A self-help book could be all that is required for some people to overcome a body image problem. After all, even with professional help, it is likely to be your own efforts between sessions that make the biggest difference. You might consider using this book with the aid of a professional; this is called ‘guided self-help’. In this case, the book can offer a shared way of understanding your problems, and the strategies to improve the way you feel.
Professional help, with an appropriately trained practitioner, is often the most effective approach. This involves working with a psychologist, psychiatrist, therapist, counsellor or nurse therapist. Cognitive behavioral therapy (CBT) can help most people and will rarely make symptoms worse. We suggest that you seek professional help if your body image problem is in the moderate to severe range, and especially if your attempts at self-help are not bearing fruit after a month or so. If you are feeling hopeless about the future and are having thoughts about ending your life, please seek professional help immediately.
If you are prescribed medication like Prozac, you can virtually guarantee that any pharmacy you go to will give you the right dosage and that the Prozac will be of the same quality. Unfortunately, this is not always true of psychological therapy. Of all the different forms of psychotherapy, only CBT has been shown to work effectively for a body image problem and is likely to be the treatment of choice. When choosing a suitable therapist, the alarm bells should ring when you encounter therapists who:
• do not tell you what type of therapy you are receiving
• just keep asking ‘How does that make you feel?’
• spend most of the time wanting you to discuss your childhood and the cause of your body image problem
• do not share their understanding of what maintains your problem
• do not problem-solve with you
• do not negotiate relevant homework between sessions
• do not monitor your progress in overcoming your symptoms.
If you are not sure, ask what type of therapy or counselling you are receiving. There is no evidence that general counselling, psychodynamic therapy, psychoanalytical therapy, hypnotherapy or transactional analysis is of any benefit for moderate to severe body image problems. People can find such approaches supportive or helpful for some issues but they are rarely helpful by themselves in overcoming a body image problem. Supportive psychological therapy might also help people to a degree with mild problems.
Similarly, beware of a doctor who offers only medication without also recommending a psychological treatment. There might also be problems with obtaining psychological therapies on the NHS because of the lack of funding but this is not the fault of the doctor. This is a problem that requires political action and takes a long times to solve. In the meantime seek support, use the principles outlined in this book (or other CBT-based self-help material), and consider asking your doctor for medication or consider private therapy.
You might have a number of worries about seeking help such as:
• ‘What if it doesn’t help?’
• ‘It will be too embarrassing to tell them about my problem.’
• ‘They’ll think I’m mad and want to keep me in hospital.’
• ‘What if they pass the information on to social services or my employer?’
If you find it difficult to talk about some of your worries, it’s usually helpful to say you are embarrassed or ashamed. Remember that worrying is normal and any health professional who has the slightest experience with body image problems will be sensitive to your difficulties. He or she will not consider you mad or want to keep you in hospital against your will. Individuals are assessed for detention only in extreme circumstances: if you are a danger to yourself or others (for example, if you are actively suicidal, neglecting yourself badly or are very underweight). Such information is kept confidential and cannot be shared with other agencies or your employer without your permission. It does not go on any employment records or to social services. Only in extreme circumstances would a therapist ask someone to assess the impact of a person’s body image problem on his/her family and children. Treatment may not help initially, as it can take a few weeks to take effect, but if nothing is risked, nothing is gained and your problem is likely to persist for some time. Furthermore, CBT or medication very rarely makes your problem worse.
In teaching centres, you may be asked if a student or trainee may sit in. It is important to continue training others in psychological treatment but you are entitled to refuse without it affecting your treatment.
Remember, as with all other thoughts, try to treat your thoughts about seeking help as ‘just thoughts,’ which are likely to be quite common under the circumstances. Rather than trying to ignore them, or debating them in your mind, take your thoughts with a pinch of salt and act consistently towards pursuing your goal of overcoming your body image problem.
You will get most from a psychological therapy if you:
• keep your appointments
• are honest and open with your therapist
• tell your therapist if you do feel very embarrassed or ashamed about your symptoms
• attempt the homework agreed between you and your therapist during therapy sessions (having a good relationship with your therapist is important, but adherence to daily testing out of alternatives is the biggest predictor of success in therapy)
• challenge your usual way of responding to your problem (e.g. the way you check, compare, brood, avoid) and act as if you don’t have an emotional problem (even if you don’t believe it)
• act against the way you feel and do it ‘unconfidently’ and ‘uncomfortably’ even if you are not sure it will work
• have clear goals that you want to achieve and you can agree on with your therapist
• regularly monitor your progress with your therapist, using progress charts or scales
• tape-record the sessions so you can listen to them again
• give the therapist feedback.
You might find that you are not ready for CBT and it might be better to return when you feel more committed to change and able to do the homework regularly. Don’t believe you are a ‘hopeless case’ – change is nearly always possible. Even a small change is worth making, and then you can build on it. Don’t be afraid to seek a second opinion or a referral to a specialist centre.
There is a range of mental health professionals who will offer help for a body image problem. Most mental health teams are multidisciplinary, which means that they include people from different professional backgrounds.
• Psychiatrists are medical doctors who specialize in mental disorder. They can prescribe medication for BDD or bulimia and will probably be more knowledgeable about dosage and other issues required for BDD and bulimia than your family doctor. Only a few psychiatrists are trained in CBT.
• Clinical psychologists have a basic training in psychology and have then trained in the clinical application of psychological assessment and therapies. They do not prescribe medication. Many will offer CBT but might not have had the specialist training and supervision required.
