Free Counselling Dissertation

This study looks at the value of counselling in supporting clients with low self-esteem and low confidence due to poor body image. The complex nature of poor body image and its links to low self-esteem and other negative conditions are traced. The nature of the more serious condition, body dysmorphic disorder, is set out. The role played by the media is considered in detail, as is the differences between men and women regarding poor body image. In order to understand the best approaches in counselling and therapy for clients with poor body image, various theoretical positions are set out. The discussion of the nature of body image issues informs the discussion of three different therapeutic approaches to poor body image. Different approaches are compared. All have value, and it is suggested that further research might compare approaches to better tailor provision of care for sufferers. A short primary study seems to confirm these findings.

1.1 Overview
Poor body image is a common problem in Western and Westernised societies, particularly amongst girls and women, although increasingly, also, in men. Having a poor body image may also lead to other psychosocial problems and clinical difficulties such as eating disorders, depression, social anxiety and low self-esteem (Strachan and Cash, 2002). Relatively recently, ‘Body Dysmorphic Disorder’ (BDD) has been recognised as a clinical condition. In this, individuals have an extremely distorted body image, and are preoccupied by a real or imagined defect in their appearance (Insel Insel, Turner and Ross, 2009)
There is an important distinction to make between body dissatisfaction and body dysmorphic disorder (BDD), with the latter more serious; however both can be targets for counselling and psychotherapy (Veale, 2004). There have been numerous attempts to place body image dissatisfaction and BDD within a theoretical framework, with conflicting and over-lapping explanatory systems used, and the variety of theoretical frameworks is matched by a wide variety of techniques used to treat these conditions. Cognitive behaviour therapy (CBT) specially modified for body image problems, for example, is an emerging therapy and is being utilised to help individuals with body image dissatisfactions and dysphoria. This therapy has been seen to be effective in altering body image perception directing a more positive outlook for obese patients, as well as patients suffering from BDD, and various elements of CBT have been implemented into the treatment of eating disorders with considerable success (Strachan and Cash 2002). Despite the success and prevalence of CBT and other cognitive approaches, other treatments do exist, for example dissonance-based prevention programmes have been usefully applied, particularly for university age women. Other therapeutic perspectives based around person-centred themes are not so prevalent, but seem to offer an alternative approach to treating body image problems and BDD, although are used less often nowadays and seem under-researched in comparison.
This paper will critically evaluate various elements of body image, self-esteem and confidence, drawing upon various studies mainly emanating from the UK, Europe and the US. It focuses upon studies incorporating weight, self-esteem and the media influence in order to reflect an evolving problem that concerns both males and females, from adolescence into adulthood.The study will first take a general view of the nature of body image and dissatisfaction with body image, tracing its impact, diagnosis, treatment and various theories which have been developed to explain it, and will look particularly at the connection between media influences and body image. The condition of BDD or ‘imagined ugliness’ will also be discussed. Once the nature of the problem has been established, different treatment possibilities will be explored, looking particularly at counselling and psychotherapy, and issues associated with these. The different therapeutic approaches will be traced, and the established success of cognitive-based methods will be acknowledged. Whether client-centred approaches, originating in Object theory and in work by Carl Rogers, offer a viable alternative will also be discussed. Although the primary focus in the study will be to understand the benefits and drawbacks of different therapeutic approaches, a primary study will also be included in the research to interview recipients of different therapies and analyse their response to treatment options. The primary study will be informed by the areas discussed in the secondary review.

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1.2 Importance and relevance of the study
BDD, eating disorders, excess dieting and exercise are damaging to the health and are increasing in both men and women, with the prevalence rate reported as 0.7% in the general population, 5% in cosmetic surgery settings, and 12% in a dermatology clinic (Veale, 2004). Such disorders are detrimental to both physical and mental health, and can have further effects by influencing others to mirror the behaviour of sufferers, particularly if the subjects are in a position of authority (Yager and O’Dea 2009). They are highly disruptive in terms of daily functioning (Chrisler and McCreary, 2010). It is therefore useful to look at the most effective measures for treating such disorders and preventing their occurrence.

1.3 Research aims and overall methodology
The main part of the study will take the form of a critical review of secondary literature gathered from academic databases and utilising a number of keyword searches including the terms ‘body image’, ‘body image disorder’, ‘body dysmorphic disorder’, ‘eating disorders’, ‘CBT’ ‘CT’ ‘person-centred therapy’ and ‘client-centred therapy’, both alone and in combination.
The study aims first to understand the nature of disfunctions in body image and its relation to self-esteem, and to look at the condition of body dysmorphic disorder, and to understand ways in which these conditions are theorised, particularly in regards to media influence upon their development.It also aims to uncover the most successful forms of treatment for poor body image and BDD, and to present this in the light of the discussion of the nature of the conditions. Finally, it aims to compare treatment options and discover whether there is a place for person-centred therapies alongside education programmes and cognitive therapies.
A short primary study will also be conducted. This will gather quantitative data from a number of people who have had therapy treatment in the past, to collect details about treatments undertaken, and to assess how successful the recipients of therapy felt their treatment to be.Full details of methodology for the primary research will be set out below.
2. Body image, self-esteem and the impact of media, gender and other factors.

2.1 Overview
The term ‘body image’ can be traced to the English word ‘body’ which originally meant ‘person’, and to the Latin verb ‘imaginari’, which means to represent through an image. The term was first used in the 30’s by Schilder, who described a person’s body image as the picture they make in their mind representing the way their body appears to them (Flaming, 1993).

2.2 Impact of poor body image
Poor body image has been associated with a number of other negative health issues including depression, low self-worth, poor nutrition and eating disorders (Eldin and Golanty, 2009). Poor body image and high levels of dissatisfaction with the body can also impact upon career choice. Higher levels of BDD and associated disorders have been found amongst young people training for professions including nutrition and other careers (nutritionists, psychologists, dieticians, home education teachers) associated with eating and health. An Australian study for example found that health and physical education teachers had significantly higher levels of over exercising, exercising disorders, poor body images and increased dissatisfaction (Yager and O’Dea, 2009).

2.3 Body image and self-esteem
Particularly linked with low body image are issues of self-esteem.Self-esteem according to Harter (1990) is composed of two aspects, firstly how a person believes themselves to be perceived by significant others and secondly, how they view their performance in areas considered important. Body image is also characterised as divided into different components. Some distinguish two elements, perceptual (evaluation of one’s physical body) on the one hand and affective / cognitive on the other (a person’s attitudes towards his or her body) (Allgood-Merton and Lewinsohn, 1990). Others distinguish a third element, the behavioural, looking at actions toward and involving the body. In either case, a poor body image can be thought of as a failure of function of one or more of the three constituent components (Farrell, Safran and Lee 2006).
There has been a large interest over the last 30 to 40 years in the way body image perception, distortion and self-esteem are connected. The bulk of these studies have been directed towards students, with particular attention paid to females and adolescents (Furnham, Badmin and Sneade, 2002). For example, Mellor, Fuller-Tyszkiewicz, McCabe and Ricciardelli, in an Australian study, found that higher self-esteem is associated with lower body dissatisfaction, and that women are more dissatisfied with their bodies than men. A comparative study of boys and girls carried out by Allgood-Merton and Lewisohn (1990) indicated that body image is a critical component of self-esteem within the age group 13 to 18, particularly for girls. Studies are not confined to the UK, New World and USA, but have been carried out across the world including Hong-Kong and Poland, with widespread agreement that poor body image is associated with a number of negative outcomes including eating disorders. The research into a positive correlation between satisfaction with the body and enhanced self-esteem is less conclusive, but a connection seems to have been established in studies of both men and women (Furnham et al, 2002). Grilo Grilo, Maseb, Brody, Burke-Martindale and Rothschild (2005), for example, found a correlation between self-esteem and body image dissatisfaction among obese men and women seeking surgery.

2.4 The relationship between body image and weight.
Issues of body image have been correlated with weight issues. Adolescent girls and women are the two groups most predisposed to poor body image and most likely to use dieting to overcome their issues (Groesz 2002). A number of studies have underlined the connection between weight and poor body image, for example one US study found that between those individuals classified as overweight are more likely to have lower self-esteem and poor body image (Pesa et al, 2000). Studies also found such a correlation amongst men (Silberstein, Striegel-Moore, Timko and Rodin, 1988). Being overweight is also associated with reduced emotional well-being, as suggested by a study by Loth, Mond, Wall and Neumark-Sztainer of around 2,500 adolescents. In addition, children who are overweight are in danger of being stigmatized and isolated from their peers. These results are more notable among women than men, although this difference only appears during adolescence (Loth et al 2010).

