Foreword xv Preface xvi 1 Background, Clinical Problems, Common Presentation andTreatment Considerations 1 Physical and Treatment-Related Factors 3 Socio-Cultural Factors 3 Psychological Factors and Processes 3 Body Image Disturbance 3 Clinical Problems and Presentation 4 Common Features in Referral 8 Visibility of Condition 8 Shame 9 The Meaning of Visible Difference 9 The Experience of Loss 9 Physiological Responses 10 Culture 10 Gender 11 Age 11 Expectations of Treatment 11 Association of Physical Change with Psychological Outcome 12 Fix It Solutions 12 Treatment Considerations 13 2 A Stepped-Care Approach to Psychosocial Intervention15 The PLISSIT Model 16 Level 1: Permission 16 Level 2: Limited Information 18 Level 3: Specific Suggestions 18 Level 4: Intensive Treatment 19 3 Models and Frameworks: Expanding the Conceptual Approach toManaging Appearance-Related Distress 21 Explanation for Choice of Therapeutic Approach 22 Behavioural Approaches: Fear Avoidance and Social SkillsTraining 22 Building an Evidence Base 25 Cognitive Approaches: Comparison of Appearance Anxiety andSocial Phobia 26 Use of Safety Behaviours 28 Anticipatory and Post-Event Processing 29 The Role of Assumptions and Schema in Appearance Anxiety 32 Summary 33 Deriving a Cognitive Behavioural Treatment Model: IdentifyingFactors and Processes Contributing to Successful Adjustment to Disfiguring Conditions34 Working Framework of Adjustment to Disfiguring Conditions 34 The ARC Framework of Adjustment to Disfiguring Conditions 34 Predisposing Factors 35 Intervening Cognitive Processing 36 Socio-Cognitive Processing 37 Outcomes 41 The ARC Research Programme Findings 43 The Studies 43 Summary of Findings 43 Key Messages from the Research Programme 45 Implication of These Findings for Design of Interventions 45 Summary 47 4 Clinical Assessment 48 Eliciting the Problem 49 Summarizing 51 Motivation and Self-Efficacy 52 Readiness for Change 53 Measurement Tools 55 Generic Measures of Psychological Constructs (as used in the ARCStudy) 55 Measures of Psychological Constructs Specifically Related toAppearance 57 Measures of Body Image 58 Measures of Psychological Constructs Specifically Related to aCondition Type 58 Body Dysmorphic Disorder (BDD) 59 Core Clinical Dataset 59 Regular Subjective Measures of Frequency for Events, Thoughtsand Feelings 60 Goal Setting 61 The SMART Acronym 61 Challenges in Treatment for Appearance-Related Problems 62 Introducing a Biopsychosocial Model 62 Treatment ''buy-in'' 63 5 Social Skills and Coping Strategies 64 Staring, Questions, Comments and Loss of Anonymity 66 Making the Most of Appearance 66 Developing a Positive Approach to Visible Difference 67 Posture, Smiling and Eye Contact 67 Developing Verbal Skills 68 Learning to Have a Conversation 68 Answering Questions About Appearance 68 Managing Staring 70 Putting it into Practice 71 Taking the Initiative in Social Encounters 72 Managing Anger and Developing Assertiveness 73 Anger 73 Managing Intimacy 75 Disclosing a Disfiguring Condition to a Partner 75 Summary 77 6 Cognitive Behavioural Therapy 78 Techniques in Cognitive Behavioural Therapy 79 Socratic Dialogue 79 Eliciting Negative Automatic Thoughts 82 Unhelpful Beliefs Record Form 84 Negative Automatic Thinking Styles Associated with Anxiety84 Triple Column Technique 87 Pie Charts 87 Manipulating Safety Behaviours 88 Anxiety management techniques 88 Target, Tools, Troubleshoot, Test 89 Cost-Benefit Analyses 90 Some Techniques for Dealing with Appearance-RelatedSelf-Criticism and Shame 93 Functional Analysis of Self-Criticism 94 Identifying the power of self-criticism 94 Summary 97 7 Planning Treatment and Sessional Guides 98 Introduction 102 Working at Level 1 102 Working at Level 2 104 Working at Level 3 105 Session 1 106 Structure Outline 106 Working at Level 3 Using FaceIT (www.faceitonline.org.uk)108 Working at Level 4 using CBT 108 Planning Treatment and Sessional Guides 108 Clinical Examples 112 Example 