This chapter will help you do things in life that are important to you. It will also enable you to enter situations that you have been avoiding because of your anxiety that something bad might happen. This might include public and social situations that you have been anxious about. Some people may be completely housebound. Others may avoid going to family or social gatherings; going to school or university; going to work; going to a doctor to be examined; dating or being intimate; being outdoors or being in bright lighting; having a haircut; shopping for clothes; using a public changing room or going swimming. Sometimes avoidance can include trying to suppress distressing pictures in your mind. Other people might avoid looking at a bodily feature in mirrors (as this might trigger unpleasant thoughts or memories) or because it takes too long to finish a ritual such as checking in the mirror.
We strongly recommend that you work through Chapter 4 (What keeps a body image problem going?) and Chapter 5 (Setting yourself on the right course) before working through this chapter. The earlier chapters will help you to identify the behaviors that are maintaining your anxiety, shame and preoccupation. You can then use those behaviors as targets for change, applying the principles outlined in this chapter.
Behavioral experiments involve making predictions to see whether something is true or not. For instance, you might be predicting that, if you enter a social situation and look into people’s eyes and smile, then they will humiliate and tease you.
Such experiments can be incorporated into the principle of graded exposure. With a body image problem, ‘exposure’ means facing the situations and activities you fear and have been avoiding. This is best done gradually and step by step (‘graded’).
Exposure also needs to be done without using any safetyseeking behaviors. In body image problems these include many different ways of escaping and trying to cope – for example, keeping your head down, using excessive make-up, wearing bulky clothes, keeping your hand up to your face, checking in a mirror or brooding in your head. However, safety behaviors can have a number of unintended consequences. They may prevent you from finding out that what you are predicting is not true. They also tend to make you more self-conscious, more preoccupied with your appearance and more distressed, as you also have to monitor whether your safety behavior is working. Lastly, they may make you appear cold and unfriendly in social situations.
Sometimes people fear that too much anxiety can be harmful. It’s true that exposure is best done in a graded manner, with a series of steps (called a ‘hierarchy’), so that you face your less intimidating fears first and confront the most difficult last. But grading your exposure is just a means to an end, and the sooner you can reach the top of your exposure hierarchy the better. Remember that anxiety, though uncomfortable, will not damage you. In dealing with a body image problem, you have to turn your thinking ‘upside down’: the more you try to avoid anxiety in the short term, the more of it you’re likely to get in the long term.
With any exposure program, it really is important to stick with the session until your anxiety has reduced, otherwise you may end up reinforcing the idea that anxiety is harmful. On average, exposure might take up to an hour, but sometimes it doesn’t take that long. If the anxiety is persisting for longer than this, then you may be performing a subtle safety behavior or not fully engaging in the exposure. Think really carefully about whether you are doing anything to temporarily reduce or control your fear within the situation. If you think that something you are doing might just be a way of staving off your fear, try your exposure without it. If you still find that your anxiety does not subside even when you’ve ‘stuck with it’ for at least a couple of hours then it might be best to seek professional help to make progress.
When you experience fear without a safety behavior, the anxiety gradually fades and the urge to use your safety behavior will also fade. When you repeat the exposure (preferably as soon after the first exposure as possible), the anxiety will decrease further, and so on each time you do the exposure. Exposure is best done in a way that allows you to test out your predictions – for example, you might want to test a prediction that your anxiety will go on for ever and ever. This is called a behavioral experiment to see whether your predictions come true, and we will discuss this in more detail on page 186.
One way of remembering what exposure and response prevention means is the ‘FEAR’ acronym:
Face
Everything
And
Recover.
A ‘hierarchy’ is a ranked list of your triggers – the things you tend to fear or avoid because they activate your worries. These may be activities, situations, people, words or ideas – the range will depend on your particular worry. A checklist of situations or activities that you might be avoiding can be found in Chapter 5. You can use this list as a basis for developing a hierarchy. We have included a table for you to complete on page 178.
The nature of an exposure task will depend upon your problem and whether you are someone who is avoiding lots of situations or activities (where it’s easier to come up with suitable exposure) or if you are a person who has lots of safety-seeking behaviors (such as checking) where you may need to be a little more creative. We discuss this on page 182. Always plan your exposure in a series of steps, within a particular timeframe, that lead up to your final goals. You then attempt to carry out the steps in sequence, like a set of instructions.