2.5 The relationship between poor body image and other factors
A number of other factors including race, gender and socio-economic status contribute to perceptions of body image: a study in the USA with over 1000 older adults showed race and gender and socio-economic differences signicant factors in how subjects perceived their weight (Schieman, Pudrovska and Eccles, 2007). It should be noted however that this study looked at perceptions of being over-weight alone, rather than body image in general. Within school children, it has also been found that lower socio-economic status is correlated with being overweight, having erratic meal patterns, disordered eating and body image issues, while self-esteem is lowest amongst girls in middle or higher socio-economic status (SES) For boys, self-esteem is lowest with low SES (O’Dea and Caputi 2001). Other studies have found that dieting is most common in higher SES (Walters and Kendler 1995).
Racial factors can also play a part: Xue, Zhou and Zhou (2003) suggest that Chinese males are susceptible to idealized body images. In addition, there is some suggestion in research that white women are more concerned with body image and weight than are men or black women, with corresponding higher incidences of bulimia and anorexia nervosa (Henriques and Calhoun, 1999).
Country of origin can also make a difference. While many studies look at the situation in Western countries such as the UK and USA, other studies have looked at other areas. Bissell and Chung (2009) looked at South Korea, finding that there are significant differences between the way people in South Korea and USA evaluate attractiveness in others, and the way this links to self-esteem and other variables including BMI. There is some suggestion in research that white women are more concerned with body image and weight than are men or black women, with corresponding higher incidences of bulimia and anorexia nervosa (Henriques and Calhoun, 1999).
2.6 Gender, media influences and body image
One major mediating factor in poor body image is gender, and many studies have investigated this area. Gender is a key factor as it impacts social norms and meanings associated with appearance. It is important to recognise that both men and women can be effected by body image issues, in order that prevention and treatment be given where it is most needed.
While there are important insights in theories rooted in individualistic and internally focussed psychoanalysis and therapy, the predominant theoretical position on poor body image traces a link between social and cultural influences, particularly those from the media, and dysfunctional views of one’s body. This theoretical background will be examined in more detail below.This influence has distinct characteristics for men and women. Whereas it was previously assumed that only women are influenced by media ideals of body image and thinness, more recent research shows that men are also subject to intense pressure to confirm to stereotypical ideals. However, for women particularly, idealised female figures in media have a negative impact on body image and self esteem. (Xue et al, 2003). Up to 19% of US female students are reported to be bulimic, and 61% have some form of eating disorder below the clinical level (chronic dieting, binging, purging). Between 70 and 94% of female students want to be slimmer, with 80 to 91% dieting (Yager and O’Dea, 2008). There is higher pressure on women to be thin and attractive, and women are traditionally expected to be more involved with their appearance than are men (Scheiman et al, 2007). The correlation between a negative body image and a poor self concept has been studied over several decades. Despite this awareness of the problem, women still find it a challenge to accept their bodies, and this lack of comfort with their appearance expands beyond immediate dissatisfaction with looks to effect other aspects of their lives including their concept of self (Dworkin and Kerr, 1987).
The role the media plays in women’s poor body image has expanded greatly with the advent of new communication possibilities, but has been around for centuries. Objectification of women’s appearance has occurred since early culture with a standard of beauty portrayed through art, literature and music. Nowadays, however, the explosion of accessibility and universality through electronic and print media have been highlighted by body image and eating disorder experts as increasing pressure on women to be concerned with their appearance (Thompson and Heinberg, 1999).
Repeated exposure to media, both directly and indirectly (both by experiencing images of women in the newspapers or on TV, for example, but also through conversations with peers, family members and other members of society) mean that pressures to be thin are transferred, and younger women are particularly vulnerable However, the relationship is not a straightforward one, but is mediated by factors including extent of the internalisation of the ideal, social comparison and the extent to which a schema for thinness is active (Lopez-Guimera Lopez-Guimera, Levine, Sanchez-Carracedo and Fauquet, 2010). Numerous studies have looked at various elements of specific media; television exposure (Gonzalez-Lavin and Smolak, 1995; Stice, Schupak-Neuberg, Shaw and Stein, 1994); type of program viewed (Tiggemann and Pickering, 1996), and exposure to print media (Stice et al, 1994) for example. There is widespread agreement that the media overall portray idealized images of women and thus contribute to negative feelings about body image and the development of pathological beliefs in some women. These studies have been reinforced by more recent investigations (Tucci Peters, 2008).
Of particular importance in idealising women’s appearance and leading to negative body image are women’s magazines. These have played this part over several decades. Women’s magazines have played an ambiguous role. As early as the 1980’s women’s fashion magazines such as Cosmopolitan and Elle began to publish articles reporting women’s eating disorders, and during the 90’s a new trend for fitness magazines heralded a new style with an emphasis on positive self-esteem and self-acceptance. A positive attitude about your own body was publicised, and portrayed as being a prerequisite for overall self-confidence. Further, during the mid 90’s a condition known “ body image distortion” – or BID, was also highlighted by fashion magazines who emphasised their social conscience and relevance to real women. Such magazines recognised BID as a “serious illness”, threatening many women and linked with low self-esteem, sometimes reported to be more common than anorexia and bulimia nervosa. On the other hand, while promoting their caring credentials through discussing eating disorders and problems of poor body image, magazines continued to portray idealised images of women, particularly with the development of digital imaging techniques and the enhanced possibilities for presenting a fiction as photo-realistic reality. Women are bombarded through fashion shoots with the message that ‘pretty women equal thin women’ (Markula, 2001). Research in this area confirms that exposure to editorial and advertisements in women’s magazines impact upon body image through promotion of standards of beauty (Groesz, 2002). The first meta-analytical statistical review of media impact upon girls and women from 25 previous studies revealed that individuals expressed differences in their motives for social comparison with their own image and that this was associated with diverse measures of negative body image. Results in this study supported the inverse relationship of body image after participants viewed images on thin models in comparison with images of average size models, plus-sized models and inanimate objects (Groesz, 2002; Stormer and Thompson, 1996). In addition, such magazines promote a need for endless consumption of lifestyle accessories and garments, with the underlying message that women need to purchase the latest styles to be acceptable. Some also argue that magazines thereby support capitalism and patriarchy (Gough-Yates 2003).
Women are also more subject to gender-related harassment in public than are men, perhaps as a result of widespread dissemination of idealised images. A recent study has suggested that these experiences of harassments and women’s emotional reactions to such incidents can play a part in feelings of low self-esteem and poor body image as well as feelings of shame and dislike towards the body (Lord, 2010). Low body image, when combined with high self-esteem, has also been linked to indirect aggressive behaviours amongst young women (Young, 2008).
While the impact of media upon body image has been, until recently, predominantly studied in women, it is gradually being recognised that men are also prone to body dissatisfaction through media influence. Men’s concerns tend to differ from those of women, most notably in that men’s main concern is muscle, with men reporting more desire for increased muscle mass than women (Krayler et al, 2007). Higher levels of muscle dissatisfaction have been correlated with higher levels of depression, lower self-esteem, pathological eating patterns and higher levels of social anxiety. Body fat is also an area of concern for men, and this has also been associated with other conditions including eating pathology, social anxiety and depression. Height dissatisfaction has been studied less, but also appears as a cause of body image dissatisfaction in men (Blashill, 2010). Gay men are less studied, but would appear to report higher levels of muscle dissatisfaction and desire for thinness than heterosexual men.
Research into men’s issues with body image started in the 80’s. An early study revealed almost 100% of college-aged men were dissatisfied with a part of their body, and 70% thought a discrepancy existed between their current and ideal body shapes (Mishkin, 1986). More recent studies have confirmed the existence of a range of eating disorders and dysfunctions in body image in men, including disordered eating, body dysmorphic disorder and excessive exercising (Drummond, 2002). Between 17 and 30% of undergraduate men diet to lose weight; there is also increasing adaptation of weight lifting, body building and steroid use.5-10% of individuals with eating disorders are male (Yager and O’Dea 2008).
Initially, it was assumed that men would not be influenced by images of idealised bodies in the media as, it was hypothesised, men are less affected by visual images than women. Later investigation found, to the contrary, that men find visual material more evocative than females and therefore are faced with a greater degree of body image concerns than was originally thought (Barthel, 1992). A study carried out by Agliata and Tantleff-Dunn (2004), incorporating several previous studies, suggested that when men are exposed to media images of the ideal male body, which is defined as “lean and muscular”, it can lead to negative effect upon their mood and their satisfaction with their body. There has also been an explosion of men’s media over the last 20 years, with magazines devoted to health and fitness, ‘lads’ culture, and the ‘metrosexual’ man, concerned with his looks and physical impact upon others.The development of these ‘fashionable masculinities’ can be seen as a by-product of capitalism, as corporations attempt to sell new and profitable market segments to both advertisers and consumers. While the traditional markets for image related products – women – is more or less saturated, and while the gay market will always form a minority group, the target group of heterosexual men is underdeveloped (Cova, Kozinets and Shankar 2007). It is unsurprising therefore that the last 2 decades have seen an explosion in the volume and variety of idealised male images. As a result, men are beginning to face the same pressures as women to possess physical characteristics considered attractive and masculine. There are specific differences between the way a desirable body is communicated to each gender. Male-targeted magazine often advertise exercise and weight lifting to a greater extent than in female magazines, which focus on dieting. Print media encourages males to mould their bodies into their ideal shape, through exercise and subject them to a “culture of masculinity” (Agliata and Tantleff-Dunn, 2004). In addition, it has been suggested that exposure to ‘Lad’ Magazines, such as the 90’s UK publication ‘Loaded’, which feature highly sexualised images of desirable and seemingly available women paradoxically increases awareness of male readers own bodies. A study amongst undergraduate men found that such magazines can lead to increased dissatisfaction with body image in men, perhaps due to assimilation and subsequent projection to their own case of messages about women and idealized images (Aubrey and Taylor, 2005).

