion,negavefeelingscanalsobeprompted
bydiengeitherbecauseoflowenergylevelsor,whenthedietfails,feelingsofselfhatred(Munschand
Beglinger2005)Thesuccessofdissonancebasedprevenonprogrammes(discussedbelow)addssupport
tothedualpathwaymodel,assuchprogrammestargettheinternalisedidealofthinness(Sce,Mazo,
WeibelandAgras,2000).

Socialcomparisontheorysuggeststhatpeopleprocesssocialinformaonbycomparingthemselveswith
othersandbyidenfyingsimilariesanddierences.Itcanhelpusunderstandtheprocessesbywhich
socialmessagesconcerningappearanceinuencepeoplesbodyimage.Thetheorysuggestsarelaonship
betweenana ribute(theaspectwhichiscompared,forexampleweight),thetarget(thepersonwith
whichthea ributeiscompared)andthecomparisonappraisal(thewaythecomparisoniscarriedout).
Itcanbeusedtoelucidatethewaysinwhichmediamessagesinuencethewaypeopleperceivetheir
bodies.TheideawasintroducedbyFesnger(1954).Dierentcomparisonappraisalsareuseddepending
uponcontext.Theycanbeselfevaluaon,selfimprovementorselfenhancement.Therstconsistsof
gatheringinformaonabouthowonerelatestoothers.Selfimprovementconcernslearninghowto
changeaparcularcharacterisc,andselfenhancementisamechanismwherebytheotherisdiscounted
asnotrelevanttotheself,orlackinginothera ributestheselfpossesses(Krayleretal2007).

2.8.3TheDevelopmentaltransionmodel
Bycontrast,theDevelopmentalTransionModeltakesadierentperspecve,andisrootedin
psychoanalyctheory.ItcanbetracedtoObjectRelaonsTheory,thenoonthattheselfdevelops
throughinteraconwithanenvironment,whichwasdevelopedbyanumberofwritersincluding
Winnico andKlein.Thedevelopmenttransionmodelisconcernedwithproblemsthatoccurasachild
separatesfromhisorhermotheraspartoftheprocessofindividuaon.Thisprocessisthoughttobe

easierformen,becausetheydonothavethesamelevelofidencaonwiththeirmother.Inorderfor
womentosuccessfullyseparatefromtheirmother,theyneedtodealwithfeelingsofangertowardstheir
mother.Onewayinwhichthismighttakeplaceisbythedaughterturningthesefeelingsofrageagainst
themselves,andbecomingaperfectdaughter,wellbehaved,cleanandneat.Theirbodybecomestheir
enemy,anobjecttobecontrolled,andcanbeassociatedwiththemother.Thedaughterstrivestocontrol
herbodytopreventitbecominglikethatofhermother.Theprocessofindividuaonrsttakesplacein
earlychildhood,butcanresurfaceatadolescenceasthedaughtersbodystartstochangeandresemble
thatofthemother.Suchdysfunconaltransionsareparcularlylikelytooccurwherethemotheris
overcontrolling,orwheresheseesthedaughteraspartofherself,hopingtoliveoutherowndreams
vicariously(Yates,1991).Theoriesrootedinpsychoanalysisseemtotakeasecondplacetotheorieswhich
underlinetheroleplayedbysocialandculturalcondions,parcularlygiventhecentralroleplayedbythe
media,butgiventhecomplexityofthephenomenonofeangdisordersandpoorbodyimage,itis
importantnottoruleouttheinsightsgeneratedbyamoreindividualisc,internalperspecve.

3.Bodydysmorphicdisorder.
Theseconsabovehavegivenabroadpictureofthenatureofbodyimage,theimpactofpoorbody
imageandtheoriesofhowthesedevelop.Onespecicnegavecondionwhichdeservesmore
consideraonisthementaldisorderBodyDysmorphicDisorder,asittakesapoorbodyimagetoan
extremewhereitbecomesallconsumingforthesuerer.Bodydysmorphicdisorder(BDD)isalsoknown
asdysmorphobiaandisanunderrecognisedbutseverecommonmentalcondion.Althoughrst
describedbyEnricoMorselliin1891,ithasonlyrecentlybeenthesubjectofresearch.BDDisa
distressingorimpairingpreoccupaonwithanimaginedorslightdefectinonesappearance(Phillips
andDiaz,1997).

3.1Denionsofbodydysmorphicdisorder
BDDismuldimensionalandhasbothposiveandnegaveaspects(Cash,2002).Itconsistsofthree
components,oneconcerningtheperceptual,oneconcerningatudesandoneconcerningbehaviours
(Cash,2002;JarryandBerardi2004).PerceptualfactorsofBDDincludeinaccurateesmaonsofbody
sizeorweight,orseeingafeatureasveryuna racve.Atudinalfactorsincludetheextentof
sasfaconand/ordissasfaconwithappearanceandthewayappearanceisselfevaluated.
Behaviouralfactorsincludeacngoutsuchasrepeatedcheckingofperceivedimperfecons(Jarryand
Berardi2004).FeaturesofBDDconnueoverme,butarealsochangedasaresultofexperienceandthe
environment(Melnyk,CashandJanda2004).BDDiso enfoundwithothercondions,forexamplepoor
psychologicaladjustmentordepression,socialphobiaandobsessivecompulsivedisorder(OCD)(Phillips
2005;Pollice,Bianchini,Giuliani,Zoccali,Tomassini,Mazza,Ussorio,Paesani,RonconeandCasacchia
2009).ThereisadegreeofheterogeneityamongstthoseaectedbyBDD,aseachsuererpresentswith
verydierentsymptomsfromadissasfaconwiththenosetofeelinggenerallyugly,howeverthe
underlyingpathologyisthatBDDsuerersarepreoccupiedwiththeideathattheirappearance,ora
featureofit,isuna racve,uglyordeformed.Furthertothis,overmenatureofthedisturbancemay
change,o enexplainingwhypostsurgery,BDDpaentso enaredissasedwiththeresults(Veale
2004).Unfortunately,thiscondionhassignicantlyhighlifemeratesofsuicidalideaon(approx78
81%)anda emptsofsuicide(2228%)(Phillips,2005)withapoorprognosisforrecovery.BDDisa
dynamiccondion,whichaectstypicallyfacialaws,asymmetric/disproporonatebodyfeatures,
incipientbaldness,acne,wrinkles,vascularmarkingsorextremesofskincolour.BDDhasbeenlinkedto
requestsforcosmecsurgeryprocedures.Ithasbeenesmatedthatbetween6and15%ofpeople
requesngplascsurgerysuerfromthedisorder(Polliceetal2009,pp.510).Giventheseverityofthe
condion,thereisaclearneedtondsuccessfultreatmentroutesinaddiontoaddressingpoorbody
imagegenerally.

3.2Riskfactors

RiskfactorsforBDDincludegenecpredisposion,shyness,perfeconism,anxioustemperament,
childhoodadversity(e.g.teasing/bullyingaboutappearanceorcompetence),historyofdermatologicalor
otherphysicalsgmata(e.g.acne)andhavinganhighersensivitytoaesthecsthantheaverageperson.
Thisheightenedaesthecsensivityequatestoagreateremoonalresponsetootherindividualswhom
theyndmorephysicallya racveandelevatestheirvalueofappearanceandidenty(Veale,2004)

3.3Clinicalfeaturesanddiagnosis
Individualsmaydescribethemselvesasuna racve,mosto enfocusingontheirfaciala ributesortheir
head,howeverthisdispleasurecanincludeanybodyarea,orinfacttheirenrebody.Thisconcerncan
takeupalmost38hoursoftheirday,carryingoutrepevebehaviourssuchasmirrorchecking,andis
o enassociatedwithemoonssuchasrejecon,lowselfesteem,shame,embarrassment,unworthiness
andbeingunlovedbythosearoundthem.ThediagnosisofBDDusuallyoccursa er15yearsformthe
onsetofthismentaldisorder,thisisduetomanypaentsbeingtooashamedtorevealtheirsymptoms
howeverwhenexposedtoadoctoristypicallydiagnosedusingtheDSMIVcriteria(Veale,2004;Phillips,
2004).

