This clinical manual provides a CBT-based psychosocial intervention for use with individuals distressed about their appearance due to a disfigurement from birth, accident or illness, or those coping with another visible difference.

• Contains a wealth of case material with specific relevance to physical health conditions that affect appearance, practical advice on assessment, and session-by-session guidance for addressing common issues
• Written by leading academics and clinicians working in the management of disfigurement and rational appearance anxiety
• Uses a flexible stepped-care model that allows for use by experienced CBT practitioners as well those wishing to deliver a more basic psychological intervention
• Identifies the psychological factors involved in appearance anxiety while also addressing the practical concerns of living with a visible difference, such as managing the reactions of others

Alex Clarke is a clinical and health psychologist specializing in disfigurement and altered appearance.

Andrew R. Thompson is Reader in Clinical Psychology at the University of Sheffield NHS Clinical Psychology Doctoral Training Programme.

Elizabeth Jenkinson is a registered Practitioner Health Psychologist, Chartered Psychologist and Senior Lecturer in Health Psychology at the University of the West of England.

Nichola Rumsey is Vocational Training Charitable TrustProfessor of Appearance Research at University of the West of England and is Co-Director of the Centre for Appearance Research.

While introductory texts on disfigurement and specialist titles on normative body image concerns exist, there are few materials available for clinicians working with people with a problematic appearance. This clinical handbook is the first to provide a stepped-care CBT-based psychosocial intervention for use with individuals anxious about their appearance due to a disfigurement from birth, accident or illness, or those coping with another visible difference.

This book is the result of a collaboration between clinicians and academics on a large-scale research project funded by The Healing Foundation.It describes detailed clinical intervention that integrates data analysis from the study with a comprehensive review of existing research. It provides practical advice on assessment and session-by-session guidance for addressing common issues. The manual is built around clinical cases with specific relevance to physical health conditions that affect appearance. It draws on the work of Adrian Wells and David Clark by using approaches evaluated with social anxiety to treat anxiety related to disfiguring appearance.

This is an indispensable guide for clinical and health psychologists working with patients with appearance anxiety, as well as other healthcare practitioners navigating the practical and psychological concerns related to this patient population.

Foreword xv

Preface xvi

1 Background, Clinical Problems, Common Presentation and Treatment Considerations 1

Physical and Treatment-Related Factors 3

Socio-Cultural Factors 3

Psychological Factors and Processes 3

Body Image Disturbance 3

Clinical Problems and Presentation 4

Common Features in Referral 8

Visibility of Condition 8

Shame 9

The Meaning of Visible Difference 9

The Experience of Loss 9

Physiological Responses 10

Culture 10

Gender 11

Age 11

Expectations of Treatment 11

Association of Physical Change with Psychological Outcome 12

Fix It Solutions 12

Treatment Considerations 13

2 A Stepped-Care Approach to Psychosocial Intervention 15

The PLISSIT Model 16

Level 1: Permission 16

Level 2: Limited Information 18

Level 3: Specific Suggestions 18

Level 4: Intensive Treatment 19

3 Models and Frameworks: Expanding the Conceptual Approach to Managing Appearance-Related Distress 21

Explanation for Choice of Therapeutic Approach 22

Behavioural Approaches: Fear Avoidance and Social Skills Training 22

Building an Evidence Base 25

Cognitive Approaches: Comparison of Appearance Anxiety and Social Phobia 26

Use of Safety Behaviours 28

Anticipatory and Post-Event Processing 29

The Role of Assumptions and Schema in Appearance Anxiety 32

Summary 33

Deriving a Cognitive Behavioural Treatment Model: Identifying Factors and Processes

Contributing to Successful Adjustment to Disfiguring Conditions 34

Working Framework of Adjustment to Disfiguring Conditions 34

The ARC Framework of Adjustment to Disfiguring Conditions 34

Predisposing Factors 35

Intervening Cognitive Processing 36

Socio-Cognitive Processing 37

Outcomes 41

The ARC Research Programme Findings 43

The Studies 43

Summary of Findings 43

Key Messages from the Research Programme 45

Implication of These Findings for Design of Interventions 45

Summary 47

4 Clinical Assessment 48

Eliciting the Problem 49

Summarizing 51

Motivation and Self-Efficacy 52

Readiness for Change 53

Measurement Tools 55

Generic Measures of Psychological Constructs (as used in the ARC Study) 55

Measures of Psychological Constructs Specifically Related to Appearance 57

Measures of Body Image 58

Measures of Psychological Constructs Specifically Related to a Condition Type 58

Body Dysmorphic Disorder (BDD) 59

Core Clinical Dataset 59

Regular Subjective Measures of Frequency for Events, Thoughts and Feelings 60

Goal Setting 61

The SMART Acronym 61

Challenges in Treatment for Appearance-Related Problems 62

Introducing a Biopsychosocial Model 62

Treatment 'buy-in' 63

5 Social Skills and Coping Strategies 64

Staring, Questions, Comments and Loss of Anonymity 66

Making the Most of Appearance 66

Developing a Positive Approach to Visible Difference 67

Posture, Smiling and Eye Contact 67

Developing Verbal Skills 68

Learning to Have a Conversation 68

Answering Questions About Appearance 68

Managing Staring 70

Putting it into Practice 71

Taking the Initiative in Social Encounters 72

Managing Anger and Developing Assertiveness 73

Anger 73

Managing Intimacy 75

Disclosing a Disfiguring Condition to a Partner 75

Summary 77

6 Cognitive Behavioural Therapy 78

Techniques in Cognitive Behavioural Therapy 79

Socratic Dialogue 79

Elici...