This chapter is designed to help you define your problem and monitor the severity of your body image problems and their impact on your life. Identifying and rating the current severity of your body image problem at the outset will give you a reference point against which you can measure your progress. You may find it helpful to make additional copies of these questionnaires to help you to measure your progress. They are designed to help you define the nature of the problem and its effect on your life. Some of them can be completed weekly to determine whether you are making progress or not.
Please study this example before completing Questionnaire 5.1. In a moment, we shall ask you to describe the feature(s) of your body that you dislike or would like to improve. If you want to improve more than one feature, please list all the features. The example is based on a woman whose main worry was her nose and who was concerned to a lesser extent by her skin and bottom. She is currently seeking cosmetic surgery for her nose.
Please describe the feature(s) of your body that you dislike or would like to improve and tick the box if you are seeking a cosmetic or dermatological procedure for the feature either now or in the future.
Please tick the appropriate box.
We will then ask you to draw a pie chart and estimate the percentage of concern allocated to each feature. The person above completed her pie chart like this.
QUESTIONNAIRE 5.1: IDENTIFYING THE PROBLEM FEATURE
Describe the feature(s) of your body that you dislike or would like to improve.
Now draw a pie chart and estimate the percentage of concern allocated to each feature. Please ensure that your percentages add up to 100 per cent!
From now on, we will refer to these concerns as your ‘feature(s)’.
The next set of questions relates to how noticeable you think your feature is. You may find it helpful to discuss this aspect of the problem with a trusted friend or therapist. You could ask this person to rate the features using the same scale without him or her knowing how you rated yourself.
QUESTIONNAIRE 5.2: RATING THE NOTICEABILITY OF YOUR PROBLEM FEATURE
1. How noticeable do you feel your feature is to other people (if you do not camouflage yourself, e.g. with clothes, padding and/or makeup, and the feature has not been pointed out to them)?
a. Please specify the first feature you are rating
b. Please specify the second feature you are rating (if applicable)
c. Please specify the third feature you are rating (if applicable)
d. Please specify the fourth feature you are rating (if applicable)
2. How do you feel your feature compares to the same feature possessed by other people of the same age, sex, and ethnic group?
a. Please specify the first feature you are rating
b. Please specify the second feature you are rating (if applicable)
c. Please specify the third feature you are rating (if applicable)
d. Please specify the fourth feature you are rating (if applicable)
The following questionnaire has been designed for you to use weekly or fortnightly to monitor your progress in overcoming your body image problems.
QUESTIONNAIRE 5.3: RATING THE SEVERITY OF YOUR BODY IMAGE SYMPTOMS
Answer the following questions by circling a number that best describes the past week.
1. Frequency – How much of your time on an average day has been occupied by worries about your appearance and related behaviors (e.g. checking, comparing) over the past week?
2. Distress – How much distress have your worries about your appearance caused you? Or how much distress have you felt when confronted with a situation you wanted to avoid?
3. Handicap – How much have worries about your appearance and related behaviors (e.g. checking, avoiding) interfered with friendships, relationships, family life or your ability to perform at work or study?
4. Avoidance – How much have you avoided situations or activities or thoughts that are related to your worries about your appearance?
The next questionnaire focuses on the extent to which you avoid situations, people, or activities because of your preoccupation with your appearance. You can use a number of the items you avoid in order to test out your fears in Chapter 7 (Taking action).
QUESTIONNAIRE 5.4: AVOIDING SITUATIONS
What do you avoid because of the way you feel about your feature(s)? Please read the situations below and in the second column rate the degree of anxiety that you anticipate in each of the situations on a scale between 0 and 100 where ‘0’ is no anxiety at all and ‘100’ is total panic. In the third column, rate the degree to which you currently avoid each of these situations on the following scale:
Please add other situations or activities that you avoid at the end of the list.
The following questionnaire focuses upon the things you may be doing excessively or more precisely because of your preoccupation with your appearance. You can use this checklist to help identify the rituals and safety behaviors that you are going to target for change in Chapter 7.
QUESTIONNAIRE 5.5: PERFORMING RITUALS AND SAFETY BEHAVIORS
Please read the list of actions below that you might perform because of the way you feel about your feature(s). In the second column, rate the frequency with which you use each of the behaviors on the following scale:
The next step is to rate the impact of your problems on your everyday life. We have provided a standard questionnaire that serves this purpose. It can be repeated at regular intervals (for example fortnightly) to monitor your progress.
QUESTIONNAIRE 5.6: RATING THE IMPACT ON YOUR LIFE
1. If you have a long-term partner, please answer a. If you do not have a partner, please answer b.
a. To what extent does your preoccupation with your feature(s) affect your relationship with an existing partner (e.g. affectionate feelings, number of arguments, enjoying activities together)?
b. If you do not have a long-term partner, to what extent does your preoccupation with your feature(s) currently affect you and your potential partner when you are dating or developing a relationship?
2. To what extent does your preoccupation with your feature(s) currently have an effect on a sexual relationship (e.g. enjoyment of sex, frequency of sexual activity)?
Tick box, if you have no sexual relationship for reasons other than avoiding sex because of your preoccupation with your feature(s). 
3. To what extent does your preoccupation with your feature(s) currently interfere with your ability to work or study, or your role as a homemaker? (Please rate this even if you are not working or studying: we are interested in your ability to work or study.)