TheDSMIVTRdiagnosccriteriaforBDDisasfollows:
a)Preoccupaonwithanimagineddefectinappearance.Ifaslightphysicalanomalyexiststhepersons
concerninmarkedlyenhanced,
b)thepreoccupaoncreatesclinicallysignicantdistressorimpairmentinsocial,occupaonalorother
importantareasoffunconing
c)thepreoccupaonisnotbe eraccountedforanyanothermentaldisorder(e.g.bodydissasfacon
withbodyshapeandsizeinanorexianervosa).
(Phillips,2005).

AnumberofmeasureshavebeenusedtotestforBDD,includingtheSelfreportSymptomInventoryand
theBodyUneasinessTest(Polliceetal2009).InstrumentscommonlyusedtomeasureBDDincludethe
BodyShapeQuesonnairewhichlooksatconcernsaboutindividualssizeandshape,the
MuldimensionalBodySelfRelaonsQuesonnaire,anatudinalmeasure,theBodyImageAvoidance
Quesonnaire,whichassessesbodyimageissuesintermsofavoidancebehaviour,theAppearance
SchemasInventory,measuringbodyimageatude,andtheSituaonalInventoryofBodyImage
Dysphoria,whichmeasuresthefrequencyofnegavebodyemoons.(JarryandBerardi2004).Other
instrumentsincludetheBodyCathexisScale,lookingat46bodypartsandfuncons,andtherelatedSelf
Cathexisscale,containing55itemswhichrepresentconceptualaspectsoftheself.Bothareratedona5
pointLickertscale(1wishtochange,5sasedwiththeaspect)(DworkinandKerr,1987).

3.4Prevalence
AlthoughBDDoccursrelavelyfrequentlyinbothclinicalandnonclinicalsengs,nolargescale
epidemiologicalsurveyshavebeencarriedouttodate.WithintheUK,onlytwostudieshavebeen
reportedinthecommunityandshowtheprevalencetobe0.7%,occurringatahigherfrequencyin
adolescentsandyoungadults.Bothgendersseemtobeaectedequally,andthemajorityofsuerersfall
intothecategoryofsingle,separatedorunemployed(Phillips,2004;Veale,2004).AnItalianstudyhas
suggestedthatitaectsahigherpercentageofthepopulaon,at12%(Polliceetal2009).Therateof
BDDamongstpeopleseekingcosmecsurgeryishigh:ofthosepresenngatcosmecsurgeryclinicsitis
esmated615%suersfromBDD,andwithindermatologicalsengstheesmateis912%(Phillips
2005).

3.5Treatment

TreatmentofBDDusuallyinvolvescosmecsurgerydermatologicaltreatment(wherethereisan
associatedcosmeccondion),pharmacotherapyintheformofserotoninreuptakeinhibitors(SSRI)or
cognivebehaviourtherapy(CBT)(Veale,2004).

Althoughpsychotherapyoponsavailablehavebeenseldomresearched,CBTdoesappearanecient
formoftreatment.Numerousstudieshaveusedacombinaonofcogniveelements(e.g.cognive
restructuring)alongsidebehaviouralelements,whichconsistspredominantlyofexposureandresponse
prevenon(ERP).ERPaimstodecreasesocialavoidanceandrepevebehaviours(suchasmirror
checkingandgrooming).Therehasbeenreportedposivecorrelaonbetweenvariouscombinaon
therapieswithBDDsymptomseverityshowingasignicantdecline.Thereisnopublisheddatato
substanatetheuseofothertypesofpsychotherapyotherthanCBT(Phillips2004).Inaddion,aschool
intervenonprogrammeconsisngofclasseslookingatmediaimagesofwomen,bodysizeandweight
controlmethodswasfoundtohavesomesuccessinreducingBDD(Paxton1991).Intervenon
programmestypicallyinvolvelargergroupsofpaentsandassuchmightbelesscostlythanCTorCBT
whicho eninvolveonetoonetherapysessions.Socialcomparisontheorycanalsobeusedtobuilda
caseforintervenonprogrammetreatmentsforEDandBDD,asithelpsusunderstandwhysome
individualsdontreactnegavelytocomparisonswithmediaimagesaboutbodyshapeandweight.
Programmeswhichbuildresistancetoknownriskfactorssuchasidealmediaimagesareuseful,with
cogniveintervenonsseemingtoproducegoodeects(Krayleretal2007).YagerandODea(2010)
studiedtheeectoftwointervenonsamongtraineePEandHealtheducaonteachers,idenedasat
riskofpoorbodyimage.Oneintervenonwasaselfesteemandmedialiteracyprogramme,thesecond
combinedselfesteemandmedialiteraturewithdissonanceandusedonlineandcomputerbased
acvies.Intervenon2producedthebestresults,parcularlyformen.

WhileCBTandCTandintervenonprogrammesseemappropriatetreatmentsforBDD,andlaterthese
treatmentswillbediscussedinmoredetail,therewouldseemtobeacaseforusingmorepersoncentred
therapeucapproacheswhichaimtoworkwiththeclientsinternalrepresentaonsoftheirappearance.
ThefollowingseconwilllookattreatmentapproachesforBDDinparcular,butalsoforpoorbody
imageandrelateddisordersingeneral.

4.Counsellingtherapies
4.1Thedevelopmentofcounselling
WhiletherootsofcounsellingcanbetracedbacktoGreekandRomanmes,moderncounselling
developedoutofareaconagainstthereligiousworldviewwhichpredominatedunlthelate19th
century.Upunlthisme,behavioursthatwewouldnowcharacteriseasmedicalcondionswereseen
assignsofdemonicpossession,withinthatprevailingreligiousframeworkofgoodagainstevil.Pioneering
workbyscienstsincludingPinel,MesmerandCharcothelpedestablishthecurrentmedicalframeworkin
whichmentalcondionswereseenasillnesses,similartophysicalillnessandequallytreatable.Thisnew
approachmeantthattreatmentoponsformentalillnessesappeared(Laungani2004).

ModerncounsellingcanbetracedbacktoFreudsworkinthe1880s.Freuddevelopedawayofworking
withpaentswithhysteria,calledpsychoanalysis.Hesuggestedthatunconsciousforcesshapepeoples
aconsandbeliefs.Approachestotherapydescendingfrompsychoanalysisfocusuponthedynamic
relaonshipsbetweenpartsofthepsycheandtheoutsideworld.Freudianpsychoanalysishasbeen
extremelyinuenalnotonlyinpsychologyandpsychiatrybutinrelatedeldssuchasliteratureandart.

Adierentapproachwasputforwardbythebehaviourists,primarilySkinner.Behaviourismrejectsthe
noonoftheunconsciousandspulatesthatmentalprocessescanbethoughtofintermsofbehaviours
andobservablevariables.AthirdwaywasputforwardbyCarlRogers,inuencedbyAlderandrank.
Client,orPersoncentredtherapyfocusesupontheexperiencedworldoftheclient,rejecngthe
untestableconstructsofpsychoanalysiswhileaccepngtheinternalworldofsubjecveexperienceruled
outbythebehaviourists.PersoncentredtherapydevelopedintohumaniscapproachesincludingGestalt
therapyandpsychodrama(Mulhauser,2010).

Thegrowthinthepracceofcounsellinghasbeenparcularlyrapidoverthelast50yearsorso.Thiscan
betracedtoanumberoffactors,includingagrowthinpeoplesawarenessofandinterestintheselfand
identy,anincreasinglyfragmentedsocietyinwhichalienaonisincreasinglycommonandinwhichmany
lacksocialsupportsystems,andachangeinthenatureofnursingandothercaringprofessionswhich
meantheyareunabletocarryoutthecounsellingfunconswhichusedtobepartoftheirrole(Robband
Barre ,2003).

Unl1977,whentheBrishAssociaonofCounsellingwasestablished,counsellingpraconerswere
enrelyunregulated,andanyonecouldpracceasacounsellorwithoutchecks.Theestablishmentofthe
BACmeantamovetowardsprofessionalizaonwithaccreditaonandchecksonpraconers.
MembershipoftheBACgrewrapidly,andtheorganisaonsplitinto7divisionsinordertobe erreect
theverycomplexneedsoftodayssociety.TheBACwasrenamedtheBrishAssociaonofCounselling
andPsychotherapyin2000(Laungani,2004).