7.4 112 Session 1 112 Session 2 116 Review Data 116 Set Agenda 116 Restatement of Formulation 117 Elicit Patient Understanding 118 Session 3 118 Review of Homework and Reformulation 118 Set Agenda 119 Introduction to Answering Questions About Her Face 119 Role of Self-Focused Attention Discussed 119 TTTT 119 Homework 119 Session 4 119 Review of Homework and Reformulation 119 Set Agenda 120 Reattribution of Beliefs 120 Design Behavioural Experiments 121 Homework 121 Session 5 121 Review of Homework 121 Set Agenda 121 Strategies for Attentional Training 122 Development of Personal Coping Approaches 122 Homework 122 Session 6 122 Review of Homework 122 Measure Noticeability and Worry 122 Reattribution of Beliefs 122 Feedback from Behavioural Experiments 122 Development of Personal Coping Approaches 123 Homework 123 Session 7 123 Review of Homework 123 Set Agenda 123 Schema-Focused Reattribution 123 Preparation for Ending 123 Homework 123 Session 8 124 Review of Homework 124 Schema-Focused Reattribution 124 Planning for Ending 124 Homework 124 Session 9 124 Homework 124 Agenda 124 Outcome 125 Example 7.5 126 Session 1 126 Summary 129 Session 2 130 Review Data 130 Introduction to Social Comparison Processes 130 Restatement of Formulation 130 Elicit Patient Understanding 131 Introduction to Compassionate Thinking 132 Homework 132 Session 3 132 Review of Homework and Reformulation 132 Set Agenda 132 TTTT 132 Introduction to NATs 132 Section 4 133 Review of Homework and Reformulation 134 Set Agenda 134 Reattribution of Beliefs 136 Design Behavioural Experiments 136 Session 5 137 Review of Homework and Reformulation 137 Set Agenda 137 Session 6 137 Review of Homework and Reformulation 137 Set Agenda and Review Progress 138 Measure Noticeability and Worry 138 Reattribution of Beliefs 138 Feedback from Behavioural Experiments (Disclosure) 138 Homework 138 Sessions 7, 8 and 9 138 Review of Homework and Development of Final Reformulation (SeeFigure 7.13) 138 Set Agenda 139 Focus on Schema-Focused Reattribution 139 Session 10 140 Outcome 140 Example 7.6 140 Session 1 140 Summary 144 Session 2 144 Review Data 144 Noticeability and Worry Graph 145 Set Agenda 145 Introduction to Social Comparison Processes 146 Self-Efficacy 146 Safety Behaviours 146 Restatement of Formulation 146 Homework 147 Session 3 147 Review of Homework and Reformulation 147 Set Agenda 147 TTTT 147 Anxiety Management 148 Introduction to NATs 148 Homework 148 Session 4 148 Review of Homework and Reformulation 148 Set Agenda 148 Design Behavioural Experiments 149 Homework 149 Session 5 149 Review of Homework 149 Set Agenda 149 Homework 149 Session 6 150 Review of Homework 150 Set Agenda 150 Measure Noticeability and Worry 150 Design of Behavioural Experiments 151 TTTT: Role Play Her Response If Her Breasts Are Mentioned151 Homework 151 Session 7 151 Review of Homework 151 Set Agenda 151 Focus on Reattribution 151 Preparation for Ending 152 Homework 152 Sessions 8, 9 and 10 152 Session 11 152 Homework 154 Agenda 154 Outcome 154 Example 7.

7 154 Session 1 154 Summary 157 Session 2 157 Review Data 157 Plan Homework 158 Therapeutic Buddy 158 Homework 158 Session 3 158 Review of Homework and Reformulation 158 Homework 159 Session 4 160 Review of Homework and Reformulation 160 Set Agenda 160 Set Homework 160 Session 5 160 Review of Homework 160 Set Agenda 160 Homework 161 Session 6 161 Review of Homework and Reformulation 161 Set Agenda 161 Completion of Rating Scales and Outcomes 161 Sessions 7 and 8 161 Set Agenda 161 Session 9 162 Completion of Rating Scales and Outcomes 162 Summary and Feedback 162 Outcome 162 Long-Term Outcome and Maintenance of Change 162 Complete Maintenance 162 Partial Maintenance 163 Slip-Back and Sub-maintenance 163 Slip-Back and Failure 163 Social Support and Therapeutic Partners 164 Summary 164 Additional Resources 165 8 The Emerging Adult: Facilitating Transition from Child toAdult Service 166 Introduction 167 Introducing the Problem.