You can measure the amount of distress caused by each trigger using a rating scale of ‘SUDs’. SUDs stands for Standard Units of Distress, in which 0 is no distress at all and 100 is overwhelming distress. In the second column of the table, you can give each trigger a rating according to how much distress you would expect to feel if you experienced that trigger and didn’t perform a safety-seeking behavior. For example, you may rate being intimate as causing 90 SUDs out of 100. Another individual might rate going swimming as 99 SUDs out of 100, and so on.
Here is a sample hierarchy table.
Decide which targets you will take from your hierarchy and deliberately face your fear. Choose targets that are challenging but not overwhelming. Some of the situations will need to be broken down into smaller steps – thus for someone who is housebound, the first step may be to open the curtains or go into the garden. However, don’t spend too much time on the easier targets, if they are not sufficiently challenging. You may need to ask a friend to come up with suitable tasks that are more anxiety-provoking. Always ensure that your exposure is challenging and potent enough. Don’t spend time on targets that are mild and only increase anxiety slightly.
One of your predictions might be how severe the distress is going to be, or how long it might go on for at the end of exposure. Or it may be helpful to test whether the result of the exposure bests fits ‘Theory A’ or ‘Theory B’ (see Chapter 4, page 85). Theory A (the one that you are following) is that you have an appearance problem, which will lead to you being alone and rejected. Theory B is that you have a problem with being preoccupied and worried by your appearance. This predicts that by following Theory A you are increasing your preoccupation and distress about your appearance. When you act as if Theory B is right, then your preoccupation and distress about your appearance will decrease. Other predictions for exposure tasks might include that you will be humiliated or that people will recoil in horror, and these are all testable.
Always ensure that the predictions you make are based on objective information – for example, what you think someone will say or how they will behave towards you. Thus it won’t be helpful if your prediction is that people will think that you are ugly, as you can’t read their minds. It is more helpful to observe people’s behavior and go by what they say and do. In this situation, you need to be especially careful not to use any safety-seeking behaviors. For example if you keep your head down, give poor eye contact and say very little, then you are less likely to be aware of how people are acting towards you, and they are more likely to assume that you are not interested in them and to avoid you. You may, in turn, interpret this as evidence that you are ugly. You should therefore try to practise giving appropriate eye contact and smiling. Make a conscious effort to stand upright and look straight ahead. If you smile, strangers are more likely to respond positively. When you have your head down, hurrying past, then you are more likely to be self-focused and get information about your surroundings from what your mind is telling you.
You should also maintain good eye contact. This signals that you have an interest in others and that you are listening, and tells you whose turn it is to speak in a conversation. Trying to avoid the gaze of others will always be viewed negatively. You are signalling that you do not want to engage in any kind of contact with the other person.
Try to engage in conversation whenever you can. It is harder to do so if you are focused on how you look and how people are responding to you, rather than listening and being involved in what people are saying. Anxiety tends to heighten the temptation to ‘self-monitor’ so it is harder to focus on what is going on around you. Asking people about themselves, what they do for a living, whether their children go to the local school and similar questions are all ways of initiating a conversation. Similarly, topical subjects are things that other people will have a view about. The result of the latest big football match, the latest soap, the price of petrol, or news headlines are all good subjects to start conversations about.
If you are doing exposure in front of a mirror that you have previously avoided, then do not make predictions about how ugly or unattractive you think you are. Rating yourself as ‘ugly’ or ‘unattractive’ is an evaluation that others may or not agree with. We know that such ratings are usually based on ‘ghosts from the past’ and that various emotions will bias your rating. Stick to objective information, like the colour of your eyes and your height and weight. We will discuss this further in the section on mirrors (see page 188).
Keep a record of your predictions and whether they occurred or not on your record sheet (see page 184).
Face your fear long enough for your anxiety to subside of its own accord, ideally by at least half. For example, when you enter a swimming pool, don’t rush into the water so that your body is under the water immediately. Sit beside the pool for a while or stroll up and down the side and smile at others before getting in to the water. Distress will decrease only when you give it a long enough time and learn that bad things won’t happen when you face your fears.
Repeat the exposure as often as possible – several times a day – until the anxiety has subsided between the sessions. Remember, you can never do too much exposure. Always think about how you can incorporate exposure into your everyday life so that it makes it easier to carry it out on a daily basis.
Ensure exposure is done with a constant stimulus, rather than escaping or using a safety behavior and then returning to the situation.