Inlinewiththehistoricaldevelopmentoutlinedabove,psychologicaltherapiesgenerallyareorganised
intothreecategories;behaviouraltherapies,psychoanalycalandpsychodynamictherapiesand
humanisctherapies.Behaviouraltherapiesfocusesoncognionsandbehaviourandencompasses
cognivetherapy(CT)andcognivebehaviourtherapy(CBT).Thesecondcategoryincludes
psychoanalyctherapyandpsychodynamictherapy,withcentralimportancegiventotheunconscious
relaonshippa erns,whichhaveevolvedfromchildhood.Finally,thethirdcategoryofHumanisc
Therapiesprioriseselfdevelopmentandthehereandnow.InaddiontoPersonCentredCounselling
(alsoknownasClientcentredorRogeriancounselling)andGestalttherapy,humaniscapproaches
includetransaconalanalysis,transpersonalpsychologyandpsychosynthesisandexistenaltherapy
(CounsellingDirectory2011[online]).TreatmentsforpoorbodyimageandBDDtendtobedrawnfrom
therapiesofthebehaviouraltype,althoughacasecanbemadeforabroaderapproachtotreatment.

4.2ThePracceofcounsellingforpoorbodyimage
Higgins(1987)outlinedtwobasickindsofnegavepsychologicalsituaons,rstlytheabsenceofposive
outcomes,eitheractualorexpected.Thisisconnectedwithdepressiveemoonssuchasdisappointment,
dissasfaconandsadness).Thesecondisthepresenceofnegaveoutcomes(actualorexpected),which
isconnectedinturntomoreacvenegaveemoonssuchasfear,threatandedginess.Therapiesaimed
atcounteracngapoorbodyimagehavetodealprimarilywiththerstsituaon.

Therapyforpeoplewithpoorbodyimageandrelateddisordersseekstoencourageposivethinkingin
ordertoboosttheclientsselfesteemandovercomelowcondencebyalteringthesethoughtsand
behaviours.Counsellingandtherapycanalsotargetissuesbyprevenngbehaviourswhichresultfrom
individualsinternalisingmediaimages,promoteposiveinternalisaonofhealthynorms,andinform
clientsaboutthenegaveconsequencesofextremeweightlossbehavioursina emptstogainanideal
look(ThompsonandHeinberg,1999).Thecounsellorcanworkwithaclientwithpoorbodyimagein
severalpraccalways.First,heorshecanlookatpreviouspa ernsinhowtheclientcopedwithbody

imagechangesinthepast.Thesepa erns,onceuncovered,canbeexaminedandanalysed.Helpful
copingstrategiescouldbeusedagain,andnegaveonesrejected.Thecounsellorcanalsolookatthe
supportsystemaclienthasinordertoplantherapymoreeecvely.Ifmembersofaclientsfamily,for
example,reinforceunhelpfulbehavioursthiscouldberaisedwiththeclient(Flaming,1993).

4.2.1Ethicalissues
Counsellingandtherapyforpoorbodyissues,should,liketreatmentsforothermentalhealthproblems,
beconductedethicallyatallmes.TheBrishAssociaonforCounsellingandPsychotherapy(BACP),rst
publishedin2002,setsoutanethicalframeworkwhichissubjecttoconnualrevision(BACP2001,200,
2007,2009,2010).Thisframeworksetsoutareaswhichneedtobeincorporatedbytherapistsand
counsellorsinanyclientstreatment.Theseareasincludevalues,principlesandpersonalmorals.The
fundamentalvaluesofcounsellingandpsychotherapyincluderespecnghumanrightsanddignity,
protecngclientsafety.Inaddion,therapistneedtoensuretheymaintainintegrityinrelaonshipswith
clients,thattheyalwaysacttoimproveprofessionalknowledge,thattheyaimtoreducesueringand
personaldistressandtomaketheclientsexperiencemoremeaningfulandeecve.Theyshouldalso
strivetoimproverelaonshipsbetweenindividualsandtorespectthediversityofhumancultureand
striveforequality(BACP,2010).Thetherapistorcounsellorshouldalsotrytointegrateethicalprinciples
intohisorherpracceincludingtrustworthiness,autonomy,respectfortheclientsselfgoverning,
promongtheclientswellbeing,fosteringselfrespectintheclientandbeingcommi edtoavoiding
harmingtheclient(BACP,2010).

4.3TypesoftherapyandtheirusefulnessforBDDandbodyimage
problems
Empiricalevidencefromanumberofstudiessuggeststhatcounsellingisapowerfulinstrumentin
promongbodyandselfacceptanceinwomen.Evidenceexistsparcularlyfortheeecvenessof
cognivetherapyandcognivebehaviouraltherapy(DworkinandKerr1987),althoughotherapproaches
havebeenshowntobesuccessful(prevenonprogrammes)andothertherapiesseem,thoughrelavely
unexplored,tooeralternavesforclientsforwhomCTorCBTdonotworkwell.

4.3.1Cognivetherapytechniques(CT).
Cognivetherapy(CT)hasemergedasasuccessfultherapeucapproachfordepression,alteringstates
ofirraonalthoughtandreshapingselfstatementstoamoreposiveoutlook.Thismoregeneralideaof
ulisingcognivetherapiestoaddressirraonalbeliefscanbeusefullyadaptedtowardsovercominga
disturbedbodyimageandassociangnegaveselfconcepts(DworkinandKerr,1987)CTinvolves
educang,idenfyingandreplacingbeliefsandthoughtswhichmightbeconsidereddistorted,andby
idenfyingthemalteringtheassociatedhabitualbehavioursandthoughtstowhichtheyarerelated.
CognivetherapywasoriginallydevelopedbyBeck(1976),andisbasedaroundthenoonthat
dysfunconalrepresentaons(schemata)ariseinchildhoodasaresultofproblemsinrelaonships,
parcularlywithparents.CThasfourmaincomponents,rst,aneducaveelement(o enpaentsare
uninformedabouttheircondion),secondgoalseng(gengpaentstocarryoutprogressivelymore
challengingacvies,o enaspartofhomeworktasks),thirdidenfyingnegavethoughts(clientsmay
beunawareofthethoughtpa ernsthatareholdingthemback)andfourthlychallengingnegaveand
unhelpfulthoughts(ChampionandPower,2000).Bybecomingawareofirraonalbeliefsandchallenging
them,clientsareempoweredtoexchangethemformoreposiveones.Onceclientsunderstandthe
mechanismforchallengingandchangingtheirthoughts,theyareabletodothisforthemselvesoutsideof
therapysessions.CThasbeenshowntobeeecveintreangBDD,butnomoresothanother
techniques.Focusuponchangingnegaveselfstatementsintoposiveones,teachesclientsmethodsfor
doingthisbythemselves,canincludehomeworktasks(DworkinandKerr1987).

4.3.2Cognivebehaviouraltherapy(CBT).
CogniveBehaviouralTherapydevelopedfromCognivetherapy,andcombinesbothcogniveand
behaviourtherapies,incorporangthewayonethinks(cognive)aswellashowthesethoughtsare
respondedto(behaviour).SimilarlytoCT,itconcentratesonthehereandnow,andupondisassembling

overwhelmingproblemssotheyaresmallerandeasiertomanage(Farrelletal2006).Italsouses
addionalbehaviouralreinforcementsforexampleselfreinforcementandimaginaveorfantasy
exercises.Therehavebeensuggesonsthatimaginaveacviesparcularlycanbeusedwithin
therapiesforeangbehaviours,asimaginaonisapowerfuladapveacvitythathelpsclientsorganise
eventmeanings,planforthefutureandguidethemingoalachievementanddecisionmaking.While
imaginaoncanworknegavelybybeingusedasacopingmechanismwithnegaveselfimagesand
fantasyandhelpinternalisenegaveperceponsofbodyimage,itcanalsobetargetedasaposive
strategytohelpchangeinsetbeliefpa erns(HutchinsonPhillipsHutchinsonPhillips,JamiesonandGow,
2005).