2.7 Measuring body dissatisfaction and poor body image
A number of scales have been introduced to help assess the extent of body dissatisfaction, including the Pictorial Body Image Scale (PBI), Body Dissatisfaction subscale of Eating Disorders Inventor (EDI), Visual Analogue Scale (VAS) amongst others. The Body Esteem Scale (BES) incorporates weight satisfaction, and can also be used as a measure of physical attractiveness assessment (Groesz, 2002).

2.8 Theories of poor body image
Research has suggested that there is an investment in an ideal of thinness in girls as young as 3 (Harriger Harriger, Calogero, Witherington and Smith 2010), so it is important to look at how such ideals are ingested, and theories of how poor body image comes about. By understanding how this happens, and particularly whether poor body image is primarily caused by external influences in society or culture or by traumas to the psyche at key developmental periods, it is easier to select appropriate types of therapy or counselling to address the problem. Equally, by understanding that different theories can have value for explaining body issues, it is possible to see the value of different ways of treating the disorder. Theories of poor body image can be placed in the context of ideas about how body image in general comes about. Some suggest that the development of body image has four characteristics. It is first an integration of physical, psychological and social factors, second it changes over time, third it is a learned behaviour, and fourth it has both conscious and unconscious components The physical element concerns the way in which someone relates his or her body to the rest of the environment. Psychological issues concern the values attributed to different parts of the body and the way in which the self is defined in terms of these. These values can change of time, and different parts of the body become more or less important at different life stages. Finally, sociological aspects include the way other people react to a person’s body, and how these reactions are processed by the subjectBody image changes over time, as a result of changes in the three factors described above. Developing the ability to use different senses, for example, triggers body image changes. In addition, changes in the environment impact upon body images. Finally, body image is psychologically complex containing both elements in conscious awareness and elements which are hidden from awareness (Flaming, 1993). Such an understanding of the multi-faceted development of body image could be seen to lend weight to the validity of different treatment programmes to account for the complex nature of the condition with conscious and unconscious elements and with causes both internal and external.
There are a number of theories which suggest ways in which a poor body image develops. These divide broadly into two types, those which link poor body image to social and cultural factors primarily the objectification of the body in the media, and those which develop from a psychoanalytical model which prioritises internal processes of the psyche. Each type of theory can be used to support a different treatment approach. It has been seen above that the media play an enormous role in creating and maintaining idealised body image and awareness of individual shortfalls in both men and women. This role is confirmed by the first two theories discussed below.

2.8.1 Objectification theory
Objectification theory was developed by Fredrickson and Roberts (1997), but is rooted in earlier feminist theory such as works by De Beauvoir, It describes a process whereby the sexualisation of women’s bodies is the norm. Women come to see themselves as objects to be looked at critically. Women learn early, both directly and through indirect influence, that looks are a currency, and that how people assess looks determines how an individual is treated. This has an effect upon social and economic life outcomes. Women develop a ‘third person’ perspective upon their bodies, in order to anticipate criticism and control how they are treated. This supplants a more healthy ‘first person’ perspective or ‘inside’ view of their body. The process of objectification, the theory suggests, leads to a variety of negative emotional and behavioural consequences including increased self-consciousness and increased preoccupation with the outward appearance of the body, rather than with its efficiency or health. Objectification can also lead to shame, disgust and anxiety as the body fails to correspond to desired ideals, and also to a range of behavioural and emotional outcomes including eating disorders. Objectification theory also predicts different stages of objectification, from the start of the process at puberty, when the maturing female starts to experience external attention and critical, sexually related evaluation from others, through to mid-life, when women are more able and willing to step out of the arena of body assessment (Chrisler, 2004). The media plays a central part in the process of objectification which results in individuals taking the perspective of an outsider on their physical self, and to constantly monitor their appearance (Aubery 2006).The initial development of objectification theory suggested that women are more susceptible to objectifying their bodies and to the feelings of shame and anxiety generated when they feel their bodies as objects to be viewed and evaluated by others are less than perfect. However, it has more recently been suggested that men also can be affected by the process, with a recent study, for example, finding that increases in body surveillance after exposure to sexually objectifying media occur only in men (Aubrey, 2006).In addition, more recent explorations have pointed out that not only is much this research amongst men carried out only with heterosexual men, but also that gay men seem to have higher levels of body dissatisfaction than heterosexual men. This is an area which demands exploration, and there have been some attempts to explain it rooted in developing objectification theory by suggesting that gay men are under more pressure to have a body that is desirable and attractive, as they are (like heterosexual women) trying to attract men as partners, and men place more emphasis upon physical attractiveness.In addition, gay culture and media highlights male attractiveness, thus increasing the pressure on gay men (Blashill, 2010).
Other theories, less directly related to objectification theory, include the ‘femininity hypothesis’, which suggests that gay men have higher levels of ‘female’ traits than heterosexual men, and that these traits are associated with higher body dysmorphia. (Lakkis, Ricciardelli, and Williams, 1999).

2.8.2 Other theories incorporating social influences
Other theories incorporating media influences include the Dual Pathway Model, with foundations of low self-esteem, and the Social Comparison Model, which traces a relationship between media exposure to pressures and elevated internalisation of media values. These models all aim to explain specific mechanisms by which the media generate negative effects (Thomson and Heinberg, 1999).
The Dual Pathway Model develops out of objectification theory. Originally suggested by Stice and Agras (1999), it holds that body dysmorphia is created by a social and cultural pressure to be thin, often through media influences. A ‘thin ideal’ is internalised by this social pressure. The dysfunctional body image thus created can leads to eating disorders and other negative behavioural patterns through two pathways, either of which is sufficient to cause these patterns. The two pathways are the ‘Restraint’ and the ‘Affective’ pathway. With the restraint pathway, dissatisfaction with the body leads to attempts to restrain eating which in turn causes pressure upon the individual, leading to eating behaviours such as binging. The affect pathway sees body dysfunctional views provoking negative feelings about the self as negative assessments of appearance lead to negative emotions. In addition, negative feelings can also be prompted by dieting either because of low energy levels or, when the diet fails, feelings of self-hatred (Munsch and Beglinger 2005) The success of dissonance-based prevention programmes (discussed below) adds support to the dual pathway model, as such programmes target the internalised ideal of thinness (Stice, Mazotti, Weibel and Agras, 2000).
Social comparison theory suggests that people process social information by comparing themselves with others and by identifying similarities and differences. It can help us understand the processes by which social messages concerning appearance influence people’s body image. The theory suggests a relationship between an attribute (the aspect which is compared, for example weight), the target (the person with which the attribute is compared) and the comparison appraisal (the way the comparison is carried out).It can be used to elucidate the ways in which media messages influence the way people perceive their bodies. The idea was introduced by Festinger (1954). Different comparison appraisals are used depending upon context. They can be self-evaluation, self-improvement or self-enhancement. The first consists of gathering information about how one relates to others. Self-improvement concerns learning how to change a particular characteristic, and self-enhancement is a mechanism whereby the other is discounted as not relevant to the self, or lacking in other attributes the self possesses (Krayler et al 2007).

2.8.3 The Developmental transition model
By contrast, the Developmental Transition Model takes a different perspective, and is rooted in psychoanalytic theory. It can be traced to Object Relations Theory, the notion that the self develops through interaction with an environment, which was developed by a number of writers including Winnicott and Klein. The development transition model is concerned with problems that occur as a child separates from his or her mother as part of the process of individuation. This process is thought to be easier for men, because they do not have the same level of identification with their mother. In order for women to successfully separate from their mother, they need to deal with feelings of anger towards their mother. One way in which this might take place is by the daughter turning these feelings of rage against themselves, and becoming a perfect daughter, well-behaved, clean and neat. Their body becomes their enemy, an object to be controlled, and can be associated with the mother. The daughter strives to control her body to prevent it becoming like that of her mother. The process of individuation first takes place in early childhood, but can resurface at adolescence as the daughters body starts to change and resemble that of the mother. Such dysfunctional transitions are particularly likely to occur where the mother is over-controlling, or where she sees the daughter as part of herself, hoping to live out her own dreams vicariously (Yates, 1991). Theories rooted in psychoanalysis seem to take a second place to theories which underline the role played by social and cultural conditions, particularly given the central role played by the media, but given the complexity of the phenomenon of eating disorders and poor body image, it is important not to rule out the insights generated by a more individualistic, internal perspective.
3. Body dysmorphic disorder.
The sections above have given a broad picture of the nature of body image, the impact of poor body image and theories of how these develop. One specific negative condition which deserves more consideration is the mental disorder ‘Body Dysmorphic Disorder’, as it takes a poor body image to an extreme where it becomes all consuming for the sufferer.Body dysmorphic disorder (BDD) is also known as “dysmorphobia” and is an under recognised but severe common mental condition. Although first described by Enrico Morselli in 1891, it has only recently been the subject of research. BDD is a “distressing or impairing preoccupation with an imagined or slight defect in ones appearance” (Phillips and Diaz, 1997).