Do the exposure without using distraction, drugs, alcohol or a safety-seeking behavior such as saying a phrase to yourself or obtaining reassurance. It’s important to ‘fully engage’ with the situation, allow the intrusive thoughts and images to enter your mind, and for your anxiety to increase and fall naturally. Re-read the section on attention and task-concentration training in Chapter 6 (page 138) and make sure that when you do exposure you are focused on the world around you and fully aware of what you can see, hear and smell.
If you are not sure whether what you are doing is a safety-seeking behavior, ask yourself what the aim is before you carry it out. If the aim is to reduce what you think is potentially harmful to you, or the degree to which you would be able to control the harm, then it is a safety-seeking behavior.
If you can’t resist doing a safety behavior, you must redo the exposure so that you always finish with exposure. For example, if you put your hand up to your face to hide your skin and keep your head down to avoid any eye contact, then you need to re-expose yourself. This means taking your hand down and smiling at the person.
Just ‘notice’ or ‘be aware’ of any unpleasant images or thoughts that are self-attacking, judging or blaming that might occur during the exposure. This is especially important if your exposure is reactivating an old memory, which has been traumatic for you. The goal is just to accept the intrusive thoughts and feelings. Distance yourself from them and do not buy into their content. Wait for the anxiety to fade by itself. The issue here is acceptance and not trying to control from or escape from the anxiety. We will discuss this in more detail shortly.
Always monitor your exposure so you can learn from it and see your progress. Re-rate your distress at the end of exposure and see whether you over-estimated the degree of distress that would occur or how long it would last for.
This is also essential when you are seeing a therapist so that he or she can monitor whether you are doing the exposure that you negotiated with your therapist in the previous session.
A common obstacle is the belief that I can only stop avoiding situations or drop my safety behaviors ‘when I feel comfortable or “right”’; or when ‘I know for certain that the consequences I fear will not happen’; or when ‘I feel confident enough to test out my fears’. This applies to a wide range of avoidance and safety behaviors. There may be a high-level emotional intolerance and a struggle to stop controlling events. Progress will occur if you are willing to accept and embrace uncomfortable thoughts and feelings and willing to take a ‘leap of faith’. This means doing tasks uncomfortably, with some uncertainty and lack of confidence in the short term, in order to obtain the long-term gains. Some people may have a good intellectual understanding of the problem but not be ready to change their behavior in order to test out their predictions. In such situations, you may have to think about taking smaller steps and get professional help. Whatever happens, you need to really commit yourself to testing out an alternative, otherwise your suffering is likely to persist.
You might be concerned at some of the suggestions that a therapist or we might make for exposure at the top of your hierarchy but they are a means towards an end. As soon as you have overcome your body image problem, you can bin them. People sometimes complain that what they are being encouraged to do during exposure is ‘abnormal’ and therefore unreasonable. Thus, someone who is preoccupied with their spots or the redness of their skin may be encouraged to exaggerate their redness or spots by the use of make-up. Another person who has been encouraged to refrain from washing their hair or applying make-up for two weeks might say something like ‘Even someone without a body image problem wouldn’t do that!' as if the therapist is being entirely unreasonable. (We’re not saying therapists are never unreasonable; it’s just that this is more likely to be a problem of misunderstanding!) However, for someone with a body image problem who believes that others would reject her and she would be alone all her life, then it is a powerful way of testing this out.
Thus, the ultimate tasks will not only involve the dropping of safety behaviors but also the highlighting or exaggerating of the ‘defect’. If you think about it, many treatments for human ailments involve doing the unusual. Consider how ‘abnormal’ it is to swallow toxic chemicals every day; but chemotherapy treatment for cancer involves exactly that. Likewise, it’s not exactly normal to wrap a leg in plaster, but if you have a broken leg, it’s very helpful! We accept these ‘abnormal’ activities as part of ‘normal’ treatment for physical problems. Part of the problem when tackling a psychological problem is that, because of the stigma and shame surrounding psychological and emotional problems, the normal processes of overcoming fears are not so readily discussed and understood.
Would you expect a medication to be effective if you took less than the recommended dose and took it less often than prescribed?
We have discussed how you can make predictions to see whether something is true or not – this is called a behavioral experiment. If you are not sure whether something you do helps or not, compare the effect of increasing and decreasing the behavior (e.g. checking in a mirror more often than usual compared to not checking at all) for a sufficient period of time to see whether you become more or less preoccupied.
Here is another example of a behavioral experiment. Katja was preoccupied with lines on her skin over her arms. She used a thick moisturizer daily to reduce ‘wrinkles’. She was very reluctant to give up using it but agreed to compare the effect of (a) using the moisturizer on one arm; and (b) using no moisturizer on the other arm.