ThisaddionofbehaviouralaspectstocreateCBTmeansthetherapyisamorepowerfulwaytotackle
problemsbyallowingclientsnotonlytochangetheirbeliefsystemsintomoreposiveones,butalso
teachingtechniquesforclientstousetoreinforcegoodpracce(DworkinandKerr,1987).CBTcan
incorporatenumeroustechniquesincludingcogniverestructuring(quesoningandchallenging
problemacthoughts),behaviouralexperiments(praccalacviestesngprediconswhichemanate
fromproblemacbeliefsandthoughts)andsizepercepontraining(reviewingtheaccuracyoftheclients
bodysize)(Farrelletal,2006).

Cash(1995)andRosen(1997)havedevelopedCBTtechniquesspecicallyforusewithpeoplewithpoor
bodyimageandeangdisorders.Theirprogrammehasbecomewidelyused,andhasbeentestedand
foundtohavegoodresultsforatleasta36monthperioda ercompleon.Theprogrammeconsistsof
threeelementswhichworktogether:rstlypsychoeducaonaboutbodyimage,secondguidedexercises
whichhelptheclientassessandchallengenegavethoughts,andthirdskillsteachingtoenabletheclient
tomastersituaonsthathavebeenshowntoleadtobodyanxietyinthepast(LevineandSmolak,2005).
Inotherresearchcarriedoutwithpaentswhohaveviligo,avisibledisgurement,CBTwas
demonstratedtobeeecveinenhancingonesselfesteemandbodyimage(Papadopoulos,BorandLegg
1999).CBThasbeenfoundrepeatedlytobeaveryeecvetreatmentforpoorbodyimage(Jarryand
Berardi2004).

CBThasbeenusedspecicallyforBDD.Itisamulcomponentapproachwhichinvolvesanassumpon
thatdysfunconalthoughtsandbehavioursarelearntresponsesandcanbeunlearnedandmoreposive
responsesputintheirplace.CBTforBDDcanincludeselfmonitoring,desensivisaon,cognive
restructuringandbehaviouralmodicaonaswellasgroupwork(JarryandBerardi,2004).However,
JarryandBerardi(2004)comparedanumberoftreatmentprogrammesforBDDusingCBT,andfoundthat
whilealladdressedtheatudinalcomponentoftheillness,onlysomealsoaddressedtheperceptualand
emoonalcontents.Theyfoundthatbodyimagetherapy,baseduponCBTtechniques,isveryeecve
withimprovementstotheatudinalandbehaviouralcomponentsoftheillnessa ertreatment.Atudes
towardseang,andbehaviouralsoimproveda erCBTbasedintervenons.JarryandBerardisofCBT
basedtreatmentsalsoseemtoindicatethenecessityofatherapist.WhileselfadministeredCBTcanbe
eecve,theabsenceoftherapistseemstohinderbehaviouralchangesandmakeclientlessableto
comply.

Veale(2004;2001)hasdevelopedamodelforexplainingBDDbaseduponcognivebehaviouraltheory.
VealesmodelrelatestothatdevelopedbyCashandPruzinskytoexplainbodyweightandshape
dissasfaconinthenonclinicalseng,butisapplicablespecicallytoBDDandincorporatesfeatures
uniquetothedisorder,includingtheclientsrelaonshipwithreecvesurfacesforexamplemirrors
whichcantriggersymptoms.HismodelhelpsunderstandwhysymptomsofBDDaremaintained,andcan
beusedbyatherapisttohelptheclientunderstandhisorhersymptomsandovercomethem.Inhis
model,thereisacomplexrelaonshipbetweentheclientsnegaveappraisaloftheirbodyimageonthe
onehand,andseveralotherfactorsontheother:theprocessingoftheselfasanaesthecobject;
ruminaononuglinessandcomparingtheselftotheideal;negavemoodandsafetybehavioursto
disguisetheappearance.Thereisatwowayrelaonshipbetweentheclientsappraisalandeachofthese

fourfactors.Inaddion,triggerscanacttostartacyclicalrelaonshipbetweenthenegaveselfappraisal
andprocessingoftheselfasanaesthecobject(Veale2001;2004).Sofar,Vealesmodelseemsnotto
havefedintothefurtherdevelopmentofCBTtechniquesforBDD.

4.3.3Personcentredtherapy
Client,orpersoncentredtherapyisanapproachrootedinthesubjecveexperienceofindividuals.It
contrastswiththeFreudianapproach,whichlooksattheplayofinuenceswhichhavecontributedtothe
clientssituaon,butalsowithCTandCBTapproachesasitplaceslessemphasisupontheclients
behaviours.ThePersoncentredtherapistisconcernedwiththeclientspersonalviewoftheworld,and
howthatclientinterpretsandmakessenseofevents.Itassumesahumaniscpsychology,ratherthana
behaviouristone.Inordertobesuccessful,thetherapistshouldunderstandtheclientslife,valuesand
experience.Personcentredtherapyalsodiersfromcogniveapproachesinthatthela erpriorisethe
processofthought,whiletheformerconcentratesuponfeelingsandemoons.

KeyideasinpersoncentredtherapyweredevelopedbyCarlRogers.Rogersbelievedthathumansstrive
towardsselfactualisaon,thateveryonewantstomakefullandbestuseoftheirpotenal.Healso
assumedthatpeopleareinherentlygood,andthatirraonalbeliefsandactsareaconsequenceoffear.
KeyconceptsRogersdevelopedincludethenoonofselfimagehowapersonseeshisorherself.This
selfimagedeterminesapersonsoutlookonlifeandhisbehaviour.Hedisnguishedfurtherbetweenan
idealselfimagehowapersonthinksheorsheshouldbeandhowtheyperceivethemselvesto
actuallybe.Rogerssuggestedthattheselfimage(orselfconcept)canbecongruentwithrealitymatch
experienceorincongruent,forexamplewhensomeoneperceivesthemselvesasbeinghated,without
therebeinganyevidenceforthis.Rogeriantherapythereforehastwoaims,rstlytoreconciledierences
betweenrealityandtheselfimage,andsecondtoreconciledierencesbetweentheconceptoftheideal
selfandtheconceptoftheactualself(GroenmannandBuckenham,1992).Arelatedconcepttotheidea
ofcongruenceandincongruencewasputforwardbyGoman(1963),whosuggestedthenoonofsgma
asana ributewhichisdeeplydiscredingfortheindividualsinvolved.AccordingtoGoman,asgma
emanatesduringsocialinteraconswherebyanindividualsactualsocialidenty(characteriscs/traits
thoughttobepossessedbythisindividual)failtomeettheexpectaonsofthesocieesatudeofwhat
constutesnormal,thatbeinghis/hervirtualsocialidenty.Thissituaonresultsinapredicament
wherebytheindividualhasaspoiledsocialidenty,andassumedtobeincapableofsasfyingtherole
requirementsofsocialinteracons(KurzbanandLeary,2001).Variousa emptstoconceptualisesgma
developingtheworkofGomanhavebeenproposedsince,allsharingafundamentaltenetthat
sgmazaonofanindividualoccursthroughtheculminaonofnegaveevaluaon,whetherintermsof
discreding,adversea ributes,theperceponofillegimacyorasaresultofdevaluedsocialstatus
(KurzbanandLeary,2001).ExamplesofthedevelopmentoftheconceptincludethatbyJonesJones,
Farina,Hastorf,Markus,MillerandSco (1984),whoestablishedasixdimensionalmethodforexamining
sgmaassociatedhealthcondions.Thesixdimensionsarersttheextenttowhichthecondioncanbe
concealed(isthecondionobvioustoothersandwhatistheextentofthevisibility?),secondthecourse
ofdisorder(thegeneralpa ernofchangeandoutcomeofthecondioninqueson),thirddisrupveness
(towhatextentdoesthecondionhinderscommunicaonandinteracon?),fourthaesthecqualies(to
whatextentdoesitmakethesuererrepellent,uglyorupseng?), horigin(thestateofaairsin
whichthecondionemanated)andnally,peril(towhatextentdoesthecondionposeathreatto
others?).Inaddion,LinkandPhelan(2006),describedsgmaarisingasresultofacombinaonof
interrelatedelements,essenallyencompassingtheseveissues;idenfyingandlabellinghuman
dierences,processingstereotype,separangthemandusmentality,experiencesofdiscriminaon
andlossofstatusandnallytheexerciseofpower.Thisnoonofsgmataseemsparcularlyapplicable
tothewaythepersonwithBDDviewstheaspectofhisorherbodythatisunacceptabletothem.