• Counselling psychologists have a basic training in psychology and are then trained in counselling and therapy. They do not prescribe medication. Some offer CBT but might not have had the specialist training required.
• Nurse therapists are originally trained in psychiatric nursing, and in the UK most have specialized in CBT.
• Psychotherapists and counsellors come from a broad range of therapy backgrounds. Most will listen to you and help you to work through issues in your life. They do not prescribe medication. They are not usually trained in CBT.
• All of the above may be suitably trained and supervised in CBT but will not have a lot of experience with body image problems!
It is important to realize that, at the time of writing, there is nothing to stop anyone calling themselves a counsellor or psychotherapist, whether or not they are properly trained. No therapist with a recognized professional qualification is going to mind you asking about his or her relevant training and qualifications. It is very important to satisfy yourself about these things as well as the type of therapy used. Here are some questions that you may want to ask:
• What experience has he or she got of treating body image problems (for example, how many patients or clients has he or she treated)?
• What therapy does he or she use?
• If providing CBT, is he or she accredited or accreditable as having a minimum training in CBT?
• What are his or her expectations for change at the end of therapy and do these match your goals?
• Do you get on with the therapist?
Of course you will want someone who is experienced with body image problems, but if he or she is not, try to judge whether he or she is willing to learn more. Details of finding an accredited therapist are given below.
If you want to complain about any professional, think clearly about the nature of the problem – for example, is it the type of treatment, the therapist, the location, or something else?
Are there contributing factors (e.g. the personality of your therapist or you feeling more depressed)? Can you sort it out with the therapist or another member of the team? Can you think of possible solutions to discuss with the professional? If the professional is refusing further therapy, listen to his or her reasons and write them down. If the reasons are financial (for example, it costs too much), don’t give up, as you could have to persist to get another opinion.
If you would like professional treatment in the UK, your family doctor or general practitioner is the best place to start. He or she will usually be aware of what services are available locally. If you are worried about seeing your GP, take a relative or friend with you. If you find it difficult to talk to your GP, write a letter and give it to him or her. At your consultation, write down the key points that you want answered. You can always change your GP if you think you might be better understood or treated by another.
The information that you tell your GP is confidential and cannot be shared without your permission. If your local mental health service is unable to assist, they might refer you to a national service. Unfortunately, getting referred to a specialist service is not always easy (due to funding shortages) and will usually depend upon the support of your local mental health team. Make it clear that you will need cognitive behavioral therapy from a trained practitioner. For therapy services in the NHS, you can usually be referred only to a department and not to a particular individual. Despite this, you could find it helpful to do your own research and find out the names of recommended therapists from a support group or national charity (see the list of addresses given in Appendix 1).
In their treatment guidelines for OCD and BDD, the National Institute of Health and Clinical Excellence (NICE) recommend that patients should have access to an OCD/ BDD multidisciplinary healthcare team which will focus on the more severe cases and decide who should be referred onwards to a national service. One of the authors of this book (David Veale) runs a national service in the UK for BDD at the South London and Maudsley Trust. This is for out-patient treatment or for a more intensive treatment program on a residential unit. There is also a separate stream of funding from the Department of Health for a treatment refractory service – further details can be found on the website www.iop.kcl.ac.uk/ncg.
In the UK, it is usually quicker to obtain help privately but this does not necessarily mean that the treatment will be any better. Good and bad treatment can occur both in the public and the private sector. It is best to ask for recommendations from your local support group or a national charity, which may keep a directory of practitioners. In the UK, you can also try searching for a private accredited therapist on the website of the British Association for Behavioural and Cognitive Psychotherapies (www.babcp.com) in the ‘Find a Therapist’ section. Not all cognitive behavioral therapists bother to become accredited and there are many from psychiatry, psychology or nursing backgrounds who are excellent cognitive behavioral therapists.
In the USA, finding a cognitive behavioral therapist may be difficult depending on where you live. You could ask for a referral from your family doctor or recommendation from an academic psychiatry or psychology department. The best recommendation could come from your local support group or charity. It is likely to be a member of the Association for Behavioral and Cognitive Therapies, which maintains a directory of therapists who can be contacted (www.aabt.org). As in the UK, it is usually quicker to obtain help privately but this does not mean you will necessarily get any better treatment. Good and bad treatment can occur both in the public and the private sector.
The European Association for Behavioural Cognitive Therapies lists member associations on its website http://www.eabct.com. Details of the Australian Association for Cognitive and Behavioural Therapy can be found on its website at http://www.aacbt.org/.
In addition to professional help, national charities and local support groups can be invaluable. In the UK if you have BDD, support the BDD Foundation, BDD Help or OCD Action. If you have a disfigurement, support Changing Faces. For an eating disorder, support BEAT (formerly known as the Eating Disorders Association). In the USA, if you have BDD, you can support the Neysa Jane BDD fund and the OCD Foundation.
These charities will offer you information on local resources and support groups, which provide a forum for mutual acceptance, understanding and setting of goals. They will also be able to recommend local therapists or psychiatrists. People new to the area can talk to others who have learnt successful ways of coping. Reading books and Internet articles about body image problems are useful ways of getting further information or support. The more you know about the problem and the more you can become your own therapist, the better equipped you will be to overcome it. And when you recover from your body image problem, you can help raise funds for research into better treatments, and campaign for better services and for training for more cognitive behavioral therapists in public medicine. Unfortunately, many of these charities are too small to be able to focus enough energy on raising funds for research, especially compared with the big charities dealing with cancer or heart disease.