I will use moisturizer as usual only on my left arm. I will not use it on my right arm. I will not make a special effort to conceal my arms.
It will be very distressing (100%) to see my right arm developing wrinkles.
My distress over my wrinkles is likely to increase over several days.
I predict others will notice my wrinkles and say something.
I did leave the cream off my right arm as planned.
My distress was about 70%.
The distress decreased over several days and I began to think less about it.
Others were unable to predict which arm had been moisturized either by looking at it or feeling it with their fingers. The results best fit the theory that I have a problem with being excessively preoccupied with my skin and that it is my solutions that maintain this preoccupation.
For people with body image problems, mirrors (and other reflective surfaces) can present a real problem. Mirrors or reflective surfaces are commonly used as a safety behavior to check on appearance. If this is a problem for you then the first step is to see how often you are checking in a mirror. You can do this using a record sheet like the one overleaf. Some people check in a mirror 30, 50 or hundreds of times a day. If this is the case with you, it’s best to use a tally counter and to carry over the total to the chart. This method will tell you exactly how often you are checking and will give you a baseline so that you can tell in future whether or not your checking is decreasing over time.
Keeping a record will also make you more aware of when you are checking so that you can resist it in future. There are of course many different ways of checking. These might include long checks in front of a mirror, doing something like styling or cutting your hair, plucking eyebrows, picking spots, applying make-up and trying to do mental cosmetic surgery. Or it may take the form of brief glances in shop windows or the backs of CDs. Alternatively, you may be doing internal checking of the picture in your mind or your memory of how you last looked. If your feature (e.g. your thighs) can be examined directly, you might not need a mirror to check. Add a tick or a click on your tally counter whenever you do any of these checking activities.
EXERCISE 7.4: THE A, B, C, D, E OF UNDERSTANDING YOUR CHECKING
Activating Event
Describe a recent typical situation in which you were checking the feature (e.g. looking in the mirror or a reflective surface or pinching your skin). Did you experience a picture in your mind or memory before the checking started?
Behavior
What did you actually do? What was your mind telling you as you checked? How long did it last?
Immediate Consequences
Was there any pay-off from checking? For example, did you avoid anything that was uncomfortable? Did you briefly feel more certain about how you do look? Did you feel you were doing something to improve your appearance?
What effect did the checking have on the way you felt?
What effect did the checking have on how you acted? What effect did it have on the time you were able to devote to what is important in your life?
What effect does checking have on the people around you?
Did you do anything in excess as a consequence of checking (e.g. drink more, use drugs, binge-eat, purge?)
Overall, how helpful was it to give into your urge to check?
What alternatives could you find that are consistent with your goals and valued directions instead of checking?
Effect of Alternative Directions
What effect did following your alternative direction have?
Is there a pattern to the situations that are typically linked to checking? For example, can you do anything do to prevent such situations arising?
Examples of the reasons that people with body image problems give for checking are:
• I hope that I don’t look as bad as I think I look.
How long does the hope last for? What happens after that?
• I have to know what I look like before I do anything.
Might there a better way of knowing how you feel?
• I have to know for certain how I appear in public.
For how long do you feel certain that you know what you look like? Then what happens?
• I believe that if I stare long enough, I might see a different image.
Does staring make you more objective?
• If I resist looking in the mirror then I will feel worse.
Does this really fit in with your experience?
• I need to see what I don’t like about myself.
Does this teach you anything new?
• If I don’t look then I might forget how ugly I am.
What is the cost of having this on your mind? Will you really forget?
Some of these assumptions can be tested in an experiment, using two different timeframes. Compare checking once a day with checking 20 times a day and ask yourself whether increasing the checking leads you to be more or less certain about how you look. You should also ask yourself whether increasing the checking makes you more preoccupied and distressed.
We hope you agree that mirror checking is unhelpful and needs to be used only for functional reasons. We would encourage you to work towards the following goals:
(a). To use mirrors at a slight distance or ones that are large enough to incorporate most of your body.
(b). To deliberately focus your attention on your reflection in a mirror, rather than on an internal impression of how you feel.
(c). To only use a mirror for an agreed function (e.g. shaving, putting on make-up) for a limited period of time.
(d). To use a variety of different mirrors and lights, rather than sticking to one which you ‘trust’.
(e). To scan your body and focus your attention on the whole of your face or body, rather than on a specific ‘defect’ or detail. (People without body image problems tend to focus their attention on features that are considered to be more attractive. This is an alternative strategy.)