Cricismsofpersoncentredtherapytendtocomefromapsychoanalycperspecve,andfocusuponits
lackofexplanatorypowerasamodel.Cricsforexampleclaimthatitlacksatheoryofpersonality,and
especiallyisunabletoaccountforchilddevelopment.Inaddionitcannotexplainhowneurosesand
psychosesdevelop(Wilkinson2003).


Oneargumentforulisingapersoncentred,humaniscapproachisthatsuchapproachesintegratethe
bodymorefullyintothetherapeucprocess.Whileallschoolsoftherapyacknowledgetheimportanceof
thebody,theyfrequentlylimititsinvolvementtoverbal,symbolicandintellectualdiscussions.Paent
iniatedmovementtendtobeignoredbymanyschoolsofpsychotherapy(Miller2000).Millerdoesnot
menon,butthiscanalsobesaidtobetrueofCTandCBT.Bydeniontheseapproachesconcentrate
uponthoughtsandchangingthem,ratherthanintegrangbodysensaons.Clientcentredtherapies,
however,aremorelikelytointegratethebodyintosessions.BernesTransaconalAnalysisurgesthe
therapisttolookforreferencestobodypartsliketheanusandmouth.Otherclientcentredapproaches
suchasGestalt,psychodramaandBioenergecAnalysisintegratetheclientsphysicalbeingperhapsby
repeangclientgesturesortryingtouncoverhowpastexperienceshavebeenintegratedintotheclients
body.Bioenergecanalysis,forexample,suggeststhattheclientusesphysicaltechniquesinchildhood
suchasmusclecontraconorreduconinbreathingtocopewithdicultsituaons,andthatphysical
exercisescanhelpunlocktheselongstandingnegavepa erns.Suchapproachesseetheclientas
embodiedratherthanasasetofcognions(Miller2000).
Rowansuggeststhatwhiletherearethreewaysinwhichtherapycanconceptualisethebody,which
correspondtothreelevelsinamodelbyWilber(1996),mosttherapiesconcentrateundulyupontherst
way.Atlevelone,thebodyisseenasseparatefromthemind,onecanbetreatedinindependencefrom
another.Atleveltwo,mindandbodyareintegrated,andtheclientisencouragedtoseeitinthiswayalso.
Atlevelthree,thebodyandmindarebothpartofagreaterwhole(Rowan2000).

Anotherreasonwhyaclientcentredapproachmightbeusefulisthatthereissomeevidencethatpeople
withproblemswitheangalsohaveproblemswithinterpersonalrelaonships.CTandCBTdonotwork
onsuchrelaonships.Interpersonalissuescanbothcauseandperpetuatedysfunconalatudestothe
body.Personbasedapproachesareabletohelppaentsdealwithissuesthathavebeendeeply
entrenched.
Reecvetherapytechniquesareoneformofpersoncentredtherapywhichseemsparcularlyusefulfor
treangBDD.SuggestedbyDworkinandKerr(1987),reecvetherapyappliesthebasicprinciplesof
clientcentredtherapyandconsistsofexploringthepaentsfeelingsaboutbodyimageduringkey
periodsintheirdevelopment.Itdoesnotincludetechniquesforchallengingnegaveandirraonal
beliefs,butratherfocusesuponexploringfeelingsaboutbodyimageusingtechniquessuchasreecon,
paraphrasingandjournalbasedhomework.Byexploringtheclientsfeelingsaboutbodyimage,and
lookingbacktokeylifestages,theapproachdierssharplyfromthatofCTandCBT.DworkinandKerr
(1987)founditaseecveasCBT.Whileitlacksthecomplexityofapproachoftrueclientcentred
therapies,itisslluseful.Thisalsosuggeststhatemoonallyfocussedwhichlookattheinternalworldof
theclienttherapiesmaybeuseful.Researchhasinfactsuggestedalinkbetweenoutcomesintherapyand
theextenttowhichclientsareabletoexploreandanalyseemoonalmeanings.Therehasbeenli le
tesngoftreatmentswhichworkinthisway,despitearecognionthatCBTmaynotsuitallpaents(Jarry
andBerardi2004).

4.3.4Prevenonprogrammes
OnepossiblecriqueofbothCBT/CTstrategiesandpersonbasedtherapeucapproachesisthatthey
focusupontheindividualratherthansocietyorcultureasawhole.Suchpraccesmightbesaidtoisolate
individualclientsbyremovingthemfromthesocialenvironmentwherenegavethoughtsandpercepon
ofselfemerge.Therapistsaimtotreatindividualbehavioursandatudesbyeitherchallengeemoons
andthoughtsorbyuncoveringtheirrootinchildhoodexperienced.Assuchtheyareaddressedas
symptomsofadisorderratherthanasavalidresponsetoaharshsocialclimate.Anotherapproachwould
betolookatoutsideinuencesincludingthemedia(Markula2001).Whilethisawarenesscanbe
integratedintotherapyandcounselling,otherstrategiesfortreatmentareverydierent.Onesuch
strategyisthetreatmentprogrammesforeangdisordersandpoorbodyimage.Suchprogrammes
typicallytargetindividualsatalifestageparcularlypronetosuchproblems,forexamplefemale
undergraduates.Theyalsotypicallyinvolvegroupsofclients,ratherthanthetherapeucfocusupon
individuals.Anotherfeatureisthefocusuponteachingmediaawareness.Typicalprogrammestakea

mulfacetedapproach,forexamplecombiningstrategiestoreducetheinternalisaonofthethinideal
withpromoonofbodystrategythroughlifeskillsandamedialiteracypromoon.Stressmanagement
skillscanhelpimprovecommunicaonanddecisionmakingandotheracviespromoteselfesteem.
GailGail,McVey,Kirsh,Maker,Walker,Mullane,Laliberte,EllisClaypool,Vorderbrugge,Burne ,Cheung
andBanks(2010),forexample,testedsuchaprogrammeamongstuniversitystudentsalongsidea
universityhealthpromoonteam.

SceandShaw(2004)havelookedindetailattheeecvenessofsuchprogrammes.Theytracethe
developmentfromtheearlydidaccpsychoeducaonalmaterialabouteangdisorders.Theseearly
a emptswerebasedonanassumponthatinformingparcipantsoftheadverseeectsofeang
disorderswouldactasadeterrent.Thenextwaveofprogrammesretainedthedidacccontentand
universalfocusbutalsoincludedteachingtoolsforresisngsocialandculturalpressurestowardsthethin
ideal,duetoacknowledgingthatsuchpressuresplayakeypartindevelopingeangpathology.Thethird
generaonofintervenonshavetargetedprogrammesathighriskindividualsandhaveahighdegreeof
interacvity,asithasbeensuggestedthatsuchtargengrendersprogrammesmoreeecve.Prevenon
programmesarethoughttobemosteecvewhendeliveredduringtheperiodofdevelopmentinwhich
condionemerges.