How many working days have you lost in the past year because of your preoccupation with your feature(s)?
4. To what extent does your preoccupation with feature(s) currently interfere with your social life with other people (e.g. parties, pubs, clubs, outings, visits, home entertainment)?
5. To what extent does your preoccupation with your feature(s) currently interfere with your private leisure activities done alone, (e.g. reading; gardening; collecting; walking alone, etc.)?
6. To what extent does your preoccupation with your feature(s) currently interfere with your home management (e.g. cleaning, tidying, shopping, cooking, looking after your home or children, paying bills, etc)?
7. To what extent does your preoccupation with your feature also cause you difficulty in its functioning? (For example, if you dislike the shape of your jaw, it might cause difficulty with a poor bite with your teeth; or if your nose is crooked, it might cause difficulty breathing.)
Rating the severity of your depressive symptoms at the start and at regular intervals will help you to monitor your progress and assess whether what you are doing is effective or not. Even if you decide not to use any self-help techniques or decide to take medication, it is still important to monitor your progress so you should still do these exercises. You can then report back to the doctor and decide whether to try an alternative approach. You can also use the Hospital and Anxiety Depression Scale in Appendix 2 (page 385) to monitor depression and anxiety.
Building a list of your problems helps in a number of ways. First it helps you to break down your body image problem into specific areas to tackle. It also gives you a chance to rate these problems overall now, so that you can re-rate them to help measure your progress. This is Catherine’s list of problems.
SAMPLE PROBLEM LIST
Severity rating: 0–10 (10 being most severe)
1. Feeling very preoccupied and ashamed about my skin, leading me to worry about it most of the day, and to spend approximately 4 hours applying make-up if I have to leave the house.
Rating: 10
2. Feeling depressed, leading me to spend as much time as I can at home and not keeping on top of my bills and domestic chores.
Rating: 8
3. Frequently checking in mirror and comparing my skin to people in the media, leading me to feel envious towards people with far better skin than me.
Rating: 7
Now make your own list of problems and rate the severity of each one.
Next, you need to write a description of your goals relating to the problems that you have described and the values you have identified. Start with short-term goals, which are easier to tackle, and set yourself a realistic timetable by which you intend to move onto the next set of goals. Here is Catherine’s list of goals.
Try to make your own goals as specific, observable and realistic as possible.
Some individuals with body image problems have forgotten what is normal or healthy. To help generate ideas for healthy alternative behaviors, consider the following questions:
• What did you do before you had a body image problem?
• If you had a twin, who was the same as you in every respect but without a body image problem, what would they do?
• What would a healthy role model of yours do?
You will need to ask yourself these questions for goals in the short, medium and long term. You can then monitor your progress towards your goals on a scale of zero to 10, where zero is no progress at all towards the goal and 10 means the goal has been achieved and sustained. Your goals should relate to your valued directions in life and tackle what you have been avoiding. The next section will help you identity your valued directions.
Progress rating: 0–10 (10 being most severe)
Short term
1._______________________________________
2._______________________________________
3._______________________________________
Medium term
1._______________________________________
2._______________________________________
3._______________________________________
Long term
1._______________________________________
2._______________________________________
3._______________________________________
Many body image problems are the result of becoming overly focused on your own appearance; other people’s appearance; appearance in the media; or the role of appearance in our culture. The aim of the next exercise is to gain an understanding of your values or what you want your life to stand for. This will enable you to engage in a life that has a better balance and is less dominated by appearance. Once you know what your valued directions are, you can start acting towards them.
We have adapted the ‘Valued Living Questionnaire’ from Acceptance and Commitment Therapy (Guilford Publications, 2004) by Steven Hayes, Kirk Strosahl and Kelly Wilson. There are various prompts for each area to help you write down a brief statement. You don’t have to fill in every area; just leave an area blank if you think it is inappropriate for you. After writing down your statements, you may want to clarify them with a friend or therapist. Be careful not to write down values that you think you should have just because others will approve of them. Only write down what you know to be true for yourself. It is probably a valued direction if you acted on it consistently before you experienced your body image problem. If you have had a body image problem for many years, you may struggle with this exercise, but you should persevere because it is very important.
Note that values are not goals – they are more like compass points, and they need to be lived out by committed action. Goals are part of this process. With values, you never reach your destination because there is always something more you can do to work towards them. If your valued direction in life is to be a good parent, then your first goal might be to spend a few hours just hanging out with your son or daughter and playing with him or her. Other goals might be to get your son or daughter through school or college. It might take some time to discover all of your values, so here are some prompts to help you:
• Imagine what aspects of life you would be engaging in if you were not feeling shamed or preoccupied with your appearance at this moment. We understand that you might feel upset at the things you seem to have lost but this exercise will help you chart your course on the journey you wish to take.
• Brainstorm all the activities/interests you can think of, and consider which might be close to your valued directions.
• Remind yourself of what you used to value or aspire to when you were younger. Have any of these values simply been ‘squashed’ by your body image problem?
• Consider whether a fear of what other people will think, or a fear of failing, might be holding you back from pursuing your valued directions.
• Consider a role model or hero and the values he or she holds.
• Have a chat with a trusted friend (or therapist) who knows you well and see what he or she would guess your values to be.
• Be prepared to experiment and ‘try on for size’ living consistently with a given valued direction to see how it ‘fits’.
Now try to define your own valued directions in life.