(f). To avoid making any judgements about your appearance. Just be aware of any intrusive thoughts and images about being ugly without buying into them. Take the position of an observer of passing traffic, rather than trying to control the traffic and believing that what enters your mind must be true.
(g). Not to use mirrors that magnify your reflection.
(h). Not to carry small hand mirrors around with you to make checking ‘easier’.
(i). Not to use ambiguous reflections (e.g. windows, the backs of CDs or cutlery or mirrors that are dusty or cracked).
(j). Not to use a mirror when you have the urge to check but to try and delay the response and do other activities until the urge has diminished.
(k). Not to ‘swing’ from excessive mirror checking to avoiding mirrors all together. It’s important to learn to resist the urge to check or scrutinize whilst in the presence of your own reflection.
For some people, it is more important to monitor how long the mirror gazing lasts. For example, a single use of the mirror can sometimes last several hours. Here, the criteria used to finish a check may be problematic. Thus, someone may finish mirror gazing when they feel ‘comfortable’ or ‘just right’. Deciding whether you are going to stop checking or applying make-up based on how you ‘feel’ will inevitably cause problems. When finishing a ritual, do not go by how you ‘feel’. Instead, refocus your attention and concentrate on the environment around you and what you see. This means finishing using the mirror when you still feel anxious, acting against the way you feel. This goes against the grain when you believe you have to be guided by your feelings or ‘sixth sense’. The problem is that you are receiving a false signal of danger and you have now got used to it. The goal is to finish using a mirror or grooming or combing your hair when you can see that it looks ‘good enough’. As an experiment, you might want to alternate between using a ‘just right’ feeling and ‘just doing it’ without using internal criteria.
If you can reduce the amount of make-up or grooming, then this will reduce significantly the amount of time you spend in front of a mirror. It is also worth remembering that when women reduce excessive camouflage on their faces, they may well receive comments from others that they look different. This is not the same as being ‘ugly’!
Some people may avoid ‘unsafe’ mirrors. Avoiding mirrors altogether is an unrealistic goal and will cause problems in the long term. Mirror feedback is sometimes necessary in people who are avoiding all or certain mirrors. It can be done as graded exposure with varying degrees of light or the amount of body exposed. If the problem is with the whole body then a swimming costume can be worn if someone else is present. When you look in the mirror, it is important to describe your appearance objectively, e.g. the colour of your eyes, your complexion, height, build, etc. Observe and describe but do not ‘rate’ or value these features. Scan the whole of your body and do not focus attention on a specific ‘defect’ or go into any detail. Look at the person in the mirror as if they were a stranger.
Like mirrors, photographs can present a real difficulty for people with body image problems. Many people will avoid having their photograph taken, or tear photographs up. Alternatively, they might repeatedly have their photograph taken in a photo booth to ‘check’ whether their appearance has changed. Photographs can also fuel the brooding tendency, when you look at a photograph taken at a time when you thought you looked acceptable and repeatedly go over the thought ‘if only I looked like that now’. As with mirrors, try to integrate photographs as part of your normal everyday life and allow your mind to become used to them again. This may form part of the ‘exposure’ program described above. Alternatively, if you are using photos to check your appearance, then monitor how often you are checking, using the Exercise 7.3 form on page 189, and carry out the same analysis as you did for mirror checking.
Photo or video feedback can sometimes be helpful if you can make a specific prediction beforehand of how you look and you are not using a camera for frequent checking. For example, the degree of redness can be calibrated against a colour chart showing varying degrees of redness. Other predictions can be made by drawing what you imagine, and it may be possible to superimpose an outline of a drawing onto an actual photo of the feature using photo editor software. Thus, a person who feels he has a disproportionately large forehead or chin, which he has drawn in profile, may have it superimposed onto a photo of his actual face to examine the difference between the two.
In general, these approaches probably need the guidance of a therapist. For example, they may not be helpful for people with a disfigurement. Good-quality lighting and equipment is also important to avoid adding unhelpful shadows or distortions.
When watching a video or looking at a photo, make sure that you are not self-focused but look at it as if you are watching a stranger. Only make observations on what you see (not what you feel and not making a rating of how ugly you look). Remember that a video camera may also have the effect of making you look heavier.
Now ask yourself:
• Were the things that you were afraid of as noticeable as you felt they would be?
• What does the photo/video tell you about using the picture in your mind to judge how you come across?