3.1 Definitions of body dysmorphic disorder
BDD is multi-dimensional and has both positive and negative aspects (Cash, 2002). It consists of three components, one concerning the perceptual, one concerning attitudes and one concerning behaviours (Cash, 2002; Jarry and Berardi 2004). Perceptual factors of BDD include inaccurate estimations of body size or weight, or seeing a feature as very unattractive. Attitudinal factors include the extent of satisfaction and / or dissatisfaction with appearance and the way appearance is self-evaluated. Behavioural factors include ‘acting out’ such as repeated checking of perceived imperfections (Jarry and Berardi 2004). Features of BDD continue over time, but are also changed as a result of experience and the environment (Melnyk, Cash and Janda 2004). BDD is often found with other conditions, for example poor psychological adjustment or depression, social phobia and obsessive compulsive disorder (OCD) (Phillips 2005; Pollice, Bianchini, Giuliani, Zoccali, Tomassini, Mazza, Ussorio, Paesani, Roncone and Casacchia 2009). There is a degree of heterogeneity amongst those affected by BDD, as each sufferer presents with very different symptoms from a dissatisfaction with the nose to feeling generally ugly, however the underlying pathology is that BDD sufferers are preoccupied with the idea that their appearance, or a feature of it, is unattractive, ugly or deformed. Further to this, over time nature of the disturbance may change, often explaining why post-surgery, BDD patients often are dissatisfied with the results (Veale 2004). Unfortunately, this condition has significantly high lifetime rates of suicidal ideation (approx 78-81%) and attempts of suicide (22-28%) (Phillips, 2005) with a poor prognosis for recovery. BDD is a dynamic condition, which affects typically facial flaws, asymmetric/disproportionate body features, incipient baldness, acne, wrinkles, vascular markings or extremes of skin colour. BDD has been linked to requests for cosmetic surgery procedures. It has been estimated that between 6 and 15% of people requesting plastic surgery suffer from the disorder (Pollice et al 2009, pp. 5-10). Given the severity of the condition, there is a clear need to find successful treatment routes in addition to addressing poor body image generally.

3.2 Risk factors
Risk factors for BDD include genetic predisposition, shyness, perfectionism, anxious temperament, childhood adversity (e.g. teasing/bullying about appearance or competence), history of dermatological or other physical stigmata (e.g. acne) and having an higher sensitivity to aesthetics than the average person. This heightened aesthetic sensitivity equates to a greater emotional response to other individuals whom they find more physically attractive and elevates their value of appearance and identity (Veale, 2004)

3.3 Clinical features and diagnosis
Individuals may describe themselves as unattractive, most often focusing on their facial attributes or their head, however this displeasure can include any body area, or in fact their entire body. This concern can take up almost 3-8 hours of their day, carrying out repetitive behaviours such as mirror checking, and is often associated with emotions such as rejection, low self-esteem, shame, embarrassment, unworthiness and being unloved by those around them. The diagnosis of BDD usually occurs after 15 years form the onset of this mental disorder, this is due to many patients being too ashamed to reveal their symptoms however when exposed to a doctor is typically diagnosed using the DSM-IV criteria (Veale, 2004; Phillips, 2004).
The DSM-IV-TR diagnostic criteria for BDD is as follows:
a) Preoccupation with an imagined defect in appearance. If a slight physical anomaly exists the persons concern in markedly enhanced,
b) the preoccupation creates clinically significant distress or impairment in social, occupational or other important areas of functioning
c) the preoccupation is not better accounted for any another mental disorder (e.g. body dissatisfaction with body shape and size in anorexia nervosa).
(Phillips, 2005).
A number of measures have been used to test for BDD, including the Self-report Symptom Inventory and the Body Uneasiness Test (Pollice et al 2009). Instruments commonly used to measure BDD include the ‘Body Shape Questionnaire’ which looks at concerns about individuals size and shape, the ‘Multidimensional Body-Self Relations Questionnaire’, an attitudinal measure, the ‘Body Image Avoidance Questionnaire’, which assesses body image issues in terms of avoidance behaviour, the ‘Appearance Schemas Inventory’, measuring body image attitude, and the Situational Inventory of Body Image Dysphoria, which measures the frequency of negative body emotions. (Jarry and Berardi 2004). Other instruments include the Body-Cathexis Scale, looking at 46 body parts and functions, and the related Self-Cathexis scale, containing 55 items which represent conceptual aspects of the self. Both are rated on a 5-point Lickert scale (1 wish to change, 5 satisfied with the aspect) (Dworkin and Kerr, 1987).

3.4 Prevalence
Although BDD occurs relatively frequently in both clinical and non-clinical settings, no large scale epidemiological surveys have been carried out to date. Within the UK, only two studies have been reported in the community and show the prevalence to be 0.7%, occurring at a higher frequency in adolescents and young adults. Both genders seem to be affected equally, and the majority of sufferers fall into the category of single, separated or unemployed (Phillips, 2004; Veale, 2004). An Italian study has suggested that it affects a higher percentage of the population, at 1-2% (Pollice et al 2009). The rate of BDD amongst people seeking cosmetic surgery is high: of those presenting at cosmetic surgery clinics it is estimated 6-15% suffers from BDD, and within dermatological settings the estimate is 9-12% (Phillips 2005).

3.5 Treatment
Treatment of BDD usually involves cosmetic surgery dermatological treatment (where there is an associated cosmetic condition), pharmacotherapy in the form of serotonin-reuptake inhibitors (SSRI) or cognitive behaviour therapy (CBT) (Veale, 2004).
Although psychotherapy options available have been seldom researched, CBT does appear an efficient form of treatment. Numerous studies have used a combination of cognitive elements (e.g. cognitive restructuring) alongside behavioural elements, which consists predominantly of exposure and response prevention (ERP). ERP aims to decrease social avoidance and repetitive behaviours (such as mirror checking and grooming). There has been reported positive correlation between various combination therapies with BDD symptom severity showing a significant decline. There is no published data to substantiate the use of other types of psychotherapy other than CBT (Phillips 2004). In addition, a school intervention programme consisting of classes looking at media images of women, body size and weight control methods was found to have some success in reducing BDD (Paxton 1991). Intervention programmes typically involve larger groups of patients and as such might be less costly than CT or CBT which often involve one-to-one therapy sessions. Social comparison theory can also be used to build a case for intervention programme treatments for ED and BDD, as it helps us understand why some individuals don’t react negatively to comparisons with media images about body shape and weight. Programmes which build resistance to known risk factors such as ideal media images are useful, with cognitive interventions seeming to produce good effects (Krayler et al 2007). Yager and O’Dea (2010) studied the effect of two interventions among trainee PE and Health education teachers, identified as at risk of poor body image. One intervention was a self-esteem and media literacy programme, the second combined self-esteem and media literature with dissonance and used online and computer-based activities. Intervention 2 produced the best results, particularly for men.
While CBT and CT and intervention programmes seem appropriate treatments for BDD, and later these treatments will be discussed in more detail, there would seem to be a case for using more person-centred therapeutic approaches which aim to work with the client’s internal representations of their appearance. The following section will look at treatment approaches for BDD in particular, but also for poor body image and related disorders in general.
4. Counselling therapies
4.1 The development of counselling
While the roots of counselling can be traced back to Greek and Roman times, modern counselling developed out of a reaction against the religious world view which predominated until the late 19th century. Up until this time, behaviours that we would now characterise as medical conditions were seen as signs of demonic possession, within that prevailing religious framework of good against evil. Pioneering work by scientists including Pinel, Mesmer and Charcot helped establish the current medical framework in which mental conditions were seen as illnesses, similar to physical illness and equally treatable. This new approach meant that treatment options for mental illnesses appeared (Laungani 2004).
Modern counselling can be traced back to Freud’s work in the 1880’s. Freud developed a way of working with patients with hysteria, called ‘psychoanalysis’. He suggested that unconscious forces shape people’s actions and beliefs. Approaches to therapy descending from psychoanalysis focus upon the dynamic relationships between parts of the psyche and the outside world. Freudian psychoanalysis has been extremely influential not only in psychology and psychiatry but in related fields such as literature and art. A different approach was put forward by the behaviourists, primarily Skinner. Behaviourism rejects the notion of the unconscious and stipulates that mental processes can be thought of in terms of behaviours and observable variables. A ‘third way’ was put forward by Carl Rogers, influenced by Alder and rank. ‘Client’, or ‘Person’-centred therapy focuses upon the experienced world of the client, rejecting the untestable constructs of psychoanalysis while accepting the internal world of subjective experience ruled out by the behaviourists. Person-centred therapy developed into humanistic approaches including Gestalt therapy and psychodrama (Mulhauser, 2010).
The growth in the practice of counselling has been particularly rapid over the last 50 years or so. This can be traced to a number of factors, including a growth in people’s awareness of and interest in the self and identity, an increasingly fragmented society in which alienation is increasingly common and in which many lack social support systems, and a change in the nature of nursing and other ‘caring professions’ which mean they are unable to carry out the counselling functions which used to be part of their role (Robb and Barrett, 2003).
Until 1977, when the British Association of Counselling was established, counselling practitioners were entirely unregulated, and anyone could practice as a counsellor without checks. The establishment of the BAC meant a move towards professionalization with accreditation and checks on practitioners. Membership of the BAC grew rapidly, and the organisation split into 7 divisions in order to better reflect the very complex needs of today’s society. The BAC was renamed the British Association of Counselling and Psychotherapy in 2000 (Laungani, 2004).
In line with the historical development outlined above, psychological therapies generally are organised into three categories; behavioural therapies, psychoanalytical and psychodynamic therapies and humanistic therapies. Behavioural therapies focuses on cognitions and behaviour and encompasses cognitive therapy (CT) and cognitive behaviour therapy (CBT). The second category includes psychoanalytic therapy and psychodynamic therapy, with central importance given to the unconscious relationship patterns, which have evolved from childhood. Finally, the third category of Humanistic Therapies prioritise self-development and the “here and now”. In addition to Person-Centred Counselling (also known as “Client-centred” or “Rogerian” counselling) and Gestalt therapy, humanistic approaches include transactional analysis, transpersonal psychology and psychosynthesis and existential therapy (Counselling Directory 2011 [online]). Treatments for poor body image and BDD tend to be drawn from therapies of the behavioural type, although a case can be made for a broader approach to treatment.
4.2 The Practice of counselling for poor body image
Higgins (1987) outlined two basic kinds of negative psychological situations, firstly the absence of positive outcomes, either actual or expected. This is connected with depressive emotions such as disappointment, dissatisfaction and sadness). The second is the presence of negative outcomes (actual or expected), which is connected in turn to more active negative emotions such as fear, threat and edginess. Therapies aimed at counteracting a poor body image have to deal primarily with the first situation.
Therapy for people with poor body image and related disorders seeks to encourage positive thinking in order to boost the client’s self-esteem and overcome low confidence by altering these thoughts and behaviours. Counselling and therapy can also target issues by preventing behaviours which result from individuals internalising media images, promote positive internalisation of healthy norms, and inform clients about the negative consequences of extreme weight loss behaviours in attempts to gain an ‘ideal’ look (Thompson and Heinberg, 1999). The counsellor can work with a client with poor body image in several practical ways. First, he or she can look at previous patterns in how the client coped with body image changes in the past. These patterns, once uncovered, can be examined and analysed. Helpful coping strategies could be used again, and negative ones rejected.The counsellor can also look at the support system a client has in order to plan therapy more effectively. If members of a client’s family, for example, reinforce unhelpful behaviours this could be raised with the client (Flaming, 1993).

