I related some of my client’s and other colleagues' accounts of searching for a therapist who specializes in body dysmorphia and body image issues to Meredith Cariski. She wrote this very accurate fictionalized account of the difficulties in finding such a specialist.
As a body dysmorphic client, deciding to bring up weight and body issues always puts freaked out butterflies in my overweight stomach. It is debilitatingly scary to talk about weight to anyone let alone a therapist.
Unequivocally, it is because of previous horror story experiences. I have had therapists react to bringing up the subject in a variety of, for lack of better words, stupid and thoughtless ways.
Therapist #1 just pussyfooted around the issue. It was obvious that this was not their specialty, and when I brought it up and they practically ignored it. That minimized the subject which is the last thing I needed. I knew that she was not the therapist for me because she did not know how to deal with me and with me not being able to take on this problem myself, I rendered her useless and purposeless.
Therapist #2 proceeded to go to his overflowing bookshelf after I mentioned my body image traumas and sifted through generic weight loss books from the shelf. He gently said “Let’s follow this.” The nerve! I can buy a book myself, no thank you very much. And what is hilarious is, I actually had that book and it is as pointless as his advice. I don’t need a book, I need understanding and guidance from my therapist. I told him this and he recommended more guide books and PDFs. Literally face palmed right in front of him.
Therapist #3 tried failed intervention after intervention. She told me to go to my primary care doctor to discuss this instead, suggested a diabetic prevention program, a lifestyle coach, and an exercise coordinator. I tried to express that my qualms were not just about weight loss, it was about body image from deep seated issues and the media. She told me to stay away from all forms of technology. Sure, that is totally realistic and beneficial. Not!
Therapist #4 does not deserve much explanation. After I mentioned my troubles and difficulties, he proceeded to say: “But you look fine.” Great, because looking fine is my only goal. And, I don’t look fine! Why would I bring it up if I thought I looked fine? Thank you for the unwarranted opinion though. There were so many sarcastic and sadistic expressions I wanted to communicate and display, but I held my breath and tried to maintain a neutral facial expression before I left vehemently and slammed the door behind me.
I felt completely hopeless and lost because I came to the conclusion that there was not a therapist on this planet that could help me. I realized I probably needed someone who has been there, experienced my perspective first hand, but could I ever find such an individual? I did, and my world became a place of openness instead of feeling like it was crushing and crashing down upon my full sized body.
Brian Baumal Writes
Meredith, the issues you created in your fictional account are painfully common among those with body dysmorphia. Over the past three months, I have had one client and one therapist colleague report exactly some of the incidences that occurred to you. I do not want to be unfair to my fellow therapists though. There are some stats in Canada that show well under 10% of psychiatrists feel they have received enough training in eating disorders, which likely includes body dysmorphia. Moreover, the very first time I sat across from a body dysmorphic client, I felt extremely thrown off balance, wondering if I heard the client correctly. However, I then realized that if I am thrown off balance by the client’s view of the body, I have to wonder how the client themselves feels about the situation they are discussing.
There are, however, ways of addressing this, that should be fairly well-known to many skilled therapists. Most therapists, in one way or another practice present-centered therapy. In expressing dissatisfaction with one’s body whether the image is distorted or not, the client is still expressing dissatisfaction in that moment. Two interventions that tend to work well are 1) “How does it feel to live in a body that you dislike so much” and/or 2) “You say that your body appears [fat/tall/thin/frail/big-boned, etc…]. What does that feel like to you.”
A more “clever” intervention, especially for a therapist working with body dysmorphia for the first time, may be to say “I bet many people tell you that you look just fine. What’s it like when you have one image of your body and others have a different one?” The responses back, Meredith, may very-well be the ones your fictional client had towards the therapist who said “but you look just fine”. The therapist will hopefully realize -and count his/her lucky stars – that he/she didn’t say “you look just fine”, because he/she would have invoked the reactions you described. However, the therapist should store that answer in his/her mind and know that such comments will elicit such feelings, and likely tank the therapeutic relationship.
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A more advanced intervention would be something like “It seems you have a vision for your body, what it is like to have a body that does one thing and your mind that wants another?”
You will notice that these interventions avoid any sort of sense of battle around truth or reality. This – in no way shape or form – supports the client’s distorted body image. Rather, like most therapeutic orientations, we want to know the client’s feelings and/or how the client experiences any given situation. The fact is this - Tens of thousands of times a day across North America, someone says to a therapist “My boss told me I suck at my job” or “My spouse was the worst possible person on the face of the earth to me this morning” or “The guy who cut me off in traffic this morning did it because he drives a Ferrari and I only drive a Chevy.” Very few therapists would seek to establish the accuracy of these accounts, especially in the first few sessions. So, in fact therapists often work entirely on client perceptions and self-reports, and body perception is not any different.
The goal of therapy is to restore a healthy relationship with body image by working through the experience of living in a body that is foreign to, but not separate from the client, and to have clients understand how the two are related and linked together. I cannot tell you how important addressing body image issues is important to weight management, eating disorders and food addiction. If an individual remains at war with their body, proper weight management and recovery from eating disorders becomes nearly impossible. You were right to look for a therapist who can work with body image issues the same way they work with most any other condition.