‘I am delighted to see this publication which for the first time reports on a large scale study to underpin and draw RC CBT together therapeutic approaches for people with disfiguring conditions. This work demonstrates The Healing Foundation’s umla r commitment to both the surgical and psychological aspects of disfiguring conditions and in doing so, clearly demonstrates sk ee how research can effectively underpin real improvements in every day health care.’ y, for T Sir Stuart Rose, The Healing Foundation ah n o d m ‘This is an outstanding new resource for any practitioner who is seeking to help someone who is anxious, preoccupied or N p distressed by a disfiguring condition or an aspect of their appearance. The authors masterfully assemble the evidence of these es wo Appearance Anxiety complex needs and how best to intervene – and the working through of very real case studies makes this a very practical en guide to enabling people to adjust. It should be widely welcomed and will hopefully influence practice worldwide.’ ll, J James Partridge, Changing Faces e n k ‘Alex Clarke and colleagues draw on considerable experience, contemporary models and research evidence in presenting in s this unrivalled CBT manual and service provision guide. They show how to use powerful cognitive and behavioural o n Psychosocial Interventions for techniques to deal with the noticeability of visible difference and elevated worry and distress. All clinicians who deal with , disfigurement or worry about appearance should read this invaluable book. It is a significant resource.’ Adrian Wells, University of Manchester, UK Anxiety due to Visible Difference ‘Many people with a visible difference face significant challenges to their quality of life that stem from their appearance C concerns. Grounded in psychological science and compassion, this valuable practitioner resource provides step-by-step guidance in assessment and treatment and is chock-full of clinical examples. The authors have skilfully composed a truly B Alex Clarke, Andrew R. Thompson, life-changing book.’ Thomas F. Cash, Old Dominion University, USA T Elizabeth Jenkinson, Nichola Rumsey Author, The Body Image Workbook and Rob Newell f While introductory texts on disfigurement and specialist titles on normative body image concerns exist, there are few o materials available for clinicians working with people with a problematic appearance. This clinical handbook is the first to r 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. A This book is the result of a collaboration between clinicians and academics on a large-scale research project funded by p 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 p 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 e anxiety to treat anxiety related to disfiguring appearance. a This is an indispensable guide for clinical and health psychologists working with patients with appearance anxiety, as well r as other healthcare practitioners navigating the practical and psychological concerns related to this patient population. a n c Alex Clarke is a Clinical and Health Psychologist specializing in disfigurement and altered appearance. e Andrew R. Thompson is Reader in Clinical Psychology at the University of Sheffield NHS Clinical Psychology Doctoral Training Programme. A Elizabeth Jenkinson is a registered Practitioner Health Psychologist, Chartered Psychologist and Senior Lecturer in Health Psychology at the University of the West of England. n Nichola Rumsey is Vocational Training Charitable Trust Professor of Appearance Research at the University of the West of x England and is Co-Director of the Centre for Appearance Research. i e Rob Newell is Emeritus Professor of Nursing Research at the University of Bradford. t y pb_9781118523421.indd 1 17/9/13 07:59:19 CBT for Appearance Anxiety An evidence based approach produced as part of the research programme: Identifying factors & processes contributing to successful adjustment to disfiguring conditions Funded by: The Healing Foundation, in association with The Welton Foundation and the Worshipful Company of Tin Plate Workers Written by: Alex Clarke, Andrew Thompson, Elizabeth Jenkinson, Nichola Rumsey, Rob Newell and on behalf of the ARC consortium: James Byron-Daniel, Roger Charlton, Sally-Ann Clarke, Diana Harcourt, Hayley McBain, Antje Lindenmeyer, Tim Moss, Stanton Newman, Krysia Saul, Eleanor Walsh, Paul White, Emma Thomas With contributions from Heidi Williamson Jenny Barke and Esther Hansen CBT for Appearance Anxiety Psychosocial Interventions for Anxiety Due to Visible Difference Alex Clarke, Andrew Thompson, Elizabeth Jenkinson, Nichola Rumsey and Rob Newell This edition first published 2014 © 2014 John Wiley & Sons, Ltd Registered Office John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Offices 350 Main Street, Malden, MA 02148-5020, USA 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK For details of our global editorial offices, for customer services, and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell. The right of Alex Clarke, Andrew Thompson, Elizabeth Jenkinson, Nichola Rumsey and Rob Newell to be identified as the authors of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Limit of Liability/Disclaimer of Warranty: While the publisher and author(s) have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. It is sold on the understanding that the publisher is not engaged in rendering professional services and neither the publisher nor the author shall be liable for damages arising herefrom. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloging-in-Publication Data Clarke, Alex, 1953– CBT for appearance anxiety : psychosocial interventions for anxiety due to visible difference / Alex Clarke, Andrew Thompson, Elizabeth Jenkinson, Nichola Rumsey, and Rob Newell. pages cm Includes bibliographical references and index. ISBN 978-1-118-52343-8 (cloth) – ISBN 978-1-118-52342-1 (pbk.) 1. Anxiety disorders–Treatment. 2. Body image–Psychological aspects. 3. Disfigured persons–Psychology. 4. Cognitive therapy. I. Thompson, Andrew R. (Andrew Robert), 1970- II. Jenkinson, Elizabeth (Psychologist) III. Rumsey, Nichola. IV. Newell, Robert, 1954- V. Title. VI. Title: Cognitive behavior therapy for appearance anxiety. RC531.C52 2013 616.85′22–dc23 2013021913 A catalogue record for this book is available from the British Library. Cover design by Nicki Averill Design & Illustration Set in 10/12.5pt Minion by SPi Publishers, Pondicherry, India 1 2014 In memory of Mr. Michael Brough, Consultant Plastic Surgeon, Royal Free Hospital, London Contents 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 viii Contents 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