4.2.1 Ethical issues
Counselling and therapy for poor body issues, should, like treatments for other mental health problems, be conducted ethically at all times. The British Association for Counselling and Psychotherapy (BACP), first published in 2002, sets out an ethical framework which is subject to continual revision (BACP 2001, 200, 2007, 2009, 2010). This framework sets out areas which need to be incorporated by therapists and counsellors in any client’s treatment. These areas include values, principles and personal morals. The fundamental values of counselling and psychotherapy include “respecting human rights and dignity, protecting client safety”. In addition, therapist need to ensure they maintain integrity in relationships with clients, that they always act to improve professional knowledge, that they aim to reduce suffering and personal distress and to make the client’s experience more meaningful and effective. They should also strive to improve relationships between individuals and to respect the diversity of human culture and strive for equality (BACP, 2010). The therapist or counsellor should also try to integrate ethical principles into his or her practice including trustworthiness, autonomy, respect for the client’s self-governing, promoting the client’s well-being, fostering self-respect in the client and being committed to avoiding harming the client (BACP, 2010).

4.3 Types of therapy and their usefulness for BDD and body image problems
Empirical evidence from a number of studies suggests that counselling is a powerful instrument in promoting body- and self-acceptance in women. Evidence exists particularly for the effectiveness of cognitive therapy and cognitive behavioural therapy (Dworkin and Kerr 1987), although other approaches have been shown to be successful (prevention programmes) and other therapies seem, though relatively unexplored, to offer alternatives for clients for whom CT or CBT do not work well.

4.3.1 Cognitive therapy techniques (CT).
Cognitive therapy (CT) has emerged as a successful therapeutic approach for depression, altering states of irrational thought and re-shaping self-statements to a more positive outlook. This more general idea of utilising cognitive therapies to address irrational beliefs can be usefully adapted towards overcoming a disturbed body image and associating negative self-concepts (Dworkin and Kerr, 1987)CT involves educating, identifying and replacing beliefs and thoughts which might be considered distorted, and by identifying them altering the associated habitual behaviours and thoughts to which they are related. Cognitive therapy was originally developed by Beck (1976), and is based around the notion that dysfunctional representations (schemata) arise in childhood as a result of problems in relationships, particularly with parents. CT has four main components, first, an educative element (often patients are uninformed about their condition), second goal setting (getting patients to carry out progressively more challenging activities, often as part of homework tasks), third identifying negative thoughts (clients may be unaware of the thought patterns that are holding them back) and fourthly challenging negative and unhelpful thoughts (Champion and Power, 2000). By becoming aware of irrational beliefs and challenging them, clients are empowered to exchange them for more positive ones. Once clients understand the mechanism for challenging and changing their thoughts, they are able to do this for themselves outside of therapy sessions. CT has been shown to be effective in treating BDD, but no more so than other techniques. Focus upon changing negative self-statements into positive ones, teaches clients methods for doing this by themselves, can include homework tasks (Dworkin and Kerr 1987).

4.3.2 Cognitive behavioural therapy (CBT).
Cognitive Behavioural Therapy developed from Cognitive therapy, and combines both cognitive and behaviour therapies, incorporating the way one thinks (cognitive) as well as how these thoughts are responded to (behaviour). Similarly to CT, it concentrates on the ‘here and now’, and upon disassembling overwhelming problems so they are smaller and easier to manage (Farrell et al 2006). It also uses additional behavioural reinforcements for example self-reinforcement and imaginative or fantasy exercises. There have been suggestions that imaginative activities particularly can be used within therapies for eating behaviours, as imagination is a powerful adaptive activity that helps clients organise event meanings, plan for the future and guide them in goal achievement and decision making. While imagination can work negatively by being used as a coping mechanism with negative self-images and fantasy and help internalise negative perceptions of body image, it can also be targeted as a positive strategy to help change inset belief patterns (Hutchinson-Phillips Hutchinson-Phillips, Jamieson and Gow, 2005).
This addition of behavioural aspects to create CBT means the therapy is a more powerful way to tackle problems by allowing clients not only to change their belief systems into more positive ones, but also teaching techniques for clients to use to reinforce good practice (Dworkin and Kerr, 1987). CBT can incorporate numerous techniques including cognitive restructuring (questioning and challenging problematic thoughts), behavioural experiments (practical activities testing predictions which emanate from problematic beliefs and thoughts) and size-perception training (reviewing the accuracy of the clients body size) (Farrell et al, 2006).
Cash (1995) and Rosen (1997) have developed CBT techniques specifically for use with people with poor body image and eating disorders. Their programme has become widely used, and has been tested and found to have good results for at least a 3-6 month period after completion. The programme consists of three elements which work together: firstly psycho-education about body image, second guided exercises which help the client assess and challenge negative thoughts, and third skills-teaching to enable the client to master situations that have been shown to lead to body anxiety in the past (Levine and Smolak, 2005). In other research carried out with patients who have vitiligo, a visible disfigurement, CBT was demonstrated to be effective in enhancing ones self-esteem and body image (Papadopoulos, Bor and Legg 1999). CBT has been found repeatedly to be a very effective treatment for poor body image (Jarry and Berardi 2004).
CBT has been used specifically for BDD. It is a multi-component approach which involves an assumption that dysfunctional thoughts and behaviours are learnt responses and can be unlearned and more positive responses put in their place. CBT for BDD can include self-monitoring, desensitivisation, cognitive restructuring and behavioural modification as well as group work (Jarry and Berardi, 2004). However, Jarry and Berardi (2004) compared a number of treatment programmes for BDD using CBT, and found that while all addressed the attitudinal component of the illness, only some also addressed the perceptual and emotional contents. They found that body image therapy, based upon CBT techniques, is very effective with improvements to the attitudinal and behavioural components of the illness after treatment. Attitudes towards eating, and behaviour also improved after CBT based interventions. Jarry and Berardi’s of CBT-based treatments also seem to indicate the necessity of a therapist. While self-administered CBT can be effective, the absence of therapist seems to hinder behavioural changes and make client less able to comply.
Veale (2004;2001) has developed a model for explaining BDD based upon cognitive behavioural theory. Veale’s model relates to that developed by Cash and Pruzinsky to explain body weight and shape dissatisfaction in the non-clinical setting, but is applicable specifically to BDD and incorporates features unique to the disorder, including the client’s relationship with reflective surfaces for example mirrors which can trigger symptoms. His model helps understand why symptoms of BDD are maintained, and can be used by a therapist to help the client understand his or her symptoms and overcome them. In his model, there is a complex relationship between the client’s negative appraisal of their body image on the one hand, and several other factors on the other: the processing of the self as an aesthetic object; rumination on ugliness and comparing the self to the ideal; negative mood and safety behaviours to disguise the appearance. There is a two way relationship between the client’s appraisal and each of these four factors. In addition, triggers can act to start a cyclical relationship between the negative self-appraisal and processing of the self as an aesthetic object (Veale 2001; 2004). So far, Veale’s model seems not to have fed into the further development of CBT techniques for BDD.