Interacveprogrammeshavebeenshowntobemoreeecvethandidaccones,perhapsbecausethe
formatallowsparcipantstoengagemorefullywiththecontentoftheprogramme.Interacveexercises
alsoallowparcipantstoapplytaughtskills.Theyarealsomosteecvewhentheyarespreadoutovera
periodofme,forexampleatleast3hourlongsessionsonceperweek.Thebreakbetweensessions
allowsparcipantstoreectuponthecontent,trynewskillsandseekadviceinsubsequentsession.
Contentisalsoimportantwherethefocusisuponestablishedriskfactors,thereismoresuccessthan
wherenonestablishedriskfactorsaretargeted.Inparcular,programmesthataimtoincreaseresistance
tosocialpressures,increaseselfesteemandbodysasfaconproducebe ereectsthanthosewhichdo
notaddresssuchfactors.Successfulprogrammesshouldalsoimproveeangpathology(SceandShaw,
2004)

Oneeecveformofprevenonprogrammeisthedissonancebasedprevenonprogramme.Theseare
basedaroundthenoonofcognivedissonanceprevenon.InuencedbyScesdualpathwaymodel,
programmestrytoreducetheextenttowhichthethinidealisinternalisedbyinducingcognive
dissonance,anuncomfortablepsychologicalstatethatoccurswhenbeliefsandaconsareinconsistent.
Typicaldissonancebasedprevenonprogrammesincludeaseriesofverbal,wri enandbehavioural
exercisesthatchallengetheidealofthinness,forexamplediscussingproblemswiththeidealandnegave
consequencesoftryingtoa aintheideal.Whenindividualshavetoanalyseanddefendabelief,theyare
moreopentochangingthatbeliefa ertheexerciseiscompleted.Dissonanceprevenonhasbeentested
andappearstoreduceeangdisorderriskfactorssignicantly,anddosooveraperiodofmeextending
beyondtheprogrammeperiod.Perez,BeckerandRamirezsuggestthatnotonlyaresuchprogrammes
eecve,butalsothattheycanbedisseminatedinthewidercommunitysuccessfully(Perezetal,2010).

Oneadvantageoftheseprogrammesisthattheyseemtobeabletopreventthedevelopmentofseverer
bodyissuecondionsbytargengindividualswhoareatriskanddoingsosuccessfully.Thecostof
implemenngthemisthereforelikelytobelowerthanintensetherapyonceacondionisestablished,
andthecosttothesuererisalsoless,asthedisorderdoesnotbecomesodevelopedastonegavely
eectlifecondions.Inaddion,JarryandBerardi(2004)suggestthatthereisaneedtolookatthe
eecvenessofothertherapeuctreatments,forexamplereecvetherapy,exercisetherapy,weight
control,andtheuseofVRenvironment.

5.Discussionofdierenttherapeucapproachestobodyimage
disorders
Thereareadvantagestoeachtreatmenttype.CBTinparcularhasbeenshowntobeeecveforbody
imageproblemswhenadministeredindividually,ingroupsandselfadministered(LembergandCohen,
1999).ThecombinaonofCTwithbehaviouraltechniques,e.g.reinforcementandimageryisa
parcularlypowerfulandecaciouscombinaon(DworkinandKerr,1987).NotonlyisCBTableto
reducenegavebodyissues,therearealsootherposiveeectsdocumentedincludingimprovedsocial
funconingandincreasedselfesteem(LembergandCohen1999).CBTtreatmentsseemtorepresentan
advanceonCTtreatmentsastheyincorporatebehaviouralmodicaonintoprogrammes.Veale(2004)
haspresentedacoherentmodelofBDDrootedincognivebehaviouralprinciples.Inaddion,CBTandCT
twellintothecurrenthealthclimate.Theyareo enpreferredastherapyoponsbytheNHSasthey
oeralowcostalternave,thatisrelavelyquicktoadminister.Theyseemtobebasedonsound
sciencprinciplesandaremoreeasilytestedandveriedinresearchstudies.Theydeliverawiderange
oftestableoutcomes.Consequently,theyareacceptedasmoreeecvesoluonstoarangeofproblems
(WilsonandSyme2006).However,therearealsoargumentsforthepersoncentredapproach.Some
clientsareunwillingtotakepartinCBTorCT,ndingitmechaniscandformulaic.Personcentred
therapiestakethebackgroundoftheclientintoaccount,anditispossiblethatbyuncoveringdeepseated
issueswiththetherapist,longerlasngsoluonscanbefound.TypicalstudiesofCTandCBTseemto
showsuccessbothatthemeoftreatmentandforaperioda ertreatment,howeveritisunclearhow
longthiseectslast.Moreresearchisneededtolookatwhetherpersoncentredtherapiesoeralonger
termsoluontobodyimageissues.Moreover,personcentredtherapiesseemtoacknowledgethe
importanceofthebody,andoerawaytointegratethebodyintotherapy.WhileCTandCBTbothdeal
withissuesaboutthewayclientsseetheirbody,theydosoinahighlyverbalised,nonphysicalway,which
couldbearguedtobeadisadvantage.WhileRT,aformofpersonbasedtherapy,wasshownbyDworkin
andKerr(1987)tobelesseecvethanCTandCBT,itisslleecveasatherapy,andmoreresearch
woulddeterminewhetherparcularclientgroupsaremoreabletobenetfromthislongerterm
treatment.Moreover,DworkinandKerr(1987)suggestthatthereasonRTislesseecveisthatitisa
shorttermformofpersoncentredtherapy.Itispossiblethatlongertermoponswouldbemore
eecve.

Treatmentprogrammes,forexampledissonancebasedprogrammes,alsooerathirdalternave.These
programmeshaveanumberofadvantages.First,theyareprimarilyoeredtogroupsofclientsrather
thanindividuals,andassucharealowercostopon.Secondly,theymovethefocusoftreatmentaway
fromthesituaonoftheindividualtothewaythatindividualisinuencedbyfactorsinsociety.They
provideawaytoacknowledgethecentralimportanceofsocialfactors,parcularlythemedia,increang
distortedbodyimages,andteachclientstoresistsuchpressure.CounsellorscarryingoutbothCBTand
personcentredtherapiesmaynotbeawareoftheextenttowhichtheymaintainthestatusquo.They
needtoexaminetheirownatudestobodyimageandweight,toavoidanassumponthattheclientis
inthewrong.Theyneedtotakeintoaccountwiderresearchforexampleintodangersofdiengandalso
issuessuchasthewaysocietyhighlightsanidealofperfectlooks(DworkinandKerr1987).Bystarng
fromthesocialandculturalperspecve,treatmentprogrammesrenderthisneedunnecessary.

GiventhatallthreetypesoftreatmentforBDDandotherbodyimageproblemshavebenetsand
drawbacks,andgiventhatthebulkofresearchlooksatindividualtreatmenttypes,itwouldbeinteresng
tocomparethethreedierenttreatmentsinonestudytodeterminewhichismosteecve,orwhether
eachismosteecvewithaparculardemographicorpersonalitytype.Afurtherstudyofthisnature
wouldallowtreatmentprogrammestobetailoredtotheindividualandtherefore,itwouldbehoped,be
moresuccessful.

AnotherwaytoinformthedevelopmentoftherapiesforBDDmightbetotakeonboardasuggesonby
WoodBarcalowetal(2010).Theypointoutthatresearchershavesofarconcentrateduponthenegave

featuresofbodyimageinordertotransformthemintoposiveimages.Theyhavetendingindoingsoto
conceptualisetheposiveaspectsofbodyimageassimplytheabsenceofnegavefactors.However,this
isanincompletestrategy,becausetheabsenceofpathologydoesnotalwayssignalourishing(Wood
Barcalowetal2010,p.106).Therehasbeenli leresearchdoneonthenatureofaposivebodyimage,
butthatwhichhasbeendoneindicatesthatposivebodyimagediersqualitavelyfrombothnegave
andnormaveimages.Onestudyin2004(Williams,CashandSantos)suggestedthatpeoplewitha
posiveimagehavelowerinternalisaonofmediainuence,greaterselfesteem,be ersocialsupport
andhigherphysicalacvity.Othercharacteriscsincludelookingfavourablyatthebody,accepngthe
body,andrespecngitsneeds(WoodBarclaowetal,2010).

Inaddion,thedierencesbetweenmenandwomenintermsofbodydissasfaconhavebeenpointed
outabove.Ithasnowbeenrecognisedthatmen,likewomen,cansuerfrompoorbodyimage,butthey
seemtohaveadierentexperienceoftheirbodywithanawarenessofmuscleandbodyfatparcularly.
Gaymenalsohavetheirownpreoccupaons.Withthisinmind,ausefulfurtherstudymightlookatthe
waysinwhichtherapyofanymemightbeadaptedtothesedierencesinperspecvebetweenthe
gendersandsexualies.Forexample,intervenonprogrammestargetedatmenmightlookathowmedia
imagesofmenarechangingwithagrowthinadversingofmensbeautyproducts,anincreasein
magazinestargetedatmen,andsimilarfactors.CBTandCTapproachesmightulisequesonswhichtake
intoaccountthedierencesbetweenmenandwomeninregardtowhattheymightconsidertobe
una racveabouttheirbody.Inaddion,andiffurtherresearchindicatestheneed,itmightbeusefulto
lookatwaysethnicity,raceandsocialclassimpactuponbodydysmorphia.Forexample,ifwomenofa
highersocialclassaremorelikelytosuerfromBDD,targetedintervenonprogrammeswouldneedto
takethisintoaccount.

