CBT for Appearance Anxiety: Psychosocial Interventions for Anxiety due to Visible Difference

319 Pages·2013·7.73 MB·English

by  Alex Clarke

‘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
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commitment to both the surgical and psychological aspects of disfiguring conditions and in doing so, clearly demonstrates sk
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how research can effectively underpin real improvements in every day health care.’ y, for
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Sir Stuart Rose, The Healing Foundation ah
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‘This is an outstanding new resource for any practitioner who is seeking to help someone who is anxious, preoccupied or N
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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
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‘Alex Clarke and colleagues draw on considerable experience, contemporary models and research evidence in presenting in
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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
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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
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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.
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This book is the result of a collaboration between clinicians and academics on a large-scale research project funded by
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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
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Alex Clarke is a Clinical and Health Psychologist specializing in disfigurement and altered appearance.
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Andrew R. Thompson is Reader in Clinical Psychology at the University of Sheffield NHS Clinical Psychology Doctoral

Training Programme.
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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
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Rob Newell is Emeritus Professor of Nursing Research at the University of Bradford.
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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
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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.
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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
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particular purpose. It is sold on the understanding that the publisher is not engaged in rendering professional
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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