4.3.3 Person-centred therapy
Client, or person-centred therapy is an approach rooted in the subjective experience of individuals. It contrasts with the Freudian approach, which looks at the play of influences which have contributed to the client’s situation, but also with CT and CBT approaches as it places less emphasis upon the client’s behaviours. The Person-centred therapist is concerned with the client’s personal view of the world, and how that client interprets and makes sense of events. It assumes a humanistic psychology, rather than a behaviourist one. In order to be successful, the therapist should understand the client’s life, values and experience. Person-centred therapy also differs from cognitive approaches in that the latter prioritise the process of thought, while the former concentrates upon feelings and emotions.
Key ideas in person-centred therapy were developed by Carl Rogers. Rogers believed that humans strive towards self-actualisation, that everyone wants to make full and best use of their potential. He also assumed that people are inherently good, and that irrational beliefs and acts are a consequence of fear. Key concepts Rogers developed include the notion of ‘self-image’ – how a person sees his or her self. This self-image determines a person’s outlook on life and his behaviour. He distinguished further between an ideal self-image – how a person thinks he or she should be – and how they perceive themselves to actually be. Rogers suggested that the self image (or self-concept) can be congruent with reality – match experience – or incongruent, for example when someone perceives themselves as being hated, without there being any evidence for this. Rogerian therapy therefore has two aims, firstly to reconcile differences between reality and the self-image, and second to reconcile differences between the concept of the ideal self and the concept of the actual self (Groenmann and Buckenham, 1992). A related concept to the idea of congruence and incongruence was put forward by Goffman (1963), who suggested the notion of stigma as ‘an attribute which is deeply discrediting’ for the individuals involved. According to Goffman, a stigma emanates during social interactions whereby an individual’s actual social identity (characteristics/traits thought to be possessed by this individual) fail to meet the expectations of the societies attitude of what constitutes normal, that being his/her virtual social identity. This situation results in a predicament whereby the individual has a spoiled social identity, and assumed to be incapable of satisfying the role requirements of social interactions (Kurzban and Leary, 2001). Various attempts to conceptualise stigma developing the work of Goffman have been proposed since, all sharing a fundamental tenet that stigmatization of an individual occurs through the culmination of negative evaluation, whether in terms of discrediting, adverse attributes, the perception of illegitimacy or as a result of devalued social status (Kurzban and Leary, 2001). Examples of the development of the concept include that by Jones Jones, Farina, Hastorf, Markus, Miller and Scott (1984), who established a six-dimensional method for examining stigma-associated health conditions. The six dimensions are first the extent to which the condition can be concealed (is the condition obvious to others and what is the extent of the visibility?), second the course of disorder (the general pattern of change and outcome of the condition in question), third disruptiveness (to what extent does the condition hinders communication and interaction?), fourth aesthetic qualities (to what extent does it make the sufferer repellent, ugly or upsetting?), fifth origin (the state of affairs in which the condition emanated) and finally, peril (to what extent does the condition pose a threat to others?). In addition, Link and Phelan (2006), described stigma arising as result of a combination of interrelated elements, essentially encompassing these five issues; identifying and labelling human differences, processing stereotype, separating “them” and “us” mentality, experiences of discrimination and loss of status and finally the exercise of power. This notion of stigmata seems particularly applicable to the way the person with BDD views the aspect of his or her body that is unacceptable to them.
Criticisms of person-centred therapy tend to come from a psychoanalytic perspective, and focus upon its lack of explanatory power as a model. Critics for example claim that it lacks a theory of personality, and especially is unable to account for child development. In addition it cannot explain how neuroses and psychoses develop (Wilkinson 2003).
One argument for utilising a person-centred, humanistic approach is that such approaches integrate the body more fully into the therapeutic process. While all schools of therapy acknowledge the importance of the body, they frequently limit its involvement to verbal, symbolic and intellectual discussions. Patient initiated movement tend to be ignored by many schools of psychotherapy (Miller 2000). Miller does not mention, but this can also be said to be true of CT and CBT. By definition these approaches concentrate upon thoughts and changing them, rather than integrating body sensations. Client centred therapies, however, are more likely to integrate the body into sessions.Berne’s ‘Transactional Analysis’ urges the therapist to look for references to body parts like the anus and mouth. Other client-centred approaches such as Gestalt, psychodrama and Bioenergetic Analysis integrate the clients physical being perhaps by repeating client gestures or trying to uncover how past experiences have been integrated into the clients body. Bioenergetic analysis, for example, suggests that the client uses physical techniques in childhood such as muscle contraction or reduction in breathing to cope with difficult situations, and that physical exercises can help unlock these long standing negative patterns. Such approaches see the client as embodied rather than as a set of cognitions (Miller 2000).
Rowan suggests that while there are three ways in which therapy can conceptualise the body, which correspond to three levels in a model by Wilber (1996), most therapies concentrate unduly upon the first way. At level one, the body is seen as separate from the mind, one can be treated in independence from another. At level two, mind and body are integrated, and the client is encouraged to see it in this way also. At level three, the body and mind are both part of a greater whole (Rowan 2000).
Another reason why a client centred approach might be useful is that there is some evidence that people with problems with eating also have problems with interpersonal relationships. CT and CBT do not work on such relationships. Interpersonal issues can both cause and perpetuate dysfunctional attitudes to the body. Person based approaches are able to help patients deal with issues that have been deeply entrenched.
Reflective therapy techniques are one form of person-centred therapy which seems particularly useful for treating BDD.Suggested by Dworkin and Kerr (1987), reflective therapy applies the basic principles of client-centred therapy and consists of exploring the patient’s feelings about body image during key periods in their development. It does not include techniques for challenging negative and irrational beliefs, but rather focuses upon exploring feelings about body image using techniques such as reflection, paraphrasing and journal based homework. By exploring the client’s feelings about body image, and looking back to key life stages, the approach differs sharply from that of CT and CBT. Dworkin and Kerr (1987) found it as effective as CBT. While it lacks the complexity of approach of true client-centred therapies, it is still useful. This also suggests that emotionally-focussed which look at the internal world of the client therapies may be useful. Research has in fact suggested a link between outcomes in therapy and the extent to which clients are able to explore and analyse emotional meanings. There has been little testing of treatments which work in this way, despite a recognition that CBT may not suit all patients (Jarry and Berardi 2004).