6.Primaryresearchmethodology
Thendingsfromthesecondarydatastudycanbecomparedwiththeresearchcollectedfromthe
primarystudy.

Theprimaryresearchstudycollectedquantavedataamongstpeoplewhohadundergoneoneofthree
typesoftherapytreatment(takingpartinaprevenonprogramme,personcentredtherapyorrelated
treatmenttype,orCBT/CTvariaons).Theaimwastocomparerespondentsrangsoftheirtreatment
typetoseeifthereissignicantdierencesbetweeneachofthethreebroadtypesoftreatmentfora
numberoffactorsincludingeecvenessoftreatmentinraisingselfesteemandeecvenessof
treatmentinimprovingbodyimage.Whilequalitavedata,textbased,moredetailedinformaon
gatheredindepthfromfewerrespondentsgivesadeeperpictureofanissue(Gray2009),thequantave
datawasselectedinthisinstanceasitwasfeltthatresultscouldbetestedforsignicancestascally.
Aquesonnairewasdesignedtocollectinformaonfromrespondents.Anumberofdemographic
quesonswereincluded,includingage,genderandsocioeconomicbackground,inordertolookatthe
impactsuchvariableshadonresponsestotherapy.Abovethedierencesbetweenthesexesforbody
imageproblemswasdiscussed,andgiventhatmenandwomenhavedierentconcernsabouttheirbody
itispossiblethattheyreactdierentlytodierenttherapytypes,forexample.Inaddion,anumberof
quesonstocollectdataabouttherapytypewereincluded,forexampleaskingthelengthofmesince
therapy,andduraonofthetherapy,aswellasthetypeoftherapycarriedout.Themajorityofquesons
askedrespondentstoratetheirsasfaconwithdierentaspectsoftheirtherapyona1to5Likertscale,
where1meansnotatalland5completelysased.Thequesonnairestartedwithabrief
introducontothestudystangpurposeofthedatacolleconandemphasisingcondenality.

Babbie(2010)disnguishesbetweentwomaintypesofsampling(theprocesswherebythepeople
interviewedareselected).Probabilitysamplingdrawsindividualsrandomlyfromtheenrepopulaonof

interest.Inthiscase,itwouldbeeveryoneintheUKwhohadundergonetherapyforpoorselfesteemand
issueswiththebody.Thisisclearlynotappropriateforthissurvey,asthereisnoonelistavailable
containingallthispopulaon.Thetypeofsamplingusedwasnonprobability.Condenallyposeda
majorissuefordatacollecon.Itwasnotpossibletoobtainlistsofindividualswhohadundergone
therapyfromhealthservices,PrimaryHealthcareTrustsorsimilarasauthorieswouldnotreleasesuch
data.Itwasnecessarytondindividualswhohadhadtherapyforbodyissuesand/orselfesteeminother
ways.Itwasdecidedtoapproachusersofonlineinternetforumsdealingwithpoorbodyimageand
relatedcondions,andbasedintheUK.Oneadvantagewouldbethatforumuserswouldbemorelikely
tohavehadtherapy,comparedwiththegeneralpopulaon,howeveronedisadvantagewasthatitmight
introduceunconsciousbiasintotheresults.Forexample,peoplewhouseinternetforumsmighthavea
parcularpersonalitytypewhichisalsoassociatedwithaparcularlystrongorpoorresponsetotherapy.
Thisbiaswouldskewtheresultsofthestudy,astheonlypeopleinterviewedwouldtendtowardsa
posiveornegaveresponse.

ThreeforumsforpeoplewithBDDandassociatedproblemswereapproached.Inallcases,theforum
moderatorwascontactedtoexplainbriefdetailsaboutthestudy,andaskpermissiontopostonthe
forumsrequesngvolunteerstotakepartbycomplengthequesonnaire.Itwasstressedthatallresults
werecompletelycondenalandwouldbeusedinstascalformonly,withnopersonaldetailsa ached.
Ofthethreeforums,only2respondedtotheinialemail,andonlyonegavepermissiontopostthe
request.Onefurtherproblembecameclearwhentherequestforvolunteerswasposted.Althoughmany
usersrespondedwell,sayingtheywereinterestedinthestudyandsupporteditsvalue,veryfewusers
werewillingtogiveuptheiranonymitybypassingontheiremailaddressforthequesonnairetobe
forwardedtothem.Intotal,19respondentswererecruited,andoftheseonly8returnedcompleted
quesonnaires.Itiswidelyheldthatasamplesizeofatleast30isnecessarytoallowstascalteststo
beperformedonthedata,andrecommendedthattheminimumbaseismuchhigher(Cohen,Manion,
MorrisonandMorrison2007).Consequently,thedatacollectedforthestudywasnotanalysed
stascally,althoughitwasdecidedtolookattheresultsingeneralterms.

7.Primaryresearchresultsanddiscussion
All8respondentsansweredallthequesons.Allhadcompletedtherapy,andallhadnishedwithinthe
last5years.Allbut1respondentswerewomen,andagesweredistributedasfollows:
Age
1624
2534
3544
4554
5564
65orover

Number
1
3
1
2
0
1

Table1:Agedistribuon

Itisperhapsunfortunatethatonly1respondentwasaman,astheresultscannotthrowlightonthe
discussionaboveindicangdierencesbetweenthegendersintermsofbodyissues.

4respondentshadhadCBT,with1havingCT.Onehadpersoncentredtherapy,andtwocounselling.CT
andCBTtreatmentshadbeenoeredbytheNHS,withcounsellingandpersoncentredtherapiesfunded
privately.ThosewiththeNHSwerenotoeredothertreatmentopons.Therewasadisncon
betweentherapiesoftheCT/CBTtypeandcounsellingandpersoncentredtherapy,withtheformer

therapiestakingplaceovermuchshortersessions,typicallybetween2to5sessions.Thepersonwhohad
personcentredtherapyhad1050sessions,andthecounsellingrespondentsbothstatedtherapylasted
610sessions.Perhapsunsurprisingly,giventhenatureoftheinternetforumsfromwhichtheywere
recruited,allrespondentsreportedissueswithpoorbodyimage.Table2reportstheresultsofQ7inmore
detail.
Problem
Poorbodyimage
Lowselfesteem
BDD
Eangdisorder
Otherproblem

Number
8
6
3
2
4

Table2:Areastackledbytherapy

Thehighnumberofrespondentswhoalsoreportedlowselfesteeminaddiontopoorbodyimage
conrmsthediscussionabove,wherethelinkbetweenthetwocondionswaspointedout.Other
problemsreportedincludeddepressionandanxiety.

ThedivisionofrespondentsbetweenCT/CBTontheonehandandcounselling/personcentredtherapyon
theotherseemstobecorrelatedwithadierenceinresponsestothesasfaconquesonsatQ8.While
themeansasfaconamongstthe5peopleundergoingtherapyoftheCT/CBTtypewas4.2,themean
sasfaconforthoseundergoingcounselling/personcentredtherapywas3.8.Thisissllfairlyhigh,and
closetothescoreforCT/CBT,butalsosomewhatlower.Thisaddsali leweighttotheview,discussed
above,thatCT/CBTismoreeecve.ThisisunderlinedbytheresultofQ8C,withthemeanscorefor
sasfaconfortheeecvenessofCT/CBTrespondentsis4.1,andthemeanforpersoncentredtherapy/
counsellingis3.9.CT/CBTalsoscoredslightlyhigherforgivingtoolstodealwithdicultsituaons
outsideoftherapy(4.0asopposedto3.7).Theresultsfor8B8Dand8Esuggest,however,thatperson
centredtherapy/counsellingaremoreeecveinotherareas.Theyscorehigheronthemeanthando
CT/CBT,asfollows:

MeanscoreCT/CBT
Q8B:Sasfaconwith
3.9
relaonshipwiththerapist
Q8D:Sasfaconwithextent 3.4
towhichtherapylookedat
roleplayedbysocialand
culturalfactors
Q8E.Sasfaconwithextent 3.7
towhichtherapylookedat
roleplayedbypersonalhistory
andbackground

Meanscorecounselling/
personcentredtherapy
4.4
3.9

4.3

Table3:MeanScores,Q8B,DandE

Theseresultssuggestthattherearesomeaspectsforwhichpersoncentredtherapyapproachesaremost
successful.However,whilethesemightleadtogreaterclientinvolvementandsasfaconfortheseareas,
theeecvenessofCTandCBTwassllratedhigher.Unfortunatelytherewerenoresultsatallfor
prevenonprogrammes,soitwasnotpossibletotestresponsestotheseformsoftreatment.