4.3.4 Prevention programmes
One possible critique of both CBT / CT strategies and person-based therapeutic approaches is that they focus upon the individual rather than society or culture as a whole. Such practices might be said to isolate individual clients by removing them from the social environment where negative thoughts and perception of self emerge. Therapists aim to treat individual behaviours and attitudes by either challenge emotions and thoughts or by uncovering their root in childhood experienced. As such they are addressed as symptoms of a disorder rather than as a valid response to a harsh social climate. Another approach would be to look at outside influences including the media (Markula 2001). While this awareness can be integrated into therapy and counselling, other strategies for treatment are very different.One such strategy is the treatment programmes for eating disorders and poor body image. Such programmes typically target individuals at a life-stage particularly prone to such problems, for example female undergraduates. They also typically involve groups of clients, rather than the therapeutic focus upon individuals. Another feature is the focus upon teaching media awareness. Typical programmes take a multi-faceted approach, for example combining strategies to reduce the internalisation of the thin ideal with promotion of body strategy through life skills and a media literacy promotion. Stress management skills can help improve communication and decision making and other activities promote self-esteem.Gail Gail, McVey, Kirsh, Maker,Walker, Mullane, Laliberte, Ellis-Claypool, Vorderbrugge, Burnett, Cheung and Banks (2010), for example, tested such a programme amongst university students alongside a university health-promotion team.
Stice and Shaw (2004) have looked in detail at the effectiveness of such programmes. They trace the development from the early ‘didactic psychoeducational material about eating disorders’. These early attempts were based on an assumption that informing participants of the adverse effects of eating disorders would act as a deterrent. The next wave of programmes retained the didactic content and universal focus but also included teaching tools for resisting social and cultural pressures towards the thin ideal, due to acknowledging that such pressures play a key part in developing eating pathology. The ‘third generation’ of interventions have targeted programmes at high-risk individuals and have a high degree of interactivity, as it has been suggested that such targeting renders programmes more effective. Prevention programmes are thought to be most effective when delivered during the period of development in which condition emerges.
Interactive programmes have been shown to be more effective than didactic ones, perhaps because the format allows participants to engage more fully with the content of the programme. Interactive exercises also allow participants to apply taught skills. They are also most effective when they are spread out over a period of time, for example at least 3 hour-long sessions once per week. The break between sessions allows participants to reflect upon the content, try new skills and seek advice in subsequent session. Content is also important – where the focus is upon established risk factors, there is more success than where non-established risk factors are targeted. In particular, programmes that aim to increase resistance to social pressures, increase self-esteem and body satisfaction produce better effects than those which do not address such factors. Successful programmes should also improve eating pathology (Stice and Shaw, 2004)
One effective form of prevention programme is the ‘dissonance-based’ prevention programme. These are based around the notion of ‘cognitive dissonance prevention’. Influenced by Stice’s dual pathway model, programmes try to reduce the extent to which the thin ideal is internalised by inducing cognitive dissonance, ‘an uncomfortable psychological state that occurs when beliefs and actions are inconsistent’.Typical dissonance-based prevention programmes include a series of verbal, written and behavioural exercises that challenge the ideal of thinness, for example discussing problems with the ideal and negative consequences of trying to attain the ideal. When individuals have to analyse and defend a belief, they are more open to changing that belief after the exercise is completed. Dissonance prevention has been tested and appears to reduce eating disorder risk factors significantly, and do so over a period of time extending beyond the programme period. Perez, Becker and Ramirez suggest that not only are such programmes effective, but also that they can be disseminated in the wider community successfully (Perez et al, 2010).
One advantage of these programmes is that they seem to be able to prevent the development of severer body issue conditions by targeting individuals who are at risk and doing so successfully. The cost of implementing them is therefore likely to be lower than intense therapy once a condition is established, and the cost to the sufferer is also less, as the disorder does not become so developed as to negatively effect life conditions. In addition, Jarry and Berardi (2004) suggest that there is a need to look at the effectiveness of other therapeutic treatments, for example reflective therapy, exercise therapy, weight control, and the use of VR environment.
5. Discussion of different therapeutic approaches to body image disorders
There are advantages to each treatment type. CBT in particular has been shown to be effective for body image problems when administered individually, in groups and self-administered (Lemberg and Cohen, 1999). The combination of CT with behavioural techniques, e.g. reinforcement and imagery is a particularly powerful and efficacious combination (Dworkin and Kerr, 1987). Not only is CBT able to reduce negative body issues, there are also other positive effects documented including improved social functioning and increased self-esteem (Lemberg and Cohen 1999). CBT treatments seem to represent an advance on CT treatments as they incorporate behavioural modification into programmes. Veale (2004) has presented a coherent model of BDD rooted in cognitive behavioural principles. In addition, CBT and CT fit well into the current health climate. They are often preferred as therapy options by the NHS as they offer a low cost alternative, that is relatively quick to administer. They seem to be based on sound scientific principles and are more easily tested and verified in research studies. They deliver a wide-range of testable outcomes. Consequently, they are accepted as more effective solutions to a range of problems (Wilson and Syme 2006). However, there are also arguments for the person-centred approach. Some clients are unwilling to take part in CBT or CT, finding it mechanistic and formulaic. Person-centred therapies take the background of the client into account, and it is possible that by uncovering deep seated issues with the therapist, longer lasting solutions can be found. Typical studies of CT and CBT seem to show success both at the time of treatment and for a period after treatment, however it is unclear how long this effects last. More research is needed to look at whether person-centred therapies offer a longer-term solution to body image issues. Moreover, person-centred therapies seem to acknowledge the importance of the body, and offer a way to integrate the body into therapy. While CT and CBT both deal with issues about the way clients see their body, they do so in a highly verbalised, non physical way, which could be argued to be a disadvantage.While RT, a form of person-based therapy, was shown by Dworkin and Kerr (1987) to be less effective than CT and CBT, it is still effective as a therapy, and more research would determine whether particular client groups are more able to benefit from this longer-term treatment.Moreover, Dworkin and Kerr (1987) suggest that the reason RT is less effective is that it is a short-term form of person-centred therapy. It is possible that longer-term options would be more effective.
Treatment programmes, for example dissonance based programmes, also offer a third alternative. These programmes have a number of advantages. First, they are primarily offered to groups of clients rather than individuals, and as such are a lower cost option. Secondly, they move the focus of treatment away from the situation of the individual to the way that individual is influenced by factors in society. They provide a way to acknowledge the central importance of social factors, particularly the media, in creating distorted body images, and teach clients to resist such pressure.Counsellors carrying out both CBT and person-centred therapies may not be aware of the extent to which they maintain the status-quo. They need to examine their own attitudes to body image and weight, to avoid an assumption that the client is in the wrong. They need to take into account wider research for example into dangers of dieting and also issues such as the way society highlights an ideal of perfect looks (Dworkin and Kerr 1987). By starting from the social and cultural perspective, treatment programmes render this need unnecessary.
Given that all three types of treatment for BDD and other body image problems have benefits and drawbacks, and given that the bulk of research looks at individual treatment types, it would be interesting to compare the three different treatments in one study to determine which is most effective, or whether each is most effective with a particular demographic or personality type. A further study of this nature would allow treatment programmes to be tailored to the individual and therefore, it would be hoped, be more successful.
Another way to inform the development of therapies for BDD might be to take on board a suggestion by Wood-Barcalow et al (2010). They point out that researchers have so far concentrated upon the negative features of body image in order to transform them into positive images. They have tending in doing so to conceptualise the positive aspects of body image as simply the absence of negative factors. However, this is an incomplete strategy, because ‘the absence of pathology does not always signal flourishing’ (Wood-Barcalow et al 2010, p. 106). There has been little research done on the nature of a positive body image, but that which has been done indicates that positive body image differs qualitatively from both negative and normative images. One study in 2004 (Williams, Cash and Santos) suggested that people with a positive image have lower internalisation of media influence, greater self-esteem, better social support and higher physical activity. Other characteristics include looking favourably at the body, accepting the body, and respecting its needs ( Wood-Barclaow et al, 2010).
In addition, the differences between men and women in terms of body dissatisfaction have been pointed out above. It has now been recognised that men, like women, can suffer from poor body image, but they seem to have a different experience of their body with an awareness of muscle and body fat particularly. Gay men also have their own preoccupations. With this in mind, a useful further study might look at the ways in which therapy of any time might be adapted to these differences in perspective between the genders and sexualities. For example, intervention programmes targeted at men might look at how media images of men are changing with a growth in advertising of men’s beauty products, an increase in magazines targeted at men, and similar factors. CBT and CT approaches might utilise questions which take into account the differences between men and women in regard to what they might consider to be unattractive about their body. In addition, and if further research indicates the need, it might be useful to look at ways ethnicity, race and social class impact upon body dysmorphia. For example, if women of a higher social class are more likely to suffer from BDD, targeted intervention programmes would need to take this into account.
6. Primary research methodology
The findings from the secondary data study can be compared with the research collected from the primary study.
The primary research study collected quantitative data amongst people who had undergone one of three types of therapy treatment (taking part in a prevention programme, person-centred therapy or related treatment type, or CBT / CT variations). The aim was to compare respondents’ ratings of their treatment type to see if there is significant differences between each of the three broad types of treatment for a number of factors including effectiveness of treatment in raising self-esteem and effectiveness of treatment in improving body image. While qualitative data, text-based, more detailed information gathered in-depth from fewer respondents gives a deeper picture of an issue (Gray 2009), the quantitative data was selected in this instance as it was felt that results could be tested for significance statistically.
A questionnaire was designed to collect information from respondents. A number of demographic questions were included, including age, gender and socio-economic background, in order to look at the impact such variables had on responses to therapy. Above the differences between the sexes for body image problems was discussed, and given that men and women have different concerns about their body it is possible that they react differently to different therapy types, for example. In addition, a number of questions to collect data about therapy type were included, for example asking the length of time since therapy, and duration of the therapy, as well as the type of therapy carried out. The majority of questions asked respondents to rate their satisfaction with different aspects of their therapy on a 1 to 5 Likert scale, where 1 means ‘not at all’ and 5 ‘completely satisfied’.The questionnaire started with a brief introduction to the study stating purpose of the data collection and emphasising confidentiality.
Babbie (2010) distinguishes between two main types of sampling (the process whereby the people interviewed are selected). Probability sampling draws individuals randomly from the entire population of interest. In this case, it would be everyone in the UK who had undergone therapy for poor self-esteem and issues with the body. This is clearly not appropriate for this survey, as there is no one list available containing all this population. The type of sampling used was non-probability. Confidentially posed a major issue for data collection. It was not possible to obtain lists of individuals who had undergone therapy from health services, Primary Healthcare Trusts or similar as authorities would not release such data. It was necessary to find individuals who had had therapy for body issues and/or self esteem in other ways. It was decided to approach users of online internet forums dealing with poor body image and related conditions, and based in the UK.One advantage would be that forum users would be more likely to have had therapy, compared with the general population, however one disadvantage was that it might introduce unconscious bias into the results. For example, people who use internet forums might have a particular personality type which is also associated with a particularly strong or poor response to therapy. This bias would skew the results of the study, as the only people interviewed would tend towards a positive or negative response.
Three forums for people with BDD and associated problems were approached. In all cases, the forum moderator was contacted to explain brief details about the study, and ask permission to post on the forums requesting volunteers to take part by completing the questionnaire. It was stressed that all results were completely confidential and would be used in statistical form only, with no personal details attached. Of the three forums, only 2 responded to the initial email, and only one gave permission to post the request. One further problem became clear when the request for volunteers was posted. Although many users responded well, saying they were interested in the study and supported its value, very few users were willing to give up their anonymity by passing on their email address for the questionnaire to be forwarded to them.In total, 19 respondents were recruited, and of these only 8 returned completed questionnaires.It is widely held that a sample size of at least 30 is necessary to allow statistical tests to be performed on the data, and recommended that the minimum base is much higher (Cohen, Manion, Morrison and Morrison 2007). Consequently, the data collected for the study was not analysed statistically, although it was decided to look at the results in general terms.
7. Primary research results and discussion
All 8 respondents answered all the questions. All had completed therapy, and all had finished within the last 5 years. All but 1 respondents were women, and ages were distributed as follows:
65 or over1
Table 1: Age distribution
It is perhaps unfortunate that only 1 respondent was a man, as the results cannot throw light on the discussion above indicating differences between the genders in terms of body issues.
4 respondents had had CBT, with 1 having CT. One had person-centred therapy, and two counselling. CT and CBT treatments had been offered by the NHS, with counselling and person-centred therapies funded privately. Those with the NHS were not offered other treatment options. There was a distinction between therapies of the CT/CBT type and counselling and person-centred therapy, with the former therapies taking place over much shorter sessions, typically between 2 to 5 sessions. The person who had person-centred therapy had 10-50 sessions, and the counselling respondents both stated therapy lasted 6-10 sessions.Perhaps unsurprisingly, given the nature of the internet forums from which they were recruited, all respondents reported issues with poor body image. Table 2 reports the results of Q7 in more detail.
Poor body image8
Low self esteem6
Eating disorder2
Other problem4
Table 2: Areas tackled by therapy
The high number of respondents who also reported low self esteem in addition to poor body image confirms the discussion above, where the link between the two conditions was pointed out.Other problems reported included depression and anxiety.
The division of respondents between CT/CBT on the one hand and counselling/person centred therapy on the other seems to be correlated with a difference in responses to the satisfaction questions at Q8. While the mean satisfaction amongst the 5 people undergoing therapy of the CT/CBT type was 4.2, the mean satisfaction for those undergoing counselling/person centred therapy was 3.8. This is still fairly high, and close to the score for CT/CBT, but also somewhat lower. This adds a little weight to the view, discussed above, that CT/CBT is more effective. This is underlined by the result of Q8C, with the mean score for satisfaction for the effectiveness of CT/CBT respondents is 4.1, and the mean for person centred therapy / counselling is 3.9. CT/CBT also scored slightly higher for giving tools to deal with difficult situations outside of therapy (4.0 as opposed to 3.7). The results for 8B 8D and 8E suggest, however, that person-centred therapy / counselling are more effective in other areas. They score higher on the mean than do CT/CBT, as follows:
Mean score CT/CBTMean score counselling / person-centred therapy
Q8B: Satisfaction with relationship with therapist3.94.4
Q8D: Satisfaction with extent to which therapy looked at role played by social and cultural factors3.43.9
Q8E.Satisfaction with extent to which therapy looked at role played by personal history and background3.74.3
Table 3: Mean Scores, Q8B, D and E
These results suggest that there are some aspects for which person-centred therapy approaches are most successful. However, while these might lead to greater client involvement and satisfaction for these areas, the effectiveness of CT and CBT was still rated higher. Unfortunately there were no results at all for prevention programmes, so it was not possible to test responses to these forms of treatment.
Due to the low response rate, the results from the questionnaire could not be assessed for statistical significance. It was therefore decided to extend the literature review element of the dissertation to make up for this shortfall. However, the data that was collected does not contradict the findings from the literature review, and in some areas reinforces it. The link between poor body image and other issues including eating disorders, weight and self-esteem is confirmed by the conditions reported by respondents.That CBT and CT are preferred by the NHS seems to be confirmed by the results of the study, as only privately funded respondents had other therapy options.
Unfortunately the lack of male respondents meant that the theories about gender-based differences between body image issues could not be tested. This is an area which could be investigated in further primary studies. In addition, further studies could look at the impact of the media in more detail, perhaps tracing media exposure amongst people with eating disorder, the extent to which people with BDD and poor body image compare themselves with media ideals, and differences between men and women’s ‘reading’ of the media.
8. Conclusion
This study has aimed to look at the increasing problem of poor body image. Originally thought to effect women rather than men, it is increasingly found in men also. It has a number of negative consequences for individuals, so there is a need to find an effective treatment. The first part of the study examined how poor body image and BDD comes about, and its relation to self-esteem and other weight issues. There are a number of theories which attempt to explain the issue, and it seems clear that media influence plays a large part in making individuals uncomfortable with their body. While there is a clear difference between men and women regarding the extent to which each gender displays body image issues and regarding the content of poor body image, other demographic factors including race, ethnicity and socio-economic group play a part. The second section of the study looks at treatments for poor body image and BDD. Treatment options divide roughly into three categories, cognitive or cognitive-behavioural approaches, person-centred therapies and intervention programmes. Each type of treatment has positives and negatives; CBT and CT seem effective although may not be suitable for all clients, person-centred therapies can also be effective and allow a deeper perspective, while prevention programmes address the social and cultural context. Person-centred therapies have been somewhat overlooked of late, despite their potential for going deeper into issues and incorporating the body more fully into their methodologies. A small primary study looked at experiences of therapy for people with BDD and body image problems, and seemed to broadly confirm the results of the secondary data discussed, however problems with data collection meant the results were not statistically significant.
This study has clear limitations. The primary research was very limited, although areas were suggested for further study. In addition, there exist other treatment options aside from the ones discussed which might offer useful solutions. Finally, space restraints mean that only limited discussion of some relevant areas has been possible.
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Appendix 1: Questionnaire
Information about Study
Thank you for agreeing to help with this research study. I am a student working on a dissertation about the use of counselling for body image and related issues. The results of the study will be used to inform others and may help with future research projects.
Any information you give on this questionnaire is completely confidential. Your name will
not be associated with any of the information, nor will it be possible to identify you from the information collected. Data collected will be used only for the purposes of this study, and will be destroyed after the study is over.
Please answer all the following questions and return by email to the address given.Indicate your answer by an ‘X’ or tick. Where more than one answer is possible, the question instructions will make this clear. If you are not sure how to answer any questions, please email me for further help.
Q1. How long is it since you received your last therapy session(s)(if you have had more than one series of therapy, please think about your most recent treatments)
1. Over 10 years ago
2. between 5 and 10 years ago
3. 2-5 years ago
4. 1-2 years ago
5. Under 1 year ago
6. I am still undergoing therapy
Q2. How long was your therapy?
1. 1 session only
2. 2-5 sessions
3. 6-10 sesssions
4. 10-50 sessions
5. Over 50 sessions
6. I am still undergoing therapy
Q3. Was your therapy privately funded, or obtained through the NHS?
1. Privately funded
2. NHS
Q4. What type of therapy did you have?
1. Cognitive Therapy
2. Cognitive Behavioural Therapy
3. Counselling (unspecified)
4. Person Centred Therapy (Sometimes known as client centred therapy)
5 Education programme (typically in groups, aimed at raising awareness of body image issues)
6. Other therapy type (PLEASE WRITE IN)
Q5. Were you offered different treatment options?
1. Yes
2. No
Q6. Did you have a preference for type of treatment?
1. Yes
2. No
Q7. What areas did your therapy tackle MULTIPLE ANSWERS POSSIBLE
1. Poor body image
2. Low self esteem
3. Body Dysmorphic Disorder
4. Eating disorder
5. Other area (PLEASE WRITE IN)
Q8. On a scale of 1 to 5, where 1 means ‘not at all satisfied’, and 5 means ‘completely satisfied’, how satisfied were you with the following aspects of your therapy?
Q8A. Length of treatment:
1 – not at all satisfied 2 3 4 5 – completely satisfied
Q8B. Relationship with therapist:
1 – not at all satisfied 2 3 4 5 – completely satisfied
Q8C. Effectiveness of treatment:
1 – not at all satisfied 2 3 4 5 – completely satisfied
Q8D. Looking at social and cultural factors and the role they played in your condition:
1 – not at all satisfied 2 3 4 5 – completely satisfied
Q8E. Looking at your personal history and background and the role they played in the problem
1 – not at all satisfied 2 3 4 5 – completely satisfied
Q8F. Giving you a set of tools you can use to deal with difficult situations outside therapy:
1 – not at all satisfied 2 3 4 5 – completely satisfied
Q8G. Satisfaction with therapy overall
1 – not at all satisfied 2 3 4 5 – completely satisfied
Finally, there are just a few questions to help us compare your answers with those of others
Q9. Are you male or female?
1. Male
2. Female
Q10. Which of the following age groups do you fall into?
1. 16-24
2. 25-34
3. 35-44
4. 45-54
5. 55-64
6. 65 and over
What is your occupation?
1. Student
2. Working full-time
3. Working part-time
4. Unemployed seeking work
5. Not working through ill-health
6. Retired
7. Looking after family
8. Carer
9. Not working for other reason
Thank you for your help!

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