Duetothelowresponserate,theresultsfromthequesonnairecouldnotbeassessedforstascal
signicance.Itwasthereforedecidedtoextendtheliteraturereviewelementofthedissertaontomake
upforthisshor all.However,thedatathatwascollecteddoesnotcontradictthendingsfromthe
literaturereview,andinsomeareasreinforcesit.Thelinkbetweenpoorbodyimageandotherissues
includingeangdisorders,weightandselfesteemisconrmedbythecondionsreportedby
respondents.ThatCBTandCTarepreferredbytheNHSseemstobeconrmedbytheresultsofthe
study,asonlyprivatelyfundedrespondentshadothertherapyopons.

Unfortunatelythelackofmalerespondentsmeantthatthetheoriesaboutgenderbaseddierences
betweenbodyimageissuescouldnotbetested.Thisisanareawhichcouldbeinvesgatedinfurther
primarystudies.Inaddion,furtherstudiescouldlookattheimpactofthemediainmoredetail,perhaps
tracingmediaexposureamongstpeoplewitheangdisorder,theextenttowhichpeoplewithBDDand
poorbodyimagecomparethemselveswithmediaideals,anddierencesbetweenmenandwomens
readingofthemedia.
[levelfreerestricted]

8.Conclusion
Thisstudyhasaimedtolookattheincreasingproblemofpoorbodyimage.Originallythoughttoeect
womenratherthanmen,itisincreasinglyfoundinmenalso.Ithasanumberofnegaveconsequences
forindividuals,sothereisaneedtondaneecvetreatment.Therstpartofthestudyexaminedhow
poorbodyimageandBDDcomesabout,anditsrelaontoselfesteemandotherweightissues.Thereare
anumberoftheorieswhicha empttoexplaintheissue,anditseemsclearthatmediainuenceplaysa
largepartinmakingindividualsuncomfortablewiththeirbody.Whilethereisacleardierencebetween
menandwomenregardingtheextenttowhicheachgenderdisplaysbodyimageissuesandregardingthe
contentofpoorbodyimage,otherdemographicfactorsincludingrace,ethnicityandsocioeconomic
groupplayapart.ThesecondseconofthestudylooksattreatmentsforpoorbodyimageandBDD.
Treatmentoponsdivideroughlyintothreecategories,cogniveorcognivebehaviouralapproaches,
personcentredtherapiesandintervenonprogrammes.Eachtypeoftreatmenthasposivesand
negaves;CBTandCTseemeecvealthoughmaynotbesuitableforallclients,personcentred
therapiescanalsobeeecveandallowadeeperperspecve,whileprevenonprogrammesaddressthe
socialandculturalcontext.Personcentredtherapieshavebeensomewhatoverlookedoflate,despite
theirpotenalforgoingdeeperintoissuesandincorporangthebodymorefullyintotheir
methodologies.AsmallprimarystudylookedatexperiencesoftherapyforpeoplewithBDDandbody
imageproblems,andseemedtobroadlyconrmtheresultsofthesecondarydatadiscussed,however
problemswithdatacolleconmeanttheresultswerenotstascallysignicant.

Thisstudyhasclearlimitaons.Theprimaryresearchwasverylimited,althoughareasweresuggestedfor
furtherstudy.Inaddion,thereexistothertreatmentoponsasidefromtheonesdiscussedwhichmight
oerusefulsoluons.Finally,spacerestraintsmeanthatonlylimiteddiscussionofsomerelevantareas
hasbeenpossible.

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Appendix1:Quesonnaire
InformaonaboutStudy
Thankyouforagreeingtohelpwiththisresearchstudy.Iamastudentworkingonadissertaonabout
theuseofcounsellingforbodyimageandrelatedissues.Theresultsofthestudywillbeusedtoinform
othersandmayhelpwithfutureresearchprojects.

Anyinformaonyougiveonthisquesonnaireiscompletelycondenal.Yournamewill
notbeassociatedwithanyoftheinformaon,norwillitbepossibletoidenfyyoufromtheinformaon
collected.Datacollectedwillbeusedonlyforthepurposesofthisstudy,andwillbedestroyeda erthe
studyisover.

Pleaseanswerallthefollowingquesonsandreturnbyemailtotheaddressgiven.Indicateyouranswer
byanXorck.Wheremorethanoneanswerispossible,thequesoninstruconswillmakethisclear.If
youarenotsurehowtoansweranyquesons,pleaseemailmeforfurtherhelp.

Q1.Howlongisitsinceyoureceivedyourlasttherapysession(s)?(ifyouhavehadmorethanoneseries
oftherapy,pleasethinkaboutyourmostrecenttreatments)

1.Over10yearsago
2.between5and10yearsago
3.25yearsago

4.12yearsago
5.Under1yearago
6.Iamsllundergoingtherapy

Q2.Howlongwasyourtherapy?
1.1sessiononly
2.25sessions
3.610sesssions
4.1050sessions
5.Over50sessions
6.Iamsllundergoingtherapy

Q3.Wasyourtherapyprivatelyfunded,orobtainedthroughtheNHS?
1.Privatelyfunded
2.NHS

Q4.Whattypeoftherapydidyouhave?
1.CogniveTherapy
2.CogniveBehaviouralTherapy
3.Counselling(unspecied)
4.PersonCentredTherapy(Somemesknownasclientcentredtherapy)
5Educaonprogramme(typicallyingroups,aimedatraisingawarenessofbodyimageissues)
6.Othertherapytype(PLEASEWRITEIN)

Q5.Wereyouoereddierenttreatmentopons?
1.Yes
2.No

Q6.Didyouhaveapreferencefortypeoftreatment?
1.Yes
2.No

Q7.Whatareasdidyourtherapytackle?MULTIPLEANSWERSPOSSIBLE
1.Poorbodyimage
2.Lowselfesteem
3.BodyDysmorphicDisorder
4.Eangdisorder
5.Otherarea(PLEASEWRITEIN)

Q8.Onascaleof1to5,where1meansnotatallsased,and5meanscompletelysased,how
sasedwereyouwiththefollowingaspectsofyourtherapy?
Q8A.Lengthoftreatment:
1notatallsased2345completelysased
Q8B.Relaonshipwiththerapist:
1notatallsased2345completelysased
Q8C.Eecvenessoftreatment:
1notatallsased2345completelysased
Q8D.Lookingatsocialandculturalfactorsandtheroletheyplayedinyourcondion:
1notatallsased2345completelysased
Q8E.Lookingatyourpersonalhistoryandbackgroundandtheroletheyplayedintheproblem
1notatallsased2345completelysased
Q8F.Givingyouasetoftoolsyoucanusetodealwithdicultsituaonsoutsidetherapy:
1notatallsased2345completelysased
Q8G.Sasfaconwiththerapyoverall
1notatallsased2345completelysased

Finally,therearejustafewquesonstohelpuscompareyouranswerswiththoseofothers
Q9.Areyoumaleorfemale?
1.Male
2.Female

Q10.Whichofthefollowingagegroupsdoyoufallinto?
1.1624
2.2534

3.3544
4.4554
5.5564
6.65andover

Q11.
Whatisyouroccupaon?
1.Student
2.Workingfullme
3.Workingpartme
4.Unemployedseekingwork
5.Notworkingthroughillhealth
6.Rered
7.Lookinga erfamily
8.Carer
9.Notworkingforotherreason
Thankyouforyourhelp!
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